Risk Factors in Developing Diabetic Foot Ulcers Among Patients in DM Foot Clinic at East

Avenue Medical Center from January 2013 to January 2015

Karen S. Cabigas
 INTRODUCTION

Background/Significance of the Study

Diabetic Foot Ulcers are complex, chronic wounds which have long-term impact on the
morbidity, mortality, and quality of patients’ lives. Unlike other chronic wounds, diabetic foot
ulcer is often complicated by wide-ranging diabetic changes, such as neuropathy and vascular
disease. Developing diabetic foot ulcer is a major event in the life of a person with diabetes and
a marker of serious disease and comorbidities. Without early and optimal intervention, the
wound can rapidly deteriorate, leading to amputation.

The reasons for the increased incidence of this lower extremity complication in DM
involve the interaction of several pathogenic factors: neuropathy, abnormal foot biomechanics,
PAD, and poor wound healing. The peripheral sensory neuropathy interferes with normal
protective mechanisms and allows the patient to sustain major or repeated minor trauma to the
foot, often without knowledge of the injury. Disordered proprioception causes abnormal weight
bearing while walking and subsequent formation of callus or ulceration. Motor and sensory
neuropathy lead to abnormal foot muscle mechanics and to structural changes in the foot.
Autonomic neuropathy results in anhidrosis and altered superficial blood flow in the foot, which
promote drying of the skin and fissure formation. PAD and poor wound healing impede
resolution of minor breaks in the skin, allowing them to enlarge and to become infected. Risk
factors for foot ulcers or amputation include: male sex, diabetes >10 years’ duration, peripheral
neuropathy, abnormal structure of foot (bony abnormalities, callus, thickened nails), peripheral
arterial disease, smoking, history of previous ulcer or amputation, and poor glycemic control.
Large calluses are often precursors to or overlie ulcerations.

Diabetic neuropathy is defined as the presence of signs and symptoms of peripheral nerve
dysfunction in people with diabetes after exclusion of other causes. There is loss of pain,
vibration, pressure, touch sensation. Peripheral arterial disease can be found in approximately
half of patients with foot ulcer. PAD and neuropathy are frequently present in the same patient.
It is likely that a reduction in skin blood-flow, due to macrovascular disease, renders the skin
more susceptible to elevated biomechanical stress, impairs wound healing and decreases local
immunity, which can lead to severe infections.
Review of Literature

Diabetic foot ulcer (DFU) is a common complication affecting 15% of people with
diabetes. DFU has a 1% to 4% annual incidence rate and 15% to 25% lifetime risk. It is
becoming a great concern affecting quality of life, and social and economic aspects. In the
Philippines, DFUs are very common, accounting to 16-20% of the yearly emergency room
admissions at the PGH. In a local study done at University of Santo Tomas Hospital, DFU occur
in 19% among patients with diabetes mellitus.

The presence of diabetic foot was increased by male gender. [1] In a study by Simon et
al., there is a 1.4 fold increased prevalence of diabetes complications among men comparing to
women. [2] A local retrospective study done at Quirino Memorial medical Center showed that
diabetic foot ulcers occur mostly in the 6th decade of life with a mean age of 57 + 14.07 years and
the ratio is 1.6 males to 1 female. [12]

There is also an association between the risk of diabetic foot and the patient’s height as
similar to the findings described by Sosenko et al. [4] This effect is probably related to increased
risk of demyelination process in tall patients, comparing to individuals with shorter lower limbs
nerve fibers. [1] The correlation of diabetes duration and diabetic foot risk is corresponding with
studies performed by several authors, e.g. Ashok et al. [5] The risk of neuropathy is increased
after 10-12 years of type 2 diabetes duration [3,8].

In another retrospective done at the Chomi Medical and Surgical Clinic (CMSC) in
General Santos City showed that a ratio of 1.4 males: 1 female was observed in having diabetic
foot ulcers. For both genders, the mean age is between the 5th and 6th decade of life. [9]

Most patients who develop diabetic foot ulcer have low educational attainment. Highest
percentage were among illiterate. [10] This may be due to that lack of education leads to
unawareness of diabetic foot problems and their prevention. In a study done by Baqir et al, the
highest percentage of participants were without work, this because most were old patients (55-
64) years, and females and most of them were housewives. [10].

The patient’s body weight and waist circumference length increases diabetic foot. [1] It
is in correspondence with Boyko et al. studies, who described that the risk of diabetic foot
increases when patient's weight is 20 kg higher than optimal body weight [6]. In the study by
Chomi, majority of the patients belong to the normal and overweight category. [9] Other studies
show correlation between metabolic control of diabetes and the incidence of neuropathy, diabetic
foot and even LLA [4,7]. The risk factors for neuropathy were male gender, age, disease
duration, poor level of education, poor glycemic control and type 2 DM. [8].

However, according to Booy et al. studies, there is no correlation between the risk of
neuropathy in type 2 diabetes patients and the frequency of hyperlipidaemia, hypertension or
smoking [24]. Another study conducted confirmed no correlation with higher incidence of
diabetic foot in population with hyperlipidaemia [1].

Rationale

The socio-economic burden incurred due to diabetes foot ulcer and related complications
such as amputations are immense. These include direct costs of medications, hospitalizations,
cost of treatment and supplies. Patients and relatives also incur indirect costs that may include
loss of time from work, loss of income from the patient, and diversion of family resources from
basic needs. These burden and the added psychological weight of having difficulty ambulating
presents the importance of establishing this study.

Research Question

What are the risk factors in developing diabetic foot ulcers present among the patients
seeking consult in DM Foot Clinic at East Avenue Medical Center?

Objectives

The general objective of the study is to establish the correlation of each risk factor for developing
diabetic foot ulcer to the severity of the wound.

The specific objectives of the study are:

1.) To determine the prevalence of patients with diabetic foot ulcers

2.) To present the demographic profile of patients with diabetic foot ulcer at DM Foot Clinic
in East Avenue Medical Center
 3.) To establish the occurrence of the following risk factors in patients with DM foot ulcer:
a. Smoking
b. Hypertension
c. Glucose control
d. Neuropathy
e. Peripheral Arterial Disease
f. Alcohol intake

METHODOLOGY

Study Design

Cross-sectional

Study Setting

East Avenue Medical Center, DM Foot Clinic Outpatient Department

Study Population

Medical charts of patients at the DM Foot Clinic at the East Avenue Medical Center from
January 2013 to January 2015 will be retrieved and reviewed. Patients will be labeled as having:

1. Diabetes - if a patient had a FBS > 126mg% on 2 determinations, RBS > 200mg% with symptoms, 2
hour blood sugar after a 74 grams oral glucose tolerance test of > 200mg% (based on the WHO criteria),
or had been taking medications for diabetes.

2. Neuropathy - if a patient had any evidence of loss of sensation using the monofilament test, tuning fork
test for vibration; or physician-diagnosed based on patients symptoms.

3. Peripheral arterial disease (PAD) - if a patient had an ankle brachial pressure index (ABPI) < 0.9 with
intermittent claudication, significant occlusion on arterial Doppler, or physician diagnosed based on
patients symptoms.

4. Hypertension - if a patient had a blood pressure of > 140/90, or had been taking medications for
hypertension.

5. Current smoker - if a patient had been actively smoking within 1-2 years.
6. Significant alcohol intake - if a patient had taken >24 ounces of beer or >10 ounces of wine, or >3
ounces of 80 proof whiskey a day for men; >12 ounces of beer or 5 ounces of wine, or >1.5 ounces of 80
proof whiskey a day for women based on the Joint National Committee on Hypertension VII or physician
diagnosed as indicated in the chart.

Inclusion/Exclusion Criteria

Charts of patients in the DM Foot Clinic who sought consult from January 2013 to
January 2015 will be included. Those who are diagnosed to have diabetes mellitus prior to
developing the DFU will be included.

Tables

Demographic Profile of Patients with Diabetic Foot Ulcers

BMI
Mean Height Overweigh
Gender Number Age Weight Underweight Normal t Obese
Male            
Female              

Age, Average Blood Glucose and Duration of Disease of Patients with Diabetic Foot Ulcer

Average Blood
Gender Number Age Glucose Duration of Disease
Male    
female        
 Risk Factors among Patients with Diabetic Foot Ulcers

Risk Factor Number

Smoking  
Hypertension  
HbA1C > 6.5  
Peripheral Arterial Disease
Neuropathy  
With significant alcohol intake