Risk Factors Associated with Foot Ulcers in People with Diabetes and Leprosy in a Nepalese Population

ORCID

Abstract

Introduction: Foot ulcers are associated with stigma and reduce quality of life, impede socioeconomic output and lead to further complications such as amputation and death. This thesis aimed to investigate risk factors for foot ulceration in people with diabetes or leprosy. Secondary aims were to describe the prevalence of foot ulceration, the site and severity of ulceration and its current management.Methods: Three approaches were taken (1) a literature review of risk factors for ulceration of people with diabetes in the South Asian region and people with leprosy globally (2) a review of inpatient and outpatient medical records of people with diabetes or leprosy and (3) an observational study of foot health and risk factors in people with diabetes and leprosy. The medical record review and observational study occurred across 6 sites over Nepal covering the lowlands (Terai) and hilly regions including one specialized leprosy hospital.Results and Findings: The literature review highlighted 36 studies of risk factors in diabetes and 11 studies in leprosy with findings synthesised in accordance with PRISMA guidelines. In the diabetes review, risk factors were categorised into non-modifiable and modifiable themes. Non-modifiable risk factors were organised across three sub-themes: biological determinants (age and sex), disease progression and complications (diabetes duration, macrovascular and microvascular complications, peripheral vascular disease, and prior diabetes-related complications), and genetic and molecular predisposition. Modifiable risk factors were categorised into intrinsic factors (metabolic and biochemical, biomechanical and foot-related, and haemodynamic) and extrinsic factors (behavioural, treatment-related, and environmental and socioeconomic). In the leprosy review, non-modifiable risk factors comprised biological determinants, established disease sequelae, and neuropathy, while modifiable risk factors were grouped into intrinsic factors (biomechanical and systemic health) and extrinsic factors (footwear and orthotics, self-care behaviour, treatment status, and occupational exposure).The medical notes review (diabetes: inpatient n=769, outpatient n=511; leprosy inpatient n=153, outpatient=111) suggested a prevalence of foot ulceration of 6.4% for diabetes and 58.8% for leprosy in the inpatient population. Descriptions of ulcer severity and site and current management were limited in the diabetic population. For the inpatient leprosy cohort current foot ulceration was associated with more severe disability ratings, sensory loss, the need for footwear provision and lower socioeconomic groups. For the inpatient diabetes cohort current foot ulceration was associated with neuropathy, being male, having lower low density lipoprotein levels and living in the lowlands (Terai) with smoking and alcohol consumption being close to significance.The observational study involving individuals with diabetes (n = 89), leprosy (n = 91), and healthy controls (n = 25) suggested a prevalence of current foot ulceration of 24.7% in the diabetes cohort and 48.4% in the leprosy cohort. Multivariate logistic regression analysis revealed one risk factor of neuropathy in the diabetes cohort (Nagelkerke R² = 0.38; odds ratio (OR) = 0.028; 95% confidence interval (CI): 0.004–0.224), whilst in the leprosy cohort current foot ulceration was predicted by a model comprised of independent factors of neuropathic pain (OR 0.006; 95% CI 0.001-0.068), neuropathy (OR 0.028; 95% CI 0.001-0.796) and inability to speak Nepali (OR=0.066; 95%CI 0.007-0.651), with the absence of each factor coded as the reference category. Ulcer location highlighted that ulcers could appear on the plantar and dorsal of the foot and around the ankle.Discussion & Conclusions: Foot ulceration in diabetes and leprosy is multifactorial but neuropathy is a central factor. Ulcer site may differ from published accounts in other countries suggesting causes other than an insensate foot with deformity combined with high plantar pressures. A high number of unreported relevant clinical descriptors in the diabetic population highlights the need to increase knowledge about ulceration and its assessment. There is a need in Nepal to train specialists in foot care to address the growing burden of diabetic foot ulceration.

Awarding Institution(s)

University of Plymouth

Supervisor

Jonathan Marsden, Jennifer Freeman, Joanne Paton

Document Type

Thesis

Publication Date

2026

Embargo Period

2027-06-03

Deposit Date

July 2026

Creative Commons License

Creative Commons Attribution-NonCommercial 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License

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This item is under embargo until 03 June 2027

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