Epidemiology/Health Services/Psychosocial Research B R I E F
R E P O R T
Urban-Rural Differences in the Prevalence of Foot Complications in South-Indian Diabetic Patients VIJAY VISWANATHAN, MD, PHD SIVAGAMI MADHAVAN, BSC SEENA RAJASEKAR, BA
SNEHALATHA CHAMUKUTTAN, MSC, DPHIL, DSC RAMACHANDRAN AMBADY, MD, PHD, DSC,
D
This study was therefore done in an outpatient diabetes clinic to determine the prevalence of foot complications among patients coming from urban and rural areas in South India.
iabetes is recognized to be common in Asian Indians. The number of people with diabetes in the world is expected to double between 2000 and 2030. The greatest absolute increase in the number of people with diabetes will be in India (1). Regional studies from urban areas of India have shown a several-fold increase in the prevalence of diabetes in the last 2 decades (2). In a national survey reported in 2001, a concomitant increase in prevalence of impaired glucose tolerance (IGT) was noted (3). In four of six cities, the ratio of IGT to diabetes was greater than one, implying the possibility of a future conversion of IGT subjects to diabetes. An urban-rural difference in the prevalence rate was found, indicating that the environmental factors related to urbanization had a significant role in increasing the prevalence of diabetes (4). It was shown that diabetes had increased threefold over a span of 14 years in a rural population in southern India (5). The prevalence of diabetes in the urbanizing rural population was found to be midway between the rural and urban population (6). In India, diabetic foot infection is a common cause for hospital admission among diabetic patients and is caused by a number of sociocultural practices (7). The economic and emotional consequences for the patient and the family can be enormous (8). There is not much comparative data on the occurrence of foot complications between urban and rural populations.
FRCP
RESEARCH DESIGN AND METHODS — The study subjects were selected from the foot clinic of the M.Viswanathan Hospital for Diabetes, which is a large referral center for diabetes in southern India. Patients of different socioeconomic status visit the hospital. In this project, 2,642 patients (1,751 men and 891 women) with a high-risk foot were selected according to criteria of the International Consensus on the Diabetic Foot (9). The study subjects were divided as urban, patients staying in cities and bigger towns (n ⫽ 1,377), and rural, patients staying in the villages away from main town or city (n ⫽ 1,265). Patients were included in the project if the diagnosis of a high-risk foot was made after foot examination. Neuropathy was diagnosed by biothesiometer (10). A vibration perception threshold ⬎25 V was considered abnormal. Peripheral vascular disease was diagnosed as an ankle brachial index ⬍0.8. The demographic details regarding the patients were noted. Patients were also questioned regarding history of foot ulceration, smoking, and the usage of footwear. All study subjects were given intensive education regarding foot care and were also regularly followed up. Patients with a history of foot infection were asked to come every 3 months and others once
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From the M. Viswanathan Hospital for Diabetes and Diabetes Research Centre, Chennai, India. Address correspondence and reprint requests to Dr. Vijay Viswanathan, MD, PhD, Diabetes Research Centre No.4, Main Road, Royapuram, Chennai 600 013, India. E-mail:
[email protected]. Received for publication 21 September 2005 and accepted in revised form 17 November 2005. Abbreviations: IGT, impaired glucose tolerance. A table elsewhere in this issue shows conventional and Syste`me International (SI) units and conversion factors for many substances. © 2006 by the American Diabetes Association. The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
DIABETES CARE, VOLUME 29, NUMBER 3, MARCH 2006
in 6 months. They were instructed to visit the center if any sign of lesion appeared. Recurrence of ulceration was defined as any ulceration at the same or at a different site. At the follow-up examination done 24 months later, the same parameters were measured and recorded for all of the patients. Details of foot problems such as ulceration, infection, gangrene, and amputation were collected. Statistical comparisons Values in the text and tables are presented as means ⫾ SD. Group comparisons were done by 2 or Student’s t test as relevant. P values of ⬍0.05 were considered significant. Factors contributing to foot infection were identified using a multiple logistic regression analysis using foot infection as the dependent variable. RESULTS — The characteristics of patients in the study groups are shown in Table 1. Intergroup differences were absent in the duration of diabetes and the prevalence of peripheral vascular disease. The mean age of the urban sample was higher than that of the rural sample (P ⫽ 0.01). Prevalence of foot infection was higher among rural than urban patients (26 vs. 34%, P ⫽ 0.0001). Amputation rates were also higher among rural than urban patients (3 vs. 8%, P ⬍ 0.05). The follow-up details of the study patients are shown in Table 2. Recurrence of foot infection was higher among rural than urban patients (8 vs. 13%, P ⫽ 0.003). Surgical intervention was also more frequent among rural than urban patients (6 vs. 10%, P ⫽ 0.04). Multiple regression analysis was done using foot infection as the dependent variable. In urban subjects, foot infection was influenced only by barefoot walking. A similar result was obtained in the rural subjects. In both urban and rural patients, foot infection was influenced by smoking and lesser use of customized footwear. CONCLUSIONS — Management of diabetes and its complications in a rural setting poses a formidable challenge. It 701
Prevalence of foot complications Table 1—Baseline characteristics of study groups
n Men/women (n) Mean age (years) Mean duration of diabetes (years) Mean HbA1c (%) PVD Smokers Foot infection Amputation Customized footwear Barefoot walking
motivation to implement preventive strategies in rural patients.
Urban
Rural
1,377 845/532 60.6 ⫾ 9.2 12.9 ⫾ 8.0 9.4 ⫾ 2.1 210 (15) 25 (2) 359 (26) 45 (3) 846 (61) 156 (11)
1,265 906/359 59.4 ⫾ 9.1 12.5 ⫾ 7.6 9.6 ⫾ 2.2 166 (13) 70 (6) 427 (34) 98 (16) (8) 630 (49) 195 (15)
2
2.3 25.2 18.3 24.9 35.7 9.2
P
0.01* 0.2 0.02* 0.1 0.0001* 0.0001* 0.0001* 0.0001* 0.002*
Data are means ⫾ SD and n (%). *Significant. PVD, peripheral vascular disease.
has been reported that diabetic patients who wore footwear both inside and outside their homes developed lesser foot problems than those patients who wore footwear only when they went outside their homes (11). In India, patients with diabetic neuropathy who live in rural areas are more prone to foot ulcers than those who live in urban areas for various reasons. The main common predisposing factor is barefoot walking, which can result in injury to the feet. Secondly, individuals in rural areas often sleep in huts or farmhouses where rodents are common; rodent bites to the feet of the patients with diabetes can lead to chronic ulcers (7). Such injuries result in frequent and long-term admission to the hospital and cause much morbidity. The reason for the high prevalence of foot infection could be attributed to greater prevalence of barefoot walking (11 vs. 15% for urban and rural, respectively, P ⫽ 0.002), lesser use of customized footwear (61 vs. 49% for urban and rural, respectively, P ⬍ 0.05), and increased prevalence of smoking (2 vs. 6% for urban and rural, respectively, P ⬍ 0.05). Foot ulceration is generally preventable, and relatively simple interventions can reduce amputations by up to 80%
(12). There are strong indications that the number of amputations can be drastically reduced through the implementation of foot care programs. Studies investigating the effects of such programs report amputation reduction rates between 44 and 85% (13–15). In our earlier study (16), the recurrence rates for ulcers in neuropathic subjects were estimated at 52%. In India, there is a poor awareness regarding the need for foot care among diabetic patients (17). In a recent study, it was shown that strategies such as intensive management and foot care education were helpful in preventing newer problems and surgery in diabetic foot disease (18). The study reported that there were fewer recurrences of ulcers and that the healing process was faster in subjects adhering to the foot care advice than in those who did not follow the advice. Rural subjects have lower educational status, and therefore more intensive methods for awareness are required. In conclusion, rural patients had a higher prevalence of foot ulceration when compared with urban patients. Despite receiving counseling similar to that of the urban patients, rural patients were more prone to reulceration and to need surgical intervention. This calls for more aggressive methods of patient education and
Table 2—Comparison between the study groups at follow-up Urban n Patients in for review Reulceration Surgical intervention Data are n (%). *Significant.
702
1,377 631 (46) 50 (8) 36 (6)
Rural 1,265 532 (42) 71 (13) 52 (10)
2
P
8.5 4.1
0.003* 0.04*
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