Diabetes and Ramadan Fasting (2024): A Thematic Overview

Keywords

Ramadan fasting - diabetes - patient perspectives - health care professionals - diabetes technology - pharmacological therapy

Introduction

Millions of Muslims around the world observe Ramadan fasting (RF). It lasts for 1 month per lunar calendar. RF entails abstinence from food, water, all oral substances, intravenous fluid therapy, and smoking between dawn and sunset.[1] Ramadan's impact on health and disease stems from the physiological effects of prolonged fasting during the daytime, possible overfeeding at night, and its various social changes, such as changes in exercise and sleep patterns. The last three decades witnessed a rising interest in research on RF in health and disease.[2] Diabetes is the most extensively studied single medical condition in connection with RF.[3]

Here, we provide a concise thematic overview of the global research conducted during 2024 on the impact of RF on people with diabetes.[4] [5] [6] [7] [8] [9] [10] We aim to offer a bird's eye view of the literature published in a year, which may help readers catch up with the year's research production at a glance.

Materials and Methods

This is a narrative, nonsystematic review of the literature retrieved from two online databases over a full calendar year (2024). The PubMed search engine of the National Center for Biotechnology Information at the U.S. National Library of Medicine and Google Scholar search engine were used. The search term [“Ramadan fasting” AND diabetes], with time filters from January 1, 2024 to December 31, 2024, was used to identify the relevant records. Seventy-two records were identified in PubMed, and further records were identified on Google Scholar. The pooled lists were retrieved and examined for relevance, reviewed, and narrated thematically.[4] [5] [6] [7] [8] [9] [10] We have previously demonstrated that most of the literature on RF is well covered in these two databases.[2] The aim was to provide a concise but adequately representative theme surrounding RF. No statistical analysis was conducted on the data included in the original articles, and detailed numerical presentations were avoided. Original articles, systematic reviews, and meta-analyses were included, but short narratives, other statements, and case reports were excluded. A couple of abstracts were included when deemed to be particularly valuable. Due to the heterogeneity of the publications, we have chosen to use the narrative rather than systematic review.

Key Findings

All retrieved records were identified, and after being manually scrutinized, they were deemed relevant and included in the review process. [Table 1] lists the various themes that emerged from the literature review. The results are presented following the same thematic flow.

Table 1 Emerging themes from the review of the literature on “diabetes and Ramadan fasting” published in 2024

Epidemiological observation of Ramadan fasting in people with diabetes

Experience and validation studies of the IDF-DAR risk stratification scale/tool in the real world

New and revisited data on old and new pharmacological diabetic therapies during Ramadan fasting: New data, subanalyses, and systematic reviews and meta-analyses

Role of technology in treatment and monitoring of diabetes during Ramadan fasting

Ramadan fasting in high-risk groups and special populations

Professional perspectives

Patients perspectives

Abbreviation: IDF-DAR, International Diabetes Federation-Diabetes and Ramadan Alliance.

Epidemiology

Fasting during Ramadan is common among individuals with type 2 diabetes (T2D), though it carries potential risks. Hassanein et al[11] [12] analyzed 12,529 T2D patients fasting during Ramadan (2020 and 2022). They found that 85.1% fasted for at least 1 day, with an average fasting duration of 27.6 days, 15.5% experienced hypoglycemia, 11.7% requiring emergency care, 14.9% experienced hyperglycemia, with 6.1% requiring emergency care, and patients with longer diabetes duration and higher glycosylated hemoglobin (HbA1c) (> 9%) faced greater risks.

Regional differences in fasting-related complications were notable. For instance, North Africa had the highest hypoglycemia rates (25.2%), Gulf nations reported the highest hyperglycemia rates (30.2%), and South Asia had the lowest rates of hypoglycemia (8.4%) and hyperglycemia (7.0%).

Effectiveness of Pre-Ramadan Education and Risk Assessment

Education before Ramadan is often recommended to mitigate risks, but its effectiveness remains debated. Sokwalla[13] conducted a case–control study in Kenya and found that patients who received pre-Ramadan diabetes education were significantly more likely to self-monitor blood glucose (98.3% vs. 75.3%). However, fasting outcomes—including hypoglycemia and hyperglycemia rates—did not differ considerably between educated and noneducated groups.

Similarly, Qasim et al[14] examined 304 T2D patients in Iraq and found that (1) 13.8% had at least one hypoglycemic episode and (2) no significant correlation was found between hypoglycemia and diabetes duration or oral hypoglycemic agents. These findings suggest that while education promotes self-monitoring, its direct impact on fasting outcomes remains unclear.

Validation of the International Diabetes Federation-Diabetes and Ramadan Alliance Risk Stratification Tool

The International Diabetes Federation-Diabetes and Ramadan Alliance (IDF-DAR) group risk calculator, which categorizes diabetes patients for fasting advisability, continues to gain interest. In 2024, seven studies validated its risk stratification. Shamsi et al[15] assessed its accuracy in Bahrain, facilitating health care professionals' (HCPs) decisions on fasting exemptions. Their prospective study included 757 randomly selected patients, evaluating fasting risks pre- and post-Ramadan. Among 611 analyzed patients (mean age 59.8 years, 52.8% female, 95.3% with T2D), risk classification was 27.8% low, 38.1% moderate, and 34% high. Fasting completion correlated with risk scores, with hypoglycemia being the primary reason for breaking fast. Shaltout et al[16] employed a modified Delphi method to refine risk stratification for fasting people with diabetes mellitus. Their expert panel classified patients into four risk levels, considering diabetes type, complications, fasting duration, and socioeconomic factors. The study underscored the necessity of risk assessment to optimize patient outcomes. Malik et al[17] conducted a 3-month study in Pakistan, categorizing 460 diabetes patients using the IDF-DAR 2021 tool. Of the 144 high-risk patients who fasted, 57.9% experienced hypoglycemia. Significant associations emerged between fasting outcomes and diabetes type, control, and duration. Alfadhli et al[18] validated the IDF-DAR tool in Saudi Arabia with 466 patients (79.4% T2D, 20.6% T1D). Risk distribution was 56.9% high, 24.7% moderate, and 18.4% low. High-risk patients faced more hypoglycemia and hyperglycemia, yet 70.4% of moderate- and 53.2% of high-risk individuals completed fasting. Afandi et al[19] analyzed data from 12,059 patients in the DaR Global Study (2020–2022), identifying regional fasting disparities and significant risk factors such as diabetes duration, age, HbA1c > 9%, insulin use, and vascular complications. Khorasani et al[20] stratified 317 Iranian diabetic patients based on IDF-DAR guidelines, categorizing 36.3% as low, 40% as moderate, and 23.7% as high risk. Their study suggested most patients could fast but recommended further validation through longitudinal studies. Alguwaihes et al[21] examined IDF-DAR predictability in 963 Saudi people with type 1 diabetes (PwT1D), finding 66% high risk, 34% moderate, and none low risk. High-risk patients had more fasting breaks and emergency room (ER) visits, while pre-Ramadan education reduced ER visits by 47%. Al-Sofiani et al[22] compared fasting experiences in 294 PwT1D using different insulin delivery methods. Automated insulin delivery (AID) users had the highest fasting completion and best glycemic control, with significantly better time-in-range (TIR) and fewer glycemic fluctuations than other groups. Their study emphasized the efficacy of AID system in managing diabetes during RF.

Diabetes Medications

Several studies assessed the safety and efficacy of various classes of diabetes medications during RF including original studies and meta-analyses ([Table 2]).[23] [24] [25] [26] [27] [28] [29] [30] [31] [32]

Table 2 Summary of the original studies on the efficacy and safety of different pharmacological agents during Ramadan in 2024

Author (region) (Ref)	Drugs (patients)	Acronym, setting, and/or design	Conclusions
Uddin et al, Bangladesh[23]	Gliclazide MR 60 mg (N = 98 T2D)	DIA-RAMADAN; Subanalysis in the Bangladeshi cohort	Bangladeshi patients with T2D treated with Gliclazide MR 60 mg can fast safely with a very low risk of hypoglycemia while maintaining glycemic control and body weight
Baloch et al[24]	Dapagliflozin (DAPA)	Safety and efficacy of dapagliflozin in patients with T2D during RF: an experience from tertiary care hospital	Adding DAPA significantly reduced HbA1c and blood pressure without severe hypoglycemia, diabetic ketoacidosis, or urinary tract infections
Hassanein et al (Arabian Gulf)[28]	iGlarLixi and SGLT-2i (N = 174 T2D)	SoliRam: Subset for safety and effectiveness of concomitant use in adults with T2D	Concomitant iGlarLixi and SGLT-2i use with or without other OADs is safe in T2D adults during the Ramadan fast. There is a low risk of hypoglycemia and improvements in glycemic outcomes
Hassanein et al (Arabian Gulf)[29]	iGlarLixi (N = 234 T2D)	SoliRam subgroup analysis	iGlarLixi is an effective and well-tolerated treatment in T2D during Ramadan, and is associated with low hypoglycemia risk
Hassanein et al (Egypt, Jordan, Lebanon, and Turkey)[30]	Gla-300 (N = 140 T2D)	Prospective, observational, noncomparative, multicenter study during Ramadan	Insulin Gla-300 maintained the glycemic control of T2D patients who fast during Ramadan without increased risk of hypoglycemia
Baharum et al (Malaysia)[31]	Three types of basal insulin (Glargine U-100, Levemir, and Insulatard) (N = 46 T2D and CKD)	A single-centered, prospective observational study for safety and efficacy	All three insulins demonstrated similar levels of safety and efficacy among those with T2D and DKD observing RF

Abbreviations: CKD, chronic kidney disease; DKD, diabetic kidney disease; OAD, oral antidiabetic drug; RF, Ramadan fasting; SGLT2i, sodium-glucose cotransporter-2 inhibitors; T1D, type 1 diabetes; T2D, type 2 diabetes.

Oral Agents

Uddin et al[23] analyzed Bangladeshi patients from the DIA-RAMADAN study on Gliclazide MR 60 mg. Among 98 patients, most were at moderate/low risk for fasting. Switching the dose to evening resulted in no severe hypoglycemia, a mean HbA1c reduction of –0.1%, and stable fasting plasma glucose (FPG) and body weight. Gliclazide MR 60 mg was deemed safe for fasting patients.

Baloch et al[24] studied dapagliflozin (DAPA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i), in diabetic patients taking metformin and DPP-4 inhibitors. Adding DAPA significantly reduced HbA1c and blood pressure without severe hypoglycemia, diabetic ketoacidosis (DKA), or urinary tract infections. Abdelgadir et al[25] analyzed the DAR global survey on SGLT2i safety in fasting T2D patients across the Middle East and North Africa. Among 5,865 patients, 2,379 used SGLT2i. Hypoglycemia was lower in SGLT2i users (8%) versus those on insulin or sulfonylureas (SUs). ER visits increased 3.5-fold when insulin and SUs were added to SGLT2i. Waheed et al[26] reviewed studies on SGLT2i use in fasting T2D patients. Across 359 participants, SGLT2i use had no significant impact on kidney function. Nakhleh et al[27] evaluated SGLT2i safety during RF, finding a symptomatic hypoglycemia rate of 12.5%, which increased when combined with insulin or SUs. Patients were advised to adjust insulin doses and ensure adequate hydration. Abdelgadir et al[25] reviewed studies on SGLT2i safety during RF, finding no significant links to DKA, hospitalization, or thrombosis. A few studies reported hypovolemia and estimated glomerular filtration rate (eGFR) reduction, though these findings lacked clinical significance.

Injectables and Combinations

Hassanein et al[28] [29] assessed iGlarLixi and SGLT-2i therapy in T2D patients. Hypoglycemia incidence was low in both users and nonusers of SGLT-2i. Improvements in HbA1c and FPG, with slight weight reduction, were observed. No serious adverse events occurred, demonstrating the safety of this regimen during RF. Another study by Hassanein et al[30] evaluated Gla-300 insulin in T2D patients across four countries. Insulin doses remained stable, and glycemic control was maintained without increased hypoglycemia risk. Regular self-monitoring was advised. Baharum et al[31] compared basal insulins in T2D patients with mild to moderate chronic kidney disease (CKD) during RF. A prospective study of 46 patients showed similar safety and efficacy among insulin Glargine U-100, Levemir, and Insulatard users. Pathan et al[32] investigated once-weekly semaglutide in T2D patients. Semaglutide improved glycemic control, weight loss, and dyslipidemia with minimal hypoglycemic episodes.

In summary, the studies conducted in 2024 confirm the safety of various diabetes medications during RF, including insulin, SUs, SGLT2i's, and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). While self-adjustment of drugs is common, it does not significantly impact glycemic outcomes. Gliclazide MR, dapagliflozin, and semaglutide maintain glycemic control with minimal hypoglycemia. SGLT2i, when used without insulin or SUs, reduces hypoglycemia risk. Adherence to oral semaglutide dosing and glucose monitoring is crucial for optimal outcomes. Further research is needed to refine medication strategies for fasting T2D patients.

Diabetes Technology

Several studies considered the role of advanced technology in diabetes management during Ramadan.[33] [34] [35] [36] [37] [38] [39] Key studies exploring diabetes management during Ramadan, focusing on education, AID, continuous glucose monitoring (CGM), and hybrid closed-loop (HCL) systems are summarized in [Table 3]. Mackenzie et al[33] developed and evaluated two Ramadan-focused diabetes education massive open online courses (MOOCs) for Ramadan 2023: one for HCPs in English and another for people with diabetes in English, Arabic, and Malay. A user-centered iterative design was used, incorporating feedback from a 2022 pilot MOOC. Evaluation involved pre- and postcourse surveys, demonstrating MOOCs' potential for scalable, culturally tailored diabetes education. Elbarbary et al[34] conducted a systematic literature review (SLR) on the MiniMed 780G AID system (MM780G) for PwT1D during RF. Six studies were reviewed, leading to consensus recommendations on pre-Ramadan counseling, MM780G settings, and safety measures. The SLR found that MM780G maintains glycemic control, reduces hypoglycemia, and enables PwT1D to fast for more days. However, post-Iftar hyperglycemia remains a challenge. Al Hayek and Al Dawish[35] examined glycemic risk index (GRI) changes in 186 PwT1D using intermittent scanning CGM before, during, and after Ramadan. GRI improved by 54.6%, hypoglycemic components decreased by 60%, and hyperglycemia dropped by 40.5% during fasting, though these benefits reversed post-Ramadan. Adolescents and insulin pump users had better outcomes. Findings highlight the potential of GRI for improving diabetes management. Haraj et al[36] compared glycemic fluctuations in fasting and nonfasting T2D patients during Ramadan. A prospective study of 39 patients used CGM. Fasting patients had an HbA1c of 7.36% and averaged 4.03 daily hyperglycemia episodes, mainly at Suhoor and Iftar. Nonfasting patients had more hyperglycemia but showed significant HbA1c improvement post-Ramadan. Education, risk stratification, and CGM monitoring are crucial for managing T2D during Ramadan. Al Hayek et al[37] assessed glucose changes in 93 T2D patients on nonintensive insulin using intermittently scanned CGM before, during, and after Ramadan. HbA1c, average glucose, and glucose variability significantly improved during fasting, but time spent below 54 mg/dL slightly increased. Self-care behaviors were inadequate in 32.3% of participants. Findings suggest RF benefits glucose control in T2D patients not on intensive insulin therapy. Al-Sofiani et al[38] evaluated the MiniMed 780G system in real-world users during Ramadan. Data from 449 users showed stable glycemic control with no increased daytime hypoglycemia risk. The system adapted quickly to fasting-related lifestyle changes, maintaining safety and effectiveness. Outenah et al[39] studied HCL therapy in 20 PwT1D during Ramadan. No significant differences were found in TIR, time below 70 mg/dL, or HCL usage compared with pre-Ramadan. No acute metabolic events occurred, suggesting HCL therapy maintains glycemic control during fasting.

Table 3 Summary of studies on the use of technology in managing diabetes during Ramadan

Authors (Ref)	Aims	Technology	Conclusions
Mackenzie et al (International)[33]	Two parallel massive open online courses (MOOCs) in RFDE for HCPs and PWD	A user-centered iterative platform utilized by HCPs, PWDs, their family, friends from 50 countries (N = 1,531)	MOOCs could deliver culturally tailored, high-quality, scalable, multilingual RFDE to HCPs and PWD
Elbarbary et al (International)[34]	Systematic review. Pre-Ramadan guidance on the MM780G and the IDF-DAR guidelines	MiniMed 780G AID system (MM780G) in PwT1D during RF	AID also helps PwT1D fast for more days of Ramadan than other less advanced treatment modalities
Al Hayek and Al Dawish (Saudi Arabia)[35]	The effects of RF on glycemic control in T1D, focusing on GRI for hypo- and hyperglycemia	Intermittent scanning CGM	RF significantly improved GRI and its components in individuals with T1D
Haraj et al (Morocco)[36]	To evaluate and compare glycemic fluctuations in fasting and nonfasting T2D patients during RF	iPro®2 CGMS (Medtronic). 39 T2D	The high prevalence of hyperglycemia, especially in nonfasting patients, underlines the need for tailored treatment adjustments to achieve optimal glycemic control
Al Hayek et al (Saudi Arabia)[37]	To assess glucometric changes in T2D patients before, during, and after RF	isCGMs in 93 T2DM patients	RF could improve glycemia in T2DM patients who are not on intensive insulin and have a relatively low incidence of hypoglycemia
Al-Sofiani et al (Arabian Gulf)[38]	The effectiveness and safety of the MiniMed 780G AID system in real world during RF	CareLink, MiniMed 780G system in 449 T1DM	The system is effective, safe, and fast in adapting to the substantial changes that occur in the lifestyle during RF
Outenah et al (France)[39]	How RF could challenge metabolic control in T1DM	CGM under hybrid closed-loop (HCL) therapy in 20 T1DM patients	There was no difference in TIR and other parameters, including time under 70 mg/dL. No cute metabolic events were observed

Abbreviations: AID, automated insulin delivery; CGM, continuous glucose monitoring; GRI, glycemia risk index; HCL, hybrid closed-loop; HCP, health care professional; IDF-DAR, International Diabetes Federation-Diabetes and Ramadan Alliance; isCGM, intermittent scanning CGM; PWD, people with diabetes; PwT1D, people with type 1 diabetes; RF: Ramadan fasting; RFDE, Ramadan-focused diabetes education; T1D, type 1 diabetes; T2D, type 2 diabetes; TIR, time-in-range.

In summary, these studies emphasized the role of diabetes management during Ramadan, focusing on education, AID, CGM, and HCL systems. MOOCs provide scalable, multilingual diabetes education. The MiniMed 780G maintains glycemic control and enhances fasting safety. Glycemic control improves during fasting but often reverts post-Ramadan. CGM highlights hyperglycemia risks, especially in nonfasting T2D patients. HCL therapy remains effective during fasting, supporting its use in PwT1D. Personalized strategies and education remain critical for optimal diabetes management during Ramadan.

Challenges in Special Populations[40]

Several studies addressed the special challenges of fasting during Ramadan in high-risk groups and special populations under different clinical and sociodemographic settings. These will be discussed briefly below. Farooq et al[40] assessed adherence to IDF-DAR guidelines in high-risk diabetic patients. Of 130 participants, 40% fasted against medical advice, with hypoglycemia significantly higher in the fasting group (58.3% vs. 29.3%, p = 0.021). The study underscores the need for improved patient education.

Khan et al[41] examined the effects of RF on ER visits among 200 diabetic patients. The frequency of diabetic emergencies decreased from 59.6% before Ramadan to 23.1% during and 17.3% post-Ramadan, indicating RF does not increase risks when properly managed. For instance, Rizwanullah et al[42] documented a euglycemic DKA (eDKA) case in a 50-year-old woman triggered by fasting and a urinary tract infection. Despite normal blood sugar, metabolic acidosis and hyperkalemia required hemodialysis, highlighting the need for vigilant eDKA diagnosis even with normal glucose levels. Also, Baynouna Alketbi et al[43] assessed frailty in 204 elderly Abu Dhabi residents during Ramadan using the FRAIL (Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight) tool. They found that 53.4% were frail or pre-frail, with adverse events more common among frail patients (one-third) versus pre-frail (11.2%) and robust (6.3%). The study emphasized discrepancies between physicians' assessments and structured frailty scores.

Haroon et al[44] conducted a prospective study in Karachi to evaluate fasting safety in diabetic and nondiabetic patients with stable CKD during Ramadan. Monitoring 68 patients before, during, and after Ramadan, they observed no renal function decline and noted significant improvements in blood pressure, serum creatinine, and uric acid (p < 0.0001). Furthermore, Ashkbari et al[45] examined RF's impact on CKD patients' lipid profiles, uric acid, and HbA1c. Four studies found no significant changes in cholesterol, low-density lipoprotein, triglycerides, uric acid, or HbA1c post-Ramadan (p > 0.05), suggesting a neutral effect.

Jemai et al[46] studied 140 high-risk diabetic patients fasting during Ramadan. Despite observing hypoglycemia (12.1%) and hyperglycemia (11.4%), overall glycemic control improved with reductions in fasting blood glucose and HbA1c (p < 0.05). Creatinine clearance remained stable, indicating RF can be tolerated with proper supervision. Also, Elshabrawy et al[47] classified 90 diabetic patients into high-, moderate-, and low-risk fasting groups. Hypoglycemia was significantly more frequent in high-risk patients (p < 0.05), while DKA incidence was numerically but not statistically higher (p > 0.05). Only high-risk patients had significantly declined eGFR, underscoring increased risks for PwT1D.

Hamdi et al[48] surveyed 56 PwT1D in Malaysia, finding that despite 80% being high risk, most intended to fast. Only 40% accurately assessed their risk, stressing the need for better fasting education. Also, Alguwaihes et al[49] conducted a 3-year study on young adult PwT1D in Saudi Arabia. CGM revealed significant hyperglycemic spikes after Iftar and Suhoor, persisting post-Ramadan, highlighting the need for insulin adjustments and improved fasting guidelines.

Aljahdali et al[50] explored RF's impact on cardiometabolic health in 68 Saudi adults with diabetes. Fasting led to weight loss, reduced waist and hip circumference, increased high-density lipoprotein cholesterol, and decreased inflammatory markers, suggesting potential benefits for diabetic patients. Hifdi et al[51] analyzed 48 patients with cardiovascular, metabolic, and renal complications, finding that 70% occurred during Ramadan. Fasting was linked to increased cardiovascular (49% vs. 22%) and metabolic (43% vs. 22%) complications, highlighting the importance of risk stratification and medical supervision.

Professional Perspectives

Several studies highlighted the role of education and HCPs in managing diabetes during Ramadan.[52] [53] [54] [55] [56] [57] [58] [59] These will be briefly summarized below:

Educational interventions: Firdausa et al[52] found structured education improved diabetes knowledge (30.65–92.47%) and self-care (83.87–94.08%), with significant gains in eating behavior (p = 0.046), medication adherence (p = 0.001), and glucose monitoring (p = 0.001).

Physician awareness: Mohamed et al[53] reported that 55.8% of 52 non-Muslim physicians in Saudi Arabia treated diabetic patients during Ramadan but lacked formal guidance, highlighting a need for targeted training.

Artificial intelligence (AI) in fasting safety: Ahmed and Akl[54] emphasized the use of AI tools like CGM and predictive models (e.g., PROFAST) to optimize diabetes management.

Research trends: Baharuddin and Wijaya[55] reviewed 206 studies, noting fasting's metabolic benefits and the underrepresentation of Indonesia and Brunei in research.

Pharmacists' role: Ulutas Deniz et al[56] reported that Turkish pharmacists provide medication and diet advice but face high workloads and misconceptions about their expertise, suggesting expanded training.

Good health and well-being: AbuShihab et al[57] linked RF research to Sustainable Development Goal 3 (Good Health and Well-Being), focusing on noncommunicable disease reduction but gaps in broader health outcomes. Reflection on RF.

Knowledge of HCPs: Hillier et al[58] reported Western HCPs lacked awareness of fasting risks, recommending multilingual resources and cultural competency training.

Role of general practitioners (GPs): Ali[59] highlighted GPs' roles in pre-Ramadan education, medication adjustments, and public awareness campaigns.

Patients' Perspectives

Several studies reveal patient challenges and motivations for fasting despite medical risks.[60] [61] [62] [63] [64] [65] [66] [67] [68]

Education & risk management: Oueslati et al[60] found pre-Ramadan education improved glucose monitoring (35.6–75%, p < 0.001) but increased hyperglycemia (3–14.9%, p < 0.001), emphasizing better risk stratification.

Perceptions and social factors: Yildirim Keskin et al[61] found that T2D patients valued fasting's spiritual significance but needed tailored education and support.

Adolescent fasting risks: Rahme et al[62] found that 34% of 44 adolescents with uncontrolled T1D fasted despite health risks due to religious and social motivations, calling for revised guidelines.

Psychosocial impact: Missaoui et al[63] linked lower self-esteem to high-risk fasting patients, highlighting the need for emotional support.

Fasting against medical advice: Aljanahi and Afandi[64] reported a 56-year-old T2D patient fasting without medical guidance, stressing the need for personalized management.

Gestational diabetes in Ramadan: Al-Marzouqi et al[65] found fasting among 20 pregnant women was influenced by spiritual and social factors but complicated by health risks and inconsistent medical advice.

Health care–religion conflicts: Makakena[66] found many diabetic patients self-managed fasting without medical input, stressing clearer national guidelines and doctor–religious leader collaboration.

Self-care and knowledge: Boujelben et al[67] found that 56% of 70 Tunisian diabetics recognized hypoglycemia risks, but only 27% understood high-risk scenarios, highlighting the need for clearer medical guidance.

Fasting safety factors: Alharbi et al[68] linked diabetes type, age, and medication use to fasting risks, emphasizing education and preventive strategies.

Limitations and Gaps

The article is limited by its concise thematic overview of the global research conducted during a limited duration of a single year. The subjects are chosen by their publication year. However, it adds to the previously published articles on the same subject.[4] [5] [6] [7] [8] [9] [10] Restricted by the volume and readability, only articles focused on diabetes and Ramadan were included. The impact of RF on wider aspects of health care is being published elsewhere. Due to the inhomogeneity of the studies, narrative rather than systematic reviews was deemed more appropriate. A single year's study could not identify gaps in the research due to selection bias. This calls for a more subject-based review of the literature to draw a wider picture of knowledge, yet this article is meant to provide a quick update of the latest research and key opinions described in the past year.[69]

Conclusion

The 2024 literature on diabetes and RF continues to refine best practices for safe fasting. Key takeaways include: risk stratification tools like IDF-DAR effectively identify high-risk patients. Advances in insulin delivery and CGMs improve fasting outcomes. Pharmacotherapy options such as GLP-1 RAs and SGLT2is remain safe but require monitoring. Fasting offers metabolic benefits, including improved lipid profiles and reduced inflammation. Future research should focus on enhancing risk assessment models and optimizing technology-driven solutions to improve diabetes management during RF further.

Effective education, physician training, AI integration, and pharmacist involvement can help diabetic patients fast and safely. Expanding research and interdisciplinary collaboration will further improve Ramadan diabetes management. Diabetic patients often fast despite medical risks, driven by religious beliefs, social factors, and limited medical guidance. Studies emphasized the need for personalized education, stronger physician–patient communication, and spiritual leader involvement to ensure safe fasting practices.

• References

• 1 Beshyah SA, Fathalla W, Saleh A. et al. Ramadan fasting and the medical patient: an overview for clinicians. Ibnosina J Med Biomed Sci 2010; 2 (05) 240-257
• 2 Beshyah WS, Beshyah SA. Bibliometric analysis of the literature on Ramadan fasting and diabetes in the past three decades (1989-2018). Diabetes Res Clin Pract 2019; 151: 313-322
• 3 Beshyah SA. Fasting during Ramadan for people with diabetes: medicine and Fiqh united at last. Ibnosina J Med Biomed Sci 2009; 1 (02) 58-60
• 4 Beshyah SA, Ali KF, Hafidh K, Hajjaji IM. Ramadan fasting and diabetes 2019: the year in review. Diabetes Res Clin Pract 2021; 172: 108593
• 5 Hafidh K, Ali KF, Beshyah SA. Ramadan fasting, and diabetes practice and research (2020): the year in review. J Diabetes Endoc Pract 2021; 4 (02) 46-58
• 6 Hafidh K, Ali KF, Beshyah SA. Ramadan fasting in health and disease (2020): a narrative review of the literature. Ibnosina J Med Biomed Sci 2021; 13 (02) 102-121
• 7 Beshyah SA, Almalki MH, Azzoug S, Barake M, Al Dahmani K, Chihaoui M. Diagnosis and management of Cushing's disease: a survey of endocrinologists from the Middle East and North Africa. J Diabetes Endocr Pract 2022; 5: 21-28
• 8 Beshyah SA, Hafidh K, Kenz S, Elmehdawi RR, Mohamed G, Eledrisi M. Ramadan fasting and diabetes (202): the year in review. J Diabetes Endocr Pract 2022; 5 (01) 8-20
• 9 Hafidh K, Besheya TA, Elmehdawi R, Beshyah SA. Ramadan fasting and diabetes (2022): the year in review. J Diabetes Endocrine Pract 2023; 6: 104-117
• 10 Abusahmin H, Abdelgadir E, Eledrisi MS. et al. Diabetes and Ramadan fasting (2023): the year in review. J Diabetes Endocrine Practice 2024; 7: 53-65
• 11 Hassanein M, Ahmedani MY, Shaltout I. et al. Ramadan fasting among adults with T2D in five geographically different regions: the DAR 2020 global survey. Diabetes Epidemiol Manag 2024; 16: 100229
• 12 Hassanein M, Binte Zainudin S, Shaikh S. et al. An update on the current characteristics and status of care for Muslims with type 2 diabetes fasting during Ramadan: the DAR global survey 2022. Curr Med Res Opin 2024; 40 (09) 1515-1523
• 13 Sokwalla S. Effect of pre- Ramadan risk assessment and education on fasting- related patient outcomes in ambulant adults living with diabetes mellitus: a multi-center case control study. J Kenya Assoc Phys 2024; 6 (02) 1
• 14 Qasim BA, Ahmed MJ, Mohammed AA. Incidence of hypoglycemia among patients with type 2 diabetes who fasted during Ramadan. Advanced Med J 2024; 9 (01) 160-166
• 15 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
• 16 Shaltout I, Abdelwahab AM, El Meligi A. et al. Risk stratification in people with diabetes for fasting during Ramadan: consensus from Arabic Association for the Study of Diabetes and Metabolism. Curr Diabetes Rev 2024; 20 (07) e201023222409
• 17 Malik SE, Kanwal S, Haider I. et al. Risk stratification, intention to fast, and outcomes of fasting during Ramadan in people with diabetes presenting to a tertiary care hospital. Endocr Pract 2024; 30 (10) 951-956
• 18 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
• 19 Afandi B, Hafidh K, Malek R. et al. Characteristics of non-fasting patients with diabetes type 2 in the DAR global surveys of 2020 and 2022. Diabetes Epidemiol Manag 2014; 15 (06) 100217
• 20 Khorasani ZM, 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
• 21 Alguwaihes A, Alotaibi M, Al-Sofiani M. et al. The updated International Diabetes Federation-Diabetes and Ramadan 2021 risk calculator and prediction of type 1 diabetes-related complications during Ramadan in real-world setting. Endocr Pract 2024; 30 (12) S9
• 22 Al-Sofiani ME, Alharthi S, Albunyan S, Alzaman N, Klonoff DC, Alguwaihes A. A Real-world prospective study of the effectiveness and safety of automated insulin delivery compared with other modalities of type 1 diabetes treatment during Ramadan intermittent fasting. Diabetes Care 2024; 47 (04) 683-691
• 23 Uddin MF, Khan MA, Selim S. et al. Real-world evidence on the effectiveness and safety of gliclazide MR 60 mg in Bangladeshi patients with type II diabetes during fasting: a sub-analysis from the global DIA-RAMADAN study. J Comp Eff Res 2024; 13 (02) e230132
• 24 Baloch AA, Shabir KU, Kiran Z. et al. Safety and efficacy of dapagliflozin in patients with type 2 diabetes mellitus during fasting in the month of Ramadan: an experience from tertiary care hospital. Int J Diabetes Dev Ctries 2024;
• 25 Abdelgadir E, Bashier A, Ashfaq F. et al. Efficacy and safety of sodium-glucose cotransporter-2 (SGLT2) inhibitor use during Ramadan fasting: a systematic review. J Diabetes Endocrine Practice 2024; 07 (04) 176-184
• 26 Waheed MA, Diffala Suwileh SAS, Rashid K, Ansar F, Elzouki A. Effect of SGLT2 inhibitors on kidney function of type 2 diabetes patients during Ramadan: a systematic review. Qatar Med J 2024; 2024 (03) 26
• 27 Nakhleh A, Mazareeb J, Darawshi S, Masri A, Shehadeh N. Safety and effectiveness of sodium-glucose co-transporter 2 inhibitors on glycemic control in patients with type 2 diabetes mellitus fasting during Ramadan: a review. Clin Med Insights Endocrinol Diabetes 2024;17:11795514241238058
• 28 Hassanein M, Malek R, Al Sifri S. et al. Safety and effectiveness of concomitant iGlarLixi and SGLT-2i use in people with T2D during Ramadan fasting: a SoliRam study sub-analysis. Diabetes Ther 2024; 15 (11) 2309-2322
• 29 Hassanein M, El Naggar A, Al Sheikh A. et al. Safety and effectiveness of iGlarLixi in adults with type 2 diabetes mellitus from Gulf countries during Ramadan holy month: a subgroup analysis of the SoliRam observational study. Diabetes Res Clin Pract 2024; 209: 111567
• 30 Hassanein M, Shaltout I, Malek R. et al. Real-world safety and effectiveness of insulin glargine 300 U/mL in participants with type 2 diabetes mellitus during the period of Ramadan in four countries (Egypt, Jordan, Lebanon, and Turkey): a prospective observational study. Curr Diabetes Rev 2024; 20 (05) e110823219694
• 31 Baharum NH, Wan Muhammad Hatta SF, Zainordin NA, Abdul Ghani R. Safety and efficacy of different basal insulin in type 2 diabetes mellitus with chronic kidney disease in Ramadan: prospective observational study. BMC Endocr Disord 2024; 24 (01) 260
• 32 Pathan MF, Akter N, Selim S. et al. Safety and efficacy of semaglutide use in diabetes during Ramadan fasting: a real-world experience from Bangladesh. Bangladesh J Endocrinol Metab 2024; 3 (01) 26-35
• 33 Mackenzie SC, Dickson J, Mehar S. et al. Digitising diabetes education for a safer Ramadan: design, delivery, and evaluation of massive open online courses in Ramadan-focused diabetes education. Prim Care Diabetes 2024; 18 (03) 340-346
• 34 Elbarbary N, Alguwaihes A, Zarif H. et al. MiniMed 780G system use in type 1 diabetes during Ramadan intermittent fasting: a systematic literature review and expert recommendations. Diabetes Technol Ther 2025; 27 (01) 72-85
• 35 Al Hayek A, Al Dawish MA. Improvement of glycemia risk index and continuous glucose monitoring metrics during Ramadan Fasting in type 1 diabetes: a real-world observational study. J Diabetes Sci Technol 2024;19322968241301750:19322968241301750
• 36 Haraj NE, Harouna Malam Brah NA, Elaziz S, Chadli A. Evaluation of glycemic control in patients with diabetes by a continuous glucose monitoring system during the month of Ramadan. Cureus 2024; 16 (10) e72710
• 37 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
• 38 Al-Sofiani ME, Petrovski G, Al Shaikh A. et al. The MiniMed 780G automated insulin delivery system adapts to substantial changes in daily routine: lessons from real world users during Ramadan. Diabetes Obes Metab 2024; 26 (03) 937-949
• 39 Outenah C, Ly Sall K, Penfornis A, Amadou C, Dardari D. Automated insulin delivery system: a solution for moderate to high-risk Ramadan fasting in people living with type 1 diabetes. Diabetes Technol Ther 2024; 26 (11) e881-e884
• 40 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
• 41 Khan MY, Khan S, Ali S. et al. Influence of fasting on emergency visits to a tertiary care hospital by fasting diabetic patients in Ramadan. Journal of Health and Rehabilitation Research 2024; 4 (02) 572-576
• 42 Rizwanullah AT, Ahmadi T, Ahmad A, Khan W, Rosario-Curcio JC. Euglycemic diabetic ketoacidosis with acute renal failure: a challenging case for clinicians. Cureus 2024; 16 (05) e60171
• 43 Baynouna Alketbi LM, Afandi B, Nagelkerke N. et al. Frailty assessment and outcomes in primary care for patients with diabetes during Ramadan: implications for risk evaluation and care plans. Front Med (Lausanne) 2024; 11: 1426140
• 44 Haroon A, Riaz M, Rabbani B, Saeed A. Safety of fasting in diabetic and non-diabetic patients with stable chronic kidney disease during Ramadan. Pak J Med Sci 2024; 40 (04) 563-567
• 45 Ashkbari A, Nikbakht HA, Amirkhanlou S. et al. Impact of Ramadan fasting on lipid profile, uric acid, and HbA1c in CKD: a systematic review and meta-analysis. Prim Care Diabetes 2024; 18 (03) 277-283
• 46 Jemai C, Nouira M, Htira Y. et al. Description of clinical profile, acute complications and glycemic control after Ramadan fasting in a Tunisian population of patients with diabetes. Hum Nutr Metab 2024; 200285
• 47 Elshabrawy AM, Khalil UA, Assyorcid MH. et al. The challenge of Ramadan fasting in patients with type 1 diabetes mellitus. Zagazig Univ Med J 2024; •••
• 48 Hamdi NH, Ng YS, Tong CV. Type 1 Diabetes Mellitus Patients in a Single Tertiary Centre. In: 14th MEMS Annual Congress 2024 (MAC 14) EP_A043 page 35
• 49 Alguwaihes A, Alrajeh A, Alyusuf E. et al. Altered Ramadan fasting glycemic profiles of adults with type 1 diabetes reveal strong evidence of underestimated insulin adjustments: a 3-year observational study in Arab settings. Endocr Pract 2024; 30 (12) 1901794
• 50 Aljahdali A, Al-Maiman R, Al-Orf S, Bawazeer N. Impact of Ramadan fasting on cardiometabolic and inflammatorybiomarkers among Saudi adults with diabetes. Curr Diabetes Rev 2024; 20 (09) e080124225329
• 51 Hifdi Z, Laidi S, Elamari S, Marouan F. Acute complications in diabetic patients during the month of Ramadan: about 48 cases. Endocrine Abstracts 2024; 99: 458
• 52 Firdausa S, Syahrizal D, Rachmah R. et al. Fasting and diabetes: an interventional approach to enhance knowledge and self-care during Ramadan. Preprint: DOI: 10.21203/rs.3.rs-5286441/v1
• 53 Mohamed HA, Nasser RN, Doumit J. Physicians' knowledge from different religious background on management of diabetic patients during Ramadan fasting in Saudi Arabia. International Journal of Religion 2024; 5 (06) 457-463
• 54 Ahmed A, Akl MM. Using artificial intelligence to guide physicians in making fasting decisions for diabetics during Ramadan. Qeios 2024; PPR807444 (preprint)
• 55 Baharuddin B, Wijaya A. Metabolism and diabetes in Ramadan fasting: exploring health trends and relationships through systematic literature network analysis. Narra J 2024; 4 (02) e850
• 56 Ulutas Deniz E, Ceylan C, Kaya HS. Community pharmacists' experiences regarding the treatment management of people with diabetes during Ramadan: a phenomenological study. J Am Pharm Assoc (Wash DC) 2025; 65 (01) 102303
• 57 AbuShihab K, Obaideen K, Alameddine M. et al. Reflection on Ramadan fasting research related to Sustainable Development Goal 3 (Good Health and Well-Being): a bibliometric analysis. J Relig Health 2024; 63 (05) 3329-3359
• 58 Hillier KAW, Longworth ZL, Vatanparast H. Healthcare professionals knowledge, attitude, practices, and perspectives providing care to Muslims in Western countries who fast during Ramadan: a scoping review. Appl Physiol Nutr Metab 2024; 49 (04) 415-427
• 59 Ali M. Responsibilities of general practitioners regarding diabetes mellitus during the month of Ramadan. Cureus 2024; 16 (03) e55977
• 60 Oueslati I, Cherif L, Aloui E, Mabrouk M, Yazidi M, Chihaoui M. Ramadan diurnal intermittent fasting in patients with diabetes: assessment of knowledge, practices, risk of complications, and impact of pre-Ramadan education. J Diabetes Metab Disord 2024; 24 (01) 9
• 61 Yildirim Keskin A, Şentürk S, Teke ZB. Ramadan as religious ritual: experiences of Muslim people with type 2 diabetes in Türkiye regarding Ramadan. Diabetes Res Clin Pract 2024; 215: 111802
• 62 Rahme Z, Mesbah N, Taha N. et al. Reasons behind fasting Ramadan against medical advice for individuals under 18 years with uncontrolled type 1 diabetes—a tertiary center experience. Diabetes 2024; 73 (01) 642
• 63 Missaoui AM, Mnif F, Soomauroo S. et al. Ramadan fasting prohibition among Muslim individuals with diabetes: exploring cultural impacts on self-esteem. Endocrine Abstracts 2024; 99: EP801
• 64 Aljanahi MH, Afandi BO. Ramadan fasting and feasting illustrated!. J Diabetes Endocrine Prac 2024; 07 (03) 145-148
• 65 Al-Marzouqi Z, Momani A, Al-Mamari H. Ramadan fasting experience of pregnant women with gestational diabetes mellitus. Adv Biomed Health Sci 2024; 3 (04) 177-184
• 66 Makakena RHG. Views and experiences on fasting during Ramadan among Muslim patients with type 2 diabetes: a phenomenological inquiry. Internet Document. Accessed May 8, 2025 at: https://ojs.upmin.edu.ph/index.php/jcsh/article/view/63/66
• 67 Boujelben K, Ben Salah D, Touzi F. et al. Knowledge of diabetes mellitus during Ramadan fasting among Tunisian patients with diabetes mellitus. Endocrine Abstracts 2024; 99: EP524
• 68 Alharbi M, Almuzaini A, Alsaadi G. et al. Eid-al-Fitr festivity and Ramadan fasting attitude among individuals with diabetes from Saudi Arabia. IJMDC 2024; 8 (08) 1933-1945
• 69 Beshyah SA, Ali KF, Hajjaji IM. et al. Knowledge gaps and perceptions of future research directions on management of diabetes during Ramadan fasting: an online survey of physicians. Diabetes Res Clin Pract 2021; 177: 108923