Risk factors for occurrence and recurrence of diabetic foot ulcers among Iraqi diabetic patients.

There are a few studies that discuss the medical causes for diabetic foot (DF) ulcerations in Iraq, one of them in Wasit province. The aim of our study was to analyze the medical, therapeutic, and patient risk factors for developing DF ulcerations among diabetic patients in Baghdad, Iraq.

Diabetes mellitus (DM) is a chronic metabolic disorder that is highly prevalent around the world (1). DM is a challenging disease with many complications that is usually difficult to manage successfully. Many patients do not achieve good glycemic control and continue to suffer health problems as a result (1–3). Diabetic foot (DF) ulceration is one of the most common complications among diabetic patients (4). It has been shown that such a complication is highly prevalent among Iraqi diabetic patients (5, 6). DF ulceration is associated with significant morbidity and mortality (7, 8). Although many studies worldwide explained the risk factors for developing DF ulcerations (9, 10), but there are a few studies that discuss the medical causes for DF ulceration in Iraq, one of these studies was done in Wasit province (11). The aim of our study was to analyze the medical, therapeutic, and patient risk factors for developing DF ulcerations among diabetic patients in Baghdad, Iraq.

Patients and methods

A cross-sectional study in questionnaire format (Appendix) was prepared by the authors of this study and given to a convenient sample of adult diabetic patients who were receiving medical treatment. This study was done in a surgical ward in a Baghdad teaching hospital during January 2015–April 2015. An additional 10 diabetic patients who are related to the authors of this study were invited to participate in this study to increase the sample size. Seventy-nine patients who provided their verbal informed consent were included in this study. Ethical approval for this study was obtained from the Ethical Committee of Pharmacy College–Baghdad University. In this study, the term DF referred to present and/or history of DF ulcer.

Statistical analysis

Statistical software (SPSS v. 12, Chicago, IL) was used for data input and analysis. Continuous variables were presented as mean±standard deviation (SD), and discrete variables were presented as numbers and frequencies. Chi-square test for independence was used to test the significance of association between discrete variables.

Unpaired t test was used to test the significance of difference in the mean of two independent samples. Pearson's correlation was used to test the correlation between continuous variables. For doing correlations, each categorical answer was rated using suitable ascending numbers starting from zero.

All P values used were asymptotic and two sided. Findings with a P value less than 0.05 were considered significant.

Results

The results shown in Table 1 indicate that diabetic patients who suffered from DF were significantly older than those without DF. A long history of DM (more than 10 years) was associated with the development of DF, while the presence of comorbid diseases was not associated with the development of DF.

Table 1

Demographic data of the patients

Parameter	Patients with diabetic foot	Patients without diabetic foot	P
Number of patients	54	25	0.001
Age	54.87±11.05	48.92±11.18	0.029
Gender
Male (%)	28 (52%)	16 (64%)	0.312
Female (%)	26 (48%)	9 (36%)
Duration of diabetes mellitus
Less than 5 years (%)	12 (22%)	13 (52%)
5–10 years (%)	13 (24%)	3 (12%)	0.009
More than 10 years (%)	29 (54%)	9 (36%)
Ratio of patients with other comorbid conditions (hypertension, cardiac disease, renal problems, eye problems) (%)	16/54 (29.6%)	18/25 (72%)	0.000
Educational level
Limited educational level (non-educated or primary school) (%)	29 (54%)	19 (76%)	0.132
Low educational level (secondary and tertiary school) (%)	13 (24%)	2 (8%)
High educational level (college) (%)	12 (22%)	4 (16%)

Table 2 shows that the most important factors that made diabetic patients more prone to develop DF were using a combination of insulin and oral antidiabetic agents, physical activity, and unavailability of medications in the public sector.

Table 2

Factors that affect diabetic patients to develop diabetic foot

Parameter		DM patients with DFN=54	DM patients without DFN=25	P
Medication used	Oral antidiabetics (%)	24 (44%)	20 (80%)	0.009
	Insulin (%)	11 (20%)	3 (12%)
	Both (%)	19 (36%)	2 (8%)
Presence of home glucose meter	Yes available (%)	33 (61%)	16 (64%)	0.804
	Not available (%)	21 (39%)	9 (36%)
Measuring blood glucose level	Daily (%)	11 (20%)	5 (20%)	0.930
	Weekly (%)	13 (24%)	7 (28%)
	Rarely (%)	30 (56%)	13 (52%)
Regular physician visit	Yes (%)	10 (19%)	8 (32%)	0.184
	No (%)	44 (81%)	17 (68%)
Therapy compliance and adherence	Yes (%)	32 (59%)	10 (40%)	0.110
	No (%)	22 (41%)	15 (60%)
Source of used medications	Public diabetic centers (free of charge) (%)	23 (43%)	7 (28%)	0.213
	Private community pharmacies (with fee) (%)	31 (57%)	18 (72%)
Knowledge about disease and its complication	Yes (%)	22 (41%)	7 (28%)	0.274
	No (%)	32 (59%)	18 (72%)
Knowledge about hyperglycemia symptoms	Yes (%)	11 (20%)	7 (28%)	0.452
	No (%)	43 (80%)	18 (72%)
Anyone helps you in your treatment	Yes (%)	24 (44%)	10 (40%)	0.710
	No (%)	30 (56%)	15 (60%)
Availability of prescribed medication in public centers	Yes (%)	3 (13%)	5 (72%)	0.002
	No (%)	20 (87%)	2 (28%)
Patients who stop treatment if medications are not available freely	Yes (%)	6 (30%)	2 (33%)	0.876
	No (%)	14 (70%)	4 (67%)
Regular foot inspection	Yes (%)	27 (50%)	8 (32%)	0.134
	No (%)	27 (50%)	17 (68%)
Physical activity	Yes (%)	41 (76%)	11 (44%)	0.005
	No (%)	13 (24%)	14 (56%)

DM: diabetes mellitus; DF: diabetic foot.

Table 3 shows that the frequency of DF occurrence is well correlated with the absence of a home glucose meter, less frequent blood glucose measurements, and with long duration of DM.

Table 3

Correlation between different parameters on diabetic foot frequency

Parameter	R	P
Medication used	0.236	0.086
Presence of glucose meter in patient's home	−0.274	0.045
Frequency of measuring blood glucose level	0.331	0.014
Medication adherence	0.169	0.223
Knowledge about hyperglycemia symptoms	−0.143	0.302
Knowledge about disease complication	0.149	0.281
Help with the treatment	0.221	0.108
Regular foot inspection	0.189	0.172
Physical activity	−0.172	0.215
Duration of disease	0.438	0.001
Gender	−0.058	0.945
Age	−0.070	0.901
Presence of comorbid conditions	0.229	0.101

Table 4 shows that the high cost of home glucose meter strips was the main cause for unavailability of this apparatus.

Table 4

Reason for non-availability of home glucose meters for patients with diabetic foot

Parameter			P
Absence of home glucose meter	High cost of the apparatus	6	0.049
	High cost of apparatus strips	15

Discussion

This study showed that the age of diabetic patients who suffer from DF were significantly higher than those without DF. Similarly, it was found that most of the patients who developed DF were in their fifth and sixth decades of life, with mean age of 59.3 years (12); furthermore, a long history of DM (more than 10 years) was associated with development of DF. In contrast to the finding in this study, researchers found that the duration of DM is not related to DF risk for patients in the United States (10), while another studies showed that diabetic patients who develop DF are usually those with long history of DM (12, 13).

Another important finding in this study is that the patient's educational level was not significantly different between diabetic patients with DF and those without DF; in contrast to the finding of this study, low educational level was a risk factor to develop DF in diabetic patients in the UAE (14). This difference may be because low level of education is very common among Iraqi diabetic patients (15).

In this study, the presence of comorbid diseases was not associated with the development of DF; while in many other studies comorbidities are associated with increasing DF incidence (17–19). One possible explanation for this strange finding is that whenever the demand for glycemic control increased (as in patients with medical comorbidities), the patient compliance with medical advice will be increased (19). This in turn could mean better glycemic control and fewer complications from hyperglycemic attacks (20, 21).

This study has shown there are many risk factors that make the diabetic patients more prone to develop DF, at which patients who are using a combination of insulin and oral antidiabetic agents were at high risk to develop DF. The same finding was observed in an Indian study where diabetic patients who use a combination of insulin plus oral hypoglycemic agents are at higher risk of developing DF ulcers (22). The use of combined therapy in diabetic patients is common and may be because DM is one of the diseases that progress and become less responsive to treatment with time (23). This hypothesis is consistent with the findings in this study because patients with a long history of DM were at high risk from recurrent DF ulcers. Moreover, it is well known that the use of many medications decrease patient compliance to therapy (24), which further mean losing glycemic control (20) and increasing DF ulcer risk to the patient (21).

Additionally, another finding in this study was the association between physical activity and the risk of developing DF, despite the fact that physical activity can improve glycemic control (25). This might be explained by the fact that most diabetic patients in this study had low educational levels, and around 50% of them did not inspect their feet regularly. This could result in a higher chance of foot wounds and blisters through physical activity. This in turn might be translated into higher risk for developing DF ulcers. This study also showed that unavailability of medications in the public sector, the free sector, is one of the major risk factors to develop DF ulcerations since nearly one third of participating patients stated that they will stop using their treatment if it is not freely supplied to them, this finding may be rational since many people in Iraq are below poverty line (26) and thus they are unable to purchase their medications from private pharmacies.

It is well known that DF has a high recurrence rate (27). In this study it was found that the frequency of DF occurrence was well correlated with less-frequent blood glucose measurements and with the absence of home glucose meters. Most patients in this study stated that they didn't own a home glucose meter because even if they can purchase the apparatus they aren't able to afford the costly strips for the regular glucose monitoring. In this regard, the lack of home glucose meters is surely linked with less-frequent glucose monitoring, which was further linked to bad glycemic control (28), and eventually to more complications with DF. This finding is closely related to what is found by Mehmood et al., at which better glycemic control is associated with better outcomes for patients with DF and may decrease the rate of DF recurrence (29).

There are some limitations in this study like the small sample size and the cross-sectional rather than longitudinal design that affect the reliability of study conclusions and therefore, a longitudinal large-scale study should be performed to confirm the results of this study. It is recommended that the Iraqi Ministry of Health ensure adequate and continuous supply not only of antidiabetic medications but also of glucose meter strips; furthermore diabetic educational programs should be made freely available to all diabetic patients to ensure a better glycemic control which eventually decrease the risk of diabetic complications.

In conclusion, older patients, long history of DM, using multiple antidiabetic medications, and physical activity with less frequent inspection of the feet were some of the major risk factors for developing DF among Iraqi diabetic patients, while the frequency of glucose monitoring is inversely related to the recurrence of DF ulcers.