Adverse Glycemic Outcomes in Patients with Diabetic Neuropathy and Diabetic Foot Who Fast during Ramadan: Subanalysis of the Diabetes and Ramadan (DaR) Global Survey 2020–2022

Abstract Individuals with type 2 diabetes mellitus (T2DM) with diabetic peripheral neuropathy (DPN) or diabetic foot (DF) disease may be at increased risk of adverse glycemic events during Ramadan. This study evaluated fasting behavior and glycemic outcomes in participants with T2DM, categorized as without DPN/DF, with DPN, and with DPN + DF. Data from 12,530 participants in the Diabetes and Ramadan Global Survey (2020–2022) were analyzed. Outcomes included the prevalence of those who fasted and episodes of hypo- and hyperglycemia. DPN and DPN + DF were present in 18.8 and 3.5% of participants, respectively. The rate of fasting declined with increasing complication burden (no DPN/DF 88.1%, DPN 78.2%, DPN + DF b%, p ≤ 0.0001). The odds of hyperglycemia, breaking the fast due to hyperglycemia, and severe hyperglycemia were higher in those with DPN (adjusted odds ratio [AOR]: 1.59, 2.14, and 3.17, respectively, all p < 0.0001), and DPN + DF (AOR: 1.63, 2.36, and 3.47, respectively, all p = < 0.05– < 0.0001) compared with T2DM without DPN/DF. Patients with DPN had the highest odds of daytime hypoglycemia (AOR: 1.71 vs. 1.54, p < 0.0001) and breaking fast due to hypoglycemia (AOR: 1.59 vs. 1.38, p < 0.0001) compared with T2DM without DPN/DF. The rate of severe hypoglycemia did not differ between groups (1.7 vs. 2.2 vs. 3.4%, p = 0.06). Participants with DPN monitored glucose more frequently when fasting but were less likely to receive Ramadan-focused education (both p ≤ 0.0001). Although the majority of patients with T2DM fasted, those with DPN and DF were least likely to fast during Ramadan. However, among those who fasted, the presence of DPN and especially DPN + DF was associated with a higher risk of hyperglycemia and hypoglycemia. Pre-Ramadan assessment and targeted education are key in enabling safer fasting in patients with T2DM and DPN, especially those with DPN + DF.