Associations of prenatal exposure to Ramadan with small stature and thinness in adulthood: results from a large Indonesian population-based study

Ramadan during pregnancy and offspring health outcomes over the life course: a systematic review and meta-analysis

BACKGROUND

Intermittent fasting, such as during Ramadan, is prevalent among pregnant women. However, the association between Ramadan during pregnancy and offspring health along the life course has not been fully established.

OBJECTIVE AND RATIONALE

Fetal programming research indicates that prenatal exposures, particularly during early pregnancy, can cause long-term structural and physiological changes that adversely affect offspring health. Our objective was to systematically identify and assess the evidence regarding Ramadan during pregnancy.

SEARCH METHODS

A total of 31 studies were sourced from PubMed, EMBASE, Web of Science, and EconLit. Included studies evaluated outcomes in individuals with prenatal Ramadan exposure, compared to unexposed Muslim controls. Main outcomes were birth weight, gestational length, and sex ratio in newborns; height, mortality, and cognition in children; and disabilities, chronic diseases, and human capital accumulation in adults. Each study was evaluated for risk of bias. The overall quality of evidence was appraised using the GRADE system. Random-effects meta-analyses were conducted for outcomes analyzed in at least three primary studies.

OUTCOMES

The initial search identified 2933 articles, 1208 duplicates were deleted. There were 31 publications fulfilled the eligibility criteria for the qualitative synthesis; 22 studies were included in meta-analyses. The overall quality of the evidence was low to moderate and differed by study design and outcome. Among newborns, prenatal Ramadan exposure was not associated with birth weight (mean difference (MD) -3 g (95% CI -18 to 11; I2 = 70%) or the likelihood of prematurity (percentage point difference (PPD) 0.19 (95% CI -0.11 to 0.49; I2 = 0%)). The probability that the newborn is male was reduced (PPD -0.14 (95% CI -0.28 to -0.00; I2 = 0%)). This potentially reflects sex-specific mortality rates resulting from adverse in utero circumstances. In childhood, the exposed performed slightly poorer on cognitive tests (MD -3.10% of a standard deviation (95% CI -4.61 to -1.58; I2 = 51%)). Height among the exposed was reduced, and this pattern was already visible at ages below 5 years (height-for-age z-score MD -0.03 (95% CI -0.06 to -0.00; I2 = 76%)). A qualitative literature synthesis revealed that childhood mortality rates were increased in low-income contexts. In adulthood, the prenatally exposed had an increased likelihood of hearing disabilities (odds ratio 1.26 (95% CI 1.09 to 1.45; I2 = 32%)), while sight was not affected. Other impaired outcomes included chronic diseases or their symptoms, and indicators of human capital accumulation such as home ownership (qualitative literature synthesis). The first trimester emerged as a sensitive period for long-term impacts.

WIDER IMPLICATIONS

Despite the need for more high-quality studies to improve the certainty of the evidence, the synthesis of existing research demonstrates that Ramadan during pregnancy is associated with adverse offspring health effects in childhood and especially adulthood, despite an absence of observable effects at birth. Not all health effects may apply to all Muslim communities, which are diverse in backgrounds and behaviors. Notably, moderating factors like daytime activity levels and dietary habits outside fasting hours have hardly been considered. It is imperative for future research to address these aspects.

REGISTRATION NUMBER

PROSPERO (CRD42022325770).

Ramadan fasting in the third trimester of pregnancy and postpartum colostrum cortisol concentrations in Morocco

Breast milk cortisol concentration varies among and within lactating women, but the causes and consequences of variation are not yet fully understood. This study investigated whether maternal fasting from food and water for over 16 h per day during the third trimester of pregnancy was associated with increased concentrations of cortisol in colostrum during the month of Ramadan in a Moroccan sample. Participants were women who gave birth at the public maternity hospital in Rabat, Morocco throughout the month of and month following Ramadan. Participants completed interviews (N = 92), underwent anthropometric assessment (N = 73), and colostrum samples (N = 63) were collected approximately 48-72 h postpartum. Cortisol analysis was completed on a subset of colostrum samples (N = 43). Women were categorized as fasting every day of Ramadan before giving birth (N = 52/92, 57%), fasting some days (N = 29/92, 32%), and not fasting (N = 11/92, 11%). For women who fasted, average fasting duration was 19.5 days (range: 1-29 days), and average time between the last day of fasting and birth was 8.8 days (range: 0-43 days). The number of days of fasting was positively associated with cortisol concentrations in colostrum (p < .009) in a multivariate analysis controlling for maternal anthropometry, hypertension and/or diabetes, and reasons for opting out of fasting. Each day of fasting was associated with a 4.05% increase in colostrum cortisol. Results are consistent with the hypothesis that maternal fasting during the third trimester of pregnancy increases breast milk cortisol and thus alters the hormonal milieu to which the infant is exposed.

Ramadan intermittent fasting reduces visceral fat and improves gastrointestinal motility

BACKGROUND

Ramadan is a model of intermittent fasting linked with possible beneficial effects. Scarce information, however, is available about the combined effects of Ramadan intermittent fasting (RIF) on anthropometric and metabolic indices, gastrointestinal symptoms, and motility.

METHODS

In 21 healthy Muslims, we assessed the impact of RIF on caloric intake, physical activity, gastrointestinal symptoms and motility (gastric/gallbladder emptying by ultrasonography, orocaecal transit time by lactulose breath test), anthropometric indices, subcutaneous and visceral fat thickness (ultrasonography), glucose and lipid homeostasis.

RESULTS

Mean caloric intake decreased from a median of 2069 kcal (range 1677-2641) before Ramadan to 1798 kcal (1289-3126) during Ramadan and increased again to 2000 kcal (1309-3485) after Ramadan. Although physical activity remained stable before, during, and after RIF, body weight, body mass index and waist circumference decreased in all subjects and in both genders, together with a significant decrease in subcutaneous and visceral fat thickness and insulin resistance. The postprandial gastric emptying speed was significantly faster after than before RIF. Fasting gallbladder volume was about 6% smaller after, than before Ramadan, with a stronger and faster postprandial gallbladder contraction. After RIF, lactulose breath test documented increased microbiota carbohydrate fermentation (postprandial H2 peak), and faster orocaecal transit time. RIF also significantly improved gastric fullness, epigastric pain and heartburn.

CONCLUSIONS

RIF generates, in healthy subjects, multiple systemic beneficial effects in terms of fat burden, metabolic profile, gastrointestinal motility and symptoms. Further comprehensive studies should assess the potential beneficial effects of RIF in diseased people.

Ramadan during pregnancy and neonatal health-Fasting, dietary composition and sleep patterns

BACKGROUND AND OBJECTIVES

Large shares of pregnant Muslims worldwide observe the Ramadan fast. Previous research showed that Ramadan during pregnancy is associated with adverse offspring health outcomes lasting throughout the life-course. Evidence on effects on birth outcomes is inconclusive, however, and previous research did not consider the role of dietary composition and sleep patterns during Ramadan. This study systematically documents maternal lifestyle during Ramadan and assesses if diet and sleep adaptations to Ramadan, independent of and in addition to maternal fasting, are associated with neonatal health outcomes.

METHODS

This study reports a survey of 326 Muslims who delivered their baby in Mainz, Germany, linked to maternal & infant hospital records. Participants reported on fasting, dietary composition and sleep schedules while pregnant during Ramadan.

RESULTS

Fasting during pregnancy was associated with reduced birthweight, in particular for fasting during the first trimester (-352ˑ92g, 95% CI: -537ˑ38; -168ˑ46). Neither dietary composition nor altered sleep were directly associated with birthweight. However, dietary composition during Ramadan outside of fasting hours seems to moderate the fasting-birthweight association, which disappeared for women switching to high-fat diets.

CONCLUSIONS

The finding that dietary intake during Ramadan potentially moderates the fasting-birthweight association is of high relevance to pregnant Muslims who wish to fast and their healthcare professionals, since dietary choices outside of fasting hours are often relatively easily modifiable. This is the first study to include information on maternal diet and sleep during Ramadan, and additional research is needed to assess the roles of specific (macro)nutrients and food groups.

In utero Ramadan exposure and child nutrition

In this study, we empirically analyse whether in utero exposure to the Ramadan fasting period is negatively associated with child nutrition. The data for the analyses come from a retrospective assessment of 759,799 children from 103 Demographic and Health Surveys (DHS) across 56 countries during 2003-2020. Considering the month-long Ramadan exposure as a natural experiment, we implement an intent-to-treat framework, comparing stunting and underweight among children aged 0-5 years who were exposed to Ramadan fasting at any time in utero with those who were not exposed. Our findings do not show significant evidence to conclude that in utero exposure to the Ramadan fasting period is negatively associated with child nutrition. On the contrary, except for stunting in Muslim children who had in utero exposure to Ramadan fasting during the first months of pregnancy, we find no significant association between in utero exposure to Ramadan fasting and child stunting and underweight. Our main results are robust to multiple robustness checks.

Maternal intermittent fasting in mice disrupts the intestinal barrier leading to metabolic disorder in adult offspring

Maternal nutrition plays a critical role in energy metabolism of offspring. We aim to elucidate the effect of long-term intermittent fasting (IF) before pregnancy on health outcomes of offspring. Here we show long-term IF before pregnancy disrupts intestinal homeostasis of offspring with subsequent disorder of glucose and lipid metabolism. This occurs through the reduction in beneficial microbiota such as Lactobacillus_intestinalis. Our observations further support the concept that intestinal microbiota in offspring is vulnerable to maternal nutrition, and its homeostasis is critical for the integrity of intestinal barrier and metabolic homeostasis.

Impact of prenatal exposure to Ramadan on disability in Pakistan among adults age 18-64

Purpose

Temporary disruptions to eating and sleeping patterns due to exposure to Ramadan during pregnancy have been shown to increase the probability of disability and chronic health problems later in life. This study aims to analyze the intent-to-treat effect of prenatal exposure to Ramadan (the Islamic month of fasting) on individual disabilities for individuals age 18 to 64 across three provinces encompassing 94% of Pakistan's population.

Subjects and methods

The study uses observational data from 2017 to 2019 by the UN-supported Multiple Indicator Cluster Survey (MICS) on 187,265 adults in Punjab, 71,895 adults in Sindh, and 91,283 in Khyber Pakhtunkhwa, Pakistan. Excluding data on those age > 64 and observations with incomplete data, multivariate regression analysis was conducted on the data of around 277,000 individuals to assess the risk of disability due to pregnancy coinciding with Ramadan.

Results

Considering exposure to Ramadan by calendar month prior to birth, women exposed in particular months have lower rates of disability related to sight (-0.3 percentage point, p < 0.1), memory (-0.3 pp., p < 0.05), and mobility (-0.6 pp., p < 0.05) but a higher chance of hearing problems (0.2 pp., p < 0.1) as compared to women who were not exposed in utero, while men exposed in particular months have a higher likelihood of a disability in sight (0.5 pp., p < 0.05), hearing (0.4 pp., p < 0.05), communication (0.5 pp., p < 0.01), memory (0.5 pp., p < 0.05), or mobility (0.9 pp., p < 0.01) as compared to men who were not exposed to Ramadan and women who were similarly exposed. Considering the provinces separately, the results were dominated by Punjab where overlap of pregnancy with Ramadan increased the likelihood of men experiencing a severe disability in hearing, communication, memory, or mobility. Men in Sindh were more likely to experience a memory or mobility disability, and men in Khyber Pakhtunkhwa were less likely to experience a communication or memory disability.

Conclusions

Pregnant women should be counseled regarding the alterations in eating, nutrition, and sleep patterns that may occur during Ramadan, as exposure to Ramadan during pregnancy increases rates of sight, hearing, memory, communication, and mobility disabilities in men.

Global Research Trends of Health-Related Publications on Ramadan Fasting from 1999 to 2021: A Bibliometric Analysis

Ramadan fasting is one of the five pillars of Islam. The current study aims to examine, analyze, and identify trends of health-related publications on Ramadan fasting. In total, 1468 documents retrieved from Scopus were analyzed. The mean number of authors per document was 3.7, with an average of 13.3 citations per document. The UK ranked first (12.3%, n = 181) regarding the number of documents, followed by Iran (10.4%, n = 153) and then Saudi Arabia (9.8%, n = 144). The most active journal was "Diabetes Research and Clinical Practice" (4.9%, n = 72). Publications related to diabetes and fasting constituted around 29.7% (n = 436) of the literature. The research volume on Ramadan fasting has been noticeably growing. More reliable research is required to aid healthcare professionals in providing patient-specific care.

Long-Term Outcomes of in Utero Ramadan Exposure: A Systematic Literature Review

Health outcomes of in utero Ramadan exposure have been reported in a systematic literature review; however, the available literature on long-term effects were not fully covered. Our study aims to specifically review the long-term outcomes of in utero Ramadan exposure. We searched for original research articles analyzing any long-term outcome of in utero Ramadan exposure, excluding maternal and perinatal outcomes. Sixteen studies from 8304 non-duplicate search results were included. Most studies suggest negative consequences from in utero Ramadan exposure on health, as well as on economic outcomes later in adulthood. Higher under-five mortality rate, higher mortality under three months, and under one year, shorter stature, lower body mass index, increased incidence of vision, hearing and learning disabilities, lower mathematics, writing and reading scores, as well as a lower probability to own a home were associated with Ramadan exposure during conception or the first trimester of pregnancy. Furthermore, age and sex seem to play a pivotal role on the association. Existing studies suggest that in utero Ramadan exposure may adversely impact long-term health and economic well-being. However, evidence is limited. Meanwhile, increasing awareness of the potential risks of Ramadan fasting during pregnancy should be raised among pregnant women and clinicians and other antenatal care workers should promote better maternal healthcare.

Ramadan Fasting during Pregnancy and Health Outcomes in Offspring: A Systematic Review

Ramadan is one of the five pillars of Islam, during which fasting is obligatory for all healthy individuals. Although pregnant women are exempt from this Islamic law, the majority nevertheless choose to fast. This review aims to identify the effects of Ramadan fasting on the offspring of Muslim mothers, particularly on fetal growth, birth indices, cognitive effects and long-term effects. A systematic literature search was conducted until March 2020 in Web of Science, Pubmed, Cochrane Library, Embase and Google Scholar. Studies were evaluated based on a pre-defined quality score ranging from 0 (low quality) to 10 (high quality), and 43 articles were included. The study quality ranged from 2 to 9 with a mean quality score of 5.4. Only 3 studies had a high quality score (>7), of which one found a lower birth weight among fasting women. Few medium quality studies found a significant negative effect on fetal growth or birth indices. The quality of articles that investigated cognitive and long-term effects was poor. The association between Ramadan fasting and health outcomes of offspring is not supported by strong evidence. To further elucidate the effects of Ramadan fasting, larger prospective and retrospective studies with novel designs are needed.

The Impact of Prenatal Exposure to Ramadan on Child Anthropomorphic Outcomes in Pakistan

OBJECTIVES

This study analyzes the intent-to-treat effect of prenatal exposure to Ramadan (the Islamic month of fasting) on outcomes including stunting and underweight for children under age 5 years in Pakistan born between 2003 and 2018.

METHODS

The study uses observational data from four rounds of the UN-supported Multiple Indicator Cluster Survey (MICS) data collected on 204,186 children under-5 from Punjab, Pakistan in 2007-2008, 2010-2011, 2013-2014, and 2017-2018. Excluding data on outliers and observations with incomplete data, multivariate logistic regression analysis was conducted on the appended cross-sectional data of 179,943 children under-5 to assess the risk of stunting or underweight according to the month of gestation coinciding with Ramadan.

RESULTS

We observe a significant increase in the risk of stunting and underweight associated with exposure to Ramadan following an inverted-U pattern. The peak impact of Ramadan exposure on a child being underweight occurs in the third month of pregnancy, where the probability of being underweight is 20 percent higher as compared to children whose gestation did not coincide with Ramadan. The peak impact of Ramadan exposure on stunting occurs in the fourth month of pregnancy, where the probability of stunting is 22 percent higher as compared to children whose gestation did not coincide with Ramadan. These results vary little by gender. In contrast, exposure to Ramadan in the ninth month of gestation is associated with a reduction in the risk of stunting for boys and underweight for both boys and girls.

CONCLUSIONS FOR PRACTICE

Our analysis indicates that prenatal exposure to Ramadan during the first two trimesters have negative implications for children's growth. The study highlights the critical role of maternal habits during early pregnancy, especially nutritional intake, for the long-term physical development of children.

Short-term fetal nutritional stress and long-term health: Child height

OBJECTIVE

This study examined the impact of in utero exposure to Ramadan, the Islamic fasting month, by trimester on height at ages 0 to 18 for a sample of children from Tehran, Iran. If exposure to Ramadan is associated with significant nutritional stress to the fetus, the fetus's adaptive responses to nutritional insufficiency could manifest as changes in height during childhood, long before any effects on aging or disease risk at older ages.

METHODS

Children who were exposed and not exposed to Ramadan in utero were compared to identify any systematic difference between their parents' and households' characteristics (including height, age, education, and indicators of wealth). Also, the seasonal pattern of food consumption in Tehran was analyzed. Finally, the association of child height with prenatal exposure to Ramadan was measured, controlling for seasonality and parent and household.

RESULTS

Ramadan associated fasting in the second trimester of gestation was associated with 0.091 age-adjusted SDs (ie, 0.60-0.67 cm) decrease in children's height at age 10 years or older. The negative association was largest in male children and was approximately 1 cm at age 12 years or older among male children.

CONCLUSION

Maternal Ramadan fasting in the second trimester, the critical period for long bone development, was associated with decreased height. Exposure to ritual fasting is important because approximately 75% of all Muslim children are exposed to Ramadan in utero.

Ramadan exposure and birth outcomes: a population-based study from the Netherlands

BACKGROUND

Ramadan, the Islamic month of daytime fasting, is observed by many pregnant Muslims. Although pregnant women are exempt, many prefer to fast. Previous research has shown long-term adverse effects on various health outcomes among the offspring, but evidence on effects on perinatal outcomes is mixed. This study investigates effects of Ramadan during pregnancy among Muslims in the Netherlands.

METHODS

Data from the Perinatal Registry of the Netherlands (Perined) on all births between 2000 and 2010 to mothers recorded as Mediterranean (i.e. of Turkish/Moroccan descent, a proxy for Muslim) (n = 139,322) or as ethnically Dutch (n = 1,481,435) were used. Ramadan exposure was defined using an intention-to-treat approach as the occurrence of a Ramadan during gestation. Muslims with versus without a Ramadan occurring during gestation were compared using difference-in-differences analyses. In these multiple linear/logistic regressions, non-Muslims were additionally included in order to take out potentially remaining confounding through seasonal effects.

RESULTS

The occurrence of a Ramadan during pregnancy among Muslims was not associated with altered birth weight, gestational length, newborn's sex, perinatal mortality, low Apgar, or mild congenital anomalies. Odds for severe congenital anomalies were higher among the exposed (odds ratio: 1.17; 95% confidence interval: 1.00, 1.37), but this association became non-significant when adjusting for multiple testing.

CONCLUSIONS

Despite earlier research showing long-term adverse health effects of prenatal exposure to Ramadan, there seems to be little or no relation between exposure to Ramadan during pregnancy and birth outcomes.

The effects of prenatal exposure to Ramadan on stature during childhood and adolescence: Evidence from the Indonesian Family Life Survey

Many pregnant Muslim women fast during the Muslim holy month of Ramadan. A number of studies have reported negative life outcomes in adulthood for children who were prenatally exposed to Ramadan. However, other studies document minimal to no impact on neonatal indicators. Using data from the Indonesian Family Life Survey consisting of 45,246 observations of 21,723 children born to 9771 mothers, we contribute to the current discussion on prenatal exposure to Ramadan by examining the effects on stature (height-for-age Z-scores, weight-for-age Z-scores, and body-mass-index-for-age Z-scores: HAZ, WAZ, and BAZ, respectively) from early childhood to late adolescence (0-19 years of age). We introduce an objective mother's religiosity indicator to improve the intention-to-treat estimations. Children were classified into three groups based on their mother's religion-religiosity: religious Muslims, less-religious Muslims, and non-Muslims. Using cluster-robust mother fixed-effects, we found negative effects on stature for children born to religious Muslim mothers. The effects were age-dependent and timing-sensitive. For example, children born to religious Muslim mothers were shorter in late adolescence (15-19 years of age) compared to their unexposed siblings if they were prenatally exposed in the first trimester of pregnancy (HAZ difference = -0.105 SD; p-val. <0.05). Interestingly, we found positive effects on stature for exposed less-religious Muslim children that peak in early adolescence (10-14 years of age) and negative effects on stature for exposed non-Muslim children that occur only in early childhood (0-4 years of age). We nuance our discussion of health and socioeconomic factors to explain these surprising results.

Perspectives and pregnancy outcomes of maternal Ramadan fasting in the second trimester of pregnancy

Background

There are controversies over the effects of Ramadan fasting on pregnancy outcomes, and women’s perspectives of fasting are diverse. This study aimed to assess the perspectives and pregnancy outcomes of maternal Ramadan fasting in the second trimester of pregnancy.

Methods

A case-control study was conducted at Hawler Maternity Teaching Hospital of Erbil, Iraq from October 2017 to January 2018. Out of 301 participating women, 155 fasted during the second trimester of their current pregnancy, while the remaining 146 did not. Mothers were asked concerning their fasting behaviors and perception of fasting during pregnancy. The main outcomes of this study were gestational diabetes, preterm labour, preeclampsia, low birth weight, Apgar score, height, weight, and head circumference of the newborn.

Results

About 80% of the women in the fasting group fasted for 21–29 days during Ramadan, out of whom 38.7% completed fasting for the entire Ramadan period. The results revealed that the decision to fast during pregnancy was negatively associated with the mother’s educational level and occupation. Weight gain during pregnancy in the fasting women was approximately 0.4 kg less than those who did not fast. The incidence of gestational diabetes was 2.6% in the fasting women, while it was 8.3% in the non-fasting mothers (P = 0.02). Regression analysis showed that women who did not fast during the second trimester of pregnancy were 1.51 times more likely to develop gestational diabetes [odd ratio (OR) 1.51; 95% confidence intervals (CI) 0.06, 0.74, P = 0.01]. It was also found that among the women in the fasting categories, those who fasted for 21–29 days during pregnancy had a lower risk of gestational diabetes compared to the other groups. More than half of the mothers in the fasting group (60%) perceived that fasting during pregnancy was compulsory for healthy and non-healthy women, comparing with those who did not fast.

Conclusion

It was found that fasting during the second trimester of the pregnancy decreased the risk of gestational diabetes and excessive weight gain during pregnancy. Most of Iraqi women did not fully recognize their right to be exempted from fasting during pregnancy by the Islamic law.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2275-x) contains supplementary material, which is available to authorized users.

Ramadan Exposure In Utero and Child Mortality in Burkina Faso: Analysis of a Population-Based Cohort Including 41,025 Children

Ramadan exposure in utero can be regarded as a natural experiment with which to study how nutritional conditions in utero influence susceptibility to disease later in life. We analyzed data from rural Burkina Faso on 41,025 children born between 1993 and 2012, of whom 25,093 were born to Muslim mothers. Ramadan exposure was assigned on the basis of overlap between Ramadan dates and gestation, creating 7 exclusive categories. We used proportional hazards regression with difference-in-differences analysis to estimate the association between Ramadan exposure at different gestational ages and mortality among children under 5 years of age. Under-5 mortality was 32 deaths per 1,000 child-years. Under-5 mortality among Muslims was 15% higher than that among non-Muslims (P < 0.001). In the difference-in-differences analysis, the occurrence of Ramadan during conception or the first or second trimester was associated with higher under-5 mortality rates among Muslims only. The mortality rates of children born to Muslim mothers were 33%, 29%, and 22% higher when Ramadan occurred during conception, the first trimester, and the second trimester, respectively, compared with children of non-Muslim mothers born at the same time (P = 0.01, P < 0.001, and P = 0.007). Having a Muslim mother was not associated with mortality when the child was not exposed to Ramadan, born during Ramadan, or exposed during the third trimester. Observance of Ramadan during early pregnancy can have detrimental consequences for the future health of the unborn child.

As Long as the Breath Lasts: In Utero Exposure to Ramadan and the Occurrence of Wheezing in Adulthood

While prenatal exposure to Ramadan has been shown to be negatively associated with general physical and mental health, studies on specific organs remain scarce. In this study, we explored whether Ramadan exposure during pregnancy affects the occurrence of wheezing, a main symptom of obstructive airway disease. Using data from the Indonesian Family Life Survey collected between 1997 and 2008 (waves 2-4), we compared wheezing occurrence among adult Muslims who had been in utero during Ramadan with that in adult Muslims who had not been in utero during Ramadan. Wheezing prevalence was higher among adult Muslims who had been in utero during Ramadan, independent of the pregnancy phase in which the exposure to Ramadan occurred. Moreover, this association tended to increase with age, being strongest among those aged about 45 years or older. This is in line with fetal programming theory, suggesting that impacts of in utero exposures often manifest only after reproductive age. Particularly strong associations were detected for smokers. The respiratory system of prenatally exposed Muslims thus seems to perform worse in mitigating later ex utero harmful influences such as smoking. This study suggests that exposure to Ramadan during pregnancy may have lasting consequences for adult lung functionality.

Ramadan Observance during Pregnancy in Germany: a Challenge for Prenatal Care

INTRODUCTION

Fasting during Ramadan while pregnant has been shown to have long-term negative effects on the offspring's physical and cognitive health. Even though most Muslims do not believe pregnant women are obligated to fast during Ramadan, fasting rates of up to 87% have been reported for pregnant women. No data exists to date about Ramadan adherence and behavior in Germany.

METHODS

The Mainz Study of Ramadan and Pregnancy surveyed pregnant Muslims and new Muslim mothers in Mainz between October 2016 and January 2017 and collected information on Ramadan adherence and behavior. We also collected data on personal characteristics and opinions, to identify determinants of fasting using statistical analysis.

RESULTS

We found that 43% of pregnant Muslim women fasted at least one day during Ramadan 2016. Women who fasted were significantly younger and less educated. There was no significant difference in terms of country of origin between those women who fasted and those who did not. Only 49% of women who fasted and 38% of women who did not fast discussed their Ramadan behavior with their doctor. Less than 2% of women reported being proactively approached by their doctor.

CONCLUSION

To ensure that pregnant Muslim women living in Germany can make their fasting decision based on objective information, it is necessary to raise awareness about Ramadan fasting during pregnancy among medical professionals in Germany.

Ramadan during pregnancy and birth weight of newborns

Previous studies suggest that Ramadan exposure during pregnancy might affect the health of women and their babies, particularly through the effect of fasting. This study aimed to evaluate the association between Ramadan exposure and fasting during pregnancy on the birth weight of newborns. This study concerned 1351 pregnant women from a prospective cohort in Jakarta, Indonesia. Ramadan exposure was based on the actual overlap between Ramadan and pregnancy. Women's fasting behaviour was recorded among 139 women who came for antenatal care between 10 July 2013 and 7 August 2013, and those who had fasted for at least 1 d (n 110) were classified as exposed to Ramadan fasting. Furthermore, a 24 h dietary recall was performed and repeated 1 month later. Birth weight of newborns who were exposed to Ramadan during pregnancy did not significantly differ from those who were not, both in the total and trimester-specific analysis. Maternal fasting did not seem to affect the birth weight of newborns (-72 (95 % CI -258, 114) g; P = 0·44), although there was a non-significant trend towards lower birth weight with fasting in the second and third trimester. Women who fasted had significantly lower total energy, macronutrient and water intake as compared with women who did not. Women's intake was also lower during Ramadan (regardless of their fasting behaviour) as compared with 1 month later. Lifestyle changes that occur with Ramadan and fasting during pregnancy are associated with lower reported energy intake. We cannot conclude on the effect of fasting on birth weight due to low statistical power.

Prevalence of low birth weight, macrosomia and stillbirth and their relationship to associated maternal risk factors in Hohoe Municipality, Ghana

INTRODUCTION

birth weight is vital to the development potential of the newborn. Abnormal birth weight (such as low birth weight and macrosomia) is an important determinant of child survival, disabilities, stunting, and long-term adverse consequences for the onset of non-communicable diseases in the life course and therefore demands appropriate public health interventions. Stillbirths are also considered one of the most important, but most poorly understood and documented adverse outcomes of pregnancy. Therefore, this study aimed to assess the prevalence of abnormal birth weight and related maternal risk factors, as well as pregnancy outcomes, such as stillbirth.

METHODS

a retrospective study design was used to analyze 4262 delivery records for singleton pregnancies from January 2013 to December 2014 seen at the Hohoe municipal hospital, Volta region in Ghana. The data on birth weight and related factors were derived from the delivery book. Data was analyzed using STATA. Multinomial logistic regression was used to assess the association between maternal factors such as parity, age and intermittent preventive treatment of malaria, sex of infant and abnormal birth weight. Association between stillbirth and related factors was assessed using logistic regression.

RESULTS

prevalence of low birth weight (<2.5kg) was 9.69% and macrosomia (≥4.0kg) was 3.03%. There was an increased risk of a first born being of low birth weight than second or third born (RR; 2.04, CI; 1.59-2.64, p<0.0001). There were also an increased risks of mothers <20 years giving birth to low-birthweight infants (RR; 1.46, CI; 1.11-1.93, p=0.007) compared to mothers who were within the age ranges of 20-30 years and also among those who took only one (RR; 1.57, CI; 1.02-2.39, p=0.039) or no intermittent preventive treatment for malaria during pregnancy (RR; 1.57, CI; 1.24-1.98, p=<0.0001) compared to those who took three doses. Risk of macrosomic birth was particularly high among 5th born (RR; 2.66, CI; 1.43-4.95, p=0.002) compared to first or second born. Stillbirth rate was 27/1000 births. Thirty-two percent of the stillbirths (n=38) had low birth weight whereas 6.8% (n=8) were macrosomic. There was a greater than fivefold (AOR; 5.6, CI; 3.6-8.7) and greater than twofold (AOR; 2.4, CI; 1.1-5.3, p=0.025) increase in odds for stillbirth among low birth weight and macrosomic infants respectively.

CONCLUSION

macrosomia and low birth weight co-existed among infants in Hohoe municipality, both of which are associated with adverse pregnancy outcome such as stillbirth. Given the apparent association between maternal age <20 years and increased risk, health promotion strategies aimed at preventing pregnancies among teenagers could be implemented to aid the reduction of stillbirth rates.

Early-Life Conditions, Rapid Demographic Changes, and Older Adult Health in the Developing World

The demographic transition of the 1930s-1960s dramatically improved life expectancy in some developing countries. Cohorts born during this time are increasingly characterized by their survivorship of poor early-life conditions, such as poor nutrition and infectious diseases. As a result, they are potentially more susceptible to the effects of these conditions at older ages. This study examines this conjecture by comparing obesity, diabetes, and hypertension in older adults born in the beginning portion of the 1930s-1960s across different mortality regimes using a subset of harmonized cross-national data from seven low- and middle-income countries (RELATE, n = 16,836). Using birthplace and height as indicators of early-life conditions, the results show (1) higher prevalence of obesity and diabetes and higher likelihood of obesity, diabetes, and hypertension in middle-income countries, but (2) no convincing evidence to indicate stronger effects of early-life conditions on health in these countries. However, shorter adults living in urban areas were more likely to be obese, indicating the overall importance of early-life conditions and the potential negative impact of urban exposures during adulthood. Obesity results may foreshadow the health of future cohorts born in the later portion of the 1930s-1960s as they reach older ages (60+).

Babies of the War: The Effect of War Exposure Early in Life on Mortality Throughout Life

There is increasing evidence that circumstances very early in our lives, and particularly during pregnancy, can affect our health for the remainder of life. Studies that have looked at this relationship have often used extreme situations, such as famines that occurred during wartime. Here we investigate whether less extreme situations during World War II also affected later-life mortality for cohorts born in Belgium, France, The Netherlands, and Norway. We argue that these occupied countries experienced a considerable deterioration in daily life situations and show that this resulted in strongly increased mortality rates and lower probabilities of survival until age 55 among civilian populations who had been prenatally exposed to wartime circumstances. However, this mortality effect among the prenatally exposed is entirely concentrated in the first years of life, particularly infanthood. Once we condition on having survived the first years of life, those who had been prenatally exposed do not have higher mortality rates. This suggests that "culling" is important and that effects found in earlier studies may have been biased downward substantially.

Famines in the last 100 years: implications for diabetes

Overnutrition is a major cause of diabetes. The contrary situation of undernutrition has also been suggested to increase the risk of the disease. Especially undernutrition during prenatal life has been hypothesized to program the structure and physiology of the fetus in such a way that it is more prone to develop diabetes in later life. Famines over the last 100 years have provided historical opportunities to study later-life health consequences of poor nutritional circumstances in early life. The majority of studies based on famine exposure during prenatal life clearly show that diabetes risk is increased. Postnatal famine exposure in childhood, adolescence, or young adulthood also seems to raise risk for diabetes, although prenatal famine effects seem to be more substantial. These study results not only have implications for the consequences of famines still happening but also for pregnancies complicated by factors mimicking poor nutritional situations.

Experiences and outcomes of maternal Ramadan fasting during pregnancy: results from a sub-cohort of the Born in Bradford birth cohort study

BACKGROUND

Observing the fast during the holy month of Ramadan is one of the five pillars of Islam. Although pregnant women and those with pre-existing illness are exempted from fasting many still choose to fast during this time. The fasting behaviours of pregnant Muslim women resident in Western countries remain largely unexplored and relationships between fasting behaviour and offspring health outcomes remain contentious. This study was undertaken to assess the prevalence, characteristics of fasting behaviours and offspring health outcomes in Asian and Asian British Muslim women within a UK birth cohort.

METHODS

Prospective cohort study conducted at the Bradford Royal Infirmary UK from October to December 2010 comprising 310 pregnant Muslim women of Asian or Asian British ethnicity that had a live singleton birth at the Bradford Royal Infirmary. The main outcome of the study was the decision to fast or not during Ramadan. Secondary outcomes were preterm births and mean birthweight. Logistic regression analyses were used to investigate the relationship between covariables of interest and women's decision to fast or not fast. Logistic regression was also used to investigate the relationship between covariables and preterm birth as well as low birth weight.

RESULTS

Mutually adjusted analysis showed that the odds of any fasting were higher for women with an obese BMI at booking compared to women with a normal BMI, (OR 2.78 (95% C.I. 1.29-5.97)), for multiparous compared to nulliparous women(OR 3.69 (95% C.I. 1.38-9.86)), and for Bangladeshi origin women compared to Pakistani origin women (OR 3.77 (95% C.I. 1.04-13.65)). Odds of fasting were lower in women with higher levels of education (OR 0.40 (95% C.I. 0.18-0.91)) and with increasing maternal age (OR 0.87 (95% C.I. 0.80-0.94). No associations were observed between fasting and health outcomes in the offspring.

CONCLUSIONS

Pregnant Muslim women residing in the UK who fasted during Ramadan differed by social, demographic and lifestyle characteristics compared to their non-fasting peers. Fasting was not found to be associated with adverse birth outcomes in this sample although these results require confirmation using reported fasting data in a larger sample before the safety of fasting during pregnancy can be established.

Ramadan fasting and newborn's birth weight in pregnant Muslim women in The Netherlands

Many Muslim women worldwide are pregnant during Ramadan and adhere to Ramadan fasting during pregnancy. In the present study, we determined whether maternal adherence to Ramadan fasting during pregnancy has an impact on the birth weight of the newborn, and whether the effects differed according to trimester in which Ramadan fasting took place. A prospective cohort study was conducted in 130 pregnant Muslim women who attended antenatal care in Amsterdam and Zaanstad, The Netherlands. Data on adherence to Ramadan fasting during pregnancy and demographics were self-reported by pregnant women, and the outcome of the newborn was retrieved from medical records after delivery. The results showed that half of all the women adhered to Ramadan fasting. With strict adherence to Ramadan fasting in pregnancy, the birth weight of newborns tended to be lower than that of newborns of non-fasting mothers, although this was not statistically significant ( - 198 g, 95 % CI - 447, 51, P= 0·12). Children of mothers who fasted in the first trimester of pregnancy were lighter at birth than those whose mothers had not fasted ( - 272 g, 95 % CI - 547, 3, P= 0·05). There were no differences in birth weight between children whose mothers had or had not fasted if Ramadan fasting had taken place later in pregnancy. Ramadan fasting during early pregnancy may lead to lower birth weight of newborns. These findings call for further confirmation in larger studies that should also investigate potential implications for perinatal and long-term morbidity and mortality.

Invited commentary: is prenatal fasting during Ramadan related to adult health outcomes? A novel and important question for epidemiology

In this issue of the Journal, Van Ewijk et al. (Am J Epidemiol. 2013;177(8):729-736) report intriguing associations between prenatal exposure to the religious month of Ramadan and body anthropometry among adult Muslims in Indonesia. They categorized prenatal exposure according to the relative timing of Ramadan and the individual's birth date. Because the data were derived from a study of adults, they could not determine whether an individual's mother had fasted during Ramadan or not. Therefore, they used an intention-to-treat analysis to compare the outcomes for groups categorized as unexposed with the outcomes for groups categorized as exposed during specified periods of gestation. Periconceptional exposure to Ramadan was associated with a 0.8-cm reduction in average adult height. Exposure in mid- or late gestation was associated with slightly lower adult weight. We address 5 questions raised by this study: 1) Can Ramadan fasting be considered a mild form of acute starvation?; 2) Are the findings consistent with other knowledge about prenatal nutrition and offspring outcomes?; 3) Are there other explanations for the associations that were found?; 4) Are the results internally coherent and robust enough to support the 2 main findings?; and 5) What strategies could be used to further advance this important field of research?