Ramadan Fasting in Individuals with Diabetic Retinopathy: A Retrospective Cohort Study from the Diabetes and Ramadan Global Survey

Abstract Data on the impact of diabetic retinopathy (DR) on Ramadan fasting are limited. DR is not currently considered in pre-Ramadan risk stratification. However, its association with longer diabetes duration, poor glycemic control, and insulin use may increase vulnerability to adverse events during fasting. To evaluate fasting safety in patients with DR using data from the Diabetes and Ramadan (DaR) Global Survey. This retrospective cohort study analyzed data from the DaR Global Survey conducted in 2020 and 2022 across multiple world regions. Patients with confirmed DR (DR group, n = 1,795) were compared with individuals without DR (control group, n = 10,735). Demographic and clinical data were collected through structured post-Ramadan clinic interviews. Primary outcomes included self-reported hypoglycemia, hyperglycemia, emergency visits, hospitalizations, and fasting interruption. Multivariate logistic regression was used to adjust for age, sex, diabetes duration, glycated hemoglobin (HbA1c), and insulin use. Individuals with DR had longer diabetes duration, comparable HbA1c, and greater insulin use compared with those without DR. DR was independently associated with a 45% lower likelihood of fasting during Ramadan (adjusted odds ratio [AOR]: 0.55, p ≤ 0.0001). Among those who fasted, hypoglycemia rates were similar in the DR (16.2%) and non-DR (14.6%) groups (p = 0.5), but hyperglycemia was more prevalent in DR (24.1 vs. 13.8%; p < 0.001). DR was also independently associated with breaking the fast due to hypoglycemia (AOR: 1.34), hypoglycemia requiring medical attention (AOR: 1.76), and hyperglycemia (AOR: 1.50). DR was independently linked to lower fasting rates and higher risks of hypoglycemia, hyperglycemia, and medical interventions during Ramadan. These findings underscore the importance of incorporating DR assessment into fasting risk stratification tools to improve patient safety.