Knowledge and attitude on the role of lifestyle modifications in the management of diabetes in Jeddah, Saudi Arabia

ABSTRACT

Background

Public knowledge about the role of lifestyle in managing type two diabetes (T2D) is an essential preventive strategy. Despite efforts in public awareness, the prevalence continues to rise, with the majority relying on the availability of effective therapeutics, underestimating the role of healthy lifestyle changes. This study aims to assess public awareness of the impact of lifestyle modification in managing T2D in a major metropolitan city in Saudi Arabia, which will help inform the health management authority in the country on the level of public awareness and advise on the development of educational programs.

Methods

An observational cross-sectional survey study comprising 16 knowledge and 6 attitude questions was conducted among the population over 18 years old using online survey. After validation, the online self-developed questionnaire was distributed through social media.

Results

The knowledge and attitude scores were similar between males and females. Participants with a family member or friend with T2D demonstrated higher knowledge scores. However, the attitude scores did not differ significantly based on family or friend relationships.

Conclusion

The knowledge and attitude on the role of lifestyle modifications in preventing and managing T2D is moderate, implying an opportunity for innovative strategies to raise public knowledge and attitude.

KEYWORDS:

• Diabetes
• knowledge
• attitude
• prevention
• management
• lifestyle modification

1. Introduction

Diabetes can manifest asymptomatically for long before the diagnosis. The onset of type two diabetes (T2D) occurs at least 4–7 years before clinical diagnosis [1]. Diabetic individuals may thus remain untreated long before the appearance of symptoms. It’s estimated that up to one-third of adults with diabetes are unaware they are already diabetic [2]. The essential factor in the unawareness of the diabetes infliction in individuals is the lack of knowledge of its symptoms, risk factors, and prevention [3].

In a healthy person, the pancreas releases insulin to help store dietary sugar intake. T2D occurs when there is insufficient insulin production, or the body has difficulty responding appropriately to insulin; thus, excess glucose fails cellular internalization and accumulates in the blood. Persistent elevation of blood glucose leads to multifaceted and exponential bodily damage arising from distorted cellular functions [2].

T2D is a growing epidemic as the number of patients worldwide has doubled over the past three decades. In 2010,it was estimated that 285 million people worldwide were diabetic, and 90% of them were T2D [4]. In 2017, approximately 462 million individuals were affected by T2D [5]. There are 110 million people with diabetes in China alone, about 69 million in India, and almost 10% of The United States population [6]. Saudi Arabia (KSA) is no stranger to the diabetes epidemic, with the seventh-highest rate of diabetes in the world and the second-highest rate in the Middle East. A recent study on people over 30 years old found that 50% of Saudi people were pre-diabetic or diabetic [7]. According to a study in Al-Qassim, the prevalence of T2D in the Saudi population across all age groups was 11.9% in 2014 [8].

Overweighting, obesity, heredity, and lifestyle, which include smoking and alcoholism, are risk factors and significant causes of T2D [9]. Moreover, T2D is genetically linked, so individuals with a family history of the disease are at higher risk [2]. Age and ethnicity are also risk factors for developing T2D. In 2016, more than 1.9 billion adults were overweight, with 650 million reaching obesity [10]. As mentioned, lifestyle patterns are one of the critical risk factors for developing T2D. Lifestyle choices, such as a high fat and carbohydrate diet, alcohol intake, and physical sedentary are well-established risk factors. A study showed that 81% of Saudi adult males were physically inactive, and 99.5% of adult females in the Asir province did not exercise [7]. Hence, the Saudi population leans toward a sedentary lifestyle, thus contributing to the risk of developing T2D.

There are several ways to manage and prevent T2D and its symptoms, such as medicines, exercise, diet, supplements, and healthy lifestyle changes [11]. However, using diabetes medications usually coincides with side effects leading to compliance issues. Common side effects include nausea, stomach upset, pancreatitis, joint pain, weight gain, diarrhea, etc [12]. Maintaining a healthy lifestyle is one of the best ways to prevent and manage T2D. Furthermore, raising awareness about healthy lifestyles would greatly benefit the general population on the importance of lifestyle modifications to prevent and manage diabetes.

Therefore, assessing public knowledge and attitudes about the role of lifestyle modification in preventing and managing T2D is necessary for developing public awareness programs. Such assessment studies have been reported locally and abroad, often assessing limited variables at a time or in a specific population group. For example, the study reported in South Africa assessed the knowledge and attitude regarding lifestyle modification in T2D among diabetic patients rather than the general population [13]. Similarly, a study in the United States assessed the management and prevention of T2D to diet and obesity [14]. Likewise, a study in the Al-Qassim region in Saudi Arabia assessed the knowledge and awareness of diabetic patients on lifestyle modification, mainly focusing on diets as a risk factor [15]. To our knowledge, studies in Saudi Arabia have yet to assess awareness of broader topics of lifestyle changes’ role in the development of T2D. In addition to diets, our study also assessed people’s knowledge of the risk factors related to exercise and supplements on the development of T2D. Assessing the awareness of such a critical topic in the community will help inform the health management authority in the country on the level of public awareness and advise on the development of educational programs. Therefore, this study aimed to assess the public awareness in Saudi Arabia about the impact of lifestyle modification in preventing and managing diabetes.

2. Methods

This study was an observational cross-sectional. Convenience sampling was used by distributing an online survey that was prepared and sent to the public of Jeddah using social media and messaging apps. The study was conducted among the population of Jeddah, with both genders being included. The minimum age was 18, including both diabetic and nondiabetic people. The calculated sample size was 385 considering the following criteria: margin of error: 5%, confidence interval: 95%. This was based on the population of Jeddah, which is 4 million people.

A 22-item self-administered questionnaire had three sections. The first section collected socio-demographic and clinical data (Table 1). The second section had 16 questions regarding knowledge, and the third had 6 attitude questions. The scoring knowledge questions were from 1 to 5 on a Likert scale as strongly agree, agree, neutral, disagree, and strongly disagree. Attitude questions were multiple choices from 0–4. The total score ranges were 16 to 80 for the knowledge section and 0 to 24 for the attitude section (Tables 2, 3). Then, according to the scores, participants were classified into three groups: good, moderate, and poor. The cutoff for the attitude was 0–7 for poor, 8–14 for moderate, and 15–24 for good. The cutoff for the knowledge was 16–39 for poor, 40–59 for moderate, and 60–80 for good. The survey was conducted and completed in 2 months.

Table 1. Items of questionnaire for demographics characteristics.

Demographics Characteristics
Gender	Male
	Female
Age	≥18
	Less than 18
Marital Status	Single
	Married
	Separated
	Widow
Educational Level	Primary School
	Middle School
	High School
	College
	University
	None
Employment Status	Employed
	Self-Employed
	Retired
	Unemployed
Work in the medical field	Yes
	No
Monthly Income (SAR*)	No Income
	Less than 5000
	5,000–9,999
	10,000–19,999
	20,000–39,999
	40,000–50,000
	More than 50,000
Have type 2 diabetes	Yes
	No
Family member with type 2 diabetes	Yes
	No
	Not Sure
Friend with type 2 diabetes	Yes
	No
	Not Sure
Following a specific type of diet	Yes
	No

*SAR: Saudi Riyal (the currency of Saudi Arabia) = 0.267 USD.

Table 2. Items of questionnaire assessing the participant knowledge.

Question	Response
I know what type 2 diabetes illness is	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the main hormone that plays a major role in type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of obesity on developing T2D	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of high blood pressure on developing T2D	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I believe type 2 diabetes is inherited	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of alcohol consumption on developing T2D	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of consuming cinnamon on the blood sugar	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of consuming red meat on type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of consuming salt on type 2 diabetes patients	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of eating fruits on type 2 diabetes patients	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know how many calories I should eat a day to prevent the development of risk factors that lead to type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of cardiovascular exercises on type 2 diabetes patients	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I believe that patients with type 2 diabetes need to avoid carbs	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of taking supplements that contain Magnesium on type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of consuming apple cider vinegar on type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree
I know the effect of consuming ginseng on type 2 diabetes	Strongly agree	Agree	Neutral	Disagree	Strongly disagree

Table 3. Items of questionnaire assessing participant attitude.

Question	Response
How often do you do physical activity weekly? e.g. walking, running, outdoor bicycle etc …	Never	1–2 days	3–4 days	5–6 days	Everyday
How much red meat do you consume weekly	Never	Once/Twice	Three/Four times	Five/Six times	Everyday
How much do you do strength exercises weekly, e.g. lifting weights, push-ups, squats, etc.?	Never	1–2 days	3–4 days	5–6 days	Everyday
How often do you visit a physician to monitor blood glucose levels	Never	Every 9–12 months	Every 5–8 months	Every 2–4 months	Monthly
How often do you drink alcohol weekly	Never	Once/Twice	Three/Four times	Five/Six times	Everyday
How often do you have breakfast weekly	Never	Once/Twice	Three/Four times	Five/Six times	Everyday

The questionnaire was validated and checked for reliability. Two medical educationists performed the face validity as reported before [16]. It was assessed for physical and ocular examination for the suitability of the items and vocabulary level. The items were also checked for construction of the questions and their eligibility and logicality with a clear direction of the difficulty of the question and doable within the allotted time limit of completing the questionnaire [16]. The content validity was conducted by two associated professors with seven years of experience in medical research as independent subject experts to assess whether the questions and their corresponding options are suitable for extracting the desired information to answer the objectives [17]. The questionnaires were then distributed for pilot testing in the relevant population through social media (the relevant population here is the general population of Jeddah). There were 38 participants in the pilot study [18]. Internal consistency (Cronbach’s alpha) was also calculated as 0.607 [18].

The participant data was stored on computers, accessed by the research team only, and protected by a password. No names or identifiable information was collected from the patient file. The informed consent has been taken from the participant on the survey’s cover page, along with a copy of IRB (Institutional Review Board) approval number SP21J/122/03 granted from King Abdullah International Research Center, Jeddah, Saudi Arabia.

3. Data analysis

Data were analyzed using Microsoft Excel Version 16.56 using the data analysis tool and SPSS 20. Demographic data, such as gender, age, level of education, and income, were summarized using descriptive statistics. Mean and standard deviation were used for numerical variables presentation, while proportions were categorical to describe the demographics data. Inferential analysis was done using an independent t-test and ANOVA to determine if there was a significant difference between the means of the groups. Variables were entered in the model if the univariate association was statistically significant, p < 0.05. Hypothesis testing was performed at the 0.05 level of significance.

4. Results

4.1. Descriptive statistics

In this study, the total participants were 406. Of them, n = 199 (49%) male and n = 207 (51%) female. The age of all the participants was equal or over 18 years. Most participants, n = 293 (72.2%), had a university education, while n = 58 (14.3%) had a high school education. N = 47 had a college education (11.6%), while n = 5 (1.2%) had a middle school education. Lastly, n = 3 (0.7%) had none. Regarding the employment status, more than half of the participants were unemployed, n = 222 (54.7%). A rough third of the participants were employed, n = 118 (29.1%). Some were retired, n = 46 (11.3%), and n = 20 (4.9%) was self-employed. About one-third of the respondents, n = 140 (34.5%), had a monthly income less than 5000SR (Saudi Riyal), which is 1000SR above the minimum wage, and approximately about one-quarter, n = 107 (26.4%), had no income. n = 52 (12.8%) had an income ranging from 5000sr − 9999 SAR. A similar number of participants, n = 64 (15.8%), had incomes ranging from 10,000–19,999 SAR, and n = 28 (6.9%) had incomes ranging from 20,000–39,999 SAR. Only n = 9 (2.2%) had salaries ranging from 40,000 to 50,000 SAR, and n = 6 (1.5%) had more than 50,000 SAR incomes. Most participants n = 343 (84.5%) do not work in the medical field, while only n = 63 (15.5%) did. Although only n = 35 (8.6%) of the participants had T2D, n = 213 (52.5%) had a family member with T2D. n = 66 (16.6%) were unsure if their family members had T2D. Almost half of the participants n = 176 (43.3%) did not have a friend with T2D, while n = 143 (35.2%) did. The rest of the participants, n = 87 (21.4%), were unsure if they had a friend with T2D. Most participants, n = 349 (86%) were not following a certain type of diet, while n = 57 (14%) were (Table 4).

Table 4. General characteristics of participants (n = 406).

Demographics Characteristic	Category	N	%
Gender	Male Female	199 207	49 51
Age	≥18	406	100
Marital Status	Single Married Separated Widow	238 149 13 6	58.6 36.7 3.2 1.5
Educational Level	Primary School Middle School High School College University None	0 5 58 47 293 3	0 1.2 14.3 11.6 72.2 0.7
Employment Status	Employed Self-Employed Retired Unemployed	118 20 46 222	29.1 4.9 11.3 54.7
Work in the medical field	Yes No	63 343	15.5 84.5
Monthly Income (SAR*)	No Income Less than 5000 5,000–9,999 10,000–19,999 20,000–39,999 40,000–50,000 More than 50,000	107 140 52 64 28 9 6	26.4 34.5 12.8 15.8 6.9 2.2 1.5
Have type 2 diabetes	Yes No	35 371	8.6 91.4
Family member with type 2 diabetes	Yes No Not Sure	213 127 66	52.5 31.1 16.3
Friend with type 2 diabetes	Yes No Not Sure	143 176 87	35.2 43.3 21.4
Following a specific type of diet	Yes No	57 349	14 86

*SAR: Saudi Riyal (the currency of Saudi Arabia) = 0.267 USD.

4.2. Inferential statistics

The mean ±SD of knowledge was 52.5 ± 11.3, and regarding the attitude, the mean ±SD was 11.9 ± 2.7. Among all the participants, the knowledge was poor in n = 58 (14.3%), moderate in n = 229 (56.4%), and good in n = 119 (29.3%). In addition, the levels of attitude among all the participants were poor in n = 11 (2.7%), moderate in n = 286 (70.4%), and good in n = 109 (26.8%). Regarding the knowledge and attitude of the general population about physical activity on prevention and management of T2D, the levels of knowledge and attitude were poor in n = 68 (16.7%), moderate in n = 285 (70,2%), and good in n = 53 (13%). Next, the knowledge and attitude of using supplements in the management of T2D were poor in n = 61 (15%), moderate in n = 286 (70.4%), and good in n = 59 (14.5%). Finally, the knowledge and attitude of the general population regarding the role of diet in the prevention and management of T2D were poor in n = 51 (12.5%), moderate in n = 277 (68.2%), and good in n = 78 (19.2%) (Table 5).

Table 5. Mean, standard deviation, and significance of the scores of participant response in knowledge and attitude.

Variables	Knowledge (Mean ± SD)	Attitude (Mean ± SD)
Gender Male Female P-value	51.9 (± 12.5) 53.1 (± 10.1) 0.280	12.1 (±2.9) 11.8 (±2.5) 0.250
Work in the medical field Yes No P-value	58.5 (± 10.3) 51.8 (± 11.4) 0.001	12.2 (±2.7) 11.9 (±2.7) 0.510
Educational Level None Primary school Middle school High school College University P-value	46.7 (± 18.3) - 54.4 (± 4.3) 51.8 (± 12.2) 54.5 (± 10.7) 52.3 (± 11.3) 0.626	13.3 (± 1.5) - 12.2 (±1.9) 11.7 (± 2.8) 12.14 (± 2.5) 11.9 (± 2.8) 0.824
Following any specific type of diet Yes No P-value	56.8 (± 9.3) 51.8 (± 11.8) 0.001	13.3 (± 2.9) 11.7 (± 2.6) 0.001
Diabetic Status Diabetic Non-Diabetic P-value	59.0 (± 7.2) 51.9 (± 11.4) 0.001	13.2 (± 2.4) 11.8 (± 2.7) 0.002
Family member with type 2 diabetes Yes No Not sure P-value	54.4 (± 10.7) 51.2 (± 11.3) 48.9 (± 12.2) 0.033	11.7 (±2.5) 12.1 (± 2.9) 12.4 (± 2.9) 0.391
Friend with type 2 diabetes Yes No Not sure P-value	55 (± 10.5) 51.7 (± 11.7) 49.9 (± 11.0) 0.027	12.4 (± 2.8) 11.5 (± 2.7) 12.1 (± 2.5) 0.016

The knowledge of males and females toward the role of lifestyle modifications (Physical activity, diet, and supplements) in the management and prevention of T2D had a p-value = 0.28 with a mean ± SD 51.9 ± 12.5 in males and 53.1 ± 10.07 in females. Moreover, the attitude had a p-value = 0.25 with a mean ± SD of 12.11 ± 2.9 in males and 11.8 ± 2.5 in females. This specifies no gender difference in knowledge and attitude for the above-mentioned questions (Table 5).

The mean ±SD knowledge of diabetic participants was 59.0 ± 7.2 and was 51.9 ± 11.4 in non-diabetic participants with a p-value < 0.001. Furthermore, the mean ± SD attitude of diabetic participants was 13.2 ± 2.4 and was 11.8 ± 2.7 in non-diabetic participants with p-value <0.001. Next, the mean ± SD knowledge of the participants who work in the medical field was 58.5 ± 10.3 and was 51.8 ± 11.4 in participants who do not work in the medical field with p-value <0.001. However, the mean ± SD attitude of respondents who work in the medical field was 12.2 ± 2.7 and 11.9 ± 2.7 in respondents who do not work in the medical field with p-value = 0.510. Also, the mean ± SD knowledge of the participants who are following a particular type of diet is 56.8 ± 9.3 with a p-value <0.001, and the mean ± SD attitude in respondents who don’t follow any diet is 13.3 ± 2.9 with a p-value < 0.001. (Table 5).

The results showed that participants with a family member with T2D had a higher mean of knowledge, with a mean of 54.4, than those who did not have or were ‘not sure,’ with means of 51.2 and 48.9, respectively. However, the difference in means was significant only when comparing those who had a family member with T2D to those who did not have or were ‘not sure,’ with a p-value of 0.033 and 0.002, respectively. Next, the means of knowledge in participants with a friend of T2D, who did not have a friend with T2D, and who were ‘not sure’ were 55.0, 51.7, and 49.9, respectively. Nevertheless, the means differed significantly only when comparing those with a friend with T2D to those who did not or were ‘not sure,’ with a p-value of 0.027 and 0.003, respectively. In contrast, the attitude of participants who were ‘not sure’ had a higher mean of 12.4 compared to those who did not have or had a family member with T2D, with means of 12.1 and 11.7, respectively, and these means did not differ significantly between any two groups. Lastly, the means of attitude in participants with a friend of T2D, who were ‘not sure,’ and who did not have a friend with T2D were 12.4, 12.1, and 11.5, respectively, but the only differed significantly between those who had a friend with T2D and those who did not have with a p-value of 0.016 (Table 5).

5. Discussion

Numerous studies have highlighted the crucial role of diet and exercise in the management of T2D. A balanced and healthy diet, along with regular physical activity, can help control blood sugar levels, improve insulin sensitivity, promote weight loss, and reduce the risk of complications associated with T2D [19]. Dietary modifications often involve reducing the intake of refined carbohydrates, added sugars, and saturated fats, while emphasizing the consumption of whole grains, fruits, vegetables, lean proteins, and healthy fats [20]. Regular exercise, including aerobic activities and strength training, can enhance insulin action, improve glycemic control, and contribute to weight management [21]. Due to the lifestyle practices in Saudi Arabia, T2D is prevalent among its population. A recent study collected data on people 30 years old and above and found that 50% of the Saudi population were pre-diabetic or diabetic [7]. This study focuses on the knowledge and attitude regarding lifestyle modifications in preventing and managing diabetes among the Jeddah, Saudi Arabia population. Our findings suggest that, on average, the knowledge and attitude regarding lifestyle modifications in preventing and managing diabetes is moderate, with 56.4% scoring moderate in knowledge and 78.6% scoring moderate in attitude. This indicates a reasonable level of awareness among the participants, which can serve as a foundation for promoting further education and interventions in daily clinical practice. However, a recent study in Vietnam showed some significant relational characteristics, such as race and blood sugar, that differed significantly in knowledge about T2D; marital status and family type were statistically significantly related to the patient’s attitude toward the disease [22]. Moreover, another study in Dhaka showed that the relationship between sex and marital status with no statistically significant knowledge and attitude [23]. Therefore, some characteristics related to the knowledge and attitude, such as educational level, income, marital status, and family type. These characteristics differ from population to population so the results will differ. One significantly influential factor in a participant’s knowledge and attitude toward diabetes is their monthly income and employment status. Poverty has shown to increase type 2 diabetes incidence and inequality of care [24]. An increased prevalence of diabetes among impoverished communities can be attributed to the presence of unsafe living conditions, unhealthy habits, obesity, and elevated stress levels [25–27] With more than half of our participants being unemployed, n = 222 (54.7%), the general knowledge and attitude of our participants may be negatively impacted.

A recent study in Italy found that only 16.7% of their participants knew the principal risks and protective factors of T2D, a much lower knowledge score than our study (56.4% scoring moderate and 29.3% scoring good) [28]. This could be because the prevalence of diabetes in KSA is higher than in Italy, which could affect the population’s awareness. Another study in Kenya found that 72.8% of the participants scored poorly in knowledge, while 14.3% in our study scored poorly [29]. This could be due to the education gap between the two countries. As stated in their study, the knowledge is deficient regarding diabetes. Also, there was low knowledge of diabetes among healthcare workers who are expected to deliver health education. A study in Sri Lanka showed that 39.0% of their participants scored moderate, and 38.0% scored above moderate in T2D knowledge [30]. Meanwhile, our study had a higher percentage of participants scoring moderate in knowledge but a lower percentage scoring above moderate. This could be explained by knowing that 52.5% of the respondents had a relative who was diagnosed with T2D; however, 15.5% of the respondents work in the medical field, which may be a cause of increasing their knowledge about T2D since Saudi Arabia is the seventh highest rate of diabetes in the world. A study in Karachi showed a significant statistical difference regarding the knowledge difference between genders [31]. The Male’s Mean Knowledge score (7.6 ± 6.6) was better than the female’s (5.5 ± 6.2) with P < 0.001, while our study had a mean (± SD) 51.9 (± 12.5) in males and 53.1 (± 10.1) in females, with P = 0.280, which likely due to the equality of education between males and females. In Gujarat, India, most participants had good knowledge of diabetes but poor attitudes [32]. In our study, the majority scored moderately in both knowledge and attitude. Knowing someone close to diabetes may affect the person’s knowledge and attitude depending on the level of support and care given to the DM patient. Also, a study in Thailand suggests that higher education or employment is related to increasing knowledge [33]. These studies show different results in different populations, therefore, it is essential to consider cultural and social factors that may influence the adoption of healthy lifestyle practices. Traditional lifestyle and cultural norms may impact attitudes toward lifestyle modifications. Understanding and addressing these factors can help tailor interventions to the specific needs and preferences of the population. For example, incorporating culturally appropriate dietary choices and incorporating physical activities that align with cultural practices can enhance the acceptance and effectiveness of these interventions.

Participants who had a family member with T2D had better knowledge than those without. Similar to the Italian study, their results revealed that those with close relatives with diabetes, compared with those who did not have them (25.4% vs. 13.2%), were more likely to have this knowledge with p-value = 0.000 [28]. However, the difference in attitude between the two groups was insignificant (p-value >0.05). Although people who knew someone with T2D had more knowledge than people who did not, their attitudes did not differ. Those with relatives who have T2D may have higher attitudes, perceptions, and knowledge since T2D is a genetic factor, which may make them more cautious about their lifestyle choices. Also, people with T2D family members may have more exposure to the life of a diabetic. This may include symptoms, treatments, side effects, and other lifestyle factors. On the other hand, friends have a lesser effect on knowledge, perception, and attitude because no genetic risk factor is at play. Also, most people do not live with their friends, so their exposure to the diabetic lifestyle is lessened. Those with a family member or friend with T2D have better knowledge than those without because they are exposed to the illness through said family member or friend. The two groups ’ attitudes towards T2D may not differ because one’s knowledge about T2D is not directly related to their health and lifestyle choices. Furthermore, they did not experience the symptoms and risks of the disease first-hand. Thus, they do not have a concrete reason to change their lifestyle in the face of a threat to their health. Due to the high prevalence of T2D in KSA, the awareness and knowledge of the people have been raised. However, traditional lifestyle and culture could influence the low attitude. In comparing those who had a family member with T2D with those who were unsure if they had a family member with the condition, members with an afflicted family member were shown to have better knowledge. This can be attributed to knowing someone first-hand with the condition, which would increase one’s exposure to it, increasing knowledge.

Participants who had a friend with T2D had better knowledge than those who did not have a friend with T2D and those who were unsure. However, participants who had a friend with T2D had better attitudes than those who did not, but the difference in attitude between those who had a friend and those who were unsure was insignificant. Participants who had a relative with diabetes had the best knowledge, with a mean of 54.4 (±10.7). Participants who did not have a family member with T2D had better knowledge than participants who were unsure if they had an afflicted family member but had lower knowledge than those who did, with a mean of 51.2 (±11.3). Those unsure if they had a relative with diabetes scored the lowest in knowledge, with a mean of 48.9 (±12.2). The significance for knowledge was p = 0.033. Those who had relatives with diabetes had the best knowledge of diabetes because of their exposure to diabetes through their relatives.

However, participants unsure if they had a family member with diabetes scored the best attitude with a mean of 12.4 (±2.9). Next, participants with no relatives had the second-best reported attitude, with a mean of 12.1 (±2.9). Participants who had relatives with diabetes scored the lowest attitude, with a mean of 11.7 (±2.5) and a significance of p = 0.391. Those participants who had friends with diabetes had better knowledge than those who did not, with a mean of 55 (±10.5) and 51.8 (±11.7), respectively, and a significance of p = 0.027.

There were similar results with attitude, with participants who had friends with diabetes scoring an attitude of 12.4 (±2.8). Those with no friends with diabetes scored an attitude of 11.5 (±2.7) and a significance of p = 0.016.

In recent years, the culture surrounding health and fitness in Saudi Arabia has significantly improved. The Saudi General Sports Authority has reported that the percentage of Saudis over 15 years of age who exercise at least once a week has increased from 13% in 2015 to 23% in 2020 [34]. Due to this, we can hold a positive outlook for continued growth and interest in health and fitness within the kingdom. This is important because maintaining a healthy diet and exercising regularly can aid in the prevention of T2D among the population.

The generalizability of the results is limited because our study is electronically survey-based, so specific population demographics were excluded from participating, such as those without internet and electronic devices. However, this is not significant since, in 2021, 97.5% of the population above the age of 15 owned a mobile phone, with 93% having access to the internet [35]. Furthermore, using convenience sampling can cause an over- or under-representation of the population. Also, the inability to generalize the study’s findings to the population because our questionnaire was distributed by social media [36]. Lastly, the survey did not have the perfect number of questions to assess the full scope of a participant’s knowledge and attitude. Despite this, the findings are nonetheless valid for exploring the population’s knowledge and attitude regarding the lifestyle modifications that can be used to prevent T2D.

6. Conclusion

Our study has found that the general population of Jeddah, Saudi Arabia, has moderate knowledge and a moderate attitude toward lifestyle modifications in preventing and managing diabetes. Further research is required to target demographics needing access to electronics or the internet to assess a generalized population demographic. Furthermore, the study should be done on a wider scale to cover more varied demographics. It can be done differently by manually distributing surveys to a population that does not have access to the Internet. Regardless, our results show that there is vast room for improvement in the knowledge and attitude of these lifestyle modifications and that awareness should be raised by conducting health campaigns in public areas, for instance, to deliver the information that is needed for managing T2D by lifestyle modification and increase the awareness of knowing the risk factors of T2D to avoid it.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Ethics statement

The work described in this article has been approved by the Institutional Review Board at King Abdullah International Medical Research Center (No.SP21J/122/03). Participatory consent was obtained from all participants using a consent form at the beginning of our survey.

Author contribution statement

All authors have equally contributed to the conception and design of the article and interpreting the relevant literature and have been involved in writing the review article or revised it for intellectual content. Authors have agreed to the journal in which this paper was submitted. All authors have reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage. All authors have agreed to take responsibility and be accountable for the contents of the article and to share responsibility to resolve any questions raised about the accuracy or integrity of the published work.

Data availability statement

The raw data used to produce this manuscript is available upon request.

Additional information

Funding

This paper was not funded.