The Influence of Gender as a Risk Factor in Diabetic Foot Ulceration

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Author(s): 
Thanh Dinh, DPM1 and Aristidis Veves, MD, DSc2

Diabetic foot complications such as ulcerations are a major health problem, estimated to occur in up to 15% of patients with diabetes during their lifetime.1 If insufficiently treated, these ulcerations can lead to lower extremity amputations and even death.2,3 The total cost of diabetic foot complications in the United States has been projected to approach $4 billion annually, as extrapolated from the costs of ulcer care and amputations.4 Therefore, identification of risk factors for foot ulceration is useful in both screening and prevention of these complications in the diabetic population.

Numerous risk factors for the development of foot ulceration have been documented. These risk factors include: peripheral neuropathy, high plantar foot pressures, limited joint mobility, and peripheral vascular disease.5–10 Reported in approximately 30% to 50% of all patients with diabetes, peripheral sensory neuropathy has been found to be the most common and sensitive predictor for foot ulceration in the diabetic patient.11,12 In a study that specifically studied casual pathways of diabetic foot ulceration, the presence of neuropathy was reported in 78% of feet with ulcers.13

While peripheral neuropathy appears to be the major clinical risk factor associated with foot ulceration, socio-demographic factors also appear to influence the likelihood of foot ulceration. Socio-demographic risk factors include: race, education level, and gender.14,15 These studies observed that foot ulcerations predominantly afflict men, with poorer outcomes such as amputations also more prevalent in men.16 While diabetic foot complications appear to demonstrate preponderance towards male gender, it remains unknown whether gender is a single, independent risk factor for diabetic foot ulceration.

In a previous large, prospective trial that the authors’ unit coordinated, 29% of all patients with diabetes, including men and women, were shown to ulcerate over a 30-month period.17 In the present study, these same data are analyzed separately for men and women. The main goal of this study is to examine whether gender influences the incidence of foot ulcers and if gender is a significant risk factor for diabetic foot ulceration.

References: 

1. Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P, Showstack JA. Lower-extremity amputations in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12(1):24–31.
2. Apelqvist J, Larsson J. Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med. 1993;233(6):485–491.
3. Boyko EJ, Ahroni JH, Smith DG, Davignon D. Increased mortality associated with diabetic foot ulcer. Diabet Med. 1996;13(11):967–972.
4. Dinh TL, Veves A. Treatment of diabetic ulcers. Dermatol Ther. 2006;19(6):348–355.
5. Veves A, Murray HJ, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia. 1992;35(7):660–663.
6. Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJ. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care. 1998;21(7):1071–1075.
7. Birke JA, Franks BD, Foto JG. First ray joint limitation, pressure, and ulceration of the first metatarsal head in diabetes mellitus. Foot Ankle Int. 1995;16(5):277–284.
8. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care. 1994;17(6):557–560.
9. Sosenko JM, Kato M, Soto R, Bild DE. Comparison of quantitative sensory-threshold measures for their association with foot ulceration in diabetic patients. Diabetes Care. 1990;13(10):1057–1061.
10. McNeely MJ, Boyko EJ, Ahroni JH, Stensel VL, Reiber GE, Smith DG, Pecoraro RF. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216–219.
11. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care. 1994;17(6):557–560.
12. Adler AI, Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Smith DG. Risk factors for diabetic peripheral sensory neuropathy. Results of the Seattle Prospective Diabetic Foot Study. Diabetes Care. 1997;20(7):1162–1170.
13. Reiber GE, Vileikyte L, Boyko EJ, del Aquila M, Smith DG, Lavery LA, Boulton AJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999;22(1):157–162.
14. Tseng CH. Prevalence and risk factors of diabetic foot problems in Taiwan: a cross-sectional survey of non-type 1 diabetic patients from a nationally representative sample. Diabetes Care. 2003;26(12):3351.
15. Qari FA, Akbar D. Diabetic foot: presentation and treatment. Saudi Med J. 2000;21(5):443–446.
16. Benotmane A, Mohammedi F, Ayad F, Kadi K, Azzouz A. Diabetic foot lesions: etiologic and prognostic factors. Diabetes Metab. 2000;26(2):113–117.
17. Pham H, Armstrong DG, Harvey C, Harkless LB, Giurini JM, Veves A. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care. 2000;23(5):606–611.
18. Dyck PJ. Detection, characterization, and staging of polyneuropathy: assessed in diabetics. Muscle Nerve. 1988;11(1):21–32.
19. Bloom S, Till S, Sönksen P, Smith S. Use of biothesiometer to measure individual vibration perception thresholds and their variation in 519 non-diabetic subjects. Br Med J(Clin Res Ed). 1984;288(6433):1793–1795.
20. Young MJ, Breddy JL, Veves A, Boulton AJ. The prediction of diabetic neuropathic foot ulceration using vibration perception thresholds. A prospective study. Diabetes Care. 1994;17(6):557–560.
21. McNeely MJ, Boyko EJ, Ahroni JH, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. How great are the risks? Diabetes Care. 1995;18(2):216–219.
22. Donaghue VM, Veves A. Foot pressure measurement. Orthop Phys Ther Clin N Am. 1997;6:1–16.
23. Delbridge L, Perry P, Marr S, et al. Limited joint mobility in the diabetic foot: relationship to neuropathic ulceration. Diabet Med. 1988;5(4):333–337.
24. Fernando DJ, Masson EA, Veves A, Boulton AJ. Relationship of limited joint mobility to abnormal foot pressures and diabetic foot ulceration. Diabetes Care. 1991;14(1):8–11.
25. Zochodne DW. Diabetes mellitus and the peripheral nervous system: manifestations and mechanisms. Muscle Nerve. 2007;36(2):144–166.
26. Kilo S, Berghoff M, Hilz M, Freeman R. Neural and endothelial control of the microcirculation in diabetic peripheral neuropathy. Neurology. 2000;54(6):1246–1252.
27. Brussee V, Cunningham FA, Zochodne DW. Direct insulin signaling of neurons reverses diabetic neuropathy. Diabetes. 2004;53(7):1824–1830.
28. Stevens MJ, Feldman EL, Green DA. The aetiology of diabetic neuropathy: the combined roles of metabolic and vascular defects. Diabet Med. 1995;12(7):566–579.
29. Cohen JA, Jeffers BW, Faldut D, Marcoux M, Schrier RW. Risks for sensorimotor peripheral neuropathy and autonomic neuropathy in non-insulin-dependent diabetes mellitus (NIDDM). Muscle Nerve. 1998;21(1):72–80.
30. Lim SC, Caballero AE, Arora S, et al. The effect of hormonal replacement therapy on the vascular reactivity and endothelial function of healthy individuals and individuals with type 2 diabetes. J Clin Endocrinol Metab. 1999;84(11):4159–4164.

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