For many persons with diabetes (PWD), maintaining healthy skin and feet is a tremendous challenge. The term “diabetic foot” has been used to describe foot-related complications caused by diabetes. Persons with diabetes experience many health care concerns, including monitoring for high blood sugar, with hemoglobin A1c (HbA1c) ideally measured every 3 months to avoid hyperglycemia or hypoglycemia. A value of 6.5 (average blood sugar (abs) ~7 mmol/L) is considered diagnostic for diabetes. Hemoglobin A1c is a log function, with the 90-day blood sugars being much higher as the value increases. An HbA1c of 7.0 (abs 8) is often considered good control, with 8.4 (abs 10.8) a reasonable control for persons with hypoglycemic episodes and elderly patients. A value of 9.0 (abs 12) is considered a target for the developing world, especially in countries with low-resource health care systems. Persistently high blood sugar is associated with an increased incidence of arterial disease (check dorsalis pedis and/or posterior tibial) and earlier onset of neuropathy (any 4 or more negative monofilament tests out of 10 test areas on foot is considered diagnostic). There are several articles in this issue of Advances in Skin & Wound Care that define some of the challenges that PWD face in managing disease-related events and complications. There are numerous barriers to self-management for persons with diabetic foot ulcers (DFU). A central theme includes diabetic blood sugar control and related complications. A study by Zhuang and colleagues from China examined the barriers to self-management for patients with DFU, which can be due to neuropathy, vascular disease, or a combination of both components. In their systemic review, the authors identified 14 studies with 256 participants. A meta-analysis revealed several foot ulcer self-management cognitive factors, including knowledge gaps with low self-efficiency that set the stage for emotional and behavioral complications such as adherence to treatment. To correct treatment adherence, emotional and environmental factors, policy, and cultural issues need to be considered as part of health care planning and subsequently incorporated into care plans to improve patient outcomes. This patient-empowerment strategy with adequate support systems is a key element that facilitates improved adherence to self-management. Patient education needs to be improved, and this should ideally be done in person with a family member or close friend utilizing an interactive format. A greater emphasis is needed on how healthy lifestyle, including diet and exercise, can prevent recurrences. Environmental habits include a controlled low rate of alcohol consumption and smoking cessation. Exercise programs that do not result in increased plantar pressure accompanied by effective plantar pressure redistribution (offloading devices) may include stationary bicycle riding and swimming. Self-management also requires support from within the medical system to facilitate a home health network, including an interprofessional team of physicians, nurses, and allied health who can specialize in diabetes medical control factors linked with diabetic foot care. Günbaş and colleagues from Turkey interviewed qualitatively 24 patients with previous DFUs. Issues preceding foot ulcers included ingrown toenails, toe blisters, ulcers post callus removal, and a loss of protective sensation linked to not noticing foot ulcers. All 5 of these findings are in the simplified 60-second diabetic screening tool and the importance of regular foot screening for PWD.1 Again, the largest problem in this study was the lack of patient education with inadequate foot care. Another study, by Nehila and colleagues, examines a clinical tool, the revised Baux Score (rBaux), that estimates the risk of mortality for patients with various types of burn injury. The authors suggest that a history of diabetes may be an additional risk factor to add to the current scoring system. The initial Baux Score examined the patient’s age and the body burn injury percentage. The rBaux score added inhalation injury with 17 points if this complication was present and 0 points if it was absent. The authors studied data from 5 years at a Level I Florida trauma center. They analyzed 963 burn patients over the age of 18 with a mean age of 47±17 years and a total body burn surface area of 9±13%. Inhalation injury was present in 9% (84 patients). In addition to the current rBaux score components and a history of diabetes, the authors also identified third-degree burn status as a potential risk factor for their 4% fatality rate. The authors hypothesized that excess inflammation and reduced angiogenesis may be responsible for this increased diabetes-related mortality. Further study is needed, and the duration of diabetes and HbA1c, along with other complications, need to be studied to clarify this association. The articles in this issue remind us that we need more diligent and regular screening for the high-risk diabetic foot and better HbA1c and blood pressure control. Each of these steps improves patient outcomes and saves money for health care systems. This is a great opportunity to improve the quality of life and healthy living for PWD so they can age with an active and fulfilling lifestyle.
Sibbald et al. (Fri,) studied this question.