Stream	Abstract - Diabetic Foot
Topic	Complications - foot

Abstract title	Association between Vitamin D status and Foot ulcer in Type 2 Diabetes Mellitus:a cross sectional study on 300 patients.

Co-authors	S. Ganapathy Kumari1, A. Vijayakumar1, V. Gadadharan1, R. Vijayakumar1, S. M Nair2.
1Medical Trust Hospital and Diabetes Care Centre, General Medicine, Pathanamthitta, India.
2Medical Trust Hospital and Diabetes Care Centre, Clinical Research, Pathanamthitta, India.

Abstract body	
Background
Vitamin D deficiency has been shown to alter insulin synthesis and secretion. It may predispose to glucose intolerance, altered insulin secretion and type 2 diabetes mellitus. Studies have reported low levels of vitamin D in chronic kidney disease (CKD). There is some evidence that vitamin D deficiency is associated with poor clinical outcomes in those with CKD. Low 25(OH)D levels are associated with all cause mortality and cardiovascular disease in patients with CKD. 25(OH)D stimulates the cell differentiation and reduces cell proliferation in human body. This helps in cell growth and wound healing.
Aim
To assess the vitamin D levels in diabetic foot ulcer patients and to assess whether there is any relationship between Vitamin D deficiency and presence of diabetic foot ulcer
Method
300 patients with diabetic foot ulcer treated at a diabetic foot care centre during a 6 month period were selected randomly for the study. History, general examination, foot examination details and relevant investigations were noted at the time of initial presentation. Patients on renal replacement therapy and those taking vitamin D supplements were excluded from the study. A vitamin D level < 10µg/ml was considered as severe deficiency. Values between 10 to 30 µg/ml were considered as insufficiency and values >30 µg/ml were considered as normal.  
Results
Of the 300 patients with foot ulcer, severe vitamin D deficiency was found in 112 patients (37.8%) and insufficiency was present in 147 patients (49.7%). Only 12.5% had sufficient vitamin D levels. 85.5% of males with diabetic foot ulcer had either severe vitamin D deficiency or insufficiency while 92.2% of females with diabetic foot ulcer had severe vitamin D deficiency or insufficiency. And this difference is statistically significant ( p<0.003). Only 19% of those patients with severe vitamin D deficiency or insufficiency had an HbA1c 6-8%, while 33% of them had an Hba1c 8-10% and 48% had HbA1c >10%. So  81% of those with vitamin D deficiency had an uncontrolled HbA1c at the time of presentation with ulcer. Of the patients with severe vitamin D deficiency 23.2% had nephropathy and of those with vitamin D insufficiency 11.6% had nephropathy while only 10.8% of those with no deficiency had nephropathy which is statistically significant. (P<0.026). 89%of those with either severe vitamin D deficiency or insufficiency had neuropathy while only 78% of those with normal vitamin D levels had neuropathy.  Among patients with  severe vitamin D deficiency  61.3% are either overweight or obese. Regarding the association between site of ulcer and vitamin D levels, logistic regression analysis was done to estimate the unadjusted odd’s ratio. Patients with ulcer on the plantar aspect of the foot were 3.5 times more likely to have severe vitamin D deficiency as compared to patients with big toe ulcers.

Table 1: Prevalence and severity of Vitamin D Deficiency in patients with Diabetic foot ulcer
Vitamin D Status	Frequency n (%)
No deficiency (>30 µg/ml)	37 (12.5)
Insufficiency (10-30 µg/ml)	147 (49.7)
Severe deficiency (<10 µg/ml)	112(37.8)
 
Table 2.Association between Gender and Nephropathy with vitamin D levels
Variables	Severe deficiency    n (%)	Insufficiency n (%)	No deficiency n (%)	P Value
				
				
				
Sex				0.003
Male	66 (31.7)	112 (53.8)	30 (14.4)        	0.026
Female	46 (52.3)	35 (39.8)	7 (8.0)	
Nephropathy				
Present	26 (23.2)	17 (11.6)	4 (10.8)	
Absent				
86 (76.8)	130 (88.4)	33 (89.2)		
0.026
 
Table 3: Site of ulcer and Vitamin D levels
Site of ulcer	Severe Vit D deficiency (%)	Odds ratio (95% CI)	P-value
Big toe	41.2	1	
Other toes	41.4	1.00(0.37-2.76)	0.99
Plantar aspect of foot	71.4	3.57(1.11-11.48)	0.03
Heel	57.1	1.90(0.54-6.71)	0.32
Dorsum of foot	65.4	2.70(0.93-7.78)	0.07
Others	72.7	3.8(1.19-12.16)	0.02
		
		
	


Discussion
Vitamin d deficiency either mild or severe is seen in majority of patients with Diabetic foot ulcer. Feet of diabetic patients are prone to develop ulcers due to a variety of causes including neuropathy, peripheral vascular disease and Charcot’s foot. Whether vitamin D deficiency contributes to these factors by altering the immune system, cell differentiation and wound healing is yet to be established.
Conflict of Interest	I have no potential conflict of interest to disclose

Association between vitamin D status and foot ulcer in type 2 diabetes mellitus: a cross sectional study on 300 patients