Introduction

According to the International Diabetes Federation (IDF) ¹ in 2021, about 537 million people are living with Diabetes Mellitus (DM) and this number is expected to increase to 643 and 783 million by 2030 and 2045, respectively. Vascular and neuropathic complications of DM cause diabetic foot (DF) with the presence of difficult-to-heal ulcers and this being the main risk factor for non-traumatic amputations ^2-5. The global prevalence of DF is estimated to be approximately 6%, according to a 2016 systematic review and meta-analysis ⁶. This is a difficult disease to address because of the number of procedures, disciplines involved and the impact on lifestyle ⁷.

Lifestyle is the set of decisions made by each individual that will affect his health and over which he has some degree of voluntary control ⁸. Thus, an inadequate lifestyle has brought as a consequence that the figures of DM continue to increase and therefore its complications. However, educating the patient to opt for a healthy lifestyle is not the only thing to do; it is necessary to address the concept of self-care in order to know the patient's condition and his or her capacity for self-care against the disease, in order to help the patient to achieve and maintain self-care actions with the aim of preserving life, recovering from the disease and facing its consequences ⁹.

The importance of this review is to be a reference on the current literature encompassing the variables: self-care and lifestyle in the patient at risk of DF and thus emphasize in clinical nursing practice the usefulness of publicizing and disseminating validated instruments and international recommendations for the implementation of appropriate self-care measures in the prevention of DF. In view of the above, the research question arises: How is the lifestyle and self-care in the patient at risk of DF? Therefore, the present objective was established to analyze the available scientific evidence on the lifestyle and self-care of patients at risk of DF.

Methodology

The study design was a review of the literature, the guiding questions were formulated prior to the search for articles: How is the lifestyle and self-care in patients at risk of DF? How is the self-care of women compared to the self-care of men? What is the risk of DF and what are the main symptoms referred to in the literature? What does the scientific literature refer to lifestyle and self-care in patients at risk of DF? Data collection was performed in October 2022, in the databases Virtual Health Library (VHL), National Library of Medicine (NIH), EBSCO host database portal (part of the corporation founded by Elton Bryson Stephens, hence the acronym EBSCO: Elton B. Stephens Company), Scientific Electronic Library Online (Scielo), PubMed Central (PMC), and Google Scholar.

Inclusion criteria included documents in English and Spanish, between the years 2016 to 2022, nursing articles that mentioned two or more variables of interest: Self-care, lifestyle and DF risk; articles without open access, duplicates, gray literature and that did not meet the objective of the present review were excluded. The following descriptors were used in Spanish and English: diabetes mellitus, lifestyle, diabetic foot, diabetic foot ulcer, self-care, self-help. In addition, the Boolean operators AND, NOT and OR were used. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flowchart was used to structure the research according to the checklist items, in addition to contributing to the formulation of the search strategy ¹⁰. From the search through the consulted databases, when applying the inclusion criteria of start question, year and key words, only 14 articles were selected, (Figure 1).

Source: Own-development

Figure 1 Results from 2016 to 2022, in accordance with the PRISMA 2020 Declaration ¹⁰. 

Through critical reading, characteristics were observed and grouped by affinity of each one of them, and the evidence included was organized in a table, mentioning the study, design, journal and published year, country of origin, level of evidence, instruments used in the study, sample and main results. To assess the methodological quality of the manuscripts included, we used the PRISMA statement ¹⁰ for systematic reviews; Melnyk's levels of evidence ¹¹, Strengthening the Reporting of Observational studies in Epidemiology (STROBE) ¹² statements for observational studies; the Consolidated Standards of Reporting Trials statement for experimental studies (CONSORT) ¹³ and the Consolidated criteria for reporting qualitative research (COREQ) ¹⁴ checklist for qualitative studies.

Results

According to the design of the articles, 64.3 % of the articles corresponded to observational studies (cross-sectional ^2,15-21, cases and controls ²²), 14.3 % to systematic reviews, meta-analyses ^23,24, and experimental studies ^5,25 respectively and 7.1 % to qualitative ethnographic studies ²⁶. On the other hand, 64.3 % corresponded to the Spanish language and 35.7 % to English. In relation to their origin it was found that 35.7 % were articles from Colombia ^2,5,17,18,26, 7.1 % were from countries such as Mexico ¹⁶, Brazil ¹⁵, Peru ¹⁹, Chile ²¹, Cuba ²⁵, Korea ²⁰, State of Palestine ²², Iran ²⁴ and Ethiopia ²³ each.

According to the hierarchical evidence classification system of the articles ¹¹, 64.3 % met the characteristics of level VI evidence ^2,15-21,26, 14.3 % with level V ^23,24, 7.1 % with level IV ²² and 14.3 % was level III ^5,25. For systematic reviews and meta-analyses, a score of 16 ²⁴ and 22 points ²³ was obtained. For observational studies, scores of 19 points ^20,22, 17 points ^15,21, 16 points ^2,16,17, 14 points ¹⁸, and 12 points ¹⁹ were obtained. As for the experimental studies, scores of 17 points ⁵ and 16 points ²⁵ were obtained, and finally for the qualitative study, 24 points ²⁶ were obtained, (Table 1).

Characteristics of studies: It was identified that in the case-control study ²² in 413 patients (control n=205 consisted of patients without foot ulcer; cases n=208 with ulcer no smaller than 0.5 cm²), showed that the control group had higher mean scores on the diabetic foot self-care behavior scale (DFSBS) than the case group P < 0:001.

Referring to the systematic review and meta-analysis ²³, it was found that DF ulcer was significantly associated with the presence of calluses on lower limbs, poor self-care practices and advanced age. In addition, it was found that sex was not significantly associated with the presence of DF ulcer. Another systematic review ²⁴ showed that the factors that influenced the severity of DF ulcers were smoking, high BMI, hyperglycemia, type of treatment, patient complications, advanced age and vascular status. In cross-sectional research with a sample of 1,515 individuals aged 40 years or older, a significantly higher prevalence of foot self-care deficits and less healthy behavior was established in men ¹⁵. While in 302 participants it was found that there was no association between the risk of DF with the sex variable; in addition, they suggested a possible association with the degree of risk and final self-care score (p <0.10) ¹⁸.

In a descriptive study ²⁰ performed in 131 patients, the patients showed that foot care behaviors were associated with the experience of diabetic education-hospitalization-complications, method of treatment, glycosylated hemoglobin (HbA1C) levels and perceived family support. Another quantitative research ¹⁹ in 56 patients hospitalized with DM2 when analyzing the self-care practices performed, it was found that 46.4 % had moderate self-care practices, the most frequent with 69.6 % was to check the feet; additionally, another observational study ²¹ with 60 patients, found that 88.3 % maintained correct foot hygiene; the attendance to the podiatrist was presented in 58.3 %. In spite of the data obtained, 22.4 % presented foot lesions, of which only 61 % used the treatments.

In an educational intervention ⁵ with 79 participants, half of them were placed in high DF risk categories where the most frequent classification was zero due to the absence of sensory neuropathy. In a qualitative study ²⁶, they found that, in self-care practices, family members only intervened when the patient found it difficult to perform self-care activities; there were deficiencies in foot self-care practices, they referred to the use of traditional herbal remedies of their culture in foot care and in the control of hyperglycemia.

Moreover, a correlational study ¹⁶ reported that the risk of DF was related to self-care barriers in DM, diabetes (r=0.224, p<0.5) and BMI (r=0.255, p<0.5). In addition, it was found healthy lifestyle and a maximum risk of DF in 24.8 % of cases. Lifestyle was related to self-care barriers in DM. Additionally, in 304 patients there was statistical correlation between level of education and knowledge (p<0.01), also self-care practices and sex became factors that could have a negative effect on both knowledge and maintenance of self-care practices ².

In another correlational study in 59 patients ¹⁷, when evaluating self-care agency, it was found that 74.6 % obtained a good level according to the self-care agency assessment scale (ASA); 31 % obtained a 2b risk classification when presenting peripheral vascular disease in the lower limbs; likewise, a negative statistical correlation was shown in the variables self-care agency and DF risk categorization.

Within the quasi-experimental studies ²⁵, it was shown that education after an educational intervention had an impact on the incorporation of new practices and thus decreased the risk of DF.

Discussion

The main self-care activities most frequently performed by patients were drying the interdigital spaces after bathing and the least frequent was walking barefoot at home or in other places ¹⁹. While in some other studies the main prevention activity chosen was recognizing when there are glucose fluctuations and knowing what to do in the situation, and the least frequent was recognizing the changes caused by the disease itself at the emotional, personal, and occupational levels ⁵. It was found that slightly less than half of the participants received education on the prevention of DF ²⁷. In others, slightly less than half of the patients were unaware of the disease and its complications ²⁸. It has been seen that patients who do not perform the necessary care for the prevention of DF are those who do not have knowledge about DM2, in addition it can be identified as a risk factor, because it leads to a lack of access to information for an adequate practice of self-care of the feet and an adequate metabolic control in the development of complications, in particular of DF ^2,29. However, there are studies that mentioned that despite the fact that the participants have a good to fair knowledge about the pathology, little less than a quarter of the sample carry out preventive measures ³⁰.

Furthermore, in a qualitative study ²⁶ they mentioned that the type of self-care in the practice of foot care and DM2 control can be influenced by the cultural and family context; this is similar to other studies where foot care was associated with the perceived family support for the disease by being involved when the patient is unable to perform such activities ²⁰.

There was a difference in the level of knowledge before and after an educational intervention, the difference was statistically significant; after an educational intervention, a high level of knowledge was achieved by the patients in slightly more than half of the sample ²⁵. Thus, therapeutic education programs with group interventions benefit patients in empowerment, in addition to being more likely to positively modify their self-care and therefore their lifestyle ²⁵.

Regarding self-care and lifestyle in relation to sex, it is essential to evaluate self-care in people, since this would identify both strengths and weaknesses existing in the lifestyle, so as to improve good practices and eradicate concepts related to sex, such as aspects of diet, correct footwear and adherence to pharmacological treatment ²¹. It was reported regarding lifestyle, through the use of an elaborated instrument that regular physical activity, drug addictions such as alcohol and tobacco consumption were more prevalent among men. In relation to self-care, women presented greater prevalence in the use of diets for food control and in self-care of the feet; however, men showed better habits in relation to adequate footwear. The variables related to self-care were found to be associated with sex, so that men presented greater self-care deficits and consequently are considered a risk factor for amputation in people with DF ¹⁵.

Besides, another study ² mentioned that there was a statistical correlation between self-care practices and sex, since women in their daily life acquire multiple roles that can be considered as a negative effect on the maintenance of self-care practices. Even so, results present in another research ¹⁸ mentioned that sex had no relevance in risk prediction, in comparison to other variables that did increase the risk of DF such as years with diagnosis, final DF risk score and age of the patients; as well as what was reported in another research ²² where an association was also found between longer duration of DM2 and the development of DF ulcer.

Referring to the risk level, a study conducted in Colombia in 2016, studied the classification of risk of developing DF in 59 individuals with a median age of 63 years through the instruments established in the International Consensus on DF, in which the participants were most frequently found at Risk 2b presenting peripheral vascular disease ¹⁷. Along the same lines, an educational intervention ⁵ was conducted in 79 patients with a median age of 62 years, with a higher frequency of risk level zero without the presence of sensory neuropathy. Another study from Colombia ¹⁸ found a low risk level in 81 out of 100 individuals for developing DF. However, in a study conducted in a Mexican population, high risk and maximum risk of developing DF were found more frequently by using the risk assessment scale of the foot in diabetic patients ¹⁶. Regarding the figures present, according to one study ³¹, the highest prevalence of DF was found in North America, followed by Africa, Asia, Europe and Oceania.

Regarding the most common symptoms presented by the participants, in a median age of 62 years were neuropathy, vascular condition, skin changes and inadequate footwear; however, in other studies the most frequent symptomatology was tingling and alteration in foot pulses ⁵. Similarly, age was a variable of interest in the increased risk of DF, it was mentioned that both peripheral arterial disease and diabetic neuropathy affect people from the fifth decade of life onwards ¹⁸, in addition to the fact that age influences the severity of DF ulcers ²⁴.

Regarding the relationship between self-care and the risk of DF, in a Palestinian sample it was reported that there was a positive association between the development of DF and inadequate self-care of the feet ²². While a study in Colombia revealed that when measuring the relationship between DF risk categorization and self-care agency, a high negative correlation was found between the variables ¹⁷. Similarly, in a systematic review and meta-analysis, DF ulcer was associated with the presence of poor self-care practice ²³. For this reason, the association between risk and practices allows us to identify relevant aspects during patient care and therefore the measurement of both variables allows us to detect deficiencies that require a different strategy ¹⁸.

Conclusions

An association between self-care deficit and the risk of DF was found, especially in the elderly. Most of the articles were developed in Colombia and only one in Mexico. This article mentions the factors that influence the risk of DF; however, it only includes the pre-elderly and old age periods. Consequently, new research is needed to include the variables lifestyle, self-care and risk of DF, as well as to expand the age range to establish effective early measures and reduce the risk of DF; in addition to emphasize health personnel to establish strategies and carry out improvement plans in order that patients lead a healthy lifestyle, perform appropriate self-care activities and podiatric care such as nail trimming, footwear, and skin as preventive measures against the development of DF.

Conflict of interests

The authors stated that there was no conflict of interests.

Financing

The authors stated that there was no financing of any kind.