Ramadan 2021: fasting during the COVID-19 pandemic
This year marks the second Ramadan carried out under the shadow of the COVID-19 pandemic. It is an event that already comes with additional layers of risk for Muslims with diabetes, as Dr Sarah Ali, consultant in endocrinology, diabetes and general medicine at the Royal Free London NHS Foundation Trust told the South Asian Health Foundation (SAHF) and Diabetes and Ramadan (DAR) International Alliance Annual Diabetes in Ramadan Conference.
Over the past year, as is now widely understood, it has become apparent that certain factors increase the risk of severe COVID-19 infection, such as age and gender, as well as pre-existing medical conditions, including diabetes. Indeed, one third of COVID-19 deaths in hospital are in people with diabetes, with poor glucose control and other co-morbidities contributing to an additional increase in risk. Certain ethnicities are also a factor and a significant proportion of Muslim populations are at higher risk of severe disease.
So what bearing should these factors have on the way people with diabetes choose to observe Ramadan? In her presentation at this year’s Diabetes in Ramadan conference, Dr Ali reminded listeners that grounds for exemption from fasting include acute illness – and that includes COVID-19.
The medical recommendation is that people experiencing symptoms of COVID-19 should not fast and that those with type 1 diabetes should not fast if there are high rates of transmission in their country. However, many people choose to fast regardless of an exemption on medical grounds - and it’s the job of healthcare professionals to help them do this as safely as possible. SAHF guidelines covering fasting during the pandemic are freely available at https://onlinelibrary.wiley.com/doi/full/10.1111/dme.14312
The risks associated with fasting for people with diabetes, such as hypo- and hyperglycaemia, diabetic ketoacidosis, hyperglycaemic hyperosmolar syndrome, dehydration and thrombosis, are well established and much discussed. However, it is important that people with diabetes, their carers and healthcare professionals are aware that concurrent COVID-19 may precipitate these complications or exacerbate the risks.
Dr Ali emphasised that education and awareness are key, with assessment and counselling at least one to two months before Ramadan and educating the family or caregivers of people with diabetes who wish to fast. She also pointed out that it is well worth asking patients about their experience of fasting during Ramadan in 2020 (also during the pandemic); their input may help to guide advice for Ramadan this year and in future years.
Good glucose control mitigates the risk of complications from COVID-19, so if a patient develops symptoms they must check their levels frequently and also break the fast. This COVID-19 caveat has now been added into guidelines around breaking a fast.
Dr Ali also covered pharmacological management during COVID-19 – an area of guidance in which it’s vital to stay up to date. For example, metformin must be stopped if someone develops severe symptoms of COVID-19.
One of the final points arose from a survey of people with type 2 diabetes during Ramadan in 2020 – of those advised not to fast, the survey found that 86.3% did not, demonstrating that discussion and education have a huge impact on patients.
Lastly, she touched on the important subject of COVID-19 vaccinations during Ramadan, emphasising that it does not break the fast if you have it during the fasting hours, and neither does having a lateral flow test.
The views expressed in this article are those of the author, Dr Eleanor D Kennedy.