The diabetic foot: amputations are preventable

People with diabetes are at risk of nerve damage (neuropathy) and problems with the blood supply to their feet (ischaemia). Both neuropathy and ischaemia can lead to foot ulcers and slow-healing wounds which, if they get infected, may result in amputation.

In 2000 the International Diabetes Federation endorsed the International Working on the Diabetic Foot as a Consultative Section on the Diabetic Foot. Together the organizations established goals for the future of diabetic foot care worldwide.

Goals

* to inform people of the extent of diabetic foot problems worldwide
* to raise awareness of the diabetic foot among those at risk and those in a position to take action
* to persuade healthcare decision makers that action is both possible and affordable
* to warn healthcare decision makers of the consequences of not taking action
* to inform people with diabetes of the measures they can take to prevent foot complications

Diabetes is a serious chronic disease. In 2003 the global prevalence of diabetes was estimated at 194 million. This figure is predicted to reach 333 million by 2025 as a consequence of longer life expectancy, sedentary lifestyle and changing dietary patterns. This rise is likely to bring a proportional increase in the numbers of people with diabetes complications, including problems of the foot.

Most amputations begin with a foot ulcer

Diabetic foot ulcers as a result of neuropathy or ischaemia are common. In developed countries, up to five per cent of people with diabetes have foot ulcers, and one in every six people with diabetes will have an ulcer during their lifetime. Foot problems are the most common cause of admission to hospital for people with diabetes. In developing countries, foot problems related to diabetes are thought to be even more common. Without action, global amputations rates will continue to rise.

Every 30 seconds a leg is lost to diabetes somewhere in the world

Extensive epidemiological surveys have indicated that between 40% and 70% of all lower extremity amputations are related to diabetes. This means that every 30 seconds a lower limb is lost to diabetes. The vast majority (85%) of all diabetes-related amputations are preceded by foot ulcers.

For most people who have lost a leg, life will never return to normal. Amputation may involve life-long dependence upon the help of others, inability to work and much misery. 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.

In developed countries diabetic foot care accounts for up to 20% of total healthcare resources available for diabetes. In developing countries, it has been estimated that foot problems may account for as much as 40% of the resources available. In western countries, the economic cost of a diabetic foot ulcer is thought to be between US$7,000 and US$10,000. Where healing is complicated and amputation required, this cost may increase to as much as US$65,000 per person.

Up to 85% of amputations can be prevented

In most cases, however, diabetic foot ulcers and amputations can be prevented. Researchers have established that between 49% and 85% of all amputations can be prevented. It is imperative, therefore, that healthcare professionals, policymakers and diabetes representative organizations undertake concerted action to ensure that diabetic foot care is structured as effectively as local resources will allow. This will facilitate improvements in foot care for people with diabetes throughout the world and bring about a reduction in diabetic-foot-related morbidity and mortality.

Significant reductions in amputations can be achieved by well-organized diabetic foot care teams, good diabetes control and well-informed self care

There is strong evidence to indicate that foot care is best delivered when it is provided by a multidisciplinary team. This should closely involve the person with diabetes and his or her family, along with healthcare professionals from different specialties. Ideally the team will include a physician, a nurse, a specialist educator, a podiatrist, a surgeon, an orthotist (shoemaker) and an administrator. The podiatrist is a key member of the multidisciplinary diabetic foot team. At present there is a lack of trained podiatrists working in diabetic foot care. Mandatory minimal skills and equipment for those offering a podiatry service should be controlled to ensure that people with diabetes are not put at increased risk by unregulated, unqualified and poorly equipped practitioners.

IDF’s position is that management in the prevention and treatment of diabetic foot problems includes the following:

* Annual inspection of the foot
* Identification of the foot at risk
* Education of people with diabetes and healthcare professionals
* Appropriate foot wear
* Rapid treatment of all foot problems

Only through a multidisciplinary approach addressing the diversity of possible foot problems in people with diabetes can the desired reduction in amputation rates be achieved.

Conclusion

It is now time to take appropriate action to ensure that people with diabetes everywhere receive the quality of care that they deserve. It is hoped that global awareness of diabetes and its complications will be raised and that the necessary attention will be paid to the need for improved foot care for people with diabetes throughout the world.

IDF recommends that every individual with diabetes receive the best possible foot care. At the organizational level, diabetic foot care should be structured in such a way as to optimize treatment and prevention possibilities. For this to be feasible all parties involved (i.e. healthcare providers, policymakers and patient organizations) should recognize the need for combined action.

~ International Diabetes Federation ~