Electrochemical Skin Conductance as a Novel Tool for Diabetic Foot Ulcer Risk Stratification and Prevention
4 min read
Introduction
Diabetic foot ulcers (DFUs) are a major and often debilitating complication of diabetes, contributing significantly to patient morbidity, mortality, and healthcare costs. Despite advancements in diabetes care, the incidence of DFUs remains high, with a substantial impact on quality of life and healthcare resources. A recent study published in the journal Frontiers in Endocrinology compared the use of electrochemical skin conductance (ESC) to the current standards in DFU detection. The current method for assessing DFU risk primarily involves clinical examination, including the monofilament test, which is subjective and dependent on the examiner’s skills. Therefore, there is a need for objective, reproducible, and reliable methods for early detection of at-risk patients.
One of the many complications of diabetes is peripheral neuropathy, which, if left untreated, can lead to DFUs. Electrochemical Skin Conductance (ESC) is a promising non-invasive diagnostic tool that can be used to assess autonomic nerve activity. ESC is measured in-clinic using Sudoscan, which assesses small fiber peripheral neuropathies, specifically the innervation around the sweat glands, by stimulating the glands and measuring the conductance (in µS) of chloride ions contained in the sweat. Lower ESC values indicate more severe neuropathy. This study investigates the association between ESC and DFU risk stratification, offering a potential new approach to managing and preventing diabetic foot complications.
Methods
This study was a retrospective analysis involving 2,149 diabetic patients from four clinics in Greater Paris University Hospitals, the largest hospital system in Europe and one of the largest in the world. The primary aim was to evaluate the relationship between ESC measurements and DFU risk, as classified using the 2016 International Working Group on Diabetic Foot (IWGDF) grading system. This grading system assigns DFU risk based on clinical evaluation, including the presence of neuropathy, ulceration, and other factors.
To assess the predictive performance of ESC in DFU risk stratification, the study incorporated a range of factors: age, sex, type of diabetes, and results from the monofilament test, which is a standard assessment of peripheral neuropathy. The study employed regression and Receiver Operating Characteristic (ROC) analyses to explore the predictive value of ESC measurements for different DFU risk categories.
Results
The study revealed a significant correlation between ESC values and DFU risk grades (p<0.001). Specifically, lower FESC values were associated with higher grades of DFU risk, suggesting that reduced sweat gland function, indicative of small fiber neuropathy, plays a role in the progression of foot ulcers in diabetic patients.
One of the most noteworthy findings of this study was that ESC measurements were able to identify patients at risk for DFUs who would not have been classified as high risk using the standard IWGDF grading system. Specifically, ESC detected autonomic dysfunction and small fiber nerve involvement in 43% patients classified as grade 0 (13% with severe cases of neuropathy), who otherwise showed no obvious signs of risk through traditional assessments, showing better granularity in the lower grades for better risk stratification.
The findings of this study suggest that Electrochemical Skin Conductance (ESC) provides a valuable, reproducible, and operator-independent tool for assessing DFU risk. ESC measurements offer an objective method for identifying early signs of small fiber neuropathy, a critical factor in the development of DFUs. Unlike traditional risk stratification, which relies heavily on clinical judgment and may overlook early-stage neuropathy, ESC can detect subtle changes in nerve function that precede visible foot ulcers.
The ability of ESC to detect at-risk patients in the grade 0 category, who would otherwise be overlooked by conventional classification methods, highlights its potential role in preventing DFUs. By identifying patients with early-stage nerve dysfunction, ESC could facilitate earlier intervention, potentially reducing the incidence of foot ulcers, amputations, and associated healthcare costs.
The ability to detect DFU risk early using ESC shows promise for the prevention of amputation.Therefore, we conclude that feet skin conductance is a relevant parameter for detecting diabetic foot syndrome, specifically at an early stage when there is still no presence of feet ulceration or wounds. A recent meta-analysis on ESC supports this conclusion, indicating that ESC, when combined with temperature measurements, serves as a valuable tool for the early detection of diabetic foot syndrome. ESC can be measured in-clinic, using Sudoscan, and at home using Withings Body Pro 2. Measuring ESC through home use of the Body Pro 2 scale allows for additional data collection and better assessment of trends and progression between appointments. Through this enhanced monitoring of DFU risk, care teams can better risk-stratify and provide targeted care that could prevent amputations and complications.
Electrochemical skin conductance (ESC) is a non-invasive measurement of the sudomotor function. It measures sweat gland nerve supply and assesses disorders of the autonomic nervous system, which is part of the peripheral nervous system.
Why is ESC important?
A significant number of diabetes patients will be affected by diabetic peripheral neuropathy (DPN) in their lifetime, and the percentage of diabetes patients who might develop a diabetic foot ulcer (DFU) is also considerable. In addition, studies have shown that the 5-year mortality rate of DFU is comparable to cancer mortality. Given these urgent concerns, electrochemical skin conductance is a crucial tool for health care providers.
But this key measurement doesn’t just provide an essential health care solution. Consider the increased average medical costs for patients with diabetes, the billions of dollars in costs for patients with DFU in addition to the costs of the diabetes itself, and the tens of thousands of dollars in per-patient Medicare reimbursement and reimbursement per patient with diabetes-related foot amputation. It’s clear that electrochemical skin conductance can reduce the costs of diabetes patient care, as well as many of the risks to patient health.
Unfortunately, the current diabetes patient journey presents significant roadblocks, including the low percentage of diabetes patients who actually have an annual foot exam, the number of patients who are misdiagnosed due to unreliable tools, and the lack of patient monitoring. These issues highlight the need for connected health products that can measure ESC and other key biomarkers. These devices and systems can empower patients to take charge of their home health monitoring and motivate them to make beneficial lifestyle changes. They can provide care teams the consistent, accurate data they need to make the right treatment decisions, elevating overall care and improving health outcomes. And of course, they can lower care costs. The health risks to diabetes patients are real and significant — but real and significant solutions exist that can create positive impacts all around.
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Partner
HabitNu
Challenge
Meet targeted 5% weight loss goal per member with a connected scale that would seamlessly integrate into existing workflow.
Solution
Withings Body Scale
Results
57% of active participants had a 5% of more weight loss and achieved a group weight loss of 11.8%
‘‘Ongoing participant engagement is key to the success of the HabitNu program, and the Withings scale is an essential component. We value the top-of-the-line scale and the support our participants receive from Withings Health Solutions.’’
Dr. Sindhu Rajan, CEO of HabitNu
BACKGROUND
HabitNu is a digital health company that provides Centers for Disease Control (CDC) recognized lifestyle modification programs designed to help members with diabetes prevention and chronic disease management. As part of delivering a successful program, HabitNu required to achieve a targeted 5% weight loss for each member. As a result, the company needed a best-in-class and trusted scale vendor to partner with to ensure members could easily and consistently track their weight throughout the program.
CHALLENGE
HabitNu sought an accurate and automated way to collect members’ weight data and demonstrate the targeted 5% or more weight loss for each member. They were also looking for a connected scale vendor that would seamlessly integrate with their existing workflow and provide them with extensive technical and member troubleshooting support.
SOLUTION
HabitNu partnered with Withings Health Solutions to provide the Wifi-based Body scale, along with the Withings HealthMate app that syncs seamlessly with HabitNu’s app. Once the member steps on the Body scale, the data is captured by the Withings HealthMate app and flows directly to HabitNu’s app. Members can track their meals, physical activity, as well as their daily weigh-in data. With the help of Withing’s onboarding team, HabitNu had their app sync with Withings devices in a matter of days.
The sleekly-designed connected scale instantly provides HabitNu with accurate weight and BMI data from its members. The member’s data is then analyzed and displayed for HabitNu health coaches to assess and guide each member’s progress along their health journey.
The scale’s intentionally designed habit-forming features, like displaying the weather forecast when a member steps on the scale, seamlessly becomes part of their daily routine. Members are also empowered to make healthier choices when seeing their weight trends over time and not just the latest number at weigh in.
‘‘The scale provides awesome features. I am so grateful for not only being able to continually see my weight loss progress in terms of pounds and the decreased BMI, but the icing on the cake is the weather notification.’’
- HabitNu member
‘‘The Withings scale was quick and easy to set up. It syncs easily with my phone and the HabitNu app. I also like that it shows gains and losses each time I weigh myself.’’
- HabitNu member
Withings dropships the scales directly to HabitNu members via an API integration, streamlining the logistics process and removing the headache and cost of operating a fulfillment center. “Having a smooth workflow is very important to us,” said Dr. Rajan. “With Withings, we can place orders for new members with just a click of a button. The whole process is very easy.”
RESULTS
Since 2017, HabitNu has offered a Withings Body scale to each of their new members, resulting in healthier life choices and increased program engagement. “The data we’re collecting demonstrates high levels of member adherence and improved health outcomes,” said Dr. Rajan.
In fact, a recent study of a year-long HabitNu Diabetes Prevention Program consisting of 4635 participants using the Withings Body scale showed that 79% of the participants actively engaged with the scale and the HealthMate app. With this program, HabitNu effectively demonstrated that 57% of the active participants had a 5% or more weight loss, and achieved a total group weight loss of 11.8%.
5%
more weight loss among participants actively engaged with the Withings Body Scale
Interested in partnering with us?
Contact Us
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What is Electrochemical Skin Conductance?
Electrochemical skin conductance (ESC) is a non-invasive measurement of the sudomotor function. It measures sweat gland nerve supply and assesses disorders of the autonomic nervous system, which is part of the peripheral nervous system.
Why is ESC important?
A significant number of diabetes patients will be affected by diabetic peripheral neuropathy (DPN) in their lifetime, and the percentage of diabetes patients who might develop a diabetic foot ulcer (DFU) is also considerable. In addition, studies have shown that the 5-year mortality rate of DFU is comparable to cancer mortality. Given these urgent concerns, electrochemical skin conductance is a crucial tool for health care providers.
But this key measurement doesn’t just provide an essential health care solution. Consider the increased average medical costs for patients with diabetes, the billions of dollars in costs for patients with DFU in addition to the costs of the diabetes itself, and the tens of thousands of dollars in per-patient Medicare reimbursement and reimbursement per patient with diabetes-related foot amputation. It’s clear that electrochemical skin conductance can reduce the costs of diabetes patient care, as well as many of the risks to patient health.
Unfortunately, the current diabetes patient journey presents significant roadblocks, including the low percentage of diabetes patients who actually have an annual foot exam, the number of patients who are misdiagnosed due to unreliable tools, and the lack of patient monitoring. These issues highlight the need for connected health products that can measure ESC and other key biomarkers. These devices and systems can empower patients to take charge of their home health monitoring and motivate them to make beneficial lifestyle changes. They can provide care teams the consistent, accurate data they need to make the right treatment decisions, elevating overall care and improving health outcomes. And of course, they can lower care costs. The health risks to diabetes patients are real and significant — but real and significant solutions exist that can create positive impacts all around.
Click the button below to download the infographic.
Our patient-centric care solution utilizes portable Withings cellular devices that are not tied to a single patient. Instead, care teams can use one device to collect and transmit data for an unlimited number of individuals. The integrated cellular connectivity automatically directs the data into the correct patient’s medical record, simplifying data collection and improving care delivery regardless of the setting.