As the Canadian physicians who are collaborating with the Ministry of Health in the Guyana Diabetic Foot Project, we would like to respond to the important editorial of January 27 entitled “Deadly Diabetes.” We want to commend the editors for addressing the urgent problem of diabetes in Guyana and agree with them that adult onset diabetes (Type 2) can be considered a tsunami which is spreading throughout Guyana and the rest of the world.
The Diabetes Atlas estimates that diabetes prevalence in Guyanese adults will rise from a current nine per cent to 17 per cent (over 125,000) by 2030. The cause for the increase is obesity, lack of exercise and inappropriate diet. The Ministry of Health is responding to this threat through collaborations like the Guyana Diabetic Foot Project.
While the project name derives from the original focus on diabetic foot problems, the project is now a comprehensive sustainable initiative to improve the multi-level chronic disease program in the public health system.
We began addressing the foot problem in 2008, because of its association with a high rate of preventable lower limb amputations. For a number of reasons, including climate and poverty, diabetic foot complications are particularly common and severe in the developing world.
The Caribbean region has some of the highest rates of amputation in the world. A 2006 World Bank study cites foot care for high risk patients, together with improved long term blood sugar regulation and blood pressure control, as the highest level diabetes priorities in developing countries. The project, funded by the Canadian International Development Agency, targets these issues. Phase 2 is currently operating in Regions Two to Region Six and Region Ten, where more than 90 per cent of Guyanese citizens live.
Prevention is the key to solving diabetic foot problem and we have developed a simplified 60-second foot screen that identifies the 50 per cent of persons with diabetes who are high risk. These individuals are being referred to the diabetic foot centres in Georgetown and the regional centres that are being established.
High risk patients receive intensive education on foot care and foot wear and have special shoes prescribed when required to redistribute the pressure in the sole of the foot. We encourage all persons with diabetes to have their feet examined regularly by trained health care professionals who will complete the screening test.
At present, there is a large burden of foot ulcers. Holistic treatment focuses on treating the cause – blood sugar control, infection and redistributing abnormal pressure on the bottom of the foot due to associated loss of protective sensation. The project pays attention to the concerns of the patient and provides local wound care using scientific best practices. This approach was developed by one of the authors and is recognized by the World Health Organization. The results to date have been gratifying.
In answer to a specific question raised in the editorial, there has been a sustained and ongoing reduction in the number of major amputations (whole foot or above) of about 50 per cent since the opening of the DFC in 2008. This represents a saving of four limbs per month, totalling 168 limbs saved to date.
With the number of diabetic foot admissions in Georgetown increasing, the proportion of patients requiring major leg amputations has been reduced even more – from 35 per cent to 13 per cent. As the prevention programme takes hold we anticipate that these numbers will continue to improve, saving the legs of more people with diabetes.
The editorial speaks of the lack of local use of treatment modalities available in high income countries. In our view, uncritical use of expensive treatments will divert precious resources required to develop and sustain an integrated approach to the problem. Removable cast walkers cost about $30,000 patient and our devices cost $5,000. We can treat six times the number of patients at the same cost!
Regranex gel, applicable for less than 5%of patients, is no longer available in Canada due to lack of proof that it represents value for money.
In April 2010, with our assistance the Ministry introduced HbA1c testing to measure the 90 day average blood sugar. This test is the gold standard for blood sugar control. Currently, over 2500 patients have been tested and we are working together to make this a regional service.
We think the Guyanese people have reason to be proud of the Ministry of Health and that Guyana can be considered a leader in the Caribbean.
R Gary Sibbald MD
Brian Ostrow MD
Julia Lowe MBChB
University of Toronto, Canada
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