Diabetic foot abnormalities are clearly one of the most important complications of diabetes mellitus (DM) and the leading cause of hospitalization with substantial morbidity, impairment of quality of life, and high treatment costs .^1,2 It not only occurs as a typical complication in the late stages of diabetes but also in patients with newly diagnosed DM.

Motor neuropathy leads to muscle atrophy, foot deformity, altered biomechanics of walking, and redistribution of foot pressures during standing and walking, which lead to callus. ^3,4 Abundant callus formation on pressure points (which act like a foreign body and further increase pressure) together with thinning of the submetatarsal head fat-pads, additionally increases the force of plantar pressure and ultimately results in foot ulceration.

The risk of ulceration is proportional to the number of risk factors. The risk is increased by 1.7 in persons with isolated peripheral neuropathy, by 12 in those with peripheral neuropathy and foot deformity, and by 36 in those with peripheral neuropathy, deformity, and previous amputation, as compared with persons without risk factors.⁵

In developing countries, which will experience the greatest rise in the prevalence of type 2 DM in the next 20 years, people at greatest risk of ulceration can easily be identified by careful clinical examination of the feet. Education and frequent follow-up is indicated for these patients.⁶ As the world is facing an epidemic of type 2 DM and an increasing incidence of type 1 DM, the International Diabetes Federation has chosen to focus on the global burden of diabetic foot disease in 2005.

Data on diabetic foot in Iraq are scanty and anecdotal.⁷

The aim of this study was to estimate the prevalence of diabetic foot abnormalities among patients with type 2 DM and the predictors of these abnormalities in Basrah.

This was a cross sectional study of patients attending the out patient clinic of two hospitals in Basrah (the General and the Teaching) for the period from January to the end of December 2005.All patients had type 2 DM. Diabetes and hypertension was defined as self-reported physician diagnosis of diabetes and hypertension.⁸

For all patients history was taken including age of the patients, smoking status, job, and qualifications (years of school achievement). Social class was calculated,and each patient was classified into low and other socioeconomic status, based on the aggregate score of education, occupation, and income.⁹ They were asked about duration of diabetes, medications, hospitalization and previous diabetic foot problems. Subjects reporting smoking at least one cigarette per day during the year before the examination were classified as smokers. All patients were examined for weight, height, blood pressure, body mass index (BMI), and calculated according to Quetelet formula (weight in kilograms divided by height in metres squared). Skin and peripheral pulsation were examined .Both feet were examined for structural foot abnormalities and skin changes.

Structural foot abnormalities were defined as follows: prominent metatarsal heads were defined as "any palpable plantar prominences of the metatarsal site of the foot," and high medial arch (pes cavus) as "an abnormally high medial longitudinal arch, which extends between the first metatarsal head and the calcaneus". ^4,10,11 Extension contracture at the metatarsophalangeal (MTP) joint with flexion contracture at the proximal interphalangeal (PIP) joint is called hammer toe, while hyperextension of the MTP and flexion of the PIP and distal interphalangeal (DIP) joint is termed a claw toe. Wasting was considered when there is guttering between metatarsal heads.

Skin was examined for callus which was defined as any hyperkeratotic formation due to shear stresses, usually in proximity to a bony prominence. Dryness was assessed objectively; fissures were included as any skin break that does not fit for the definition of foot ulcer below. Nail changes included any longitudinal ridging, fissuring, separations, loss or thickening.^4,10,11 Diabetic foot ulcer was defined as any full-thickness skin lesion distal to the ankle excluding minor abrasions, fissures or blisters. Interdigital fungal infection (Tinea pedis) was considered as any white, macerated skin between any web spaces.¹²

Metabolic control was according to American Diabetes Association (ADA) with fasting plasma glucose of 90-130 (5.0-7.2) mg/dL (mmol/L) and postprandial plasma glucose of less than 180 (< 10.0) mg/dL (mmol/L).¹³ An average of at least 3 readings were taken.
Diagnosis of peripheral neuropathy was according to quantitive assessment of symptoms and physical finding according to others' practice.¹⁴

Electrocardiography (ECG) was done for all and urine examined for overt proteinuria. Proteinuria was diagnosed on the basis of persistent frank proteinuria without erythrocytes or white blood cells in urine. Electrocardiographic changes were considered according to practice.¹⁵

Heart failure diagnosis was based on history and physician diagnosis with echocardiography.

Continuous variables were summarized as the mean ± SD. Categoric variables were summarized as percentages. For statistical analysis a chi-square test was used. A comparison of 2 means was carried out with an unpaired Student t test. The level of significance was set to be < 0.05 throughout the analysis.

The total number of patients was 182 (80 males and 102 females), with mean age of 56±8.4 year, and qualification of 2.5 ±4 year ( table-1). Duration of DM was 7.6±6.1 year and BMI of 25.6±2.5. Sixty eight point six percent were non- employed and 77.4% were from a rural area. Most subjects were from a low social class (86.8%). Their treatment was diet with oral hypoglycemic drugs in 73.6% and most had non-optimal glycemic control (94.5%) according to ADA. Hypertension was present in 52.1% with heart failure in 20.8%, ECG changes in 63.7% and proteinuria in 26.3%.

Structural foot abnormalities reported in diabetic patients were prominent metatarsal heads in 36.2%, wasting in 11.5%, hammer toes in 10.9%, pes cavus in 5.4%, claw toes in 3.8%, and amputees in 2.1% (table-2). While skin changes included dryness of the skin in 17%, fissures in the skin in 14.7%, callosities in 14.2%, Tinea pedis in 13.7%, foot ulcer in 13.7%, and nail changes in 7.1%. Peripheral neuropathy and dermopathy was seen in 21.9% and 6% respectively.

Diabetic foot abnormalities were reported in 46.7% of patients (table-3). Most patients had more than one abnormality. Variables that predict foot abnormalities (statistically significant) were higher age, male sex, less school achievement, longer duration of DM, higher BMI, smoking history, low social class, insulin use, hypertension, heart failure, and proteinuria.

Foot abnormalities were reported in 46.7% in this study with mean age of 62±6.2 year. A population based study in Minnesota showed that most diabetic patients have foot problems after age 40 and that the incidence of these problems increases with age.¹⁶

The commonest structural foot abnormalities in our study were prominent metatarsal heads (36.2%), followed by wasting (11.5%), then hammer toes (10.9%) and claw toes (3.8%).These changes alter foot biomechanics which will increase risk of ulceration and amputation.¹⁷

In this study diabetic foot ulcer was present in 13.7% of patients. This alarmingly high figure, is comparable with the figure (11.9%) in Algeria.¹⁸ To complicate the story of diabetic foot care in our area, we have no podiatry services available and since amputations are preceded by foot ulcers in 75-85% of cases.⁶ These figures seems amazing, for the future amputation in our diabetics.

Commonest skin changes in the study were dryness of the skin followed by fissures in the skin and callosities. The explanation of these skin changes is autonomic neuropathy which is reflected by decreased sweating, loss of skin temperature regulation, and autosympathectomy. Anhydrosis results in xerotic skin and predisposes skin to fissures, cracks, and callus formation.¹⁹

Predictors of foot abnormalities in this study were higher age, male sex, less school achievement, longer duration of diabetes mellitus, higher BMI, smoking history, low social class, insulin use, hypertension, heart failure and Proteinuria. Similarly ADA consensus group found that among persons with diabetes, the risk of foot ulceration was increased among men, patients who had had diabetes for more than 10 years, and patients with poor glucose control or with cardiovascular, retinal, or renal complications.¹⁷ And the benefit of education in reducing diabetic foot ulcers and lower-extremity amputation is well documented.²⁰ In a large Italian case-control study possible risk factors for ulcer formation were, male sex, and lack of diabetes education.²¹ While in Jordan amputation of the lower limbs correlates with duration of diabetes, poor glycemic control, smoking, neurological impairment, peripheral vascular disease and microalbuminuria.²² Lavery et al, in a multivariate model, have also demonstrated that poor glucose control, duration of diabetes over 10 years, and male sex are also significant risk factors for foot ulceration.⁵

Diabetic foot abnormalities were reported in 46.7% of patients. Variables predicting foot abnormalities (statistically significant) were higher age, male sex, less school achievement, longer duration of diabetes mellitus, higher BMI, smoking history, low social class, insulin use, hypertension, heart failure and proteinuria. We are calling for organization of the foot-care service in Basrah, and education should be tailored to the patient's understanding and social background to manage an epidemic of foot abnormalities expected to be seen in the near future.

Table -1-patient's characteristics

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Table-2-foot abnormalities

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Table-3 -predictors of foot abnormalities

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