The amputee gets lost in the American health care system because of fragmentation across the continuum. The journey of the diabetic patient with limb loss through the health care system is even more precarious than that of the traumatic amputee. Interventions to address these secondary conditions and improve the health and outcomes of persons with disability have focused on standard medical treatments, such as medication or physical rehabilitation therapies, often to the exclusion of psychosocial interventions. Each member of the amputee rehabilitation team plays a specific and important role in the care and recovery of the person with limb loss.
Key points
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The amputee gets lost in the American health care system because of fragmentation across the continuum, especially those that are diabetic related but includes those that are trauma related.
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The journey of the diabetic patient with limb loss through the US health care system is even more precarious than that of the traumatic amputee.
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Interventions to address these secondary conditions and improve the health and outcomes of persons with disability have focused on standard medical treatments, such as medication or physical rehabilitation therapies, often to the exclusion of psychosocial interventions.
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Each member of the amputee rehabilitation team, if trained well, plays a specific and important role in the care and recovery of the person with limb loss.
The amputation of a limb represents a rare disease that has significant burden on the US health care system. Amputation rates in the total population, including individuals without diabetes, those with peripheral arterial disease (PAD) alone, and those that are cancer related, are not known. But it is startling to understand that estimates of 300 to more than 500 amputations occur in the United States every day. No active surveillance efforts, such as registry, currently exist. In this respect, those with limb loss in America have been forgotten in the health care system. A registry would give a clear picture of the landscape of limb loss in America and provide data to support research and help establish evidence-based interventions for patients with limb loss. To form and maintain a registry takes an act of Congress with a line item approved by the US congressional appropriations committee. From the respected research that has been done, it is estimated that nearly 2 million persons are living with limb loss in the United States. It is projected that the number of people living with the loss of a limb will more than double by 2050. According to recent data, more than 147,000 amputation procedures were performed in the United States in 2010. Of these procedures, more than 57,000 or nearly 40% were performed on patients with a principal diagnosis of diabetes. The costs associated with limb loss in terms of health care expenditures and on the burden of disease on those who have a limb amputated are staggering. Annually, the immediate health care costs associated with the amputation of a limb, not including prosthetic or rehabilitation costs, total nearly than $8 billion. When the costs of prosthetic care, rehabilitation, and other health care costs are accounted for, the economic costs associated with amputation are significantly higher. It is estimated that the 5-year health care costs associated with limb loss are more than $500,000 per person, nearly double the lifetime health care costs of an average person. In addition, the 5-year prosthetic costs for a person with limb loss are estimated to be as high as $450,000. The health care costs associated with limb loss are further compounded by the disease burden on those who have a limb amputation.
People with limb loss must often manage multiple chronic health conditions, face an elevated risk for developing even more chronic health conditions, and experience mortality rates higher than many common chronic diseases. The amputation of a limb is frequently an outcome of an existing chronic condition (eg, diabetes or vascular disease). Additionally, having limb loss itself is associated with many chronic conditions. People who have a limb amputated are at an increased risk of cardiovascular disease, obesity, joint and bone issues, and experience high rates of depression and emotional distress. People with limb loss also experience 5-year mortality rates higher than many cancers. Studies estimate the 5-year mortality rate of people with limb loss to be between 50% and 74%. For patients who are 65 years or older and have a limb amputation due to vascular disease, the 1-year mortality rate is estimated to be 36%. This mortality rate increases with the increasing level of amputation. Those who lose a limb due to complications related to diabetes are also predicted to suffer subsequent amputation to either the ipsilateral or contralateral limb within the years following the initial amputation. Their only hope is focused prevention strategy.
Traumatic limb loss
Patients with an amputation get lost in the American health care system because of fragmentation across the continuum, including those who lost a limb due to trauma. Trauma is the second leading cause of amputation in the United States. About 30,000 traumatic amputations occur in this country every year. Four of every 5 traumatic amputation victims are male, and most of them are between the ages of 15 and 30. Based on the National Trauma Databank version 5 from 2000 to 2004, there were 8910 patients who had an amputation (1.0% of all trauma patients). Of these, 76.9% had digit and 23.1% had limb amputation. Of those with limb amputation, 92.7% had a single limb amputation. Lower extremity amputations (LEA) were more frequent than upper extremity amputation (UEA) among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt trauma in 83%; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%), whereas motorcyclists (86.2% vs 13.8%) and pedestrians (91.9% vs 8.1%) had more LEA. Patients with LEA were more likely to require discharge to a “skilled nursing facility”; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. The person who experiences a traumatic limb amputation is initially dependent on the surgical trauma team with regard to medical knowledge, skill, and ability to programmatically access a full complement of resources to care for this individual with limb loss. The initial events are centered on sustaining life, then on complex decisions of possible limb salvage and residual limb preservation. This phase can last less than 24 hours or years depending on circumstances and health care team guidance.
The numbers of those with major traumatic limb loss are relatively small, especially when considering that they are spread throughout the United States. This impacts the trauma team’s experience regarding decisions of limb preservation as well as technical skill for performing major limb amputation. The approach and outcomes are variable in the United States. Using the recommended standardized surgical techniques for closure and neuroma prevention, when possible, is paramount to meet the goal of functional restoration. As the acute trauma team moves from viewing the amputation as “a therapeutic failure” to “the best therapeutic option,” planning for functional restoration comes more clearly into view.
The patients journey in the US health care system after the amputation is one even more variable than the initial immediate trauma phase. The Emergency Medical System directs those at risk to “trauma centers,” where it is implied that standardized programs and a full cadre of specialists are ready to care for the trauma victim. The expectation is that after the “usual trauma care” the person with limb loss will be embraced by a comprehensive and cohesive team of rehabilitation professionals with extensive experience. Their experience is evident through a defined program spanning from the time of limb loss through lifetime care, with links to the larger health care system. This is often not the case, even when the person is initially admitted to one of the most sophisticated health care systems in one of the most affluent cities in the United States. It would follow that if it is not happening in one of the “Top Hospitals” it is again unlikely that such a program is “usual care” in the regional trauma centers throughout these United States. The person with limb loss and their supports string together the health care providers who assist them with obtaining therapy services, a prosthesis, progressive healing, and pain management. Significant time is lost without a navigator and a defined amputee specialty care team.
There are few Amputee Specialty Programs in the United States, as they are not “usual care,” except in the Department of Veterans Affairs (VA) system. The journey of functional restoration and maximizing quality outcomes for the person with traumatic limb loss is usually in the hands of the person with limb loss and the soloed individual health care providers and prosthetists that he or she encounters. Programmatic components that have been found to be significantly beneficial for the person with limb loss, such as ones that address adjustment, depression, pain, and valuable peer support, do not exist in the “usual care” experience in the United States. The outcomes for functional restoration after traumatic amputation are at risk and variable. The Department of Defense hospitals and the VA hospitals have produced successful programs, benchmarks, and outcomes that need to be translated into “usual care” in our civilian health care system.
Traumatic limb loss
Patients with an amputation get lost in the American health care system because of fragmentation across the continuum, including those who lost a limb due to trauma. Trauma is the second leading cause of amputation in the United States. About 30,000 traumatic amputations occur in this country every year. Four of every 5 traumatic amputation victims are male, and most of them are between the ages of 15 and 30. Based on the National Trauma Databank version 5 from 2000 to 2004, there were 8910 patients who had an amputation (1.0% of all trauma patients). Of these, 76.9% had digit and 23.1% had limb amputation. Of those with limb amputation, 92.7% had a single limb amputation. Lower extremity amputations (LEA) were more frequent than upper extremity amputation (UEA) among patients in the single limb amputation group (58.9% vs 41.1%). The mechanism of injury was blunt trauma in 83%; most commonly after motor vehicle collisions (51.0%), followed by machinery accidents (19.4%). Motor vehicle collision occupants had more UEA (54.5% vs 45.5%), whereas motorcyclists (86.2% vs 13.8%) and pedestrians (91.9% vs 8.1%) had more LEA. Patients with LEA were more likely to require discharge to a “skilled nursing facility”; whereas those with UEA were more likely to be discharged home. Traumatic limb amputation is not uncommon after trauma in the civilian population and is associated with significant morbidity. The person who experiences a traumatic limb amputation is initially dependent on the surgical trauma team with regard to medical knowledge, skill, and ability to programmatically access a full complement of resources to care for this individual with limb loss. The initial events are centered on sustaining life, then on complex decisions of possible limb salvage and residual limb preservation. This phase can last less than 24 hours or years depending on circumstances and health care team guidance.
The numbers of those with major traumatic limb loss are relatively small, especially when considering that they are spread throughout the United States. This impacts the trauma team’s experience regarding decisions of limb preservation as well as technical skill for performing major limb amputation. The approach and outcomes are variable in the United States. Using the recommended standardized surgical techniques for closure and neuroma prevention, when possible, is paramount to meet the goal of functional restoration. As the acute trauma team moves from viewing the amputation as “a therapeutic failure” to “the best therapeutic option,” planning for functional restoration comes more clearly into view.
The patients journey in the US health care system after the amputation is one even more variable than the initial immediate trauma phase. The Emergency Medical System directs those at risk to “trauma centers,” where it is implied that standardized programs and a full cadre of specialists are ready to care for the trauma victim. The expectation is that after the “usual trauma care” the person with limb loss will be embraced by a comprehensive and cohesive team of rehabilitation professionals with extensive experience. Their experience is evident through a defined program spanning from the time of limb loss through lifetime care, with links to the larger health care system. This is often not the case, even when the person is initially admitted to one of the most sophisticated health care systems in one of the most affluent cities in the United States. It would follow that if it is not happening in one of the “Top Hospitals” it is again unlikely that such a program is “usual care” in the regional trauma centers throughout these United States. The person with limb loss and their supports string together the health care providers who assist them with obtaining therapy services, a prosthesis, progressive healing, and pain management. Significant time is lost without a navigator and a defined amputee specialty care team.
There are few Amputee Specialty Programs in the United States, as they are not “usual care,” except in the Department of Veterans Affairs (VA) system. The journey of functional restoration and maximizing quality outcomes for the person with traumatic limb loss is usually in the hands of the person with limb loss and the soloed individual health care providers and prosthetists that he or she encounters. Programmatic components that have been found to be significantly beneficial for the person with limb loss, such as ones that address adjustment, depression, pain, and valuable peer support, do not exist in the “usual care” experience in the United States. The outcomes for functional restoration after traumatic amputation are at risk and variable. The Department of Defense hospitals and the VA hospitals have produced successful programs, benchmarks, and outcomes that need to be translated into “usual care” in our civilian health care system.
Nontraumatic limb loss
Peripheral Arterial Disease
Lower-extremity PAD is a serious disease that affects approximately 8 to 12 million Americans. Prevalence increases dramatically with age and disproportionately affects African-Americans. The hardened arteries found in people with PAD may be the first sign that a person has a systemic process of hardened and narrowed arteries, supplying critical organs such as the heart and the brain, threatening life not just limb. As a result, people with PAD who are at risk for limb loss are also at high risk for having a heart attack or a stroke. Conversely, but not as frequently recognized, 40% of patients with coronary artery disease (CAD) have PAD.
There is significant overlap, as the evidenced-based treatment of one treats the other. The signs and symptoms of PAD may not arise until later in life. For many, the outward indications will not appear until the artery has narrowed by 60% or more. One in 3 people age 70 or older has PAD. The disease prevalence increases with age and approximately 20% of Americans age 65 and older have PAD. As the population ages, the prevalence could reach up to 16 million in those older than age 65. Of all people with PAD, 2% will progress to major amputation. One method the body uses to adapt to the narrowed arteries is the development of smaller peripheral arteries that allow blood flow around the narrowed area. This process is known as collateral circulation and may help explain why many can have PAD without feeling any symptoms. When a piece of cholesterol, calcium, or blood clot abruptly breaks from the lining of the artery or a narrowed artery blocks off completely, blood flow will be totally obstructed and the organ supplied by that artery will suffer damage. The organs in PAD most commonly affected and researched are the legs. The most advanced stages of PAD can lead to critical limb ischemia (CLI). The pain caused by CLI can wake up an individual at night. This pain, also called “rest pain,” can be relieved temporarily by hanging the leg over the bed or getting up to walk around. The legs and feet have such severe blockage that they do not receive the oxygen-rich blood required for basic mobility and cannot repair openings in the skin. This often progresses to a very painful pivotal ischemic episode resulting in amputation. A recent study indicates that early revascularization may prevent this progression. Revascularization was associated with a 40% reduction in amputation rates in patients with PAD, according to research that evaluated 1906 procedures over 2 decades. The investigators found that as use of revascularization to improve circulation rose, the amputation rate dropped. The study covered 1990 to 2009.
The prevalence of PAD is 20% higher in the diabetic population. People with diabetic-related amputation have a significant degree of PAD but there is a distinct group of amputees who have PAD alone. Some studies have found that 1 of 3 people older than 50 with diabetes has PAD, and PAD is even more common in African American and Hispanic patients who have diabetes. People who have both diseases are much more likely to have a heart attack or stroke than those who have PAD alone. Because many people with diabetes do not have feeling in their feet or legs due to nerve disease, they may have PAD but cannot feel any symptoms. Ankle brachial index is a simple, sensitive, and specific test that is essential for primary health care providers to use as a screen. Guidelines released by leading vascular organizations recommend that people older than 50 with diabetes are tested for PAD. Testing is also recommended for people younger than 50 with diabetes and with other risk factors, such as smoking, high blood pressure, or cholesterol problems. PAD warning signs, which include fatigue and tiredness or pain in your feet, legs, thighs, or buttocks that always happens when you walk but that goes away when you rest, cannot be ignored. Unfortunately, most people with PAD do not have any symptoms until the disease is significantly advanced.
Diabetes
Diabetes is a leading cause of nontraumatic lower extremity amputations (NLEAs). Rates of NLEAs serve as an important gauge of the effectiveness of efforts to reduce diabetes complications because they are associated with numerous modifiable risk factors, including high blood pressure, high lipid and glycemic levels, and screening and care for high-risk feet. The number of US residents with diagnosed diabetes increased dramatically from 5.4 million in 1988 to 26.0 million in 2012, or 8% of the population. The estimated number of diabetes-related NLEAs has been reported to be approximately 200 a day in the United States. One recent study found that the rate of amputation may be declining among Americans with diabetes.
Rates of foot and leg amputations among Americans with diabetes may vary widely according to where they live. In a recent study, researchers found that in some parts of the country the rate can be almost double the national average, at least among older Americans. The investigators reported that in 2008, certain pockets of Arkansas, Louisiana, Mississippi, Oklahoma, and Texas had the highest rates of diabetes-related amputation among Medicare beneficiaries at approximately 7.5 per 1000. That compared with a national rate of 4.5 per 1000 in the same year. Certain locations, such as portions of Arizona, Florida, Michigan, and New Mexico, had particularly low rates. There, older adults with diabetes had amputations at a rate of 2.4 to 3.5 per 1000.
In very basic terms, amputation is a complication of diabetes because the disease often causes nerve damage over time. The architecture of the foot changes and thus the standard contoured shoe becomes an ill-fitting shoe and a source of injury to the foot. When people lose sensation in their feet and legs, they may not notice an abrasion, blister, or sore. Most people without normal pain sensation are less likely to notice, become alarmed, and get help until the injury becomes infected. Those wounds can be difficult to heal because diabetes often causes poor blood circulation to the distal lower limbs. A large number persons with diabetic-related limb loss do not seek attention for their foot until presenting to the emergency department with extensive infection and/or irreversible ischemia. Infection spreads into the deep tissues, often quickly, and in many cases amputation of part of the foot or leg is necessary to prevent a dangerous, systemic infection.
It is unusual to find a diabetic patient with limb loss who understood before the amputation that he or she was at significant risk for limb loss because of diabetes. The usual response is that “I had no idea this could happen,” even though it is known that limb amputation rate is 8 times higher among people with diabetes than the nondiabetic population. This is a failure of understanding and information transfer by our health care professionals to those who are at risk: the patients they serve.
Obesity
Limb loss and “the obesity paradox”
Two-thirds of US adults are overweight or obese. If obesity rates continue on their current trajectories, by 2030, 13 states could have adult obesity rates higher than 60%, 39 states could have rates higher than 50%, and all 50 states could have rates higher than 44%. The number of obese adults, along with related disease rates and health care costs, are on course to increase dramatically in every state in the country over the next 20 years, according to F as in Fat: How Obesity Threatens America’s Future 2012 . This report suggests that states could prevent obesity-related diseases and dramatically reduce health care costs if they reduced the average body mass index (BMI) of their residents by just 5% by 2030.
Obesity is a precursor to adult-onset diabetes. It has been well established that obesity promotes insulin resistance through the inappropriate inactivation of a gluconeogenesis, where the liver creates glucose for fuel and which ordinarily occurs only in times of fasting. One would predict higher rates of NLEA, given this significant link and epidemic of those with obesity and related diabetes. Paradoxically, a recent study has shown a higher BMI is associated with lower 5-year NLEA risk among nonelderly diabetic men. Individuals with BMI (morbidly obese) of 40.0 kg/m 2 or higher are almost half as likely to have any or major NLEA at the 5-year follow-up than those with BMI (overweight) of 25.0 to 29.9 kg/m 2 . These results run counter to an extensive body of literature that suggests obesity is associated with adverse health outcomes in the general population as well as among diabetic patients.
It needs to be highlighted that this nonelderly population is in contrast to the elderly diabetic population who experience most of the limb loss in the United States. It is unclear if the morbidly obese survive to these older ages, as according to the National Obesity Observatory, life expectancy is reduced 10 years for those with a BMI higher than 40 kg/m 2 . This paradox is also interesting when considering the finding that showed a significant J-shaped association between BMI and foot ulceration. Those with BMI higher than 40 kg/m 2 were found to be twice more likely to develop foot ulceration during a 5-year follow-up than overweight individuals. Because foot ulcers are the single most important risk for NLEA, results that showed decreasing NLEA risk with increasing BMI are unexpected. The reason for the paradox is yet to be explained; possibly, severely obese individuals experience more foot ulceration as well as better wound healing than individuals with lower BMI.
Weight gain after limb loss
Those with limb loss have been found to be at particular risk of developing an increase in body fat after amputation along with the associated obesity-related diseases. Given the limb loss and change in body mass there is no current accurate BMI guide that defines one across the spectrum as underweight through morbidly obese. Despite this, a study of NLEA among participants in the National Health and Nutrition Examination Survey (NHANES) Epidemiologic Follow-up Study found that people with lower extremity amputation had a higher baseline BMI than those without a lower extremity amputation. The increases in body fat have been linked directly with higher amputation level. The frequency of obesity increased with the level of amputation. For example, obesity rates in those with unilateral transtibial amputation equaled 37.9%; in those with transfemoral amputation, 48.0%; and in subjects with bilateral transfemoral or transfemoral plus transtibial amputation, 64.2%. Obesity progressed early during the first year after amputation. BMI failed to correlate with functional outcome and, specifically, obesity did not predict a poorer prognosis.
In a comprehensive rehabilitation program it is important to start education and counseling regarding nutrition, exercise, and the threat of obesity. Creating understanding of the significant threat of obesity after limb loss allows the patient with limb loss to make better choices. It also allows the rehabilitation team to set goals not just around mobility but about weight control and cardiovascular health. In a comprehensive amputee specialty program in which lifetime follow-up is possible, monitoring weight gain and providing strategies for control are integral interventions. Weight gain of as little as 10 pounds can change the customized fit of the socket causing skin irritation and gait dysfunction.
Health disparity
In the United States there is a significant health disparities exist within the limb loss community, as 42% of those with limb loss are identified as belonging to a racial or ethnic minority group (LLTF). Even though access to care has improved remarkably for racial minorities over the past 2 decades, it is known that minorities are disproportionately affected by multiple barriers to care: grounded in financial, language, cultural, logistical, organizational, institutional, and systemic differences. Providing adequate access to care may not be sufficient to eliminate ethnic disparities in health. In the Health Disparities and Inequities Report of 2011 by the Centers for Disease Control and Prevention (CDC), minority groups were overrepresented in every diagnostic category monitored except suicide and drug-induced death, where whites prevailed. Minorities have been noted to participate to a greater extent in adverse health risk behaviors, demonstrate decreased compliance with prescribed medical treatment, and have concerns about their ability to trust medical providers. African-American and Hispanic individuals were less likely to use most preventive services when compared with non-Hispanic white individuals.
African American Individuals
Higher amputation rates among black patients may be the result of less aggressive limb salvage care. Black patients with PAD undergo amputation at 2 to 4 times the rate of white patients. Black and Hispanic patients with PAD and diabetes experience a greater incidence and odds of amputation when compared with non-Hispanic white patients. In addition, the literature also supports a greater severity of amputation as expressed by higher amputation levels among minorities compared with non-Hispanic white patients. Black female patients have been reported to have greater than 7 times the rate of amputation than white women. Several studies have reported minority patients are much less likely to receive preventive vascular screenings and procedures. Black patients are much less likely than white patients to undergo attempts at limb salvage before amputation. Elderly black amputees were significantly less likely than white amputees to have undergone 1, 2, 3, or more revascularizations before amputation.
Many studies have evaluated what happens to black and white patients who present to a hospital with limb ischemia. In general, these studies have shown that black patients more frequently undergo amputation, and white patients more frequently undergo revascularization. Whether this disparity can be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making is unclear. Reasons for this disparity are likely to include differences in insurance coverage, socioeconomic status, comorbid conditions, or pattern or severity of disease at presentation, but studies have not been able to eliminate a persistent difference in amputation rates due to race. It is unknown if a biologic difference in the pattern or progression of arterial disease among black compared with white patients exists that may preclude revascularization as a viable means of preventing or delaying amputation. Data suggest that black patients do not present later with more advanced disease than white patients as an explanation of this disparity. It is interesting that toe amputation is the single procedure for which black and white patients saw similar rates before major lower extremity amputation, which suggests a true racial disparity with regard to attempts at limb salvage before major amputation in the black population. Shamefully, with this overwhelming amount of data and evidence there is no concerted, focused program in the United States addressing limb loss among minority groups; particularly in the African American subgroup. This is another example of the person at risk for limb loss or with limb loss being forgotten in our fragmented health care system.
Native Americans
Diabetes is the fourth leading cause of death among American Indians and Alaska Natives, and mortality due to diabetes among American Indians and Alaska Natives is 4 times higher than that of the US general population. Heart disease, the leading cause of American Indian and Alaska Native mortality, appears to be more often fatal among American Indians than in other populations. The morbidity burden among the American Indian with diabetes exceeded that of other US adults with diabetes by 50%.
American Indian adults with diabetes were significantly more likely to have renal failure, lower-extremity amputations, and neuropathy than were other US adults with diabetes. The rate for amputations among American Indian adults was greater than 10 times that of other US adults. The Strong Heart Study is a study of cardiovascular disease and its risk factors in 13 American Indian communities. Data on the presence or absence of amputations were collected at each of 3 serial examinations (1989–1992, 1993–1995, and 1997–1999) by direct examination of the lower extremity. Of the 1974 individuals with diabetes and without NLEA at baseline, 87 (4.4%) experienced an LEA during 8 years of follow-up. Amputation of toes was most common, followed by transtibial and transfemoral amputations. Odds of LEA were higher among individuals with unfavorable combinations of risk factors, such as high ankle-brachial index (1.40), longer duration of diabetes, less than a high school education, and elevated HbA(1c). The adjusted risk of LEA in men was twice that of women. For the Native American patients there has been educational programmatic outreach by the CDC through the Amputee Coalition. This can be a model used for other minority groups at risk.
The Importance of Focused Education
The importance of education in reducing risk of LEA was shown in a previous study of black and white Americans in the NHANES Epidemiologic Follow-up Study. This study showed that although there were substantially higher age-adjusted rates of lower extremity amputation in African-Americans, compared with white Americans, this excess risk was eliminated when the presence of a high school education was considered, along with age, diabetes, smoking, and hypertension. Of particular interest in this report and the Strong Heart Study is the nearly identical adjusted risk estimates associated with having a high school education: in the NHANES Follow-up Study, the adjusted risk estimate for LEA associated with having completed high school was 0.47, and the corresponding risk estimate in the Strong Heart Study was 0.46. Thus, in African-American and American Indian populations, completing high school reduces the risk of LEA by greater than 50%. Understanding the importance of education and specifically the risk level for those who have not completed a high school level of education allows public health measures to be targeted and efficient. Finally, the higher risk in American Indian males compared with females is interesting and may be related to more severe peripheral neuropathy. For example it is known that there is less peripheral neuropathy and lower rates of NLEA in diabetic South Asians compared to Europeans. It is also possible that men experience more minor trauma to the foot that ultimately results in NLEA. Both of which stress the importance of identifying the neuropathy early in those at risk and educating those at higher risk for limb loss about importance of monitoring their feet at all times.
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