Preventing Diabetes Poor Foot and Leg Circulation

pre diabetes exercise and diet healthy foot and leg circulationWe often motivate people to stop prediabetes before it turns into full type 2 diabetes by educating them about the potentially devastating complications that many diabetics develop. One of them is narrowing of blood vessels causing decreased poor circulation to the feet and legs resulting in cramping and pain upon trying to walk any distance beyond that required to move around the house. Act now to prevent diabetes circulation problems.

One of the common topics here at Nutrientology is the importance of healthy circulation to the feet and legs for functional movement so you can remain independent well into your senior years. Healthy blood flow to strong feet and legs is very important to keep you moving, independent and out of the gosh darn nursing home.

Many of the articles here at the blog have discussed the living layer that lines your blood cells, known as the endothelium. In this article, I am not going to discuss the endothelium. I’m sure you have had your fill for a while :).  I am going to talk about the blood vessels on a larger scale.

As regular readers know, blood vessels are not simply like pipes carrying water to your house. They are living tissue, and you need to think of them like you think of your heart – as a living tissue – not a sump pump. Your blood vessels will respond favorably to a healthy lifestyle.

Decreased circulation to the feet is a condition known medically as Peripheral Arterial Disease and goes by the letters P.A.D.  It can have devastating effects not only to the feet, but to the legs, and thighs as well. Diabetes and pre-diabetes are especially known to impact the blood circulation system of the feet, legs and elsewhere.

peripheral arterial disease (PAD)PAD is caused by narrowing of the blood vessels – called arteries – that supply blood to the lower extremities (thighs, legs and feet). The narrowing of blood vessels in PAD is caused by atherosclerosis. This happens when plaque, a substance made up of immune system cells, fatty material, calcium and clotting products, builds up on the walls of the arteries that supply blood to the legs. This plaque build up causes the arteries to narrow or become blocked. When blood flow to the feet and legs starts to decrease you may see loss of hair, thinning skin, color changes in your skin, and cramping with walking such that you have to stop and rest. This cramping discomfort is called claudication.

PAD reduces or stops blood circulation to the feet and legs causing them to hurt or feel numb. If severe enough, blocked blood flow can cause tissue death. If this condition is left untreated, it can lead to amputation.

carotid cardiovascular diseaseStudies show that 40-60% of patients with PAD also have some degree of diseased circulation in their heart and/or brain. Because of this, a person with PAD has an increased risk of heart attack, stroke and “mini-stroke.”

If one part of the body’s circulation is developing blockage, it is likely that there are blockages elsewhere. You can often stop or reverse the buildup of plaque in your arteries with diet changes, exercise, and other efforts to improve your lipid-cholesterol levels and high blood pressure.

PAD can go undetected in the early stages because it may not cause symptoms until it has become bad enough. As PAD develops, and the decreased blood flow to the feet and legs begins to set in, some people may actually just unconsciously slow down and not exert themselves. This can mask the disease until it has progressed to a more significant and dangerous degree.

The American College of Cardiology and American Heart Association have published guidelines for the management of patients with peripheral arterial disease (PAD). They state the key questions to ask regarding possible PAD are:

  • Any exertional limitation of the lower extremity muscles.
  • Any history and walking impairment…described as fatigue, aching, numbness or pain.
  • Any poorly healing or non-healing wounds of the legs or feet.
  • Any pain at rest localized to the lower leg or foot and its association with the upright or recumbent positions.

If you have these symptoms, do not assume you have poor circulation to the feet and legs. There are other medical conditions that can cause this. Other potential causes are spinal problems, fibromyalgia, some medications, mineral deficiency and simply age, but blood circulation problems should be ruled out.


What are PAD Risk Factors?

There are several risk factors for the development of PAD including:

According to the American College of Cardiology and the American Heart Association, if you fall into one of the groups below you are at risk for peripheral arterial disease (PAD):

• Age less than 50 years, with diabetes and one other PAD risk  such as: smoking, poor levels of blood fats, high blood pressure, or an increase in the blood of something called homocysteine.

• Age 50 to 69 years and history of smoking or diabetes

• Age 70 years and older

• Leg symptoms with exertion (suggestive of claudication) or leg pain at rest

• Abnormal lower extremity pulse examination

• Known atherosclerotic coronary (heart), carotid (brain), or renal (kidneys) artery disease

human blood flow circulationNotice the last risk category? Remember poor circulation in the heart, brain or kidneys is associated with poor circulation to the feet and legs because your circulation is a closed system; problems with blood circulation in one area, such as the legs, may mean disease in other areas such as the blood vessels that supply the heart muscle, or carotid blood vessels that supply the brain.

If you are in any one of these categories, you should at least have an examination of the circulation to your feet and legs. If further evaluation is needed – based on your history and clinical exam – there is a simple noninvasive test that can be done on the feet and legs to better determine the degree of circulation deficiency that you may have. I’ll talk about that below….read on.


What can you do to try to prevent or slow the development of poor circulation to your feet?

no smokingDon’t smoke, eat a diet and live a lifestyle that encourages healthy blood fats and cholesterol, as well as healthy blood pressure, and normal blood sugar levels. Doing this has been shown to be effective in preventing the cardiovascular problems associated with PAD.

There are things you can do to prevent decreased circulation to the feet and legs and keep functionally moving and ALIVE.

Prevention of PAD, is divided into two categories:

1. Primary prevention – preventing PAD in the first place. Preventing this problem in the first place should be an important goal for people who want to continue to engage in a healthy moving lifestyle. You will not be able to keep up with your kids and grandkids if you have poor circulation to the feet and legs. I hope most of the readers fall into this PAD prevention category.

2. Secondary prevention – treating PAD after it is already present.

Both ways can help you over time, but you need to act now. Obviously, it is better to prevent PAD in the first place. You can control some of the things that put you at risk for PAD, and some you may not be able to control.

PAD risk factors outside your control include:

  • being male
  • being older than 50 years of age
  • being African-American
  • having a family history of circulation problems

If you have several of these risk factors, it makes the factors you can control that much more important.

PAD risk factors under your control include:

  • smoking
  • high blood pressure
  • unhealthy levels of blood fats and cholesterol
  • homocysteinemia (increased levels of something called homocysteine in the blood).
  • the food you eat, i.e., diet
  • how much you move

Nutrientology readers know that blood pressure and levels of fats and cholesterol are related to what they eat and how much they move. If you are living a life geared toward prevention of PAD, you are living in a way that is beneficial to your health in every area. The “side effect” of preventing PAD through a proper diet, some exercise, and an overall healthy lifestyle is that you will prevent many other medical problems, increase your quality of life, and decrease your overall risk of medical problems and possible premature death.


What are your options for PAD prevention and/or management?

Depending on how extensive the PAD is, patients and physicians typically attempt to address the problem with exercise, medications, or performing some surgical procedure to try to open up or bypass the blockage.

Medications are often a first-line approach. Many doctors do not believe that exercise is beneficial, and in many, if not most, cases it is because they do not believe patients will make the necessary lifestyle changes. In many, if not most, cases I am afraid they are correct. Which category are you?

There are medications available, but why go there first? Medications have side effects. Proper Food, Movement and Lifestyle modifications should be attempted before – or in conjunction with – going to the pharmacy. Talk to your doctor about what you can do.


Quit. Cigarette smoking is a big cause of PAD. Smokers are typically diagnosed with PAD about 10 years earlier than nonsmokers. If you quit smoking you can improve your PAD, or at least stabilize your feet and leg circulation.

It has been shown that non-smokers who undergo surgery to improve their circulation have higher success rates, and better overall survival rates than smokers. Actually, cigarette smoking can affect healing after most surgical procedures.

High blood pressure

blood pressure monitorReducing excess body weight through eating the right food and getting regular exercise is the best way to support a healthy blood pressure, regardless of whether or not you need medicine. Do not use alcohol and sodium in excess. Pursue a healthy lifestyle and work with your doctor to get off the drugs – or at least reduce the dosage or number of drugs required. High blood pressure is one of the components of prediabetes-metabolic syndrome, so pursuing a diet that reduces insulin resistance is favorable for improved blood pressure.

Unhealthy levels of blood fats and cholesterol

There is also clear evidence that high levels of “bad fats” in the blood can cause PAD and make it more severe over time. Although a topic of active and evolving research, levels of certain types of blood fats, known as low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL), triglycerides, and HDL-cholesterol (HDL) are accepted risk factors for decreased circulation to the feet and legs. I have posted about the different types of cholesterol and some things you can do to encourage healthy cholesterol levels.

Relatively high levels of HDL are associated with less blood vessel narrowing and less “hardening of the arteries” in the feet and legs. As I have previously discussed here at the blog, many believe the ratios of total cholesterol to HDL-cholesterol as well as triglycerides to HDL-cholesterol are the more important indicators of circulation health, including the risk of PAD and cardiovascular disease in general.

Speak to your doctor about not only your total cholesterol level, but the different blood fats that are added together to give you your total cholesterol number. Many doctors are trained to key in on the LDL-cholesterol level, but there is another school of thought stating that the LDL level is not as significant as healthy levels of triglycerides and HDL. Bottom line, look at the whole shebang.


People who develop cardiovascular disease early in life tend to have a significantly higher amount of homocysteine in their blood, and it appears to be an independent risk factor. Homocysteine is poorly understood. The B vitamins – B12, B6 and Folate – are involved in homocysteine metabolism, and there is some evidence that certain B vitamins can support lower homocysteine levels.

Doctors do not typically check levels of homocysteine. I suspect it’s because they really do not know what to do with an elevated result. I was at a lecture recently given by a vascular surgeon. He mentioned elevated homocysteine as a risk factor for PAD. I asked him how many doctors who refer patients to him have checked homocysteine. He said, “Very few.”

Diet – The food you eat.

mediterranean diet for pre diabetesThe best diet for cardiovascular health is a source of controversy, and is covered at length here at Nutrientology so I will not go into it here. The diet science literature is not definitive, partly because diet and nutrition are such difficult areas to study. People are different, and there are many variables that need to be accounted for over an extended period of time in order to come up with strong conclusions. Having said that, here at Nutrientology we generally advocate a lower carbohydrate approach. After all, we speak mostly to pre-diabetics who, by definition, have an intolerance to carbohydrates.

Keep it simple. Eat real, quality, unprocessed food in moderation – “Real carbohydrates” meaning vegetables and fruits. Eat starchy vegetables after “exercise” or some type of movement activity.


Many people ask, “Can I exercise with bad circulation in my feet and legs?” Generally speaking, yes…some regular physical movement or “exercise” needs to be part of your lifestyle for a healthy life, but the results of studies looking at the effects of exercise for PAD have been mixed. PAD does present some special challenges and considerations. Given that movement is such an integral part of our overall health, unless there is some medical contraindication, it seems to me that one should favor movement over doing nothing…Read on.

Talk to your doctor first, consider an exercise professional and start slowly. If you think you may have symptoms of PAD, such as the cramping claudication discussed above, you especially must have your physician in the loop. As you now know, patients with cramping PAD are likely to have more significant problems with their heart circulation – remember your circulation is a “closed-loop.” Although PAD that does not hurt can sometimes be just as bad, if not worse. Exercising with PAD leg pain – known as claudication – is tricky. Talk to your doctor before beginning.

You do not need to go to the gym and walk on a treadmill for 45 minutes to an hour. Get together with a friend, and just get out and move around. Some structured walking is good, but less structured activity is good as well. Beware of the heat if you live in a warmer climate. Engaging in an exercise lifestyle is a process, not an event.

Some form of light resistance training (“weightlifting”) should also be done a couple times a week. Try to be as regular as you can. A hospital gym or medically supervised facility is a good place for higher risk newbies to start an exercise program. If you have claudication, they will typically have you walk to a level that brings on a mild degree of discomfort, and then have you rest. If your circulation is improving, you should be able to go a little further over time. Several studies have shown that supervised exercise regimens have been proven to give good results and should be recommended to patients. Here is one review of studies on the topic.

pedometerDo not be hesitant to exercise in a more supervised atmosphere in order to exercise properly and sufficiently. Studies have shown that people regularly misjudge the amount of exercise they perform believing they have done a lot more exercise than they actually have. A pedometer is a good way to more objectively measure the amount of exercise-movement that you have engaged in during the day, either as formal exercise, or simply walking around performing the functions of your day. It will take at least 3 months before you start to see and feel some of the benefits.

The development of PAD, the resultant poor walking ability and the possible claudication discomfort is complex and not fully understood. Many studies show that the amount of blood flow blockage does not directly correlate with amount of functional compromise in your ability to walk and move around. In other words, someone could have significant decreased blood flow to the feet and legs and still be functional, and another person could have less blockage, but have a greater amount of functional disability. When people with PAD undergo exercise training, their foot and leg blood circulation can improve, but functional improvement may not necessarily occur. If this is you, do not be discouraged. Your health on the whole is still benefitting.

The muscles of the legs, particularly your calf muscles, are most affected by decreased circulation to the feet and legs. Because of this, people with PAD have smaller, poorer quality and weaker calf muscles than someone without PAD. The functional strength of your legs is soooooo important for healthy aging. If you are medically capable, you should be doing at least some resistance and balance exercises for your feet and legs if you want to be a successful functional senior citizen enjoying grandchildren, and not roaming the halls of a nursing home with claudication.


How do you know if you have PAD?

There are ways to check for PAD. A clinical history and exam is initially performed. If there is reason to suspect you may have a relevant decrease in blood flow, there is a relatively simple non-invasive test that can be performed that measures the blood pressure at different levels throughout your legs, and also uses ultrasound to get a visual representation of how healthy and elastic your blood vessels are. Blood vessels that are narrowed and hardened will show a particular type of “waveform” during the test and healthy “elastic” blood vessels will show another.

The American Diabetes Association (ADA) position statement on foot care states,

initial screening for peripheral arterial disease should include a history of claudication and an assessment of the pedal pulses. Consider obtaining an ankle-brachial index as many patients with PAD are asymptomatic.”

In plain English, this means that if you have cramping in your legs when walking, you should have a doctor check to see if you have a pulse beat in your feet and get a blood pressure reading at your ankle, if necessary.

They go on to say that,

the risk of ulcers or amputations is increased in people who have had diabetes greater than 10 years, are male, have poor glucose control, or have cardiovascular, retinal or renal complications.”

They are talking about foot and leg skin ulcers and foot amputation. Retinal and renal complications refer to eye and kidney problems, respectively.

A simple way to determine the health of blood circulation to the feet and legs is by what is called the Ankle-Brachial index (ABI). This is your systolic blood pressure at the ankle divided by the systolic blood pressure at the arm. So, if your systolic blood pressure in your arm is 130 and your systolic blood pressure at your ankle is 90. That is 90/130 = 0.69. This number is consistent with PAD.

It is best to get an ABI test with a Doppler waveform analysis of the lower limbs. A recent study reported that people who had ABI screenings that included an arterial waveform analysis had a 78% rate of PAD diagnosis, whereas only 13% of the people who did not elect ABI screening were diagnosed with PAD based on their symptoms and physical exam.


Pharmacy medicines for PAD

There are also pharmacy medications that are used in some cases such as pentoxyfilline, aspirin, cilostazol and clopidogrel, either alone or in combination with other medications. These medicines are usually used when disease is evident or impending. They have been shown to be effective, although some medicine combinations can increase the risk of bleeding.


Surgery for decreased circulation to the feet and legs

There are various surgical approaches to help improve blood flow to the feet and legs in people with PAD. This topic is beyond the scope of this article.
Hopefully the readers without PAD will use this information as the basis for a conversation with their doctor, and live a lifestyle that will decrease their chance of developing cardiovascular disease, including the decreased circulation to the feet and legs preventing a functional, moving and independent life well into their senior years. Stay in touch with Nutrientology to learn more about what you can do to promote strong functional feet and legs.


The information provided is for educational and informational purpose only and is not intended to diagnose, treat, cure or prevent any disease. Any reader who is concerned about his or her health should contact a physician for advice.


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About Robert Creighton

Dr. Creighton is a podiatrist and foot surgeon with over 26 years in podiatric practice treating thousands of patients afflicted with the physiological, physical, and psychological side effects and complications of diabetes and pre-diabetes metabolic syndrome. He believes these disorders present a pressing public health concern that need to be more actively addressed in a multidisciplinary way. Dr. Creighton graduated from what is now the Temple University School of Podiatric Medicine after receiving his undergraduate degree in Biology. He is certified by the American Board of Foot and Ankle Surgery, a member of the American Public Health Association, an American College of Sports Medicine certified personal trainer and a Member of the American Nutrition Association.

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