Fasting and Diabetes: An Interventional Approach to Enhance Knowledge and Self-Care during Ramadan

doi:10.21203/rs.3.rs-5286441/v1

Background. The aim of this study was to assess the impact of educational interventions on the knowledge and self-care practices of diabetes patients who fast during Ramadan. People diagnosed with type 2 diabetes were selected from outpatient clinic at Dr. Zainoel Abidin Hospital. Educational intervention was delivered before and during Ramadan. Disease knowledge and self-care practices were assessed by using Diabetes Knowledge Questionnaire and Diabetes Self-Management Questionnaire. Chi-square test was used to analyse the changes before and after educational intervention.

Results. There were 186 diabetes patients involved in this study with average age of 59.77 ± 9.64 years, body mass index was overweight at 24.78 ± 3.62 kg/m² and poor HbA1c at 9.21 ± 2.62 %. The DKQ scores spotted a substantial improvement, with a vast majority (92.47%) achieving the good knowledge category compared to the previous percentage of 30.65%. There was also a significant change in DMSQ scores before and after the educational intervention. Pre-intervention, 83.87% of DMSQ scores were optimal self-care practice, while 16.13% were suboptimal. After intervention, it changed significantly, with 94.08% of those characterized as having optimal self-care habits. Three items of DMSQ subscales showed significant changes which were eating behavior (p 0.046), medication taking (p 0.001), and glucose monitoring (p 0.001).

Conclusion. The study suggests that the educational intervention effectively improved both the knowledge and self-care practices of diabetes patients, as evidenced by the significant positive changes in knowledge and self-practice scores. This implies the potential for such interventions to contribute positively to the management and overall well-being of individuals with diabetes.

DKQ

DMSQ

Ramadan

Aceh

Education

Fasting during Ramadan is an important spiritual practice for millions of Muslims worldwide. However, for people with diabetes, managing health while fasting presents particular concerns. There needs to be a nuanced approach that maintains a balance between religious observance and optimal health throughout Ramadan because of the intersection of religious obligation and health concerns. According to studies, a considerable proportion of diabetics prefer to fast throughout Ramadan, with roughly 43% of persons with type 1 diabetes and 79% of people with type 2 diabetes fasting during this time. It is crucial to comprehend and tackle the difficulties encountered by patients with diabetes during fasting (Hanif et al., 2020).

Assessment of knowledge and self-care routines among diabetics fasting throughout Ramadan is critical for obtaining optimal health outcomes. Almansour et al. (2017) stressed the influence of religious rituals, such as fasting during Ramadan, on the management of diabetes and the use of medication. This underscores the importance of implementing interventions to improve health outcomes for individuals who observe these practices (Almansour et al., 2017). In addition, there is a need of healthcare practitioners' expertise and actions in effectively managing diabetes during Ramadan. This highlights the need for complete assistance and direction for patients with diabetes who are fasting (Ali et al., 2016).

A study that introduced an education program during Ramadan, the Diabetes Education and Medication Adjustment in Ramadan (DEAR), aimed to prepare individuals for self-management during fasting through tele-health support, emphasizing the importance of tailored programs to meet the specific needs of this population (Zainudin et al., 2018). Another trial demonstrated the efficacy and safety of using the Fasting Algorithm for Singaporeans with Type 2 Diabetes (FAST) throughout Ramadan, demonstrating the possibility for structured interventions to help diabetics while fasting (Lum et al., 2020).

The assessment of knowledge and self-care practices holds paramount importance in ensuring optimal health outcomes, especially during periods of religious fasting like Ramadan. This study utilized two assessment tools, namely the Diabetes Knowledge Questionnaire (DKQ) and the Diabetes Self-Management Questionnaire (DSMQ), to comprehensively evaluate the knowledge base and self-care practices of individuals with diabetes observing fasting during Ramadan.

The Diabetes Knowledge Questionnaire (DKQ) has been widely recognized and utilized as a validated instrument to assess the depth and breadth of knowledge regarding diabetes among affected individuals (Zakiudin et al., 2022). Its comprehensive nature encompasses various facets of diabetes, enabling a thorough evaluation of an individual's understanding of their condition, treatment modalities, lifestyle modifications, and potential complications. In parallel, the Diabetes Self-Management Questionnaire (DSMQ) serves as a crucial tool for evaluating the self-care practices adopted by individuals living with diabetes (Schmitt et al., 2022). Scientific evidence consistently demonstrates that effective self-care behaviors, including adherence to medication regimens, dietary modifications, regular blood glucose monitoring, physical activity, and coping strategies, significantly influence diabetes management outcomes and overall health.

By employing the DKQ and DSMQ within the unique context of Ramadan fasting, this study aims to to assess the impact of educational interventions on the knowledge and self-care practices of diabetes patients who fast during Ramadan. This research was conducted in Aceh, the only province in Indonesia ruled by Sharia law (Safrilsyah, 2012), which has distinct cultural and religious behaviours. Ramadan nuances in Aceh are differed from those in other Indonesian areas. Coffee shops and restaurants, for example, are closed throughout the day, except during the hours leading up to Maghrib (sunset). During Ramadan, work hours are frequently reduced, giving for more time for worship and reflection. Although subtle, Aceh's cultural and legislative issues might affect and encourage fasting among its population. Our research will look into how these various cultural components affect diabetes control during Ramadan in this particular Indonesian province.

This study employed a prospective interventional design, one group, pre and post-test study. The subjects were recruited from the Endocrine and Thyroid Polyclinic at Dr. Zainoel Abidin Hospital in Aceh, Indonesia. Individuals with type 2 diabetes mellitus (T2DM) for at least 6 month at the time of sampling who were over 18 and planned to fast during Ramadan were eligible. Other types of diabetes (gestational, autoimmune, drug induced diabetes) were ruled out. The intervention was educational approach by performing educational approach to the patient.

Before Ramadan, participants performance on diabetes knowledge and self-care practises were assessed using the Diabetes Knowledge Questionnaire (DKQ) and the Diabetes Management Self-Efficacy Questionnaire (DMSQ). After completion the first round of assessment, participants were given educational flashcards outlining Ramadan fasting rules and preparation to this religious moment. This was a first step educational approach. The next step was conducted during Ramadan, in which participants received weekly phone calls. These calls performed several functions, including inquiring about any instances of diabetes-related problems (such as hypoglycemia or ketoacidosis), providing reminders about the necessary treatment, and monitoring their blood glucose levels. This intervention was delivered four times to ensure consistent support and guidance. After Ramadan, participants were administered the DKQ and DMSQ questionnaires for the second time.

Data were analyzed by Statistical Package for Social Science (SPSS 25.0. Inc., Chicago, IL, USA). Descriptive statistics were employed to summarize demographic characteristics. Data distribution was assessed by the Kolmogorov Smirnov test. Chi square test was utilized to compare pre- and post-intervention scores for DKQ and DMSQ. Significance levels were set at p < 0.05.

Instrument

We employ two measurement tools to gain a holistic understanding of diabetes management during Ramadan, including Diabetes Knowledge Questionnaire (DKQ) (Garcia et al., 2001; Zakiudin et al., 2022), and Diabetes Self-Management Questionnaire-Revision (DSMQ-R) (Schmitt et al., 2022). Details of each part are explained in the following section.

DKQ-24

The Diabetes Knowledge Questionnaire-24 (DKQ-24) consists of 24 questions designed to test patients' knowledge about diabetes. It was developed by the Starr County Diabetes Education Study (Garcia et al., 2001) and was translated and validated in Bahasa Indonesia (Zakiudin et al., 2022). A copy of the DKQ-24 was distributed to each participant and were instructed to carefully answer each question which include three answer possibilities (yes, no, don’t know). Correct answers score 4.16 points, while incorrect or unknown answers receive 0 points. The points are added together to yield a total score for the DKQ-24. A total score of less than 55 indicates a fair knowledge, a total score of 56 to 75 indicates moderate knowledge, and a total score of 76 to 100 indicates good knowledge.

DMSQ

The 27-item Diabetes Self-Management Questionnaire-Revised (DSMQ-R) (Schmitt et al., 2022) is a revised version from a 16-item DSMQ (Schmitt et al., 2013). It is designed to assess a patient's self-care practices and behaviors related to diabetes management. The DSMQ employs a Likert scale, with responses ranging from 0 (does not apply to me) to 3 (applies to me very much). Some questions are reverse-coded, which means that greater scores indicate a lower value. After reversing the scores of negative sentences, the final score is calculated by summing all 20 items (for those who do not use intensive insulin) or 27 items (for those who do). The score is then transformed into a number between 0 and 10. To be more specific, this questionnaire has five subscales measurement which consist of eating behaviours (6 items), glucose monitoring (4 items), medication adherence (5 items), physical activity (3 items), and cooperation with team (4 items). The remaining 5 items serve as global statements and are only included in the total scale. However, it should be emphasised that the 27-item DSMQ is only applicable to patients on intense insulin medication, whereas for patients not on intensive insulin therapy, a total of 20 items on general behaviours should be used. The detailed explanation is available to be downloaded as a supplementary material (Schmitt et al., 2022). In this study, a cut point of 5 was set as the threshold, which means that a score of 0 to 5 is deemed suboptimal, while a score greater than 5 is considered optimal involvement in diabetic self-care practises.

Subject characteristics

Table 1 presents the characteristics of the subject. The study sample consisted of 186 individuals diagnosed with type 2 diabetes mellitus with an average (± SD) age of 59.77 ± 9.64 years. The average (± SD) of body mass index (BMI) was overweight at 24.78 ± 3.62 kg/m². Both genders equally participated in this study which included 94 (50.54%) males and 92 (49.46%) females. In terms of educational background, 52.23% of the participants had finished high school level or less, 37.10% had completed graduate-level education, and 9.68% had obtained a postgraduate degree. The average (± SD) value of HbA1c was 9.21 ± 2.62%.

Table 1

Subject characteristic
Characteristic	Total	SD
Sex Male Female	186 94 92	100% 50.54% 49.46%
Age (y)	59.77	9.64
Educational background High school Graduate Post graduate	99 69 18	53.23 37.10 9.68
BMI (kg/m²)	24.78	3.62
HbA1c (%)	9.21	2.62

DKQ and DMSQ results

The distribution of diabetes knowledge scores, as measured by the DKQ before and after intervention, is shown in Table 2. These scores are divided into three categories: low, moderate, and high.

Table 2

Knowledge and Self Practice Level of the Subject
Characteristic	Before Intervention		After Intervention		P value
DKQ Score	N	%	N	%
Fair Moderate Good	47 82 57	25.27 44.09 30.65	2 12 172	1.08 6.45 92.47	0.001
DMSQ Score
Suboptimal Optimal	30 156	16.13 83.87	11 175	5.91 94.08	0.001

Table 2 depicts the comparison between diabetes knowledge (assessed by DKQ scores) before and after educational intervention during Ramadan. According to the result, before to intervention, DKQ scores were predominantly spread throughout moderate (44.09%) and good (30.65%) knowledge categories, with a significant number classified as fair (25.27%). Following the intervention, there was a notable transformation in the DKQ scores, as an overwhelming majority (92.47%) achieved the good knowledge category. Fair and moderate populations dropped to 1.08% and 6.45%, respectively. Using the chi squared test, this result revealed a significant difference (p < 0.001) as well.

The notable change in the distribution of DMSQ scores before and after the educational intervention was also evident which implies a significant improvement in the self-care practices of individuals with diabetes. Pre intervention, the DMSQ scores were distributed across the optimal self-care practice category (83.87%), with a smaller proportion categorized as suboptimal (16.13%). Post-intervention, there was a considerable shift in DMSQ scores, with a substantial increase in the proportion of individuals categorized under optimal self-care practices (94.08%). The percentage of individuals in the suboptimal category significantly decreased to 5.91%. This shift towards optimal self-care practices suggests that the intervention had a positive impact on the participants' ability to adhere to medication regimens, dietary modifications, regular blood glucose monitoring, physical activity, and cooperation with coping strategies.

Table 3

DMSQ Subscale
Characteristic	Before Intervention n (%)		After Intervention n (%)		P value
DMSQ-R Subcsale
1. Eating behavior
Suboptimal Optimal	26 160	13.98 86.01	13 172	7.03 92.97	0.046
2. Medication taking
Suboptimal Optimal	46 140	24.73 75.27	18 167	9.73 90.27	0.001
3. Glucose Monitoring
Suboptimal Optimal	130 56	69.89 30.11	76 109	41.08 58.92	0.001
4. Physical activity
Suboptimal Optimal	61 125	32.80 67.20	59 126	31.89 68.11	0.891
5. Cooperation with diabetes team
Suboptimal Optimal	26 160	13.98 86.02	18 167	9.73 90.27	0.237

When the DMSQ was specified in each item, there was 3 subscales with significant changes (p < 0.05) after the intervention which were eating behavior (p 0.046), medication taking (p 0.001), and glucose monitoring (p 0.001). On the other side, there were no significant change was observed in physical activity (p 0.891) and cooperation with diabetes team (p 0.237) before and after the intervention.

This study aimed to provide a portrait of diabetes patients’ knowledge and self-care practices before and after educational intervention. There were substantial improvements in diabetes knowledge and self-care practises before and after the educational approach during Ramadan. The findings of this study may aid in developing appropriate techniques to promote patient self-management in diabetic patients who wish to fast.

The patient's mean BMI was 24.78 ± 3.62 kg/m², indicating that the BMI range was overweight. This finding is connected to study conducted in T2DM patients in Pakistan (Bukhsh et al., 2019) and South Africa (Groenewald et al., 2009), where the prevalence of overweight and obesity was prevalent among diabetes patients. This could be attributed to the fact that the prevalence of overweight and/or obesity among T2DM patients is much greater than in the general population (Reddy et al., 2015). The equal participation of males and females (50.54% versus 49.46%) in this study can be influenced by various factors, including but not limited to prevalence of diabetes, healthcare seeking behavior, awareness and education, and access to healthcare services.

The mean age of participant in this study was 59.77 ± 9.64 years which suggested that age as a risk factor for developing diabetes. Most persons with T2DM in industrialized nations are over 60, while in developing countries, the majority of patients with DM are under 60, with the highest number (43.2%) in those aged 40–59 (Ntontolo et al., 2017). This result was also the same with other study which found that the average age of diabetes population is 58.43 years; and normally, type 2 diabetes occurs in old age (Bukhsh et al., 2019).

The mean (± SD) value of HbA1c at 9.21 ± 2.62% implies that, on average, the diabetes patients in this study have poor glycemic control, as the recommended target for most individuals with diabetes is typically below 7%. This result suggests that the individuals may be at an increased risk of diabetes-related complications due to elevated blood sugar levels. Therefore, there is a need for interventions to improve glycemic control and reduce the risk of long-term complications associated with uncontrolled diabetes (Zainudin et al., 2018).

This study implemented educational interventions in three ways: oral explanation, flyer distribution, and weekly phone calls. These interventions have been found to help individuals improve their knowledge and self-care practices. Several studies showed that educational interventions improve diabetic knowledge (assessed by DKQ score) and self-care practices (assessed by DMSQ score).

Knowledge assessment

The drastic change in the distribution of DKQ scores before and after the educational intervention for individuals willing to fast during Ramadan in Aceh is evident from the striking values observed. The significant increase in the proportion of individuals categorized under the good knowledge level post-intervention (92.47%) compared to pre-intervention (30.65%) demonstrates the efficacy of the educational approach. The intervention appears to have led to a remarkable improvement in diabetes-related knowledge among participants.

Various research has supported the knowledge improvement from the educational intervention's influence on raising knowledge among diabetics, as seen in this finding. For instance, a meta-analysis found that self-efficacy-focused education improved knowledge and self-management practices among diabetics (Jiang et al., 2019). Similarly, a pretest post-test study to assess the effectiveness of prerecorded educational messages delivered over the phone to diabetes patients found that a brief telephone-based diabetes education intervention can have a significant impact on improving general diabetes knowledge and self-care practices (Boren et al., 2006).

Furthermore, Ramadan-specific research have stressed the need of improving health outcomes for Ramadan observers, especially those with diabetes (Almansour et al., 2017; Salti et al., 2004). These findings highlight the importance of specialized educational interventions during Ramadan to meet the unique obstacles that people with diabetes encounter while fasting. Furthermore, study examined the influence of Ramadan-focused education programs on diabetes management while fasting, reinforcing the significance of educational interventions in enhancing knowledge and self-care practices during Ramadan (Ibrahim et al., 2023).

Self-care practice assessment

The significant difference observed in DMSQ scores before and after the educational intervention during Ramadan in Aceh suggests a notable positive impact of the intervention on the participants' self-care practices related to diabetes. The significant increase in the proportion of individuals categorized under optimal self-care practices post-intervention (94.08%) compared to pre-intervention (83.87%) indicates the effectiveness of the educational approach.

Some studies have found that educational interventions can enhance diabetic patients' self-care practices throughout Ramadan. For example, a randomized controlled trial found that Ramadan-focused education improved diabetes management and clinical outcomes while fasting (Ibrahim et al., 2023). Similarly, McEwen et al. (2015) reported that a personalized diabetes education program reduced hypoglycemia episodes and acute complications during Ramadan. Another study explored the effectiveness of the fasting algorithm in managing glycemic control throughout Ramadan and found a beneficial impact on self-care practices, as seen by improved glycemic control during fasting (Lum et al., 2020).

While the results show a remarkable improvement, there might be underlying factors influencing the drastic change besides the educational intervention. Factors such as participant motivation, comprehension of the educational material, Participant adherence to the educational guidelines or concurrent external sources of information could have contributed to the observed changes in DKQ and DMSQ scores.

Self-care practice subscale assessment

This study further elaborated on the DMSQ subscale. Interestingly, three subscales showed substantial improvement: eating behavior, medication taking, and glucose monitoring. These changes suggest a notable improvement in these aspects of diabetes self-care practices among individuals who participated in the educational intervention between pre and post Ramadan. Some possible explanation on these changes likely due to the focused educational intervention (Ebadi Fardazar et al., 2017) in which participants have received guidance on diet modification during fasting, fasting practices, increased health awareness, and supportive environment (Bouchareb et al., 2022; Eid et al., 2017). During Ramadan, individuals' eating habits may change since they fast from sunrise to sunset. This shift in dietary patterns and meal timings can have an impact on eating behavior and medication use, necessitating modifications to medication schedules and glucose monitoring to correspond with fasting and mealtimes. Furthermore, the religious importance of Ramadan may raise health awareness among individuals, resulting in better adherence to medication regimens and vigilant glucose monitoring to guarantee optimal health during fasting. Furthermore, the communal character of Ramadan observance may generate a supportive environment, encouraging people to stick to their medication schedules and practice regular glucose monitoring in order to manage their diabetes while fasting effectively.

However, the lack of significant improvement in physical activity and cooperation with the diabetes team could be due to various reasons. Muslims with diabetes may have specific concerns that make them hesitant to engage in regular physical activity or exercise during Ramadan, such as risk of hypoglycemia, fear of dehydration, alterations in medication timing, concerns about health risks, religious obligations and priorities individual variation in health conditions, and cultural and social factors. Individuals with diabetes who fast might be concerned about the increased risk of hypoglycemia due to alterations in mealtime and reduced food intake. Physical activity can further lower blood sugar levels, which may lead to hypoglycemia if not managed properly. Engaging in physical activity while fasting can increase the risk of dehydration, especially in combination with limited fluid intake during fasting hours. Some individuals with diabetes may fear that exercise or physical activity could lead to health complications or exacerbate their condition, especially if they haven't been physically active regularly or if they have pre-existing complications related to diabetes. In Aceh, people tend to prioritize their religious obligations practices such as prayers and Quranic recitation over physical activity, leading to a lack of motivation or time for exercise.

Recommendation

The development and utilization of Ramadan-focused education programs to allow healthcare providers (HCPs) to provide better care and ensure the safety of people with diabetes who fast during Ramadan is still needed (Hassanein et al., 2019). The study by Hassanein et al. (2019) highlights the various challenges for people with diabetes who fast during Ramadan and the need to improve their diabetes management. This can be achieved by providing pre-Ramadan structured patient education along with specific management guidelines for healthcare providers (Hassanein et al., 2021;. Lee et al., 2017)

Limitation

The study might lack assessment of the sustained long-term impact of the educational intervention. Without follow-up evaluations beyond the immediate post-intervention period, the lasting effectiveness of the intervention remains uncertain. While the dramatic shift in DKQ scores and three subscales of DMSQ suggests a significant positive impact of the educational intervention on diabetes knowledge among individuals willing to fast during Ramadan in Aceh, further investigation and consideration of potential influencing factors are necessary to comprehensively understand the observed changes.

An educational intervention on diabetes patients' knowledge and self-care practices during Ramadan resulted in significant increases in both knowledge and self-care behaviors, particularly in eating behavior, medication adherence, and glucose monitoring. The intervention, which included oral explanations, flyer distribution, and weekly phone calls, was successful in improving participants' comprehension of diabetes management and encouraging optimal self-care habits. Despite the overall excellent results, several areas, such as physical activity and collaboration with the diabetes team, showed less substantial improvement, which could be attributed to unique concerns or cultural constraints. This study stresses the effectiveness of educational interventions in improving diabetes management during Ramadan and the necessity for ongoing efforts to assist diabetics in optimizing their self-care habits, particularly in the setting of religious observances.

BMI

Body mass index

DKQ

Diabetes Knowledge Questionnaire

DM

Diabetes Mellitus

DMSQ

Diabetes Self-Management Questionnaire-Revised

HbA1c

Glycated Haemoglobin

HCPs

Healthcare providers

LPPM

Lembaga Penelitian dan Pengabdian kepada Masyarakat

SPSS

Statistical Package for Social Science

T2DM

Type 2 Diabetes Mellitus

Ethics approval and consent to participate

This study received ethical approval from the local Institutional Review Board no 026/ETIK-RSUDZA /2023. Informed consent was obtained from all participants prior to their involvement in the study.

Consent for publication

The authors grant permission to publish this paper. All co-authors have been informed and agree to the terms. The content is original, has not been previously published, and does not violate any third-party rights.

Competing interest

The authors state that the manuscript has no conflicts of interest.

Funding

This study was supported by the Research and Community Service Institution (LPPM) of Universitas Syiah Kuala from the Lektor Research Grant with contract Program Research Year 2023 Number: 666.049/UN11/SPK/PNBP/2023.

Author Contribution

The study's design, data collection, manuscript preparation and writing, and review were all efforts inwhich each author had a hand.

Acknowledgement

We thank the enumerators—Rumaisha Yasmin, Nailal Hidayati, Syaza Azra, and Ghina Mardhatillah—for their essential contributions to this work. We also thank all the patients who participated, who made this research possible.

Availability of data and material

The datasets utilized in the present study are available upon reasonable request from the corresponding author.

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No competing interests reported.

Fasting and Diabetes: An Interventional Approach to Enhance Knowledge and Self-Care during Ramadan

Status:

Version 1

Abstract

Figures

Background

Methods

Instrument

DKQ-24

DMSQ

Results

Subject characteristics

DKQ and DMSQ results

Discussion

Knowledge assessment

Self-care practice assessment

Self-care practice subscale assessment

Recommendation

Limitation

Conclusion

Abbreviations

Declarations

Competing interest

Funding

Author Contribution

Acknowledgement

Availability of data and material

References

Additional Declarations

Status:

Version 1