The Diabetic Foot Robert J. Hinchliffe, Nicolaas C. Schaper, Matt M. Thompson, Ramesh K. Tripathi
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s1THE DIABETIC FOOTs2
s3THE DIABETIC FOOT
Edited by ROBERT J. HINCHLIFFE, MD, FRCS Senior Lecturer and Honorary Consultant in Vascular Surgery St George's Vascular Institute St George's Healthcare NHS Trust London UK NICOLAAS C. SCHAPER, MD, PhD Professor of Endocrinology Department of Internal Medicine, Division of Endocrinology Maastricht University Hospital Maastricht The Netherlands MATT M. THOMPSON, MD, FRCS Professor of Vascular Surgery St George's Vascular Institute St George's Healthcare NHS Trust London UK RAMESH K. TRIPATHI, MD, FRCS, FRACS(Vasc) Director and Professor of Vascular Surgery Narayana Institute of Vascular Sciences Narayana Hrudayalaya Healthcare Bangalore India CARLOS H. TIMARAN, MD Associate Professor of Surgery Chief of Endovascular Surgery Division of Vascular and Endovascular Surgery Department of Surgery University of Texas Southwestern Medical Center Dallas, Texas USA
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s5Preface
Diabetes is reaching epidemic proportions across the globe. It is one of the few diseases that can lay claim to affect multiple organ systems. One of the most feared complications of diabetes for those people who have the misfortune to develop it is lower limb disease, foot ulceration and ultimately, amputation.
Until recently, diabetic foot disease has been a relatively neglected complication of diabetes, but slowly the wheel is turning. Patients, healthcare professionals and politicians have started to realise the quite staggering burden of foot disease for individuals and society. Evidence of this may be seen in the ever increasing numbers of scientific publications on the subject.
Because diabetes is a truly multi-organ disease, it requires input from a variety of healthcare specialists, none of whom should be expected to manage these complications in isolation. Indeed, for many specialists diabetes-related foot disease represents the most challenging aspect of their individual specialty.
If lower limb and specifically foot complications are managed in a timely and expert fashion, ulcers will be healed, limbs preserved and lives saved. Delay, or poor management, including failure to use evidence-based therapies, will result in ulcers that fail to heal, amputations and deaths.
This book was developed with all those who manage patients with diabetes – and specifically, diabetes-related complications of the lower extremity, be they generalists or specialists – in mind. It summarises the current best available evidence on diabetic foot disease for busy clinicians. Bringing together a variety of experts from across the world, it provides a keen insight to the current management of all aspects of diabetic foot disease. Specifically, the experts have amassed and sifted through the wealth of data now emerging on this topic and provided a clear and concise summary that readers will find easy to access rapidly. The book is separated into the main themes of diabetic foot disease, from its epidemiology and natural history, through to the practical organisation of care and the diagnosis and management of neuropathy, peripheral arterial disease, infection and Charcot disease. Each chapter helpfully provides a brief summary, highlights current controversies and focuses the reader on current and future areas of research.
Robert J. Hinchliffe
Nicolaas C. Schaper
Matt M. Thompson
Ramesh K. Tripathi
Carlos H. Timaran
July 2014
s6Contributors s12Introduction
Karel Bakker
 
BACKGROUND
The ‘diabetic foot’ defined as ‘infection, ulceration and/or destruction of deep tissue associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb in people with diabetes’ () has for centuries been neglected. It only started to generate serious interest in the 1980s. Diabetic foot complications were rightly feared by patients and clinicians alike because of their association with high rates of lower extremity amputations (LEA). The vast majority, some 85% of these amputations, is preceded by a foot ulcer. The most important factors relating to the development of these ulcers are peripheral neuropathy, foot deformities, minor foot trauma, and peripheral arterial disease (PAD). Once an ulcer has developed, infection and PAD are major causes of amputation. However, with timely and expert care, many amputations may be prevented and most ulcers will heal.
 
■ PREVALENCE
It is estimated that in 2013 approximately 382 million – 8.3% of the world's population – people had diabetes, and about 80% of these people live in developing countries. By 2035, the global estimate is expected to rise to >592 million – 9.9% of the adult population. Worryingly, type 2 diabetes is increasing among young people as well as older people around the world ().
The spectrum of foot lesions varies from region to region due to differences in socioeconomic conditions, standards of foot care, and the quality of footwear. It has been calculated that in developed countries, one in six people with diabetes will have an ulcer during their lifetime. In developing countries, diabetes-related foot problems are thought to be even more common. Every year, more than 1 million people with diabetes lose a leg as a consequence of this disease. This means that every 20 seconds a lower limb is lost due to diabetes somewhere in the world.
 
■ HISTORY
During the 19th century and for much of the 20th century, disease of the lower limb in patients with diabetes was conceptualized not, as it is now, as ‘the diabetic foot’ or as ‘a diabetic foot ulcer’ but as ‘gangrene in the diabetic foot’ or as ‘diabetic gangrene’ (). The prognostically and therapeutically important distinction between gangrene due to vascular insufficiency and gangrene due to infection in a limb with a normal or near normal blood supply was not made until about 1893 (). The advent of aseptic surgery improved the survival of amputation flaps, but surgery remained a hazardous undertaking until the discovery of insulin. The increasing workload attributable to diabetic foot disease after the introduction of insulin is reflected in the publications on diabetes in the 1920s. In some hospitals in North America, this led to initiatives in prophylactic care and patient education, the importance of which were only more widely appreciated some 60 years later. A continuing emphasis on ischemia and infection as the major causes of diabetic foot disease led to a neglect of the role of neuropathy. In consequence, the management of diabetic neuropathic ulceration entered a prolonged period of therapeutic stagnation at a time when significant advances were being made in the management of lepromatous neuropathic ulceration. The association between gangrene and diabetes was recognized by () and also by (). The importance of pressure and callus in the pathogenesis and persistence of ulcers was recognized by (). It was understood that foot ulcers could be healed by prolonged bed rest, but that recurrence was likely when the patient mobilized. Amputation of part of the foot was often recommended for persistent or recurrent ulcers, even though the risk of further ulceration in the deformed foot or in the amputation stump was well known.
It was Treves who also described for the first time the use of sharp debridement in the treatment of neuropathic ulceration. He recognized that a reduction in pressure on the foot was required if recurrence was to be prevented. Treves established three principles in the treatment of neuropathic ulceration, namely sharp debridement, off-loading of pressure for both treatment and prevention, and education about foot care and footwear. However, at least as regards diabetic neuropathic ulceration, these three principles were then largely forgotten for the next 40 years.
Whether the arrival of insulin in 1922 improved the survival in patients with gangrene cannot be determined from the literature (). It is likely that many of the patients who are now treated surgically would have been considered unfit for surgery in the preinsulin years. However, the increasing workload attributable to diabetic foot disease is reflected in a fourfold increase in the number of pages that devoted to the subject between the second and fourth editions in 1928 of his textbook.
Joslin and others expressed their view that prophylactic care and education were essential and they mentioned virtually all of the points that we would teach our patients today. The teaching of foot care was considered so important that by 1928 the clinic at the Deaconess Hospital in Boston had assigned one graduate nurse and two pupil nurses to this duty; and it was not just theoretical oral teaching and written advice that was provided because ‘every diabetic patient receives at least one demonstration and lesson…’ () A treatment room for diabetes-related foot problems, staffed by two chiropodists and one nurse, had been opened in the clinic in 1927, an early example of multidisciplinary teamwork and one that extended to the clinic's relationships with chiropodists outside the hospital. Like doctors in other clinics, Joslin had been aware that some diabetic foot problems were the result of uninformed chiropody, but instead of blaming the chiropodists he took steps to bring them on board and by 1934 he could write that: ‘Our Boston chiropodists are useful allies. Nowadays we do not see gangrene which has developed at the hands of a chiropodist. At the start of our work with them we consulted with the leaders of their State and National Societies and these excellent men have guided us in our contacts’ ().
Other early converts to the need for education on foot care were the Montreal General Hospital where foot care leaflets were given to all patients by 1927 () and the Bellevue Hospital in New s13York, which started a diabetic foot room in May 1933 (). It is amazing that it has taken dozens of years for other clinics to embrace these principles and even more amazing that some still do not do so.
Henry Connor wrote ‘to those of us who came into the field of diabetic foot disease in the 1970s and early 1980s, it often seemed that the diabetic foot was the forgotten specialty of the chronic complications of diabetes’ and there is some evidence to support this belief (). A search of PubMed (www.ncbi.nlm.nih.gov/entrez/query.fcgi 2006) demonstrates that in each decade from 1950 onward there have been fewer papers published on the diabetic foot than on diabetic neuropathy or nephropathy or retinopathy (Table 0.1). For example, in the 1950s there were more than twice as many papers on retinopathy as on foot disease. The data show that foot disease lagged further and further behind the other complications until the end of the 1980s. Only in the 1990s did the trend start to reverse. A similar pattern is to be found in the formation of the Study Groups of the European Association for the Study of Diabetes; the Foot Study Group was the last group to be formed, in 1998, some 10 years after the neuropathy, nephropathy, and retinopathy groups.
Why was there this lag period in the study of diabetic foot disease? It is tempting to attribute the deficiency in publications to a lack of technology for investigating foot disease. But this cannot explain the lack of progress in the field of diabetic neuropathic ulceration at a time when significant advances were being made in the management of neuropathic ulcers in leprosy. The use of special footwear to prevent ulcers or their relapse in patients with leprosy was described by Paul Brand already in 1950 (). Brand used clay to obtain standing impressions of his patient's feet and these were used to produce molded rubber insoles. This was 26 years before Holstein's paper on insoles for diabetic shoes (). By 1963, Brand and his colleagues were using thin transducers in patients with leprosy to make in-shoe pressure measurements that they used to guide their research and shoe manufacturing (, ). He showed that neuropathic ulcers were treatable and preventable. This was 10 years before the earliest diabetic publications on this subject (, ).
Why were those who worked with patients with diabetes in more affluent societies so much slower to learn the same lessons? Connor believes that it was, in large part, due to classification and terminology. The diabetic foot is, of course, a more complex entity than its lepromatous counterpart in that it has a heterogeneous aetiology comprising an important vascular element in addition to the neuropathic component, and also because infection plays a significant role along with hyperglycemia.
The issues over terminology extended beyond neglect of the neuropathic component. The dominance of negative terms such as ‘diabetic gangrene’ only finally disappeared during in the 1980s–1990s (, ). As long as clinicians continued to think of diabetic foot lesions predominantly in negative terms like gangrene and amputation, it was almost inevitable that they would do so in an aura of therapeutic nihilism. When more neutral terms came to the fore, the minds of diabetologists were opened to the possibility of therapeutic advance. The author believes that the number of different specialists involved in diabetic foot care may also have been counterproductive. In essence, no single specialty was able to identify and drive the diabetic foot care agenda. Only after the development of a multi- or interdisciplinary team approach were major steps forward made.
 
■ 1980 AND ON
An important development following the long lag period was the foundation of diabetic foot clinics in the 1980s in the USA and Europe, notably at the University of Miami, USA; Geneva, Switzerland; San Antonio, USA; Kings College Hospital, London, UK, Manchester Infirmary, UK; Deaconess Hospital, Boston, USA; and the Heemstede Hospital, Heemstede, the Netherlands. The spin-off effect of this was significant throughout the world. Likewise, more awareness was created by the first international diabetic foot meetings. Among the first events of this kind were the University of Texas Health Science Center 1st meeting (1985), the first Malvern Foot meeting (1986) in the UK, the High Risk Diabetic Foot Conference in Boston (1988), and the first International Symposium on the Diabetic Foot (ISDF) in Noordwijkerhout, the Netherlands (May 1991) ().
The foundation of the Diabetic Foot Study Groups (DFSG) was an important development as well. Creating a platform for researchers in the field with the slogan ‘together are we stronger’ focused on the importance of better management and prevention of diabetic foot ulcers and their consequences.
The American Diabetes Association (ADA) Foot Council had its first meeting in 1987 and, as already mentioned, the DFSG Europe was founded in 1998 in Barcelona. In the meantime, several more study groups were formed elsewhere (e.g., GLEPED [South America] and the Pan African DFSG and the local DFSG in India, Pakistan, Israel, Greece, Egypt, France, Belgium, the Netherlands, Germany, Portugal, Spain, and very recently the Gulf Diabetic Foot Study Group).
Data to underpin the clinical effectiveness of these MDT foot clinics and initiatives started to filter through soon afterward. Edmonds showed for the first time that a multidisciplinary diabetic foot clinic approach could reduce the number of amputations significantly ().
A groundbreaking initiative took place in Italy in 1989. At a well-attended international workshop, representatives of government health departments and patient organizations from all European countries met with diabetes experts under the aegis of the regional offices of the World Health Organization (WHO) and the International Diabetes Federation (IDF) in St Vincent, Italy, on 10–12th October, 1989. They unanimously agreed upon the following recommendations and urged that they should be presented in all countries throughout Europe for implementation. The so-called ‘St Vincent Declaration’ was a result of this important workshop (Saint The Vincent Declaration on diabetes care and research in Europe 1989).
Figure i: First International Symposium on the Diabetic Foot (ISDF). Noordwijkerhout, the Netherlands, May 1991: organizing committee. Standing from left to right: Andrew J M Boulton (UK), Karel Bakker (the Netherlands), Jan A Rauwerda (the Netherlands), Per E Holstein (Denmark), Folke Lithner (Sweden), Bob PJ Michels (the Netherlands). Kneeling: Lawrence B Harkless (USA). Standing above: Arie C Nieuwenhuijzen Kruseman (the Netherlands).
s14
At the conclusion of the St Vincent meeting, all those attending formally pledged themselves to strong and decisive action in seeking implementation of the recommendations on their return home. One of the 5-year targets was to ‘reduce by one half the rate of limb amputations for diabetic gangrene.’ Unfortunately this goal, at least for the time being, appears to represent a ‘bridge too far.’ It is remarkable that there remains a lack of willingness in many countries' ministries of health to invest in preventive measures.
 
■ BARRIERS
In recent years, many efforts have been undertaken to teach all healthcare workers involved in the treatment of people with diabetes. Nevertheless, there are numerous barriers to the implementation of universal good care, involving the attitudes and beliefs of doctors, other healthcare professionals, and patients, and the structure of healthcare systems all of which can conspire to prevent patients with diabetes from receiving the appropriate care they desperately need ().
Barriers to the implementation of foot care are everywhere. Their presence is often expected in developing countries, but be assured that barriers are easily encountered in the most highly specialized diabetic foot care centers. Sometimes the most glaring barriers are not identified and therefore completely overlooked, preventing patients from receiving the best available foot care. Potential barriers can be grouped together in three distinct categories: availability of healthcare, patient-related factors, and healthcare system ().
 
■ Availability of healthcare
In some areas of the world, there is a complete lack of dedicated clinics for patients with diabetes-related foot disease. As facilities in certain areas provide care for a large geographical area, patients may be forced to travel enormous distances of up to hundreds of kilometers.
Even when clinics are available, healthcare providers working in those facilities may not be interested in diabetic foot pathology or may not have the appropriate knowledge or training. This will result in delays or even an absence of adequate foot care. Certain doctors may adhere to beliefs that interfere with their willingness to put effort into diabetic foot problems. Patients who seek alternative forms of medicine may be excluded from care as they may be considered unwilling to follow directions ().
The availability of specific tools can differ to a huge extent between different facilities. Even when a strict protocol is implemented and local guidelines have been developed, the care provided is still different. In the Eurodiale study, it was found that among 1232 patients in 14 European centers, 27% of people had a referral delay of >3 months. Casting was performed in only 35% of cases with a plantar ulcer (percentage range: 0–68%). Vascular imaging in severe limb ischemia was performed in 56% of cases, ranging between 14% and 86% in the different centers ().
Another serious problem is the lack of availability of licensed podiatry education. Podiatry is considered to be the cornerstone of good diabetic foot care. In the >200 countries in the world, there exist only 19 trainings facilities with a course duration of 3 years or more, of which 13 are in Europe. It is estimated that well-trained podiatrists are active in only 35 countries. It is the aim of programs such as the Diabetic Foot Care Assistants education program varying from 2 weeks (basic course) to 10 weeks (advanced course) will help to fill the gap (), but so far only a very few countries have adopted such programs.
 
■ Patient-related factors
The presentation of patients to the appropriate healthcare providers is dependent on many factors. The most recognized barrier is the presence of neuropathy. The absence of the ‘gift of pain’ creates a patient delay. They do not feel problems with their feet, denying them the ability to act accordingly. The presence of retinopathy in people with diabetes may also prevent them from actually seeing callus, erythema, ulceration, or any other pending foot problem.
Education is therefore pivotal and needs to be provided to patients in a simple, consistent and repetitive manner. Lack of education has proven to be a risk factor for the occurrence of ulceration in >90% of cases in a study from Egypt (). Factors that need to be addressed in providing education are language barriers, illiteracy, availability of educational programs, and documentation. Unfortunately, there remains a lack of funding for preventive measures throughout the world.
A patient's fear of losing a limb may act as another barrier to attending a diabetic foot clinic. In many cultures, there are specific beliefs that prevent patients from getting appropriate care. Alternative healers are present in every corner of the world. This problem is not uniquely encountered in developing countries. In the most modern communities, specific alternative modalities are at hand. Religious habits or lifestyle choices that influence the risk of foot problems include barefoot walking or kneeling while at prayer.
 
■ Healthcare system
Differences in the financial organization of care directly influence the possibility of using care facilities. When all care is reimbursed by the government, care may be easily available to patients. However, when care is provided only by private insurance cover or even self-payment, certain types of care may be restricted or simply not obtainable.
On a more macroeconomical level, it is instrumental to realize that the amount of money dedicated to care as a whole and the diabetic foot in particular differs enormously between countries and fluctuates over time (). Ultimately the individual healthcare system at hand determines the availability of specific specialists, multidisciplinary teams, and the presence of protocols.
 
■ ACHIEVEMENTS
 
■ International Working Group on the Diabetic Foot
Diabetic foot ulcers and their consequences do not only represent a major personal tragedy for the person suffering from an ulcer and his/her family but also place a considerable financial burden on the healthcare system and society in general. Ulcers of the foot in diabetes are the source of major suffering and cost. At least 25% will not heal and up to 28% may result in some form of amputation.
Because of this devastating problem, experts in the field felt the need to do more than organizing and attending meetings to create more awareness to exchange research results and to discuss better management of diabetic foot problems. Internationally acknowledged guidelines were needed. Investing in a diabetic foot care guideline is one of the most cost-effective forms of healthcare expenditure, provided the guideline is goal focused and properly implemented. Therefore, the International Working Group on the Diabetic Foot (IWGDF) was founded in 1996.s15
Other aims of the IWGDF were to stimulate proper research and to guide scientific meetings, of which the very successful quadrennial ISDF (since 1991 in Noordwijkerhout, the Netherlands) is by far the most striking example.
The IWGDF is instrumental in acting as a consultant for the implementation of programs such as the ‘Step-by-Step’ (SbS) program, improving diabetic foot care in developing and low income countries, the ‘Train-the-Foot-Trainer, how to set up Step-by-Step program’ (TtFT) programs, the Diabetic Foot Care education program for Assistants, and postgraduate courses. In 2000, Sir George Alberti, President of the IDF at that time, invited the IWGDF to become a Consultative Section of the IDF.
 
■ Development of IWGDF guidelines
The guideline process started with a constituent meeting in Malvern, United Kingdom. A steering committee was installed and gathered in 1997 with the task of designing a first draft on a variety of topics (). In 1998, 23 representatives from 23 countries met to comment on the concept and to come to an agreement. In 1999, the IWGDF published the International Consensus on the Diabetic Foot and Practical Guidelines on the Management and the Prevention of the Diabetic Foot to Date for the first time. This publication has been translated into 26 languages, and more than 80,000 copies were distributed globally. In order to further implement the International Consensus document, the IWGDF recruited local champions as members of the IWDGF and these members now represent >100 countries around the world.
Workings groups of independent experts in the field were asked on a quadrennial basis to revise and update the chapters of the original text, according to current knowledge and standards. Since 2007, the guidelines have been based on evidence in the literature. At a Consensus Day (preceding the ISDF meetings) all representatives of the IWGDF network gather to discuss comments and to give their final approval of and undersign the quadrennial IWGDF Consensus guidelines ( and ). The most recent guidelines were launched in May 2011 (). This ongoing process is guided by the IWGDF Editorial Board ().
 
■ World Diabetes Day 2005
The theme for 2005 was ‘Diabetes and Foot Care,’ completing the series of themes on diabetes complications that began in 2001. The IWGDF/IDF Consultative Section was asked to lead this project. Unlike previous campaigns, where activity was concentrated on or around World Diabetes Day (WDD) on November 14th, the year marked the beginning of a year-long focus for the campaign. IDF had spread activities over the year in order to extract the maximum benefit from the awareness-raising opportunities that presented themselves. It was that goal that drove the awareness campaign for 2005. Preparation for an annual campaign has allowed the IDF to draw greater attention to the theme of WDD. This has been made possible thanks to the support and collaboration of the IDF's partners in the global diabetes community, the IWGDF country representatives, and its sponsors.
WDD 2005 reached its largest audience ever. The IWGDF/IDF held press conferences, TV interviews, and diabetic foot meetings in all regions. WDD was promoted at 53 important diabetes congresses, exhibitions, and meetings around the world. The Lancet devoted a special issue to diabetic foot disease (). WDD material was translated into 25 different languages. As a result of the 12-month global campaign, it is believed that information on diabetes-related foot problems reached half a billion people – including people with diabetes, healthcare providers, and, very importantly, healthcare decision makers.
Figure ii: International Guidelines on the Management and Prevention of the Diabetic Foot, Tunbridge, UK. June 1997 Steering Committee, sitting from left to right: Jan Apelqvist (Sweden), Gayle Reiber (USA), Lisbeth Vang (Denmark), Jenniffer A Mayfield (USA), Andrew JM Boulton (UK). Standing in front: CV Krishnaswami (USA). Back row: Nicolaas C Schaper (the Netherlands), the late Melcher GK Falkenberg (Sweden), David L Steed (USA), Henry Connor (UK), Per E Holstein (Denmark), Peter R Cavanagh (USA), William H van Houtum (the Netherlands), Lawrence A Lavery (USA), Karel Bakker (the Netherlands).
Figure iii: International Symposium on the Diabetic Foot (ISDF), Noordwijkerhout, the Netherlands, May 2011 IWGDF Consensus Day.
 
■ Website
The new IWGDF website was launched in March 2013. The complete 2011 Consensus guidelines (with French and Spanish translations) are on the site, as well as all the IWGDF and IDF Consultative Sections' programs and their implementation processes. In addition, the names and addresses of all of the IWGDF representatives from >100 countries are provided. A news page covering recent developments in ‘the foot world’ will be updated regularly. This important medium will not only unify the diabetic foot world but will also, without doubt, contribute to more awareness throughout the world ().
 
■ IMPLEMENTATION
In the new century, several implementation programs have been designed and implemented. The most important ones of these are the ‘Step-by-Step’ and ‘Train-the-Foot-Trainer’ programs.s16
Figure iv: International Symposium on the Diabetic Foot (ISDF), Noordwijkerhout, the Netherlands, May 2011: all members of the IWGDF working group.
These projects have delivered a tremendous spin-off effect and have led to better care and a reduction in LEAs.
 
■ Step-by-Step program
In 2003, the IWGDF, together with the Diabetic Foot Society of India (DFSI) and the Muhimbili University College of Health Sciences, Dar-es-Salaam, Tanzania (MUCHS), initiated a foot care project called ‘Step-by-Step, improving diabetic foot care in the developing world.’ This was made financially possible by the World Diabetes Foundation (WDF). Other successful projects as in the Caribbean region were financed by Rotary Clubs in several countries led and funded by the Rotary Club of Ledbury, UK, Rotary International, and IDF.'
The SbS is a 2-year project. Teams consisting of a doctor and a nurse or paramedic are invited to attend a basic and an advanced course. During the 2 years, data collection is mandatory. The goal is to improve educational skills and the management of diabetic foot problems. By doing so, the program has created a cascade effect and sustainability in a variety of regions and countries. An experienced national and international faculty is responsible for both teaching and the practical sessions. Medical equipment and educational materials are provided to all participants. Very successful pilot programs in India and Tanzania in 2004 and 2005 have led to the instigation of these projects in a dozen or more countries. Several countries have used the positive cascade effect of the SbS programs to continue their activities in so-called ‘Step-by-Step and on’, which has led to even more sustainability ().
If one takes the situation in Tanzania, before 2004 there was only one diabetic foot clinic in the whole country. After pivotal work by Dr Z. G. Abbas, the number of specialized foot clinics rose to 43 in 2009, allowing more people to receive appropriate foot care. He demonstrated in a recent publication that, the continuous expansion of foot clinics and the SbS programs, as well as an increasing interest in the problem generally, has led to a significant reduction in LEAs in his country ().
Thus far, this program has been successfully rolled out in India, Tanzania, Pakistan, Egypt, Botswana, Democratic Republic of Congo and Guinea, Mali, Kenya, and in the Caribbean region: Barbados, St Lucia, St Maarten, St Kitts, British Virgin Islands, Dominica, Antigua, Trinidad & Tobago, and Grenada.
Figure v: The front cover of the journal, The Lancet, 2005.
 
■ Train-the-Foot-Trainer program
The spin-off effect of the SbS courses is significant. Because of its success, there is a rapidly increasing demand for these programs in countries throughout the world. As a result, it was felt that in order to sustain this good initiative, a new model had to be adopted, which was robust both in financial and manpower terms.
For this reason, at the end of 2010, the Step-by-Step Development and Research Group (SSDRG) of the IWGDF initiated the idea of developing the ‘Train-the-Foot-Trainer’ program, describing how to set up a Step-by-Step project aimed to reach more regions in a shorter period and respond in an efficient way the demands of the s17population. Local top-level educators were invited to participate in regional programs.
The first pilot project was successfully held as a TtFT course in the SACA (South and Central America) region in Brasilia, Brazil, from December 5th to 8th, 2012. Almost all of the South American and some Central American countries participated. The cascade effect has been impressive: 80% of all 14 participating countries have, within a period of 6 months after the TtFT project, begun to set up basic SbS courses. The second TtFT course was held in June 2013 in Tobago. 21 countries from the Caribbean region and some Central American countries participated. More TtFT programs are planned to be executed in other regions around the world.
 
■ THE FUTURE
Overcoming barriers and creating change are dependent on individuals supporting the same cause and having sufficient influence on the different organizational levels within healthcare organisations. To acheive this, resources are desperately needed, as this process can be very time- and manpower-consuming. Therefore, the availability of motivated personnel, sufficient funds, materials, and limitless energy is key. However, it is also important for improvement that the stakeholders involved really do what they are saying they are doing in terms of the evidence-based management of patients with diabetes-related foot problems.
Educative prevention programs are mandatory to reduce suffering and costs. Healthcare departments have to take the lead: ‘pay first and harvest later’ has to be their adage. All health-care providers involved, including vascular and orthopedic surgeons as well as interventional radiologists in the field, have to work together in an interdisciplinary team. Diabetic foot clinics throughout the world should be recognized and credentialed, based on the minimal criteria such as have been developed in Belgium and Germany ().
 
■ ACKNOWLEDGEMENT
The author is grateful to Dr Edgar Peters, who produced .
Table i   Number of publications on diabetic foot disease since 1950
1950–1959
1960–1969
1970–1979
1980–1989
1990–1999
2000–2009
2010–2013
All dates
Diabetic foot disease*
65
270
451
1048
2488
4884
2221
11403
A: diabetic foot OR diabetic feet
34
106
210
702
2053
4226
1936
9232
B: diabetic ulcer
9
81
123
325
627
1394
691
3239
C: diabetic gangrene
40
124
185
252
295
330
116
1359
D: diabetic amputation
2
73
149
297
805
1457
709
3485
Ratio C+D/A+D
0.98
1.05
1.00
0.53
0.41
0.32
0.31
0.39
*Search term for diabetic foot disease: diabetic foot or diabetic feet or diabetic ulcer or diabetic gangrene or diabetic amputation (from Pub Med. Access date April 30, 2013).
■ REFERENCES
  1. Abbas ZG, Lutale JK, Bakker K, et al. The ‘Step by Step’ Diabetic Foot Project in Tanzania: a model for improving patient outcomes in less-developed countries. Int Wound J 2011; 8:169–175.
  1. Bakker K, Abbas ZG, Pendsey S. Step by Step, improving diabetic foot care in the developing world. A pilot study for India, Bangladesh, Sri Lanka and Tanzania. Pract Diabetes Int 2006; 23:365–369.
  1. Bakker K, Apelqvist J, Schaper NC. International Working Group on Diabetic Foot Editorial Board. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28:225–231.
  1. Bakker K, Schaper NC, on behalf of the International Working Group on the Diabetic Foot Editorial Board. The development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28:116–118.
  1. Barrett JP, Mooney V. Neuropathy and diabetic pressure lesions. Orthop Clin North Am 1973; 4:43–47.
  1. Bauman JH, Girling JP, Brand PW. Plantar pressure and trophic ulceration: an evaluation of footwear. J Bone Joint Surg 1963; 45-B: 652–673.
  1. Brand PW. The orthopaedic care of leprosy patients. J Christ Med Assoc India, Burma Ceylon 1950; 25: 1–8. Copyright 2008 John Wiley & Sons, Ltd. Diabetes Metab Res Rev 2008; 24:S7—S13. DOI: 10.1002/dmrr
  1. Brandaleone H, Standard S, Ralli EP. Prophylactic foot treatment in patients with diabetes mellitus. Ann Surg 1937; 105:120–124.
  1. Cavanagh P, Attinger C, Abbas Z, et al. Cost of treating diabetic foot ulcers in five different countries. Diabetes Metab Res Rev 2012; 28:107–111.
  1. Connor H. Some historical aspects of the diabetic foot disease. Diabetes Metab Res Rev 2008; 24:S7–S13.
  1. Edmonds ME, Blundell MP, Morris ME, et al. Improved survival of the diabetic foot: the role of a specialized foot clinic. Q J Med 1986; 60:763–771.
  1. El-Nahas MR, Gawish HMS, Tarshoby MM, State OI, Boulton AJM. The prevalence of risk factors for foot ulceration in Egyptian diabetic patients. Pract Diabetes Int 2008; 25:362–366.
  1. Godlee RJ. On amputation for diabetic gangrene. Med Chir Trans 1893; 76:37–55.
  1. Hodgkin T. On diabetes. Assoc Med J 1854; 2:916–918.
  1. Holstein P, Larsen K, Sager P. Decompression with the aid of insoles in the treatment of diabetic neuropathic ulcers. Acta Orthop Scand 1976; 4:463–468.
  1. International Diabetes Federation. Diabetes Atlas, 6th edn, 2013.
  1. IWGDF international consensus guidelines on the management and prevention of the diabetic foot 2011: www.iwgdf.org.
  1. Joslin EP. The treatment of diabetes mellitus. 2nd edn, 1917:423–427; 4th edn, 1928:785—802.Lea and Febiger:  Philadelphia,  PA.
  1. Joslin EP. The menace of diabetic gangrene. N Engl J Med 1934; 2:16–20.
  1. Kahn CR, Weir GC (eds). Joslin's diabetes mellitus, 13th edn. Lea and Febiger,  Philadelphia,  PA: 1994 p54.
  1. Lobmann R, Müller E, Kersken J, et al. Germany: Analysis of quality in specialized diabetic foot care centres. Diabet Foot J 2007; 10:68–72.
  1. Marchal de Calvi A. Des rapports de la gangr'ene et de la glycosurie. Gazette des Hâopitaux Civils et Militaires 1852; 25:178.
  1. McKittrick LS, Root HF. Diabetic Surgery. Lea and Febiger,  Philadelphia,  PA: 1928 pp92–104.
  1. Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 2008; 25:700–707.s18
  1. Oakley W. Diabetes in surgery. Ann R Coll Surg Engl 1954; 15:108–119.
  1. Rabinowitch IM. An address on diabetic gangrene. Can Med Assoc J 1927; 17:27–35.
  1. The Saint Vincent Declaration on diabetes care and research in Europe. Acta Diabetologia. 1989; 10:143–144.
  1. Stokes IAF, Faris IB, Hutton WC. The neuropathic ulcer and loads on the foot in diabetic patients. Acta Orthop Scand 1975; 46:839–847.
  1. Treves F. Treatment of perforating ulcer of the foot. Lancet 1884; 2:949–951.
  1. Tripp-Reimer T, Choi E, Skemp Kelley L, Enslein JC. Cultural barriers to care: inverting the problem. Diabetes Spectrum 2001; 14:13–22.
  1. Tulley S, Foster A, van Putten M, Urbančič-Rovan V, Bakker K. Diabetic foot care training in developing countries: addressing the skills shortage. Diabetic Foot J 2009; 12:14–22.
  1. van Houtum WH. Barriers to the delivery of diabetic foot care. Lancet. 2005; 366:1678–1679.
  1. van Houtum WH. Barriers to implementing foot care. Diabetes Metab Res Rev 2012; 28:112–115.
  1. Ward D. Footwear in leprosy. Lepr Rev 1962; 33: 94–105.47.