Fasting and Pregnancy G I Serour FRCOG FRCS

Fasting and Pregnancy G. I. Serour, FRCOG, FRCS, FACOG, FSOGC, FJSOG, FSIGO, FIFFS, FEBCOG (Hon. ) Professor of Obstetrics and Gynaecology, Director, International Islamic Center for Population Studies and Research, Al-Azhar University Clinical Director, The Egyptian IVF-ET Center, Maadi, Cairo, Egypt FIGO Past President 3/18/2018 25 th EBCOG/ 15 th TSOG Joint Congress, Antalya, 17 th – 21 st May 2017 1

Conflict of interest I declare I have no conflict of interest in this presentation. 3/18/2018 2

Items Addressed • Fasting in different societies. • Pregnancy and fast. • Biological mechanism for impact of fast on pregnancy. • Does the duration/or time of fast have different impact on outcome of pregnancy. • What can I do- fast or not to fast? 3/18/2018 3

Fasting In Different Societies The Muslims: Lunar month of Ramadan from Dawn to Sunset. The Jews: Yom Kippur and Ninth of AV 25 hours fast. 4

Ramadan Fast Each year about 400 millions out of 1. 2 billion Muslims conduct this duty. Eating, drinking and smoking are forbidden from sunrise until sunset. 5

Ramadan follows a lunar calendar, and thereby falls on different dates and seasons in different years. 6

In the summer time the fasting hours may be about 18 hours every day or even longer in the northern part of the sphere. 7

Duration of Fasting in Ramadan in Different Countries 2016 Denmark Sweden and Norway Middle East countries Australia Argentina 3/18/2018 21 hours 20 hours 15 hours 10 hours <10 hours 8

Religion/ Fast In Islam it is an obligation for all adults and healthy Muslims to fast during the holy month of Ramadan. (183) O ye who believe! Fasting is prescribed to you as it ﺍ ﺍ ﺍﻳ آﻭﺍ ﺍﻟ ﺍ ﺍ ﻯ ﺍﻳ ﻥ ﻭ was prescribed to those before you, that ye may (learn) self 183 ﺳﻮﺭﺓ ﺍﻟﺒﻘﺮﺓ – ﺍﻵﻴﺔ restraint, 3/18/2018 9

Exemptions (185). . ﺍ ﻳ ﺍﻟ ﺍ ﺍ ﻳ ﺍ ﻥ ﺍ ﻳﺍ ﻯ . . . ﻥ ﻧ ﺍﻟ ………. . So every one of you who is present (at his home) during that month Ramadan should spend it in fasting, but if any one is ill, or on a journey, the prescribed period (Should be made up) by days later. Allah intends every facility for you; He does not want to put you to difficulties. 3/18/2018 10 185 ﺳﻮﺭﺓ ﺍﻟﺒﻘﺮﺓ – ﺍﻵﻴﺔ

Many Muslim scholars argue that Ramadan fast is not obligatory for pregnant women. Thus there is a scope for adaptation in practices. 11

Fasting during pregnancy is a debatable matter subject to various behaviours. Some pregnant women insist to fast and others do not fast or frequently break their fasting during the day. Some prefer to consult their HCPs concerning to fast or not. 12

Meal skipping, morning sickness and dieting during pregnancy, specially prior to pregnancy recognition, are fairly common in non Muslim communities and are comparable to fasting in terms of effects on the intrauterine environment.

Pregnancy and fast 3/18/2018 14

Questions posed by women about Fasting during pregnancy 1 - Is it safe for me and the baby? 2 - Does it matter whether I fast in the first, second or third trimester of pregnancy? 3 - Does the duration of fasting matter? 4 - If I fast- how can I make fasting safe? 5 - How best to break my fast? 6 - When should I be advised against fasting? 15

Pregnancy is a physiological condition that its concurrence with fasting introduces some controversies about condition of the mother and the fetus. 16

As a result of long hours of abstinence of food and liquids during pregnancy numerous metabolic, endocrinal changes, and adaptations occur. This may cause undesirable and harmful effects on the mother and the fetus. Najmudeen M, 2016. British Journal of Medicine & Medical Research, 17 16, (12): 1 -14, 2016

Possible Undesirable And Harmful Effects On The Mother • • • Increased risk of hyperemesisgravidarum. Increased prevalence of UTI. Hypoglycemia. Ketosis. Elevation of maternal cortisol levels. Preterm delivery due to elevated maternal CTRH concentration. • Sleep pattern and physical activity changes. - Rabinerson D et al 2000. J. Psychosom. Obstet & Gynecol 2000; 21: 189 -1. - Malhorta A et al 1989. Br. J Nut. 1989; 61: 663 -72. - Kavehmanesh Z et al 2004. J. perinato; . 2004; 24: 748 -50. 3/18/2018 - Hermann TS et al, 2001. AM J. Obstet & Gynecol. 2001; 185: 403 -412 18

Possible Undesirable And Harmful Effects On The Fetus • Reduction in fetal breathing movements. • Reduction in fetal biophysical profile. • Reduction in birth weight. • Cognitive ability of baby. • Adult disease development. 3/18/2018 - Mirghani HH et al 2004. J. Obstet & Gynecol 2004; 24 : 635 -7. - Cross JH et al, 1990. Arch Dis Child. 1990; 65: 1053 -6 19

However there is no robust scientific evidence to support most of the aforementioned increased risks associated with fasting. - Enozia Vakil, 2015 - Najmudeen M, 2016. British Journal of Medicine & Medical Research, 16, (12): 1 -14, 2016 20

Biological Mechanisms relevant for impact of fast on pregnancy outcome. 21

Biological Mechanisms A set of biochemical changes known as “accelerated starvation” occurs in pregnant women who undergo an extended period of fasting. Women experience profound declines in blood sugar level and sharp increase in ketones and free fatty acids due to metabolization of their stores of fat. 22

The hypoglycemia or hyperketonuria may affect: - Neonatal weight. - Neonatal mortality. - Disability. - Sadeghpoor. 2001. J. of Shahid Beheshty University of Medical Sciences 2001; 37: 33 -7. Behrman R E et al 2010. Textbook of pediatrics. 19 th ed. Philadelphia: Saunder. 2010; 520 -55. 23

Prentice et al 1983 and Malhotra et al 1989 had shown that such conditions can arise in fasting women as little as 12 hours whether in developed or developing countries. - Prentice et al 1983, Human nutrition. Clinical nutrition, 37(4): 283 -94, July 1983. -A. Malhorta et al 1989. British Journal of Nutrition. 61(3) : 663 -672, May 1989. 24

Exposure to ketones early in pregnancy had been linked to neurological impairment in animals*. In Human Rizzo et al 1991 had shown the association of ketone exposure in diabetic mothers to diminished cognitive ability**. *Hunter and Sadler 1987. Teratology, 36: 259 -64, 1987. **Rizzo et al 1991. New England J. of Medicine, 325: 911 -916, 1991 25

Fetal Programming Theory The developmental origins of health and adult disease has emphasized how environmental exposures in pregnancy, such as nutritional disruptions, can lead to developmental and metabolic adaptation to improve the likelihood of survival to reproductive age in the perceived environment at birth P. Gluckman and M. Hanson 2005. Development and Disease. Cambridge 26 University Press, Cambridge, 2005

Predictive Adaptive Response (PAR) PARs make the baby more prone to develop: - Coronary heart disease. - Hypertension. - Type 2 diabetes Godfrey KM et al 2001. Public Health Nutrition 2001, 4(2 B): 611 -24 27

Van Ewijk (2011) in Indonesia found more coronary heart problems and diabetes in Muslims whose in utero period overlapped with Ramadan as compared with Muslims who were unexposed to fasting. Van Ewijk, 2011. Journal of health Economics, 30: 1045 -1058, 2011 28

Disruption to the flow of glucose are thought to be one of the key signals of poor environmental condition during fetal development. The developing embryo will change the relative assignments of cells to the inner cell and outer cell mass according to whether it perceives a problem in glucose supply. P. Gluckman and M. Hanson 2005. Development and Disease. Cambridge 29 University Press, Cambridge, 2005, p. 31 -32

Ramadan fasting has also been linked to alterations in placental size and growth due to fetal. programming. Alwasel et al 2010. Placenta, 31(7): 607 -610, 2010 30

The fetal brain is especially susceptible to the fetal environment that might irreversibly damage it. Nutritional shocks in the first half of pregnancy may be specially harmful and may play a contributing role in the development of certain psychiatric diseases. P. Gluckman and M. Hanson 2005. Development and Disease. Cambridge 31 University Press, Cambridge, 2005, p. 31 -32

Accelerated starvation caused by fasting during pregnancy is correlated with malfunctioning of certain cognitive functions. Rizz T et all 1991. new England J. of Medicine 1991; 3251, 911 -916. 32

Prenatal nutritional deprivation in fasting women can lead to elevation of levels of the hormone cortisol and alterations in the neuro-endocrine system (HPA axis) which can result in cognitive deficits in children. - A. Kapoor et al 2006. Journal of Physiology, 572(1): 31 -44, 2006. - O. Dikensoy et al 2009. Archives of gyncol and Obstet. 279 (2): 119, 2009. - K. Z. Lewinn et al 2009. Int. J. of Epidemiology, 38(6): 1700 -1710, 2009. - Aizer et al 2009. Evidence from Siblings manuscript, Brown University, Feb. 2009 33

Effect of Fasting on Labor Market behavior 155 million Muslims potentially exposed to their Mother’s Fasting Indonesia - Work fewer hours - More likely to be self employed - Score lower on Raven’s colored progressive matrices assessment - Lower on math test scores 4. 5% 3. 2% 5. 9% 7. 9% Those affected children reported lower birth weight Indonesian Family life Survey (IFLS) 2012. M. F. Majd. Jel Codes 11, 112, 115, J 13, 34 3/18/2018 J 22, J 24, Z 1, z 12

Almond and Mazumder (2011) found that full exposure to Ramadan fasting in the first month of pregnancy in USA, Uganda, and Iraq increased the likelihood of a disability by about 20% with specially large effects on mental/learning disabilities and the effects are significant in the first three gestation months. Almond and Mazumder 2011. American Economic Journal: 35 Applied Economics. 3(4) October 2011

National Bureau of Economic Research Reported that the diurnal fast undertaken by pregnant Muslims during the month of Ramadan constitutes a modifiable determinant of prenatal development that has significant long-term effects on academic outcomes. Douglas Almond et al. 2011. NBER Working Paper No. 17713, December 2011. JEL No. 112, 114, 124, J 15 36

National Bureau of Economic Research NBER Compared persons born just before Ramadan, and thereby not exposed to fasting during pregnancy, to those exposed at different months of gestation using an “intent to treat” approach. Douglas Almond et al. 2011. NBER Working Paper No. 17713, December 2011. JEL No. 112, 114, 124, J 15 37

The math scores of students who were exposed to Ramadan during the first trimester are reduced by 0. 06 to 0. 08 standard deviations, academic scores by 0. 05 to 0. 08 standard deviations. Douglas Almond et al. 2011. NBER Working Paper No. 17713, December 2011. JEL No. 112, 114, 124, J 15 38

Early research has not demonstrated any effect on Apgar scores, birth weight, gestational age at delivery, or infant well-being - Kaplan M et al, 1983. JAMA. 250: 1317 -138. - Cross JH et al 1990. Arch Dis Child. 65: 1053. - Hefni M et al 1993, Saudi Med J. 14 (2): 130132 3/18/2018 39

Historical. . Cohort study of fast in 293 pregnant patients (Iran) Birth weight Fasting days No fasting 1 -10 days of fasting 11 -20 days fasting More than 20 days of fasting 3/18/2018 Mean neonatal weight 3348. 461 3198. 285 3429. 206 3326. 346 Standard deviation P-value +339. 949 +584. 5686 0. 145 +462. 6372 +483. 4729 Sarafraz N et al 2014. J. Fasting health 2014: 2(1) 40

Historical. . Cohort study of fast in 293 pregnant patients (Iran) Birth weight Trimesters First trimester Second Trimester Third Trimester P-value 3/18/2018 Fasting 3360. 133 (+481. 603) 2976. 923 (+698. 991) 3250. 000 (+212. 132) Non - Fasting 3378. 484 (+350. 215) 3050. 000 (+241. 522) 3400. 000 (+102. 122) 0. 025 0. 194 Sarafraz N et al 2014. J. Fasting health 2014: 2(1) 41

Effect of Ramadan Fasting on Neonatal Birth Weight There is no significant relationship between the neonatal birth weight and maternal fasting during pregnancy. Sarafraz N et al, 2014. J. Fasting Health, 2014, 2 (1) 42

Non- stress tests are more likely to be non-reactive during the period of fasting but return to reactive after dinner. - Modawiss, 1990. Saudi Med. J. 11: 51 -54. Altaani MI. 1999. J Arab Board Med specialization 1(3): 100 -103 3/18/2018 43

Does the duration or timing of fast have an impact on the outcome of pregnancy? 44

The outcome of pregnancy was assessed by Vahid et al in 123 pregnant women who fasted for various number of days in the 1 st , 2 nd, and 3 rd trimester versus 66 pregnant women without fasting. For statistical analysis of data, covariance analysis and SPSS package were used. Vahid Ziaee et al, 2010. Iran J. pediatric. Vol. 20 (No. 2): 181 -186 45

Incidence of fasting in studied mothers and with regard to trimesters Group Without fasting 1 -10 days fasting 11 -20 days fasting >20 days fasting Total First Trimester Second Trimester Third Trimester Total 31 (47. 0%) 6 (21. 0%) 14 (40. 0%) 31 (51. 0%) 82 (43. 0%) 15 (22. 7%) 10 (35. 7%) 11 (31. 4%) 20 (33. 3%) 56 (29. 6%) 20 (30. 3%) 12 (42. 9%) 10 (28. 6%) 9 (15. 0%) 51 (27. 0%) 66 (34. 9%) 28 (14. 8%) 35 (18. 5%) 60 (31. 7%) 189 (100%) Vahid Ziaee et al, 2010 3/18/2018 Iran J. pediatric. Vol 20 (No 2): 181 -186 46

Comparison of pregnancy outcome indices in pregnant mothers with number of days on fasting Parameters Mean (SD Weight (kg) Length (cm) Head circumference (cm) Without fasting 1 -10 days fasting 11 -20 days of fasting More than 20 days fasting P-value 3. 01 (0. 5) 49. 7 (2. 9) 34. 4 (1. 4) 3. 27 (0. 5) 49. 9 (1. 7) 34. 5 (1. 4) 3. 01 (0. 3) 50. 2 (2. 5) 34. 4 (1. 6) 2. 96 (0. 7) 49. 2 (44) 33. 7 (2. 3) 0. 1 Vahid Ziaee et al, 2010 Iran J. pediatric. Vol 20 (No 2): 181 -186 3/18/2018 0. 5 0. 1 47

Comparison of mean weight, height, and neonatal circumference IN mothers on fasting in different trimesters of pregnancy First Trimester (n=44) Second Trimester (n=31) Third Trimester (n=31) P-value Weight (kg) 2. 998 (0. 676 2. 949 (0. 733) 3. 105 (30. 585) 0. 3 Length (cm) 49. 0 (3. 9) 33. 9 (2. 2) 50. 1 (4. 3) 33. 9 (2. 5) 20. 2 (3. 3) 34. 4 (1. 9) 0. 6 Parameters Mean (SD) Head circumference (cm) Vahid Ziaee et al, 2010 3/18/2018 Iran J. pediatric. Vol 20 (No 2): 181 -186 0. 4 48

According to these findings, in healthy women with appropriate nutrition, Islamic fasting has no inappropriate effect on intrauterine growth and birth –time indices. Meanwhile , relative risk of low weight birth was 1. 5 in mothers on fasting at first trimester as compared to non-fasting mothers. Vahid Ziaee et al, 2010. Iranian Journal of pediatrics, Vol. 20 (No. 2), June 2010, P. 181 -186 49

Effect of Fasting on Renal and Bone function of pregnant women There is no sufficient evidence regarding the adverse effects of Ramadan fasting on biochemical substances relating to the renal and bone function of pregnant fasting women. Khoshed A et al, 2013. J. Fasting Health, 2013, 1 (2): 79 -84 50

What can I do ? 3/18/2018 51

Is fasting during Pregnancy OKAY? Consult your HCP before deciding to fast for a discussion on whether you can fast to satisfy your religious priorities or not to fast for protections of your own health as well as your baby’s health. 52

How to make fasting in pregnancy easier? • Drink – Drink on the eve of the fast. • Avoid stressful situations. • Take things easy and accept help. • Keep cool. • Plan your days and take regular rests. • Do not walk long distances. • Cut down on house work. • Do not miss your predawn meal. • Have plenty to drink between dusk and dawn (1. 5 -2 Liters). • Avoid caffeine drinks 53

What is the best way to break the fast? • Choose a variety of healthy food. • Have plenty to drink at Iftar. • Choose foods that release energy slowly (wholegrains and seeds, high-fibre foods such as Pulses and vegetables, dried fruits). • Avoid having lots of sugary foods. • Rather than high-fat, refined foods, choose potatoes or chickpeas and, • Get plenty of proteins from beans, meat and eggs. 54

Warning signs that warrant breaking the fast • Bleeding. • Nausea and vomiting. • A clear decrease in fetal movement. • Very thirsty. • Blurred vision and/or intense headache. • Dizziness. • Extreme fatigue and weakness. • Failure to put on weight. • Low and concentrated urinary output. 55

Conclusion Most of the existing studies on fast in pregnant women are small or methodologically flawed. The fasting is not starving. The healthy body adapts to different nutritional status. 56

Conclusion Fasting in the first trimester could be harmful for the fetus as organogenesis occurs during this period and it is particularly sensitive to nutrient deficiencies. 57

Conclusion There is lack of a conclusive evidence of the negative effects of fasting on maternal, fetal health and fetal programming due to lack of long term robust studies. 58

Conclusion Healthy and well nourished women could fast with some necessary precautions after considering their individual circumstances as the number of fasting hours, climate condition, working circumstances and personal preference. 59

Though some research suggested that maternal fast increases the potential to developing irreversible mental and physical disabilities in the children, current research suggests that it has no deleterious impacts on birth weight or biochemical and biophysical parameters of babies. 60 - Najmudeen M, 2016. British Journal of Medicine & Medical Research, 16, (12): 1 -14, 2016

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