Diabetes is a growing health crisis in India, with an alarming rise in cases over the past few decades. One of the most debilitating complications of this condition is the development of foot ulcers, which can lead to severe consequences if left untreated, including amputation and even mortality. As the country grapples with this challenge, a unique collaboration between academia, industry, and the government is paving the way for innovative solutions that could revolutionise the management of diabetic foot complications.

The quadruple helix model

Patients with diabetes are at a higher risk of foot disorders such as loss of sensation in the feet, reduced blood flow to the feet and foot deformities. The Digital Podiatry Clinic (D‑PoC) is a unique effort aimed at early screening and management of diabetic foot disorders. This project is spearheaded by the Bengaluru Science and Technology cluster (BeST), an initiative by the Office of the Principal Scientific Adviser to the Government of India, and is a collaboration between the Indian Institute of Science (IISc), the Karnataka Institute of Endocrinology and Research (KIER), and FootSecure. IISc, with its cutting-edge research facilities, provided the platform for innovation. KIER, a renowned healthcare institute, offered its clinical expertise. FootSecure has brought in international collaborations, clinical inputs and would help in deployment of D‑PoC at scale. Finally the BeST cluster is providing the financial and administrative support needed for the project. 

From the lab to the public

G K Ananthasuresh, a Professor from IISc developed cutting-edge technologies for the D‑PoC project. He generated a mechanical finite element model of the foot that can generate a computational contact pressure map. Traditionally, contact pressure maps are generated in the clinic by asking a patient to stand on an instrument called a pedoscan. The pressure map may be used to predict foot complications that may arise in a patient. It was not an easy task for Ananthasuresh, a mechanical engineer by training, since the foot is a complex structure with 26 bones. He worked closely with Pavan Belehalli, Head — Department of Podiatry, KIER, to understand and model the intricacies of the foot. His team has also developed self-offloading diabetic footwear capable of regulating pressure distribution during walking to help patients with foot ulcers. 

Then, they joined forces with Sanjay Sharma, Podiatric Surgeon & Founder of FootSecure, to take this innovation to the public. Sharma adds,

There are about 74 million people with diabetes, about 50% of them associated with diabetic foot conditions, and only about 200 people are actively working on diabetic foot conditions.

To tackle the huge number of patients with diabetes, the team envisions D‑PoCs that would be as widespread as telephone booths. A model of the D‑PoC is already active at KIER, and more D‑PoCs are planned to be set up soon. The BeST cluster is facilitating the scaling up of the D‑PoCs by pitching it to various government offices. The BeST cluster is also working to take the D‑PoCs to healthcare professionals. They have obtained permission from the Ministry of Health and Family Welfare, and a D‑PoC will soon be deployed there itself. 

Inside a D‑PoC

The D‑PoC is designed to be user-friendly and non-invasive. A patient entering a D‑PoC will first fill in their details, such as their history of diabetes, duration of symptoms, and medication and so on in a trilingual hand-held device such as an iPad. This will help to build a diabetic foot registry for further research. Then the D‑PoC will contain three devices connected to a dashboard and trained paramedical staff to assist the patient. The patient has to first walk on a pedo-scanner which gives the pressure areas of the foot. Then, the patient is assessed using ​‘NEUROTOUCH’, a small portable device which can identify the level of peripheral neuropathy and the nerves that are injured in the feet. 

Following this, they undergo Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) tests to check for blood flow impediments in the foot. Based on the results of the three tests, the patients are informed how likely they are to get a diabetic foot complication and how often they would be required to undergo a foot evaluation. The aim is to create a digital footprint for each patient, predicting their chances of developing complications over time and providing preventive podiatry care, like the customised footwear developed by the team.

Since patients may not be able to interact with a medical doctor at D‑PoCs, Ananthasuresh is also working on building a chatbot based on a large language model to answer questions that patients might have regarding their test results. 

Roadblocks to revolution

Despite the significant progress made, the D‑PoC project faces several challenges, including securing adequate funding, raising awareness among the general public, and ensuring accessibility to digital clinics. While the BeST cluster has provided funding for a few D‑PoCs, obtaining funds to set up D‑PoCs across Karnataka, and even across India remains a challenge. After setting up the D‑PoCs, raising awareness among people to visit D‑PoCs for foot examinations is another challenge. Ananthasuresh says,

“When Sharma told me that he had just performed diabetic foot surgery on a 30-year-old software engineer, I was shocked. Even the educated urban population lack awareness about diabetic foot complications.”

To address the challenge of staffing the D‑PoCs with adequate manpower, the clinics are designed to be user-friendly and straightforward to operate. Even if nurses are unavailable, the team envisions training paramedics or individuals with as little as a 10^th-grade education to run the D‑PoCs efficiently. With proper training, these clinics can be managed by individuals without advanced medical qualifications, making it easier to scale up and reach remote areas where healthcare resources may be limited.

The vision for D‑PoCs

In addition to the existing features, the team is working on enhancing the D‑PoCs with advanced capabilities for dressing diabetic wounds. The vision is to enable paramedical staff at the clinics to capture images of a patient’s wound using a simple camera or smartphone. These wound images will then be analysed by an AI-based tool that will assist the paramedical staff in making informed decisions about wound care, even in the absence of a specialised physician on-site. 

This collaborative effort serves as a shining example of what can be achieved when academia, industry, and government work together. By leveraging their unique strengths, the D‑PoC team have created a solution with the potential to transform the lives of millions living with diabetes. As Ambarish Ghosh, Professor IISc and Co-Principal Investigator BeST Cluster, remarked, 

This team has set up a very ambitious goal using minimal resources – a model to be emulated for future research and development endeavours.