Outcome of clinical foot examination in relation to self-perceived health and glycaemic control in a group of urban Tanzanian diabetic patients

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Abstract

Diabetic foot complications were studied in 153 patients at the university clinic in Dar es Salaam (56 insulin treated, 77 treated with oral agents and 20 with diet only). Neuropathy disability and symptoms scores were used to diagnose peripheral neuropathy (PN). Peripheral vascular disease (PVD) was classified as ankle/brachial pressure index less than one. The degree of metabolic control was assessed by glycated haemoglobin (HbA1c) and self-perceived health was measured with SF-36. PN was present in 28.1% of patients and 12.5% had PVD. Patients with PN had higher age and later onset of diabetes in comparison with patients without foot complications. Patients with PVD had longer duration of diabetes and higher systolic and diastolic blood pressure compared with those free from PVD. HbA1c and body mass index did not seem to influence the occurrence of PN or PVD. Patients with PN had significantly poorer self-perceived health, whilst PVD-patients had health scorings equal to patients without any foot complications. PN, but not PVD, appeared to have a negative influence on patients self-perceived health. In comparison with studies from the industrial world, foot problems are as common in diabetic patients living in a developing country.

Introduction

Foot complications are major problems in diabetic patients in industrial countries. The prevalence of peripheral neuropathy (PN) has been reported to be between 13 and 54% in different patient groups 1, 2, 3, 4, 5, while that of peripheral vascular disease (PVD) has varied between 11 and 25% 2, 5, 6.

In African diabetic patients, several earlier studies have reported a lower prevalence of PN and PVD than what was found in European and North American patient groups 7, 8, 9. This could be due to a shorter duration of diabetes in African patients. However, in a recently published study from Sudan [10], the authors found a higher prevalence of PN (37%) and PVD (10%) than earlier reported despite a short duration of diabetes. It is also known that long periods of insulin shortage are common in African countries and lead to high mortality rates in acute diabetes complications and long periods of poor glycaemic control [11]. There is a known correlation between glycaemic control and the development of late complications 12, 13, 14and it has also been reported that European and American diabetic patients with long-term complications and poor glycaemic control experience a deteriorated self-perceived quality of life 15, 16. Because of periods of insulin shortage followed by poor glycaemic control in African diabetic patients, it could be expected that the prevalence of foot complications would be as high as in European patient groups, which in turn, probably affects quality of life. The aim of the current study, therefore, was to highlight foot problems in relation to glycaemic control and quality of life in diabetic patients living in an urban area of Tanzania.

Section snippets

Subjects

The number of diabetic patients registered at the diabetes clinic at Muhimbili Medical Centre (MMC) is unknown. According to the morbidity and mortality study [21]1250 newly diagnosed patients were registered at MMC during a 6 year period (1981–1987). In a follow-up study in 1989 276 of them had died. During a 5-week period (five clinic days) 209 diabetic patients visited the diabetes clinic at MMC. Into the current study patients were selected randomly as the first eight patients entering into

Clinical characteristics and glycaemic control

The mean age of the 153 patients (77 men, 76 women) was 44.2 years (S.D. 14.4 years), the mean age at onset was 39.3 years (S.D. 13.8 years) and the mean duration of diabetes was 5.2 years (S.D. 5.9 years) with 20.4% of the patients having a duration≥10 years. The mean BMI was 24.4 kg/m2 (S.D. 4.8). A total of 18% were classified as underweight, 36% as overweight and 10% as obese. Half of the patient group (50.3%) was treated with oral antidiabetic agents, 36.6% had insulin treatment and 13.1%

Discussion

The findings of a 28% incidence of confirmed neuropathy and 12.5% PVD amongst our diabetes patients are in accordance with most other estimates 1, 2, 3, 4, 10. Modified versions of neuropathy symptoms and disability scores have been used as criteria for PN in different studies. Moreover, it has been demonstrated that PN affects some 13–54% of the diabetic population and PVD, 11–25% [20].

A recent Swedish study [14]and particularly the DCCT study [13], has confirmed a strong association of

Acknowledgements

This work was supported by grants from The Swedish Red Cross and Lions Club, Sweden. We thank Boehringer-Mannheim, Scandinavia for provision of the blood and urine test-equipment.

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