The Foot in Diabetes
Introduction
Definition : Diabetes Mellitus is the condition whereby the pancreas has a reduced output or complete lack of insulin production. Insulin lowers blood glucose levels by converting glucose into glucagon for storage. If there is little or no insulin present, then blood glucose levels remain high which has many pathological effects on body tissues.
Diabetes was first described in 1500BC by Hess Raa, the pharoah’s physician who noted the accumulation of ants around the urine of some people. Ancient Egyptian papyrus from Luxor contains an accurate description of diabetes, and goes so far as to suggest means of treatment by diet. Probably the greatest advance in diabetic medicine was the isolation of insulin, by Banting & Best, in 1921.
Today we recognise:
- Type I diabetes – formerly IDDM(Insulin Dependant Diabetes Mellitus) . These patients control blood glucose levels using diet and insulin injections
- Type II diabetes – formerly NIDDM ( Non-Insulin Dependant Diabetes Mellitus). These patients use diet and oral hypoglycaemic drugs to control their blood glucose levels.
- Other classifications include gestational diabetes and impaired glucose tolerance.
According to the Department of Health, the prevalence of DM in the UK indigenous population is 3.6% but is set to rise to 6.5% by 2025. In India the prevalence is 30% as it is in the Middle East. The World Health Organisation reports there are 250 million diabetes patients worldwide. By 2025 this figure will rise to 380 million.
Effects of Diabetes Mellitus
Throughout the body systems, diabetes can present the patient with:
- Retinopathy – eye problems
- Nephropathy – kidney complications
- Peripheral vascular disease – poor blood supply/perfusion to extremities
- Increased risk of heart disease
- Increased risk of infection – bacteriological , viral and fungal
- Peripheral neuropathy
Combined these with other problems such as depression, erectile dysfunction and reduced life expectancy it’s a pretty nasty combination of symptoms awaiting a diabetes patient.
Until recently, footcare in diabetes was underfunded, and often portrayed as the “Cinderella” of diabetes care. Studies have shown the financial advantages of early intervention, as well as improving patient morbidity and survival.
Its easy to downgrade the importance of foot examination alongside kidney failure, blindness and heart disease, but consider these statistics;
In 1985, Palumbo and his workers reported they expect 15% of all diabetes patients to suffer a foot ulcer during their lifetime.
After ulceration, a diabetic foot is 58 times more likely to ulcerate again.
Foster 1992 reported that 85% of major diabetic amputations (below knee or above) are preceded by a foot ulcer.
Diabetes is the main cause of non-traumatic lower limb amputations in the UK
Every 30 seconds, somewhere in the world, a limb is lost to diabetes
According to the International Diabetes federation 85% of diabetes related amputations are preventable
Type II diabetes, controlled by oral drugs and diet, are at a greater risk of complication than the Type I. There is no such thing as “mild diabetes”. The so called “milder” version is far more likely to result in complications. (Boulton 1991)
What can you do as a podiatrist?
Early intervention is crucial so screen your patients for signs of diabetes. Patient education, and continual reinforcement, is vital.
Often confused, screening and assessment are two different processes:
Screening – this involves tests to discover if a patient is at risk of ulceration. If the patient is deemed to have a risk then they ought to be assessed.
Assessment – used once the patient has been identified as being at risk ,assessment is when a clinician utilises a small battery of tests to assess the level of risk .
Once a risk category has been defined an appropriate level of advice and care ought to be provided to the patient.
Why not log-in and browse the Assessment of the Diabetic Foot page. There are downloads available for patient information leaflets, neuropathic assessment and user guides for diagnostic equipment products.