Emerging Trends in Diabetic Foot Ulcer Management in India

Abstract

India is home to some 50 million diabetics (not a statistic to shout loud about), and 15% of this population suffer or are likely to suffer from the dreadful complications of diabetes, including the diabetic foot. There are well-understood pathological reasons and social factors that contribute adversely to this problem. For example, walking barefoot for social or religious reasons, being unable to afford any footwear, or wearing ill-fitting or inappropriate footwear on account of ignorance of good care all lead to foot damage that may not be treatable with medicines alone. Some form of amputation is often needed to treat the infected foot in order to spare a patient’s life. Worldwide, more than 1 million amputations are performed each year as a consequence of diabetes, which means that a lower limb is lost to diabetes somewhere in the world every every 30 seconds. Up to 85% of all amputations in people with diabetes are preceded by foot ulcers. In 90% of foot ulcer cases with diabetes, sensory neuropathy is part of the problem. Significant reductions in amputations may be achieved by well-organized diabetic foot ulcer care teams, good diabetes control, and wellinformed self care. Similar statements frequently appear not only in academic journals dedicated to diabetes management but also on Web sites of professional societies. Why does IJLEW wish to devote a special issue to this problem? The answer is to tease out the emerging trends in diabetic foot disease in India. As presented in the pages to follow, epidemiological data gathered around India indicate a rising prevalence of diabetes in urban areas. It also appears that there are differences in the prevalence of diabetes between urban and rural areas. This suggests that urbanization and all the ills that follow may have a role in the increase of this disease. It is also possible that equally reliable knowledge of the disease in rural areas is yet to be reported. It has been well advertised that urban, that is, modern ways of living are associated with lack of fitness in the young as well as in adults. This has also been associated with an increase in obesity in several societies on most continents. In India, however, central obesity is common despite low overall rates of obesity. The adverse effect of central obesity is manifested as an increasing basal metabolic index both in men and women. That some 75% of the type 2 diabetes patients have a first-degree family history of diabetes indicates a strong familial aggregation in Indian diabetic patients in the Indian subcontinent. On another note, Yagnik, after studies on birth weights, has argued in this issue of IJLEW that we should recognize the “thin-fat Indian baby” on account of high visceral fat content and lower-than-should-be-the-case maternal nutrition during pregnancy. This may be an excellent opportunity to practice prevention. The overall prevalence of neuroischemia in the subcontinental Indian is low as compared with Western patients, though it increases with age and, probably, smoking in males. Could health care education be usefully targeted in this direction? Prevention requires a sound understanding of a problem as well as resources with which it is practiced. In India, health care facilities are less well distributed than in other developing nations such as Brazil. This is especially so in regard to the diabetic population. The delivery of health care is shared by state-run institutions as well as a flourishing private sector. In state-run institutions, health care is delivered free of charge. In the private sector, hospitals and clinics charge fees for services provided. In the wellconnected bigger cities (or metros), high-tech treatment for diabetes may be found. The converse would appear to be the case in rural communities. It is well known and accepted that standard care for diabetic foot disease is best provided by a multidisciplinary team that should include trained foot care assistants. In India, there is a crying need for trained foot care assistants who can offer first-level support at the rural village and city levels. The foot care assistant is less trained than a medical doctor and is, therefore, less expensive and more accessible. This professional should work closely with the multidisciplinary team. Is there a case for putting telemedicine to best use here? Given telemedicine support, a medical/surgical consultation can become easier and swifter. The foot care assistant will be better empowered by the knowledge that a clinician is at hand. Indian software houses enjoy the privilege of leading the world; surely, these leaders would find it relatively easy to bend their skills to enable broadband communication and swift