The Diabetic sweet spot was initially conceived as a way of helping my daughter to prevent the common complications with the feet that so often develop in people with diabetes, and so help her to stay as safe as possible knowing what can go wrong generally, being aware of her own personal risk and knowing how to act to minimise that risk. It is in affect the safest possible place for someone with diabetes to be whether they have type 1 or 2.
By living in it you should be able to live a full and active life doing the things you enjoy with your loved ones for many years to come.
Living in the diabetic sweet spot.
By diabetic sweet spot I mean that the person with diabetes will have put themselves in the best possible place to live safely with their diabetes. My life with diabetes has helped me realise that there are three factors we need to take seriously in order to live with the least risk of developing complications. These factors can be applied to every aspect of diabetes be it diet, exercise, taking your medication, or foot care.
The sweet spot values:
1. Knowledge about your condition.
2. Awareness and acceptance of your personal risk.
3. Taking appropriate and timely action.
So you could for example apply it to knowing what to eat, accepting the risk to your blood sugars if you eat certain things and then taking action to ensure you don’t eat them.
Likewise it may be the knowledge that thickened toenails could ulcerate and lead to infection and then becoming aware that you are at risk because you have a thickened nail. Knowledge and awareness don’t keep you safe by themselves.
You have to add the magic ingredient – taking action. So in our second example, you could get your nails thinned down by a professional. Once you’ve taken that step, then and only then are you in the sweet spot for that particular issue. The diabetic sweet spot is a process rather than a place – you can stay there in safety by choosing to do the right things or you can leave at any time. That depends on your choices and your way of life. Always make sure you stay safe by learning, applying what you learn to your situation and then acting.
Undefeeted aims to give you a comprehensive knowledge about feet and what can go wrong with them. More importantly, it will help you understand your own feet and how diabetes can affect them – or may already be affecting them.
At any point in life it is vital that you have a healthy attitude towards learning and even more so if you have found yourself in unfamiliar territory such as having been diagnosed with diabetes.
Nothing in all the world is more dangerous than sincere ignorance and conscientious stupidity.
This is so true. Being truly unaware of the dangers of diabetes and the risks it poses to your feet is certainly dangerous but at least you can learn and change .Whereas being aware of the dangers and then not taking any notice is really stupid. Its more dangerous because you are unlikely to be sensitive any more to further advice.
As a person who is living life with diabetes, it is critical that you have a positive attitude towards learning about your condition and how it can affect you.Then you will gain the knowledge you need to be able to get into the diabetic sweet spot
It goes without saying that you also need someone to teach you about the condition and what you can do to help yourself. It’s best if you look to an expert for your information. With babies and children, parenting books, grandparents, and friends with children can be invaluable. It’s just the same with diabetes – it is best to learn about your condition and its associated risks from an expert and people with experience. It would be silly taking time to listen to someone (including yourself ) if they don’t know much about diabetes.
That is why I wrote the book “undefeeted by diabetes” to share the expertise and experience I have not only with my daughter but with people throughout the world living with Diabetes.
In the course of this book I introduce the idea of diabetic sweet spot groups diabetic sweet spot groups which will give you a perfect opportunity to gain as well as share a wealth of knowledge.
Because gaining this knowledge is so important please click on the links below either to get a free couple of chapters from “undefeeted by diabetes” or to purchase the entire book.
Undefeeted by diabetes is available in paperback, in digital format and is presently being converted to an audio book.
Perhaps before talking about risk awareness we should encourage you to become feet aware as most of us meander through life paying very little attention to them until they develop a painful problem (or in the case of someone with diabetes a problem that should be causing pain but that is not perceived by the person.
Pain is in fact a gift as it warns us of present and developing danger.
Lets face it most of us do not place anywhere near as much importance on our feet in life as we do our eyes or teeth.
Becoming aware of the risk you are at in any area of life is valuable as it empowers you to avoid the possible consequences of that risk.
Crucially it is important to realise that as you walk through your life, your risks will change. Often we need someone with an outside view to warn us but as you learn you will become more and more self aware of those risks. Imagine a young child and its dad at the railway station .The dad will be aware of the risks to that child and will warn it and teach it so it knows for the future. Next they exit the station and are on the side of a busy road, the child needs to be taught a whole load of new risk factors.
In fact the parent also has to be aware of the risks so they can help warn and remind the child of the danger. Likewise it is very important that you have a sweet spot buddy (accountability buddy) to act on your behalf warning you and reminding you.
The problem is in my view that its all very well becoming aware that there is a risk but its altogether another thing taking that risk on board and learning specifically how you can minimise it.
This taking it on board is largely a mindset issue and a person’s mindset above all else will determine the level of risk they are willing to live with or conversely how they will respond to minimise that risk.
Mindset is important on two levels:
1. You have to grasp how important your feet are.
2. You must understand that as a person with diabetes your feet are at risk. That risk could be imminent danger to your feet or a long term risk of problems developing later in life.
Your mindset can be affected by various traits in your life :
Pride/Ego (believing you are superhuman),
Unable to accept it,
We would like you to gain a real understanding of the risk you are at because without that you are unlikely to act to save yourself. The majority of us don’t place much importance on our feet until they bother us and even then we often put up with the discomfort for a while before seeking help. Some people with diabetes may not feel the discomfort and therefore won’t realise they need help until things have got a lot worse; even if their feet haven’t deteriorated to this point and they can feel the problem, it is still vital that they get it seen to quickly.
There are two key ways to become aware of your risks.
Self tests can be helpful to get an initial picture of your personal risk factors but should not be relied on solely as a professional eye of someone with experience is the only way of truly understanding your specific risks.
Here at undefeeted we have produced some videos to help you with performing the self tests. There are also opportunities to attend live webinars where these tests will be discussed and demonstrated.
Palpation of pulses
There are two main pulses in the foot. As the arteries pass down the legs and into the feet they become narrower. The pulse of each heartbeat should be felt both behind the inside ankle bone and on the top of the foot.
Capillary refill time.
The capillaries are the very small blood vessels that take the blood with all its oxygen and nutrients to the most peripheral tissues. This test measures the time it takes for the blood to come back into the toe after it’s squeezed out. This is something you can do at home – simply squeeze the end of your toe gently but firmly, let go and time how long it takes for the colour to come back. Ideally it should take about three seconds. In my experience it can take a while even in some young healthy people so in the absence of any other negative findings it is not too serious. However it should alert you to the fact that if it takes a long time for the capillaries to fill up whilst your arteries are functioning well then if you allow your arteries to deteriorate (or fur up), it will become even harder for the blood to fill the capillaries leading to complications both in healing and in cold weather.
Using the back of your hand or a friend’s is a basic way of assessing temperature differences in the leg and foot. In recent years the use of infra red digital thermometers has made it easy for us to check the temperature of the skin surface. The lower leg’s temperature is taken as well as the end of the big toe. We are looking for a small difference – the smaller the better – although there can be a big range of normal readings. What we don’t want is a big difference. In my experience, depending on other symptoms, anything over 10 degrees Celsius could be a cause for concern and may need further investigation.
Conversely an elevated temperature can be cause for concern as it may indicate infection, frictional forces or a rare condition called a Charcot joint (see Chapter 10 of undefeated by diabetes). There is also evidence to suggest that in many cases prior to a breakdown or an ulcer forming, the temperature in that local area may be raised.
Recently it has been shown that if an area of skin is raised in temperature by more than 2.2 degrees centigrade, then there is an increased likelihood of it breaking down into an ulcer in the near future. If a difference like this is noted either compared to the surrounding skin or compared to the same site on the other foot, then a professional opinion should be sought as a matter of urgency.
Self - Testing your sensation
The ‘touch the toes’ test as promoted by Diabetes UK.
Credit should be given to Dr Gerry Rayman and his team at Ipswich Hospital whose research showed that a simple test involving touching a person’s toes very lightly while they have their eyes closed is a reliable way of indicating if there is loss of sensory protection.
Again with your eyes shut your friend touches your feet alternately with a cold object such as a metal spoon and then with a plastic pen or similar. Before touching the feet, get the patient to feel the difference in their wrist. You should be able to tell the difference in temperature. If you can’t this is cause for concern in a person with diabetes
Testing for autonomic nerve function
Another useful test involves testing the autonomic nervous system with the use of a special chemical pad called a neuropad which changes colour in the presence of sweat. As the sweat glands are controlled by the autonomic nerves, it follows that if the skin is especially dry as in the case of autonomic nerve dysfunction, then the pad won't be activated to change colour thus giving an indication of that dysfunction.
Here’s one more check that you can do for yourself. If your bathroom floor is tiled, next time you get out of the bath see what footprint you leave on the floor. Does the arch flatten out as in the flat foot diagram on the left or is there little pressure in the middle of the foot like the high arched foot on the right? Perhaps it is relatively normal as in the middle example. Beware though; if it looks normal don’t be lulled in to a false sense of security, this is not the only aspect of foot structure that can go wrong.
In the book “Undefeeted by diabetes” you will find details of what you need to be aware of, along with details of some of the self tests you can do and information on the type of tests that your Podiatrist will do for you.
We have also compiled a list of registered practitioners who are Podiatrists willing to give up their time to perform a free diabetic foot assessment. This is much more thorough than the routine annual screening performed by Practice nurses and GP’s as would be expected from a professional trained specifically on the feet.
What to expect from a proper diabetic foot assessment.
When deciding to go and get your feet looked at it is worth asking what you will be checked for as some checks are more intensive than others. Some you may find extremely thorough while others may work below the standards set out in The Society of Chiropodists and Podiatrists guidelines (our professional body).
You may also be wondering who you should see – a chiropodist or a podiatrist? And what’s the difference between them anyway?
Podiatrist or chiropodist – who should I see?
It’s hardly surprising that people are confused as even within our profession there is some perplexity – if you ask five podiatrists and five chiropodists that question you’d probably get 10 different answers.
The general impression appears to be that a chiropodist deals with hard skin and nails whereas a podiatrist also addresses the gait and foot structure. Just to clarify here in the UK there is no difference between the two. The two names are interchangeable. In fact the Society of Chiropodists and Podiatrists voted on whether to drop ‘chiropodist’ from their name to help reduce public confusion. Apparently there were enough people within the profession favouring it to warrant keeping the two names.
Originally we were called chiropodists but podiatrist became more widely used to align us with the rest of the world such as the US and Australia. So there is no difference and you can see any chiropodist or podiatrist (registered in the UK with the Health and Care Professions Council or HCPC) who should provide a high level of care for your lower limbs. In the UK there is no difference between chiropodists and podiatrists. The two names are interchangeable.
Prior to 2005 there was no protection of our title and there were two main routes to be able to practice, either a three-year degree (previously a diploma) or a five-week correspondence course.
When the protection of title came in those who had only done the correspondence course were required to meet certain standards to ensure the protection of the general public. A large number did not meet this standard and so forfeited the right to call themselves either podiatrist or chiropodist. (It is illegal for them to do so or to suggest that they are able to provide chiropody/podiatry treatments.)
We have gone to great lengths to enroll as many like minded Podiatrists as possible to enable you to find someone close to you to provide a free diabetic foot check.
The Traffic Light System.
When you’re deciding which podiatrist (or chiropodist) to book in with, it would be worth asking them if they’re aware of the Traffic Light System. My friend and colleague Duncan Stang (National Diabetes Foot Coordinator for Scotland) introduced this risk stratification and triage system in Scotland. It’s been very successful and has been taken up by many foot health professionals. It has been recognised by NICE (National Institute for Health and Care Excellence) and Diabetes UK and has been adopted throughout the rest of the UK. Following the screening process, the system ensures each patient is assigned a risk category according to their risk of developing a foot ulcer. Although not a full assessment Duncan’s research shows that the tests within the Traffic Light System give sufficient information to allow the person to be screened, given a risk category and hence advice on how to best manage themselves. It also implements a treatment/management plan according to the patient’s needs.
The tests allow a health professional with minimal training to screen you for your risk status which will be communicated to you so you are aware of how at risk you are and what level of input from podiatry services you should be receiving. This is important if you want to live in the sweet spot and hopefully not develop any foot problems. It also allows you to be referred for further in-depth assessment or care as appropriate for your level of risk.
The Traffic Light System: know your risk rating.
Your annual foot screening should tell you what level of risk you have been placed in.
There are four levels of risk:
• Low (green).
• Moderate or increased (amber).
• High (red).
• Active (the speed camera).
The screening looks at:
1. Can you feel a 10g monofilament or vibration sensation?
2. Can the health professional palpate the pulses in your feet?
3. Has the foot any deformity?
4. Is there any significant callus?
5. Are there any signs of ulceration?
6. Is there any previous history of ulceration?
7. Do you feel any pain?
8. An inspection of your shoes.
9. Are you able to do your own self-care (i.e. can you reach and/or see your feet) or do you have someone who can help you?
After the assessment, you will be assigned to a risk level and an appropriate treatment/ management plan is put in place.
Find an undefeeted practitioner.
If there is no practitioner close to you already signed up as a preferred undefeeted practitioner please do ask them if they have heard of undefeeted as we are constantly looking for more practices to join the undefeeted campaign, trying to make it easier for people with diabetes to access a free podiatric diabetic foot check
Although an in-depth knowledge of what can go wrong is critical it only gets us part of the way into the sweet spot. Likewise having the right mindset and accepting you are more at risk than people without diabetes is crucial to getting into the sweet spot.
However the importance of acting on what you have learned should never be under estimated. It is only when you have all 3 factors in place that you can truly know that you are right at the heart of the sweet spot and therefore in the safest possible place.
This is possibly the hardest of the 3 to attain as it often involves changing the habits of a lifetime. Within the book are pages to record what you learn generally about diabetes, specifically about your feet and what actions you need to take. You are then encouraged to plan what you are going to work on over the next 6 months concentrating on three things each month. This will help the more disciplined of people to achieve all they need to, so that they get into the sweet spot. It is our experience that people need more assistance with achieving all their goals and so we provide various options .We would recommend choosing one of these options if you are in any doubt of being able to achieve your action plan by yourself.
1. A free reminder service to remind you when each month is up and that you should be moving onto the next 3 things.
Share as much or as little as you wish of your knowledge concerns and questions with like minded people with diabetes and professionals in our facebook forum.
4. Online webinar courses with fortnightly Q&A sessions.
My personal journey both trying to remain in the driving seat of diabetes and in running my businesses has led me to realize that for me and many other people some form of accountability is beneficial.
This may be able to be gained through your accountability buddy or sweet spot group However there appears to be demand for some degree of professional interaction in helping many people stick to their commitments which often involves quitting hard to change habits or introducing new activities that may be time consuming or unattractive at first.
A more bespoke way to achieve this level of mentorship is to commit to a period of fortnightly skype calls on a group or 121 basis with a qualified registered UNDEFEETED PRACTITIONER.
Typically this may be a 3 month or 6 month duration.During your first consultation we will identify with you your biggest concerns and agree on a plan to implement changing those weaknesses into strengths.
We offer two tiers of live mentorship online –In a group setting over a skype call which has the advantages of others sharing their experiences and being able to hold each other accountable as well as being facilitated and held accountable by an expert. This level of mentoring has the added benefit of leveraging the costs keeping them down. The second on line level of mentoring is One to One, again by skype where you get the benefit of tailoring your journey to better blood glucose control and living in the Diabetic sweet spot with an expert along side you keeping you accountable.
Even though you may have read the book Undefeeted by diabetes ow many appointments the make available and may have an accountability buddy, be part of a sweet spot group and have started taking appropriate action, it is still of utmost importance that you schedule an appointment with a Podiatrist in person who will be able see things your untrained eye cannot and so be able to enlighten you to the true state of your feet and associated risks.Appointments for this are available with an initial 15 minutes diabetic foot assessment often being offered for free. Costs for subsequent appointments or treatment should be negociated with the podiatry practice you are due to attend. Undefeeted has no association with these practitioners and only serves to make you aware that they are there as an option for you to choose. It is your responsibility to enquire of their fee structure for any treatment beyond this initial 15 minute assessment.Undefeeted allows practitioners to become “preferred” if they have self disclosed their training,experience, CPD and professional indemnity. Please note it is not your right to have a free session, these practitioners are giving up their time to see you. It would be unsustainable to see people for free all day long so it is down to the individual practitioner.
Similarly to the online mentorship we realized a need for 2 similar tiers of face to face mentoring.
Firstly in small groups of 3-5 people which again has the advantages of others sharing their experiences and being able to hold each other accountable as well as being facilitated and held accountable by an expert.. This level of mentoring has the added benefit of leveraging the costs keeping them down.
Secondly as a face to face on a one to one basis which typically suits those of you who are too busy to fit in with the schedules of others or those of you who would rather keep your feet to yourself.
Benefit from live or recorded webinar courses and get the opportunity to ask the experts questions as the series progresses.
Courses are designed to specifically address your needs and fears so that by the end of a typical 6 week course you are better placed within the sweet spot with your weaknesses having become your strengths, Live webinars will sometimes be interspersed amongst these courses with q & a sessions.
For people enrolled in these courses who need more bespoke advice than the q & a can provide live telephone consultations with an undefeeted preferred practitioner will also be available for a small fee.
In our experience readers of all the knowledge in the book find it helpful to have some further support to help them fulfill the taking action part of getting into the sweet spot.
This service is free and aims to jog the memories of those of you trying to act upon what you have read in the book with no further financial outlay. For some self motivated and dedicated people this will be all they need to ensure they continue to do the right things and achieve maximum benefit. In effect if following the books guidelines it will help to remind you when each month is up that you should be moving onto the next 3 things that need tackling.
A whole group of accountability buddies would be even better.
My personal experience and that of my patients has taught me that there is power in numbers. Just think of the help and support you’d get if you regularly met up with other people with diabetes who were also working their way towards the sweet spot. And you would be able to help them too. I hope that in time there will be sweet spot groups dotted around in local communities. They will be a safe place for people to share their difficulties, inspire others with their successes, offer support during hard times and generally help one another along the sometimes difficult road of living successfully and safely with diabetes. As you read on you will increasingly see the benefit and need for this.
To help my vision become a reality please let us know if you would like to begin/lead a sweet spot group in your area.
We will let you know your nearest and update you regularly as more get formed.
If there are none near you why not get together and form one as local and convenient to you as possible.