Key Messages
(i) What is already known: Intermittent fasting, including Ramadan fasting, has been linked to metabolic and anti-inflammatory benefits in healthy adults; occupational health implications for workers in high-risk sectors remain largely underexplored.
(ii) What this study adds: This review bridges clinical evidence on Ramadan fasting physiology with Italian occupational health legislation (Legislative Decree 81/2008) and Islamic jurisprudence exemptions, proposing a practical framework for occupational physicians.
(iii) How this might impact practice: Occupational health physicians gain evidence-based recommendations for individualized risk assessment, work schedule adaptation, and culturally sensitive communication with Muslim workers in construction, logistics, and shift-work settings.
Summary
Ramadan fasting shares a structural resemblance to the 16:8 intermittent fasting model that has drawn considerable research attention over the past decade. For Italian occupational medicine, this is no longer a niche question. Approximately 1.2–1.6 million workers in Italy come from Muslim-majority countries—many of them in construction, logistics, and manufacturing—and they fast for up to 18–20 hours a day when Ramadan falls in summer. This review examines what the evidence says about the metabolic effects of Ramadan fasting, the genuine health benefits it can confer, and—crucially from a clinical standpoint—the risks it poses in specific occupational contexts. Dehydration, hypoglycemia, and fatigue are the obvious concerns. Less discussed are the risks for workers with silent nephrolithiasis, and the practical problem of conducting biological monitoring during a month when plasma volume and nutritional status are anything but stable. Ramadan also represents an underused health promotion opportunity: since smoking invalidates the fast under Islamic jurisprudence, this month offers a uniquely motivated window for smoking cessation counselling among Muslim workers. The regulatory framework for all of this, in Italy, is Legislative Decree 81/2008.
1. Introduction
Intermittent fasting—broadly, any pattern that alternates deliberate food restriction with normal eating—has accumulated a substantial evidence base over the past two decades [1,2]. The 16:8 protocol is the variant most studied under controlled conditions. Ramadan fasting follows a strikingly similar structure: Muslims abstain from food, water, and certain other activities from dawn (Fajr prayer) until sunset (Maghrib prayer) for 29–30 consecutive days. It is not a diet—it is a religious obligation. That distinction matters clinically, because the motivational and social dynamics around Ramadan fasting are fundamentally different from those of elective protocols.
Italy has somewhere between 1.2 and 1.6 million active workers from Muslim-majority countries—Morocco, Albania, Pakistan, Bangladesh, and Egypt are the most represented nationalities—though INPS statistical data do not disaggregate by religion, so this estimate is the author’s own elaboration from nationality-based figures [3,4]. Add to this the UCOII estimate of approximately 100,000 Italian-born Muslims, and the picture is clear: fasting workers are present across virtually all Italian workplace sectors, and are disproportionately concentrated in higher-risk ones [5,6]. Construction sites, logistics platforms, waste collection services—these are where the occupational physician’s attention is most needed during Ramadan.
The fasting window varies considerably by season and latitude. When Ramadan falls in winter, the fast may last only 10–12 hours. In summer in northern Italy, it can extend to 18–20 hours. The Islamic calendar is roughly 11 days shorter than the Gregorian, so Ramadan cycles through all seasons over approximately 33 years [1,7]. Occupational physicians should bear the summer scenario in mind when advising workers about risk in the coming years.
An important caveat before proceeding: most metabolic research on intermittent fasting involves healthy volunteers under controlled conditions, with standardized meals and sleep schedules. Real Ramadan fasting is embedded in cultural, family, and social contexts—late-night gatherings, disrupted sleep, highly variable Iftar composition. The Italian National Institute of Health (ISS) and the Italian Society of Human Nutrition (SINU) both caution against uncritical extrapolation of controlled fasting benefits to populations with pre-existing conditions [8].
This review aims to synthesize available evidence on the physiological effects and health risks of Ramadan fasting, and to translate it into a practical framework for occupational physicians operating under Italian Legislative Decree 81/2008 (Testo Unico sulla Sicurezza sul Lavoro).
2. Methods
This is a narrative review. The literature search covered PubMed, Scopus, and Google Scholar for publications from 2010 to 2025, using the following terms: “intermittent fasting,” “Ramadan fasting,” “metabolic switch,” “autophagy,” “microbiota.” General PRISMA principles were followed, without formal prospective protocol registration. Priority was given to meta-analyses, randomized controlled trials, and large observational studies. Studies involving fewer than 10 participants or without a comparison group were excluded unless explicitly designated as pilot studies with appropriate methodological transparency [9]. Italian regulatory documents, INAIL guidelines, and grey literature on Ramadan and workplace safety were also consulted. No ethical approval was required, as this study does not involve human participants.
3. Results
A preliminary note on risk framing: fasting is not inherently dangerous. For healthy adults without chronic conditions, it is generally well tolerated. Clinical and occupational concern is concentrated in specific subgroups—diabetic workers, those with renal or cardiovascular disease, pregnant or lactating women, the elderly—and in specific job tasks where impaired vigilance, dehydration, or hypoglycemia can translate directly into injury.
3.1. Temporal Sequence of Metabolic Changes
3.1.1. Up to approximately 12 hours: glycogen depletion phase
In the first hours of fasting, energy metabolism runs on circulating blood glucose and hepatic glycogen. This phase is essentially a continuation of normal post-absorptive physiology; lipolysis begins but remains modest, and protein catabolism is minimal [10]. The transition point—when glycogen is sufficiently depleted that the organism must shift strategy—occurs somewhere between 10 and 14 hours, depending on body composition, habitual diet, and activity level [1,11]. For a sedentary office worker, this may not happen until hour 12 or 13. For someone doing manual labour in summer heat, it can happen earlier.
3.1.2. From 12 to 20 hours: metabolic switch to ketone bodies
Once hepatic glycogen is sufficiently depleted, the organism shifts toward ketone body production as an alternative fuel—what Anton et al. aptly termed the “metabolic switch” [7]. AMPK is activated, mTOR is suppressed, and fatty acid oxidation increases. Ketogenesis at this stage is generally mild, not the deep ketosis of prolonged starvation, but physiologically meaningful [1,11]. Associated with this shift, at least in structured protocols, are improvements in insulin sensitivity, appetite reduction, and anti-inflammatory signalling [1,2,12]. Whether these effects translate reliably to real-world Ramadan fasting—with its disrupted sleep, variable Iftar composition, and high social caloric load—is more complicated. The evidence is suggestive but not conclusive [1,11].
3.2. Cellular-Level Effects
3.2.1. Insulin sensitivity and glycemic profile
A meta-analysis of daytime Ramadan fasting found modest but significant improvements in fasting glucose in healthy subjects (Hedges’ g = 0.150; 95% CI: 0.064–0.236), though inter-study heterogeneity was high [1]. Insulin sensitivity results are more mixed: some observational studies found meaningful reductions in fasting insulin and HOMA-IR (p=0.005 and p=0.009 respectively), while others found no effect [1,11]. These discrepancies probably reflect differences in meal quality at Suhoor and Iftar, sleep disruption, and whether workers are losing fat mass or simply water weight.
3.2.2. Autophagy and cellular repair
Autophagy—the cellular self-cleaning process that removes damaged organelles and misfolded proteins—is one of the more compelling biological rationales for fasting. Mindikoglu et al. (2020) reported that 30 days of dawn-to-sunset fasting was associated with an “anticancer proteomic signature,” including upregulation of proteins involved in DNA repair, lipid metabolism, and circadian rhythm regulation [11]. These findings are biologically plausible and consistent with preclinical autophagy data [12,13]. That said, the leap from proteomic signatures to longevity or cancer prevention in humans remains unproven—the clinical trial evidence is simply not there yet [2,14].
3.2.3. Inflammatory marker reduction
On inflammatory markers, the picture is relatively consistent. A meta-analysis found significant reductions in IL-6 (Hedges’ g = 0.407), TNF-α (Hedges’ g = 0.371), and CRP/hs-CRP (Hedges’ g = 0.119) following Ramadan fasting in healthy adults, with the CRP reduction more pronounced in non-obese individuals [1]. These are modest effect sizes, but directionally meaningful for occupational medicine, where chronic low-grade inflammation contributes to musculoskeletal disease burden.
3.3. Systemic Health Effects
Systemic effects depend heavily on who is fasting and how. Genetic background, habitual diet, gut microbiota composition, medication use, and the composition of Suhoor and Iftar meals all modulate outcomes. The figures below should be read as population estimates, not predictions for individual workers.
3.3.1. Cardiometabolic health
The LORANS (London Ramadan Study) cohort showed post-Ramadan reductions of −7.29 mmHg systolic (95% CI: −4.74 to −9.84) and −3.42 mmHg diastolic (95% CI: −1.73 to −5.09)—clinically relevant figures for workers on antihypertensive medications, whose doses may need temporary adjustment [15]. A companion meta-analysis of 33 studies found smaller but consistent mean reductions: −3.19 mmHg systolic and −2.26 mmHg diastolic, attributed to weight loss, diuresis, and reduced sympathetic tone [15]. Lipid profiles also tend to improve: post-Ramadan HDL rises (p=0.01), LDL falls (p=0.03), total cholesterol falls (p=0.03), though triglycerides are inconsistent—likely reflecting the fried foods common in Iftar traditions [1,15,16].
3.3.2. Body composition
Fernando et al. (2019) found a mean weight reduction of −1.34 kg (95% CI: −1.61 to −1.07; p<0.001) after Ramadan in healthy non-athlete adults, with fat mass accounting for the majority of loss [9]. Effects were more pronounced in overweight and obese individuals. Worth noting: most parameters returned toward baseline within 2–5 weeks post-Ramadan. This is not a lasting weight loss intervention. For occupational purposes, the main implication is that body composition, plasma volume, and cardiovascular tolerance to physical exertion may be temporarily altered during the month.
3.3.3. Gut microbiota
Özkul et al. (2019), in a pilot study of nine participants (17 fasting hours/day, 29 days), documented significant increases in Akkermansia muciniphila (p=0.004) and Bacteroides fragilis (p=0.008), with concurrent reductions in fasting glucose and total cholesterol [14]. Pramono et al. (2024) confirmed phenotype-dependent microbiota modulation by intermittent fasting in a systematic review [17]. The findings are biologically plausible. The caveat is that the Özkul study involves nine people and no control group—causal conclusions are premature.
3.3.4. Cancer-related metabolic markers
Al-Jafar et al. (2024) applied metabolomics to 37 healthy fasting subjects and found that Ramadan fasting reduced GlycA—an acetylated glycoprotein marker of chronic inflammation linked to genomic instability [18]. Metabolic risk scores for lung cancer (−9.6%; p<0.001), colorectal cancer (−2.4%; p<0.001), and breast cancer (−1.1%; p=0.006) declined significantly, driven primarily by GlycA changes. These are surrogate marker data. They do not establish that fasting prevents cancer. The metabolic switch hypothesis is supported by preclinical autophagy research but remains unvalidated in human clinical outcomes [2,11,12,13].
3.4. Risks and Limitations of Fasting
Ramadan fasting is not risk-free. Islamic law acknowledges this: the Quran (Sura Al-Baqarah, 2:185–186, 195) explicitly exempts those for whom fasting would cause harm. The challenge for the occupational physician is identifying who falls into that category before something goes wrong at work.
Diabetic workers carry the highest documented risk. The EPIDIAR study—covering 12,243 patients across 13 countries—found severe hypoglycemic episodes increased 4.7-fold in type 1 diabetes (0.14 vs. 0.03 episodes/month; p=0.0174) and 7.5-fold in type 2 diabetes (0.03 vs. 0.004 episodes/month; p<0.0001) during Ramadan [19]. The ADA and the Italian Diabetes Society (SID) recommend close glycemic monitoring, medication dose adjustment, and hydration support for fasting diabetic patients [19,20]. Pregnant and lactating women, elderly workers (>65 years, at risk for sarcopenia and orthostatic hypotension), and those with cardiovascular, hepatic, or eating disorders all represent additional risk categories.
A risk that receives less attention—partly because it presents silently until it does not—is nephrolithiasis. Fasting from dawn to sunset during summer means 18–20 hours of total fluid restriction. For workers with asymptomatic kidney stones or subclinical chronic kidney disease, this level of dehydration can trigger acute ureteral colic in circumstances where the stone would otherwise have remained quiescent. In the author’s clinical practice, this has not been a theoretical concern: several Muslim workers presented to emergency services during Ramadan with first-ever episodes of renal colic, subsequently found to have pre-existing nephrolithiasis that had never previously caused symptoms. Pre-Ramadan assessment should therefore include renal function screening and urinary tract evaluation for workers in heat-exposed or physically demanding roles, even when they are asymptomatic.
Ramadan is also, unexpectedly, a health promotion opportunity. Smoking is considered haram during fasting hours under Islamic jurisprudence—it invalidates the fast. A smoker who observes Ramadan strictly therefore abstains from tobacco for 14 to 20 hours daily, for an entire month. That is a pharmacologically meaningful period of repeated daily abstinence, reinforced by a powerful religious motivator. Occupational physicians conducting pre-Ramadan fitness-for-duty assessments are well placed to channel this motivation: brief counselling, nicotine replacement therapy during non-fasting hours, and structured cessation support can all be offered at this visit. The religious commitment provides a reinforcement that secular cessation programmes rarely achieve.
3.5. Occupational Health Implications
Under D.Lgs. 81/2008, the medico competente is responsible for evaluating individual fitness for work, and prolonged fasting that may impair vigilance, thermoregulation, or cardiovascular stability falls within this remit. In high-risk sectors—construction, logistics, shift work—schedule adaptations, temporary task reallocation, or specific monitoring plans may be warranted [5,6].
The INAIL operational guidelines (Casucci et al., 2014) offer a practical checklist for employers: identify fasting workers; flag high-risk individuals to the occupational physician; redistribute physical workloads; ensure access to rest and recovery spaces; stock water, ice, and mineral salts; coordinate emergency procedures; and train supervisors with cultural mediators [5]. These measures integrate naturally with the D.Lgs. 81/2008 risk management framework.
Italy’s climate adds another layer of complexity. In the Po Valley and much of the south, summer temperatures routinely exceed 35°C. A worker fasting 18–20 hours in that environment faces a compounding of thermal stress and physiological depletion—reduced plasma volume, impaired thermoregulation, lower blood pressure, slower reaction times. Add hypoglycemia, and the risk profile becomes acute for anyone working at height, operating machinery, or in confined spaces [5,8].
One job category that deserves specific mention is waste collection. Workers in this sector routinely hang from the rear platform of collection vehicles while the truck moves between stops. The author has personally observed episodes of pre-syncope and acute lightheadedness in waste collection workers during summer Ramadan shifts, arising from the combination of dehydration, postural cardiovascular stress, and ambient heat. A transient loss of grip strength or consciousness in this position can be fatal. Individual reassessment before Ramadan is advisable for these workers, and temporary reassignment to driving or indoor roles should be considered where the risk cannot be adequately controlled.
Other risks worth flagging: electrolyte disturbances (hypokalemia, hypomagnesemia) in workers with high sweat rates; gallstone formation from prolonged gallbladder contraction; gastroesophageal reflux from large Iftar meals; and metabolic rebound if Iftar is heavily caloric (>50% from sugars and saturated fats), which can abort the ketogenic phase, spike insulin, and negate the metabolic benefits of the preceding fast.
Biological monitoring during Ramadan requires a specific note. Blood sampling late in the fasting day—afternoon, before Iftar—is problematic. Hemoconcentration from dehydration inflates hemoglobin, erythrocyte indices, and serum protein values; certain toxicological markers, metals in particular, can appear artificially elevated beyond what reflects true occupational exposure. Conversely, sampling shortly after Iftar introduces postprandial confounding. In the author’s experience managing occupational biological monitoring programs, the most practical approach is to defer non-urgent sampling to the post-Ramadan period wherever feasible. When deferral is not possible, the fasting duration and time elapsed since the last meal should be explicitly documented in the laboratory report, so that results can be interpreted in the appropriate physiological context.
Practical clinical recommendations for the medico competente: a pre-Ramadan fitness-for-duty review covering comorbidities, current medications, and the worker’s previous fasting history; proactive coordination with treating physicians for temporary adjustments to hypoglycemics, antihypertensives, and diuretics; clear worker education on hydration strategies during non-fasting hours, Iftar composition, and warning signs requiring medical attention; and communication that offers guidance, not prohibition. Most Muslim workers understand both their bodies and their religious obligations. The physician’s job is to help them fast safely, not to discourage a practice that is central to their religious identity.
Islamic jurisprudence (fiqh) provides explicit exemptions for workers whose health is genuinely at risk—the ill, the traveller, the elderly, the pregnant. The occupational physician who knows these exemptions can give workers a medically grounded basis for consulting their religious authority about a dispensation. This is often more acceptable to the worker than a physician’s unilateral recommendation, and it integrates prevention with the cultural respect that D.Lgs. 81/2008 ultimately requires.
4. Discussion
The evidence reviewed here supports a nuanced position: Ramadan fasting is neither the metabolic panacea it is sometimes presented as in popular media, nor the straightforward occupational hazard that a reflexively risk-averse reading of D.Lgs. 81/2008 might imply. For most healthy workers, the month passes without serious incident. For a specific subset—workers with metabolic or renal disease, those in high-risk job tasks, those fasting in summer heat—careful pre-Ramadan planning is not optional [1,2,5,6,8,10,11].
The metabolic benefits are real but conditional. Improvements in insulin sensitivity, inflammatory markers, and body composition are consistently reported across the literature, but they materialize reliably only when meals are nutritionally balanced, sleep disruption is limited, and workers are not under severe physical or thermal stress. Under the occupational conditions most relevant to Italian high-risk sectors, some of these conditions simply do not hold [13,14,15,16].
The clinical observations reported in this review—pre-syncopal episodes in rear-platform waste workers, acute renal colic in workers with previously silent nephrolithiasis, and confounded biological monitoring results—are not exceptional cases. They are the kind of cases that accumulate quietly in occupational medicine practice in northern Italy without ever making it into a prospective study design. Bringing them into print is one way to begin closing the gap between published evidence and clinical reality for Italian occupational physicians.
The smoking cessation opportunity merits emphasis. Occupational medicine has a long tradition of using workplace contact to deliver public health interventions that would not otherwise reach certain populations. Muslim workers who are observing Ramadan correctly are already doing something pharmacologically significant—abstaining from tobacco for 14 to 20 hours a day for a month. Structured cessation support at the pre-Ramadan visit costs little and can make a meaningful difference.
This review has limitations that should be stated clearly. The literature on Ramadan fasting and metabolism is predominantly from Middle Eastern and Southeast Asian populations, not European workers performing the specific tasks that Italian occupational medicine encounters. Prospective data on occupational injury rates, productivity, and biological monitoring validity during Ramadan in Italy do not exist. Publication bias likely inflates the apparent metabolic benefits. What is needed—and what this review cannot provide—is prospective multicenter European data, controlled trials of workplace accommodation strategies, and health economic analyses of Ramadan-related productivity changes.
5. Conclusions
Ramadan fasting matters for Italian occupational medicine—not as a curiosity, but as a recurring annual event involving over a million workers in some of the country’s highest-risk sectors. The metabolic evidence is genuinely interesting and, for most workers, broadly reassuring. The occupational risks are real and manageable—but only if the medico competente takes the trouble to identify vulnerable workers before the month begins, not when they present to the emergency department. Biological monitoring should be deferred or interpreted with documented caution. Workers with silent renal disease need pre-screening. Waste collection workers on rear platforms warrant individual risk reassessment. And the smoking cessation opportunity—perhaps the single most actionable public health implication of this review—should not be passed over. The occupational physician who approaches Ramadan with preparation, cultural sensitivity, and a clear regulatory framework is in a position to make that month safer for the workers who observe it.
Supplementary Materials: Not applicable.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable. This study is a narrative review of published literature and does not involve human participants or animals.
Informed Consent Statement: Not applicable.
Acknowledgments: The author acknowledges the PROMUS Association for their support.
Declaration of Interest: The author declares no conflict of interest.
Author Contribution Statement: T.T. conceived and designed the review, conducted the literature search, performed the data synthesis, and wrote the manuscript as sole author.
Declaration on the Use of AI: The author used AI-assisted tools (Perplexity AI) for literature search support, language drafting assistance, and initial text organization. The author assumes full responsibility for the final content, including the accuracy of all scientific claims, data interpretation, and bibliographic references, which were independently verified against primary sources. No AI tool was used in the study design, critical appraisal, or formulation of conclusions. AI tools were not listed as authors, in accordance with ICMJE recommendations.
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