Among the many chronic complications of diabetes, diabetic foot has remained the most feared complication, with both patients and treating health care professionals sharing the dread in equal measure.
Devastating consequences like limb amputation has made such fear abundantly justified. Despite it being the most feared complication, ignorance about diabetic foot continues to dominate the reasons for many of the avoidable limb amputations. In fact, patient education, proper care of feet and appropriate foot wear can prevent occurrence of many of the foot ulcerations. It has been realized that 85% of all limb amputations are preceded by trivial foot lesions. Prompt recognition and aggressive treatment of such trivial foot lesions can prevent many of the limb amputations. Looking at patient's feet and picking up foot lesions when they are young is the key to success. Unfortunately such simple but important steps are easily overlooked by many of us.
Globally over 1 million lower limbs are amputated every year, in fact every 30 seconds a limb is lost to diabetes somewhere in the world. A person with diabetics is up to 40 times more likely to suffer a lower extremity amputation than a nondiabetic.
Diabetic foot is a significant economic problem. The cost of treatment of foot ulcer in Western countries ranges from 7,000 USD to 10,000 USD. The direct cost of an amputation associated with diabetic foot is estimated to be between 30,000 USD and 60,000 USD. In India, with majority not covered by medical insurance, the entire cost (direct and indirect both) has to be borne by the patient, and, often, it is the breadwinner of the family who happened to be the victim. Loss of wages after the amputation and huge cost incurred on treatment shatters the family both socially and economically. Rough estimates indicate that about 100,000 lower limbs are amputated in India every year, of which 75% are on neuropathic feet with secondary infection. These amputations are potentially preventable. In view of enormous problem of diabetic foot in India, the Step-by-Step foot care project was conceived in the year 2003, with a common objective of improving diabetes foot care in the developing world. The Project Committee consisted of Sharad Pendsey, India (Chairman); Karel Bakker, The Netherlands; Ali Foster, United Kingdom; Zulfiqarali G Abbas, Tanzania (Chairman); and Vijay Viswanathan, India.
The project has received generous funding from the World Diabetes Foundation and academic support from International Diabetes Federation, International Working Group on the Diabetic Foot, Diabetic Foot Society of India, and Muhimbili University College of Health and Allied Sciences, Dar es Salaam, Tanzania.
GOALS
- To increase the meager awareness of diabetic foot problems
- To provide sustainable training of health care professionals in the management of diabetic foot
- To facilitate the cascading of information from health care professionals who have undergone training to other health care professionals and thus expand expertise
- To reduce the risk of lower limb complications in people with diabetes
- To empower diabetics in better foot care, early problem detection and in seeking timely help.
METHODS
Special foot care education materials, both visual and audio-visual, were designed specifically for people with diabetes 2in developing countries. Foot care education materials, visual and audio-visual, were also designed for health care professionals working with people suffering from diabetes in developing countries. Kits of diagnostic instruments (10 g monofilament, tuning fork, etc.) were distributed to participants, also including Podiatric Instruments' Kits (Bard Parker handle with surgical blades, nail clipper, nail files, artery and tooth forceps, scoop, probe and scissors).
PROJECT AT A GLANCE
In all, 115 teams of doctors and nurses working with the same doctor were selected for training in diabetes foot care [India (94), Bangladesh (3), Sri Lanka (2), Nepal (1) and Tanzania (15)]. The participants selected were specifically from smaller cities and towns, and who had no previous training in diabetes foot care. They were offered a 2-day Basic Course in 2004 followed by a 2-day Advanced Course in 2005. The courses were held in the four metros of India (New Delhi, Mumbai, Chennai, Kolkata), with 25 teams participating in each metro and at Dar es Salaam Tanzania with 15 participating teams. A national and international faculty of experienced educators in the field was responsible for teaching and chairing the practical sessions. Apart from theory lectures, emphasis was given on live case demonstration, hands on experience and practical problem solving.
In summary, the attending delegates were trained in preventative diabetic foot care.
- Primary prevention: Screening of high-risk feet and proper advice on preventive footwear.
- Secondary prevention: Management of trivial foot lesions like callus removal, treatment of nail pathologies, de-roofing blisters, etc.
- Tertiary prevention: Prompt referral to specialist for advanced foot lesions.
IMPACT
One hundred and fifteen foot care clinics (minimum model) were started.
It was anticipated that delegates will cascade information to larger number of diabetics, as also to other health care professionals, including paramedics, physicians, educators, health care policymakers and laypeople. The formal training was expected to reduce the amputation rate among these patients by about 50%.
RESULTS
The data was collected by a questionnaire sent to all participating delegates, and results of 1st year after the Basic Course and 2nd year after the Advanced Course were evaluated. Eighty-five teams, from India, responded to the questionnaire for both the years. From the overview of the work carried out by the delegates it was apparent that there was a significant increase in every activity they conducted in the 2nd year, over the 1st year. In the absence of any formal training in diabetes foot care, about 20% of patients with trivial foot lesions would be expected to have lower extremity amputation. Thus, with appropriate treatment of trivial foot lesions in the 1st year, at least 900 lower limbs and in the 2nd year 1,943 limbs were salvaged by the participants of the Step-by-Step foot care project.
CONCLUSION
This carefully designed and executed project to improve diabetic foot care in the developing world turned out to be a major success. The strength of the Step-by-Step program is that the project consists of a 2-year set up: a Basic and an Advanced Course to be attended by the same delegates. The prerequisite to participate in the first course was to agree to attend the second course. This pilot project is now being implemented in various parts of the world like Caribbean islands, South America, Pakistan, Egypt and several countries in Africa.
The Step-by-Step foot care project came out a grand success and was very well received across India. Actually, it kick-started a national movement regards diabetic foot. However, in a vast country like India, such a project need to be continued until evident results get palpable; and then a level is to be maintained to sustain gains effected.
In the developing world including India, we need to have three-tier system wherein each district had a Minimal Care Diabetic Foot Center. These centers will mean to carry out educational activities, screening of high risk feet, advice regarding preventive foot wear and manage trivial foot lesions. These may thus prevent trivial foot lesions advancing into a catastrophe. Larger cities had better had an Intermediate level Diabetic Foot Center. These centers are meant for surgeries like debridement and amputations, offloading advice and to maintain good liaison between minimal care centers. The Tertiary Foot Care Center will have facilities for carrying out complex foot surgeries, including revascularization and infrapopliteal bypass surgery.
The Public Health Care System in India is overburdened because of high prevalence of both communicable as well as non-communicable diseases. Private health care and the corporate sector should take up the responsibility of providing affordable health care to general population. Medical insurance is a way away from penetrating the masses. Let policies be formulated that afforded each individual reasonable health insurance cover.
There is nothing inevitable about lower limb amputation. These can certainly be reduced, in the least by 50%, if proper therapeutic strategies were implemented. In parts of the developed world, 50% reduction in lower limb amputation is 3already achieved. Preventive strategies like glycemic control, screening the high risk feet, proper foot wear and sustainable education of all afflicted with diabetes should go a long way in arresting this most feared complication of diabetes. Given the increasing longevity of the general population, well controlled diabetics too will live longer; imposing additional burden of many more ageing with peripheral vascular disease and critical leg ischemia. Strategies and facilities to tackle this are yet in infancy in most parts of this country, and wherever these do happen to be around, have seemed out of common reach. But, there is always ground to stay optimistic. The sum total interest in the arena of diabetic foot is growing by leaps in the medical fraternity. It is very much hoped that more and more health care professionals will pick up the gauntlet of managing the hitherto neglected diabetic foot. Step-by-step, diabetics will need to be goaded to turn away from the amputation path and to instead embrace the chance to save their foot.