NICE (National Institute for health and Care Excellence), a UK body tasked with the assessment and review of new and established treatments based on robust clinical evidence, have just released their latest guidelines (aimed at delivery of care in the NHS) on diagnosis and management of primary diabetes in adults, diagnosis and management of both primary and secondary in children and ‘young people’, and the prevention and management of diabetic foot problems.
The introduction of the latter highlights the problems of the diabetes epidemic within the UK, and reflected all over the world. Diabetes is on an inexorable rise (at least 50% in the past 6 years), and with it comes a host of acute and chronic medical problems, and the consequences are an earlier death in those with diabetes often through prolonged, chronic, debilitating illness.
The key to avoidance of complication is sugar control to as normal a level as possible. This needs proactive care and patient collaboration, equity of provision and education.
As societies, there needs to be a rethink about nutrition – the most important cause of diabetes. Irrespective of your genetic make-up, if you eat too much and exercise too little you increase the risk of developing secondary diabetes. More information on the types and causes are found on the NIDDK website.
The diabetic foot comes to my attention as a vascular surgeon increasingly frequently. It is the major cause of non-traumatic amputation and is usually associated with a preexisting, inadequately treated, diabetic foot ulcer. Early and effective treatment of a foot ulcer can prevent major amputation. Late intervention can result in disfigurement, dysfunction and limb loss. Prevention is cheap, intervention (and the sequalae) is expensive. Treatment is multidisciplinary with specialist physicians, surgeons and podiatrists essential components of care but the key member of the team is the person with diabetes themselves; without self motivated and managed care the attrition will continue.
The KEY RECOMMENDATIONS:
Care within 24 hours of diagnosis (Early intervention)
Across all settings (Pathways to incorporate community, specialist clinics, and in-patient services)
Preemptive risk assessment and risk management (Foot protection service)
Rapid referral pathways for acute diabetic foot problems (Early initiation of treatment under specialist teams)
Patient education (Critical engagement and self determination)
Establish local treatment guidelines for established disease (Specialist team direction and resource support)
Research (the effects of monitoring on outcome, what care pathways work, impact of education and psycho-behavioral management, which dressings are most effective, how best to manage the Charcot foot)
To these recommendations I’d add that there is little that can be achieved by them or the research targets if there is no way of effectively reporting outcomes in a reliable and comparable way. There has been progress in this with the introduction of the WIFI (Wound, Ischaemia, Foot Infection) scheme for stratification of diabetic foot. This should have been incorporated into the new recommendations as a core standard of reporting, and in that omission there has been a significant missed opportunity to really push both the research and care of the diabetic foot forward.