Key learning points:
– How diabetes affects the feet and reducing the risk of diabetic foot problems
– Educating staff on the management of diabetic feet
– The role of the primary care nurse in supporting and empowering patients who have diabetes
Diabetes mellitus is a chronic disease affecting around 3.2 million people in the UK. This figure is expected to rise by the year 2025 to around five million.1 The burden of this on the person with diabetes, their family and the health economy is vast in terms of financial and personal implications. The NHS budget currently spent on treating diabetes-related complications is already around £10 billion, which is 10% of its national budget.
Foot problems can affect people with poorly-controlled diabetes whether they have type 1 or type 2 diabetes. Poor diabetes control commonly leads to damage to the nerves and blood vessels, and are part of the metabolic syndrome resulting in neuropathy, peripheral arterial disease and atherosclerosis. Foot problems are one of the long-term complications along with the plethora of other co-morbidities, including circulatory disease, myocardial infarction, cerebra vascular disease, retinopathy and nephropathy. People with sensory, motor or autonomic neuropathy are at high risk, due to reduced sensation, change in foot shape (which can predispose callus formation), charcot arthopathy and increased callus and anhidrosis (reduction of sweating which causes very dry skin).
Feet are at risk of injuries due to a lack of sensation which could result in wounds and poor healing (particularly if there is a reduced blood supply) leading to possible amputation. Ischaemia can also lead to amputation if revascularisation cannot be achieved by angioplasty or bypass. People with diabetes are at an increased risk of amputation compared to the non-diabetic population.2 At least 10% of the diabetic population will have a diabetic ulcer at some stage of the disease.2,4 It is estimated that over 6,000 leg, foot and toe amputations are carried out on people with diabetes in the UK annually and survival rates post amputation are only a staggering 80% at five years.2 Often, diabetes is an insidious disease because the person with diabetes can feel well with poorly controlled diabetes, not realising the damage being done to them internally.
However, we can see our feet, and patients must be advices to inspect their feet on a daily basis as it is an important aspect of diabetes care.
In 2012, in acknowledgment of the poor management of foot care and the discrepancy of services across the UK, Diabetes UK developed a footcare pathway – Putting Feet First.3 The National Institute of Clinical Excellence (NICE) closely followed in 2015 with their guidance – Diabetic foot problems: prevention and management4 – to help standardise care. Healthcare professionals (HCPs) working with diabetes can access free online training through the charity’s foot care team,3 a framework for foot risk awareness and a useful resource with training modules. This framework for risk is also endorsed by NICE.
Within the Putting Feet First3 framework the identification and classification has a green, amber and red ‘traffic light’ risk algorithm. It recommends treatment or rapid referral to the multidisciplinary foot team locally, either immediately if it is limb/life threatening, or within 24 hours if the risk is high. Other risk assessments within the categories should be undertaken between two to eight weeks depending on the severity, and have regular follow ups.4
Treatment of diabetic foot ulcers or charcot arthropathy under the care of a diabetes specialist podiatrist and the diabetic foot care team encompass off loading, with non-weight bearing air boots or casts, antibiotics, wound debridement, and dressings. If ischaemia is profound, an urgent vascular referral and assessment is paramount.
The role of the healthcare professional is to empower patients with the knowledge to manage this chronic disease and understand why they need to:
1. Reduce their blood glucose levels and blood pressure.
2. Stop smoking, if they do so.
3. Reduce the amount of saturated fat and simple carbohydrates that they consume daily, to reduce this risk of long-term complications.
This can be assisted with structured patient education programmes such as: diabetes education and self management for ongoing and newly diagnosed (DESMOND)5 and dose adjustment for normal eating (DAFNE),6 but education and support must be lifelong and ongoing.7,8 Patients also need to understand the importance of concordance with medication to support these strategies so that evidence-based targets are achieved as much as possible.7,8
It is our responsibility as healthcare professionals (HCPs) to alert patients to the implications of neuropathy and ischaemia so that regular foot care and inspection is encouraged and maintained. Daily cleansing and moisturising of the feet, wearing good-fitting footwear, regular careful toenail cutting and alleviation of corns and calluses must be performed on a regular basis. This can be done by using either a pumice stone, foot file or seeing a podiatrist/chiropodist depending on the patients’ risk category. It is important that people with diabetes are encouraged to attend their annual diabetes review, where feet are inspected for any deformity, callus or signs of ulceration, with sensation and vibration checks and affirmation of pedal pulses to ascertain their risk, and the need for further triage if necessary. A useful resource for patients at increased risk is the booklet Foot Attack, which is available free of charge from the Diabetes UK online shop.3
People with diabetes should also be made aware of the 15 healthcare essentials,9 these are checks they should be receiving on an ongoing basis. Included in this are foot checks by HCPs, which must be undertaken on diagnosis, and at least at their annual review. This must be done by a HCP who is trained in delivering foot checks. If a HCP is unsure of the correct method of examining feet to assess and look for abnormalities, it is important that they spend time shadowing a diabetes specialist podiatrist for information and training on this procedure. When preforming a foot check the patient’s socks and shoes are removed so an examination of the feet can take place. It is also important to examine footwear, making sure that they fit the person correctly, and don’t cause any rubbing. Socks must also be suitable and preferably seamless.
While examining the feet, the HCP should take a history from the patient, so that an assessment can be made on presence/absence of sensation (using 10g monofilament), colour of the feet, any warmth or inflammation, deformity, ischaemia (palpating foot pulses), presence of corns or calluses or breaks in the skin.3,4 Two or more of the following, previous or present foot ulcer or amputation, neuropathy, peripheral vascular disease or foot deformities result in the classification of an ‘at risk’ foot. It is documented that as much as a third of the diabetic population are within this category,3 and these patients must be referred to the multidisciplinary foot team. Any limb-threatening or life-threatening diabetic foot problem such as ulceration, suspected infection, ischaemia, gangrene or charcot arthropathy must be referred immediately to acute care.3,4
Patients with painful neuropathy not managed with simple analgesics will need further medication in the form of tricyclic amitriptyline, 10-25mg at night gradually increasing to a maximum of 150mg daily, or the anticonvulsant drug gabapentin, 100mg gradually increasing to an effective individual response. If this is not effective, it is advisable to refer onto the foot clinic for further advice on medication.
It is important not to forget the vulnerable and elderly in residential homes who may not receive regular foot care, or an annual review. Additionally, those HCPs working within primary care and the community setting need to be receiving support and education through a locally-implemented education programme.10 The risk of foot ulceration is greater in this age group due to reduced mobility and other health related conditions. It is important that the care staff have local access to diabetes training, incorporating foot care within that training, from a diabetes specialist podiatrist.
It can be demonstrated that reducing the risk of foot problems is multi-faceted. Local commissioning groups need to invest and provide an integrated foot care pathway that staff have access to. This must be provided along with regular training and updates for knowledge to be disseminated. With a NICE endorsed framework to supports this.4
HCPs need to support patients to manage their disease and reduce their risk of developing diabetes-related foot problems. This can hopefully improve the overall quality of life for the person with diabetes, and help to reduce the burden on healthcare nationally.
1. Diabetes UK. State of the Nation, 2013. diabetes.org.uk/State-of-the- Nation-2013 (accessed 5 October 2015).
2. Public Health England. Diabetes Footcare Activity Profiles, 2014. yhpho.org.uk/diabetesprofilesfoot (accessed 5 October 2015).
3. Diabetes UK. Putting feet first, 2012. diabetes.org.uk /Putting-Feet-First (accessed 5 October 2015).
4. National Institute for Clinical Excellence. Diabetic foot problems: prevention and management. nice.org.uk/guidance/ng19 (accessed 5 October 2015).
5. The DESMOND. Diabetes education for self-management of ongoing and newly diagnosed, 2008. desmond-project.org.uk (accessed 5 October 2015).
6. The DAFNE. Dose adjustment for normal eating, 2002. dafneonline.co.uk/ (accessed 5 October 2015).
7. National Institute for Clinical Excellence. Diabetes in adults. nice.org.uk/qs6 (accessed 5 October 2015).
8. National Institute for Clinical Excellence. Type 1 diabetes in adults: diagnosis and management. nice.org.uk/guidance/ng17 (accessed 5 October 2015).
9. Diabetes UK. Diabetes 15 Healthcare essentials. diabetes.org.uk/15 (accessed 5 October 2015).
10. Diabetes UK. Good clinical practice guidelines for care home residents with diabetes, 2010. diabetes.org.uk/ (accessed 5 October 2015).