"Among the many chronic complications of diabetes, diabetic foot has remained the most feared complication, with both patients and treating health care professionals sharing the dread in equal measure. Devastating consequences like limb amputation has made such fear abundantly justified. Despite it being the most feared complication, ignorance about diabetic foot continues to dominate the reasons for many of the avoidable limb amputations. In fact, patient education, proper care of feet and appropriate foot wear can prevent occurrence of many of the foot ulcerations. It has bccn realized that 85% of all limb amputations are preceded by trivial foot lesions. Prompt recognition and aggressive treatment of such trivial foot lesions can prevent many of the limb amputations. Looking at patient's feet and picking up foot lesions when they are young is the key to success. Unfortunately such simple but important steps are easily overlooked by many of us. Globally' over 1 million lower limbs are amputated every year, in fact every 30 seconds a limb is lost to diabetes some- where in the world. "
A person with diabetics is up to '10 times more likely to suffer a lower extremity amputation than a nondiabetic. Diabetic foot is a significant economic problem. 'lhc cost of treatment of foot ulcer in Western countries ranges from 7,000 USD to 10,000 USD. The direct cost of an amputation associated with diabetic foot is estimated to be between 30,000 USD and 60,000 USD. In India, with majority not covered by medical insurance, the entire cost (direct and indirect both) has to be borne by the patient, and, often, it is the breadwinner of the family who happened to be the victim. Loss of wages after the amputation and huge cost incurred on treatment shatters the family both socially and economically. Rough estimates indicate that about 100,000 lower limbs are amputated in India every year, of which 75%
are on neuropathic feet with secondary infection. Ihese amputations are potentially preventable. In view of enormous problem of diabetic foot in India, the Step-by-Step foot care project was conceived in the year 2003, with a common objective of improving diabetes foot care in the developing world. Ihe Project Committee consisted of Sharad Pendsey, India (Chairman); Karel Bakker, The Netherlands; Ali Foster, United Kingdom; Zulfiqar Ali G Abbas, Tanzania (Chairman); and Vijay Viswanathan, India. "Ihe project has received generous funding from the World Diabetes Foundation and academic support from International Diabetes Federation, International Working Group on the Diabetic Foot, Diabetic Foot Society of India, and Muhirnbili University College of Health and Allied Sciences, Dar es Salaam, Tanzania.
GOALS
To increase the meager awareness of diabetic foot problems
To provide sustainable training of healthcare professionals in the management of diabetic foot
To facilitate the cascading of information from health care professionals who have undergone training to other healthcare professionals and thus expand expertise
To reduce the risk of lower limb complications in people with diabetes
To empower diabetics in better foot care, early problem detection and in seeking timely help.
'Ihe Step-by-Step foot care project came out a grand success and was very well received across India. Actually, it kick-started a national movement regards diabetic foot. However, in a vast country like India, such a project need to be continued until evident results get palpable; and then a level is to be maintained to sustain gains effected. In the developing world including India, we need to have three-tier system wherein each district had a Minimal Care Diabetic Foot Center. These centers will mean to carry out educational activities, screening of high risk feet, advice regarding preventive footwear and manage trivial foot lesions. "Ihese may thus prevent trivial foot lesions advancing into a catastrophe. Larger cities had better had an Intermediate level Diabetic Foot Center. These centers are meant for surgeries like debridement and amputations, offloading advice and to maintain good liaison between minimal care centers. The Tertiary Foot Care Center will have facilities for carrying out complex foot surgeries, including revascularization and infrapopliteal bypass surgery. The Public Health Care System in India is overburdened because of high prevalence of both communicable as well as non-communicable diseases. Private health care and the corporate sector should take up the responsibility of provid- ing affordable health care to general population. Medical insurance is a way away from penetrating the masses. Let policies be formulated that afforded each individual reason- able health insurance cover. There is nothing inevitable about lower limb amputation. "These can certainly be reduced, in the least by 50%, if proper therapeutic strategies were implemented. In parts of the developed world, 50% reduction in lower limb amputation is already achieved. Preventive strategies like glycemic control, screening the high risk feet, proper foot wear and sustainable education of all afflicted with diabetes should go a long way in arresting this most feared complication of diabetes. Given the increasing longevity of the general population, well control- led diabetics too will live longer; imposing additional burden of many more ageing with peripheral vascular disease and critical leg ischemia. Strategies and facilities to tackle this are yet in infancy in most parts of this country, and wherever these do happen to be around, have seemed out of common reach. But, there is always ground to stay optimistic. The sum total interest in the arena of diabetic foot is growing by leaps in the medical fraternity. It is very much hoped that more and more health care professionals will pick up the gauntlet of managing the hitherto neglected diabetic foot. Step-by step, diabetics will need to be goaded to turn away from the amputation path and to instead embrace the chance to save their foot.
A person with diabetics is up to '10 times more likely to suffer a lower extremity amputation than a nondiabetic. Diabetic foot is a significant economic problem. 'lhc cost of treatment of foot ulcer in Western countries ranges from 7,000 USD to 10,000 USD. The direct cost of an amputation associated with diabetic foot is estimated to be between 30,000 USD and 60,000 USD. In India, with majority not covered by medical insurance, the entire cost (direct and indirect both) has to be borne by the patient, and, often, it is the breadwinner of the family who happened to be the victim. Loss of wages after the amputation and huge cost incurred on treatment shatters the family both socially and economically. Rough estimates indicate that about 100,000 lower limbs are amputated in India every year, of which 75%
are on neuropathic feet with secondary infection. Ihese amputations are potentially preventable. In view of enormous problem of diabetic foot in India, the Step-by-Step foot care project was conceived in the year 2003, with a common objective of improving diabetes foot care in the developing world. Ihe Project Committee consisted of Sharad Pendsey, India (Chairman); Karel Bakker, The Netherlands; Ali Foster, United Kingdom; Zulfiqar Ali G Abbas, Tanzania (Chairman); and Vijay Viswanathan, India. "Ihe project has received generous funding from the World Diabetes Foundation and academic support from International Diabetes Federation, International Working Group on the Diabetic Foot, Diabetic Foot Society of India, and Muhirnbili University College of Health and Allied Sciences, Dar es Salaam, Tanzania.
GOALS
To increase the meager awareness of diabetic foot problems
To provide sustainable training of healthcare professionals in the management of diabetic foot
To facilitate the cascading of information from health care professionals who have undergone training to other healthcare professionals and thus expand expertise
To reduce the risk of lower limb complications in people with diabetes
To empower diabetics in better foot care, early problem detection and in seeking timely help.
'Ihe Step-by-Step foot care project came out a grand success and was very well received across India. Actually, it kick-started a national movement regards diabetic foot. However, in a vast country like India, such a project need to be continued until evident results get palpable; and then a level is to be maintained to sustain gains effected. In the developing world including India, we need to have three-tier system wherein each district had a Minimal Care Diabetic Foot Center. These centers will mean to carry out educational activities, screening of high risk feet, advice regarding preventive footwear and manage trivial foot lesions. "Ihese may thus prevent trivial foot lesions advancing into a catastrophe. Larger cities had better had an Intermediate level Diabetic Foot Center. These centers are meant for surgeries like debridement and amputations, offloading advice and to maintain good liaison between minimal care centers. The Tertiary Foot Care Center will have facilities for carrying out complex foot surgeries, including revascularization and infrapopliteal bypass surgery. The Public Health Care System in India is overburdened because of high prevalence of both communicable as well as non-communicable diseases. Private health care and the corporate sector should take up the responsibility of provid- ing affordable health care to general population. Medical insurance is a way away from penetrating the masses. Let policies be formulated that afforded each individual reason- able health insurance cover. There is nothing inevitable about lower limb amputation. "These can certainly be reduced, in the least by 50%, if proper therapeutic strategies were implemented. In parts of the developed world, 50% reduction in lower limb amputation is already achieved. Preventive strategies like glycemic control, screening the high risk feet, proper foot wear and sustainable education of all afflicted with diabetes should go a long way in arresting this most feared complication of diabetes. Given the increasing longevity of the general population, well control- led diabetics too will live longer; imposing additional burden of many more ageing with peripheral vascular disease and critical leg ischemia. Strategies and facilities to tackle this are yet in infancy in most parts of this country, and wherever these do happen to be around, have seemed out of common reach. But, there is always ground to stay optimistic. The sum total interest in the arena of diabetic foot is growing by leaps in the medical fraternity. It is very much hoped that more and more health care professionals will pick up the gauntlet of managing the hitherto neglected diabetic foot. Step-by step, diabetics will need to be goaded to turn away from the amputation path and to instead embrace the chance to save their foot.
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