Note to the Reader: These articles summarize the "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes," authored by Robert J. Snyder et al., published as a supplement to Ostomy Wound Management in April 2010.
Published as a supplement to the April 2010 issue of Ostomy Wound Management was a pivotal reference paper titled, "Consensus Recommendations on Advancing the Standard of Care for Treating Neuropathic Foot Ulcers in Patients with Diabetes."1 The authors are a recognized group of leading experts in the field who convened the consensus panel.
The world's population with diabetes will increase from 171 million to 366 million by 2025.2 In the U.S., there are an estimated 24 million people with diabetes. Up to 25% of those with diabetes will develop a foot ulcer in their lifetimes.3 That translates roughly to 1-2% of the diabetic patients per year.
Diabetic foot ulcers (DFU) and lower extremity amputations (LEA) are a costly problem. In 2007, it was estimated that $30 billion was spent for the care of those two conditions.4
The recommendations from the consensus panel are important because they help to update the standard of care based on a review of 111 studies. The recommendations are divided into three categories: Assessment, Treatment, Advanced Therapies.
In this issue we will look at recommendations on assessment of the diabetic foot ulcer.
Recommendations on Assessment of the Diabetic Foot Ulcer
The team approach to assessment and management of the DFU is recognized as the standard of care. No physician "is an island", and the co-morbidities within the diabetic foot cross multiple physician disciplines. A thorough history should be performed. Since wound healing delays can occur with anemia, renal insufficiency, and uncontrolled blood sugar, a CBC and HbA1c should be performed at baseline. If osteomyelitis is suspected, erythrocyte sedimentation rate (ESR) and (CRP) should be ordered.
The patient's nutritional status should be assessed by history and serum pre-albumin. Historical concerns are unintentional weight loss, chronic alcohol use, and problems chewing or swallowing. Smoking is a risk factor for peripheral arterial disease (PAD) and delays wound healing. One should remember the four A's of smoking cessation: Ask about smoking, Advise to quit, offer Assistance, Arrange follow-up.
Neurologic screening should consist of 10 gram monofilament and 128-Hz tuning fork tests. Vascular evaluation is more complicated. There is no single test that can completely evaluate vascular health. Palpation of pulses or ante brachial index (ABI) cannot be relied upon in this population. The absence of pulses is a good indicator of poor flow, but the presence of pulses cannot rule out arterial insufficiency. The toe brachial index (TBI) is less susceptible to false readings due to diabetic arterial calcification. Skin perfusion pressure (SPP) measures capillary pressure in the skin and is very sensitive at uncovering vascular disease in diabetics as well as predicting wound healing. Transcutaneous oximetry (TCPO2) can validate referral for hyperbaric oxygen. Vascular imaging tests should be performed by an appropriate specialist if there is reasonable suspicion of underlying vascular disease.
The foot examination should include assessment of dermatologic changes, musculoskeletal deformities, and ulcer evaluation. Dermatologic changes can show inflammation by thermometry or thermography. Also, it can reveal ischemia by the presence of purpura, fat atrophy, loss of hair growth, or taut skin. The podiatrist is a key member of the team for understanding the biomechanical abnormalities that lead to ulceration. Range of motion of the ankle and first metatarsophalangeal joints should be assessed for restriction in dorsi-flexion. Inspect for deformities associated with Charcot joint disease.
Radiography is useful to help uncover osteomyelitis or deformities. The foot should be x-rayed at baseline and it is appropriate to perform bilateral x-rays for comparison.
The wound assessment and documentation includes size, depth, shape, probing, undermining, condition of the wound bed, and condition of the periwound area. One should use a standard wound classification scheme. The consensus panel recommends use of the University of Texas Classification.5
Infection is devastating to the diabetic foot and its evaluation is primarily clinical. Heat, redness, pain, and swelling are the classic symptoms. The diabetic neuropathic patient does not always exhibit all those signs, so one should be aware of secondary signs like exudate, delayed healing, discolored granulation tissue, and malodor. Culture should only be taken if the clinician suspects infection.
Showing posts with label prediabetes. Show all posts
Showing posts with label prediabetes. Show all posts
Tuesday, April 26, 2011
Tuesday, March 15, 2011
Is 'Borderline' Diabetes Really Diabetes?
Q: I just learned that I'm a "borderline" diabetic, even though my blood glucose reading was very close to normal. Now I'm not sure what to do. Should I be consistently checking my blood sugar level, eating differently, or taking medication as though I actually have diabetes? I don't want to develop diabetes, but I don't want to take unnecessary precautions either.
A: Great question! Now that you've been diagnosed with prediabetes, prevention is key. Prediabetes is characterized by either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Both of these terms refer to the level of sugar in the bloodstream, and they're both ways of saying that you have prediabetes.
If your fasting glucose level (a test in which blood is drawn after six hours without food) is between 100 and 125 mg/dl, you have IFG. If your blood sugar level two hours after a glucose challenge test is between 139 and 200 mg/dl, you have IGT.
Okay — now that we have the classification straight, why should you be worried about these numbers if yours are not in the diabetic range? Here's why: As your blood glucose rises above the normal level, your risk of developing damage in the body's small blood vessels, and ultimately your risk of a heart attack or stroke, also rises. In addition, having abnormal glucose levels is a risk factor for developing outright diabetes in the future.
By bringing you blood sugar levels back in the normal range, you can probably prevent the onset of diabetes and other complications, such as coronary artery disease. It is not absolutely essential to frequently check your glucose levels at home as long as you and your doctor monitor them periodically.
The precautions that you can and should take to prevent complications and the onset of diabetes consist of the same habits you'd cultivate to stay healthy in general. These include exercising, eating healthfully and not excessively, and maintaining your ideal body weight. One study showed that among a group of individuals who had prediabetes, those who lost as little as 7 percent of their body weight delayed the onset of diabetes or prevented it. There are also medicines that have been shown to prevent diabetes. While I do not recommend medicines to all people with prediabetes, it might be advisable in some cases. I wish you luck in this journey toward health.
A: Great question! Now that you've been diagnosed with prediabetes, prevention is key. Prediabetes is characterized by either impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Both of these terms refer to the level of sugar in the bloodstream, and they're both ways of saying that you have prediabetes.
If your fasting glucose level (a test in which blood is drawn after six hours without food) is between 100 and 125 mg/dl, you have IFG. If your blood sugar level two hours after a glucose challenge test is between 139 and 200 mg/dl, you have IGT.
Okay — now that we have the classification straight, why should you be worried about these numbers if yours are not in the diabetic range? Here's why: As your blood glucose rises above the normal level, your risk of developing damage in the body's small blood vessels, and ultimately your risk of a heart attack or stroke, also rises. In addition, having abnormal glucose levels is a risk factor for developing outright diabetes in the future.
By bringing you blood sugar levels back in the normal range, you can probably prevent the onset of diabetes and other complications, such as coronary artery disease. It is not absolutely essential to frequently check your glucose levels at home as long as you and your doctor monitor them periodically.
The precautions that you can and should take to prevent complications and the onset of diabetes consist of the same habits you'd cultivate to stay healthy in general. These include exercising, eating healthfully and not excessively, and maintaining your ideal body weight. One study showed that among a group of individuals who had prediabetes, those who lost as little as 7 percent of their body weight delayed the onset of diabetes or prevented it. There are also medicines that have been shown to prevent diabetes. While I do not recommend medicines to all people with prediabetes, it might be advisable in some cases. I wish you luck in this journey toward health.
Monday, February 28, 2011
Only 7% of the 60 Million with Prediabetes Are Aware
Measuring glycated hemoglobin levels may be an appropriate means of catching patients with prediabetes....
Ronald Ackerman, MD, MPH, of Indiana University, and colleagues reported in Preventive Medicine that, HbA1c testing yielded similar probabilities for developing diabetes and heart disease as those estimated by using the 2003 American Diabetes Association definition for prediabetes. "The A1c test may provide a badly needed, clinically practical indicator of the composite risk for incident diabetes and cardiovascular disease," they wrote.
Fasting plasma glucose and two-hour plasma glucose, two commonly used tests for assessing diabetes and prediabetes, are limited because they require a patient to return on a separate day after an overnight fast and remain in the office for 2-3 hours which is a potential barrier to test completion, the researchers said.
Measuring HbA1c is easier -- it requires only one blood draw. In June 2009, the International Expert Committee, which represents several major diabetes groups, recommended using HbA1c to diagnose diabetes.
The recommendations of the committee have stirred up some controversy, still, the researchers said, only about 7% of patients with prediabetes -- who are thus at risk for later diabetes and heart disease -- are aware of their status.
To estimate the risks of developing diabetes and cardiovascular disease for adults with different HbA1c levels, Ackerman and colleagues assessed data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006.
Among adults who met the 2003 ADA definition for prediabetes, the probabilities for developing Type 2 disease over 7.5 years and cardiovascular disease over 10 years were 33.5% and 10.7%, respectively.
The researchers found that using HbA1c alone -- with a range of 5.5% to 6.5% defining prediabetes -- would identify a population with comparable risks for diabetes and heart disease (32.4% and 11.4%, respectively).
But using a slightly higher cutoff -- beginning at 5.7% -- would identify increased risks of 41.3% for diabetes and 13.3% for heart disease.
These risks are comparable to those seen in patients enrolled in the Diabetes Prevention Program, which had an enrollment criteria of both elevated fasting plasma glucose and impaired glucose tolerance, the researchers said.
Thus, they concluded, using a bottom cutoff of 5.7% for diagnosing prediabetes may be more appropriate.
Either way, they said, HbA1c measurement "should be considered a means of identifying greater numbers of patients at risk for diabetes and heart disease" -- especially because "of its practical nature and wide availability."
The study was limited by its use of cross-sectional data, and it may be lacking in generalizability. For instance, a greater number of African Americans would be identified as having prediabetes than if using fasting plasma glucose or two-hour plasma glucose testing, the researchers noted.
Ronald Ackerman, MD, MPH, of Indiana University, and colleagues reported in Preventive Medicine that, HbA1c testing yielded similar probabilities for developing diabetes and heart disease as those estimated by using the 2003 American Diabetes Association definition for prediabetes. "The A1c test may provide a badly needed, clinically practical indicator of the composite risk for incident diabetes and cardiovascular disease," they wrote.
Fasting plasma glucose and two-hour plasma glucose, two commonly used tests for assessing diabetes and prediabetes, are limited because they require a patient to return on a separate day after an overnight fast and remain in the office for 2-3 hours which is a potential barrier to test completion, the researchers said.
Measuring HbA1c is easier -- it requires only one blood draw. In June 2009, the International Expert Committee, which represents several major diabetes groups, recommended using HbA1c to diagnose diabetes.
The recommendations of the committee have stirred up some controversy, still, the researchers said, only about 7% of patients with prediabetes -- who are thus at risk for later diabetes and heart disease -- are aware of their status.
To estimate the risks of developing diabetes and cardiovascular disease for adults with different HbA1c levels, Ackerman and colleagues assessed data from the National Health and Nutrition Examination Survey (NHANES) 2003-2006.
Among adults who met the 2003 ADA definition for prediabetes, the probabilities for developing Type 2 disease over 7.5 years and cardiovascular disease over 10 years were 33.5% and 10.7%, respectively.
The researchers found that using HbA1c alone -- with a range of 5.5% to 6.5% defining prediabetes -- would identify a population with comparable risks for diabetes and heart disease (32.4% and 11.4%, respectively).
But using a slightly higher cutoff -- beginning at 5.7% -- would identify increased risks of 41.3% for diabetes and 13.3% for heart disease.
These risks are comparable to those seen in patients enrolled in the Diabetes Prevention Program, which had an enrollment criteria of both elevated fasting plasma glucose and impaired glucose tolerance, the researchers said.
Thus, they concluded, using a bottom cutoff of 5.7% for diagnosing prediabetes may be more appropriate.
Either way, they said, HbA1c measurement "should be considered a means of identifying greater numbers of patients at risk for diabetes and heart disease" -- especially because "of its practical nature and wide availability."
The study was limited by its use of cross-sectional data, and it may be lacking in generalizability. For instance, a greater number of African Americans would be identified as having prediabetes than if using fasting plasma glucose or two-hour plasma glucose testing, the researchers noted.
Friday, September 24, 2010
Stop the Progress of Prediabetes
You can prevent this precursor to Type II diabetes from developing into full-blown disease.
By Madeline Vann, MPH
Medically reviewed by Cynthia Haines, MD
By some estimates, one-third of adults in the United States have a condition called prediabetes; 13 percent have type 2 diabetes. Prediabetes may be more common in men (36 percent) than in women (23 percent).
Prediabetes means that while your blood sugar levels are higher than normal, that level isn’t high enough to warrant a diabetes diagnosis. However, a prediabetes diagnosis means it is time for action to prevent diabetes. "In simple terms, there is a gap between what we call diabetes, which is a fasting blood sugar of 126 and above, and normal, which is less than 100 fasting," explains Vivian Fonseca, MD, a professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans.
"In between," he continues, "you have impaired fasting glucose. If you do a glucose tolerance test, and you are in the gap, you have prediabetes. You are at risk for getting diabetes in the future and you are also at risk for heart disease."
Type 2 Diabetes: Prevention
If are told your blood sugar is abnormally high, you’ve just had a red flag waved in front of you. You’re being warned that unless you make some changes in your life today, your future will probably include a diabetes diagnosis.
"Walking 30 minutes a day and reducing weight by 5 percent can decrease the risk [of getting type 2 diabetes] by 60 percent over three years," says Dr. Fonseca. While there are medications that have the same effect, lifestyle change is less expensive and has fewer side effects, Fonseca says.
Cutting your weight is crucial. "One of the links with obesity is that fat induces a mild low-grade inflammation throughout the body that contributes to heart disease and diabetes," Fonseca explains. Without making any changes, you could develop type 2 diabetes within 10 years of first developing prediabetes.
Type 2 Diabetes: Who should be Tested?
Prediabetes is a "silent" condition, says Fonseca. While some people may experience symptoms of diabetes such as fatigue or increased urination, most people’s blood sugar rises without any outward signs at all. This means you might not know you need to be tested for prediabetes — and even if you are screened, your doctor might not give you all the information you need to prevent it.
For these reasons, diabetes experts developed criteria for those who should be tested. The American Diabetic Association recommends that any adult age 45 or older should be tested for diabetes and prediabetes.
The ADA also recommends that any adult under age 45 who is overweight and has at least one of the following risk factors should be tested:
• Family history (especially parent or sibling with diabetes)
• Physically inactive lifestyle
• Native American, African-American, or Hispanic heritage
• Prior gestational diabetes diagnosis
• Birth of a baby over nine pounds in weight
• High blood pressure or treatment for high blood pressure
• Polycystic ovarian syndrome (PCOS) diagnosis
• Dark, velvety rash around the armpits or neck
• History of heart disease
If your test reveals that you have prediabetes, you should be tested again in one to two years, depending on your doctor’s recommendations.
Type 2 Diabetes: Types of Tests
There are two tests used to screen for diabetes and prediabetes:
• Fasting plasma glucose: a test of your blood after you haven’t eaten for eight hours (usually overnight)
• Oral glucose tolerance test: a comparison of your blood taken first after eight hours without food (fasting) and then two hours later after you have consumed a sugary drink given to you by the lab technician.
If you fit the screening criteria listed above, make an appointment to get tested as soon as possible. It could be the first step toward preventing the development of type 2 diabetes.
By Madeline Vann, MPH
Medically reviewed by Cynthia Haines, MD
By some estimates, one-third of adults in the United States have a condition called prediabetes; 13 percent have type 2 diabetes. Prediabetes may be more common in men (36 percent) than in women (23 percent).
Prediabetes means that while your blood sugar levels are higher than normal, that level isn’t high enough to warrant a diabetes diagnosis. However, a prediabetes diagnosis means it is time for action to prevent diabetes. "In simple terms, there is a gap between what we call diabetes, which is a fasting blood sugar of 126 and above, and normal, which is less than 100 fasting," explains Vivian Fonseca, MD, a professor of medicine and pharmacology and chief of endocrinology at Tulane University Health Sciences Center in New Orleans.
"In between," he continues, "you have impaired fasting glucose. If you do a glucose tolerance test, and you are in the gap, you have prediabetes. You are at risk for getting diabetes in the future and you are also at risk for heart disease."
Type 2 Diabetes: Prevention
If are told your blood sugar is abnormally high, you’ve just had a red flag waved in front of you. You’re being warned that unless you make some changes in your life today, your future will probably include a diabetes diagnosis.
"Walking 30 minutes a day and reducing weight by 5 percent can decrease the risk [of getting type 2 diabetes] by 60 percent over three years," says Dr. Fonseca. While there are medications that have the same effect, lifestyle change is less expensive and has fewer side effects, Fonseca says.
Cutting your weight is crucial. "One of the links with obesity is that fat induces a mild low-grade inflammation throughout the body that contributes to heart disease and diabetes," Fonseca explains. Without making any changes, you could develop type 2 diabetes within 10 years of first developing prediabetes.
Type 2 Diabetes: Who should be Tested?
Prediabetes is a "silent" condition, says Fonseca. While some people may experience symptoms of diabetes such as fatigue or increased urination, most people’s blood sugar rises without any outward signs at all. This means you might not know you need to be tested for prediabetes — and even if you are screened, your doctor might not give you all the information you need to prevent it.
For these reasons, diabetes experts developed criteria for those who should be tested. The American Diabetic Association recommends that any adult age 45 or older should be tested for diabetes and prediabetes.
The ADA also recommends that any adult under age 45 who is overweight and has at least one of the following risk factors should be tested:
• Family history (especially parent or sibling with diabetes)
• Physically inactive lifestyle
• Native American, African-American, or Hispanic heritage
• Prior gestational diabetes diagnosis
• Birth of a baby over nine pounds in weight
• High blood pressure or treatment for high blood pressure
• Polycystic ovarian syndrome (PCOS) diagnosis
• Dark, velvety rash around the armpits or neck
• History of heart disease
If your test reveals that you have prediabetes, you should be tested again in one to two years, depending on your doctor’s recommendations.
Type 2 Diabetes: Types of Tests
There are two tests used to screen for diabetes and prediabetes:
• Fasting plasma glucose: a test of your blood after you haven’t eaten for eight hours (usually overnight)
• Oral glucose tolerance test: a comparison of your blood taken first after eight hours without food (fasting) and then two hours later after you have consumed a sugary drink given to you by the lab technician.
If you fit the screening criteria listed above, make an appointment to get tested as soon as possible. It could be the first step toward preventing the development of type 2 diabetes.
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