Personalized risk stratification in diabetic foot disease

Background

For healthcare professionals working with people with diabetes, this is a familiar challenge: it is not always easy to predict who will actually develop a foot ulcer or ultimately face an amputation. In current practice, that risk is usually assessed on the basis of well-known medical factors, such as neuropathy, peripheral arterial disease, foot deformities, and a history of ulceration. These factors are important, but they do not always provide the full picture. In the consultation room and during follow-up visits, it becomes clear that patients with seemingly similar risk factors can still have very different outcomes.

This raises the question of what else may be at play. Factors such as biomechanics, mobility, behaviour, and daily loading can have a major influence on the development of foot problems, yet they still receive limited attention in existing risk stratification systems. The same applies to personal differences, for example those related to gender or cultural background. As a result, part of the risk remains out of view, while this is exactly where opportunities may lie for earlier recognition, more targeted guidance, and prevention that is better tailored to the individual patient.

With that in mind, the DIALECT project takes a broader and more person-centred approach. Using an extensive set of disease-specific, biomedical, and behavioural data from three existing, unique, and large-scale datasets, the project investigates which modifiable, biomechanical, behavioural, and other personal factors contribute to the risk of foot ulcers and amputations, particularly in people who are already at increased risk. The aim is to refine existing risk stratification and at the same time identify starting points for more personalised prevention and treatment.

Approach

The project uses register-based data and information from research on the lower extremities, physical functioning, biomechanics, and mobility in people with type 1 and type 2 diabetes. It consists of three longitudinal, population-based studies, in which clinical, laboratory, and behavioural data on diabetic foot complications are brought together from local data sources, including the database of Steno Diabetes Center Copenhagen, as well as from Danish national registers.

Using a variety of statistical methods, the project examines which factors are associated with the development of foot ulcers, ulcer recurrence, and amputations. Based on these analyses, a personalised prediction model will be developed and validated for the risk of ulcers and amputations. In addition, the possibility of external validation will be explored using the Sci-Diabetes database via the Glasgow Safe Haven patient record system.

The strength of this approach lies in the combination of medical data with information on functioning and behaviour. This makes it possible to create a richer and more human picture of who is vulnerable, and why. For healthcare professionals, this may help not only to assess risks more accurately, but also to translate them more effectively into appropriate screening, follow-up, guidance, and treatment. In that way, this research speaks directly to clinical practice: recognising signals in time, having the right conversation, and preventing serious complications wherever possible.

research team

The doctoral candidate is part of the Complications Research Group within the Department of Clinical and Translational Research at Steno Diabetes Center Copenhagen. Within this research group, she works together with a multidisciplinary team of clinicians, epidemiologists, and statisticians. There is also close collaboration with another doctoral candidate within DIALECT, whose work focuses on patient involvement and shared decision-making.

This combination of expertise is of great value. Good prevention of diabetic foot problems requires not only medical knowledge, but also insight into behaviour, functioning, and the daily reality of patients. By bringing these different perspectives together, the project aims to connect more closely with the questions that arise in clinical practice and with the need for care that is not only well founded, but also truly fits the person in front of you.

Steno Diabetes Center Copenhagen

Steno Diabetes Center Copenhagen (SDCC) is part of the public healthcare system of the Capital Region of Copenhagen and is the largest diabetes centre in Scandinavia. Each year, more than 11,000 people with diabetes from the region are treated there. The centre brings together patient care, research, health promotion, and education, with a strong focus on translational research, care, and prevention.

SDCC has more than 400 employees, including physicians, nurses, dietitians, patient coordinators, podiatrists, and laboratory technicians. More than half of them are involved in research, either full-time or part-time. In 2021, SDCC was recognised by the World Economic Forum’s Global Coalition for Value in Healthcare as one of the best hospitals in the world in the field of value-based healthcare for people with diabetes and other chronic conditions.