Introduction

Chronic obstructive pulmonary disease (COPD) is an increasing cause of global morbidity and currently the third major cause of mortality globally.¹ Reduced physical activity (PA) is a common in COPD, only 31% of patients met the recommended physical activity level, compared with 73% of comparators.² It is associated with poorer outcomes, including mortality³ and reduced health related quality of life (HRQoL).⁴ Consequently, assessing and promoting physical activity is increasingly becoming a public health priority.⁵

In Saudi Arabia, the burden of COPD appears to be increasing. A study reported that 14.3% of individuals exhibited COPD-related symptoms—defined as chronic productive cough and/or dyspnea. However, the study did not clarify how many of these individuals had a prior diagnosis of COPD, nor did it specify whether diagnoses were confirmed through spirometry.⁶ A systematic review found high levels of inactivity in adults and children from Saudi Arabia.⁷ A further systematic review including 48 studies from Saudi Arabia found high levels of inactivity particularly in women due to conservative dress, need for chaperones and lack of facilities with other contributors being climate, age, low education.⁸

Patients with COPD in the United Kingdom (UK) have reduced step count compared with controls which was independently associated with increased level of dyspnea (p<0.05).² Factors related to a decline in PA in COPD include: COPD severity, musculoskeletal strength and breathlessness.^9–11 However, these studies have been undertaken in Europe and the results may not reflect other geographical regions and cultures.

There is some evidence that men with COPD in Saudi Arabia spent less time engaged in walking-based activity than healthy controls (22±8% versus 37±7% of waking hours; p<0.001).¹² There were moderate to strong inverse associations between the physical and emotional response components of the Dyspnea-12 (D-12) questionnaire and time spent engaged in walking-based activity both (r: ≥-0.52, p<0.01).¹²

There are limited data comparing PA and HRQoL between people with and without COPD from Saudi Arabia. Therefore, this study aimed to explore the levels of PA, and HRQoL in community-dwelling people with COPD and people without COPD in Saudi Arabia.

Material and methods

Study design

This was a cross-sectional survey in community-based people with and without COPD (comparators) living in Saudi Arabia. An online survey was sent to all participants and data was collected using link to Redcap¹³ available from January 2022 to July 2022.

Participants

People with COPD were recruited from outpatient cardiopulmonary rehabilitation clinics in Saudi Arabia, with diagnoses confirmed through clinical spirometry testing. However, spirometry data was not available for classification severity of airway obstruction. Participants were identified via a clinical database and had previously consented to be contacted for research purposes. The comparator group was recruited through the Public Pension Agency in Saudi Arabia. Inclusion and exclusion criteria are shown in Table 1.

Sample size was calculated based on PA levels using G-power software using t-test, medium effect size 0.5, α level 0.05 and power (1-B) level 80%. The required sample size was 64 participants in each group.

All participants gave online informed consent, and the study had gained approval from a UK University Research Ethics Committee (REC788), and University Research Ethics Committee in Saudi Arabia (IRB No 21/0550) and King Fahad Medical City (IRB No. 21-283E).

Demographic data

Participants completed the online survey including self reported age, sex, height and weight, from which body mass index (BMI) was calculated.

Physical activity assessment

Physical activity was assessed using the official Arabic short-version of IPAQ, which is reliable and valid internationally, and is available at www.ipaq.ki.se.¹⁴ IPAQ-SF collects duration of walking, moderate-intensity and vigorous intensity activity over the past seven days. Metabolic equivalents (MET)-min per week is calculated as: walking = (3.3 × walking minutes × days); moderate activity = (4.0 × moderate activity minutes × days); vigorous activity = (8.0 × vigorous activity minutes × days). Low PA level is defined as <600 METmin/week, moderate PA is defined as 600-1499 METmin/week and high PA was defined as ≥1500METmin/week.

Health Related Quality of Life

All participants self-completed a EQ-5D-5L questionnaire, valid and responsive in COPD¹⁵ (Arabic version, reliable and valid).¹⁶ The EQ-5D-5L includes five dimensions; rated on a 1-5-point Likert scale, from which an EQ-5D-5L index is generated (higher scores indicate better QoL). In addition, a visual analogue scale (VAS) (0-100) rating of health (a lower score indicates a worse perceived health status) was completed. Index scores were obtained using the EQ-5D-5L population-based value set for Egyptians (range − 0.964 to 0.948).¹⁷

Dyspnea-12

For people with COPD, dyspnea was recorded using the validated Arabic D-12, which comprises 12 items, each scored 0-3, higher scores indicating greater severity.¹⁸

Data analysis

Data were analysed by SPSS software version 27, statistical significance p<0.05. IPAQ-SF results were presented as the median and interquartile range [IQR] (for total MET-minutes results) and proportions as recommended by the IPAQ manual. Continuous data were checked for normality. Differences between COPD and comparators were analysed using the Mann–Whitney U test. The chi-square test was used for IPAQ categorical classification. Relationships between variables was analysed using Spearman rank correlation.

Results

A total of 101 participants (people with COPD n=50, comparators (without COPD) n=51) were included after excluding four COPD participants and five comparators due to incomplete data. There were more males (80%) with COPD than comparators (55%) (p<0.05) and people with COPD were older (mean age 64.2 ± 10.2 years), than comparators (50.2 ± 8.6 years) (p<0.05). There was no difference in BMI between the groups (Table 1).

People with COPD reported median [IRQ] 0 [0-0] min/week of vigorous PA while comparators reported a median of 0 [0-60] min/week (p = 0.006). For moderate PA, people with COPD reported a median of 0 [0-32] min/week, and comparators a median of 25 [0-120] min/week (p = 0.023). Walking was the predominant PA in COPD and comparators, with no differences between groups in walking or all domains of PA (p>0.05) (Table 2).

In people with COPD, 56% (n=28) met the criteria for low PA level (<600 MET-min/day) and 45% (n=23) of the comparator group. In people with COPD, 28% (n=14) and 24% (n=12) in the comparator group met the criteria for moderate PA level (600-1499 METS-min/week). Eight people with COPD (16%) and 16 comparators (31%) met the criteria for high level of activity (>1500 METS-min/week) (all p>0.05).

Health-related Quality of Life

There was a statistically significant difference in HRQoL between COPD (EQ-5D-5L index median [IQR] 0.722 [0.50-0.840]), and comparators (0.877 [0.736-1.00]), (p<0.001). Overall general health (EQ-VAS) was lower in COPD, 67 [40-81] than comparators 82 [70-90] (p<0.001).

Dyspnea

The mean ± standard deviation D-12 score for people with COPD was 15.12± 9.7. IPAQ total activity (METS) was related to D-12 rs= -0.567 p<0.05 and duration of walking rs= -0.402 p<0.05. There was no relationship between D-12- with EQ-5D-5L in COPD (p>0.05).

Discussion

This is the first study to evaluate PA, HRQol in people with COPD and comparators (without COPD) in Saudi Arabia. Although this study did not find a significant difference in median total PA between people with COPD and comparators, there was significant difference in moderate and vigorous activities (p<0.05). However vigorous activity was median of zero in both groups demonstrating negligible levels of vigorous activity in both groups. There was no difference in walking time per week between people with COPD and comparators, which contrasts with a study of men with COPD from Saudi Arabia who spent less time engaged in walking-based activity than healthy controls (22% versus 37% of waking hours; p<0.001),¹² and a UK study which found people with COPD have reduced step count compared to controls (p<0.05).² This may be explained by differences in recruitment sources, gender distribution and disease severity across study populations; although the current survey lacked spirometry data, to access COPD severity.

The categorical analysis of IPAQ in our study indicated that 56% of people with COPD and 45% of comparators had low levels of PA. Only 28% of people with COPD and 24% comparators, met the criteria for moderate PA, while 16% of COPD participants and 31% of comparators reported vigorous activities. The results are similar to a previous study of PA (IPAQ-SF) from a random sample of people, (aged 15-78 years) from Riyadh, Saudi Arabia. Results showed 40.6% of people were categorised as inactive (<600 Met-min/week), 34.3% were minimally active (600-1499 METmin/week) and 25.1% were physically active (>1500 METmin/week) (based on IPAQ activity categories or equivalent).¹⁹

Our study revealed that walking was the most reported physical activity among the study participants, 86% of people with COPD and 94% of comparators, reported engaging in walking for at least 10 minutes on five or more days per week. Similarly in a population-based study in Saudi Arabia, walking was the most frequently practiced physical activity among individuals accounting for 56% of the total activities performed.²⁰ This preference should be taken into account when promoting PA, as tailoring programs to individual preferences and needs can facilitate behavior change.²¹

The median MET-minutes/week for the COPD group (519) and comparators (735) in this study was lower than the baseline median of 1193 MET-minutes/week reported in a recent study that examined the validity of IPAQ-SF in a COPD population (mean age 68 years) from Portugal.²² This suggests people with and without COPD from Saudi are less physically active than people with COPD in the Portuguese study. A systematic review comparing IPAQ among individuals aged 18-65 years across countries demonstrated lower activity levels reported in Saudi in compared to countries, including New Zealand, USA and countries in Europe.²³ The low levels of PA identified in COPD and comparators living in Saudi Arbia may be because of other contributing factors which may influence PA participation. Donnelly et al. identified multiple barriers to physical activity in Arabic countries. At the individual level, perceived benefits of PA, existing health conditions, personal willpower, motivation, goals, and time influence PA. At the sociocultural level, religion, cultural attitudes, beliefs, practices, and informal support contribute to PA. At the organisational and political level, the physical environment, accessibility of facilities, organisational support, and health information impact PA levels.²⁴ These factors may extend to the whole population including people with COPD and may subsequently impact general health and QoL. A systematic review of barriers and facilitators to PA following pulmonary rehabilitation in people with COPD in Western Countries, identified theme relating to Beliefs, Social Support and Environmental Factors.²⁵ Additional cultural and contextual differences exist, may extend to the general population of Saudi Arabia. As expected, in our study, people with COPD reported lower HRQoL and overall general health compared with comparators, indicating a poorer QoL. A systematic review showed that in COPD, symptoms, exacerbations, and reduced activity have a greater negative impact on HRQoL than impaired lung function,²⁶ similarly a Jordanian study found symptoms affected PA and HRQol.²⁷ The EQ-VAS score in people with COPD (median 67) was comparable to a previous observational study including people with COPD from Saudi Arabia and Turkey recruited by hospital physicians, EQ-VAS score of 70 ±14.²⁸

The EQ-5D-5L utility index in people with COPD of 0.766 , VAS 67 was higher than a UK based study that reported a mean EQ-5D-5L utility index of 0.68 (±0.24) and EQ-VAS 61.0 (±20.6) values for people with COPD.¹⁵ This variation may be due to differences in disease severity although lung function was only weakly related to HRQoL other factors including other health conditions, psychological wellbeing and culture may contribute to differences in HRQoL in people with COPD.²⁹

Dyspnea

The present study reported a mean score of 15 for people with COPD, suggesting moderate dyspnea. Dyspnea was lower than the mean score reported in a previous study conducted amongst COPD patients in Saudi Arabia (22.4 ±3.6) reported as part of a validity and reliability study of the D-12.^12,18 This may be due to differences in participants’ lung function, between the two studies, although direct comparisons were not possible. These findings suggest that our study participants experienced less breathlessness than previous studies, which may explain the lack of difference in IPAQ-SF between COPD and comparators and better HRQoL compared to previous studies.

A study of men with COPD in Saudi Arabia reported a mean D-12 score of 19.1 ± 3.5 and found moderate to strong associations between its physical and emotional response components and time spent in walking-based activity (r ≥ 0.46, all p < 0.01).¹² Similar relationships were identified between D-12 and walking duration rs=-0.402 and total METS rs= -0.567 in the present study. Breathlessness is common in COPD which can lead to reduced activity, additional barriers for people with COPD include impaired lung function, fatigue and psychosocial factors.³⁰ Further research is required to explore context and cultural factors in Saudi Arabia to support physical activity promotion.

Strengths and Limitations

The strengths of the study included the use of Arabic versions of validated and widely accepted outcome measures. Additionally, a detailed data-cleaning process enhanced the quality and accuracy of the results. However, there were some limitations as the sample size did not meet the planned number (n=128) and the high variability of data, (large IQR), mean the study may be underpowered to detect significant differences. As the groups were not matched differences in age and gender distribution between groups may have introduced confounding variables. Although people with COPD were recruited from respiratory clinics with confirmed diagnoses, the lack of spirometry data limited to the ability to describe the severity of airways obstruction. Additionally, reliance on self-reported data may have introduced recall and social desirability biases. The use of a convenience volunteer sample through online surveys further limited generalisability, as this method might result in sample not representative of the broader population.

Conclusion

This study has important clinical and research implications. PA is low in COPD and the general population in Saudi Arabia, therefore further investigation of the perspectives of people with COPD and without COPD are needed to understand barriers and facilitators of physical activity. This will inform strategies to promote PA in the general population and COPD in Saudi Arabia, which is timely considering the changes taking place in Saudi Arabia as part of Vision 2030.

Disclosure

The author(s) report no conflicts of interest in this work.

Declaration of interest

None of the authors have any financial and personal relationships with other people or organisations that could inappropriately influence the work.

Funding

This study is supported via funding from Prince Sattam bin Abdulaziz University project number (PSAU/2026/R/1447).

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