Differences in foot self-care and lifestyle between men and women with diabetes mellitus

ABSTRACT Objective: to investigate differences with regard to foot self-care and lifestyle between men and women with diabetes mellitus. Method: cross-sectional study conducted in a sample of 1,515 individuals with diabetes mellitus aged 40 years old or older. Poisson regression models were used to identity differences in foot self-care deficit and lifestyle between sexes, adjusting for socioeconomic and clinical characteristics, smoking and alcohol consumption. Results: foot self-care deficit, characterized by not regularly drying between toes; not regularly checking feet; walking barefoot; poor hygiene and inappropriately trimmed nails, was significantly higher among men, though men presented a lower prevalence of feet scaling and use of inappropriate shoes when compared to women. With regard to lifestyle, men presented less healthy habits, such as not adhering to a proper diet and taking laboratory exams to check for lipid profile at the frequency recommended. Conclusion: the nursing team should take into account gender differences concerning foot self-care and lifestyle when implementing educational activities and interventions intended to decrease risk factors for foot ulceration.


Method
Cross-sectional study conducted with individuals with DM2, 40 years old or older, living in the urban area of a large city in the South of Brazil. To establish a representative and stratified sample per region, a prevalence of 11% of diabetic individuals in the population aged 40 years or older was considered (13) . The individuals selected in the draw were invited to participate in the study through a telephone call or printed invitations received from the community health agents. Data were collected at PHC services. Those who failed to attend the date scheduled for data collection after three attempts, were not located at the address recorded in the medical file, or refused to participate in the study were replaced by another participant selected by a new draw until the sample was complete.
An instrument developed by Bortoletto et al. (4) was adapted and used in this study. This tool addresses socioeconomic variables, lifestyle, clinical conditions, foot self-care and includes clinical examination of lower limbs. An interview was conducted with the participants to identify socioeconomic characteristics and variables related to lifestyle and foot self-care. The medical files were also consulted to verify variables that showed the patient's clinical conditions. After the interview, body weight and height were measured and the participants' lower limbs were clinically assessed.
The variables of interest were those related to foot self-care and lifestyle of the individuals with diabetes. Foot self-care was assessed according to the interviewees' reports: dry between toes after shower (yes/no); regularly assess lower limbs (yes, no); regularly walk barefoot (yes, no); and perform foot scalding (yes, no). At the time of the interview, we also Rossaneis MA, Haddad MCFL, Mathias TAF, Marcon SS.
verified whether shoes were appropriate (yes, no), and whether hygiene was properly performed and toenails were properly trimmed (yes, no) (2,5,14) . Foot scalding consists in immersing the feet in a container with warm water. Hygiene was considered appropriate when the participant's feet were clean, dry, and with normal odor. Closed toe shoes with one extra centimeter in the internal part, made of soft leather or canvas/cotton, were considered appropriate (2,(4)(5) .
With regard to the variables concerning lifestyle, the participants were asked whether they followed an appropriate diet, exercised regularly (physical activity for at least 30 minutes more than three times a week), whether they smoked or consumed alcohol in excess (more than one dose per day for women and two daily doses for men). They were also asked whether they had regular laboratory exams to control DM. People diagnosed with DM are recommended to have their glycated hemoglobin (HbAc1) assessed at least once every six months and the lipid profile once a year (2) .
The lipid profile consists of assessing triglycerides, total cholesterol, low-density lipoproteins (LDL) and highdensity lipoproteins (HDL) (2) . Body weight and height were also verified and the body mass index (BMI) was determined: BMI ≥ 25 kg/m 2 (2) was considered overweight.
Socioeconomic variables included sex, age, marital status, self-reported race, education, and socioeconomic status according to ABEP (Brazilian Association of Survey Companies) (15) . Socioeconomic status was classified  (2) .
Prevalence ratio (PR) was used for the analysis of association. The Wald Chi-square test was performed with a level of significance of 5% to determine whether there were differences between men and women with regard to variables related to lifestyle, laboratory exams according to the recommended schedule and foot selfcare. Afterwards, these analyses were adjusted according to socioeconomic and clinical variables, using Poisson Regression models. Thus, variables that presented p<0.20 in the bivariate analysis with lifestyle and foot self-care variables were selected. These variables were selected to adjust the model, considering that diabetes mellitus is associated with people's living conditions and aggravates over time according to the patients' clinical aspects.
The female sex was established as reference because recent studies have identified that men more frequently present DM-related self-care deficit when compared to women (7,10,12) . Statistical (Table 3).

Discussion
This study revealed that most practices related to changes in lifestyle that are required to properly control DM and foot self-care, to prevent ulceration, are associated with gender. Proper diet was more prevalent among women, as reported in another study conducted with 4,839 people with DM, in which women reported a more frequent daily consumption of fruits and vegetables and low intake of fatty foods, when compared to men (10) .
In contrast, being a man was associated with a higher prevalence of regular exercise. This result was also verified in other studies in which women with DM tended to be less physically active than men (7)(8), while men were less adherent to recommended diet (7,16) and glycemic monitoring (7) .
Regarding the control of DM by taking laboratory exams to check for glycated hemoglobin and lipid profile, men presented a higher prevalence of deficit with regard to this aspect. This result may be associated with the fact that women are more attentive to symptoms and physical signs of diseases and more frequently seek health services than men (8,10) . Additionally, other studies identified that women present a higher prevalence of changes in the lipid profile and therefore require medication to treat dyslipidemia early (2,7,9) . With regard to diabetic foot self-care, men presented greater deficit comparing to women. A prospective study with seven years of follow-up identified that being a male was a risk factor for amputation among patients with diabetic feet, together with other factors such as long time since diagnosis, high glycated hemoglobin, retinopathy and the use of insulin (17) .

Another important aspect verified in this study
refers to the fact that women present greater prevalence of foot self-care, such as drying between toes after shower, checking feet regularly, properly trimming nails to avoid lesions and ingrown toenails, not going barefoot, and performing proper hygiene. These actions suggest women acquired knowledge about self-care necessary to prevent ulceration in the lower limbs. Drying between toes after shower and performing proper hygiene of feet decrease the risk of bacterial and fungal infections, some of the main conditions that precede the amputation of lower limbs (4,12,14) .
Still with regard to the nursing consultation, examining lower limbs and stratifying the individual's risk for developing ulcers is key to prevent and treat diabetic feet (2) . A study assessing the effectiveness of a nursing care program delivered to individuals with DM was conducted during two years and verified that this strategy decreased the risk of ulceration in the participants' lower limbs and prevented the emergency of new ulcers among those with a history of previous lesion. The care measures that were implemented during the program included regular assessment of feet, self-care education, treatment of ulcers and mycoses, skin hydration, and referral to medical specialties for the more severe cases, among others (21) .
Healthcare workers have to pay attention to these aspects in an attempt to identify clinical changes and the care needs of patients to control DM, prevent chronic complications, and treat diabetic feet early on (2,14) . Note that orientation regarding the therapeutic plan and selfcare education needs to take into account that men and women hold different beliefs regarding the benefits of DM-related self-care. Other studies (16)(17) verified that women present better education in DM and higher expectations regarding the benefits accruing from selfcare, while men are usually reluctant to acknowledge their health problems and seek professional care.
Another study addressing male self-perceived health verified that most men, even after receiving the diagnosis of a chronic disease, did not seek medical care, mainly alleging lack of time due to working days, incompatibility between their schedules and the health services' functioning hours, lack of severe symptoms, or because they faced more difficulty to access healthcare services than women (16) . With regard to women with DM, the study identified that they needed greater professional and familial support to adhere to the treatment than men. Lack of support also influenced the adoption of a proper diet because women were not willing to cook foods, necessary for their diet, but which their families did not appreciate, such as restricted salt and sugar. Additionally, those women facing financial hardship consider it selfish to buy foods that exclusively meet their needs (8) . It is worth noting that the health of men and the aspects involved in the management of their health is a challenge for healthcare workers who need strategies that enable these patients to more frequently seek care and adhere to NTCD prevention and control measures.