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

<ns3:p>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.</ns3:p>