Joey Wahler (Host): It can complicate diabetes. So, we're discussing diabetic vascular disease. Our guest is Dr. William Veale. He's a vascular surgeon with Jackson Hospital. This is Vital Signs, candid conversations with providers who care. Thanks so much for joining us. I'm Joey Wahler. Hi there, Dr. Veale. Welcome.

William Veale, MD: Thank you.

Host: Great to have you with us. We appreciate the time. So first, in a nutshell, what exactly is diabetic vascular disease and just how common is it?

William Veale, MD: Diabetics have effect of a large number of organs, and every organ has a blood vessel that feeds it. Diabetes tends to hit small blood vessels. So, it can affect kidneys, eyes, feet, hands. Anything that has blood supply is affected by the disease process of diabetes or diabetics. How common is it, particularly in the deep south? It's exceedingly common, very common, and it's on the rise.

Host: And so, what are the symptoms? How does it manifest itself?

William Veale, MD: From a vascular surgery standpoint, we see the patients that have complications related to their diabetic small vessel disease. So, they might have kidney disease, they might have small vessel disease in their feet. They might have ischemia. They might have diabetic foot ulcers, vision changes, and also loss of kidney function.

Host: And so, how do you actually go about diagnosing this officially?

William Veale, MD: So for the peripheral vascular component or the legs, we typically have multitude of different tests that we can do, going from exceedingly common tests that are easy and quick and cheap to very expensive and complicated tests. And so, we obviously try to start with the easiest test first to establish a baseline amount of blood flow.

Host: What diabetic patients in particular are most at risk here?

William Veale, MD: Anytime you have diabetes, the less well-controlled your diabetes is, the more likely you are to have complications. So, there's a rating system for diabetics called A1c, and it's literally a grade. And the lower the number, the better off you are. So, a 5 or 6 is like an A; 7 is like a B; 8 or 9 is kind of like a C, and anything above 10 is a D or an F.

Host: Gotcha. And so, who should be tested for this condition, even short of obvious symptoms taking place?

William Veale, MD: For diabetes, you know, obviously, that's a primary care issue, but anybody that has weight concerns or unexplained medical issues should go see their primary care doctor. And then, from a diabetic standpoint, any diabetic should be evaluated at some point for vascular health because the risks of ignoring it is much higher than the risk of evaluating.

Host: And I'm going to ask you a little bit about that in a moment or two. But obviously, Doctor, diabetes is a condition that has to be managed closely on a regular basis, no matter what level of it a patient has. We like to think that such patients stay on top of things very diligently. Is that always the case?

William Veale, MD: No. Particularly in our part of the country, the degrees of poverty, lack of education, lack of funding, lack of healthcare, lack of physicians, particularly in rural communities is a real problem. And so, here in the deep south, education, health education, and infrastructure are all lacking.

Host: And so, having said that, just how often are those with diabetic vascular disease in that position, because things have been let go for too long, perhaps for any one of the number of things you just mentioned there?

William Veale, MD: So, I don't really see the healthy diabetics. Occasionally, we'll have them refer to us, but we most often see the diabetics who are having complications of their disease and even folks that do a fairly good job of managing their diabetes can have a complication, you know, cut their toe on pop-top, and then now they've got a wound that won't heal.

Host: And so, talk to us please about what a difference it makes if there is early intervention for this condition, as opposed to if it has been ignored for some time.

William Veale, MD: Absolutely. Anything, whether it's a transmission in your car or a wheel out of balance, human conditions aren't that different. And so, it's a lot easier to catch things early and to reverse that course of action. And there's a lot of conservative measures we can do. Just like increasing walking and checking your feet two or three times a day, those are things that anybody can do to help their vascular health. And so, we love to catch folks early on and help them stay out of trouble. It's a lot harder to rescue somebody once their foot's infected.

Host: Absolutely. And because of the fact that, as you touched on briefly earlier, diabetes often affects various organs in the body, things can spiral out of control very quickly if this isn't managed properly, yes?

William Veale, MD: Absolutely.

Host: So, how is diabetic vascular disease typically treated? What are the options?

William Veale, MD: First step is diagnosing it and determining the degree of disease. And so, the test for us that I like immensely because, as we said, it's quick and dirty-- but it's not really dirty-- it's a blood pressure cuff on the ankle, but it gives us a percentage of the blood flow to the feet.

And once we know there's a decrement or a decrease in the blood flow to the feet, we can tolerate a decrease. But if a severe decrease in blood flow is present, that presents a problem for healing or just day-to-day function. And so, we have a way to evaluate that. And then, treatment can include angiograms or conservative management and health, lifestyle changes, anywhere up to major surgery. But we try to avoid the surgery and try to start with the conservative stuff first.

Host: So, let me ask you about that first, in terms of lifestyle changes, what can be done to try preventing these vascular issues? How about dietary changes? What are the keys there?

William Veale, MD: You can turn on CBS or ABC or NBC and see all kinds of diet recommendations. And obviously, avoiding high sugar processed foods, everybody should do that. We all know the right things to eat, but we choose not to.

Host: Unfortunately. So, how about regular exercise for these patients we're talking about? What's the minimum that they really need, whether they're getting it or not?

William Veale, MD: Any walking is good. So if a person's out walking to their mailbox, that's better than nothing. We recommend a mile a day for folks who can do that.

Host: A few other things for you. Can such vascular problems be cured with treatment or are they simply kept under control and managed?

William Veale, MD: Yeah, there's no cures. I always tell people, if you eat Snickers and candy bars for 50 years and you never brush your teeth, it's hard to make the cavities go away. So, we can't completely turn people back into teenagers. What we can do is supplement the blood flow that their foot's getting. We can improve what they have in most cases, but we can't reverse the tide of neglect.

Host: Absolutely. You mentioned surgery. You try to avoid it, but sometimes it's a necessary option. What's involved there if needed?

William Veale, MD: So, we have two options for procedures. There's open surgery, which is complex and involved. It doesn't even take long in some cases. And we try to avoid amputations, but that's a common procedure that we do for the diabetics who are uncontrolled, maybe don't even know they have had diabetes for 20 years.

But then, on the other end of the spectrum, we have what we call angiograms or leg caths, or it's sort of like everybody knows about a heart cath. Well, a leg cath is the same thing, except we're shooting dye down the leg. And we're trying to open up the blood vessels from the inside with balloons, catheters, wires, atherectomy devices. There's all laundry list of procedures that we can do to open up the blood flow, and that's without surgery, that's without incisions. It's all percutaneous with a little cocktail medicine. You don't even have to go fully to sleep. And we like doing those if we can catch it early, but not too early.

Host: You mentioned amputation. And we hear sometimes about famous people losing a leg as a result of this type of a condition. You would think that the threat of that would be enough for people to stay on top of this. But as you mentioned, unfortunately, not always the case, right?

William Veale, MD: Yeah. We've known for 50 years that smoking's bad for your health, but people still do it. And so, diet is even harder. I mean, we all like sugar. We're programmed to like sugar. So, mentioning famous people, Deion Sanders has had multiple toes removed. In fact, I think he's missing half of one foot. And it's just because diabetes is a tough disease to treat in the United States of America because the food that we have is so loaded with sugar and other pollutants.

Host: And then, finally, I know this last question in summary here, Doctor, again, more easily said than done for sure, but you touched on some of the factors in this part of the country where people don't necessarily have access to the healthcare they need for a variety of reasons. If that's the case, let's say someone wants to be diligent, they're trying to be, but they don't have the resources, they don't have access to the proper care. What can they do?

William Veale, MD: We end up seeing people in the emergency room because they don't have resources, they don't have assets, they don't have a primary care physician. But we always try to get people-- once they're admitted to the hospital, we can get them aftercare outside the hospital.

 There's almost always an organization that's there to help in every community, but it depends on the community. So, you have to really dig deep. And sometimes we just find those folks through the hospital. That's why small hospitals are important.

Host: Oh, for sure. And then, how frustrating for you as someone that treats this to be dealing often with people that are in a situation where what they have could have been avoided?

William Veale, MD: I think that's true of everybody who's in a developed country, for the most part. Maybe not every specialty, but my specialty, I have smokers and diabetics. So, I think that's just part of life, is that knowing that we all have our struggles, so people need help. I struggle with the computer, so I've got somebody there to help me with a computer.

Host: You're certainly a realist, Doctor. We appreciate that.

William Veale, MD: Yeah.

Host: Folks, we trust you are now more familiar with diabetic vascular disease. Dr. Veale, keep up all your great work. And thanks so much again.

William Veale, MD: All right, Joey. Thank you.

Host: For more information, please visit jacksonclinic.org. Now, if you found this podcast helpful, please do share it on your social media. I'm Joey Wahler, and thanks so much again for being part of Vital Signs, candid conversations with providers who care.