Quality of Life among Saudi Diabetics

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Journal of Diabetes Mellitus, 2014, 4, 225-231
Published Online August 2014 in SciRes. http://www.scirp.org/journal/jdm
http://dx.doi.org/10.4236/jdm.2014.43032
How to cite this paper: Al-Shehri, F.S. (2014) Quality of Life among Saudi Diabetics. Journal of Diabetes Mellitus, 4, 225-231.
http://dx.doi.org/10.4236/jdm.2014.43032
Quality of Life among Saudi Diabetics
Fahad S. Al-Shehri
Joint Program of Family Medicine, Abha, KSA
Email: fahdshar@hotmail.com
Received 9 June 2014; revised 5 July 2014; accepted 1 August 2014
Copyright © 2014 by author and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Abstract
Aim of study: To assess QOL among Saudi diabetics and to identify the possible risk factors asso-
ciated with lower QOL. Patients and Methods: This study comprised 400 diabetic patients attend-
ing the Diabetes Clinic at the University Diabetes Center in Riyadh. They were interviewed using
the Audit of Diabetes Dependent QOL (ADDQOL). Results: Most diabetic patients (78.7%) had neg-
ative (i.e., unfavorable) ADDQOL scores. Diabetic patients' age, education and occupation were not
significantly associated with their QOL. Female patients had significantly worse QOL than male pa-
tients (p = 0.026). Married patients had significantly worse QOL compared with non-married pa-
tients (p = 0.012). Patients with type 2 diabetes had significantly worse QOL than those with type 1
diabetes (p = 0.029). Duration of diabetes was not significant factors as regard their QOL, with the
worst QOL among those with more than 20 years of diabetes. The degree of diabetes control was
significantly and directly associated with QOL score (p < 0.001). The worst QOL was expressed
among poorly controlled diabetes while the best was among patients with excellent control. QOL
of diabetics was less among those who had diabetes complications, i.e., neuropathy (p = 0.03), re-
tinopathy (p < 0.001), and diabetic foot (p = 0.031). However, difference was not significant ac-
cording to those with nephropathy. Conclusions: QOL of Saudi adult diabetic patients is not favor-
able. Personal characteristics associated with worse QOL among diabetics include female gender,
and being married. Disease characteristics associated with worse QOL include being a type 2 di-
abetic and those with uncontrolled diabetes. Main complications associated with worse QOL
among diabetics include retinopathy, diabetic foot and neuropathy.
Keywords
Quality of Life, Diabetes Mellitus, Retinopathy, Nephropathy, Neuropathy, Diabetic Foot
1. Introduction and Aim of Study
As advances in medical technology and new, more aggressive treatments succeeded in increasing survival rates,
attention increasingly turned towards the quality of life (QOL) of patients rather than longevity alone. Today,

F. S. Al-Shehri
226
QOL assessment measures are routinely used to evaluate the human and financial costs and benefits of different
health programs and medical interventions. Health-related QOL (HRQOL) is concerned with QOL within the
specific context of health [1].
The prevalence of diabetes mellitus is reaching epidemic proportions in many parts of the world. It is an in-
creasingly important public health concern. In the United States, diabetes is present in 8% of the adult popula-
tion, and is associated with a two-fold increase in age-adjusted mortality [2]. In many developing countries, in-
cluding Saudi Arabia, the incidence of diabetes is increasing and its prevalence is also approaching epidemic
proportions [3]. In a national Saudi study to assess prevalence of diabetes mellitus between the ages of 30-70-
years, Al-Nozha et al. (2004) [4] reported that 4004 out of 16917 (23.7%) were diagnosed to have diabetes. Di-
abetes mellitus was more prevalent among Saudis living in urban areas of 25.5% compared to rural Saudis of
19.5% (p < 0.00001). Despite the readily available access to healthcare facilities in KSA, a large number of di-
abetics 1116 (27.9%) were unaware of having DM.
Diabetes has detrimental effects on a range of health outcomes including QOL [5]. Almost two decades ago,
Stewart et al. (1989) [6] noted that diabetes impairs all dimensions of health except mental health and pain. In a
more recent multinational study, diabetes was found to have a notable impact on general health [7]. The magni-
tude of impact of diabetes on QOL was reported to be equivalent to that of having cardiovascular conditions,
cancer and chronic respiratory disease [8].
Several studies have demonstrated that diabetes has a strong negative impact on the HRQOL, especially in the
presence of complications [9]-[11]. However, most of the studies on diabetes and QOL have been conducted in
developed countries [12] and studies of the QOL in diabetic patients in developing countries are rare [13] [14].
Since patient’s perceptions about diabetes and diabetes-related complications may have a significant influence
on their QOL, the relationship between QOL and diabetes mellitus should be elucidated. Hence, this study
aimed to assess QOL among Saudi diabetics and to identify the possible risk factors associated with lower QOL.
2. Patients and Methods
This research followed a hospital-based cross-sectional study design. It was conducted at the “University Di-
abetes Center” in Riyadh. All diabetic patients who fulfilled the inclusion criteria constituted the study popula-
tion. These inclusion criteria were: adult Saudi diabetic patients, whose disease duration is more than one year,
non-pregnant (for females), living in Riyadh. This study comprised 400 diabetic patients.
All diabetic patients included in the present study were interviewed using the “Audit of Diabetes Dependent
Quality Of Life (ADDQOL)”. The ADDQOL was designed by Bradley et al. (1999) [15] to be a reliable and va-
lid instrument for the assessment of QOL. Those who score > 0 are considered to have good QOL, −0.1 to −2.0
have bad QOL, −2.1 to −4.0 have very bad QOL, while those with scores less than −4.0 have extremely bad
QOL.
The questionnaire was translated into simple Arabic language by the researcher. A pilot study was conducted
at the Diabetes Clinic at King Abdul-Aziz University Hospital in Riyadh on 40 diabetic patients who were not
included into the main study. This pilot study aimed to test the clarity of questionnaire’s wording.
Data were collected from patients’ records, concerning their demographic characteristics, last HbA1c level.
The level of control of diabetes was assessed according the level of HbA1C. Those who have their HbA1C < 7
were considered to have excellent diabetes control, those with 7 - 8 have good control, those with 8.1 - 11 have
fair control, while those with >11 have poor control [16]. Diabetes complications were identified by presence of
retinopathy (assessed by history of visual disturbance, history of cataract and fund us examination by an oph-
thalmologist), nephropathy (assessed by proteinuria or raised serum urea and creatinine after exclusion of other
causes), neuropathy (assessed by a history of numbness or decreased sensation and evidence of decreased sensa-
tion or reflexes on neurological examination or evidence of electrophysiological testing). Diabetic foot (assessed
by a history of foot care behavior and foot examination for peripheral neuropathy (PN), peripheral vascular dis-
ease (PVD), and foot deformities. PN was evaluated using the Semmes-Weinstein monofilament test. PVD was
graded by clinical measures and Doppler examination (ankle:brachial index < 0.9)
Data analysis was carried out using the Statistical Package for Social Sciences (SPSS ver. 14.0). Descriptive
statistics were applied (i.e., frequency, percentage, mean and standard deviation). Difference between mean
ADDQOL scores was compared using Student’s and ANOVA tests. Significance level was set at p < 0.05.

F. S. Al-Shehri
227
3. Results
Table 1 shows that less than one fourth of diabetic patients had good QOL (85%, 21.3%), hence, most diabetic
patients (315%, 78.7%) had negative (i.e., unfavorable) ADDQOL scores. Almost half of diabetics had their
scores ranging from very bad (186%, 46.5%) to extremely bad (18%, 4.5%).
Table 2 shows that about half of diabetic patients were females (51.8%), about three fourths aged more than
40 years. Most patients were married (84.5%). Almost one third of patients were illiterate (30.5%), while almost
two thirds were not working (62.5%). Diabetic patients' age, education and occupation are not significant va-
riables as regard their QOL. Female patients had significantly worse QOL (p = 0.026). Married patients had sig-
nificantly worse QOL compared with non-married patients (p = 0.012).
Table 3 shows that most patients were type 2 diabetics, whose duration of diabetes was 10 - 20 years in more
than half of them (56%) and treated with oral hypoglycemic (50.5%). In almost half of cases, diabetes control
was favorable, being either excellent (25%) or good (25.5%). Complications of diabetes were mainly retinopa-
thy (42.5%) or neuropathy (28.3%). Patients with type 2 diabetes had significantly worse QOL than those with
type 1 diabetes (p = 0.029). QOL was less among diabetics with less than 10 years duration of disease, followed
by a relatively better QOL among those with10 - 20 years and then the worse QOL was present among those
with more than 20 years of diabetes. Moreover, oral hypoglycemic treatment was associated with relatively bet-
ter QOL compared with those who were on insulin treatment or those with combined oral hypoglycemic and in-
sulin. However, duration of diabetes as well as the type of treatment was not significant factors as regard their
QOL. The degree of control of disease among diabetics was significantly and directly associated with their QOL
Table 1. Distribution of ADDQOL grades.
ADDQOL Scores No. %
•
>0 (Good)
85 21.3
• −0.1to −2.0 (Bad) 111 27.8
• −2.1 to −4.0 (Very Bad) 186 46.5
• <−4.0 (Extremely Bad) 18 4.5
Table 2. Distribution of mean ADDQOL scores according to personal characteristics of study sample.
Variables No. % Mean + SD p-value
Age groups (in years)
<20 20 5.0 −1.47 + 1.52
21 - 40 81 20.3 −2.56 + 2.03
41 - 60
249
62.3
−2.55 + 1.95
>60 50 12.5 −2.48 + 2.10 0.121
Sex:
Females 207 51.8 −2.69 + 2.01
Males
193
48.3
−2.25 + 1.92
0.026
Marital status
Single 50 12.5 −1.84 + 1.61
Married 338 84.5 −2.61 + 2.02
Divorced
12
3.0
−1.61 + 1.43
0.012
Education
Illiterate 122 30.5 −2.53 + 1.97
School 187 46.8 −2.52 + 2.03
University
91
22.8
−2.33 + 1.89
0.718
Occupation
Governmental 83 20.8 −2.32+1.68
Business 16 4.0 −3.63+2.89
Professional
51
12.8
−2.32+1.82
Unemployed 250 62.5 −2.49+2.02 0.097

F. S. Al-Shehri
228
Table 3. Distribution of mean ADDQOL scores according to disease characteristics.
Variables No. % Mean + SD p-value
Type of diabetes
Type 1 57 14.3 −1.95 + 1.57
Type 2 343 85.8 −2.56 + 2.03 0.029
Duration of diabetes (years)
<10 127 31.8 −2.40 + 1.94
10 - 20 224 56.0 −2.17 + 1.95
>20 49 12.3 −2.72 + 2.20 0.640
Diabetes control
Excellent (HbA1C < 7%) 100 25.0 −1.57 + 1.68
Good (HbA1C = 7% - 8%) 102 25.5 −2.45 + 1.79
Fair (HbA1C = 8.1% - 11%) 184 46.0 −2.88 + 1.98
Poor (HbA1C > 11%) 14 3.5 −3.98 + 2.73 <0.001
Diabetes complications
Neuropathy
Yes 113 28.3 −2.83 + 2.05
No 287 71.7 −2.34 + 1.94 0.030
Retinopathy
Yes 170 42.5 −2.88 + 1.98
No 230 57.5 −2.18 + 1.93 <0.001
Nephropathy
Yes 43 10.8 −2.90 + 1.71
No 357 89.2 −2.43 + 2.00 0.142
Diabetic foot
Yes 20 5.0 −3.36 + 2.02
No 380 95.0 −2.39 + 1.95 0.031
(p < 0.001). The worst QOL was expressed among poorly controlled diabetes while the best was among patients
with excellent control. QoL of diabetics was worse among those who had diabetes complications, i.e., neuropa-
thy (p = 0.03), especially retinopathy (p < 0.001), and diabetic foot (p = 0.031). However, difference was not
significant according to nephropathy.
4. Discussion
This study showed that the majority of Saudi diabetic patients had non-favorable ADDQOL scores. More than
one fifth of patients scored less than −4.0 (i.e., worst QOL).
It has been repeatedly and consistently stated that diabetes has detrimental effects on QOL. Diabetes has been
stated to impair all dimensions of health [5] [7] [17].
This study showed that, as regard patients’ personal characteristics, patients’ age, education and occupation
were not significant variables as regard their impact on QOL. On the other hand, female patients had signifi-
cantly worse QOL. This sex-difference could be partly explained by the worse situation of female patients in
respect to the disease and an evidence for gender inequalities in some communities.
In Riyadh, KSA, Abdel-Gawad (2002) [3] reported that males had significantly higher satisfaction. Similar
difference in QOL of both genders was observed in a study conducted in Iran by Aghamollaei et al. (2003) [18].
In western countries, lower QOL in diabetic women was also reported by Rubin and Peyrot (2004) [9] in USA
and Redekop et al. (2002) [19] in the Netherlands.
This study showed that married patients had significantly worse QOL compared with non-married patients.
This finding may be explained by the fact that married diabetic people have more responsibilities and more per-
sons to look after in addition to their disease, compared with those diabetics who are not married.
Laine and Caro (1996) [20] noted that hypoglycemia may harm the marital relationship, academic achieve-

F. S. Al-Shehri
229
ment, and performance on the job. Under certain circumstances, both insulin and oral hypoglycemic agents can
cause the blood glucose to fall below 40 mg/dL. This stimulates counter-regulatory hormones, giving rise to a
range of signs and symptoms, and functional impairment.
In KSA, Abdel-Gawad (2002) [3] stated that married patients reported significantly higher satisfaction, less
impact, few worry and better total QOL. Less educated respondents reported significantly fewer worries than
those of higher education. Interestingly, education played no independent role with respect to QOL.
Brown et al. (2000) [21] reported that neither gender, level of education nor age significantly affected the
QOL associated with diabetes.
The present study showed that patients with type 2 diabetes had significantly worse QOL than those with
type-1 diabetes. Moreover, QOL was worse among diabetics with less than 10 years duration of disease, fol-
lowed by a relatively better QOL among those with 10 - 20 years and then the worse QOL was present among
those with more than 20 years of diabetes.
Brown et al. (2000) [21] noted that the type of diabetes, length of time of diabetes seemed not to have an im-
pact over QOL.
The degree of control of disease among diabetics was significantly and directly associated with their QOL (p
< 0.001). The worst QOL was expressed among poorly controlled diabetes while the best was among patients
with excellent control.
De Grauw et al. (2001) and Walling (2002) [22] [23] emphasized the importance of diabetes control. They
stated that strict control of blood glucose levels in diabetic patients can result in a reduction of one fourth of mi-
crovascular complications.
The present study showed that complications of diabetes were very common, mainly retinopathy (42.5%) or
neuropathy (28.3%). QOL of diabetics was less among those who had diabetes complications, especially retino-
pathy (p < 0.001), diabetic foot (p = 0.031) and neuropathy (p = 0.03). However, difference was not significant
according to those with nephropathy.
Abolfotouh (1999) [24] stated that, as a complication of diabetes, neuropathy can cause numbness, foot drop,
diarrhea, pain, and total erectile impotence. Woodcock et al. (2004) [25] noted that diabetic retinopathy is one of
three serious microvascular complications of diabetes, the other two being diabetic neuropathy and diabetic
nephropathy.
Al-Khader (2001) [26] stated that there are no precise data available on the incidence of nephropathy in Saudi
diabetics. What is known is that the vast majority of Saudi diabetics entering dialysis (96%) are of Type 2. In a
study of a diabetes outpatient clinic, 12.8% of patients had dipstick proteinuria and of the remaining patients
41.3% had microalbuminuria [27]. Al-Khader (2001) [26] warned that, with the growing magnitude of diabetic
nephropathy, sooner or later the KSA is going to face a ‘medical catastrophe’ at dialysis units.
The presence of diabetic complications, such as retinopathy, peripheral vascular disease, coronary artery dis-
ease, peripheral sensory neuropathy, and depression, has been associated with poorer QOL in a number of stu-
dies [21] [28].
Tennvalla and Apelqvistb (2000) [29] reported that patients with current foot ulcers experience lower QOL
than those who have healed primarily without any amputation.
Benbow et al. (1998) [30] noted that painful diabetic neuropathy has a considerable impact on QOL. Pain was
associated with a reduction in sleep, walking and ability to perform domestic duties. It has been shown that
when chronic diabetic neuropathic pain is reduced there is an associated increase in exercise tolerance and better
QOL.
In conclusion, QOL of Saudi adult diabetic patients is not favorable, personal characteristics associated with
worse QOL among diabetics include female gender, and being married, disease characteristics associated with
worse QOL among diabetics include being a type 1 diabetic and those with uncontrolled diabetes (i.e., >HbA1c >
8), and the main complications associated with worse QOL among diabetics include retinopathy, diabetic foot
and neuropathy.
It is recommended that the health care team for diabetics (e.g., nurses, general practitioners, diabetologists,
podiatricians, etc) should not be only disease-centered, QOL of the diabetic patient should always be regularly
assessed and improved accordingly. The presence of one or more risk factors associated with poorer QOL
among diabetics should attract the attention of health care providers to be assessed and managed, health educa-
tion of diabetic patients should be fully and regularly implemented to cover the importance of improving their
QOL, proper diabetes control should be enforced, and reasons for suboptimal diabetes control should be inves-

F. S. Al-Shehri
230
tigated and managed accordingly.
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