Ramadan Fasting Improves Health‐Related Quality of Life in Patients With Secondary Adrenal Insufficiency: A Prospective Interventional Case‐Control Study

ABSTRACT

Introduction

Intermittent fasting (IF) exposes patients with adrenal insufficiency (AI) to complications related to undertreatment. We aimed to determine the effect of IF during Ramadan on the quality of life of patients with secondary adrenal insufficiency (SAI) compared to healthy controls.

Subjects and Methods

It is a prospective case‐control study conducted at the Department of Endocrinology of La Rabta University Hospital in Tunisia. Fifty patients with SAI and 100 age‐, sex‐ and body mass index‐matched controls were enrolled and followed up throughout Ramadan 2023. All participants answered the Addison's disease quality of life questionnaire (AddiQoL) before Ramadan and during the third week of fasting.

Results

There were 33 women and 17 men, median age: 43 years (IQR: 34–55), median duration of SAI: 7.5 years (IQR: 4–12.5), treated with hydrocortisone at a median dose of 0.24 mg/kg/day (IQR: 0.20–0.27). Before Ramadan, there was no significant difference between patients and controls in the global AddiQoL score, fatigue score, and emotional sphere score (89 vs. 93, p = 0.196; 24 vs. 24, p = 0.354, and 24 vs. 25, p = 0.536, respectively). The score of AI symptoms was altered in patients (27 vs. 30, p = 0.021). During fasting, the global AddiQoL score (8.2% vs. 0%, p = 0.005), the fatigue score (8% vs. −1.7%, p = 0.003), the emotional sphere score (4.2% vs. 0%, p = 0.009), and the AI symptoms' score (9.1% vs. 0%, p = 0.017) improved in patients compared to controls.

Conclusion

Ramadan fasting improved the quality of life in SAI patients by reducing fatigue, emotional stress, and AI symptoms.

Trial Registration

Registered on ‘ClinicalTrials.gov’ under the identifier ID: NCT05827965.

1. Background

Ramadan fasting (RF) is practised by more than one billion Muslims around the world. It is a dry intermittent fasting (IF) that consists of abstaining from eating, drinking, and medication intake from predawn to sunset [1]. The fasting period can last up to 22 h, depending on the region and the season. The duration of Ramadan is 29 or 30 days. Secondary Adrenal Insufficiency (SAI) is the most common form of adrenal insufficiency (AI) [2]. It is characterised by a glucocorticoid deficiency, with no mineralocorticoid deficiency, as aldosterone secretion mainly depends on the renin‐angiotensin system [3].

Only a few studies concerned RF in patients with SAI and evaluated the risk of complications and the consequences on the quality of life (QoL). So, RF in patients with AI was associated with complications such as intense asthenia, dizziness, headache, and signs suggestive of dehydration and hypoglycemia [4, 5, 6, 7]. In the same way, physicians' practices on RF in patients with AI are different. In a study, 76.7% of the patients were advised by their physician not to fast [4]. In another study, only 36.5% believed that patients with AI can fast [8]. Nearly half of the physicians (45.5%) believed that RF had an impact on glucocorticoid replacement therapy and required specific concern [9]. To prevent these complications while allowing patients with AI to fast safely, a literature review and guidelines for clinical practice on RF in patients with AI were published in 2021 [5]. It suggested a risk stratification of the patients and recommendations for fasting, including lifestyle measures, drug adjustment, and when to break the fast. Recently, it was shown that these measures enabled more patients with SAI to fast and reduced the frequency of complications during fasting [10]. The changes in QoL during RF in patients who received this therapeutic education remain unclear.

The study aimed to evaluate the impact of RF on the QoL in patients with SAI who received a therapeutic education compared to healthy controls.

2. Methods

Parts of the study design and the population characteristics have already been described in a previous publication that concerned the complications of RF in patients with SAI [10]. It was a single‐centre prospective interventional case‐control study carried out between March and April 2023 at the Department of Endocrinology in La Rabta University Hospital. The study included patients with SAI, aged 18 years or older, receiving glucocorticoid replacement therapy for at least 1 year, and wishing to fast during Ramadan 2023. Controls were fasting subjects with no AI and were selected to match patients for age, sex, and body mass index (BMI). Subjects with severe comorbidities including heart, respiratory, liver, or renal failure (creatinine clearance < 60 ml/min/1.73 m²), advanced neoplasia, undernutrition, diabetes insipidus, diabetes mellitus, neuro‐psychiatric disorders, infectious or chronic inflammatory diseases, hyperthyroidism, uncontrolled hypothyroidism, alcoholism, diuretic drug intake, use of glucocorticoids for indications other than AI, enzyme‐inducing drugs, and pregnant or breastfeeding women were excluded. Subjects were enrolled between March 1st and March 22nd, 2023. All subjects provided a written informed consent. The study was approved by the ethics committee of La Rabta University Hospital (CERB 1/2023).

During the first visit, patients were asked about their medical history and current treatments. The aetiology of SAI, other affected pituitary axes, serum cortisol level at diagnosis, and renal clearance were determined from the patient's medical file. Weight, height, and lying blood pressure (BP) were measured. Afterwards, all enrolled patients were provided with therapeutic education according to the guidelines published in 2021 [5]. Patients' knowledge about the disease was strengthened. Patients were advised to take a rich predawn meal as late as possible, have normal salt intake, and drink sufficient fluid during the non‐fasting periods. Vigorous physical activity and hot temperature exposure while fasting were prohibited. Patients were also advised to take the main dose of hydrocortisone at the predawn meal and the second dose at the sunset meal. The breaking of the fast was indicated if the patient experienced symptoms such as fever, vomiting, diarrhoea, in case of intercurrent illness, or the occurrence of any other sign of adrenal crisis. Education was provided by the same investigator in groups of two to three patients. A written form of the main education points was provided to each patient (Appendix 1).

Quality of life was evaluated using the Addison's disease Quality of Life Questionnaire (AddiQoL). It is a 30‐item questionnaire with a global score ranging from 30 to 120. It evaluates four domains of QoL: fatigue, emotional sphere, AI symptoms, and miscellaneous questions that include sexuality, sleep, and intercurrent diseases. Each domain is explored by 5 to 9 questions. There are two types of questions: positive questions and negative ones. Each positive question is graded from 1 to 4, and each negative question from 4 to 1, 1 being the worst score possible and 4 being the best score. The questionnaire was already translated into Arabic and used in former studies [11, 12]. Patients and controls responded to the questionnaire before Ramadan 2023, and then again during the third week of fasting. For the four patients and three controls unable to independently complete the questionnaire (non‐literate, elderly), the investigator did it on their behalf by asking them the questions and writing their answers before Ramadan and again during the third week of fasting by phone. Throughout the fasting month, all participants were also asked to complete follow‐up sheets detailing the number of fasting days, non‐fasting days, instances of breaking the fast, and the occurrence of any complications.

Ramadan 2023 started on March 23rd and ended on April 20th. The number of fasting days was 29. The fasting period, from predawn to sunset, lasted for a mean duration of 14 h and 22 min.

Fifty‐nine SAI patients were enrolled. Nine patients were excluded as they were lost to follow‐up [10]. Data from 50 patients and 100 age‐, sex‐ and BMI‐matched controls were analysed.

2.1. Statistical Analysis

Data were analysed using the Statistical Package for the Social Sciences version 21 (SPSS Inc., Chicago, IL, USA). Shapiro‐Wilk test showed that almost all continuous variables were not normally distributed. Data were expressed as median [Interquartile range (IQR)] for continuous variables and as a percentage for categorical ones. The variation of the AddiQoL score (Δ AddiQoL) was defined as the difference in the score during the third week of RF and the score before Ramadan divided by the score before Ramadan and expressed as a percentage. QoL was considered improved when Δ AddiQoL score was > 0 and non‐improved when Δ QoL score was ≤ 0. The non‐parametric Mann‐Whitney test was used to compare continuous variables of independent groups, and the Wilcoxon test was used to compare those of paired groups. Pearson's chi‐square and Fisher's exact tests were used to compare categorical variables of independent groups, and the Mc Nemar test was used to compare those of paired groups. Spearman's correlation analysis was used to assess the linear relationship between two continuous variables. The relationship was considered statistically significant when the p‐value was less than 0.05.

3. Results

3.1. Characteristics of the Population

The data of 50 patients (33 women) and 100 controls (66 women) were analysed. The median age was 43 years (IQR: 34–55) in the patients and 42 (IQR: 33–54) in the controls, p = 0.386. The median duration of SAI was 7.5 years (IQR: 4–12.5). All patients were treated with hydrocortisone at a median daily dose of 20 mg (IQR: 15–20), corresponding to 0.24 mg/kg (IQR: 0.20–0.28). Hydrocortisone was taken twice a day in 47 patients, three times a day in two cases, and once in one case. Thyrotropin deficiency was present in 22 patients (44%) who were substituted with l‐thyroxine at a mean dose of 96 ± 33 µg/day (25–150). Gonadotropin deficiency was present in 20 cases (40%). Ten men were taking testosterone, and two women were taking oestrogen and progesterone replacement therapy. Growth hormone deficiency was present in five patients (10%). It was not investigated in the others. None of the patients received growth hormone replacement therapy. Nearly half of the patients (52%) were not working (retired, unemployed, housewife), 17 (34%) had minimal to moderate physical work, and seven (14%) had moderate to intense physical work. None of them took any leave during Ramadan. All controls and 34 patients (68%) were former fasters, and 16 (32%) were new fasters. Like most Tunisians, the participants' religiosity is traditional and moderate.

The recommendations were overall respected during RF. The predawn meal was taken during the last hour before sunset in 27 cases (63%), between one and 2 h before the fasting in 15 cases (35%), and 3 h before in one case (2%). The main dose of hydrocortisone was taken during the last hour before dawn in 19 cases (38%), between one and 2 h before dawn in 28 cases (56%), and 3 h before dawn in one case (2%).

The median number of fasted days (IQR) was 26 (23–29) in patients and 29 (24–29) in controls, p = 0.098. More than half of the patients (62%) and 97% of controls fasted for the whole month of Ramadan, excluding menstruation days for women, p = 0.000. No case of adrenal crisis was observed during the fasting period. Complications occurred in 38 patients (76%) and 47 controls (47%), p = 0.001. Fasting was temporarily broken for a complication by 16 patients (32%) and three controls (3%), p = 0.001. The most frequent symptoms reported by patients were headache (64%), intense asthenia (60%), and orthostatic dizziness (54%).

3.2. Quality of Life Outside Ramadan Fasting

Before RF, the median global AddiQoL score, fatigue, emotional sphere, and miscellaneous questions scores were not different between patients and controls (Table 1). However, patients complained more about limitations in daily work, getting ill more easily, and taking a longer time to recover from illness. They also had more difficulties in thinking clearly than controls. Patients reported feeling more relaxed and sleeping better than controls. Nearly all questions exploring AI symptoms had a significantly lower score in patients. They complained of excessive sweating, headache, nausea, joint or muscle pain, and lower extremity weakness. Patients expressed serious concern about their health (Table 1).

Table 1.

Quality of life scores in patients with secondary adrenal insufficiency and controls before and during the third week of Ramadan fasting.

AddiQoL	Quality of life outside Ramadan fasting			Quality of life during Ramadan fasting
Quality of life domains, median (IQR)	Patients (n = 50)	Controls (n = 100)	p	Patients (n = 50)	Controls (n = 100)	p
Global score	89 (79–102)	93 (86–102)	0.196	101 (87–107)	94 (84–102)	0.007
Fatigue score	24 (19–27)	24 (22–27)	0.354	27 (24–29)	23 (21–26)	0.033
Q1. I feel good about my health	3 (2–4)	3 (2–4)	0.609	3 (3–4)	3 (2.25–4)	0.048
Q2. I can keep going during the day without feeling tired	3 (2–4)	3 (2–3)	0.702	3 (2.5–4)	3 (2–3)	0.018
Q3. Normal daily activities make me tired	3 (2–4)	3 (3–4)	0.228	4 (3–4)	3 (3–3)	0.014
Q4. I have to struggle to finish jobs	3 (2–4)	3 (3–4)	0.429	3 (2–4)	3 (2–4)	0.750
Q5. I have to push myself to do things	3 (2–4)	3 (3 – 4)	0.622	4 (3–4)	3 (3–4)	0.138
Q23. My ability to work is limited	3 (2–4)	4 (3–4)	0.002	4 (3–4)	3 (3–4)	0.211
Q26. I feel full of energy	3 (2–3)	3 (2–3)	0.791	3 (2–4)	3 (2–3)	0.051
Q27. I feel physically fit	3 (2.8–3)	3 (2–3)	0.629	3 (3–3)	3 (2–3)	0.459
Emotional sphere score	24 (20–28)	25 (23–26)	0.536	27 (23–29)	25 (22–27)	0.019
Q11. I am relaxed	3 (2–4)	3 (2–3)	0.030	3 (3–4)	3 (2–3)	0.001
Q12. I feel low or depressed	3 (3–4)	3 (3–4)	0.186	4 (4–4)	3 (3–4)	0.001
Q13. I am irritable	2.5 (2–3)	3 (3–3)	0.233	3 (2–4)	3 (3–3)	0.369
Q14. I find it difficult to think clearly	3 (2–4)	3 (3–4)	0.016	3 (2–4)	3 (3–4)	0.528
Q15. I am lightheaded	3 (3–4)	4 (3–4)	0.112	3 (3–4)	4 (3–4)	0.130
Q24. I can concentrate well	3 (2–4)	3 (3–3)	0.727	4 (3–4)	3 (3–3)	0.433
Q25. I am happy	3 (3–4)	3 (3–3)	0.659	3 (3–4)	3 (3–3)	0.006
Q30. I cope well in emotional situations	3 (3–3)	3 (3–3)	0.741	3 (3–4)	3 (3–3)	0.729
Adrenal insufficiency symptoms score	27 (23–32)	30 (27–33)	0.021	30 (26–33)	31 (28–33)	0.910
Q6. I lose track of what I want to say	3 (2–4)	3 (2.3–3)	0.876	3 (2–3.5)	3 (3–3.7)	0.417
Q9. I feel unwell first thing in the morning	3 (3–4)	3 (3–4)	0.428	4 (3–4)	3 (3–4)	0.038
Q16. I sweat for no particular reason	3 (3–4)	4 (3–4)	0.034	4 (3–4)	4 (4–4)	0.112
Q17. I get headaches	3 (2–3)	3 (3–4)	0.006	3 (2.5–4)	3 (3–4)	0.674
Q18. I get nauseous	4 (3–4)	4 (3.3–4)	0.027	4 (3–4)	4 (3–4)	0.108
Q19. My joints and/or muscles ache	3 (2–3.2)	3 (3–4)	0.039	4 (3–4)	3 (3.5–4)	0.913
Q20. I have back pain	3 (2–4)	3 (3–4)	0.898	4 (3–4)	3 (3–4)	0.338
Q21. My legs feel weak	3 (2–4)	4 (3–4)	0.037	3 (3–4)	3 (3–4)	0.556
Q22. I worry about my health	3 (2–4)	3 (3–4)	0.003	4 (2.5–4)	4 (3–4)	0.272
Miscellaneous questions score	15 (13–18)	15 (13–17)	0.861	17 (14–18)	15 (13–17)	0.141
Q7. I sleep well	4 (3–4)	3 (2–4)	0.042	4 (2–4)	3 (2–4)	0.182
Q8. I feel rested when I wake up in the morning	3 (2–4)	3 (2–3)	0.120	4 (2–4)	3 (2–3.7)	0.013
Q10. I am satisfied with my sex life	4 (2–4)	3 (2–4)	0.246	4 (3–4)	3 (2.5–4)	0.032
Q28. I get ill more easily than others	3 (2–3)	3 (3–4)	0.000	3 (3–4)	3 (3–4)	0.003
Q29. I take a long time to recover from illness	3 (2–3)	3 (3–4)	0.003	3 (3–3)	3 (3–4)	0.045

Note: Data are expressed as median (interquartile range).

The study of the factors associated with the QoL of the patients with SAI showed that the global AddiQoL score was higher in men than in women [102 (90–111) vs 86 (74–95), p = 0.000]. Serum cortisol level at diagnosis was correlated with the global AddiQoL score (Table 2).

Table 2.

Correlations between clinical and biological parameters and AddiQoL global score before Ramadan fasting in patients with secondary adrenal insufficiency.

	AddiQoL score before Ramadan
	r	P
Age	−0.113	0.436
Disease duration	−0.117	0.419
Daily hydrocortisone dose	0.173	0.230
BMI	−0.142	0.326
SBP	0.078	0.590
DBP	0.118	0.414
Renal clearance	0.216	0.154
Serum cortisol level at diagnosis	0.363	0.013

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; SBP, systolic blood pressure; r, correlation coefficient.

3.3. Quality of Life During Ramadan Fasting

The median global AddiQoL score, fatigue, and emotional sphere scores were higher in patients than in controls (Table 1). Patients felt better about their health, got less tired, felt more relaxed, less depressed, and happier, and were more satisfied with their sexual life than controls. The score of AI symptoms was not different between the two groups during Ramadan. Patients reported feeling less morning unwellness than controls (Table 1).

3.4. Impact of Ramadan Fasting on the Quality of Life of Patients With SAI

The global AddiQoL score increased by 8.2% after 3 weeks of RF in patients (p = 0.002), the fatigue score increased by 8% (p = 0.010), the emotional sphere score by 4.2% (p = 0.020), the AI symptoms score by 9.1% (p = 0.000). There was no change in the score for miscellaneous questions. The global score, fatigue, emotional sphere, and AI symptoms scores significantly improved during RF in patients compared to controls (Figure 1). Quality of life improved in 35 patients with SAI (70%), was stable in 2 (4%) and worsened in 13 (26%). There were no significant differences in clinical and biological parameters between patients with improved QoL and those with non‐improved QoL during RF (Table 3).

Figure 1.

The differences in AddiQoL score between Ramadan fasting and outside Ramadan fasting in patients with secondary adrenal insufficiency and controls.

Table 3.

Clinical and biological parameters of patients with secondary adrenal insufficiency according to the variation of the quality of life during Ramadan fasting.

	Quality of life during Ramadan fasting
	Improved (n = 35)	Non‐improved (n = 15)	p
Age (years)	43 (35–57)	43 (26–54)	0.421
Female	24 (69)	9 (60)	0.558
Disease duration (years)	8 (4–11)	7 (3–20)	0.758
Daily hydrocortisone dose (mg/kg)	0.24 (0.21–0.27)	0.26 (0.20–0.31)	0.735
Global AddiQoL score before Ramadan	89 (79–97)	95 (72–112)	0.211
BMI (kg/m2)	28.9 (24.5–32.0)	29.2 (19.8–34.3)	0.799
SBP (mmHg)	120 (110–130)	110 (100–130)	0.349
DBP (mmHg)	70 (60–80)	60 (60–70)	0.303
Renal clearance (ml/min/1.73 m2)	105 (95–137)	111 (90–156)	0.745
Serum cortisol level at diagnosis (nmol/l)	165 (83–248)	248 (110–359)	0.095
Number of fasted days	28 (24–29)	25 (11–29)	0.128
Complications during fasting	26 (74)	12 (80)	1.000

Note: Data are expressed as median (interquartile range) for continuous variables and number (percentage) for categorical ones.

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; SBP, systolic blood pressure.

4. Discussion

Outside RF, QoL was overall not different in patients and controls, except for symptoms of AI. During the third week of fasting and after the patients received a therapeutic education, the AddiQoL global score, fatigue score, emotional sphere score, and AI symptoms score significantly improved in patients compared to controls.

4.1. Quality of Life in Patients With Adrenal Insufficiency Outside Ramadan Fasting

Few studies evaluated QoL in patients with AI. All these studies observed an impairment in the QoL at variable degrees of severity [13, 14, 15, 16]. In this study, there was no significant difference between the global AddiQoL score, the fatigue score, and the emotional sphere score between patients and controls before Ramadan. However, some aspects of QoL were altered in patients, such as the ability to work and to think clearly. Symptoms of AI were significantly more frequent in patients than in controls. Concern about one's health, a greater frequency of intercurrent diseases, and a longer recovery period were also noted. Indeed, this may be due to cortisol deficiency throughout the day. A multicentric study conducted in 2015 in France evaluated self‐perceived subjective health in 94 patients with AI receiving glucocorticoid replacement therapy. Twenty‐one per cent of patients considered themselves unable to work or were on sick leave due to their disease. Thirty‐eight per cent were absent from work or school over the past 3 months because of AI symptoms [17]. Another study assessed QoL in 529 patients with AI in the USA using the SF‐36 questionnaire. The patients described poor physical well‐being compared to healthy controls [18].

The QoL was also studied in patients receiving other glucocorticoid replacement therapies. The QoL was evaluated by three different questionnaires (SF‐36, Giessen Complaint List (GBB‐24), and Hospital Anxiety and Depression Scale) in 427 patients with primary AI treated with either hydrocortisone or prednisolone. It showed an altered QoL with no differences in these scores between the two molecules [14]. Mongioi et al. and Giordano et al. showed an improvement in the QoL of patients with AI after the switch from hydrocortisone to dual‐release hydrocortisone [19, 20].

Besides the type of glucocorticoid replacement therapy, other factors have been implicated in the QoL in patients with AI. As in the present study, male sex was associated with a better QoL the study of Zdrojowy‐Wełna et al. [21]. A younger age was also associated with a better QoL [21]. Higher serum cortisol levels at diagnosis were associated with a better QoL in the present study, probably indicating a less severe cortisol deficiency.

4.2. Quality of Life of Healthy Individuals During Ramadan Fasting

A few studies evaluated QoL during RF in healthy individuals. The present study showed no change in the QoL in the control group. Nugraha et al. showed that QoL domains (fatigue, mood, and sleepiness during daytime) were not different in fasting and non‐fasting healthy subjects during Ramadan [22]. Lauche R et al. showed that satisfaction with health, ease of life, and mindfulness significantly improved during RF in the group that received lifestyle and dietary education compared to the conventional group [23]. These data showed that RF does not impair the QoL in healthy individuals and can even improve it.

4.3. Quality of Life in Patients With Adrenal Insufficiency During Ramadan Fasting

We observed a significant improvement in the QoL during RF in patients with AI. Quality of life improved despite a higher frequency of complications during fasting in the patients (76% vs. 47% in controls, p = 0.001), which were mainly headache (64%), intense asthenia (60%), and orthostatic dizziness (54%). No severe complications occurred. The improvement of the QoL can be explained by the pride felt by the patients with AI in the ability to fast during the holy month of Ramadan. Hence, RF was described as a ‘feeling of empowerment’ or ‘being a good Muslim believer’ [24]. The ability to fast made the patients proud and reassured them about their healthcare. This is why most patients seek comfort in fasting, making them feel like other healthy individuals.

A previous cross‐over study compared QoL in 53 patients with SAI treated either with hydrocortisone or prednisolone showed no difference in AddiQoL score between the two molecules [12]. The global score before Ramadan was lower than in the present study (median (IQR) = 81 (48–114) vs 89 (79–102), respectively), with no increase during RF (median (IQR) = 81 (39–115) vs 101 (87–107) during fasting, respectively). The improvement of the QoL in the present study, particularly in AI symptoms, can be attributed to the effects of the therapeutic education performed before Ramadan and the close medical support throughout the fasting month by one of the investigators. Another study showed an improvement in QoL SF‐36 score during RF in 20 patients with AI treated with prednisolone 5 mg a day, particularly in role limitations due to physical health problems and bodily pain [25].

No clinical or biological parameter was associated with the improvement or not of the QoL during fasting in patients with SAI. Particularly, disease duration, daily hydrocortisone dose, and renal clearance were not associated with the variation in the QoL. Also, the number of fasted days and the frequency of complications during fasting were not associated with the variation in the QoL.

This was a prospective study including patients with SAI receiving glucocorticoid replacement therapy and a double number of healthy age‐, sex‐, and BMI‐matched controls. To our knowledge, it is the first study that evaluated the variation of AddiQoL score before and during RF between patients with SAI and matched controls. We excluded other pathologies, such as diabetes and uncontrolled hypothyroidism, which can interfere with fasting and QoL. The questionnaire was mainly self‐administered by the patients and the controls, reducing reporting biases. Some limitations should be acknowledged. As there is no specific questionnaire for SAI, we used the AddiQoL questionnaire, which is a specific questionnaire for primary AI, including questions about signs related to undertreatment with glucocorticoids. In fact, the main concern during fasting is replacement therapy with glucocorticoids and the risk of undertreatment, which could lead to adrenal crisis. The same questionnaire was used to evaluate QoL in the patients and the controls to enable comparisons. Growth hormone and gonadotropin deficiencies are known to negatively impact QoL [26, 27, 28]. Growth hormone can particularly increase the risk of hypoglycemia, mainly in children. In the present study, we compared the same patients during two different periods where Ramadan fasting was the only difference.

Therapeutic education and drug adjustment for RF in patients with SAI enabled more patients to fast with a lower prevalence of complications [10] and an improvement in the QoL. More studies are needed to determine the most appropriate management of SAI during fasting.

5. Conclusion

Quality of life improved during RF in patients with SAI who received a therapeutic education compared to healthy controls. There was less fatigue, emotional stress, and AI symptoms. Age, sex, duration of the disease, and the dose of hydrocortisone were not associated with the improvement of the QoL.

Author Contributions

Melika Chihaoui, Ibtissem Oueslati, and Mariam Mabrouk conceived and designed the study, Mariam Mabrouk carried out clinical investigations, all authors analyzed and discussed the data, Melika Chihaoui wrote the first draft of the manuscript. All authors critically revised and approved the final version of the manuscript.

Ethics Statement

All procedures performed in studies involving human participants were in accordance with the ethical standards and with the 1964 Helsinki Declaration. Approval was granted by the Ethics Committee of La Rabta University Hospital (reference number: CERB 1/2023).

Consent

Written informed consent was obtained from all individual participants included in the study.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Appendix 1.