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Diabetic foot ulcers: How to reduce your risk

Diabetic foot ulcers: How to reduce your risk

If you’ve been diagnosed with diabetes, you’ll already know you’re at risk of having problems with your feet. But why does having diabetes make you susceptible to foot ulcers, and what can you do to keep your risk as low as possible?
 
According to Patient UK, an estimated 10 per cent of people with diabetes will have a diabetic foot ulcer – also known as diabetic foot – at some point in their lives (i). A survey carried out in England and Wales called the National Diabetes Footcare Audit suggests certain factors make you more likely to develop diabetic foot ulcers, including the following:
 

  • 87 per cent of people with diabetic foot ulcers have type 2 diabetes as opposed to type 1 diabetes

  • 70 per cent are male

  • 92 per cent are of white ethnicity

  • 57 per cent have above-ideal blood sugar levels (58mmol/mol or higher) before getting an ulcer


A foot ulcer is an open wound or sore on your foot that’s slow to heal. They can affect any part of your feet but are most common under your big toes and on the balls of your feet.
 
The problem with diabetic foot ulcers, however, is that they can become infected. If this happens you’ll need treatment, usually with medication and dressings. And if the infection becomes severe you may even need surgery. In fact, in the very worst cases, a foot ulcer can get so bad that the foot and sometimes also part of the leg has to be amputated (according to the charity Diabetes UK, diabetes causes one amputation every hour in the UK (iii)).
 
Thankfully you can prevent most foot problems by taking good care of your feet and keeping your blood sugar levels under control. But why does diabetes cause foot problems in the first place?
 

What causes diabetic foot ulcers?

 

Nerve damage


There are a few reasons why people with diabetes are more prone to foot ulcers, one of which is that having high blood sugar levels – even if they’re only mildly high – can over time damage some of your nerves. Called diabetic neuropathy, this can cause pain, tingling, and a loss of sensation in your feet, and is more likely to happen if you’re older or you’ve had diabetes for a long time. Not having much or any sensation in your feet means if you get a small cut, sore, or blister you may not realise it. And if you don’t check your feet regularly, any of these can become worse and often quickly develop into an ulcer.

Lots of things can cause cuts or sores on your feet, including:
 

  • Wearing badly fitting shoes that rub your feet

  • Walking barefoot

  • Having cracked, dry skin or calluses

  • Having a foot problem such as a bunion

  • Having leg problems that affect how you walk


People with diabetes also have an increased risk of developing a condition called peripheral arterial disease, which is where your blood vessels (arteries) become more narrow than normal. Since the blood vessels in the legs are often affected, it means you can have poor circulation in your feet. This in turn can make any cuts or sores on your feet slow to heal, and thereby more prone to developing into ulcers. If you have poor blood supply to your feet, they’re also more likely to become damaged.
 
Besides having diabetes, things that can make you more susceptible to developing peripheral arterial disease include smoking, having high cholesterol, and high blood pressure.

Meanwhile, if you have problems with your eyesight or limited mobility they can also make it hard for you to spot problems with your feet (limited mobility, for instance, can stop you from reaching your feet, which means you won’t be able to inspect them or take care of them very well).
 
If you’ve previously had a diabetic foot ulcer or an amputation, this too increases your risk of having another foot ulcer. 
 

How do I know if I have a diabetic foot ulcer?


For people with diabetes being aware of the signs of a foot ulcer is essential, since the earlier you treat it, the faster it will heal. According to Diabetes UK, the following are signs of foot problems that need attention as soon as possible (iv):
 

  • Numbness or a tingling sensation 

  • Pain that feels like burning

  • Dull ache

  • Shiny, smooth skin on your feet 

  • Hair loss on your legs and feet

  • Loss of feeling in your feet or legs

  • Feet that are swollen

  • Feet that don’t sweat

  • Wounds or sores that don’t heal

  • Wounds, sores, cuts or blisters that you can’t eel

  • Cramp in your calves while resting or walking

  • Feet that have changed shape or colour

  • Hot or cold feet

  • Unpleasant smell coming from a foot wound


If you notice any of the above it’s important to get your feet checked out by your GP, your diabetes nurse or another health professional who’s involved in your diabetes care. Even if the problem seems small or insignificant, it could become serious very quickly, so get professional medical advice as soon as you can.
 

Charcot foot

 

What is Charcot foot?

 

Charcot foot is a serious foot complication affecting people with diabetes that can lead to the development of a foot ulcer. If you have diabetic neuropathy it can make you more likely to develop Charcot foot, the symptoms of which include:
 

  • Swelling

  • Change in shape

  • Heat (the affected foot feels warmer than the other)

  • Change in skin colour


Charcot foot develops when your foot becomes injured – if you break one or more bones, for instance – but you don’t realise it because you don’t feel any pain. If you continue to walk and put pressure on your foot, the bones and joints can change shape, making your foot swollen, red, hot and misshapen. Once this happens, your risk of developing a foot ulcer becomes higher.
 
If you notice any of these signs, take the weight off your affected foot straight away and consult your GP or another health professional involved in your care as soon as you can.
 

Checking and caring for your feet if you have diabetes


Checking your feet on a daily basis is important if you have diabetes, particularly if you have reduced sensation in your feet and can’t feel when a problem might be developing. Checking daily may sound like a bit of a chore, but it’s a good idea because it helps you to get to know your feet really well, making you more likely to spot any changes or potential problems quickly. Try making a foot check part of one of your usual routines – for instance, you may want to check your feet first thing in the morning or last thing at night.
 

  1. First take your shoes and socks off. Feel both your feet to get an idea of the temperature of the skin – they shouldn’t be either hot or cold, and they should both feel the same temperature.

  2. Take a really good look at your feet and check for areas of thick, hard skin as well as any blisters, cuts or other sores. Notice if there are any changes in their shape or colour. If you have difficulties reaching the soles of your feet, try using a mirror. If, however, you have problems with your vision, try asking someone you live with or a friend or carer to check your feet for you.

  3. Make a point of checking between your toes too – keep a look-out for any dry, flaky or cracked skin (including athlete’s foot, which can cause flaky skin and cracks between your toes).

  4. Check your toenails – are they too long or digging into your skin?

 
If you don’t have reduced sensitivity in your feet, it’s still a good idea to have a regular check to find out whether or not a problem could be developing. Ideally, this should be done with another person who should very lightly touch the big toe, middle toe and little toe of each of your feet in turn with their index finger. All you have to do is – while keeping your eyes shut – say whether they are touching a toe on your right or left foot. If you identified the wrong foot when two or more of your toes were touched, see your GP for a full foot examination.
 
There’s more information about the toe touch test including a video on how to do it at diabetes.org.uk/.
 
Checking your feet yourself regularly is a great way to help prevent foot ulcers. However, you should also have an annual foot check. Foot checks are usually carried out at your GP’s surgery as part of your annual diabetes checks, so if you need more information speak to your doctor.
 

Foot care basics


Checking your feet is one of the steps towards helping prevent diabetic foot ulcers. Here are some other foot carefootcare tips that could help stop any problems developing:


• Wash your feet daily and dry them well but gently, taking care not to damage the skin between the toes.
 
• Moisturise your feet daily too as it can help prevent dry skin. Ask your GP or a member of your diabetes care team to recommend a moisturiser that would be best for you – medical moisturisers called emollients are often used, but a health professional can tell you which one you should use. Be careful when you moisturise your feet, as it’s important to avoid getting any cream between your toes. Also avoid using talcum powder, especially between your toes.
 
• If you have any corns, verrucas, calluses or other foot problems, don’t try to treat them yourself (corn plasters can, for instance, harm your skin). Anyone who has diabetes should have these and other foot problems treated by a foot specialist called a podiatrist (ask your GP for a referral if you don’t already have a podiatrist).
 
• Keep your toenails at a manageable length – though not too short – and in good condition. Rather than cutting them straight across, cut them by following the shape of the end of your toe. Avoid cutting into the sides of the nails though, as this could damage your feet or lead to the development of an ingrown toenail (if your toenails are digging into your skin, see a podiatrist to have them treated). Avoid using anything sharp to clean underneath and down the sides of your toenails.
 
• Choose well-fitting shoes that give your toes plenty of room. Try to avoid high heels, as they put a lot of pressure on your toes. Similarly, avoid slip-on shoes, sandals, flip-flops and shoes with pointed toes. When you buy a new pair, try breaking them in slowly before wearing them for an extended amount of time to avoid getting blisters.
 
• Check the insides of your shoes each time before you put them on – try to feel for anything that could cut or damage the skin such as rough edges or sharp little stones.
 
• Also avoid wearing shoes without socks – but make sure your socks aren’t too tight, especially around the ankle, as it could affect your circulation.
 

Keep your lifestyle healthy


Other things you can do to help reduce your risk of developing foot problems include:
 

  • Stop smoking (if you smoke it can affect your circulation, including the blood flow to your feet: ask your GP or diabetes nurse for advice about smoking aids such as nicotine patches, lozenges and gums that can help reduce nicotine cravings, but keep a close watch on your blood sugar levels while you’re using them since nicotine can affect your carbohydrate metabolism (v)). 

  • Eat healthily and stay active (ask a member of your diabetes care team for details if you’re not sure about what you should eat or how much or what type of exercise you should do). 

  • As well as keeping your blood sugar levels controlled, try to make sure your blood pressure and cholesterol levels are healthy too, as it can help reduce your risk of developing diabetic neuropathy and peripheral arterial disease. Check out the advice in our guides on blood sugar and cholesterol.

 

How do you treat a diabetic foot ulcer?


Checking your feet daily can help you spot the early signs of a diabetic foot ulcer. However, the signs aren’t always obvious and can be easily missed until the ulcer has become infected. If this does happen you may notice a stain on your socks or shoes that’s leaked from the ulcer, or an unpleasant smell coming from your foot. Other signs that suggest you may have a serious foot problem include redness, swelling and discolouration of the skin around the ulcer (including skin that’s turned black).
 
If you notice any of these things, in addition to the signs to look out for listed above, speak to your GP, diabetes nurse or podiatrist as soon as you can. If an ulcer has formed, you will need treatment to stop an infection developing or to prevent an infection getting any worse. Most diabetic foot ulcers can be treated at home with the help of your GP and other community-based health professionals. Treatment includes:
 

  • Resting the affected foot and taking pressure offof the ulcer as much as possible (by wearing special shoes, for instance).

  • Regular cleaning of the ulcer and surrounding skin and a protective dressing to cover the ulcer.

  • Removal of any hard skin that’s stopping the ulcer from healing as well as any other dead skin and tissue (debridement). 

  • A course of antibiotics to treat an infected ulcer and any skin surrounding it that’s also been infected. 


Some people may need hospital treatment for a foot ulcer, which includes:
 

  • A minor operation to drain the ulcer and clear the dead tissue if the infection is severe.

  • A minor operation to increase blood supply to the affected area by bypassing or widening the arteries.

  • In very severe cases, surgical amputation may be necessary.

 

Nutritional support for diabetes


Nutritional supplements should never be used as an alternative to conventional diabetes medicines or medical care. However, some may be helpful in supporting your immune system as it fights an infection (such as a foot ulcer, for instance). Certain supplements are thought to help with blood sugar control too, but if you have diabetes check with your GP before taking these or any other supplements, as having blood sugar levels that are too low can put you at risk of a serious complication called hypoglycaemia (hypo).
Find out more about hypos in our guide to diabetes

If you want to consider taking a supplement, a multivitamin and mineral product is a great place to start, as it can make sure you’re getting all the nutrients your body needs for overall good health. This can be particularly useful if your diet isn’t always as healthy as it should be. Discover further details about multivitamin supplements including which one may be the most suitable for you by reading our guide to multivitamins and daily requirements

Meanwhile other supplements you may want to consider include:
 

Cinnamon  

 
While it may taste delicious in apple pie, cinnamon is also one of the oldest remedies used in traditional Chinese medicine. It’s often recommended by natural therapists for people with type 2 diabetes, as there is some evidence it may help improve blood sugar levels (vi).
 

Alpha lipoic acid

 
This fatty acid is a powerful antioxidant and some studies suggest it may help control blood sugar levels (vii) as well as improve insulin sensitivity in people with type 2 diabetes (viii). Indeed alpha lipoic acid supplements have been used widely in Germany to treat diabetic neuropathy, and at least one study suggests it may well be effective (ix). However, if you have diabetes always consult your GP before taking alpha lipoic acid as it may boost insulin activity.
 

Magnesium

 
Some experts believe people who have diabetes also have low magnesium levels (x), possibly because diabetes or the medicines used to treat it may cause magnesium deficiency. Elsewhere researchers have discovered magnesium may help with blood sugar control (xi).
 

Turmeric

 
A well-known curry spice, turmeric contains a compound called curcumin that has several potential health benefits, including the ability to reduce blood sugar levels – though to date most studies have been carried out in animals rather than humans, which means the available evidence isn’t as strong as it could be. Some researchers, however, have studied the effects of taking curcumin in people with diabetic foot ulcers (xii). They found those taking the curcumin supplements experienced improved blood sugar level control, though they didn’t notice any significant improvement in wound healing.
 

High-strength fish oils

 
Omega-3 fatty acids – particularly EPA and DHA, the two main omega-3s found in oily fish such as salmon, trout, sardines and mackerel, as well as fish oil supplements – are widely considered helpful for general health and wellbeing, including regulating the immune system (xiii). Fish oil supplements are widely available, but vegetarians and vegans can get these beneficial omega-3 fats too by taking supplements that contain omega-3 oils derived from marine algae.
 

Fenugreek

 
Commonly used in Indian and Middle Eastern cuisines, fenugreek is both a herb (leaves) and a spice (seeds). The seeds have also been used traditionally as a medicine for centuries in some parts of the world (in Ayurvedic medicine, for instance). These days, herbal practitioners often recommend fenugreek seeds to people with diabetes, as it’s thought the seeds may help increase the body produce insulin. There is also some evidence fenugreek seeds may be helpful in controlling type 2 diabetes and reducing insulin resistance, though supporting studies to date are small in scale (xiv). However, don’t take fenugreek if you’re pregnant or breastfeeding.
 

Vitamin D

 
Best known for helping the body absorb calcium, vitamin D is also thought to play a part in regulating the immune system. Indeed, experts believe being deficient in vitamin D may be associated with an increased susceptibility to infection (xv).

Unfortunately, vitamin D deficiency is common in some countries including the UK, which explains why Public Health England advises adults and children over the age of one-year-old to consider taking a daily supplement containing 10mcg of vitamin D, particularly during autumn and winter (xvi). However if your skin is rarely exposed to the sun – if you spend most of your time indoors, for instance, or if your skin is always covered when you’re out and about – you may also want to think about taking vitamin D throughout the year. People with dark skin from African, Afro-Caribbean and South Asian backgrounds should consider taking vitamin D all year round too, PHE advises.

The recommended form of vitamin D is vitamin D3 or cholecalciferol, as it the natural form of vitamin D the body makes when it’s exposed to sunlight. Vitamin D3 supplements are available in tablet form, and now you can get them in veggie-friendly drops too. However most vitamin D3 supplements are made from the fat of lamb’s wool, which means they’re unsuitable for vegans. The good news is that these days vegan vitamin D3 supplements sourced from lichen are more widely available.
 

High-strength anthocyanidins

 
Found in dark-skinned fruits such as blueberries, cranberries, raspberries, blackberries and red grapes – as well as vegetables such as red cabbage, red onions and aubergines –  anthocyanidins and their derivatives anthocyanins are potent antioxidant compounds. They may be useful for people with diabetes as they help strengthen and repair the walls of veins and capillaries by protecting collagen in the body (collagen being the structural protein that gives blood vessels their strength).
 
Anthocyanidins are also available in supplement form (choose a product that combines anthocyanidins with vitamin C, as vitamin C supports the body’s ability to produce collagen).
 
Foot care is important for anyone who has diabetes. But while it may seem like a big commitment, taking care of your feet can help prevent problems in the long term. This guide gives you a good idea of the steps you should take to keep your feet healthy. It also shows how to spot any potential problems early, which can help stop them from developing into anything serious. Meanwhile, you can read our guide to common foot problems as well as many other health and wellbeing issues in our pharmacy health library.
 


References:

(i) Available online: https://patient.info/doctor/diabetic-foot
 
(ii) Available online: https://www.diabetes.org.uk/resources-s3/2017-09/NDFA_EasyRead17%20FINAL.pdf
 
(iii) Available online: https://cdn.shopify.com/s/files/1/1922/6045/files/Diabetes_and_looking_after_your_feet_for_web_6ec78309-b1c1-471e-be15-99184b252dcb.pdf?v=1610532172
 
(iv) Available online: https://www.diabetes.org.uk/guide-to-diabetes/complications/feet/serious-foot-problem
 
(v) Available online: https://www.royalfree.nhs.uk/services/services-a-z/stop-smoking-service/nicotine-replacement-therapy/
 
(vi) Mang. B, Wolters. M, Schmitt. B, et al. Effects of a cinnamon extract on plasma glucose, HbA, and serum lipids in diabetes mellitus type 2. Eur J Clin Invest. 2006;36:340-344. Available online: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2362.2006.01629.x

Akilen. R, Tsiami. A ,Devendra. D, Robinson. N, et al. Glycated haemoglobin and blood pressure-lowering effect of cinnamon in multi-ethnic Type 2 diabetic patients in the UK: a randomized, placebo-controlled, double-blind clinical trial. Diabet Med. 2010;27(10):1159-1167. Available online: https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2010.03079.x

Pham. AQ, Kourias. H, Pham. DQ. Cinnamon supplementation in patients with type 2 diabetes mellitus. Pharmacotherapy. 2007 Apr;27(4):595-9.Available online: https://accpjournals.onlinelibrary.wiley.com/doi/abs/10.1592/phco.27.4.595

Kirkham S, Akilen R, Sharma S, Tsiami A. The potential of cinnamon to reduce blood glucose levels in patients with type 2 diabetes and insulin resistance. Diabetes Obs Metab. 2009 Dec;11(12):1100-13. Available online: https://dom-pubs.onlinelibrary.wiley.com/doi/10.1111/j.1463-1326.2009.01094.x
 
(vii) Poh. ZX., Goh KP., A current update on the use of alpha lipoic acid in the management of type 2 diabetes mellitus. Endocr Metab Immune Disord Drug Targets. 2009 Dec;9(4):392-8. Available online: https://www.eurekaselect.com/article/30245
 
(viii) Evans JL, Goldfine ID. Alpha-lipoic acid: a multifunctional antioxidant that improves insulin sensitivity in patients with type 2 diabetes. Diabetes Technol ther. Autumn 2000;2(3):401-13. Available online: https://www.liebertpub.com/doi/10.1089/15209150050194279
 
(ix) Ziegler. D, Ametov. A, Barinov. A, et al. Oral treatment with {alpha}-lipoic acid improves symptomatic diabetic polyneuropathy: The SYDNEY 2 trial. Diabetes Care. 2006;29:2365-2370. Available online: https://care.diabetesjournals.org/content/29/11/2365
 
(x) Elamin. A, Tuvemo. T. Magnesium and insulin-dependent diabetes mellitus. Diabetes Res Clin Pract. 1990;10:203-209. available online: https://www.diabetesresearchclinicalpractice.com/article/0168-8227(90)90062-X/pdf.

Barbagallow M, Dominguez LJ. Magnesium and type 2 diabetes. World J Diabetes 2015 Aug 25; 6(10):1152-57. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4549665/
 
(xi) Song. Y, He. K, Levitan. EB. Effects of oral magnesium supplementation on glycaemic control in Type 2 diabetes: a meta-analysis of randomized double-blind controlled trials. Diabet Med. 2006;23:1050-1056. Available online: https://onlinelibrary.wiley.com/doi/10.1111/j.1464-5491.2006.01852.x
 
(xii) Mokhtari M., Razzaghi R, Momen-Heravi M. The effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, double-blind, placebo-controlled trial. Phytother Research: PTR (2020) 35(4):2099–107. Available online: https://onlinelibrary.wiley.com/doi/10.1002/ptr.6957
 
(xiii) Gutierrez S, Svahn SL, Johansson ME. Effects of Omega-3 Fatty Acids on Immune Cells. Int J Mol Sci. 2019 Oct; 20(20): 5028. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6834330/
 
(xiv) Yilmaz Z et al. Supplements for Diabetes Mellitus: A Review of the Literature. Pharm Pract 2017 Dec;30(6):631-638. Available online: https://journals.sagepub.com/doi/10.1177/0897190016663070.

Kassaian N et al. Effect of fenugreek seeds on blood glucose and lipid profiles in type 2 diabetic patients. nt J Vitam Nutr Res 2009 Jan;79(1):34-9. Available online: https://econtent.hogrefe.com/doi/10.1024/0300-9831.79.1.34 .

Gupta A, Gupta R, Lal B. Effect of Trigonella foenum-graecum (fenugreek) seeds on glycaemic control and insulin resistance in type 2 diabetes mellitus: a double blind placebo controlled study. Physicians India 2001 Nov;49:1057-61. Available online: https://pubmed.ncbi.nlm.nih.gov/11868855/
 
(xv) Aranow. C. Vitamin D and the Immune System. J Investig Med. (2011 Aug).59(6): 881–886. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3166406

Hewisom. M. Vitamin D and immune function: an overview. Proc Nutr Soc. (2012 Feb).;71(1):50-6. Available online: https://www.ncbi.nlm.nih.gov/pubmed/21849106
 
(xvi) Available online: https://www.gov.uk/government/news/phe-publishes-new-advice-on-vitamin-d



 

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Disclaimer: The information presented by Nature's Best is for informational purposes only. It is based on scientific studies (human, animal, or in vitro), clinical experience, or traditional usage as cited in each article. The results reported may not necessarily occur in all individuals. Self-treatment is not recommended for life-threatening conditions that require medical treatment under a doctor's care. For many of the conditions discussed, treatment with prescription or over the counter medication is also available. Consult your doctor, practitioner, and/or pharmacist for any health problem and before using any supplements or before making any changes in prescribed medications.

 
 
Our Author - Christine Morgan

Christine

Christine Morgan has been a freelance health and wellbeing journalist for almost 20 years, having written for numerous publications including the Daily Mirror, S Magazine, Top Sante, Healthy, Woman & Home, Zest, Allergy, Healthy Times and Pregnancy & Birth; she has also edited several titles such as Women’ Health, Shine’s Real Health & Beauty and All About Health.

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