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ALL ABOUT DIABETIC FOOT
January 12, 2021

Let’s take a quiz: of the terrible tolls diabetes can take on the body, what puts people in the hospital the most? Heart disease, stroke, kidney failure? No, none of these. It is a largely vastly ignored, largely under-reported, yet one of the most serious complications of the disease: diabetic foot, a major public health problem in India. With that as a starter, let’s take a deep dive into what exactly is diabetic foot, how can you spot it and how to take care of it.

Diabetic foot is defined by the World Health Organization as: “The foot of a diabetic patient that has the potential risk of… infection, ulceration, and/or destruction of deep tissues, associated with neurologic abnormalities, various degrees of peripheral vascular disease, and/or metabolic complications of diabetes.”

  • Diabetic foot is one of the most common complications in India. 1 in 6 people with diabetes develop sores, ulcers and life-threatening infections on their feet.
  • It is the commonest reason for hospitalization for people with diabetes(about 30%) in India. About 80,000 to one lakh amputations take place a year, although 75% of the cases are preventable.
  • Diabetes foot takes up about 20% of total health-care costs, more than all other diabetic complications in India. For individuals, the cost of treating diabetic foot ulcers is the same as about 6 years of average annual income.
  • The pain, suffering, loss of mobility, dependence on others, limitations imposed by the change of role and employment opportunities—make it one of the worst diseases with respect to quality of life.
  • A diabetic foot wound presents on the plantar surface of the foot or toes and results from walking on a foot with lack of sensation.
  • What puts most at risk in India is walking barefoot. Due to social, religious and economic compulsions, many people walk barefoot. Foot ulcers happen mostly from injury with sharp or hard objects when people walk barefoot, or on a hot surface that results in a burn.
  • Inappropriate footwear and ill-fitting shoes are yet another reason of high-grade foot ulcers found in people with a diabetic foot.
  • Indians are known to sit cross-legged for hours, at work or as they pray. In diabetics with nerve damage, repeated and prolonged pressure on the foot often lead to ulceration and infection.
  • Toe rings are worn by Indian women often cut off oxygen and blood supply. Along with heat, dust and sweat, fungal infection sets in deep inside the foot, leading to ulceration.
  • Late presentation of foot lesions complicates disease outcomes. Patients often approach informal care providers, alternative medicine prescribers, village quacks or others who are not medically qualified to deal with diabetic foot—a problem that interferes with treatment.
  • About 90% of people with diabetes foot in India do not see a specialist, depending on home remedies instead.
  • For people with long-term diabetes, high blood glucose damages nerves and blood vessels. Because legs have the longest nerves and arteries, adequate oxygen and nutrients do not reach the feet, diminishing sensation and stability. This makes people vulnerable to injury and wounds, which they don’t feel until infection sets in.
  • Diabetic peripheral neuropathy (nerve damage from high blood sugar) leads to numbness, loss of sensation, and pain in the feet; triggers almost 90% of diabetic foot ulcers.
  • Peripheral Artery Disease (PAD) or plaque formation in the lower extremity arteries, due to diabetes, is a major risk factor for lower-extremity amputation.
  • Neuropathy and PAD distort the biomechanics of the foot. With inability to feel pressure or position sense, deformity and muscle imbalance, the foot remains in contact with the ground longer, walking pattern changes, marked by wobble and frequent falls.
  • Unlike other infections, diabetic foot infections are silent: there is no fever, swelling, or pain. One needs a very high level of suspicion to detect those.
  • Because diabetic foot ulcers are a pressure injury, no amount of antibiotics or dressings heal them, unless the pressure is reduced.
  • Diabetic foot also happens from Charcot’s Foot, a severe complication due to nerve damage, that leads to weakening and collapse of bones in foot and ankle. The symptoms suddenly manifest after an injury. Leads to deformity, ulceration and loss of function.
  • Early detection of diabetes, high degree of foot-care and prompt referral to a diabetes care facility, if the slightest signs are felt, is the key to salvaging the limb for people with diabetes.
  • All diabetic patients should have a haemoglobin A1c drawn to assist in diabetic management and patient education.
  • Doctors recommend simple procedures and tools to prevent diabetic foot: check your feet every day to catch cuts, bumps and other injuries early; get corns or other lesions removed very cautiously and superficially;
  • Get your doctor to examine your feet at least once a year for nerve damage and poor circulation; don’t ignore pain or change in the shape of your feet.
  • A simple preventive test is to ask the patients to feel with the back of their hand the 1st, 3rd and 5th metatarsal heads. If they are warmer than the rest, then it means the patient is walking beyond the limit that the foot can bear.
  • Don’t walk barefoot, wear socks instead, or in thin-soled standard slippers, whether at home or when outside. If the feet change shape, try special therapeutic shoes to take pressure off the feet; look for shoes that have soft insoles; choose leather, canvas, or suede materials to allow adequate air circulation.
  • Inspect feet and the inside of shoes daily; wash feet (with careful drying particularly between the toes); avoid using chemical agents or plasters to remove callus or corns; use emollients to lubricate dry skin; cut toenails straight across.
  • When diabetic foot patients lie in beds, they still get blisters and ulcers, although there is no pressure on their feet. The simplest preventive measure is to raise the foot by placing pillows underneath.
  • Ulcers need to be cleaned regularly with clean water or saline, debrided when possible in order to remove debris from the wound surface and dress them with a sterile dressing.
  • During winter, patients of diabetic foot should not use heaters or heating pads. With a lack of sensation in the feet, patients often do not realise they are being burned until they smell the skin burning.
  • Doctors have conventionally considered amputation as inevitable for most diabetics with foot issues. But amputation is expensive and severely reduces quality of life. They also put stress on the heart. With the rapid innovation of novel drugs, bio-engineered skin replacements, oxygen therapies, devices and surgical procedures, 50% of diabetic foot amputations can be prevented now.

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