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type 2 diabetes

  1. 1. TYPE II DIABETES AND WOUND HEALING A PUBLICATION OF NATIONAL HEALING CORPORATION ® Diabetes and wound healing Development of Over 20 million Americans have diabetes. Having type 2 diabetes increases the risk for many serious type 2 diabetes complications including vascular disease, blindness, Several risk factors are asso- diabetic foot ulcers, and end-stage renal disease. ciated with the development Approximately 15% of people with diabetes will devel- of type 2 diabetes, also op a foot ulcer due to neuropathy or vascular disease. known as adult-onset dia- Diabetes remains the leading cause of non-traumatic betes. These include heredi- amputation and having an amputation had a signifi- ty, age, diet, inactivity, seden- cant impact on five-year survival. In 2006, National tary lifestyle, and obesity. Healing treated over 8,000 patients with diabetes and a lower extremity wound. Although the exact causes ALTHOUGH THE EXACT CAUSES OF of type 2 diabetes are still TYPE 2 DIABETES ARE STILL Treating these complex patients requires a multi- unclear, the disease has a UNCLEAR, THE DISEASE HAS A disciplinary team committed to patient and family strong hereditary connection. STRONG HEREDITARY CONNECTION. education. Motivating patients to improve their diet According to www.dlife.com, and increase their exercise can have an impact on Race also may determine individuals who have a parent healthcare spending. Family education can increase one’s likelihood of getting or sibling with type 2 dia- awareness for those with a hereditary disposition. As the disease. Type 2 diabetes betes have a ten to 15% healthcare professionals it is crucial to deliver a con- is more common among chance of developing the sistent message about the benefits of diet and exer- Native Americans, African- disease. What’s more, the cise for patients. At National Healing Wound Centers, Americans, and Hispanics risk is much higher if that we help each patient take control of their disease. when compared with sibling is an identical twin. Caucasians and Asians. This issue of Wound Healing Perspectives is For those with a genetic (continued on page 3) designed to help you tailor your approach to each tendency toward the disease, patient’s needs as you touch the lives of this rapidly type 2 diabetes can be trig- HIGHLIGHTS INSIDE growing group. gered by such environmental factors as inactivity or Nutrition and diet.....................2 Sincerely, poor diet. According to Dietary modifications.................2 www.healthatoz.com, women who have had gesta- The Glycemic Index...................3 tional diabetes during preg- The “Diabetes Food Pyramid” Robert Kirsner, MD, PhD nancy have an increased risk vs. “MyPyramid”........................4 > Chairman, Medical Advisory Board of acquiring type 2 diabetes later in life. In addition, Fiber and glucose control .........4 women who give birth to Nutrition and wound healing ....5 babies weighing nine pounds or more also have an Exercise and diabetes................6 increased risk of developing Women and metabolic www.nationalhealing.com the disease. syndrome...................................7 888.332.0202 Working with a Wound Healing Center...............8
  2. 2. Nutrition and diet Nutrition Since sucrose Guidelines for does not in- crease glycemia Diabetics to a greater ex- The ADA has specific tent than goals of medical nutrition isocaloric therapy for people with amounts of Dietary diabetes. This includes achieving and maintaining starch, sucrose and sucrose- modifications near-normal levels of blood glucose through an containing foods do not need to adequate diet, sufficient encouraged. Following a healthy diet is be restricted; physical activity, as well Individuals receiving key to preventing type 2 however, they should as the possible use of fixed daily insulin doses diabetes. According to Hu et be substituted for hypoglycemic agents should try to be consis- al, previous studies have other carbohydrate and/or insulin. Additional tent in day-to-day shown that individuals have sources or, if added, goals include achieving carbohydrate intake. a reduced risk of acquiring covered with insulin or optimal serum lipid lev- Carbohydrate and type 2 diabetes if they con- other glucose-lowering els, consuming adequate monounsaturated fat sume a diet high in cereal medication. calories to maintain de- together should provide fiber and polyunsaturated Non-nutritive sweeten- sirable weight, preventing 60–70% of energy fat but low in saturated fat, ers are safe when or treating diabetes- intake. However, the trans fats, and glycemic consumed within the related disease, improv- metabolic profile and load, which suggests the acceptable daily intake ing overall health by need for weight loss disease can be prevented levels established by maintaining a balanced should be considered with behavior modification. A HEALTHY DIET SHOULD INCLUDE CARBOHYRATES In terms of carbohydrate in- take, the ADA recommends FROM WHOLE GRAINS, FRUITS, VEGETABLES, AND that diabetes patients focus LOW-FAT MILK. on total carbohydrate intake rater than the type of the Food and Drug intake of the macronutri- when determining the carbohydrate being con- Administration. ents and micronutrients, monounsaturated fat sumed. According to a 2001 Individuals receiving and consuming adequate content of the diet. ADA study by McIntosh and intensive insulin thera- amounts of water. Sucrose and sucrose- Miller, individuals should py should adjust their containing foods should consume 20-35 grams of pre-meal insulin doses The ADA’s nutrition guide- be eaten in the context total fiber from soluble and based on the carbohy- lines for diabetics now of a healthy diet. insoluble sources a day, drate content of meals. emphasize a diet high in including fruits, vegetables, Although the use of low SOURCE: EVIDENCE-BASED monounsaturated fat so and whole grains. glycemic index foods NUTRITION PRINCIPLES AND diabetics are no longer RECOMMENDATIONS FOR THE may reduce postprandi- TREATMENT AND PREVENTION OF limited to a high-carbohy- Caffeine also may reduce al hyperglycemia, DIABETES AND RELATED drate/low-fat diet, COMPLICATIONS, DIABETES CARE, glucose uptake, according there is not sufficient offering diabetics many JANUARY, 2002, AMERICAN DIABETES to a 2005 study by Lee, evidence of long-term ASSOCIATION. more food choices and Hudson, Kilpatrick, Graham, benefit to recommend less restrictions. Below and Ross, although the the use of low glycemic are the ADA’s recommen- clinical implications of index diets as a primary dations: these findings remain to be strategy in food/meal A healthy diet should determined. planning. include carbohydrates Consuming dietary from whole grains, fiber, upwards of 50 fruits, vegetables, and grams per day, is low-fat milk. 2 WOUND HEALING PERSPECTIVES SPRING 2007
  3. 3. The significance of fiber DIETARY SOLUBLE FIBER t According to McIntosh and t Miller, consuming a high-fiber Gel formation in the stomach diet may help people with type 2 diabetes achieve reductions in t t blood glucose and lipid levels. Whether people with diabetes Delayed gastric emptying can achieve and maintain a t fiber intake of 25-50 g/day for t more than 6 weeks is unknown. Many consumers with diabetes Uniform levels of CHO to The need additional nutrition education to incorporate more the small intestine t glycemic high fiber food into their usual diets. The impact of increasing t Flattened blood glucose curve index fiber consumption among The glycemic index (GI) is people with diabetes in poor used to control appetite t metabolic control is worthy of and manage weight and t investigation. blood glucose levels. The Insulin surge GI ranks carbohydrate-rich foods by how much they Dietary Soluble Fiber figure. Possible mechanism by which soluble dietary fiber raise blood glucose levels lowers serum glucose. Note: CHO = carbohydrate. SOURCE: MCINTOSH, ADA relative to white bread, which has a GI of 100. The index has several Development of type 2 diabetes (continued from page 1) limitations: It does not measure how Other risk factors for de- the disease have been earlier NHANES, the fast blood glucose levels veloping type 2 diabetes found in younger average age of diagnosis increase. include taking specific individuals. for type 2 diabetes was Carbohydrate complexity drugs, such as diuretics 52 years. In the later and fiber content can and steroids in addition to Authors of this study NHANES, the average change the GI value. chronic stress, low birth used figures from the age was 46 years. Foods have different weight, associated fetal National Health and values depending on malnourishment, and Nutrition Examination Indeed, the most impor- ripeness, preparation gene mutations Survey (NHANES), a se- tant determinant for type method, and when eaten [dlife.com]. ries of surveys conducted 2 diabetes is being with certain other types across the United States, overweight. According to of food. The risk for developing which included a house- a 2001 study by Hu, GI values vary from type 2 diabetes also hold interview, a medical Manson, Stampfer, and person to person and the increases with age. exam, as well as labora- Colditz, individuals with a time of day food is eaten. According to tory and other testing. body-mass index at the healthatoz.com, half of Researchers compared high end of the normal Although it can help all new cases of the results from two range (25 or above) are patients fine-tune their disease occur in people NHANES studies, one associated with an food choices and improve over the age of 55. Yet which ran from 1988 to increased risk of post-meal blood glucose according to a 2005 1994 and the other from diabetes. Weight loss levels, the best strategy is American Diabetes 1999 to 2000. When the and weight control, to monitor total grams of Association (ADA) study two time periods were therefore, are the most carbohydrates. by Koopman, Mainous, compared, data revealed effective ways to reduce and Diaz, that age that the age of diagnosis the risk of getting type 2 threshold may be getting dropped six years from diabetes. lower, as more cases of the earlier study. In the WWW.NATIONALHEALING.COM 3
  4. 4. The ADA’s “Diabetes Food Pyramid” vs. the USDA “MyPyramid” For one, it does not servings recommended classify the food but daily among the meals Fiber and rather groups foods based on their and snacks one eats each day. glucose In April 2005, the United carbohydrate and protein content. In order Portion size also differs control States Department of Agriculture (USDA) re- to consume the same carbohydrate content in from what is recommend- ed by the USDA. For Although some debate ex- leased a new food guid- each serving, the portion example, a serving of ists about the significance of ance system replacing sizes vary. For example, pasta or rice is 1/3 cup in fiber on metabolic control the former Food Guide foods such as potatoes the Diabetes Food among people with type 2 Pyramid. The new system, and other starchy vegeta- Pyramid and 1/2 cup in the diabetes, according to a called "MyPyramid," pro- bles are grouped together USDA pyramid. A serving 2001 study by McIntosh and vides a set of tools based with the grains, beans, of fruit juice is 1/2 cup in Miller, patients with type 2 on calorie requirements and starchy vegetables the Diabetes Food diabetes who consumed a to help Americans make instead of with traditional Pyramid and 3/4 cup in the diet high in fiber-rich foods healthy food choices. vegetables. In addition, USDA pyramid. This (e.g., 50 grams of fiber per cheese is in the meat variation in portion size day, 50% soluble) for six The ADA’s “Diabetes Food group instead of the milk is needed to make the weeks had significant Pyramid” divides food into group. carbohydrates about the improvement in glycemic six groups, which vary in same in all the servings control and lipid panels size. The largest group— The Diabetes Pyramid listed. when compared to patients comprised of grains, gives diabetics a range of who consumed a diet with moderate amounts of fiber THE ADA RECOMMENDS THAT INDIVIDUALS DIVIDE THE (e.g., 25 grams of fiber per NUMBER OF SERVINGS RECOMMENDED DAILY AMONG day, 50% soluble). THE MEALS AND SNACKS ONE EATS EACH DAY. Consuming a diet rich in soluble and insoluble fiber beans, and starchy veg- servings. For those has other reported benefits etables—is on the bottom following the minimum as well. Not only do of the chart, which means number of servings in individuals feel satiated, that diabetics should eat each group, about 1,600 total energy intake and more servings of these calories should be adiposity are reduced, and foods than any other consumed. For those who constipation, diverticuli, and food group. The smallest eat at the upper end of other gastrointestinal tract group—which includes the range, approximately disorders can be prevented fats, sweets, and alco- 2,800 calories are al- [McIntosh, et al]. hol—is at the top of the lowed. The exact number pyramid, meaning that of servings depends on diabetics should eat very the person’s diabetes few servings of these food goals, calorie and groups. nutrition needs, as well as lifestyle and food The Diabetes Food preferences. The ADA Pyramid is different from recommends that individ- the USDA’s “MyPyramid.” uals divide the number of 4 WOUND HEALING PERSPECTIVES SPRING 2007
  5. 5. Nutrition and wound healing Adding an Proper wound healing can be a problem for diabetic prolonged inflammatory phase in the wound receiving nutrition alone [Zulkowski]. Protein- exercise patients. The increased glucose level in individu- healing cascade. calorie malnutrition should be considered in program als with diabetes causes Malnutrition also has wound healing, notes For patients with type 2 cell walls to become rigid, been linked to the develo- Collins, since patients diabetes, exercise is not which impairs blood flow ment of pressure ulcers, with diabetes often have a only beneficial but pivotal through the small vessels according to Zulkowski progressive loss of lean in managing the disease. at the wound surface, in a 2006 article citing body mass, which is then According to a 2004 impeding red blood cell research involving older replaced with a metaboli- ADA study by Zinman, permeability and flow, adults in nursing homes. cally inactive fat mass. Ruderman, Campaigne, states Nancy Collins in a Additional research also Hyperglycemia also Devlin, and Schneider, 2003 article. What’s more, revealed that older adults impedes wound healing, physical activity may im- this chain of events leads with eating problems so proper nutrition (also prove insulin sensitivity and to impaired hemoglobin and/or weight loss issues known as medical nutri- help to decrease elevated release of oxygen and also carry an increased tion healing) should be blood glucose levels into nutrient deficits in the risk of developing pres- discussed during wound the normal range. Exercise wound [Collins, 2003]. sure ulcers [Zulkowski]. healing visits. Many also helps in glycemic An increased amount of different nutritional control, can reduce levels of Decreased immune func- protein is required for the approaches to diabetes triglyceride-rich very-low- tion also contributes to body to heal properly, and are now available, includ- density lipoprotein, as well poor wound healing in sufficient hydration aids ing the no concentrated as reduce hypertension. patients with diabetes. in tissue perfusion since sweets diet, the exchange When blood glucose dehydration affects blood system, carbohydrate Since each individual has a levels are persistently volume, circulation, and counting, and the different fitness level elevated, chemotaxis (the skin turgor [Zulkowski]. glycemic index. The diet depending on their age and process when additional ultimately should be current level of physical white cells move to the Some medications, such tailored to the individual’s activity, a standard recom- site of an infection) and as the anabolic steroid preference and personali- mendation for diabetic phagocytosis (the inges- oxandrolone, have been ty. For example, certain patients is that the exercise tion of bacteria by white prescribed to people with patients may prefer to regimen start with a five- cells) are compromised significant unintentional follow a simple diet to ten-minute aerobic [Collins]. Both of these weight loss. Although re- approach while others a warm-up period comprised processes are key to con- search specific to elderly more precise approach of walking or cycling at low trolling wound infections. patients is lacking, re- [Collins]. intensity [Zinman et al, search conducted on 2004]. Muscles should According to Collins, burn patients taking then be stretched and the diabetic infections also oxandrolone suggests exercise activity should take longer to heal favorable results. These follow. A cool down lasting because of delayed patients were able to about five to ten minutes to macrophage introduction regain weight and muscle lower the heart rate to its and diminished leukocyte mass two to three times pre-exercise level should migration, which cause a faster than patients conclude each session. WWW.NATIONALHEALING.COM 5
  6. 6. Exercise and diabetes Physical activity increas- with diabetes mellitus (median dose 245 ingly is being used as a should undergo all appro- mg/day), as reflected by a therapeutic tool for priate diagnostic studies. decrease in A1C levels patients with diabetes or Exams should screen for and fasting plasma glu- those at risk for develop- the presence of macro- cose concentration, stat- ing the disease. Studies and microvascular ed a 2006 ADA study by have shown that decreas- complications that could Wagner, Degerblad, Aerobic ing levels of activity and the increase in obesity worsen with exercise. A medical history and Thorell, and Nygren. exercise are to blame for the type 2 diabetes epidemic. physical examination should focus on the Two clinical trials pub- lished in late 2002 provide For patients with type 2 symptoms of disease strong evidence for the When considering aerobic diabetes, physical activity affecting heart and blood value of resistance activity, there are several improves the metabolic vessels, eyes, kidneys, training in people with points for the diabetic abnormalities of type 2 and the nervous system. type 2 diabetes, which patient to remember, diabetes, improves insulin A graded exercise test improves insulin sensitiv- according to Zinman et al. sensitivity, and aids in may also help if a patient ity to about the same For one, special precautions diminishing elevated is about to start a moder- extent as aerobic exer- should be taken when the blood glucose levels into ate-to-high intensity ex- cise. As a result, today physical activity involves the the normal range. For ercise program [Zinman the American College of feet. The use of silica gel or these reasons, the ADA et al]. Sports Medicine (ACSM) air midsoles as well as recently revisited its recommends a resistance polyester or blend position statement on the At least 150 minutes per training regimen for type (cotton/polyester) socks relationship between week of moderate- 2 diabetics whenever will help prevent blisters exercise, physical activity, intensity aerobic physical possible. and keep feet dry, important and diabetes to include activity and/or at least for minimizing trauma to both physical activity and 90 minutes per week of the feet. Similarly, for those resistance training vigorous aerobic exercise with peripheral neuropathy, [Zinman, Ruderman, is recommended for proper footwear is essen- Campaigne, Devlin, and people with type 2 dia- tial. As a result, individuals Schneider, 2004]. betes. In type 2 diabetes must inspect their feet patients, glycemic control closely for blisters and Before indicating an was significantly other potential damage exercise program or improved when exercise before and after physical increasing a patient’s was combined with activity. Individuals should level of exercise, a patient acarbose treatment also maintain adequate hydration when exercising, especially in the heat. Fluid EXERCISES FOR DIABETIC PATIENTS WITH should be taken early and LOSS OF PROTECTIVE SENSATION frequently throughout the excercise sessions. Recommended exercise Contraindicated exercise Although high resistance Swimming Treadmill exercise with weights is Bicycling Prolonged walking considered acceptable for young individuals with Rowing Jogging diabetes, it is not wise to Chair exercises Step exercises recommend it to older Arm exercises people with long-standing diabetes [Zinman et al]. Other non-weight-bearing exercise 6 WOUND HEALING PERSPECTIVES SPRING 2007
  7. 7. Metabolic syndrome Are your patients’ waist- coronary heart disease if An HDL-cholesterol lines getting bigger? If they have metabolic level below 50 mg/dL they measure more than syndrome than someone (at or below 40 mg/dL 34 inches around, these who does not. in men) individuals should be Metabolic syndrome is A blood pressure level examined carefully since also a strong predictor of at or above 130 mm Hg a large waist could be systolic or 85 mm Hg one sign of metabolic diabetes. It's very rare to have diabetes without diastolic Getting your syndrome. Defined as a cluster of also having metabolic syndrome. The two to- The best treatment option for patients with metabol- patients risk factors associated with obesity, an estimated gether push a patient’s risk of heart disease up ic syndrome is to lose weight and exercise, started 24% of Americans over by 50%. which if accomplished, can improve every one of Helping patients find a person- age 20 and 44% of If your patient has three al reason to exercise may be Americans over age 50 the five markers. One of the following five risk large study found meta- the key in getting them to have metabolic syndrome. factors, he/she could have adopt an exercise program The syndrome can repre- bolic syndrome complete- metabolic syndrome: ly disappeared in 30% of more readily, states Marrero sent a very serious health (2005). This can be done by danger for your patients. A waist circumference participants who rode a stationary bike three discussing the various health, For example, it can more than 34 inches times a week (starting social, and psychological bene- significantly increase a (more than 40 inches in at 30 minutes a session fits of exercise. Selecting the patient’s risk of develop- men) and working their way up right exercise program and the ing atherosclerosis, A fasting blood glucose to 50 minutes) for 20 suitable form of exercise for stroke, and peripheral level at or above weeks. the patient is the next step. vascular disease. Patients of 110 mg/dL Thus, administering a graded are also up to 3.5 times Triglycerides at or SOURCE: THE NATIONAL WOMEN’S HEALTH REPORT exercise test also is more likely to die from above 150 mg/dL recommended. Individuals should be aware of any physical limitations that Selected bibliography might result in physical dis- Bussau VA, Ferreira LD, Jones TW, Fournier PA. (2006). The 10-s Maximal Sprint: A Novel Approach to comfort or potentially cause Counter an Exercise-Mediated Fall in Glycemia in Individuals with Type 1 Diabetes. Diabetes Care, 29:3, 601- a health threat. According to 606. • Colberg SR, Parson HK, Nunnold T, Holton DR, Vinik AI. (2006). Effect of a Single Bout of Prior Moderate Exercise on Cutaneous Perfusion in Type 2 Diabetes. Diabetes Care, 29:10, 2316-2318. • Collins N. the ACSM, diabetics should (2003). Diabetes, Nutrition, and Wound Healing. Advances in Skin and Wound Care: The Journal for undergo a medical exam to Prevention and Healing, 16:6, 291-294. • Franz MJ. (2005). Hot Topic: Glycemic Index. American Dietetic determine the existence of any Association. • Guelfi KJ, Jones TW, Fournier PA. (2005). The Decline in Blood Glucose Levels Is Less With Intermittent High-Intensity Compared With Moderate Exercise in Individuals With Type 1 Diabetes. Diabetes musculoskeletal/orthopedic Care, 28:6, 1289-1294. • Hu FB, Manson JE, Stampfer MJ, Colditz G, et al. (2001). Diet, Lifestyle, and the Risk concerns that may prompt of Type 2 Diabetes Mellitus in Women. The New England Journal of Medicine. 345:11, 790-797. • Koopman them to omit certain exercises. RJ, Mainous AG 3rd, Diaz VA, et al.(2005). Changes in Age at Diagnosis of Type 2 Diabetes Mellitus in the United States, 1988 to 2000. Annals of Family Medicine, 3, 60-63, 2005. • Lee SJ, Hudson R, Kilpatrick K, Similarly, any existing Graham TE, Ross R. (2005). Caffeine Ingestion is Associated With Reductions in Glucose Uptake Independent co-morbidities should be iden- of Obesity and Type 2 Diabetes Before and After Exercise Training. Diabetes Care, 28:3, 566-572. • Marrero tified and considered in the DG. (2005). Time to Get Moving: Helping Patients With Diabetes Adopt Exercise as Part of a Healthy Lifestyle. Clinical Diabetes, 23:4, 154-159. • McIntosh M, Miller C. (2001). A Diet Containing Food Rich in Soluble and exercise prescription. For Insoluble Fiber Improves Glycemic Control and Reduces Hyperlipidemia Among Patients With Type 2 example, if the patient has an Diabetes Mellitus. Nutrition Reviews. 59:2, 52-55. • Ohio State University. (2006). Exercise Speeds Wound Healing. • Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa C. (2004). Physical Activity/Exercise and open wound, he/she should Type 2 Diabetes. Diabetes Care, 27:10, 2518-2539. • Sigal RJ, Kenny GP, Wasserman DH, Castaneda-Sceppa take special precautions and C, White RD. Physical Activity/Exercise and Type 2 Diabetes: A Consensus Statement from the American consult a primary care physi- Diabetes Association. Diabetes Care, 29:6, 1433-1438. • Wagner H, Degerblad M, Thorell A, Nygren J, et al. (2006). Combined Treatment with Exercise Training and Acarbose Improves Metabolic Control and cian before starting an exercise Cardiovascular Risk Factor Profile in Subjects With Mild Type 2 Diabetes. Diabetes Care, 29:7, 1471-1477. • program. Others may need to Zinman B, Ruderman N, Campaigne BN, Devlin JT, Schneider SH. (2004). Physical Activity/Exercise and use alternate equipment, such Diabetes. Diabetes Care, 27, S58-S62. • Zulkowski K. (2006). Nutrition and Aging: A Transdisciplinary Approach. Ostomy/Wound Management. 53:10, 53-57. as an incumbent bicycle, for example [Marrero]. WWW.NATIONALHEALING.COM 7
  8. 8. QUESTIONS OR COMMENTS? Contact Heather Cicero at 888.332.0202 or hcicero@nationalhealing.com Wound Healing Perspectives STAFF James E. Patrick, CEO Laura McMullen, Editor Erica Park, Researcher Lisa Sedelnik, Writer Heather Cicero, Layout Design CLINICAL ADVISORS Katy Rowland, RN, MBA SVP, Clinical Development Robert S. Kirsner, MD, PhD Chairman, Medical Advisory Board Working with a Wound Healing Center John Duffy, Jr. BSN, MSHCA, RN, CNA, BC One of the questions lying diseases, such as with the primary care Regional Director, Clinical Services physicians ask most fre- diabetes, are at high risk physician and other Cindy Stedman RN, BSN, CWOCN, CDFN quently is “When should I for hard-to-heal wounds specialists in healing Regional Director, Clinical Services refer my patients to a or other skin disorders their wounds, while Wound Healing Center?” that require a wound always reporting back This is particularly specialist’s attention. to the primary care NATIONAL HEALING www.nationalhealing.com important as advances Physicians at Wound physician who specializes continue in wound Healing Centers have in the patient’s overall ©2007, National Healing Corporation healing techniques, experience treating large care. technology, and materi- numbers of diabetic 8 als. Patients with under- patients and work closely CONTACT YOUR LOCAL WOUND HEALING CENTER IF Your diabetic patient has a wound that persists for Your diabetic patient has a chronic wound and a more than 30 days with standard wound treatment remote infection Your diabetic patient has a chronic wound and Your diabetic patient has a chronic wound that involves neuropathy deeper soft tissues or bone Your diabetic patient has a chronic wound and has Your diabetic patient has a chronic wound with puru- hypoxia lent drainage, surrounding cellulitis or inflammation, Your diabetic patient has necrotic tissue or foreign edema, exposed bone or joint, sinus tracts, or deep debris such as sutures at the wound site abscesses www.nationalhealing.com 888.332.0202