Managing diabetic foot ulcers remotely
Indigenous patients and others outside urban centres are at higher risk of diabetic foot ulcers and need additional resources for effective management (1,900 words, 9 minutes)
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Indigenous communities have high rates of diabetes-related ulcers and foot amputations, Dr. Gary Sibbald said during a presentation at the second annual Indigenous Skin Spectrum Summit on June 11, 2022. He noted that Indigenous communities in remote areas do not have access to the medical resources available in Canada’s major urban centres, so a different approach is needed to manage these patients.
Dr. Sibbald is a professor of medicine and public health at the University of Toronto, co-founder of Wounds Canada, and the former director of the Wound Healing Clinic at Women’s College Hospital, Toronto. He is the current Project ECHO Ontario skin and wound care program director.
According to Dr. Sibbald, rates of type 2 diabetes and metabolic syndrome are increasing worldwide due to changes in diet, lifestyle, and way of life, noting that rates among Indigenous populations are growing at an even faster rate.
“Northern Ontario has three times the rate of diabetic foot amputations per 10,000 people than the Greater Toronto Area,” said Dr. Sibbald. “Long-term survival after major lower extremity amputation is low for all people but even lower for the First Nations.”
Among Indigenous people, up to 80% of the population is at lifetime risk of diabetes. That figure is 50% in the general population, he said.
“We need to preserve Indigenous diets, lifestyles, cultures, and ways of life that can minimize the risk of these chronic diseases, including type two diabetes,” he said.
For remote Indigenous communities, Canada should follow the Diabetes Control Priorities for Developing/Low Resource Regions developed by Narayan et al [https://www.ncbi.nlm.nih.gov/books/NBK11777/ ], said Dr. Sibbald. These priorities include:
Increasing efforts toward glycemic control
Maintaining hemoglobin A1C test levels of seven or lower
Lowering average blood sugar levels
Controlling blood pressure to prevent foot ulcers
Canadians with diabetes often do not have annual foot exams, Dr. Sibbald said. He noted that only 52% of Canadians with diabetes have these exams, which is a lower rate than most Western countries.
A relatively inexpensive tool that can aid patient self-monitoring is an infrared thermometer, Dr. Sibbald said. These can be purchased online. He noted that in randomized, controlled trials, patients with diabetes who used infrared thermometers to measure the temperature on five areas on their feet could detect hot spots that were early signs of injury. They were also able to restrict their activity, so repeated damage to the exact location did not progress. These patients developed far fewer ulcers than those receiving standard care.
To improve outcomes for patients with diabetic ulcers, Dr. Sibbald said there are programs available in the north that offer micro-credentials in wound care and treatment. The programs, run by educational institutions, government ministries, and healthcare organizations, allow physicians to take 30 hours of courses. These courses can be done online. He said he is also involved in developing toolkits to help physicians in the north address diabetic foot care.
Bottom Line: Remote northern Indigenous communities have rising rates of type 2 diabetes and foot amputations from diabetic ulcers. These communities need more testing for blood sugar levels and blood pressure. Patients with diabetes need regular foot exams for diabetic ulcers. Resources are available that can help improve outcomes, but these resources may be underused.
From the literature on diabetes in skin of colour
Yarning about foot care: Evaluation of a foot care service for Aboriginal and Torres Strait Islander Peoples
This project evaluated an Aboriginal and Torres Strait Islander foot care service (the Buridja Clinic) to prevent and manage diabetes-related foot disease. The authors assess the program from a community perspective using culturally appropriate methods.
The study involved an audit of occasions of service at the clinic, a feedback survey, and yarning circles with the clinic’s Aboriginal and Torres Strait Islander clients. Yarning or dialogue circles are essential teaching and learning strategies in Australian Aboriginal and Torres Strait Islander cultures.
Investigators identified several strengths of the clinic design, including yarning circles, group booking, and student placement. Participants reported some limitations, including difficulty with transport and limited opening hours. They also encouraged clinic staff to increase their community engagement by clinic staff.
Determinants of wellness: A perspective on diabetes and Indigenous health
The author of this letter argues that while social and structural determinants of health can describe unequal health outcomes related to race, ethnicity, and other factors, they may be over-generalized in some cases.
In particular, they note that bundling all Indigenous peoples and cultures across Canada into one category misses significant differences.
“Pan-Indigenous research flattens diverse cultures, communities, realities, and data into a single ‘Indigenous’ identifier,” they write. “Although it may not be intentional, pan-Indigenous approaches lead to erroneous conclusions and possibly harmful interventions that risk perpetuating health inequities.”
Association of type 2 diabetes with central-scalp hair loss in a large cohort study of African American women
This study estimated the association between type 2 diabetes and severe central hair loss in African American women. The authors analyzed data from the Black Women’s Health Study, which has biennially collected data in the U.S. since 1995. This detailed analysis is based on the results of a 2015 hair-loss questionnaire completed by 5,389 women.
The authors found that African American women with diabetes were 1.68 times more likely to have severe hair loss than those without the condition. In women who had diabetes for ten years or longer, this rate increased to 2.05 times.
The investigators conclude that type 2 diabetes was associated with an increased risk of severe central scalp hair loss in African American women. They suggest that patients with type 2 diabetes should be followed closely for central scalp hair loss to ensure appropriate treatment can be offered.
Is ethnicity an appropriate measure of health care marginalization? A systematic review and meta-analysis of the outcomes of diabetic foot ulceration in Aboriginal populations
This review and analysis study examined six cohort studies from Canada, the United States, Australia, and New Zealand that compared the outcomes of Aboriginal and non-Aboriginal patients with diabetic foot ulcers (DFUs). These study populations totalled 244,792 patients—2,609 Aboriginal and 242,183 non-Aboriginal.
While the investigators found that the aboriginal population had a higher rate of major amputation than the non-Aboriginal population (odds ratio 1.85), the authors noted that four studies had a moderate risk of bias. Two studies had a severe risk of bias.
The authors conclude their findings support the idea that DFU outcomes, particularly the rate of major amputations, are worse in Aboriginal populations in the same geographic areas. However, not all the studies accounted for rurality in the same way. This finding could impact the interpretation of the outcomes, they concluded.
VIDEO: Diabetes and my nation—Diabetes care and management in indigenous populations in Canada
At the intersection of skin and society
Black Ice, a documentary about the history, influences, and marginalization of Black Canadians in ice hockey, will premiere at the 2022 Toronto International Film Festival as a Gala Presentation.
Entertainment news website 6ixbuzz interviewed the film’s Oscar-nominated director, Hubert Davis, about the documentary, the process of filming it, and the history involved.
The documentary is partly based on a 2004 book of the same title, authored by George and Darril Fosty.
Davis, whose previous documentary Hardwood (2005) earned him the Oscar nomination, told 6ixbuzz that he had not heard of Canada’s Coloured Hockey League until producer Vinay Virmani pitched him on the project.
“I was surprised that the league existed at the time it did,” Davis told the news outlet. He said that people did not usually associate Black people in Canada participating in competitive sports as early as 1895.
“There was this kind of thriving Black community in Canada, and it’s not something we hear about. It’s not in our history books.”
Davis noted earlier attempts to tell the story of Black hockey in Canada, including the 2015 documentary Soul on Ice. However, they did not catch mainstream attention, he said.
The film festival will run from Sept. 8 to 18 in Toronto. Ticketing information and other details are available at www.tiff.net.
August is National Hair Loss Awareness Month in the U.S.
Aug. 23—Sept. 1 is World Water Week
Something to think about in the week ahead…
At the 2022 Summer of Dialogue Colloquium, Focus on the Black Dermatology Patient, Toronto-based dermatologist Dr. Renée Beach presented a talk on how Black patients in Ontario perceive few dermatologists as truly understanding them culturally and medically. Dr. Beach discussed the importance of education to ensure in the future Black patients may be confident in receiving the best possible care from any dermatologist.
Register now for the 2022 Skin Spectrum Summit
Registration is open for the 8th annual Skin Spectrum Summit. This all-day hybrid event will be held on Saturday, Sept. 17, 2022, from 8:00 a.m. to 4:30 p.m. EDT. Delegates can attend the Summit in person at the Chestnut Conference Centre in Toronto, and the presentations will also be viewable virtually through a webinar platform.
The Skin Spectrum Summit is a landmark educational congress of healthcare professionals dedicated to providing better dermatologic care for Canada’s diverse population.
The conference provides education on treating patients across all six Fitzpatrick skin types, emphasizing care for Types IV-VI.
Confirmed faculty for the 8th annual Skin Spectrum Summit include:
Dr. Andrew F. Alexis
Dr. Yvette Miller-Monthrope
Dr. Danielle Marcoux
Dr. Rachel Netahe Asiniwasis
Dr. Raed Alhusayen
Dr. Gary Sibbald
Dr. Geeta Yadav
Dr. Monica Li
Dr. Victoria Smart
Dr. Renée Beach
Dr. Jaggi Rao
Read Skin Spectrum Weekly for updates on Summit faculty and programs.
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