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Journal of Health Sciences and Medicine

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Original Article
The hidden impact: frailty and malnutrition in patients with diabetic foot ulcers
Abstract
Aims: Diabetic foot ulcers (DFUs) are a significant complication affecting over 30% of individuals with diabetes, leading to increased morbidity and mortality. This study investigates the relationships between frailty, nutritional status, and quality of life in patients aged 50 and older diagnosed with DFUs.
Methods: A total of 100 participants with DFUs were prospectively included in the study, with assessments conducted using the Edmonton Frailty Scale and the Mini Nutritional Assessment Scale. Quality of life was evaluated using the EQ-5D-3L scale. Demographic data, concomitant diseases, medications, HbA1c levels, and participants’ height, weight, and circumferences of the upper arm, calf, and waist were recorded. The data analysis was performed using statistical software.
Results: The findings revealed that 50% of patients exhibited varying degrees of frailty, and 85% were at risk of malnutrition. Both frailty and malnutrition were associated with a significant decline in quality of life. Notably, patients with normal nutritional status reported higher quality of life scores compared to those at risk of malnutrition or malnourishment.
Conclusion: This study underscores the need for a holistic approach to managing DFUs that integrates frailty and nutritional status assessments. Targeted interventions addressing these factors are essential for improving health outcomes and enhancing the quality of life for individuals living with diabetes. The findings advocate a shift from a narrow focus on wound management to a broader, more comprehensive care strategy.

Keywords : Diabetic foot ulcers, frailty, nutrition, quality of life

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1. Sinclair A, Saeedi P, Kaundal A, Karuranga S, Malanda B, Williams R. Diabetes and global ageing among 65-99-year-old adults: findings from the International Diabetes Federation Diabetes Atlas, 9<sup>th</sup> edition. Diabetes Res Clin Pract. 2020;162:108078. doi:10.1016/j.diabres.2020. 108078
2. Y&uuml;celer Ka&ccedil;maz H, Kahraman H, Akın S, S&ouml;z&uuml;er E. The effects of frailty on quality of recovery and complications in older adults undergoing major abdominal surgery: a prospective cohort study. J Health Sci Med. 2023;6(5):1133-1141. doi:10.32322/jhsm.1350264
3. B&ocirc;as NCRV, Salom&eacute; GM, Ferreira LM. Frailty syndrome and functional disability among older adults with and without diabetes and foot ulcers. J Wound Care. 2018;27(7):409-416. doi:10.12968/jowc.2018.27.7.409
4. Aydemir A, Yıldırım G&uuml;rkan D, Kapukaya EE, Korkmaz M. The investigation of frailty level and factors affecting frailty in older adults with osteoarthritis; a cross-sectional study on Turkish population. J Health Sci Med. 2024;7(4):387-394. doi:10.32322/jhsm.1453110
5. Sinclair AJ, Abdelhafiz AH. Unravelling the frailty syndrome in diabetes. Lancet Healthy Longev. 2021;2(11):e683-e684. doi:10.1016/S2666-7568 (21)00256-7
6. Fernando ME, Blanchette V, Mishra R, et al. Frailty in people with chronic limb threatening ischemia and diabetes-related foot ulcers: a systematic review. Ann Vasc Surg. 2023;89:322-337. doi:10.1016/j.avsg. 2022.09.057
7. Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016;33(11):1493-1498. doi:10.1111/dme. 13054
8. Maltese G, Basile G, Meehan H, et al. Frailty is associated with impaired diabetic foot ulcer healing and all-cause re-hospitalization. J Nutr Health Aging. 2022;26(2):169-173. doi:10.1007/s12603-022-1726-7
9. Tamura Y, Omura T, Toyoshima K, Araki A. Nutrition management in older adults with diabetes: a review on the importance of shifting prevention strategies from metabolic syndrome to frailty. Nutrients. 2020;12(11):3367. doi:10.3390/nu12113367
10. Ni Lochlainn M, Cox NJ, Wilson T, et al. Nutrition and frailty: opportunities for prevention and treatment. Nutrients. 2021;13(7):2349. doi:10.3390/nu13072349
11. Da Porto A, Miranda C, Brosolo G, Zanette G, Michelli A, Ros RD. Nutritional supplementation on wound healing in diabetic foot: what is known and what is new? World J Diabetes. 2022;13(11):940-948. doi:10. 4239/wjd.v13.i11.940
12. Brookes JDL, Jaya JS, Tran H, et al. Broad-ranging nutritional deficiencies predict amputation in diabetic foot ulcers. Int J Low Extrem Wounds. 2020;19(1):27-33. doi:10.1177/1534734619876779
13. Hong J, Huang QQ, Liu WY, et al. Three nutritional indices are effective predictors of mortality in patients with type 2 diabetes and foot ulcers. Front Nutr. 2022;9:851274. doi:10.3389/fnut.2022.851274
14. Arshad MA, Arshad S, Arshad S, Arshad S, Abbas H. The quality of life in patients with diabetic foot ulcers. J Diab Metab. 2020;11(2):1-2. doi:10.35248/2155-6156.20.11.e101
15. Pedras S, Carvalho R, Pereira MG. Quality of life in Portuguese patients with diabetic foot ulcer before and after an amputation surgery. Int J Behav Med. 2016;23(6):714-721. doi:10.1007/s12529-016-9567-6
16. Argyriou C, Dimitriadou I, Saridi M, Toska A, Lavdaniti M, Fradelos EC. Assessment of the relation between depression, frailty, nutrition and quality of life among older adults: findings from a cross-sectional study in Greece. Psychogeriatrics. 2024;24(5):1065-1074. doi:10.1111/psyg.13160
17. Rolfson DB, Majumdar SR, Tsuyuki RT, Tahir A, Rockwood K. Validity and reliability of the Edmonton Frail Scale. Age Ageing. 2006;35(5):526-529. doi:10.1093/ageing/afl041
18. Ayg&ouml;r HE, Fadıloğlu &Ccedil;, Şahin S, Aykar FŞ, Ak&ccedil;i&ccedil;ek F. Validation of Edmonton Frail Scale into elderly Turkish population. Arch Gerontol Geriatr. 2018;76:133-137. doi:10.1016/j.archger.2018.02.003
19. Navarro-Flores E, de Bengoa Vallejo RB, Losa-Iglesias ME, et al. The reliability, validity, and sensitivity of the Edmonton Frail Scale (EFS) in older adults with foot disorders. Aging (Albany NY). 2020;12(24):24623-24632. doi:10.18632/aging.202140
20. Cereda E. Mini nutritional assessment. Curr Opin Clin Nutr Metab Care. 2012;15(1):29-41. doi:10.1097/MCO.0b013e32834d7647
21. EuroQol Group. EuroQol-a new facility for the measurement of health-related quality of life. Health Policy. 1990;16(3):199-208. doi:10.1016/ 0168-8510(90)90421-9
22. Byrnes J, Ward L, Jensen S, et al. Health-related quality of life in people with different diabetes-related foot ulcer health states: a cross-sectional study of healed, non-infected, infected, hospitalised and amputated ulcer states. Diabetes Res Clin Pract. 2024;207:111061. doi:10.1016/j.diabres.2023.111061
23. Maity S, Leton N, Nayak N, et al. A systematic review of diabetic foot infections: pathogenesis, diagnosis, and management strategies. Front Clin Diabetes Healthc. 2024;5:1393309. doi:10.3389/fcdhc.2024.1393309
24. Wang A, Lv G, Cheng X, et al. Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition). Burns Trauma. 2020;8:tkaa017. doi:10.1093/burnst/tkaa017
25. Sinclair A, Bellary S, Dhatariya KK. Diabetes in older adults-time to include frailty as a care indicator. Diabet Med. 2021;38(5):e14560. doi:10. 1111/dme.14560
26. Alshanberi AM. Frailty in the Kingdom of Saudi Arabia-prevalence and management, where are we? Healthcare. 2023;11(12):1715. doi:10.3390/healthcare11121715
27. Lauwers P, Dirinck E, Van Bouwel S, et al. Malnutrition and its relation with diabetic foot ulcer severity and outcome: a review. Acta Clin Belg. 2022;77(1):79-85. doi:10.1080/17843286.2020.1800315
28. Kurian SJ, Baral T, Unnikrishnan MK, et al. The association between micronutrient levels and diabetic foot ulcer: a systematic review with meta-analysis. Front Endocrinol (Lausanne). 2023;14:1152854. doi:10. 3389/fendo.2023.1152854
29. Basiri R, Spicer MT, Ledermann T, Arjmandi BH. Effects of nutrition intervention on blood glucose, body composition, and phase angle in obese and overweight patients with diabetic foot ulcers. Nutrients. 2022; 14(17):3564. doi:10.3390/nu14173564
30. Deng L, Du C, Song P, et al. The role of oxidative stress and antioxidants in diabetic wound healing. Oxid Med Cell Longev. 2021;2021:8852759. doi:10.1155/2021/8852759
31. Basiri R, Spicer M, Levenson C, Ledermann T, Akhavan N, Arjmandi B. Improving dietary intake of essential nutrients can ameliorate inflammation in patients with diabetic foot ulcers. Nutrients. 2022; 14(12):2393. doi:10.3390/nu14122393
32. Basiri R, Spicer MT, Levenson CW, Ormsbee MJ, Ledermann T, Arjmandi BH. Nutritional supplementation concurrent with nutrition education accelerates the wound healing process in patients with diabetic foot ulcers. Biomedicines. 2020;8(8):263. doi:10.3390/biomedicines8080263
33. Armstrong DG, Mills JL, Molina M, Molnar JA. Nutrition interventions in adults with diabetic foot ulcers. Guideline Central. 2021. Accessed February 23, 2022. http://eguideline.guidelinecentral.com/i/1428995-nutrition-in-dfu-guidelines-advisory-pocket-guide/0?
34. Luo R, Ji Y, Liu YH, Sun H, Tang S, Li X. Relationships among social support, coping style, self-stigma, and quality of life in patients with diabetic foot ulcer: a multicentre, cross-sectional study. Int Wound J. 2023;20(3):716-724. doi:10.1111/iwj.13914
35. Hanlon P, Faur&eacute; I, Corcoran N, et al. Frailty measurement, prevalence, incidence, and clinical implications in people with diabetes: a systematic review and study-level meta-analysis. Lancet Healthy Longev. 2020;1(3): e106-e116. doi:10.1016/S2666-7568(20)30014-3
36. Chao CT, Wang J, Chien KL; COhort of GEriatric Nephrology in NTUH (COGENT) study group. Both pre-frailty and frailty increase healthcare utilization and adverse health outcomes in patients with type 2 diabetes mellitus. Cardiovasc Diabetol. 2018;17(1):130. doi:10.1186/s12933-018-0772-2
37. Chittrakul J, Siviroj P, Sungkarat S, Sapbamrer R. Multi-system physical exercise intervention for fall prevention and quality of life in pre-frail older adults: a randomized controlled trial. Int J Environ Res Public Health. 2020;17(9):3102. doi:10.3390/ijerph17093102
38. Nakazeko T, Shobako N, Shioya N, et al. Frailty-preventing effect of an intervention program using a novel complete nutritional &ldquo;COMB-FP meal&rdquo;: a pilot randomized control trial. Nutrients. 2023;15(20):4317. doi:10.3390/nu15204317
39. Peng LN, Cheng YC, Yu PC, Lee WJ, Lin MH, Chen LK. Oral nutritional supplement with &beta;-hydroxy-&beta;-methylbutyrate (HMB) improves nutrition, physical performance and ameliorates intramuscular adiposity in pre-frail older adults: a randomized controlled trial. J Nutr Health Aging. 2021;25(6):767-773. doi:10.1007/s12603-021-1621-7
40. Zhang T, Qin J, Guo J, et al. Prevalence and influencing factors of malnutrition in diabetic patients: a systematic review and meta-analysis. J Diabetes. 2024;16(10):e13610. doi:10.1111/1753-0407.13610
41. Wang YC, Liang CK, Chou MH, et al. The effectiveness of frailty intervention for older patients with frailty during hospitalization. J Nutr Health Aging. 2023;27(6):413-420. doi:10.1007/s12603-023-1924-y
42. Kim J, Nomkhondorj O, An CY, Choi YC, Cho J. Management of diabetic foot ulcers: a narrative review. J Yeungnam Med Sci. 2023;40(4):335-342. doi:10.12701/jyms.2023.00682
43. Hansen CA, Hjelmgaard CMH, Kristensen M&Oslash;, Berthelsen C. Patient involvement in diabetes-related foot ulcers: what do patients need and prefer when undergoing treatment at multidisciplinary outpatient foot centres? A phenomenological hermeneutic study. Int Wound J. 2024; 21(12):e70128. doi:10.1111/iwj.70128
Article available in :
Volume 8, Issue 2, 2025
Page : 262-268
https://doi.org/10.32322/jhsm.1608035
Article Information
Received : 26 Ara 2024
Accepted : 07 Şub 2025
Published : 21 Mar 2025
Corresponding Author :

Levent Demir: Department of Underwater and Hyperbaric Medicine, Kayseri City Training and Research Hospital, Kayseri, Turkiye

[email protected]
Citation : Demir L, Avcı M, Kahraman M, Kılıç S. The hidden impact: frailty and malnutrition in patients with diabetic foot ulcers. J Health Sci Med. 2025;8(2):262-268.

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