Don't always have your noses up. Look down at your feet too!

Click here to listen to AUDIO PODCAST of interview with Dr APS Suri
(here is another audio podcast featuring Dr APS Suri)
On an average, a person walks a distance of more than three trips round the earth in one life time. With such high demands on our dainty feet, quality foot care is essential. This is exactly what the recently organized midterm Continuing Medical Education (CME) meeting on the ‘High Risk Diabetic Foot’ was about. It was a meeting of the brains, to deliberate about the feet. Read more
The meet was organized in Kanpur, India, jointly by the Indian Podiatry Association, UP Chapter of Association of Surgeons of India (ASI), and Hyperbaric Society of India, with a view to discuss the latest happenings in the field of diabetic foot care.

Hyperbaric oxygen therapy is a very new but exciting technique in diabetic wound healing. Dr Tarun Sahni of Apollo Hospital, New Delhi (who is also President of Hyperbaric Society of India) gave interesting insights in the use of high pressure oxygen for treatment of all sorts of wounds, including diabetic foot ulcers.

Dr APS Suri, who has done pioneering work in the field of podiatry in India, and is the President of Indian Podiatry Association, spoke on the management of diabetic foot and the role of various techniques, including stem cell therapy, in Diabetic Foot Care. He was of the opinion that the beauty of feet should last forever. We need to walk better and live better. And to achieve this, health professionals, as well as patients, need to be trained.

Dr Anil Gombar, Senior Physician at Max Hospital, New Delhi, kick started the discussion by acknowledging that we are indeed living in a diabetic world. Diabetes is a disease of the whole body, affecting the brain, eyes, heart, kidneys, and the peripheral nervous system.
One in every six diabetic patients suffers from a foot ulcer, and every 30 seconds a foot is lost to diabetes somewhere in the world.

Comprehensive foot care programmes can reduce amputations by 45% to 85%.
So, a multidisciplinary approach is required. According To Dr A.K.Khanna, head of surgery department, BHU, infection of the diabetic foot is like a snakes and ladders situation. We try to heal the wound, but infection changes the scenario. The deeper the wound, more are the chances of an infection.
The goal of surgery should be to save the foot. The three pronged strategy should be to prevent, identify/ treat and educate. We have come a long way from the days when Hippocrates had said that for an obstinate ulcer, sweet wine and lots of patience should be enough.

Dr Rishi Shukla, Endocrinologist at Regency Hospital, Kanpur, minced no words when he candidly accepted that a majority of the lower limb amputations due to diabetes are preventable. But the main hurdle is the virtual non existence of screening programmes, coupled with a lack of multi disciplinary team work. He rued the fact that diabetes management is mostly restricted to digital management. Patients, rural as well urban, are generally ignorant about the importance of feet, which are generally kept unclean. Even the clinicians do not look at the feet. Those who do examine them are indifferent towards implementing the findings. So, medical attention is generally confined to managing blood sugar levels.

Professor (Dr) Rama Kant, a world renowned surgeon, and presently Head of the Department of Surgery, CSMMU, Lucknow, stressed upon (i) a proper examination of foot and footwear (which should include probing), (ii) meticulous diabetes control, (iii) prompt control of poly microbial infections, and (iv) surgical management by aggressive debridement. He said that good podiatry was the need of the time and the key to success. He also cautioned that diabetic foot wounds need to be irrigated and not merely cleaned. Prof Rama Kant is the Head of Surgery department at CSM Medical University (upgraded King George's Medical College - KGMC) and President of ASI, UP.

There are many barriers to foot care. But the biggest one is ignorance. Shortage of podiatrists in the country adds to the problem. Team work and care can reduce ulcer formation and amputation.
Intensive patient education regarding proper foot care is the need of the hour.

People with diabetes should make it a matter of habit to inspect their feet daily, and immediately report to the doctor at the slightest sign of an ulcer or callus. There are special mirrors available, to check for feet ulcers. Feet need to be washed, dried and lubricated (but not between toes) daily. Dry and cracked skin leads to ulcers. Barefoot walking is a big NO, even on clean and smooth floors. Temperature extremes are to be avoided. There was an example of a patient who came very near to amputation just because he enjoyed a steam/sauna bath in a 5star hotel.

A whopping 41 million Indians (14% of urban people and 3% of villagers) are at risk of diabetic foot. So it is important to discuss the role of preventive and therapeutic foot wear. Such footwear is required to (i) prevent amputation, (ii) protect the skin from external trauma, and (iii) protect the insensitive foot from plantar pressure.

Optimal and comfortable footwear (which does not include the popular Hawaii chappals), should be worn at all times. Neuropathic shoes, having shear- reducing and/or rocker soles are now available in the market. Evenings are the best time to buy shoes, as the feet are swelled to the maximum then. Shoes of black colour, or with pointed toes, or slip-ons should be avoided. Care of socks is equally important. It is best to buy cotton socks which are white in colour, so that any bleeding ulcer can be detected immediately. These days, cheap, seamless and silver impregnated socks are available. These are ideal for people with diabetes. Else, wear the normal cotton socks turned inside out.

Dr Sanjay Kala, Associate Professor at GSVM Medical College Kanpur, was rightly of the opinion that amputation is not the answer. We have to preserve the foot. This can be achieved by a comprehensive team approach of multispecialty experts including vascular surgeons, pedorthotists, plastic surgeons, podiatrists, psychologists, nurse educators and expert dressers working together, with the cooperation of the patient. Only then can the present number of over 80,000 diabetes related amputations done annually in India, be brought down substantially.

In the words of Dr Jean Claude Mbanya, President of the International Diabetes Federation (IDF), “With relatively low investment, it is possible to advance education and prevention that will result in lower rates of amputation, and better quality of life for people with diabetes. The time to act is now!"

Shobha Shukla
(The author is the Editor of Citizen News Service(CNS), has worked earlier with State Planning Institute, UP, and teaches Physics at India's prestigious Loreto Convent. Email: shobha@citizen-news.org, website: www.citizen-news.org)

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