In a Jamaica Observer article of October 19, 2019, it was revealed that Jamaica leads the world in the rate of limb amputations.

Dr Ragoobirsingh, who is a University of West Indies (UWI) professor of medical biochemistry and diabetology, was quoted in the article as stating that Jamaica has one amputation per 1,500 diabetic patients and enjoys the unenviable position of being the amputation capital of the world.

Most amputations are related to complications from poorly controlled diabetes or untreated vascular disease of the lower extremities. The prevalence for diabetes in Jamaica is about eight to 10 per cent. Among Jamaican women the rate is 9.3 per cent compared with 6.4 per cent for men. In the Caribbean Basin, the prevalence of diabetes is thought to be about eight to 15 per cent. The actual prevalence of lower extremity vascular disease in Jamaica is not established.

In 2003, the worldwide prevalence of diabetes was estimated at 5.1 per cent among persons between 20 and 79 years of age. By 2025, the worldwide prevalence is projected to rise to 6.3 per cent – a 24 per cent increase compared with 2003. In numerical terms, the global estimate for diabetes was 194 million people, a figure that is projected to rise to 333 million people by the year 2025. The World Health Organization estimates that by 2025, prevalence rates for diabetes in developing countries will increase by 170 per cent from 84 million to 228 million representing about 70 per cent of diabetics worldwide.

The World Health Organization (WHO) estimates from 2001 show that 959,000 deaths worldwide were caused by diabetes, accounting for 1.6 per cent of all deaths, and approximately three per cent of all deaths caused by non-communicable diseases. 

How does diabetes affect the lower limbs and lead to amputation?

The impact of diabetes on the legs is multifactorial involving the blood vessels (peripheral artery disease) and nerves to the lower extremities (peripheral neuropathy) as well as the poor wound healing commonly seen in the diabetic population especially those with poor diabetic control. 

Peripheral artery disease (PAD)

Peripheral artery disease (PAD) is a frequent complication of diabetes that can lead to limb loss through amputation. PAD is a type of atherosclerosis, like coronary artery disease. Atherosclerosis is a process resulting in the accumulation of cholesterol and fibrous tissue in the walls of arteries. This process over time leads to the obstruction of blood vessels and poor blood flow to the organs supplied. Diabetes is a risk factor for the development of atherosclerosis and can affect several areas of the body including the lower extremities. Inadequate blood flow to the legs may not produce any symptoms initially. However, patients may experience many symptoms including claudication (pain in the legs when walking), ulceration of the skin, pain in the legs at rest, loss of hair on the legs, loss or change in sensation, loss of muscle mass and death of parts of the leg requiring amputation.

Lower extremity atherosclerosis (PAD) affects an estimated 8.5 million people in the United States and up to 200 million worldwide. The exact number of affected people in Jamaica is not known, mainly because only scant attention has been paid to this disease in Jamaica. PAD is found in one in five individuals older than age 60 years. It is the third most common manifestation of atherosclerosis after coronary artery disease and cerebrovascular disease or stroke.

PAD is often under-diagnosed and inadequately treated and death rates from PADs are continuing to rise. If left untreated, PAD is progressive and can lead to frequent hospitalisations, limb amputation, and death. Peripheral artery disease is also associated with coronary heart disease and cerebrovascular disease. Nearly one out of two individuals with PAD will experience a heart attack, stroke, vascular death, or hospitalisation over a three-year period. Research from the Heart Institute of the Caribbean cardiologists indicate that PAD is a significant problem among Jamaican patients with diabetes, underlying coronary artery disease and those older than 60 years old. 

Lower extremity infections in the diabetic patient (The diabetic foot)

The second diabetic complication leading to amputation is diabetic foot. This is a severe infection of the lower extremity leading to large areas of tissue death which, unfortunately, will need to be surgically excised or amputated. There are several reasons for increased susceptibility to lower extremity infection in diabetics.

Diabetics often have what is known as a peripheral neuropathy in which there is poor sensation to the hands and feet. This may result in a high incidence of skin breakdown from traumatic injury to the feet. These episodes of injury may be relatively mild and given the absence of pain sensation, the patient may be unaware of the injury. Open wounds in a diabetic patient that are untreated over time have a high risk of becoming infected. In addition to injury, the elevated blood sugars, and insulin deficiency in the diabetic patient lead to immune dysfunction with decreased chemical and cellular response to infection. This makes any infective process in a diabetic patient more difficult to overcome than in the normal non-diabetic population. PAD also plays a role as adequate blood flow and adequate oxygen delivery are important parts of the body’s response to an infected area. Poor blood flow in PAD impairs the immune response and wound healing and increases the risk of limb loss and possible amputation. 

Why should amputations be avoided?

If a person loses some part of his body by amputation because of diabetes or peripheral artery disease, the risk for death is significantly increased.

All amputations adversely impact the survival of patients with diabetes or PAD; however, a person’s rate of survival depends on what type of amputation that is done. According to data from multiple publications, once you have an amputation, you are literally marked for death. Twenty-five per cent of those with amputation of a toe die within five years.

For those with “below the knee amputation”, about 50 per cent will be dead in five years. The story is much worse for those with above the knee amputation with more than eight out of 10 dying within five years. The grim outcome following amputations in patients with diabetes or PAD should serve as a strong stimulus to do all we can to avoid the complications from poor circulation and infections in these patients that would lead to amputations and to consider alternative treatment strategies in these patients short of amputations. 

How can you avoid amputations if you have been diagnosed with diabetes?

The simple answer is to follow your treatment recommendations religiously, pay close attention to your feet and report early signs of poor circulation or infection to your physician and ensure that you are treated aggressively both for the diabetes and the poor circulation and/or infection. This means that patients with diabetes must pay attention to factors that will improve their blood glucose and circulation.

In an interview with the Sunday Observer, reported on September 13, 2014, consultant endocrinologist and head of medicine at UHWI, Professor Michael Boyne proposed a simplified ABCD approach that remains relevant today. A represents A1C, a measure of your blood sugar control, B stands for blood pressure, and C stands for cholesterol, which all are essential in improving your circulation and reducing the risk of complications and possible amputation. Diet (D), exercise (E) and foot care (F) are also important. Smoking must also be avoided or stopped, and blood pressure controlled. 

What is a Vascular Profile Study and how can that help save your legs from amputation? 

A Vascular Profile Study can simply be thought of as a way of determining if the lower extremities have adequate blood flow. There are several methods of doing this, including doing blood pressures at various levels of the lower extremities at rest and with exercise and comparing them to blood pressures in the upper extremities (The ankle brachial index or ABI). If significant obstruction is present, the blood pressures in the legs will be lower than expected. Looking at the volume and velocity of pulses (pulse wave velocity or PWV) in the lower extremities can also give an idea as to the presence and severity of arterial obstruction.

Our team at HIC have demonstrated that Vascular Profile studies are very useful in identifying patients at risk for limb loss in Jamaica. Early diagnosis of PAD will lead to initiation of appropriate treatment and mitigating the risk of future amputation. Once evidence of obstruction is found and the severity estimated, prognostication can be made as to the occurrence of symptoms and of severe sequalae of peripheral arterial disease including the risk of limb loss.

Several leading international professional societies have issued recent guidelines recommending targeted performance of Vascular Profile study in those with diabetes, symptoms of atherosclerosis and at increased risk of PAD. Current guidelines recommend routine vascular profile with the ABI for the following individuals:

• Age 65 years

• Age 50-64 years and a current smoker or has diabetes mellitus

• Age 50 years with diabetes mellitus and an additional risk factor for atherosclerosis

• Known atherosclerosis in another vascular bed (for example, prior heart attack or stroke)

• Symptoms of PAD, such as claudication or other signs of the disease

Adherence to these guidelines has been shown in multiple studies to improve survival, reduce limb amputations and other complications of diabetes and atherosclerosis, improve quality of life for patients and greatly decrease the cost of treatment in the long run. If you have been diagnosed with diabetes or fit into any of the categories above, please demand that your physician obtains a Vascular Profile study on you at least once a year as part of the overall care plan to keep you free from limb amputation. 

Amputation Prevention Programme at HIC

We have recently launched the Amputation Prevention Programme at the Heart Institute of the Caribbean (HIC) and we follow these guidelines strictly on all our patients. The Amputation Prevention Programme at HIC is structured to function as a multi-disciplinary care team that includes internists, general cardiologists, interventional cardiologists, cardiac and vascular surgeons, nutritionists and wound care specialists. All our patients are regularly evaluated with Vascular Profile Study and treatment adjustments made to keep them safe and free from complications and risk of amputation and premature death and disability. In patients with severe peripheral vascular disease, we offer an alternative to amputation using aggressive medical treatment combined with non-surgical peripheral angioplasty or where necessary, surgical bypass techniques to restore circulation in the legs to prevent limb loss. Amputation of the limbs should always be the absolute last option when medical, interventional, and surgical limb preservation techniques have failed. 

Dr Ernest Madu, MD, FACC; and Paul Edwards, MD, FACC are Consultant Cardiologists at Heart Institute of the Caribbean (HIC) and HIC Heart Hospital.

Dr Madu is a main TED Speaker whose talk has been seen and shared by more than 500,000 viewers. He has received the Distinguished Cardiologist Award, the highest award from the American College of Cardiology and has been named among the 100 most influential people in healthcare. Dr Madu is also a recipient of the Global Health Champion Award from the University of Pennsylvania.

Correspondence to info@caribbeanheart.com or call 876-906-2107.