Joy Pape's Website

An Ounce of Prevention Can Keep Your Feet Healthy for Life

Joy Pape — Wed, 29 Nov 2006 16:36:45 GMT

We sure do take our feet for granted. That is, until we have diabetes or start having foot problems. Some people start hearing about the relationship of diabetes and feet problems the first time they are diagnosed. For others, it may be their feet that take them to their health care provider for help. No pun intended. Really, some people may have noticed a change in their feet – a sore that won’t heal, pain, numbness, tingling, or even a change in the shape of their feet. They go to their health care provider for help with their feet and they are told they have diabetes, or elevated blood glucose (blood sugar).

For the most part, when foot problems occur related to diabetes, this is called peripheral neuropathy. Peripheral neuropathy is nerve damage that affects the feet, legs, or hands. It can cause pain, numbness, or a tingling feeling in these areas.

Diabetes is the leading cause of amputations. Don’t let this scare you. It doesn’t have to happen to you. We at dLife want to help you understand some things that may be happening with your feet and ways to prevent problems so you can keep your feet healthy for life.

Elevated blood glucose can affect your feet in many ways. It can:

• damage your nerves, resulting in increased pain, decreased feeling or no feeling;
• affect the circulation to your feet causing pain and decreased healing;
• increase your chance for infection due to the effect on your blood cells, nerves, and circulation;
• cause stiff joints;
• and cause bone changes.

If untreated, these problems can cause only more problems. If treated, many problems can be prevented. Remember, the first and best step for preventing foot problems is diabetes management which starts with knowing what to do, then doing it. This includes understanding problems as they arise.

We receive a lot of questions from our dLife family regarding foot problems. We listen to you! I may not be able to respond personally to each question, but I will respond to groups of questions about the same subject.

One subject is pain. A lot of people ask about the pain they are experiencing. As mentioned above, long-term elevated blood glucose levels can affect your nerves and your circulation. Both your nerves and your circulation can be associated with pain, but for different reasons.

High blood glucose can damage your nerves causing a lot of problems, some of which are:

• Increased sensation, like when it bothers you if anything touches your skin;
• Pain;
• Decreased sensation – not being able to feel;
• A change in how your feet perspire – dry feet or “wet” feet;
• Changes in temperature;
• Changes in the shape of your foot.

High blood glucose levels can damage your circulation as well. The damage to the nerves works with your circulation to affect your feet also. The main concerns with high blood glucose and circulation are related to pain and decreased healing.

I Can’t Exercise Because of My Feet

Joy Pape — Wed, 29 Nov 2006 14:43:13 GMT

We all seem to have excuses why we can't do things to improve our diabetes management, especially when it comes to exercise or being more physically active. Many people with diabetes say, "I can't exercise because of my feet." After years of experience with diabetes and foot care, I listen when someone tells me that. For many, it's not just an excuse not to exercise, it's the truth…that is, until they learn what they can do. Let's face it, most of us can do something more. Having diabetes and foot problems doesn't excuse you from moving more, but there are some things you need to know.

Know what kind of foot problems you have.
It's important that all people who have diabetes also see a podiatrist. A podiatrist is a doctor who treats people who have foot problems. Podiatrists also help people keep their feet healthy by providing regular foot examinations and treatment.

If you have not yet had a visit with a podiatrist, ask your health care provider to refer you to one. Then, when you see your podiatrist, ask him or her what kind of foot problems you have. You may know your feet are bothering you, but you don't know exactly why. Your podiatrist should be able to diagnose the type of foot problem you have.

Know what kind of exercise you would like to do.
Discuss the types of exercise you want to do with your podiatrist. He or she will then most likely recommend whether the exercise you want to do is appropriate for you and teach you how to do it safely. Teaching you how to do it safely will require that you have the correct footwear for the activity. Your podiatrist will refer you to a certified pedorthist to work with you and your footwear according to your podiatrist's footwear prescription, or your podiatrist will personally help you select the shoes, socks, and possibly custom made orthotics. Wearing proper footwear should help you do the exercise correctly without causing problems.

Know how to exercise safely with diabetes and foot problems.
Before starting any exercise program, it is important you speak with your primary health care provider about your plans. You may be able to get started right away, or you may need to take some tests to make sure the exercise is safe for you.

With most foot problems, wearing the correct footwear can make all the difference. For example, if you have hammertoes, wearing shoes with a large toebox can prevent you from ulcers forming on the joints of your toes due to joints rubbing against your shoe.

If you have peripheral neuropathy, it is important to avoid repetitive weight bearing activities such as jogging, taking l-o-n-g walks, or step aerobics. This repetition can in time cause foot sores, broken bones, and even deformities.

Some activities that don't put stress on your feet include:

Bicycling;
Seated exercises;
Arm and upper body exercises;
Swimming;
Just being more active.
Remember, when it comes to diabetes and footcare, an ounce of prevention is worth more than a pound of treatment. Two of the most important things you can do when it comes to your feet are:

Work to get and keep your blood glucose in normal range
Look at your feet at least daily. Look at the top of your foot, the bottom, between your toes, your heels, don't miss a spot. If you can't see well enough, get a mirror designed to help you reach your foot or have someone look at your feet for you. If you notice any changes such as redness, a new sore, or have any concerns, stop doing that particular exercise and contact your health care provider right away.
So, go, get your help to get moving, and EnJOY!

The Do's and Don'ts of Footcare

Joy Pape — Wed, 29 Nov 2006 14:15:10 GMT

A dlife reader asks:
My right big toe has a medium size wound on the bottom side that just will not fill in and heal. I have tried all the ointments and creams, dressings, bandages, you name it and nothing works. Meanwhile, I have ruined many a right sock with soaked pus/blood/fluids and my right shoe stinks beyond belief (even with the shoe powders used).

My work requires me to be on my feet for 10-12 hours a day and I do wear good shoes. I keep my blood sugar levels under 100 and test every day, eat the right foods and exercise as much as possible. I have been having foot pains and numbness in both feet now for almost a year and sort of fear the worst is coming... any suggestions???

Tony Graham
Bend, OR

Joy Pape, RN, BSN, CDE,WOCN,CFCN answers:

Hi Tony. I'm so glad you wrote. I know dLife contacted you as soon as we received your note instructing you to GO TO YOUR DOCTOR RIGHT AWAY! I hope you followed that advice.

This sounds like a good time to start with the basics of diabetes foot care. As with most complications of diabetes, KNOWLEDGE is the prevention and treatment. Knowing what to do and doing it can help you prevent foot problems and keep your feet for a lifetime.

If you have diabetes, there are a lot of things you can do to prevent problems from developing in your feet. , Dr. Richard Bernstein MD in his book Dr. Bernstein’s Diabetes Solution, Revised and Updated The Complete Guide to Achieving Normal Blood Sugars recommends the following:

• Never walk barefoot, either indoors or out.

• Purchase shoes or sneakers late in the day, when foot size is the greatest. Shoes must be comfortable at the first wearing and should not require breaking in. Request shoes with deep, wide toe boxes. Pointed-toe shoes should not be worn, even if the tips are blunted. Some dress shoes are now available with wide, deep shoes and walking shoes are especially accommodating and even have removable insoles so that orthotics (see below) will fit, without making the shoe too tight. If necessary, I prescribe orthopedic or custom oxfords for patients.

• Inspect the insides of your shoes daily for foreign objects, torn lining, protruding nails, or bumps. Have them repaired if you find any of these.

• Don’t wear sandals with thongs between the toes.

• Try to alternate at least two different pairs of shoes every few days.

• Ideally your feet should be examined daily for possible injury or signs of excessive rubbing or pressure from shoes(blisters, cracks or other openings in the skin, pink spots, or calluses). Be sure to check your toes. Inspect your soles. If necessary use a mirror or ask another person to check them. Contact your physician immediately if any of these signs are found.

• If the skin of your feet is dry, lubricate the entire foot. Suitable lubricants include olive oil, any vegetable oil, vitamin E oil, emu oil, mink oil, and emulsified lanolin. Many oils and lotions that contain products as major ingredients are available commercially. Do not use petroleum jelly (Vaseline), mineral oil, or baby oil and they are not absorbed by the skin.

• Do not smoke cigarettes. Nicotine can cause closure of the valves that permit blood to enter the small vessels that nourish the skin.

• Keep feet away from heat. Therefore no heating pads, hot water bottles, or electric blankets. Do not place feet near sources of warmth such as radiators or fireplaces. Baths and showers should feel cool-not-not even lukewarm. Temperature should be estimated with your hand or a bath thermometer, not with your feet. Water temperature should be less than 92 degrees F, as even this temperature can cause burns when circulation is impaired. A bath thermometer is suggested.

• Wear warm socks and shoes of adequate size when outside in cold weather. It is wise for all diabetics to have the circulation in their meet measured every few years. If circulation is impaired, do not remain in the cold for more than twenty minutes at a time.

• Do not soak your feet in water for more than 3-4 minutes. This causes macerated skin, which breaks down more easily and doesn’t heal well. When bathing or showering, get in, get washed and get out. Don’t soak. Beware of rain, swimming pools, and any environment that may wet your feet or your shoes. If you swim regularly for exercise, before getting in the water, rub petroleum jelly (Vaseline) on your feet to protect them from the water. After leaving the water, remove the petroleum jelly with a towel.

• Do not put adhesive tape or other adhesive products like corn plasters in contact with your feet. Fragile skin might be peeled off when the tape is removed. When applying a bandage, tape should not be applied to the skin, but to the bandage only.

• Do not put any medications in contact with your skin that are not prescribed by your physician. Many over-the-counter medications, such as iodine, salicylic acid, and corn-removal agents, are dangerous. Iodine products or hydrogen peroxide should never be applied to wounds.

• If the skin of your feet is dry, your cardiologist should try to avoid medicines called beta blockers for hypertension or heart disease, as these can inhibit perspiration that moistens the feet.

• Do not attempt to file down, remove, or shave calluses or corns. This is dangerous. The toughened skin of a callus is the body’s way of protecting against irritation, such as by a shoe that rubs your foot. Filing it off removes that protection, and in my experience, this is the most common initial cause of foot ulcers and resultant amputations. If calluses are present, show them to your physician. Ask her or a podiatrist to arrange for your shoes to be stretched, prescribe special shoes, or prescribe orthotic inserts. Your physician may instruct you in the use of a shoe stretcher or a “ball and ring,” both of which can be ordered by a shoe repair shop. By eliminating the pressure on your foot, the callus should resolve over time.

• Do not trim your toenails if you cannot see them clearly. Ask a friend or relative, podiatrist, or your physician to do this for you. If the corners of your nails are pointed, you can file them with an emery board or have someone else trim them.

• If you have thickened toenails, ask your physician to have clippings tested for fungal infection. If infection is present, he should prescribe tincture of fungoid. This solution must be applied twice daily to the nails to be effective. It must be used for about twelve months to effect a cure. It helps to first have thickened nails ground down by a podiatrist, but he/she must be very careful not to damage skin or nail bed.

• Don’t wear stockings or socks with elastic bands that are tight enough to cause visible depressions in the skin. Don’t use garters. Don’t wear socks with holes or that have been darned, have thick seams or are so large that they bunch up.

• Phone your physician immediately if you experience any injury to your foot. I consider ever a minor foot injury to be an emergency. Procrastination can be dangerous.

So Tony, we do hope you followed our advice by going to your health care provider and getting the help you need. We know foot wounds don’t usually heal quickly. We hope your wound is healing and you will use preventative measures in the future to help you keep your feet healthy for a lifetime.

When it comes to diabetes and feet, there are no truer words than
“An ounce of prevention is worth a pound of cure.”

EnJoy!

Joy Pape, RN, BSN, CDE, WOCN, CFCN

Shoes Can Make or Break Your Outfit

Joy Pape — Wed, 29 Nov 2006 15:50:06 GMT

We're taking a break from our wound care series to help you get through the holidays. I can't really say this isn't part of wound care because if you're wearing the wrong shoes you can get wounds. Wearing the right shoes are one way to prevent foot problems that can ultimately end up in amputations. I don't mean to scare you here, but it's the truth.

I'm sure you've heard the saying, "Shoes can make or break an outfit." This has to do with fashion. I'm not so sure people take health into consideration with that statement. We should.

How many times have you worn shoes because of how they look only to have your feet killing you for days, weeks, even months afterwards? I did it one day last summer. It wasn't worth it. For those of us living with diabetes it's very dangerous

Many of us think we just need to avoid high heels and all will be okay. I've been pretty excited to see flats with rounded toes become more fashionable and available this year. I went and bought my "ballerina" shoes this summer just to find out that flat and round is not always the answer. I broke too many rules trying to make these shoes work. Here's how it all worked to turn into a painful disaster with my cute little ballerina shoes.

As much as you may hate rules, there are rules to buying and wearing shoes; especially for people who have diabetes. At this time of the year, many of us want a pair of shoes that look great with our clothes. There are shoes out there, it just takes some knowledge, time, and following the rules. Maybe you can learn from my mistakes and avoid foot problems from "breaking the shoe rules."

True confessions from a shoe-buying rule breaker.

Rule #1 – Avoid high heels. High heels place undue pressure on areas of your feet that weren't made to carry this kind of load. Wearing them can lead to changes in the shape of your feet and breakdown or sores that may not heal.

I followed this one. My thoughts were, "Oh, flats are in style now. I can pick out a pair of flats and they will work. Good deal."

Rule #2 – Avoid pointed toes. Pointed-toe shoes cause your toes to be squashed, squeezed, and pinched into a shoe. There is usually not enough width in the toe box either. All of these can cause your toes and joints to rub against your shoe and cause sores, which may not heal.

I followed this one too. I was doing good so far. "The shoes are flat, they have rounded toes and they are the right color. I'm in business." The problems were starting to show. I started to cave. They really weren't wide enough and the toe box was pretty flat.

These look like they'll work, don't they? Not!

Rule #3 – Make sure the shoes feel good in the store before you buy them. Shoes don't always stretch. If they do, you may have problems if you wear them before they do. Don't accept the thought that they will stretch.

This is where I started going off the deep end. I felt it a bit on my right bunion. I haven't felt my bunion for a very long time. The very fact that I felt it should have told me something. But no. They were too good looking, flat, round toed, the right color and the right price. I justified buying them. "They're leather, they'll stretch." I knew better. I'm happy to say my wounds healed, but there was no guarantee.

Rule #4 – Buy shoes later in the day. Feet swell as the day goes on so it's best to buy your shoes when your feet are at their largest.

I honestly can't tell you what time I bought these shoes. I was in a hurry to find the right shoes for the right occasion. Watch out for being in a hurry and giving in.

Rule #5 – Wear new shoes at home a few hours a day to see how they feel before wearing them outside. Doing this allows you to see if they are comfortable or cause any problems before you wear them outside. If you do this, you still have the hope of taking them back if you find out they don't work.

It was the last minute. I didn't know what to wear with my outfit to my important meeting. There were those new shoes staring at me that matched my suit perfectly. I didn't take the time to try them out. They didn't work and I couldn't take them back. Money down the drain.

Rule #6 – When wearing new shoes, always have a backup pair of comfortable shoes to wear. This helps your feet get used to another pair of shoes. If there is a problem, at least you're not in the shoes all day.

I admit I had the thought to take another pair of shoes with me that day. I didn't listen. I didn't want to carry a big tote bag with shoes in them. I told myself, "They'll be just fine."

Rule #7 – Always wear good-fitting socks or stockings under shoes. Wearing a good pair of socks or stockings under your shoes helps prevent the rubbing that causes sores.

Again, I didn't listen. I was more concerned about fashion. The summer look is now to go without socks or stockings. Not only did the shoes rub a sore on my bunion area, but also at the back of my shoe.

For some great tips on socks see this American Podiatric Medical Association brochure.

There are more rules/tips to buying shoes. Please see last year’s holiday article for more on this important topic.

So, the rules haven't change. We just need to follow them to stay in fashion and in health. I learned my lesson. I hope you learned too. Make wise choices, have a good time. And remember, it’s not ALL about how you look.

EnJOY!

Stay on Your Toes

Joy Pape — Wed, 29 Nov 2006 16:35:48 GMT

This month a lot of people want to know how to find a "diabetic foot doctor." I commend you for wanting to see a specialist for your feet. That tells me you realize the importance of taking care of your feet. I hope you are realizing this because you are keeping on top of things and learning more everyday about the importance of keeping up and learning all you can about your diabetes.

There are several ways to find a "diabetic foot doctor." One way is to speak to your health care provider and ask for a referral to see a podiatrist. Another way is to check with The American Podiatric Medical Association (APMA) where you can link to Find a Podiatrist on the home page. Call 1-800-FOOTCARE (366-8227) for information on Foot Health. For general questions call 1-301-571-9200.

I've also been asked several questions about where people can buy comfortable shoes. I'm so glad you asked about comfortable shoes and not beautiful shoes. Again, many of you are learning and thinking. Don't get me wrong, we all like nice-looking shoes, but comfort and protection are of utmost importance.

I think it's important for people who have diabetes to work with foot/shoe specialists to help pick out shoes. Not only will you get a good recommendation or even a good pair of shoes, but also a foot exam with education of how to take care of your feet. Many stores claim they have shoes for people who have diabetes but I recommend to people who have diabetes that they see a podiatrist or a Certified Pedorthist (CPED). Remember, diabetes puts you at risk for serious foot problems. Your feet should be taken seriously and so should your footwear that protects your feet. Many problems are caused by ill-fitting shoes.

Many podiatrists work with Certified Pedorthists. The field of pedorthics is the design, manufacture, modification, and fit of footwear, orthotics, and devices to prevent or alleviate foot problems caused by disease, overuse, or injury. A Certified Pedorthist has fulfilled and maintains educational requirements to be certified by the Board for Certification in Pedorthics. See their website for help finding a CPED in your area.

People who have diabetes and any foot problems, including thick nails and discoloration should see a podiatrist. Together you can decide the best prevention and treatment for you. Your podiatrist can also refer you to a CPED to help you pick out the best shoes just for you. Together they will know what insurance covers and help you with that also. Some shoe stores are owned by a CPED or have a CPED working there who can help you, so be sure to ask when you go looking for shoes.

So remember, there are lots of us who have diabetes. Our feet are all different and our feet are important. Treat them with the care they deserve. See a specialist. You'll be glad you did.

EnJoy!

Neuropathy by Any Other Disease is Still Neuropathy

Joy Pape — Wed, 29 Nov 2006 15:51:07 GMT

Thanks for writing me your questions this month. Most everyone who has diabetes sees their pharmacist on a regular basis, but we don’t always think of our pharmacist as part of our diabetes team. They are very much a part of our team! In fact most of us see or talk with our pharmacist more than any other health care provider we work with. With that being so, just think of all the people they get to talk with and learn from to be able to help you. I’ve asked Jimmy Bennett Registered Pharmacist, Certified Diabetes Educator to help me with the questions you’ve sent me this month.

Thanks for asking. We at dLife will continue to do our best to get your questions answered.

Here goes…EnJOY! and thank you, Jimmy.
Q: My husband’s feet are swollen and red. This has concerned me but his reply is this is a side effect of the Thyroid medication.

A: I would not suggest that you accept the swollen and red feet as a side effect of thyroid problems or thyroid medicine. These symptoms could be due to a number of different causes. If your husband has diabetes his physician needs to take a look at his feet and let you two know what is causing the problem whether it be poor circulation, some form of neuropathy, a side effect to a medicine or something else. Also ask him what you should do about it and he or she should be able to suggest a solution based on the diagnosis.

Q: By accident I found that I could control my pain and cold, almost freezing sensations of the feet, which would have me ready to go to the mental institution. For a cancer concern, I was given a Duragesic patch. It worked wonders for my neuropathy yet, it is to last three days and it only lasts two days then the pain is so bad, I need to apply another patch. Is there an additional medication I can take to help the patch last longer?

A:Remember that diabetic neuropathy just gets worse if you blood sugar is not under tight control so you must address that situation. In the meanwhile you are hurting so you need some immediate relief. The Duragesic patches are supposed to last for three days. The medicine actually seeps through the patch very slowly and predictably for 72 hours. It also takes a few hours to start to work when you first put a patch on. In some cases we see that on the last day the pain may come back. I don’t know that there is anything that will actually make the medicine work much better on that third day. You may want to speak with the physician about the possibility of applying the patch a little closer together than every three days. You have to be careful about that though since you could actually get more medicine in your system and cause some side effects.

You might also look for creams containing L Arginine. L Arginine has been studied and has shown some benefit in painful neuropathy. There is a nonprescription treatment called capsaicin that can be rubbed on. It must be applied four times daily for a number of days until it reaches its maximum effect.

You may also want to ask your doctor about some of the new medicines for neuropathy such as Lyrica or Cymbalta.

Q: I have both multiple sclerosis and diabetes (for about 13 years), diagnosed 6 months apart. Diabetes educator and general practitioner say the numbness and tingling is from diabetes neuropathy. My MS doctor says it's from MS. Either way, it is neuropathy, I guess. I have dry feet, and I've been using Eucerin or Aquaphor cream on the feet. Do you have any suggestions for a different cream? And, how about some suggestions for not getting socks all "goopy" with the cream? Thanks.

A:Although Eucerin and Aquaphor are very good for dry skin, you may want to consider a less “goopy” cream or lotion. The urea containing creams and lotions work in a unique manner to keep the skin soft. There are some generic brands but a couple of good brand names are Carmol and Dermal Therapy. Another good cream is Neoteric Diabetic Skin Care Cream. These rub in easily and leave your skin soft but not too greasy.

You might also look for creams containing L Arginine. L Arginine has been studied and has shown some benefit in painful neuropathy. There is a nonprescription treatment called capsaicin that can be rubbed on. It must be applied four times daily for a number of days until it reaches its maximum effect.

Finding a Foot Doc

Joy Pape — Sun, 06 Aug 2006 01:50:04 GMT

Many people ask me how to find a "diabetic foot doctor." I commend you for wanting to see a specialist for your feet. That tells me you realize the importance of taking care of your feet. I hope you are realizing this because you are keeping on top of things and learning more everyday about the importance of keeping up and learning all you can about your diabetes.
There are several ways to find a "diabetic foot doctor." One way is to speak to your health care provider and ask for a referral to see a podiatrist. Another way is to check with The American Podiatric Medical Association (APMA) web site, where you can link to Find a Podiatrist on the home page. Call 1-800-FOOTCARE (366-8227) for information on Foot Health. For general questions call 1-301-571-9200.

Summer Feet

Joy Pape — Sun, 06 Aug 2006 01:50:15 GMT

Here it is: Summertime. I bet many of you wore sandals in the summer... that is B.D., or Before Diabetes. I bet a lot of you still wear sandals. Not the best option for shoes for people who have diabetes. But let's be real: I know many of you still wear sandals. I also know that most women get pedicures so their feet and toes will look delicious in those sandals, although pedicure are not the best choice for people who have diabetes.

But you can have diabetes and pretty up your feet and nails. Here are some practical tips of how to have prettier, healthier summer feet and nails for people who have diabetes and must have that pedicure.

Welcome!

Joy Pape — Sun, 06 Aug 2006 01:10:16 GMT

Welcome to my home on the web, where you can find resources and tools to help manage your diabetes. Use this site to send me email, check my schedule, download blood glucose logs and other helpful tools, and learn more about diabetes.

The tabs located at the top right of the page will help you find what you need. Use the "About Me" tab to find out more about me and see my group schedule. The "Resources" tab is a library of helpful tools and information to help you manage and learn more about your diabetes. Finally "Blog" will take you to a collection of my personal tips, practice updates, and other useful information that is updated regularly.