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Lower Extremity Amputations Among Persons with Diabetes Mellitus -- Washington, 1988

Diabetes mellitus is the leading cause of lower extremity amputations (LEAs) in the United States, accounting for approximately 50% of all nontraumatic LEAs (1). To assist public health programs in preventing diabetes-related LEAs in Washington state, the diabetes-control program of the Washington Department of Health characterizes LEAs. This report summarizes an analysis of the incidence of LEAs during 1988 among Washington residents with and without diabetes.

The analysis included all hospitalizations in Washington in 1988 except hospitalizations from Veterans Administration, military, and psychiatric facilities. The criterion for LEA classification was any International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedural code of 84.10-84.19 recorded on state hospital discharge records; cases of traumatic amputation (ICD-9-CM diagnostic codes 800-995.89) were deleted from the analysis. The criterion for diabetes classification was any ICD-9-CM diagnostic code of 250.0-250.9 listed among the discharge diagnoses. Estimates of the number of persons with diabetes were calculated by applying National Health Interview Survey diabetes prevalence rates for 1988 to Washington population estimates for 1988. The population-attributable risk (PAR)--the proportion of all new nontraumatic amputations associated with diabetes--was calculated using a standard formula (2).

In 1988, 1087 residents of Washington had nontraumatic LEAs; 543 (50%) of these persons had diabetes. Although the overall rate of LEA among persons with diabetes was 5.1 per 1000 persons (95% confidence interval (CI)=4.7-5.5), county-specific rates varied substantially, ranging from 1.6 per 1000 (95% CI=0.5-2.7) to 11.7 per 1000 (95% CI=6.8-16.6).

The incidence rate of LEA for persons with diabetes was substantially higher for males (5.3 per 1000 (95% CI=4.7-5.9)) than for females (3.6 per 1000 (95% CI=3.1-4.1)). Compared with females without diabetes, the risk for LEA was greatest for females aged less than 45 years (relative risk (RR)=218.1; 95% CI=123.6-384.7) and lowest for females aged greater than or equal to 75 years (RR=6.0; 95% CI=4.5-8.1) (Table 1).*

Among persons with diabetes, the rate of LEA was more than 40 times that for persons without diabetes. Based on PAR calculations for males and females, depending on age, 38%-66% and 30%-69% of all nontraumatic LEAs, respectively, were directly attributed to diabetes. Reported by: FA Connell, MD, Univ of Washington, Seattle; C Shaw, MPH, J Will, PhD, Washington Dept of Health. Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The clinical and pathologic changes that necessitate LEA in persons with diabetes are related to several problems, including peripheral neuropathy, peripheral vascular disease, and infection (3). For example, peripheral neuropathy may result in loss of sensation in the feet and the development of foot deformities; these deformities, in turn, can cause pressure points that may ulcerate. Inadequate blood supply and infection may then result in osteomyelitis and gangrene that necessitate LEA.

Based on national surveillance data, in 1987 there were approximately 56,000 LEAs among persons with diabetes in the United States--a hospital discharge rate of 8.2 per 1000 persons with diabetes (4). One of the national health objectives for the year 2000 is to reduce this rate to 4.9 per 1000 persons with diabetes (5). The risk for LEA within the population with diabetes increases by age and by the duration of diabetes. Therefore, to achieve the national objective, clinicians must promptly identify persons who are at increased risk, take measures to both treat and prevent foot ulcers, and prevent the recurrence of foot ulcers (6).

In the United States, an estimated 44%-85% of LEAs among persons with diabetes can be prevented with improved foot-care programs (7). This will require clinicians to provide patients with information about proper foot care and the need for daily foot inspection as well as intensified collaboration among medical and public health practitioners. For example, CDC has provided recommendations for identifying when patients' feet are at increased risk, preventing and treating foot ulcers, halting the recurrence of foot ulcers, and educating patients and their families about proper foot care (8).

State and county surveillance data, such as those developed by the Washington Department of Health, will assist public health practitioners and health-care providers in directing services to the populations with greatest need and track progress toward the year 2000 objective. By using this approach, 44%-85% of all diabetes-related LEAs in the United States may be prevented (7); for example, in Washington approximately 240-460 LEAs could be prevented each year with appropriate targeting of improved foot-care programs. The Washington State Diabetes Control Program provides community health centers and hospitals with educational materials and technical assistance to prevent diabetes-related LEAs; based on the analysis in this report, such resources can be targeted especially toward counties that have high rates of diabetes-related LEAs.


  1. Most RS, Sinnock P. The epidemiology of lower extremity amputations in diabetic individuals. Diabetes Care 1983;6:87-91.

  2. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research: principles and quantitative methods. 1st ed. Belmont, California: Lifetime Learning Publications, 1982.

  3. Palumbo PJ, Melton LJ. Peripheral vascular disease and diabetes. Chapter XV. In: Harris M, ed. Diabetes in America. Washington, DC: US Department of Health and Human Services, Public Health Service, National Institutes of Health, 1985; NIH publication no. 85-1468.

  4. CDC. Diabetes surveillance, 1980-1987. Atlanta: US Department of Health and Human Ser vices, Public Health Service, 1990.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives--full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

  6. Levin ME, O'Neal LW, eds. The diabetic foot. 4th ed. St. Louis: CV Mosby, 1988.

  7. Bild DE, Selby JV, Sinnock P, Browner WS, Braverman P, Showstack JA. Lower extremity amputation in people with diabetes: epidemiology and prevention. Diabetes Care 1989;12:24-31.

  8. CDC. The prevention and treatment of complications of diabetes mellitus: guide for primary care practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

*Seventy percent of the study's population (95% confidence interval=64%-76%) was diagnosed with eye disease (i.e., nonproliferative diabetic retinopathy, preproliferative diabetic retinop athy, proliferative diabetic retinopathy, diabetic maculopathy, cataracts, or glaucoma) at or within 1 year of evaluation by a diabetes-control program.

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