Chinese experts’ perspectives on the definition of change from “diabetic foot” to “diabetes-related foot disease”

The 2023 edition of the International Working Group on the Diabetic Foot (IWGDF) Guidelines for the Prevention and Management of Diabetes-related Foot Disease was released during the 9th International Symposium on the Diabetic Foot in Hague, Netherlands, on May 13, 2023. These guidelines include changes to relevant terminology and definitions, notably replacing "diabetic foot" with "diabetes-related foot disease" and substituting "diabetic foot ulcer" with "diabetes-related foot ulcer". The former change encompasses not only modifications in terminology but also alterations in definition, whereas the latter constitutes merely a textual adjustment without altering the underlying definition.[1] On December 15, 2023, the Group on Diabetic Foot and Peripheral Vascular Disease of the Chinese Diabetes Society convened a vigorous debate regarding this modification. Associate Professor Jun Xu, as a proponent of the affirmative stance, advocated for the new definition, emphasizing its congruence with China's contemporary circumstances. Conversely, Professor Wuquan Deng, representing the opposing viewpoint, expressed dissent, contending that the current terminology was developed based on China's actual situation. The modification primarily stems from literature obtained from the American Association of Diabetes Educators and the American Diabetes Association.[2] The term "diabetic foot" has been revised to "diabetes-related foot disease." The authors argue that the previous use of "diabetic" carried a connotation of discrimination; thus, it is preferable to use the phrase "person with diabetes" when referring to individuals affected by this condition. In terms of definition, the revised concept encompasses both diabetes (whether newly diagnosed or pre-existing) and foot disease (fundamental components). "Diabetes-related foot disease" can be diagnosed based on any one of the following seven factors: peripheral neuropathy, peripheral artery disease, infection, ulcer(s), neuro-osteoarthropathy, gangrene, or amputation.[1] Integrating these factors with the fundamental components constitutes "diabetes-related foot disease," encompassing all aspects covered by diabetic foot. When diabetes is accompanied by foot disease and peripheral neuropathy, or when it coexists with foot disease and peripheral artery disease, the original high-risk foot category is also encompassed within the scope of "diabetes-related foot disease". This expanded definition has resulted in a sevenfold increase in the number of patients diagnosed with diabetic foot.[1,3] Emphasizing early attention and intervention for preventing diabetic foot complications can effectively mitigate the progression toward severe conditions such as gangrene and amputation. Overall, there has been a shift in focus toward reducing the significant burden on patients, their families, medical insurance, and society caused by diabetic foot complications. The prevention of diabetic foot is more important than treatment. Patients with peripheral neuropathy and/or peripheral artery disease, conditions affecting 20–30% or more of individuals with diabetes, are at high risk for developing diabetic foot. According to the new definition, these patients also belong to diabetes-related foot disease. In daily diagnosis and treatment, follow-up can be conducted according to the IWGDF risk classification, which can effectively reduce the occurrence of diabetes-related foot ulcers. This approach is more suitable for community doctors or endocrinologists to handle. When peripheral neuropathy and/or peripheral artery disease develop into foot ulcers, management should be transferred to a professional team for multidisciplinary treatment. However, Professor Wuquan Deng raised an objection and pointed out that the term "diabetic foot" was proposed by Professor Joslin in 1928, making it nearly 100 years old. This term has been deeply ingrained in the collective consciousness, and healthcare professionals and patients worldwide have grown accustomed to its usage. For example, although diabetes was initially named based on the presence of glucose in urine, current diagnostic criteria for diabetes rely on blood glucose and glycated hemoglobin levels rather than urine glucose levels. Nonetheless, this does not justify a change in the nomenclature of diabetes. Although the scope of "diabetes-related foot disease" has expanded with regard to prevention efforts, it does not facilitate future clinical practice and communication effectively, resulting in a complex amalgamation of reported cases within the literature (combining high-risk foot conditions with diabetic foot complications), which impedes comparative analysis. In addition, he used ChatGPT (OpenAI, L.L.C.,San Francisco, California, USA) to analyze the evolving landscape from diabetic foot to diabetes-related foot disease. Artificial intelligence (AI) suggests considering five dimensions: comprehensiveness, complexity of diagnosis and treatment, resource allocation, cultural and regional differences, and support from scientific evidence. First, the revised term is more comprehensive, as it includes peripheral neuropathy, peripheral artery disease, infection, ulceration, neuro-osteoarthropathy, gangrene, or amputation—broadening the diagnostic spectrum to encompass earlier pathological changes and high-risk conditions. However, this increased inclusiveness introduces diagnostic and treatment complexity. Second, individuals previously identified as "at risk" are now considered to have a disease, which may inflate case counts, complicate care pathways, and potentially strain clinical decision-making and triage systems. Third, in resource-limited settings such as many regions in China, this redefinition may overwhelm primary healthcare infrastructure and insurance frameworks, especially when high-risk but non-ulcerative cases are labeled as diseases. Fourth, cultural and regional medical practices vary significantly; in China, for instance, the term "diabetic foot" has deep-rooted familiarity among healthcare workers and patients alike, and abrupt terminological shifts may disrupt communication, education, and reporting consistency. Last, the current evidence base remains insufficient to definitively support the superiority of this new classification in improving long-term clinical outcomes. Although the redefinition emphasizes prevention, it lacks robust validation through randomized controlled trials or longitudinal cohort studies. Thus, caution should be exercised when contemplating a name change. The development of high-risk foot disease does not inevitably progress into diabetic foot disease, presenting challenges in terms of medical resources and insurance coverage, as well as imposing a psychological burden on high-risk people and their families. This can give rise to social issues, especially in developing countries with limited access to healthcare resources. Preventing the progression from high-risk foot to diabetic foot carries a distinct connotation compared to treating established cases of diabetic foot disease.[4] At present, there is insufficient evidence to support the expansion of the concept to apply to China's national conditions. Actually, the stage of high-risk foot has already prompted medical professionals, patients with these risks, and their caregivers to prioritize podiatric concerns. The wording has been revised from diabetic foot ulcers to diabetes-related foot ulcers while preserving the definition unchanged. Currently, clinicians predominantly encounter patients presenting with diabetic foot ulcers. The presence of a foot ulcer in an individual previously diagnosed with or currently suffering from diabetes mellitus is typically accompanied by peripheral neuropathy and/or peripheral artery disease in the lower extremity, which aids in establishing an accurate diagnosis. A consensus has been reached on utilizing the definition of diabetic foot ulcer as more suitable for clinical application. Professor Deng referred to recent publications from reputable journals that continue to use the term "diabetic foot".[5,6] After the debate, Professor Zhangrong Xu, the conference chairman, extended an invitation to all participants for a show-of-hands vote. Only one vote favored the alternative nomenclature and definitions. Consensus was reached that embracing the concept of diabetic foot and diabetic foot ulcers would be more appropriate for clinical practice in China. We posit that modifying the definition of diabetic foot to diabetes-related foot disease may engender certain psychological and medical reimbursement challenges in China. Funding This study was supported by grants from the Science and Technology Bureau of Sichuan Province (No. 2024YFFK0290), the Health Commission of Sichuan Province (No. 23LCYJ042), the 1.3.5 Project for Disciplines of Excellence, and West China Hospital of Sichuan University (No. ZYGD24005).