das magazin / 20 January

    Diabetic Foot: a constant battle

    An Interview with Dr. Nashat Ali Hassan Ghandoura

    BirthplaceJeddah, Saudi Arabia
    ProfessionAdvisor on General Surgery and Head of the “Diabetic Foot” department of the King Fahad Hospital, Jeddah
    Areas of expertiseContributor to and participant of national and international conferences on Diabetic Foot; Vice President of the Diabetic Foot Committee of the Saudi Arabian Ministry of Health; Member of the Technical Committee for Diabetes Centres of the Saudi Arabian Health Ministry; Founder and member of the Working Group for Diabetic Foot of the Gulf States; Member of the European Wound Management Association (EWMA)
    Practical experience  

    Over 30 years

    You are THE expert for issues pertaining to diabetic foot in the Gulf region. How is it that the subject of diabetic foot has become so important in your professional career?

    In Saudi Arabia, diabetes is a hot topic. Diabetic foot (DF) is a serious complication of diabetes as it has huge repercussions on the patient’s condition and quality of life, as well as being associated with a highly significant socioeconomic impact. In 2008, I founded the “diabetic foot” department of the King Fahad Hospital in Jeddah, the first department dedicated to the disease in Saudi Arabia. Before 2008, these cases would often come to have a dramatic end, i.e. major amputations were involved. At that time, 33 out of 100 patients at the department of general surgery were patients with DF. As there were no community visits for treatment in Saudi Arabia, these patients would be admitted to hospital for 4-6 weeks. For this multi-dimensional disease, diabetes, there were no treatment guidelines or dedicated institutions, and these factors contributed to the high amputation rate. The main objective of my department is to improve the quality of care and quality of life of our patients. 60% of the Saudi population is younger than 30 years old.

    Which generation is the most affected by diabetes in Saudi Arabia?

    A large proportion of people aged 30 to 40 have type-2 diabetes. A study carried out by the King Saud University in Riad in 2012 showed that 24-28% of our population suffers from diabetes. The numbers just keep growing: In 2025, one in three people under the age of 50 will be affected, with one in two over-50s suffering from either diabetes or pre-diabetes. 15% of diabetics suffer from DF, with 15% of these patients developing osteomyelitis, a chronic inflammation of the bone and bone marrow. 15% of patients with DF will end up having to undergo either minor or major amputation procedures. The study also shows that 6-8% of patients with DF had to be admitted to hospital due to severe infection, chronic ischaemia of the legs, or other complications. The 5-year mortality rate amongst patients who undergo major amputations is as high as 80%. We see DF as a constant, ongoing battle.

    What are the most urgent problems which your patients have presented with, and how do you (try to) resolve them?

    A lack of awareness and knowledge on the part of patients! They are unaware of the significance and urgency of their situations, meaning they will often put off going to the doctor until the last minute. Some of these cases develop polyneuropathy, where they lose sensation in their limbs. These patients frequently come from rural areas, and have no blood testing (or very little) to monitor their diabetes making it even more challenging to save their limbs.

    And what about you? What challenges have you faced when treating your patients?

    The majority of medical devices we use to treat DF, such as dressings, debridement products, or total contact casts, are available in our country. The challenges we face relate to low levels of patient knowledge, awareness, and compliance. Additionally, we see the fact that the health services have insufficient experience in treating diabetes, particularly in rural areas. To raise awareness, we offer training courses and conferences. We see how doctors, nurses and diabetes centres exchange knowledge and experience, and we have already seen some improvements. Despite there being 23 diabetes centres in Saudi Arabia, patients are often referred to us from these centres as the level of knowledge across the different units varies.

    You’ve highlighted the importance of further education and training. What do you consider the most important training topics to be?

    Firstly, speaking to patients and their relatives, and explaining their situation to them; and secondly, early recognition of DF, and identification of the early stages of DF. Around 85% of diabetic foot ulcers could be avoided! If we were to “avoid” 50-60% of these DF patients, we would have really achieved something significant, in my opinion!

    What are your objectives in your day-to-day work?

    I would definitely say, to reduce the number of limb amputations! As well as improving treatments for primary ulcers before patients develop osteomyelitis. For this to be successful, we have to work in multidisciplinary teams of experts, e.g. vascular and plastic surgeons, dieticians, nursing staff, podiatrists, and orthopaedic technicians who produce custom-made footwear.

    And what are you goals for the next few years?

    50-60 % of patients with avoidable cases of DF should not even have developed the disease in the first instance. I am planning on setting up a podiatry school for doctors and nurses, as well as a DF specialist centre.

    What is the thing you enjoy most about your day-to-day work?

    I get a real sense of joy when I see that my patients are happy, when I know that I have given them back a better quality of life following a foot ulcer healing up, or when we have managed to save one of their limbs, and some patients even mention me in their prayers.