Reclassification toward higher risk without predictive superiority: Evaluating the 2026 versus 2021 IDF-DAR risk calculators for Ramadan fasting in adults with diabetes mellitus
Keywords:
Diabetes mellitus, Ramadan, Fasting, International Diabetes Federation, IDF-DAR, hypoglycemia, Hyperglycemia, MuslimAbstract
Background and Objectives: An updated 2026-version of the 2026 International Diabetes Federation and Diabetes & Ramadan (IDF-DAR) Alliance risk calculator has replaced the 2021-version. This study aimed to compare pre-Ramadan risk categorisation and complication occurrences during Ramadan using both versions of the calculator among Muslims with diabetes mellitus (DM)
Methods: This prospective observational study included 638 adults with DM (mean age: 52 years; 67% female) who intended to fast during Ramadan 2026 and attended public and private endocrine centres in Bangladesh. Pre-Ramadan baseline data were evaluated to categorize participants into low (0–3), moderate (3.5–6), or high (>6) risk groups using both tools. The investigators conducted follow-up evaluations within two weeks post-Ramadan.
Results: The 2026 calculator reclassified significantly more participants upward into higher-risk categories than the 2021 version (15% vs. 8% downward; P<0.001). A total of 59 people were lost to follow-up, and three died. Of 576 participants completing follow-up, 51 (8.9%) developed hypoglycemia and 95 (16.5%) developed hyperglycemia. Both calculators demonstrated modest (AUC: 0.6–0.7) and comparable predictive accuracy for hypoglycemia (z-statistic=-0.21, P=0.834) and hyperglycemia (z-statistic=-0.5, P=0.594). High-risk individuals had significantly higher odds of hypoglycemia (OR: 2.7 for 2021, P=0.001 vs 2.4 for 2026, P<0.001) and hyperglycemia (OR: 2.2 for 2021, P=0.014 vs 2.3 for 2026, P<0.001) than non-high-risk individuals (low and moderate risk), using both calculators.
Conclusions: The updated 2026 IDF-DAR calculator stratifies more patients into higher-risk categories while maintaining comparable predictive ability for glycemic complications compared with the 2021 version.
[J Assoc Clin Endocrinol Diabetol Bangladesh, 2026;5(Suppl 1): S41]
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Copyright (c) 2026 Md. Rakibul Hasan, Choman Abdullah Mohana, Mohaiminul Abedin, Muhammad Abdul Hannan, Md. Firoj Hossain, Md Shamim Hossan, Md. Ahasanul Haque, Kishore Kumar Shil, Md Rakib Mia, Md Abu Shehab, Satyajit Mallick, Raisa Akter, Md Shahed-Morshed
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