Diabetes is a complex yet common disease that impacts over 34 million Americans. Blood glucose is just the tip of the iceberg; related complications include neuropathy, eye disease, ketoacidosis, kidney disease, cardiovascular disease and more. In fact, it could be said that diabetes is a “whole body” disease, in the sense that it spirals out to cause devastating problems that impact many regions of the body, including mental health. It’s a constellation of complications that stack up to make overall health suffer in the diabetes patient.
When it comes to diabetes prevention and management, it’s difficult to decide where to begin. There certainly must be an effort upfront to prevent diabetes altogether, and many programs already focus on prediabetes and lifestyle changes to help avoid new diagnoses for Americans. In addition, many medical specializations dig into the particular area that they know the best: heart, skin, eyes, etc.
In an ideal world, diabetes management is a holistic approach that involves an interconnected team of physicians, other health providers, innovative technologies, and concentrated programs. In today’s pandemic-exhausted one, we struggle to find the best way to juggle all of these complications, and it’s hard to keep patients feeling optimistic about their diabetes.
As we know, diabetes is a comorbidity that can cause more severe symptoms in COVID positive patients. This knowledge, along with the sense that diabetes is overwhelming the entire body, can quickly deplete a patient’s reserve of positive energy. Despite all their best efforts, diabetes is a disease that can often spiral out of control and make a patient feel helpless.
While it’s critical to maintain this “whole body” approach, it’s also important to prioritize complications. One of the most debilitating complications of diabetes is diabetic amputation, but it’s often not top of mind for many patients with diabetes — or the providers treating other diabetic complications. Yet every four minutes, a lower limb is amputated due to diabetes.
It’s not just the single amputation itself that’s so harrowing, although it certainly is. What’s even more concerning is that one amputation often comes with another, and these amputations compound upon each other and can lead to death. Nineteen percent of patients with diabetes suffer another amputation within one year after their first surgery, and nearly 37% do so within five years. That’s nearly half of them, and that five-year mark has a shocking mortality rate: The five-year mortality rate following amputation is twice the five-year pooled mortality rates for all reported cancer of 31%.
The impact on mental health is also particularly alarming, as many amputees struggle to regain mobility and fight an uphill battle that seems to be never ending. Recent studies found that patients with diabetic foot complications fear amputation more than death. This one very specific complication arises from diabetic foot ulcers, which are actually highly preventable, and spreads throughout a patient’s life — dragging down morale, causing depression, increasing risk of additional complications, and making every single thing harder.
Foot health is an integral part of diabetes management, yet the rate of diabetic amputation drastically rises for many of our nation’s most vulnerable patients: rural Americans, Black Americans (3x more likely to have an amputation), Veterans , and those living in the nation’s poorest communities (39% more likely to have a high-level amputation). Amputations are much more common within these diabetic populations, and the impact is extraordinarily devastating. In fact, it could be said that the greatest marker of health inequity is diabetic amputation. Everything is harder for these patients, including cost, access, and transportation. Reaching them should be paramount as a terrible cycle can tighten quickly due to these factors, leading to more amputations, fewer resources, and increased mortality rates.
The significance of preventing diabetic amputations has not gone unnoticed, even if the focus of many diabetic programs isn’t on foot health. Several measures, including the recently proposed Amputation Reduction and Compassion Act and The Initiative to End Diabetic Limb Loss from the Veterans Health Administration Innovation Ecosystem are examples of proactive approaches for raising awareness and leveraging new technologies in the fight against diabetic amputation. There are ways to reach patients that are high-risk for diabetic amputations, and one way is to isolate the cause of amputation: the diabetic foot ulcer.
Between 6-46% of patients with a foot ulcer and diabetes ultimately progress to an amputation. But every amputation can be prevented if the foot ulcer heals before it progresses. That’s why it makes sense to focus on the prevention of diabetic foot ulcers in order to eliminate potential amputations. As we’ve seen, these amputations don’t cause problems related to limb loss alone. Their impact is far-reaching, “whole body” reaching.
To prevent diabetic foot ulcers, excellent foot care with a podiatrist and vascular specialist are key. For many at-risk patients, it can be difficult to find this care or keep appointments. Several organizations, including the VA and Independence Blue Cross of Philadelphia, have collaborated with virtual care models that combine thermometry with wraparound virtual support.
Thermometry is a proven method of monitoring feet for signs of inflammation and has been supported by The International Workgroup on the Diabetic Foot, The Wound Healing Society, and The American College of Foot and Ankle Surgeon. In particular, thermometry has been very effective when deployed in the patient’s home with a mat that reads temperatures daily and is coupled with ongoing virtual care support. This model can reach patients with diabetes in those vulnerable populations and support a lower-touch telehealth system during the pandemic. It demonstrates a 97% detection of diabetic foot ulcers five weeks before wound opening, and engagement rates are high at 75% after one year.
We know that diabetes is a disease that can impact the patient’s entire body, spreading complications throughout many physiological systems and debilitating the mental health of those who struggle against it. While diabetes management can take many approaches, it’s integral that we recognize the huge impact of diabetic amputations and take steps to prevent them. Diabetic amputations are particularly brutal in the way they impact patients, and they’re entirely preventable. Through innovative collaborations and new legislation, we can bring solutions to the forefront and save patients from the tragic cycle and web of diabetic amputations.
Jon Bloom is an anesthesiologist.
Image credit: Shutterstock.com
