Diabetics Are Not Being Screened Enough—And It's Leading to Amputations
Mar 12, 2026
Every 3 minutes and 30 seconds in the United States, someone with diabetes loses a limb (American Diabetes Association, 2024). In Singapore, the statistics are equally alarming. Despite being a developed nation with advanced healthcare infrastructure, Singapore records one of the highest diabetes-related amputation rates in the developed world (SingHealth, 2024).
The tragedy? Most of these amputations are preventable through systematic screening and early intervention.
The Scale of the Crisis
Singapore faces a diabetes epidemic. One in nine adults has diabetes—approximately 450,000 people (AIA Singapore, 2020). By 2050, this number is projected to reach one million if current trends continue. The Ministry of Health launched the War on Diabetes in 2016, recognizing the massive health and economic burden: costs are expected to double from S$940 million in 2014 to S$1.8 billion by 2050.
Lower extremity complications represent the most disabling diabetes complication. The lifetime risk of developing a foot ulcer ranges from 15% to 25% among people with diabetes (SingHealth, 2024). Critically, foot ulcers precede 80% of all lower limb amputations in those with diabetes.
A 2021 study tracking diabetes-related lower extremity complications across Singapore's National Healthcare Group cluster over 10 years revealed the magnitude of the problem (Ang et al., 2021). Among patients with type 2 diabetes, the cumulative incidence of complications was substantial, with amputations occurring at rates that position Singapore unfavorably compared to other developed nations.
The human cost extends beyond the surgery itself. A Channel NewsAsia investigation found that 13% of diabetic patients below the age of 50 had developed complications that could require amputation (CNA Lifestyle, 2017). Mr. Toh Eng Cheng, a 52-year-old former security supervisor, underwent nine foot-related operations and five lower limb angioplasties over just one year following an innocuous injury to his toe. He lost his gangrenous toe and six others—but considers himself fortunate not to have lost his entire leg (Straits Times, 2018).
Global Context
Singapore's challenge mirrors a global crisis. Worldwide, the annual incidence of diabetes-related minor amputations is estimated at 139.97 per 100,000 people with diabetes, while major amputations occur at a rate of 94.82 per 100,000 (Narres et al., 2017). In the United States alone, 160,000 people with diabetes undergo amputation annually, with 80% of non-traumatic lower limb amputations attributable to diabetes complications (American Diabetes Association, 2024).
Five-year survival rates after amputation are worse than those for coronary artery disease, breast cancer, and colorectal cancer. Amputation rates also reveal stark disparities: they are substantially more prevalent among people of color and vary dramatically by socioeconomic status and geography.
The Screening Gap
International guidelines are clear. The International Working Group on the Diabetic Foot (IWGDF) 2023 update emphasizes systematic screening as the cornerstone of amputation prevention (IWGDF, 2023). The IWGDF recommends that all people with diabetes receive an annual comprehensive foot examination to identify risk factors for ulceration and amputation.
Despite these guidelines, screening rates remain inadequate globally and in Singapore. The gap between evidence-based recommendations and clinical practice stems from multiple factors:
Time Constraints
Primary care consultations in Singapore typically run 15-20 minutes. A comprehensive diabetic foot examination requires removing shoes and socks, inspecting skin integrity, palpating pulses, testing protective sensation with monofilament, and assessing foot deformities. Many clinicians deprioritize foot screening when competing demands like glycemic control, blood pressure management, and lipid monitoring consume consultation time.
Knowledge Gaps
Not all primary care physicians receive comprehensive training in diabetic foot assessment. The technical aspects of monofilament testing, recognition of Charcot foot, and identification of peripheral arterial disease require specific competencies that may not be routinely reinforced in general practice.
Patient Engagement
Patients often underestimate foot complication risks. Without visible symptoms, many individuals with diabetes fail to mention foot concerns or request examination. The insidious nature of diabetic neuropathy means sensation loss progresses silently until protective sensation is already compromised.
System-Level Barriers
Healthcare systems may lack structured protocols ensuring every diabetes patient receives annual foot screening. Without systematic recall systems and standardized documentation, screening becomes opportunistic rather than universal.
The Cascade from Undetected Neuropathy to Amputation
Diabetic peripheral neuropathy affects up to 50% of people with long-standing diabetes. Loss of protective sensation means patients cannot feel minor trauma—a pebble in a shoe, a blister from new footwear, or thermal injury from walking barefoot. These minor injuries, unnoticed and untreated, progress to ulceration.
Once a foot ulcer develops, the risk trajectory accelerates. Ulcers provide entry points for infection. Diabetes impairs immune response and microvascular circulation, limiting the body's ability to fight infection and heal wounds. Infection can spread rapidly to deeper tissues and bone (osteomyelitis). When infection becomes uncontrollable or tissue becomes gangrenous, amputation becomes the only option to save the patient's life.
The progression is preventable at multiple intervention points—but only if screening identifies at-risk patients before ulceration occurs.
Evidence That Screening Works
Singapore's own data demonstrates that systematic approaches dramatically reduce amputation rates. The National Healthcare Group's integrated diabetic foot programme reduced major amputations by 40% (Straits Times, 2018). This programme incorporated structured screening protocols, multidisciplinary wound care teams, and coordinated follow-up.
The Ministry of Health's 2018 National Diabetic Foot Workgroup developed a strategic framework specifically targeting lower extremity amputation reduction (MOH Singapore, 2018). The strategy emphasized early identification through screening as the foundation for preventing progression to amputation.
What Effective Screening Looks Like
The IWGDF 2023 guidelines specify that annual foot screening should include (IWGDF, 2023):
Visual Inspection: Examine for skin breakdown, calluses, deformities, and signs of infection or ischemia.
Neuropathy Assessment: Test protective sensation using 10g monofilament at standardized sites on each foot. Loss of protective sensation dramatically increases ulceration risk.
Vascular Assessment: Palpate pedal pulses and assess for signs of peripheral arterial disease. Diminished perfusion impairs healing and increases amputation risk.
Biomechanical Assessment: Identify foot deformities, limited joint mobility, and gait abnormalities that create pressure points predisposing to ulceration.
Risk Stratification: Classify patients into risk categories (low, moderate, high) to determine appropriate follow-up intervals and preventive interventions.
Closing the Gap
Several strategies can improve screening rates:
System Integration: Electronic medical record prompts can flag patients due for annual foot screening. Automated recall systems ensure no patient falls through the cracks.
Task Shifting: Trained nurses, podiatrists, and allied health professionals can perform standardized foot assessments, reducing physician time burden while maintaining quality.
Patient Education: Empowering patients to perform daily self-inspection and recognize warning signs creates an additional safety net. Patients who understand risks become active participants in prevention.
Quality Metrics: Healthcare systems should track and report diabetic foot screening rates as a quality indicator. Transparency drives accountability and improvement.
Technology Solutions: Automated assessment platforms can standardize screening, reduce time requirements, and generate structured documentation for electronic medical records. These technologies can democratize access to high-quality screening regardless of clinician expertise.
The Path Forward
Diabetic foot complications represent a solvable problem. The evidence base is clear: systematic screening identifies at-risk patients, early intervention prevents ulceration, and timely management of ulcers prevents amputation.
Singapore has demonstrated that structured programmes work. The 40% reduction in major amputations achieved through the National Healthcare Group's integrated approach provides a roadmap (Straits Times, 2018). Scaling this success across all healthcare clusters requires commitment to universal screening protocols, adequate resource allocation, and multidisciplinary care coordination.
For the 450,000 Singaporeans living with diabetes today—and the million projected by 2050—the question is urgent: will we implement the screening systems necessary to prevent preventable amputations? The technology exists. The clinical guidelines are established. The evidence of effectiveness is compelling.
What remains is execution. Every foot saved, every life preserved, and every patient spared the devastating impact of amputation depends on closing the screening gap. The tools are in our hands. It is time to use them.
Seamless XR's Achilles platform delivers automated, standardized diabetic foot screening in under 5 minutes per patient. The system combines vibration perception testing with thermal mapping to detect early neuropathy and vascular complications—enabling clinicians to systematically screen every diabetic patient and identify at-risk feet before ulceration occurs.
References
American Diabetes Association (2024). Statistics About Diabetes. Retrieved from diabetes.org
AIA Singapore (2020). The War on Diabetes. Retrieved from aia.com.sg
Ang, Y., Yap, C. W., Saxena, N., Lin, L. K., & Heng, B. H. (2021). Diabetes-related lower extremity amputations in Singapore. Singapore Medical Journal. doi:10.1007/s00105-020-04750-8
CNA Lifestyle (2017). Young diabetics in Singapore at risk of amputations. Channel NewsAsia.
International Working Group on the Diabetic Foot (2023). IWGDF Guidelines on the Prevention and Management of Diabetic Foot Disease. Retrieved from iwgdfguidelines.org
Ministry of Health Singapore (2018). National Diabetic Foot Workgroup Strategic Framework. Retrieved from moh.gov.sg
Narres, M., Kvitkina, T., Claessen, H., Droste, S., Schuster, B., Morbach, S., Rümenapf, G., Van Acker, K., & Icks, A. (2017). Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review. PLoS ONE, 12(8), e0182081.
SingHealth (2024). Diabetic Foot Care and Prevention. Retrieved from singhealth.com.sg
Straits Times (2018). Singapore steps up fight against diabetes-related foot complications. The Straits Times.