Dangerous Denial

by Tracy Austin, M.D.

When I was a medical student, I met a patient that forever changed the way I looked at diabetes. She was an elderly black woman, visiting our family medicine clinic. It had been a pretty long, uneventful day. Then, a nurse handed me a new patient’s chart. “That is so sad,” was all she said.

As I flipped through the chart, I read that my patient was complaining of a “wound.” I browsed through her list of medical conditions: hypertension, diabetes and osteoarthritis. I also saw that she had missed a follow-up appointment and possibly needed refills on medications. As far as her vitals, her blood pressure was elevated, but everything else—her pulse, her heart rate, her temperature—was normal. I gathered my materials and headed to her room.

I made my way down the hallway to room B, becoming aware of a faint, yet foul odor. As I made my way closer, the odor grew stronger. I paused for a moment, not sure what I was smelling. Then, as I opened the door to room B, I was overwhelmed by the unforgettable odor of rotting flesh. My patient’s foot was necrotic, and although there were many factors leading up to that sad state of affairs, the ultimate culprit was diabetes.

Many Americans are developing diabetes. In fact, they spend many years in a state of pre-diabetes, now termed "America's largest healthcare epidemic.” Pre-diabetes is a condition of abnormally elevated blood glucose, but not levels high enough for the diagnosis of diabetes. As of 2009, there are 57 million Americans who have pre-diabetes.

Diabetes mellitus, most simply referred to as diabetes, is a condition of deficient insulin production and/or the body’s resistance to insulin’s effects. Insulin is what enables cells to absorb glucose. Thus, in diabetes, glucose accumulates in the blood and is not able to be absorbed and utilized, resulting in widespread damage and complications.

There are two main types of diabetes: type 1 and type 2. Type 1 diabetes is an autoimmune-mediated condition. It occurs when a person’s own cells attack the cells that produce insulin. There is no known preventive measure against developing type 1 diabetes. It is estimated that 5-10% of Americans who are diagnosed with diabetes have type 1. Type 2 diabetes, the most common type of diabetes, is characterized by the body’s resistance to insulin’s effects combined with reduced insulin production. Pre-diabetes is a precursor to type 2 diabetes.

There are numerous theories to explain the surge of pre-diabetes and type 2 diabetes in the US. Factors such as increased weight and obesity have been implicated. The rate of obesity in US citizen is increasing, in adults and children. Though it can be caused by uncontrollable factors such as age and heredity, type 2 diabetes is largely a condition that can be prevented and controlled by modifiable factors such as diet and exercise. Unfortunately, the abundant availability of high calorie, unhealthy foods, coupled with poor eating habits and inactive lifestyle, factors that are very common in our country, have largely contributed to the development of pre-diabetes and type 2 diabetes.

Pre-diabetes and diabetes may go unnoticed for years because the symptoms are typically mild, non-existent or sporadic. However, when the condition goes uncontrolled, as in cases of non-diagnosis or non-compliance by patients in treatment, severe long-term complications can result. These serious, and mostly irreversible complications include but are not limited to: kidney failure (diabetic nephropathy), vascular disease (coronary artery disease, ulcers, wound necrosis), vision loss (diabetic retinopathy), sensory or pain deficits (diabetic neuropathy), liver damage and heart failure (diabetic cardiomyopathy). People must understand that diabetes is a serious condition, with serious ramifications. It’s important for patients, with and without diabetes, to take their health seriously and actively work at controlling their blood glucose and maintaining a healthy lifestyle.

The patient I encountered as a medical student was a long-term, uncontrolled diabetic. She had been noncompliant with recommended treatment because of financial difficulties. As a result, she developed diabetic neuropathy and vascular disease. A few weeks prior to our meeting, she stepped on a sharp object. Because she had diminished sensation, due to her diabetic neuropathy, she did not sense pain from the cut. As a result, her open wound went unattended for a couple of days. Additionally, her vascular disease resulted in poor blood circulation and inability for her wound to heal normally. Though she eventually bandaged the wound herself, her condition worsened, but she was mostly unaware of the severity. At the prompting of her son, she came to the clinic for an evaluation. By that time, her wound had become necrotic.

More than anything else, I remember her face. Throughout the entire examination, she smiled and expressed thanks for my care of her. I remember thinking, “Wow, this looks so painful, but she’s smiling and really can’t feel it.” She was a sweet, pleasant woman. Unfortunately, I did not have good news for her; she would have to go to the hospital. As I talked about her condition and prepared paper work to admit her to the hospital, I delicately tried to explain the severity of her wound. She seemed a bit perplexed that diabetes had caused her condition. She admitted that she hadn’t taken her medications as directed, and knew that she could have made better food choices. She looked down at her foot, sighed, and expressed a desire to make more of an effort.

She then asked about what the hospital would do for her wound. I paused, thinking about how to respond. The truth was, I did not know exactly what they would do. I knew the possibilities, but not what they would do definitively. As I began to tell her what tests would be run, and the possible medical treatments, she smiled, happy that her condition would finally be adequately treated. I then took a deep breath before notifying her of another possible treatment, the surgical treatment—amputation. It was at that moment that her warm smile faded. Once again, I became acutely aware of the smell from her flesh. I knew that my words had cut her deeply and I tried to offer some reassurance, but her eyes began to well with tears, and she said nothing. I kept talking, trying to comfort her; I wanted desperately to see her smile again. But there was nothing. I then asked her if she had any questions, but she just shook her head and spoke softly, “No, thank you again for helping me.”

Read more of Dr. Tracy Austin's work at The Kitchen Prescription.