Posted on Wednesday, August 1, 2018
Diabetes is an endemic in Singapore that many, including the Ministry of Health, is becoming increasingly concerned about. Today, we’ve got Ari Tria Dzulkifle and Sani Kamis, podiatrists from the Singapore Diabetic Foot Centre (SDFC) here to tell us more about diabetes and the work they are doing at SDFC.
Int: Hello Ari. Hello Sani. Thank you for joining us today. Can either of you tell me more about what to look out for when someone is diagnosed with diabetes?
Ari Tria (A): When a person is diagnosed with diabetes, the key to any treatment is to maintain their blood sugar levels at a healthy level. This is usually accomplished through a combination of the following – medications, dietary restrictions or changes, regular exercise, and weight loss.
Sani Kamis (S): Diabetes mainly affects the eyes, kidneys, and the feet, so healthcare providers pay particular attention to these parts of the body when consulting with patients with diabetes. As podiatrists, we focus on treating the foot.
Int: How does diabetes affect the foot? I mean, I understand if the eyes and kidneys are affected as they are very sensitive organs, but why does it affect the foot?
S: Diabetes affects the blood vessels. As the foot is the furthest part of the human body, blood circulation there is always easily affected by changes in other parts of your body. Once circulation is affected, it will result in malnourishment of certain structures of the limb, including the nerves. That’s when complications such as diabetic neuropathy come about. With diabetic neuropathy, you lose your protective sensation. In almost all cases, nerve damage is unlikely to heal completely. It’s also common for people with diabetes to develop further complications as well.
Int: So when you say you lose sensation, you mean you won’t be able to feel as well?
S: Correct, you may also feel uncomfortable or strange sensations such as tingling or numbness. even without something to trigger it.
Int: You mentioned further complications earlier, what might some of them be?
S: As I touched on earlier, when your circulation is affected, the nourishment of your bones and skin will also be affected. Your skin integrity may be loosened up and your bones can become more fragile. All of these contribute to changing the biomechanics of your entire body.
Int: It sounds like if it affects my feet, I could actually have trouble walking, trip more, or break my bones more easily.
S: Yes, it may also affect collagen, reducing the flexibility of your joints.
A: We put a lot of pressure on our feet. Coupled with poor footwear choices, this raises a lot of potential for foot injuries or other complications.
Int: It sounds like there are a lot of potential problems for that could happen due to diabetes. So Ari, could you please tell us more about what SDFC can do for patients when it comes to diabetes?
A: As a podiatrist, our aim is to prevent foot complications from developing. I’m pleased to be part of the team at SDFC, the first private podiatry practice in Asia that is so specialised in the treatment of diabetic foot conditions and wounds. Here, we perform comprehensive diabetic foot assessments for every one of our patients. This is necessary as we need to establish the patient’s behavioural patterns, identify any factors that may affect the patient’s rate of healing and recovery, and assess the patient’s understanding of their condition and treatment options. Furthermore, we need to consider the risk stratification and classification of the patient. Based on standard guidelines, individuals with diabetes are recommended to go for a foot check at least once a year. Once any changes are identified, patients have to be monitored more closely. Neuropathic changes are particularly dangerous as the loss of sensation can lead to patients developing injuries that they are unaware of. If these injuries go untreated, the likelihood and severity of complications increases dramatically.
Int: If a patient’s condition worsens, they’ll be required to come in for more checkups. Correct?
S: Yes, that’s right. Also, if we detect any issues that could flare up in a very short period of time, we recommend patients to come in more often and also teach them to look out for certain symptoms so that they can come in as quickly as possible if they notice anything.
A: One of the big things we look out for when dealing with diabetic foot conditions is any signs or symptoms of ulceration.
Int: What is ulceration? Is it similar to the mouth or stomach ulcers we hear about?
A: While the public is more familiar with stomach or mouth ulcers, these can also develop on your lower limbs or other parts of your body.
This is particularly common for patients diagnosed with diabetic neuropathy. Because their pain sensation is impaired, they may not notice if their shoes are too tight or uncomfortable; this constant irritation causes a blister to form on the skin. Over time, the blister continues to go unnoticed while the tissue is further damaged. Infection is an additional risk due to the prolonged open wound. As patients with diabetes also heal at a slower rate due to their impaired blood circulation, all of these factors contribute to it turning into a non-healing wound, also known as a chronic wound.
Int: Is there a fixed guide for when a wound is considered chronic?
S: In healthcare, conditions are usually considered chronic if they last beyond three months. For diabetic wounds, there are secondary complications such as infections or the wound spreading and breaking down of tissue or skin integrity.
Int: So why is it so important to prevent ulceration?
A: Ulceration is particularly dangerous as it is an open wound that invites infection, as well as damaging surrounding tissue and potentially causing cell death. This creates a cascading effect. As more cells die in the area, the cells surrounding those cells are also more likely to die, causing cell death to spread throughout the area.
The most common solution is to remove this dead tissue, either through surgery or non-surgical means. Surgical removal can range from removing the patch of affected skin to removing whole limbs or organs. This poses extra risks for diabetic patients as their impaired healing also means they take longer times to recover from such surgery while being at greater risk for further complications to develop. In fact, it is common for subsequent amputations to occur once the first amputation has taken place.
Int: Sani, if I’m understanding correctly, you’re saying my toe could fall off, all by itself.
S: That’s correct, and it could all start with a little wound first.
Int: Wow, that’s something that will definitely stick in my mind. So how can you prevent this?
A: This is where early intervention at SDFC comes in. By treating and informing patients about their conditions, we can help them avoid from developing chronic wounds that pose a long-term risk for amputation. For patients who show up with more severe conditions, have had previous amputations, or have chronic wounds, we are able to offer wound care services and nerve stimulation treatment. We are also able to help them monitor and speed up their healing processes, reduce the risks of incurring further injury through offloading their wounds and the use of prescribed diabetic orthotics th at are customised to their needs.
Int: Thank you very much. I think the both of you have given us a lot to think about diabetes and its potential dangers. Thank you, Ari and Sani, for joining us today.