The month of November is dedicated to raising awareness about two important global health conditions: diabetes and pressure injuries (PIs). Diabetes is increasing in prevalence worldwide, but especially in low- and middle-income countries. World Diabetes Day is an official UN day held every year on November 14. Further, November 16 marks "Stop Pressure Injury Day," which is aimed at PI awareness with special emphasis on prevention. Pressure injuries from masks and proning^1-3 increased during the COVID-19 crisis and merit future attention.

World Diabetes Day occurs on the birthday of Sir Fredrick Banting, who co-discovered insulin at the University of Toronto over 100 years ago. The discovery of insulin represented a new maintenance disease status for diabetes, rather than a death sentence. Yet, this discovery also created a need for awareness of diabetic complications, such as lower limb amputations, and the importance of preventing them. Poor diabetes management increases the risk of complications by damaging the small vessels (affecting the eyes and kidneys and leading to neuropathy) and large vessels (impacting the heart and related to peripheral vascular disease and stroke). Diabetes complications can reduce the lifespan of persons with diabetes by 10 years.

Wound healers need to link chronic disease management to improved healthcare provider and patient education. Traditionally, we train healthcare professionals in silos, and have a pyramid of educational levels: continuing education programs have a certificate of attendance (Level 1); participant satisfaction comes with relevant presentations that relate to practice (Level 2) and the educational process provides new knowledge (Level 3); competence (Level 4) is the ability to translate new knowledge for practice and clinical performance (Level 5) is a re-enforcing strategy to reflect on practice and fine tune new knowledge for improved patient outcomes (Level 6); population health (Level 7) improves patient care with healthcare system-enhanced, cost-effective outcomes.⁴ Patient outcomes and healthcare system enhancement have been targeted by the Narayan principles,⁵ which identified three double-win strategies: screening for the high-risk diabetic foot, targeting a HbA1c (glycated hemoglobin) value under 9%, and a conservative BP control figure of 140/90 mmHg.

Representatives of every country met at the 2022 75th World Health Organization (WHO) Assembly and agreed to set five targets around diabetes diagnosis and care access.⁶ The first goal is to diagnose diabetes earlier. Only an estimated 40% of individuals with diabetes have a known diagnosis with a target increase to 80% by 2030. One way to diagnose diabetes is with a HbA1c over 6.5%. Ideally, providers should measure HbA1c levels for every patient with a chronic wound, but it may be especially important for patients with leg and foot ulcers because patients with diabetes have a high incidence of peripheral arterial disease and neuropathy. The WHO-recommended target HbA1c level of 8% or lower is a realistic global objective. The third WHO recommendation is BP control, with a modest target of 140/90 for 80% of individuals. In a model of healthcare outcomes, achieving these three 80% targets would result in a gain of 64 median disability life years per 1,000 population.⁷

The other two main WHO targets are statins for 60% of people with diabetes and access to insulin for 100% of those with type 1 diabetes. The co-discoverers of insulin (Banting, Best, and Collub) sold their co-owned American patent for insulin for $1 dollar each to the University of Toronto, hoping that insulin would be available for all persons with diabetes. Yet, there is limited insulin access in many African countries, and the cost of a single vial can be 2 weeks or more of a worker's salary.⁸

We need to improve interprofessional diabetic care, taking a whole-person approach (eg, including quality of life, mental health). A coordinated and integrated team should include vascular expertise, infection management, and plantar pressure redistribution as part of the prevention and management of foot abnormalities.⁹ In a wholistic approach for wound healing and limb preservation efforts, interprofessional teams should include endocrine/diabetic specialists with metabolic expertise, mental health experts, general internists, family doctors, nurses, and allied health professionals. Healthcare systems need to facilitate care across the continuum, track healthcare system gaps, and improve the infrastructure for patient-centered concerns. As a society we need to provide equal access to care and insulin for all!

R. Gary Sibbald, MD, Med, FRCPC (Med Derm), FAAD, MAPWCA, JM

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Elizabeth A. Ayello, PhD, MS, RN, CWON, MAPWCA, FAAN

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The references are available as supplemental digital content at http://links.lww.com/NSW/A165.