THE DIABETIC FOOT DISORDER IN ARAB’S

COUNTRIES: A NEGLECTED CLINICAL PROBLEM

By

Professor Hasan Ali Alzahrani, M.D., FRCS(Glasg)

Chairman, "Mohammad Hussein Al-Amoudi Chair for Diabetic Foot Research"

President of the Saudi society for vascular Surgery(SSVS)

Head of Vascular Surgery Division, Department of Surgery,

Medical college,

King Abdulaziz University (KAU)

6

حفل توقيع دعم الكرسيم17/6/2008-هـ13/6/1429الثالثاء

Background Diabetes Mellitus is by far the most common metabolic disorder

in SA

Its prevalence varies worldwide (International Diabetes Federation IDF, 2011)

Factors influencing the prevalence of DM include

– socioeconomic status.

– Age.

– Sex.

– Genetic susceptibility.

– Life style, and other environmental factors.

IDF’s 2011 Prevalence Rates

DM is a Global Health Problem

The United Nations Resolution (61/225),

has already been adopted unanimously

in 2006, recognizes diabetes as a

serious and costly disease that poses a

threat to individual well-being and

economic progress

Saudi Arabia is a country of over 20

million and a rapidly developing country.

During past two to three decades the

tremendous surge in socioeconomic

growth has considerably influenced the

life style of people.

SA in the Eye of the DM Storm

The 2011 IDF’s comparative prevalence

rate of DM in SA was 20%;

approximately 3 million Saudi diabetics

Studies showed that NIDDM increased

to 28.8% in male and 24.9% in female

over the age of 60.

Complication

Complications

“Diabetic foot” refers to a group of

disorders caused by long term

complications on the diabetic’ feet

Causal Pathways for Foot Ulcers

Neuropathy

Deformity

ULCER

% Causal Pathways

Neuropathy: 78%

Minor trauma: 79%

Deformity: 63%

Behavioral ?

Diabetes Care. 1999; 22:157

Poor self-foot care

Minor Trauma

- Mechanical (shoes)

- Thermal

- Chemical

Foot care practices among 747 diabetics

attending PHC in Jeddah

- The median score of the practice was 14

out of 33.

- (49.8%) always do not wear the covered

shoes.

- In Pakistan; Mortza et al study found that (22.2%)

male and (43.8%) female patients were

using open shoes .

(Kadi MH, Alzahrani HA; J KAU-Med Sci, 2011)

Foot Care & Prevention Issues

Foot care practices-contd

- 43.8% of the patients do not check the

inside of their shoes

- 40.3% do not wear socks

In Jeddah’s diabetics there is:

1- Weakness in certain aspects of foot care’s knowledge

2- Weakness in many aspects of foot care’s practices

3- The lower socio-economic group are at higher risk of

the above

Conclusions

1- There is need to start a well organized foot care

educational programs.

2- The foot care education program need to be in conjunction

with a continuous program of periodic screening in high

risk patients

Recommendations

Risk Stratify for Ulcer Risk

Diabetes Care. 2001;24:1442

Diabetes Metab. 2003;29:261

Risk LevelFoot Ulcer

%/yr

% Office Patients

(diabetes clinics)

3: Prior

amputation

Prior ulcer

28.1%

18.6%7%

2: Insensate and

foot deformity or

absent pedal

pulses

6.3% 10%

1: Insensate 4.8% 17%-30%

0: All normal 1.7% 66%

50% ofamputations

50% of patients

50% of patients

Tragic “Rule of 50”

Transfemoral/

transtibial

level

2nd amputation

in

5 years

Die in 5 years

Clinical Care of the Diabetic Foot, 2005

Prevention is better than Cure

90% of the amputations performed on

diabetics are preventable

However, once DFU occurred it has to

be treated aggressively “Foot Attack”

How many amputations per year?

SAUDI ARABIA: Riyadh has three

diabetes-related amputations each

dayArab News / AFP / March 10, 2009

Some 90 people a month have a foot

amputated due to diabetes in the Saudi

capital, a doctor said yesterday,

Scientific Data

Data about the diabetes-related lower

extremities amputations DRLA in Saudi

Arabia SA and perhaps in all of Middle

East and North African (MENA)

countries is limited in view of:

- the absence of national registries

- Lack of published research (only 115 in

Pubmed upto April 2012)

The DFR Chair aimed to:

- Challenge the media figures by reviewing the

author’s local data-base, available published

data as well as analyzing the Saudi MoH

reports to estimate the magnitude of the

problem in SA and perhaps MENA countries.

- Review the published studies from Arab’s

countries

Articles published on DFDs by our group (12)

-Al-Zahrani H, Saban S, Merdad H. Management of diabetic foot ulcer. Asian J

Surg, 1991; 14(1): 24-27.

- Al-Zahrani H. Role of vascular surgery in the management of diabetic foot

problems. Annals of Saudi Medicine, 1991; 11(6): 719-720.

-Al-Zahrani H, Ghandourah N, Merdad H. Limb amputations in Western Saudi

Arabia. Asian J. Surg, 1992; 15(3): 119-122.

-Al Zahrani H. Diabetic foot infection - two years experience. Saudi Med J,

1996; 17(4): 544.

- Alzahrani H, etal. The distribution of peripheral arterial disease in a defined

population of elderly high-risk Saudi patients. Int Angiol 1997

-Badri M, Alzahrani H, etal. Exteremities amputations in King Abdulaziz

University Hospital: Five years experience. King Abdulaziz Medical Journal,

2011.

Articles- contd.

Tashkandi W, Badri M, Badawood S, Ghandourah N, Alzahrani H.

Limb amputations in 3 major hospitals in Jeddah, Western Saudi

Arabia. King Abdulaziz Medical Journal, 2011.

Kadi MA, Alzahrani HA. The Foot care knowledge and practice among

diabetic patients attending primary health care centers in Jeddah city.

King Abdulaziz Medical Journal, 2012.

Alzahrani HA. The diabetes-related lower extremities amputations in

Saudi Arabia. Annals Annals of Vascular Diseases, 2012

Alzahrani HA and et al. The Management of DFD in Six major

hospitals in Jeddah. Asian J of Med Res, 2012

Alzahrani HA. The direct cost of diabetic foot management in some of

private hospitals in Jeddah, Saudi Arabia. Int J of Diabetes in

Developing Countries, 2013

Alzahrani HA and et al.The Diabetic Foot Research in Arabs’

Countries. OJEMD, 2013

Tragic “Rule of 15”

15% of diabetics will develop Foot ulcers in

their lifetime which equals 375,000 in SA

15% of these foot ulcers will result in LEA

Amputation i.e. 56,225 in SA

Clinical Care of the Diabetic Foot, 2005

Clinical Care of the Diabetic Foot, 2005

Diabetic Amputations in Saudi Arabia

MOH reported 652 amputations in its

annual report (2008).

In Jeddah 128 in 3 major hospitals of

2000 beds

Presenting Symptoms & Signs indicating

amputation

0

20

40

60

80

100

120

140

160

180

Ulcer

(64.4%)

Infection

(51.2%)

Ischemia

(35.6%)

Gangrene

(6.9%)

Polydactyly

(4%)

Others ( )

161

128

89

2410 6

Number of Amputation per each individual

Patient

Number Of Amputation Frequancy %

Once 198 89.2%

Twice 20 9%

Trice 4 1.8%

The total number of patients accounted for 222 patients out of them 198 (89.2%)

had been undergone amputations once, and the rest had multiple amputations either

twice 20 (9%) or thrice 4(1.8%).

Two patients had both lower and upper limb minor amputations at the same setting

for polydactyly making a total of 252 amputations in 250 operations.

Occurrence of Post Operative

Complications

yes

28%

No

72%

yes

No

Description Jeddah Riyadh KSA+

Assumption * 696 1,080 5,102

Method 1 averages ** 306 668 3,616

Method 2 averages *** 345 814 4,325

( Both studies averages ) 325 741 3,970

Methods-contd.

The averages of the three methods in both studies

were taken and it is found that

325 amputations are estimated to happen annually

in Jeddah compared to 741 in Riyadh

and 3970 for the whole kingdom i.e. 2.5

amputations per 10,000 population

DR-Amputations in SA and MENA

These figure are less than the one quoted in

media by 31%.

When applied to (MENA) countries, 44,208

amputations are predicted annually.

Conclusion

Half a million of (MENA)’s countries citizens are

likely to have a minor or major diabetes-related lower

extremities amputations over the coming decade

Amputation was significantly higher in

male patients, co-morbid disease,

peripheral vascular disease

Mortalities among Patients who

Undergone AmputationsYes

7%

NO

93%

Yes

NO

The Diabetic Stairway to HeavenDM- DFD- Loss of Limb- Death

Conclusion

Most of the amputees will not be re-habilitated and

may lose their jobs or incomes

Cost of Amputations

The Diabetic Foot Research in

Arabs’ Countries

-By April 2012, a total of 906 articles were published on

DM, out of them 115 (11.6%) were related to DFDs.

-The largest number of DM/DFDs research came from

G1 countries (n=437/51) followed by G2 (n=307/38)

and finally G3 (n=162/26)

- Saudi Arabia was the top on the list of all studied

countries with 31 studies related to DFDs out of the 187

on DM (16.5%).

Recommendations

In view of this, national registries are timely

needed in KSA and other (MENA) countries.

Public health education programs are recommended.

Guidelines in approaching diabetic foot is essential with multidisciplinary approach.

Vascular assessment should be a routine

step in diabetic foot management.

More prospective studies, and wider scale

studies is needed to determine of burden of

diabetic related amputation problem.

DFD is still a major health problem in

Saudi Arabia which is witnessing a”

Pandemic” of diabetic complications.