diabetes.ppt

Diabetes Mellitus
Definition
• A multisystem disease related to:
– Abnormal insulin production, or
– Impaired insulin utilization, or
– Both of the above
• Leading cause of heart disease, stroke, adult
blindness, and non-traumatic lower limb
amputations

Normal Insulin Metabolism
• Insulin
– Produced by the  cells of the islets of
Langherans of the pancreas
– Facilitates normal glucose range of 3.9
– 6.7 mmol/L

• Promotes glucose transport from the
blood stream across the cell
membrane to the cytoplasm of the
cell

•  Insulin after a meal:
• Stimulates storage of glucose as
glycogen
• Inhibits gluconeogenesis
• Enhances fat deposition in adipose
tissue
• Increases protein synthesis

• Fasting state
– Counter-regulatory hormones (especially
glucagon) stimulate glycogen  glucose
• When glucose unavailable during fasting
state
– Lipolysis (fat breakdown)
– Proteolysis (amino acid breakdown)

ALTERED CHO METABOLISM
 Insulin

 Glucose Utilization
+
 Glycogenolysis

Hyperglycemia

Glucosuria
 (osmotic diuresis)

Polyuria*
(and electrolyte imbalance)

Polydipsia*
* Hallmark symptoms of diabetes

ALTERED PROTEIN METABOLISM
 Insulin

 Protein Catabolism

 Gluconeogenesis
(amino acids  glucose)

Hyperglycemia

Weight Loss and Fatigue

ALTERED FAT METABOLISM
 Insulin

 Lipolysis

 Free fatty acids + ketones

Acidosis + Weight Loss

Type 1 Diabetes Mellitus
• Formerly known as “juvenile onset” or
“insulin dependent” diabetes
• Most often occurs in people under 30
years of age
• Peak onset between ages 11 and 13

Etiology and Pathophysiology
• Progressive destruction of pancreatic 
cells
• Autoantibodies cause a reduction of 80%
to 90% of normal  cell function before
manifestations occur

• Causes:
– Genetic predisposition
• In an individual with a genetic
predisposition, an event such as
virus or toxin triggers autoimmune
destruction of -cells probably over
a period of several years.

Onset of Disease
• Manifestations develop when the
pancreas can no longer produce insulin
– Rapid onset of symptoms
– Present with impending or actual
ketoacidosis

Onset of Disease
• Weight loss
• Polydipsia (excessive thirst)
• Polyuria (frequent urination)
• Polyphagia (excessive hunger)
• Weakness and fatigue
• Ketoacidosis

Onset of Disease
• Diabetic ketoacidosis (DKA)
– Life-threatening complication of Type 1
DM
– Occurs in the absence of insulin
– Results in metabolic acidosis

Clinical Manifestations
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss

• Accounts for 90% of patients with diabetes
• Usually occurs in people over 40 years old
• 80-90% of patients are overweight

• Insulin resistance
– Body tissues do not respond to insulin
– Results in hyperglycemia
• Decreased (but not absent) production of
insulin

Onset of Disease
• Gradual onset
• Person may go many years with undetected
hyperglycemia
• Marked hyperglycemia (27.6 – 55.1
mmol/L)

Risk factors
• Type 2 DM
– Family History
– Obesity
– Habitual physical inactivity
– Previously identified impaired glucose
tolerance
(IGT) or impaired fasting glucose (IFG)
– Hypertension
– Hyperlipidemia

Clinical Manifestations
• Non-specific symptoms
• Fatigue
• Recurrent infections
• Prolonged wound healing
• Visual changes

Gestational Diabetes
• Develops during pregnancy
• Detected at 24 to 28 weeks of gestation
• Associated with risk for cesarean delivery,
perinatal death, and neonatal complications

Secondary Diabetes
• Results from another medical condition or
due to the treatment of a medical condition
that causes abnormal blood glucose levels
– Cushing syndrome (e.g. steroid administration)
– Hyperthyroidism
– Parenteral nutrition

Diabetes Mellitus
Diagnostic Studies
1. Glucosuria
– To detect glucose in urine by a paper strip
• Normal kidney threshold for glucose is essential
• 2. Ketonuria
– To detect ketonbodies in urine by a paper strip

3. Fasting blood glucose
– Glucose blood concentration in samples obtained
after at least 8 hours of the last meal
4. Random Blood glucose
– Glucose blood concentration in samples obtained at
any time regardless the time of the last meal

5. Glucose tolerance test
– 75 gm of glucose are given to the patient with 300 ml
of water after an overnight fast
– Blood samples are drawn 1, 2, and 3 hours after
taking the glucose
– This is a more accurate test for glucose utilization if
the fasting glucose is borderline

Diabetes Mellitus
Collaborative Care
• Goals of diabetes management:
– Reduce symptoms
– Promote well-being
– Prevent acute complications
– Delay onset and progression of long-term
complications

Diabetes Mellitus
Collaborative Care
• Patient teaching
• Nutritional therapy
• Drug therapy
• Exercise
• Self-monitoring of blood glucose

pharmacological therapy
- Insulin (Type 1 and Type 2 DM)
- Sulfonylurea (Type 2 DM)
- Biguanides (Type 2 DM)
- Meglitinides (Type 2 DM)
- Thiazolidinediones Glitazones (Type 2
DM)
 a-Glucosidase inhibitors (Type 2 DM)

Diabetes Mellitus
Drug Therapy: Insulin
• Exogenous insulin:
– Required for all patient with type 1 DM
– Prescribed for the patient with type 2 DM
who cannot control blood glucose by other
means

Diabetes Mellitus
• Types of insulin
– Human insulin
• Most widely used type of insulin
• Cost-effective
•  Likelihood of allergic reaction

Diabetes Mellitus
– Insulins differ in regard to onset, peak
action, and duration
– Different types of insulin may be used for
combination therapy

Diabetes Mellitus
– Rapid-acting: Lispro
– *Short-acting: Regular
– *Intermediate-acting: NPH or Lente
– Long-acting: Ultralente, Lantus

Diabetes Mellitus
• Insulin
– Cannot be taken orally
– Self-administered by SQ injection

Diabetes Mellitus
• Insulin delivery methods
– Ordinary SQ injection
– Insulin pen
• preloaded with insulin; “dial” the dose
– Insulin pump
• Continuous “basal” infusion. At mealtime, user
programs to deliver “bolus” infusion that
correlates with amount of CHOs ingested. Allows
tight control and greater flexibility with meals
and activity

Diabetes Mellitus
• Insulin delivery methods
– Intensive insulin therapy
• Multiple daily injects and frequent SMBG

Diabetes Mellitus
• Problems with insulin therapy
– Hypoglycemia (BS < 3.9 mmol/L)
• Due to too much insulin in relation to glucose
availability

Diabetes Mellitus
• Problems with insulin therapy
– Hypoglycemia
– Allergic reactions
• Local inflammatory reaction
– Lipodystrophy
• Hypertrophy or atrophy of SQ tissue r/t frequent
use of same injection site. Less common now b/c
pork and beef insulin infrequently used

Diabetes Mellitus
Drug Therapy: Oral Agents
• Not insulin
• Work to improve the mechanisms in which
insulin and glucose are produced and used
by the body

Diabetes Mellitus
Drug Therapy: Oral Agents
• Increase insulin production by pancreas
• Reduce glucose production by liver
• Enhance insulin sensitivity and glucose
transport into cell
• Slow absorption of carbohydrate in
intestine

1. Sulfonylureas
• Stimulate the pancreatic secretion of insulin
• First generation
• e.g. tolbutamide, chlorpropamide, and acetohexamide
• more potential for drug interactions and side effects
• Second generation
• e.g. glimepiride, glipizide, and glyburide
• less potential for drug interactions and side effects
• All sulfonylurea drugs are equally effective in reducing
the blood glucose when given in equipotent doses.

2. Short-acting Secretogogues
– Repaglinide
– Nateglinide
– Stimulation of the pancreatic
secretion of insulin
– The insulin release is glucose dependent and is
decreased at low blood glucose
– With lower potential for hypoglycemia
(incidence 0.3%)
– Should be given before meal or with the first
bite of each meal. If you skip a meal don’t take
the dose!

3. Biguanides Metformin
(Glucophage
– Reduces hepatic glucose production
– Increases peripheral glucose utilization
– Nausea, vomiting, diarrhea, and anorexia
– Phenformin: another biguanide, was taken off the
market because it causes lactic acidosis in almost
50% of patients
– As a precaution metformin should not be used in
patients with renal insufficiency, CHF, conditions
that lead to hypoxia

4. Glitazones
– Reduces insulin resistance in the periphery
(Sensitize muscle and fat to the action of
insulin) and possibly in the liver
– The onset of action is slow taking 2-3
months to see the full effect
– Edema and weight gain are the most
common side effects. (no hepatotoxicity)

5. a-Glucosidase Inhibitors
• Acarbose - Miglitol
• Prevent the breakdown of sucrose and complex
carbohydrates
– The net effect is to reduce postprandial blood
glucose rise
– Postprandial glucose conc is reduced.

Diabetes Mellitus
Nutritional Therapy
• Within the context of an overall
healthy eating plan, a person with
diabetes can eat the same foods as a
person without diabetes
• Overall goal of nutritional therapy
– Assist people to make changes in
nutrition and exercise habits that will
lead to improved metabolic control

Diabetes Mellitus
Nutritional Therapy
• Type 1 DM
– Diet based on usual food intake, balanced
with insulin and exercise patterns
• Type 2 DM
– Emphasis placed on achieving glucose,
lipid, and blood pressure goals
– Calorie reduction

Management of Diabetes
What is a nutritive diet ?
 Balanced in Nutrition distribution.
 Balanced in Quantity/calories as per
individual needs.
 Balanced in Number of meals.
 Balanced in Timing of meals.
D iet
D iet
Copyright © Year 2005

D iet
D iet
Nutritional requirement
 CHO, protein, fat - calorie providing nutrients.
 Vitamins, minerals and water - no calories.
 Fiber - slows absorption gives satiety feeling,
reduces cholesterol, eases bowel movements.

D iet
D iet –
– F ood Pyr amid
F ood Pyr amid
Fats, Oils & Sweets
USE SPARINGLY
Vegetable
Group.
3-5 SERVINGS
Milk, Yogurt &
Cheese Group
2-3 SERVINGS
Meat, Poultry, Fish,
Eggs & Nuts Group.
2-3 SERVINGS
Fruit Group.
2-4 SERVINGS
Bread, Cereal,
Rice, Pasta Group.
6-11 SERVINGS
Source: The Food Guide Pyramid, United States Department of Agriculture.

D iet
D iet –
– Sour ce of N utr ition
Sour ce of N utr ition
Carbohydrates (CHO)
Carbohydrates (CHO)
They are the main source of energy
Simple CHO
Simple CHO
Root vegetables,
refined flour, sugar,
jaggery, bakery
products, pasta,
sago etc.
(X)
(not preferred)
Complex CHO
Complex CHO
Raw vegetables, whole
grain cereals,dark
green leafy vegetables,
sprouts, whole pulses,
fruits etc.
()
(preferred)

D iet
D iet –
Skimmed milk, Paneer,
Curds, Chicken, Sprouted
Legumes/Pulses,
Soya beans/flour, Egg
white, Fish
()
(preferred)
They are the building blocks
needed for growth and repairing tissues
Red meat, Creamy
milk, Nuts, Cheese
(X)
(not preferred)
Proteins
Proteins

D iet
D iet –
Saturated
Monounsaturated Polyunsaturated
Remains liquid in room temperature
Remains solid in
room temperature
Fats
Unsaturated

D iet
D iet –
Fiber
 It increases the bulk of the diet.
 It helps in decreasing plasma cholesterol,
triglyceride levels, glucose levels.
 It gives the feeling of satiety because of its
water holding property.
Sources
- Covering of pulses and grains.
- Vegetables (raw or half-cooked).
- Whole fruits.

D iet Planning
D iet Planning
Remember - When there is hypoglycemia
 Check blood glucose level.
 Consume simple carbohydrate.
 Do not panic and overreact.
 Review with the doctor or the educator.

Diabetes Mellitus
Nutritional Therapy
• Alcohol
• High in calories
• Promotes hypertriglyceridemia
• Can cause severe hypoglycemia b/c
inhibits glucose production by liver

M an agem en t of D iabet es
Ex er cise
Ex er cise

Diabetes Mellitus
Exercises
• Exercise
– Essential part of diabetes management
– Increases insulin sensitivity
– Lowers blood glucose levels
– Decreases insulin resistance

Diabetes Mellitus
• Exercise
– Take small carbohydrate snacks before
30 min during exercise to prevent
hypoglycemia
– Exercise after meals
– Exercise plans should be individualized
– Monitor blood glucose levels before,
during, and after exercise

Exer cise
Exer cise –
– Safety Tips
Safety Tips
 Always test blood sugar before and after
exercise.
 Have at least 15 grams of fast-acting
carbohydrate to treat low blood sugar.
 Always warm up first and cool down after
exercise.

Exer cise
Exer cise –
– Safety Tips
Safety Tips
 Wear shoes that fit properly and inspect
your feet after activity for blisters or sores.
 Drink lots of water, especially in hot
weather.

Exer cise
Exer cise –
– A Few A ler ts
A Few A ler ts
 In full or empty stomach.
 When insulin action is at peak.
 Under extreme temperatures.
 During other illnesses.
 If blood sugar over 250 and Ketones.
 If chest pain occurs during exercise.
Do not exercise

M an agem en t of D i abet es
M onitor ing
M onitor ing

Diabetes Mellitus
Monitoring Blood Glucose
• Self-monitoring of blood glucose (SMBG)
– Allows self-management decisions
regarding diet, exercise, and medication
– Important for detecting episodic
hyperglycemia and hypoglycemia
– Patient education is crucial

Extremely useful for outpatient monitoring specially for patients
who need tight control for their glycemic state.
A portable battery operated device that measures the color
intensity produced from adding a drop of blood to a glucose
oxidase paper strip.
e.g. One Touch, Accu-Chek, DEX, Prestige and Precision.

Diabetes Mellitus
Nursing Management
Nursing Diagnoses
• Ineffective therapeutic regimen
• Fatigue
• Risk for infection
• Powerlessness

Diabetes Mellitus
Nursing Management: Planning
• Overall goals:
– Active patient participation
– No episodes of acute hyperglycemic
emergencies or hypoglycemia
– Maintain normal blood glucose levels
– Prevent chronic complications
– Lifestyle adjustment with minimal stress

Diabetes Mellitus
Nursing Management
Nursing Implementation
• Health Promotion
– Identify those at risk
– Routine screening for overweight adults
over age 45
– Diabetes prevention (weight control)

Diabetes Mellitus
Nursing Management
Nursing Implementation
• Ambulatory and Home Care
– Insulin therapy and oral agents
– Personal hygiene
– Medical identification and travel
– Patient and family teaching

Diabetes Mellitus
Nursing Management
• Stress Management
– Emotional and physiological stress increase
BG → hyperglycemia
– Often need more insulin to maintain control
(Type II diabetics normally controlled by
OA may temporarily need insulin)

Diabetes Mellitus
Nursing Management
• Stress Management
– When ill
• Continue regular diet and ↑ intake of non-caloric
fluids
• Take insulin/OA as prescribed and check BG
Q4h
• If BG > 13.3 mmol/L, check urine for ketones
and report moderate to high ketone levels

Com pli cat i on s of D i abet es

Complications of Diabetes
Chronic
Microvascular
complications
Macrovascular
complications
Acute
Hyperglycemia
Hypoglycemia

A cute Complications
A cute Complications
Hyperglycemia
Hypoglycemia
Acute

H yper glycemia
H yper glycemia
Watch for: Symptoms noticed within hours to several days
 Increased Thirst & Urination.
 High Blood Glucoselevels.
 K etones in urine
 Fatigue.

H yper glycemia
H yper glycemia -
- Causes
Causes
Too much food
Emotional Stress
Not enough exercise Infection, fever, illness
Not enough insulin

H yper glycemia
H yper glycemia
What to do:
 Call Doctor immediately.
 Take fluids without sugar if able to
swallow.
 Test Blood sugar Frequently.
 Test urine for K etones.

High blood sugar levels can lead to:
 Diabetic Keto Acidosis (DKA).
 Hyperglycemic Hyperosmolar Non-
ketotic Syndrome (HHNS).
H yper glycemia
H yper glycemia

D iabetic K eto A cidosis (D K A
D iabetic K eto A cidosis (D K A )
)
 The blood glucose >250 mg/dl.
 pH <7.3
 Urine ketones moderately positive.
 Serum ketones positive in 1:4 dilution.

D iabetic K eto A cidosis
D iabetic K eto A cidosis -
- Causes
Causes
Too much food
Emotional Stress
Missed insulin or Tablets
Infection, fever, illness
Interfering Drugs

D iabetic K eto A cidosis
D iabetic K eto A cidosis –
– Signs & Symptoms
Signs & Symptoms
Lethargy
Changed mental status Pain in the abdomen
Urination Thirst
Fruity smell
in the breath

Management Goals
 Restore & maintain normal glucose
metabolism.
 Correct fluid & electrolyte imbalance.
 Prevent further complications.
 Provide education and follow-up.

"Avoid anymore DKA"
"Avoid anymore DKA"
Patient & family
Education

Diabetes Mellitus
Acute Complication: HHNS
• BG > 44.5 mmol/L
• Occurs in Type II diabetics (often elderly)
• Causes: similar to DKA
• Pathophysiology
– Similar to DKA, except there is enough
insulin to prevent ketosis (fat breakdown),
but not enough to prevent hyperglycemia
– Extreme hyperglycemia causes
intracellular dehydration d/t movement of
water from cells

Diabetes Mellitus
Acute Complication: HHNS
• Clincial manifestation dehydration,
weakness, polyuria, polydipsia,
somnolence, seizures, coma
– Treatment
• Re-hydrate
• Insulin IV
• Monitor closely

H ypoglycemia
 Encountered mostly by taking patients on
Insulin and drugs that simulate insulin
secretion.
 Should be alert when blood sugar is < 70
mg/dl.
 Severity, glucose level and signs & symptom
may differ in different people.

H ypoglycemia
H ypoglycemia -
- Symptoms
Symptoms
Watch for: Symptoms noticed within hours to several days
 Cold sweats, faintness, dizziness.
 Headache.
 Pounding of heart or trembling.
 Blurred vision
 Hunger
 Inability to awaken
 Personality changes.
 Fatigue.

H ypoglycemia
H ypoglycemia -
- Causes
Causes
Excessive exercise
Too much insulin
Not enough food/
Delayed meals

H ypoglycemia
H ypoglycemia -
- Tr eatment
Tr eatment
Treatment
Self-treated with
simple sugar,
glucose tablets or
sweetened fluids

H ypoglycemia
H ypoglycemia -
- Tr eatment
Tr eatment
Treated with help of
glucose tablets /
sugar with additional
food
Treatment

H ypoglycemia
H ypoglycemia -
- Tr eatment
Tr eatment
IV glucose or
injection glucagon
(s/c)
Treatment

H ypoglycemia
H ypoglycemia -
- Pr ecautions
Pr ecautions
 Learn about hypoglycemia.
 Adhere to the timings and quantity of food and
medicine
 Carry simple carbohydrate containing snacks always.
 Do not keep long gap between meals.
 In case of longer sports activities, take breaks,
drink lot of water and have snacks.
 Keep injection glucagon ready
 Educate family members & co-workers
 Carry a medical identity card

H ypoglycemia
H ypoglycemia
Remember - When there is hypoglycemia
 Check blood glucose level
 Consume simple carbohydrate.
 Do not panic and over react.
 Review with the doctor or the educator.

Chr onic Complications
Chr onic Complications
Microvascular
complications
Macrovascular
complications
Chronic

M icr ovascular Complications
Diabetic Retinopathy
Diabetic Nephropathy
Diabetic Neuropathy
Microvascular Complications

D iabetic Retinopathy
 Diabetic retinopathy is a potentially
blinding complication of diabetes that
damages the eye's retina.
 It occurs when diabetes damages the tiny
blood vessels in the retina. At this point,
most people do not notice any changes in
their vision.

 Macular edema: damaged blood vessels
leak fluid and lipids onto the macula. The fluid
makes the macula swell, blurring vision.
 Proliferative stage: Fragile, new blood
vessels grow along the retina and in the clear,
gel-like vitreous that fills the inside of the eye.
Without timely treatment, these new blood
vessels bleed, cloud vision, and destroy the
retina.

D iabetic Retinopathy -
- D etection
D etection
Diabetic retinopathy is detected during
an eye examination that includes:
 Visual acuity test: How well one see various
distances.
 Pupil dilation: Widen the pupil to see more of the
retina for signs of diabetic retinopathy.
 Ophthalmoscopy: Examination of the retina using
an ophthalmoscope.
 Tonometry: A standard test that determines the fluid
pressure inside the eye. Elevated pressure is a
possible sign of glaucoma.

- Tr eatment
Tr eatment
There are two treatments for diabetic
retinopathy:
 Laser Surgery
 Vitrectomy

- Tr eatment
Tr eatment
A vitrectomy is performed if you have a lot
of blood in the vitreous. It involves removing
the cloudy vitreous and replacing it with a
salt solution. Because the vitreous is mostly
water, you will notice no change between
the salt solution and the normal vitreous.

Diabetic Nephropathy
 When blood sugar levels are high, sugar is passed
into the urine.
 When this happens, the pressures are higher in the
kidney filtering system (the glomerulus) and
changes in the small blood vessels of the kidney
can occur.
 This increased pressure causes damage to the
filtering system so that some proteins start leaking
through the filter and appear in the urine.

D iabetic N eur opathy
 Diabetic neuropathy, or “damage to the
nerves”, is a condition seen after puberty,
usually in people who have had very high
sugar levels for a long time.
 Neuropathy may cause
 Gastrointestinal problems, Urinary Tract Infection,
too much of sweating, dryness of skin, severe pain
on lower extremities, loss of sensation, heart
problems and orthostatic hypotension.
 Diabetic foot.

Sensory
Diabetic Neuropathy
Autonomic Motor

Sensor y N eur opathy
Sensor y N eur opathy
 Sensory Neuropathy affects one of the
nerves that take information to brain about
sensation.
 Leads to pain, numbness, tingling in
extremities.

A utonomic N eur opathy
A utonomic N eur opathy
 Autonomic Neuropathy affects the nerves
that control involuntary activities such as
action of stomach, heart and blood pressure.
 Leads to Diabetic Diarrhea, Impotence,
bladder is unable to empty completely,
orthostatic hypotension and the ability to
exercise.

M otor N eur opathy
M otor N eur opathy
 Motor Neuropathy affects the nerves that
carry signals to muscles like walking,
running.
 Leads to muscle weakness.

 Diagnosis
 Weak Knee jerk/ ankle jerk.
 Electromyogram
 Nerve Conduction Studies

 Treatment
 No way to heal or replace damaged
nerve cells.
 Keep Blood Glucose levels as close to
normal as possible.
 Exercise
 Painkillers/ Antidepressants.

Per ipher al A r ter ial D isease
Per ipher al A r ter ial D isease
 Peripheral arterial disease (PAD) is a form of
peripheral vascular disease that occurs when blood
vessels in the legs are narrowed or blocked by
atherosclerosis, decreasing blood flow to the feet
and legs.
 One in three people with diabetes over age 50 is
estimated to have this condition.
 If undetected, PAD can lead to amputations of the
lower limbs and increase a person's risk of
intermittent claudication.

Severely infected foot Blood decompression
Neuro-ischemic foot
D iabetic F oot
D iabetic F oot

 Nerves damaged by the disease are not as
sensitive to pain, heat or cold, so people with
diabetes can injure their feet, not know it, and
develop infections.
 Poor circulation compounds the problem, by
reducing the number of infection-fighting white
blood cells that are carried to and from the wound
site. If left untreated, a slow-to-heal and infected
wound (ulcer) can, ultimately, lead to amputation.
D iabetic F oot
D iabetic F oot

D iabetic F oot
D iabetic F oot -
- Symptoms
Symptoms
 Tingling, numbness, pain, or the loss of
sensation in the feet.
 Restricted blood flow to the legs and
feet.
 Foot deformities, including hammertoes.
 Stiff joints.

Foot Car e
Foot Car e -
- D Os
D Os
 Wash feet daily.
 Inspect feet and toes, especially in between,
daily.
 Wear thick, soft socks.
 Cut toenails straight across.
 Be measured and fitted each time you buy a
new pair of shoes.
 Lose weight.
 Exercise.

F oot Car e
F oot Car e –
– D on’ts
D on’ts
 Never go barefoot.
 Avoid high heels, sandals and shoes with
pointed toes.
 Don’t smoke and drink only in moderation.
 Avoid soaking your feet.

 Don’t wear anything that is too tight
around the legs.
 Never use heating pads or hot water
bottles on cold feet.
 Avoid over the counter medications for
corns, calluses, or warts.
F oot Car e
F oot Car e –
– D on’ts
D on’ts

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