Diabetes poses a significant public health challenge for the United States. Among complications of diabetes, foot infections are responsible for more hospitalizations than any other complication that people with diabetes face. For patients with diabetes, 15% will develop a foot ulcer (an open wound on the toe or foot) or gangrene (dead tissue caused by an infection or a severe lack of blood flow) sometime in their lifetime.
Early signs of a potential foot ulcer or infection include dry, cracked or scaly skin, redness and rash. Once an ulcer is more advanced, you might notice symptoms like a callus, discoloration, discharge or a strong odor. Left untreated, foot ulcers and infections can lead to lower extremity amputations. From 12% to 24% of people with diabetes with a foot ulcer or gangrene will require amputations, making diabetes the leading cause of nontraumatic lower extremity amputations in the United States.
Current data suggests that the incidence of diabetes-related amputations is significantly higher in minority populations, with a rate that is 50% higher in Hispanic adults and twice as high in African Americans. Native Americans, Asian Americans and Pacific Islander populations face an even higher risk, while exposure to diabetes education in these communities is low. One study showed only 3.2% of Asian Americans know that the long-term consequence of diabetes includes lower extremity amputations.
The care for foot infections and ulcers is costly, and the financial burden further increases when a person with diabetes loses a limb. Postamputation costs include rehabilitation, disability payments, prosthesis and loss of productivity. And once a patient with diabetes loses a leg, there is a 50% chance of them losing their other leg within five years.
Education Is Essential
The key to preventing amputations is preventing foot ulcers. To do so, Paul Han, D.P.M., M.S., clinical consultant of podiatric surgery in City of Hope’s Department of Diabetes, Endocrinology & Metabolism, emphasizes patient education as the most effective way to prevent diabetic amputations and infectious foot ulcers. A board-certified foot and ankle surgeon, Han specializes in diabetic foot complications and is an expert in limb preservation in diabetes patients. He has treated patients with diabetic foot complications for more than 30 years.
Han estimates that he performs about five amputations each month that “could have been easily prevented.” “It is important to teach people with diabetes to be aware of and recognize the early signs that might indicate a risk of foot ulcers and infection, so that a timely medical intervention can be made,” Han said, who recently published the third edition of his book, What’s the Foot Got to Do With My Diabetes? “I want to let our patients know that prevention is possible once they learn about the disease.”
The Impact on Minority Populations
Raynald Samoa, M.D., assistant clinical professor in City of Hope’s Department of Diabetes, Endocrinology & Metabolism, agrees.
“Studies show that certain communities experience a disparity of risk of these complications, such as foot wounds and amputations. Research suggests that early detection and appropriate podiatric care can significantly decrease the disproportionate burden experienced by vulnerable communities of African Americans, Hispanic Americans, Native American Indians, Native Hawaiians and Pacific Islanders,” Samoa said.
“As an endocrinologist, I recommend we should teach people with diabetes how to recognize subtle signs that may occur that often precede foot ulcers, so that they are able to seek the necessary podiatric care.”
What to Look for
Han says patients should be aware of gradual changes in sensations in the foot, such as tingling, burning and the feeling of pins and needles. This is known as neuropathy, which is diagnosed by visiting a specialist. Neuropathy can eventually lead to a loss of sensation, which makes the person more likely to experience repetitive foot trauma. This trauma can lead to foot injuries and ulcers that may become infected. Diabetes patients with hammertoes and bunions need to pay particular attention to shoes, as improperly fitted shoes can lead to corns and calluses that can become infected wounds.
A specialist will also be able to identify gradual loss of blood circulation to the lower extremities. This is caused by vascular damage in the lower legs due to high circulating blood sugar, leading to a buildup of plaque in major lower leg arteries and reduced blood flow. It is therefore imperative that patients with diabetes maintain stable blood sugar levels to prevent this vascular damage, and to visit a podiatrist regularly.
In most cases, through vigilance and working with a podiatrist, diabetes patients can avoid these complications. Data has shown that keeping blood sugar at normal levels reduces the risk of diabetic complications, including foot complications, by 50%. His mission, Han says, is to “teach people how to recognize any subtle signs to get timely intervention so that foot infection and wounds can be prevented. My motto is, ‘Educate, don’t amputate!’”