Malnutrition and its relation with diabetic foot ulcer severity and outcome: a review.

BACKGROUND: Malnutrition has a detrimental effect on wound healing; hence, it might influence the outcome in people with a diabetic foot ulcer (DFU).The aim of this manuscript is to overview studies that describe the prevalence of malnutrition in DFU patients and assess the relation between malnutrition, DFU severity, and outcome. METHODS: A literature review was performed. Malnutrition had to be defined by anthropometry and/or validated screening and assessment tools. RESULTS: Five papers were included: one RCT, three prospective cohort studies and one retrospective observational study. A substantial number of patients were at risk for malnutrition (49%-70%) or were malnourished (15%-62%). In one study, nutritional status was related to DFU severity. Three authors demonstrated a negative influence of malnutrition on outcome. Two studies examined the prevalence of malnutrition after six months, but did not detect a decline in malnutrition rates. CONCLUSIONS: Despite a large heterogeneity, all papers indicated that malnutrition is highly prevalent among DFU patients. Notwithstanding the lack of unequivocal evidence, malnutrition might have a negative influence on DFU outcome. Therefore, clinicians should pay attention to the nutritional status of people with a DFU.Abbreviations: BMI: Body Mass Index; DFU: Diabetic Foot Ulcer; DM: Diabetes Mellitus; GNRI: Geriatric Nutritional Risk Index; HbA1c: Glycated Hemoglobin; IWGDF: International Working Group on the Diabetic Foot; LEA: Lower Extremity Amputation; MNA: Mini Nutritional Assessment; MNA-SF: Mini Nutritional Assessment-Short Form; MUST: Malnutrition Universal Screening Tool; NRS-2002: Nutritional Risk Screening-2002; PAD: Peripheral Arterial Disease; RCT: randomized controlled trial; SGA: Subjective Global Assessment.

Malnutrition according to the 2018 GLIM criteria is highly prevalent in people with a diabetic foot ulcer but does not affect outcome.

OBJECTIVE: To estimate the prevalence of protein-energy malnutrition in people admitted for a diabetic foot ulcer (DFU) and to assess the relationship between malnutrition and DFU severity and outcome. METHODS: This prospective, observational cohort study included individuals consecutively admitted for a DFU between July 2016 and September 2019. The Global Leadership Initiative on Malnutrition (GLIM) criteria determined the prevalence of malnutrition. The SINBAD score reflected DFU severity. Outcome was evaluated at discharge and at 6 months. The independent contribution of nutritional status on DFU severity and outcome was investigated using logistic regression analysis. RESULTS: A total of 110 patients were included. Malnutrition, as defined by the GLIM criteria, was diagnosed in 26 cases; malnutrition was moderate in 9 and severe in 17. DFU severity differed significantly between subjects with malnutrition versus without malnutrition (SINBAD: 3.85 vs. 3.81, p = 0.012). Logistic regression analysis showed that severe malnutrition (p = 0.015) and hemoglobin level (p = 0.003) were independently linked to DFU severity. At 6-month follow-up, 39 DFU were healed, 36 patients had undergone an amputation (32 minor, 4 major) and 8 had died. No differences were noted in outcome at discharge or at 6 months according to nutritional status. CONCLUSIONS: In 24% of patients, malnutrition was diagnosed. Severely malnourished individuals presented with more severe ulcers. However, malnutrition had no impact on the short-term outcome of a DFU.

Diet and paraoxonase 1 enzymatic activity in diabetic foot patients from Romania and Belgium: favorable association of high flavonoid dietary intake with arylesterase activity.

BACKGROUND/AIMS: The antiatherosclerotic enzyme paraoxonase (PON1) is affected by disease and lifestyle. We investigated the impact of diet in diabetic foot patients from 2 European countries. METHODS: Dietary intake and serum PON1 activity, using as substrate paraoxon (paraoxonase) or phenylacetate (arylesterase), were assessed in patients from Bucharest (n = 40) and Antwerp (n = 30) and in 34 healthy controls. RESULTS: The diabetic patients had lower paraoxonase and arylesterase activities than the controls. Arylesterase was lowest in the Bucharest patients, 116 +/- 42 U/ml, versus 141 +/- 43 and 184 +/- 49 U/ml in the Antwerp patients and controls, respectively (p < 0.0005). The Bucharest patients had worse glycemic control, higher blood pressure, lower HDL cholesterol and a diet richer in cholesterol and poorer in monounsaturated fats and fish. In contrast, their median intake of vitamins E and C, folic acid and flavonoids was higher, 82 mg (range: 4-259 mg), versus 28 mg (range: 5-169 mg) aglycone units in Antwerp (p = 0.005). Flavonoid intake predicted arylesterase independently of HDL cholesterol, region and sex (beta = 0.27; p = 0.03), and patients with high intake achieved normal levels of arylesterase (30.1 +/- 10.0 U/micromol in the highest versus 21.0 +/- 8.2 U/micromol total cholesterol in the lowest tertile; p = 0.02). CONCLUSION: A flavonoid-rich diet is positively associated with PON1 arylesterase activity in diabetic foot patients.

Time course of oxidative stress status in the postprandial and postabsorptive states in type 1 diabetes mellitus: relationship to glucose and lipid changes.

OBJECTIVE: The aim of this study was to compare oxidative stress status (OSS) with blood glucose and lipid changes during the fasting, postprandial and postabsorptive phases in type 1 diabetes mellitus. METHODS: Twenty-three patients on intensive insulin treatment received a standard fat-rich breakfast and lunch. OSS was monitored at fasting (F), just after the post-breakfast glycemia peak (BP) (identified by continuous subcutaneous glucose monitoring), 3.5-h post-breakfast (B3.5), just after the post-lunch peak (LP), just after the post-lunch dale (LD) and 5 hours after lunch (L5). RESULTS: Whereas whole blood glutathione and plasma protein thiols increased in the postprandial period (from 6.52 +/- 1.20 (F) to 7.08 +/- 1.45 micromol/g Hb (BP), p = 0.005), ascorbate decreased gradually from 44 +/- 17 (F) to 39 +/- 19 micromol/L (LD), p = 0.015. Retinol and alpha-tocopherol also decreased from 27.1 +/- 7.0 (F) to 25.3 +/- 5.2 micromol/L (BP), p = 0.005. Uric acid decreased later, from 213 +/- 77 (BP) to 204 +/- 68 micromol/L (B3.5), p = 0.01, but then increased in LP (231 +/- 70 micromol/L) and LD to values higher than F (215 +/- 64, micromol/L, p = 0.01). Malondialdehyde increased gradually from 1.02 +/- 0.36 (F) to a maximum of 1.14 +/- 0.40 micromol/L (LP). In the postabsorptive phase (L5) all parameters except for thiols reverted to fasting concentrations. CONCLUSIONS: In type 1 diabetes lipid peroxidation increases during the postprandial phase in parallel to glucose and triglyceride changes. Blood antioxidants, however, followed diverse patterns of change.