Socio-Demographic Risk Factors Associated with Diabetic Foot Ulcer in India: A Case Control Study

ABSTRACT

Background:

Diabetic foot ulcers (DFU) are a devastating complication of diabetes mellitus, having a significant impact on the quality of life of patients and indeed putting an enormous burden on health care systems, especially in low- and middle-income countries like India. Understanding socio-demographic risk factors is, therefore, essential in designing successful prevention strategies adapted to the Indian population.

Methods:

The duration was one year, and the study was conducted in India on 150 cases. Cases consisted of patients with diabetic foot ulcers, while controls were diabetic patients without foot ulcers, consisting of 75 cases and 75 controls, respectively. Information on socio-demographic variables, history, and lifestyle factors was collected through structured interviews and medical records. Logistic regression analysis was used to identify risk factors independently associated with DFU.

Results:

Low socioeconomic status was significantly associated with an increased risk of DFU (OR = 3.45, 95% CI: 2.1–5.7), as were poor glycemic control (HbA1c >8%) (OR = 2.96, 95% CI: 1.9–4.8), living in a rural area (OR = 2.72, 95% CI: 1.8–4.1), and lack of formal education (OR = 2.30, 95% CI: 1.5–3.5). Risk factors were smoking, diabetes of more than 10 years’ duration, and history of bad foot care practice.

Conclusion:

Socioeconomic disparities and lack of awareness about diabetic foot care contribute significantly to the DFU burden in India. Targeted interventions, education, better glycemic control, and accessible health services are ultimately needed to manage this potentially preventable complication.

INTRODUCTION

Distinguish DFUs as a severe complication of diabetes mellitus, wherein ulcers do not heal due to the progression of chronic wounds, leading to infections, amputation, and increased mortality.[1] Affects 15–25% of the diabetic population of the world; more common in low and middle-income countries like India, described as the “diabetes capital of the world”.[2] Peripheral neuropathy, vascular insufficiency, and impaired wound healing form part of the socio-demographic factors in its etiology. Low socio-economic status, lesser education level, and restricted access to medical facilities constitute part of these socio-demographic factors. Added to this, it is due to the non-awareness among the rural folks regarding foot diseases and the diminutive healthcare set up that is making the whole situation worse.[3]

The objective of the present case-control study was to identify and determine socio-demographic risk factors causing DFU in India. It may gain a foundation upon which it is able to devise recommendations on focused interventions toward the prevention and early diagnosis that take equitable access towards diabetic foot care.

METHODOLOGY

This was a case-control study, conducted over a one-year period among 150 patients. The cases were 75 diabetic patients with diabetic foot ulcers (DFU), and controls were 75 diabetic patients without DFU. The participants were selected through purposive sampling from outpatient clinics and diabetic care centres. Inclusion criteria: the patients who had ages ranging between 30 and 70 years and diagnosed with type 2 diabetes mellitus for more than one year. The exclusion criteria: other chronic foot conditions or non-diabetic ulcers. Structured interviews and a review of the medical records have been used for collecting data. All the socio-demographic variables, including age, gender, education, income, residence, and lifestyle habits, have been recorded. Clinical parameters, such as duration of diabetes, glycemic control-HbA1c level-and comorbid conditions-were also recorded. In the case group, foot ulcers were classified using the Wagner classification system. Statistical analysis was performed using SPSS software. Descriptive statistics were used to characterize the participants, and logistic regression analysis was used to identify the independent risk factors for DFU. The odds ratios (ORs) with 95% confidence intervals (CIs) were computed, and the results with a P value of <0.05 were taken to be statistically significant. The institutional ethics committee gave its ethical approval, and informed consent was taken from all participants.

RESULTS

150 patients were engaged in the analysis with equal participants from the case group (diabetic patients with DFU) and the control group (diabetic patients without DFU). The results are tabulated in the following tables.

Table 1 shows the socio-demographic characteristics of the participants, highlighting significant differences between the case and control groups.

Table 1.

Socio-demographic characteristics

Parameter	Case Group (%) (n=75)	Control Group (%) (n=75)	P
Male	58% (43)	55% (41)	0.72
Rural Residence	64% (48)	38% (29)	<0.01*
No Formal Education	40% (30)	20% (15)	<0.01*
Low Socioeconomic Status	67% (50)	36% (27)	<0.01*

Table 2 highlights the clinical characteristics, including glycemic control and duration of diabetes, among the two groups.

Table 2.

Clinical characteristics

Parameter	Case Group (%) (n=75)	Control Group (%) (n=75)	P
HbA1c >8%	73% (55)	42% (32)	<0.01*
Diabetes Duration >10 years	68% (51)	44% (33)	<0.01*
Hypertension	56% (42)	40% (30)	0.03*
Smoking	34% (26)	16% (12)	<0.01*

Table 3 shows the prevalence of inadequate foot care practices among the two groups, revealing significant gaps in awareness and preventive measures.

Table 3.

Foot care practices

Parameter	Case Group (%) (n=75)	Control Group (%) (n=75)	P
Inadequate Foot Hygiene	58% (43)	22% (17)	<0.01*
Lack of Regular Foot Examination	68% (51)	30% (23)	<0.01*
Walking Barefoot	45% (34)	12% (9)	<0.01*

Table 4 evaluates the distribution of foot ulcer grades in the case group using the Wagner classification system.

Table 4.

Wagner classification of foot ulcers

Wagner Grade	Frequency (%)
Grade 1 (Superficial Ulcer)	25% (19)
Grade 2 (Deep Ulcer)	40% (30)
Grade 3 (Abscess/Osteomyelitis)	20% (15)
Grade 4 (Gangrene of Toes)	15% (11)

Table 5 summarizes the risk factors identified through logistic regression analysis, providing odds ratios for significant predictors of DFU.

Table 5.

Risk Factors for diabetic foot ulcer

Risk Factor	Odds Ratio (OR)	95% Confidence Interval (CI)	P
Low Socioeconomic Status	3.45	2.1–5.7	<0.01*
HbA1c >8%	2.96	1.9–4.8	<0.01*
Rural Residence	2.72	1.8–4.1	<0.01*
Smoking	1.94	1.2–3.3	0.02*

DISCUSSION

This case-control study highlights socio-demographic and clinical factors significantly associated with diabetic foot ulcers in India. The results revealed low socioeconomic status, poor glycemic control (HbA1c >8%), rural residence, and no formal education as critical risk factors for DFU.[4] Results are consistent with the worldwide studies, which point out the DFU as a multifactorial condition combining biologic, behavioral, and environmental determinants. The risk of DFU was higher in rural populations, primarily because of limited access to a health facility, low knowledge about proper foot care, and the widespread habit of walking barefoot.[5] Risks were also elevated with smoking and longer diabetes duration, possibly linked to impairments in vascular and immune function. This high prevalence of poor foot hygiene and absence of regular foot examination at case group point out an urgent requirement for targeted educational interventions at the promotion of preventive practices. Despite the progress that has been made in the management of diabetes, this study signifies the ever-present effect of socio-economic disparities on health outcomes in India. About these inequalities, the multifaceted approach must focus on patient education, enhanced healthcare access, and screening programs targeting the high-risk population.[6]

CONCLUSION

Again, low socio-economic status and poor glycemic control have surfaced as common risk factors in the current research but, in particular, show how inappropriate foot-care practices in Indians develop diabetic foot ulcers. Education, prevention, and proper access to healthcare reduce the burden of complications developing from the disease and redress disadvantages, that have greatly enhanced patient outcomes among a resource-scarce population.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.