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Open Space

Diabetes wake-up call after years of neglect in Asia

Bobby Ramakant

Diabetes mellitus is emerging as a major health problem in Asian countries with world's highest number of people with diabetes living in the region. This warning came from International Awardee (2005) of World Health Organization (WHO) Prof (Dr) Rama Kant, who was delivering a guest lecture on 'newer horizons in management of diabetic foot' at McCormick Hospital in Chiang Mai, Thailand.

Countries like India have an estimated 34 to 35 million of people suffering from diabetes, which is the highest in the world. The prevalence of Diabetes in urban population is 17% and in rural it is 2.5%. This indicates impact of life style and nutritional habits. Among the chronic complications of diabetes, diabetic foot is the most devastating complication and is the leading cause of leg amputation among diabetics. It is estimated that in India alone about 50,000 legs are amputated every year, of which almost 75 percent are potentially preventable, said Professor (Dr) Rama Kant.

This problem is further compounded by the lack of awareness, practice of barefoot walking, home surgery, faulty footwear (slippers) and delay in reporting. The cost, both in terms of human health as well as economic burden of the foot ulcer treatment and complication is very high. In countries like Thailand or India, foot care is very critical as a significant majority of the population stays in rural areas. Therefore prevention of ulcer and its subsequent complications is of utmost importance, stressed Professor Kant.

Prof Rama Kant, who heads the Department of Surgery at King George's Medical University (KGMU) and has been the former Chief Medical Superintendent of Gandhi Memorial & Associated Hospitals, was recently elected as President of Lucknow College of Surgeons and medical university teachers' association. The noted Surgeon from India is here in Thailand interacting with Thai medical fraternity on improving healthcare responses to better control diseases like diabetes.

McCormick Hospital began in 1889 when Dr. McKean, the first long-term physician, arrived in the north of Thailand and started a dispensary and medicine building with 8 to 10 beds. Dr. McKean made his own smallpox vaccine and quinine pills for malaria and opened the Thailand's first facility for leprosy patients. Later with support from Dr. Cyruss McCormick of Chicago the Mc Cormick Hospital grew by 1925 providing healthcare with different speciality units. It is a modern general hospital with about 19,000 patient-admission per year, and approximately 40,000 outpatients benefitting annually. It is also affiliated with the Royal Family of Thailand as the present King's father, a physician, practiced in this hospital.

Back in 1864, a noted surgeon Marchal de Calvi had warned, but medical science took more than 100 years to accept, that "Having amputated one leg, often the opposite leg is affected, gangrene sets in and soon the patients succumb to the horrible suffering. Having relieved him of his local affliction (by amputation), I have done nothing but mutilate him." The need for efforts to reduce lower limb complications amongst people with diabetes is important, more so in Asian countries, where ignorance and barefoot walking plus other socio-economic practices lead to needless amputations. A diabetic foot patient suffers damage to nerves which make the feet numb and insensitive.' Lack of awareness, socio-cultural practices like bare-foot walking, delayed consultation of specialists due to ignorance and improper management are among the factors leading to amputations. If one leg was removed the chances were high for the other to get amputated within three years.

The findings of several studies reporting statistically significant protective effects from therapeutic footwear may have been influenced by several design issues. When considering the appropriateness of therapeutic footwear recommendations for moderate-risk patients, clinicians and patients should jointly explore individual strategies to decrease events that lead to foot ulcers.

All-cause mortality is high after an amputation in both diabetic and non-diabetic patients. Mortality rates, hospital stay, and postoperative complications are not different between diabetic and non-diabetic amputees. No modifiable factors, with the exception of nephropathy, were found to improve survival in amputees. Peripheral vascular disease and neuropathy are the main cause of amputations; prevention, therefore, of these complications is warranted to prevent amputations and the subsequent high mortality.

Recent trends are focusing on prevention by life style modifications, adequate control, multi-speciality treatments and aggressive debridements, open traditional and endovascular surgery, use of stents for improving circulation followed by free use of latest dressing techniques, use of different growth factors, off-loading of pressure points, use of modified shoes and also occasional use of boot therapy or modified boot therapy with a special equipments, said Professor Kant.

With use of the latest techniques incidence of major amputations has gone down drastically and only minor amputations are done at our centre.

(Bobby Ramakant is Asian Correspondent, writing on health and development issues since 1991 for Asian and African media. He can be contacted at: bobbyramakant@yahoo.com)

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