Expert Addresses Global Diabetes

By Brian McCurdy, Associate Editor

“Diabetic foot disease is truly a global problem. Every patient of whatever race, with diabetes of whatever type, is at potential risk for developing foot problems,” noted Andrew Boulton, MD, during his keynote address, “The Diabetic Foot: A Global View,” at the Annual Scientific Meeting of the American Podiatric Medical Association in Seattle.
Introduced by legendary Paul Brand, MD, Dr. Boulton cited rising prevalence rates of diabetes and alarming statistics in other countries. Dr. Boulton strongly emphasized the need for better education on the causes of diabetic foot ulcers, treatment and the importance of increasing the presence of podiatry in other parts of the world to help in the prevention and management of diabetic foot complications.
“The aims in managing diabetic foot problems should primarily be concerned with limb preservation at all costs,” noted Dr. Boulton, a Professor of Medicine at the University of Manchester in the United Kingdom and Visiting Professor of Medicine at the University of Miami School of Medicine Division of Diabetes.
“The need for a better understanding of the pathogenesis and treatment of diabetic foot ulceration is strongly supported by the literature and depressing statistics. Trends in amputations have not shown any tendency towards improvement in recent years and foot ulceration remains the (most common) cause for hospitalization of diabetic (patients) in many Western countries.”
In the United Kingdom, Dr. Boulton noted diabetic patients are four times more likely to be admitted to hospitals and those with peripheral neuropathy have a 16-fold risk of hospitalization. He points out the U.K. probably has no more than 20 specialist multidisciplinary diabetic foot clinics for a population of about 55 million.
Dr. Boulton noted the cost of healing for diabetic foot ulcers with hospitalization and surgery in Sweden was $57,300 per case, compared to $8,500 per case just for primary healing in 1990. The standard of screening and educational foot care is generally higher in Scandinavian countries than in the rest of Europe, Dr. Boulton noted. While he said podiatrists are available in all these countries, few diabetic patients have access. He added that Sweden, Norway, Finland and Denmark all have multidisciplinary foot centers. However, Dr. Boulton noted podiatric education and the definition of podiatry are very different in various countries.

A Stunning Lack Of Access To Podiatric Services
There is a severe lack of access to podiatric services in several countries that have rapidly escalating prevalence of diabetes, according to Dr. Boulton.
For example, 1 to 5 percent of India’s 1 billion people, about 30 million, have type 2 diabetes. The hallmark of diabetes is gross infection, according to Dr. Boulton. He says factors which contribute to late presentation include frequent barefoot gait, attempts at home surgery, trusting in faith healers and undetected diabetes. While India has a few specialized centers in major cities, Dr. Boulton said diabetic foot care is mostly disorganized and India lacks podiatrists and orthotists.
Diabetic foot care is also very problematic in South Africa. Ten percent of a country with 40 million people have diabetes. Dr. Boulton said there are only 200 podiatrists in the country, not all hospitals have podiatrists and the level of diabetic foot care varies greatly across the country.
“It appears that whereas the illusion of good global foot care remains, we have reason to be hopeful that improvements will continue,” said Dr. Boulton.
He cited the efforts of the Netherlands where well-trained podiatrists are available specifically for diabetic patients in 32 percent of the hospitals. He noted Belgium’s national training program in diabetic foot care for those who treat diabetic patients and doctors who work at multidisciplinary foot clinics. Dr. Boulton also praised Australia for its “well-developed healthcare system” and its efforts to establish a national diabetes foot care network to address the shortage of multidisciplinary clinics.

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