Diabetes Management

with low risk foot care

Sue Spencer
Structure of the day
• Introductions
• Myth busting
• Type 1 diabetes
• Type 2 diabetes
• Low risk foot assessment, care & advice
• Reflections and evaluation
Mythbusting
What is diabetes?
• Diabetes mellitus (DM) is a group of diseases
characterised by high levels of blood glucose resulting
from failure in insulin production, insulin action at cell
level, or both.
• There are TWO main types of diabetes that most
HCPS will encounter. These are known as Type 1 and
Type 2.
• The incidence of diabetes in the UK is rising and
considered one of the most significant health
problems of the 21st century.
• The number of people known to have diabetes has
risen from 1.4. million in 1996 to over 2.5 million in
2013; thought to rise to over 4 million by 2025
Background issues
• Diabetes reduces life expectancy by 10-15
years.
• Actual deaths from diabetes related morbidity is
grossly underestimated as death certificates
may not indicate diabetes as a contributory
disease.
• Certain populations are at high risk of
developing diabetes including people over 70,
populations of Afro Caribbean origin and those
from the Indian subcontinent.
• The growth rate of diabetes is considered to be
of epidemic proportions and thought to cost
health care systems around 1 in 5 of every £
spent (20%)
Type 1 diabetes
• Formerly known as insulin-dependent diabetes
occurs in children and young adults – although not
exclusively. Type 1 diabetes can develop at any age
and should not be overlooked in older adults.
• Type 1 diabetes accounts for around 10% of adults
with diabetes
• Presenting symptoms are :-
– Thirst (polydypsia)
– Weight loss
– Fatigue
– Passing more urine (polyuria)
Type 1 diabetes
• It is an auto-immune disease with destruction of the B
cells in the pancreas.
• No insulin is produced and rate of destruction can be
very rapid
• The trigger for the auto-immune response is still
unknown but there are thought to be a number of
contributory factors
• The auto-immune response in adults may more
insidious than in children (happen over a longer period
of time) and the trigger for diagnosis may be concurrent
illness i.e. Infection, MI, CVA, or surgery etc
• ALL require insulin as treatment for their diabetes
Insulin
Insulin is a hormone produced in the
pancreas by the B cells (islets of
Langerhans) and is the body’s
mechanism for regulating blood glucose
levels.
Insulin is released directly into the
blood stream on demand and is finely
tuned to maintain homeostasis
Digestion and action of insulin
Diagnosis of Diabetes Mellitus
• Diagnosis is made on two fasting blood
glucose greater than 7 mmol/l
• Type 1 diabetes is often diagnosed with
presentation of symptoms and history
taking
• Oral glucose tests are now rarely used
except in ante-natal screening
• HbA1C can also be used to diagnose
diabetes values between 42 -47 considered
“at risk” of diabetes, 48 and above
confirms diabetes
Treatment of type 1
• Insulin (alongside dietary modification)
is the ONLY current treatment given by
subcutaneous injection or continuous
infusion pump
Commonly used insulin
• Fast acting analogues – Novorapid and
Humalog –
• Short acting insulin – Actrapid and Humulin
S
• Isophane insulin – intermediate acting
Insulatard and Humulin I
• Long acting analogues – Levemir (Detemir)
and Lantus (Glargine)
• Pre-mixed insulin – NovoMix 30 (30%
novorapid + 70% insulatard) or Humulin
M3 (30/70 mix of Humulin S & I)
Overview of Action
Injection sites
If a person injects insulin three or more
times a day then it’s a good idea to rotate
injection sites.
Injecting in the same place much of the time
can cause hard lumps or extra fat deposits to
develop.

These lumps are not only unsightly; they can

also change the way insulin is absorbed,
making it more difficult to keep your blood
glucose on target.

Follow these two rules for proper site

rotation:
1. Same general location at the same time
each day.

2. Rotate within each injection site.

Site rotation
Acute Diabetes Complications
– Hypoglycaemia
• blood glucose levels fall below 4 mmol/l
• Symptoms –

• Treatment
– 4-6 glucose tablets or 150 ml of lucozade or 4-5 jelly
beans or 150 mls coke or 200 mls fruit juice
– Wait 10 minutes and check blood glucose if still
below 4 repeat
– If 2 hours or more until next meal have 2 plain
biscuits or piece of fruit or a small yoghurt or slice of
bread or toast
Common Causes of hypoglycaemia

• Too much insulin or oral medication

• More than usual exercise
• Changing injection site
• Change of schedule
• Delayed or reduced carbohydrate intake
• Alcohol
• Travel
Hyperglycaemia
• High blood glucose due to infection or
other concurrent illness (usually above 12
mmol/l)
• If blood glucose level is high for just a short
time, emergency treatment won’t be
necessary. But if it stays high you need to
take action to prevent developing diabetic
ketoacidosis
• If raised blood glucose levels then urine
must be tested for ketones.
• Increased insulin may be required –
specialist advice should be sought
Common causes of hyperglycaemia

• Untreated diabetes
• Reduced mobility
• Infection or illness
• Stress
• Too much carbohydrate/sugar intake
• Insufficient medication
• Overuse of injection sites
• Weight increase
• Too little insulin
Monitoring blood glucose levels
• Integral part of self-management of
condition
• Can improve glycaemic control in type 1
diabetes
• Frequency of testing, access to strips
and devices should be agreed between
person with diabetes and health care
provider
• Self-monitoring should be taught close
to time of diagnosis
Monitoring blood glucose levels
Type 2 diabetes
• If you have type 2 diabetes your body
does not use insulin properly. This is
called insulin resistance.
• At first, the pancreas makes extra insulin
to make up for it but, over time it is not
able to keep up and does not make
enough insulin to keep blood glucose at
normal levels.
Treatment
1. Diet and increased activity (lifestyle)
2. Introduction of medication
– Biguanide – metformin

– Sulphonylureas - gliclazide
– Alpha glucosidase inhibitor – acarbose

– Prandial glucose regulators – repaglinide,

nateglinide
Medication continued
– Thiazolidinediones (glitazones) –
Pioglitazone
(reduces insulin resistance/increases insulin
sensitivity)
– Incretin mimetics – exanatide, liraglutide,
lisientatide
– DPP-4 inhibitors (gliptins) – 5 in this class
all names end **gliptin
– SGLT2 inhibitors – dapagliflozin,
canagliflozin, empagliflozin (newest)
Food
The traditional pyramid of
food/healthy plate is
coming under closer
scrutiny and there is much
debate as to the best
balance for people with
diabetes. As with much
advice it may need to be
tailored individually
depending on their
physiological response.
Co-morbidity
People with type 2 diabetes are more likely
to also have:-
• Hypertension
• Hyperlipidaemia (dyslipidaemia)

People with type 2 diabetes are more at risk of :-

• Ischaemic heart disease
• Cardiovascular disease
Consequences of diabetes
• Vascular complications of diabetes
include coronary heart disease,
cerebrovascular disease and peripheral
vascular disease
• These comprise 75% of causes of death
in type 2 and 35% in type 1.
• Diabetes can affect eyesight, kidneys
and nerve supply
Key points
• Diet and lifestyle are cornerstone of
treatment in type 2 diabetes
• Weight management is central to reducing
blood glucose levels and insulin resistance
• Medication requirements will depend on
individual needs and negotiated with
patient.
• Information, education and decision
sharing are also crucial components in
successful management (health literacy)
Seeing the person
• Consultation style
• Asking questions
• Listening
• Referring on
• Information giving
• Listening
Type 2 – the blame and shame disease

• Recent research has indicated that people with type 2

diabetes often feel stigmatised.
• They feel they are blamed for their disease, subject to
negative stereotyping, being discriminated against or
having restricted opportunities.
• People are unwilling to disclose condition to others
and have psychological and emotional distress

Browne at al (2013) available from

http://bmjopen.bmj.com/content/3/11/e003384.full
Prevention or delay of diabetes:
Life style modification
 Research studies have found that lifestyle changes can
prevent or delay the onset of type 2 diabetes among high-
risk adults.

 These studies included people with IGT (pre-diabetes) and

other high-risk characteristics for developing diabetes.

 Lifestyle interventions included diet and moderate-

intensity physical activity (such as walking for 2 1/2 hours
each week). Health literacy a crucial issue..

 In the Diabetes Prevention Program, a large prevention

study of people at high risk for diabetes, the development
of diabetes was reduced 58% over 3 years.
 Low risk foot assessment, care & advice

• Identify current knowledge of diabetes care

• Identify the importance of regular foot screening for
ALL people with diabetes
• Understand the purpose and outcomes of foot
screening for people with diabetes
• Discuss the importance of addressing person’s
understanding of the importance of foot screening
and foot care.
• Demonstrate how to undertake low risk foot
screening as per local protocol
• Discuss the importance of accurate documentation
and referral to appropriate services
 Why feet are important

• Foot ulcers and other lower-limb complications secondary to diabetes

are common, complex and costly
• Increases morbidity and mortality
• People with diabetes often have difficulty recognising their risks
• Also loss of sensation may mean injury goes undetected
• Consistent provision of foot-care services and preventative care reduce
amputation rates
• Never assume that people understand or implement foot care advice –
repetition and reinforcement very important
• ALL members of the practice team should have basic knowledge and
understanding of the importance of foot care in diabetes
• If problems occur rapid and appropriate response is essential to avoid
deterioration
• https://www.youtube.com/watch?v=Vk
4xPfgnXWU
 Low risk foot screening

• Ensure this is not initial foot screening

• Documented that patient is “low risk”
i.e. has no loss of sensation or
peripheral vascular disease
• Screening should be undertaken each
time the patient visits or at least once a
year
• Ensure there is an agreed local policy for
referral if problems detected
 Patient history

• Ask if they have any concerns about

their feet
• Review diabetes history and awareness
of diet, blood glucose levels, BP etc
• Ask patient if they have ever been
advised that reduced sensation or
circulation in lower limb
• Smoking status
 Physical examination

• Inspection of the feet – any red areas,

skin breakdown, hair loss
• Skin condition is early warning system –
inspect for callous, wounds, fissures,
maceration, nail dystrophy or nail loss.
• Skin discolouration or loss of hair
growth may be first signs of vascular
insufficiency
• Callous and/or hard skin ++ can be
precursors to ulcer formation
 What to ask

• How long had diabetes

• Any previous concerns
• Any surgery on lower limb
• Smoking status
• Has patient noticed any tingling, burning
• Restless legs or pain at rest
• Changes in skin colour
• Visit to chiropodist/podiatrist
• Any loss of sensation
 What to look for

• Nails – discoloured, ingrown or

elongated?
• Any signs of fungal infection?
• Any callous, lesions or corns?
• Any open wounds or fissures?
• Any interdigital maceration
• Temperature of foot
• Any redness from footwear?
 Assessing loss of sensation

• Monofilament
• Patient should be looking away
• Slowly push monofilament so it bends –
ask if can feel sensation
Monofilament
 Musculoskeletal examination

• Full range of movement?

• Any obvious deformities?
• Any areas hot, red or inflammed?
• Any sign of footwear damage?
 Vascular examination

• Any evidence of reduction in hair

growth on foot or lower limb?
• Are dorsalis pedis and posterior tibial
pulses palpable?
• Any temperature difference between
calves and feet, or between left and
right foot?
 Patient Education

• Smoking cessation
• Glycaemic control
• BP and weight
• Holiday advice
• Referral advice
 Daily foot care

• Visually examine the feet

• Ask carer or family member if not able
to visualise themselves
• Check shoes
• Keep feet dry – change socks every day
 Footwear education

• Know to whom to report any new

lesions or concerns
• Remind patient of the risks of barefoot
walking
• Assess wear of shoes and whether any
concerns
• Holiday advice
Group activity

15 minute - practical
Reflections
Documentation
Footcare advice
Group activity

10 minute – action points

• Competence checklist
• If in doubt - ask
• Refer on if any concerns
• If in doubt – ask
Referral pathways
 Resources
https://www.diabetes.org.uk/putting-feet-first

http://www.diabetesandprimarycare.co.uk/media/
content/_master/3977/files/pdf/dpc16-6-307-
16.pdf
Take home messages
• What changes might you make in practice?
• Is there anything else would you like to know?
• Are there key knowledge needs and/or
professional development needs?
• Do you know your specialist team and have
you considered shadowing them as part of
your CPD?
• Comments and feedback
Useful resources
The most authoritative and reliable source of information
for both patients, families, carers and professionals is
Diabetes UK. They have a huge range of resources, most of
them free. http://www.diabetes.org.uk/
There is also information available from NHS Choices
http://www.nhs.uk/Conditions/Diabetes
type2/Pages/Introduction.aspx
Information on evidence based practice is available from
http://www.evidence.nhs.uk/search?q=evidence%20ba
ed%20practice%20diabetes
Any questions?