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

Abstract

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.

Risk Stratification in People with Diabetes for Fasting During Ramadan: Consensus from Arabic Association for the Study of Diabetes and Metabolism

“…A “perfect storm” of metabolic abnormalities, such as hyperglycemia, hypoglycemia, and ketosis, may occur in diabetic pregnant women who fast during Ramadan [ 80 ]. There is an underlying pathophysiology of insulin shortage and/or resistance, which may result in increased gluconeogenesis, glycogenolysis, and ketogenesis when PwDM fast because reduced glucose intake suppresses insulin production [ 81 ].…”

“…This can result in an abnormally high maternal ketogenesis response to fasting [ 82 , 83 ]. Therefore, Ramadan fasting in pregnant women with diabetes may represent a “perfect storm” of circumstances that leads to potentially serious metabolic changes, like ketogenesis [ 80 ].…”

Effect of Ramadan Fasting on Blood Glucose Level in Pregnant Women with Gestational and Type 2 Diabetes

“…10 Further, according to a recent review, at least 80% of healthy Muslim women who are pregnant fast despite medical advice against it and religious exemptions, with more than 50% fasting for the entire month. 11 However, this may not be cause for concern, because for pregnant women who do not have diabetes, fasting during Ramadan in the second trimester of pregnancy has been found to have some benefits: for example, it decreases excessive weight gain and the incidence of gestational diabetes. 12 …”