Preventive measures don't lessen foot ulcer risk

Patients with diabetic neuropathy at high risk for developing foot ulcers do not experience better outcomes by following the common preventive foot-care recommendations outlined in the American Diabetes Association guidelines, says Loretta Vileikyte, MD, University of Manchester, UK. "For high-risk patients, we need to search for more efficacious behavior modification recommendations," she says.

Dr. Vileikyte followed for 18 months 369 patients with diabetic neuropathy who had a neuropathy disability (NDS) score of 3 or greater. "We wanted to focus on patients with dense neuropathy," she says. Average patient age was 62.7 years; mean baseline NDS was 7.4; 75% of patients had type 2 diabetes; 38% had at least one prior foot ulcer; and 28% had a new ulcer develop during the 18-month study period. Of the newly developed ulcers, 69% were recurrent.

Patients were asked whether they routinely practiced preventive measures including daily foot examination, testing water temperature, checking the insides of shoes, having feet measured for shoes, wearing sneakers or lace-up shoes, routine visits to a foot specialist, cutting nails straight across, and wearing new shoes for shorter duration. They were also asked to report how often they engaged in potentially foot-damaging behavior such as wearing shoes with no socks and walking barefoot.

"Interestingly, patients who reported more preventive behaviors and fewer potentially damaging behaviors at baseline were more likely to develop a foot ulcer during the study," Dr. Vileikyte reports. She says the results showed the strongest predictor of new ulcer development was previous ulcer history, which was associated with a 2.49-fold increase in new ulcer development during the 18-month study (p<0.001). Other predictors of ulcer development included younger baseline age (odds ratio [OR]=0.96; p=0.001), higher NDS score (OR=1.21; p=0.015), and presence of clawed or hammer toes (OR=2.20; p=0.006).

"Our data do not support the commonly held belief that simple behavioral strategies can outweigh the impact of physical factors for foot ulceration in high-risk patients," says Dr. Vileikyte.