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DOI: 10.5205/reuol.9199-80250-1-SM1006201601
ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
Sociodemographic and clinical factors of the
ORIGINAL ARTICLE
FATORES SOCIODEMOGRÁFICOS E CLÍNICOS DOS PACIENTES ATENDIDOS NO
AMBULATÓRIO DO PÉ DIABÉTICO DE UM HOSPITAL ENSINO
SOCIODEMOGRAPHIC AND CLINICAL FACTORS OF PATIENTS FROM A DIABETIC
FOOT OUTPATIENT CLINIC AT A TEACHING HOSPITAL
FACTORES SOCIODEMOGRÁFICOS Y CLÍNICOS DE PACIENTES TRATADOS
EN UN AMBULATORIO DE PIE DIABÉTICO DE UN HOSPITAL UNIVERSITARIO
Denilson Pereira Jose1, Jéssica Santos de Almeida2, Cléa Dometilde Soares Rodrigues3, Claudia
Bernardi Cesarino4
RESUMO
Objetivo: identificar os fatores sociodemográficos e clínicos dos pacientes com diagnóstico de
diabetes tipo1 e 2. Método: estudo descritivo, com abordagem quantitativa, em 121 prontuários
eletrônicos de pacientes com diabetes tipo1 e 2 atendidos no ambulatório do pé diabético de um
hospital de ensino de São José do Rio Preto/SP. Os dados foram analisados pelo teste qui-quadrado,
teste t Student e Análise de Variância (ANOVA); análise multivariada com a aplicação da Análise
Múltipla de Correspondência. Resultados: dos 121 pacientes, 66,12% eram do sexo masculino, 32%
residiam em São José do Rio Preto/SP, 38,02% tinham ensino fundamental incompleto, 71,07%
apresentavam união estável, com idade média de 54,17±15,37 anos, sendo que a faixa etária variou
de 21 a 60 anos. Quanto às características clinicas, verificou-se que 72,34% com DM do tipo 2,
56,19% apresentaram presença de feridas, 43,80% a Classificação de Wagner de grau 0 (risco
elevado, porém ausência de úlcera). Conclusão: fazem-se necessários maiores investimentos em
estratégias de educação em saúde, intensificando os programados por equipe multidisciplinar da
área da saúde. Descritores: Diabetes Mellitus; Pé diabético; Enfermagem.
ABSTRACT
Objective: to identify the demographic and clinical factors of patients diagnosed with type 1 and
type 2 diabetes. Method: descriptive study, with a quantitative approach, using the electronic
records from 121 patients, receiving care at a diabetic foot clinic within a teaching hospital of São
José do Rio Preto/SP, with type 1 and type 2 diabetes. The data were analyzed by the Chi-square
test, the Student’s t-test, Analysis of Variance (ANOVA); Multivariate analysis along with the
application of the Multiple Correspondence Analysis. Results: 66.12% of the 121 patients were male,
32% were living in São José do Rio Preto/SP, 38.02% had an incomplete elementary level education,
and 71.07% were in a stable relationship, with an average age of 54.17±15.37 years, with the age
group ranging from 21 to 60 years. In regards to the clinical features, 72.34% had type 2 DM, 56.19%
presented evidence of lesions and 43.80% were classified at grade 0 on the Wagner scale (high risk,
no obvious ulcer). Conclusion: more investment in health education strategies is required, as is
intensifying those already administered by multidisciplinary healthcare teams. Descriptors:
Diabetes Mellitus; Diabetic foot; Nursing.
RESUMEN
Objetivo: identificar los factores sociodemográficos y clínicos de los pacientes con
diagnóstico de diabetes tipo 1 y 2. Métodos: investigación descriptiva con abordaje
cuantitativa, cuyos datos fueron obtenidos por medio de búsqueda de 121 historiales
electrónicos de pacientes con diagnóstico de diabetes tipo 1 y 2 tratados en el ambulatorio
del pie diabético de un hospital universitario de São José do Rio Preto/SP desde julio de
Português/Inglês
Rev enferm UFPE on line., Recife, 10(6):680-5, jun., 2016
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ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
DOI: 10.5205/reuol.9199-80250-1-SM1006201601
Sociodemographic and clinical factors of the
2010 hasta julio de 2012. Resultados: de los 121 pacientes, 66,12% eran del sexo
masculino, 32% residían en São José do Rio Preto/SP, 38,02% tenían enseñanza primaria
incompleta, 71,07% presentaban unión estable, con edad media de 54,17±15,37 años,
siendo que el rango etaria varió de 21 a 60 años. Cuánto a las características clínicas, se ha
verificado que 72,34% con DM de tipo 2, 56,19% presentaron presencia de heridas, 43,80% la
Clasificación de Wagner de grado 0 (riesgo elevado, pero con ausencia de úlcera).
Conclusión: Es necesario más investimento en estrategias de educación en salud,
intensificando los programados por equipo multidisciplinar de la área de salud.
Descriptores: Diabetes mellitus; Pie diabético; Enfermería.
1
Nurse, Master’s in Nursing, Postgraduate in Nursing, Faculty of Medicine at São José do Rio
Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected]
2
Nursing Academic, Undergraduate Course in Nursing, Faculty of Medicine at São Jose do Rio
Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected];
3,4
Nurse, PhD lecturers, Department of General Nursing, Faculty of Medicine at São Jose do Rio
Preto/FAMERP. São José do Rio Preto (SP), Brazil. E-mail: [email protected],
[email protected].
INTRODUCTION
Diabetes mellitus (DM) has become the epidemic of the century due to it being the most
frequent chronic disease in our society. The disease is a serious public health problem because of its
various complications, its increased prevalence with advancing age, in both sexes, and its
characterization with hyperglycemia. This increase in blood glucose is due to insufficient production
or decreased action of insulin.1-2 10 to 12 million people are estimated to have diabetes in Brazil,
which is increasing in its prevalence along with the aging population, increased urbanization,
sedentary lifestyles and obesity, all of which occur most frequently in the 45 to 64-year-old age
group.3-4
In 2000, there were 171 million individuals with diabetes and the estimate for 2030 is
approximately 438 million, 90% of which will have type 2 diabetes. Almost four million annual
deaths are attributed to diabetes, which accounts for 6.8% of the total number of deaths
worldwide.5
One of the most devastating chronic complications of DM is diabetic foot. Diabetic foot is defined
as an infection, a deep tissue ulceration and neuropathy with varying degrees of peripheral vascular
disease. These conditions often emerge after the individual has had DM for 10 years and are
responsible for primary amputations and the reason why many are admitted to hospital, when
compared with other problems related to diabetes, the result of which being increased morbidity
and mortality.6-7 In patients with diabetes the possibility of developing ulcers on the feet is 15%,
these being infected or ischemic lesions, in which the risk of amputation is 90 times greater
compared to the diabetic patients with no infections or ischemia on the lower limbs.8
“The makeup of tissue lesions in diabetic patients can be very varied. There are some proposed
classification systems whose purpose is to standardize the study of these lesions. The first system,
designed by Wagner in 1979, is still in use today. Wagner’s classification groups the ulcerations in
accordance with the depth of the skin damage and the presence of ischaemia”.9:83
Thus, the aim of our study is to identify the sociodemographic and clinical factors of patients
diagnosed with type 1 and type 2 diabetes.
METHOD
This is a descriptive study with a quantitative approach. The data were obtained through
research in electronic medical records spanning July 2010 to July 2012 in the municipality of São
José do Rio Preto, in the Brazilian state of São Paulo. The chosen unit was a diabetic foot
outpatient clinic. Records of patients who were diagnosed with type 1 and 2 diabetes and met the
inclusion criteria were analyzed: all correctly completed records containing data, deemed
important by the researcher, from patients over 18 years of age. All electronic records with
incomplete data were excluded.
Collecting the data involved the use of an instrument developed by the researchers, containing
the following sociodemographic information: gender; age group; ethnicity; marital status;
Português/Inglês
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DOI: 10.5205/reuol.9199-80250-1-SM1006201601
ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
Sociodemographic and clinical factors of the
educational level in addition to clinical data: type of diabetes; the presence of wounds and the
Wagner classification.7
Grade 0
High risk, no obvious ulcer
Grade 1
Superficial ulcer, not infected in clinical terms
Grade 2
Deep ulcer, more or less cellulitis, with no abscess or
osteomyelitis
Grade 3
Deep ulcer with osteomyelitis or abscess formation
Grade 4
Localized gangrene
Grade 5
Gangrene covering the entire foot.
Figure 1. Wagner Classification for diabetic foot lesions.
The associative statistical analysis involved using the Chi-square test; comparative statistical
analysis be means of the Student’s t-test for independent samples and for the Wagner classification,
the Analysis of Variance (ANOVA) was used; multivariate analysis using Multiple Correspondence
Analysis. All statistical tests were performed considering a significance level of P<0.05.
This research project was approved under the protocol number-03829512.7.0000.5415 by the
Committee of Ethics in Research with Human Beings at the institution where the study was
conducted.
RESULTS
The survey results showed that our study investigated a population of 121 patients, aged
between 21 and 60 years, with a mean age of 54.03± 15.42 years. 66.12 of the subjects were male,
41.32% lived in São José do Rio Preto, 50.41% had an incomplete elementary level education and
71.07% had a stable marital status (Table1).
Table 1. Percentage of the sample’s characterization variables
of the patients evaluated in the study. São José do Rio Preto
(SP), Brazil.
Characterization variables
n
%
Gender
121
100
Female
41
33.88
Male
80
66.12
Marital status
121
100
With spouse
86
71.07
Without spouse
35
28.93
Color
121
100
White
112
92.56
Non-white
9
7.44
Origin
121
100
Macro-region
23
19.01
Micro-region
48
39.67
São José do Rio Preto
Education
Complete elementary
Incomplete elementary
Illiterate
Complete university
Profession
Retired
Retail
Housewife
Student
Services
50
121
46
61
12
2
121
30
8
25
4
54
41.32
100
38.02
50.41
9.92
1.65
100
24.79
6.61
20.66
3.31
44.63
Table 2 shows the percentages referring to the clinical characteristics, the diseases related to
diabetes, the risk factors and the hospitalizations resulting from the disease. In all cases, the
patients showed no diseases associated to diabetes and, in addition, the majority of the patients
showed no amputations resulting from the disease. With regards to the risk factors, most of the
evaluated patients were not smokers, alcoholics and had not been hospitalizations as a result of the
disease.
Português/Inglês
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DOI: 10.5205/reuol.9199-80250-1-SM1006201601
ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
Sociodemographic and clinical factors of the
Table 2. Percentages for the clinical features, the diseases related to
diabetes, the risk factors and the hospitalizations of the evaluated patients.
São José do Rio Preto (SP), Brazil.
Study variables
n
%
Clinical
characteristics
and Neuropathy
121
100
related diseases
No
81
66.94
Yes
40
33.06
Retinopathy
121
100
No
106
87.60
Yes
15
12.40
Nephropathy
121
100
No
103
85.12
Yes
18
14.88
Dyslipidemia
121
100
No
109
90.08
Yes
12
9.92
Hypertension
121
100
No
71
58.68
Yes
50
41.32
Osteomyelitis
121
100
No
100
82.64
Yes
21
17.36
Amputations
121
100
No
104
85.95
Yes
17
14.05
Risk factors
Smoking
121
100
No
101
83.47
Yes
20
16.53
Alcoholism
121
100
No
112
92.56
Yes
9
7.44
Hospitalizations
No
114
94.21
Yes
7
5.79
Type 2 diabetes and a grade 0 on the Wagner classification were prevalent in our study (Table
3).
Table 3. Percentages of the key variables: type of diabetes and
Wagner classification. São José do Rio Preto (SP), Brazil.
Key variables
n
%
Type of diabetes
94
100
Type 1
26
27.66
Type 2
68
72.34
Wagner classification
121
100
Grade 0
53
43.80
Grade 1
19
15.70
Grade 2
38
31.40
Grade 3
11
9.09
Associative tests were used to relate the qualitative variables. Thus, type of diabetes (Table 4)
and the Wagner classification (Table 5) were associated with characterization variables such as
gender, color, marital status, origin and education. The results show that there was no significant
association between the type of diabetes and the Wagner classification with the sample
characterization variables (P>0.050).
Table 4. Associative results for the type of diabetes type compared with the
sociodemographic sample characterization variables. São José do Rio Preto (SP), Brazil.
Sample characterization variables
Gender
Color
Marital status
P-Value1
Type of diabetes
Type 1
Type 2
Female
12 (46.15%)
21 (30.88%)
Male
14 (53.85%)
47 (69.12%)
White
24 (92.31%)
64 (94.12%)
Non-white
2 (7.69%)
4 (5.88%)
With spouse
17 (25.76%)
49 (74.24%)
Português/Inglês
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0.170
0.752
0.530
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DOI: 10.5205/reuol.9199-80250-1-SM1006201601
ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
Origin
Education
Sociodemographic and clinical factors of the
Without spouse
9 (32.14%)
19 (67.86%)
Other States
6 (23.08%)
12 (17.65%)
Region
9 (34.62%)
30 (44.12%)
São Jose do Rio Preto
11 (42.31%)
26 (38.24%)
Illiterate
5 (45.45%)
6 (54.55%)
Less than 7 years
13 (28.26%)
33 (71.74%)
Less than 7 years
8 (21.62%)
29 (78.38%)
0.676
0.317
1
P-Value referring to the Chi-square test (P<0.05).
Table 5. Associative results from the Wagner classification compared with the sample characterization variables.
São José do Rio Preto (SP), Brazil.
Sample characterization variables
Wagner classification
P-Value1
Grade 0
Grade 1
Grade 2
Grade 3
Gender
Female
19 (35.85%)
5 (26.32%)
14 (36.84%)
3 (27.27%)
0.170
Male
34 (64.15%)
14 (36.84%)
24 (63.16%)
8 (72.73%)
Ethnicity
White
49 (92.45%)
18 (94.74%)
36 (94.74%)
9 (81.82%)
***
Non-white
4 (7.55%)
1 (5.26%)
2 (5.26%)
2 (18.18%)
Marital status
With spouse
36 (41.86%)
14 (16.28%)
29 (33.72%)
7 (8.14%)
0.771
Without spouse
17 (48.57%)
5 (14.29%)
9 (25.71%)
4 (11.43%)
Origin
Macro
10 (18.87%)
1 (5.26%)
11 (28.95%)
1 (9.09%)
0.346
Micro
21 (39.62%)
10 (52.63%)
13 (34.21%)
4 (36.36%)
SJRP
22 (41.51%)
8 (42.11%)
14 (36.84%)
6 (54.55%)
Illiterate
3 (25.00%)
3 (25.00%)
6 (50.00%)
0 (0.00%)
0.211
Education
Less than 7 years
31 (50.82%)
9 (14.75%)
14 (22.95%)
7 (11.48%)
Less than 7 years
19 (39.58%)
7 (14.58%)
18 (37.50%)
4 (8.33%)
P-Value1 referring to the Chi-square test (P<0.05). * ** P-Value not determined due to lack of sampling
representativeness.
Table 6 shows the results from the association of the type of diabetes with the clinical variables
and the diseases related to diabetes. The results show that the type of diabetes was significantly
associated with dyslipidemia (P=0.019), given that all patients with type 1 diabetes did not show
dyslipidemia, in other words, this type of disease is associated with type 2 diabetes.
Table 6. Associative results of the type of diabetes type compared with the clinical variables
and the associated diseases. São José do Rio Preto (SP), Brazil.
P-Value1
Clinical variables and related
diseases
Type of diabetes
Type 1
Type 2
Nephropathy
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
17 (65.38%)
9 (34.62%)
24 (92.31%)
2 (7.69%)
22 (84.62%)
4 (15.38%)
26 (100%)
0 (0.00%)
18 (69.23%)
8 (30.77%)
23 (88.46%)
3 (11.54%)
25 (96.15%)
47 (69.12%)
21 (30.88%)
61 (89.71%)
7 (10.29%)
59 (86.76%)
9 (13.24%)
60 (88.24%)
8 (11.76%)
38 (55.88%)
30 (44.12%)
56 (82.35%)
12 (17.65%)
57 (83.82%)
Yes
1 (3.85%)
11 (16.18%)
Retinopathy
Nephropathy
Dyslipidemia
SAH
Osteomyelitis
Amputations
0.729
0.696
0.789
0.019
0.233
0.457
0.077
1
P-Value referring to the Chi-square test (P<0.05).
Table 7 shows the association between the Wagner classification compared with the clinical
variables and the diseases associated with diabetes.
Table 7. Associative results from the Wagner classification compared with the clinical variables
and the associated diseases. São José do Rio Preto (SP), Brazil.
Clinical variables and
Wagner classification
P-Value1
related diseases
Grade 0
Grade 1
Grade 2
Grade 3
Nephropathy
No
46 (44.66%)
16 (15.53%)
33 (32.04%)
8 (7.77%)
0.719
Yes
7 (38.89%)
3 (16.67%)
5 (27.78%)
3 (16.67%)
Retinopathy
No
51 (48.11%)
18 (16.98%)
29 (27.36%)
8 (7.55%)
0.010
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Yes
2 (13.33%)
1 (6.67%)
No
46 (44.66%)
16 (15.53%)
Yes
7 (38.89%)
3 (16.67%)
Dyslipidemia
No
47 (43.12%)
17 (15.60%)
Yes
6 (50.00%)
2 (16.67%)
SAH
No
37 (52.11%)
7 (9.86%)
Yes
16 (32.00%)
12 (24.00%)
Osteomyelitis No
51 (51.00%)
16 (16.00%)
Yes
2 (9.52%)
3 (14.29%)
Amputations
No
47 (45.19%)
18 (17.31%)
Yes
6 (35.29%)
1 (5.88%)
P-Value1 referring to the Chi-square test (P<0.05).
Nephropathy
DOI: 10.5205/reuol.9199-80250-1-SM1006201601
Sociodemographic and clinical factors of the
9 (60.00%)
33 (32.04%)
5 (27.78%)
36 (33.03%)
2 (16.67%)
23 (32.39%)
15 (30.00%)
28 (28.00%)
10 (47.62%)
31 (29.81%)
7 (41.18%)
3 (20.00%)
8 (7.77%)
3 (16.67%)
9 (8.26%)
2 (16.67%)
4 (5.63%)
7 (14.00%)
5 (5.00%)
6 (28.57%)
8 (7.69%)
3 (17.65%)
0.719
0.592
0.033
<0.001
0.290
Figure 1 shows a two-dimensional graph based on the Multiple Correspondence Analysis, showing
the location of each of the evaluated variables in the study referring to Diabetes and the Wagner
classification.
Figure 2. Two-dimensional graph referring to the multiple correspondence analysis. São José do
Rio Preto (SP), Brazil
DISCUSSION
According to the results in Table 1, most of the patients were male individuals of working age.
These findings are in accordance with a study performed on patients admitted to the Hospital de
Clínicas da Universidade Federal do Triângulo Mineiro in order to make a connection between
amputations and diabetes.10 There was also a quantitative cross-sectional study, whose goal was to
evaluate foot care in people with diabetes, that found a predominance of male individuals.11
However, these findings disagree with a study that evaluated quality of life and comorbidities in
elderly residents of Uberaba city, which showed a predominance of female individuals. 12 Similar
studies with a predominance of female individuals disagree with the findings from our study.13-14
In regards to the marital status results of our study, 71.07% of the evaluated individuals had a
spouse, which is an important factor in terms of the care process for the disease, namely given that
a supportive family structure reduces future complications and thusly improves quality of life for
the sufferer. When the sufferer lives alone there is a strong presence of contributing factors in the
genesis of diabetic foot ulcers.15-18
In regards to skin color there was an observed predominance of white individuals, which
corroborates a study that identified a connection between white patient’s knowledge regarding DM
and foot care2. These data disagree with a study conducted at a hospital in Salvador-BA, which was
evidenced by the significantly higher number of non-white diabetic patients19. In terms of origin,
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DOI: 10.5205/reuol.9199-80250-1-SM1006201601
Sociodemographic and clinical factors of the
most of the patients were from São Jose do Rio Preto, which is possibly because where the
specialist hospital is located.
The patients involved in our study had an incomplete elementary school education level, which is
important as poorly educated individuals are not aware of the contributing factors that trigger
chronic complications due to their inability to read and write, as well as in terms of their awareness
and adherence to treatment and self-care related to diabetes.2,13,20 As regards the profession,
44.63% of the individuals had an active working life, with the disease not being a contributing factor
to not working.
A cross-sectional study, which was performed on the adult population in the urban region of
Pernambuco city in 2008 and 2009, demonstrated that there was no prevalence of diabetes in
patients with hypertension, as was the case in our study.21 Analyzing the association between
diabetes and hypertension in another cross-sectional study, using micro data from the Brazilian
National Household Sample Survey in São Paulo, showed a disagreement with our findings in relation
to this association, since insulin therapy does not respond well to the effects of vascular resistance
in hypertensive patients, which is true even when antihypertensive medications are used, making
hypertensive patients vulnerable to developing diabetes.22 The Brazilian Diabetes Society highlights
that 90 to 95% of the clinical form of diabetes is the more common type 2.16,23 Findings from
research conducted in Londrina Paraná highlighted that factors such as obesity and physical
inactivity are associated with genetic factors and a longer-living population, thereby promoting
conditions for the emergence of the disease.24
The Wagner classification in our study was grade 0, i.e., absence of ulcers. This fact provided us
with information regarding the educational activities conducted in the aforementioned outpatient
clinic, showing the importance of collaborating for self-care and treatment adherence. Studies
indicate there are advantages in implementing education programs in diabetes, mainly in terms of
group actions that are aimed at reducing costs and improving effectiveness. The guidelines from
the Brazilian society of diabetes recommend that education in diabetes is the primary tool for
ensuring self care. This education is concerned with patient self-control and extends to the family
members and/or caregivers who have an affect on habit and behavior changes.16
It is worth highlighting that these actions must be performed by a multidisciplinary team in order
that these actions provide maximum effectivity. In this sense, the treatment’s effectiveness is
maximized, which confirms the improvement in clinical outcomes and quality of life.25
The results show that the grade of the wounds evaluated by the Wagner classification were
associated with retinopathy (P=0.010), SAH (P=0.033) and osteomyelitis (P<0.001). Most of the
patients with retinopathy showed a grade 2 on the Wagner classification, while most of those who
did not show retinopathy had grade 0. There was a similar pattern for the patients with
osteomyelitis, i.e., most patients with osteomyelitis were grade 2 in the Wagner wound
classification. As regards hypertension, most patients who did not show this condition were grade 0
in the Wagner wound classification.
These results demonstrate that alcoholism and smoking are neither significantly with the type of
diabetes nor the Wagner classification. 2 million Brazilians are estimated to have some grade of
diabetic retinopathy, and it is these individuals who are at risk of blindness. The fact is that if
retinopathy is detected early then this could be reduced by at least 5%.26 Retinopathy is a serious
problem in this population as it prevents or hinders evaluation. As regards the lesion condition,
according to the Wagner classification, 44% of the patients under study were observed with at grade
0, i.e., an absence of wounds; 16% at grade 1; 31% at grade 2 and 9% at grade 3. These data
disagree with a study conducted in the Brazilian state of Sergipe, within the Brazilian Unified Health
System (Sistema Único de Saúde - SUS), to estimate the direct costs of hospitalizations in the SUS,
which verified a wound predominance of grade 4 (45.9%) and grade 5 (18.3%) i.e. the patients’
wounds were in a more serious condition.17 During a descriptive cross-sectional study performed at a
Basic health Unit-Saúde Escola Marco linked to the State University of Pará, which investigated all
patients involved in the Hiperdia program, 72% of the participants were found to have plantar
callosities while 44% had a history of previous ulcers on their feet.18 In another study with a
quantitative descriptive approach, held at a Basic Health Unit in the State of Paraná, whose goal
was to evaluate the risk for diabetic foot of people involved in the Hiperdia program, showed that
16% of patients had ulcers on their feet or had had amputations, which represents a approximate
proportionality of one person with an ulcer or amputation for every six people evaluated.19
Figure 2 shows some interesting tendencies from a multivariate analysis point of view. Upon
evaluating the location of the variables in the two-dimensional graph, it is possible to assume that a
patient with grade 0 lesions on his/her diabetic foot will typically have type 1 diabetes. In addition,
Português/Inglês
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ISSN: 1981-8963
Jose DP, Almeida JS de, Rodrigues CDS et al.
patients...
DOI: 10.5205/reuol.9199-80250-1-SM1006201601
Sociodemographic and clinical factors of the
patients with grade 2 lesions, according to the Wagner classification, are usually retinopathy
sufferers. The presence of grade 3 lesions are related to hospitalization and amputation, i.e. the
most serious grade in our study that is related to hospitalization and a greater likelihood for
amputations. Grade 1 lesions are directly related to type 2 diabetes and patients with associated
diseases such as nephropathy, SAH, neuropathy and dyslipidemia, as well as with risk factors such as
smoking and alcoholism. Diabetic foot ulcers stem from a loss of protective sensation, factors such
as wearing inappropriate shoes, falling, erratic nail cutting and walking barefoot also contribute to
a high risker of developing ulcers.16,22-23. In regards to smoking, 16.53% of the participants were
smokers, which is a lower prevalence compared to national rates and is a determining factor for the
group under study. These risk factors have a gradual contribution towards the emergence and
deterioration of lesions on the foot, smoking in turn releases nicotine and causes vasoconstriction
within the blood vessel, thereby reducing the supply of oxygen and nutrients to the tissues, and can
even affect micro- and macrocirculation. 16 As regards alcoholism, the recommendation is to totally
restrict alcohol among diabetics, especially in people with diabetic neuropathy resulting from
deleterious effects to the body.27 Smoking causes an increase of lipid concentration by reducing
insulin sensitivity, therefore, tobacco consumption should be avoided, as information contained in
the literature states that 95% of amputees are smokers.16 Dyslipidemia is certainly associated with
type 2 diabetes, which acts directly on the pancreatic β-cells causing lipotoxicity and is present in
hospitalized patients with diabetes and foot ulcers in the SUS, and hyperglycemia which increases
the risk of cardiovascular diseases (CVD) by two to four times, as it causes atherosclerotic disease,
which can include coronary heart disease (CHD), peripheral vascular disease (PVD), cerebrovascular
disease that is responsible for 75% of deaths, and 50% by CHD.
Other important issues related to dyslipidemia are related to the presence of essential fatty
acids, which greatly contributes to the deterioration of Schuam cells’ function and triggers the
emergence of diabetic neuropathy.28 There are very few research projects in Brazil that are related
to amputation and diabetes. However, one study worth highlighting was performed in Sergipe that
screened 109 patients in order to compare the amounts that SUS paid to clinics/hospitals, 39.4% of
hospitalized individuals were discharged with no amputation; 47.7% discharged following
amputation; 12.8% died. The average cost of hospitalization is also an important piece of data,
which is seven times higher than the amount paid by SUS and reinforces the negative impact of
complications stemming from diabetic foot.29 However, during a retrospective study conducted
between 2009 and 2011 at a Chinese hospital on hospitalized individuals with ulcers on the feet, the
highest level of amputations was found in patients with Wagner classification grade 3, which
provides further evidence that there is no significant difference among the groups evaluated in
relation to how long the individual has had diabetes and educational program.30
CONCLUSION
The results from this study demonstrated that the sociodemographic and clinical factors of the
patients, from our study, diagnosed with type 1 and type 2 diabetes are in agreement with those of
other Brazilian studies. The diabetic patients were verified to be poorly educated white adult men
of working age who were in a stable relationship at the time. In regards to the clinical
characteristics, there was an observed predominance of type 2 diabetes, the Wagner classification
of which was grade 0 (High risk, no obvious ulcer). Our study made it possible to characterize the
population under investigation, which could assist professionals from the health care area. This
contribution would permeate knowledge regarding the prevention of diabetic foot in terms of
evaluating those at risk from diabetic foot, following the international prevention guidelines, as
well as the educational measures.
The results from our study indicate that it is necessary to have continuous educational
interventions from the earliest time, which will strengthen the prevention of the risk factors
mentioned here in programs performed by multidisciplinary teams from the healthcare profession.
It is worth mentioning that future studies are needed to guide further interventionist strategies.
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Submitted: 9/16/2015
Accepted: 4/28/2016
Published: 6/1/2016
Correspondence
Denilson Pereira Jose
Rua Professor Francisco Purita, 407, Ap.404
CEP 15084-090  São José do Rio Preto (SP), Brasil
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