Diabetics Are Urged to Check Legs

There's grim news on the diabetes front: Nearly two-thirds of diabetics aren't properly controlling their blood sugar. And one in three older diabetics likely also has a serious leg disease that could cost their limb — or their life.

This year, specialists for the first time are urging every diabetic over age 50 to get tested for the leg disease, called peripheral arterial disease or PAD.

Testing is simple — just check blood pressure in the ankle. If it's significantly lower than blood pressure in the arm, PAD may be narrowing leg arteries and slowly choking off blood flow.

Severe PAD can lead to amputation. Worse, if your leg arteries are clogged and stiff, your heart arteries are too. Having PAD quadruples your risk of a heart attack or stroke, important to know so you can seek protective treatment.

Anybody can get PAD. At least 12 million Americans are thought to have it, most of them undiagnosed. But diabetes damages the blood vessels in ways that make patients especially susceptible to cardiovascular disease, meaning diabetics are most at risk, concludes an expert panel brought together by the American Diabetes Association.

Studies suggest one in three diabetics over age 50 may have PAD. So the diabetes association panel wants all diabetics that age to get screened for PAD. If results are normal, get rechecked every five years, say the recommendations, published last month in the journal Diabetes Care.

"This is news to a lot of people, even within the diabetes community, that this is really a very prevalent condition that to this point has been under-addressed," says Dr. Peter Sheehan, director of the Diabetes Foot & Ankle Center at New York University School of Medicine, who authored the testing recommendations.

Consider testing younger diabetics if they have other risk factors for PAD: smoking, high blood pressure, high cholesterol, or they've had diabetes for more than a decade, the recommendations say.

Anyone with symptoms of PAD — legs that hurt or tire easily while walking — should seek testing, too. But most PAD sufferers never report symptoms, plus diabetes causes nerve damage that can blunt those patients' ability to feel the warning pains.

"It doesn't come up until complications start to set in," warns Joseph Carpenter of East Hanover, N.J., whose PAD was diagnosed only after he needed a triple heart bypass.

Treatment includes exercise and blood thinning medicine for the legs plus therapy to reduce the heart-attack risk. For severe leg blockages, surgery to bypass the clogged artery can save the limb.

Diabetics may have to ask for the PAD test, called an ankle brachial index. It's unlikely that primary care physicians yet have heard to add it to the list of tests for diabetics.

Another exam, the A1C check, given every three months, shows blood-sugar averages, the best measure of how well diabetes is controlled.

Just 37 percent of the nation's 18 million diabetics have optimal control, an A1C level below 7, says the government's new National Healthcare Quality Report.

A normal A1C level is a score of 6. U.S. diabetics average a 9, minimal control. Specialists recommend striving for at least 7, because every point-drop lowers the risk of severe diabetes complications by 40 percent.

Yet 13.5 percent of diabetics have A1C levels that surpass the very dangerous 9.5, the government says. By one recent estimate, at least 13,000 lives a year could be saved just by improving those worst-case levels.

That's a huge underestimate, says a frustrated Dr. James Gavin, head of the National Diabetes Education Project. Far more lives could be saved if more diabetics aimed for optimal instead of minimal control, but too few physicians push that message, he says.

So what should patients do when their A1C comes back above 7?

"This is something you should not really tolerate without taking some action for more than, say, a six- to eight-week period," Gavin says.

First, check your schedule. Could it be a temporary spike due to unusual stress or special occasions like holiday parties?

If not, increase daily blood-sugar monitoring. Getting optimal A1C levels requires daily blood glucose measurements of 90 to 130 before meals, or less than 180 two hours after a meal.

Knowing when you exceed those levels shows where to adjust treatment, such as diet, a dose increase of oral medicine, or adding some form of insulin.

Too often, patients with the most common form of diabetes, Type 2 or adult-onset, save insulin as a last-ditch resort when using it sooner could keep them healthier, Gavin says. He cites an endocrinology practice that got its 100 patients below an A1C of 7 in just six months, mostly through more aggressive insulin use.

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