Foot Care Awareness In Urban Puducherry Diabetes Patients

Diabetes Mellitus is a potential epidemic with growing Prevalence across the globe. It is recognized according to the International Diabetic Federation Atlas 2017, that as of 2017 the Prevalence of Diabetes Mellitus in the World is 425 million and an estimated 48% increase is expected to bring this number to 629 million patients by 2045.

The Region of South East Asia including India contributes to a large chunk of this population, with an established prevalence of 82 million as of 2017 with an expected increase by 84% to an estimated 151 million by 2045, second only to the largest fraction contributed by the Western Pacific. [1] The prevalence of diabetes in India, between 1990 and 2016, has risen in India and the increase was noted to be highest in the state of Tamil Nadu. Age-standardized Disability-adjusted life-year (DALY) rate in India for diabetes has increased by 39. 6% from 1990 – 2016. This was notably the highest increase among the major non-communicable diseases. [2]

Definitions

• Diabetes Mellitus (DM) is diagnosed if one or more of the following criteria are met: (1) Fasting Plasma Glucose ≥ 7. 0 mmol/L (126 mg/dL); (2) Two – hour plasma glucose ≥ 11. 1 mmol/L (200 mg/dL) following a 75g oral glucose load; (3) A random glucose > 11. 1 mmol/L (200 mg/dL) or HbA1c ≥ 48 mmol/L (equivalent to 6. 5%).
• Impaired Glucose Tolerance (IGT) is diagnosed if both of the following criteria are met: (1) Fasting Plasma Glucose < 7. 0 mmol/L (126 mg/dL) and; (2) Two – hour plasma glucose ≥ 7. 8 < 11. 1 mmol/L (≥ 140 to < 200 mg/dL) following a 75g oral glucose load.
• Impaired Fasting Glucose (IFG) is diagnosed if both of the following criteria are met: (1) Fasting plasma glucose 6. 1 – 6. 9 mmol/L (110 to 125 mg/dL) and; (2) Two – hour plasma glucose < 7. 8 mmol/L (140 mg/dL) following a 75g oral glucose load. [3]
• Regular exercise: At least 30 minutes of brisk walking for 4 days or more in a week.
• Regular blood sugar testing: Every quarterly check-up of blood sugar.
• Treatment compliance: Daily consumption of medication as advised by the physician. [4]

Types of Diabetes Mellitus:

The types of Diabetes Mellitus include Type 1 (also called Insulin Dependent Diabetes Mellitus or Juvenile Diabetes Mellitus) and Type 2 (also called Adult Onset Diabetes Mellitus). Type 2 is due to insulin resistance developed by the body and Type 1 in most cases involves an autoimmune destruction of the β cells of islets of pancreas. [5]

Complications of Diabetes Mellitus

Epidemiology and Pathogenesis of Diabetic Complications

There is growing evidence that the underlying mechanisms in the pathogenesis of diabetic complications include certain genetic and epigenetic modifications, nutritional factors, and sedentary lifestyle. [6] In animal – zebrafish diabetic models the role of epigenetic mechanisms on the persistence of diabetic complications even after euglycemic control is achieved – a condition known as Metabolic Memory – has been studied. The conclusion of the above study was that DNA – Methylation, in or near genes belonging to DNA replication / DNA metabolism process group, might play a key role in this process. [7] Ageing, Male gender, Smoking, Low levels of Physical Activity and High Cholesterol have been recognized as independent predictors of Macro-vascular complications. Conversely, Smoking, Hypertension, and Duration of DM over 10 years have proven to be predictive factors for Micro-vascular complications. [8]

Micro-vascular Complications

The mechanisms of micro-vascular complications include; the production of Advanced Glycation End Products (AGEs), the creation of pro-inflammatory microenvironment and the induction of oxidative stress. With regard to the presentation of these complications, Diabetic Neuropathy is the most common complication of Diabetes Mellitus, Diabetic Nephropathy is the leading cause for End-Stage Renal Disease and Diabetic Retinopathy is one of the leading causes for blindness in working-age adults. [9, 10]

Macro-vascular Complications

Atherosclerosis is more common in people with Diabetes Mellitus than in the people without Diabetes. A study Describes that DM increases the risk of stroke in people aged 20 to 65 years more than 5 times. [11]

Miscellaneous Complications

Diabetic Cardiomyopathy is a complication that develops independent of coronary artery disease or hypertension and may contribute to morbidity and mortality. [12, 13] Epidemiological and basic science evidence suggestpossible shared pathophysiology between type 2 DM and Alzheimer’s Disease (AD), it has been hypothesized that AD might be “Type 3 Diabetes”. [14]

Diabetic Neuropathy and Foot Care in India

Currently, India is a country with the second-highest number of people with type 2 DM. With this, there is a rise in associated complications as well which has increased individual’s health expenditure. [15] A 2018 study estimates 7% adults with diabetes in India, with a higher level in urban (9. 8%) than in the rural area (5. 7%), a higher proportion of males (7. 1%) than females (6. 8%). [16] A rural Indian study cited that the prevalence of diabetic foot ulcer among outpatient and inpatient diabetics was found to be 10. 4% and around 8. 7% of people with diabetes suffered from foot ulcers during 1st year of onset. [17]

The diabetic foot ulcers frequently become infectedand are the common cause of lower extremity amputation in these patients. [18] Diabetic foot ulcer incidence has been proved to decrease with consistent foot care education. [19] In developing countries like India, where the resources are limited, and treatment costs for diabetes are constantly increasing, the self-care component among patients with diabetes may lead to better economic and therapeutic outcomes. [20]

The present study includes 60 patients diagnosed with Type II Diabetes Mellitus, majority of whom are males (58. 34%) and the majority of participants were over the age of 55 years (66. 67%). A bulk (61. 67%) of the participants belonged to the upper-lower class according to the Modified Kuppusamy Socioeconomic scale. [21] There was a strong positive correlation (r=0. 729) between the awareness and practices of foot care in diabetic patients. This study showed statistically significant low mean scores of awareness in diabetic patients with increasing age (p=0. 009) and low mean scores of practice of foot care in diabetics who received no advice on foot care prior to the study (p=0. 0008).

Similar results were observed in a study done by Deepa L. N et al in Karnataka, India which found a strong positive correlation (r =0. 87, pA similar study in Saudi Arabia done byQadi M A et al in the year 2011 showed that the practice scores were significantly lower in educational level. [23] However, a more recent study by AlhuqaylAA et al (2019) showed the prevalence of high knowledge on foot care in diabetic patients have improved since then to about 53. 3%, which was concluded to be promising and better compared to previous studies in Saudi Arabia. [24]

A 2015 study done in a rural area in Kancheepuram, Tamil Nadu by Shrivastava PS et al observed that while the majority of the subjects (82. 5%) agreed to be regularly wearing footwear, only 17. 5% of them took extra care about their feet. Said study also came to the conclusion that while the majority of the subjects had correct and adequate knowledge, they were significantly lacking in terms of self-care practices. [4]

A cross-sectional study in Taiwan in 2012 by Chin Y et al via a logistic regression model revealed that select action cues (recommendations from family, friends or health professionals) played a significant role in the patients’ foot care practices. [25] A 1-year interventional study done by Kotru S et al, 2015 in Punjab, India observed that intensive education, training, and customized footwear reduced the risk of developing new ulcers / diabetic foot by 13%. [26] An open-label randomized control study conducted in AIIMS New Delhi by Rahaman HS et al observed that there was a statistically significant improvement in knowledge and foot care practices in diabetic patients as early as 3 months after an intervention using a patient module with audio-visual display and a pamphlet on diabetes foot care. [27]

The results of the present study in Puducherry, India match the ones mentioned above and stresses the importance of advice regarding diabetic foot care to patients at the time of diagnosis/during subsequent follow-ups.

Conclusion

This study quantitatively and qualitatively assesses the awareness and practice among the urban diabetic population about foot care and prevention of extreme complications of diabetic neuropathy leading to amputation. The dearth of resources in developing countries like India, the increasing trend of cost of treatment of diabetes and its complications with the exponential rise in the incidence of diabetes make prevention of the aforesaid complications even more vital than managing the same.

Thus, with increasing awareness and good practices of diabetic foot care, morbidity, mortality and financial strain over the patient can be largely reduced and the patient’s quality of life along with DALY rates can be improved with minimal expenditure. This can also be achieved by means of audio-visual, educational pamphlets or one to one patient education by the health personnel at the time of diagnosis or during follow-up visits. Further interventional studies in this regard will prove useful to evaluate and improve foot care practices in diabetics.