Frequency of foot ulcers in people with type 2 diabetes, presenting to specialist diabetes clinic at a Tertiary Care Hospital, Lahore, Pakistan

Diabetes mellitus is one of the most prevalent endocrinopathies associated with a number of complications. It is now reaching epidemic proportions in the world, according to the International Diabetes Federation (IDF) 2017 estimates, 425 million people in the world has diabetes and is expected to increase to 629 million in the year 2045. According to the IDF 6.94% of the population of the Pakistan has diabetes and by the year 2045 it is likely to increase to 8.45% [1].

In people with diabetes, lower limb complications are becoming a major public health concern and the incidence is increasing both in developed and developing countries of the world [2, 3]. Foot ulcers are a serious limb-threatening complication of diabetes mellitus [4]. Diabetic foot ulcer (DFU) is defined as the presence of full-thickness lesion distal to the ankle [5]. The global prevalence of DFU was 6.3% and it was more common in people with type 2 diabetes [6] Microvascular and macrovascular complications, peripheral neuropathy, and duration of diabetes mellitus, high levels of HbA1C and trauma are considered as factors contributing to the risk of foot ulcer [7]. In people with diabetes, peripheral neuropathy (PN) results in loss of perception of pain and propioception by the patient, repeated trauma to the foot may not be perceived by the patient and may give rise to symptoms which include formation of callus on weight bearing areas which can lead to development of ulcers [8]. Neuropathic ulcers are the most common type of ulcers resulting from tissue-damage due to mechanical weight applied to a foot with loss of propioception, touch, vibration, and pressure and pain sensation [9].

One of the known macrovascular complications of diabetes mellitus is damage to blood vessels resulting in peripheral arterial disease (PAD). There is high prevalence of PAD in diabetics which can predispose to the formation foot ulcers [10]. Poor control of blood glucose level impairs the cross linking of collagen and functioning of matrix metalloproteinase which adversely affects wound healing [9]. Hyperglycemia also results in poor functioning of polymorph nuclear leukocytes, which predisposes to onychomycosis and toe-web infections, and ultimately results in damage to the skin [11]. Diabetic foot lesions now considered to be the most common cause of hospital admission and lower limb amputation than any other complication of diabetes, screening all patients with diabetes is of immense importance to identify the subjects at risk for developing foot ulcers [12, 13]. There are ethnic differences in the risk of foot ulcer, as South Asians and African-Caribbean have low foot ulcer risk to that of Europeans [14]. In Pakistan 11.77% of the population had type 2 diabetes mellitus [15], as the number of people with diabetes mellitus is increasing, it is likely to increase the burden of diabetic foot disease in Pakistan. The objective of the current study was to determine the prevalence of foot ulcer in diabetics presenting to specialist diabetes clinic at a tertiary care hospital and its association with age, gender, BMI, duration of diabetes, PN, PAD and control of blood sugar level.

In the present study 13.4% of the diabetics, presenting to specialist diabetes tertiary clinic were less than 40 years of age. This shows that type 2 diabetes is now occurring at a younger age in Asian population. The frequency of females presented to diabetic clinic was more as compared to males in the present study; however a study carried out in same region has reported the prevalence of 11.20% in males and 9.91% in females with diabetes [15]. Significant number of subjects (89%) developed foot ulcers after 45 years of age and 11% of the subjects developed ulcers of the of foot ulcer at a much younger age, this is further enhanced by the significant association of foot ulcer with age, which is consistent with previous data [22].

Mean age of male and females with type 2 diabetes was 53 and 49 years respectively. The present data signifies that females are at risk of developing diabetes at an earlier age as compared to males. PAD and PN are the complications of diabetes predisposing to foot ulcers, 6.68% of the subjects were found to have PAD, and 26% were identified with PN. The PN was a major factor contributing to the risk for foot ulcers in diabetics; this result is consistent with the previous reports emphasizing the importance of PN in foot [23, 24].

Diabetic foot disease is largely preventable; however it is still a significant cause of hospitalization in people suffering from diabetes mellitus. The prevalence of DFU in the present study was 7.02%, in contrast to this previous studies in which the prevalence was less [6, 14, 25]. According to the present data, 61% of the subjects had ulcers on the planter surface, 31% on the dorsal surface of the foot, 75% of the subjects with DFU had more than 6 years of diabetes in present study; the significant association of foot ulcer with duration of diabetes is in accordance with previous data. In contrast to this it has been reported the risk of foot ulceration is not related to duration of diabetes [26]. The current study reported no association of foot ulcer with gender, which is in accordance with previous studies, [27, 28] in contrast to this few studies have reported males are at more risk of foot disease [29, 30] Data is available suggesting that screening all patients with diabetes is of great importance, to recognize those at risk for developing foot ulceration [31]. Heath education of patients, self examination of feet and optimum control of blood glucose is important for prevention of foot ulcers [32]. In depth knowledge and communication among physicians is vital for preventing the serious limb threatening complications of diabetic foot disease. [33].

As the number of people with diabetes is increasing in Pakistan [1], it is likely to increase the burden of diabetic foot disease in this population. Greater part of the world is severely lacking in foot care specialists and centers, Pakistan is also amongst countries where few foot care services are available. Patient’s education regarding self examination of foot, and identifying the diabetics at increased risk of developing foot ulcers, not only at specialist centers but also training the family physician to carry out routine foot examination will be the most valuable approach to prevent the progression to limb amputation. Proper assessment of the DFU and appropriate management ensure better prognosis.

Prevalence of foot ulcer in people with type 2 diabetes presenting to specialist diabetes clinic at a tertiary care hospital is 7.02% in the current study. Peripheral neuropathy, peripheral arterial disease, female sex, increasing age, increase in duration of diabetes and high levels of HbA1C increases foot ulcer risk in diabetics. An optimum control of blood glucose, proper feet examination of every person with diabetes and management of associated risk factors may go a long way in preventing foot ulceration. It will reduce hospital admissions and lower limb amputations.