Saturday, 23 July 2011

Diabetes and Foot Care

Published in "City Times", the daily supplement of The Khaleej Times

Foot care for diabetics.

Diabetes mellitus is a chronic disease that affects the lives of about 16 million people in the United States and a third of them are not even aware they have the disease! The long-term effects of diabetes include damage to the nerves, blood vessels, eyes, heart, kidneys and feet.

There were 141,000 diabetics in the UAE in the year 2000 and this will increase up to 260,000 in the year 2025! While 15.2% of the population was diagnosed as prediabetic, 19.6% had diabetes. 45% were diagnosed for the first time with Type 2 Diabetes, reveals Dr.Fatma H.Al Marashi, Chief of Division of Endocrinology, Diabetes and Metabolism, Specialist Physician and Endocrinologist, Welcare Hospital, Dubai.

It is believed that 15% of diabetics will experience a foot ulcer sometime in their lifetime and roughly 14% - 25% of these individuals will require amputation. Further, the probability of a second amputation within 3 to 5 years of the first amputation is claimed to be as high as 50%. Also, the 5-year mortality rate after amputation could range between 39% - 68%.

But a lot of these amputations can be very much prevented and the key to this prevention in diabetic patients is early recognition and regular foot screenings, at least annually, from a treating physician, Diabetic Educator and/or podiatrist a foot specialist, who should be an integral part of a team of specialists, treating and managing diabetic patients, emphasizes Dr. Al-Marashi.

Diabetic foot conditions develop from a combination of factors, which include poor blood circulation and neuropathy. When blood circulation is poor, there is a narrowing of the arteries, which often results in a significant decrease in supply of blood to the lower extremities. The poor circulation contributed to diabetic foot problems by reducing the oxygen and nutrition supply to the skin and other tissues, which results in poor healing of injuries in the region. In addition, the poor circulation also leads to swelling and dryness of the foot.

Diabetic Neuropathy can make patients insensitive to pain, heat and cold. As a result, when they get minor cuts, scrapes, blisters, or pressure sores as from ill-fitting footwear, they may not be aware of them since they are unable to feel the pain occasioned by these conditions. If these injuries, no matter how minor, are left untreated, complications may result and lead to ulceration and possibly even amputation. Most diabetic foot ulcers form over areas of bony prominence especially when bunions, calluses or hammertoe formations lead to abnormally prominent bony points. Foot deformities are believed to be more common in diabetic patients due to atrophy of the intrinsic musculature responsible for stabilizing the toes.

Diabetic peripheral neuropathy is characterized by numbness, weakness, hyperesthesia or abnormal perceptions such as pins and needles sensation, automatic changes leading to decreased sweating and dry skin which breaks easily and loss of protective sensation (LOPS), explains
Dr. Al-Marashi.

LOPS is a major factor in the pathogenesis of foot injury and it is defined as the degree of sensory loss which permits skin injury to occur without being perceived by the patient as painful. Approximately 15% of diabetic patients sustain lower extremity ulcers and may re-acquire them in the absence of preventive and protective intervention, warns Dr.Al-Marashi. “Diabetic foot ulcers account for more than 20% of total hospital days for diabetics and are the leading cause of hospital admissions for patients with diabetes. Further, complications from diabetes wound ulcer account for more than 50% of all non traumatic amputation in USA and more than 70 % in UAE.”

According to US studies, foot inspection is rarely part of the office visit in as little as 12% instances. In the UAE, this is less than 0.5%, says Dr. Al-Marashi. Yet, all patients with diabetes need to be tested for LOPS at least once a year, preferably 3 – 4 times annually. And this can be done in a very simple manner by using monofilaments. The cost-effective, simple diagnostic tool, opines Dr.Al-Marashi, must be carried by every doctor who is taking care of patients with diabetes. Foot examination is an essential component in the standards of care for patients with diabetes.

The warning signals that patients with diabetes can look for in their feet are: changed skin color, skin temperature of the feet – cold feet are indicative of affected vascular system, swelling of the foot or ankle, open wounds or sores that are slow to heal, ingrown and fungal toenails, dry cracks in the skin, particularly around the heel, absence of otherwise normal hair, especially in men, on distal third of the legs.

Risk Factors for Lower Extremity Amputation in the Diabetic Foot.
Absence of protective sensation due to peripheral neuropathy.
Arterial insuffiency.
Foot deformity and callus formation resulting in formation resulting in focal areas of high pressure.
Autonomic neuropathy causing decreased sweating and dry, fissured skin.
Limited joint mobility.
Impaired Vision.
Poor glucose control leading to impaired wound healing.
Poor footwear that causes skin breakdown or inadequately protects the skin from high-pressure and shear forces.
History of foot ulcer or lower extremity amputation.

Early recognition of diabetic neuropathy, coupled with appropriate intervention, can reduce, and in some instances, prevent many of the disastrous medical, psychological and economic complications of the foot associated with diabetes, emphasizes Dr. Al-Marashi. “In this regard, patient education regarding appropriate care of an existing wound is a crucial factor in the healing process. Patients with diabetes, who have no wound, need to be educated about foot care and need to know why foot care is important for them. And above all, doctors should be aware of simple tests to check for diabetic neuropathy and become alert to the situation and educate their patients on foot care.”

It is very important for patients with diabetes to take the necessary precautions to prevent all foot related injuries. Due to the consequences of neuropathy, daily observation of the feet is very important. With necessary preventative foot care measures, for patients with diabetes can reduce the risks of serious foot conditions.

Footwear and orthotics play an important role in diabetic footcare. Orthotics designed with appropriate material for protecting the insensitive diabetic foot, are usually recommended. By customizing footwear. Diabetic footwear should also provide protective benefits in that they should have high and wide space in the toe area, removable insoles for fitting flexibility with room for inserting orthotics if required and should have the soles designed to reduce pressure in the areas of the foot most susceptible to pain.

Simple measures to take care of the feet in patients with diabetes:
• First and foremost, control blood sugar levels.
• Exercise on a regular basis; if overweight or obese, take appropriate measure to bring down your weight.
• Check your feet everyday for cuts, sores or any blisters, injuries, etc.
• For areas of the soles of the feet that you are unable to reach, inspect, using a mirror.
• If you spot an injury, check it out with your physician.
• Wash your feet regularly with warm water and wipe them dry.
• Use moisturizers to keep them from becoming dry.
• Before a bath, check the water temperature to ensure that it is not too hot.
• Be careful when trimming your toenails.
• Do not meddle with corns, calluses or warts and try to remove them yourself.
• Do not walk barefoot.
• Always wear socks; preferably cotton ones, while walking.
• Wear appropriate footwear that is neither tight nor loose, leaving enough space for you to wiggle your toes.
• Certain types of footwear, high heels, shoes with pointed toes can put undue pressure on various parts of the feet, thereby causing injuries. Avoid such footwear.
• When you buy new shoes, don’t walk with them right away. Use them for short periods of time – for 10-20 minutes at a time, before walking long distances with them, so as to prevent ‘bite’ from new footwear.
• When in the hot sand, near fires, etc, always wear shoes.
• Similarly, in very cold conditions, protect your feet well; keep them warm to avoid frostbite.
• Stop smoking since it certainly affects the blood sugar level and the vascular disease. For a diabetic, smoking is like adding fuel to file.
• Excess alcohol can contribute to nerve damage, which is one of the consequences of diabetes. Drinking can accelerate damage associated with diabetes and thereby increases the possibility of overlooking an injury. Therefore avoid excessive drinking.
• It is important to keep the blood flowing to your feet. So do not cross your leg and sit on a chair for long periods of time.


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