Chapter2

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Chapter II
MAGNITUDE OF THE PROBLEM IN INDIA
The estimated number of persons with diabetes in this country today is about 32
million.1 It doubles in number for diabetic feet. But it also translates to a huge
absolute number across the country. The number of studies quoted below, revealing
Indian statistics show the percentage of various diabetic foot abnormalities. Diabetic
foot disease is one of the most frequent causes of hospitalisation and is one of the
expensive complications of diabetes.2,3 The socio economic burden the diabetic foot
causes on the country's resources is tremendous. We can get a measure of the
problem by knowing in our country the frequency, types and causes of Diabetic Foot
lesions, and the way injury and infection contribute to it. It will also be useful to
know how resource utilization could be managed to take better care of diabetic foot.
Frequency of diabetic foot lesions in India:
Dr. Mohan has reported the prevalence of diabetic foot among those attending the
center at 3% in the first 40,000 patients seen at MVDSC, in Chennai.3
Dr. Ramachandran has reported an overall prevalence of diabetic foot as 15.3% in
type 2 diabetic out of 74,000 diabetics having medical records at DRC in Chennai.4
DiabCare Asia study has reported an incidence of 5-9% of active / healed ulcers and
1% of amputation in a snap shot picture of 2660 patients across 26 diabetes care
centers in India.5
In another study of 5516 patients with diabetes across the country from 250 odd
towns, non healing wound was the presenting feature in 7.4%. The prevalence of
neuropathy obtained was 15.9% with non healing wound adding 10.8% to it.8
The frequency of Neuropathic Foot:
Neuropathy really sets the stage as the single, most frequent cause, for diabetic foot
complications in India. Clinical and sub-clinical neuropathy is present in diabetics in
India up to or more than 37%.5 The incidence of neuropathy rises as the duration of
diabetes increases.5
It is also well known that percentage of prevalence of neuropathy in any cohort rises
depending upon the modalities used to detect it.
Dr Vijay Viswanathan et al reported a prevalence of neuropathy as 10% among a
population of 267 persons with type 2 diabetes, rising with the duration. In his
patients, prevalence of neuropathy with diabetes less than 5 years was 6.8% and in
more than 10 years duration, it was 17. 8%.6
Dr A Sundaram from Dr Ambedkar Institute of Diabetes, Chennai has reported
Neuropathic abnormalities in the form of mild to severe deficits of vibration
perception threshold up to 83%. His cohort is of 6800 patients tested out of 25000 that

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the clinic has been treating for diabetes for last several years in a Government
Medical College in Public Health System (unpublished data).
The diabetic neuropathy with a foot lesion:
An ulcer, however presents a different and serious profile.
The available Indian data indicates a very high prevalence of neuropathy among
ulcerated diabetic foot.
In a series of over 5000 patients with foot lesions, Dr. Pendsey has reported 76.78% of
amputations were carried out in patients who had neuropathy.7
In another study of 1010 consecutive patients of type 2 diabetes a high prevalence of
neuropathy was noted by considering the surrogate markers of neuropathy like dry
skin (signifying sudomotor dysfunction as an indicator of autonomic neuropathy) 77
%, heel fissures 59 %, callus 13 %. 8a
Dr Mohan et al reported foot ulcers in 69.85% as purely neuropathic ulcers and 23.3%
having Neuro-ischaemic ulcers.9
Dr Levin reports that prevalence of neuropathy can be as high as 50% with diabetes
of more than twenty-five years duration.10
Dr. Boulton and others have reported as much as 80% prevalence of neuropathy in a
foot lesion.11
Dr Vijay has reported prevalence of neuropathy in those with recurrent foot
ulceration around 38%.6
The role of vasculopathy or angiopathy in diabetic foot ulcer:
Dr Mohan in 1187 patients with foot lesions reported purely ischemic ulcers in 6.85%
and mixed neuroischaemic ulcers in 23.3%. He also reported a sharp rise of
peripheral vascular disease above the age of 50 years, increasing further with
diabetes duration. Dr Mohan also reported prevalence of PVD as 6.3% among
diabetics as compared to 2.7% in non-diabetic population.12
Dr Pendsey has reported 23.21% patients who underwent amputations had
vasculopathy causing ischaemia.13
It is generally believed that 75-90% of patients with foot lesions will have neuropathy
in India and 10-15% will have vasculopathy. There would be some who have
neuroischaemic foot as well.
Bhagwan Mahaveer Jain Hospital, Bangalore17, did 86 infra-popliteal bypasses in
the first half of 2001. Of these 45. 80% were patients with Diabetes Mellitus.
Dr Sundaram has reported only 2.1% vascular problems in his cohort of 5000
mentioned above.

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Infection or injury:
Dr Mohan has reported 17.9% of 1187 patients having neither neuropathy nor
vasculopathy and infection and injury were probably the only factors.14
Resource utilization:
Mohan et al, reported an overall incidence of 3% foot lesions accounting for 24% of
all admissions at his center.14
Ramachandran has reported that treatment cost of foot problem consume
approximately 32.3% income. He also reports that hospitalized patients with
diabetic foot complications spend 14% more money than those treated as out
patients.15
Bal has reported that 3.4% patients with diabetes utilize 12 to 15% of the health care
resources. He also reports that cost of primary healing of diabetic foot infection in
India varies between 25 to 50 thousand rupees.16
The economic cost of diabetes in India has been estimated in Bangalore Urban
Diabetes Study by Anil Kapur et al for more than 600 patients studied in Bangalore
urban population. 45.3% reported some complication with foot, 20.2% were
hospitalized and 15.2% received surgical treatment. Of the 20.2% (53) hospitalized,
43/53 were required to stay in the hospital for more than 7 days, 2 with six and five
days, and 2 for only one day. As a comparison, no other complication in these patient
exceeded 30% (as compared to 45.3% in foot).2
It should be emphasized that we still have little data that represents a cross section of
India on the various aspects of foot care in India. We need more data to be aware of
the relative contribution of various factors that lead to diabetic foot and its
complications to orient our resources for training and treatment of Diabetic foot.
In a larger study based on the experience of BUDS study quoted above consisting of
5516 patients across India 29.7% hospitalizations were due to either non healing
wound or neuropathy. The average stay in the hospital for non healing wound was
25.7 days and for neuropathic complications about 16 days. On an average non
healing wounds cost per patient per hospitalization Rs 19600 and for neuropathy Rs
11,200.8
A Note for Policy Makers and Professionals:
Many authorities have observed that the burden of infectious diseases will come
down in rapidly developing nations. At the same time the burden of chronic
metabolic diseases will go up as is amply seen in the world as well as in Indian
Statistics on Diabetes. Notwithstanding a decline or otherwise in the infective /
infectious diseases the metabolic disorders themselves have become a 'Public Health
Issue.' Policy makers have acknowledged this fact. In India efforts are on to address
this issue of better diabetes treatment in health care delivery system where it had a
lower priority hitherto, through training and empowerment.

4. 7
It makes sense to place diabetes as the central paradigm of the non communicable
diseases. The well supported guidelines on diabetes management, on hypertension
and lipids clearly have an additional, substantial benefit in terms of cardiovascular
diseases associated with diabetes in far too excess a percentage. It is also equally
apparent from the details of the preceding chapter that foot care problems within
diabetes practice are substantial, costly, disabling and associated with high mortality.
Emphasis on better and focused diabetes care will also lead to greater effort to save
foot. Thanks to the efforts of various initiatives in the last six years which have
generated high level of awareness and disseminated information, knowledge and
have caused development in this field. As a result Professionals who traditionally
focused on diabetes have also started focusing on foot. Given that the demands on
technology and training in foot care are not high, that small interventions could go a
long way in preventing amputations it will be desirable development if professionals
also take this aspect of care enthusiastically to focus on reduction of amputation as
the primary goal, our efforts in putting this book together as a support to their
initiative will be fulfilling.
As the next step we believe the professionals and the Governments should come
together and carry on the initiatives for better care, more awareness, more training
and boost the movement that has begun. Each party has different resources that can
be combined effectively. We appeal to all to consider this collaboration.
References:
1. King H, Aubert RE, Herman WH (1998) Global Burden of Diabetes,1995-2025;
Prevalence, numerical estimates, and projections. Diabetes Care 21:1414-1431.
2. Rayappa PH, Raju KNM, Kapur A, Bjork S, Sylvest C, Dilip Kumar KM.
Economic Cost of Diabetes Care : The Bangalore Urban district diabetes
study. International Journal of Diabetes in Developing countries (1999) 19:87-
96.
3. Dr. Viswanathan Vijay, Dr. Rajashekar, Dr. Seena B.A, Dr. Subramanian,
Lalitha, Chamukuttan Snehalata, Ambady Ramachandran MD Ph D. A
Simple Device For Foot Pressure Measurement. Diabetes Care 1998; 21:1205-
1206.
4. P H Rayappa, KNM Raju, Anil Kapur, Economic Costs Of Diabetes Care J.
Diabetes In Developing Countries 1999 Vol 19 Pp 87-96-3.
5. Boulton AJM: The Diabetic Foot: Neuropathic In Etiology, Diab
Med1990:7:852-8.
6. Dr Vijay Viswanathan: Personal communication.
7. Dr Sharad Pendsey: Personal Communication.
8. Aspects of Diabetes In India, A Nationwide Survey, Research and Clinical
Forums Vol 25, Number 1 2003 edited by Stephan Bjork.

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8a. Viswanathan Vijay and others, Routine foot examination. Practical Diabetes
International, 2000;17(4):112-114.
9. Dr V Mohan personal communication.
10 Levin ME, An overview of the diabetic foot: pathogenesis, management and
prevention of lesions. Int.J.Diab.Dev Countries 1999 ; 14:39-47.
11. Dr AJM Boulton : Personal Communication.
12. Premalatha (Gopal) and others, Prevalence and risk factors of Peripheral
vascular diseases in a selected south Indian population. Diabetes Care,
2000;23(9):1295-1300.
13. Dr Sharad Pendsey: Personal communication.
14. Dr V Mohan : Personal communication.
15. Dr Ramachandran: Personal communication.
16. Dr Arun Bal : Personal communication.
17. Dr K R Suresh : Personal communication.