The effect of applying Ramadan education and awareness program on clinical outcomes among Type 2 diabetes mellitus patients who fast during Ramadan

The effect of applying Ramadan education and awareness program on clinical outcomes among Type 2 diabetes mellitus patients who fast during Ramadan 

Hazhar Salih Mohammed ¹, Dr.Dler Shamsulddin Hamid ²

1. Department of adult nursing, College of Nursing, University of Sulaimani, City of Sulaimani, Iraq;
2. Department of medicine, College of medicine, University of Sulaimani, City of Sulaimani, Iraq.

Corresponding author: Hazhar Salih Mohammed

Email: hejarsalih94@gmail.com

ORCID

ABSTRACT

Fasting during Ramadan is a spiritual and religious practice. Fasting increases the risk of complications in people with diabetes, including hypoglycaemia and hyperglycaemia. There is a lack of evidence-based medicine in the field of managing diabetes during Ramadan. In fact, a variety of recommendations are based more on expert opinion than on clinical evidence.

Objectives: To evaluate the effectiveness of applying Ramadan education and awareness program on blood glucose profile among Type 2 Diabetes Mellitus patients who fast during Ramadan.                   

Methods: This is a quantitative design of a quasi-experimental study which involved 84 type 2 diabetic patients, recruited one week before Ramadan at the Diabetes and Endocrine Center in Sulaimani city. The Enrolled patients were divided in to two groups 43 patients were in the first group, Group A, who participated in a 1-hour education program with repeated follow up throughout the month of investigation. The control group, Group B, was made up of 41 patients who were invited but did not enter in the program.

Results:  After Ramadan, there was a mean weight reduction of 0.9 kg in intervention group. A considerable improvement observed in the Mean of blood glucose among the intervention group, it declined from (182.3 mg/dl) to (171.3 mg/dl). In the intervention group (74.4%) of patients reported not experiencing any symptoms. whereas, in the control group this proportion is (53.7%).

Conclusions: This Ramadan-focused educational program supported type 2 diabetic patients in weight loss, improved glucose control, and safer fasting during Ramadan.

Keywords: type 2 diabetes, Ramadan education, Fasting 

INTRODUCTION

Fasting during Ramadan is a spiritual and religious practice (Shiju et al., 2022). Every healthy adult Muslims must practice it (Sahin et al., 2013). Even though the Quran exempts those who are diagnosed with illness from fasting, the majority of Muslim practitioners who have diabetes do not see themselves as sick and continue to fast(Lee et al., 2017) The practice of fasting increases the risk of complications in people with diabetes, including hypoglycaemia, hyperglycaemia, and ketoacidosis, because it alters physiological factors like eating habits and circadian rhythms (Hanif et al., 2020). The International Diabetes Federation has recommended structured education programs as important for enabling patients to better manage their diabetes (International Diabetes Federation, 2021). Diabetes education with a Ramadan focus can be a beneficial tool to improve health care for diabetics during Ramadan since it will allow patients to fast safely.(Muhammad Yakoob Ahmedani et al., 2016) Medical practitioners should be aware of the dietary, physical activity, and medication-taking changes that come with fasting during Ramadan, as well as the risks (primarily hypoglycaemia and hyperglycaemia) and methods for dealing with those changes and reducing those risks(McEwen et al., 2015) Recommendations have been made to prevent or lower the risk of problems in diabetic patients who fast, and it is clear that therapeutic education focused on the month of Ramadan, including dietary modifications and glycaemic self-monitoring is essential (Jamoussi et al., 2017). This study's primary goal is to evaluate the effectiveness of applying Ramadan education and awareness program on blood glucose profile among Type 2 Diabetes Mellitus patients who fast during Ramadan.

METHOD

This is a quantitative design of a quasi-experimental study which involved 84 type 2 diabetic patients, recruited one week before Ramadan at the Diabetes and Endocrine Center in Sulaimani city. Muslim patients with Type 2 DM who insisted on fasting attending the Diabetes and endocrine Center in Sulaimani City were enrolled, Type 2 DM patients on lifestyle measures, oral medications and/or injection therapies, Type 2 DM Patients with ≥18 years of age, Both genders, those who had been receiving diabetes related treatment for at least 1 year prior to the study and who consented to the study were included. We excluded type 2 DM patients with the following complications or comorbidities:  chronic liver disease, chronic renal diseases, diabetic retinopathy, severe anaemia and those patients on medications known to cause hyperglycemia like corticosteroids.. The recruited patients were divided in to two groups 43 patients were in the first group, Group A, who participated in a 1-hour education program with repeated follow up throughout the month of investigation. The control group, Group B, was made up of 41 patients who were included but did not participate in the program. The objectives of this education programme were to help patients develop the knowledge and self-care abilities necessary to manage their disease more effectively during the month of Ramadan. Objectives of the programme:

• Balanced dietary intake in terms of both quality and quantity (limiting fatty and fried foods and products with high glycemic index.
• During non-fasting periods, avoid dehydration by consuming enough liquids.
• Identifying the clinical signs of hypoglycemia and hyperglycemia and what to do if they occur.
• Proper therapeutic compliance through adherence to doctor-recommended therapy changes.
• Focus on the importance of SMBG for detecting hypoglycemia (<70 mg/dl) and hyperglycemia (>300 mg/dl), which are signs that it is time to break the fast.

Our education programme followed all the principles of structured education as outlined in the International Diabetes Federation (IDF, 2021).

Body mass index, Body weight, Waist circumference, fasting blood sugar (FBS), HbA1c were measured also self-awareness was assessed by an 11 questions after Ramadan fasting.

Data analysis was conducted on Statistical Package for Social Sciences (SPSS), version 22.0. All the continuous variables, i.e. age, duration of diabetes, waist circumference, body weight, body mass index (BMI), fasting blood sugar, HbA1c, were presented as Mean ± SD. Categorical variables, such as gender, education level, occupation, and types of management were presented in the form of number and percentage.  A paired t-test was utilized to find the difference in mean values, and chi square was used for categorical variables. P <0.05 was considered statistically significant.

RESULTS

A total of 84 patients with type 2 diabetes (37 males and 47 females) attended the pre Ramadan recruitment inter-view. Participants divided into two groups; 43 patients in study group and 41 patients in control group. Table 1 summarizes the demographic distribution of the enrolled patients in the study, and no role of statistical significance in demography.

Table 2 summarizes the Effects of a Ramadan education and awareness program on the clinical characteristics of the patients in the control and intervention groups. After Ramadan, there was a mean weight reduction of 0.9 kg in intervention group compared with a 1.0 kg mean weight gain in control group. Level of BMI among the studied group generally, there is a considerable improvement in BMI among the experimental group when comparing the results at baseline data in the same group. While, when results are compared to baseline data from the same group, the BMI level among the control group typically worsens. Among participants in the study group waist circumference positive changes observed, the mean difference in this group decreased from (97.7 cm) to (96.6 cm). In contrast, the mean difference in the control group increased from (100.8 cm) to (101.7 cm). Regarding the comparison of means for the blood glucose at baseline and after implementation of the program, there is a considerable improvement in Mean of blood glucose among the experimental group, it declined from (182.3 mg/dl) to (171.3 mg/dl). In contrast, the mean for the blood glucose in controlled group rose from          (201.8 mg/dl) to (230.5 mg/dl). When comparing the HbA1c means at baseline and after the program's implementation, the experimental group's HbA1c mean improved, it declined from (8.33%) to (8.15%). while, the mean of the controlled group rose from (8.44%) to (8.84%). Table 3 summarizes the impact of RFEP on         frequency of hypoglycemic symptoms during Ramadan. In the experimental group (74.4%) of patients reported not experiencing any symptoms. whereas, in the control group this proportion is (53.7%). Furthermore, Only 2.3% of the patients in the study group experienced hypoglycemia once during Ramadan, compared to 9.7% of the patients in the control group. in addition, about 14.9% of the patients in the study group experienced hypoglycemia more than twice during Ramadan, compared to 34.1% of the patients in the control group

Table 1. Demographic characteristics related to patients.

      Table 2    Effects of a Ramadan-focused education program on the clinical characteristics of the patients in the control and intervention groups

Table 3 Effects of Ramadan education and awareness program on the occurrence of hypoglycaemias during Ramadan.

DISCUSSION

The sample size for this study was eighty four, the mean age of participants was comparable between two groups, 57.6 years in the study group and 55.9 years in the controlled group. the majority of patients (34.6%) had diabetes for more than ten years, (78.6%) of patients took oral anti-diabetic medications, while (19%) of participants took tablets and insulin, The majority of patients (84%) reported having co-morbidities. Regarding participant body weight, the current study found that after the program's implementation, patients in the study group experienced positive changes in their weight. The mean difference of patients body weight in the study group dropped from (79.2 kg) to (78.3 kg). An average weight loss of 0.7 kg was observed in the patient group that received educational programme in the study READ (Ramadan Education and Awareness in Diabetes) (Bravis et al., 2010), which was carried out in England in 2010 with 111 type 2 diabetics treated with ADO. Also, According to a study by (McEwen et al., 2015) there was an average weight loss of 0.7 kg between the beginning and the end of Ramadan. while, A study in Singapore assessed the Ramadan Fasting and Related Changes Glycaemia, Caloric Intake, and Body Composition with Differences in Gender revealed a similar body weight in intervention group patients (Yeoh et al., 2015). These variations can be related to different Ramadan customs and food practices in various nations.

 According to the current study findings, Ramadan focused education program had a significant association with patients BMI, in this study, BMI level was decreased by 0.20 among the study samples. Similar findings were presented in studies (Muhammad Y. Ahmedani et al., 2014) (El Toony et al., 2018)(Tourkmani et al., 2021).

In this study, glycaemic control indicators also improved after intervention of the program. For instance, FBG was decreased by 21.5 mg/dl in interventional group, HbA1c by 0.23% among the study samples. Similar findings were presented in a study by (Prataksitorn & Singchungchai, 2014) in Thailand which observed the impact of Ramadan-focused education on Type 2 diabetic Muslims' awareness and glycemic control In the month of Ramadan, reported FBG decreased from 178.62 mg/dl to 160.13mg/dl and HbA1c by 0.23%.This is in addition to a former study at 2012 on 71 Diabetic patients to investigate the impact of Glycemic control and "Targeted Diabetes Education" during Ramadan fasting. The result of this study reported mean fasting blood glucose was reduced by 57 mg/dL, HbA1c by 1.5% in the intervention group (Mustafa et al., 2012).

The main issue for diabetic patients during Ramadan is the risk of hypoglycemia(Ahmad et al., 2012), in the present study more patients in the study group (74.4%) than in the control group (53.7%%) reported not experiencing any symptoms. in addition, only 2.3% of patients in the study group experienced hypoglycemia symptoms more than twice during Ramadan, compared to 17.1% of patients in the control group. The risk of hypoglycemia seems to be decreased as a result of the Ramadan-focused educational program, This finding is in keeping with the a controlled intervention based study by (Tourkmani et al., 2021)  on 262 type 2 diabetes patients reported that the Ramadan Focused Education Program had a positive effect and can be a helpful tool to get better results, like fewer cases of hypoglycemia and safe fasting for T2D patients during Ramadan. Additionally, a study in Egypt assessed the effect of structured diabetes education on diabetic patients' glycemic control while fasting during Ramadan revealed a 31% reduction in hypoglycemic events in intervention group patients (Nassar et al., 2021).

CONCLUSIONS

Participants in the Ramadan-focused educational program had improved overall BMI, weight, FBS, and HbA1c control during Ramadan and were less likely to develop hypoglycemia. This educational program on Ramadan helped type 2 diabetic patients fast more safely during the holy month.

ETHICAL CONSIDERATIONS COMPLIANCE WITH ETHICAL GUIDELINES

The current study was presented to the ethics committee of University of Sulaimani, College of Nursing, and College of Medicine. Ethical approval was guaranteed by the ethical committee of the medical colleges / university of Sulaimani and approval by them. 

FUNDING

This research did not receive any grant from Funding agencies in the public, commercial, or Non-profit sectors. 

AUTHOR’S CONTRIBUTIONS

Study concept, Writing, Reviewing the final edition by all authors.

DISCLOSURE STATEMENT:

The authors report no conflict of interest.

ACKNOWLEDGEMENTS

We thank the anonymous referees for their useful suggestions.

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