Amputations Linked to Diabetes

31 August 2005 (Last Updated August 31st, 2005 18:30)

The link between diabetes and foot problems (sometime requiring amputations) cannot be doubted. Professor Pierre Lefèbvre, president of the International Diabetes Federation, explains how healthcare strategies can help bring down the need for amputations.

Every year, the International Diabetes Federation (IDF) organises the World Diabetes Day (WDD) campaign in collaboration with the WHO. This global awareness campaign aims to inform the public of the causes, symptoms, complications and treatments associated with diabetes.

"Diabetes is the fourth or fifth leading cause of death in most developed countries."

WDD serves as an important reminder that the incidence and prevalence of diabetes is increasing all over the world, and that it creates significant human, social and economic costs. Yet, its frequency, cost and impact on quality of life is currently underestimated. Awareness at all levels of society is therefore the key to tackling the diabetes epidemic.

Each year, WDD is centred on a theme related to diabetes. Since 2001 particular attention has been paid to diabetes complications.

This year, IDF is raising awareness of the serious complications diabetes can cause the feet, a costly complication that is potentially preventable if the right strategies are in place to prevent or detect it.

THE BURDEN OF DIABETES

Diabetes is the fourth or fifth leading cause of death in most developed countries and each year, over three million deaths worldwide are attributable to diabetes-related causes.

IDF estimates that currently some 194 million people worldwide, or 5.1% of the adult population, have diabetes and that this figure will rise to 333 million by 2025 as a consequence of longer life expectancy, sedentary lifestyle and changing dietary patterns. This rise is likely to bring a proportional increase in the number of people with diabetes complications.

The general public is often unaware of the long-term damage to the body, particularly the failure of various organs and tissues that are associated with elevated levels of blood glucose. However, people with diabetes are two to four times more likely to develop cardiovascular disease than people without diabetes, and 25 times more likely to lose a leg than people without the condition. Somewhere in the world a leg is lost to diabetes every 30 seconds.

The incidence of blindness due to diabetic retinopathy is 25 times higher in people with diabetes than in the general population. Diabetes is the leading cause of kidney failure in the developed world, and accounts for approximately 35% to 40% of new cases of endstage renal disease each year.

Research estimates that up to 70% of all lower-limb amputations are related to diabetes. The goal of the WDD 2005 campaign is to convey and promote the message that it is possible to reduce amputation rates by up to 85% through prevention, the aggressive management of existing diabetes and the provision of appropriate education for people with diabetes and healthcare professionals.

"The incidence and prevalence of diabetes is increasing all over the world."

People with diabetes are at risk of neuropathy and problems with the blood supply to their feet (ischaemia). Nerve damage results in a reduced ability to feel pain and injuries often go unnoticed. Ischaemia can slow down any wound healing. Both neuropathy and ischaemia can lead to foot ulcers.

Infections in these wounds may ultimately result in amputation. A foot ulcer precedes over 85% of diabetes-related lower extremity amputations.

DIABETIC FOOT ULCERS ARE COMMON

In developed countries, up to 5% of people with diabetes have foot ulcers, and one in every six people with diabetes will develop an ulcer during their lifetime.

Ulcers can occur for a variety of reasons. The most common, besides neuropathy and ischaemia, are deformity of the foot (whether from birth, caused by unsuitable shoes or due to previous surgery), injuries (caused by pieces of grit in shoes, rough seams, sharp objects which have penetrated the sole of the shoe or burns) or infection. In people with diabetes, wound healing is often slow and the body's ability to fight infection may be weakened.

In developing countries, foot problems related to diabetes are thought to be even more common. Half of all leg amputations occur in people with diabetes. In some areas, where such factors as ethnicity, climate and social conditions increase risk, the number of amputations is proportionally higher in people with diabetes. In India, for example, 40,000 legs are amputated per year, most of them as a result of a foot infection in diabetes sufferers.

IDF figures estimate that the number of people with diabetes in the country will double in the next 25 years and that this is likely to bring a proportional increase in the number of ulcers and amputations if nothing is done.

THE HORRORS OF AMPUTATION

The impact of diabetic foot disease on people's lives is devastating. For most people who have lost a leg, life will never return to normal. Amputation may involve life-long dependence upon the help of others, inability to work and personal misery.

"People with diabetes are two to four times more likely to develop cardiovascular diseases."

The diabetic foot is also a significant economic problem. Foot problems are the most common cause of admission to hospital for people with diabetes. In developed countries, it is estimated that foot problems account for 12% to 15% of total healthcare resources. In developing countries, they may account for as much as 40% of the total resources.

The direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. The estimated cost for three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to be between $16,000 and $27,000.

The corresponding cost for someone who eventually needs an amputation ranges from $43,000 to $63,000 – mainly due to the increased need for home care and social services.

With relatively low investment the number of amputations can be significantly reduced. Aggressive management of the diabetic foot can prevent amputations in most cases. Even when amputation takes place, the remaining leg and the person's life can be saved by good follow-up care from a multidisciplinary foot team. Education of people with diabetes and healthcare providers is essential. Healthcare providers need to be trained in order to detect problems early and take appropriate action.

TREATING THE PROBLEM

There are many causes of diabetic foot ulcers and many different treatments are required. The aim here is not to describe them, as there are publications that do so in great detail.

Ideally, foot care should be provided by a multidisciplinary team. This should closely involve the person with diabetes and his or her family along with healthcare professionals from different disciplines. The ideal team would include a physician, a nurse, a specialist educator, a podiatrist, a surgeon, an orthotist (shoemaker) and an administrator. This strategy can help many ulcers to heal and allow many people with diabetic foot ulcers to walk again.

Multidisciplinary teams working in dedicated foot clinics have achieved great results, such as 49% to 85% decrease in amputations. They underline the need to provide funding and support to create new clinics along the same lines.

"One in every six people with diabetes will develop an ulcer during their lifetime."

However, these interventions are not available and affordable in every country. Local adaptation, therefore, will be needed to suit different situations and ensure that minimum standards are reached.

A few key conditions should be in place such as a process of diabetic foot screening, foot care education programmes for people with diabetes and healthcare providers, a diabetic foot emergency service, footwear service and good record keeping.

The global awareness activities of IDF will be successful if more people without diabetes become aware of the epidemic, and if people already living with diabetes receive the quality of care they deserve. IDF and WHO call on healthcare decision-makers and healthcare professionals everywhere to take the appropriate actions to ensure that both goals are achieved.