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

BACKGROUND: The categorization and assessment of diabetes-related risks during Ramadan have evolved significantly over three decades. Research interest in the health effects of fasting has grown significantly, with diabetes emerging as the most extensively studied condition. AIM: To explore the historical development of risk stratification approaches for Ramadan fasting in people with diabetes, culminating in the 2021 International Diabetes Federation-Diabetes and Ramadan (IDF-DAR) risk assessment tool. We also evaluated the evidence for its validation and real-world utility. METHODS: The PubMed and Google Scholar databases were searched using the term "Diabetes AND Ramadan AND Risk Assessment". Eligible studies included full-text articles on risk stratification concept and tools for diabetes during Ramadan. Selected studies were reviewed and synthesized thematically. RESULTS: Risk categorization began with a dichotomy and tripartite models and progressed to a four-tier narrative scale. In 2021, the IDF-DAR tool introduced a point-based system with three risk categories. Validation studies across diverse populations demonstrated strong predictive value, though moderate inter-clinician variability and potential overestimation in type 2 diabetes cases were noted. CONCLUSION: The IDF-DAR risk stratification tool significantly advances individualized diabetes care during Ramadan. Its conservative bias in some populations and variability in physician scoring suggests the need for standardized training.