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<meta name="robots" content="NOINDEX,NOFOLLOW,NOARCHIVE,NOIMAGEINDEX" /><meta name="citation_inbook_title" content="Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet]" /><meta name="citation_title" content="Background to foot care for people with diabetes" /><meta name="citation_publisher" content="University of Sheffield" /><meta name="citation_date" content="2003" /><meta name="citation_author" content="School of Health and Related Research (ScHARR), University of Sheffield" /><meta name="citation_fulltext_html_url" content="https://www.ncbi.nlm.nih.gov/books/NBK51725/" /><link rel="schema.DC" href="http://purl.org/DC/elements/1.0/" /><meta name="DC.Title" content="Background to foot care for people with diabetes" /><meta name="DC.Type" content="Text" /><meta name="DC.Publisher" content="University of Sheffield" /><meta name="DC.Contributor" content="School of Health and Related Research (ScHARR), University of Sheffield" /><meta name="DC.Date" content="2003" /><meta name="DC.Identifier" content="https://www.ncbi.nlm.nih.gov/books/NBK51725/" /><meta name="DC.Language" content="en" /><meta name="description" content="Diabetes is a complex metabolic disorder, characterised by a raised blood glucose concentration. Diabetes is becoming increasingly common in the UK. It is estimated that approximately 1.3 million people have diagnosed diabetes (the age-standardised prevalence of diagnosed diabetes is estimated to be 2.23 per 100 males and 1.64 per 100 females). The incidence of diabetes has been estimated at 1.7 new diagnoses per 1000 population per year. It is also thought that many people have undiagnosed Type 2 diabetes (with estimates of between 600,000 to 800,000 people who have not been diagnosed.). By the year 2010 it is projected that the number of people in the United Kingdom with diabetes will reach 3 million, and that the majority of these new cases will be of Type 2 diabetes (Department of Health 2002). Most people who have diabetes in the UK have Type 2 diabetes (approximately 85%). Type 2 diabetes is usually diagnosed in people over the age of 40, however it is increasingly being diagnosed in younger people, including children. Type 2 diabetes is more common in certain groups, estimates are of up to six times more common in people of South Asian descent, three times more common in those of African and African-Caribbean descent, and is more common in people of Chinese descent compared with the white population. Prevalence also rises with age, with one in 20 people over the age of 65 in the UK having diabetes and one in five in people over the age of 85 years. Whilst diabetes is more common in men, women are at greater risk of dying from the disease (Department of Health 2001)." /><meta name="og:title" content="Background to foot care for people with diabetes" /><meta name="og:type" content="book" /><meta name="og:description" content="Diabetes is a complex metabolic disorder, characterised by a raised blood glucose concentration. Diabetes is becoming increasingly common in the UK. It is estimated that approximately 1.3 million people have diagnosed diabetes (the age-standardised prevalence of diagnosed diabetes is estimated to be 2.23 per 100 males and 1.64 per 100 females). The incidence of diabetes has been estimated at 1.7 new diagnoses per 1000 population per year. It is also thought that many people have undiagnosed Type 2 diabetes (with estimates of between 600,000 to 800,000 people who have not been diagnosed.). By the year 2010 it is projected that the number of people in the United Kingdom with diabetes will reach 3 million, and that the majority of these new cases will be of Type 2 diabetes (Department of Health 2002). Most people who have diabetes in the UK have Type 2 diabetes (approximately 85%). Type 2 diabetes is usually diagnosed in people over the age of 40, however it is increasingly being diagnosed in younger people, including children. Type 2 diabetes is more common in certain groups, estimates are of up to six times more common in people of South Asian descent, three times more common in those of African and African-Caribbean descent, and is more common in people of Chinese descent compared with the white population. Prevalence also rises with age, with one in 20 people over the age of 65 in the UK having diabetes and one in five in people over the age of 85 years. 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<div class="pre-content"><div><div class="bk_prnt"><p class="small">NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.</p><p>School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet]. Sheffield (UK): University of Sheffield; 2003. (NICE Clinical Guidelines, No. 10.)</p></div><div class="bk_msg_box bk_bttm_mrgn clearfix bk_noprnt"><div class="iconblock clearfix"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/niceng19guid/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng19guid-lrg.png" alt="Cover" height="100px" width="80px" /></a><div class="icnblk_cntnt"><ul class="messages"><li class="info icon"><span class="icon"><a href="/books/n/niceng19guid/">See 2019 update</a></span></li></ul></div></div></div><div class="messagearea bk_noprnt" style="margin-bottom:1.3846em "><ul class="messages"><li class="warn icon"><span class="icon">This publication is provided for historical reference only and the information may be out of date.</span></li></ul></div><div class="bk_prnt"><p style="color:red;"><strong>This publication is provided for historical reference only and the information may be out of date.</strong></p></div><div class="iconblock clearfix whole_rhythm no_top_margin bk_noprnt"><a class="img_link icnblk_img" title="Table of Contents Page" href="/books/n/nicecg10/"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-nicecg10-lrg.png" alt="Cover of Clinical Guidelines for Type 2 Diabetes" height="100px" width="80px" /></a><div class="icnblk_cntnt eight_col"><h2>Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet].</h2><a data-jig="ncbitoggler" href="#__NBK51725_dtls__">Show details</a><div style="display:none" class="ui-widget" id="__NBK51725_dtls__"><div>NICE Clinical Guidelines, No. 10.</div><div>School of Health and Related Research (ScHARR), University of Sheffield.</div><div>Sheffield (UK): <a href="https://www.sheffield.ac.uk/scharr" ref="pagearea=page-banner&targetsite=external&targetcat=link&targettype=publisher">University of Sheffield</a>; 2003.</div></div><div class="half_rhythm"><ul class="inline_list"><li style="margin-right:1em"><a class="bk_cntns" href="/books/n/nicecg10/">Contents</a></li></ul></div></div><div class="icnblk_cntnt two_col"><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/nicecg10/ch2/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/nicecg10/ch4/" title="Next page in this title">Next ></a></div></div></div></div></div>
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<div class="main-content lit-style" itemscope="itemscope" itemtype="http://schema.org/CreativeWork"><div class="meta-content fm-sec"><h1 id="_NBK51725_"><span class="label"> 3</span><span class="title" itemprop="name">Background to foot care for people with diabetes</span></h1></div><div class="jig-ncbiinpagenav body-content whole_rhythm" data-jigconfig="allHeadingLevels: ['h2'],smoothScroll: false" itemprop="text"><div id="ch3.s1"><h2 id="_ch3_s1_">Introduction</h2><p>Diabetes is a complex metabolic disorder, characterised by a raised blood glucose concentration. Diabetes is becoming increasingly common in the UK. It is estimated that approximately 1.3 million people have diagnosed diabetes (the age-standardised prevalence of diagnosed diabetes is estimated to be 2.23 per 100 males and 1.64 per 100 females). The incidence of diabetes has been estimated at 1.7 new diagnoses per 1000 population per year. It is also thought that many people have undiagnosed Type 2 diabetes (with estimates of between 600,000 to 800,000 people who have not been diagnosed.). By the year 2010 it is projected that the number of people in the United Kingdom with diabetes will reach 3 million, and that the majority of these new cases will be of Type 2 diabetes (<a href="/books/n/nicecg10/references.rl1/#references.r44" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r44/" data-bk-pop-others="" class="bk_pop">Department of Health 2002</a>). Most people who have diabetes in the UK have Type 2 diabetes (approximately 85%). Type 2 diabetes is usually diagnosed in people over the age of 40, however it is increasingly being diagnosed in younger people, including children. Type 2 diabetes is more common in certain groups, estimates are of up to six times more common in people of South Asian descent, three times more common in those of African and African-Caribbean descent, and is more common in people of Chinese descent compared with the white population. Prevalence also rises with age, with one in 20 people over the age of 65 in the UK having diabetes and one in five in people over the age of 85 years. Whilst diabetes is more common in men, women are at greater risk of dying from the disease (<a href="/books/n/nicecg10/references.rl1/#references.r45" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r45/" data-bk-pop-others="" class="bk_pop">Department of Health 2001</a>).</p><p>As a chronic disease, Type 2 diabetes can have a major impact on almost all aspects of life, not just health and well-being, including life expectancy, lifestyle, work and income.</p><p>Foot problems in diabetes results from complications such as <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d40/">peripheral vascular disease</a> or <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d34/">neuropathy</a>. Peripheral vascular disease is the damage caused to large blood vessels supplying lower limbs. This can result in poor circulation, which can result in pain, and also predispose to the development of foot ulcers and ultimately <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a>. Peripheral neuropathy, degeneration of the peripheral nerves, which leads to loss of sensation and autonomic dysfunction may also lead to severe foot problems.</p><div id="ch3.s2"><h3>The impact and cost of diabetes</h3><p>The National Service Framework (<a href="/books/n/nicecg10/references.rl1/#references.r45" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r45/" data-bk-pop-others="" class="bk_pop">Department of Health 2001</a>) described the costs and impact associated with diabetes. This includes the significant direct personal costs, for people with diabetes, including costs associated with managing their diabetes. The average cost in 1999 was estimated to be £802 per year plus lost earnings. The presence of diabetic complications increases personal expenditure three-fold, and doubles the chance of having a carer.</p><p>The impact on the National Health Service and social care was also discussed in the National Service Framework. It was estimated that around 5% of total NHS resources and up to 10% of hospital in-patient resources are used for the care of people with diabetes. People with diabetes are twice as likely to be admitted to hospital as the general population and, once admitted, are likely to have a length of stay that is up to twice the average. It was also argued that the presence of diabetic complications increases NHS costs more than five-fold, and increases by five the chance of a person needing hospital admission. One in 20 people with diabetes incurs social services costs and, for these people, the average annual costs were £2,450 (1999). More than three-quarters of these costs were associated with residential and nursing care, while home help services accounted for a further one-fifth. The presence of complications increased social services costs four-fold.</p><p>The costs associated with foot ulcers was looked at by <a href="/books/n/nicecg10/references.rl1/#references.r152" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r152/" data-bk-pop-others="" class="bk_pop">Ramsey et al. (1999)</a>. This was a partial US cost study. It attempts to cost the care required over a two-year period for an individual with a newly diagnosed foot ulcer compared to patients with diabetes without a foot ulcer. It is therefore a partial cost of illness study. Reported in 1995 US dollars with a 5% discount rate applied to year two costs, the costs were derived by comparing matched pairs of patients diabetes with newly diagnosed ulcers and without foot ulcers. Few details are given as to the actual source or methods of costing, in contrast to the statistical analysis applied to the data. Costs appear to be based entirely on a database of accounting costs, although it is claimed that this is an accurate method of calculating the actual costs of services. It does include items such as overheads.</p><p>Results show that the costs of foot ulcer patients outstrip those of non foot ulcer patients by a factor of approximately 1.5–2.4 times in the year before diagnosis, 5.4 times greater in the year following diagnosis, and remain at 2.8 times greater in the second year.</p></div><div id="ch3.s3"><h3>Delivering care</h3><p>It is clear that a partnership between the person with diabetes and the health care professionals and others involved in their care, including informal carers, can improve both outcomes and quality of life for people with diabetes.</p><p>A postal survey (response rate 70%) of general practices conducted in late 1997 found that 96% of responding practices had diabetes registers (identifying 1.9% of their population as having diabetes). Seventy one per cent of responding practices held clinics run by a GP and nurse or by a nurse alone. Overall, practices provided most of the care for 75% of their patients with diabetes (<a href="/books/n/nicecg10/references.rl1/#references.r150" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r150/" data-bk-pop-others="" class="bk_pop">Pierce et al 2000</a>).</p><p>Inequalities exist in risk of developing diabetes, in access to health care services and health outcomes, with those less socially advantaged likely to have higher risk of development, poorer access and outcomes.</p></div><div id="ch3.s4"><h3>Prevalence of clinical diabetic polyneuropathy</h3><p>In a large retrospective cohort study of 8,905 patients with Type 1 or Type 2 diabetes, in a health maintenance organisation (USA), the cumulative incidence for foot ulcers over three years (1993–1995) was 5.8%. Of these, 77 (15%) developed <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d38/">osteomyelitis</a> and 80 (15.6%) required <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a>. Survival at three years was lower for foot ulcer patients than for age and sex matched patients with diabetes but without foot ulcers (p<0.001) (<a href="/books/n/nicecg10/references.rl1/#references.r152" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r152/" data-bk-pop-others="" class="bk_pop">Ramsey et al 1999</a>).</p><p>In a survey of 2633 Spanish patients with diabetes, aged 15–74 years, 22.7% had diabetic polyneuropathy, diagnosed as a <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d34/">neuropathy</a> Disability Score of >5 regardless of Neuropathy Symptom Score, or a Neuropathy Disability Score of 3–5 in conjunction with a Neuropathy Symptom Score of at least 5 (<a href="/books/n/nicecg10/references.rl1/#references.r194" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r194/" data-bk-pop-others="" class="bk_pop">Young et al 1993</a>). No differences in prevalence were seen by sex, but the prevalence in insulin-dependent patients was 12.9% and in non-insulin dependent patients 24.1% (p<0.001). Prevalence increased with increasing age and with increasing duration of diabetes since diagnosis (p<0.001). Prevalence was lower in those attending primary care centres (21.0%) compared with those being treated in hospital clinics (26.7%) (p<0.05). Multiple logistic regression analysis found that age and duration of diabetes were both associated with diabetic polyneuropathy in Type 2 patients (p<0.001) whereas the association was only seen for duration of diabetes in Type 1 patients (p<0.05). A second model also found an association between the origin of patients (in terms of whether they attended, and were recruited from, hospital clinics or primary health care centres) as well as the other two factors, in Type 2 patients, with those from hospitals having higher prevalence (p<0.001) (<a href="/books/n/nicecg10/references.rl1/#references.r26" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r26/" data-bk-pop-others="" class="bk_pop">Cabezas-Cerrato 1998</a>).</p></div><div id="ch3.s5"><h3>Incidence of amputation</h3><p>In a cohort study of a population-based sample of Type 1 and Type 2 people with diabetes in Wisconsin, followed up for between four and ten years, the ten year cumulative incidence of lower-limb <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a> was 5.4% in Type 1 and 7.3% in Type 2. In those with Type 2, logistic regression identified a history of ulcers (OR 3.3, 95% CI 1.6, 6.8), glycosated haemoglobin level (OR 1.3, 95% CI 1.1, 1.5), duration of diabetes (OR 1.6 for 10 years, 1.1, 2.5), sex (OR 2.6 for men, 1.3, 4.9), diastolic blood pressure (OR 0.7 for 10 mm Hg, 0.5, 1.0) and proteinuria (OR 2.4, 1.0,5.7) as significantly associated with incidence of lower-extremity amputation (all p<0.05) (<a href="/books/n/nicecg10/references.rl1/#references.r129" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r129/" data-bk-pop-others="" class="bk_pop">Moss SE et al 1996</a>). At the 14 year follow-up in the same study, a multiple logistic regression analysis found that the same variables, with the exception of proteinuria, were associated with lower limb amputation in Type 2 patients. More severe retinopathy was also found to be a risk factor (OR for one step 1.07, 1.00, 1.13) (<a href="/books/n/nicecg10/references.rl1/#references.r128" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r128/" data-bk-pop-others="" class="bk_pop">Moss et al 1999</a>).</p><p>Patients with current foot ulcers rated their health-related quality of life (assessed using the EQ-5D) significantly lower than patients who had healed primarily without <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a> (p=0.004). However quality of life is reduced after major amputations (<a href="/books/n/nicecg10/references.rl1/#references.r169" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r169/" data-bk-pop-others="" class="bk_pop">Tennvall and Apelqvist 2000</a>).</p><p><a href="/books/n/nicecg10/references.rl1/#references.r127" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r127/" data-bk-pop-others="" class="bk_pop">Morris et al (1998)</a> reported a retrospective cohort study of all 221 first lower-limb amputations in Tayside, Scotland between January 1993 and December 1994 and on a prevalence cohort of 7,079 patients with diabetes on January 1st, 1993. Of the 221, sixty had diabetes, of which four were Type 1 and fifty six Type 2. The age and sex standardised incidence density per 100,000 person years in Type 1 was 20.10 and in Type 2, 247.91.</p><p><a href="/books/n/nicecg10/references.rl1/#references.r138" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r138/" data-bk-pop-others="" class="bk_pop">New et al (1998)</a> used a population based district diabetes information system in Salford, England to determine the incidence and prevalence of lower limb <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a>, 1992 to 1996, and the proportion in those recently diagnosed with diabetes. The incidence of diabetes-related lower limb amputation was 475 per 100,000 diabetic patient years (10.2 per 100,000 population per year), with 16 (20.2%) of the amputations occurring within one year of diagnosis of diabetes. The age standardised incidence rate of diabetes related to lower limb amputations was 13.1 (95% CI 9.0, 17.2) times greater than for the general population.</p><p>In Denmark the incidence rate for major amputations in patients with diabetes (both Type 1 and Type 2) fell between 1981 and 1995 (<a href="/books/n/nicecg10/references.rl1/#references.r85" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r85/" data-bk-pop-others="" class="bk_pop">Holstein et al, 2000</a>).</p></div></div><div id="ch3.s6"><h2 id="_ch3_s6_">The burden of foot problems</h2><p>Among people with diabetes, foot complications are common. Overall, 20–40% of people with diabetes are estimated to have <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d34/">neuropathy</a> (depending on how it is defined and measured) and about 5% have a foot ulcer (<a href="/books/n/nicecg10/references.rl1/#references.r97" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r97/" data-bk-pop-others="" class="bk_pop">Kumar et al, 1994</a>; <a href="/books/n/nicecg10/references.rl1/#references.r137" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r137/" data-bk-pop-others="" class="bk_pop">Neil at al, 1989</a>; <a href="/books/n/nicecg10/references.rl1/#references.r183" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r183/" data-bk-pop-others="" class="bk_pop">Walters et al, 1992</a>).</p><p>The St Vincent declaration called for a 50% reduction in <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a> from diabetic gangrene, reflecting the belief that much morbidity is preventable by better patient management (<a href="/books/n/nicecg10/references.rl1/#references.r191" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r191/" data-bk-pop-others="" class="bk_pop">World Health Organisation, 1990</a>). A retrospective survey of the population of people with diabetes in Newcastle-upon-Tyne (UK) undergoing non-traumatic amputation (that is planned amputations undertaken as part of treatment rather than those caused by trauma such as road traffic accident), found that of the patients receiving hospital care, only half had complete foot evaluations in the year preceding initial ulceration or gangrene (<a href="/books/n/nicecg10/references.rl1/#references.r42" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r42/" data-bk-pop-others="" class="bk_pop">Deerochanawong et al, 1992</a>). Another retrospective study investigated causal pathways to amputation in a series of 80 diabetic lower-extremity amputees. A causal sequence of minor trauma, cutaneous ulceration and wound-healing failure applied to 72% of amputations (<a href="/books/n/nicecg10/references.rl1/#references.r143" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r143/" data-bk-pop-others="" class="bk_pop">Pecoraro et al, 1990</a>). This guideline addresses the evidence that improved outcomes are achievable by appropriate monitoring and intervention.</p></div><div id="ch3.s7"><h2 id="_ch3_s7_">Natural history of foot complications in diabetes</h2><p>The diabetic foot may be defined as a group of syndromes in which <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d34/">neuropathy</a>, <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d28/">ischaemia</a>, and infection lead to tissue breakdown resulting in morbidity and possible <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a> (<a href="/books/n/nicecg10/references.rl1/#references.r192" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r192/" data-bk-pop-others="" class="bk_pop">World Health Organisation, 1995</a>).</p><p>Peripheral <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d34/">neuropathy</a> in feet leads to loss of sensation and autonomic dysfunction. Peripheral vascular disease in the form of atherosclerosis of the leg vessels causes loss of circulation (<a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d28/">ischaemia</a> which is often bilateral, multisegmental, and distal). Infection often complicates neuropathy and ischaemia and is responsible for considerable damage in diabetic feet. Two broad pathologies result from these processes.</p><blockquote><p><i>Neuropathic feet</i>, where good circulation remains, are warm, numb, dry, usually painless and pulses remain palpable. Neuropathic ulcers, found mainly on the soles of feet, and neuropathic (or Charcot) joints are the two main complications which may result.</p><p><i>Neuro-ischaemic feet</i> are cool and pulses are absent. Pain at rest, ulceration at the edges of the foot from localised pressure damage, and gangrene may occur in addition to neuropathic complications.</p></blockquote><p>Approximately 50% of people with diabetes who present at dedicated foot clinics have neuropathic feet and approximately 50% have neuro-ischaemic feet (<a href="/books/n/nicecg10/references.rl1/#references.r61" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r61/" data-bk-pop-others="" class="bk_pop">Edmonds et al, 1986</a>, <a href="/books/n/nicecg10/references.rl1/#references.r172" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r172/" data-bk-pop-others="" class="bk_pop">Thomson et al, 1991</a>). Purely ischaemic feet, where these occur, are managed identically to neuro-ischaemic feet (<a href="/books/n/nicecg10/references.rl1/#references.r62" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r62/" data-bk-pop-others="" class="bk_pop">Edmonds et al, 1996</a>). In a local population study of 1077 diabetic patients, 7.4% were found to have past or present foot ulceration, of which 39.4% were neuropathic, 24.2% were vascular and 36.4% mixed (<a href="/books/n/nicecg10/references.rl1/#references.r183" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r183/" data-bk-pop-others="" class="bk_pop">Walters et al 1992</a>). More broadly, glycaemic control, ethnic background, duration of disease and cardiovascular factors are all associated with increased risk of complications.</p><p>Foot ulcers are susceptible to infection and <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d44/">polymicrobial infection</a> may spread rapidly causing overwhelming tissue destruction (<a href="/books/n/nicecg10/references.rl1/#references.r61" data-bk-pop-rid="/books/n/nicecg10/references.rl1/def-item/references.r61/" data-bk-pop-others="" class="bk_pop">Edmonds et al, 1986</a>). This process is the main reason for major <a class="def" href="/books/n/nicecg10/appendixes.app24/def-item/glossary.gl1-d5/">amputation</a> in neuropathic feet. Potential strategies to minimise the sequelae of foot complications include: early recognition of the ‘at risk’ foot; prompt use of preventative measures; and rapid and intensive treatment of foot complications in multidisciplinary foot care services.</p></div><div id="bk_toc_contnr"></div></div></div>
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<div class="post-content"><div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © 2003, School of Health and Related Research (ScHARR), University of Sheffield.</div><div class="small"><span class="label">Bookshelf ID: NBK51725</span></div><div style="margin-top:2em" class="bk_noprnt"><a class="bk_cntns" href="/books/n/nicecg10/">Contents</a><div class="pagination bk_noprnt"><a class="active page_link prev" href="/books/n/nicecg10/ch2/" title="Previous page in this title">< Prev</a><a class="active page_link next" href="/books/n/nicecg10/ch4/" title="Next page in this title">Next ></a></div></div></div></div>
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<div xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance"></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Views</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="PDF_download" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/NBK51725/?report=reader">PubReader</a></li><li><a href="/books/NBK51725/?report=printable">Print View</a></li><li><a data-jig="ncbidialog" href="#_ncbi_dlg_citbx_NBK51725" data-jigconfig="width:400,modal:true">Cite this Page</a><div id="_ncbi_dlg_citbx_NBK51725" style="display:none" title="Cite this Page"><div class="bk_tt">School of Health and Related Research (ScHARR), University of Sheffield. Clinical Guidelines for Type 2 Diabetes: Prevention and Management of Foot Problems [Internet]. Sheffield (UK): University of Sheffield; 2003. (NICE Clinical Guidelines, No. 10.) 3, Background to foot care for people with diabetes.<span class="bk_cite_avail"></span></div></div></li><li><a href="/books/n/nicecg10/pdf/">PDF version of this title</a> (888K)</li><li><a href="#" class="toggle-glossary-link" title="Enable/disable links to the glossary">Disable Glossary Links</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>In this Page</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="page-toc" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="#ch3.s1" ref="log$=inpage&link_id=inpage">Introduction</a></li><li><a href="#ch3.s6" ref="log$=inpage&link_id=inpage">The burden of foot problems</a></li><li><a href="#ch3.s7" ref="log$=inpage&link_id=inpage">Natural history of foot complications in diabetes</a></li></ul></div></div><div class="portlet"><div class="portlet_head"><div class="portlet_title"><h3><span>Other titles in this collection</span></h3></div><a name="Shutter" sid="1" href="#" class="portlet_shutter" title="Show/hide content" remembercollapsed="true" pgsec_name="source-links" id="Shutter"></a></div><div class="portlet_content"><ul xmlns:np="http://ncbi.gov/portal/XSLT/namespace" xmlns:xsi="http://www.w3.org/2001/XMLSchema-instance" class="simple-list"><li><a href="/books/n/nicecollect/">National Institute for Health and Clinical Excellence: Guidance
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