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Steps toward saving diabetic feet

Diabetes-related amputations have skyrocketed -- but doctors say that with vigilance, prevention and better circulation treatment, it doesn't have to be that way.

March 22, 2009|Shari Roan

Los Angeles has one of the highest diabetes-related amputation rates in the country. Yet vascular surgeon Dr. George Andros can't seem to draw enough attention to the problem, which has skyrocketed not just here but nationally.

"It's not sexy," he acknowledges. "Who cares about diabetic feet? It has no sizzle."

Over the last 15 years, the U.S. rate of foot amputations from complications of diabetes has soared, approaching 100,000 annually, according to studies and government statistics.

Andros is among hundreds of health professionals internationally who say that's simply too high -- even accounting for the growing prevalence of the disease -- and are trying to figure out what to do about it. They concluded a three-day meeting on diabetic feet Saturday in Los Angeles.

A few nations have lowered their rates far below the United States', so it is possible to minimize amputations.

But the problem is complex. Diabetic amputees are often racial minorities, poor, obese or elderly, according to government data. Amputation prevention requires vigilance -- and often expensive medical care.

For The Record
Los Angeles Times Tuesday, March 24, 2009 Home Edition Main News Part A Page 4 National Desk 1 inches; 41 words Type of Material: Correction
Diabetes: An article in Sunday's Section A on diabetic foot care said Dr. George Andros was affiliated with Providence St. Joseph Medical Center. Andros is no longer with Providence St. Joseph and has moved to Valley Presbyterian Hospital in Van Nuys.

"These are old people, fat people, people who get ignored," says Andros, co-chairman of the just-concluded Diabetic Foot Global Conference.

The numbers, and the disparities, are likely to grow. The proportion of Americans with diabetes -- now 8% -- is expected to double in a decade because of obesity among young people.

Los Angeles' proportion is especially high, because of its concentrations of populations more likely to develop the disease: Latinos, African Americans and Pacific Islanders.

Diabetes can necessitate amputation because over time it weakens nerves, the immune system and circulation, allowing foot infections or inflammation to spread if not treated early.

But the U.S. healthcare system is poorly designed for what diabetics need most, preventive care; instead it doles out money for expensive urgent care such as amputations, says Andros, who is affiliated with Providence St. Joseph and Providence Holy Cross medical centers.

The cost of treating the disease rose 26%, to $116 billion, in the United States from 2002 to 2007, according to a new report by the diabetes consulting firm Close Concerns. Meanwhile, the cost of treating complications rose a staggering 110%, to $40 billion.

Patients' vigilance and better medical care could prevent 90% of diabetes-related amputations, experts say.

Ideally, prevention would begin with doctors and patients doing everything they can to prevent ulcers within a healthcare system that reimburses for those efforts, says Dr. David G. Armstrong, a podiatrist and director of the Southern Arizona Limb Salvage Alliance who co-chaired the conference with Andros.

For example, monitoring skin temperature with foot thermometers can detect heating, a sign of inflammation. And a new scale equipped with a lighted, magnified, mirrored surface lets diabetics check their weight while quickly examining their feet.

Data show such measures can reduce foot ulcers threefold to tenfold.

Simple visual foot exams (conducted regularly) and use of protective socks and shoes could preserve many limbs.

"It seems so simple," Armstrong says. "But this area gets such a short shrift."


How it begins

Most people with diabetes have Type 2. Type 1 diabetes, usually diagnosed in childhood, is thought to be caused by genetics or a viral infection.

Diabetics of both types are at increased risk for many conditions, including heart attack, stroke, kidney failure and blindness. Seemingly healthy feet may seem like the least of their worries, even though a third of diabetes-related hospitalizations are for foot ailments, says Armstrong.

"We have to counsel people that having a foot wound is like having a feared disease like cancer or HIV," Armstrong says. "But we don't do that."

The path to amputations begins somewhat benignly, with a numbness in the feet called peripheral neuropathy, from poor circulation. But the numbness -- developed by about half of adult diabetics -- means that a blister, cut or sore toe can go unnoticed.

"They can walk on a nail and they won't feel it for days or know it's there until they hear a tapping on the floor," Armstrong says. "They can wear a hole in their feet the same way you and I wear a hole in a sock or shoe. They've lost that protective sensation of pain."

About 15% of diabetics develop a foot ulcer. That's when the real danger sets in, says Dr. Joseph L. Mills, a vascular surgeon at the University of Arizona.

"We often don't see these patients until they have a problem," he says.

"They come in too late, and they lose a leg."

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