Accepted Manuscript

Experiences of patients with diabetes observing the Ramadan fast

Diabetes Centre, Dammam Medical Complex, Dammam, Eastern Province

Ebtesam M. Ba-Essa, Mohammed Hassanein, Sahar Abdulrhman, Malak

Alkhalifa, Zinab Alsafar

PII: S0168-8227(19)30102-0
DOI: https://doi.org/10.1016/j.diabres.2019.03.031
Reference: DIAB 7676

To appear in: Diabetes Research and Clinical Practice

Received Date: 19 January 2019

Revised Date: 1 March 2019
Accepted Date: 25 March 2019

Please cite this article as: E.M. Ba-Essa, M. Hassanein, S. Abdulrhman, M. Alkhalifa, Z. Alsafar, Experiences of
patients with diabetes observing the Ramadan fast, Diabetes Research and Clinical Practice (2019), doi: https://
doi.org/10.1016/j.diabres.2019.03.031

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 Experiences of patients with diabetes observing the Ramadan fast
Diabetes Centre, Dammam Medical Complex, Dammam, Eastern Province

Ebtesam M. Ba-Essa1, Mohammed Hassanein2, Sahar Abdulrhman3, Malak Alkhalifa 4, Zinab

Alsafar5
1,3
Diabetes and Endocrine Centre, Dammam Medical Complex, Dammam, Saudi Arabia
2
Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates
3,4
Internal Medicine Department, Dammam Medical Complex, Dammam, Saudi Arabia
Correspondence; Ebtesam Ba-Essa, MBBS, MRCP, FRCP, ABIM, Director of Endocrine &
Diabetes Center, Dammam Medical Complex, PO Box 250, Dammam, Postcode 31411, Kingdom of
Saudi Arabia. E-mail: emsbaessa@hotmail.com

Abstract
AIMS— To describe the experience and behavior of diabetes patients toward Ramadan
fasting. A Secondary purpose was to describe diabetes treatment and hypoglycemia during
Ramadan.
METHODS— A prospective, non-randomized study for 2 years. Participants were stratified
for fasting according to ADA recommendations. Results are presented using mean, standard
deviation and percentages.
RESULTS— Total of 400 participants, 10% with DM1 and 90% with DM2. Mean ± SD
glycosylated hemoglobin was 9.3 ± 2.2 for DM1 and 8.9 ± 2.1 for DM2. More than 80% of
individuals who experience fasting were in the higher risk group. The higher the ADA risk
stratification, the higher the risk of hypoglycemia and the number of broken fast days (P-value
< 0.05). Hypoglycemia risk was higher in DM1 (65%) as compared to DM2 (14.7%) P-value
<0.05. During hypoglycemia, 15.4% of DM1 and 29.3% of DM2 subjects continued fasting.
Hypoglycemia was highest with insulin alone or insulin with oral agents as compared to oral
agents alone (P-value < 0.05). Oral agents excluding sulfonylurea have the lowest rate of
hypoglycemia as compared to oral agents including sulfonylurea (P-value = 0.002).
Hypoglycemia before Ramadan increased the risk of hypoglycemia during Ramadan (53.3%),
(P-value = 0.0065) and it was highest among insulin only users (50%).
CONCLUSIONS— Despite medical advice, the majority of type 1 and 2 diabetes participants
fasted, and continued the fast when hypoglycemic regardless of their ADA risk status. Insulin
therapy with or without oral agents and previous episodes of hypoglycemia before Ramadan
predicted hypoglycemia risk during Ramadan.

Keywords: Diabetes mellitus, Ramadan fasting, hyperglycemia, hypoglycemia, education,

Oral Hypoglycemic Drug, Insulin.

1. Introduction
A large number of Muslim patients with diabetes fast globally every year for one lunar month
during Ramadan as an obligatory religious duty [1,2], however, individuals whose health is
likely to be worsened are exempt from fasting. Many Muslims, even those who could seek the
exemption, have an intense desire to participate in fasting during Ramadan despite the risk
associated with fasting and advise provided by healthcare professionals not to fast. These
patients represent a challenge not only for themselves but also for healthcare professionals [3].
A large epidemiological study of Muslims with diabetes in 13 Muslim countries (n=12 914)
the EPIDIAR study—showed that 43% of patients with type 1 and 79% of those with type 2
diabetes mellitus (DM) fasted during Ramadan [4]. Some individuals with diabetes in the
higher risk groups who insist to fast against medical advice, are able to fast the full month with
no major hypoglycemia. New era in the treatment of diabetes with drugs that have improved
pharmacokinetics and reduced risk for hypoglycemia along with Ramadan-focused patient
education programs may play a role in safer fasting. Much of what is recommended for the
management of patients with diabetes during fasting in Ramadan is based on expert opinion.
Few randomized controlled studies have investigated best treatment regimens during Ramadan
in individuals with diabetes. Management of diabetes during Ramadan fasting requires full
collaboration between the patient and diabetes care team and is based on a mutual
understanding of the religious obligations and medical aspects of fasting [5,6].
This study investigated the experience and behavior of patients with diabetes who undertake
the fast of Ramadan in the Eastern province, Dammam, Saudi Arabia, to understand their
practice and experiences, Ramadan-related awareness and health-related needs. A secondary
purpose of this study was to determine the safety and effect in relation to use of diabetes
medication on the glycemic control during Ramadan fasting and the risk for hypoglycemia and
to find some predictors associated with increased risk for hypoglycemia during fasting.

2. Materials and methods

2.1. Study design and participants
This is a prospective, non-randomized study conducted in an outpatient setting of a
secondary/tertiary referral hospital at the Endocrinology and Diabetes Centre of Dammam
Medical Complex, Eastern Province, Saudi Arabia. The total duration of the study
corresponded to the period of the month preceding Ramadan, during, and one month after the
end of Ramadan for 2 consecutive years (2015, 2016). Prior to their inclusion, all adult eligible
individuals who declared the interest in fasting consented to participate in the study after
approval of hospital ethical committee. The eligibility criteria for inclusion were all individuals
> 14 years with the diagnosis of type 1 or 2 DM who had decided to fast Ramadan. Exclusion
criteria were those below 14 years of age, those who did not intend to fast the month of
Ramadan and those advised not to fast. All subjects included in the study received Ramadan
focused diabetes education which included educational dietary counseling sessions addressing
meal planning, exercise, self-monitoring of blood glucose (SMBG), recognizing and managing
acute complications, and guidance about management of medication during Ramadan.
Participants were stratified by their physician according to American Diabetes Association
(ADA) recommendations [7].
 2.2. Data collection
424 subjects with diabetes (192 males, and 232 females) were selected and interviewed
during the study period. Patients were asked to answer a questionnaire and responses were
recorded by the trained staff. Questionnaire data included demographic details and medical
characteristics; disease duration, diabetes type, body mass index (BMI) before or during and
up to 1 month after Ramadan, blood tests for glycosylated hemoglobin (HbA1c), serum
creatinine, and eGFR 1 month before and up to 1 month after Ramadan, presence of any
diabetes-related complications (neuropathy, nephropathy, retinopathy, diabetes foot
complications, peripheral vascular disease (PVD), Coronary artery disease (CAD), stroke
and/or transient ischemic attacks (TIA) and erectile dysfunction), self-monitoring of blood
glucose (SMBG) and its frequency, and a section on the types of antidiabetic agents used and
regimens. Information about the presence of diabetes complications was based on related
symptoms, confirmed diagnosis with the appropriate test, follow up and/or receiving specific
treatment with the concerned specialty. Data also included responses to fasting the previous
Ramadan, reasons for not fasting or breaking fast if applicable, number of broken fast days
(excluding breaking fast for menstruation as women are excused and prohibited to keep
fasting during the days of their menses), experienced symptoms of hypoglycemia and/or
blood glucose level below 70 mg/dl (3.9 mmol/l) during Ramadan fasting and the months
before fasting, action taken when hypoglycemia occurred, breaking fast for hyperglycemia
during fasting with blood glucose (BG) > 200mg/dl (11.1 mmol/l).
2.3. Statistical analysis
Responses to questions about knowledge and practices are presented in the form of numbers
and percentages. The data was tabulated on Microsoft Excel. Values were expressed mainly
as mean, standard deviation (SD) and percentages. Comparisons were performed using
analysis of variance for variables and chi-square, Fisher exact test or students paired` t’ test
and odds ratio (OR) wherever appropriate. P value < 0.05 was considered statistically
significant.

3. Results
Total of 424 subjects were interviewed, (n = 24) patients were excluded as they did intend not
to fast based on health care providers advise. Reasons for not fasting were; new onset diabetes,
unstable blood glucose, recurrent hypoglycemia, renal failure secondary to diabetes on dialysis
and for other reasons not related to diabetes. 400 patients were included based on their
previous experience with fasting Ramadan with diabetes and they intended to fast.
3.1. Demographic Characteristics of the Study Population
The overall demographic features of the study population are shown in Table 1. Total of (n =
40; 10%) of the study population corresponds to type 1 diabetes, and (n = 360; 90%)
corresponds to type 2 diabetes. The mean age was 27.6 years for DM1 and 53.8 years for
DM2, with a mean duration of diabetes of 12.6 years for DM1 and 12.5 years for DM2
subjects. Mean body mass index (BMI) at baseline was 26.5 kg/m2 for DM1 and 33.9 kg/m2
for DM2 and A1c at baseline 9.3 for DM1 and 8.9 for DM2.
3.2. Diabetes-Related complications and associated risk factors
Data on the presence of any diabetes-related complications and associated risk factors was
available in 187 subjects (27 type 1 and 160 type 2 DM) and are shown in Table 1 . The
overall frequency of diabetes complications and comorbidities was relatively high which
reflects the selection bias since these are patients who attend clinic in secondary/tertiary care
hospital.
 3.3. Metabolic Control and Clinical changes after Ramadan
Data for pre and post Ramadan measurement were available mainly for people with DM2.
Weight: it was noticed that 20.1% of participants experienced weight loss after Ramadan, 9.0%
experienced weight gain, and 70.9% experienced no change in weight. BMI after Ramadan
decreased from a mean ± SD of 32.49 kg ± 7.35 to 32.26 ± 7.49 P Value (0.012).
HbA1c: Mean ± SD of HbA1c was 8.79 ± 2.02 before Ramadan and 8.59 ± 1.87 after
Ramadan with a mean ± SD change of 0.2 ± 0.15, P Value (0.022).
3.4. Fasting by ADA Risk Stratification
High risk and very high risk category were routinely advised not to fast. Overall > 80% of
individuals with both types of diabetes who fasted during Ramadan were in the higher risk
groups P value <0.05.
Table 2 show that type 1 DM (15% high-risk category and 85% very high-risk); hypoglycemia
occurred during fasting hours in 66.7% and 64.7% respectively. For type 2 DM (8.3% low-risk
category, 4.2% moderate-risk category, 52.8% high-risk category, 30.0% very high-risk
category), hypoglycemia during fasting hours occurred in 3.3%, 6.7%, 30.0% and 27.8%
respectively. The risk of hypoglycemia in the higher risk group was significantly higher as
compared to lower risk group P value = 0.0004.
The mean ± SD number of days of not fasting were 0 days for (low risk), 1 day (moderate
risk), 2.2 days ± 1.8 (high risk), and 2.7 days ± 3.7 (very high risk), Chart 1. 17 people with
type 2 diabetes (4.7%) could not be categorized because of lack of adequate information.
3.5. Incidents of Hypoglycemia and Patients Attitudes and behavior
As shown in Table 3; in type 1 DM cohort; the overall incidence of hypoglycemia during
Ramadan was (n = 26; 65%), with major hypoglycemia (required emergency department visit
and/or hospital admission) in (n = 1; 3.8%). Hypoglycemia occurred at different times during
fasting hours. The number of broken fast days ranged from 1 to10 days with a mean ± SD of
4.0 days ± 3.3. About 15.4% continued fasting when had hypoglycemia during fasting hours.
In Type 2 diabetes cohort; the overall hypoglycemia was (n = 89; 24.7%), with major
hypoglycemia in one subject of the high risk category (n=1, 1.1%). Hypoglycemia occurred at
night when not fasting in (n = 7; 7.9%), and during fasting hours in (n = 82; 92.1%). 24
(29.3%) continued the fast despite of hypoglycemia during fasting hours. The number of
broken fast days Ranged from 1 to 20 days with a mean ± SD of 2.6 days ± 3.4. Experience of
hypoglycemia during fasting was higher among female (59.1%).
Out of those who could remember and determine the time of hypoglycemia, 43.8% occurred
within 2 hours of iftar time, 31. 2% at 2 – 6 hours before iftar, and 18.8% occurred > 6 hours
before iftar. Resistance to break fasting occurred in 43%, 40% and 16.7% respectively.
The risk of hypoglycemia was significantly higher in type 1 DM subjects as compared to type
2 DM with P value < 0.05 with no significant difference in the risk of major hypoglycemia
between the 2 groups P value = 0.35. Overall resistance to break fasting was 26%, resistance to
break fasting was not statistically significant between type 1 DM and type 2 DM subjects (P
value = 0.16).
3.6. Treatment and hypoglycemia
Table 4 Summarize the medications and Risk of hypoglycemia; among type 2 DM
participants,
In the group with hypoglycemia during the month of fasting, we looked into patients with
repeated hypoglycemic events in relation to type of medication regimen; 1-4 times, > 4 times.
For type 2 DM; it was observed that the risk of hypoglycemia was highest in insulin only users
(46.9%) and Insulin + oral agents (35.2%) as compared to oral agents only (14.0%) with P
value < 0.00001 which is statistically significant. The risk of hypoglycemia between insulin
only users and Insulin + oral agents was not statistically significant (P = 0.16).
The risk of hypoglycemia was lowest with oral agents only (14.0%), and observed to be
significantly lower as compared to insulin only (P = 0.00001) and to insulin + OHA (P
<0.000015). Oral agents only including SU had significantly higher rate of hypoglycemia
(20.2%) as compared to oral agents excluding SU (4.9%) (P value = 0.002).
None of the subjects on oral agents only excluding SU had hypoglycemia > 4 times. In type 1
DM subjects the observed hypoglycemia and frequency of > 4 times was higher among those
on premixed regimen out of total on the same regimen 71.4% and 60% respectively. The 1
subject who had major hypoglycemic events that required emergency department visit was also
on premixed insulin. Out of the 2 subjects with DM1 on insulin pump therapy, 1 was able to
fast the whole month with no hypoglycemia and the other subject had 1 minor hypoglycemia
during fasting.
3.7. Relationship between previous episodes of hypoglycemia and hypoglycemia during
Ramadan;
Chart 2 show that almost half those with hypoglycemia before Ramadan (53.3%) are likely
to have hypoglycemia during Ramadan, Odds ratio (OR) 2.7, and P value = 0.0065 which is
statistically significant.
Hypoglycemic episodes > 4 times during the month of fasting occurred in 25% of those with
hypoglycemia before the month of fasting. All subjects who had pre-Ramadan hypoglycemia
and during the month of fasting were on insulin based therapy (50% were on insulin therapy
alone, 37.5% MDDI ± Non-SU-OHA and 12.5% on basal insulin + SU-OHA).
3.8. Self-monitoring of blood glucose (SMBG)
Glucometers and strips were provided for free to all people with diabetes following in the
diabetes center irrespective of the type and the modality of treatment.
Out of those with Type 1 DM, and with the available data (100%), monitored blood glucose
during fasting. The frequency of monitoring ranged from 1 – 3/day (mean 2 ± 0.9), and
(28.6%) monitored blood glucose when had symptoms only.
Out of those 176 with Type 2 DM and the available data, (83%) monitored blood glucose
during fasting. Out of those who monitored their blood glucose (50%) were on insulin based
therapy. The frequency ranged from 1 – 7/day (mean 2.1 ± 1.2), and (22.7%) monitored blood
glucose when had symptoms only, and once daily was the most common pattern.

4. Discussion
Many individuals with diabetes who were cautioned against fasting by their physician, still
insist on and fast during the month of Ramadan posing a management challenge for themselves
as well as for healthcare providers. In our study, all participants of type 1 and 2 diabetes fasted,
regardless of their ADA risk status category, and this was consistent with what has been
reported in the CREED study [8]. In this study more than 80% of individuals with diabetes
who experienced fasting during Ramadan were in the higher risk groups. Also it was noticed in
this study that the higher risk group and ADA risk stratification, the higher the reduced number
of broken fast days for hypoglycemia. These results are comparable to those reported by
Mustafa HE et al [9] where more than 60% of patients with diabetes who fasted during
Ramadan were in the higher risk groups (very high-risk category 33.8%, high-risk category
29.6%) and that some patients in the first 3 groups managed to fast the full month and the
reduction in fasted days was obvious in the group identified as the very high risk.
The overall risk of hypoglycemia was higher for DM1 as compared to DM2. However, the risk
of severe hypoglycemia was rare during fasting among both groups. In a retrospective study of
glycemic trends during Ramadan in fasting diabetic subject's frequency of hypoglycemia was
21.7% whereas 4% patients had major hypoglycemic episodes [10].
It was observed that 15.4% of DM1 cohorts and 29.3% DM2 continued fasting when
hypoglycemia occurred during fasting hours, and the closer the hypoglycemic event to the time
of iftar the higher the resistance to breaking fast. These results emphasis the importance of
education about the risks associated with untreated hypoglycemia and the need to break fasting
when it occurs at any time during fasting hours even if happened close to the time of iftar. A
number of reasons for fasting against medical advice among patients with diabetes are reported
in the literature. They include the psychological impact of non-fasting in the form of the
feeling of exclusion associated with the denial of the disease and the feeling of medical
opposition to divine power and spiritual imperatives [11]. Ramadan-focused education was
shown to be beneficial in empowering those living with diabetes to change their lifestyles
during Ramadan [12]. Many structured educational programs such as DAFNE for type 1
diabetes and DESMOND and X-pert for type 2 diabetes have been developed [13-15].
Ramadan-specific diabetes education programs that focus on the avoidance of both
hypoglycemia during the day and hyperglycemia after the main evening meal has also been
developed [16,17]. If patients insist on fasting against medical advice, the physician should
discuss treatment goals and negotiate with his/her patient the need for fasting, any changes to
treatment, diet, and blood glucose self-monitoring [11,16].
The incidence of hypoglycemia during Ramadan for DM2 participants was highest for those
treated with insulin alone and those on combination of Insulin + OHA. These results were
similar with what has been reported by Abdul Jabbar et al in the CREED study that the
incidence of hypoglycemia during Ramadan for participants treated with a combination of oral
anti-diabetic medication and insulin (13.5%) was similar for those treated with insulin alone
(16.8%) [8]. But when looking at the details of our data for those treated with insulin in
combination with oral agents the risk was lower if basal insulin is used with non-SU oral
agents as compared to other more intensive insulin regimens. This observation may support the
reported lower risk of hypoglycemia with basal insulin analogs as compared to the use of
premixed insulin formulations for type 2 diabetes [18]. Indeed, the IDF-DAR guidelines has
placed basal insulin as moderate/low risk and this data supports this risk categorization (16).
Sulphonylurea and other insulin secretagogue still represent one of the treatment modalities in
Ramadan despite the hypoglycemia and weight gain effect. Glyburide (glibenclamide) might
be more significantly associated with the risk of hypoglycemia, compared to the second
generation of sulfonylureas, particularly gliclazide, glimepiride, and glipizide [19,20]. In this
study, the repeat rate of hypoglycemia > 4 times was nil on oral agents only excluding SU. The
one subject who had major hypoglycemic events that required emergency department visit;
was on SU. In general, both Gliclazide and Glibenclamide were used equally however, the
exact number in this study population cannot be determined. Oral DPP-4 inhibitors represent
an important substitute to SU for patients with type 2 diabetes during fasting with less
hypoglycemic risk and the neutral weight effect. The VIRTUE (Vildagliptin experience
compared with sulphonylureas observed during Ramadan) reported significantly lower
hypoglycemic events with vildagliptin (36 events/669, 5.4%) compared with SUs in Muslim
patients with type 2 diabetes fasting during Ramadan [21].
In this study the risk and repeat rate of hypoglycemia > 4 times for type 1 diabetes was
observed to occur more frequently with those on premixed insulin regimen 70:30. The one
subject who had major hypoglycemic events that required emergency department visit was also
on premixed insulin 70:30.
 It was noticed in this study that hypoglycemic events before Ramadan increases the risk and
frequency of hypoglycemia during Ramadan especially if the subject on insulin based therapy.
This result is consistent with what has been reported by the CREED study that hypoglycemic
episode before Ramadan increases an individual’s risk of having an episode during Ramadan
[8].
In this study, a significant reduction of 0.2% in mean HbA1c was observed during Ramadan
fasting. This result is similar to has been reported by Melanie Yee Lee Siaw in Singapore with
0.3% reduction of HbA1c in Ramadan [22].
The Limitation of the study; considering this study completed in a secondary/tertiary care
center, so it may be subjected to some bias in term of the rate of complications, the number of
type 2 DM participants on more complex regimens and insulin therapy. Also considering the
high baseline HbA1c that reflect the barriers of tight glycemic control in the region that may
underestimate and bias the hypoglycemia risk and results. Other limitations that may reduce
the significance of some of the results is the small sample size for the people with type 1
diabetes, some information such as the presence of complications and comorbidities, the
incidence of hypoglycemia, and the management of diabetes relied on patient self-reporting
and were not systematically validated by case ascertainment from medical records.

The present study provided an overview of characteristics of people with diabetes attending
2ry/3ry care service in Saudi Arabia who fast Ramadan and some of the predictors of the
hypoglycemia risk. Consequently, many had diabetes for several years and diabetes related
complications was encountered in a sizeable proportion of the study population. Fasting was
associated with significant reduction in BMI and HbA1c. Rates of hypoglycemia were much
higher in people with type 1 diabetes than in type 2 diabetes during Ramadan.
Insulin therapy with or without oral agents as well as previous episodes of hypoglycemia
before Ramadan predicted risk of hypoglycemia during Ramadan. Despite medical advice,
the majority of type 1 and 2 diabetes participants fasted, and continued the fast when
hypoglycemic regardless of their ADA risk status category which emphasizes the need for
pre-Ramadan patient education. Due to the nature of the study cohort, these results could not
be generalized to all people with diabetes.

Financial support and sponsorship

Nil.

Conflicts of interest
There are no conflicts of interest.

Acknowledgment
We are most grateful to physicians, and diabetes health educators with Particular
acknowledgment to Mrs. Hanaadi Alkhaldi, Seba Alibrahim, Rabab Alhabib and Nora
Alghatani for the valuable assistance in this study

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 Table 1: Demographic and clinical characteristics of the study population

Type 1 DM Type 2 DM

Number (%) Mean ± SD Number (%) Mean ± SD

Number of patients 40 (10%) 360 (90%)
SEX
Female 22 (55) 197 (54.7)
Male 18 (45) 163 (45.3)
AGE Range 14 – 55 yrs. 27.6 yrs. ± 13.0 Range 23 – 82 yrs. 53.8 yrs. ± 9.3
Duration of DM (Years) Range 1 – 30 yrs. 12.6 yrs. ± 8.5 Range 1 – 40 yrs. 12.5 yrs. ± 8.3
Overall Weight BMI (baseline) Range 18 – 39 26. 5 ± 6.1 Range 24 – 64 33.9 ± 7.0
Overall HbA1c (baseline) Range 5.9 – 13.8 9.3 ± 2.2 Range 4.6 – 17.4 8.9 ± 2.1
Hypertension 14.9 - 63.8 -
Dyslipidemia 22.2 - 72.5 -
Obesity + overweight 37.5 - 96.7 -
BMI ≥ 25 – 29.9 2.5 26.7
BMI ≥ 30 35 70.0
Retinopathy 18.5 - 26.9 -
Coronary artery disease 7.4 - 16.9 -
Stroke/TIA 0 - 3.8 -
Nephropathy 3.7 - 8.8 -
Neuropathy 26 - 43.8 -
Diabetic foot 7.4 - 6.9 -
Peripheral vascular disease 0 - 0.6 -

Table 2: Hypoglycemia during fasting in type 1 and 2 diabetes by ADA risk

stratification status

Continued
ADA risk Total Hypoglycemia No Hypoglycemia
n (%) P-value fasting when
Stratification n (%) n (%)
hypoglycemic
Type 1 DM
Low 0 (0.0) 0 (0.0) 0 (0.0) -
Moderate 0 (0.0) 0 (0.0) 0 (0.0) 0.009 -
High 6 (15) 4 (66.7) 2 (33.3) 1 (25)
Very high 34 (85) 22 (64.7) 12 (35.3) 3 (13.6)
Type 2 DM
Low 30 (8.3) 1(3.3) 29 (96.7) 0 (0)
Moderate 15 (4.2) 1(6.7) 14 (93.3) 0.0004 0 (0)
High 190 57 (30.0) 133 (70.0) 15 (28.8)
(52.8)
Very high 108 30 (27.8) 78 (72.3) 9 (32.1)
(30.0)
*Unknown 17 (4.7) 0 (0.0) 17 (100.0) -
* 17 participants did not have adequate information to complete ADA risk stratification
Chart 1: Diabetes related mean number of broken days for hypoglycemia by ADA risk
stratification status of the studied subjects with type 2 DM

Mean number of broken days for hypoglycemia by ADA risk

stratification

low 0
Moderate risk 1
High risk 2.2
Very high risk 2.7
0 0.5 1 1.5 2 2.5 3

Table 3: Hypoglycemia during fasting in type 1 and 2 diabetes

Type 1 DM Type 2 DM
n (%) n (%)
Over all Hypoglycemia 26 (65) 89 (24.7)
Hypoglycemia during fasting hours 26 (100) 82 (92.1)
Hypoglycemia during non-fasting hours 0 7 (7. 9)
* Major hypoglycemia 1 (3.8) 1 (1.1)
Minor hypoglycemia 25 (96.2) 88 (98.9)
Continued fasting when hypo 4 (15.4) 24 (29.3)
Broken fast days (mean ± SD) due to 4.0 days ± 3.3 2.6 days ± 3.4
diabetes related issues
Range of broken fast days 1-10 days 1-20 days
* Major hypoglycemia defined as any symptomatic hypoglycemia required emergency
department visit or hospital admission

Table 4: hypoglycemia and repeated rate of hypoglycemia in relation to medications

Total on regimen n (%) with Repeat rate
Treatment n (%) hypoglycemia 1- 4 times > 4 times
on regimen n (%) n (%)
TYPE 1 DM
Basal-Bolus/pre-mixed
40 26 (65) 17 (65.4) 9 (34.6)
insulin/Insulin pump
TYPE 2 DM
Insulin only 49 (13.6) 23 (46.9) 20 (87) 3 (13)
Insulin + OHA 108 (30.0) 38 (35.2) 36 (94.7) 2 (5.3)
Basal Insulin + SU-OHA 47 (13.1) 14 (29.8) 13 (92.9) 1(7.1)
Basal Insulin + Non-SU-OHA 12 (3.3) 0 (0) 0 (0) 0 (0)
MDDI ± Non-SU-OHA 49 (13.6) 24 (49) 23 (95.8) 1(4.2)
Oral agents only 200 (55.6) 28 (14.0) 23 (82.1) 5 (17.9)
Oral agents (including SU) 119 (33.1) 24 (20.2) 19 (79.2) 5 (20.8)
Oral agents (excluding SU) 81 (22.5) 4 (4.9) 4 (100) -
Lifestyle only 3 (0.8) 0 (0) - -
*Multiple daily dose of insulin (MDDI); Basal-Bolus, basal-plus, or premixed insulin twice daily
Chart 2: Relationship between previous episodes of hypoglycemia and hypoglycemia
during Ramadan

Relationship between previous episodes of hypoglycemia and hypoglycemia during Ramadan

100%
80%
46.7
60% 70.5
40%
20% 53.3
29.5
0%
Hypoglycemia before & during Ramadan Hypoglycemia during Ramadan but not before

Hypoglycemia No Hypoglycemia