Ramadan has started. What advice should we give to patients at risk who want to fast?
Approximately 200 000 Muslims live in Norway (1). During the month of Ramadan, it is customary for all healthy adult Muslims to fast from dawn (suhur) to sunset (iftar). This year, Ramadan began on April 24th and will end with the celebration of Eid-al-fitr on May 24th.
Due to the COVID-19 pandemic, many patients and doctors wonder whether it is safe to fast this year or not.
The risk of fasting and COVID-19
At present, there is no evidence that fasting itself increases the risk of contracting viral infections, including COVID-19 (2). Nor are there any studies as yet on the clinical course of COVID-19 in people who are fasting. Islam already exempts children and pregnant women as well as those with chronic illnesses such as diabetes mellitus, renal failure, heart and lung disease, and cancer from fasting. These patients have a higher risk of developing a severe form of COVID-19 (3–5). The same applies to those over the age of 65. In the case of healthy individuals in this age group, health personnel should perform a clinical assessment in agreement with the patient. During the pandemic, it is crucial that health personnel who treat/follow-up patients with severe illnesses or in a higher age group actively discuss fasting during Ramadan. If clinically indicated, patients should be advised against fasting.
Dehydration and the risk of COVID-19
People who are fasting will have no fluid intake for 16–18 hours. Even though this will result in temporary dehydration, it is highly unlikely that it will lead to chronic or severe dehydration in healthy individuals. Moreover, dehydration is a greater challenge in countries with a warmer climate than Norway. As far as we know, there is no evidence that temporary dehydration or dry mucous membranes increase the risk of contracting COVID-19 or of developing a more severe clinical course if infected. We recommend that when fasting, people should drink 2–4 litres of fluid during the hours from sunset to dawn. At the start of the pandemic in Western countries, some advice was circulating on social media that frequent water intake would help prevent COVID-19. However, there is no evidence to support this claim. In our opinion, good hygiene and social distancing play a much more important role.
Sharing iftar meals and praying together
During Ramadan this year, all mosques are closed, and it is very important to remind people that even though they traditionally share the evening meal when breaking the fast and pray together, government advice at the end of April/start of May states that no more than five people (apart from those living in the same household) are allowed to meet. In addition, they must keep a distance of 1–2 metres from each other. As far as possible, it is best to avoid such gatherings. Notably, preserving one’s own health and that of others is a key tenet of Islam. Muslim religious communities worldwide, including in Norway, have cancelled religious gatherings, referring to the prevention of infection as an important religious act and a true virtue.
Advantages of fasting
Several studies show that intermittent fasting, as in the case of Ramadan, has positive metabolic impacts and reduces stress and anxiety levels (6–8). In fact, experimental studies indicate that fasting can have a beneficial effect on the immune system (9).
There is no evidence that healthy individuals are at higher risk of being infected with COVID-19 or developing severe illnesses due to intermittent fasting in the month of Ramadan. However, we recommend health personnel to actively discuss fasting with their patients. Those who have symptoms of COVID-19 must contact health personnel and if necessary, break the fast. People with severe chronic or acute illness should refrain from fasting – and Islam allows for exemption in such cases. Finally, health personnel must reiterate the infection prevention measures and recommend that patients avoid socialising even though this is an important tradition during Ramadan.
We recommend health personnel to actively discuss fasting with their patients
In general, we must take a critical approach to the evidence on the usefulness of the advice given. If not, we run the risk that important and effective measures against COVID-19 – such as good hand hygiene, social distancing, and self-isolation for those infected – are swamped in the flow of information. Considerable research efforts are being devoted to mapping the various aspects of the pandemic, and we look forward to the provision of clearer, research-based advice on fasting as well. In any case, we would like to wish you all a happy Ramadan.