Screening And Management Of âThe Diabetic Footâ - Bpac.org.nz

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Supporting the PHO Performance ProgrammeDiabetes in New Zealand – a growing concernIn 2000 the Ministry of Health acknowledged thatdiabetes was a major concern in New Zealand and arange of preventative measures and increased treatmentoptions were introduced. 1 At that time there wereapproximately 125,000 people with Type 2 diabetesin New Zealand and it was projected that this numberwould increase to 180,000 in 2011. 1 This estimate hasalready been far exceeded with approximately 270,000people in New Zealand (5 – 7% of the population)currently diagnosed with diabetes. 2The “Get Checked” annual health review includes:▪▪A HbA 1c▪▪ Blood pressure, lipid profile, height and weight▪▪Kidney function (microalbuminuria)▪▪ Assessment of peripheral circulation and sensationof the feet▪▪▪▪Retinal check (at least every two years)Follow-up plan for careThe Ministry of Health has labelled this the “Diabesity”epidemic, relating the significant rise in the number ofpeople with Type 2 diabetes to the rising rates of obesity.People of Māori, Pacific or Indo-Asian ethnicity are twoto three times more likely to have diabetes and this is amajor contributor to increasing health inequalities. 2Information for the annual review can be collectedthroughout the year, or alternatively as a more formal“one-off” process.An annual check for people with diabetes is also a PHOPerformance Programme (PPP) indicator.Interventions to reduce morbidity and mortality fromdiabetes focus on education, prevention and earlydetection of diabetes and its complications.The PPP goal is for at least 80% of all people withdiabetes enrolled in a practice to have an annualdiabetes review.“Get Checked” yearly to prevent diabetes complicationsPart of the Ministry of Health’s “Diabetes 2000 Initiative”was the implementation of the annual, free “Get Checked”programme. The goal of the programme is to increaseintervention before more serious complications ofdiabetes develop.“The Diabetic Foot” is a common complicationof diabetesPeripheral neuropathy and arterial disease are commoncomplications of diabetes and are the main risk factors forthe development of ulcers, infection and ultimately lowerextremity amputation. 3, 4BPJ | Issue 31 | 35
Neuropathy results in ulcer formation and other footcomplications by decreasing pain sensation andperception of pressure. This also causes muscleimbalance that leads to foot deformity and impairedmicrocirculation and integrity of the skin. 5A foot affected by neuropathy is described as warm, dryand numb, 3 although sensory neuropathy can be verypainful. Pain, burning and tingling that is especially worseat night and relieved by getting up and walking, is highlysuggestive of diabetic peripheral neuropathy.A foot affected by peripheral arterial disease is describedas cold and without detectable pedal pulses. The patientoften experiences pain when walking or if severe, atrest. Once ulcers form, the capacity for them to healis compromised by diminished blood flow in the foot. 5Wounds can deteriorate rapidly and patients are atincreased risk of developing serious infection. 3These syndromes are collectively referred to as “TheDiabetic Foot” and this is one of the most commoncomplications occurring among people with diabetes inNew Zealand. 3Management of “The Diabetic Foot” in primary carefocuses on:1. Regular (at least yearly) screening for foot problemsin people with diabetes to prevent ulcer formation2. Prompt treatment and referral, if required, for anydetected foot problems3. Education about preventing foot problems fromoccurring or worseningScreening for diabetic foot complicationsFoot checks should begin immediately after a person hasa confirmed diagnosis of type 2 diabetes and at leastyearly thereafter (as part of an annual diabetes review). Ifthe patient has characteristics that increase their risk offoot complications (see opposite page) or once evidenceof diabetic foot complications has been detected, feetshould be checked every three to six months. 3 Somepatients at very high risk of foot damage e.g. loss of feelingin the foot, no detectable pedal pulses or active ulcerationmay be considered for review even more frequently, i.e.every one to three months. These recommendations aresummarised in Table 1.Table 1: Recommended frequency of examination for diabetic foot complicationsStage of progressionConfirmed diabetesRecommended frequency of foot checkAs soon as possible after diagnosis, annually thereafterFirst signs of foot problems identifiedor patient at high riskActive ulceration and infection or veryhigh riskEvery three to six monthsRegular assessment until active problems resolved, then everyone to three months36 | BPJ | Issue 31
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Screening And Management Of âThe Diabetic Footâ - Bpac.org.nz