The development of global consensus guidelines on the management and prevention of the diabetic foot 2011


K. Bakker, International Working Group on the Diabetic Foot, Heemsteedse Dreef 90, 2102 KN Heemstede, The Netherlands.



Diabetic foot ulcers are the source of major suffering and very large costs for both the patient and the health-care system, and every 30 s, a leg is lost somewhere in the world. Investing in a diabetic foot care guideline can therefore be one of the most cost-effective forms of health-care expenditure, provided the guideline is goal focused and properly implemented. The objective of the International Working Group on the Diabetic Foot (IWGDF) is to develop guidelines that will reduce the effect of diabetic foot disease through cost-effective and quality health care, based on the principles of evidence-based medicine. These guidelines are produced by working groups of experts in the field and are endorsed by the more than 100 country representatives of the IWGDF. In 2009, the IWGDF invited again three working groups to write consensus guidelines on peripheral arterial disease, infection, and wound healing. New texts were produced according to a systematic review of the literature in order to inform protocols for routine care and to highlight areas that should be considered for further study. During a meeting of the members of the IWGDF in May 2011, the new set of guidelines was approved and is published in this journal. Copyright © 2012 John Wiley & Sons, Ltd.


It is estimated that in 2011, approximately 366 million people have diabetes – 7.0% of the world's population. Around 80% of these people live in developing countries. By 2030, the global estimate is expected to rise to 552 million – 8.3% of the adult population. Worryingly, type 2 diabetes is increasing among young people as well as older people around the world [1].

Every year, more than 1 million people with diabetes lose a leg as a consequence of this disease. This means that every 30 s, a lower limb is lost to diabetes somewhere in the world [2]. Most of these amputations are preceded by a foot ulcer. The most important factors relating to the development of these ulcers are peripheral neuropathy, foot deformities, minor foot trauma, and peripheral arterial disease (PAD) [3]. Once an ulcer has developed, infection and PAD are the major causes for amputation [4, 5].

The spectrum of foot lesions varies from region to region because of the differences in socio-economic conditions, standards of foot care, and quality of footwear. It has been calculated that in developed countries, one in six people with diabetes will have an ulcer during their lifetime. In developing countries, diabetes-related foot problems are thought to be even more common.

Diabetic foot ulcers and their consequences not only represent a major personal tragedy for the person experiencing an ulcer and his/her family [6], but also place a considerable financial burden on the health-care system and society in general [7].

It is now recognized that type 2 diabetes in children is becoming a global public health issue. It is inevitable that these young people will go on to develop diabetes-related microvascular and macrovascular complications, including disabling and life-threatening foot problems, at a relatively early age.

Ulcers of the foot in diabetes are the source of major suffering and cost. At least one quarter will not heal, and up to 28% may result in some form of amputation. Investing in a diabetic foot care guideline is therefore one of the most cost-effective forms of health-care expenditure, provided the guideline is goal focused and properly implemented [8, 9].

International Working Group on the Diabetic Foot

The International Working Group on the Diabetic Foot (IWGDF) was founded in 1996 and subsequently became in 2000 a Consultative Section of the International Diabetes Federation (IDF) and in 2010 an integrated part of the IDF programme as IDF Diabetic Foot Programme. In 1999, the IWGDF published for the first time the International Consensus on the Diabetic Foot and Practical Guidelines on the Management and the Prevention of the Diabetic Foot. To date, this publication has been translated into 26 languages, and more than 80 000 copies were distributed globally. In order to implement the International Consensus, the IWGDF recruited local champions as members of the IWGDF, and nowadays, these members represent more than 100 countries around the world.

In 2005, IWGDF decided that the International Consensus texts should be updated and expanded. Working groups of independent experts in the field were asked to revise and update the chapters of the original text, according to current knowledge and standards; this process was guided by the IWGDF Editorial Board. Finally, after a thorough review by all IWGDF representatives and a plenary meeting in which almost all IWGDF representatives from over the world participated, the new set of guidelines were agreed upon and were endorsed. In 2007, three evidence-based consensus reports were produced: ‘footwear and off-loading’, ‘wound management’, and ‘osteomyelitis’ [10].

In 2009, the IWGDF invited again three working groups to produce three new specific guidelines on wound healing, infection, and PAD based on the following:

  1. A systematic review of interventions to enhance the healing of chronic ulcers of the foot in diabetes
  2. A systematic review of the effectiveness of interventions in the management of infection in the diabetic foot
  3. A systematic review of the effectiveness of revascularisation of the ulcerated foot patients with diabetes and PAD

Methods used to design guidelines

The recommendations in the specific guidelines were linked to the supporting scientific evidence. To identify the available literature, we performed a systematic search of the currently available electronic databases using predefined search strategies. Subsequently, data were abstracted systematically and the literature was graded according to the methodological quality to assess the strength of the evidence. For the applicability of the recommendations for daily clinical practice, the recommendations were judged with regard to generalizability, applicability, and the clinical effect [11]. In this manner, the link was made between the scientific evidence and recommendations for daily clinical practice. Although much insight has been gained from studies of normal subjects, only studies that drew from the target population of diabetic patients have been included. As might be expected, some published work of members of the committee was considered in the review, and strict rules were used to guard against conflicts of interest. Extracted data were summarized in evidence tables. The evidence tables were compiled after collective discussion within each working group, and conclusions were drawn in the review reports, and subsequently, recommendations were formulated as specific guidelines. All documents were written without any influence from the pharmaceutical industry or other interest groups.


After careful consideration by the IWGDF Editorial Board, the 2011 review reports and specific guidelines were sent to the IWGDF representatives from more than 100 countries for comments. On a special Consensus Day before the Sixth International Symposium on the Diabetic Foot in May 2011, all representatives were invited to reach consensus on the three specific guidelines (Figure 1). During that day, some additional comments were incorporated in the texts, and the final texts were eventually endorsed by the IWGDF representatives. These review reports and 2011 guidelines on wound healing, infection and PAD are published in the current issue of DMRR.

Figure 1.

International Working Group on the Diabetic Foot delegates from all over the world participated on the Consensus Day to approve the guidelines on 10 May 2011 in Noordwijkerhout, The Netherlands


The guideline project of the IWGDF is a rather unique project; it is truly multidisciplinary with the participation of the many disciplines involved in the diabetic foot, it is a continuous process for already 15 years, and a worldwide implementation is guaranteed by the more than 100 country representatives. The future will see the further implementation and evaluation of the IWGDF Consensus Guidelines 2011. These guidelines will be further developed to keep in step with the advances in research and practice; moreover, they will be expanded to include more topics once sufficient evidence is present to enable an evidence-based consensus process.

More than ever before, it is imperative that appropriate action be taken to ensure access to quality care for all people with diabetes, regardless of their age, geographic location, or social status [12]. The IWGDF hopes that global awareness of diabetes and foot complications will continue to increase. The need for improved foot care for people with diabetes throughout the world must be recognized. If the IWGDF recommendations are followed, the improved management of the diabetic foot will undoubtedly lead to a worldwide reduction in limb loss.


International Working Group on the Diabetic Foot would like to express its deep gratitude to the many authors and members of the working groups who have collaborated tirelessly, lending their expertise and dedication to the realization of this huge project.

Sincere thanks also go to the sponsors, who, by providing generous and unrestricted educational grants, made it possible for IWGDF to develop the International Consensus and Practical and Specific Guidelines on the management of the diabetic foot 2011.

International Working Group on the Diabetic Foot DVDs with all guideline texts, reviews, and other documents can be purchased through the IDF website at

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Conflict of Interest

None declared.