Factors associated with peripheral neuropathy among patients with type 2 diabetes mellitus: A cross-sectional study

Pankaj Punjot; Ravin Bishnoi; Ravi Kant; Suresh K Sharma

doi:10.4103/JCDM.JCDM_6_20

ORIGINAL ARTICLE

Year : 2021 | Volume : 1 | Issue : 1 | Page : 25-30

Factors associated with peripheral neuropathy among patients with type 2 diabetes mellitus: A cross-sectional study

Pankaj Punjot¹, Ravin Bishnoi¹, Ravi Kant², Suresh K Sharma³
¹ Diabetes Nurse Educator, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
² Division of Diabetes and Metabolism, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
³ College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India

Date of Submission	08-Dec-2020
Date of Decision	20-Jan-2021
Date of Acceptance	16-Mar-2021
Date of Web Publication	18-May-2021

Correspondence Address:
Prof. Suresh K Sharma
College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCDM.JCDM_6_20

Abstract

Background: Diabetes mellitus (DM) is a major health problem globally. It is estimated that approximately 50% of people with diabetes suffer from diabetes peripheral neuropathy (DPN). All patients with diabetes should be screened for peripheral neuropathy. Therefore, this study was undertaken to explore and determine the factors associated with peripheral neuropathy. Materials and Methods: A cross-sectional study was conducted on patients with type 2 DM and with peripheral neuropathy at a patient visiting diabetes clinic of a tertiary care center. Neuropathy analysis was done by a peripheral neuropathy analyzer (Vibrotherm: EN ISO 13485:2012). The test consisted of four different steps: The first step was vibration perception for a six-point assessment of each foot; then, cold perception; hot perception; and finally, a 10g Semmes-Weinstein monofilament test. Descriptive and inferential statistics were used for data analysis. Result: Out of 50 patients, the maximum were male (70%); mean age was 55.80 ± 11.48 years; 50% were living in urban areas, 40% in rural areas, and 10% in semi-urban areas; 34% were farmers, 26% were doing jobs, 24% were housewives, and 16% were businessmen. The mean duration of type 2 DM was 8.34 ± 7.89 years, and HbA1c (glycated hemoglobin) was 9.47 ± 3.17. Overall, 44 patients had neuropathy; among them, 29 had only large fiber neuropathy, 42 had small fiber neuropathy, and 27 had both small and large fiber neuropathy. Large fiber neuropathy was found to be significantly associated with HbA1c level and the duration of DM, and mixed fiber neuropathy was found to be significantly associated with the age of the participants (P < 0.05). Conclusion: Peripheral neuropathy is very common in patients with type 2 DM; it is associated with age, level of HbA1c, and the duration of DM, so early action should be taken to mitigate its occurrence.

Keywords: Associated factors, diabetes mellitus, HbA1c, peripheral neuropathy

How to cite this article:
Punjot P, Bishnoi R, Kant R, Sharma SK. Factors associated with peripheral neuropathy among patients with type 2 diabetes mellitus: A cross-sectional study. J Cardio Diabetes Metab Disord 2021;1:25-30

How to cite this URL:
Punjot P, Bishnoi R, Kant R, Sharma SK. Factors associated with peripheral neuropathy among patients with type 2 diabetes mellitus: A cross-sectional study. J Cardio Diabetes Metab Disord [serial online] 2021 [cited 2023 Jun 6];1:25-30. Available from: http://www.cardiodiabetic.org/text.asp?2021/1/1/25/316099

Introduction

DM is a major health problem globally that increases the economic burden of every country in the world. According to the International Diabetes Federation in 2019, the global increasing trend of diabetes is that 463 million adults are currently living with DM. Among these, 352 million adults have uncontrolled glycemic profiles worldwide.^[1],[2] Diabetes is expected to affect 552 million people by 2030. Approximately 62.4 million people in India have diabetes. Diabetes will worsen the life of the patient, as it has micro- and macrovascular complications.^[3],[4] Foot problems and foot diseases are very common in patients with diabetes. Approximately 30% of patients with diabetes younger than 40 years of age are affected by foot problems. Early identification and screening of peripheral neuropathy will improve the quality of life among patients with diabetes and reduce the risk of foot complications.^[5],[6]

The factors that influence diabetes and its complications are gender, age, duration of diabetes, treatment modalities, and glycemic control. Peripheral neuropathy is higher in cases of a longer duration of diabetes, poor glycemic control, and improper foot care. Neuropathy is a very common problem among people with diabetes and if not screened on time, it may lead to foot complications and amputation. Peripheral neuropathy is more prevalent in patients with a fasting blood sugar that is higher than 125mg/dL, with advancing stages of life and duration of diabetes.^[7] Glycemic control of patients with diabetes is highly associated with diabetic complications. Poor glycemic control will end up in micro- and macrovascular complications. Uncontrolled HbA1c with a long duration of glycemic variability triggers complications such as DPN, which shows symptoms such as numbness, tingling, warmness, and paresthesia.^[8]

Diabetes and its complications are rapidly becoming the world’s most significant cause of morbidity and mortality. It is estimated that approximately 50% of people with diabetes suffer from DPN.^[1],[9] Overall, DPN has a significant impact on the quality of life, work productivity, and health-care resource utilization due to prolonged hospitalization. Variability in HbA1c is also associated with a higher risk of cardiovascular disease and microvascular complications in patients with type 2 DM.^[10],[11] All patients with diabetes should be screened for peripheral neuropathy and should be examined with the same every year. The examination should include vibration, temperature, and the pricking method. The symptoms are worse at night and also the patients should be examined for pain. Whenever a patient with diabetes visits the physician, their foot should be examined for complications such as ulcers, deformities, or others.^[11],[12] DPN is also associated with a blood disorder and hemoglobin levels. The HbA1c variation triggers DPN and any blood disorder, thus also leading to microvascular complications.^{[13],[14],[15],[16]} With this background in mind, the present study was designed to determine the factors influencing peripheral neuropathy among patients with type 2 DM.

Materials and Methods

A cross-sectional exploratory study was conducted among participants with type 2 DM aged between 25 and 80 years who were complaining of peripheral neuropathy, such as pain, numbness, the sensation of pricking, the feeling of excess heat in the foot, etc. Patients with acute complications, thyroid dysfunction, malignant tumors, anemia, folate and Vit B 12 deficiency, neurological disorders, and those with no HbA1c records were excluded from the study. The total enumeration sampling technique was used to enroll the patients who visited the diabetes clinic from October 2019 to April 2020 at the tertiary care teaching hospital of Uttarakhand. A total of 4,123 patients visited the clinic during the study period. After excluding patients who did not meet the inclusion criteria, the study finally included 50 patients.

The patients were explained about the procedure before conducting the examination. Peripheral sensory perception was detected with four methods: vibration perception, cold temperature, hot temperature perception, and touch sensation. A peripheral neuropathy analyzer (Vibrotherm: EN ISO 13485:2012), comprising a combination of a digital biothesiometer and a thermometry hot and cold probe, and a 10 gm Semmes-Weinstein monofilament was used to detect small fiber and large fiber peripheral neuropathy. Small fiber loss was identified with temperature perception, and large fiber loss was detected by vibration and touch perception. The severity of the perception loss was interpreted by the reference values mentioned in [Table 1].

Table 1: Severity of the perception loss reference values

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Ethical clearance was obtained from the Institutional Ethics Committee. Written informed consent was obtained from all the participants after explaining the pros and cons of the study. The analysis was performed by using SPSS, version 23. Descriptive statistics (mean, standard deviation, percentage, and frequency) were used to describe the demographic characteristics of the participants. Inferential statistics included Freidman test and Fisher-Freeman-Halton test; nonparametric tests were used due to the non-normal distribution of the data. The level of significance was taken at a P-value of ≤0.05.

Results

A total of 50 patients were studied, with the majority, that is, 70% of them, being males. Half of the participants (50%) were living in urban areas, and 40% were from rural areas. Most of the participants, that is, 34%, were farmers, followed by 26% who had jobs. There were 52% of the participants who were vegetarians. The majority of the participants (44%) had DM for less than five years, followed by 28% with DM for 5–10 years and more than 10 years. Most of the participants, that is, 56%, had an HbA1c level of more than 8%. Only 16% of the participants smoked, and 10% consumed alcohol regularly. The sociodemographic and clinical profile of the enrolled patients is shown in [Table 2].

Table 2: Sociodemographic and clinical profile of the participants (n = 50)

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Out of 50 patients, 44 (88%) had neuropathy, whereas six (12%) had no peripheral neuropathy at all. Of all the patients who had neuropathy, 84% of the participants had small fiber neuropathy, 58% had large fiber neuropathy, and 54% had mixed fiber neuropathy, as shown in [Table 3].

Table 3: Frequency and percentage distribution of peripheral neuropathy among patients (n = 50)

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There was no significant difference in baseline age (56.27 ± 11.06 vs 52.33 ± 14.89), duration of DM (8.83 ± 8.23 vs 04.71 ± 2.98), and HbA1c level (9.61 ± 3.22 vs 8.43 ± 2.77) between the two groups (neuropathy versus patients with non-neuropathy with type 2 DM) at P-value ≤0.05, as illustrated in [Table 4].

Table 4: Comparison of quantitative variables among patients with and without peripheral neuropathy.

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Vibration perception (biothesiometery) loss was present in the right foot of 26 patients and in the left foot of 25 patients. Severe loss was found in the right foot of 16 participants and in the left foot of 13 participants. Cold perception loss was found in the right foot of 21 patients and in the left foot of 25 patients; out of these, severe cold perception loss was reported in the right and left foot each of two patients, whereas mild loss was reported in the right and left foot each of 16 patients. Hot perception loss was present in the right foot of 31 patients and in the left foot of 32 patients; out of these, severe loss was found in the right foot of seven patients and in the left foot of six patients, as reported in [Table 5].

Table 5: Severity of biothesiometer, cold and hot perception loss in both feet

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The presence of overall peripheral neuropathy was not found to be associated with any of the demographic and clinical variables. However, there was a statistically significant association of large fiber neuropathy with HbA1c level (P = 0.05) and with the duration of type 2 DM, (P = 0.004). In addition, mixed fiber neuropathy was significantly associated with the age of the participants, (P = 0.04), as summarized in [Table 6].

Table 6: Associations between sociodemographic and peripheral neuropathy in patients with type 2 DM

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Discussion

The current study examined the associated factors for peripheral neuropathy in patients with diabetes in a tertiary care center. Peripheral neuropathy was assessed by a Vibrotherm analyzer and a 10g Semmes-Weinstein monofilament. The test was performed for those patients who reported signs of peripheral neuropathy.

Many factors were reported to be associated with peripheral neuropathy in various studies, such as: older age, longer duration of diabetes, higher HbA1c level, blood sugar levels, treatment modalities, and comorbidities. In the current study, neuropathy was found to be significantly associated with many of the factors mentioned earlier, which is comparable to many studies conducted in Iran, Bangladesh, Saudi Arabia, and the United States.^{[17],[18],[19],[20]} Older age, male sex, longer duration of diabetes, smoking, and lower HDL-c were reported to be associated with peripheral neuropathy.^[20] The mean age of the patients who participated in the current study was almost similar to that of various studies conducted across the world.^[2],[17] The presence of both types of neuropathy (small and large fiber) was significantly associated with older age (P < 0.04). Similarly, a study conducted in the United Kingdom and Germany reported that the age of patients with neuropathy was more than that of patients without neuropathy.^[21] Another study also reported older age as an associated factor for peripheral neuropathy.^[22] Based on the patients’ responses, peripheral neuropathy was found to be more in males (60%) and less in females (40%), which was comparable with a study previously conducted in Jordan^[2]; however, a study conducted in Uganda reported contrary results.^[10]

In the current study, large fiber neuropathy was found to be significantly associated with the duration of diabetes (P < 0.05); this was comparable to studies conducted in Malaysia and Saudi Arabia, which reported that a longer duration of diabetes increases the risk of DPN.^[19],[22] Glycemic control was not found to be associated with patients with type 2 DM in a study conducted in the United States^[20]; however, in the current study, HbA1c level >8% was found to be significantly associated with large fiber neuropathy. One recent study from Taiwan also reported that a higher mean HbA1c level is associated with diabetic neuropathy, as assessed by a nerve conduction study.^[23] Another study also reported that poor glycemic control is independently associated with distal symmetrical polyneuropathy.^[24] The current study reported more cases of neuropathy in patients who were taking only oral hypoglycemic agents (OHA) than those were on insulin or a combination of OHA and insulin; however, this was not statistically significant. A study from Tanzania found a significantly higher prevalence of neuropathy (P = 0.004) in patients receiving only OHA than patients receiving insulin or a combination of insulin and OHA.^[9]

The findings of this study highlighted the necessity of intensive programs for the early detection of peripheral neuropathy and the immediate implementation of diabetes education in patients with long-standing and uncontrolled diabetes. Moreover, the first and ultimate measure to prevent the development of neuropathy is good glycemic control; this can be achieved by continuous adherence to a modified lifestyle and other glycemic control strategies such as adherence to treatment regimen, good dietary habits, and regular exercise. This can delay more serious complications such as diabetic foot and foot ulcer. Nevertheless, we need to keep in mind that action to stop the diabetes epidemic is the best solution for preventing its complications.

Conclusion

The increasing rate of diabetes globally is a concern. The rate of peripheral neuropathy is high. Many factors contribute to the high prevalence rate of peripheral neuropathy, such as older age, longer duration of diabetes, and uncontrolled HbA1c. There is an urgent need for the routine screening of diabetes mellitus include its potential complications. The screening of DPN may be cost-effective and can prevent diabetic foot ulcer in future. Good glycemic control and lifestyle modifications can prevent DPN; watchful screening needs to be incorporated as a part of routine patient health education during follow-up clinic visits. The routine as well as conscious monitoring and self-assessment of the patient’s feet can also prevent further nerve damage.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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