The COVID-19 pandemic has laid bare the heightened mortality risk among those with obesity and diabetes, and especially those whose diabetes is poorly controlled (Tan et al, 2020). Unfortunately, the incidence of obesity globally has increased significantly over the past 25 years (Alberca et al, 2020), with the proportion of those who are overweight or obese in the UK being among the highest in Europe (Eurostat, 2020). The increase in obesity has been mirrored by an increase in the incidence of diabetes, with 90% of the 4.8 million people with diabetes in the UK having type 2 diabetes (Diabetes UK, 2020).
Jenny Harries, England's Deputy Chief Medical Officer, has urged people to lose weight so that they are less vulnerable should they become infected with the SARS-CoV-2 virus. This advice stems from the growing evidence that obesity is associated with an inappropriate immune response to the SARS-CoV-2 virus, resulting in severe COVID-19 (Alberca et al, 2020). Additionally, obesity is the strongest risk factor for type 2 diabetes, with weight loss and calorie restriction reversing type 2 diabetes (World Health Organization (WHO), 2016). However, long-term weight loss requires sustained motivation and personal discipline, which is difficult for many.
The complications of diabetes are well known and double the risk for a wide range of vascular diseases, resulting in coronary heart disease and strokes as well as peripheral vascular changes (Emerging Risk Factors Collaboration et al, 2010). Diabetic foot disease caused by peripheral vascular disease and microvascular changes is of growing concern, especially as delayed or ineffective management may contribute to increased lower limb amputation rates. Nickinson et al's (2019) systematic review found time delays across all elements of the management pathway reflecting poor health-seeking behaviours, poor healthcare assessment and barriers relating to referral and treatment within the care pathway. For example, the lack of clinical guidelines and inadequate wound care training are among the barriers impeding the incorporation of advancing technologies (Foong et al, 2020). A phenomenological study has also suggested poor team communication, heavy workloads, the absence of structured and validated assessment tools and difficulties in incorporating risk stratification into diabetic foot screening in busy primary care settings (Formosa et al, 2019).
Turns (2013) described how to assess a diabetic foot as part of the annual foot review of all housebound clients in line with the National Institute for Health and Care Excellence (2019) guidelines regarding diabetic foot care. District nurses can play a key role in preventing avoidable deterioration of the foot and identifying those who need a referral.
‘Long-term weight loss requires sustained motivation and personal discipline, which is difficult for many.’