Mental Wellbeing and Quality of Life Among Patients With Diabetes Suffering From Hypoglycaemia in Saudi Arabia

Background Diabetes mellitus is a global burden that is considered a major public health concern for many countries. Saudi Arabia is ranked second among the highest percentages of diabetes worldwide, with more than 7 million patients with diabetes reported in 2017, with an estimated prevalence to be around 14%. Psychological and mental health outcomes are poorer in patients with diabetes who are suffering from hypoglycaemia. The aim of the study was to investigate the mental wellbeing and quality of life of patients with diabetes suffering from hypoglycaemia in Saudi Arabia. Methods A cross-sectional study using an online self-administered questionnaire was conducted between the 13th of June and the 19th of July 2021 in Saudi Arabia. Results A total of 69.7% of the study participants scored below 13 on the WHO-5 scale, which indicates poor mental wellbeing status and possible depression, and reduced quality of life. A total of 67.8% of the study participants scored equal to or greater than 8 on the PAID-5 scale, which indicates possible diabetes-related emotional distress that warrants further assessment. The majority of the study participants (83.4%) scored equal to or greater than 28 on the fear of hypoglycaemia scale, which is classified as having fear of hypoglycaemia. Conclusion Depressive symptoms and reduced quality of life are common among patients with diabetes mellitus suffering from hypoglycaemia in Saudi Arabia.


Introduction
Diabetes mellitus (DM) is a highly prevalent disease in Saudi Arabia and worldwide. Moreover, DM is considered a major public health concern for many countries in the world [1]. According to the World Health Organization (WHO), Saudi Arabia is ranked second among the highest percentages of diabetes worldwide, with more than 7 million patients with diabetes reported in 2017 [2], with the prevalence being estimated to be around 14% [1]. Patients with diabetes are usually treated with pharmacological treatment to control their blood sugar levels, and this put them at higher risk of developing some life-threatening and costly complications such as hypoglycaemia [3][4][5].
avoidance of treatment [13]. The quality of life of patients suffering from hypoglycaemia is affected due to reasons such as social and behavioural embarrassment [14,15]. In addition, previous studies have reported that the psychological and mental health outcomes are poorer in patients with diabetes who are suffering from hypoglycaemia [16]. These studies also highlighted a variation in outcomes and associations at the country level and the need for further research in this area.
Previous studies investigating the mental burden and the effect on quality of life of hypoglycaemia in patients with diabetes are limited with few studies that mainly focused on the elderly population [16]. However, in recent years, more younger patients are diagnosed with both types of diabetes [17][18][19]. In addition, no previous studies have investigated this issue in the Middle East. Therefore, this study aimed to investigate the mental wellbeing and the quality of life of patients with diabetes and suffering from hypoglycaemia in Saudi Arabia.

Objectives
The primary objective of the study was to investigate the mental wellbeing and quality of life of patients with diabetes suffering from hypoglycaemia in Saudi Arabia. Secondary objectives were to explore diabetesrelated emotional distress and the level of fear of hypoglycaemia among patients with diabetes in Saudi Arabia.

Study design
A cross-sectional study using an online self-administered questionnaire was conducted between the 13th of June and the 19th of July 2021 in Saudi Arabia.

Sampling strategy
Convenience sampling techniques were used to recruit the study participants. Patients with diabetes mellitus who were aged 18 years and above and who were using antidiabetic therapy were invited to participate in the study. These inclusion criteria were highlighted in the invitation letter that was sent along with the study survey link. Social media platforms such as WhatsApp, Twitter, and Facebook were used to recruit the study participants.

Questionnaire tool
Three previously validated assessment scales were used in this study [20][21][22][23]. The questionnaire was translated into Arabic and validated by three experts in the field. The World Health Organization (WHO)-5 measure of mental wellbeing (five items scale) [20] measures the degree of positive mental well-being in the past two weeks. Each item is scored using a six-point Likert scale that ranges from zero (not present) to five (constantly present). The total possible score for this scale ranges from 0 to 25, where scores below 13 indicate poor mental wellbeing and possible depression and reduced quality of life [20]. Problem Areas in Diabetes Scale (PAID-5) (five items scale) [21,22] scale measures diabetes-related emotional distress that warrants further assessment. Each item is scored using a five-point Likert scale that ranges from zero (not a problem) to four (serious problem). The total possible score for this scale ranges from 0 to 20, where scores equal to or greater than eight indicates possible diabetes-related emotional distress that warrants further assessment [21,22]. 15-item Fear of Hypoglycaemia scale (FH-15) [23] measures diabetic patients fear of hypoglycaemia using a five-point Likert scale that ranges from one (strongly disagree) to five (strongly agree). The total possible score for this scale ranges from 15 to 75, where scores equal to or greater than 28 would be classified as having fear of hypoglycaemia [23].

Statistical analysis
Data were analysed using Statistical Package for Social Science (SPSS) software, version 27 (IBM Corp, Armonk, NY, USA). Categorical variables were reported as frequencies and percentages. Significant predictors of poor mental wellbeing, problem areas in diabetes, and fear of hypoglycaemia were determined using binary logistic regression. A confidence interval of 95% (P < .05) was applied to represent the statistical significance of the results, and the level of significance was predetermined as 5%.

Results
A total of 603 participants were involved in this study. More than half of them (56.2%) were females while a similar percentage (56.5%) were aged 35 years and below. A total of 65.8% are married. Sixty per cent of them reported that they are holding college/university degree or above. Around 44.0% of them reported that they are employed. The majority of them (72.1%) reported that they have type 2 diabetes mellitus. Around 40.0% of them reported that they have diabetes for a duration of five years or below. Around 44.0% of the study participants reported they are using oral antidiabetic therapy. Less than half of the study participants (45.9%) reported that they were admitted to the hospital for hypoglycaemic episodes in the previous six months. However, more than half of them (54.9%) reported experiencing a drop in the blood sugar level but did not require them to go to the hospital and were able to deal with it alone or with the help of those close to them. The majority of the study participants (85.1%) reported that they experience hypoglycaemic events at different frequencies. For further details on the participants' demographic characteristics, refer to Table 1

Measure of mental wellbeing
A total of 69.7% of the study participants scored below 13 on the WHO-5 scale, which indicates poor mental wellbeing status and possible depression and a reduced quality of life.

Problem Areas in Diabetes Scale (PAID-5)
A total of 67.8% of the study participants scored equal to or greater than 8 on the PAID-5 scale, which indicates possible diabetes-related emotional distress that warrants further assessment. Table 3 below highlights the current diabetes problems among the study participants. The most commonly reported serious problems were coping with complications of diabetes and feeling that diabetes is taking up too much of the mental and physical energy every day, with 19.9% and 18.1%, respectively. On the other hand, 17.6% of our study participants reported that they do not feel depressed when they think about living with diabetes.

Fear of hypoglycaemia
The majority of the study participants (83.4%) scored equal to or greater than 28 on the fear of hypoglycaemia scale, which is classified as having fear of hypoglycaemia.

Predictors of poor mental wellbeing, problem areas in diabetes, and fear of hypoglycaemia
Binary logistic regression was used to identify predictors of poor mental wellbeing, problem areas in diabetes, and fear of hypoglycaemia. Three independent regression models were conducted to identify the predictors of the three outcome measures.
Patients aged 31-35 years, those with a duration of diabetes (6-10 years), those who are on insulin therapy, and those who have reported hospital admission for hypoglycaemic episodes in the previous six months were more likely to have poor mental wellbeing status compared to others (p<0.05). Patients aged 31-35 years and 41-45 years, those with a duration of diabetes (6-10 years), and those who have reported hospital admission for hypoglycaemic episodes in the previous six months were more likely to have diabetes-related emotional distress compared to others (p<0.01). Patients aged 31-35 years, those with a duration of diabetes (6-10 years), and those who have reported hospital admission for hypoglycaemic episodes in the previous six months were more likely to have fear of hypoglycaemia compared to others (p<0.05). For further details, refer to

Discussion
In this study, the mental wellbeing and the quality of life of patients with diabetes and suffering from hypoglycaemia in Saudi Arabia were investigated. The majority of the study participants (85.1%) reported that they have experienced hypoglycaemic events. Around (45.9%) reported that they were admitted to the hospital for hypoglycaemic episodes in the previous six months, with around (54.9%) reported experiencing a drop in the blood sugar level but did not require them to go to the hospital. A previous study that investigated the prevalence of hypoglycaemia among patients with diabetes in Saudi Arabia reported that around 52% of the study participants reported that they had at least one hypoglycaemic attack [17]. This result is consistent with our results. However, it is important to mention that this study was conducted on patients during the month of Ramadan where Muslim individuals usually fast meaning that they are at higher risk of hypoglycaemia due to changes in their diet [17]. Another cross-sectional survey study that was also conducted in Saudi Arabia reported that the prevalence of diabetic coma among the studied diabetic patients was 57.5% and that the type of coma was mainly hypoglycaemia in 70.7% of the study participants [18]. These results are also similar to the results reported in our study.
In our study, around 69.7% of the study participants had a low score (below 13) on the WHO-5 scale indicating poor mental wellbeing status, possible depression, and reduced quality of life. Additionally, only a minority of study participants (2.6-4.5%) reported being free of any mental health problem. A previous study that included around 17,000 patients with areal-world data from Germany reported that 27.0% of the study sample were likely to have depression according to the WHO-5 scale [19]. Our study reported almost double of these results. However, it is important to highlight that depression is also a multifactorial disease and that several factors could initiate symptoms of depression [24]. The mental status of patients with diabetes is hugely affected by multiple factors including restriction of diet, lifestyle modifications, polypharmacy and anxiety and depression about the complications of the diseases as well [25][26][27].
Patients with diabetes usually suffer from mental and emotional issues which can affect the quality of life of these patients. These issues are likely to be due to disease and treatment-related complications including hypoglycaemia [28]. In our study, around 67.8% of the study participants reported that they have some possible diabetes-related emotional distress, with around 89.1% of the study participants reported being worried about the future and complications of diabetes. In addition, around 90.0% of the study sample had issues in coping with the complication of diabetes. These results were consistent with previous studies reporting that diabetes micro-and macrovascular complications have a negative impact on patients' quality of life [29,30]. Patients with diabetes are likely to have an increased risk of morbidity and mortality. Some of these complications may hugely affect the quality of life of patients with diabetes such as cardiac, neurological and nephrological complications [31,32].
Our study also showed that most of the study participants (83.4%) expressed fear of hypoglycaemia. Hypoglycaemic patients may experience fear and anxiety about future hypoglycaemic events, putting them in fear and distress. This was highlighted in a previous qualitative study that reported that hypoglycaemic concerns are significant in patients with diabetes [33]. In addition, a previous study that was conducted in Saudi Arabia reported an increased fear of hypoglycaemia among adolescents patients with diabetes [34], with similar other reviews reporting that fear of hypoglycaemia remains a major issue among patients with diabetes [35]. Due to the unpleasant aspects of hypoglycemia, diabetic patients become anxious and concerned about having recurrent and frequent hypoglycaemic events [23]. This might lead to changes in their treatment plan and considering less intensive antidiabetic therapy [4]. Additionally, diabetic patients at higher risk of developing hypoglycaemia might adopt over-compensatory behaviours in order to avoid the aversive symptoms of hypoglycaemic events, including treatment nonadherence (taking lower insulin dose) or skipping it [36].
Our results showed that patient's aged 31-35 and 41-45 years, with diabetes for 6-10 years, on insulin therapy, and hospitalized for hypoglycaemic episodes in the preceding six months were more likely to have poor mental wellbeing, diabetes-related emotional distress, and have fear of hypoglycaemia. These findings are consistent with previous research indicating that patients with more chronic diseases and more severe diseases are at an increased risk of developing poor mental health and quality of life [37]. Moreover, the study results corroborate prior research indicating that patients with younger age at diagnosis, longer duration of diabetes, and insulin therapy are more likely to develop poor mental health and quality of life [17,19].
Doctors and health care professionals must be aware of such results and more attention to hypoglycaemic events and complications must be made [38]. Public health awareness and preventions strategies must be provided for patients with diabetes mellitus.
This study has several strengths. First, it is the first study in Saudi Arabia that investigated the mental health status and the quality of life of patients with diabetes mellitus suffering from hypoglycaemia. Secondly, in this study, we used three validated scales to investigate the study's objective, which increased the reliability of our findings. This study, however, has some limitations. First, the study is a cross-sectional survey, which limits our ability to control for multiple factors. Second, our study sample was recruited through an online survey. However, our data collection occurred during the COVID-19 pandemic, during which the majority of Saudi citizens worked virtually and online. As a result, it is reasonable to assume that this will not affect the overall conclusion.

Conclusions
Depressive symptoms and reduced quality of life are common among patients with diabetes mellitus suffering from hypoglycaemia in Saudi Arabia. Future studies to investigate the factors associated with these symptoms are needed.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.