The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the use of offloading interventions to promote the healing of foot ulcers in people with diabetes and updates the previous IWGDF guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. For healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, we recommend that a nonremovable knee‐high offloading device is the first choice of offloading treatment. A removable knee‐high and removable ankle‐high offloading device are to be considered as the second‐ and third‐choice offloading treatment, respectively, if contraindications or patient intolerance to nonremovable offloading exist. Appropriately, fitting footwear combined with felted foam can be considered as the fourth‐choice offloading treatment. If non‐surgical offloading fails, we recommend to consider surgical offloading interventions for healing metatarsal head and digital ulcers. We have added new recommendations for the use of offloading treatment for healing ulcers that are complicated with infection or ischaemia and for healing plantar heel ulcers. Offloading is arguably the most important of multiple interventions needed to heal a neuropathic plantar foot ulcer in a person with diabetes. Following these recommendations will help health care professionals and teams provide better care for diabetic patients who have a foot ulcer and are at risk for infection, hospitalization, and amputation.

Multiple disciplines are involved in the management of diabetic foot disease, and a common vocabulary is essential for clear communication. Based on the systematic reviews of the literature that form the basis of the International Working Group on the Diabetic Foot (IWGDF) Guidelines, the IWGDF has developed a set of definitions and criteria for diabetic foot disease. This document describes these definitions and criteria. We suggest these definitions be used consistently in both clinical practice and research to facilitate clear communication between professionals.

Objective No study has reported global disability burden estimates for individual diabetesrelated lower extremity complications (DRLECs). The Global Burden of Diseases (GBD) study presents a robust opportunity to address this gap.Research Design and Methods GBD 2016 data including prevalence and years lived with disability (YLDs) for the DRLECs of diabetic neuropathy, foot ulcer, and amputation with, and without prosthesis were used. GBD estimated prevalence using data from systematic reviews and DisMod-MR 2.1, a Bayesian meta-regression tool. YLDs were estimated as the product of prevalence estimates and disability weights for each DRLEC. We reported global, sex-, age-, region-and country-specific estimates for each DRLEC for 1990 and 2016. ResultsIn 2016, an estimated 131 million (1.8% of the global population) had DRLECs. An estimated 16.8 million YLDs (2.1% global YLDs) were caused by DRLECs, including 12.9 million (95% uncertainty interval: 8.30 to 18.8) from neuropathy only, 2.5 million (1.7 to 3.6) foot ulcers, 1.1 million (0.7 to 1.4) amputation without prosthesis, and 0.4 million (0.3 to 0.5) amputation with prosthesis. Age-standardised YLDs rates of all DRLECs increased by between 14.6% to 31.0% from 1990 estimates. Male-to-female YLD ratios ranged from 0.96 for neuropathy only to 1.93 for foot ulcers. Aged groups 50-69 years accounted for 47.8% of all YLDs from DRLECs.Conclusions These first ever global estimates suggest DRLECs are a large and growing contributor to the disability burden worldwide, and disproportionately affect males and middle-to-older aged populations. These findings should facilitate policymakers worldwide to target strategies at populations disproportionately affected by DRLECs.