Saturday, September 28, 2019

Retrospective #224: Diabetic Foot: A Cinderella Condition?!!!

The full title of this Medscape Medical News story is, “Diabetic Foot: A Cinderella Condition, Needs a Team Approach.” The simple title, “Diabetic Foot Needs a Team Approach,” would have been much better, but would get fewer “clicks.” It was actually a good story. The findings were reported at the ADA’s 2014 Scientific Session. The key takeaways:
     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 commenters 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 their establishing a limb-salvage program, 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 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. Wow!
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 of going forward with a “uniform, multidisciplinary approach” and a “national treatment plan” for diabetic foot has the potential for “a Cinderella ending.” I’ll try to imagine that that is what was intended by the title.
I haven’t written about diabetic foot before except to mention that diabetic neuropathy (the cause of “diabetic foot”), along with nephropathy and retinopathy, are the three major classes of diabetic Microvascular Complications, as well the seldom mentioned erectile dysfunction (ED). Cardiovascular disease (CVD) – as in “They all die of CVD” – is the major Macrovascular Complication of Type 2 diabetes. Hopefully, your A1c is much, much lower than 9%. That average glucose (eAG) of 212mg/dl 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 this disease, if you follow “usual care,” is scary enough. Reading about the complications and the likely prognosis is ever scarier. Reading the five bullets above is downright terrifying. But you can do your homework and choose a course of action to avoid all of this.
The first A1c that I ever had, long before that test was common, was given to me by an endocrinologist 26 years ago in 1993. 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 (20 grams a day) for almost a year. My A1c was then 5.4%. I would love to have known what it was just before I began to eat Very Low Carb. It would certainly have been “out of control.” My FBS’s were in the 150s and I was maxed out on 2 oral anti-diabetes meds and starting a 3rd.
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? Are you a gambler? Just be aware: Diabetes Foot is NOT a Cinderella Condition.

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