Open Access Original

Article DOI: 10.7759/cureus.9199

Correlation of Hemoglobin A1c With Wagner

Classification in Patients With Diabetic Foot
Umar Farooque 1 , Ashok Kumar Lohano 2 , Sadam Hussain Rind 3 , Muhammad Saleem Rind Sr. 4 , Sundas
Karimi 5 , Ali Jaan 6 , Farah Yasmin 7 , Omer Cheema 8

1. Neurology, Dow University of Health Sciences, Karachi, PAK 2. Medicine, Peoples University of Medical and Health
Sciences for Women, Nawabshah, PAK 3. Internal Medicine, Peoples University of Medical and Health Sciences for
Women, Nawabshah, PAK 4. Medicine, College of Physicians and Surgeons Pakistan, Karachi, PAK 5. General Surgery,
Combined Military Hospital, Karachi, PAK 6. Internal Medicine, King Edward Medical University, Mayo Hospital,
Lahore, PAK 7. Cardiology, Dow University of Health Sciences, Karachi, PAK 8. Internal Medicine, Dow University of
Health Sciences, Karachi, PAK

Corresponding author: Umar Farooque, [email protected]

Abstract
Introduction
Diabetic foot is a common complication of diabetes mellitus (DM). The Wagner classification is mostly used
to grade its severity. The correlation between the hemoglobin A1c (HbA1c) and the Wagner classification is
still controversial. Therefore, the purpose of this study is to determine the correlation of HbA1c with Wagner
classification in patients with diabetic foot.

Materials and methods

This cross-sectional study was conducted at a major hospital in Shaheed Benazirabad in which 88 patients
aged 18-65 years, of either gender, with a known history of DM type I or type II, and diagnosed with diabetic
foot were enrolled for six months. Blood samples were collected to check the HbA1c levels. Wagner
classification grading was performed after the examination of diabetic foot ulcers. Demographics such as
age, gender, duration of DM, and other risk factors of foot ulcers were also noted. The mean and standard
deviation for continuous variables, such as age and HbA1c level, and the frequency and percentage for
categorical variables, such as distribution of age, distribution of HbA1c, gender, duration of DM, grades of
Wagner classification, and other risk factors of foot ulcers, were calculated. The correlation of HbA1c with
Wagner classification was also calculated by applying the chi-square test and taking p ≤ 0.05 as significant.

Results
The mean age of the study population was 47.4 ± 10.6 years. Of the 88 patients, 15 (17.04%) were 25-35 years
of age, 34 (38.63%) were 36-50 years of age, and 39 (44.31%) were 51-65 years of age; 45 (51.13%) patients
were males and 43 (48.86%) patients were females. The mean HbA1c level of the study population was 9.07 ±
Received 06/23/2020
1.65%; 5 (5.68%) patients had 6.5-7.5%, 34 (38.63%) patients had 7.6-8.5%, 24 (27.27%) patients had 8.6-
Review began 06/29/2020 9.5%, and 25 (28.41%) patients had an HbA1c level of >9.5%. Twelve (13.63%) patients had ≤ 7 years, 18
Review ended 07/14/2020 (20.45%) had 8-15 years, and 58 (65.9%) had >15 years of duration of DM. Zero (0%) patients had grade 0, 1
Published 07/15/2020 (1.13%) patient had grade 1, 6 (6.81%) patients had grade 2, 29 (32.95%) patients had grade 3, 32 (36.36%)
© Copyright 2020 patients had grade 4, and 20 (22.72%) patients had grade 5 of Wagner classification. 23 (26.13%) patients
Farooque et al. This is an open access had foot abnormalities, 19 (21.59%) patients had nephropathy, 13 (14.77%) patients had neuropathy, 14
article distributed under the terms of the (15.91%) patients had hypertension, 9 (10.22%) patients had retinopathy, 3 (3.41%) patients had foot
Creative Commons Attribution License
ulcers/toe amputation, 2 (2.27%) patients had a cognitive deficit, and 5 (5.68%) patients had cardiovascular
CC-BY 4.0., which permits unrestricted
use, distribution, and reproduction in any diseases. The correlation of HbA1c with Wagner classification was found statistically significant with p <
medium, provided the original author and 0.00001.
source are credited.

Conclusions
The older age, male gender, longer duration of DM, increased HbA1c, and previously existing foot
abnormalities in diabetic patients are the risk factors of diabetic foot. The monitoring of HbA1c can help
predict the diabetic foot in the aforesaid high-risk diabetics because the HbA1c linearly rises with the higher
grades of Wagner classification of diabetic foot. Subsequently, the strict control of HbA1c as well as patient
education about proper foot care can help prevent diabetic foot and its complications. However, more
studies on larger scales are needed to establish the factual relationship between HbA1c and Wagner
classification.

Categories: Endocrinology/Diabetes/Metabolism, Internal Medicine

Keywords: hba1c, diabetic foot, wagner classification, positive correlation, human, diabetes mellitus, complications

Introduction

How to cite this article

Farooque U, Lohano A, Hussain Rind S, et al. (July 15, 2020) Correlation of Hemoglobin A1c With Wagner Classification in Patients With Diabetic
Foot. Cureus 12(7): e9199. DOI 10.7759/cureus.9199
 The diabetic foot has a prevalence of 4% to 10%, with an annual incidence of 1% to 4.1% in patients with
diabetes mellitus (DM). All ethnic groups have a 25% lifetime prevalence of diabetic foot [1].

The most frequently used classification system for the diabetic foot that evaluates ulcer depth and bone
involvement is the Wagner classification, which aids in the execution of a proper treatment plan and
estimation of the possible outcomes. The other, not usually applied, classification systems assess ischemia,
neuropathy, and the degree of infection [2,3].

The frequency of diabetic foot ulcers in different regions of the foot and the grades of Wagner classification
has already been defined. Aamir et al. stated that diabetic foot ulcers were at the forefoot in 59%, midfoot in
25%, and hindfoot in 16% of patients [4]. Hasan et al. determined the frequency of grades of Wagner
classification and showed that 5.5% of patients had grade 1, 30% had grade 2, 20% had grade 3, 33.3% had
grade 4, and 11.1% had grade 5 ulcers [5]. Ashraf et al. stated that 74% of patients had grade 2 and grade 3
ulcers, whereas 24% of patients had grade 5 ulcers. They also found that 75% of patients were cured with
limb salvage, whereas 25% could not recover without limb amputation. They also established that 22.6% to
47% of these ulcers were neuropathic, 59% were neuro-ischemic, and 18.3% were ischemic in nature [6].

The current literature is debatable about the correlation between hemoglobin A1c (HbA1c) levels and the
Wagner classification. Therefore, our study is aimed at determining the correlation of HbA1c with different
grades of Wagner classification in patients with diabetic foot.

Materials And Methods

Study design and sampling
This cross-sectional study was conducted at Peoples Medical College Hospital, Shaheed Benazirabad, from
October 10, 2019, to April 10, 2020 (for six months). Non-probability consecutive sampling technique was
used. Through Raosoft sample size calculator, the sample size came out to be 88 patients by taking a
confidence interval of 95% and a prevalence of 25%, and keeping the margin of error at 9%. Inclusion criteria
are age 18-65 years, either gender, a previously diagnosed DM type I or type II, and a diagnosed diabetic foot
ulcers. Young patients who had insulin-dependent diabetes were classified as having type I DM, and middle-
to old-aged patients who were on oral hypoglycemic drugs were classified as having type II DM. Exclusion
criteria excluded patients having liver malignancy, end-stage renal disease, co-existing viral infection (such
as hepatitis B), pregnancy, traumatic ulcers, vascular disorders, Buerger’s disease, and peripheral vascular
disease, or using interferon therapy.

Data collection
Patients presenting to the outpatient department or admitted to the hospital and meeting the
inclusion/exclusion criteria were enrolled in this study. The pros and cons of the study were explained, and
informed consent was obtained. A blood sample was collected and sent to the institutional laboratory for the
HbA1c level analysis. Grading of the diabetic foot was performed after examination of the wound using
Wagner classification, as shown in Table 1 [7].

Grade Lesion

0 No open lesions; may have deformity or cellulitis

1 Superficial diabetic ulcer (partial or full thickness)

2 Ulcer extension to the ligament, tendon, joint capsule, or deep fascia without abscess or osteomyelitis

3 Deep ulcer with abscess, osteomyelitis, or joint sepsis

4 Gangrene localized to the portion of the forefoot or heel

5 Extensive gangrenous involvement of the entire foot

TABLE 1: Wagner ulcer classification system

Patient demographics such as age, gender, duration of DM, and other risk factors of foot ulcers (foot
abnormalities, nephropathy, neuropathy, hypertension, retinopathy, foot ulcers/toe amputation, cognitive
deficit, and cardiovascular diseases) were asked by the researcher and entered in the questionnaire.

Data analysis
Data were entered and analyzed using SPSS Version 20 (IBM Corp., Armonk, NY, USA). Mean and the

2020 Farooque et al. Cureus 12(7): e9199. DOI 10.7759/cureus.9199 2 of 8

 standard deviation were calculated for age and HbA1c level. Frequency and percentage for range of age,
range of HbA1c, gender, duration of DM, grades of Wagner classification, and other risk factors of foot
ulcers (foot abnormalities, nephropathy, neuropathy, hypertension, retinopathy, foot ulcers/toe
amputation, cognitive deficit, and cardiovascular diseases) were also calculated. Correlation of HbA1c with
Wagner classification was also calculated, the chi-square test was applied, and p ≤ 0.05 was considered as
significant.

Results
The mean age of the patients was 47.4 ± 10.6 years, as shown in Table 2.

Minimum Maximum Mean Standard deviation

Age (years) 18 65 47.4 10.6

TABLE 2: Analysis of age

Of the total 88 patients, 15 (17.04%) patients aged 25-35 years, 34 (38.63%) patients aged 36-50 years, and
39 (44.31%) patients aged 51-65 years, as shown in Figure 1.

FIGURE 1: Age distribution

There were 45 (51.13%) male and 43 (48.86%) female patients, as shown in Figure 2.

2020 Farooque et al. Cureus 12(7): e9199. DOI 10.7759/cureus.9199 3 of 8

 FIGURE 2: Gender distribution

The mean HbA1c level of the patients was 9.07 ± 1.65%, as shown in Table 3.

Minimum Maximum Mean Standard deviation

HbA1c level (%) 6.5 11.5 9.07 1.65

TABLE 3: Analysis of HbA1c level

HbA1c, hemoglobin A1c

There were 5 (5.68%) patients with 6.5-7.5%, 34 (38.63%) patients with 7.6-8.5%, 24 (27.27%) patients with
8.6-9.5%, and 25 (28.41%) patients with >9.5% of HbA1c level, as shown in Figure 3.

FIGURE 3: HbA1c distribution

HbA1c, hemoglobin A1c

The duration of DM was ≤7 years in 12 (13.63%) patients, 8-15 years in 18 (20.45%) patients, and >15 years

2020 Farooque et al. Cureus 12(7): e9199. DOI 10.7759/cureus.9199 4 of 8

 in 58 (65.9%) patients, as shown in Figure 4.

FIGURE 4: Distribution of duration of diabetes mellitus

There were 0 (0%) patients with grade 0, 1 (1.13%) patient with grade 1, 6 (6.81%) patients with grade 2, 29
(32.95%) patients with grade 3, 32 (36.36%) patients with grade 4, and 20 (22.72%) patients with grade 5 of
Wagner classification, as shown in Figure 5.

FIGURE 5: Distribution of grades of Wagner classification

There were 23 (26.13%) patients with foot abnormalities, 19 (21.59%) patients with nephropathy, 13
(14.77%) patients with neuropathy, 14 (15.91%) patients with hypertension, 9 (10.22%) patients with
retinopathy, 3 (3.41%) patients with foot ulcers/toe amputation, 2 (2.27%) patients with a cognitive deficit,
and 5 (5.68%) patients with cardiovascular diseases. These frequencies of other risk factors of foot ulcers are
shown in Figure 6.

2020 Farooque et al. Cureus 12(7): e9199. DOI 10.7759/cureus.9199 5 of 8

 FIGURE 6: Frequency of other risk factors of foot ulcer

Correlation of HbA1c with Wagner classification showed a statistically significant linear relationship with p
< 0.00001. Mostly, patients with grade 4 and 5 were found to have HbA1c > 8.5%. However, patients with
grades 1-3 also had HbA1c > 6.5%. These findings are shown in Table 4.

Parameter Wagner classification p-Value

HbA1c Grade 1 Grade 2 Grade 3 Grade 4 Grade 5

6.5-7.5% 1 0 4 0 0

7.6-8.5% 0 6 21 7 0
<0.00001
8.6-9.5% 0 0 4 18 2

>9.5% 0 0 0 7 18

TABLE 4: Correlation of HbA1c with Wagner classification

HbA1c, hemoglobin A1c

Discussion
This study indicates that there is a linear relationship between the HbA1c level and the grades of Wagner
classification. Patients classified in grades 0-2 of Wagner classification had slightly elevated HbA1c levels,
whereas patients with grades 3-5 had the highest HbA1c levels mainly due to non-compliance of the
patients.

Diabetic foot syndrome includes several diabetic foot pathologies such as infection, neuropathic
osteoarthropathy, and diabetic foot ulcers. Diabetic foot, which is about 15% of these and is projected to
grow up to 25%, is the most hazardous condition, which may lead to limb amputation [8].

Diabetic foot is caused by minor injuries that are not perceived for a long time by diabetic patients due to
peripheral nerve dysfunction. Furthermore, peripheral nerve dysfunction often gets associated with
peripheral arterial disease leading to the deficient blood supply to the limbs, a condition known as diabetic
angiopathy, which may also cause diabetic foot. Therefore, the diabetic foot can be neuropathic, neuro-
ischemic, or ischemic alone [6,9,10].

Zubair et al. and Ozenc et al. established a contradictory correlation between HbA1c level and Wagner
classification. Zubair et al. found a statistically significant, whereas Ozenc et al. found a statistically
insignificant correlation [11,12]. Sarinnapakorn et al. also showed that HbA1c level and fasting plasma
glucose are not markedly related to diabetic foot, but about 50% of type II DM patients had an intermediate
or high risk of diabetic foot. They categorized foot ulcer risk into low, intermediate, and high, each having a

2020 Farooque et al. Cureus 12(7): e9199. DOI 10.7759/cureus.9199 6 of 8

 probability of 55.8%, 33.6%, and 10.6%, respectively. They found that the major risk factors of foot ulceration
were age, duration of DM, estimated glomerular filtration rate (eGFR), dyslipidemia, hypertension,
numbness, nephropathy, cardiovascular disease, abnormality of foot, anomalous sensation, pulse drop,
ulcer, amputation, abnormal ankle-brachial index, and cerebrovascular accidents [13]. Likewise, 26.13% of
our patients had foot abnormalities, 21.59% had nephropathy, 14.77% had neuropathy, 15.91% had
hypertension, 10.22% had retinopathy, 3.41% had foot ulcers and toe amputation, 2.27% had a cognitive
deficit, and 5.68% had cardiovascular diseases. Similarly, Wu et al. found 42% of patients suffering by foot
anomalies, out of which 65% had hallux vagus [14].

The precautionary measures that patients should be educated about to decrease the incidence of the diabetic
foot include strict glycemic control with lifestyle modification and compliance to medication, regular
screening for foot ulcers, and self-examination for foot skin lesions, fungal infections, and
deformities [1,15,16].

Conclusions
The high-risk diabetic patients for diabetic foot are those with older age, male gender, longer duration of
DM, raised HbA1c, and preexisting foot abnormalities. The HbA1c can be used as a screening tool in the
aforementioned high-risk diabetic patients for the diabetic foot to predict its occurrence, as HbA1c has a
linear relationship with the grades of Wagner classification of diabetic foot. This can help decrease the
incidence of the diabetic foot and its related complications such as amputations, infections, disability, and
death through tighter control of HbA1c and awareness about proper foot care because strict glycemic control
decreases the neuropathic and vascular complications of DM. However, further large-scale studies are
needed to find out the true association between HbA1c and Wagner classification.

Additional Information
Disclosures
Human subjects: Consent was obtained by all participants in this study. Peoples University of Medical and
Health Sciences for Women, Shaheed Benazirabad issued approval PUMHSW/SBA/REGISTRAR:/342/48.
Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.
Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the
following: Payment/services info: All authors have declared that no financial support was received from
any organization for the submitted work. Financial relationships: All authors have declared that they have
no financial relationships at present or within the previous three years with any organizations that might
have an interest in the submitted work. Other relationships: All authors have declared that there are no
other relationships or activities that could appear to have influenced the submitted work.

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