Diabetes, Dialysis and the Diabetic Foot: a timely reminder

On July 28 2008, on this website I wrote about Dialysis and the diabetic foot, with a description of a foot ulcer patient.

Last week I was invited to speak to patients of the Cape Town Dialysis Clinics about foot care; during my preparation I came across some startling evidence proving that dialysis is an independent risk factor for foot ulceration if you have diabetes and require dialysis.

We already know that impaired kidney function increases the risk of foot ulcers – also referred to in my 2008 Blog – but this 2010 research proves that:

If you have diabetes and are receiving dialysis, you are 5 times more likely to develop foot ulcers, compared to someone with diabetes who is not on dialysis.

Scary but true clear evidence from a study completed at Manchester UK.

The research showed that patients on dialysis have more nerve damage, circulatory problems and a history of foot ulcers and amputations.

There is a 25% lifetime risk of people with diabetes developing foot ulcers so the key issue whatever your status is prevention.

Diabetic foot ulcers have multiple causes, some are: external trauma from footwear, neuropathy, arterial damage, poor self-care, lack of access to care, poor treatment.

However, as with all research you must ask – “so what?” This patient group did not include any people of colour, so it may not apply totally to South African patients.

So what to do? our objective is always to PREVENT complications.

Every person with diabetes must have an ANNUAL FOOT EXAMINATION so that they understand their level of risk for developing foot complications.

in addition individual education on self management of their diabetes. this is a team effort, paying attention to cardio-vascular health, eyesight, footwear selection and fitting, foot biomechanics (and possibly insoles or orthotics), plus probably the most important factor – can you invest in the care being offered?

Always “take care of your pair”.

The Diabetic and the barley bag – part 2

Loss of sensation and reduced blood flow to the lower limbs and feet are a well known complication of diabetes. As winter progresses, people with diabetes are at increased risk from problems associated with damage caused by trying to keep the feet warm. The lady I wrote about on May 7 is still at high risk.

Fortunately she is sticking to her care routine and the toe has stabilised. The blistered skin dried and formed a hard crust – actually this is a dry gangrenous crust – has formed over the centre of the wound, but the edges are clean and pink. The primary key to a successful outcome is control of blood sugar and that is good. Secondary is the quality of wound care and hopefully we are up to standard.

The biggest problem we have when treating diabetic foot ulcers is to keep weight off, called off-loading. Naturally, this is very difficult for a patient who knows they have a foot ulcer, but doesn’t feel any pain. Remember, pain stops us from doing further damage to an injured body part.

Here are a few WINTER FOOT TIPS FOR PEOPLE WITH DIABETES.(It’s winter in the southern hemisphere).

Keep up the daily washing and drying -especially drying

Keep up/start a daily routine of gently massaging moisturiser into your legs and feet

Remember that your shoes may become tighter because you are wearing socks and closed shoes

When you take off your shoes, check your feet for tell-tale red marks – this means dangerous pressure

Check that your shoes do fit, you possibly haven’t worn then for some months

Thicker-soled shoes will keep your feet warmer

Don’t let your boots squeeze your calf muscles and reduce circulation

Keep your feet warm at night – wear socks. NOT nylon, but cotton or wool or mixtures

Heat your bed BEFORE you get in and turn off electric blankets and heating pads. Remove hot water bottles

Try to avoid sitting in draughts – difficult, because we have houses that are designed for coolness

Wrap a blanket around your legs and feet if you are in a cold room

Never sit too close to any fire or heater – (people have fallen asleep and burnt their legs & feet)

Try to keep your excercise routine going, even though it’s darker morning and evening

p.s. Cape Mohair make excellent socks

Diabetic Foot Dangers – ‘the barley bag’

As winter approaches the southern hemisphere, the risks of damage to the feet of people with diabetes increase. The weather turned nasty in Johannesburg last weekend – wet and cold – as a result I saw my first Autumn diabetic foot disaster yesterday. A burn on the big toe of a lady who went to bed with her ‘barley bag’. It doesn’t have to be barley, rice, lentils, in fact anything that can be heated in the microwave.

After heating the bag in the microwave this lady put it into the bed to warm it up. Her big mistake was, that when she went to bed she didn’t remove the bag from the bed. During the night her foot came to rest on the bag and burned her big toe, leaving a blister along the whole length it.

When she saw me, the blister had broken and the base was infected. So now she is under treatment for a foot ulcer. The sad thing is that I spent months in 2007 succesfully healing an ulcer on this lady’s other big toe.

So what’s the message? You could say the ulcer is a result of a failure of diabetic foot health education – we didn’t get the right message across – but it does highlight the fact that everybody involved in diabetic foot care has to be constantly alert to potential dangers. In this case we have a high risk patient with peripheral vascular disease and diminished sensation who made a mistake with serious consequences. So what are the key messages for winter protection for the diabetic foot?

• wash and dry your feet thoroughly
• remove any heating bags or hot water bottles before getting into bed
• turn off any heating pads or electric blankets when you get into bed
• make sure your winter socks are not too tight on your feet and around your legs
• take care that you can wriggle your toes in your shoes when you have thicker socks on
• remember that a thicker-soled shoe will keep your feet warmer
• if you live in a winter rainfall area, dry your feet as soon as possible after they get wet
• try wearing loose-fitting cotton or woollen socks in bed
• if your feet swell during the day, remember to allow for it when you wear your winter shoes or boots
• STOP SMOKING!

Take care of your pair and see a podiatrist