The facts are devastating. Diabetes is the number one cause of nontraumatic amputations among Americans, with over 86,000 lower-extremity amputations occurring each year. That is about 236 lower-extremity amputations every day!

The good news is that it is often possible to prevent these amputations. Reliable and simple risk factors can identify those among the estimated 16 million Americans with diabetes who are at special risk for foot ulcers that often lead to amputations, and, with proper care, about 50 percent of lower-extremity amputations in people with diabetes can be prevented. Even when complications are already present, we can do a lot to stop them from getting worse.

Most people think of diabetes mellitus in two major forms: type 1 or type 2. Type 1 diabetes, previously called juvenile-onset or insulin-dependent diabetes, typically occurs in people under age 30 and it happens much more frequently in the white population than in minority communities. It seems to be caused by an autoimmune or “self-destructive” process involving the beta or insulin-producing cells in the pancreas. Because these cells are destroyed by the body’s own immune system, people with type 1 diabetes have to take insulin to replace what the beta cells no longer make. Stopping insulin replacement in these people results in a rapid breakdown in fat and muscle tissues, with severe acidosis (too much acid in the body) and coma.

Type 2 diabetes, previously called adult-onset or non-insulin-dependent diabetes, typically appears after age 40 and is closely associated with weight gain and physical inactivity. Type 2 diabetes accounts for at least 90 percent of all cases in the United States and is especially common in minority communities. Proper diet and activity, along with oral medications, can often control the blood sugar in people with type 2 diabetes; however, as the disease progresses, these people might also need insulin treatment.

While the basic causes of these two common types of diabetes are different, they both result in abnormal body metabolism (especially high blood sugars), abnormal fat metabolism and often high blood pressure. If the abnormal metabolism cannot be brought under reasonable control with diet and medicine, people with both types of diabetes can develop complications, including eye, kidney, nerve, feet, and heart problems.

Scientific studies, however, indicate that if people with diabetes tightly control their blood glucose, blood pressure, and blood fat levels, their chances of developing these problems can be significantly decreased. We have also learned that detecting changes in foot shape, sensation, and blood flow, with three relatively simple and inexpensive office tests, allows us to predict those who are at greater risk to develop ulcers and amputations.

Living with diabetes is a daily challenge. Many things people take for granted, such as eating any time and exercising freely, become real problems for people with diabetes, who must carefully balance food, physical activity, and medication to prevent complications.

Diabetes also poses problems for us as a nation. First, the prevalence of diabetes has increased dramatically over the past decade in the United States and throughout the world. By the year 2025, the five countries with the highest incidence of diabetes will be India, China, the United States, Pakistan, and Indonesia. In the United States, there has been a 33 percent increase in the frequency of diabetes over the last eight years; at the same time, there has been an increase in weight gain and physical inactivity. This increase in the number of people with diabetes represents new cases, not just better detection of those with diabetes.

Secondly, the onset of diabetes, especially type 2 diabetes, seems to be occurring at younger ages. In the past, people were typically in the 50s when they were diagnosed with type 2 diabetes. Now we are seeing a greater increase in diabetes among people ages 30 to 39, which means that they will have the condition for a longer time.

Finally, we are concerned that with more cases of diabetes of longer duration, we will see more of the potentially devastating complications, including nerve and foot disease – and, ultimately, more lower-extremity amputations.

Facing these scientific data and concerns, we must ask ourselves what the public health community is doing about these problems. Government agencies and the private sector have different responsibilities to address the challenges of diabetes by finding a cure or preventing the disease.

Recently, there has been a lot of media coverage around the possibility of a “cure” for type 1 diabetes. In an important study from Canada, several patients with longstanding type 1 diabetes received injections of isolated beta cells (insulin-producing cells obtained from recently deceased individuals). These patients also received special experimental medicines to prevent rejection of these “foreign cells,” and after about a year, they were able to control their blood sugars without insulin injections. A much larger study is now in progress where people with type 1 diabetes are receiving the so-called “Edmonton protocol.” The results of this study should give us important information about how effective this approach is.

There are, unfortunately, no promising long-term scientific studies supporting a “cure” for type 2 diabetes, which has a different disease process from type 1.

Research on primary prevention falls within the purview of the National Institutes of Health (NIH). Important and exciting clinical trials are under way to determine how both types of diabetes can be prevented, and results are expected in a couple of years.

Once reliable scientific studies are published and discussed, it becomes primarily the responsibility of the CDC to “translate” the findings into communities through programs that will improve the daily management of diabetes. The CDC supports 59 Diabetes Control Programs (DCPs) in all states and territories. These DCPs, in cooperation with many partners – such as the American Diabetes Association (ADA) and the American Association of Diabetes Educators (AADE) – work through community education projects to help people keep abnormal metabolism in check. With this strong base of scientific information, other government and private sector programs can also improve their delivery of care for people with diabetes and foster improved insurance coverage for these prevention programs.

Sometimes, however, despite valiant efforts by everyone, diabetes complications still develop. Once they do, CDC programs strive to identify them early and treat them aggressively to prevent progression.

We are all working for and anticipating the great day that we will find a cure for diabetes or successful ways to prevent it. But today, we can do a better job in helping people with diabetes keep their limbs and lead satisfying, productive, and happy lives. To accomplish this, we must work together toward this goal every day. What can you do to help? If you have diabetes, get regular treatment and follow your health professional’s advice to prevent severe complications. Reach out to family and friends and encourage them to be physically active and pay attention to their nutritional needs to prevent obesity and maybe diabetes.

For more information about diabetes, call the CDC’s Diabetes Inquiry Line toll-free at 1- 877-CDC-DIAB or 232-3422 (English and Spanish) or visit the Web site at www.cdc.gov/diabetes

About the Author:

Frank Vinicor, MD, MPH, is director, division of diabetes translation, Centers for Disease Control and Prevention, Atlanta, Georgia.

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