Ramadan and Gestational Diabetes: maternal and neonatal outcomes in Muslim women 

Turki AlMogbel1,2,3, Glynis Ross1,2, Ted Wu1 , Lynda Molyneaux1,2, Maria Constantino1, 2, Margaret McGill1,2, Anna-Jane Harding1, Christine Pech1, Abdullah Alrasheed1,2, Jencia Wong1,2

1 Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
2 Sydney Medical School, University of Sydney, Sydney, NSW, Australia
3 Buraydah Diabetes Center, King Fahad Specialist Hospital, Ministry of Health, Buraydah, Saudi Arabia



Background
Gestational diabetes (GDM) has been reported to affect up to 50% of pregnancies in Muslim countries (1). Fasting during the Islamic holy month of Ramadan is one of the five pillars of Islam whereby no food or drink is consumed from dawn to sunset. Despite allowed exemptions from fasting for medical reasons (2), ~50% of Muslim women with GDM still opt to fast, to share the spiritual and social experiences with their family (3, 4). Irrespective of whether fasting is undertaken, meals during Ramadan are often altered in both macronutrient content and size (5, 6). This intermittent fasting and feasting pattern of eating and/or change in meal type in Ramadan, may affect metabolic fuels and adversely impact fetal and maternal outcomes in the context of GDM. There is a paucity of data in this area to guide clinicians.

Aim
To examine the relationship between exposure to the month of Ramadan in Muslim women with GDM and pregnancy outcomes using systematically and prospectively collected data from a multiethnic GDM database.

Method
Outcomes for 345 self-reported Muslim women with singleton pregnancies who attended a major Sydney teaching hospital during the period 1989-2010, were available for study. We examined fetal and maternal outcomes in relation to (i) the number of days exposed to Ramadan (ii) trimester exposure to Ramadan, with those never exposed as comparator in both analyses. Statistical significance was defined as p-value < 0.05. The study protocol was approved by the Hospital ethics committee.

Results
For the analysis by days of exposure to Ramadan, exposure was divided into never exposed (n=48), exposed for 1-10 days (n=17), 11-20 days (n=23) and 21-30 days (n=257). There were no differences in maternal age, ethnicity, pre-pregnancy BMI, and gestation at diagnosis. Insulin use, maternal weight gain, preterm delivery and caesarean section were similar between the groups (p>0.05 for all). No significant differences in macrosomia, large for gestational age (LGA) or small for gestational age (SGA) infants were seen. There was a trend for an increasing prevalence of neonatal hyperbilirubinemia with more Ramadan days-exposure (ptrend =0.004). The odds ratio (OR) for risk of hyperbilirubinemia was 3.9 (1.1-13.1, p=0.03) for the highest days-exposure group after adjustment for gestational age, ethnicity, gender and birthweight centile. Conversely, exposure to Ramadan was associated with a lower prevalence of neonatal hypoglycemia. The OR for neonatal hypoglycemia was 0.4 (0.2-0.9, p=0.02) for the longest exposure group after adjustment for insulin treatment, gestational age, and birthweight centile.     

There were 48, 59, 75 and 56 pregnancies with no exposure, purely first, second and third trimester exposure to Ramadan respectively. There were no differences in maternal age, ethnicity, pre-pregnancy BMI between the groups. Differences in gestation at GDM diagnosis and family history of GDM were seen (p< 0.05 for both). Maternal weight gain, preterm delivery and cesarean section were similar between the groups (p>0.05 for all). There were no differences in macrosomia, LGA or SGA by trimester exposure, however there was a significant trend towards increasing neonatal hyperbilirubinemia by later trimester exposure (ptrend =0.02). The OR for hyperbilirubinemia was 4.2 (1.1-15.5, p=0.04) and 5 (1.3-19, p=0.02) for the second and third trimester exposure respectively, after adjustment for gestational age, ethnicity, gender and percentile birth weight. Later trimester exposure to Ramadan was associated with a lower prevalence of neonatal hypoglycemia (ptrend =0.048). The OR for neonatal hypoglycemia was 0.3 for both 2nd and 3rd trimester exposure (p=0.03; p=0.06 respectively) after adjustment for insulin use, gestational age, and birthweight centile.     

Discussion  
To our knowledge this is the first study to examine the association of Ramadan and pregnancy outcomes in a large Muslim GDM cohort.  No excess in macrosomia, LGA or SGA infants were seen irrespective of the number of days or trimester of exposure which is reassuring. Furthermore, exposure to Ramadan appears to be associated with a lower prevalence of neonatal hypoglycemia implying more favourable glycemic control. However, of concern is the finding of a near four-fold excess of neonatal hyperbilirubinemia after adjustment for known risk factors for those exposed to Ramadan especially in later pregnancy. Whether our findings are specific to fasting per se or the overall altered dietary patterns in Ramadan cannot be determined. These findings indicate a need for further study in GDM. 
 



 
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Ramadan and gestational diabetes: maternal and neonatal outcomes in Muslim women