Personalized risk reduction strategies utilizing the diabetes and ramadan risk calculator: a narrative review

Abstract

The Diabetes and Ramadan Risk Calculator, developed in 2021, is a pivotal tool for assessing fasting-related risks among patients with diabetes. This ground-breaking innovation offers a quantitative assessment of risk scores during fasting, revolutionizing the landscape of diabetes management during Ramadan. Many components assessed by the calculator are amenable to modification, presenting an opportunity for year-round intervention to mitigate risk scores and subsequent fasting risks.

By targeting modifiable risk factors and adapting strategies over time, individuals with diabetes can proactively diminish their fasting-related risks, safeguarding their physical well-being and spiritual engagement and potentially improving their overall diabetes control.

This review aims to elucidate the evolution of the strategies for addressing modifiable risk factors, reducing risk scores and levels, and ensuring safe fasting practices.

Introduction

Ramadan, a sacred time for Muslims worldwide, is marked by fasting, a practice rich in spiritual significance. For individuals managing diabetes, however, observing Ramadan presents unique challenges. The dawn-to-dusk complete fasting and disrupted sleep patterns can exacerbate hypoglycemia, hyperglycemia, ketoacidosis, and dehydration [1–4]. Despite these hurdles, surveys reveal that the majority of individuals with diabetes fast during Ramadan, often against medical advice [5–10]. Recent data indicate that 83% of those with type 2 diabetes (T2D) and 71% of those with type 1 diabetes (T1D) choose to fast, with many fasting for over 15 days [11, 12]. However, due to health concerns, some opt not to fast or break their fast [12]. Achieving a delicate balance between fasting and good diabetes management necessitates a tailored approach to mitigate risks effectively.

Fasting risk assessment in diabetes and Ramadan fasting guidelines have evolved over the years, culminating in the IDF-DAR risk stratification calculator released in 2021 [1–4, 8, 9].

This tool has become instrumental in guiding physicians and patients toward personalized risk reduction strategies by objectively considering various risk factors. Recent studies have underscored the calculator’s reliability, validating its role as an essential fasting risk assessment tool [13–15].

This article stresses the importance of personalized risk management strategies tailored to individual needs. By consistently addressing modifiable risk factors and adapting strategies over time, we empower individuals to understand their current Ramadan risk scores. Subsequently, fostering safer and spiritually fulfilling fasting experiences and allows patients to accept the possibility of not fasting if deemed to be of a high-risk level.

Methods

This narrative review aimed to report risk management strategies utilizing the Diabetes and Ramadan Risk Calculator by targeting modifiable factors. Specifically focusing on reviewing pertinent studies on the 14 distinct elements utilized in the risk calculator, which include: type of diabetes, duration of diabetes, presence and frequency of hypoglycemia, glycemic control, type of treatment, type and consistency of glycemic monitoring, presence of chronic and/or acute diabetes complications, patient cognitive and physical conditions, duration of fasting, type of labour during fasting, and past fasting experiences as detailed in Fig. 1 [4].

Fig. 1.

Ramadan Risk Calculator

To accomplish this, we conducted a targeted literature search to identify relevant studies addressing these elements. The search strategy included databases such as PubMed, Embase, and relevant clinical trial registries. Studies were selected based on their relevance to the specific elements and their contributions to understanding risk reduction strategies for individuals with diabetes during Ramadan fasting. Additionally, insights from clinical practice and expert opinions were integrated to provide a comprehensive understanding of the role of these factors in diabetes management during Ramadan fasting.

Discussion

The complexity of diabetes and Ramadan Fasting

Navigating Ramadan fasting with diabetes presents formidable challenges. The spiritual discipline of abstaining from food and drink from dawn to sunset can impact blood glucose control, potentially leading to complications in some people with diabetes, such as dehydration, hypoglycemia, hyperglycemia, and diabetic ketoacidosis [1]. While guidelines for managing diabetes during Ramadan have historically relied on expert opinion and extrapolations from non-Ramadan studies, recent years have witnessed a shift towards evidence-based recommendations supported by observational and interventional studies conducted specifically during Ramadan [10]. Regardless of their origins, these recommendations prioritize patient safety, aligning with fasting’s fundamental purpose. The intricacies of diabetes management during Ramadan are further heightened by factors like treatment modalities, complications, and geographical variations in fasting hours, seasonal influences, and fluctuations in physical activity levels (4, 9, 13, and 24).

Understanding the diabetes and ramadan risk calculator

Acknowledging the multifaceted nature of these challenges, a collaborative effort among healthcare professionals and researchers resulted in the development of the diabetes and Ramadan risk calculator [4]. This innovation stemmed from recognizing the considerable variation among clinicians in assessing fasting-related risks during Ramadan, as it was noted that different physicians categorised the same clinical scenario from low to high even within the same country [13]. This is a cause for potential confusion among people with diabetes. While previous diabetes and Ramadan guidelines depended on tables to categorize the level of risk with a maximum of two clinical parameters that would be encountered for a clinical decision, the recent risk calculator integrates 14 critical elements, encompassing diabetes type, frequency of hypoglycemia, duration of fasting, and more, facilitating personalized risk assessments (See Table 1). Furthermore, the risk calculator has received endorsement from religious authorities, lending it significant credibility in counselling patients about their fasting risks pre-Ramadan and ensuring adherence to healthcare advice [4]. Real-world studies have validated the calculator’s efficacy in predicting fasting-related risks [30, 31]. Its user-friendly interface enables easy implementation across diverse clinical settings [14, 15].

Table 1.

Classification of risk factors for Diabetes Management during Ramadan Fasting

Non-modifiable risk factors	Modifiable risk factors with intervention	Modifiable risk factors with time!
Age	Pre-Ramadan glycemic control	Severity or presence of microvascular complications
Type of diabetes	Frequency and severity of hypoglycemia	Severity of macrovascular complications
Duration of diabetes	Appropriateness of Self-monitoring of BG	History of acute complications
Irreversible cognitive dysfunction	Intensity and duration of ohysical activity during fasting	Negative past Ramadan Experiences
Frailty	Type of medications
Duration of fast	Home and social support

A key strength of this tool lies in its delineation of non-modifiable and modifiable risk factors. Non-modifiable factors, such as age, gender, ethnicity, diabetes type, and duration, serve as foundational considerations, enabling patients and clinicians to establish realistic fasting expectations (Table 1). However, the calculator’s true potency lies in assessing modifiable risk factors, which can be actively influenced through lifestyle adjustments and medical interventions. These factors include glycemic control, dietary habits, occupational demands, exercise timing and intensity, hypoglycemia history, blood glucose monitoring, medication regimens, and home support systems (Table 1).

Time and frequency of fasting risk assessment

While classically, the risk stratification process should occur on an annual basis a few weeks pre-Ramadan, It is important to ensure post-Ramadan assessment as this would provide valuable feedback on the last Ramadan experience and comprehensively reflect on the non-modifiable and, more importantly, on the modifiable risk factors. Indeed, several factors may evolve, warranting ongoing dynamic assessments. This is particularly important as many people wish to fast on many days during the year [11–13]. Holistic risk reduction strategies encompass pre-Ramadan risk scoring and preparation, optimizing glycemic control, addressing hypoglycemic episodes, continuous patient education, vigilant monitoring, medication adjustments, and bolstering home and community support systems (See Table 2). This comprehensive approach ensures timely adaptation to the evolving needs of individuals with diabetes, fostering safer and more fulfilling fasting experiences during Ramadan.

Table 2.

Various aspects of personalized risk reduction strategies

Aspect	Personalized Risk Reduction Strategies
Pre-Ramadan Glycemic Control	Optimal control of blood glucose levels before Ramadan, achieved through medication adjustments, regular monitoring, and lifestyle modifications.
Dietary Management	Nutritional guidance, balanced meal planning for Suhoor and Iftar, and portion control to maintain optimal nutrition and glycemic control.
Timing of Exercise	Individualized guidance on the timing and intensity of exercise to regulate blood glucose levels and improve insulin sensitivity while avoiding hypoglycemia.
History of Hypoglycemia	Medication review, hypoglycemia preparedness, and education on recognizing and managing hypoglycemic events
Blood Glucose Monitoring (BG)	Regular self-monitoring of BG levels and Continuous Glucose Monitoring (CGM) before, during, and after fasting periods to ensure optimal glycemic control and detect any fluctuations promptly.
Types of Medications	Modifying medication regimens, including timing, dose, or type changes, to minimize the risk of hypoglycemia and maintain stable blood glucose levels.
Home Support and Communication	Involvement of family members of the elderly, open communication, and educating the support system about diabetes management and emotional support to ensure safety and well-being.
Work during Fasting	Discussions about work schedules and potential accommodations and considering the impact of job type and duration on management.
Post-Ramadan Evaluation	A comprehensive health assessment, medication adjustments, and reassessment of dietary plans based on post-Ramadan experiences.
Availability of Resources	Access to medications, hospitals, follow-up care, and other resources to optimize diabetes management and reduce risk during fasting.
Psychological Support	Addressing psychological aspects and fostering patient confidence, motivation, and empowerment through informed discussions and risk reduction strategies.

Pre-ramadan glycemic control

Optimal pre-Ramadan diabetes control has been correlated with a reduced incidence of hypoglycemia and hyperglycemia during Ramadan fasting [16–18]. Healthcare providers should collaborate closely with individuals with diabetes to achieve optimal diabetes control before fasting during Ramadan. This may entail adjusting medications and insulin doses, regularly monitoring blood glucose levels, adopting healthy lifestyle habits such as maintaining a balanced diet, exercising regularly, and seeking medical attention.

History and frequency of Hypoglycemia

A history of hypoglycemia can indeed increase the risk of hypoglycemic events during Ramadan fasting [2]. However, individuals with any degree of hypoglycemia have the potential to improve their risk score through diligent management. Consulting with a healthcare provider (HCP) and fostering close collaboration with tailored management strategies could reduce the frequency of hypoglycemia. Modifying treatments and frequent blood glucose monitoring during Ramadan is advisable for those intending to fast. Additionally, individuals with diabetes should receive education on hypoglycemia management and the guidelines for breaking their fast if symptoms arise or if their blood glucose levels fall below a certain threshold. This proactive approach helps mitigate the risk of severe hypoglycemia and improves their overall risk score for fasting during Ramadan.

Medications adjustments

The risk calculator identifies the risk of hypoglycemia for different classes of medications during Ramadan fasting. Opting for new classes with a lower propensity for hypoglycemia, whenever possible, can notably reduce the risk score and, hence, the risk of fasting [26].

Additionally, Individuals taking medications that lower blood glucose levels should consult their healthcare provider before fasting during Ramadan to determine their risk score and whether adjustments to their medication regimen are necessary. Such adjustments may entail changes in timing, dose, or type of medication, along with additional monitoring of blood glucose levels during fasting [4].

In general, insulin and sulfonylureas (SUs) are associated with a higher risk of hypoglycemia on normal days, particularly during Ramadan fasting, especially if taken without appropriate adjustments to the dosing regimen. Consequently, insulin users may need alterations in the timing or dose of insulin injections or alternative insulin formulations, such as rapid-acting insulin analogues [28]. Additionally, newer insulin pump devices offer added reassurance by minimizing hypoglycemia risk in patients with Type 1 Diabetes, thereby further optimizing diabetes management during Ramadan fasting [23, 25].

Similarly, individuals on older generations of SUs, such as glibenclamide, or modern SUs, particularly those with tight glycemic control or engaged in significantly intense physical activity, are at increased risk of hypoglycemia, especially if taken without food [20, 27]. Therefore, individuals using sulfonylureas may need to adjust the timing or type of their medication during Ramadan fasting. Meglitinides stimulate insulin secretion and have a rapid onset and short action duration, making them useful for postprandial glucose control. However, their short duration of action can also increase the risk of hypoglycemia during fasting. Conversely, several classes of diabetes medications, including metformin, GLP1-RA, SGLT2 inhibitors, DPP4 inhibitors, and TZDs, are less likely to provoke hypoglycemia during Ramadan fasting [21]. Patients at risk for hypoglycemia and those with previous hypoglycemic episodes during fasting should be considered for such medications. Additionally, it is crucial to note that some individuals on multiple medications, excluding insulin and SUs, could also develop hypoglycemia, possibly due to factors like age or frailty. Hence, those with tight glycemic control must consult their HCP before fasting for Ramadan.

The role of education

An overarching principle that underpins the use of diabetes and Ramadan risk calculators is the role of diabetes self-management education and support. The American Diabetes Association Standards of Medical Care of 2023 stated that all people with diabetes should participate in self-management education and support to facilitate the knowledge, decision-making, and skills mastery for diabetes self-care [19]. The preparation for fasting in Ramadan should be taken as an opportunity to address not only the principles of safe fasting as stated above but also to review other diabetes management issues, such as diet, self-monitoring of blood glucose, as well as the avoidance and management of hypoglycemia and hyperglycemia. Surveys have shown that many patients with diabetes who intend to fast during Ramadan are not receiving education, highlighting an area that needs to be addressed to help patients with diabetes fast safely during Ramadan [7, 11–13].

Self-monitoring of blood glucose (SMBG) and continuous glucose monitoring (CGM)

Rigorous monitoring of glucose levels through Self-Monitoring of Blood Glucose (SMBG) or advanced Continuous Glucose Monitoring (CGM) systems provides insights into blood glucose trends, enabling patients to promptly adjust medications or dietary choices to prevent acute diabetes complications like hypoglycemia and hyperglycemia [22]. The Diabetes and Ramadan risk calculator assigns lower scores to individuals who monitor their blood glucose appropriately, especially if done more frequently, thus reducing their overall risk. This proactive approach enhances safety and well-being by empowering patients with vital information and tools for effective blood glucose management.

Diet

Understanding the appropriate diet during Ramadan can help reduce the risk of both hypoglycaemia and hyperglycemia. Hence, collaborating with a registered dietitian to create a personalized meal plan for fasting hours is essential. The Ramadan Nutrition Plan (RNP), developed by experts in diabetes and Ramadan fasting, accessible through the Diabetes and Ramadan application or website, can facilitate this process [3, 4]. A balanced Sohour meal, comprising slow-digesting carbohydrates, proteins, fats, and ample fluids, helps maintain hydration throughout the day. Similarly, Iftar meals should begin with dates and include a balanced assortment of nutrients. Educating patients about portion control to prevent overeating during Iftar and Sohour is vital, as smaller, well-balanced meals are easier to manage regarding blood glucose levels [3, 4].

Exercise timing

Exercise significantly reduces the risk score by regulating blood glucose levels and enhancing insulin sensitivity. However, exercising during fasting hours requires careful consideration to avoid hypoglycemia or dehydration. Seeking individualized guidance from a healthcare provider or qualified fitness professional is crucial to determining the optimal type and timing of exercise based on the individual’s health status, fitness level, type of treatment and preferences. Moderate-intensity exercises like jogging may be more suitable during eating hours to prevent excessive strain on the body and mitigate the risk of complications.

Home support

Lack of home support for the elderly can indeed elevate the risk score during Ramadan fasting, and in some cases, it may even warrant advising against fasting altogether. However, home support plays a pivotal role in reducing risk levels and ensuring the safety of elderly individuals with diabetes who wish to fast. Ramadan fasting necessitates significant adjustments to daily routines, including meal timing, sleep patterns, and physical activity, which can be particularly challenging for the elderly or frail [4].

Home support can provide practical assistance with meal preparation, medication management, and blood glucose monitoring. Moreover, beyond practical assistance, home support offers emotional and social support, providing encouragement, reassurance, and companionship to help individuals manage feelings of isolation or loneliness during fasting.

Overall, home support is a crucial component of safe and successful Ramadan fasting for elderly individuals with diabetes, ultimately contributing to a lower risk score and improved fasting safety.

The type and duration of work

The type and duration of work during fasting hours significantly impact the safety of fasting and may contribute to an increased risk score. The nature of an individual’s job or occupation directly influences their daily routine, level of physical activity, heat exposure, and hydration status, all crucial factors in diabetes management during Ramadan. Addressing the type and duration of work during fasting hours as part of personalized risk reduction strategies is essential, particularly in Muslim-majority countries where this practice is routine. Previous studies, such as the Ramadan study of individuals treated with Glargine 300, have highlighted disparities in the frequency of hypoglycemia between different regions, with speculation suggesting that the intensity of working hours may be a contributing factor [29]. Healthcare providers should collaborate with patients to tailor their diabetes management plans to specific work-related challenges, ensuring their well-being even in demanding work environments while confidently observing Ramadan fasting.

The availability of resources

Availability of resources can significantly impact several elements of the Ramadan risk assessment, consequently influencing the risk stratification process. For instance, utilizing the risk calculator in a well-resourced specialist diabetes centre resulted in the classification of 649 patients into 52% low, 26% moderate, and 22% high risk, respectively, whereas using the same risk calculator in a limited resource setting led to the classification of 300 patients into 14% low, 24% moderate, and 62% high risk, respectively [14, 15]. This demonstrates the versatility of the risk calculator in adapting to various resource settings, cultural contexts, and geographical locations. Access to more modern medications with lower hypoglycemia risk, as well as the availability of blood glucose monitoring tools, follow-up care, and other resources, is essential in optimizing diabetes management during Ramadan fasting, ultimately contributing to improved risk scores and patient outcomes.

Psychological impact and physician-patient collaboration

Beyond the clinical aspects, the calculator offers a profound psychological impact. Visually demonstrating the potential risk reduction associated with various practices instils confidence in patients and motivates them to participate actively in their health management. Moreover, it facilitates informed discussions between physicians and people with diabetes, fostering a collaborative approach that acknowledges the individuality of each patient’s experience and the acceptability of the medical decision (4, 9, and 13).

Limitations of the risk calculator

Although several studies have verified the utility and validity of the Diabetes and Ramadan Risk Calculator, notable limitations warrant consideration. Many studies on Ramadan fasting are not randomized controlled studies, and consequently, the level of evidence on which the risk calculation depends is low [4]. Further research is required to improve the accuracy of the risk calculator, particularly in diverse patient populations and settings. Despite these limitations, the calculator remains a valuable tool for personalized risk assessment and management of diabetes during Ramadan fasting with exceptional adaptability. Risk scores can change over time as patients implement risk reduction strategies, rendering it a dynamic and evolving tool. (4, 8, and 10).

Conclusion

The Diabetes and Ramadan risk calculator is a pivotal tool in the realm of diabetes management during Ramadan fasting, offering numerous advantages in reducing patient risk scores. By integrating 14 key elements and providing personalized risk assessments, this innovative tool empowers clinicians and patients alike to make informed decisions tailored to individual needs. Its adaptability and dynamic nature allow for ongoing monitoring and adjustment of risk scores, fostering patient engagement and empowerment in their health management journey. Furthermore, the calculator facilitates collaborative discussions between physicians and patients, acknowledging each individual’s unique circumstances and preferences. Patients can track their progress using the calculator and implement effective risk-reduction strategies, ultimately ensuring safer and more successful fasting experiences. As we navigate the complexities of diabetes management during Ramadan, the Diabetes and Ramadan Risk Calculator remains an indispensable resource in optimizing patient care and promoting physical well-being and spiritual fulfilment. More research is required to strengthen the accuracy of the risk calculator further.

Authors contributions

BA proposed the review idea and drafted the manuscript. MS, KH and MH critically reviewed and modified the manuscript. All authors approved the final version before its submission.

Funding

No funding was available for this work.

Data availability

Not applicable.

Declarations

Ethical approval

Not applicable.

Conflict of interest

The authors declared that they have no conflict of interest.