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 Table of Contents  
Year : 2021  |  Volume : 12  |  Issue : 1  |  Page : 41-45

Assessment of footwear among patients with diabetes mellitus: A cross-sectional descriptive study from south India

Department of Endocrinology, Believers Church Medical College Hospital, Thiruvalla, Kerala, India

Date of Submission04-Apr-2020
Date of Decision20-May-2020
Date of Acceptance20-Jun-2020
Date of Web Publication25-Dec-2020

Correspondence Address:
Dr. Anulekha Mary John
Department of Endocrinology, Believers Church Medical College Hospital, Saint Thomas Nagar, Kuttapuzha (PO), Thiruvalla 689103, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_16_20

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Background: Diabetic peripheral neuropathy, a well-known complication of diabetes mellitus, leads to insensate foot, prone for ulceration. Inappropriate footwear and walking barefoot increases this risk in a neuropathic foot. A diabetic foot ulcer can be very costly, affecting the quality of life adversely and also result in amputation. A well-fitting, good footwear plays an important role in preventing injury and ulceration. In this study, we aimed to assess the footwear of patients with diabetes. Materials and Methods: This study was conducted during May 2019. Alternate patients among 230 patients were selected, and 112 patients with type 2 diabetes were included. Every patient was educated regarding all aspects of diabetes. Feet of each patient were examined. Biothesiometry, monofilament, and footwear assessments were performed. Results: Among 112 patients enrolled, 69 (61.6%) were males and 43 (38.3%) females. Mean age was 60.2 ± 11.7 years, and age ranged from 21 to 83 years. Duration of diabetes ranged from less than a year to 45 years. Of the total patients, 73 (65.17%) had significant diabetic peripheral neuropathy when assessed objectively, using biothesiometry and 10 g Semmes–Weinstein monofilament. Only 10 (8.9%) patients had footwear made of microcellular rubber. Only 15 (13.3%) wore a footwear with backstrap. Among those with neuropathy, only 4 (3.5%) had microcellular rubber (MCR) footwear with a backstrap. Optimal toe box was seen in 98 (87.5%) patients as most patients wore open footwear. Most of our patients wore footwear that was too hard, with shore value on durometry ranging from 60 to 75. Only 5 (4.46%) patients had desirable soft insole. Conclusion: No patient had an optimal footwear that fulfilled all criteria required for a foot with diabetic peripheral neuropathy. Hence, in addition to screening for neuropathy and regular checking of feet, it is also important to look at patient’s footwear and make necessary amendments periodically.

Keywords: Biothesiometry, diabetes education, durometry, ideal footwear, peripheral neuropathy

How to cite this article:
John AM, Charley JK, Joy J. Assessment of footwear among patients with diabetes mellitus: A cross-sectional descriptive study from south India. J Diabetol 2021;12:41-5

How to cite this URL:
John AM, Charley JK, Joy J. Assessment of footwear among patients with diabetes mellitus: A cross-sectional descriptive study from south India. J Diabetol [serial online] 2021 [cited 2022 Jun 30];12:41-5. Available from: https://www.journalofdiabetology.org/text.asp?2021/12/1/41/304348

  Introduction Top

Prevalence of diabetes mellitus is increasing at an alarming rate.[1] India is estimated to have 61.3 million diabetics, which is projected to be more than 100 million by the year 2030.[2] Diabetic peripheral neuropathy is notorious in causing foot ulcers. It can be costly,[3] affect quality of life,[4] lead to morbidity,[5] and be burdensome.[6]

Our objective was to assess the footwear used by patients with diabetes, attending an integrated diabetes clinic under endocrinology department, in a tertiary care teaching hospital of south India. We assumed that a person with diabetes, who is well aware of peripheral neuropathy and its complications, would be careful in choosing appropriate footwear. So, assessing one’s footwear will help us understand a patient’s awareness and knowledge regarding peripheral neuropathy as well as foot care.

  Materials and Methods Top

Study design and place

This cross-sectional, observational, descriptive study was conducted in a tertiary care hospital in central Kerala, among a population that was economically stable and well educated.

Sampling and subjects

Subjects were patients who visited a specialized clinic called integrated diabetes clinic of endocrinology department. This study was done after obtaining consent and with both institutional review board as well as ethical committee clearance. This was done during the month of May 2019. Inclusion criteria consisted of patients older than 18 years of age, with type 2 diabetes mellitus, who were ambulatory. Gestational diabetes, patients on wheelchair, patients with end-stage organ damage or post-stroke, and patients with type 1 diabetes were excluded.

Every alternate patient with type 2 diabetes who came to the integrated diabetes clinic during this period was selected.


In the integrated diabetes clinic, every patient is educated by well-trained diabetes nurse educators. Diabetes educators are health-care professionals who apply in-depth knowledge and skills in the management of diabetes by communication and counseling, enabling patients to manage daily and future challenges. Neuropathy assessment was done as part of routine evaluation, and a face-to-face interview was conducted to assess footwear usage and patient preference. Demographic details, personal information, information regarding the duration of diabetes, general physical examination, foot examination details, and so on, were obtained. Vibration perception threshold was also done using a biothesiometer as part of foot examination in every patient. Footwear was examined by a trained doctor, and the hardness of insoles was recorded using a durometer. All details were entered into a pro forma.

Patient education and ethics

This study was approved by the institutional review board and ethical committee. Every patient was educated regarding all aspects of diabetes such as diet modification, exercises, insulin storage and administration techniques, insulin dose adjustments, foot care, and lifestyle modifications. Feet of each patient were examined carefully, looking for calluses, ulceration, fungal infections, fissuring, nail infections, and nail-related abnormalities such as ingrown or abnormally cut nails and paronychia. Biothesiometry, ankle reflex, and monofilament testing along with footwear assessment were performed. Footwear was assessed by inspection—looking at the type of footwear, material used for the soles, presence of backstrap, appropriate fitness, and width of toe box, and shore value was assessed using a durometer.

Patients were advised on foot care as well as ideal footwear. A comfortable footwear made of microcellular rubber (MCR), with backstrap was advised.

All statistical analyses were performed in Microsoft Excel.

  Results Top

A total of 230 patients who visited the integrated diabetes clinic in the month of May 2019 were considered for this study. Every alternate patient was selected for the study, excluding those who were wheelchair bound. A total of 112 patients were enrolled. Of these, 69 (61.6%) were men and 43 (38.4%) were women [Figure 1]. Mean age was 60.2 ± 11.7 years, and age ranged from 21 to 83 years [Figure 2]. Mean age of men was 60.35 ± 11.34 years. Mean age of women was 58.57 ± 11.68 years. Duration of diabetes ranged from less than a year to 45 years. One-third of our patients had diabetes for over 15 years [Figure 3].
Figure 1: Gender distribution

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Figure 2: Age distribution

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Figure 3: Duration of diabetes

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Of the patients, 73 (65.17%) had diabetic peripheral neuropathy when assessed objectively using biothesiometry and 10 g Semmes–Weinstein monofilament [Figure 4].
Figure 4: Diabetic peripheral neuropathy

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Only 10 (8.9%) patients had footwear made of MCR. Only 15 (13.3%) wore a footwear with backstrap. Among those with neuropathy, only 4 (3.5%) patients had an MCR footwear with a backstrap [Figure 5] and [Figure 6]. Optimal toe boxes were seen in 98 (87.5%) patients as most patients wore open footwear. Most of our patients wore a footwear that was too hard, with shore value on durometry ranging from 60 to 75. Only 5 (4.46%) patients had desirable soft insoles. No patient had an optimal footwear that fulfilled all criteria required for a foot with diabetic peripheral neuropathy [Table 1].
Figure 5: Patients with microcellular rubber footwear and those with backstrap

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Figure 6: Diabetic peripheral neuropathy patients with microcellular rubber footwear, which has backstrap

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Table 1: Footwear and neuropathy data

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  Discussion Top

It is estimated that over 387 million people worldwide are diagnosed with diabetes mellitus.[7] The importance of protecting the body from hyperglycemia cannot be overstated; the direct and indirect effects of hyperglycemia, on the human vasculature is the major source of morbidity and mortality in both type 1 and type 2 diabetes. Generally, the injurious effects of microvascular complications include nephropathy, neuropathy, and retinopathy.[8] Though macrovascular complications often result in mortality, it is the microvascular complications that result in chronic debilitation and lead on to poor quality of life. It is observed that, by the time diabetes mellitus is diagnosed, more than 10% of patients would have one or two risk factors such as neuropathy or peripheral vascular disease.[9] Of all microvascular complications, diabetic peripheral neuropathy seems the most ignored. Often testing for neuropathy is done only when a patient develops dysesthesia or ends up with a diabetic foot ulceration or amputation. Moreover, even after establishing a diagnosis of peripheral neuropathy, patients are not well educated regarding foot care or footwear.

Adequate knowledge of diabetes is a key component of diabetes care. Many studies have shown that increasing patient knowledge regarding disease and its complications has significant benefits with regard to patient compliance and reduction of complications associated with disease.[10] Similarly, good knowledge and practice regarding diabetic foot care will reduce the risk of diabetic foot complications and ultimately amputation.

Repetitive stress including shear and pressure are among the risk factors that cause plantar ulceration in a neuropathic foot.[11] Inappropriate footwear or walking barefoot increases the mechanical stress in the presence of neuropathy.[12]

An ideal footwear in patients with diabetes should be well fitting, with an outsole that is protective, and should accommodate the shape of one’s foot.[13] More importantly, it should have an insole, which is able to distribute the plantar pressure equally. It should be shock absorbing and soft, but sufficiently resilient and non-slippery.[14] Insole made of MCR manufactured with a shore hardness of 15 Shore A has helped prevent high pressure points and thus avoid plantar ulcers in anesthetic feet.[15] Similarly, it is also important to have a footwear with backstrap and a wide enough toe box.

This particular region in the state of Kerala, where the study was conducted, has a well-informed, literate, and affluent population. All these patients were already well informed regarding diabetes and its complications. However, despite good awareness about diabetes and its complications, preventive actions are not always practiced. It is important to take precautions to prevent the complications. In this study, we found that though all patients with neuropathy were clearly instructed regarding optimal footwear, only a very small proportion of them chose to wear one. There could be several reasons for this. We have gathered some from our clinical experience. The elderly people have issues with balance and mobility, and hence it is difficult to use a footwear with backstrap. One needs to bend down to wear the strap, be it a buckle or Velcro. Also, though Kerala is the largest rubber-producing state, MCR footwear is expensive. This is another reason for not buying them. Kerala gets monsoon rains during most months of the year, and patients find it easier to wear open Hawaii chappals in the rains, and keep their expensive MCR footwear safe at home, even when they own one.

It is believed that annually one million limb amputations occur worldwide due to diabetic foot.[16] Footwear usage is one of the important modalities of foot care to maintain good foot health and protect it from trauma. Once the patient has diabetic foot, the usage of footwear by the patient becomes essential. Footwear plays an important role in the management of foot problems.[17] It is often considered to be one of the most common interventions for biomechanical abnormalities of the foot.[18]

Footwear serves to protect the feet, reduce abnormal pressure, and limit formation of ulcers. There has been a recommendation on the usage of footwear for different risk levels in Western literature.[19] There are studies from India, where usage of inappropriate footwear was high among patients with established diabetic foot complications.[20]

Patient education and foot care are very important measures that reduce foot complications. However, literature suggests that many of these do not happen in practice.[21] Therefore, in addition to screening for neuropathy and regular checking of feet, it is also important to look at a patient’s footwear and make necessary amendments periodically. This will go a long way in increasing awareness among patients with diabetes and will help to avoid future diabetic foot ulceration and also reduce unnecessary financial burden.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Papatheodorou K, Papanas N, Banach M, Papazoglou D, Edmonds M Complications of diabetes 2016. J Diabetes Res 2016;2016:6989453.  Back to cited text no. 1
Whiting DR, Guariguata L, Weil C, Shaw J IDF Diabetes Atlas: Global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2011;94:311-21.  Back to cited text no. 2
Kerr M, Rayman G, Jeffcoate WJ Cost of diabetic foot disease to the National Health Service in England. Diabet Med 2014;31:1498-504.  Back to cited text no. 3
Nabuurs-Franssen MH, Huijberts MS, Nieuwenhuijzen Kruseman AC, Willems J, Schaper NC Health-related quality of life of diabetic foot ulcer patients and their caregivers. Diabetologia 2005;48:1906-10.  Back to cited text no. 4
Jupiter DC, Thorud JC, Buckley CJ, Shibuya N The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2016;13:892-903.  Back to cited text no. 5
Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J The global burden of diabetic foot disease. Lancet 2005;366:1719-24.  Back to cited text no. 6
Saurabh S, Sarkar S, Selvaraj K, Kar SS, Kumar SG, Roy G Effectiveness of foot care education among people with type 2 diabetes in rural Puducherry, India. Indian J Endocrinol Metab 2014;18:106-10.  Back to cited text no. 7
Fowler MJ Microvascular and macrovascular complications of diabetes. Clin Diabetes 2008;26:77-82.  Back to cited text no. 8
Chiwanga FS, Njelekela MA Diabetic foot: Prevalence, knowledge, and foot self-care practices among diabetic patients in Dar-es-Salaam, Tanzania—A cross-sectional study. J Foot Ankle Res 2015;8:20.  Back to cited text no. 9
Obirikorang Y, Obirikorang C, Anto EO, Acheampong E, Batu EN, Stella AD, et al. Knowledge of complications of diabetes mellitus among patients visiting the diabetes clinic at Sampa Government Hospital, Ghana: A descriptive study. BMC Public Health 2016;16:637.  Back to cited text no. 10
Waaijman R, de Haart M, Arts ML, Wever D, Verlouw AJ, Nollet F, et al. Risk factors for plantar foot ulcer recurrence in neuropathic diabetic patients. Diabetes Care 2014;37:1697-705.  Back to cited text no. 11
Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA, Bakker K; International Working Group on the Diabetic Foot. Prevention and management of foot problems in diabetes: A summary guidance for daily practice 2015, based on the IWGDF guidance documents. Diabetes Metab Res Rev 2016;32(Suppl 1):7-15.  Back to cited text no. 12
Bus SA, van Netten JJ, Lavery LA, Monteiro-Soares M, Rasmussen A, Jubiz Y, et al; International Working Group on the Diabetic Foot. IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 2016;32(Suppl 1):16-24.  Back to cited text no. 13
Dahmen R, Haspels R, Koomen B, Hoeksma AF Therapeutic footwear for the neuropathic foot: An algorithm. Diabetes Care 2001;24:705-9.  Back to cited text no. 14
Paul SK, Rajkumar E, Mendis T Micro cellular rubber (MCR)—A boon for leprosy affected patients with anesthetic feet in preventing secondary impairments. Int J Foot Ankle Res 2014;7:A92.  Back to cited text no. 15
Hadi Sulistyo AA, Sae Sia W, Maneewat K The effect of a foot care camp on diabetic foot care knowledge and the behaviours of individuals with diabetes mellitus. J Res Nurs2018;23:416–25.  Back to cited text no. 16
Williams A Footwear assessment and management. Podiatry Manag 2007;26:165.  Back to cited text no. 17
Uccioli L, Giacomozzi C Biomechanics and choosing footwear for the diabetic foot. Diabetic Foot J 2009;12:165-75.  Back to cited text no. 18
Ferguson TS Foot care and footwear practices in patients with diabetes: Simple interventions and adherence to guidelines may be limb saving. West Indian Med J 2012;61:657-8.  Back to cited text no. 19
Chandalia HB, Singh D, Kapoor V, Chandalia SH, Lamba PS Footwear and foot care knowledge as risk factors for foot problems in Indian diabetics. Int J Diabetes Dev Ctries 2008;28:109-13.  Back to cited text no. 20
Dikeukwu RA, Omole OB Awareness and practices of foot self-care in patients with diabetes at Dr Yusuf Dadoo District Hospital, Johannesburg. J Endocrinol Metabol Diabetes South Africa 2013;18:112-8.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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