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

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.