# Independent associations of mental health and diabetes complications with health‐related quality of life: Evidence from a cross‐sectional study

## TL;DR

This study finds that both diabetes complications and mental health significantly impact the quality of life for people with diabetes, with depression being the strongest predictor.

## Contribution

The study demonstrates that mental health factors contribute as much as diabetes complications to health-related quality of life in diabetes patients.

## Key findings

- Mental health factors like depression, diabetes distress, and fear of hypoglycaemia significantly reduce health-related quality of life.
- Diabetes complications such as neuropathy and diabetic foot syndrome also independently lower quality of life.
- Depression is the strongest predictor, reducing health-related quality of life by up to 21%.

## Abstract

Health‐related quality of life (HRQoL) is a key patient‐reported outcome in diabetes care, yet the extent to which somatic and psychological factors are associated with HRQoL remains unclear. This study examined how demographic, diabetes‐related, medical, and psychological factors were independently associated with HRQoL in adults with diabetes.

A cross‐sectional online survey was conducted among adults with diabetes in Germany (September 2024–February 2025). HRQoL was assessed using the EuroQol 5‐Dimension 5‐Level questionnaire (EQ‐5D‐5L). Participants also completed the PHQ‐8 for depressive symptoms, the problem areas in diabetes (PAID) scale, and the hypoglycaemia fear survey (HFS‐II). Clinical variables were self‐reported and included diabetes type, duration, HbA1c, body mass index (BMI), and complications. Tobit regression accounted for the censored EQ‐5D distribution. Blockwise multivariable models evaluated incremental explained variance across demographic, diabetes‐related, comorbidity, and mental‐health domains.

Of 1581 invitees, 734 completed the EQ‐5D (mean age 56 ± 14 years; 73% type I). In multivariable analyses, female sex (β = −0.045), higher BMI (β = −0.029), diabetic foot syndrome (β = −0.078), neuropathy (β = −0.123), and elevated depressive symptoms (β = −0.212), diabetes distress (β = −0.069), and fear of hypoglycaemia (β = −0.085) were all independently associated with lower EQ‐5D utilities (p < 0.01). Mental‐health variables explained a similar proportion of variance (≈22%) as diabetes‐related complications (≈20%). Mental health factors like depression, diabetes distress, and fear of hypoglycaemia showed highly significant associations with reduced HRQoL by up to 27%.

Both diabetes complications and mental health determine HRQoL in people with diabetes. Depression emerged as the strongest independent predictor reducing HRQoL by up to 21%. This underscores the importance of mental health for HRQoL. This findings highlight the relevance of integrating mental health assessment into diabetes management.