A foot ulcer is the most devastating and costly complication of diabetes, with high morbidity and mortality, and affecting 15–25% of patients with diabetes during their lifetime. They require a comprehensive and complicated healthcare plan to manage the disease and keep from having the worst outcome.

Diabetic peripheral neuropathy (damaged nerves) and peripheral arterial disease (a build-up of fatty deposits in the arteries, restricting blood supply to leg muscles) are the main risk factors for the development and outcome of a foot ulcer. Peripheral arterial disease is estimated to be present in 50% of patients with a foot ulcer. Foot infections and co-morbidities are also important factors related to the outcome of a foot ulcer.

The risk of amputation at six months has been found to be 25% in cases involving arterial disease alone; it is much higher if the disease is associated with a severe infection in the foot. Thankfully, healthcare practices in the region are tackling the problem head on and revealing new ways of curtailing the rates, making huge differences to the numbers and to patients’ well-being.

Hidden dangers

Diabetes has become among the biggest health problem in many countries, especially low and middle-income ones. Such growth has a major impact on the quality of life for hundreds of millions of people, overwhelming the capacity of many national healthcare systems, and adversely impacting the economy of countries that are most in need of development.

Diabetes can have a negative effect on the skin, muscles, bones, tendons, nerves and blood vessels of the lower extremities. High blood-glucose levels can damage the nerves and blood vessels in the legs and feet, causing loss of feeling and a change in the natural gait of a patient.

Many patients don’t even notice a foot injury until it causes a serious sore or infection. Poor blood flow (peripheral vascular disease) causes cold feet and increases the risk of infection or ulceration. Peripheral neuropathy is the main cause of diabetic foot ulcers and the number one reason why a diabetes sufferer is admitted to hospital, affecting up to 60% of diabetes sufferers. Approximately 25% of diabetes sufferers will develop a foot ulcer and 50% of those ulcers will become infected, leading to increased risk of amputation.

Dr Almoutaz Alkhier Ahmed, a family medicine specialist and diabetologist, with a special interest in managing diabetic foot in family medicine practice, believes that the 85% of all amputations related to diabetes are preceded by foot ulcers, which are mostly caused by a lack of proper education. “People practice a lot of bad habits that negatively affect their feet. An example of this is wearing inappropriate footwear, such as high-heeled shoes,” he says.

Arab footwear habits are certainly contributing to neuropathy. “The Middle East region has its own distinct cultural features. One of these features is traditional footwear. Keep in mind the geographical location of most Arab countries, and the unique climates of the region – these factors make traditional footwear inappropriate. But people are always proud of their culture, with its positive and negative components. [Traditional] footwear is made of leathers, mostly goat’s leather, which does not cover the foot well, and has very thin soles, [so] the foot is almost in contact with the ground. These features put feet at risk of dryness, and damage by sharp objects scattered on the ground.”

This is backed up by other research. Professor Hasan Ali Alzahrani, president of the Saudi Society for Vascular Surgery and head of the vascular surgery unit at King Abdulaziz University Medical College, noted in 2015 that, according to a study at a primary health centre in Jeddah, 49.8% of over 700 recorded diabetic patients did not wear covered shoes. “This is a huge issue in the region [that explains] why foot ulcers are so prevalent – covered shoes are an effective and extremely easy way of reducing cuts and scrapes on a diabetic patient’s foot.”

One step at a time

Most physicians and diabetic specialists recommend a multidisciplinary approach that focuses on the patient to combat the illness. This style of patient-centric care has been shown to improve healing rate and reduce ulcer recurrence, bringing about a huge 70% decrease in amputations.

Care of patients with diabetic foot extends from primary preventive care, patient education and using preventive offloading measures, to secondary curative care to heal ulcers and treat local diabetes-related diseases, as well as post-ulcer preventive care. Continuous care of patients who have healed from ulcers and are at risk of developing new ulcers is strongly indicated. It is essential, too, that physicians, especially at primary healthcare, recognise diabetic foot problems in time to intervene or refer the patient to a specialised diabetic-foot centre.

Amputations, once seen as the remit of war-torn countries and motor-vehicle accident victims, may become a depressingly familiar sight in many parts of the world once again, over the coming decades. The prevalence of diabetes is a contributing factor. The number of people worldwide with diabetes who are 20–79 years of age in 2010 was 6.4%, or 285 million adults; this figure is projected to increase to 7.7%, or 439 million affected adults, by 2030. Between 2010 and 2030 there will be a 69% increase in the number of adults with diabetes in developing countries and a 20% increase in developed countries.

In 2010, four out of the top five countries with diabetes were in the Arab world: United Arab Emirates (18.7%), Saudi Arabia (16.8%), Bahrain (15.4%) and Kuwait (14.6%). Foot amputations due to ulcers are a big problem in the MENA region, so any way that the condition can be prevented will save heartache, time and, importantly, a significant amount of money.

But what are other reasons for why occurrences of foot amputations are so high in the region, and what specific causes and alternate factors relating to the procedure are there? Is it really as simple as sandals?

Prevention and health promotion are the first steps to control the prevalence of amputation in the Middle East.

“Unfortunately, the health plans in the Middle East region are directed towards the curative part in healthcare, which I like to call ‘targeting the outcome’, and forget about the preventive part, or targeting the process,” Ahmed explains. “Diabetic foot problems are the end result of a lot of risk factors.”

The role of primary healthcare

As with many dramatic reductions in healthcare afflictions, the answer has not been a wondrous new treatment or a fantastical new instrument that can change a patient’s life. It has rather been the old-fashioned approach of educating those with diabetes on what ignoring the symptoms can do.

A better level of specialisation has occurred in the region. Podiatrists and foot nurses offering education, diagnosis, and preventive and curative treatment for patients with diabetes-related foot problems are now widespread in private hospitals across the area.

Prevention, early detection and treatment of ulcers to avoid amputation are the main objective of the foot clinic. This improves the quality of life for the patients and significantly reduces the burden on the healthcare system.

One topic on which patients are being educated is their choice of shoes. This problem is now being addressed among the leading healthcare workers in the country, but, like many other initiatives, will take time to trickle down into the consciousness of diabetes sufferers.

“Investment into prevention is a long-run strategy, and most healthcare decision-makers like the short-term strategies. Prevention and health promotion are the first steps to control the prevalence of amputation in the Middle East region,” Ahmed says.

Recently, the numbers of amputations are reported to have dropped, and Ahmed is hopeful this will be a sign of more things to come. “It seems like a good result, but we need to look deeply into such reports. A lot of reports are based on data from weak studies. From my experience, we still face an increasing number of amputations, especially in poor, developing countries in the Middle East, where patients mostly contact healthcare facilities in the late stage.”

Diabetic peripheral neuropathy and peripheral arterial disease are still the major cause of amputation.

“Prevention and health promotion are the cornerstones to reduce the prevalence of amputation,” Ahmed stresses. “Teach the patient self foot care well, and allow him/her to discover areas of thick [calloused] skin. Noticing such simple details may prevent a major event like amputation.”

“It is important to integrate foot-care service in primary healthcare services, as this is the front line of healthcare.” he says. Easy access to this care would allow the healthcare providers to discover simple, preventable foot care diseases and spread the foot care education among patients and their caregivers. Ahmed also recommends – principally for the MENA region, but also globally – proper wound care for diabetics, in order to reduce the number of amputations and other complications.

Working as a team

“A lot of discussions were raised recently on the patient approach and its [impact] on the outcome of healthcare. Patient-centric approaches and considering the patient as your partner is the preferable approach to me, and I’ve adopted it in my daily practice,” he says of positive changes he has seen in wound care.

The rapid innovation in wound-care dressing materials and the introduction of digital technology is attracting the attention of many working in the field, which will hopefully enable further lowering of the rate.

“We always need to remember that foot care is multidisciplinary work that should be done by well-trained teams,” Ahmed concludes. “The success started by good communication with patients and continuous follow-up must be worked on. Good glycaemic control is behind a safe journey for all diabetic patients through their life with diabetes.” He hopes, like many, that simple educational tools and persistent patient care will help to keep the number of amputations in decline.