Comment on “Atherosclerosis index and diabetic foot ulcers: an NHANES database investigation”

To the Editor, Ju et al leverage NHANES (1999–2018) to examine whether four composite “atherosclerosis indices” (AIP, NHHR, LAP, VAI) are associated with diabetic foot ulcers (DFU) among adults with diabetes[1]. This topic is clinically relevant because DFU remains a common, morbid complication with substantial recurrence and amputation risk, and scalable risk stratification tools are still needed[2]. A key strength is the pragmatic use of routinely available metabolic inputs (lipids and anthropometrics), which could facilitate risk enrichment in primary care and population health settings[1]. The consistent directionality across multiple indices also supports the biological plausibility that an atherogenic–visceral adiposity phenotype correlates with DFU risk – compatible with the established role of peripheral arterial disease (PAD) in impaired perfusion and ulcer non-healing[3]. However, several issues temper immediate clinical translation. First, the cross-sectional NHANES design cannot establish temporality; reverse causation is plausible if DFU-related inflammation, immobility, or nutritional change worsens lipid/adiposity profiles[1]. Second, DFU ascertainment in large surveys is often questionnaire-based and may inflate prevalence or misclassify chronic wounds – important given the notably high DFU prevalence reported[1]. Third, DFU pathogenesis is multifactorial, and residual confounding is likely without granular measures of neuropathy, objective PAD severity (ABI/toe pressures), prior ulcer history, and preventive foot-care behaviors – drivers emphasized in contemporary DFU epidemiology and guideline frameworks[3,4]. For the field, the most useful next step is to quantify incremental utility: do these indices improve prediction beyond established clinical factors and basic PAD markers, and can they identify patients who benefit from intensified foot surveillance or vascular assessment?[3] This commentary conforms to the TITAN 2025 guideline on transparency and accountable reporting[5].