Diabetes is one of the commonest chronic diseases in the UK and its prevalence is increasing. That is the stark statement that opens the new NICE guideline on diabetic foot problems.1 In 2013, it says, there were almost 2.9 million people in the UK diagnosed with diabetes but by 2025 that figure is expected to rise to more than 5 million.
Foot complications are common in people with diabetes. Around 10 per cent of people with the disease will have a diabetic foot ulcer at some point in their lives. NICE defines this as “a localised injury to the skin and/or underlying tissue, below the ankle, in a person with diabetes”.
The risk of foot problems in people with diabetes is increased, the guidelines say, largely because of either diabetic neuropathy (nerve damage or degeneration because of the high blood sugar levels) or peripheral arterial disease (poor blood supply due to diseased large and mediumsized blood vessels in the legs), or both:
NICE goes on to point out that diabetes is also the commonest cause of non-traumatic limb amputation, with diabetic foot ulcers preceding more than 80 per cent of amputations in people with diabetes.
After a first amputation, people with diabetes are twice as likely to have a subsequent one as people without the disease. According to Diabetes UK, more than 135 people with diabetes have a leg, foot or toe amputated each week.
It should be noted that, 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 sub-groups than in the general population of people with diabetes in the UK.
Examples of limb-threatening and life-threatening diabetic foot include:
“Diabetic foot problems are serious and if not managed appropriately can lead to minor or major amputations and even death,” says Rachel Berrington, diabetes specialist nurse and NICE guideline developer. “Mortality rates after diabetic foot ulceration and amputations are high, with up to 70 per cent of people dying within five years of having an amputation and around 50 per cent dying within five 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. This guideline sets the standard for managing diabetic foot problems for all people with diabetes, including children and young people, in all NHS settings, says Berrington.
“For example, the guideline identifies people who need immediate attention from the multidisciplinary foot care service or acute services. The guideline also highlights the need for clear information and education for all people with diabetes about diabetic foot problems, so they know what care to expect, the importance of foot care and who to contact in an emergency.”
Foot problems in people with diabetes can quickly become devastating for the person concerned – and extremely costly for the NHS. A report published in 2012 estimated that around £650 million (£1 for every £150 the NHS spends) goes on foot ulcers or amputations each year.
With foot care screening programmes across the UK described by NICE as variable, the guidance covers the prevention and management of foot problems in children, young people and adults with diabetes, with the aim of reducing variation in practice. It recommends that commissioners and service providers ensure there is a foot protection service for preventing, treating and managing diabetic foot problems in the community.
Community pharmacy is ideally placed to supply relevant information and signpost people to the help they need.
NICE advises that patients with diabetic foot problems and/or their family members or carers should be provided with information and clear explanations about the risk of developing a diabetic foot problem when diabetes is diagnosed, during assessments, and if problems arise.
In April, Diabetes UK estimated that more than 400,000 people with diabetes in England were not having an annual foot check, despite the recommendation by NICE. The charity also claimed that in many cases where people do get foot checks, they are not thorough enough, with some people not even being asked to remove their shoes or socks.3
Its Putting Feet First campaign4 encourages all healthcare professionals to:
The community pharmacy team can help by:
It is also important to make sure people with diabetic foot problems know to:
The risk of developing a diabetic foot ulcer is assessed as: