Download a health briefing on diabetes

Diabetes and Your Feet
(Physician’s Name Here)
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Expected Increase in Diabetes From
2000 to 2030
2000: 151 million patients
2030: 370 million patients (~145% increase)
14.2 M
26.5 M
+23%
+24%
84.5 M
+57%
9.4 M
+50%
15.6 M
+44%
1.0 M
+33%
Zimmet P, et al. Nature. 2001;414:782-787.
Prevalence of Diabetes in the US
Now up to 18 Million
5%
95%
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
Leading cause
of blindness
in working age
adults Diabetic
Retinopathy
Diabetic
Nephropathy
Leading cause of
end-stage renal
disease
2 to 4 fold
increase in
cardiovascular
mortality
Stroke and stroke
Cardiovascular
Disease
Diabetic
Neuropathy
Leading cause of nontraumatic
lower extremity amputations
• Infected wounds:
most common
reason for hospital
admission
– Infection:Ulcer ratio
= 0.56
• 1 in 5 leads to lower
extremity
amputation
Incidence (1000 person years)
How do diabetic foot problems
compare with other diabetescomplications?
70
60
50
40
30
20
10
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Trautner, et al, Invest Opthalmol Vis Sci, 2003
Lavery, Armstrong, et al, Diabetes Care, 2003
Fedele, et al, J Urol, 2001
Bruno, Diabetes Care, 2003
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 Monitoring
Patient 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 Complications
Risk Reduction per 1% Decrease in A1C
DCCT
Eye
Kidney
Nerve
2738%
22-28% 29-35%
Heart
40%
Kumamoto 28%
50%
↑NCV
25%
UKPDS
26%
18%
14%
19%
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
2
3
4
1
6
5
8
7
9
10
Left
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
Diabetic Foot Ulcer
Pressure x Cycles of Repetitive
Stress = Wound
Deformity
Repetitive Stress
(Activity)
A PRESSURE-ACTIVITY IMBALANCE
Neuropathy
Lavery, Armstrong, et al, Diabetes, Care, 2003
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 muscletendon 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
Pressure
Desquamation
Blisters
Callus Ulcer
Adapted from Janisse, 1995.
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, 2002
Boulton & 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!!!!!