Keywords
diabetes - Ramadan - IDF-DAR risk stratification - hypoglycemia - hyperglycemia -
DKA
Introduction
Ramadan, the ninth month of the Islamic lunar calendar, requires Muslims to fast from
dawn to sunset. This practice is obligatory for all physically and mentally capable
Muslims and lasts 29 to 30 days, during which individuals abstain from consuming food
or drink during daylight hours. Ramadan holds deep cultural and spiritual significance
within the Islamic community, serving as a time for reflection, devotion, and self-discipline.
However, fasting during this holy month can be challenging, particularly for individuals
with chronic medical conditions like type 1 diabetes (T1D)[1]
Fasting during Ramadan is an integral part of the Islamic faith, observed by millions
of Muslims worldwide yearly. However, since illness is an inherent aspect of human
life, it is crucial to understand how it affects fasting during Ramadan.[2] Acute illnesses during Ramadan can range from mild to severe, potentially impacting
a person's ability to fast safely. Mild conditions like upper respiratory tract infections
or headaches typically do not require breaking the fast. In contrast, severe illnesses
such as chest infections, strokes, myocardial infarction, or severe gastroenteritis
may necessitate hospitalization. Patients recovering from such illnesses can compensate
for missed fasts after Ramadan.[1]
Individuals with chronic conditions can often fast safely under controlled conditions.
Those with well-managed chronic illnesses, such as type 2 diabetes (T2D) controlled
with oral hypoglycemic agents, dyslipidemia, or hypertension, can usually fast without
adverse effects. However, in advanced chronic conditions, such as cancer, complicated
T1D, or terminal illnesses, fasting may pose significant health risks. Avoiding fasting
is advised in such cases, and a Fidya (monetary payment in place of fasting) should
be given.[1]
Despite the exemptions for individuals with serious health conditions like diabetes,
a substantial proportion of patients with T2D still choose to fast during Ramadan.
The EPIDIAR study reported that 78.7% of patients with T2D fasted during Ramadan,
while the CREED study found that 63.6% of patients with T2D observed the fast. These
findings demonstrate that many patients prioritize fasting despite potential health
risks.[2]
[3] According to the EPIDIAR study conducted in 2001, 42.8% of patients with T1D and
78.7% of those with T2D experienced sharp fluctuations in blood sugar (BS) levels
during Ramadan. Similarly, a study in Pakistan reported that 35.3% of T1D patients
and 23.2% of T2D patients experienced hypoglycemic episodes during Ramadan fasting.
Additionally, 33.3% of T1D patients and 15.4% of T2D patients experienced hyperglycemic
episodes accompanied by symptoms.[2]
[3]
[4]
The risks associated with Ramadan fasting for persons with diabetes include hypoglycemia,
dehydration, hyperglycemia, diabetic ketoacidosis (DKA), and thrombosis.[1]
[2]
[5]
[6]
[7] Studies have demonstrated that structured education programs can reduce the risk
of hypoglycemia and DKA during Ramadan fasting.[8]
[9]
[10] Such programs help promote safe fasting practices, enabling individuals to fulfill
their religious obligations while maintaining their health.
This article will assess the validity of the new International Diabetes Federation-Diabetes
and Ramadan International Alliance (IDF-DAR) risk stratification tool for Ramadan
fasting in predicting the ability of persons with diabetes to fast safely. Additionally,
it will assess the impact of a well-structured pre-Ramadan education program based
on the IDF-DAR risk stratification in helping patients to fast safely and reducing
fasting-associated complications as recommended by previous studies.[8]
[9]
Methods
This multicenter prospective observational study was carried out in three diabetes
centers (Suhar Hospital, Falaj Al Qabial Health Centre, and Sur Diabetes Centre) in
Oman from January to March 2024.
All eligible patients seeking diabetes care in the three study settings were invited
with a clear orientation about the study. They were provided with a preassessment
and introduced to a well-structured educational program 4 to 8 weeks before Ramadan.
A written treatment plan was provided to every person with diabetes intending to fast
during Ramadan. It included individualized treatment objectives, prescribed medication
dosage, recommended timing, self-monitoring of blood glucose (SMBG), expected complications,
and appropriate steps to seek medical advice via an allocated WhatsApp number. A structured
data collection sheet was developed to collect required data from the participants
during routine diabetes clinic visits within 2 months pre-Ramadan, including age,
sex, education level, diabetes mellitus type and duration, diabetes complications,
hemoglobin A1c (HbA1c), creatinine level, and estimated glomerular filtration rate.
Based on the collected information, the IDF-DAR risk stratification scoring tool was
used to classify patients with diabetes into high-risk, moderate-risk, and low-risk
groups.[1] The fasting decision was based on the patient's preference and the health care provider's
recommendations. In addition, participants were asked to fill out a follow-up questionnaire
during and after Ramadan, indicating fast completion, fast-breaking reasons, and the
impact of fasting on BS control, diet control, and intensity of physical exercises.
SPSS, version 23, was used in the analysis of data. The chi-square test and logistic
regression were applied to predict factors affecting the management to fast the whole
month of Ramadan. Odds ratios (ORs) with 95% confidence intervals (CIs) were also
calculated. Hypotheses were statistically tested at a 5% level of significance.
Results
Demographic Characteristics
This study encompassed a cohort of 326 patients with diabetes, comprising 157 males
(48.2%) and 169 females (51.8%). Most participants (74%) had completed at least a
basic level of education. Of the cohort, 230 (70.6%) were diagnosed with T2D, while
96 (29.4%) had T1D. The number of people who decided not to fast or fasted some days
is as follows: Out of 73 who broke fast, 14 decided not to fast the whole month.
IDF-DAR Risk Stratification Scores
Based on the IDF-DAR risk stratification score, 125 (38.3%) were classified as high
risk, 103 (31.6%) as moderate risk, and 98 (30.1%) as low risk. The IDF-DAR risk stratification
revealed a significant difference by diabetes type (p < 0.001). Notably, 61 patients with T1D (63.5%) were classified as high risk compared
to 64 patients with T2D (27.8%) ([Fig. 1]).
Fig. 1 International Diabetes Federation-Diabetes and Ramadan International Alliance (IDF-DAR)
risk categories by types of diabetes.
Clinical Correlations of the IDF-DAR Risk Scores
There was a significant correlation between IDF-DAR risk stratification and HbA1c
levels (p < 0.001). The average HbA1c level was higher in the high-risk group (9.7%) compared
to the moderate-risk (8.7%) and low-risk (7.5%) groups. Additionally, risk increased
with greater severity of renal dysfunction (p = 0.016) but decreased significantly with age (p < 0.001).
Table 1
IDF-DAR risk categories by patients' characteristics (N = 326)
|
Characteristics
|
All patients
|
IDF-DAR risk category
|
p-Value
|
|
Low risk
|
Moderate risk
|
High risk
|
|
Sex (n, %)
|
Male
|
157 (48.2)
|
55 (35.0)
|
43 (27.4)
|
59 (37.6)
|
0.132
|
|
Female
|
169 (51.8)
|
43 (25.4)
|
59 (34.9)
|
67 (39.7)
|
|
|
Age (mean ± SD)
|
|
45.7 ± 18.6
|
51.4 ± 15.8
|
45.2 ± 19.5
|
41.5 ± 18.8
|
0.001
|
|
Type of diabetes (n, %)
|
T1DM
|
96 (29.4)
|
0 (0.0)
|
35 (36.5)
|
61 (63.5)
|
0.001
|
|
T2DM
|
230 (70.6)
|
98 (42.6)
|
67 (29.1)
|
65 (28.3)
|
|
|
Renal function (n, %)
|
(eGFR > 60)
|
296 (90.8)
|
96 (32.4)
|
91 (30.7)
|
109 36.8)
|
0.003
|
|
(eGFR 30–60)
|
26 (8.0)
|
2 (7.7)
|
11 (42.3)
|
13 (50.0)
|
|
|
(eGFR < 30)
|
4 (1.2)
|
0 (0.0)
|
0 (0.0)
|
4 (100.0)
|
|
|
Pre-Ramadan HbA1c (%) (mean ± SD)
|
8.7 ± 2.3
|
8.7 ± 2.3
|
7.5 ± 1.8
|
8.7 ± 2.0
|
9.7 ± 2.4
|
|
All patients
|
98 (30.0)
|
102 (31.3)
|
126 (38.7)
|
|
Abbreviations: eGFR, estimated glomerular filtration rate; IDF-DAR, International
Diabetes Federation-Diabetes and Ramadan International Alliance; SD, standard deviation;
T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.
Impact of the IDF-DAR Risk Scores on the Ability to Fast
The mean fasting days per risk group were as follows: average fasting days = 27.5
days; low risk = 29.9 days; moderate risk = 28.1 days; and high risk = 25.1 days.
Based on the logistic regressions depicted in [Table 2], a significant association was observed between diabetes type and the ability to
fast throughout Ramadan ([Table 1]). Only 51% of patients with T1D managed to fast the entire month, compared to 89%
of those with T2D. The odds of breaking the fast were 7.65 times higher among T1D
patients than T2D patients (OR = 7.65, 95% CI: 4.31–13.56). The IDF-DAR risk stratification
also significantly predicted fasting ability (p = 0.001). Among the low-risk group, 97% completed the fast, compared to 82% in the
moderate-risk group and only 58% in the high-risk group. Compared to the low-risk
group, the odds of breaking the fast were 6.79 times higher in the moderate-risk group
(95% CI: 1.93–23.85) and 22.87 times higher in the high-risk group (95% CI: 6.87–76.19).
[Fig. 2] shows the ability to fast the whole of Ramadan by types of diabetes and IDF-DAR
risk categories.
Table 2
Simple logistic regressions of the associations between managing Ramadan fasting and
patients' characteristics
|
Manage fasting the whole month of Ramadan?
|
p-Value
|
Odds ratio
|
95% CI
|
|
No
|
Yes
|
|
n (%)
|
n (%)
|
|
Sex
|
Male
|
35 (22.4)
|
121 (77.6)
|
0.538
|
1
|
|
|
Female
|
38 (22.6)
|
130 (77.4)
|
|
1.01
|
(0.60, 1.70)
|
|
Type of diabetes
|
T1DM
|
47 (49.5)
|
48 (50.5)
|
0.001
|
7.65
|
(4.31, 13.56)
|
|
T2DM
|
26 (11.4)
|
203 (88.6)
|
|
1.00
|
|
|
Renal function
|
(eGFR > 60)
|
67 (22.8)
|
227 (77.2)
|
0.911
|
1
|
|
|
(eGFR 30–60)
|
5 (19.2)
|
21 (80.8)
|
0.678
|
0.81
|
(0.29, 2.22)
|
|
(eGFR < 30)
|
1 (25.0)
|
3 (75.0)
|
0.917
|
1.13
|
(0.12, 11.04)
|
|
IDF-DAR risk category
|
Low risk (0–3)
|
3 (3.1)
|
95 (96.9)
|
0.001
|
1
|
|
|
Moderate risk (3.5–6)
|
18 (17.8)
|
83 (82.2)
|
0.003
|
6.87
|
(1.95, 24.14)
|
|
High risk (> 6)
|
52 (41.6)
|
73 (58.4)
|
0.001
|
22.56
|
(6.77, 75.12)
|
|
All patients
|
73 (22.5)
|
251 (77.5)
|
|
|
|
Abbreviations: CI, confidence interval; eGFR, estimated glomerular filtration rate;
IDF-DAR, International Diabetes Federation-Diabetes and Ramadan International Alliance;
T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus.
Note: Out of 73 who broke their fast, 14 decided not to fast the whole month. Average
fasting days: low-risk (29.9), moderate-risk (28.1), and high-risk (25.1).
Fig. 2 Ability to fast the whole of Ramadan by types of diabetes and International Diabetes
Federation-Diabetes and Ramadan International Alliance (IDF-DAR) risk categories.
Impact of Pre-Ramadan Education
Pre-Ramadan education had a statistically significant impact on fasting outcomes (p < 0.001). [Table 3] shows that participants who acknowledged its importance were more likely to fast
for the entire month than those who did not recognize its role. They also reported
better management of fasting-related fatigue (83%) and improved BS control (82%).
In addition, most of those who experienced breaking the fast during the previous Ramadan
(88%) could fast the entire month.
Table 3
The perception of patients on the impact of pre-Ramadan education on managing Ramadan
fasting
|
Manage fasting the whole month of Ramadan?
|
p-Value
|
|
No
|
Yes
|
|
n (%)
|
n (%)
|
|
Do you think that education helped you fast more days this year?
|
Yes
|
45 (17.2)
|
217 (82.8)
|
0.001
|
|
No
|
10 (35.7)
|
18 (64.3)
|
|
|
I do not know
|
18 (56.3)
|
14 (43.8)
|
|
|
Do you think that education has made you less tired during the fast this year?
|
Yes
|
44 (17.2)
|
212 (82.8)
|
0.001
|
|
No
|
14 (40.0)
|
21 (60.0)
|
|
|
I do not know
|
15 (48.4)
|
16 (51.6)
|
|
|
Did Ramadan help you in controlling your BG?
|
Yes
|
47 (17.7)
|
218 (82.3)
|
0.001
|
|
No
|
12 (41.4)
|
17 (58.6)
|
|
|
I do not know
|
14 (50.0)
|
14 (50.0)
|
|
|
Required admission?
|
Yes
|
4 (66.7)
|
2 (33.3)
|
0.022
|
|
No
|
66 (21.0)
|
248 (79.0)
|
|
|
Managed to fast last year
|
Yes
|
30 (11.6)
|
228 (88.4)
|
0.001
|
|
No
|
42 (65.6)
|
22 (34.4)
|
|
Abbreviation: BG, blood glucose.
Outcomes
Hypoglycemia occurred in 37% of the participants, hyperglycemia in 20.5%, and both
in 1.4% of participants. These were the primary reasons for breaking the fast, followed
by doctor's advice (13.7%) and women's health considerations (11%). However, only
1.9% of patients required hospitalization during Ramadan, with five out of six cases
due to DKA and one due to severe hyperglycemia.
Discussion
This study was conducted among 326 subjects with T1D and T2D attending three diabetes
clinics in Oman for 4 to 8 weeks pre-Ramadan in 2024. The aims were to assess the
predictability features of the IDF-DAR risk stratification tool for Ramadan fasting
and to evaluate the impact of the given structured pre-Ramadan education on the fasting
experience.
The IDF-DAR risk stratification was used in this study to assess patients' risks and
predict their ability to fast.[1] The risk classifications were as follows: 30.1% of the participants were classified
as low risk, 31.6% as moderate risk, and 38.3% as high risk. These findings align
with several previous studies, with some differences in the proportion distributions.[11]
[12]
[13] In contrast, Malik et al[14] and Kamrul-Hasan et al[15] found a lower proportion in the high-risk category compared to the low-risk category.
When combining the high- and moderate-risk categories, the overall recommendation
in these studies was against fasting, but the decision to fast was based on patients'
preferences. The variation in risk classifications could be attributed to differences
in the level of diabetes clinics (tertiary or primary care) and patients' characteristics
such as age, type of diabetes, and duration of diabetes.
Overall, this study provided further evidence of IDF-DAR risk stratification's ability
to predict the nonfasting of patients with diabetes during Ramadan, aligning with
previous research findings.[12] The ability to fast the entire month decreased with increased IDF-DAR risk stratification,
as 97% of the low-risk group were able to fast the entire month compared to 82% of
the moderate-risk group and 58% of the high-risk group. ORs showed that the high-risk
group had a 22-fold and the moderate-risk group had a 6-fold increase in the likelihood
of fast-breaking compared to the low-risk group. Compared with Alfadhli et al,[12] the high-risk group exhibited a 6.7-fold increase, and the moderate-risk exhibited
a 3.2-fold increase in the risk of fast-breaking compared to the low-risk group. Additionally,
Shamsi et al[13] reported a high percentage of fasting the whole month among the three risk categories
and a significantly increased risk of fast-breaking among the high-risk and moderate-risk
groups compared to the low-risk groups.
The proportions of T1D involved in previous research were low compared to T2D.[8]
[12]
[13]
[16] T1D accounted for 29.4% of the participants in the current study cohort. Although
63.5% were classified as a high-risk group, half (50.5%) could fast all days of Ramadan.
This positive outcome aligns with the DAR-MENA findings, where 48.5% of T1D were managed
to complete the fasting.[17] In contrast, Alfadhli et al reported that only 13.5% of T1D patients were fasting
the entire month, as 84.4% of them were classified as having high-risk scores.[12]
The current findings indicated that fast-breaking is more frequently associated with
hypoglycemia (37%) than hyperglycemia (20.5%), with only one case admitted due to
severe hyperglycemia. As an alignment, several studies have shown that patients with
diabetes who experienced fast-breaking suffered more from hypoglycemia than hyperglycemia,
particularly among high-risk individuals.[12]
[14]
[18] However, Alfadhli[19] and Hassanein et al[18] reported a higher rate of participants experiencing hyperglycemia than hypoglycemia
during Ramadan fasting. In addition, the observed admission rate was higher among
those who experienced hyperglycemia than hypoglycemia.[5]
[18] These contradictions in findings could be attributed to the variations in study
populations in terms of age, duration of diabetes, type of diabetes, strategies of
management, and individual adherence to medical recommendations during fasting. In
the current study, patients had received comprehensive and structured pre-Ramadan
education. It included written materials and individualized management plans covering
risk stratification, medication adjustment, meal planning, and SMBG. Patients were
provided 24-hour access to the diabetes care team via WhatsApp for real-time support
and received continuous reinforcement through educational videos and visual materials.
This finding highlights the pivotal role of personalized, guideline-based education
in enabling safe fasting practices even among high-risk patients.
In the present study, a few patients with diabetes (1.9%) required hospitalization
during Ramadan, and the majority were attributed to DKA. As an alignment, Abdelgadir
et al[6] reported DKA as being higher in Ramadan compared to Shaaban but mainly among T1D
patients. They attributed this result to medication noncompliance and the lack of
a pre-Ramadan health education program. According to them, those with a pre-Ramadan
history of DKA need to be advised against fasting. In contrast, several studies have
revealed no seasonal variations in the rate of DKA and found no significant association
between Ramadan fasting and DKA occurrence compared to other months.[20]
[21]
[22] Tong et al[23] found that admissions due to diabetes in Ramadan are less when compared to pre-
and post-Ramadan. Similarly, an earlier critical reappraisal of the literature up
to 2019 suggested no increased risk of DKA during Ramadan fasting.[24]
The findings highlighted the significant impact of pre-Ramadan structured educational
programs on fasting preference and outcomes, reinforcing the necessary role of health
care providers in providing patients with structured guidance and follow-up. Participants
who acknowledged the educational program reported a higher likelihood of fasting throughout
Ramadan, experiencing less fasting fatigue, and improved BS control. In addition,
88% of patients with a previous history of fasting could manage to fast during the
current Ramadan. This indicates the role of education in preparing individuals with
adequate physiological and dietary adjustments for safe fasting. These findings are
consistent with previous studies. El Toony et al[10] demonstrated that pre-Ramadan education, particularly for high-risk patients, reduces
anticipated adverse events during fasting. In addition, Mohamed et al[9] and Farooq et al[8] recommended providing patients with diabetes with a well-structured pre-Ramadan
educational program based on the IDF-DAR guidelines to ensure safer fasting experiences
and better glycemic control.
The current study has some limitations. The variations in the level of management
provided to patients with diabetes between the three diabetes centers involved in
the study: Suhar Hospital, Sur Diabetes Specialised Centre, and Falaj Al-Qabail Health
Centre. The results may not represent the remaining diabetes centers not involved
in the study. From a strength perspective, this study supports the validity of using
IDF-DAR risk stratification and previous studies in the field. Moreover, it provides
a baseline for further improvement in the preeducation program and follow-up of patients
with diabetes before, during, and after Ramadan.
Conclusion
The IDF-DAR risk stratification has proven to be a reliable and valid tool for predicting
the risk of adverse events due to fasting in patients with diabetes. Additionally,
pre-Ramadan education plays a vital role in minimizing fasting-related complications.
The evidence highlights the significant risks associated with fasting for persons
with diabetes, particularly concerning glycemic fluctuations. This underscores the
need for personalized medical guidance and careful monitoring for patients with diabetes
who choose to fast during Ramadan. We can significantly reduce severe complications
and hospital admissions for high-risk patients by implementing well-structured education
programs and a clear written plan. That is, patients with well-controlled diabetes
can fast more safely with a minimum risk of complications.
The current perceived results support applying the IDF-DAR risk stratification among
patients with diabetes to provide them with a suitable individual educational plan.
Diabetes clinics should establish clear pre-Ramadan education strategies at least
1 to 2 months before Ramadan. Telemedicine can be utilized to educate patients and
maintain seamless communication. Patients are encouraged to adhere to medical guidance,
control their BS levels, SMBG, and stay in regular contact with their health care
providers.
