Knowledge, attitude, practices and provision of healthcare to fasting patients with diabetes: a national survey
Maheen Nizam, Muhammad Yakoob Ahmedani

Background
Fasting during Ramadan is obligatory for all adult healthy Muslims across the world. Through literature review, it has been found out that there are various articles published for the awareness of patients and general population regarding safe fasting during Ramadan. In Pakistan most of the patients with diabetes prefer to fast. However, nationwide data regarding knowledge, attitude practices of fasting patients with diabetes and provision of care to these patients during Ramadan is scarce.
Aim
1.	1. To observe the knowledge, attitude, practices among fasting patients with diabetes during Ramadan
2.	2. To assess availability of appropriate care to the fasting patients with diabetes during Ramadan.
Method
This observational study was conducted at multi tertiary and primary care centers from all over Pakistan, started from November 2016 to March 2017(Muslim year 1437). Ethical approval for the study was obtained from the Institutional Review Board of Baqai Institute of Diabetology and Endocrinology (BIDE). Fasting patients with diabetes across the country who give informed consent was included in the study. Patients with diabetes who do not fast, Non-Muslim diabetic patients and children less than 12 years of age were excluded from the study.
At each center, health care professionals involved in the care of patients with diabetes were requested to complete the questionnaire to fasting patients with diabetes using convenience sampling. An identical standardized questionnaire-based interview was conducted on one-to-one basis across the country. Information regarding demographic, anthropometric measurements, number of days of fasting, type of treatment of diabetes, Ramadan related knowledge, attitude and practices was collected. Pre-Ramadan diabetes education, adjustment of medication dosage and timings, frequency of blood glucose monitoring, development of hypoglycemia and hyperglycemia symptoms and their frequency during Ramadan were also taken. All the data was centralized into the computer database of BIDE. Statistical Package for Social Sciences (SPSS) version 20 was used to analyze the date.
Results
Out of 832 patients 51(6.1%) with type 1 and 781(93.8%) with type 2 diabetes 363(43.6%) were male and 469(46.4%) were female. Mean age of participants was 51.7 ±12.20 years and mean duration of diabetes was 9.4±6.70 years. Around one third (68.5%) patients with diabetes hold fast 21-30 days during Ramadan. Out of total participants434 (51.4%) believed that breaking the fast is prohibited during Ramadan and 389(46.1%) patients consider that needle prick for testing blood sugar is not allowed while fasting. Three eighty five (45.9%) presume insulin injections during fasting can break the fast and 353(42%) do not take any oral medication in Sehri. Four forty eight (68.1%) do not check their blood sugar in hypoglycemia and 466(73.6%) in hyperglycemia. Majority of (81.1%) fasting patients with diabetes do not have an access to any helpline serves during Ramadan. Around half of the (44.9%) people with diabetes do not follow the recommended diet during Ramadan although they realize that the recommended diet is very important; while 216(31.2%) patients with diabetes were assess their blood glucose 1-3 times in a week during Ramadan.
Discussion
Results of this survey showed that there is a significant lack of awareness and misconceptions among fasting patients with diabetes across the country. Standardized diabetes care is not uniformly available for patient at primary and tertiary care level during Ramadan. There is an immense need to promote educational programs and CMEs to increase knowledge among doctors, healthcare professionals and patients regarding safe fasting with diabetes during Ramadan.