Disparities in lower extremity amputation among native americans with diabetic foot ulcerations

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Review Article
Vascular Diseases and erapeutics
Vascul Dis er, 2020 doi: 10.15761/VDT.1000176 Volume 5: 1-5
ISSN: 2399-7400
Disparities in lower extremity amputation among Native
Americans with diabetic foot ulcerations
Lyndsay Kandi and Tze-Woei Tan*
University of Arizona College of Medicine, Tucson, Arizona
*Correspondence to: Tan TW, FACS, Division of Vascular and Endovascular Surgery,
University of Arizona College of Medicine, 1501 North Campbell Ave, Room 4402,
Tucson, AZ 85724, Tel: 520-626-6598; Fax: 520-626-4008; E-mail: ttan@surgery.
arizona.edu
Key words: native Americans, race, disparities, diabetic foot ulcers, lower extremity
amputation
Received: April 12, 2020; Accepted: April 24, 2020; Published: April 27, 2020
Background
It is a well-documented declaration that the Native American (NA)/
American Indian (AI) population is disproportionately aected by
many chronic conditions. Among the chronic and oen fatal ailments,
diabetes mellitus (DM) is a prevailing diagnosis [1]. According to the
2017 American Diabetes Association, DM is responsible for signicant
deaths and is a substantial cost to society at $327 billion USD in the
United States (US) [2]. Complications of DM include peripheral
artery disease (PAD), a macrovascular complication, and peripheral
neuropathy (PN), a microvascular condition, which in turn cascade
into other adverse health outcomes [3,4]. Impaired vascular ow and
loss of sensitivity to the extremities, particularly to the feet, likewise
increases risk of diabetic foot ulceration (DFU) [3,4]. As a consequence
of an infected foot ulceration and subsequent osteomyelitis or gangrene,
patients may undergo lower extremity amputation (LEA) [4,5]. DFU
not only limits mobility and causes pain and discomfort, but foot
ulceration may even increase mortality rates and reduce life expectancy
[6,7]. e rate of recurrence for DFU within 1 year is roughly 40%,
about 60% within 3 years, and 65% within 5 years [8].
Lower extremity amputation is 10 to 20 times more common in
patients with PAD secondary to diabetes compared to non-diabetics,
with up to 75% of LEAs being performed in these patients [9]. e
opposite leg in up to 42% of diabetic patients is amputated within three
years [10]. In 2010, 73,000 amputations were performed in diabetic
patients, accounting for more than 50% of amputations in the US [4].
Mortality, quality of life, and physical function are signicantly worst
aer major amputations (ankle and above) [3,11]. Approximately half
of amputees will die within one year and as many as 70% of amputees
have a 5-year mortality rate [11]. In addition, the cost to US healthcare
payers due to DFUs and subsequent lower LEAs was estimated to be
$11 billion USD in 2001 [12].
Minority populations such as NA, African Americans (AAs), and
Hispanics are disproportionately aected by DM. According to the 2017
National Diabetes Statistics Report by the CDC, the NA population has
the highest rate of prevalence of diabetes at 15.1%, followed by AAs
with 12.7%, and Hispanics at 12.1%, while DM was prevalent in only
7.4% of non-Hispanic whites (whites) [13]. ese same subgroups also
experience more diabetes-related complications, such as PAD, DFUs,
and LEAs [14-16]. NAs, AAs, and Hispanics likewise have higher rates
of premature mortality as well as worse diabetes outcomes compared
to whites [17,18]. It is estimated that American Indians (AIs) have four
times higher mortality rate due to diabetes than that of the US general
population [18]. Additionally, the rate for LEAs among NAs was greater
than that of the general population [19]. e WHO Multinational
Study of Vascular Disease in Diabetes from 2001 likewise established
incidences of amputation secondary to DM of the NA population to
be 31.0 and 9.7 per 1,000 persons, respectively [20]. Furthermore, NAs
in the state of Arizona are at a higher risk of LEA [21]. Other minority
groups such as AA and Hispanic patients are more likely to undergo a
major LEA as opposed to limb salvage than whites [22].
e dierences in outcomes and therapeutic approaches to a
diabetic patient with a foot ulcer has been studied extensively in AAs
and whites, yet what factors contribute to disparities in diabetes-related
LEAs among the NA population remains unclear. With a projected
population of 10.2 million individuals by 2060, it is imperative to
understand and address inequalities of the NA population as it relates
to their health [23]. is review seeks to ascertain elements leading
to major LEAs among the NA population with DFUs. Among the
signicant factors leading to elevated risks of leg amputation that
are included in this discussion are predisposing genetics, lifestyle
behaviors, access to healthcare, socioeconomic status, patient attitude
towards Western medicine, and healthcare provider bias.
Current State of Evidence
e review focuses on the NA population, referring to indigenous
persons in the US of federally recognized tribal aliation and
including Alaskan Natives (AN). ere are 573 NA tribes that are
legally recognized by the Bureau of Indian aairs of the US as of July
2018, of which include 231 tribes located in Alaska [24]. While it may
seem unreasonable to place all 573 tribes under one group and make
generalizations, recent literature has indicated that all NA populations
in North and South America derive from a single population [25].
ough each tribe may have its own unique customs, traditions, or
even phenotypic features, NAs across all tribal aliations share a
common genotype [25].
Predisposing Genetics
e NA population is genetically predisposed to developing DM.
Via genome-wide association studies (GWAS), recent literature has
discovered more than 70 genomic regions in which single nucleotide
polymorphisms (SNPs) are correlated with Type 2 DM. Of these regions,
nine SNPs have been identied in AI and more specically, the DNER

Kandi L (2020) Disparities in lower extremity amputation among native americans with diabetic foot ulcerations
Vascul Dis er, 2020 doi: 10.15761/VDT.1000176 Volume 5: 2-5
locus conferred susceptibility for young-onset T2DM in Pima Indians
of Arizona [26,27]. Additionally, other SNPs have been associated with
higher 2-hour glucose concentrations, insulin resistance, lower acute
insulin secretion, higher BMI, and higher percent body fat [28-31].
Native Americans are also modestly predisposed to developing
PAD [32]. A recent study found a polymorphism of the gene encoding
methylenetetrahydrofolate reductase (MTHFR) that is more prevalent
of NAs of Oji-Cree descent [32]. While this gene has been linked
to retinopathy, nephropathy, atherosclerosis, and coronary artery
disease, this study determined the MTHFR 677C>T polymorphism
also demonstrated a modest genetic inuence on the development of
PAD [32]. Another study found a common functional variant of the
cholesterol transporter, ABCA1, that is exclusive to people of Native
American populations, and is a major determinant of HDL-C levels as
well as a higher BMI [33].
Lifestyle Behaviors
Researchers have delved into what lifestyle factors may be
contributing to the development of DM and its consequences in the
NA population. Native Americans have a higher prevalence of tobacco
use, obesity and physical inactivity, binge-drinking, sugar-sweetened
beverage consumption, high blood pressure, and report of fair or
poor health status [1,34-36]. It has also been shown that compared
with whites, NAs reported a lower prevalence of having a personal
doctor or healthcare provider, fruit and vegetable consumption, cancer
screening, and seatbelt use [34]. ere is even data to suggest that
mental illnesses such as depression disproportionately aects the NA
population, which is also linked with worse glycemic control [37].
Socioeconomic Status
e NA population still faces a large socioeconomic gap as
compared to non-Hispanic whites. Data suggests that NAs report lower
levels of educational attainment with 80.2% of the population having
graduated high school and only 14.7% of the population obtaining
a bachelor’s degree [38]. e NA population also reports a lower
income level at $41,882 and an unemployment rate of 42.5% of able-
bodied persons, according to 2017 U.S. Census Bureau data [39]. e
highest poverty rate by race is found among the NA population [39].
Comparatively, more than one third of non-Hispanic whites obtained
a bachelor’s degree or higher, while the median household income for
this population was found to be $65,145 [38,39]. One study also noted
that AIs have a signicantly higher risk than non-Hispanic whites for
medical cost diculties [1].
Access to Healthcare
Indian Health Services (IHS) is an agency within the Department of
Health and Human Services that is responsible for providing healthcare
to the NA population [40]. It delivers medical care to approximately 2.6
million AIs in 37 states nationwide with 28 acute-care, 50-bed hospitals
in eight of those states [40,41]. e focus of IHS is to deliver primary
and obstetric care to tribes in the western United States, and thus, have
little to no resources for complex cases such as DFU and LEA [41]. In
2018, Congress set the IHS budget at $4.7 billion USD, a reduction of
$59 million USD below scal year 2017 [42]. Servicing 2.6 million AIs,
each person using IHS services is essentially allocated $1,807 USD [42].
Provider Bias
ere is evidence of both healthcare provider racism and
unconscious racial biases. Green, et al. found signicant pro-White
bias among internal medicine and emergency medicine residents,
while James SA supported this nding, indicating a “pro-white”
unconscious bias in physician’s attitudes towards, and interactions
with, patients [43,44]. In a survey assessing implicit and explicit
racial bias by Emergency Department (ED) providers in care of NA
children, it was discovered that many ED providers had an implicit
preference for white children compared to those who identied as NA
[45]. Indeed, racism and stigmatization are identied as being many
American Indians’ experiences in healthcare.
A study published in 2018 found that NA participants reported
more frequent episodes of poor treatment and lower levels of
treatment satisfaction with Western medicine [45]. Native American
persons were the most likely racial group to report discrimination in
health care, with discrimination being perceived by 7.1% of the AI
alone group, 8.8% of those identifying as both NA and white (add of
those), 5.6% of AAs, 4.3% of whites, and 2.6% of Asian Americans
[45]. Another study indicated NA parents were 25 times more likely to
perceive racial discrimination in the healthcare service for their child
than white parents [46]. Racist encounters experienced by NA persons
also leads to fear of utilizing conventional healthcare services [47]. Due
to this, many NA may even forego care altogether to avoid anticipated
racism [48]. Other bodies of literature support this claim, indicating
certain minority groups are more likely to have negative perceptions
of healthcare professionals and services [17]. For the NA population
especially, the injustices committed by Western health systems precipitates
mistrust, and such institutions are believed to contribute to poor health
[48]. Additionally, having strong cultural ties leads NAs to seek physicians
of their own ethnic background, but with only about 0.5% of all practicing
US physicians, this population remains grossly underserved [48].
Patient Attitude Towards Western Medicine
Western healthcare institutions also do not consider spiritual facets
of health, which may be perceived as a limitation of such medicine
because the biological healthcare model is not “holistic” [49]. us,
many NAs seek counsel and care from traditional healers, whose
treatment plans include plant-based medicines, rituals and ceremonies
in order to re-establish mental, spiritual, emotional, and physical
balance of the patient [50]. Yet many physicians express disagreement
with their patients using traditional Native medicines while under their
care because they are unsure of what Native medicine or traditional
Native healing entails, further widening the cultural divide between
NA patient and doctor [51]. In fact, research indicates that sickness
explanatory models that are discordant between healthcare providers
and patients may reduce communication ecacy, adherence to
treatment plan, and negatively impact health [52].
With regards to self-care behaviors in NAs with diabetes-such as
daily glucose monitoring, daily foot checks, smoking status, physical
activity, and daily fruit/vegetable consumption – a study using the
Behavioral Risk Surveillance System (BRSS) data reported that NAs
are more likely to engage in higher levels of diabetic self-care as
compared to AAs, Hispanics, and whites [53]. While this data is self-
reported, another source used objective data to establish lower rates of
HbA1c control and adherence to oral medication-compliance in the
NA population, but similar blood pressure and cholesterol outcomes
compared to whites [54].
Discussion
With the NA population being genetically predisposed to
developing diabetes and peripheral artery disease, lifestyle factors

Kandi L (2020) Disparities in lower extremity amputation among native americans with diabetic foot ulcerations
Vascul Dis er, 2020 doi: 10.15761/VDT.1000176 Volume 5: 3-5
are of utmost importance in minimizing complications such as foot
ulceration and major amputation. Enforcing dietary restrictions such
as limiting carbohydrates and sugar, tobacco and alcohol use, as well
as increasing fruit and vegetable consumption and physical activity
should be encouraged. Perhaps working with a Nutritionist or Dietician
may facilitate healthier habits, and considerations to access to care
should be taken into account. As such, home healthcare and educator
visits, or online modules to increase health literacy and maximize well-
being may benet this population as it faces signicant transportation
diculties.
ere is particularly a well-demonstrated link between tobacco use
and development of PAD, which is strongly linked to DFU and LEA
[55]. Several studies have indicated that the NA population is a robust
user of tobacco products [34,56]. Additional literature has found that
AIs/ANs with diabetes were found to smoke two to three times the
rate of those that are current non-diabetic smokers [36]. Furthermore,
NAs with diabetes that are current smokers were more likely to have
glycosylated hemoglobin A1c levels at 8.0% or higher [36]. Having poor
glycemic control likewise increases the complication rate, especially
with macrovascular injuries, and reduces favorable outcomes [17].
us, it is imperative to help NAs with smoking cessation to prevent
these adverse manifestations.
With many NAs living in low socioeconomic factors and having
poor access to health care, these patients are at a greater risk for diabetes-
related cardiovascular disease, including PAD. One study found a
relationship between eight-year incidence of LEA in NAs with diabetes
and risk by sex, educational attainment, renal function, and glycemic
control [21]. Additional research by the CDC supports this data, stating
prevalence of DM and its complications varied by educational and
socioeconomic status, with those having lower educational and income
levels at an increased risk [13]. It can be postulated that with many NAs
living in poverty and lacking health insurance, aording medication
such as insulin or metformin is simply unreasonable. is could in part
explain the poor HbA1c control and medication compliance.
According to Richardson, et al. who used data from the 2007 Health
Information National Trends Survey, people of lower educational
backgrounds were less likely to seek health information [57]. e
participants that reported lower income also indicated decreased
condence in their ability to obtain health information, and higher
levels of mistrust in Western healthcare professionals than whites and
those of higher income [57].With many NAs desiring care of culturally-
competent healthcare professionals, there is a need for more physicians
that identify as NA. Several medical schools are attempting to ll this
void. But in 2017, a mere 100 NA students applied and of those 100,
only 42 NAs were accepted into medical school [58].
More work needs to be done in reaching out to AI students
and encouraging them to consider a career as a physician. For so
many, medical school – and even a bachelor’s degree-seems like an
unattainable dream. With reservations rampant with substance and
alcohol abuse, domestic violence, and poverty, many NA youth do not
have the same opportunities nor support as those living o-reservations
[59,60]. Several studies have indicated that NA youth face higher levels
of substance use, alcohol abuse, and smoking as compared to their
non-Native counterparts [60,61]. Likewise, AIs face a substantially
higher rate of alcohol-attributable death than whites [61].
ere are programs that seek to inspire AI youth to pursue Science,
Technology, Engineering, and Math (STEM) elds. e National
Science Foundation awards grants to educational institutions that have
ongoing projects, and even recruits students from underrepresented
groups, including the NA population. Yet more programs should
target elementary school education to inspire interest and expose the
youth to careers in STEM, and even more work needs to be done to
attenuate drug and alcohol use in NA adolescents.
Despite existence of such facilities dedicated to NAs, access to
healthcare remains a disparity for many NAs. Indian Health Services
hospitals face an increase in the number of NAs using their services
yet oer a narrow scope of services and even more limited access
to specialists [41]. Due to funding constraints, referrals to outside
specialists are not always approved, and preventative care services
such as mammograms are oen denied46 [41]. As such, NAs oen
have diculty getting high-quality, timely healthcare. Because their
hospitals are older, acute-care facilities, IHS struggles to adequately
treat complicated inpatient cases, uses outdated equipment, and a
shortage of essential medications raises concerns about patient safety.
Certainly, Center for Medicare Services (CMS) found IHS hospital
sta to lack training and knowledge on emergency procedures and
attributed three patient deaths in 2014 to sta’s lack of prociency and
inability to identify problems [41].
Yet there are 13 states without IHS facilities, and those that do have
IHS institutions experience issues as described above [40]. Aside from
IHS facilities, the NA population is becoming increasingly more urban,
with 71% of the population living in urban areas, according to the
US Census38. But many NAs lack health insurance and cannot aord
medical care outside of IHS services, so many do without treatments
or seeing a healthcare provider [62]. Many AIs have not seen a medical
professional in over one year, citing costs [62]. ose NAs that do live
in rural areas or on reservations also face diculties with accessing
healthcare, particularly preventative and specialty care. Additionally,
almost half of the NA population live more than 60 miles from care,
thus it is a lengthy drive to access services. Tribal lands also feature
inadequate transportation infrastructure, making it dicult for NAs
living on the reservation to travel to hospitals, among other places.
e inferior road conditions oen delay emergency responders from
providing timely assistance and jeopardizes the health, safety, and
security of tribal members and those utilizing tribal roads.
Another attempt at encouraging health insurance coverage and
access for American Indians was put forth by the Aordable Care Act
(ACA), an expansion to Medicaid that was signed into law in 2010.
is insurance plan was geared toward low-income families to ensure
coverage and attainment of health services. In 2015, nearly 1.5 million
AIs were enrolled in Medicaid, and healthcare-facilities that serve
primarily Native populations received most of their reimbursements
from Medicaid [63]. With medications to manage diabetes covered
under ACA, this may also help control poor HbA1c and improve
compliance with treatment plan. While this may be a step in the right
direction, future studies would have to look at whether the ACA has
helped curb diabetic complications such as ulcerations and LEAs in the
NA population.
Healthcare providers’ biases may be inuencing medical decision-
making, shaping physician behavior, and produce a dierence in
medical treatment of patients of various ethnic backgrounds. A body
of literature has indicated that higher implicit bias was associated with
disparities in treatment recommendations, expectations of healing,
pain management, and empathy [64]. It may even contribute to the
disparities observed in major LEA. As demonstrated above, the NA
population is more likely to undergo primary LEA and less likely to

Kandi L (2020) Disparities in lower extremity amputation among native americans with diabetic foot ulcerations
Vascul Dis er, 2020 doi: 10.15761/VDT.1000176 Volume 5: 4-5
have limb salvage. is may be in part due to perceived non-compliance
with treatment plan.
Perceived discrimination may be aecting self-care practices in
NAs with DFUs or even prevent them from seeking treatment. Some
studies have indicated that NAs with diabetes remain below the
national average for adherence to self-management recommendation
in daily foot checks and diabetes self-care behaviors [4,6] From a
psychological standpoint, feelings of anxiety, fear, and dread at being
diagnosed with diabetes may even inuence care-seeking and self-care
behaviors [52]. Furthermore, NA elders perceived noncompliance with
medical recommendations as socially desirable [52]. us, perhaps a
more culturally-sensitive approach to medical care and education
such as diabetes self-care classes may help to increase compliance and
reduce complications.
Some medical experts have urged Western physicians to partner
with traditional healers in order to best serve the NA patient. is may
help reduce the anxiety and perceived discrimination and engage the
patient more in their own care. Of note, some centers oer traditional
food and even employ a traditional healer to accommodate its roughly
40% NA population78 [65]. Future studies should look at compliance
rates with cultural-appropriate treatment plan, and if it shows
promising results, apply these practices to other hospitals that serve the
NA populations.
In 1997, Congress established the Special Diabetes Program for
Indians in response to the diabetes endemic that was hitting the NA
population [66]. e $150 million USD grant allows for funding of 404
IHS, tribal, and urban health programs across the US to help prevent
and treat diabetes [66]. A lifestyle intervention is a part of the program,
enforcing such factors as healthy eating and physical activity [66]. To
date, roughly 4,500 participants have completed follow-up assessments
and demonstrated improvement in key diabetes risk factors [66]. e
Native Diabetes Well Program by the CDC aims to honor the balance
of cultural practices and western science in Indian Country to promote
health and help prevent type 2 diabetes among NAs who are at risk
[67]. It provides books for school-aged children about preventing DM
while respecting traditional ways, educational and reference materials,
and even a Traditional Foods Program that played a role in addressing
food insecurity in NA communities [67]. ese programs have also
intervened and oered insight to Tribal schools as they developed their
health and wellness policies. Longitudinal data will need to be collected
in order to determine ecacy of these programs, and whether or not
they are helping to curb incidence of DM in younger NAs.
Conclusion
e complications of diabetes, including foot ulcers and LEAs, are
severe and costly to society. Compared to other groups, NAs experience
a disparate rate of diabetes, DFUs, and LEAs. Factors leading to
disparities in diabetes-related amputations in this population include
personal, environmental, and healthcare level determinants. ere
is a pressing need to address the health disparities among the NA
population, which is at-risk and oen underserved.
Funding
TT was funded by National Institutes of Health/National Institute
of Diabetes and Kidney Disease (NIDDK) (K23DK122126).
Conicts of Interest
None.
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