Foot complications among diabetics attending a district hospital in Kenya: Predisposing factors and possible intervention

Author Information

M.M. Obimbo, MBChB, P.K. Bundi, BSc (Anat) and F. Collis, MSSCh, Dip. PodMed, MBChB, J.A.
Ogeng’o, BSc (Anat), MBChB, PhD, Department of Human Anatomy, School of Medicine, University of Nairobi, P.O. Box 30197-00100, Nairobi, Kenya

Corresponding author:

Dr. M.M. Obimbo, Department of Human Anatomy, School of Medicine, University of Nairobi, P.O. Box 30197 00100, Nairobi, Kenya. Email:

Abstract

OBJECTIVES: To relate skin health, footwear practices and foot care education with occurrence of foot complications among diabetics attending a district hospital in Kenya.

PATIENTS AND METHODS: Two hundred and nineteen patients attending the diabetic clinic at the Kikuyu Mission Hospital (99 males, 120 females) were studied. They were examined for the presence, type and cause of foot complication, skin health, education on foot care and footwear.

RESULTS: Twenty nine point two percent of the patients had foot complications, with 95% of these presenting with diabetic ulcer, the rest had Charcot’s foot or cellulitis. The diabetic foot ulcer was traumatic in 75.4% and spontaneous in 24.6%. Fifty seven percent of the patients had risky footwear, associated with development of foot ulcer (p = 0.001). Ninety eight percent of the patients with foot complications had either atrophic or dry skin (p = 0.001). Fifty two point four percent had not received foot care education, with males who had received education being more than females (p = 0.05).

CONCLUSION: The rate of foot complications among diabetics is higher than previously observed. Diabetic foot ulcer, the commonest complication, is mostly traumatic. Patients with foot care education, proper footwear and good skin health had lower incidence of traumatic diabetic foot ulcer. Dissemination of foot care education and use of right footwear for diabetics may reduce the incidence of complications.

Introduction

Uncontrolled Diabetes Mellitus (DM) is associated with a wide range of complications, some of which require surgical attention (1). About 10% of diabetic patients develop foot complications (2). These include foot ulcer, Charcot’s foot and diabetic cellulitis (3,4). The increase in foot complications in diabetics may be directly related to foot wear practices, skin health and foot care education.

In the developed world, emphasis on the use of appropriate footwear for diabetics is almost universal (5,6), and issues of compliance are now a priority (8). Skin complications in DM largely result from the combined effect of hyperglycemia, neuropathy, microvascular and macrovascular angiopathies. Poor skin care, with attendant infections, increases the risk of developing diabetic foot ulcers and cellulitis (8). This is the subject of extensive foot education and foot care campaigns in developed countries (10). Little is known about footwear, skin health and foot care education and their relationship to foot complications among diabetics in Kenya.

This study investigated the relationship between diabetic foot complications and foot care education, skin health and footwear practices in patients attending a diabetic clinic in a Kenyan District Hospital.

Materials and methods

Two hundred and nineteen consenting patients with the diagnosis of diabetes mellitus attending the Kikuyu Mission Hospital between 1st June and 1st September 2007 were recruited. Ethical approval was sought from the Kikuyu Mission Hospital Management Board. Patients were free to opt out of the study once recruited. The pre-study estimate of proportion was obtained from a previous study that employed a similar method as this study. Patients who already had amputations and those younger than twenty years of age were excluded from the study. Patients were identified and interviewed by the specialized clinical officers, nurses and medical officers working in the diabetic unit, the medical and surgical wards. Patients were interviewed on the level of their diabetic education as follows:

Question

What is diabetes?Correct response given 1 mark

Name two complications of diabetesAny two correct responses 2 marks

Is foot ulcer one of the diabetes complications?Given 1 mark for correct response

Give two ways of preventing foot ulcers in diabetic patientsGiven 2 marks for any two correct response

Patients who scored four out of six marks were considered to be educated on diabetes and foot care. They were asked on their footwear practices at home and the place of work through making inquiries whether they put on shoes while at home and to state which kind of shoes they put on; flip-flops, sandals or closed rubber/ leather shoes. The former were considered risky whereas the latter were considered appropriate. Patient footwear at the time of examination was classified as appropriate (if the shoe fit the patient adequately and no excessive pressure was applied on the feet) or inappropriate. The patients were asked for the duration of DM and the cause of foot ulcers – whether spontaneous or traumatic. Patients’ files were scrutinized for co-morbid conditions such as peripheral neuropathy, hypertension and skin health. Skin health was classified as atrophic if the foot skin was wrinkled with exaggerated bony prominences; dry if fissures were observed and normal if healthy. Diabetic ulcer, Charcot’s foot and cellulitis were examined for their magnitude, anatomical location and bilateral differences. Vascular assessment was done, with the pulses of anterior, posterior