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  1. 1. Diabetes & Foot
  2. 2. Diabetes mellitus (DM) is a Heterogeneous chronic Metabolic disorderHyperglycaemia results from a defect in insulin action and / or deficiency ofinsulin secretion.
  3. 3. In type I diabetes mellitus, the body simply does not make insulin (5% ofdiabetics).In type II diabetes, either the body does not make enough insulin or the cellsbegin to resist it (95% of diabetics).
  4. 4. DM : Leading cause of death and morbidityMorbidity implies the effects due to the disease, which reduce or mar thequality of life of the affected person. It causes blindness, heart attack,stroke, kidney failure and amputation.This ailment is affecting younger people also. In the past decade, theincidence among people in the 30‘s has jumped by 70%. It is up by 10% amongunder the 30s.This implies that these younger people will be struggling with amputations,blindness and heart disease at the prime of their life.
  5. 5. Diagnosis of Diabetes is for lifeEntails certain lifestyle and social restraintsMounting therapeutic obligationsProblems of employment and insuranceExtreme care to be exercised in pronouncing such a diagnosisDelay in diagnosis raises the risk of issue damage and long term complications
  6. 6. PrevalenceIndia had 19.4 million diabetics in 1995India will have 57.2 million patients in 2025 India tops the list of diabetes in 1995 and 2025 alsoThe world wide prevalence of diabetes will be 300 million in 2025 of which 72million will be in developed countries and 228 million in developing countriesThat is: 75% of diabetics will be in developing countries
  7. 7. Ten top countries – Number of adults with DM in Millions S.NO COUNTRY 1995 COUNTRY 2025 1 India 19.4 India 57.2 2 China 16 China 37.6 3 US 13.9 US 21.9 4 Russian Federation 8.9 Pakistan 14.5 5 Japan 6.3 Indonesia 12.4 6 Brazil 4.9 Russian Federation 12.2 7 Indonesia 4.5 Mexico 11.7 8 Pakistan 4.3 Brazil 11.6 9 Mexico 3.8 Egypt 10 Ukraine 3.6 Japan 8.5 11 All other countries 49.7 103.6 Total 135.3 300WHO Tech report 1985
  8. 8. The Rising Prevalence of Diabetes In Developing Countries 140 120 100 Millions 80 60 40 20 0 20-44 Yrs 46-64 Yrs 65 Yrs 1995 2025
  9. 9. The rising prevalence of Diabetes world wide 300 300 250  200 177 1985 150 135 1995  2000 100 2025 50 30 0 1985 1995 2000 20254 million deaths per year related to DM. (9% of the global total.)
  10. 10. Factors for Rising of Diabetic Epidemico Genetic Predispositiono Environmental factors  Sedentary life style  Change in food habits  Stress of Urban livingo Increase in populationo Increasing aging population (Longevity)o High Ethnic susceptibility
  11. 11. Effects of UrbanizationConsumption of excess caloriesReduction in complex carbohydrates with increased consumption single sugarsand fatAvailability of energy saving methods of transport and labour hence severelyreduced physical activity.Increased levels of stress.
  12. 12.  Factors Responsible  Unchangeable Modifiable Preventable Male Gender Dyslipidaemia life styleF.H. of Diabetes mellitus Hypertension Obesity Ageing Diabetes Smoking Viral infections Alcohol Stress Sedentary Food habits
  13. 13. Indications for testing for diabetes in asymptomatic, undiagnosed individuals.                 Testing for diabetes should be considered in all individuals at age 45 years, and above and, if normal, it should be repeated at 2 year intervals.  
  14. 14. Testing should be considered at a younger age or be carried out morefrequently in individuals who:  o Are obese ( BMI over > 27)o  Those with a family history of DM (especially first degree)o Those with diabetes developing during pregnancy (GDM)o  Mother of a big baby at birth (above 3.5 kg)o Mother prone for diabeteso  Low birth weight child (IUGR)–child can develop diabetes in futureo Have a HDL cholesterol < 35mg/dl and /or a triglyceride level >200mg/dl.o  On previous testing , had IFG or IGTo Are members of high risk ethnic population (South Asians)o  Poly cystic Ovarian Disease in Females
  15. 15. Prevalence of complications at diagnosis 50% of patients had complications at diagnosiso   37% had retinopathyo  18 % had microalbuminuriao 10% had peripheral neuropathy. UKPDS
  16. 16. Chronic complications of Diabetes o Mortality is increased by 200%o Heart disease and stroke rate is 200% to 400%.o Blindness 10 times more common in diabetes.o Gangrene and amputation of lower limbs about 20 timeo Second leading cause of fatal renal disease.o Other chronic complication (neuropathy, infections and sexualdysfunctions)o As a result of diabetes, hospitalisation expense increase by 2 to 3 folds (WHO expert committee on Diabetes mellitus)
  17. 17. Cost of diabetic careEstimated annual cost of diabetes care would be Rs.9,000 crores and theaverage expenditure per patient per year would be a minimum of Rs 5,000/-For an average Indian family with an adult with Diabetes, as much as 25% ofthe family income may be devoted to diabetes care. WHO
  18. 18. ECONOMIC BURDEN $ 948 Photocoagulation Disability benefit for $14,296 blindness (yearly) Acute cardiovascular disease $ 15,952 hospitalization $ 31,225 Lower extremity ulcer /infection/amputation Renal replacement treatment of ESRD (yearly) $ 46,207 Multiple insulin injection (yearly) $ 3324 Max SU + Metformin (yearly) $3041 Insulin + Maximum OHA (yearly) $2757 Evaluation for proteinuria $1080Preventive Vascular foot evaluation(yearly) $124measures / Evaluation for neuropathy $106comprehensive Yearly Ophthalmictreatment Exam $100 Treatment of complications
  19. 19. Annual Direct Cost: (Background variable adjusted)for routine treatment, not requiring hospitalization in different settings.Total patients 611 - - - - - - - - Rs 5959 Type I (35)   6432 Type 2(576)   5928   OHA alone (395) 4722   Insulin alone/OHA (217) 8195 SEX Male(335) 5580   Female(276) 6417Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999 HYPERGLYCAEMIA – ECONOMIC BURDEN
  20. 20. PLACE GOVERNMENT (172) Rs 2855  Private (439) 7176Duration Less than 5 years (216) 5522  5 to 14 years (277) 6240  15 plus years (118) 6063Stay Urban 5756  Rural 6266 Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999 HYPERGLYCAEMIA – ECONOMIC BURDEN
  21. 21. Complications None (185) 5606   I (168) 5616   II (134) 5954   III plus (124) 6747Rayappa PH et al., Int. J. Diab. Dev. Countries. : July to September 1999. HYPERGLYCAEMIA – ECONOMIC BURDEN
  22. 22. New Indian Express on 18/02/2000 MAN USES SPEEDING TRAIN TO AMPUTATE HIS GANGRENOUS FOOT This is the tragic story of the 45-year-old man with diabetes who developed gangreneof his foot last September. The foot would not heal and the resulting pain and lack ofmobility meant that he had to give up his work as a plumber. The alternativeemployment he took up - selling fruits at the side of the road – was not a successbecause of the foots offensive smell. No one would buy his fruits.Attendance of the doctors for dressing and other treatment were costing him Rs 75/-each time and he was told that the amputation he needed would cost Rs 15,000.As a consequence of this advice, he decided to use the local train to amputate hisfoot. He survived, but how long remains to be seen.This is an effort to make sense of cost effectiveness information ondiabetes programmes and its importance for physicians and policy planners.
  23. 23. EXPECTED ECONOMIC BURDEN DUE TO DM RELATED COMPLICATIONS IN THE YEAR 2025  Diabetic Retinopathy Rs. 1,425 crores/ yearAssumption: 5% of DM will undergo laser therapy. Rs. 5,000 for laser treatment Renal Disease Rs. 28,500 crores/yearAssumption: 5% of the DM patients will need dialysis. Rs.1,00,000/ for dialysisCoronary Artery Disease Rs. 28,500 crores/yearAssumption: 5% of DM patients will need bypass surgery. Rs. 1,00,000/ for bypass Foot Complications Rs. 5,700crores/year
  24. 24. The economic burden of diabetesIndia is the ‘ Diabetes Capital of the world’ A dubious distinction Can we afford it?
  25. 25. “Walk more , Eat less” Sir George Alberti, President IDFWhy are so many people suffering from DM in IndiaEthnic predispositionIndians are centrally fat (fat around the waist) due to lack of exerciseEconomic growth – prosperity - change in dietary habits and adopting ofwestern style fast food
  26. 26. Strategies for primary prevention of macrovascular complications Life style modificationsDietExerciseOptimisation of body weightCessation of smokingReduction of mental stressMetabolic control of DiabetesOptimum control of Blood pressureDrug TherapyAspirinLipid lowering agents
  27. 27. Annual screening for complications of Diabetes Target organs Procedure  Retina Visual Acuity Opthalmoscopy  Renal Micro albumin estimation Macro albumin estimation Peripheral nerves Foot examination 10 gm monofilament for detection of loss of protective sensations Biothesiometry Plantar pressure measurement  Cardiovascular ECG Blood pressure: Supine, sitting and standing Estimation of serum lipids  Peripheral vessels Palpation of all peripheral pulsation and foot examination Ankle/ Brachial pressure measurement (ABI)
  28. 28. Hyperglycemia - prevention FINNISH STUDYSelection: 522 middle aged (mean 55 years) Obese (mean BMI 31 kg/m2) All were IGT. DURATION: 3.2 years.CONTROL GROUP INTERVENTION GROUPBrief diet Intensive individualized instructionExercise On weight reduction, food intake, and physical activityRESULT: 58%, relative reduction in the incidence of diabetes in the interventiongroup compared with control subjects.
  29. 29. HYPERGLYCAEMIA - PREVENTION Weight control is the single most important lifestyle factor for prevention of type 2diabetes. Subjects: 84, 941. ALL ARE FEMALES.Period: 16 years.Results: 91 % of cases of type 2 diabetes can be prevented by adhering to 5 lifestyle criteria: Weight loss Regular exercise Diet modification Abstinence from smoking Consumption of limited amounts of alcohol N Engl Med 2001: 345: 790-797.
  30. 30. Hyperglycemia - preventionDiabetes Prevention Program (DPP)Selection: 3234 individuals. Mean age 51 years. More obese, (mean BMI 34 kg/ m2) All were IGT.Duration: 2.8 years. Division: 3 groups.Lifestyle group Intensive nutrition and exerciseMasked medication group Metformin + diet + ExercisePlacebo group Placebo + diet + exerciseResult: 31% relative reduction in the progression of diabetes in the Metformin groupcompared with other subjects.
  31. 31. What are the new developments worldwide? NOTHING NEW2000 years ago, Hippocrates saidNo exercise Obesity Various illnesses RELEVANT EVEN TODAYPrimary Diabetes Mellitus is a lifestyle related disease.We cannot rely on drugs to correct lifestyle.
  32. 32. Diabetic foot epidemiologyo Cellulites occurs 9 times more frequently in diabetics than non-diabeticso Osteomyelitis of the foot 12 times more frequently in diabetics than non- diabeticso Foot ulcerations and infections are the most common reason for a diabetic to be admitted to the hospital
  33. 33. Diabetic foot ulcer epidemiologyo 25 % of diabetics will develop a foot ulcero 40-80% of these ulcers will become infectedo 25 % of these will become deepo 50 % of patients with cellulites will have another episode within 2 years
  34. 34. Epidemiology (of amputation)o 25-50 % of diabetic foot infections lead to minor amputationso 10-40 % require major amputationso 10-30 % of patients with a diabetic foot ulcer will go on to amputation
  35. 35. Diabetic foot & issueso $34,700/year (home care and social services) in amputeeo After amputation 30% lose other limb in 3 yearso After amputation 2/3rds die in five yearso Type II can be worseo 15% of diabetic will develop a foot ulcer
  36. 36. Pathophysiologyo Vascular diseaseo Neuropathy ▫ Sensory ▫ Motor ▫ autonomic
  38. 38. Ulcer Classification Wagner’s Classification 0 – Intact skin (impending ulcer) 1 – Superficial 2 – Deep to tendon bone or ligament 3- Osteomyelitis 4 – Gangrene of toes or forefoot 5 – Gangrene of entire foot
  39. 39. Classification type 2 or 3
  40. 40. Diabetic foot gangrene
  41. 41. Message for people with diabetic foot• Multi-disciplinary approach needed• Going to be an increasing problem• High morbidity and cost• Solution is probably in prevention• Most feet can be spared…at least for a while
  43. 43. Thank you