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VOLUME 15 NUMBER 1 • JULY 2018
ACHIEVING BEST PRACTICE
SA JOURNAL OF DIABETES & VASCULAR DISEASE
Risk factors for diabetic foot ulceration
SIMISO NTULI, CRAIG VINCENT LAMBERT, ANDRÉ SWART
Correspondence to: Simiso Ntuli
Department of Podiatry, Faculty of Health Sciences, University of
Johannesburg, Johannesburg, South Africa
e-mail:
sntuli@uj.ac.zaCraig Vincent Lambert
Department of Emergency Medical Care, Faculty of Health Sciences,
University of Johannesburg, Johannesburg, South Africa
André Swart
Faculty of Health Sciences, University of Johannesburg, Johannesburg,
South Africa
S Afr J Diabetes Vasc Dis
2018;
15
: 32–36
Abstract
Objective:
The main purpose of the study was to investigate
the need for podiatrists as members of the primary
healthcare team. One of the objectives of the study was
to determine the percentage of patients presenting at the
two primary healthcare clinics who are at risk of developing
foot complications as a result of an underlying concomitant
systemic disease.
Methods:
This was a descriptive, cross-sectional study in
which data were collected from patients presenting at
two homogeneously selected primary healthcare clinics in
Johannesburg. Nursing staff assisted by a final-year podiatry
student collecteddata using a self-constructeddata-collection
form from each consenting patient as part of their routine
patient consultation. Simple descriptive statistics were used
for data analysis.
Results:
Data were collected and analysed from 1 077 patients
and showed that 29% of the patients had diabetes. Diabetic
foot ulceration risk factors that were recorded included
peripheral neuropathy in 74% of the diabetic patients,
structural foot deformities in 47%, peripheral vascular
symptoms in 39% and foot ulcer in 28% of the diabetic
patients.
Conclusion:
Early identification of diabetic patients who
are at high risk of diabetic foot ulceration is important
and can be achieved via mandatory diabetic foot screening
with subsequent multi-disciplinary foot-care interventions.
Understanding the factors that place patients with diabetes
at high risk of ulceration, together with an appreciation of
the links between different aspects of the disease process
and foot function, is essential for the prevention and
management of diabetic foot complications.
Keywords:
diabetic foot ulceration, diabetic foot risk factors,
primary healthcare, podiatry services, diabetic foot assessment
Introduction
Diabetes mellitus is a disease affecting many systems and tissues,
and foot problems, including foot ulcerations, are common in
patients with diabetes. In 2015, there were 2.8 million diabetics in
South Africa.
1
The majority of diabetic patients in South Africa (SA)
are most likely seen at primary healthcare clinics (PHC). These clinics
bring healthcare as close as possible to where people live and work,
are the first line of access for people needing healthcare services,
and in some cases are the only available platform for delivery of
healthcare for most of the population.
2,3
In Gauteng province where
this study was done, 740 118 diabetic patients presented at various
PHC clinics for routine diabetic follow-up visits in 2012/13.
4
Foot problems are an associated complication and are an
increasing problem among individuals with diabetes. Risk factors
such as peripheral neuropathy, peripheral arterial disease and
structural foot deformities put the foot at risk of ulceration.
Healthcare professionals at PHC level are mandated and are
accountable for screening, early identification, and referral to more
advanced levels of sophisticated care and/or treatment if the need
arises.
5-7
However, with regard to patients at risk of diabetic foot
ulcerations, it remains unclear if this is done as there are no data on
the diabetic risk factors recorded in patients presenting at various
PHC clinics in SA.
Diabetic foot ulceration (DFU) develops as a result of a
combination of factors that together lead to tissue breakdown. The
most frequently occurring causal pathways to the development of
foot ulcers include peripheral neuropathy, vascular disease, foot
deformity and trauma.
Early identification of patients with diabetes mellitus who are at
high risk of DFU is important, as between 10 and 25% of diabetic
patients are likely to develop DFUs at some stage of their lives,
which may lead to foot or leg amputations in 25 to 50% of these
patients.
8,9
Available data in SA suggest that 60.2% of all non-
traumatic lower-limb amputations in public hospitals in SA are
accountable to diabetes, with unpublished data from two separate
public hospitals showing an amputation rate of 78.5%, with 85%
of these beginning with a foot ulcer.
10,11
In most cases, by the time
patients with diabetic foot ulcerations are referred, it is often too
late to save the foot.
12
Currently, the PHC clinics provide an ideal setting for early
diabetic foot risk identification, as these facilities are primarily
focused on preventative care and early risk identification rather than
a curative approach.
13-15
However, nurses who are at the coalface of
primary healthcare delivery are overworked and do not have time
to provide comprehensive care in all consultations.
16
This may lead
to diabetic foot assessment being omitted as part of the diabetic
patient routine assessment. This assertion is supported by the lack
of data on diabetic foot risk factors emanating from PHC clinics.
There is, therefore, a need to look at including other healthcare
cadres to ensure essential delivery of foot health services, including
to the diabetic patients. A multi-disciplinary approach underscoring
a comprehensive preventative strategy, including early risk detection
via mandatory foot assessment, patient and staff education,
and multi-factorial treatment of diabetic foot ulcers is needed.
The literature shows that in some cases, such approaches have
reduced amputations by more than 50%.
17-20
Such interventions
will ensure good outcomes for diabetic patients, as well as prompt
treatment and or referral where needed. This may be difficult to
realise immediately as currently, foot health service guidelines or