The Assessment of Diabetic Ketoacidosis Awareness Among Diabetic Patients and Their Caregivers in Makkah, Saudi Arabia: A Cross-Sectional Study

Introduction: Diabetic ketoacidosis (DKA) is a life-threatening complication of diabetes mellitus (DM). It occurs due to a decrease in the level of insulin and an increase in the level of glucose in the blood, which makes cells unable to use glucose as an energy source and begin to break fat into ketones; an overload of ketones levels in the blood can lead to DKA. The aim of the study is to assess awareness of DKA among diabetic patients and their caregivers in Makkah City, Saudi Arabia. Methods: This study is a cross-sectional study collected through an online questionnaire of diabetic patients and their caregivers in Makkah City. A self-reported questionnaire designed in Arabic and English through the use of Google Forms, it distributed electronically via social media to the target population with the objectives of the survey. Results: A total of 400 participants were included, 73% of them were males, while 27% were females. A 9% of the participants have been diagnosed with DKA. A high awareness level about DKA was found in 32.5% of participants, while 67.5% had a poor awareness level. Factors associated with a high level of awareness towards DKA are young age, being single, students and having a previous DKA diagnosis. Conclusion: Regarding our participants who have poor awareness of DKA, further education for diabetic patients and their caregivers about DKA is crucial to prevent life-threatening complications, and improve quality of life for these patients.


Introduction
A collection of metabolic conditions known as diabetes mellitus (DM) is characterized by high blood glucose levels due to decreased insulin circulation in the body, insulin resistance, or increased synthesis of counterregulatory hormones [1].Globally, Saudi Arabia ranks seventh in the incidence of DM.One of the complications of DM is diabetic ketoacidosis (DKA); in Saudi Arabia, the frequency of DKA at the presentation of type 1 DM (T1DM) is very high.DKA is a life-threatening complication of diabetes and needs urgent medical attention [2].The incidence of mortality may range from 4% to 40% in developing countries [3,4].
DKA is usually associated with T1DM, but it also can affect patients with type 2 DM (T2DM) [5].Several papers have been done to study DKA in diabetic patients among different age groups with different methods in different countries.For example, a study among diabetic patients in Riyadh to measure their awareness of DKA showed that 38.67% have poor awareness of complications, and 67.34% have poor knowledge about management [6].In another study, to assess the level of awareness among diabetic patients on how to avoid DKA in India, it was revealed that 80% have a poor level of knowledge [7].
According to the International Diabetes Federation (IDF), Saudi Arabia is ranked in the top 10 countries with the highest expected prevalence of diabetes in 2011 (16.2%) and 2030 (20.8%) [8].Additionally, DKA is one of the most acute and serious complications of DM, for which treatment in many cases should be given in an intensive care unit [9].Therefore, educating diabetic patients and their caregivers about DKA is crucial to prevent this life-threatening complication and improve the quality of life for these patients.The aim of the study is to assess awareness of DKA among diabetic patients and their caregivers in Makkah City, Saudi

Data analysis
Data was collected through Excel sheets (Microsoft® Corp., Redmond, WA, USA) and enrolled into Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 21, Armonk, NY).A descriptive study was done by using frequency and percentage to summarize the data.The overall awareness level regarding DKA was graphed after assessing and summing up discrete scores for different correct awareness items.Each correct answer was given one point.The overall awareness score was categorized as a poor level if the participants' score was less than 60% of the overall score, and a good level of awareness was considered if the participant's score was 60% or more of the overall score.

Results
A total of 400 diabetic patients and their caregivers were included.Participants' ages ranged from 15 to 64 years.The total number of participants who completed the questionnaire was 400; the total number of males was 292 (73%), while the number of females was 108 (27%).The majority of the sample (50.8%) was between the ages of 15-24.The major nationality at this was Saudi (95.3%).

Diabetes mellitus (DM) and diabetic ketoacidosis (DKA) data
No % Were you diagnosed with diabetes mellitus (DM)?

Awareness of DKA among diabetic patients and their caregivers
Generally, 33.8% of the study participants correctly defined DKA as a complication of diabetes and requires an urgent intervention, 38.3% knew that DKA is considered as a life-threatening condition, 43.5% knew that DKA might affect other systems in the body, like the brain and heart.On the other hand, 32.3% disagreed that DKA affects children only.Regarding causes and risk factors, 29.3% know that the main reason for DKA is forgetting to take insulin injections.Regarding causes and risk factors, 83 (20.8%) are aware that physical activity may be one of the triggers of DKA, 156 (39%) reported that the incidence of DKA is decreased when the normal level of HbA1c is maintained, 20.8% know that physical exertion could be one of the causes of DKA, and 63 (15.8%) reported that infection could be one of the causes of DKA as reported by of participants (Table 3).

Overall awareness level of DKA among diabetic patients and their caregivers
Figure 1 shows that 130 (32.5%) of participants had a high awareness level about DKA while 270 (67.5%) had a poor awareness level.

Factors associated with diabetic patients and caregivers' awareness of DKA
The participants' group aged 25-34 years had an overall good awareness of DKA versus other aged groups with a statistically significant difference (P=.013).Also, the good overall awareness level among the marital status of participants showed a significant difference (P=.001).Overall, a good awareness level about participant employment had a significant difference (P=.003).Those who were diagnosed with DKA had a higher overall awareness level than those who were not diagnosed with DKA (Table 5).

Discussion
The current study aimed to assess awareness of DKA among diabetic patients and their caregivers.The study showed that most participants were young, patient caregivers, while nearly one-fifth were the main diabetic cases.Also, very few per cent of the patients had DKA.
Regarding participants' awareness of DKA, the study showed that only one-third of the respondents (32.5%) were knowledgeable of DKA, whilst two-thirds (67.5%) had a low level of awareness.In more detail, about one-third of the study participants correctly defined DKA, and more than one-third knew that DKA is considered a life-threatening condition.Less than half of them reported that DKA may affect other systems in the body, like the brain and heart, but only one-third disagreed that DKA affects children only.
Our result is in line with other studies (Farran et al., 2020) [6], which found that the majority of participants have poor knowledge about the DKA regarding risk factors, management and complications.Also, another study (Alanazi et al., 2018) [10] showed that more than half of the diabetic patients in Riyadh City had a low level of awareness about the risk factors of DKA.Other research in Sudan (Elhassan et al., 2022) [11] revealed that 56.9% of participants had poor knowledge about DKA and low practice scores (0-2 out of 6).Also, a study in India (Thakare et al., 2021) [7] showed that a large majority (80%) of diabetic patients lack knowledge about DKA.As for the main cause, less than one-third (29.3%) know about forgetting to take insulin injections.The most known aggravating factor was abnormal levels of HbA1c (39%).These results differ from other studies (Satti et al., 2013) [12], revealing that infection is the major cause of DKA.
Additionally, the outcome of this study regarding factors associated with participants' awareness level showed that higher awareness level was significantly associated with having a history of DKA and young age participants who were mainly students and singles.While another study (Farran et al., 2020) [6] revealed a relationship between the level of awareness regarding DKA management and having a first-degree relative with diabetes.
However, a lower level of awareness was more common among married and unemployed participants.Also, participants who think that diabetic patient has high knowledge about DKA are significantly associated with low levels of awareness.Although, these results could be different from other studies, like the study from Hamed et al. (2021) [14].These differences could be attributed to different samples, times and socioeconomic status.
This lack of awareness can lead to significant financial and health burdens for patients and their families, as well as the country and government.Therefore, educating diabetic patients and their caregivers about DKA is crucial to prevent life-threatening complications, improve the quality of life for these patients, and enhance the health and economic system.
We recommend the Ministry of Health take a step for inverse education about diabetes and its complications, especially DKA.

Limitations
The study was done only in Makkah city, which is why it can't be generalized.Further investigations need to be done.

Conclusions
In conclusion, the awareness level of our participants toward DKA was poor.However, a history of having DKA, a young age, being single, and being a student are associated with a higher level of awareness.
Collaborative efforts and further education about DKA need to be enhanced among diabetic patients and their caregivers to prevent life-threatening complications, improve the quality of life for patients, and enhance the health and economic system.Also, further research needs to be done about diabetes and DKA to determine the level of awareness of diabetic patients and their caregivers in our area.

TABLE 2 : Diabetes and DKA history among study participants
Exactly 36 (9%) were diagnosed with DKA; 101 (25.3%) of participants believed they had good information about DKA and 299 (74.8%) believed they had low information about DKA.Regarding participant opinion, 251 (62.8%) think diabetic patients have low knowledge about DKA.