Impact of the IDF-DAR Risk Stratification and Pre-Ramadan Education on Diabetes-Related Complications

Abstract

Background

Ramadan, the ninth month of the Islamic lunar calendar, requires Muslims to fast from dawn to sunset. However, fasting during this holy month can be challenging, particularly for individuals with chronic diseases like diabetes mellitus.

Objectives

This study aims to assess the validity of the new International Diabetes Federation-Diabetes and Ramadan International Alliance (IDF-DAR) risk stratification tool for Ramadan fasting in predicting persons with diabetes' ability to fast safely and assess the impact of well-structured pre-Ramadan education in helping patients to fast safely and reducing fasting-associated complications.

Methods

This prospective observational study was carried out in three diabetes centers in Oman from January to March 2024. All eligible patients seeking diabetes care in the study settings were invited. They were provided with a prefasting risk assessment and introduced to a well-structured educational program with a follow-up during and after Ramadan to record progress conditions. Variables were statistically described, and the hypotheses were tested at a 5% significance level using SPSS, version 23.

Results

IDF-DAR stratification revealed a significant difference in diabetes type and a significant correlation with hemoglobin A1c levels. Half (51%) of patients with type 1 diabetes mellitus managed to fast the entire month compared to the majority (89%) of those with type 2 diabetes mellitus. Breaking the fast was more often associated with hypoglycemia (37%) and hyperglycemia (20.5%). Only 1.9% of patients required hospitalization during Ramadan, mainly due to diabetic ketoacidosis.

Conclusion

The IDF-DAR risk stratification has proven to be a reliable and valid tool for predicting the risk of adverse fasting events in patients with diabetes. Pre-Ramadan education plays a vital role in minimizing fasting-related complications.

Keywords

diabetes - Ramadan - IDF-DAR risk stratification - hypoglycemia - hyperglycemia - DKA

Introduction

Ramadan, the ninth month of the Islamic lunar calendar, requires Muslims to fast from dawn to sunset. This practice is obligatory for all physically and mentally capable Muslims and lasts 29 to 30 days, during which individuals abstain from consuming food or drink during daylight hours. Ramadan holds deep cultural and spiritual significance within the Islamic community, serving as a time for reflection, devotion, and self-discipline. However, fasting during this holy month can be challenging, particularly for individuals with chronic medical conditions like type 1 diabetes (T1D)[1]

Fasting during Ramadan is an integral part of the Islamic faith, observed by millions of Muslims worldwide yearly. However, since illness is an inherent aspect of human life, it is crucial to understand how it affects fasting during Ramadan.[2] Acute illnesses during Ramadan can range from mild to severe, potentially impacting a person's ability to fast safely. Mild conditions like upper respiratory tract infections or headaches typically do not require breaking the fast. In contrast, severe illnesses such as chest infections, strokes, myocardial infarction, or severe gastroenteritis may necessitate hospitalization. Patients recovering from such illnesses can compensate for missed fasts after Ramadan.[1]

Individuals with chronic conditions can often fast safely under controlled conditions. Those with well-managed chronic illnesses, such as type 2 diabetes (T2D) controlled with oral hypoglycemic agents, dyslipidemia, or hypertension, can usually fast without adverse effects. However, in advanced chronic conditions, such as cancer, complicated T1D, or terminal illnesses, fasting may pose significant health risks. Avoiding fasting is advised in such cases, and a Fidya (monetary payment in place of fasting) should be given.[1]

Despite the exemptions for individuals with serious health conditions like diabetes, a substantial proportion of patients with T2D still choose to fast during Ramadan. The EPIDIAR study reported that 78.7% of patients with T2D fasted during Ramadan, while the CREED study found that 63.6% of patients with T2D observed the fast. These findings demonstrate that many patients prioritize fasting despite potential health risks.[2] [3] According to the EPIDIAR study conducted in 2001, 42.8% of patients with T1D and 78.7% of those with T2D experienced sharp fluctuations in blood sugar (BS) levels during Ramadan. Similarly, a study in Pakistan reported that 35.3% of T1D patients and 23.2% of T2D patients experienced hypoglycemic episodes during Ramadan fasting. Additionally, 33.3% of T1D patients and 15.4% of T2D patients experienced hyperglycemic episodes accompanied by symptoms.[2] [3] [4]

The risks associated with Ramadan fasting for persons with diabetes include hypoglycemia, dehydration, hyperglycemia, diabetic ketoacidosis (DKA), and thrombosis.[1] [2] [5] [6] [7] Studies have demonstrated that structured education programs can reduce the risk of hypoglycemia and DKA during Ramadan fasting.[8] [9] [10] Such programs help promote safe fasting practices, enabling individuals to fulfill their religious obligations while maintaining their health.

This article will assess the validity of the new International Diabetes Federation-Diabetes and Ramadan International Alliance (IDF-DAR) risk stratification tool for Ramadan fasting in predicting the ability of persons with diabetes to fast safely. Additionally, it will assess the impact of a well-structured pre-Ramadan education program based on the IDF-DAR risk stratification in helping patients to fast safely and reducing fasting-associated complications as recommended by previous studies.[8] [9]

Methods

This multicenter prospective observational study was carried out in three diabetes centers (Suhar Hospital, Falaj Al Qabial Health Centre, and Sur Diabetes Centre) in Oman from January to March 2024.

All eligible patients seeking diabetes care in the three study settings were invited with a clear orientation about the study. They were provided with a preassessment and introduced to a well-structured educational program 4 to 8 weeks before Ramadan. A written treatment plan was provided to every person with diabetes intending to fast during Ramadan. It included individualized treatment objectives, prescribed medication dosage, recommended timing, self-monitoring of blood glucose (SMBG), expected complications, and appropriate steps to seek medical advice via an allocated WhatsApp number. A structured data collection sheet was developed to collect required data from the participants during routine diabetes clinic visits within 2 months pre-Ramadan, including age, sex, education level, diabetes mellitus type and duration, diabetes complications, hemoglobin A1c (HbA1c), creatinine level, and estimated glomerular filtration rate.

Based on the collected information, the IDF-DAR risk stratification scoring tool was used to classify patients with diabetes into high-risk, moderate-risk, and low-risk groups.[1] The fasting decision was based on the patient's preference and the health care provider's recommendations. In addition, participants were asked to fill out a follow-up questionnaire during and after Ramadan, indicating fast completion, fast-breaking reasons, and the impact of fasting on BS control, diet control, and intensity of physical exercises.

SPSS, version 23, was used in the analysis of data. The chi-square test and logistic regression were applied to predict factors affecting the management to fast the whole month of Ramadan. Odds ratios (ORs) with 95% confidence intervals (CIs) were also calculated. Hypotheses were statistically tested at a 5% level of significance.

Results

Demographic Characteristics

This study encompassed a cohort of 326 patients with diabetes, comprising 157 males (48.2%) and 169 females (51.8%). Most participants (74%) had completed at least a basic level of education. Of the cohort, 230 (70.6%) were diagnosed with T2D, while 96 (29.4%) had T1D. The number of people who decided not to fast or fasted some days is as follows: Out of 73 who broke fast, 14 decided not to fast the whole month.

IDF-DAR Risk Stratification Scores

Based on the IDF-DAR risk stratification score, 125 (38.3%) were classified as high risk, 103 (31.6%) as moderate risk, and 98 (30.1%) as low risk. The IDF-DAR risk stratification revealed a significant difference by diabetes type (p < 0.001). Notably, 61 patients with T1D (63.5%) were classified as high risk compared to 64 patients with T2D (27.8%) ([Fig. 1]).

Fig. 1 International Diabetes Federation-Diabetes and Ramadan International Alliance (IDF-DAR) risk categories by types of diabetes.

Clinical Correlations of the IDF-DAR Risk Scores

There was a significant correlation between IDF-DAR risk stratification and HbA1c levels (p < 0.001). The average HbA1c level was higher in the high-risk group (9.7%) compared to the moderate-risk (8.7%) and low-risk (7.5%) groups. Additionally, risk increased with greater severity of renal dysfunction (p = 0.016) but decreased significantly with age (p < 0.001).

Table 1 IDF-DAR risk categories by patients' characteristics (N = 326)

Characteristics		All patients	IDF-DAR risk category			p-Value
			Low risk	Moderate risk	High risk
Sex (n, %)	Male	157 (48.2)	55 (35.0)	43 (27.4)	59 (37.6)	0.132
	Female	169 (51.8)	43 (25.4)	59 (34.9)	67 (39.7)
Age (mean ± SD)		45.7 ± 18.6	51.4 ± 15.8	45.2 ± 19.5	41.5 ± 18.8	0.001
Type of diabetes (n, %)	T1DM	96 (29.4)	0 (0.0)	35 (36.5)	61 (63.5)	0.001
	T2DM	230 (70.6)	98 (42.6)	67 (29.1)	65 (28.3)
Renal function (n, %)	(eGFR > 60)	296 (90.8)	96 (32.4)	91 (30.7)	109 36.8)	0.003
	(eGFR 30–60)	26 (8.0)	2 (7.7)	11 (42.3)	13 (50.0)
	(eGFR < 30)	4 (1.2)	0 (0.0)	0 (0.0)	4 (100.0)
Pre-Ramadan HbA1c (%) (mean ± SD)		8.7 ± 2.3	8.7 ± 2.3	7.5 ± 1.8	8.7 ± 2.0	9.7 ± 2.4
All patients			98 (30.0)	102 (31.3)	126 (38.7)

Abbreviations: eGFR, estimated glomerular filtration rate; IDF-DAR, International Diabetes Federation-Diabetes and Ramadan International Alliance; SD, standard deviation; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

Impact of the IDF-DAR Risk Scores on the Ability to Fast

The mean fasting days per risk group were as follows: average fasting days = 27.5 days; low risk = 29.9 days; moderate risk = 28.1 days; and high risk = 25.1 days.

Based on the logistic regressions depicted in [Table 2], a significant association was observed between diabetes type and the ability to fast throughout Ramadan ([Table 1]). Only 51% of patients with T1D managed to fast the entire month, compared to 89% of those with T2D. The odds of breaking the fast were 7.65 times higher among T1D patients than T2D patients (OR = 7.65, 95% CI: 4.31–13.56). The IDF-DAR risk stratification also significantly predicted fasting ability (p = 0.001). Among the low-risk group, 97% completed the fast, compared to 82% in the moderate-risk group and only 58% in the high-risk group. Compared to the low-risk group, the odds of breaking the fast were 6.79 times higher in the moderate-risk group (95% CI: 1.93–23.85) and 22.87 times higher in the high-risk group (95% CI: 6.87–76.19). [Fig. 2] shows the ability to fast the whole of Ramadan by types of diabetes and IDF-DAR risk categories.

Table 2 Simple logistic regressions of the associations between managing Ramadan fasting and patients' characteristics

		Manage fasting the whole month of Ramadan?		p-Value	Odds ratio	95% CI
		No	Yes
		n (%)	n (%)
Sex	Male	35 (22.4)	121 (77.6)	0.538	1
	Female	38 (22.6)	130 (77.4)		1.01	(0.60, 1.70)
Type of diabetes	T1DM	47 (49.5)	48 (50.5)	0.001	7.65	(4.31, 13.56)
	T2DM	26 (11.4)	203 (88.6)		1.00
Renal function	(eGFR > 60)	67 (22.8)	227 (77.2)	0.911	1
	(eGFR 30–60)	5 (19.2)	21 (80.8)	0.678	0.81	(0.29, 2.22)
	(eGFR < 30)	1 (25.0)	3 (75.0)	0.917	1.13	(0.12, 11.04)
IDF-DAR risk category	Low risk (0–3)	3 (3.1)	95 (96.9)	0.001	1
	Moderate risk (3.5–6)	18 (17.8)	83 (82.2)	0.003	6.87	(1.95, 24.14)
	High risk (> 6)	52 (41.6)	73 (58.4)	0.001	22.56	(6.77, 75.12)
All patients		73 (22.5)	251 (77.5)

Abbreviations: CI, confidence interval; eGFR, estimated glomerular filtration rate; IDF-DAR, International Diabetes Federation-Diabetes and Ramadan International Alliance; T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.

Note: Out of 73 who broke their fast, 14 decided not to fast the whole month. Average fasting days: low-risk (29.9), moderate-risk (28.1), and high-risk (25.1).

Fig. 2 Ability to fast the whole of Ramadan by types of diabetes and International Diabetes Federation-Diabetes and Ramadan International Alliance (IDF-DAR) risk categories.

Impact of Pre-Ramadan Education

Pre-Ramadan education had a statistically significant impact on fasting outcomes (p < 0.001). [Table 3] shows that participants who acknowledged its importance were more likely to fast for the entire month than those who did not recognize its role. They also reported better management of fasting-related fatigue (83%) and improved BS control (82%). In addition, most of those who experienced breaking the fast during the previous Ramadan (88%) could fast the entire month.

Table 3 The perception of patients on the impact of pre-Ramadan education on managing Ramadan fasting

		Manage fasting the whole month of Ramadan?		p-Value
		No	Yes
		n (%)	n (%)
Do you think that education helped you fast more days this year?	Yes	45 (17.2)	217 (82.8)	0.001
	No	10 (35.7)	18 (64.3)
	I do not know	18 (56.3)	14 (43.8)
Do you think that education has made you less tired during the fast this year?	Yes	44 (17.2)	212 (82.8)	0.001
	No	14 (40.0)	21 (60.0)
	I do not know	15 (48.4)	16 (51.6)
Did Ramadan help you in controlling your BG?	Yes	47 (17.7)	218 (82.3)	0.001
	No	12 (41.4)	17 (58.6)
	I do not know	14 (50.0)	14 (50.0)
Required admission?	Yes	4 (66.7)	2 (33.3)	0.022
	No	66 (21.0)	248 (79.0)
Managed to fast last year	Yes	30 (11.6)	228 (88.4)	0.001
	No	42 (65.6)	22 (34.4)

Abbreviation: BG, blood glucose.

Outcomes

Hypoglycemia occurred in 37% of the participants, hyperglycemia in 20.5%, and both in 1.4% of participants. These were the primary reasons for breaking the fast, followed by doctor's advice (13.7%) and women's health considerations (11%). However, only 1.9% of patients required hospitalization during Ramadan, with five out of six cases due to DKA and one due to severe hyperglycemia.

Discussion

This study was conducted among 326 subjects with T1D and T2D attending three diabetes clinics in Oman for 4 to 8 weeks pre-Ramadan in 2024. The aims were to assess the predictability features of the IDF-DAR risk stratification tool for Ramadan fasting and to evaluate the impact of the given structured pre-Ramadan education on the fasting experience.

The IDF-DAR risk stratification was used in this study to assess patients' risks and predict their ability to fast.[1] The risk classifications were as follows: 30.1% of the participants were classified as low risk, 31.6% as moderate risk, and 38.3% as high risk. These findings align with several previous studies, with some differences in the proportion distributions.[11] [12] [13] In contrast, Malik et al[14] and Kamrul-Hasan et al[15] found a lower proportion in the high-risk category compared to the low-risk category. When combining the high- and moderate-risk categories, the overall recommendation in these studies was against fasting, but the decision to fast was based on patients' preferences. The variation in risk classifications could be attributed to differences in the level of diabetes clinics (tertiary or primary care) and patients' characteristics such as age, type of diabetes, and duration of diabetes.

Overall, this study provided further evidence of IDF-DAR risk stratification's ability to predict the nonfasting of patients with diabetes during Ramadan, aligning with previous research findings.[12] The ability to fast the entire month decreased with increased IDF-DAR risk stratification, as 97% of the low-risk group were able to fast the entire month compared to 82% of the moderate-risk group and 58% of the high-risk group. ORs showed that the high-risk group had a 22-fold and the moderate-risk group had a 6-fold increase in the likelihood of fast-breaking compared to the low-risk group. Compared with Alfadhli et al,[12] the high-risk group exhibited a 6.7-fold increase, and the moderate-risk exhibited a 3.2-fold increase in the risk of fast-breaking compared to the low-risk group. Additionally, Shamsi et al[13] reported a high percentage of fasting the whole month among the three risk categories and a significantly increased risk of fast-breaking among the high-risk and moderate-risk groups compared to the low-risk groups.

The proportions of T1D involved in previous research were low compared to T2D.[8] [12] [13] [16] T1D accounted for 29.4% of the participants in the current study cohort. Although 63.5% were classified as a high-risk group, half (50.5%) could fast all days of Ramadan. This positive outcome aligns with the DAR-MENA findings, where 48.5% of T1D were managed to complete the fasting.[17] In contrast, Alfadhli et al reported that only 13.5% of T1D patients were fasting the entire month, as 84.4% of them were classified as having high-risk scores.[12]

The current findings indicated that fast-breaking is more frequently associated with hypoglycemia (37%) than hyperglycemia (20.5%), with only one case admitted due to severe hyperglycemia. As an alignment, several studies have shown that patients with diabetes who experienced fast-breaking suffered more from hypoglycemia than hyperglycemia, particularly among high-risk individuals.[12] [14] [18] However, Alfadhli[19] and Hassanein et al[18] reported a higher rate of participants experiencing hyperglycemia than hypoglycemia during Ramadan fasting. In addition, the observed admission rate was higher among those who experienced hyperglycemia than hypoglycemia.[5] [18] These contradictions in findings could be attributed to the variations in study populations in terms of age, duration of diabetes, type of diabetes, strategies of management, and individual adherence to medical recommendations during fasting. In the current study, patients had received comprehensive and structured pre-Ramadan education. It included written materials and individualized management plans covering risk stratification, medication adjustment, meal planning, and SMBG. Patients were provided 24-hour access to the diabetes care team via WhatsApp for real-time support and received continuous reinforcement through educational videos and visual materials. This finding highlights the pivotal role of personalized, guideline-based education in enabling safe fasting practices even among high-risk patients.

In the present study, a few patients with diabetes (1.9%) required hospitalization during Ramadan, and the majority were attributed to DKA. As an alignment, Abdelgadir et al[6] reported DKA as being higher in Ramadan compared to Shaaban but mainly among T1D patients. They attributed this result to medication noncompliance and the lack of a pre-Ramadan health education program. According to them, those with a pre-Ramadan history of DKA need to be advised against fasting. In contrast, several studies have revealed no seasonal variations in the rate of DKA and found no significant association between Ramadan fasting and DKA occurrence compared to other months.[20] [21] [22] Tong et al[23] found that admissions due to diabetes in Ramadan are less when compared to pre- and post-Ramadan. Similarly, an earlier critical reappraisal of the literature up to 2019 suggested no increased risk of DKA during Ramadan fasting.[24]

The findings highlighted the significant impact of pre-Ramadan structured educational programs on fasting preference and outcomes, reinforcing the necessary role of health care providers in providing patients with structured guidance and follow-up. Participants who acknowledged the educational program reported a higher likelihood of fasting throughout Ramadan, experiencing less fasting fatigue, and improved BS control. In addition, 88% of patients with a previous history of fasting could manage to fast during the current Ramadan. This indicates the role of education in preparing individuals with adequate physiological and dietary adjustments for safe fasting. These findings are consistent with previous studies. El Toony et al[10] demonstrated that pre-Ramadan education, particularly for high-risk patients, reduces anticipated adverse events during fasting. In addition, Mohamed et al[9] and Farooq et al[8] recommended providing patients with diabetes with a well-structured pre-Ramadan educational program based on the IDF-DAR guidelines to ensure safer fasting experiences and better glycemic control.

The current study has some limitations. The variations in the level of management provided to patients with diabetes between the three diabetes centers involved in the study: Suhar Hospital, Sur Diabetes Specialised Centre, and Falaj Al-Qabail Health Centre. The results may not represent the remaining diabetes centers not involved in the study. From a strength perspective, this study supports the validity of using IDF-DAR risk stratification and previous studies in the field. Moreover, it provides a baseline for further improvement in the preeducation program and follow-up of patients with diabetes before, during, and after Ramadan.

Conclusion

The IDF-DAR risk stratification has proven to be a reliable and valid tool for predicting the risk of adverse events due to fasting in patients with diabetes. Additionally, pre-Ramadan education plays a vital role in minimizing fasting-related complications.

The evidence highlights the significant risks associated with fasting for persons with diabetes, particularly concerning glycemic fluctuations. This underscores the need for personalized medical guidance and careful monitoring for patients with diabetes who choose to fast during Ramadan. We can significantly reduce severe complications and hospital admissions for high-risk patients by implementing well-structured education programs and a clear written plan. That is, patients with well-controlled diabetes can fast more safely with a minimum risk of complications.

The current perceived results support applying the IDF-DAR risk stratification among patients with diabetes to provide them with a suitable individual educational plan. Diabetes clinics should establish clear pre-Ramadan education strategies at least 1 to 2 months before Ramadan. Telemedicine can be utilized to educate patients and maintain seamless communication. Patients are encouraged to adhere to medical guidance, control their BS levels, SMBG, and stay in regular contact with their health care providers.

Conflict of Interest

None declared.

Acknowledgments

We are indebted to staff in the Endocrine and Diabetes Unit in Suhar Hospital, diabetic team at Falaj Al Qabial and Sur Diabetic Center for their contributions in the education and collection of data pre- and post-Ramadan.

Authors' Contributions

Conception, data collections, or design: A.A.R., H.A.R., S.A.G., I.A.A., M.A.M., M.A.E., S.A.B., S.A.S., A.K., K.M.A.

Acquisition, analysis, or interpretation of data: H.A.R.

Drafting the work or revising: A.A.R., H.A.R., K.M.A.

Final approval of the manuscript: A.A.R, H.A.R.

Compliance with Ethical Principles

This research was approved by from the MoH research committee (MOH/CSR/24/28022). Informed consent was obtained from all patients with a clear explanation of their privacy, confidentiality, and voluntary participation.

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Publication History

Article published online:
06 June 2025