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 The impact of
Diabetic foot ulcer on Quality of Life:

As shown in table (6) Multivariate Analysis of Variance (MANOVA)
was performed to test the effect of  variables
on quality of life scales. As shown in table (6), the variables of gender,
stressful life events, Peripheral Vascular Disease (PVD) and BMI were

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In this study, females had significantly lower health-related
quality of life with DFS-SF than males (P-value 0.038). Patient with stressful
life events had significantly lower health-related quality of life score using
DFS-SF scale or Physical and Mental Components Summaries scores using SF-8
scale than patients without stressful life events in last year (P-values were
0.000 for DFS-SF, 0.013 PCS8 and 0.006 MCS8 respectively).

Health-related quality of life score of DFS-SF as well as Physical
Component Summary-8 were significantly lower in diabetic patients with foot
ulcer and PVD in comparison to those with foot ulcer without PVD (P-value 0.004
for DFS-SF, 0.016 for PCS8 respectively). Additionally, obese patients with
diabetic foot ulcer had lower DSF-SF and physical component summary-8 scores
than non-obese (p-values 0.024, 0.036) respectively.

As shown in table (7), females
scored significantly lower than males on the Physical health and Negative
emotions DSF-SF subscales than men (P-values: 0.023, and 0.015 ) respectively.

The study participants who had an educational level of more than
high school, were more worried about ulcer subscale in comparison to those with
educational level than high school (P-value 0.024). While those with family
income more than 500 JD’s scored higher on physical health subscale in
comparison with their counterparts (p-value= 0.003).

Scores in the most of DFS-SF subscales were lower in participants
who had stressful life events in the last year. P-values were (0.000) for Leisure/Enjoying
life, (0.000) for Physical Health, (0.001) for Dependency/Daily life, (0.009)
for Negative Emotions  and (0.008) for Bothered
by ulcer care.

Our results also showed that patients who did not have ischemic
foot ulcer had a better health related quality of life for the following
subscales: Dependency/Daily life and worried about ulcer (P-values: 0.005 and
0.018) respectively.

Presence of retinopathy
was associated with poor quality of life on leisure/ enjoying life as well as
dependency subscales (p-values= 0.031 and 0.007) respectively.

Finally, obese
participants scored lower on bothered by ulcer care subscale than non-obese participants
(p-value= 0.022).



In this
study, diabetic patients with foot ulcers had significantly low median (SD)
Diabetic Foot Scale-Short Form score (DFS-SF) 42.1±17.0 as well as low median
Physical and Mental Components Summary scales scores (PCS8 and MCS8) (39.3±9.9
for PCS8 and 41.9±11.1 for MCS8 respectively) using the SF-8 health
questionnaire for assessing health-related quality of life.

SF-8 Physical
and Mental Components Summary scale scores for quality of life in the study
were lower compared with the general population of North Jordan. SF-36
population norms among the general population of North Jordan were established
in a study conducted by Khader et al. (2001), which set the mean (SD) SF-36
scale scores for the population of north Jordan. Physical Function was set at
66.5 (28.3), Role-Physical was set at 60.4 (34.8), 56.4 (26.7) for Bodily Pain,
64.0 (18.5) for General Health, 55.7 (19.5) for Vitality, Social Functioning
was set at 66.4 (22.2), 58.7 (40.2) for Role-Emotional and 61.2 (22.2) for
Mental Health. Khader et al., study also found that males scored the highest
(66.8) in Social Functioning and the lowest (55.8) in Vitality. Women had the
highest score (69.8) in Physical Function, but their lowest score was in Bodily
Pain (54.6).

Similar to
our findings are those of Ashford, who assessed quality of life of 21 DFU
patients. Ashford’s study reported that families of DFU patients were unable to
do certain procedures, which led to family-related problems. Such problems
included wound dressing, moderate mobility reduction shopping and taking a
shower, and had negative impact on patients’ quality of life.(24) The
cross-sectional study by Goodridge et al. on 114 adult individuals with
diabetic foot ulcers established that patients with diabetic foot ulcers had a
poorer physical quality of life than patients with unhealed ulcers.(25) Recent US and UK studies showed that diabetic
foot ulcers adversely affect the quality of life of patients.(26,27)

Our data
showed that females had significantly lower health-related quality of life than
males. Women are likely to be more concerned about their health conditions and
their impact on family environment than men, particularly among housewives. In
agreement with our finding most previous studies had shown that males had
better health than females. Lebanese women had a lower quality of life than
Lebanese men.(19) Canadian men had
markedly higher scores than women in all SF-36 Health Survey domains.(28) Similarly, US men fared better than
women in all SF-36 domains.(29) Except
for the General Health domain, British male scores were also higher than
females’.(30) Comparable to our findings are those
based on different surveys conducted on Spanish patients. Those results proved
that women had a poorer quality of life. (31) 

Vascular Disease (PVD) and diabetes often entail neuropathy, foot ulcer, increased
risk of developing gangrene, ischemia and amputation to lower extremities.(32,33) Disability
and inability to mobilize, and decreased physical functioning are further
complications of diabetes. As impaired lower extremity functioning may lead to
poorer quality of life, it is considered an important predictor of future
disability. Diabetes-based loss of mobility, placement at nursing facilities
and possible disability may elevate in PVD patients. (34,35)This
study showed that patients with both diabetic foot ulcers and PVD scored
significantly lower in terms of quality of life lower than patients without
PVD. Consistent with our findings, are Dolan et al.’s (2002) also determined
that diabetic patients with PVD had poorer lower limb function than
non-diabetic patients with PVD. DM patients, when compared to non-diabetic
patients, were younger, had a higher BMI, had worse neuropathy scores, and had
greater number of cardiovascular morbidities. Though diabetic patients
expressed the presence of exertional leg pain, they were less prone to report
classical symptoms of intermittent claudication.(36) Siersma et al., study (2013), also
reported that such factors as limb-threatening ischemia, inability to stand or
walk independently, ulcer size and C-creative protein concentration most
importantly contributed to health-related quality of life.(37) In addition,
Lloyd et al., (2001) proved that PVD in diabetic patients associated
significantly with Lower Physical and Social Functioning scales scores, whereas
CAD most frequently associated with significant reduction in health-related
quality of life, particularly in the physical domains.(38)

Our data also
showed that obese diabetic patients with foot ulcers had significantly lower
quality of life than non-obese diabetic patients with foot ulcers. Consistent with
our result Redekop et al., study (2002) also showed that obesity, diabetic
complications and insulin-based therapy associated with poorer quality of life
in T2DM patients.(39) Adeyemi et al., (2014) also concluded that
diabetic patients who were obese or morbidly obese had significant associations
with lower Physical Component Summary-12 than DM patients of normal weight.(40)

Our study
showed that patients with diabetic foot ulcers and stressful life events scored
lower than those without stressful life events on health-related quality of
life. Stressful life events, linked to wound healing, will eventually mark an
increase in the negative mood and result in improper sleep patterns. (41)
Recently, many Studies have illustrated the mechanism of stress in slowing the
healing rate of acute and chronic ulcers, which leads to long-term of ulcer
care and this creates further burden, pressure and low quality of life (Itani, 2015).(42)
To determine the link between stress and healthy human immunity, a meta-analysis
was conducted which found that consistent and prolonged stress resulting from
divorce, bereavement, care-giving, and unemployment led to increased
circulation of neutrophils and monocytes, as well as to a reduction in natural
killer cell activity, and to decreased lymphocyte proliferation and antibody
(43) In addition, stress
will increase glucocorticoid level, (44) thus decreasing growth factors and
increasing certain pro-inflammatory cytokines. This will result in excessive
activation of matrix-metalloproteinase, marking the breakdown of extracellular
matrix molecules and growth factors. It will also inhibit the proliferation of
fibroblast and keratinocytes, ultimately leading to preventing wound healing. (45)Moreover,
the release of catecholamine (epinephrine and norepinephrine) in response to stress
causes alterations of the immune cell function. Releasing catecholamine also
elevates blood glucose levels, thus contributing delay in wound healing. (46)

Our  result agreed with other results conducted by
Margarita, et al., (2011),  and found
that perceived social support and stressful life events have independent
significant effects on the HRQoL in CAD patients, especially in female
patients.(47) Also Walders-Abramson, et al., (2014), examined the
relationship between stressful life events and physiological measures,
medication adherence, depressive symptoms, and impaired quality of life in
adolescents with T2DM. The odds of having clinically elevated depressive
symptoms or impaired QOL were associated with a two-fold increase among those
reporting at least one major stressful event. (48)


Diabetic foot
ulcer patients have significantly low median (SD) Diabetic Foot Scale-Short
Form score (DFS-SF) 42.1±17.0 as well as low median Physical and Mental
Components Summary scales (PCS8 and MCS8) (39.3±9.9 for PCS8 and 41.9±11.1 for
MCS8) using SF-8 health questionnaire for assessing health-related quality of
life. Female gender, obesity, presence of PVD and stressful life events were
the most important factors associated with lower quality of life in patients
with diabetic foot ulcer.

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