Cambodia’s Diabetes Crisis Shows First in the Foot: What the Circulation Has to Do With It
For World Diabetes Day, Dr Andrew Choong wrote for Cambodianess on why a foot wound that will not heal is often the first sign of diabetes and poor circulation, and what can be done about it.
November 14 is World Diabetes Day. Ahead of it, Cambodianess has published my opinion piece on a pattern I see in patients from across the region, and which Cambodia’s own data describe clearly: diabetes that nobody knew about, discovered because of a foot wound that would not heal. This post sets out the argument for readers in Singapore and for families in Cambodia who are deciding what to do next.
How much diabetes does Cambodia have?
More than it knows. In the 2023 national survey carried out with the World Health Organization, 6.7 per cent of adults said they had been diagnosed with diabetes, and a further 9.3 per cent had it without knowing. The International Diabetes Federation now estimates about 720,000 Cambodian adults are living with the condition. When diagnosis comes late, the complications have often had years to develop, and the foot is where they tend to show first.
Why does diabetes show first in the foot?
Two things happen at once. High blood sugar damages the small nerves, so the foot loses its warning system: a blister, a stone in the shoe or a burn from a hot surface goes unfelt. At the same time it narrows the arteries of the leg, so when the skin does break, there is not enough blood flow to heal it. A wound that would close in two weeks in a healthy foot can stay open for months, and an open wound is an invitation to infection.
In the European Eurodiale study of people presenting with a new diabetic foot ulcer, about half already had narrowed leg arteries, and where the arteries were narrowed and the wound infected, the ulcer healed in only 69 per cent at one year. Circulation is not a side issue in diabetic foot care. It is often the deciding one.
What is happening in Cambodia’s clinics?
Reports from the diabetic foot clinic at a public hospital in Phnom Penh describe patients arriving weeks, months or even years after an ulcer began, frequently with advanced infection, and at the time of that report only two government facilities in the country offered focused diabetic foot care. Distance, cost, traditional remedies tried first, and fear of amputation all delay the visit. By the time the foot is seen, the choice is sometimes between a long, uncertain course of treatment and losing part of the limb.
What is the four-week rule?
It is the single most useful habit I can offer a patient, a family or a clinic. Any foot wound in a person with diabetes that has not clearly improved after four weeks of proper dressing and rest has a reason. Very often that reason is the blood supply. Four weeks is long enough to know that dressings alone are not working, and short enough that the arteries can still be assessed and treated before infection reaches bone. A wound that is not shrinking at four weeks needs someone to look at the arteries.
How is the circulation in the foot checked?
It should be measured, not guessed. Feeling for pulses is the start, but pulses can be hard to feel in a swollen or scarred foot. A handheld Doppler, a device the size of a torch, lets a nurse hear the blood flow and measure the ankle and toe pressures against the arm. Where those are low, a colour duplex ultrasound scan shows exactly which arteries are narrowed and where. This is the same sequence the current international guideline recommends, and none of it requires a hospital. I have explained the leg arteries and what we look for on the peripheral arterial disease page and in this short video on diabetes, the arteries and foot care.
How is the blood flow restored?
Where an artery is narrowed or blocked, the aim is to reopen it so the wound has the blood it needs to heal. Most of this is now done from the inside: a needle puncture in the groin or the foot under local anaesthetic, a fine wire and balloon passed through the narrowing, and sometimes a stent to hold the artery open. Bypass surgery still has its place for long blockages. The methods are described on the leg angioplasty and stenting page and the diabetic foot wound care page. Even after a wound heals, diabetic foot ulcers come back in about 40 per cent of people within a year, so the foot checks do not stop.
“Diabetes is going to be part of Cambodia’s future. Losing a leg to it does not have to be.”
What did I ask Cambodia to do?
Three things, none of them expensive. First, add a foot and pulse check to every routine diabetes review, once a year even when there is no wound. Second, put handheld Dopplers in provincial hands and train staff to use them, so the circulation can be measured outside Phnom Penh. Third, agree a simple rule for referral: a foot wound that is not better in four weeks goes to someone who can look at the arteries.
Read the full article
The op-ed, “Cambodia’s Diabetes Crisis: The Foot Is Where It Shows First”, was published by Cambodianess on 17 October 2026, with all its sources linked. It is my second piece for Cambodianess, after the World Thrombosis Day article in early October; both are listed on the press page.
Preparing for a vascular review
If you or a family member has diabetes and a foot wound that has not improved in four weeks, bring to the appointment a note of when the wound began, what has been tried, the most recent blood sugar and kidney results, and any scans already done. Photographs of the wound over time help. Patients travelling from Cambodia and elsewhere in the region will find practical details on the international patients page, and can reach the clinic through the contact page.