Peter Lazzarini Preventable Diabetes Amputation Interview

Peter Lazzarini Preventable Diabetes Amputation Interview

As many as 3,600 diabetes-related amputations that occur in Australia are "entirely preventable" and result from inadequate monitoring of the disease, according to new analysis by medical experts.

A national diabetes conference has been told that around 85 per cent of harrowing amputations could be avoided each year if more was done at a national level to prevent risk factors, monitor those at risk and respond to diabetes nerve and circulation damage that affects the legs and feet.

"Monitoring individuals at increased risk is crucial so early ulcer detection and treatment can occur - translating to reduced amputations," said Associate Professor Paul Wraight who heads the Diabetic Foot Unit at The Royal Melbourne Hospital.

Australia has one of the highest rates of lower limb amputations in the developed world with around 85 diabetes sufferers having a foot or part of their leg removed each week.

"Feet are often the forgotten complication of diabetes. Unlike kidney disease and cardiovascular disease, there aren't national networks and protocols established to oversee individuals with diabetes related foot complications," A/Prof Wraight said.

Assoc. Prof Wraight believes a hospital and community-based care program focused on diabetic foot health, involving GPs, specialists, nurses and allied health professionals, may hold the key to reducing lower limb amputation among people with diabetes.

The introduction of a multidisciplinary foot care program at The Royal Melbourne Hospital has seen the number of individuals with diabetes having their feet examined rise from 35 to 100 per cent. "Amputation rates dropped immediately following the introduction of the program, with amputation rates down 60% by the end of the first year," said Assoc. Prof Wraight.

"We are working to roll-out this model of care to other hospitals around the country, but increased funding is desperately needed," he said.

"It's a simple proposition - ignore the feet and diabetes will continue to be the leading cause of lower limb amputation. By focusing on the feet of individuals with diabetes thousands of amputations can be prevented."

Peter Lazzarini, who is a Senior Research Fellow at the Queensland University of Technology, explained that "it wasn't until the last few years when we began to analyse the data against world standards that we realised there was a real problem with the number of amputations".

Global data indicates that men have lower limbs removed at twice the rate of women. Men are also more likely to develop nerve and circulation problems at a younger age and that these diabetes related conditions can then progress more rapidly to amputation.

Australia's indigenous population is also at higher risk of diabetes-related amputation, with a ten times higher rate of hospitalisation than non-indigenous Australians.

The majority of lower limb amputations are performed on those who have had poorly controlled diabetes for more than 10 years which has led to nerve damage, poor circulation and foot ulcers and/or infection.

"The key to avoiding amputation in the first instance is blood sugar control," said Mr Lazzarini. "In addition, people should have an annual diabetes foot check-up to assess damage to the nerves and identify whether vascular disease has developed."

"For those who have developed nerve damage or vascular disease it is important that they see their doctor and podiatrist at least every few months and check their feet daily for signs of foot ulcers or infection," he concluded.

"If there is failure to respond to treatment, referral to a multidisciplinary foot team is critical," said Assoc. Prof Wraight.

Interview with Peter Lazzarini

Peter Lazzarini is a Senior Research Fellow at the Queensland University of Technology.

Question: Can you talk about why diabetes-related amputations occur?

Peter Lazzarini: Diabetes amputations are one of the major complications of diabetes and diabetes' resultant abnormal blood glucose levels. High blood glucose levels (that aren't controlled) significantly increase the risk of people developing macrovascular and microvascular complications like heart disease, stroke, kidney failure, blindness and amputation. The reason diabetes causes a significant proportion of amputations (around 60% of all amputations in Australia in the study we've recently published) is that it causes damage to the nerves and blood vessels in the peripheries of the body if blood glucose levels are too high and unchecked. As the feet are the most peripheral parts of our bodies they tend to be affected first and with the most severity, plus, we place a lot of pressure on our feet by walking on them and damaging them more readily anyway. This gives people a very high risk of getting sores in their feet, called foot ulcers, that they may not feel and can easily get infected and then may lead to an amputation. The studies show these foot ulcers precede 85% of diabetes amputations so if we can prevent the foot ulcers we can prevent most amputations.

So to put it simply people with diabetes that have high glucose levels over a number of years, have very high risks of losing feeling in their feet (nerve damage called 'peripheral neuropathy') and circulation to their feet (blood vessel damage called 'peripheral vascular disease'). When people can't feel their feet, or any damage to their feet, they tend to get more problems like cuts, scratches and wounds they can't feel or didn't even know happened until they see blood on the floor or smell a wound. Now if they have circulation damage on top of this their bodies find it also difficult to heal up the wound which provides a really good environment for infection. And if the infection remains unchecked it can become severe and can then lead to needing an amputation. All this can happen without people experiencing any pain, but in someone without diabetes the wound and any infection would be very painful and people would usually get off to the doctor to do something about it.

So most of the problems really occur because people with diabetes can lose feeling in their feet and they lose what we sometimes call the 'gift of pain'. So they often say that these people with diabetic neuropathy can wear a hole in their foot, like you or I might wear a hole in their sock ... their bodies just can't tell them anything is wrong in their feet, so they are less inclined to do anything to fix the wound etc as they mightn't even know.


Question: How are as many as 85% of diabetes-related amputations preventable?

Peter Lazzarini: Well firstly, as I mentioned about 85% of diabetes amputations are usually preceded by a foot ulcer, with or without infection. So if we can protect feet by self-checking, wearing well-fitting footwear and getting check-ups we can prevent a lot of ulcers and in turn a lot of amputations. However, the studies across the world consistently show, most of the reductions come from having the right health systems working and talking together. Studies in the UK, US, Europe, Asia and now Australia, show if we have the right health systems, health professionals and treatments in place that diabetes amputation rates drop dramatically ... by up to 85% in some studies and in the studies we've done in Australia by up to 65%. These "right systems" mean we need people being screened annually by their GP or podiatrist, if they find a nerve or circulation problem they should be referred to an expert podiatrist to care for their feet every few months to prevent a foot ulcer and if they end up with a foot ulcer they are then immediately referred to a multi-disciplinary foot team or clinic to heal that wound quickly and prevent an amputation.

Arguably the most important facet of the system to reduce amputations is this 'multi-disciplinary foot team' to heal ulcers quickly. These teams usually include a doctor and podiatrist at the very least working together, but also should include a nurse, orthotist and surgeon working in tandem to help heal up that wound as quickly as possible. We need all the skills of the those health professionals to heal the wound as quickly as possible. We've found no single health professional has all the skills to heal the wound up quickly themselves. For example, we need the doctor's skills to deal with the glucose levels, blood pressure, and cholesterol levels and antibiotics for any infection and we need the podiatrist's skills in wound dressings, getting rid of any dead skin and tissue in the wound and prescribing the right moonboot or cast to take pressure of the wound. If the wound is more serious the podiatrist and doctor then need the skills of expert wound nurses or diabetes nurses, orthotists for footwear and surgeons to maybe do a procedure that will help prevent an amputation or even perform an early minor amputation to prevent a larger amputation.


Question: How does the Australian diabetes-related amputations rate compare with other countries?

Peter Lazzarini: Not too well unfortunately. Reports show we have the second worst diabetes amputation rate in the developed world behind the US. For example the average number of diabetes amputations that occur in every 100,000 people in the developed world each year now is around 12 per 100,000 (that means on average that 12 people will have an amputation in a town or city of 100,000 people each year). In Australia our rate in 1997 was already 14, in 2004 was 17 and in 2008 was 18 and we now estimate it is 20. This is compared to the UK which is around 7-9 and most of Europe which is 11-12. Out of interest the US has rates of over 30 and we think this is because of their disjointed health system, and potentially rates of diabetes and obesity, especially compared with the more collaborative health system in the UK.

So our rate can certainly be improved and this improvement will come with ensuring we have the right health systems in place to make sure we can treat people with diabetes nerve damage, circulation damage or a foot wounds early and effectively with the right health professionals before they need amputation. Plus, then monitoring them to make sure their foot ulcer doesn't return by protecting their feet with the right shoes, checks, assessments and treatments. We find that diabetes foot disease responds really well when all the parts of the system and health professionals in the system communicate and work well together. That means the GP knows when to refer to the podiatrist and the podiatrist and GP know when to refer to the multi-disciplinary team and all these guys have access to the right treatments like wound dressings, moonboots, casts and footwear.


Question: One person every five minutes is diagnosed with diabetes; what behavioural changes can assist people to prevent diabetes?

Peter Lazzarini: Most people can reduce their risk of developing diabetes by living a healthy lifestyle, that means eating a healthy diet (for example the 2 and 5 serves of fruit and veggies and a diet low in fat) and being active (for example over 30 mins walking on most days). Unfortunately our lifestyle these days makes it much easier to eat quick high fat food and not be active.


Question: What behavioural changes can assist people to manage diabetes?

Peter Lazzarini: Leading a healthy lifestyle of good diet and increased activity is imperative, plus, seeing your GP and Diabetes Educator to ensure you have the right medications to help your body to control your blood glucose levels, blood pressure and blood lipids or cholesterol. If the GP or Educator is having trouble controlling your blood glucose levels you should be immediately referred to an endocrinologist who is the expert on blood glucose control to look at other medication mixes and/or insulin. But again people can really help their bodies out by giving it the right food or fuel and burning that fuel effectively (glucose) with exercise.


Question: What is blood sugar control?

Peter Lazzarini: Blood sugar or blood glucose is the level of sugar in your blood. We all need glucose in our blood to live, but we need it at safe levels. Glucose is the sugar that essentially comes from the food you eat and in people without diabetes their bodies can control the level of glucose in their blood naturally by using insulin to help store glucose in the cells in the body for use later on with activity. However, in people with diabetes their bodies either find it hard to produce enough insulin to store this glucose in their cells or their insulin is a little faulty and isn't able to help store the glucose in the cells as it used too. When the glucose can't be stored properly anymore then it is allowed to float around in your blood at high concentrations and it's these high concentrations which damages the blood vessels etc. People then usually need medications either to help fix the faulty insulin or sometimes faulty storage cells or they just need more insulin to store the sugar and need injections of insulin.


Question: What is the importance of an annual diabetes foot check-up?

Peter Lazzarini: It is critically important to have an annual foot check when you have diabetes as you should have your eyes, kidneys and heart checked. The annual foot check can be performed quickly and painlessly by your GP, podiatrist or nurse. They will check your feeling in your feet with a little instrument that looks like a piece of fishing line, and check your circulation getting to your feet by checking the pulses in your feet. They will also inspect your feet to spot areas that might present future problems like bunions, wounds etc. Then as mentioned before if the GP or podiatrist identify a nerve, circulation or wound problem they should be referring you off to people to look at that and seeing you more often to check your feet. It's important to note though that around 60-70% of people with diabetes wont develop any nerve or circulation damage, and therefore, their risk of a foot ulcer or amputation is low and pretty much as low as someone without diabetes, however, around 15% of people with diabetes will develop a foot ulcer in their lifetime and the rest will have this nerve or circulation damage without a foot ulcer. So that annual diabetes foot check to work out if you have foot damage and what you need to do about it is vitally important and may also give you peace of mind for a year at the very least.


Question: What other monitoring processes need to be followed for those who have diabetes?

Peter Lazzarini: People with diabetes need to ensure their blood glucose levels, blood pressure and blood lipids are in check and at safe levels. So they really need to work with their GP and other health professionals if they are finding it difficult to control these levels. Furthermore, the guidelines suggest that people with diabetes should pretty much have annual checks for their risk of developing complications such as a heart disease, kidney disease, eye disease and foot disease. And if any problems are identified they should be referred to the right health professional to help them reduce their risk, this may mean a diabetes educator, dietician or exercise physiologist to help with their lifestyle factors of diet and activity, it may mean a podiatrist for their foot complications, an optometrist or ophthalmologist for their eye complications, renal nurse or nephrologist for the kidneys, cardiologist for their heart complications and looking after all this should be the endocrinologist who is the expert in complex diabetes management.


Question: Why are men having lower limbs removed at twice the rate of women?

Peter Lazzarini: This is a really good question. The short answer is we don't exactly know, however, the long answer is we think it is a combination that males have a lot of 'slightly mores' than females. And what I mean by that is there are slightly more males than females diagnosed with diabetes, males tend to get diabetes neuropathy or nerve damage slightly more quickly than females (and one reason seems to be that this nerve damage happens to nerves that are longer, and therefore, in people who are taller which is often males), females' sex hormones like oestrogen tend to protect their blood vessels more, and therefore, males get slightly more blood vessel damage than females, plus, we suspect that males tend to not look after themselves as well as perhaps we should before it's too late. So overall we think it's because males get slightly more diabetes, more and quicker nerve damage and circulation damage which means they have much more chance of getting a foot ulcer overall and then the 'she'll be right mate' attitude means they may not get off to the doctor or podiatrist as quickly as they should until it's too late ... in this instance the saying should probably be "she won't be right mate" and get off and do something quickly.

Interview by Brooke Hunter