We read the article by Abdelbaki et al. [1] titled “Ramadan fasting following laparoscopic sleeve gastrectomy: a prospective online survey cohort study in Egypt” with great interest. In that article, the authors investigated the effects of LSG for 218 patients with obesity during Ramadan fasting.

In the Islamic tradition, adult Muslims are mandated to engage in intermittent fasting during Ramadan, which falls on the ninth month of the lunar calendar. This pivotal religious practice is observed by an excess of 1.5 billion followers worldwide [2]. Fasting during Ramadan includes complete abstinence, sometimes for more than 12 hours, and there may be risks for patients with bariatric-metabolic surgery (BMS).

In the present study, 70.2% of 218 patients were able to fast for the entire month, and the longer the postoperative time, the greater their ability to fast. Fluid consumption, total calorie intake, and protein intake significantly decreased during fasting. Muslim patients with obesity may be advised to consider delaying surgery for a few months after Ramadan, avoid overeating during non-fasting hours, and sufficient fluid consumption and protein intake should be emphasized during fasting. Current guidelines recommend a minimum daily protein intake of 90 g and highlight awareness about protein intake during fasting [3].

We suggest several comments for a more instructive study. First, this study was based on an online survey, in which recall bias can occur. We recommend a dietary diary for BMS patients, which includes details on caloric counts, protein intake, micronutrient intake, and physical activity. These records would be useful for physician research as well as patient postoperative management. Second, Farey et al. [4] reported that patients undergoing LSG exhibited markedly increased levels of C-peptide, insulin, and leptin, alongside notably reduced levels of ghrelin, glucose-dependent insulinotropic peptide, and resistin, when compared to individuals in a non-obese cohort. These laboratory data allow us to better understand the mechanism related to changes after LSG. Finally, as the authors also described, it was not clear whether weight loss in LSG patients was from the fat or lean body mass. Body composition measurements are simple and might help achieve a more precise conclusion. Further research should include dietary information, nutritional laboratory markers, hormonal levels, and body composition data to investigate the effect of BMS during intermittent fasting.

The authors are to be commended for presenting this very interesting topic of fasting ability after LSG during Ramadan fasting that should be evaluated in larger prospective clinical trials, including laboratory data or other types of metabolic surgery.

Conflict of interest

All authors have no conflicts of interest to declare.

Funding/support

None.