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Diabetic foot disease: When the alarm to action is missing
diabetes research and clinical practice 109 (2015) 551–552
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
International Diabetes Federation
Diabetic foot disease: When the alarm to action is missing§ Kristien Van Acker 1
Did you know that every 20 s an amputation caused by diabetes occurs somewhere in the world? Paradoxically 85% of all amputations caused by diabetes are preventable. If amputation is almost always preventable then this is good news for people at greatest risk for diabetic foot disease. Sadly, amputations are still occurring at too great a rate in high, lowand middle-income countries. Problems related to the feet are among the most serious and most feared complications of diabetes. It is well known that diabetic foot disease is a source of major suffering and financial burden for patients. People with diabetic foot ulceration and amputation are observed to be suffering from reduced quality of life (QoL) in terms of pain, time lost from work and reduced socialisation leading to isolation and despair. The start of the diabetic foot disease process is the loss of protective sensation, meaning that a person is already suffering from relatively severe neuropathy. When blood glucose, blood cholesterol and blood pressure are excessively and consistently high, diabetes provokes damage to nerves throughout the body and this is called neuropathy. The most commonly affected areas are the extremities, particularly feet. Damage in the feet is called peripheral neuropathy, which may lead to pain and tingling but, more commonly, to loss of feeling. Even if an injury develops, the individual with peripheral neuropathy will not feel the pain associated at the site of the lesion. In other words, the alarm to action is missing. The development of lesions with no appropriate and immediate action leads to infection and further destruction of deep tissues. When impaired peripheral circulation is present the situation can escalate further and very quickly to minor or major amputation.
§
Worldwide, the number of ulcers and amputations are very high and diabetic foot ulceration precedes 85% of diabetesrelated amputations. The yearly incidence is around 2–4% in developed countries and at least 4–8% in developing countries. This translates to approximately 1.1 million amputations in Africa (estimated to rise to 9.9 million in 2030) and 1.25 million in South and Central America (estimated to rise to 2.5 million by 2030). The statistics represent millions of personal tragedies but also the huge financial burden of diabetic foot disease and amputation on families. In low-income countries the cost of treating a complex diabetic foot ulcer can be equivalent to 5.7 years of annual income, potentially resulting in financial ruin for patients and their families. Since 2006, the International Working Group on the Diabetic Foot (IWGDF) together with the International Diabetes Federation (IDF) have collaborated to provide diabetic foot programmes worldwide. The strategic objective is to decrease the risk of diabetic foot disease to patients, and raise awareness with healthcare providers and governing bodies, too. There are three levels of intervention required to meet the specific targets. Level 1: Programmes called ‘‘Train the Foot Trainer’’ (TtFT) implement the Step by Step Foot projects which are focused on the following processes: Investment in national structures with secondary and reference centres of interdisciplinary diabetic foot services. Many disciplines work together for early treatment of simple and more complicated ulcers. It is proven in the literature that this approach reduces amputation in developing and developed countries
This article first appeared in the July 2015 online issue of the International Diabetes Federation’s magazine Diabetes Voice (http://www. idf.org/diabetesvoice). 1 Dr Kristien Van Acker is a diabetologist and started, in 1989, the first interdisciplinary diabetic foot clinic in Antwerp. Today working in Chimay, Belgium, she is Chair of the International Working Group on the Diabetic Foot (www.iwgdf.org) and IDF Consultative Section on the Diabetic Foot. http://dx.doi.org/10.1016/j.diabres.2015.07.005 0168-8227/# 2015 Published by Elsevier Ireland Ltd.
552
diabetes research and clinical practice 109 (2015) 551–552
alike. Centres are responsible for setting up referral and contra-referral strategies, where the delay to referral will be set as low as possible. The trainees, national key-opinionleaders, also give training to healthcare providers in their regions for prevention. As all of these interventions concern national healthcare, political involvement is a must. Before trainees can come to a 4-day course they need a letter of collaboration from their national patient organisation and an approval of contact from their ministry of health. Level 2:
specific education on foot self-care is necessary. The patient will be asked to look daily at his or her feet and this sometimes requires the help of a family member. Good foot hygiene and nail care is a must, as is the protection of the feet with appropiate footwear. As the last condition is not always present in developing countries, patient organisations need to accept the idea that special shoes given to people at risk of diabetic foot disease is as important as ensuring that insulin or oral medications are available.
Members of the working group believe that success depends upon healthcare providers who can be considered ‘‘gatekeepers,’’ as they are able to determine the group of patients at the highest risk for developing foot-ulcers. Patients at high risk are the following:
In 2012, a TtFT course for the South and Central America region included 58 delegates from 14 countries. In 2014, the two and a half year implementation phase of this great effort was complete. In a two year period, more than 3000 healthcare providers (doctors and nurses) were trained in the countries of Latin America. Additionally, more then 150 new diabetic foot clinics were established. We hope that national patient organisations will help this advancement and empower people with diabetes to care for their feet. What will it take to achieve success today and tomorrow? Trained healthcare providers who work together to improve diabetic foot care and informed patients who perform their daily foot-care regimen and recognise when an ulcer or infection is present and, without any delay, get immediate help.
Designated by an orange light: peripheral neuropathy and peripheral arterial disease and/or with foot deformities; Designated by a red light: peripheral neuropathy and a history of foot ulcer or any level of lower-extremity amputation. Currently, only 20 countries have healthcare providers trained in specialised foot care, also known as podiatrists or podiatry care. Podiatrists are very good gatekeepers. To make up for the lack of podiatry care, a common programme called the Diabetic Foot Care Assistant programme (DFC Ass programme) has been developed to fill the gap, particularly in developing countries. In the last phase of this programme the working group will help set up podiatry care on a mid- to long-term basis in those countries. Level 3: Preventive care must be encouraged and directed to the patient with empowerment strategies. This intervention can be carried out with every national diabetes patient organisation. National associations can encourage the necessary skills and education for people with diabetes. We consider it a patient right to know their individual personal risk-category for developing a diabetic foot ulcer. From the moment red or orange has been designated,
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
International Diabetes Federation
Diabetic foot disease: When the alarm to action is missing§ Kristien Van Acker 1
Did you know that every 20 s an amputation caused by diabetes occurs somewhere in the world? Paradoxically 85% of all amputations caused by diabetes are preventable. If amputation is almost always preventable then this is good news for people at greatest risk for diabetic foot disease. Sadly, amputations are still occurring at too great a rate in high, lowand middle-income countries. Problems related to the feet are among the most serious and most feared complications of diabetes. It is well known that diabetic foot disease is a source of major suffering and financial burden for patients. People with diabetic foot ulceration and amputation are observed to be suffering from reduced quality of life (QoL) in terms of pain, time lost from work and reduced socialisation leading to isolation and despair. The start of the diabetic foot disease process is the loss of protective sensation, meaning that a person is already suffering from relatively severe neuropathy. When blood glucose, blood cholesterol and blood pressure are excessively and consistently high, diabetes provokes damage to nerves throughout the body and this is called neuropathy. The most commonly affected areas are the extremities, particularly feet. Damage in the feet is called peripheral neuropathy, which may lead to pain and tingling but, more commonly, to loss of feeling. Even if an injury develops, the individual with peripheral neuropathy will not feel the pain associated at the site of the lesion. In other words, the alarm to action is missing. The development of lesions with no appropriate and immediate action leads to infection and further destruction of deep tissues. When impaired peripheral circulation is present the situation can escalate further and very quickly to minor or major amputation.
§
Worldwide, the number of ulcers and amputations are very high and diabetic foot ulceration precedes 85% of diabetesrelated amputations. The yearly incidence is around 2–4% in developed countries and at least 4–8% in developing countries. This translates to approximately 1.1 million amputations in Africa (estimated to rise to 9.9 million in 2030) and 1.25 million in South and Central America (estimated to rise to 2.5 million by 2030). The statistics represent millions of personal tragedies but also the huge financial burden of diabetic foot disease and amputation on families. In low-income countries the cost of treating a complex diabetic foot ulcer can be equivalent to 5.7 years of annual income, potentially resulting in financial ruin for patients and their families. Since 2006, the International Working Group on the Diabetic Foot (IWGDF) together with the International Diabetes Federation (IDF) have collaborated to provide diabetic foot programmes worldwide. The strategic objective is to decrease the risk of diabetic foot disease to patients, and raise awareness with healthcare providers and governing bodies, too. There are three levels of intervention required to meet the specific targets. Level 1: Programmes called ‘‘Train the Foot Trainer’’ (TtFT) implement the Step by Step Foot projects which are focused on the following processes: Investment in national structures with secondary and reference centres of interdisciplinary diabetic foot services. Many disciplines work together for early treatment of simple and more complicated ulcers. It is proven in the literature that this approach reduces amputation in developing and developed countries
This article first appeared in the July 2015 online issue of the International Diabetes Federation’s magazine Diabetes Voice (http://www. idf.org/diabetesvoice). 1 Dr Kristien Van Acker is a diabetologist and started, in 1989, the first interdisciplinary diabetic foot clinic in Antwerp. Today working in Chimay, Belgium, she is Chair of the International Working Group on the Diabetic Foot (www.iwgdf.org) and IDF Consultative Section on the Diabetic Foot. http://dx.doi.org/10.1016/j.diabres.2015.07.005 0168-8227/# 2015 Published by Elsevier Ireland Ltd.
552
diabetes research and clinical practice 109 (2015) 551–552
alike. Centres are responsible for setting up referral and contra-referral strategies, where the delay to referral will be set as low as possible. The trainees, national key-opinionleaders, also give training to healthcare providers in their regions for prevention. As all of these interventions concern national healthcare, political involvement is a must. Before trainees can come to a 4-day course they need a letter of collaboration from their national patient organisation and an approval of contact from their ministry of health. Level 2:
specific education on foot self-care is necessary. The patient will be asked to look daily at his or her feet and this sometimes requires the help of a family member. Good foot hygiene and nail care is a must, as is the protection of the feet with appropiate footwear. As the last condition is not always present in developing countries, patient organisations need to accept the idea that special shoes given to people at risk of diabetic foot disease is as important as ensuring that insulin or oral medications are available.
Members of the working group believe that success depends upon healthcare providers who can be considered ‘‘gatekeepers,’’ as they are able to determine the group of patients at the highest risk for developing foot-ulcers. Patients at high risk are the following:
In 2012, a TtFT course for the South and Central America region included 58 delegates from 14 countries. In 2014, the two and a half year implementation phase of this great effort was complete. In a two year period, more than 3000 healthcare providers (doctors and nurses) were trained in the countries of Latin America. Additionally, more then 150 new diabetic foot clinics were established. We hope that national patient organisations will help this advancement and empower people with diabetes to care for their feet. What will it take to achieve success today and tomorrow? Trained healthcare providers who work together to improve diabetic foot care and informed patients who perform their daily foot-care regimen and recognise when an ulcer or infection is present and, without any delay, get immediate help.
Designated by an orange light: peripheral neuropathy and peripheral arterial disease and/or with foot deformities; Designated by a red light: peripheral neuropathy and a history of foot ulcer or any level of lower-extremity amputation. Currently, only 20 countries have healthcare providers trained in specialised foot care, also known as podiatrists or podiatry care. Podiatrists are very good gatekeepers. To make up for the lack of podiatry care, a common programme called the Diabetic Foot Care Assistant programme (DFC Ass programme) has been developed to fill the gap, particularly in developing countries. In the last phase of this programme the working group will help set up podiatry care on a mid- to long-term basis in those countries. Level 3: Preventive care must be encouraged and directed to the patient with empowerment strategies. This intervention can be carried out with every national diabetes patient organisation. National associations can encourage the necessary skills and education for people with diabetes. We consider it a patient right to know their individual personal risk-category for developing a diabetic foot ulcer. From the moment red or orange has been designated,