Diabetes and Feet: Everything you need to know! JACLYN GLAZEBROOK ADVANCED PODIATRIST: DIABETES Nottingham University Hospitals – Dundee House, City Hospital Jaclyn.Glazebrook@nottshc.nhs.uk

What do you need to know? Why all the fuss?: Facts and Figures How does diabetes affect the feet? Neuropathy Peripheral Arterial Disease Other Risk Factors What do we do when we find a problem? = Podiatry & MDFT Referral

So…what’s all the fuss about the diabetic foot? Facts & Figures…

The Human Cost…

The Human Cost… 80% of amputations are PREVENTABLE >1 in 10 of these people will go on to have an amputation of some form England 2016: More than 135 amputations a week in people with diabetes 1 in 6 (17%) die within a year, 78% in 5 years Only 50% of people who have had amputation survive for 2 years 80% of amputations are PREVENTABLE

£1 in every £150 spent in NHS The Financial Cost… Diabetes Foot Ulcers and Amputations in NHS England (2012) £639-662 million in 2010-11 £1 in every £150 spent in NHS Equates to 0.7% of total NHS budget £306-323 million: primary/outpatient care £256-263 million: inpatient care/A&E £76 million: post amputation care

But what does that mean to me? Nottingham: 2012 - 2015 Inpatient Care Episodes Inpatient Care Nights spent in hospital Episodes of care amputation occurred Nottm NE CCG 474 (244 pts) 4278 70 Nottm West CCG 278 (121 pts) 2301 30 Rushcliffe CCG 309 (134 pts) 31 Nottm City CCG 1095 (471 pts) 8952 139 South Notts 2156 (970 pts) 17832 270 England 167,224 1,357,714 22109

But what does that mean to me? Nottingham: 2012 - 2015 Major Amputations Minor Amputations Total No. Per 1000 people with DM Compare 2009-12 Per 1000 People with DM Compare 2009-12 Nottm NE CCG 17 0.8 ↓ 24% 53 2.3 ↑ 90% Nottm West CCG 8 0.6 ↓ 22% 22 1.5 ↑ 114% Rushcliffe CCG 7 0.4 ↓ 46% 24 ↓ 27% Nottm City CCG 38 ↑ 24% 101 2.2 ↑ 65% South Notts 70 200 England 6821 15,288 1.8

Diabetes Foot Problems = And in clinical terms… Diabetes Foot Problems = Most common reason for hospital admission for people with diabetes Longest episodes of inpatient care for people with diabetes Increase in Multi Drug Resistant Organisms Increase in Hospital Acquired Infections Major Long-Term Impact on Quality of Life

Risk Factors for Developing Diabetic Foot Complications: So…how does diabetes affect the feet…In real terms Risk Factors for Developing Diabetic Foot Complications: Peripheral Neuropathy Peripheral Arterial Disease Significant structural deformity Skin changes/significant callus Previous ulceration/amputation Inability to self care Poorly fitting footwear Chronic Kidney Disease

Peripheral Neuropathy… Damage to the peripheral nervous system High blood glucose damages small blood vessels that feed the nerves A sufficient supply of nutrients and oxygen no longer reaches the nerve, causing the nerve to become damaged and eventually die Affects between 20-40% of people with diabetes

Peripheral Neuropathy affects… Sensory Nerves – Transmit pain, temperature & touch Many Many people who have sensory neuropathy often have no symptoms and are often unaware of it’s presence damage causes: Reduced sensation Pins and needles Reduced awareness of pain Burning Reduced awareness of hot and cold Numbness = Loss of Protective Sensation (sensory neuropathy)

Loss of Protective Sensation?

What else can’t they feel??? Ouch??? Able to pass sterile probe through connecting ulcers without feeling it! What else can’t they feel???

Peripheral Neuropathy affects… Motor Nerves Carry impulses from the brain & spinal cord to muscles enabling movement damage causes: Weakness of the small muscles that maintain normal foot shape = change to foot shape Loss of muscle strength which affects muscle movement = Altered Foot Shape = High pressure = Callus =Tissue Stress = Increased Mechanical Load & Shear = Reduced Shock Absorption

Peripheral Neuropathy affects… Autonomic Nerves - Regulate sweating and perfusion to the limbs damage causes: Reduced sweating Dry inelastic skin Inhibited thermoregulatory function = development of splits, cracks and fissures = portal of entry for bacteria ESSENTIAL to provide good quality emollients and advise on daily use FOREVER