The Journal for Nurse Practitioners 20 (2024) 104893

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The Journal for Nurse Practitioners

journal homepage: www.npjournal.org

Intermittent Fasting: Exploring Approaches, Benefits, and Implications

for Health and Weight Management
Kathleen Nye, Craig Cherrin, Jan Meires

a b s t r a c t
Keywords: Intermittent fasting is an eating pattern that restricts food intake for specific periods. Studies have shown that
intermittent fasting intermittent fasting can be an effective method for weight loss because it reduces overall calorie intake and
metabolic health
increases metabolism. However, consulting a health care professional before starting any new diet or exercise
time-restricted eating
weight loss
regimen is recommended. This article presents an overview of intermittent fasting, its pathophysiology,
associated health benefits, and adverse effects, and provides a guide for the provider in prescribing it.
© 2023 Elsevier Inc. All rights reserved.

Introduction Obesity-related complications can include, but are not limited

to, type 2 diabetes, high blood pressure, stroke, fatty liver and more
Intermittent fasting (IF) is a popular weight loss method that has severe liver disease, sleep apnea, osteoarthritis, gallstones, high
gained attention for its simplicity and results. Unlike traditional cholesterol, gout, and certain types of cancer.2 Obesity is a multi-
calorie-restricted diets, IF restricts the time when food is faceted disease influenced by genetic factors, behaviors, and envi-
consumed. Recent research has suggested that IF can be an effective ronmental conditions. Factors contributing to obesity include poor
and sustainable approach for improving weight loss, lean body dietary habits, insufficient physical activity, and limited access to
mass, and metabolic health markers such as blood pressure, blood nutritious food.2 Obesity can be associated with several endocrine
sugar levels, and cholesterol. Patients should consult a health care alterations from hypothalamicepituitary hormone axis changes.
provider before beginning a new dietary regimen to review any These include hypothyroidism, Cushing’s disease, hypogonadism,
ongoing medical condition(s) or if they are taking medication. The and growth hormone deficiency. The bidirectional relationship
information in this article will assist nurse practitioners (NPs) in between sleep and obesity is further elucidated in newer studies,
becoming familiar with the potential risks and benefits of IF and in demonstrating how sleep deprivation can lead to weight gain and
understanding which patients are appropriate candidates for this how obesity can exacerbate sleep disorders.3 Modern lifestyles
regimen. often expose individuals to chronic stress, which may contribute to
obesity through mechanisms such as overeating and hormonal
imbalances. Additionally, obesity can be a source of stress due to
Background societal pressures and self-stigma.4 In 2019, the estimated annual
medical expenditure for treating or managing obesity-related
In the United States, the alarming rise of obesity has become a complications in the United States was nearly $173 billion.2 The
national epidemic, with profound consequences for the health and medical costs for adults living with obesity were $1,861 higher than
well-being of millions of Americans. There is an urgent need for those for individuals maintaining a normal BMI.
comprehensive efforts to address this complex issue. The Centers
for Disease Control and Prevention (CDC) reports that obesity is a Pathophysiology
widespread, severe, and expensive health concern in the United
States. Obesity is a chronic medical condition characterized by an The body regulates caloric intake and fasting states constantly.
excessive accumulation of body fat that may harm an individual’s In brief, when food is consumed, it is broken down into simple
health and well-being. It is typically quantified using the body mass products, including glucose, that go through glycolysis for energy
index (BMI), calculated by dividing a person’s weight in kilograms production. Typically, food can stay in the stomach for 6 to 8 hours
by the square of their height in meters (kg/m2). According to the after eating. The body will become euglycemic in 2 to 3 hours in
World Health Organization (WHO) classification, obesity is defined healthy individuals. With high glucose levels from food, the body
as follows: a BMI of 25 to 29.9 is considered overweight, a BMI of 30 secretes insulin for uptake and storage from the beta cells in the
to 39.5 is considered obese, and a BMI of 40 or greater is morbid pancreas. Glucose is stored in the body in several places, including
obesity.1 the liver and muscle (glycogen synthesis).5 When glucose levels are

https://doi.org/10.1016/j.nurpra.2023.104893
1555-4155/© 2023 Elsevier Inc. All rights reserved.
2 K. Nye et al. / The Journal for Nurse Practitioners 20 (2024) 104893

low, glucagon is secreted from the alpha cells in the pancreas for promising adjunct therapy for some patients with diabetes or
glucose homeostasis. When food enters and stimulates the stom- prediabetes to improve their overall health.7
ach, several hormones are at play. Within several minutes, incre-
tins, which include GIP (glucose-dependent insulinotropic peptide) Weight Loss
and GLP-1 (glucagon-like peptide -1), are secreted from endocrine
cells. Several processes are involved, including the regulation of Decreased caloric intake can achieve desired weight loss for
insulin.5 The dipeptidyl peptidase 4 (DPP-4) enzyme deactivated patients with an elevated BMI. Numerous dietary approaches exist
the incretins quickly. Hence, DPP-4 medications such as Januvia are that individuals may explore to achieve weight loss or enhance
developed to delay incretin degradation. Ghrelin and leptin are 2 of their overall well-being; however, the effectiveness of these diets is
many hormones that control appetite and fullness. Leptin decreases not universal, and some may come with considerable costs or po-
one’s appetite, while ghrelin increases it.5 Carbohydrates and pro- tential risks. It is crucial to recognize that dietary outcomes are
teins can be converted into fat cells to build the adipose tissues for a highly individualized; what proves unsuccessful for one person
store of energy, also known as lipogenesis.5 might yield positive results for another.
A comparison analysis several years ago found no difference in
Various Approaches to IF weight loss outcomes, whether there was a focus on fats, proteins,
or carbohydrates, as long as a significant reduction in calorie
IF is a dietary approach that involves scheduling periods of intake.8 On the other hand, a systematic review documented that IF
fasting with regular eating. Several types of intermittent fasting shows promise in treating obesity with improved glycemic control,
include time-restricted eating, whole-day fasting, alternate-day showcasing a different approach to calorie restriction.9
fasting, and more. Each class incorporates a different fasting
period and frequency, each with unique characteristics. Reduced Inflammation

The 16/8 Method Obesity is linked to long-lasting, mild inflammation in the body.
This inflammation occurs because specific immune cells, called
The 16/8 Method involves fasting for 16 hours daily and eating macrophages, become more active and release substances that
within an 8-hour window. For example, a person might skip promote inflammation (such as tumor necrosis factor-a and
breakfast and eat their meals between 12:00 PM and 8:00 PM. This is interleukin-6). In people with obesity, the body’s fatty tissue also
one of the most popular and accessible IF methods, making it a adds to the inflammation. IF can enhance metabolic efficiency in
good option for beginners.6 several ways. It helps regulate blood sugar levels and reduces
oxidative stress that can harm cells. Additionally, IF positively af-
The 5:2 Diet fects the immune system by improving gut health and supporting a
healthy gut microbiome, both of which are crucial for overall im-
This method involves eating 5 days a week and restricting cal- munity. One of the fundamental mechanisms is the activation of
orie intake to 500 to 600 calories on 2 nonconsecutive days. This autophagy, a cellular process that helps eliminate damaged cells
approach allows for more flexibility on nonfasting days and can be a and proteins, ultimately contributing to reduced inflammation.10
good option for those who prefer not to fast daily. Alternate-day Fitzgerald and colleagues conducted a preliminary study
fasting involves “modified” fasting every other day, whereas the examining the safety and practicality of various calorie-restriction
24-hour fast (or the “Eat-Stop-Eat” method) consists of fasting for (CR) diets for individuals with multiple sclerosis (MS). They also
24 hours once or twice a week.6 aimed to measure the impact of these diets on weight and self-
reported outcomes. The 36 participants were assigned to 1 of 3
The 12/12 Method diet plans for 8 weeks: a daily CR diet with a 22% energy reduction,
an intermittent CR diet with a 75% energy reduction for 2 days and
This method involves fasting for 12 hours each day and eating no reduction for 5 days, or a stable-weight diet with no energy
within a 12-hour window. For example, a person might eat be- reduction. Although there were no significant differences in weight
tween 8:00 AM and 8:00 PM. This method is less restrictive than the changes between the different CR diets, those on the daily CR diet
16/8 method and can be a gentle introduction to IF.6 experienced slightly more weight loss. Both CR diets led to notable
improvements in emotional well-being and depression scores
compared with the control group, with an average increase of 1.69
Health Benefits of IF
points over the 8 weeks. The study suggests that CR diets can be a
safe and viable method for weight loss in individuals with MS and
Insulin
may contribute to enhanced emotional health.11
A randomized controlled trial published in 2021 by Che et al
found that time-restricted eating can improve insulin sensitivity in Disadvantages of IF
patients diagnosed with diabetes or prediabetes. Sixty patients
participated in a 10-hour restricted feeding treatment program. The The disadvantages and side effects of IF can vary among in-
10-hour time-restricted feeding (TRF) group fed freely from 8:00 to dividuals. Side effects may include headaches, lethargy, con-
18:00 and fasted from 18:00 to 8:00 daily (a 14-hour fast) in the 12- stipation, dehydration, hypoglycemia, sleep disturbances,
week intervention. According to this study, TRF intervention disordered eating, dizziness, and irritability.12
decreased fasting glucose levels by 15% and hemoglobin A1c
(HbA1c) values by 18%, approximately twice the effect of diabetes Potential Health Concerns and Contraindications
medicine. HbA1c is a form of hemoglobin chemically modified by
the attachment of glucose (sugar) molecules. It is used as a marker Some individuals may not be ideal candidates for IF because of
to estimate a person’s average blood glucose levels over the past 2 specific health concerns that make this dietary approach
to 3 months. These findings suggest that time-restricted eating is a unsuitable.
 K. Nye et al. / The Journal for Nurse Practitioners 20 (2024) 104893 3

Individuals With Diabetes disorders or unhealthy food relationships.18 IF is marketed as a

weight loss tool, which can exacerbate an unhealthy preoccupation
IF is not indicated for type 1 diabetes. IF is not recommended for with food and body weight. This can harm individuals with body
type one diabetes because of the risk of profound hypoglycemia. image issues or an eating disorder.
Although IF may improve the body’s response to insulin, it can be
challenging to maintain stable blood sugar levels and adjust med-
Individuals With a Weakened Immune System
ications to prevent low blood sugar. As a result, IF can pose chal-
lenges for people with diabetes in managing their condition.
IF might not suit people with compromised immune systems
However, some studies have shown benefits for individuals with
because it can exacerbate their condition. Those with weakened
type 2 diabetes. Consulting a health care professional is essential
immunity, such as patients undergoing chemotherapy, individuals
before starting IF in this case.
with HIV/AIDS, or those with autoimmune disorders, may need
consistent energy and nutrient intake to support their body’s de-
Pregnant and Breastfeeding Women
fense mechanisms. By imposing periods of fasting, IF could disrupt
their nutritional balance, potentially worsening their health status.
IF may lead to insufficient intake of nutrients during pregnancy
One study on IF and its effects on the immune system found that
or breastfeeding, potentially affecting the health of the mother and
although it could alter the gut microbiota and confer some pro-
the child. Evidence shows that the mother’s diet greatly determines
tection in central nervous system autoimmunity, further investi-
the nutritional quality of breast milk. Taking in fewer calories
gation is needed to determine effectiveness in weakened immune
means fewer vitamins and minerals, decreasing nutrients.13
systems.19 The study mainly focused on the potential benefits for
A systematic review and meta-analysis conducted by Glazier
individuals with MS, an autoimmune disorder. However, the results
et al, published in BMC Pregnancy and Childbirth in 2018, evaluated
should be interpreted cautiously when considering individuals
the effect of Ramadan fasting on perinatal outcomes. It was found
with compromised immunity.19
that although birth weight was not significantly affected, placental
A 2023 Quality of Life Research review examined fasting during
weight was notably lower in fasting mothers, suggesting potential
cancer treatment. The review, which analyzed various studies
underlying impacts not fully understood or explored. The review
involving 379 patients, found no beneficial effects of short-term
highlighted the need for more comprehensive studies to ascertain
fasting on the quality of life for cancer patients undergoing treat-
the broader effects of fasting during pregnancy because individual
ment. Moreover, no evidence suggests that fasting regimens
study results are conflicting and often limited by small sample
reduced chemotherapy’s side effects or toxicities. In fact, due to the
sizes. Given the potential risks and the lack of conclusive evidence
severe impact of unintentional weight loss on clinical outcomes,
supporting the safety of IF during pregnancy and breastfeeding, it is
fasting is not recommended for cancer patients.20 Further investi-
generally advised against it until more definitive research is
gation is needed to determine effectiveness in weakened immune
available.14
systems.
Low Bone Density
Implications for Practice
Minerals, including vitamin D, are shown to decrease with CR
with loss of bone density. Therefore, patients with osteopenia or IF is a viable method for managing weight and improving
osteoporosis are at greater risk.15 A review published in 2019 various health parameters, as outlined in this article. Integrating
explored the effects of CR, IF, and vegetarian/vegan diets on bone psychotherapy and physical therapy can offer a multidimensional
health, mainly focusing on bone mineral density (BMD) and frac- approach to support their weight loss journey and overall well-
ture risk. This review found that CR (but not IF) reduces BMD being when considering the holistic care of patients exploring or
without affecting bone quality, although data are limited. It also practicing IF.
noted that vegetarian diets, and particularly vegan diets, are asso-
ciated with significantly lower BMD values than omnivorous diets
Psychotherapeutic Support
and could potentially increase the risk of fractures. Individuals
following these diets were advised to be aware of the risk of
Psychotherapy, mainly cognitive behavioral therapy (CBT) and
osteoporosis and fractures and to ensure adequate calcium and
other behavioral interventions can be instrumental in addressing
vitamin D intake.15
the psychological aspects of weight management and diet adher-
ence. The noted reduction in obesity following psychotherapy
History of Behavioral Disorder
sessions in one study suggests that integrating psychotherapy can
enhance the effectiveness and adherence to diet regimens like IF.21
Committing to IF can be challenging. Even with successful out-
Additionally, psychotherapy can help address emotional or behav-
comes from establishing an IF regimen, there is a chance for a
ioral challenges during IF. It provides a supportive environment for
regain of weight, compounding further behavioral challenges due
individuals to explore and overcome barriers to their weight loss
to ongoing weight issues. A comparison study of IF versus contin-
goals.
uous CR showed good weight loss, each regaining the weight back
to baseline by 12 months.16 In addition, fatigue, poor sleep quality,
and nausea were significant in a meta-analysis for fasting Physical Therapy and Exercise
intervals.17
Patients with any eating disorders must be carefully screened Physical therapy and structured exercise programs can signifi-
before considering IF, which may trigger or exacerbate disordered cantly contribute to the success of weight management efforts in
eating patterns or unhealthy preoccupations with food. It involves individuals practicing IF. Given that sedentary lifestyles are a sig-
restricting food intake for a certain period, which can trigger feel- nificant risk factor for noncommunicable diseases, incorporating
ings of deprivation and lead to an obsession with food. This can be regular physical activity and therapy can help mitigate these risks
especially problematic for individuals with a history of eating while supporting weight loss and improving physical health.22
4 K. Nye et al. / The Journal for Nurse Practitioners 20 (2024) 104893

Collaborative Health Care Approach explores the effect of added sugar on appetite, evaluating studies
that investigated energy consumption, satiety, and appetite hor-
Integrating psychotherapy and physical therapy underscores the mones such as leptin and ghrelin. Added sugar intake may affect
importance of a collaborative health care approach. NPs, dietitians, these parameters, increasing hunger and overeating.26
psychotherapists, and physical therapists can work together to
provide a comprehensive care plan for patients. This collaborative Long-Term Sustainability
approach aligns with the personalized care model emphasized, Although IF can be effective for weight loss and may improve
especially when advising on IF regimes. Providing patients with a cardiovascular and metabolic health, the long-term sustainabil-
robust support system encompassing dietary counseling, psycho- ity of these effects requires further study. It is essential to bal-
logical support, and physical activity guidance can significantly ance the caloric intake during the eating window to maintain
enhance the effectiveness and sustainability of IF as a weight the benefits of IF. 27 Adverse effects such as hunger, irritability,
management strategy. and impaired cognition may dissipate within a month of the
regimen. The data on IF’s safety and long-term sustainability are
Education and Continuous Monitoring sparse.27

As mentioned, educating patients on healthy eating habits, Conclusion

portion control, nutrient-dense foods, and the benefits and risks
associated with IF is crucial. Continuous monitoring and regular IF has emerged as a promising, cost-effective dietary approach
assessments by NPs and other health care professionals can help with numerous potential health benefits, including weight loss,
track progress, ensure the safety and appropriateness of the IF improved metabolic health, and enhanced cognitive function.
regimen, and adjust care plans as necessary. However, it is not suitable for everyone, and specific individuals
may face contraindications or adverse effects. The NP’s role is
Research on Combined Interventions crucial in recommending IF. Before recommending a dietary
intervention, they must assess each patient’s unique needs, medical
A systematic review that included behavioral weight manage- history, and lifestyle. By providing individualized guidance and
ment interventions alongside physical activity components further monitoring patient progress, NPs can help ensure that IF is imple-
validated the significance of a multifaceted approach in weight mented safely and effectively, ultimately empowering patients to
management, highlighting the potential for synergistic benefits optimize their health and well-being.
when combining dietary, psychotherapeutic, and physical in-
terventions.23 The combination of psychotherapy and physical CRediT Author Statement
therapy, personalized IF regimens, and continuous health care
professional support presents a comprehensive and individualized Kathleen Nye: Writing e review & editing, Writing e original
approach to weight management. This holistic model can yield draft, Supervision, Conceptualization. Craig Cherrin: Writing e
better adherence to IF regimens, improved weight loss outcomes, review & editing, Writing e original draft, Supervision. Jan Meires:
and enhanced overall patient well-being. Writing e review & editing, Data curation.
Although IF can effectively manage caloric intake and promote
weight loss, it is not a license to eat whatever one wants during the Declaration of Competing Interest
eating window. Here are a few reasons.
In compliance with standard ethical guidelines, the authors
Caloric Balance report no relationships with businesses or industries that may pose
Weight management is ultimately about balancing calories a conflict of interest.
consumed and burned. Even when practicing IF, weight gain may
still occur if more calories are consumed than burned during the Funding
eating window. Eating high-calorie, low-nutrient foods can easily
lead to a caloric surplus. The authors received no funding for this article.

Nutritional Quality
Supplementary Data
The quality of the food consumed matters for overall health. A
study published by the British Medical Journal recommends food-
Supplementary Appendix associated with this article can be
based prevention of chronic disease risk, advocating for a diet
found at https://doi.org/10.1016/j.nurpra.2023.104893.
high in fruits, vegetables, whole grains, and fish while suggesting
lower consumption of red and processed meats and sugar-
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