Conway McLean, DPM, Journal columnist

Once again, Diabetes Awareness Month is upon us. But very little has changed in how we go about preventing the debilitating consequences to the feet. Certainly, as many are aware, diabetes mellitus is associated with multiple complications, from heart disease to vision problems, clogged arteries, and very notably kidney disease. But, in this author’s opinion, not enough press is given to the problem of “diabetic foot disease.”

We are referring to the high rate of foot ulcerations, infections, and amputations that occur to these individuals. It is true we have made great strides in how many of these infections we are able to resolve and ulcers to heal. But the statistics are very clear, when someone with diabetes has their 1st foot ulcer, they become significantly more susceptible to further ulcerations. Additionally, the longer an ulcer is open, the greater the risk of infection, also often meaning hospitalization and/or amputation.

Unfortunately, the consequences to the feet go far beyond the development of an open sore or an aggressive infection. The statistics are very clear: when a diabetic suffers a major amputation, the mortality rate is frighteningly high. The clear majority of diabetics who have an amputation don’t live another three to five years. Thus, when we are able to prevent a major amputation, we not only save a limb, we also save a life.

Most diabetics who have a major amputation (i.e. a foot or a leg) cannot successfully use a prosthesis. This means they are confined to a wheelchair, resulting in a great reduction in activity levels. The consequences to one’s metabolism, heart function, and a variety of important indicators of health and well-being are all reduced.

Numerous studies have investigated how we can prevent these untoward results. Rather than treating an ulcer better, which is certainly a good thing, prevention is better on so many levels. Skin provides a wonderful barrier to infection, but some kind of opening allows bacterial invasion. And diabetic infections can spread rapidly. When people with diabetes are taught all the various components of diabetic home care, less ulcers and infections occur.

Perhaps the most glaring number concerning diabetes is how many of these amputations didn’t need to happen. Estimates claim 85% of the major diabetic amputations performed were preventable, a sad statistic. The key is preventing the initial skin breakdown, regardless of the cause, be it pressure from a tight shoe or a minor skin injury (often the result of a diabetic trimming their abnormal toenails). Too often, this is the seminal event, leading to a cascade of problems.

But it is possible to reduce the number of these skin injuries. This does not require some advanced technology or wound healing marvel. And the studies bear this out: simply being educated in best home foot care practices leads to a marked reduction in these complications. We need to teach people living with diabetes how to take care of their feet.

Unfortunately, our healthcare system has failed these people. When someone is diagnosed with diabetes, they usually are sent to a diabetic educator. This is a critically important step, teaching the individual how to manage their blood sugar, about the critically important dietary changes, and use of their diabetic medications. This turns out to be a significant amount of education, and therefore time consuming. As a generalization, diabetic educators do not provide the specific information concerning diabetic foot care these people need.

It’s an important lesson: they can develop a very serious foot problem (like an open sore or deep foot infection) and experience no pain, the result of diabetic neuropathy. These degenerative changes of various types of nerves in the body occur eventually to most diabetics. And this harmful process occurs to all sorts of nerves, even those going to the heart and the brain.

An inability to fight infection is another critical component of the stairway to amputation. Even the most minor opening in the skin, perhaps a simple crack in the skin from dryness, can and has led to infection and amputation. Diabetes interferes with the functioning of your immune system, allowing these infections to spread quickly and aggressively.

The third component of this equation, all resulting from diabetes, is an increased tendency for clogging of both the large and smallest arteries of the feet. This has multiple effects since, without sufficient blood, we are unable to fight infection or build new tissue, a necessary part of healing. It is well recognized, diabetes interferes with wound healing, often a tremendous obstacle to those of us practicing wound care in this population.

I’m on a mission to educate these individuals, whether in my daily practice of podiatric medicine, through lecturing, or publications such as this. If you are involved in a community group, organize an event to have appropriate members educated. The most common reason a diabetic is admitted to the hospital is a foot problem, typically an infection. But proper diabetic foot care, a result of directed education, generally minimizes the likelihood this admission is necessary.

As a culture, as a society, we have failed to provide the timely, appropriate education shown to reduce these consequences. We need to teach these people and their families how to take care of their feet. Until a dedicated program is instituted nationally providing for this educational process, their best opportunity is to consult with a foot specialist dedicated to this educational effort. By working together to make these changes and develop effective programs, at least locally, we can reduce the number of limbs and lives lost to diabetes. Prevention should be the goal, and education is the key.

EDITORS NOTE: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.