Fasting with Diabetic Foot Ulcer (The SAFE-FAST Study): Study on Assessment and Fasting Eligibility for Individuals with Diabetic Foot Ulcer during Fasting in Ramadan

Abstract Primary objective: This article evaluates fasting behaviors, clinical outcomes, and adherence to medical guidance among individuals with diabetic foot ulcers (DFUs) during Ramadan. Secondary objective: This article explores the applicability and limitations of the Diabetes and Ramadan (DaR) risk score in individuals with DFUs, and identifies patient-level factors influencing the decision to fast. A real-world observational study (2021–2024) at a tertiary center in Thi-Qar, Iraq, involving 3,236 individuals with DFUs. Participants underwent pre-, intra-, and post-Ramadan evaluations, including DaR risk stratification, Wagner grading for DFU severity, metabolic profiling, and monitoring of fasting adherence, complications, and therapeutic changes. The data were processed and analyzed using IBM SPSS Statistics version 26. The descriptive analysis was done for all clinical parameters using mean, standard deviation, and frequency distributions. The comparative analysis employs chi-square tests to compare the fasting and nonfasting groups, and analysis of variance tests to compare the means of continuous parameters. All analyses were conducted at a 95% confidence interval, with p ≤ 0.05 considered statistically significant. Fasting individuals tend to be younger, had shorter diabetes duration, milder DFUs, and better metabolic profiles. However, some individuals who chose to fast demonstrate major high-risk features, including recurrent hypoglycemia and hypoglycemia unawareness, both of which are recognized by successive international Ramadan fasting guidelines as significant safety concerns warranting fasting interruption or avoidance. Self-monitoring of blood glucose adherence was suboptimal. Most fasters completed over half the month, but some discontinued due to dysglycemia, ulcer deterioration, or serious complications, including hospitalization, amputation, or cardiovascular events. The DaR score, while partially reflective outcome, did not account for DFU-related risks. This study highlights the need for DFU-specific considerations in risk assessments during the month of Ramadan. Despite the absence of formal guidance, many patients chose to fast based on perceived health status. The findings underscore the importance of individualized care, culturally informed counseling, and enhanced risk tools to support safe fasting decisions in this group.