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CC BY 4.0 · Journal of Diabetes and Endocrine Practice 2026; 09(01): 108-114
DOI: 10.1055/s-0045-1812099
Original Article

Correlation between Pre-Ramadan HbA1c Levels and Fasting Outcomes in Individuals with Type 2 Diabetes: Evidence from the Global 2020–2022 DAR Survey

Authors

  • Bachar Afandi

    1   Endocrine Division, Tawam Hospital & STMC, Al Ain, United Arab Emirates
    2   Department of Medicine, College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates

  • Khadija Hafidh 

    3   Diabetes Unit, Rashid Hospital, Dubai, United Arab Emirates
    4   Department of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates

  • Georgios Ponirakis

    5   Weill Cornell Medical College in Qatar, Doha, Qatar

  • Mohamed Habib

    6   Scientific Affairs Department, DaR International Alliance, Alexandria, Egypt

  • Rayaz Malik 

    5   Weill Cornell Medical College in Qatar, Doha, Qatar
    7   Research Division, Qatar Foundation, Education City, Medicine, Doha, Qatar

  • Reem Alamoudi 

    8   Department of Diabetes and Endocrinology, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Medicine, Jeddah, Saudi Arabia

  • Inass Shaltout

    9   Department of Medicine, Cairo University, Cairo, Egypt

  • Rashed Malek

    10   Endocrine Department, University Ferhat Abbas of Setif, Sétif, Wilaya de Sétif, Algeria

  • Zanariah Hussein

    11   Endocrine Institute, Hospital Putrajaya, Melayu, Kuala Lumpur, Malaysia

  • Mohamed Hasannien 

    4   Department of Medicine, Mohammed Bin Rashid University, Dubai, United Arab Emirates
    12   Endocrine Department, Dubai Hospital, Dubai, United Arab Emirates

Funding None.
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Abstract

Background

Glycemic control prior to Ramadan is considered an essential determinant of fasting safety in individuals with diabetes. While the International Diabetes Federation-Diabetes and Ramadan Alliance risk calculator incorporates glycated hemoglobin (HbA1c) into fasting risk stratification, there is limited evidence to validate the cutoffs of < 7.5% and > 9% for predicting fasting outcomes.

Objective

This study evaluates the association between pre-Ramadan HbA1c categories and key fasting-related outcomes in a large multinational cohort of individuals with diabetes.

Methods

This subanalysis of the Diabetes and Ramadan (DaR) Global Survey categorized participants from 7 global regions covering more than 20 countries into three groups based on pre-Ramadan HbA1c: < 7.5%, 7.5 to 9%, and > 9%. Outcomes included fasting participation, hypoglycemia, hyperglycemia, and fasting interruptions due to glycemic events. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated for participants with HbA1c > 9% compared to those with HbA1c < 7.5%.

Results

Of 11,717 participants, 37.7% had HbA1c < 7.5%, 33.8% had 7.5 to 9%, and 28.5% had > 9%. Fasting participation was highest in the < 7.5% group (89.3%) and lowest in the > 9% group (80.5%; OR 0.49, 95% CI 0.43–0.56). Compared to < 7.5%, HbA1c > 9% was associated with increased odds of hyperglycemia (OR 5.10), breaking the fast due to hyperglycemia (OR 5.63) and severe hyperglycemia (OR 8.11), daytime hypoglycemia (OR 1.48), and hypoglycemia-related fasting interruption (OR 1.77). Severe hypoglycemia rates did not differ significantly between HbA1c groups.

Conclusion

Higher pre-Ramadan HbA1c was associated with lower fasting participation and a greater risk of hyperglycemia and hypoglycemia-related complications. These results support the use of the current HbA1c thresholds in Ramadan risk assessment and emphasize the importance of optimizing glycemic control and providing targeted education before Ramadan.

Keywords

Ramadan fasting - T2 diabetes mellitus - HbA1c - glycemic control - hypoglycemia - hyperglycemia - risk assessment - DAR risk calculator

Authors' Contributions

All authors contributed toward conception, data collection, writing, and final approval of the manuscript.


Statement of Ethics

Ethical approval was granted for the initial DAR Global Survey from Dubai Health Authority.




Publication History

Article published online:
31 October 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

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