Over my career, diabetes foot disease has evolved from a ‘Cinderella’ subject to a subspecialty in diabetes and endocrinology. This increased recognition is long overdue. The cost of managing foot ulcers in diabetes has been estimated at £1 billion annually in England alone,1 and accounts for 450,000–900,000 hospital bed days per year.2
Among the thousands of amputations performed each year, the five-year mortality following major amputation is over 70%.3 A longitudinal study found a hazard ratio for death of 2.2 post-amputation, after adjusting for known risk factors, including cardiovascular disease, chronic kidney disease and co-morbidities.4
While much of the focus has been on amputation rates, the impact of foot ulcers is often neglected. The five-year mortality for someone with a diabetes foot ulcer is greater than for most major cancers.5 Most of us are aware that diabetes is associated with a higher mortality rate. However, a recent study of 12,000 people with type 2 diabetes in Salford, UK, found that most of this excess mortality was amongst those with a history of diabetes foot disease, with a standardised mortality ratio (adjusted for deprivation) of 1.13 for those with no history of a foot ulcer, compared to 2.6 for those with a history of foot ulceration.6
'While much of the focus has been on amputation rates, the impact of foot ulcers is often neglected. The five-year mortality for someone with a diabetes foot ulcer is greater than for most major cancers.'
When looking at these stark population data, it can be easy to forget the huge impact on the person living with a diabetes foot complication. Having a diabetes foot ulcer is associated with a lower quality of life than being on haemodialysis or having a diabetes macrovascular complication.6 Foot ulcer management carries the burden of frequent clinic visits and restrictions on activity and work, which in turn create financial insecurity, loss of self confidence, and stress, as well as the stigma of a chronic wound and anxiety about amputation.
THE UNDERLYING BIOLOGY
Our feet are amazing pieces of engineering, with 26 bones, 30 joints and over 100 muscles, tendons and ligaments maintained by a sophisticated vasculature. The foot is an ecosystem of interconnected anatomy and physiology that maintains foot health and allows most of us to take our feet for granted. Infected foot wounds need 5–10 times more blood flow than intact skin. Diabetes neuropathy not only leads to loss of protective pain sensation, it also disrupts the autonomic autoregulation of arteries and capillary beds. This, combined with macrovascular disease, means infection and necrosis can establish rapidly.
ADVANCES IN MANAGEMENT
There have been major advances in our approach to diabetes foot disease. Osteomyelitis is recognised as an important cause of chronic foot ulcers and amputation, which can often be treated successfully with targeted antibiotics.7 Tibial angioplasty and stenting are commonplace, with high success rates, and developments in offloading and orthopaedic reconstruction are able to address ulcers secondary to foot deformity, including Charcot’s. However, major variation in foot outcomes persists. Between 2018 and 2021 there was a fourfold variation in major amputations and an eightfold variation in minor amputations across Clinical Commissioning Groups in England.8
The National Diabetes Foot Care Audit (NDFA) has shown that seamless integration of foot services with strong collaborative relationships across community and hospital teams significantly improve outcomes for people with foot complications.2 These data are supported by a recent analysis of clinical negligence claims for diabetes foot complications.9 Sadly, overstretched budgets and current commissioning arrangements mean such integration and collaboration are becoming increasingly difficult.
IMPROVING DATA COLLECTION
'Seamless integration of foot services with strong collaborative relationships across community and hospital teams significantly improve outcomes for people with foot complications.'
High-quality data are essential to improving outcomes. However, we still do not even know how many people have foot ulcers. Case ascertainment for the NDFA remains low and this will continue to be a problem while data collection remains manual.
Counting foot ulcers presents challenges, with individual patients often having multiple ulcers – some healing, some relapsing. However, the real challenge is making foot disease a sufficient priority, so that the resources are found to create the foot templates in our electronic patient records, and the algorithms to count ulcers reliably from these data.
AVOIDING STIGMA IS IMPORTANT
Foot complications happen because the ecosystem has failed. Yet healthcare professionals often criticise the individual for not taking better care, wearing the wrong shoes or simply walking too much. For many, taking sick leave is not an option, and resting their foot would mean income or even job loss. Wanting to take your grandchildren to the park should not be equated with not caring about one’s health.
The stigma and judgement projected by health professionals are internalised by patients. However, the huge regional variations in foot outcomes show that it is our healthcare structures and ourselves, as health professionals, that need to do better. The Language Matters movement10 has made huge strides in changing the way health professionals think and talk about diabetes, and is a must for all doctors working in diabetes.
The burden of diabetes foot disease remains too high. High-quality research and innovation are essential, but we need to be much smarter in collecting and using data, with strong leadership at local and national levels, to ensure integration of foot services across community and secondary care. We need to recognise the huge individual burden of diabetes foot disease, and ensure we respond with kindness and empathy.
WING MAY KONG
Consultant Physician Endocrinology and Diabetes, London Northwest NHS Trust, and Head of Ethics, Undergraduate Medicine, Imperial College London
REFERENCES
1. Kerr M et al. 2019 Diabetic Medicine https://doi.org/10.1111/dme.13973.
2. Health Quality Improvement Partnership 2019 National Diabetes Foot Care Audit: Fourth Annual Report https://www.hqip.org.uk/resource/national-diabetes-foot-care-audit-fourth-annual-report.
3. Armstrong DG et al. 2023 JAMA https://doi.org/10.1001/jama.2023.10578.
4. Hoffstad O et al. 2015 Diabetes Care https://doi.org/10.2337/dc15-0536.
5. Kerr M 2012 Foot Care for People with Diabetes: the Economic Case for Change https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/footcare-for-people-with-diabetes.pdf.
6. Stedman M et al. 2023 Diabetes, Obesity & Metabolism https://doi.org/10.1111/dom.15260.
7. Senneville É et al. 2024 Diabetes/Metabolism: Research & Reviews https://doi.org/10.1002/dmrr.3687.
8. Office for Health Improvement and Disparities 2025 Public Health Profiles: Diabetes https://fingertips.phe.org.uk.
9. Mottolini N 2022 Diabetes and Lower Limb Complications: a Thematic Review of Clinical Negligence Claims https://resolution.nhs.uk/2022/06/13/diabetes-and-lower-limb-complications-a-thematic-review-of-clinical-negligence-claims.
10. NHS England 2023 Language Matters: Language and Diabetes https://www.england.nhs.uk/long-read/language-matters-language-and-diabetes.
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