Diabetes is a serious disease that affects millions of Americans, and that number is going to astronomically grow as the baby boomer generation ages further. Complications associated with diabetes can be devastating, and can lead to organ failure and even death. Foot-related complications in particular are very common in diabetes, and unfortunately cause the majority of leg amputations performed by surgeons. Comprehensive care by a podiatrist can identify foot problems early before they lead to leg loss, and in many cases can prevent those problems in the first place. This article will discuss the ways a podiatrist can protect diabetic feet, and ultimately save a diabetic’s limb and life.
Diabetes is a disease in which glucose, the body’s main source of ‘fuel’, is not properly absorbed into the body’s tissues and remains stuck in the bloodstream. Glucose is a type of ’sugar’ derived from the body’s digestion of carbohydrates (grains, breads, pastas, sugary food, fruits, starches, and dairy) The body needs a hormone called insulin, which is produced in the pancreas, to coax the glucose into body tissue to fuel it. Some diabetics are born with or develop at a young age an inability to produce insulin, resulting in type 1 diabetes. The majority of diabetics develop their disease as they become much older, and the ability of insulin to coax glucose into tissue wanes due to a sort of resistance to or an ineffectiveness of the action of insulin. This is called type 2 diabetes. Diabetes can also develop from high dose steroid use, during pregnancy (where it is temporary), or after pancreas disease or certain infections. The high concentration of glucose in the blood that remains out of the body tissue in diabetes can cause damage to parts all over the body. Organs and tissue that slowly are damaged by high concentrations of glucose stuck in the blood include the heart, the kidneys, blood vessels, the brain, the nerve tissue, skin, and the immune and injury repair cells. The higher the concentration of glucose in the blood, and the longer this glucose is present in the blood in an elevated state, the more damage will occur. Death can occur with severe levels of glucose in the blood stream, although this is not the case in most diabetics. Most diabetics who do not control their blood glucose well develop tissue damage over a long period of time, and serious disease, organ failure, and the potential for leg loss does eventually arrive, although not right away.
Foot disease in diabetes is common, and one of the more devastating and taxing complications associated directly and indirectly with high blood sugar. Foot disease takes the form of decreased sensation, poor circulation, a higher likelihood of developing skin wounds and infections, and a decreased ability to heal those skin wounds and infections. Key to this entire spectrum of foot complications is the presence of poor sensation. Most diabetics have less feeling in their feet than non-diabetics, due to the indirect action increased glucose has on nerve tissue. This decreased sensation can be a significant numbness, or it can be a mere subtle numbness that makes sharp objects seem smooth, or erases the irritation of a tight shoe. Advanced cases can actually have phantom pains of burning or tingling in addition to the numbness. With decreased sensation comes a much greater risk for skin wounds, mostly due to the inability to feel pain from thick calluses, sharp objects on the ground, and poorly fitting shoes. When a wound has formed as a result of skin dying under the strain of a thick corn or callus, from a needle or splinter driven into the foot, or from a tight shoe rubbing a friction burn on the skin, the diabetic foot has great difficulty starting and completing the healing process. Untreated skin wounds will break down further, and the wound can extend to deeper tissue, including muscle and bone. Bacteria will enter the body through these wounds, and can potentially cause an infection that can spread beyond the foot itself. A diabetic’s body has a particularly difficult time defending itself from bacteria due to the way high glucose affects the very cells that eat bacteria, and diabetics tend to get infected by multiple species of bacteria as well. Combine all this with decreased circulation (and therefore decreased distribution of nutrients and chemicals to preserve foot tissue and help it thrive), and one has all the components in place for a potential amputation. Amputations are performed when bacteria spreads along the body and threatens death, when wounds and foot tissue will not heal as a result of gangrene from advancing tissue death and infection, and when poor circulation will not allow the tissue to thrive ever again. The statistics following a leg amputation are grim: about half of diabetics who undergo one amputation will require an amputation of the other foot or leg, and about that same number in five years will be dead from the heart strain endured when one’s body has to expend energy to use a prosthetic limb.
A podiatrist can ensure that all the above complications are significantly limited, and in some cases prevented all together. Podiatrists are physicians who specialize solely in the care of foot and ankle disease, through medicine and surgery. The attend a four year podiatric medical school following college, and enter into a two or three year of hospital-based residency program after that to hone their advanced reconstructive surgical skills, and to study advanced medical. Podiatrists are generally considered the experts on all things involving the foot and ankle, and their unique understanding amongst other medical specialties of how the foot functions in relationship to the leg and ground (biomechanics) allows them to target therapy towards controlling or changing that function in addition to treating tissue disease. A great majority of the problems that lead to diabetic amputations start off as problems related to the structure of the foot and how it relates to the ground and to the shoe worn above. Controlling or repairing these structural problems will often result in prevention of wounds, which in turn will prevent infection, gangrene, and amputation.
To start with, a podiatrist will provide a diabetic patient with a complete foot exam that takes into account circulation, sensation, bone deformities, and skin issues, and pressures generated by walking and standing. From this initial assessment, a protection and treatment course can be created specific to the individual needs of the diabetic for maintenance, protection, and active treatment of problems that do develop. Commonly performed maintenance services include regular examinations several times a year to identify developing problems, care of toe nails to prevent a diabetic with poor sensation from accidentally cutting themselves when attempting to trim their nails, regular thinning of calluses to prevent wounds from developing, and repetitive education on diabetic foot problems to ensure proper habits are followed. Preventative services include using special deep shoes with protective inserts in diabetics at-risk for developing wounds from regular shoes, assessment of potential circulation problems with prompt referral to vascular specialists if needed, and possible surgery to reduce the potential of wounds to develop over areas of bony prominences. Active treatment of foot problems performed by a podiatrist involves the care and healing of wounds, the treatment of diabetic infections, and surgery to address serious foot injury, deep infections, gangrene, and other urgent problems. Because of a podiatrist’s unique understanding of the way the foot structure affects disease and injury, all treatment will be centered around the principles of how the foot realistically functions in conjunction with the leg and the ground. This becomes invaluable in the struggle to prevent diabetic wounds and infections, while allowing one to remain mobile and active at the same time.
The essential goal of a podiatrist in caring for a diabetic patient is to prevent wounds, infections, and the amputations that result. This philosophy is called limb salvage, and it is accomplished through the above listed methods. Because of the severity of foot disease as a complication of diabetes, a podiatrist is an integral part of a diabetic’s care, and sometimes can even be the physician that diagnoses diabetes in the first place if foot disease appears as an early symptom of undiagnosed diabetes. For these reasons, all diabetics should be assessed by a podiatrist for potential problems, and those at-risk for foot wounds and infections should have regular foot examinations and preventative treatment. As a final note, online resources by podiatrists discussing diabetic foot issues abound, including a regular blog by this author (thediabeticfoot.blogspot.com). While these resources do not replace a diabetic foot exam, they do help educate diabetics on how best to care for their feet, and what to do if problems develop. This can lead to better knowledge and understanding of foot issues when diabetics begin to see a podiatrist regularly, and can help prevent early foot complications from developing.
Showing posts with label glucose. Show all posts
Showing posts with label glucose. Show all posts
Tuesday, January 4, 2011
Saturday, January 1, 2011
Sugar Substitutes: What's Their Real Value?
About 15 percent of Americans use sugar substitutes to cut calories, control diabetes, or prevent cavities. Yet just how much is safe to consume?
Sugar-free foods and drinks are lower in calories than their full sugar alternatives, but are they good options for weight loss? While sugar substitutes are generally safe, the debate about how they should be used continues.
Sugar Substitutes: A Short and Sweet History
The first sugar substitute, saccharin, was discovered in the late 1800s and gained prominence in manufacturing during the World Wars, when sugar was rationed. The business of sugar-free foods and drinks began to boom in the 1960s when clinicians realized the importance of controlling weight gain in the management of diabetes.
Since then, as people became more health-conscious and wanted to shun sugar, manufacturers responded with a host of sugar substitutes. They are:
• Aspartame, approved in 1981 by the U.S. Food and Drug Administration (FDA) and now in more than 6,000 foods and drinks
• Acesulfame-K, FDA-approved in 1988
• Sucralose (Splenda, SucraPlus), approved in 1998 for limited use and in 1999 for general use
• Neotame, approved in 2002
Other sugar substitutes are being developed, and many products contain a mix of sugar substitutes to enhance flavor. Each sugar substitute is several thousand times sweeter than sugar, but has a slightly different flavor. Whether you reach for the pink, blue, or yellow packet to sweeten your coffee is a matter of personal taste. Sugar substitutes are now so common that many people use them without consciously considering their use as a weight-loss strategy.
Sugar Substitutes: Their Role in Your Diet
As part of an overall healthy diet, sugar substitutes are believed to reduce calories and the risk of cavities. Interestingly, controlled studies that compare weight loss between people who use sugar substitutes and those who consume sugar show very little difference in weight loss between the two groups, although over the long term, sugar substitutes can help maintain weight loss.
Conscious calorie-cutting strategies can include sugar-free products. Replacing a sugary drink with a sugar-free drink will reduce your calorie intake, and cutting back by just one full sugar soda a day could result in losing over 1.4 pounds in 18 months. The key to losing weight using sugar-free products is to use them strategically.
Sugar Substitutes: How Much Can You Have?
A big question surrounding sugar substitutes is how much diet soda is safe to drink. Though you might never consider consuming this much in a day, the FDA says these are the maximum amounts allowable for daily consumption, listed by type of sugar substitute:
• Aspartame: 18 to 19 cans of diet soda
• Saccharin: 9 to 12 packets
• Acesulfame-K: 30 to 32 cans of diet soda
• Sucralose: 6 cans of diet soda
Sugar Substitutes: Reality Check
A realistic use of sugar-free products looks quite different.
A regular amount for a sugar substitute is two servings a day, says dietitian Liz Weinandy, RD, MPH, a dietitian in the non-surgical weight-loss program at Ohio State University Medical Center in Columbus. “My concern comes when people do multiple servings, like a six-pack of diet pop a day. Many times they are trying to use a sugar substitute in place of food. Some are very nutritious, like light yogurt, but while sugar-free soda doesn’t have calories, it also doesn’t have stuff in it that’s good for you.”
Further, consuming a lot of sugar-free drinks could hurt your weight-loss strategy. Studies show that when a sugar substitute is added to a product that has no other nutritional content (such as water), it increases hunger. This is true regardless of the type of sugar substitute used. Sugar substitutes in foods do not have this effect.
Sugar Substitutes: Who Should Avoid Them
While sugar substitutes are generally considered safe, Weinandy advises against giving children sugar-free foods and drinks — unless a doctor has said otherwise — and says pregnant women also should be cautious. “Drink water or fruit juice during pregnancy,” Weinandy suggests. “Limit diet pop to one per day at most.”
Additionally, people who have the disease phenylketonuria need to avoid aspartame, which contains phenylalanine, one of the amino acids in protein. Phenylketonuria is a genetic disorder in which the body cannot fully break down phenylalanine. If levels of it get too high in the blood, mental retardation could result.
For most people, sugar substitutes are a safe alternative to sugar. They may be helpful, in reasonable amounts, with weight loss and weight management when they are part of a balanced, healthy diet.
By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH
Sugar-free foods and drinks are lower in calories than their full sugar alternatives, but are they good options for weight loss? While sugar substitutes are generally safe, the debate about how they should be used continues.
Sugar Substitutes: A Short and Sweet History
The first sugar substitute, saccharin, was discovered in the late 1800s and gained prominence in manufacturing during the World Wars, when sugar was rationed. The business of sugar-free foods and drinks began to boom in the 1960s when clinicians realized the importance of controlling weight gain in the management of diabetes.
Since then, as people became more health-conscious and wanted to shun sugar, manufacturers responded with a host of sugar substitutes. They are:
• Aspartame, approved in 1981 by the U.S. Food and Drug Administration (FDA) and now in more than 6,000 foods and drinks
• Acesulfame-K, FDA-approved in 1988
• Sucralose (Splenda, SucraPlus), approved in 1998 for limited use and in 1999 for general use
• Neotame, approved in 2002
Other sugar substitutes are being developed, and many products contain a mix of sugar substitutes to enhance flavor. Each sugar substitute is several thousand times sweeter than sugar, but has a slightly different flavor. Whether you reach for the pink, blue, or yellow packet to sweeten your coffee is a matter of personal taste. Sugar substitutes are now so common that many people use them without consciously considering their use as a weight-loss strategy.
Sugar Substitutes: Their Role in Your Diet
As part of an overall healthy diet, sugar substitutes are believed to reduce calories and the risk of cavities. Interestingly, controlled studies that compare weight loss between people who use sugar substitutes and those who consume sugar show very little difference in weight loss between the two groups, although over the long term, sugar substitutes can help maintain weight loss.
Conscious calorie-cutting strategies can include sugar-free products. Replacing a sugary drink with a sugar-free drink will reduce your calorie intake, and cutting back by just one full sugar soda a day could result in losing over 1.4 pounds in 18 months. The key to losing weight using sugar-free products is to use them strategically.
Sugar Substitutes: How Much Can You Have?
A big question surrounding sugar substitutes is how much diet soda is safe to drink. Though you might never consider consuming this much in a day, the FDA says these are the maximum amounts allowable for daily consumption, listed by type of sugar substitute:
• Aspartame: 18 to 19 cans of diet soda
• Saccharin: 9 to 12 packets
• Acesulfame-K: 30 to 32 cans of diet soda
• Sucralose: 6 cans of diet soda
Sugar Substitutes: Reality Check
A realistic use of sugar-free products looks quite different.
A regular amount for a sugar substitute is two servings a day, says dietitian Liz Weinandy, RD, MPH, a dietitian in the non-surgical weight-loss program at Ohio State University Medical Center in Columbus. “My concern comes when people do multiple servings, like a six-pack of diet pop a day. Many times they are trying to use a sugar substitute in place of food. Some are very nutritious, like light yogurt, but while sugar-free soda doesn’t have calories, it also doesn’t have stuff in it that’s good for you.”
Further, consuming a lot of sugar-free drinks could hurt your weight-loss strategy. Studies show that when a sugar substitute is added to a product that has no other nutritional content (such as water), it increases hunger. This is true regardless of the type of sugar substitute used. Sugar substitutes in foods do not have this effect.
Sugar Substitutes: Who Should Avoid Them
While sugar substitutes are generally considered safe, Weinandy advises against giving children sugar-free foods and drinks — unless a doctor has said otherwise — and says pregnant women also should be cautious. “Drink water or fruit juice during pregnancy,” Weinandy suggests. “Limit diet pop to one per day at most.”
Additionally, people who have the disease phenylketonuria need to avoid aspartame, which contains phenylalanine, one of the amino acids in protein. Phenylketonuria is a genetic disorder in which the body cannot fully break down phenylalanine. If levels of it get too high in the blood, mental retardation could result.
For most people, sugar substitutes are a safe alternative to sugar. They may be helpful, in reasonable amounts, with weight loss and weight management when they are part of a balanced, healthy diet.
By Madeline Vann, MPH
Medically reviewed by Pat F. Bass III, MD, MPH
Wednesday, September 1, 2010
Simple Blood Test Predicts Who Might Develop Type 2 Diabetes Among Healthy Women
Doctors may have identified a new and simple way to predict risk for developing Type 2 diabetes. The result of a simple blood test may be the earliest alert to doctors and patients to implement lifestyle changes that may delay or prevent the onset of the disease….
Samia Mora, M.D., and colleagues at Harvard Medical School and the Brigham and Women's Hospital used Nuclear Magnetic Resonance (NMR) to investigate the relationship of NMR-measured lipoproteins and the development of future Type 2 diabetes. The outcome of Dr. Mora's work showed that NMR-measured lipoprotein particles were associated with development of Type 2 diabetes, independent of other risk factors, particularly HDL-cholesterol and triglycerides measured by standard laboratory methods.
According to Dr. Mora, "Our findings indicate for the first time that even before the onset of clinical Type 2 diabetes, the size and number of the lipoprotein particles may indicate which women go on to develop future disease. This could provide an important opportunity for a woman with a normal blood glucose, but an abnormal NMR lipoprotein test result, to intervene early by following a healthy diet, losing weight, and increasing her physical activity level, all known ways to reduce her chance of developing diabetes even years before she gets a high glucose reading."
Doctors typically look for increases in glucose and triglycerides, and decreases in HDL cholesterol, to determine if a patient is becoming pre-diabetic. Even before changes in glucose levels are detectable, there are significant changes in the metabolism of cholesterol and triglycerides.
LDL "bad" cholesterol, HDL "good" cholesterol and triglycerides, are carried throughout the body inside molecules called lipoprotein particles. The particles travel into artery walls where they deposit the cholesterol, which forms artery-clogging plaque. Researchers wanted to know the significance of the particle size and number in apparently healthy individuals: could these readings predict future disease? Could they, in fact, predict who might develop Type 2 diabetes in time for early intervention?
The researchers conducted a study of 26,836 initially healthy women who were then followed for 13 years, during which 1,687 developed Type 2 diabetes. Dr. Mora noted, "Our study, which was conducted in a large population of healthy women, found that larger LDL and HDL particles were associated with lower risk and smaller LDL and HDL particles were associated with higher risk of diabetes. Even in women with normal triglyceride and HDL cholesterol measured by standard tests, having smaller LDL particles imparted higher risk of diabetes."
The team concluded that NMR-measured lipoprotein particle size and number provide an opportunity to better predict a healthy woman's chance of developing future diabetes, a type of early warning system. "Our finding suggests that these lipoprotein alterations may occur years before onset of overt hyperglycemia and clinical diagnosis of diabetes, providing a potential opportunity for the early detection and prevention of Type 2 diabetes and its complications."
Although standard laboratory tests can be used to measure the cholesterol and triglycerides carried by the particles, these tests do not provide a reliable indication of the number or size of the particles in the bloodstream. Particle number and size can be measured from a small blood specimen using another test (NMR), technology that has been used in research settings for over 40 years. More recently, NMR has been used in the clinical laboratory to determine particle number and size in the blood.
Samia Mora, M.D., and colleagues at Harvard Medical School and the Brigham and Women's Hospital used Nuclear Magnetic Resonance (NMR) to investigate the relationship of NMR-measured lipoproteins and the development of future Type 2 diabetes. The outcome of Dr. Mora's work showed that NMR-measured lipoprotein particles were associated with development of Type 2 diabetes, independent of other risk factors, particularly HDL-cholesterol and triglycerides measured by standard laboratory methods.
According to Dr. Mora, "Our findings indicate for the first time that even before the onset of clinical Type 2 diabetes, the size and number of the lipoprotein particles may indicate which women go on to develop future disease. This could provide an important opportunity for a woman with a normal blood glucose, but an abnormal NMR lipoprotein test result, to intervene early by following a healthy diet, losing weight, and increasing her physical activity level, all known ways to reduce her chance of developing diabetes even years before she gets a high glucose reading."
Doctors typically look for increases in glucose and triglycerides, and decreases in HDL cholesterol, to determine if a patient is becoming pre-diabetic. Even before changes in glucose levels are detectable, there are significant changes in the metabolism of cholesterol and triglycerides.
LDL "bad" cholesterol, HDL "good" cholesterol and triglycerides, are carried throughout the body inside molecules called lipoprotein particles. The particles travel into artery walls where they deposit the cholesterol, which forms artery-clogging plaque. Researchers wanted to know the significance of the particle size and number in apparently healthy individuals: could these readings predict future disease? Could they, in fact, predict who might develop Type 2 diabetes in time for early intervention?
The researchers conducted a study of 26,836 initially healthy women who were then followed for 13 years, during which 1,687 developed Type 2 diabetes. Dr. Mora noted, "Our study, which was conducted in a large population of healthy women, found that larger LDL and HDL particles were associated with lower risk and smaller LDL and HDL particles were associated with higher risk of diabetes. Even in women with normal triglyceride and HDL cholesterol measured by standard tests, having smaller LDL particles imparted higher risk of diabetes."
The team concluded that NMR-measured lipoprotein particle size and number provide an opportunity to better predict a healthy woman's chance of developing future diabetes, a type of early warning system. "Our finding suggests that these lipoprotein alterations may occur years before onset of overt hyperglycemia and clinical diagnosis of diabetes, providing a potential opportunity for the early detection and prevention of Type 2 diabetes and its complications."
Although standard laboratory tests can be used to measure the cholesterol and triglycerides carried by the particles, these tests do not provide a reliable indication of the number or size of the particles in the bloodstream. Particle number and size can be measured from a small blood specimen using another test (NMR), technology that has been used in research settings for over 40 years. More recently, NMR has been used in the clinical laboratory to determine particle number and size in the blood.
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