Diabetic Foot Care
Diabetes mellitus is a chronic disease that affects the lives of about 16 million people in the United States, 5.4 million of whom are unaware that they even have the disease. Every day, 2,200 new cases of diabetes are diagnosed, and an estimated 780,000 new cases are identified each year. The disease is marked by the inability to manufacture or properly use insulin, and impairs the body’s ability to convert sugars, starches, and other foods into energy. The long-term effects of elevated blood sugar (hyperglycemia) are damage to the eyes, heart, feet, kidneys, nerves, and blood vessels.
Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, fatigue, slow-to-heal wounds, and susceptibility to certain infections. People who have any of these symptoms and have not been tested for diabetes are putting themselves at considerable risk and should see a physician without delay.
Part of keeping your diabetes in control is testing your blood sugar often. Ask your doctor how often you should test, and what your blood sugar levels should be. Testing your blood and then treating high blood sugar early will help you to prevent complications.
The socioeconomic costs of diabetes are enormous. The costs have been estimated at $98 billion annually, about $44 billion of which are direct costs from the disease with $54 billion indirectly related. Diabetes is the sixth leading cause of death by disease in the United States, and individuals with diabetes are two to four times as likely to experience heart disease and stroke.
The growth of the disease worldwide is especially alarming. The World Health Organization (WHO) expects the number of new diabetes cases to double in the next 25 years from 135 million to nearly 300 million. Much of this growth will occur in developing countries where aging, unhealthy diets, obesity, and sedentary lifestyles will contribute to the onset of the disease.
While there is no cure for diabetes, there is hope. With a proper diet, exercise, medical care, and careful management at home, a person with diabetes can keep the most serious of the consequences at bay and enjoy a long, full life.
How Do You Get Diabetes?
No one knows why people develop diabetes, but once diagnosed, the disease is present for life. It is a hereditary disorder, and certain genetic indicators are known to increase the risk of developing diabetes. Type 1, previously known as insulin-dependent diabetes mellitus or juvenile-onset diabetes, afflicts five to ten percent of diagnosed cases of diabetes. This type occurs most frequently in children and adolescents, and is caused by the inability of the pancreas to produce the insulin needed for survival. Type 2, previously called non insulin-dependent diabetes mellitus or adult-onset diabetes, affects the other 90-95 percent of all diagnosed cases of diabetes, many of whom use oral medication or injectable insulin to control the disease. The vast majority of those people (80 percent or more) are overweight; many of them obese, as obesity itself can cause insulin resistance.
Certain characteristics put people at a higher risk for developing Type 2 diabetes. These include:
African Americans are 1.7 times more likely to have diabetes than the general population, with 25 percent of African Americans between the ages of 65 and 74 diagnosed with the disease.
Hispanic Americans are almost twice as likely to develop type 2 diabetes, which affects 10.6 percent of that population group.
Native Americans are at a significantly increased risk for developing diabetes, and 12.2 percent of the population suffers from the disease. In some tribes, as many as 50 percent of its members have diabetes.
Of all the risk factors, weight is the most important, with more than 80 percent of diabetes sufferers classified as overweight.
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The Role of Your Podiatric Physician
Because diabetes is a systemic disease affecting many different parts of the body, ideal case management requires a team approach. The podiatric physician, as an integral part of the treatment team, has documented success in the prevention of amputations. The key to amputation prevention in diabetic patients is early recognition and regular foot screenings, at least annually, from a podiatric physician.
In addition to these check ups, there are warning signs that you should be aware of so that they may be identified and called to the attention of the family physician or podiatrist. They include:
Ulceration is a common occurrence with the diabetic foot, and should be carefully treated and monitored by a podiatrist to avoid amputations. Poorly fitted shoes, or something as trivial as a stocking seam, can create a wound that may not be felt by someone whose skin sensation is diminished. Left unattended, such ulcers can quickly become infected and lead to more serious consequences. Your podiatric physician knows how to treat and prevent these wounds and can be an important factor in keeping your feet healthy and strong. New to the science of wound healing are remarkable products that have the appearance and handling characteristics of human skin. These living, skin-like products are applied to wounds that are properly prepared by the podiatric physician. Clinical trials have shown impressive success rates.
What is a Diabetic Foot Ulcer?
A diabetic foot ulcer is an open sore or wound that most commonly occurs on the bottom of the foot in approximately 15 percent of patients with diabetes. Of those who develop a foot ulcer, six percent will be hospitalized due to infection or other ulcer-related complication.
Diabetes is the leading cause of non traumatic lower extremity amputations in the United States, and approximately 14 to 24 percent of patients with diabetes who develop a foot ulcer have an amputation. Research, however, has shown that the development of a foot ulcer is preventable.
Who Can Get a Diabetic Foot Ulcer?
Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics and older men are more likely to develop ulcers. People who use insulin are at a higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.
How do Diabetic Foot Ulcers Form?
Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of feeling in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain and one may not even be aware of the problem. Your podiatric physician can test feet for neuropathy with a simple and painless tool called a monofilament.
Vascular disease can complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body’s ability to fight off a potential infection and also retard healing.
What is the Value of Treating a Diabetic Foot Ulcer?
Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated for several reasons such as, reducing the risk of infection and amputation, improving function and quality of life, and reducing health care costs.
How Should a Diabetic Foot Ulcer be Treated?
The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.
There are several key factors in the appropriate treatment of a diabetic foot ulcer:
Not all ulcers are infected; however if your podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.
There are several important factors to keep an ulcer from becoming infected:
For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.
The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.
Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.
For a wound to heal there must be adequate circulation to the ulcerated area. Your podiatrist can determine circulation levels with noninvasive tests.
Controlling Blood Glucose
Tightly controlling blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with a medical doctor or endocrinologist to accomplish this will enhance healing and reduce the risk of complications.
A majority of noninfected foot ulcers are treated without surgery; however, when this fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps.”
Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and what is being applied to the wound. Healing may occur within weeks or require several months.
How Can a Foot Ulcer be Prevented?
The best way to treat a diabetic foot ulcer is to prevent its development in the first place. Recommended guidelines include seeing a podiatrist on a regular basis. He or she can determine if you are at high risk for developing a foot ulcer and implement strategies for prevention.
You are at high risk if you:
Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and elevated blood glucose are important in the prevention and treatment of a diabetic foot ulcer. Wearing the appropriate shoes and socks will go a long way in reducing risks. Your podiatric physician can provide guidance in selecting the proper shoes.
Learning how to check your feet is crucial in noticing a potential problem as early as possible. Inspect your feet every day—especially between the toes and the sole—for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a health care provider, remove your shoes and socks so your feet can be examined. Any problems that are discovered should be reported to your podiatrist as soon as possible, no matter how “simple” it may seem to you.
The key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care:
The old saying, “an ounce of prevention is worth a pound of cure” was never as true as it is when preventing a diabetic foot ulcer.
Of the sixteen million Americans with diabetes, 25% will develop foot problems related to the disease, and may be at risk for serious complications. Protective footwear can help in the fight to prevent a large percentage of the 68,000 diabetic amputations that occur each year.
Medicare recognizes the importance of preventative foot care and has recently passed the Therapeutic Shoe Bill which provides coverage for "at risk" diabetic patients for one pair of high quality shoes and 3 pairs of removable protective shoe inserts each calendar year.
Check out the selection of shoes available on display and ask your doctor for more information.