Diabetic Management 1

Running head: DIABETIC MANAGEMENT

Diabetic Management

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Research Topic/Hypothesis: The Management of Diabetics

The ability to manage diabetics in the field of nursing is becoming an extremely

important public health issue. The rate of diabetes is rapidly increasing throughout the world.

The care and treatment of diabetes takes up a great deal of public and private medical resources,

particularly in developing nations. The Caribbean has been chosen as the focus for this research.

Country Focus: Caribbean

Narayan et al (2006) estimated that as of 2003, 19,026 people in Latin America and the

Caribbean were afflicted with this disease. It is estimated that by 2025, over 36,000 people in

Latin America and the Caribbean will have diabetes, rising from 6.0% in 2003 to 7.8% in 2025.

Worldwide, in 2003, the prevalence of diabetes was 5.1% for people between the ages of 20 and

79 (Narayan et al., 2006). The direct medical costs for this region for diabetes related medical

expenses were $8,676 US million in 2003 alone. In 2001, there were 163,000 deaths in Latin

America and the Caribbean related to diabetes. The Disability-adjusted years in 2001 reached

2,775,000 (Narayan et al., 2006, Table 30.1).

Summary of the Study

Background

The costs of diabetes in the developing world were the highest in Latin America and the

Caribbean. Diabetes lowers the quality of life among the afflicted persons. Coupled with the

already low standard of living, the need is high to alleviate this disease in the Caribbean area as

much as possible. This study will explore whether or not women’s likelihood of wearing

appropriate shoes is will change after appropriate nursing education.

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Methods

The study will be comprised of a focus group of 15 to 20 females patients aged 20 to 79

selected randomly from the female patients who have received nursing education on the need to

wear appropriate footwear. The sample will be a convenience sampling and participants will be

chosen randomly until a minimum of 20 patients have agreed to come to the focus group. It is

anticipated that out of 20, 15 will actually attend. However, if the larger number attends, that is

acceptable.

The data will be collected using note taking by the moderator. The session will also be

tape-recorded directly onto a laptop for review later by the researcher. Informed consent by

participants will be required. Analysis will be conducted using content analysis.

Introduction and Literature Review

One of the most devastating side effects of diabetes is the diabetic foot syndrome

(Chandalia et al., 2008; Price, 2004). Bus et al. (2011) pointed out that foot ulcerations are one of

the most prevalant of the long-term complications of diabetes, and can lead to infection and

amputation. Viswanathan et al. (2004) suggested that diabetic patients who have already had

ulcers or amputations are at particular risk for ulceration, infection, and amputation. Further, as

the foot alters depending on the dynamics of the foot and its injuries, joint deformities can

develop, and new ulcers can form (Viswanathan et al., 2004). The issue is so critical that

Maciejewski et al. (2004) reported that preventing the formation of foot ulcers should be one of

the major clinical objectives in the care of diabetes. Maciejewski et al. (2004) cite a study by

Pecoraro et al. (1990) which showed that in the US, 68% of all amputations were related to

diabetes. Efforts to prevent ulcers can help avoid other serious side effects that would reduce the
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quality of life for patients and would increase the overall health costs of the patient, and thus the

nation (Maciejewski et al., 2004).

In 2004, Price reported that there had been few studies which really investigated quality

of life of patients of diabetes who had suffered foot complications. It is clear that amputation can

have a drastic impact on anyone’s life; without feet, or with the unbalance that results from

partial amputation, the ability to ambulate becomes a real concern. The inability to ambulate can

interfere not only with the patient’s social life (Boutoille et al., 2008; Narayan, 2006) but with

their general physical limitations. Further, with obesity so concurrent with obesity that the

combination is sometimes call ‘diabesity’ (Farag & Gaballa, 2011), patients can ill afford to have

physical limitations that preclude getting regular physical exercise. Finally, Willrich (2005) and

Boutoille et al., (2008) both suggested that quality of life may be as low for groups that develop

ulcers as for groups of patients who experience amputation.

Chandalia et al. (2008) asserted that the majority of the symptoms relating to diabetic

foot syndrome are preventable and relate to patient knowledge and to improper footwear.

Chandalia et al. (2008) suggest that patients are typically not educated as to how to properly care

for their feet or how to control their diabetes. In addition, the habit in India is to go barefoot

indoors, with a significant number of Indians going barefoot outdoors. When Indians visit

relgious shrines, they are also likely to go barefoot (Chandalia et al., 2008). The authors assert

that in India (as well as other hot climates, which would include the Caribbean), hot pavement

and softened asphalt roads can lead to serious injury.

Other factors that may contribute to injury include style of shoes (in India, pointed), the

lack of socks, lack of straps, and exposed heels and toes (Chandalia et al., 2008). Chandalia et al.

(2008) suggested that corns, calluses, foot fissures, deformities, and nail abnormalities were all
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precursors of further problems that could be expected to occur if the feet did not receive better

care. One of the methods of care involves utilizing better footware. However, for many years, the

asumption has been made that good diabetic footwear is ‘ugly’ and that diabetic footwear that is

not ugly is unlikely to be good (Boulton & Jude, 2004). Although it seems at first glance to be a

facetious concern, that footwear may be ‘ugly’, the presumption was made that patients would

not wear ugly footwear, thus condeming themselves to wearing footwear that was bad for

diabetic feet (Boultion & Jude, 2004).

Boulton and Jude (2004) argue that there is abumdant anecdotal evidence that bad, or low

quality, footwear contributes to the development of toe ulcers and foot lesions, ut little empirical

evidence. One European study suggested that bad footwear contributed to 21% of all foot uclers.

In studies where the patients were actually given footwear, they were only worn 22% of the time,

because patients believed they were ugly. The authors suggest that a deeper issue is whether or

not therapeutic footwear can really prevent development of food ulcers (assuming of course tha

thtey are worn). Boulton and Jude (2004) conclude that as of the time of the article, there was no

real evidence that therapeutic footwear, even if worn, would make a difference in outcome. They

recommneded this as an area of future study and research.

Viswanathan et al.’s 2004 study of 241 diabetic patients concluded that therapeutic

footwear is useful in reducing the numbers of new ulcers and by inference the rate of amputation

in the diabetic community. This group of patients was studied for 9 months and utilized a control

group to ensure that differences in results came from footwear. Maciejewski et al. (2004)

concluded after a literature study that emphasis should be placed on decreasing incidents that

might lead to foot ulcers, on an individual basis rather than a universal recommendation.

Ullbrecht et al., 2004 reported that it was important for patients to wear their therapeutic shoes,
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but that there was at that point no real way to determine which type of footwear would serve best

for any given foot and patient characteristic. Bus et al. (2011) studied plantar pressure in diabetic

patients and concluded that in-shoe plantar pressure was an accurate tool to evaluate footwear

quality and improve outcome, while Price (2004) merely suggested that patients who received

orthotic treatment had a better outcome overall. Chandalia et al. (2008) studied patients who used

sturdy shoes and compared them to patients who utilized open toed and heeled shoes, and

concluded that the sturdier shoe brought better outcomes; they did not study any use of orthotic

shoes.

Actis et al. (2008) reported that “There is evidence that appropriate footwear is an

important factor in the prevention of foot pain in otherwise healthy people or foot ulcers in

people with diabetes and peripheral neuropathy” (p. 363) but did not provide evidence of this.

Instead, they studied the design of orthotics and orthotic inserts and concluded that insertion of a

set of plastizote plugs under the foot’s impact area would be of greatest efficacy to the patient.

Four shoe insole models were produced from measurements of the pressure the patient put on the

shoes. The results showed that using soft localized plugs inserted into the insole would reduce

peak plantar pressure in the metartarsal region of the foot. However, the team suggested that

additional testing be conducted to study the results of plug usage when the skin had already

broken down or when there was forefoot pain.

Search Strategy

Research strategy involved the use of medical literature data bases. Initial search was

conducted on the terms <diabetes> and <foot care>. Subsequent searches included the terms

<stress>, <pressure>, <shoes>, <amputation> and <hot>. Of the articles that resulted from these
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searches in various combinations, 12 articles were in the final group selected for inclusion in the

literature and background.

Conceptual Framework

This exploratory research will investigate whether adult diabetic female patients who

have received education in the necessity of adequate footwear seem to be more likely to wear

‘sturdy’ shoes such as running shoes with modified insoles, or whether they are likely to

continue to wear higher fashion shoes during casual wear.

Hypothesis, Research Questions, and Objectives

Will adult women who have received education in the necessity of adequate footwear

seem to be likely to wear sturdy shoes, such as running shoes with specially modified insoles, or

will they be likely to continue to wear higher fashion shoes during casual wear?

Fifteen to 20 adult female patients who have received patient education in the need to

wear appropriate footwear will be selected for participation in a focus group which will meet to

discuss diabetes and footwear selections. The discussion will revolve around shoes, diabetes,

shoe styles, personal needs, and desires regarding shoes. The aim will be to determine if

educating diabetic women in the need to protect their feet will help them make the decision to

put form over fashion. At the end of the focus group the women will be asked if their opinion of

wearing appropriate shoes changed after receiving education on the need to wear the shoes.

Methodology

Study Design

The study will be an exploratory design with a population of 15-20 female participants

selected from the treatment population. The sampling will be a convenience sampling from the

group of female patients aged 20-79. Patients will be selected at random from the group of
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female adult patients who have received appropriate education on the need to maintain adequate

footwear. Patients will be selected until 20 female patients have agreed to participate in the focus

group. Fifteen patients will be required to attend in order to have the group.

Data Collection

Data will be collected during the focus group. The moderator will take notes and will

record the session on the laptop. Reliability is not a consideration with this method of study. The

exploratory nature of the study is intended to gather data to suggest future study. As a result,

validity is relative only to the specific study group.

Data Analysis and Limitations

Data analysis will be textual analysis based on participant responses and recorded

responses, as well as the participant’s answer as to whether or not the education changed their

minds about wearing less appropriate shoes. The aggregate responses to this question will be

compared to the textual analysis. The limitation of the study is that it will be limited to a small

group in a limited practice. However, exploratory studies are intended to suggest other avenues

of future research and are not intended to be generalizable.

Ethical Considerations

Participants will be given informed consent letters and asked to sign an agreement. No

one will be physically hurt during this research. Ethical considerations revolve around privacy.

All documentation, including recordings, will be kept locked up except when the researcher is

using them, and no information will be recognizable on an individual basis or linked with a name

or medical record.
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Budget and Gant Chart

The researcher will use a laptop and a room for the focus group that is already available

to her. Healthy snacks and drinks for the focus group are expected to cost $50. Copying/printing

costs are expected to be approximately $25. No other expenses are expected except the

researcher’s time, which is contributed.

The Gantt Chart for the project is presented below:

Figure 1. Gantt Chart Project Schedule

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References

Actis, R. V. Ventura, L., Lott, D., Smith, K., Commean, P., Hastings, M., & Mueller, M. (2008).

Multi-plug insole design to reduce peak plantar pressure on the diabetic foot during

walking. Med Biol Eng Comput, 46, 363-371.

Boulton, A. &. & Jude, E. (2004). Therapeutic footwear in diabetes: The good, the bad, and the

ugly? Diabetes Care, 27(7), 1832-1833.

Boutoille, D. F., Feraille, A., Maulaz, D., & Drempf, M. (2008). Quality of life with diabetes-

associated foot complications: Comparison between lower-limb amputation and chronic

foot ulceration. Foot Ankle Int, 29(11), 1074-1078.

Bus, S., Haspels, R., & Busch-Westbroek, T. (2011). Evaluation and optimization of therapeutic

footwear for neuropathic diabetic foot patients using in-shoe plantar pressure analysis.

Diabetes Care, 34, 1595-1600.

Chandalia, H., Singh, D., Kapoor, V., Chandalia, S, & Lamba, P. (2008). Footwear and foot care

knowledge as risk factors for foot problems in Indian diabetics. Int J Diab Dev Ctries,

28(4), 109-113.

Farag, Y., & Gaballa, M. (2011). Diabesity: An overview of a rising epidemic. Nephrology,

Dialysis, Transplantation, 26(1), 28-35.

Maciejewski, M., Reiber, G., Smith, D., Wallace, C., Hayes, S., & Boyko, E. (2004).

Effectiveness of diabetic therapeutic footwear in preventing reulceration. Diabetes Care,

27(7), 1774-1782.

Narayan, K., Zhang, P., Kanaya, A., Williams, D., Engelgau, M., Imperatore, G., &

Ramachandran, A. (2006). Chapter 30 diabetes: The pandemic and potential solutions. In

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D. B. Jamison (Ed.), Disease Control Priorities in Developing Countries (2nd ed.).

Washington, DC, USA: World Bank.

Price, P. (2004). The diabetic foot: Quality of life. Clinical Infectious Diseases, 39(Suppl 2),

S129-S131.

Ullbrecht, J., Cavanagh, R., & Caputo (2004). Foot problems in diabetes: An overview. Clinical

Infectious Diseases, 39(Supplement 2), S73-S82.

Viswanathan, V., Madhavan, S., Gnanasundaram, S., Gopalakrishna, G., Das, B., Rajasekar, S.,

& Ramachandran, A. (2004). Effectiveness of different types of footwear insoles for the

diabetic neuropathic foot. Diabetes Care, 27(2), 474-477.

Willrich, A., Pinzur, M., McNeil, M., Juknelis, D., & Lavery, L. (2005). Health related quality of

life, cognitive function, and depression in diabetic patients with foot ulcer or amputation.

A preliminary study. Foot Ankle Int, 26(2), 129-134.

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Appendices

Data Collection Measures

Questions that may stimulate discussion for the focus group:

 How long have you had diabetes?

 Do you feel like you learned anything new about care of your feet in the

education session with the nurse?

 What do you think of diabetic shoes in general?

 Do you wear diabetic shoes?

 Why or why not?

 Would you wear them if they were “prettier” or more stylish?

 Would you wear running shoes with special inserts, for casual wear?

 Did learning about footware in your education session make you more likely to

wear diabetic shoes?

Consent Forms
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References

(Narayan, 2006)

(Bus, 2011)

(Maciejewski, 2004)

(Viswanathan, 2004)