A study of 713 adults attending a specialist diabetes centre in Buraydah, Saudi Arabia, found a strong association between International Working Group on the Diabetic Foot (IWGDF) risk categories and the presence of active diabetic foot ulcers. The researchers say the findings support routine risk stratification in specialist care, while noting that further prospective research is needed to assess how well the system predicts future ulcers.
The retrospective, cross-sectional study examined clinical records of adults with diabetes attending the centre’s diabetic foot service. Active ulcers were recorded in 21 of the 713 patients, or 2.9% of the group. Prevalence increased across the IWGDF categories: no active ulcers were identified in the very-low-risk group, compared with 0.8% in the low-risk group, 4.8% in the moderate-risk group and 38.5% in the high-risk group.
What the risk categories assess
The IWGDF system classifies a person’s risk by assessing factors including loss of protective sensation, peripheral artery disease, foot deformity and a history of ulceration or lower-limb amputation. Its prevention guideline recommends screening and follow-up at intervals based on the person’s risk category.
In the Saudi study, the system had a c-statistic of 0.938 for distinguishing patients who had an active ulcer from those who did not. At the moderate-or-high-risk threshold, sensitivity was 90.5% and the negative predictive value was 99.7% within this cohort. These measures describe how the classification performed in identifying ulcers that were already present among the patients studied.
That distinction matters: the study was cross-sectional, so it did not establish whether the categories accurately predict which patients will develop an ulcer in the future. The authors call for prospective studies to test that question. The findings also come from a specialist centre and should not automatically be assumed to represent all people with diabetes in Saudi Arabia or other countries.
Age, HbA1c and risk
The researchers found that older age and higher glycated haemoglobin (HbA1c) were associated with moderate or high IWGDF risk. Gender was not independently associated with that risk category. The study did not find a statistically significant difference in active-ulcer prevalence between men and women; the number of ulcer cases was small. These results describe associations and do not establish that age or HbA1c alone caused the ulcers.
Relevance for O&P and multidisciplinary foot care
For orthotists and other O&P professionals, the findings reinforce the importance of structured foot assessment and referral pathways. Deformity, footwear and areas exposed to repeated pressure can be relevant to device design and modification, while suspected ulcers or vascular concerns require appropriate clinical assessment and management.
Risk scoring does not replace examination, diagnosis or individual treatment planning. The IWGDF guidance connects risk classification with follow-up, education and preventive care. A patient’s needs may involve several disciplines, including diabetes care, podiatry, vascular services, wound care and orthotics. Saudi clinical guidance also recommends regular foot assessment for people with diabetes and more frequent review for those with relevant risk factors.
The study provides local evidence from a Saudi specialist service for using the established IWGDF categories to identify patients who currently have a higher likelihood of active ulceration. Its results support systematic screening, but prospective and multicentre research will be needed to determine how well the approach forecasts future ulcers across broader populations.
- Bioengineer.org: Simple Foot Risk Score Shows Striking Accuracy in Spotting Diabetic Ulcers
- PubMed: Clinical Performance of the IWGDF Risk Stratification System
- Springer: Full study in Diabetes Therapy
- IWGDF: 2023 Prevention Guideline
- Saudi Ministry of Health: Saudi Diabetes Clinical Practice Guidelines
- Saudi Ministry of Health: Diabetic foot care and prevention