Co-design of a nutrition intervention for diabetes-related foot ulceration

Diabetes-related foot ulcers (DFU) are common, with 56,000 Australia presenting with DFUs every year (1) . Optimal nutrition is critical in wound healing, however, in DFU there is limited data available on nutritional status and healing outcomes. Therefore, the aim is to summarise the work leading to the development of a co-designed intervention for individuals with DFU and determine the dietary intake of individuals with DFU. Three separate studies were conducted: (1) qualitative interviews within individuals with DFU, (2) qualitative interviews with health care professionals working with people with DFU, and (3) comparison of current dietary intakes of individuals with DFU against international guidelines. To explore the individual with DFU perspective, a qualitative study using a reflexive thematic approach of conversational style interviews was undertaken. A targeted heterogenous sample with active or recent history of DFU, were recruited from a high-risk foot service in New South Wales, Australia. To gain an understanding of the perspectives of Australian health professionals involved in the care of individuals with DFU regarding nutrition assessment and management, semi-structured interviews were conducted nation-wide. To compare dietary intake, descriptive analysis was conducted. Dietary intake was collected using the Australian Eating Survey food frequency questionnaire and used to generate nutrient intake data. Nineteen interviews with individuals with DFU identified negative experiences with dietitians, seeing them as judgemental. Dietary misconceptions were common, with many having an unhealthy perception of food and no participants previously given personalised dietary advice for wound healing. However, it was evident that participants were willing to do anything to improve their wound healing, including a dietary intervention. Participants expressed a strong preference for personalised, face-to-face dietary advice. A total of 19 health professionals participated in interviews. Major barriers to implementation of nutrition assessment and management were identified: inadequate time, lack of knowledge and lack of clinical guidance. Facilitators included: professional development, a standardised clinical pathway and screening tool, and a resource addressing wound healing and diabetes management. One hundred and fifteen participants with DFU were included in the dietary analysis. Most individuals with DFU did not meet current consensus guidelines for optimal dietary intake for wound healing. Inadequate intake of protein, vitamin A, vitamin C, vitamin E and zinc was identified 46%, 45%, 26%, 86%, and 37% of participants, respectively. This body of work highlighted that individuals with DFU are interested in receiving personalised medical nutrition therapy, however they are not currently meeting higher wound healing nutrient requirements. Furthermore, health care professionals are not confident in supporting these individuals. These findings suggest that co-designing interventions for individuals with DFU needs to utilise co-design of the patient and clinician perspective to increase acceptability of the nutrition intervention.