How does self-care affect diabetic foot outcomes?

Diabetic foot complications can be very devastating and demanding upon health and social care resources. With the epidemic trend of diabetes, these problems will only increase unless we can become more effective at prevention. I have chosen to highlight four papers, three of which I wish to comment upon. Two of these focus upon patient education and the third on pre-surgical glycaemic control.

One of the greatest weapons we have to fight the war against the devastating army of progressive diabetic foot complications is education. It is something that we all know is essential, but the evidence for successful outcomes is poor. As a clinician and educator, I have my own views about this and some recent papers have now given some very helpful insight.

Natovich and her colleagues in Israel (summarised alongside) looked at the cognitive function of a group of patients with diabetic foot ulcers who were matched by age and sex with a control group without ulcers. The groups were well matched for diabetes type and duration. The investigators examined six cognitive domains: memory, executive function, reaction time, attention, psychomotor abilities (using both a series of computerised and paper-and-pencil tests) and, from these, estimated premorbid cognition values. All values were adjusted for age and education levels. Their results showed that individuals in the diabetic foot group were cognitively impaired, whereas the control showed no cognitive impairment. The results persisted after multivariate analysis for depression and smoking. This gives a clear message as to why current methods of health education appear to have limited success. We need to be mindful of this regarding self-care advice and management goals.

On the same theme, a randomised controlled pilot study by McBride and colleagues (summarised on the following page) investigated whether increased patient shared decision-making (“Decision Navigation”) increased decision self-efficacy and foot-treatment adherence in patients with a diabetic foot ulcer. Thirty patients received Decision Navigation sessions and 26 received usual care as the control group. Primary outcomes included decision self-efficacy, adherence to foot treatment as reported by the participant, and adherence to foot treatment as reported by the clinician. Secondary outcomes included foot ulcer healing rate, health-related quality of life, decision conflict and decision regret. This study found no impact upon primary or secondary outcomes in either group. This is perhaps more understandable given the outcome of the Natovich study.

The final paper to mention is a study by Nayak and Kirketerp-Møller (summarised on the following page), which will be of interest to those in secondary care. Undertaken in Denmark, it aimed to establish if a high perioperative random blood glucose (RBG) concentration among patients with diabetes with non-traumatic lower-extremity amputation (LEA) is associated with poor post-operative outcomes (re-amputation and mortality) within 3 months. This was a retrospective study over 12 months, reviewing records to gather preoperative and 3-month postoperative surgical, medical and physiological data. Three preoperative RBG readings were taken (before meals), and the values were tested and calibrated by the Department of Clinical Biochemistry.

The median preoperative RBG level was 8.6 mmol/L (range, 4.6–18.7 mmol/L), with tertile (T) ranges as follows: T1, 4.0–7.0 mmol/L; T2, 7.1–11.0 mmol/L; and T3, >11.0 mmol/L. Mortality and re-amputation within 3 months were recorded as 27% and 16%, respectively. In the T3 group, the age-adjusted hazard ratio for re-amputation was 0.77 (95% confidence interval [CI], 0.16–3.62) compared with the Q1 group, and for mortality it was 1.90 (95% CI, 0.50–7.22). Although this study was retrospective with a relatively small sample size of 81 patients, it does show that a high perioperative RBG level does not have a negative effect upon outcome. Thus, valuable time and resources can be saved trying to optimise RBG in elective diabetic LEAs, although, of course, normoglycaemia should be striven for.

To read the article summaries, please download the PDF
 

This Charming Man
Matthew Young has stepped down from the Editorial Board of Diabetes Digest. His ability to come up with a song title for every commentary in the last 15 years is a most impressive achievement, and we are grateful for all his hard work and insight. We wish him the best of luck for the future.