1) The document describes a preventive foot clinic in India that screened 6,800 diabetic patients. 2) It found that 83.8% of patients had foot problems like neuropathy, ulcers, and calluses. Neuropathy was the most common issue. 3) Through education on foot care, monitoring of patients, and prescribing treatments, the clinic aims to reduce amputation rates by focusing on prevention and early detection of foot complications from diabetes.

1. Preventive Foot Clinics
Sanjeev Kelkar

2. Why Preventive Foot Clinics?
• Need
• Concept
• Actualization
• Experience
• Learning

3. Preventive Foot Clinics
• Ulcer – gangrene – amputation – going on for long
across the world and our country
• Energy and resources spent – huge
• Treat as you can, send when it complicates
• An Attitude for early detection when no co-
morbidities are present difficult to inculcate both
among the HCPs and patients
• Treating an unborn future that does not get
conceived

4. Diabetic Foot Statistics
• Estimated life time risk of diabetic foot - 15%
•
• 5-10% of all diabetic patients have or have had
foot ulceration of various degrees and about 1%
have undergone amputation
• Diabetes accounts for up to 50% of non traumatic
leg amputations*
• Of all the diabetic amputees about 50% will lose
their life or their other leg by 3 years

5. Major Problem in India
• Neuropathic ulcer ( 85--95 %), Eminently preventable
• Patients are younger,
• Mean age of amputation earlier,
• Far too many amputations for neuropathic ulcer.
• Neuropathy that is significant enough to cause foot
ulceration may affect 40% of diabetic population,
especially elderly with type 2 diabetes.
• Upto 35% of all diabetic patients have asymptomatic
neuropathy
• Diabetic Neuropathy affects 70% of the Diabetes patients
–

6. The Compounded Problem
• Component causes leading to foot ulcers
• Peripheral neuropathy : 78%
• Minor trauma : 77%
• Deformity : 63%
• Edema : 37%
• Peripheral ischemia : 35%
• Callus : 30%
• Infection : 01%

7. The Compounded Problem
• Contra-lateral amputation rate of 12 to 28%
between 1 to 3 yrs
• Mortality - 16 to 38% :1 year
• - 35 to 65% :3 year
• - 75 to 80% : 5 year

8. Preventive Foot Clinics
Concept

9. Concept
• Assembly line operation
• Multiport data entry
• End to end solution
• Skill transfers

10. CLINICAL EXAMINATION

11. 1
2
3
1. Monofilament
2. Doppler
3. VPT
Overview

12. DIABETES EDUCATORS AT FOOT CLINIC

13. DIABETES EDUCATORS AT FOOT CLINIC

14. PREVENTIVE FOOT CARE,
AID, KMCH, CHENNAI, INDIA
INDIVIDUAL COUNSELING

15. EDUCATOR’S COUNSELING THE PATIENTS
FOOT CARE - THE 10 COMMANDMENTS

16. THE 10 COMMANDMENTS OF FOOT CARE
EXPLAINED BY NURSE EDUCATOR

17. Preventive Foot Clinics - Assets
• Enablers: Aware profession, available
infrastructure within the country
• Need: People from the lower economic
strata have much higher levels of
complications across the board –
BUDS, CODI, NUDS,

18. Preventive Foot Clinics
• Data entered online by three different
persons – baseline at the reception, clinical
by the doctor, SW MF, VPT, HCP in VPT
negative patients by trained techs,
• Doppler for PVD

19. Preventive Foot Clinics
• Footwear inspection by a trained podiatrist,
advice given,
• Second phase of preventive foot clinic –
• Aims at establishing capacity to manufacture in
house foot wear, outsource it
• The clinic charges for an extended period, not on
a visit to visit basis,
• People pay –tariff low

20. Preventive Foot Clinics
These trained but non medical persons, they
handle different jobs
eg baseline clinical data work at reception,
help manage data entry etc.

21. • Understand the problems

22. Preventive Foot Clinics
• We can’t treat all, all along with the
complications and all the works associated
with it – let us face it
• But we can teach and prevent
• The real solution is prevention prevention
and prevention

23. PREVENTIVE FOOT CARE CLINIC
Dr. AMBEDKAR INSTITUTE OF DIABETES
KILPAUK MEDICAL COLLEGE HOSPITAL
Summary Statistics
TOTAL NUMBER OF PATIENTS SCREENED :
6800 AS ON 14.7.2005

24. Number of patients examined : 6800
Number of patients with Foot problem : 5700
P. Neuropathy : 83.8%,
PVD : 3.5 %,
Foot ulcers : 4.5%
Preventive foot care education : All 6800
Number of patients undergoing Minor / Major Amputations : 36

25. 43
57
0
10
20
30
40
50
60
MALE FEMALE
MALE FEMALE
TOTAL SCREENED - n = 6800
%
FOOT EXAMINATION IN DIABETES

26. 83.8
36.4
47.4
0
10
20
30
40
50
60
70
80
90
TOTAL MALE FEMALE
% OF MALES & FEMALES WITH FOOT PROBLEMS
n = 6800
1) 16.2 % Did not have foot Problems
2) Problems were more in Females

27. FOOT PROBLEMS AT SCREENING - AID KMCH - CHENNAI
0
Ulcer
Amputation
Gangrene
Corn
ClawtoesFissures
Calluses
Fung. Inf IngrownToe Nails
(n = 6800)
%ofFootProblems
57.8
45.8
49.8
13.8
3.3 2.9
4.5
0.5 0.8
0
10
20
30
40
50
60

28. MONOFILAMENT EXAMINATION - n = 6800
60.5%
39.5%
0
10
20
30
40
50
60
70
P. Neuropathy in Diabetics - 1
NORMAL
ABNORMAL
%ofproblems
Monafilament test is less reliable than VPT

29. 16.2
83.8
24.5
31.8 27.5
0
20
40
60
80
100
Normal Total VPT
+ve
Mild Moderate Severe
Normal Total VPT +ve Mild Moderate Severe
(n = 6800)
P. Neuropathy in Diabetics - 2
Loss of VPT is more reliable test than MF

30. 1.5
8.2
34.7
54.3
1.3
0
10
20
30
40
50
60
Non DM <5 6 to 15 16 to 25 >25
DURATION OF DM – WITH FOOT PROBLEMS
(n = 6800)
Footproblems%
Duration in Years
> 256 to 15< 5
More than 50% have foot problems at < 5 years
16-25

31. FOOT WEAR IN DIABETICS - n = 6800
41
20.8
16.7 15.9
3.8
1.8
0
5
10
15
20
25
30
35
40
45
Hawai Plastic Others Bare
Footed
LeatherHawai MCR Plastic Others
Foot Problems are more with Hawai & Plastics even with MCR –
Great Toes / Little Toes were outside the Foot Wear.
FootWear%

32. 34.7%
83.8%
3.5%
n = 6800
NEUROPATHY Vs VASCULAR PROBLEMS IN DIABETICS
NEUROPATHY
VPT MF DOPPLER AB INDEX
VASCULAR
PVD is very minimal in this study

33. Action
• Evaluate the findings
• Pass the patient through an education
session, put relevant educational material
in vernacular in the hand
• Monitoring advised,
• Revisit fixed, drugs prescribed

34. What Paul Brand Said - We did
• The single most important intervention to
reduce amputation is to remove the
footwear and see the feet of a diabetic
• Paul Brand as told to the Americans

35. Educate, educate and educate
Effect Of Patient Education On
Amputation Rates
Knee & Above
12%
15%
5%
46%
35%
60%
Toe & Metatarsal
Below Knee
No Education
Education
University Hospital of Geneva 1979-1989. All comparisons p<0.001. Assal JP et
al. Diabete Metab 1993.