Disparities in diabetic foot examinations: A cross-sectional analysis of the Behavioral Risk Factor Surveillance System

Abstract

Introduction: Diabetes Mellitus (DM) is a growing problem in the US and causes serious health complications such as cardiovascular disease, end-stage renal disease, peripheral neuropathy, foot ulcers, and amputations. There are guidelines in place for prevention of foot ulcers in individuals with diabetes; however, adherence to these guidelines appears to be poor due to financial barriers, time and resource constraints among physicians, and lack of education among patients. Poor mental health and poor physical health often arise from DM and also contribute to development of other complications. Thus, our objective was to identify how frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity affect annual foot examinations in individuals with diabetes.

Methods: We performed a cross-sectional analysis of the 2021 Behavioral Risk Factor Surveillance System (BRFSS) datasets to determine the relationship between annual foot examinations and frequent poor mental health days, a depressive disorder diagnosis, frequent poor physical health days, or physical inactivity. We used a bivariate logistic regression model to determine these associations using odds ratios (OR). The regression model was controlled for age, sex, race/ethnicity, health insurance, level of education, current smoking status, and BMI category.

Results: Our results showed 72.06% of individuals with frequent poor mental health days received a foot check, compared with 76.38% of those without poor mental health days—a statistically significant association (AOR: 1.25; 95%CI: 1.09-1.43). Of those reporting a sedentary lifestyle with no physical activity, 73.15% received a foot check, compared with 77.07% of those who were physically active which was also statistically significant (AOR: 1.31; 95%CI: 1.14-1.49). Although having a depressive disorder diagnosis and reporting frequent poor physical health days had lower rates of annual foot examinations, these results were not statistically significant. Rates of foot checks were also lower among individuals who were female (X2 = 6.22, .013), Hispanic (X2 = 7.91, < .0001), lacked insurance (X2 = 51.24, < .0001), were currently smoking cigarettes (X2 = 12.24, <.001), did not complete high school (X2 = 12.24, <.001), had a BMI < 25 (X2 = 8.90, .003), or were less than 35 years of age (X2 = 14.97, < .0001).

Conclusions: Individuals reporting frequent poor mental health days or a sedentary lifestyle were statistically less likely to obtain an annual foot examination. These results are likely explained by a decrease in motivation to partake in self-care among those with poor mental health or sedentary lifestyles. The critical nature of foot ulcer prevention highlights the need to identify groups that do not utilize preventive care so further complications may be avoided. Interventions such as increased mental health screening, counseling or support groups, exercise classes, and educational materials may increase utilization of preventive services among individuals with diabetes, and thus increase the rates of annual foot examinations and prevent foot ulcer development and amputations.