Is it safe for patients with COVID-19 to fast in Ramadan?

April 22, 2020

Asli Kalin, Ammad Mahmood, Salman Waqar, Asim Yusuf, Nazim Ghouri, Naveed Sattar, Tahseen Chowdhury and Nazim Ghouri

On behalf of the Oxford COVID-19 Evidence Service Team

Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences

University of Oxford

And the British Islamic Medical Association

Editorial input from Trisha Greenhalgh

Correspondence to ramadanreview@britishima.org

VERDICT

Ramadan, a month of fasting for Muslims, begins on 23rd April. This review provides information to clinicians looking after people who have symptoms of COVID-19 and are thinking about fasting. We found no specific studies looking at fasting in the context of COVID-19. There is no evidence to suggest an adverse effect from fasting during the Covid-19 pandemic on asymptomatic healthy individuals who have previously fasted safely. However, patients with fever and prolonged illness secondary to Covid-19 can become severely dehydrated and are at risk of sudden acute deterioration. As such, these patients should not fast (or cease fasting) and ensure adequate hydration . Prior to commencing fasting, any comorbidities need to be risk stratified and discussed with the patient’s clinician. In light of this, we have developed a risk matrix spanning a range of conditions with a view to help patient-centered shared decision-making.

BACKGROUND

There are approximately 2.7 million Muslims in the UK, constituting 4.8% of the population1. Muslims are required to fast during the month of Ramadan (from around 23rd April to 23rd May 2020) by abstaining from food and drink from sunrise to sunset. However, there are exceptions to this. One of them is that people who are ill or have certain medical conditions do not have to fast.

The arrival of Ramadan amidst the COVID-19 pandemic has led to clinicians and patients asking questions about the safety of fasting in this month, particularly in light of the higher than expected disease burden and severity amongst the Black and Minority Ethnic (BAME) populations2. The purpose of this review is to provide guidance to clinicians looking after patients with symptoms of COVID-19 who are thinking about fasting in Ramadan. It considers current evidence on COVID-19 and fasting, as well as religious guidance around Ramadan, and aims to provide recommendations for health professionals who are counselling such patients. Medical research on Ramadan is a nascent field and many studies are of poor quality with limited direct clinical applicability. Ultimately the final decision to fast or not rests with the individual concerned, in discussion with their clinician and trusted religious authority.

CURRENT EVIDENCE

What we know about the clinical course of COVID-19 infections:

The majority of COVID-19 infections either do not produce any symptoms or cause a self-limiting flu-like illness, whilst up to 20% can cause severe or critical illness3. Many of the clinical features such as fever, prolonged illness, headache, loss of taste and smell, and extreme fatigue can all lead to reduced fluid intake and significant dehydration4. Rapid deterioration can occur within hours, especially in the second week, with fever and respiratory compromise5.

Ethnicity, obesity and type 2 diabetes:

Furthermore, recent epidemiological data points suggest certain Muslim communities in the UK may be at higher risk of severe COVID-19 infection. Indeed, obesity6, diabetes7 and ethnicity8 have all been associated with severity of COVID-19. A recent publication by Khunti has highlighted higher mortality rates amongst BAME communities8. This has also been found to be the case in the US9. A significant proportion of Muslims in the UK are of BAME origin, particularly from South Asian and African backgrounds, who also have lower cut-offs for defining obesity10. The rising prevalence of diabetes in Muslim communities has also been well established11. Indeed, it is estimated that 325 000 UK Muslims have diabetes1. Thus, the prevalence of diabetes in UK Muslims is 12.5% which is double that of the general population12.

Obesity poses a risk on the pathogenicity of COVID-19 and the course of the disease, with some commentary to suggest that increased adiposity may undermine the pulmonary microenvironment13, increase diabetes risks and lessen general cardiorespiratory reserve14. Kassir15 also noted thrombotic events were an aggravating cause of death in COVID-19 infections, with dehydration increasing the risk of hypercoagulability.

Thromboembolic risk is known to be higher in patients with obesity than in the general population. It logically follows that obesity can be an aggravating risk factor for death from COVID‐19 infection. The American Centres for Disease Control (CDC) state that severe obesity also increases the risk of acute respiratory distress syndrome (ARDS), which is a major complication of COVID-19 and can cause difficulties to provide respiratory support for seriously ill patients16.

Fasting, dehydration and outcomes in COVID-19 infection

Fasting in Ramadan involves abstention from drinking any fluids during daylight hours. Whilst dehydration during the fast is expected, whether fasting leads to chronic dehydration is unclear17. Patients with symptoms due to COVID-19 infection such as fever, loss of taste and fatigue may be at higher risk of dehydration. The link between dehydration and outcome in COVID-19 infection is still emerging. Two observational studies from China show patients who died of SARS-COVID-19 had higher serum creatinine at presentation18,19 though a difference in requirement for ICU care was not seen in another study20. One study found patients who died were more likely to present with fever18 whilst others found no difference in mortality19 or requirement for ICU care20. Conversely guidelines for intensive care units advocate cautious fluid resuscitation due to risk of myocardial complications and ARDS21,22. Hydration status at presentation was not specifically defined or commented on in studies.

Salem et al (2020) have recently reviewed the link between intermittent fasting and immunity in Ramadan in light of COVID-1923. They state that there is “no detrimental effects on health have been directly attributed to negative water balance during Ramadan in healthy subjects”, as well as reaffirming that no studies have been done with COVID-19 infection.

EMERGING EVIDENCE IN COVID-19

No known evidence in literature. Interim guidance from the World Health Organization suggests that it is safe to fast for otherwise healthy individuals who have previously fasted safely24.

CONCLUSIONS

Patients with fever and prolonged illness secondary to COVID-19 can become severely dehydrated and are at risk of sudden acute deterioration. Such patients should terminate their fast early or abstain from fasting during Ramadan and ensure adequate hydration (Figure 1). Further caution should also be applied where other co-morbidities are present25.

The British Islamic Medical Association has also published guidance on fasting in the context of medical conditions other than COVID-1925 with particular advice on fasting with co-morbidities in the presence of COVID-19. A risk matrix spanning a range of medical conditions has been developed, in collaboration with several subject experts, with a view to help patient-centred shared decision-making.

*Determined by any of the following

Prior experience of fasting with such an illness

Common knowledge

The advice of an appropriate clinician

Figure 1- Dealing with acute illness during Ramadan including Covid-19 symptoms25

This is also in accordance with Islamic jurisprudence and guidance published by the British Board of Scholars and Imams (BBSI) 26. Indeed, Islam allows and indeed encourages the sick person to eat and drink as needed when sick, and subsequently make up their fasting days when they are better and stronger. The BBSI also emphasizes the need to maintain social distancing measures during the month of Ramadan.

The presence of the current COVID-19 pandemic is not a contraindication to fasting in otherwise healthy individuals who are asymptomatic23. Good hydration should be encouraged in non-fasting hours.

Disclaimer: the article has not been peer-reviewed; it should not replace individual clinical judgement and the sources cited should be checked. The views expressed in this commentary represent the views of the authors and not necessarily those of the host institution, the NHS, the NIHR, or the Department of Health and Social Care. The views are not a substitute for professional medical advice.

AUTHORS

Dr Asli Kalin is an Academic General Practitioner at the University of Oxford

Dr Salman Waqar is an Academic General Practitioner at the University of Oxford

Dr Ammad Mahmood is a Neurology Registrar, Clinical Research Fellow, University of Glasgow

Shaykh Dr Asim Yusuf is a Consultant Psychiatrist in Wolverhampton, and the Chair of the British Board of Islamic Scholars and Imams

Dr Nazim Ghouri is a Consultant Endocrinologist and General Physician, Queen Elizabeth University Hospital, Glasgow and Honorary Clinical Senior Lecturer, University of Glasgow

Prof Naveed Sattar is a Professor of Metabolic Medicine at the Institute of Cardiovascular & Medical Sciences at the University of Glasgow, as well as an Honorary Consultant in Metabolic Medicine at the Glasgow Royal Infirmary

Prof Tahseen Chowdhury is a Consultant Endocrinologist at the Department of Diabetes and Metabolism at the Royal London Hospital. He runs a large specialist Diabetes and Metabolism unit, dealing with diabetes particularly amongst the Bangladeshi community of Tower Hamlets. He has a research / clinical interest in diabetes in South Asians and diabetic kidney disease.

Dr Nazim Ghouri is a Consultant Endocrinologist and General Physician, Queen Elizabeth University Hospital, Glasgow and Honorary Clinical Senior Lecturer, University of Glasgow

SEARCH TERMS

Search strategy

PubMed and Google Scholar databases were searched between 5-21 March 2020 for all studies from database inception. We used search terms to describe fasting in Ramadan along with terms to describe Covid-19, infection and dehydration. Titles and abstracts were screened to assess suitability for inclusion. Existing reviews of literature on these topics were also snowballed for references where appropriate. No language or study restrictions were applied, but due to pragmatic considerations only English language papers were reviewed. Due to time restrictions no critical appraisal checklist was used, nor was the review registered.

Where possible, authors brought in literature and context from non-Ramadan studies on COVID-19 to help frame the recommendations.

REFERENCES