Medically reviewed by Dr. Tom Biernacki, DPM — Board-Certified Podiatric Surgeon — Balance Foot & Ankle, Howell & Bloomfield Hills, MI. Last updated April 2026.

Preventing Diabetic Foot Amputation: A Podiatrist’s Complete Guide

Medically Reviewed by Dr. Thomas Biernacki, DPM
Board-certified podiatrist at Balance Foot & Ankle Specialists, Michigan. Fellowship-trained in foot and ankle surgery with extensive clinical experience in diabetic limb salvage and wound care.
Last reviewed: April 2026

Quick Answer: Up to 85 percent of diabetes-related amputations are preceded by a foot ulcer — and the majority of those ulcers are preventable with proper daily foot care, appropriate footwear, regular podiatric examinations, and early intervention at the first sign of skin breakdown. As a podiatrist who treats diabetic foot complications daily, I cannot emphasize this enough: the path from healthy foot to amputation is not inevitable. It follows a predictable sequence — neuropathy leads to unnoticed injury, injury leads to ulceration, ulceration leads to infection, and infection leads to amputation. Breaking any link in that chain saves the limb.

Affiliate Disclosure: This article contains affiliate links to products we personally recommend. If you purchase through these links, we may earn a small commission at no additional cost to you. We only recommend products we use in our clinical practice.

Table of Contents

• Diabetic Amputation Statistics
• The Pathway from Diabetes to Amputation
• Understanding Diabetic Neuropathy
• Peripheral Arterial Disease and Diabetes
• How Diabetic Foot Ulcers Form
• Daily Foot Inspection Protocol
• Proper Footwear for Diabetic Patients
• Protective Insoles for Diabetic Feet
• Diabetic Foot Skin Care
• Safe Nail Care for Diabetics
• Blood Sugar Control and Foot Health
• Improving Circulation in Diabetic Feet
• Compression Therapy for Diabetic Patients
• Early Wound Care to Prevent Escalation
• How Often Diabetics Should See a Podiatrist
• Most Common Amputation Prevention Mistake
• Warning Signs That Require Immediate Care
• Complete Diabetic Foot Protection Kit
• Diabetic Foot Care at Balance Foot & Ankle
• Frequently Asked Questions
• Sources

A diabetes diagnosis changes many things, but losing a foot or leg should never be one of them. Yet every year, approximately 130,000 Americans with diabetes undergo lower extremity amputations — a number that represents an enormous amount of preventable suffering. If you or someone you love has diabetes, this article is one of the most important things you can read. The research is clear: comprehensive preventive foot care reduces amputation rates by 49 to 85 percent. That is not a marginal improvement — it is a transformational difference between keeping your feet and losing them. Every strategy in this guide is backed by evidence and implemented daily in our clinic, where our mission is to ensure that no patient with diabetes ever faces an avoidable amputation.

The Staggering Statistics of Diabetic Amputation

The scope of diabetes-related amputations in the United States is staggering and demands attention. Approximately 130,000 to 154,000 lower extremity amputations are performed annually in the United States, and diabetes is the leading cause — accounting for over 60 percent of non-traumatic amputations. A person with diabetes is 15 to 40 times more likely to require a lower limb amputation than someone without diabetes. Perhaps most alarming is the cascade effect: after a first amputation, the 5-year risk of a contralateral amputation (losing the other limb) ranges from 28 to 51 percent, and the 5-year mortality rate following major lower extremity amputation in diabetic patients exceeds 50 percent. These statistics are devastating — but they also represent an enormous opportunity for prevention. Research from multidisciplinary diabetic foot teams worldwide has demonstrated that structured preventive programs reduce amputation rates by 49 to 85 percent. The gap between what is possible and what is currently happening represents thousands of limbs that could be saved every year with proper care.

The Pathway from Diabetes to Amputation: Understanding the Chain

Diabetic amputations do not happen suddenly — they follow a predictable, stepwise pathway that offers multiple intervention points where the chain can be broken. The process begins with diabetic peripheral neuropathy: chronically elevated blood glucose damages the small nerves in the feet, causing progressive loss of protective sensation. When you cannot feel pain, pressure, or temperature changes in your feet, you cannot detect injuries that would immediately alert a person with normal sensation. The second link is foot deformity and biomechanical abnormality: neuropathy affects not only sensory nerves but motor nerves as well, leading to intrinsic muscle atrophy, hammertoe formation, prominent metatarsal heads, and Charcot foot — all of which create areas of abnormally high pressure. The third link is skin breakdown: when a numb, deformed foot experiences repetitive pressure in a shoe, the skin breaks down into an ulcer. The fourth link is infection: an open wound in a foot with compromised circulation and immune function is highly susceptible to bacterial invasion, which can rapidly progress from superficial infection to deep tissue involvement, osteomyelitis (bone infection), and gangrene. The final link is amputation — the surgical removal of non-viable tissue when infection and tissue death have progressed beyond salvage. Understanding this chain empowers you to break it at any point.

Understanding Diabetic Neuropathy: The Silent Threat to Your Feet

Diabetic peripheral neuropathy is the single most important risk factor for foot ulceration and amputation, present in approximately 50 percent of diabetic patients with a disease duration of 10 years or more. The condition develops insidiously: early symptoms may include tingling, burning, or shooting pains in the feet (painful neuropathy), but as the nerve damage progresses, these symptoms often give way to numbness — and it is this loss of protective sensation that creates the danger. A patient with advanced neuropathy can step on a tack, develop a blister from an ill-fitting shoe, or burn their foot on hot pavement without feeling anything. In our clinic, we regularly see patients who have been walking on an open wound for days or weeks without awareness. The monofilament test — where a podiatrist touches the foot with a thin nylon fiber — is the standard screening tool for protective sensation loss. If you cannot feel the monofilament at four or more sites on each foot, you have lost enough protective sensation to be at significant ulcer risk. Early detection of neuropathy through regular podiatric screening allows preventive measures to be implemented before an ulcer develops.

Peripheral Arterial Disease: The Vascular Component of Diabetic Foot Risk

Peripheral arterial disease (PAD) — the narrowing of blood vessels supplying the legs and feet — is present in approximately 20 to 30 percent of diabetic patients and dramatically increases amputation risk. While neuropathy determines whether an ulcer develops, vascular disease determines whether it heals. Adequate blood flow delivers the oxygen, nutrients, immune cells, and antibiotics necessary for wound healing, and when this delivery system is compromised, even minor wounds stall or deteriorate. The classic symptoms of PAD include calf cramping with walking (claudication), cold feet, absent pedal pulses, and delayed capillary refill — but diabetic neuropathy can mask the claudication pain, meaning PAD may be present without typical symptoms. Screening for PAD in diabetic patients involves pulse palpation, ankle-brachial index (ABI) measurement, and when indicated, arterial duplex ultrasound or angiography. When significant PAD is identified, vascular intervention — angioplasty, stenting, or bypass surgery — may be necessary to restore adequate blood flow before a foot wound can heal. The combination of neuropathy and PAD in the same patient creates the highest amputation risk category and demands the most vigilant preventive approach.

How Diabetic Foot Ulcers Form: The Biomechanics of Breakdown

Understanding how diabetic foot ulcers form is essential for prevention because it reveals the specific mechanisms you can interrupt. The most common diabetic foot ulcer develops at a site of abnormally high plantar pressure — typically under a prominent metatarsal head, at the tip of a hammertoe, or over a bony prominence on the medial or lateral foot. In a person with normal sensation, this excessive pressure would cause discomfort long before tissue damage occurs, prompting them to shift their weight, adjust their shoe, or stop the offending activity. In a neuropathic foot, no such warning signal exists. The repetitive loading cycle — estimated at 5,000 to 10,000 steps per day for an ambulatory person — creates cumulative micro-trauma to the pressurized tissue. The body initially responds by forming a callus (thickened skin) at the pressure point, but the callus itself becomes a rigid mass that further concentrates pressure on the underlying soft tissue, creating a vicious cycle. Eventually, the tissue beneath the callus breaks down, forming a pre-ulcerative hemorrhage (bleeding under the callus) that progresses to an open wound. This entire process can unfold over days to weeks in a foot with no protective sensation, and the patient may not discover the ulcer until it is already infected.

Daily Foot Inspection: The Most Important Habit for Diabetic Patients

Daily foot inspection is the single most important habit any diabetic patient can develop, and it is the cornerstone of every amputation prevention program worldwide. The entire inspection takes less than two minutes and should become as automatic as brushing your teeth. Examine every surface of both feet systematically: the soles (use a mirror or smartphone camera if flexibility is limited), between all toes, the nail beds, the heels, and the tops of the feet. You are looking for any change from the previous day: new redness, swelling, blisters, calluses, cracks in the skin, areas of warmth, ingrown toenails, color changes, or any wound — no matter how small. Also check the inside of your shoes before putting them on: a small pebble, a bunched sock, or a loose insole can create a pressure point that leads to an ulcer in a neuropathic foot. If you find anything abnormal during your inspection, contact your podiatrist the same day. The reason daily inspection prevents amputations is simple: it catches problems at the earliest possible stage, when they are easiest to treat. A blister caught on day one is a minor inconvenience; a blister missed for two weeks can become an infected ulcer requiring hospitalization.

Proper Footwear: Your First Line of Defense Against Ulceration

For diabetic patients with neuropathy, footwear is not a fashion choice — it is a medical device that protects vulnerable feet from the external forces that cause ulceration. Diabetic-appropriate shoes must have several specific features: extra depth to accommodate deformities without creating pressure points, a wide toe box that does not compress the toes, a seamless interior lining that eliminates friction sources, a firm heel counter for stability, a rigid or rocker-bottom sole that reduces forefoot pressure during push-off, and a secure closure system (laces or Velcro) that prevents the foot from sliding inside the shoe. Medicare and most insurance plans cover therapeutic shoes and custom-molded shoes for diabetic patients who meet specific criteria — an underutilized benefit that every qualifying patient should take advantage of. Perhaps most importantly, diabetic patients should never walk barefoot, even indoors. Stepping on a small object, stubbing a toe on furniture, or walking on a hot surface can create injuries that a neuropathic foot cannot detect until significant damage has occurred.

Protective Insoles: Redistributing Pressure to Prevent Ulcers

The right insole is arguably the most impactful single intervention for preventing diabetic foot ulcers because it directly addresses the biomechanical cause of tissue breakdown — concentrated plantar pressure. A well-designed insole redistributes weight-bearing forces across the entire plantar surface, reducing peak pressure under vulnerable metatarsal heads and bony prominences by 30 to 50 percent. For diabetic patients who do not yet require custom-molded orthotics, the PowerStep Pinnacle Insoles provide an excellent combination of structured arch support and cushioned metatarsal contouring that protects the forefoot from excessive pressure concentration. The firm polypropylene arch shell stabilizes the midfoot and prevents the pronation-driven metatarsal overloading that creates ulcer-prone pressure points, while the dual-layer cushion absorbs impact forces that would otherwise be transmitted directly to the skin. We recommend PowerStep insoles as a foundational prevention tool for every diabetic patient — even those without current foot problems — because they provide the pressure redistribution that can prevent the first ulcer from ever forming. For patients with existing deformities, Charcot foot, or prior ulcer history, custom-molded total-contact insoles fabricated from a cast of the foot provide the most precise pressure relief available.

Diabetic Foot Skin Care: Maintaining the Barrier

Healthy, intact skin is the body’s primary barrier against infection, and maintaining skin integrity is a critical component of diabetic foot care. Diabetic skin tends to be dry and prone to cracking, particularly on the heels and along the borders of the feet — these cracks (fissures) are entry points for bacteria that can lead to serious infections. A daily moisturizing routine using a urea-based or emollient cream on the soles, heels, and dorsum of the feet keeps the skin supple and prevents fissure formation. However, never apply moisturizer between the toes — this area is already prone to moisture retention, and adding cream creates a macerated environment that promotes fungal infection and skin breakdown. Calluses should be managed carefully: while mild callus reduction with a pumice stone after bathing is acceptable, aggressive callus debridement should be performed by a podiatrist who can assess the tissue beneath the callus for pre-ulcerative changes. For managing dry, cracked skin that becomes painful or inflamed, Doctor Hoy’s Natural Pain Relief Gel provides gentle, natural anti-inflammatory relief without the harsh chemicals that can further compromise sensitive diabetic skin.

Safe Nail Care for Diabetic Patients

Improper nail care is a surprisingly common cause of diabetic foot infections and hospitalizations. Ingrown toenails, nail injuries from aggressive trimming, and fungal nail infections all create potential entry points for bacteria in feet with compromised immune function and circulation. Safe diabetic nail care follows specific rules: cut nails straight across (never curved into the corners, which promotes ingrowth), use clippers rather than scissors or knives, file sharp edges with a nail file rather than tearing them, and never use sharp instruments to clean under the nails. If you have thickened, fungal, or difficult-to-trim nails, have them professionally trimmed by your podiatrist — this simple preventive service is covered by Medicare for diabetic patients and can prevent the nail injuries that lead to serious infections. Never use chemical nail removers, over-the-counter ingrown toenail treatments, or “bathroom surgery” to address nail problems — these approaches carry significant infection risk in diabetic feet. If you develop an ingrown toenail, redness around a nail, or any nail drainage, see your podiatrist promptly rather than attempting home treatment.

Blood Sugar Control: The Foundation of Foot Preservation

Glycemic control is the foundational strategy for preventing all diabetic complications, including neuropathy, vascular disease, and ultimately amputation. The landmark Diabetes Control and Complications Trial (DCCT) demonstrated that intensive glucose control reduces the risk of developing neuropathy by 60 percent — a remarkable reduction that underscores how powerfully blood sugar management influences foot health. For patients who already have neuropathy, improved glycemic control slows progression and may partially restore nerve function in early-stage disease. The target hemoglobin A1c for most diabetic patients is below 7 percent, though individual targets may vary based on age, comorbidities, and hypoglycemia risk — work with your endocrinologist or primary care physician to determine your optimal A1c goal. Beyond A1c, minimizing blood sugar variability (the spikes and crashes that occur throughout the day) is increasingly recognized as important for nerve health. Consistent carbohydrate management, regular physical activity, medication adherence, and blood glucose monitoring all contribute to the stable glycemic environment that protects your nerves and blood vessels from progressive damage.

Improving Circulation in Diabetic Feet

Maintaining adequate blood flow to the feet is essential for tissue viability, wound healing, and infection resistance. Several modifiable lifestyle factors significantly impact peripheral circulation in diabetic patients. Smoking cessation is the single most impactful circulatory intervention — smoking constricts blood vessels, accelerates atherosclerosis, and reduces oxygen delivery to the feet, and quitting smoking improves peripheral blood flow within weeks. Regular physical activity, particularly walking, stimulates collateral vessel development (the body grows new small blood vessels around blocked segments) and improves overall cardiovascular function — aim for 150 minutes of moderate activity per week as tolerated. Cholesterol management and blood pressure control reduce the progression of peripheral arterial disease. Avoid sitting with crossed legs for prolonged periods, which compresses blood vessels. Elevate your feet when resting to reduce edema that compresses capillaries and impairs tissue perfusion. Keep feet warm with socks rather than heating pads or hot water, which can burn neuropathic feet without the patient’s awareness.

Compression Therapy for Diabetic Patients

Appropriate compression therapy can benefit many diabetic patients by reducing lower extremity edema, improving venous return, and supporting tissue perfusion — all of which contribute to healthier foot tissue that resists breakdown. However, compression in diabetic patients requires careful consideration of vascular status: patients with significant peripheral arterial disease may not tolerate compression, and an ABI measurement should be performed before initiating any compression program. For diabetic patients with adequate arterial flow and significant lower extremity edema, graduated compression socks reduce the fluid accumulation that stretches skin, impairs tissue oxygenation, and increases susceptibility to breakdown. The DASS Performance Compression Socks provide moderate graduated compression that effectively manages edema while remaining comfortable for daily wear. The moisture-wicking fabric keeps the foot dry — critical for diabetic skin that is susceptible to maceration — and the seamless toe construction eliminates the friction points that can initiate skin breakdown in neuropathic feet. We recommend DASS compression socks for our diabetic patients with edema and adequate arterial circulation as a daily wear option that supports overall foot health.

Early Wound Care: Stopping Ulcers Before They Escalate

When a diabetic foot wound is detected early, the window for successful intervention is wide open — and the actions taken in the first 24 to 48 hours can determine whether the wound heals uneventfully or spirals into a limb-threatening emergency. At the first sign of any skin break, blister, or pre-ulcerative lesion: clean the area gently with mild soap and water, apply a thin layer of antibiotic ointment, cover with a non-adherent sterile dressing, and offload the area by avoiding pressure on that spot. Then contact your podiatrist immediately — same-day evaluation is standard of care for any new wound in a diabetic foot. Do not use hydrogen peroxide, Betadine, or alcohol on the wound, as these agents are cytotoxic to healing tissue. Do not apply adhesive tape directly to diabetic skin, which can tear easily. Do not attempt to “walk it off” or assume a small wound is insignificant — in a neuropathic foot with compromised circulation, a minor wound can progress to a deep infection within 48 to 72 hours. Professional wound assessment includes probing the wound to determine depth, assessing for bone involvement, obtaining cultures if infection is suspected, and initiating an appropriate offloading strategy to protect the wound from further pressure.

How Often Should Diabetic Patients See a Podiatrist

The frequency of podiatric visits for diabetic patients depends on their risk stratification. The International Working Group on the Diabetic Foot (IWGDF) recommends a risk-based schedule: patients with diabetes but no neuropathy or PAD should be screened annually; patients with neuropathy but no deformity or PAD should be seen every 6 months; patients with neuropathy plus deformity or PAD should be seen every 3 months; and patients with a history of prior ulcer or amputation should be seen every 1 to 3 months. During these visits, your podiatrist performs a comprehensive neurovascular examination, assesses your footwear and insoles, manages calluses and nail problems, identifies emerging deformities, and adjusts your prevention plan as needed. These visits are covered by Medicare and most insurance plans for diabetic patients. In our clinic, we find that consistent podiatric care combined with patient education creates a partnership that dramatically reduces ulcer incidence — our patients who attend regular appointments have significantly lower ulcer rates than those who are seen only when problems develop.

🔑 Most Common Amputation Prevention Mistake: The single most common mistake that leads to preventable diabetic amputations is delaying care when a foot problem is first noticed. In our clinic, we see patients who noticed a small wound, blister, or color change on their foot and waited days, weeks, or even months before seeking treatment — by which time a minor problem has progressed to a deep infection requiring aggressive intervention. The golden rule for diabetic foot care is: any new wound, color change, swelling, warmth, or drainage on a diabetic foot is a same-day call to your podiatrist. Not tomorrow, not next week, not “when it gets worse.” Today. This single behavior change — immediate response to any foot abnormality — prevents more amputations than any other intervention.

✅ Complete Diabetic Foot Protection Kit — Podiatrist Recommended:

Our recommended daily protection system for diabetic feet addresses pressure, circulation, skin health, and pain management:

1. Pressure Redistribution: PowerStep Pinnacle Insoles — reduce peak plantar pressure by 30-50% under vulnerable metatarsal heads
2. Edema Management: DASS Performance Compression Socks — graduated compression with moisture-wicking, seamless toe construction
3. Skin Protection: Doctor Hoy’s Natural Pain Relief Gel — gentle anti-inflammatory for cracked skin and minor irritation

This combination provides daily protection for diabetic feet, addressing the three key risk factors: excessive pressure, poor circulation/edema, and skin integrity compromise.

⚠️ Diabetic Foot Emergency Signs — Seek Immediate Care:

• Any open wound, cut, or skin break on a diabetic foot
• Redness, warmth, or swelling that is new or spreading
• Drainage (pus, blood, or clear fluid) from any foot wound
• Dark discoloration or blackening of skin (possible gangrene)
• Red streaking from a wound traveling up the foot or leg
• Fever or chills accompanying any foot abnormality
• Sudden onset of severe foot pain in a previously numb foot
• Foot or ankle that becomes hot, swollen, and red without injury (possible Charcot)
• Foul odor from a wound or between toes
• Loss of feeling in a foot that previously had sensation

Diabetic Foot Care at Balance Foot & Ankle

At Balance Foot & Ankle Specialists, our diabetic foot program provides comprehensive preventive care and limb salvage services. We perform thorough neurovascular screening, provide professional nail care and callus management, fit therapeutic shoes and custom orthotics, and manage diabetic wounds with evidence-based protocols. Our goal is to ensure that no patient with diabetes faces a preventable amputation. For patients with active wounds, we offer advanced wound care including sharp debridement, offloading strategies, infection management, and coordination with vascular surgery when revascularization is needed. Our Michigan locations serve diabetic patients throughout Southeast Michigan who need expert podiatric care.

Watch: Diabetic Foot Care Tips from a Podiatrist

Frequently Asked Questions About Diabetic Foot Amputation Prevention

How common is amputation in diabetic patients?

Approximately 130,000 to 154,000 lower extremity amputations are performed annually in the US, with diabetes accounting for over 60 percent. A person with diabetes is 15-40 times more likely to require amputation than someone without diabetes. However, structured preventive care programs reduce amputation rates by 49-85 percent, making the majority of these amputations preventable.

What is the most important thing I can do to prevent diabetic foot amputation?

Daily foot inspection is the single most impactful habit. Checking both feet every day takes less than two minutes and catches problems at the earliest stage when they are easiest to treat. Combined with proper footwear, protective insoles like PowerStep Pinnacle, and regular podiatric care, daily inspection forms the foundation of amputation prevention.

Can diabetic neuropathy be reversed?

Early-stage diabetic neuropathy may partially improve with aggressive glycemic control — the DCCT study showed intensive glucose management reduces neuropathy risk by 60 percent. However, advanced neuropathy with significant nerve fiber loss is generally permanent, which is why prevention and early detection through regular screening are so important. Even when neuropathy cannot be reversed, its consequences (ulcers and amputations) can be prevented.

How often should I see a podiatrist if I have diabetes?

Visit frequency depends on your risk level: annually if you have no neuropathy or PAD, every 6 months if you have neuropathy alone, every 3 months if you have neuropathy plus deformity or PAD, and every 1-3 months if you have a history of prior ulcer or amputation. Medicare and most insurance cover these visits for diabetic patients.

Are compression socks safe for diabetic patients?

Compression socks like DASS Performance Compression Socks are safe and beneficial for diabetic patients with adequate arterial circulation and lower extremity edema. However, patients with significant peripheral arterial disease should have an ABI measurement before starting compression. Your podiatrist can determine whether compression therapy is appropriate for your specific vascular status.

Sources

1. Armstrong DG, et al. “Diabetic Foot Ulcers and Their Recurrence.” New England Journal of Medicine. 2017;376(24):2367-2375.
2. Bus SA, et al. “IWGDF Guidance on the prevention of foot ulcers in at-risk patients with diabetes.” Diabetes/Metabolism Research and Reviews. 2016;32(S1):16-24.
3. Diabetes Control and Complications Trial Research Group. “The effect of intensive treatment of diabetes on the development and progression of long-term complications.” NEJM. 1993;329(14):977-986.
4. Pecoraro RE, et al. “Pathways to diabetic limb amputation: basis for prevention.” Diabetes Care. 1990;13(5):513-521.
5. Lavery LA, et al. “Preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool.” Diabetes Care. 2007;30(1):14-20.

Protect Your Feet from Diabetic Complications

Our diabetic foot program at Balance Foot & Ankle Specialists provides comprehensive screening, preventive care, and limb salvage services. Early intervention saves limbs — schedule your diabetic foot evaluation today.

📞 Schedule Your Diabetic Foot Evaluation

Related Diabetic Foot Care Guides

• Podiatrist-Recommended Foot Care Products 2026
• Best Insoles for Plantar Fasciitis
• Diabetic Foot Care Guide
• Peripheral Neuropathy Treatment
• Wound Care Services

When to See a Podiatrist for Diabetic Foot Care

If you have diabetes, regular podiatric care is essential for preventing ulcers and amputations. Don’t wait for a wound to develop — early screening and preventive care save limbs. At Balance Foot & Ankle, we provide comprehensive diabetic foot care at our Howell and Bloomfield Hills offices.

Learn About Our Diabetic Foot Care Program | Book Your Appointment | Call (810) 206-1402

Clinical References

1. Armstrong DG, Boulton AJM, Bus SA. “Diabetic foot ulcers and their recurrence.” New England Journal of Medicine. 2017;376(24):2367-2375.
2. Lavery LA, Hunt NA, Ndip A, Lavery DC, Van Houtum W, Boulton AJM. “Impact of chronic kidney disease on survival after amputation in individuals with diabetes.” Diabetes Care. 2010;33(11):2365-2369.
3. Bus SA, van Netten JJ, Lavery LA, et al. “IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes.” Diabetes/Metabolism Research and Reviews. 2016;32(Suppl 1):16-24.