Foot ulcers and multiple amputations are major causes of morbidity and disability for people living with diabetes. Podiatric experts say early recognition and management of risk factors can prevent or delay the onset of adverse outcomes, reports Associate Editor ADEKUNLE YUSUF.
Olufemi Sadipe had a flourishing career as a chartered accountant. Although he was aware of his diabetes status and adhered strictly to his dietary and medication prescriptions for over 20 years, he paid the price of not seeking the review of his medical condition until he developed diabetes foot ulcer in 2017. He suffered the pain of parting with his toes, which still did not heal up until a specialist who told him after tests that the damage to his leg had gone beyond the knee. After multiple amputations in Nigeria and the United States, he now lives to tell his story.
So was Samuel (real name concealed) who developed ulcer foot while still in the university. It affected him so much that he went through multiple amputations, having had his condition mismanaged in the public hospitals where he was admitted for months before he was attended to for a surgery that eventually went awry. He had to travel to India before his condition got better. His travails, which started in 2006, have reduced him to an amputee.
In Nigeria, there is a rising crisis of diabetes foot ulcer, a major complication of diabetes mellitus, with the country’s moribund health sector unable to cope with the requisite special skills needed to heal the wounds and restore smiles on the faces of patients until many cases go from bad to worse. Medical records show that diabetes foot ulcer is responsible for worsening rate of multiple amputations among Nigerians living with diabetes, as high as 53.2 per cent of the number of people with foot ulcer in some parts of the country. Experts also lament further that this has made diabetes foot the most common cause of non-traumatic amputations in Nigeria, though similar tales of lamentation persist in many other countries.
Tales of diabetes foot complications like the ones above abound in the country, sometimes leading to multiple amputations and deaths that are probably avoidable. Determined to stem the tide, Rainbow Specialist Medical Centre, a private hospital focused on the management of diabetes and other endocrine and metabolism conditions, has taken up the gauntlet by organising an annual diabetes foot and podiatry workshop designed to equip Nigerian doctors, other health workers and people living with diabetes with the basic knowledge and skills on diabetes foot care.
The five-day workshop, which is the sixth in the series, was organised in collaboration with the World Walk Foundation (Jamaican chapter) and supported by leading diabetes care companies in the country, would arrest the steady increase of diabetes mellitus and its complications in the country. According to Dr. Afokoghene Isiavwe, medical director, Rainbow Specialist Medical Centre, the workshop, which focuses on building capacity at the primary care level, also featured a diabetes refresher course for primary and secondary health care workers and insulin refresher workshop for both primary and secondary healthcare workers as well as basic and advanced certified diabetes foot course in order to upgrade the skills of the first-line responders in the diabetes foot crisis.
“It is important that primary care health workers should know the basics of diabetes such as how to recognise symptoms, how to diagnose and even know how to start treatment and most important, when to refer the patients. This will prevent misdiagnosis and mismanagement. The primary care service is essential because that’s where the people first present to whenever they have health challenges. Over the years, Rainbow Specialist Medical Centre, Lekki, has been holding this capacity building workshop for Nigerian health workers both in public and private institutions,” Dr. Isiavwe said.
Experts say diabetes can lead to many different types of foot complications, including foot (a fungal infection), calluses, bunions and other foot deformities, or ulcers that can range from a surface wound to a deep infection. Longstanding high blood sugar can damage blood vessels, decreasing blood flow to the foot. This poor circulation can weaken the skin, contribute to the formation of ulcers, and impair wound healing. Some bacteria and fungi thrive on high levels of sugar in the bloodstream, and bacterial and fungal infections can break down the skin and complicate ulcers. Elevated blood glucose levels over time can also damage the nerves of the foot, decreasing a person’s ability to notice pain and pressure.
More serious complications include deep skin and bone infections, doctors said. Gangrene (death and decay of tissue) is also a very serious complication that may include infection; widespread gangrene may require foot amputation. Approximately five percent of men and women with diabetes eventually require amputation of a toe or foot. This tragic consequence can be prevented in most patients by managing blood sugar levels and daily foot care.
At the diabetes foot workshop in Lagos, podiatrists and other medical experts expressed concern over the rising scourge of diabetes foot complications, resulting in an increase in multiple amputations in the country. To stem this dangerous tide, they said Nigeria will need to improve its healthcare delivery by having strong diabetes foot care protocol at the primary care level to address the situation. If this is done, it will help to save more limbs from amputation and reduce unnecessary deaths.
Dr. Isiavwe said diabetes is a global emergency with associated complications, which require training first responders and community health extension workers to improve management and prevention of the disease complications, as well as raise awareness on proper foot care in persons living with diabetes mellitus. She described diabetes foot first responders as persons with specialised training, who are among the first to arrive and provide assistance at the scene of an emergency, which would stand in the gap to reduce diabetes amputation. She, however, added that it is important to ensure primary healthcare workers are trained to be able to recognise the high risk diabetes foot and know how to promptly triage the cases to reduce delays in getting appropriate foot care services.
“What we have now is that the first responders: the community health extension workers, and pharmacists, who are the people the diabetes patients meet on a day-to-day basis, don’t know much about diabetes. This leads to trial and error and by the time these patients get to centres that know how to treat diabetes properly, it is usually too late and all that can be done is to cut the limb to save lives,” she stressed.
According to the president, World Walk Foundation, Owen Bernard, for every five seconds, a lower limb is lost to amputation as a result of complication from diabetes. This, he noted, is due to lack of education about the disease and the inability to identify its symptoms. Bernard lamented that there are no enough health personnel on diabetes treatment and care in many countries across the world, noting that it is important to train as many personnel as possible in the health centres in Nigeria. This, he said, will help to salvage some of the disease problems at the primary care level. He said the ultimate aim is to help reduce the rate of diabetes and prevent amputations because diabetes foot complications place a lot of burden on individuals in Nigeria where over seventy per cent of healthcare access is done through out-of-pocket spending.
While stressing that governments at all levels need to do more in the treatment of diabetes, Prof Felicia Anumah of the Department of Medicine, University of Abuja Teaching Hospital, lamented that diabetes has become a huge problem in Nigeria. With increasing complications arising from diabetes, which are sometimes so dangerous that they can result into deaths of patients if not addressed in time, she condemned the high costs of accessing diabetes treatment in the country.
The Prof of endocrinology and diabetology noted that the problem most times with the diabetes foot patient is that, by the time he/she gets to the health centre where the right and proper care can be given, it is usually late. This usually leaves amputation in about 50 per cent of cases as the only option to save that person’s life, she said. “The plight of the common Nigerian is death due to lack of early detection, no funds, or ignorance or refusal for immediate treatment of worst stage diabetes, which leads to amputation,” she maintained. Anumah stressed that the reason for the above situation is that the National Health Insurance Scheme (NHIS) is still at the nursery stage, with coverage of less than five percent of the Nigerian population, which has encouraged an out-of-pocket system as far as healthcare access is concerned in the country.
She said with diabetes complications like kidney failure, heart attack, stroke and even amputation very expensive to treat, there is little hope for poor patients. According to her, it costs nothing less than N100,000 a week for dialysis, and about N360,000 to N540, 000 for diabetes treatment and much more for amputation. “Diabetes is an expensive disease; so is the treatment. Then the complications again add more to the cost. If a patient has, for example, kidney failure from diabetes, for that person in our Nigeria setting, it is like actually writing a death sentence and placing it on the forehead of that person. This is because even if it is just dialysis to just help the person to be averagely alright to be doing his/her normal work, that individual will need like N100, 000 per week to survive and that is a very expensive life.
“How many Nigerians can sustain that? Now for diabetes foot, if someone has a diabetes foot and is admitted, before that person is discharged, that person may need like N360, 000 to N540, 000. That is about $1,500 equivalent just for that particular admission for the treatment. Subsequent ones will still cause more problems and if the person needs to have amputation, the cost is more and that is why I am saying that this out-of-pocket system that we are running cannot work,” she said.