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Living with Diabetes

By: Darleth Romana-Bantiles, MDLiving with Diabetes

Diabetes is a chronic illness that impairs a patient’s body to metabolize sugar (glucose) for energy. Long-term management, characterized by a stable blood sugar level, is necessary to avoid complications that not only affect the quality of life but may decrease productivity and even have debilitating or fatal consequences.
If you have diabetes, it is a good thing to check whether you have experienced any of the following symptoms:
Tingling or numbing sensation in the hands and feet
Heaviness on the limbs
Cracked or dry shiny skin on the legs and feet
Change in the color of your legs 
Leg cramps that are becoming frequent with exertion, and relieved by rest
Hair loss on your feet and legs
Slower growth of your toenails
Erectile dysfunction in men
Poor pulses especially in the lower extremities
Wounds on the extremities that do not heal 
Having experienced any of those mentioned may be an indication that a person with diabetes has Peripheral Arterial Disease (PAD). This condition of the blood vessels is characterized by numbness or pain/cramping on exertion because there is decreased flow of oxygen to the muscles due to blood vessel blockage. PAD is a chronic and lifestyle-limiting disease that commonly occurs in diabetic patients. The American Diabetic Association (ADA) estimates that 1 in every 3 persons with diabetes (and above the age of 50 years) has PAD. It is just unfortunate that most patients do not detect PAD during the initial stages, because of the numbing symptom associated with it. Most patients will seek to consult and get diagnosed with PAD, only when their legs are already gangrenous or there are large ulcerations. It is also important to detect PAD early on because it is an independent predictor of inadequate blood supply in the vessels of the heart and brain (cardiovascular ischemia and cerebrovascular ischemia, respectively). Simply put, having PAD increases a diabetic patient’s risk for heart attack or stroke. 
Altered metabolism causes changes in the vessels
Nitric oxide (NO), which causes dilation of blood vessels, is decreased in diabetic patients. Conditions that may affect NO amounts in the arteries of these people are increased blood sugar, an excess of free fatty acids and insulin resistance. Aside from reducing concentrations of NO, the diabetic state also increases the production of endothelin-1, a potent compound that narrows the blood vessels. Diabetes also enhances blood clotting that may narrow vessels further.
Having mentioned the mechanisms involved in the development of PAD among people with diabetes, there are several factors that have been identified to aggravate blood vessel disease, namely: smoking, hypertension, and persistently high cholesterol and sugar levels in the blood.
To evaluate PAD in diabetic patients, their medical history will be reviewed and a physical exam will be performed by a physician. Cramping pain, any ulceration on the legs, ankle systolic blood pressure, brachial artery blood pressure and peripheral pulses will be thoroughly assessed. The ADA recommends that people with diabetes, older than 50 years of age, have their ABI (ratio of the ankle systolic blood pressure divided by the brachial artery blood pressure) measured and re-checked every 5 years. However, persons with diabetes, who are younger than 50 years of age, may also have their ABI checked when they are overweight and have high blood pressure, high blood cholesterol levels, a personal or family history of heart attack or stroke, and are smokers. The ankle-brachial index (ABI) ideally shows a higher blood pressure in the ankle area, over the arm blood pressure. The normal ABI is 0.91-1.40. When the value is lower, PAD should be highly suspected.
There are several imaging techniques that can also be used to diagnose PAD:
Angiogram. A dye is injected into the blood vessels thru a catheter and x-rays are taken to show whether arteries are narrowed or blocked.
Ultrasound. Sound waves are used to produce images of the blood vessels on a viewing screen.
MRI (magnetic resonance imaging). Special scanning techniques are utilized to detect blockages within blood vessels.
Lifestyle changes beyond sugar control
When PAD ensues and is not managed, limb amputation may be a possibility. In fact, most amputations in diabetic patients are due to severe PAD. Moreover, when a person with diabetes also has other conditions like hypertension and high blood cholesterol, graver consequences of PAD could be fatal. Poor circulation and blood vessel narrowing in the heart may lead to a heart attack, while a stroke could happen when the brain blood vessels are involved. 
The importance of avoiding spikes in blood sugar levels cannot be overemphasized in the prevention and management of PAD. Glycosylated hemoglobin (HbA1c), a good measure of blood sugar control for around 3 months, is recommended to be <7.0% by the ADA to avoid blood vessel complications. Some practical ways to ensure good blood sugar control are:
Being more physically active
Maintaining a healthy body weight
Eating a diet low on salt, fat, and carbohydrates
Complying with the doctor-prescribed schedule of taking supplements and medications
However, once PAD is suspected, smoking cessation and management of hypertension and lipid issues are also needed. According to research, smoking duration (similar to diabetes chronicity) is directly correlated to development and progression of PAD. Smoking is considered the most important risk factor for PAD. If a person with diabetes also has hypertension and high cholesterol levels, all the more a balanced diet should be eaten. Medications or supplements for the said conditions may also be taken for better health management.  
Regular inspection and care of the feet and skin will go a long way in the prevention of wounds and infections. Diabetic patients should always be on the lookout for sores, rashes or blisters, and any painful or red areas on the feet. 
Very severe cases of PAD may require surgery to redirect blood flow around a blockage. Blockages may also be managed with angioplasty, a procedure utilizing a catheter with a balloon device that is inserted and inflated in the blood vessel to clear it; in some cases, a stent may be placed inside the blood vessel to also keep it open efficient blood flow. Medications to increase blood flow in the vessels may also be prescribed to patients with severe PAD. There are drugs that dilate the vessels, while there are also some that make blood thinner and allow better flow all throughout the body. Gingko may also be taken with a doctor’s supervision, as it is known to provide a blood-thinning effect. A supervised exercise training program may also be started by a patient with PAD, to facilitate long-distance and pain-free walking. Regular exercise improves oxygen utilization by the body and relives the PAD symptoms.
With or without PAD, a person with diabetes will definitely benefit from making lifestyle changes and adopting healthier habits. Smoking cessation, having a balanced diet, increasing physical activity, keeping an ideal body weight, compliance with prescribed medications and supplements, and having regular medical evaluations are all for the best. After all, even a chronic condition should not hamper anyone from having the highest quality of life possible.
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