Diabetes From The Feet Upwards
It is estimated that over half a million people with Type II diabetes have yet to be diagnosed; in part because no-one is actively seeking them out. During my time as a domiciliary chiropodist I encountered a growing number of undiagnosed diabetics amongst my elderly patients. It soon became apparent, to myself and my colleagues, that the over 65s were suffering from this obesity related condition long before it was recognised as a serious public health issue.
The Middlesex dominated the centre of Fitrovia. It treated the sick and injured of central London and beyond; the hospital of choice for passengers ill on arrival at Heathrow. Victims of the worst excesses of the city arrive in the Soho annex handcuffed to policemen. Some patients more memorable than others. The pilot of a long-haul flight who died of an undiagnosed exotic disease. The prostitute covered in bruises, pale and disorientated as though having just emerged from some subterranean world, her head shaved so parasites eating into her scalp could be removed. A baptism of fire for a student nurse from the leafy suburbs of London. A world away from the winding lanes and tranquil villages of Cambridgeshire where I ended up practising as a domiciliary chiropodist.
The healthcare sector has changed beyond recognition since the 1970s. A cohort of elderly patients has passed through the system. The baby boomers time forgot, born during the decade following the First World War. Eclipsed by us, the ‘sixties generation’ – called that even though most of us were born during the 1940s and 1950s. They built the NHS that brought us into this world then almost destroyed it during their journey into the next one. They gave us bed blocking in the 1990s as hospitals struggled to reinvent themselves as the managers of gradual decline rather than repairers of broken bones.
‘Breathing their last’, literally in many cases. Most of my male patients died from one form of lung disease or another. They had worked on farms, driving agricultural machinery through clouds of dust, or in the nearby stoneworks which manufactured corrugated asbestos sheets. Always a cigarette hanging from the corner of their mouth; Woodbines and arc welding proved a particularly lethal combination. Unless they were unlucky, careless when washing clothes, wives outlived their husbands. Twenty years of gradual decline or a slow journey into the twilight world of dementia.
Patients with dementia were unpredictable. Calm and withdrawn most of the time but always with the threat of a panic attack. Screams and abuse having suddenly discovered someone sat in front of them with a scalpel in their hand. But I learned to deal with patients suffering from dementia on those long night shifts at The Middlesex during the winter of 1973, when student nurses often found themselves in sole charge of a 24-bed ward.
No incident during my time as a chiropodist stands out as remarkable, but I do remember my first diabetic patient. The condition hadn’t been diagnosed but all the tell-tale signs were there and I had them marked down for the disease during the initial assessment. The lack of sensation. An angry swelling around what would otherwise have been just another ingrowing toenail. Even so I wasn’t prepared for the eruption of foul-smelling pus followed by a stream of blood that was still flowing 20 minutes later. I was painfully aware that the hospital treatment room, where the patient should have been, was over 10 miles away. Instead of lying on an operating table they were sitting on their settee, dog beside them. No reassuring voice of a doctor over my shoulder, just a hyperactive celebrity chef shouting out from the television set. They should share the blame for this, I thought, pressing the alginate dressing against the wound for 30 minutes just hoping the bleeding would stop.
Domiciliary chiropodists fall into one of three groups. The unregistered ‘nail trimmers’ charging £15 per appointment who practise in care homes or community centres. Patients are wheeled in as if on a production line. Typically, each treatment takes between 10 and 15 minutes. Corns are pared, nails clipped and callouses removed – nothing too complicated. At the other end of the scale, the practitioners with their own surgery who fix ingrowing nails, surgically remove verrucas, corns and infected nails. They charged £40 upwards and between £150 and £200 to remove a nail. In the middle are HPC (Healthcare Professional Council) registered practitioners, such as myself, who provided everything, with the exception of nail removal, in the patient’s home. At £30 a session, care homes are not interested in this level of treatment and per day I was actually receiving less than the nail trimmers. Unless treating a couple, each treatment took approximately 50 minutes: 10 minutes to get there, 10 minutes to set up and the remainder treating the patient. There were always a few minutes for a chat, sometimes a cup of tea, and help with getting support from social services, dealing with utilities and, in some cases, finding the patient a reliable gardener or a home help. Little wonder the days were long and I always ran late.
The NHS treated a patient for free and, while I was practising, the local Trust attempted on more than one occasion to set up its own specialist chiropody unit. Patients were referred to the unit by their GP. While it was tempting to persuade difficult to treat patients to press their GP for a referral, the NHS unit quickly reached full capacity. Then the flow of patients reversed and the NHS persuaded patients to seek treatment from a private chiropodist. Being an ex-nurse and HPC registered, the NHS tended to push difficult patients in my direction and assumed this explained the increase in diabetic patients. However, talking to colleagues, it was clear that complications related to diabetes were overtaking lung disease as the principal cause of death among the over 65 demographic. The disease regularly featured in our professional body’s journal and we were targeted by companies selling diagnostic equipment. Conferences that once dealt with mundane issues such as the treatment of fungal toenails and corns now had whole days given over to diabetes.
At some point during the conference, a speaker would reel off a number: 549,000. It is estimated that over half a million people with Type II diabetes have yet to be diagnosed. This is approximately one in eight of the number of people believed to have the disease. The figure appears in the business plans of start-ups launching new diagnostic devices. It is used by the NHS when pressing the government for extra funding. A gun pressed to the head of the Department of Health. A looming heath crisis, replacing dementia as the existential threat to healthcare free at the point of delivery. In the US the number is bigger: eight million undiagnosed cases. Just as the potential growth in internet users drove the dotcom market during the 1990s, so the ‘unlit’ number of diabetes cases underpins the burgeoning market for blood-testing kits. The fact the NHS isn’t actively seeking out the 549,000 potential patients (and as a chiropodist I didn’t exactly receive a round of applause when I discovered one) is of little consequence.
While those 549,000 undiagnosed cases make it impossible to predict the size of the diabetes ‘market’ accurately, the additional burden each sufferer places on the healthcare system is less of an unknown. Aseptic techniques are important when practising chiropody in a patient’s home. Even the most straightforward cases require all instruments to be kept in sterile pouches until used. Used instruments are cleaned in an ultrasonic bath then repacked in pouches and sterilised using an autoclave. My autoclave held 12 sets of instruments and I was using two sets per patient. The machine defied all attempts to run it on Economy 7. The house lights would dim when it was turned on. Second to petrol, electricity was my largest business expense. I inherited many of my patients from a chiropodist who used the same set of instruments on all his patients. HPC registration ended this practice. In some cases, the constant unpacking of instruments seemed overkill for a procedure that was little more than nail clipping for people who could no longer reach their feet. The two sets of instruments were merely prudent to prevent nail infections being transferred from one foot to the other.
Diabetes brings with it a significant increase in the cost of treatment. It wasn’t uncommon to use one set of instruments per infected toe; in difficult cases, two sets on the same toe. But the cost in sterilisation was small compared to the extra time needed for the treatment itself. Not only was the appointment longer but there were follow-up visits, usually within seven days, to replace dressings and check for infection. Fitting these follow-ups between scheduled appointments spread across a catchment area covering a large part of South Cambridgeshire took time, used extra petrol and reduced the number of patients I was treating in a day. There were also frequent letters to the patients’ GPs keeping them updated on treatment plans and requesting antibiotics. Patients with dementia were expensive to treat: they forgot appointments or refused to answer the door. But this was solved by having a carer or relative arrange the appointment and to be there with the patient on the day. Diabetes, however, transformed a simple procedure into something akin to a surgical operation.
It was P.J.O’Rourke who said he had just one word for people nostalgic for the ‘good old days’: ‘dentistry’. Many healthcare procedures look primitive in retrospect. But take a scalpel to a diabetic’s foot in the living room of a house and there’s no need to wait for history to judge us; it already looks as dated as barbers carrying out routine surgery. My overheads were low and I could absorb the cost of treating diabetics. However, a domiciliary NHS chiropodist could afford to spend little more than 20 minutes with a patient; any more than that and the treatment was deemed uneconomic. The NHS would have found it prohibitively expensive to take on every diabetic I was treating, significantly more than the £28 per patient I was charging. Only once, in a case where the patient’s house was so unclean that even with the best aseptic techniques treatment would have been reckless, was I able to refer a diabetic patient to the NHS. Unfortunately, chiropody is always at the top of the list when Trusts are scaling back services. So those 549,000 suspected diabetics everyone is looking for may remain undetected for quite some time. In fact, a whole generation of sufferers has already slipped through the net.
While a growing number of diabetics, actual and potential, enabled health providers and medical device manufacturers to push diabetes up the healthcare agenda, it was the link to obesity that politicised the disease, and during my time as a chiropodist I noticed another trend: old people were becoming fatter.
No press mention of obesity is complete without a stock photograph showing a middle-aged couple, bulging out of their XL sized clothing, side by side pushing a trolley full of shopping across a supermarket car park, or overweight pre-teens clutching cans of carbonated drink. Forgotten are the grandparents. The perception is they were more restrained and conservative in their eating habits. But my patients were the first to be struck down. Long before the moral panic over childhood obesity complications arising from Type II diabetes was the primary reason why a patient’s notes migrated into the archive section of the filing cabinet. The rest of the world didn’t notice because we tend to equate old with becoming ill. When a person of advanced years struggles while climbing steps it could be because their lungs are failing or perhaps because they are overweight. We seldom ask which, it’s just old age.
Few noticed my elderly patients become obese because they did it in private. The loss of mobility that came with excess weight confined them to their armchairs. Only when people of working age caught up with their parents was obesity at last public and visible. Then we were sharing a public space with people whose condition was regarded by many as being self-afflicted. Caused by gluttony and a lack of restraint. They were eating more than their fair share of food, making themselves ill and then using more than their fair share of the NHS.
So obesity among the over 65s (or over 70s as many of my patients will be now) has been largely overlooked. But they, like the person rushed into the Middlesex Hospital, provide us with important clues as to the source of what later became a global epidemic.
The elderly were first to fall victim to the food industry’s sleight of hand. That sounds harsh. Perhaps ‘conjuring trick’ is a more charitable description of how food was made to disappear. Out of sight only briefly but while behind the magician’s cloak, transformed. Only the oldest of my patients saw the trick from beginning to end. They can still remember Sunday afternoons walking in the fields surrounding the village, crushing ears of wheat in their hand. The days were already long gone when the plumpness of the grains, once the chaff had been blown away, determined how much the farmer would pay for their labour that year. But it still has some bearing on the price of bread. The grain would be milled into flour which was turned into bread in the village bakery. Potatoes when harvested would be sold in the village shop. Apples from the orchards and honey from the beehives; food remained in view from the farm to the plate. My elderly patients were the last generation for whom there was a link between the land surrounding the villages and the food they ate.
Orchards have been grubbed up and with them went the beehives. Potatoes are now grown in prairie sized fields in the Fens; apples are grown in Spain and Chile. Clouds of dust still rise from the combine harvester each summer as they gather monocrops: wheat, barley or oil seed rape. But for those watching they might as well be a robot building cars in South Korea. The oil seed rape is merely another industrial feedstock destined for use as cooking fat or, perhaps, biodiesel. The wheat may become cattle feed or it might end up in biscuits.
But a fanfare and a flourish when the magician’s wand is pulled from behind the curtain because now it is a bouquet of garishly coloured flowers. No longer bland monocrops but delicious foods. Not just a tray of bread in the bakery or a sack of potatoes in the village shop but part of a proliferation of choice extending down both sides of the supermarket aisle. Choice which is, in reality, an illusion. The magician (and he had a name, Howard Moskowitz) merely added flavouring and colouring along with sugar, fat and salt to these monocrops, transforming them into a seemingly endless variety of products. Processed food because ‘manufactured’ sounds a little too industrial.
The most important part of any magic trick is convincing the audience it isn’t a trick at all. A generation used to real food accepted the synthetic substitute because it was injected into their past. Described as ‘fresh’, ‘healthy’, ‘original’, ‘traditional’ or ‘natural’ and in packaging with pictures of cottages and the word ‘farm’ printed on it. Less sceptical and more trusting than their children, this was a generation that handed over their savings to rogue builders and clicked on links in emails from Nigerian princes. They were easy prey for those celebrity chefs who I heard over my shoulder each afternoon. My patients watched as the chefs prepared what they claimed was good wholesome food. Unfortunately, the ingredients placed into the mixing bowl bore very little resemblance to those which found their way into products sold in supermarkets. Products which the celebrity chefs were happy to lend their name to. Like the Worther’s Originals in the bowl on the sideboard (a product that didn’t exist until the 1960s) the history of food had been turned into a fairy story.
A deadly illusion because the arrival of that fat- and sugar-laden food coincided with retirement and, in many cases, a sedentary lifestyle with too much armchair and an excess of television. Most of my patients never realised their diet had changed or why they were putting on weight. Diabetes when diagnosed came as a shock, to them at least.
There was something rather ironic about being struck down with osteomyelitis. Just as the number of patients hacking and wheezing away their final years began to decline, I inhaled a fleck of diseased skin. There is a condition called chiropodist’s lung. It is caused by breathing in dust which becomes airborne when sanding hard skin from patients’ feet. It is how a lot of chiropodists end their career. We wear masks of course, most of the time. But this wasn’t chiropodist’s lung. An annoying cough, but soon accompanied by a pain in the wrist and at the top of the spine. I regained consciousness in intensive care. Two operations on my wrist as my chiropody practice was being negotiated away. Colleagues taking portfolios of patients, the diabetics spread evenly among them to mitigate risk. Up until this point I’d never counted them.
To be honest, I had already decided it was time for a career change. The osteomyelitis merely forced my hand – pardon the pun. Common with many domiciliary care workers, the burden of spending all my working hours with the sick and elderly was weighing heavy. ‘Twenty years’ time and this will be me,’ crossed my mind more than once. It was difficult to focus on the fit and elderly among my patients especially when finding myself treating a new generation of patients. No more reminiscing about working with my father-in-law. Now I was treating people who went to school with my husband. It is hard to watch someone’s body rotting away from the feet upwards. Hard not to take ownership of the condition if you are the one who diagnosed it and is left to treat it. Plenty of gallows humour of course: ‘Do I get my chiropody for half price now?’ a patient asked after losing the first leg. ‘Free if you lose the other one,’ I replied, but they seldom lived to find out.
The transition from chiropodist to nutritionist would have happened at some point. I was already playing this role with many of my diabetic patients. A healthy diet had come too late for many but at least it slowed the progression of the disease. Putting together a treatment plan was not quite so simple as it had been with chiropody. As a chiropodist, like my colleagues I relied on peer-reviewed research to develop best practice. There was a professional body which disseminated this research, a monthly journal and regular conferences. There were clear audit trails between the precursors of a condition, the symptoms and the condition itself.
Fungal toenails usually resulted from contact with contaminated water, with cross-country runners, keen gardeners and farm workers being particularly susceptible. Verrucas were usually contracted in swimming pools and communal showers. Schoolchildren brought them into the household and they spread throughout the family. Treatment regimes were standard and backed up by research and clinically tested medications. Outside of chiropody the same methodical approach was used to treat those lung conditions. But this clarity is absent in nutrition, in the main due to that link between diabetes and obesity.
We have been here before with blood pressure. Merely one of the precursors to developing heart disease or a stroke, this condition was eventually regarded by many as a disease in its own right. An increasing number of actors in the healthcare market claimed ownership of this ‘disease’. Manufacturers of monitoring devices and suppliers of medications that reduced blood pressure manoeuvred themselves into the cardiology market claiming to cure something that was, in reality, merely avoidable. Your device or pills will always look sexier if you give the impression they cure a disease. Even complementary health practitioners claimed to cure blood pressure rather than help the patient reduce the condition that caused it. Cardiologists took the same approach when applying for research grants, as did the charities that funded the research.
Like high blood pressure, obesity is increasingly promoted as a disease. Again, medical researchers and complementary health practitioners lay claim to the condition as do the charities that raise funds for research into heart disease, strokes and diabetes. But, as with high blood pressure, obesity is merely a condition rather than a disease. It can lead to a grossly overweight person contracting diabetes or suffering heart disease but it is a precursor to these diseases. It is preventable, usually by modifying your food intake and lifestyle, rather than curable. So when it is claimed that a gastric bypass cures obesity this is misleading; rather it prevents the excess of food causing the condition from being digested. Clinicians and charities are not the only ones misrepresenting obesity; dietitians, food companies and various pressure groups also talk up the condition. Each has their own reason for doing so. Different this time, however, is the environment within which this discussion is taking place.
Researchers no longer need to go through the long painful process of publishing peer-reviewed papers as charities and pressure groups funding their research will help them promote it on social media. They will feed it to the press from where it will find its way into TV documentaries.
The link between diet and obesity should complete an audit trail leading all the way from the food producer to the diabetic consumer. However, the diet plan or slimming industry has positioned itself midway between the two. It is obviously keen to promote obesity as a disease as it is in the business of ‘curing’ it. Little more than semantics perhaps but it neatly severs the link between the ingredients in food and diseases such as diabetes. It also creates a symbiotic relationship between the food producers and the diet industry. It becomes the consumer’s responsibility to seek a cure for obesity before they develop complications related to it.
We would have clarity if a single body, for example The Medical Research Council, oversaw the funding of research into diet and nutrition then managed the dissemination of results. Instead we have a plethora of organisations, both commercial and non-profit, competing for attention. Many operate within a complex web of vested interests and overlapping agendas. An example of the confused state of nutritional research is the recent dispute regarding the validity of the Department of Health’s Eatwell Plate and the controversy over the rushed publication of research into the impact of low-fat and lower cholesterol diets.
Devising a treatment plan in an environment where everyone is shouting at once is the most challenging part of being a nutritionist. Researchers rush to publish through multiple unmoderated channels. Organisations funding research use selected, eye-catching results as media soundbites. The patient is exposed to multiple interpretations of the same raw data on which you base their treatment. This never happened when treating a patient suffering from lung disease, cancer or dementia.
The Middlesex Hospital closed in 2005 and the site was redeveloped. Still there in Foley Street is John Astor House, the nurses’ residence where I collapsed into bed exhausted at the end of my shift. Like many young nurses, what motivated me then was the belief that I was making a difference, however small: ‘If I can help just one person,’ was always in the back of my mind. And taking a broader view I was never fighting this battle alone. The police would track down the pimp in Soho who mistreated the prostitute and researchers would eventually identify that mysterious disease which was poised to sweep the world.
Even when travelling those country lanes there was a sense that care wasn’t provided to my patients in a vacuum. There was health and safety legislation that ensured the next generation were not choking in dust. The number of people dying from tobacco-related diseases fell following a sustained multiagency initiative to curb smoking. Within chiropody itself aseptic techniques improved. Even shoe designers eventually took podiatry into consideration when designing footwear. The feeling was one of repairing the damage caused by legacy practices.
Nutrition is different. ‘If I can help just one person …’ Well, at the end of the day, I’ve helped just one person. Tomorrow there will be another and then another. The NHS may be lining up with the other bucket shakers when it warns of the cost of dealing with a ‘tsunami’ of diabetics, but in one key respect it is right. There is no plan to deal with the impact of this disease or even coherent research on which to base a plan. There’s no strategy to contain the diabetes or even to stop the number of sufferers rising year on year. The food industry will carry on producing more diabetics than the NHS and private domiciliary health workers can ever hope to cope with. They will carry on doing so while the public perceives obesity as a disease which can be cured rather than a precursor to diabetes. The days when those 549,000 undiagnosed diabetics slip away quietly in their living rooms or care homes are over. Those ultimately responsible for causing the disease must either take action to prevent it or bear the cost of treating it.
Susan Krueger is a practising nutritionist based in Cambridge and author of Overweight – So Whose Fault is That?