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The Diabetic Foot

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• First Online: 10 February 2017
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• Dennis Shavelson 2 ,
• John Steinberg 3 &
• Bradley W. Bakotic 4  

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Diabetes is reaching epidemic proportions and carries the risk of multiple complications. Diseases of the foot are among the most feared complications of diabetes. Physician education plays a significant role in preventing, diagnosing, monitoring, and treating the diseases of the foot. This chapter is designed to provide an overview of both education about and the care of diabetic feet. It contains tables and illustrations meant to allow readers to “take home” important information they can share with patients and colleagues.

As this is the third printing of this text and chapter, I feel obliged to preface this update by stating that researchers found a 52 % drop in the incidence of diabetic foot infection in the USA from 1996 to 2010. The findings of a study published in the American Journal of Infection Control also revealed that lower-extremity amputation from diabetic foot infection dropped from 33.2 % in 1996 to 17.1 % in 2010 (Duhon BM, et al., Am J Infect Control. 2015. doi:10.1016/j.ajic.2015.09.012).

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Diabetic Foot

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Department of Surgery, Beth Israel Medical Center, New York, NY, USA

Dennis Shavelson

Division of Wound Healing, Department of Plastic Surgery, Georgetown University School of Medicine, Washington DC, USA

John Steinberg

Dermatopathologist & Chief Executive Officer, Integrated Physician Solutions, Alpharetta, Georgia, USA

Bradley W. Bakotic

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Correspondence to Dennis Shavelson .

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Lenox Hill Hospital Division of Endocrinology, New York, New York, USA

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Shavelson, D., Steinberg, J., Bakotic, B.W. (2017). The Diabetic Foot. In: Poretsky, L. (eds) Principles of Diabetes Mellitus. Springer, Cham. https://doi.org/10.1007/978-3-319-20797-1_25-2

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DOI: https://doi.org/10.1007/978-3-319-20797-1_25-2

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Clinical updates

Diabetic foot, satish chandra mishra.

1 Department of Surgery, Bhabha Atomic Research Centre Hospital, Mumbai, India

Kunal C Chhatbar

2 KHM Hospital, Mumbai, India

Aditi Kashikar

3 Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India

Abha Mehndiratta

4 Global Health and Development Group, Imperial College London, St Mary’s Hospital, London, UK

Associated Data

What you need to know.

• Diabetic foot can be prevented with good glycaemic control, regular foot assessment, appropriate footwear, patient education, and early referral for pre-ulcerative lesions
• Examine the feet of people with diabetes for any lesions and screen for peripheral neuropathy and peripheral arterial disease, which can lead to injuries or ulceration
• Refer patients with foot ulceration and signs of infection, sepsis, or ischaemia immediately to a specialised diabetic foot centre for surgical care, revascularisation, and rehabilitation

Foot disease affects nearly 6% of people with diabetes 1 and includes infection, ulceration, or destruction of tissues of the foot. 2 It can impair patients’ quality of life and affect social participation and livelihood. 3 Between 0.03% and 1.5% of patients with diabetic foot require an amputation. 4 Most amputations start with ulcers and can be prevented with good foot care and screening to assess the risk for foot complications. 5 We provide an update on the prevention and initial management of diabetic foot in primary care.

Sources and selection criteria

This clinical update is based on recommendations in the standard treatment guideline, The diabetic foot: prevention and management in India 2016, published by the Indian Ministry of Health and Family Welfare. 33 A multidisciplinary guideline development group consisting of surgeons, primary care practitioners, and a patient representative developed these guidelines, with inputs from experts in diabetes, diabetic foot rehabilitation, and vascular surgery. The group included representation from rural and urban India, and public and private sectors.

The guideline development group selected recommendations from the National Institute for Health and Care Excellence clinical guideline 19. Diabetic foot problems: prevention and management. Updated 2016, International Working Group on the Diabetic Foot guidance on the prevention of foot ulcers in at-risk patients with diabetes 2015, National Institute for Health and Care Excellence. Peripheral arterial disease: diagnosis and management. Guideline 147, 2012, and Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections, 2012. 9 10 21 32 Some recommendations were adopted unchanged, whereas others were adapted taking into account the challenges of a low resource setting, such as availability of public and private health infrastructure, equipment, staffing, and current capacity at different levels of care.

What causes diabetic foot?

Uncontrolled diabetes contributes to the development of neuropathy and peripheral arterial disease by complex metabolic pathways. 6 Loss of sensation caused by peripheral neuropathy, ischaemia due to peripheral arterial disease, or a combination of these may lead to foot ulcers. A systematic review (78 studies from 84 cohorts) reports a prevalence of 0.003-2.8% for diabetes related peripheral neuropathy and 0.01-0.4% for diabetes related peripheral arterial disease. 4 Figure 1 ​ 1depicts depicts factors that contribute to foot complications.

Fig 1  Risk factors and mechanism for foot ulcer and amputation

Diabetes is also implicated in Charcot arthropathy, which involves progressive destruction of the bones, joints, and soft tissues, most commonly in the ankle and foot. Diabetes related Charcot’s arthropathy has a reported prevalence between 0.08% and 13%, but there are no high quality epidemiological studies on Charcot’s foot. 7 8 A combination of neuropathy, abnormal loading of foot, repeated micro trauma, and metabolic abnormalities of bone leads to inflammation, causing osteolysis, fractures, dislocation, and deformities.

In low and middle income countries barefoot walking, lack of awareness, delay in seeking care, and shortage of trained healthcare providers and foot care services are common factors that add to the burden of foot disease.

How is it diagnosed?

A thorough foot examination is important to detect the disease early. Screening for peripheral neuropathy and peripheral arterial disease can help identify patients at risk of foot ulcers. A history of ulcers or amputations and poor glycaemic control increase the risk.

Assess the patient’s general condition for signs of toxicity or sepsis such as feeling unwell, looking sick, showing abnormal behaviour, circulation, or respiration, with or without fever. Examine the feet at each follow-up visit for active disease such as ulceration or gangrene (fig 2 ​ 2). ). Look for lesions such as fungal infection, cracks and skin fissures, deformed nails, macerated web spaces, calluses, and deformities such as hammer toes, claw toes, and pes cavus, which increase the risk of ulceration (fig 3 ​ 3). ). Feel the temperature of the feet with the dorsum of your hand. A cold foot might suggest ischaemia, and increased warmth with redness and swelling might suggest inflammation such as acute Charcot foot or cellulitis.

Fig 2  Gangrene and ulcer in foot at high risk (previous toe amputation)

Fig 3  Hammer toe deformity with callus and ulcer. Hammer toe is caused by weakened muscles in the foot. The joint connecting the foot with the toe bends upwards (metatarsophalangeal extension) and the joint in middle of the toe bends downwards towards the floor (proximal interphalangeal flexion). This results in the toe curling under the foot and being subjected to excessive ground reaction forces during walking.

Peripheral neuropathy

The aim of screening is to identify patients with loss of protective sensation in the feet. Most guidelines recommend the 10 g monofilament for neuropathy assessment (fig 4 ​ 4) ) in people with diabetes. 9 10 This monofilament exerts a 10 g buckling force when it bends. An inability to sense a 10 g pressure is the current consensus definition of loss of protective sensation. The test is portable, cheap, and easy to perform (box 1). 12 15 Despite the widespread use of the monofilament test, its accuracy in diagnosing neuropathy is variable. 16 The test may be combined with another test to screen for neuropathy, such as a biothesiometer or a graduated tuning fork (Rydel Seiffer) to assess vibration perception threshold. 17 18

Fig 4  Monofilament test: testing sites and application. The nine plantar sites are the distal great toe; third toe; fifth toe; first, third, and fifth metatarsal heads; medial foot, lateral foot, and heel; and one dorsal site

Box 1: Monofilament test (fig 4 ​ 4 )

Procedure —Ask the patient to sit or lie down with both legs stretched out and soles exposed. Explain the procedure and make him or her familiar with the sensation by applying the monofilament on a sensitive area such as the palm. Ask the patient to close his or her eyes and to say “yes” every time touch is felt on the soles, no matter how lightly it is perceived. Place the monofilament at 90° to the skin and press it till it buckles to 1 cm, then hold there for 1-2 seconds and remove. 11 Test different sites in a random sequence with a pause (sham application) to prevent the patient from guessing the next application. If the patient fails to respond at a site, revisit the same site two more times in a random sequence during the assessment. If the patient does not perceive the sensation all the three times, then record the result as loss of protective sensation. 11 Loss of protective sensation even at a single site puts the patient at risk for foot complications.

Test sites and threshold —Most studies recommend testing at 10 sites.

Inability to perceive a 10 g monofilament three times at even a single site means the patient has loss of protective sensation. 11 12

Inter-observer variability —This is reported to be more on the heels, with a higher chance of a false positive result. 13 Exercise caution before labelling a heel as insensate, especially if screening a population where barefoot walking is common.

Durability of monofilaments —Monofilaments tend to fatigue with repeated use, and a 24 hour recovery period is recommended after 100 compression cycles. 14 Replace a monofilament after three months of regular use.

Peripheral arterial disease

Ask for a history of intermittent claudication and rest pain, which suggest peripheral arterial disease. 19 Palpate the posterior tibial artery and dorsalis pedis artery in both feet and record pulsations as absent or present. 20

The ankle brachial index is an adjunct measure to diagnose peripheral arterial disease. 19 21 It is the ratio of the highest systolic blood pressure at the ankle (dorsalis pedis artery or posterior tibial artery) to the systolic blood pressure at the arm, and is measured using a Doppler device. 10 See box 2 on grading the severity of obstruction. Measurement of the ankle brachial index is user dependent. People with diabetes can often have falsely raised ankle brachial index levels as a result of poor compressibility from calcified arteries. 21 Furthermore, availability of equipment, time constraints, and lack of training are reported as major barriers to ankle brachial index testing in primary care. 23 24 25

Box 2: Ankle brachial index

The severity of peripheral arterial disease is interpreted 22 :

• 0.91-1.3—Normal
• 0.70-0.90—Mild obstruction
• 0.40-0.69—Moderate obstruction
• <0.40—Severe obstruction
• >1.3—Poorly compressible vessel

On the basis of this initial assessment, patients can be categorised as having a low, moderate, or high risk of diabetic foot (see infographic). 9

How can it be prevented?

Regular foot examination.

The suggested frequency for follow-up is based on expert consensus (see infographic). For people at low risk, continue annual foot assessments as they could progress to moderate or high risk. Emphasise the importance of foot care and monitoring glycaemic control.

More frequent follow-up is advised in patients at moderate or high risk, such as those with a foot deformity or with a diagnosis of peripheral neuropathy or peripheral arterial disease at initial assessment. Repeat testing for neuropathy is not necessary if diagnosed previously. Neuropathy reversal is not established in studies. A quick inspection for a breach in skin integrity or ulceration should suffice. Patients with asymptomatic peripheral arterial disease may be followed up in primary care and managed as in guidelines for peripheral arterial disease. 21

Refer patients with calluses and deformed toe nails to preventive podiatry services for basic nail and skin care, including debridement of calluses. Timely referral to foot protection services for control of risk factors in patients with diabetes prevents infection, gangrene, amputation, or death, and reduces hospital admissions and costs. 9

Glycaemic control

Early and good glycaemic control is effective in preventing neuropathy but there is a lack of studies to show that glycaemic control reverses neuropathy. 26 Discuss optimal blood sugar and glycated haemoglobin (HbA 1c ) targets with patients and monitor these as per standard guidelines for diabetes care to prevent or slow the progression of peripheral neuropathy. 27 28

Patient education

Offer people with diabetes or their caregivers, or both, oral and written information on:

• The importance of blood glucose control and modifiable cardiovascular risk factors such as diet, exercise, body weight, and cessation of smoking.
• The importance of foot care and advice on basic foot care (see box 3). While offering advice consider the patient’s cultural practices and religious beliefs as well as social and family support.
• The person’s current risk of developing a foot problem.
• When to seek professional help and who to contact in foot emergencies.

Box 3: Tips on foot care for people with diabetes 19

• Inspect both feet daily, including the area between the toes. Ask a caregiver to do this if you are unable to.
• Wash the feet daily with water at room temperature, with careful drying, especially between the toes.
• Use lubricating oils or creams for dry skin, but not between the toes.
• Cut nails straight across.
• Do not remove corns and calluses using a chemical agent or plaster. They should not be excised at home and must be managed by trained staff.
• Always wear socks with shoes and check inside shoes for foreign objects before wearing them.
• Avoid walking barefoot at all times.
• Ensure a qualified healthcare provider examines your feet regularly.
• Notify the healthcare provider at once if a blister, cut, scratch, or sore develops.

Evidence for the effectiveness of patient education on foot care is lacking. A Cochrane review of 11 randomised controlled trials concluded that brief foot care education alone does positively influence patient knowledge and behaviour in the short term, but it is ineffective in preventing diabetic foot ulcers. Education in a structured, organised, and repetitive manner, combined with preventive interventions may, however, prevent foot problems. 29 Although the International Working Group on the Diabetic Foot acknowledges the limited evidence on long term efficacy of patient education, it recommends some form of patient education to improve their foot care knowledge and behaviour. 10

Occlusive footwear causes sweating and can predispose to fungal infection, 30 31 particularly in tropical countries. Ideally, footwear for people with diabetes should have a wide toe box, soft cushioned soles, extra depth to accommodate orthoses if required, and laces or Velcro for fitting and adjustments. A new pair of shoes can be worn for a short while daily until comfortable. Patient compliance to prescribed footwear is usually poor, particularly at home where they are more active. 29 Patients with plantar ulcers at forefoot or heel may be offered offloading footwear (fig 5 ​ 5) ) to allow ulcer healing and prevent recurrence.

Fig 5  Offloading footwear reduces pressure on a specific part of the foot to allow an ulcer on that part to heal or to prevent new ulcers. The top figure shows footwear that reduced pressure on the forefoot and the footwear shown underneath allows pressure on the heel to be offloaded

When to refer?

Refer immediately patients with a life threatening or limb threatening problem such as foot ulceration with fever or any signs of sepsis; ulceration with limb ischaemia; gangrene, or a suspected deep seated soft tissue or bone infection usually indicated by either a grossly swollen foot with shiny skin and patches of discoloration or a gritty feel to the bone during a probe to bone test in an open wound. 9 Refer to a specialised diabetic foot centre or to general surgery for wound care, offloading, revascularisation if needed, and rehabilitation.

Explain to patients the need to seek specialist care to limit complications. Provide detailed and clear communication before patients are referred so that multidisciplinary care can be facilitated at the earliest opportunity.

Before referral, wash the ulcer with clean water or saline and apply a sterile inert dressing such as a saline soaked gauze to control exudates and maintain a warm, moist environment for healing. Avoid microbicidal agents such as hydrogen peroxide, povidone iodine, or chlorhexidine to clean or dress the ulcer as these are cytotoxic. Costly antimicrobial dressings are not recommended. 9 Adjust dressings, footwear, and ambulation to avoid weight bearing on an ulcerated foot. 32 Early and aggressive treatment to control infection is important, especially in the presence of an ulcer. Start antibiotic treatment according to antibiotic policy based on local resistance patterns. Before starting antibiotics, take a piece of soft tissue from the base of the ulcer for culture and sensitivity, or take a deep swab for culture. 9 Refer urgently, within one or two days, patients with a history of rest pain, uncomplicated ulcer, or acute Charcot foot. 9 For patients with rest pain or intermittent claudication, offer referral to vascular intervention services for further investigations such as Duplex ultrasonography, and consideration for revascularisation. 21

The management and referral pathways between primary care, specialty diabetic foot centres, and multidisciplinary foot care services need to be integrated (see infographic).

How can diabetic foot care services be organised in India?

Nearly 415 million people globally have diabetes, with 75% living in low and middle income countries. In India about 70 million people have diabetes, and the number is projected to rise to 125 million by 2040. 34

The National Institute for Health and Care Excellence guideline on diabetic foot recommends a three tier system for foot care: primary healthcare for preventive services and appropriate referral of diabetic foot; foot protection services at community level for podiatric care and management of simple foot problems; and multidisciplinary foot care services at tertiary level to handle complex foot problems. 9

In low and middle income countries, primary care doctors are not trained in diabetic foot care, podiatry as a discipline is emerging, and multidisciplinary foot care services are available at few tertiary care centres.

We recommend training primary care doctors in diabetic foot care, particularly in countries with a high burden of diabetes. Referral hospitals should develop diabetic foot centres under the specialty of general surgery. These centres would provide foot protection services such as callus debridement and nail care, and surgeries such as wound debridement and minor or major amputations. Multidisciplinary foot care services should be provided at all tertiary level hospitals with facilities for vascular intervention and orthoses.

Education into practice

• In your practice, what proportion of people with diabetes have had a foot evaluation in the past 12 months?
• Describe how you would screen patients with diabetes for peripheral neuropathy and peripheral arterial disease.
• How would you advise a patient with diabetes about foot care?

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

Additional resources

For healthcare providers.

• Indian Ministry of Health and Family Welfare. Standard treatment guidelines: The diabetic foot: prevention and management in India, 2016. http://clinicalestablishments.nic.in/En/1068-standard-treatment-guidelines.aspx http://clinicalestablishments.nic.in/WriteReadData/5381.pdf
• International Working Group on the Diabetic Foot. Guidance on footwear and offloading interventions to prevent and heal foot ulcers in people with diabetes. www.iwgdf.org/files/2015/website_footwearoffloading.pdf
• National Institute for Health and Care Excellence clinical guideline on diabetic foot problems: prevention and management, 2015. www.nice.org.uk/guidance/ng19/chapter/1-recommendations
• National Institute for Health and Care Excellence clinical guideline on peripheral arterial disease: diagnosis and management 2012, updated 2017. www.nice.org.uk/guidance/cg147 .
• Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections, 2012. https://academic.oup.com/cid/article-lookup/doi/10.1093/cid/cis346

For patients*

• NHS Choices. Diabetes. www.nhs.uk/Conditions/Diabetes/Pages/Diabetes.aspx
• NHS Choices. How to look after your feet if you have diabetes. www.nhs.uk/Livewell/foothealth/Pages/Diabetesandfeet.aspx
• NHS Choices. Why feet sensations are lost and how to take care of them. www.nhs.uk/Conditions/Peripheral-neuropathy/Pages/Complications.aspx
• NHS Choices. What does a podiatrist do and how can a podiatrist help you? www.nhs.uk/livewell/foothealth/pages/foot-problems-podiatrist.aspx
• NHS Choices. How do common foot problems look? www.nhs.uk/Tools/Pages/Foot-problems-a-visual-guide.aspx

*All these web links are freely available on the internet.

Suggestions for future research

• Does grading the severity of peripheral arterial disease using the ankle brachial index help guide interventions to prevent foot ulcers in people with diabetes?
• What is the sensitivity of the monofilament test to diagnose peripheral neuropathy, and the interobserver variation among trained providers?
• What model of patient education is effective in preventing diabetic foot complications?

Web Extra. 

Extra material supplied by the author

Infographic

Contributors: SM, KC, and AM conceived and designed the review. SM and KC created the first draft. AM and AK revised the content and approved the final version to be published. All authors act as guarantors.

Funding: The Indian Ministry of Health and Family Welfare funded the process for development of the standard treatment guideline on Diabetic Foot. The Department for International Development funded the technical assistance provided by Global Health and Development Group (formerly NICE International) to the Guideline Development Group on diabetic foot.

Competing interests: We have read and understood BMJ policy on declaration of interests and declare the following: SM, KC, and AK were members of the guideline development group for the standard treatment guideline on the diabetic foot: prevention and management in India, 2016 published by the Ministry of Health and Family Welfare, government of India. AM provided technical input on methodology to this guideline development group.

Provenance and peer review: This article is one of a series commissioned by the BMJ from the Global Health and Development Group at Imperial College London (formerly NICE International) as part of the International Decision Support Initiative ( www.idsihealth.org ). The BMJ retained full editorial control over external peer review, editing, and publication. Open access fees are funded by the Bill and Melinda Gates Foundation.

Patient consent: All photographs have been included after taking patient consent.

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Thermography, temperature, pressure force distribution and physical activity in diabetic foot: a systematic review.

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1. introduction.

• The presence of diabetic neuropathy and its associated complications in the foot;
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Rosell-Diago, M.P.; Izquierdo-Renau, M.; Julian-Rochina, I.; Arrébola, M.; Miralles, M. Thermography, Temperature, Pressure Force Distribution and Physical Activity in Diabetic Foot: A Systematic Review. Appl. Sci. 2024 , 14 , 8726. https://doi.org/10.3390/app14198726

Rosell-Diago MP, Izquierdo-Renau M, Julian-Rochina I, Arrébola M, Miralles M. Thermography, Temperature, Pressure Force Distribution and Physical Activity in Diabetic Foot: A Systematic Review. Applied Sciences . 2024; 14(19):8726. https://doi.org/10.3390/app14198726

Rosell-Diago, Maria P., Marta Izquierdo-Renau, Iván Julian-Rochina, Manel Arrébola, and Manuel Miralles. 2024. "Thermography, Temperature, Pressure Force Distribution and Physical Activity in Diabetic Foot: A Systematic Review" Applied Sciences 14, no. 19: 8726. https://doi.org/10.3390/app14198726

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• Research article
• Open access
• Published: 20 March 2020

Diabetic foot care: knowledge and practice

• Aydin Pourkazemi 1 ,
• Atefeh Ghanbari   ORCID: orcid.org/0000-0002-7949-5717 2 ,
• Monireh Khojamli 1 ,
• Heydarali Balo 1 ,
• Hossein Hemmati 1 ,
• Zakiyeh Jafaryparvar 1 &
• Behrang Motamed 3  

BMC Endocrine Disorders volume  20 , Article number:  40 ( 2020 ) Cite this article

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Diabetic foot ulcers (DFUs) are common problems in diabetes. One of the most important factors affecting the quality of diabetes care is knowledge and practice. The current study aimed at determining the knowledge and practice of patients with diabetes regarding the prevention and care of DFUs.

The current analytical, cross sectional study was conducted in Guilan Province (north of Iran) on 375 patients registered in the medical records as type 2 diabetes mellitus. Demographic characteristics, knowledge, and practice of participants were recorded in a questionnaire during face-to-face interviews conducted by the researcher. Descriptive and inferential statistics were performed using SPSS version18.

The mean score of knowledge was 8.63 ± 2.5 out of 15, indicating that the majority of participants had a poor knowledge (84.8%). The mean practice score was 7.6 ± 2.5 out of 15, indicating that a half of them had poor performance (49.6%). There was a significant and direct correlation between knowledge and practice. Knowledge level, place of residence, marital status, and history of admission due to diabetic foot were predictors of practice score.

Conclusions

According to the low level of knowledge and practice in patients with diabetes regarding the prevention and care of DFUs, and considering the significant relationship of some demographics of patients with knowledge and practice scores, a targeted educational program is needed to promote knowledge of patients with diabetes.

Peer Review reports

What is already known about this subject?

Diabetes accounted for 1.3 million deaths (2.4% of all death). The prevalence of diabetes varies among countries in Eastern Mediterranean Region (EMR).

Prevalence of diabetes mellitus in Iran ranged 20 to 30% in different provinces with higher frequency among females from 1990 to 2013.

Among people living with diabetes mellitus, 20% are at risk for foot ulceration as a result of neuropathy.

Diabetic foot ulcers (DFUs) are one of most common diabetes complications with 0–4% prevalence.

Good knowledge and practice regarding DFU reduces the risk of diabetic foot complications and ultimately amputation.

What are the new findings?

- In the current study, 84.8% of the participants had poor knowledge and only 8.8% had good practice. There was a direct and significant correlation between knowledge and practice.

The lowest knowledge scores belonged to the use of talcum powder or other powders and not using lotions between the toes.

The strongest variables related to practice were knowledge, place of residence, marital status, and history of admission due to diabetic foot, indicating that these four variables were the predictors of practice score.

How might this impact on clinical practice in the foreseeable future?

Patients’ knowledge about foot ulcer prevention should be promoted based on guidelines both in community and hospitals.

Adherence to guidelines prevents DFU; targeted interventions directed toward patients/health care providers can lead to reduced DFU complications.

Diabetes mellitus is a group of common metabolic disease characterized by hyperglycemia. Due to multiple and prolonged complications, diabetes affects almost all systems of the body [ 1 ]. Diabetes caused 1.3 million deaths (2.4% of all death) and 56 million disability adjusted life years (DALYs) in 2013. The diabetes DALY rate increased from 589.9 per 100,000 in 1990 to 883.5 per 100,000 populations in 2013. Total DALYs from diabetes increased by 148.6% during 1990–2013; population growth accounted for a 62.9% increase, and aging and increase in age-specific DALY rates accounted for 31.8 and 53.9%, respectively [ 2 ]. The prevalence of diabetes varies among countries in EMR. In Saudi Arabia, the prevalence of diabetes was reported 13.4% Saudis aged 15 years or older [ 3 ] and in Pakistan 12.1% for males and 9.8% for females aged ≥25 years [ 2 ]. A systematic review on the prevalence of type 2 diabetes in Iran showed a range of 3 to 20% in different provinces [ 4 ].

Of people living with diabetes, 20% are at high risk of foot ulceration as a result of neuropathy [ 5 ]. Diabetic foot ulcers (DFU S ) comprise 12–15% of total estimated cost of diabetes in the developed countries, increasing to 40% in the developing countries [ 6 ]. DFUs are one of the most common diabetes complications with 4 to 10% prevalence in the affected population [ 7 ]. The overall incidence of DFU is 5.8–6.0% in some particular diabetic in the U. S, while it is 2.1–2.2% in smaller populations in Europe [ 8 ]. Treating foot ulcers can be expensive and it is evident that about 49–85% of all DFU S can be prevented by raising awareness and taking proper measures [ 7 ]..

Among the complications of diabetes, DFU S affects the patient’s quality of life in case of amputation. However, it is possible to prevent amputation using educational and care strategies [ 9 ]. Data show that 25% of patients with diabetes develop a foot ulcer in their lifetime and that the cost of treating a DFU S is more than twice that of any other chronic ulcer [ 10 ]. Diabetic foot amputation remains an unpleasant impact on patients’ life more than other complications [ 11 , 12 ]. Delays in referral of serious foot problems are of particular concern [ 5 ]. Ndosi et al., reported that 15.1% of patients died within the year of presentation, the ulcer had healed in 45.5%, but recurred in (9.6%). Participants with a single ulcer on their index foot had a higher incidence of healing than those with multiple ulcers (hazard ratio 1.90, 95% CI 1.18 to 3.06) [ 13 ].

Understanding the level of knowledge and practice in patients with diabetes is important in planning for the better control of diabetes and its complications. A study by Ahmad and Ahmad on 124 patients with diabetes in North India reported that 60.5 and 79.0% got lower scores in knowledge and practice toward diabetes, respectively [ 14 ]. Jackson IL et al., reported that 79.5% of patients with diabetes in Nigeria had more than 70% of overall knowledge about self-care [ 15 ]. The results of a study in Malaysia showed that the most patients (58%) had poor knowledge and 61.8% of them had poor practice of foot care [ 16 ].

Among diabetes complications, the foot ulcers are considered as the most preventable ones. Risk factors of DFU S are correlated with poor practices and knowledge. Good knowledge and practice toward diabetic foot care reduces the risk of diabetic foot complications and ultimately amputation [ 7 ]. According to American Diabetes Association, annual assessments of knowledge, skills and behaviors are necessary for patients with diabetes [ 15 ].. The current study was conducted to assess patients’ knowledge and practice toward diabetic foot care. No similar study is conducted in Rasht City (the capital of Guilan Province, Northern Iran) thus far; therefore, the present study aimed at evaluating the level of practice and knowledge toward foot care in patients with type 2 diabetes mellitus. Health system can prevent DFU and amputation by applying a strategy to raise knowledge in patients.

Study design and subjects

The current analytical, cross sectional study was conducted at a clinic in Razi Hospital, affiliated to Guilan University of Medical Sciences, which is the only endocrine disease referral center across the province. Data were gathered from May to July 2017 and the subjects were selected by consecutive sampling. To Diagnostic and classify the patients, the American Diabetic Association, the diagnostic criteria were utilized [ 17 ]. Patients with diabetes receive care, education, treatment, and other services at this center. The center also delivers healthcare services to outpatients and inpatients, as well as routine training. The research project was approved by the Deputy of Research, Guilan University of Medical Sciences. Participation in the study was voluntarily and the subjects were informed about their right to withdraw from the study at any stage. The participant’s privacy was respected, and data were kept confidential and utilized for study purposes only. Participants were asked to read and sign an informed consent form. Inclusion criteria were: receiving the diagnosis of type 2 diabetes mellitus, age 18 years or above, taking anti-diabetic medications for at least 1 month prior to the study, having clinical records at the center, and willing to participate in the study. The exclusion criteria were: critically ill patients with diabetes, pregnant or newly diagnosed (less than 1 month) patients, receiving any other treatment or therapy, and having major psychiatric problems. A structured datasheet was used to collect demographic and clinical information of the patients using paper-based and digital records archives. Some information was also collected by a medical student through face-to-face interviews. A paper-based questionnaire was distributed among both outpatients and inpatients. Wagner DFU classification system was used to classify the patients based on ulcers. In this hospital, we assessed peripheral neuropathy, retinopathy and peripheral vascular disease (PVD), respectively by using monofilament testing, optometrist or ophthalmologist reports and the clinical diagnosis documented by the surgeon or, if available, images taken through arterial Doppler or angiography. Macro vascular disease was defined as any macro vascular complications other than PVD including prior myocardial infarction, angioplasty, coronary artery bypass grafting, ischemic heart disease, or stroke [ 18 ].

In the current study, having one or two more complications was considered a positive condition. The sample size was determined 375 considering 95% confidence interval with d = 0.05 and P  = 0.58. A total of 375 out of 395 distributed questionnaires were completed and returned; the response rate was 94.4%.

A three-section questionnaire was used in the current study. First section included demographic characteristics such as age, gender, and duration of diabetes mellitus, place of residence, occupation, and level of education, marital status, and body mass index. Second part consisted of 15 questions about knowledge scored based on nominal (yes/no/I don’t know) scale, and third part with 15 questions focusing on practice was scored based on “yes/no” scale. The questionnaire was used to measure the level of knowledge and practice of subjects toward diabetic foot care. Patients’ demographic data were collected to analyze factors associated with knowledge and practice toward diabetic foot care. Each correct answer was given 1 point; however, wrong answers or choosing “I don’t know” option was given 0 point. The total score for each part ranged 0 to 15. Good or poor level of knowledge was determined based on the 75% of the maximum score of the questionnaire; therefore, the scores higher than 11.25 were considered good and those lower than 11.25 were considered poor. Examples of the questions included “Do you care about your diabetes?”; “Do you wash your feet every day?”; “Do you check the water temperature before using it?” and “Do you dry your feet after washing?”

The questionnaire was translated into the Persian language. Following the translations conducted by an Iranian professor of English literature, a native bilingual English speaker translated it back into English. Content validity was determined by gathering the views of 15 medical and nursing professionals after reviewing the questionnaire. Content validity ratio (CVR) and content validity index (CVI) of the questionnaire were assessed. Mean scores of CVI and CVR were higher than 0.80. Cronbach’s α coefficients were computed to evaluate reliability of knowledge and practice, which were 0.80 and 0.85, respectively.

Statistical analysis

After collecting data, descriptive statistics (frequency, mean, and standard deviation) were employed to summarize patients’ socio-demographic data and Chi-square test to investigate association between predictors (factors) and knowledge and practice level. In order to assess the differences between groups, the Wilcoxon, Mann-Whitney, and Kruskal-Willis tests were used for continuous variables. Factors related to knowledge and practice was estimated by multiple regressions. In this research, wrong answers and “I don’t know” merged as poor awareness. In order to assess the relationship between individual variables with knowledge and practice, we had to integrate these two items in order to have a better analysis. Variables with a P -value of < 0.1 were included in the multi-variate models. P -value < 0.05 was considered as the level of significance. All analyses were performed using SPSS version 18.

The mean (± SD) age of the 375 participants was 55.4 (±12.9) years, and 56.4% were female. Majority of patients had diabetes for less than 10 years (54.1%), were female (56.5%), urban residents (62.1%), illiterate or had elementary education (73.1%), did not have normal BMI (69.8%), and (10.6%) patients had 2 and more complications (Table  1 ). In terms of knowledge, only 57 participants (15.2%) had good knowledge, most of them (84.8%) had poor knowledge, and the mean score of patients’ knowledge was 8.63 ± 2.65. The highest percentage of correct answers was found with the knowledge about “The need for meeting or consulting a physician, if there were signs of wounding” (88.8%), followed by “Not walking without shoes” (83.5%) and “Washing and changing socks” (9.81%). The lowest knowledge was about “The use of talcum powder or other powders between the toes” (3.5%), followed by “Not using lotion between the toes” (22.24%), and “The proper method of trimming the toenails” (23.2%).

In terms of practice, only 33 patients (8.8%) had a good practice; most of them (91.2%) had a poor practice (Table  2 ), and the mean score of patients’ practice was 7.6 (± 2.5). The participants reported their best practice toward “Importance of diabetes control” (80.5%), followed by “Meeting or consulting a physician, in case of signs of DFU” (79.2%). The poorest practice was toward “The use of talcum powder between the toes” (2.7%), followed by “Proper method of trimming the toenails” (25.9%), and “Keeping the foot skin soft” (30.9%).

There was a direct and significant correlation between knowledge and practice ( P  < 0.0001, r < 0.8) (Fig.  1 ). There was a significant relationship between knowledge score and gender, duration of diabetes, occupation, level of education, place of residence, having DFU, hospital stay history, and amputation history.

Correlation Between Khowledge and Practice

The study results showed that patients with more than 10 years history of diabetes, history of DFU, history of hospital stay or experience of lower limb amputation due to DFU, female gender, and the ones with complications had higher knowledge ( P  < 0.05).

There was a significant correlation between practice score and gender, duration of diabetes, occupation, level of education, and place of residence (P < 0.05) (Table  3 ).

Also, based on multiple regression, the strongest variables related to practice were knowledge score ( P  < 0.0001), place of residence ( P  < 0.03), marital status ( P  = 0.008), and DFU ( P  = 0.02), indicating that these four variables were the predictors of foot care practices in the current study (Table  4 ).

In the current study, majority of patients with diabetes had lower levels of education. Studies report that level of knowledge depends on the level of education [ 14 , 19 ]. Understanding this variable is highly important in designing strategies to prevent diabetes.

In the current study, most patients had lower scores of knowledge and practice toward foot care, and the mean practice score was lower than the mean knowledge score, which was similar to the findings of Muhammad-Lutfi’s and Kim’s studies [ 16 , 20 ]. A study conducted on patients with diabetes in Western Nepal reported poor KAP (knowledge, attitude and practices) score; they indicated that the plausible factors could be lack of knowledge, lack of information, and literacy level of the studied population [ 21 ]. Another study on young Saudi females with diabetes also reported poor KAP scores [ 19 ]. Some studies reported that patients with diabetes had good level of knowledge about diabetes [ 7 , 16 , 22 , 23 ]. The differences in knowledge about foot care among patients with diabetes across the studies could be due to different trainings on diabetes care provided by the health care professionals in different settings [ 23 ] and also the literacy level of the studied subjects.

Several studies reported poor foot care practices among patients with diabetes. Kheir et al., reported poor practices toward regular inspection of feet among patients in Qatar [ 24 ]. Hamidah et al., from Malaysia observed that 28.4% of patients newly diagnosed with diabetes practiced good habits towards foot care [ 25 ]. Desalu et al., from Nigeria observed that only 10.2% of patients with diabetes had good foot care practices [ 26 ]. It was difficult to compare the results of the current study with those of other studies since the nature of the study populations and the applied measurements were different.

In the current study, there was a direct and significant correlation between knowledge and practice scores; therefore, with an increase in the knowledge score, the practice score also increased. Other studies also showed that patients who receive trainings on foot care checked their feet regularly [ 20 ]. Patients who are advised to take care of their feet and the ones whose feet are regularly checked by physicians have better practices toward foot care [ 27 ].

In the current study, the lowest knowledge scores were regarding the application of talcum powder or other powders and not using lotions between the toes, and the proper way of trimming the toenails; while the lowest practice scores were related to the application of talcum powder between the toes, the proper way of trimming the toenails; keeping the foot skin soft, and avoid dryness.

It should also be noted that due to wet climate in the North of Iran, use of lotion between the toes is not common. Nevertheless, it also needs training. Patients with diabetes need to keep between their toes dry using talcum powder and avoid the application of lotion since it is important as a hygienic measure for feet in preventing fungal infection [ 28 ]. Patients should also use skin moisturizers daily to keep the skin of their feet soft and should trim their toenails straight across (not rounded) to prevent damage to their toes [ 29 ].

In the current study, gender, duration of disease, occupation, place of residence, level of education, having DFU, and a history of hospitalization, amputation, and complication had significant relationships with knowledge. Also, gender, duration of disease, place of residence, occupation, and level of education had significant relationships with practice. It was found that knowledge level was higher in females, patients with a diabetes history of more than 10 years, and the ones underwent amputation due to DFU compared to the others; in addition, females, patients with a diabetes history of more than 10 years, and urban residents had better performance. The current study results showed that males were usually reluctant to disclose their health problems and seek professional care. Also, males presented greater deficit in self-care compared to females [ 30 ].

In the study by Muhammad-Lotfi, age, gender, level of education, and duration of diabetes had no significant relationship with knowledge and practice. This finding was in agreement with that of the current study [ 16 ], but another study indicated a significant relationship between the level of education and knowledge [ 31 ].

People with higher education are expected to be more likely to read and receive information about their illness and foot care and understand the information provided by medical staff in health care settings.

But in the current study, there was no significant relationship between the level of education and knowledge or practice, which could be due to the poor and inadequate resources of information about diabetes at the community level, since both educated and uneducated groups had inadequate information. It may also be due to the fact that in spite of possessing knowledge, due to the lack of time, heavy work load, and lack of adequate insurance coverage, patients could not take good care of their feet in practice, which requires more studies to root out the causes.

Nevertheless, the attitude of patients toward self-care in addition to sufficient knowledge was not studied in the current study. As observed in the present study, patients with a history of DFU or hospital stay, and even amputation and complication had higher knowledge level. It could be due to the fact that while completing the questionnaire, the current knowledge level of the subjects was questioned, which indicated that training medical centers can raise the level of knowledge in patients with DFU. In many Iranian state hospitals, diabetic training programs are not well organized, and the existing programs are weak. It is believed that knowledge about diabetes in the general population as well as patients with diabetes in Iran is not enough and there is a dire need for a good program for diabetes [ 32 ].

The collected data indicated that patients with diabetes had poor practice and knowledge about foot care. This is basically due to lack of proper communication between patients and medical team and inadequate education. Based on nurses’ opinion, recommendations and guidelines play an effective role in prevention, treatment, and reduction of complication among patients with DFU. Therefore, adaptation, implementation, and evaluation of the educational programs were recommended [ 33 ].

Thus, patients should be trained for foot ulcer prevention based on clinical practice guidelines for diabetes mellitus both in the community and hospitals. The results of the current study encouraged a positive outlook: A diabetes educator should give necessary advices to patients during every visit, in order to improve their perception about disease, diet, and lifestyle changes and help them control their glycemic level and overcome the complications of diabetes.

According to the principle of “prevention is better than cure” and considering the predictive factors in the current study including poor knowledge, urban residency, being single, and lack of DFU, more attention should be paid to patients possessing risk factors .

Knowledge and practice toward foot care were poor in most patients with diabetes. There was a significant relationship between some demographic characteristics of patients and knowledge and practice toward foot care. The level of knowledge, place of residence, marital status, and history of hospital stay due to DFU were the predictors of practice in patients with diabetes.

The strength of the current study was that it was the first, study to discuss this important issue in Guilan Province. The study also had some limitations; first, since the work had a cross sectional design, the direction of relationships and causal relationships cannot be determined. Second, the result of the study should be interpreted with caution, since they were obtained from a single center; a clinic-based study. Hospital-based studies cannot provide a true picture of knowledge and practice in the community. The current study sample did not represent the whole Iranian population consisting of several ethnicities. In this research, responses of the wrong answers and “I don’t know” have been grouped together, in order to achieve better analysis. Perhaps with increasing sample size, we could solve this problem in future studies.

Adequate knowledge and good practices are important to effectively control diabetes mellitus. Patients require continuous support of family members and community in order to modify their lifestyle and behaviors and make sustainable changes in order to better control their diabetes disease. Also, education about diabetes mellitus and its risk factors should be provided through mass media in order to effectively control it in the community.

Availability of data and materials

The datasets used and /or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

Content validity index

Content validity ratio

Diabetic foot ulcers

Eastern Mediterranean Region

World health organization

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Acknowledgements

The authors wish to thank all the individuals who helped throughout the study, especially Razi Clinical Research Development Center.

The study was funded by the Deputy for Research; Guilan University of Medical Sciences. The funder had no role in the study design, data analysis and interpretation, and writing of the manuscript.

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Aydin Pourkazemi, Monireh Khojamli, Heydarali Balo, Hossein Hemmati & Zakiyeh Jafaryparvar

Social Determinants of Health Research center, nursing and midwifery school, Guilan University of medical sciences, Rasht, Iran

Atefeh Ghanbari

Department of internal medicine , Razi Hospital ,School of Medicine, Guilan university of Medical Sciences, Rasht, Iran

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PA, KM, and GA: the study design; PA,KM and MB: data collection; PA, KM, GA, HH, and BH: data analysis; PA, GA, KM, BH, HH, MB and JZ: data interpretation and drafting of the manuscript. All authors read and approved the final version of the manuscript.

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Pourkazemi, A., Ghanbari, A., Khojamli, M. et al. Diabetic foot care: knowledge and practice. BMC Endocr Disord 20 , 40 (2020). https://doi.org/10.1186/s12902-020-0512-y

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Received : 07 January 2019

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DOI : https://doi.org/10.1186/s12902-020-0512-y

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