Diabetes-Related Foot Ulcer Incidence Rose From Early 1990s Through 2013

Diabetic foot ulcer
diabetes foot at sole of foot and sole of big toe, foot screen in diabetes patient for prevent complication
Certain risk factors were consistent predictors of DFU hospitalization regardless of FDS phase, making a case for a temporal shift of inpatient care strategies over those decades.

Incident diabetes-related foot ulcer (DFU) hospitalizations related to type 2 diabetes (T2D) increased from the early 1990s to the late 2010s, especially in younger patients and those with peripheral sensory neuropathy (PSN), according to the results of a study published in Diabetes Care.

Although DFU is a common and debilitating complication of diabetes, data relating to temporal trends are sparse.

To determine if there was a change in 5-year DFU hospitalization incident rates (IRs) in recent decades, data from the Fremantle Diabetes Study (FDS) were analyzed. In the first phase of the study (FDS1), 1296 individuals (51.4% women) with a mean age of 64.0 (±11.3) years were recruited in 1993 to 1996 and in the second phase (FDS2), 1509 individuals (48.2% women) with a mean age of 65.4 (±11.7) years were recruited in 2008 to 2011.

Individuals who had clinically defined T2D and had not experienced a DFU were included. Incident DFU was identified by its relevant diagnosis codes.

In the FDS1 cohort, an IR for DFU hospitalization of 1.9 (95% CI, 0.9-3.3) per 1000 person-years was observed compared with an IR of 4.5 (95% CI, 3.0-6.4) per 1000 person-years for FDS2. The crude incident rate ratio (IRR) for DFU hospitalization for the FDS1 cohort was 2.4 (95% CI, 1.17–5.28) compared with the FDS2 cohort (P =.013).

No incident DFU hospitalization was observed in the FDS1 cohort for individuals aged over 61 years compared with 11 individuals in the FDS2 cohort (P =.041). A significantly greater number of individuals who were diagnosed with T2D at less than 50 years of age experienced incident DFU hospitalization in the FDS2 cohort (61.3%) compared with the FDS1 cohort (9.1%; P =.004).

The results of this study indicated that incident hospitalization for DFU has increased from the early 1990s to the late 2010s. This increase is likely due to changes in the incidence of known DFU risk factors such as glycemic control, PSN, peripheral arterial disease, and diabetic nephropathy.

Limitations to this study include its use of DFU hospitalization data, excluding analysis of less severe DFU incidences. Changes in T2D and DFU diagnostic criteria, treatment protocols, and awareness may have impacted incident rates over time.

Future research including analysis of incidence rates of less severe DFU are warranted. Analysis controlling for changes in diagnostic criteria and treatment protocols should also be another consideration.


Hamilton EJ, Davis WA, Siru R, Baba M, Norman PE, Davis TME. Temporal trends in incident hospitalization for diabetes-related foot ulcer in type 2 diabetes: the Fremantle Diabetes Study. Diabetes Care. Published online February, 2021. doi:10.2337/dc20-1743