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Lower Extremity Amputations: Black Men With Diabetes Overburdened

Authors:

Abstract

Diabetes affects almost 24 million people in the United States, and nearly one-fourth of them are unaware of their disease. 1 Minorities are disproportionately affected and are more likely to have complications. 2 One of the most serious long-term complications of diabetes is lower extremity amputation. Patients with diabetes account for the majority of nontraumatic lower extremity amputations. 1 Lower extremity infections are among the top 10 reasons for hospitalizations among patients with diabetes, accounting for a large proportion of the annual $174 billion in diabetes-related costs. 1,3 Morbidity and mortality rates associated with lower extremity amputation are significant. 4 Black men are 1.7 times more likely to undergo primary and repeat amputation than any other racial group. 5 Risk Factors Risk factors for diabetes complications include the following: 1 • inadequate control of blood glucose • smoking • obesity or overweight • lack of physical activity • hypertension • poor control of blood cholesterol. To prevent complications, the Centers for Disease Control and Prevention recommends strict glucose control, maintenance of normal blood pressure and lipids, and preventive care for eyes, kidneys and feet. Risk factors for lower extremity amputation include peripheral vascular disease, neuropathy, previous ulcer or amputation, and foot deformity. 6–8 But these factors alone cannot predict the incidence of lower extremity amputation.
Lower Extremity Amputations: Black Men With Diabetes
Overburdened
Jeanne Lowe, RN and Joseph D. Tariman, NP
Diabetes affects almost 24 million people in the United States, and nearly one-fourth of them
are unaware of their disease.1 Minorities are disproportionately affected and are more likely
to have complications.2
One of the most serious long-term complications of diabetes is lower extremity amputation.
Patients with diabetes account for the majority of nontraumatic lower extremity amputations.
1 Lower extremity infections are among the top 10 reasons for hospitalizations among patients
with diabetes, accounting for a large proportion of the annual $174 billion in diabetes-related
costs.1,3 Morbidity and mortality rates associated with lower extremity amputation are
significant.4
Black men are 1.7 times more likely to undergo primary and repeat amputation than any other
racial group.5
Risk Factors
Risk factors for diabetes complications include the following:1
inadequate control of blood glucose
smoking
obesity or overweight
lack of physical activity
hypertension
poor control of blood cholesterol.
To prevent complications, the Centers for Disease Control and Prevention recommends strict
glucose control, maintenance of normal blood pressure and lipids, and preventive care for eyes,
kidneys and feet.
Risk factors for lower extremity amputation include peripheral vascular disease, neuropathy,
previous ulcer or amputation, and foot deformity.68 But these factors alone cannot predict the
incidence of lower extremity amputation.
Copyright ©2010 Merion Publications
Jeanne Lowe is a nurse who is a predoctoral research fellow at the University of Washington School of Nursing. She is a certified wound
care nurse specialist.
Joseph Tariman is an adult nurse practitioner who owns JD Tariman Consulting and lives in Seattle.
This column was developed with the Men's Health Network. Learn more at http://www.menshealthnetwork.org.
NIH Public Access
Author Manuscript
Adv Nurse Pract. Author manuscript; available in PMC 2010 June 3.
Published in final edited form as:
Adv Nurse Pract. 2008 November ; 16(11): 28.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Preventive care for amputation includes annual foot examinations, a foot check at each office
visit, patient education about self-care, and strict glucose management.9 Any skin breakdown
on a lower extremity requires immediate evaluation.
Guidelines for Foot Care
American Diabetes Association guidelines for prevention and management of diabetic foot
complications are described below.
For all patients with diabetes, perform an annual comprehensive foot examination to identify
risk factors for ulcers and amputations. Use a monofilament, tuning fork, palpation and a visual
examination.
Provide general foot self-care education to all patients with diabetes.
A multidisciplinary approach is recommended for patients with foot ulcers and high at-risk
status, especially patients with a history of ulcers or amputation.
Refer to foot care specialists patients who smoke, who have loss of protective sensation and
structural abnormalities, and who have prior lower-extremity complications.
Initial screening for peripheral arterial disease should include a history of claudication and an
assessment of pedal pulses. Refer patients with significant claudication or a positive ankle-
brachial score for further vascular assessment.
By identifying race and ethnicity, socioeconomic level and insurance status as independent
risk factors for predicting amputation, disproportionately affected groups can be targeted for
health system improvements.10 If ignored, disparities will continue. NP
References
1. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and
national estimates on diabetes in the United States. 2007 [Accessed Sept. 5, 2008]. Available at:
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.
2. Lavery LA, et al. Diabetes-related lower-extremity amputations disproportionately affect blacks and
Mexican Americans. South Med J 1999;92(6):593–599. [PubMed: 10372853]
3. Russo, C.; Jiang, H. Hospital stays among patients with diabetes. U.S. Agency for Healthcare Research
and Quality, Healthcare Cost and Utilization Project (HCUP) Statistical Brief #17. 2004 [Accessed
Sept. 5, 2008]. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb17.pdf.
4. Faglia E, et al. New ulceration, new major amputation, and survival rates in diabetic subjects
hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up. Diabetes Care 2001;24(1):
78–83. [PubMed: 11194246]
5. Feinglass J, et al. Racial differences in primary and repeat lower extremity amputation: results from a
multihospital study. J Vasc Surg 2005;41(5):823–829. [PubMed: 15886667]
6. Birke JA, et al. Factors associated with ulceration and amputation in the neuropathic foot. J Orthop
Sports Phys Ther 2000;30(2):91–97. [PubMed: 10693087]
7. Margolis DJ, et al. Diabetic neuropathic foot ulcers and amputation. Wound Repair Regen 2005;13
(3):230–236. [PubMed: 15953040]
8. Smith DG, et al. Minor environmental trauma and lower extremity amputation in high-risk patients
with diabetes: incidence, pivotal events, etiology, and amputation level in a prospectively followed
cohort. Foot Ankle Int 2003;24(9):90–695.
9. American Diabetes Association. Standards of medical care in diabetes — 2008. Diabetes Care 2008;31
(Suppl 1):S12–S54. [PubMed: 18165335]
Lowe and Tariman Page 2
Adv Nurse Pract. Author manuscript; available in PMC 2010 June 3.
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
10. Eslami MH, et al. The adverse effects of race, insurance status, and low income on the rate of
amputation in patients presenting with lower extremity ischemia. J Vasc Surg 2007;45(1):55–59.
[PubMed: 17210382]
Lowe and Tariman Page 3
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... Key Words: Diabetes mellitus; Self -care; Diabetic foot. (SAURABH et al., 2013;PINO et al., 2011;LOWE et al., 2008;GAMBA et al., 2004;SPICHLER et al., 2004) ...
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Hospital stays among patients with diabetes. U.S. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) Statistical Brief #17
  • C Russo
  • H Jiang
Russo, C.; Jiang, H. Hospital stays among patients with diabetes. U.S. Agency for Healthcare Research and Quality, Healthcare Cost and Utilization Project (HCUP) Statistical Brief #17. 2004 [Accessed Sept. 5, 2008]. Available at: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb17.pdf.
National diabetes fact sheet: general information and national estimates on diabetes in the United States
  • Disease Centers
  • Control
  • Prevention
Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States. 2007 [Accessed Sept. 5, 2008]. Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf.
Standards of medical care in diabetes -2008
American Diabetes Association. Standards of medical care in diabetes -2008. Diabetes Care 2008;31 (Suppl 1):S12-S54. [PubMed: 18165335]