Type 2 Diabetes Mellitus and its related foot complications in Malaysia

Incidence of Type 2 Diabetes Mellitus in Malaysia:

In Malaysia, the First National Health and Morbidity Survey (NHMS 1) conducted in 1986 reported a prevalence of diabetes mellitus of 6.3% [1]. In the Second National Health and Morbidity Survey (NHMS 2) in 1996, the prevalence had risen to 8.3% [2]. The prevalence of diabetes had increased drastically to 14.9 per cent in 2006 for the same age group; an increase of 80% based on the Third National Health and Morbidity Survey 2006 (NHMS 3) [3]. Currently, it is estimated that one out of eight Malaysians aged 30 years and above has diabetes, which amounts to over 1.6 million adults in Malaysia. The World Health Organisation (WHO) has estimated that in 2030, Malaysia would have a total number of 2.48 million diabetics compared to 0.94 million in 2000 - a 164% increase.

Incidence of foot related complications:

Foot ulceration associated with infection is one of the leading causes of hospitalization patients with diabetes mellitus. Approximately 15% of all patients with diabetes will develop a foot or leg ulceration at some time during the course of their disease.[1-3]

Several population-based studies report an annual incidence of diabetic foot ulceration in the range of 2% to 3% in patients with either Type 1 or Type 2 diabetes, while the prevalence varies between 4% and 10%

Numerous risk factors for diabetic foot ulceration have been ascertained. Aside from the major factors of neuropathy, ischemia, pressure (trauma), and infection, multiple other contributory factors interact to produce foot lesions. Intrinsic risk factors include metabolic or biologic characteristics that may or may not be causally related to diabetes but do contribute to the aetiology of ulceration.

Symptom of diabetes:

48% of patients above the age of 30 years old are not aware that they have diabetic. The majority are asymptomatic. Patients should be aware of common symptoms of diabetes which include polyuria (increased frequency of urination), polydipsia (increased thrist), easily tired and sudden unexplained weight loss [4].

Classification diabetic foot complications
Diabetic Foot Problems are best classified according to King’s Classification [5].
Stage 1: Normal
Stage 2: High Risk
Stage 3: Ulcerated
Stage 4: Cellulitic Stage
Stage 5: Necrotic
Stage 6: Major Amputation

Post Ray’s amputation+ incision and drainage

The surgical wound located at the dorsal surface of the right foot. The wound bed consists of granulation tissues and slough. This is not a well-healing wound.

Investigations

Glycosylated hemoglobin level must be taken to obtain information of the patient’s glucose control over the past 3 months. This investigation is based on the fact that in the normal 120 day life span of the red blood cell, excess glucose molecules will react with hemoglobin, forming glycosylated hemoglobin. In individuals with poorly controlled diabetes, the level of glycosylated hemoglobins will be elevated.

Plain radiograph of foot and ankle can also be taken to make sure there is no involvement of bone to rule out osteomyelitis.

Doppler ultrasound also is significant to investigate the peripheral circulation of foot to prevent ischemia.

Diabetic Foot Care Treatment

Self-Care at Home

A person with diabetes should do the following:

• Foot examination: Examine your feet daily and also after any trauma, no matter how minor, to your feet. Report any abnormalities to your physician. Use a water-based moisturizer every day (but not between your toes) to prevent dry skin and cracking. Wear cotton or wool socks. Avoid elastic socks and hosiery because they may impair circulation.

• Eliminate obstacles: Move or remove any items you are likely to trip over or bump your feet on. Keep clutter on the floor picked up. Light the pathways used at night - indoors and outdoors.

• Toenail trimming: Always cut your nails with a safety clipper, never a scissors. Cut them straight across and leave plenty of room out from the nailbed or quick. If you have difficulty with your vision or using your hands, let your doctor do it for you or train a family member how to do it safely.

• Footwear: Wear sturdy, comfortable shoes whenever feasible to protect your feet. To be sure your shoes fit properly, see a podiatrist (foot doctor) for fitting recommendations or shop at shoe stores specializing in fitting people with diabetes. Your endocrinologist (diabetes specialist) can provide you with a refferel to a podiatrist ororthopedist who may also be an excellent resource for finding local shoe stores. If you have flat feet, bunions, or hammertoes, you may need prescription shoes or shoe inserts.

• Exercise: Regular exercise will improve bone and joint health in your feet and legs, improve circulation to your legs, and will also help to stabilize your blood sugar levels. Consult your physician prior to beginning any exercise program.

• Smoking: If you smoke any form of tobacco, quitting can be one of the best things you can do to prevent problems with your feet. Smoking accelerates damage to blood vessels, especially small blood vessels leading to poor circulation, which is a major risk factor for foot infections and ultimately amputations.

• Diabetes control: Following a reasonable diet, taking your medications, checking your blood sugar regularly, exercising regularly, and maintaining good communication with your physician are essential in keeping your diabetes under control. Consistent long-term blood sugar control to near normal levels can greatly lower the risk of damage to your nerves, kidneys, eyes, and blood vessels.

Medical Treatment

• Antibiotics: If the doctor determines that a wound or ulcer on the patient’s feet or legs is infected, or if the wound has high a risk of becoming infected, such as a cat bite, antibiotics will be prescribed to treat the infection or the potential infection. It is very important that the patient take the entire course of antibiotics as prescribed. Generally, the patient should see some improvement in the wound in two to three days and may see improvement the first day. For limb-threatening or life-threatening infections, the patient will be admitted to the hospital and given IV antibiotics. Less serious infections may be treated with pills as an outpatient The doctor may give a single dose of antibiotics as a shot or IV dose prior to starting pills in the clinic or emergency department.

• Referral to wound care center: Many of the larger community hospitals now have wound care centers specializing in the treatment of diabetic lower extremity wounds and ulcers along with other difficult-to-treat wounds. In these multidisciplinary centers, professionals of many specialties including doctors, nurses, and therapists work with the patient and their doctor in developing a treatment plan for the wound or leg ulcer. Treatment plans may include surgical debridement of the wound, improvement of circulation through surgery or therapy, special dressings, and antibiotics. The plan may include a combination of treatments.

• Referral to podiatrist or orthopedic surgeon: If the patient has bone-related problems, toenail problems,corn and callus hammertoes, bunions, flat feet, heel spurs, arthritis, or have difficulty with finding shoes that fit, a physician may refer you to one of these specialists. They create shoe inserts, prescribe shoes, remove calluses and have expertise in surgical solutions for bone problems. They can also be an excellent resource for how to care for the patient’s feet routinely.

• Home health care: The patient’s doctor may prescribe a home health nurse or aide to help with wound care and dressings, monitor blood sugar, and help the patient take antibiotics and other medications properly during the healing period.

References

1. National Health and Morbidity Survey 1986

2. National Health and Morbidity Survey 1996

3. National Health and Morbidity Survey 2006

4. Mafauzy M. Diabetes Mellitus in Malaysia. Medical Journal of Malaysia. 2006.

5. Edmonds ME and Foster AVM. Managing the diabetic foot, 2nd ed. (Blackwell, London, 2005).

Malaysia endocrine and metabolic society,Ministry of health,acdemic of medicine malaysia,Persatuan diabetic malaysia.