Diabetic foot is a major public health challenge in India: Dr Arun Bal

[Photo] [Audio podcasts] Although estimates of people with diabetes in India are getting updated on an ongoing basis, there are at least 47 million people with diabetes in India. "That means we have 94 million feet to look after" said Dr Arun Bal, founder-President of Diabetic Foot Society of India (DFSI) and one of the legendary diabetic foot surgeons in the country, associated with Raheja Hospital, Fortis Hospital and Hinduja Hospital, besides being a visiting Professor at Amrita Vishwa Vidyapeeth. "13.5 million feet will develop ulcers and 100,000 amputations will take place in India alone due to diabetic foot. Diabetic foot is a major public health problem in India" said Dr Bal.

Dr Arun Bal was a faculty at the Amrita Diabetic Foot Conference (ADFC 2011) which is being organized by Amrita Institute of Medical Sciences and Research Centre (AIMS) in Kochi, India (6-7 May 2011).

Why do people with diabetes develop foot problems? "There are three reasons: neuropathy, vasculopathy and injury" said Dr Arun Bal. "Out of these three reasons, at least injury is completely preventable if people with diabetes take adequate care" said Dr Bal.

Speaking on why diabetic foot lesions are often missed, Dr Bal said that often usual signs and symptoms of infection are absent, patients don't complain of pain, low levels of awareness exist at primary healthcare level and diabetic foot lesions are 'silent'. He said that unless people with diabetes take very good care of their feet it is likely that they will end up with ulcers in their feet which trigger the disease to take a completely different progression path and at times it becomes unmanageable.

Doctors are taught since generations that every infection will have fever, every ulcer will have swelling, and this is absent in diabetic foot patients. "You require a very high level of suspicion because diabetic foot lesions are like icebergs as we see only a small part" said Dr Bal.

Quoting JA Lindsay, Dr Bal said "For one mistake made for not knowing, ten mistakes are made for not looking – therefore healthcare providers must properly examine patients’ feet at every visit."

"Across South-East Asia there is an unwritten policy that no complaint, no examination. This needs to be changed because by the time patients of diabetic foot start complaining it is often too late" said Dr Arun Bal.

"Diabetic foot ulcer is a mechanical problem and no amount of antibiotics or dressings will heal the ulcer unless the pressure is reduced" said Dr Arun Bal.

90% loss of limb takes place due to a pressure injury. Dr Bal explained the biomechanics of a normal foot and said that heel strike is central, pronation is controlled by small muscles, contact time of 1st meta tarsal (MTP) is less, weight shifts from 1st MTP joint to other MTP joints, and supination of forefoot completes stance phase.

Human foot is made up of 26 bones and 29 joints but they don't rattle because of plantar fascia. Plantar fascia is important component as it gives stability to the foot in take off position. Also small muscle control reduces the sheer force, said Dr Bal.

However in patients with diabetic foot, the two feet alternate in pronation and supination heel strike phases, the contact time increases of 1st MTP joint, sheer force increases at 3rd MTP joint and supination at heel strike causes 5th MTP joint callus.

That is why we often see patients with diabetic foot wobbling if they try to walk fast because it is uncoordinated walk and lacks joint position sense, sensory input and poor muscle control. They often fall down because of this, said Dr Bal.

When peak plantar pressure goes up beyond 600 pascals, in non-diabetic people there is an instant recovery but in people with diabetes the recovery is delayed which causes inflammation, warmth and erythema, said Dr Bal.

"A simple preventive test is to ask the patients to feel with the back of their hand the 1st, 3rd and 5th MTP head, if they are warmer than the remaining MTPs, then it simply means that the patient is walking unlimited beyond the limit which her or his foot can bear" said Dr Bal.

Quoting Leonardo da Vinci, Dr Arun Bal said he described the human foot as a masterpiece of engineering and a work of art. "Foot is most energy efficient machine. This energy efficiency is lost in diabetes due to neuropathy" said Dr Bal.

"We need to diagnose neuropathy at a very early stage" said Dr Bal. "Often it is believed feet that sweats do not ulcerate. But in patients with diabetic foot, often neuropathy has progressed to such an extent that they don’t sweat, and do ulcerate" said Dr Bal.

Most of the diabetologists and physicians club the neuropathy as sensory-motor neuropathy – but these are different components and often don’t progress parallel. Sensory neuropathy causes inability to feel pressure, loss of position sense that causes change in walking patterns, while motor neuropathy causes deformity, hyperpronation, muscle imbalance and weakness, change in walking pattern, and causes the foot to remain in contact with the ground for a longer time,

Dr Bal said that 'impulse loading' is a product of pressure and ground contact time of the feet and is more relevant than only high pressure to manage diabetic foot. A classic example of this phenomenon is when diabetic foot patients are lying in our hospital beds, there is very low pressure on their feet but still they get blisters and eventually ulcers. The simplest preventive measure is to raise the foot of the patient by placing pillow. This is why majority of diabetic foot ulcers are in the 1st MTP region.

Another check healthcare providers can do is to check the extension of 1st MTP – normal is 15 degrees in standing position so if this gets reduced in subsequent clinic visits, that means there is limited joint mobility which is developing that will increase the pressure and might cause breakdown in the skin. Such patients need proper footwear to protect their feet.

Early detection of diabetes, high degree of foot-care and prompt referral to a diabetes care facility if the slightest signs are felt is a key to salvaging the limb.

Bobby Ramakant - CNS 

Published in: 
Citizen News Service (CNS), India/Thailand
Wikio News, UK
Elites TV News, California, USA
The States Times, Jammu & Kashmir 
CNS Diabetes Media Initiative, India