Current issues of ACP Journal Club are published in Annals of Internal Medicine


Implementing risk reduction strategies led to a reduction in foot abnormalities in patients with type 2 diabetes

ACP J Club. 1993 Nov-Dec;119:70. doi:10.7326/ACPJC-1993-119-3-070

Source Citation

Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. Ann Intern Med. 1993 Jul 1;119:3641.



To evaluate the effectiveness of a patient, health-care provider, and systems intervention in reducing foot abnormalities in patients with type 2 diabetes mellitus.


Randomized controlled trial with 1-year follow-up.


Academic general medicine practice.


395 patients (mean age 60 y, 81 % women) with type 2 diabetes mellitus seen ≥ 2 times in the previous year by the same health-care provider. Exclusion criteria were pregnancy, major psychiatric illness, terminal illness likely to cause death in < 1 year, renal failure, previous bilateral amputations above or below the knee, or an inability to provide any self-care. 352 patients (89%) completed the study.


191 patients were allocated to the intervention group that included several risk-reduction strategies. Patients received foot-care education and entered into a behavioral contract for desired self-foot care. Health-care providers were given practice guidelines and informational flow sheets on foot-care-related risk factors for amputation in diabetic patients. 205 patients assigned to the control group received usual care.

Main outcome measures

Serious foot lesions, patient knowledge and performance of appropriate foot care assessed blindly, frequency of foot examinations by health-care providers, and number of referrals to specialty clinics.

Main results

Patients assigned to the intervention group had fewer foot abnormalities at 1 year compared with control patients. The odds ratio for serious foot lesions was 0.41 (95% CI 0.16 to 1.00), indicating a reduced likelihood of abnormalities in intervention patients. Intervention patients more frequently reported washing as well as avoiding soaking their feet; inspecting their feet and the inside of shoes; drying between toes; and filing calluses. Intervention patients were more likely to have foot examinations during office visits (68% vs 28%, P< 0.001) and to receive footcare education (42% vs 18%, P< 0.001). Physicians assigned to intervention patients were more likely to examine patients' feet and to refer patients to the podiatry clinic (11% vs 5%, P = 0.04).


An intervention designed to reduce risk factors for foot amputations reduced the prevalence of foot abnormalities and improved foot-care behavior by patients with type 2 diabetes and interventions by their health-care providers.

Source of funding: Centers for Disease Control and Prevention.

For article reprint: Dr. D.K. Litzelman, Indiana University School of Medicine, Department of Medicine, WD/OPW M200, Indianapolis, IN 46202, USA. FAX 317-630-2667.


Foot abnormalities are a major cause of disability, morbidity, and mortality in the patient with diabetes. Because of complications from diabetes, such as neuropathy and vasculopathy, foot trauma in a patient with diabetes can cause cutaneous ulceration and, with impaired wound healing, lead to lower-extremity amputation. A recent study confirmed this risk, reporting that men and women with diabetes had a 10.3- and 13.8-fold higher risk, respectively, for lower-extremity amputation (1).

Patients with diabetes who are at high risk for developing foot abnormalities need to be identified. Clinical practice recommendations from the American Diabetes Association suggest doing foot examinations at regular visits (2). Additionally, a comprehensive neurologic, vascular, musculoskeletal, skin, and soft-tissue evaluation should be done initially and then annually (2). Patients with diabetes also need to be educated to care for their feet properly, to avoid foot trauma, and to examine their feet; they should also be encouraged to reduce risk factors such as smoking.

The study by Litzelman and colleagues shows that a team approach involving both the patient and health-care professional can be successful. Interventional guidelines, including patient education for self-foot care and practice guidelines for the health-care provider, can be successfully implemented as a means to reduce risk factors for lower extremity amputation.

Richard J. Weiss, MD
Newcomb Medical CenterVineland, New Jersey, USA


1. Siitonen O, Niskonen L, Laakso M, etal. Lower extremity amputations in diabetic and nondiabetic patients. Diabetes Care. 1993;16:16-20.

2. Clinical Practice Recommendations 1991-1992. Foot care in patients with diabetes mellitus. Diabetes Care. 1992;15 (Supp 2):19-20.