PREVALENCE OF RISK PREVALENCE OF RISK FACTORS FOR DIABETIC FACTORS FOR DIABETIC FOOT ULCER AND RISK FOOT ULCER AND RISK

STRATIFICATION IN TYPE 2 STRATIFICATION IN TYPE 2 DIABETESDIABETES

DR. NEETA DESHPANDEDR. NEETA DESHPANDEASSOCIATE PROF.,JN MEDICAL ASSOCIATE PROF.,JN MEDICAL COLLEGE AND KLE HOSPITAL, COLLEGE AND KLE HOSPITAL,

BELGAUMBELGAUM

INTRODUCTIONINTRODUCTION

40-70% of LL amputations related to 40-70% of LL amputations related to DMDM

Substantial emotional, physical and Substantial emotional, physical and financial lossesfinancial losses

Illiteracy, lack of knowledgeIlliteracy, lack of knowledge

Largely preventable through early Largely preventable through early detection of “high-risk” feet, detection of “high-risk” feet, preventive footwear and counselingpreventive footwear and counseling

AIMS AND OBJECTIVESAIMS AND OBJECTIVES

To know prevalence of risk factors for To know prevalence of risk factors for diabetic foot ulceration and diabetic foot ulceration and stratification into risk categoriesstratification into risk categories

To correlate risk categories to age, To correlate risk categories to age, duration of DM, glycemic control and duration of DM, glycemic control and SESSES

INCLUSION CRITERIAINCLUSION CRITERIA

All known cases of type 2 DM of more All known cases of type 2 DM of more than 1 year durationthan 1 year duration

EXCLUSION CRITERIAEXCLUSION CRITERIA

Patients with current foot ulcerPatients with current foot ulcer

Patients of DM admitted for other Patients of DM admitted for other neurological causesneurological causes

METHODOLOGYMETHODOLOGY215 type 2 diabetics who were willing 215 type 2 diabetics who were willing to participate in the study were to participate in the study were questioned in detail – age, duration questioned in detail – age, duration of diabetes, footwear practices, level of diabetes, footwear practices, level of education, symptoms of of education, symptoms of neuropathy, vasculopathy, previous neuropathy, vasculopathy, previous foot ulcer/amputationfoot ulcer/amputationThorough foot examination was doneThorough foot examination was doneBlood sample was collected for Blood sample was collected for HbA1cHbA1c

Definitions of recorded dataDefinitions of recorded data

HISTORY OF FOOT ULCER – Healed HISTORY OF FOOT ULCER – Healed foot ulcer of more than 3 months foot ulcer of more than 3 months durationduration

HISTORY OF LL AMP – Non-traumatic HISTORY OF LL AMP – Non-traumatic amp at any level in the LLamp at any level in the LL

PAD – Intermittent claudication or h/o PAD – Intermittent claudication or h/o reconstructive vascular surgery reconstructive vascular surgery and/or absence of foot pulsesand/or absence of foot pulses

Definitions of recorded data - contdDefinitions of recorded data - contd

SENSORY NEUROPATHY - SENSORY NEUROPATHY - > > 1 “no 1 “no response” to 10 g MF applied to 10 response” to 10 g MF applied to 10 sites (9 plantar and 1 dorsal) and/or sites (9 plantar and 1 dorsal) and/or NDSNDS

FOOT DEFORMITY – hallux valgus, FOOT DEFORMITY – hallux valgus, overlapping toes, fixed clawed toes, overlapping toes, fixed clawed toes, pes cavus/planus, Charcot foot, pes cavus/planus, Charcot foot, prominent metatarsal headsprominent metatarsal heads

NEUROPATHY DISABILITY NEUROPATHY DISABILITY SCORE – RIGHT AND LEFTSCORE – RIGHT AND LEFT

VibrationVibration sense sense (dorsum of big toe) : (dorsum of big toe) : Present=0, Present=0, reduced/absent=1reduced/absent=1Pin prickPin prick : : Present=0, Present=0, reduced/absent=1reduced/absent=1Ankle jerkAnkle jerk : : present=0, present present=0, present on reinforcement=1,on reinforcement=1,

absent=2absent=2

TOTAL SCORE:TOTAL SCORE:

3-4 Mild neuropathy3-4 Mild neuropathy

5-7 Moderate5-7 Moderate

8-10 Severe8-10 Severe

CLASSIFICATION OF INTERNATIONAL CLASSIFICATION OF INTERNATIONAL WORKING GROUP ON DIABETIC FOOTWORKING GROUP ON DIABETIC FOOT

RISK CATEGORYRISK CATEGORY

00

11

22

33

DESCRIPTIONDESCRIPTIONNo sensory neuropathyNo sensory neuropathy

Sensory neuropathy Sensory neuropathy onlyonly

SN+PVD &/or SN+PVD &/or deformitydeformity

Previous Previous ulcer/amputationulcer/amputation

Statistical MethodsStatistical Methods

.Chi – square test and unpaired ‘t’ test.Chi – square test and unpaired ‘t’ test

Age and Sex distributionAge and Sex distribution

AGEAGE MALEMALE FEMALEFEMALE TOTALTOTAL

45-5545-55 7070 3838 108108

56-6556-65 4242 3737 7979

66-7566-75 1818 44 2222

76-8576-85 44 22 0606

134134 8181 215215

Duration of diabetesDuration of diabetes

61

77

58

127

0

10

20

30

40

50

60

70

80

No.

of

Cases

< 5 6 to 10 11 to 15 16 to 20 > 20

Duration of Diabetes

Prevalence of risk factorsPrevalence of risk factorsCASESCASES PERCENTAGEPERCENTAGE

NeuropathyNeuropathy 8383 38.638.6

VasculopathyVasculopathy 2222 10.2310.23

Foot Foot deformitydeformity

1212 5.585.58

Prev Prev ulcer/ampulcer/amp

1010 4.654.65

Prevalence of risk factorsPrevalence of risk factors

83

22

12 10

0

10

20

30

40

50

60

70

80

90

No.

of

Cases

Neuropathy Vasculopathy Foot deformities Previous ulcer oramputation

Graph showing Prevalence of Neuropathy, Vasculopathy, Foot deformities and previous ulcer or amputation in the study population

Neuropathy Disability ScoreNeuropathy Disability ScoreNo. Of CasesNo. Of Cases PercentagePercentage

Mild (NDS 3-Mild (NDS 3-4)4)

4545 54.2254.22

Mod (NDS 5-Mod (NDS 5-7)7)

1616 19.2819.28

Severe (NDS Severe (NDS 8-10)8-10)

2222 26.5026.50

Mean duration of diabetesMean duration of diabetesMean (Years)Mean (Years) SDSD

Group 0Group 0 54.854.8 2.72.7

Group 1Group 1 1212 2.612.61

Group 2Group 2 17.517.5 1.451.45

Group 3Group 3 2121 3.623.62

Mean duration of diabetesMean duration of diabetes

5.8

12

17.5

21

0

5

10

15

20

25

Mean d

ura

tion o

f dia

bete

s (

Yrs

)

Group 0 Group 1 Group 2 Group 3

Graph showing mean duration of diabetes in each group distribution

Mean AgeMean Age

52.959.28

68.9276

0

10

20

30

40

50

60

70

80

Mean A

ge o

f th

e P

atients

(Yrs

)

Group 0 Group 1 Group 2 Group 3

Graph showing mean age of the patients in each group distribution

Glycemic controlGlycemic control

HbA1cHbA1c GoodGood

(<8%)(<8%)FairFair

(8.1-10%)(8.1-10%)PoorPoor

(>10%)(>10%)

Group 0Group 0 6464 2020 1616

Group 1Group 1 4343 4949 88

Group 2Group 2 2525 3333 4242

Group 3Group 3 1010 4040 5050

Glycemic controlGlycemic control

64

2016

4349

8

25

33

42

10

40

50

0

10

20

30

40

50

60

70

Group 0 Group 1 Group 2 Group 3

Graph showing Percentage of patients of different glycemic control in each group distribution

Good Fair Poor

Barefoot walkingBarefoot walking

42

5870

30

83

17

100

00

20

40

60

80

100

Perc

enta

ge

Group 0 Group 1 Group 2 Group 3

Graph showing Percentage of Bare foot walkers in each group distribution

Present Absent

Level of educationLevel of education

44 45 4349

3219

75

178

100

0 00

20

40

60

80

100

Perc

enta

ge

Group 0 Group 1 Group 2 Group 3

Graph showing level of Education in group

Iliterate Schooling College

ConclusionsConclusionsOverall prevalence of neuropathy is higher Overall prevalence of neuropathy is higher than vasculopathy (38.6% Vs 10.2%)than vasculopathy (38.6% Vs 10.2%)

Age (p<0.01), duration of diabetes Age (p<0.01), duration of diabetes (p<0.001) and glycemic control (p<0.001) and glycemic control (p<0.01)are significantly correlated to (p<0.01)are significantly correlated to high-risk feethigh-risk feet

Barefoot walking (p<0.001) and level of Barefoot walking (p<0.001) and level of education (p<0.0002) are important risk education (p<0.0002) are important risk factors factors