The effect of Ramadan fasting during pregnancy on perinatal outcomes: a systematic review and meta-analysis

Effects of Modified Ramadan Fasting on Mental Well-Being and Biomarkers in Healthy Adult Muslims - A Randomised Controlled Trial

BACKGROUND

Ramadan fasting has seen increased attention in research, often with inconsistent findings. This study aims to investigate whether dietary and lifestyle modifications during Ramadan can improve well-being and health in healthy adult Muslims.

METHOD

A randomised controlled trial with two parallel groups was conducted in an outpatient clinic of a university hospital in Essen, Germany, in 2016. Healthy adult Muslims (n = 114) aged 18-60 years were randomised to a modified fasting group; i.e., they received educational material prompting dietary and lifestyle modifications pre-Ramadan, and a control group who undertook Ramadan fasting as usual. Primary outcome was quality of life (WHO-5 Well-Being Index). Secondary outcomes included sleep quality, spirituality, and mindfulness (all self-report), body weight, body mass index, body fat, waist circumference, hip circumference, blood pressure, and heart rate, as well as blood serum biomarkers. Safety was examined via adverse events.

RESULTS

The modified fasting group reported significantly higher quality of life (WHO-5) compared to the control after Ramadan (MD 5.9; 95% CI, 0.02-11.8; p < 0.05). Group differences in favour of the modified fasting were also found for satisfaction with health (MD 5.9, 95% CI 0.19-11.67), ease of life (MD 4.1, 95% CI 0.38-7.80) and mindfulness (MD 7.6, 95% CI 2.68-12.52), reductions in weight (MD, - 0.9 kg; 95% CI - 1.39 to - 0.42), BMI (MD - 0.3 kg/m2, 95% CI - 0.50 to - 0.15), hip circumference (MD - 0.3 kg/m2, 95% CI - 0.50 to - 0.15), and diastolic blood pressure (MD - 2.8 mmHg, 95% CI - 5.15 to - 0.43). About 60% of participants reported adverse events, mostly headaches/migraines, dizziness/fatigue, common cold, and gastrointestinal symptoms, with no group differences. One serious non-related adverse event each occurred in both groups.

CONCLUSION

Pre-Ramadan dietary and lifestyle advice can lead to short-term improvements in mental and physical well-being of adult Muslims observing Ramadan. As such, this study demonstrates the potential benefits of culturally appropriate health interventions in a religious context.

TRIAL REGISTRATION

ClinicalTrials.gov (Identifier NCT02775175).

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.

Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative)

Ramadan fasting (RF) involves abstaining from food and drink during daylight hours; it is obligatory for all healthy Muslims from the age of puberty. Although sick individuals are exempt from fasting, many will fast anyway. This article explores the impact of RF on individuals with kidney diseases through a comprehensive review of existing literature and consensus recommendations. This study was conducted by a multidisciplinary panel of experts.The recommendations aim to provide a structured approach to assess and manage fasting during Ramadan for patients with kidney diseases, empowering both healthcare providers and patients to make informed decisions while considering their unique circumstances.

Caring for Muslim Patients: A Primer for the Obstetrician Gynecologist

Studies show that Muslim American patients experience discrimination and feel uncomfortable seeking appropriate health care for various reasons. Obstetrician-gynecologists should be educated regarding Islamic perspectives on topics such as modesty, sexual health, contraception, abortion, infertility, and fasting during pregnancy. Understanding the barriers Muslim patients face and improving cultural humility will improve the quality of sexual and reproductive care delivered to Muslim patients.

[Intermittent fasting: effects in diverse clinical settings]

Introduction

Introduction: intermittent fasting plans propose to limit food intake during specific periods as nutritional therapeutic strategies to treat different metabolic conditions in various clinical entities. However, the heterogeneity between each context of intermittent fasting could generate different results in metabolic parameters. Objective: to evaluate the clinical application of intermittent fasting and to discern whether it offers advantages over other traditional strategies. Methods: structured questions were formulated (PICO), and the methodology followed the guidelines established by the PRISMA 2020 statement. The search was conducted in different databases (PubMed, Cochrane Library and Google Scholar). Results: we found 3,962 articles, of which 56 were finally included; 3,906 articles that did not directly or indirectly answer the structured questions were excluded. Conclusions: compared to conventional diets, the various AI schemes do not generate advantages or disadvantages in terms of weight loss and lipid profile, although in the alternate-day variant there are greater insulin reductions than those observed in the continuous energy restriction. The heterogeneity of the interventions, the populations studied, the comparators, the results, and the type of design make it impossible to extrapolate the effects found in all clinical scenarios and generalize the recommendations.

Ramadan fasting intentions among pregnant women in Lebanon

BACKGROUND

According to Islam's teachings, women are religiously exempt from fasting during pregnancy if a woman is concerned about her health or that of the fetus. This study assesses the intentions of pregnant women to fast during Ramadan and evaluates the contribution of items derived from the theory of planned behavior (TPB) in predicting these intentions.

METHODS

A cross-sectional survey was carried out in Arabic on a convenience sample of 181 pregnant women in Lebanon using a mixture of in-person (46), telephone (31), and online recruitment (104) techniques from February to April 2020. An Exploratory Bayes Tree Analysis was done to examine which TPB items appeared to separate the intention to fast in the best possible way. Then, an ordinal regression was completed followed by a latent class analysis to examine specific classes of participants that could be determined based on the regression results.

RESULTS

Overall, 58% of participants had the intention to fast all days of Ramadan, 22% had the intention to fast some days and 20% did not intend to fast for any duration. A model was run with perceptions of physical ability, Islam guidance, husband's opinion importance, mother's opinion beliefs, and impact on general health as predictors (R2 = 0.74). A four-cluster model was chosen as the most parsimonious one in interpretation, where classes one and two included the groups of women who intended to fast month-long with differences in predictors. Class three represented the group of women who did not have the intention to fast and the final class represented the group of women who had the intention to fast some days of the month. The women's belief in their physical ability to fast and the opinion of the pregnant women's mothers were very important in deciding the participants' intention to fast.

CONCLUSIONS

Items derived from TPB constructs helped in producing a model predicting women's intention to fast during Ramadan. Educational messages and interventions related to fasting while pregnant may be delivered by individuals with legitimacy among pregnant women such as those viewed by the target population as powerful motherly figures in their communities.

Preterm Birth and Its Association with Maternal Diet, and Placental and Neonatal Telomere Length

Preterm birth (PTB), a multi-causal syndrome, is one of the global epidemics. Maternal nutrition, but also neonatal and placental telomere length (TL), are among the factors affecting PTB risk. However, the exact relationship between these factors and the PTB outcome, remains obscure. The aim of this review was to investigate the association between PTB, maternal nutrition, and placental-infant TL. Observational studies were sought with the keywords: maternal nutrition, placental TL, newborn, TL, and PTB. No studies were found that included all of the keywords simultaneously, and thus, the keywords were searched in dyads, to reach assumptive conclusions. The findings show that maternal nutrition affects PTB risk, through its influence on maternal TL. On the other hand, maternal TL independently affects PTB risk, and at the same time PTB is a major determinant of offspring TL regulation. The strength of the associations, and the extent of the influence from covariates, remains to be elucidated in future research. Furthermore, the question of whether maternal TL is simply a biomarker of maternal nutritional status and PTB risk, or a causative factor of PTB, to date, remains to be answered.

Gestational Early-Time Restricted Feeding Results in Sex-Specific Glucose Intolerance in Adult Male Mice

The timing of food intake is a novel dietary component that impacts health. Time-restricted feeding (TRF), a form of intermittent fasting, manipulates food timing. The timing of eating may be an important factor to consider during critical periods, such as pregnancy. Nutrition during pregnancy, too, can have a lasting impact on offspring health. The timing of food intake has not been thoroughly investigated in models of pregnancy, despite evidence that interest in the practice exists. Therefore, using a mouse model, we tested body composition and glycemic health of gestational early TRF (eTRF) in male and female offspring from weaning to adulthood on a chow diet and after a high-fat, high-sucrose (HFHS) diet challenge. Body composition was similar between groups in both sexes from weaning to adulthood, with minor increases in food intake in eTRF females and slightly improved glucose tolerance in males while on a chow diet. However, after 10 weeks of HFHS, male eTRF offspring developed glucose intolerance. Further studies should assess the susceptibility of males, and apparent resilience of females, to gestational eTRF and assess mechanisms underlying these changes in adult males.

Effect of Ramadan Fasting in Turkey Upon Fetal Well-being and Perinatal Outcomes During the Last-Trimester of Pregnancy

Ramadan, a one-month period in which eating and drinking are prohibited from sunrise to sunset, is considered sacred by Muslims. According to Islamic rules, fasting is obligatory for adults and healthy people, but patients and travelers are exempted from this rule. It is not clear whether pregnant women can fast during Ramadan. This cross-sectional case-control study included low-risk pregnant women at 32-37 weeks of gestation in Turkey. We examined healthy women in the last period of their pregnancy and found similar perinatal outcomes between the fasting and nonfasting participants. In the evaluation of fetal well-being, a decrease in the number of accelerations in the non-stress test (NST) and the need to repeat the test were found to be statistically significantly higher in fasting pregnant women. We consider that this may prolong the evaluation period and increase unnecessary hospitalizations due to nonreactive NST results. More randomized controlled trials are needed to conclude that fasting during pregnancy is safe.

Maternal and perinatal outcome of Ramadan fasting in women with gestational diabetes

Objective

To compare maternal and perinatal outcome of Ramadan fasting during pregnancy in women with/without gestational diabetes.

Methods

This prospective case-control study was conducted at Department of Obstetrics & Gynecology Unit 1 Ruth PKM Civil Hospital & Dow Medical College and Holy Family Hospital, Karachi during 1st April to 31st July, 2022. In this study normoglycemic pregnant women and those identified as gestational diabetes (n=52) on oral glucose tolerance test, who fasted during Ramadan were included. Women, on diet control or diet plus metformin were included in the study. Study questionnaire included demographic details, days of fasting, self-reported hypoglycemic episodes. Maternal outcomes included preterm birth, pregnancy induced hypertension. Perinatal outcome included hyperbilirubinemia, hypoglycemia, weight of placenta, and apgar score.

Result

Eighty two women were included in the study, gestational diabetes (n=57) and normoglycemic (n=25). Average days of fasting were 16 ±9.0 days (range 5-30). Women with GDM were older (28.6 vs. 26.0 years, p-value=0.034), had raised levels of HbA1c (5.5 vs. 5.1, p-value=0.004), mean FBS (102.8 vs. 84.6 mg/dl, p-value <0.001), mean RBS (135.3 vs. 106.4 mg/dl, p-value <0.001) and had higher BMI at delivery (31.0 vs. 26.6 kg/m2, p-value=0.004). HbA1c (p-value=0.016) and head circumference of baby (p-value=0.038) were found lower in the group who fasted for more than 20 days among normoglycemic pregnant women. No other maternal and neonatal outcomes were found to be significantly affected by Ramadan fasting among pregnant women with/without GDM.

Conclusion

Gestational diabetes do not affect maternal and perinatal outcome among pregnant women.

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.

Religious fasting and its impacts on individual, public, and planetary health: Fasting as a "religious health asset" for a healthier, more equitable, and sustainable society

Religious fasting is practiced by people of all faiths, including Christianity, Islam, Buddhism, Jainism, as well as Hinduism, Judaism, and Taoism. Individual/clinical, public, global, and planetary health has traditionally been studied as separate entities. Nevertheless, religious fasting, in conjunction with other religious health assets, can provide several opportunities, ranging from the individual to the population, environmental, and planetary levels, by facilitating and supporting societal transformations and changes, such as the adoption of healthier, more equitable, and sustainable lifestyles, therein preserving the Earth's systems and addressing major interconnected, cascading, and compound challenges. In this review, we will summarize the most recent evidence on the effects of religious fasting, particularly Orthodox and Ramadan Islamic fasting, on human and public health. Further, we will explore the potential effects of religious fasting on tackling current environmental issues, with a special focus on nutrition/food restriction and planetary health. Finally, specific recommendations, particularly around dietary intake during the fasting rituals, will be provided to ensure a sustainable healthy planet.

Bibliometric overview of Ramadan fasting studies during 2010-2021

BACKGROUND AND AIMS

To quantify the bibliometric parameters of Ramadan fasting literature from 2010 to 2021.

MATERIALS AND METHODS

Scopus was searched for all articles related to Ramadan fasting or Islamic fasting from the beginning of 2010 to the end of 2021. Only original articles and reviews were included and their bibliometric and scientometric parameters were determined using Excel, Graph Pad Prism, VOSviewer, and Sci2 tool software.

RESULTS

Finally 1276 articles, including 1109 original articles and 167 reviews, were included. These articles had 14263 citations and an H-index of 48. Based on the number of publications, top institute, top journal, top country, and top authors were University of Sfax (n = 48 articles), Diabetes Research and Clinical Practice (n = 69), the United States (n = 144), and Chtourou H & Hassanein M (n = 38), respectively. Also, Diabetes Research and Clinical Practice had a strong bibliographic coupling with other journals. The recent bursting words were adrenal insufficiency and COVID-19. The most co-occurred topics were the effect of Ramadan fasting on diabetic patients, pregnant women, and glycemic state and body composition of diabetic patients.

CONCLUSION

This study provided a comprehensive bibliometric overview of Ramadan fasting literature from 2010 to 2021. The temporal change in the number of publications and other analyses on the literature of 2019, 2020 and 2021 showed that substantial increasing publications with new emerging subjects had become of interest to many researchers during the last three years.

Fructosamine as an Index of Short-Term Glycemic Control in Pregnant Women with Diabetes: Before, During and After Ramadan

Purpose

Impact of ramadan fasting on healthy and women with diabetes is already known. However, there is a scarcity of data on impact of fasting on pregnant women with diabetes. Moreover, religious and medical recommendations advise pregnant women against fasting as it is unsafe. Despite being exempted, many pregnant Muslim women with diabetes still choose to fast during ramadan. This study investigated different glycemic marker as an indicator for diabetes control in fasting pregnant women.

Patients and Methods

This is a prospective observational study. A total of 89 pregnant diabetes women were recruited. Blood glucose was self-monitored in all the pregnant women using glucose monitoring device at home. We measure the fructosamine, HbA1c levels before, during and after ramadan.

Results

Pregnant women with type 1 diabetes were 14 (25%), type 2 diabetes were 21 (37.5%), and gestational diabetes were 21 (37.5%). The mean fructosamine level decreased during and after ramadan in gestation diabetes pregnant women compared to type 2 diabetes and type 1 diabetes pregnant women subjects (p = 0.009).

Conclusion

The present study indicates that pregnant women with diabetes were able to fast during ramadan and there fructosamine level reduced during fasting. Utilization of fructosamine for short-term monitoring of glycemic control in addition to home glucose monitoring in pregnant women with diabetes will provide a good index of glycemic control.

Recommendation

Religious and medical recommendations advise pregnant women against fasting as it is unsafe, and they are under high risk. However, if they insist to do fast, they must do under strict medical supervision and fructosamine can be used as a glycemic control marker.

Community food beliefs during pregnancy in rural kebeles of Ofla Woreda, Northern Ethiopia: an explorative qualitative study

Background

Dietary related misconceptions during pregnancy affect the heath of mothers and their growing babies. Misconceptions vary from place to place and from community to community. Understanding of a given community’s food perceptions during pregnancy helps policy makers able to design cultural appropriate interventions. In Ethiopia, however, evidences on food beliefs and perceptions during pregnancy are limited. Therefore, this study is aimed at qualitatively assessing community food beliefs during pregnancy in rural kebeles of Ofla Woreda, Northern Ethiopia.

Methods

We conducted 10 in-depth interviews (n = 10) and four focus group discussions (n = 32) among purposively selected community groups including pregnant mothers, religious leaders, and elders in rural kebeles of Ofla Woreda, Northern Ethiopia. Data were transcribed word-for-word, translated into English, and uploaded into ATLAST ti version 7.5.1.6. Data were analyzed following the principles of thematic analysis. Line-by-line coding was applied to identify codes; identified codes were categorized based on their similarities and differences and themes were developed inductively.

Results

Three main themes were identified inductively; foods positively and negatively linked with pregnancy; perceived benefits and harms of alcoholic drinks during pregnancy; and religion and fasting. In this study, consumptions of animal source foods such as egg were discouraged because such foods were perceived to increase the risk of having big baby that could delay delivery. However, intakes of locally produced alcoholic drinks during pregnancy were encouraged by the local community. Furthermore, avoidance of animal source foods and meal skipping during religious fasting-periods were also common practices among pregnant mothers in the study area.

Conclusions

This study explored misconceptions on food intakes during pregnancy. Positive attitude towards intake of “soft” alcoholic drinks might result in alcohol related teratogenic effects. Restriction on the intakes of nutrient rich diets due to religious fasting and other misconceptions would lead to insufficient nutrient intake both to the mothers and their growing fetus. Culturally appropriate intervention to improve awareness on healthy dietary intake during pregnancy is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04593-3.

Impact of maternal intermittent fasting during pregnancy on cardiovascular, metabolic and renal function in adult rat offspring

Pregnant Muslim women are exempt from fasting during Ramadan; however a majority are reported to fast. The impact of this form of maternal intermittent fasting (IF) on fetal development and offspring health is not well defined. Using a rat model, we have shown previously that maternal IF results in fetal growth restriction accompanied by changes in placental nutrient transport function. The aim of this study was to assess cardiovascular, metabolic and renal function in adult offspring of IF-exposed dams. Food was withheld from Wistar rats from 17:00 to 09:00 daily throughout pregnancy; controls had ad libitum access to food. Birth weight was unaffected; however male IF pups grew more slowly up to 10 weeks of age (P < 0.01) whereas IF females matched their control counterparts. Systolic blood pressure (SBP), glucose tolerance and basal renal function at 14 weeks were not affected by IF exposure. When offered saline solutions (0.9–2.1%) to drink, females showed a greater salt preference than males (P < 0.01); however there were no differences between dietary groups. A separate group of pups was weaned onto a 4% NaCl diet. SBP increased in IF pups sooner, at 7 weeks (P < 0.01), than controls which became hypertensive from 10 weeks. Renal function did not appear to differ; however markers of renal injury were elevated in IF males (P < 0.05). Maternal IF does not affect resting cardiovascular, metabolic and renal function; but when challenged by dietary salt load male IF offspring are more prone to renal injury.

Meal patterning and the onset of spontaneous labor

BACKGROUND

There is a lack of consensus in the literature about the association between meal patterning during pregnancy and birth outcomes. This study examined whether maternal meal patterning in the week before birth was associated with an increased likelihood of imminent spontaneous labor.

METHODS

Data came from 607 participants in the third phase of the Pregnancy, Infection, and Nutrition Study (PIN3). Data were collected through an interviewer-administered questionnaire after birth, before hospital discharge. Questions included the typical number of meals and snacks consumed daily, during both the week before labor onset and the 24-hour period before labor onset. A self-matched, case-crossover study design examined the association between skipping one or more meals and the likelihood of spontaneous labor onset within the subsequent 24 hours.

RESULTS

Among women who experienced spontaneous labor, 87.0% reported routinely eating three daily meals (breakfast, lunch, and dinner) during the week before their labor began, but only 71.2% reported eating three meals during the 24-hour period before their labor began. Compared with the week before their labor, the odds of imminent spontaneous labor were 5.43 times as high (95% CI: 3.41-8.65) within 24 hours of skipping 1 or more meals. The association between skipping 1 or more meals and the onset of spontaneous labor remained elevated for both pregnant individuals who birthed early (37-<39 weeks) and full-term (≥39 weeks).

CONCLUSIONS

Skipping meals later in pregnancy was associated with an increased likelihood of imminent spontaneous labor, though we are unable to rule out reverse causality.

Ramadan Fasting and Maternal and Fetal Outcomes in Pregnant Women with Diabetes Mellitus: Literature Review

There is an emerging Muslim and diabetic population in the United States and other Western countries and majority of pregnant women and patients with diabetes mellitus choose to fast during Ramadan. Fasting during Ramadan in pregnant women with diabetes may represent a 'perfect storm' of metabolic disturbances including hyperglycemia, hypoglycemia and ketosis. Recent continuous and flash glucose monitoring data suggests increased glycemic variability (fasting hypo- and post-Iftar hyperglycemia) in non-pregnant patients with diabetes during Ramadan. Only five small-scale studies, predominantly focused on women with gestational diabetes mellitus in Muslim-majority nations have explored maternal glycemic outcomes during Ramadan which is associated with lower mean blood glucose levels and higher frequency of fasting hypoglycemia. Data is limited however on important clinical outcomes such as symptomatic and serious hypoglycemia requiring hospitalization. Results have been conflicting regarding maternal Ramadan fasting and association with fetal outcomes in women without diabetes. Only one recently published study reported on perinatal outcomes in pregnant women with gestational diabetes which found no effect of Ramadan exposure on mean birthweight or macrosomia frequency but lower neonatal hypoglycemia prevalence, however a significant limitation was lack of documentation of maternal fasting status. At this stage, due to paucity of data, the current medical recommendation is against Ramadan fasting for pregnant Muslim women with diabetes. Large-scale population-based studies are warranted regarding maternal and fetal outcomes in pregnant fasting women with diabetes and such studies should characterize maternal fasting status and have meaningful and consistent clinical outcomes. High-quality data derived from these studies can assist clinicians in providing more evidence-based advice to safely navigate both mother and fetus through a potentially challenging pregnancy.

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 exposure during early pregnancy and risk of stillbirth in Arab women living in Canada

BACKGROUND

Data on fasting during Ramadan and the risk of preterm birth and child mortality are conflicting, but the association with stillbirth is unknown.

OBJECTIVE

We studied the relationship between Ramadan and the risk of stillbirth for Arab women in Quebec, Canada.

METHODS

We conducted a retrospective cohort study using birth certificates for Arab women in Quebec, Canada, between 1981 and 2017. The exposure was Ramadan in the first and second trimester (1-27 weeks of gestation), and the outcome was early (<28 weeks) or late (≥28 weeks) stillbirth. We used log-binomial regression models to estimate risk ratios (RR) and 95% confidence intervals (CI) for the association between Ramadan and risk of stillbirth. We adjusted models for maternal characteristics and assessed associations by cause of death.

RESULTS

The study included 78,349 live births and 274 stillbirths. There were 3.5 stillbirths per 1,000 pregnancies for women exposed to Ramadan between weeks 1-27 of gestation (95% CI 3.0, 4.0), and 3.4 per 1,000 for unexposed women (95% CI 2.8, 4.1). Compared with no exposure, Ramadan between weeks 1-27 was not associated with the risk of early (RR 1.32, 95% CI 0.76, 2.28) or late stillbirth (RR 0.93, 95% CI 0.70, 1.23) in adjusted models. RRs for early stillbirth were 1.40 for Ramadan between weeks 15-21 (95% CI 0.70, 2.80) and 1.38 for Ramadan between weeks 22-27 (95% CI 0.67, 2.84). Relative to no exposure, Ramadan between weeks 15-21 was associated with early stillbirth due to congenital anomaly (RR 3.96; 95% CI 1.35, 11.57) in unadjusted models. There was no association with other causes of stillbirth.

CONCLUSIONS

There is no evidence that Ramadan is associated with the risk of early or late stillbirth overall. Further research is needed to confirm an association with stillbirth due to congenital anomalies.

Intermittent fasting in adrenal insufficiency patients: a review and guidelines for practice

Ramadan fasting is a religious duty for adult Muslims. Even though sick people are exempted from fasting, numerous are those who insist on fasting, and seek advice from their physicians. The role of the physician is to support his patient and preserve his health. However, little is known about intermittent fasting in adrenal insufficiency. The aim of this review was to determine the risks of fasting in patients with adrenal insufficiency, the subjects at risk of complications, and the measures that can be undertaken for safe fasting. The analysis of the data of the different studies showed that there is a risk of complications during fasting in these patients. Optimal glucocorticoid replacement therapy for safe fasting has not yet been determined. Finally, a risk stratification and the modalities of the pre-Ramadan visit for adrenal insufficiency fasting patients have been suggested.

Development of national dietary and lifestyle guidelines for pregnant women in Lebanon

Although a number of international diet and lifestyle guidelines during pregnancy (DLGP) exist in the literature, contextualization to low- and middle-income settings is less common. The aim of this study was to present the Lebanese DLGP and to describe the process followed for their development. A mixed-method approach was used including a review and synthesis of existing international DLGP and a consensus building nominal group technique (NGT) with a multidisciplinary group of experts (n = 11). During the meeting, participants identified the themes of the guidelines, formulated the wording of each themes' guideline and translated the guidelines to the Arabic language. Consensus was defined as an agreement of 80%. Reviewing the literature, a list of 17 main topics were found to be common themes for the DLGP. For the Lebanese DLGP, participants in the NGT meeting selected seven themes from this list: gestational weight gain, diet diversity, hydration, food safety, harmful foods, physical activity and breastfeeding. In addition, the group formulated three themes based on merging/modifying existing themes: supplementation, alcohol and smoking and religious fasting. Two context-specific new themes emerged: wellbeing and nutrition resilience. For each of the identified themes, the group agreed upon the wording of its guidelines and description. This study is the first from the Eastern Mediterranean Region to develop through consensus building, context and culture-specific dietary and lifestyle guidelines for pregnant women. Putting maternal nutrition at the heart of tackling malnutrition and its detrimental health outcomes is a core investment for a better maternal and child health.

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.

Maternal intermittent fasting during pregnancy: a translational research challenge for an important clinical scenario

In volume 135, issue 11 of Clinical Science, Alkhalefah et al. report that, in pregnant rats, repeated, cyclic fasting, mimicking the fasting experienced by observant Muslim pregnant women during Ramadan, alters placental amino acid transport and increases the incidence of low birth weight. Though Muslim women are exempt, many observe Ramadan: >500 million fetuses worldwide may be exposed to Ramadan fasting in each generation, and low birth weight increases the risk of developing chronic disease in the future adult. Several mechanisms, including altered circadian rhythm, maternal stress, undernutrition or compensatory overeating at the breaking of fast, could, in theory, impact fetal growth during Ramadan. Limitations of the experimental model obviously prevent direct extrapolation to humans. Whether Ramadan fasting indeed affect fetal growth therefore remains unclear, as there is no clear-cut evidence from epidemiological studies. The paper illustrates the need to design further case-controlled studies in large cohorts of women who fasted at various stages of pregnancy, compared to appropriately matched women who did not fast, as well as more experimental studies focused on this issue of public health relevance.

Comprehensive analysis of the association of seasonal variability with maternal and neonatal nutrition in lowland Nepal

OBJECTIVE

To provide a comprehensive seasonal analysis of pregnant mothers' eating behaviour and maternal/newborn nutritional status in an undernourished population from lowland rural Nepal, where weather patterns, agricultural labour, food availability and disease prevalence vary seasonally.

DESIGN

Secondary analysis of cluster-randomised Low Birth Weight South Asia Trial data, applying cosinor analysis to predict seasonal patterns.

OUTCOMES

Maternal mid-upper arm circumference (MUAC), BMI, dietary diversity, meals per day, eating down and food aversion in pregnancy (≥31 weeks' gestation) and neonatal z-scores of length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ) and weight-for-length (WLZ).

SETTING

Rural areas of Dhanusha and Mahottari districts in plains of Nepal.

PARTICIPANTS

2831 mothers aged 13-50 and 3330 neonates.

RESULTS

We found seasonal patterns in newborn anthropometry and pregnant mothers' anthropometry, meal frequency, dietary diversity, food aversion and eating down. Seasonality in intake varied by food group. Offspring anthropometry broadly tracked mothers'. Annual amplitudes in mothers' MUAC and BMI were 0·27 kg/m2 and 0·22 cm, with peaks post-harvest and nadirs in October when food insecurity peaked. Annual LAZ, WAZ and WLZ amplitudes were 0·125, 0·159 and 0·411 z-scores, respectively. Neonates were the shortest but least thin (higher WLZ) in winter (December/January). In the hot season, WLZ was the lowest (May/June) while LAZ was the highest (March and August). HCAZ did not vary significantly. Food aversion and eating down peaked pre-monsoon (April/May).

CONCLUSIONS

Our analyses revealed complex seasonal patterns in maternal nutrition and neonatal size. Seasonality should be accounted for when designing and evaluating public heath nutrition interventions.

Incidence of urinary ketosis and the effect of carbohydrate drink supplementation during fasting for elective caesarean section: Audit

Elective lower segment caesarean section patients are routinely instructed to fast from food for 6h before surgery, with clear fluids up until 2h before surgery. We conducted an audit examining the true fasting times of mothers undergoing an elective caesarean section and the incidence of urinary ketones before and after introducing a preop carbohydrate drink (Nutricia preOp 400ml) to be administered to all patients at 6am on the day of surgery. We audited 50 patients prior to introducing the preop carbohydrate drink and 54 patients after the introduction of a carbohydrate drink. We found the mean fasting time from last caloric intake was reduced from 13h 35min to 5h 5min after the introduction of a preoperative carbohydrate drink. We found that the incidence of urinary ketones was 40.4% prior to the introduction of a preoperative carbohydrate drink and 38.3% after the introduction of a preop drink (p = 1). If fasting times were limited to under 4h, the incidence of urinary ketones is 10%. Our audit demonstrates that reducing preoperative fasting times is possible and preventing metabolic derangements may be possible, requiring an approach targeted at keeping fasting times to a minimum.

Knowledge gaps and perceptions of future research directions on management of diabetes during Ramadan fasting: An online survey of physicians

OBJECTIVES

Current knowledge and research on diabetes and Ramadan form the basis for evidence-based clinical practice. In this context, we aimed to explore physicians' perceptions of current knowledge gaps about research fasting (RF), barriers to, and foreseeable directions for advancement of the field.

METHODS

We conducted an online survey of a convenience sample of 260 physicians from 27 countries. The survey questionnaire addressed three main domains: perceived current knowledge gaps and unmet needs in research about RF and diabetes, barriers to the conduct of research, and future directions for furthering the evidence in this field.

RESULTS

Majority of respondents (65.7%) were senior physicians in adult endocrinology/diabetes (45.9%) working at tertiary centers (65.2%). The majority (67.3%) reported seeing an average of 20+ patients with diabetes weekly and felt "very or fairly confident" in managing diabetes during RF (67.7%). The knowledge gaps identified were the management of high-risk patients with diabetes (54.1%), such as renal impairment (59.8%), and pregnancy (61.5%). The main barriers to research were lack of adequate funding to academic centers (75.7%) and lack of interest of institutions in the subject (64.6%). Future efforts should be directed at the conduct of large epidemiological studies (49.5%) or double-blinded, placebo-controlled clinical trials (48.6%) to address the former gaps. Research findings should be widely disseminated via hands-on workshops (recommended by 70.3% of respondents) or international conferences (61.2%).

CONCLUSIONS

There is a wide agreement regarding the knowledge gaps in the management of diabetes during RF. Future efforts should focus on addressing these critical deficiencies.

Maternal intermittent fasting during pregnancy induces fetal growth restriction and down-regulated placental system A amino acid transport in the rat

During Ramadan, many pregnant Muslim women fast between dawn and sunset. Although the impacts of prolonged maternal intermittent fasting (IF) on fetal growth and placental function are under-researched, reported effects include reduced placental weight and birth weight. In the present study, pregnant Wistar rats were used to model repeated cycles of IF on fetal development and placental function and to examine sex-specific effects. In the IF group, food was withdrawn daily from 17:00 to 09:00 over 21 days of gestation, while the control group received food ad libitum. Both groups had free water access. IF dams consumed less food, had significantly reduced weight compared with controls, with reduced plasma glucose and amino acids. Both fetal sexes were significantly lighter in the IF group with reduced fetal plasma amino acids. Placental weights and morphology were unchanged. The profile of placental metabolites was altered in the IF group with sex-specific responses evident. Transplacental flux of 14C-methylaminoisobutyric acid (14C-MeAIB), a system A amino acid transporter substrate, was significantly reduced in both fetal sexes in the IF group. Sodium-dependent 14C-MeAIB uptake into isolated placental plasma membrane vesicles was unchanged. The gene expression of system A transporter Slc38a1, Slc38a2 and Slc38a4 was up-regulated in IF male placentas only. No changes were observed in placental SNAT1 and SNAT2 protein expression. Maternal IF results in detrimental impacts on maternal physiology and fetal development with changes in the placental and fetal metabolite profiles. Reduced placental system A transporter activity may be responsible for fetal growth restriction in both sexes.

Religious dietary rules and their potential nutritional and health consequences

BACKGROUND

The vast majority of the world population declares affiliation to a religion, predominantly Christianity and Islam. Many religions have special dietary rules, which may be more or less strictly adhered to.

METHODS

Religious food rules were collected from holy books and religious websites as well as their translation into dietary practices. The literature was searched for potential associations between these rules and potential nutritional consequences.

RESULTS

Jewish, Islamic and Indian religions support prolonged breastfeeding. Religious avoidance of alcohol is probably beneficial to health. When strictly applied, a few rules may lead to nutritional inadequacies, mainly in populations living in unfavourable socio-economic or environmental conditions. In Jewish and Muslim observants, animal slaughtering procedures may increase the risk of iron deficiency. Jews may be at risk of excess sodium intake related to home-prepared foods. A vegan diet, as observed by some believers, often by drifting from original precepts, or by some Hindus or Buddhists, may result in vitamin B12, calcium, iron, zinc, selenium and n-3 fatty acids deficiencies.

CONCLUSION

When implemented in accordance with the rules, most religious food precepts are not detrimental to health, as suggested by the fact that they have more or less been followed for millennia. Nevertheless, some practices may lead to nutritional inadequacies, such as iron, calcium, vitamin D and vitamin B12 deficiencies. Patients with low socio-economic status, children and women of childbearing age are of particular risk of such deficiencies. Being aware of them should help health professionals to take an individualized approach to decide whether to supplement or not.

Women's fasting habits and dietary diversity during Ramadan in rural Bangladesh

Little is known about fasting practices and dietary changes during Ramadan in low‐ and lower‐middle‐income countries. Although pregnant women are exempt from fasting, they may still fast. This is of interest as dietary habits during pregnancy may affect the development of the unborn child. In a community‐based sample of young women in rural Sylhet division, Bangladesh, we described fasting practices and beliefs (n = 852). We also examined reported food group consumption and minimally adequate dietary diversity for women (MDD‐W) by Ramadan occurrence (n = 1,895) and by fasting adherence (n = 558) using logistic regression with Hindu women as a seasonal control.

During Ramadan in 2018, 78% of pregnant Muslim women fasted every day. Over 80% of Muslim women believe that they should fast during pregnancy and over 50% expect positive health effects on the mother and the unborn child. We found strong evidence that Muslim women have more diverse diets during Ramadan, with higher odds of MDD‐W (OR [95% CI]: 5.0 [3.6, 6.9]) and increased consumption of pulses, dairy, fruit, and large fish. Dietary diversity increased to a lesser extent on non‐fasting days during Ramadan. Ramadan appears to improve dietary quality in both fasting and non‐fasting Muslim women in a rural population in Bangladesh. These results help to interpret findings from studies on Ramadan during pregnancy on later‐life outcomes and thus contribute to a better understanding of intrauterine influences of maternal nutrition on healthy child development.

The role of cultural beliefs on eating patterns and food practices among pregnant women: a systematic review

CONTEXT

Despite the importance of cultural beliefs in clinical practice, few systematic reviews have investigated how these beliefs influence food practices in pregnant women.

OBJECTIVE

To explore the role of cultural beliefs in eating patterns and food practices among pregnant women, highlighting food recommendations, food taboos and restrictions, and their association with health.

DATA SOURCES

A systematic review was conducted using the following electronic databases: PubMed, Scopus, CINAHL, PsycINFO, and Web of Science from May 2014 to May 2019.

DATA EXTRACTION

Articles were included if the studies included pregnant women, analyzed how cultural beliefs may influence eating patterns, were peer-reviewed articles with original data, published in the last 5 years, and in English or Spanish language. Quality assessment was also performed.

DATA ANALYSIS

A total of 544 articles were identified in the search and 24 were included in the final analysis (17 using qualitative design, 6 using quantitative design, and 1 with a mixed-design). These studies were predominantly from the African continent (n = 15). Our findings showed that culture is a key factor related to "taboos" and food restrictions, which are transmitted by the family or members of community, having a strong religious or spiritual influence. All these restrictions are related to the fear of unfavorable pregnancy outcomes such as the risk of abortion, dystocia, and congenital macrosomia, or are used to avoid child problems such as cutaneous and respiratory disorders.

CONCLUSIONS

Findings from this study indicate cultural beliefs are strongly associated with food patterns and eating habits in pregnant women. Administrators and health professionals should be aware of these beliefs to minimize problems in the perinatal period.

Explaining changes in wealth inequalities in child health: The case of stunting and wasting in Nigeria

Background

Malnutrition is a major cause of child death, and many children suffer from acute and chronic malnutrition. Nigeria has the second-highest burden of stunting globally and a higher-than-average child wasting prevalence. Moreover, there is substantial spatial variation in the prevalence of stunting and wasting in Nigeria. This paper assessed the socioeconomic inequalities and determinants of the change in socioeconomic inequalities in child stunting and wasting in Nigeria between 2013 and 2018.

Methods

Data came from the 2013 and 2018 Nigeria Demographic and Health Survey. Socioeconomic inequalities in stunting and wasting were measured using the concentration curve and Erreygers’ corrected concentration index. A pro-poor concentration index is negative, meaning that the poor bear a disproportionately higher burden of stunting or wasting than the wealthy. A positive or pro-rich index is the opposite. Standard methodologies were applied to decompose the concentration index (C) while the Oaxaca-Blinder approach was used to decompose changes in the concentration indices (ΔC).

Findings

The socioeconomic inequalities in child stunting and wasting were pro-poor in 2013 and 2018. The concentration indices for stunting reduced from -0.298 (2013) to -0.330 (2018) (ΔC = -0.032). However, the concentration indices for wasting increased from -0.066 to -0.048 (ΔC = 0.018). The changes in the socioeconomic inequalities in stunting and wasting varied by geopolitical zones. Significant determinants of these changes for both stunting and wasting were changes in inequalities in wealth, maternal education and religion. Under-five dependency, access to improved toilet facilities and geopolitical zone significantly explained changes in only stunting inequality, while access to improved water facilities only significantly determined the change in inequality in wasting.

Conclusion

Addressing the socio-economic, spatial and demographic determinants of the changes in the socioeconomic inequalities in child stunting and wasting, especially wealth, maternal education and access to sanitation is critical for improving child stunting and wasting in Nigeria.

The efficacy of fasting regimens on health outcomes: a systematic overview

INTRODUCTION

Fasting can be defined as abstinence or reduction from food, drink, or both, for a defined period. There are many different types of fasting regimens, such as Ramadan fasting, intermittent fasting, Christian Orthodox fasting. The aim of this overview is to provide an exhaustive summary on the beneficial effects and harms associated with fasting regimens and discuss mechanisms by which this non-pharmacological approach might lead to improve human health.

EVIDENCE ACQUISITION

A systematic search was performed on MEDLINE (PubMed), Embase, Cochrane Library and CINHAL. We included systematic reviews (SRs) that report on impact of different types of fasting regimens on health. Selection of SRs, data extraction and quality assessment were undertaken in duplicate.

EVIDENCE SYNTHESIS

A total of 21 SRs were included. Cumulatively, 97 health outcomes were identified. Of them, cardiovascular risk factors were the most frequently analyzed. Ramadan fasting is associated with significant improvements in body weight and visceral lean mass, high-density lipoprotein cholesterol (HDL-c), and with reductions in low-density lipoprotein cholesterol (LDL-c) and total cholesterol (T-chol), especially in cardiac patients. Similarly, reviews on Intermittent and Orthodox fasting proved benefits of those on weight, BMI, lipidic and glucose profile, inflammatory markers.

CONCLUSIONS

Fasting regimens showed potential beneficial effects on several health indicators in adult populations. Nevertheless, evidence on some specific health dimensions (cognitive function, well-being, quality of life) is limited. Thus, in the future, further RCTs or cohort studies with good methodological quality and larger sample sizes are warranted to better understand the underlying biological mechanism and the benefits on multidimensional aspects of health.

Ramadan and Diabetes: A Narrative Review and Practice Update

Fasting in the Islamic month of Ramadan is obligatory for all sane, healthy adult Muslims. The length of the day varies significantly in temperate regions-typically lasting ≥ 18 h during peak summer in the UK. The synodic nature of the Islamic calendar means that Ramadan migrates across all four seasons over an approximately 33-year cycle. Despite valid exemptions, there is an intense desire to fast during this month, even among those who are considered to be at high risk, including many individuals with diabetes mellitus. In this review we explore the current scientific and clinical evidence on fasting in patients with diabetes mellitus, focussing on type 2 diabetes mellitus and type 1 diabetes mellitus, with brief reviews on pregnancy, pancreatic diabetes, bariatric surgery, the elderly population and current practice guidelines. We also make recommendations on the management of diabetes patients during the month of Ramadan. Many patients admit to a do-it-yourself approach to diabetes mellitus management during Ramadan, largely due to an under-appreciation of the risks and implications of the rigors of fasting on their health. Part of the issue may also lie with a healthcare professional's perceived inability to grasp the religious sensitivities of Muslims in relation to disease management. Thus, the pre-Ramadan assessment is crucial to ensure a safe Ramadan experience. Diabetes patients can be risk-stratified from low, medium to high or very high risk during the pre-Ramadan assessment and counselled accordingly. Those who are assessed to be at high to very high risk are advised not to fast. The current COVID-19 pandemic upgrades those in the high-risk category to very high risk; hence a significant number of diabetes patients may fall under the penumbra of the 'not to fast' advisory. We recognize that fasting is a personal choice and if a person chooses to fast despite advice to the contrary, he/she should be adequately supported and monitored closely during Ramadan and for a brief period thereafter. Current advancements in insulin delivery and glucose monitoring technologies are useful adjuncts to strategies for supporting type 1 diabetes patients considered to be high risk as well as 'high-risk' type 2 patients manage their diabetes during Ramadan. Although there is a lack of formal trial data, there is sufficient evidence across the different classes of therapeutic hypoglycaemic agents in terms of safety and efficacy to enable informed decision-making and provide a breadth of therapeutic options for the patient and the healthcare professional, even if the professional advice is to abstain. Thus, Ramadan provides an excellent opportunity for patient engagement to discuss important aspects of management, to improve control in the short term during Ramadan and to help the observants understand that the metabolic gains achieved during Ramadan are also sustainable in the other months of the year by maintaining a dietary and behavioural discipline. The application of this understanding can potentially prevent long-term complications.

ELECTRONIC SUPPLEMENTARY MATERIAL

The online version of this article (10.1007/s13300-020-00886-y) contains supplementary material, which is available to authorized users.

Primary Care Physicians' Knowledge, Perceptions, and Comfort Level in Managing Patients Fasting in Ramadan

Background: Once a year, Muslims fast from dawn to sunset during the month of Ramadan. While fasting has many positive health implications, it may pose risks to individuals with underlying health issues. Despite the exemption from fasting for those who are ill, many Muslims with chronic conditions choose to fast. It is unclear how many Muslim patients receive counseling on fasting. As such, the purpose of this pilot project was to assess the knowledge, perception, and comfort level of primary care physicians (PCPs) at Dalhousie University’s Department of Family Medicine in managing patients choosing to fast during Ramadan. Methods: A 16-item anonymous, self-administered, structured online survey was distributed to PCPs with an academic affiliation with the Department of Family Medicine at Dalhousie University. Participants rated their level of comfort, objective knowledge, and perceptions of managing patients fasting in Ramadan. Results: Many PCPs perceived the importance of understanding Ramadan fasting and its relevance to their patients’ health, however, they did not have adequate knowledge about the matter. The majority of PCPs felt they received inadequate training in this area and did not feel comfortable counseling and managing the health of these patients. Conclusions: The findings of this study have outlined a knowledge gap that exists within our PCP community and will help inform and prioritize educational needs and direct efforts to ensure safe patient management during Ramadan.

Maternal and Perinatal outcome after Ramadan Fasting

Objective:

To determine maternal and perinatal outcome after Ramadan fasting during pregnancy

Methods:

This cross sectional study was conducted at The Department of Obstetrics and Gynaecology, Nishtar Hospital, Multan from May to October 2019. A total of 226 women attending labour room, aged 18–35 years, having gestational amenorrhoea 15 – 40 weeks of gestation were included. Women who fasted for more than 15 days were compared with those who did not fast or fasted for less than 15 days in the month of Ramadan. Demographical profile along with maternal and perinatal outcomes were compared between the study groups considering p value less than 0.05 as significant.

Results:

Out of 226 women, 58 (25.7%) fulfilled the criteria to be included in the fasting group while remaining 168 (74.3%) were slotted in the non-fasting group. There was no difference (p value > 0.05) in between the both group with respect to demographical characteristics except significantly less women were employed in the fasting group (p value=0.0246). No statistical difference was found in terms of maternal or perinatal outcomes between both the study groups.

Conclusion:

Fasting women were not found to have poor maternal and fetal outcomes when compared to non-fasting women.

Recommendations for management of diabetes during Ramadan: update 2020, applying the principles of the ADA/EASD consensus

Fasting the Holy month of Ramadan constitutes one of the five pillars of the Muslim faith. Although there is some evidence that intermittent fasting during Ramadan may be of benefit in losing weight and cardiometabolic risk factors, there is no strong evidence these benefits apply to people with diabetes. The American Diabetes Association/European Association for the Study of Diabetes consensus recommendations emphasize the importance of patient factors and comorbidities when choosing diabetes medications including the presence of comorbidities, atherosclerotic cardiovascular disease, heart failure, chronic kidney disease, hypoglycemia risk, weight issues and costs. Structured education and pre-Ramadan counseing are key components to successful management of patients with diabetes. These should cover important aspects like glycemic targets, self-monitoring of blood glucose, diet, physical activity including Taraweeh prayers, medication and dose adjustment, side effects and when to break the fast. The decision cycle adapted for the specific situation of Ramadan provides an aid for such an assessment. Children with type 1 diabetes should strongly be advised not to fast due to the high risk of acute complications such as hypoglycemia and probably diabetic ketoacidosis (DKA), although there is very little evidence that DKA is increased in Ramadan. Pregnant women with diabetes or gestational diabetes should be advised to avoid fasting because of possible negative maternal and fetal outcomes. Hypoglycemia is a common concern during Ramadan fasting. To prevent hypoglycemic and hyperglycemic events, we recommend the adoption of diabetes self-management education and support principles. The use of the emerging technology and continuous glucose monitoring during Ramadan could help to recognize hypoglycemic and hyperglycemic complications related to omission and/or medication adjustment during fasting; however, the cost represents a significant barrier.

Fasting during Ramadan Increases Risk of Very Preterm Birth among Arabic-Speaking Women

BACKGROUND

The impact of fasting on risk of preterm birth during Ramadan is unclear.

OBJECTIVES

We evaluated the association between Ramadan fasting during pregnancy and risk of preterm birth for Arab women in Canada.

METHODS

We analyzed birth certificates from 3,123,508 deliveries in Quebec, Canada, from 1981 to 2017. We identified 78,109 births of Arabic-speaking women and determined if Ramadan occurred during any trimester of pregnancy. We calculated rates of extreme (22-27 wk), very (28-31 wk), and late (32-36 wk) preterm birth and estimated RRs and 95% CIs for the association of Ramadan fasting with risk of preterm birth by pregnancy trimester, using log-binomial regression models adjusted for maternal characteristics.

RESULTS

Arabic speakers had an overall preterm birth rate of 5.53 per 100 births, but rates varied with timing of Ramadan. Among Arabic speakers, fasting during Ramadan between weeks 15-21 of the second trimester was associated with 1.33 times the risk of very preterm birth relative to no fasting (95% CI: 1.06, 1.68). Between weeks 22 and 27 of the second trimester, fasting during Ramadan was associated with 1.53 times the risk of very preterm birth (95% CI: 1.21, 1.93). Ramadan fasting was not associated with extreme or late preterm birth regardless of the trimester of pregnancy.

CONCLUSIONS

In this study of 78,109 births to Arabic-speaking women in Quebec, Ramadan fasting during the second pregnancy trimester was associated with the risk of very preterm birth. Optimal prenatal education about nutritional needs in the second trimester of pregnancy is recommended.

Fetal Growth Restriction Prediction: How to Move beyond

The actual burden and future burden of the small-for-gestational-age (SGA) babies turn their screening in pregnancy a question of major concern for clinicians and policymakers. Half of stillbirths are due to growth restriction in utero, and possibly, a quarter of livebirths of low- and middle-income countries are SGA. Growing body of evidence shows their higher risk of adverse outcomes at any period of life, including increased rates of neurologic delay, noncommunicable chronic diseases (central obesity and metabolic syndrome), and mortality. Although there is no consensus regarding its definition, birthweight centile threshold, or follow-up, we believe birthweight <10th centile is the most suitable cutoff for clinical and epidemiological purposes. Maternal clinical factors have modest predictive accuracy; being born SGA appears to be of transgenerational heredity. Addition of ultrasound parameters improves prediction models, especially using estimated fetal weight and abdominal circumference in the 3rd trimester of pregnancy. Placental growth factor levels are decreased in SGA pregnancies, and it is the most promising biomarker in differentiating angiogenesis-related SGA from other causes. Unfortunately, however, only few societies recommend universal screening. SGA evaluation is the first step of a multidimensional approach, which includes adequate management and long-term follow-up of these newborns. Apart from only meliorating perinatal outcomes, we hypothesize SGA screening is a key for socioeconomic progress.