To be fair,
the full title of this Medscape Medical
News story is, “Diabetic
Foot: A Cinderella Condition, Needs a Team Approach.” But
really, the simpler title, “Diabetic Foot Needs a Team Approach,” would have
been much better. That’s what the story was about, and from a medical
perspective, it was a good story. The findings were reported at the ADA 2014
Scientific Session last week. A few points that caught my attention were:
● There is a
need for a “uniform, multidisciplinary approach,” with a “national treatment
plan” for diabetic foot. To this end, a U.S. National Diabetic Foot Registry is
now being established. (All four comments on the story agreed).
● At one
large “safety-net hospital system that serves a diverse patient population,” in
“2000 there was nearly a 50-50 chance that if you came in with a diabetic-foot
infection, you would lose your foot.” As a result of establishing a
limb-salvage program at this institution, there has been a staggering reduction
in the number of amputations.
● The average
age of the amputee population was 55.9 years, 72.5% of the patients were male,
and the average H1c was 9%. Seventy percent of the patients also had coronary
artery disease, and 14% end-stage renal disease.
● Amputation
was “a robust independent predictor of death, associated with a significant,
almost 85% increased risk for mortality,” with “most of the deaths – just under
50% -- due to cardiovascular disease.”
● “Even minor
amputations were associated with an almost 50% increased mortality risk, a
somewhat surprising finding.” And, “Once you have an amputation, you go down a
not very healthy road.”
The session
moderator told Medscape Medical News,
“It was…disappointing... to see that minor amputations had no better outcome –
you would expect that they would do better, but apparently not.” “But I think
that if you look at the natural course of the disease, these patients die of
cardiovascular disease – it doesn’t matter what you do to their extremity, they
all die of CVD. I guess we should expect it, but we would hope it would be
better,” he said.
Given this
dismal, if no longer abysmal outlook, I would hardly call this a Cinderella Condition.
Even having the amputation rate fall from 36% to 11% (after the limb-salvage
program was implemented at that particular safety-net hospital system), “they
all die of CVD” is not a story-book
ending. It’s not like “they lived happily ever after,” unless it is to be
inferred that the prospect going
forward of a “uniform, multidisciplinary approach” with a “national treatment
plan” for diabetic foot has the potential
for “a happy ending.” I’ll try to imagine that that is what was intended by the
stupid title.
I haven’t
written about diabetic foot before except to mention that diabetic neuropathy
(a precursor to diabetic foot), along with nephropathy and retinopathy, are the
three major classes of diabetic
complications, along with the above-mentioned cardiovascular disease (CVD)
and related microvascular complications like erectile dysfunction. Hopefully,
my readers are not there yet and never will be. Hopefully, your A1c is much,
much lower than 9%, which is truly uncontrolled. An average glucose of 212
requires drastic action on the part of both the physician and the patient.
Of course,
if you’ve somehow just been diagnosed with diabetes and have an A1c as high as
9% (or higher), you can do something
dramatic to lower it. One thing you undoubtedly will do, and are doing, is your
homework. If the doctor hasn’t scared the bejesus out of you, reading about the
progressive nature of the disease is scary enough. Reading about the
complications and the likely prognoses is likewise scary. Reading the five
bullets above is downright terrifying. But you can do your homework and choose
a course of action to avoid all this.
The first
A1c that I ever had, long before that test was common, was given to me by an
endocrinologist 21 years ago in 1993. It was 7 years after my initial diagnosis
and probably many more since I had become a full-fledged type 2. My A1c was
8.9%. Curiously – inexplicably, really – I didn’t have another A1c test for 10
years, and by this time I had already been on a Very Low Carb diet (Atkins
Induction) for almost a whole year (50 weeks). It was 5.4%. I would love to
have known what it was just before I began to eat Very Low Carb. It could very
well have been 9% or higher.
My editor
says that I was very lucky. I sometimes forget. Many people develop early signs
of complications in just a few years of “uncontrolled glucose control.” Others
not. I guess I was, and continue to be, lucky. Do you want to take a chance
that you’ll be lucky too? It’s up to you. Are you a gambler? Just be aware:
Diabetes Foot is not a Cinderella
Condition.
I also consider myself lucky, I only lost a big toe when I first was diagnosed as a T2. I had some minor infections in the first year after that, but thanks to a low carb diet I had brought my A1C down to 5.1 in that year. I have neuropathy, I sort of shuffle instead of walk, but my feet are tough. I don't get blisters or sores, I don't really have Diabetic Foot anymore. I bet a lot of those poor people who died after amputation might still be alive if they'd read your blog and were inspired to change their diet.
ReplyDeleteYou are and were lucky...and so sweet to say such nice things about my blog. That's why I do it, of course. So, thank you...and spread the word. I need more readers.
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