Nutritional status deteriorates as the severity of diabetic foot ulcers increases and independently associates with prognosis

Abstract

The prognosis for diabetic foot ulcers (DFUs) remains poor. Nutritional status has not been identified as one of the factors affecting the outcome of DFUs. Therefore, indicators correlated with nutritional status and outcome were analyzed to investigate their relationship. A total of 192 hospitalized patients with Wagner grade 1-5 ulcers and 60 patients with Wagner grade 0 ulcers (all had type 2 diabetes) were assessed by the following: subjective global assessment (SGA), anthropometric measurements, biochemical indicators and physical examinations to evaluate nutritional status, severity of infection and complications. Patient outcome was recorded as healing of the ulcer and the patients were followed up for 6 months or until the wound was healed. The percentage of malnutrition was 62.0% in the DFU patients. The SGA was closely correlated with infection (r=0.64), outcome (r=0.37) and BMI (r=-0.36), all P<0.001. The risk of poor outcome increased with malnutrition [odds ratio (OR), 10.6, P<0.001]. The nutritional status of the DFU patients was independently correlated with the severity of infection and outcome (both P<0.001) and Wagner grades and nutritional status (SGA) were independent risk factors for patient outcome (both P<0.001). Nutritional status deteriorated as the severity of the DFU increased, and malnutrition was a predictor of poor prognosis.

Figure 1

As the Wagner (W) grades increased, nutritional status, severity of infection and outcome deteriorated. (A) Nutritional status in patients with ulcers of Wagner grades 0–5. The prevalence of malnutrition was 62.0% in patients with foot ulcers. (B) Severity of infection in patients with ulcers of Wagner grades 1–5. Infection was identified in 83.9% of the DFU patients. (C) Outcome of patients with ulcers of Wagner grades 1–5. Only a small proportion of patients with ulcers of Wagner grades 1–4 did not heal well, while the outcome of patients with grade 5 ulcers was poor. (A–C) P<0.001 for the χ² analysis across all groups. DFU, diabetic foot ulcer.

Figure 2

Interactions of nutritional status, severity of infection and outcome. (A) Severity of infection correlated with the nutritional status. None of patients with uninfected feet were severely malnourished; only a small proportion of the mildly or moderately infected patients were severely malnourished, however, 43.2% of the patients with severe infection were severely malnourished. (B) Nutritional status associated with the severity of infection. Severe infection was observed in a small proportion (5.5%) of the well-nourished (A) patients, was 3-fold higher (17.7%) in the moderately malnourished (B) patients and 69.6% in the severely malnourished (C) group. (C) Outcome varied with nutritional status. The majority of foot ulcers in well nourished patients healed. In moderately malnourished patients, the proportion of deferment or recurrence was not large. Severely malnourished patients had high rates of mutilation and mortality. P<0.001 for the χ² analysis across all groups.