Latest research to be presented at this 12 months’s Annual Meeting of the European Association for the Study of Diabetes (EASD) in Hamburg, Germany (2-6 October) shows that amongst individuals with type 1 and sort 2 diabetes, being divorced is related to a two-thirds higher risk of lower limb amputation (LLA) (amputations below the knee level) compared with being married, and being male is related to a 57% higher risk of LLA compared with being female. The study is by Dr Stefan Jansson, Örebro University, Örebro, Sweden, and colleagues.
Deterioration within the structure of each large and small blood vessels (macrovascular and microvascular complications) is common amongst individuals with diabetes, especially amongst those that are less adherent to diabetes medications to lower blood sugar, blood fats and blood pressure. Rates of LLA have been declining for a variety of years as diabetes treatment and control has improved.
Risk aspects for lower limb amputation (LLA) in individuals with diabetes have been under-studied. On this study, the authors examined how demographic and socioeconomic, medical and lifestyle risk aspects could also be related to LLA in individuals with newly diagnosed diabetes.
The authors used Swedish national register-linked data and identified, through the Swedish national diabetes register, all individuals 18 years or older with an incident diabetes diagnosis and no previous amputation from 2007 to 2016. These individuals were followed from the date of the diagnosis to amputation, emigration, death, or the tip of the study in 2017, whichever occurred first. On this study, 98% of participants had type 2 diabetes, and a pair of% type 1 diabetes.
Several national Swedish registers were used to acquire data on incident LLA and potential risk aspects, including demographic and socioeconomic, medical and lifestyle variables. Variables with greater than 40% missing data were excluded from the evaluation. The cohort consisted of 66,569 individuals, of whom 133 had an amputation through the median follow-up of 4 years. Computer modelling was used to discover associations of the potential risk aspects have with LLA incidence.
The authors found that being divorced compared with being married was related to a 67% higher risk of LLA, and being male compared with being female was related to a 57% higher risk of LLA. Annually of additional age was related to an 8% increased risk of LLA.
The authors suggest the upper risk of LLA in divorced people could also be on account of a change in self-care and food habits observed in people after they divorce and usually tend to be living alone. Specifically with men, this is usually related to more social isolation with a secondary effect of low physical activity.
Individuals with an increased foot risk at baseline had a better risk for LLA in comparison with individuals with healthy feet (neuropathy/angiopathy – 4 times increased risk, previous wounds (ulcers) – 8 times increased risk; ongoing severe foot disease – 11 times increased risk.
Insulin treatment compared with diet-only treatment was also related to double the danger of LLA. Hypertension and HbA1c (a way of measuring blood sugar control) weren’t statistically significantly related to LLA risk. Individuals with obesity had a lower than half the danger (46%) of LLA of individuals with normal weight, while smokers had double the danger of LLA compared with non-smokers. Finally, low physical activity (lower than once per week) was related to double the danger of LLA compared with every day physical activity.
As that is an statement study, the authors cannot ensure about why there may be a lower risk of LLA in people living with obesity. The authors say that this might be right down to likelihood, or an actual effect because individuals with obesity experience more foot ulceration (foot ulcers are by far an important risk factor for LLA), but they migth have higher wound healing than individuals with lower body mass through higher mobilisation of endothelial progenitor cells, as is the case amongst people living with obesity but without diabetes. Also, some people of normal weight could have lost weight on account of illness (reverse causality) putting them at a better relative risk of LLA.
The authors say, “This study found a better risk for LLA amongst individuals with higher age, male sex, who were divorced, who had a better foot risk group, who were on insulin treatment, lower physical activity levels, and people who were smoking. Obesity was related to a lower risk for LLA. Thus, these variables could have essential roles in LLA risk amongst individuals with diabetes.”
They add: “Lifestyle variables have a powerful association with LLA, and a rise in physcial activity, avoidance of being underweight and smoking cessation could also be impactful interventions to scale back the danger of LLA. Early lower limb complications after a diabetes diagnosis or complications present at diagnosis are warning signs, and these patients ought to be given extra attention The duration of diabetes versus higher age have been debated as risk aspects for LLA. We found that older age is related to a better risk for LLA even in individuals with a brief duration of diabetes; thus, older individuals with diabetes should receive extra attention even when the disease duration is comparatively short.”
The authors declare no conflict of interest
This press release is predicated on an early release of oral presentation 216 on the European Association for the Study of Diabetes (EASD) Annual Meeting in Hamburg, 2-6 October. All accepted abstracts have been extensively peer reviewed by the congress selection committee. There is no such thing as a full paper at this stage, however the authors are completely happy to reply your questions. The research has not yet been submitted to a medical journal for publication. Because it is an oral presentation there is no such thing as a poster available.