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The relationship between dietary phytochemical index and novel anthropometric indices and the severity of diabetic foot ulcers in adults with type 2 diabetes: a cross-sectional study

BMC Endocrine Disorders volume 24, Article number: 226 (2024) Cite this article

Abstract

Background

Research on the relationship between dietary phytochemical intake and the anthropometric indices as well as the diabetic foot ulcers (DFUs) remains inconsistent. We aimed to investigate the associations of dietary phytochemical index (DPI) with the novel anthropometric indices and the severity of DFUs.

Methods

This cross-sectional study was conducted on 339 adults with type 2 diabetes. Dietary intake was assessed using three 24-hour dietary recalls. To quantify the phytochemical content of the diet, the DPI estimation was done through an equation proposed by McCarty. The International Working Group on the Diabetic Foot (IWGDF) criteria and Wagner classification system were applied to assess DFUs. New anthropometric indices including a body shape index (ABSI), body roundness index (BRI) and abdominal volume index (AVI) were calculated based on formulas. We employed analysis of variance (ANOVA), analysis of covariance (ANCOVA) and logistic regression to explore associations between DPI and the anthropometric indices and DFU variables.

Results

Our results revealed no significant association between DPI and the foot ulcer indices, following adjusting for the possible covariates. Furthermore, we also examined the relationship between diabetic neuropathy, as measured by monofilament score, and the DPI. Similarly, we did not find any substantial relationship between the DPI and monofilament score (OR: 1.18; 95% CI: 0.66–2.09; Ptrend = 0.56), as well as biochemical indices. Our analysis did not reveal any significant associations between the DPI and ABSI (OR: 0.70; 95% CI: 0.35–1.38; Ptrend = 0.30), BRI (OR: 0.80; 95% CI: 0.33–1.95; Ptrend = 0.59), and AVI (OR: 1.99; 95% CI: 0.92–4.33; Ptrend = 0.08).

Conclusions

Our study revealed no significant links between the DPI and foot ulcer indices, neuropathy measures, and anthropometric indices. These findings imply that factors beyond dietary phytochemical intake may exert greater influence on the development of foot ulcers in diabetes.

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Introduction

Considering the myriad complications of diabetes, cardiovascular diseases (CVDs) stand out as the leading cause of death in patients with diabetes mellitus [1, 2]. Nearly one-third (32.2%) of individuals with type 2 diabetes experience CVDs, contributing to approximately half of all mortality cases [3]. Diabetic dyslipidemia [4, 5] and obesity [6] are prevalent health issues in patients with diabetes. Consequently, disturbed levels of serum lipoproteins contribute to vascular obstruction, amplifying the risk of cardiovascular events in diabetic populations [7, 8]. Likewise, abnormal anthropometric indices are considered strong predictors of diabetes and worsen the progression of diabetes outcomes [9, 10]. Global reports indicate that individuals with type 2 diabetes are more likely to develop diabetic foot ulcers than those with type 1 diabetes [11]. On average, 6.4% of people with diabetes around the world are affected by diabetic foot ulcers [12].

Diabetic foot ulcers are often challenging and about one-third of ulcers fail to heal, leading to lower extremity amputation [13, 14]. While a multidisciplinary approach has been demonstrated to be effective in healing diabetic wounds [15], emerging evidence from 2 RCTs and a review suggests that dietary modifications may further enhance outcomes and reduce the ulcer size [16,17,18]. Additionally, adherence to dietary patterns rich in fruits, vegetables, whole grains, and dietary fiber, correlates with improved glycemic control and decreased risk of diabetes complications based on a RCT and a recent cross-sectional study [19, 20].

This protective effect is believed to be partially mediated by dietary phytochemicals that are natural bioactive compounds abundantly present in fresh fruits, vegetables, nuts, whole grains, legumes, and olive oil [21]. Due to the challenging nature of directly measuring phytochemicals in the diet, McCarty proposed the concept of the dietary phytochemical index (DPI) which is explained via the percentage of calorie intake from phytochemical-rich foods [22]. Prior research indicates that individuals with a higher dietary phytochemical profile exhibit a reduced risk of developing insulin resistance, hypertension, hyperlipidemia, obesity, oxidative stress, and inflammation [23,24,25,26,27].

Despite the growing interest in dietary phytochemicals, the relationship between dietary phytochemical intake and foot ulcerations, as well as anthropometric characteristics, remains underexplored. Thus, this study aims to investigate the relationship between dietary phytochemical index and novel anthropometric indices, neuropathy, and the severity of diabetic foot ulcers in adults with type 2 diabetes.

Methods

Study design and participants

This cross-sectional study was conducted on 339 adults with type 2 diabetes to investigate the relationship between dietary phytochemical index and biochemical markers related to metabolic risk factors and also the severity of diabetic foot ulcers within this population. The research was carried out at the Diabetes Research Center affiliated with Tehran University of Medical Sciences, with data collection spanning from March 2022 to January 2023. A simple random sampling was applied for participant selection and before enrolment in the study; all people provided written informed consent, indicating their agreement to participate. Data were obtained through the medical records of the participants in the study or in person and through interviews. The study protocol received approval from the Human Ethics Committee of Tehran University of Medical Sciences [IR.TUMS.EMRI.REC.1401.072].

Inclusion and exclusion criteria

People were considered eligible for inclusion in our study if they met the following criteria: aged over 18 years, diagnosed with type 2 diabetes for at least one year, presence of diabetic foot ulcers, HbA1c blood level lower than 9, possession of a complete medical record, ability to respond to questionnaire items, and willingness to participate in the study by providing consent. Conversely, individuals with specific criteria such as pregnancy or lactation, taking hormonal medications, experiencing mental or inflammatory disorders, immune system issues, cancer, and diagnosed diseases in the liver, kidney, thyroid, digestive, or cardiovascular systems were not included in the study. In addition, subjects with insufficient medical data as well as under or over-reporting dietary energy intakes (<800 or >4200 kcal/day) were excluded from the statistical analysis.

Sample size

To calculate the required sample size, the hazard ratio of diabetic neuropathy in relation with the Mediterranean diet Adherence rate was applied [28]. According to the formulas below P1: the hazard ratio of diabetic neuropathy in people with high compliance to the Mediterranean diet (0.97), P2: the hazard ratio of diabetic neuropathy in those with poor adherence to the Mediterranean diet (0.74), and r: the ratio of sick to healthy cases (0.90), C1 − B = − 0.842 and ca. / 2 = 1.96, sample size was determined.

$$\:m^{\prime\:}=\frac{\:[ca/2\sqrt{{(r}_{+1}\stackrel{-}{)p}\stackrel{-}{Q}}-{C}_{1-B}{\sqrt{{r}_{1}{P}_{1}{Q}_{1}+{p}_{2}{Q}_{2}}]}^{2}}{r\left(p2-p1\right)2}$$
$$\:\frac{m^{\prime}}{4}{\left(1+\sqrt{1+\frac{2\left(r+1\right)}{ḿr\left|{P}_{2}-{P}_{1}\right|}}\right)}^{2}$$
$$\:\stackrel{\text{-}}{\text{P}}:\frac{P1+rP2}{r+1}$$
$$\text{Q}1=1-\text{P}1=1-0.88=0.12\quad\quad\text{n}_{1}=\text{m}$$
$$\text{Q}2=1-\text{P}2=1-0.97=0.03\quad\quad\text{n}_{2}=\text{m}\times \text{r}$$
$$\:\stackrel{-}{P}=0.92$$
$$\:\stackrel{-}{Q}=1-\stackrel{-}{P}=0.08$$
$$\:\text{m}^{\prime}=\frac{\begin{array}{l}{[1.96\sqrt{\left(0.9+1\right)0.92\times\:0.08}-\left(-0.842\right)}\\{\sqrt{0.9\times\:\left(0.88\times\:0.12\right)+\left(0.97\times\:0.03\right)}]}^{2}\end{array}}{0.9({0.97-0.88)}^{2}}=151$$
$$\text{m}=\frac{151}{4}{\left(1+\sqrt{1+\frac{2\left(0.9+1\right)}{151\times\:0.9\times\:\left|0.97-0.88\right|}}\right)}^{2}=174$$
$$\text{n}_{1}=\text{m},\text{n}_{2}=\text{m}\times \text{r}$$
$$\text{n}_{1}+\text{n}_{2}=174+157=331$$

Based on this formula, a minimum of 331 subjects were needed. However, for the final sampling, a study population of 339 individuals was chosen.

Assessment of dietary intake

A 24-hour dietary recall method was utilized to assess the dietary intakes. To achieve a more accurate estimation of usual intake, three recalls were collected, covering two non-consecutive regular days and one public holiday. An experienced nutritionist conducted a face-to-face interview to record details regarding the types and quantities of food consumed over the past 24 h. Subsequently, all reported foods were converted to grams per day using Home Scale Guide [29] and imported into the Nutritionist IV software (First Databank Division, Hearst Corporation, San Bruno, CA, United States, modified for Iranian foods) to calculate each individual’s energy and nutrient intake.

Dietary phytochemical index calculation

In this study, DPI estimation was done through an applicable equation, proposed by McCarty to quantify the phytochemical content of the diet [22] which represents the percentage of energy obtained from phytochemical-rich foods. The formula employed is as follows:

$$\:\left(DPI\right)=\frac{\begin{array}{l}{dietary\:energy\:derived\:from\:phytochemical}\\{-rich\:foods\:\left(kcal\right)}\end{array}}{Total\:daily\:energy\:intake\:\left(kcal\right)}\times\:100$$

The selection of phytochemical-rich foods was performed according to the following method: Traditional Iranian breads such as Sangak and Barbari for whole grains; fruits (red, yellow, and orange varieties); vegetables (including dark green, red, orange, starchy, and others); nuts (peanuts, almonds, walnuts, pistachios, and hazelnuts); legumes such as lentils, beans, and chickpeas; soybean products; olives and olive oil; as well as natural fruit and vegetable juices (carrot, orange, and lemon juices). The exclusion of potatoes from the vegetable group in the DPI calculation was due to their minimal phytochemical content.

Biochemical assessment

After 10 to 14 h of overnight fast, we collected biochemical data, including total cholesterol (TC), high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), and triglycerides (TG), employing standardized laboratory techniques. Additionally, a physician utilized a sphygmomanometer to measure systolic (SBP) and diastolic (DBP) blood pressures on the right hand with the participant seated.

Anthropometric assessment

Anthropometric data collection involved weighing participants in light clothing and barefoot on a digital scale (SECA, Hamburg, Germany) with 0.1 kg precision. Height was measured stationary with a stadiometer, rounded to the nearest 0.5 cm. Waist and hip circumferences were measured with a tape measure, WC at the narrowest point above the umbilicus and HC at the widest point of the hip. Finally, other anthropometric indices were computed using the formulas below [30,31,32]:

$$BMI: weight(kg)\div height^{2}(m)$$
$$ABSI: WC(m)\div BMI^{2/3} \times sqrt (height(m))$$
$$BRI: 364.2-365.5 \times sqrt (1 - (WC(m)\div 2\pi)^{2} \div (0.5\times Height(m))^{2})$$
$$AVI: (2\times WC^{2}(cm))+(0.7 \times (WC (cm) - HC (cm))^{2})\div 1000$$

Assessment of sensation and foot ulcer

The IWGDF criteria were applied to assess diabetic foot ulcers [33]. The center’s physician evaluated various aspects of the ulcers, including their location, size, depth, presence of edema, and ankle-brachial index (ABI) level and offloading. The monofilament test was utilized to diagnose the severity of diabetic neuropathy [34], and a patient interview provided information on hospitalizations due to foot ulcers, debridement, and amputations. We assessed neuropathy by utilizing a 10-gram monofilament test in both feet at 10 specific sites [35, 36]. If patients felt the application of the monofilament, they responded affirmatively. If they did not perceive the monofilament at more than 8 sites, they were normal, those who felt sensation at 4–7 sites, had reduced sensation, and fewer than 3 sites had absent sensation [37,38,39]. In addition, we used the Wagner classification system [40] to assess the severity of diabetic foot ulcers, categorizing them into six grades: grade 0 signifies the absence of open lesions; grade 1 indicates destruction of skin thickness; grade 2 points to ulcer penetration through skin, fat, and ligaments without affecting bone; grade 3 for deeper tissue involvement with abscess, osteomyelitis, or tendonitis; grade 4 denotes limited necrosis in toes or forefoot necrosis; and grade 5 for necrosis of the entire foot.

Assessment of other variables

Socioeconomic status (SES) information was collected via a questionnaire covering age, marital status, education level, family size, house possession, household items, and employment. The total SES score was determined by combining the scores assigned to each item, with a higher score reflecting a more favorable socioeconomic status. Further covariate data on foot ulcer infection, debridement, shoe and sock conditions, history of chronic diseases and major adverse cardiovascular events (MACE), medication intake, use of herbal or antioxidant supplements, and smoking status was carefully documented from the patient’s medical records and interviews. Assessment of physical activity level was done using the International Physical Activity Questionnaire (IPAQ) as: (MET × Minutes × Days) [41]. Due to the low physical activity levels of the stated group, total physical activity levels were dichotomized and those with MET-min/week above 297 were considered physically active.

Statistical analysis

The study participants were first categorized into tertiles according to their DPI scores. (T1: <23.64, T2: 23.65–34.06, T3: 34.07< ). For comparing baseline quantitative and qualitative variables across the DPI tertiles, analysis of variance (ANOVA) and chi-square tests were applied respectively. Continuous variables were displayed by Mean (SD) while percentages were used to describe categorical variables. Prior research indicates that the cut-off values for AVI, BRI, and ABSI were 24.5, 4.62, and 0.091, respectively [30, 42, 43]. The comparison of nutrient intake was done by the analysis of covariance (ANCOVA). In this context, energy and macronutrients were controlled for age and gender, while extra adjustment for Kcal was performed for other nutrients. The relationships between DPI score and anthropometric indices, as well as the severity of foot ulcers, were investigated using binary logistic regression. Crude and three multivariable-adjusted models were employed, with the first tertile of DPI considered the reference category. In the initial adjusted model, the results were controlled for age, gender, and energy intake. The second model was further adjusted for smoking, socioeconomic status, physical activity, history of foot ulcers and amputations, and history of MACE, ABI and offloading. Finally, in the last model, the BMI was added to the previous adjustments to control for its potential confounding effect. To evaluate the trends of odds ratios (ORs) among DPI tertiles, categories were designated as ordinal variables. P-values less than 0.05 were designated as the statistically significant threshold. The Statistical Package for Social Sciences was used to conduct all statistical analyses (version 26; SPSS Inc., Chicago, IL).

Results

We conducted a comprehensive study to investigate the potential associations between the dietary phytochemical index and various foot ulcer indices, such as foot ulcer infection, foot ulcer area, Wagner grade. Our aim was to explore whether dietary phytochemical intake plays a role in the development and severity of foot ulcers in individuals with diabetes. We compared the general characteristics, biochemical markers, and anthropometric indices among tertiles of the dietary phytochemical index. We did not observe any significant differences in these parameters among the tertiles, as shown in Tables 1 and 2. Participants in the third tertile of the dietary phytochemical index had higher intake of carbohydrates (55.3 ± 0.8 vs. 48.6 ± 0.8%, p < 0.01), fiber (18.9 ± 0.5 vs. 14.1 ± 0.5 g/day, p < 0.01), vitamin C (136.5 ± 7.7 vs. 92.0 ± 7.7 mg/day p < 0.01), and folate (219.2 ± 8.4 vs. 185.6 ± 8.3 mcg /day p: 0.01) compared to those in the first tertile of the dietary phytochemical index (Table 3). To ensure the robustness of our findings, we adjusted for several covariates known to influence foot ulcer outcomes. These covariates included age, gender, energy intake, smoking status, socioeconomic status, physical activity level, history of foot ulcer and amputation, history of major adverse cardiovascular events (MACE), and body mass index (BMI). Our results revealed no significant association between the foot ulcer indices and the dietary phytochemical index, even after adjusting for the aforementioned covariates (Table 4). Furthermore, we also examined the relationship between diabetic neuropathy, as measured by monofilament score, and the dietary phytochemical index. However, similar to the foot ulcer indices, we did not find any substantial relationship between the dietary phytochemical index and monofilament score following adjusting for covariates in model 3 (OR: 1.18; 95% CI: 0.66–2.09; P trend = 0.56). In addition to the foot ulcer and neuropathy assessments, we explored the potential association between the dietary phytochemical index and new anthropometric indices, namely ABSI (a body shape index), BRI (a body roundness index), AVI (abdominal volume index). Our analysis did not reveal any significant associations between the dietary phytochemical index and ABSI (OR: 0.70; 95% CI: 0.35–1.38; P trend = 0.30), BRI (OR: 0.80; 95% CI: 0.33–1.95; P trend = 0.59), and AVI (OR: 1.99; 95% CI: 0.92–4.33; P trend = 0.08) (See Table 4).

Table 1 General characteristics of type 2 diabetics participants with foot ulcer across tertiles of DPI index (n = 339)
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Table 2 Biochemical, anthropometric indices and identifiers of foot ulcer of type 2 diabetics participants with foot ulcer across tertiles of DPI index (n = 339)
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Table 3 Multivariable-adjusted intakes of selected nutrients of type 2 diabetics participants with foot ulcer across tertiles of DPI index (n = 339)
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Table 4 Multivariable-adjusted odds ratio novel anthropometric indices and identifiers of foot ulcer of type 2 diabetics participants with foot ulcer across tertiles of DPI index (n = 339)
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Table 5 Multivariable-adjusted novel anthropometric indices of type 2 diabetics participants with foot ulcer across tertiles of foot ulcer area (n = 339)
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Discussion

Our study did not find any significant associations between the dietary phytochemical index and foot ulcer indices, neuropathy measures, and anthropometric indices. These results suggest that other factors, beyond dietary phytochemical intake, may be more influential in the development and severity of foot ulcers in adults suffering from diabetes.

The dietary phytochemical index (DPI) is a measure that calculates the proportion of daily caloric intake derived from foods rich in phytochemicals [22]. The hypothesis is that higher DPI values may be linked to improved health outcomes. On the other hand, diabetic foot infections contribute significantly to non-traumatic amputations and can be avoided with appropriate measures [44, 45]. The recent studies have shown a significant inverse relationship between DPI and inflammation, and oxidative stress as risk factors of CVD in the obese participants [24]. DPI has also been related to the risk of chronic diseases including type 2 diabetes, cancer, and inflammatory conditions [46,47,48]. In a cohort study, lower prevalence of hyperglycemia and hypertriglyceridemia were associated with higher DPI in adults [46, 49]. In the healthy population, higher DPI was related to lower fasting blood sugar (FBS) [50, 51].

While numerous classifications exist for evaluating diabetic foot ulcers, Wagner’s classification stands out as a straightforward and widely recognized tool for assessing diabetic foot lesions [52, 53]. The Wagner classification system provides a grading scale to assess the severity of diabetic foot lesions [54,55,56]. The Semmes-Weinstein monofilament is a cost-effective and straightforward tool that can be utilized for screening diabetic peripheral neuropathy, particularly in situations involving a large number of individuals [57, 58]. While we considered probe testing for osteomyelitis, no antibiotic treatment was assessed. Despite recommendations for antibiotic treatment, not adjusting antibiotic usage may have influenced the results [59, 60]. Additionally, other nutritional factors not evaluated may have impacted the outcomes. For example, the Controlling Nutritional Status (CONUT) score is an objective assessment using lymphocyte count, cholesterol, and albumin to evaluate nutritional status [61]. The CONUT score is a validated predictor of foot ulcer healing and mortality [62, 63]. Over the past decade, two novel anthropometric indices have been introduced as potential alternatives to conventional measures One of these indices is the A Body Shape Index (ABSI), which was introduced in 2012 [42]. ABSI aims to predict the risk of pathologies that may not be easily identified by using BMI alone. Numerous studies have linked ABSI to various health outcomes, including all-cause mortality, hypertension, diabetes, and metabolic syndrome [42, 64,65,66]. In addition to ABSI, another anthropometric index called the Body Roundness Index (BRI) was proposed by Thomas DM et al. in 2013 [67]. BRI specifically targets the prediction of visceral adiposity tissue and body fat percentage. It has demonstrated its effectiveness as a predictor of metabolic syndrome in both men and women [66]. These two anthropometric indices, ABSI and BRI, have garnered attention as potential tools for assessing health risks and predicting various metabolic conditions. Furthermore, the abdominal volume index (AVI) is an easily calculable and dependable anthropometric measure that has demonstrated a strong correlation with diabetes mellitus across multiple studies involving diverse populations [68,69,70].

The previous studies examining the correlation between the dietary phytochemical index (DPI) and cardiometabolic risk factors, as well as metabolic syndrome and inflammation, demonstrated inverse relationships between the DPI and various significant factors such as waist circumference, body mass index (BMI), insulin levels, leptin levels, and high-sensitivity C-reactive protein (hsCRP). Moreover, individuals with higher DPI scores exhibited a reduced likelihood of experiencing central obesity [71,72,73,74,75,76]. The differences in the results between our study and other studies can be explained in several ways. Firstly, there are variations in the ethnicity of the populations studied. Other studies included Korean and European populations, while our study focused on Iranian and Afghan population. Secondly, except one paper, others utilized a food frequency questionnaire (FFQ) to assess dietary intake, whereas we employed 24-hour dietary recalls. This disparity in dietary assessment methods may contribute to differing findings. Thirdly, none of the previous studies considered diabetic foot ulcer indices as outcomes. Moreover, they did not include patients with diabetic foot ulcers. While there have been no specific studies examining the association between the dietary phytochemical index and diabetic foot ulcer (DFU) indices in patients with type 2 diabetes, other studies have investigated the effects of selenium, magnesium, vitamin C, and vitamin E supplementation on the DFUs healing in this population [77,78,79,80,81,82]. It is worth noting that diets rich in phytochemicals are typically high in dietary antioxidants [83,84,85]. These previous studies, which differed in design from ours as they were randomized controlled trials and directly intervened with antioxidants rather than relying on questionnaire-based assessments, demonstrated significant improvements in foot ulcer indices [77,78,79,80,81,82]. However, the differences in study designs should be taken into consideration when interpreting these findings in relation to our own study.

Our study is the first study that included a comprehensive assessment of foot ulcer indices, neuropathy measures, anthropometric indices, and the dietary phytochemical index. This comprehensive approach allows for a thorough investigation of multiple factors potentially influencing foot ulcers in individuals with diabetes. By reporting the lack of significant associations between these variables, our study adds to the existing body of knowledge on the topic. This information is valuable for researchers and clinicians in understanding the potential factors influencing the development and severity of foot ulcers in individuals with diabetes. As a cross-sectional study, this research design cannot establish causality. The lack of significant associations between variables does not necessarily imply a lack of causal relationship. It is important to highlight this limitation to ensure proper interpretation of the results. Due to the convenience sampling method and the specific characteristics of our sampled population, the generalizability of our findings to other populations or individuals with different characteristics may be limited. It is important to acknowledge and discuss other confounders that were not accounted for in this study, as they may have influenced the results. Our study focused on the dietary phytochemical index as a measure of phytochemical intake. It is crucial to acknowledge that this index may not capture the full range of phytochemicals consumed, as dietary assessment methods have inherent limitations. Furthermore, biases regarding 24-hour dietary recalls should be considered. The 24-hour dietary recalls rely on participants’ memory to recall and report their food and beverage intake. Memory recall can be prone to errors, leading to recall bias. The timing of data collection may introduce bias due to seasonal variations in food availability and consumption habits. Certain foods may be more or less prevalent during specific seasons, impacting the representation of overall dietary patterns.

Conclusion

In conclusion, our study revealed no significant links between the dietary phytochemical index and foot ulcer indices, neuropathy measures, and anthropometric indices. These findings imply that factors beyond dietary phytochemical intake may exert greater influence on the severity of foot ulcers in adults suffering from diabetes. Additional research is required to investigate these factors further and determine their potential contribution to diabetic foot ulcer pathogenesis.

Data availability

The data used to support the findings of this study are available from the corresponding author upon request.

Abbreviations

ABI:

Ankle-brachial index

ABSI:

A body shape index

ANCOVA:

Analysis of covariance

ANOVA:

Analysis of variance

AVI:

Abdominal volume index

BMI:

Body mass index

BRI:

Body roundness index

CI:

Confidence interval

CVD:

Cardiovascular disease

DASH:

Dietary approaches to stop hypertension

DBP:

Diastolic blood pressure

DFU:

Diabetic foot ulcer

DFS:

Diabetic foot syndrome

DM:

Diabetes mellitus

DPI:

Dietary Phytochemical Index

FFQ:

Food frequency questionnaire

HC:

Hip circumference

HDL-c:

High-density lipoprotein cholesterol

hsCRP:

High-sensitivity C-reactive protein

IPAQ:

International physical activity questionnaire

IWGDF:

International working group on the diabetic foot

LDL-c:

Low-density lipoprotein cholesterol

MACE:

Major adverse cardiovascular events

OR:

Odds ratio

SBP:

Systolic blood pressure, SD: standard deviation

SES:

Socioeconomic status

TC:

Total cholesterol

TG:

Triglycerides

WC:

Waist circumference

WHO:

World Health Organization

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Acknowledgements

We would like to appreciate the reviewers for their insightful contribution.

Funding

This study was supported by Tehran University of Medical Sciences (Grant number: 1402-1-473-64147).

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  1. Moharam Jalalzadeh and Mohsen Montazer as co-first authors.

Authors and Affiliations

  1. Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran

    Moharam Jalalzadeh, Ensieh Nasli-Esfahani, Mohsen Montazer, Faezeh Geravand, Parisa Nezhad Hajian, Mohammad Heidari-Seyedmahalle & Leila Azadbakht

  2. Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences, P.O. Box: 14155/61170, Tehran, Iran

    Moharam Jalalzadeh, Mohsen Montazer, Faezeh Geravand, Parisa Nezhad Hajian, Mohammad Heidari-Seyedmahalle & Leila Azadbakht

  3. Department of Community Nutrition, School of Nutrition and Food Science, Isfahan University of Medical Sciences, Isfahan, Iran

    Leila Azadbakht

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Contributions

MJ: Contributed to data collection, imported the data for analysis, conducted the statistical analysis, and contributed to manuscript draft. EN: Designed the study and contributed to data collection. MM: Designed the study and contributed to data collection, including sampling and extracting data from the medical records, and contributed to the manuscript draft. FG: Contributed to data collection, imported the data for analysis, and contributed to the manuscript draft. PN: Contributed significantly to the manuscript draft in addition to editing, refining, and revising the content of the manuscript. MH: Contributed to data collection including sampling and extracting data from the medical records and data importation LA: Designed the study, conducted the statistical analysis, and supervised the study. The final manuscript was approved by all authors.

Corresponding author

Correspondence to Leila Azadbakht.

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Ethical approval and consent to participate

All participants (or their legal guardians) read and provided written informed consent. Informed consent for all illiterate participants was obtained from their parents and/or their legal guardian(s). This study was approved by ethics committee at Tehran University of Medical Sciences (Ethical code: IR.TUMS.EMRI.REC.1401.072). This study was conducted in accordance to Tehran University of Medical Sciences and Declaration of Helsinki guidelines and regulations.

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Not applicable for this study.

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Jalalzadeh, M., Nasli-Esfahani, E., Montazer, M. et al. The relationship between dietary phytochemical index and novel anthropometric indices and the severity of diabetic foot ulcers in adults with type 2 diabetes: a cross-sectional study. BMC Endocr Disord 24, 226 (2024). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12902-024-01734-x

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BMC Endocrine Disorders

ISSN: 1472-6823

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