Profile of Diabetic Foot Complications and itsAssociated Complications - A Multicentric Study from India

Profile of Diabetic Foot Complications and itsAssociated Complications - A Multicentric Study from India
V Viswanathan*, N Thomas**, N Tandon***, A Asirvatham+, Seena Rajasekar*,A Ramachandran *, K Senthilvasan**, VS Murugan+, Muthulakshmi+



Abstract

Aim : The aims of this study were to determine. The prevalence of foot complications such as neuropathy,peripheral vascular disease (PVD), amputations and infections and the associated diabetic complicationsand practice of foot care among these subjects.

Methods : A total of 1319 type 2 diabetic patients, were selected from four different centres across India. Thecentres were Diabetes Research Centre (DRC), Chennai, Government Rajaji Hospital (GRH), Madurai, ChristianMedical College (CMC), Vellore and All India Institute of Medical Science (AIIMS), Delhi. Details were collectedregarding foot problems and associated complications.

Results : The prevalence of neuropathy was 15% (n=193) and PVD was 5% (n=64). Infections were present in7.6% (n=100) of patients. The infection rate varied from 6–11% in the different centres. Nearly 3% of subjectshad undergone a minor or major amputation.

Discussion : This study found that the prevalence of infection was 6-11% and prevalence of amputation was3% in type 2 diabetic patients. Neuropathy (15%) was found to be an important risk factor for diabetic footinfections. Effective foot care advice should be propagated to reduce the burden imposed by diabetic footcomplication particularly in developing countries like India. ©



INTRODUCTION

Diabetes and its complications pose a major threat tofuture public health resources throughout theworld.1 Based on a compilation of studies from differentparts of the world, the World Health Organisation(WHO) has projected that the maximum increase indiabetes would occur in India.2 Considering the largepopulation and the high prevalence of diabetes, theburden of diabetes in India would become enormous.Diabetic foot infection is a common cause for the hospitaladmissions of the diabetic patients in India.1 This couldbe attributed to several sociocultural practices such asbarefoot walking; inadequate facilities for diabetic carelow education and poor socio-economic conditions.1Diabetic foot amputations are the most frequent of diabetic complications in developing countries. Patientswith foot complications spend higher percentage of theirincome (32.3%) for treatment when compared with thosewithout foot infections.3

Considering the immense burden superimposed byfoot complications, aggressive management becomesimperative. Indian data regarding various aspects of footcomplications such as percentage prevalence of footdeformity, infections and amputations and level of footcare among patients are very scarce. This study was doneto evaluate the prevalence of various diabetic footcomplications and associated complications in type 2diabetic subjects from various parts of India. The aimsof this study were to determine. The prevalence of footcomplications such as neuropathy, peripheral vasculardisease (PVD), amputations and infections andassociated diabetic complications and practice of footcare among these subjects

METHODS AND MATERIAL

A total of 1319 type 2 diabetic patients, according tothe WHO criteria, were selected from four differentcentres across India. The centres were Diabetes Research Centre (DRC), Chennai, Government Rajaji Hospital(GRH), Madurai, Christian Medical College (CMC),Vellore and All India Institute of Medical Science (AIIMS),Delhi. Among these centres, DRC is a private specialitycentre for diabetes, GRH and AIIMS are Governmentgeneral hospitals and CMC is a private charitablemedical college. Hospital based diabetes team in each ofthe above centres except DRC were invited to participatein this project. Every third type 2 diabetic subjects ofoutpatient department of the different centres attendingthe centres was recruited into this study.
*Diabetes Research Centre, 4, Main Road, Royapuram,Chennai – 600 013 [WHO Collaborating Centre for Research,Education and Training in Diabetes]; **Department ofEndocrinology, Christian Medical College, (Private CharitableMedical College), Vellore; ***All India Institute of MedicalScience (AIIMS), Delhi; +Government Rajaji Hospital, Madurai.#Rapid Publication Received : 24.8.2005; Accepted : 28.9.2005

Medical history was taken for all subjects. Detailsregarding duration, treatment of diabetes, patient’ssocial history and habit of smoking were noted. Bloodpressure was measured in all subjects in sitting positionon the right arm with a standard mercurysphygmomanometer. Mean values were determined fromtwo independent measurements taken at 5 min intervals.Hypertension (HTN) was defined as the presence ofsystolic blood pressure (SBP) of > 140 mmHg and/ordiastolic blood pressure (DBP) of > 90 mmHg or whenantihypertensive treatment was being taken.

Peripheral vascular disease was assessed usingDoppler studies. Cutaneous pressure perception wasassessed using 10g Semmes Weinstein monofilamentsat five plantar sites (1st, 3rd and 5th metatarsal heads, midfoot and the heel) on each foot. With eyes closed, thepatients were required to elicit a ‘yes / no’ response tomonofilament pressure and correctly identify the site ofcontact. Each filament was placed against the plantarsurface of the foot in a perpendicular fashion so that itbent with a constant force, with the 10g filament.Insensitivity to 10g monofilament at any one site oneither foot indicated abnormal sensation.1,2 Dataregarding myocardial infarction and ischaemic heartdisease were collected from the patient’s case sheets. Adetailed examination of the feet for the presence of footdeformity, infections and amputations was done.

A questionnaire was given to all the patients and thedetails regarding their day to day practice of footcare,types of footwear used, frequency of using the footwearand the aetiology of foot infection were noted. Thesedetails however could not be collected from AIIMS, Delhi.

Statistical Analysis

Statistical analysis was performed using SPSS, version4.0.1 (SPSS, USA) and EPI INFO V 5.01a program (CDCof Atlanta, USA and the WHO, Geneva, Switzerland).Data with normal distribution were expressed as mean± SD. ANOVA was used to determine the differencesbetween the groups. Chi square test was performed forcategorical variables. A 2-tailed p value < 0.05 wasconsidered as statistically significant. RESULTS Among the 1319 patients, 462 (35%) were selected from DRC, Chennai, 640 (46%) were included from theGovernment general hospitals, Madurai and Delhi, and253 (19%) were recruited from CMC, Vellore. All thesubjects from the four centres were age and sex matched.The mean age of the total cohort was 53 ± 11 yrs and themean duration of diabetes was 6.9 ± 5.9 yrs. The meanSBP was 133 ± 19 mmHg and DBP was 84 ± 10 mmHg.The mean blood urea, creatinine and cholesterol valueswere found to be within normal limits (Urea : 26 ± 12mg/dl , Creatinine : 0.95 ± 0.5 mg/dl, Cholesterol : 192 ±47 mg/dl). Hypertension was found in 34% (n=443)subjects and retinopathy in 15% (n=198). Among thestudy subjects, 11% (n = 148) were smokers. The prevalence of neuropathy was 15% (n=193) andPVD was 5% (n=64). Infections were present in 7.6%(n=100) of patients. The infection rate varied from 6 –11% in the different centres. Nearly 3% of subjects hadundergone a minor or major amputation. The characteristics of the subjects from the four centresare shown in Table 1 and Table 2. The prevalence ofhypertension and retinopathy was found to be thehighest among the AIIMS group. The prevalence ofneuropathy was however lowest in this group.Prevalence of myocardial infarction was found to be thehighest in CMC (5.5%). No difference in the prevalenceof PVD was noted across the four centres. The infectionrate varied from 6-11%in the different centres. Foot care practices among study subjects: Foot care practice was done by 36% (n = 400) patientsby themselves. Family members were involved in 2%(n=20) of patients and professional help was sought bynearly 2% (n=15) of subjects. Nearly, 65% of the studysubjects did not follow any footcare procedures. While 90 % of the study subjects wore footwear outsidethe house only 3% of them did so inside the house.Hawaii slippers were the most commonly used footwear(49%) followed by sandals (14%). Special diabeticfootwear and shoes were used by only 8% of the studypopulation. Bare foot walking was practiced by 7% ofthe study population. Improper footwear use, injurywhile doing a foot care procedure and unknown causesequally contributed to the development of footcomplications. DISCUSSION This study found that the prevalence of infection was6-11% and prevalence of amputation was 3% in type 2diabetic patients. Neuropathy (15%) was found to be animportant risk factor for diabetic foot infections. In a study by Chaturvedi et al,4 it was found that SouthAsians had higher prevalence of neuropathy (30%)compared with PVD (9%) and this prevalence was lesserwhen compared to the Caucasians. It has also beenshown that most of the foot problems associated withdiabetes in India are neuropathic and infective rather than vascular in origin as in developed countries.5 Theprevalence of PVD has been found to be 3.9% in anothercross-sectional population–based study conducted insouth Indians subjects which is similar to the findings of this study.6 The higher prevalence of hypertension andretinopathy in the AIIMS group of patients could beattributed to the fact that AIIMS is a large secondaryreferral centre. In this study, subjects with age >50 years had higherprevalence of all complications when compared withthose lesser than 50 years of age. Particularly theprevalence of neuropathy (72%) and PVD (80%) wasvery high. This finding is similar to the findings ofPremalatha et al7 who had shown that prevalence of PVDincreased with age. Age >50 yrs was found to beassociated with PVD (OR 6.3%), thereby identifying ageas a most significant risk factor for PVD.

It is of clinical importance that nearly 65% of the studypopulation did not follow any footcare procedures,which could be one of the major reasons for increasedprevalence of infections.

In a study by Vijay et al, it was shown that strategiessuch as intensive management and foot care educationare helpful in preventing newer problems and surgeryin diabetic foot disease. In the study of 4872 type 2diabetic patients, it was shown that patients whofollowed strict control developed lesser complicationwhen compared to those who did not follow the advice.8

Effective foot care advice should be propagated toreduce the burden imposed by diabetic foot complicationparticularly in developing countries like India.
REFERENCES

1.Vijay V, Snehalatha C, Ramachandran A. Socio-culturalpractices that may affect the development of the diabeticfoot. IDF Bulletin 1997;42:10–2.

2.Definition, diagnosis and classification of diabetes mellitusand its complication. Report of consultation. WHO, Geneva1999, Report 250.

3.Vijay V, Narasimham A, Seena R, Snehalatha C,Ramachandran A. Clinical profile of diabetic foot infectionsin South India- a retrospective study. Diabetic Medicine2000;17:215-8.

4.Chaturvedi N, Abbot CA, Whalley A, Widdows P, LeggetterSY, Boulton AJM. Risk of diabetes related amputation inSouth Asian vs Europeans in the UK. Diabetic Medicine2002;19:99–104.

5.Aleem MA. Factors that precipitate development of diabeticfoot ulcers in rural India. Lancet 2003;362:1858.

6.Mohan V, Premalatha G, Sastry NG. Peripheral vasculardisease in non-insulin dependent diabetes mellitus in southIndia. Diabetes Research and Clinical Practice 1995;27:235–40.

7.Premalatha G, Shanthirani CS, Deepa R, Markovitz J, MohanV. Prevalence and risk factors of peripheral vascular diseasein selected south Indian population. The Chennai UrbanPopulation Study. Diabetes Care 2000;23:1295–300.

8.Vijay Viswanathan, Sivagami M, Seena R, Snehalatha C,Ramachandran A. Amputation Prevention Initiative in SouthIndia: Positive impact of foot care education. Diabetes Care2005;28:1019–21.