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Diabetic Foot

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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).

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‘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)

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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.

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Countries with the highest numbers of estimated cases of diabetes for 2000 and 2030

2000 2030Ranki

ngCountry No of

diabetes (million)

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

4 Indonesia

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


10 Bangladesh

3.6 Egypt 6.7

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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

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SOUTH EAST ASIA REGION:BY 2025:Prevalence: 13.5%

Total no of DM: 145 million people

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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.

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NHMS II (1996) : 8.3%

NHMS III (2006) : 14.9% (1.6 m)

Now: > 20% (2 million)!!

(WHO- 2.48 million by 2030)

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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

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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

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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%

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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).

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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)???

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Observations- patients: Late presentation

Time for decision making

Bad general condition on admission (septicemia, severely dehydrated, anaemia, cardiac, electrolytes imbalance, DM not controlled, etc).

Alternative treatment

Refusal for treatment (AOR)

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Healthcare providers:Primary health-careTertiary health-care

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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

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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,


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National Orthopaedic National Orthopaedic Registry Malaysia Registry Malaysia


Diabetic foot/hand registryData on:

Second half of 2008 2009

17 sdp

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July- Dec 2008 2009

nn 909 1254

Mean Mean ageage

56.7 52.2

Sex (%)Sex (%) F: M= 53:47 F:M= 52: 48

Race (%)Race (%) M: 77C: 9

I: 14

M: 75C: 11 I: 12

ResidencResidence (%)e (%)

Urban: 56Rural: 42

Urban: 54Rural: 46

OccupatiOccupation (%)on (%)

H.W: 36Retired: 14

Unemployed: 11

H.W: 37Retired: 14

Unemployed: 10

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July- Dec 2008


Education Education level (%)level (%)

Non: 13Primary: 44Secondary:

40Tertiary: 3

Non: 5Primary: 48Secondary:

42Tertiary: 5

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






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July- Dec 2008


nn 909 1254

On Rx (%)On Rx (%) 85 84

Compliance Compliance (%)(%)

56 40

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

Traditional: 3

Medical: 67

Nil: 25Self: 8

Traditional: 4

Medical: 62

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July- Dec 2008


nn 909 1254

Co-Co-morbid morbid illness illness


HPT: 56IHD: 12

H’cholesterol: 10

HPT: 55IHD: 8

H’cholesterol: 11

Family hx Family hx of DM (%)of DM (%)

41 43

ComplicatComplication (%)ion (%)

Retinopathy: 14

Vascular: 18Neuropathy:



Retinopathy: 16

Vascular: 19Neuropathy:


: 8

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Health-awareness and Health-awareness and practicespractices 2008

(%)2009 (%)

Formal education

30 28.8

Aware of risk 61 64.6Wash feet 74.0 71.6

Inspect feet 51.0 51.6Apply

emollients24.0 23.8

Appropriate shoe

27.0 27.3

Keep diabetic booklet/record

25.0 23.1

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Clinical Outcome: Clinical Outcome 2008 (%)

N=9092009 (%)N=1254

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

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NHMS III (2006):

4% to 7% of known diabetics had

undergone toe or leg amputations.

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Other aspects:

Healthcare cost Productivity Social-economic burden Psychological trauma Family tension and stess

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Centers for Disease Control and Prevention - USUnited States

1995: the cost to treat a DFU over a 2-year period was $27,987

2009: $46,841

Direct costs for a treating lower-extremity amputation: $22,700 to $51,300 (USD)

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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

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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

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Financial costs

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.

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Patients not using prosthesis/orthosis

Financial Does not fit/not comfortable

Home environment Heart unable to take it

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Energy expenditure for amputation:

Amputation level

% energy above baselin


Speed (m/mi


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

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*Neuropathy (~80%)

*Vasculopathy (~47%) *Immunopathy (~58%)


* Incidence based on Nather, Clarabelle et al 2005

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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

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IMMUNOPATHY• Diabetics have inherent susceptibility to infection

• Defects in leukocyte function

leukocyte phagocytosis neutrophil dysfunction deficient white cell chemotaxis and adherence

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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)

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need periodic, thorough examination.

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FOOT AT RISK1. History of ulceration

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FOOT AT RISK 2. Presence of Peripheral vascular disease

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FOOT AT RISK 3. Presence of Neuropathy

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FOOT AT RISK 4. Presence of Deformity

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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)

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FOOT AT RISK:6. Skin Lesions

• Corn/Callus• Fungal Infection

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FOOT AT RISK:7. Nail Pathology

• Deformed Nail• Lesions – Ingrowing Toenail• Infected Nail

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General Risk Factors:

• Smoking

• Alcoholism

• Obesity

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General Risk Factors: CO-MORBIDITIES• Hypertension

• Hyperlipidemia

• Ischaemic Heart Disease

• Cerebrovascular Accident

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Occupation: Wet at work Prolonged walking or


Duration of diabetes

Education level

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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)

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Our roles?

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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

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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

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FOOT CARE1. Daily foot


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2. Use lukewarm (not hot!) water to wash feet

3. Be gentle feet washing/bathing.

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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

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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.

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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

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Surgical procedures:

Prevent recurrent foot ulcer

Reduced / avoid amputation

Improved function

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“Leg for Life”

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