Consultant Endocrinologist, St Columcille’s Hospital and St Vincent’s University Hospital, and Hse National Diabetes Programme Lead (2013-2016)
Year on year, the number of people in Ireland requiring hospital treatment for diabetes-related foot complications is increasing. What can be done to stop this worrying trend?
There are over 225,000 patients with diabetes in Ireland and around 300 patients require amputations each year. “Diabetic foot disease is one of the most common complications of diabetes, and tends to be one patients fear most,” says Dr Canavan, Consultant Endocrinologist. “If left untreated and mismanaged, it is associated with severe health complications and devastating outcomes, of which patients may not be aware.”
The National Diabetes Foot Care Programme by the HSE began in 2010 and today employs 22 podiatrists. Dr Canavan believes Ireland requires 120 podiatrists to effectively provide local screening and early intervention to the diabetes community. This is why identifying high-risk patients is critical to early intervention and effective treatment from Irelands stretched specialist services.
What is diabetic foot?
Diabetes can cause nerve damage and blood vessel disease in the feet. This can cause skin and tissue breakdown, which can develop into non-healing wounds (ulcers) and an increased risk of infection. “Patients with both nerve damage neuropathy and circulation issues are at much greater risk of a small cut or lesion to develop into an ulcer, then to an infection, which, if left untreated, can risk the whole viability of the limb,” says Dr Canavan. “It is important to note you tend to have diabetes for some time before nerve damage and circulation issues are introduced,” he says.
Identifying the disease early
Dr Canavan warns of the difficulty of self-identifying the early signs of diabetic foot and recommends patients with diabetes seek annual assessment. Key signs are frequently missed such as losing sensation in the foot, as it does not disturb sleep or cause pain, and can even lead to more damaging behaviours.
“One of the side effects of having a loss of sensation is patients look for shoes that are tighter, so as to achieve the sensation of tightness between shoe and foot. This can introduce ill-fitting footwear, injuring the foot further,” he says.
A simple, two-minute check with simple instruments can check the sensitivity of the foot to pressure – assessing the sensation response of the limb along with an assessment of circulation by examining skin colour and health along with feeling for the main pulses in the feet. This should be undertaken by your GP or diabetes team. Once this assessment has taken place, referral to podiatrist for further risk-assessment and potentially treatment plans can be initiated.
How to avoid complications
Patient education on the importance of blood glucose control and modifiable cardiovascular risk factors such as diet, exercise, body weight, and cessation of smoking are the first step to avoiding diabetic foot.
“There are a number of good education programmes around the country for patients. Xpert is a widely available community diabetes education programme and provides information on how to look after your feet and how to look after your diabetes in general,” says Dr Canavan.
Regular foot check-ups and ‘staying vigilant’ with your own foot health is also recommended to avoid developing further foot complications. “If you are in a high-risk category and you get an ulcer on your foot, treat that as an emergency and seek review from your GP, specialist podiatrist or diabetes clinic within 24hours,” says Dr Canavan.
Taking care of your feet
Many specialists recommend regular, or daily, foot checks, to identify changes in levels of sensation, coloration, lesions or shape. If you do notice any changes, contact your healthcare professional.
“A special type of nerve damage – called autonomic neuropathy – prevents sweating, thus causing hard, cracked skin where ulcers and infections can develop. If you think this is happening, contact your podiatrist; they can recommend specialist moisturisers to keep the skin supple,” he says.
If your feet are at risk, with established neuropathy or circulation problems, it is recommended that you seek a professional podiatrist with any foot care, including nail cutting and the removal of dry skin. “The analogy is you wouldn’t be expected to pull out your own teeth or do you own dentist work,” says Dr Canavan.
The future implications of diabetic foot are dependent not just on furthering investment in specialist services but also on patient participation, awareness and understanding. Through taking precautions with good glycaemic control, regular foot assessment, appropriate footwear, patient education, and early referral for pre-ulcerative lesions – cases of this debilitating diseases can be reduced.