This talk was delivered by Dr. Shashikiran Umakanth on 16 February, 2016, at Manipal University. This talk was part of the series on Diabetes Foot Care education to physicians by the World Diabetes Foundation project at Manipal for Udupi district of Karnataka, India.

1. Community
Perspectives &
Patient Role
in Diabetic Foot
Dr. Shashikiran Umakanth
Prof & Head, Department of Medicine
Dr. TMA Pai Hospital, Udupi
MMMC, Manipal University

2. World’s most populous countries: 2015
Rank Country Population
1 China 1,300 Million
2 India 1,251 Million
If diabetes was a country, it
would be the third largest
country in the world!
The cost of diabetic foot
ulcers is greater than that of
the five most expensive
forms of cancer…
4 USA 321 Million
5 Indonesia 255 Million
6 Brazil 204 Million
7 Pakistan 199 Million
8 Nigeria 181 Million
9 Bangladesh 168 Million
10 Russia 142 Million
3 Diabetes 387 Million

3. Community perspectives
 Social support
 Role of family & friends
Agenda
Patient Role
 Self-care
 Compliance

4.  Most physically obvious and often devastating
complication of diabetes
 An outcome of other complications
 neuropathy
 vasculopathy
 trauma
 infection
 ignorance
Diabetic foot
Approximately 50,000 legs are amputated every year, in India

5.  Mr. Kumar, a 55-yr-old man, has T2DM for 12 years
 Developed a diabetic foot ulcer; about 9 months later,
amputation of right great toe was done - osteomyelitis
Case of Mr. Kumar
 Mr. Kumar was a lorry driver. However, he has not been able to drive
 Now, his wife also died in an accident, while he was driving the scooter. He
is living with his elderly mother
 He has a very low mood and frequently becomes tearful
 He has many issues requiring consideration, including his non-healing
ulcer, poor glycemic control and the loss of his wife, job and income.

6. Physically obvious disease
Stress
Social
Support
Coping
Social stigma
Personal grief

7.  Higher income = more supportive behavior from family
 Support from family members = better diabetes-related
control behaviors
 Perceiving family members as non-supportive results in
 worse medication adherence and
 higher HbA1c levels
Family Support & Diabetes
Mayberry LS, Osborn CY. Diabetes Care 35(6), 1239–1245 (2012).

8.  Family members
 perceived diabetes as a cyclical illness, which is controlled by
treatment than by the individual
 reported that the patient was more emotionally distressed
(patients were unaware of this concern and had a relaxed
approach)
 knew more about diabetes than the patient reported
 less satisfied than patient about support
Family Perspectives
White P, Smith SM, Hevey D, O'Dowd T. Diabetes Educ. 35(5), 810–817 (2009).
Diabetes is an illness that affects both individuals and families

9.  Spouses play a key role in optimizing DM management
 When both have diabetes - more understanding
 Or else
 feelings of restriction of food
 spousal control over food content, for men in particular
 With increasing symptoms,
 Male patients often receive more support
 No change in support for females
Spousal Support
Beverly EA, Miller CK, Wray LA. Health Educ. Behav. 35(5), 707–720 (2008).

10.  Social support was not related to self-care behaviors
 More friends with DM = increased concern about DM
 Involving friends and family can result in increased
adherence for some self-care behaviors
 weight control
 exercise
 controlling fat & calorie intake
Social Support - Friends
Mani N, Caiola E, Fortuna RJ. J. Community Health 36(5), 728–732 (2011).

11.  Support from a person who has experience/
knowledge
 ridge between healthcare workers and patients
 Role of peer supporters is to
 assist in daily management of disease
 provide emotional/social support
 Peer support is a way to enhance motivation
Peer Support
Paul G, Smith SM, Whitford D, O'Kelly F, O'Dowd T. BMC Health Serv. Res. 7, 136 (2007)
Fisher EB, Earp JA, Maman S, Zolotor A. Fam. Pract. 27(Suppl. 1), i6–i16 (2010)

12.  Regular contact with patients through e-media is
gaining popularity
 Patients
 generally find the systems easy to use
 have positive feedback on peers reinforcing adherence
 nurse support is more valuable than peer support
Social Media
Dale J, Caramlau I, Sturt J, Friede T, Walker R. Patient Educ. Couns. 75(1), 91–98 (2009)
Roblin DW. J. Health Commun. 16(Suppl. 1), 59–76 (2011)

13. Physically obvious disease
Stress
Social
Support
Coping
Social stigma
Personal grief

14.  Change in quality of life is a stressor
 Main concern: losing independence and freedom
 Prime emotions: fear, anger, frustration and guilt
 Inability to continue with job: low self esteem
 Stress appears to delay healing - lower levels of
cytokines including IL-1α and IL-8
Effect of Stress
Glaser R, Kiecolt-Glaser JK, Marucha PT et al. Archives of General Psychiatry. 56: 450–6 (1999)

15.  A process where individuals try to manage the
perceived difference between the
 demands they are under and
 resources available to them
Coping
Demands ResourcesVs

16.  A study conducted on elderly individuals with leg
ulcers identified four coping strategies:
 feeling healthy
 altered expectation
 comparison with others - “may have been worse”
 positive thinking
Coping Strategies in Foot Ulcer
Walshe C. Journal of Advanced Nursing 22: 1092–100 (1995)

17. Challenges & Patient Roles

18.  Illiteracy
 Low socioeconomic status
 Ignorance - late
presentation by patients
 Hopelessness - amputation
is considered inevitable
Challenges - Community & Individual
 Belief in
 alternative medicine
 advertisements in lay
press that claim “100%
success & cure” for
diabetes & diabetic foot

19.  Barefoot walking
 Inappropriate footwear use - like
Hawaii slippers
 Sleeping on the floor - rat bites
 Rats nibble toes and wounds and
create deeper wounds
Challenges - Community & Individual

20.  Visiting religious places
 very hot stone paths during summer
 Compelled to walk barefoot as religion
does not permit wearing footwear
 Thermal injuries
 Sitting cross legged for long hours at
work and worship
 Pressure on lateral malleolus
Challenges - Community & Individual

21. Compliance
the action or fact of complying with a wish or command
Oxford Dictionary of English, Second Edition (Revised)

22. “My patients are very compliant”
…“to non-compliance”

23.  Patients often ignore medical advice
 Dilemma
 Respect patient autonomy OR discontinue care?
 We are trained to
 evaluate & treat patients within our scope of knowledge
 refer to specialists when necessary
Non-compliance

24.  We are not trained to deal with patients who
refuse recommended treatment
 review their options, risks and benefits
 assess competence for decision-making
 if competent, we must allow our patients to choose to do nothing
 if patient-physician relationship continues
 negotiate responsibility for outcomes and document the patient’s
understanding
Non-compliance

25. Self care

26.  Diabetic foot “defeets” people
 Let’s help in “undefeeting” people with diabetes
Diabetic foot
http://www.undefeeted.org

27. पादाग्रे वसते लक्ष्मि: पादिध्ये सरस्वती
।
पादिूले क्ष्स्िते धन्वन्तरर प्रभाते
पाददर्शनं ॥
Morning prayer in diabetes
Divinity of Prosperity:
to reduce the economic
burden of diabetic foot
Divinity of Knowledge:
for health education
about diabetic foot
Divinity of Health:
to provide holistic health
and to keep feet healthy

28. Thank you

29. Morning prayer in diabetes
Divinity of Prosperity:
to reduce the economic
burden of diabetic foot
Divinity of Knowledge:
for health education
about diabetic foot
Divinity of Health:
to provide holistic health
and to keep feet healthy

30. Thank you