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CC BY 4.0 · Journal of Diabetes and Endocrine Practice 2026; 09(01): 115-122
DOI: 10.1055/s-0045-1812872
Original Article

The Impact of Macrovascular Disease in People with Type 2 Diabetes on Ramadan Fasting Practices and Glycemic Outcomes: Insights from a Multinational Real-World Study

Authors

  • Mohamed Hassanien 

    1   Departmnet of Endocrinology, Dubai Hospital, Dubai, United Arab Emirates
    2   Department of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates

  • Bachar Afandi

    3   Department of Endocrinology, Tawam Hospital and Sheikh Tahnoun Medical City, Al Ain, Abu Dhabi, United Arab Emirates
    4   Departmnet of Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates

  • Georgios Ponirakis 

    5   Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar

  • Rayaz Malik 

    5   Medicine Department, Weill Cornell Medicine-Qatar, Doha, Qatar

  • Reem Alamoudi 

    6   Department of Endocrinology, King Abdelaziz Medical City, King Saud Bin Abdelaziz University, Riyadh, Saudi Arabia

  • Inass Shaltout

    7   Departmnet of Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt

  • Rashed Malek

    8   Department of Endocrinology, Setif University, Ferhat Abbas. Algeria

  • Fauzia Rashid

    1   Departmnet of Endocrinology, Dubai Hospital, Dubai, United Arab Emirates
    2   Department of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates

  • Zanariah Hussein

    9   Medical Endocrine Unit, Internal Medicine Department, Endocrine Institute Hospital, Putrajaya, Malaysia

  • Muhammad Yakoob Ahmadani

    10   Diabetes Research Department, Tabba Heart Institute, Karachi, Pakistan

  • Ines Khochtali

    11   Endocrinology Department, Monastir University, Monastir, Tunisia

Funding and Sponsorship This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Abstract

Background

The International Diabetes Federation–Diabetes and Ramadan (IDF-DAR) Risk Score is widely used to guide fasting recommendations for individuals with type 2 diabetes mellitus (T2D) during the month of Ramadan. Many patients with macrovascular disease (MVD) are typically classified as high-risk and advised not to fast. However, real-world practices may differ from guideline recommendations.

Objectives

This article evaluates fasting behaviors and glycemic outcomes during Ramadan among individuals with and without MVD using multinational, real-world data.

Patients and Methods

This retrospective, observational cohort study analyzed data from the 2020–2022 DAR Global Survey. The survey included 12,529 Muslim adults with T2D from seven global regions. Participants with documented MVD (n = 1,520) were compared to those without MVD as a control (n = 11,010). Key outcomes included the number of fasting days, the incidence of hypoglycemia and hyperglycemia, and the frequency of breaking fast due to glycemic events. Multivariable logistic regression adjusted for clinical and demographic covariates.

Results

Fewer individuals with MVD intended to fast (68.5% vs. 87.6%, p = 0.04), however, among those who fasted, the average number of fasting days was similar (26.9 vs. 27.7). After adjustment of all covariates such diabetes duration, age, use of insulin, level of glycosylated hemoglobin, as well as presence of other diabetes-related complication, MVD was associated with higher odds of breaking fast due to hypoglycemia (adjusted odds ratio 1.25, 95% confidence interval 1.02–1.54, p ≤ 0.05), but not with higher incidence of hypoglycemia (p = 0.51), hyperglycemia (p = 0.71), or severe events.

Conclusion

Many individuals with T2D and MVD opted not to fast. However, the majority fasted during Ramadan without increased adverse outcomes apart from increased rates of breaking fast due to hypoglycemia. This data offers insights into real-world fasting behaviors and outcomes. Further studies are needed to investigate the impact of various MVD subtypes and severities.

Keywords

type 2 diabetes mellitus - macrovascular disease - Ramadan - hypoglycemia - IDF-DAR - fasting - risk stratification

Authors' Contributions

All authors contributed toward conception, data collection, writing, and final approval of the manuscript.


Compliance with Ethical Principles

Ethical approval was granted for the initial DAR Global Survey from Dubai Health Authority.


Data Availability Statement

The data supporting this article can be made available by a reasonable request to the corresponding author.




Publication History

Article published online:
31 October 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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