Integritus Prime

In our Beyond Medicine: Lifestyle Demons series, we discuss the complications of Type 2 Diabetes (T2D) for the feet. The feet are affected in many ways. The main damage, however, occurs to the nerves and blood vessels of the feet. Foot complications occur due to high blood sugar levels and other co-existing risk factors such as smoking, high cholesterol level and high blood pressure. The initial damage is in the nerves and blood vessels, which then shows up in many different ways.

1. Nerve damage, also known as neuropathy, can manifest in a number of ways and differs from person to person. Sometimes, people with diabetes may start to feel pain, tingling, numbness or weakness in the feet and legs; other people may develop progressive loss of sensation. Sensations include touch, pain, temperature and vibration sense. Loss of sensation, especially pain, makes a person unaware of any injuries to the feet until it’s too late. Scratches may get infected, blisters may form, break and get infected, calluses may form and due to pressure from walking or standing, develop a blister underneath them and break open as an ulcer. Nerve damage generally manifests as dry skin, blisters, calluses and foot ulcers:  
   • Dry skin predisposes the diabetic person to itchiness and cracks in the skin especially on the heels.  Any break or crack in the skin may lead to infection.
   • Blisters may form due to tight or loose shoes rubbing against the skin. When there is no pain they get over looked and are prone to infection.
   • Calluses are hardened areas of skin mainly on the soul or side of the feet. These happen due to uneven pressure on the foot or friction on the sides.
   • Injuries to the soul of the feet maybe due to a foreign body in the shoe, like a pebble, which was not felt by the diabetic person. Sometimes people walk without shoes and a foreign body such as a thumbtack or broken glass or pebble embeds in the foot. Since there is no pain, it eventually leads to undetected infection.
2. Blood vessel damage in the legs is also known as peripheral vascular disease. There is hardening and narrowing of the arteries, thus limiting adequate supply of nutrients to the limbs. The damage to blood vessels in the limbs occurs faster when other risk factors, mentioned above, are present. Symptoms initially may include cold feet, pain in the calf muscles when walking and an ulcer that doesn’t heal, leading to infection and amputation.
   • Sometimes, when people with diabetes have cold feet, they tend to sit near the fireplace or use hot water bottles. This is not recommended as the heat may be too much and cause burns. Due to nerve damage the person may not be able to feel the extra heat. It is safer to wear socks to keep the feet warm.
   • Having on and off pain in the calf muscles while walking is called intermittent claudication. It happens when the blood vessels are damaged, but rest can alleviate the pain. This is an early sign that blood vessels are becoming affected.
   • Often, when person with diabetes is not examining their feet regularly, they may not notice a small thickened area of skin (a callus) on the sole of their foot, or an ulcer. If there is no pain, then there is no warning to take action. So the ulcer, or the callus with an ulcer under it, may get infected. Even this may not transmit any pain and the infection can go further up the foot into the bone. Sometimes there may be an odor or smell, which may prompt a visit to the doctors. Once the infection reaches the bone, there are limited chances of saving the foot. This is when an amputation becomes necessary. Another time there is need for amputation is when there’s gangrene or overwhelming infection of the foot or leg that threatens the life of the diabetic person. Gangrene can happen and spread fairly quickly.

To avoid foot complications, there is a need to control diabetes from the day it is diagnosed. In addition, avoid smoking, keep blood cholesterol and blood pressure under control and have regular check ups.  Examine feet regularly yourself for any thickened skin, blisters or redness. Nerve and blood vessel damage take a while to develop and you may not feel the change. It is important to check your feet regularly. If unable to see your feet yourself by bending down, use a mirror on the floor or ask a family member to check your feet for you. Cut toenails level with the skin to prevent in-growing toenails, which can provide a focus for infection.

Have a foot checkup with the doctor or podiatrist, so you have a baseline of how far your feet are affected at the time of diagnosis. If there’s no damage to the nerves or blood vessels, then you maybe asked to get another checkup every year. If nerve and/or blood vessel damage is picked up, then you need to take extra care to keep your feet safe from injury, infection and amputations.

Preventing foot complications is a better deal then getting an amputation. Knowing how the damage is caused will help you to take the appropriate precautions. Make a note of your visits to the doctor and the status of your blood sugar control, any complications that you maybe developing and be aware of the various symptoms, so you can discuss with your primary care provider at the next visit.  Share with me how you are progressing with your foot care at Margaret@alchemusprime.com.