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The Diabetic
Foot Journal


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Matthew Young
Twenty twenty-two is a momentous year. The Queen completes 70 years on the throne, I complete 60 years on the earth and The Diabetic Foot Journal reaches volume 25. The journal was started to fill a large hole in the information about diabetes foot care. As it moves to online it is still the only publication dedicated solely to the problems of the lower limb in people with diabetes.

The Diabetic Foot Journal was born from the vision of Simon Breed, then publisher of the Journal of Diabetes Nursing, later a whole family of diabetes-related journals. It became clear to Simon, in conversations with Alistair McInnes and others, that there was a need for a publication devoted to this one, in my view, the most, important complication of diabetes. After over a year of planning, it launched in March 1998. The journal started small but grew to over 20,000 copies a quarter. To begin with, there was a team of three in the office. For the first few conferences, we would set out the tables and chairs the night before and run the meeting from our own laptops. Mergers and acquisitions followed and the journal grew to be a part of the Wounds portfolio. This had strength in numbers but the day I rang the office to find no-one recognised my name, I knew there was work to do! More recently, the pandemic too has impacted the way we communicate as face-to-face editorial policy meetings disappeared over the past 2 years. Such interaction is so important in maintaining educational standards and content direction and I very much look forward to them restarting both for the intimacy they bring and for the focused discussions they trigger.

The same is true of the conferences. The conferences started as a lucky accident. The rise of skin substitutes for closing hard-to-heal diabetes foot ulcers was short lived but at the time there was a large promotional budget and with the huge potential audience of the foot journal, a conference to highlight them seemed like a natural fit. For many reasons, mainly economic, in the UK, such therapies ran out of favour within a few years. However, the conferences continued (until COVID) and so far have been attended by more than 6,000 people. The conferences have provided me with some great memories and hopefully a lot of useful education. They will return as life after the pandemic is returning. I have not worn a suit for work in over 2 years. I miss them too!

The journal has gone though many changes in 25 years. The name, the fonts, the colour scheme all evolved over time. In the past year, the journal has gone to online only. While I liked the paper copies, it is much more environmentally friendly to be online and actually increases the readership to a more global audience than before.

Fortunately, many clinicians choose the journal to publish their original research, audits and case reports. The journal still has a wide audience and although not as prestigious as some academic journals, it is a great way to build a reputation among our peers. Original articles strengthen the journal. Together with the reviews of recent literature I found that they gave me a reason to read when some other similar journals went in the bin with their wrapping intact. As the reach increases, the value of publishing original research with the journal should continue to grow.

The journal is more than just a source of information. It has also been a catalyst for change. The journal and its publishers have brought together like-minded individuals focussed on improving standards of care and, perhaps even more importantly, in the education and training of professionals. In the early days of Alistair McInnes as editor-in-chief, we questioned what it meant to be a specialist in the diabetic foot, particularly a podiatry specialist, but also latterly a diabetologist with a special interest in feet. In a time when titles like advanced highly specialised acute podiatrist were being tossed around like the leaves of a salad, but with no definition or standards to support them, we formed Podiatry in Diabetes UK, which became the Foot in Diabetes UK (FDUK). This organisation has tried to improve standards. Eventually through work, initially led from the Scottish Diabetes Foot Action Group, we produced the Competency Framework. The journal has championed both of these initiatives and supported them financially and with administrative support. The framework set out a pathway for competence from support worker to consultant. Sadly, despite support from the Royal College of Podiatry and some forward-thinking NHS Trusts, the educational network to develop staff is still lacking nationally. However, I still have hope for the future.

Podiatrists are one of the fastest growing groups of non-medical healthcare professionals who are acquiring independent prescriber status. Together with their specialist knowledge of the foot, diagnosis and treatment, I have always advocated that podiatrists should be leading diabetes foot services especially as the number of diabetes trainees with expertise in the diabetic foot seems to be reducing. For many of my diabetes colleagues, there are more exciting and frankly less troublesome areas of diabetes practice. Podiatrists are the natural leads for foot services and I believe that one day they will lead more than they do now. As general diabetes clinics have moved to virtual and remote consultations for most annual reviews, foot patients remained the only ones seen face to face with any regularity.
In ours and many other clinics, we provide more holistic reviews of diabetes than ever before. Foot patients are the most complicated of all diabetes patient groups with renal, ophthalmic, neurological, skeletal, dermatological, vascular and psychological problems. Managing these issues while trying to heal an ulcer or stabilise a Charcot is hard. I strongly believe that this changing pattern of working should be recognised and supported with articles on the wider diabetes patient and the prescribing and complication challenges faced by our foot patients as the journal moves on from its silver jubilee.
The world is a different place from 1997. I was a recently appointed consultant back then but foot clinics were still uncommon, inpatient diabetes teams even less so. While Scotland is rightly heralded for the national database SCI-Diabetes and, led by Duncan Stang (national foot coordinator for Scotland and associate editor of The Diabetic Foot Journal) and Graham Leese (chair of Scottish Diabetes Foot Action Group), the development of national screening systems, the rest of UK has also had some major initiatives too.

The work of our other associate editor, Paul Chadwick, and his colleagues in Salford too have played a key role in the development of a whole-system approach to diabetic foot care. Meanwhile, the national diabetes inpatient audit (NADIA) highlighted deficiencies in the care of foot ulcer patients in English and Welsh hospitals, which led to changes in the NICE guidelines. But as the more recent National Diabetes Footcare Audit continues to highlight, foot ulcer patients are frequently admitted to hospital, stay in for a long time and have variable outcomes. We must improve standards up to a level and ensure consistency. I would hope that the journal will continue to promote this work in the years to come.
NaDIA also highlighted the development of new pressure ulcers in diabetes patients while they are in hospital. This, in turn, led to the CPR for Diabetic Feet initiative developed under the leadership of Duncan Stang, later to become CPR for Feet. A plan to screen every patient admitted to hospital for loss of sensation and to ensure that they get appropriate heel pressure relief during their admission. The journal has helped to publicise this initiative and while the pandemic has slowed the efforts to implement it and re-audit outcomes, I am sure it has reduced the morbidity of hospital care.
I also think that CPR for feet is due for a relaunch now that services are starting to get back to normal after the strangest 2 years in my professional life. It is time to start looking after every patient not just those with COVID-19. As editor in chief, we will promote this further.

I am one of the few who started with the journal who is still in regular clinical practice. The past few years have seen the original foot clinic pioneers, Michael Edmonds, Andrew Boulton, William Jeffcoate, Gerry Rayman, Geraint Jones and others move into new phases of their careers. The leading lights of podiatry in the ‘90s and early ‘00s such as the late Alethea (Ali) Foster, Heather Murray, Jodi Binning, Debbie Sharman, Louise Mitchell are largely in managerial roles. I know others are moving up to replace them but we need more. Few, if any. diabetes nurses have replaced Anne Knowles, Nicky Every, Anne Rayman or Kath Eccles. This makes it even more important that podiatrists learn the wider skills of diabetes care.

Nostalgia is not what it used to be but for a while I have felt that the diabetic foot has lost a lot of the impetus and drive of the early days where new things were being discovered almost everyday. I think the challenges for the next 25 years will be infection recognition and management in a time of serious antibiotic resistance, the fact that we still cannot get all of our patients to heal and the increasing frailty of patients as they survive longer with diabetes. Life moves on, people move on, the journal moves on. Here is to the next 25 years of pioneering editorials, original research and opinion and educational content to support the next generation in providing the best care they can for every patient with diabetes foot disease.

Here are some of the journal editorials referred to in this commentary:

  • June 2012:
  • March 2010:
  • December 2009:
  • March 2003:
  • September 1998:
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