What is diabetes?

Diabetes is a chronic disease that occurs when the pancreas doesn’t produce enough insulin, or when the body can’t effectively use the insulin it produces.
Insulin is a hormone made by the pancreas that enables cells to take in glucose from the blood and works like a key to open cells, so that the glucose can be absorbed and converted into energy.

If the body produces insufficient insulin, or when it can’t use the insulin it produces, the glucose levels in the blood rise (hyperglycaemia).
Diabetes complications are divided into microvascular (damage to small blood vessels) and macrovascular (damage to larger blood vessels).

Microvascular complications include damage to the eyes (retinopathy) leading to blindness, to kidneys (nephropathy) leading to renal failure and to nerves (neuropathy) leading to impotence and diabetic foot disorders.

Macrovascular complications include cardiovascular disease such as heart attack, stroke and insufficiency in blood flow to the legs.

There are two main types of diabetes:
Type 1 diabetes is characterised by deficient insulin production and requires daily administration of insulin.

Type 2 diabetes results from the body's ineffective use of insulin. People with type 2 diabetes can often manage their condition with lifestyle changes alone. In many cases they need oral drugs, and sometimes insulin.

Gestational diabetes develops sometimes during pregnancy but usually disappears afterwards. Other rarer types of diabetes also exist.

Diabetes is a serious chronic disease

Diabetes is a potentially life-threatening condition, it can reduce quality of life and is costly to health systems.

Diabetes is now a worldwide epidemic, and the fourth leading cause of death in most developed countries.

The International Diabetes Federation suggests that 415 million adults in the world have diabetes. By 2040 this number is expected to rise to 642 million, or 1 adult in 10.

To date there is no cure for diabetes.

Diabetic foot: the facts

Foot complications are the most common long-term complication of diabetes.

The most serious of these are foot ulceration, infection, gangrene and amputations.

It is one of the most feared complications by patients.

Up to 25% of patients with diabetes who have a loss of sensation to their foot will develop an ulceration in their lifetime.

A foot ulcer precedes up to 85% of all diabetic lower limb amputations.

Diabetic patients with leg and foot ulcers have a lower 5 year survival (43%) than non diabetic ulcerated patients (56%) and the general population (68%).

The economic burden upon society and health resources is crippling, GBP 1.50 in every GBP 150 in the UK is spent on diabetes related treatment.

The most costly consequence of Diabetes in England is hospital admission. Almost half of all patients with diabetes, admitted to hospital, had an active foot disease (47%) and the average length of stay was longer (8 nights) compared with patients without diabetes (5 nights).

Where diabetic foot services have been introduced or improved in Europe, amputations have been avoided by up to 85% and admissions and length of hospital stays have been reduced significantly.

Every 20 seconds …

People with Diabetes are 15 times more likely to undergo amputation than other people.

Leg amputations frequently lead to death. By the time an amputation is necessary, people have usually had diabetes for many years and often have severe complications. Five years after a lower-extremity amputation, 7 out of 10 people may have died.

Life expectancy is significantly reduced following a major lower limb amputation: mortality rate is 22% 30 days after amputation, 44% at 12 months and 77% at 5 years. The statistics show that those with diabetic foot disease have a higher mortality rate than some terminal cancers.

In developing countries mortality rate can be higher, with restricted access to advanced health care, ultimately reducing the options available once treatments is accessed.

The impact of diabetic foot disease

The lives of people after an amputation are profoundly affected: many are unable to work, become dependent upon others and cannot pursue an active social life. Physical, emotional and social functions are all affected, and depression is a common occurrence.

Amputations can be prevented

Fortunately, there are ways to prevent this major public health problem by organising appropriately structured foot care services and education.

Amputations can be prevented significantly by simple but sustained interventions.

Throughout Europe and USA amputation rates have been reduced by up to 85%. The formula for these achievements share a common approach. This includes education (patients, healthcare professionals and policy makers), diabetic foot training, team building, care pathways, integrated care and audit.

Evidence suggests that providing high risk diabetic patients with regular appointments to promote education, recognising potential problems earlier and implementing appropriate care plans with multidisciplinary teams can reduce incidence of foot ulceration. This has been proven to be a cost effective strategy to reduce amputation.

Education is key to foot care

Learning how to look after the feet is fundamental to diabetes care and management. It’s an essential component of a comprehensive foot-care programme for people living with diabetes and their relatives. Specialised education is also important for the health professionals who look after them.

Additionally, it’s important that ministers of health, policy makers and stakeholders are educated about not only the impact of diabetic foot complications but how they can improve the quality of patients’ lives and make significant health/social care cost savings.

Foot problems are serious

Do you know if you are “at risk” of foot ulceration?

Foot ulcers can lead to amputation.

Foot ulcers and amputations can be prevented with good foot care.

Half of all leg amputations are performed on people with diabetes.

People with diabetes are up to 40 times more likely to undergo lower extremity amputation than people without diabetes. Five years after a lower extremity amputation, up to 70% of people may have died.

With good foot care ulcers, amputation and foot-related deaths can be prevented.

Foot problems are very expensive, common, and could be life-threatening. In developed countries, up to 5% per cent of people with diabetes have a foot problem. They use between 12% and 15% of healthcare resources. In developing countries, the latter figure may be as high as 40%.

Approximately 15% of all people with diabetes will have a foot ulcer at least once during their lifetime.

Up to 85% of all diabetic amputations begin with an ulcer.

Studies have shown that foot ulcers can be prevented and successfully treated. Therefore, it is likely that many amputations are also preventable.

A huge economic burden

Not only is the impact of amputation devastating on people’s lives, it’s one of the most costly diabetes complications for both society and people living with diabetes. While few reports on the health-economic consequences have been published, results have been consistent.

In some developing countries, diabetic foot problems may use as high as 40% of the total health resources. It is important to state that the quality of life for those with diabetic foot ulcers/amputations can be very poor and impacts significantly upon daily and family life.

The estimated cost for three years of subsequent care for a person whose ulcer has healed without the need for an amputation is from just over US $16,000 to nearly US $27,000. In Western countries, the economic cost of a diabetic foot ulcer has been estimated to be between US$ 7,000 and US$ 10,000. The direct cost of an amputation associated with the diabetic foot is estimated to be between US$ 30,000 and US$ 60,000, mainly due to the increased need for home care and social services.

Prevention of foot ulcers and amputations by various methods, including education, proper footwear, and appropriate foot care has been shown to be cost-effective or even cost-saving in people at risk. A lot can be achieved by implementing interventions such as a nationwide risk screening using very simple and easy to use tools and guidelines. Those who are at risk and implementing simple structures of basic foot care, which is relatively low cost, would have significant impacts. This is a big part of D-Foot International operational goals: “Using a little to save a lot”.

Diabetic foot: Key messages

Key messages for people with diabetes

If you have numb feet, you might not feel when you have a problem. This does not mean that it is not serious.

You may be at risk of developing problems with your feet. Make sure that your feet are checked regularly.

Make sure that your diabetes team shows you how to look after your feet and provides you with advice about what shoes to wear.

Key messages for healthcare professionals

The most significant cause of foot ulceration is undetected injury stemming from the loss of sensation or foot deformity, with a delay to healing resulting from poor blood supply.

If you think you have a foot problem, seek help, “DO NOT DELAY”. Treat a foot problem like having a heart attack “FOOT ATTACK” get help quickly. No time to lose is crucial. We need a “FOOT ATTACK” concept.

Key messages for healthcare decision-makers

Many ulcers are caused by poor or ill-fitting footwear. Adequate shoes should be provided for people with diabetes whose feet are deemed to be “At Risk”.

The people at highest risk of ulcers/amputation are those with nerve damage (neuropathy) or poor blood supply (ischaemia), especially those who have not been given or understood foot care and footwear advice. D-Foot International is trying to help change this with the Global Cooperation on Assistive Technology (GATE)a project of WHO.

There are many different causes of foot problems: healthcare professionals from different specialities need to be involved. A podiatrist (a specialist in feet) is acknowledged as the key member of a diabetic foot care team. Sadly, their profession is not world widely available. D-Foot International is trying to help change this with one of our collaborative partners the International Federation of Podiatrists (FIP-IPF).