Abstract
Introduction
Fasting during the holy month of Ramadan is a central religious practice for Muslims worldwide, including individuals living with type 2 diabetes mellitus (T2DM). Managing diabetes during prolonged fasting presents significant clinical challenges, particularly balancing glycemic control and preventing complications such as hypoglycemia. The body mass index (BMI) is a widely used surrogate marker for metabolic status and may significantly influence the physiological response and tolerance to fasting in individuals with T2DM. However, data are limited regarding the relationship between BMI and fasting experiences among diabetic individuals in diverse Muslim-majority populations. This study used data from the Diabetes and Ramadan (DaR) Global Survey, conducted via SurveyMonkey, to examine the associations between BMI and fasting-related outcomes among adults with T2DM in Muslim-majority countries. The findings may support more personalized risk stratification and clinical guidance for safe fasting practices in this population.
Methods
Using a specifically designed SurveyMonkey questionnaire, Muslim individuals with T2DM were surveyed in several countries in different geographical regions and stratified by BMI. Basic demographic, clinical, and fasting-related data were collected and analyzed using descriptive and inferential statistics to explore differences between subgroups.
Results
Among 6530 participants, 42.4% were overweight and 37.7% were obese, and obesity was more prevalent in females and the Gulf region. Individuals with obesity were younger and had a slightly longer duration of diabetes. Glycemic control (mean HbA1c ∼ 8.2–8.4%) was similar among BMI groups. Obesity was associated with higher systolic blood pressure, hypertension, hyperlipidemia, and microalbuminuria. Pharmacologic management patterns varied little, although use of GLP-1 receptor agonists was greater among individuals with obesity, and Ramadan fasting intentions and practices remained consistent across BMI groups. Self-reported hypoglycemia and hyperglycemia rates were comparable, although overweight participants had higher rates of emergency visits (p = 0.01). Most participants received Ramadan-specific diabetes education, but self-monitoring of blood glucose adherence varied.
Conclusion
Individuals with T2DM in all BMI categories were able to fast safely during Ramadan, with no significant differences in fasting behavior or adverse events. Despite a higher burden of cardiometabolic comorbidities among obese participants, glycemic control and complication rates during fasting were comparable. These findings highlight the importance of structured education and individualized care for supporting safe fasting among people with diabetes, regardless of BMI.
Keywords: BMI, Diabetes education, Hyperglycemia, Ramadan fasting, Risk stratification, Type 2 diabetes mellitus
الملخص
الخلفية
يُمثل صيام شهر رمضان تحدياً صحياً لدى المصابين بداء السكري من النوع الثاني، نظراً للتغيرات في مواعيد تناول الطعام والأدوية، وما قد يصاحبها من اضطرابات في مستويات سكر الدم. وعلى الرغم من أهمية مؤشر كتلة الجسم بوصفه مؤشراً للحالة الأيضية، لا تزال البيانات المتعلقة بتأثيره على تجربة الصيام والمضاعفات المرتبطة به محدودة، خصوصاً في المجتمعات ذات الأغلبية المسلمة. هدفت هذه الدراسة إلى تقييم العلاقة بين مؤشر كتلة الجسم والنتائج الصحية المرتبطة بصيام رمضان، بما في ذلك التحكم في مستويات سكر الدم، ونوبات انخفاضه وارتفاعه، والممارسات المتعلقة بالصيام، لدى البالغين المصابين بداء السكري من النوع الثاني، بهدف دعم التقييم الفردي للمخاطر وتحسين الإرشادات السريرية للصيام الآمن.
طرق البحث
أُجريت دراسة مقطعية متعددة البلدان اعتماداً على بيانات المسحين العالميين للسكري ورمضان (DaR) لعامي 2020 و2022. شملت الدراسة 6530 مشاركاً من البالغين المسلمين المصابين بداء السكري من النوع الثاني، جرى استقطابهم خلال الزيارات الطبية الروتينية في فترة ما بعد رمضان من مراكز الرعاية الصحية المجتمعية والمستشفيات في مناطق جغرافية مختلفة. جُمعت البيانات باستخدام استبانة موحدة أشرف على تطبيقها أطباء مدربون، وشملت الخصائص الديموغرافية والسريرية، ومدة الإصابة بالسكري، والعلاجات المستخدمة، وممارسات الصيام، والمضاعفات المرتبطة به، والتثقيف الصحي، والمراقبة الذاتية لسكر الدم. وصُنّف المشاركون إلى ثلاث فئات وفق مؤشر كتلة الجسم: الوزن الطبيعي، وزيادة الوزن، والسمنة، مع اعتماد حدود تصنيف معدلة لسكان جنوب شرق آسيا. واستُخدمت الإحصاءات الوصفية واختبار مربع كاي مع تصحيح بونفيروني للمقارنات المتعددة، إضافة إلى تحليل الانحدار اللوجستي متعدد المتغيرات لتحديد العوامل المرتبطة بمضاعفات الصيام، مع ضبط العمر والجنس ومدة الإصابة بالسكري والتثقيف واستخدام الإنسولين.
النتائج
شكّل المشاركون ذوو الوزن الطبيعي 20% من العينة، مقابل 42.4% ممن لديهم زيادة في الوزن و37.7% ممن يعانون من السمنة. وكانت السمنة أكثر شيوعاً بين الإناث، وسُجلت أعلى معدلاتها في دول الخليج والشرق الأوسط. وكان المشاركون المصابون بالسمنة أصغر سناً نسبياً، مع مدة إصابة أطول قليلاً بداء السكري. وتراوحت متوسطات الهيموغلوبين السكري (HbA1c) بين 8.2% و8.4%، مع تقارب مستويات التحكم في سكر الدم بين الفئات الثلاث. وارتبطت السمنة بارتفاع ضغط الدم الانقباضي والانبساطي، وزيادة انتشار ارتفاع ضغط الدم وفرط شحميات الدم والبيلة الألبومينية الدقيقة. كما كان استخدام ناهضات مستقبلات الببتيد الشبيه بالغلوكاغون-1 (GLP-1) أعلى لدى المصابين بالسمنة (5.3%) مقارنة بذوي الوزن الطبيعي (0.8%).
لم تظهر فروق ذات دلالة إحصائية بين فئات مؤشر كتلة الجسم في النية لصيام رمضان أو عدد أيام الصيام، إذ تراوحت نسب الراغبين في الصيام بين 85.4% و88.2%، وبلغ متوسط مدة الصيام نحو 28 يوماً. ومن بين 5675 مشاركاً صاموا رمضان، بلغت معدلات انخفاض سكر الدم المبلغ عنها ذاتياً 17.6% لدى ذوي الوزن الطبيعي، و15.3% لدى ذوي الوزن الزائد، و14.6% لدى المصابين بالسمنة، دون فروق ذات دلالة إحصائية. كما كانت معدلات ارتفاع سكر الدم متقاربة بين المجموعات، إذ بلغت 14.4% و13.3% و14.7% على التوالي.
في المقابل، كانت زيارات الطوارئ أو حالات التنويم خلال رمضان أعلى لدى ذوي الوزن الزائد (3.0%) مقارنة بالمصابين بالسمنة (1.8%) وذوي الوزن الطبيعي (2.2%)، بفروق ذات دلالة إحصائية (p = 0.01). وأظهر تحليل الانحدار اللوجستي متعدد المتغيرات ارتباط زيادة الوزن والسمنة بانخفاض احتمالات الإصابة بهبوط سكر الدم مقارنة بذوي الوزن الطبيعي؛ إذ بلغت نسبة الأرجحية المعدلة 0.82 (فاصل الثقة 95%: 0.67–0.99) و0.68 (فاصل الثقة 95%: 0.56–0.84)، على التوالي. ولم يكن مؤشر كتلة الجسم متنبئاً مستقلاً بارتفاع سكر الدم أو التنويم بالمستشفى. في المقابل، ارتبط استخدام الإنسولين بزيادة احتمالات انخفاض سكر الدم وارتفاعه والتنويم بالمستشفى، بنسب أرجحية معدلة بلغت 1.76 و1.95 و2.31، على التوالي.
وتلقى نحو 77%–74% من المشاركين تثقيفاً صحياً خاصاً بصيام رمضان، إلا أن معظم الجلسات التثقيفية لم تتجاوز 15 دقيقة. كما تراوحت نسبة المشاركين الذين لم يراقبوا مستويات سكر الدم ذاتياً بين 22.8% و27.8%، مما يشير إلى وجود فجوات في ممارسات المتابعة الذاتية أثناء الصيام.
الاستنتاج
أظهرت الدراسة أن مؤشر كتلة الجسم لم يرتبط بزيادة مستقلة في احتمالات ارتفاع سكر الدم أو التنويم بالمستشفى خلال رمضان لدى المصابين بداء السكري من النوع الثاني، رغم ارتفاع عبء عوامل الخطر القلبية والأيضية لدى المصابين بالسمنة. كما ارتبط ارتفاع مؤشر كتلة الجسم بانخفاض احتمالات الإصابة بهبوط سكر الدم بعد ضبط بعض العوامل السريرية والديموغرافية. وتؤكد هذه النتائج أهمية عدم الاعتماد على مؤشر كتلة الجسم وحده في تقييم ملاءمة الصيام، وضرورة إجراء تقييم فردي شامل للمخاطر، مع التركيز على استخدام الإنسولين والأمراض المصاحبة، وتعزيز التثقيف الصحي والمراقبة الذاتية لسكر الدم. ومع ذلك، فإن اعتماد الدراسة على البيانات المبلغ عنها ذاتياً وطبيعتها المقطعية يحدّ من إمكانية الاستدلال السببي وتعميم النتائج على جميع المصابين بالسكري.
الكلمات المفتاحية: صيام رمضان, داء السكري من النوع الثاني, مؤشر كتلة الجسم, انخفاض سكر الدم, ارتفاع سكر الدم, التثقيف الصحي لمرضى السكري, المراقبة الذاتية لسكر الدم, تقييم مخاطر الصيام
Introduction
Ramadan fasting is a pivotal religious practice for over 1.8 billion Muslims worldwide, during which abstention from food and drink is practiced between dawn and sunset. Despite medical exemptions, a substantial proportion of adults with type 2 diabetes mellitus (T2DM) choose to fast.1 This pattern disrupts conventional eating schedules, with prolonged daytime fasting followed by calorie-dense evening meals. Consequently, glycemic variability, hypoglycemia, and metabolic irregularities are key clinical concerns.2
The epidemiology of fasting with T2DM was comprehensively described in the landmark EPIDIAR study conducted across 13 Muslim-majority countries in 2001. Among the 11,173 participants with T2DM, 78.7% fasted for at least 15 days. However, the incidence of severe hypoglycemia increased approximately sevenfold during Ramadan compared with non-fasting months, highlighting the critical risk of inadequate glycemic control amid religious observance.3
Clinical observations in specific cultural contexts have provided additional insights. Maislos et al. (2001) studied 67 Bedouin Muslim T2DM patients in Israel and found a significant reduction in HbA1c after Ramadan, without substantial weight loss or increased acute complications.4 In Oman, a cohort of 334 T2DM patients experienced a slight average weight decrease (−0.49 ± 1.54 kg), but many remained with poorly controlled fasting glucose and body mass index (BMI).5
Despite growing interest in diabetes management during Ramadan, BMI is a clinically relevant dimension that remains insufficiently explored. BMI is a well-established proxy for metabolic health and insulin resistance in individuals with T2DM, but few studies have specifically evaluated its influence on fasting tolerance during Ramadan. Research suggests that Ramadan fasting may lead to modest weight reductions across BMI categories, but few comprehensive analyses have assessed BMI as a modifier of fasting-related glycemic variability, hypoglycemic risk, or pharmacologic adaptation.
The Diabetes and Ramadan (DaR) Global Survey conducted using SurveyMonkey in diverse Muslim-majority countries yielded a broad data set to explore these dynamics. Targeting T2DM patients who fasted during Ramadan, the survey captured BMI, self-reported fasting and post-prandial blood glucose levels, hypoglycemia episodes, and medication and lifestyle adjustments, as well as numerous other parameters.
Aims of the study
The aims of the present study were to evaluate the impacts of BMI on fasting-related outcomes, including glycemic control, hypoglycemia incidence, weight variation, and treatment modification, among adults with T2DM in Muslim-majority countries. The findings obtained may inform individualized clinical recommendations for Ramadan fasting, enabling personalized risk stratification based on BMI and reinforcing the importance of structured diabetes education to promote safe and effective fasting practices.
Materials and Methods
The methodology employed in the DaR global survey was previously published in “An update on the current characteristics and status of care for Muslims with type 2 diabetes fasting during Ramadan: the DAR global survey 2022”.6
Study design
A cross-sectional, multi-country survey was conducted to assess fasting practices among patients with T2DM during Ramadan in 2020 and 2022. Participants were recruited from all regions of the Muslim world. The study was approved by all local ethics committees, and informed consent was obtained from all participants.
Eligible participants were Muslim adults with diagnosed T2DM who attended routine consultations in either community or hospital-based settings during the 10-week post-Ramadan period (May–July). Physicians in various specialties (general practice, internal medicine, and endocrinology) facilitated recruitment (Figure 1).
Figure 1.
Study design.
Data collection
Trained physicians administered a standardized, structured questionnaire during patient consultations. The survey collected data on:
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Demographics and clinical background: age, sex, diabetes duration, complications, and treatment;
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Fasting practices: intention, number of fasting days, and interruptions;
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Ramadan-related complications: episodes of hypoglycemia and hyperglycemia, including frequency, timing, emergency visits, and hospitalizations;
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Education and monitoring: Ramadan-focused education and self-monitoring of blood glucose (SMBG).
Statistical analysis
Descriptive statistics were calculated to summarize baseline demographic and clinical characteristics. Continuous variables were expressed as the mean ± standard deviation (SD), and categorical variables as absolute frequencies and corresponding percentages. Participants with missing values were excluded from subgroup analyses.
Fasting-related outcomes were stratified according to BMI as follows:
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Group 1 (Normal weight): BMI <25 kg/m2 (or <23 kg/m2 for Southeast Asian (SEA) populations)
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Group 2 (Overweight): BMI = 25–29.9 kg/m2 (or 23–27.9 kg/m2 for SEA populations)
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Group 3 (People with obesity): BMI ≥30 kg/m2 (or ≥28 kg/m2 for SEA populations)
Pearson's chi-square test was used to assess subgroup differences, with Bonferroni correction for multiple comparisons. A two-sided p-value ≤0.05 was considered to indicate a significant difference. Analyses were performed using IBM SPSS Statistics v26 (Armonk, NY, USA).
Multivariate analysis
Multivariate binary logistic regression was performed to assess independent predictors of hypoglycemia, hyperglycemia, and hospitalizations among fasted participants. Models were adjusted for age, sex, diabetes duration, education, and insulin use by utilizing normal-weight BMI as the reference group.
Results (Tables 1 and 2)
Table 1.
Baseline characteristics and medication use in different BMI categories.
| BMI 9 < 25/< 23 (N = 1300) |
BMI 25–29.9/23–27.9 (N = 2770) |
BMI ≥30/≥28 (N = 2460) |
p-value | ||
|---|---|---|---|---|---|
| (N) % | (N) % | (N) % | |||
| Sex | Female | 654 (50.3) | 1341 (48.4) | 1496 (60.8) | <0.0001 |
| Male | 646 (49.7) | 1428 (51.6) | 964 (39.2) | ||
| Age | Mean (SD) | 56.4 (12.2) | 55.4 (11.5) | 54.3 (11.4) | <0.001 |
| <40 years | 113 (8.7) | 238 (8.6) | 251 (10.2) | <0.001 | |
| 40–49 years | 245 (18.9) | 629 (22.7) | 536 (21.8) | 0.53 | |
| 50–59 years | 380 (29.2) | 833 (30.1) | 804 (32.7) | 0.52 | |
| 60+ years | 561 (43.2) | 1069 (38.6) | 868 (35.3) | 0.4 | |
| Duration of diabetes | Mean (SD) | 9 (7) | 9.2 (6.9) | 9.8 (7.5) | <0.001 |
| <10 years | 780 (60) | 1654 (59.7) | 1373 (55.8) | 0.006 | |
| 10–19 years | 405 (31.2) | 850 (30.7) | 780 (31.7) | 0.98 | |
| ≥20 years | 114 (8.8) | 266 (9.6) | 307 (12.5) | 0.17 | |
| HbA1c, % | Mean (SD) | 8.4 (2) | 8.2 (1.8) | 8.3 (1.8) | 0.002 |
| <7% | 476 (38.9) | 1022 (38.3) | 934 (39.9) | 0.014 | |
| 7.5–9% | 362 (29.6) | 913 (34.2) | 732 (31.3) | 0.6 | |
| >9% | 385 (31.5) | 734 (27.5) | 674 (28.8) | 0.7 | |
| Latest systolic BP (mmHg) | Mean (SD) | 125.6 (25.1) | 129.2 (21.9) | 132 (23.5) | <0.001 |
| <130 | 693 (53.3) | 1242 (44.9) | 919 (37.4) | 0.02 | |
| 130–140 | 366 (28.2) | 926 (33.5) | 825 (33.6) | 0.5 | |
| >140 | 240 (18.5) | 597 (21.6) | 713 (29) | 0.02 | |
| Latest diastolic BP (mmHg) | Mean (SD) | 75.6 (14.6) | 78.1 (13.3) | 78.4 (14.1) | <0.001 |
| <80 | 622 (47.9) | 1138 (41) | 1025 (41.7) | <0.001 | |
| 80–90 | 604 (46.5) | 1424 (51.3) | 1192 (48.5) | 0.8 | |
| >90 | 73 (5.6) | 214 (7.7) | 241 (9.8) | 0.04 | |
| Latest LDL (mg/dL) | Mean (SD) | 94.2 (54.4) | 95.1 (50.2) | 82.6 (51.6) | <0.001 |
| <55 | 168 (19.8) | 303 (17.7) | 315 (25.9) | <0.001 | |
| 55–70 | 60 (7) | 118 (6.9) | 88 (7.2) | 0.9 | |
| 70–100 | 232 (27.3) | 514 (30) | 393 (32.3) | 0.6 | |
| 100–120 | 152 (17.8) | 243 (14.2) | 166 (13.7) | 0.3 | |
| >120 | 239 (28.1) | 534 (31.2) | 255 (20.9) | 0.05 | |
| Smoking | Current smoker | 116 (8.9) | 166 (6) | 153 (6.2) | 0.002 |
| Ex-smoker | 144 (11.1) | 306 (11.1) | 198 (8) | 0.16 | |
| Non-smoker | 1040 (80) | 2297 (83) | 2109 (85.7) | 0.2 | |
| Medication | Metformin | 907 (69.8) | 2229 (80.5) | 1965 (79.9) | <0.001 |
| Sulfonylureas | 456 (35.1) | 1171 (42.3) | 934 (38) | <0.001 | |
| DPP4_inhibitors | 289 (22.2) | 903 (32.6) | 744 (30.2) | <0.001 | |
| Thiazolidinedione | 97 (7.5) | 187 (6.8) | 139 (5.7) | 0.038 | |
| SGLT-2 | 211 (16.2) | 689 (24.9) | 621 (25.2) | <0.001 | |
| GLP1 | 11 (0.8) | 65 (2.3) | 131 (5.3) | <0.0001 | |
| Alpha glucosidase inhibitor | 28 (2.2) | 80 (2.9) | 45 (1.8) | 0.046 | |
| Insulin intermediate acting | 56 (4.3) | 103 (3.7) | 208 (8.5) | <0.001 | |
| Insulin long acting | 252 (19.4) | 541 (19.5) | 523 (21.3) | 0.17 | |
| Insulin short acting | 211 (16.2) | 385 (13.9) | 528 (21.5) | <0.001 | |
| Insulin combination | 195 (15) | 478 (17.3) | 334 (13.6) | 0.002 | |
| Any insulin | 540 (41.5) | 1142 (41.2) | 1108 (45) | 0.012 | |
| Diabetes complications | Hypertension | 476 (36.6) | 1317 (47.5) | 1312 (53.3) | 0.01 |
| Hyperlipidemia | 400 (30.8) | 1201 (43.4) | 1162 (47.2) | 0.007 | |
| Retinopathy | 168 (12.9) | 368 (13.3) | 419 (17) | <0.001 | |
| Neuropathy | 269 (20.7) | 585 (21.1) | 450 (18.3) | 0.037 | |
| Microalbuminuria | 66 (5.1) | 287 (10.4) | 241 (9.8) | 0.003 | |
| Nephropathy/CKD | 114 (8.8) | 238 (8.6) | 308 (12.5) | <0.001 | |
| Macrovascular disease (CAD, HF, stroke or TIA, PVD) | 146 (11.2) | 380 (13.7) | 331 (13.5) | 0.063 | |
| Diabetic foot problems (ulcers, amputations) | 54 (4.2) | 112 (4) | 82 (3.3) | 0.301 | |
| None | 479 (36.8) | 849 (30.6) | 690 (28) | <0.001 | |
HbA1c, glycated hemoglobin; BMI, body mass index; LDL-C, low density lipoprotein cholesterol; CAD, coronary artery disease; HF, heart failure; TIA, transient ischemic attack; PVD, peripheral vascular disease.
Table 2.
Characteristics of fasting, SMBG, and Ramadan-focused diabetes education in different BMI categories.
| BMI 9 < 25/<23 (N = 1300) |
BMI 25–29.9/23–27.9 (N = 2770) |
BMI ≥30/≥28 (N = 2460) |
p-value | ||
|---|---|---|---|---|---|
| (N) % | (N) % | (N) % | |||
| Fasted for the month of Ramadan | Yes | 1110 (85.4) | 2396 (86.5) | 2169 (88.2) | 0.06 |
| Duration of Ramadan fasting | Mean duration (days)/SD | 27.6 (5.6) | 27.9 (5) | 27.9 (5.2) | 0.226 |
| 1–7 days | 30 (2.7) | 45 (1.9) | 45 (2.1) | 0.432 | |
| 30 days | 759 (68.4) | 1687 (70.4) | 1525 (70.3) | 0.9 | |
| Intention for Shawal (post) Ramadan fasting | Yes | 325 (25) | 866 (31.3) | 699 (28.4) | 0.4 |
| Did you do SMBG during Ramadan | Yes, more frequent than before Ramadan | 154 (13.9) | 451 (18.8) | 232 (10.7) | 0.01 |
| Yes, less frequent than before Ramadan | 187 (16.8) | 367 (15.3) | 373 (17.2) | 0.8 | |
| Yes, at same frequency as before Ramadan | 460 (41.4) | 1035 (43.1) | 995 (45.8) | 0.8 | |
| No | 309 (27.8) | 546 (22.8) | 570 (26.3) | 0.5 | |
| Received education | Yes | 821 (74) | 1848 (77) | 1605 (74) | 0.9 |
| Method of education | In clinic during my routine consultation | 666 (63.4) | 1727 (66.7) | 1538 (71.2) | 0.7 |
| In group session | 119 (11.3) | 168 (6.5) | 106 (4.9) | <0.001 | |
| Online or through app | 30 (2.9) | 43 (1.7) | 39 (1.8) | 0.19 | |
| Leaflet | 237 (22.6) | 651 (25.1) | 476 (22) | 0.7 | |
| Duration of education session | 0–15 min | 693 (83.7) | 1469 (79.1) | 1308 (81.4) | 0.4 |
| >15–30 min | 126 (15.2) | 367 (19.8) | 255 (15.9) | 0.3 | |
| >30 min | 9 (1.1) | 20 (1.1) | 43 (2.7) | 0.013 | |
BMI distribution and demographics
Among 6530 participants, 20% had a normal BMI, 42.4% were overweight, and 37.7% were obese. Obesity was significantly more common among females (60.8% vs. 39.2% males; p < 0.0001). The highest prevalences of obesity were observed in Gulf (KSA, UAE, Oman, Bahrain, and Kuwait) and Middle Eastern countries (Egypt, Iraq, Türkiye, and Iran), and the lowest in the Maghreb region (Morocco, Algeria, and Tunisia) (Figure 2).
Figure 2.
Regional distribution (%) of BMI in the study cohort.
Age and diabetes duration
Obese participants tended to be younger, with a slightly lower mean age (54.3 ± 11.4 years) compared with normal-weight individuals (56.4 ± 12.2 years). Duration of diabetes was similar among BMI groups, although slightly longer in obese individuals (9.8 ± 7.5 years).
Glycemic control
HbA1c levels were comparable across groups, with mean values ranging from 8.2% to 8.4%. Approximately 30% had HbA1c >9% in each group.
Blood pressure
Obesity was associated with worse systolic blood pressure (SBP), where 29% of obese individuals had SBP >140 mmHg versus 18.5% in the normal BMI group (p = 0.02). Mean SBP increased with BMI, with 125.6, 129.2, and 132.0 mmHg in the normal, overweight, and obese groups, respectively. There was a clear, statistically significant, stepwise increase in mean diastolic blood pressure (DBP) as BMI increased (75.6 mmHg in the normal-weight group, 78.1 mmHg in the overweight group, and 78.4 mmHg in the obese group; p < 0.001.
Lipids and smoking
Low-density lipoprotein (LDL) cholesterol levels were highest in the overweight group. A lower proportion of obese patients had LDL >120 mg/dL (20.9%) compared with normal-weight individuals (28.1%). Smoking was more common among normal-weight participants, where 8.9% were current smokers compared with 6.2% in the obese group.
Diabetes-related complications
Hypertension and hyperlipidemia were significantly more prevalent among obese patients (p = 0.01 and p = 0.007, respectively). Microalbuminuria was also more common in the obese group (9.8% vs. 5.1%; p = 0.003). Rates of retinopathy, neuropathy, nephropathy, macrovascular disease, and diabetic foot were comparable among groups.
Medication patterns
Obese patients were significantly more likely to be prescribed GLP-1 receptor agonists (5.3% vs. 0.8% with normal BMI; p < 0.0001), reflecting their emerging role in weight management. Use of metformin, SGLT-2 inhibitors, and insulin therapies was broadly similar among groups.
Fasting practices during ramadan
BMI had no significant impacts on the intention to fast during Ramadan or the number of days fasted. The vast majority of participants intended to fast, with 85.4% in the normal BMI group, 86.5% in the overweight group, and 88.2% in the obese group (p > 0.05). Most fasted for the entire month, with a mean fasting duration of approximately 28 days in all groups. Short fasting durations (1–7 days) were rare and similar across BMI groups (2.7%, 1.9%, and 2.1% in the normal BMI group, overweight group, and obese group, respectively). Intention to fast during Shawwal was slightly higher among overweight participants (31.3%) compared with normal BMI (25%) and obese individuals (28.4%).
Hypoglycemia (Figure 3)
Figure 3.
Rates of occurrence, frequency, and hospitalizations due to hypo- and hyperglycemia in different BMI categories (%).
Among those who fasted (n = 5675), the incidence of self-reported hypoglycemia was slightly higher in the normal BMI group (17.6%) compared with overweight (15.3%) and obese individuals (14.6%), but the differences were not statistically significant.
The mean number of hypoglycemic days was similar among BMI groups at 4.0 days for normal BMI, 3.7 days for overweight individuals, and 3.9 days for obese individuals, and around 8–11% reported >8 days of hypoglycemia.
Emergency room visits or hospitalizations during Ramadan were significantly more common in overweight individuals (3.0%) compared with obese (1.8%) and normal-BMI participants (2.2%) (p = 0.01). The difference was statistically significant between the overweight and obese groups (p = 0.003).
Hyperglycemia and acute care utilization (Figure 3)
Among participants who fasted, the incidence of self-reported hyperglycemia was comparable across BMI groups at 14.4% in the normal BMI group, 13.3% in the overweight group, and 14.7% in obese individuals.
The mean number of hyperglycemic days was slightly higher in the obese group (5.9 ± 6.5) compared with normal BMI (4.7 ± 5.6) and overweight (5.1 ± 5.6) individuals. Those reporting >8 days of hyperglycemia were more frequent in the obese group (18.2%) than the overweight (14.2%) and normal BMI groups (13.4%).
Emergency room visits or hospital admissions due to hyperglycemia were rare in all BMI categories, with no significant differences (range: 0.58–0.78%).
Ramadan education and SMBG
Rates of Ramadan-focused diabetes education were high and similar in BMI groups at 74% in the normal BMI group, 77% in the overweight group, and 74% in the obese group. Most education was delivered during routine clinical consultations (63–71%), and leaflet provision was the second most common method. Online/app-based and group session methods were used infrequently.
Most education sessions were brief, where 79–84% lasted ≤15 min.
Among SMBG practices, the majority monitored at the same frequency as before Ramadan (∼41–46%). A higher proportion of overweight participants increased their SMBG frequency (18.8%) compared with obese (10.7%) and normal BMI individuals (13.9%). Non-monitoring rates were high in all groups (22.8–27.8%).
Multivariate analysis of fasting complications
After adjusting for clinical and demographic covariates, BMI was not an independent predictor of hyperglycemia or hospitalizations (all p > 0.05). Conversely, higher BMI was independently associated with a decreased risk of hypoglycemia compared with normal BMI individuals (overweight: adjusted odds ratio (aOR) = 0.82, 95% confidence interval (CI) = 0.67–0.99, p = 0.040; obese: aOR = 0.68, 95% CI = 0.56–0.84, p < 0.001). Across all models, baseline insulin use was identified as the strongest independent risk factor, significantly increasing the odds of hypoglycemia (aOR 1.76), hyperglycemia (aOR = 1.95), and hospital admissions (aOR = 2.31) (all p < 0.001).
Discussion
The results obtained in the present study highlight the high prevalence of overweight and obese individuals with T2DM in Muslim-majority countries, where over 80% of the cohort belonged to these categories. These findings align with regional epidemiologic trends demonstrating a growing burden of obesity-related metabolic disorders, particularly in Gulf and Middle Eastern countries, where rapid urbanization and lifestyle transitions have contributed to sedentary behavior and nutritional shifts.7 The disproportionate prevalence of obesity among females in our cohort is consistent with previous studies in the region, which attributed this trend to cultural, socioeconomic, and activity-related barriers limiting women's access to preventive health resources.8 Interestingly, individuals with obesity were slightly younger than those with normal BMI but had a longer duration of diabetes, suggesting that excess adiposity may accelerate disease onset and progression.
This sub-analysis of the DaR Global Surveys (2020–2022) provides novel insights into the relationships between BMI, metabolic parameters, and fasting behaviors in individuals with T2DM in diverse Muslim-majority settings. The observed regional variations in obesity rates, which were highest in the Gulf and lowest in the Maghreb, mirror broader socioeconomic, dietary, and lifestyle transitions occurring across the MENA region.
Despite a greater burden of cardiometabolic risk factors, including elevated SBP/DBP, hypertension, hyperlipidemia, and microalbuminuria, among individuals with obesity, overall glycemic control measured based on HbA1c was comparable in all BMI categories. This may suggest that standardized therapeutic interventions, including pharmacologic regimens, are capable of mitigating hyperglycemia irrespective of adiposity. However, the persistence of poor glycemic control (HbA1c > 9%) in approximately one-third of participants in all BMI groups highlights a concerning level of suboptimal management and the need for more aggressive, individualized approaches to diabetes care.
The higher prevalences of elevated DBP/SBP and microalbuminuria in the obese group reinforce the cumulative metabolic burden imposed by insulin resistance and obesity-associated endothelial dysfunction.3 Interestingly, the peak LDL cholesterol levels were found among overweight rather than obese individuals, which may reflect variations in lipid-lowering therapy adherence, dietary behavior, or population distribution artifacts. These differences highlight the importance of comprehensive cardiometabolic risk assessment rather than using glycemic indices alone, when managing patients with T2DM across the BMI spectrum. The unmeasured but likely higher use of statin therapy in the obese cohort was a probable driver of these paradoxical lipid patterns.
Contrary to initial expectations, BMI did not significantly influence either the intention to fast or the actual number of fasting days during Ramadan. Over 85% of participants across all BMI categories successfully completed the full month of fasting, demonstrating the feasibility of Ramadan observance in individuals with T2DM when supported by structured education and clinical guidance. These findings are consistent with previous DaR studies, which demonstrated that fasting can be safely undertaken regardless of BMI when accompanied by individualized risk assessment and pre-Ramadan counseling.3, 9
BMI itself is not a standalone risk category in the DaR guidelines, but the underlying cardiometabolic comorbidities that were significantly more prevalent in our obese cohort (such as uncontrolled blood pressure, hyperlipidemia, and microalbuminuria) are critical components of the DaR risk scoring system. Clinical risk should not be judged by visual adiposity or BMI alone, but instead through comprehensive, individualized risk stratification using the DaR calculator. This reinforces the need for targeted pre-Ramadan education, with clinicians addressing specific comorbidities and empowering patients to fast safely based on their holistic metabolic profile.
The comparable incidences of self-reported hypoglycemia and hyperglycemia among BMI groups further reinforce the safety of fasting across the adiposity spectrum. A modestly higher rate of hypoglycemia in the normal BMI group may be attributed to lower levels of insulin resistance or greater pharmacologic sensitivity, and the trend toward more frequent hyperglycemic days among obese individuals probably reflects underlying metabolic dysregulation. However, these differences were not statistically significant, so they should be interpreted with caution.
It should be noted that emergency healthcare utilization was low in all groups, suggesting that major fasting-related complications were uncommon. The unexpected finding of more emergency visits among overweight participants compared with both normal BMI and obese individuals may reflect unmeasured confounders such as medication non-adherence, variability in comorbid burden, or behavioral differences not captured within the survey framework. This pattern warrants further exploration in future studies designed to assess fasting safety stratified by both BMI and comorbidity clusters. Patients with obesity carry a higher baseline cardiometabolic burden, but higher BMI did not independently increase the risk of acute glycemic emergencies during Ramadan when matched for insulin use and diabetes duration.
The high prevalence of Ramadan-focused diabetes education in all BMI categories is an encouraging finding that reinforces the critical role of structured guidance in facilitating safe fasting practices among individuals with T2DM. Education has been consistently associated with improved fasting outcomes, particularly when delivered in advance of Ramadan and tailored to individual risk profiles.10 However, the brevity of most educational sessions, which often lasted less than 15 min, and the underutilization of digital platforms or group-based interventions highlight missed opportunities for engagement. Scalable, technology-enhanced education may be particularly valuable in resource-limited or high-volume clinical settings.
From a therapeutic standpoint, the higher prescription rate of GLP-1 receptor agonists among obese individuals aligns with contemporary guideline recommendations that advocate their use for combined glycemic and weight management.11 However, the overall utilization of GLP-1RAs remained low in the cohort, which may reflect barriers related to drug cost, regional availability, and variations in prescribing practices. Addressing these systemic limitations is essential for optimizing cardiometabolic outcomes, particularly in populations with an increasing prevalence of obesity.
Clinical implications
In clinical practice, elevated BMI should not be utilized as a standalone deterrent when counseling individuals with T2DM on their fitness to fast. Instead, pre-Ramadan consultations must prioritize individualized risk stratification, as outlined by the DaR guidelines, with a specific focus on baseline insulin use, which our multivariate analysis identified as the strongest independent predictor of glycemic emergencies. Consequently, clinical encounters must prioritize proactive insulin dose titration, regimen simplification, and the integration of technology-assisted monitoring (e.g., continuous glucose monitoring) to address suboptimal SMBG adherence and mitigate fasting-related risks across all BMI categories.
Limitations
The present study had several important limitations that must be considered when interpreting the findings. First, the reliance on self-reported data introduced the inherent risk of information bias, specifically recall and social desirability biases. For instance, social desirability may have led to an overestimation of patient adherence to SMBG practices and prescribed fasting guidelines. Conversely, recall bias could have resulted in the underreporting of mild, asymptomatic hypoglycemic events, potentially skewing the reported data toward only more memorable, severe symptomatic episodes. Furthermore, participants were recruited during post-Ramadan routine clinical consultations, so the study was susceptible to selection bias. Patients who attended these follow-ups may have represented a subpopulation with better healthcare access and higher baseline health literacy, or conversely, a higher burden of recent acute complications necessitating medical attention. Consequently, this cohort may not have perfectly represented the fasting experiences of the broader, unmonitored patient population. In addition, the cross-sectional nature of the survey prevented definitive causal inference between baseline BMI and observed fasting outcomes.
Second, our multivariate analyses adjusted for several key demographic and clinical factors, but the effects of unmeasured confounders cannot be entirely excluded. Granular variables, such as the exact dietary composition and caloric load at Iftar and Suhur, shifts in physical activity levels, sleep disruption, and precise socioeconomic status, were not systematically captured. In particular, the survey did not collect specific data on the exact magnitude of pre-Ramadan medication adjustments, such as precise insulin dose titrations or the concurrent use of lipid-lowering therapies like statins, introducing the distinct possibility of confounding by indication. For example, clinicians may have proactively managed patients with higher BMIs or those on insulin regimens much more aggressively prior to Ramadan due to their perceived baseline cardiometabolic risks. These targeted, unmeasured clinical interventions could have artificially attenuated the observed rates of adverse glycemic events within high-risk cohorts. Ultimately, the absence of these precise parameters restricted the depth of causal inference, highlighting the need for future prospective studies utilizing continuous glucose monitoring and detailed lifestyle diaries.
Conclusion
This study has several notable strengths. First, data were utilized from a large, diverse cohort of over 6500 individuals with T2DM in multiple Muslim-majority countries, enhancing the generalizability of the findings. Second, the use of BMI-specific stratification facilitated nuanced analysis of metabolic risk and fasting behavior, which have not been adequately explored previously in the context of Ramadan. Third, this study captured a wide range of clinically relevant outcomes, including glycemic control, hypoglycemia, emergency care utilization, and self-care behaviors such as SMBG and education access. Finally, by analyzing real-world data within the framework of structured Ramadan-focused diabetes education, this study yielded practical insights into safe fasting practices that can inform clinical guidelines and public health strategies.
The findings obtained in this study demonstrate that individuals with T2DM in all BMI categories can fast safely during Ramadan, provided that they receive appropriate education and medical supervision. Despite a higher cardiometabolic burden, obesity was not associated with an increased risk of fasting-related complications.
Author contribution
All authors have critically reviewed and approved the final draft and are responsible for the content and similarity index of the manuscript.
Declaration of generative AI and AI-assisted technologies in the writing process
During the preparation of this manuscript, the author(s) used [ChatGPT/Gemini] in order to make grammatical adjustments. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.
Conflict of interest
None of the authors declare any competing interests, financial or otherwise.
Footnotes
Peer review under responsibility of Taibah University.
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