Patient empowerment and glycemic control among adults with type 2 diabetes in Madinah, Saudi Arabia

Abstract

Type 2 diabetes mellitus (T2DM) is a significant public health challenge in Saudi Arabia. While glycemic control (HbA1c) is a key management goal, psychosocial factors like patient empowerment are understudied in this context. This study aimed to investigate the relationship between patient empowerment and glycemic control among adults with T2DM in Madinah. This cross-sectional analytical study was conducted between February and June 2025 in 3 primary healthcare centers and 1 specialized diabetes hospital in Madinah. A total of 300 adults with T2DM were recruited via convenience sampling, where researchers approached eligible patients in clinic waiting areas. Data were collected using a structured questionnaire and electronic medical records. Patient empowerment was measured using the Diabetes Empowerment Scale-Short Form (DES-SF). Glycemic control was the primary outcome (most recent HbA1c). Statistical analysis included descriptive statistics, nonparametric tests (Mann–Whitney U, Kruskal–Wallis), Spearman’s correlation, and multivariate linear regression to identify independent predictors of HbA1c. The mean HbA1c level was 7.99% ± 1.95, and the mean DES-SF score was 3.64 ± 0.34. The final regression model was statistically significant (P = .001). After adjusting for confounders, higher patient empowerment was a significant predictor of lower HbA1c (B = −0.792, P = .015). Older age (B = −0.018, P = .034) and being an ex-smoker (B = −0.712, P = .018) were also associated with lower HbA1c levels. This study provides evidence that higher patient empowerment is independently associated with better glycemic control in a Saudi population. These findings underscore the clinical importance of integrating empowerment-based strategies into standard diabetes care to improve patient outcomes. Routine use of the DES-SF can help clinicians and the Ministry of Health identify patients with low empowerment who would benefit from targeted support. This research provides one of the few context-specific studies in the Middle East to explicitly link patient empowerment (quantified using the validated DES-SF) with objective glycemic outcomes (HbA1c) in a Saudi population. The study’s rigor is enhanced by its relatively large, multi-clinic sample (N = 300) and the use of multivariate regression to adjust for key confounders.

1. Introduction

Diabetes mellitus remains one of the most urgent public health issues of the 21st century, impacting both developed and developing countries. According to the International Diabetes Federation, an estimated 537 million adults were living with diabetes in 2024 worldwide, projected to reach 853 million by 2050. Among these cases, type 2 diabetes mellitus (T2DM) makes up about 90% of diagnoses worldwide, making it the most common form of the disease. This burden is closely linked to modifiable lifestyle factors such as physical inactivity, obesity, and unhealthy diet, and is further worsened by population aging and urbanization.^[1]

In the Kingdom of Saudi Arabia, T2DM is particularly prevalent. The International Diabetes Federation estimates that as of 2024, 23.1% of adults aged 20 to 79 years, approximately 5.3 million individuals, are living with diabetes, placing Saudi Arabia among the top 10 countries with the highest prevalence rates globally^[1] The burden of T2DM is reflected not only in terms of morbidity and mortality but also in its substantial economic impact. This is starkly evident within the Kingdom, where the direct health expenditure related to diabetes was estimated at a staggering USD 7.34 billion for the year 2024 alone. This vast local cost is driven by diabetes-related complications, such as cardiovascular disease, nephropathy, neuropathy, and retinopathy, which are major contributors to healthcare spending, disability, and reduced quality of life.^[1] This immense burden underscores the urgent need to identify not only biomedical but also psychosocial and behavioral determinants of diabetes outcomes, which are often underexplored in the Saudi context.

A cornerstone of diabetes management is glycated hemoglobin (HbA1c), which reflects average blood glucose over 2 to 3 months and predicts long-term risks of complications. The American Diabetes Association recommends an HbA1c target below 7% for diabetic patients, with thresholds individualized according to age, comorbidities, and hypoglycemia risk.^[2,3] While HbA1c is indispensable for clinical monitoring, it does not fully capture the behavioral and psychosocial dimensions that shape diabetes outcomes. Given its reliability and clinical significance, HbA1c was chosen as the primary outcome in this study to assess the relationship between psychosocial factors – particularly empowerment – and glycemic control.

Emerging evidence highlights that effective management requires more than pharmacological intervention; psychosocial and behavioral factors play a central role.^[4,5] A key psychosocial factor is patient empowerment, defined as the process of equipping individuals with the knowledge, skills, and confidence to manage their condition.^[6] In the context of diabetes care, empowerment extends beyond education by emphasizing self-efficacy, problem-solving, and shared decision-making. Systematic reviews and meta-analyses provide consistent evidence that empowerment-based interventions improve self-care behaviors.^[7,8] However, some studies report weaker or nonsignificant associations, suggesting that empowerment is a multidimensional construct not always directly linked to short-term glycemic outcomes. This discrepancy highlights the need for more context-specific investigations.

To better understand the intricate personal journey of patient empowerment, the Diabetes Empowerment Scale (DES) was developed in 2000 to measure an individual’s psychosocial self-efficacy. Initially, a comprehensive 37-item questionnaire covering 8 key dimensions of self-management was later refined into a robust 28-item scale. From this, the even more concise 8-item Diabetes Empowerment Scale-Short Form (DES-SF) was developed to provide a brief yet powerful assessment. This short form was carefully constructed by selecting the single most impactful item from each of the original 8 conceptual areas, such as coping with emotions and setting goals, ensuring the essence of the original scale was preserved. Its value was solidified in a study where, following a patient education program, participants’ DES-SF scores improved, as did their HbA1c levels. Critically, however, the changes in these 2 measures were not correlated, revealing that the DES-SF captures a vital and independent aspect of the diabetes experience – a person’s perceived confidence and ability to manage their condition – that is not reflected by clinical markers alone^.[6]

Despite the high prevalence of diabetes in the Middle East, few studies have applied the DES or DES-SF in this region. A survey from Oman assessed empowerment among patients with type 1 diabetes and demonstrated acceptable psychometric properties of the DES-SF; however, it did not focus on type 2 diabetes.^[9] To date, no published research from Saudi Arabia has quantitatively examined empowerment using the DES-SF. Existing research has primarily focused on health literacy, patient satisfaction, or self-management behaviors.^[10,11] This leaves a significant gap, as patient empowerment itself – a measurable psychosocial factor – has rarely been quantified or statistically linked to clinical outcomes. Consequently, validated instruments like the DES-SF have seen little to no use in the Saudi context.

Based on the existing literature, it was hypothesized that higher levels of patient empowerment would be significantly associated with better glycemic control (lower HbA1c levels) in this population. Therefore, this study aims to address this gap by using the validated DES-SF to investigate the relationship between patient empowerment and glycemic control (HbA1c) among adults with type 2 diabetes in Madinah.

This study is positioned to fill a critical gap in the literature. While the biomedical aspects of T2DM in Saudi Arabia are well-documented, there is a scarcity of research that quantitatively investigates the role of psychosocial factors such as patient empowerment. The high prevalence of diabetes in the Kingdom, combined with a healthcare model that has traditionally been more disease-centered, underscores the urgent need for a patient-centered perspective. By employing the validated DES-SF, this study aims to be one of the first in the region to formally measure patient empowerment and statistically link it to an objective clinical outcome, HbA1c. The findings are intended to provide actionable evidence for clinicians and policymakers to develop and implement empowerment-based interventions tailored to the Saudi cultural context, thereby enhancing diabetes management and potentially reducing the long-term burden of the disease.

2. Materials and methods

2.1. Study design and setting

This cross-sectional analytical study was conducted between February 2025 and June 2025 among adults with T2DM. Participants were recruited from 4 outpatient clinics within the government healthcare sector in Madinah, Saudi Arabia: 3 primary healthcare centers (Al-Hijrah PHC, Al-Difaa PHC, and Al-Aliah PHC) and King Fahad Hospital’s specialized diabetes center as those PHCs represent different regions in Madinah city.

The study aimed to measure diabetic patient empowerment and examine the association between patient empowerment and glycaemic control, as measured by glycated hemoglobin (HbA1c), and to identify other significant predictors of glycaemic outcomes in this population.

2.2. Study population

A total of 300 participants were recruited through convenience sampling. The research team approached potential participants in the waiting areas of the selected clinics. The purpose and procedures of the study were explained, eligibility was confirmed, and written informed consent was obtained from all individuals before their enrollment. Inclusion criteria were a confirmed diagnosis of T2DM, and an age of 18 years or older. Individuals with Type 1 diabetes, gestational diabetes, or any cognitive impairment that could interfere with completing the questionnaire were excluded. Ethical approval for the study was obtained from the General Directorate of Health Affairs in Al-Madinah (Institutional Review Board log No: 25-006) on 28-1-2025, and informed consent was obtained from all participants before enrollment.

2.3. Sample size

The required sample size for this study was calculated using Cochran’s formula for large populations: n = (Z² × P × (1 − P))/E². Based on a 95% confidence level (Z = 1.96), a 5% margin of error (E = 0.05), and a conservative population proportion estimate of 50% (P = .5), the minimum required sample size was determined to be 385 participants.

During the data collection period, a total of 385 surveys were collected. After carefully reviewing the collected data, surveys were excluded if they had a significant amount of missing information on key variables, such as the empowerment scale or HbA1c levels, or if they did not meet all eligibility criteria upon final verification. This data cleaning process resulted in a final analytical sample of 300 complete and valid responses. A post hoc power analysis indicated that this sample size provided over 80% power to detect medium effect sizes in the final regression model.

2.4. Data collection instruments and measures

Data was collected using a structured questionnaire and a review of participants’ electronic medical records. Eligible patients were approached in clinic waiting areas. After obtaining informed consent, participants either completed the questionnaire through direct interview or via an online survey accessed through a QR code. During self-administration, the researcher was present to assist and ensure the completeness of the task. Sociodemographic data included age, sex, marital status, education, income, employment, and smoking status. The primary outcome, HbA1c, was extracted directly from electronic medical records to ensure accuracy.

Patient empowerment was assessed using the DES-SF, a validated 8-item instrument scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). The original English version demonstrated strong reliability (Cronbach’s α = 0.84)^[6] The Arabic version, validated in an Omani population, showed good internal consistency (Cronbach’s α ≈ 0.82) and construct validity^[9] Based on this evidence, the Arabic DES-SF was adopted without re-validation. Higher scores reflect greater self-efficacy and perceived control in diabetes management.

2.5. Statistical analysis

All statistical procedures were conducted using IBM SPSS Statistics for Windows, version 27.0.1 (IBM Corp., Armonk). A P-value < .05 was considered statistically significant for all inferential analyses.

2.5.1. Descriptive statistics

Descriptive statistics summarized sample characteristics. Frequencies and percentages were reported for categorical variables, while means and standard deviations or medians and interquartile ranges (IQR) were used for continuous variables, depending on distribution. Normality was assessed using the Kolmogorov–Smirnov test, which indicated non-normal distribution; thus, nonparametric tests were applied.

The Mann–Whitney U test compared median HbA1c levels between 2 groups, and the Kruskal–Wallis test was used for comparisons across multiple groups. Spearman’s rank-order correlation assessed associations between HbA1c and continuous or ordinal variables. These methods were selected for their robustness with skewed and ordinal data.

To identify independent predictors of glycemic control, a 2-step multivariate linear regression was conducted with HbA1c as the dependent variable. The initial model included sociodemographic, clinical, and psychosocial variables based on theoretical relevance. A final parsimonious model retained only statistically significant predictors. Regression coefficients (B), 95% confidence intervals, and P-values were reported. Model fit was evaluated using R² and the F-statistic.

3. Results

3.1. Sociodemographic, clinical, and behavioral characteristics

The final sample consisted of 300 adults diagnosed with T2DM. Overall, the cohort exhibited suboptimal glycemic control, with a mean HbA1c of 7.99% ± 1.95. The mean DES-SF score was 3.64 ± 0.34, indicating a moderate level of perceived empowerment. Table 1

Table 1.

Sociodemographic, clinical, and behavioral characteristics of the participants (N = 300).

		Mean	SD
Age (yr)		52.04	12.93
Duration of diabetes (yr)		11.34	7.06
Last random blood sugar (RBS; mg/dL)		143.36	45.01
HbA1c (%)		7.99	1.95
Empowerment score (1–5 scale)		3.64	0.34

		N	%
Gender	Female	181	60.3
	Male	119	39.7
Marital status	Married	209	69.7
	Single	26	8.7
	Divorced	9	3.0
	Widow	56	18.7
Educational level	Less than high school	132	44.0
	High school	43	14.3
	Diploma	15	5.0
	Bachelor’s	61	20.3
	Postgraduate studies	49	16.3
Monthly income (Saudi Riyals)	<5000	129	43.0
	5000 and 10,000	59	19.7
	10,000–20,000	72	24.0
	>20,000	40	13.3
Job status	Full-time employee	57	19.0
	Unemployed	16	5.3
	Housewife	113	37.7
	Retired	106	35.3
	Student	8	2.7
Smoking status	Ex-smoker	50	16.7
	Nonsmoker	220	73.3
	Current smoker	30	10.0

HbA1c = glycated hemoglobin (or glycated haemoglobin), RBS = random blood sugar, SD = standard deviation.

3.2. HbA1c levels and sociodemographic/behavioral characteristics

Univariate comparisons of HbA1c across sociodemographic and behavioral subgroups are presented in Table 2. Most factors, including gender, marital status, education, income, and job status, showed no significant association with HbA1c levels. Smoking status emerged as the only significant variable in these analyses (P = .029).

Table 2.

Comparison of HbA1c levels by sociodemographic and behavioral characteristics.

		HbA1c
		Mean	SD	Median	IQR	P value†/‡
Gender	Female	8.02	1.95	7.70	6.50–9.30	.615
	Male	7.94	1.97	7.50	6.30–9.20
Marital status	Married	7.94	1.99	7.50	6.40–9.20	.062
	Single	8.58	1.87	8.45	7.30–10.10
	Divorced	6.82	1.09	6.90	5.90–7.60
	Widow	8.09	1.90	7.60	6.60–9.20

		HbA1c
		Mean	SD	Median	IQR	P value†/‡
Educational level	Less than high school	8.01	1.91	7.75	6.45–9.20	.819
	High school	8.07	2.14	7.40	6.50–9.10
	Diploma	8.34	2.00	7.60	6.80–9.40
	Bachelor’s	7.76	1.89	7.40	6.20–8.90
	Postgraduate studies	8.04	2.01	7.70	6.40–9.40
Monthly income (Saudi Riyals)	<5000	8.04	2.01	7.80	6.50–9.30	.971
	5000 and 10,000	7.99	1.92	7.80	6.30–9.30
	10,000–20,000	7.87	1.87	7.35	6.50–9.05
	>20,000	8.02	2.05	7.50	6.30–8.85
Job status	Full-time employee	8.08	1.97	7.50	6.80–9.20	.070
	Unemployed	7.46	1.58	7.30	6.20–8.05
	Housewife	8.28	1.92	8.00	6.90–9.40
	Retired	7.79	2.04	7.30	6.10–9.00
	Student	6.98	1.26	6.40	6.15–7.70
Smoking status	nonsmoker	8.05	1.86	7.60	6.60–9.20	.029*
	Current Smoker	8.59	2.65	7.65	6.30–10.10
	Ex-smoker	7.37	1.77	7.10	5.70–8.20

HbA1c = glycated hemoglobin (or glycated haemoglobin), IQR = interquartile range, SD = standard deviation.

^*P < .05, significant.

^†Independent Samples Mann–Whitney U test.

^‡Independent Samples Kruskal–Wallis test.

3.3. Correlation between HbA1c and clinical and psychosocial measures

Spearman’s rank correlation analysis was employed to assess the relationships between HbA1c and key continuous variables. Consistent with clinical expectations, a statistically significant positive correlation was observed between HbA1c and random blood sugar levels (r = 0.149, P = .010), indicating that elevated random blood sugar is moderately associated with poorer long-term glycaemic control (Table 3).

Table 3.

Spearman’s correlation coefficients between HbA1c and clinical and psychosocial measures.

Correlations
			HbA1c
Spearman’s ρ	Age (yr)	Correlation coefficient	−.100
		Sig. (2-tailed)	0.085
		N	300
	Duration of diabetes (yr)	Correlation coefficient	−0.064
		Sig. (2-tailed)	0.269
		N	300
	Last RBS** (mg/dL)	Correlation coefficient	0.149*
		Sig. (2-tailed)	0.010*
		N	300
	Empowerment	Correlation coefficient	−0.109
		Sig. (2-tailed)	0.060
		N	300

HbA1c = glycated hemoglobin (or glycated haemoglobin), RBS = random blood sugar.

^*Correlation is significant at the 0.01 level (2-tailed).

^**RBS = random blood sugar.

Age demonstrated a weak negative correlation with HbA1c (r = −0.100, P = .085), although this association did not reach statistical significance. The duration of diabetes also showed no significant correlation with HbA1c (r = −0.064, P = .269). Detailed descriptive scores and correlation coefficients for the 8 individual items of the DES-SF are presented in Table S1, Supplemental Digital Content 1

The overall status of patient empowerment, encompassing descriptive statistics, correlation with HbA1c, and its role as an independent predictor in the final model, is consolidated in Table 4. The mean DES-SF score for the cohort was 3.64 ± 0.34, reflecting moderate perceived empowerment. While the unadjusted Spearman’s correlation between the aggregate empowerment score and HbA1c approached significance (P = .060), the subsequent multivariate analysis confirmed its critical role as a predictor of glycemic control. Table 4

Table 4.

Relationship between patient empowerment and HbA1c levels.

Variable	Mean (SD)	Spearman’s ρ with HbA1c	P-value (correlation)	Regression coefficient (B)		Std. error	β	P-value (regression)
Empowerment Score	3.64 (0.34)	−0.109	0.0604		−0.792	0.3235	−0.139	0.015*

HbA1c = glycated hemoglobin (or glycated haemoglobin), SD = standard deviation.

^*Spearman’s correlation indicates a weak negative association. Multivariate regression shows empowerment is a significant predictor of lower HbA1c levels (adjusted for age and smoking status).

3.4. Multivariate linear regression predicting HbA1c from age, empowerment, and smoking status

The final multivariate linear regression model explained 5.9% of the variance in HbA1c and was statistically significant (R² = 0.059, P = .001). As shown in Table 5, higher patient empowerment (B = −0.792) was confirmed as a significant independent predictor of lower HbA1c levels (P = .015). Older age and being an ex-smoker were also significant independent predictors.

Table 5.

Multivariate linear regression predicting HbA1c from age, empowerment, and smoking status.

Model		Unstandardized coefficients		Standardized coefficients	t	95% Confidence interval for B		P-value
		B	Std. error	β		Lower bound	Upper bound
Age (yr)		−.018	.009	−.120	−2.127	−.035	−.001	.034*
Empowerment		−.792	.323	−.139	−2.452	−1.428	−.156	.015*
Smoking Status	Nonsmoker	Ref	Ref	Ref	Ref	Ref	Ref	Ref
	Current Smoker	.496	.372	.076	1.333	−.236	1.227	.183
	Ex-smoker	−.712	.300	−.136	−2.378	−1.302	−.123	.018*

Model summary: R² = .059, F(4, 295) = 4.65, P = .001. Ref = Reference Group.

HbA1c = glycated hemoglobin (or glycated haemoglobin).

^*Dependent variable: HbA1c.

4. Discussion

In this cross-sectional study of Saudi adults with type 2 diabetes, higher empowerment scores showed a weak, nonsignificant correlation with HbA1c, but became a significant independent predictor after adjustment in the regression model. Older age was also linked to better glycemic control, while smoking status showed an unusual pattern: ex-smokers had lower HbA1c than both current smokers and never-smokers. These findings persisted after adjusting for potential confounders and directly address the objectives of our study.

4.1. Empowerment and glycemic control

Although the simple correlation between empowerment (measured by DES-SF) and HbA1c was weak, our regression model indicated that empowerment remained an independent predictor of lower HbA1c after adjusting for age and smoking. Patients with higher empowerment scores reported lower HbA1c, suggesting that confidence, knowledge, and self-management skills translate into measurable metabolic benefits. Similar findings were reported by D’Souza et al, who found that empowerment was an independent predictor of reasonable glycemic control (β ≈ 0.657, P = .001).^[12] An extensive US survey (n = 1258) also demonstrated a modest but significant correlation between DES-SF scores and glucose (ρ ~–0.18). However, the effect size was limited, likely due to the high level of empowerment in that sample^.[13]

Our findings align with a growing body of international literature. For instance, a study in Iran by Babazadeh et al found that self-care behaviors were significant predictors of glycemic control.^[14] While our study measured empowerment – a precursor to behavior – and theirs measured the behaviors themselves, both highlight the critical pathway from psychosocial attributes to clinical outcomes. Empowerment provides the confidence and self-efficacy needed to perform consistent self-care (e.g., medication adherence, diet), which in turn improves HbA1c. Our study suggests that interventions in the Saudi context should focus on building this foundational empowerment. Similarly, a study in Turkey by Sürücü et al found that higher patient empowerment was a significant predictor of lower HbA1c levels, reinforcing that patients who feel more in control of their condition achieve better metabolic results.^[15]

In our cohort, the mean DES-SF score was 3.6/5, reflecting moderate empowerment. This is similar to the cohort from Pakistan (mean 3.62)^[16] and Portugal (67.9/100) on a 0 to 100 transformed DES-SF (≈3.7/5),^[17] but lower than a digitally engaged US population (≈4.0).^[13] To date, no Saudi studies have reported DES-SF scores; however, related measures, such as self-efficacy, show consistent patterns. This highlights the opportunity for structured empowerment-based interventions in Saudi clinical practice.

Intervention trials support our findings. A recent meta-analysis of 15 randomized controlled trials (RCTs; 2344 patients) showed that empowerment-based programs significantly reduced HbA1c compared to usual care (standardized mean difference −0.20, 95% confidence intervals: −0.31 to −0.08), improving empowerment and diabetes knowledge.^[18] Taken together, both observational and experimental evidence suggest a plausible causal pathway: empowering patients through collaborative goal setting, psychosocial support, and skills training enhances self-care and glycemic outcomes.

However, not all studies have found strong effects. Clark et al found that empowerment and motivation showed only weak relationships with HbA1c, despite being high at baseline.^[13] This suggests that empowerment may be necessary but not sufficient on its own; instead, it works in concert with other psychosocial and clinical factors. In our setting, we did not directly measure intermediate behaviors; however, prior Saudi research supports this pathway. Al-Hayek et al reported that patients with poor HbA1c control had significantly lower medication adherence and higher diabetes-related distress.^[19] This reinforces the idea that empowerment influences glycemic control indirectly through adherence, consistency, and effective coping mechanisms.

4.2. Age and glycemic control

Older age was associated with better HbA1c outcomes in our study. While counterintuitive, given longer disease duration and comorbidities, this finding is supported by evidence from Iran, where patients aged 60 years or older had lower odds of poor control,^[20] and Korea, where the oldest patients (70–79 years) had significantly better HbA1c levels than middle-aged adults.^[21] Saudi multi-center data echo this trend: Alramadan et al identified age (≤60) as a risk factor for poor control.^[22]

Several mechanisms may explain this paradox. One likely factor is the intensity of treatment and adherence. Older patients in clinical practice may receive more intensive therapy or closer monitoring because clinical inertia is overcome later in life. Indeed, the authors of the Iranian study posited that greater attention is often paid to medication management in older adults, which could lead to better glucose control in this group.^[20] Younger adults, in contrast, might experience more lifestyle pressures (work, family responsibilities) and risk-taking behaviors that impede optimal diabetes self-management. It is also possible that some younger patients have more aggressive disease phenotypes (e.g., early-onset type 2 diabetes is often accompanied by obesity and high insulin resistance), making control harder. By the time patients reach older age, those with extremely poor control may have suffered complications or attrition (“survivor bias”), and the remaining cohort includes many who have adapted to the disease and adhered to treatment.

4.3. Smoking status

Our study found that ex-smokers had better glycemic control than both current smokers and never-smokers. This observation should be interpreted with caution, as it may reflect behavioral changes following smoking cessation or residual confounding. Because our data are cross-sectional, temporality cannot be established. Current smokers had the highest HbA1c, consistent with substantial evidence that smoking worsens hyperglycemia through insulin resistance and β-cell toxicity.^[23] Interestingly, ex-smokers had the lowest HbA1c, even outperforming never-smokers.

Active smoking is well-documented to impair glycemic control. For example, a US cross-sectional study of 282 patients with T2D found that current smokers had significantly higher HbA1c than both former and never-smokers, with smoking status emerging as an independent predictor of poor control.^[24] Mechanistic studies support these findings: nicotine reduces insulin sensitivity, increases counter-regulatory hormones, damages pancreatic β-cells, and exerts vasoconstrictive and pro-inflammatory effects, all of which disrupt metabolic regulation.^[23]

The observation that ex-smokers achieved better control than never-smokers has been reported in some studies, though it is not universal. One explanation is that quitting smoking often coincides with broader lifestyle improvements – diet, activity, and medication adherence – which may provide an advantage over individuals who never smoked but did not undergo such behavioral change. A Korean study, for instance, found that ex-smokers had slightly lower HbA1c than never-smokers (5.49% vs 5.52%) despite both being nondiabetic.^[25] Although that difference was slight, it suggests that quitting eliminates the glycemic burden of smoking and may even confer metabolic benefits over a lifetime of never smoking – perhaps because long-term never-smokers include individuals who later develop diabetes due to other risk factors. Another contributing factor could be that smokers who develop diabetes and then quit might have had to do so due to health complications, and those who successfully quit are often closely engaged with healthcare interventions (smoking cessation programs, frequent follow-ups), which can improve glycemic management via better education and monitoring.

It is important to interpret this result with caution. Not all research finds ex-smokers doing better than never-smokers; in many analyses, never-smokers have the lowest risk, and ex-smokers lie in between as intermediates.^[26] Although we adjusted for major confounders, residual confounding remains a possibility. Moreover, ex-smokers often experience weight gain after cessation, which can worsen glycemic control, especially in the short term.^[23] Controlled trials yield mixed results: a Chinese RCT of diabetic smokers found that smoking cessation did not significantly change HbA1c after 1 year, despite clear cardiovascular benefits.^[23,27] These findings suggest that any glycemic benefits of quitting may be offset by weight gain or that benefits accrue only over a longer time horizon. Indeed, some longitudinal studies indicate that HbA1c levels improve gradually in the years following smoking cessation, once weight stabilizes.^[23]

Mechanistically, cessation removes the acute metabolic strain of smoking – reduced catecholamine surge, oxidative stress, and endothelial dysfunction – which should improve insulin sensitivity. Preventing excessive post-cessation weight gain is likely crucial to realizing these benefits^[23] In our sample, the superior control among ex-smokers suggests that the advantages of quitting outweigh the downsides. This underscores the need for comprehensive care: cessation programs should be paired with dietary and physical activity support to minimize weight gain, given the well-documented vascular and renal benefits of smoking cessation in diabetes.^[23] Our findings provide an additional motivational message – quitting smoking is not only protective against complications but may also support better glycemic control in the long run.

4.4. Strengths and limitations

This study has several strengths. It included a relatively large sample from multiple clinics in Madinah, used a validated empowerment scale (DES-SF) to quantify a psychological construct, and adjusted for key confounders when examining associations. To our knowledge, this is one of the few studies in the region to explicitly link empowerment with objective glycemic outcomes in a Middle Eastern diabetes population. Findings were interpreted in light of robust international evidence, including RCTs and meta-analyses, which enhances their credibility and external relevance.

Nevertheless, limitations must be acknowledged. First, the cross-sectional design prevents causal inference; it is possible that patients with better glycemic control feel more empowered, rather than empowerment leading to improved control. Furthermore, the reduced sample size (300 instead of the planned 385) may have limited the statistical power to detect smaller associations and could constrain the generalizability of the findings.

Longitudinal studies or intervention trials are needed to clarify directionality. Second, residual confounding is likely, as unmeasured factors such as diet, physical activity, diabetes education, and social support could influence both empowerment and HbA1c. Third, smoking data lacked detail on duration and intensity, which may affect outcomes. Finally, generalizability and reliability may be limited: all participants were from Saudi Arabia, and cultural norms may influence empowerment and self-care differently compared with other regions; besides, the convenience sample was taken.

4.5. Policy and practice implications

This study underscores the importance of integrating empowerment-focused strategies into routine diabetes care in Saudi Arabia. The observed association between patient empowerment and HbA1c supports expanding diabetes self-management education beyond knowledge transfer to include confidence-building, problem-solving, and self-efficacy. Clinicians should incorporate techniques such as motivational interviewing and shared decision-making. Routine use of the DES-SF can help identify patients with low empowerment who may benefit from targeted support^.[28]

At the policy level, the Ministry of Health could adopt validated tools like the DES-SF to systematically identify and assist vulnerable patients^.[28] Community-based interventions, including peer-led education and support groups – especially those tailored for Saudi women – have demonstrated effectiveness in improving empowerment and glycemic outcomes^[28,29] Institutionalizing such programs may enhance clinical outcomes, patient satisfaction, and quality of life.

Age-specific strategies are also warranted. Younger adults, who exhibit poorer glycemic control, may benefit from digital health solutions such as mobile apps, continuous glucose monitoring with feedback, and flexible clinic scheduling^.[30,31] Workplace wellness initiatives could further support this group. Conversely, older adults may require individualized glycemic targets, geriatric assessments, and complication management, as optimal HbA1c does not eliminate other risks.^[20]

Smoking cessation should be embedded within diabetes care. Clinicians must routinely assess smoking status and provide counseling, pharmacologic aids, and behavioral support. The superior glycemic outcomes among ex-smokers in this study can serve as a motivational tool. However, post-cessation weight management should also be addressed. Policymakers could strengthen tobacco control efforts targeting diabetic populations and train educators in cessation techniques. Public campaigns should emphasize the dual harm of smoking in diabetes and highlight the metabolic and cardiovascular benefits of quitting^.[32]

5. Conclusion

This study demonstrates that higher patient empowerment, older age, and smoking cessation are independently associated with improved glycemic control among adults with type 2 diabetes in Saudi Arabia. These findings align with global evidence while offering context-specific insights for local healthcare systems.

Clinically, patient empowerment should be central to diabetes care. Health teams can foster it through structured self-management education, shared decision-making, and motivational interviewing. Targeted support is especially needed for younger adults and current smokers, who are at greater risk of poor control.

At the policy level, integrating empowerment-based programs and smoking cessation services into national diabetes care pathways may enhance outcomes and reduce complications. Validated tools such as the DES-SF can help identify patients requiring tailored interventions.^[28]

Future research should focus on longitudinal and interventional designs to clarify causal pathways – such as whether empowerment directly improves self-care and HbA1c – and to evaluate tailored models like youth-focused clinics or empowerment training modules.

Ultimately, effective diabetes management requires a holistic approach that addresses psychosocial and behavioral factors alongside clinical care. By doing so, health systems can improve not only biomedical outcomes but also patient confidence, resilience, and quality of life.^[20,28]

Acknowledgments

This scientific paper is derived from a research grant funded by Taibah University, Madinah, Kingdom of Saudi Arabia, with grant number 447-16-1174.

Author contributions

Conceptualization: Bayan Ali Shekiri.

Data curation: Bayan Ali Shekiri, Ahmad Mohammadsaleh Albediny, Ajaeb Meshal Alharbi, Ibtisam Naji Mohammad.

Formal analysis: Bayan Ali Shekiri, Ahmad Mohammadsaleh Albediny.

Investigation: Bayan Ali Shekiri.

Methodology: Bayan Ali Shekiri, Amal Mohammed Q. Surrati.

Project administration: Bayan Ali Shekiri, Amal Mohammed Q. Surrati.

Supervision: Amal Mohammed Q. Surrati.

Writing – original draft: Bayan Ali Shekiri.

Writing – review & editing: Amal Mohammed Q. Surrati.