This site uses cookies to store information on your computer, which will improve your experience. Introduction: The purpose of this systematic literature review is to review published studies on foot care knowledge and foot care practice interventions as part of diabetic foot care self-management interventions. Methods: Medline, CINAHL, CENTRAL, and Cochrane Central Register of Controlled Trials databases were searched.
Results: Thirty studies met the inclusion criteria and were classified according to randomized controlled trial (n=9), survey design (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1). Conclusion: Preventing these complications, understanding the risk factors, and having the ability to manage complications outside of the clinical encounter is an important part of a diabetes foot self-care management program.
Competing interests and funding: The authors declare that they have no conflicts of interest nor was any funding made available for this study. With an impact of over 300 million people worldwide, diabetes has become the fastest developing chronic disease (1).
Uncontrolled T2DM has serious health implications other than chronic hyperglycemia, such as heart disease, stroke, retinopathy, neuropathy, and nephropathy (2).
T2DM foot complications, which more often affect older adults, have the capacity to diminish a person’s quality of life (1). This systematic review contains research studies of foot care knowledge and foot care practices interventions.
Two investigators (TJB and ESL), independently reviewed publications by title and abstract according to the above mentioned criteria by rating the studies with a yes or no. Describe the setting, locations, and relevant dates, including periods of recruitment, exposure, follow-up, and data collection. Clearly define all outcomes, exposures, predictors, potential confounders, and effect modifiers. For each variable of interest, give sources of data and details of methods of assessment (measurement). Discuss limitations of the study, taking into account sources of potential bias or imprecision.Discuss both direction and magnitude of any potential bias. Give a cautious overall interpretation of results considering objectives, limitations, multiplicity of analyses, results from similar studies, and other relevant evidence.
An explanation and elaboration article discusses each checklist item and gives methodological background and published examples of transparent reporting.
Data abstraction was conducted by one investigator (TJB) using the procedures in Garrard’s method of literature review (17). Systematic review flow diagram on diabetes-related foot care knowledge and foot care skills interventions in US studies. The journals that have reported studies are from foot and ankle journals (n=2), diabetes journals (n=12), nursing journals (n=7), rehabilitation journals (n=4), and medical journals (n=6). This systematic review is composed of studies ranging from randomized controlled trials (n=9), surveys (n=13), cohort studies (n=4), cross-sectional studies (n=2), qualitative studies (n=2), and case series (n=1) (Supplementary Table 1). The learning outcomes of the studies were measured by general T2DM knowledge scores (36), self-care scores (30, 37–40), foot care knowledge scores (8, 29, 33, 41, 42, 43), self-efficacy scores (30, 31, 37), and physician prevention survey scores (44).
The clinical outcomes that were assessed in the studies included hospitalizations (23), ulcerations (23, 32, 42), ER visits (23), antibiotic treatments (23), foot operations (23), lower extremity amputations (23, 26), missed work days (23), presence of vascular disease (32), foot trauma (32), comorbid complications (32), foot lesions (25, 36), calluses (9), peripheral vascular disease (9), bunions (9), hammertoes (9), glucose levels (9), dorsalis pedis pulses (25), posterior tibial pulses (25), femoral pulses (25), peripheral neuropathy (25), dry or cracked skin (25), ingrown nails (25), fungal nail infections (25), fungal skin infections (25), and interdigital macerations (25).
Proper foot self-care behaviors can reduce the risk of injury, infection, and amputation in someone with an at-risk foot (37).
Foot injuries and ulceration have been associated with poor T2DM-related foot care knowledge and foot self-care skills (29). Diabetes Self Management Education (DSME) has been shown to be the foundation of care for anyone with T2DM wanting to improve disease-related health outcomes (49). This systematic literature review is a comprehensive examination of foot self-care knowledge and practice interventions conducted within the United States, solely on individuals with T2DM. The literature has shown that T2DM self-care management programs have a positive impact on self-care behaviors, as well as health outcomes, even with a lack of consensus on the best approach.
The primary author has full control of all primary data, which may be assessed by contacting the corresponding author. Associations between coping, diabetes knowledge, medication adherence and self-care behaviors in adults with type 2 diabetes. Theory-guided intervention for preventing diabetes-related amputations in African Americans. GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, p.
Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations.
Strengthening the reporting of observational studies in epidemiology (STROBE): explanation and elaboration. Management of patients with type II diabetes residing at a homeless shelter: a series of case reports. Foot care assessment in patients with diabetes: a screening algorithm for patient education and referral.
Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Foot education improves knowledge and satisfaction among patients at high risk for diabetic foot ulcer.
Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. Development and formative evaluation of a foot self-care program for African Americans with diabetes.
Facility-level variations in patient-reported footcare knowledge sufficiency: implications for diabetes performance measurement. Use of folk treatments for diabetic plantar ulcers among African Americans with type II diabetes. Comparison of three types of diabetic foot ulcer education plans to determine patient recall of education. Behaviors predicting foot lesions in patients with non-insulin-dependent diabetes mellitus.
Perceived risk of amputation, emotions, and foot self-care among adults with type 2 diabetes. Foot care practices, services and perceptions of risk among Medicare beneficiaries with diabetes at high and low risk for future foot complications. Personal and treatment factors associated with foot self-care among veterans with diabetes. Patient interpretation of neuropathy (PIN) questionnaire: an instrument for assessment of cognitive and emotional factors associated with foot self-care.
A CNS-managed diabetes foot-care clinic: a descriptive survey of characteristics and foot-care behaviors of the patient population. Diabetes self-management education for older adults: general principles and practical application.
Potential economic benefits of lower-extremity amputation prevention strategies in diabetes.
Both authors contributed to discussing the content of the article, researching data and writing the manuscript. Wen XiongWen Xiong is an attending rheumatologist at Newark Beth Israel Medical Centre, NJ, USA.
Managing diabetic ketoacidosis (DKA) in an intensive care unit during the first 24-48 hours always is advisable.


In addition, awareness of special populations such as patients with renal disease presenting with DKA is important.
DKA is diagnosed with blood and urine tests; it is distinguished from other, rarer forms of ketoacidosis by the presence of high blood sugar levels.
Diabetic ketoacidosis (DKA) is the combination of hyperglycemia, metabolic acidosis, and ketonaemia. One of the cookies used is essential for parts of the site to operate properly and has already been set.
References from the included studies were reviewed to identify any missing studies that could be included. Improving lower extremity complications associated with type 2 diabetes can be done through effective foot care interventions that include foot care knowledge and foot care practices.
Interventions and research studies that aim to reduce lower extremity complications are still lacking.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License, permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Despite cases of unreported causes of death in the United States, diabetes (T2DM) was still noted as the seventh leading cause of death in 2006 (2).
The complications do not end there; lower extremity amputations comprise over 60% of non-traumatic amputations in the United States (8).
Foot self-care behaviors, including daily inspection of feet, professional treatment, hygiene, and proper shoe gear help minimize the risk of foot complications (1).
The inclusion criteria were limited to studies that evaluated T2DM-related foot care knowledge and foot self-care interventions. The number of articles that were excluded at each stage of the selection process is presented in Fig. The Strength of Recommendation Classification Scheme (15) was used to rank all the studies based on strength and validity of the studies (18). All of the studies that measured foot care knowledge saw an improvement in health outcomes based on receipt of foot care education. Many of the behaviors demonstrating significant improvements were those surrounding daily foot checks (20, 22, 45) and proper foot self-exams (24). Many of the clinical outcomes that showed significant improvement in the studies included foot-related ulcer days (23), hospitalizations (23), hospital days (23), ER visits (23), antibiotic prescriptions (23), foot surgery (23), lower extremity amputations (23, 26), missed work days (23), ulcerations (26), foot lesions (25, 36), cracked skin (25), ingrown nails (25), fungal nails (25), macerated web spaces (25), and incidence of neuropathy (35).
Thirty-one studies investigated various foot care interventions that mostly utilized foot care education, professional foot assessments, and foot care skills, although the interventions varied between studies. Ideal foot self-care behaviors include daily foot and shoe gear checks, proper daily foot hygiene, not walking barefoot, wearing appropriate shoe gear, trimming toenails, avoiding using anything abrasive on the feet, early professional care for open wounds and lesions on the foot, and routine foot exams by a professional trained to identify diabetic foot complications (29).
This lack of knowledge has been recognized as a contributing factor to why people with T2DM do not undertake foot self-care practices (46). DSME is an essential component in the prevention of T2DM-related complications, but it also provides disease prevention for those with pre-T2DM (50). This review provides an important insight into an area of T2DM management and care that has been ignored by research studies and interventions. Standardization of these programs is needed in T2DM, but the inclusion of self-care for associated comorbidities and complications also needs deeper examination by program developers. The authors would like to thank the Transdisciplinary Center for Health Equity Research at Texas A&M University for research support. Barriers and enablers of foot self-care practices among non-institutionalized older adults diagnosed with diabetes: an integrative review. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. She is board-certified in internal medicine and rheumatology and is a fellow of the American College of Rheumatology.
During the DKA therapy, complications may arise and appropriate strategies to prevent these complications are required. Symptoms of diabetic ketoacidosis include thirst, vomiting, confusion, dry skin, dry mouth, frequent urination, and more.
Treatment involves intravenous fluids to correct dehydration, insulin to suppress the production of ketone bodies, treatment for any underlying causes such as infections, and close observation to prevent and identify complications. Only foot care knowledge and foot care practice intervention studies that focused on the person living with type 2 diabetes were included in this review. Further research is needed to test foot care interventions across multiple populations and geographic locations. Lifestyle behavior changes are required for management of this condition, including physical activity, dietary changes, monitoring blood glucose levels, and adherence to medication (3).
These T2DM-related lower extremity amputations cause critical implications for individuals, family members, and caretakers in terms of psychosocial, physical, functional, and financial implications (9).
T2DM is multifaceted and requires a multidisciplinary approach to the treatment of the condition and prevention of associated complications (11). We excluded studies that were not peer reviewed, did not discuss T2DM, contained no element of T2DM-related lower extremity complication, were not in English, and were not conducted within the United States. The reference lists of the studies included in the evaluation were also searched systematically for any eligible studies that may have been overlooked, but were not included. The methodologies and findings of the included articles were then reviewed by one investigator (TJB) for validity assessment, which included determining whether the studies were described in sufficient enough detail to include in the current review. The post-test scores of the control groups were also poorer than the post-test scores of the intervention groups, revealing the need for foot care–specific education. The learning outcomes assessed in the studies utilized self-care scores, foot care knowledge scores, and self-efficacy scores as they related to foot care. T2DM health care providers strongly encourage patients to implement these foot self-care practices (1). It is widely accepted that additional education will lead to improved knowledge, self-care behaviors, and reduction of foot complications (1). Patients that are not offered DSME have a fourfold risk of developing T2DM-related complications compared with those that have had some form of DSME (51). The studies included within this systematic literature review provide evidence of improved health outcomes, learning outcomes, and behavioral outcomes and how those outcomes ultimately improve the quality of life for those with T2DM. Future research should examine the effects of a standardized foot self-care program across multiple populations and intervention sites that focuses on the reduction of complications associated with a T2DM diagnosis.
Lahita declares that he has received consultancy fees and honoraria for speaking from GlaxoSmithKline. Her research interests focus on systemic lupus erythematosus, systemic sclerosis and vasculitis.
Treatment usually involves: Diabetic ketoacidosis starts with higher ketone levels and could become life-threatening.
Diabetic ketoacidosis is characterized by a serum glucose level greater than 250 mg per dL, a pH less than 7. The mainstay in the treatment of DKA involves the administration of regular insulin via continuous intravenous (IV) infusion or by frequent subcutaneous (SC) or. Diabetic ketoacidosis (DKA) is a dangerous complication faced by people with diabetes which happens when the body starts running out of insulin. The quality of life of someone living with T2DM can be greatly improved with the implementation of self-management education to help them manage the condition (2). T2DM-related complications account for a death risk that is two times higher than that of someone that does not have T2DM (10). The Strength of Recommendation Classification Scheme (15) was one of the quality assessment tools utilized for this review (Table 1).


The second investigator (ESL) independently reviewed and extracted data from 18 of the 31 articles that were selected for the review. Articles were excluded after not meeting the following inclusion criteria: 1) peer reviewed, 2) T2DM-related, 3) lower extremity disease component as the basis of the study, 4) study conducted in the United States, and 5) foot care education or foot care practices intervention only in participants that were living with T2DM. There were 18 studies that included female participants, 21 studies that included male participants, and nine studies that did not report the gender of the participants. The randomized controlled trials that did not receive a 1B received a 1C due to not describing the control group, not providing analysis for the intervention group, and not providing between-group analysis.
All the studies that assessed foot care practices noticed an improvement in foot care practices, but not in lower extremity complications.
The major behavioral outcomes assessed in the studies were daily foot checks and foot self-exams.
Previous studies have found an increase in foot ulcers and amputations in those patients that do not adopt these practices (45). Studies have shown that these educational interventions have the ability to lower rates of lower extremity amputations by up to 85% (52).
The limitations of this review are that it only analyzed studies within the United States and only those studies that examined foot care knowledge and foot care practices in the actual population that lives with T2DM. This potential intervention has the ability to expand the scope of DSME to not only include foot care, but also other complications associated with this condition.
She completed rheumatology fellowship at Thomas Jefferson University Hospitals, Philadelphia, PA, USA, in 2010, and medical residency at Sound Shore Medical Centre of Westchester, NY, USA, in 2008.
Appropriate treatment includes administering intravenous fluids and insulin, and monitoring glucose and electrolyte levels. Diabetic Ketoacidosis – an easy to understand guide covering causes, diagnosis, symptoms, treatment and prevention plus additional in depth medical information. Similar to how continuing education is essential for healthcare providers, there must also be continuous education for the person that is battling T2DM (4). However the development of such complications can be prevented and reduced through the implementation of comprehensive programs focused on foot care, which have been shown to greatly reduce amputation rates (8). This classification scheme uses a hierarchy to rank the strength and validity of evidence from each study included in this systematic review. Any discrepancies between the two investigators’ scores were then resolved through a second review of the abstracts, discussion of discrepancies, and a finalized consensus.
One study included Filipino participants, 17 included African-American participants, five studies included Hispanic participants, two studies included Native Americans, and 10 studies did not include participants’ racial or ethnic information. There was one study (22) that noted that improvement of practices coupled with foot care education did not reduce the incidence of lower extremity complications in the study participants. The clinical outcomes assessed in the studies varied greatly across the studies, but the most common outcome assessed was presence of ulceration, risk of amputation, or presence of a foot lesion.
DSME is effective at controlling illness and improving health, and it is accepted as a cost-effective strategy (53).
The systematic review also did not include studies that examined the foot care knowledge and foot care practices of caregivers or health care providers. Previously, Wen Xiong was a physical therapist and received a Master of Science in physical therapy at New York Medical College, NY.
But you can help prevent it by learning the warning signs and checking your urine and blood regularly. Learn about Diabetic Ketoacidosis (DKA) symptoms, diagnosis and treatment in the Merck Manual.
According to the American Association of Diabetes Educators 7 Self-Care Behaviors framework, people with T2DM should be skilled in self-care behaviors that improve their quality of life while reducing associated complications of this condition (5). This scheme allowed the investigators to rank the strength of not only randomized controlled trials, but also the strength of observational studies, cohorts, case-control studies, case series, and case reports, many of which have also been included in this systematic review. The cohort studies, case series, cross-sectional studies, and qualitative inquiries were assigned a rank of III. In the randomized controlled trials, there were no studies that reported improved outcomes in the control group as opposed to the intervention group. There are studies that have shown a clear reduction in amputation rates following a foot care intervention (48). She also worked as a postdoctoral research scientist at Columbia-Presbyterian Medical Centre, NY. The included studies were also appraised using the Strength of Reporting Observational Studies in Epidemiology (STROBE) tool (Table 2) (16). Although there were many interventions and health outcomes assessed in the included articles, consistency in the type of intervention was lacking collectively throughout the studies. DKA will lead to death in many cases, but aggressive diagnostics and treatment can be life saving. Self-care management has the capacity to reduce the gap between patient needs and available health care services to meet those needs (6). Despite evidence of the success of multidisciplinary approaches to T2DM care, this approach to care has yet to be fully implemented as part of the standard of care (14).
This tool was also used because it addresses cohort, case-control, and cross-sectional studies, which have been included in this review (16).
Health care providers must equip patients with the tools needed to effectively monitor their blood glucose levels, maintain any dietary restrictions, and be active participants in their individual self-care to control their disease (7). The purpose of this systematic literature review was to compile and evaluate published evidence for increasing foot care knowledge and self-care practices as part of a targeted T2DM foot care intervention.
The tool consists of 22 items, but the last item, funding, was omitted from the checklist, which brings the tool to 21 items (1). The majority of the included studies failed to report how the study size was calculated or any source of bias. Lahita is the Chairman of Medicine at Newark Beth Israel Medical Centre and a senior attending rheumatologist.
When high blood sugars or ketoacidosis happen, it is critical that you drink lots of fluid to prevent dehydration. Most of the studies also acknowledged that there were limitations to the generalizability of the results. He is also Professor of Medicine and Adjunct Professor of Molecular Biology and Biochemistry at Rutgers, the New Jersey Medical School, USA.
Robert Lahita conducts both clinical and basic research in the area of systemic lupus erythematosus and other autoimmune diseases. If these suggest diabetic ketoacidosis (DKA) then immediately begin resuscitation and management. DKA is a very serious but completely preventable condition that can lead to coma or death if it’s not treated promptly. He graduated from the Jefferson Medical College, Philadelphia, PA, in 1972 and trained in rheumatology at Rockefeller University, New York, in the laboratory of Henry G. The epidemiology, pathogenesis, clinical features, evaluation, and diagnosis of these disorders are discussed separately.
He completed his internal medicine training at Cornell-Weill Medical College, New York Presbyterian Hospital.Contact Robert G.



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