Addressing Diabetes Control: What Clinicians Must Know
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 • Physical Activity (PA): Defined as bodily movement produced by the contraction of skeletal muscles that substantially increases energy expenditure, whereas exercise is recognized as a subset conducted with the intention of developing physical fitness (ie, cardiovascular, strength, and flexibility training).12 A powerful modality that must be coordinated with the medication and nutrition regime. When added to insulin or oral agents, can cause uncomfortable and/or life-threatening hypoglycemic events. Associated complications (eg, diabetic retinopathy, diabetic neuropathy, or diabetic nephropathy) may necessitate certain precautions and contraindications for PA. Where there are musculoskeletal, neuromuscular, or cardiovascular impairments, a referral to a physical therapist may be appropriate.9 • Pharmacological Management: The drug armamentarium for glycemic control for patients living with DM is fairly large and growing as impairments related to DM are better understood. Different drugs and combination therapies address different pathophysiological mechanisms. The management of type 1 DM (T1DM) and T2DM is different, as these are different diseases with the similar outcome of hyperglycemia.8 Medications comprise oral classes and injectables, including insulin. • Monitoring of Glycemic Status: As performed by patients and healthcare providers, a cornerstone of DM care. Results are used to assess efficacy of overall management, to guide adjustments to MNT and exercise, to determine effectiveness of the medical plan regarding medications, and to determine how illness is affecting BG status — all for the purpose of achieving the best possible BG control.13,14 The two techniques most frequently used to assess glycemic control and the effectiveness of various interventions are patient self-monitoring of BG (which may be performed when needed by a healthcare provider, family member, or other caregiver for those who are homebound or in nursing facilities) and a laboratory test, the glycosylated hemoglobin or hemoglobin A1c (A1c) test, to measure average glycemia over the preceding 2-3 months to determine overall efficacy of the DM plan of care.9
Challenges Faced by Patients
There are many challenges in providing care for this patient population. Notable issues include those related to: 1) Education. Patients require education for self-management of DM and wound care. Many people with chronic wounds and DM do not have all of the information they need to adequately manage their disease, especially in the presence of a chronic wound that places more stress on them both psychologically and physiologically. The standard of care is referral to a comprehensive DSME/T program;1,15 however, many patients do not have access to an education center, nor do their primary care providers have the time or resources to adequately educate them regarding their DM management. Such individuals thus present to the wound clinic with a critical deficiency in their ability to manage their disease. This deficiency is often a contributing factor to the development of the wound and becomes a hindrance to healing. 2) Depression and burnout. Many people living with DM experience depression.16 With depression, DM self-management can become severely compromised, depending on the individual’s coping abilities, presenting more challenges for healing. Diabetes conveys psychological, social, and financial burdens on the affected individual. The wound brings additional psychological, social, and financial burdens.8 Burnout (ie, a sense of emotional exhaustion, depersonalization, reduced personal accomplishments) is a potential consequence of DM. Wound care providers can also become burned out from patient care, especially when there’s a perception that the patient is not self-managing the DM or the wound, thereby “sabotaging” the care plan. The psychosocial impact of DM is life-altering, especially with the addition of chronic complications that frequently accompany DM, including wounds, which patients and caregivers may consider unsightly and too odiferous. There are no easy answers or rote formulas for these challenges. Providers must simply give the most comprehensive support within their means.8 3) Adherence. Patient adherence to the overall disease management plan is critical. However, before labeling someone as “non-compliant” or “non-adherent,” the wound care clinician should assess whether the patient has a functional DM management plan individualized to his or her needs and whether the patient knows how to self-manage the DM, providing an appropriate referral as needed. Doing so promotes an environment in which the wound can close and go on to full maturation and healing. Many people living with T2DM do not receive adequate education for successful self-management, yet they are blamed for being non-adherent. Provide a referral for DSME/T if necessary and where possible, then provide ongoing monitoring of the person’s success with DM self-management as the wound is managed in the clinic. Provide encouragement, with empathy and understanding of the difficult task these patients face. Describe DM self-management as a lifelong process, and help the patient understand the benefits, including improved wound healing, that make the hard work worthwhile. This approach promotes rapport and open communication.
Wound Care Clinician’s Role
The initial examination of the patient and wound should include a basic assessment of the DM management plan. The following questions are some intake components to consider: • Have you had a series of DM self-management classes? How long ago? (If not, then a referral is indicated.) • What medications do you take for DM? List the name and dose of each medication. Note: Sometimes a person with T2DM is further along in the disease process of beta-cell failure than when he or she first started treatment for DM. Because T2DM is progressive, lifestyle management or oral medications initially prescribed may no longer provide the control they once did. The wound care clinician may recognize or suspect the medications are not providing needed coverage. Thus, a referral is necessary for evaluation of the need to add another oral medication or start insulin, especially if the patient is not having the DM regularly evaluated by his or her primary care practitioner. • Do you take your DM medications regularly without fail? If not, how often do you take them? Note: Ensure that this question is not judgmental; just try to get the facts. People who are on fixed or low incomes may take their medications sporadically to try to make them last longer. Older people may become confused about medication regimes or embarrassed to admit they need help. The wound care clinician may be the first to recognize mental status changes or signs of abuse and/or neglect that impact self-management. Adherence or non-adherence is often a complex issue reflecting other, underlying areas of concern. Other areas for targeted assessment of the patient’s DM self-management include self-monitoring of BG, nutrition and hydration, and PA. Clinicians should keep the DM-related assessment manageable and remember their role in assessing the success of the patient’s self-management is paramount for optimal wound healing outcomes.
1. American Diabetes Association. Standards of Medical Care in Diabetes—2012. http://care.diabetesjournals.org/content/35/Supplement_1/S11.fullInterna... Diabetes Federation. Accessed May 30, 2012. 2. IDF Diabetes Atlas. www.idf.org/diabetesatlas. Accessed May 30, 2012 3. Unwin N, Marlin A. Diabetes action now: WHO and IDF working together to raise awareness worldwide. Dia¬betes Voice. 2004;49:27-31. 4. CDC. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2011. www.cdc.gov/diabetes/pubs/factsheet11.htm. Ac¬cessed May 30, 2012. 5. National Diabetes Education Program, US Department of Health and Human Services. Overview of Diabetes in Children and Adolescents. http://ndep.nih.gov/media/youth_factsheet.pdf. Accessed May 30, 2012. 6. Blakytny R, Jude E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med. 2006;23:594-608. 7. Falanga, V. Wound healing and its impairment in the diabetic foot. Lancet. 2005;366:1736-1743. 8. Scarborough P. Diabetes and wound care. In: McCulloch JM, Kloth LC, eds. Wound Healing: Evidence-Based Man¬agement. 4th ed. Philadelphia, PA: FA Davis Company; 2010:231-247. 9. Scarborough P. Diabetes across the physical therapist practice patterns. In: Hardage J, ed. Focus: Physical Therapist Practice in Geriatrics 2011. Madison, WI: Section on Geriatrics; 2011. 10. AADE. AADE7M Self-Care Behaviors. Diabetes Educ. 2008;34:445-449. 11. Franz MJ, Bantle JP, Beebe CA, et al. Evidence-based nu¬trition principles and recommendations for the treatment and prevention of diabetes and related complications. Diabetes Care. 2002;25:148-198. 12. Colberg SR, Sigal RJ, Fernhall B. Exercise and type 2 dia¬betes: the american college of sports medicine and the american diabetes association: joint position statement executive summary. Diabetes Care. 2010;33:2692-2696 13. Goldstein DE, Little RR, Lorenz RA, Malone JI, Nathan DM, Peterson CM. Tests of glycemia: position statement. Diabetes Care. 2004;27(suppl 1):S91-S93. 14. Austin MA, Powers MA. Monitoring. In: Mensing C, ed. The Art and Science of Diabetes Self-Management Education Desk Reference. 2nd ed. Chicago, IL: American Associa¬tion of Diabetes Educators; 2011:167-193. 15. Funnell MM, Brown TL, Childs BP, et al. National standards for diabetes self- management education. Diabetes Care. 2011;34 (Suppl 1);S89-S96. 16. American Diabetes Association. Depression. www.diabetes.org/living-with-diabetes/complications/mental-health/depres.... Accessed May 30, 2012. Pamela Scarborough is director of public policy and education for American Medical Technologies, Irvine, CA. Jason Hardage is assistant professor in the department of physical therapy at Texas State University-San Marcos.