The impact of dietary compliance on diabetic foot ulcer healing: A cross-sectional study

Abstract

Introduction: Diabetic foot ulcers (DFUs) are a major complication of diabetes mellitus and are influenced by various factors, including dietary behavior. Proper diet adherence is essential for glycemic control and tissue regeneration, yet its role in ulcer healing remains underexplored.

Method: This cross-sectional study involved 100 type 2 diabetes mellitus patients with DFUs receiving home-based care in a community setting. Dietary compliance was measured using a structured questionnaire based on the 3J principle (meal timing, type, and portion). Ulcer healing was evaluated using the Wagner grading system. Data were analyzed using chi-square and logistic regression tests with SPSS 25.0.

Results: Among patients with high dietary compliance, 73.3% showed significant ulcer healing, compared with 42.5% in the low-compliance group (p = 0.008). Dietary compliance was a significant predictor of ulcer healing (OR = 3.18; 95% CI = 1.41–7.15).

Conclusion: Higher dietary compliance was associated with better short-term healing of diabetic ulcers. While integrating nutrition education into home care services may be a valuable component of DFU management, our findings cannot confirm its independent effect, and further prospective research is warranted to determine causality and underlying mechanisms.

Keywords: diabetic foot, diet therapy, wound healing, patient compliance, diabetes mellitus

Introduction

Diabetes mellitus is a chronic and progressive metabolic disorder affecting over 537 million adults globally, and its complications place significant burdens on individuals and healthcare systems.^[1] One of the most serious complications is diabetic foot ulcers (DFUs), which are associated with prolonged healing times,^[2] infection, amputation, and increased mortality risk.^[3] Impaired wound healing in diabetes is multifactorial, involving hyperglycemia-induced neuropathy, vascular insufficiency, and compromised immune response.^[4]

Effective DFU management requires a multifaceted approach, with glycaemia control playing a central role.^[5] Dietary compliance is a key modifiable factor that affects glucose levels and the physiological environment for wound healing.^[6] However, most existing studies have focused on clinical interventions such as debridement and topical agents, while the specific influence of dietary adherence on DFU healing remains underexplored, particularly in non-hospital settings.^[7]

This gap is particularly critical in low-resource settings, where access to specialized care is limited. There is a lack of research examining how structured dietary adherence influences DFU outcomes within home care models that involve family participation and community-based health services. This study offers a novel contribution by evaluating the impact of dietary compliance, as measured by the 3J principles (timing, portion, and type of food), on DFU healing among people living with diabetes receiving community-based home care in Indonesia. The integration of wound monitoring, nutrition education, and spiritual support in the home setting provides a holistic and contextually relevant model of care. 

The concept of dietary compliance in this study is guided by the Indonesian Ministry of Health’s “3J” principle, which emphasizes Jadwal (meal timing), Jumlah (portion size), and Jenis (food type). These components are critical for maintaining glycemic control and optimizing nutrient intake, making them a suitable framework for assessing dietary behavior in diabetic patients. The findings aim to inform more effective dietary interventions within home care frameworks to accelerate ulcer healing in diabetic patients.

Method

Study design and setting

This study employed a cross-sectional analytical design conducted between January and July 2024 in the community service area of a hospital in Central Java, Indonesia. The research was embedded within an ongoing community-based home care wound management program for patients with type 2 diabetes mellitus.

Study population and sample

The study population consisted of patients diagnosed with type 2 diabetes mellitus and diabetic foot ulcers (DFUs) who were receiving home-based wound care. Inclusion criteria included: (1) age ≥18 years, (2) presence of a DFU classified as Wagner grade 1 or 2, (3) undergoing regular home visits for wound care, and (4) consent to participate. Patients with severe cognitive impairment or active infection requiring hospitalization were excluded. The minimum sample size was calculated using the formula for a cross-sectional study, where Z = 1.96 (95% confidence level), p = 0.5 (estimated proportion of dietary compliance due to lack of prior data), and d = 0.1 (10% precision). The calculated minimum sample size was 96 participants. Considering potential non-response, we recruited 100 participants. A total of 100 participants were selected using purposive sampling, ensuring variability in dietary adherence levels and ulcer status. The complete participant recruitment process is illustrated in Figure 1.

Data collection instruments

Dietary Compliance Questionnaire: A structured and validated instrument, adapted from the Indonesian Ministry of Health’s 3J principle—Jadwal (Meal timing), Jumlah (Portion), and Jenis (Food type)—was used to assess dietary compliance. Responses were scored on a 4-point Likert scale (1 = never, 4 = always), with total scores ranging from 12 to 48. In the absence of validated cut-off points for the 3J compliance scale, participants were categorized into high dietary compliance (>median) and low compliance (≤median). The median score of 36 was the most frequent value in the distribution, resulting in slightly unequal group sizes (60% vs. 40%). The dietary compliance questionnaire consisted of 12 items covering: (1) Jadwal – eating at consistent times to maintain glucose stability; (2) Jumlah – controlling portions, particularly of carbohydrates; and (3) Jenis – choosing foods with low glycaemic index, adequate fiber, and balanced macronutrients, including lean proteins and healthy fats. Validity was assessed using Pearson correlation, with all item-total correlations greater than 0.3 considered acceptable. The instrument showed good internal consistency (Cronbach’s alpha = 0.82). We note that dietary compliance was self-reported and thus may be subject to recall bias.

Wound healing assessment: DFU healing status was assessed using the Wagner classification during routine home visits by trained nurses. Healing was defined as either a reduction in Wagner grade or complete epithelialization.

Demographic data: Age, sex, duration of diabetes, educational level, and comorbidities were recorded. Comorbidities were recorded as a binary variable (yes/no), based on the presence of at least one diagnosed chronic condition as noted in medical records. These included hypertension, dyslipidaemia, peripheral arterial disease, chronic kidney disease, and other metabolic or cardiovascular conditions.

Data collection procedures

Nurses trained in diabetic wound care and health education visited participants at home twice per week. At each visit, they conducted wound assessments, reinforced dietary education, and monitored compliance behaviours. Wound status was documented weekly for a period of four weeks. The 4-week follow-up period was chosen because it aligns with the routine evaluation cycle in our home care wound management program and reflects the short-term healing potential typically expected for Wagner grade 1 and 2 ulcers. Data on lower limb amputation (major or minor), hospital admission, or death were not systematically collected, as the study’s primary focus was short-term healing progression; however, we acknowledge that including these outcomes in future research would provide a more comprehensive assessment of patient recovery. 

Statistical analysis

Data were analysed using SPSS version 25.0. Descriptive statistics were used to summarize demographic and clinical characteristics. Chi-square tests were performed to examine associations between dietary compliance and wound healing outcomes. Logistic regression was used to determine whether dietary compliance independently predicted wound healing, controlling for potential confounders. A p-value <0.05 was considered statistically significant.

Ethical approval

Ethical approval was obtained on January 5, 2024, from a university-based health research ethics committee in Indonesia (Ref. No. 043.6/II.3.AU/F/KEPK/I/2024), in compliance with the World Health Organization (WHO) 2011 standards and the Council for International Organizations of Medical Sciences (CIOMS) 2016 guidelines.

Results

A total of 100 participants with type 2 diabetes mellitus and diabetic foot ulcers were included in the study. The mean age of participants was 58.4 ± 9.1 years; 62% were female and 38% were male. The majority of participants (74%) had lived with diabetes for more than five years, and 63% had no formal education beyond the elementary level, as shown in Table 1.

Table 1. Demographic and clinical characteristics of participants (N = 100)

Variable	Category	n (%)
Age	<60 years	56 (56.0)
	≥60 years	44 (44.0)
Sex	Male	38 (38.0)
	Female	62 (62.0)
Duration of diabetes	<5 years	26 (26.0)
	≥5 years	74 (74.0)
Education level	≤Elementary School	63 (63.0)
	>Elementary School	37 (37.0)
Comorbidities	Yes	48 (48.0)
	No	52 (52.0)

Out of the total participants, 60 individuals (60%) were categorized as having high dietary compliance, while 40 individuals (40%) demonstrated low compliance based on their scores on the 3J dietary adherence questionnaire. Participants in the high-compliance group were more consistent in meal timing (≥3 scheduled meals/day), adhered to recommended carbohydrate portions, and chose low-glycaemic index foods more frequently compared to the low-compliance group.

The distribution patterns in Table 2 suggest that participants with higher dietary compliance tended to present with less severe ulcer grades, as reflected by a greater proportion in Wagner grade 1 compared to those with low compliance. This finding may indicate that consistent adherence to dietary recommendations could be associated with better ulcer status or earlier stage presentation.

Table 2. Clinical and demographic characteristics by dietary compliance group

Characteristic	High compliance n (%) N=60	Low compliance n (%)  N=40
Wagner Grade
Grade 1	38 (63.3%)	20 (50.0%)
Grade 2	22 (36.7%)	20 (50.0%)
Educational Level
≤ Elementary School	34 (56.7%)	29 (72.5%)
> Elementary School	26 (43.3%)	11 (27.5%)
Presence of comorbidity
Yes	26 (43.3%)	22 (55.0%)
No	34 (56.7%)	18 (45.0%)

In Table 3, among those with high dietary compliance, 44 participants (73.3%) showed significant wound healing (i.e., improvement by at least one Wagner grade or complete epithelialization), compared to only 17 participants (42.5%) in the low dietary compliance group. The difference in healing rate between the two groups was statistically significant (χ² = 9.61; p = 0.002).

Table 3. Distribution of wound healing outcomes by dietary compliance

Dietary Compliance	Healed n (%)	Not healed n (%)	Total n
High (n = 60)	44 (73.3)	16 (26.7)	60
Low (n = 40)	17 (42.5)	23 (57.5)	40
Total	61 (61.0)	39 (39.0)	100

Chi-square test: χ² = 9.61, p = 0.002

Logistic regression analysis was conducted to evaluate whether dietary compliance independently predicted wound healing after adjusting for age, sex, diabetes duration, and comorbidities. High dietary compliance was found to be a significant predictor of wound healing (Odds Ratio [OR] = 3.18; 95% Confidence Interval [CI]: 1.41–7.15; p = 0.005), shown in Table 4.

Table 4. Logistic regression analysis: predictors of wound healing

Variable	OR	95% CI	p-value
High dietary compliance	3.18	1.41 – 7.15	0.005
Age ≥60 years	0.89	0.41 – 1.94	0.77
Female	1.27	0.59 – 2.75	0.54
Diabetes ≥5 years	0.92	0.39 – 2.18	0.85
Comorbidities present	0.71	0.32 – 1.56	0.39

Discussion

This study observed a statistically significant association between dietary compliance and wound healing among patients with diabetic foot ulcers (DFUs) receiving community-based home care. Participants with higher dietary compliance demonstrated a 73.3% healing rate compared to 42.5% in the lower compliance group. While multivariate analysis indicated that dietary adherence was an independent predictor of ulcer healing (OR = 3.18; p = 0.005), these findings should be interpreted cautiously due to the cross-sectional nature of the study and the limited follow-up period. Interestingly, the composite binary variable “comorbidity present/absent” was not a significant predictor of healing. This may reflect the heterogeneity of underlying conditions or the limitations of using a simplified binary measure. A similar observation was reported by Tehan et al. (2022), who also found that nutritional supplementation influenced early DFU healing while traditional risk factors did not show a significant impact in their population.^[8]

The results are consistent with previous research indicating that nutritional status plays a critical role in tissue repair and glycaemic control.^[9] Proper dietary practices such as consuming low-glycaemic index foods, maintaining balanced macronutrient intake, and adhering to regular meal schedules are associated with better blood glucose regulation, which may create a more favourable physiological environment for wound healing.^[10] Bechara et al. (2021) have similarly emphasized the association between nutrient intake and reduced risk of foot ulceration in diabetes. However, because of the study design, we cannot confirm a direct causal relationship between dietary compliance and ulcer healing; unmeasured confounders or reverse causation may also play a role.^[11]

In low-resource contexts such as Indonesia, integrating structured dietary education into home care services may offer a practical approach to support patient self-management and potentially improve healing outcomes.^[4,12] Nonetheless, further longitudinal or interventional studies are required to confirm whether improving dietary compliance directly accelerates healing and to explore the underlying mechanisms. Although current clinical guidelines often emphasize pharmacologic and topical interventions, fewer studies have examined the direct impact of dietary behaviours on DFU outcomes. Our findings contribute to the limited existing literature, suggesting that dietary compliance may be a modifiable and important factor. However, while dietary education was reinforced in both groups during home visits, significant differences in healing remained, indicating that education alone may not be sufficient without sustained adherence. In low-resource contexts, such as Indonesia, integrating structured dietary education into home care may be a valuable component of DFU management; however, further research is needed to confirm its independent effect. In the context of Indonesian healthcare, where access to specialist care may be limited, integrating dietary education within home care services provides a practical and sustainable model.^[13,14] Empowering patients and families to implement the 3J dietary principles (timing, portion, and food type) allows for more active engagement in self-care and can reduce dependency on hospital-based treatment.^[9,13]

In this study, age, sex, and comorbidities were not significant predictors of healing, which may reflect the homogeneity of the sample or context-specific influences. Other studies have reported mixed results on these variables, suggesting that their effects may be modulated by factors such as socioeconomic status, access to care, and patient engagement in self-management.^[3,14] Possible mechanisms for our findings include: (a) high dietary compliance as a proxy for other positive health behaviours such as adherence to medication, smoking cessation, or ulcer offloading; (b) absence of malnutrition among high-compliance patients; and (c) better glycaemic control. Unfortunately, we did not collect detailed data on Body Mass Index (BMI), smoking status, ulcer infection status, vascular insufficiency, or HbA1c, which could help clarify these mechanisms. Future research should incorporate these variables in a prospective design to better explain the observed associations.

Study Limitations

This study used a cross-sectional design, which limits the ability to infer causality between dietary compliance and wound healing. Additionally, dietary compliance was self-reported, which may be subject to recall bias. We also note that there was a noticeable, although statistically non-significant, difference in baseline ulcer severity (Wagner grade) between the high- and low-dietary compliance groups. This imbalance may have influenced healing outcomes and should be considered when interpreting the findings. Furthermore, the use of a non-random sampling method may affect the generalizability of the results. Future studies with longitudinal designs and objective dietary assessments are recommended.

Conclusion

This study found that higher dietary compliance was significantly associated with better wound healing outcomes in patients with diabetic foot ulcers receiving home-based care. Adherence to dietary principles—especially consistent meal timing, appropriate portion sizes, and healthier food choices—was linked with improved short-term healing rates. While integrating structured nutritional education into community health and home care programs may be a valuable component of diabetic foot ulcer management, our findings cannot confirm its independent effect. Further prospective and interventional research is needed to establish causality, clarify mechanisms, and determine the most effective strategies to improve dietary adherence and ulcer healing outcomes.

Conflict of interest: None

Financial Disclosure: No financial support was received.

Author Contributions: Conceptualization: DS, RKM; Study Design: DS, RKM; Data Collection and Processing: DS; Statistical Analysis and Interpretation: DS, PAWS; Manuscript Drafting and Revision: DS, RKM, PAWS

Acknowledgment: The authors thank the nursing team and all research participants for their time and cooperation.

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