DMRR special issue: Prevention and adherence

Prevention has traditionally been a bit of the neglected child in the diabetic foot family, but the 2015 Guidance and this special issue are trying to make up for that.

Not only with a new chapter in the Guidance ( and a systematic review on prevention (, also with five nice proceeding papers.

Dr. Bus and Dr. Van Netten hope to set a new target. After the St. Vincent Declaration of 1989 (“reduce amputations by 50%”), they argue that 75% of ulcers can be prevented. A challenging proposition, but backed up by effect sizes from various high level studies. For such a reduction, an integrated approach to prevention is needed, involving adequate footwear, education, self-management and foot surgery. Who will pick up the glove (or sock J) in Australia and start organising such state-of-the-art preventative care?

The final argument of Bus and Van Netten links beautifully with the next article of Prof. Price: we need adherent patients. Prof. Price describes the complex and multifactorial nature of adherence and the myriad barriers that exist that patients and health care professionals need to overcome. But when messages are kept simple, tailored to the individual and repeated frequently, good outcomes are possible.

A new way to look at prevention can be found in two articles focussing on exercise to either improve function or glucose regulation. The evidence for the first is not yet fully developed, but Dr. Sacco has some interesting thoughts that may be worth pursuing. The importance of changing sedentary behaviour cannot be denied after reading the overview by Dr. Henson, whether it will prevent diabetic foot ulceration as well remains to be proven.

The final paper on this topic forces us to rethink the organisation of our clinic. Traditionally, only subjective measurements were available to evaluate our high-risk patients. Dr. Bus shows that innovations in plantar pressure and temperature measurements have paved the way to an objective evaluation of the treatments we give to our patients to prevent diabetic foot ulcers. It probably won’t take long before governing bodies start demanding the objective evidence, so we’d probably better start adapting to this in our clinics now.