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DOI: 10.1055/s-0046-1815925
Predictive Ability and the Clinical Validity of IDF-DAR Risk Score and Its Elements among Fasting People with Diabetes during Ramadan
Authors
Conflict of Interest The authors declare that there are no conflicts of interest regarding the publication of this paper.
Abstract
Background and Aims
This article aims to determine the predictive ability and the clinical validity of the IDF-DAR risk score and its elements among fasting people with diabetes during Ramadan.
Methods
This prospective observational study was conducted from March to May 2022 at the Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan, with two participating centers from Peshawar (PAK) and Dubai (UAE). People with diabetes who intended to fast were recruited and categorized according to the IDF-DAR risk score. Fasting status and outcomes were assessed post-Ramadan.
Results
A total of 953 fasting people with diabetes participated, of whom 542 (56.9%) were low, 254 (26.7%) moderate, and 157 (16%) high risk. Hypoglycemia occurred in 48 (30.1%) participants in the high-risk group compared with 33(6%) in the low-risk and 17 (6.6%) in the moderate-risk groups. Hyperglycemia was reported in 18 (3.3%) low-risk, 24 (9.4%) moderate-risk, and 24 (15.3%) high-risk participants. Hospitalization occurred in 3 (1.2%) participants in the moderate-risk group. Breaking of fast was most frequent among those with high-risk scores, affecting 20 (12.7%) participants. On multivariate analysis, type 1 diabetes (T1DM) and stage-3 chronic kidney disease (CKD) were the significant predictors of adverse events during fasting, with adjusted odds ratios of 8.33 (95% CI: 4.5–15.45; p < 0.0001) and 3.01 (95% CI: 1.08–8.39; p = 0.035), respectively.
Conclusion
Our study supports the predictive ability and clinical validity of the IDF–DAR risk score. High-risk scores acquired by nonmodifiable factors, such as T1DM and stage-3 CKD, require careful consideration, while optimizing modifiable factors can lower the score and enable safer fasting.
Keywords
Ramadan fasting - IDF-DAR risk score - acute complications - chronic kidney disease - type 1 diabetesIntroduction
Fasting during Ramadan is observed by millions of Muslims worldwide and involves complete abstinence from food, drink, and oral medications during daylight hours.[1] While fasting is recommended for healthy individuals, exemptions are granted to children, the frail elderly, pregnant or nursing women, those menstruating, and people with acute or chronic health conditions.[2]
Changes in eating habits, physical activity, and sleep patterns during Ramadan can disrupt metabolic homeostasis, particularly in individuals with chronic conditions such as uncontrolled diabetes, hypertension, or chronic kidney disease (CKD). These disruptions may increase the risk of hypoglycemia, hyperglycemia, dehydration, and diabetic ketoacidosis (DKA). Despite these risks, many Muslims living with diabetes do not perceive themselves as ill or exempt and choose to fast.[3] [4] This can be challenging for both people with diabetes and their health care professionals (HCPs), highlighting the need for evidence-based recommendations to support safe fasting practices.
Earlier recommendations, such as the 2016 Diabetes and Ramadan (DAR) practical guidelines, introduced a categorical risk stratification model classifying individuals into very-high, high, and low-to-moderate risk categories.[5] However, subsequent evidence indicated that many individuals classified as high-risk were still able to complete fasting safely, suggesting that this model may have been overly restrictive.[6] To address these limitations, the International Diabetes Federation–Diabetes and Ramadan (IDF–DAR) 2021 guidelines introduced a more refined risk-scoring system. This tool incorporates multiple clinical and lifestyle parameters to guide risk assessment and facilitate shared decision-making between patients and HCPs.[7] However, the scoring system remains largely based on expert consensus, and its clinical validity and predictive accuracy are not known.
Therefore, recent studies have begun to evaluate the IDF-DAR tool's performance in real-world settings, consistently showing that higher scores are associated with lower fasting adherence and greater risk of complications, supporting its predictive validity.[8] Despite initial validations, uncertainties remain regarding its performance across different populations, highlighting the need for further evaluation.[9]
Therefore, the present study not only assesses the overall clinical validity of the IDF–DAR risk score in fasting individuals with diabetes but also examines the predictive value of its individual elements, providing a more detailed understanding of its applicability in predicting fasting adherence and acute complications.
Methodology
This prospective observational study was conducted between March and May 2022 at the outpatient departments of the Baqai Institute of Diabetology and Endocrinology (BIDE), Karachi, Pakistan, in collaboration with two additional centers: AIMS Sugar Hospital, Peshawar, Pakistan, and Pakistan Medical Center, Dubai (UAE). The study adhered to the ethical principles outlined in the Declaration of Helsinki (revised 2013). Ethical approval was obtained from the Institutional Review Board (IRB) of BIDE (IRB-BIDE/MYAHMEDANI/-07–20–21–009). For the collaborating centers, a formal permission/waiver was obtained, considering BIDE's IRB approval.
Before onset, a standardized study protocol was developed and disseminated to all three centers to maintain consistency and minimize inter-center variability. All data collectors and healthcare staff received joint online training sessions to ensure consistent use of the IDF-DAR 2021 risk classification, uniform delivery of Ramadan-focused diabetes education following IDF-DAR guidelines, and standardized administration of the questionnaire and documentation of complications.
A central monitoring team at BIDE supervised procedural adherence through weekly virtual meetings, record reviews, and random cross-checking. All three centers used the same structured tools, instructions, definitions, and follow-up procedures.
People with diabetes aged 25 to 80 years were asked during the pre-Ramadan screening visit whether they intended to fast. Eligible individuals who confirmed their intention were invited to participate, and the study objectives, procedures, risks, and benefits were explained. Written informed consent was obtained from those who agreed to participate at each of the participating centers. The IDF-DAR 2021 risk score chart was used without any modification to categorize fasting risk. All participants received individualized Ramadan-specific diabetes education, including dose adjustments, recognition of hypo- and hyperglycemia symptoms, and necessary precautions in case of acute complications. Patients identified as high-risk were specifically counseled about their elevated risk of developing complications during fasting, and only those who still chose to fast after counseling were included in the study.
A dedicated emergency contact number was provided to all participants to report any acute event during fasting. In addition, all participants, particularly those categorized as high-risk, received weekly follow-up messages and phone calls throughout Ramadan to reinforce education, assess glycemic status, and ensure timely reporting of symptoms. Those unwilling or medically advised not to fast, those not intending to participate in the study; patients with a recent history of severe hypoglycemia events (requiring assistance, seizure, or loss of consciousness); any current acute illness or hospitalization; and critically ill or clinically unstable patients were excluded.
During the pre-Ramadan visit (i.e., 4–6 weeks before Ramadan), a total of 1,053 individuals were screened for eligibility. Of these, 1,027 participants were initially recruited, while 26 were excluded because they met one or more exclusion criteria, declined to fast, refused participation, or were advised against fasting by their physicians. Data were collected using a two-section, closed-ended questionnaire: Section A was used to collect patients' demographic profile, anthropometric measurements, and fasting risk stratification using the IDF-DAR risk score. The primary outcomes of the study were major hypoglycemia and major hyperglycemia during fasting. Secondary outcomes included hospitalizations, emergency visits, or events requiring discontinuation of fasting. Participants were instructed to maintain their personal diary documenting the frequency of any of these complications that occurred during fasting. These entries were cross-verified during the post-Ramadan follow-up visit (within 4 weeks after Ramadan) along with the fasting status, using Section B of the questionnaire.
Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 20. Continuous variables were recorded as mean ± standard deviation, and categorical variables as frequency (percentages). The chi-square test or Fisher's exact test was used to compare groups. Stepwise regression was used to identify the factors that have significantly contributed to getting moderate- to high-risk scores. A p-value less than 0.05 was considered statistically significant.
Operational Definitions
Minor hypoglycemia: blood sugar level equal to or less than 70 mg/dL by capillary glucometer (irrespective of symptoms).
Minor hyperglycemia: blood sugar level equal to or greater than 200 mg/dL by capillary glucometer.
Major hypoglycemia: blood sugar level equal to or less than 40 mg/dL by capillary glucometer (irrespective of symptoms) or hypoglycemia that required third-person assistance, irrespective of blood sugar level.
Major hyperglycemia: RBS > 300, diabetic ketoacidosis, hyperosmolar hyperglycemic state.
Results
Among the 1,027 recruited participants, 42 did not fast during Ramadan and were therefore excluded from post-Ramadan assessment. An additional 32 individuals were excluded due to incomplete follow-up, missing post-Ramadan visits, or inadequate documentation of Ramadan-related data. Consequently, 953 participants who fasted during Ramadan and had complete datasets were included in the final analysis. The process of participant recruitment, exclusions, and inclusion in the final analysis is summarized in the participant flow diagram ([Fig. 1]).
The mean age of the participants was 49.24 ± 13.1 years, with an approximately equal gender distribution. Of these, 859 (90.1%) had type 2 diabetes (T2DM), and 94 (9.9%) had type 1 diabetes (T1DM). According to the IDF-DAR scoring system, 542 (56.9%) people were classified as low-risk, 254 (26.7%) as moderate-risk, and 157 (16%) as high-risk of fasting at enrollment. Baseline characteristics of the study population are summarized in [Table 1].
Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; DKA/HONC, diabetic ketoacidosis/hyperosmolar nonketotic coma; eGFR, estimated glomerular filtration rate; HbA1c, glycated hemoglobin; IDF-DAR, International Diabetes Federation Diabetes and Ramadan; SBP, systolic blood pressure; SMBG, self-monitoring of blood glucose.
Note: Data presented as n (%) or mean ± SD.
Among them, 478 (88.2%) in the low-risk group, 224 (88.2%) in the moderate-risk group, and 118 (75.2%) in the high-risk group completed fasting for the full month of Ramadan (p < 0.0001). Rates of complications varied significantly by risk category. In the high-risk group, minor and major hypoglycemia occurred in 30 (19.1%) and 18 (11.4%) participants, respectively (p < 0.0001), while 20 (12.7%) reported breaking of fast mainly due to hypoglycemic events (p < 0.0001). In the moderate-risk group, minor and major hyperglycemia were recorded in 10 (3.9%) and 14 (5.9%) participants, respectively (p = 0.02), and hospitalization occurred in 3 (1.2%) cases ([Table 2]).
Abbreviations: DKA/HHS, diabetic ketoacidosis/hyperosmolar hyperglycemic state; N/A, not applicable.
Note: Data presented as n (%); p-value < 0.05 considered to be statistically significant.
We conducted an element-level analysis to identify which specific element contributed most strongly to adverse events during fasting. For this analysis, “adverse events” were defined as the occurrence of any one of the previously described complications (minor/major hypoglycemia, hyperglycemia, breaking of the fast, or hospitalization). These adverse events were more frequent among individuals with T1DM: 39 (48.8%), p < 0.0001; those with a diabetes duration ≥10 years: 38 (47.5%), (p = 0.003); a history of hypoglycemia (<1 weekly): 22 (27.5%), (p < 0.0001); poor glycemic control: 38 (47.5%), (p = 0.004); or reduced estimated glomerular filtration rate (eGFR) between 30 and 60 mL/min/1.73 m2 (p = 0.003). Treatment with once-daily mixed insulin 2 (2.5%; p = 0.02) and multiple daily mixed insulin regimens 44 (55%; p < 0.001) was also significantly associated with adverse outcomes ([Table 3]).
Abbreviations: eGFR, estimated glomerular filtration rate; HbA1c, glycated hemoglobin; N/A, not applicable; SMBG, self-monitoring of blood glucose.
Note: Data presented as n (%) or mean ± SD. p-Value <0.05 is considered to be statistically significant.
Multivariate regression showed that the odds of developing acute complications were significantly higher among people with T1DM (AOR: 8.33, 95% CI: 4.5–15.45; p < 0.0001) and stage-3 CKD (AOR: 3.01, 95% CI: 1.08–8.39; p = 0.035; [Table 4]).
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; eGFR, estimated glomerular filtration rate.
Note: Stepwise Backward-Wald regression was used; variables included in the model: demographic characteristics and all the IDF-DAR risk score elements; p-value < 0.05 considered to be statistically significant.
Discussion
In this study, we evaluated the predictive ability and clinical validity of the IDF–DAR risk stratification tool, along with its individual elements, among fasting people with diabetes during Ramadan. Our findings demonstrate that individuals with higher risk scores were more likely to develop fasting-related complications compared with those with lower scores. Importantly, T1DM and stage-3 CKD emerged as the strongest predictors of adverse outcomes, underscoring the clinical relevance of the risk score, whereas most other elements showed limited predictive value.
At baseline, fewer than half of our cohort was classified as moderate- or high-risk; however, a considerable proportion of these individuals still fasted for the entire Ramadan month, i.e., 224 (88.2%) and 118 (75.2%), respectively. This pattern aligns closely with previous reports from Bahrain (85%), Bangladesh (72.8%, 49.3%), Saudi Arabia (70.4%, 53.2), and the UAE (84.7%, 80.2%), where moderate- or high risk-groups, including those with poorly controlled T2DM and T1DM, or advanced comorbidities, observed the full month of fasting despite medical advice.[8] [10] [11] [12] This consistent trend indicates that although the IDF–DAR tool effectively identifies individuals at higher risk, fasting decisions are often shaped by personal choices, social influences, and faith-related commitments that extend beyond clinical evaluation.[13]
In our cohort, major hypoglycemia occurred in 11.4% of high-risk individuals, almost 15-fold higher than in the moderate-risk (0.8%) and low-risk groups (0.7%). This trend of increasing hypoglycemia with higher risk scores is consistent with previous studies. Alfadhli et al reported 28.3% in the high-risk group, around threefold higher than in moderate- and low-risk groups.[11] Similarly, Mohammed et al, Al-Malki et al, and Mazloum et al showed the highest hypoglycemia rates among high-risk participants (10.5, 48.7, and 45.3%, respectively).[14] [15] [16] Kamrul-Hasan et al observed a relatively lower rate (7.5%), roughly 3.7-fold higher than the lower-risk groups.[10] A few studies, such as Baynouna et al, reported exceptions (moderate-risk: 15.8% vs. high-risk 12.7%), attributed to more conservative medication adjustments, closer monitoring, and selective fasting among high-risk individuals.[12]
Major hyperglycemia in our study was also 4.5-fold higher in high-risk participants (11.4%) compared with 5.9 and 1.1% in moderate- and low-risk groups, respectively. Similar fold increases (3.5–3.86) in the high-risk groups were observed by Kamrul-Hasan and Alfadhli et al (4.5–8.3%),[10] [11] whereas Mohammed et al reported higher absolute rates (23.8%) with comparable fold increases (threefold).[14] Although Farooq et al found that fasting participants had higher hypoglycemia (58.3 vs. 29.3%) but lower hyperglycemia (27.8 vs. 55.2%) than nonfasters,[17] risk stratification was not reported, limiting direct comparison.
Hospital admissions and acute metabolic complications observed were infrequent and mostly nonsignificant. Admissions occurred mainly in the moderate-risk group, 3 (1.2%), due to major hyperglycemia, 2 (66.6%). These rates were slightly higher than the single admission reported by Mohammed et al,[14] but lower than that reported by Alfadhli et al, 10 (3.8%), and Baynouna et al, 9 (12%), which were predominantly observed in high-risk groups.[11] [12] DKA and hyperosmolar hyperglycemic state (HHS) were similarly rare in this cohort, with DKA in one participant (0.7%) in the high-risk group and HHS in two participants (0.8%) in the moderate-risk group, consistent with that of Alfadhli et al (DKA: 0.4%) and Al-Malki (one high-risk T1DM patient hospitalized for DKA).[10] [15] Finally, the rate of breaking of fast was also higher in our high-risk participants (12.7%), mainly due to major hypoglycemia, compared with 4.3% due to moderate-risk, and 1.4% due to low-risk. These frequencies are lower than reported by Shamsi et al (25.3%) in high-risk participants, similarly due to hypoglycemia[8] and Alfadhli (61.5% of T1DM and 12.7% of T2DM).[10]
Overall, despite numerical differences, most studies agree on the central message that individuals with higher IDF–DAR risk scores experience more hypo- and hyperglycemia and related adverse events during Ramadan, supporting the clinical value of the risk score. Yet, complications are not universal: in our cohort, only 8.4% were affected, while 91.6% fasted safely despite many being classified as high risk. This shows that not everyone categorized as high-risk is at the same level of risk, as patients reach this classification for different reasons. Consequently, identifying which specific risk elements truly contribute to fasting-related adverse outcomes becomes crucial.
Therefore, our study further examined the contribution of individual IDF–DAR risk elements, and we found that T1DM, longer disease duration, poor glycemic control, impaired kidney function, complex insulin use, and a history of hypoglycemia were initially associated with complications, echoing earlier findings.[8] Interestingly, some factors showed paradoxical associations, where both regular and irregular glucose monitoring, as well as both use and non-use of sulfonylureas or other oral agents, appeared to predict complications. These patterns most likely reflect confounding by indication, surveillance bias from increased event detection, heterogeneity in therapy use, and small subgroup effects, rather than true bidirectional causal relationships.
After adjustment, only T1DM and stage-3 CKD remained significant predictors. The elevated risk in T1DM has been consistently demonstrated in the available Ramadan studies,[18] while the link with stage-3 CKD aligns with emerging evidence from multi-country and kidney-focused cohorts showing higher rates of both glycemic and nonglycemic complications in these patients.[19] [20] This may be due to altered drug handling, fluid balance issues, and reduced physiological reserves in these patients.
Taken together, our study reaffirms the clinical validity of the IDF–DAR risk score while illustrating that not all components are equally predictive of actual risk. These differences have important clinical implications. In real-world Ramadan care, many individuals categorized as “high-risk” based on their total score can still fast safely, as reflected in our study. This means clinicians should look beyond the total score and focus on the specific elements that contribute to a higher score for each patient.
People with nonmodifiable elements such as T1DM and advanced CKD need more intensive pre-Ramadan counseling, closer monitoring, and, in some cases, clear advice against fasting. At the same time, their overall risk can often be reduced before Ramadan by optimizing modifiable factors such as glycemic control, medication regimens, and prior hypoglycemia history, which in turn enhances safety and allows more individuals to fast with a lower risk of adverse events under proper medical supervision.[21]
These observations are likely relevant beyond Pakistan, as similar patterns have been described across different Muslim populations and healthcare systems.[9] [15] [22] Risk stratification also offers cost-effectiveness advantages, especially in low-resource settings, by helping clinicians focus limited time, education, and monitoring efforts on the smaller group at greatest risk.
Finally, our findings highlight clear directions for future research. More prospective studies are needed to determine which specific risk-score elements have the strongest predictive value across different regions and healthcare contexts, enabling refinement of the existing framework. Trials that test more personalized pre-Ramadan interventions, particularly for people with T1DM or CKD, could help determine which strategies truly reduce risk. Evaluating the economic impact of risk-based care pathways will also be important for creating Ramadan programs that are both effective and scalable.
Our study has several strengths. The prospective, multicenter design across three centers allowed real-time assessment of fasting-related adverse events, which were systematically documented, minimizing the risk of bias and enhancing the robustness of findings. With 953 participants, we evaluated overall risk patterns as well as individual IDF–DAR risk elements, providing practical insights for personalized pre-Ramadan care. Consistent patterns across centers suggest applicability to diverse Muslim populations and healthcare settings. However, there are limitations. Despite being multicenter, only three centers were included, which may limit broader generalizability. Some high-risk subgroups, such as stage 3 CKD or T1DM patients, were small, resulting in wide confidence intervals. The observational design cannot fully exclude residual confounding, particularly for paradoxical associations like glucose monitoring or oral agent use. Additionally, very frail patients, those with cognitive impairment, and pregnant women were underrepresented, limiting applicability to these groups
Conclusion
Our study supports the predictive ability and clinical validity of the IDF–DAR risk score for identifying individuals at higher risk of fasting-related complications during Ramadan. High-risk scores acquired by nonmodifiable factors, such as T1DM and stage-3 CKD, need careful pre-Ramadan assessment, intensive counseling, close monitoring, and, in some cases, advice against fasting. However, modifiable factors can be optimized in advance to lower the score and allow many patients to fast safely under medical supervision.
Conflict of Interest
The authors declare that there are no conflicts of interest regarding the publication of this paper.
Acknowledgments
The authors appreciate the support of Miss. Nida Mustafa (Statistician), Department of Research, Baqai Institute of Diabetology and Endocrinology, Karachi, Pakistan.
Declaration of Financial/Other Relationships
The authors report no financial or personal relationships that could have affected the conduct or outcomes of this research.
Details of the Earlier Presentation
Preliminary data of this study were presented at the International Diabetes Federation Congress 2022 (December 4–7, Lisbon, Portugal).
Authors' Contributions
S.Y.: Concept and design, data collection, data interpretation, and writing the manuscript.
M.Y.A.: Concept and design, interpretation of data, editing, and reviewing the manuscript.
S.Z.: Responsible for data collection and management in her respective areas, reviewed and approved the final manuscript.
Ethical Approval Statement
The study adhered to the ethical principles outlined in the Declaration of Helsinki (revised 2013). Ethical approval was taken from the Institutional Review Board (IRB) of BIDE (IRB-BIDE/MYAHMEDANI/-07–21–20–009). For the collaborating centers, a formal permission/waiver was obtained, considering BIDE's IRB approval.
-
References
- 1 Abusahmin H, Abdelgadir E, Eledrisi MS, Hafidh K, Beshyah SA. Diabetes and Ramadan fasting (2023): the year in review. J Diabetes Endocr Pract 2024; 7 (02) 53-65
- 2
Al-Baqarah S.
The Holy Quran. 183-185
- 3 Al Hayek A, Al Zahrani WM, Al Dawish MA. Glucometric parameter changes in patients with type 2 diabetes during Ramadan fasting: A prospective comparative real-world study. Metab Open 2024; 23: 100304
- 4 Beshyah SA. Evolution of the risk concept and assessment tools for diabetes during Ramadan fasting: a narrative review. World J Diabetes 2025; 16 (11) 110007
- 5 Hassanein M, Al-Arouj M, Hamdy O. et al; International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract 2017; 126: 303-316
- 6 Rahmatullah, Ahmedani MY, Basit A. et al. Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories. Diabetes Res Clin Pract 2022; 185: 109234
- 7 Hassanein M, Afandi B, Yakoob Ahmedani M. et al. Diabetes and Ramadan: practical guidelines 2021. Diabetes Res Clin Pract 2022; 185: 109185
- 8 Shamsi N, Naser J, Humaidan H. et al. Verification of 2021 IDF-DAR risk assessment tool for fasting Ramadan in patients with diabetes attending primary health care in The Kingdom of Bahrain: the DAR-BAH study. Diabetes Res Clin Pract 2024; 211: 111661
- 9 Jamaluddin J, Nik Abdul Kadir NA, Goh LX. et al. Validation of the IDF-DAR risk tool for fasting in Ramadan for adults with diabetes mellitus in primary care: a nationwide multicentre study in Malaysia. Prim Care Diabetes 2025; 19 (06) 608-612
- 10 Kamrul-Hasan ABM, Alam MS, Kabir MA. et al. Risk stratification using the 2021 IDF-DAR risk calculator and fasting experience of Bangladeshi subjects with type 2 diabetes in Ramadan: the DAR-BAN study. J Clin Transl Endocrinol 2023; 31: 100315
- 11 Alfadhli EM, Alharbi TS, Alrotoie AM. et al. Validity of the International Diabetes Federation risk stratification score of Ramadan fasting in individuals with diabetes mellitus. Saudi Med J 2024; 45 (01) 86-92
- 12 Baynouna Alketbi L, Afandi B, Nagelkerke N. et al. Validation of the IDF-DAR risk assessment tool for Ramadan fasting in patients with diabetes in primary care. Front Clin Diabetes Healthc 2025; 6: 1426120
- 13 Hassanein M, Al Awadi FF, El Hadidy KES. et al. The characteristics and pattern of care for the type 2 diabetes mellitus population in the MENA region during Ramadan: an international prospective study (DAR-MENA T2DM). Diabetes Res Clin Pract 2019; 151: 275-284
- 14 Mohammed N, Buckley A, Siddiqui M. et al. Validation of the new IDF-DAR risk assessment tool for Ramadan fasting in patients with diabetes. Diabetes Metab Syndr 2023; 17 (04) 102754
- 15 Almalki M, AlSaeed AA, AlNomi AA. et al. Validity of the New International Diabetes Federation-Diabetes and Ramadan (IDF-DAR) risk Stratification score and fasting experience of Saudi patients with diabetes during Ramadan: insights from a cross-sectional study. Cureus 2025; 17 (02) e79351
- 16 Mazloum Khorasani Z, Mehrad-Majd H, Yaghoubi MA. Risk stratification for fasting in diabetic patients based on the IDF-DAR guideline. J Nutr Fast Health 2024; 12 (01) 14-19
- 17 Farooq Q, Ghaffar T, Malik SE, Aamir AUH. Safety of high-risk diabetic patients during Ramadan at a tertiary care hospital in Pakistan, practicing updated IDF DAR guidelines. Pak J Med Sci 2024; 40 (05) 829-834
- 18 Safari O, Shafiee A, Heidari A. et al. Ramadan fasting among adolescents with type 1 diabetes: a systematic review and meta-analysis. BMC Endocr Disord 2025; 25 (01) 45
- 19 Hassanein M, Yousuf S, Ahmedani MY. et al. Ramadan fasting in people with diabetes and chronic kidney disease (CKD) during the COVID-19 pandemic: The DaR global survey. Diabetes Metab Syndr 2023; 17 (07) 102799
- 20 Boobes Y, Afandi B, AlKindi F. et al. Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative). BMC Nephrol 2024; 25 (01) 84
- 21 Rashid F, Abdelgadir E, Bashier A. A systematic review on the safety of Ramadan fasting in high-risk patients with diabetes. Diabetes Res Clin Pract 2020; 164: 108161
- 22 Al Awadi FF, Echtay A, Al Arouj M. et al. Patterns of diabetes care among people with type 1 diabetes during Ramadan: an international prospective study (DAR-MENA T1DM). Adv Ther 2020; 37 (04) 1550-1563
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Publication History
Article published online:
30 January 2026
© 2026. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)
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References
- 1 Abusahmin H, Abdelgadir E, Eledrisi MS, Hafidh K, Beshyah SA. Diabetes and Ramadan fasting (2023): the year in review. J Diabetes Endocr Pract 2024; 7 (02) 53-65
- 2
Al-Baqarah S.
The Holy Quran. 183-185
- 3 Al Hayek A, Al Zahrani WM, Al Dawish MA. Glucometric parameter changes in patients with type 2 diabetes during Ramadan fasting: A prospective comparative real-world study. Metab Open 2024; 23: 100304
- 4 Beshyah SA. Evolution of the risk concept and assessment tools for diabetes during Ramadan fasting: a narrative review. World J Diabetes 2025; 16 (11) 110007
- 5 Hassanein M, Al-Arouj M, Hamdy O. et al; International Diabetes Federation (IDF), in collaboration with the Diabetes and Ramadan (DAR) International Alliance. Diabetes and Ramadan: practical guidelines. Diabetes Res Clin Pract 2017; 126: 303-316
- 6 Rahmatullah, Ahmedani MY, Basit A. et al. Evidence-based risk factors for major complications during Ramadan fasting in people with diabetes grouped under IDF-DAR risk categories. Diabetes Res Clin Pract 2022; 185: 109234
- 7 Hassanein M, Afandi B, Yakoob Ahmedani M. et al. Diabetes and Ramadan: practical guidelines 2021. Diabetes Res Clin Pract 2022; 185: 109185
- 8 Shamsi N, Naser J, Humaidan H. et al. Verification of 2021 IDF-DAR risk assessment tool for fasting Ramadan in patients with diabetes attending primary health care in The Kingdom of Bahrain: the DAR-BAH study. Diabetes Res Clin Pract 2024; 211: 111661
- 9 Jamaluddin J, Nik Abdul Kadir NA, Goh LX. et al. Validation of the IDF-DAR risk tool for fasting in Ramadan for adults with diabetes mellitus in primary care: a nationwide multicentre study in Malaysia. Prim Care Diabetes 2025; 19 (06) 608-612
- 10 Kamrul-Hasan ABM, Alam MS, Kabir MA. et al. Risk stratification using the 2021 IDF-DAR risk calculator and fasting experience of Bangladeshi subjects with type 2 diabetes in Ramadan: the DAR-BAN study. J Clin Transl Endocrinol 2023; 31: 100315
- 11 Alfadhli EM, Alharbi TS, Alrotoie AM. et al. Validity of the International Diabetes Federation risk stratification score of Ramadan fasting in individuals with diabetes mellitus. Saudi Med J 2024; 45 (01) 86-92
- 12 Baynouna Alketbi L, Afandi B, Nagelkerke N. et al. Validation of the IDF-DAR risk assessment tool for Ramadan fasting in patients with diabetes in primary care. Front Clin Diabetes Healthc 2025; 6: 1426120
- 13 Hassanein M, Al Awadi FF, El Hadidy KES. et al. The characteristics and pattern of care for the type 2 diabetes mellitus population in the MENA region during Ramadan: an international prospective study (DAR-MENA T2DM). Diabetes Res Clin Pract 2019; 151: 275-284
- 14 Mohammed N, Buckley A, Siddiqui M. et al. Validation of the new IDF-DAR risk assessment tool for Ramadan fasting in patients with diabetes. Diabetes Metab Syndr 2023; 17 (04) 102754
- 15 Almalki M, AlSaeed AA, AlNomi AA. et al. Validity of the New International Diabetes Federation-Diabetes and Ramadan (IDF-DAR) risk Stratification score and fasting experience of Saudi patients with diabetes during Ramadan: insights from a cross-sectional study. Cureus 2025; 17 (02) e79351
- 16 Mazloum Khorasani Z, Mehrad-Majd H, Yaghoubi MA. Risk stratification for fasting in diabetic patients based on the IDF-DAR guideline. J Nutr Fast Health 2024; 12 (01) 14-19
- 17 Farooq Q, Ghaffar T, Malik SE, Aamir AUH. Safety of high-risk diabetic patients during Ramadan at a tertiary care hospital in Pakistan, practicing updated IDF DAR guidelines. Pak J Med Sci 2024; 40 (05) 829-834
- 18 Safari O, Shafiee A, Heidari A. et al. Ramadan fasting among adolescents with type 1 diabetes: a systematic review and meta-analysis. BMC Endocr Disord 2025; 25 (01) 45
- 19 Hassanein M, Yousuf S, Ahmedani MY. et al. Ramadan fasting in people with diabetes and chronic kidney disease (CKD) during the COVID-19 pandemic: The DaR global survey. Diabetes Metab Syndr 2023; 17 (07) 102799
- 20 Boobes Y, Afandi B, AlKindi F. et al. Consensus recommendations on fasting during Ramadan for patients with kidney disease: review of available evidence and a call for action (RaK Initiative). BMC Nephrol 2024; 25 (01) 84
- 21 Rashid F, Abdelgadir E, Bashier A. A systematic review on the safety of Ramadan fasting in high-risk patients with diabetes. Diabetes Res Clin Pract 2020; 164: 108161
- 22 Al Awadi FF, Echtay A, Al Arouj M. et al. Patterns of diabetes care among people with type 1 diabetes during Ramadan: an international prospective study (DAR-MENA T1DM). Adv Ther 2020; 37 (04) 1550-1563