HRQoL is a vital tool in the assessment of the effect of chronic diseases on quality of life. Diabetes and its related complications can have a substantial effect on HRQoL. The aim of this study was to assess the HRQoL and its associated factors among people with T2DM in Saudi Arabia. Results showed that the HRQoL for people with T2DM in Saudi Arabia was low, especially among females and those who had diabetes complications. A number of lifestyle and other modifiable factors were also found to be associated with low HRQoL.
The mean utility index and VAS score in this study were comparable to a previous single-centre small sample study from Saudi Arabia, which reported a mean utility index of 0.71 ± 0.22 and a VAS score of 68.5 ± 16.8 . A study from Iran also reported a similar mean utility index; however, the VAS score in that study was lower than that in the present study . Studies from Norway, Japan and Korea reported higher utility indexes ranging from 0.83 to 0.94 [36–38]. Differences in the populations and the healthcare systems may explain the variation in the utility index between these studies and the current study. The highest prevalence of any problems among this study’s participants was with pain-discomfort (51.6%), followed by mobility (51.0%) and then anxiety-depression (45.8%). This is in concordance with the results of studies from Iran, Japan and Norway [35–37].
Advanced age appeared to be associated with problems with usual activities and pain-discomfort but not with utility index. Similar findings regarding the effect of age on utility index were reported in previous studies from Saudi Arabia and Canada [11, 20, 39]. In contrast, other studies have shown that advanced age was associated with lower utility index [6, 10, 40]. With advanced age, there may be a reduction in body strength and physical function that affects quality of life.
Female participants in this study had a lower mean utility index compared to male participants. Many previous studies reported similar findings [10, 11, 20, 22, 35, 41, 42], and linked this association to higher rates of physical inactivity and obesity among women [20, 35, 42]. Among our participants, higher proportions of females were physically inactive and were spending more than 10 hours per day in a sitting position compared to males. The prevalence of obesity among females was also higher than that among males. This study also showed that physical inactivity was associated with problems with all of the EQ-5D-5L dimensions, while longer sitting time appeared to have a similar association except for anxiety-depression. Moreover, both physical inactivity and longer sitting time were independently associated with a lower utility index. Our finding about the association between physical inactivity and lower HRQoL is supported by previous studies [11, 15, 43, 44]. However, the current study was the first to investigate the association between longer sitting time and lower HRQoL among people with T2DM. Longer sitting time was found to be associated with higher risk of diabetes complications , which were strongly linked to lower HRQoL [15, 22, 39, 40]. Thus, maintaining HRQoL through increasing physical activity and reducing sitting time should be emphasised in the management of diabetes in Saudi Arabia.
Obesity can affect HRQoL, mainly through its impact on physical function and mental health. There are, however, conflicting reports regarding the association between obesity and HRQoL. This study showed that obesity was associated with higher risk of problems with pain-discomfort; yet, obesity did not appear to be associated with lower utility index. Similar findings were reported in another study . In contrast, some studies have reported a significant association [6, 11]. In the current study, obesity was more prevalent among young compared to old people. Young people were also less likely to have diabetes complications, which may explain why obesity was not associated with a lower utility index. Nevertheless, obesity have been linked to higher risk of diabetes complications among people with T2DM in Saudi Arabia . Therefore, controlling the body weight is an important step to lower the risk of diabetes complications and maintain HRQoL.
Similar to other studies [10, 35], the current study showed that a lower level of education was related to problems with mobility and lower HRQoL. Having a higher level of education increases the likelihood of adherence to disease management plans and healthier lifestyle behaviours which lowers the risk of diabetes complications and helps in maintaining HRQoL . Previous studies also reported an association between poor HRQoL and both lower income and rural or remote location of residence [10, 46]. The results of this study showed that, while remote area of residence was associated with problems with self-care, household income and the area of residence were not associated with a lower utility index. A similar finding regarding income was reported by another study from Saudi Arabia .
This study showed that the duration of diabetes did not affect HRQoL. Previous studies from Saudi Arabia and Iran reported similar findings [11, 20, 35]. The modality of treatment and the number of medications were also not associated with the utility index in this study; however, insulin use was associated with a lower VAS score. The results of previous studies regarding the effect of modality of treatment and the number of medications were conflicting, some studies finding an association [16, 40], and others not [20, 35].
Fear of hypoglycaemia may not affect HRQoL directly, but it may have an impact on the general quality of life through its negative effect on independence, spontaneity and enjoyment of leisure activities . This study also showed that hypoglycaemia was associated with a higher risk of anxiety-depression and that anxiety and depression were independently related to lower utility index and VAS score. Previous studies also reported an association between HRQoL and both anxiety and depression [47, 48]. Having smoked also appeared to be associated with problems with anxiety-depression, which may be explained by its known relationship with increased risk of diabetes related complications. People with diabetes are at an increased risk of developing anxiety and depression, and these mental illnesses can negatively affect the control of the disease and increase the risk of diabetes complications . To optimise HRQoL among people with T2DM in Saudi Arabia, screening and management of anxiety and depression should be prioritised among this high-risk population.
Diabetes complications have a strong impact on HRQoL. In the current study, diabetes complications were associated with a 0.16- to 0.31-point reduction in the mean utility index compared to people without complications (utility index 0.84 ± 0.17). Further analysis showed that people with macrovascular complications only, and those with microvascular complications only had a mean utility index of 0.76 ± 0.17 and 0.73 ± 0.25, respectively. For people who had both types of complications, the mean dropped to 0.57 ± 0.33. A similar decrement in the mean utility index for those with diabetes complications was reported by other studies [39, 50]. After adjustment for confounders, diabetes complications remained strongly associated with lower utility index. This is in concordance with the literature, which showed that diabetes complications have a substantial effect on HRQoL [6, 11, 15, 22, 39, 40]. Thus, the prevention of diabetes complications is a key measure in improving the quality of life for people with diabetes.
The results of the current study also showed that diabetes complications affected several dimensions of HRQoL. Neuropathy in particular had an impact on all of the HRQoL dimensions and was also associated with a lower VAS score. A strong association between neuropathy and HRQoL has been reported previously [5, 10]. Altogether, this indicates that neuropathy is a concerning condition that should be prevented or controlled through adequate screening, treatment and patient education.
Major strengths of this study were the relatively large sample size drawn from three different regions and the examinations of the effect of various demographic, behavioural, and clinical factors on HRQoL using a robust analysis method. The use of the EQ-5D-5L tool to assess HRQoL also adds strength to this study in making it easier to compare its results with those of other national and international studies. The results of this study, however, need to be interpreted in the light of being a cross-sectional, meaning that only association and not causation can be inferred from its results. Nevertheless, this study has identified factors that have strong association with lower HRQoL among people with T2DM in Saudi Arabia. Future research should focus on exploring the identified associations using prospective studies. Healthcare providers and health policy makers should also use this study’s findings to develop patient-level interventions and public health strategies to improve the quality of life of people with diabetes in Saudi Arabia.