Prevalence and factors associated with diabetic foot complications among type 2 diabetes patients in Pakistan: a cross-sectional analysis of clinical risk factors and preventive opportunities

Diabetic foot ulceration represents a devastating complication of type 2 diabetes mellitus, contributing substantially to morbidity, lower-extremity amputation, and healthcare expenditure, particularly in resource-constrained settings. This study aimed to quantify the prevalence of factors associated with increased odds with diabetic foot ulcer and active ulceration among type 2 diabetes patients and to identify clinical factors independently associated with these outcomes. A cross-sectional investigation was conducted among 462 adults with established type 2 diabetes attending specialized diabetic foot clinics at the Aga Khan Health Service Centre and the Tabba Heart Institute, Karachi, Pakistan from 1st January to 30th June 2025. Following informed consent, demographic characteristics, diabetes history, anthropometric measurements, and clinical foot examinations were documented. Neuropathy was assessed via 10-g monofilament testing, and peripheral arterial disease was evaluated through ankle-brachial index measurement. Fasting blood samples were obtained for HOMA-IR calculation. Participants were categorized into no-risk, at-risk (neuropathy, angiopathy, or foot deformity), and active ulcer groups. Binary logistic regression identified independent associated factors, with significance set at p < 0.05. Among 462 participants, 28.9% exhibited established factors associated with increased odds with ulceration, 16.6% presented with active diabetic foot ulcers, and 32.5% demonstrated either factors associated with increased odds or existing ulceration. Univariate analysis revealed significant positive associations between risk/ulcer status and advancing age, elevated BMI, diastolic blood pressure, smoking, prior ulceration or amputation, insulin resistance (HOMA-IR), dry skin, hyperkeratotic lesions, fissures, and nail deformities. Multivariable analysis demonstrated that HOMA-IR, callus/corn/fissure formation, nail deformity, onychomycosis, daily foot inspection behavior, and previous amputation history were independently associated with diabetic foot risk or ulceration. The substantial burden of factors associated with increased odds with diabetic foot and active ulceration in this Pakistani cohort underscores the imperative for systematic foot surveillance, patient education, and early intervention strategies targeting modifiable metabolic and dermatological precursors to mitigate preventable limb-threatening complications. Not applicable.