ADVERTISEMENT
Recognizing The Impact Of Sociocultural Factors On Diabetic Foot Complications In The Developing World
Many sociocultural and religious factors encourage people in India and neighboring developing countries to walk barefoot, exposing them to a risk of injury and foot lesions. In people with diabetes, such injuries might even lead to amputation. Poverty and illiteracy further influence people’s behavior, which results in negligence and delayed medical attention with aggravation of the foot lesion. Feet are vulnerable in patients with diabetes due to elevated risks for diabetic peripheral neuropathy, peripheral vascular disease (PVD) and infection.
Currently, there are 415 million people in the world with diabetes and the number is expected to rise to 642 million by 2040.1 Currently, one out of 11 people in the world is suffering with diabetes and this number will be one in 10 people in 2040. About 46.5 percent of adult patients with diabetes are undiagnosed. Every six seconds, someone dies from diabetes.
India has 69.18 million patients with diabetes mellitus.1 Diabetes is increasing faster in the world’s developing economies than in developed ones. Three-quarters of patients with diabetes live in low- and middle-income countries. Thus, the world is facing an unprecedented epidemic of diabetes. At one point, limb loss due to diabetes occurred every 30 seconds but recent research estimates this number to be every 20 seconds.2-3
A Closer Look At The Barriers To Diabetic Foot Care In India
Among the various diabetes-related practices, diabetic foot care happens to be the most neglected one.4 India’s current population is 1.28 billion people but there is not even a single podiatrist or a qualified foot nurse in the country.5 Unfortunately, podiatry is not recognized as a specialty in India so there is hardly any job opportunity for those who practice podiatry in India despite the overwhelming need for foot and ankle care.
The literacy rate in rural areas in India is 71 percent in comparison to 86 percent in urban areas.6 India currently has the highest number of illiterate people in the world.7 An average of 326 out of 1,000 students in rural areas are dropping out of school and 383 per 1,000 are dropping out in urban areas.8
About 49 percent of rural households show signs of poverty as per seven indicators of deprivation.9 Also, 51 percent of the households have “manual casual labour” as the source of income. This reflects the rather precarious existence of over 450 million people in rural India.
Therefore, the extent of poverty and deprivation is still very high in India. Illiteracy and poverty together lead to neglect of self-care and poor foot care. These factors, coupled with certain religious customs and rituals as well as sociocultural behaviors, immensely influence foot care in patients with diabetes.
The most important factor is barefoot walking. Many people walk barefoot in gardens to relieve the burning sensation in their feet due to diabetic peripheral neuropathy. They also walk barefoot on lawns due to a myth that their eyesight improves by such behavior. Barefoot walking exposes the feet to trauma and the resulting lesions tend to be painless. This leads to neglect of the foot lesions by the patients and late presentation to doctors.
There is a custom in India to visit religious places with bare feet so everybody goes barefoot in temples. Most of these temples have big open yards and corridors with concrete flooring that become very hot during summer, and may result in blisters and ulcers on soles. Then there is risk of prick injury due to foreign bodies. In the house, barefoot walking during winters results in blisters and ulcers on toes and soles.
The Muslim community in India organizes barefoot walking on fire during the “aag ka matam” ceremony, which may result in burns and ulceration. People often pledge to walk barefoot to religious places, often situated on hilltops, to express their faith and sacrifice toward God. Sometimes people remain barefoot for months and years as penance, and are likely to get injuries to feet due to trauma, pricking or hot or cold surfaces. There are many cases of rodent bites during the night with feet being insensate due to diabetic peripheral neuropathy.10
Women in India wear metallic toe rings (bichua) made up of silver or gold, which may injure some part of the other leg or foot.11 During winter, people in India are very fond of heat fomentation with a heater or a tray with fire. We see many patients with diabetes getting burn injuries in insensate feet due to diabetic peripheral neuropathy.
How Economics And Ignorance Can Lead To Diabetic Foot Complications
Economic compulsions coupled with ignorance often lead to a person walking barefoot, wearing worn out/badly repaired footwear and socks, and seeking proper medical treatment in a delayed manner, all of which contribute to the development and chronic nature of foot ulcerations in people with diabetes.
Illiterate people tend to neglect the diabetic foot lesions more frequently. They refuse to recognize the importance of wearing appropriate footwear and socks. Often, the cause of a lesion is the use of wrong footwear or socks and patients refuse to change them due to unaffordability or neglect, even when footwear or socks have caused the lesion. Sometimes, foot lesions result from self-treatment (self-surgeries/bathroom surgeries) by patients.
Often, poor and illiterate people visit “faith healers” for healing. Faith healers resort to a number of hazardous methods of treatment of diabetic foot lesions. Some of the healers ask for immediate discontinuation of current medical treatment, offer herbs and shrubs to patients, and delay their approach to appropriate modern treatment. Invariably, these faith healers are not offering free services but charge these poor patients heavily. At times, they resort to many odd and unorthodox treatments like enchanting religious rhymes or beating the patient with a broom even if the patient screams with pain and misery. Some of the faith healers even prescribe the sacrifice of animals/human lives for early healing of foot lesions.
When people develop a foot lesion, they usually tend to neglect it in the beginning. This is the phase of “denial” when patients refuse to acknowledge that they have a serious problem. Then they try home remedies, visit a “faith healer” and/or try alternative medicine and other modalities of therapy. This is the phase of “therapeutic inertia” in which the patient is simply delaying proper investigation and treatment. By this time, both diabetes control and the diabetic foot lesion would have deteriorated, and now the patient faces the risk of amputation. The patient finally reaches a surgeon, who is left with little option but to amputate.
In Conclusion
For patients with diabetes, their feet are quite vulnerable due to the potential development of diabetic peripheral neuropathy, resulting in insensate feet, impaired vascularity due to PVD and an unduly high risk of infection. These factors alone or in combination increase the risk of amputation to a very high level. Neuropathic diabetic foot ulcers, although preventable, are the primary factor leading to lower extremity amputation.12
Dr. Lakshmi K. Shankhdhar is the Medical Director and endocrinologist of North India’s only exclusive diabetes clinic, the LK Diabetes Centre in Lucknow. He is the Principal of the Lekhraj Diabetes Hospital and Medical College in Lucknow.
Dr. Kshitij Shankhdhar is a diabetologist at the Lucknow Diabetic Foot Care Clinic and Research Centre in Lucknow, India.
Dr. Uma Shankhdhar is a medical nutrition therapist at LK Diabetes Centre in Lucknow, India.
Dr. Smita Shankhdhar is a physician and diabetes educator at LK Diabetes Centre in Lucknow, India.
References
1. International Diabetes Federation. Available at www.diabetesatlas.org .
2. Bharara M, Mills JL, Suresh K, et al. Diabetes and landminerelated amputations: a call to arms to save limbs. Int Wound J. 2009;6(1):23.
3. Boulton AJ, Vileikyte L, RagnarsonTennvall G, Apelqvist J. The global burden of diabetic
foot disease. Lancet. 2005; 366(9498):171924.
4. Shankhdhar K, Shankhdhar LK, Shankhdhar U. Diabetic foot care in the land of no podiatrists. WCET Journal. 2008; 28(1):20–23.
5. https://www.livepopulation.com/country/india.html .
6. PTI. Literacy rate at 71% in rural India, 86% in urban: survey. Economic Times. Available at https://economictimes.indiatimes.com/news/economy/indicators/literacy-rate-at-71-in-rural-india-86-in-urban-survey/articleshow/47886609.cms . Published Jan. 30, 2015.
7. PTI. India has the largest number of illiterates in the world. Rediff India Abroad. Available at https://www.rediff.com/news/2007/nov/20illi.htm . Published Nov. 21, 2007.
8. Kumarl C. Literacy rate up, but so is illiteracy. The Times of India. Available at https://timesofindia.indiatimes.com/india/Literacy-rate-up-but-so-is-illiteracy/articleshow/50749744.cms . Published Jan. 28, 2016.
9. Venu MK. The socio-economic census confirms that Indians are poor. Now wait for the politics. The Wire. Available at https://thewire.in/5557/india-still-remains-a-country-with-large-numbers-of-poor/ . Published May 7, 2015.
10. Shankhdhar LK, Shankhdhar K, Shankhdhar U, Shankhdhar S. A mouse-nibbled toe in a case of diabetic peripheral neuropathy. Diab Foot J. 2016; 19(2):100–1.
11. Shankhdhar LK, Shankhdhar K, Shankhdhar U and Shankhdhar S. Reducing shear pressure to facilitate healing of a dorsal foot wound. Podiatry Today. Available at https://www.podiatrytoday.com/reducing-shear-pressure-facilitate-healing-dorsal-foot-wound . Published May 2016.
12. Boulton AJM, Kirshner RS, Vileikyte L. Neuropathic diabetic foot ulcers. N Engl J Med. 2004; 351(1):48-55.
