Article Info
Year: 2007
Month: July
Issue: 3
Reference: katheri S., Choudhry A., Alhamdan N., .Saudi Epidemiology Bulletin. 2007;14(3):.
This case-control study was conducted to assess the association between life-style related risk factors with development of foot ulcer proportions among Saudi male diabetic patients registered at diabetic clinics of primary health care centers by interviewing them and reviewing their records. The study included 333 diabetic patients, 111 of them represented case sample (diabetics with foot ulcer) and 222 represented control sample (diabetics without foot ulcer). Detailed information of each patients' age, occupation, education level, body mass index, type and duration of diabetes mellitus, mode of treatment, level of blood glucose control, presence of hypertension, hyperlipidemia, smoking, physical activity and type of shoes used were recorded. Further information from the cases included smoking practice, physical activity, type of shoes used and foot care information pertaining to the period before development of foot lesion.
Table 1 shows the relationship of health status factors and table 2 shows the relationship of life style factors with development of foot ulcers among male Saudi diabetic patients in our study. The results showed that insulin-dependent Diabetes Mellitus (DM), prolonged poorly controlled blood glucose, high cholesterol level, smoking, lack of exercise, not using well fitted shoes and poor foot-care were statistically significant high risks for development of foot ulcer, while hypertension and obesity did not show statistically significant risk.
Editorial note:
Global prevalence of DM is increasing due to population growth, aging, urbanization, increasing prevalence of obesity and physical inactivity.[1] For all age-groups worldwide, it was estimated at 2.8% in 2000 and projected to be 4.4% in 2030.[1] In Saudi Arabia, recent studies showed that the prevalence of DM among Saudis of ages 15-64 years was 19.3%.[2] Foot disease, mainly foot ulcers is a common complication among Saudi diabetic males.[3] Most Saudi patients with diabetic foot ulcers require debridement and 23.5% of them end up with major limp amputation.[4]
A tight glucose control has proven reduction of microvascular diabetic complications including peripheral sensory neuropathy, ischemia and development of foot ulcers.[3] Findings of our study showed a significant association between uncontrolled glycemia and development of foot ulcers.
A long duration of diabetes appeared to be an important factor; the study showed that the majority of cases (91.9%) developed foot ulceration 10 years after diagnosis. Insulin dependent DM in our study was significantly higher among cases (28.8%) than controls (5.9%). A correlation of foot complication with insulin dependent DM has been found in the study which revealed a high incidence of amputation among cases suffering from insulin dependent DM.
Smoking and hyperlipidemia are the most common risk factors presented in diabetic patients.[5] Smoking increases the risk of DM by increasing blood sugar level and decreasing the body's ability to use insulin. Lipid abnormalities are commonly associated with DM, particularly type 2.[6]
Exercise is one of the best ways to help maintain a healthy weight, a key factor in lowering the risk of diabetes; helping the body's cells use insulin effectively. Patients undergoing regular physical training showed a significant decrease in hyperglycaemia, hyperlipidaemia, obesity, hypertension and physiologic stress.[7]
Despite all the advances in diabetes treatment, education remains the cornerstone of diabetes management. Patients' education needs to be continued long after diagnosis and initial education. There is increasing evidence to suggest that education on foot care is essential for patients with diabetes. Educational programs improve foot care knowledge and behavior of high-risk patients.
References
- National Institute of diabetes and digestive&kidneyDiseases. National Diabetes Statistics fact sheet: general information & national estimates on diabetes in the US, 2005.
- Department of Preventive Medicine, MOH, KSA. Provisional report on non-communicable diseases risk factors surveillance 2005.
- Akbar DH, Mira SA, Zawawi TH, Malibary HM. Subclinical diabetic neuropathy: a common complication in Saudi diabetics. SMJ. 2000;21(5):433-7.
- Akbar DH, Al-Gamdi AA. Common causes of admission in diabetics. SMJ; 2000;21(6):539-42.
- Tanaka K, Katsuragi I, Masaki T, Nakagawa M, Shinohara T, Takahashi N, et al. Smoking is associated with insulin resistance and cardiovascular autonomic dysfunction in type 2 diabetic patients. Eur J Clin Invest. 2006;36(7): 459-65.
- Arcudi G, DAgostino G, Maiolo C, De Lorenzo A. Guidelines and malpractice in obesity treatment. Clin Ter. 2006;157(2): 143-52.
- Tuomilehto J, Lindstrom J, Eriksson JG, Valle TT, Hamalainen H, Laakso M, et al. Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. N Engl J Med. 2001;344(18): 1343-50.
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Table 1: Relationship of health status factors with development of foot ulcers among male diabetic patients in Riyadh, Saudi Arabia 2007.
|
||||||
|
Health Status Factors
|
Cases (111)
|
Controls (222)
|
OR
|
CI 95%
|
||
|
No
|
No
|
|||||
|
Type of DM
|
||||||
|
Insulin-dependent
Non-insulin-dependent
|
32
79
|
28.8
71.2
|
13
209
|
5.9
5.9
|
6.51
1
|
3.10-13.86
|
|
Fasting Blood Glucose
|
||||||
|
Uncontrolled
Controlled
|
91
20
|
82.0
18.0
|
94
128
|
42.3
57.7
|
6.20
|
3.45-11.20
|
|
Duration of DM
|
||||||
|
5-10 years
11-20 years
> 21 years
|
9
74
28
|
8.1
66.7
25.2
|
109
105
8
|
49.1
47.3
3.6
|
1
8.54
42.4
|
3.89-19.31
13.54-140.15
|
|
Hypertension
|
||||||
|
Yes
No
|
36
75
|
32.4
67.6
|
70
152
|
31.5
68.5
|
1.04
1
|
0.62
1.75
|
|
Hyperlipidemia
|
||||||
|
Yes
No
|
26
85
|
23.4
76.6
|
31
191
|
14
86
|
1.88
1
|
1.01-3.50
|
|
Obesity
|
||||||
|
Yes
No
|
71
40
|
64.0
36.0
|
136
86
|
61.3
38.7
|
1.12
1
|
0.68-1.85
|
|
Table 2: Relationship of Life style factors with development of foot ulcers among male Saudi diabetic patients in Riyadh, Saudi Arabia , 2007
|
||||||
|
Health Status Factors
|
Cases (111)
|
Controls (222)
|
OR
|
95% CI
|
||
|
No
|
No
|
|||||
|
Cigarette smoke
|
||||||
|
Never smokers
|
67
|
60.4
|
164
|
73.9
|
1
|
-
|
|
Current smokers
|
20
|
18
|
38
|
17.1
|
1.29
|
0.67-2.47
|
|
Ex-smokers
|
24
|
21.6
|
20
|
9
|
2.94
|
1.45-5.97
|
|
Duration of smoking
|
||||||
|
Never smokers
|
67
|
60.4
|
164
|
73.9
|
1
|
-
|
|
10-25 years
|
21
|
18.9
|
33
|
14.9
|
1.56
|
0.80-3.01
|
|
> 25 years
|
23
|
20.7
|
25
|
11.3
|
2.25
|
1.14-4.45
|
|
Exercise
|
||||||
|
Yes
|
14
|
12.6
|
139
|
62.4
|
1
|
-
|
|
Never exercised
|
97
|
87.4
|
83
|
37.4
|
11.6
|
6.00-22.77
|
|
Use well-fitting shoes
|
||||||
|
Always
|
38
|
34.2
|
136
|
61.3
|
1
|
-
|
|
Often
|
51
|
45.9
|
74
|
33.3
|
2.47
|
1.44-4.23
|
|
Infrequent
|
22
|
19.8
|
12
|
5.4
|
6.56
|
2.79-15.62
|
|
Foot care education
|
||||||
|
Yes
|
84
|
80.8
|
213
|
95.9
|
1
|
-
|
|
No
|
20
|
19.2
|
9
|
4.1
|
5.63
|
2.32-13.99
|
|
Checking feet for foot lesions
|
||||||
|
4-7 / week
|
5
|
4.5
|
56
|
25.3
|
1
|
-
|
|
1-3 / week
|
21
|
18.9
|
92
|
41.4
|
2.56
|
0.85-8.24
|
|
1-3 / month
|
44
|
39.6
|
63
|
28.4
|
7.82
|
2.72-24.20
|
|
< once/ month
|
41
|
36.9
|
11
|
5
|
41.75
|
12.11-155.43
|