Like all complications associated with diabetes, being diagnosed with diabetes does not mean that you will require an amputation. What it does mean is that you need to be more aware, make educated and thoughtful decisions, and take responsibility for your health to prevent these possibilities.

Why Amputations Happen

There are several factors that increase the risk of amputation in people with diabetes, but almost all amputations are the result of poorly healing, infected foot wounds.  People with diabetes have a 15% chance of developing foot ulcers throughout their lives.  Early and aggressive treatment is the best way to avoid further complications. Treatment varies depending on the severity, but the goals are to:

1. Remove dead tissue
2. Keep the area clean
3. Encourage healing

If initial treatments have failed to remove the affected tissues or if there are no alternate treatment possibilities, amputation may be the only option. The most common amputations in individuals with diabetes are the toe, foot, and/or leg. In some cases, subsequent amputations (ex: foot being amputated after a toe was previously amputated) may be required if steps are not taken to control risk factors after the initial procedure. Amputations are a “last resort” but are required in cases of severe tissue loss or life-threatening infection.  

Who is at Risk?

Thankfully, the number of individuals with diabetes requiring amputation has been cut in half over the past 20 years.

In 2010, 73,000 Americans with diabetes over the age of 20 had amputations.

Factors that increase the risk of amputation in people with diabetes are listed below:

• Peripheral neuropathy: Neuropathy causes numbness and decreased sensation, especially in the lower limbs, which may prevent you from feeling a wound or sore on the bottom of your feet. If you do not notice a wound, it is more likely to go unaddressed and cause infection.
• Calluses or corns: Calluses and corns are the first sign of a potential wound.If you have a history of calluses or corns, or if you notice new spots, make sure you get them checked out as soon as possible.
• Peripheral artery disease (PAD): PAD is the result of clogged arteries and prevents adequate blood flow, especially to the legs and feet. This decreases the availability of nutrients and slows wound healing, increasing the risk of infection and amputation. Vascular disease, including PAD is responsible for 80% of all amputations. The following are risk factors for PAD:

1. Kidney disease: PAD is more prevalent in people with kidney disease than in the general population.
2. Hypertension: High blood pressure (greater than 140/80 mmHg) is another major risk factor for PAD.

• Smoking: Smoking is the number one cause of PAD. Smoking speeds up atherosclerosis and constricts blood vessels. This increases risk of blood clotting and makes PAD progressively worse. Many people with diabetes who end up needing an amputation also smoke.
• Hyperglycemia: High blood sugar or poorly controlled blood sugar increases the risk for all complications of diabetes, including amputation. Hyperglycemia increases the risk of PAD which slows wound healing and increases the risk of infection.
• Smoking: Smoking increases the risk of vascular disease. Nicotine constricts blood vessels which initially causes pain in the legs. Over time, constriction limits blood flow and can lead to tissue damage. If there is no way to remove damaged tissue or if the tissue damage continues to progress, amputation may be the only option.
• Impaired vision: Visual impairment may make it difficult to see small calluses, corns, or wounds on the bottom of your feet. If unnoticed, these sores can become infected and if left untreated, may lead amputation.

Remember: most amputations associated with diabetes are preventable! The most effective steps to prevent amputation are:

1. Manage your blood sugars
2. Practice good foot care daily
3. Wear diabetic shoes
4. See your doctor regularly
5. Meet with your dietitian

Take Care of Your Diabetes

Follow these 7 self-management tips to stay on top of your diabetes care.  Start slow, set realistic goals, and tackle each strategy one at a time.

1. Healthy Eating: focus on being aware of how foods affect your blood sugar and on portioning foods consistently throughout the day.  Visit a dietitian for individualized recommendations.

• Know your carbohydrates: carbohydrates directly increase your blood sugar and are found in a variety of foods (bread, pasta/ rice, starchy vegetables, fruit, milk and yogurt, and desserts).  
• Read food labels: food labels can be very useful but also very overwhelming.  Knowing what to look for and how to use labels is very important. A dietitian can help you set nutrition goals and simplify the food label for you.
• Measure portions: you may not realize that you are eating more than you need until you compare your usual portion to the recommended portion size.
• Plan: Your liver can only store glucose (energy) for 3-5 hours. This means that your body need to be refueled about every 4 hours. Therefore, we should eat 3 meals per day! If you are not eating 3 meals per day, try adding a small snack with protein and carbohydrates every 4-5 hours.

2. Being Physically Active: Benefits of physical activity include better blood sugar control, lower cholesterol, lower blood pressure, improved mood, and decreased stress and anxiety.  The general recommendation for good health is 150 minutes of moderate intensity exercise per week ( 30 minutes 5 days per week). Start slow and set goals to gradually increase your time and intensity.

• Find things you like to do to stay motivated.
• Start slow: your body will see health improvements after just 10 minutes of activity. Start with 5 minutes and work your way up. You can even split your activity throughout the day. Consider going for a 10-minute walk after breakfast, lunch, and dinner to get to your 30-minute goal for the day.
• Keep track: tracking allows you to see progress which can help keep you motivated.

3. Monitoring: monitoring tells you if your blood sugar is within the recommended range and allows you to adjust your treatment plan. Your blood sugar will fluctuate depending on a variety of factors. Your healthcare team will let you know how to monitor your diabetes (how often and when to check your blood sugar). They should also be monitoring your A1c as well as heart health, eye health, kidney health, and foot health.

4. Taking Medication: There are a variety of medications used for treating diabetes. You may be on one or several depending on the type of diabetes you have, your lifestyle, and your history. Along with medications for treating diabetes, there may be additional medications used to help prevent or manage complications of diabetes.

• Set reminders: To ensure that you take medications at the right time, consider timing them around consistent daily activities (breakfast, bedtime, brushing teeth, etc.) or setting an alarm.
• Lowering your risk of heart disease can also lower your risk for amputation. Preventing PAD and managing high blood pressure are important in preventing amputations. Medications may be prescribed aggressively and/or preventatively (even if you do not have high blood pressure or high cholesterol) to lower these risks.

5. Problem Solving: Even if you have a plan, unexpected things happen! Use “slips” as learning experiences. Take time to figure out what went wrong and talk with your dietitian about what you can do differently if a similar situation happens in the future.

6. Reducing Risks: Take steps to prevent complications before they become a problem rather than acting after something happens.  The following are actions that you can take immediately:

• Know your A1C number
• Don’t smoke
• Visit your doctor regularly
• Get an annual eye exam
• Visit the dentist twice per year
• Practice good foot care daily
• Wear diabetic shoes
• Meet with your dietitian
• Get an annual foot exam

7. Healthy Coping: Diabetes impacts your physical and emotional health. Take time to recognize your emotions and find healthy ways to manage stress. Consider one or all the following ideas:

• Be active
• Meditate or attend faith-based activities
• Find hobbies
• Attend support groups

Uncontrolled diabetes can lead to complications affecting the whole body. Taking responsibility for what you can control is the best way to stay ahead of these complications. When it comes to preventing amputations, there are things you can do!

Practice Good Foot Care Daily

Since there are a variety of factors associated with diabetes that may prevent you from recognizing, treating, and preventing problems in your feet (neuropathy, poor wound healing, increased risk for infection, impaired vision, etc.), it is important to inspect and clean your feet everyday to decrease the risk of amputation.

Even if you do not currently have foot problems, the following steps are suggested for anyone managing diabetes to protect your feet and prevent problems from occurring.

1. Check your feet everyday: Make it a habit to check your feet every evening when you take off your shoes. If you are not able to see the bottom of your feet, use a mirror or ask someone to help you. You may have a foot problem but not feel the pain. Look for the following:

• Cuts
• Sores
• Red Spots
• Swelling
• Infected or ingrown toenail

2. Wash your feet daily: Use warm water (water that is too hot may burn your feet without your knowledge if you have neuropathy) and make sure to dry between your toes. Bacteria thrive in warm, moist environments so it is important to keep your feet dry. Wear clean socks that wick away sweat and consider using cornstarch or foot powder.

3. Do not remove calluses or corns by yourself: Use a pumice stone on warm, wet feet in areas where calluses easily form but do not use chemical removers or a nail file, clippers or scissors to remove existing areas. If done incorrectly, bacteria can get in and cause infection. Consult a specialist for removal.

4. Trim toenails: Ingrown toenails increase risk for infection. Trim nails straight across and soften sharp edges with a file. If you are not able to reach or see your feet, ask someone to help or visit your podiatrist for assistance.

5. Always wear shoes: Shoes act as a barrier between your feet and any object that might puncture your skin and create a wound. Avoid being barefoot, even in your own house.

6. Buy shoes that fit: Ill-fitting shoes can cause blisters or calluses. Find shoes that fit the shape of your feet and distribute your weight evenly. Shoes should be comfortable and provide support to all areas of the foot.

7. Schedule foot checkups: Remove your socks and shoes at every appointment to remind your doctor  to inspect your feet. Podiatrists are special foot doctors who can detect early signs of nerve damage, poor circulation and many other problems, so it is important to visit with this specialist every year.

When to See a Doctor

The following are indicators of a potential problem on the feet. Contact your doctor if you notice any of these things. Your doctor will examine your foot and determine if treatment is necessary.

• Ingrown toenail
• Blister
• Plantar warts
• Athletes foot
• Open sore
• Bleeding
• Swelling
• Redness or warmth in a specific area
• Pain
• Discolored skin
• Foul odor
• Ulcer lasting longer than 1-2 weeks
• Ulcer bigger than ¾ inch
• Deep ulcer (can see bone)

Many of these seem like common occurrences and in most cases, they are. Never question whether you should contact your provider, though. You can never be too careful when it comes to foot care and diabetes.  Early recognition and treatment are the best way to prevent problems from progressing.

There are many resources available to help with wound management, but prevention is always the ultimate goal. Not sure where to start? Dietitians at Home specializes in providing diabetic shoes, dietitian services, and Medical Nutrition Therapy to communities in the Chicagoland area. Contact us today for more information!