Psychological factors are linked to diabetes-related foot ulcers

In #FootHealthWeek2020, we take a look at a review published in Diabetes/Metabolism Research and Reviews

By Amelia Williams

Foot ulcers can be a serious complication of diabetes. Most research to date has primarily focused on the biology of diabetes-related foot ulcers. However, living with this complication can present numerous psychological challenges. A recent review has summarised some of the progress that has been made in this area of research.  

Diabetes-related foot ulcers and quality of life

Typically, diabetes-related foot ulcers have a negative impact on quality of life and wellbeing. One of the major reasons for this is due to the need to avoid bearing weight on the affected limbs. While this promotes healing, it usually restricts daily activities, as well as the ability to perform some social and family roles. Research suggests that the major impact of diabetes-related foot ulcers is related to physical rather than psychological aspects of quality of life.  However, these studies did not account for emotional responses attributed specifically to the diabetes-related foot ulcer(s). Some examples of these are fear of amputation and inter-personal emotional burden. A study which used an instrument specifically for assessment of quality of life in the context of diabetes related foot ulcers (Neuropathy and Foot‐Ulcer‐Specific Quality of Life instrument (NeuroQoL)‐emotional burden scale) revealed that living with this complication does indeed impact negatively on emotional wellbeing and mental health. These findings indicate that an illness-specific approach should be used to assess the full impact of diabetes-related foot ulcers on quality of life.

Depression and diabetes-related foot ulcers: a two-way street?

Depressive symptoms are common in individuals living with this complication. However, interestingly, the incidence of diabetes-related foot ulcers was not found to be directly linked with depression. This is a surprising finding considering the impact that this complication can have on daily living and interpersonal relationships. However, heightened symptoms of depression are largely associated with foot-related physical dysfunction and interpersonal burden. To an extent, these findings mirror those related to those of the relationship between diabetes-related foot ulcers and emotional components of quality of life. The authors caution that the use of generic scales (i.e. those that do not refer to the impact of diabetes or diabetes-related foot ulcer) may not adequately capture symptoms of emotional distress associated with this complication.

There is also emerging evidence to suggest that depression may increase the risk of diabetes-related foot ulcers. A proposed explanation for this is that symptoms associated with depression may impair a person’s ability to engage in preventative foot self-care. Preventative foot self-care can significantly reduce the risk of developing foot ulcers.

Preventative foot self-care includes activities like regular foot checking, gently washing and moisturising feet, and wearing well fitted shoes. However, some studies reveal that those experiencing depression do not necessarily engage in less preventative foot self-care.  This has led researchers to question whether there may be a biological underpinning of this relationship. However, the underlying mechanisms of this relationship are yet to be established and warrant further research.

In short, this review indicates the need for the development and implementation of measures assessing the impact of diabetes-related foot ulcers on psychological outcomes (e.g. emotional well-being, distress, depression, quality of life), so that the full impact of this complication can be understood and addressed. Additionally, the heightened risk of diabetes-related foot ulcers among people experiencing depression points to the need for the development of targeted psychological intervention for those at risk, or experiencing, diabetes-related foot ulcers.

For more about preventative foot self-care, check out this fact sheet developed by the National Diabetes Services Scheme

Vileikyte L,  Pouwer F,  Gonzalez JS.  Psychosocial research in the diabetic foot: Are we making progress? Diabetes/Metabolism Research & Reviews.  2020; 36( S1):e3257. doi:10.1002/dmrr.3257