Why the Risk for Amputations Jumps If You’re Poor and Have Diabetes

When you have diabetes, you’re at a higher risk for an amputation, particularly an amputation of a lower limb or a toe.

In fact, the American Diabetes Association reports that about 60 percent of lower-limb amputations in adults that are not caused by trauma occur in people with diabetes. The risk is present for both Type 1 and Type 2 diabetes.

And the five-year death rate for those who have had an amputation caused by a diabetic foot ulcer ranges from 35 percent to 80 percent. That percentage is even worse than some cancers, says Dr. Katherine A. Gallagher, associate professor of surgery at the University of Michigan in Ann Arbor.

This higher risk comes from a cycle of uncontrolled blood sugar over time and unnoticed and untreated infections. Someone with poorly controlled diabetes may not even know they have an infection because they’ve also developed a complication called peripheral neuropathy, which can take away feeling in the feet. These infections, if not detected or treated, can lead to the need for an amputation.

People who are economically disadvantaged and who have diabetes are at a higher risk for amputations. In fact, there’s an area of the country identified as the “diabetes belt” by the Centers for Disease Control and Prevention because of the high rates of diabetesthere. The diabetes belt includes parts of 15 states in the Southeast such as Alabama, Kentucky, Tennessee and West Virginia. “The diabetes belt counties also have high rates of poverty, low levels of college educational attainment, and the residents were predominantly African-American,” says Judith Wylie-Rosett, a registered dietitian and professor and division head of health promotion and nutrition research in the Department of Epidemiology & Population Health at Albert Einstein College of Medicine in New York City. The areas in the diabetes belt also have higher incidences of stroke and cardiovascular disease compared with other parts of the U.S., Wylie-Rosett adds.

 Other research has pinpointed that in areas with less available medical care – which often means poorer areas – the risk for amputations is higher among people with diabetes.

So why is the risk for amputation higher in those with lower incomes?

First, access to care can be more difficult, Gallagher says. Someone with a lower income may not have health insurance – or they may have it but still have trouble with related health costs. They may have a harder time getting off work or away from child care or other obligations. If you live in a rural area, it could be hard to make it to a doctor’s faraway location. All of that makes it harder to get to the doctor for regular checkups or when a problem occurs. By the time a problem gets particularly bad, there may be an infection that’s too severe to treat – and an amputation may be required.

“There may not be the money or resources except for emergency care,” says Dr. Rob Pedowitz, medical director of the Family Practice of CentraState in Freehold, New Jersey.

“Often, secondary complications, such as nonhealing wounds and peripheral neuropathy, are not detected early, making the complications much more devastating,” Gallagher says.

There’s also less knowledge about taking control of your own care, says Dr. Misty D. Humphries, assistant professor, Division of Vascular and Endovascular Surgery at the University of California–Davis Medical Center. “Patients do not realize they have control over their care. They frequently become ‘passive observers’ of their own care,” she says. However, diabetes care is largely self-managed, so when you have it, you need to take an active role.

Another issue is the high cost of healthier food, says anesthesiologist and pain physician Dr. Sheetal DeCaria of the University of Chicago. Meals with less-healthy simple carbohydrates are cheaper and often easier to obtain than fresh meals with fruits and vegetables. “For example, fish is more expensive than beef, and an avocado is more costly than a candy bar,” DeCaria says.

Despite these hurdles, if you’re living with diabetes and want to take better care of your health, keep these guidelines in mind:

  • Take your diabetes diagnosis seriously – and plan changes right away to help yourhealth. Although medications are important, they’re not the only resource to treat diabetes. “The truth is the only way to fix these conditions is a lifestyle adjustment, not simply medications,” Gallagher says.
  • See a doctor regularly. This may seem hard to do at first. However, preventing future health problems and treating any current ones while they are still minor will save you money and time (not to mention pain) in the long run, Pedowitz says. Aim to visit a doctor who can check your diabetes every three months.
  • Take better care of your feet. When you visit your doctor every three months, ask him or her to check your feet for any infections or health concerns, Pedowitz recommends. Inspect your feet daily for nicks, cuts or scrapes. Always wear protective footwear, even in the house. And see a foot doctor once a year.
  • Educate yourself about diabetes. Ask your doctor about a local certified diabetes educator or registered dietitian who you can see. A diabetes educator or dietitian can fill you in on more details about diabetes care. And look out for community healthworkshops or support groups that provide screening and education related to diabetes. “Education about the condition and how to change your life can put you in the driver’s seat of your health care and ensure that amputation is not an issue you have to deal with,” Humphries says.
  • Follow common-sense good health practices. This includes moving more, eating less sugar and simple carbohydrates (like white bread or pastas) and not smoking.

There are programs funded by the Centers for Disease Control and Prevention to help meet the challenges of addressing patients who are lower-income, living in rural areas and have other factors that are associated with diabetes and diabetes complications, Wylie-Rosett says.