ISSN 2394-7330

International Journal of Novel Research in Healthcare and Nursing

Vol. 9, Issue 3, pp: (101-107), Month: September - December 2022,
PATTERN OF SERUM VITAMIN D LEVELS AMONG PERSONS WITH DIABETIC
FOOT ULCERS
1Aina O. C., 2Owamagbe E. M., 2Wala K. T., 3Kinako S E.
1
School of Public Health, University of Port Harcourt, Rivers state, Nigeria.
2
Department of Chemical Pathology, Rivers state university, Rivers state, Nigeria
3
Department of Anatomical Pathology, Rivers state university, Rivers state, Nigeria

ABSTRACT
The study adopted the case-control study design to assess the vitamin d levels among diabetic
persons with diabetic foot ulcer and diabetic persons with no diabetic foot ulcer. A total of 176
persons (88 persons with diabetic foot ulcer and 88 diabetics with no foot ulcer) were selected
through simple random sampling techniques. Five milliliters of venous blood were aseptically
collected from each study participant Enzyme linked immunosorbent assay was used to assess
serum vitamin d levels among the participants. A structured PROFORMA data collection sheet
was used to collect demographic information from the study participants. The mean age of
persons with DFU (cases) was 56.1 ±9.6, while the mean age of persons with no DFU (control)
was 50.1 ±10.8. the gender distribution showed that 36.36% of the persons with DFU were
male and 63.64% were female, while 31.82% of persons with no DFU were male and 68.18%
were female. The mean serum vitamin D levels among the cases was 19.6 ± 13.5 compared to
36.2 ± 11.4 in the control group (p < 0.05). The results showed that 84.1% of persons with
DFU had deficient vitamin d levels and 15.9% of persons with DFU had sufficient vitamin d
levels, while 29.5% of persons with no DFU had deficient vitamin d levels and 70.5% had
sufficient vitamin d levels. The distribution of vitamin d levels between both groups was
statistically significant. Logistic regression showed that persons with DFU were 12.6 times
(95% C.I; 6.1 – 26.2) likely to have deficient/insufficient vitamin d levels compared to persons
with no DFU. Clinical interventions on vitamin d levels among diabetics is recommended to
reduce potential risks of foot ulcers and improve the quality of life among persons living with
diabetes mellitus.

Keywords: Diabetes, Foot ulcer, Vitamin D, Deficiency

INTRODUCTION
Diabetes Mellitus (DM) is a significant contributor to renal disease, heart attacks, strokes,
blindness, and lower limb amputation[1, 2]. Age-standardized diabetes mortality rates
increased by 3% between 2000 and 2019. Diabetes-related death rates rose 13% in lower-
middle income countries. Nigeria, for example, has seen a more than 100% increase in the
frequency of the illness over the past 20 years, rising from 2.2% in 1999 to over 6% in 2019[3,
4]. According to common reports, Nigeria, the most populous nation in Africa, has the highest
prevalence of diabetes in the Sub-Saharan region[5–7]. Diabetes prevalence has
disproportionately increased, and this has been attributed in large part to shifting demographic
patterns, particularly growing urbanization and the adoption of unhealthy lifestyles[3]. There
is a rise in the prevalence of diabetes-related complications and mortality that is occurring
concurrently with this increase in the disease burden[1, 7, 8]. The diabetic foot ulcer (DFU),
an expensive, painful, but avoidable consequence of diabetes that is associated with high
morbidity and death, is one of the most harmful of these complications[5, 9, 10]. DFU occurs
when a breach in the skin epithelium's continuity involving at least its complete thickness and
occurring distal to the ankle joints in a person with DM[11]. Patients with diabetes mellitus

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International Journal of Novel Research in Healthcare and Nursing

Vol. 9, Issue 3, pp: (101-107), Month: September - December 2022,
(DM) frequently develop foot ulcers; the current global incidence is 6.3%[10]. A person with
diabetes is thought to have a 25% lifetime chance of having DFU[9]. Vitamin D is a pleiotropic
steroid hormone that is required for calcium and phosphorus metabolism as well as bone
turnover regulation[11]. It is also known to have a function in inflammation, immunological
response, cell cycle regulation, and a variety of chronic diseases, including diabetes and its
complications[12, 13]. Recent research has shown an inverse relationship between vitamin D
levels and the prevalence and progression of type 2 diabetes mellitus[14, 15]. When Pena et al.
looked at the micronutrient status in diabetic individuals with foot ulcers, they found that
vitamin D insufficiency was the most prevalent problem[16]. Numerous preclinical
investigations and observational studies have shown that vitamin D promotes wound healing
in a beneficial way[17–19]. However, it is still debatable whether vitamin D has a role in the
onset and progression of diabetic foot (DF). The current study caried out a comparative
assessment of vitamin d levels among diabetics with foot ulcer and diabetics with no foot ulcer
in a clinical setting in southern Nigeria.

METHOD
The study adopted the case-control study design to assess the 25-OH-vitamin D levels among
diabetic persons with diabetic foot ulcer and diabetic persons with no diabetic foot ulcer. A
total of 88 persons with diabetic foot ulcer and 88 diabetics with no foot ulcer were selected
through simple random sampling techniques. Ethic approval to carry out the study was obtained
from the research and ethics committee of the University of Port Harcourt Teaching Hospital,
Rivers state, Nigeria. A willing informed consent was obtained from each study participant
prior to their inclusion into the study. Five milliliters of venous blood were aseptically collected
from each study participant Enzyme linked immunosorbent assay was used to assess serum 25-
OH-vitamin D levels among the participants. A structured PROFORMA data collection sheet
was used to collect demographic information from the study participants. The chi-square
statistics was used to assess the distribution of 25-OH-vitamin D levels in both groups. Logistic
regression was used to assess the association of demographic characteristics and 25-OH-
vitamin D levels among the study participants. All analysis was done with the SPSS v 25
software at a 95% confidence interval and a p-value less than 0.05 was considered statistically
significant.

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RESULTS
Table 1 shows the demographic distribution of the study participants. The mean age of persons
with DFU (cases) was 56.1 ±9.6, while the mean age of persons with no DFU was 50.1 ±10.8.
the gender distribution showed that 36.36% of the persons with DFU were male and 63.64%
were female, while 31.82% of persons with no DFU were male and 68.18% were female.
Table 1: Demographic Distribution of participants

Variable Units Case Control

n=88, (%) n=88, (%)
Age groups (years) 20 - 29 0(0.00) 2(2.27)
30 - 39 5(5.68) 14(15.91)
40 - 49 19(21.59) 25(28.41)
50 - 59 27(30.68) 28(31.82)
60 - 69 30(34.09) 15(17.05)
70 and above 7(7.95) 4(4.55)
Mean Age Mean ±SD 56.1 ±9.6 50.1 ±10.8
Gender Male 32(36.36) 28(31.82)
Female 56(63.64) 60(68.18)
Educational level No formal 6(6.82) 1(1.14)
Primary 21(23.86) 12(13.64)
Secondary 29(32.95) 35(39.77)
Tertiary 32(36.36) 40(45.45)
Marital Status Married 54(61.36) 72(81.82)
Single 8(9.09) 7(7.95)
Separated 4(4.55) 2(2.27)
Widow/Widower 22(25.00) 7(7.95)
Table 2 shows that the mean serum 25-OH-vitamin D levels among the cases was 19.6 ± 13.5
and 36.2 ± 11.4 in the control group. The t-test statistic indicates that the difference in the
mean 25-OH-vitamin D levels between both groups is statistically significant (p <0.05).
Hence, the mean serum vitamin in the cases is significantly higher compared to the controls.

Table 2: Comparison of 25-OH-vitamin D levels in study participants

Group Serum 25-OH-vitamin D (Mean ± SD)

Case 19.6 ± 13.5

Control 36.2 ± 11.4

T-test (p-value) -8.74 (0.0001)*

*Difference between both groups is statistically significant (p<0.05)

SD: Standard Deviation

Table 3 shows that 61 (69.32%) of the cases had deficient 25-OH-vitamin D levels and 13
(14.77%) of the cases had insufficient 25-OH-vitamin D level and only 14 (15.91%) had
sufficient 25-OH-vitamin D levels. It also showed the 8 (9.09%) of the control subjects had
deficient 25-OH-vitamin D levels and 18 (20.45%) of the controls had insufficient 25-OH-
vitamin D levels and 62 (70.45%) had sufficient 25-OH-vitamin D levels. Chi-square analysis

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Vol. 9, Issue 3, pp: (101-107), Month: September - December 2022,
showed that the distribution of 25-OH-vitamin D levels in both groups was statistically
significant (p = 0.0001), indicating that the proportion of deficient 25-OH-vitamin D levels
was significantly higher among the cases compared to the controls Neither cases nor controls
had sufficient 25-OH-vitamin D levels.

Table 3: Distribution of 25-OH-vitamin D levels in Study Participants

Case Control
Level Vit D n, (%) n, (%) Chi-square (p-value)
Sufficient 14(15.91) 62(70.45)

Deficient 61(69.32) 8(9.09) 71.83 (0.0001)*

Insufficient 13(14.77) 18(20.45)

Total 88 (100.0) 88 (100.0)

*Distribution is statistically significant (p<0.05)

Table 3 shows the distribution of 25-OH-vitamin D levels in both groups. The table shows that
84.1% of persons with DFU had deficient 25-OH-vitamin D levels and 15.9% of persons with
DFU had sufficient 25-OH-vitamin D levels, while 29.5% of persons with no DFU had
deficient 25-OH-vitamin D levels and 70.5% had sufficient 25-OH-vitamin D levels. The
distribution of 25-OH-vitamin D levels between both groups was statistically significant.
Logistic regression showed that persons with DFU were 12.6 times (95% C.I; 6.1 – 26.2) likely
to have deficient/insufficient 25-OH-vitamin D levels compared to persons with no DFU.

Table 4: Distribution of 25-OH-vitamin D levels in Study Participants

Group Deficient/insufficient Sufficient Total Chi-square Odds ratio

n, (%) n, (%) n (%) (p-value) (95% C.I)
DFU 74 (84.1) 14 (15.9) 88 (100.0) 53.36 (0.0001)* 12.6 (6.1 – 26.2)

No DFU 26 (29.5) 62 (70.5) 88 (100.0)

*Distribution is statistically significant (p<0.05)

DISCUSSION
Diabetic foot ulcers are responsible for considerable morbidity and mortality of diabetic
patients. Both hospitalized and patients attending ambulatory care settings who have DFUs are
shown in worldwide studies to have higher mortality rates than patients without. The study
showed that most of the persons with DFU were females. However, this is in contrast with the
reports of Adeleye et al., which reported that there was no significant association of gender and
DFU morbidity[9]. Similarly, the study by Tola et al., in bivariate analysis, from the
sociodemographic characteristic of the study participants, only age had a significant association
with DFU, whereas sex, place of residence, marital status, occupational status, duration of DM,
and family history of DM were not statistically associated with the occurrence of DFU[7]. The

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observed differences in gender distribution in the current study could be due to the relatively
higher health seeking habits among women in the study area. It was observed that average 25-
OH-vitamin D levels in persons with DFU was significantly lower compared to diabetics with
no DFU. This is consistent with reports of similar studies where significantly low levels of 25-
OH-vitamin D (<25nmol/l) have been reported among persons with DFU[14, 15, 17]. Vitamin
D has been linked by researchers to several different immunological changes that are connected
to an increased vulnerability to infection. Additionally, it has been demonstrated that active
vitamin D3 is a strong suppressor of interferon-g-mediated macrophage activation and
increases the phagocytosis and death of germs by macrophages[2, 7, 17]. It inhibits the growth
of T cells, lowers the generation of T helper type 1 cytokines, and increases T helper type 2
cytokine production. The main function of T helper type 2 cells is in response to external
infections. Vitamin D deficiency may raise the risk of infection in diabetic foot patients in
addition to hyperglycemia by further reducing the immune cells' ability to fight off infection[7,
19, 20].
In the current study, less than a quarter of the persons (15.9%) with DFU had sufficient 25-
OH-vitamin D levels compared to persons with no DFU where about 70.5% had sufficient 25-
OH-vitamin D levels. More than half (69%) of the persons with DFU were found to have
deficient 25-OH-vitamin D levels. Studies have also shown the effect of vitamin D on glucose
homeostasis, insulin resistance and b cell dysfunction in subjects at risk of type 2 diabetes and
on markers of inflammation in non-diabetic adults[2, 7, 21]. Other studies have shown that
vitamin D receptors are necessary for the self-renewal, migration, and differentiation of
epidermal stem cells and progeny during skin wound healing when the skin is wounded[2, 19,
22]. Vitamin D increased pro-angiogenic molecules in keratinocytes and encouraged the
synthesis of antimicrobial peptides, according to in a DFU model[18]. Another research found
that the loss of calcium-sensing and vitamin D receptors together slows the re-epithelialization
of wounds[23]. Vitamin D can enhance glycemic management and has indirect effects on
wound healing[11].

CONCLUSION
The findings of the study indicated that 25-OH-vitamin D levels were mostly deficient among
persons with diabetic foot ulcer. This is indicated by the significantly lower 25-OH-vitamin D
levels among person with diabetic foot ulcer compared to persons with no diabetic foot ulcer.
The findings of the study indicates that diabetic foot ulcers increase the likelihood of 25-OH-
vitamin D deficiency among persons with diabetes. The study suggests the need for vitamin D
supplementation in such patients to prevent or to adjuvant the antibiotic therapy for control of
infection.

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