Preventing the Next Generation of Foot Ulcers and Amputations
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I once had a patient who came to me for a foot exam following a recent diagnosis of prediabetes. He told me, “I’m doing as many things as possible to stay healthy. I read the health blogs, I watch my diet, I take a handful of supplements twice a day, I do aerobic exercises that include walking or water aerobics, and I do weight training a couple of times a week.”
He went on, “I thought I was doing all the right things to be healthy because my goal is to be around as long as my quality of life continues to be good … and then I got the news … both my fasting blood sugar and A1c were high enough for me to be considered prediabetic. I was really shocked because I thought I was doing everything right.”
My patient was not alone. More than 1 in 3 adults—about 96 million Americans—have prediabetes, and 81% of them don’t know they have it.1 Even though my patient did his best to be healthy, he was in the 81% who developed prediabetes and did not know it.
Educating Patients About Prediabetes
The estimated number of patients with prediabetes worldwide is at nearly 464 million.2 The presence of “pre” in prediabetes should not be glossed over. A prediabetes diagnosis means that blood sugar levels are higher than normal but not high enough for a diabetes diagnosis. Prediabetes is a serious health condition that also puts people at risk of other serious complications, including type 2 diabetes and the comorbid conditions of foot ulcers, amputations, renal failure, blindness, heart attack, and stroke.
Possible Signs and Symptoms of Prediabetes
Most people pay little attention to an isolated symptom so it’s good to remember that there are a variety of symptoms that should alert a patient to the possibility of prediabetes. Many of these signs overlap with that of type 2 diabetes, including acanthosis nigricans, retinopathic or neuropathic changes. Additionally, prediabetes can also result in no perceivable signs or symptoms.3,4
How Prediabetes May Affect the Foot and Ankle
The foot health of the next generation of patients with prediabetes may be affected by a variety of conditions that are both medical and nonmedical in origin.
To appreciate the challenge of preventing the next generation of diabetic foot ulcers and amputations, let’s first take a closer look at the medical issues. These issues include the prevalence of the comorbid conditions of peripheral neuropathy and peripheral arterial disease (PAD). In my experience, and in the literature, these may actually already be present when someone previously diagnosed with prediabetes progresses to type 2 diabetes.5 We as clinicians must monitor our patients with prediabetes and screen for these comorbidities in order to intervene early and prevent foot ulcers and amputations.
Prevalence of neuropathy in prediabetes. A 2021 study of neuropathy prevalence in people with prediabetes reviewed 1784 abstracts, 84 full-text records, and 29 studies with 9351 participants.5 The review found a wide range of prevalence estimates, but 72% of studies examined reported a prevalence of neuropathy ≥10%. In some studies the prevalence of peripheral neuropathy was as high as 30–66%.
Another study revealed the prevalence of diabetic peripheral neuropathy had been reported as high as 35% at the time of diagnosis of type 2 diabetes.6 That is suggestive of an early subclinical disease phase.
Although many patients with objective evidence of diabetic neuropathy are asymptomatic, they remain at risk for injury to insensate feet.7
Prevalence of PAD in prediabetes. In one review, at the time of diagnosis, PAD prevalence was 3.81% for all participants with prediabetes.5 In men, PAD prevalence was significantly higher than in women. The results show the existence of a low prevalence of PAD in a prediabetic population aged 45–74 years.
The development of these conditions would not normally be a focus in the care of a patient with prediabetes. The benefit of identifying prediabetes early creates a unique opportunity for risk mitigation of the developing comorbidities and prevention of ulcers and amputations.
Resolving Prediabetes by Early Intervention
It’s important to remember that prediabetes is reversible, but most people diagnosed with it don’t get the proper information on the development of lower extremity comorbid conditions. Further, they do not understand how one may reverse a prediabetic condition before it transitions into type 2 diabetes.
Early intervention has been shown to delay the onset of the comorbidities of diabetes. Oftentimes, I note that people diagnosed with prediabetes are admonished to watch their diet, to move away from prepared foods and eat more protein, fruits and vegetables, exercise, and stop smoking. And that’s it. Few people diagnosed with prediabetes ever receive a yearly screening evaluation and risk stratification as suggested by the International Working Group on the Diabetic Foot (IWGDF), whose criteria is accepted in over 100 countries for patients who have been diagnosed with diabetes. This leaves patients with prediabetes at especially high risk to become the next generation of people to suffer from foot ulcers and amputations.
We as clinicians can educate and refer patients to their primary care provider, endocrinologist, or diabetes educator to learn more about a Centers for Disease Control and Prevention–recognized National Diabetes Prevention Program lifestyle change program, which is a scientifically proven way to reverse prediabetes. That information may be found at Reversing Prediabetes Programs.4
Preventing the Next Generation of Foot Ulcers and Amputations
Eighty-five percent of lower extremity amputations in the diabetic population are preceded by a foot ulcer, so it makes sense that preventing the foot ulcer prevents the infection, the hospitalization, and most of the amputations in the diabetic population. Using this same logic, it makes sense that preventing patients who have prediabetes from developing type 2 diabetes will prevent the unrecognized development of neuropathy and PAD, which should also prevent those with prediabetes from becoming the next generation of patients with diabetes to develop foot ulcers and amputations.
What Are the Risk Factors for Developing Prediabetes?
As podiatrists, we are familiar with the risks for developing prediabetes, but it is important to look at these risks with a sharper lens. Body mass index (BMI) greater than 27, family history, advancing age, abdominal weight distribution, history of gestational diabetes, smoking, sleep apnea, and polycystic ovarian syndrome can all play a role. Patients of Black, Hispanic, Native American, Pacific Islander, or Asian heritage may also experience a higher risk level.4
Advising Patients on the Next Steps
Due to the lack of knowledge in the general population on their risks for developing prediabetes, the Centers for Disease Control and Prevention is launching a public awareness campaign centered around an online risk assessment tool. Here is the location of the Prediabetes Risk Test. Since the risk of prediabetes increases after age 45, every person who is of that age or older could benefit take this free test to determine their risk for developing prediabetes.8
Non-Medical Issues Affecting Prevention and Reversing of Prediabetes
The business model of the practice where patients receive their healthcare could influence prevention and reversal of prediabetes and the transition from prediabetes to type 2 diabetes.
In the fee-for-service medical business model, the care is more reactive in nature. So, screening or preventive care may be less likely to occur. In a value-based medical business model, the care is more proactive and includes screening and preventive care to reduce costs with an eye to patient satisfaction. This is why I feel patients who have their healthcare in the value-based medical business model could more likely reverse their prediabetes, prevent transition to type 2 diabetes, and possibly live healthier lives. But most importantly, they may not become part of the next generation of patients with ulcers and amputations.
The insurance industry, led by Medicare, has recognized the value of prevention and preventive screenings and has developed reimbursable codes for more than 25 screening tests that include diabetes screenings, diabetes management training, and the Medicare Diabetes Prevention Program.9 While these preventive screenings for patients with diabetes are worthwhile, there is no code for reimbursing of a foot exam for patients diagnosed with prediabetes. Given the likelihood of the development of comorbid lower extremity conditions and the costs of treating them, screening these patients offers an opportunity to identify and mitigate their risks for developing a foot ulcer or amputation. I believe consideration for developing a reimbursement code for a foot exam in patients classified with prediabetes makes sense for early identification and mitigation of risk factors, thus reducing the cost of healthcare and increasing the quality of life of these vulnerable patients by preventing the next generation of foot ulcers and amputation.
Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board certified by the American Board of Foot and Ankle Surgery and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. He is the author of “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On,” available at www.amazon.com.
References
1. Centers for Disease Control and Prevention. More than one in three Americans are at increased risk for type 2 diabetes, but changing the outcome is possible. Published Nov. 14, 2023.
2. Cornejo Del Río V, Mostaza J, Lahoz C, et al; on behalf SPREDIA-2 Group. Prevalence of peripheral artery disease (PAD) and factors associated: An epidemiological analysis from the population-based Screening PRE-diabetes and type 2 DIAbetes (SPREDIA-2) study. PLoS One. 2017 Oct 26;12(10):e0186220. doi: 10.1371/journal.pone.0186220. PMID: 29073236; PMCID: PMC5657631.
3. National Institute of Diabetes and Digestive and Kidney Diseases. Insulin resistance and prediabetes.
4. Mayo Clinic. Prediabetes.
5. Kirthi V, Perumbalath A, Brown E, et al. Prevalence of peripheral neuropathy in pre-diabetes: a systematic review. BMJ Open Diabetes Res Care. 2021 May;9(1):e002040. doi: 10.1136/bmjdrc-2020-002040. PMID: 34006607; PMCID: PMC8137250.
6. Watson JC, Dyck PJ. Peripheral Neuropathy: A Practical Approach to Diagnosis and Symptom Management. Mayo Clin Proc. 2015 Jul;90(7):940-51. doi: 10.1016/j.mayocp.2015.05.004. PMID: 26141332.
7. Miller RV. Limb amputations lifetime cost. Baltimore Injury Lawyer Blog. Published Jan. 4, 2020.
8. American Diabetes Association. Pre-Diabetes Risk Test.
9. Medicare Diabetes Prevention Program.
Disclaimer: The views and opinions expressed are those of the author(s) and do not necessarily reflect the official policy or position of Podiatry Today or HMP Global, their employees and affiliates. Any content provided by our bloggers or authors are of their opinion and are not intended to malign any religion, ethnic group, club, association, organization, company, individual, anyone or anything.
