|Year : 2021 | Volume
| Issue : 1 | Page : 16-28
Short screening for diabetic foot disease in an omani population at Al-Dahira, Sultanate of Oman: A cross-sectional study
Sabria A L Marshoudi1, Fatma Ahmed2, Syed Wali Peeran3, Amru AlBurji4, Khalid Al-Kalbani5, Sabri M Yousf5
1 Department of Communicable Diseases, Directorate General For Disease Surveillance and Control, Oman
2 Department of Preventive Dentistry, Faculty of Dentistry, Sebha University, Sebha, Libya
3 Senior Registrar, Armed Forces Hospital Jizan, Jizan, KSA
4 Senior Specialist Surgery, Ibri Hospital, Ministry of Health, Oman
5 Medical Officer, Ibri Hospital, Ministry of Health, Oman
|Date of Submission||06-Feb-2021|
|Date of Acceptance||13-Feb-2021|
|Date of Web Publication||14-May-2021|
Sabria A L Marshoudi
Department of Communicable Diseases, Directorate General For Disease Surveillance and Control
Source of Support: None, Conflict of Interest: None
Objective: This study aims to implement a short primary health-care screening program for diabetic foot disease (DFD) in diabetic patients and to detect the prevalence and predictors of the DFD, to determine their positive risk factors for DFD by identifying patients who have neuropathy or vascular disease, and to examine whether the predictors (neuropathy and vasculopathy) have a significant effect on DFD. Subjects and Methods: This study is a cross-sectional study conducted in different diabetic clinics located in health centers across Al-Dahira, Oman. A single, trained clinician from each health center was selected to complete the questionnaire. The sample was randomly selected among subjects already diagnosed as diabetic patients. The study was carried from July 2017 to September 2017. Diabetes mellitus (DM) patients (Type-1 and Type-2) can be affected by DFD. In Al-Dahira, Oman, both Type-I and Type-II DM visited the same clinics. The screening carried out consisted of sections dealing with information of the subjects including their smoking status, number of visits, and details about their diabetic status. A detailed examination of DF was carried over if present in the subjects. The areas that were screened for DF included skin assessment, structural examination of the DF, vascular assessment, neuropathy assessment, as well as DF ulcer assessment. Results: Out of 216 patients, the mean age was 60.56 years (standard deviation 12.74) with a range of 25 years to 97 years. Out of the total patients, there were (164 patients) 75.9% of cases are DFD. However, the prevalence of foot ulcer, gangrene, and amputations were 4.2%. Among the studied subjects, 65.9% had poor glycemic profile value. Most of the patients had a history of diabetes for more than 5 years. The results showed that the age (P = 0.038 < 0.05), physical activity (P = 0.034 < 0.05), and neuropathy (P = 0.33 < 0.05) had an association with DFD. Conclusions: A short primary health-care screening program for DFD in diabetic patients is considered a useful tool and a helpful method to increase the awareness of DFD at the community level. Further, it helps to evaluate the level of the patient's risk for prevention and further management.
Keywords: Amputation, diabetes complications, diabetes mellitus, diabetic neuropathies, epidemiology, foot ulcer, Oman, peripheral arterial disease
|How to cite this article:|
L Marshoudi SA, Ahmed F, Peeran SW, AlBurji A, Al-Kalbani K, Yousf SM. Short screening for diabetic foot disease in an omani population at Al-Dahira, Sultanate of Oman: A cross-sectional study. Dent Med Res 2021;9:16-28
|How to cite this URL:|
L Marshoudi SA, Ahmed F, Peeran SW, AlBurji A, Al-Kalbani K, Yousf SM. Short screening for diabetic foot disease in an omani population at Al-Dahira, Sultanate of Oman: A cross-sectional study. Dent Med Res [serial online] 2021 [cited 2021 Dec 2];9:16-28. Available from: https://www.dmrjournal.org/text.asp?2021/9/1/16/315965
| Introduction|| |
Diabetes mellitus (DM) is defined as “a group of metabolic diseases characterized by high blood sugar resulting from defects in insulin secretion, insulin action, or both.” DM is widely prevalent epidemic across the globe. In 2013, global statistics indicated that 382 million people had DM and in 2035, it is expected to reach 592 million. The prevalence of DM was approximately 8.4% worldwide by 2014 with type 2 diabetes making up the majority of cases.,,, According to the CDC report 2016, there were around 29 million Americans living with diabetes.
Moreover, in recent years, DM due to change in lifestyle, rampant intake of carbohydrate-rich postmodern food a rampant rise in DM is noted in the developing world. Arabic-speaking countries are no exception to this. The International Diabetes Federation has noted that Kuwait, Saudi Arabia, Qatar, and Bahrain, four Arabic-speaking countries are among the top 10 in global diabetes prevalence per capita. A concomitant rise in spending for diabetes is also expected along with the surge in DM cases.
The American Diabetic Association states that diabetic patients with chronic poor glycemic profile have a predilection to long-term damage, dysfunction, and failure of different body organs, resulting in multiple microvascular and macrovascular complications. Diabetic foot disease (DFD) is one of the microvascular complications of DM. It is a complex foot condition with peripheral neuropathy and vascular disease, complicated by infection leading to foot ulceration and is generally treated with lower limb amputation.,,
In the United States alone, the related cost of DM was $101.4 billion in 2013. This indicates that DM is the most significant and expensive medical condition. A number of studies show that DFD is highly prevalent, severe, and costly., Moreover, scientific literature shows high morbidity and early mortality in patients with DFD. The predisposing factors for DFD are infection, long duration of DM, low economic status, neuropathy, old age, smoking, tight footwear, trauma, uncontrolled glycemia, and vasculopathy.,
Studies show that amputation due to complications of DM leads to a greater reduction in quality of life more than other DM complications such as end-stage renal failure and blindness. Moreover, DFD is usually associated with an increase in the risk of cardiovascular and other mortality conditions., In addition, DFD also increases hospitalization leading to an increase in both the direct and indirect health-care costs. This increase can have a detrimental effect on the overall health-care costs and can be a cumulative burden on the budget, especially of developing countries.,
Globally, the number of diabetes cases is on the rise. Studies have noted a steady rise in the incidence and prevalence of DM in the developing world. Further, the estimations about this rise of DM among the majority of Arabic-speaking countries are worrisome as the number of people with DM is projected to increase by 96.2%., Oman is a seafaring, mineral-rich kingdom located at the southeastern tip of the Arabian Peninsula overlooking the Arabian Gulf, the Gulf of Oman, and the Arabian sea. It borders the United Arab Emirates, Saudi Arabia, and Yemen. By 2017, the total population in Oman is around is 4,708,006 people. The prevalence of DM in Oman was reported after age adjustment in 2015 as 14.8%. By 2010, DM was the fourth common cause of early death and the third prevalent cause of disability-adjusted life years lost among the Omani population. Hence, the ministry of health in Oman under its national health program has taken up the task of providing free DM screening for the general population and free treatment for DM patients. A quarter of all the outpatient attendance in regional hospitals and a considerable adult hospital admissions (9%), hospital bed occupancy (12%) on adhoc basis according to the WHO are caused by DM. Personal communication with the biostatistic department registering the diseases of public health concern informed that 6161 individuals suffer from DM among the general population of Al-Dahira (147,104 people).
In Oman, the DM patients get treatment at a primary health-care center which includes a primary care physician or family doctor, a diabetes practice nurse, and a dietitian. They provide all diabetic care support. Primary care professionals follow local DM guidelines. A mandatory annual foot examination is carried over in all known DM patients., This assessment includes “skin abnormalities, structural deformities, protective sensation, circulation, and footwear.” Each patient with DFD is assigned a trained nurse for care and health education. Further, the ministry of health by 2013 had 25 specialized nurses in DM assigned training nurses working in diabetic units across the Sultanate.
The examination of the lower limb for DM patients with complications is referred to the diabetologist. Primary health-care centers are busy and at times, lack advanced equipment and adequate training for staff to carry over neurological and vascular assessment. Hence, referral to a diabetologist is preferred.,
Aims and objectives
Implementation of a short primary health-care screening program for DFD in diabetic patients:
- To detect the prevalence and predictors of the DFD
- To study the association between neuropathy and vasculopathy with DFD in DM patients in Ibri, Al-Dahira region, Oman.
| Subjects and Methods|| |
This study is a cross-sectional study conducted in different diabetic clinics in health centers across Ibri, Al-Dahira region, Oman. A single, trained clinician from each health center was selected to complete the questionnaire. The sample was randomly selected among subjects already diagnosed as DM patients. The study was carried from July 2017 to September 2017. In Al-Dahira, Oman, both Type-I and Type-II DM visited the same clinics. The health centers, which had the highest attendance of DM patients were chosen for the study. The screening carried out consisted of sections dealing with information of the subjects including their smoking status, number of visits. Moreover, in patients with DFD, a detailed examination of DF was performed. The areas that were screened for DF included skin assessment, structural examination of the DF, vascular assessment, neuropathy assessment, as well as DF ulcer assessment.
Source and study population
The subject population is derived from five different health centers out of 13 health centers. Patients with both Type 1 and Type 2 diabetes visited the same clinics for treatment in Al-Dahira, Oman. Therefore, to avoid bias, the sample was drawn randomly from among the pool of subjects that consisted of both diabetic Type-1 and Type-2 patients.
- All diabetes patients were included in this study who attend the diabetic follow-up at the diabetic clinic at the five health centers.
- Those with prior knowledge of having DFD
- Ambulatory patients
- Patients with psychological problems/those who cannot communicate.
Variables in the study
The dependent variable of DFD includes skin appearance, structure assessment, vascular assessment, neuropathy assessment, DF ulcer assessment, gangrene, and amputation if done.
The independent variables are as follows:
- Sociodemographic variables such as age and gender
- Clinical factors: HbA1C, comorbidity (additionally known disease), category of diabetes, peripheral vascular disease, neuropathy, and duration of DM.
A single examiner interviewed the participants. A structured questionnaire was used [Appendix 1and 2]. The questions included demographic characteristics (age and gender), risk factors assessment (history of smoking, type and duration of DM, type of treatment, hypertension, dyslipidemia, and physical activity), and presence or absence of DF lesions (ulcer, callus, foot deformity, gangrene, and amputation). The history of DM retinopathy, DM nephropathy, and the results of HbA1C within the previous 6–12 months were taken from the patient's records.
An examination of both feet was carried over with the skin assessment, which included examination of the skin condition, temperature, color, onychomycosis, hair loss, callus, and tinea. Further, foot ulcer, foot deformity, Charcot, and amputation if present were recorded. Vasculopathy assessment was then done by palpating the dorsalis pedis and posterior tibial pulse. It is followed by the recording of intermittent claudication is present. A neuropathy assessment was then performed by assessing the pressure perception using a 10 g Semmes-Weinstein monofilament. In addition, a tunic fork 128 GHz and ankle jerk by a medical hummer were used to examine the vibration sense.
Participants who showed positive signs for DFD were referred to the specialist. Moreover, for participants who had ulcer, or gangrene, the ulcer assessment form was completed and then referred to the specialist for further treatment. Finally, health education was provided for DM patients who did not show signs of DFD.
The data were statistically analyzed using SPSS Inc., 233 South Wacker Drive, 11th Floor, Chicago, IL, USA. The prevalence of the predictors; age, gender, duration of DM, smoking status, history of hypertension, hyperlipidemia, neuropathy, and ischemia and their association with DFD in the studied population was analyzed using bivariate and multiple regression analysis. Descriptive analysis was done to analyze the characteristics of the studied population by using different variables.
The study was approved by the Ethics committee of the Ministry of Health, Directors General of Health Affairs, Al-Dahira Governorate, Oman [Appendix 2]. The study was explained to all the participants in the vernacular language and informed consent was obtained from all the subjects. The enrollment in this study was voluntary; the participants were free to leave the study if and when they may choose to do so. Moreover, to ensure participant's confidentiality, personal identifiers were not included in the written questionnaires.
| Results|| |
The total sample size was 216, out of which 163 (80.6%) participants had DFD. The total subjects with foot ulcer, amputation, and gangrene among the sample were 2.3%, 1.4%, and 0.5%, respectively. The sample had 21.3% with vasculopathy and 31.0% with neuropathy [Table 1],[Table 2],[Table 3].
|Table 2: Basic descriptive analysis (mean, standard deviation, number, and percentage) of independent variables|
Click here to view
|Table 3: Univariate odds ratio and confidence interval (95% confidence interval) for patients with diabetic foot disease|
Click here to view
The mean age of the studied sample was 60.56 years (standard deviation 12.74) with a range of 25 years to 97 years. The female patients were more than male patients which was 55.6% and 44.4%, respectively. All the participants were Omani. None of the participants refused to participate in the study or withdrew from the study [Table 2].
Among the total sample, 64.4% had abnormal HbA1C values more than or equal to 7. Of the participants examined, 86.1% had hypertension, and 91.2% of them had dyslipidemia. The average duration of DM was 6.82 years. Among the participants, 52.3% of the patients had DM for <5 years, 24.1% had DM up to 10 years, and around 23.7% of the total patients had it for more than 10 years. Moreover, 13.4% of the studied subjects had nephropathy and 12.5% had retinopathy. Majority of the participants (75.3%) were on the oral hypoglycemic agent. The study also showed that the majority of the studied sample (55.1%) was physically active [Table 2].
Diabetic foot disease
Among the studied subjects, females were affected by DFD more than the males. However, this difference was insignificant when ulcer, gangrene, and amputation across genders are taken into account with age, glycemic control level, smoking status, hypertension, DM nephropathy, and vasculopathy. Out of the participants affected by DFD, majority of them (60.0%) had DM duration of more than 5 years. The number of cases of foot ulcer is more than the number of cases with gangrene and amputation. Subjects with dyslipidemia, less than prescribed physical activity, on treatment, DM retinopathy and neuropathy (P = 0.013 < 0.05, P = 0.012 <0.05, P = 0.004 < 0.05, P = 0.00 < 0.05, P = 0.003 <0.05, respectively) had a statistically significant relationship with foot ulcer when bivariate analysis was used. Moreover, the bivariate analysis showed that there is a statistically significant relation between DM nephropathy (P = 0.006 < 0.05) and foot amputation [Table 3].
Positive risk factors for diabetic foot disease, neuropathy, and vasculopathy
The most frequent chronic complication in subjects with DFD was neuropathy, followed by vasculopathy. Out of the total subjects studied (n = 216), 31.0% and 21.3% had diabetic neuropathy and vasculopathy, respectively. The prevalence of neuropathy and vasculopathy was more in males compared to females and increased with an increase with age. Further, in our sample, more subjects had neuropathy compared to vasculopathy at age 55 years and above. The results also showed that the risk of neuropathy and vasculopathy increased in patients who had poor glycemic control and duration of DM for more than 5 years. Further, most of the subjects with neuropathy had dyslipidemia (P = 0.05 = 0.05), DM retinopathy (P = 0.008 < 0.05), and were only on treatment (P = 0.006 < 0.05). The relationship was statistically significant. In addition, majority of the subjects with vasculopathy were only on oral hypoglycemic agents (P = 0.013 < 0.05). This relationship was significant [Table 4].
|Table 4: Univariate odds ratio and confidence interval (95% confidence interval) for positive risk factors (neuropathy and vasculopathy) for diabetic foot disease|
Click here to view
A binary logistic regression was conducted to examine whether gender, age, smoking status, hypertension, dyslipidemia, duration of DM, diabetic nephropathy, diabetic retinopathy, physical activity, neuropathy, vasculopathy, and HbA1C had a significant association with DFD among the studied Omani population. The results showed that the age (P = 0.038 < 0.05), physical activity (P = 0.034 < 0.05), and neuropathy (P = 0.33 < 0.05) had an association with DFD which was statistically significant. However, other predictors, constant and overall statistics were not statistically significant (P > 0.05) [Table 5].
|Table 5: Logistic regression model adjusted for diabetic foot disease with independent variables (overall)|
Click here to view
Moreover, a binary logistic regression was conducted to examine whether gender, patient's age, smoking status, hypertension, dyslipidemia, diabetic nephropathy, diabetic retinopathy, physical activity, and HbA1C had a significant relation with neuropathy and vasculopathy. The results showed that the mode of treatment had a statistically significant relationship (P = 0.005 <0.05) with diabetic neuropathy and diabetic vasculopathy. However, this multivariate regression did not show a statistically significant relationship (P > 0.05) with other predictors, constant, and overall statistics [Table 6].
|Table 6: Logistic regression model adjusted for positive risk factors (neuropathy and vasculopathy) for diabetic foot disease with independent variables (overall)|
Click here to view
| Discussion|| |
In this cross-sectional study which involves 216 Omani patients with DM from different health centers in the AL-Dahira region, the prevalence and the predictor factors for DFD were examined. The prevalence of DFD among patients with DM was found to be 4.2%, out of which 2.3% had DF ulcer cases, which is within the estimated international range (1.8% to 7%). Amputation in this study was at a rate of 1.4%, which was similar to findings of the studies conducted in Germany (0.179%) and in Saudi Arabia (1.06)., The prevalence of foot gangrene, 0.5% in this study was similar to a study done in the US (0.8%), whereas a study carried over in KSA (0.19%) showed a lesser prevalence of foot gangrene than in this study. However, a study in Malaysia showed that 3% of patients with DM had foot gangrene. The reason for this difference could be attributed to the difference in lifestyle, study sample size. Moreover, KSA has a free health-care system for all its citizens, whereas in Malaysia and the USA health care is insurance-based. Hence, everyone may not be able to access the same quality of health care.
This study showed the prevalence of DFD increased with age and diabetes duration, regardless of its types. Similar studies were observed in studies done by Al-Rubeaan et al. and Shahi et al., Moreover, in this study, majority of subjects with foot ulcer were at age 65 years and old and had a DM duration of more than 10 years similar to other studies., Further, in this study, the majority of patients who had DFD (foot ulcer, amputation, and gangrene) were male which was similar to results from studies conducted by Shahi et al., Bruun et al., and Al-Rubeaan et al. Self-care, compliance to doctor's advice, taking medication, and negative smoking status may be the reason for the lower prevalence of DFD among women. However, this study did not find a significant difference between the two genders in the prevalence of neuropathy and vasculopathy.
The results of this study did not show a relationship between DFD and poor glycemic control among the Omani population. This was similar to the results of studies in the UK and Malaysian populations., However, poor glycemic control was associated with an increase in the risk of foot ulcer, amputation, and gangrene in patients with DM in other studies.,
Our study did not show a relationship between smoking and DFD which was in contrast to studies carried out by Al-Sayah et al. in Canada and Tseng in Taiwan., In our study, the sample had a very minimal number of subjects who were smokers (n = 7). This would have been the reason for our study, not showing a relationship between smoking and DFD.
The one which has most strong risk factors in this present in all DFD patients is neuropathy. This present study shows this significant relation in the binary logistic regression model as is seen in other studies., Other risk factors for DFD such as nephropathy, retinopathy, and vasculopathy in this study do not show any significant relation as compared to other studies.,,
Our study is a cross-sectional study which aims to study the prevalence of DFD among DM patients and the interrelationship of various predictors with DFD among the DM patients of the AL-Dahira region in Oman. Cross-sectional studies have the inherent weakness of being incapable of finding causality, so is the case with our study. However, within the limitations of this study, this present study provides the baseline data for further research. Moreover, it will provide a basic sketch for further interventions to support and improve foot care in the DM population of Oman. Ibri city in Oman has a heterogeneous population with a majority Arab ethnicity along with other ethnicities. This study could not record the ethnicities of the individual subjects studied. Furthermore, future studies should be conducted with larger sample size and involve samples from different regions in Sultanate and should include parameters from laboratory investigation, and describe the prevalence of other macrovascular complications (cardiovascular disease and stroke) in the Omani population.
| Conclusion and Recommendations|| |
To the best of knowledge, this is the first study carried over in Ibri, Al-Dahira region of Oman to study the prevalence of DFD and its characteristics. The following are the conclusion of the present study
- DM patients with increasing age had increased chances of DFD. Provision of adequate care and education to subjects and their caretakers should be made mandatory part of health-care education in Ibri, Al-Dahira region, Oman
- It was noted that a decrease in physical activity was correlated with an increase in DFD among DM patients. We recommend increasing awareness about the beneficial effects of physical activity among the DM patients. Physiotherapy should be provided for those who have difficulty in mobility
- The subjects also showed a significant relationship between DFD and neuropathy. Hence, the DM patients should be educated about foot self-care and other related guidelines. The patients should also be made aware of the symptoms of neuropathy and asked to contact the health-care provider if and when they notice symptoms of neuropathy.
Special thanks to my mentor Prof. Dr. Hermes Florez for guiding me through the study. I would also like to thank the Directorate of general health affairs (DGH) office, AL-Dahira governorate for allowing me to do my study in the Al-Dahira region. I am thankful to Dr. Mahmood Ibrahim, Dr. Sufian Al-Mamari, Dr. Asma AlQayodhi, and the nursing staff, especially Aisha ALyaqoobi, nurse Zwinah Al-Nassri for their kind help. Our special thanks to our statistician Mr. Khalid AlNassri, statistician, for his much-needed help.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
Appendix 2: Definitions
Diabetic foot ulcer (DFU):
DFU is defined as a painful, nontraumatic lesion which is red in color and appears on the bottom of the foot or on the toes of subjects with DM patients.
Severity of Diabetic Foot Ulcer Based on the University of Texas classification:
We have the following grades as shown in [Table 1].
It is referred to as a disease or malfunction of the nerve. The diabetic neuropathies are a heterogeneous group of motor, sensory, and autonomic disorders. It is associated with different clinical manifestations. The early detection and management of neuropathy are crucial in the patient with diabetes. Any damage to the sensory supply can lead to tingling sensation, pain, and numbness. If the motor supply is damaged weakness in the feet sets in, whereas a disturbance to the autonomic nervous supply can affect the heart rate, blood pressure, and other functions that depend on its supply.
Controlled diabetes mellitus
Glycated hemoglobin HbA1C test is performed to get an overall picture of what a patient's average blood sugar levels have been for the past period of weeks/months. According to the ADA, if the Hba1C less than 7.2%, it is normal, whereas any reading of 7.2% or more of Hba1C indicates uncontrolled glycated hemoglobin.
Physical activity is defined by Sharif et al. as “any skeletal muscle body movement that results in energy expenditure.” Scientific evidence accumulated over the last decade has demonstrated that regular exercise has a significantly beneficial role in persons with diabetes. It improves glycemic regulation as well as insulin sensitivity.,, The current physical activity guideline for American DM patients is described by CDC as follows “For substantial health benefits, adults should do at least 150 min (2 h and 30 min) a week of moderate-intensity, or 75 min (1 h and 15 min) a week of vigorous-intensity aerobic activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. Aerobic activity should be performed in episodes of at least 10 min, and preferably, it should be spread throughout the week.”, Hence, the subjects in our study were asked if they did physical activity every day.
Peripheral Vascular Disease (PVD):
PVD is a common complication of DM. It is narrowing of peripheral arteries and veins. It is diagnosed based on the presence of at least one of the following symptoms painful muscular cramping in the hip, after movement, numbness of the lower limbs, changes in the skin color over the legs, erectile dysfunction, and nonhealing sores on the toes, feet, or legs.
| References|| |
UK Prospective Diabetes Study (UKPDS) Group. Diagnosis and classification of diabetes mellitus. Diabetes care. 2004;27 Suppl 1:S5-10.
Weeratunga P, Jayasinghe S, Perera Y, Jayasena G, Jayasinghe S. Per capita sugar consumption and prevalence of diabetes mellitus—global and regional associations. BMC Public Health 2014;14:186.
Tao Z, Shi A, Zhao J. Epidemiological perspectives of diabetes. Cell Biochem Biophys 2015;73:181-5.
Guariguata L, Whiting DR, Hambleton I, Beagley J, Linnenkamp U, Shaw JE. Global estimates of diabetes prevalence for 2013 and projections for 2035. Diabetes Res Clin Pract 2014;103:137-49.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2009;32 Suppl 1:S62-7.
Boulton AJ. The diabetic foot: Grand overview, epidemiology and pathogenesis. Diabetes Metab Res Rev 2008;24 Suppl 1:S3-6.
Diabetes care and research in Europe: The Saint Vincent declaration. Diabet Med 1990;7:360.
Armstrong DG, Lavery LA, American Diabetes Association. Clinical Care of the Diabetic Foot. Amer Diabetes Assn; 2005.
Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: The economic case for the limb salvage team. J Vasc Surg 2010;52:17S-22S.
Al-Busaidi IS, Abdulhadi NN, Coppell KJ. Care of patients with diabetic foot disease in Oman. Sultan Qaboos Univ Med J 2016;16:e270-6.
Laiteerapong N, Karter AJ, Liu JY, Moffet HH, Sudore R, Schillinger D, et al
. Correlates of quality of life in older adults with diabetes: The diabetes & aging study. Diabetes Care 2011;34:1749-53.
Brownrigg JR, Davey J, Holt PJ, Davis WA, Thompson MM, Ray KK, et al
. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: A meta-analysis. Diabetologia 2012;55:2906-12.
Brownrigg JR, Griffin M, Hughes CO, Jones KG, Patel N, Thompson MM, et al
. Influence of foot ulceration on cause-specific mortality in patients with diabetes mellitus. J Vasc Surg 2014;60:982-6.e3.
Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005;366:1719-24.
Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: A systematic review and meta-analysis. QJM 2007;100:65-86.
Alzaman N, Ali A. Obesity and diabetes mellitus in the Arab world. J Taibah Univ Med Sci 2016;11:301-9.
Abuyassin B, Laher I. Diabetes epidemic sweeping the Arab world. World J Diabetes 2016;7:165-74.
Asfour MG, Samantray SK, Dua A, King H. Diabetes mellitus in the sultanate of Oman. Diabet Med 1991;8:76-80.
Chin MH, Cook S, Jin L, Drum ML, Harrison JF, Koppert J, et al
. Barriers to providing diabetes care in community health centers. Diabetes Care 2001;24:268-74.
Armstrong DG, et al
. Validation of a Diabetic Wound Classification System. The Contribution of Depth, Infection, and Ischemia to Risk of Amputation. NCBI. Available from: https://www.ncbi.nlm.nih.gov/pubmed/9589255
. [Last accessed on 2017 Oct 02].
American Diabetes Association. 10. Microvascular Complications and Foot Care. Diabetes Care 2017;40 Suppl 1:S88-98.
Sharif K, Watad A, Bragazzi NL, Lichtbroun M, Amital H, Shoenfeld Y. Physical activity and autoimmune diseases: Get moving and manage the disease. Autoimmun Rev. 2018 Jan;17:53-72. doi: 10.1016/j.autrev.2017.11.010. Epub 2017 Nov 3. PMID: 29108826.
Jenkins DW, Jenks A. Exercise and diabetes: A narrative review. J Foot Ankle Surg 2017;56:968-74.
Bird SR, Hawley JA. Update on the effects of physical activity on insulin sensitivity in humans. BMJ Open Sport Exerc Med 2016;2:e000143.
Mariam TG, Alemayehu A, Tesfaye E, Mequannt W, Temesgen K, Yetwale F, et al
. Prevalence of Diabetic Foot Ulcer and Associated Factors among Adult Diabetic Patients Who Attend the Diabetic Follow-Up Clinic at the University of Gondar Referral Hospital, North West Ethiopia, 2016: Institutional-Based Cross-Sectional Study. J Diabetes Res 2017;2017:2879249.
Abbott CA, Garrow AP, Carrington AL, Morris J, Van Ross ER, Boulton AJ, et al
. Foot ulcer risk is lower in South-Asian and african-Caribbean compared with European diabetic patients in the U.K.: The North-West diabetes foot care study. Diabetes Care 2005;28:1869-75.
Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al
. Diabetic foot complications and their risk factors from a large retrospective cohort study. PLoS One 2015;10:e0124446.
Diehm C, Schuster A, Allenberg JR, Darius H, Haberl R, Lange S, et al
. High prevalence of peripheral arterial disease and co-morbidity in 6880 primary care patients: Cross-sectional study. Atherosclerosis 2004;172:95-105.
Melton LJ 3rd
, Macken KM, Palumbo PJ, Elveback LR. Incidence and prevalence of clinical peripheral vascular disease in a population-based cohort of diabetic patients. Diabetes Care 1980;3:650-4.
Rabia K, Khoo EM. Prevalence of peripheral arterial disease in patients with diabetes mellitus in a primary care setting. Med J Malaysia 2007;62:130-3.
Shahi SK, Kumar A, Kumar S, Singh SK, Gupta SK, Singh TB. Prevalence of diabetic foot ulcer and associated risk factors in diabetic patients from North India. J Diabet Foot Complications 2012;4:83-91.
Almobarak AO, Awadalla H, Osman M, Ahmed MH. Prevalence of diabetic foot ulceration and associated risk factors: An old and still major public health problem in Khartoum, Sudan? Ann Transl Med 2017;5:340.
Bruun C, Siersma V, Guassora AD, Holstein P, de Fine Olivarius N. Amputations and foot ulcers in patients newly diagnosed with type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co-morbidity. Diabet Med 2013;30:964-72.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet 1998;352:837-53.
Khattab M, Khader YS, Al-Khawaldeh A, Ajlouni K. Factors associated with poor glycemic control among patients with type 2 diabetes. J Diabetes Complications 2010;24:84-9.
Al Sayah F, Soprovich A, Qiu W, Edwards AL, Johnson JA. Diabetic foot disease, self-care and clinical monitoring in adults with type 2 diabetes: The Alberta's Caring for Diabetes (ABCD) Cohort Study. Can J Diabetes 2015;39 Suppl 3:S120-6.
Tseng CH. Prevalence and risk factors of diabetic foot problems in Taiwan: A cross-sectional survey of non-type 1 diabetic patients from a nationally representative sample. Diabetes Care 2003;26:3351.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]