Professora Matilde Soares na capa do jornal Diabetology


Professora Matilde Soares na capa do jornal Diabetology

A Professora Matilde Soares, docente da Área de Ensino em Podologia, foi primeira autora de um artigo publicado e selecionado para ser o cover issue no jornal Diabetology. O artigo “The Utility of Annual Reassessment of the International Working Group on the Diabetic Foot Diabetes-Related Foot Ulcer Risk Classification in the Primary Care Setting—A Cohort Study” aborda a utilidade de reavaliar o risco de complicações nos pés em pessoas com diabetes num contexto de cuidados primários.

A equipa de investigação verificou que, após dois anos de seguimento, menos de 4% dos casos estudados progridem para um grau de risco mais elevado, de acordo com a classificação do International Working Group on the Diabetic Foot. Contudo verifica-se uma regressão em 2,6% dos participantes, o que pode indicar preocupações quanto à reprodutibilidade das variáveis incluídas. O estudo indica, assim, que seria possível, de forma segura, espaçar a reavaliação do risco dos pés a cada dois anos (e não as consultas de vigilância), em vez de anualmente neste cenário.


We assessed the pertinence of updating the International Working Group on the Diabetic Foot (IWGDF) risk classification yearly in people with diabetes by quantifying the changes in the risk group and its accuracy in identifying those developing an ulcer (DFU) in a primary care setting. Methods: In our retrospective cohort study, we included all people with diabetes with a foot assessment registry between January 2016 and December 2018 in the Baixo Alentejo Local Health Unit. Foot-related data were collected at baseline after one and two years. DFU and/or death until December 2019 were registered. The proportion of people changing their risk status each year was calculated. Accuracy measures of the IWGDF classification to predict DFU occurrence at one, two, and three years were calculated. Results: A total of 2097 people were followed for three years, during which 0.1% died and 12.4% developed a DFU. After two years, 3.6% of the participants had progressed to a higher-risk group. The IWGDF classification presented specificity values superior to 90% and negative predictive values superior to 99%. Conclusion: Foot risk status can be safely updated every two years instead of yearly, mainly for those at very low risk. The IWGDF classification can accurately identify those not at risk of DFU.

1. Introduction

According to the International Diabetes Federation (IDF), more than 500 million people are living with diabetes. This number is expected to rise to almost 800 million by 2045, with a marked increase in Africa (134%) and the MENA (Middle East and North Africa) region (87%) [1].

In 2021, the global diabetes prevalence in people between 20 and 79 years old was 10.5% and ranged from 9.2% in Europe up to 16.2% in the MENA region [1]. In Portugal, it was 13%, affecting almost one million people, with around half still undiagnosed.

Diabetes can lead to micro- and macrovascular complications, such as cerebrovascular disease, cardiovascular disease, nephropathy, retinopathy, peripheral artery disease (PAD), and neuropathy (DN). PAD and DN (motor, sensory, and/or autonomic), along with repetitive external or minor trauma, are the major causes of the development and worsening of foot ulcers [2].

The diabetes-related foot ulcer (DFU) incidence worldwide is estimated to be between 9.1 and 26.1 million per year, with 19 to 34% of people with diabetes developing at least one DFU during their lifetime, and although most of them will heal within one year, lower limb amputation (LLA) still occurs in 20% of cases [2].

LLA remains one of the most threatening types of diabetes-related complications for people living with the condition, mainly for those who have previously experienced foot complications [3]. Foot disease is also the leading cause of global disability burden in people with diabetes and the major reason for hospitalization [4].

Although it has been considered that DFU and LLA are the most devastating lower extremity complications due to diabetes, it was found that three-quarters of the burden arises from people with neuropathy but without these complications [5].

These data stress the importance of characterizing not only the risk of people with diabetes to develop DFU or LLA but also the global lower limb health status (namely the presence of foot deformity, PAD, DN, or other conditions that may affect the person’s quality of life and ability to identify and manage complications).

Several international guidelines recommend annual foot screening in people with diabetes considered to be at (very) low risk of complications and more regularly for those considered to be at risk, with a yearly update on the risk group assessment. However, it is unlikely that, once established, the risk factors may retrocede and that a significant proportion of people will have a progression in the risk factors in that timeframe [6].

Using the estimate of 500 million people currently living with diabetes [1] and at least two minutes spent per person to collect the information necessary to classify their risk of developing a DFU (which is highly dependent on clinical experience), there is the need for more than 17 million hours for health professionals to spend on this task yearly worldwide instead on investing in more direct preventive actions. This amount of time will only increase in the coming years, with the expected rise in diabetes prevalence.

Additionally, it has been discussed that foot screening may not directly impact reducing foot complications [7]. The stratification of people by similar levels of risk should help health professionals in their clinical management and the application of effective preventive measures according to the person’s characteristics, focusing on education, adequate footwear, the treatment of pre-ulcerative lesions, etc. However, it has been discussed that the registry of foot screening may be only a pro forma and not an act embedded in the clinical management flow, mainly in countries in which it is linked with financial consequences [7].

The International Working Group on the Diabetic Foot (IWGDF) classification is one of the most used stratification systems worldwide, with the last version being proposed in 2015 [8]. Nevertheless, their authors consider that more data on who, how, and when to screen and update the risk status is urgently needed [9].

This study aimed to assess the change in the risk factors and risk group for DFU based on the IWGDF classification (2015 version) at one and two years in a cohort of people with diabetes followed in a primary care setting. As a secondary aim, we assessed the accuracy of the IWGDF classification to identify people who developed a DFU after one, two, and three years.

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