NUTRITION
Understanding the relationship between type 1 diabetes and diet
THE SCIENCE — WHAT IS INSULIN?
e
Pe op le
This articles looks at the dietary advice that should be provided for people with type 1 diabetes. As well as focusing on healthy eating generally, blood sugar control can be optimised if both the type and amount of carbohydrate is considered. Low glycaemic index (GI) carbohydrates, where glucose is released slowly into the blood stream, may help to lower the individual’s glycated haemoglobin (HbA1c) levels (HbA1c is a form of haemoglobin that is measured to identify the average plasma glucose concentration over a prolonged time period). Carbohydrate (‘carb’) counting should be considered as it can improve glycaemic control and promote independence in regard to food choice and management of the condition. Gestational diabetes (that which develops during pregnancy) is also considered, as this can affect birth outcome, the baby’s future health and the health of the mother after the birth.
Lt d
Gaynor Bussell
ar
KEYWORDS:
T
The condition is different from type 2 diabetes, which mainly results from poor diet, lack of physical activity, excessive weight gain and genetics/family history. However, the manifestation of type 1 diabetes can be similar to that of type 2 as a result of excessive levels of glucose circulating in the blood stream.
15
W
ou nd
ype 1 diabetes was once referred to as juvenile onset diabetes as it was thought to begin in childhood or the early teenage years. However, it is now known to develop at any age, although most often affecting those under 40 (Norman, 2015). About 10–20% of adults with diabetes have type 1 (Diabetes UK, 2012a).
C
Diabetes Nutrition Carbohydrate counting Glycaemic index
©
20
Type 1 diabetes is believed to develop as a result of the immune system attacking its own insulin producing beta cells in the pancreas, where the hormone insulin is produced (Hober and Sauter, 2010). This may be triggered by a virus or other infection — genetics may also be a factor.
Symptoms of type 1 diabetes typically include thirst, tiredness and weight loss, due to glucose being washed out in the urine as it is unable to be used by the body without insulin — if untreated, this can lead to ketoacidosis and eventually coma (Medline Plus, 2015a). Treatment involves insulin therapy as diet alone cannot normalise the blood sugars. The aim of treatment for people with type 1
The main job of insulin (naturally, a peptide hormone produced by beta cells in the pancreas, although biosynthetic insulin is used medically) is to keep the sugar levels in the blood within a normal range. Carbohydrates are broken down into sugar where they enter the bloodstream in the form of glucose, acting as an energy source. The pancreas then produces insulin, which acts upon the glucose so that it can enter the body’s tissues. However, when insulin levels are high after meals, excess glucose is stored in the liver (glycogen). Between meals when insulin levels are low, the liver releases glycogen into the bloodstream as a sugar. If the pancreas secretes too little insulin (type 1 diabetes), or the body doesn’t produce enough insulin or is resistant to its action (type 2 diabetes), the level of sugar in the bloodstream increases as it cannot enter the cells. High blood sugar can lead to blindness, nerve damage and kidney damage. Source: Mayo Clinic: www. mayoclinic.org
Table 1: Blood sugar levels recommended by NICE (2004)
Gaynor Bussell, freelance dietitian and public health nutritionist
24
JCN 2015, Vol 29, No 2
Target levels by type
Before meals (pre-prandial)
Two hours after meals (post-prandial)
Non-diabetic
4.0–5.9mmol/L
Under 7.8mmol/L
Type 1 diabetes
4–7mmol/L
Under 9mmol/L
Children with type 1 diabetes
4–8mmol/L
Under 10mmol/L
“
My COPD means my appetite hasn’t been very good... TP*TUBSUFEUBLJOH'PSUJTJQ$PNQBDU1SPUFJO*UTWFSZFBTZ UPUBLFBOE*GFFMMJLF*NHFUUJOHCFUUFSRon; Camden
Lt d
”
Pe op le
t-PXNMWPMVNFBOEFBTZUPUBLF t5IFNPTUQSPUFJOSJDI FOFSHZEFOTF OVUSJUJPOBMTVQQMFNFOUPOUIFNBSLFU t#FUUFSDPNQMJBODF*
©
20
15
W
ou nd
C
ar
e
Why change to anything else?
*Greater compliance (91%) has been shown with more energy dense supplements (*2kcal/ml) such as Fortisip Compact Protein when compared to standard oral nutritional supplements. Reference: 1. Hubbard GP et al. Clin Nutr 2012:31;293–312. Nutricia Ltd., White Horse Business Park, Trowbridge, Wiltshire BA14 0XQ. Tel: 01225 751098. www.nutriciaONS.co.uk 03/15
Right patient, right product, right outcomes
NUTRITION
Although the amounts of other nutrients in the diet can affect blood sugar levels to some degree, the amount of carbohydrates consumed has the most significant effect.
If an individual is receiving insulin via a pump, then all the information will be calibrated into the machine and he or she will be instructed on how much insulin to give according to the blood glucose reading (NICE, 2008).
20
15
W
ou nd
However, over the years the advice about how to ‘count’ or monitor carbohydrate intake has almost come full circle. The favoured approach is now to adjust the amount of insulin required against the individual’s diet (WylieRosett, 2013; Schmidt et al, 2014), ensuring as much flexibility as possible so that the person with type 1 diabetes can eat a varied amount of carbohydrates from meal to meal.
©
With the help of a qualified dietician, the individual with type 1 diabetes would work out the ratio of insulin he or she needs to take versus the type/amount of carbohydrates consumed. Typically, this ratio will be worked out for the number of insulin units per 10g of carbohydrate. For this reason, people with type 1 diabetes need to know the carbohydrate value for the foods they eat and there are many carbohydrate-counting tables available (Diabetes Education Scotland, 2015). Patients should also be told that the ratio of 26 JCN 2015, Vol 29, No 2
Members of the specialist diabetes team should be able to advise on the suitability of a pump, depending on whether they feel the patient can cope with having one fitted, but generally they are often recommended for people with type 1 diabetes as they offer tighter control of insulin intake.
Lt d
Special advice is also needed in illness such as ‘flu’ , which can cause a rise in blood sugar levels as well as suppressing the appetite. When they are ill, there are two things that can happen to people with type 1 diabetes: They may not eat properly, so if they have taken insulin they may become hypoglycaemic without adequate carbohydrate Blood sugars tend to rise during illness and unless this is properly compensated for with insulin it can give rise to excess ketone production as the body starts using its own fat reserves.
Pe op le
CARBOHYDRATE COUNTING
The machine takes into account the current reading and will advise if extra bolus doses (a ‘bolus’ refers to a single dose of insulin) are needed when blood sugar levels are high. If blood sugars are low, the machine will advise the patient to take some quickly absorbed carbohydrate.
e
Patients with diabetes should also be advised on how many tests to carry out each day, with the aim of checking whether their blood sugars are being maintained at the required level (Table 1).
Patients should also be shown how to work this out for themselves and there are now special blood glucose monitors that, once pre-programmed, will indicate how much insulin is required for each dose of carbohydrate consumed.
ar
Hypoglycaemia (triggered when blood sugar levels fall under 4mmol/L) is a real risk when too much insulin is used or too little food is taken in, so community nurses should advise patients to avoid their blood sugars plummeting too low, especially at night (NICE, 2004).
carbohydrates to insulin can vary from meal to meal, under circumstances such as illness, stress, and overactivity/exercise, and depending on the most recent blood sugar reading.
C
diabetes is to keep the blood sugars to defined levels (Table 1) (National Institute for Health and Care Excellence [NICE], 2004).
Overall, it is best for an unwell person with type 1 diabetes to have some carbohydrates in the form of a glucose drink, followed by an injection of insulin (maybe slightly more than usual to compensate for the illness).
Table 2: Glycaemic index (GI) ranking of common foods Low glycaemic index (GI=55 or less)
Medium glycaemic index (GI=56–69)
High glycaemic index (GI=70 and above)
Sweet potatoes
New potatoes
Potatoes (baked, mashed, chipped)
Pasta
Basmati rice
Rice (white and brown)
Muesli, porridge, All-Bran®, Sultana-Bran,
Weetabix®, shredded wheat
Corn Flakes®, Rice Krispies®, Cheerios®, puffed wheat
Breads — rye, granary, wholegrain, sour dough, fruit bread
Pitta bread, scone, wholegrain crispbread
White bread, French bread, crisp bread, crumpets, wholemeal/ brown bread
Fruit, vegetables, fruit juice, dried Melon fruit, baked beans Milk, soya milk, fromage frais, yoghurt, custard
Ice cream*, lower fat ice cream, rice pudding*/lower fat rice pudding
Chocolate*
Crisps*, fizzy drinks*, digestive/ oat biscuits*, rich tea biscuits*, jam*, honey*, marmalade*
Broad beans, swede
Jelly beans/babies, Lucozade
*Regardless of GI, the foods with an asterisk are high in fat/low in nutrients and so should only be eaten occasionally.
Nursing in the NURSING IN THE community COMMUNITY Lt d
EWMA 2015 AT EXCEL LONDON 14 MAY 2015, 10.30 – 17:30
Pe op le
INCLUDING LUNCH AND FULL EXHIBITION ACCESS JOURNAL OF COMMUNITY NURSING
To get your chance:
e ar
ou nd
C
In association with the Journal of Community Nursing, the European Wound Management Association (EWMA) are holding their first nursing in the community wound care day on
To hear experts speak about what matters most in wound care for all those working in primary care To explore one of the biggest wound care exhibitions in the UK...
15
W
Thursday 14 May, 2015 at the Excel, London
20
Programme covers:
What the wound is telling you Preparing the wound for healing Compression therapy Selecting the right wound care product Identifying and preventing pressure ulcers as well as interactive sessions
©
register at: www.ewma2015/NICregister
‘Why is this wound smelly?’ ‘Which dressing should I use?’ ‘What is the best management for this person?’ ‘Why has this wound developed?’ ‘Do I have the skills to manage this wound?’ ‘What other factors should I consider when treating this patient’s wound?’
NUTRITION
©
20
15
W
THE GLYCAEMIC INDEX The glycaemic index (GI) is also a consideration in type 1 diabetes. This is a measure of how fast carbohydrates are broken down and released into the bloodstream as glucose. Glucose itself is given a GI of 100, with all other starchy and sugary foods given a value relative to this, i.e. pasta is released 40% slower than pure glucose and 28 JCN 2015, Vol 29, No 2
WEIGHT
Lt d
Before receiving a diagnosis, many people with type 1 diabetes will have lost some weight (Medline Plus, 2015b), and in some cases will actually be underweight. Weight loss can also be a sign that diagnosed diabetes is not being well controlled. However, once insulin therapy is started, the patient should begin to regain weight providing his or her diet is adequate. Some people with diabetes find it hard to control their weight as insulin does promote weight gain. Cutting 500–600kcal from the diet will lead to a weight loss of approximately 1kg per week, which is a good rate. In the author’s clinical experience, any higher rate of weight loss can be detrimental and is not recommended unless the patient is under close medical supervision.
Pe op le
ou nd
This is the current UK guideline for healthy eating in the general population and also applies to people with diabetes (Department of Health [DH], 1991). Those with type 1 diabetes can cut their sugar intake by half, but their total carbohydrate intake should remain at 50% — this means that more of the carbohydrates need to come from non-sugar sources such as bread, pasta, etc. In the past it has been suggested that people with diabetes, and indeed the general population, should eat fewer carbohydrates. However, current advice states that people with diabetes stick to the original advice and take 50% of their calories as carbohydrates (Diabetes UK, 2012c).
Where possible, carbohydrates should be wholegrain — this is not just because they are likely to have a lower GI, but also because wholegrain cereals are higher in fibre and are associated with protection from cardiovascular disease (Giacco et al, 2014).
e
The type and quantity of carbohydrates in the diet is an important consideration for people with diabetes. Evidence suggests that carbohydrates should constitute approximately 50% of a person’s calorie intake (Norman, 2014), but that no more than 10% of a person’s energy intake (the total calories obtained from food) should be sugars (also a carbohydrate), which equates to a person consuming a total of no more than 90g of sugars per day.
One randomised controlled trial (RCT) of 14 studies (including six on type 1 diabetes) showed that following a low GI diet improved long-term control of HbA1c (BrandMiller et al, 2003). Most wellestablished authorities on diabetes now recommend a combination of carbohydrate counting and a low GI diet for maintenance of type I diabetes (Dyson et al, 2011; Marsh et al, 2011; American Diabetes Association, 2014).
ar
Types of carbohydrate
consequently has a GI of 40 (Table 2). Slower-release carbohydrates (with lower GIs) are believed to be better for people with diabetes as they avoid high sugar ‘spikes’ and lead to improved blood sugar control — they are also believed to help with satiety so that people do not get hungry as quickly between meals (Bussell, 2014).
C
If working out the amount of insulin for each meal is considered to be too challenging for a particular patient, then advice on eating regularly, with roughly the same amount of carbohydrates (e.g. the same amount of bread at lunch time or potatoes in the evening) may be the best advice. The Diabetes UK website provides structured programmes that teach about carbohydrate counting (Diabetes UK, 2012b).
HEALTHY EATING For people with type 1 diabetes, the aim is to eat a normal healthy diet. Therefore, as well as being aware of the carbohydrate count of foods and their GI, community nurses need to advise patients to avoid excessive saturated fat and salt intake, take plenty of fibre and include adequate amounts from each of the food groups: protein, dairy, fruit and vegetables and starchy foods (for guidance on the amounts of each needed for a healthy diet, visit: www. nhs.uk/livewell/goodfood/pages/ eatwell-plate.aspx). This kind of healthy diet is more likely to keep blood sugar levels in line and help to meet the targets for blood pressure, cholesterol, etc recommended for people with type 1 diabetes. In turn this helps reduce the incidence of diabetic complications, such as kidney disease and eye problems, as well as the risk of cardiovascular disease (Lithovius et al, 2014).
If the person with type 1 diabetes does begin to cut down on food, this should be done proportionally so that 50% of the diet still comes from carbohydrate. However, it is important that the patient is careful to adjust the insulin dose to match any new weight-loss regimen. People with type 1 diabetes, as in the general population, gain weight as a result of eating too many high-fat foods such as cakes, pastries, pies, biscuits and crisps — if weight loss is required these foods need to be kept to a minimum (Delahanty and McCulloch, 2015). Fats have twice as many calories ‘gram-for-gram’ as proteins or fats, therefore, even with ‘healthier’ fats such as olive oil or oily fish it is important to monitor portion sizes.
GESTATIONAL DIABETES Sometimes the strain of pregnancy — particularly when coupled with being overweight or obese — means that the pancreas cannot cope with the body’s increasing demands for insulin. This is known as gestational diabetes and it affects approximately 5% of pregnant women (Diabetes UK, 2010). Pregnancy can also exacerbate the symptoms of existing type 1 diabetes. Gestational diabetes can also increase the risk of health problems in unborn babies, therefore it is
✓ Don’t wait for tomorrow — start caring today …. Lt d
Do you need an evidenced-based source of practical, ‘need-to-know’, key information at your fingertips?
Pe op le
The ‘Care Today’ series of annual journals cover specific areas of care vital for day-to-day practice:
ar
e
✓ Wound Care Today (now in its second volume) ✓ Skin Care Today ✓ Respiratory Care Today
©
20
15
W
ou nd
C
Their easy-to-read style combines clinical education with practical tips through:
› Point-specific posters for everyday practice
— your clinical companions
› Clinical features — written by experts in their field › Debate and discussion — on what matters most to provide patient-centred care
Visit www.jcn.co.uk for information on forthcoming journals in the series.... ... as keeping up to date has never been easier for all those working in the community. Available in print and online via:
www.jcn.co.uk
NUTRITION
W
©
20
15
Most people with type 1 diabetes are advised to work out their own ratio for the amount of carbohydrates-to-insulin required, and there is evidence that it is best for them to eat carbohydrates that have a low glycaemic index and release glucose slowly. It is also particularly important that people with type 1 diabetes follow healthy eating guidelines and keep their weight within a ‘normal’ range. This will help to improve control of their condition and reduce the risk of cardiovascular disease and other diabetic complications. JCN
REFERENCES American Diabetes Association (2014) Glycaemic Index and Diabetes. Available at: http://www.diabetes.org/food-and-fitness/ food/what-can-i-eat/understanding-
30 JCN 2015, Vol 29, No 2
enterovirus and host. Nat Rev Endocrinol 6: 279–89 Lithovius R, Harjutsalo V, Forsblom C, Saraheimo M, Groop PH (2014) The consequences of failure to achieve targets of guidelines for prevention and treatment of diabetic complications in patients with type 1 diabetes. Acta Diabetol 52(1): 31–8
Lt d
Marsh K, Barclay A, Colagiuri S, Brand-Miller J (2011) Glycemic index and glycemic load of carbohydrates in the diabetes diet. J Curr Diab Rep 11(2): 120–7 Medline Plus (2015a) Diabetic Ketoacidosis. Available at: www.nlm.nih.gov/ medlineplus/ency/article/000320.htm (accessed 15 March, 2015) Medline Plus (2015b) Type 1 Diabetes. Available at: www.nlm.nih.gov/ medlineplus/diabetestype1.html (accessed 15 March, 2015)
Pe op le
Delahanty LM, McCulloch DK (2015) Patient information: type 1 diabetes mellitus and diet (Beyond the Basics). UpToDate Available at: http://www. uptodate.com/contents/type-1-diabetesmellitus-and-diet-beyond-the-basics (accessed 15 March, 2015) DH (1991) Dietary Reference Values for Food Energy and Nutrients for the UK. DH, HMSO Diabetes Education Sctoland (2015) Carbohydrate Counting Reference Tables. Available at: www. diabeteseducationscotland. org.uk/docs/Patient/TIM/ CPCHOTablesrevised%5B1%5D.pdf (accessed 15 March, 2015)
Diabetes UK (2010) Diabetes in the UK 2010: Key statistics on diabetes. Available at: http:// www.diabetes.org.uk/documents/reports/ diabetes_in_the_uk_2010.pdf (accessed 10 March, 2015)
ou nd
Type 1 diabetes requires insulin for treatment. This needs adjusting for each individual and according to the amount of carbohydrate eaten for each meal. It is important that community nurses have some knowledge of this in case they come across patients with type 1 diabetes in their practice.
Bussell G (2014) Providing dietary advice for people with type 2 diabetes. J Comm Nurs 28(5): 60–6
e
CONCLUSION
Brand-Miller J, Hayne S, Petocz P, Colagiuri S (2003) Low-glycemic index diets in the management of diabetes: a meta-analysis of randomized controlled trials. Diabetes Care 26: 2261–7
ar
Blood glucose target levels are ‘tighter’ in women with gestational diabetes and not the same as those for women with type 1 or type 2 diabetes. New guidance from NICE recomends that a woman should be diagnosed with gestational diabetes if she has either a fasting plasma glucose level of 5.6mmol/litre or above, or a two-hour plasma glucose level of 7.8mmol/litre or above, one hour after eating (NICE, 2015).
carbohydrates/glycemic-index-anddiabetes.html (accessed 4 March, 2015)
C
important to keep the levels of glucose in the mother’s blood under control. In most cases, gestational diabetes develops in the second half of pregnancy and disappears after the baby is born. However, if gestational diabetes is present throughout a pregnancy, then it is important for the mother to keep her weight down following the birth as there is an increased risk that she will go on to develop type 2 diabetes (Mudalige et al, 2014).
Diabetes UK (2012a) Diabetes in the UK, 2012. Available at: https://www.diabetes.org. uk/Documents/Reports/Diabetes-in-theUK-2012.pdf (accessed 10 March, 2015) Diabetes UK (2012b) Carb Counting & Insulin Adjustment. Available at: http:// www.diabetes.org.uk/Guide-to-diabetes/ Managing-your-diabetes/Carb-counting/ (accessed 1 March, 2015) Diabetes UK (2012c) Consumption of Carbohydrate in People with Diabetes. Available at: www.diabetes.org.uk/About_ us/What-we-say/Food-nutrition-lifestyle/ Consumption-of-carbohydrate-in-peoplewith-diabetes (accessed 1 March, 2015) Dyson P A, Kelly T, Deakin T, et al (2011) Diabetes UK evidence-based nutrition guidelines for the prevention and management of diabetes. Diabetic Medicine 28(11): 1282–8 Giacco R, Costabile G, Della Pepa G, et al (2014) A whole-grain cereal-based diet lowers postprandial plasma insulin and triglyceride levels in individuals with metabolic syndrome. Nutr Metab Cardiovasc Dis 24(8): 837–44
Hober D, Sauter P (2010) Pathogenesis of type 1 diabetes mellitus: interplay between
Mudalige N, Thornhill L, Sinha S, Cotzias C, Dixit A (2014) 5.3 Postnatal testing for persistence of abnormal glucose metabolism after gestational diabetes: fasting plasma glucose or oral glucose tolerance test? Arch Dis Child Fetal Neonatal Available at: http://fn.bmj.com/content/99/Suppl_1/ A4.3.abstract (accessed 28 August, 2014) NICE (2004) Type 1 Diabetes: diagnosis and management of type 1 diabetes in children, young people and adults. Available at: www.nice.org.uk/guidance/cg15/chapter/ guidance (accessed 15 March, 2015) NICE (2008) Insulin Pump Therapy for Diabetes. Available at: http://www. nice.org.uk/guidance/ta151/resources/ ta151-diabetes-insulin-pump-therapyunderstanding-nice-guidance-2 (accessed 15 March, 2015) NICE (2015) New thresholds for diagnosis of diabetes in pregnancy. Available at: www. nice.org.uk/news/article/new-thresholdsfor-diagnosis-of-diabetes-in-pregnancy (accessed 15 March, 2015) Norman J (2014) Treatment of diabetes: the diabetic diet. Available at: www. endocrineweb.com/conditions/diabetes/ treatment-diabetes (accessed 28 August, 2014) Norman J (2015) Type 1 Diabetes. Available at: www.endocrineweb.com/conditions/type1-diabetes/type-1-diabetes (accessed 15 March, 2015) Schmidt S, Schelde B, Nørgaard K (2014) Effects of advanced carbohydrate counting in patients with type 1 diabetes: a systematic review. Diabet Med 31(8): 886–96 Wylie-Rosett J (2013) The role of carbohydrate counting in type 1diabetes. Lancet Diabetes Endocrinol 2(2): 97–8
The Essentials of Tissue Viability Worcester Rugby Club, WR3 8ZE
Pe op le
Thursday 30 April 2015 • 9.00am– 4.15pm
Lt d
WCAUK 5th Annual Conference
Programme Thursday 30 April 2015
Chair for the morning, Louise Toner, Associate Dean, Birmingham City University Coffee and registration
0925 – 0930
Introduction and welcome
Louise Toner, Associate Dean, Birmingham City University
0930 – 1015
Wounds – prevention, assessment and management
Richard White, Professor, University of Worcester Director, Plymouth Wound Care
1015 – 1100
Skin Tears and Minor Traumatic Wounds – prevention, assessment and management
1100 – 1130
Coffee and exhibition viewing
1130 – 1215
Leg Ulcers – prevention, assessment and management
Jeanette Milne, Tissue Viability Specialist Nurse, South Tyneside NHS Foundation Trust
1215 – 1300
Wound Dressings
Menna Lloyd Jones, Independent Tissue Viability Specialist
1300 – 1400
Lunch and exhibition viewing
1400 – 1445
Pressure Ulcers – prevention and management
Julie Evans, TV Nurse, Abertawe Bro Morgawwng University Health Board, Swansea
Essential Skin Care
Rosie Callaghan, Tissue Viability Specialist Nurse, Worcestershire Health and Care NHS Trust
1530 – 1615
Implementing Care with Care Studies – interactive session
Jackie Griffin, TV Clinical Nurse Specialist, Powys Teaching Health Board
16.15
Quiz, prizes and close
ar C
Jackie Stephen-Haynes, Professor and Consultant Nurse in Tissue Viability, Birmingham City University and Worcestershire Health and Care NHS Trust
ou nd
W
15
20
©
1445 – 1530
e
0900 – 0925
In association with: Wound Healing Practice Development Unit Faculty of Health, Education and Life Sciences Birmingham City University
Conference fee £5.00 for all members Already a member? Book your place via
[email protected] Not a member? Book your place and register to become a member via
[email protected] or ring 07938 556066
COMPRESSION
Treatment of venous and mixed aetiology leg ulcers, venous oedema and lymphoedema
20 ©
Thanks to its unique "PresSure System" and its 2 dynamic layers, ensures consistent application of the recommended therapeutic pressure of 40 mmHg*, without over pressure and slippage1. Reduced is available for patients with mixed aetiology leg ulcers or those intolerant to full compression and donates 20mmHg* is available in a Latex Free version and 2 ankle sizes (18-25 cm and 25-32 cm) to be adapted to all of patients. Two dynamic layers: • "Gold Standard" efficacy2 • Improves patient comfort and concordance3 • Easy application with consistent pressures4
• Contraindications: arterial conditions (arterial or predominantly arterial ulcers ; known or suspected arterial disease). Ankle Brachial Pressure Index (ABPI)
