{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T05:16:21Z","timestamp":1788498981136,"version":"build-2803163510"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T00:00:00Z","timestamp":1788480000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Endocrinol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Pump basal-rate reduction during Ramadan may prevent hypoglycemia but can increase hyperglycemia. Its dose-response relation and phenotype-dependent trade-off remain uncertain.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Thirty UVA\/Padova virtual patients (10 children, 10 adolescents, 10 adults) underwent paired 30-day Ramadan conditions delivering 100%, 90%, 80%, 70%, or 60% of the pump steady-state basal rate. The primary complete-case analysis included 29 virtual patients. Outcomes were time in range (TIR), time below range (TBR), time above range (TAR, including TAR\n                      <jats:italic>&amp;gt;<\/jats:italic>\n                      250 and TAR\n                      <jats:italic>&amp;gt;<\/jats:italic>\n                      300), and rescue corrections. Paired permutation tests and bootstrap intervals quantified effects. Robustness and revision analyses used three sensor seeds, three seeded meal\/timing scenarios with a held-out evaluation, a reactive-correction sensitivity analysis, a time-of-day decomposition, terminal-event reporting, and a negative-control (sham) test of the pre-Ramadan marker.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Mean TIR was 81.7%, 79.9%, 73.9%, 65.3%, and 56.0% at 100%, 90%, 80%, 70%, and 60%, respectively (\n                      <jats:italic>P &amp;lt;<\/jats:italic>\n                      0.001). Compared with 100%, 90% basal reduced TBR by 1.6 percentage points (95% CI \u22122.1 to \u22121.2) while changing TIR by \u22121.8 points (95% CI \u22123.7 to \u22120.3; Holm-adjusted\n                      <jats:italic>P<\/jats:italic>\n                      =\u00a00.031). Severe hyperglycemia rose steeply with deeper reduction (TAR\n                      <jats:italic>&amp;gt;<\/jats:italic>\n                      250: 2.9% at 100% to 14.8% at 60%). Enabling realistic reactive corrections raised TIR at the deepest policies but preserved the same policy ordering. Pre-Ramadan TBR stratified the TIR response across reduced policies (omnibus patient-blocked permutation\n                      <jats:italic>P<\/jats:italic>\n                      =\u00a00.023), with the strongest gradients at 70% and 60% basal; a negative-control analysis showed this signal was not specific to TBR but reflected a broader baseline-glycemia pattern. In a held-out scenario, a revised safety-first selection rule improved hypoglycemia-target attainment (39% to 79%) and reduced TBR by 2.9 points but incurred a 5.2-point TIR cost, demonstrating that prioritizing fasting safety involves a glycemic trade-off.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>Ramadan pump basal-rate reduction should be treated not as a uniform percentage change but as a phenotype- and context-dependent trade-off. Among the reduced policies, 90% basal produced the smallest TIR loss while lowering hypoglycemia; pre-Ramadan TBR was an exploratory candidate stratifier; and meal-size associations differed by policy. These mechanistic findings apply to simulated pump basal-rate modulation and require prospective, CGM-anchored validation before any clinical use.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fendo.2026.1922149","type":"journal-article","created":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T04:26:51Z","timestamp":1788496011000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Pre-Ramadan time-below-range stratifies the simulated pump basal-rate dose\u2013response during Ramadan fasting: a five-policy paired virtual-patient study"],"prefix":"10.3389","volume":"17","author":[{"given":"Ameen","family":"Banjar","sequence":"first","affiliation":[{"name":"Department of Information Systems and Technology, College of Computer Science and Engineering, University of Jeddah","place":["Jeddah, Saudi 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