Pre-Ramadan Evaluation in Diabetes: Preparing the Patient for Safe and Meaningful Fasting

 Pre-Ramadan Evaluation in Diabetes: Preparing the Patient for Safe and Meaningful Fasting

A Comprehensive Clinical Review

Dr Neeraj Manikath  , claude.ai

Abstract

Ramadan fasting presents unique challenges for patients with diabetes, requiring meticulous pre-Ramadan evaluation and personalized management strategies. This comprehensive review synthesizes evidence-based approaches with practical clinical pearls derived from decades of real-world experience. We explore risk stratification frameworks, medication adjustments, glycemic monitoring strategies, and patient education techniques essential for safe fasting. Special emphasis is placed on bedside nuances often overlooked in standard guidelines, including cultural competence, individualized decision-making, and management of special populations. The goal is to empower clinicians to conduct thorough pre-Ramadan consultations that balance religious observance with metabolic safety, ultimately reducing hypoglycemia, hyperglycemia, and acute complications during this sacred month.

Keywords: Ramadan fasting, diabetes mellitus, risk stratification, hypoglycemia, medication adjustment, cultural competence, patient education

Introduction

Ramadan, the ninth month of the Islamic lunar calendar, involves fasting from dawn to sunset for approximately 29-30 days. Over 1.8 billion Muslims worldwide observe this pillar of Islam, including an estimated 50 million individuals with diabetes.1,2 While Islamic law exempts those with illness from fasting, many patients with diabetes choose to fast despite medical risks, driven by profound religious conviction and community belonging.

The metabolic challenges are formidable. Prolonged fasting durations (12-18 hours depending on geography and season), abrupt dietary pattern changes, and altered medication timing create a perfect storm for dysglycemia. The landmark EPIDIAR study demonstrated stark realities: a 4.7-fold increase in severe hypoglycemia and 7.5-fold increase in severe hyperglycemia among fasting individuals with type 1 diabetes.3 Even in type 2 diabetes, hypoglycemia increased 7.5-fold.

Clinical Pearl #1: The pre-Ramadan consultation is not a single encounter but an ongoing dialogue. Initiate discussions 6-8 weeks before Ramadan to allow adequate time for medication titration, self-management education, and iterative decision-making. Patients who receive structured pre-Ramadan education have 50% fewer hypoglycemic events.4

Understanding the Clinical Context

Physiological Changes During Ramadan Fasting

During the fasting state, hepatic glycogenolysis maintains euglycemia for the first 8-12 hours, followed by gluconeogenesis and progressive insulin reduction. In healthy individuals, counter-regulatory hormones (glucagon, cortisol, growth hormone, epinephrine) prevent hypoglycemia. However, patients with diabetes—especially those on insulin or sulfonylureas—lack this physiological safety net.

Post-iftar (sunset meal) hyperglycemia is equally problematic. Patients often consume carbohydrate-rich foods rapidly after 14-16 hours of fasting, overwhelming insulin secretion or exogenous insulin dosing. This is compounded by reduced physical activity and nocturnal snacking before suhoor (pre-dawn meal).

Bedside Hack #1: Ask patients to describe their typical Ramadan day hour-by-hour during the initial consultation. Note wake times, prayer schedules, meal composition, family dynamics, and occupational demands. This granular understanding reveals individualized risk factors invisible in standardized questionnaires. For instance, a construction worker fasting in July faces vastly different risks than an office worker fasting in December.

Cultural and Religious Dimensions

Effective pre-Ramadan counseling demands cultural humility. Many patients perceive medical advice against fasting as culturally insensitive or spiritually dismissive. Frame discussions collaboratively: "How can we work together to make fasting as safe as possible?" rather than "You should not fast."

Understand that patients may fast despite high-risk categorization. Rather than abandoning these patients, intensify monitoring and provide harm-reduction strategies. Respect the decision while ensuring informed consent about risks.

Clinical Pearl #2: Partner with local religious leaders or hospital chaplains familiar with Islamic jurisprudence. Many patients trust spiritual guidance. Having an Imam affirm that "breaking fast for medical reasons is not only permitted but obligatory" can profoundly influence patient decisions. Some centers successfully use joint medical-religious counseling sessions.5

Risk Stratification: The Foundation of Pre-Ramadan Assessment

The International Diabetes Federation (IDF) and Diabetes and Ramadan (DAR) International Alliance have developed evidence-based risk stratification categories: very high, high, moderate, and low risk.6,7 However, applying these categories requires clinical judgment beyond checkbox criteria.

Very High-Risk Category

Patients in this category should be strongly advised against fasting:

•        Severe hypoglycemia or diabetic ketoacidosis within 3 months prior to Ramadan

•        Recurrent hypoglycemia or hypoglycemia unawareness

•        Poorly controlled type 1 diabetes (HbA1c >9%)

•        Advanced chronic kidney disease (eGFR <30 ml/min/1.73m²)

•        Acute illness, pregnancy (particularly first and third trimesters), or breastfeeding

•        Cognitive impairment preventing self-management

•        Patients performing high-risk physical labor (e.g., driving, operating heavy machinery)

Oyster #1 (Hidden Gem): The "3-month rule" for hypoglycemia is not arbitrary. Studies show hypoglycemia begets hypoglycemia through defective counter-regulation. A patient with severe hypoglycemia 4 months ago who has been stable since may cautiously attempt fasting with intensive monitoring, but one with an event 6 weeks ago remains high-risk despite superficial stability. Recency matters more than frequency in some cases.8

High-Risk Category

These patients can fast with intensive monitoring and medication adjustment:

•        Type 1 diabetes with reasonable control (HbA1c 7-9%)

•        Type 2 diabetes on intensive insulin regimens (e.g., basal-bolus)

•        Moderate chronic kidney disease (eGFR 30-45 ml/min/1.73m²)

•        Well-controlled diabetes with significant comorbidities (stable coronary artery disease, heart failure)

•        Elderly patients (>75 years) even with good glycemic control

Bedside Hack #2: For high-risk patients who insist on fasting, negotiate "trial fasting days" 4-6 weeks before Ramadan while on modified medication regimens. Simulate the fasting schedule on weekends with close glucose monitoring. If the patient experiences hypoglycemia <70 mg/dL or symptoms, use this as a teachable moment. Real-world data beats theoretical risk discussions.

Moderate and Low-Risk Categories

Moderate-risk patients include those with well-controlled type 2 diabetes on metformin, DPP-4 inhibitors, GLP-1 agonists, SGLT2 inhibitors, or low-dose sulfonylureas. Low-risk patients have diabetes controlled by lifestyle alone or metformin monotherapy with HbA1c <7%.

Even "low-risk" patients require pre-Ramadan counseling. Complacency breeds complications. Address dietary indiscretion at iftar, hydration strategies, and blood glucose monitoring frequency.

Clinical Pearl #3: Frailty trumps chronological age. An active 80-year-old with diabetes on metformin alone may be lower risk than a sedentary 60-year-old with heart failure on insulin. Use tools like the FRAIL scale or Clinical Frailty Scale during assessment. Frail patients—regardless of age—warrant higher risk categorization.9

Medication Management: The Art and Science

Medication adjustment is the cornerstone of safe Ramadan fasting. The principle is simple: minimize hypoglycemia risk without sacrificing glycemic control. The execution, however, demands pharmacological fluency and individualization.

Oral Hypoglycemic Agents

Metformin: The safest agent during fasting with no hypoglycemia risk. Redistribute doses: if previously twice daily, give the larger dose at iftar and smaller at suhoor. For extended-release formulations, switch to immediate-release for better dose flexibility. Caution patients about gastrointestinal side effects, which may worsen with large iftar meals.

Sulfonylureas: The Achilles heel of Ramadan management. Gliclazide modified-release and glimepiride are preferred over glibenclamide due to lower hypoglycemia rates.10 If a patient is on twice-daily sulfonylurea, shift to once-daily at iftar. Reduce the total daily dose by 30-50% and monitor closely. Better yet, transition to safer agents (DPP-4i, GLP-1 RA, SGLT2i) 6-8 weeks pre-Ramadan if HbA1c allows.

Oyster #2: Patients on sulfonylureas often present after Ramadan with paradoxical HbA1c improvement despite dose reduction. Why? Elimination of erratic eating patterns and forced portion control during iftar/suhoor create inadvertent lifestyle modification. Use this post-Ramadan "metabolic reset" to transition permanently to safer agents.

DPP-4 Inhibitors: Excellent choice. Glucose-dependent mechanism minimizes hypoglycemia. No dose adjustment needed. Continue usual regimen.

SGLT2 Inhibitors: Generally safe but counsel patients about diabetic ketoacidosis (DKA) risk, particularly in type 1 diabetes or insulin-deficient type 2 diabetes. Emphasize "sick day rules"—if vomiting, abdominal pain, or profound fatigue occur, break the fast and seek medical attention. Ensure adequate hydration between iftar and suhoor. Consider holding SGLT2 inhibitors in patients with prior DKA or during illness.11

GLP-1 Receptor Agonists: Ideal for Ramadan due to low hypoglycemia risk and beneficial effects on weight and postprandial glucose. No dose adjustment required for long-acting agents (dulaglutide, semaglutide). For short-acting exenatide, shift both doses to mealtimes (iftar and suhoor). Warn about nausea exacerbation with large iftar meals.

Bedside Hack #3: Create a "medication card" for each patient: a wallet-sized reference showing pre-Ramadan doses, Ramadan doses, and post-Ramadan doses. Include specific instructions ("Take glimepiride 2mg at iftar, skip suhoor dose"). Patients find this tangible tool more useful than verbal instructions. Laminate it so it survives the month in pockets and purses.

Insulin Management

Insulin adjustment is nuanced and requires patient-specific titration. General principles include:

Basal Insulin: For once-daily basal insulin (glargine, detemir, degludec), reduce dose by 15-30% and administer at iftar or suhoor—timing depends on individual glucose patterns. Degludec's ultra-long action (>42 hours) offers flexibility. For patients on NPH twice daily, switch to once-daily long-acting analog at iftar to reduce nocturnal hypoglycemia.

Bolus Insulin: In basal-bolus regimens, give the largest prandial dose at iftar, a smaller dose at suhoor, and omit midday doses. Start conservatively—reduce each dose by 25-30%—then titrate based on continuous glucose monitoring (CGM) or frequent fingerstick data. Rapid-acting analogs (lispro, aspart, glulisine) are preferred over regular insulin for better postprandial control.

Premixed Insulin: Problematic during Ramadan due to inflexibility. If continuation is necessary, give the larger dose at iftar and eliminate other doses. Better approach: transition to basal-bolus regimen 6-8 weeks pre-Ramadan for better dose individualization.

Clinical Pearl #4: The "Rule of 70-120" for safe fasting on insulin: Pre-suhoor glucose should be 120-180 mg/dL. If <120 mg/dL, reduce suhoor insulin by 20%. Mid-fasting glucose (afternoon) should be >70 mg/dL. If <70 mg/dL, break fast immediately and reduce next day's suhoor insulin by 30%. This simple protocol prevents 60-70% of severe hypoglycemic events.12

Insulin Pump and CGM Users

Continuous subcutaneous insulin infusion (CSII) offers unparalleled flexibility. Create separate basal profiles for fasting days: reduce basal rates by 10-40% during fasting hours, increase slightly post-iftar to manage hyperglycemia. Bolus calculators should be reprogrammed for new meal timings.

CGM is transformative during Ramadan. Real-time glucose trending allows preemptive interventions before severe dysglycemia. Set aggressive low alerts (80 mg/dL) and high alerts (200 mg/dL). Teach patients to break fasts when glucose is <70 mg/dL and trending downward, even if asymptomatic.13

Oyster #3: Hybrid closed-loop systems (automated insulin delivery) show promise for Ramadan safety. Small studies demonstrate fewer hypoglycemic events and better time-in-range compared to sensor-augmented pumps. However, these systems require meticulous carbohydrate counting at iftar/suhoor—a challenge when meals are communal and portions variable. Reserve for highly motivated, tech-savvy patients.14

Glucose Monitoring and Patient Education

Self-Monitoring Blood Glucose (SMBG) Strategy

Many patients believe that fingerstick testing "breaks the fast." Correct this misconception early. All major Islamic jurisprudence councils permit medical testing during Ramadan.15 Frame monitoring as an obligation to protect health, which Islam prioritizes.

Recommended SMBG schedule for moderate to high-risk patients:

•        Pre-suhoor (before pre-dawn meal)

•        Post-suhoor (2 hours after pre-dawn meal)

•        Midday (around 3-4 PM when hypoglycemia risk peaks)

•        Pre-iftar (just before sunset)

•        Post-iftar (2 hours after breaking fast)

Bedside Hack #4: Teach the "Rule of 3s" for breaking fast: glucose <60 mg/dL = break immediately; 60-70 mg/dL = recheck in 30 minutes, break if not rising; >250 mg/dL with ketones = break fast and seek care. Simplicity aids compliance. Write these thresholds on the medication card mentioned earlier.

Nutritional Counseling

Partner with registered dietitians experienced in Ramadan care. Key principles:

•        Iftar composition: Start with dates (traditional) and water, then a balanced meal with complex carbohydrates, lean protein, and vegetables. Avoid fried foods and concentrated sweets. The "iftar feast" mentality drives hyperglycemia.

•        Suhoor composition: Low glycemic index foods (oats, whole grains, legumes) sustain glucose levels during fasting. Include protein and healthy fats. Delay suhoor as close to dawn as possible.

•        Hydration: Aggressive hydration between iftar and suhoor (2-3 liters). Avoid caffeine and sugary drinks. Dehydration exacerbates hyperosmolar states and increases thrombotic risk.

•        Nocturnal snacking: Discourage continuous grazing between iftar and suhoor. If needed, one small snack with complex carbohydrates 2-3 hours before sleep.

Clinical Pearl #5: "Reverse dumping syndrome" post-iftar is real. Rapid consumption of high-carbohydrate foods after prolonged fasting causes exaggerated insulin secretion, followed by rebound hypoglycemia 2-3 hours later. Educate patients to eat slowly over 30-45 minutes, not 5 minutes. This simple behavioral modification dramatically reduces post-iftar glucose excursions.

Physical Activity

Exercise counseling during Ramadan requires nuance. Vigorous exercise while fasting increases hypoglycemia and dehydration risk. Recommend light-to-moderate activity (walking, gentle swimming) post-iftar or 1-2 hours after suhoor. Taraweeh prayers—prolonged standing and bowing—provide modest physical activity and should be factored into insulin dosing.

Oyster #4: Patients often lose weight during Ramadan but regain it afterward. The weight loss stems from caloric restriction and altered meal timing, not metabolic advantage. Frame Ramadan as a "metabolic boot camp"—use it to establish healthy eating patterns and portion control that continue post-Ramadan. This mindset shift transforms Ramadan from a temporary disruption to a sustainable lifestyle change.

Special Populations and Clinical Scenarios

Elderly Patients

Elderly individuals face compounded risks: polypharmacy, cognitive decline, impaired hypoglycemia awareness, and reduced thirst perception. Even "well-controlled" elderly patients warrant close monitoring.

Simplify regimens aggressively. Transition complex insulin regimens to once-daily basal insulin plus safer oral agents. Involve caregivers in monitoring and medication administration. Set liberalized glycemic targets (HbA1c 7.5-8.5%) to prioritize safety over tight control.

Bedside Hack #5: Use the "teach-back" method rigorously in elderly patients. After explaining the Ramadan plan, ask them to explain it back to you in their own words. Cognitive screening tools (Mini-Cog, Montreal Cognitive Assessment) help identify patients needing enhanced support. Those scoring poorly should fast only under direct caregiver supervision.

Pregnant and Lactating Women

Pregnancy with diabetes during Ramadan is complex. Islamic law exempts pregnant women from fasting, and medical consensus strongly discourages it due to maternal-fetal risks.16 However, some women fast during early pregnancy before diagnosis or against medical advice.

For those who insist, counsel about fetal growth restriction, preterm labor, and neonatal hypoglycemia. Insulin requirements change unpredictably. Daily monitoring by a maternal-fetal medicine specialist is mandatory. Break fast immediately if glucose <70 mg/dL or >180 mg/dL, or if ketones are detected.

Lactating women need additional calories (450-500 kcal/day) and fluids. Fasting may compromise milk production. Emphasize hydration between iftar and suhoor and monitor infant weight gain.

Chronic Kidney Disease

CKD complicates Ramadan fasting through multiple mechanisms: altered drug metabolism, volume depletion, and electrolyte disturbances. Patients with eGFR >45 ml/min/1.73m² can usually fast safely with adjustments. Below this threshold, individualize carefully.

Metformin is contraindicated below eGFR 30 ml/min/1.73m². Sulfonylureas (except gliclazide) accumulate in renal failure—avoid or reduce doses significantly. SGLT2 inhibitors lose efficacy below eGFR 45 ml/min/1.73m² and increase DKA risk. Prefer DPP-4 inhibitors (dose-adjusted for renal function) and insulin.

Clinical Pearl #6: Dialysis patients who fast face unique challenges. Schedule hemodialysis sessions post-iftar when possible. Avoid excessive fluid removal that worsens dehydration. Peritoneal dialysis patients can continue exchanges but must adjust insulin doses in dextrose-containing dialysate. Multidisciplinary coordination with nephrology is essential.

Cardiovascular Disease

Patients with diabetes and established cardiovascular disease (prior MI, stroke, heart failure) are high-risk for Ramadan complications. Dehydration increases blood viscosity and thrombotic risk. Hypoglycemia can provoke arrhythmias and myocardial ischemia.

Counsel about warning symptoms: chest pain, palpitations, severe dyspnea, dizziness. These mandate immediate fast-breaking and medical evaluation. Continue cardioprotective medications (statins, antiplatelets, ACE inhibitors) without modification. Ensure adequate hydration to mitigate thrombotic risk.

When to Break the Fast: Clear Guidelines

Establishing clear, actionable criteria for breaking fasts prevents ambiguity and patient hesitation. Provide these in written form:

MANDATORY fast-breaking criteria:

•        Blood glucose <70 mg/dL on fingerstick or CGM

•        Blood glucose >300 mg/dL, especially with ketonuria or ketonemia

•        Hypoglycemic symptoms (tremor, sweating, confusion, palpitations) even if glucose appears normal (glucose lag)

•        Any acute illness (fever, vomiting, diarrhea, significant infection)

•        Dehydration symptoms (dizziness, dark urine, decreased urine output)

•        Cardiovascular symptoms (chest pain, severe dyspnea, palpitations)

Bedside Hack #6: Role-play fast-breaking scenarios during the pre-Ramadan visit. Ask: "If your glucose is 65 mg/dL at 2 PM, what do you do?" Patients who can verbalize the correct action ("Break my fast with 15g fast-acting carbohydrate, recheck in 15 minutes") demonstrate understanding. Those who hesitate need more education. This active learning cements knowledge better than passive instruction.

Oyster #5: The "15-15 rule" works during Ramadan too: 15g fast-acting carbohydrate (3-4 glucose tablets, 4oz juice, 1 tablespoon honey), wait 15 minutes, recheck glucose. If still <70 mg/dL, repeat. Once >70 mg/dL and symptoms resolve, consume a snack with complex carbohydrates and protein to prevent recurrence. Breaking a fast for hypoglycemia is not failure—it's wisdom.

Post-Ramadan Transition: The Overlooked Phase

Pre-Ramadan counseling often neglects post-Ramadan management. Eid al-Fitr—the festival marking Ramadan's end—involves celebratory meals and sweets, creating hyperglycemia risk. Abrupt return to pre-Ramadan medication doses without gradual uptitration causes dysglycemia.

Schedule a post-Ramadan follow-up within 1-2 weeks. Review glucose logs, assess HbA1c (if appropriate timing), and adjust medications back to pre-Ramadan regimens or optimize based on Ramadan performance. Some patients maintain better control during Ramadan—leverage this success.

Clinical Pearl #7: Use the "Ramadan report card" approach. During post-Ramadan follow-up, review: days successfully fasted, hypoglycemic episodes, hyperglycemic episodes, ER visits, and subjective well-being. Frame it constructively—not as judgment, but as collaborative data review. Patients who struggled need enhanced support for next year; those who succeeded deserve validation and can potentially attempt fasting with less aggressive monitoring.

Building a Multidisciplinary Ramadan Diabetes Program

Optimal Ramadan diabetes care transcends individual physician consultations. Successful programs integrate:

•        Endocrinologists/diabetologists: Lead clinical decision-making and complex case management

•        Diabetes educators: Provide structured education on monitoring, medication administration, and sick-day rules

•        Dietitians: Develop culturally appropriate meal plans and nutritional counseling

•        Pharmacists: Review medication regimens, identify drug interactions, and reinforce administration instructions

•        Social workers: Address socioeconomic barriers to medication access, monitoring supplies, and dietary recommendations

•        Community health workers: Bridge clinical care with community education, mosque outreach, and culturally concordant support

Bedside Hack #7: Host "Ramadan Preparation Workshops" 4-6 weeks pre-Ramadan. These group sessions—led by the multidisciplinary team—cover risk stratification, medication adjustment, monitoring, nutrition, and patient testimonials. Group dynamics foster peer support and normalize medical precautions. Patients learn from each other's experiences. Offer sessions in multiple languages and provide childcare to maximize accessibility.

Technology and Innovation in Ramadan Diabetes Care

Telemedicine and Remote Monitoring

The COVID-19 pandemic accelerated telemedicine adoption, with sustained benefits for Ramadan care. Virtual check-ins during Ramadan—weekly or biweekly—allow real-time medication titration without requiring clinic visits during fasting hours.

Remote glucose monitoring platforms (e.g., Dexcom Clarity, LibreView) enable clinicians to review CGM data and provide feedback asynchronously. Patients upload glucose logs via smartphone apps, and clinicians adjust regimens through secure messaging.17

Clinical Pearl #8: Establish a "Ramadan hotline"—a dedicated phone number or messaging platform where patients can reach a nurse or physician for urgent questions during fasting hours. Most queries are simple ("My glucose is 75 mg/dL, should I break my fast?") and prevent unnecessary ER visits or dangerous decisions. Triage protocols empower nurses to manage routine issues and escalate complex cases.

Mobile Applications

Specialized Ramadan diabetes apps provide prayer times, iftar/suhoor reminders, medication alerts, and glucose logging. Some integrate with CGM systems for comprehensive tracking. While promising, ensure apps are evidence-based and not commercial marketing tools.

Oyster #6: Gamification in diabetes apps shows emerging utility. Apps that reward consistent glucose monitoring with "badges" or "streaks" leverage behavioral psychology. During Ramadan, when motivation peaks due to religious commitment, gamified elements can reinforce positive behaviors. However, avoid apps that penalize missed targets—guilt and shame undermine adherence.

Cultural Competence: Beyond Clinical Knowledge

Cultural competence is not cultural proficiency—you need not be Muslim to provide excellent Ramadan diabetes care. You must, however, demonstrate respect, curiosity, and humility.

Key principles:

•        Ask, don't assume: Not all Muslims fast identically. Practices vary by sect, culture, and individual interpretation. Ask patients about their specific Ramadan plans.

•        Use appropriate terminology: "Suhoor" (pre-dawn meal), "iftar" (fast-breaking meal), "taraweeh" (evening prayers). Using correct terms signals respect.

•        Acknowledge spiritual significance: Frame discussions around supporting patients' religious goals, not undermining them. "I want to help you fast safely" vs. "You shouldn't fast."

•        Involve family: Ramadan is communal. Engage family members in education—they prepare meals, notice hypoglycemia symptoms, and provide accountability.

•        Recognize diversity: Muslim communities span ethnicities, languages, and cultures. Avoid stereotyping. A Bangladeshi immigrant's Ramadan differs from an Arab-American's.

Bedside Hack #8: Learn a simple Arabic greeting: "Ramadan Mubarak" (Blessed Ramadan) or "Ramadan Kareem" (Generous Ramadan). This small gesture—offered genuinely—builds rapport instantly. Patients feel seen and respected. Non-Muslim clinicians who make this effort often inspire greater trust than Muslim clinicians who appear disinterested in the religious context.

Conclusion

Pre-Ramadan evaluation in diabetes is a complex, multifaceted clinical challenge demanding medical expertise, cultural sensitivity, and individualized care. The stakes are high—hypoglycemia can be life-threatening, yet overly restrictive advice alienates patients and prompts them to fast without medical guidance, paradoxically increasing risk.

The principles outlined here—evidence-based risk stratification, judicious medication adjustment, intensive monitoring, structured patient education, and culturally competent communication—form the foundation of safe Ramadan fasting. However, medicine is art as much as science. Each patient presents unique circumstances requiring clinical judgment, empathy, and flexibility.

Ultimately, our goal is not merely glycemic control but holistic well-being. For many patients, successfully fasting during Ramadan carries profound spiritual meaning, strengthening faith, community connection, and personal discipline. When we help patients fast safely, we honor their values while protecting their health. This synthesis of clinical excellence and cultural respect represents the highest calling of medicine.

Final Pearl: The most important intervention is presence. Be available—before, during, and after Ramadan. Patients who feel supported by their healthcare team are more likely to monitor diligently, adjust medications appropriately, and break fasts when medically necessary. Your commitment to their care validates their effort to balance faith and health. This therapeutic relationship, more than any algorithm or protocol, ensures meaningful and safe fasting.

 

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Conflicts of Interest: The author declares no conflicts of interest related to this manuscript.

Funding: No external funding was received for this work.

Correspondence: For inquiries regarding this review article, please contact the editorial office of the journal.