Do you walk barefoot or wear tight shoes? You could be at risk for AMPUTATION: Top podiatrist reveals surprising common habits people think are harmless

More than 38 million Americans suffer from diabetes, putting them at risk of deadly related health complications.

One of the most common are foot or leg amputations.

Every three minutes and 30 seconds, an American has a limb amputated due to diabetes, amounting to approximately 160,000 every year.

Amputations are a risk factor of diabetes because the long-term high blood sugar the condition causes can trigger nerve damage and difficulties with circulation.

Over time, this leads to an increased risk of injury that the body struggles to heal, causing an infection that leads to amputation.

As a podiatrist who has seen hundreds of people with diabetes, I've observed common behaviors that increase a person's risk of a foot amputation.

Whether it is an unexplained change of sensation in the feet or a penchant for not wearing shoes, I've compiled a list of red flags that I warn my patients against in order to protect them from the life-changing surgery.

IGNORING LOSS OF SENSATION OR TINGLING IN THE FEET

It is a shockingly common view among patients with diabetes that losing sensation in the feet is not something to worry about.

But this is a symptom of diabetic neuropathy, a condition in which high blood sugar levels damage nerves, typically in the feet, legs, hands and arms, causing a loss of sensation.

It can also be a sign of a reduction in blood flow to the feet, caused by high blood sugar levels narrowing blood vessels.

Both of these things can raise the risk of diabetic foot ulcers (DFUs), open sores on the foot that can easily become infected, and lead to an amputation.

Up to half of patients with diabetes have diabetic neuropathy.

And estimates suggest that about 20 percent of diabetics who develop a moderate or severe foot infection will require an amputation, according to a 2017 study published in the New England Journal of Medicine.

Signs of diabetic neuropathy normally start in the toes, with someone losing feeling in the tips, before it advances up the foot.

Patients can check for signs of diabetic neuropathy by inspecting the foot for redness or cracks and lightly touching the fingers to the toes while looking away, checking whether they can feel the sensation.

Similarly, one of the most frequently reported symptoms I hear from a patient with diabetes-related foot symptoms is tingling in the feet, which may indicate peripheral neuropathy.

Diabetes-related peripheral neuropathy is also caused by high blood sugar levels damaging nerves.

Either type of neuropathy is serious because the change in or loss of feeling could raise the risk of injury or infections that lead to amputations.

WEARING THE WRONG FOOTWEAR

The footwear a patient uses can play a key role in ensuring they do not develop any issues that may lead to an amputation.

These include wide-fitting composite boots or shoes, which accommodate diabetics at risk of ulceration, when a sore appears - and breaks open - on the surface of the foot, raising the risk of infection.

The wider footwear helps because it can minimize friction between the foot and the shoe, helping to reduce the risk of skin damage.

For people who want to wear high heels, it is important for patients to acknowledge that these could lead to foot deformities such as bunions, ankle equinus, limited ankle flexibility and hammer toes.

All of these increase friction between the foot and shoes.

I have seen these issues particularly among farmers with diabetes because they are more likely to wear rubber rain boots, which can cause excessive rubbing on the foot.

And suffering from neuropathy raises the risk of foot ulcers even more.

An elderly gentleman who had played golf his entire adult life came to me with sores on the outside of his feet.

He didn't realize he had developed neuropathy and was therefore unable to feel that he had ulcers.

After explaining that a mix of the narrowness of his golf shoes and neuropathy had caused the sores, I explained that further rubbing could cause further breakdown of the sore and infection.

Following treatment and advice the patient changed his shoes to wider fitting ones and wore white diabetic socks to check for blood stains. He also started using a mirror at the end of the bed to check his feet first thing in the morning and last thing at night.

Making these simple changes helped protect his feet and let him enjoy playing golf.

WALKING BAREFOOT OUTSIDE

Another common concern I see in my diabetic patients is whether they can walk barefoot outside.

As this is a major 'red flag' for a risk of future amputation, I tell them it significantly raises their risk of suffering from an ulceration or infection.

While barefoot outside, it is possible that they will step on a sharp object that could puncture the foot and cause an infection, or an open sore that is already on the foot could then become infected.

My approach to this question, however, is always to focus on the patient's goal, such as to walk in the garden, and then to provide a clinical plan to help them get there.

Helping patients with diabetes understand the risks of their decisions is far more productive in the long term than dismissing the meaning and root of their question.

Jonathan Brocklehurst, MSc, MIRL, MRCPod, is a podiatrist based in the UK.