With Diabetes Assuming Epidemic Proportions, Foot Doctors Look For A Leg Up

PODIATRISTS, tenders of corns, bunions and other troubles of the humble foot, are classified as second-class citizens in the medical world – a rung below full-fledged M.D.s. But with the surge in people with diabetes, they’re playing a particularly vital role these days in preventing amputations. And there’s a move afoot to boost their official status as well, reports Jan Ferris of the Sacramento Bee.

Dr Jon A. Hultman

“We kind of see ourselves as the profession that keeps people walking,” said Dr. Jon Hultman, executive director of the California Podiatric Medical Association.

Obesity is the primary culprit for the boom in cases of type 2, or adult-onset, diabetes. As the numbers rise, so does the need for early treatment – especially of foot sores or ulcers that can quickly threaten the lower limbs. Sixty percent of all non-traumatic amputations in the U.S. are due to diabetes, according to the American Diabetes Association.

Indeed, podiatry (foot care) for people with diabetes is one of the most overlooked aspects of diabetes management. Reviewing the community discussion regarding podiatry and particularly for visiting podiatrists reveals that many people with diabetes are entirely unaware that they need to take special care of their feet and visit a podiatrist at once if problems arise. Higher levels of blood glucose can damage the nerve endings in many areas of the body and organs, which is why tight blood glucose control is an essential aspect of diabetes care.

But here’s the thing: Though podiatrists can operate on the foot and ankle, give injections and provide other medical care, they aren’t licensed doctors of medicine, or M.D.s. As such, Hultman and others maintain, the state’s 1,800 doctors of podiatric medicine (DPMs) are hamstrung by law from treating many of the 7.5 million Californians insured through Medi-Cal (due to a 2009 state budget cut), partnering fully in the hospital care of diabetic patients and gaining access to first-rate residencies in their podiatric training.

“We’ve evolved over the last 30 or 40 years. What hasn’t changed is this limited license,” Hultman said. “We’re treated differently even though the way we practice is essentially the same.”

Indeed, on a given day with the Sutter Medical Group, 30-year podiatrist Dr. Spencer Lockson treats the foot from several angles: dermatological, as in athlete’s foot and eczema; bone and joint issues, such as bunions, fractures and “hammer toe” deformities; and nerve conditions, which are often associated with diabetes. “We avoid amputations the best we can,” he said.

Foot Doctors Can Help Diabetics Avoid Amputation

Podiatrists have attracted an unlikely ally in the bid to boost their status: the California Medical Association. The powerful doctors’ lobbying group is notorious for its turf battles with chiropractors, nurse practitioners and others it defines as “mid-level practitioners and other allied health professionals.”

But this time around, the CMA is playing the opposite role. It’s teaming up with the California Podiatric Medical Association and the California Orthopaedic Association to consider putting the training of foot specialists on par with M.D. standards, according to CMA Chief Executive Officer Dustin Corcoran.

The three groups are creating a task force to review the curriculum at California’s two podiatry schools and, depending on the outcome, appeal jointly to the national Liaison Committee on Medical Education to reclassify the licensing for podiatrists.

Dr. Lawrence Harkless, a podiatrist and dean of the Pomona-based College of Podiatric Medicine at the Western University of Health Sciences, believes the move makes good sense. “I don’t have an M.D., but I practice medicine every day. If I’m that close, why not just be it?” he said.

The first two years of podiatric training are similar to those for full-fledged physicians, with the emphasis on anatomy, physiology, pathology and other core subjects. Podiatry students jump into more specialized training the next two years, then generally spend the last two or three years as hospital residents. Training for licensed medical doctors generally takes several years longer, with the length for residencies determined by the specialty.

At his first hospital internship in Texas in the 1970s, Harkless worried he’d be less prepared than his M.D. peers. “After two months, I knew I learned more than anybody about feet,” said Harkless, considered a national pioneer in the field of diabetic limb salvage. “But if you have a different degree, they want to make you feel less than.”

Corcoran of the California Medical Association agrees the perception is not always favorable. He and Hultman are expecting pushback on the collaboration to bring podiatry into the medical mainstream. “There will be a freak-out, those naysayers, who say, ‘They’re just the foot guys and will always just be the foot guys’,” said Corcoran. But this is really how scope of practice should be decided.”

Shortage Of Vascular Surgeons In India Costs 80,000 Limbs Every Year

With a physician shortage in California, and the aging baby boomers’ growing need for care, podiatry may become a more attractive option if granted M.D. status, he added.

Franklin High School graduate Brittany Rice just completed her first year at the California Podiatric School of Medicine at Samuel Merritt University in Oakland. She is used to frequently explaining that podiatry is a credible medical field. “I know people in society put the M.D. on a higher pedestal. They don’t take us seriously,” said Rice, who is considering specializing in diabetes care. “Not that (a change in licensing) would affect what I do, just how people perceive the profession.”

Sacramento podiatrist Kevin Kirby isn’t convinced. He chose podiatry school in the 1980s, in part because of its “efficient” focus on the foot and a postgraduate commitment of six years instead of eight or nine. If new requirements called for additional training, he wonders if students would just choose a different branch of medicine.

“I never had the feeling that I was a lesser doctor because I had a DPM,” said Kirby, who is on staff at two Sacramento hospitals and shares his practice with an orthopedic surgeon. “For me, I don’t lose any sleep over this. I’m plenty busy. I do a lot of good for people.”

Courtesy: Sacramento Bee

Low-Carb, Higher-Fat Diets Add No Arterial Health Risks To Obese People Seeking To Lose Weight

OVERWEIGHT and obese people looking to drop some pounds and considering one of the popular low-carbohydrate diets, along with moderate exercise, need not worry that the higher proportion of fat in such a program compared to a low-fat, high-carb diet may harm their arteries, suggests a pair of new studies by heart and vascular researchers at Johns Hopkins.

Dr Kerry J. Stewart

“Overweight and obese people appear to really have options when choosing a weight-loss program, including a low-carb diet, and even if it means eating more fat,” says the studies’ lead investigator exercise physiologist Kerry Stewart, Ed.D.

Stewart, a professor of medicine and director of clinical and research exercise physiology at the Johns Hopkins University School of Medicine and its Heart and Vascular Institute, says his team’s latest analysis is believed to be the first direct comparison of either kind of diet on the effects to vascular health, using the real-life context of 46 people trying to lose weight through diet and moderate exercise.

The research was prompted by concerns from people who wanted to include one of the low-carb, high-fat diets, such as Atkins, South Beach and Zone, as part of their weight-loss program, but were wary of the diets’ higher fat content.

In the first study, presented June 3 at the annual meeting of the American College of Sports Medicine in Denver, the Johns Hopkins team studied 23 men and women, weighing on average 218 pounds (about 99 kg) and participating in a six-month weight-loss program that consisted of moderate aerobic exercise and lifting weights, plus a diet made up of no more than 30 percent of calories from carbs, such as pastas, breads and sugary fruits.  As much as 40 percent of their diet was made up of fats coming from meat, dairy products and nuts.

This low-carb group showed no change after shedding 10 pounds (4.5 kg) in two key measures of vascular health: finger-tip tests of how fast the inner vessel lining in the arteries in the lower arm relaxes after blood flow has been constrained and restored in the upper arm (the so-called reactive hyperemia index of endothelial function), and the augmentation index, a pulse-wave analysis of arterial stiffness.

Low-carb dieters showed no harmful vascular changes, but also on average dropped 10 pounds in 45 days, compared to an equal number of study participants randomly assigned to a low-fat diet. The low-fat group, whose diets consisted of no more than 30 percent from fat and 55 percent from carbs, took on average nearly a month longer, or 70 days, to lose the same amount of weight.

“Our study should help allay the concerns that many people who need to lose weight have about choosing a low-carb diet instead of a low-fat one, and provide re-assurance that both types of diet are effective at weight loss and that a low-carb approach does not seem to pose any immediate risk to vascular health,” says Stewart. “More people should be considering a low-carb diet as a good option,” he adds.

Because the study findings were obtained within three months, Stewart says the effects of eating low-carb, higher-fat diets versus low-fat, high-carb options over a longer period of time remain unknown.

However, Stewart does contend that an over-emphasis on low-fat diets has likely contributed to the obesity epidemic in the United States by encouraging an over-consumption of foods high in carbohydrates. He says high-carb foods are, in general, less filling, and people tend to get carried away with how much low-fat food they can eat. More than half of all American adults are estimated to be overweight, with a body mass index, or BMI, of 26 or higher; a third are considered to be obese, with a BMI of 30 or higher.

Stewart says the key to maintaining healthy blood vessels and vascular function seems ‒ in particular, when moderate exercise is included ‒ less about the type of diet and more about maintaining a healthy body weight without an excessive amount of body fat.

Among the researchers’ other key study findings, presented separately at the conference, was that consuming an extremely high-fat McDonald’s breakfast meal, consisting of two English muffin sandwiches, one with egg and another with sausage, along with hash browns and a decaffeinated beverage, had no immediate or short-term impact on vascular health.  Study participants’ blood vessels were actually less stiff when tested four hours after the meal, while endothelial or blood vessel lining function remained normal.

Researchers added the McDonald’s meal challenge immediately before the start of the six-month investigation to separate any immediate vascular effects from those to be observed in the longer study. They also wanted to see what happened when people ate a higher amount of fat in a single meal than recommended in national guidelines.

Previous research had suggested that such a meal was harmful, but its negative findings could not be confirmed in the Johns Hopkins’ analysis.  The same meal challenge will be repeated at the end of the study, when it is expected that its participants will still have lost considerable weight, despite having eaten more than the recommended amount of fat.

“Even consuming a high-fat meal now and then does not seem to cause any immediate harm to the blood vessels,” says Stewart.  However, he strongly cautions against eating too many such meals because of their high salt and caloric content.  He says this single meal ‒ at over 900 calories and 50 grams of fat ‒ is at least half the maximum daily fat intake recommended by the American Heart Association and nearly half the recommended average daily intake of about 2,000 calories for most adults.

All study participants were between the age of 30 and 65, and healthy, aside from being overweight or obese.  Researchers say that in the first study, because people were monitored for the period they lost the same amount of weight, any observed vascular differences would be due to what they ate.

Source: Johns Hopkins School of Medicine

Watch this video on Low-Carb, High-Fat Diet featuring Dr Mary Vernon.

Diabetes: ‘Gold Standard’ HbA1c Test Not So Great For Dialysis Patients ‎

In situations where rapid changes occur in blood sugar, the glycated albumin (GA) test gives a more accurate picture of diabetes control

BLOOD sugar monitoring is a vital part of diabetes management. Patients and physicians rely on the hemoglobin A1c (HbA1c) test to measure an individual’s average blood sugar level over the prior three months. It is the most commonly used long-term blood sugar test, and the gold standard for the medical community.

While the American Diabetes Association has deemed the HbA1c test an effective tool for diagnosing diabetes, kidney doctors recently determined that the HbA1c is not as useful for managing patients with diabetes and advanced kidney failure. Another test, the glycated albumin or GA assay, appears to be far more effective in this setting, they say.

The GA test, developed by Tokyo-based Asahi Kasei Pharma Corporation, measures blood sugars over the past 17 days, as opposed to the longer time frame for HbA1c. In situations where rapid changes occur in blood sugar, the GA gives a more accurate picture of diabetes control. The GA test used in this study is available in Japan, China and South Korea, but is not yet FDA approved in the United States.

According to a new study at Wake Forest Baptist Medical Center, which appears online in the Clinical Journal of the American Society of Nephrology and is scheduled for the July print issue, many organs don’t function properly in severe kidney failure. For example, most dialysis patients have anemia with fewer red blood cells than they should, which has a dramatic impact on the accuracy of the HbA1c reading.

Hemoglobin inside red blood cells carries oxygen in the body. Blood sugar chemically interacts with the hemoglobin to identify a value for HbA1c. But HbA1c results are only accurate when red cells have a normal lifespan. Dialysis patients have shorter red cell survival, reducing the time that sugar in the bloodstream has to interact with hemoglobin, and causing lower HbA1c values.

“Doctors long thought the HbA1c predicted outcomes in diabetes. This test is not predictive of outcomes in diabetes patients with kidney disease on dialysis. Dialysis patients and physicians get a false sense of security because their lower HbA1c actually relates to shorter red cell survival, yet suggests diabetes control is better than it really is,” explained Barry I. Freedman, M.D., John H. Felts III Professor and lead investigator.

“This is the first study showing that a blood sugar test predicts risk of death in diabetic dialysis patients, as well as risk of hospitalization,” Freedman said. “This test provides the missing link that will allow dialysis patients and physicians to accurately gauge risk. The association is clear: high GA readings predict higher risk.”

Freedman and colleagues evaluated 444 patients with diabetes undergoing dialysis. Patients continued their normal treatment and HbA1c monitoring, but also agreed to have a GA test every three months for an average of more than 2.3 years.

Wake Forest Baptist researchers compared the patients’ HbA1c and GA test results, assessing their ability to predict hospitalizations and survival. They found that the HbA1c failed to predict these important medical outcomes. In contrast, the GA was a strong predictor of patient survival and hospitalizations.

Nearly 500,000 people are on dialysis in the Unites States and diabetes is the cause of kidney failure in nearly 50 percent of them. Diabetes is the most common cause of kidney failure worldwide and is associated with high mortality rates – more than 20 percent of dialysis patients die each year. As such, there is an urgent need for accurate blood sugar testing in diabetic dialysis patients.

Freedman suggests physicians not rely on the HbA1c in dialysis patients, instead suggesting that blood glucose levels be directly monitored with multiple daily readings until the GA test is available in the states.

The GA test is not limited only to dialysis patients. Some studies have shown that shorter-term markers for glucose control may lead to better management of glucose than longer-term measures with the HbA1c test. So, instead of waiting 3-6 months for an HbA1c test, which is the current recommendation, the rapid and inexpensive GA test could be performed monthly.

Several studies have confirmed that measurements of GA and HbA1c are closely correlated. Though the GA test has been available in labs for years, Epinex Diagnostics, the developer of the rapid result GA measurement called G1A™, believes the mounting scientific evidence that supports GA testing will eventually gain wide acceptance among professionals. Numerous studies show the need for a mid-range test that could be performed monthly as another means of helping people with diabetes manage their glucose levels more effectively.

Sources: Wake Forest Baptist Medical Center, Epinex Diagnostics

Diabetes Can Shorten Working Life, Force Early Retirement, Cause Financial Stress

“As a T2 diagnosed around 2.5 years ago, I am feeling increasingly exhausted to the point of not being able to sleep (partially due to my work), and have all kinds of other T2 symptoms which combined with tiredness and stress are really getting me down, and making me so depressed… I feel that the stress is sending sugar levels up… Yes I sound a wreck…but this is really beginning to get to me… I just feel I can hardly manage with the diabetes, work and enforced H.E. study for the next year just to keep the job, by the time I graduate I will be ready to retire, or fit to drop – one or the other.”

–       An anguished 60-year-old British woman diagnosed with type 2 diabetes writing in a discussion forum

A UK survey carried out by Cardiff University researchers last year about the effect of diabetes on their lives, almost 74% of patients reported that diabetes influenced their decisions regarding major life changing events. Among the respondents, 40% said that diabetes had influenced their decision to take early retirement and 22% said it had influenced a decision to change profession. Respondents also said that diabetes had influenced decisions to change lifestyle (22%) or have children (14%).

Now a new study provides more evidence that people with diabetes may leave the workforce sooner than employees without diabetes – suggesting that the common disease could be taking a large economic toll, according to French researchers.

The findings, reported in the journal Diabetes Care, echo those from a U.S. study that was reported in 2004. In that study, adults with diabetes were less likely to be working in their 50s than similar adults without the disease. And researchers estimated that between 1992 and 2000, diabetes accounted for $4.4 billion in lost income due to earlier retirement and nearly $32 billion due to work disability.

The French study of more than 3,000 employees of France’s national gas and electric company found that diabetic workers were more likely to retire or go on disability in their 50s than workers of the same age who had similar jobs but no diabetes. “Diabetes can impact individuals’ ability to maintain employment through different pathways,” said senior researcher Dr. Rosemary Dray-Spira, of the French national research institute INSERM, told Reuters Health

For example, diabetes complications such as vision loss and nerve damage can lead to mobility problems or amputations that make it difficult or impossible for people to do their jobs. Diabetes is also often linked with medical conditions, like heart disease or kidney disease. Then there is obesity, one of the major risk factors for developing diabetes. Dray-Spira’s team found that obesity seemed to explain much of the higher risk of work disability among people with diabetes.

These latest findings, Dray-Spira’s team writes, underscore the point that diabetes “has major social and economic consequences for patients, employers, and society.” The results are based on data from a long-term health study of employees at the French national gas and electric company. Between 1989 and 2007, 506 workers developed diabetes.

Dray-Spira’s team compared each of those workers with five diabetes-free co-workers the same age and in the same job type. Overall, diabetics were less likely to still be working in their mid-50s. By age 55, 52 percent of workers with diabetes were still on the job, versus 66 percent of those without diabetes.

The gap narrowed by the time the workers were 60 years old, the official retirement age in France during the study period. At age 60, 10 percent of diabetic workers were still on the job, compared with 13 percent of their co-workers. In addition, by age 60, roughly five of every 100 diabetics were on disability, compared to roughly one of every 100 non-diabetics.

Dray-Spira noted that France has both a relatively young retirement age and a universal healthcare system. The impact of diabetes on retirement and disability could be greater, she said, in a country where people typically work longer and lack universal healthcare – like the U.S. “The major implication of our results is that particular attention should be paid to help people with diabetes in maintaining employment,” Dray-Spira said.

Work life problems faced by diabetics extend even beyond retirement. Last year an Australian study published in The British Journal of Diabetes & Vascular Disease  noted: “Compared with those who are in full-time employment with no health condition, those who have retired early due to diabetes have significantly lower odds of owning any wealth (odds ratio 0.03, 95% confidence interval 0.00–0.30).

“Among those with any accumulated wealth, the value of this wealth is 90% less for people who are out of the labor force due to diabetes relative to those in full-time employment, after adjusting for age, sex and education (p=0.037). Retiring from the labor force early due to diabetes is likely to cause large financial stress in the future as not only have retired individuals lost an income stream from paid employment, but they also have little or no savings to draw upon.”

Sources: Reuters Health, Diabetes.co.uk, Diabetes Care

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