The Critical Relationship Between Diabetes and Leg Amputations, By Mukaila Kareem
The mantra about “exercise is medicine” is true but it lies in understanding the various metabolic pathways by which the body burns energy substrates, as opposed to counting calories and taking advantage of other functions of contracting muscles, which are separate and apart from the conventional locomotor apparatus of the movement stereotype.
The art of physiotherapy evolved slowly to rehabilitate the wounded soldiers and physically impaired children through the tragic combinations of the two World Wars and polio epidemic. It is now a well-respected evidence-based profession, and physiotherapists are often referred to as experts in movement. To mark the World Physiotherapy Day on September 8, I was invited by the Nigeria Association of Physiotherapy Students (NAPS) to deliver a Zoom presentation titled “21st Century Physiotherapy in Reversing Modern Chronic Diseases.” As I was preparing for the for the presentation, I was determined to overcome these two challenges: first, as a village boy from my home state of Osun, I still struggle mightily when it comes to technology and the virtual presentation sometimes feels like soliloquising, as it lacks the full physical human interaction with the audience. Second, being a former NAPSITE, I am aware that NAPS membership is open to both pre-clinical and clinical students, and given how broad the topic was, I wanted to make sure the presentation was understandable without too much medical terms and not lose the pre-clinical students.
The crux of my presentation was that conventional medical practice, based on the germ theory of disease, is highly effective in curing all kinds of infectious diseases but is not suited for curing modern chronic diseases, such as hypertension, diabetes and heart diseases. I made them aware that the difference between acute (infectious) and chronic (modern) diseases is that the treatment goal is to cure acute conditions, while the principal goal in chronic diseases is not to cure but to control or manage these conditions through expensive multiple medications, until they progress to complications, such as physical impairment and even death, hence the term ‘chronic’ or ‘noncommunicable diseases’.
As would-be physiotherapists or experts in movement, especially in 21st century, I tried to sensitise them that beyond movement, the skeletal muscle is not only the largest organ in the body but it is the biggest organ in blood sugar clearance to prevent diabetes, and that through regular activity, contracting muscle also functions as endocrine and immune organ to prevent modern chronic diseases. As such, these functions need to be harnessed because modern chronic diseases cannot be cured or prevented by medicine, and in the words of a renowned endocrinologist, Dr. Robert Lustig, “there is no medicalised prevention” for chronic diseases, which are often called the diseases of physical inactivity, metabolic disease, lifestyle disease or the disease of civilisation. These terms make it clear that these diseases are uniquely ours and are rarely found even in the presently dwindling hunting and gathering societies.
…excessive accumulation of sorbitol inside nerve cells leads to nerve damage and the loss of sensation in the feet, which accounts for most of the leg amputations in patients with diabetes. This so called “sorbital or polyol pathway” also contributes to blindness, kidney damage and erectile dysfunction in patients with diabetes.
I should add the unanticipated technical hitch that got me on a second speaker slot and the added challenge of wrapping up my presentation before 8 o’ clock a.m. Eastern U.S. time for the daily mandatory office meeting. I was however pleased with the quality of questions I got, particularly one that had to do with the connection between non-healing foot wounds and amputations in people with diabetes. This was directly connected to my presentation on how nerve fibres do not depend on insulin to pick up glucose, a profound nerve characteristic that is not understood by the general population and is yet to be well explained by the health community to prevent diabetic complications. Nerve cells have no capacity for fuel storage and in persistent high levels of blood glucose, these cells helplessly convert excess glucose to a sugar alcohol called sorbitol, an intermediate substance, which would normally be converted to fructose in liver cells to make fat for future energy needs. Therefore, excessive accumulation of sorbitol inside nerve cells leads to nerve damage and the loss of sensation in the feet, which accounts for most of the leg amputations in patients with diabetes. This so called “sorbital or polyol pathway” also contributes to blindness, kidney damage and erectile dysfunction in patients with diabetes.
As a physiotherapist of more than three decades, I have seen far more preventable amputations than I can remember. Here is a depressing fact by Foluso Fakorede, a Nigerian-American cardiologist practicing in Mississippi: In United States, “approximately 200,000 non-traumatic amputations occur… Every 17 seconds someone is diagnosed with diabetes, and everyday 230 Americans with diabetes will suffer an amputation.” Furthermore, according to Dr. Fakorede, “throughout the world, it is estimated that every 30 seconds a leg is amputated and 85% of these amputations were the result of a diabetic foot ulcer”.
…my message to the young physiotherapy students, as future professionals, was to follow the tradition with which our profession responded to war injuries from the two World Wars and physical impairments from polio epidemics in the past generation. This can only be achieved through commitment to learning…
The United States spent a whopping $3.6 trillion in healthcare alone in 2018. Nigeria, a developing country, projected to surpass the U.S. population in 2050, cannot afford this enormous cost. Therefore, my message to the young physiotherapy students, as future professionals, was to follow the tradition with which our profession responded to war injuries from the two World Wars and physical impairments from polio epidemics in the past generation. This can only be achieved through commitment to learning, and as my favourite professor charged my classmates at the end of our last and final day of doctorate programme: “we have the right to learn.”
Again, my thanks NAPS for the invitation and kudos to the student who asked the critical question that generated this article. The mantra about “exercise is medicine” is true but it lies in understanding the various metabolic pathways by which the body burns energy substrates, as opposed to counting calories and taking advantage of other functions of contracting muscles, which are separate and apart from the conventional locomotor apparatus of the movement stereotype.
Mukaila Kareem, a doctor of physiotherapy and physical activity advocate, writes from the U.S.A and can be reached through firstname.lastname@example.org