Addressing Diabetes Control: What Clinicians Must Know

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Pamela Scarborough, PT, DPT, MS, CDE, CWS, CEEAA & Jason Hardage, PT, DPT, DScPT, GCS, NCS, CEEAA

  While many comorbidities have the potential to impact wound healing, this is especially true of diabetes mellitus (DM), a common disease among patients living with wounds. The impairments related to the disease state of DM affect all wound etiologies and impair all phases of healing. Healthcare professionals must understand the DM disease process and its implications in order to promote optimal wound healing. While another provider oversees the medical management and coordinates the team care of DM, the wound care clinician should ensure adequate control of the disease is met. This article provides an overview of DM epidemiology, its effects on healing, the clinical challenges it poses, and considerations for wound care clinicians. (For information on pathophysiology, consult other sources, including standards of care by the American Diabetes Association.1)

Epidemiology & Implications

  DM has been at epidemic levels worldwide for some time,2,3 having far-reaching implications for public health and healthcare systems. The statistics are, in all probability, underreported4 (see Table 1). Diabetes has a profound impact on health, comprising a leading cause of such secondary complications as heart disease, kidney disease, retinopathy, neuropathy, and lower-limb amputation. Making matters worse, younger people are acquiring type 2 DM (T2DM) as early as age 10.5 Accordingly, providers are seeing younger people experiencing DM-related complications, including wound healing issues. Current evidence demonstrates that DM inhibits all phases of wound healing via impaired function of the primary cells responsible for wound repair (ie, neutrophils, macrophages, and fibroblasts), frequently resulting in slow-healing or chronic, nonhealing wounds. In addition, there is decreased efficacy of cytokines and growth factors in people living with DM and accompanying hyperglycemia. The accumulation of advanced glycosolated end products, nitric oxide dysfunction, decreased insulin availability or increased insulin resistance, and altered homocysteine levels also contribute to the complex host of impairments that affect healing. Microvascular and macrovascular, neuropathic, immune function, biochemical, and hormonal abnormalities contribute to the altered tissue-repair processes in people with DM and hyperglycemia.6 One example of a DM-mediated impairment in wound healing is susceptibility to infection. Under normal conditions, during the coagulation phase, there is immediate fibrin plug formation as platelets aggregate at the wound site. The platelets release various growth factors and cytokines, which cause recruitment of inflammatory cells. However, in a hyperglycemic environment, there is a delay in fibrin plug formation, leaving the wound open to contaminants, in addition to a delay (and decrease) in the release of growth factors and cytokines, causing impaired recruitment of inflammatory cells. With this delay, the individual is prone to infection. In fact, people living with DM have more frequent infections than those without DM.6 Research in human and animal models has identified many of the changes that contribute to faulty wound healing at the molecular level. Additionally, focused research on the causes of and interventions for diabetic neuropathic foot wounds remains ongoing.7 While the underlying mechanisms of the effects of DM on healing have been extensively investigated over the past few decades, more work is needed to fully elucidate the complex, multifaceted pathophysiologic relationship between DM and defective healing.6,8

Medical Management & Team Care

  Diabetes management requires a team approach to patient-centered care, with the patient being an integral member of the team. While the medical team leader is the physician or advanced-practice nurse who uses input, education services, and treatment recommendations from other healthcare providers, daily disease management is provided by the patient (or caregiver when impairments prohibit self-management).8 Following are the basic elements of a well-rounded DM management program:

    • Diabetes Self-Management Education/Training (DSME/T): Defined by the American Association of Diabetes Educators as a collaborative process through which people living with or at risk of DM gain the knowledge and skills needed to modify behavior and successfully self-manage the disease and its related conditions (see Table 2).10 Aims to achieve optimal health status, better quality of life, and reduced healthcare costs by incorporating the needs, goals, and life experiences of the patient while evidence-based standards of care are met. Informed decision-making and problem-solving are crucial.10 Standards of care require patients receive self-management education upon diagnosis.1,15

    • Medical Nutrition Therapy (MNT): The preferred term when referring to nutrition interventions, as opposed to “diabetic diet,” “diet therapy,” or “dietary management.” A comprehensive approach to eating that the patient learns to employ for optimal control of blood glucose (BG), with weight control a secondary outcome. Goal is “to assist and facilitate individual lifestyle and behavior changes that will lead to improved metabolic control.”11

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