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Letter to the Editor: The first Ramadan during COVID-19 pandemic: 1.8 billion Muslims should fast or not?

      Dir Sir,
      With great interest we have read the recent article entitled “Fasting glucagon concentrations are associated with longitudinal decline of β-cell function in non-diabetic humans” which was published in your valuable journal [
      • Adams J.D.
      • Dalla Man C.
      • Laurenti M.C.
      • Andrade M.D.H.
      • Cobelli C.
      • Rizza R.A.
      • et al.
      Fasting glucagon concentrations are associated with longitudinal decline of β-cell function in non-diabetic humans.
      ]. We want to congratulate the authors for this successful article, and make a new contribution about fasting during COVID-19 pandemic.
      In early December 2019, a novel coronavirus emerged in China [

      Prem K, Liu Y, Russell TW, Kucharski AJ, Eggo RM, Davies N, et al. The effect of control strategies to reduce social mixing on outcomes of the COVID-19 epidemic in Wuhan, China: a modelling study. Lancet Public Health.

      ]. Due to high rate of transmission of the disease, officially confirmed cases have been reported in most countries around the world [

      Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet

      ,

      Saglietto A, D'Ascenzo F, Zoccai GB, De Ferrari GM. COVID-19 in Europe: the Italian lesson. Lancet

      ]. With the introduction of the disease as a pandemic, the importance of COVID-19 is increasing day by day [
      ]. In addition, the confirmed cases of this disease in Muslim-majority countries are prevalent [

      Takian A, Raoofi A, Kazempour-Ardebili S. COVID-19 battle during the toughest sanctions against Iran. Lancet.

      ,
      • Ebrahim S.H.
      • Memish Z.A.
      COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia.
      ,

      Mousavi SH, Shah J, Giang HTN, Al-Ahdal TMA, Zahid SU, Temory F, et al. The first COVID-19 case in Afghanistan acquired from Iran. Lancet Infect Dis.

      ]. 1.8 billion Muslims live in more than 180 countries around the world [
      • Ebrahim S.H.
      • Memish Z.A.
      COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia.
      ,
      ]. One of the main activities of Muslims in less than one month later (Ramadan: the ninth month in the Islamic calendar) is fasting [
      • Al-Arouj M.
      • Assaad-Khalil S.
      • Buse J.
      • Fahdil I.
      • Fahmy M.
      • Hafez S.
      • et al.
      Recommendations for management of diabetes during Ramadan.
      ]. To date, various studies have been conducted on the health effects of fasting [
      • Talib S.
      • van de Poll S.W.E.
      Brugada syndrome diagnosed after Ramadan.
      ,
      • The L.
      Ramadan: health effects of fasting.
      ]. Majority of them, studied the impact of fasting on the lipid profile, diabetes and, body weight [
      • Sheikh A.
      • Wallia S.
      Ramadan fasting and diabetes.
      ]. In addition, recent studies have shown the effect of fasting on the immune system [

      Nagai M, Noguchi R, Takahashi D, Morikawa T, Koshida K, Komiyama S, et al. Fasting-refeeding impacts immune cell dynamics and mucosal immune responses. Cell. 2019;178:1072–87.e14.

      ,
      • Buono R.
      • Longo V.D.
      When fasting gets tough, the tough immune cells get going—or die.
      ]. It can be concluded that the results of previous studies on the immune system have been inconsistent. With the increasing importance of COVID-19, a fundamental question needs further investigation. During the outbreak of new corona, healthy Muslims must fast in this Ramadan as in previous years? In the next section, we briefly reported some concerns.
      Due to suppression of immune system, patients with or recently recovered from cancer, are susceptible to COVID-19 [

      Burki TK. Cancer care in the time of COVID-19. Lancet Oncol.

      ,
      • Liang W.
      • Guan W.
      • Chen R.
      • Wang W.
      • Li J.
      • Xu K.
      • et al.
      Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China.
      ]. In the one hand, the effect of fasting on suppressing immune system remains unclear [

      Nagai M, Noguchi R, Takahashi D, Morikawa T, Koshida K, Komiyama S, et al. Fasting-refeeding impacts immune cell dynamics and mucosal immune responses. Cell. 2019;178:1072–87.e14.

      ,
      • Buono R.
      • Longo V.D.
      When fasting gets tough, the tough immune cells get going—or die.
      ] and on the other hand recent review study reveals the positive effect of fasting during Ramadan on treatment of cancer [
      • Longo Valter D.
      • Mattson Mark P.
      Fasting: molecular mechanisms and clinical applications.
      ]. Further confirmed protocols and guidelines must produce to clarify the status of fasting or not fasting for Muslims.
      Beginning of the Ramadan is considered for reducing smoking among Muslims. However, only little studies have shown the effect of smoking on increasing the chance of COVID-19 [

      Olds JL, Kabbani N. Is nicotine exposure linked to cardiopulmonary vulnerability to COVID-19 in the general population? FEBS J..n/a.

      ], more studies are needed in this regard.
      A recent study revealed that, due to the treatment protocol, patients with hypertension, or diabetes, who are treated with ACE2-increasing drugs, are at higher risk for severe COVID-19 infection [

      Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection? Lancet Respir. Med.

      ]. Due to the effect of fasting on Diabetes, Blood fat and Hypertension, rigorous studies are needed to find the effect of fasting on reducing/increasing the chance of a healthy person to becoming ill.

      Competing interests

      None declared.

      References

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        • Dalla Man C.
        • Laurenti M.C.
        • Andrade M.D.H.
        • Cobelli C.
        • Rizza R.A.
        • et al.
        Fasting glucagon concentrations are associated with longitudinal decline of β-cell function in non-diabetic humans.
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      2. Haines A, de Barros EF, Berlin A, Heymann DL, Harris MJ. National UK programme of community health workers for COVID-19 response. Lancet

      3. Saglietto A, D'Ascenzo F, Zoccai GB, De Ferrari GM. COVID-19 in Europe: the Italian lesson. Lancet

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        • Memish Z.A.
        COVID-19: preparing for superspreader potential among Umrah pilgrims to Saudi Arabia.
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        Recommendations for management of diabetes during Ramadan.
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