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Prevention of diabetes-related foot complications

 - Diabetes-related foot problems are a common complication of diabetes

 - Nurses play a pivotal role in the management and prevention of foot problems in people with diabetes

 - A large percentage of diabetes-related foot problems are avoidable with high quality care and support for self-management

The prevalence of diabetes continues to rise and it is estimated that by 2025 at least five million people will have diabetes in the United Kingdom.1 Advances in medical knowledge, technologies and treatments all contribute to people living longer. It is also acknowledged that diabetes is now the biggest cause of stroke, blindness, end-stage renal failure, amputation and premature death associated with cardiovascular disease. 

As well as the emotional and other costs to individuals, the social and economic costs of diabetes are becoming an increasing burden.2 In 2010-11 it was estimated that approximately 10% of the NHS budget was spent on diabetes and, of this, somewhere in the region of 80% was spent on treating potentially avoidable complications of the condition.3

The National Service Framework for Diabetes4 was developed with the intention of improving standards of care for people with diabetes and reducing variations in care and National Institute of Health and Care Excellence (NICE) quality standards for diabetes in adults were published in 2011.5 Despite guidance and recommendations, it appears that variations still exist. Information from the National Diabetes Audit 20116,7 indicates that there continues to be variation in the number of people over the age of 12 receiving the care processes recommended by NICE1,6,7 with a significant number of adults with diabetes not receiving their '15 Healthcare essentials'.8

Diabetes-related foot problems are a common complication of diabetes. Fifteen in every hundred people with diabetes will develop a foot ulcer in their lifetime.9

Key facts in diabetes-related foot problems

The numbers

Based on United Kingdom population surveys, prevalences of diabetes-related foot complications recorded are:

 - 23-42% for neuropathy.

 - 9-23% for vascular disease.

 - 5-7% for foot ulceration.10

Approximately 61,000 people with diabetes are thought to have foot ulcers at any given time.11 Around 6,000 people with diabetes have leg, toe, or foot amputations each year, many of which are thought to be avoidable,11 and the risk of amputation in a person with diabetes is 23 times that of someone without diabetes.11

The cost 

Approximately £1 in every £150 the NHS spent in England 2010-11 was for diabetes-related foot ulceration and amputation. This was equivalent to 0.6-0.7% of NHS expenditure with approximately 10% of the total NHS budget being spent on diabetes.12

The cause 

Poorly controlled diabetes increases the risk of diabetes-related complications. The main diabetes-related foot complications are associated with nerve damage or damage to the blood supply. Active ulceration increases the risk of amputation. With the correct management up to 80% of amputations are avoidable.13

While not all people with diabetes will develop foot complications, some of the important factors, which may lead to amputation, are considered to be:

 - Peripheral neuropathy: reduced nerve functioning due to peripheral diabetic neuropathy. This means that the nerves which usually carry pain sensation to the brain from the feet do not function as well as they should. 

 - Peripheral arterial disease: narrowing of the arteries that can reduce the blood flow to the feet.

 - Significant structural foot deformities: resulting in areas of increased pressure which may lead to ulceration.

 - Significant callus: resulting in increased pressure to underlying tissues which may result in a breakdown and ulceration.

 - Minor foot trauma: causing injury which may lead to ulceration. 

 - Poorly fitting footwear: resulting in trauma to areas of the foot which may lead to ulceration.

 - Previous foot ulceration: this is the highest risk factor for future ulceration visual/mobility problems - resulting in the patient being unable to check their feet.10

Amputations and foot ulcers have a huge impact on quality of life, with up to 80% of people dying within five years of having had an amputation.13 Alongside this, amputation rates vary widely between and within geographical areas.14

The role of the primary care or community nurse

All healthcare professionals have an important role to play in the fight against diabetes-related complications - prevention, reducing hospital admissions and amputations. Given how common diabetes-related foot problems are they should be everybody's business. 

Nurses in the United Kingdom work in a variety of settings, and play a variety of crucial roles in the prevention and management of diabetes-related foot complications. 

It is important to remember that most people with diabetes spend only about 1% of their time with healthcare professionals, the rest of the time they are self-managing their condition. Active engagement in discussions and care planning to support self-management is essential. 

Many diabetes structured education programmes only mention diabetes-related foot complications briefly, if at all. Lifestyle advice and adjustments to dietary intake and physical activity levels requires some consideration, and where possible people with diabetes who smoke should be reminded of the benefits of stopping smoking. 

There is evidence that improvements to blood glucose, blood pressure and blood lipids control can positively impact on reducing the likelihood of diabetes-related complications. 

Community nurses and nurses working in nursing homes or community hospital settings, when providing holistic care for people with diabetes, with or without other long-term conditions, should be aware of the increased risk of diabetes-related foot complications associated with reduced levels of mobility and possibly reduced ability to self-care. 

Nurses may or may not undertake the annual foot review of a person with diabetes. At a minimum they should be aware of potential problems and be able to signpost people with diabetes should they require information, support and/or onward referral. 

It is important that people with diabetes receive a good quality diabetes foot check and the information that they need to help prevent or manage diabetes-related foot problems. 

In many areas, this will be undertaken by the general practitioner, practice nurse or healthcare assistant or healthcare support worker, depending on the configuration of the practice diabetes team. 

Best practice and current recommendations

It has been suggested that “people with diabetes should be considered to have 'at-risk' feet unless proven otherwise.”15 

Figure 1 illustrates the 'Footcare pathway for people with diabetes', republished courtesy of Diabetes UK, from the Putting Feet First campaign launched in 2012.16 

This supports the general management approach to the prevention and management of diabetes-related complications, and the recommendations for care of people with foot emergencies and foot ulcers respectively, from the 2004 NICE Clinical Guideline 10.17

General management approach (17)

 - Effective care involves a partnership between patients and professionals, and all decision making should be shared.

 - Arrange recall and annual review as part of ongoing care.

 - As part of annual review, trained personnel should examine patients' feet to detect risk factors for ulceration. 

 - Examination of patients' feet should include:

 1. Testing of foot sensation using a 10g monofilament or vibration

 2. Palpation of foot pulses

 3. Inspection of any foot deformity and footwear.

 - Classify foot risk as:

 1. At low current risk.

 2. At increased risk.

 3. At high risk.

 4. Ulcerated foot.

Care of people with foot emergencies and foot ulcers17

 - Foot care emergency (new ulceration, swelling, discolouration).

 1. Refer to multidisciplinary foot care team within 24 hours.

 - Expect that team, as a minimum to:

 1. Investigate and treat vascular insufficiency.

 2. Initiate and supervise wound management.

 - Use dressings and debridement as indicated.

 - Use systemic antibiotic therapy for cellulitis or bone infection as indicated.

 1. Ensure an effective means of distributing foot pressures, including specialist footwear, orthotics and casts.

The importance of people having their foot checks (with socks and shoes off) cannot be emphasised enough.16 As part of the Putting Feet First campaign literature is available for patients on an easy test they can get their friends or relatives to do the 'touch the toes test'.18 

There are also a number of other accompanying resources, such as information leaflets for each of the levels of risk, which can be individualised.

Following an annual diabetes foot review, people with diabetes should: 

 - Be told their risk status and understand the implications of it.

 - Know how to look after their own feet.

 - Realise the importance of urgently seeking medical attention in the event of any problems.

It is important that people with diabetes are given sufficient information to help them to enable the early identification of problems so that they can seek appropriate support, advice and onward referral if required. 

Readers are also encouraged to visit the interactive online resource 'Diabetes Foot Screening - Foot Risk Awareness and Management Education'19 at for 

further information and learning and development, and addresses the competences required to undertake a diabetes foot assessment. 

At the Annual Professional Conference Diabetes UK launched their most recent tool 'How to Spot a Foot Attack'. It is aimed at people with diabetes who are at high risk of a 'foot attack'. It is a booklet which gives people with diabetes vital information to access help quickly, and includes a card that the person can keep in their wallet with important contact numbers they can use in the event of a foot emergency.20

It may be useful for nurses and practice diabetes teams to consider the following:

 - What are the roles of the various members of the practice team in relation to the prevention and management of diabetes-related foot problems?

 - Who will undertake the annual foot review?

 - Are we recording the patient's foot risk status correctly to meet the requirements of the Quality Outcomes Framework?

 - What information and resources do we have available to give to patients so that they understand their risk status?

 - Do we have the latest resources from Diabetes UK and/or the local specialist teams?

 - What is the referral pathway to and the contact details for

 1. Community podiatry?

 2. The foot protection team?

 3. The specialist diabetes foot clinic?

 - What other opportunities do we have to support and educate people with diabetes regarding prevention of diabetes-related foot problems?


While it is recognised that diabetes-related foot complications place a huge burden on the individual and on the NHS, it is certain that more can be done to decrease the number of people affected by this common yet avoidable problem. 

Nurses have a pivotal role to play, however, partnership working with people with diabetes, other healthcare professionals and clinical commissioning groups (CCGs), is essential in efforts to increase knowledge, action and service provision in relation to this important area, with the aim of reducing diabetes-related foot complications, ulceration and unnecessary and avoidable amputations, to ultimately improve the quality of life for people with diabetes. 


1. Diabetes UK. State of the Nation, England 2013. London: Diabetes UK; 2013.

2. McInness A. Diabetic foot disease in the United Kingdom: about time to put feet first. Journal of Foot and Ankle Research 2012;5:26.

3. Hex N, Bartlett C, Wright D, Taylor M, Varley D. Estimating the current and future costs of Type 1 and Type 2 diabetes in the UK, including direct health costs and indirect societal and productivity costs. Diabetic Medicine 2012; 29:855-862. 

4. Department of Health. National Service Framework for Diabetes. London: Department of Health; 2001. 

5. National Institute for Health and Clinical Excellence. NICE quality standards for diabetes in adults. London: NHS; 2011.Available at

6. Health and Social Care Information Centre. National Diabetes Audit 2011-12. Report 1: Care Processes and Treatment Targets. Leeds: HSCIC; 2013.  

7. Health and Social Care Information Centre. National Diabetes Audit 2011-12. Report 2: Complications and Mortality. Leeds: HSCIC; 2013. 

8. Diabetes UK. 15 Healthcare Essentials - the care you should receive. London: Diabetes UK; 2013.

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10. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005;12:1719-24. 

11. NHS Diabetes. Factsheet No 37. Foot care for people with diabetes in the NHS in England: The economic case for change. London: NHS Diabetes; 2012. 

12. Right Care. NHS Atlas of Variation in Healthcare. NHS: London; 2011.

13. Khanolkar MP, Bain SC, Stephens JW The Diabetic Foot. QJM 2008;101:685-95.

14. Diabetes UK. Postcode lottery of diabetes amputations “getting worse”. Diabetes UK, London; 2014.  

15. Hall G. Foot care and surveillance. In: Hall G, Providing diabetes care in general practice : a practical guide to integrated care (5th edn). London: Class Publishing; 2007.

16. Diabetes UK. Putting Feet First. London: Diabetes UK; 2012.

17. National Institute for Health and Clinical Excellence. NICE Clinical Guideline 10 Type 2 diabetes - prevention and management of foot problems. London: NHS; 2004.

18. Diabetes UK. Touch the toes test. Diabetes UK: London; 2012.

19. Scottish Diabetes Group. Diabetes Foot Screening - Foot Risk Awareness and Management Education (FRAME). Scotland: The University of Edinburgh; 2014.

20. Young B. Preventing a “foot attack”. Diabetes & Primary Care 2014;16:2:62.