Global Epidemiology of Diabetic Foot: A Systematic Review and Meta-Analysis

Diabetic foot (DF) disease, including ulcerations, amputations, and infections, represents a major cause of morbidity and mortality in individuals with diabetes mellitus (DM). Despite their substantial clinical, social, and economic burden, robust global epidemiological estimates remain limited due to fragmented evidence and heterogeneous methodologies. This systematic review and meta-analysis aimed to provide reliable pooled estimates of incidence and prevalence of DF disease, to explore geographic and demographic variations, and to assess the types of data sources available for epidemiological research.

Following PRISMA guidelines (PROSPERO registration CRD42025640944), PubMed, Embase, CINAHL Plus, and Cochrane Library were systematically searched from inception to December 21, 2024, for observational studies in adults (≥ 18 years) with DM reporting epidemiological measures of DF disease. Data extraction and quality appraisal (Joanna Briggs Institute checklists) were independently performed by four reviewers. Random-effects meta-analyses were conducted using generalised linear mixed-effects models to calculate pooled complication-specific prevalence and incidence rates among patients with diabetes. Heterogeneity among study estimates was assessed using Cochran's Q test, I² statistic, and the between-study variance (τ²). To identify sources of heterogeneity, meta-regression analyses were performed considering study-level covariates (modifiers).

Eighty-nine studies were included (18 prospective cohorts, 33 retrospective cohorts, 38 cross-sectional), enrolling between 92 and 29,650,811 participants, with data from Europe (N = 29, 32.6%), Asia (N = 25, 28.1%), Africa (N = 16, 18.0%), America (N = 16, 18.0%), and Oceania (N = 3, 3.4%). Pooled global incidence rates were 10.93 cases/1000 person-years (95% CI, 6.67-17.91) for ulcerations, 3.58 (95% CI, 1.93-6.63) for amputations, and 19.11 (95% CI, 4.81-75.97) for infections. Pooled prevalence estimates were 54.57 cases/1000 persons (95% CI, 37.63-78.52) for active ulcerations, 72.63 (95% CI, 48.21-108.02) for past ulcerations, 14.75 (95% CI, 9.52-22.77) for amputations, and 39.17 (95% CI, 6.81-195.07) for infections. Substantial heterogeneity (I² > 90%) was observed, with significant modifiers including geographical region, diabetic foot identification method, data source, study setting, age, diabetes duration, and length of follow-up. Rates in America and Africa were generally above the global pooled average, whereas those in Europe, Asia, and Oceania were below.

Globally, DF disease is common and severe, with incidence and prevalence rates underscoring its important public health impact. Heterogeneity across studies highlighted the influence of geography, methodology, and data sources. These findings may support future clinical and pharmacoepidemiological studies that evaluate new interventions and monitor temporal trends using large-scale data.