No mean feat

As we head into a new year, we are delighted to be publishing several clinical research papers focussing on the foot in diabetes. Diabetes foot research can be challenging as people living with foot ulceration or Charcot neuroarthropathy often have significant comorbidities. Foot care was one of the domains of diabetes care that was relatively protected from the impact of the covid19 pandemic as multidisciplinary diabetic foot clinics remained open throughout, with enhanced personal protective equipment for both clinicians and service users. However, annual review care processes, including routine foot examination for people without diabetes foot complications were affected and an increased risk of mortality was identified in those who did not receive all eight care processes over that period.1 Foot surveillance was most severely impacted with a 37.5% reduction in completion of that care process compared to previous years and, while it is not known if improved foot surveillance care process completion would reduce mortality, optimising completion of all eight processes appears to be important. Support to optimise diabetes foot examination in a variety of care settings is explored in this issue of Diabetic Medicine in an assessment of the quality of YouTube videos available online.2 The authors found that the videos are frequently watched but are of low quality and reliability with a need for reputable sources which adhere to standards to address this. An absence of standards is also explored in a commentary that discusses the terminology used by healthcare professionals and suggesting that screening and assessment are used in future documents with harmonisation of that language.3 Using agreed terminology can be a powerful tool to avoid confusion felt by people with diabetes and healthcare professionals and, in line with the language matters principle, to avoid any pejorative meaning to the words used. Along with standards for online video education and terminology, the costeffectiveness impact of adherence to guidelinebased care for people with diabetes is estimated.4 Perhaps unsurprisingly, but very reassuringly, increased adherence to guidelinebased care is associated with reduced cost and greater effectiveness. These findings, taken together, might seem to suggest that one size fits all but that is rarely the case in medicine and especially not in the context of complex foot care. From a large NHS dataset, variance in outcomes from diabetes foot complications is reported, even after adjustment for demographic characteristics, ulcer severity, smoking, body mass index and comorbidities.5 Other factors, therefore, drive variance in outcomes and, in a different manuscript from Australia, the authors report that dietary supplementation and lower levels of socioeconomic deprivation are associated with diabetic foot ulcer healing.6 Important opportunities to improve care are often at a system wide level and the data in this issue of Diabetic Medicine suggest that education, terminology, robust guidelines, pathways for assessment, and social factors all have a role in the complex diabetes foot. As always, interventions may be challenging to implement and clinical studies will remain difficult but further data, especially in large, wellcurated, comprehensive datasets such as the National Diabetes Audit will continue to contribute to the evidence base.