Introduction

Type 1 diabetes mellitus (T1DM) remains a serious health issue worldwide. The condition arises from autoimmune destruction of pancreatic beta cells, leading to an absolute requirement for exogenous insulin therapy. Ramadan fasting presents both medical challenges and deeply personal spiritual considerations for young Muslim patients with T1DM. Although Islamic teachings provide exemptions from fasting for those with significant health risks, such as T1DM patients, due to the potential for serious adverse effects, especially those with a history of severe hypoglycemia, hypoglycemia unawareness, or poor glycemic control [1, 2], social pressures, the desire for peer inclusion, and spiritual fulfillment often drive many young patients to fast against medical advice [3–5]. Most patients with T1DM attempt to fast during Ramadan every year [1, 2].

Ramadan fasting brings notable physiological changes, particularly in relation to daily biological rhythms and patterns of cortisol release [6, 7], because Ramadan fasting leads to meal timing shifts from daytime to nighttime hours. These changes can disturb the body’s usual metabolic balance so that blood glucose levels may vary considerably, increasing the risk of severe daytime hypoglycemia and post-Iftar hyperglycemia [8, 9]. In high-resource settings, these risks are progressively reduced through the use of modern diabetes technologies such as advanced hybrid closed-loop (AHCL) systems and continuous glucose monitoring (CGM), which enable real-time alerts and automated insulin modifications [10, 11]. However, a substantial gap exists in low-resource settings (LRS), where accessibility to such technologies and new insulin analogs is severely limited [12, 13].

In several LRS environments, diabetes management relies mainly on conventional human insulin and inconsistent self-monitoring of blood glucose (SMBG) [12, 14]. Limited access to reliable equipment and supplies increases vulnerability to acute adverse effects such as severe hypoglycemia and diabetic ketoacidosis (DKA) [15]. Current international guidelines provide general guidance on fasting and diabetes. However, the guidelines often do not offer detailed, specific, and practical protocols for clinicians working without advanced technology, leaving a gap in the standard of care for Muslim patients in developing countries [16, 17]. Recent research suggests that in such settings, structured education before Ramadan and individualized risk stratification become the most critical pillars of safety [18–20].

Furthermore, new innovations such as artificial intelligence (AI)-driven decision support and culturally tailored digital health applications are beginning to offer low-cost solutions to fill this gap in care [21–23]. However, there is still a need for clinical evidence showing that stable metabolic outcomes can be achieved in LRS through conventional management intensified by structured education.

Therefore, this study was designed to examine changes in metabolic control and insulin modifications during Ramadan fasting among young Muslims with T1DM in a low-resource setting in Surabaya, Indonesia. The analysis focused on assessing fasting blood glucose (FBG) trends, alterations in insulin dosing, and the incidence of acute complications throughout the fasting period. The objective was to establish a practical framework for safe fasting management that may also be relevant for other resource-limited settings. We hypothesize that a combination of proactive insulin titration and comprehensive patient education can help preserve glycemic stability and reduce adverse events, even in the absence of advanced diabetes technology.

Material and methods

Results

The study enrolled 25 pediatric patients with T1DM, consisting of children and adolescents with an average age of 14.4 ±1.9 years. Their mean BMI was 19.3 ±2.8 kg/m². The cohort was predominantly female (80%), and more than half (52%) had been diagnosed with T1DM for 1–5 years. Regarding treatment patterns, insulin detemir was the most common basal insulin used (60%), while insulin aspart was the primary bolus insulin choice (76%) with dosing based on carbohydrate counting and insulin sensitivity factors. Patients were instructed to have heavy meals during Iftar. Notably, nearly all patients (96%) had received structured counseling before Ramadan, indicating a high level of exposure to pre-fasting education. Comprehensive baseline characteristics are presented in Table I.

The average HbA_1c was 10.2 ± 2.3%, reflecting suboptimal long-term glycemic control. However, longitudinal analysis of FBG demonstrated a stable trend despite the fasting intervention. The mean FBG showed a slight decrease from 202.9 ±49.9 mg/dl before Ramadan to 193.4 ±47.6 mg/dl during the fasting month, then increased again to 206.9 ± 50.8 mg/dl in the post-Ramadan period (Table II). Statistical analysis through paired comparisons confirmed that these fluctuations were not significant (p > 0.05 for all time points), suggesting that glucose levels were generally maintained without meaningful variation throughout Ramadan (Table III).

The transition to a fasting schedule was managed through conservative insulin dose modifications. The mean TDD was adjusted from 0.84 ±0.18 U/kg/day to 0.80 ±0.19 U/kg/day (p = 0.62), representing a total reduction of approximately 5%. This adjustment was mostly caused by a 6.79% reduction in basal insulin. The basal and bolus insulin relative proportions remained stable during Ramadan, with basal insulin accounting for 51.2 ±10.6% of the TDD. Further analysis did not demonstrate any meaningful relationship between FBG levels and the insulin modification approach, patient age, or T1DM duration.

Safety outcomes showed a favorable shift during the fasting period compared to the participants’ clinical history. The incidence of hypoglycemia declined from a pre-Ramadan rate of 28% (n = 7) to 12% (n = 3) during the fasting month. Most notably, the 16% (n = 4) history of DKA recorded in the three months before the study was completely mitigated, with zero DKA events (0%) reported during Ramadan. All reported hypoglycemic episodes during fasting were mild and successfully handled by the participants or their caregivers without the need for emergency medical intervention or hospitalization.

Discussion

In Ramadan lifestyle changes, behavioral and physiological changes occur; treatment modification and potential complications should be considered [24]. These study results provide critical information about the metabolic stability and safety of Ramadan fasting among young Muslims with T1DM in an LRS. The results of this study indicate that Ramadan fasting can be both practical and safe for young Muslims with T1DM when it is accompanied by comprehensive education and personalized adjustments to insulin therapy. Despite the high baseline HbA_1c (10.22%), the participants maintained stable FBG levels throughout the holy month, with a significant reduction in acute complications compared to their pre-Ramadan clinical history. This stability is particularly meaningful considering the physiological challenges of fasting and socioeconomic constraints commonly encountered in LRS.

Increased glycemic variability can be a challenge for patients with diabetes who fast during Ramadan [25]. This condition presents a unique physiological challenge that involves more than a simple reduction in calorie intake. The abrupt shift to a nocturnal lifestyle, characterized by late-night “feasting” and predawn meals, significantly disturbs the circadian rhythm and the natural release patterns of cortisol [6, 7]. Such disruptions may affect insulin sensitivity and metabolic flexibility. In our study, the stability of FBG levels suggests a successful adaptation to these shifts. However, global literature warns that the high-fat and high-carbohydrate food intake during Iftar often leads to prolonged postprandial hyperglycemia, which can be underestimated by patients [7, 26].

Furthermore, temporary changes in eating schedules and caloric intake during Ramadan may influence metabolic regulation more broadly. In our study, FBG values increased again after Ramadan (206.90 mg/dl). This rise may be associated with the challenges of readjusting to regular circadian rhythms and dietary patterns [26, 27].

In LRS, decisions regarding insulin therapy are frequently influenced by affordability rather than ideal guidelines. While international guidelines, such as the International Society for Pediatric and Adolescent Diabetes 2022 LRS consensus, encourage the use of long-acting and rapid-acting insulin analogs to reduce hypoglycemia risk, many families in LRS still rely on conventional human insulin (neutral protamine Hagedorn and regular) due to cost constraints [12, 14]. Our study participants, primarily using regimens such as insulin detemir and aspart, achieved a 5% reduction in TDD, which was sufficient to prevent daytime hypoglycemia without precipitating DKA. Initially, children and adolescents with T1DM in our study typically undergo insulin modifications before Ramadan, which initially include a 20% reduction in the total daily insulin dose. However, during monitoring, episodes of hyperglycemia were observed at the time of breaking the fast, prompting further refinement of the insulin regimen. In our study, insulin modifications were performed individually for each patient, based on their insulin sensitivity factor and insulin-to-carbohydrate ratio. These modifications were carried out under the supervision of a pediatric endocrinologist.

This practical approach for adjusting insulin dose is supported by evidence suggesting that even without advanced technology, meticulous dose modifications (often a 10–30% reduction in basal insulin) can ensure patient safety [28]. The ongoing HumAn-1 clinical trial in Bangladesh and Tanzania is currently addressing this very dilemma, evaluating whether the clinical benefits of expensive insulin analogs truly outweigh the cost-effectiveness of human insulin in similar LRS contexts [13].

A major theme in recent literature (2024–2025) is the expanding gap between high-resource and low-resource diabetes care. In high-income countries, technologies such as CGM, flash glucose monitoring, and AHCL systems have revolutionized fasting safety by revealing asymptomatic hypoglycemia [10, 29]. Systems such as AHCL with “low-glucose suspend” features significantly increase the “time in target range” for adolescents [11]. However, in our setting, such technologies remain a luxury. Our results demonstrate that structured education can serve as a potent “low-tech” substitute for these advanced systems. In the absence of CGM, the use of conventional glucose logbooks and empowered SMBG remains the cornerstone of care [30]. To help address these disparities, digital health innovations such as the Okuma app in Nigeria or AI-driven platforms such as ChatGPT in Saudi Arabia are being introduced as more cost-effective tools to enhance patient self-management and education [21, 22].

The fact that no case of DKA occurred in this research highlights the importance of thorough preparation, such as structured pre-Ramadan education before Ramadan begins. The Carbohydrate, Insulin, Collaborative Education and Diabetes Education and Medication Adjustment in Ramadan programs have shown that when patients and families are taught to manage carbohydrates and are able to identify early warning signs, the likelihood of serious adverse events can be drastically minimized [20, 30]. Education must address common misconceptions, such as the belief that finger-prick testing breaks the fast, which may lead patients to avoid regular monitoring and compromise safe diabetes management [2, 15].

In LRS, the role of the multidisciplinary team is expanded to include non-specialist health workers and community pharmacists. In environments where endocrinologists are limited, non-specialist providers frequently take on a larger role in guiding insulin modifications and patient counseling. Furthermore, the spiritual and psychological support of the patient’s family is crucial. Adolescents often fast to satisfy spiritual goals or to avoid feeling socially excluded, and without family support, they may resort to hiding their fasting practices or adjusting insulin doses without supervision, which can increase the precipitating complications [3, 5].

Severe hypoglycemia is a major challenge for patients with T1DM who fast during Ramadan, with an increasing number of severe hypoglycemia events per month up to 5 times. The reduction in hypoglycemia from 28% to 12% in our cohort is consistent with the preventive risk assessment strategy promoted by the International Diabetes Federation–Diabetes and Ramadan practical guidelines [4, 18, 19]. Identifying high-risk individuals before Ramadan – those with a history of DKA or poor glycemic control – is an ethical mandate for healthcare providers [8, 9]. While we observed safety even in a group with high HbA_1c, this should not lead to overconfidence. Instead, it highlights that intensive monitoring under close supervision can protect even vulnerable patients. Broader metabolic considerations, such as changes in lipid profiles and liver function due to the high-fat Iftar diet, should also be monitored [26, 27].

The future of Ramadan management in LRS lies in the integration of AI and machine learning to predict complication risks based on minimal clinical data [23]. Such innovations could expand access to structured risk assessment, for primary care physicians who may not have advanced diabetes training [16, 17]. Moreover, strengthening collaboration between clinicians and religious authorities can ensure that the message of “safety first” is religiously validated [1, 2].

Conclusions

Ramadan is a period of challenging glycemic control. This study demonstrates that Ramadan fasting in young Muslims with T1DM in LRS is achievable and safe when managed through a comprehensive, education-centered approach. The success of our participants, despite technological limitations, emphasizes that personalized insulin modifications and patient empowerment are the most critical factors in ensuring a safe religious observance. As we move toward 2026 and beyond, the focus must remain on bridging the healthcare disparity through innovative, low-cost solutions and culturally sensitive clinical guidelines. Treatment plans, including insulin regimen dose and timing, should be optimized well in advance of Ramadan to reduce risk and redistribute bolus doses to coincide with Iftar and Suhoor meals. Nutritional advice should emphasize complex carbohydrates, high fiber intake, and adequate hydration during non-fasting hours to minimize glucose excursions.