Does Ramadan cause to iron deficiency in pregnancy?

Objective

We designed this study to evaluate whether or not Ramadan fasting causes iron deficiency in pregnancy.

Methods

There was not a significant difference between the serum levels of CRP before and after Ramadan in Group1a-Group 1b and Group 2a-Group 2b.There was not a significant difference between Group 1a- Group 2a, Group 1b-Group 2b for serum CRP levels .There was a slight decrease in serum ferritin levels in all Groups, but this decrease was not statistically significant .The ferritin levels were similar in Group1a- 2a, and Group 1b-2b .The haemoglobin levels was increased in all groups, but this increase was not statistically significant. The haemoglobin levels were also similar in Group1a- 2a, and Group 1b-2b

Results

This study was carried out in Obstetrics and Gynecology Department of Gaziantep University Hospital, between September 23th and October 23th in year 2006 (during Ramadan). Fourty-one consecutive healthy women with uncomplicated pregnancies of 20 weeks or more who were fasting during Ramadan were included in the study group (Group 1). The control group (Group 2) consisted of 31healthy pregnant women who were not fasting during the study period.Before and after Ramadan, we measured plasma C reactive protein levels (CRP), serum ferritin levels, and haemoglobin levels (Hb) in all patients.Any patients who had a sign of infections ( elevated white blood cell, elevated CRP) excluded from the study to prevent the confusing ferritin elevations.The patients who had ferritin levels < 15 µg/L excluded from the study before Ramadan.

Conclusion

Ramadan does not cause a significant change in serum CRP, ferritin, and haemoglobin levels if enough iron supplemantation provides in pregnancy.

Keywords

Ramadan, pregnancy, iron deficiency

Introduction

Ramadan is the holiest month in the Islamic calendar and Muslims fast during this month (1).Believers are commanded to abstain from food, drink and conjugal relationships from sunrise to sunset as a sing of restraint and introspection. The food and fluid intake are mainly nocturnal and usually, food frequency and quantity, sleep duration at night and daily physical activity are reduced .The food habits are not similar outside and during Ramadan in that the proportion of fat, protein and carbohydrate intake can differ during Ramadan.There is a tendency to consume foods and drinks that are richer in carbohydrates than those consumed during other months of the year (2).The limitation in consumption of the meat and fresh fruit in daily diet causes to iron deficiency in low socio-economic group (3). In this study, we aimed to show whether Ramadan causes iron deficiency by measuring serum ferritin and haemoglobulin levels in pregnacy

Methods

This study was carried out in Obstetrics and Gynecology Department of Gaziantep University Hospital, between September 23th and October 23th in year 2006 (during Ramadan). Fourty-one consecutive healthy women with uncomplicated pregnancies of 20 weeks or more who were fasting during Ramadan were included in the study group (Group 1a and 1b). Group 1a consisted of 28 fasting pregnant patients in second trimester, Group 1b was also consisted of 13 fasting pregnant patients in third trimester.The control group (Group 2a and 2b) consisted of 31healthy pregnant women who were not fasting during the study period.Group 2a consisted of 19 non fasting pregnant patients in second trimester, Group 2b consisted of 12 non fasting pregnant patients in third trimester.Before and after Ramadan serum ferritin, haemoglobin, and CRP levels measured in all patients.Ferritin was measured by immunchemiluminescent method by using Immulite 2000 autoanalyser and kits from (Diagnostic Products Corporation, Los Angeles, ABD).Ferritin levels of <15µg/L is consistent with iron depletion and ferritin levels of <12µg/L are associated with iron depletion anemia.Any patients who had ferritin levels <15µg/L was excluded from the study before Ramadan.
Hb values were measured in Sysmex XT 2000 I automated hematology analyzer((Roche Diagnostics GmbH, Mannheim, Germany).Serum CRP levels were determined on a Behring BNA 100 nephelometrically (Dade, Behring Marburg, Germany).
Multivitamin (Materna, Wyeth), calcium 1gr/day (Cal-D Vita, Roche) and iron (100 md/day) (Ferplex Fol, Abdi Ibrahim) supplementation were given to all subjects. All the subjects were advised to drink at least 2 liter water every night to prevent hypo-hydratation and urinary tract infections. 

Results

Statistically Analysis: All comparisons in and between the groups was done by Simple Paired t-test . Sigma Stat 3.0 was used for statistical analysis. P value<0.05 was accepted as significant. 
There was not a significant difference between the serum levels of CRP before and after Ramadan in Group1a-Group 1b and Group 2a-Group 2b (p=0.71, p=0.57).There was not a significant difference between Group 1a- Group 2a, Group 1b-Group 2b for serum CRP levels (p=0.62, p=0.71).There was a slight decrease in serum ferritin levels in all Groups, but this decrease was not statistically significant .The ferritin levels were similar in Group1a- 2a, and Group 1b-2b (p=0.57, p=0.63).The haemoglobin levels was increased in all groups, but this increase was not statistically significant. The haemoglobin levels were also similar in Group1a- 2a, and Group 1b-2b (p=0,71, p=0.67) (Table-1).

Discussion

During Ramadan, Muslims refrain from eating, drinking, smoking, and sexual relations from sunrise until sunset.The period in which the person fasts may vary depending on the geographical location of the country and the season of the year, and can be as long as 18 hours/day in the summer of temperate regions (2).It has been established that a given nutrient ingested at an unusual time can induce different metabolic effects, and the Ramadan fasting provides an excellent opportunity to study the effects of the prolonged reduction of meal frequency on body metabolism (4).
It has been showed that Ramadan fasting caused less weight gain and energy intake in second and third trimester in Turkish pregnant women.The percentage of protein (for first trimester) and corbohydrates (for all trimester) from total energy was higher in fasting group(5).Another study has been showed that there is a tendency to consume foods and drinks that are richer in carbohydrates than those consumed during other months of the year (2).
Nutritional anemias are considered to be one of the most common nutritional disorders of the world and are widespread in developing countries (6). Less consumption of the meat and fresh fruits results in low dietary intake of iron espeacilly in low socio-economic pregnant women (3).
In healthy subjects, the plasma ferritin concentration is a biomarker for mobilisable body iron reserves.In general, ferritin levels of <30 µg/L indicate a low iron status, small or no iron reserves as verified by the absence of bone marrow haemosiderin.Ferritin levels of <15 µg/L is consistent with iron depletion and ferritin levels of <12 µg/L are associated with iron deficincy anemia (7, 8).In women with inflammatory of infectious disorders, plasma ferritin can be falsely elevated out of proportion with body iron reserves.If such conditions are suspected, plasma CRP should be measured as well, in order to assess the degree of inflamation.We also measured CRP levels to prevent any elevation in ferritin levels due to infections (9).It has been suggested that women with plasma ferrin of >70 µg/L do not need iron supplements; those with ferritin of 30-70 µg/L should take 30-40 mg ferrous iron per day and those with ferritin of < 30 µg/L should take 80-100 mg ferrous iron per day ( 8).It has been reported that 65 mg ferrous iron /day from 20 weeks gestation was adequate to prevent iron deficiency anaemia in all women (10).In our study, all patients’ ferritin levels was slightly under 30 µg/L, and gestational age was ≥ 20 weeks therefore; we supplemented 80-100 mg ferrous iron per day.It is also prevent to increase ferritin levels during the Ramadan. In conclusion, Ramadan fasting does not cause iron deficiency and does not change ferritin levels if enough iron supplementation provides in pregnacy.

Conclusion

In conclusion, Ramadan fasting does not cause iron deficiency and does not change ferritin levels if enough iron supplementation provides in pregnancy.

References

1) Frost G, Pirani S.Meal frequency and nutritional intake during Ramadan: a pilot study.Hum Nutr Appl Nutr . 1987;41:47-50..
2) Ziaee V, Razaei M, Ahmadinejad Z, Shaikh H.The changes of metabolic profile and weight during Ramadan fasting.Singapore Med J 2006; 47:409-413.
3) Islam MZ, Allardt CL, Bhuyan MAH, Salamatullah Q.Iron status of premenopausal women in two regions of Bangladesh: prevelance of deficiency in high and low socio-economic groups.Eur J of Clin Nutr 2001; 55:598:604.
4) Nelson W, Cadotte L, Halberg F.Circadian timing of single daily meal affects survival of mice.Proc Soc Exp Biol Med 1973; 144:766-769..
5) Kiziltan G, Karabudak E, Tuncay G, Avsar F, Mungan O,Meral P .Dietary intake and nutritional status of Turkish pregnant women during Ramadan.Saudi Med J 2005;26:1782-1787..
6) World Health Organization.Iron deficiency anemia.Assessment, prevention and control.World Health Organization 2001 WHO/NHD/01.3..
7) Milman N, Strandberg NS, Visfeldt J.Serum ferritin in healthy Danes: relation to marrow haemosiderin iron stores.Dan Med Bull 1983; 30:115-120.
8) Worwood M.Laboratory determination of iron status.In:Brock JH, Halliday JW, Pippard MJ, Powell LW.Iron metabolism in health and disease.Saunders, London 1994; 449-476.
9) Milman N.Prepartum anemia: prevention and treatment.Ann Hematol 2008: July 19.
10) Scanlon KS, Yip R, Schieve LA, Cogswell ME.High and low haemoglobin levels during pregnancy :differential risks for preterm birth and small gestational age.Obstet Gynecol 2000;96:741-8.