The number of people living with diabetes across the Middle East and North Africa increased from approximately 11.7 million in 1990 to 66.6 million in 2023, creating a rapidly expanding need for lifelong treatment, complication screening and specialist diabetic-foot care.

New cases rose from around 640,000 to 3.19 million during the same period, while diabetes-related deaths increased from 38,100 to 127,200. Disability-adjusted life-years, which measure the combined impact of premature death and living with illness or disability, climbed from 1.90 million to 8.02 million.

The findings come from a study examining Global Burden of Disease estimates across 21 countries between 1990 and 2023. The analysis shows that population growth and ageing explain only part of the increase. After adjusting for age, diabetes incidence rose by 92%, prevalence more than doubled and the associated disability burden increased by 48%.

For prosthetists, orthotists, podiatrists and rehabilitation providers, these figures point towards a major increase in demand for foot screening, pressure-relieving orthoses, therapeutic footwear, wound prevention and post-amputation rehabilitation.

Diabetes is becoming a permanent structural pressure

Diabetes is not managed through a single clinical intervention.

A person diagnosed in early or middle adulthood may require decades of medication, glucose monitoring, cardiovascular-risk management and screening for kidney, eye, neurological and foot complications.

As the number of people living with diabetes expands, healthcare systems must provide continuous care rather than responding only when patients develop an emergency.

Without regular screening and early intervention, manageable complications can progress into:

Peripheral neuropathy
Loss of protective sensation
Foot deformity
Callus and localised pressure
Ulceration
Infection
Charcot neuroarthropathy
Partial-foot or major-limb amputation

The greatest risk is that already stretched health systems will continue to concentrate resources on acute hospital treatment while underinvesting in the community services needed to prevent complications.

For diabetic-foot care, this can mean patients first entering the system when an ulcer has become infected or limb salvage is already difficult.

Survival alone is not enough

The study highlights the difference between reducing mortality and reducing disability.

A country may improve diabetes survival while still accumulating a large population living with complications, reduced mobility and economic dependency.

Lebanon, for example, recorded the lowest age-standardised diabetes mortality among the highlighted countries in 2023, but also had the region’s highest proportion of diabetes-related disease burden associated with disability.

This distinction matters for rehabilitation planning.

Longer survival can increase demand for:

Diabetic-foot surveillance
Custom foot orthoses
Therapeutic footwear
Offloading devices
Mobility aids
Post-amputation prosthetic care
Long-term rehabilitation
Home and community support

Health systems therefore need to measure more than deaths and hospital admissions. They should also examine ulcer recurrence, amputation rates, mobility, participation and quality of life.

Younger men are carrying a growing burden

The demographic profile of diabetes in MENA is also changing.

In 1990, women had higher diabetes-related DALY rates across most adult age groups. By 2023, men carried the higher burden in most groups from the age of 15 onwards.

Among men aged 15 to 39, DALY rates increased by 133%, compared with an 83% rise among women of the same age. Among adults aged 55 and older, increases among men ranged from 70% to 84%, substantially higher than those recorded among women.

This shift has implications for workplace health and foot-care services.

Working-age men may delay seeking treatment, particularly when symptoms appear manageable or attending appointments means losing income. People employed in construction, transport, manufacturing, security and other physically demanding occupations may also spend long periods standing or wearing restrictive footwear.

Employers and occupational-health providers could help identify risk earlier through:

Diabetes screening
Foot and footwear checks
Neuropathy assessment
Education on warning signs
Referral for pressure analysis
Access to appropriate insoles and footwear
Protected time for medical appointments

Preventive services should not wait until the patient retires or develops an ulcer.

High body-mass index remains the leading risk factor

High body-mass index was the largest modifiable contributor to diabetes-related disability in every country included in the analysis.

The attributable burden ranged from approximately 524 DALYs per 100,000 people in Yemen to 2,208 per 100,000 in Bahrain.

Increased body weight can also intensify the mechanical pressures affecting the diabetic foot.

Higher plantar loads, reduced mobility and inappropriate footwear can combine with neuropathy to increase the risk of callus, skin breakdown and ulceration.

Orthotic management may therefore require more than arch support. It can involve:

Plantar-pressure measurement
Total-contact insoles
Multi-density materials
Localised offloading
Rocker modifications
Extra-depth footwear
Custom-moulded shoes
Regular review of wear and compression

The prescription must be based on risk, deformity, skin condition and footwear rather than body weight alone.

Air pollution adds a wider public-health dimension

Particulate-matter pollution was identified as the second-largest contributor to diabetes-related disability across all 21 countries, accounting for between 187 and 606 DALYs per 100,000.

In several countries, the diabetes burden attributed to air pollution was greater than that associated with tobacco.

This finding reinforces the view that diabetes cannot be addressed solely through advice directed at individuals.

Food systems, urban planning, transport, air quality, working conditions and access to safe physical activity all influence risk.

Extreme heat can also restrict outdoor activity across parts of the Middle East, while car-dependent cities may make routine walking difficult.

Effective prevention therefore requires cooperation between health, transport, environment, education, labour and finance authorities.

The regional burden varies substantially

Diabetes does not affect every MENA country in the same way.

In 2023, diabetes-related DALY rates varied approximately 3.6-fold, from around 974 per 100,000 people in Yemen to 3,461 per 100,000 in Bahrain.

Saudi Arabia recorded the highest incidence rate among the country comparisons, while Lebanon recorded the lowest mortality rate.

These differences show why one regional service model will not be sufficient.

Countries with high prevalence and disability may require strong primary-care screening, retinal and kidney monitoring, diabetic-foot clinics and long-term orthotic provision.

Countries with high premature mortality may need earlier diagnosis, more reliable medication supplies and improved management of cardiovascular and acute complications.

Conflict-affected countries face additional barriers involving displacement, destroyed health facilities, interrupted insulin supplies and limited access to specialist rehabilitation.

Conflict makes foot complications harder to prevent

In Afghanistan, Libya, Palestine, Sudan, Syria and Yemen, continuity of diabetes treatment can be disrupted by insecurity, displacement and damaged healthcare infrastructure.

Patients may lose access to insulin, glucose testing, suitable footwear and routine foot checks. Medical records may be lost when families move, while wound-care and rehabilitation services may be concentrated far from displaced communities.

A minor wound can therefore become a limb-threatening infection because the patient cannot obtain antibiotics, dressings, offloading or vascular assessment.

Humanitarian diabetes programmes should include more than medicine distribution.

They should also provide:

Basic foot screening
Patient education
Protective footwear
Simple offloading devices
Portable clinical records
Referral routes for infected ulcers
Access to surgical and rehabilitation services
Prosthetic follow-up for people with previous amputations

Foot protection should be integrated into chronic-disease programmes from the beginning rather than added only when ulceration becomes widespread.

Diabetic-foot services need to move closer to patients

Hospital-based specialist clinics remain essential for complex cases, but they cannot manage the entire regional burden.

Most screening and prevention should take place in primary care and community settings.

A tiered pathway could include:

Community and primary care

Healthcare workers could perform skin inspection, pulse checks, monofilament testing and basic footwear assessment.

Patients identified as low risk could receive education and scheduled review.

Specialist foot-protection services

People with neuropathy, deformity, callus or previous ulceration could be referred to podiatrists, orthotists and specialist nurses for pressure management and footwear provision.

Multidisciplinary diabetic-foot teams

Patients with active ulceration, infection, Charcot changes or vascular disease would require coordinated care involving endocrinology, vascular surgery, orthopaedics, infectious-disease specialists, wound care, podiatry and rehabilitation.

Post-amputation rehabilitation

People who undergo amputation should enter an organised pathway covering wound healing, residual-limb management, prosthetic fitting, mobility training and prevention of complications in the opposite limb.

The objective should be to intervene at the lowest appropriate level before the condition progresses.

Orthotists can play a larger role in prevention

Orthotists are well positioned to support the growing diabetic-foot population, particularly where podiatry services remain limited.

Their contribution may include:

Foot and footwear assessment
Plantar-pressure analysis
Prescription of accommodative orthoses
Design of total-contact insoles
Footwear modification
Custom therapeutic footwear
Charcot restraint orthotic walkers
Post-operative and wound-offloading devices
Monitoring device wear and pressure areas
Education for patients and caregivers

However, device provision should remain part of a clinical pathway.

A scan or pressure image cannot independently determine whether a patient has infection, vascular insufficiency or active Charcot neuroarthropathy. Patients with warning signs require medical assessment rather than immediate retail insole fitting.

Clinics should establish clear referral protocols and document outcomes such as pressure reduction, skin condition, ulcer recurrence and patient adherence.

Prosthetic demand will rise without stronger prevention

The increase in diabetes prevalence is likely to create additional demand for partial-foot, transtibial and transfemoral prosthetic rehabilitation unless ulcer prevention and limb-salvage services improve.

Diabetes-related amputation frequently occurs after repeated ulceration, infection and vascular disease.

Patients may also face higher risks during prosthetic rehabilitation, including:

Delayed wound healing
Fluctuating residual-limb volume
Fragile skin
Reduced sensation
Cardiovascular limitations
Kidney disease
Impairment of the opposite foot

A person with a unilateral diabetic amputation may be at substantial risk of developing an ulcer or amputation on the remaining limb.

Prosthetic rehabilitation should therefore include regular inspection and protection of the contralateral foot.

Appropriate footwear, pressure-relieving insoles and education must continue even after the patient receives a prosthesis.

Digital technology can support scaling

Digital systems may help countries manage the growing demand for diabetic-foot services.

Useful tools include:

Electronic risk registers
Automated recall systems
Digital foot scanning
Plantar-pressure platforms
Remote orthotic design
Teleconsultation
Wound-imaging systems
Shared multidisciplinary records

Digital workflows can reduce delays and allow specialist professionals to support clinics in remote locations.

A local provider could capture a foot scan or pressure measurement and share it with a regional orthotic centre for design and production.

However, technology must be appropriate to the health system.

Conflict-affected and lower-resource settings may benefit more from portable records, dependable screening tools and locally repairable products than from complex systems dependent on continuous connectivity and proprietary software.

Local production can improve access and affordability

The scale of regional demand will be difficult to meet through imported custom products alone.

Local and regional manufacturing could reduce delivery times and costs for:

Multi-density diabetic insoles
Custom foot orthoses
Toe fillers
Partial-foot devices
Therapeutic footwear
Offloading walkers
Custom ankle-foot orthoses

Digital milling and 3D printing may support distributed production, but conventional fabrication will remain important where equipment, electricity or technical support is limited.

The priority should be consistent clinical quality rather than the manufacturing method itself.

Products must be made from suitable materials, matched to the patient’s risk and reviewed after delivery.

Prevention is less costly than amputation

A major lower-limb amputation creates long-term costs involving surgery, hospitalisation, prosthetic provision, physiotherapy, replacement devices and loss of employment.

The financial and social impact frequently extends to the patient’s family, particularly when relatives must reduce work or education to provide care.

Investment in foot screening, offloading and therapeutic footwear is therefore not only a clinical priority but also an economic strategy.

Health systems should track:

Number of high-risk patients screened
Time from ulcer detection to specialist review
Ulcer-healing rates
Recurrence rates
Minor- and major-amputation rates
Access to orthoses and therapeutic footwear
Prosthetic rehabilitation outcomes
Return to work and independent mobility

These indicators would provide a clearer picture of whether diabetes programmes are preventing disability rather than simply treating disease.

A defining challenge for MENA rehabilitation

The rise from 11.7 million to 66.6 million people living with diabetes represents one of the most significant long-term pressures facing MENA healthcare systems.

The challenge will not be solved solely through awareness campaigns or hospital treatment.

It requires a connected system of prevention, primary care, foot protection, limb salvage and rehabilitation.

For the region’s orthotists and prosthetists, the implications are substantial.

Demand will grow for pressure assessment, custom insoles, therapeutic footwear, offloading devices and post-amputation care. Providers that build strong links with diabetes, vascular, wound-care and primary-care teams will be increasingly important.

The opportunity is not simply to supply more devices.

It is to prevent ulcers, preserve limbs and ensure that people who do undergo amputation can return to safe and independent mobility.