Conway McLean, DPM

Did you know that November is Diabetes Awareness Month? Why do we need such a thing? Everyone has heard of diabetes, we all know of its existence and basically what it is. Most would say it is a disease where there is sugar in your blood stream. What’s the big deal? Why do we need a day devoted to the condition? Is there a hypertension day?

This is partially because diabetes is such an unusual disease. For example, how well you take care of the disease makes a big difference to the course of the disease and the complications that develop. There’s a lot to learn about how to control the condition, especially the consequences of diabetes. In contrast, look at high blood pressure. Stay away from salt, get some exercise. That’s kind of it. But diabetes self-care is rather complicated. This is why insurance companies will pay you to see an educator who focuses solely on caring for diabetes, from the use of the various medications, the dietary changes and food choices, to checking one’s blood sugar. There’s a lot to learn.

When uncontrolled, this all too common disease play’s havoc with many critical components of the human body. Blindness can occur, though much less common in these days of modern pharmaceuticals. Kidney disease remains a severe and debilitating complication of diabetes. Better control of your blood sugar can reduce many of these consequences of the malady, now considered epidemic in its prevalence.

Unfortunately, one of the most devastating effects of living with diabetes is limb loss, i.e. amputation. Nothing will change your quality of life faster. Many of those individuals who suffer such an event are not braceable, meaning they are not able to use a prosthetic and are therefore confined to a wheelchair for the rest of their life. Surprisingly, although the reasons have not been defined, loss of a foot and leg appears to shorten a person’s lifespan considerably. A majority don’t live another five years. Yet experts believe 85% of diabetic amputations are preventable, a staggering figure. Clearly, we are not doing a good job of diabetic foot care and foot education.

How do we, as a society, deal with this result? What resources go into altering the pathway, the chain of events, that make this procedure necessary? True, we have a diabetes month but where is the diabetic amputation prevention week? Our health care system has tended to categorize amputation in with the condition that most led to it, be it arterial disease or heart disease. Yet, among the medical community specializing in diabetic limb loss, it is well recognized that a specific chain of events are what typically culminate in an amputation. These generally start with skin breakdown, leading to bacterial invasion, allowing the development of an infection, which then spreads rapidly. Bone infection too often ultimately develops.

The components of this process can be distilled down to the “Terrible Triad” of diabetes. One part of this trilogy is the arterial disease that so often develops. Another is the immunopathy, meaning someone with diabetes is not able to fight off bacteria well. Consequently, any kind of opening in the skin (which, when healthy, is a wonderful barrier to bacterial invasion) can result in a limb-threatening infection. Third, and definitely the most insidious of the three, are the nerve changes.

This latter condition is called neuropathy, specifically diabetic peripheral neuropathy (since there are many other causes for neuropathy). A small minority of diabetics develop painful neuropathy, but much more common is a condition whereby certain pain signals are not received by the brain. How often has a diabetic presented to his podiatrist for some other reason, only to be told they have a hole in their foot, an ulcer, a problem the individual was completely unaware of.

Humans grow up and spend the majority of their lives with the belief that a body part, which is not painful, has no problem. It is human nature to use pain as a criteria, an alarm, if you will, that a problem has developed. What to do when that system fails, when we experience no change in sensation from an open sore or infected foot? Complicating these alterations in sensation is the complexity of the human nervous system, with its multitude of different sensory apparatus. Numerous different nerve receptors are present in the skin and the joints of the foot. Rarely are all these nerves affected equally by diabetes, meaning a diabetic will still feel certain sensations normally, while others they’ll be completely unaware of.

Too often, it is the nerve changes that initiate the process leading to ulceration, infection and amputation. 90 percent of the people with some type of neuropathy (and there are many different causes) are unaware they have this dangerous yet painless condition. Even those with pre-diabetes are prone to developing it.

Where does a newly diagnosed diabetic receive this education into skin care for their feet, proper shoe use, monitoring of potential changes preceding skin breakdown, and all the other facets of diabetic amputation prevention? I am saddened to say generally it is nowhere. A referral to a diabetic educator is routinely performed, yet foot care education is sorely lacking. The tasks required of the diabetic educator are sufficiently complex (plus they don’t have the specific training in diabetic foot care), making it rare that this aspect of diabetes is properly discussed.

This is one area in which podiatry excels. Some very good studies have examined this and revealed the care of a podiatrist lowers amputation rates. Even the American Diabetes Association recommends such focused educational efforts. No other specialty is as tuned in to the changes leading to ulceration-infection-amputation. Certainly, many podiatrists focus their practice on other aspects of lower extremity medicine, such as sports medicine or surgery. But wound care is an important part of the medical care provided by a great number of podiatric physicians, myself included. I sincerely believe educating those individuals with diabetes is one of the most important tasks I can perform as a physician.

I am so committed to this paradigm, that better education will result in fewer diabetic amputations and thus fewer deaths, that I am offering to speak on diabetic foot care to any community group or organization in the U.P. who feel their members would benefit. I will give my time freely to speak to those with diabetes and pre-diabetes, their loved ones or friends. I am offering these educational efforts initially in the form of a lecture and discussion at 5 p.m. Dec. 3 at my office. A thorough review of these concepts and principles will be provided.

If you know someone with diabetes or pre-diabetes, urge them to learn about how to take care of their feet. Many of these critical lessons can be learned online, although there is abundant inaccurate information there as well. Learning to live with diabetes takes time and effort. But, with the right lessons and the right lifestyle changes, you too can live a full life. Not everyone with diabetes or pre-diabetes suffers a foot problem, but enough do that learning about good foot care will pay dividends for many years to come.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments atdrcmclean@outlook.com.