Diabetes is a growing problem in our country. One out of three Americans adults have what is called pre-diabetes. Ninety percent of those people don’t even know that they have that condition. Finding out is important, because up to a third of people who have it go on to develop diabetes itself within five years.
Dr. Stephen Merena, DO, podiatrist at the UVM Medical Center, is an expert in diabetes as it relates to foot care. Listen to an interview with Dr. Merena to learn how to take care of your feet if you have diabetes. You can listen at the link below or read the transcript that follows.
What happens when you have diabetes?
Diabetes is a metabolic disorder that can affect your ability to properly metabolize glucose and there’s different forms of diabetes, but essentially when it’s poorly controlled, over time it can cause a lot of different medical problems on different parts of the body.
Why do people with diabetes get foot problems? Is it the circulation?
One of the concerns is that you can get circulatory changes, specifically in the leg, that can result in decreased blood flow to the feet. The other concern that also puts patients at risk is the presence of what’s called peripheral neuropathy. Neuropathy describes changes to the small nerves in your feet that allow you to sense things properly. With neuropathy that sensation starts to diminish or change to where you may injure yourself but not be aware of that type of change.
What’s the connection between the sugar problem and circulation and nerves, for that matter?
I don’t have a vascular background, but the atherosclerosis, or a thickening of the artery wall – plaque formation within the vessels within the leg – well it can accelerate over time with the presence of poorly controlled diabetes. That results in less oxygen, oxygenated blood flow to the foot that would otherwise keep the tissue healthy.
And then neuropathy? Why does that come about?
Peripheral neuropathy still has lot of research behind it as far as exactly what happens at the cellular level. The correlation is that with elevated blood sugar over a sustained period of time, the nerves become damaged to the point of where they relay a sensory effect that allows you to interpret what you’re feeling will be dulled or diminished or the motor nerves that provide your ability to utilize the muscles within your foot or leg, they can start to lose that motor innervation.
What are some typical injuries or problems that result from all that?
For patients where they’ve developed some sensation loss, they may be more prone towards friction or pressure-related injury, especially to the bottom of the foot or bony areas on different parts of their foot or ankle. With repetitive injury it can lead towards blistering, redness, swelling, and ultimately it could lead towards what’s called a foot ulcer where you have a full thickness breakdown in the skin. Your skin, which acts as a barrier around your entire body, is then compromised and it’s a free-for-all at that point as far as things being able to get into that wound, in particular bacteria, which can cause serious infections.
Neuropathy is not something that in and of itself can be typically cured. You can improve or slow down the progression of one’s disease or the progression of one’s neuropathy by addressing your diabetes, and certainly the earlier the better. Managing acute wounds with or without infection is recognition that, yes, there is a problem, and then dealing with it effectively.
How do you advise patients in taking care of their feet?
As somebody who educates many patients, especially before they developed a serious life-threatening or limb-threatening type of issue or injury or wound, I try to give them a few manageable things to try. You think about things like inspect your feet every day, and then try to break it down to where if you brush your teeth every day, you put your glasses on every day, you should visually inspect your feet. Picking proper shoes. You would think that’s an easy enough, kind of a given type of thing that we all do, but with diabetic patients it’s that much more important that that shoe is going to fit them properly.
Where do you buy special footwear?
For patients who were in the higher risk category we’ll certainly recommend prescription diabetic shoe gear which can be professionally fit or sometimes even molded into the shape of their foot, depending upon the problem.
What is involved in a visual foot inspection?
First and foremost, before you even focus in on your feet, acknowledging and managing your blood sugar is by far and away the most important thing that you can do. From there, foot specific things are to avoid walking barefoot, especially in your house, again making sure that whatever shoe that you put on your feet is fitting you properly, checking your feet frequently, especially when you get a new pair of shoes and not presuming that they fit you probably. If you see something that looks worrisome but doesn’t necessarily hurt, it’s very important to reach out to a healthcare provider and let them know so that they can help you and so that things don’t steamroll out of control.
The devil with this is with the presence of neuropathy, if somebody without neuropathy were to develop redness or swelling or a blister on their foot, that would be quite painful for them to the point of where they would remove their shoes, start walking with a limp or favoring it because they would know something was happening. In the case where a patient has diabetes and has developed some sensation loss with peripheral neuropathy, they are unaware that this process leading towards skin breakdown and/or possibility of infection can be developing, and their recognition of the problem may be significantly delayed.
What do you do about an ulcer or a breach in the skin?
If somebody identifies that they have a sore that is on the bottom of their foot, they are aware that this is a problem, they need to immediately contact either their primary care physician, a specialist who deals with foot-specific or diabetic foot-specific type problems. They need to get off of their foot. The treatment can range from either just being placed on an antibiotic and monitoring the wound until it heals properly, and in some instances if infection has gotten to a point of where it may threaten the foot or the limb, hospitalization and/or surgery might be required.
Some people sadly do lose parts of their foot, and sometimes a full amputation, right?
Yeah, so unfortunately statistics have shown that with many diabetic patients who develop wounds that have trouble healing, the endpoint can be amputation and it can either be of either just part of the foot or a toe. In some cases, in order to save the person’s life, the limb has to be removed in order to do that.
Wound care is a really particularly difficult thing. Why is that and what’s the biggest challenge to staying on top of it from a medical standpoint?
Wound care is going to be based upon adequate blood flow to the wound. If you have poor blood flow to the wound, that is something that needs to be addressed. I will commonly work with the vascular surgeons here at The University of Vermont Medical Center in order to recruit their expertise. Appropriately managing blood sugar is important. Smoking cessation is important. Nutrition – a lot of patients may or not be eating as well as they can in order to give themselves a good chance as far as healing.
I would say the biggest challenge for diabetic patients individually is keeping the weight off of their foot. I think we take for granted our ability to walk around and be as mobile as we are on any given day, and with all our activities of daily living and occupations and so on and so forth. To ask a patient to remain non-weight-bearing or to offload a wound such that it can heal, especially in the absence of pain, can be very difficult.
There is a condition not as well-known called pre-diabetes, and some people might not even think to worry about this sort of thing.
I think you know in discussing wound care, ulcers, infections, these are – from a foot standpoint – these are the endpoints of many years of having diabetes. These things do not happen overnight. Neuropathy as a precursor to wounds, takes time. It’s not a ‘wake up one morning and my feet feel numb’. It is something that can take place over many years of time. In addressing patients who may not even be managed on medication, per se, and be given an official diagnosis of diabetes, they have this pre-diabetic delineation which I think is smart to reach out to these patients who may have a very high risk of becoming diabetic and then having subsequent complications. The idea would be to have patients to be able to manage themselves at a younger age at an earlier point in the disease, and for the benefit a decade later.