Lieutenant Dan had good advice for Forest Gump. If you recall, in the movie he had two pieces of advice when Mr. Gump arrived in Vietnam for the war. He told him to take care of his feet and not to do anything stupid like dying. Pretty good advice. This same advice could be given to people who have type 2 diabetes.
Type 2 diabetes is more vicious and wicked than many people realize. From the liver and kidneys to the heart and brain, diabetes eventually affects every part of the body, but it frequently involves the feet first. Ironically it is our skin, the largest organ, that is often neglected, by both doctors and patients, and it is a key reason why the feet suffer. When people think of addressing type 2 diabetes with exercise and nutrition, which is correct, the skin, and specifically the feet, should not be overlooked. In fact, the International Diabetes Federation (IDF) has publically stated this year that “a paradigm shift is urgently needed to treat diabetic foot disease preventatively.”
How diabetes affects the feet
Feet perform two basic tasks which are to adapt to terrain and distribute pressure. The skin on your feet is remarkable as it can stand hundreds of pounds of pressure per square inch. However, as nerve damage and decreased mobility of the foot in people with type 2 diabetes can not only result in loss of a limb but the loss of a life. The IDF states that understanding the importance of this issue is lacking within the medical community and describe diabetic foot care as fragmented and haphazard.
So, what’s going on?
Basically, there are three nerves at work; sensory, motor and autonomic. As diabetes results in decreased ability of these nerves to function optimally calluses develop on the foot which leads to ulcers, which become infected which can lead to amputation. Without proper sensory nerves, you could step on sharp objects and not realize the severity of it. Without proper motor nerves, atrophy of small muscles can lead to foot deformities meaning more repetitive pressure in a small area of the foot. The most overlooked are the autonomic nerves which help with perspiration. This is why people with diabetes can have rough dry skin and need to treat their skin daily with a good skin balm.
Decreased sensation, more pressure on small areas of the foot and dry cracking skin. You can see how this can lead to foot problems. This often leads to infections via ulcers that can get right down to the bone. Not fun. Also, higher sugar levels in the blood can affect the Achilles tendon adding to poor mobility.
So, what’s being done?
The feet can be the barometer for type 2 diabetes, something even many doctors aren’t aware of. For this reason, both the International Diabetes Federation (IDF) and American Diabetes Association (ADA) highlighted this in their 2017 reports. The ADA’s published their updated diabetes guidelines this month and it was an intensive look at all aspects of diabetes with one chapter, “Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes – 2018” dedicated to foot health. It was basically 9 points that highlighted the need to have annual foot examinations and to provide general preventative foot self-care education to all patients with diabetes. For high-risk patients with diabetes they recommended specialized footwear but in general suggested that anyone with diabetes wear shoes with a broad and square toe box, laces with 3 or 4 eyes per side, padded tongue, quality lightweight materials and sufficient size to accommodate a cushioned sole.
Who would have thought people with diabetes needed to be so aware of their feet and the shoes they bought! Well, the aforementioned IDF report, all 70 pages of it, was dedicated to this. Published in June the report, entitled “IDF Clinical Practice Recommendations on the Diabetic Foot – 2017; a guide for healthcare professionals” was aimed at the medical profession to bring awareness to this so that they could better inform their patients. 70 pages is a lot to digest so mercifully they created an abbreviated version of these guidelines. The ‘Diabetic Foot Screening Pocket Chart’ was produced and distributed to primary care physicians, nurses, registered dietitians and nutritionists and other healthcare professionals.
When you think about it, by the time someone is usually referred to a specialized diabetic foot expert the problem is typically quite advanced. The main goal of the guidelines is to promote early detection and intervention by bringing awareness to those on the front line of healthcare so that proper foot health is addressed.
The IDF pocket chart allows the healthcare worker to determine which of the 4 risk categories, 0, 1, 2 or 3 a patient should be designated. Even category risk 0 patients are advised to have proper footwear and inspect their feet daily. Risk 1 are advised to have molded insoles while 2 and 3 should get into custom-made footwear.
Overall the chart is a convenient way to teach the healthcare worker how to teach the patient to take care of their feet and to bring awareness of foot care to the diabetic population.
Can current medical advice make it worse?
In a roundabout way, yes it can. Think about it. Your doctor discovers you have prediabetes or type 2 diabetes. Naturally, exercise is brought up which often includes lots of walking or slow jogging. This makes sense at first because each hour per day of increment brisk walking is associated with a 34% reduction in the risk of developing type 2 diabetes and a consistent walking routine can lower weight and blood sugar levels. Perfect. But according to the IDF it is estimated that less than 30% of physicians recognize the symptoms of diabetic peripheral neuropathy, even when it is symptomatic, and discusses it with their patients.
So, while walking is good, too much walking can be bad in many instances, something that is not brought up. This is why certain shoes and daily skin balm treatment should be part of a someone’s routine who has type 2 diabetes. On top of this, I personally recommend that people who are quite heavy spend more time on an exercise bike thus reducing the stress on their feet while they drop their weight.
Everyone should get checked out for pre-diabetes or type 2 diabetes annually. If you are diagnosed remember that a proper diet and moderate exercise can make dramatic improvements. However, as I hope I have illustrated here, talk to your doctor about your skin and specifically your feet. Make sure they have the aforementioned IDF pocket chart and use it to make a thorough examination.