Written by Fariah Rahman, General Member
Diabetes is a chronic condition that affects millions of people worldwide. You may have family members or friends diagnosed with it. My mother and many relatives on her side have diabetes so it runs in my family. This includes my diabetic great uncle who had complications with an infection on his foot. Unfortunately, he didn’t treat it soon enough and had to get a major amputation to cut off his foot. I was shocked as I had no idea that diabetes could reach such a severe stage where someone’s foot had to be amputated. This amputation can drastically impact someone’s life. This led me to investigate how diabetes could lead to lower limb amputations, what the risk factors were, and what steps we could take to protect ourselves from reaching that stage.
What factors can lead to an amputation?
Amputations are associated with reduced mobility and a poorer quality of life. It can have a negative financial impact on patients, their families, and the healthcare system (Schaper et al., 2012). Before requiring a lower limb amputation, a diabetic patient may develop a foot ulcer (UC Davis Health, 2022). Foot ulcers can occur in patients with type 1 or type 2 diabetes (Lin et al., 2020). This can occur when diabetes and blood sugar levels are poorly managed leading to nerve damage and the risk for an infection. It can also result in poor blood circulation which can inhibit the healing of skin wounds leading to ulcers (UC Davis Health, 2022). High blood sugar levels can also impact the body’s ability to fight off an infection. Nerve damage can lead to neuropathy and the reduced ability to feel pain in the feet which can impact the patient’s awareness of any problems occurring in that area (University of Michigan Health, n.d.). To treat diabetic ulcers, the patient may have to meet with their healthcare providers multiple times over several months as they can take a very long time to heal. The ulcer can get infected and lead to gangrene which is the death of tissue due to the loss of blood flow in that area and can increase the risk of amputation (Lin et al., 2020; Marks, 2024; UC Davis Health, 2022). High-quality treatment of the ulcer may help reduce the risk of amputation. Osteomyelitis, which is the infection of the bone, can also increase incidence of amputations (Lin et al., 2020; Mayo Clinic, 2022).
A diabetic patient may get a minor amputation which is below the ankle or a major amputation which is above the ankle (Gurney et al., 2017). A history of recurrent foot ulcers, poor vascular health, sex, ethnicity, and lower socioeconomic status are associated with an increased risk of having an amputation (Gurney et al., 2017; Lin et al., 2020). A New Zealand study found that Indigenous diabetic patients may be at a higher risk of amputation than those who are not Indigenous after studying the Māori population. Men may be at higher risk of amputations possibly due to reduced health-seeking behavior to medically treat their feet on time, higher levels of smoking and increased risk of vascular disease (Gurney et al., 2017). Patients with recurrent foot ulcers should be thoroughly treated to avoid further progression and limb loss (Lin et al., 2020). A prior amputation can also increase the risk of subsequent amputations. The underlying risk factors that caused the first amputation may still be present leading to more amputations in the future. Patients who undergo amputations often have comorbid conditions such as peripheral vascular disease, renal disease, congestive heart failure, heart attacks, and cerebrovascular disease, which increase the risk of amputation. Peripheral vascular disease is also a pathway that can lead to amputations and indicates disease progression (Gurney et al., 2017). Smoking is also a risk factor for lower limb amputations for patients with diabetic foot ulcers and quitting this harmful behavior may provide better health outcomes for them (Lin et al., 2020).
Amputations and Death
The mortality rate is high amongst diabetic amputees. Some patients who get an amputation may have a shortened life expectancy and live for a few more years after the operation. This can be due to the poor overall health of these patients due the severe stage of diabetes and the presence of multiple comorbid conditions (Lin et al., 2020; Gurney et al., 2017).
How can we reduce the risk of amputations?
To help reduce the rate of amputations, diabetic foot ulcers and infections should be treated thoroughly through a multidisciplinary, coordinated support system (Schaper et al., 2012). Patients should have access to a network of specialized diabetic foot teams. Not treating the ulcer early enough can lead to poor outcomes and early detection of ulcers can reduce the rate of amputations (Schaper et al., 2012). Unfortunately, this was the case for my great uncle. He kept ignoring the problem in his foot to the point it got much worse and it had to be amputated. If you have any family members or friends with diabetes, remind them to get their feet professionally checked regularly to ensure they can catch any problems early on. They can also take steps to reduce the risk of getting a diabetic foot ulcer. This includes managing their blood sugar, quitting smoking, keeping their feet clean, and eating a protein-rich healthy diet (UC Davis Health, 2022).
Clear guidelines should be created to identify at-risk patients. As a systematic solution, we can develop a program for early detection of ulcers and referral to specialized diabetic foot teams that include diabetes specialists, vascular surgeons, chiropodists, and specialized nurses. To reduce amputations, there needs to be a high standard of care, sufficient staff, clear referral guidelines, and a holistic approach in place as diabetes is a lifelong, chronic condition (Schaper et al., 2012).
References
Diabetic ulcers affect the skin, cognition and mental health. UC Davis Health. (2022, April 4). https://health.ucdavis.edu/news/headlines/diabetic-ulcers-affect-the-skin-cognition-and-mental-health/2022/04#:~:text=Diabetic%20ulcers%20are%20a%20serious,wounds%20develop%20into%20diabetic%20ulcers
Frequently asked questions: Diabetic foot ulcers. University of Michigan Health. (n.d.). https://www.uofmhealth.org/conditions-treatments/podiatry-foot-care/frequently-asked-questions-diabetic-foot-ulcers
Gurney, J. K., Stanley, J., York, S., Rosenbaum, D., & Sarfati, D. (2017). Risk of lower limb amputation in a national prevalent cohort of patients with diabetes. Diabetologia, 61(3), 626–635. https://doi.org/10.1007/s00125-017-4488-8
Lin, C., Liu, J., & Sun, H. (2020). Risk factors for lower extremity amputation in patients with diabetic foot ulcers: A meta-analysis. PLOS ONE, 15(9). https://doi.org/10.1371/journal.pone.0239236
Marks, H. (2024, May 27). Gangrene: Symptoms, causes, diagnosis, treatment, and prevention. WebMD. https://www.webmd.com/skin-problems-and-treatments/gangrene-causes-symptoms-treatments
Mayo Foundation for Medical Education and Research. (2022, November 8). Osteomyelitis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/osteomyelitis/symptoms-causes/syc-20375913
Schaper, N. C., Apelqvist, J., & Bakker, K. (2012). Reducing lower leg amputations in diabetes: A challenge for patients, healthcare providers and the healthcare system. Diabetologia, 55(7), 1869–1872. https://doi.org/10.1007/s00125-012-2588-z