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The Effects of Dietary Fasting On Physical Balance Among Healthy Young Women
The Effects of Dietary Fasting On Physical Balance Among Healthy Young Women
The Effects of Dietary Fasting On Physical Balance Among Healthy Young Women
http://www.nutritionj.com/content/9/1/18
Abstract
Background: The study examined the effects of dietary fasting on physical balance among young healthy women.
Methods: This study undertaken involving 22 young healthy women (age = 22 ± 1.5) using a within subject
counterbalanced 2-week crossover study design. Participants were asked to refrain from consuming any food or
beverage for 12 hours prior to the fasting trial and to maintain their regular diet for the non-fasting trial. Measures
included: a background questionnaire, 24-hour dietary recall, and functional reach and timed single-limb stances.
Results: Fasting resulted in significant declines in functional reach (p < 0.01), and ability to balance in a single limb
stance with eyes open, on both the dominant and non-dominant legs (p < 0.01 and p < 0.01, respectively), and with
eyes closed on the dominant leg (p < 0.01).
Conclusions: The findings have implications for athletic performance in younger individuals as well as emphasizing
the need for health education for young women to avoid skipping meals.
individuals have an increased balancing ability over sed- elite men such as athletes or soldiers [17-20]. None of the
entary individuals of a similar stature [15]. However, over studies involved individuals from the general population
the short-term, fatiguing exercise has been shown to or women. As indicated earlier sex differences in the abil-
reduce balance [16]. While physical activity and nutrition ity to maintain balance have been reported [13,14]. In
are important parts of overall health, limited research, to addition, young women are more likely to skip meals and
date, has examined the specific relationship between not eat for extended periods of time due to a self-imposed
nutrition and balance. The few studies that do exist have weight loss strategy. Studies have examined the role of
used balance tests as a secondary measurement within an skipping breakfast on cognition but not physical function
overall study of nutrition and performance among elite in general and balance in particular with young women
male athletes, and show that a decrease in dietary intake [27]. Thus, the purpose of this study was to examine the
negatively affects one's ability to maintain balance [17- effects of dietary fasting on physical balance among
20]. young women.
Fasting is a state of nutritional imbalance, which is gen-
erally characterized by an absence or interruption of Methods
caloric intake over a period of time [21]. Physiologically, Participant selection and study design
the body shifts into a state of early fasting, also known as A sample of 22 Caucasian women was recruited for this
a post-absorptive state, 3 to 12 hours after eating. After study. Given the lack of research in this area involving
12 hours of fasting, the post-absorptive state shifts to that young healthy women, power analysis was not per-
of a fasting state, which is characterized by hypoglycemia formed. Participants were included only if they had no
or low blood sugar levels and the associated increase in health conditions that could be worsened by fasting or
gluconeogenic activity, with amino acids being the pri- that could affect their ability to balance (diabetes, recent/
mary source of substrate [21-23]. Although nutrition chronic head injuries and/or lower extremity disabilities,
imbalance has not been identified as a direct risk factor low blood pressure, vestibular and/or inner ear prob-
related to falls, the symptoms of hypoglycemia include a lems). Participant recruitment was completed through
lack of coordination, staggering gait, fatigue, disorienta- advertisement in the University bulletin after the study
tion, dizziness, and vertigo. These symptoms are well- design and protocol were approved by the authors' insti-
known risk factors for impaired balance and falls in the tutional Research Ethics Board. The participants pro-
elderly population [24-26]. It is not uncommon for vided signed informed consent prior to participation.
younger and older individuals to practice partial fasting The present study adopted a within subject counterbal-
[27]. People may skip meals and not eat for extended anced crossover design, given the many advantages
periods of time due to a self-imposed weight loss strategy, inherent in this design--all subjects served as their own
delayed eating due to the administration of medication or controls and therefore reduced possible error variance,
medical testing (e.g., fasting blood tests), or because of while reducing the needed sample size. Each participant
adherence to religious practices. The interruption of was tested under fasting and non-fasting conditions, with
caloric intake places additional stress on the body, and half of the participants randomly assigned to start under
could undermine the body's ability to perform daily living the non-fasted condition and the remaining half com-
tasks. pleted the fasted trial first. The conditions were reversed
The potential implication of fasting on functional during the second trial and the two trials were separated
capacity has not been well examined. Studies investigat- by a two week duration time span to avoid learning
ing the effects of fasting on functional performance, as effects. All participants completed the same set of tests at
determined by various fitness indicators such as endur- each trial, in the same order. Standardized testing proce-
ance and balance, have used a wide variety of fast dura- dures and equipment were used throughout the study.
tions, ranging from 14 hours to 3.5 days [19,20]. A limited The testing took place in the investigator's research labo-
number of studies show that fasting contributes to ratory. Snack bars and juice boxes were available for the
decreased endurance capacity and reaction time, as well participants to consume after study testing. No other
as reduced static and dynamic balance performance, incentives were provided to the participants.
along with increased heart rate and blood lactate levels
during exercise, all of which are detrimental to perfor- Fasting and non-fasting protocol
mance [17,18]. Studies have shown that the ability to Participants were provided with the fasting/non-fasting
maintain balance is affected after fatiguing exercise [16]. protocol prior to each test period. Thus, it was not possi-
Researchers have found that compensatory mechanisms ble to blind study participants to the testing condition. All
exist to help maintain balance and these mechanisms are laboratory tests took place between 9 and 11 am in order
more active after fatiguing exercise [1,19,20]. The major- for all participants to avoid time of day variations. For the
ity of these studies, however, have involved functionally fasting trial, participants were asked to refrain from con-
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suming food or beverages for a minimum of 12 hours the ground or without losing balance. Three trials were
prior to testing. Specifically, all participants were performed with the farthest reach identified as the final
instructed to consume an evening meal before 8 pm prior score.
to the day of testing and to refrain from any food or bev- Static balance
erages until the time of testing in the laboratory. Fasting The single limb stance was used to assess static balance
protocol was planned to mimic the scenario of skipping [1]. This test can be performed in various time durations
breakfast which is common among young women, or (e.g., 10, 25, 45 seconds or maximum time to exhaustion
overnight fasting necessary for certain blood tests (e.g., or termination) as well as with and without the use of a
fasting blood glucose). For non-fasting tests, participants force platform. In the present study, the test was con-
were instructed to maintain normal eating habits on both ducted on the gym floor and the maximum duration the
the day prior to and the day of testing. In both test condi- participant could maintain a single limb stance was
tions, participants were asked to refrain from strenuous recorded in seconds on both the dominant and non-dom-
physical activity to minimize the role of carry-over effects inant legs, as well as in eyes open and eyes closed condi-
such as fatigue, muscle damage, or physiological potenti- tions [29], to avoid ceiling effect, given the involvement of
ation. Prior to each testing period, a pre-trial checklist healthy young women in this study. The dominant leg
was completed to provide information on each partici- was determined by assessing which foot took the first
pant's past 24 hours of activity (e.g., timing of last meal, step when participants were asked to initiate gait. Partici-
exercise performed, and injuries/health episodes since pants stood on the dominant leg, raising their non-domi-
the previous contact). nant leg to a 90 degree angle at the hip and the knee joints
while keeping their hands down by their sides. In this
Measures study, the test was terminated if the participant volun-
The measures included: a background questionnaire, tarily asked to stop for any reason (e.g., sore leg), if the
nutritional intake, balance tests, and a pre-trial checklist. knee dropped below 90 degrees, if one placed the foot on
Background questionnaire the floor, or began to use arms to maintain balance. The
This questionnaire was used to elicit information related reasons for the termination of the test were recorded for
to the participants' demographic characteristics (age, each of the four static balance testing conditions. The
education, ethnicity, employment, and financial status) same set of termination criteria were used in both the
and health status (perceived health, tobacco use, and fasting and non-fasting trials. Trials were conducted
physical activity level). The questionnaire was completed using the same protocol for both legs and under both
by the participants once, prior to the first testing period. conditions--eyes open and eyes closed. A practice trial
Nutritional intake was provided to each participant to ensure proper form
A 24-hour food recall was used to collect data on average was used during the actual trial. One test trial was com-
caloric intake of the participants. The recalls were con- pleted for each condition to prevent fatigue and practice
ducted by the student investigator trained in the protocol, effects.
using a standard form and adopting strategies to avoid Pre-trial checklist
recall bias by asking the participants to record food intake During each test session, participants completed a pre-
for 24 hours prior to the food recall interview [28]. trial checklist. This checklist gathered information
Recalls were collected once during the study period and related to fasting duration, level of physical activity prior
at mid-point between the two trials. to testing, and any change in health since recruitment or
first testing.
Physical testing
Physical testing included: 1) dynamic balance and 2) Data analysis
static balance. These measures were completed twice, Data from the two trials were numerically coded and
once in the fasted condition and again in a non-fasted entered into a Statistical Package for the Social Science
condition. database [30] for analyses. Descriptive statistics (means
Dynamic balance and frequencies) were used to describe the demographic
The functional reach (FR) test was used to assess and health characteristics as well as balance measures.
dynamic balance [8]. For this test, the difference in centi- Subsequently, paired t-test was conducted to examine the
metres between the participant's standing arm length and changes in balance performance scores for the two trial
maximal forward reach was recorded. While standing conditions. Completed dietary recalls were entered into a
with feet flat on the floor, the standing arm length was dietary analysis program, Food Processor SQL [31], and
measured using a metric measuring tape fixed to the wall. were used to calculate an average nutrient intake for a 24-
Participants were then asked to reach as far forward as hour period. Similarly, foods consumed for breakfast (in
possible, without taking a step, without their heels leaving the same 24-hour period) were analyzed using Food Pro-
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cessor SQL to calculate the average nutrient intake. Based expected, there was a statistically significant difference in
on the difference of nutrient intake for the whole day ver- the time of last meal for the fasted and non-fasted trials
sus breakfast, an average "caloric loss" for fasted trials was (p = 0.011). The average daily caloric intake was 2062
calculated. The significance level was set at (p ≤ 0.05) for kcals with 15.2% of these calories coming from protein,
all statistical procedures. 60.2% from carbohydrates and 28% from fat. When ana-
lyzing the breakfast meal individually, the average total
Results calories from breakfast alone was 465.8 kcals or 22.6% of
A total of 22 female, Caucasian university students partic- the day's total calories. The breakfast meal consisted pri-
ipated in this study without any attrition between trials. marily of carbohydrate calories (74.6%) and interruption
Descriptive statistics on the demographic characteristics of the consumption of breakfast contributed to an aver-
and health status are presented in Table 1. The age of age caloric deficit of 465.8 kcals during the fasted trial.
study participants ranged from 18 to 23 years with a Table 2 presents the mean scores for each of the bal-
mean of 21.8 years (SD = 1.5). Of the study participants, ance measures assessed, based on the trial condition
95.4% rated their perceived health status as excellent to (fasted or non-fasted). For the single limb stance test,
good and all the participants were non-smokers. Over there was a decrease in duration (seconds) of the partici-
90% of the study participants consumed alcohol on a reg- pants' ability to maintain balance as the level of difficulty
ular basis. The majority of the participants reported per- increased, from eyes open, dominant leg to eyes closed,
forming regular physical activity (90.9%) with a range of non-dominant leg in both fasted and non-fasted trials,
four to six days a week (63.6%) for a duration of 30 min- albeit the fasted trial had consistently lower scores com-
utes or longer (90.9%) each time. The perceived health pared to non-fasted trial. Similarly, for the functional
and physical activity status was self report and no defini- reach test, the participants' score was lower in the fasted
tions were provided. None of the participants reported trial compared to non-fasted trial. Paired comparison t-
any injuries or medical conditions that could affect their test showed that fasting resulted in statistically significant
balance. declines in functional reach (p < 0.01), the ability to bal-
Data from the pre-trial checklist showed that a mini- ance in a single limb stance with eyes open, on both the
mum 12-hour fast was followed by the participants dur- dominant and non-dominant leg (p < 0.01 for both) and
ing the fasted trial, with a mean fast of 15 hours. As with eyes closed trial on the dominant leg (p < 0.01)
among healthy young adults. No statistically significant
Table 1: Descriptive statistics on the demographic and
change was observed for the static balance test in the eyes
health characteristics of the participants closed condition on the non-dominant leg (p = 0.13).
Along with the decline in balance performance
Characteristics n = 22 between trials, an increased postural response (e.g.,
stumble, use of arms, knee lowered) was recorded as the
Age in Years (mean ± SD) 21.77 ± 1.5 reason for test termination as the degree of difficulty pro-
Number of Years in 3.5 ± 1.3 gressed in the single limb stance (from eyes open domi-
University (mean) nant leg to eyes closed non-dominant leg) and from the
Ethnicity (%) non-fasted to fasted trial (see Table 3). Specifically, in
non-fasted conditions, the frequency of stumbling as the
Caucasian 100
reason for termination increased with the increase in the
Employment Status (%)
level of difficulty in the four trials (from eyes open, domi-
Part-time 63.6 nant leg trial to the eyes closed non-dominant leg trial).
Do not work during 36.4 However, under fasted conditions, participants showed
school year an increase in postural responses, mainly stumbling,
Financial Status (%) leading to termination in both the eyes open and closed
Easily meets needs 40.9 conditions in the dominant leg but the trend was not true
Just meets needs 40.9 for non-dominant leg. In each of the trials, those in the
fasted condition reported higher frequency of stumble
Barely meets needs 18.2
compared to those in non-fasted condition except for the
Perceived Health Status (%)
trial with the highest level of difficulty (eyes closed, non-
Excellent to good 95.4 dominant leg) in which the scores in seconds were similar
Fair to poor 4.5 (as shown in Table 2).
Non-smoker (%) 100
Perceived Regular Physical 90.9 Discussion
Activity (% yes) The present study provided insights into the relationship
between dietary fasting on static and dynamic balance.
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Table 2: Comparison of scores of physical measures between non-fasted and fasted trials
Specifically, in a sample of physically active and healthy the range of 14 hours to 3.5 days of fasting duration
young women, dietary fasting of a 12-hour period reported in existing studies, it is similar to the standard
affected the individuals' ability to maintain dynamic and fasting protocols required for certain blood tests and suf-
static balance as measured using the functional reach and ficiently long for the body to switch from a post-absorp-
single limb stance tests, respectively. As indicated earlier, tive state into a fasting state [17-21]. By using a fast
there is a paucity of research examining this issue among duration that mimicked a skipped breakfast scenario or
young women who are more likely to skip meals and not fasting blood test, the study protocol reflected a common
eat for extended periods of time to lose weight. No other fasting situation in the general population. The results
study was found in the literature which examined static can therefore be applied to everyday situations, instead of
and dynamic balance in fasting condition in women, what happens under extreme fasting situations (e.g., 3.5
although decline in balance has been reported in studies days of fasting). In the present study, it was estimated that
which involved functionally elite men such as athletes or fasting could have contributed to a 465.8 kcals deficit or
soldiers [17-20]. approximately 25% of daily intake when compared to the
In addition to the decreased duration of balance ability non-fasted condition. Although there are no comparable
between fasted and non-fasted trials, increased postural data, studies have used a standard breakfast of 595 kcals
control mechanism responses were noted which resulted for male participants [17]. Further research is needed to
in the termination of the test. In the present study, at the examine the physiological mechanisms underlying the
easier stages of the single limb stance test (eyes open), the relationship between fasting and balance including the
majority of the participants stopped due to sore leg. How- role of energy regulating hormones (insulin, leptin, adi-
ever, as the difficulty increased (eyes closed) more of the ponectin, ghrelin) as well as the resulting metabolic and
body was required to maintain postural control resulting biochemical changes (e.g., hypoglycemia). Association
in more stumbling and use of arms to aid balance. Under between nutrition and falls should be examined further in
fasting conditions, during both the eyes open and eyes the population of older adults [26].
closed trials, the majority of the stances were terminated While the results of the present study have furthered
due to a stumble. This is consistent with previous studies our understanding of the relationship between dietary
which suggest that individuals use various postural strat- fasting and its effect on physical balance among healthy,
egies for the maintenance of balance after fatiguing exer- young women, it is not without limitations. The study
cise [1,19,20]. The fasting condition placed additional recruited participants through a non-random sampling
stress on the body's ability to balance and therefore, approach. As such, self selection bias would be inherent
required a larger postural response in order to maintain in the sampling approach. Also, with the lack of research
balance. in this area, it was not possible to calculate an appropriate
In the present study, a minimum fasting duration of 12 sample size. However, based on the changes observed in
hours was adopted. Although this is slightly lower than the present study in the functional reach test, which is an
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Table 3: Reasons for Termination of Single Limb Balance Trial (Percentage reporting Postural Response)
indicator of dynamic balance, it can be estimated that 20 cal significance in the day to day functioning given the
participants are required for each group to study whether higher levels of functional threshold in young individuals,
there is a gender difference in the observed effects of fast- these small changes in balance may affect athletic perfor-
ing. Additionally, it was not possible to gather dietary mance if the young women are also actively competing in
data in fasting and non-fasting states. Future studies sport in which balance is integral to performance (gym-
should calculate the actual caloric deficit between the two nastics, skating). Also, changes in balance could limit
conditions. elderly individuals from performing basic activities as
The present study also had several strengths. The use of well as predispose them to high risk for falls. Future stud-
a within subject counterbalanced crossover design was a ies are needed to test the sport performance and fall risk
major strength of this study. This set-up allowed many prepositions. Falling is a complex problem influenced by
advantages; all participants performed the tests in fasted a multiplicity of risk factors, yet the inability to maintain
and non-fasted conditions, served as their own controls balance (i.e., postural instability) is one of the best predic-
and therefore reduced possible error variance, while tors of falls among the elderly individuals [24,32]. Given
reducing the needed sample size. This is the first study to the high incidence of falls and the debilitating conse-
date that has examined the relationship between dietary quences such as hip fracture among the older population
fasting and physical balance as its primary focus within [25], future studies are needed to demonstrate the effects
the general population, with the use of a common fasting of aging on the relationship between fasting and balance.
duration (e.g., skipping breakfast). Standardized testing In these studies, the appropriateness of measure such as a
procedures and protocols were used to minimize vari- single limb stance with increasingly difficulty conditions
ance errors and ensure reproducible data. (eyes closed) for frail older adults and the related safety
The findings raise issues to be addressed in future concerns should be considered.
research. For example, while a small decline in balance
Competing interests
may not translate into difficulties in performing activities The authors declare that they have no competing interests.
of daily living in younger individuals or have serious clini-
Johnson and Leck Nutrition Journal 2010, 9:18 Page 7 of 7
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Authors' contributions 21. Groff J, Gropper S: Advanced Nutrition and Human Metabolism. United
CSJ contributed to the conceptualization and design, as well as to the analysis, States: Wadsworth Thomson Learning; 2000.
interpretation and writing of the article. KRL contributed to the conceptualiza- 22. Halberg N, Henriksen M, Soderhamn N, Stallknecht B, Ploug T, Schierling
tion and design, data collection and analysis, and writing of the article. Both P, Dela F: Effect of intermittent fasting and refeeding on insulin action
authors have read and approved the final manuscript. in healthy men. J Appl Physiol 2005, 99(6):2128-36.
23. Varady KA, Hellerstein MK: Alternate-day fasting and chronic disease
Acknowledgements prevention: a review of human and animal trials. Am J Clin Nutr 2007,
Primary author acknowledges the financial support for the project by the 86(1):7-13.
Canadian Institutes of Health Research - New Investigator Award. 24. Steinman BA, Pynoos J, Nguyen AQ: Fall risk in older adults: Roles of self-
rated vision, home modification and limb function. J Aging Health 2009,
Author Details 21(5):655-676.
1Faculty of Kinesiology and Health Studies, University of Regina, 3737 Wascana 25. Public Health Agency of Canada: A report on seniors' falls in Canada.
Parkway, Regina, Saskatchewan S4S 0A2, Canada and 2Formerly, School of Minister of Public Works and Government Services Canada; 2005.
Nutrition & Dietetics, Acadia University, 12 University Avenue, Wolfville, Nova 26. Johnson CS: The association between nutritional risk and falls among
Scotia, B4P 2R6, Canada frail elderly. The Journal of Nutrition, Health & Aging 2003, 7(4):247-250.
27. Rampersaud GC, Pereira MA, Girard BL, Adams J, Metzl JD: Breakfast
Received: 14 July 2009 Accepted: 13 April 2010 habits, nutritional status, body weight, and academic performance in
Published: 13 April 2010 children and adolescents. Am Diet Assoc 2005, 105(5):743-60.
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