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Study: People with diabetes need to wear protective shoes indoors too

NEW YORK (Reuters Health) - Diabetic patients too often walk without wearing their custom-made shoes designed to prevent foot sores that can lead to infections and amputations, new research finds.
"It's very important that patients wear prescribed footwear as much as possible," said senior author, Sicco Bus, staff scientist with the Academic Medical Center at the University of Amsterdam in the Netherlands. "High-risk patients are too low in their adherence, and that needs to be improved."
The research, published in Diabetes Care, monitored the walking habits of 107 diabetic patients during a two-week period and found that for nearly a third (29 percent) of the steps patients took, they didn't wear their custom-made shoes.
In the group of mostly white male retirees, patient adherence to the prescribed footwear ranged widely, from 10 to 100 percent.
The diabetic study participants were at high risk for preventable foot ulcers because of decreased feeling in their feet and previously-healed foot ulcers.
Even more alarming, researchers noted, patients failed to wear their ulcer-preventing shoes for 39 percent of the steps taken at home, where the majority of walking occurred.
Patients took an average of about 4,000 steps inside the home and 2,600 steps outside - where they walked in their protective shoes 87 percent of the time.
"Patients generally think they have to primarily wear their footwear when they go outside, even though the doctor tells them to wear (customized shoes) as much as possible," Bus told Reuters Health.
The researchers did not examine whether wearing prescription footwear less often led to increased foot ulcers, but unprotected diabetic feet are considered particularly vulnerable to injury because of decreased sensation, insufficient blood flow, dry cracked skin, foot deformities and slow wound healing.
Researchers assume custom-made footwear helps diabetic feet, a notion never tested with appropriate clinical trials, said Dr. Dereck Hunt, an associate professor of internal medicine at McMaster University in Canada who runs a diabetes clinic.
"We lack high-quality data, so that makes it more difficult for groups to focus on developing strategies to address adherence," Hunt told Reuters Health.
Each year, an estimated 600,000 diabetic patients get foot ulcers, resulting in 80,000 amputations, according to the American Diabetic Association.
And prior research suggests that less than a third of diabetic patients with existing foot problems wear their prescribed footwear 80 percent of the time or more, Bus and colleagues write.
During the current study, the researchers used shoe-implanted monitors that sample temperature to determine when patients were wearing their customized shoes and ankle monitors to record the number of steps taken.
Participants also kept diaries of times when they were inside or outside of the home. The patients were told the objective of the research was to study temperature and not shoe compliance.
Beyond custom-made protective footwear, experts said preventive treatments for foot ulcers typically include appropriate screening for foot deformities or sores, adequate follow up from podiatrists and proper foot care such as callous removal and nail care.
"With a little bit of common sense and technology, we can start to address this problem," said Dr. David Armstrong, professor of surgery and director of the Southern Arizona Limb Salvage Alliance at the University of Arizona.
Some technologies under exploration include shoe implants that ping to remind diabetic patients to wear their custom-made shoes and sensor mats that can detect weaknesses in the soles of feet.
Bus and his colleagues are also exploring whether making patients conscious of their non-compliance might help improve adherence.
Bus also suggests that diabetic patients keep a pair of pressure-relieving shoes or sandals specifically for indoor use.
"I can understand pretty well why patients take off their shoes when they are in the house because I do it myself, too," he said. "These shoes are quite heavy."

Can Carrots Reduce the Effect of Diabetes-Causing Genes?

In the latest revelation about the human genome, researchers say individuals with a certain genetic mutation that predispose them to diabetes may be able to rely on beta carotene to reduce their symptoms.
Scientists from Stanford University report in the journal Human Genetics on an unique study in which they matched genetic variants linked to type 2 diabetes, in which people fail to make enough insulin to process glucose in the diet, against lifestyle risk factors associated with the disease, including diet and behaviors such as smoking and physical activity. Genetic analysis alone, in which scientists compare the genomes of those with diabetes against those without the disease, has previously identified 90 potential genetic changes that can increase the risk of diabetes, but none were especially strong contributors to the disease, and it wasn’t clear which combination of these DNA changes posed the greatest risk. Similarly, lifestyle factors such as diet or exposure to pollutants, which can be measured in blood or urine, couldn’t fully explain risk for the disease either. But by knitting the two databases together, the Stanford researchers say they may have identified some gene-environment match-ups that not only increase risk for diabetes, but may also help to protect against it as well.
“Over the past seven to nine years, [researchers] have been finding genetic risk factors. Some of them are pretty potent and have a lot of effects, but a lot is still relative. We are not really finding the smoking guns of the genome that we were expecting, that would really tell us why diseases like Type 2 diabetes have some genetic basis,” says study author Dr. Atul Butte, an associate professor of systems medicine in pediatrics at Stanford.
Using data from the National Health and Nutrition Examination Survey, he and his colleagues found five major environmental factors associated with diabetes; all five, including levels of beta-carotene (a precursor to vitamin A), and a form of vitamin E, could be measured in the blood or urine. They then studied the levels of these five factors in people with different combinations of 18 of the major genetic variants linked to diabetes to see if certain DNA patterns were connected to specific nutrient levels. “We realized that maybe some of the reason why these genetic markers aren’t really that potent or haven’t been that potent in other people’s studies, is that the genes themselves may not cause diseases. It’s the genes with the environment that cause disease.”
In other words, having a genetic mutation isn’t enough; that genetic mutation, in the presence of high or low levels of certain nutrients, might prime the body to process glucose less effectively. That may be the case with people who harbor the gene variant SLC30A4, which codes for a protein that is involved in helping beta cells in the pancreas make insulin, which is critical for breaking down glucose in the diet. Both beta carotene, which is commonly found in carrots, and gamma tocopherol, a form of vitamin D, which is found in vegetable fats like canola oils and margarine, interact with the gene and influence risk for Type 2 diabetes, but in opposite ways. Higher beta carotene levels appears to protect against diabetes, and presumably improve the gene’s efficiency in producing insulin, while elevated gamma tocopherol may increase a person’s risk for the disease.
“What the findings suggest is that if you have a genetic marker now or a predisposition for Type 2 diabetes, all you really need to do is increase the number of carrots you eat to increase your beta carotene, and maybe you can compensate for having that spot in your genome,” says Butte.
If only it were that easy. Butte’s work is still preliminary, and further studies would be needed to confirm that increases beta carotene levels in the diet would be sufficient to offset the effect of the diabetes-causing genetic variants. But, says Butte, the results are promising, especially when previous studies have identified other healthy behaviors that can reduce the risk of type 2 diabetes, such as eating less sugar and exercising daily. His findings, however, suggest more specific changes that could protect against the disease. ”It’s not easy to lose weight and to change your appetite and what we eat, but it’s a whole lot easier than changing our DNA,” he says. “It’s not destiny when you have something written in your DNA, but here’s one way to potentially change risk by searching out for certain environmental factors that we can change and do something about our genetics.”

Preventing Kidney Disease May Cut Diabetes Deaths, Study Says

THURSDAY, Jan. 24 (HealthDay News) -- For people with type 2 diabetes, the key to living a long and healthy life may lie in avoiding kidney disease, now that new research finds the combination is particularly lethal.
The study found that 10-year mortality rates for people with both type 2 diabetes and kidney disease is more than 31 percent. But for people with only type 2 diabetes, the death rate after a decade was 12 percent. For those with neither condition, the 10-year death rate was about 8 percent.
"We've all been trained to think of type 2 diabetes as a bad thing, but it's particularly bad when you get kidney disease, too," said study author Dr. Maryam Afkarian, a kidney specialist and an assistant professor of medicine at the University of Washington in Seattle.
On the other hand, "We found that type 2 diabetes may not affect mortality as much if you don't get kidney disease," she said.
Results of the study are published in the February issue of the Journal of the American Society of Nephrology.
People with type 2 diabetes do not produce or properly use insulin, a hormone needed to convert food into energy. In the United States, about 26 million people have diabetes, and the number is growing. Type 2 diabetes has long been associated with an increased risk of death, especially from cardiovascular disease. And kidney disease is common in people with type 2 diabetes.
To better understand how the two diseases behave together, the researchers reviewed 10 years of data from the U.S. National Health and Nutrition Examination Survey, involving more than 15,000 people. About 42 percent of people with type 2 diabetes had kidney disease, they found.
When the researchers controlled the data to account for factors such as age, sex and body-mass index -- a calculation based on height and weight -- as well as duration of diabetes, the rates of death remained high for people with kidney disease and diabetes, at about 23 percent. The 10-year mortality for those with only type 2 diabetes was 9 percent when the data was adjusted for such factors, while the rate of death for people without diabetes or kidney disease was about 3 percent.
"As we expected, those with diabetes and kidney disease had a lot higher risk of mortality," said Afkarian.
"Clearly, we're not at the point of stopping type 2 diabetes," she said, "so the next question becomes, 'What happens if we can keep the kidneys healthy?'"
She said prevention efforts should focus on people who have diabetes but not kidney disease. "Try to control your risk factors to prevent kidney disease," she suggested. And, the biggest risk factor is uncontrolled blood sugar.
However, there also is a genetic component to developing kidney disease, she said. So, if you have those genes, you may develop kidney disease even if your blood sugar is well-controlled. But for most people with type 2 diabetes, controlling blood sugar levels can help prevent kidney disease, or at least slow its progression, she said.
Dr. Joel Zonszein, director of the Clinical Diabetes Center at Montefiore Medical Center in New York City, approved of the analysis. "It shows that once someone is sick, it's a bad marker," he said.
"We always have to emphasize much more on prevention. There's a nice correlation between A1C (a long-term measure of blood sugar control) and kidney disease. And people without high blood pressure tend to do better," he noted.
The problem, he said, is that it's often "a long time before people are diagnosed with type 2 diabetes, and when they are diagnosed, they're often undertreated, which leads to uncontrolled diabetes."
Zonszein said many people with type 2 diabetes who should be taking cholesterol and blood-pressure lowering medications aren't on them. Afkarian said people who have both type 2 diabetes and kidney disease should be monitored more closely by their physicians.
It's important to remember that it's much easier to prevent kidney disease than to stop it once it's begun, Afkarian said.
"There's a long time to intervene before kidney disease sets in," she said. "It can make all the difference in the world."