Examining Racial Disparities in Amputation Due to Diabetes

People of Color are disproportionately affected by amputation as a result of unmanaged type 2 diabetes. Here’s why — and what’s being done about it.

When Tyrone McCray limped into the ER with a swollen left foot in December 2019, he knew it was related to his type 2 diabetes, diagnosed about 8 years earlier.

Although he’d managed his condition with the help of his podiatrist, the leg had proved problematic, with bouts of swelling and pain. Now he was struggling with a sore that wouldn’t heal on his sole.

At the hospital, a surgeon he’d never met before walked in and let him know they were going to amputate the leg from the knee down, and it was going to be done immediately as a way to save the rest of the leg. The surgeon told him to get ready mentally for the change.

But McCray balked.

“He was so rude, like taking my leg was nothing — like it was ripping a piece of paper out of a notebook,” he recalls. “I told him I wanted a second opinion and to talk to [my podiatrist], and that’s what ended up saving my leg.”

“I’ll never forget that moment of helplessness when I wasn’t presented with any other options. I started crying, I was there alone, and I couldn’t believe it. Now, I think about all the people who probably think they have no choice and they lose their limbs, and that’s heartbreaking,” he says.

McCray has no idea if the lack of empathy and dearth of comprehensive treatment choices was related to the fact that he’s Black, but he knows People of Color are often subject to inequities in health treatment. That extends to amputation.

According to the American Diabetes Association (ADA), compared to non-Hispanic white Americans, Black Americans face rates of amputations up to 4 times higher, indigenous communities have amputation rates that are 2 times higher, and those in LatinX communities are 1.5 times more likely to have an amputation.

The organization adds that diabetes is the single greatest factor in amputations, and an individual who’s had this type of procedure has a worse chance of 5-year survival than someone with breast cancer, colorectal cancer, or coronary artery disease.

Since amputations are substantially more prevalent among People of Color, that means their lives are more at risk —and it’s often an unnecessary risk, says Robert Gabbay, MD, chief science and medical officer at the ADA.

“The big message here is that most amputations are so preventable,” he says. “Yet they’re done anyway, especially for People of Color, and that causes a ripple effect for their health. In fact, 1 in 10 patients will die within 30 days of amputation, and for the rest, the chances of seeing that 5-year milestone is only 50%. We need to change this.”

There are several factors why there are higher amputations among People of Color, he adds. Recognizing these is a big step toward building enough awareness for that much-needed change.

Here’s a look at the top reasons, along with advocacy efforts that could create a shift in how diabetes-related amputations are considered.

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Social determinants of health play a major role

Social determinants of health are the conditions of places where people are born, live, work, and play that can have a huge effect on their health and well-being. Examples include:

• economic stability
• healthcare access
• education quality
• community support
• neighborhood environment

All of these can present challenges for People of Color who have diabetes, says Tyrone McCray’s doctor, Gary Rothenberg, DPM, a podiatrist and clinical assistant professor at the University of Michigan. He’s also director of medical affairs for Podimetrics, an organization focused on putting an end to unnecessary amputations.

The group put together a 2022 report of patient perspectives on diabetes and found that 63% of Hispanic individuals with type 2 diabetes faced financial strain. That can have an effect on healthcare, especially when people are paying out of pocket for many services and medications.

When the result is skipped appointments — or not making them in the first place — these individuals may miss early signs of peripheral artery disease, such as numbness or slow wound healing.

Another social determinant of health is food insecurity, Rothenberg adds.

“Diabetes is a disease process that is highly influenced by what you’re eating,” he says. “If you’re not able to get the right foods to support your health, that’s a problem. That can lead to uncontrolled diabetes that, in time, may increase amputation risk.”

According to research done in 2016, African Americans are considered the “least healthy ethnic group” in the United States, in large part because of social determinants of health. The researchers called this “a somber legacy of years of racial and social injustice and a formidable challenge to equitable healthcare for all.”

A researcher’s commentary in the journal The Lancet on diabetes, race, and amputations notes that these inequalities lead to not just higher amputation rates among People of Color (particularly Black Americans) but also more diabetes complications in general, including kidney failure, heart disease, and retinopathy.

The researcher suggests that several things all combine to create inequality, including:

• structural racism
• underinvestment
• medical neglect in hospitals and clinics
• social determinant of health factors, such as healthcare access

Many people aren’t aware of the severity of diabetes

Anyone can develop type 2 diabetes without fully grasping how serious the condition can become. This isn’t unique to any race, ethnicity, gender, geographic location, age, or socioeconomic level.

This happened with actor Julian Brittano, 44, who was diagnosed with type 2 diabetes in 2008 but didn’t do much to manage the condition for over a decade.

He believed losing weight would be enough to reverse the disease, so he didn’t monitor his glucose levels or pay attention to any symptoms. Then he injured his big toe and the spiral began.

“This was all on me,” he says. “I take accountability because I wasn’t monitoring and wasn’t taking medications as prescribed. I was heavily into nightlife, not getting much sleep, drinking too much alcohol, and eating what I wanted. That turned into a harsh lesson about not tending to my health.”

The toe injury turned into sepsis and amputation. Brittano says it was a wake-up call to change everything about his diabetes management, including medication compliance, sleep, nutrition, and mindset.

“A lot of people have apprehension about dealing with doctors. They approach medical care with fear and uncertainty,” he explains. “But you need to stay on top of it for yourself. You need to take responsibility for your health and learn to listen to your body.”

What’s being done?

Addressing all these factors simultaneously can be challenging, but Gabbay of the ADA hopes that awareness among health professionals and people living with diabetes can make a difference.

To help with that, the ADA has launched the Amputation Prevention Alliance, highlighting that 85% of diabetes-related amputations are preventable.

“Part of the mission of this effort is to educate people on procedures that can save limbs because there are alternatives,” he says. “There needs to be more work done at every level, from access to healthy food to getting people into yearly checkups to talking about treatment options when a limb is at risk for amputation.”

Advocacy like this is particularly crucial for prompting people to get checked, especially before they start having symptoms. For example, Brittano knows he may have been able to avoid his toe amputation and get on a healthier track if he’d taken the disease more seriously when he was diagnosed.

Self-advocacy is crucial

For those who feel they may be experiencing discrimination in a healthcare setting, McCray’s advice is to get educated about treatment options and get a second opinion — and even a third if necessary — to become an advocate for your health.

Since that day in December when he was crying alone at the thought of losing his leg, he’s become an outspoken patient advocate, not just for People of Color but for everyone who may be at risk of being in the same situation someday.

“No one should have to feel the way I did in that hospital room when I felt like I didn’t matter, like I was invisible,” he says. “Educate yourself so you never get to that point.”