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Diabetes Mellitus (DM) presents as a global economic burden.1 In New Zealand, the prevalence for undiagnosed DM in Māori is higher than that for non-Māori, presenting as an opportunity to reduce significant mortality and morbidity in this population.2Complications arising from DM account for 20% of all deaths among Māori as compared to 4% in other New Zealanders.3 In one study, a high proportion of ulceration and amputation as a consequence of diabetes was observed in Māori.4 A further study reports that Māori were less likely to have on-going DM related-care due to poor perception of risk.5 Therefore for Māori, non-participation in ‘ongoing care' can intensify the problem due to the inability to detect or manage signs or symptoms of diabetes-related complications.6When undetected and untreated, the effect of foot problems in people with DM can progress rapidly and lead to morbidity and mortality from complications such as ulceration, gangrene and amputation.3,7 Appropriate screening ensures effective targeting of at-risk populations, early intervention, and surveillance of those detected with significant pathology.8-9Previous studies have reported on the major contributing factors to diabetic foot pathology, which often occurs in conjunction with other organ complications.8,10-11 Of these, neuropathy and mechanical stress are the key factors in predisposing the foot to increased plantar pressures effectively resulting in ulceration.10,12-13 Furthermore, peripheral arterial disease, infection, patient disability, maladaptive self-care behaviour and access barriers consequently place the foot at higher risk of a major complication.7,10,14The national introduction of the ‘Get Checked Programme' provided the first opportunity to gather information pertaining to glycaemic control, lifestyle behaviour, diabetes-related cardiovascular disease, renal disease, retinal screening, and foot screening data.3 However, the programme was not designed to identify the level of susceptibility of risk to the foot.The need to undertake an assessment that includes the identification of the level of risk was therefore required.3 The assessment should also indicate frequency of monitoring and classification of risk status, in order to implement effective management plans.Therefore, whilst it is clear that Māori are more significantly at risk of diabetes-related complications, data regarding characteristics and management for foot pathology is limited in this population.The aim of this study was to select Māori with Type 2 diabetes, who had either not received an annual ‘Get Checked' review or who presented with features of an at risk foot; and through the use a podiatric diabetic assessment tool, determine clinical and foot characteristics.Methods Study design—This study used a cross-sectional design and was undertaken in the Waitemata district, Auckland, New Zealand. The study was conducted between 2007 and 2008. Ethical approval was obtained from the Auckland University of Technology University ethics committee (07/198) for review prior to submitting to Northern Y ethics committee (NTY/05/08/055). Participants were recruited from two Māori Primary Health Organisations (PHOs) and identified by a data search using Medtech-32. A query build function was set up to include participants with T2DM; ≥18 years old; Māori; who had not received a national diabetes assessment for >12 months;3 had undetected pedal pulses, absence of sensation, previous history of peripheral vascular disease, or ulceration as determined by the ‘Get Checked' Programme.3 Two research investigators accessed electronic patient records. One investigator was responsible for initial contact with the participants via telephone to explain the aim of the study. Informed consent was obtained from all participants. Exclusion criteria included those who were not registered with the PHO; who had a below knee amputation or who attended regular podiatry appointments. Two experienced podiatric practitioners involved in working with Māori undertook all podiatric assessments. To ensure consistency between the two practitioners, each practitioner undertook a single training session prior to data collection. Demographic characteristics including age (years), gender, body mass index (kg/m2), disease duration (years) and medical conditions were recorded. Smoking status was also reported. Perception of risk, past history of foot or leg ulceration/amputation, past history of lower extremity revascularisation were also recorded. Clinical data including; serum glycated haemoglobin levels HbA1c and HbA1c >8% over a 6-month period; pharmacological management for DM (insulin, and oral hypoglycaemic agents), as well as regular (daily) and irregular (every other day) self-monitoring of blood glucose levels were collected. Foot risk status was recorded using a modified classification based on a previously published classification system.10 The podiatric diabetic assessment tool included a neurovascular, musculoskeletal and education component. The vascular assessment included a history of intermittent claudication.15 Pedal pulse assessment, visual identification of skin integrity, and ankle-brachial index (ABI) were obtained. The neurological assessment was based on the neuropathy signs (NDS) and symptom scoring system (NSS).16 The musculoskeletal assessment included the evaluation for limited joint mobility in the hands17 and feet. Lower extremity nail and skin conditions were also recorded.18 Participants were asked to report on self-care behaviours and self-knowledge which included daily foot inspection, application of skin moisturises, avoiding situations of risk (avoiding heaters or walking barefoot); as well as understanding the benefits of good glycaemic control, and foot problems associated with neuropathy.3,8,19 Participant's responses were recorded as either ‘yes' or ‘no', for example, ‘yes' if the patient had a level of understanding and if they practiced self-care behaviours regularly. Statistical analyses—Age, BMI, disease duration, HbA1c, ABI, NSS and NDS were described as a mean (SD). All other demographic, clinical, general medical and foot education characteristic scores were described as percentages (%). Data was analysed using SPSS version 17.0 software. Results Fifty-three Māori participants with diabetes had a mean (SD) age of 53.7 years (10.7 years). The cohort consisted of 47% of women. The mean duration of diabetes was 12.0 (5.2) years. The mean (SD) BMI was 37.8 kg/m2 (8.1). Of this cohort, 25% of participants were current smokers and 28% had a low perception of how these risk factors impact on diabetes-related complications. Foot ulceration/amputation history was reported in 17% and 6% reported a past history of lower extremity re-vascularisation. The majority of participants were classified in category 2 or category 3 as demonstrated in Table 1. Regular and irregular self-checking of blood glucose levels were reported (46% and 41% respectively) and elevated HbA1c levels (>8%) were common amongst 42% of participants. Pharmacological management is demonstrated in Table 1. Other risk factors for diabetes-related complications such as obesity, hypertension, dyslipidaemia and retinopathy were reported (62%, 49%, 55%, 21%). No participants were diagnosed with end-stage renal failure requiring dialysis. Intermittent claudication was present in 11% of participants. ABI mean (SD) are reported in Table 1. The mean (SD) for the NSS was 3.2 (2.8), and NDS score was 2.0 (2.0). Dry skin featured highly (70%). Hallux valgus (bunion) deformity was observed in 11% of participants and 30% of participants demonstrated hallux limitus. Clawing of the lesser toes was found in 38% of participants. A high number of participants presented with nail conditions (64%). Charcot foot was not observed. Many participants presented with pre-ulcerative lesions (53%) and 8% with current ulceration. Table 1. Screening characteristics Podiatric assessment and current management Results Insulin 11 [21%] n, [%] Oral Hyperglycaemic Agents 48 [91%] n, [%] Classification of foot risk status n [%] Category 2: 19 [36%] Category 3: 24 [45%] Category 4: 6 [11%] Category 5: 2 [4%] Category 6: 2 [4%] ABI: Right DP 1.07 (0.16) Mean (SD) ABI: Right PT 1.12 (0.17) Mean (SD) ABI: Left DP 1.08 (0.16) Mean (SD) ABI: Left PT 1.12 (0.17) Mean (SD) Achilles Tendon Reflex: Right Present Reinforcement Absent n [%] 33 [65%] 8 [15%] 10 [20%] Achilles Tendon Reflex: Left Present Reinforcement Absent n [%] 33 [65%] 10 [20%] 8 [15%] Bioesthesiometer (V): Right 19.3 (13.8) Mean (SD) Bioesthesiometer (V): Right 16.2 (11.2) Mean (SD) Diabetes-related knowledge was favourable in this cohort (98%), and positive foot care behaviour was present in 32%. Previous foot care from podiatrists (more than one year ago) had been received from 62% of the participants, whilst 4% reported previous use of a public orthotic service. Other features of the self care behaviours and knowledge are demonstrated in Table 2. Table 2. Foot care behaviours and knowledge characteristics Participant knowledge and foot care behaviours Results n [%] Smoking effects on circulation 46 [86%] Neuropathy and foot problems 52 [98%] Circulation and foot problems 50 [94%] Understands the causes of amputation 51 [96%] Use of moisturisers 51 [96%] Drying feet after bathing 52 [98%] Avoiding heaters and barefoot 51 [96%] Footwear advice 51 [96%] Understands the benefits of exercise 52 [98%] Contacting podiatrist 51 [96%] Discussion Māori are over-represented in diabetes-related complications compared with New Zealand Europeans. The podiatry assessment tool in this study was used to determine clinical and foot characteristics in a selected group of Māori with diabetes. One feature of the assessment tool is screening for peripheral neuropathy. Peripheral neuropathy is a consequence of hyperglycaemia, increasing age and progression of DM.16 We found that the majority of participants in this population did not display clinical evidence of distal symmetrical sensorimotor neuropathy as compared to a large multi-centred trial.16 Of the four signs which comprise the neuropathy disability score, loss of vibration sense featured highly although this did not affect the overall score. The inclusion criteria was designed to capture those with ‘at risk' foot characteristics as determined by the ‘Get Checked' initiative.3 The podiatry assessment tool is therefore useful in detecting further signs of neuropathy. The vascular assessment included a non-invasive clinical test (ABI) to detect clinical signs of peripheral arterial disease (PAD). The current study demonstrated mean ABI readings of normal range, despite claims of that ABI assessment is impractical and nondiagnostic in people with diabetes.20 Whilst having a low ABI is an independent risk factor for cardiovascular disease (<0.9), having an ABI reading of >1.3 is indicative of arterial wall calcification, a common finding in people with DM.20 A small number of participants in this study complained of symptoms associated with PAD, which is consistent with other studies.20 However, symptomatic pain query as well as relying on absent pedal pulses can underestimate the prevalence of PAD. More than half of the participants in this study displayed risk factors for PAD such as poor blood glucose control, dyslipidaemia and hypertension. The musculoskeletal assessment screened for limited joint mobility. Limited joint mobility has been suggested to be a major contributing factor to increased forefoot plantar pressure.21,22Hyperglycaemia contributes to collagen cross-linking and reduction in elasticity in tendons.21Hence, the arch looses stability during propulsion ultimately increasing pressure particularly to the metatarsophalangeal joints.21 This could explain why some participants in this cohort displayed evidence of pre-ulcerative lesions. A previous study has reported that when tendon and joint stiffening occurs, neuropathy is usually present.16 However, a limitation of previous studies is that they have not taken into consideration specific ethnic characteristics that may affect plantar fascia thickness and plantar pressure in the forefoot. Comparative studies on Māori with and without diabetes are required. A modified classification of foot risk status was adapted in order to determine the level of risk in which the foot is susceptible to developing foot ulceration.10,19 A high number of participants in the current study displayed clinical evidence that would support regular review from their podiatrist for management and surveillance of foot risk factors. There are no current guidelines for podiatrists or referrers to podiatrists in New Zealand. Therefore, the modified classification used in the study is useful for determining management plans that include primary and secondary referral. The modified classification fits with other studies, although the categorisation used is more sensitively designed for the likely health issues arising from within specific populations.10 In addition, the modified classification builds on and refines the approaches already identified as being effective in this field. To that extent, the modified classification used in our study is more detailed and has the added benefit of targeting risk factors efficiently, permitting even more appropriate referral. The classification builds upon the information gathered from the podiatric diabetic assessment tool and participants are able to move between risk depending on their collective assessment. Each category is then deliberate in its attempt to prompt the clinician to manage the patient accordingly.19 Previous studies indicate the success of podiatry-specific foot education programmes in diabetes.8-9 Foot-care behaviour was positively modified in 70% of participants with established neuropathy contributing to the reduction of foot ulcerations signifcantly.9 Furthermore, previous work has reported that foot care behaviours reduced the incidence of callosities in a podiatrist led group as compared to a control group, reducing plantar pressure.8 The programme used in the current study could offer support as to reasons why the study population did not attend with major complications such as neuropathic ulceration indicating the benefits of foot care education. However, in order to sustain positive behaviour, podiatry led-programmes need to be sustainable and implemented before or as close as possible to the diagnosis of neuropathy in order to achieve clinical benefits.8-9 We found a small number of the current population had an overall low perception of their risk of diabetes-related complications, although almost all participants had good general knowledge about diabetes and its associated complications which is partly in agreement with an earlier study.5 We also found that many of the participants in this study had visited a podiatrist more than a year prior to the study. This result may be largely due to the podiatrist's long history with both medical centres, and may not be representative of regional podiatry services. However, the current results are encouraging and indicate that previous education may be significant in influencing foot care behaviour. A high number of people in this study had never smoked cigarettes, or had ceased smoking cigarettes (more than one year abstinence). Our findings are similar to that of a previous South Auckland survey, where participants with diagnosed diabetes also reported low cigarette smoking rates.5 These findings conflict with another study, which report a high prevalence rate of smoking among Māori as compared to non- Māori (35% and 13% respectively) with diabetes.23However, there is no data reflecting current cessation rates between these two groups in people without diabetes. The findings from the current study deserve further exploration and offer encouraging results. There are several limitations to this study that warrant discussion. The current study had no comparison or control groups so we do not know if the podiatry program reduced the impact of diabetes-related complications. Future randomised longitudinal intervention studies are warranted to address this as well as compare Māori and non-Māori utilising this programme. The modified classification tool and self-reported knowledge questions used in the current study have not been assessed in terms of validity or reliability in the current population. The tool was developed by clinicians to incorporate foot-related problems within the multidisciplinary diabetes team. Although the assessment tool was designed to be consistent with M&#

Summary

Abstract

Aim

The prevalence of diabetes and its associated manifestations is higher in New Zealand M ori than New Zealand Europeans. There is no current evidence regarding podiatric clinical characteristics of M ori with diabetes. The aim of this study was to determine the clinical and foot characteristics of M ori with diabetes using a podiatry-specific assessment tool.

Method

This study used a cross-sectional design. Participants with diabetes were recruited from two M ori Primary Health Organisations. Podiatric-specific characteristics (vascular, neurological and musculoskeletal) were recorded. Patient demographics and general medical conditions were also recorded.

Results

Fifty-three participants were recruited and displayed risk factors for diabetes-related complications (mean disease duration 12 years, mean HbA1c 8.3%) including 49% of participants with hypertension. Podiatric-specific characteristics revealed unremarkable neurovascular results. However, many participants presented with pre-ulcerative lesions and current pedal ulceration (53% and 8% respectively). Although many participants had good foot-care knowledge (>85%), a modified classification tool of foot risk status determined that a high percentage of participants required regular podiatric management and screening (60%).

Conclusion

Despite this population living with a chronic condition for more than 10 years and displaying poor long-term glycaemic control, there was no evidence of microvascular or macrovascular complications in the lower limb. However, there was a high prevalence of pre-ulcerative lesions which unmonitored and undetected may predispose the foot to ulceration. The detection of current ulceration in this study alongside other risk factors for diabetes-related complications necessitates the need for appropriate podiatric screening and podiatry management.

Author Information

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Auckland; Angela Bayley, Manager, Orthotic Centre Wellington Ltd, Thorndon, Wellington; Keith Rome, Professor in Podiatry, AUT University, Auckland

Acknowledgements

The authors thank the Health Research Council of New Zealand, New Zealand Sock Company (Ashburton, New Zealand), Merino Lanolin Cream Company (Auckland, New Zealand), the Orthotics Centre Ltd (Ellerslie, Auckland, New Zealand), Adam Rome, and Emma Hoult for their support of the project.

Correspondence

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Faculty of Health & Environmental Sciences, 90 Akoranga Dr, Northcote 0627, Private Bag 92006, Auckland 1142, New Zealand.

Correspondence Email

belinda.ihaka@aut.ac.nz

Competing Interests

None declared.

Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047-1053.Simmons D, Rush E, Crook N. Prevalence of undiagnosed diabetes, impaired glucose tolerance, and fasting glucose among M ori in Te Wai o Rona: Diabetes prevention study. N Z Med J. 2009;122:30-38.The New Zealand Guidelines Group. 2003. Management of Type 2 Diabetes. Wellington.Simmons, D, Kenealy T, Scragg R. Foot care among diabetic participants in South Auckland.N Z Med J. 1995;108:106-8.Simmons D, Fleming C. Prevalence and characteristics of diabetic participants with no ongoing care in South Auckland. Diabetes Care. 2000;23:1791-1793.Simmons D, Schaumkel J, Cecil A, et al. High impact of nephropathy on 5-year mortality rates among participants with type 2 diabetes mellitus from a multi-ethnic population in New Zealand. Diabet Med. 1999;16:926-931.Lipsky B, Berendt A, Deery H, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39:885-910.Ronnemaa T, Hamalainen H, Toikka T, Liukkonen. Evaluation of the impact of Podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care.1997;20:1833-1837.Calle-Pascual A, Duran A, Benedi A, et al. A preventative foot care programme for people with diabetes with different stages of neuropathy.Diabetes Res Clin Pract. 2002;57:111-117.Armstrong D, Lavery L, Harkless L. Treatment-based classification system for assessment and care of diabetic feet.J Am Podiatry Med Assoc. 1996; 86:311-316.Mayfield J, Reiber G, Sanders L, et al. Preventative foot care in people with diabetes.Diabetes Care.1998;21:2178-2172.Cavanagh P, Ulbrecht J, Caputo G. New developments in the biomechanics of the diabetic foot. Diabetes Metab Res Rev.2000;16:S6-S10.DAmbrogi E, Giurato L, DAgostino M, et al. Contribution of plantar fascia to the increased forefoot pressures in diabetic participants. Diabetes Care. 2003;26:1525-1528.Adler A, Boyko E, Ahroni J, Smith D. Lower-extremity amputation in diabetes. Diabetes Care. 1999;22:1029-1035.Leng G, Fowkes F. The Edinburgh claudication questionnaire: an improved version of the WHO/ROSE questionnaire for use in epidemiological surveys. J Clin Epidemiol. 1992;45:1101-1109.Boulton A, Young M, Macleod A, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom Hospital clinic population. Diabetologia. 1993;36:150-154.Kim R, Edelman S, Kim D.Musculoskeletal complications of diabetes mellitus. Clin Diabetes. 2001;19:132-135.de Sonnaville J, Colly L, Wijkel D, Heine R. The prevalence and determinants of foot ulceration in type II diabetic participants in a primary health care setting.Diabetes Res Clin Pract. 1997;35:149-56.National Institute for Public Health and Mental Health Research. An intervention trial for M ori at risk of diabetes-related lower limb pathology. Auckland, 2010.Al-Qaisi M, Nott D, King D, Kaddoura S. Ankle brachial pressure index (ABPI): An update for practitioners. Vasc Health Risk Manag. 2009;5:833-841.DAmbrogi E, Giacomozzi C, Macellari V, Uccioli L. Abnormal foot function in diabetic participants: the altered onset of windlass mechanism.Diabet Med. 2005;22:1713-1719.Caselli A, Pham H, Giurini J, et al. The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration.Diabetes Care. 2002;25:1066-1071.Robinson T, Simmons D, Scott D, et al. Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand. N Z Med J. 2006;119:1-10.Smith, L. Decolonizing methodologies: Research and indigenous peoples.New York: Zed Books;1999.

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Diabetes Mellitus (DM) presents as a global economic burden.1 In New Zealand, the prevalence for undiagnosed DM in Māori is higher than that for non-Māori, presenting as an opportunity to reduce significant mortality and morbidity in this population.2Complications arising from DM account for 20% of all deaths among Māori as compared to 4% in other New Zealanders.3 In one study, a high proportion of ulceration and amputation as a consequence of diabetes was observed in Māori.4 A further study reports that Māori were less likely to have on-going DM related-care due to poor perception of risk.5 Therefore for Māori, non-participation in ‘ongoing care' can intensify the problem due to the inability to detect or manage signs or symptoms of diabetes-related complications.6When undetected and untreated, the effect of foot problems in people with DM can progress rapidly and lead to morbidity and mortality from complications such as ulceration, gangrene and amputation.3,7 Appropriate screening ensures effective targeting of at-risk populations, early intervention, and surveillance of those detected with significant pathology.8-9Previous studies have reported on the major contributing factors to diabetic foot pathology, which often occurs in conjunction with other organ complications.8,10-11 Of these, neuropathy and mechanical stress are the key factors in predisposing the foot to increased plantar pressures effectively resulting in ulceration.10,12-13 Furthermore, peripheral arterial disease, infection, patient disability, maladaptive self-care behaviour and access barriers consequently place the foot at higher risk of a major complication.7,10,14The national introduction of the ‘Get Checked Programme' provided the first opportunity to gather information pertaining to glycaemic control, lifestyle behaviour, diabetes-related cardiovascular disease, renal disease, retinal screening, and foot screening data.3 However, the programme was not designed to identify the level of susceptibility of risk to the foot.The need to undertake an assessment that includes the identification of the level of risk was therefore required.3 The assessment should also indicate frequency of monitoring and classification of risk status, in order to implement effective management plans.Therefore, whilst it is clear that Māori are more significantly at risk of diabetes-related complications, data regarding characteristics and management for foot pathology is limited in this population.The aim of this study was to select Māori with Type 2 diabetes, who had either not received an annual ‘Get Checked' review or who presented with features of an at risk foot; and through the use a podiatric diabetic assessment tool, determine clinical and foot characteristics.Methods Study design—This study used a cross-sectional design and was undertaken in the Waitemata district, Auckland, New Zealand. The study was conducted between 2007 and 2008. Ethical approval was obtained from the Auckland University of Technology University ethics committee (07/198) for review prior to submitting to Northern Y ethics committee (NTY/05/08/055). Participants were recruited from two Māori Primary Health Organisations (PHOs) and identified by a data search using Medtech-32. A query build function was set up to include participants with T2DM; ≥18 years old; Māori; who had not received a national diabetes assessment for >12 months;3 had undetected pedal pulses, absence of sensation, previous history of peripheral vascular disease, or ulceration as determined by the ‘Get Checked' Programme.3 Two research investigators accessed electronic patient records. One investigator was responsible for initial contact with the participants via telephone to explain the aim of the study. Informed consent was obtained from all participants. Exclusion criteria included those who were not registered with the PHO; who had a below knee amputation or who attended regular podiatry appointments. Two experienced podiatric practitioners involved in working with Māori undertook all podiatric assessments. To ensure consistency between the two practitioners, each practitioner undertook a single training session prior to data collection. Demographic characteristics including age (years), gender, body mass index (kg/m2), disease duration (years) and medical conditions were recorded. Smoking status was also reported. Perception of risk, past history of foot or leg ulceration/amputation, past history of lower extremity revascularisation were also recorded. Clinical data including; serum glycated haemoglobin levels HbA1c and HbA1c >8% over a 6-month period; pharmacological management for DM (insulin, and oral hypoglycaemic agents), as well as regular (daily) and irregular (every other day) self-monitoring of blood glucose levels were collected. Foot risk status was recorded using a modified classification based on a previously published classification system.10 The podiatric diabetic assessment tool included a neurovascular, musculoskeletal and education component. The vascular assessment included a history of intermittent claudication.15 Pedal pulse assessment, visual identification of skin integrity, and ankle-brachial index (ABI) were obtained. The neurological assessment was based on the neuropathy signs (NDS) and symptom scoring system (NSS).16 The musculoskeletal assessment included the evaluation for limited joint mobility in the hands17 and feet. Lower extremity nail and skin conditions were also recorded.18 Participants were asked to report on self-care behaviours and self-knowledge which included daily foot inspection, application of skin moisturises, avoiding situations of risk (avoiding heaters or walking barefoot); as well as understanding the benefits of good glycaemic control, and foot problems associated with neuropathy.3,8,19 Participant's responses were recorded as either ‘yes' or ‘no', for example, ‘yes' if the patient had a level of understanding and if they practiced self-care behaviours regularly. Statistical analyses—Age, BMI, disease duration, HbA1c, ABI, NSS and NDS were described as a mean (SD). All other demographic, clinical, general medical and foot education characteristic scores were described as percentages (%). Data was analysed using SPSS version 17.0 software. Results Fifty-three Māori participants with diabetes had a mean (SD) age of 53.7 years (10.7 years). The cohort consisted of 47% of women. The mean duration of diabetes was 12.0 (5.2) years. The mean (SD) BMI was 37.8 kg/m2 (8.1). Of this cohort, 25% of participants were current smokers and 28% had a low perception of how these risk factors impact on diabetes-related complications. Foot ulceration/amputation history was reported in 17% and 6% reported a past history of lower extremity re-vascularisation. The majority of participants were classified in category 2 or category 3 as demonstrated in Table 1. Regular and irregular self-checking of blood glucose levels were reported (46% and 41% respectively) and elevated HbA1c levels (>8%) were common amongst 42% of participants. Pharmacological management is demonstrated in Table 1. Other risk factors for diabetes-related complications such as obesity, hypertension, dyslipidaemia and retinopathy were reported (62%, 49%, 55%, 21%). No participants were diagnosed with end-stage renal failure requiring dialysis. Intermittent claudication was present in 11% of participants. ABI mean (SD) are reported in Table 1. The mean (SD) for the NSS was 3.2 (2.8), and NDS score was 2.0 (2.0). Dry skin featured highly (70%). Hallux valgus (bunion) deformity was observed in 11% of participants and 30% of participants demonstrated hallux limitus. Clawing of the lesser toes was found in 38% of participants. A high number of participants presented with nail conditions (64%). Charcot foot was not observed. Many participants presented with pre-ulcerative lesions (53%) and 8% with current ulceration. Table 1. Screening characteristics Podiatric assessment and current management Results Insulin 11 [21%] n, [%] Oral Hyperglycaemic Agents 48 [91%] n, [%] Classification of foot risk status n [%] Category 2: 19 [36%] Category 3: 24 [45%] Category 4: 6 [11%] Category 5: 2 [4%] Category 6: 2 [4%] ABI: Right DP 1.07 (0.16) Mean (SD) ABI: Right PT 1.12 (0.17) Mean (SD) ABI: Left DP 1.08 (0.16) Mean (SD) ABI: Left PT 1.12 (0.17) Mean (SD) Achilles Tendon Reflex: Right Present Reinforcement Absent n [%] 33 [65%] 8 [15%] 10 [20%] Achilles Tendon Reflex: Left Present Reinforcement Absent n [%] 33 [65%] 10 [20%] 8 [15%] Bioesthesiometer (V): Right 19.3 (13.8) Mean (SD) Bioesthesiometer (V): Right 16.2 (11.2) Mean (SD) Diabetes-related knowledge was favourable in this cohort (98%), and positive foot care behaviour was present in 32%. Previous foot care from podiatrists (more than one year ago) had been received from 62% of the participants, whilst 4% reported previous use of a public orthotic service. Other features of the self care behaviours and knowledge are demonstrated in Table 2. Table 2. Foot care behaviours and knowledge characteristics Participant knowledge and foot care behaviours Results n [%] Smoking effects on circulation 46 [86%] Neuropathy and foot problems 52 [98%] Circulation and foot problems 50 [94%] Understands the causes of amputation 51 [96%] Use of moisturisers 51 [96%] Drying feet after bathing 52 [98%] Avoiding heaters and barefoot 51 [96%] Footwear advice 51 [96%] Understands the benefits of exercise 52 [98%] Contacting podiatrist 51 [96%] Discussion Māori are over-represented in diabetes-related complications compared with New Zealand Europeans. The podiatry assessment tool in this study was used to determine clinical and foot characteristics in a selected group of Māori with diabetes. One feature of the assessment tool is screening for peripheral neuropathy. Peripheral neuropathy is a consequence of hyperglycaemia, increasing age and progression of DM.16 We found that the majority of participants in this population did not display clinical evidence of distal symmetrical sensorimotor neuropathy as compared to a large multi-centred trial.16 Of the four signs which comprise the neuropathy disability score, loss of vibration sense featured highly although this did not affect the overall score. The inclusion criteria was designed to capture those with ‘at risk' foot characteristics as determined by the ‘Get Checked' initiative.3 The podiatry assessment tool is therefore useful in detecting further signs of neuropathy. The vascular assessment included a non-invasive clinical test (ABI) to detect clinical signs of peripheral arterial disease (PAD). The current study demonstrated mean ABI readings of normal range, despite claims of that ABI assessment is impractical and nondiagnostic in people with diabetes.20 Whilst having a low ABI is an independent risk factor for cardiovascular disease (<0.9), having an ABI reading of >1.3 is indicative of arterial wall calcification, a common finding in people with DM.20 A small number of participants in this study complained of symptoms associated with PAD, which is consistent with other studies.20 However, symptomatic pain query as well as relying on absent pedal pulses can underestimate the prevalence of PAD. More than half of the participants in this study displayed risk factors for PAD such as poor blood glucose control, dyslipidaemia and hypertension. The musculoskeletal assessment screened for limited joint mobility. Limited joint mobility has been suggested to be a major contributing factor to increased forefoot plantar pressure.21,22Hyperglycaemia contributes to collagen cross-linking and reduction in elasticity in tendons.21Hence, the arch looses stability during propulsion ultimately increasing pressure particularly to the metatarsophalangeal joints.21 This could explain why some participants in this cohort displayed evidence of pre-ulcerative lesions. A previous study has reported that when tendon and joint stiffening occurs, neuropathy is usually present.16 However, a limitation of previous studies is that they have not taken into consideration specific ethnic characteristics that may affect plantar fascia thickness and plantar pressure in the forefoot. Comparative studies on Māori with and without diabetes are required. A modified classification of foot risk status was adapted in order to determine the level of risk in which the foot is susceptible to developing foot ulceration.10,19 A high number of participants in the current study displayed clinical evidence that would support regular review from their podiatrist for management and surveillance of foot risk factors. There are no current guidelines for podiatrists or referrers to podiatrists in New Zealand. Therefore, the modified classification used in the study is useful for determining management plans that include primary and secondary referral. The modified classification fits with other studies, although the categorisation used is more sensitively designed for the likely health issues arising from within specific populations.10 In addition, the modified classification builds on and refines the approaches already identified as being effective in this field. To that extent, the modified classification used in our study is more detailed and has the added benefit of targeting risk factors efficiently, permitting even more appropriate referral. The classification builds upon the information gathered from the podiatric diabetic assessment tool and participants are able to move between risk depending on their collective assessment. Each category is then deliberate in its attempt to prompt the clinician to manage the patient accordingly.19 Previous studies indicate the success of podiatry-specific foot education programmes in diabetes.8-9 Foot-care behaviour was positively modified in 70% of participants with established neuropathy contributing to the reduction of foot ulcerations signifcantly.9 Furthermore, previous work has reported that foot care behaviours reduced the incidence of callosities in a podiatrist led group as compared to a control group, reducing plantar pressure.8 The programme used in the current study could offer support as to reasons why the study population did not attend with major complications such as neuropathic ulceration indicating the benefits of foot care education. However, in order to sustain positive behaviour, podiatry led-programmes need to be sustainable and implemented before or as close as possible to the diagnosis of neuropathy in order to achieve clinical benefits.8-9 We found a small number of the current population had an overall low perception of their risk of diabetes-related complications, although almost all participants had good general knowledge about diabetes and its associated complications which is partly in agreement with an earlier study.5 We also found that many of the participants in this study had visited a podiatrist more than a year prior to the study. This result may be largely due to the podiatrist's long history with both medical centres, and may not be representative of regional podiatry services. However, the current results are encouraging and indicate that previous education may be significant in influencing foot care behaviour. A high number of people in this study had never smoked cigarettes, or had ceased smoking cigarettes (more than one year abstinence). Our findings are similar to that of a previous South Auckland survey, where participants with diagnosed diabetes also reported low cigarette smoking rates.5 These findings conflict with another study, which report a high prevalence rate of smoking among Māori as compared to non- Māori (35% and 13% respectively) with diabetes.23However, there is no data reflecting current cessation rates between these two groups in people without diabetes. The findings from the current study deserve further exploration and offer encouraging results. There are several limitations to this study that warrant discussion. The current study had no comparison or control groups so we do not know if the podiatry program reduced the impact of diabetes-related complications. Future randomised longitudinal intervention studies are warranted to address this as well as compare Māori and non-Māori utilising this programme. The modified classification tool and self-reported knowledge questions used in the current study have not been assessed in terms of validity or reliability in the current population. The tool was developed by clinicians to incorporate foot-related problems within the multidisciplinary diabetes team. Although the assessment tool was designed to be consistent with M&#

Summary

Abstract

Aim

The prevalence of diabetes and its associated manifestations is higher in New Zealand M ori than New Zealand Europeans. There is no current evidence regarding podiatric clinical characteristics of M ori with diabetes. The aim of this study was to determine the clinical and foot characteristics of M ori with diabetes using a podiatry-specific assessment tool.

Method

This study used a cross-sectional design. Participants with diabetes were recruited from two M ori Primary Health Organisations. Podiatric-specific characteristics (vascular, neurological and musculoskeletal) were recorded. Patient demographics and general medical conditions were also recorded.

Results

Fifty-three participants were recruited and displayed risk factors for diabetes-related complications (mean disease duration 12 years, mean HbA1c 8.3%) including 49% of participants with hypertension. Podiatric-specific characteristics revealed unremarkable neurovascular results. However, many participants presented with pre-ulcerative lesions and current pedal ulceration (53% and 8% respectively). Although many participants had good foot-care knowledge (>85%), a modified classification tool of foot risk status determined that a high percentage of participants required regular podiatric management and screening (60%).

Conclusion

Despite this population living with a chronic condition for more than 10 years and displaying poor long-term glycaemic control, there was no evidence of microvascular or macrovascular complications in the lower limb. However, there was a high prevalence of pre-ulcerative lesions which unmonitored and undetected may predispose the foot to ulceration. The detection of current ulceration in this study alongside other risk factors for diabetes-related complications necessitates the need for appropriate podiatric screening and podiatry management.

Author Information

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Auckland; Angela Bayley, Manager, Orthotic Centre Wellington Ltd, Thorndon, Wellington; Keith Rome, Professor in Podiatry, AUT University, Auckland

Acknowledgements

The authors thank the Health Research Council of New Zealand, New Zealand Sock Company (Ashburton, New Zealand), Merino Lanolin Cream Company (Auckland, New Zealand), the Orthotics Centre Ltd (Ellerslie, Auckland, New Zealand), Adam Rome, and Emma Hoult for their support of the project.

Correspondence

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Faculty of Health & Environmental Sciences, 90 Akoranga Dr, Northcote 0627, Private Bag 92006, Auckland 1142, New Zealand.

Correspondence Email

belinda.ihaka@aut.ac.nz

Competing Interests

None declared.

Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047-1053.Simmons D, Rush E, Crook N. Prevalence of undiagnosed diabetes, impaired glucose tolerance, and fasting glucose among M ori in Te Wai o Rona: Diabetes prevention study. N Z Med J. 2009;122:30-38.The New Zealand Guidelines Group. 2003. Management of Type 2 Diabetes. Wellington.Simmons, D, Kenealy T, Scragg R. Foot care among diabetic participants in South Auckland.N Z Med J. 1995;108:106-8.Simmons D, Fleming C. Prevalence and characteristics of diabetic participants with no ongoing care in South Auckland. Diabetes Care. 2000;23:1791-1793.Simmons D, Schaumkel J, Cecil A, et al. High impact of nephropathy on 5-year mortality rates among participants with type 2 diabetes mellitus from a multi-ethnic population in New Zealand. Diabet Med. 1999;16:926-931.Lipsky B, Berendt A, Deery H, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39:885-910.Ronnemaa T, Hamalainen H, Toikka T, Liukkonen. Evaluation of the impact of Podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care.1997;20:1833-1837.Calle-Pascual A, Duran A, Benedi A, et al. A preventative foot care programme for people with diabetes with different stages of neuropathy.Diabetes Res Clin Pract. 2002;57:111-117.Armstrong D, Lavery L, Harkless L. Treatment-based classification system for assessment and care of diabetic feet.J Am Podiatry Med Assoc. 1996; 86:311-316.Mayfield J, Reiber G, Sanders L, et al. Preventative foot care in people with diabetes.Diabetes Care.1998;21:2178-2172.Cavanagh P, Ulbrecht J, Caputo G. New developments in the biomechanics of the diabetic foot. Diabetes Metab Res Rev.2000;16:S6-S10.DAmbrogi E, Giurato L, DAgostino M, et al. Contribution of plantar fascia to the increased forefoot pressures in diabetic participants. Diabetes Care. 2003;26:1525-1528.Adler A, Boyko E, Ahroni J, Smith D. Lower-extremity amputation in diabetes. Diabetes Care. 1999;22:1029-1035.Leng G, Fowkes F. The Edinburgh claudication questionnaire: an improved version of the WHO/ROSE questionnaire for use in epidemiological surveys. J Clin Epidemiol. 1992;45:1101-1109.Boulton A, Young M, Macleod A, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom Hospital clinic population. Diabetologia. 1993;36:150-154.Kim R, Edelman S, Kim D.Musculoskeletal complications of diabetes mellitus. Clin Diabetes. 2001;19:132-135.de Sonnaville J, Colly L, Wijkel D, Heine R. The prevalence and determinants of foot ulceration in type II diabetic participants in a primary health care setting.Diabetes Res Clin Pract. 1997;35:149-56.National Institute for Public Health and Mental Health Research. An intervention trial for M ori at risk of diabetes-related lower limb pathology. Auckland, 2010.Al-Qaisi M, Nott D, King D, Kaddoura S. Ankle brachial pressure index (ABPI): An update for practitioners. Vasc Health Risk Manag. 2009;5:833-841.DAmbrogi E, Giacomozzi C, Macellari V, Uccioli L. Abnormal foot function in diabetic participants: the altered onset of windlass mechanism.Diabet Med. 2005;22:1713-1719.Caselli A, Pham H, Giurini J, et al. The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration.Diabetes Care. 2002;25:1066-1071.Robinson T, Simmons D, Scott D, et al. Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand. N Z Med J. 2006;119:1-10.Smith, L. Decolonizing methodologies: Research and indigenous peoples.New York: Zed Books;1999.

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Diabetes Mellitus (DM) presents as a global economic burden.1 In New Zealand, the prevalence for undiagnosed DM in Māori is higher than that for non-Māori, presenting as an opportunity to reduce significant mortality and morbidity in this population.2Complications arising from DM account for 20% of all deaths among Māori as compared to 4% in other New Zealanders.3 In one study, a high proportion of ulceration and amputation as a consequence of diabetes was observed in Māori.4 A further study reports that Māori were less likely to have on-going DM related-care due to poor perception of risk.5 Therefore for Māori, non-participation in ‘ongoing care' can intensify the problem due to the inability to detect or manage signs or symptoms of diabetes-related complications.6When undetected and untreated, the effect of foot problems in people with DM can progress rapidly and lead to morbidity and mortality from complications such as ulceration, gangrene and amputation.3,7 Appropriate screening ensures effective targeting of at-risk populations, early intervention, and surveillance of those detected with significant pathology.8-9Previous studies have reported on the major contributing factors to diabetic foot pathology, which often occurs in conjunction with other organ complications.8,10-11 Of these, neuropathy and mechanical stress are the key factors in predisposing the foot to increased plantar pressures effectively resulting in ulceration.10,12-13 Furthermore, peripheral arterial disease, infection, patient disability, maladaptive self-care behaviour and access barriers consequently place the foot at higher risk of a major complication.7,10,14The national introduction of the ‘Get Checked Programme' provided the first opportunity to gather information pertaining to glycaemic control, lifestyle behaviour, diabetes-related cardiovascular disease, renal disease, retinal screening, and foot screening data.3 However, the programme was not designed to identify the level of susceptibility of risk to the foot.The need to undertake an assessment that includes the identification of the level of risk was therefore required.3 The assessment should also indicate frequency of monitoring and classification of risk status, in order to implement effective management plans.Therefore, whilst it is clear that Māori are more significantly at risk of diabetes-related complications, data regarding characteristics and management for foot pathology is limited in this population.The aim of this study was to select Māori with Type 2 diabetes, who had either not received an annual ‘Get Checked' review or who presented with features of an at risk foot; and through the use a podiatric diabetic assessment tool, determine clinical and foot characteristics.Methods Study design—This study used a cross-sectional design and was undertaken in the Waitemata district, Auckland, New Zealand. The study was conducted between 2007 and 2008. Ethical approval was obtained from the Auckland University of Technology University ethics committee (07/198) for review prior to submitting to Northern Y ethics committee (NTY/05/08/055). Participants were recruited from two Māori Primary Health Organisations (PHOs) and identified by a data search using Medtech-32. A query build function was set up to include participants with T2DM; ≥18 years old; Māori; who had not received a national diabetes assessment for >12 months;3 had undetected pedal pulses, absence of sensation, previous history of peripheral vascular disease, or ulceration as determined by the ‘Get Checked' Programme.3 Two research investigators accessed electronic patient records. One investigator was responsible for initial contact with the participants via telephone to explain the aim of the study. Informed consent was obtained from all participants. Exclusion criteria included those who were not registered with the PHO; who had a below knee amputation or who attended regular podiatry appointments. Two experienced podiatric practitioners involved in working with Māori undertook all podiatric assessments. To ensure consistency between the two practitioners, each practitioner undertook a single training session prior to data collection. Demographic characteristics including age (years), gender, body mass index (kg/m2), disease duration (years) and medical conditions were recorded. Smoking status was also reported. Perception of risk, past history of foot or leg ulceration/amputation, past history of lower extremity revascularisation were also recorded. Clinical data including; serum glycated haemoglobin levels HbA1c and HbA1c >8% over a 6-month period; pharmacological management for DM (insulin, and oral hypoglycaemic agents), as well as regular (daily) and irregular (every other day) self-monitoring of blood glucose levels were collected. Foot risk status was recorded using a modified classification based on a previously published classification system.10 The podiatric diabetic assessment tool included a neurovascular, musculoskeletal and education component. The vascular assessment included a history of intermittent claudication.15 Pedal pulse assessment, visual identification of skin integrity, and ankle-brachial index (ABI) were obtained. The neurological assessment was based on the neuropathy signs (NDS) and symptom scoring system (NSS).16 The musculoskeletal assessment included the evaluation for limited joint mobility in the hands17 and feet. Lower extremity nail and skin conditions were also recorded.18 Participants were asked to report on self-care behaviours and self-knowledge which included daily foot inspection, application of skin moisturises, avoiding situations of risk (avoiding heaters or walking barefoot); as well as understanding the benefits of good glycaemic control, and foot problems associated with neuropathy.3,8,19 Participant's responses were recorded as either ‘yes' or ‘no', for example, ‘yes' if the patient had a level of understanding and if they practiced self-care behaviours regularly. Statistical analyses—Age, BMI, disease duration, HbA1c, ABI, NSS and NDS were described as a mean (SD). All other demographic, clinical, general medical and foot education characteristic scores were described as percentages (%). Data was analysed using SPSS version 17.0 software. Results Fifty-three Māori participants with diabetes had a mean (SD) age of 53.7 years (10.7 years). The cohort consisted of 47% of women. The mean duration of diabetes was 12.0 (5.2) years. The mean (SD) BMI was 37.8 kg/m2 (8.1). Of this cohort, 25% of participants were current smokers and 28% had a low perception of how these risk factors impact on diabetes-related complications. Foot ulceration/amputation history was reported in 17% and 6% reported a past history of lower extremity re-vascularisation. The majority of participants were classified in category 2 or category 3 as demonstrated in Table 1. Regular and irregular self-checking of blood glucose levels were reported (46% and 41% respectively) and elevated HbA1c levels (>8%) were common amongst 42% of participants. Pharmacological management is demonstrated in Table 1. Other risk factors for diabetes-related complications such as obesity, hypertension, dyslipidaemia and retinopathy were reported (62%, 49%, 55%, 21%). No participants were diagnosed with end-stage renal failure requiring dialysis. Intermittent claudication was present in 11% of participants. ABI mean (SD) are reported in Table 1. The mean (SD) for the NSS was 3.2 (2.8), and NDS score was 2.0 (2.0). Dry skin featured highly (70%). Hallux valgus (bunion) deformity was observed in 11% of participants and 30% of participants demonstrated hallux limitus. Clawing of the lesser toes was found in 38% of participants. A high number of participants presented with nail conditions (64%). Charcot foot was not observed. Many participants presented with pre-ulcerative lesions (53%) and 8% with current ulceration. Table 1. Screening characteristics Podiatric assessment and current management Results Insulin 11 [21%] n, [%] Oral Hyperglycaemic Agents 48 [91%] n, [%] Classification of foot risk status n [%] Category 2: 19 [36%] Category 3: 24 [45%] Category 4: 6 [11%] Category 5: 2 [4%] Category 6: 2 [4%] ABI: Right DP 1.07 (0.16) Mean (SD) ABI: Right PT 1.12 (0.17) Mean (SD) ABI: Left DP 1.08 (0.16) Mean (SD) ABI: Left PT 1.12 (0.17) Mean (SD) Achilles Tendon Reflex: Right Present Reinforcement Absent n [%] 33 [65%] 8 [15%] 10 [20%] Achilles Tendon Reflex: Left Present Reinforcement Absent n [%] 33 [65%] 10 [20%] 8 [15%] Bioesthesiometer (V): Right 19.3 (13.8) Mean (SD) Bioesthesiometer (V): Right 16.2 (11.2) Mean (SD) Diabetes-related knowledge was favourable in this cohort (98%), and positive foot care behaviour was present in 32%. Previous foot care from podiatrists (more than one year ago) had been received from 62% of the participants, whilst 4% reported previous use of a public orthotic service. Other features of the self care behaviours and knowledge are demonstrated in Table 2. Table 2. Foot care behaviours and knowledge characteristics Participant knowledge and foot care behaviours Results n [%] Smoking effects on circulation 46 [86%] Neuropathy and foot problems 52 [98%] Circulation and foot problems 50 [94%] Understands the causes of amputation 51 [96%] Use of moisturisers 51 [96%] Drying feet after bathing 52 [98%] Avoiding heaters and barefoot 51 [96%] Footwear advice 51 [96%] Understands the benefits of exercise 52 [98%] Contacting podiatrist 51 [96%] Discussion Māori are over-represented in diabetes-related complications compared with New Zealand Europeans. The podiatry assessment tool in this study was used to determine clinical and foot characteristics in a selected group of Māori with diabetes. One feature of the assessment tool is screening for peripheral neuropathy. Peripheral neuropathy is a consequence of hyperglycaemia, increasing age and progression of DM.16 We found that the majority of participants in this population did not display clinical evidence of distal symmetrical sensorimotor neuropathy as compared to a large multi-centred trial.16 Of the four signs which comprise the neuropathy disability score, loss of vibration sense featured highly although this did not affect the overall score. The inclusion criteria was designed to capture those with ‘at risk' foot characteristics as determined by the ‘Get Checked' initiative.3 The podiatry assessment tool is therefore useful in detecting further signs of neuropathy. The vascular assessment included a non-invasive clinical test (ABI) to detect clinical signs of peripheral arterial disease (PAD). The current study demonstrated mean ABI readings of normal range, despite claims of that ABI assessment is impractical and nondiagnostic in people with diabetes.20 Whilst having a low ABI is an independent risk factor for cardiovascular disease (<0.9), having an ABI reading of >1.3 is indicative of arterial wall calcification, a common finding in people with DM.20 A small number of participants in this study complained of symptoms associated with PAD, which is consistent with other studies.20 However, symptomatic pain query as well as relying on absent pedal pulses can underestimate the prevalence of PAD. More than half of the participants in this study displayed risk factors for PAD such as poor blood glucose control, dyslipidaemia and hypertension. The musculoskeletal assessment screened for limited joint mobility. Limited joint mobility has been suggested to be a major contributing factor to increased forefoot plantar pressure.21,22Hyperglycaemia contributes to collagen cross-linking and reduction in elasticity in tendons.21Hence, the arch looses stability during propulsion ultimately increasing pressure particularly to the metatarsophalangeal joints.21 This could explain why some participants in this cohort displayed evidence of pre-ulcerative lesions. A previous study has reported that when tendon and joint stiffening occurs, neuropathy is usually present.16 However, a limitation of previous studies is that they have not taken into consideration specific ethnic characteristics that may affect plantar fascia thickness and plantar pressure in the forefoot. Comparative studies on Māori with and without diabetes are required. A modified classification of foot risk status was adapted in order to determine the level of risk in which the foot is susceptible to developing foot ulceration.10,19 A high number of participants in the current study displayed clinical evidence that would support regular review from their podiatrist for management and surveillance of foot risk factors. There are no current guidelines for podiatrists or referrers to podiatrists in New Zealand. Therefore, the modified classification used in the study is useful for determining management plans that include primary and secondary referral. The modified classification fits with other studies, although the categorisation used is more sensitively designed for the likely health issues arising from within specific populations.10 In addition, the modified classification builds on and refines the approaches already identified as being effective in this field. To that extent, the modified classification used in our study is more detailed and has the added benefit of targeting risk factors efficiently, permitting even more appropriate referral. The classification builds upon the information gathered from the podiatric diabetic assessment tool and participants are able to move between risk depending on their collective assessment. Each category is then deliberate in its attempt to prompt the clinician to manage the patient accordingly.19 Previous studies indicate the success of podiatry-specific foot education programmes in diabetes.8-9 Foot-care behaviour was positively modified in 70% of participants with established neuropathy contributing to the reduction of foot ulcerations signifcantly.9 Furthermore, previous work has reported that foot care behaviours reduced the incidence of callosities in a podiatrist led group as compared to a control group, reducing plantar pressure.8 The programme used in the current study could offer support as to reasons why the study population did not attend with major complications such as neuropathic ulceration indicating the benefits of foot care education. However, in order to sustain positive behaviour, podiatry led-programmes need to be sustainable and implemented before or as close as possible to the diagnosis of neuropathy in order to achieve clinical benefits.8-9 We found a small number of the current population had an overall low perception of their risk of diabetes-related complications, although almost all participants had good general knowledge about diabetes and its associated complications which is partly in agreement with an earlier study.5 We also found that many of the participants in this study had visited a podiatrist more than a year prior to the study. This result may be largely due to the podiatrist's long history with both medical centres, and may not be representative of regional podiatry services. However, the current results are encouraging and indicate that previous education may be significant in influencing foot care behaviour. A high number of people in this study had never smoked cigarettes, or had ceased smoking cigarettes (more than one year abstinence). Our findings are similar to that of a previous South Auckland survey, where participants with diagnosed diabetes also reported low cigarette smoking rates.5 These findings conflict with another study, which report a high prevalence rate of smoking among Māori as compared to non- Māori (35% and 13% respectively) with diabetes.23However, there is no data reflecting current cessation rates between these two groups in people without diabetes. The findings from the current study deserve further exploration and offer encouraging results. There are several limitations to this study that warrant discussion. The current study had no comparison or control groups so we do not know if the podiatry program reduced the impact of diabetes-related complications. Future randomised longitudinal intervention studies are warranted to address this as well as compare Māori and non-Māori utilising this programme. The modified classification tool and self-reported knowledge questions used in the current study have not been assessed in terms of validity or reliability in the current population. The tool was developed by clinicians to incorporate foot-related problems within the multidisciplinary diabetes team. Although the assessment tool was designed to be consistent with M&#

Summary

Abstract

Aim

The prevalence of diabetes and its associated manifestations is higher in New Zealand M ori than New Zealand Europeans. There is no current evidence regarding podiatric clinical characteristics of M ori with diabetes. The aim of this study was to determine the clinical and foot characteristics of M ori with diabetes using a podiatry-specific assessment tool.

Method

This study used a cross-sectional design. Participants with diabetes were recruited from two M ori Primary Health Organisations. Podiatric-specific characteristics (vascular, neurological and musculoskeletal) were recorded. Patient demographics and general medical conditions were also recorded.

Results

Fifty-three participants were recruited and displayed risk factors for diabetes-related complications (mean disease duration 12 years, mean HbA1c 8.3%) including 49% of participants with hypertension. Podiatric-specific characteristics revealed unremarkable neurovascular results. However, many participants presented with pre-ulcerative lesions and current pedal ulceration (53% and 8% respectively). Although many participants had good foot-care knowledge (>85%), a modified classification tool of foot risk status determined that a high percentage of participants required regular podiatric management and screening (60%).

Conclusion

Despite this population living with a chronic condition for more than 10 years and displaying poor long-term glycaemic control, there was no evidence of microvascular or macrovascular complications in the lower limb. However, there was a high prevalence of pre-ulcerative lesions which unmonitored and undetected may predispose the foot to ulceration. The detection of current ulceration in this study alongside other risk factors for diabetes-related complications necessitates the need for appropriate podiatric screening and podiatry management.

Author Information

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Auckland; Angela Bayley, Manager, Orthotic Centre Wellington Ltd, Thorndon, Wellington; Keith Rome, Professor in Podiatry, AUT University, Auckland

Acknowledgements

The authors thank the Health Research Council of New Zealand, New Zealand Sock Company (Ashburton, New Zealand), Merino Lanolin Cream Company (Auckland, New Zealand), the Orthotics Centre Ltd (Ellerslie, Auckland, New Zealand), Adam Rome, and Emma Hoult for their support of the project.

Correspondence

Belinda Ihaka, Lecturer, Department of Podiatry, AUT University, Faculty of Health & Environmental Sciences, 90 Akoranga Dr, Northcote 0627, Private Bag 92006, Auckland 1142, New Zealand.

Correspondence Email

belinda.ihaka@aut.ac.nz

Competing Interests

None declared.

Wild S, Roglic G, Green A, et al. Global prevalence of diabetes: estimates for the year 2000 and projections for 2030. Diabetes Care. 2004;27:1047-1053.Simmons D, Rush E, Crook N. Prevalence of undiagnosed diabetes, impaired glucose tolerance, and fasting glucose among M ori in Te Wai o Rona: Diabetes prevention study. N Z Med J. 2009;122:30-38.The New Zealand Guidelines Group. 2003. Management of Type 2 Diabetes. Wellington.Simmons, D, Kenealy T, Scragg R. Foot care among diabetic participants in South Auckland.N Z Med J. 1995;108:106-8.Simmons D, Fleming C. Prevalence and characteristics of diabetic participants with no ongoing care in South Auckland. Diabetes Care. 2000;23:1791-1793.Simmons D, Schaumkel J, Cecil A, et al. High impact of nephropathy on 5-year mortality rates among participants with type 2 diabetes mellitus from a multi-ethnic population in New Zealand. Diabet Med. 1999;16:926-931.Lipsky B, Berendt A, Deery H, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2004;39:885-910.Ronnemaa T, Hamalainen H, Toikka T, Liukkonen. Evaluation of the impact of Podiatrist care in the primary prevention of foot problems in diabetic subjects. Diabetes Care.1997;20:1833-1837.Calle-Pascual A, Duran A, Benedi A, et al. A preventative foot care programme for people with diabetes with different stages of neuropathy.Diabetes Res Clin Pract. 2002;57:111-117.Armstrong D, Lavery L, Harkless L. Treatment-based classification system for assessment and care of diabetic feet.J Am Podiatry Med Assoc. 1996; 86:311-316.Mayfield J, Reiber G, Sanders L, et al. Preventative foot care in people with diabetes.Diabetes Care.1998;21:2178-2172.Cavanagh P, Ulbrecht J, Caputo G. New developments in the biomechanics of the diabetic foot. Diabetes Metab Res Rev.2000;16:S6-S10.DAmbrogi E, Giurato L, DAgostino M, et al. Contribution of plantar fascia to the increased forefoot pressures in diabetic participants. Diabetes Care. 2003;26:1525-1528.Adler A, Boyko E, Ahroni J, Smith D. Lower-extremity amputation in diabetes. Diabetes Care. 1999;22:1029-1035.Leng G, Fowkes F. The Edinburgh claudication questionnaire: an improved version of the WHO/ROSE questionnaire for use in epidemiological surveys. J Clin Epidemiol. 1992;45:1101-1109.Boulton A, Young M, Macleod A, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom Hospital clinic population. Diabetologia. 1993;36:150-154.Kim R, Edelman S, Kim D.Musculoskeletal complications of diabetes mellitus. Clin Diabetes. 2001;19:132-135.de Sonnaville J, Colly L, Wijkel D, Heine R. The prevalence and determinants of foot ulceration in type II diabetic participants in a primary health care setting.Diabetes Res Clin Pract. 1997;35:149-56.National Institute for Public Health and Mental Health Research. An intervention trial for M ori at risk of diabetes-related lower limb pathology. Auckland, 2010.Al-Qaisi M, Nott D, King D, Kaddoura S. Ankle brachial pressure index (ABPI): An update for practitioners. Vasc Health Risk Manag. 2009;5:833-841.DAmbrogi E, Giacomozzi C, Macellari V, Uccioli L. Abnormal foot function in diabetic participants: the altered onset of windlass mechanism.Diabet Med. 2005;22:1713-1719.Caselli A, Pham H, Giurini J, et al. The forefoot-to-rearfoot plantar pressure ratio is increased in severe diabetic neuropathy and can predict foot ulceration.Diabetes Care. 2002;25:1066-1071.Robinson T, Simmons D, Scott D, et al. Ethnic differences in Type 2 diabetes care and outcomes in Auckland: a multiethnic community in New Zealand. N Z Med J. 2006;119:1-10.Smith, L. Decolonizing methodologies: Research and indigenous peoples.New York: Zed Books;1999.

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