Diabetes and Your Feet

(Physician’s Name Here)

(Practice Name Here)

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Expected Increase in Diabetes From 2000 to 2030

Zimmet P, et al. Nature. 2001;414:782-787.

14.2 M14.2 M

+23%+23%

15.6 M15.6 M

+44%+44%

9.4 M9.4 M

+50%+50%

26.5 M26.5 M

+24%+24%

84.5 M 84.5 M

+57%+57%

1.0 M1.0 M

+33%+33%

2030: 370 million patients (~145% increase)

2000: 151 million patients

Prevalence of Diabetes in the US Now up to 18 Million

95%

5%

The Facts About Diabetes • Diabetes affects minority populations

disproportionately:

-2.3 million African Americans age 20 or older have diabetes

-1.2 million Mexican Americans age 20 and older have diabetes

-diabetes can affect up to 50 percent of some Native American populations

Diabetic Complications Affect Every Part of The Body

DiabeticRetinopathy

Leading causeof blindness

in working ageadults

DiabeticNephropathy

Leading cause of end-stage renal

disease

CardiovascularDisease

Stroke

2 to 4 fold increase in cardiovascular mortality and stroke

DiabeticNeuropathy

Leading cause of nontraumatic lower extremity amputations

How do diabetic foot problems compare with other diabetes-

complications?• Infected wounds:

most common reason for hospital admission– Infection:Ulcer ratio

= 0.56

• 1 in 5 leads to lower extremity amputation

Trautner, et al, Invest Opthalmol Vis Sci, 2003Lavery, Armstrong, et al, Diabetes Care, 2003

Fedele, et al, J Urol, 2001Bruno, Diabetes Care, 2003

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20

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60

70

Incid

ence (1000 p

ers

on y

ears

)

Financial implications

• 7th leading cause of death

• Direct and indirect costs 2002 was $132 billion

• 25% of all Medicare expenditures

Diabetes Can Be Controlled

• Diabetes treatment includes “food management” to control blood sugar, getting regular physical activity, taking oral medications and/or insulin, and monitoring blood glucose levels.

• By keeping blood sugar levels in the normal range, people with diabetes lower their risk of long-term complications of diabetes, such as eye disease, kidney disease, and nerve damage.

UKPDS, NDEP

Blood Sugar/Glucose MonitoringPatient Home & Office Setting

• Patient education & encouragement in maintaining good glucose control is essential in avoiding complications; both in a primary care and specialist clinic setting.

A1c An Indication For Healing

• HbA1C (Now simply A1c)

Reveals a combination/average; reflects mean of fasting and post-meal glucose levels for past 2-3 months

Good indicator of how a patient will heal, as well as how well the blood sugar is controlled on a daily basis

Reduced Risk of Diabetes ComplicationsRisk Reduction per 1% Decrease in A1C

Eye Kidney Nerve Heart

DCCT 27-38%

22-28% 29-35% 40%

Kumamoto 28% 50% ↑NCV 25%

UKPDS 19% 26% 18% 14%

Patient Education

• Ask the patient if they know how diabetes affects the foot and if they have ever had their foot examined. This question can provide information on the presence or absence of effective behaviors to institute prevention through appropriate self-maintenance.and recognition of pivotal events

Patient Education (continued)

• Helping patients recognize pivotal events that require professional medical attention.

• Knowing the duration of diabetes and level of control (A1c #) would indicate level of risk of developing co morbid systemic disease involving the foot since manifestations of complications are time and control dependent.

• Checking your own feet everyday and seeing a podiatrist at the earliest sign of redness, skin breakdown

UKPDS, DCCT, CDC, ADA, UTHSC-San Antonio

Risk Factors Leading to Ulceration

• Neuropathy• Foot deformities• History of foot ulcers/amputations

Adapted from Armstrong et al, 1991; Pecoraro et al, 1990; Mayfield et al, 1996.

Neuropathy

• The presence of subjective complaints : tingling, burning, numbness or formication (sensation of bugs crawling on skin) may indicate the clinical presence of peripheral sensory neuropathy.

Neuropathy in People with Diabetes

• Neuropathy is present in >80% of diabetic patients with foot

ulcers

Neurosensory Testing

Neurosensory Testing

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2 34

5 6 7

8 9

10Left

Placement of Semmes-Weinstein monofilament

Ulcerations Are Pivotal Events In Limb Loss

• Portal for infection• Necrosis in the presence of critical ischemia

Etiology of Neuropathic Diabetic Foot Ulcers

Pressure x Cycles of Repetitive

Stress = Wound

DeformityRepetitive Stress

(Activity)

Neuropathy

Diabetic Foot Ulcer

Lavery, Armstrong, et al, Diabetes, Care, 2003

A PRESSURE-ACTIVITY IMBALANCE

Diabetic Amputation• Ulceration usually precedes an amputation

• Amputation 15 times more likely in people with diabetes

• 50% have contralateral amputation within 3-5 years

• 3-year mortality rate 20-50%

Adapted from reiber et al, 1995; CDC, 1997; Jiwa, 1997; Glover et al, 1997.

Musculoskeletal

• Biomechanical changes in the diabetic foot develop in conjunction with muscle-tendon imbalances as a result of motor neuropathy. These deformities include the presence of hammertoes, bunions, high arched foot, or flatfoot, all of which increase the potential for focal irritation of the foot within the shoe.

Example of Shoe Pressure

• This photo shows the results of shoe pressure on the foot where the shoe in not properly fitted to accommodate an individual’s foot size.

Foot Deformities

• Corns and calluses (hyperkeratotic lesions) of the feet are a result of elevated areas of focal mechanical pressure and shearing of the skin. This focal build-up often precedes breakdown of skin forming either a blister or ulceration.

Charcot Arthropathy

Structural Deformities

Bunions

Hammertoes

Arthritis

Calluses

Skin – Athletes Fee & Psoriasis with Fungal Infection in wound

Skin Infections

Toenail Infections

Toenails – Treated

Vascular Disease

• P.V.D.• Reduced Peripheral

Circulation

Perpheral Arterial Disease

• Symptoms of cramping of the calf when walking the requires frequent periods of rest- “intermitant claudication”

• Intense cramping and aching to the toes only at night characteristically relieved with hanging the feet down or with walking

PAD

• This symptom signifies the end-stage disease.

• Though poor blood supply is not an dependent risk factor for the development of ulceration, it is a significant risk factor for amputation.

Non-Invasive Vascular Test

• A non-invasive vascular test was performed in order to determine blood flow levels in a diabetic patient with a leg wound. Good vascular status aids in healing potential.

Offloading Its Importance for Reducing Foot Pressure

Points

Adapted from Janisse, 1995.

Pressure

DesquamationBlistersCallus Ulcer

Off-loading : For Healing & Prevention

• Total contact casting

• Removable walker

• Felt and foam• Half-shoe• Scotch cast boot

• For Prevention• Extra-depth shoe• Custom-molded

shoe• Custom Insoles• Oxford type

athletic shoe

• Adapted from Janisse, 1995; Lavery et al, 1996

Examples of Off-Loading Devices

Example of Off-loading Treatment

“Instant Total Contact Cast”

Armstrong, et al, J Amer Podiatr Med Assn, 2002Boulton & Armstrong, Diabetes Care, 2003

“How might I prevent recurrence?”

Computerized Gait Analysis

Custom Orthotics

Appropriate Footwear

Additional Methods/Aids In Reducing Footwear Friction

Surgical Intervention

Diabetic Foot Screening

• L.E.A.P.• Lower Extremity

Amputation Prevention

• Proactive Screen• Low Risk• Moderate Risk• High Risk• (Refer to Handout)

Thank You!!!!!