Diabetic foot and diabetes-related amputations in Belgium : facts, figures and the underexposed nutritional aspect
Authors:   , Lauwers Patrick 
Published: October 2024

Diabetes mellitus (DM) is a major global health concern, with a steady increase in prevalence. One of the most frequent, and most feared, complications of DM is a diabetic foot ulcer (DFU). In Western countries, DM is the most frequent indication for lower extremity amputations (LEA). International guidelines on the diagnosis and treatment of the diabetic foot are updated on a regular base and focus on the three corner stones of the diabetic foot: neuropathy, angiopathy, and infection. Nevertheless, many other factors in the pathogenesis of the diabetic foot still need to be unraveled. In chronic ulcers, the relation between nutritional status and delayed wound healing is well-known. However, data on the relation between DFU and nutritional status is scarce. Hence, the first aim of this PhD dissertation is to assess the prevalence of malnutrition in a Belgian single center DFU cohort, and to assess a possible link between DFU severity and outcome. The second aim is to investigate the nationwide burden of LEA in Belgium, reflected by temporal trends in incidence of minor and major amputations, total medical costs in the twelve months preceding and following LEA, and mortality rates after LEA. Two databases were created. First, a prospective observational cohort study including 110 individuals admitted to the Antwerp University Hospital due to a DFU was initiated. Besides a large set of clinical data, an in-depth analysis of the nutritional status was included based on questionnaires, anthropometry, and bio-electrical impedance analysis. Malnutrition was defined by the GLIM criteria. The incidence of malnutrition in this DFU cohort was determined, and the link between nutritional status and DFU severity and outcome was studied as well. Second, a national daAbstract 10 tabase covering all individuals undergoing LEA in Belgium in the decade 2009-2018 was set up, including both people with and without diabetes. A comparison group of individuals without LEA was included as well. Temporal trends in amputations were analyzed, as well as mortality rates and total medical costs of major and minor LEA. Malnutrition, as defined by the GLIM criteria, was diagnosed in 26 of 110 patients (23.6%). More severe ulcers were observed in the group of severely malnourished individuals, but malnutrition did not affect short-term outcome. LEA is associated with high total medical costs. Median total medical costs in individuals with diabetes amounted to €49 735 in the 12 months before and €45 740 in the 12 months following major amputation. For minor LEA, these costs were €24 243 and €21 445 respectively. Over the study period, the incidence of major LEA diminished from 56.2 to 30.7/100 000 person-years in individuals with DM, whereas the incidence of minor LEA remained stable (non-significant reduction from 54.3 to 45.0/100 000 person- years). Nevertheless, high mortality rates were observed in individuals with DM after major (and minor) LEA: 13.1% mortality rates after thirty days, 35.8% after 1 year, and 68.5% after 5 years (4.7%, 20.1%, and 51.8% after minor LEA, respectively). The incidence of major LEA decreased significantly in Belgium in individuals with diabetes. Nevertheless, both major and minor amputations remain associated with high mortality rates and high total medical costs. Few data exist on the eventual impact of malnutrition on DFU severity and outcome. In a personal series, malnutrition was highly prevalent. Although malnutrition was related with DFU severity, no impact on short-term outcome was observed.