Sockwear Recommendations for People with Diabetes
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Clinical Decision Making Sockwear Recommendations for People With Diabetes Carol B. Feldman, MSN, RN, CDE, and Ellen D. Davis, MS, RN, CDE Case Presentation A.B., a 55-year-old man who had adequate blood glucose control. His monofilament testing confirmed that been diagnosed with type 2 diabetes 6 most recent HbA1c was 6.5%. foot sensation was intact. He had easi- months ago, was a new patient in the The skin on his feet was intact, ly palpable pedal pulses and no edema. foot clinic of the Durham VA without redness, and its texture was During routine discussion of foot- Medical Center. At the time of his smooth and soft. His nails were intact care precautions, he asked what kind first visit, he was taking metformin, without signs of onychomycosis. The of socks he should wear to prevent 500 mg twice a day, and maintained shape of his feet was normal, and problems. Discussion Good foot care practices are impor- physicians, podiatrists, staff nurses, Although they expressed concern that tant for people with diabetes. A large and certified diabetes educators socks should be comfortable, they percentage of diabetic patients under- (CDEs) from Duke University Medical were also likely to recommend specific go nontraumatic amputation after Center, the Durham VA Medical fabric types. Most of the nurses diabetic neuropathy renders them Center, and surrounding areas to thought people with diabetes should unable to feel festering foot injuries. explore providers’ sockwear recom- wear cotton or wool socks. But those What’s more, within 3 years of a first mendations and the reasoning behind recommending acrylic fabrics said amputation, up to half of these them. they were “better,” more absorbent, patients have a second either new and more comfortable. same side or contralateral amputa- Physicians and podiatrists tion. Within 5 years, as many as 80% Our survey of 12 physicians and podi- Diabetes educators have died.1,2 atrists revealed that sockwear is not a Our third survey involved 11 CDEs, As care providers, we are responsi- subject about which physicians feel who were the most vocal group on the ble for the self-care practices our particularly concerned. Most said they subject of sockwear. Like the general patients use every day. Pronounce- never make sock recommendations. staff nurses, most of the CDEs ments such as, “People with diabetes One said he was more likely to make thought that cotton or wool socks need to keep their feet dry” and a comment on socks if a patient had were preferable. The main reason for “Moisture promotes fungal growth” signs of tinea pedis. their recommendation was absorben- are common, and it is widely assumed Of those who do make recommen- cy. Several CDEs referred to perspir- that the sock fabric our patients wear dations, one said she usually asks ing feet or excess moisture and said determines how moist or dry the skin patients to wear cotton or wool socks that cotton was better at addressing on their feet will be. because they are associated with less this problem. There are three schools of thought moisture and because she prefers nat- However, some of the CDEs sur- regarding the best fabric for socks ural fibers. Another recommends and veyed did recommend acrylic socks. worn by people with diabetes. Some wears acrylic socks because these One educator said she had changed professionals recommend cotton/wool were recommended to him by staff at her advice regarding cotton versus socks. Others recommend socks or an athletic shoe store. A podiatrist acrylic based on an article she had stockings of acrylic or a synthetic said he prefers a cotton/wool/acrylic read in the American Diabetes blend. And still others advise their blend. Association (ADA) magazine patients to wear comfortable, well-fit- Doctors who suggest that patients Diabetes Forecast, which stated that ting socks without regard to the type wear particular socks recommend people with diabetes should not wear of fabric. comfort above all else. Two physi- cotton.3 cians mentioned that socks should One CDE warned against wearing Sockwear Recommendation Survey not be too tight. dark socks “because of the dye.” Diabetes care providers often answer That recommendation, outdated by at questions such as A.B.’s without con- General staff nurses least 50 years, is based on the fear sidering whether there are any When we performed the same survey that dyes will not be colorfast and research data to support their answer. with 11 general staff nurses, it became will “bleed” into open wounds. We conducted an informal survey of clear that nurses had a different focus. At least one person in each of our 59 Diabetes Spectrum Volume 14, Number 2, 2001 Clinical Decision Making three surveyed groups mentioned noted that, although cushioned socks and to select socks made from materi- Thorlo socks. However, these profes- can help prevent callus formation, als that will wick moisture away from sionals seemed unaware that Thorlo they may be too tight in some shoes. the skin, such as cotton or wool and socks are made of an acrylic/nylon/ The article also cautioned against synthetic/acrylic blends. spandex blend; they recommended wearing cotton socks during exercise. Although diabetes educators base that people wear this brand while also The rationale was that the cushioning their practices on many sources, one recommending cotton/wool fabrics. fibers compress over time, and cotton important source is the handbook does not wick away moisture; there- titled A Core Curriculum for Educational Materials Review fore, feet remain moist. (Wicking is Diabetes Educators.18 This resource A sampling of patient education mate- the ability of the fiber to pull mois- advises diabetes educators to teach rials from different sources also sug- ture from the skin’s surface toward people to wear cotton or wool socks. gests that patients are not getting uni- the outer surface of the fabric, where It does not mention fabrics with form information about sockwear. it can evaporate.13) wicking action. The most recent Diabetes Forecast In another text on diabetes foot Government and pharmaceutical article on this topic14 suggests that care, McDermott2 offers an interest- company literature any sock fabric is fine for everyday ing cautionary note: people with dia- Government sources recommend cot- wear, whereas acrylic or polypropy- betes are often given “misinforma- ton and wool socks for diabetic lene fabrics are best for exercising. tion” that is not scientifically based. patients to help keep feet dry.4,5 They Articles in other publications for He advises educators to recommend also reinforce the need to wear socks people with diabetes also offer differ- cotton but notes that blends are also at all times. ing recommendations. One article in acceptable. Health care providers often use Diabetes Self-Management,15 for Haas and Ahroni19 advise educators general diabetes care and diabetes example, advised wearing only cotton to teach patients who have a tendency foot care literature provided by phar- socks and recommended avoiding toward “sweaty” feet to wear cotton maceutical companies in making rec- knee-high and tight socks and chang- or wool socks to absorb moisture. ommendations to patients. Virtually ing socks frequently for people who Clearly, then, the people educating all of these materials make some refer- tend to perspire heavily. The article the diabetes educators also have dif- ence to wearing socks.6–11 noted that tight socks are more con- fering opinions on the most appropri- Many do not make specific fabric stricting, and cotton allows air to ate fabric for socks. recommendations, but they do sug- penetrate and absorb perspiration. gest that people avoid tight socks. Another article from the same publi- The Research Some suggest that white cotton or cation16 recommended wearing socks Luckily, some research-based evidence wool socks are preferable, saying this made of synthetic fibers that wick is available on this topic. A few stud- is because “cotton socks allow feet to away moisture when participating in ies have looked at what happens to breathe and helps prevent sweating.” active sports. feet wearing socks of differing fabrics Rarely do these materials cite In her book 101 Foot Care Tips and constructions. Also, the textile research data for what they present. for People With Diabetes,17 advanced industry has conducted research into Roche Diagnostics/Boehringer practice diabetes nurse Jessie H. fiber composition and characteristics. Mannheim Corporation lists an Ahroni offers perhaps the most com- In 1989, Veves et al.20 used Thorlo Accu-Chek Amputation Prevention prehensive set of foot care recommen- socks to show that cushioning Initiative Advisory Board on the back dations for people with diabetes. decreased vertical pressure to the dia- page of its foot care pamphlet.9 The Echoing the Diabetes Forecast articles betic foot. They concluded that in Takeda/Lilly10 diabetes care materials mentioned above, she advises people conjunction with wearing proper contain a fairly lengthy bibliography. whose feet perspire excessively to orthoses, cushioning can help to pre- Unfortunately, their only reference to wear acrylic blends because of the vent ulcer formation. socks is a warning that people should wicking action of acrylic fibers. She In 1990, the same authors21 looked not go barefoot. recommends socks with cotton or at the duration of cushioning effects. wool because these fibers are In this study, they found that a cush- Books and magazines for patients “breathable,” but she notes that the ioned sock, while losing some of its A wealth of health care information, sock fabric should include some effects, provided more pressure relief including sockwear recommendations, acrylic or other synthetic for its wick- than being barefoot, even after 6 can be found in the numerous books ing action.