Foot complications are one of the most serious causes of morbidity, disability, poor quality of life, and resource use among diabetic people (1). The adoption of preventive strategies to reduce the rate of foot problems thus represents an important priority. In fact, a strategy that includes prevention, patient and staff education, multidisciplinary treatment of foot complications, and close monitoring has been demonstrated to be very effective in reducing amputation rate (2).

In the context of a nationwide outcomes research program (the QuED project), we investigated several aspects related to foot care in 3,564 patients with type 2 diabetes enrolled by 125 diabetes outpatient clinics and 103 general practitioners.

Details on study design have been reported elsewhere (3). Briefly, all patients with type 2 diabetes were considered eligible, irrespective of age, duration of diabetes, and treatment. Foot complications included ulcers, gangrene, nontraumatic amputations, and claudicatio intermittens.

Patients filled out a questionnaire investigating whether they had received information about foot care, how often they had had their feet examined in the last year, and how often they usually checked their feet. Analyses were adjusted for patient case mix and physician-level clustering using multivariate multilevel logistic regression models (4).

The prevalence of lower limb complications was 6.8%. Seventy-two percent of the patients declared that they had received foot education, but only 49% reported that they had had their feet examined in the last year. Patients with ≤5 years of school education (odds ratio [OR] 1.3, 95% CI 1.1–1.6) and those with low income (≤$12,000) (1.2, 1.0–1.4) were more likely not to receive foot education. The presence of foot complications, peripheral vascular disease, cardiac-cerebrovascular disease, and diabetic neuropathy were not independently associated with a greater chance of receiving foot education. Foot examination was more likely to be performed in low-income patients (1.3, 1.1–1.6) and in those with foot complications (1.5, 1.1–2.1) but not in those with diabetic neuropathy, peripheral vascular disease, or cardiac-cerebrovascular disease. Foot examination tended to be performed less frequently by general practitioners and other specialists in diabetes outpatient clinics as opposed to diabetologists, even though the statistical significance was reached only for the comparison between general practitioners and diabetologists (0.6, 0.4–1.0).

Overall, 33% of the patients declared that they never checked their feet. Patients who had received foot education (OR = 2.5, 95% CI 2.0–3.0) and those who had had their feet examined by their physician (1.7, 1.4–2.0) were more likely to check their feet regularly. Similarly, patients with foot complications (2.2, 1.5–3.2), but not those with peripheral vascular disease, cardiac-cerebrovascular disease, or diabetic neuropathy, were more likely to check their feet.

In conclusion, the attention to foot complications is generally poor, and a substantial proportion of type 2 diabetic patients is not offered foot education and examination, even in those subgroups showing a significant increase in the risk of foot complications. Even in the presence of foot complications or major risk factors, one-quarter of the patients did not pay any attention to foot care. Those patients who had received foot education and had had their feet examined were significantly more likely to regularly check their feet. This finding underlines the crucial role of physicians in orienting patient practices.

Humphrey AR, Dowse GK, Thoma K, Zimmet PZ: Diabetes and nontraumatic lower extremity amputations: incidence, risk factors, and prevention: a 12-year follow-up study in Nauru.
Diabetes Care
Larsson J, Apelqvist J, Agardh CD, Stenstrom A: Decreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?
Diabet Med
Belfiglio M, De Berardis G, Franciosi M, Cavaliere D, Di Nardo B, Greenfield S, Kaplan SH, Pellegrini F, Sacco M, Tognoni G, Valentini M, Nicolucci A, Caimi V, Capani F, Corsi A, Della Vedova R, Massi Benedetti M, Nicolucci A, Taboga C, Tombesi M, Vespasiani G: The relationship between physicians’ self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes.
Diabetes Care
Snijders TAB, Bosker RJ.
Multilevel Analysis: An Introduction to Basic and Advanced Multilevel Modeling.
London, SAGE Publications,