Diabetes-Related Lower Extremities Amputations in Saudi Arabia: The Magnitude of the Problem

Abstract

Background: Data on diabetes-related lower extremities amputations in the Kingdom of Saudi Arabia (KSA) and perhaps in all of Middle East and North African (MENA) countries are limited, in view of the absence of national registries.

Methods: This review aims to challenge media figures by review of data in the local database of the author, available published data, as well as by analysis of recent annual reports of the Saudi Ministry of Health to estimate the magnitude of the problem. Different methods of analysis are used based on the number of beds, operations and admissions in KSA to generate approximate figures of the annual expected numbers of amputations in KSA and MENA countries. The 2010 International Diabetes Federation IDF comparative prevalence rate of 16.8% was used to standardize the analysis methods.

Results: Findings of 2 previous studies and 3 analytical methods led me to the prediction that about 325 amputations are likely to occur annually in Jeddah compared to 741 in Riyadh and 3970 in KSA. When we applied the results of KSA to those of MENA countries, 44208 amputations were predicted annually.

Conclusion: Half a million diabetes-related amputations of the lower extremities are likely to occur in KSA and MENA countries over the coming decade. National registries are urgently needed.

Introduction

More than 50% of lower limb amputations are performed on diabetic patients.¹⁾ Diabetic foot disorders/ulcers (DFD/DFU) are one of the common chronic complications of diabetes, which may lead to major and minor limb loss.^2–5) These amputations are usually associated with an extended hospital stay, high mortality and low rehabilitation rates.^2,4,5)

On the 10th of March 2009, Dr Abdulaziz Al-Gannass, a foot and ankle surgeon at the National Guard King Abdulaziz Medical City in Riyadh, KSA, told the AFP (Agence-France-Presse) news agency that the number of diabetes-linked amputations is rising quickly and beginning to occur at younger ages. He added that some 90 diabetic amputations are performed monthly, i.e. three per day were performed in the KSA capital of Riyadh.⁶⁾ This information was published by many newspapers and media sites on the web, sometimes without mentioning Al-Gannass saying that he “could not provide a figure for such cases.” This piece of information was continuously quoted by public reporters in media.

In view of the absence of national registry and official data for diabetes-related amputations in KSA and perhaps in most of the Middle East and North African Countries (MENA), it may be the time to challenge the above quoted figures in view of the most recent Saudi official data as reported by the Saudi Ministry of Health and Saudi Central Department of Statistics & Information,^7,8) as well as reviewing the author’s local data-base^4,5) and available data published in the literature^9–14) aiming to estimate the magnitude of the problem and forecast the future not only in KSA but perhaps in other similar countries with high steadily increasing prevalence rates of diabetes particularly Arab¹⁰⁾ and MENA countries.^15,16) Such data may be used as an indirect indicator or marker for measuring the effectiveness of prevention and management provided to diabetics suffering from foot ulceration. This may also excite policy makers to launch national registries for diabetes-related amputations in KSA and MENA countries, which are confronting an impending health crisis.

Methods

Aim

To estimate the likely annual occurrences of diabetes-related lower extremities amputations and address the need for national registries in KSA and MENA countries.

Design

In view of the absence of a Saudi national registry for amputations, the author tried to verify if the previously quoted figure in media was correct and generate approximate figures for the prevalence of diabetic amputations. Different calculation formulae were used, based on the most recent information published by our group^4,5) in Jeddah, which is the second largest city in KSA, aiming to predict the total number of amputations performed annually, in all of KSA. Such information is needed as a base-line indicator for effectiveness of health care services provided. It will also help in future health plans and for forecasting the future magnitude of diabetic lower extremities amputations not only in KSA but also in all Arab and MENA countries, which share high prevalence rates of diabetes, and common cultural and social backgrounds.

Assumption

Based on the figure quoted by Al-Gannass⁶⁾ of KSA, a total of at least 1080 diabetes-related amputations (i.e. 90/ month) are performed annually in Riyadh, the capital of KSA, which has a population of 5.25 million. This means an incidence rate of 205 amputations per million, 2.0 per 10 000 population, or 1 amputation per 4878 of the total population of Riyadh (1:4878, approximate incidence rate of 0.02% in the overall population). This rate of amputation increases when only the diabetic population in adults is considered. The IDF 2010 comparative prevalence rate of 16.8% of diabetes in KSA general population was used in this study for the sake of standardization of source of Arab and MENA country estimations Table 1. The IDF estimated a total of 15.186 million as population at risk of having DM (representing 60% of population above 20 years).¹⁵⁾ This percentage is almost similar to the Saudi MOH report.⁷⁾

The approximate numbers in the population at risk, numbers of diabetics and estimated amputation rates based on the above assumption of amputation rate in capital of KSA are shown in Table 2 in Riyadh, Jeddah, KSA, and MENA countries. If Riyadh has more than half a million of diabetic patients for whom 1080 amputations were performed, this means simply one amputation will be performed on every 490 diabetic patients (approximately 1:500 ratio) i.e. a prevalence rate of 0.2% in Riyadh diabetics’ population. Based on this assumptive rate, one can predict that Jeddah will record 690 amputations/year, KSA 5,102 and MENA countries 64070 amputations/year, Table 2.

These above figures will be challenged below using Jeddah’s data to reach an estimate of the annual numbers of amputations expected in KSA and MENA countries.

Data Sources

Data from the following sources were reviewed and analyzed aiming to estimate the magnitude of the problem:

• Reported prevalence rates of diabetes by IDF¹⁵⁾

• Two previously published studies by the author’s group in Jeddah^4,5)

• Annual report of Saudi Ministry of health 2009⁷⁾

• Saudi Central Department of Statistics & Information CDSI 2010 national census⁸⁾

Results

Saudi Population

According to the most recent CDSI 2010 national census,⁸⁾ the population in KSA reached 27136977 (including 8429401 expatriates). The Saudi CDSI report also indicated a 3.2% growth rate compared to 2004’s census.⁸⁾ It also showed that Riyadh’s population is around 5 million (5254560) compared to 3.5 million (3456259) in Jeddah which is the second largest city in KSA.⁸⁾ Forty percent of the population is below 20 years of age,^7,15) Table 1. Based on the above figures, comparisons will be done with studies done in Jeddah and correlate it to Riyadh’s incidence rate of 0.2% risk of amputation in diabetics Table 2.

Estimation Methods

King Abdulaziz University Hospital KAUH, Jeddah Study⁴⁾

KAUH is a tertiary care general hospital and has all specialties and sub-specialties. It is the only public university hospital in Jeddah city, with a bed capacity of 650, during the period of our studies (reached 702 lately), which represents 1.26% of the whole KSA bed capacity 55932 beds in all sectors. In 2009,⁷⁾ the total number of surgical operations performed in KAUH was 9342 which represent 1% of the total number performed in the whole KSA 929403. KAUH contributed to all hospitals’ admissions in KSA (3.0 million admissions) by admitting 41227 patients i.e. 1.4% of the KSA’s admissions.

In a retrospective study over a five year period (January 2004–December 2008), we reported 222 diabetes-related lower limb amputations performed in KAUH. This means that approximately 45 amputations were performed on diabetic patients per annum or 1 amputation to every 14 beds in KAUH (1:14), or 1 amputation in every 208 surgical operations performed (1:208) or 1 amputation in every 916 patients admitted to KAUH (1:916).

In Table 3, the previous rates are applied to Jeddah, Riyadh and the whole KSA aiming to predict the number of amputations in Jeddah, Riyadh and the whole Kingdom. The figures obtained are 306, 650 and 3053 amputations respectively based on the amputation: beds ratio at KAUH. These amputation numbers are higher based on operation ratio 431, 890, and 4,476 but lower based on admission ratio 182, 464, and 3321 respectively. The averages for these figures are 306 for Jeddah, 668 for Riyadh and 3616 for the whole KSA. It is obvious, therefore, that the current estimation of 668 is less than the quoted number of 1080 by 38.0%.

Diabetes-related amputations in three major public hospitals in Jeddah⁵⁾

In 2008, the amputations number performed on diabetic patients in 3 major hospitals in Jeddah was 128. The 3 major hospitals had a total bed capacity of 2052 (about 50% of Jeddah’s bed capacity) and admitted 72937 patients over one year period. Surgeons performed approximately 24342 operations in all disciplines. Calculations were again done on the same line of previous study, Table 4. The averages of the three methods were 345 amputations for Jeddah, 814 for Riyadh and 4325 for KSA.

Finally, averages of three methods in both studies were taken, and it was found that 325 amputations are estimated to be performed annually in Jeddah, compared to 741 in Riyadh and 3970 for the whole kingdom i.e. 2.5 amputations per 10000 population. Again, this figure is less than the one quoted by 31%, Table 5. When applied to MENA countries, 44208 amputations are predicted annually.

Discussion

Diabetes is the global epidemic of the 21st century. The number of adults with diabetes in the world was 135 million in 1995. At present, 366 million people are affected by diabetes worldwide and 80% of them live in low and middle-income countries.¹⁶⁾ By 2030, the global burden of diabetes is projected to increase to 552 million people.¹⁶⁾ Between 2010 and 2030, there will be a 69% increase in the number of adults with diabetes in developing countries and a 20% increase in developed countries.¹⁷⁾

Data that has been accumulated over the last three decades confirms an epidemic of type 2 diabetes in KSA.¹¹⁾ KSA is one of the top ten countries (number 6) for prevalence of diabetes and is expected to continue in the coming two decades with prevalence rate of 20.0% in the age group 20–79 years.¹⁶⁾ Other countries in the “top-ten” included Kuwait 21.1, Lebanon 20.2, Bahrain 19.9 and United Arab of Emirates 19.2 as reported by IDF recently.¹⁶⁾ The published diabetes mellitus DM prevalence rates in KSA vary. These rates are still not well known due to various methodologies used by researchers.^{10–12,15,16)} For instance Al-Nozha et al.¹²⁾ conducted a national survey and reported a prevalence rate of 23.7% in the adult Saudi population above 30 years of age (26.2% in males versus 21.5% in females). In contrast, Elhadad et al.¹¹⁾ reviewed all of studies and commented that the last rate is somewhat inflated. The International Diabetes Federation IDF in 2010 reported a comparative prevalence rate of 16.8% in the age group between 20–79 years.¹⁵⁾ In this study, the IDF prevalence rate of 16.8% of diabetes in the general population of KSA was used¹⁵⁾ as it is more conservative and was generated by an international body after a review of various published studies. It is closer to the period during which previous studies of the population of Jeddah were performed.

Diabetes-related lower-extremity amputations rates are important indicators for the effectiveness of health care provided to diabetic patients including prevention and management of foot ulcers and to forecast the magnitude of the problem. Unlike developed countries where data on the incidence of amputations can be obtained relatively easily,¹⁸⁾ these rates are unknown in most of developing countries, which record high prevalence of diabetes such as KSA and MENA countries. Amputationfigures require very careful interpretation. Variations in the definition of amputation (i.e. major, above ankle; or minor, distal to ankle), selection of the population, and the choice of numerator and denominator make it difficult to perform comparisons. In addition to disease severity, many aspects of the structure of care services affect this decision, including access to primary care, quality of primary care, delays in referral, availability and quality of specialist resources, and prevailing medical opinion. It follows that a high incidence of amputation can reflect a higher disease prevalence, late referral, limited resources, or a particularly interventionist approach by a specialist team.¹⁸⁾ In KSA and perhaps most of MENA countries cultural, social and individual patient factors play a major role on the amputations’ decision. This makes cross comparison between different data more complicated. However, amputations’ rates will definitely help as a base-line indicator¹⁹⁾ in the same country or similar countries that share racial and cultural backgrounds, and health care systems, such as those of MENA countries. The current study aims to raise the level of awareness in these countries about the need for national registries for amputations among diabetics who represent 20% of their nations.

It is estimated that 325 amputations are likely to be performed in Jeddah compared to 741 in Riyadh and 3970 for the whole kingdom. These figures are less than the one quoted in media by 31%. This means an incidence rate of 2.6 per 10000 people at risk. This rate is on the low side but within the range published in industrialized countries, which ranged from 0.06 to 3.83 per 10 (3) people at risk.¹⁸⁾ The figures generated in the current study are for all amputations i.e. major and minor. According to our previous studies, major amputations accounted for 45%⁴⁾and 38%⁵⁾ i.e. average of 41.5% are majors. Based on the current data, it can be predicted that 1647 major amputations are performed annually in KSA.

Up to my knowledge, this is the first report which tried to predict the magnitude of the diabetes-related lower-extremity amputations rates in KSA and MENA countries and to challenge the figures quoted in media. However, it is still a “snapshot” on a complex health problem. However, there are significant limitations in this exercise. Firstly, it is based on the two studies of the author’s group. One of the two studies⁴⁾ was a retrospective single center study, and the second,⁵⁾ a multi-central study. However, it was not as comprehensive as the others because it was conducted in only three major hospitals in Jeddah. Secondly, amputation figures were generated by diverse methods, which included amputations per hospital beds, per operations and per admissions. The second reason may be a point of strength rather than weakness as using multiple methods of calculations will reduce the possibility of bias when only one variable is used. Finally, whatever is done will not replace the accurate data collection in a prospective setup.

Intended future registries will hopefully establish, not only the overall future trends of amputation in general, but also the high-low amputation ratio, i.e. the major: minor ratio, which is important in proper evaluation of improvements in care organization and multidisciplinary-centered protocols.^19,20) Similar to developed countries²¹⁾ such registries will give opportunities for cross-national learning to improve health system performance. It will also help in assessing the outcomes of newer modalities of treatment.^22–24)

This work shows the difficulty and shortcomings of scattered data in the literature and will support the timely need for accurate data-base sources. United Nations Resolution 61/225, has already adopted unanimously in 2006, recognizes diabetes as a serious and costly disease that poses a threat to individual well-being and economic progress, especially in low- and middle-income countries.²⁵⁾ It also addressed the problems of data accuracy in less-developed countries by stating “In view of absence of transparency, public health services, national registries, national diabetes programs and national well-designed community studies, most of the available published data including those published by recognized international bodies are not accurate”.²⁵⁾

In conclusion, half a million of MENA country citizens are likely to have a minor or major diabetes-related amputations according to the figures generated in the current study of KSA. Most of the amputees will not be rehabilitated and may lose their jobs or incomes. In view of this, national registries are urgently needed in KSA and MENA countries.