{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,4]],"date-time":"2026-10-04T09:52:20Z","timestamp":1791107540450,"version":"4.1.0"},"reference-count":35,"publisher":"Springer Science and Business Media LLC","license":[{"start":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T00:00:00Z","timestamp":1790985600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T00:00:00Z","timestamp":1790985600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100001826","name":"ZonMw","doi-asserted-by":"publisher","award":["10310032130006 and10310012310009"],"award-info":[{"award-number":["10310032130006 and10310012310009"]}],"id":[{"id":"10.13039\/501100001826","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Diabetologia"],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Aims\/hypothesis<\/jats:title>\n                    <jats:p>Insights into the environmental impact of diabetes care are scarce and are absent regarding treatments for diabetes-related foot disease. We aimed to compare the environmental impacts of three offloading pathways for people with a plantar foot ulcer.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We performed a bottom-up, process-based life-cycle assessment according to ISO standards. We defined three evidence-based offloading pathways from first visit to healing: total contact cast (TCC), non-removable walker and removable walker. Inventory data were collected for all activities within scope (materials, waste, transport, energy consumption). Life-cycle assessment was performed using ReCiPe-2016 midpoint and endpoint methods, employing SimaPro and Ecoinvent 3.10. Monte Carlo simulation with 1,000,000 individuals provided the environmental impact per offloading pathway.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      Environmental impact was lowest for the removable walker pathway and highest for the TCC for all 18 midpoints and five endpoints. For global warming, the mean impact was 141 kg CO\n                      <jats:sub>2<\/jats:sub>\n                      -equivalents (CO\n                      <jats:sub>2<\/jats:sub>\n                      -eq) (SD: 88; 95% prediction interval 67, 377) for the TCC pathway, 108 kg CO\n                      <jats:sub>2<\/jats:sub>\n                      -eq (SD: 62; 95% prediction interval 59, 276) for the non-removable walker and 90 kg CO\n                      <jats:sub>2<\/jats:sub>\n                      -eq (SD: 57; 95% prediction interval 36, 244) for the removable walker. The largest environmental impact came from patient transport (59\u201378% of all impact per pathway in CO\n                      <jats:sub>2<\/jats:sub>\n                      -eq).\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions\/interpretation<\/jats:title>\n                    <jats:p>Diabetes-related plantar foot ulcer treatment pathways with a walker are likely to result in lower environmental impact compared with the TCC pathway, with the lowest impact for the removable walker pathway. This resulted from using a single device (i.e. no replacements required) and, for the removable walker, fewer visits, despite longer time to healing. Taking environmental impact into account may alter clinical decision-making in offloading treatment.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00125-026-06891-3","type":"journal-article","created":{"date-parts":[[2026,10,3]],"date-time":"2026-10-03T20:21:01Z","timestamp":1791058861000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Environmental sustainability of offloading care pathways for people with a diabetes-related foot ulcer: a life-cycle assessment"],"prefix":"10.1007","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6420-6046","authenticated-orcid":false,"given":"Jaap J.","family":"van Netten","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0009-0412-2930","authenticated-orcid":false,"given":"Florine I.","family":"de Haes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8357-9163","authenticated-orcid":false,"given":"Sicco A.","family":"Bus","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4104-5112","authenticated-orcid":false,"given":"Marieke E.","family":"Sijm-Eeken","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,10,3]]},"reference":[{"issue":"10465","key":"6891_CR1","doi-asserted-by":"publisher","first-page":"1847","DOI":"10.1016\/S0140-6736(24)01822-1","volume":"404","author":"M Romanello","year":"2024","unstructured":"Romanello M, Walawender M, Hsu SC et al (2024) The 2024 report of the Lancet Countdown on health and climate change: facing record-breaking threats from delayed action. 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After signing non-disclosure agreements, we (the authors) have gained full and unrestricted access to all information of this life-cycle assessment, and we guarantee that we could check and confirm all content. Sustainability experts from \u00d6ssur provided feedback on this manuscript and checked the content in relation to the non-disclosure agreement, but \u00d6ssur had no say in the content and interpretations in this manuscript, nor in the decision to publish. We would like to acknowledge and thank the students from Amsterdam UMC and Technical University Delft who contributed to parts of this research: M. Gerritsen, L. van den Acker, V. Veger, J. Essenburg, F. Toxopeus, F. Voorhorst and M. Dijkstra. We would like to thank L. Snijder, Amsterdam UMC Centre for Sustainable Healthcare, for her expert input in the development of the protocol and the first ideas related to this LCA. We would like to thank L. Vossen, Amsterdam UMC Department of Rehabilitation, for her support in creating the figures. We did not use AI in the writing process.","order":1,"name":"Ethics","label":"Acknowledgements","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"The data and the script used for simulating the TCC care pathway is available on the Open Science Framework [\n                      \n                      ]. The scripts for simulation of the walker pathways are structured in a similar way and cannot be shared, given the confidentiality agreement with \u00d6ssur and the terms and conditions of using SimaPro.","order":2,"name":"Ethics","label":"Data availability","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"This work was supported by seed funding from Amsterdam UMC and by grants 10310032130006 and 10310012310009 from the Dutch Medical Research Council (ZonMw). The funding sources had no role in study design, data collection and interpretation, writing of the report, and decision to submit.","order":3,"name":"Ethics","label":"Funding","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"The authors declare that there are no relationships or activities that might bias, or be perceived to bias, their work.","order":4,"name":"Ethics","label":"Authors\u2019 relationships and activities","group":{"name":"EthicsHeading","label":"Ethics"}},{"value":"JJvN contributed to conceptualisation, methodology, validation, investigation, resources, data curation, writing of the original draft, visualisation, supervision, project administration and funding acquisition. FIdH contributed to methodology, software, validation, formal analysis, investigation and writing \u2013 review & editing. SAB contributed to conceptualisation, writing \u2013 review & editing, and funding acquisition. MES-E contributed to methodology, software, validation, formal analysis, investigation, data curation, writing \u2013 review & editing, project administration and funding acquisition. All authors gave final approval of the version to be published. JJvN is the guarantor of this work.","order":5,"name":"Ethics","label":"Contribution statement","group":{"name":"EthicsHeading","label":"Ethics"}}]}}