SLR - December 2014 - Meredith Ward

Nutritional Status Deteriorates as the Severity of Diabetic Foot Ulcers Increases and Independently Associates with Prognosis

Reference: Zhang SS, Tang ZY, Fang P, Qian HJ, Xu L, Ning G. Nutritional Status Deteriorates as the Severity of Diabetic Foot Ulcers Increases and Independently Associates with Prognosis. Exp Ther Med. 2013 Jan;5(1):215-222.

Scientific Literature Review

Reviewed By: Meredith Ward, DPM
Residency Program: St. Francis Hospital and Medical Center, Hartford CT

Podiatric Relevance: Diabetic foot ulcers (DFU) are a common and serious complication of diabetes, which are commonly treated by podiatric physicians. The prognosis for these ulcerations remains poor and DFU are often associated with significant mortality. Nutritional status is an important and often overlooked treatment of DFUs, and may play a role in the severity and prognosis of these ulcerations.

Methods: One Hundred Ninety-two patients with Wagner grade 1-5 ulcers and 60 cases of Wagner grade 0 ulcers were evaluated over a one year period. Upon admission a subjective global assessment (SGA) was performed based on medical history and physical examination. It was utilized to categorize patients into one of the following groups: well nourished, moderately malnourished, or severely malnourished. Nutrition status was evaluated using total protein, serum albumin, HbA1c, and total cholesterol levels. Peripheral neuropathy was evaluated based on clinical examination and nerve conduction studies. Peripheral vascular disease of the lower extremity was identified utilizing Doppler ultrasonography, CT angiography, MR angiography, or contrast angiography. Ulcers were determined to be infected if purulent discharge and two other local signs of infection were present. Patients were treated with insulin to control blood glucose, hemorheologic agents and trophic nerve agents to improve foot blood supply, and antibiotics when infection, debridement/partial amputation, abscess or gangrene were present. Blood and/or albumin infusion was used if severe anemia or hypoproteinemia existed. Outcomes were evaluated over 6 months and defined as healing (ulcer healed), deferment (ulcer did not heal), recurrence (ulcer recurred), above ankle amputation, or mortality.

Results: Wagner grade 1-5 group indicators of nutritional status were overall lower than those in patients with Wagner grade 0 ulcers. Only 11.5 percent of Grade 0 ulcers were malnourished where 62 percent of grades 1-5 were malnourished. While few well-nourished patients developed moderate or severe infection and 86.3 percent of well-nourished patients healed, 69.5 percent of severely malnourished patients developed severe infections and tended to deferment of recurrence of ulceration. Patients who were severely malnourished were extremely more likely to have a poor outcome than well-nourished patients (69.6 percent vs 17.8 percent; P<0.001). SGA results correlated duration of DFU, infection status, Wagner grades, BMI, urine protein leakage and outcome. Severity of infection and outcome were both shown to be independently associated with patient’s nutritional status to a P-value of <0.001. Additionally, independent risk factors were severity of DFU and nutritional status with a P-value of <0.001.

Conclusions: This study was the first to identify nutritional status as a predictor of clinical outcomes of DFU patients. Malnutrition at presentation of DFU is predictive of poor outcomes. Even with proper nutritional supplementation, infection control, and foot care, the prognosis for malnourished patients is poor. Assessment of nutritional status in patients with DFU should be emphasized, as it is a predictor of outcome. If DFU patients with severe malnourishment receive sufficient nutritional intervention, their prognosis may be improved.

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