Associations of Glycemic Control, Age, and Sex with Diabetic Foot Risk and Active Foot Ulceration among Patients with Diabetes in Saudi Arabia: A Cross-Sectional Study.

Abstract

Introduction: Diabetic foot disease is one of the most severe complications of diabetes mellitus, contributing substantially to hospitalization, lower limb amputation, and premature mortality. This study evaluated the associations of glycemic control (glycated hemoglobin [HbA1c]), age, and sex with diabetic foot risk and ulceration among patients attending a tertiary diabetes center in Qassim, Saudi Arabia.

Methods: This retrospective cross-sectional study included a census sample of 710 eligible electronic medical records of patients with a confirmed diagnosis of diabetes mellitus and a documented diabetic foot assessment between January 2022 and December 2024. No a priori sample size calculation was performed. The primary outcome was at-risk diabetic foot status (International Working Group on the Diabetic Foot category ≥ 1), and the secondary outcome was active foot ulceration. Multivariable logistic regression was used to identify factors independently associated with each outcome.

Results: The mean age was 57.6 ± 14.0 years; 337 patients (47.5%) were male and 373 (52.5%) were female, and 93.2% had type 2 diabetes mellitus. At-risk diabetic foot status was present in 53.2% of patients, and active foot ulceration was present in 3.0%. Ulcer prevalence increased across HbA1c categories (1.9%, 2.6%, and 6.3%), and at-risk status increased with age (39.6-62.1%). Older age (odds ratio [OR] = 1.028; 95% confidence interval [CI] 1.016-1.039; P < 0.001) and male sex (OR = 1.403; 95% CI 1.036-1.901; P = 0.029) were independently associated with the at-risk status. HbA1c was not independently associated with at-risk status (P = 0.422) or ulceration (P = 0.077).

Conclusions: Ulcer prevalence increased with poorer glycemic control; however, the adjusted HbA1c-ulceration association was not significant in the primary model. Key confounders were unavailable in the dataset, including diabetes duration, neuropathy and peripheral arterial disease severity, and renal function. Therefore, residual confounding cannot be excluded, and HbA1c's role in diabetic foot risk should not be discounted. These findings suggest that diabetic foot screening and preventive care should be tailored to specific age and sex groups, involving multiple healthcare disciplines.