New Aussie guidelines for diabetes foot disease

Diabetes Feet Australia, a division of the Australian Diabetes Society, has developed new evidence-based guidelines for the prevention and management of diabetes-related foot disease.

The changes — the first update since 2011 — include more specific self-monitoring, footwear prescription, surgical treatments, and activity management practices for those at increased risk of the condition. 

For those already impacted by diabetes-related foot disease, there are new ulcer, infection, and peripheral artery disease classification systems, with more specific recommendations to help resolve issues.  

“We’ve observed over the years that well-directed implemented guidelines are critical to underpinning quality care and there are a number of areas of the guidelines that have been improved and updated compared with the ones from 2011,” co-author Professor Stephen Twigg explained.  

Diabetes-related foot disease (DFD) is a leading cause of hospitalisation, amputation, disability, and health care costs, which has been defined as ‘infection, ulceration, or tissue destruction of the foot in a person with diabetes.’ 

DFD affects around 50 000 people in Australia each year, causing 28,000 hospitalisations, 5000 amputations and $1.6 billion in costs. Further, 300 000 Australians are at risk of risk of developing DFD annually, and Aboriginal and Torres Strait Islander Peoples have up to a 38-fold risk of developing DFD as well as ensuing amputations. 

Despite the large national DFD burden, Australian regions implementing guideline-based care have demonstrated large reductions in their regional DFD burdens and costs. However, as the most recent Australian guideline on DFD was published in 2011, many of its recommendations are now outdated, and the body of research on DFD has since expanded considerably. 

The most obvious change in the new guidelines is that they contain 98 recommendations across six DFD fields, whereas the previous guideline only contained 25 recommendations across four: 

  • Prevention — screening, education, self-care, footwear, and treatments to prevent diabetic foot disease; there are 15 prevention recommendations covering screening, education, self-care, footwear, and treatments for people at risk of DFD. 
  • Classification — classifications systems for ulcers, infection, ischemia, and auditing; there are five classification recommendations covering ulcer, infection, ischemia, and auditing. The Site, Ischemia, Neuropathy, Bacterial Infection, Area, and Depth (SINBAD) wound classification system is strongly recommended as the minimum standard to document and communicate DFU characteristics with other health professionals. 
  • Peripheral artery disease — examinations and imaging for diagnosis, severity classification, and treatments; there are 17 PAD recommendations covering diagnosis, severity classification, medical and surgical treatments for people with DFU and all are new, as no PAD recommendations were made in the previous guideline. 
  • Infection — examinations, cultures, imaging and inflammatory markers for diagnosis, severity classification, and treatments; there are 35 infection recommendations covering diagnosis, severity classification, and medical and surgical treatments for people with DFU. All are new, as no infection recommendations were made in the previous guideline. 
  • Offloading — pressure offloading treatments for different ulcer types and locations; there are 13 recommendations covering offloading for different situations in people with DFU. Offloading is defined as the relief of mechanical stress (pressure) from a specific area of the foot. Nearly all the recommendations are new, as only two offloading recommendations were made in the previous guideline.  
  • Wound healing — debridement, wound dressing selection; there are 13 wound healing recommendations covering debridement, wound dressing selection, and other wound treatments in people with DFU, and half of these recommendations are new compared with the previous guideline. 

The new guidelines have used the internationally recommended GRADE methodology, rather than the historical NHMRC approach, and have been endorsed by 10 national peak bodies, including the Australian Diabetes Society, the Australian and New Zealand Society for Vascular Surgery, the Australasian Society for Infectious Diseases, the Australian Podiatry Association, and Wounds Australia. 

Co-author, Associate Professor Pete Lazzarini, pointed out that Diabetes Feet Australia has also created an interactive platform for the guidelines, which health care practitioners can use with their patients. 

“GPs or podiatrists or nurses with a patient with diabetes-related foot disease in front of them can click on these pathways to identify the recommendations that apply for that particular patient in terms of assessment, education and management,” he said. 

The six full guidelines are available at