Wounds International, Vol 1; Issue 2Practice Innovative approaches for improving diabetic foot care in India

Innovative approaches for improving diabetic foot care in India

09/02/10 | Diabetic foot ulcers | Kshitij Shankhdhar, Lakshmi Kant Shankhdhar, Uma Shankhdhar, Smita Shankhdhar

Innovative approaches for improving diabetic foot care in IndiaThis short report discusses the problems of delivering high quality diabetic foot care in India and looks at recent innovations developed at a research centre in Lucknow. The introduction of simple, affordable approaches has been shown to provide practical solutions for people with diabetic foot problems. These include an easy to use offloading device and an education programme using mobi-films.



India has the largest diabetes population in the world with more than 50 million people diagnosed with the condition. This situation is unlikely to change with the World Health Organization predicting that 80% of all new cases of diabetes will be from the developing countries by 2025 [1]. Up to 25% of people with diabetes will develop a diabetic foot ulcer [2]. All patients will require regular screening to detect lesions early and prevent amputations.

In the United States (US), there are currently ten schools of podiatric medicine and reportedly over 13,000 podiatrists who offer foot care services. Despite this, each year, more than 80,000 amputations are performed in the US due to diabetes. In India, there are no schools of podiatry and there are no trained podiatrists or foot nurses. Consequently, diabetic foot care remains one the most neglected aspects of diabetes care in India.



Poor economic conditions and low literacy are key challenges for healthcare providers in India. Poverty in India is widespread, with the nation estimated to have a third of the world's poor. According to a 2005 World Bank estimate, 42% of people in India are living below the international poverty line of $1.25 a day. India also has the largest illiterate population of any nation, with an adult literacy rate of 66%, which is well below the world average literacy rate of 84%. A lack of awareness and education about the complications of diabetes leads to late presentation, lack of compliance, self-surgeries and faith-related practices.

Eight percent of the worldwide diabetes population live in the US, yet the US spends more than 50% of all global expenditures for diabetes care. On the other hand, only 10% of the 1.2 billion people in India have medical insurance. Poor affordability for appropriate treatment leads to increased risk for amputations, re-amputations and death. This is further compounded by the fact that many people walk barefoot in India, while the wearing of inappropriate or poor quality footwear increases the risk of trauma and subsequent ulceration.

Podiatry as a profession is non-existent in India and management of foot problems tends to be provided by either surgeons or orthopaedists, who, at times, are overly aggressive in their approach and will perform surgical procedures early rather than focusing on preventive measures, such as screening and offloading.



The LK Diabetes Centre was established 18 years ago by Dr Lakshmi Kant Shankhdhar and Dr Uma Shankhdhar and is the first private diabetes centre in North India. As a family the Shankhdhars work together as the diabetes foot care team (see author details at the end of the article) and have developed a number of innovative approaches to tackle common foot problems [3]. These include:

  • New method of patient education through mobi-films. These are short educational films that involve patients in their production and are made using mobile phones. The films are then distributed via MMS (multimedia messaging service) and displayed in the waiting room of the diabetes clinic, at camps and during diabetes programmes
  • Development of software to help plan diets for patients with diabetes. Specialised diet plans are prescribed for people with diabetes complications like nephropathy. The menus can be adapted for the four regions of India
  • Newer approach to insulin therapy using acarbose as a regulatory switch, for fine-tuning of glycaemic control
  • Development of a foot stand, the 'Samadhan Stand' to facilitate foot examination and podiatric care
  • Development of the Samadhan System of offloading (see page 2).


Page Points

  • WHO predicts that the majority of new cases of diabetes will be from the developing world by 2025
  • Diabetic foot care is one of the most neglected aspects of diabetes care in India
  • The LK Diabetes centre has developed a number of innovative approaches for improving diabetic foot care in India