G Model
DSX-381; No. of Pages 6 Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original Article
Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice Almoutaz Alkhier Ahmed, MSc in diabetes, IIWCCa,*, Saad Abdulrahman Algamdi, ABCMa, Abdullah M. Alzahrani, SBFM, ABFMb a b
National Guard Health Affairs, Specialized Polyclinics, Jeddah, Saudi Arabia National Guard Health Affairs, Jeddah, Saudi Arabia
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes Diabetic foot Diabetic ulceration
Introduction: Diabetes mellitus is a global health problem with rising prevalence worldwide. Diabetes mellitus is a multisystem disease affects many systems and tissues. Foot problems are not uncommon with diabetes and foot ulceration is one of theses problems. Risk factors for foot ulcerations may differ from community to community based on many factors. Objectives: To determine the risk factors for diabetic foot ulceration among Saudi diabetic patients with type 2 diabetes attending primary care center. Methodology: Cross sectional study was designed. Four hundred subjects were selected randomly. Inclusion criteria were settled. Three hundred and fifty subjects (350) were participated. Especial assessment form was designed. Data was collected and analyzed using SPPS ver 14. Results: Three hundred and fifty subjects were participated (57% male and 43% female). The prevalence of peripheral vascular disease was 15%, hulux vulgus 22.5%, inappropriate foot wear 41%, peripheral neuropathy 47.5%. Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration. Conclusion: Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration. ß 2014 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Diabetes mellitus (DM) became global health problem. The prevalence of DM has increased continuously during the last years. Diabetes mellitus increases in distribution until it became as one of the big health problems in most countries especially; the low- and middle-income countries. Such expansion will have a major impact on the quality of life of hundreds of millions people and their families, overwhelm the capability of many national healthcare systems, and impact adversely upon the economy of those countries that are in most need of development [1]. Prevalence of diabetes varies between countries due to different factors. The global number of people with diabetes in the age group between 20 and 79 years will be 6.4%, affecting 285 million adults in 2010, and will increase to 7.7% and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries [2].
* Corresponding author. E-mail address: [email protected] (A.A. Ahmed).
In 2010, four out of the top five countries with diabetes were from the Arab world; United Arab Emirates (18.7%), Saudi Arabia (16.8%), Bahrain (15.4%) and Kuwait (14.6%) [3]. A steady increase in diabetes prevalence has been noted in Saudi Arabia [4] (Fig. 1). Consequently, this was followed by increase in the prevalences of diabetes complications. A lot of changes affected the Saudi community lead to this change in diabetes map in Saudi Arabia. Foot problems are common and disabling complications with diabetes. It frequently leads to amputation. In a community survey done in UK, the prevalence of diabetic foot ulcers was 5.3% in patients with type 2 diabetes [5]. Also in this survey they found that 7.4% of patients with type 1 and 2 had a history of active or previous foot ulcers [5]. In USA in a hospital based survey [6], the researchers found that the prevalence of diabetic foot ulceration was 5.8%. In another survey done in Netherlands, a mean incidence of new ulceration among patients with type 2 alone was found to be 2.1% annually [7]. In Arab countries there are no sufficient data help in recognizing the magnitude of the problem. From the few studies published about the problem of diabetic foot in Arab world, a great variation
http://dx.doi.org/10.1016/j.dsx.2014.04.004 1871-4021/ß 2014 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
2
Prevalence of DM in SA1982-2004
25
23.7
20
15
10
9.7
5
4.3
10.15
4.6
2.5 0
Bacchus 82
Fatani 87
Abu-Zied 92
Hazmi 96
Nuaim 97
Nuzha 2004
Fig. 1. Prevalence of diabetes in Saudi Arabia.
had been noticed in the prevalence of this problem due to different factors [8]. In a study done in Iran [9] aimed to examine the characteristics of patients with diabetic foot ulcers attending an outpatient diabetic clinic in Kerman province which is located in the southeastern of Iran, the investigator examined 247 patients with diabetes with mean age 52() 12 years, the prevalence of diabetic foot was 4%, callus 12% and 50% for heal cracks [9]. Another study [10] found that the prevalence of diabetic foot was 4.7% among a sample of 375 Saudi patients with type 2 diabetes. He did a comparison with a correspondence Swedish diabetic patients (age group 46-69years), prevalence of ulcers was (2.3%) in Saudi group which was significantly lower than in Swedish patients. This finding may explained by different styles of footwear [10]. An interesting study done in Saudi Arabia [11], authors in this paper reported that 59% of their studied patients had foot ulcers 19 and 65% of these patients with ulcers need Debridement. In a retrospective study [12] the researchers stated that the prevalence of diabetic foot lesions was found to be 10.4%. In another study [13] done in King Khalid University Hospital, Riyadh from January 2003 to June 2006 included 184 diabetic nephropathy patients who were referred to nephrology clinic; the researchers found that the prevalence of diabetic foot was 13.5%. Also the researchers in this study concluded that baseline creatinine clearance and proteinuria, high systolic blood pressure, advanced age and longer duration of diabetes were the most significant risk factors for developing complications [13]. In another study [14] aimed to know the characteristics and risk factors of 13 diabetic patients undergoing chronic hemodialysis at King Abdul-Aziz University Hospital in Jeddah found that 7.7% of the participants had gangrenous foot. She explained her findings to poor glycemic control, inadequate treatment of hypertension, high smoking rate and inadequate screening for microalbuminuria [14]. 1. Methodology A cross sectional study conducted from the beginning of January to the end of December 2012. Four hundred patients were selected randomly. Every selected patient was informed about the study and gets his/her agreement to be included. Only 350 subjects with type-2 DM participated in the study. Table 1 showed the characters of study group. Literature review had been done. Three experts had been invited to extract
the most correlated risk factors to diabetic foot ulceration. Definition of each risk factor had been stated. Participants’ medical records were reviewed and patients were assessed using new designed assessment form. There were inclusion criteria which were:
Saudi nationality Had medical record Had type 2 diabetes Had no current ulceration Had no recent surgical foot intervention Had no recent foot trauma Data collected and analyzed using SPSS software
2. Results The current study included 350 participants (200 male; 57% and 150 female; 43%). Table 1 showed some personal and clinical characters of participants. As shown in Table 2, 56% of the patients have hypertension, 72% have dislipidaemia, 69% checked glucose regularly, 34% have glycemic control of HbA1c 7.5 Dyslipidaemia Smoking Heart diseases Diabetic neuropathy Peripheral pulsation Present Absent Diabetic retinopathy Irregular glucose checking Irregular exercise Family history of diabetes Previous history of ulceration Hulux vulgus Inappropriate foot wear Other diseases
56% 66% 72% 18% 6% 48%
(n = 196) (231) (n = 252) (n = 63) (n = 21) (n = 168)
85% (n = 297) 15% (n = 53) 22% (n = 77) 31% (n = 109) 63% (n = 220) 78% (n = 273) 7% (n = 24) 22.56% (n = 79) 41% (n = 143) 24% (n = 84)
During peripheral vascular assessment, peripheral pulsation was not felt in 15% of patients (32 male and 20 female). Among foot deformities hulux vulgus was the most common (22.5%) deformity and it was noticed more in female group (30%) than in male group (17%). Interestedly, inappropriate foot wear was the second common risk factor. Forty one percent (41%) of patients (143 patients; 87 male and 56 female) had inappropriate foot wear. Inappropriate traditional foot wears were the commonest foot wears problem (Table 3). Among male participants; risk factors were higher except foot deformity (hulux vulgus). Table 3 and Fig. 3 showed the differences between risk factors among male and female participants. Diabetic neuropathy was the commonest risk factor among both groups (50% in male, 45% in female) followed by Inappropriate foot wear (44.5% in male and 36% in female). Diabetic neuropathy and inappropriate foot wear was found in 37% of participants. It was more common in male than in female (85 males vs. 45 females). In patient with impalpable pulse, 95% had hypertension and dyslipidaemia or they use treatment for hypertension and dyslipidaemia (50 participants; 32 males vs. 18 female). Among those with impalpable pulse, dorsalis pedis was the commonest impalpable vessel (95%), while posterior tibialis was the second impalpable vessel (90%) while in 5% of impalpable
Risk factor
Male 57% (N 200)
Hypertension Dyslipidaemia Smoking Heart diseases Diabetic neuropathy Peripheral pulsation Present Absent Diabetic retinopathy Irregular glucose checking Irregular exercise Family history of diabetes Previous history of ulceration Hulux vulgus Inappropriate foot wear
56.5% (n 113) 75.5% (n 151) 21.5% (n 43) 7.5% (n 15) 50% (n 100) 85% (n 169) 15% (n 31) 23% (n 46) 22% (n 44) 64% (n 128) 88.5% (n 177) 8.5% (n 17) 18% (n 36) 44.5% (n 89)
Female 43% (N 150)
P value
55.3% (n 67.3% (n 13.3% (n 4% (n 6) 45.3% (n
68)
0.8415 0.0719 0.024 0.2301 0.3173
85% (n 128) 15% (n 22) 20.7% (n 31) 43.3% (n 65) 62% (n 98) 64% (n 96) 4.7% (n 7) 28.7% (n 43) 36% (n 54)
0.999 0.999 0.6171 0.0001 0.711 0.0001 0.1936 0.0010 0.0010
83) 101) 20)
pulse both were not felt. All foot with impalpable pulse been referred to our vascular clinic. Chi-square test was used to detect any statistical difference between the prevalence of risk factors between males and females. Interestedly there was no statistically significant differences in prevalence of hypertension, dyslipidaemia, heart disease, diabetic neuropathy, diabetic retinopathy, history of previous ulceration and palpable and impalpable vessels between males and females, while there was statistically significant differences in other risk factors; Smoking, irregular glucose checking, irregular exercise, family history of diabetes, hulux vulgus and inappropriate foot wear (P value 7.5%.
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 4
A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
Fig. 3. Prevalence of risk factors in males and females samples (%). HTN, hypertension; Dyslip, dyslipidaemia; H.Dis, heart diseases; D.Neuro, diabetic neuropathy; P.Puls (–), peripheral pulsation absent; D.Retino, diabetic retinopathy; N.R.Glu.Che, no regular glucose checking; N.R.Exer, no regular exercise; F.H.D, family history of diabetes; P.H.Ulc, previous history of ulceration; H.V, hulux vulgus; I.F.Wear, inappropriate foot wear; HbA1c (–), HbA1c >7.5%.
various studies have used different techniques and definitions to identify different foot pathologies and also the population at risk. An interested paper from Malta [16] looked at prevalence of risk factors for diabetic foot complications found that the prevalence of hulux vulgus was 49.1% while it was 22% in our study. This could be explained by the small size of the Malta study (234 participants) while it was 350 participants in our study, also the race variation may affect this high prevalence among Malta study participants. Interestedly, prevalence of hypertension and dyslipidaemia were both high in both studies .in Malta study they were 71.2% and 65.8% respectively while they were 56% and 72% respectively in our study. These finding could be explained by the low prevalence of controlled diabetic subjects. In Malta study 54% recalled mean HbA1c 7.2% while only 34% in our study recalled mean HbA1c 7.5% or below. In our study the prevalence of diabetic neuropathy was found to be 48% while it was 12.965% in Malta study (12.76% in left feet and 13.17% in right feet). This difference may be due to the differences in definition of diabetic neuropathy and method of diagnosis. In both study the prevalence of inappropriate foot wear was high. In Malta study it was 56% and in our study it was 41%. Traditional foot wears in Arab countries was standing behind this high prevalence in our study. Environmental factors in Saudi
Fig. 4. Clusters of risk factors.
Arabia and other Arab countries such as dry weather and some religious believes also add to this high prevalence [8]. In population-based studies, the prevalence of diabetic neuropathy varies widely, according to the study populations, definitions and methods used. An interested community based study done in UK [17] recruited 34,198 participants with type 2 diabetes (47.1% female) found other risk factors than our study. In addition to the peripheral diabetic neuropathy and peripheral arterial disease, they found that foot mycoses and open wound of the foot are both risk factors for foot ulceration. They found low prevalence of diabetic peripheral neuropathy than our prevalence (6% vs. 48%). The UK study shared approximately results with German study [18]. The German study found the prevalence of peripheral diabetic neuropathy was 9.7%. Another population base studies [19,20] have higher prevalence than the UK and German studies. In our study, the prevalence of PAD was 15%. An interesting paper from UK [21] determined the prevalence of PVD in patients with type 2 diabetes in the UK to be 11% (95% CI: 9.1–13.7). Sixteen percent of the diabetic population in a primary care setting in Malaysia was diagnosed with PVD [22]. Prevalence of PVD in the Australian diabetic population was found to be 13.9% among patients with known diabetes and 6.9% in those newly diagnosed [23]. The Seattle diabetic foot study [24] had different point of view. The beauty of this study is that it was prospective study and looked at the effect of autonomic neuropathy on ulcer development. The Seattle study involved 749 subjects. Age and gender are of the study limitations. Most of the subjects were elderly (mean age 63.2 years) and the majority were males 98%). The Seattle study concluded that reduction of foot sensitivity due to peripheral sensory neuropathy detected by insensitivity to 5.07 monofilament, past history of amputation or foot ulcer, insulin use, Charcot deformity, 15 mmHg higher dorsal foot transcutaneous Po2, Twenty kilograms higher body weight, 0.3 higher ankle–arm index, poor vision and 13 mmHg orthostatic blood pressure fall are
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
independently related to foot ulcer. Interestingly, this study did not look for the inappropriate foot wear as risk factor. This could be explained that this problem was not found in the American community or the age of participants affect this factor. From East Africa, an interesting cross sectional study recruited 1788 subjects looked at risk factors related to development of foot ulcers in diabetic patients [25]. The researchers found that neuropathy was found in 78% of patients and interestingly associated with high HbA1c and ischemia was found in 48.5% and more associated to systolic hypertension and dyslipidaemia. Only 18.3% recalled HbA1c
DSX-381; No. of Pages 6 Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
Diabetes & Metabolic Syndrome: Clinical Research & Reviews journal homepage: www.elsevier.com/locate/dsx
Original Article
Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice Almoutaz Alkhier Ahmed, MSc in diabetes, IIWCCa,*, Saad Abdulrahman Algamdi, ABCMa, Abdullah M. Alzahrani, SBFM, ABFMb a b
National Guard Health Affairs, Specialized Polyclinics, Jeddah, Saudi Arabia National Guard Health Affairs, Jeddah, Saudi Arabia
A R T I C L E I N F O
A B S T R A C T
Keywords: Diabetes Diabetic foot Diabetic ulceration
Introduction: Diabetes mellitus is a global health problem with rising prevalence worldwide. Diabetes mellitus is a multisystem disease affects many systems and tissues. Foot problems are not uncommon with diabetes and foot ulceration is one of theses problems. Risk factors for foot ulcerations may differ from community to community based on many factors. Objectives: To determine the risk factors for diabetic foot ulceration among Saudi diabetic patients with type 2 diabetes attending primary care center. Methodology: Cross sectional study was designed. Four hundred subjects were selected randomly. Inclusion criteria were settled. Three hundred and fifty subjects (350) were participated. Especial assessment form was designed. Data was collected and analyzed using SPPS ver 14. Results: Three hundred and fifty subjects were participated (57% male and 43% female). The prevalence of peripheral vascular disease was 15%, hulux vulgus 22.5%, inappropriate foot wear 41%, peripheral neuropathy 47.5%. Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration. Conclusion: Peripheral neuropathy and inappropriate foot wear were the commonest risk factors for foot ulceration. ß 2014 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Diabetes mellitus (DM) became global health problem. The prevalence of DM has increased continuously during the last years. Diabetes mellitus increases in distribution until it became as one of the big health problems in most countries especially; the low- and middle-income countries. Such expansion will have a major impact on the quality of life of hundreds of millions people and their families, overwhelm the capability of many national healthcare systems, and impact adversely upon the economy of those countries that are in most need of development [1]. Prevalence of diabetes varies between countries due to different factors. The global number of people with diabetes in the age group between 20 and 79 years will be 6.4%, affecting 285 million adults in 2010, and will increase to 7.7% and 439 million adults by 2030. Between 2010 and 2030, there will be a 69% increase in numbers of adults with diabetes in developing countries and a 20% increase in developed countries [2].
* Corresponding author. E-mail address: [email protected] (A.A. Ahmed).
In 2010, four out of the top five countries with diabetes were from the Arab world; United Arab Emirates (18.7%), Saudi Arabia (16.8%), Bahrain (15.4%) and Kuwait (14.6%) [3]. A steady increase in diabetes prevalence has been noted in Saudi Arabia [4] (Fig. 1). Consequently, this was followed by increase in the prevalences of diabetes complications. A lot of changes affected the Saudi community lead to this change in diabetes map in Saudi Arabia. Foot problems are common and disabling complications with diabetes. It frequently leads to amputation. In a community survey done in UK, the prevalence of diabetic foot ulcers was 5.3% in patients with type 2 diabetes [5]. Also in this survey they found that 7.4% of patients with type 1 and 2 had a history of active or previous foot ulcers [5]. In USA in a hospital based survey [6], the researchers found that the prevalence of diabetic foot ulceration was 5.8%. In another survey done in Netherlands, a mean incidence of new ulceration among patients with type 2 alone was found to be 2.1% annually [7]. In Arab countries there are no sufficient data help in recognizing the magnitude of the problem. From the few studies published about the problem of diabetic foot in Arab world, a great variation
http://dx.doi.org/10.1016/j.dsx.2014.04.004 1871-4021/ß 2014 Diabetes India. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
2
Prevalence of DM in SA1982-2004
25
23.7
20
15
10
9.7
5
4.3
10.15
4.6
2.5 0
Bacchus 82
Fatani 87
Abu-Zied 92
Hazmi 96
Nuaim 97
Nuzha 2004
Fig. 1. Prevalence of diabetes in Saudi Arabia.
had been noticed in the prevalence of this problem due to different factors [8]. In a study done in Iran [9] aimed to examine the characteristics of patients with diabetic foot ulcers attending an outpatient diabetic clinic in Kerman province which is located in the southeastern of Iran, the investigator examined 247 patients with diabetes with mean age 52() 12 years, the prevalence of diabetic foot was 4%, callus 12% and 50% for heal cracks [9]. Another study [10] found that the prevalence of diabetic foot was 4.7% among a sample of 375 Saudi patients with type 2 diabetes. He did a comparison with a correspondence Swedish diabetic patients (age group 46-69years), prevalence of ulcers was (2.3%) in Saudi group which was significantly lower than in Swedish patients. This finding may explained by different styles of footwear [10]. An interesting study done in Saudi Arabia [11], authors in this paper reported that 59% of their studied patients had foot ulcers 19 and 65% of these patients with ulcers need Debridement. In a retrospective study [12] the researchers stated that the prevalence of diabetic foot lesions was found to be 10.4%. In another study [13] done in King Khalid University Hospital, Riyadh from January 2003 to June 2006 included 184 diabetic nephropathy patients who were referred to nephrology clinic; the researchers found that the prevalence of diabetic foot was 13.5%. Also the researchers in this study concluded that baseline creatinine clearance and proteinuria, high systolic blood pressure, advanced age and longer duration of diabetes were the most significant risk factors for developing complications [13]. In another study [14] aimed to know the characteristics and risk factors of 13 diabetic patients undergoing chronic hemodialysis at King Abdul-Aziz University Hospital in Jeddah found that 7.7% of the participants had gangrenous foot. She explained her findings to poor glycemic control, inadequate treatment of hypertension, high smoking rate and inadequate screening for microalbuminuria [14]. 1. Methodology A cross sectional study conducted from the beginning of January to the end of December 2012. Four hundred patients were selected randomly. Every selected patient was informed about the study and gets his/her agreement to be included. Only 350 subjects with type-2 DM participated in the study. Table 1 showed the characters of study group. Literature review had been done. Three experts had been invited to extract
the most correlated risk factors to diabetic foot ulceration. Definition of each risk factor had been stated. Participants’ medical records were reviewed and patients were assessed using new designed assessment form. There were inclusion criteria which were:
Saudi nationality Had medical record Had type 2 diabetes Had no current ulceration Had no recent surgical foot intervention Had no recent foot trauma Data collected and analyzed using SPSS software
2. Results The current study included 350 participants (200 male; 57% and 150 female; 43%). Table 1 showed some personal and clinical characters of participants. As shown in Table 2, 56% of the patients have hypertension, 72% have dislipidaemia, 69% checked glucose regularly, 34% have glycemic control of HbA1c 7.5 Dyslipidaemia Smoking Heart diseases Diabetic neuropathy Peripheral pulsation Present Absent Diabetic retinopathy Irregular glucose checking Irregular exercise Family history of diabetes Previous history of ulceration Hulux vulgus Inappropriate foot wear Other diseases
56% 66% 72% 18% 6% 48%
(n = 196) (231) (n = 252) (n = 63) (n = 21) (n = 168)
85% (n = 297) 15% (n = 53) 22% (n = 77) 31% (n = 109) 63% (n = 220) 78% (n = 273) 7% (n = 24) 22.56% (n = 79) 41% (n = 143) 24% (n = 84)
During peripheral vascular assessment, peripheral pulsation was not felt in 15% of patients (32 male and 20 female). Among foot deformities hulux vulgus was the most common (22.5%) deformity and it was noticed more in female group (30%) than in male group (17%). Interestedly, inappropriate foot wear was the second common risk factor. Forty one percent (41%) of patients (143 patients; 87 male and 56 female) had inappropriate foot wear. Inappropriate traditional foot wears were the commonest foot wears problem (Table 3). Among male participants; risk factors were higher except foot deformity (hulux vulgus). Table 3 and Fig. 3 showed the differences between risk factors among male and female participants. Diabetic neuropathy was the commonest risk factor among both groups (50% in male, 45% in female) followed by Inappropriate foot wear (44.5% in male and 36% in female). Diabetic neuropathy and inappropriate foot wear was found in 37% of participants. It was more common in male than in female (85 males vs. 45 females). In patient with impalpable pulse, 95% had hypertension and dyslipidaemia or they use treatment for hypertension and dyslipidaemia (50 participants; 32 males vs. 18 female). Among those with impalpable pulse, dorsalis pedis was the commonest impalpable vessel (95%), while posterior tibialis was the second impalpable vessel (90%) while in 5% of impalpable
Risk factor
Male 57% (N 200)
Hypertension Dyslipidaemia Smoking Heart diseases Diabetic neuropathy Peripheral pulsation Present Absent Diabetic retinopathy Irregular glucose checking Irregular exercise Family history of diabetes Previous history of ulceration Hulux vulgus Inappropriate foot wear
56.5% (n 113) 75.5% (n 151) 21.5% (n 43) 7.5% (n 15) 50% (n 100) 85% (n 169) 15% (n 31) 23% (n 46) 22% (n 44) 64% (n 128) 88.5% (n 177) 8.5% (n 17) 18% (n 36) 44.5% (n 89)
Female 43% (N 150)
P value
55.3% (n 67.3% (n 13.3% (n 4% (n 6) 45.3% (n
68)
0.8415 0.0719 0.024 0.2301 0.3173
85% (n 128) 15% (n 22) 20.7% (n 31) 43.3% (n 65) 62% (n 98) 64% (n 96) 4.7% (n 7) 28.7% (n 43) 36% (n 54)
0.999 0.999 0.6171 0.0001 0.711 0.0001 0.1936 0.0010 0.0010
83) 101) 20)
pulse both were not felt. All foot with impalpable pulse been referred to our vascular clinic. Chi-square test was used to detect any statistical difference between the prevalence of risk factors between males and females. Interestedly there was no statistically significant differences in prevalence of hypertension, dyslipidaemia, heart disease, diabetic neuropathy, diabetic retinopathy, history of previous ulceration and palpable and impalpable vessels between males and females, while there was statistically significant differences in other risk factors; Smoking, irregular glucose checking, irregular exercise, family history of diabetes, hulux vulgus and inappropriate foot wear (P value 7.5%.
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 4
A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
Fig. 3. Prevalence of risk factors in males and females samples (%). HTN, hypertension; Dyslip, dyslipidaemia; H.Dis, heart diseases; D.Neuro, diabetic neuropathy; P.Puls (–), peripheral pulsation absent; D.Retino, diabetic retinopathy; N.R.Glu.Che, no regular glucose checking; N.R.Exer, no regular exercise; F.H.D, family history of diabetes; P.H.Ulc, previous history of ulceration; H.V, hulux vulgus; I.F.Wear, inappropriate foot wear; HbA1c (–), HbA1c >7.5%.
various studies have used different techniques and definitions to identify different foot pathologies and also the population at risk. An interested paper from Malta [16] looked at prevalence of risk factors for diabetic foot complications found that the prevalence of hulux vulgus was 49.1% while it was 22% in our study. This could be explained by the small size of the Malta study (234 participants) while it was 350 participants in our study, also the race variation may affect this high prevalence among Malta study participants. Interestedly, prevalence of hypertension and dyslipidaemia were both high in both studies .in Malta study they were 71.2% and 65.8% respectively while they were 56% and 72% respectively in our study. These finding could be explained by the low prevalence of controlled diabetic subjects. In Malta study 54% recalled mean HbA1c 7.2% while only 34% in our study recalled mean HbA1c 7.5% or below. In our study the prevalence of diabetic neuropathy was found to be 48% while it was 12.965% in Malta study (12.76% in left feet and 13.17% in right feet). This difference may be due to the differences in definition of diabetic neuropathy and method of diagnosis. In both study the prevalence of inappropriate foot wear was high. In Malta study it was 56% and in our study it was 41%. Traditional foot wears in Arab countries was standing behind this high prevalence in our study. Environmental factors in Saudi
Fig. 4. Clusters of risk factors.
Arabia and other Arab countries such as dry weather and some religious believes also add to this high prevalence [8]. In population-based studies, the prevalence of diabetic neuropathy varies widely, according to the study populations, definitions and methods used. An interested community based study done in UK [17] recruited 34,198 participants with type 2 diabetes (47.1% female) found other risk factors than our study. In addition to the peripheral diabetic neuropathy and peripheral arterial disease, they found that foot mycoses and open wound of the foot are both risk factors for foot ulceration. They found low prevalence of diabetic peripheral neuropathy than our prevalence (6% vs. 48%). The UK study shared approximately results with German study [18]. The German study found the prevalence of peripheral diabetic neuropathy was 9.7%. Another population base studies [19,20] have higher prevalence than the UK and German studies. In our study, the prevalence of PAD was 15%. An interesting paper from UK [21] determined the prevalence of PVD in patients with type 2 diabetes in the UK to be 11% (95% CI: 9.1–13.7). Sixteen percent of the diabetic population in a primary care setting in Malaysia was diagnosed with PVD [22]. Prevalence of PVD in the Australian diabetic population was found to be 13.9% among patients with known diabetes and 6.9% in those newly diagnosed [23]. The Seattle diabetic foot study [24] had different point of view. The beauty of this study is that it was prospective study and looked at the effect of autonomic neuropathy on ulcer development. The Seattle study involved 749 subjects. Age and gender are of the study limitations. Most of the subjects were elderly (mean age 63.2 years) and the majority were males 98%). The Seattle study concluded that reduction of foot sensitivity due to peripheral sensory neuropathy detected by insensitivity to 5.07 monofilament, past history of amputation or foot ulcer, insulin use, Charcot deformity, 15 mmHg higher dorsal foot transcutaneous Po2, Twenty kilograms higher body weight, 0.3 higher ankle–arm index, poor vision and 13 mmHg orthostatic blood pressure fall are
Please cite this article in press as: Ahmed AA, et al. Surveillance of risk factors for diabetic foot ulceration with particular concern to local practice. Diab Met Syndr: Clin Res Rev (2014), http://dx.doi.org/10.1016/j.dsx.2014.04.004
G Model
DSX-381; No. of Pages 6 A.A. Ahmed et al. / Diabetes & Metabolic Syndrome: Clinical Research & Reviews xxx (2014) xxx–xxx
independently related to foot ulcer. Interestingly, this study did not look for the inappropriate foot wear as risk factor. This could be explained that this problem was not found in the American community or the age of participants affect this factor. From East Africa, an interesting cross sectional study recruited 1788 subjects looked at risk factors related to development of foot ulcers in diabetic patients [25]. The researchers found that neuropathy was found in 78% of patients and interestingly associated with high HbA1c and ischemia was found in 48.5% and more associated to systolic hypertension and dyslipidaemia. Only 18.3% recalled HbA1c
