SLR - July 2020 - Matthew M. Knabel

Micronutrient Status in Diabetic Patients with Foot Ulcers

Reference: Guilherme Pena, Beatrice Kuang, Prue Cowled, Stuart Howell, Joseph Dawson, Ross Philpot, and Robert Fitridge. Micronutrient Status in Diabetic Patients with Foot Ulcers. Advances in Wound Care. Jan 2020.9-15.

Scientific Literature Review

Reviewed By: Matthew M. Knabel
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatric Relevance: Nutrition can be an overlooked variable for healing in our patients and especially in diabetic patients whose nutritional status is often suboptimal. The primary goal of this study was to assess the prevalence of vitamin and micronutrient deficiency in diabetic patients with foot ulcers seen either in an outpatient setting within multidisciplinary foot clinics, or inpatients admitted to their vascular service. The secondary goal was to correlate micronutrient levels with disease severity and other clinical factors, namely duration of diabetes, HbA1c levels, grip strength, and smoking status.

Methods: One hundred and thirty-one patients were recruited for the study between February 2017 and September 2018. Plasma levels of vitamins A, C, D and E; and copper, zinc and ferritin were measured at recruitment. Measurements were taken from venous blood draws by phlebologist. Demographic information and clinical data were prospectively obtained during patient assessment, including age, gender, weight, height, BMI and smoking status. In addition, grip strength and WiFi score were also recorded. 

Results: The elements most frequently found to be deficient, in descending order, were vitamin D, vitamin C, zinc, ferritin, and vitamin A. None of the patients had low levels of vitamin E or copper. Twenty-seven percent of patients had normal levels of vitamin C. The remainder had suboptimal levels with just over half of all the patients having low or no measurable plasma levels of this vitamin. There was no association between the duration of diabetes, HbA1c levels, grip strength, smoking habits and BMI to levels of vitamin A, C and zinc. Patients with a higher burden of foot disease as assessed by the WiFi score had lower levels of vitamin C (p = 0.02) and higher ferritin level (p = 0.004). Lower grip strength and smoking habit were associated with lower vitamin D levels (p = 0.02 and 0.01, respectively).

Conclusions: This study has demonstrated that micronutrient deficiencies are very common in diabetic patients with foot ulcers/wound with Vitamin D being most common deficiency. The reason for low vitamin levels in the studied patients is likely multifactorial, with poor intake playing a major role. The authors concluded that vitamin and mineral deficiency should be considered in all diabetic patients with foot wounds. Foot ulcers are a common and challenging complication of diabetes and constitute a substantial burden for these patients. The management should be based on intensive multimodality therapy aiming to achieve wound healing, reduce risk of re-ulceration, and an improving quality of life. Data for wound healing in regards to nutritional status is widely debated. There are many variables to look at making the most important contributors of a deficiency difficult to quantify. In high risk patients it may be helpful to optimize those patients by taking labs and seeing if nutrient supplementation could be instituted to possibly help.

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