Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia

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However, evidence on seizure outcomes during fasting is sparse in South-East Asia (SEA), where dietary and sleep-wave patterns differ from Middle Eastern cohorts. This multicenter study evaluated seizure frequency changes and associated factors among Indonesian Muslim people with epilepsy (MPWE) who fast during Ramadan. Methods A prospective pre-post multicentered observational cohort study was initiated in March 2023 – May 2024 across five hospitals and three cities in Indonesia. Participants were MPWE aged over 18 years old. Data were collected from the same participants one month before and during Ramadan at outpatient neurology clinics. Demography and clinical characteristics, along with Ramadan observance status, medication adherence, sleep duration, and quality of life, were assessed through medical records and questionnaires. Associations with seizure frequency change were analyzed using bivariate analysis and logistic regression. Results Among 122 participants, 102 (83.6%) fasted during Ramadan; 25.9% reported increased seizures. All individuals who were seizure-free pre-Ramadan remained seizure free. Carbohydrate over consumption at iftar independently predicted seizure increase (OR 3.816;95% CI 1.364-10.675). Sleep duration during Ramadan was not significantly associated to changes of seizure frequency. Conclusion Ramadan fasting appears safe for MPWE with prior seizure freedom. Excessive carbohydrate intake at iftar may elevate seizure risk, representing a modifiable intervention target. This study provides the first multicenter Indonesian evidence to inform culturally tailored clinical guidance for fasting decisions in epilepsy. 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F1000Research 2026, 15 :89 ( https://doi.org/10.12688/f1000research.176642.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Research Article Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] Fitri Octaviana https://orcid.org/0000-0002-9704-7141 1,2 , Kheng Seang Lim 3 , Ismi Adhanisa Hamdani 4 , [...] Gotot Sumantri 5 , Izati Rahmi 6 , Andre . 7 , Winnugroho Wiratman 1,2,8 , Luh Ari Indrawati 1,2 , Adrian Ridski Harsono 8 , Astri Budikayanti 1,2 Fitri Octaviana https://orcid.org/0000-0002-9704-7141 1,2 , Kheng Seang Lim 3 , [...] Ismi Adhanisa Hamdani 4 , Gotot Sumantri 5 , Izati Rahmi 6 , Andre . 7 , Winnugroho Wiratman 1,2,8 , Luh Ari Indrawati 1,2 , Adrian Ridski Harsono 8 , Astri Budikayanti 1,2 PUBLISHED 20 Jan 2026 Author details Author details 1 Neurology, Universitas Indonesia Fakultas Kedokteran, Jakarta, Special Capital Region of Jakarta, 10430, Indonesia 2 Neurology, Rumah Sakit Dr Cipto Mangunkusumo, Central Jakarta, Jakarta, 10430, Indonesia 3 Division of Neurology, Department of Medicine, University of Malaya Faculty of Medicine, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia 4 Neurology, Ciawi General Hospital, Bogor, West Java, Indonesia 5 Neurology, Pasar Rebo Hospital, Jakarta, DKI Jaya, Indonesia 6 Neurology, Pasar Minggu Hospital, Jakarta, DKI Jaya, Indonesia 7 Neurology, Universitas Katolik Indonesia Atma Jaya Fakultas Kedokteran, North Jakarta, Special Capital Region of Jakarta, Indonesia 8 Neurology, Universitas Indonesia Hospital, Depok, West Java, Indonesia Fitri Octaviana Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Kheng Seang Lim Roles: Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ismi Adhanisa Hamdani Roles: Data Curation, Investigation Gotot Sumantri Roles: Data Curation, Investigation, Resources Izati Rahmi Roles: Data Curation, Investigation, Resources Andre . Roles: Data Curation, Investigation, Resources Winnugroho Wiratman Roles: Conceptualization, Formal Analysis, Software, Visualization, Writing – Original Draft Preparation Luh Ari Indrawati Roles: Investigation, Methodology, Software, Validation Adrian Ridski Harsono Roles: Data Curation, Formal Analysis, Investigation, Validation, Visualization Astri Budikayanti Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Introduction Ramadan fasting is practiced by millions of people with epilepsy worldwide. However, evidence on seizure outcomes during fasting is sparse in South-East Asia (SEA), where dietary and sleep-wave patterns differ from Middle Eastern cohorts. This multicenter study evaluated seizure frequency changes and associated factors among Indonesian Muslim people with epilepsy (MPWE) who fast during Ramadan. Methods A prospective pre-post multicentered observational cohort study was initiated in March 2023 – May 2024 across five hospitals and three cities in Indonesia. Participants were MPWE aged over 18 years old. Data were collected from the same participants one month before and during Ramadan at outpatient neurology clinics. Demography and clinical characteristics, along with Ramadan observance status, medication adherence, sleep duration, and quality of life, were assessed through medical records and questionnaires. Associations with seizure frequency change were analyzed using bivariate analysis and logistic regression. Results Among 122 participants, 102 (83.6%) fasted during Ramadan; 25.9% reported increased seizures. All individuals who were seizure-free pre-Ramadan remained seizure free. Carbohydrate over consumption at iftar independently predicted seizure increase (OR 3.816;95% CI 1.364-10.675). Sleep duration during Ramadan was not significantly associated to changes of seizure frequency. Conclusion Ramadan fasting appears safe for MPWE with prior seizure freedom. Excessive carbohydrate intake at iftar may elevate seizure risk, representing a modifiable intervention target. This study provides the first multicenter Indonesian evidence to inform culturally tailored clinical guidance for fasting decisions in epilepsy. READ ALL READ LESS Keywords Epilepsy, Ramadan Observance, Fasting, Seizure frequency, Indonesia Corresponding Author(s) Fitri Octaviana ( [email protected] ) Close Corresponding author: Fitri Octaviana Competing interests: No competing interests were disclosed. Grant information: This work was supported by the PUTI UI Grant No. NKB-630/UN2.RST/HKP.05.00/2024. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2026 Octaviana F et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Octaviana F, Lim KS, Hamdani IA et al. Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] . F1000Research 2026, 15 :89 ( https://doi.org/10.12688/f1000research.176642.1 ) First published: 20 Jan 2026, 15 :89 ( https://doi.org/10.12688/f1000research.176642.1 ) Latest published: 20 Jan 2026, 15 :89 ( https://doi.org/10.12688/f1000research.176642.1 ) 1. Introduction Indonesia is the most populous Muslim-majority country in the world, with around 87% of its population adhering to Islam. 1 Observance during the holy month of Ramadan is a key religious obligation for capable adult Muslims, and it is widely practiced across the nation. This practice entails abstaining from eating, drinking, smoking, intercourse, and taking oral medications from dawn until sunset, which is usually 13 hours long in Indonesia. Meanwhile, epilepsy, a chronic neurological disorder characterized by recurrent seizures, and the prevalence is estimated to be 4.3-8/1000 population in Indonesia. 2 Given that the majority of Indonesians are Muslim, and a large proportion of Muslim people with epilepsy (MPWE) in the country are also encouraged to fast during Ramadan, this may pose challenges for managing their condition during the holy month. Ramadan observance including Ramadan fasting can have notable effects on epilepsy, particularly due to the metabolic changes it induces. This includes alterations to the body’s glucose metabolism, increases in fatty acid oxidation, and potential fluctuations in ketone body production, which in turn affect brain function on a cellular and molecular level. 3 These changes may impact seizure frequency, as some individuals are sensitive to variations in blood glucose levels. Observing Ramadan includes waking for suhoor —a pre-dawn meal typically taken around 03:00–04:00 a.m.—and engaging in early morning prayer, both of which can disrupt normal sleep patterns. Such sleep disturbances may be detrimental for people with epilepsy, as sleep deprivation is a well-established trigger for seizures. 4 Moreover, Ramadan observance requires patients with epilepsy to modify the timing of their anti-seizure medications (ASM) to fit within the non-observance hours, which can affect drug absorption, adherence, and steady state. 5 This disruption in medication regimens may result in suboptimal seizure control, increasing the risk of breakthrough seizures. 6 Despite the potential risks, Indonesia currently lacks specific guidelines for epilepsy patients during Ramadan observance. Research from other Muslim-majority countries, particularly in Arab states, has explored the relationship between Ramadan observance and epilepsy, but similar studies have not yet been conducted in Indonesia. 7 Given the significant differences in demographics and healthcare infrastructure between Indonesia and the Arab world, the results of those studies may not be directly applicable. This study aims to fill that gap by investigating the effects of Ramadan observance on seizure frequency in Indonesia and identifying factors associated with seizure activity during the Ramadan observance month. The findings of this research could inform the development of official guidelines for epilepsy patients in Indonesia. 2. Materials and Methods 2.1 Study design and ethical approval This prospective pre-post multicentered observational cohort study was initiated following ethical approval from the Health Research Ethics Committee of the Faculty of Medicine, University of Indonesia (Ethics Approval No. KET-267/UN2.F1/ETIK/PPM.00.02/2023), granted on 6 March 2023. Logistic regression sample size estimation was used to determine a sample size of 130 participants, adjusting for participant drop-out or missing data. Data collection was conducted across two consecutive Ramadan fasting periods, corresponding to Hijri calendar years 1444 and 1445 (Gregorian years 2023 and 2024, respectively). During the first year, data collection commenced on 8 March 2023 and concluded on 21 May 2023, one month after the end of Ramadan fasting period. In the second year, data collection commenced on 12 February 2024, one month prior to Ramadan, and ended on 9 May 2024, one month after Ramadan fasting period. Primary data sources included questionnaires administered starting one month before the start of Ramadan and repeated during Ramadan to assess changes in clinical outcomes. Secondary data sources were obtained from medical records. All data were collected at the outpatient neurology clinic of five hospitals from three different cities: Cipto Mangunkusumo National Referral Hospital (CMH), Atma Jaya Hospital (AJH), Pasar Minggu Hospital (PMH), Pasar Rebo Hospital (PRH), and Ciawi General Hospital (CGH). 2.2 Inclusion and exclusion criteria The study population included Muslim patients aged 18 years or older, diagnosed with epilepsy and receiving treatment at the outpatient clinic. Patients with mental retardation, severe psychiatric disorders, or those unwilling to provide informed consent were excluded from the study. All participants gave informed consent before inclusion in the study. 2.3 Data collection and variables Data were collected using both medical records and structured questionnaires administered one month before the start of Ramadan and repeated during Ramadan. 2.3.1 Baseline data Baseline data were acquired using data from structured questionnaires that captured demographic information (e.g., age, gender, educational status, marital status, employment status). Information on seizure characteristics (e.g., seizure frequency, seizure type), number of ASMs used, seizure-free status, and duration of seizure freedom was collected from medical records. Seizure type was classified as either focal or general, while seizure freedom was defined as the absence of seizures for a minimum 12-month period before data collection. Sleep duration was defined as the number of hours spent asleep at night for the past month. Medication adherence, which could change during Ramadan observance due to fasting, was measured in our study using the Morisky Adherence Questionnaire (MAQ), which consists of four yes/no questions. Responses were scored as either 0 (yes) or 1 (no), with total scores ranging from 0 to 4. Patients with a score of 4 were classified as adherent, while those scoring 0–3 were considered nonadherent. 8 2.3.2 Follow-up Follow-up data was collected using structured questionnaires that captured information on whether or not participants participated in Ramadan observance and engaged in midnight prayers. The questionnaire also contained items collecting data of the volume of liquids consumed per day during Ramadan, and overconsumption of carbohydrates at iftar (breaking fast), which was defined as consumption of carbohydrates over twice the normal amount at Iftar and was assessed subjectively. Sleep duration and medication adherence during Ramadan was also included in the follow-up questionnaire. 2.3.3 Outcome The outcome of this study, seizure frequency, was categorized as an increase or decrease in seizure frequency by comparing the number of seizures recorded in the one-month period before and during Ramadan. 2.4 Statistical analysis Data were analyzed using SPSS software version 26.0 (IBM Corp., Armonk, NY, USA). The dependent variable was the change in seizure frequency one month before Ramadan and during Ramadan. Categorical variables were presented as percentages, while continuous variables were initially assessed for normality. Based on the results of the Kolmogorov-Smirnov test, they were then reported either as mean and standard deviation (SD) for normally distributed data or as median and range for non-normally distributed data. For bivariate analysis, Chi-square tests, likelihood ratio tests, or Fisher’s exact tests were used for categorical variables, while Mann-Whitney U or independent T-tests were used for continuous variables. Multivariate logistic regression was performed to control for potential confounders, with variables showing a p-value < 0.1 in the bivariate analysis included in the multivariate model. All assumptions, including the absence of outliers and multicollinearity, were satisfied before performing regression analyses. 3. Results 3.1 Demography and clinical characteristics of participants Of the144 individuals approached, 134 were eligible and consented, and 122 completed follow-up. CMH contributed the largest proportion (58.3%). The median age was 30.5 years (18-74), and slightly more than half were female. Most participants had completed senior high school. Among the employed population, 58.1% continued working during Ramadan. Table 1 summarizes all demographic and clinical characteristics. Table 1. Demography and clinical characteristics of participants (n = 122). Variables N (%) Age (years) (median (min-max)) 30.5 (18-74) Gender ■Female 66 (54.1) ■Male 56 (45.9) Educational Status ■Uneducated 1 (0.8) ■Elementary school 18 (14.8) ■Junior high school 19 (15.6) ■Senior high school 55 (45.1) ■College/University 29 (23.8) Married 62 (50.8) Employed 62 (50.8) Working during Ramadan among employed participants (n = 62) 36 (58.1) Did not engage in midnight prayers 75 (61.5) Age at seizure-onset (years) (median (min-max)) 17 (0.2-68) Duration of epilepsy (years) (median (min-max)) 11 (0.33-59) Seizure-free 26 (21.3) Duration of seizure-freedom (months) (median (min-max)) 21 (12-91) Focal Seizures 84 (68.9) Participants on polytherapy ASM regimens 67 (54.9) Ramadan Observance 102 (83.6) Volume of fluids consumed/day during Ramadan (ml) (median (min-max)) 1500 (400-3000) Carbohydrate overconsumption during iftar (n = 102) 30 (29.4) Seizure frequency one month before Ramadan ■No seizure 71 (58.2) ■1-5x 39 (32) ■>5x 12 (9.8) Seizure frequency during Ramadan ■No seizure 72 (59) ■1-5x 41 (33.6) ■>5x 9 (7.4) Good medication adherence one month before Ramadan 59 (48.4) Good medication adherence during Ramadan 72 (59) Sleep duration one month before Ramadan (hours) (median (min-max)) 7 (1.5-12) Sleep duration during Ramadan (hours) (median (min-max)) 5.5 (2-9.5) Median age at seizure onset was 17 years (0.2-68), with a median epilepsy duration of 11 years (0.33-59). Only 21.3% were seizure-free. Focal epilepsy was the most common seizure type (68.9%). Polytherapy was used by 54.9% participants. Among all participants, 83.6% fasted during Ramadan. Median fluid intake was 1,500 ml/day (400-3,000), and 29.4% reported carbohydrate overconsumption at iftar. Seizure frequency improved slightly during Ramadan, with a reduction in participants experiencing >5 seizures/month (from 9.8% to 7.4%). Medication adherence appeared higher during Ramadan (59%) compared to pre-Ramadan (48.4%). Sleep duration decreased from 7 hours pre-Ramadan to 5.5 hours during Ramadan ( Table 1 ). 3.2 Factors associated with increased seizure frequency Among those who fasted (n = 102), 25.9% experienced an increase in seizure frequency. Significant factors in bivariate analysis ( Table 2 ) included being non-seizure-free before Ramadan (p = 0.002), carbohydrate overconsumption at Iftar (p = 0.004), and longer sleep duration during Ramadan (p = 0.041). All pre-Ramadan seizure-free participants remained seizure-free. Table 2. Factors associated with an increase in seizure frequency during Ramadan among observant participants (n = 102). Variables No increase in seizure frequency (n = 81) Increase in seizure frequency (n = 21) p OR (95%CI) N (%) N (%) Gender •Female 42 (79.2) 11 (20.8) 0.966 * 1.02 (0.39-2.67) •Male 39 (79.6) 11 (20.4) Age (median (min-max)) 30 (18-74) 35 (18-62) 0.691 † Marital Status •Not Married 40 (80) 10 (20) 0.885 * 1.07 (0.41-2.81) •Married 41 (78.8) 11 (21.1) Occupational Status •Unemployed 39 (86.7) 6 (13.3) 0.107 * 2.23 (0.82-6.58) •Employed 42 (73.7) 15 (26.3) Working during Ramadan among employed participants (n = 57) •No 21 (87.5) 3 (12.5) 0.067 ** 4.00 (0.98-16.26) •Yes 21 (63.6) 12 (36.4) Midnight prayers •No 45 (80.4) 11 (19.6) 0.794 * 1.14 (0.43-2.97) •Yes 36 (78.3) 10 (21.7) Seizure type •Focal 55 (80.9) 13 (19.1) 0.603 * 1.30 (0.48-3.53) •General 26 (76·5) 8 (23.5) Seizure-free before Ramadan •No 56 (72.7) 21 (27.3) 0 . 002 ** 0.73 (0.63-0.83) •Yes 25 (100) 0 (0) Number of ASMs used •Monotherapy 38 (82.6) 8 (17.4) 0.469 * 1.44 (0.54-3.84) •Polytherapy 43 (76.8) 13 (23.2) Carbohydrate overconsumption during Iftar •No 64 (86.5) 10 (13.5) 0 . 004 * 4.14 (1.51-11.37) •Yes 17 (60.7) 11 (39.3) Medication adherence one month before Ramadan •Non-adherent 44 (83) 9 (17) 0.463 * 1.59 (0.60-4.18) •Adherent 37 (75.5) 12 (24.5) Medication adherence during Ramadan •Non-adherent 35 (77.8) 10 (22.2) 0.717 * 0.84 (0.32-2.19) •Adherent 46 (80.7) 11 (19.3) Sleep duration one month before Ramadan (hours) (median (min-max)) 7 (1.5-10) 7 (4-12) 0.353 † Sleep duration during Ramadan (hours) (median (min-max)) 5 (2-9) 6.5 (2-9) 0 . 041 † * Chi-square; ** Fischer’s Exact; † Mann-Whitney. Logistic regression analysis included carbohydrate overconsumption during iftar, and sleep duration during Ramadan. Seizure-free status was excluded from multivariate analysis due to zero events in that group. The analysis revealed that participants who overconsumed carbohydrates were 3.81 times more likely to experience an increase in seizure frequency. Sleep duration, however did not display a significant association with an increase in seizure frequency ( Tables 2 and 3 ). Table 3. Multivariate regression analysis on factors associated with increase in seizure frequency. Variable B Wald p OR (95% CI) Constant -3.439 9.320 0.002 - Carbohydrate overconsumption at iftar (Yes) 1.339 6·508 0.011 3 · 816 (1.364-10.675) Sleep duration during Ramadan 0.286 2.305 0.129 1.331 (0.920-1.924) 4. Discussion This prospective multicenter study demonstrates that Ramadan fasting is generally safe for Indonesian MPWE, with most participants experiencing stable or improved seizure control. This finding is consistent with studies from other Muslim-majority populations, which largely show that Ramadan fasting does not inherently worsen seizure frequency. 9 – 11 Animal study showed intermittent fasting prevented the rise in blood glucose and reduced seizure-induced astrogliosis by preventing the glial fibrillary acidic protein (GFAP) expression and the morphological complexity of astrocytes in the hippocampal region. Hippocampal hyperexcitability during interictal stage could be modulating by reduction glucose metabolism. 12 In the instances where increases in seizure frequency do occur, the main cause is mainly attributed to lower medication adherence due to alterations in the timing of drug consumption. 13 Other causes include sleep deprivation, emotional stress, and metabolic changes such as dehydration and hypernatremia. 14 , 15 4.1 Seizure-free status All participants who were seizure-free before Ramadan remained seizure-free throughout the fasting month. This aligns consistent with prior studies showing that sustained pre-Ramadan seizure freedom is a strong predictor of safe fasting. 16 Although the sample size of seizure-free individuals was modest, the absence of any breakthrough events underscores the strength of pre-existing seizure control as a predictor of fasting safety. This is aligned with international Ramadan epilepsy recommendations, yet our data provide the first prospective Southeast Asian evidence confirming this pattern. 4.2 Carbohydrate overconsumption at Iftar Carbohydrate overconsumption emerged as a significant predictor of seizure increase. Acute postprandial hyperglycemia may lower the seizure threshold through effects on ion channels, oxidative stress, and excitatory transmission. 17 – 19 Evidence supporting this mechanism is indirectly reinforced by the anti-seizure effects of ketogenic and low-carbohydrate diets, which stabilized neuronal activity via ketone-mediated pathways. 20 , 21 Our finding likely reflects Indonesia dietary patterns, where iftar meals often include rice, noodles, sweet drinks, and fried foods – resulting in high glycemic loads. This culturally specific behavior may explain why similar studies in Middle Eastern populations have not highlighted carbohydrate excess as a major seizure trigger. Although carbohydrate intake was assessed subjectively, the strength of the association suggest that the immediate metabolic transition following iftar may represent a vulnerable period for individuals with epilepsy. Rapid rises in postprandial glucose can enhance neuronal excitability through ion-channel modulation, oxidative stress pathway, and glutamatergic transmission, providing biological plausibility for our observation. 17 – 19 This finding should therefore be interpreted not as evidence of a definitive causal mechanism, but as a clinically meaningful hypothesis that identifies a modifiable behavioral factor. Future studies employing quantitative dietary assessments or continuous glucose monitoring could further clarify the metabolic dynamics influencing seizures risk during Ramadan. 4.3 Sleep duration Contrary to expectations, longer – not shorter – sleep duration was associated with increased seizure frequency in bivariate analysis. This is likely confounded: individuals experiencing more seizures may have required additional restorative sleep. After adjustment in multivariate analysis, sleep duration was not an independent predictor. Prior studies also found no consistent link between sleep duration during Ramadan and seizure risk. 9 , 10 4.4 Geographic relevance Evidence on Ramadan fasting and epilepsy from South-East Asia (SEA) is scarce. Indonesia and neighboring countries share dietary habits characterized by high carbohydrate consumption. Indonesian iftar meals commonly involve sweetened beverages, rice-based dishes, and fried snacks – patterns distinct from Middle Eastern diets that are relatively higher in protein and fat. These differences may influence glycemic fluctuations and seizure susceptibility. Thus, this study provides the first multicenter prospective evidence describing seizure-related outcomes during Ramadan in Indonesian MPWE. These findings underscore the need for locally contextualized guidelines, rather than solely on data from other regions. Although this study is observational and relies on self-reported measures, such an approach is appropriate and necessary for Ramadan-related research, where controlled fasting manipulation is neither ethical nor feasible. Observational methods also capture real-world behaviors that laboratory paradigm may miss, including cultural eating patterns, medication timing preferences, and personal fasting motivations. Importantly, the consistency of the seizure-free subgroup demonstrates a clinically meaningful pattern that is unlikely to be explained solely by measurement limitations. Thus, while caution is warranted in interpreting causal mechanisms, the findings provide actionable insights that reflect how MPWE actually experience and manage Ramada fasting. 4.5 Medication adherence and dosing patterns Although adherence improved during Ramadan, no significant association was observed with seizure change. This may be due to the MAQ’s stringent scoring system; even minor delays in dosing classify participants as non-adherent. Minor schedule deviations may not meaningfully affect seizure risk, particularly for ASMs with long half-lives. Nonetheless, simplified once – or twice – daily dosing regimens remain ideal for fasting patients. 22 4.6 Limitations Several limitations exist in this study. Participating in Ramadan observance constitutes significant lifestyle changes in multiple aspects, including but not limited to: changes in sleep pattern, eating patterns, work, and dosing regimens, which could all effect seizure frequency. While this study has managed to find the relationship of these major contributing factors towards seizure frequency, participating in observance during Ramadan may entail other changes that could affect seizure frequency (e.g. changes in physical activity, stress, dehydration status), which was not accounted for in our study. Future studies could also focus more on certain aspects such as changes in plasma drug concentrations with different dosing regimens during Ramadan fasting and its effect on seizure. Observance during Ramadan also varies in different countries, most notably by difference of fasting duration (time from dusk to dawn), in which countries closer to the equator will have shorter fasting durations. This means that the results of this study might not be applicable to MPWE in other countries, especially those with significantly longer fasting duration. As this was an observational study, causal inference cannot be established. Nonetheless, controlled experimental manipulation of fasting behavior is not ethically feasible, making observational approaches the most appropriated method for examining Ramadan practices. Additionally, the robust stability observed among seizure-free participants suggests that certain clinical patterns can still be discerned despite methodological limitations. Future studies incorporating objective metabolic measures (e.g., glucose or ketone monitoring), wearable sleep tracking, or quantitative dietary analysis would strengthen mechanistic interpretation. 4.7 Clinical implications for Ramadan fasting The present findings support a practical, risk-stratified framework for guiding fasting decisions among MPWE. Patients who have maintained seizure freedom for at least 12 months appear to constitute a low-risk group, demonstrating high tolerance to the metabolic, behavioral, and medication timing changes inherent to Ramadan. Conversely, individuals with active seizures may benefit from close monitoring and targeted counseling- particularly regarding carbohydrate load at iftar, which emerged as a potentially modifiable contributor to seizure worsening. These results suggest that clinicians should move beyond generalized assumption about the risks of fasting and instead integrate individualized factors (i.e., seizure-free status, dietary habits, medication timing) into shared decision-making discussions before Ramadan. 5. Conclusion Ramadan fasting was well-tolerated by most MPWE, and seizure-free individuals maintained seizure stability throughout the fasting month. This finding reinforces seizure-free status as a practical, reliable predictor of fasting safety and provides clinicians with a clear criterion for guiding fasting decisions. Excessive carbohydrate intake at iftar emerged as a modifiable behavioral risk factor for seizure exacerbation, emphasizing the value of dietary counseling during pre-Ramadan preparation. These findings offer region-specific evidence for the development of fasting guidelines in Indonesia and comparable Muslim populations. Future studies should explore objective metabolic monitoring and dietary quantification to refine seizure-risk stratification and inform individualized fasting recommendations. Ethics approval statement This study was approved by the Health Research Ethics Committee of the Faculty of Medicine, Universitas Indonesia on 6 March 2023 (No. KET-267/UN2.F1/ETIK/PPM.00.02/2023), in accordance with the Declaration of Helsinki involving human participants. Patient consent statement This study adhered to the guidelines set forth by the International Committee of Medical Journal Editors (ICMJE). Written informed consent was obtained voluntarily by all participants before participation. The identities and personal information of all participants were kept confidential. Data availability statement The data analysed during this study are not publicly available due to ethical, and confidentiality restrictions. According to the approved study protocol, unrestricted sharing of individual-level data is prohibited. However, requests for access to de-identified data for verification may be considered on a case-by-case basis, subject to approval by the ethics committee and the principal investigator. Requests should be directed to the Health Research Ethics Committee of the Faculty of Medicine, Universitas Indonesia through the principal investigator Fitri Octaviana at [email protected] . References 1. Masyarakat BH: Data, dan Informasi. Jumlah Penduduk Menurut Agama. Satu Data Kementerian Agama. Jakarta: Kementerian Agama Republik Indonesia; 2022 Aug [cited 2024 Jun 4]; 1–5. Reference Source 2. Beghi E, Giussani G, Nichols E, et al. : Global, regional, and national burden of epilepsy, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. The Lancet Neurology. 2019; 18 : 357–375. PubMed Abstract | Publisher Full Text | Free Full Text 3. 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PubMed Abstract | Publisher Full Text Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Jan 2026 ADD YOUR COMMENT Comment Author details Author details 1 Neurology, Universitas Indonesia Fakultas Kedokteran, Jakarta, Special Capital Region of Jakarta, 10430, Indonesia 2 Neurology, Rumah Sakit Dr Cipto Mangunkusumo, Central Jakarta, Jakarta, 10430, Indonesia 3 Division of Neurology, Department of Medicine, University of Malaya Faculty of Medicine, Kuala Lumpur, Federal Territory of Kuala Lumpur, Malaysia 4 Neurology, Ciawi General Hospital, Bogor, West Java, Indonesia 5 Neurology, Pasar Rebo Hospital, Jakarta, DKI Jaya, Indonesia 6 Neurology, Pasar Minggu Hospital, Jakarta, DKI Jaya, Indonesia 7 Neurology, Universitas Katolik Indonesia Atma Jaya Fakultas Kedokteran, North Jakarta, Special Capital Region of Jakarta, Indonesia 8 Neurology, Universitas Indonesia Hospital, Depok, West Java, Indonesia Fitri Octaviana Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Kheng Seang Lim Roles: Supervision, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Ismi Adhanisa Hamdani Roles: Data Curation, Investigation Gotot Sumantri Roles: Data Curation, Investigation, Resources Izati Rahmi Roles: Data Curation, Investigation, Resources Andre . Roles: Data Curation, Investigation, Resources Winnugroho Wiratman Roles: Conceptualization, Formal Analysis, Software, Visualization, Writing – Original Draft Preparation Luh Ari Indrawati Roles: Investigation, Methodology, Software, Validation Adrian Ridski Harsono Roles: Data Curation, Formal Analysis, Investigation, Validation, Visualization Astri Budikayanti Roles: Conceptualization, Data Curation, Formal Analysis, Methodology, Validation, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This work was supported by the PUTI UI Grant No. NKB-630/UN2.RST/HKP.05.00/2024. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (1) version 1 Published: 20 Jan 2026, 15:89 https://doi.org/10.12688/f1000research.176642.1 Copyright © 2026 Octaviana F et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Octaviana F, Lim KS, Hamdani IA et al. Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] . F1000Research 2026, 15 :89 ( https://doi.org/10.12688/f1000research.176642.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 20 Jan 2026 Views 0 Cite How to cite this report: Sinha JK. Reviewer Report For: Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] . F1000Research 2026, 15 :89 ( https://doi.org/10.5256/f1000research.194721.r456620 ) The direct URL for this report is: https://f1000research.com/articles/15-89/v1#referee-response-456620 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 14 Feb 2026 Jitendra Kumar Sinha , Symbiosis Institute of Health Sciences (SIHS), Symbiosis International University, Pune, Maharashtra, India Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.194721.r456620 The manuscript entitled “Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia” presents a timely and regionally relevant prospective multicenter study addressing an important clinical dilemma in Muslim-majority settings. The authors should be commended for ... Continue reading READ ALL The manuscript entitled “Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia” presents a timely and regionally relevant prospective multicenter study addressing an important clinical dilemma in Muslim-majority settings. The authors should be commended for enrolling - 122 participants, across 5 hospitals and employing a pre–& post Ramadan design with multivariate logistic regression. The finding that all patients who were seizure-free for ≥12 months remained seizure-free during Ramadan is clinically meaningful and aligns with prior literature, reinforcing seizure-free status as a pragmatic predictor of fasting safety. Suggestions for improvement: Provide clearer operational defn & validation method for carbohydrate over-consumption. Consider the penalizd regression to handle zero-event predictors (seizure-free status). Include seizure etiology and ASM type/half-life in multivariate analysis. Elaborate on power calculation and achieved sample size (122 vs. 130 planned). Discuss potential recall bias and seizure diary use explicitly. Provide the effect size interpretation in clinical terms (absolute risk increase?). Clarify whether analyses were restricted to fasting participants only in all models. Improve language consistency and minor grammatical corrections throughout the discussion. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Neuroscience I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Sinha JK. Reviewer Report For: Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] . F1000Research 2026, 15 :89 ( https://doi.org/10.5256/f1000research.194721.r456620 ) The direct URL for this report is: https://f1000research.com/articles/15-89/v1#referee-response-456620 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 20 Jan 2026 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 Version 1 20 Jan 26 read Jitendra Kumar Sinha , Symbiosis Institute of Health Sciences (SIHS), Symbiosis International University, Pune, India Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Sinha J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 14 Feb 2026 | for Version 1 Jitendra Kumar Sinha , Symbiosis Institute of Health Sciences (SIHS), Symbiosis International University, Pune, Maharashtra, India 0 Views copyright © 2026 Sinha J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The manuscript entitled “Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia” presents a timely and regionally relevant prospective multicenter study addressing an important clinical dilemma in Muslim-majority settings. The authors should be commended for enrolling - 122 participants, across 5 hospitals and employing a pre–& post Ramadan design with multivariate logistic regression. The finding that all patients who were seizure-free for ≥12 months remained seizure-free during Ramadan is clinically meaningful and aligns with prior literature, reinforcing seizure-free status as a pragmatic predictor of fasting safety. Suggestions for improvement: Provide clearer operational defn & validation method for carbohydrate over-consumption. Consider the penalizd regression to handle zero-event predictors (seizure-free status). Include seizure etiology and ASM type/half-life in multivariate analysis. Elaborate on power calculation and achieved sample size (122 vs. 130 planned). Discuss potential recall bias and seizure diary use explicitly. Provide the effect size interpretation in clinical terms (absolute risk increase?). Clarify whether analyses were restricted to fasting participants only in all models. Improve language consistency and minor grammatical corrections throughout the discussion. Is the work clearly and accurately presented and does it cite the current literature? Partly Is the study design appropriate and is the work technically sound? Partly Are sufficient details of methods and analysis provided to allow replication by others? Partly If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? No Are the conclusions drawn adequately supported by the results? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Neuroscience I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (0) Sinha JK. Peer Review Report For: Seizure-Free Status Predicts Safe Ramadan Fasting in Epilepsy: A Multicenter Prospective Cohort from Indonesia [version 1; peer review: 1 approved with reservations] . F1000Research 2026, 15 :89 ( https://doi.org/10.5256/f1000research.194721.r456620) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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