Diabetic Foot & Ankle
ISSN: (Print) 2000-625X (Online) Journal homepage: http://www.tandfonline.com/loi/zdfa20
Diabetes-related foot disorders among adult
Ghanaians
Osei Sarfo-Kantanka, Ishmael Kyei, Jean Claude Mbanya & Micheal OwusuAnsah
To cite this article: Osei Sarfo-Kantanka, Ishmael Kyei, Jean Claude Mbanya & Micheal OwusuAnsah (2018) Diabetes-related foot disorders among adult Ghanaians, Diabetic Foot & Ankle, 9:1,
1511678, DOI: 10.1080/2000625X.2018.1511678
To link to this article: https://doi.org/10.1080/2000625X.2018.1511678
© 2018 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Group.
Published online: 05 Sep 2018.
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DIABETIC FOOT & ANKLE
2018, VOL. 9, 1511678
https://doi.org/10.1080/2000625X.2018.1511678
CLINICAL RESEARCH ARTICLE
Diabetes-related foot disorders among adult Ghanaians
Osei Sarfo-Kantanka
a
, Ishmael Kyeib, Jean Claude Mbanyac and Micheal Owusu-Ansahd
a
Directorate of Internal Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana; bGeneral Surgery Department, Komfo Anokye
Teaching Hospital, Kumasi, Ghana; cDepartment of Medicine, University of Yaoundé 1, Yaounde, Cameroon; dDepartment of Family
Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
ABSTRACT
ARTICLE HISTORY
Background: Diabetic foot remains a challenge in most low-middle-income countries
(LMICs). A severe deficit in data exists on them in sub-Saharan Africa (SSA). Up-to-date data
on the longitudinal trajectories and determinants can provide a benchmark for reducing
diabetic foot complications in SSA.
Objective: The primary objective of this study was to estimate trends in the incidence of
diabetic foot and determine predictors in an adult Ghanaian diabetes cohort.
Design: The study is a retrospective longitudinal study over a 12 year period.
Methods: We applied Poisson regression analysis and Cox proportional hazard models to
demographic and clinical information obtained from patients who enrolled in a diabetes
specialist clinic in Ghana from 2005 to 2016 to identify longitudinal trends in incidence and
predictors of diabetic foot.
Results: The study comprised 7383 patients (63.8% female, mean follow-up duration:
8.6 years). The mean incidence of foot disorders was 8.39% (5.27% males and 3.12% females).
An increase in the incidence of diabetic foot ranging from 3.25% in 2005 to 12.57% in 2016,
p < 0.001, was determined. Diabetic foot, with adjusted hazard ratio (HR; 95% confidence
interval (CI)), was predicted by disease duration, that is, for every 5-year increase in diabetes
duration: 2.56 (1.41–3.06); male gender: 3.51 (1.41–3.06); increased body mass index (BMI),
that is, for every 5 kg/m2: 3.20 (2.51–7.52); poor glycaemic control, that is, for every percentage increase in HbA1c: 1.11 (1.05–2.25), hypertension: 1.14 (1.12–3.21); nephropathy: 1.15
(1.12–3.21); and previous foot disorders: 3.24 (2.12–7.21).
Conclusions: We have found a trend towards an increased incidence of diabetic foot in an
outpatient tertiary diabetes setting in Ghana. Systemic and individual-level factors aimed at
preventive foot screening as well as vascular risk factor control should be intensified in
diabetic patients in Ghana and other LMICs.
Abbreviations: BMI: Body Mass Index, BP: Blood Pressure, CI: Confidence Interval, HR: Hazard
Ratio, HbA1c: Glycated Hemoglobin, PAD: Peripheral Arterial Disease, NCDs: Non
Communicable Disease, SSA: Sub Saharan Africa.
Received 28 April 2018
Revised 30 July 2018
Accepted 5 August 2018
Introduction
Of the many complications of diabetes, foot disorders
represent the commonest, with a lifetime risk of 25% [1].
Diabetic foot defined as the foot of a diabetic patient with
ulceration, infection and destruction of the deep tissues,
associated with neurological abnormalities and various
degrees of peripheral vascular disease (PVD) in the lower
limb [1]. It is associated with both short- and long-term
increase in morbidity, mortality and lower limb amputation [2,3]. Besides, management involves significant cost
inputs regarding investigations and therapy [4]. Among
high-income countries, an evident reduction in the incidence of the diabetic foot has been recorded over the past
three decades [5–8]. These achievements were mostly
through a campaign of increased screening, widespread
adoption of multidisciplinary foot clinics and stringent
vascular risk factor management [9,10]. On the contrary,
CONTACT Osei Sarfo-Kantanka
Ghana
osarfokantanka21@gmail.com
KEYWORDS
Ghana; incidence; diabetic
foot; foot screening; chronic
disease
a high incidence of diabetic foot, with incidence usually
upwards of 10% has been recorded in low-middleincome countries (LMICs), particularly those in subSaharan Africa (SSA) [11–14].
In LMICs, particularly those in SSA, health systems
are not well equipped to provide care for non-communicable diseases (NCDs) such as diabetes. Instead, they
have been set up purposely to combat infectious disease.
Many factors including fragmentation of care, limited
resource allocation, lack of training among health-care
professionals and low health literacy among patients
contribute to a high incidence of complication such as
diabetic foot [15]. Both community- and hospital-based
studies are needed to address this challenge. Such studies
will provide the required information on critical local
drivers of the high incidence of diabetic foot.
Research on diabetic foot is limited to developed
countries, the few conducted in SSA are old and
Endocrine and Diabetes Unit, Komfo Anokye Teaching Hospital, Kumasi, 1934,
© 2018 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
2
O. SARFO-KANTANKA ET AL.
cross-sectional in design. Longitudinal studies
detailing foot complications from SSA is non-existent. The primary aim of this study was to estimate
recent trends in the incidence of diabetic foot and
identify their predictors using an outpatient diabetes cohort from one of Ghana’s leading tertiary
hospitals.
where indicated. Patients after enrolment are followed up between 2 and 6 times a year based on
glycaemic control and complication profile.
Data collection
The organisation of the Diabetes Clinic
The study involved patients who enrolled in the clinic
between 1 January 2005 and 31 December 2016. A
flow chart of patient selection for this study is shown
in Figure 1. A total of 9383 patients enrolled in the
clinic during the period under review. We excluded
342 patients because their records were incomplete,
657 because they presented to the clinic with prevalent ulcers and 947 were omitted because they were
lost to follow-up within a year of enrolment. Trained
research assistants extracted relevant data from medical records of remaining 7383 patients, after satisfaction with the criteria for diagnosis of diabetes
mellitus using the criteria by the World Health
Organisation, that is, an elevated fasting plasma glucose level (≥7 mmol/L) on two occasions or oral
glucose tolerance test ≥11.1 mmol/L or a selfreported physician diagnosis of diabetes or current
use of glucose-lowering drugs [17]. Data recorded
include age, gender, duration of diabetes, type of
diabetes, hypertension (defined as BP > 140/
90 mmHg on two or more readings) [18], BMI,
glycated haemoglobin (HbA1c), lipid profile, renal
function, current smoking and alcohol consumption.
The Diabetes Clinic was set up in 1992 and runs daily
clinics receiving referrals from most parts of Ghana
with over 22,000 patients enrolled so far. At enrolment, sociodemographic and other relevant clinic
information is obtained from patients. They are
examined thoroughly for vital signs such as blood
pressure (BP) and pulse rates, performed by trained
nurses. Each patient rests for at least 5 min before BP
measurement while sitting in a chair with both feet
flat on the floor, arms supported at the level of the
heart on a table. Anthropometric measurement
including weight and height was performed by standard methods and body mass index (BMI) derived by
dividing the weight in kilograms by the square of the
height in metres.
Laboratory investigations including fasting blood
glucose, glycated haemoglobin and lipid profiles are
recorded. Patients are screened for complications
including renal; using urinalysis, creatinine and estimated glomerular filtration rate, eye complications;
using an ophthalmoscope, or retinal camera, neuropathy; using microfilament for protective sensation; a
128-mHz tuning fork for the sense of vibration; and
ankle reflex testing using a Patella hammer on the
Achilles’ tendon. Macrovascular complication was
screened for using electrocardiogram, peripheral
arterial pulsation and ankle-brachial index testing
Foot examination
Foot assessment including the presence or otherwise
of diabetic foot and the type was recorded. Other
examination documented included the presence or
otherwise of foot ulcers, pressure marks, callus,
amputation/s, posterior tibial or dorsalis pedis arterial
pulses and Charcot’s joints. Foot sensation was
assessed using a combination of symptoms like paresthesia’s, numbness together with 10-g Semmes
Weinstein monofilament examination of the plantar
aspects of the great toe, the first and fifth metatarsals
and recorded. Inability/reduced ability to perceive the
applied pressure at one or more of the three sites with
the buckling of the filament was recorded as defective
sensation. Vibration sense was tested using a 128-Hz
tuning fork using the on-off methods at bony prominences of the leg. Reflexes graded as reduced, normal
or exaggerated response were recorded. Peripheral
neuropathy was diagnosed based on one or more
combinations of sensory, reflex or vibration sense
testing abnormalities. Peripheral artery disease
(PAD) was diagnosed based on symptoms such as
intermittent claudication, leg pain and so on allied
to ankle–brachial index measurement (less than 0.9),
clinical presentation of ischemia or gangrene. The
diagnosis in some instances was confirmed by
Materials and methods
Study area and population
The study was approved by the Committee on
Human Research Publication and Ethics of the
School of Medical Sciences, Kwame Nkrumah
University of Science and Technology. This longitudinal retrospective was conducted at the Komfo
Anokye Teaching Hospital (KATH), a leading tertiary
referral hospital in Ghana. The hospital is located in
the second largest city in Ghana, Kumasi. The location of Kumasi in the central point of the transportation network in Ghana makes it accessible to an
estimated 10 million people from 6 out of the 10
regions of Ghana and other neighbouring countries.
With an estimated prevalence of over 7%, Kumasi has
one of the highest urban diabetes prevalence in the
country [16].
DIABETIC FOOT & ANKLE
3
Patients enrolled from 1st January 2005-31st
December 2016
N=9329
Excluded
Incomplete data n= 342
Prevalent ulcers n=657
Patients eligible for study inclusion
N= 8330
Loss to follow up
n =947
Patient included in the study analysis
N=7383
Figure 1. Flow chart of patients enrolled in the diabetes clinic during the study period.
Table 1. Baseline characteristic of eligible patients.
Characteristics
Females
Males
Age at diagnosis (years)
Type of diabetes
Type 1
Type 2
Other types
Body mass index (kg/m2)
Mean duration of diabetes (years)
Mean follow-up period (years)
Smoking (yes)
Alcohol (yes)
HbA1c (%)
Insulin usage (yes)
Lipid-lowering drugs (yes)
Antihypertensive drugs (yes)
Antiplatelet (yes)
Number (%)
7383 (100%)
4712 (63.8)
2671 (31.2)
54.2 ± 11.9
866 (11.7)
6412 (86.9)
105 (1.4)
25.7 ± 12.2
5.2
7.6
112 (1.5)
2654 (35.9)
9.4 ± 2.1
1589 (21.5)
2376 (32.2)
4976 (67.4)
2443 (33.1)
confidence interval (CI)) for predictors of diabetic
foot during the study period. Covariates shown by
previous studies to be associated with diabetic foot
disorders were selected for analysis. They included
duration of diabetes in years, gender, HbA1c (%
increase), type of diabetes, hypertension, nephropathy, statin, aspirin use and previous foot disorders. In bivariate analyses, a p-value of 0.10 was
set for selection of variables into the final multivariable model with visual inspection for compliance with collinearity assumption. A two-sided
p-value of <0.05 was considered significant in all
statistical analysis with no adjustments made for
multiple comparisons. We expressed variables as
mean and standard deviation (SD) and dichotomous values as absolute numbers and percentages.
Doppler ultrasonography/magnetic resonance imaging and angiography.
Results
Baseline characteristics and sample size
Statistical analysis
We defined the primary outcome of the study as
the incidence rate of foot disorders, calculated as
the number of individuals who reported with a
new diabetic foot disorder per person-year under
observation. We used a Poisson regression model
to examine for trends in the incidence rate of
diabetic foot with categorical year variables. We
used multivariable Cox proportional hazard models to estimate hazard ratios (HRs; and their 95%
In total, 7383 patients were included in the analysis,
as shown in Figure 1. Table 1 summarises the baseline characteristics of the eligible patients. The mean
age at diagnosis of the predominantly female (63.8%)
cohort was 54.2 ± 11.9 years, mean BMI of
25.7 ± 12.2 kg/m2 and mean diabetes duration of
5.5 years. The mean HbA1c was 9.4 ± 2.3, and the
mean duration of follow-up was 7.6 years. The total
number of person-years of follow-up was
189,541 years.
4
O. SARFO-KANTANKA ET AL.
Total
Male
Female
15
Incidence rate
p<0.01
10
5
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Figure 2. Trends in the incidence rates of diabetic foot disorders in central Ghana.
The incidence rate of diabetic foot disorders
Figure 2 shows variation in the incidence rate of
diabetic foot within the cohort: There was a significant increase in the incidence rate of diabetic foot
from 3.25% in 2005 to 12.57% in 2016. The mean
incidence rate over the 12-year study period was
8.31%, with the incidence rate among males, 5.06%
(2.30–6.52%) higher than in females, 3.33% (0.92–
5.24%). The difference in frequency between the two
groups varied significantly during the years under
study. During the early period under review, that is,
between 2005 and 2006, the incidence rate of the
diabetic foot was comparable among males and
females; however, the period between 2007 and 2012
was characterised by a significantly higher incidence
rate in males compared to females. In more recent
years, that is, 2013–2016, the gender difference in
incidence rate narrowed significantly.
foot disorders had one or more abnormalities of the
foot. These include 456 (14.6%) with reduced foot
pulses/gangrene, 374 (10.2%) with reduced ankle–
brachial index recording, 1469 (42.6%) with reduced
foot sensation, 779 (22.6%) with callouses, 52 (1.5%)
with documented Charcot’s joints, 968 (10.7%) with
reduced/absent vibration sense and 179 (5.2%) with
amputations.
Causes of foot disorders
The type of foot disorders presented is shown in
Figure 3. In general terms, neuropathic complications
including ulcers represented the highest proportion
of diabetic foot cases within the cohort representing
74.4% of diabetic foot disorders. PADs/gangrene
represented 25.6% of foot disorders, although the
percentage of complications attributed to PAD
increased over the later years.
Foot examination results
Predictors of foot disorders
Table 2 shows the results of documented foot examination during the study period. Overall 3449 (46.7%)
individuals had documented foot examination results.
Approximately 66.7% of all individuals examined for
Multivariable Cox regression analysis was used to
determine predictors of diabetic foot in our diabetes
cohort with results shown in Table 3. Duration of
diabetes predicted diabetic foot; every 5-year increase
in diabetes duration increased the risk of diabetic foot
by 2.5-fold (HR: 2.56, 95% CI: 1.41–3.06, p = 0.008);
male gender increased the risk of foot disorders by 3.5fold (HR: 3.51, 95% CI: 1.41–3.06, p < 0.001); and
increased BMI, that is, every 5 kg/m2 increase in BMI
increased the risk of diabetic foot by about 3-fold (HR:
3.20, 95% CI: 2.51–7.52, p < 0.001). A percentage
increase in HbA1c increased the risk of diabetic foot
by 11% (HR: 1.11, 95% CI: 1.05–2.25, p = 0.03), presence of hypertension increased the risk of diabetic foot
by 14% (HR: 1.14, 95% CI: 1.12–3.21, p < 0.001),
Table 2. Prevalence of risk factors for foot disorders.
Abnormality
Absent/reduced pedal
pulses
Reduced ankle–brachial
index
Reduced foot sensation
Callus
Charcot’s joints
Reduced vibration sense
Previous amputations
At least one component documented n
(%)
N = 3449
456 (13.2)
374 (10.8)
1469 (42.6)
779 (22.6)
52 (1.5)
968 (10.7)
179 (5.2)
5
DIABETIC FOOT & ANKLE
Neuropathic disorders
Peripheral vascular disorders
Diabetic foot (number)
500
400
Chi Square-trend
p<0.01
300
200
100
0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Year
Figure 3. Causes of diabetic foot disorders in central Ghana.
Table 3. Multivariate Cox proportional hazard analysis for predictors of foot disorders in the diabetes cohort.
Predictor
Gender
Male
Female
Duration of diabetes
A 5-year increase
Type of diabetes
Type 1
Type 2
Body mass index
Each 5-kg/m2 increase
Glycaemic control
A percentage increase in HbA1c
Dyslipidaemia
Present
Absent
Hypertension
Nephropathy
Lipid therapy
Antiplatelet therapy
Previous foot disorders
Unadjusted HR (95% CI)
p-value
Adjusted HR (95% CI)
p-value
6.93 (3.11–8.00)
1
<0.001
2.51 (1.88–4.23)
<0.001
3.40 (2.92–3.99)
<0.001
2.36 (1.21–3.16)
0.008
1
1.20 (0.8–2.13)
0.17
5.3 (3.11–8.96)
<0.001
3.2 (2.51–7.25)
<0.001
1.23 (1.08–1.42)
0.003
1.11 (1.05–1.25)
0.03
0.84 (0.51–1.36)
1
2.51 (1.02–1.71)
5.6 (2.3–8.3)
1.02 (0.67–1.32)
0.56 (0.12–1.12)
7.32 (4.31–12.34)
0.47
–
–
<0.001
0.07
0.13
0.23
<0.001
1.14 (1.12–3.21)
2.15(1.92–3.21)
–
–
3.24 (2.12–7.12)
<0.001
0.002
–
–
0.001
CI: confidence interval; HR: hazard ratio.
nephropathy increased it 2-fold (HR: 2.15, 95% CI:
1.12–3.21, p < 0.001) and previous foot disorders
increased the risk of foot disorders 3 times (HR: 3.24,
95% CI: 2.12–7.21, p < 0.001). Dyslipidemia, lipid and
platelet therapy had no predictive effect on the occurrence of diabetic foot in our cohort.
Discussion
This study detailing trends in the incidence of diabetic foot in a low-resource diabetes setting represents the first of its kind in SSA, by providing
longitudinal data. We have demonstrated that within
a 12-year observation period, the incidence of diabetes within the cohort quadrupled. Although in a
tertiary referral setting, the majority of patients had
no documented foot examination. Additionally, we
found an increasing trend towards PVD as an underlying cause of diabetic foot, despite neuropathic
disorders of the foot dominating generally.
Furthermore, development of diabetic foot in our
cohort was predicted by duration of diabetes, male
gender, poor glycaemic control, hypertension,
nephropathy and previous foot disorders.
In most of SSA and other countries in the LMIC
in general, varying incidence of diabetic foot, ranging
between 10.2% and 38.9%, has been reported [19–
24]. Our study showing a mean diabetic foot incidence of 8.3% is lower than previous findings from
LMICs. Perspectives need to be exercised, however,
as most of the reported studies on the subject in SSA
are old and cross-sectional in design. However, our
annual incidence is higher than that observed in
developed countries, where a dramatic reduction in
the rate of diabetic foot has been recorded over the
past two decades [8,25,26]. The North-West and
West of Ireland diabetic foot studies conducted in
the United Kingdom and the Republic of Ireland
6
O. SARFO-KANTANKA ET AL.
reported diabetic foot incidence of 2.2% and 2.6%,
respectively [8,27]. Similarly, Muller et al. and de
Sonnaville et al. both from the Netherlands indicated
an incidence of 2.1% and 1.8%, respectively [28,29].
Ramsey et al. also reported an incidence rate of 2.0%
in the United States [30]. It should be noted that
both the North-West and West of Ireland studies
concentrated on diabetic foot ulcers, the findings,
however, pointed to a low incidence of diabetic
foot. Diabetic care in Europe and other developed
areas is well organised, unlike in LMIC where care is
inadequate and at best fragmented, often faced with
many barriers [31,32]. Care in developed countries
involves the use of multidisciplinary and streamlined
pathways as well as monitoring for early symptoms
and signs of the diabetic foot complications. These
measures have contributed significantly to the reduction of the incidence of diabetic foot. An additional
layer of evidence outlining the effectiveness of these
measures in reducing diabetic foot can be found in
African countries such as Tanzania and Egypt
[33,34]. In these countries, the introduction of the
Step by Step and the Bridges Projects, involving
physician and patient training on early recognition
of diabetic foot, as well as multidisciplinary diabetic
foot care, has resulted in a significant reduction in
the incidence of diabetic foot in both countries.
There is increasing prevalence of diabetes in both
countries notwithstanding.
Although most foot disorders in SSA are neuropathic in origin, a trend towards an increasing role of
PVD has been recently noted [35]. We confirmed this
in our study, where despite an increase in the incidence of neuropathic foot disorders in general, there
was an increase in the rate of PVD during the later
years under study. The increasing role of PVD as a
cause of foot disorders can be attributed to the high
prevalence of independent vascular risk factors in the
general population and most especially among the
diabetic population, hyperglycaemia itself being a
significant vascular risk factor [36,37]. In our diabetes
cohort, for instance, the situation was compounded
by the fact that only a third of them were on conventional antiplatelet and lipid-lowering drug therapy. This may have resulted in the increasing
incidence of PVD in our patients.
We found a relatively low prevalence of foot
examination reported; as less than a half of the
patients had one or more documented foot examination during the period under study. This is
abysmal compared to the findings from the
United Kingdom where a reported 87% of diabetic
patients had complete foot examination records
[38]. Although a relatively low and somehow comparable prevalence of 56% was obtained in a study
in the Netherlands, the study involved general
practices, unlike our study which took place in a
tertiary referral setting where higher standards are
expected [39]. Although an explanation to this
finding can be found in the fact that a complete
and diligent registration occurs in developed countries for chronic diseases such as diabetes, we cannot discount the fact that foot screening is a critical
component of efforts to improve diabetes care [40].
The low prevalence of foot examination records in
our cohort can be attributed to a low routine foot
examination among diabetic patients, mostly basing
the need for foot examination on the presence or
otherwise of symptoms and unmistakable evidence
of foot abnormalities. It is particularly instructive
to note that a significant proportion of our cohort
who underwent foot examination recorded a high
prevalence of risk factors for diabetic foot as well as
complications. We can, therefore, assume that consistent foot screening in this cohort can help reduce
the high diabetic foot incidence by enabling earlier,
easy to achieve preventive interventions to be
employed.
We have shown in this study that diabetic foot
in our cohort is independently linked to an
increase in diabetes duration, male gender, hypertension, nephropathy as well as previous foot disorders. These findings are consistent with previous
results that have identified these factors as being
integral to the development of diabetic foot [41,42].
The role of poor glycaemic control in the causation
of microvascular complications such as diabetic
peripheral neuropathy, for instance, was well established in both Diabetes Complication and Clinical
Trial for type 1 diabetic patients and the UK
Prospective Diabetes Study for type 2 patients
[43,44]. Similarly, the influence of nephropathy
and hypertension on the development and advancement of atherosclerotic lesions, especially macrovascular complications such as PVD/gangrene has
been well studied [45].
The higher incidence of diabetic foot observed in
males compared to females in this study, despite
females forming two-thirds of the cohort, brings to
the fore the issue of gender-related disparity in health
outcomes as a significant public health issue, which
require urgent attention [46]. A considerable number
of males with chronic diseases such as diabetes,
mostly present late for care, do not receive treatment
at all or are not compliant with their diabetes treatment. This leads to males suffering severe complications such as diabetic foot at a higher rate than
females.
Study limitations
The strength of this study is in its longitudinal design,
a novel, as well as diabetic foot research in SSA, is
concerned. It being a retrospective study serves as a
DIABETIC FOOT & ANKLE
limitation because it usually underestimates the incidence rate as individuals tend to underreport and
indulge in alternative therapy for such complications.
Also, an increased risk of bias may have occurred due
to the study involving only a single diabetes centre.
Although we have accessed the influence of various
factors that might influence the presence of diabetic
foot in this cohort, our inability to report on the level
of health professional and patient knowledge on diabetic foot as well as other systemic deficiencies also
serves as a limitation for this article. Again, future
studies on the predictors of foot ulceration in patients
with risk factors for diabetic foot will be hugely
beneficial.
Conclusions
To conclude, the incidence rate of diabetic foot quadrupled over a 12-year period in a diabetes cohort in
Ghana. Less than half of the group had foot examination records, despite a high prevalence of risk factors
for diabetic foot. There is a need to institute patient
level and systemic preventive measures for diabetic foot
including patient education, task shifting of diabetic
foot care, peer support as well as routine screening
for symptoms and early remediable signs.
Disclosure statement
No potential conflict of interest was reported by the
authors.
Funding
The study was funded by the lead author.
Notes on contributors
Osei Sarfo-Kantanka made substantial contributions to the
conception, design, data acquisition, analysis and drafting
of this article.
Ishmael Kyei made significant contributions to the analysis
of data and drafting of this article.
Jean Claude Mbanya made substantial contributions to the
concept, design and critical revision of this article.
Micheal Owusu-Ansah made significant contributions to
the concept and data acquisition and also critically revised
this article. All authors provided final approval of the
version to be published.
ORCID
Osei Sarfo-Kantanka
5749
http://orcid.org/0000-0002-4451-
7
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