As many experts predicted, the worldwide prevalence of diabetes continues to increase. About 425 million people worldwide now have diabetes; half of these are undiagnosed.1 Complications of diabetes, especially foot ulcers and lower limb amputation, are of great concern.2 While this issue’s fascinating continuing education article reports on diabetic myonecrosis (a rare complication of diabetes), the prevention of diabetic foot amputations is a more common and pressing concern that requires global attention. The 5-year survival rate following amputation is lower than that of breast cancer in females or prostate cancer in males.3 The United Nations and others have taken note and are discussing diabetes and other noncommunicable diseases this month in New York City.4
Scientists from the University of Toronto sold the patent rights to insulin for Can $3 so it would be available to all persons with diabetes requiring insulin. Despite this gift to the world, the cost of insulin is unaffordable to people in Africa and other low-income regions. In 2016, two Cape Town Declarations of Action on the reduction of diabetic foot amputations and insulin access for all were signed by a group of nongovernmental organizations. These declarations were designed to galvanize people into action for improved diabetes foot care and insulin access.
The vast majority of diabetic foot amputations are preventable. A patient-centered approach by a coordinated interprofessional team can be an effective management plan by implementing the 5 S’s:
1. Screening: Health providers and systems should use validated screening tools including the Simplified 60 Second Diabetic Foot Screening Tool.5,6
2. Smoking cessation: Tobacco use is a known risk factor associated with diabetes-related lower limb amputations. Make appropriate interventions available to patients.
3. Shoes: Shoes, as well as socks and offloading devices, are an essential part of diabetic foot ulcer prevention and treatment. Provision at point of care and affordability of these devices are essential.
4. Systemic blood glucose and blood pressure control: Lowering hemoglobin A1c, controlling blood pressure, and diabetic foot screening are all potential solutions to the diabetes pandemic.7 Improving access to insulin and other essential medicines is key to avoiding diabetic foot amputations.
5. Skin temperature assessments: Infrared thermometry is a simple, inexpensive, and effective tool for clinicians to assess infection even in low- and middle-income populations.8 Research has validated that commercial, nonmedical devices are just as effective as medical-grade infrared thermometers.9
The editors ask Advances in Skin & Wound Care readers two things: What can you do in your local communities and practice to prevent diabetic foot amputations? And how can you move policy makers and politicians in your community toward evidence-based action to reduce diabetic foot amputation?
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
Elizabeth A. Ayello, PhD, RN, CWON, ETN, MAPWCA, FAAN
1. International Diabetes Federation. World Diabetes Atlas. 8th ed. 2018. www.diabetesatlas.org
. Last accessed July 24, 2018.
3. Armstrong DG, Wrobel J, Robbins JM. Guest editorial: are diabetes-related wounds and amputations worse than cancer? Int Wound J 2007;4:286–7.
5. Woodbury MG, Sibbald RG, Ostrow B, Persaud R, Lowe JM. Tool for rapid and easy identification of high risk diabetic foot: validation and clinical pilot of the Simplified 60 Second Diabetic Foot Screening Tool. PLoS One 2015;10(6):e0125578.
6. Sibbald RG, Ayello EA, Alavi A, et al. Screening for the high-risk diabetic foot: a 60-second tool (2012). Adv Skin Wound Care 2012;25(10):465–76.
7. Narayan KV, Zhang P, Kanaya AM, et al. Diabetes: the pandemic and potential solutions. In: Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006.
8. Sibbald RG, Mufti A, Armstrong DG. Infrared skin thermometry: an underutilized cost-effective tool for routine wound care practice and patient high-risk diabetic foot self-monitoring. Adv Skin Wound Care 2015;28(1):37–44.
9. Mufti A, Coutts P, Sibbald RG. Validation of commercially available infrared thermometers for measuring skin surface temperature associated with deep and surrounding wound infection. Adv Skin Wound Care 2015;28(1):11–6.