Diabetic foot as a complication of diabetes?

To better understand the onset of diabetic foot, let's first discuss what diabetes is and what its complications are.

Factually speaking, diabetes actually means elevated sugar levels in the body.

But where is this sugar located and why is its level elevated?

Simply put, the cause of elevated sugar (glucose) levels is a relative or absolute lack of insulin.

Insulin is a hormone that is made in the pancreas. Specifically, it is made in the beta cells of the islets of Langerhans, if you wanted to know more.

This hormone has the job of transporting sugar obtained from food into the cells where it is converted into energy.

All this happens in the liver, where insulin takes up the glucose in the blood and makes a sort of store of it. This stored sugar is called glycogen.

Sugar (glucose) is primarily found in the blood and is needed as energy for the muscles and brain.

In the muscles, it then transports glucose to the muscle cells. This provides the primary energy for the working muscles. One of the symptoms of diabetes is general fatigue. Logically - this is conditioned by a failure of glucose transport to the muscle cells.

Important to understanding the pathophysiology of diabetes is that insulin lowers blood glucose levels by causing its uptake. Thus, its lack or reduced effect causes elevated blood sugar levels.

This is actually diabetes.

Classification of diabetes

Let us now look at the classification of diabetes.

We know several types, two of which should interest us most in terms of diabetes mellitus (the technical name for diabetes) as a disease of civilization.

In general, diabetes is related to excess diet and overconsumption, which is why its proportion is highest in developed countries.

Its overall proportion is approximately 10 %. It is believed that a certain percentage of the population remains undiagnosed.

Unhealthy eating habits and overeating are among the factors that promote the development of diabetes. Diabetes itself then increases the percentage of patients with cardiovascular disease.

Read more:
Classification of diabetes
Symptoms of diabetes and its complications

Type 1 diabetes mellitus

This type of diabetes is caused by complete or partial insulin deficiency. This is caused by the destruction of the site of insulin production, i.e. the beta cells in the pancreas mentioned above. If only something like 20% of these cells remain, diabetes will start to manifest itself.

Most of the time, the insulin-producing cells are destroyed by an autoimmune process called insulitis. The causative agents are thought to be various viral diseases. These include mainly parotid gland inflammation, measles, and possibly influenza or parainfluenza.

In most cases, it manifests itself in youth. Sometimes it can even appear later. A genetic origin is also assumed, but it must still be linked to some external factor that triggers the autoimmune reaction.

The diagnosis of this type of diabetes is made on the basis of elevated blood sugar levels, i.e. hyperglycaemia. Then there is glycosuria, in other words the presence of glucose in the urine, and ketonuria. This means ketone bodies in the urine. By these we mean acetoacetic acid and acetone.

Patients are dependent on an external supply of insulin to the body.

Type 2 diabetes mellitus

It mainly means resistance, i.e. the resistance of cells to the effects of insulin. There is also a disorder of its secretion.

Type 2 diabetes is up to 10 times more common than type 1.

It occurs mainly in adulthood, rarely below the age of 30. It occurs mainly in obese patients, which is due to its cause.

It is caused by a disproportion between the production and action of insulin in the target cells.

The cells are insensitive or resistant to its action, resulting in so-called insulin resistance. The compensation is increased production by the pancreatic cells, i.e. hyperinsulinaemia. Initially, the body manages to overcome this limit of cellular resistance and maintains blood glucose levels at acceptable levels.

Later, with constant and frequent stimulation of insulin production, the pancreatic cells wear out and insulin production starts to decrease. This also increases blood sugar levels, hyperglycaemia develops and diabetes manifests.

This type of diabetes is strongly genetic. It is also associated with other diseases such as:

• metabolic syndrome
• pancreatitis
• cystic fibrosis
• pheochromocytoma

Common external factors that cause this type of disease are considered to be overeating, poor diet composition, lack of exercise, obesity or smoking and many others.

Also read the article on metabolic syndrome.

Symptoms of diabetes

The optimal blood sugar level, if we have not taken any food for at least 8 hours, is 5.6 mmol/l. As a rule, values between 4 and 6 mmol/l are considered normal.

The symptoms of diabetes are similar in both types.

Due to low insulin levels or increased resistance of the cells to its action, hyperglycaemia occurs. This means that the blood sugar level is increased. At the same time, the sugar level is reduced where it should not be, in the cells. Mainly in the muscle cells and in the cells of the central nervous system, i.e. in the brain.

The cells start looking for another source of energy.

If there is no medium in the body for the transfer of sugar from the blood to the cells, or even no medium at all, the cells get their energy from fat stores. To release this energy, the fats must be converted into ketone bodies. And these are atecoacetic acid and acetone. Their production increases and one of the symptoms of diabetes, acetone halitosis, manifests itself.

When the production of ketone bodies exceeds their utilization, what is called ketoacidosis develops. This is an increased production of ketone bodies in the body.

Since ketone bodies are water soluble, they are excreted from the body in the urine. We have another symptom here, and that is ketonuria. That is an increased amount of ketone bodies in the urine.

When acidosis is exacerbated, the respiratory centre in the medulla oblongata is stimulated.

The elevated blood sugar level itself means that it is also passed into the excreted urine at an increased rate. This is called glycosuria.

Glucose and ketone bodies are osmotically active. This means that more water enters the urine along with them, causing polyuria. It's actually excessive urination.

If water is drained from the body, dehydration occurs to a greater extent. This lost water the body tries to regain and polydipsia occurs. This is excessive thirst.

Excessive urination causes a feeling of thirst. With it comes excessive fluid intake. This causes excessive excretion of water from the body and so on.

The symptoms of diabetes are listed in the table below.

Complications of diabetes

Complications of diabetes can be divided into acute and chronic.

The acute ones occur quickly, usually when there is a violation of lifestyle or a mistake in treatment. The chronic ones develop slowly and are usually caused by the effect of the disease itself on the body.

For better orientation, the following table gives a breakdown of the complications of diabetes

Of all the complications of diabetes, we will be most interested in the chronic ones.
In terms of the development of the diabetic foot, they are the cause of it.

In this article you can read about the other complications of diabetes.

Chronic complications of diabetes

Again, hyperglycemia acts as the main mechanism for their development. Compensation for diabetes must be consistent if we want to avoid such problems.

Chronic complications of diabetes most commonly affect the blood vessels. They are divided into macrovascular and microvascular according to the involvement.

A breakdown of chronic complications of diabetes is given in the table below

Macrovascular complications of diabetes

This is an affection of the large blood vessels. It is caused by atherosclerosis.

Ischaemic disease of the lower limbs

In the beginning, it manifests itself as leg pain on walking. Later, due to impaired supply of nutrients to the tissues, changes occur in the skin and bones. In the last stage, diabetic gangrene develops, which is usually an indication for amputation of the affected limb. The whole set of such problems is called diabetic foot.

Ischaemic heart disease

This is a consequence of involvement of the coronary arteries of the heart muscle. It can progress to the acute form, which is myocardial infarction. In diabetics, it often occurs without a main clinical symptom and without chest pain.

Ischaemic brain disease

This is a stroke. In this case, the ischaemic form is often present, i.e. caused by a lack of blood supply to the brain tissue.

Microvascular complications of diabetes

This is a full-body involvement of small blood vessels. Factors that accelerate these processes include high blood pressure and excessive protein intake. A genetic factor is also possible. These changes are most pronounced in three places. The retina, kidneys and nerve fibres.

Diabetic retinopathy

It is manifested by changes in the blood vessels of the retina. There is a gradual deterioration of vision. Treatment is carried out by an ophthalmologist, for example by using a laser.

Diabetic nephropathy

Affection of the blood vessels of the kidneys results in a reduced function of the glomeruli, i.e. a reduction in their ability to filter. Often results in their failure. Therapy involves reducing protein intake, good compensation for the diabetes itself and treatment of high blood pressure.

Diabetic neuropathy

It is a common complication. It reduces mobility and sensitivity, particularly of the lower limbs. Thus it is a major factor in the development of diabetic foot. Good compensation for diabetes is considered an effective basis for its treatment.

We will stop here for a moment longer.

Diabetic neuropathy is a major factor in the development of diabetic foot syndrome.

It is actually nerve damage that manifests itself in typical symptoms:

• paresthesia - tingling in the limbs.
• dysesthesia - impaired sensation in the limbs
• rest pain in the lower limbs

Approximately 50% of cases of diabetes develop diabetic neuropathy.

It can be expected in any diabetic patient with type 1 diabetes of more than 5 years duration. Patients with type 2 diabetes, regardless of its duration, are another risk group.

The risk factors that cause it are different. Some can be easily influenced, others cannot.

These include age, smoking, alcohol, socioeconomic status, duration of diabetes itself, genetic factors, renal failure and, of course, microvascular impairment.

Diabetic neuropathy affects both the peripheral and autonomic nervous system. There are many forms of this problem. However, it most commonly manifests as symmetrical distal sensory-motor neuropathy and cardiac autonomic neuropathy.

Symmetrical distal sensory-motor neuropathy

This form is a major contributor to the development of diabetic foot.

It is characterised by reduced sensitivity of the fingers and feet. The characteristic symptom is nocturnal muscle spasms of the lower limbs accompanied by pain and increased fatigue. The nutrition of the skin of the lower limbs is impaired, resulting in damage to the skin.

Cardiac autonomic neuropathy

It is manifested by orthostatic hypotension, i.e. low blood pressure, which is related to the standing position of the body. Other problems it causes are cardiac arrhythmias, palpitations even at rest, ischaemia of the heart muscle or swelling of the lower limbs.

Diabetic foot

Can be defined as infection, ulceration and destruction of deep tissues along with neurological abnormalities associated with ischemic disease of the lower limbs.

Complications from even minor lower limb injuries are a risk. These may result in amputation.

Consistent preventive measures can reduce the risk of lower limb amputation by up to 50%.

Diabetic foot is caused by ischaemic and neuropathic complications of the lower limbs.

As a result of the ischaemia of the lower limbs, the blood supply and therefore the nutrients to the lower limbs are impaired. This results in the development of various skin defects.

Neurological impairment in turn causes a deterioration in sensitivity.

Otherwise, the formula "ischaemic lower limb disease and diabetic neuropathy = high risk of diabetic foot" could be applied.

Their manifestations are different. In many ways, they're contradictory, but ultimately destructive.

Ischemic manifestations:

• impaired blood flow to the lower limbs
• the leg is cold
• the skin is pale, dark at the puncture site
• peripheral pulsations are weak or absent

As a result of the poor blood supply, various defects are formed on the skin. These are mainly located on the peripheral parts, i.e. on the toes, heel or edge of the foot. Even a slight touch makes the area painful. The skin may peel off.

In the next stage, gangrene can occur. It is a secondary necrosis, i.e. tissue death. This condition is very dangerous and is treated by amputation.

The affected area is black and hard.

Neuropathic manifestations:

• postural and gait disturbances
• loss of protective sensitivity of the skin
• the leg is warm, pink and dry
• peripheral pulsations are palpable

Because of the loss of sensation in the lower limbs, patients often do not feel pain.

This is a great risk for the development of minor injuries, which the affected person often does not even know about. Due to the primary disease of diabetes, wounds heal only slowly. This causes further complications and the development of skin damage and defects.

Newly formed defects are 45% neuropathic, 7% ischemic and 48% mixed aetiology.

Classification of diabetic foot syndrome

There are several classifications of diabetic foot. The most common is the Wagner classification.

It is based on the assessment of the depth of ulceration (penetration of the ulcer) and the presence of infection at the site of the lesion.

By way of explanation, ulceration means what is known as ulceration.

It is usually regarded as a standard, as it predicts the risk of amputation of the limb. The disadvantage is that it does not distinguish the presence or absence of ischaemia in grades 1 to 3. This significantly worsens the prognosis of the skin defect.

The Wagner classification is given in the table below

Treatment of diabetic foot

All degrees of damage according to the Wagner classification are more or less in the care of the attending physician. His advice and instructions should be followed.

At grade 0, when the skin cover is not yet damaged, but risk factors are present, certain principles must be followed.

Care consists of regular examinations and patient education. This is aimed at self-examination and treatment of the lower limbs, treatment of their neuropathy or ischemia.

The care of the lower limbs of patients with diabetes mellitus with lower limb ischemia or neuropathy consists of the following:

• consistent treatment of diabetes and, where appropriate, high blood pressure.
• lifestyle changes, i.e. stop smoking, drinking alcohol, increase exercise, reduce weight
• checking the lower limbs and feet every day
• washing the feet every day and drying them thoroughly
• applying cream to dry skin
• do not go barefoot
• avoid sharp objects when treating the feet
• inspecting the inside of shoes
• changing socks daily, preferably wearing white socks (you can see traces of blood on them if there is an injury)

It can be concluded that by early and consistent treatment of diabetes mellitus itself, the risk of developing its complications can be eliminated. However, the main focus should be on preventing their occurrence. This will in turn improve the quality of life of the affected person.

Read also the article on weight loss