Diabetic foot ulcer prevention winning debate against wound care

ALG CEO Hugh Sheridan has called for greater emphasis to be placed on the prevention of diabetic foot ulcers rather than wound care.

Speaking after the 7th International Symposium on the Diabetic Foot in The Hague, Sheridan said: “For years, the wound care industry has dominated the subject of diabetic foot, but the feedback at the conference was that there was a desire for the agenda to move more towards preventative action.

“For too long, the provision of consumable wound dressings has dominated the market as opposed to prevention methods which can drastically reduce the risk of ulcers occurring.”

Here, Michelle Weddell, ALG’s Head of Education, explains why she thinks the focus needs to change.

Every diabetic is at risk of developing foot pain and ulcers. They are seen as a common complication of diabetes.

But in the 21st century I believe there is more we should be doing to help prevent diabetic foot ulcers.

We need better use of international guidelines, rigorous screening and assessment systems in place to stop patients slipping through the net, we need better informed patients and health care workers, a national foot helpline and, most importantly, we need to focus on prevention.

Diabetes affects more than 380 million people worldwide and the number of people with the disease is increasing in every single nation.

By 2030, at least 550 million people will have diabetes – that is an incredible 10 per cent of the world’s adult population.

Diabetics have a much greater risk of developing problems with their feet because their raised blood sugars can damage circulation and sensation. Poor circulation can make it more difficult for ulcers to heal. And high glucose levels can slow down the healing process of an infected foot ulcer.

In the UK we have some excellent systems such as the Annual Foot Check where patients’ feet are examined and tested for numbness or changes in sensation with a tuning fork or a fine plastic strand called a monofilament. Yet there are no national guidelines to state the precise areas of the foot that should be tested.

And despite this annual patient review, and as Diabetes UK has reported, over 400,000 people with diabetes in the UK are currently still not getting their feet checked. It is a ticking timebomb.

Approximately £1 in every £150 the NHS spends is on diabetic ulceration and amputation. But with the right education, screening and the appropriate management I believe that 80 per cent of all diabetic foot amputations could be prevented.

What is worse is what is happening in other parts of the world.

The more I travel the more it becomes apparent that the diabetic care around the world differs. In the Middle East diabetes foot care concentrates on wound care and healing. An incredible 25 per cent of the population in Saudi has diabetes.

A sedentary lifestyle, increasing consumption of a fast food diet and a lack of exercise are possibly to blame – and the problem is likely to keep growing.

In many regions around the world there is no national guidance on diabetic footcare with a few following the International Diabetic Federation guidelines. There are no real prevention strategies and limited foot screening. There are very few podiatrists. The focus is mainly on treating wounds. Wounds that should never have been allowed to develop. And there are people who may have had wounds for years without their foot status being properly diagnosed.

We need to better identify people with problems and put them in a risk category. We need to be putting all the money into wound care and go back to basics. It is essential when people have lost feeling in their feet that education is given. Prevention with biomechanics and offloading orthotics is required when hard skin and calluses have developed on the sole of the feet. Prevention is too late when ulcers develop as you are trying to save the limb from amputation.

Podiatrists have a huge role to play in the future of providing better care – and we need more British and Australian trained podiatrists out in the Middle East.

When I went to Oman two years ago, there were four podiatrists. I returned this year and the number had grown to 12. Yet when I worked in an East Lancashire NHS Trust there were 50 podiatrists on staff in a small geographic area compared to a country like Oman.

At the recent Gulf Diabetic Foot Conference in Oman and the International Symposium on the Diabetic Foot in The Hague I spoke about the importance of offloading and biomechanics. Proper offloading is critical to the prevention of diabetic foot ulcers.

Pressure causes calluses to form on a patient’s feet. Because a diabetic cannot feel pressure a blister can easily form which, if not dealt with properly, can get bigger until it forms under a callus. If the foot is not regularly checked by a podiatrist that person can end up with a wound on their foot. Even if it heals the problem of pressure is still there.

Every foot at increased risk should have regular recall and review by specialist podiatrists providing intensive management. Where needed, they should then be referred to an orthotist for special footwear and other interventions such as ankle foot orthoses to minimise the risk of trauma.

Plantar callus, a risk factor for ulceration, indicates abnormal foot pressures and occurs most frequently under the metatarsal heads. Specially designed insoles (or orthoses) as inserts to patients’ shoes or in combination with specially designed shoes are a relatively cheap and effective way of reducing abnormal foot pressures and thus foot ulcers.

I believe off-loading is the future for diabetes care. Easing the pressure load on a patient’s foot gives wounds a chance to heal but, more importantly, if that pressure can be offloaded before risk factors such as blisters even present then ulcers can be prevented from occurring in the first place. This has huge impact for a patient’s quality of life.

Around 60-70 per cent of those with diabetes will develop peripheral neuropathy, or lose sensation in their feet. And more than 90 per cent of people with diabetic peripheral neuropathy are unaware they have it.

Sensory testing used in conjunction with ongoing physician care is a simple way to help decrease the incidence of foot ulcerations and amputations.

Monofilaments are a reliable and cost effective method of testing for the presence or absence of protective sensation, which can identify patients at risk of developing diabetic foot ulcers.

I would like to see every hospital that has doctors dealing with diabetics using monofilaments on their patients’ feet. There also needs to be international guidelines stating exact areas of the foot that should be tested as some doctors are not testing enough of the foot.

Instead of investing in expensive equipment such as hyperbaric oxygen chambers or wound-care products to treat foot ulceration, money would be better spent on employing more well-trained podiatrists, creating a recognised foot care training programme for nurses and developing a worldwide consensus on how to treat this growing disease.

Perhaps then frightening words like foot ulceration, infections, gangrene and amputation can be consigned to medical history.