The prophylaxis of diabetic foot syndrome is deficient

Diabetic foot syndrome is a secondary disease of diabetes mellitus and often leads to non-traumatic amputations. These are associated with high medical costs, loss of quality of life and high mortality (Heller et al. 2004). Diabetic foot syndrome occurs with a prevalence of 6.5% among type 2 diabetes patients (Lauterbach et al. 2010). Endogenous risk factors such as B. diabetic polyneuropathy or peripheral arterial disease (PAD) have a prevalence of 30% and 25%, respectively (Lauterbach et al. 2010). Prevention of diabetic foot syndrome is therefore very important. In addition to the endogenous risk factors mentioned, exogenous factors such as: For example, inadequate footwear or poor foot care play a crucial role (Uccioli et al. 1995; Chantelau/Haage 1994; Brent et al. 2006). According to the International Consensus on the Diabetic Foot (1999), the prevalence of diabetic foot syndrome could be reduced through, among other things, regular inspections of the feet and footwear, training of patients and family members and the wearing of suitable footwear. An important and effective intervention measure is to train and instruct patients to self-inspect their feet.

>> The treatment and care of patients with diabetic foot syndrome can only be achieved through an interdisciplinary approach (Haslbeck 2000). National care guidelines, disease management programs, and structured patient education programs have long been established, yet many diabetic patients are unaware that they have a lot to do for their feet themselves (Morbach et al. 2004). Effective prevention of diabetic foot syndrome requires early identification of patients at risk, communication of this risk to the patients, and subsequent implementation of sustained education and close monitoring of all risk factors (Davidson et al. 1981). Patient care must foster personal responsibility and awareness of the problem (Nalini et al. 2005).
Numerous studies demonstrate the importance of regular foot and shoe examinations for prevention (Apelqvist et al. 1993; Litzelmann et al. 1993; Levin 1995; Barnett et al. 1995). However, only a few studies demonstrate patients' awareness of the problem, their knowledge of the measures they take, and the measures they implement. Therefore, the aim of this study was to identify and quantify risk factors and indicators for the development of diabetic foot syndrome due to patient behavior and the failure or inappropriate implementation of preventive measures. To this end, diabetic patients were surveyed regarding their knowledge of diabetic foot syndrome prevention and personal behavioral measures.
material and methods
Survey location and period
Between January and July 2008, randomly selected diabetic patients at the Red Cross Hospital in Kassel and an affiliated diabetes specialist practice were systematically surveyed about their knowledge of diabetic foot syndrome prevention, foot care measures, and the frequency and procedure of medical examinations. An interviewer informed the study patients about the study, and their consent to participate was obtained. Furthermore, the study patients were informed that the collection and responses to the questions had no connection whatsoever with the individual course and treatment of their disease. The questionnaire contained 20 closed questions with predetermined answers or answer categories. The questions and answers were read aloud to all study patients in the same order, and the answers were recorded directly on the questionnaire. Data collection was strictly anonymous. 93 patients with manifest type 1 or type 2 diabetes mellitus were surveyed within a six-month period. A representative survey was not intended.
Behavioral factors influencing the development of diabetic foot syndrome were differentiated into „appropriate“ and „unsuitable measures“ and analyzed gender-specifically among all study patients.
classification
For the evaluation of footwear and foot care measures, a division into „suitable“ and „unsuitable“ was also made:
The following are considered suitable: sufficiently large shoes with a firm sole (also for home use), daily shower followed by an inspection of the feet and the spaces between the toes, the use of moisturising creams/urea creams, and the use of files to shorten the nails.
The following are considered unsuitable: open shoes, such as sandals or bathing shoes, sports shoes with soft soles, rubber boots, health shoes with pre-shaped footbeds, felt slippers, walking in socks or barefoot, scissors/nail clippers, callus planes, corn plasters, foot baths, and the use of alkaline soaps.
Risk factors for the development of diabetic foot syndrome: foot wounds during the course of diabetes, peripheral circulatory disorders, diabetic polyneuropathy.

Evaluation
The analysis was descriptive. 95% confidence intervals were calculated for the proportions. The frequencies of categorical characteristics and the association of categorical characteristics between the groups were compared using the chi-square test. The frequencies of ordinal variables within the groups were calculated using the Wilcoxon test for non-parametric distributions. Spearman's correlation was used to calculate the associations between the ordinal variables. All analyses were performed using the statistical program SAS version 9.2.

Results
Of the 93 patients surveyed, 46 were women and 47 were men. 851 patients had type 2 diabetes. The mean duration of diabetes was 15.6 years. Over half of the respondents were older than 65.

Patient knowledge/level of knowledge
311,000 of the patients surveyed (n=93) were unaware of whether they had diabetic polyneuropathy and/or peripheral circulatory disorders. The difference in lack of knowledge between men and women was not significant (p=0.234).

Analysis of preventive patient behavior
Only 20% of the patients surveyed (n=90) reported wearing appropriate footwear. However, 48% also wore open shoes, such as sandals or flip-flops. Furthermore, 15% of the diabetic patients surveyed reported wearing comfortable shoes with a pre-shaped footbed. The difference in wearing appropriate footwear between men and women was not significant (p=0.641) (Fig. 1).
Over half of the patients surveyed (n=93) wore unsuitable shoes at home. The difference between men and women was also not significant (p=0.631) (Fig. 2).
When asked about the provision of special diabetic footwear, 57% of men reported wearing special footwear for diabetes patients, such as adapted ready-to-wear or custom-made shoes. In contrast, women reported wearing special footwear significantly less frequently (p=0.008).
In terms of hygienic foot care, 78% of all respondents (n=92) performed inappropriate measures. The difference between men and women was not significant.
Inappropriate foot care items were used by 22% of all respondents (n=85). Men reported using inappropriate foot care items more frequently than women (19.5% vs. 31%, respectively). This difference was significant (p<0.001).

Analysis of the processes and frequencies of medical examinations
52% of all respondents reported seeing a doctor regularly once a quarter due to their diabetes. For 75% of respondents (n=92), their doctor had never examined their shoes or socks. Furthermore, 17% of the male respondents had never undergone a tuning fork examination to diagnose diabetic polyneuropathy (Table 1). Patients who visited their doctor more frequently also had a tuning fork test performed more frequently (p=0.048) (Table 1).

Analysis of risk factors for the development of diabetic foot syndrome
Key risk factors negatively associated with the development of diabetic foot syndrome were male gender (OR: 3.14), wounds caused by improper foot care (OR: 3.38), and lack of foot check-up by a physician (OR: 4.20).
Potential protective factors for preventing diabetic foot syndrome included the use of professional foot care by a podiatrist (OR: 0.05) and daily self-inspection of the feet (OR: 0.28). Other protective factors included the following foot care practices: the use of pumice stone for callus care (OR: 0.37), the use of sand files for toenail trimming (OR: 0.29), and the use of urea-containing creams for foot skin care (OR: 0.15). Wearing appropriate shoes/slippers (OR: 0.20) also showed a positive influence on preventing diabetic foot lesions (Table 2).
discussion
During the planned survey period, 93 study patients were interviewed. Despite the small number of patients, the results provide a clear trend and demonstrate the diversity of perceptions and self-assessment among diabetic patients regarding diabetic foot syndrome. Awareness of symptoms and risk factors and raising awareness of the problem are extremely important for the prevention and treatment success of diabetic foot syndrome. Diabetic patients are taught to wear the correct footwear in specific patient training sessions. It is difficult for them to actually do this because, due to neuropathic changes, they do not notice that their previous footwear no longer fits. The lack of sensory perception in neuropathic foot disease must therefore be compensated for by competent problem awareness on the part of the patient and regular professional check-ups and/or self-inspection.
Some studies have clearly shown that unsuitable footwear is the main trigger for the initial lesion in diabetic patients, with up to 50% of the risk being (Spraul 1999). Due to the reduced sensitivity in existing polyneuropathy, many patients wear shoes that are too tight (Uccioli et al. 1995). Shoes with straps, hard toe caps or seams, i.e. shoes that exert local pressure, are also unsuitable for the neuropathic foot (Brent et al. 2006; Morbach et al. 2004). Patients at risk should wear closed shoes of sufficient size both outdoors and at home. In the patient survey conducted, 48% of those questioned stated that they wear open shoes, such as sandals or bathing shoes. The risk of foot injury is very high with open shoes. If the injury is caused by a shoelace, for example. If the injury goes unnoticed, for example, due to existing polyneuropathy, an ulcer can develop from this injury, which can even progress to gangrene. Up to 15% of patients wore health shoes with pre-shaped footbeds. This type of footbed is usually not suited to the deformed patient's foot. The gripping ridges do not fit the anatomy of the foot and can cause skin lesions/blisters due to shear forces.
When it comes to foot care for diabetic patients, a distinction can be made between appropriate and inappropriate tools/measures. Up to 28% of respondents used nail scissors or nail clippers, thus putting them at increased risk of injury. 40% of respondents did not inspect their feet daily, and 78% used inappropriate foot hygiene measures.
Professional foot care and preventive support from a podiatrist are currently only partially available for diabetic patients. Another cross-sectional analysis of 230 diabetic patients who visited a podiatric practice for the first time showed that 58% of the patients already had extensive nail and foot mycoses, and up to 89% had foot deformities with tuning fork sensitivity values below 4/8 (Lauterbach et al. 2010).
In the present survey, 35% of patients with current foot injuries were not even familiar with the profession of podiatrist. However, 37% of these patients had already been to a non-specialized, medical podiatrist. Diabetic patients should only have professional foot care performed by specially trained podiatrists. 45% of the surveyed patients with current foot injuries had never been to a podiatric clinic (p<0.0001).
Women visited a podiatrist significantly more often (p=0.0295). Only 13% of women had never seen a podiatrist.
The extent to which the criteria examined influence the incidence of diabetic foot syndrome needs to be investigated in further studies. Whether improved information sharing increases patient compliance should also be investigated in future studies.
This study clearly demonstrated the incomplete knowledge of patients regarding diabetic foot syndrome. Wearing unsuitable shoes and performing inappropriate foot care procedures due to patient ignorance and noncompliance are common. Thus, this study demonstrates that diabetic foot syndrome prevention is deficient.