Ignorance Is Not Bliss In Diabetes Treatment And Care

Today diabetes has overtaken HIV/AIDS, taking 3.2 million lives every year as compared to 3 million HIV related deaths. Together with other non-communicable diseases (NCD) it has replaced infectious diseases as the major cause of mortality in the world. India has the second highest incidence of diabetes in the world with over 47 million people in the country living with the disease, and the numbers are rising every day.  Apart from affecting the metabolism of the body, diabetes also affects the eyes, heart and kidneys, and causes severe foot problems resulting in an estimated 50,000 lower limb amputations every year, which is likely to increase to 100,000 amputations in the near future. Thus diabetes impacts not only the quantity, but also the quality of life.

The statistics is scary indeed. But what is the way out? It is one thing to pontificate and another to take simple action at preventive and curative stages. The best option obviously is to try to avoid the disease by avoiding processed /high fat foods and a sedentary lifestyle. But still the disease may creep upon one stealthily with no obvious external symptoms, and one may have it before one knows it. So, coupled with leading a healthy life style, it is also important to go for routine medical checkups, including the blood sugar test,— which, sadly, is not happening  even in the urban populace of India, forget about the rural areas where medical facilities and personnel  are woefully lacking, despite numerous welfare schemes of the government.

All said and done, if at any stage the disease is diagnosed then, neither the treating physician nor the patient should remain complacent towards this silent killer. The two main components of diabetes are blood vessel damage and nerve damage (neuropathy). Blockage of the blood vessels results in lack of blood supply. The first symptom of neuropathy is numbness in the feet and sensation block. Loss of protective sensation of pain is a major cause of creating what is called the ‘diabetic foot’.

So apart from diet/sugar control, one needs to take extra care of the feet. Any person, who has been living with diabetes for 5 years or more, should go for foot examination once every six months. Very often even the doctors may miss out on the initial symptoms of a tiny abrasion/wound in the feet which, if left untreated, develops into an ulcer. These ulcers act as portals for the entry for bacteria leading to serious infections, which, in the immuno-compromised diabetic patient, can result in amputations or even death. Frequent and thorough foot examinations on part of the doctor, as well as the patient are a must.

According to Dr Arun Bal, one of the legendary diabetic foot surgeons of India, associated with Raheja Hospital, Fortis Hospital and Hinduja Hospital, ‘Doctors are taught that every infection will have fever and every ulcer will have swelling. But this is absent in diabetic foot lesions which are like 'silent' icebergs—we see only a small part of them. They are often missed because the usual signs of infection are absent, and patients don't complain of pain. So, unless people living with diabetes take very good care of their feet, it is likely that they will end up with ulcers in their feet which can trigger the disease to take a completely different progression path and even become unmanageable.’

He aptly quotes JA Lindsay--"For one mistake made for not knowing, ten mistakes are made for not looking" and advises strongly that healthcare providers must properly examine patients’ feet at every visit.

Dr Miranpuri, a reconstructive foot surgeon from Detroit, argues for collaborative and comprehensive care of people with diabetic foot with the goal to save the limb. He emphasizes that, ‘Both doctors and patients need to be aware of the risk factors in diabetes and be trained to handle them. There is a need for some ancillary support (in the form of medical educators) in the hospitals to interact with the patients, as very often the physicians do not have enough time and patience with the patient.  This becomes all the more important in India where patients, very often, may be poor and uneducated and lack proper knowledge of the consequences of not following the doctors’ instructions. This is especially true of Indian women, who are programmed not to care for themselves, and hence tend to neglect themselves completely.’

Professor (Dr) Rama Kant, a noted surgeon and President-elect of Association of Surgeons of India (ASI), also feels that awareness should reach the masses through doctors. He laments that, ‘Primitive and modern methods co exist in India. As far as control and management of diabetic wound infection is concerned, there is not much difference between 19th and 21st century rural India. Infection control and meticulous examination of foot as well as footwear is very important. There have to be preventive societal programmes. People need to be aware to understand the earliest symptoms of ulceration and see a specialist. We need to innovate and try to save the patient’s heel, even if it looks ugly and bad.’

Dr Rajesh Kesavan, diabetic foot specialist from Chennai, rues that time is ticking fast. With a view to improve the existing situation he suggests that—“Diabetic foot problems and diabetic neuropathy should be made a compulsory part of medical curriculum; more medical professionals should be trained in quality wound care management; and research should be encouraged for developing cheaper and  better wound  care products and therapeutic footwear.”

So, cost effective methods, coupled with doctor’s ability to diagnose correctly and timely, is the need of the hour. At present patients are ignorant and indulge in negative socio cultural practices—like walking barefoot, wearing foot jewellery (especially toe rings), wearing Hawaii slippers, which, though  popular in India, are very harmful. Sometimes even doctors and surgeons are not aware of diabetic foot problems themselves, and may not even do routine examination of the foot, in a proper way. It should be remembered that ‘many wounds look innocuous but may not be inert. So, all wounds need to be probed.’

There is also a need for patients and general public to know about the importance of correct footwear. Faulty footwear and/or walking bare foot, which is so very common in India, are an invitation to infected ulcers and eventually amputation. According to Dr David Nielson of USA, a patient should be well aware of the consequences of non compliance of doctors’ suggestions. This is especially true in patients who have to wear a diabetic shoe, which should not be taken off at any time of walking, even for a small distance. Very often patients do not realize the seriousness of this instruction and tend to under comply. This prolongs the treatment without yielding purposeful results.

Experts also stress upon counselling by trained personnel. Depression therapy is a must, so that the patient not only learns to manage diabetes but also feel happy with life in general.

Let us hope that everything will be fine one day. To think that everything is fine today is an illusion.

Shobha Shukla - CNS
(The author is the Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP. Email: shobha@citizen-news.org, website: http://www.citizen-news.org)

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