The incidence of diabetes mellitus is increasing in populations across Africa. A parallel increase in the incidence of foot complications in these populations has been documented (Abbas and Archibald, 2005). Factors associated with poor outcomes include delays in seeking medical attention and ulcers that have progressed to gangrene at the time of presentation. Data from a recently published study (Step by Step Project) have demonstrated a marked improvement in diabetic foot care in less-developed countries through a formal program of education for healthcare professionals and people with diabetes in the management of diabetic foot problems. It is anticipated that interventions like the Step by Step Project that focus on the dissemination of education and learned skills among healthcare personnel (training the trainers) and patients alike will ultimately reduce the number of lower extremity amputations among people with diabetes and provide an innovative, sustainable paradigm for the prevention of diabetic foot complications in less-developed countries.

Diabetes mellitus reached epidemic proportions in much of the less-developed world over a decade ago and the number of people afflicted with the condition in these regions is projected to increase from 84 million in 2000 to 228 million by 2030 (Amos et al, 1997; Wild et al, 2004). As expected, incidence and prevalence rates have been increasing in many African countries and have largely been attributed to the increasing sedentary lifestyle and diet associated with urbanisation (Amos et al, 1997; McLarty et al, 1990).
    Currently, there are 7–8 million individuals with diabetes resident on the African continent (McLarty et al 1990; Amos et al, 1997; Abbas et al 2002; Gulam-Abbas et al 2002; Wild et al, 2004; Abbas and Archibald, 2005). In the poorer African nations, high costs and a lack of trained medical personnel and facilities often preclude the institution of the diabetic foot management paradigm that is standard in Europe and North America. These limitations are compounded by the reality that diabetes already imposes a heavy burden on the health services in some African countries, where resources are already scarce or cut back. For example, nearly 4% of the annual healthcare budget in the Gambia is spent exclusively on the treatment of diabetes and in Tanzania, the total government expenditure on health as a percentage of total expenditure declined from 5% in 1988/89 to 2.8% in 1992/93; per capita health expenditure declined in Tanzania from about US$7 in 1980 to US$2 in 1992/93 (Rolfe et al, 1992; Msambichaka, 1997). The seriousness of the crisis is underscored by current estimates that sub-Saharan Africa is part of the world that will experience the greatest rise in diabetes prevalence over the next 20 years (Wild et al, 2004).

Foot complications in Africans with diabetes
In Africa, foot complications are the main cause of prolonged hospital stays for people with diabetes and are associated with substantial mortality, constituting a major public health problem (McLarty et al, 1990; Abbas et al, 2002; Gulam-Abbas et al, 2002; Abbas and Archibald, 2005). In Tanzania, the highest mortality rates are observed in people with severe gangrenous ulcers not treated with aggressive surgery (Gulam-Abbas et al, 2002).