Doctors target diabetic foot loss

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.

“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.”

Doctors can do more, too. For example, they need to ask diabetic patients to remove their shoes and socks during checkups, says Dr. Gerry Rayman, an expert on diabetic feet at Ipswich Hospital in Britain. Physicians are also too quick to recommend amputation, he says, when they should first try limb-sparing surgery to restore circulation in the leg, such as bypass surgery or angioplasty. Until recently, such surgery had been considered too complex.

Rayman reported a 73% reduction in diabetic amputations at Ipswich Hospital from 1995 to 2005.

Sweden has seen a similar drop in diabetic amputations -- 78%, even as diabetes rates have risen -- because it has emphasized ulcer prevention and more aggressive treatment to restore blood flow in the leg, Dr. Jan Apelqvist of University Hospital of Malmo reported Thursday at the Diabetic Foot Global Conference.

Gilbert Merrill of Oxnard, 73, swears by circulation-improving surgery. The retired federal worker, who was diagnosed with diabetes 25 years ago, noticed tingling in his toes a few years ago and, several months later, a tiny cut on a right toe.

He sought treatment at a wound care center, but the ulcer became larger. The toes on his left foot also became inflamed.

He was told the right toe should be amputated. “But they told me they couldn’t guarantee it would heal. If it doesn’t heal, they would have to cut off more of my foot, and they might amputate up to my knee,” Merrill recalled.

“I said, ‘No, I don’t want an amputation.’ ”

He was referred to Andros, who performed bypass surgery last May to restore circulation. A month later, Merrill had surgery on the left foot.

“After the surgeries, my ulcers started to clear up little by little,” Merrill says. “My toes are as good as new. I walk every day now and do a little maintenance around my house. Before the surgeries, I couldn’t walk much.”


Concentrated effort

Better treatment may start with specialized care, such as at a diabetic foot clinic or by a team including both podiatrists and vascular surgeons.

“The problem with diabetic foot care is that it hasn’t had its own specialty,” Armstrong says. “The care in this area is so fragmented.”

At last week’s meeting, experts preached the “toe and flow” approach -- pairing a foot care doctor, such as a podiatrist, and a vascular surgeon. “Almost immediately these amputation rates begin to drop” with such coordination, Armstrong says.

Reducing amputations could save the nation millions of dollars, he says. A full foot amputation -- surgery and hospitalization -- costs $25,000 to $65,000, excluding rehabilitation.

Treating a single diabetic foot wound costs $7,000 to $28,000 over a two-year period, according to one study. Hyperbaric oxygen treatment, which increases the capacity of the blood to carry oxygen to infected tissue and heal wounds, costs from $8,000 to $10,000, Armstrong says.

A yearly foot exam, special shoes, a foot mirror or thermometer cost far less, although such measures may not be covered by health insurance.

Under the U.S. reimbursement system, Armstrong says, “prevention doesn’t pay. But it’s so important.

“We need to ask: How can we take the long view?”