'Social deprivation' and risk for diabetic foot complications

NewsBot · Jan 9, 2013

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Impact of health-care accessibility and social deprivation on diabetes related foot disease
G. P. Leese, Z. Feng, R. M. Leese, C. Dibben, A. Emslie-Smith
Diabetic Medicine (in press)

Aims
To determine whether geography and/or social deprivation influences the occurrence of foot ulcers or amputations in patients with diabetes

Methods
A population-based cohort of people with diabetes (n = 15 983) were identified between 2004 and 2006. Community and hospital data on diabetes care, podiatry care and onset of ulceration and amputation was linked using a unique patient identifier, which is used for all patient contacts with health-care professionals. Postcode was used to calculate social deprivation and distances to general practice and hospital care.

Results
Over 3 years’ follow-up 670 patients with diabetes developed new foot ulcers (42 per 1000) and 99 proceeded to amputation (6 per 1000). The most deprived quintile had a 1.7-fold (95% CI 1.2–2.3) increased risk of developing a foot ulcer. Distance from general practitioner or hospital clinic and lack of attendance at community retinal screening did not predict foot ulceration or amputation. Previous ulcer (OR 15.1, 95% CI 11.6–19.6), insulin use (OR 2.7, 95% CI 2.1–3.5), absent foot pulses (5.9: 4.7–7.5) and impaired monofilament sensation (OR 6.5, 95% CI 5.0–8.4) all predicted foot ulceration. Previous foot ulcer, absent pulses and impaired monofilaments also predicted amputation.

Conclusion
Social deprivation is an important factor, especially for the development of foot ulcers. Geographical aspects such as accessibility to the general practitioner or hospital clinic are not associated with foot ulceration or amputation in this large UK cohort study.
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Admin2 · Jan 9, 2013

Re: 'Social deprivation' and risk for diabetic foot complication

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NewsBot · May 25, 2013

Spirituality and subjective wellbeing in patients with lower-limb ulceration.
Salomé GM, Pereira VR, Ferreira LM.
J Wound Care. 2013 May 8;22(5):230-236.

Objective: To assess subjective wellbeing and spirituality in patients with either venous leg ulcers (VLUs) or diabetic foot ulcers (DFUs).

Method: This was a prospective, descriptive, analytical study conducted from December 2011 to October 2012. The study was approved by the Institutional Research Ethics Committee. A convenience, non-probability sample of 80 patients with either VLUs (n=40) or DFUs (n=40) were consecutively selected from an outpatient clinic of a university hospital in the city of Pouso Alegre, Brazil. Most participants were practising Catholics. The Subjective Wellbeing Scale and Spirituality Self-Rating Scale were administered to all participants.

Results: Thirty-two (80%) patients with foot ulcers and 22 (55%) patients with leg ulcers reported going to church sometimes or rarely. Most participants regarded religiosity and spirituality as synonymous, and living with the ulcers was seen as a punishment. The mean scores on the positive affect, negative affect, and life satisfaction components of the Subjective Wellbeing Scale were 2.48, 1.57 and 1.88, respectively, for patients with DFUs, and 2.55, 1.55 and 1.50, respectively, for patients with VLUs, with significant difference in life satisfaction between groups (p=0.003). The mean score on the Spirituality Self-Rating Scale was 11.40 for patients with VLUs and 12.85 for those with DFUs, showing that the participants had low levels of spirituality. l

Conclusion: VLUs and DFUs had a negative impact on subjective wellbeing and spirituality, but patients with DFUs showed poorer subjective wellbeing and spirituality than those with VLUs.
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wdd · May 26, 2013

It would be excellent if they could be cured of their ulcers but if that's not possible curing them of their religosity would seem just as likely to positively impact their affect and life satisfaction scores.

NewsBot · Nov 12, 2013

Socioeconomic deprivation independently predicts symptomatic painful diabetic neuropathy in type 1 diabetes.
Anderson SG, Malipatil NS, Roberts H, Dunn G, Heald AH.
Prim Care Diabetes. 2013 Nov 7.

INTRODUCTION:
Painful peripheral neuropathy in people with type 1 diabetes is a disabling and costly complication. A greater understanding of predisposing factors and prescribing may facilitate more effective resource allocation.
METHODS:
The Townsend index of deprivation (numerically higher for greater disadvantage) was examined in the pseudonymised records of 1621 (684 females) individuals with type 1 diabetes and related to prevalence of drug treated severe diabetes related neuropathic pain.
RESULTS:
Treatment for neuropathic pain was initiated in 280 patients, who were older at 57.1 vs 45.6 years and had greater BMI (29.8 vs 27.8kg/m2; p<0.0001). HbA1C was similar between groups, whilst eGFR was lower in the neuropathic pain group. Amitriptyline was the most commonly prescribed agent (46.8% of total prescriptions). Duloxetine (60mg daily) was prescribed in 9.3% of cases. There were significant differences between the groups for the Townsend index, with a greater proportion (34.3% vs 21.7%) of patients with treated neuropathic pain having a score of ≥1 (X2=19.9, p<0.001). Multivariate logistic regression analyses indicated that each unit increment in Townsend index was associated with a 11% increased odds of requiring neuropathic pain treatment [odds ratio (95% CI) 1.11 (1.05-1.17), p<0.001]. This was independent of age: 1.04 (1.02-1.05), BMI: 1.03 (1.01-1.05), HbA1C: 1.15 (1.05-1.24), male gender: 0.74 (0.55-0.98), systolic BP and eGFR. Inclusion of depression and mixed anxiety/depressive disorder did not change the risk estimates.
CONCLUSION:
Amitriptyline was the most commonly used agent for treatment of diabetes related neuropathic pain with Duloxetine much less used. A higher level of socioeconomic deprivation may predispose to severe neuropathic pain in diabetes. Differential allocation of resources may benefit this group.
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NewsBot · Nov 4, 2018

Perception of social support in individuals living with a diabetic foot: A qualitative study
JoshuaPalayaab1SuePearsonaToniNashb
Diabetes Research and Clinical Practice 31 October 2018

Aim
To explore the perception of social support in individuals living with a diabetic foot in order to influence future service delivery in management of similar individuals.

Method
A purposive sample of eight participants with a diabetic foot were recruited from a public podiatry service in Tasmania, Australia. A hermeneutic phenomenology qualitative approach was used with individual semi-structured interviews conducted using an interview guide designed to gain insight into five pre-determined measures of social support. Hybrid thematic analysis was used to produce the final results.

Results
Five clusters of themes emerged; emotional self-efficacy, isolation and stress; transport needs linked to physical or social functioning; perception of social support from health professionals; reciprocal support including health professionals facilitating support and financial support.

Conclusion
The findings have major implications for three broad areas; recognition and management of psychosocial well-being, the need for patient centred care approaches and inclusion and equity in health care and society. Adopting measures that are informed by these findings in current day management practices will complement the existing body of evidence on addressing factors for developing and treating ulceration.
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NewsBot · Jan 25, 2020

Perceived Social Support in Individuals With Diabetic Foot Ulcers: A Cross-sectional Survey.
Laopoulou F, Kelesi M, Fasoi G, Vasilopoulos G, Polikandrioti M.
J Wound Ostomy Continence Nurs. 2020 Jan/Feb;47(1):65-71

PURPOSE:
Explore levels of perceived social support and the associated factors among patients with diabetic foot ulcers (DFUs).

DESIGN:
Cross-sectional survey.

SUBJECTS AND SETTING:
Outpatients (n = 140) with DFUs attending a diabetic clinic affiliated with a public hospital in Athens, Greece, for wound care and follow-up visits after healing.

METHODS:
Data collection included demographic, clinical, self-report, and perceived social support, measured with the Multidimensional Scale of Perceived Social Support (MSPSS), during one-on-one interviews at the post-healing follow-up visit.

RESULTS:
For perceived social support, 50% of patients (average age 70 years) scored above 24, 24, and 18 (median) on the MSPSS in the categories of receiving support from significant other, family, and friends, respectively, suggesting high levels of perceived social support. Other statistically significant associations were observed for perceived social support from significant other, family, and friends and marital status (P = .001, P = .001, and P = .004, respectively), patients level of information about their health (P =.002, P =.001, and P =.001, respectively), family level of information (P = .001, P = .001, and P = .004, respectively), and how closely they followed period foot checks (P = .001, P = .002, and P = .011, respectively) and diet (P = .001, P = .001, and P = .001, respectively).

CONCLUSIONS:
Data from our study show that higher levels of perceived social support from significant others, family, and friends were linked to patients and others, being better informed about health status, and other self-care behaviors. Findings underscore the need for health care providers to recognize that social support is an important component of overall DFU management and may guide future interventions to determine which are most effective in enhancing socially supportive behaviors.
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NewsBot · Jan 25, 2021

Social Deprivation and Incident Diabetes-Related Foot Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study
Jenny Riley et al
Diabetes Care. 2021 Jan 22

Objective: To investigate the relationship between social deprivation and incident diabetes-related foot disease (DFD) in newly diagnosed patients with type 2 diabetes.

Research design and methods: A population-based open retrospective cohort study using The Health Improvement Network (1 January 2005 to 31 December 2019) was conducted. Patients with type 2 diabetes free of DFD at baseline were stratified by Townsend deprivation index, and risk of developing DFD was calculated. DFD was defined as a composite of foot ulcer (FU), Charcot arthropathy, lower-limb amputation (LLA), peripheral neuropathy (PN), peripheral vascular disease (PVD), and gangrene.

Results: A total of 176,359 patients were eligible (56% men; mean age 62.9 [SD 13.1] years). After excluding 26,094 patients with DFD before/within 15 months of type 2 diabetes diagnosis, DFD incidentally developed in 12.1% of the study population over 3.27 years (interquartile range 1.41-5.96). Patients in the most deprived Townsend quintile had increased risk of DFD compared with those in the least deprived (adjusted hazard ratio [aHR] 1.22; 95% CI 1.16-1.29) after adjusting for sex, age at type 2 diabetes diagnosis, ethnicity, smoking, BMI, HbA1c, cardiovascular disease, hypertension, retinopathy, estimated glomerular filtration rate, insulin, glucose/lipid-lowering medication, and baseline foot risk. Patients in the most deprived Townsend quintile had higher risk of PN (aHR 1.18; 95% CI 1.11-1.25), FU (aHR 1.44; 95% CI 1.17-1.77), PVD (aHR 1.40; 95% CI 1.28-1.53), LLA (aHR 1.75; 95% CI 1.08-2.83), and gangrene (aHR 8.49; 95% CI 1.01-71.58) compared with those in the least.

Conclusions: Social deprivation is an independent risk factor for the development of DFD, PN, FU, PVD, LLA, and gangrene in newly diagnosed patients with type 2 diabetes. Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities.
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NewsBot · Jul 15, 2021

Association between socioeconomic position and diabetic foot ulcer outcomes: a population-based cohort study in South Korea
Jeong Hyun Ha et al
BMC Public Health. 2021 Jul 14;21(1):1395

Background: Low socioeconomic position (SEP) is associated with a high incidence of diabetic foot ulcers (DFUs). However, reports on the association between SEP and DFU outcomes are limited. Therefore, in this study, we investigated this association and determined the prognostic factors of DFU outcomes.

Methods: The total cohort comprised 976,252 individuals. Using probability sampling, we randomly selected a sample of patients by reviewing the data from the Health Insurance Review and Assessment Service database of South Korea during 2011-2015. Residence, household income, and insurance type represented SEP. The primary outcome was amputation, and the secondary outcome was mortality. A multivariate model was applied to identify the predictive factors. Amputation-free survival and overall survival were calculated using the Kaplan-Meier method.

Results: Among 976,252 individuals in the cohort, 1362 had DFUs (mean age 62.9 ± 12.2 years; 42.9% were women). Overall amputation and mortality rates were 4.7 and 12.3%, respectively. Male sex (hazard ratio [HR], 2.41; p < 0.01), low SEP (HR 5.13, 5.13; p = 0.018), ophthalmopathy (HR, 1.89; p = 0.028), circulatory complications (HR, 2.14; p = 0.020), and institutional type (HR, 1.78; p = 0.044) were prognostic factors for amputation. Old age (HR, 1.06; p < 0.01), low SEP (HR, 2.65; p < 0.01), ophthalmopathy (HR, 1.74; p < 0.01), circulatory complications (HR, 1.71; p < 0.01), and institution type (HR 1.84; p < 0.01) were predictors of mortality.

Conclusions: DFU patients with a low SEP are strongly associated with increased amputation and mortality rates. Along with age and comorbidities, SEP could provide the basis for risk assessment of adverse outcomes in DFU. Providing targeted care for this population considering SEP may improve the prognosis.
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NewsBot · Jan 26, 2022

Social determinants of diabetes-related foot disease among older adults in New South Wales, Australia: evidence from a population-based study
Moin Uddin Ahmed, Wadad Kathy Tannous, Kingsley Emwinyore Agho, Frances Henshaw, Deborah Turner & David Simmons
Journal of Foot and Ankle Research volume 14, Article number: 65 (2021)

Background
Diabetes-related foot is the largest burden to the health sector compared to other diabetes-related complications in Australia, including New South Wales (NSW). Understanding of social determinants of diabetes-related foot disease has not been definitive in Australian studies. This study aimed to investigate the social determinants of diabetes-related foot disease in NSW.

Methodology
The first wave of the 45 and Up Study survey data was linked with NSW Admitted Patient Data Collection, Emergency Department Data Collection, and Pharmaceutical Benefits Scheme data resulting in 28,210 individuals with diabetes aged 45 years and older in NSW, Australia. Three outcome variables were used: diabetes-related foot disease (DFD), diabetic foot ulcer (DFU), and diabetic foot infection (DFI). They were classified as binary, and survey logistic regression was used to determine the association between each outcome measure and associated factors after adjusting for sampling weights.

Results
The prevalence of DFD, DFU and DFI were 10.8%, 5.4% and 5.2%, respectively, among people with diabetes. Multivariate analyses revealed that the common factors associated with DFD, DFU and DFI were older age (75 years or more), male, single status, background in English speaking countries, and coming from lower-income households (less than AUD 20,000 per year). Furthermore, common lifestyle and health factors associated with DFD, DFU, and DFI were low physical activity (< 150 min of moderate-to-vigorous physical activity per week), history of diabetes for over 15 years, and having cardiovascular disease.

Conclusion
Our study showed that about 1 in 10 adults with diabetes aged 45 years and older in NSW reported DFD. Interventions, including the provision of related health services aimed at reducing all forms of DFD in NSW, are recommended to target older individuals with a long history of diabetes, and coming from lower-income households.
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NewsBot · Mar 8, 2022

Effects of social deprivation and healthcare access on major amputation following a diabetic foot ulcer in a French administrative area: Analysis using the French claim data
Jean-Baptiste Bonnet et al
Diabet Med. 2022 Feb 24

Aim: The link between social deprivation and the development of diabetic foot ulcer (DFU) is still widely debated. The study objective was to evaluate the relationship between lower limb amputation, social deprivation level, and inequalities in access to care service among people with DFU. This regional pilot study was conducted at the living area level and based on the French National Health Data System (SNDS).

Methods: We conducted a retrospective cohort study using hospital and primary care claim data in the Languedoc-Roussillon region. DFUs were determined using an original algorithm of care consumption or hospital diagnosis. The primary end point was amputation at 1 year. Secondary end points were mortality at 1 year and impact of potential access to care on amputation.

Results: We included 15,507 people from 2015 to 2017. Amputation and mortality rates were 17.5 and 117 per 1000 person-years. The least precarious living areas showed better prognoses (relative risk = 0.46; 95% CI 0.27-0.66). Territorial accessibility to a private-practice nurse, unlike physician accessibility, was associated with better results on major outcomes (p = 0.004).

Conclusion: This is the first study using SNDS to study the care pathway of DFU management within and outside the hospital. High social deprivation in a living areas seems to be associated with more major amputations after a DFU.
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NewsBot · Nov 21, 2022

Complications related to diabetic foot ulcer and associated social vulnerability factors at a referral centre in Brazil
Monique Magnavita Borba da Fonseca Cerqueira et al
J Wound Care. 2022 Nov 2;31(11):946-960

Objective: To analyse the prevalence and associated social vulnerability factors of complications related to diabetic foot ulcer (DFU) among individuals followed up in a public care centre in Brazil.

Method: This is a cross-sectional study carried out with individuals followed up at the diabetic foot service of the State Referral Center for Diabetes and Endocrinology Assistance (CEDEBA) between December 2019 and October 2020, during the COVID-19 pandemic. Descriptive analysis and comparison of the prevalence of complications related to DFU were carried out. The factors associated with the outcome variables were verified by hierarchical logistic regression analysis.

Results: Among the 253 participants in this study, 30.4% had an active ulcer, 57.1% had a previous ulcer and 45.1% had an amputation. Lower limb ulcers were positively associated with male sex (prevalence ratio (PR): 1.22 (1.04-1.43)) and negatively associated with age >60 years (PR: 0.71 (0.61-0.83)), screening for diabetic foot (PR: 0.79 (0.67-0.92)) and the use of public transport to access CEDEBA (PR: 0.82 (0.71-0.96)). On the other hand, amputations were positively associated with male sex (PR: 1.61 (1.23-2.11)) and not working (PR: 3.83 (1.48-9.95)) and negatively associated with age >60 years (PR: 0.57 (0.45-0.74)) and the use of public transport to access CEDEBA (PR: 0.63 (0.49-0.81)).

Conclusion: The prevalence of complications was higher than in previous studies, and associated with sociodemographic and clinical characteristics. Further research should be encouraged to investigate the role that determinants of health play in the course of the disease, contributing to the construction of strategies that incorporate formulations developed in the social and economic spheres to broaden the impact of health actions on the prevention of major diabetic foot complications.
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NewsBot · Dec 15, 2022

Relationship Between Social Isolation and Health Behaviors and Ulcer Severity in Diabetic Foot Patients
Qiu-Ping Lu et al
Sichuan Da Xue Xue Bao Yi Xue Ban. 2022 Nov;53(6):998-1002

Objective: To explore the relationship between social isolation and health behaviors and ulcer severity in patients with diabetic foot.

Methods: A cross-sectional study was conducted with 160 patients suffering from type 2 diabetes mellitus combined with diabetic foot. The patients received treatment at the Department of Endocrinology and Metabolism, Nanfang Hospital, Southern Medical University between September 2020 and December 2021. Patient information was collected, including the scores for Lubben Social Network Scale and the Wagner classification of foot ulcers. Analysis was conducted to study the characteristics of the patients' health behaviors, including whether they received information and education on diabetic foot, whether there were delays in their attempt to access medical service, the frequency of foot examinations, etc. In addition, patient demographic data were collected, including sex, age, education, and employment status. According to their scores for Lubben Social Network Scale, the patients were divided into a social isolation group ( n=60) and a non-social-isolation group ( n=100). The severity of the foot ulcers and the health behaviors of the two groups were compared to identify differences.

Results: The findings suggest that, compared with the non-social-isolation group, the social isolation group had a higher proportion of diabetic foot patients with Wagner grade 3-5 diabetic foot ulcers ( P<0.05). Analysis of the health behaviors showed that the social isolation group had a higher proportion of diabetes foot patients who had never undergone examination of their feet and those who had delayed attempts to access medical service for their condition ( P<0.05). There were no significant differences between the two groups in terms of whether the patients had received information and education concerning diabetic foot, causes of foot injury, self-treatment of wounds, smoking, and drinking. Correlational analysis suggested that the scores of Lubben Social Network Scale were negatively correlated with the delayed attempts to access medical service ( r=-0.353, P=0.001), that is, the higher the degree of social isolation, the longer the delay in patients' attempt to access medical service for their diabetic foot.

Conclusions: Social isolation is correlated to health behaviors and ulcer severity in patients with diabetic foot. Giving more attention to the problem of social isolation of diabetic foot patients and increasing their ties with the social environment and the members of their social network may have a positive effect on improving the delays in diabetic foot patients' attempt to access medical service, which is particularly important for follow-up treatment.
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NewsBot · Sep 5, 2023

Socioeconomic Deprivation as a Predictor of
Lower Limb Amputation in Diabetic Foot Disease
Ahmad Bilal , Danuksha K. Amarasena , Anand Pillai
Cureus

The prevalence of diabetes and its complications are on the rise worldwide. This is particularly prevalent in
low- and middle-income countries. The Index of Multiple Deprivation (IMD) is a measure of relative social
deprivation. This index classifies England into small subsets called lower layer super output areas (LSOAs)
and then ranks these LSOAs into deciles from the most deprived to the least deprived area. We used this to
analyse the relationship between deprivation and outcomes in diabetic foot disease (DFD).
Methods
We evaluated patients admitted to our multidisciplinary unit with DFD over a five-year period. Their postal
codes were used to classify these patients into IMD deciles with decile 1 representing the 10% of most
deprived LSOAs and decile 10 the least deprived areas in the country. We used this classification to analyse
the relationship between deprivation and its influence on surgical outcomes and lower limb amputation. We
specifically compared those falling in the top five against the bottom five deciles.
Results
Our cohort consisted of 70 patients with diabetes who had surgery on their diabetic foot. Of this cohort, 33
(47%) of these underwent amputation. The majority of these procedures were minor amputations conducted
on the forefoot (75.6%) and there were no below knee amputations. Of those requiring an amputation, 27
patients (81.8%) had an IMD decile of 5 or below, and only six (18.2%) patients had above 5.
Conclusion
Our study shows that the likelihood of amputations related to diabetic foot disease is inversely proportional
to the index of multiple deprivation.
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