History of Type 1 Diabetes Mellitus

Type 1 diabetes mellitus (DM), once known as juvenile diabetes

or insulin-dependent diabetes is a chronic condition in which the
pancreas produces little or no insulin, a hormone needed to allow sugar
(glucose) to enter cells to produce energy. (Mayo Clinic, 2014)
Despite active research, type 1 DM has no cure. But it can be
managed. With proper treatment, people with type 1 DM can expect to
live longer, healthier lives than did people with type 1 DM in the past.
The exact cause of type 1 diabetes is unknown. In most people
with type 1 diabetes, the body's own immune system which
normally fights harmful bacteria and viruses mistakenly destroys the
insulin-producing (islet) cells in the pancreas. Genetics may play a role
in this process, and exposure to certain environmental factors, such as
viruses, may trigger the disease. (Mayo Clinic, 2014)
Internationally, rates of type 1 DM are increasing. In Europe, the
Middle East, and Australia, rates of type 1 DM are increasing by 2-5%
per year. The prevalence of type 1 DM is highest in Scandinavia (ie,
approximately 20% of the total number of people with DM) and lowest
in China and Japan (ie, fewer than 1% of all people with diabetes).
Some of these differences may relate to definitional issues and the
completeness of reporting. (WHO, 2015)
In the Philippines there are no nationwide prevalence or
incidence studies on Type 1 diabetes mellitus. (DOH, 2013)
Screening for Type 1 DM is not recommended at the moment for
the following reasons:
The disease is of low prevalence although an increasing trend is
observed. Exact prevalence/incidence has yet to be established.
Screening using serologic markers are not readily available and
expensive, thus, making screening not cost-effective.
Since clinical trials for interventions to prevent or delay Type 1
diabetes have not been proven effective, Diabetes Mellitus 16th Edition
2014 screening for T1 diabetes is NOT recommended.

History of Type 2 Diabetes Mellitus

Type 2 diabetes is characterized by a combination of peripheral
insulin resistance and inadequate insulin secretion by pancreatic beta
cells. Insulin resistance, which has been attributed to elevated levels of

free fatty acids and proinflammatory cytokines in plasma, leads to

decreased glucose transport into muscle cells, elevated hepatic
glucose production, and increased breakdown of fat. (Mayo Clinic,
2014)
Globally in 2013, it is estimated that almost 382 million people
suffer from diabetes for a prevalence of 8.3%. North America and the
Caribbean is the region with the higher prevalence of 11% having 37
million people with diabetes followed by the Middle East and North
Africa with a prevalence of 9.2% having 35 million people with
diabetes. Western Pacific is the region with higher number of people
living with diabetes (138 million), however its prevalence is 8.6%, close
to the prevalence of the World. (Martinez, 2013)
In the Philippines there are no nationwide prevalence or
incidence studies on Type 2 diabetes mellitus. The DOH, however,
keeps statistics on diabetes mellitus regardless of what type. Diabetes
Mellitus has been consistently included in the top 10 leading causes of
mortality in the Philippines since 2004. Since then, the rate of diabetes
mellitus has been continuously increasing. In 2009, which is the latest
statistic available, diabetes mellitus was recorded to have a rate of
24.2. (DOH, 2013)
Usual symptoms of type 1 and type 2 DM include:
Polyuria
Polyphagia
Polydypsia
Unexplained weight loss
Fatigue and weakness
In females, vaginal yeast infection
Slow-healing sores
Frequent infections
Areas of darkened skin
Although both types of diabetes mellitus share the same symptoms,
those of type 2 are less pronounced. This leads, to later diagnosis of
type 2 DM.
People with diabetes can develop many complications like foot
problems. Even ordinary problems can get even worse and lead to
serious complications.
Footwear

Poorly fitting shoes are a common cause of diabetic foot

problems. If the patient has red spots, sore spots, blisters, corns,
calluses, or consistent pain associated with wearing shoes, new
properly fitting footwear must be obtained as soon as possible. If the
patient has common foot abnormalities such as flat feet, bunions, or
hammertoes, prescription shoes or shoe inserts may be necessary.
(American Diabetes Association, 2015)
Neuropathy
Foot problems most often happen when there is nerve damage,
called neuropathy. This can cause tingling, pain, burning, stinging or
weakness in the foot. It can also cause some loss of feeling in the foot,
so you can injure it and not know it. Poor blood flow or changes in
shape of the feet or toes may also cause the problem. (American
Diabetes Association, 2015)
Also, they may be unable to sense the position of their feet and
toes while walking and balancing. With normal nerves, a person can
usually sense if their shoes are rubbing on the feet or if one part of the
foot is becoming strained while walking. (American Diabetes
Association, 2015)
A person with diabetes may not properly sense minor injuries
(such as cuts, scrapes, blisters), signs of abnormal wear and tear (that
turn into calluses and corns), and foot strain. Normally, people can feel
if there is a stone in their shoe, then remove it immediately. A person
who has diabetes may not be able to perceive a stone. Its constant
rubbing can easily create a sore. (American Diabetes Association,
2015)
If you do not feel a cut or sore on the foot because of
neuropathy, the cut could get worse and become infected. It is
estimated that up to 10% of people with diabetes will develop foot
ulcers. (American Diabetes Association, 2015)
Skin Changes
Diabetes can cause changes in the skin of your foot. Drying of
skin on the foot is common. The skin may peel and crack because of
the dryness. The problem is that the nerves that control the oil and
moisture in the foot no longer work. (American Diabetes Association,
2015)
Calluses

Calluses occur more often and build up faster on the feet of

people with diabetes. This is because there are high-pressure areas
under foot. Too much callus may mean that you will need therapeutic
shoes and inserts. (American Diabetes Association, 2015)
If the calluses are not trimmed, it will get very thick, break down
and turn into ulcers or open sores. Never try to cut calluses or corns by
yourself because it can lead into ulcers and infections. Only health care
providers can cut the calluses.
Infections
Athlete's foot, a fungal infection of the skin or toenails, can lead to
more serious bacterial infections and should be treated promptly.
Ingrown toenails should be handled right away by a foot specialist.
Toenail fungus should also be treated. (Elsevier, 2012)
Foot Ulcers
Foot ulcers occur most often on the ball of the foot or on the
bottom of the big toe. Ulcers on the side of the foot are usually due to
poorly fitting shoes. Neglecting ulcers can lead into infections, which in
turn can lead to loss of a limb.
Taking x-rays of your foot to make sure the bone is not infected is
also important whenever you have foot ulcers. If the ulcer is not
healing and you circulation is poor, the health care provider may need
to refer you to a vascular surgeon. High blood glucose levels make it
hard to fight infection. (American Diabetes Association, 2015)
Poor Circulation
Poor circulation or poor blood flow can make the foot less able to
fight infection and to heal. Diabetes causes blood vessels of the foot
and leg to narrow and harden. Controlling some things which can cause
poor circulation like smoking is also applicable.
Especially when poorly controlled, diabetes can lead to
accelerated hardening of the arteries or atherosclerosis. When blood
flow to injured tissues is poor, healing does not occur properly. Any
trauma to the foot can increase the risk for a more serious problem to
develop.Exercise is good for poor circulation. It stimulates blood flow in
the legs and the feet. (American Diabetes Association, 2015)
Smoking

Smoking any form of tobacco causes damage to the small blood

vessels in the feet and legs. This damage can disrupt the healing
process and is a major risk factor for infections and amputations. The
importance of smoking cessation cannot be overemphasized. (Ferry,
2014)
Amputations
People with diabetes are far more likely to have a foot or leg
amputated than other people. Many people with diabetes have
peripheral arterial disease (PAD), which reduces blood flow to the feet.
Also, many people with diabetes have nerve disease, which reduces
sensation. Together, these problems make it easy to get ulcers and
infections that may lead to amputation. Most amputations are
preventable with regular care and proper footwear. (Elsevier, 2012)
Bacterial Infection
Foot infections are common in patients with diabetes and are
associated with high morbidity and risk of lower extremity amputation.
Diabetic foot infections are classified as mild, moderate, or severe.
Gram-positive bacteria, such as Staphylococcus aureus and betahemolytic streptococci, are the most common pathogens in previously
untreated mild and moderate infection. The diagnosis of diabetic foot
infection is based on the clinical signs and symptoms of local
inflammation. Infected wounds should be cultured after debridement.
Tissue specimens obtained by scraping the base of the ulcer with a
scalpel or by wound or bone biopsy are strongly preferred to wound
swabs. Imaging studies are indicated for suspected deep soft tissue
purulent collections or osteomyelitis. (Bader, 2008)
Veterans Health Administration Footcare Survey
The Veterans Health Administration Footcare Survey was
developed in 2001 and administered in eight VA medical centers after
obtaining Human Subjects approval. Questions on health transitions,
physical function, and overall health were derived from the SF-36 and
the Medical Outcomes Study. Relevant questions on foot-risk factors,
self-care behaviors and education were derived from the Diabetes
Quality Improvement Project Survey and supplemented by expert
opinion. Study team members, including clinical foot care experts,
survey design experts, and psychometricians then reviewed items for
structure and clarity before pilot testing the questionnaire with patient
focus groups. The final, machine-readable survey covers demographic,
general health and diabetes, diabetes education and foot self-care

information. The questions also probed barriers to foot self-care,

receipt of professional foot care, specialized footwear and satisfaction
with current foot care. (Olson, 2009)
Multiple dimensions of behavior were self-reported including foot
self-care, footwear use, and foot care-seeking behaviors. In addition, a
series of questions asked about foot care provided by clinicians, eg,
callus care. Foot care education questions were introduced using the
framing question, How much have you ever been taught about taking
care of your feet? Responses were scored on a 4-point ordinal scale
where 1 = Nothing at all; 2 = A little bit; 3 = Some, but would like to
know more; and 4 = Enough. The responses enough and nothing at
all were selected from the questions regarding self-reported foot care
education. Race was grouped into four categories: White (including
Hispanic), African American, Asian, and American Indian/Pacific
Islander. (Olson, 2009)
The Diabetes Quality Improvement Project
The Diabetes Quality Improvement Project (DQIP) is a coalition of
public and private entities formed in July 1997. The steering
committee, composed of representatives from four organizations, met
with the overall goal of establishing a set of diabetes-specific
performance and outcome measures that would allow for fair
comparisons of health care plans, stimulate quality improvement, be
based on scientific evidence, and yet be user-friendly to payers and
consumers. (McLaughlin, 2000)
Following a thorough analysis and discussion, the committee
formally adopted the original list of seven accountability measures:
percentage of patients receiving >1 HbA1c test/year; percentage with
the highest risk glucose level; percentage assessed for nephropathy;
percentage receiving a lipid profile once in 2 years; percentage with a
low-density lipoprotein cholesterol of <130 mg/dl; percentage with
blood pressure of <140/90 mm Hg; and percentage receiving a
periodic dilated eye exam, as well as two new measures: those
receiving an annual foot examination and those receiving counseling
on smoking cessation. In addition, the committee approved three
quality improvement measures: self-management education, medical
nutrition therapy, and interpersonal care (patient satisfaction).
(McLaughlin, 2000)
Diabetic Foot Care Overview
Diabetes mellitus (DM) represents several diseases in which high
blood glucose levels over time can damage the nerves, kidneys, eyes,
and blood vessels. Diabetes can also decrease the body's ability to
fight infection. When diabetes is not well controlled, damage to the

organs and impairment of the immune system is likely. Foot problems

commonly develop in people with diabetes and can quickly become
serious.
With damage to the nervous system, a person with diabetes may
not be able to feel his or her feet properly. Normal sweat secretion and
oil production that lubricates the skin of the foot is impaired. These
factors together can lead to abnormal pressure on the skin, bones, and
joints of the foot during walking and can lead to breakdown of the skin
of the foot. Sores may develop.
Damage to blood vessels and impairment of the immune system
from diabetes makes it difficult to heal these wounds. Bacterial
infection of the skin, connective tissues, muscles, and bones can then
occur. These infections can develop into gangrene. Because of the poor
blood flow, antibiotics cannot get to the site of the infection easily.
Often, the only treatment for this is amputation of the foot or leg. If the
infection spreads to the bloodstream, this process can be lifethreatening.
People with diabetes must be fully aware of how to prevent foot
problems before they occur, to recognize problems early, and to seek
the right treatment when problems do occur. Although treatment for
diabetic foot problems has improved, prevention - including good
control of blood sugar level - remains the best way to prevent diabetic
complications.
People with diabetes should learn how to examine their own feet
and how to recognize the early signs and symptoms of diabetic foot
problems. They should also learn what is reasonable to manage routine
at home foot care, how to recognize when to call the doctor, and how
to recognize when a problem has become serious enough to seek
emergency treatment.
Sources:
World Health Organization , 2014
Department of Health, 2013
Ramon Martinez. (2013). Prevalence of Diabetes in the World, 2013.
Philippine Practice Guidelines on the Diagnosis and Management of
Diabetes Mellitus (2014)
Robert Ferry Jr., MD. Diabetic Foot Care.
Sue McLaughlin. The Diabetes Quality Improvement Project. Diabetes
Spectrum
Volume 13 Number, 2000, Page 5
American Diabetes Association. Diabetic Foot Complications. 2015

Olson, J. M., Hogan, M. T., Pogach, L. M., Rajan, M., Raugi, G. J., &
Reiber, G. E. (2009). Foot care education and self management
behaviors in diverse veterans with diabetes. Patient Preference and
Adherence, 3, 4550.
Bader, Mazen. Diabetic Foot Infection. (2008)