The Growing Burden of Diabetes-Related Foot Disease in Aotearoa New Zealand

Diabetes-related foot disease, often abbreviated as DRFD or DFD, represents a major health challenge in Aotearoa New Zealand, where an estimated 110,000 people live with some form of this condition. With diabetes prevalence standing at around 6.7% among adults—equating to roughly 347,000 individuals in 2024—this complication arises primarily from neuropathy, poor circulation, and infections, leading to ulcers, gangrene, and in severe cases, amputations. Recent data highlights nearly 1,200 diabetes-related lower limb amputations annually, a 55% increase over the past decade, placing immense strain on the public health system.

The financial toll is staggering, with each diabetic foot ulcer episode costing upwards of NZD 30,000 in treatment, encompassing hospital stays, surgeries, and outpatient care. For context, major amputations alone exceed NZD 40,000 per procedure, underscoring the urgency for better prevention and management strategies. In New Zealand's unique cultural landscape, where Māori and Pacific peoples face disproportionately higher risks—Māori are 2.8 times more likely to undergo amputation—this issue intersects with equity concerns, demanding culturally responsive approaches.

Universities play a pivotal role here, training podiatrists, endocrinologists, and researchers through programs that blend clinical practice with innovative studies, ultimately aiming to reduce this preventable burden.

Introducing the DINGO Study: Pioneering Insights into New Foot Infections

The Diabetic Foot Infection Longitudinal Outcome (DINGO) study marks a significant advancement in understanding diabetes-related foot infections (DFI), the precursors to most DRFD hospitalizations and amputations. This prospective observational research, published in BMJ Open Diabetes Research & Clinical Practice, involved 234 patients across 20 hospitals in Australia and New Zealand from 2018 to 2020, with 19 participants from key NZ sites including Auckland City Hospital, Middlemore Hospital, and Waikato Hospital.

Led by researchers affiliated with institutions like the University of Auckland—such as Jennifer Wong from Waikato Hospital and the Department of Medicine—the study focused on patients presenting with a new DFI alongside a foot ulcer. It categorized infections as mild, moderate/severe without osteomyelitis (bone infection), or moderate/severe with osteomyelitis, using International Working Group on the Diabetic Foot (IWGDF) and Infectious Diseases Society of America (IDSA) guidelines. This binational collaboration highlights the value of regional higher education networks in tackling shared health challenges.

Patient demographics reflected real-world diversity: mean age 61 years, 77% male, 88% with type 2 diabetes, and notable representation of Māori (3%) and Pacific peoples (3%), emphasizing relevance to Aotearoa's population.

Study Methodology: A Rigorous Prospective Approach

Conducted as a multicenter cohort study, DINGO enrolled adults aged 18+ with diabetes, a foot ulcer, and symptoms of acute DFI lasting less than two weeks. Data collection via REDCap electronic database ensured standardized tracking of demographics, clinical features, treatments, and outcomes at 6 weeks and 6 months. Primary outcome was healing of the index ulcer (sustained epithelialization for two weeks) or amputation site at six months.

Antibiotic management was scrutinized: intravenous (IV) duration classified as short (<7 days) or extended (≥7 days), total duration as short (<2.5 weeks), medium (2.5-6.5 weeks), or long (≥6.5 weeks). Multivariable logistic regression adjusted for confounders like age, Wound/Ischemia/Infection (WIfI) grades, prior amputations, and site effects, providing robust analysis free from bias.

Microbiology insights revealed methicillin-resistant Staphylococcus aureus (MRSA) in 7% and Pseudomonas aeruginosa in just 3%, challenging overuse of broad-spectrum agents.

Key Findings: Healing Rates, Amputations, and Antibiotic Insights

Healing rates at six months were promising yet variable: 73% for mild DFI, 68% for moderate/severe without osteomyelitis, and 62% for cases with osteomyelitis. Notably, infection resolution at six weeks hovered around 67-69% across severities, indicating consistent early response. Minor amputations were far more common in osteomyelitis cases (57% vs. 18%), with only two major amputations reported, both in severe groups.

Antibiotic practices showed medians of 18 days total for mild, 20 for moderate/severe without osteomyelitis, and 34 for osteomyelitis cases. Despite longer courses for severe infections, multivariable analysis found no link between IV duration, total antibiotic length, or severity and healing— a counterintuitive result suggesting other factors like wound grade drive outcomes.

These results, drawn from real-world data, inform evidence-based care and underscore gaps in current protocols.

Antibiotic Stewardship: Rethinking Duration in DFI Treatment

Overuse of antipseudomonal agents (54% initially) despite low Pseudomonas rates (3%) signals opportunities for stewardship. Short IV courses sufficed in 60% of cases without compromising outcomes, supporting guideline shifts toward oral transitions. In New Zealand, where Health NZ | Te Whatu Ora manages rising caseloads, these findings advocate shorter, targeted therapies to curb resistance and costs.

• Short IV (<7 days): 67% healing
• Extended IV (≥7 days): 66% healing
• No significant adjusted odds ratio differences

For clinicians trained at NZ universities like Otago or Auckland, integrating such data into residency programs could optimize protocols.

Photo by diabetesmagazijn.nl on Unsplash

Health Equity Challenges: Disparities for Māori and Pacific Communities

Māori face amputation rates 65-2.8 times higher than non-Māori, compounded by access barriers in rural areas. DINGO's inclusion of 3% Māori and 3% Pacific patients mirrors these inequities, where systemic factors amplify risks. Culturally safe interventions, like those researched at Auckland University of Technology, emphasize whānau involvement and community podiatry.

Higher education must prioritize training in te Tiriti o Waitangi principles, fostering researchers who address these gaps through grants from Health Research Council NZ.

The Push for National Diabetic Foot Guidelines in Aotearoa

Unlike Australia, New Zealand lacks comprehensive DFD guidelines, relying on NZ Society for the Study of Diabetes (NZSSD) screening tools and international IWGDF standards. Recent calls, including a 2025 Journal of Foot and Ankle Research paper, urge standardized pathways to slash preventable amps by 80%.

The NZSSD Foot Screening and Risk Stratification Tool guides annual assessments, but implementation varies. Universities can lead guideline development via multidisciplinary teams.NZSSD Diabetes Foot Screening Tool (PDF)

Universities Driving Innovation in Diabetes Foot Research

NZ universities like Auckland, Otago, and AUT spearhead DRFD efforts. Jennifer Wong's involvement exemplifies clinician-researcher synergy at University of Auckland, while bibliometric analyses reveal growing output since 1970, though gaps persist in high-impact trials. Health Research Council funding supports projects like ischemic ulcer patches at Otago.

Podiatry programs at AUT train specialists in high-risk foot care, blending theory with clinics. Aspiring academics can pursue PhDs in endocrinology or vascular research, advancing prevention tech.

Future Directions: Trials, Tech, and Training

DINGO calls for pragmatic RCTs targeting subgroups, redefining endpoints beyond six-month healing. Emerging tech like AI risk prediction and wearable monitors hold promise, with universities piloting telehealth for rural Māori. Multidisciplinary clinics have cut costs by 25% in pilots, per vascular studies.

To explore careers in this field, check higher ed jobs in podiatry and diabetes research across NZ universities.

Career Pathways in Diabetes Foot Management and Research

Demand surges for podiatrists, endocrinologists, and researchers skilled in DFI. NZ registers ~500 podiatrists, with roles in Health NZ high-risk clinics offering senior positions up to NZD 120k+. University lecturing in podiatry at AUT or research fellowships at Auckland blend academia with impact.

• Podiatrist: Diabetes clinics, private practice; graduate entry ~NZD 70k
• Researcher: PhD grants via HRC; focus on equity trials
• Clinician-Educator: Train med students on WIfI grading

Visit university jobs and higher ed career advice for openings in NZ health faculties. Platforms like Rate My Professor offer insights into top mentors in endocrinology.

Photo by isens usa on Unsplash

Actionable Insights and Call to Collaborative Action

This research empowers proactive care: prioritize screening, target antibiotics judiciously, and advocate for guidelines. For academics, it opens doors to trials enhancing Māori outcomes. Explore faculty positions, research assistant jobs, and recruitment in NZ's vibrant health sector. Together, we can halve preventable amputations.