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

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