Improve Diabetic Foot Care in Arab World, Slash Amputations

This from Medscape and Lisa Nainggolan
It features Monira Al Arouj from the Dasman Institute, Kuwait. 

DOHA, Qatar — The provision of foot care to diabetic patients in the Middle East and North Africa (MENA) is generally nonexistent or woeful at best, according to a talk by one expert here at the recent Excellence in Diabetes 2014 meeting.
However, there are some notable exceptions, and countries in the region need to learn from these good local examples, Monira Al Arouj, MD, from the Dasman Diabetes Institute, Kuwait, told the conference.
“Every 30 seconds a leg is lost due to diabetes somewhere in the world,” adding up to more than 1 million amputations performed annually, with over 70% of leg amputations due to diabetes, she noted. But “up to 85% of amputations can be avoided” with proper care, she emphasized.
Together with colleagues, Dr. Al Arouj set up the first diabetic foot clinic in Kuwait and has since helped get another 5 clinics up and running there.
She explained that diabetic foot disease is a leading cause of hospital admission, and most amputations begin with a foot ulcer. One in 6 people with diabetes will get a diabetic foot ulcer, and diabetic foot disease is the most serious, common, and costly complication of diabetes.
Thus, many countries in the world, both in the MENA region and elsewhere, can learn from the successful existing programs that are ongoing in several nations, she emphasized.
Barriers to Inadequate Care: Podiatry Services Lacking
Dr. Monira Al Arouj
Dr. Al Arouj began by outlining a number of risk factors for diabetic foot complications that are particularly relevant to the Arab world. These include hot, dry weather, which means sandals are a common choice of footwear or people frequently chose to go barefoot, out of habit or necessity.
“This leaves the foot open to trauma,” she observed.
Islam is the dominant religion in most countries in the region, and while people do wash their feet for prayer 5 times a day, “leading to regular foot inspection, people often neglect to dry their feet properly, and this can lead to infection.”
There is also a high prevalence of illiteracy as well as poor health education in general and a reliance on traditional medicine, which, together with the fact that podiatry services are often nonexistent, does not bode well, she noted.
Indeed, the lack of any comprehensive podiatry service in most countries is a major barrier to care, she noted, adding that only 19 countries worldwide actually have licensed schools of podiatry. And podiatrists are currently working in only around 35 countries in the world, “suggesting approximately 180 nations are without podiatry services.”
Related, and also playing a role, is a lack of orthotics and suitable shoes, as well as the low awareness of the problem of diabetic foot disease among healthcare professionals and the absence of a multidisciplinary-team approach, Dr. Al Arouj explained.
And compounding the problem further is poor reporting of diabetic foot ulcers and amputations, with few national registries for diabetes-related amputation, making it difficult to obtain reliable figures on the extent of the problem in the MENA region, she lamented.
Hope on the Horizon? Pakistan Sets the Course
MENA covers 20 countries, from Morocco and Algeria in the west to Pakistan in the east, and includes wealthy oil- and gas-rich Middle Eastern nations such as Qatar and Saudi Arabia, as well as poorer African countries such as Sudan.
“Unfortunately, foot care is insufficient in many of these countries. We don’t have formal training for podiatry or suitable shoes or orthotics, and the concept of the multidisciplinary team doesn’t exist.”
However, there is hope, Dr. Al Arouj told the meeting, as she proceeded to describe a number of success stories from the MENA region, whereby foot care in diabetes has improved considerably. These include Pakistan and Egypt, which have become involved in a global initiative from the International Diabetes Federation (IDF) and the World Diabetic Foundation (WDF), called the Step-by-Step program. And in Kuwait, Oman, Qatar, Saudi Arabia, and the United Arab Emirates there are also good local initiatives, she noted.
In Pakistan, for instance — where 7.1 million people have diabetes and almost half a million have a diabetic foot ulcer — the National Diabetes and Diabetic Foot Program was established in 2007. It focused on improving awareness and early identification of diabetic foot problems.
There were 178 foot-care teams (doctors and paramedics) trained, and 101 foot-care assistants graduated from a foot-care training course. Low-cost off-loading devices such as the “healing sandal” were developed, and 115 diabetes foot-care clinics have been established across the country. Meanwhile, 408 doctors have been trained in continuing medical education (CME) for diabetic foot.
Pakistan has also established a 1-year diploma in diabetology (78 doctors trained) and a diploma in diabetes education (83 educators trained), as well as public-awareness programs, Dr. Al Arouj said.
“Their results are excellent, and they have reduced their amputations by 75% in tertiary centers and by 50% nationwide,” she noted.
Dr. Al Arouj went on to describe similar projects in Mansoura and Alexandria in Egypt; at the Diabetic Foot and Wound Clinic at Hamad General Hospital, in Doha, Qatar; and in Riyadh and Mecca in Saudi Arabia.
And initiatives in the early stages of development include one at the National Diabetes and Endocrine Center in Oman and at the Dubai Diabetes Center in the United Arab Emirates.
Kuwait Experience: Amputations Cut by More Than 50%
Finally, Dr. Al Arouj recounted her own experience in Kuwait, which grew from a retrospective analysis of 86 diabetic patients admitted with foot ulcers in 1989.
“We found a very high amputation rate of 55% and prolonged hospital stays of 66 days,” she recalled. “This prompted us to start our first diabetes foot clinic in our hospital, and we formulated a team of educators, nurses, a surgeon, and a physician.” At that time, they did not have a podiatrist, although one was later appointed, she noted.
The surgeon trained the doctor and nurses in foot care, such as debridement, “to take the place of the podiatrist.”
The results of the first 5 years, from 1995 to 1999, were “encouraging,” she explained. “We saw 874 patients because we were the only foot clinic in the country, so they came to us from everywhere. The amputation rate was reduced by more than 50%, from 22% in 1995 to 8.9% in 1999.”
“This encouraged us to take the results to [the Ministry of Health], and we convinced the policymakers that we have to start a foot clinic in each of our 5 general hospitals.” Each of these sent a doctor and 2 nurses to the Dasman Diabetes Clinic for 3 months to be trained by the podiatrist who had been employed there, “and then they went back to start their own clinics.”
And now, in Dasman Diabetes Clinic, “there are 2 fully registered podiatrists and 5 registered nurses who were trained to do the job of a podiatrist,” she explained.
“We have 3 treatment rooms, 1 specialized room with negative pressure and an air extraction system, and 1 isolation room with negative pressure for infectious diseases.” The clinic also has a vascular lab and ultrasound, computed tomography, and MR imaging. “We are also in the process of developing a computerized in-shoe dynamic-pressure measuring system, a computerized automatic orthotic-making machine for construction of long-term orthotic offloading shoe devices, and a hyperbaric oxygen chamber,” Dr. Al Arouj said.
From June 2008 to June 2013, she and her colleagues had seen 1310 patients referred from primary healthcare or other foot clinics. Of these, 45% came with an ulcer, but “35% of patients were referred just for being ‘high risk,’ which reflects the [new] awareness of diabetic foot by healthcare providers in our country,” she observed.
Nevertheless, she said there is still a great need for preventive programs to be implemented, and more research from the MENA region is needed.
“Diabetes foot care in the MENA nations is still suboptimal, and although we have some good initiatives — and the help and support given by the IDF and WDF is good — we need to implement this in more and more countries,” she concluded.

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