Between the years 1990 and 1998, the prevalence of diabetes increased by 33%; this increase was observed across different sex, age, and ethnic groups.

Diabetes is a high-morbidity chronic illness in which patients require continuous medical care and education in self-management to prevent acute complications and to reduce the risk of associated comorbidities and even mortality.

A number of disease-management programs have been implemented to control diabetes. Diabetes Self-Management Education (DSME) is considered the cornerstone of care for all persons with who want to achieve successful health-related outcomes. The National Standards for DSME recommend an individualized assessment, the development of an educational plan, and periodic reassessments by participants and instructors in order to select appropriate educational materials and interventions. However, it is a continuous challenge to keep patients motivated and in compliance with guidelines.

For example, in our study, patients were likely to skip individual self-care elements; 37.9% reported no foot care, 37.7% reported no exercise, and 54.4% reported no time for food shopping or preparation. These findings may be attributed to the low rate of cooperation between patients and physicians in terms of setting treatment goals and strategies in the primary care setting .

Foot care programs do not preclude the risk of developing foot ulcers, but they do decrease the risk by about 13-fold. Specific self-care behaviors are associated with diabetes outcomes, but almost 33% of patients do not perform foot self-examina-tion. Even with intensive therapy, the prevalence of lower-extremity disease is high in diabetic patients; this includes peripheral arterial disease, peripheral neuropathy, foot ulcera-tion, and lower-extremity amputations. In adults over 40 years of age in the U.S., that prevalence is approximately 4.5%. Prevalence rates are twice as high for individuals with a diagnosis of diabetes, and they are even higher for those with other risk factors such as peripheral neuropathy and peripheral vascular disease. Foot ulcers are a major cause of morbidity and mortality for patients with diabetes.

From the viewpoint of disease management, the economic burden of morbidity is also considerable; direct medical and