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

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

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.

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.

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.

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.