Preventative foot care for people living with diabetes

Riaan Knight, a medical orthotist and prosthetist, explains why preventative foot care is so important for people living with diabetes.


Father’s loss of limb directs choice of career

As a medical orthotist and prosthetist, I frequently deal with the debilitating effects of foot ulcers and amputation caused by vascular disease. Sadly, in my practise, vascular disease is almost always directly linked to diabetes.

Speaking from personal experience, I can’t emphasise enough the importance of diabetic foot care. As a young man, I had to watch my dad, who was diabetic, deal with the devastating effects of a recurring foot ulcer.

At first, he lost his mobility, he had to walk with crutches. Later, he lost his ability to drive a vehicle and then eventually, as to stop infection from spreading, he had to undergo an amputation of his left lower limb.

Although the medical aspect was dealt with successfully, he now faced a new dilemma, he used up all available sick leave and had to deal with the loss of his income.

On the upside, his successful rehabilitation with a prosthetic limb left a huge impression on me. I immediately knew I wanted to study medical orthotics and prosthetics.

It was during my studies that I realised to my dismay that if only the medical team followed proper orthotic management protocols, he may have never had re-ulceration or limb amputation. Research proved the effectiveness of foot orthotic treatment to assist in recurring foot ulcers.

I have often asked myself could we have cured his foot ulcer? Could we have prevented the amputation of his limb? What I do know is that foot orthotic studies confirm positive results.

Study with astounding results

A well-known study, done on the effectiveness of orthotic treatment in patients with recurrent diabetic foot ulcers, by Fernandez ML, Et al, published in the American Journal of Podiatric Medicine showed astounding results:

  • “Before foot orthotic treatment, the re-ulceration rate in diabetic patients was 79% and the amputation rate was 54%. Two years after the start of orthotic therapy, the re-ulceration rate was 15% and the amputation rate was 6%.
  • Orthotic therapy reduced peak plantar pressures in patients with re-ulcerations and in those without.
  • Sick leave was reduced from 100% to 26%.”

The results are staggering. Yet, sadly the incidence of pressure ulcers in the diabetic community remains high and may very well increase.

Diabetes on the rise

The World Health Organisation (WHO) has predicted that there will be 380 million diagnosed diabetic patients worldwide by 2025. They further determined that Africa will face the second highest increase in prevalence of the disease.

A research study by the Non-Communicable Diseases Research Unit, based at Tygerberg Hospital, confirmed this “increase” prediction for South Africa. Their research found an above normal increase in persons diagnosed with diabetes in SA.

In fact, they state that the prevalence of diabetes increased amongst the female population from 8 to 14% and amongst male population from 5 to 10% for the period between 1980 and 2014.

Risk for foot ulcers

WHO further state that the lifetime risk for foot ulcers in people with diabetes is estimated to be as high as between 15 and 25%. Research further showed that 85% of all amputations done in diabetics are preceded by ulceration.

The at-risk diabetic would need to take cognisance of the fact that due to insufficient vascularity and neural dysfunction associated with diabetic neuropathy, he/she will always be at risk of developing a plantar foot ulcer. Preventative action should be high priority.

Preventative plantar pressure screening is essential

Unfortunately, an aspect that can greatly assist with the early detection of possible ulcer prone areas of the diabetic neuropathic foot has been ignored to a fair extend. Preventative plantar pressure screening is essential. Stop the ulcer before such can develop.

I am obviously aware of all other avenues of diabetic screening and complication prevention protocols. But, I do feel that it’s of paramount importance that diabetic foot care screening via specialised medical plantar pressure devices are developed and implemented in addition to those throughout South Africa.

Although such medical devices are available in the private sector, only a small handful is available to state patients. The conundrum is to convince government to invest in such fairly-expensive systems.

However, the money saved in long-term (unnecessarily used to fund wound treatment and limb prosthetics) would be astronomical and will far outweigh the initial set up cost.

Studies prove effectiveness of these systems

The effectiveness of these systems has been proved in many a medical research study. A study, by Joslin Beth Israel, Et al, at the Deaconess Foot Centre, Harvard Medical School, concluded that both the rearfoot and forefoot pressures are increased in the diabetic neuropathic foot, indicating an imbalance in pressure distribution with increasing degrees of neuropathy. The later stages of peripheral neuropathy play an important role in the aetiology of diabetic foot ulceration.

Another study, by the Department of Internal Medicine, Academic Medical Centre, University of Amsterdam, showed that claw/hammer toe deformity is associated with elevated plantar pressures at the metatarsal heads in neuropathic diabetic patients. This condition increases the risk for plantar ulceration.

The fact remains that even healthy tissue placed under abnormal pressure over a prolonged period will break down and ulcerate. Unfortunately, in the case of diabetic patients even more so.

How does a plantar pressure device work?

Planter pressure devices can predict areas of abnormal pressures by measuring pressure over time and relating such to normative values from healthy individuals.

Another plus point is the ability of specialised integrated software as to recommend areas and percentage of correction to be applied via a suitable foot orthotic.

I strongly advise all high-risk diabetics to seek referral from their diabetologist (or medical doctor) to undergo such preventative foot care (preventative plantar measurement) screening on an ongoing basis. Prevention is better than the cure.

MEET OUR EXPERT


Riaan Knight is a medical orthotist and prosthetist based in Port Elizabeth. He has been in private practise since 1994. He served as Chairperson to the South African Orthotic and Prosthetic Association for 10 years and is regarded as the forefather of plantar pressure measurement devices in SA. Riaan was the first person (2003) to import and train local orthotists on the use and advantages of plantar pressure measurement devices in SA.


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How to recover from an injury if you have diabetes

Saadia Jantjes shares advice to help you recover from an injury if you have diabetes.


Leading a healthy and active life is an essential aspect of managing diabetes. When a body injury occurs, it often presents challenges in maintaining fitness, preventing weight gain and could potentially have negative effects both physically and mentally. Recovering from an injury is tough, and even more so for someone living with diabetes.

When it comes to recovering from an injury while managing diabetes, you could be faced with thoughts and fears of gaining fat, losing muscle and how to adjust insulin doses now that you are relatively less active.

Being immobile increases the rate of muscle loss, thus making you more sensitive to insulin.

So, how do you manage an injury while still managing your diabetes?

Check your glucose levels

Often. Because most injuries require a period of rest and recovery, if you are injured and you were particularly active and fit, you will now face a period of relative inactivity.

You’ll need to check and test your glucose levels as often as you can to gain as much information as possible to understand how your body is reacting to a significant lack of exercise or movement.

Once you have collected this information, it’ll make it easier to see when and how you would need to adjust your insulin doses.

When you have recovered from your injury, the same strict management and regular testing will gradually get you back to your pre-injury fitness level without experiencing phases of hypoglycaemia.

Nutrition

Nutrition will become a key element in both diabetes and injury management. Now that your energy expenditure is relatively less due to being injured, you can’t expect to continue eating the same way without an effect on weight and blood glucose levels.

With a decreased energy expenditure, comes a decrease in caloric intake. Depending on the period of recovery and absolute rest, you will have to adjust your calorie intake.

A calorie and carb tracking app, like MyFitnessPal, will help you keep track of your daily consumption in relation to your activity levels.

Protein is a vital macronutrient when recovering from an injury, as are vitamins A, C and D, calcium and zinc.

Adopting a well-balanced diet of wholesome foods can meet your injury management needs as well as your diabetes needs.

Consult your dietitian if you are struggling to manage your blood glucose levels or start to experience weight gain after facing an injury.

Positive and optimistic

Staying positive and optimistic while recovering from an injury is challenging. Especially if it means forfeiting a race, competition or a goal which you had been working towards.

Keep motivated by putting as much effort into your rehabilitation and recovery as you would have if you were indeed training for that 10km race.

Have a solid support structure in your family, friends and those involved in your rehab, like your physiotherapist, biokineticist or trainer. Make sure these people are aware of your goals so that they are implemented into your recovery programme.

Alternate activities

Find alternate activities to keep your fitness levels up. Continuing to exercise while you have an injury ultimately depends on the severity of the injury as well as the location of the injury.

For example, if you have a broken wrist, you could still walk, do aqua aerobics or resistance training, or spinning. However, if you are recovering from a back operation, your activity options are significantly less and could be limited to only walking for a few minutes at a time.

Again, consult your healthcare professionals, like the operating surgeon or a physiotherapist, if you are worried that you’ll be causing more harm than good by doing some exercise.

Recovering from an injury is always a setback, both mentally and physically. Be patient. Allow your body to heal through rest and recovery, while still maintaining a positive outlook to your daily activities, and you’ll be back to your best in no time.

MEET OUR EXPERT


Saadia Kirsten Jantjes is a physiotherapist with a passion for health and wellness. With a second degree in Sport Science, exercise is one of her favourite rehabilitation tools, to not only rehab injuries but prevent injuries too. Saadia has her own private practice in Morningside, Johannesburg, while working at a Sub-Acute Clinic and furthering her studies in Pilates.


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Baqsimi – a nasal glucagon

Dr Louise Johnson explains why it’s good news that a nasal glucagon, sold under the name Baqsimi, was approved in July by the US FDA. The bad news is that it will be some time before it is available in South Africa. 


Baqsimi, manufactured by Eli Lilly, is the first nasal glucagon approved for the emergency treatment of severe hypoglycaemia that can be administered without an injection.

The risk of hypoglycaemia

Millions of people living with diabetes are on insulin to control their blood glucose levels and to prevent long-term complications of diabetes.

Insulin can cause hypoglycaemia (low blood glucose), potentially severe and even life-threatening complications that burdens insulin users each day1.

The risk is relevant to all Type 1 diabetes patients and 30% of Type 2 diabetes patients receiving insulin treatment.

Severe hypoglycaemia is defined as an episode of low blood glucose, wherein a person with diabetes requires assistance from a third party to treat the episode.

In the T1D Exchange Patient Registry, it was indicated that this occurs more frequently than previously thought2.

The fear of another hypoglycaemic episode often leads to reduced glucose control to allow glucose to remain higher than desired. This increases the risk of both microvascular and macrovascular complications3.

It’s acknowledged that, if it was not for the fear of hypoglycaemia, people with diabetes could have normal to near normal glucose levels and avoid the complications of hyperglycaemia (high blood glucose).

Challenges with management of severe hypoglycaemia

Glucagon hypo kit

Glucagon is the treatment of choice in severe hypoglycaemia. It is very unstable in the liquid form and is therefore available in a hypo kit.

This kit consists of a pre-filled liquid syringe and a vial of dry powder. It must be mixed by the third party who then administers the treatment during an episode of severe hypoglycaemia.

It can be very daunting for the third party, usually a non-medical person, to observe the person with diabetes having hypoglycaemic seizure or being in a hypoglycaemic coma.

Study

In a study, in which parents of children with Type 1 diabetes used a glucagon hypo kit in a simulated emergency hypoglycaemia, it showed that the parent took between two minutes and 12 minutes to get the solution ready and inject it into a piece of meat (to simulate a thigh muscle).

The study consisted of 136 parents who were all trained before the study. The data shows that despite the training, 69% of the parents had trouble with the hypo kit.

These were all handling difficulties, such as opening the pack, removing of the needle sheath, mixing the ingredients and bending needles4.

The great concern in this study was that 6% aborted the injection entirely and 4% injected only air or water from the prefilled syringe.

This data clearly indicates the need for a better, safer and easier way of giving glucagon in an emergency.

A unique and critical aspect of glucagon use is the intended user. Unlike insulin, a third party gives glucagon. This is the co-worker, teacher, friend, child, sport coach, etc. This is almost never a trained medical professional.

The previous study clearly shows that this leads to suboptimal use of otherwise effective medication, delays in treatment and costly use of emergency services and hospitalisation.

Nasal glucagon

In 1983, it was shown that glucagon administered with a carrier drug, such as sodium glycocholate, could raise blood glucose levels when administered as intranasal drops.

Despite promising data, research into nasal glucagon was minimal. Reasons are debatable. Some of the reasons given are the fact that the market is very small for this drug and new promising drugs, such as the SGLT2 inhibitors, came onto the market and many more.

In recent years though, there was renewed interest to address the unmet need for a glucagon delivery system that is easy for healthcare providers to teach and easy for caregivers and third parties to administer.

Introducing Baqsimi

Baqsimi is a dry powder glucagon formulation in a compact, highly portable, single-use nasal powder dosing device that allows for a single-step nasal administration.

The caregiver simple inserts the device into the nasal opening and fully depresses the plunger. This gently expels the powder into the nasal cavity.

The product has been designed that no breathing is necessary as it is absorbed from the nasal mucosa. The dosage is a fixed 3mg dosage for all people with diabetes from four years of age.

What are the side effects of Baqsimi?

  • Nasal irritation (runny nose, congestion, sneezing, cough, nasal bleed) – 12,4% people experienced these side effects. The nasal irritation in injectable glucagon was only 1,3%.
  • Nausea (26%), headache (18%), vomiting (15%). These last three side effects were also experienced in intramuscular injected glucagon preparations in 33,8%, 9,3%, and 13,9%.

Warnings and precautions

Intranasal glucagon should not be used in persons with hypoglycaemia of chronic nature due to starvation; low adrenal gland functioning (Addison’s disease); insulinoma (tumour of pancreas) or pheochromocytoma (tumour of adrenal gland tissue (which produces catecholamine and where glucagon can cause a dangerously high blood pressure)).

Previously allergic reaction to glucagon with injectable form should be avoided.

It also carries a warning that it should not be used in those that have been fasting for long periods. The reason for this is that it causes low levels of reusable glucose in the liver.

Drug interaction

Patients taking beta-blockers may have a transient increase in blood pressure and pulse rate when given nasal glucagon.

Patients taking indomethacin may have no response to nasal glucagon, or even lower glucose. In such situations, per mouth or IV or IM glucose should be given5.

In conclusion, we can at long last be excited about an easy-to-administer drug for people with diabetes on insulin that should need this in a hypoglycaemic emergency. It will, however, still take some time to arrive in South Africa.


References:

  1. Pontiroli A.E. “Intranasal glucagon: A promising approach for treatment of severe hypoglycaemia.”Journal of Diabetes Science and Technology,2015 :vol9(1) p38-43
  2. Beck R. et. al. ‘The T1D Exchange Clinic. Registry.’ J Clin endocrinol Metab ,2012;97 p4383-4389
  3. Cryer P. ‘Hypoglycemia in diabetes: Pathophysiology, Prevalence and Prevention. 2nd Alexandria V.A.: American Diabetes Association,2012
  4. Harris G et.al. ‘Glucagon administration –underevaluated and undertaught.’ Practical Diabetes Int 2001:18;22-25
  5. (GN HCP ISI 24Jul 2019 (Eli Lilly Baqsimi package insert)
Dr Louise Loot

MEET OUR EXPERT


Dr Louise Johnson is a specialist physician passionate about diabetes and endocrinology. She enjoys helping people with diabetes live a full life with optimal quality. She is based in Pretoria in private practice.


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