History of Foot Ulcer Increases Mortality Among Individuals With Diabetes

Ten-year follow-up of the Nord-Trøndelag Health Study, Norway

  1. Marjolein M. Iversen, MSN1,2,
  2. Grethe S. Tell, PHD, MPH2,
  3. Trond Riise, PHD2,
  4. Berit R. Hanestad, PHD2,
  5. Truls Østbye, MD, PHD3,
  6. Marit Graue, PHD1 and
  7. Kristian Midthjell, MD, PHD4
  1. 1Faculty of Health and Social Sciences, Bergen University College, Bergen, Norway;
  2. 2Department of Public Health and Primary Health Care, University of Bergen, Bergen, Norway;
  3. 3Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina;
  4. 4The HUNT Research Center, Norwegian University of Science and Technology, Verdal, Norway.
  1. Corresponding author: Marjolein M. Iversen, marjolein.iversen{at}


OBJECTIVE To compare mortality rates for individuals with diabetes with and without a history of foot ulcer (HFU) and with that for the nondiabetic population.

RESEARCH DESIGN AND METHODS This population-based study included 155 diabetic individuals with an HFU, 1,339 diabetic individuals without an HFU, and 63,632 nondiabetic individuals who were all followed for 10 years with mortality as the end point.

RESULTS During the follow-up period, a total of 49.0% of diabetic individuals with an HFU died, compared with 35.2% of diabetic individuals without an HFU and 10.5% of those without diabetes. In Cox regression analyses adjusted for age, sex, education, current smoking, and waist circumference, having an HFU was associated with more than a twofold (2.29 [95% CI 1.82–2.88]) hazard risk for mortality compared with that of the nondiabetic group. In corresponding analyses comparing diabetic individuals with and without an HFU, an HFU was associated with 47% increased mortality (1.47 [1.14–1.89]). Significant covariates were older age, male sex, and current smoking. After inclusion of A1C, insulin use, microalbuminuria, cardiovascular disease, and depression scores in the model, each was significantly related to life expectancy.

CONCLUSIONS AN HFU increased mortality risk among community-dwelling adults and elderly individuals with diabetes. The excess risk persisted after adjustment for comorbidity and depression scores, indicating that close clinical monitoring might be warranted among individuals with an HFU, who may be particularly vulnerable to adverse outcomes.


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    • Received April 3, 2009.
    • Accepted August 28, 2009.
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  1. Diabetes Care vol. 32 no. 12 2193-2199
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