Health Conditions News

Jan272012

Amputations Drop for U.S. Diabetics

by Mary Pickett, M.D.
Harvard Medical School

People with diabetes are much less likely to lose a limb or a toe because of the disease, new research shows. The study found that the amputation rate for diabetics has dropped by more than half since the mid-1990s. Researchers from the U.S. Centers for Disease Control and Prevention did the study. It was based on hospital discharge records. Amputations are most common among people with diabetes who are elderly or have had the disease for at least 10 years. So the study focused on people age 40 and older. The amputation rate was 11.2 per 1,000 people in 1996. By 2008, the number of Americans with diabetes more than tripled. But the amputation rate dropped to about 4 per 1,000. Researchers said this drop probably was the result of better treatments. The journal Diabetes Care published the study. The Associated Press wrote about it January 25.

What Is the Doctor's Reaction?

Aside from war injuries, diabetes is the most common reason that a person might need to have a foot or leg amputated. But a new study has reported good news: Since the mid-1990s, the rate of amputations for people with diabetes has dropped in half. The study comes from the U.S. Centers for Disease Control and Prevention.

As a primary care doctor, I could not be more pleased by this news. It is a sign that we are doing several things right. Truly not just one thing, but several. That's because in order to prevent amputations, we have to prevent several other health problems linked with diabetes, all at once.

Here are two ways that diabetes can lead to an amputation.

Poor sugar control in diabetes can lead to nerves that do not feel properly and arteries that are diseased. Usually, both nerve damage and artery damage contribute at the same time.

Nerve damage: How does nerve damage lead to amputations? Nerve damage in the feet is called peripheral neuropathy. Nerves that lose feeling or go numb can't tell you if your shoes rub or fit poorly. They can't tell you if uneven cushioning in your shoes is causing a buildup of thickened skin called a callus.

    → Foot calluses: A callus puts pressure on the softer tissues beneath the skin surface. From this pressure, a blood blister may form. Irritation from the blood blister can wear away the center of your callus from the inside out. This creates a hole. This can lead to …

      → Foot ulcers: Foot ulcers can take a long time to heal. They can get infected. This can lead to …

        → Amputation: If an infection does not clear, a toe or part of the foot may need to be amputated.

Artery damage: Poor blood sugar control, smoking, high blood pressure and cholesterol problems can all lead to atherosclerosis (artery disease.) But how does this cause amputations?

    → Peripheral vascular disease: This disease causes arteries in the legs to become narrow. Blood flow is limited. This causes leg pain with exercise. This can lead to …

      → Gangrene: When peripheral vascular disease is severe, the tips of the toes don't get enough oxygen. A black spot forms on the tip of the toe. It's small, but it can grow. This dead skin tissue is called gangrene. This can lead to …
        → Amputation: If gangrene does not improve, it will develop infection. If an infection does not clear, amputation of a toe, the foot, or part of the leg may be needed.

In order to prevent amputations, diabetes needs comprehensive care. This means medicines to control blood sugar. However, it also means all of these things:

  • Good blood pressure control
  • Attention to weight
  • Control of cholesterol
  • Not smoking
  • Repeated foot inspections
  • Aspirin for some diabetics
  • Good care of the eyes and kidneys

What Changes Can I Make Now?

If you have diabetes, see your doctor every six months to make sure you stay ahead of any further health problems.

Take especially good care of your feet:

  • Bathe your feet daily. Make sure you dry completely between the toes.
  • Trim your toenails with a nail file. Do not use scissors or clippers, which can break the skin. File your nails straight across. You can file a curve at the edge of each nail to avoid bothering the next toe. But don't clip the nail with scissors at its corners. It is easy to cut the nail too close at the corners. This can lead to an "ingrown" nail.
  • Be sure that your shoes have good cushioning.
  • If the skin on your feet is dry, a moisturizing cream will help. Apply it sparingly, however, and not between the toes.
  • Inspect your feet daily. Be on the lookout for a blister, red area or callus. If you find one, decrease the pressure by changing or stretching your shoes. See a podiatrist (foot specialist) for treatment.
  • Don't go barefoot. This is particularly important if any part of your foot is numb.

A yearly foot exam is recommended as well. Either your primary care doctor or a podiatrist can do this exam.

What Can I Expect Looking to the Future?

Today’s low amputation rates show the progress we have made in treating diabetes. Much of the improvement is thanks to medicines that control blood sugar.

Amputations in the 1990s were a sign that we had few options for control of diabetes. Before 1990, we had insulin, but no other effective medicines to treat diabetes. Now we have a large variety of medicines that can control blood sugar. We also have medicines for high cholesterol and far more options for blood pressure management. Studies also have convinced us of the benefits we get from using them.

Much of the improvement in our care of diabetes has occurred in the most recent decade. Amputation rates will continue to go down, because doctors and diabetics have become focused on goals and guidelines of care.

Categories: Diabetes

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