Diabetic foot problems: prevention and management

Context

Diabetes is one of the most common chronic diseases in the UK and its prevalence is increasing. More than 4.9 million people in the UK have diabetes. Around 90% of these people have type 2 diabetes, around 8% have type 1 diabetes, and about 2% have rarer types of diabetes. By 2030, it is estimated that more than 5.5 million people in the UK will have diabetes. In England, the number of people diagnosed with diabetes increased between 2006 and 2019 from 1.9 million to 3.3 million. The life expectancy of people with diabetes is shortened by up to 15 years, and 75% die of macrovascular complications.

The risk of foot problems in people with diabetes is increased, largely because of either diabetic neuropathy (nerve damage or degeneration) or peripheral arterial disease (poor blood supply due to diseased large- and medium-sized blood vessels in the legs), or both. Peripheral arterial disease affects 1 in 3 people with diabetes over the age of 50 and can also increase the risk of heart attack and stroke. For more information, see the NICE guideline on peripheral arterial disease.

Foot complications are common in people with diabetes. It is estimated that 10% of people with diabetes will have a diabetic foot ulcer at some point in their lives. A foot ulcer can be defined as a localised injury to the skin and/or underlying tissue, below the ankle, in a person with diabetes.

Diabetes is the most common cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80% of amputations in people with diabetes. More than 7,000 diabetes-related amputations are reported in the UK per year. People are at higher risk of diabetes-related major and minor limb amputations if they are male, from the most deprived areas, aged over 65, or of white European family background. After a first amputation, people with diabetes are twice as likely to have a subsequent amputation as people without diabetes. Mortality rates after diabetic foot ulceration and amputation are high, with up to 70% of people dying within 5 years of having an amputation and around 50% dying within 5 years of developing a diabetic foot ulcer. This high mortality rate is believed to be associated with cardiovascular disease, and emphasises the importance of good diabetic and cardiovascular risk management. Although people of South Asian, African and African Caribbean family origin are more at risk of diabetes, there is no evidence that the prevalence of diabetic foot ulceration and amputation is higher in these subgroups than in the general population of people with diabetes in the UK.

Foot problems in people with diabetes have a significant financial impact on the NHS through primary care, community care, outpatient costs, increased bed occupancy and prolonged stays in hospital. The NHS spends at least £10 billion a year on diabetes, equivalent to 10% of its budget. Of this, 80% is spent on treating complications, and diabetic foot care is estimated to cost the NHS in England over £1 billion per year. Diabetic foot care accounts for more healthcare costs in England than breast, prostate and lung cancer combined. Much of these costs come from treating prolonged and severe ulceration.