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Investing in a diabetic foot care guideline could be one of the most cost-effective forms of healthcare expenditure

Karel Bakker, Heemstede, The Netherlands, chair of the International Working Group
on the Diabetic Foot (IWGDF) and of the International Diabetes Federation’s Diabetic
Foot Programme shares the importance of the 2011 Practical and Specific Guidelines on
the Management and Prevention of the Diabetic Foot.


What is the importance of these guidelines? It is estimated that in 2011 approximately
350 million people have diabetes—6.6% of the world’s population. Around 80% of these
people live in developing countries. By 2030, the global estimate is expected to rise to over
440 million—7.8% of the adult population. Every year, more than one million people with
diabetes lose a leg as a consequence of their condition. This means that every 30 seconds a
lower limb is lost to diabetes somewhere in the world. The majority of these amputations

are preceded by a foot ulcer. The most important factors relating to the development of
these ulcers are peripheral neuropathy, foot deformities, minor foot trauma, infection and
peripheral arterial disease. The spectrum of foot lesions varies from region to region due to
differences in socio-economic conditions, standards of foot care, and quality of footwear.
In developed countries, one in six people with diabetes will have an ulcer during their
lifetime; in developing countries, diabetes-related foot problems are thought to be even more
common. From all ulcers of the foot in diabetes only two-thirds will eventually heal. Up to
28% may result in some form of amputation. These complications do not only represent a
major personal tragedy for each person suffering from a diabetic foot ulcer; they also place a
considerable financial burden on healthcare and society in general. It is now recognised that
type 2 diabetes in children is becoming a global public health issue. It is inevitable that these
young people will go on to develop diabetes-related micro- and macrovascular complications,
including disabling and life-threatening foot problems, at a relatively early age. Investing
in a diabetic foot care guideline can be one of the most cost-effective forms of healthcare
expenditure, provided the guideline is goal-focused and properly implemented.

What new information is contained in the new guidelines which was not present in
the previous version? One of the major achievements and the first of its kind was the
creation of an evidence-based “Systematic Review of the Effectiveness of Revascularisation
of the Ulcerated Foot”, covering over 20,000 articles derived from Medline and Embase.
It was executed by an international working group of renowned experts in the field from
both sides of the ocean. It consisted of vascular surgeons, interventional radiologists,
endocrinologists/diabetologists, and epidemiologists. In the systematic review, the available
evidence of the efficacy and risks of vascular procedures to improve wound healing and
to prevent amputation are described. These data were summarised in a concise set of
guidelines: “Specific Guidelines for the diagnosis and treatment of peripheral arterial disease
in a patient with diabetes and ulceration of the foot 2011” that can be used in daily practice.
After careful consideration by the IWGDF editorial board, the review report and specific
guidelines were sent to the IWGDF representatives from over 100 countries for comments.
On a special Consensus Day prior to the 6th International Symposium on the Diabetic Foot
(ISDF) on 10 May 2011, in Noordwijkerhout, The Netherlands, all representatives were
invited to reach consensus on the three specific guidelines.

How can these guidelines help interventional radiologists? One new aspect was the
growing role of endovascular procedures in the management of peripheral arterial disease.
One of the important conclusions was that although comparative studies are lacking in this
area, both open and endovascular procedures seem to have equivalent benefits and risks.
However, the results of both open and endovascular procedures will greatly depend upon
the morphological distribution of peripheral arterial disease, as well as the local availability
and expertise in a given centre. The definitive choice for either treatment should therefore
be based on a multidisciplinary discussion that includes the different vascular specialists
involved, including specialists with expertise in endovascular procedures.

Please add any other material you wish to highlight…Based on these guidelines, which
can be tailored to suit local circumstances, health workers can also be trained, and their
knowledge and skills improved. One of the unique aspects of the IWDGF is its truly
multidisciplinary approach, and experts from many different areas are involved, such as
diabetologists, vascular and orthopaedic surgeons, podiatrists, radiologists, infectious disease
specialists, movement scientists, rehabilitation doctors, wound care specialists, general
practitioners, and many others. It is of major importance that these new guidelines and

recommendations are known and implemented within every clinic that treats diabetic foot
problems. A multidisciplinary approach and better logistics will be of huge benefit to diabetic
patients with peripheral arterial disease. Interventional radiologists can play an important role
in this treatment and this role will be even more important if this is done in such a team.

When do you expect that these guidelines will be published? We expect it to be published
in early 2012 in several peer reviewed journals.

For DVDs of the International Consensus on the Diabetic Foot and Practical and Specific
Guidelines on the Management and Prevention of the Diabetic Foot 2011, visit: http://
www.shop.idf.org/ Points to ponder

Diabetic foot problems are common, very expensive and life-threatening

• Every 30 seconds a lower limb is lost somewhere in the world due to diabetes

• Up to 70% of all lower-leg amputations are performed in patients with diabetes

• Up to 85% of all amputations are preceded by an ulcer