Thank you so much for joining me on today’s episode of Simple Health Radio.

Today’s question comes to us from Terry Fletcher, who is a
Healthcare Coding and Reimbursement Consultant. She is the host of the Code Cast Podcast and you can visit her website
www.terryfletcher.net

She sent us a great question about foot problems. Let’s have a listen.

First off, let me thank Terry for sending in a great question. She has sent us with questions before and she’s always been a great supporter of our show through social media.

In order to answer the question about this patient who is having a foot procedure and possible diabetes, we have to first understand the relationship between blood sugar and the human body.

Blood sugar is also called glucose. Glucose is used by the brain as a fuel source and also used by the rest of the body as a source of energy. Most of the glucose that we use in our body comes from the foods that we eat. A lot of foods have different types of sugar in them. For example, fruits, bread, and pasta all have different types of carbohydrates which can be broken down into sugar.

However, it’s interesting that the body can actually create its own sugar as well. The medical term for that is called gluconeogenesis. Gluconeogenesis occurs primarily in the liver.

Why would we need to make our own sugar?

There’s a couple of reasons that happens. When somebody goes to sleep after having dinner, the body will digest and absorb all the carbohydrates, sugar, protein, and other vitamins. That process takes a few hours.

What happens early in the morning before you wake up. That’s when your blood sugar is the lowest it’s going to be. You can’t wake up to eat at that point. It might be 3 in the morning. The brain still needs glucose to function in the body still needs sugar as an energy source even though you’re sleeping. So at that point, the liver will actually create sugar. That’s called gluconeogenesis.

The trouble is that people who are diabetic have high blood sugar, to begin with, they eat certain foods that increase the blood sugar even more, and the liver is also producing blood sugar at night. So some of the medications that we use to target diabetes are actually based on gluconeogenesis. One of the most common is called metformin. Metformin turns the switch off at the liver so that it doesn’t produce extra sugar. For many people, that’s all they need and that can go a long way to helping to control her diabetes.

Now, what happens if people are taking their diabetes medications and the blood sugar still remains high especially for months or years.

We have to think of sugar as a very sweet poison. While it is an energy source, it’s toxic to a lot of organs in the body.

There are 4 major organs that I think of what I see somebody who is a very poorly controlled diabetic. We’ll go through them one by one.

Diabetes causes blindness. The blood sugar damages the eyes and the nerves. It causes blood vessels to form abnormal growths in the eyes and it’s 1 of the leading causes of blindness worldwide.

Diabetes causes heart attacks. Excess blood sugar is very thick and causes blood clots to form throughout the body, but especially around the heart. Having diabetes is considered an equivalent of coronary artery disease which means high cholesterol and high blood pressure.

Diabetes damages the kidneys. It is 1 of the leading causes of chronic renal failure in the United States. Because there’s so much blood sugar and the kidneys are working so hard to filter it out, a causes damage. The sugar will start to spill out into the urine and it causes ketones to develop. Ketones are a byproduct of very high sugar and it can cause people to go into DKA also called diabetic ketoacidosis which is a type of diabetic coma. People can die from that in just a few hours if they’re not treated in the ER and admitted to the ICU right away.

The final structures that I think about are the feet. There are entire textbooks have been written about diabetic foot infections, foot ulcers, and neuropathy. So let me talk about those all in detail.

First let’s talk about diabetic neuropathy. Remember we talked about damage throughout the body from high blood sugar. Blood sugar is a poison. Blood sugar eats away at the nerves and especially the lining of the nerves which is called myelin.

Think about your phone charger. When you plug it into the wall, you expect the electricity, travel safely through the wire directly into your phone’s battery. Myelin is the plastic coating that prevents the sparks from going outside of their circuit.

With neuropathy, the blood sugar eats away at the myelin creating sparks all throughout the wires which are the nerves.

This causes different symptoms, including severe pain, numbness, tingling, or burning. It also causes people to lose sensation. That means if they step on a thumbtack or a piece of glass, they may have bleeding, but they have no idea when they stepped on it or how long something has been in their foot.

Any foreign body that gets stuck in the foot must come out. If it festers for too long, it’s going to cause complications.

People with neuropathy have trouble walking. They’ll miss a step or their fall frequently. They may not know if they’re standing on a hot surface like a sidewalk in the summertime. It directly leads to other complications, including ulcers and infections.

The lifetime risk for a diabetic person to develop a foot ulcer is 25%. That means one out of four diabetics at some point will have an ulcer in their foot. An ulcer is a hole that develops over time and it goes through the skin, into the soft tissue, and sometimes all the way to the bone. Over 60% of all amputations in the US are directly due to diabetic foot ulcers.

What’s the difference between a foot ulcer and a foot infection? With a foot ulcer, the physical signs are all there meaning there is damage to the soft tissue and the underlying structures. However, when you do cultures or other blood work, there won’t be any bacteria. So these people need wound care chronically often times for months in order to heal the structures properly.

Diabetic foot infections are even more serious. The feet are naturally dirty. We walked barefoot throughout our homes. We take showers and stand on wet surfaces. We put on shoes and socks that may be contaminated.

If you have ulceration and on top of that you have bacteria growing in the wound, it can cause some serious permanent damage which will lead to amputations.

How do we know when a foot is infected? Often times it will have redness, heat coming out of the foot, pain, swelling, and usually pass or smell. If the infection goes deeper into the soft tissue and infects the bone, the medical term is called osteomyelitis.

People with any osteomyelitis require at least 8 weeks of IV antibiotics. Oral antibiotics don’t work. Pills and topical creams don’t work. It has to be IV antibiotics through a PICC line or a special IV that can be administered in their house or in a nursing home. Otherwise, that foot will have to undergo amputation.

A podiatrist is a foot specialist. All diabetics should see a foot specialist at least once a year. They should have a foot examination by the family doctor at every visit to test for neuropathy, nerve damage, and look for ulcers or infections.

Now we can talk specifically about the case that Terry described.

This podiatrist found something in the foot that was either a foreign body or an infection. He already knows that if this patient is diabetic, they have a high risk of developing an ulcer, severe infection that may require hospitalization or amputation.

The other issue is that no matter what he does on that visit, the patient is going to go back home and continue to walk on different surfaces. There is a high risk the patient will come back in a few weeks or a few months with the same problem. So if that person keeps getting foreign bodies in the foot, keeps getting recurrent ulcers, or constantly develops infections, eventually, the medical treatment is not going to work. The end result is going to be in amputation.

This is a case where you really want to be focused on prevention. Optimize the blood sugar, make sure people take the medications every day, whether tablets or injections, make sure they see the foot doctor at least once a year, but preferably more often, and protect the feet by all means.

So I want to thank Terry again for a great question about foot issues and diabetes. I think the podiatrist was doing everything correctly in order to be extra cautious with this person who had a foot issue and possibly undiagnosed diabetes.

You can learn more about the work that Terry does by listening to the CodeCast Podcast. You can visit our website to get the show notes and the links to her page and her podcast.

If you have a question you want me to answer, just record it on your phone and connect with us on social media. Will make an episode just about your topic. You can visit us online at www.SimpleHealthRadio.com

References:

https://www.apma.org/Patients/FootHealth.cfm?ItemNumber=981

https://health.clevelandclinic.org/diabetic-foot-ulcers-why-you-should-never-ignore-them/

https://www.aafp.org/afp/2013/0801/p177.html

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