A MAJOR HEALTH CONCERN
is a chronic disease which afflicts about 16 million people in
the United States, half of whom are unaware they have the disease.
It is a metabolic disease characterized by elevated glucose (blood
sugar), resulting from defects in secretion of the hormone insulin,
defects which cause tissue to resist absorption of insulin, or
both. Chronic elevation of blood sugar (hyperglycemia) is associated
with long-term damage to the eyes, heart, kidneys, feet, nerves,
and blood vessels.
Symptoms of hyperglycemia
may include frequent urination, excessive thirst, extreme hunger,
unexplained weight loss, tingling or numbness of the feet or
hands, blurred vision, slow-to-heal wounds, and susceptibility
to certain infections. Those who have any of these symptoms and
have not been tested for the disease should see a physician without
diabetes are prone to many complications, both acute and chronic.
About 15 percent of those with diabetes will develop an open
wound (ulceration) on a foot during their lifetimes, and 20 percent
of these ulcerations will lead to amputations. The annual incidence
of nontraumatic lower extremity amputations among people with
diabetes is about 54,000, according to the American Diabetes
Association. Among African-Americans, the amputation rate is
1 1/2 to 2 1/2 times that of whites, and Native Americans have
even higher rates, three or four times that of whites.
AN UNWELCOME LIFETIME COMPANION
Diabetes, once diagnosed, is present for life. Considerable
research is focused on finding a cure, and much progress has
been made in treatment and control of the disease.
The majority of
people with diabetes have type II diabetes. Type I, insulin-dependent
diabetes mellitus, once referred to as juvenile, or juvenile-onset
diabetes, afflicts five to 10 percent of people with diabetes.
Type II, non-insulin-dependent diabetes mellitus, once known
as adult-onset diabetes, afflicts the other 90-95 percent, many
of whom use oral medication or injectable insulin. The vast majority
of those people (80 percent or more) are overweight, many of
them obese. Obesity itself can cause insulin resistance.
The socioeconomic costs of diabetes are enormous. The dollar
costs have been estimated at $92 billion annually, about equally
split between direct medical costs and indirect costs. Diabetes
is the fourth leading cause of death by disease in the United
States. Individuals with diabetes are two to four times as likely
to experience heart disease and stroke. It is the leading cause
of end-stage kidney disease and new cases of blindness among
adults under 75.
The trauma of
amputation is particularly debilitating. It often ends working
careers, and restricts social life and the independence which
mobility affords. For more than 50 percent of those who experience
an amputation of one limb, the loss of another will occur within
three to five years.
The key to amputation prevention is
early recognition and foot screening, at least annually, of at-risk
individuals. Those individuals considered to be at high risk
are those who exhibit one or more of six characteristics: (1)
peripheral neuropathy, a nerve disorder generally characterized
by loss of protective sensation and/or tingling and numbness
in the feet; (2) vascular insufficiency, a circulatory disorder
which inhibits blood flow to the extremities; (3) foot deformities,
such as hammertoes; (4) stiff joints; (5) calluses on the soles
of the feet; and (6) a history of open sores on the feet (ulcerations)
or a previous lower extremity amputation.
THE ROLE OF THE PODIATRIC PHYSICIAN
of podiatric medicine is a foot care specialist with skills in
recognition and treatment of diabetic foot conditions. Because
diabetes is a systemic disease, affecting many organs of the
body, ideal case management requires a team approach, involving
the podiatrist as well as the family physician, several medical
specialists, and a dietitian. The podiatric physician, as an
integral part of the treatment team, has documented success in
the prevention of amputations. It is one of the most serious
conditions treated by podiatric physicians, whose training stresses
salvage of the foot rather than amputation.
approach to prevention of complications must include good glucose
control, adherence to diet, an exercise program, proper medication
and hygiene, and regular foot care. Those who follow the medical
team's advice have a good chance of preventing or delaying the
complications of the disease, and living normal lives. Furthermore,
with such a regimen as groundwork, it is estimated that more
than half of the lower extremity amputations among people with
diabetes could be prevented.
The American Podiatric
Medical Association is a partner in diabetes educational outreach
programs of the National
Institute of Diabetes and Digestive and Kidney Diseases.
For the person with diabetes who has not yet developed foot complications,
there are warning signs which should be recognized and called
to the attention of the family physician or podiatrist.
- elevation of skin temperature
- color changes of the skin
- swelling of the foot or ankle
- pain in the legs, either at rest or while
- open sores, with or without drainage, that
are slow to heal
- ingrown and fungus-infected toenails
- corns or calluses with bleeding within the
- dry fissures (cracks) in the skin, especially
around the heel
Ulceration is a common occurrence of the diabetic
foot. Poorly fitted shoes, or something as seemingly trivial
as a stocking seam, can create a wound that cannot be felt and
may not immediately be seen by someone whose level of skin sensation
has been minimized. Left unattended, such an ulcer can quickly
become infected and lead to serious consequences.
VISIT A PODIATRIC PHYSICIAN REGULARLY
For the person with diabetes a number of practices and precautions
should be employed. Regular visits to a podiatric physician for
foot inspections, no less than annually and preferably more often,
are recommended. The doctor may conduct specific diagnostic tests
to assess the presence or progression of diabetes complications.
Such tests may include assessments of circulation, using an instrument
known as the Doppler for measurement of blood flow; vibration
sense, using a tuning fork; sensation (light touch and deep pressure),
using a plastic monofilament slightly thicker than a toothbrush
bristle in what is called the Semmes-Weinstein test; and foot
structure, using X-rays. The podiatric physician will probably
also reinforce self foot care, reminding patients of previously
dispensed advice. There is a sizable list of "do's and don't's."
Shoes are at the top of the list. Poorly fitted shoes are involved
in as many as half of the problems that lead to amputations.
Foot shape and size may change over the years; peripheral neuropathy
contributes to change. Everyone, particularly those with diabetes,
should be fitted by experienced shoe fitters for every new pair
New shoes should
be comfortable at the time they're purchased -- they should not
require a break-in period -- but it is a good idea to wear them
for only short periods of time at first. Shoes should have leather
or canvas uppers, fit both the length and width of the foot,
leaving room for the toes to wiggle freely, and be cushioned
and sturdy. Athletic footwear may fit the bill nicely. It's a
good idea to change shoes during the day, to relieve pressure
Avoid high heels
and shoes with pointed toes. Never wear shoes with open toes
or heels, including sandals, especially those with straps between
the first two toes. Shake shoes out and feel inside them for
rough stitching or foreign objects, such as small pebbles. Never
go without socks. Diabetics who have difficulty finding shoes
that fit should ask a podiatrist to prescribe corrective shoes,
or refer them to a shoe specialist, the pedorthist.
For those eligible,
Medicare provides coverage for extra depth shoes or specially
molded shoes, and inserts, for those with advanced cases of diabetes.
The medical or osteopathic doctor treating an individual for
diabetes can certify the need for therapeutic shoes, and a medical
or podiatric physician can prescribe.
Wash feet daily, using mild soap and lukewarm water. Those with diabetes
should always test bath water temperature with a thermometer
or the elbow, since the feet may be unable to detect scalding
temperatures. Dry feet carefully with a soft towel, especially
between the toes, and dust them with talcum powder. If the skin
is dry, use a good moisturizing cream daily, but avoid getting
it between the toes.
Feet and toes should be inspected daily
for cuts, bruises, and sores, or other changes that are less
obvious. If self-inspection is hampered by age or other factors,
use a mirror or get the assistance of another person.
Wear thick, soft socks;
avoid mended socks or those with seams,
which could cause blisters or other skin injuries. Never go barefoot,
even inside your own home, and especially out of doors on unfamiliar
terrain such as the beach or grassy areas.
Smokers should give up the habit. The consumption of alcohol should be moderated. Tobacco
can contribute to circulatory problems, and alcohol to neuropathy.
Exercise is important.
Walk as frequently as possible; it's the
best overall conditioner for the feet.
People with diabetes are commonly overweight. That approximately
doubles the risk of complications; close observance of good dietary habits is important.
For cold feet at night, wear loose socks
(don't use heating pads or hot water bottles, or other external
Don't use garters or elastics to hold
up stockings, and don't use panty girdles that are too tight
around the legs.
Cut toenails straight across, then
use an emery board to gently file away sharp corners. Don't cut
into the corners.
Never try to cut calluses with a razor
blade, or anything else, without professional guidance, and never use commercial preparations
to remove corns or warts; they contain chemicals which can burn the skin.