Is walking barefoot a risk factor for diabetic foot disease in developing countries?

Introduction: Walking barefoot is common in poorer developing countries which have large rural populations. Although high rates of foot injury could be expected among those who walk barefoot, walking barefoot as a risk factor for diabetic foot disease is rarely documented in the literature.

Methods: Two preliminary clinical studies were undertaken to investigate whether there is a causal link between walking barefoot and diabetic foot ulcers. The first study investigated whether being barefoot was a factor in initiating foot ulceration. In the second study, 204 consecutive diabetic outpatients were studied to further investigate the association between diabetic foot disease and walking barefoot.

Results: In the first study, of the 75 consecutive diabetics admitted for foot ulceration of less than 4 weeks, 32 (42.4%) had foot ulcers resulting from injuries by sharp or hard objects. Of those injured, 27 (84%) were barefoot at the time of the injury. This suggested that walking barefoot is a risk factor for foot ulcers, and that using footwear has the potential to prevent foot ulcers. In the second study, the relative risk of foot ulcers among barefoot diabetics was 2.21 (95% CI 1.55 to 3.14) compared with those using some form of footwear. A history of foot ulcers was more frequent in the group who wore footwear less than 10 hours per day, compared with those who used footwear more than 10 hours. The prevalence of web space and nail infections was also higher in the group who wore footwear less than 10 hours per day, compared with those who used footwear for more than 10 hours.

Conclusion: The data suggest that walking barefoot is a risk factor for diabetic foot disease. Thus, public health messages in developing countries with large rural populations who walk barefoot should strongly advise diabetics to use footwear for a greater part of the day. This may be overlook in literature originating from affluent countries where footwear use is the norm. Further studies are indicated to investigate potential associations between walking barefoot, rurality and cultural factors.