Ramadan Fasting during the COVID-19 pandemic: Impact on Young and Adult individuals with and without Type 2 Diabetes.

Background: Many Muslims in the UK perform dawn-to-dusk fasting, with no food and water, for 29–30 days during the month of Ramadan. However, there has been no research regarding Ramadan fasting (RF) among young people in the UK, including children with type 2 diabetes (T2D), compared to adults with T2D. The COVID-19 pandemic created unique circumstances for fasting during Ramadan that have not been previously experienced in recent history. The quarantine restriction measures were associated with a significant impact on human health and lifestyle. The potential benefits or harms associated with fasting during a pandemic period have not been well investigated. Therefore, this thesis aimed to explore the impacts of RF on diet, physical activity, sleeping pattern, mental health, and glycaemic control among people with and without T2D during the COVID-19 pandemic (2020 and 2021) in the UK. Methods: Based on secondary/primary research approaches and descriptive quantitative research methods, three studies were undertaken. First, a systematic review and meta-analysis of observational studies was conducted to explore the impact of RF on glycaemic control in patients with T2D. The quality assessment was examined using the National Heart, Lung, and Blood Institute (NHLBI) tool. RevMan software was used to conduct the metaanalysis. Second, a cross-sectional retrospective survey-based study examined the effects of the COVID-19 pandemic on Ramadan 2020 among people with and without T2D aged 12-80 years old. The study was conducted in Muslim communities in the UK from November 2020 to February 2021. Third, a prospective, observational, cross over, pilot study investigated the effects of RF during the COVID-19 pandemic on children and young adults with T2D aged 12-24 years old. This study was conducted in three diabetes centres in the UK from March 2021 to June 2021. The COVID-19 restrictions created recruitment challenges, and face-to-face contact with the participants was not possible. Therefore, online questionnaire surveys were used to collect data before and after RF. SoGoSurvey software was used to design both retrospective and prospective questionnaires, and they were sent to the target age group, which planned to fast during Ramadan for a minimum of 10 days. Statistical analysis was performed using SPSS, and FFQ EPIC Tool for Analysis (FETA) software was used to determine the intake of different nutrients. Ethical approvals were obtained from the Health Research Authority (HRA) and the Faculty of Health and Life Sciences Research Ethics Committee (EREC) at De Montfort University. Results: The systematic review included 5,554 participants, comprising 54% males and 46% females. The pooled analysis showed that HbA1c and FBG significantly decreased after RF compared to the pre-fasting stage, with WMD = 0.55 mg/dl, CI: 0.33-0.77, P < 0.00001, Ι2 = 93%, and WMD = 12.42, CI: 6.46-18.38, P < 0.0001, Ι2 = 81%, respectively. However, a non-significant difference was observed in body weight in fasting patients after RF compared to the pre-fasting stage. Although, the 12 selected studies contained young adults with T2D, studies that solely focused on this group were not identified. In the retrospective study, eighty-one participants, including 49 females (aged 12-51) and 32 males (aged 13-65), were enrolled. The vast majority of the participants are healthy individuals, and 4 participants with T2D were recruited. In addition, 52 participants, including children (4 out of 11) and individuals with T2D (2 out of 4), fasted the whole month of Ramadan 2020. The diet pattern was balanced with good consumption of fruit and vegetables, with a slight increase in carbohydrate and protein intake compared to the recommended levels. There was evidence of a relationship between weight gain and eating desserts (X2 = 27.187, P = 0.026). The sleeping pattern varied, and most people were physically inactive. This was significantly associated with the reported impacts of the COVID-19 pandemic on body weight in Ramadan 2020 (X2= 26.749, P = <0.001). Furthermore, there was strong evidence of a relationship between the reported less physical activity and the COVID-19 associated mental health problems (Χ² =37.530, P = <0.001). In the prospective study, 9 participants with T2D, including 7 females and 2 males aged from 14-22 years old (mean age 17±3) with no comorbidities, fasted safely during Ramadan 2021. The glucose parameters, including HbA1c (P = 0.715), weight (P = 0.343), and body mass index (BMI) (P = 0.249) did not change after Ramadan. Most participants (N=8) were less active during fasting, and a sleeping pattern was reported (N=4) to be fairly bad. However, RF was associated with increased consumption of healthy food and decreased consumption of sugary 3 drinks. The COVID-19 pandemic was associated with weight gain, decreased consumption of healthy food, and deterioration in mental health (depression and anxiety). However, this improved during fasting, and no weight gain was reported. Conclusion: This is the first research study to provide evidence that some young people, including children in the UK, including those with T2D, fasted the whole month of Ramadan with no comorbidities. This study reported that fasting during the COVID-19 pandemic was not stressful, and the diet pattern was balanced, with improvement in mental health in patients with T2D in particular. However, restrictions on physical activity were associated with negative impacts on body weight and mental health in some people. A meta-analysis study revealed that RF improves glycaemic control in adults with T2D. In the future, much bigger studies are necessary to determine the impacts of the COVID-19 pandemic on young people with T2D. This could be done through retrospective data from patients in hospitals and medical centres, especially in terms of their adherence to medication, diet, and physical activities.