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Risk of Diabetic Foot Ulcer and Its Associated Factors Among Bangladeshi Subjects: a Multicentric Cross-­ Sectional Study

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Risk of Diabetic Foot Ulcer and Its Associated Factors Among Bangladeshi Subjects: a Multicentric Cross-­ Sectional Study Open access Original research BMJ Open: first published as 10.1136/bmjopen-2019-034058 on 28 February 2020. Downloaded from Risk of diabetic foot ulcer and its associated factors among Bangladeshi subjects: a multicentric cross- sectional study Palash Chandra Banik ,1,2 Lingkan Barua ,2 Mohammad Moniruzzaman ,1 Rajib Mondal,2 Farhana Zaman,1 Liaquat Ali3 To cite: Banik PC, Barua L, ABSTRACT Strengths and limitations of this study Moniruzzaman M, et al. Objective To assess the risk of diabetic foot ulcer (DFU) Risk of diabetic foot ulcer and find out its associated factors among subjects with ► This is the first study in Bangladesh that assesses and its associated factors type 2 diabetes (T2D) of Bangladesh. among Bangladeshi subjects: the risk of diabetic foot ulcer (DFU) using a standard Design, setting and participants This cross- sectional a multicentric cross- tool. study recruited 1200 subjects with T2D who visited sectional study. BMJ Open ► For the first time, the associated factors of DFU were 16 centres of Health Care Development Project run by 2020;10:e034058. doi:10.1136/ explored to guide the prevention effort. bmjopen-2019-034058 Diabetic Association of Bangladesh. ► Sex- specific and area- specific difference in the risk Primary and secondary outcome measures Risk of DFU of DFU will help to identify the disparities and pro- ► Prepublication history and was assessed using a modified version of International additional material for this mote decentralisation of diabetes care for all. Working Group on the Diabetic Foot (IWGDF) Risk paper are available online. To ► Because of the cross- sectional design, we could not Classification System. The modified system was based view these files, please visit establish any causal relationship between the con- on five parameters, namely peripheral neuropathy (PN), the journal online (http:// dx. doi. tributing factors and risk of DFU. org/ 10. 1136/ bmjopen- 2019- peripheral arterial diseases (PAD), deformity, ulcer history ► The risk of DFU may be overestimated or underesti- and amputation. The risks were categorised as group 0 (no 034058). mated as all centres did not provide the same quality PN, no PAD), group 1 (PN, no PAD and no deformity), group diabetes care. Received 03 September 2019 2A (PN and deformity, no PAD), group 2B (PAD), group 3A Revised 14 December 2019 (ulcer history) and group 3B (amputation). The associated Accepted 20 January 2020 factors of DFU risk were determined using multinomial http://bmjopen.bmj.com/ logistic regression for each risk category separately. double the number.2 Among the clinical Results Overall, 44.5% of the subjects were found ‘at classifications of DM, type 2 diabetes (T2D) risk’ of DFU. This risk was higher among men (45.6%) is more common and prevalent in certain than women and among those who lived in rural areas (45.5%) as compared with the urban population. According ethnic groups, with estimates up to six times to IWGDF categories, the risk was distributed as 55.5%, more common in the people of South Asian 4.2%, 11.6%, 0.3%, 20.6% and 7.9% for group 0, group 1, descent, three times more common in those group 2A, group 2B, group 3A and group 3B, respectively. of African and African-Caribbean descent The associated factors of DFU (OR >1) were age ≥50 and is more common in people of Chinese on September 28, 2021 by guest. Protected copyright. years, rural area, low economic status, insulin use, history descent compared with the white population.3 © Author(s) (or their of trauma, diabetic retinopathy and diabetic nephropathy. Like in other developed and developing employer(s)) 2020. Re- use Conclusion A significant number of the subjects with permitted under CC BY-NC. No T2D under study were at risk of DFU, which demands an countries affected by it, it is also highly prev- commercial re- use. See rights effective screening programme to reduce DFU-rela ted alent in Bangladesh. Evidence suggests that and permissions. Published by 9.7% of Bangladeshi adult population (>35 BMJ. morbidity and mortality. 1 years) are diabetic and 22.4% are predia- Community Medicine, 4 Bangladesh Institute of Health betic. A trend analysis revealed an increasing Sciences, Dhaka, Bangladesh prevalence of DM in Bangladesh, from 4% 2 INTRODUCTION Noncommunicable Diseases, In recent years, diabetes mellitus (DM) has in 1995–2000 and 5% in 2001–2005 to 9% Bangladesh University of Health in 2006–2010, respectively.5 As the preva- Sciences, Dhaka, Bangladesh become a fast- growing public health problem 3Biochemistry and Cell Biology, that affects both developed and developing lence of diabetes increases, the prevalence Bangladesh University of Health countries.1 The International Diabetes Feder- of long- term diabetes- related complications Sciences, Dhaka, Bangladesh ation reports that about 415 million people is also likely to increase. Diabetic foot ulcer (DFU) is a common and major complication Correspondence to globally had DM in 2015 and it is projected Palash Chandra Banik; to affect 642 million by 2040. It was deemed of diabetes, representing a major healthcare palashcbanik@ gmail. com possible that by the year 2040 it might even burden with significant morbidity.6 Banik PC, et al. BMJ Open 2020;10:e034058. doi:10.1136/bmjopen-2019-034058 1 Open access BMJ Open: first published as 10.1136/bmjopen-2019-034058 on 28 February 2020. Downloaded from Diabetic foot is defined as the presence of infection, foot risk assessment and associated factors among Bangla- ulceration and/or destruction of deep tissues associated deshi subjects are absolutely lacking. Hence, we were with neurological abnormalities and various degrees prompted to assess the risk of foot ulcers and sought of peripheral arterial disease (PAD) in the lower limb to determine the factors that influence the risk among in patients with diabetes.7 It is a significant cause of patients with T2D of Bangladesh. morbidity and can lead to prolonged hospital stays, which is evidenced by the fact that ~20% of diabetes- related 8 hospitalisations are related to DFU. The mortality rate METHODS in patients with DFU is also high and is approximately Study design 9 twice that of the patients without ulceration. Other than This cross-sectional study was conducted among 1200 morbidity and mortality, the toll of economic burden in subjects with T2D who visited several centres of Health terms of direct and indirect costs is also high for those Care Development Project run by the Diabetic Associ- having DFU, estimated approximately €11.6 billion per ation of Bangladesh (DAB). A total of 16 centres were year for Europe in 2017 and €7.6–11 billion among selected: 7 from Dhaka and 9 from the northern part 7 Medicare beneficiaries of the USA from 2007 to 2014. of Bangladesh. We purposefully selected the centres Another issue related to foot ulcers among patient with and followed convenient sampling technique to collect diabetes is the health- related quality of life that cannot be data from subjects with diabetes. Our exclusion criteria measured in economic terms. It has been reported that included presence of DFU during the interview (active patients with foot ulcers or amputation have low health- ulcer), acute illness of the subject, unwillingness to related quality of life because of substantial depression participate and mental instability. To meet the eligibility and other physical problems like inability to do simple criteria, all subjects were screened for DFU, based on 7 tasks or recreational activities. their self- reported statement, their clinical history, foot The major risk factors of DFU are a loss of protective examination and medical records review. sensation due to diabetic peripheral neuropathy (DPN), PAD and trauma. However, the first two are not inde- Data collection and measurement pendently responsible for DFU; it is the combination The data collection comprised two phases and was neuropathy and PAD with trauma that leads to foot prob- conducted from July 2011 to June 2012. In the first phase, lems. It has been reported that trauma and PAD are major a face- to- face interview was conducted using a pretested contributors to foot ulceration and diabetic neuropathy is questionnaire adapted from the STEP- wise approach to the common denominator in almost 90% of DFU cases. Surveillance (STEPS) of non-communicable diseases risk There are some other risk factors namely male gender, factors of WHO.14 The questionnaire collected sociode- previous foot ulceration or amputation, foot deformities, mographic and behavioural risk factors (tobacco use, calluses, Charcot arthropathy and high plantar pressures physical inactivity), status of diabetes (duration, medica- http://bmjopen.bmj.com/ which have been associated with an increased risk for foot tion) and its complications (retinopathy, nephropathy) ulceration. There are some diabetes- related risk factors and foot problem- related information (neuropathy, PAD, also that influence the risk of foot ulcers such as the dura- trauma, foot hygiene) of the participants. The blood tion of diabetes, poor glycaemic control, diabetic reti- glucose levels (fasting/2- hours post meal) and informa- nopathy or nephropathy, poor compliance with medical tion about diabetic nephropathy or retinopathy in the instructions and neglectful behaviour. Some societal and participants were extracted from their diabetes records behavioural risk factors also show significant associa- book. The last record within one month was used to assess tion with DFU including low socioeconomic
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