**1. Introduction**

Type 2 Diabetes Mellites (TTDM), which is approximately 95% of all diabetic patients in 2010, affected 280 million (approximately 6.2%) of the world's population and is thought to increase to 7.5% by 2030 [1, 2]. This is thought to be due to an increase in the number of obese individuals which leads primarily to an increase in their incidence of TTDM. Most scientists and medical professionals believe that obesity begins at a BMI of 30 and severe obesity at a BMI of 40 but many studies are now suggesting that BMI is not a truly accurate measure of obesity [3]. Most TTDM patients are obese and about 2-3 percent of patients have current active foot ulcers and up to 25% will eventually develop foot ulcers [4]. This occurs as a result of uncontrolled diabetes that interferes with wound healing, reduces pain response, and causes problems with proper blood circulation. Although ulcers can actually occur anywhere on the body, the feet are most vulnerable.

The chief cause of foot ulcerations is due to diabetic neuropathy. High blood glucose levels cause arteries to harden and develop plaques that limit blood flow to tissues including nerves and the heart. This causes reduced nutrient and oxygen uptake by the nerves causing neuropathy. Diabetic neuropathy affects both the somatic as well as autonomic nervous systems resulting in a complex group of pathophysiological disorders. One of the manifestations of these disorders in the diabetic foot which can result in anatomical and physiological changes in the foot such as ulcerations and infections because of a lack of wound healing and a delayed immune response. Since

the feet are frequently covered and the soles are exposed to compression from walking feet when it comes to ulcerations, the feet are the most vulnerable part of the body. Wound healing is slowed for several reasons. Hyperglycemia is a contributing factor to atherosclerosis. This limits the blood flow, especially to the heart but also to any wounds and the feet tend to be even more susceptible [5, 6]. Nerve damage can cause a loss of sensation in the foot and peripheral vascular disease that can go unnoticed. If these conditions become severe enough, this can cause further damage to bone, joints, and soft tissue and if not treated can eventually lead to amputation [7, 8]. Life expectancy following amputation is about 50% within five years [9, 10] although many of those deaths could be due to contributing comorbidities related to diabetes-induced cardiovascular disease [3].

It would seem to suggest that control of diabetes and its symptoms would be the best way to prevent ulcerations. However, it does not fully eliminate the risk [11]. There are two major forms - Type 1 and Type 2 diabetes but there are other less wellknown forms as well which include gestational and atypical diabetes. They have very similar symptoms, but their causes can be quite different and are often misdiagnosed [12]. If the weight and diet are left unchanged despite control of diabetic symptoms, there is still a risk of ulcerations, especially on the feet. To eliminate the risk altogether, the weight must be lost, and diabetes must go away completely to eliminate the risks.

One can certainly do regular foot inspections to avoid the worse complications of foot ulcers and be sure that their diabetes is under control. Metformin is the most used drug to treat diabetic patients but other drugs such as incretin agonists particularly GLP-1 and DPP4 inhibitors are also being used and often in combination with Metformin [13].

Some patients also use insulin injections as well. None of these drugs ensure that diabetes can be controlled at all times which makes foot inspections required.

Children can also develop foot ulcers and more and more studies are showing that the mother can contribute to these problems [14]. Cesarean sections rather than vaginal births can alter the seeding of microbiota during the birth process. In addition, the mother if she is diabetic or has elevated blood sugar, these sugars can be passed along to the infant during breastfeeding causing the infant to have elevated blood sugars [14]. Studies have been performed up to about four months of age which is the median age at which infants begin to eat solid food. Infants were divided into four groups based on cesarean versus vaginal birth and breast milk versus formula and found that vaginal births with breast milk fared better when their microbiota were compared [15]. Breast milk also contains a great number of good bacteria as well from the skin microbiota that can be missing if the mother fails to breastfeed [14]. These combinations can lead to obesity and diabetes in young children and eventually to the complications of diabetes previously described for adults including foot ulcers.
