Diabetic foot ulcers: a silent killer of veterans

By David G. Armstrong

[Original Article]

Veterans who survive the horrors of war or the other dangers of military service often die years later from a silent but deadly scourge: diabetic foot ulcers, open sores or lesions that typically start on the bottom of the foot.

About 40% of people afflicted with this problem die within five years. The annual cost to America’s health care system for treating complications of these foot ulcers is greater than treating the five most common types of cancer, and are responsible for the vast majority of non-combat amputations seen among veterans. Yet too little is being done to prevent them.
One way to honor our military veterans on this Veterans Day and to care for them in the years to come is to invest more in targeted research to learn why foot ulcers are so common in people with diabetes and why they recur so frequently, as well as to embrace new ways to prevent them from occurring.

I first encountered diabetic foot ulcers as a fourth-year student in podiatric medicine when I was assigned to a Veterans Affairs medical center in Los Angeles. One of my patients, a veteran with diabetes, had a callus — an area of thickened skin — on his foot. It was about the size of a dime and was so generally insignificant that it would normally be ignored, but something about it didn’t look right. As I trimmed this bump of toughened skin, I identified an infected abscess and an ulcer. 

We treated the ulcer without the use of anesthesia because this patient had lost the ability to sense pain in his feet, a condition called neuropathy that is common for people with diabetes and that contributes to the development of foot ulcers. In an individual without diabetes and neuropathy, a callus would cause a painful pressure point. A person with diabetic neuropathy won’t feel that pain and will literally wear hole in his or her foot, as you or I might wear a hole in a shoe or a sock. When it comes to diabetes, what you can’t feel can hurt you.  

​All this patient told me was, “Thank you, son. I so very much appreciate you looking after me.”

Today, I have the privilege of looking after a center at the University of Southern California that spans four hospitals and a diverse population of some 10 million people. The lessons learned from that one patient, however, can be applied every day in my practice.

The most common reason someone is admitted to a VA hospital is diabetes. In fact, 60% to 70% of hospitalized veterans in the United States have this disease. And the complication of diabetes that is most likely to cause veterans to be admitted to a treatment center is an infected foot ulcer. Much of this happens in silence, as these patients, who often have a great tolerance for pain to begin with, further lose the feedback because of diabetic neuropathy.

Because of the silent nature of diabetic foot ulcers, they represent a big problem that few have heard of. People don’t drop dead from a “foot attack” like they do from a heart attack, but they are dying from them all the same. Indeed, after an amputation, an individual may not get out of bed much in the following months, or even years, causing his or her overall health to deteriorate, culminating in death from a stroke or heart attack. Although a foot ulcer precipitated this awful spiral, it is not recorded as a cause of death, obscuring its contribution to the death. 

Approximately 40% of individuals with diabetes who develop a foot ulcer get another one within a year. Two-thirds will get another one within three years, and three-quarters will get another within five years. Just as with cancer, men and women with diabetic foot ulcers aren’t healed — they are in remission.

Despite how devastating these ulcers are for those who suffer from them, and despite the massive costs they incur on the health care system, too few research dollars go toward understanding or fixing them. The National Institutes of Health spends about $1 billion per year on diabetes research, a relatively small amount considering that diabetes is a $300 billion problem. But the NIH spends just $1 million per year on lower-extremity diabetic research even though problems with the lower extremities are responsible for thousands of times that in annual diabetes costs.

Fortunately, the VA is highly aware of the seriousness of diabetic foot ulcers. In fact, it is a pioneer when it comes to treating them, employing all kinds of next-generation technologies and textiles that can detect the beginnings of a diabetic foot ulcer and give patients, patient’s families, and even their care teams an early warning.

Until we find the root cause of diabetic foot ulcers and identify highly effective ways to prevent and treat them, what we really need is a subscription prescription: making preventive items such as socks, shoes, and bandages available through a monthly subscription package, just like getting Netflix or Spotify. Such items are essential for helping stop the development of diabetic foot ulcers, mainly because they minimize pressure points when patients walk. If this type of service was readily available, patients with limited mobility or resources would be able to get the essentials they need when and where they need them.

​Veterans have always been near and dear to my heart. One of my grandfathers served in World War I, and the other served in World War II. Both received quality care from the VA. I am proud of the VA’s efforts to treat and prevent diabetic foot ulcers today, but the thing that’s holding it back from doing even more is education: addressing the funding disparity in diabetes research begins with awareness.

I’m confident that those who learn about the threat this quiet killer poses to veterans will want to take action. Our veterans are counting on it.

​David G. Armstrong is professor of surgery and director of the Southwestern Academic Limb Salvage Alliance at the Keck School of Medicine of the University of Southern California.