1. Diabetic Foot in Jordan: Challenges and Solutions
Nidal Younes MD
Professor of Endocrine Surgery and Diabetic Foot Consultant- NCDEG

3. International Diabetes Federation’s
Diabetes mellitus
Chronic metabolic disorder, characterized by chronic hyperglycemia.
leading to long-term damage, dysfunction and failure of various organs such as the heart kidneys, eyes and foot ulcers.
it affects about 8.3% of the world’s population
International Diabetes Federation’s

4. Diabetes is a huge and growing problem…
2014
2035

5. Diabetes is a huge and growing problem…

6. Diabetes in the Arab world
IDF Diabetes Atlas fourth edition. International Diabetes Federation

7. Diabetes in Jordan
The prevalence of diabetes increased 31.5 % from 1994 to 2008
Kamel Ajlounia et al An increase in prevalence of diabetes mellitus in Jordan over 10 years.Journal of Diabetes and its Complications: 22 (5) September–October 2008, 317–324 ( from 13.4 to 17.1%
The Jordanian Diabetes Crisis
International Economic Development Program 2008 Gerald R. Ford School of Public Policy University of Michigan
 A recent study found that less than 20% of adults in the Kingdom are at a healthy weight.

8. An increase in prevalence of diabetes mellitus in Jordan over 10 years
Kamel Ajlouni,et al Journal of Diabetes and its Complications
Volume 22, Issue 5, 317–324

10. Diabetic foot
Diabetic Foot is the anatomical area below the malleoli in a person with diabetes mellitus.
The American Diabetes Association
Group of syndromes in which neuropathy, ischaemia and infection lead to tissue breakdown, resulting in morbidity and possible amputation
World Health Organization, 1995.

11. Foot complications of diabetes

12. Diabetic foot The prevalence of foot ulcerations among diabetics 4-6%
lifetime risk of a person with diabetes developing a foot ulcer could be as high as 25% resulting in more hospital stay days than all other diabetic complications combined
Singh et al, . JAMA 2005; 293: 217–28.

13. What is the burden of diabetic foot.
Foot ulcers cause
- Substantial morbidity
- high treatment costs
-The most important risk factor for
lower-extremity amputation
- Perioperative mortality is 9% -15%
Every 20 seconds a lower limb is lost somewhere in the world as a consequence of diabetes
Singh et al, . JAMA 2005; 293: 217–28

14. Health related quality of life
Negative psychological and social effect
reduction in social activities
increased family tensions for patients and their caregivers (spouses or partners)
limited employment, and financial hardship.

15. Prognosis after major amputation

17. Burden of diabetic foot ulcers in Jordan
1142 patients attending the (NCDG) randomly selected during 2001 The prevalence of DFU was 4%
Jbour et al , Saudi Med J 2003; Vol. 24 (7)

18. Burden of diabetic foot ulcers in Jordan
1000 patients attending the (NCDG) randomly selected during 2006
prevalence of foot ulcers 4.6%
sensory neuropathy 14.9%
lower limb ischemia 7.5%
amputation 1.7%.
Bakri F *, Allan A Khader Y, Younes N, Ajlouni K: Prevalence of diabetic foot ulcer and its associated risk factors among diabetic patients in Jordan JMJ Sep2011

19. Risk factors for diabetic foot
ulcerations in Jordan
Ulcers
n (%)
PVD
Monofilament
Amputation
Age
21-40
41-50
51-60
61-70
1 (2)
9 (5.8)
36 (10.8)
19 (6.8)
p = 0.003
22 (6.6)
39 (13.9)
p =0.000
5 (10)
11 (7.1)
47 (14.1)
69 (24.6)
p= 0.000
0 (0)
1 (0.6)
8 (2.4)
13 (4.6)
p= 0.037
Duration of DM <5
5-10
>10
1 (0.3)
12 (4.2)
56 (16.0)
p=0.000
9 (2.5)
17 (5.9)
67 (19.1)
15 (4.1)
126 (35.9)
2 (0.7)
21 (6)
HbA1C
HbA1C < HbA1C >7
7 (2.8)
62 (8.3)
p=0.001
10 (4)
83 (11.1)
15 (6)
143 (19.1)
1 (0.4)
23 (3.1)
p=0.009
Faris al Bakri et al JMJ

20. The burden of diabetic foot
The incidence of Charcot 1.9 cases/1000 people with diabetes in Jordan
Clinical factors associated with Charcot foot. Mohammed Al Mousa, Mahmoud Al-Ardah, Jihad Al-Ajlouni, Nidal Youne. The Diabetic Foot Journal.2011, Vol 14, No 3, pages 124–129

21. Recurrent foot ulceration
141 patients newly diagnosed with foot ulceration attended the diabetic foot clinic at NCDEG
76 patients developed recurrent foot ulceration during two years, and the incidence rate was 58.5% / 2 years
Sinan F. Tabanjeh Recurrent Foot Ulcers; Frequency and Associated Risk Factors Master thesis 2014

22. Diabetic foot and anemia
Frequency of anemia in DFU 69%
Predictors of anemia
Kidney disease
Acid reducers
Amputation
Grade 3 ulcerations
Razan Tubieleh, Anemia in diabetic foot patients at Jordan University Hospital: master thesis 2015

23. Diabetic foot and psychatric disorders
A cross sectional study on 260 patients with DF at the NCDEGD revealed:
Prevalence of Anxiety 37.7%
Duration of the diabetes (< 10) coronary artery disease and foot ulcer duration (< 7month)
Prevalence of depression, 39.6%
female gender, non- smoker, retinopathy, vitamin deficiency and foot ulcer duration (≥ 7 month)
Ali Hussain Master thesis : psychatric disorders among DF patients 2015

24. Reem Moh’d Al-Qaddah. knowledge and practice of foot care 2012
Knowledge, education!
Among 982 patients with diabetes attending KHMC
24.8% had poor practice of foot car
16.6% had poor knowledge of foot care
Reem Moh’d Al-Qaddah. knowledge and practice of foot care 2012

25. The severity of diabetic foot ulcers at JUH
84 patients evaluated according to DEPA score
(D: depth, E : extent of infection, P: phase of healing,
A: associated etiology)
32 pt (38%) had a score < mild disease
34 pt (40%) had a score of moderate disease
10 pt (12%) had a score > ( severe disease)
Excellent healing in 49/84 (58%) healing at 10 wks
Good healing in 16/84 (19%) healing at 20 wks
Poor healing in 6/84 (7%) no healing at 20 wks
Younes et al. Foot & Ankle surgery 2004; 43(4):

26. Among this diabetes crises, What can we do to prevent foot complications?

28. Prevention of diabetic foot ulceration
Primary prevention
aim at diabetes management
Secondary prevention
Aim at good foot care/foot at risk
Tertiary prevention
Ulcer healing should be followed by a well coordinated program of secondary prevention

29. Health care system improvement
Create training program that would complement current certificate and degree programs offered at recognized centers (NCDEG)
Provide incentives for diabetic foot related doctor training.
Diabetes care centers
Diabetes foot care centers
from the International Economic Development Program 2008 Gerald R. Ford School of Public Policy University of Michigan diabetes crises in Jordan

30. Diabetic foot clinics Jordan university Hospital 1997 NCDEG 2003
Royal military services
Scattered services in the private sector

34. Services provided at these centers
Assessment and evaluation
Management of foot ulceration
Wound bed preparation
Incision and drainage
Debridements
Vascular evaluation
Special surgeries ie .tendon excision
Offloading
Vacuum drainage
Oxygen therapy
Blood sugar control
Antibiotics

38. outcome
Implementing a lower extremity disease management program consisting of screening and treatment protocols for diabetic members in a managed care organization decreased the incidence of amputations by 47.4%
Review Towards less amputations in diabetic patients. Incidence, causes, cost, treatment, and prevention--a review.Larsson J, Apelqvist J Acta Orthop Scand Apr; 66(2):181-92

39. Outcome
Awareness of diabetic foot care, as well as its prevention and proper management, resulted in a 50% reduction in major amputation rates
Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.Van Gils CC, Wheeler LA, Mellstro M, Brinton EA, Mason S, Wheeler C Diabetes Care May; 22(5):

40. Conclusion Diabetic foot disease A serious problem Preventable problem
Adequate diabetes care
Adequate foot care
Patient education
Identify patients at risk
Daily foot inspections by patient.
Custom fitted Shoe
Refer at risk patients to Diabetic foot center
Adequate metabolic and infection control

41. To provide adequate foot care for diabetic patients:
CONCLUSION
To provide adequate foot care for diabetic patients:
1. Patient education
- Daily foot inspections by patient (SIF)
- Custom fitted Shoe
2. Identify patients at risk
3. Refer at risk patients to Diabetic foot centers
- Provide multidisciplinary team-coordinated by surgeon
4. Early evaluation and management
5. Adequate metabolic and infection control