As an internist, my specialty is the prevention and treatment of adult diseases. One of the most common of these diseases is diabetes.
There are two main variants of diabetes: Type I (juvenile) and Type II. Type II accounts for about 95% of the 20 million cases of diabetes in the U.S. Diabetes is can be a disabling and deadly disease, but not because of the blood sugar fluctuations per se. High blood sugar damages blood vessels, which in turn damages the organs they supply.
We generally divide diabetic complications into two categories: microvascular (small blood vessel), and macrovascular (large blood vessel).
Microvascular complications include things like kidney failure, blindness, and nervous system damage (such as painful peripheral neuropathy which causes numbness and burning especially of the feet).
Macrovascular complications include strokes and heart attacks. Heart disease and stroke account for about 65% of deaths in diabetics.
Prevention of these complications has been the goal of diabetic treatment for years. Large-scale studies of type I and type II diabetics have shown that better control of blood sugar levels (to an extent: data indicate that being too aggressive can increase mortality) reduces the incidence of microvascular complications) . Control of cholesterol and blood pressure have been shown to prevent macrovascular complications in type II diabetes. (DCCT and UKPDS)
What does this mean in the day to day life of a diabetic? One of the most devastating complications of diabetes is amputation, which is often due to both the macrovascular and microvascular complication of peripheral neuropathy. This can begin as a tingling, burning pain in the feet, but can lead to loss of sensation. Small injuries can rapidly become limb-threatening. (Warning: Yucky picture under the fold)
In 2002, over 80,000 amputations were done on diabetics. Evidence suggests that we have the ability to prevent one-half to two-thirds of amputations. Prevention includes yearly foot exams by a medical professional, including simple tests of sensation and blood flow. Evidence supports that prompt referral to a podiatrist for specialized foot care and cessation of all smoking can help prevent amputation.
I recommend that all my diabetics check their feet daily, with a mirror if necessary, and call me promptly with any problems. I examine their feet every three months, and encourage them to follow up with a podiatrist.
So that’s that. Sort of.
Diabetic peripheral neuropathy (DPN) is often a precursor to foot ulceration and amputation. The evidence supports control of blood sugar as the primary way to prevent neuropathy, and the above interventions to prevent complications. There are a number of drugs that can be used to treat the symptoms of DPN, although none is perfect. There is also interest in newer agents, such as alpha-lipoic acid, in the treatment of DPN. But now, one of the health gurus at the Huffington Post is weighing in, and the information is wrong, and probably dangerous.
Robert Kornfeld is a podiatrist. For all I know, he is an excellent podiatrist. But his knowledge about diabetes is incomplete. Like many alternative medicine practitioners, he falsely equates the benefits of behavioral changes with a lack of benefit of medical therapies:
In my opinion, one of the biggest misconceptions in modern medicine is the assumption that diabetes can be controlled by medication alone. The truth is that it simply can’t be. Somehow our culture has developed this fantasy that people can eat anything they want, do no exercise, and any health complications will be resolved with a few pills or injections. Nothing could be further from the truth.
His opinion is not the same as evidence. “The truth” is that diabetes can, and often is, well-controlled by medicine alone. This isn’t because real doctors prefer it that way; it is because many diabetics cannot adhere to diet and exercise programs, and many diabetics do not have enough pancreatic beta cell function left to avoid medications. Kornfeld’s musings on the limitations of various sorts of laboratory measurements are interesting, but are simply his opinion. We can and must have proxy measurements for diabetic control. Fasting blood glucose and hemoglobin A1C have been studied extensively, and rising measurements directly correlate with the pathologic vascular changes of diabetes. This, and the fact that it is possible to correlate peripheral neuropathy and measurements of glucose control such as HbA1C renders Kornfield’s beliefs moot.
This isn’t to say dietary modification isn’t useful, but to imply that this is the only way to prevent diabetic complications is fallacious. Kornfield goes on to give dietary advice which may or may not be good, but as a professor of mine once said, “there is a reason podiatrists are only licensed to practice below the leg.” His assertion that organic foods are less “toxic” and an important part of a diabetic diet is simply ridiculous.
As the image above should illustrate, diabetes is a serious problem, a threat to life and limb, and people who litter the world with bad advice are as much a part of the problem as a big piece of chocolate cake—but not quite as yummy.