You finally get home after grocery shopping and you suddenly hear your grandson shout, "Papa, your foot is bleeding!" You turn your eyes to the floor in disbelief only to realize that your foot is indeed bloody and that you have left a trail of blood all along your kitchen floor.

People with diabetes can develop foot sores (ulcers) without their knowledge. This is caused by one of the many complications of the disease diabetic neuropathy, which reduces sensation on the skin. It comes at great cost.

Diabetic neuropathy is the reason a cut, sore or other foot injury can go unnoticed. It is a condition that manifests in a "glove and stocking" distribution and presents with numbness, burning and tingling sensations of the hands and feet. Diabetic neuropathy also affects muscle function and can lead to foot deformities including bunions, hammertoe and other structural changes of the foot and ankle.

Secondary postural changes along with altered sensation make one prone to ulceration, sprains, stress fractures, joint dislocations and other injuries that affect the form and function of the foot. Without proper foot care, including regularly scheduled exams by a health care professional, diabetic neuropathy can set the stage for potentially disabling and even life-threatening complications.

Weight-bearing pressures over bone prominences in the diabetic foot as a result of neuropathy constitute "problem spots" which lead to callus formation. The thickened skin first cracks and then progresses to ulcerations if left untreated. Many of us in Hawaii walk barefoot and wear slippers, increasing the chance of callus formation, ulceration and especially infection because of increased contact with germs in the environment.

Studies have shown that foot ulcerations precede limb amputation 85 percent of the time, and up to 25 percent of patients with diabetes will develop a foot ulcer during their lifetime. Since Hawaii has the highest rate of diabetes in the country, it comes as no surprise that the rate of diabetes-related foot problems and limb amputation in Hawaii is equally high.

Foot ulcers and amputations are estimated to have cost the U.S. health care system tens of billions of dollars. Researchers have demonstrated that treatment of diabetic foot ulcers costs significantly less than amputation, making reduced amputation rates a benefit to both patients and the health care system at large.

Studies have reported costs for treating foot ulcers ranging between $7,439 and $20,622 per episode. Direct costs of major limb amputations may be as high as $70,434, and the lifetime costs of an amputation are substantially higher than that.

Studies have demonstrated that podiatric physicians involved in the care of the diabetic patients lower health care costs by decreasing the rate of ulceration and amputation. A podiatrist will assess the risk of developing a foot ulcer by examining the function of a patient’s nerves, the integrity of one’s skin and the adequacy of the body’s circulation. Simple outpatient diagnostic modalities can be implemented to identify disease in its earliest stage.

In collaboration with your primary care physician, a podiatrist might refer you to other specialists (i.e., a neurologist, vascular surgeon or cardiologist). Preventive treatment modalities such as nail and skin care and prescription of diabetic therapeutic footwear also can be provided to minimize the likelihood of complications among people with diabetes.

If you have diabetes, it is important to inspect your feet regularly and think twice about walking barefoot or wearing slippers. Talk to your doctor about seeing a podiatrist for an annual diabetic foot exam.

Ira “Kawika” Zunin, M.D., M.P.H., M.B.A., is a practicing physician. He is medical director of Manakai o Malama Integrative Healthcare Group and Rehabilitation Center and CEO of Global Advisory Services Inc. Please submit your questions to info@manakaiomalama.com.