Diabetes Distress Linked to Foot-Risk in Primary Care
Key Takeaways
- Among 1,563 adults with diabetes in Brazilian primary health care, 39.8% were classified as being at some risk for diabetes-related foot disease.
- Participants with a diabetes-related foot disease risk classification had higher diabetes-related distress than those without identified risk.
- Difficulty caring for the feet and loss of protective sensation were independently associated with higher diabetes-related distress after adjustment.
- Good glycemic control was associated with lower diabetes-related distress, while women, younger adults, insulin users, and participants who were overweight also tended to have higher scores.
In a study of diabetes distress and foot-risk status in primary care, investigators conducted a cross-sectional analysis of baseline data from the cohort Occurrence of Diabetic Foot and Associated Factors. The sample included adults aged 18 years or older who were registered in urban Family Health Strategy units in a municipality in Minas Gerais, Brazil, and recruited between June 2022 and July 2023. Diabetes-related foot disease (DFD) risk was classified with International Working Group on the Diabetic Foot criteria after foot and leg examination for peripheral arterial disease (PAD) and loss of protective sensation (LOPS), while diabetes-related distress was measured with the Brazilian Problem Areas in Diabetes (B-PAID) scale, with scores of 40 or higher defining high distress. Adjusted analyses used Gamma regression.
Median diabetes-related distress was 16 (IQR 27), and participants with diabetes-related foot disease risk had higher distress, with a median of 17 (IQR 30). A substantial share of the cohort fell into a foot-risk category, and insulin use and poor glycemic control also tracked with greater distress in bivariate patterns.
In the 1,071 participants with HbA1c results available from the previous 3 months, the final adjusted Gamma model found that greater difficulty caring for the feet was associated with higher distress, with β=1.129 (95% CI 1.014–1.257), and loss of protective sensation was also associated with higher distress, with β=1.311 (95% CI 1.110–1.549). In the paper’s results section, participants with good glycemic control had lower diabetes-related distress than those with poor control (β=0.850, 95% CI 0.761–0.951). Female sex, age younger than 60 years, insulin use, and overweight status were also associated with higher distress in that final model.
The authors noted that the cross-sectional design supports association rather than causation. They also reported that comorbidities and life events that could influence diabetes-related distress were not evaluated. Because the population came from urban Family Health Strategy units in a single municipality in Minas Gerais, the findings are most directly applicable to similar Brazilian primary care settings rather than broadly generalizable to North American practice.
The authors concluded that diabetes-related distress tracked with sociodemographic and clinical features in this Brazilian primary care population, particularly loss of protective sensation, difficulty with foot care, and glycemic control. They also identified primary care as the setting where psychosocial burden and foot-risk monitoring intersect during longitudinal diabetes management.
Clinician Questions
How was diabetes-related foot disease risk classified in adults with diabetes in Brazilian primary care?
Risk was classified with International Working Group on the Diabetic Foot criteria after foot and leg examination for peripheral arterial disease and loss of protective sensation, using categories 0 through 3 based on combinations of peripheral arterial disease, loss of protective sensation, foot deformity, prior ulcer or amputation, and end-stage renal disease.
What clinical tests were used to identify loss of protective sensation in this diabetes foot-risk assessment?
Loss of protective sensation was assessed with a 128 Hz tuning fork and a 10 g Semmes-Weinstein monofilament, and it was considered present when no vibratory or tactile response was observed.
Which patients were included in the HbA1c analysis of diabetes-related distress?
Glycated hemoglobin analyses were limited to participants with HbA1c results from testing within the previous 3 months, so this was a subset of the broader Brazilian primary care cohort rather than the full sample.
How far can these findings on diabetes distress and foot-risk be generalized beyond Brazilian primary care?
These findings came from a cross-sectional baseline analysis of adults with diabetes registered in urban Family Health Strategy units in one municipality in Minas Gerais, Brazil, so they support association rather than causation and may not generalize beyond similar primary care populations.