Author:
Dr Yousef abdullah Al Turki
Associate Professor and Consultant Family Medicine
Department of Family and Community Medicine
King Khalid University Hospital
College of Medicine
King Saud University
P.O Box 28054 Riyadh 11437
Saudi Arabia
Telephone :096614671942
Fax: 096614671967
Email: yalturki@ksu.edu.sa

ABSTRACT

Objectives: To estimate the prevalence of diabetic foot among diabetic patients attending a primary care clinic at a teaching hospital, Riyadh, Saudi Arabia.

Method: A cross sectional study was conducted during the period from June 2009 till January 2010 in a primary care clinic at King Khalid University hospital, Riyadh, Saudi Arabia. All diabetic patients attending a primary care clinic were interviewed and examined by a consultant family physician who filled the data collection form containing clinical aspects about patients' foot care and diabetic control. Relevant laboratory results were taken from patients` files. The following aspects have been determined as follows: age of patients, type of diabetes, type of treatment, duration of diabetes, does the patient have diabetic foot now, does he/she have previous amputated foot or partial amputation, does the patient care for his/her feet regularly at home, does he/she use suitable shoes, does he/she use moisturising cream for his/her foot, does the patient follow blood sugar levels at home gluco meter regularly, is the patient followed with regularly by their his physician , does the patient follow medical instruction and comply with medication regularly. Recent HBA1C and Fasting blood sugar has been recorded from the patients' files. All data was entered into the computer using Statistical Package for Social Science version 15 and statistical analysis has been done, with P value considered to be significant when it is more than 0.05%.

Results :The study showed that the prevalence of diabetic foot among 224 diabetic patients attending a primary care clinic, was 6.2%, and 1.3% of diabetic patients had amputated foot. About half of the diabetic patients were 60 years and above. Most of the patients (69.7%) were on oral hypoglycemic agents, and 28.1% were on insulin. Only 31.7% had HBA1C less than 7, 33% followed their blood sugar levels regularly at home by gluco meter, and only 30.8% of diabetic patients examined their feet regularly at home.

Conclusions and recommendations: The prevalence of diabetic foot is common among diabetic patients attending a primary care clinic, which emphasized the importance of improving the quality of diabetic care especially in the elderly, to reduce diabetic foot complications, and to reduce the burden of amputation on elderly patient life, family, community, and health services. More research would be helpful regarding prevention and early management of diabetic foot in the elderly, in a primary care setting in Saudi Arabia.

Key words: Diabetic foot, elderly, primary care.

INTRODUCTION

Diabetes is reaching epidemic proportions and with it carries the risk of complications. Disease of the foot is among one of the most feared complications of diabetes especially among elderly patients. The ultimate endpoint of diabetic foot disease is amputation, which is associated with significant morbidity and mortality, besides having immense social, psychological and financial consequences(1). Almost half of diabetes-related hospital admissions are for lower limb disease, which emphasizes the need to be aware of potential problems and offer appropriate and reinforced patient education (2). Almost 50% of patients with diabetic foot syndrome undergo major or minor amputation especially in the elderly age group (3,4). Foot complications are considered one of the most expensive diabetes complications to treat (5). One study indicates that considerable differences exist between diabetic foot patients from western communities and developing countries when developing programmes for treatment and prevention of diabetic foot complications in developing countries need to be considered (6). The prevalence of concomitant complications of diabetes is high among Saudis, as one study reflects that diabetes and its complications have progressed in Saudi Arabia. Not only has the prevalence rate of each complication risen, but multiple complications were also frequent (7). Another study in Saudi Arabia showed that diabetes control at primary care level is poor in spite of significant resource allocation (8). The aims of this study were to estimate the prevalence of diabetic foot among diabetic patients attending a primary care clinic at a teaching hospital, in Riyadh, Saudi Arabia.

METHOD

A cross sectional study was conducted during the period from June 2009 till January 2010 in a primary care clinic at King Khalid University hospital, Riyadh, Saudi Arabia.

All diabetic patients attending a primary care clinic were interviewed and examined by a consultant family physician who filled the data collection form containing clinical aspects about the patients' foot care and diabetic control. Relevant laboratory result was taken from patients` files.

The following aspects have been determined as follows: age of patients, type of diabetes, type of treatment, duration of diabetes, does the patient have diabetic foot now, does the patient have previously amputated foot or partial amputation, does the patient care for his feet regularly at home, does the patient use suitable shoes, does the patient use moisturising cream for his/her feet, does the patient follow blood sugar levels at home by gluco meter regularly, is the patient followed up by his/her physician regularly, does the patient follow medical instruction and take medication regularly. Recent HBA1C and Fasting blood sugar has been recorded from the patients' files. All data was entered into the computer using Statistical Package for Social Science version15, and statistical analysis has been done, with P value considered to be significant when it is more than 0.05%.

DISCUSSION

Diabetes is one of the growing health problems in the elderly population in the world and in the Middle East region in general and Saudi Arabia in particular (9-13).

The present study highlighted that diabetic foot is still a common health problem which affects the patient's quality of life, especially after amputation. The prevalence of diabetic foot among attending diabetic patients in this study was 6.2%. Other studies showed that the prevalence ranges from 4% to 10% in different countries (14-19).

The social and economic burden of diabetic foot in the elderly can be reduced through early diagnosis and treatment (20--24).

Regular foot examination by patients might help to detect early wounds, but in this study only 30.8% of attending diabetic patients do regular checkup and foot examination by themselves. Effective and good diabetic education has long been acknowledged as essential in the maintenance of good glycemic control and prevention of diabetic complications. It is widely accepted as the cornerstone of successful diabetes management and as the best prescription for diabetes(25,26). In the current study only 31.7% of diabetic patients had HBA1C less than 7. In the ADVANCE trial, an intensive glucose- control strategy, lowered the average glycated hemoglobin value to 6.5% in a broad range of patients with Type 2 diabetes and reduced the incidence of the combined primary outcome of major macro vascular and micro vascular events (27). Most of the diabetic patients in this study (75.9%) were followed up regularly by their primary care physician. A Quality Improvement intervention for diabetic patients based in community health centers is particularly relevant today because of the substantial growth in both the number of sites and numbers of patients served over the past decade. One study showed that participating in collaboration with community health centers improved the processes of care related to prevention, screening, disease monitoring and treatment for diabetes(28). Improving doctor- patient relationships with diabetic patients especially the elderly, is important for effective communication and to facilitate patient's education especially regarding the prevention of diabetic foot. Patients who are satisfied with their care are more likely to be self-confident, motivated, practice healthy behaviors and follow medical advice (29).

In conclusion, the prevalence of diabetic foot is common among diabetic patients attending a primary care clinic, which emphasizes the importance of improving the quality of diabetic care, especially in elderly patients, to reduce diabetic foot complications and to reduce the burden of amputation on elderly patient life, family, community, and health services. More research would be helpful regarding prevention and early management of diabetic foot in elderly patients in the primary care setting.

REFERENCES

1. Khanolkar M, Brain S, Stephens W. The diabetic foot. QJM 2008;101(9):685-695.
2- Marilyn E. Risk reduction and care for the diabetic foot. Practice nurse
2008;36(4):21-26.
3- Samann A, Tajiyeva O, Muller N, Tschavner T, Hoyer H, Wolf G, etal. Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross sectional study. Diabetic Medicine 2008;25(5):557-563.
4- Jennifer M, Gayle R, Robert N, Tom G. Do foot examinations reduce the risk of Diabetic amputation? Journal of Family Practice 2000;49(6):499-504.
5- Maskari F, El-Sadig M. Prevalence of risk factors for diabetic foot complications. BMC Family Practice 2007;8:59-68.
6- Morbach S, Lutalet K, Viswanathan J, Mollenberg J, Ochs H, Rajashekar S, etal. Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabetic Medicine 2004;21(1):91-95.
7- Al Wakel J, Sulimani R, Al-Asaad H, Al-Harbi A, Tarif N, Al-Suwaida A, etal. Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution. Ann Saudi Med 2008;28(4):260-266.
8-Al- Hussein F. Diabetes control in a primary care setting: a retrospective study of 651 patients. Ann Saudi Med 2008;28(4):267-271
9- Ahmed A. Review on the prevalence of Diabetic Foot and its Risk Factors in Saudi Arabia. Middle East Journal of Family Medicine 2009;7(6): 29-34
10- Steinbrook R. Facing the Diabetes Epidemic- mandatory reporting of Glycosylated hemoglobin value in New York city. N Engl J Med 2006;354:545-548
11- Hossain P, Kawar B, El Nahas M. Obesity and Diabetes in the Developing World- A Growing Challenge. N Engl J Med 2007;356:213-215
12- Chang J, Malik V, Jia W, Kadowaki T, Yajnik C, Hoyoor K, etal. Diabetes in Asia, Epidemilology, Risk factors, and pathophysiology. JAMA 2009;301(20):2129-2140
13- Mokdad A, Ford E, Bowman B, Dietz W,Vinicor F, Bales V, etal. Prevalence of obesity, Diabeters, and obesity related health risk factors. JAMA 2003;289:76-79
14- Beckman J, Creager M, Libby P. Diabetes and Atherosclerosis, Epidemiology, Pathophysiology, and management. JAMA 2002;287:2570-2581
15- Karter A, Ferrara A, Liu J, Moffet H, Ackerson L, Selby j. Ethnic disparities in diabetic complications. JAMA 2002;287:2519-2527
16- Singh N, Armstrong D, Lipsky B. Preventing Foot ulcers in patients with Diabetes. JAMA 2005;293:217-228
17-Malgrange D, Richard J, Leymarie F. Screening Diabetic patients at risk for foot ulceration. Amulti- centre hospital based study in France. Diabetes and Metabolism 2003;29(3):261-268
18- Desonnaville J, Colly L, Wijkel D, Heine R. The Prevalence and determinant of foot ulceration in type 2 diabetic patients in a primary health care setting. Diabetes Research and Clinical Practice 1997;35(2):149-156
19-Ribe L, Rustoen T, Bir;elard R, Honestard R, Paul S, Miaskowski C. The Prevalence and occurrence of diabetic foot ulcer pain and its impact on health related quality of life. The Journal of Pain 2006;7(4):290-299
20- Armstrong D, Lavery L. Diabetic foot ulcers: Prevention, diagnosis and classification. American family Physician 1998;57(6):1325-1336
21- Game F. Management of osteomyelitis of the foot in diabetes mellitus. Nature Review Endocrinology 2010;6:43-47
22- Al Fadda A, Bin Abdulrahman K. Assessment of care for type 2 Diabetic Patients at the primary care clinics of a referral hospital. Journal of family and Community Medicine 2006;13(1):13-17
23- Embil L, Trepman E. A case of diabetic charcot arthropathy of the foot and ankle. Nature Review Endocrinology 2009;5:577-581
24- Sawacha Z, Cristoferi G, Guarneri G, Corazca S, Dona G, Denti P, etal. Characterizing multi segment foot kinematics during gait in diabetic foot patients. Journal of Neuro Engineering and Rehabilitation 2009;6:37-48
25- Khaldi Y, Khan M. Audit of a diabetic health education program at a large primary health care center in Asir region. Saudi Med J 2000;21(9):838-842.
26- Tuomilehto J, Lindstrom J, Erikson J,Valle T, Hanelainen H, Parikka P, etal. Prevention of Type 2 Diabetes Mellitus by changes in lifestyles among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-1350
27- The Advance Collabratiove Group. Intensive Blood Glucose Control and Vascular outcomes in patients with Type 2 Diabetes. N Engl J Med 2008;358:2560-2572
28- Landon B, Hicks L, Malley j, Lieu T, Keagan T, Mcneil B, etal. Improving the management of chronic disease at community health centers. N Engl J Med 2007;356:921-934
29- Conboy L, Macklin E, Kelley J, Kokkotou J, Lembo A, Kaptchuk T. Which patients improve: Characteristics increasing sensitivity to a supportive Patient- Practitioner relationship. Social Science and Medicine 2010;70(3):479-484
Khanolkar M, Brain S, Stephens W. The diabetic foot. QJM 2008;101(9):685-695.
2- Marilyn E. Risk reduction and care for the diabetic foot. Practice nurse
2008;36(4):21-26.
3- Samann A, Tajiyeva O, Muller N, Tschavner T, Hoyer H, Wolf G, etal. Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross sectional study. Diabetic Medicine 2008;25(5):557-563.
4- Jennifer M, Gayle R, Robert N, Tom G. Do foot examinations reduce the risk of Diabetic amputation? Journal of Family Practice 2000;49(6):499-504.
5- Maskari F, El-Sadig M. Prevalence of risk factors for diabetic foot complications. BMC Family Practice 2007;8:59-68.
6- Morbach S, Lutalet K, Viswanathan J, Mollenberg J, Ochs H, Rajashekar S, etal. Regional differences in risk factors and clinical presentation of diabetic foot lesions. Diabetic Medicine 2004;21(1):91-95.
7- Al Wakel J, Sulimani R, Al-Asaad H, Al-Harbi A, Tarif N, Al-Suwaida A, etal. Diabetes complications in 1952 type 2 diabetes mellitus patients managed in a single institution. Ann Saudi Med 2008;28(4):260-266.
8-Al- Hussein F. Diabetes control in a primary care setting: a retrospective study of 651 patients. Ann Saudi Med 2008;28(4):267-271
9- Ahmed A. Review on the prevalence of Diabetic Foot and its Risk Factors in Saudi Arabia. Middle East Journal of Family Medicine 2009;7(6): 29-34
10- Steinbrook R. Facing the Diabetes Epidemic- mandatory reporting of Glycosylated hemoglobin value in New York city. N Engl J Med 2006;354:545-548
11- Hossain P, Kawar B, El Nahas M. Obesity and Diabetes in the Developing World- A Growing Challenge. N Engl J Med 2007;356:213-215
12- Chang J, Malik V, Jia W, Kadowaki T, Yajnik C, Hoyoor K, etal. Diabetes in Asia, Epidemilology, Risk factors, and pathophysiology. JAMA 2009;301(20):2129-2140
13- Mokdad A, Ford E, Bowman B, Dietz W,Vinicor F, Bales V, etal. Prevalence of obesity, Diabeters, and obesity related health risk factors. JAMA 2003;289:76-79
14- Beckman J, Creager M, Libby P. Diabetes and Atherosclerosis, Epidemiology, Pathophysiology, and management. JAMA 2002;287:2570-2581
15- Karter A, Ferrara A, Liu J, Moffet H, Ackerson L, Selby j. Ethnic disparities in diabetic complications. JAMA 2002;287:2519-2527
16- Singh N, Armstrong D, Lipsky B. Preventing Foot ulcers in patients with Diabetes. JAMA 2005;293:217-228
17-Malgrange D, Richard J, Leymarie F. Screening Diabetic patients at risk for foot ulceration. Amulti- centre hospital based study in France. Diabetes and Metabolism 2003;29(3):261-268
18- Desonnaville J, Colly L, Wijkel D, Heine R. The Prevalence and determinant of foot ulceration in type 2 diabetic patients in a primary health care setting. Diabetes Research and Clinical Practice 1997;35(2):149-156
19-Ribe L, Rustoen T, Bir;elard R, Honestard R, Paul S, Miaskowski C. The Prevalence and occurrence of diabetic foot ulcer pain and its impact on health related quality of life. The Journal of Pain 2006;7(4):290-299
20- Armstrong D, Lavery L. Diabetic foot ulcers: Prevention, diagnosis and classification. American family Physician 1998;57(6):1325-1336
21- Game F. Management of osteomyelitis of the foot in diabetes mellitus. Nature Review Endocrinology 2010;6:43-47
22- Al Fadda A, Bin Abdulrahman K. Assessment of care for type 2 Diabetic Patients at the primary care clinics of a referral hospital. Journal of family and Community Medicine 2006;13(1):13-17
23- Embil L, Trepman E. A case of diabetic charcot arthropathy of the foot and ankle. Nature Review Endocrinology 2009;5:577-581
24- Sawacha Z, Cristoferi G, Guarneri G, Corazca S, Dona G, Denti P, etal. Characterizing multi segment foot kinematics during gait in diabetic foot patients. Journal of Neuro Engineering and Rehabilitation 2009;6:37-48
25- Khaldi Y, Khan M. Audit of a diabetic health education program at a large primary health care center in Asir region. Saudi Med J 2000;21(9):838-842.
26- Tuomilehto J, Lindstrom J, Erikson J,Valle T, Hanelainen H, Parikka P, etal. Prevention of Type 2 Diabetes Mellitus by changes in lifestyles among subjects with impaired glucose tolerance. N Engl J Med 2001;344:1343-1350
27- The Advance Collabratiove Group. Intensive Blood Glucose Control and Vascular outcomes in patients with Type 2 Diabetes. N Engl J Med 2008;358:2560-2572
28- Landon B, Hicks L, Malley j, Lieu T, Keagan T, Mcneil B, etal. Improving the management of chronic disease at community health centers. N Engl J Med 2007;356:921-934
29- Conboy L, Macklin E, Kelley J, Kokkotou J, Lembo A, Kaptchuk T. Which patients improve: Characteristics increasing sensitivity to a supportive Patient- Practitioner relationship. Social Science and Medicine 2010;70(3):479-484