We thank Elhadd and Al-Amoudi (1) for their comments and interest in our article (2). Like them, we are also concerned by the very high rate of severe hypoglycemia and hyperglycemia in patients with diabetes who fast during Ramadan. We agree with them that patients with renal disease may have increased risk of hypoglycemia and that adolescent patients with poor glycemic control or recurrent hypoglycemia may also represent high-risk patients for developing hypoglycemia during fasting.

We thank Davidson (3) for his remarks. Our intent in recommending the addition of complex carbohydrates to a mixed meal at predawn was to keep a sustained increase in the appearance of glucose in the circulation to avoid hypoglycemia. We agree that initiation of hydrolysis of carbohydrates and the rate of appearance and the level of glucose soon after ingestion of simple or complex carbohydrates are fairly similar (4,5). However, these studies suggest that following the ingestion of complex carbohydrates, the day-long glucose concentrations (4) and the area under the curve for glucose (5) are larger for complex carbohydrates. Similar to these findings, Wolsdorf et al. (6) found that ingested uncooked starch behaves as a reservoir for continuous release of glucose compared with the absorption of ingested dextrose that occurs over a shorter period of time. Finally, and most importantly, ingestion of simple carbohydrates in the absence of additional protein or fat at Ifatr (the breaking of the fast) enables rapid absorption of glucose when blood glucose levels are apt to be at their nadir, levels that could explain the relatively higher rates of hypoglycemia in the pre-Iftar period (7).

1.
Elhadd TA, Al-Amoudi AA: Recommendations for management of diabetes during Ramadan (Letter).
Diabetes Care
29
:
744
-745, 2006
2.
Al-Arouj M, Bougeurra R, Buse J, Hafez S, Hassanein M, Ibrahim MA, Ismail-Beigi F, El-Kebbi I, Khatib O, Kishawi S, Al-Madani A, Mishal AA, Al-Maskari M, Nakhi AB, Al-Rubean K: Recommendations for management of diabetes during Ramadan.
Diabetes Care
28
:
2305
–2311,
2005
3.
Davidson MB: Recommendations for management of diabetes during Ramadan (Letter).
Diabetes Care
29
:
745
,
2006
4.
Hollenbeck CB, Coulston AM, Donner CC, Williams RA, Reaven GM: The effects of variations in percent of naturally occurring complex and simple carbohydrates on plasma glucose and insulin response in individuals with non-insulin-dependent diabetes mellitus.
Diabetes
34
:
151
–155,
1985
5.
Wahlqvist ML, Wilmshurst EG, Richardson EN: The effect of chain length on glucose absorption and the related metabolic response.
Am J Clin Nutr
31
:
1998
–2001,
1978
6.
Wolfsdorf JI, Plotkin RA, Laffel LM, Crigler JF Jr: Continuous glucose for treatment of patients with type 1 glycogen storage disease: comparison of the effects of dextrose and uncooked starch on biochemical variables.
Am J Clin Nutr
52
:
1043
–1050,
1990
7.
Akram J, De Verga V, the Ramadan Study Group: Insulin lispro (Lys(B28), Pro(B29)) in the treatment of diabetes during the fasting month of Ramadan.
Diabet Med
16
:
861
–866,
1999