Journal of Tissue Viability (2011) 20, 100e106

www.elsevier.com/locate/jtv

Clinical study

Self-esteem in patients with diabetes mellitus

and foot ulcers
Geraldo Magela Salomé*, Donata Maria de Souza Pellegrino, Leila Blanes,
Lydia Masako Ferreira

Division of Plastic Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil

KEYWORDS Abstract Aim: To evaluate self-esteem in individuals with diabetes mellitus (DM)
Quality of life; and foot ulcers.
Diabetes mellitus; Methods: This was a controlled, cross-sectional, analytical study. We selected 50
Diabetic foot individuals with DM and foot ulcers (study group), as well as 50 with DM and without
foot ulcers (control group). Self-esteem was evaluated using the Federal University
of São Paulo/Paulista School of Medicine Portuguese-language version of the Rosen-
berg Self-Esteem Scale, on which scores range from 0 to 30, higher scores indicating
lower self-esteem.
Results: Of the individuals evaluated, 27 (54%) of those in the study group and
31 (62%) of those in the control group were classified as being of low socioeconomic
status (monthly income at or above, but less than double, the national minimum
wage). In addition, 27 (54%) of the study group patients had type 2 DM, compared
with 29 (58%) of those in the control group. Hypertension was observed in 31 (62%)
of the study group patients and 29 (58%) of the control group patients. Of the
patients in the study group, 33 (66%) had been diagnosed with heart disease,
compared with 23 (46%) of those in the control group. High Rosenberg Self-Esteem
Scale scores (21e30) were more common in the study group, being observed in
30 (60%) of the patients, whereas 33 (66%) of the control group patients had low
scores (0e10).
Conclusion: Foot ulcers appear to have a negative impact on the self-esteem of
patients with DM.
ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author. Disciplina de Cirurgia Plástica, Universidade Federal de São Paulo, Rua Napoleão de Barros 715 - 4o andar,
Vila Clementino, 04024-002 São Paulo, Brazil. Tel.: þ55 11 55764118.
E-mail address: salomereiki@yahoo.com.br (G.M. Salomé).

0965-206X/$36 ª 2010 Tissue Viability Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jtv.2010.12.004
Self-esteem in patients with diabetes mellitus and foot ulcers
Introduction
Globalization and changes in the process of demo-
graphic transition have increased life expectancy,
and the population is therefore susceptible to
certain noncommunicable diseases associated with
aging, constituting a public health problem [1].
Diabetes mellitus (DM) is a heterogeneous
syndrome, with a multifactorial etiology, resulting
from a lack of insulin or from the inability of the
body to process insulin efficiently [2].
The World Health Organization and the Interna-
tional Diabetes Federation estimated that, in 2002,
approximately 160 million individuals worldwide
had DM. The projections for 2025 are that 300
million individuals will have DM [3].
The direct cost of DM ranges from 2.5% to 15% of
the annual health budget, depending on the
prevalence of DM and on the degree of sophisti-
cation of the treatment available. The direct cost
of DM in Brazil has been estimated at approxi-
mately US$ 3,900,000,000, in comparison with US$
800,000,000 in Argentina and US$ 2,000,000,000 in
Mexico [4].
Diabetic foot is among the most common
complications of DM. It is characterized by foot
ulcers resulting from the vascular or neurological
changes (or a combination of the two) that are
typically found in patients with DM. Diabetic foot is
a chronic complication that occurs, on average, 10
years after the onset of the disease, and it is the
principal cause of hospitalization among patients
with DM [5]. This type of lesion causes patient
suffering (including changes in lifestyle and quality
of life) and often prevents patients from per-
forming their regular activities. In addition, the
socioeconomic costs of diabetic foot are high due
to amputations, which constitute a major cause of
disability, incapacitation, early retirement, and
avoidable death [6].
The first half of the 21st century brought a high
degree of technological sophistication in the
monitoring of DM patients, with or without foot
ulcers. Therefore, in order to ensure quality of life
(which influences self-esteem), it is important to
invest in the prevention of complications, avoiding
hospitalization and, consequently, public expen-
ditures [7].
Quality of life has been defined as the perception
of individuals regarding their health status in rela-
tion to social, physical, psychological, economic,
and spiritual aspects [8].
The skin has long been extremely important from
a psychological standpoint, influencing emotional
stability in a quite specific manner. Skin lesions can
101
trigger mental and psychosocial disorders that have
an impact on the quality of life, self-esteem, and
self-image of patients [9].
It has become increasingly important to eval-
uate self-esteem in individuals with skin lesions,
because such lesions alter the standard of living
and lifestyle of those individuals. Desires and
values are often unfulfilled and disparaged. Indi-
viduals feel rejected and live in isolation because
of the smell and appearance of the lesions.
The importance of self-esteem for social and
individual well-being is internationally recognized.
Nevertheless, there have been few studies inves-
tigating self-esteem in Brazil, and there is a lack of
population-based studies in particular. One of the
obstacles to an epidemiological approach to self-
esteem is the lack of instruments that have been
validated for use in Brazil; this prevents this
attribute from being better understood in the
context of scientific investigation [10].
The objective of the present study was to
evaluate the self-esteem of individuals with DM,
with and without foot ulcers, thereby providing
relevant information that can have implications
for the treatment of such individuals.
Material and methods
This was a controlled, cross-sectional, analytical
study conducted at a hospital in the state of São
Paulo, Brazil. The study group (diabetic foot
group) comprised 50 patients (18 years of age)
with DM and foot ulcers. In the selection of
patients, no restrictions were imposed regarding
the number of ulcers or the time elapsed since the
onset of the ulcers. The control group comprised
50 individuals (18 years of age) with DM and
without foot ulcers. All of the participants were
selected from among those followed at the
hospital where the data were collected.
The data were collected between January 20,
2009 and July 20, 2009.
The study design was approved by the Research
Ethics Committee of the Federal University of São
Paulo. Written informed consent was obtained
from all participating patients.
The data were collected by the researchers
themselves. The participants were interviewed in
a quiet, isolated room.
We used a standardized questionnaire in order
to collect demographic and clinical data. For the
evaluation of self-esteem, we used the Federal
University of São Paulo/Paulista School of Medicine
Portuguese-language version of the Rosenberg Self-
102
Esteem Scale, validated for use in Brazil [11]. The
scale is a specific instrument for measuring quality
of life. It comprises 10 closed questions, the
answer options being “strongly agree”, “agree”,
“disagree”, and “strongly disagree”. The score for
each item therefore ranges from 0 to 3. The total
score ranges from 0 to 30, higher scores translating
to lower self-esteem [11].
For the statistical analysis, we used the chi-
square test, the Student’s t-test, and the nonpara-
metric ManneWhitney test. For all statistical tests,
the level of significance was set at 5% (p < 0.05).
Results
As can be seen in Table 1, 22 (44%) of the patients
in the diabetic foot group were in the 60e69 year
age bracket, compared with only 15 (30%) of the
those in the control group. Of the 50 diabetic foot
group patients, 28 (44%) were male, as were 19
(38%) of the control group patients. White indi-
viduals accounted for 66% of the patients in the
diabetic foot group and 72% of those without. Of
the 50 patients in the diabetic foot group, 20 (40%)
were married, compared with 26 (52%) of those in
the control group. In addition, 23 (46%) of the
diabetic foot group patients were illiterate, as
were 29 (58%) of the control group patients.
Furthermore, 18 (36%) of the patients in the dia-
betic foot group were retired, as were 25 (50%) of
those in the control group. Monthly family income
was at or above, but less than double, the national
minimum wage in 27 (54%) of the diabetic foot
group patients and 31 (62%) of the control group
patients. There were no significant differences
between the groups under study in terms of any of
the sociodemographic characteristics evaluated.
Table 2 shows the descriptive statistics (mean
and standard deviation) related to the age of the
patients in the groups under study.
Table 3 shows the clinical profile of the two
groups in terms of the type of diabetes, as well as
the presence of hypertension and heart disease. As
can be seen, 27 (54%) of the diabetic foot group
patients had type 2 DM, as did 29 (58%) of the
control group patients. Of the 50 patients in the
diabetic foot group, 31 (62%) had hypertension and
33 (66%) had heart disease, compared with 29
(58%) and 23 (46%), respectively, of those in the
control group. In terms of the prevalence of heart
disease, the difference between the two groups
was significant (p ¼ 0.044).
As can be seen in Table 4, the majority of the
patients in the diabetic foot group scored above 20
G.M. Salomé et al.
on Rosenberg Self-Esteem Scale score ranging,
whereas the majority of those in the control group
had a score of 10 or below. For this parameter,
there were significant differences between the
two groups (p < 0.001).
Table 5 shows the mean and median of the
Rosenberg Self-Esteem Scale scores for the groups
under study.
Discussion
In patients with chronic diseasesdprincipally in
those with DM and in those with DM and foot
ulcersdthemes such as health, quality of life, and
self-esteem have piqued the interest of
researchers attempting to understand the multi-
dimensional nature of the living conditions of
these individuals.
The foot is a structure that provides humans
with support and locomotion, as well as being
esthetically important; it comprises numerous
structures, which must be in harmonious balance
in order to perform their functions [12].
Diabetic foot is a chronic complication of DM and
is characterized by infection, ulceration, or
destruction of deep tissue, associated with neuro-
logical abnormalities and various degrees of
peripheral vascular disease in the lower limbs [8]. In
addition to its acute and chronic complications,
diabetic foot, which can result in amputation, has
major socioeconomic repercussions related to
incapacity for work and work absenteeism, as well
as to the high costs of control and treatment [12].
According to França and Tavares [13], foot
ulcers affect work productivity and result in
retirement due to disability, as well as limiting
activities of daily living and leisure activities. For
many patients, venous disease translates to pain,
loss of mobility or functional capacity, and wors-
ening of quality of life.
Because DM patients with foot ulcers begin to
depend on their families and friends to perform their
activitiesdhousehold activities, leisure activities,
social activities, or family activitiesdthey lose their
autonomy.
In the present study, most of the participants
(in both groups) were over 60 years of age.
According to the latest census conducted in Brazil
(in 2000), elderly individuals account for 8.6% of
the Brazilian population as a whole, which means
that the elderly population of the country has
increased by 1.02% since the previous census,
conducted in 1991 [14]. Farinasco et al. investi-
gated 86 elderly patients and reported that the
Self-esteem in patients with diabetes mellitus and foot ulcers 103

Table 1 Sociodemographic characteristics of the two groups.

Variable Group pa
With foot ulcers Without foot ulcers
N % n %
Age bracket
28e39 years 3 6.0 3 6.0 0.579
40e49 years 9 18.0 9 18.0
50e59 years 13 26.0 14 28.0
60e69 years 22 44.0 15 30.0
70e86 years 3 6.0 9 18.0
Total 50 100 50 100.0

Race
White 33 66.0 36 72.0 0.517
Non-White 17 34.0 14 28.0
Total 50 100 50 100

Gender
Male 22 44.0 31 62.0 0.071
Female 28 56.0 19 38.0
Total 50 100 50 100

Marital status
Single 7 14.0 7 14.0 0.641
Married 20 40.0 26 52.0
Separated 15 30.0 11 22.0
Widow/Widower 8 16.0 6 12.0
Total 50 100 50 100

Level of education
Illiterate 23 46.0 29 58.0 0.221
<9 years of schooling 4 8.0 9 18.0
9 years of schooling 7 14.0 4 8.0
High school (incomplete) 13 26.0 5 10.0
High school (complete) 20 2.0 1 2.0
College (complete) 15 4.0 2 4.0
Total 50 100 50 100

Occupation
Retired 18 36.0 25 50.0 0.233
Homemaker 15 30.0 8 16.0
Unemployed 7 14.0 0 0.0
Electrician 3 6.0 3 6.0
Painter 5 10.0 3 6.0
Other 2 4.0 11 22
Total 50 100 100 100

Family income
1  the national MW 27 54.0 31 62.0 0.569
2e3  the national MW 16 32.0 15 30.0
>3  the national MW 7 14.0 4 8.0
Total 50 100 50 100
MW: minimum wage.
a
Chi-square test.
104 G.M. Salomé et al.

Table 2 Descriptive statistics of the age of the patients, by group.

Group Age
n Mean SD Minimum Maximum
With foot ulcers 50 56.90 10.0757 34 71
Without foot ulcers 50 58.16 12.4595 28 86
Total 100 57.53 11.2909 28 86
Student’s t-test.

self-reported health status ranged from good to
excellent in 47.7%, as well as that 77.9% were still
independent, despite the fact that 76.7% had two
or more diseases [15]. There has been consider-
able debate regarding the importance of employ-
ing teams of health professionals in order to
implement preventive measures and measures to
promote health among elderly individuals and
their families.
Although a certain degree of physiological
impairment (limitation of the ability to perform
activities of daily living) is an expected conse-
quence of aging, this impairment is more severe
among elderly individuals with foot ulcers. The
intensity and frequency of this impairment vary
and depend on the living conditions of individuals
in different socioeconomic, historical, and cultural
contexts [15].
One study investigating patients with foot ulcers
reported that most of the patients were male and
illiterate [16].
The level of education certainly plays a role in
determining whether elderly individuals, princi-
pally those with chronic diseases, will require the
Table 3 Clinical profile of the two groups.
Variable Group
With foot ulcers Without foot ulcers
n % n %
Type of diabetes
1 23 46.0 21 42.0
2 27 54.0 29 58.0
Total 50 100 50 100
assistance of a caregiver, since they have to deal
with medications, dressing changes, and diets that
are often complex. However, the dynamics of
living can be completely different when the level
of education is higher, since patients with a higher
level of education often have more job opportu-
nities and higher salaries [17].
In the present study, arterial hypertension was
observed in 58% of the control group patients and
62% of the diabetic foot group patients. Of the
control group patients, 66% had heart disease, as
did 46% of the diabetic foot group patients, and
the difference between the two groups was
statistically significant.
It is known that the prognosis for patients with
DM and heart disease is poorer than is that for DM
patients without heart disease, as are short-term
survival and treatment response; it is also known
that the former group of patients are at a higher
risk of recurrence [18].
Shukla et al. evaluated pain in 50 patients with
chronic skin lesions and concluded that such pain
negatively affected the quality of life of those
individuals [19].
In patients with DM, foot ulcers cause suffering,
resulting in changes in lifestyle and quality of life
[5]. This condition often prevents such individuals
from performing social, leisure, and family activi-
pa
ties due to limited work capacity and work
absenteeism in their economically productive
years [20].
In the present study, Rosenberg Self-Esteem
0.687 Scale scores were in the 21e30 point range for 60%

Arterial hypertension Table 4 Rosenberg Self-Esteem Scale scores, by

Yes 31 62.0 29 58.0 0.683 group.
No 19 38.0 21 42.0 Rosenberg Self-Esteem With foot Without foot
Total 50 100 50 100 Scale score ulcers ulcers
n % n %
Heart disease
Yes 33 66.0 23 46.0 0.044 0e10 11 22 33 66
No 17 34.0 27 54.0 11e20 9 18 10 20
Total 50 100 50 100 21e30 30 60 7 14
a Total 50 100 50 100
Chi-square test.
Self-esteem in patients with diabetes mellitus and foot ulcers
Table 5 Descriptive statistics of the Rosenberg
Self-Esteem Scale scores.
Group Rosenberg Self-Esteem Scale score
n Mean Median Margin
With foot ulcers 50 2.48 3.0 3 Conclusions
Without foot 50 0.48 0.0 2
ulcers
Total 100 1.48 1.0 3 Based on the data presented here, we conclude
of the diabetic foot group patients, compared with
only 14% of the control group patients, whereas
scores were in the 11e20 point range for 18% and
20%, respectively, and in the 0e10 point range for
22% and 66%, respectively. These data indicate
that foot ulcers have a negative effect on the self-
esteem of patients with DM.
The inability to perform all of the instrumental
activities of daily living affects the social lives of
individuals with DM and foot ulcers and is a potential
cause of distress among the individuals themselves
and their families; the latter, depending on the
professional activity of the individuals, will have to
devote more time, energy, and financial resources
to meeting those demands [19,20].
Diabetic foot has a major socioeconomic impact
related to expenditures related to treatment and
hospitalization (prolonged and recurrent), as well
as to physical and social impairment, such as job
loss and reduced productivity. Diabetic foot has an
impact on the social lives of individuals because it
negatively affects self-image and self-esteem, as
well as the roles these individuals play in their
families and in society; in addition, if there is
physical limitation, social isolation and depression
can occur [7,19e21].
The present study underscores the need to
change the focus of health care for DM patients
with foot ulcers. Efforts should be made in order to
identify, in the daily routine of health care
services (at hospitals, at outpatient clinics, via
home care, etc.), changes in the emotions, quality
of life, and functional capacity of such patients, as
well as their principal health care needs. There is
also a need to increase the knowledge that care-
givers have on how to deal with the disabilities
resulting from foot ulcers.
Due to the needs that have emerged in recent
decades with the increase in the number of
chronic diseases and of patients with skin lesions,
it is essential to change the focus of the academic
development and improve the qualifications of
health care workers, giving emphasis not only
to theoretical content but also to health care
practice.
105
Further studies involving larger patient samples
(multicenter studies) are needed in order to
understand the magnitude of all aspects of the
quality of life of patients with DM.
that foot ulcers have a negative effect on the self-
esteem of patients with DM.
Conflict of interest
None of the authors have any conflict of interest.
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