Diabetes Mellitus in India

The foot has always been the forgotten child of medicineIt is a glamorous part of the body

For healthcare providers and patients? It is an unglamorous part of the body to which they hardly give anyattentionDiabetic Foot? MOST feared complication - for the patients' point of view?

MOST devastating - for the doctors' point of view

India already faces a grave problem with the largest number of subjectswith diabetes (approximately 72.9 million in the year 2017) and by the year2045 it may be 134.

3 million. That means almost 264.4 million legs are atrisk of the diabetic foot, its ulcer and leading to amputations. ? 25% diabetics develop foot ulcers in their life timeDiabetic foot ulcers are common - in fact, 1 in 4 people with diabetes willdevelop at least one ulcer post -diagnosis.

In Indian scenario, there are 60%people are undiagnosed. Due to long standing undiagnosed uncontrolleddiabetes, they are prone to have micro as well as macrovascularcomplications at the time of diagnosis. 50% of newly diagnosed people withthe diabetes have one of the complications at the time of the diagnosis.

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Even patients present to the clinics with the burned ulcer due to thermalburn injury on back side of the bike due to slippage of the footwear and603they don't feel the heat of the silencer. So, there are many cases reportedwith non healing ulcer at the time of the 1 st visit.

Among the all complication of the diabetes, Foot complications are amongthe most serious and costly complications of diabetes. Diabetic foot is thecommonest indication of the hospitalisation and it requires longest hospitalstay.

In 2007, one third of diabetes costs were estimated to be linked tofoot ulcers.

Compared to people with diabetes without foot ulcers, the costof care for people with diabetes and with foot ulcers is 5.4 times higher inthe year of the first episode and 2.6 times higher in the year of the secondepisode of foot ulcer. Mor eover, among patients with foot ulcers, costs fortreating those with the highest grade ulcers were eight times highercompared to treatment of the lowest grade foot ulcers.

According to International Diabetes Federation (IDF), in year 2017, 7 9% ofadults with diabetes are living in low - and middle -income countries. Mostlythese countries have poor health / medical insurance support frominsurance industry or government and so diabetes and diabetic footcomplications are the major burden to these countries citizens.

An ulcer for mation is beginning of the end? 85% of the amputations are preceded by trivial foot ulcerAmputation in people with diabetes is 10 to 20 times more commoncompared to those of non -diabetic people. 75% of all leg amputationshappen in people with diabetes . After unilateral below knee or above ankleleg amputation, five year mortality is 80 %.

About 1 million people loosealeg, every year, due to diabetes. Every 30 seconds a lower limb (leg) or604part of a lower limb is lost to amputation somewhere in the world asaconsequence of diabetes. ? Up to 85% of the amputations are preventable with com prehensivemanagement.

The key elements of preventive care include: annual examination of thefeet by health care providers to determine risk factors for ulceration,subsequent examination of high -risk feet at each patient visit, patienteducation about daily self -care of the feet and careful glucosemanagement.

The awareness and education about Diabetes , diabetes footproblem and Diabetes related other complications are must. Primarily, based on the outcome of the study and considering the highprevalence of diabetic foot complications in all profile of the diabeticindividuals from th e time of the diagnosis to as diabetes advances; weventure to give following recommendations:

At the community level

As India has no subsidized, coordinated diabetes care programme, the needof the hour is a drastic change in our approach with more emphasis on thepreventive aspects of diabetes for the benefit o f the community. Preventivemeasures for diabetes must be initiated in India at least before the diabetessets in to any complications occur in order t o decrease the spiraling cost ofdiabetes to the citizens of India.

The first step towards combating rising rates of diabetes leg amputations,we must act on public awareness about diabetes and its risk factors,particularly the outcomes of the diabetes . Community education aboutdiabetes, diabetes risk factors, it s preventions and diabetes c omplicationpreventions along with healthy diet, recommended physical activity,weight -stress management and regular preventive hygiene - health care arestrongly recommended.

The social media campaigns (Facebook,Wh atsapp, Twitter, etc) can be support for the mass public awareness . Projects like FOCUS on FEET , to create awareness for the diabetes andfoot care should be encouraged. The need of the hour is early screening for diabetes and its complicationsin the population and institution s as prev entive measures at an early ageto the high risk individuals or diabetics.

The target population has to be defined for this purpose. Thecharacteris tics of people with diabetic foot often include older age individualwith positive family history along with longer diabetic duration , presence ofhyp ertension, diabetic retinopathy or smoking history.

The earlypreventive actions to be taken in these individuals from cessation ofsmoking to glycemic control along with other comorbidities control/treatment . There is an urgent need to develop a cost -effective prot ocol for diabetescare aimed at improving disease control and diabetes complicationprevention. W hich can prevent, delay or limit the development ofcomplications in both Type 1 and Type 2 diabetes.

Such a protocol like PROJECT SHRAVAN must be integrated into patient care by making thefamily member of the patient as an important team member for the patientdiabetes and foot complications prevention as w ell as managemen t. The606training of the family member along with empowerment and continuesmonitoring can play a key role in the foot care of the patients with diabet es.

Building support group team whic h includes diabetes educator, podiatrynurse, dietician , counsellor , psychologist, podiatry footwear maker, etc. toprevent the 1st amputation to occur. As needing the 1st amputa tion isapoor prognostic sign and 28% to 51% of these pa tients require a 2 ndamputation within 5 years. The Support group can meet on regular basesto share their learning and experience from their daily clinical pract icewhich can be implemented at the community level.

The TRAIN THECOBBLER project is evolved from the support group meeting and thesecobbler s can be vary handful from the early bedside screening for theperipheral vascular disease and neuropathy to preventive and therapeuticfootwear production. At the community level, ther e should be mass feet washing ceremonydisplay. W hich represents the importance of the feet care in diabetes andcreate the awareness for the diabetes and diabetes foot complica tions'prevention.

At health care provider level

Majority of higher level leg amputations in diabetes are due to preventableand inadequately treated foot ulcers . There should be a structur eddiabetic foot management protoco l incorporated into bothundergraduate and postgraduate medica l education.

Education, supportedby an appropriate incentive programme, is pa rticularly im portant for theGeneral Practitioners (GPs) / Primary Care Provider / Family physicians;who play a key role in the care of patients with diabetes. On same values607based the TRAIN THE FOOT TRAINERS program is created for the PHCdoctors or the doctors of the areas where no availability of the podiatry orsu pper speciality facilities and to man age the foot problem at primary level.

At health care institue level

There is also a need to improve case record maintenance / developregistries and perf orm outcomes research to define standards and identifypatients at risk. Through registry b y identify ing the patient at risk , the focuson th e importance of early diagnosis, lifestyle changes - training andregular monitoring to reduce the burden of complications can be given.

Promoting the self -routine foot care and glycemic monitoring regularlywould prevent the cost of the diabetes complication in the se individuals . This integrated approach would help provide better care early in the courseof the disease and reduce the rate of complications and associated costsfor all patients, regardless of education and/or income.

At health care governance level

The current thrust of health care services in India is towards the treatmentand prevention of communicable disease. This needs to be reviewed andan added impetus towards preventing and treating non -communicablediseases is the need of the hour.

To be cost effective, diabetes health careshould be linked with health care to control risk factors like hypertension,dyslipidemia, tobacco and alcohol abuse etc. For this purpose, the healthcare professional should receive additional training and this can yield richdividends at a low cost.

With such a health care delivery system, one would achieve, improvedpatient adherence to medical regimens, enhanced patient confidence,improved utilization of effective treatments with proper glycemic control,reduction of ischemic heart disease, decreased progression to blindness,decreased progression to renal failure and less number of lower extremityamputations. This wou ld also cause a shift in overall health utilization fromamputation and high cost complication related hospitalizations to low costpreventive services.

At the clinic level

Loss of the limb is the outcome of the treatment in major part of India dueto lack of comprehensive multi -discipli nary team approach. That resultsinto both the economic burden and loss quality of life experienced byadiabetic individual could be attributed to its morbidity associated with eitherdiabetic foot problem, non healing ulcer or amputation.

In view of the highprevalence of micro -macrovascular complications and associated riskfactors in diabetics in India, there is a need for scre ening all diabeticsfor complications at the time of diagnosis and annually thereafter.

This includes retinal screening for detecting retinopathy, microalbuminuriafor diabetic nephropathy, examination of pedal pulses and peripheraldoppler for peripheral vascular disease, 12 lead electrocardiography forcoronary artery disease and if indicated Treadmill and Echocardiography aswell as a complete foot examination including monofilament testing andbiothesiometry for diabetic neuropathy.

The study highlight s the ne ed ofthe organised comprehensive multi -disciplinary teamed diabetesfoot care clinics / centres to reduce foot complications and amputations by up to 85%. As diabetic treatment continuous for life so regular check-ups are required to avoid or restrict co -morbidities attached to diabetes.

The early approaches for preve ntion of complications should targetglycemic control, hypertension control and control of dyslipidemia. Suchamulti factorial approach is necessary to prevent complicati on. As intensive blood glucose management.