December 03, 2019 A step in the right direction

Open sores on the feet (also known as foot ulcers) are common in people with diabetes. Following a foot care action plan to prevent foot ulcers is vital, since a foot ulcer increases a person’s risk not only for more foot ulcers but for other foot complications such as infections and amputations. “That is a scary statement, but people need to know that foot ulcers are very serious,” says Dr. Zaina Albalawi, a clinical assistant professor at Memorial University and an endocrinologist in St. John’s, and co-author of the Foot Care chapter in Diabetes Canada’s 2018 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada.

“Once a person with diabetes has a foot ulcer, recurrence is very common,” she says.

About 40 per cent of people will have another foot ulcer within a year of their first one healing, and up to 65 per cent of people will have another ulcer within five years if they do not take preventive steps.

Albalawi encourages people to have their feet inspected by their health-care provider at every visit and to be tested for diabetic peripheral neuropathy (or nerve damage) at least once a year. (A yearly test is essential, as a person’s risk level can change over time.)

The test is simple and painless: A thin nylon rod is pressed to different areas of the foot to determine if the person can feel it. This helps determine a person’s level of risk for future foot problems. The diabetes team can then work with a person to develop an action plan based on that risk level.

People who have no obvious foot problems and no loss of sensation are considered low risk. Their plan would likely include good blood sugar management and a regular foot care routine such as:

• Examining feet and legs daily

• Going to a health-care professional for treatment of any corns, cuts, ingrown toenails, and more

• Caring for toenails regularly

• Applying moisturizing lotion if feet are dry (but not between the toes)

• Wearing properly fitting footwear

• Testing bath water with elbow before stepping in, to make sure the water is not too hot

People are considered at higher risk if they have any loss of sensation in their feet, issues such as bunions or calluses, or complications such as an ulcer. Their action plan might include foot care education, professionally fitted footwear, and referral to a specialized diabetes foot care clinic.

Efforts are underway to improve foot care and reduce amputations. Diabetes Canada and Wounds Canada—along with other key patient and health-care organizations, researchers, and frontline health-care providers—are working together to gain government funding for amputation prevention devices (known as offloading devices), which are specialized products that relieve pressure and, in so doing, help with healing and reduce the risk of amputation. Learn more at The Economic Impact of Amputation Prevention Devices.

Learning by experience

Mark Hough* knows first-hand how important foot care is. When he was diagnosed with type 2 diabetes in his early 20s, he barely gave the disease a second thought. “Like a lot of young guys, I thought I was invincible,” he says.

For almost 10 years, Hough treated his diabetes like it was more of a nuisance than anything he should be concerned about. Yes, he took the oral diabetes medications his doctor prescribed, but he made only half-hearted attempts to improve his diet. He rarely checked his blood sugar (glucose) levels and hardly ever checked his feet for cuts or sores.

It was not until he developed his first foot ulcer (the result of poor-fitting boots) that Hough realized the importance of good diabetes management, including foot care. But by then, the damage had been done—he had developed diabetic peripheral neuropathy, or nerve damage (see sidebar, “Nerve Damage Can Lead to Amputations”). Over the past 10 years, Hough has had many ulcers, resulting in several surgeries on his feet and two toe amputations. Despite taking charge of his foot care in recent years—he now inspects his feet every day and visits a diabetes foot care clinic twice a week—he currently has two ulcers on his left foot that still have not healed after more than six months.

“My amputations and recurring ulcers have changed the way I live my life, my future career path, basically how I go about my day every single day,” says Hough. “If I could go back 20 years, I would tell my younger self to take my diabetes and foot care seriously.”

The good news? With proper screening, care, and devices, up to 85 per cent of amputations are preventable. “Diabetes foot care requires a team, and the most important person on that team is the person with diabetes. I encourage people to choose to be proactive in caring for their feet and working with their diabetes team to prevent complications,” Albalawi says.

*Name changed for confidentiality.

Did you know?

Taking care of your feet and managing your blood sugar levels will help you stay in good health. Visit Foot Care: A Step Toward Good Health for practical tips for a daily foot-care routine.

Nerve damage can lead to amputations

Diabetic peripheral neuropathy is nerve damage caused by long-term high blood sugar levels. It is a complication of both type 1 and type 2 diabetes. This nerve damage increases the risk for foot ulcers as it “takes away the gift of pain,” explains Dr. Zaina Albalawi. “If you don’t feel pain, you are more likely to injure your foot by stepping on something or wearing tight-fitting shoes. Unless you regularly check your feet, you will not know there is a problem until skin breaks down and an ulcer starts.”

Learn more at Nerve Damage & Amputation.

(This article appeared in Diabetes Dialogue, Summer 2019)