Diabetes Consultant at Central Middlesex Hospital, London North West University Healthcare and clinical lead for the North West London Diabetes Foot Project Dr Wing May Kong believes that people with diabetes need to have access to the information they need to manage their foot health and should be confident that every health professional they meet can give them the right advice if they have a foot problem. She explains why collaborating with podiatrists is so vital for people with diabetes.
We tend to take our feet for granted despite how much work they do every day! For most of us, I think our feet could do with a little more love, but for people with diabetes it is especially important. Our footcare transformation work in North West London (NW London) began in 2017. We established a Diabetes Footcare Network made up of our foot teams, community health providers and importantly, people with diabetes to improve diabetes footcare services across NW London.
A blister is a minor inconvenience and sore feet usually quickly recuperate after a rest. But diabetes can damage the nerves and blood flow to the foot which can mean that minor wounds or blisters don’t heal and become an ulcer (a non-healing open wound). An ulcer can get infected and deteriorate to the point of needing to go into hospital or even needing amputation over just a few days and sometimes even less. So, it’s really important that every health professional who has contact with people with diabetes (which means virtually all health professionals!) is able to give the right advice if asked about a foot problem.
Reading about diabetes-related problems can seem quite scary, so it’s helpful to focus on what we can do to keep healthy (feet included) and what we need to feel confident about where and when to get help if a problem develops.
Early intervention is key
When I first started as a doctor it was fairly common for people to have unknowingly lived with diabetes for several years, even up to a decade, before they were diagnosed. But by this time diabetes had often already caused serious damage to their eyes or kidneys or feet. Today, the annual diabetes health checks (checking blood sugar levels, heart disease risk, kidneys, etc) and annual eye screening pick up diabetes damage early, before it’s caused any health problems - and there’s lots that can be done to stop the damage getting worse.
Lifestyle changes – healthier eating, stopping smoking, regular exercise can have huge benefits for feet, as well overall health. Prioritising lifestyle changes isn’t easy so finding support that works for the individual is important. As well as General Practice or diabetes teams, there are local diabetes peer support groups and the NW London online diabetes information hub, KnowDiabetes, has lots of really useful advice that includes local people sharing their own experiences of diabetes.
Diabetes is more common amongst people from black or Asian ethnic backgrounds and amongst people experiencing higher levels of social deprivation. We’re aware that people living with diabetes don’t always get access to the right care at the right time. We are determined to change this. We have started a project with researchers from Queen Mary’s University London, to address health inequalities in relation to footcare in NW London. We are working with local communities to understand how we can communicate more effectively with different groups about footcare and how we ensure our services are accessible to everyone. For instance, getting time off work to attend clinics is often difficult for people in low paid work.
We also need to do more to support people experiencing homelessness who face many barriers to accessing healthcare. Some of these barriers are practical – not having a smartphone or data or a place to charge your phone leaves you excluded from digital support and communication. Also, mental health problems are more common, which can make it difficult for someone to prioritise their footcare.
Our foot care campaign makes a difference here
Last November the KnowDiabetes team, alongside podiatrists, diabetes specialists like myself and people with diabetes, created a campaign to enhance foot care knowledge with weekly emails over 6 weeks to 596 people with Type 1 diabetes and 17,642 with Type 2 diabetes. We built the campaign around a foot health quiz, which enabled people to check how much they knew about keeping their feet healthy. Tips and advice were included in the quiz as well as links to footcare videos and healthy lifestyle information on our KnowDiabetes website. Almost 6,000 people visited our KnowDiabetes footcare pages and over 600 of them downloaded healthy meal plans with a choice of foods from different cultures (South Asian, Caribbean, Arabic, Caribbean and West African) as well a low carb meal plan.
You can try the foot quiz and start receiving these insightful campaigns by registering for a free Know Diabetes account.
Our campaign included information on annual diabetes foot checks. The foot check looks for damage to the nerves and blood vessels and is used to work out the risk of serious foot problems. People who are at high or moderate risk should see a podiatrist regularly. This is important even if someone is low risk, as low risk isn’t no risk, so we recommend that everyone with diabetes does a 30 second daily visual foot check, as this helps pick up new problems early. The campaign’s foot quiz results have provided useful insights which we will use to improve how we provide footcare - almost half of the people who took part in the email campaign did not know their foot risk and a third hadn’t had a foot check for over a year.
All our evidence shows that if you have a diabetes foot ulcer, you are much more likely to heal and keep all your toes if you are seen promptly by a multidisciplinary diabetes foot team. But people are often unsure if a foot problem needs an urgent review, so our campaign included a link to a video to address this: ‘What if I have a blister or small wound on my foot?’.
With diabetes, foot wounds may not hurt. People can mistakenly take this to mean that it’s not too bad, but in fact it’s a sign of nerve damage. It’s the nerves that control the microscopic blood vessels in your feet to ensure a good healing response. So, if there’s nerve damage, it will be difficult for wounds to heal.
The benefits of multi-disciplinary care
Our podiatrists are the bedrock of our multidisciplinary diabetes foot team. They provide the specialist wound care which is essential for ulcers to heal. Foot problems are often complicated to manage so in NW London we hold weekly multidisciplinary team meetings, consisting of diabetes specialists, podiatrists who are diabetes specialists, vascular surgeons, microbiologists, orthopaedic surgeons and radiologists, to ensure people with complex diabetes foot problems get the best care.
The podiatrists across NW London (and across the country) have been amazing in their commitment to improving footcare services across NW London and also at the individual level. They work across the community and in hospitals and enable us to tailor our service to the needs of the person with diabetes.
For instance, for people who are frail or have advanced dementia with foot ulcers, attending a hospital clinic every week may be too much of a burden. So, we work closely with community podiatrist teams who can assess the patient at home and take samples and liaise with district nurses and GPs so that they get the care and treatment they need.
The impact of foot ulcers is often underestimated. Whilst diabetes nerve damage means that ulcers may not be painful in the usual way, they are often associated with neuropathic pain caused by the nerve damage. People describe this as like an electric shock going through the foot at random times. This is particularly distressing for people who are less able to communicate their pain or are unable to understand what’s going on. For instance, a person with advanced dementia might just become withdrawn, refuse food or get agitated, but successfully treating the foot ulcer can have a transformative effect. The podiatrist’s holistic understanding of what is going on supported by the specialist team in the hospital means we can provide the right care in the right place.
My feet are painful what should I do? Watch this video to find out more.
A lot of our diabetes footcare transformation work went on hold during the pandemic, but we kickstarted it again with our footcare campaign. As we move out of lockdown, we will continue our partnership working to ensure we’re putting our best foot forward to provide the best inclusive, educational and preventative diabetes care.