Lowering the risk of neuropathy, foot ulcers and amputations.

Peripheral neuropathy is one of the most common long-term complications of Type 2 diabetes. A population-based study in the north of England showed that 42% of Type 2 diabetic patients had clinical evidence of neuropathy. The Diabetes Control and Complications Trial (DCCT) has shown that the incidence of neuropathy in Type 1 diabetes can be reduced by over 50% with intensive therapy and optimal glycaemic control. Hyperglycaemia is believed to be a major aetiological factor in the development of neuropathy in Type 2 diabetes. Neuropathy cannot be diagnosed through history alone; therefore, careful examination of the feet for evidence of sensory loss and an assessment of the circulation must form part of the annual review of each patient. Peripheral somatic and autonomic neuropathy, together with peripheral vascular disease, are major contributing factors to the development of foot ulcers. In addition, abnormalities of foot shape (e.g. claw toes, prominent metatarsal heads) and the presence of plantar callus are signs of foot-ulcer risk. Effective patient education can reduce the incidence of foot ulceration and amputation by over 50%; therefore, all patients with a high risk of foot ulcers should be informed and, if indicated, referred for regular podiatry. The team approach to diabetic foot problems is an effective method of providing treatment for active ulcers. This should be followed by appropriate education, the provision of follow up and if indicated, suitable footwear and hosiery. Key members of the team are the podiatrist, the specialist nurse and the orthotist; medical staff may include the diabetologist and a vascular or orthopaedic surgeon. Thus, the risk of foot ulceration and amputation can be reduced by careful screening and patient education, without the need for expensive equipment.