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The prevalence and predictors of
diabetes in a private health insurance
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scheme: An analysis of three million

beneficiaries in Saudi Arabia
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Website:
www.jfcmonline.com Nasser Aljehani, Suliman Alghnam1, Ada Alqunaibet2, Shehana Alwahabi3,
DOI:
Husein Reka4, Rimah Almohammed5, Abdullah Almaghrabi4, Shabab Alghamdi6
10.4103/jfcm.jfcm_139_23

Abstract:
BACKGROUND: Noncommunicable diseases (NCDs) are a leading threat to population health in
Saudi Arabia. Addressing NCDs is a priority for health‑care transformation, and understanding the
Department of
current disease prevalence is crucial. The prevalence in other settings is unknown because studies
Enablement, Council have relied on data from households or public health‑care institutions. This study aims to investigate
of Health Insurance, the prevalence and predictors of diabetes in the privately insured population.
1
Department of Population MATERIALS AND METHODS: This retrospective study explored the prevalence and predictors of
Health, King Abdullah diabetes in beneficiaries aged 15 years or older who sought medical care in 2022. Data were sourced
International Medical
from the National Platform for Health and Insurance Exchange Services, a unified health insurance
Research Center, King
Saud Bin Abdulaziz claim platform. We used the International Classification of Disease‑10 to capture the condition. To
University for Health identify predictors of diabetes, we employed a backward selection approach for logistic regression.
Sciences, King Abdulaziz RESULTS: Over 3.3 million beneficiaries sought medical care during the study. The population was
Medical City, 2Public relatively young aged 26–39 years, (47.5%) and two‑thirds of males. The prevalence of diabetes was
Health Intelligence, 11.0% and varied across regions, with the highest in Bahah (18.4%) and the lowest in Jizan (9.5%).
Saudi Public Health
Age, gender, nationality, insurance company size, body mass index, region, hypertension, and
Authority, 3Department
of Data Management coronary heart disease were significant predictors of diabetes. Hypertensive patients were over
and Artificial Intelligence, five times more likely to have diabetes than those without hypertension (odds ratio OR = 5.08;
Council of Health 95% confidence interval CI = 5.02–5.24). Saudis were 30% more likely to have diabetes than other
Insurance, 4Department nationalities (OR = 1.3; 95% CI = 1.28–1.31).
of Policy Development,
CONCLUSION: We found a higher prevalence of diabetes in privately insured beneficiaries than
Council of Health
Insurance, 5Research
the recent national estimate. This necessitates population health management strategies at all
and Development levels (primary, secondary, and tertiary) to mitigate the burden of diabetes in privately insured
Section, Council of Health individuals. This study provides valuable baseline data for the prevalence of diabetes in this
Insurance, 6Secretary population and emphasizes the urgent need for targeted interventions, especially in regions with a
General Office, Council of higher prevalence.
Health Insurance, Riyadh,
Keywords:
Saudi Arabia
Diabetes, epidemiology, prevalence, private health insurance, risk factors, Saudi Arabia
Address for
correspondence:
Dr. Suliman Alghnam,
King Abdullah International Introduction the many NCDs, diabetes mellitus (DM) is
Medical Research of growing concern because of its prevalence
Center, King Saud Bin
Abdulaziz University for
Health Sciences, King
N oncommunicable diseases (NCDs)
threaten population health in many
countries, Saudi Arabia not excepted.[1] Of
and association with adverse health
outcomes, such as cardiovascular disease,
renal disease, eye and nerve damage, and
Abdulaziz Medical City,
National Guard Health mortality.[2,3] Various risk factors of DM,
Affairs, Riyadh 11312, This is an open access journal, and articles are
Saudi Arabia. distributed under the terms of the Creative Commons
E‑mail: alghnam.s@gmail. Attribution‑NonCommercial‑ShareAlike 4.0 License, which How to cite this article: Aljehani N, Alghnam S,
com allows others to remix, tweak, and build upon the work Alqunaibet A, Alwahabi S, Reka H, Almohammed R,
non‑commercially, as long as appropriate credit is given and the et al. The prevalence and predictors of diabetes in
Received: 30‑05‑2023 new creations are licensed under the identical terms. a private health insurance scheme: An analysis of
Revised: 30‑10‑2023 three million beneficiaries in Saudi Arabia. J Fam
Accepted: 13‑11‑2023 Community Med 2024;31:36-41.
Published: 08-01-2024 Forreprintscontact:[email protected]

36 © 2024 Journal of Family and Community Medicine | Published by Wolters Kluwer - Medknow
 Aljehani, et al.: Prevalence and predictors of diabetes in a private health insurance scheme in Saudi Arabia

such as sedentary lifestyle have increased. As a result, of the prevalence, and burden of DM in the private sector
the disease has increased in prevalence in the past is urgent.
several decades.[4‑9] Nevertheless, there are no consistent
estimates for its prevalence in Saudi Arabia, as the latest Therefore, the aim of the present study was to describe
published estimate from the Ministry of Health hovers the prevalence and risk factors for DM of privately
around 8.0%. In contrast, early national estimates suggest insured beneficiaries in Saudi Arabia. Of particular
that as many as 13.2% of adults have DM.[4,9] importance is the understanding of disease prevalence
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in different segments of the population, including

The Saudi Vision 2030 has prioritized NCDs to improve non‑Saudi workers. This group represents the majority
population health, life expectancy, and quality of life.[10] of beneficiaries covered under CHI. Findings from
As a part of the Vision, the Saudi Council of Health this study can inform policymakers, clinicians, and
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Insurance (CHI), the regulatory body tasked with researchers about the underlying burden to guide
regulating health insurance in Saudi Arabia, has devised prevention programs that can improve health outcomes
a Population Health Management strategy focusing on and reduce health‑care expenditures.
five conditions over the next 5 years.[10] The targeted
conditions include DM, hypertension, obesity, coronary Materials and Methods
heart disease (CHD), and smoking.
This retrospective study examined individuals with
Several lines of evidence suggest that understanding private health insurance coverage from January 1 to
the underlying burden of DM in various population December 31, 2022. The investigation focused on those
segments is vital for the provision of adequate who sought medical care and for whom hospitals
health‑care resources.[11,12] Privately insured individuals submitted health insurance claims for services provided
in Saudi Arabia may differ from the overall population during that year. In 2022, there were 24 health insurance
in terms of age, gender, or other factors owing to being companies varying in size from small firms insuring a few
on employer‑based compulsory health insurance. This thousand beneficiaries to major corporations covering
population represents 32% of the overall population, millions. We classified insurers as large (more than
with more than 11 million beneficiaries, with prospects 500,000 beneficiaries) and small or medium (<500,000
of this population increasing to 22 million beneficiaries beneficiaries). In fact, the two largest companies insured
by 2030.[13] Therefore, understanding the disease burden over half of the covered population in 2022. Ethical
of this population is crucial to moving a reactive approval was obtained from the Institutional Review
curative health‑care model to a proactive one that Board vide letter No. IRB/0589/22 dated 17/03/2022
focuses on population health. Thus, epidemiological with a waiver of informed consent since there was no
data are needed to set the underlying burden of various direct contact with human subjects in this study.
population segments and monitor the trend over time.
National surveys by the Ministry of Health provide Data for the study were sourced from the National Platform
insights into the overall burden.[4] However, they are for Health and Insurance Exchange Services (NPHIES),
resource‑intensive, time‑consuming, and capture only a a unified health insurance claim platform.[18] NPHIES
broad snapshot without segmenting the population.[14] is a standardized platform that processes all health
Thus, utilizing secondary data sources to examine disease insurance claims based on a mandatory Minimum Data
burden has gained interest in recent years.[15] With Set (MDS). The MDS includes patient‑level information
its large target population, CHI represents the most on diagnosis, procedures, medications, and claim values.
significant source of administrative data on disease
prevalence in the country without national surveys. A diabetic patient was identified as having an
International Classification of Disease 10 diagnosis of
Despite the importance of understanding the underlying DM (ICD = E10‑E14, excluding gestational diabetes).
burden of DM in various population segments in All types of DM except for gestational diabetes were
Saudi Arabia, all studies have examined the prevalence included in the study and further stratified during the
of DM using data from governmental hospitals. In analysis.
particular, the prevalence in private healthcare settings
has not been examined;[16,17] although there have been Data were extracted from the electronic database of
several studies using data from governmental hospitals. the CHI. Microsoft® Structured Query Language was
Considering the rise in the prevalence of DM and the employed to determine cases based on predefined ICD‑10
associated adverse health outcomes, the magnitude of the codes for diagnosis. Demographic variables such as age,
difference between the insured and the total population, gender, nationality, insurance provider, and region were
the lack of consistent estimates of the prevalence of DM, also extracted. Furthermore, clinical parameters such as
particularly in the private sector context, the examination weight, height, hypertension (ICD‑10: I10‑I15), and CHD
Journal of Family and Community Medicine - Volume 31, Issue 1, January-March 2024 37
 Aljehani, et al.: Prevalence and predictors of diabetes in a private health insurance scheme in Saudi Arabia

were obtained. Cardiac patients are those diagnosed There was a variation in the prevalence of DM in the
with ischemic heart diseases using the ICD‑10 codes: regions in Saudi Arabia [Figure 1]. The highest prevalence
I20‑I25. We calculated body mass index (BMI) based on of DM was in the Bahah region (18.4%), whereas the
weight and height variables extracted from the NPHIES lowest was in Jizan (9.5%). Whereas the high estimate
database. The equation is the weight (in kg) divided by in Bahah was consistent with the national average, the
height (in meters squared). The latest measurement was lowest prevalence was not. The prevalence of DM in
used because it was possible that the database included the Western regions was similar (Makkah = 13.5% and
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all the weight and height measurements for every visit Madinah = 14.2%) but slightly lower in the Eastern
to a health‑care facility. Subjects were categorized Region (12.8%).
using the Centers for Disease Prevention and Control
as underweight (BMI <18.5), normal (BMI = 18.5–24.9), In the regression analysis, all variables included in the
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overweight (BMI = 25–29.9), or obese (≥30).[19] initial model remained significant and were retained
in the final model [Table 2]. Patients aged 40–64 years
STATA 17 (StataCorp LLC, College Station, TX) was were over six times more likely to suffer from DM than
utilized as the Statistical Package for all Statistical those between 15 and 18 (odds ratio [OR] =6.2; 95%
Analyses. Descriptive statistics and frequency tables confidence interval [CI]: 5.9–6.5). On the other hand,
were generated to characterize the demographics and a much smaller effect was found when males were
disease prevalence in the population. Chi‑square tests 10% more likely to suffer from DM than females. Higher
and Cramer V estimates were calculated by diabetes BMI was significantly associated with increased odds
status and presented. Region‑specific prevalence rates of DM. Obese patients were three times more likely
were calculated for each region and compared with the to suffer from DM than those underweight (OR = 3.0;
national estimates from the latest Ministry of Health 95% CI: 2.8–3.1). Moreover, hypertension was
World Survey.[4] associated with five‑fold increased odds of DM
compared with those without hypertension (OR = 5.1;
A logistic regression model with a backward selection
95% CI: 5.0–5.2).
approach was constructed to identify DM predictors. This
method includes all potential predictors, retaining those
below the statistical threshold. Insurance category was
Discussion
not considered in the regression model as it could reflect
We found a higher prevalence of DM than the recent
the underlying population served rather than being a
national estimate reported in Saudi Arabia. This is
predictor of DM. The cutoff for maintaining variables
concerning because it is expected that since the younger
in the model was a P < 0.1. Age, gender, BMI, CHD,
and working population constitutes most of the insured
hypertension, insurance provider, and region were all
population, their health should be better than the overall
treated as categorical variables in the model. A P < 0.05
population. Nevertheless, reports before 2019 in Saudi
was established as the cutoff for statistical significance.
Arabia suggested a higher DM prevalence than 8.0%.[9]
Nonetheless, population health management approaches
Results
are needed to facilitate prevention at all levels of the
Over 3.3 million beneficiaries sought medical care privately insured population (primary, secondary, and
during the study period. The population was relatively tertiary).[20]
young (26–39 years, 47.5%), and around two‑thirds were
males [Table 1]. Of those with complete weight and 30
height data, 38.2% were overweight and 36.4% were 25
obese patients. Over 400 thousand (11.0%) were seen by 20
a physician for diabetes‑related conditions. Those with
15
DM were more likely to be older males, and a little over
half were non‑Saudis. In addition, over a third of the 10

diabetic population was obese, whereas the prevalence 5

of obesity among nondiabetics was 17.9% (P < 0.01). 0
Around 45.7% of the patients had missing weight or
Riyadh

Eastern Province

Makkah

Madinah

Asir

Qassim

Jizan

Najran

Tabuk

Hai'l

Northern Borders

Bahah
Jawf

height information. Diabetic individuals were also

more likely than nondiabetics to suffer from other
conditions such as hypertension (44.5% vs. 6.1%,
Privately insured National
P < 0.01) and CHD (8.6% vs. 1.2%, P < 0.01). Cramer’s
effect size ranged between 0.0 in nationality to 0.4 in Figure 1: The prevalence of diabetes mellitus in the 13 regions of Saudi Arabia
hypertension [Table 1]. compared to the estimates reported in the Ministry of Health in 2019

38 Journal of Family and Community Medicine - Volume 31, Issue 1, January-March 2024
 Aljehani, et al.: Prevalence and predictors of diabetes in a private health insurance scheme in Saudi Arabia

Table 1: Descriptive characteristics of the study population by diabetes status

Characteristics Non‑DM (n=2,952,429) Diabetic (n=401,750) Total (n=3,354,179) Cramer V P‑value
N (%) N (%) N (%)
Age
15–18 112,305 (4.0) 2397 (0.6) 114,702 (3.6) 0.33 <0.01
19–25 348,506 (12.6) 8264 (2.1) 356,770 (11.3)
26–39 1,424,887 (51.3) 79,229 (20.3) 1,504,116 (47.5)
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40–64 816,538 (29.4) 238,184 (61.1) 1,054,722 (33.3)

≥65 74,170 (2.7) 61,682 (15.8) 135,852 (4.3)
Gender
Female 1,115,615 (37.8) 133,339 (33.2) 1,248,954 (37.2) 0.03 <0.01
Male 1,836,814 (62.2) 268,411 (66.8) 2,105,225 (62.8)
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Nationality
Non‑Saudi 1,528,227 (51.8) 206,745 (51.5) 1,734,972 (51.7) 0.00 <0.01
Saudi 1,424,202 (48.2) 195,005 (48.5) 1,619,207 (48.3)
Insurance size
Large 2,068,031 (70.0) 290,280 (72.3) 2,358,311 (70.3) 0.01 <0.01
Small and medium 884,398 (30.0) 111,470 (27.7) 995,868 (29.7)
BMI category
Underweight 29,919 (1.0) 886 (0.2) 30,805 (0.9) 0.14 <0.01
Normal 398,081 (13.5) 33,006 (8.2) 431,087 (12.9)
Overweight 602,692 (20.4) 93,480 (23.3) 696,172 (20.8)
Obese 527,902 (17.9) 135,198 (33.7) 663,100 (19.8)
Missing 1,393,835 (47.2) 139,180 (34.6) 1,533,015 (45.7)
Hypertension
Nonhypertensive 2,773,153 (93.9) 222,822 (55.5) 2,995,975 (89.3) 0.40 <0.01
Hypertensive 179,276 (6.1) 178,928 (44.5) 358,204 (10.7)
CHD
Non‑CHD 2,918,218 (98.8) 367,013 (91.4) 3,285,231 (97.9) 0.17 <0.01
CHD 34,211 (1.2) 34,737 (8.6) 68,948 (2.1)
CHD=Coronary heart disease, BMI=Body mass index, DM=Diabetes mellitus

This is the first analysis of the privately insured found it associated with many conditions, such as DM
population of Saudi Arabia. Because prior literature and cardiovascular diseases. A study of those aged
suggests that the prevalence of DM has increased in 35–70 years suggested that one‑half of this age group
the past few decades, continuous monitoring of the was obese, and over a third was overweight.[23] There
prevalence and its associated predictors is vital to is a pressing need to address obesity in the privately
addressing the disease.[4‑9] While this is the first attempt insured population to reduce its impact on the incidence
to capture those with private insurance, our findings may of NCDs. Equally important is improving data quality
underestimate the actual burden of DM because it is likely and completeness, as over 40% of the study population
that some of these patients receive care in governmental had missing values.
health‑care facilities. However, as a part of the health‑care
transformation in Saudi Arabia, this double eligibility This study has several implications. First, health insurance
is expected to disappear with the implementation of regulators may use this finding to further enhance current
Article 11 in CHI, which states that any health benefits prevention and disease management strategies to reduce
provided by government facilities are to be covered by the the impact on population health. Second, other agencies,
insurance provider.[21] Differences from previous reports such as Public Health Authority, can complement these
may be due to differences in the underlying population efforts by working with providers to introduce various
or a change in the underlying disease burden. A study effective interventions and measure their effects to
by Alghnam et al., suggests that the prevalence of DM is reduce the risk of DM and other chronic conditions. One
around 18% among beneficiaries in a public health‑care of the primary goals of the transformation is to reduce
system.[3] Unfortunately, DM is expected to increase in the prevalence of diabetes and obesity between 2016
Saudi Arabia if there are no significant interventions to and 2030.[13] Therefore, the already devised population
reduce its risk factors such as obesity.[22] health management approaches should be part of the
qualification requirements to facilitate prevention in
In our study, obesity was found to be higher than the privately insured population at all levels (primary,
the national findings. Previous local literature has secondary, and tertiary).[20]
Journal of Family and Community Medicine - Volume 31, Issue 1, January-March 2024 39
 Aljehani, et al.: Prevalence and predictors of diabetes in a private health insurance scheme in Saudi Arabia

Table 2: Logistic regression analysis: factors relied on self‑report measures of DM, we utilized health
associated with diabetes in the privately insured insurance claims where services related to DM were
population in Saudi Arabia rendered. Despite the strengths of this study, we must
Variable OR (95% CI) acknowledge some limitations. First, our analysis is
Age based on those who visited a health‑care facility and
≤18 Reference represented a portion of the population. Therefore, it is
19–25 1.04 (0.98–1.09)
not unlikely that those seeking medical care might be
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26–39 1.9 (1.80–1.99)

sicker than those who did not seek healthcare. On the
40–64 6.2 (5.90–6.54)
other hand, our study does not capture undiagnosed
≥65 12.3 (11.66–12.90)
diabetics. According to previous reports, these patients
Gender
represent a sizable section of the DM population.[9] The
Female Reference
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 01/23/2024

Male 1.10 (1.09–1.10)

cross‑sectional nature of the present analysis does not
Nationality
imply causality as some factors such as hypertension may
Non‑Saudi Reference have arisen after becoming diabetic. Finally, although
Saudi 1.30 (1.28–1.31) the large sample size is a strength of the study, this
Regions might have revealed some small differences that are
Riyadh Reference not truly meaningful. However, the inclusion of the
Asir 1.32 (1.25–1.40) logistic regression approach deals with the quantifying
Bahah 1.34 (1.18–1.52) measures of association for the various variables, which
Eastern province 1.06 (1.05–1.08) were consistent with prior literature.
Ha’il 1.20 (1.1–1.3)
Najran 1.13 (1.04–1.24) Conclusion
Makkah 1.15 (1.09–1.17)
Madinah 1.20 (1.16–1.24) The study provides a baseline for the prevalence of DM in
Jazan 0.92 (0.83–1.02) the privately insured population. Future studies should
Northern borders 0.98 (0.84–1.14) evaluate prevention strategies to reduce the burden of
Alqasim 1.00 (0.98–1.09) DM on population health in Saudi Arabia.
Tabuk 0.89 (0.80–0.99)
Jawf 0.94 (0.80–1.11) Financial support and sponsorship
BMI category
Nil.
Underweight Reference
Normal 1.6 (1.50–1.68)
Conflicts of interest
Overweight 2.1 (1.9–2.25)
There are no conflicts of interest.
Obese 3.0 (2.8–3.18)
Hypertension
Nonhypertensive Reference References
Hypertensive 5.08 (5.02–5.24)
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