Dietary knowledge assessment among the patients with type 2 diabetes in Madinah: A cross-sectional study 

Background There is a huge burden of nutrition-related non-communicable diseases, and diabetes is one of the leading chronic nutrition-related diseases affecting more than 500 million people globally. Collecting information regarding the awareness of dietary and nutrition knowledge among diabetic patients is the first step to developing a disease prevention program. Thus, this study primarily aims at assessing the dietary awareness of diabetes patients attending the diabetic centre in Madinah governorate, Saudi Arabia. Methods The study was started in November 2020 and ended in October 2021. The study participants (315) were type 2 diabetes mellitus (T2DM) patients attending a diabetic centre in Madinah, Saudi Arabia. A self-prepared dietary knowledge questionnaire (DKQ) was used in this research. The variables include balanced diet, food type, food choice, carbohydrate, protein, and fat. Knowledge score was, and the total score was levelled/categorized into ‘good’, ‘average’, and ‘poor’. Data were analysed by SPSS v.26. Results The study results identified the current knowledge of T2DM patients about different dietary items. The knowledge score of 62.2% of participants showed an average level of dietary knowledge, which is statistically significant. When we separately evaluated their understanding of different dietary components, we found that T2DM patients had poor knowledge of carbohydrates (30.15%), fat, food choices (47.7%), and type (34.6%). However, they had acceptable knowledge of proteins (56.5%). Conclusion Our participants exhibited acceptable knowledge about proteins but poorer knowledge of other food groups. A healthy, well-balanced diet is essential for excellent glycaemic control. Educating and arranging a health education program regarding dietary knowledge is recommended, specially designed for diabetic patients so that patients can opt for a healthier lifestyle


Methods
The study was started in November 2020 and ended in October 2021.The study participants (315) were type 2 diabetes mellitus (T2DM) patients attending a diabetic centre in Madinah, Saudi Arabia.A selfprepared dietary knowledge questionnaire (DKQ) was used in this research.The variables include balanced diet, food type, food choice, carbohydrate, protein, and fat.Knowledge score was, and the total score was levelled/categorized into 'good', 'average', and 'poor'.Data were analysed by SPSS v. 26.Any reports and responses or comments on the article can be found at the end of the article.

Introduction
Today's world has a huge burden of nutrition-related non-communicable diseases. 1Diabetes is one of the leading chronic nutrition-related diseases affecting more than 500 million people globally (around 6.3% of the world's population). 2,3iabetes is the ninth primary cause of mortality. 2It is also estimated that over 1.5 million deaths were directly caused by diabetes alone. 4However, the main concern raised recently is that greater than one-third of diabetes-related mortalities occur in individuals younger than 60. 5 The International Diabetes Federation (IDF) for the Middle East and North Africa (MENA) recently estimated that diabetes prevailed at 18% in Saudi Arabia alone. 3udies have shown a continuous upward trend in the prevalence of diabetes. 2There is also an increased burden of human suffering as measured by disability-adjusted life years (DALYs) because of diabetes.However, many countries have implemented a significantly high budget for health care expenditure. 6Non-modifiable risk factors like age and familial history can be one of the causes of the continuous upward trend. 7At the same time, modifiable risk factors include increased body mass index due to processed high caloric unhealthy diet and physical inactivity for type 2 diabetes mellitus (T2DM). 4,7cent analysis has reported that for the management of diabetes, only pharmacologic approaches are not sufficient. 2The management of diabetes is a multifactorial process involving demographic and social factors that influence the treatment outcomes. 8There are also patient-related factors, such as self-care behaviours, that have a strong influence on glycaemic intolerance. 9Blood glucose monitoring, diabetes-related knowledge, and dietary knowledge all come under self-care behaviours. 10Similarly, Dietary monitoring is necessary to predict patients' quality of life, nutritional status, and risk factors to avoid chronic diabetes-related complications. 10rly onset T2DM usually occurs in <45 years; its main contributor include obesity, dyslipidaemia, smoking, and a sedentary lifestyle. 11Simple lifestyle modifications are effective in preventing or delaying complications in T2DM patients. 4Dietary modifications and nutrition knowledge are the cornerstones of diabetes type 2 management. 12Eating habits are directly related to dietary knowledge and significantly contribute to glycaemic control. 12Nutrition knowledge helps individuals with diabetes to optimize their quality of life. 13tients with T2DM often face difficulty identifying the recommended diet, including its quality and quantity.The collection of food and dietary habits is affected by the knowledge of a patient concerning a suggested diet. 14A study on dietary knowledge among T2DM patients conducted in the Almajamah area of Saudi Arabia found poor awareness, attitudes, and practices toward healthy dietary habits.Only one-sixth of the studied population followed a strict diabetic diet that represented a poor diabetic control level. 15Non-adherence to dietary plans with inadequate knowledge is facing in many countries, 16 which in turn is associated with inadequate family support 17 and decreased motivation. 18Diabetes in < 60 years of age is most prevalent in low-and middle-income countries, while in high-income countries, this is mostly found in the ageing population (>60 years of age). 15Collecting information regarding the awareness of dietary and nutrition knowledge among diabetic patients is the first step to developing a disease prevention program.Although there is an increased prevalence of T2DM, studies have shown that the dietary knowledge among patients is insufficient. 15nowing the level of knowledge and perception of dietary habits in T2DM patients helps provide them with more efficient and beneficial education.Therefore, this study aims to assess the dietary knowledge among diabetic patients attending the diabetic centre, Madinah governorate, Saudi Arabia.

Ethical statement
Ethical approval was obtained from Research and Studies Department of Health Affairs, Ministry of Health, Madinah, Saudi Arabia (IRB#544).All patients who gave voluntary written informed consent for participation before data collection were included in the study.The study participants' information was kept confidential and anonymous.

REVISED Amendments from Version 1
This updated version of the article provides a more comprehensive exploration of the impacts of the Dietary knowledge among the patients with type 2 diabetes in Madinah.In new version, minor corrections have been done throughout the manuscript mainly related to grammar and sentence formation.Study limitations are also better explained now in discussion.
Any further responses from the reviewers can be found at the end of the article

Study design
This study was a cross-sectional descriptive, single-centre study conducted at Al-Madinah Al Munawarah, the second holiest city in Islam, in the Hejaz region of western Saudi Arabia.The study was started in November 2020 and ended in October 2021.

Study population
The study population consist of patients with Type 2 Diabetes mellitus attending a diabetic centre in Madinah, Saudi Arabia.The inclusion criteria were type 2 diabetic patient, > 18 years of age, and the participation was voluntary.Those who were type 1 diabetic patients, < 18 years old and those with mental impairment or who did not consent to participate were excluded from the study.A systematic random sampling technique was utilized for participant recruitment and data collection.

Sample size
Population size: the total number of type 2 diabetic patients attending the diabetic centre.
Confidence limit: 5% confidence interval: 95% Diabetes prevalence in KSA: 18% 3 Using Epi info to calculate the sample size, the calculated sample size was 227.However, it was increased to 315 to overcome the possibility of outliers and missing data (if any).

Study tools
The self-prepared Dietary Knowledge questionnaire (DKQ) used in this research consisted of multiple-choice questions (MCQs) prepared after an extensive literature review.The questionnaire was face validated by faculty members of the university.Back-to-back translations (Arabic and English) were made by the native Arabic speaker and reviewed by the corresponding author to improve the clarity of the questions. 30,31The pilot study was also conducted, and the changes were done according to responses and unclear questions.The researcher interviewed ten patients (started 15 September 2020 and ended in 20 September 2020) from outside the selected class to test the feasibility of the questionnaire, the time taken to finish the interview.These ten cases were not included in main study.Those questions that were unclear or that did not cover the study concept were modified accordingly.The questionnaire was adapted from a published article, 19 which showed the Cronbach Alpha of that questionnaire was 0.869.

Data collection technique
The questionnaire was distributed online through google survey forms.The completed version of the forms was saved in the secured email (which was only assessed by the study supervisor) and collected after the required sample size was achieved.Selection bias is common in population-based studies; to overcome this we sent invitations to all the relevant participants who attended the clinics.Therefore, who those who were willing to participate filled the online questionnaire.
The questionnaire was self-administered and consisted of 19 questions with multiple choices.Variables include knowledge about a balanced diet, food type, food choice, carbohydrates, proteins, and fats.However, only one response is correct.The correct response was coded 1, and all others were coded 0. Therefore, the total score = 19 (< 8 = poor level, 8-12 = average level, and > 12 good knowledge level).The higher score of the individual corresponded to higher dietary knowledge.However, each variable's quantitative scores were categorized into 3: <50% as poor knowledge, 50-75% as acceptable, and >75% as adequate knowledge. 12,20ta entry and analysis All data were analysed by SPSS software version 26.The normality of the quantitative variables was checked.The frequency (percentage) of correct responses for each variable was presented.Outliers were detected through Z-scores.Knowledge score was, and the total score was levelled/categorized into 'good', 'average', and 'poor'.One-sample T-test was performed to evaluate the dietary knowledge of T2DM individuals.A p-value of <0.05 is considered statistically significant.

Results
The overall frequency and percentage of correct responses were presented against each item in Table 1. 29The dietary knowledge questions were also categorized into food choices, knowledge about carbohydrates, fats/oil, protein, and type of food.Most patients select correct food choices for diabetes (85.4%).While very few (19%) know which of the food they can freely eat.Almost half of the participants knew how to treat low blood sugar (42.5%).The median knowledge score of participants for the food choices was 1(0-3), corresponding to poor knowledge (47.3%) about food choices for T2DM.
Regarding the knowledge about dietary group carbohydrates, two-fifths of the participants correctly identified the food with the highest carbohydrate percentage.Around two-thirds of the participants knew that bread, cereals, rice, and pasta are a rich source of carbohydrates.Many participants did not know which food contained the highest amount of sugar (82.9%).However, most participants (61%) correctly responded about whole grains foods.The majority know that eating too much sugar will lead to diabetes (80%).The median knowledge score about carbohydrates was three (0-5), while the percentage showed poor overall knowledge of carbohydrates (30.15%).
Regarding dietary knowledge about protein, most participants correctly identified the food with the highest protein percentage (71.1 %), and most knew the complete source of protein (75.6%).The median knowledge score of protein was 2 (0-2), and the percentage showed an almost acceptable level of knowledge of protein (56.5%).Concerning the fat and oil group, most of the patients know food with the highest percentage of fat (73.7%) and which is highest in fat (51.4%).
Only one fifth of the participants knew the food product with a high cholesterol level.While a majority of the patients correctly identified that fat is a rich source of calories (88.9%).The median knowledge score of fat was 2 (0-3), whereas, in terms of percentage, T2DM patients have poor knowledge of fat (47.7%).There were various statements on a selection of food types.The median knowledge score of food type was four (0-5), with the percentage showing that T2DM patients have poor knowledge of food type (34.6%).
The study results showed that all the z-scores of dietary knowledge score were less than three, whereas the minimum z-score was -2.85 and the maximum was 2.08.There was no outlier detected in the dietary knowledge variable.The mean dietary knowledge score (total 19 items) was 10 (8-12), with a minimum of three and a maximum of 16.However, most of the study participants (62.2%) showed average dietary knowledge (Figure 1).One sample T-test statistics confirmed that the T2DM patient's average level of dietary knowledge is statistically significant (p < 0.0006).

Discussion
The study results identified the current knowledge of T2DM patients about different dietary items.The knowledge score of 62.2% of participants showed an average level of dietary knowledge, which is statistically significant.When we separately evaluated their awareness of different dietary components, we found that T2DM patients have poor knowledge about carbohydrates, fats, food choices, and food types.However, they had acceptable knowledge of proteins.
Different studies around the world showed various levels of dietary knowledge among type 2 diabetic patients.In agreement with our study, another study conducted on T2DM patients in Iran showed average levels of dietary knowledge. 21In contrast, a study reported inadequate dietary knowledge among T2DM females of Amman, Jordan. 20 study conducted in Ethiopia found a poor level of dietary knowledge and practices. 22r study results showed that the majority of the participants answered that they know what a diabetic diet (85.4%) is; however, they have poor knowledge regarding individual food components and what should be used with hypoglycaemia (42.5%).Comparing our results with another study, only 43.9% of individuals know the recommended meal for diabetes/ day, and only 44.5% know what should be used with hypoglycaemia. 20rbohydrates are an important macronutrient that affects the postprandial glycaemic index.Another study conducted among Emirati and Omani adults concluded that individuals have insufficient knowledge of carbohydrates. 23Likewise, another Saudi study showed participants had poor knowledge about carbohydrates but had good dietary knowledge regarding other good groups, including fat and protein. 14Most participants correctly identified the main carbohydrate source in the diabetic diet, but most did not know the food with the highest sugar content.Global estimates from 165 countries found a strong positive association between diabetes prevalence and per capita sugar consumption. 24ring the last decades, many countries have experienced a major shift in food choices and nutritional transition from the Mediterranean diet to more processed/junk foods.Likewise, lack of physical activity, urbanized lifestyle, and increased food consumption cause an increase in nutritional problems with a high prevalence of obesity that triggers many chronic diseases. 20In Saudi Arabia, food choices and portion sizes with a sedentary lifestyle were dramatically increased, resulting in a high prevalence of obesity and diabetes.Moreover, they also consume too many sugary drinks. 25A recent randomized controlled trial of diabetic patients demonstrated that simplified diabetes nutrition education greatly impacts glycaemic control. 26

Strengths and limitations
The first limitation is the study's cross-sectional nature, which limits the temporal association between disease and exposure.Secondly, the study participants were only recruited from a single centre; therefore, the generalizability of the study results should be interpreted with caution.Thirdly, the sociodemographic data were not collected for this study hence, the comparison and difference of knowledge across different socioeconomic groups was not evaluated.However, there are also some strengths of the study.First, a valid questionnaire was used, and study participants were recruited through systematic random sampling.Second, the sample size was calculated, and a maximum number of participants was recruited to overcome the missing data.

Conclusion
A healthy, well-balanced diet is essential for excellent glycaemic control. 27Appropriate self-care and effectual metabolic regulation control prevent hypoglycaemia, other metabolic complications, and ketoacidosis. 27Nutrition plays a key role; food with high fibre, low fat, and limited carbohydrate should be taken at regular intervals. 25All food groups should be included in the daily diet. 28Our participants showed acceptable protein knowledge but poorer knowledge of other food groups.It is not an easy job to increase the awareness and knowledge of nutrition and a healthy diet in diabetic individuals in our society.Self-dietary management is the first and foremost step in providing knowledge and skills to people with diabetes concerning treatment, medications, and nutritional aspects as defined by American Diabetes Association (ADA). 25A healthy diet is considered an integral part of diabetes management.Likewise, a healthy lifestyle, regular exercise, weight management, and a well-balanced diet can improve diabetic patients' health.Educating and arranging a health education program regarding dietary knowledge is recommended, specially designed for diabetic patients so that patients can opt for a healthier lifestyle.There is also a need to emphasize preventive measures with research based on an effective region-specific diet and nutritional knowledge that can be provided to everyone, including prediabetics and those with diagnosed diabetes.

Extended data
Figshare: Dietary knowledge assessment among the patients with type 2 diabetes in Madinah: A cross-sectional study.https://doi.org/10.6084/m9.figshare.22123001.v1. 30is project contains the following extended data: Study population: start sentence with "The study population".2nd line remove coma after patient.Change 3rd sentence to "Those who were type 1 diabetic patients < 18 years old and those with mental impairment or who did not consent to participate were excluded from the study".
5th line, the numeral 10 is used instead of the word spelled out.Consider spelling out the number.
6th line, replace it with this sentence "selected class to test the feasibility of the questionnaire, the time taken to finish the interview".
10th line, google to Google.
11th line, change sentence to "Selection bias is common in population-based studies; to overcome this we sent invitations to all the relevant participants who attended the clinics.
12th line, change sentence to "Therefore, who are only willing to participate filled out the online questionnaire".
Data entry: 2nd line, response to responses Results: Two third to two-third One fifth to one-fifth Last paragraph, 3rd line, change these sentences "with a minimum of three and a maximum of 16"."However, most of the study participants (62.2%) showed average dietary knowledge". Discussion: 1st paragraph, 4th line, fat to fats, type to types.
4th paragraph, 3rd line, change sentence "likewise, another Saudi study…" to "Likewise, another Saudi study showed participants had poor knowledge".

Conclusion:
3rd line: change sentence to "All food groups should be included in the daily diet" 9th line: change sentence "It is recommended to…" to "Educating and arranging a health education program regarding dietary knowledge is recommended, specially designed for diabetic patients so that patients can opt for a healthier lifestyle".
Overall: For consistency, consider replacing words with the British English spelling.For example, leveled to levelled, center to centre, behavior to behaviour, fiber to fibre.

Is the work clearly and accurately presented and does it cite the current literature? Yes
Is the study design appropriate and is the work technically sound?Partly

Are sufficient details of methods and analysis provided to allow replication by others? Yes
If applicable, is the statistical analysis and its interpretation appropriate?Yes Are all the source data underlying the results available to ensure full reproducibility?Yes

Are the conclusions drawn adequately supported by the results? Yes
Competing Interests: No competing interests were disclosed.
I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

the work clearly and accurately presented and does it cite the current literature? Yes Is the study design appropriate and is the work technically sound? Yes Are sufficient details of methods and analysis provided to allow replication by others? Yes If applicable, is the statistical analysis and its interpretation appropriate? Partly Are all the source data underlying the results available to ensure full reproducibility? Yes Are the conclusions drawn adequately supported by the results? Yes
Nutritional Knowledge Questionnaire in Diabetics (Arabic).docx.(Blank Arabic version of the questionnaire) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).suitable methodology throughout the study; however, it is noteworthy that the authors acknowledged a limitation that they didn't collect sociodemographic data, which constitutes a substantial concern.It is strongly advised that future research endeavors incorporate sociodemographic questions, as these factors have the potential to influence statistical analysis and subsequent findings.
employed Competing Interests: No competing interests were disclosed.Reviewer Expertise: Public health, statistics, epidemiology.I confirm that I

have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.
Study design first sentence: replace it with this "This study was a cross-sectional descriptive study conducted at Al-Madinah Al Munawarah, the second holiest city in Islam, in the Hejaz region of western Saudi Arabia."