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made up of calcium, cholesterol, fat, and other substances found in the bloodstream. People without diabetes get this thickening and hardening of the arteries as well, but unfortunately these problems can happen sooner and can be more severe in people with diabetes. PAD is 20 times more common in people with diabetes than in the general population. Other things that put you at risk of developing PAD are smoking, poor nutrition, lack of exercise, high blood fat levels (including cholesterol), and high blood glucose levels. Gangrene, or the death of tissues, is the most serious stage of PAD.

      You can help to avoid or limit PVD by stopping smoking and keeping your blood fats and blood glucose levels as close to normal as possible. See a registered dietitian (RD) for help with your meal plan and add more physical activity to your lifestyle.

      Your primary care physician, your endocrinologist, and your podiatrist should check you for PAD at least once a year. He or she will ask about cramping in your legs when you walk and will examine your feet and legs and feel for pulses, located in the groin, behind the knee, at the ankle, and on top of the foot. You may need to have the blood pressure in your ankles, arms, legs, and toes checked. (The arteries in toes don’t get stiff, so measuring blood pressure there may be more accurate.) A Doppler machine may be used; this test is painless. Some experts suggest that people with diabetes who are over the age of 50 should have a baseline Doppler exam (also called an ankle brachial [arm] index) to compare the blood pressure in their feet and arms. You may need a test to measure how much oxygen gets to the skin of your feet.

      If you have an ulcer that won’t heal, or areas of your foot that break down despite wearing properly fitted shoes, you may need special X-rays and scans. These tests take pictures of the blood flow from your thigh to your toes. For arteriogram X-rays, you get an intravenous injection of a special solution so that the blood vessels show up clearly on the X-ray. This solution is called “dye,” although it really does not change the color of anything. People with poor circulation should consult with a vascular surgeon—a doctor who specializes in this type of problem. If you have questions, ask your provider and the people performing the tests to explain things to you.

      The hallmark sign of poor circulation is pain or cramping in the calf or the thigh (usually the calf) that occurs when you walk a short distance. This pain is a sign that the muscles are not getting enough oxygen. If you slow or stop and rest for a few minutes, the oxygen supply usually catches up with the demand and you can walk a little farther before the pain reoccurs. The medical term for this condition is “intermittent claudication.” Claudication is similar to angina in people with poor circulation to the heart, except it occurs in the leg muscles. With angina there is chest pain that is relieved by resting the heart.

      Other signs of poor circulation are pain at rest, nonhealing ulcers, absent or weak pulses in the feet or legs, a decrease in blood pressure in the feet and legs, or a lack of hair growth on the lower legs. A blue or purplish color, especially when your feet are hanging down, is also a sign of circulation problems.

      If you think you may have poor circulation, ask your provider to evaluate it. Poor circulation is caused by a blockage in the arteries supplying blood to the feet. The blockage may need to be removed or bypassed with vascular surgery. A simple treatment is to walk every day. This exercise can force the body to form new blood vessels and improve the circulation in your feet and legs. Having poor circulation in your feet also puts you at greater risk for heart disease.

      Cold feet may be a sign of poor circulation; however, many things can cause cold feet, so it’s not necessarily a circulation issue. If you think you have poor circulation, have your feet evaluated by your health care provider. The best thing to do for cold feet is to wear one or two pairs of thick socks or warm house slippers—but check to be sure that your shoes are not too tight. Try the thin silk socks that are worn under regular socks for added warmth. There are also special socks available that warm feet safely. Getting up and walking around or getting regular exercise helps keep your feet warmer.

      Do not use heating pads or hot water bottles on your feet. Don’t sit too close to a space heater, fireplace, or campfire. If you have any diabetic nerve damage, you cannot feel when your feet are too hot or are getting burned, and you could be badly injured. In addition to making your feet feel cold, nerve damage can affect blood flow and sweating in the feet. It’s best to wear socks and get up and move around.

      Smoking is clearly connected to developing cardiovascular (heart and blood vessel) disease. When you smoke, the combustion products of tobacco are absorbed into the bloodstream. These chemicals stimulate the release of other chemicals, which injure the blood vessels and encourage thickening and hardening of the arteries. Smoking also causes your blood vessels to constrict, or clamp down, limiting the amount of blood that can circulate. Because the constriction of the blood vessels by tobacco lasts for hours, smoking even as few as two cigarettes a day can affect your circulation all day long.

      Smoking and diabetes are a deadly combination for the vascular system. If you have diabetes and smoke you are greatly increasing the risk of amputation! Fortunately, there are many new medications and good programs to help people quit smoking. If you smoke and you’re ready to quit, ask your health care provider to refer you to one of these programs.

      Preventing PVD is much easier than treating it. That is why your health care provider will stress that you quit smoking, keep your blood pressure and blood glucose on target, control your cholesterol and triglycerides, lose weight, and stay active. Your doctor can prescribe some medications to treat PVD. Taking an aspirin a day can help prevent heart attacks and strokes, so some people think that it might help prevent PVD, too. Aspirin is not recommended for everyone and can interact with other medications you may be taking, so ask your provider before you start taking aspirin daily.

      If you have intermittent claudication (pain in your calves with walking), you might be asked to walk even more. Usually you are encouraged to walk to the point of pain, pause, and then walk a little more. Ask your provider to give you instructions. Walking may help stimulate new vessels to grow and this will improve circulation.

      If the tests for PVD show that you have blockage in the larger arteries to your feet or legs, surgeons may try to correct it. One surgery cleans out the artery that is blocked. Another method—angioplasty—involves passing a deflated balloon on a tube to the point where the blockage occurs. The balloon is carefully inflated to open the narrowed artery, and sometimes a stent (a tiny metal device shaped like a spring) is inserted in the artery to keep it open. This surgery is most successful with a small blockage in a healthy artery. A third surgical method is to bypass the blocked area by using a blood vessel from another part of the body (or an artificial blood vessel). While complicated, this surgery can help save a foot, a leg, or a life. People with diabetes often have blockages in the arteries of the lower legs and feet, making it difficult to restore circulation. The relatively new ability to do bypass surgery on the small arteries of the foot has saved many legs. Not all vascular surgeons do this surgery, so check to be sure that yours can. Your providers will carefully evaluate your condition before recommending surgery.

Deformities

      A foot deformity is any change in the normal shape of the foot. For people with diabetes, a deformity may be complicated by the additional risk factors of poor sensation and poor circulation. It is the combination of these factors that can make foot deformities dangerous.

      Common deformities include bunions, hammertoes, claw toes or mallet toes, curving of the toes toward each other, tailor’s bunions, enlargements or bumps of bone behind the heels or on the top or bottom of the foot, and Charcot deformities, which may look like a collapsing of the foot at the arch. These deformities are associated with increased pressure and sheer stress on the skin, resulting in skin breakdown.

      A bunion is a deformity in the joint of the big toe that causes the toe to point away from the arch instead of straight ahead. There is usually an unsightly bump on the inside of the foot, just behind the big toe. It is believed that uneven weight distribution during walking and stresses in the joints cause bunions. Heredity is an issue in the cause of bunions, so if you have a family member who suffers

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