As we are in Type 2 Diabetes Prevention Week from 23rd to 29th May, we are highlighting the importance of preventive foot care for patients with diabetes. Founder of the London Diabetes Centre, Dr Ralph Abraham, shares his thoughts.
Type 2 is by far the most common type of diabetes, accounting for more than 90% of all cases. According to Diabetes UK, there are 13.6 million people at risk of type 2 diabetes in the UK. Although it is typically diagnosed more frequently in mid-life, we are now seeing a rising trend of type 2 diabetes being found in children as childhood obesity also rises. Diabetes currently costs our health system almost £10 billion.
Statistics about the widespread prevalence of diabetes can be disheartening, but we should not forget how much good progress has been made in diabetes care over the years. However, one particularly alarming statistic is the growing number of amputations reported: There are 176 leg, toe and foot amputations every week in England, according to Diabetes UK.
Amputation is often a result of a diabetic foot ulcer that can lead to many days in hospital. Even after the operation, the patient continues to significantly impact healthcare expenditure with an increasing number of days spent in hospital. For the patient, an amputation, regardless of whether it is defined as minor or major, is devastating and life changing. It’s also associated with a shortened life expectancy.
People with diabetes develop foot ulcers on the soles of the feet and 10-15% of them do not heal. An adequate supply of blood both from the large feeding arteries and the smaller ones, as well as normal nerve function, are critically important in helping the healing process. Eventually, if there is insufficient blood, the result is a black toe or foot gangrene, often with accompanying infection that can spread.
Much is already done to stop the progression of foot ulcers during simple foot care routines and check-ups, which should be part of your regular diabetes care programme. Of course, prevention is always better, and every effort should be made to achieve normoglycaemia ‒ that is when a diabetic person has a normal concentration of sugar in their blood. Alcohol and some medications that cause neuropathy (a group of diseases resulting from damaged or malfunctioning of nerves that causes weakness, numbness and pain in hands and feet) should be avoided. Additionally, off-loading (relieving local pressure) of feet that are vulnerable to the formation of a diabetic ulcer could save a foot.
You’re probably aware that people with diabetes are at increased risk of foot ulcers and amputation because high blood glucose can damage blood vessels, affecting how blood flows to the feet and legs. This is indeed true of the small blood vessels to the feet but larger blood vessels throughout the body, if blocked or stenosed (narrowed), also limit blood supply and the chance to heal. Larger arteries can get blocked with cholesterol-laden atheroma (atherosclerosis or “hardening of the arteries”). Unfortunately, cholesterol treatment is rarely matched to risk. Ever since we learned that statins were an effective and safe way to treat the bad LDL (low-density lipoprotein) cholesterol, a standard prescription is often made, but it’s not tailored to a person’s specific risk. This often means undertreatment of the patient with increased risks of early arterial disease.
When a diabetic ulcer is not healing because of inadequate blood flow, much can be done by bypassing blocked blood vessels surgically so that blood flow to the foot can be improved. However, these large vessel arterial supply problems could be better managed many years earlier. This comes down to the realisation that a lower LDL cholesterol is always more appropriate in a patient who is vulnerable to early atherosclerosis. Doctors must use more innovative ways of identifying which patients will be threatened with blood supply problems in the legs- should they live long enough.
Currently, most patients with diabetes are routinely treated with a statin or other cholesterol-lowering medication to help keep arteries open and prevent heart attacks and strokes. But there are stronger drugs now available for lowering LDL cholesterol and even opening arteries to improve blood supply. Getting these drugs to patients who need them, using coronary artery calcium scores, quantitative carotid ultrasound or knowledge of past cardiovascular events, would play a significant role in reducing the number of amputations. While the drugs are expensive, the costs of an amputation far exceed this ‒ without taking into account the distress and suffering of the patient.