DR.MOHAMMAD ANWAR HAU B ABDULLAHHOSPITAL RAJA PEREMPUAN ZAINAB II.
Global Prevalence of Global Prevalence of Diabetes Diabetes
2003: 194 million 2010: 265 million
2025: 333 million (predict) 2030: 366 million.(longer life expectancy, sedentary lifestyle and changing dietary patterns).
‘Global diabetes tsunami ’ Adult population with
diabetes: About 5% in Europe 10-12% in Asia 30-40% in Pacific Island nation
‘Global diabetes will become the health crisis of 21st century’
(Prof Paul Zimmet. Director of WHO Collaborating Centre for Diabetes)
International Diabetes International Diabetes Federation (IDF): 2010Federation (IDF): 2010
5 countries with the largest numbers of people with diabetes are India, China, the US, Russia and Brazil.
5 countries with the highest diabetes prevalence in the adult population are Nauru, the UAE, Saudi Arabia, Mauritius and Bahrain.
Countries with the highest numbers of estimated cases of diabetes for 2000 and 2030
ngCountry No of
Country No of diabetes (million)
1 India 31.7 India 79.4
2 China 20.8 China 42.3
3 USA 17.7 USA 30.3
8.4 Indonesia 21.3
5 Japan 6.8 Pakistan 13.9
6 Pakistan 5.2 Brazil 11.3
7 Russia 4.6 Bangladesh
8 Brazil 4.6 Japan 8.9
9 Italy 4.2 Philippines
3.6 Egypt 6.7
Prevalence of diabetes Prevalence of diabetes in WHO Western Pacific in WHO Western Pacific regionregionCountry year 2000 year 2030China 20.76 million 42.32
millionJapan 6.76 8.91Philippines 2.77 7.78Korea 1.86 3.78Malaysia 0.94 2.48Australia 0.94 1.67Singapore 0.33 0.69New Zealand 0.18 0.31 Total 35 million 71 million
SOUTH EAST ASIA REGION:BY 2025:Prevalence: 13.5%
Total no of DM: 145 million people
DIABETES IN MALAYSIA
1.6 Million Malaysian Adults May Have Diabetes
PUTRAJAYA, Aug 11,2009 (Bernama) -- It is estimated that one out of eight Malaysians aged 30 years and above has diabetes, which amounts to over 1.6 million adults, based on the Third National Health and Morbidity Survey (NHMS) 2006.Director-General of Health Tan Sri Dr Mohd Ismail Merican said the prevalence of diabetes also showed a drastic increase of 80 per cent over a period of just 10 years, from 8.3 per cent in 1996 to 14.9 per cent in 2006 for the same age group.Even more worrying, he said, was that one third of those who had diabetes were undiagnosed, and were not aware of their condition.
PREVALENCE OF DM IN MALAYSIA NHMS I (1986) : 6.3%
NHMS II (1996) : 8.3%
NHMS III (2006) : 14.9% (1.6 m)
Now: > 20% (2 million)!!
(WHO- 2.48 million by 2030)
Diabetes Risk for developing various serious
health problems that may affect: HeartsHearts Eyes Eyes
Kidneys Kidneys PregnancyPregnancy
NerveNerve Sexual functionSexual function
Skin and feet-----> ulcers and Skin and feet-----> ulcers and infectioninfection
Foot ulceration is one of the most common complications in patients with diabetes.
The most common cause of admission to hospital for people with diabetes.
Shorten life expectance and increased mortality
Facts about diabetic foot Facts about diabetic foot ulcerulcer Diabetic ulcer account for 85% of non-traumatic lower extremity amputation.
Diabetic patients is 15x more likely to undergo lower extremity amputation.
3%-4% of diabetes patients have foot ulcer or deep infection at any time.
12% - 24% of diabetes patients with foot ulcer require amputation.
3 -5 year risk of needing contra-lateral amputation is 50%
Estimated every 30 (20) seconds a lower limb is lost to diabetes.
3 -5 year risk of needing contra-lateral amputation is 50%
• 69% of diabetic amputees will not survive past five years (2004).
48,000 to 64,000 of patients with diabetic foot ulcer (3% - 4%) at any time???
4,800 to 6,400 amputation (10% of foot ulcer patients require amputation)???
DIABETIC FOOT-MALAYSIAN SCENARIO
Observations- patients: Late presentation
Time for decision making
Bad general condition on admission (septicemia, severely dehydrated, anaemia, cardiac, electrolytes imbalance, DM not controlled, etc).
Refusal for treatment (AOR)
Healthcare providers:Primary health-careTertiary health-care
Observations- healthcare providers
Knowledge DM and foot care (NorAziana; Nur Azlina 2009)- 30-40% average to low; dressing materials
Attitude- not serious and aggressive enough (DM control)
Misleading- Diabetic treatment, direct selling etc
Health-care system No dedicated diabetic foot-care team
(not glamorous work)
Not many – interested (junior doctors)
Lack of expert in various fields (vascular, endocrine, podiatric, prosthetic and orthotic)
Lack of facilities (angio etc).
Low priority- OT Wound-care in primary health (dressing,
National Orthopaedic National Orthopaedic Registry Malaysia Registry Malaysia
Diabetic foot/hand registryData on:
Second half of 2008 2009
July- Dec 2008 2009
nn 909 1254
Mean Mean ageage
Sex (%)Sex (%) F: M= 53:47 F:M= 52: 48
Race (%)Race (%) M: 77C: 9
M: 75C: 11 I: 12
ResidencResidence (%)e (%)
Urban: 56Rural: 42
Urban: 54Rural: 46
OccupatiOccupation (%)on (%)
H.W: 36Retired: 14
H.W: 37Retired: 14
July- Dec 2008
Education Education level (%)level (%)
Non: 13Primary: 44Secondary:
Non: 5Primary: 48Secondary:
Type of DM Type of DM (%)(%)
Type 1: 13Type 2: 87
Type 1: 16Type 2: 84
Duration of Duration of DM (year)DM (year)
Type I: 10.5Type II: 11.3
Type I: 11.9Type II: 10.4
Mean Mean duration duration
prior prior admission admission and stay and stay
July- Dec 2008
nn 909 1254
On Rx (%)On Rx (%) 85 84
Compliance Compliance (%)(%)
Type of DM Type of DM treatment treatment
Diet: 8OHA: 61 Insulin:
16Insulin + OHA: 7
Diet: 12OHA: 65
Insulin: 15Insulin + OHA: 10
Rx prior to Rx prior to admission admission
Nil: 25Self: 4
Nil: 25Self: 8
July- Dec 2008
nn 909 1254
Co-Co-morbid morbid illness illness
HPT: 56IHD: 12
HPT: 55IHD: 8
Family hx Family hx of DM (%)of DM (%)
ComplicatComplication (%)ion (%)
Health-awareness and Health-awareness and practicespractices 2008
Aware of risk 61 64.6Wash feet 74.0 71.6
Inspect feet 51.0 51.6Apply
Keep diabetic booklet/record
Clinical Outcome: Clinical Outcome 2008 (%)
Wound (Wd) healed 13 14.8Wd clean, granulate, discharged outpatient dressing 65 67.9
Amputation, stump healed 9 9.6Amputation, stump infected 2 1.2Death, due to septicemia 1 1.3Death, due to medical problem 0 0.2Discharged at own risk (AOR Discharged) 4 5.0
NHMS III (2006):
4% to 7% of known diabetics had
undergone toe or leg amputations.
Healthcare cost Productivity Social-economic burden Psychological trauma Family tension and stess
Centers for Disease Control and Prevention - USUnited States
1995: the cost to treat a DFU over a 2-year period was $27,987
Direct costs for a treating lower-extremity amputation: $22,700 to $51,300 (USD)
2001: the estimated total cost of Rx of diabetic foot ulceration and amputation: $10.9b
2007: total cost of diabetic care $174 billion: $116 billion in direct costs and $58.3 billion in indirect costs (transportation, time etc).
70% of cost due to hospitalization
Economic burdenEconomic burdenSweden (1998): Total direct costs for healing of
infected ulcers not requiring amputation are approximately $17,500 USD
Total costs for lower-extremity amputations are approximately $30,000-$33,500 USD depending on the level of amputation
10 per cent of the NHS budget; around £9 billion a year based on 2007/2008 budget.– £173 million a week– £25 million a day– £1 million an hour– £17,000 a minute– £286 a second.
Patients not using prosthesis/orthosis
Financial Does not fit/not comfortable
Home environment Heart unable to take it
Energy expenditure for amputation:
% energy above baselin
O2 cost (ml/kg/
Long BKA (>50%)
10 70 0.17
Average BKA 25 60 0.20Short BKA
(<20%)40 50 0.20
Bilateral BKA 41 50 0.20AKA (<1/3, >2/3) 65 40 0.28Wheelchair 0 - 8 70 0.16
*Vasculopathy (~47%) *Immunopathy (~58%)
PATHOGENESIS OF DFP
* Incidence based on Nather, Clarabelle et al 2005
NEUROPATHY (30 – 50% with DM > 10 yrs)
• Major factor in diabetics leading to diabetic foot problems Sensory Autonomic Motor
•Root CauseRoot Cause of all of all diabetic foot diabetic foot problemsproblems
IMMUNOPATHY• Diabetics have inherent susceptibility to infection
• Defects in leukocyte function
leukocyte phagocytosis neutrophil dysfunction deficient white cell chemotaxis and adherence
VASCULOPATHY (6% to 23%)
• Microangiopathy Involving terminal arterioles (thickening of basement membrane of endothelium)
• Atherosclerosis Involving large and medium sized vessels Usually Crural Involvement Pattern - Anterior and
Posterior Tibial vessels in the leg. Dorsalis Pedis and Posterior Tibial vessels in the foot are usually patent (Pomposelli, 1995)
In Singapore, incidence of vasculopathy is in 46.8% based clinically on absence of pulses.
ABI < 0.8 is 31% using Doppler ultra sound probe(Adriaan, Nather et. al., 2005)
FOOT AT RISK-
need periodic, thorough examination.
FOOT AT RISK1. History of ulceration
FOOT AT RISK 2. Presence of Peripheral vascular disease
FOOT AT RISK 3. Presence of Neuropathy
FOOT AT RISK 4. Presence of Deformity
FOOT AT RISK 5. Inappropriate or No Footwear A B
•Over 70% of patients wear slippers or no footwear most of the time (Kathryn, Nather, Zameer A et. al., 2005)
FOOT AT RISK:6. Skin Lesions
• Corn/Callus• Fungal Infection
FOOT AT RISK:7. Nail Pathology
• Deformed Nail• Lesions – Ingrowing Toenail• Infected Nail
General Risk Factors:
General Risk Factors: CO-MORBIDITIES• Hypertension
• Ischaemic Heart Disease
• Cerebrovascular Accident
Occupation: Wet at work Prolonged walking or
Duration of diabetes
Management Surgical drainage/ debridement
(repeated) - surgical, chemicals, ultrasonic, pulse jets
Dressing (materials and solutions).
Correction of deformity Off-loading amputation Rational use of antibiotics
(appropriate sample for culture; follow up on the laboratory result)
Diabetes and diabetic foot care
Make the diabetic patient/family members aware through continual education, self responsibility and self care that---->
it is possible to lead a normal life through healthy lifestyle, diet, exercises and control of blood sugar and care of the feet
Health education Continuous and tirelessly About diabetes and its complications Important of good diabetic control (role
model) About foot-care How to recognised foot at risk/ trouble.
His/her responsibility for lifelong care of diabetes and feet Important: they must comply
FOOT CARE1. Daily foot
2. Use lukewarm (not hot!) water to wash feet
3. Be gentle feet washing/bathing.
FOOT CARE4. Moisturize feet – be careful with the web space .
5. Nail cutting
6. Wear clean, dry socks (NEVER use heating pad or hot water
bottle)- keep foot warm
7. Avoid walk barefoot.
8.Comfortable well fitting shoe
8.Shake out shoes and feel the inside before wearing
8.Never treat corns or calluses themselves.
FOOT CARE11. Diabetic control
12. Stop smoking
13. Periodic foot examination
14. Keep the blood flowing to feet (ELEVATE, WIGGERS TOES, MOVING ANKLE) , avoid cross-leg or hanging leg/feet too long
PREVENTION BETTER THAN
Prevent recurrent foot ulcer
Reduced / avoid amputation
THEME FOR DIABETES 2011:
“Leg for Life”
THANK YOU VERY MUCH