The diabetic foot disorder in arabs countries a neglected clinical problem

1. THE DIABETIC FOOT DISORDER IN ARAB’S
COUNTRIES: A NEGLECTED CLINICAL PROBLEM
By
Professor Hasan Ali Alzahrani, M.D., FRCS(Glasg)
Chairman, "Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research"
President of the Saudi society for vascular Surgery(SSVS)
Head of Vascular Surgery Division, Department of Surgery,
Medical college,
King Abdulaziz University (KAU)

6. 6

8. ‫الكرسي‬ ‫دعم‬ ‫توقيع‬ ‫حفل‬
‫الثالثاء‬13/6/1429‫هـ‬-17/6/2008‫م‬

10. Background
 Diabetes Mellitus is by far the most common metabolic disorder
in SA
 Its prevalence varies worldwide (International Diabetes
Federation IDF, 2011)
 Factors influencing the prevalence of DM include
– socioeconomic status.
– Age.
– Sex.
– Genetic susceptibility.
– Life style, and other environmental factors.

12. IDF’s 2011 Prevalence Rates

13. DM is a Global Health Problem
 The United Nations Resolution (61/225),
has already been adopted unanimously
in 2006, recognizes diabetes as a
serious and costly disease that poses a
threat to individual well-being and
economic progress

14.  Saudi Arabia is a country of over 20
million and a rapidly developing country.
 During past two to three decades the
tremendous surge in socioeconomic
growth has considerably influenced the
life style of people.

15. SA in the Eye of the DM Storm

16.  The 2011 IDF’s comparative prevalence
rate of DM in SA was 20%;
approximately 3 million Saudi diabetics
 Studies showed that NIDDM increased
to 28.8% in male and 24.9% in female
over the age of 60.

18. Complication

19. Complications
“Diabetic foot” refers to a group of
disorders caused by long term
complications on the diabetic’ feet

21. Causal Pathways for Foot Ulcers
Neuropathy
Deformity
ULCER
% Causal Pathways
Neuropathy: 78%
Minor trauma: 79%
Deformity: 63%
Behavioral ?
Diabetes Care. 1999; 22:157


Poor self-foot care
Minor Trauma
- Mechanical (shoes)
- Thermal
- Chemical

22. Foot care practices among 747 diabetics
attending PHC in Jeddah
- The median score of the practice was 14
out of 33.
- (49.8%) always do not wear the covered
shoes.
- In Pakistan; Mortza et al study found that (22.2%)
male and (43.8%) female patients were
using open shoes .
(Kadi MH, Alzahrani HA; J KAU-Med Sci, 2011)
Foot Care & Prevention Issues

23. Foot care practices-contd
- 43.8% of the patients do not check the
inside of their shoes
- 40.3% do not wear socks

24. In Jeddah’s diabetics there is:
1- Weakness in certain aspects of foot care’s knowledge
2- Weakness in many aspects of foot care’s practices
3- The lower socio-economic group are at higher risk of
the above
Conclusions

25. 1- There is need to start a well organized foot care
educational programs.
2- The foot care education program need to be in conjunction
with a continuous program of periodic screening in high
risk patients
Recommendations

26. Risk Stratify for Ulcer Risk
Diabetes Care. 2001;24:1442
Diabetes Metab. 2003;29:261
Risk Level
Foot Ulcer
%/yr
% Office Patients
(diabetes clinics)
3: Prior
amputation
Prior ulcer
28.1%
18.6%
7%
2: Insensate and
foot deformity or
absent pedal
pulses
6.3% 10%
1: Insensate 4.8% 17%-30%
0: All normal 1.7% 66%

27.  50% of
amputations
 50% of patients
 50% of patients
Tragic “Rule of 50”
Transfemoral/
transtibial
level
2nd amputation
in
 5 years
Die in  5 years
Clinical Care of the Diabetic Foot, 2005

28. Prevention is better than Cure
 90% of the amputations performed on
diabetics are preventable
 However, once DFU occurred it has to
be treated aggressively “Foot Attack”

30. How many amputations per year?
SAUDI ARABIA: Riyadh has three
diabetes-related amputations each
day
Arab News / AFP / March 10, 2009
Some 90 people a month have a foot
amputated due to diabetes in the Saudi
capital, a doctor said yesterday,

31. Scientific Data
Data about the diabetes-related lower
extremities amputations DRLA in Saudi
Arabia SA and perhaps in all of Middle
East and North African (MENA)
countries is limited in view of:
- the absence of national registries
- Lack of published research (only 115 in
Pubmed upto April 2012)

32. The DFR Chair aimed to:
- Challenge the media figures by reviewing the
author’s local data-base, available published
data as well as analyzing the Saudi MoH
reports to estimate the magnitude of the
problem in SA and perhaps MENA countries.
- Review the published studies from Arab’s
countries

33. Articles published on DFDs by our group (12)
-Al-Zahrani H, Saban S, Merdad H. Management of diabetic foot ulcer. Asian J
Surg, 1991; 14(1): 24-27.
- Al-Zahrani H. Role of vascular surgery in the management of diabetic foot
problems. Annals of Saudi Medicine, 1991; 11(6): 719-720.
-Al-Zahrani H, Ghandourah N, Merdad H. Limb amputations in Western Saudi
Arabia. Asian J. Surg, 1992; 15(3): 119-122.
-Al Zahrani H. Diabetic foot infection - two years experience. Saudi Med J,
1996; 17(4): 544.
- Alzahrani H, etal. The distribution of peripheral arterial disease in a defined
population of elderly high-risk Saudi patients. Int Angiol 1997
-Badri M, Alzahrani H, etal. Exteremities amputations in King Abdulaziz
University Hospital: Five years experience. King Abdulaziz Medical Journal,
2011.

34. Articles- contd.
 Tashkandi W, Badri M, Badawood S, Ghandourah N, Alzahrani H.
Limb amputations in 3 major hospitals in Jeddah, Western Saudi
Arabia. King Abdulaziz Medical Journal, 2011.
 Kadi MA, Alzahrani HA. The Foot care knowledge and practice among
diabetic patients attending primary health care centers in Jeddah city.
King Abdulaziz Medical Journal, 2012.
 Alzahrani HA. The diabetes-related lower extremities amputations in
Saudi Arabia. Annals Annals of Vascular Diseases, 2012
 Alzahrani HA and et al. The Management of DFD in Six major
hospitals in Jeddah. Asian J of Med Res, 2012
 Alzahrani HA. The direct cost of diabetic foot management in some of
private hospitals in Jeddah, Saudi Arabia. Int J of Diabetes in
Developing Countries, 2013
 Alzahrani HA and et al.The Diabetic Foot Research in Arabs’
Countries. OJEMD, 2013

35. Tragic “Rule of 15”
 15% of diabetics will develop Foot ulcers in
their lifetime which equals 375,000 in SA
 15% of these foot ulcers will result in LEA
Amputation i.e. 56,225 in SA
Clinical Care of the Diabetic Foot, 2005
Clinical Care of the Diabetic Foot, 2005

36. Diabetic Amputations in Saudi Arabia
 MOH reported 652 amputations in its
annual report (2008).
 In Jeddah 128 in 3 major hospitals of
2000 beds

37. Presenting Symptoms & Signs indicating
amputation
0
20
40
60
80
100
120
140
160
180
Ulcer
(64.4%)
Infection
(51.2%)
Ischemia
(35.6%)
Gangrene
(6.9%)
Polydactyly
(4%)
Others ( )
161
128
89
24
10 6

38. Number of Amputation per each individual
Patient
Number Of Amputation Frequancy %
Once 198 89.2%
Twice 20 9%
Trice 4 1.8%
The total number of patients accounted for 222 patients out of them 198 (89.2%)
had been undergone amputations once, and the rest had multiple amputations either
twice 20 (9%) or thrice 4(1.8%).
Two patients had both lower and upper limb minor amputations at the same setting
for polydactyly making a total of 252 amputations in 250 operations.

39. Occurrence of Post Operative
Complications
yes
28%
No
72%
yes
No

40. Description Jeddah Riyadh KSA+
Assumption * 696 1,080 5,102
Method 1 averages ** 306 668 3,616
Method 2 averages *** 345 814 4,325
( Both studies averages ) 325 741 3,970

41. Methods-contd.
The averages of the three methods in both studies
were taken and it is found that
325 amputations are estimated to happen annually
in Jeddah compared to 741 in Riyadh
and 3970 for the whole kingdom i.e. 2.5
amputations per 10,000 population

42. DR-Amputations in SA and MENA
These figure are less than the one quoted in
media by 31%.
When applied to (MENA) countries, 44,208
amputations are predicted annually.

43. Conclusion
Half a million of (MENA)’s countries citizens are
likely to have a minor or major diabetes-related lower
extremities amputations over the coming decade

44. Amputation was significantly higher in
male patients, co-morbid disease,
peripheral vascular disease

46. Mortalities among Patients who
Undergone Amputations
Yes
7%
NO
93%
Yes
NO

47. The Diabetic Stairway to Heaven
DM- DFD- Loss of Limb- Death

48. Conclusion
Most of the amputees will not be re-habilitated and
may lose their jobs or incomes

52. Cost of Amputations

53. The Diabetic Foot Research in
Arabs’ Countries
-By April 2012, a total of 906 articles were published on
DM, out of them 115 (11.6%) were related to DFDs.
-The largest number of DM/DFDs research came from
G1 countries (n=437/51) followed by G2 (n=307/38)
and finally G3 (n=162/26)
- Saudi Arabia was the top on the list of all studied
countries with 31 studies related to DFDs out of the 187
on DM (16.5%).

54. Recommendations
In view of this, national registries are timely
needed in KSA and other (MENA) countries.

55.  Public health education programs are
recommended.
 Guidelines in approaching diabetic foot
is essential with multidisciplinary
approach.

57.  Vascular assessment should be a routine
step in diabetic foot management.
 More prospective studies, and wider scale
studies is needed to determine of burden of
diabetic related amputation problem.

58.  DFD is still a major health problem in
Saudi Arabia which is witnessing a”
Pandemic” of diabetic complications.