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VOLUME 15 NUMBER 1 • JULY 2018
35
SA JOURNAL OF DIABETES & VASCULAR DISEASE
ACHIEVING BEST PRACTICE
characteristics of such foot assessment to be undertaken would
include the removal of shoes and socks for a careful inspection
of both feet, including between the toes (Table 3). Ideally, every
diabetic patient should be screened for evidence of DFU risk factors
at least annually at their PHC clinic.
For example, diabetic peripheral neuropathy risk factors, which
are associated with a seven-fold increase in risk of ulceration,
29,30
and was recorded in patients in this study, can be identified by a
simple clinical observation. Such an observation would including
looking for features such as small-muscle wasting, clawing of the
toes, prominence of the metatarsal heads, distended dorsal foot
pains (a sign of sympathetic autonomic neuropathy), dry skin and
callus formation. Additional tests may include a vibrating 128-Hz
tuning fork, and the 10-g monofilament to be used at specific sites
of the foot.
Assessment of the actual foot structure for deformity should
also be undertaken. Structural foot deformities, when combined
with neuropathy and ensuing altered biomechanics, may lead to
abnormal loading of the foot or abnormal plantar pressure, leading
to ulcer formation.
24
Foot deformities were noted on patients in this
study as well as actual foot ulcers in diabetic patients. Patients in
this study were at an increased risk of amputation as 28% had foot
ulcers and 39% had symptoms of peripheral arterial disease.
31,32
Studies done on the diabetic population in SA suggest that foot
health at PHC level ranges from non-existent, to mostly ignored, or
disorganised, at best. One study done at an out-patient department
of a district hospital found that 67.5%of diabetic patients had never
had their feet examined by either a doctor or a nurse at a PHC.
33
Other studies have found that primary and secondary prevention
were not prioritised in routine diabetic patient clinical care and that
foot screening is often neglected at PHC level.
34,35
Although our findings are suggestive of the need for preventative
measures, including having diabetic foot assessment included as
a mandatory item of routine diabetic patient care at PHCs, poor
diabetic foot care at PHC level is understandable. Nurses at PHCs
have a heavy patient load, which may limit patient consultation
times and getting through their patient load may lead to a situation
where possibly, feet assessment may be the last thing on both the
nurses’ and patients’ minds during consultation.
16,36
Therefore,
there is a need to consider the involvement of podiatrists at PHCs
to undertake diabetic foot assessment and risk stratify patients as
well as provide treatment for some of the foot pathologies at this
level of care.
37
Podiatrists play a key role in the prevention (includes regular
foot examinations, risk stratification and appropriate footwear
recommendations) and treatment of foot deformities and
complications related to diabetes at PHC level. A podiatric approach
to diabetic foot ulceration is distinctive in that the diabetic foot
ulceration is not viewed in isolation but rather in the perspective
of the overall structure and function of the foot, ankle and lower
limb. Therefore, podiatric treatment of DFUs includes a focus on
biomechanical anomalies that often precede ulcer formation.
Further, simple interventions such as regular callus debridement to
prevent increases in focal pressures can reduce the likelihood of
ulcer formation.
Conclusions
We have provided some evidence of patients presenting at PHCs
with risk factors for DFU. Our findings should be used as an
indicator of a silent but imminent public health problem that is likely
to impose significant challenges on the South African healthcare
systems in the near future. This is indicative of a need for effective,
early preventative approaches, primarily the early identification of
at-risk patients at PHC level.
In our healthcare structures, a substantial number of diabetic
patients are most likely seen at PHC facilities across SA and a
considerable number may be at risk of DFUs. Early identification of
at-risk patients could prevent or delay development of DFUs, and
in cases where patients already have DFUs, prompt management
or referral with subsequent multi-disciplinary foot-care intervention
could be assured. Therefore, there is a need for diabetic foot
assessment to be mandated as a part of routine diabetic patients
care at PHC level.
Significance of the study
• There are limited data available on diabetic foot risk factors
across all levels of care in South Africa.
• The study found that up to 74% of patients presenting at PHC
facilities in this study had symptoms of diabetic peripheral
neuropathy and 28% had foot ulcers.
• The findings are suggestive of a need for diabetic foot
assessment to be mandated at PHC level as part of the routine
diabetic patient assessment and for podiatrists to be involved at
this level of care.
Acknowledgements
I am grateful to the nurses (especially the clinic managers) and the
patients from the two clinics who took part in this study, as well
Be there
for those
priceless
moments.
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NS2 08/7.5/0182. For full prescribing information, refer to the professional information approved by
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0860 PHARMA (742 762) / +27 21 707 7000
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