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The big picture: lower extremity complications of diabetes

David G Armstrong

Over the past decade, for the first time in human history, more people died from non-communicable diseases (NCDs) than from all the plagues in the world combined. The ‘big three’ of those NCDs include cancer, heart disease and diabetes. While inexorably linked to one another in terms of morbidity and mortality, diabetes is singular in its silent and sinister characteristics — because of neuropathy, peripheral artery disease and other comorbidities, people with diabetes suffer from silent heart attacks and silent ‘foot attacks’.

While diabetes may be the frequently ignored sibling within NCDs, the diabetic foot is, without question, the equivalent within diabetes. Figure 1 displays the relative size of populations of diabetes and its lower extremity complications in the USA using best available prevalence data (Barshes et al, 2013; Amputee Coalition, 2015). We believe, however, that these data are directly transferable to the NHS and beyond. Up to a third of direct costs of care for diabetes are spent on the lower extremities. While this is true, less than a factor of 0.0017 is spent on federally funded research and development in the USA (Armstrong et al, 2013).  

This astonishing gap between this public health problem and clinically meaningful clinical resource shifts and research has led toward efforts to improve awareness — often by comparing diabetic feet to other NCDs. Efforts from Diabetes UK to ‘Put Feet First’ have developed pathways to avoid a ‘foot attack’ (Hitman, 2015). We have frequently compared diabetic foot morbidity and mortality with cancer (Armstrong and Mills, 2013; Miller et al, 2014). 

But there is hope. We are beginning to see the fruits of worldwide efforts pay off in reduction of amputation in parts of Europe (Kennon et al, 2012; Lombardo et al, 2014), as well as in the USA (Li et al, 2012). We need to remain ever vigilant, however. Indeed, it is entirely plausible that these data may ultimately be linked to efforts made in early screening and interdisciplinary teams, and we may one day congratulate ourselves with the epidemiologic equivalent of a day at the beach. However, it is equally possible that these data may, with the rise of diagnosis of diabetes and people living longer with complications, be a moment of calm before the next big wave. 

Over the past decade, for the first time in human history, more people died from non-communicable diseases (NCDs) than from all the plagues in the world combined. The ‘big three’ of those NCDs include cancer, heart disease and diabetes. While inexorably linked to one another in terms of morbidity and mortality, diabetes is singular in its silent and sinister characteristics — because of neuropathy, peripheral artery disease and other comorbidities, people with diabetes suffer from silent heart attacks and silent ‘foot attacks’.

While diabetes may be the frequently ignored sibling within NCDs, the diabetic foot is, without question, the equivalent within diabetes. Figure 1 displays the relative size of populations of diabetes and its lower extremity complications in the USA using best available prevalence data (Barshes et al, 2013; Amputee Coalition, 2015). We believe, however, that these data are directly transferable to the NHS and beyond. Up to a third of direct costs of care for diabetes are spent on the lower extremities. While this is true, less than a factor of 0.0017 is spent on federally funded research and development in the USA (Armstrong et al, 2013).  

This astonishing gap between this public health problem and clinically meaningful clinical resource shifts and research has led toward efforts to improve awareness — often by comparing diabetic feet to other NCDs. Efforts from Diabetes UK to ‘Put Feet First’ have developed pathways to avoid a ‘foot attack’ (Hitman, 2015). We have frequently compared diabetic foot morbidity and mortality with cancer (Armstrong and Mills, 2013; Miller et al, 2014). 

But there is hope. We are beginning to see the fruits of worldwide efforts pay off in reduction of amputation in parts of Europe (Kennon et al, 2012; Lombardo et al, 2014), as well as in the USA (Li et al, 2012). We need to remain ever vigilant, however. Indeed, it is entirely plausible that these data may ultimately be linked to efforts made in early screening and interdisciplinary teams, and we may one day congratulate ourselves with the epidemiologic equivalent of a day at the beach. However, it is equally possible that these data may, with the rise of diagnosis of diabetes and people living longer with complications, be a moment of calm before the next big wave. 

REFERENCES:

Amputee Coalition (2015) Limb Loss Statistics. Available at: http://bit.ly/1GD9u5J (accessed 24.09.2015)
Armstrong DG, Mills JL (2013) Toward a change in syntax in diabetic foot care: prevention equals remission. J Am Podiatr Med Assoc 103: 161–2
Armstrong DG, Kanda VA, Lavery LA et al (2015) Mind the gap: disparity between research funding and costs of care for diabetic foot ulcers. Diabetes Care 36: 1815–7
Barshes NR, Sigireddi M, Wrobel JS et al (2013) The system of care for the diabetic foot: objectives, outcomes, and opportunities. Diabet Foot Ankle 4
Hitman GA (2015) Putting feet first. Diabet Med 32: 705–705
Kennon B, Leese GP, Cochrane L et al (2012) Reduced incidence of lower-extremity amputations in people with diabetes in Scotland: a nationwide study. Diabetes Care 35: 2588–90
Miller JD, Salloum M, Button A et al (2014) How can I maintain my patient with diabetes and history of foot ulcer in remission? Int J Low Extrem Wounds 13: 371–7
Li Y, Burrows NR, Gregg EW et al (2012) Declining rates of hospitalization for nontraumatic lower-extremity amputation in the diabetic population aged 40 years or older: U.S., 1988-2008. Diabetes Care 35: 273–7
Lombardo FL, Maggini M, De Bellis A et al (2014) Lower extremity amputations in persons with and without diabetes in Italy: 2001–2010. PLoS One 9: e86405

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