Posts for: January, 2015
Canada Should Follow Finland's Example in the Fight Against Diabetes.
Journalist H.L. Mencken wrote that "for every complex problem there is a solution that is clear, simple and wrong." That observation aptly describes a prevailing attitude toward type 2 diabetes, which characterizes diabetes as a problem that could clearly be fixed if people would simply move more and eat less. Such a suggestion ignores much of what is known about the causes of the most prevalent and rapidly growing form of diabetes in Canada, and places an unwarranted burden of blame on those affected by it.
Type 2 diabetes is a complex problem with roots in genetics, the environment and individual behavioural choices. The role of genes is evident in the epidemiologic patterns of the disease. It is a condition that runs in families and few individuals diagnosed with type 2 diabetes do not have at least one relative who is affected. It is also more prevalent in certain population groups, most notably First Nations.
For some of those who carry a potent genetic risk for diabetes, no amount of physical fitness or healthy eating will protect them from developing the disease.
A second, less appreciated contributor to the growing diabetes epidemic is the role of the environment, specifically factors such as the walkability of neighbourhoods, food security and local access to health-related facilities and services.
Recent research in Toronto has demonstrated that, all else being equal, men living in the least walkable parts of the city are 32 per cent more likely to develop diabetes than those living in the most walkable neighbourhoods. For recent immigrants to Canada (many from parts of the world where the genetic risk is higher), the effect is even more striking, with a risk 58 per cent higher in the least walkable neighbourhoods. Similar results were found in women, with risk increases of 24 per cent for long-term residents and 67 per cent for recent arrivals.
It is also true that for people who are at risk of developing diabetes, behavioural
choices that promote obesity increase that risk. Improving the diet and physical activity level of persons at high risk has been shown to reduce the risk by nearly 60 per cent.
Studies documenting the impact of behavioural changes are noteworthy because small changes in weight -- on average, a loss of only five to 10 per cent -- has significant benefits. Such findings have been widely promoted by public health agencies and practitioners in an attempt to empower individuals to reduce their risk of developing diabetes. However, over-emphasizing the importance of weight reduction may have contributed to unbalanced messaging to the public around the causes of the disease. It's time to right the balance.
To simply blame individual behavioural choices as the root cause of the diabetes epidemic does a disservice to those with the disease by creating stigma (a stigma which can even spill over to those with type 1 diabetes, a disease that it is not linked to obesity).
But there is an even greater danger with a simplistic understanding of diabetes that focuses exclusively on individual choice -- it diverts attention and resources from other approaches which may be more effective at addressing the diabetes epidemic.
It is projected that by the year 2020, one in three Canadians will have either diabetes or pre-diabetes, a statistic that crystalizes the need for more emphasis on prevention, and illustrates why individual interventions alone are unlikely to be enough.
We can turn to Finland for inspiration.
In the late 1960s, North Karelia, a province in Finland, was found to have the world's highest documented rate of cardiovascular death among middle-aged men. In response, provincial representatives signed a petition to the Finnish government for urgent assistance to reduce the high burden of disease. Within a year, a multi-stakeholder community-based approach engaged food retailers, the food products industry and even the agricultural sector where, for example, a drop in demand for high fat milk products was managed by supporting dairy farmers to become berry farmers.
What was the outcome?
Over the next three decades, death rates from heart disease fell by 80 per cent and significant reductions were also seen in rates of stroke and cancer. This comprehensive approach that sought to address the whole population had a remarkable impact.
Can this experience be reproduced in Canada? There will be a number of challenges, but perhaps the first step is to effectively confront the misconception that diabetes is exclusively the fault of those who eat too much and move too little.
Diabetes is a complicated problem and that simple response has delayed real action.
A painful form of arthritis in the foot affects one in six people over 50 - more than previously thought, research suggests.
Experts at Keele University's Arthritis Research UK Primary Care Centre studied more than 5,000 people with painful foot osteoarthritis.
The condition is caused by inflammation in and around the joints, damage to cartilage and swelling. People can suffer a range of symptoms including pain, stiffness and difficulty moving and often have osteoarthritis in other joints, such as hips or knees.
The study found that foot osteoarthritis affects more women than men, while those who have spent a lot of time in manual work are more likely to develop it.
Three quarters of people with the condition reported having difficulty with simple day-to-day activities such as walking, standing, housework and shopping.
Dr Edward Roddy, clinical senior lecturer in rheumatology at Keele University, said the research had focussed on "midfoot" joints, which previous studies have neglected to do.
He said a "substantial proportion of people" with painful foot osteoarthritis have the problem in this area, meaning there has been a previous underestimate in how common it is.
He added: "Foot osteoarthritis is a more common and disabling problem than we previously thought, making everyday tasks difficult and painful for people affected.
"While it's been known for decades that joints in the foot can be affected by osteoarthritis, much of the previous research has focussed on the hip and knee areas, and research into the foot has concentrated almost entirely on the 'bunion joint' at the base of the big toe.
"However, by looking at the whole foot and the impact on people's lives, it's clear the problem is more widespread than we anticipated.
"Doctors and other healthcare professionals should also be aware of osteoarthritis as a common cause of foot pain in this age group."
According to Arthritis Research UK, 7% of people aged 45 and over have sought treatment for osteoarthritis in the foot or ankle, including 9% of those aged 75 and over.
Professor Anthony Redmond, spokesman for the charity, said: "This is a very important study. We know that foot problems become more much common as we get older but the medical and healthcare community have been guilty in the past of dismissing this as just an inevitable part of ageing.
"The new study tells us that these problems in the midfoot involve some of the same processes that affect arthritic hips and knees: conditions that are taken much more seriously.
"We have long known about some forms of osteoarthritis in the feet such as bunions, which are a common type of osteoarthritic damage affecting the big toe joints and are taken much more seriously, with both non-surgical and surgical treatments widely employed.
"The study tells us that if we want to keep our over-50s active and healthy we should be similarly serious about 'arch' or midfoot pain."
He called for wider use of X-rays to check for signs of the condition.
He added: "While osteoarthritis does not yet have a miracle cure, the associated pain and disability are not inevitable and people with foot pain should be given genuine treatment options - something can always be done."
Poor or neglected feet often lead patients down the path of ulceration, infection and amputation.1 People with diabetes are at higher risk for these sequelae. Up to 25 percent of the diabetic population will have at least one foot ulceration during their lifetime with 85 percent of lower-limb amputations being preceded by an ulcer.2,3
The latest Centers for Disease Control and Prevention (CDC) National Diabetes Statistics Report (2014) reported 29.1 million people (9.3 percent) in the United States have diabetes.4 The cost of treatment of diabetes and its complications in the United States in 2007 was approximately $116 million with 33 percent of that amount going toward ulcer treatment.3 This number is likely to increase as the diabetic population continues to grow with current estimates suggesting that diabetes will affect 366 million people worldwide by 2030.1
The purpose of this article is to remind us, as podiatric physicians, of the often underappreciated and perhaps sometimes forgotten importance of routine diabetic foot care. Although nail pathology may not be the most glamorous aspect of podiatry, it is our “bread and butter” and we need to be experts in providing this service to our patients.
How Nail Changes Can Lead To Ulcers
There are several pathways to ulceration in patients with diabetic neuropathy, ranging from biomechanical issues causing calluses to stepping on a foreign body. One pathway toward ulceration that we may overlook is the dystrophic, mycotic and neglected toenail. Dystrophy in the toenail can be a manifestation of hereditary, congenital or acquired conditions.
In the patient with diabetes, the origins of ulcers lie in microtrauma or changes in the vascular and nutritional supply to the toenail. Onychomycosis results from dermatophytes (most notably Trichophyton rubrum and Trichophyton mentagrophytes), yeasts (Candida albicans) and non-dermatophyte molds.5,6 It is this thickened nail that causes injury to adjacent skin (whether on the same toe or neighboring toe, known as a “kissing ulcer”) and can erode the nail bed and hyponychium, progressing to nail bed ulceration, paronychia, cellulitis of the skin or osteomyelitis to the underlying bone.7,8 The nail bed is a very thin tissue layer between two and five cells thick with the distal phalanx located directly beneath, putting it at increased risk of bone infection.9
Researchers have shown that one in three patients with diabetes has onychomycosis, making them 2.77 times more likely to develop onychomycosis versus people without diabetes.5,8 Authors have identified tinea pedis infection as another starting point and predictor of foot ulceration in the diabetic population.10 Onychomycosis can precipitate tinea pedis and vice versa.10-12 Regardless of the starting mechanism, both fungal infections may lead to foot ulceration, cellulitis, osteomyelitis, gangrene and lower extremity amputation.13,14 Physicians can easily manage and treat onychomycosis and tinea pedis with scheduled podiatric assessment and intervention.
Predisposition to secondary (bacterial) infections may be a consequence of simply having diabetes. This is due to the multiple levels of compromise these patients have, whether it is diabetic peripheral and autonomic neuropathy, peripheral vascular and microvascular disease, immunosuppression, diabetic retinopathy, poor blood glucose control and/or a history of amputation.1,10,15 Even increased age, obesity and limited mobility can increase the potential for infection and are also obstacles to appropriate self care.5,15 Neuropathy prevents patients from feeling any trauma from the nail itself or shoe trauma that may be occurring in this local environment.