A World Of Difference In Diabetic Foot Care

Kshitij Shankhdhar, MBBS, Dip Diab

      Every 30 seconds, a lower limb is lost as a consequence of diabetes. Worldwide, more than a million amputations are performed each year as a consequence of diabetes. Up to 85 percent of all amputations in people with diabetes are preceded by foot ulcers.

      With approximately 42 million people with diabetes, India heads the list of 10 most affected nations in the world. Current estimates indicate that India shall continue to hold the same position even in 2025.

      Indeed, diabetes mellitus is proving to be a global epidemic with a major impact on developing countries in the world. The World Health Organization (WHO) predicts that approximately 80 percent of all new cases of diabetes are expected to occur in developing countries.

      Barefoot walking is a major factor that leads to diabetic foot lesions in developing countries. Seventy-five percent of the population in India lives in villages where barefoot walking is a common practice. More than 35 percent of the 1.3 billion population in India lives below poverty line. Poor people genuinely cannot afford to purchase good footwear and therefore walk barefoot in day-to-day life.

      Another reason for barefoot walking is the social factor. In Indian villages, the farmers work barefoot in the fields. In India, it is a custom to remove footwear while entering the premises of kitchen. Indian temple etiquette stipulates that one should take off shoes before entering the temple premises. The same applies to certain churches in India too. In the Muslim religion, there is a custom called “Aag ka matam” or walking on fire, which takes place during the Moharram celebration. Many people walk barefoot as penance to please the almighty.

      A lack of awareness also contributes to the problem. Given the large numbers of people walking barefoot, there are innumerable foot lesions. However, these lesions are often neglected by patients due to diabetic neuropathy. In 90 percent of foot ulcer cases in patients with diabetes, sensory neuropathy is part of the problem. Indeed, as J.A. Lindsay said, “For one mistake made for not knowing, ten mistakes are made for not looking.”

      In India, there is no institution that provides regular structured podiatric education. One can count the number of podiatrists on one hand. Most of them have acquired experience in podiatry by visiting reputed podiatric centers of the world and attending sessions on foot care during international conferences. Even among these podiatrists, most are surgeons or orthopedists who are more inclined to perform surgical procedures early and ignore preventive podiatry, which might save catastrophe in many cases.

      Ignorance and negligence go hand in hand since most physicians do not bother to undertake even clinical examination of the feet, which costs nothing and can do wonders in many cases. The combination of well organized diabetic foot care teams with a strong emphasis on good diabetes control and well informed self-care can lead to significant reductions in amputations. There is a strong evidence to indicate that optimal foot care is best delivered by a multidisciplinary team with a podiatrist as a lead member of the foot care team.

      Consider the following statistics. There are currently 24 million people in the United States who have diabetes whereas there are 42 million people in India who have the disease. Eight percent of the worldwide diabetes population live in the U.S. yet the U.S. spends more than 50 percent of all global expenditures for diabetes care. On the other hand, only 10 percent of the 1.3 billion population in India have medical insurance coverage and more than 80 million people in India go to bed hungry.

      In the U.S., there are currently nine schools of podiatric medicine (with a 10th school starting classes in the fall of 2009) and reportedly over 13,000 podiatrists offer foot care services. In India, we do not even have a single practicing DPM.

      These figures reflect how fortunate the U.S. population is when it comes to the availability of podiatric medical services and the opportunity for podiatry.

      Dr. Shankhdhar is a diabetologist. He established the first diabetic foot clinic of North India at the Lucknow Diabetic Foot Care Clinic and Research Centre in Lucknow, India. Dr. Shankhdar has presented his work in the field of diabetic foot care at a variety of international conferences including the American Diabetes Association annual conference, the Diabetic Foot Global Conference (DFCon) and the Malvern International Diabetic Foot Conference.

      Dr. McCord is a Diplomate with the American Board of Podiatric Surgery. He practices at the Centralia Medical Center in Centralia, Wash.


John H. McCord, DPM


thank you, these information were very much useful to me. [from sri lanka].

Actual scenerio of Foot care problem in India have been brilliently presented,


Asoke sengupta

Excellent Article. Would someone be able to answer the following question. Does any of the 10 podiatry schools educate better than the others when it comes to diabetic foot care and wound care?

Thanks & Regards,

Charles Lind

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