Evolution of the risk concept and assessment tools for diabetes during Ramadan fasting: A narrative review

Abstract

BACKGROUND

The categorization and assessment of diabetes-related risks during Ramadan have evolved significantly over three decades. Research interest in the health effects of fasting has grown significantly, with diabetes emerging as the most extensively studied condition.

AIM

To explore the historical development of risk stratification approaches for Ramadan fasting in people with diabetes, culminating in the 2021 International Diabetes Federation-Diabetes and Ramadan (IDF-DAR) risk assessment tool. We also evaluated the evidence for its validation and real-world utility.

METHODS

The PubMed and Google Scholar databases were searched using the term “Diabetes AND Ramadan AND Risk Assessment”. Eligible studies included full-text articles on risk stratification concept and tools for diabetes during Ramadan. Selected studies were reviewed and synthesized thematically.

RESULTS

Risk categorization began with a dichotomy and tripartite models and progressed to a four-tier narrative scale. In 2021, the IDF-DAR tool introduced a point-based system with three risk categories. Validation studies across diverse populations demonstrated strong predictive value, though moderate inter-clinician variability and potential overestimation in type 2 diabetes cases were noted.

CONCLUSION

The IDF-DAR risk stratification tool significantly advances individualized diabetes care during Ramadan. Its conservative bias in some populations and variability in physician scoring suggests the need for standardized training.

Key Words: Diabetes; Ramadan; Risk stratification; International diabetes federation-diabetes and Ramadan; Hypoglycemia; Hyperglycemia; Diabetic ketoacidosis

Core Tip: Risk assessment is a core value in the management of Muslims with diabetes during Ramadan fasting. The International Diabetes Federation-Diabetes and Ramadan risk stratification tool significantly advances individualized diabetes care during Ramadan. While generally effective, its conservative bias in certain populations and variability in physician scoring suggests the need for standardized training and further research.

INTRODUCTION

Adult Muslims worldwide observe Ramadan fasting (RF), which involves abstaining from food, water, oral medications, intravenous fluids, and smoking from dawn to sunset during the ninth lunar month of the Islamic calendar[1]. The physiological impact of RF includes prolonged fasting hours, changes in meal patterns, and alterations in circadian rhythm, which collectively influence health and disease patterns[1].

Islam is the world’s second-largest religion, representing approximately one-third of the global population[2]. There are about 2.0 billion Muslims. Although Muslims can be found all over the world, the majority live in northern and central Africa, the Middle East, and Southeast Asia. Many adult Muslims (80%-97%) observe fasting[3]. The prevalence of diabetes is rising globally, and Muslim-majority countries are experiencing a particularly sharp increase[4]. The physiology of fasting in people with diabetes varies with the type of diabetes. During the early stages of type 2 diabetes (T2D), adopting a fasting or extremely low-calorie diet, or practicing controlled fasting with slight weight loss, can lead to positive outcomes for the underlying pathophysiological factors of insulin resistance and adiposity, ultimately resulting in the normalization of blood sugar levels[4,5]. Nonetheless, in the absence of exogenous insulin, there is a theoretical possibility of significant hyperglycemia and clinically relevant ketogenesis in individuals with advanced T2D and those with type 1 diabetes (T1D)[4,5].

Over the last three decades, research interest in the health effects of RF has significantly increased, with diabetes emerging as the most extensively studied condition. A convergence between medical and religious perspectives on diabetes management during Ramadan has emerged, promoting more unified patient guidance[6]. In parallel, many professional societies and groups of experts have developed clinical practice guidelines to help manage diabetes safely during Ramadan[7-15]. Recent research interests have focused on epidemiology, therapeutic advancements, and the integration of diabetes technologies[16].

A consistent feature across these guidelines is the emphasis on individual risk assessment for patients with diabetes who intend to fast. Initially, risk assessment approaches were simplistic. Over time, these evolved into more nuanced systems.

This review aims to: (1) trace the evolution of risk concepts and assessment tools for people with diabetes fasting during Ramadan; (2) describe the components and scoring methodology of the International Diabetes Federation-Diabetes and Ramadan (IDF-DAR) risk assessment tool; and (3) summarize and critically appraise the published validation studies to date.

MATERIALS AND METHODS

This review follows a narrative, non-systematic approach informally guided by PRISMA guidelines to synthesize the evolution of risk assessment in people with diabetes intending to fast during Ramadan.

Research questions

What are the recognized and debated complications of RF in individuals with diabetes? How has the concept of risk assessment evolved in this context? What are the design and features of the 2021 IDF-DAR risk stratification tool? How valid and useful is the IDF-DAR tool across diverse settings and populations?

Search strategy and data sources

A literature search was conducted using PubMed and Google Scholar. The primary search term was: "Diabetes AND Ramadan AND Risk Assessment". No time filters were applied. The last search was completed in May 2025. A total of 52 records were identified. Reference lists from key articles were also manually reviewed for relevant articles.

Inclusion and exclusion criteria

English full-text articles on risk assessment tools for diabetes and Ramadan were included. Abstracts only, editorials, non-English papers, and non-diabetes-related Ramadan studies were excluded.

Data extraction and synthesis

Articles were screened and organized according to the research questions. No formal bias assessment was performed. Thematic synthesis was used. The narrative approach was used due to the wide scope of the research questions and different type of research work identified. A total of 13 validation and utilization studies were identified and included in the narration.

RESULTS

Complications of RF in people with diabetes

Fasting during Ramadan poses multiple challenges for people with diabetes, particularly due to prolonged fasting hours, changes in meal timing, and limited fluid intake. Despite these risks, many fast[17]. Several studies have shown that patients using insulin or sulphonylureas have a higher risk of hypoglycemia during RF compared to those taking newer drugs, such as SGLT2 inhibitors, DPP4 inhibitors, and GLP-1RAs[4,5,18-20]. The most commonly reported complications include hypoglycemia and hyperglycemia, both of which may become more frequent during fasting. In hot and humid climates, prolonged fasting can lead to dehydration, further complicating glycemic control. Table 1 outlines recognized and hypothetical complications, some of which remain debated or poorly quantified in clinical studies.

Table 1 The classically reiterated potential complications (confirmed, disputed and hypothetical) of Ramadan fasting in people with diabetes.

Type	Potential complication	Status	Notes
Glycemic	Hypoglycemia	Well-documented	Especially in insulin or sulfonylurea users
Glycemic	Hyperglycemia	Well-documented	May result from feasting and reduced medication adherence
Fluid/electrolyte	Dehydration	Documented	Worsened by hot climates and prolonged fasting hours
Vascular	Thrombosis (complication of dehydration)	Disputed	Suggested link via hemo-concentration, not firmly established
Reproductive	Risk to pregnancy and fetus	Well-acknowledged	Particularly in uncontrolled diabetes or comorbid pregnancies
Metabolic	Diabetic ketoacidosis and hyperosmolar hyperglycemic states	Mixed evidence	Earlier studies reported risk; recent data show inconsistent patterns
Trauma-related	Accidents due to hypoglycemia	Hypothetical	Mostly anecdotal; underreported in clinical trials
Long-term glycemic control	Complacency’s impact on year-round diabetes management	Hypothetical	Proposed risk due to temporary dietary changes and relaxed self-monitoring

Studies provide mixed findings regarding the incidence of complications. For example, the DAR-MENA T1D study found that nearly half of the participants fasted the full month, with hypoglycemia rates comparable to pre-Ramadan levels[18]. Conversely, in the DAR-MENA T2D study, the hypoglycemia rate rose significantly during Ramadan (10.4% vs 4.9%)[19]. Similarly, the seminal EPIDIAR study documented a fivefold increase in hyperglycemia in people with T2D during Ramadan[20], while Ahmedani et al[21] reported symptomatic hyperglycemia in 33.3% (T1D) and 15.4% (T2D).

Importantly, these risks appear most pronounced in individuals with T1D. A global survey of 1054 patients with T1D reported that, although 27% were able to fast throughout Ramadan, 60% experienced hypoglycemia, and 45% experienced hyperglycemia, with 7% requiring hospitalization[22].

Regarding diabetic ketoacidosis (DKA), earlier literature suggested increased incidence during Ramadan. However, more recent literature challenged this assumption, finding no consistent evidence linking fasting with higher DKA rates.

In summary, although complications are not universal, they occur with sufficient frequency - especially in high-risk groups. Physicians should be cognizant of the various risk factors that may put patients at a high risk and thus enabling a careful individualized risk assessment (Table 2).

Table 2 Factors contributing to risk of complications during Ramadan fasting.

Category	Contributing factors
Ramadan-specific	Length of fasting hours1. Season and climate (temperature/humidity). Geographic location
Diabetes-specific	Type of diabetes (T1D > T2D risk). Duration of diabetes. Level of control (tight or poor)2. Presence of complications. Type of therapy (e.g., insulin, sulfonylureas)3. Proneness to hypoglycemia. Hypoglycemia unawareness
Individual and social-related	Age (higher risk in adolescents and elderly). Sex. Occupation (e.g., physical labor). Pregnancy/Lactation. Frailty/cognitive impairment. Motivation and cultural beliefs. Access to care and self-monitoring tools. Family and social support. Prior fasting experience

¹Duration of fasting is between dawn and sunset, which is dependent on the location and time of year.

²Both poor control (e.g., HbA1c > 9%) and very tight control increase fasting-related risks.

³Hypoglycemia during Ramadan fasting in those receiving insulins and sulphonylureas in general than in more modern medications such as SGLT2 inhibitors, DDP4 inhibitors and GLP-1 RA.

T1D: Type 1 diabetes; T2D: Type 2 diabetes.

Evolution of the risk assessment concept and tools

The approach to assessing risk in people with diabetes during Ramadan has been significantly transformed. Initially, risk classification relied heavily on general advisories that discouraged fasting altogether for people with diabetes. Over time, a more individualized framework emerged, grounded in clinical evidence and contextual judgment (Table 3). A pivotal moment occurred in 1988, when a tripartite model was introduced, categorizing patients into "absolute contraindication", "relative contraindication", or "fasting allowed", using medicalized terminology to guide decisions[7-11]. In the 2000s, a more nuanced narrative risk assessment model developed, classifying patients into four tiers: Low, moderate, high, and very high risk. This model gained traction in various international guidelines between 2005 and 2017[12-14]. The most recent shift occurred in 2021, with the launch of the IDF-DAR Risk Assessment Tool, Hassanein et al[14] lead the development of IDF-DAR tool on behalf of the IDF-DAR group by converting the previously published narrative scale. This tool uses a numerical scoring system to categorize patients into three risk groups: Low, moderate, or high. This calculator-based approach significantly evolved from prior qualitative models, offering greater objectivity and clinical usability. This paradigm reflects a broader shift in diabetes care during Ramadan, prioritizing personalized evaluation, education, and dynamic treatment strategies over blanket prohibitions[15].

Table 3 Evolution of the concept of risk assessment in diabetes and Ramadan fasting.

Phase	Timeframe	Approach	Representative sources
Dichotomy model Pre-	1988	Medical interpretations for religious commentaries “Fatwas”: To fast or not to fast	Anecdotal medical translations of the general religious guidance: Fasting allowed vs not allowed from first safety principles
Medical model	1988-2002	Tripartite clinical categorization: Fasting allowed, relative/absolute contraindications	Sulimani et al[7], 1988; Kadiki et al[8], 1989
Narrative risk assessment	2005-2020	Risk tiers: Low, moderate, high, very high; qualitative criteria	Al-Arouj et al[13], 2005; Hassanein et al[14], 2017
Quantitative risk assessment	2021-present	Calculator-based, point system with numeric thresholds and three categories	IDF-DAR Risk Assessment Tool Hassanein et al[15], 2022
Validation	2021-2025	Multi-country evaluation and real-world utility testing of the IDF-DAR tool	Studies from Bahrain, Saudi Arabia, United Arab Emirates, Bangladesh, Oman, Sudan

IDF-DAR: International diabetes federation-diabetes and Ramadan.

The IDF-DAR risk stratification tool

The IDF-DAR tool was developed to standardize pre-Ramadan risk assessment based on clinical and demographic variables influencing fasting safety[15]. It assigns weighted scores to factors such as diabetes type, duration, glycemic control (HbA1c), history of hypoglycemia or DKA, renal function, macrovascular disease, cognitive status, treatment regimen, pregnancy, frailty, and past fasting experiences (Table 4). A patient’s total score corresponds to a risk category: Low (0-3 points), moderate (3.5-6 points), and high (> 6 points) (Table 4). Physicians are advised to discourage fasting in patients in the moderate- and high-risk categories, although shared decision-making remains essential, as many still choose to fast despite the risks. The tool is designed to support patient education and individualized treatment planning, and it should be re-applied annually to reflect changes in clinical status.

Table 4 The International Diabetes Federation-Diabetes and Ramadan risk assessment tool (2021) for people with diabetes intending to fast during Ramadan.

International Diabetes Federation-Diabetes and Ramadan risk assessment tool
Section A: Narrative risk factors and numerical risk scores
Risk element	Score
(1) Diabetes type
T1D	1
T2D	0
(2) Diabetes duration
≥ 10 years	1
< 10 years	0
(3) Hypoglycemia
Hypoglycemia unawareness	6.5
Recent severe hypoglycemia	5.5
Multiple weekly hypoglycemia	3.5
Hypoglycemia less than 1 time per week	1
No hypoglycemia	0
(4) HbA1c
> 9% (11.7 mmol/L)	2
7.5%-9% (9.4–11.7 mmol/L)	1
< 7.5% (9.4 mmol/L)	0
(5) Type of treatment
Multiple daily mixed insulin injections	3
Basal bolus/insulin pump	2.5
Once daily, mixed insulin	2
Basal insulin	1.5
Glibenclamide	1
Gliclazide/MR or glimepride or repeglanide	0.5
Other therapies, excluding sulfonylureas or insulin	0
(6) Self-monitoring of blood glucose
Indicated but not conducted	2
Indicated but conducted suboptimally	1
Conducted as indicated	0
(7) Acute complications
DKA/HHS in the last 3 months	3
DKA/HHS in the last 6 months	2
DKA/HHS in the last 12 months	1
No DKA/HHS	0
(8) MVD
Unstable MVD	6.5
Stable MVD	2
No MVD	0
(9) Renal function status
eGFR < 30 mL/min	6.5
eGFR 30-45 mL/min	4
eGFR 45-60 mL/min	2
eGFR > 60 mL/min	0
(10) Pregnancy
Pregnant not within targets	6.5
Pregnant within targets	3.5
Not pregnant	0
(11) Frailty and cognitive function
Impaired cognitive function or frail	6.5
> 70 years old with no home support	3.5
No frailty or loss in cognitive function	0
(12) Physical labor
Highly intense	4
Moderate intense	2
None	0
(13) Previous Ramadan experience
Overall negative experience	1
No negative or positive experience	0
(14) Fasting hours
≥ 16 hours	1
< 16 hours	0
Section B: Sum of risk scores and their corresponding categories
Score 0-3	Low risk
Score 3.5-6	Moderate risk
Score > 6	High risk

DKA: Diabetic ketoacidosis; HbA1c: Glycosylated hemoglobin; HHS: Hyperglycemic hyperosmolar states; eGFR: Estimated glomerular filtration rate; MVD: Macrovascular disease.

Validation and utility of the IDF-DAR tool

Several studies have assessed the validity, reliability, and clinical utility of the IDF-DAR tool in diverse settings. These studies consistently support the predictive power of the tool, although they also reveal some limitations, particularly in classification sensitivity and physician application. The characteristics, key outcomes, and conclusions of these studies are summarized in Table 5 and briefly discussed below.

Table 5 Summary of validation and utilization studies of the International Diabetes Federation-Diabetes and Ramadan risk assessment tool.

Ref.	Population	Study design	Key outcomes	Conclusions
Afandi et al[23] (2023) (International)	312 physicians; 26 risk scenarios	Survey-based assessment	Wide variation in moderate-risk classification; accuracy 33%-85%	Need for standardized training in tool application
Mohammed et al[24] (2021); (Multisite)	659 patients (91.5% T2D) (M: 52.1%, F: 47.9%; mean age: 53.5 years)	Prospective, pre-/post-Ramadan	Higher risk scores correlated with fasting non-adherence and more hypoglycemia/hyperglycemia	Tool reliably predicts fasting capability and risk level
Noor et al[25] (2023) (Sudan)	300 patients (79% T2D)	Cross-sectional, hospital-based	Most classified as high-risk; age significant predictor	The tool is effective, but demographic context matters
Kamrul-Hasan et al[26] (2023) (Bangladesh)	1,328 adults with T2D (M: 38.9, F 61.1%; mean age 511 years)	Prospective, peri-Ramadan	Low complication rates; 71% fasted despite high-risk classification	The tool may overestimate risk in some T2D populations
Shamsi et al[27] (2024) (Bahrain)	611 patients (95.3% T2D) (M: 40.2%; F: 52.8%; mean age: 59.8 years)	Prospective	Hypoglycemia was the leading reason for breaking fast	Supports the tool's predictive validity
Malik et al[28] (2024) (Pakistan)	144 high-risk patients (M: 174, F: 286)	Observational	57.9% experienced hypoglycemia despite counselling	The tool correctly flags individuals who need enhanced monitoring
Alfadhli et al[29] (2024) (Saudi Arabia)	466 patients (M: 196, F: 270; mean age: 55.4 years)	Observational	56.9% were high-risk; > 50% fasted anyway	The tool helps guide decision-making but must be balanced with patient autonomy
Baynouna Alketbi et al[30] (2025)	435 United Arab Emirates patients (246 M, 189 F; 66.6% > 50 years; 16.1% > 70 years	Validation study	High-risk linked to age, frailty, adverse events	Tool effective across primary care settings
Almalki et al[31] (2025) (Saudi Arabia)	303 patients (163 F; mean age: 50.5 years)	Cross-sectional	Hyperglycemia is more frequent in high-risk group; best adherence in moderate-risk group	The tool may be conservative in some subgroups
Reesi et al[32] (2025) (Oman)	326 Patients (M: 157, F:169; mean age: 45.7 years)	Multicenter observational	T1D patients had more complications and DKA episodes	Reinforces tool’s validity and risk-based decision-making, especially in high-risk groups
Khorasani et al[33] (2024) (Iran)	317 Patients with Diabetes in Iran (M: 108, F: 209; mean age: 58.9 years)	Single center observational	Patients were stratified according to the three IDF-DAR risk groups. Majority of the patients fell into the low and moderate risk categories	Majority should not be entirely exempted from RF. However, the validity evaluated through prospective longitudinal studies
Oueslati et al[34] (2025) (Tunisia)	140 patients with/without pre-Ramadan education. (M: 54, F: 86; mean age 56 years)	Intervention study	Pre-Ramadan education-improved lifestyle monitoring; metabolic event reduction not significant	The tool adds value as preventive guidance rather than a corrective measure

DKA: Diabetic ketoacidosis; T1D: Type 1 diabetes; T2D: Type 2 diabetes; IDF-DAR: International Diabetes Federation-Diabetes And Ramadan; M: Male; F: Female.

The studies used different designs and approaches. For instance, Afandi et al[23] explored clinician consistency using 26 scenarios scored by 312 specialists. Results showed moderate agreement overall, with significant discrepancies in moderate-risk cases, suggesting the need for training and calibration in tool application. Several other studies used real patients with variable outcome measures. For example, Mohammed et al[24] evaluated 659 patients and found strong correlations between higher risk scores and adverse outcomes (e.g., hypoglycemia and hyperglycemia), affirming the predictive validity of the tool. Noor et al[25] (Sudan) and Kamrul-Hasan et al[26] (Bangladesh) found that while the tool correctly flagged high-risk individuals, it may be conservative in classifying T2D patients, potentially leading to over-cautious recommendations. More recently, Shamsi et al[27] (Bahrain) and Malik et al[28] (Pakistan) confirmed that hypoglycemia was the primary cause of fasting interruption and that high-risk classification aligned with complication rates. Also, Alfadhli et al[29] (Saudi Arabia) observed that more than half of high-risk patients fasted despite the risk, highlighting the need for individualized discussions beyond tool-based categorization. In addition, Baynouna Alketbi et al[30] (United Arab Emirates) and Almalki et al[31] (Saudi Arabia) found a clear correlation between higher risk scores and complication rates but also emphasized that older age and frailty independently contribute to fasting difficulty. Most recently, Reesi et al[32] studied 326 patients in a multicenter observational study in Oman. They demonstrated that T1D patients had more complications and DKA episodes. They reinforced the validity and risk-based decision-making of the IDF-DAR tool, especially in high-risk groups.

Finally, both Khorasani et al[33] and Oueslati et al[34] utilized the IDF-DAR risk tool in nonvalidation studies. The former group found that majority of the patients fell into the low and moderate risk categories, suggesting that they should not be entirely exempted from fasting during Ramadan but they suggested that validity of this patient stratification in various fasting populations needs to be evaluated through prospective longitudinal studies[35] The latter group, used the IDF-DAR when evaluating the knowledge and practices of people with diabetes, and the prevalence of complications during RF before and after an education program[36].

These studies support the IDF-DAR tool as a valuable adjunct in Ramadan planning for people with diabetes. However, they also underscore the importance of clinical discretion, context-specific adaptation, and ongoing education to optimize outcomes.

DISCUSSION

This is the first review to chronologically trace through these developments and appraise their rationale and limitations. This should put a historical perspective into the current guidance and provides a critical overview of its basis and the ongoing validation and utility studies. The narrative approach with some scoping elements was imposed by the nature, long time frame and wide scope of the available literature. Therefore, it was used for the sake of comprehensiveness and inclusiveness.

Over the past three decades, risk assessment strategies have evolved from broad advisories[7-11] to nuanced, patient-centered frameworks[15]. This was facilitated by the increased interest in the subject, more available observational and experimental data and more profession interaction with view of producing evidence-based guidelines. The development of the IDF-DAR Risk Stratification Tool in 2021[15] marked a significant advancement, introducing a point-based scoring system that supports objective, individualized decision-making moving from the narrative approach adopted in the past.

Validation and utilization studies conducted across multiple countries and populations consistently demonstrated the utility of the tool in predicting fasting capability and complication risk. However, its performance varies by context. In some settings, especially among patients with T2D, the tool may overestimate risk, thus giving overcautious advice and perhaps unnecessarily preventing willing patients from fasting[25,26]. Moreover, inter-clinician variability in applying the tool - particularly in moderate-risk cases - highlights the need for standardized training and clinical discretion. Filling yet another form in a busy clinic may seem a daunting task, but it should not be viewed as such since it is needed only once a year in most patients[23]. Also, more focused validation studies to address specific questions are needed. Future validation and utility studies should consider inclusion of specific subgroups to address the impact of sex, age and sociocultural factors. Systematic review of suitable validation studies could help consolidate the messages from these isolated populations and help mitigate the negative impact of small sample size and other confounders from different settings.

Despite these limitations, the IDF-DAR tool currently offers a practical, evidence-informed foundation for pre-Ramadan consultations endorsed by the latest American Diabetes Association guidelines[35]. When combined with structured Ramadan-focused patient education and personalized management strategies, it can empower healthcare providers to guide patients in making safer, more informed fasting decisions. The tool may provide an opportunity for a structured shared-decision way to mitigate the impact of the observed practices of fasting against medical advice[17].

The current literature lacks some important data on the longitudinal validity of the IDF-DAR tool, such as duration of follow-up, and fasting adherence tracking. Further validation through longitudinal multicenter studies, real-world effectiveness trials, and adaptation for special populations (e.g., adolescents, elderly, or those using insulin pumps) will be crucial. The tool is available on mobile Apps and its further integration into electronic health records and mobile health platforms may enhance accessibility and impact. More professional support to these efforts is needed to build on the IDF-DAR scale and develop it further in different contexts. Regrettably, a recent consensus deviated from the IDF scale with no clear evidence-based justification[36] and another group made no reference to the IDF-DAR risk scale[37].

In summary, the IDF-DAR tool supports the shift toward safer, more informed RF practices for people with diabetes. Healthcare providers play a central role in its effective application, ensuring that risk assessment is not merely categorical - but contextual, compassionate, and continuous. The tool itself and the validation and real-world utility studies should help bridge the knowledge and research gaps in a critical aspect of RF. Healthcare professionals’ hesitancy in using these tools can be overcome by focused education and support from professional bodies with interest in RF practice and research[38].

This is the first comprehensive review on the history, evolution and current status of the conceptual framework of the principles and tools of risk assessment of people with diabetes observing RF. Although the narrative review method offered a broad overview and flexibility encompassing many studies of different designs, it can be prone to bias and may lack rigor in methodology, making it less reliable for drawing definitive conclusions or informing practice. In contrast, systematic reviews and meta-analyses prioritize a structured, transparent, and reproducible approach, minimizing bias, but potentially are more time-consuming, resource-intensive, and restrictive, particularly when the targeted studies are heterogeneous in scope and design. There is a global generalization issue due to over-representation of studies from Middle East and North Africa and South Asia. However, the tool is dynamic and a revised version is expected in 2026.

CONCLUSION

RF presents measurable risks for individuals with diabetes, but these risks vary and can be effectively stratified. The IDF-DAR tool represents a critical evolution in diabetes care, moving toward personalized, evidence-based guidance. Validation studies show strong predictive performance, particularly when paired with structured patient education. Still, the tool may overestimate risk in some populations and is subject to clinician variability. Ongoing training and refinement will further improve its utility. Ultimately, the IDF-DAR tool enhances Ramadan care planning, empowering clinicians and patients to make safer, more informed fasting decisions. Ready availability in rural and low incomes settings may require production in paper formats. Other future direction should concentrate on longitudinal endpoints of achieved fasting days, lower risk of hypoglycemia and hyperglycemia leading to breaking of fasting and/or hospitalization and also patients’ satisfaction and quality of life.