Dietary Behaviors and Psychosocial Factors of People Managing Diabetes During Fasting: A Qualitative Study from Five US Muslim Communities ^†

Abstract

Objectives: This study sought to understand dietary behaviors among US Muslim people with Type 2 diabetes while managing diabetes and fasting during Ramadan, identify key psychosocial factors influencing behaviors, and examine how identified factors influence diet behaviors and health outcomes from the patient’s perspective. Methods: The study employed community-engaged research principles and qualitative research design. Twenty-two adult Muslim adults living with Type 2 diabetes for over 6 months participated in semi-structured one-on-one interviews. Participants were recruited from five US communities using purposive sampling. Three trained researchers used abductive coding, combining deductive and inductive approaches, to analyze the data. Results: Six main themes emerged from the data: (1) changes in dietary habits during Ramadan; (2) strong influence of religious, cultural and social practices on dietary behaviors; (3) variable self-efficacy in managing dietary behaviors; (4) impact of prior habits and current blood glucose status; (5) decision-making based on diabetes-related health outcomes (e.g., experiencing low blood sugar); (6) participants’ perception of Ramadan as an opportunity for sustainable behavioral changes. Conclusions: This study is among the first to document the dietary behaviors and key psychosocial factors influencing dietary behaviors and health outcomes for US Muslim people with Type 2 diabetes during Ramadan. The study suggests that interventions to improve diabetes control and promote diabetes remission among Muslims can benefit from cultural tailoring that draws on Ramadan religious, cultural and social practices to encourage sustainable behavioral change.

1. Introduction

Estimates from 2017 indicate that 3.45 million Muslims reside in the United States [1]. This number is projected to double by 2050 [1]. Muslims belong to diverse racial/ethnic backgrounds. About 58% of US Muslims were born in a country other than the US [1]. About 150 million Muslims are diagnosed with diabetes worldwide [2]. There is a high prevalence of diabetes in the U.S., with people from racial and cultural minorities being the most impacted. People from South Asia (e.g., Pakistan, India, Afghanistan) constitute 35% of the US Muslim population and report a significantly higher prevalence of diabetes (26.7%) compared to Whites (6.3%), African Americans (16.4%) and Latinos (14.5%) [3]. Similarly, Middle Eastern and North African (MENA) people make up to 25% of the first-generation Muslim population in the US [1], out of which 73 million people are already living with diabetes. This number is expected to reach 136 million by 2045 [4]. The high prevalence of diabetes among these groups highlights the magnitude of the disease burden and the need to address the barriers to optimal health outcomes.

One of the main pillars of Islam is fasting during the ninth month of the lunar calendar; the month of Ramadan. Specific religious regulations require Muslims to abstain from consuming anything by mouth (e.g., food, drink, medicine) from dawn to sunset (i.e., the fasting period of the day) for fasting to be considered valid. Fasting hours vary by location, year, and slightly by day because they depend on the lunar calendar. So, in some areas and certain times of the year, US Muslims might fast for more than 15 h per day. Since Islam emphasizes ease and simplicity in worship, adherents are advised not to endure undue harm, excusing Muslims who fall under certain criteria to not fast for Ramadan [5]. For example, people who are ill with chronic conditions (e.g., diabetes mellitus) that place them at high risk of complications can be exempted from fasting [6]. Patients who miss fasting can either make up for those days after Ramadan if they are able, or they can pay a certain amount to charity instead. However, some Muslims who are ill still choose to fast for many reasons including: (1) wanting to receive the spiritual rewards by fulfilling this pillar; (2) desire to enjoy the social benefits of fasting with family and friends [7,8,9].

Diabetes self-management requires consistent and meticulous daily engagement in specific behaviors to achieve diabetes control and effective outcomes. The Association of Diabetes Care and Education Specialists (ADCES) within the ADCES7 framework identifies the self-care behaviors that are cornerstones for diabetes self-management [10]. It encompasses seven main domains to guide people with diabetes through self-management activities [10]. The self-care behaviors include: (1) healthy coping; (2) healthy eating; (3) being active; (4) taking medication; (5) monitoring blood sugar; (6) reducing risk; (7) problem solving [10].

Muslims make different lifestyle changes during Ramadan (e.g., food intake habits), some of which might place those living with diabetes at risk of developing complications. A study conducted in 13 Muslim majority countries found that about 80% of the 11,000 participants who had Type 2 diabetes fasted for at least 15 days during the month of Ramadan [11]. Severe hypoglycemic and hyperglycemic events were significantly higher during Ramadan compared to other months of the year [11,12]. Severe hyperglycemic events were significantly associated with changes in food intake and sugar intake [11]. Although the majority of Muslim people with diabetes choose to fast, many do not disclose this decision with their healthcare providers [9,13,14]. Previous studies of this population showed that participants are reluctant to disclose their decision to fast during Ramadan because they believe non-Muslim providers lack the knowledge to support their decision to fast and help them manage their diabetes appropriately while fasting [9,13]. This belief leads majority of Muslims who fast to withhold some vital information from their providers, including the challenges they encounter while fasting (e.g., dehydration) and the need for help in navigating these issues [9,13]. These studies highlight a gap in both healthcare providers’ understanding of the dietary changes and challenges that Muslims with diabetes undergo during Ramadan and study participants’ self-efficacy in starting conversations about navigating effective diabetes-self management while fasting with their healthcare providers. Our study aims to fill this gap by understanding dietary behaviors, the related factors, and how diabetes self-management is influenced by these behaviors for US Muslim with diabetes who observe Ramadan fasting. This information is crucial for healthcare providers to enhance cultural awareness and deliver patient-centered care.

The ADCES7 framework outlines key components essential for achieving each diabetes self-care behavior [10]. For example, self-efficacy is critical for self-care, while establishing healthy eating patterns and monitoring portions are crucial for maintaining a healthy diet [10]. The social cognitive theory (SCT) provides a framework for understanding health behavior promotion and change through a triadic interaction of behavioral patterns, environmental influences, and cognitive functioning [15,16]. Behavioral patterns focus on individual’s actions, including learned behaviors, skills, and habits [15,16]. Environmental factors are external influences that impact an individual’s behavior and cognitive functioning [15,16]. They include physical surroundings, social interactions, and cultural norms. Cognitive functioning focuses on self-efficacy and how individuals perceive and interpret their experiences, and the expected outcomes associated with their actions [15,16]. Self-efficacy is the individual’s confidence in their ability to perform certain behaviors to achieve specific outcomes [15,16]. As people try to predict the outcomes of their actions to motivate themselves, these motivations are still influenced by self-efficacy. Even though people may expect positive outcomes from engaging in a certain behavior, they will not pursue it unless they believe in their abilities to perform it [15,16]. Yet, the expected outcomes from certain behaviors are tied to self-efficacy beliefs.

The overarching goal of this research is to understand dietary behaviors among US Muslim people with Type 2 diabetes while managing diabetes and fasting to inform the development of interventions to support safe fasting during Ramadan. Guided by the ADCES7 framework and the SCT, this study specifically aims to: (1) investigate dietary behaviors while managing diabetes and fasting during the month of Ramadan in US Muslims with Type 2 diabetes; (2) identify key psychosocial factors influencing these behaviors; and (3) examine how identified factors influence dietary behaviors and overall health outcomes during Ramadan. Ultimately, we hope that this research will inform the development of culturally tailored interventions to improve diabetes control, promote diabetes remission, and encourage sustainable behavioral change among Muslims during Ramadan.

2. Materials and Methods

2.1. Study Design

This study employed community-engaged research principles and qualitative research design. The study drew from two methodological approaches: ethnography and interpretive phenomenology [17]. The ethnographic approach enabled the authors to focus on the shared views of Muslims who fast across their different cultural and social backgrounds while interpretive phenomenology allowed for deeper exploration of how Muslims living in the US make meaning of their diabetes self-management and fasting, through distinct cultural and social lenses. Consolidated criteria for reporting qualitative research (COREQ) was followed in reporting this study [18].

2.2. Sample Size and Participant Selection

The five domains of information power guided the sample size determination: (1) study aim, (2) specificity of sample, (3) use of theory, (4) quality of dialogue, and (5) analysis strategy [19]. These domains were reflected in this study: (1) specific inclusion criteria were employed to guide recruitment to ensure relevance to the study aims. The inclusion criteria required participants to be adult Muslim males and females who reside in the U.S., diagnosed with Type 2 diabetes, and taking oral or injection medications for diabetes for at least 6 months. (2) Specificity of sample was determined based on recommendations from our community partners who identified the six largest community groups in their healthcare system to capture the heterogeneity in the U.S. Muslim population. Recruitment from these communities was based on country of origin and spoken languages at home: Arabic (Middle Eastern and North African), Dari (Afghan refugees), English (White and African American), Rohingya (people from Myanmar), Somali (people from Somalia), and Urdu (people from Pakistan and India). The number of participants was set for up to 5 people per language group to enable the team to reflect on similarities and differences between the six groups while gaining valuable information from each group. (3) This research employed different theories as described in the introduction and methods. (4) Quality of dialogue was emphasized during interviews as they were all led by the main author and lasted for up to 90 min to allow for rich conversations. (5) The analysis strategy focused on using abductive thematic analysis and senior qualitative research experts were consulted frequently during the analysis process to ensure rigor and sufficient interpretive insights across groups [10,15,16]. Based on these domains and recommendations from Hagman and Wutich to include 20–40 participants for cross cultural research [20], a total sample size of 30 participants was determined to be ideal for this study [21].

2.3. Setting and Recruitment

Partnering with two major community organizations in Milwaukee, WI, USA was crucial to build trust with different communities and their leaders. This community participatory approach ensured that this research was driven by these communities’ needs. One of the community partners identified the largest groups within their healthcare system to help capture the diversity of the US Muslim population. There were six groups in total based on country of origin, and main language spoken at home: Arabic (Middle Eastern and North African), Dari (Afghan refugees), English (White and African American), Rohingya (people from Myanmar), Somali (people from Somalia), and Urdu (people from Pakistan and India).

To recruit from these hard-to-reach communities, the research team employed multiple strategies including direct-to-participant recruitment process by leveraging personal connection with healthcare providers in these communities. Also, researchers engaged with communities through events and volunteering activities. Building a trust-based connection was the first most important step to be able to start advertising and recruiting participants. Recruitment of participants was an ongoing process as interviews were conducted. The overall recruitment of participants took about one year. The research team was able to reach 5 of the total 6 target groups, only the Somali community was not represented in this research as planned.

2.4. Data Collection and Procedure

2.4.1. Interview Procedure

One-on-one interviews took place either in-person or virtually by phone, depending on the participant’s location of residence at the interview time and their ability to travel to the interview location. Participants who lived in a nearby city and were willing to meet in-person were interviewed in a private meeting room at one of the research partnering organizations. Participants who lived in the city where the institution is located were interviewed in a private meeting room on-campus. Interviews were conducted virtually via a phone call with participants who resided outside of the state, preferred to meet virtually, or were not able to travel to any of the interview sites. A.A. conducted interviews with Arabic-, and English-speaking participants without the need for language interpretation services and conducted interviews of Rohingya-, Dari-, and Urdu- speaking participants with interpretation services.

A semi-structured interview guide was created by the research team and reviewed by experts and community advisory board members. The ADCES7 framework and the SCT guided the development of the interview guide [10,15,16]. The interview guide included questions specific to different domains: access to care and medications, diabetes self-management behaviors on a regular basis and during Ramadan (medication use, diet, exercise, blood sugar self-monitoring, and management of complications like high or low blood sugar) and use of complementary and alternative medicine [10]. While the proposed duration for each interview was one hour, the actual interview lengths ranged from 45 to 90 min. Interviews were conducted over 6 months between end of July 2022 to January 2023.

2.4.2. Presence of Non-Participants

Participants were asked to attend the interview alone without any family members. This was carried out to encourage participants to share information openly in a private discussion. Interpreters were also present when needed either in person or over the phone.

2.4.3. Recordings and Transcription

All interviews were recorded directly to a secure Box drive provided by the department’s cybersecurity office. Recordings were only accessible to the research team members. All interviews except the Arabic ones were transcribed by professional transcribing services who accessed the audio recordings through a secure Box folder. A.A. transcribed and translated all Arabic interviews. All recordings were reviewed and trimmed of any identifiable information using the “Audacity” application before being shared with the professional transcriber. To ensure the accuracy of transcription, A.A. shared with the transcriber a list of terms that are not known for English-speakers and the corresponding recording’s time stamps. The inaudible sections of the recordings were provided with time stamps back to A.A. by the transcriber. A.A. listened to the recordings to correct the highlighted inaccuracies in the transcripts.

2.5. Research Team and Reflexivity

The PI (A.A.) conducted all interviews with all research participants. A.A. obtained extensive qualitative research training during her PhD studies, participated in multiple qualitative classes and workshops at various U.S. institutions (e.g., Harvard University, University of Wisconsin-Madison, and University of Michigan), and has been mentored by professors experienced in qualitative research.

A.A. is a Muslim Middle Eastern who is a second-generation Palestinian refugee and a first-generation U.S. immigrant. While these experiences have inspired the research idea, A.A. tried to keep these experiences apart when conducting the interviews and analyzing data. Strategies that helped A.A. to keep an objective eye include continuous meeting discussions with mentoring professors, recommendations from the advisory group members, and discussions with the coding team.

Two trained researchers in qualitative research worked with A.A. throughout the research process. E.S. is a Nigerian Christian researcher and was a Ph.D. candidate in the United States during the study period. E.S. acquired qualitative skills from her classes, previous research, and the mentorship of experienced professors. Her unique experiences, cultural background, and being a person with no affiliation to the Muslim community were paramount to providing an objective lens to the research project.

S.A. has a PharmD and has been involved in conducting qualitative interviews and research projects during her professional studies under the mentorship of experienced professors in qualitative research. S.A. is a Muslim, Middle Eastern, Egyptian, was a clinical pharmacy resident in the U.S. dedicated to providing quality healthcare services. E.S., and S.A.’s identities and cultural background helped provide perspective in group discussions, as well as context when coding interviews. Given their different cultural background and lack of relationship with participants, the coding team approached data analysis with cultural humility and sensitivity to participants’ experiences.

2.6. Data Analysis

Three researchers with terminal degree training (PharmD and PhD) and experience with qualitative analysis worked independently to conduct abductive analysis instead to derive themes from data [22]. Deductive coding followed the Social Cognitive Theory [15,16]. The team started coding with 3 interview transcripts to create the initial codebook. The team lead A.A. created a coding assignment sheet for weekly assignments. Each week included two designated transcripts to be coded by E.S., and S.A., and four transcripts to be coded by A.A. The PI coded all 22 interview transcripts and each one of the other coders (E.S. and S.A.) analyzed 11 interview transcripts. Therefore, each transcript was coded by A.A. and one other coder. The research team held a weekly meeting during the coding process for discussions. Transcripts for participants who spoke the same language were grouped to be coded during the same week. This enabled the research team to reflect on within-group similarities and differences during weekly meetings. During weekly meetings, researchers discussed immerging codes, grouped them into themes, and solved discrepancies in coding [23]. A.A. reviewed coding discrepancies and discussed them with E.S. and S.A. to reach consensus. NVivo (Release 14.23.2 from Lumivero in Denver, CO, USA) software was used for data analysis.

2.7. The Study’s Trustworthiness: Triangulation

To ensure the credibility of this qualitative work, the research team involved multiple forms of triangulation. First, multiple investigators were involved along the different project stages as deemed necessary for each step [24,25]. Initially, a mixed and diverse group of advisory board members from the community along with senior and junior researchers worked together to focus the research objectives. In addition to consulting with experienced scientists in a working qualitative research group, the advisory board members informed the creation of the interview questions. Finally, three diversely trained researchers from various backgrounds worked collaboratively through all phases of the thematic analysis process [26]. Furthermore, experienced mentors oversaw and guided the project along all the different steps. The involvement of different investigators was important to reduce the potential individual biases, enhance the objectivity of this research, and ensure its rigor [26].

Second, theory triangulation was employed to diversify the perspectives in achieving this study objectives [24,25]. This research was guided by the ADCES7 framework and the SCT. Both models informed the development of the interview guide and questions, and the SCT guided the analysis and interpretation of data in addition to the inductive analysis [10,15,16,22].

Third, methodological triangulation by employing ethnography and interpretive phenomenology methodologies to ensure a nuanced and balanced analytical process [17,24,25,27].

Fourth, triangulation via data sources was conducted by collecting data from people who belong to five different communities and speak various languages [24,25]. This helped in identifying the commonalities and differences in their experiences and practices to further inform the development of future interventions [25]. Additionally, a mixed and diverse group of advisory board members that included people with diabetes and healthcare providers, informed the development of this research at different stages of the project.

3. Results

Table 1. Summary of participants’ demographics (n = 22).

Demographic	Total
Age [Average (SD) in years]	55.6 (SD = 15.1)
Gender
Female	14
Male	8
Education
Less than high school	11
High school	3
Some college education	4
Bachelor or graduate degree	4
Income
Less than 25,000 USD	18
25,001–50,000 USD	0
50,001–75,000 USD	0
More than 75,000 USD	4
Insurance
Insured	20
Not insured	2

summarizes the demographic characteristics (n = 22) of two dyads consisting of individuals from the same household. Fourteen women and 8 men were interviewed; their age ranged between 26 and 80 years.

Table 2. Themes and subthemes of dietary behaviors and self-management of diabetes during Ramadan.

Main Themes	Subthemes
Changes in Dietary Habits during Ramadan Compared to Regular Days	Subtheme 1: General Changes in Mealtime.
	Subtheme 2: Amount of Food.
	Subtheme 3: Types of Food.
Dietary Behaviors Influenced by:	Subtheme 1: Religious Practices
	Subtheme 2: Cultural Diet
	Subtheme 3: Social Events
Self-Efficacy in Managing Dietary Behaviors When Food is Present on the Iftar Table
Dietary Behavior Influenced by Prior Practice and Resulting Physical Outcomes.
How Decisions are Made Based on Outcomes and Other Factors
Ramadan is an Opportunity for Behavioral Changes that Can Be Sustained Beyond the Month of Fasting

presents the themes and subthemes derived from the data analysis [28]. Six major themes emerged: (1) changes in dietary habits during Ramadan compared to regular days; (2) dietary behaviors influenced by religious practices, cultural diet, and social events; (3) self-efficacy in controlling dietary behaviors when food is present on the Iftar table; (4) dietary behavior influenced by prior practice and resulting physical outcomes; (5) how decisions are made based on outcomes and other factors; (6) Ramadan is an opportunity for behavioral changes that can be sustained beyond the month of fasting [28]. Appendix A presents detailed quotes related to each theme and subtheme [28].

3.1. Theme 1: Changes in Dietary Habits During Ramadan Compared to Regular Days

Participants described the changes in their dietary habits that occur during Ramadan compared to regular days outside Ramadan.

3.1.1. Subtheme 1: General Changes in Mealtime

Generally, people would have two main meals, one before the start of fasting, and one at the time of breaking the fasting. The period of fasting during the day varies depending on the season of the year and the geography.

Some people would have a pre-dawn meal (Suhoor) before the start of fasting. It is recommended by the prophet, but not all people would have it.

“At suhoor, I would eat a date, prunes, dried apricot and a piece of almond and walnut, and then I would take my metformin” Arabic P2

“When it is Suhoor time, I won’t eat it.” Rohingya P2

At time of breaking the fast people have a breakfast meal (Iftar) after sunset.

“Typically, about 45 minutes before Iftar, my job is to go out and get all the food ready when the wife is not cooking. Then I set it up, and we’re all sitting at the table looking at the clock, and right when it’s exactly that time... Dua’a and just start eating whatever is in front of you” English P2

Some people may have snacks between these two meals in the period of time between sunset to pre-dawn. This could happen especially during the last 10 days when people stay up all night praying. However, this theme did not come up in our data.

3.1.2. Subtheme 2: Amount of Food

People described the amount of food consumed during Ramadan compared to regular days. Some participants tend to eat more during Ramadan.

“The food in Ramadan is 10% more than our food during days outside of Ramadan.” Arabic P1

Other participants tend to eat less during Ramadan.

“Also, during Ramadan, we eat less than the other days outside of Ramadan, so I think that’s maybe because the stomach shrinks.” Afghan P1

“During Ramadan, I eat less, I don’t eat too much.” Arabic P5

Other participants tend to eat the same amount.

“Nothing, it is normal. It is in my nature during Ramadan, even before starting to take metformin, I did not use to eat a lot at the time of breaking the fast. Only soup and Fattoush salad.” Arabic P2

3.1.3. Subtheme 3: Types of Food

People described types of food consumed during Ramadan compared to regular days.

Some participants expressed that the types of food may change on the Ramadan table.

Fried, oily, and carbohydrate-rich food: Some participants intentionally try to avoid fried food and carbohydrates, while others describe how these kinds of food increase on the Iftar table.

“I break my fast, I’m using a date, vegetables. But I avoid to using fried food like rice because rice is not good for the diabetic patient.” Afghan P2

“The Iftar changes quite a bit…my family like to have fried stuff, and there are more carbohydrate and stuff for Iftar.” English P1

Desserts: Generally, participants tend to make more desserts during Ramadan compared to regular days. Some may eat more; others may not eat as much even though they make more of it during Ramadan.

“During regular days, we don’t eat as much desserts and it is much less frequent. But during Ramadan, we eat desserts every day; we eat Qatayef, Kunafeh and all of that.” Arabic P3

“Some people would be waiting for Ramadan to have Qatayef dessert. I make these desserts for my family, but I don’t eat any of it.” Arabic P2

Types of food stay the same: Some participants who expressed a change in food at the time of Iftar, still state that the food at the time of Suhoor did not change.

“So Suhour was mostly what I would eat, like a breakfast. So that didn’t change.” English P1

Other participants expressed that even their food at the time of iftar did not change from regular days.

“At breakfast, I have to eat figs with almonds and walnuts. That in addition to soup and salad, I would eat a good amount of salad. For soup, every day I would have oat soup.” Arabic P2

“We cook regular food, make salad, yogurt with dates and stuff like that” Arabic P5

3.2. Theme 2: Dietary Behavior Influenced by Religious, Cultural, and Social Factors

3.2.1. Subtheme 1: Dietary Behaviors Influenced by Religious-Learned Practices

Some participants adhere to specific “prophetic” practices in diet. Participants eat in moderation and follow the third rule mentioned in the prophetic practices.

“If you have to eat, eat in small quantities; the prophet Mohammed, peace be upon him, told us how we should eat; “A human being fills no worse vessel than his stomach. It is sufficient for a human being to eat a few mouthfuls to keep his spine straight. But if he must (fill it), then one third of food, one third for drink and one third for air [29].” Arabic P5

Participants break their fast with specific types of food such as dates and water based on the prophetic practice: Anas bin Malik narrated: “The Messenger of Allah would break the fast with fresh dates before performing Salat. If there were no fresh dates then (he would break the fast) with dried dates, and if there were no dried dates then he would take a few sips of water [30].”

“During breaking the fast, we make Dua’a [supplication], then we break the fast with water and date.” Afghan P1

3.2.2. Subtheme 2: Dietary Behaviors Influenced by Cultural Diets

Some specific “not so healthy” types of food that have become stable on the Ramadan Iftar table (e.g., starting with fried appetizers and ending with desserts).

“The iftar changes quite a bit because, I think this comes from the Indian cuisine side. My family likes to have fried stuff, and there are more carbohydrates and stuff for iftar, and so if I cook that, I end up eating that. That’s the problem.” English P1

“During regular days, we don’t eat as much desserts and it is much less frequent. But during Ramadan, we eat desserts every day; we eat Qatayef, Kunafeh and all of that. During regular days, if there is a dessert at home, you usually eat a small piece, and you don’t eat as much.” Arabic P3

“We make desserts during Ramadan, but I don’t eat it.” Arabic P5

3.2.3. Subtheme 3: Dietary Behaviors Influenced by Social Events

Social events can take place at people’s houses or at public places like the mosque.

Iftar gatherings and invitations to people’s houses. This has three implications:

First, social norms and expectations from the host provide extended tables of food with wide varieties to feed the invited guests.

“This is a normal thing during Ramadan. If you are inviting people over, you have to make desserts, and if you are invited, there are always desserts.” Arabic P3

“When there’s more food, and you cook more food, of course, you eat more. And then, so it’s true for even I invite someone over and I’m invited somewhere, or if we just gather together to break our fast, it just results in high blood sugar.” English P1

Second, social pressure and expectations from the guest to eat when arriving at the host’s place. It is not considered polite to not eat the food given to you by your host. In some instances, people put the food in your face and insist that you eat it.

“When I am by myself, I can control what I eat, and I can hold myself from eating what I should not be eating. However, when I am invited over at somebody’s house, I have to eat (I am obligated to eat) so that the people who invited us over don’t feel sad because I am not eating their food. Also, we are humans, and we love to eat, but when you are by yourself you can control it unlike when you are invited over at somebody’s house…And they keep telling you, you have to eat this, and you have to eat that, so you get embarrassed if you keep telling them I don’t want to eat this or that.” Arabic P5

Third, when invited over, you follow your host’s way of breaking the fast and you do not have control over the type of food presented to you. Which could be different than what you are used to in your home. In a sense, this could impact health outcomes. It is not common to ask invitees for food preferences or allergies, just as it is not common to make requests from your host as a guest.

“Any family events are usually on weekends, …somebody holds Iftar. We go over there, come back home four pounds heavier...There’s obviously more variety of food” English P2

“..when you are invited over at someone’s house for Ramadan breakfast, you will follow their way of breaking the fast. So, if they don’t serve soup, you can’t tell them I want soup..” Arabic P4

Iftar gatherings at public events like the mosque or fundraising galas. This has two implications:

First, the idea of mass feeding and focusing on certain types of food like a carbohydrate rich diet.

“Any kind of potluck you go to, there’s a lot of not-so-healthy options. But there are some really good ones too. When they’re mass feeding, you’re going to have far more like carbohydrates or high-glycemic index foods that are presented just because they can go a lot farther. You don’t see a lot of chicken breast, grilled chicken. You’ll see a chicken casserole with lots of carbs and cheese.” English P4

Second, the environmental influences including the social pressure to eat and the fear of missing out on certain types of food.

“During Ramadan, when they’re giving it, I eat it. It’s so full of sugar, like the sweets. But, for me, the biggest issue is not so much eating the sweets or portions. People giving me food and eat and eat. The thing is everybody around you is eating. Nobody around you is eating in small portions, so that makes you join the party.” English P2

3.3. Theme 3: Self-Efficacy in Managing Dietary Behaviors When Food Is Present on the Iftar Table

Some participants expressed low self-efficacy in controlling diet when many varieties and amounts of food are present on the Iftar table after a long day of fasting.

“After I break the fast. I try fruits, it doesn’t happen. I don’t have so much self-control, so I end up eating quite a bit of stuff that I shouldn’t be eating…when you break your fast, there’s food. So that is, I think, the biggest challenge.” English P1

Others showed strong self-efficacy capabilities in managing diet despite the presence of different types of food on the Iftar table.

“Some people would be waiting for Ramadan to have Qatayef dessert. I make these desserts for my family, but I don’t eat any of it…I did not talk with the nutritionist about the diet during Ramadan, that was something that I came up with. Also, “each human can be their own physician”, each person knows what harms them and what does not, for those who want to take control. Those who can’t control themselves, they would say; I will eat anything and just take my insulin. From my perspective, this dessert is not worth it. This insulin injection is destroying you, in the future it may destroy your organs while you are not realizing it.” Arabic P2

3.4. Theme 4: Dietary Behavior Influenced by Prior Practice and Resulting Physical Outcomes

Common learned practices of ways to break the fast are based on experiential learning and experienced outcomes. There are two general ways of how participants break their fast. Some participants follow a healthier practice of breaking the fast by starting with dates, soup, then pray (as a way to take a break from eating to alert the stomach and give it time to prepare for the incoming food), then they eat the main meal after the prayer.

“First, I drink some water, and then I just pray. And after that, I get my main meal.” Afghan P3

“In terms of food, we are Palestinians, so we eat the Palestinian cuisine. After we have soup, we take appetizers like salads, samosa, moa’janat (savory pies), …, simple things like that, we drink lots of water, usually we like to first pray Maghrib. Say that prayer take 15–20 minutes then we come back to eat the main dish. That is the normal that we do.” Arabic P4

While the other way is to start eating the main meal directly without breaking to pray:

“Right when it’s exactly that time, moment of time... Dua’a [supplication] and just start eating, you know, soup or anything, whatever is in front of you” English P2

“Honestly, I don’t pray before eating the meal. I eat, then hardly pray the Maghrib” Arabic P1

Experiential learning explained: Participants explained the reasoning behind eating a little bit of food to alert the stomach by giving it time during the prayer break before eating the full meal.

“In Ramadan, when we break our fast, we start with soup, we don’t start by indulging in stuffed grape leaves or zucchini or rice, because the stomach is empty all day, this is logical. Until the stomach gets the message and understands that food is coming, then you start eating other kinds of food. The same with your day-to-day routine, in the morning you take breakfast, for me breakfast is important. If you stop eating until 1 pm, your body metabolism has stopped working since 8 am... But when you eat snacks, you are preparing your body and telling it, that there is more food coming, so you keep it engaged like an engine.” Arabic P4

Experienced outcomes explained: Participants described how they experience better outcomes when following the “healthier way” of breaking the fast compared to times when they are not able to follow this “healthier way” of breaking the fast. (i.e., how they feel after breaking the fast).

“100%, there is a big difference. Because when you are invited over at someone’s house for Ramadan breakfast, you will follow their way of breaking the fast. So, … you have to eat differently, then your body will feel different, you feel that there is something not normal in your body, as if you are very full of food in your stomach (food coma, lethargy). So, you get affected a lot. So, when you stand up to pray it feels different too.

Also, in our house, when we have people over for breakfast, we don’t pray then eat, we continue eating the main meal with guests before praying Maghrib. First thing you notice is that performing the prayer becomes really hard because, your stomach is very full and starts taking all blood flow from your body to digest the food, so your body becomes weak, and you become lazy and lethargic. So, of course it is totally different based on how you break your fast.” Arabic P4

Participants who do not follow the healthier way of breaking the fast expressed how their body feels heavy after eating and how hard it is for them to perform the prayer.

“Honestly, I don’t pray before eating the meal.… There is a strange thing in myself, after I break my fast, I feel cold, even if it is summer, I would still cover myself with a heavy duvet. Until my body start burning the food that I ate, and that is when I remove the cover. I feel that my body becomes heavy once I break the fast. So, I hardly could pray Maghrib and then directly go take a nap.” Arabic P1

3.5. Theme 5: How Decisions Are Made Based on Outcomes and Other Factors

Participants explained how they make decisions (e.g., whether to fast or not, dietary changes) based on experienced and expected outcomes, geography and the season of the year in which Ramadan falls. Participants make decisions on whether to fast based on the experienced outcomes, such as dehydration, medication related adverse events, low blood sugar and related symptoms like fainting.

“When I first was diagnosed with diabetes, I used to fast. I fasted for about 3–4 years. But the last 2 years, I started experiencing low blood sugar episodes while fasting... when it is about 2–3 hours before breaking the fast, I would feel that I am tired, and I can’t.” Arabic P3

“I feel dehydrated, I feel cramps. My mouth gets really dry. And I drink a lot of water, so I cannot stop drinking water. Even my doctor told me the medication you take, it makes you urinate more, so you need to drink more water. So, I cannot stop that, so I have to drink water during the day. So that’s why I’m not able to fast.” Urdu P3

Based on experiential learning and expected outcomes, participants explained how they adopt healthy practices (e.g., diet-related, adherence to medications) to avoid experiencing adverse outcomes like low blood sugar, high blood sugar, and dehydration.

“[I have not experienced low blood sugar levels when fasting], because I complement my diet at time of breaking the fast by eating dried fruits. These fruits provide sugar that is healthy… not like the Kunafeh desserts that are full of sugar.” Arabic P2

“I don’t drink coffee during Ramadan, because if I drink coffee, I will feel thirsty the whole day.” Arabic P4

“In Suhoor, so I prefer to drink a lot of water. I think it will be very helpful for me.” Afghan P2

“After taking food, after the iftar, I know that my sugar will go up, but I take medication after the iftar, after the Athan (call for prayer).” Urdu P5

One participant who lives in Texas, explained how the geographical location and the season of the year in which Ramadan fall may influence health outcomes and ability to fast.

“I am in Texas, about 5 years ago, Ramadan was really hard because it was in the summer and it was very hot and the temperature can get up to 120 F, so you lose a lot of water due to heat. My work is mainly in the office or at home, so everything is air conditioned. But if I lose a lot of water and it affects my blood sugar, then I break my fast, but so far, I never had to break my fast.” Arabic P4

3.6. Theme 6: Ramadan Is an Opportunity for Behavioral Changes That Can Be Sustained Beyond the Month of Fasting

Some participants perceive Ramadan as an opportunity for behavioral change that could be sustained beyond Ramadan.

Participants perceive Ramadan as an opportunity to organize dietary habits.

“Ramadan is beautiful. Ramadan helps you regulate your life and your diet…Ramadan is nice because it helps in organizing the kind of diet even for the family. For our family, in Ramadan we don’t cook traditional food that has rice such as Maqlooba. Breakfast is mainly grilled meats, Fattoush salad, soup, and fried Kibbeh. So, it becomes a system for the whole household. You feel that the whole house gets within this organized system during Ramadan.” Arabic P2

Even participants who do not believe in eradicating non-healthy food from the Iftar table are open for incorporating small changes.

“Honestly, there is no change that we can do [norm of having dessert], these are [cultural] rituals that we are used to. The only change you can do is to just try to eat a little bit instead of eating a lot. You can’t just have savory food, you need to have desserts. There is no solution for this issue, the solution is that you try to eat the desserts in small amounts.” Arabic P3

The experienced implications of dietary changes during Ramadan on health outcomes.

“When I am fasting, I feel more refreshed and energized than when I am not fasting … because I am fasting, I don’t eat during the day. When you are not fasting, you keep eating, and you eat this and that… this way of always eating makes you tired.” Arabic P5

“I feel a lot better in Ramadan month…. Maybe because, during Ramadan, we are not eating so many food, and maybe that is the reason that I feel better.” Afghan P3

“If my diet is not controlled, then my blood sugar is not controlled.” Arabic P4

How participants perceive the possibility of sustaining dietary changes beyond Ramadan.

“For our household, …. It can be sustained through the way of dieting. We have to have soup, and salad every day. We only have 2 meals; I have breakfast with my husband. When our daughter come back from work at around 6–7 pm, we have our dinner/second meal. At around 6 or 7 pm that is nighttime, it is hard to have heavy meals, so we continue having a diet similar to Ramadan.” Arabic P2

4. Discussion

This qualitative study investigated dietary behaviors among US Muslims living with Type 2 diabetes during the month of Ramadan. Participants described the changes in dietary habits during the month of fasting. They elaborated on how different religious practices, cultural diets, and social events influence their dietary behavior during this time of the year. Some people demonstrated strong abilities to manage their dietary behaviors while others did not. Participants explained how they learned through experiences to adopt certain practices (e.g., the way of breaking the fast) to improve their health outcomes. People’s cognition of their health outcomes enabled them to make decisions to avoid complications and adverse events while fasting. Finally, Ramadan presented an opportunity for positive behavioral changes that could be sustained beyond this month of the year and impact their overall wellbeing.

This study included five different communities, the main difference between them was the cultural diets that people consumed at the time of breaking the fast. For example, some people enjoyed having fried food like Samosas while others emphasized the importance of having desserts after eating the main meal. This finding aligns with previous research that described the increased consumption of desserts during Ramadan in some cultures [31]. On the other hand, none of the study themes were more prominent in one community than in the others. There were commonalities in dietary behaviors influenced by different psychosocial factors (e.g., religious-inspired practices, communal gatherings, sharing and eating food) whether positively or negatively.

Some people in this study focused more on cultural and social practices, with less emphasis placed on the religious purposes behind fasting including purifying the soul and developing self-discipline [32]. Some people may lack the knowledge and/or the self-control abilities to practice healthy fasting, affecting their outcomes negatively. For this group, social and communal events largely influenced their dietary behaviors during Ramadan. This impact was primarily due to the types of food available, the expectations set by social norms to offer an extensive food menu, and the social pressure to eat the food presented. Similar findings were documented in recent research conducted in the United Kingdom where perceived social norms restricted individuals’ autonomy in making food choices during Ramadan. These findings contrast with a study conducted in Indonesia, where Muslim people found that social gatherings influenced better self-management through social support [33]. It is worth noting that Indonesia is a Muslim-majority country with a more supportive environment for fasting compared to western countries. Additionally, the study was not conducted within the context of Ramadan so results may vary in other settings [32,33].

This study highlights that, while cultural meals and social events could negatively influence diabetes outcomes, many individuals from various cultures were inclined toward religious practices and ways of breaking fast (e.g., eating just enough to replenish without indulging) that promoted positive health outcomes.

Adapting and implementing culturally sensitive and religiously inspired educational programs can promote the positive outcomes associated with safe, balanced, and informed religious fasting practices [34,35,36,37]. While other western countries have implemented such programs, the US still has much progress to make. These programs can highlight the role of fasting in supporting self-management activities, ensuring that individuals can maintain their health while observing their religious practices [33,38]. A principle proven successful in previous research for Arab American individuals with diabetes is the importance of receiving instructions in Arabic and having family members understand food choices [14]. These factors were significant predictors of the perceived importance of diabetes self-management [14]. Community-based participatory research can serve as a foundation for creating these educational materials by actively involving religious leaders, patients, and healthcare professionals from the relevant cultures. An emphasis can be placed on the importance of consuming balanced Mediterranean diet and its impacts on diabetes outcomes, especially given the countries of origin for many Muslims [39,40]. Integrating these principles into diabetes education programs can help individuals make healthier food choices that align with their cultural and religious practices.

On the other hand, fasting Ramadan encourages people to adopt positive behavioral changes to become a better version of themselves as Muslims and humans. Our results showed that people found it beneficial for their health outcomes to follow a structured daily schedule for mealtime and adhering to a specific strategy when breaking their fast. The gradual attainment of behavioral habits during Ramadan helped some participants to sustain them beyond the month. This model could inform future studies in developing culturally appropriate strategies to help diabetes patients establish long-term self-management habits [41,42].

As a result of engaging in more disciplined eating behaviors, most participants in this study felt that they better managed their diabetes while fasting and experienced better physical outcomes. This discipline prevented them from continuously snacking throughout the day, to the point where some people wished that Ramadan could be extended year-round. Previous literature suggested that correct adherence to Religious practices promoted diabetes self-management [41], and showed associations with improved glycemic control among people with Type 2 diabetes [43]. Healthcare providers should take advantage of the motivations that Ramadan presents as an opportunity to counsel eligible patients not only to fast safely, but to also choose at least a small self-management habit to be sustained beyond the month. Specific tools such as motivational interviewing and habit formation can help healthcare providers guide the patients in choosing their specific self-management behavioral goal and create manageable aims with reasonable expectations [42,44,45,46,47].

Participants in this study were cognizant of their health status while fasting. Many noted making decisions about whether to fast based on experienced symptoms and outcomes, such as medication-related adverse events, or symptoms of low blood sugar. Some participants were aware of the symptoms of low blood sugar and would abstain from fasting if they felt their glycemic control would be compromised. However, other participants experienced blood sugar related complications and still insisted on continuing their fast. These findings align with results from Bouchareb et al. 2022; they explained the three stages in deciding whether to fast: (1) experiencing positive outcomes and continuing to fast; (2) encountering challenges but insisting on fasting; (3) suffering many difficulties and deciding not to fast [7]. Our study further explains that the decision-making process extends beyond just choosing whether to fast. It encompasses adopting healthy practices, such as making healthy food choices to prevent complications, discontinuing caffeine intake, and increasing water consumption. Clinicians should promote a shared decision-making process that actively involves the patient and provides them with comprehensive individualized education [7,48]. This education should enhance their understanding of potential symptoms and equip them with strategies to respond effectively, thereby preventing complications, ensuring safe fasting practices, and improving their health outcomes [48,49,50,51].

Given the rising number of Muslims in the US and the high prevalence of diabetes in this population, there is a need to develop and deliver culturally tailored educational programs to Muslims with diabetes who fast during Ramadan. Additionally, it is important to develop educational programs for healthcare providers to understand the significance, physical practices, and behavioral aspects of fasting from a religious perspective. This educational material should also emphasize the importance of cultural sensitivity and understanding of diverse populations. Methods such as motivational interviewing [46,47] and factors addressed in this paper, can be effectively employed to support the adaptation and creation of educational materials addressing gaps in healthcare practices [52,53,54]. Educational materials designed to improve healthcare clinicians’ understanding of fasting and its management in people with diabetes can be integrated into medical school curricula, residency programs, and continuing education credits [55,56].

Strengths and Limitations

This study presents notable strengths. It includes five culturally and linguistically unique US Muslim populations, offering valuable insights into the relationship between culture, religion, and their influence on behavior and health outcomes. Both refugees and immigrants were included, which enriches the diversity of gathered perspectives. A pharmacist scientist who is well-versed in diabetes management and identifies as a Muslim led this study, enabling her to provide an empathetic and informed approach to this study. Further, involving a team of experienced researchers from different backgrounds helped maintain an objective perspective throughout the study. However, there are limitations to this study. The interviewer is fluent in Arabic and English so interviews conducted in these languages flowed more seamlessly, allowed for better rapport-building, and in-depth responses compared to other interviews. Therefore, important information may have been lost in translations for non-Arabic and non-English-speaking participants. Also, since this study was not conducted during Ramadan, participants may have experienced recall bias, potentially affecting the accuracy of their remembrances.

5. Conclusions

This study is among the first to document the dietary behaviors and key psychosocial factors influencing dietary behaviors and health outcomes for US Muslim people with Type 2 diabetes during Ramadan. This study provides extensive understanding of the dietary and behavioral changes that occur during the month of Ramadan from the perspectives and experiences of Muslims with diabetes from five different US communities and demonstrates the powerful influences of psychosocial factors on dietary behaviors and health outcomes for US Muslims with diabetes. Ramadan as a spiritual month presents a significant opportunity for incorporating and encouraging behavior changes to support diabetes self-management activities. Although some people believed that they were not able to make drastic changes in dietary habits during Ramadan, they were receptive and willing to explore incorporating small changes. The results of this study present opportunities for healthcare providers to support Muslim patients in adhering to safe fasting by providing them with the necessary education and tools. This study suggests that interventions to improve diabetes control and promote diabetes remission among Muslims can benefit from cultural tailoring that draws on Ramadan religious, cultural and social practices to encourage sustainable behavioral change. Further research is needed to implement and assess the effectiveness of patient-informed and culturally tailored diabetes interventions during Ramadan. Importantly, the reports from Muslim patients could become key content for new providers who are beginning to offer support to these patients. This training could begin for young university students as well as ongoing continuing education (CE) credit courses for older practitioners.