Can Shoes Be “Tiny Coffins”. Yes, they can.

(Please read comment section below. Author Chris McDougall has posted an informative comment and added to the quotes seen in Born To Run.  I’ll extract from the quotes, but be sure to read the comment. (If it says “comments closed”, which the blog does automatically at a set time interval, please click on the blog title which will open this entry in full, with the comments visible.) The thrust of this blog entry will remain the same. For me the deadly shoes I’m speaking of point to the neuropathic foot which was a large part of Paul Brand’s professional life work. )

Paul Brand, M.D. (1914 – 2003) was quoted by Chris McDougall in Born To Run as essentially saying that if everyone stopped wearing shoes, his office would be less busy and most foot problems would disappear in a generation.

Paul Brand 2002

While many may think Paul Brand had an ordinary waiting room, he did not. Brand did not specialize in treating the usual foot problems. He was a brilliant innovator on the special problem of diseases which cause loss of pain sensation via neuropathy.  He worked for many years at the National Hansen’s Disease Center at Carville in Louisiana. He specialized in  the orthopedic treatment of Hansen’s Disease (leprosy). Among other innovations, his work led to contact casting to help heal ulcers in feet with neuropathy, such as diabetics and those with Hansen’s Disease.  He contributed a good deal to knowledge about the significance of neuropathy in the creation of ulcers and to the care of insensitive feet. (Brand also worked extensively on hands with problems related to neuorpathy and insensitivity.) These neuopathies also affected strength rations of opposing muscle groups which often led to significant foot problems including hammer toes and bunions. Insensitivity combined with altered biomechanics, physical deformity, create special problems in walking and wearing shoes, particularly ones that are not fit well and do not serve to balance areas that are overloaded by pressure (pressure points on toes, hallux valgus, or on the plantar surface (metatarsal area or any other part of the bottom of the foot).

Brand worked with patients whose shoes often did create significant and even life threatening problems. Lacking sensation, because of neuropathy, they couldn’t feel the blisters, ulcerations, and infections developing. Another one of his sayings was “Pain is god’s greatest gift”. A shocking statement, but he said that because those lacking normal sensation did terrible damage to themselves.

As tiny coffins in this case, the shoes which caused the problem could lead to an amputation of a foot or leg in a diabetic which would lead to a second amputation more than 50% of the time within 2 years. Amputation in diabetics also is known to have a high mortality rate over 5 years (up to 74%, note that bypass operations may help). Slow healing ulcers have a death from all causes mortality of up to 50% within 5 years. This is worse than many forms of cancer.

Chris McDougall has provided some direct quotes, ( I believe from one of Brand’s biographical works – which will is now added to my reading list.) I’ll add some of those here. For the remainder, please be sure to read the comment section.

“A high proportion of the world’s population walks barefoot most of the time, and the average person who walks barefoot has much healthier feet than the average person who wears shoes.”, said Dr. Brand. Speaking of his own personal experience he said that “The barefoot walker receives a continuous stream of information about the ground and about his own relationship to it, while a shod foot sleeps inside an unchanging environment. Sensations that are not used or listened to become decayed and atrophy. There is a sense of aliveness and joy which I experience walking barefoot that I never get in shoes.”

Chris reports that Dr. Brand said this of normal people in normal shoes. And adds that Dr. Brand was a proponent of barefoot walking and sports. We will accept that as Dr. Brand’s opinion and statement and warn people who do suffer from pain insensitivity to not take this as advice directed at them. They are usually given special advice to not go barefoot, and in many cases to have carefully designed shoes, often custom, with special insoles or diabetic orthotics designed to decrease pressure, and to lessen excessive pressures over areas at risk. In spite of this care problems may still develop and this is only a cursory and incomplete look at these problems and their causes.  Patients with pain insensitivity must perform a self-inspection daily.

I was lucky to meet Dr. Brand in 2002 at the American Podiatric Medical Association meeting in Seattle, Washington. Dr. Brand opened a special section on insensitive feet which included presentations by his former prodigies on their current work. While I spend more time working with athletes, all knowledge is helpful, and Dr. Brand was a true icon.

While I scoffed the other day at  the quote in the New York Times about shoes as tiny coffins that halted evolution, in cases like these they truly are tiny coffins. They could cause your loss of limb and ultimately put you at a much higher than normal risk of death. Seeing the New York Times quote calling them “tiny coffins” did immediately make me think of the neuropathic foot. We’ve previously discussed the cost of amputation. We also see that diabetic ulcers and amputation are also deadly problems.

Preventative care, helpful? Yes, of course.  Make sure it gets properly included in any health care reform. Medicare ( a government run system) includes special shoes, non-custom inserts, yearly foot checks, and some  insurance carriers include this also. Some policies cover custom orthotics for diabetics, but not for runners. The policies and medicare aren’t quite up to speed but they are improving. Make sure that encouraging healthy life habits and preventative care is incorporated in some fashion and included as a core feature in future health policy to assist in decreasing the overall cost of care and in particular the cost of chronic illness. If you are diabetic, get your feet checked regularly, check them yourself, and learn how to both check and care for them. Exercise as recommended by your physician, and make sure you eat correctly, and monitor and control your blood sugar appropriately. Follow advice from your podiatrist on what foot wear  and socks are best for you.

For the runners, I expect you should shortly find here some blogs on what bad can come to you from your shoe, and what steps to take.

References:

Diabetic foot ulcers: prevention, diagnosis and classification.
Armstrong DG, Lavery LA. Am Fam Physician. 1998 Mar 15;57(6):1325-32, 1337-8.

Evaluation of Removable and Irremovable Cast Walkers in the Healing of Diabetic Foot Wounds: A randomized controlled trial. D. G. Armstrong, L. A. Lavery, S. Wu, and A. J.M. Boulton. Diabetes Care, March 1, 2005; 28(3): 551 – 554.

Revisiting the Total Contact Cast. Maximizing off-loading by wound isolation. Petre, M, Tokar, P, et. al. Diabetes Care  April 2005   vol. 28  no. 4  929-930

The total contact cast. A therapy for plantar ulceration on insensitive feet
WC Coleman, PW Brand, and JA Birke. J Am Podiatr Med Assoc, Vol. 74, Issue 11, 548-552, November 1, 1984

Mortality rates and diabetic foot ulcers. Robbins JM, Strauss G, Aron D, Long J, Kuba J, Kaplan Y. J Am Podiatr Med Assoc. 2008 Nov-Dec;98(6):489-93.

What is the most effective way to reduce incidence of amputation in the diabetic foot? Apelqvist J, Larsson J. Diabetes Metab Res Rev. 2000 Sep-Oct;16 Suppl 1:S75-83.

Diabetes Res Clin Pract. 1997 Jul;37(1):41-7. Mortality following lower extremity amputation in minorities with diabetes mellitus. Lavery LA, van Houtum WH, Armstrong DG, Harkless LB, Ashry HR, Walker SC.

Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. Moulik PK, Mtonga R, Gill GV. Diabetes Care. 2003 Feb;26(2):491-4.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Faglia E, Favales F, Morabito A. Diabetes Care. 2001 Jan;24(1):78-83.

The Numbers You Can’t See

These are the hidden numbers. This is the truth from the recent Washington Post/ABC poll on opinions entitled “What Do Insured Think of Health Reform”. Three questions asked and three answered by a significant majority who clearly are positive on health care reform  in spite of all the negatives spun every hour on every station and in every newspaper. And we wonder why other polls have the papers dying, surviving only on life support.

Here are the numbers graphed from the poll.

Majority favors health care reform. Minority in panic mode.

Those are the real numbers which include those who believe their coverage, costs, and quality of care will be the same, no better, no worse, with the proposed health care reforms. A solid majority still believes that health care reform will not leave them worse off, not cost more, and will not provide worse quality of care. Every hour we hear and read more and more misleading information.

Today’s Washington Post quoted Robert J. Bendon of Harvard’s School of Public Health and Kennedy School of Government as saying “recent polls show most Americans do not anticipate any aspect of their health care improving if the president’s health-reform proposals were enacted.” This is not exactly the truth. It is as true as last weeks misleading graph shown on This Week with George Stephanopoulos. “This Week” was informed that their graph omitted significant numbers and declined to respond or correct their misinformation.

Here is an image of the misleading graph, missing those who felt that their care would remain as good as it is today. The numbers and missing numbers speak for themselves. No wonder people aren’t sure what to think. They are not being given reliable, accurate, and truthful information by those whose charge it is to do so. Anyone care to explain the constant “grin” by some of those delivering the misleading figures?

Misleading Graph, Missing Data

When Obama speaks a certain segment of the population seems to get red in the face and lose control. This seems to be a serious manifestation of OPS (Obama Panic Syndrome) which is difficult, if not impossible to treat. When Obama talked about Diabetic amputations he did make a mistake in the specifics of payment but was correct in the general cost. He said that the surgeon was paid over $35,000 immediately for the surgery. Surgeons never are paid immediately, and they receive nowhere near that amount. The American College of Surgeons states that Medicare payment to the surgeon for a foot amputation is under $800.

The cost that Obama mentioned was the total cost as declared in numerous articles, studies, and reviews on diabetic foot and limb care. The $35,000 – $50,000 or more cost of an amputation is often used. It just is not the amount the surgeon receives. When I listened to news clips, I misheard what he said as total cost. But he did mistakenly say this was what the surgeons received. Some felt that doctors and surgeons had been impugned. I did not feel that way. I believed Obama was again mentioning the benefits of limb preservation and preventative care in Diabetes as he has done before. Perhaps not as artfully as previously, but still an important and valuable reminder of the value of preventative care, which is not handled as well as it could be by many private insurance plans and even Medicare. So a reality check and a quick web search shows that Obama was mistaken about the surgeon reimbursement, and he must have meant total cost, and not physician reimbursement. There was no cause for OPS to set in.

Diabetes is a serious illness that requires careful management, dietary support, and exercise to minimize complications. The complications from diabetes can include painful neuropathy, renal failure, eye and vision problems and limb amputations. Diabetes is the major cause of the majority of non-traumatic amputations. More than 50% of those who have had one limb amputated go on to have the other amputated within 5 years.

According to Hospital Management Magazine ( and echoed by many other sources): “the direct cost of an amputation associated with the diabetic foot is estimated to be between $30,000 and $60,000. The estimated cost for three years of subsequent care for individuals whose ulcer has healed without the need for amputation has been estimated to be between $16,000 and $27,000.”

“With relatively low investment the number of amputations can be significantly reduced. Aggressive management of the diabetic foot can prevent amputations in most cases. Even when amputation takes place, the remaining leg and the person’s life can be saved by good follow-up care from a multidisciplinary foot team. Education of people with diabetes and healthcare providers is essential. Healthcare providers need to be trained in order to detect problems early and take appropriate action.”

Medscape reports similar numbers and notes that 57,000 amputations per year (about 150/day) are performed. They also note that 5 – 17% will die during the surgery and an additional 2-23% will die within 30 days of the surgery. The 5 year survival rate is only 40% and 25% in the elderly.

If you listen closely, you’ll hear others talk about the cost of diabetes, diabetic ulcerations, and amputations in diabetics. You’ll hear them talk about preventative care and the importance of maintaining a healthy body weight, eating healthy, not smoking, and regular exercise ( 30 minutes moderate exercise x 5 days/week, 2 days/week strength training). I recently heard Mike Huckabee speak about these very issues at the Annual meeting of the American Podiatric Medical Association.  If I recall correctly he did mention the same numbers as total cost of an amputation. Huckabee also mentioned that he thought maintaining healthy life habits was worthy of an insurance discount. He said this to cheers from those assembled. When Obama says the same thing, OPS sets in, and instead of cheers, I often hear mumbles asking how will the government measure this, and why will they be in our business and private lives.

My opinion is that both the media covering this could use more physicians to help them discern truth from lie and Obama needs more physicians to help review his examples, analagies, and specifics. And we all need to rise above special interests, people who represent and are paid by special interests and keep a cool and objective head as we examine this difficult problem. Maintaining a balance between a “public” option and private insurance firms is important as is determining a fair and proper way to pay for changes. But this is clearly the time for change.

Changes – David Bowie

The following is based on a quick twitter chat with someone who needed to obtain 2 Valium for a Lasik eye procedure.

How could you go wrong? You have a fine insurance plan. You can obtain any prescription you like for only meeting a $30 deductible. That goes for the $80 athlete’s foot prescription to the $180 antibiotic/steroid combo ear drops. You are set. No government big brother socialist between you and your money, your doctor or your pharmacist. Only you and that plastic card separate you from the medicine you need. The marketplace is a wonderful thing. And of course there is no such thing as an aberrant market. All markets are perfect or they wouldn’t be markets, they’d be cooperatives or something we don’t understand at all.

Here you are pharmacy assistant. My super duper pharm discount card is yours for the asking.

2 10mg Valium…. How much is that and yes, generic is fine.

$30?? …. (expletive deleted)!!!

Well, where did things go wrong? It seems that Valium according to the Epocrates Database should cost about $4 per tablet for the brand name and 40 cents for generic. Something seems to be wrong with this picture. The charge was $30. The way the pharmacy views this and the way it is likely defined is that the $30 is a co-payment or processing fee for submitting the prescription to your private insurance health plan (which you never want to leave home without or trade in for something unknown that might even have death squads waiting for you).

Many prescriptions cost more than $30 so a $30 co-payment is not awful. But it is awful if your big chain pharmacy is charging you $30 for an 80 cent prescription. They should have informed you that it would be much cheaper to purchase the medicine without submitting it to your insurance carrier. I recommend going back to the pharmacy and complaining to them of this unethical behavior. You should also ask them where they are sending the data with your name, social security number, address and dosage of the medication without ever asking your permission.  Apparently this seems to happen often. I had heard that the drug information was separated from name but read just this week, that apparently it is not.

The take away lesson is to first ask how much the medicine costs without a prescription card, and how much it is with the prescription card. Then you’ll know if you are saving or losing money by using the prescription card. This will be the same, most likely whether you are in a government operated program such as medicare, or a “you pay your way and premium” public option plan.  There should be a safeguard to prevent you from being charged more on a “co-pay” then the cost of the prescription, but it isn’t there yet. Of course that could ruin the perfect market place we are said to have.

For several years Canada has been the primary souce of production of technetium-99m, an isotope that according to the New York Times is used in more than 40,000 medical procedures a day in the United States. The procedures are important and critical to good medical care. The procedures include tests for cardiac disease, bone cancer, metastatic bone cancer (from cancers such as breast cancer and prostate cancer) and kidney function in children. I often order this test for suspected stress fractures. Bone scans are much less expensive than MRIs and at times will show subtle bone activity missed by the MRI. (Of course the MRI sometimes detects bone stress injuries that the bone scan does not, and MRIs include a different kind of detail and information on cartilage, ligaments and tendons.)

Ontario, Canada was the home to the 51 year old reactor primarily used in production. It has been shut down until at least the end of the year  for safety reasons. The next most frequently used production facility, a 47 year old reactor in Holland, is scheduled to be shut down for maintenance shortly.

A few years ago congress had to pass legislation to allow the export of Uranium 235 to Canada to manufacture the Technetium-99m. At that time they were well aware that there were no U.S. facilities available to manufacturer this critically needed medical compound. Plans were bandied about at that time to start construction of new facilities that would take about 5 years to build. Apparently nothing was passed, since new legislation is being discussed at this time. It is time to get cracking on this and not to pat yourselves on the back for the fine job being done. Scanning for simple tests will soon not be as inexpensive, uncomplicated, and simple as it is today. More expensive and in some cases more complicated procedures will need to be performed.

In view of the tainted Heparin, for which no clear answer was ever offered, perhaps we shouldn’t be surprised at the slow response.

This is another failure to maintain domestic manufacturing capacity for needed materials and products. Apparently in the nuclear plant production area there is a tremendous lack of interest, knowledge, and desire about the production of new plants. When 10,000 scientist members of the American Academy for the Advancement of Science (AAAS) were recently polled,  the scientists were found to favor the new production of nuclear plants by 70%, while the public favored this by only 51%. There were a number of other interesting items in the survey, including political affiliations, evolution, and global warming. The suvey may be viewed online at the Pew Research Center.

Perhaps the take away lesson is that when you know there is impending disaster in the near future, you need to carefully consider what actions are needed. But you must act. You can’t table resolutions  and delay action while taking money from special interests and missing the big picture.

Pew Research Survey On Science

It just doesn’t add up when you mix and match numbers that aren’t meant to be simply added together. When you have numbers that represent things that can’t be merely added together and derive from different measuring systems, you can’t simply join them together. If you thoughtlessly and carelessly put the numbers together, you could crash a space landing craft, as happened when meters and feet were jumbled together by NASA and NASA’s private industry contractors some years back. In 1999, this resulted in the Mars Climate Orbiter plunging and crashing onto the surface of Mars. And that was “rocket science”.

The numbers I’m talking now  are health care cost numbers that have been bandied about both left and right. The latest bit of what I call the 3 D’s (dumb, deceptive, and dangerous) of thinking and posturing was seen in David Broder’s column today in which he quoted Democratic Senator Ron Wyden (D Oregon) as saying:

“As you look at what is being proposed [in two Senate committees] you don’t see savings in the 10-year budget. That’s why the discussion has shifted to finding new money to finance expanded coverage. But at home, when you tell people we’re already spending $2.5 trillion a year on health care and now we’re going to spend $1 trillion more, it just doesn’t add up.”

No, unfortunately that doesn’t add up at all. Nor should it. You can’t take a yearly figure, the $2.5 trillion dollars and then seemingly add $1 trillion more to it and now you don’t make any sense at all. And this comes from a democratic senator who 3 years ago proposed his very own healthcare and health insurance reform bill. His bill declared savings of over $1 trillion over 10 years. The savings was declared by having the cost not climb by the amount it would have been anticipated to climb over that period. This form of logic and calculation has been used by nearly everyone speaking about healthcare costs. We’ll let it be. But both Weyden and Broder should know better than to jumble these numbers up in such a deceptive manner.

You can’t take a yearly figure and then add to it a 10 year cost to it, pretending that the 10 year cost is an annual, yearly expenditure. That is deceptive and dangerous, and likely calculating rather than merely dumb. It is intended to mislead rather than enlighten. We shouldn’t expect that from elected officials, representatives to government, appointed officials, pundits, talk show hosts and participants. Nor should it be acceptable from columnists both noted and those of little renown, nor should it come from bloggers. Yet this sort of unexamined rhetoric and misleading numbers appears often. I have no explanation for this phenomena.

Certainly there are good features in Weyden’s program. Many of these I wrote about back under Bush 41. A more global amortization of costs and risks, elimination of prior existing condition clauses and more. And Wedyen specifically promised a plan as good as what those in the federal government have. And that is a very fair, and well administered system. But that was great 20 years ago. We do need something outside the current system to serve as a model, example, and fail safe system. And we do need it to be cost effective.

We need to cut health care costs. We need to lessen the risk of chronic disease. We need any addition to the system to be paid for in some manner by itself. We also need to look at the costs to the economy of chronic illness, absenteeism, lack of productivity caused by illness. We need to look at the costs to the economy of health related bankruptcy. We need to examine the health fairs, such as those in Tennessee where people come from several states away to sit and stand in lines of people, hundreds long, to receive treatment in groups inside tents giving the appearance of an American refugee camp. There is more, but you’ve seen it elsewhere and either related to what you’ve read or ignored it.

There are a few proposals that may help control costs. The first was a bill proposed in the senate that the premiums charged (yes, there will be and should be premiums charged) for a government system should be at acturarial prices. The other proposals include what may ultimately be cost savers such as shared electronic medical records, and incentives for healthy lifestyle. Of course in some camps the term “lifestyle” has other connotations. But here and where it is applied to heathy living choices it means:

1. No smoking.
2. Healthy body weight.
3. A healthy diet including a variety of vegetables eaten every day.
4. Meet the recommended exercise requirements:
5. 30 minutes of moderate exercise x 5 days per week or 20 minutes of vigorous exercise x 3 days per week (Not enough in my book. I think you should add 10 minute warm up and 5 minute cool down to high intensity training. But then you are actually exercising for 35 minutes.)

Exercise is one of the most important components of a cost reduction plan for health care. In combination these items would all help reduce the incredibly high 65% over weight and obese figures for the U.S. adult population. Childhood obesity also bodes poorly for the future. As we compare these numbers and our health care dollars spent with other nations, one could observe that we far “out weigh” the other nations. Along with obesity, an awful diet, and a loss of regular physical education in schools we are becoming sicker at earlier ages and less productive as individuals and a nation. The costs of chronic disease occurring earlier in life than they should if one adheres to the 4 healthy life habits are an incredible economic burden. A delay in onset of chronic disease, meaning it will occur later in life, and compression of illness, meaning it appears so late in life, that you don’t suffer for years and years with the chronic disorder, will dramatically reduce the cost of the chronic diseases to society.

According to the peer reviewed journal article by Reeves and Rafferty (2005), only 3% follow the healthy life habits mentioned above. So get a move on, shape up, and help reduce health care costs. And don’t forget that we do need a lean, efficient, and effective health care system. This means changes and reform. And perhaps a blog entry entitled the “7 Habits of Highly Effective and Healthy People”. We’ve got 4 above, and I have no problem suggesting another 3.

References on Fitness, Life Choices, Health, and Chronic Diseases

1. Reduced Disability and Mortality Among Aging Runners: A 21-Year Longitudinal Study. Chakravarty, Eliza F. MD, MS; Hubert, Helen B. PhD; Lingala, Vijaya B. PhD; Fries, James F. MD. Archives of Internal Medicine. Volume 168(15), 11/25 August 2008, p 1638–1646
2. Effects of Exercise Modality on Insulin Resistance and Functional Limitation in Older Adults: A Randomized Controlled Trial. Davidson, Lance E. PhD; Hudson, Robert MD, PhD; Kilpatrick, Katherine MD; Kuk, Jennifer L. PhD; McMillan, Kathleen MSc; Janiszewski, Peter M. MSc; Lee, SoJung PhD; Lam, Miu PhD; Ross, Robert PhD. Archives of Internal Medicine: Volume 169(2), 26 January 2009, p 122–131
3. Effect of a lifestyle intervention on change in cardiorespiratory fitness in adults with type 2 diabetes: results from the Look AHEAD Study . Jakicic, J.M., Jaramillo, S.A., Balasubramanyam, A., Bancroft, B., Curtis, J.M., Mathews, A., Pereira, M., (…), Ribisl, P.M.    2009    International Journal of Obesity
   Article in Press. 20 January 2009; doi:10.1038/ijo.2008.280.
4. Treadmill exercise activates subcortical neural networks and improves walking after stroke: a randomized controlled trial. Luft, A.R., Macko, R.F., Forrester, L.W., Villagra, F., Ivey, F., Sorkin, J.D., Whitall, J., (…), Hanley, D.F.    2008    Stroke; a journal of cerebral circulation 39 (12), pp. 3341-3350
5. Laukkanen JA, Kurl S, Salonen R, et al. The predictive value of
   cardiorespiratory fitness for cardiovascular events in men with
   various risk profiles: a prospective population-based cohort study.
   Eur Heart J. 2004;25:1428–37.
6. Katzmarzyk PT, Church TS, Blair SN. Cardiorespiratory fitness
   attenuates the effects of the metabolic syndrome on all-cause and
   cardiovascular disease mortality in men. Arch Intern Med. 2004;
   164:1092–7.
7. Physical Activity and Coronary Heart Disease in Men: The Harvard Alumni Health Study . Sesso, Howard D. ScD; Paffenbarger, Ralph S. Jr MD, DrPH; Lee, I-Min MBBS, ScD
   Circulation Volume 102(9), 29 August 2000, pp 975-980
8. Healthy Lifestyle Characteristics Among Adults in the United States, 2000. Mathew J. Reeves, PhD; Ann P. Rafferty, PhD.  Arch Intern Med. 2005;165:854-857.