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About diabetes

1 in 11 adults are living with diabetes2

Diabetes mellitus is a serious, long-term condition that nearly half a billion people are living with worldwide. It occurs when there are raised levels of glucose in a person’s blood because their body cannot produce any or enough insulin, or cannot effectively use the insulin it produces.

Insulin is an hormone produced in the pancreas that enables glucose from the bloodstream to enter the body’s cells, where it is absorbed and converted into energy. If the body produces insufficient insulin, or the cells are unable to respond to it, the blood glucose levels will rise causing hyperglycemia, which is the clinical indicator of diabetes.

The estimated prevalence of diabetes (type 1 and type 2 combined, both diagnosed and undiagnosed) in people aged 20–79 years has risen to 463 million (9.3% of the global population). Without sufficient action to address the pandemic, it is predicted that 578 million people (10.2% of the population) will have diabetes by 2030. That number will jump to a staggering 700 million (10.9%) by 2045.3

There are two main types of diabetes:

Type 1 diabetes is the result of an autoimmune reaction in which the body’s immune system attacks the insulin-producing cells of the pancreas. As a consequence, very little to no insulin of insulin is produced. At present, what causes this destructive process is not fully understood and cannot be prevented. But a likely explanation is that the combination of genetic susceptibility and an environmental trigger initiate the autoimmune reaction.
Type 1 diabetes can develop at any age, symptoms are most commonly developed and noticed when they are in young and hence many are diagnosed at an early age.

People with type 1 diabetes need daily insulin injections to regulate their glucose level in an appropriate range. Without insulin injection, patients with type 1 diabetes would not survive. However, with appropriate insulin treatment, regular glycemic control and monitoring, education and support, they can live healthy lives; prevent or delay many complications associated with diabetes.


Type 2 diabetes is the most common type of diabetes, accounting for around 90% of all diabetes worldwide.  ‘Insulin resistance’, occurs in type II diabetes, during which the body becomes insensitive to insulin and the body’s cells are unable to respond efficiently to insulin to utilize blood glucose and stabilise blood glucose. As a result, there is an increase in insulin production and the occurance of hyperglycemia at the same time. At present, the causes of type 2 diabetes are not fully understood. But there is a strong link with overweight and increasing age, as well as with ethnicity and family history. Also it is the result of a combination of multi-gene predisposition and environmental triggers.
Type 2 diabetes is more common in older adults, but an upward trend is seen in children and younger people due to the rising levels of obesity, physical inactivity and inappropriate diet. The cornerstone of type 2 diabetes treatment is the promotion of a healthy lifestyle, including increased physical activity and a healthy diet. However, if attempts to change lifestyle are not enough to control blood glucose, oral medication (or insulin) will be required.

  • Gestational diabetes develops sometimes during pregnancy but usually disappears afterwards.
  • Other rarer types of diabetes also exist.

Over the long term, high glucose levels are associated with the development of serious and life-threatening complications and the reduction of quality of life.

Chronically high blood glucose levels can lead to damage of many of the body’s organs, leading to disabling and life-threatening health complications such as cardiovascular diseases, nerve damage (neuropathy), kidney damage (nephropathy), eye disease (leading to retinopathy, visual loss and even blindness) and diabetic foot complications (leading to lower limb amputation).


Diabetic foot syndrome/ulceration is one of the most common, costly and severe complications of diabetes.

There are several factors that lead to diabetic foot
ulceration and low likelihood of ulcer healing:

Loss of Protective Sensation (LOPS)

Diabetes is associated with LOPS due to Neuropathy. Neuropathy is the damage of the nerves due to chronic high blood glucose. When peripheral neuropathy appears (which is the most common form of diabetic neuropathy), nerves lose their effectiveness: whether it is their motor, sensitive or autonomic functions.
Loss of Protective Sensation (LOPS) makes the foot susceptible to trauma, as it allows injuries to go unnoticed, leading to ulceration. Patients with LOPS can lose their normal ability to perceive pain, heat or cold on their feet. When proprioception and protective sensory are reduced, patients become unaware of position of their foot when walking and unnotice of abnormal pressure over bony prominence or foreign objects in shoes. As a result, the foot can respond by growing hard skin, or callus, in attempt to protect itself, but this may lead to foot deformations and ulceration if left unnoticed and untreated.

For instance, patients with LOPS can cut themselves on the foot when stepping on a glass without noticing it.

Foot deformities

For a diabetic, foot complications are an ever-present risk. This risk further increases with the presence of foot deformities or deformity related to diabetes. In a diabetic, damage to the nerve supply of foot muscles causes weakening of the muscles and potentially leading to a change in shape of the feet. This creates new abnormal pressure points and bony prominence which can cause sores and ulceration if neglected not adjusted for new abnormality.
The most common foot deformities are: hammer toe, claw toe, hallux valgus… The most severe and disabling foot deformities from diabetes is Charcot neuroarthropathy.

Peripheral arterial disease (PAD)

PAD is promoted by smoking, high blood pressure and hypercholesterolemia.
Diabetes promotes the deposition of cholesterol on the walls of the arteries of the lower limbs, and contributes to the formation of atheroma plaque. As a result, blood flows through the legs and feet with difficulty as the arteries in the legs become narrowed or blocked (arteriosclerosis). If the supply of blood to the tissues of the foot becomes poor, the foot will have poorer wound healing potential.
Because of that, PAD increases the risk of foot ulceration and their severity. When an artery is blocked or narrowed, the part of the body it supplies doesn’t get enough oxygen. The condition is called ischaemia.

PAD may reduce the delivery of oxygen in the muscles (ischaemia), which can cause leg pain with walking or rest pain in legs when legs are not in dependent position. In the presence of sensory neuropathy or after traumatic injury, PAD will aggravate the injury and potentially delay healing leading to iscemic ulcer because of the reduction of oxygenation and arterial supply. These are very painful arterial ulcers that can affect the anywhere on the leg, especially at the edge of the foot or the ends of the toes, and ulcer usually appear as pale and dry.

When an artery is blocked or narrowed, the part of the body it supplies doesn’t get enough oxygen. The condition is called ischaemia.

Previous history of foot ulceration or amputation

After successful healing, the recurrence rates of diabetic foot ulcers are 40% within a year and 65% within 3 years.4

“Thus, it may be more useful to think of patients who have achieved wound healing as being in remission rather than being healed”


the consequences of diabetic foot

1 in 4

1 in 4
with diabetes will potentially develop a foot ulcer

every 20

every 20
diabetes causes a foot amputation

70% of amputated

70% of amputated
will not be alive in 5 years


Due to diabetic foot, people with diabetes are 15 times more likely to undergo amputation than other people.
Diabetes has become the leading cause of amputations worldwide. The lives of people after an amputation are profoundly affected: many are unable to work, become dependent upon others and cannot pursue an active social life. Physical, emotional and social functions are all affected and depression is a common occurrence.
Five years after a lower extremity amputation, up to 70% of people may have died.

1. Setacci C, de Donato G, Setacci F, Chisci E. Diabetic patients: epidemiology and global impact. J Cardiovasc Surg (Torino). 2009 Jul, 50(3) : 263-73

2. International Diabetes Federation Atlas – 9th edition 2019


3. Saeedi P. et al. Global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: Results from the International Diabetes Federation Diabetes Atlas, 9th edition. Diabetes Research and Clinical Practice 157 (2019) 107843

4. Armstrong DG, Boulton AJM, Bus SA. Diabetic Foot Ulcers and Their Recurrence. N Engl J Med 2017; 376: 2367–75.


5. Whiting, D. R., Guariguata, L., Weil, C., and Shaw, J. 2011. “IDF Diabetes Atlas: Global Estimates of the Prevalence of Diabetes for 2011 and 2030.” Diabetes Res. Clin. Pract. 94 (3): 311-21.

Fortunately, clinical studies have shown that foot ulcers can be prevented and successfully treated through more prevention, early identifications of patients at higher risk for foot ulceration and appropriate referral of patients presenting with a diabetic foot ulcer to specialized settings.