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People with diabetes-related foot disease are often not sufficiently educated on preventing and managing foot ulcers and other related conditions, and more research is needed to find the best approach so people with this condition can best manage themselves.
Diabetes prevalence has steadily increased over the past 20 years, with approximately one in 20 Australians having this disease (here). The management of blood glucose and treatments to reduce the risk of complications imposes substantial burden on people with diabetes, as well as on their carers and health care systems. This burden continues to increase as the available treatments expand.
Diabetes-related foot disease is one of the most common and more burdensome complications, and is estimated to affect more than 130 million people worldwide and cause 17 million years lived with disability (2% of the global disability burden; here).
Once diabetes-related foot disease (eg, foot ulcer) develops, treatment to resolve the problem is frequently prolonged, intensive and may require hospital admission (here). Recurrence is very frequent, affecting over half of patients. Treatment is ideally delivered by a multidisciplinary high risk foot service consisting of endocrinologists, podiatrists, vascular surgeons, wound care specialists and orthopaedic specialists.
Patients and caregivers play a key role in the treatment of diabetes-related foot disease and in preventing further complications. This includes the day-to-day management of glucose and prescribed medication. People with a history of diabetes-related foot disease usually have peripheral neuropathy (here) and need to inspect their feet daily for signs of impending ulcers or foreign bodies, and use footwear to offload high plantar pressures. Given the complexity of treating diabetes and preventing foot complications, patient education is critical (here and here), but how this is best delivered is not currently understood.
How can the broad scope of this need for structured education be clarified?
Meta-analyses of randomised controlled trials are considered the gold standard for informing medical recommendations. In our recent systematic review, we evaluated the impact of educational programs in people with diabetes-related foot disease. Key data we collected included the type of educational intervention tested, how the education was delivered, the amount of time spent with patients, the outcomes assessed and the risk of bias of each trial.
No two interventions were alike, with Table 2 in our review summarising the wide breadth of educational approaches used in the 29 eligible randomised controlled trials that included nearly 4000 patients in total. Some interventions lasted less than an hour, while some had several hours’ worth of patient interactions covering varied combinations of foot care advice, lifestyle advice, medication advice, practical aspects of caring for the feet and providing resources for foot care. The most frequently assessed outcome was the incidence of foot ulceration and amputation — although type of amputation was not reported.
A meta-analysis on the findings from eight of the studies suggested that, overall, the educational programs reduced the risk of foot ulceration by half and amputation risk (any amputation) decreased by about one-third. The confidence intervals were wide and approached 1.00, indicating uncertainty in these findings. Overall, blood sugar (glucose) attached to glycated haemoglobin was significantly decreased in participants allocated to the educational programs, suggesting better diabetes control. Most studies reported that the education programs improved participants’ knowledge of caring for their feet and increased the frequency of behaviours of caring for their feet. Marked heterogeneity in the design of the education programs was noted and it was unclear what form of education was most beneficial.
How can our understanding of diabetes-related foot disease education be further improved?
Medical guidelines, such as those for diabetes-related foot disease, draw on data from medical studies, with the level of certainty in the results informing how practice should change. Our study highlights two key points:
- structured education for people with diabetes-related foot disease can provide meaningful reductions in diabetes-related foot disease events such as foot ulcers and amputation; and
- it is still unknown what specific parts of this education make a difference to patients.
The findings of our systematic review suggest that structured education of people with diabetes-related foot disease can improve patient knowledge and increase self foot care, which likely results in reduced risk of complications. It is, however, unclear what specific elements should make up an education program and how this is best delivered. Further research is needed to better understand patients’, caregivers’ and health professionals’ needs in education to prevent diabetes-related foot disease. Large trials are also needed to test how this education can be best delivered.
We argue that consumer and wider stakeholder engagement is needed to develop the most effective education programs needs for treating this condition. This must cover the number of educational sessions, the duration of sessions, the use of technology, the specific educational items, the need for behaviour support techniques and the best delivery platform. It is also important to consider if how the education is integrated with other elements such as foot monitoring and clinical reviews.
Ultimately, further trials testing different education programs are needed. These programs would be expected to report on foot ulcer incidence, amputation incidence and type, and use validated assessments of patient knowledge and self-care behaviours.
Aaron Drovandi is a Senior Lecturer in Medical Education at the University of Manchester, and Adjunct Research Fellow at Queensland Research Centre for Peripheral Vascular Disease.
Professor Jonathan Golledge is a Vascular Surgery Staff Specialist at the Townsville University Hospital, and Head of the Queensland Research Centre for Peripheral Vascular Disease and its pre-clinical arm the Vascular Biology Unit at the College of Medicine and Dentistry at James Cook University.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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This problem is not managed well. Every diabetic patient with a peripheral neuropathy should have arterial studies to check the arterial supply as commonly the problem in healing is a lack of arterial inflow. This is very hard to check clinically and the foot can appear warm and pink. To be really sure – just as with coronary arteries – an angiogram is required and often the problem is distal tibial artery disease which needs to be treated. Too often the disease is far too advanced by the time they are referred to the high risk foot clinic and the only option is amputation. There is also a significant problem with effective offloading which is done very poorly by hospitals and not at all in the community. There are not nearly enough health professionals (podiatrists or physios) that can apply a good total contact cast and the supposed “off loading” shoes provided of the shelf do not off load at all. Even custom made foot wear often fails and this is due to a lack of checking the shoes with in shoe pressure transducers to confirm that effective off loading has been achieved. There is also the problem that patients for some reason feel that when they are home that it is safe to walk bare foot without their off loading device – as if there is something magical about the floors in the home. This is why TCCs are so effective – because patients cannot remove them. We have a huge number of issues to improve in hospitals and outpatient departments. Education will not help if there is not an effective solution offered.