BMJ: Diabetic foot

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Summarised from BMJ Clinical Update Diabetic Foot by Mishra et al Mumbai and London 18 Nov 17

Foot disease troubles 6% of people who have diabetes and includes infection, ulceration or destruction of tissues of the foot. It can affect both social life and work. Up to 1.5% of diabetic people will end up with an amputation. Good foot care, screening and early treatment of ulceration is hoped to prevent a foot problem developing into a need for amputation. This article gives an update on the prevention and initial management of the diabetic foot that can be expected from primary care.

A combination of poor blood sugar control, foot neglect, lack of appropriate footwear, insufficient patient education and failure to find and treat pre-ulcerative lesions cause increasing foot damage and worsens the outlook.  Nerve and blood vessel damage make damage more likely to go unnoticed and more difficult to heal.

A careful examination of the feet by the patient or carer every day is a good idea. A careful examination by health professionals also detects problems early. Fungal infections, cracks and skin fissures, deformed nails, macerated web spaces, callouses, and deformities such as hammer toes, claw toes, and pes cavus increase the risk of ulceration.  Cold feet can suggest poor blood supply and warm feet can be an indicator of infection.

Monofilaments are often used to detect neuropathy at annual assessments. Pain after walking a certain distance and pain at rest suggest peripheral arterial disease.

Assessments every three to six months is needed for medium risk feet and every one or two months for high risk feet.

As neuropathy is difficult to reverse once established, prevention is key. Optimal glycaemic control is extremely important. Smoking cessation, maintaining a normal weight and continued exercise help the circulatory system.  Patients also know how to check their feet and who to get help from if they find problems. New shoes should be worn in gradually to prevent blisters.

Health care professionals need to send urgent cases to a specialised diabetic foot centre if at all possible. Such cases would include foot ulceration with fever or any signs of sepsis, ulceration with limb ischaemia, gangrene,  or suspected deep seated soft tissue or bone infection.

Ulcers are best washed in clean water or saline with a moist gauze dressing.  Anti-microbial agents can be cytotoxic  and can affect wound healing. Weight bearing on the area needs to be avoided. Tissue will be taken for bacterial culture and antibiotics prescribed due to local policies.

Referral within a day or two is needed for rest pain, an uncomplicated ulcer or an acute Charcot foot. (suspected fracture due to neuropathy).

Patients with rest pain and intermittent claudication need vascular referral.

Here are the top tips for patients:

Inspect your feet daily including between the toes and if you can’t do it yourself get someone else to do so

wash your feet in warm but not hot water daily and dry carefully especially between the toes

use oil or cream on dry feet but not between the toes

cut nails straight across and if necessary go to a podiatrist for this

Don’t do home treatments for corns and callouses

Check your shoes for objects or rough areas inside them and wear socks with them

avoid walking barefoot

get your feet examined regularly by a health care professional

notify the appropriate health care professional if you develop a blister, cut, scratch or sore on your feet

Public Health Collaboration Conference 2018: a great success for Lifestyle Medicine

I was delighted to attend and speak at the third PHC conference in London this year.  We met at the Royal College of General Practitioners in London on the sweltering weekend of the Royal Wedding. Apart from superb international speakers we were treated to low carb, high protein food, such as one would typically eat on a ketogenic diet. Instead of picking at our dinners as we often have to do with mass catering  we could eat the whole lot. Great!

Dr Peter Brukner from Australia started off the weekend with a review of what was happening in the low carb world. There are more and more reports coming out describing the advantages of ketogenic and low carb diets to different groups of people but the establishment are fighting back viciously as can be seen by the attack on Professor Tim Noakes in South Africa.  Indeed if his defence lawyers and expert witnesses had not worked for free he would be bankrupt.  This is a terrible way to wage war on doctors who are acting in the best interests of their patients.

Dr Aseem Malhotra also described bullying tactics that had been used against him when he was a junior doctor and first becoming publicly engaged in the low carb debate. I have been subjected to this as well.  Professor Iain Broom showed that the proof that low carb diets are superior to low fat diets goes back 40 years.

Dr Zoe Harcombe gave us an explanation of how the calories in- calories out idea just doesn’t add up. The well known formulas about how many calories you need to avoid to lose weight don’t work in practice because of the complex compensatory mechanisms we have to avoid death from starvation.  How you put this over to patients and give them useful strategies for weight loss and blood sugar control was explored by Dr Trudi Deakin.

Food addiction is a real issue, at least it is for the majority of the audience in attendance, who answered the sort of questions usually posed by psychiatrists when they are evaluating drug addiction.  Unlike drugs, food can’t entirely be avoided but ketogenic diets are one tool that can be used to break  unhealthy food dependence. This worked for presenter Dr Jen Unwin who at one point had a really big thing for Caramac bars.  I haven’t seen these in years but they did have a unique taste.

Dr David Unwin showed clearly that fatty liver is easily treatable with a low carb diet.

Dr Joanne McCormick describes how her fortnightly patient group meetings are making change accessible for her patients and how many GPs in the audience could broach the subject in a ten minute consultation.

The website Diabetes.co.uk will shortly be starting up a type one educational programme online that all are welcome to join. I discussed the issue of what blood sugar targets are suitable for different people and how they can achieve this with dietary and insulin adjustment.

Dr David Cavan spoke about reversing diabetes in patients in Bermuda. Although Bermuda looks idyllic the reality is that good quality food is about five times as expensive in the UK as it is all shipped in. Many inhabitants work their socks off but barely cover their costs and cheap sugared drinks and buns are their staple diet. Despite these setbacks he managed to persuade a lot of diabetic patients to ditch the carbs and this had favourable results even after the educational programme had stopped.

A cardiologist Dr Scott Murray described the effects of metabolic syndrome on the heart and really why sticking stents in diseased arteries is too little, too late. He is convinced dietary change is needed to reverse and prevent heart disease. This is the first time I have been told that certain types of heart failure and atrial fibrillation are direct effects of metabolic syndrome on the heart.

The importance of exercise for physical and mental well being was not neglected and we had Dr Zoe Williams describing the great benefits that even the minimum recommended exercise can produce.

Dr Simon Tobin and Tom Williams spoke enthusiastically about Parkrun. This is a free event that runs every Saturday morning in parks all over the world. You can choose to walk, jog or run the course.

Claire McDonnell-Liu is the mother of two children who have greatly benefited from a ketogenic diet. The conditions are urticaria and epilepsy.  Although NHS dieticians do help families with childhood epilepsy who want to use a ketogenic diet, they can’t do it unless drugs have failed, as this is NICE guidance. I wonder how many children would benefit in fit reduction without side effects of drugs if this guidance was changed?

This was a fabulous conference with a positive enthusiastic vibrancy. Thanks to Sam Feltham for organising this event especially since he has become a new dad as well.

The Public Health Collaboration are putting all the talks on You Tube.

I was interviewed about diabetes and women’s health issues for Diabetes.co.uk and Diet Doctor and these interviews and many others will be available for you all to see to improve your lives with diabetes.

 

 

 

#TalkAboutDiabetes – Diabetes Awarness Week June 2018

What do you struggle with when you’re talking about diabetes? It’s Diabetes Week 2018 (June 11-18) and the theme of this year’s awareness-raising seven days is the stuff we find awkward, embarrassing, difficult or even funny to mention.

Here are mine:

  • I don’t like telling people in general. I’m not ashamed or embarrassed; I just don’t like drawing attention to myself.
  • Jelly baby etiquette. When you eat sweeties in front of someone, politeness dictates you offer them around. But they’re the medicine that corrects low blood sugars*, so stinginess is understandable.
  • Explaining a hypo when you’re in the middle of one. Most of my low blood sugar episodes are manageable. But I can be in the middle of a conversation and my mind goes blank. “Bear with me! My mind’s distracted. It’s screaming ‘SUGAR, SUGAR, SUGAR’ at me. My word power will return in a few minutes,” is what I should say.
  • Or don’t talk to me. When I’m high, conversation is too much effort. Please don’t take it personally.
  • I don’t talk much either when I’m high because I’m conscious of the nasty taste in my mouth and am reluctant to impose halitosis on anyone.
  • And don’t take the grumpiness low blood sugars produce personally either. First aiders once told me about diabetics who punched people when they were low, so grumpiness seems moderate in comparison.
  • Please know that managing diabetes is like having a part-time job that you do on top of everything else.
  • If you manage to work out I’m hypo long before I do, be aware I’ll deny it in an exasperated fashion. “Flip’s sakes, no I’m not. Look I’ll even do the blood test to show you and here it…oh. Alright then.”
  • Sometimes when I say I can’t do something because of the diabetes, I might be using it as a fab, ready-made excuse. It’s not me, it’s you. OH NO! I’ve just given away diabetes’ best-kept secret!

*I told a little girl my jelly babies were medicine once. She gave me one of those, ‘why do adults lie to me?’ looks.

BMJ: Varicoceles can be a marker for metabolic syndrome and type two diabetes

Nancy Wang from Stanford University is a urologist and says, “Varicoceles which are varicose veins of the spermatic cords, are associated with low testosterone. This in turn makes men more likely to develop metabolic risks and heart disease. No one has connected the dots before now”.

These men have higher risks of heart disease, diabetes, and hyperlipidaemia.

My comment: Varicoceles feel just  like a bag of worms in the scrotum. Up to one in 5 men will develop these over their lifetime. 

Diabetes Athlete Survey

Are you physically active and do you have diabetes (of any type)? Now is your chance to share how you manage your diabetes regimen while doing a variety of activities! A new edition of Dr. Sheri Colberg’s book, Diabetic Athlete’s Handbook, is coming out in Spring 2019. Please complete the diabetic athlete survey at the link below no later than […]

via Do Diabetic Athlete Survey by May 15 — Dr. Sheri’s Blog

Eatwell plate advice doesn’t reduce cardiovascular disease

UPDATED_Eatwell_guide_2016_FINAL_MAR23-01

 

Adapted from  BMJ 27 Jan 2018 from a study reported in PLOS Med

The UK Food Standards Agency uses a scoring system of their own devising to determine whether a food is “healthy” or not.  Fruit, vegetables, fibre and protein get top marks and saturated fat, sugar and salt get a fail.

When 25 thousand participants in the European Prospective Investigation of Cancer study completed a seven day food diary at the start of the study, and their food choices were marked on perceived health benefits, there was no difference in the incidence of cardiovascular disease over the next 16 years.

Time to lay the Eatwell Plate advice in the bin?

 

Yummy Lummy’s Low-Carb Chicken Casserole

This post belongs to Yummy Lummy – I cook, photograph and eat food with the occasional restaurant review!. Whisky flavoured chicken blue cheese casserole Whisky flavoured chicken and blue cheese casserole may sound weird but the taste is amazing, especially with some nice Danish blue cheese melted throughout the chicken and vegetable mix. 34 more…

via Whisky flavoured chicken blue cheese casserole — Yummy Lummy