Dr. Conway McLean

Chances are excellent you have experience with diabetes. It could be a family member afflicted or you yourself have developed the disease. Because of its growing prevalence, this is an illness most of us need to be familiar with. In the US, billions of dollars are spent in the care of this ubiquitous malady and its many complications.

As many Americans know too well, diabetes is associated with a variety of life altering problems, with an increasing risk of cardiovascular disease being one of the most commonly cited, with kidney disease being another. To reduce these risks, the recommendations include improved exercise levels and a healthier diet, both serving to better control blood sugar levels.

Regardless of whether someone has type I or II, the sensory nerves usually become impaired, a condition called neuropathy. Reduced function of the sensory nervous system, which occurs in most, starts farthest from your core. This obviously is the toes and feet. This leads to some extremely serious complications because of the loss of the gift of pain.

In addition, individuals with the disease develop immune system problems. This means they are unable to fight off bacteria when they get through the body’s outer barrier, our skin. It’s an amazing organ, able to keep our fluids in and the bad stuff out, preventing the invasion of the millions of microbes in our environment, while working to maintain our fluid balance.

The clogging that often develops in the arteries of the legs means the skin isn’t as healthy and so not as strong or durable. The subtle narrowing of our arteries results in reduced repair functions and more frequent defects in this outer layer. And it further reduces our ability to fight off infection.

The pain accompanying the typical skin injury is beneficial. The discomfort alerts the individual to the injury and they are at least aware of it. But because of the neuropathy, someone with diabetes won’t get this signal, that damage has occurred. When there is some type of breach in this essential envelope, bacterial invasion commonly results, leading to infection. And these can worsen quickly in this population.

Because of these and other factors, people with diabetes commonly experience foot problems. Too many Americans afflicted with this disease develop open sores that won’t heal or become infected requiring hospitalization. It’s this initial injury that leads to bacterial invasion, infection, surgery, hospitalization, even amputation. And there’s nothing people with diabetes fear more than loss of a leg, even more than death.

Wound care has become an important subspecialty in medicine secondary to the blossoming senior population and the rise in the incidence of diabetes. Many diabetics develop a wound but these take time and patience to heal. And the longer a wound in a diabetic stays open, the greater the risks of infection and amputation.

Newer techniques can lead to closure but frequently doctors find it easier, more definitive, and less time consuming, to simply amputate. Too many limbs are lost because of a failure to utilize patience and the more effective methods of diabetic wound care. And outdated, ineffective techniques continue to be utilized in most rural communities since many providers never learn of the most effective methods achieving wound closure.

Because of the large number of diabetic individuals in our society, we have been able to study the consequences of the infections and amputations. Sadly, when the part removed consists of a foot or the lower leg, most are unable to successfully utilize a prosthesis. The consequence is a lifetime of immobility, confined to a wheelchair, unable to ambulate with any degree of success. It is theorized this is the reason that so many amputees die during the next five years. Thus, by saving a leg, we are, in effect, saving a life.

As recommended by the American Diabetes Association, educating people with diabetes about these problems and how to prevent them significantly reduces the number of amputations. They need to learn about the critical need for recurring foot inspections, optimizing skin health, and that they can have a potentially limb threatening problem and have no pain.

Experts claim 85% of all diabetic amputations are preventable, best achieved with specialized education in diabetic foot care, as well as ongoing evaluation of their foot health status. Unfortunately, in rural communities, the vast majority of individuals with diabetes receive no education whatsoever in these consequences. Occasionally, they will meet with a diabetic educator to learn about blood sugar control, optimal nutrition, but nothing about the foot problems. The result? Too often, some extremely minor problem has a horrific outcome.

In the majority of rural communities, a referral to the appropriate specialist, typically a podiatrist knowledgeable in diabetic foot care, is never made. Many primary care providers believe they can treat everything. They are generalists, knowledgeable about many topics but they aren’t masters of diabetic foot care. That is a unique specialty, requiring an understanding of the physiology of sensation, the critical importance of arterial disease, the demands of weight bearing. A podiatrist specializing in diabetic care is the best resource for this educational task.

Why is it that so many primary care providers in rural communities do not make these referrals? Nor do they provide this essential information themselves. How can they not know about the need for this education, proven so effective in the studies? The consequence is that they are consigning some percentage of their patients to hospitalization, surgeries, amputation, and potentially even death, because of their inaction.

How will that care and education be applied in your community? Is there a provider devoted to teaching these individuals how to keep their feet functioning? It would seem that here there is no longer.

This article was authored by Dr. C. McLean, a board certified podiatric physician, formerly of Superior Foot and Ankle Centers.