Diabetes and Ramadan Fasting (2024): A Thematic Overview

Abstract

Objectives

We aimed to provide a narrative overview of the global literature production during 2024 on diabetes and Ramadan fasting (RF).

Materials and Methods

A narrative, nonsystematic review of the international literature from two major medical online databases (PubMed and Google Scholar) in one calendar year (2024). The search term “Ramadan fasting AND Diabetes” was used, and relevant literature was narrated in a concise thematic account.

Results

Themes from a review of the literature on RF published in 2024 included studies on the epidemiology of fasting in the real world, nutrition, and metabolism during fasting. Several studies assessed the validity of the recently proposed risk stratification tool. The use and safety of different pharmacological therapeutic agents such as sulphonylureas, newer basal insulin analogs, and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose co-transporter 2 (SGLT2) inhibitors were also studied in various geographical and socioeconomic settings. The role of diabetes technology in Ramadan was the focus of several studies of insulin pumps and monitoring. Special interest was in the high-risk groups, such as acute complications and fasting in chronic kidney disease. Several groups also considered professional and patient perspectives.

Conclusion

The literature on RF and diabetes in 2024 continued to address epidemiology, risk stratification, the safety of pharmacological agents, diabetes technology, issues about high-risk patients, and patient perspectives.

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.

Conflict of Interest

None declared.

Disclaimer

To the best of our abilities, we presented our perception of the published work in good faith. Original authors cannot be held responsible for any misrepresentation.

Compliance with Ethical Principles

No ethical approval is required a review-type of study.

Authors' Contributions

S.A.B. proposed the study, performed the literature searches, and drafted the manuscript. All authors reviewed the document for intellectual content and approved its final version.

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Publication History

Article published online:
22 May 2025