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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