Diabetes-related lower-extremity amputation is often described as a consequence of neuropathy, ischemia, and infection. Those biological drivers are real, but they do not fall evenly across the population. Research from the past decade shows that race, ethnicity, geography, income, and neighbourhood conditions are all associated with who loses a limb, and how early in the course of foot disease care is received. Understanding these patterns is clinically important because many of them point to modifiable gaps in access rather than to differences in disease biology.
The Scale of the Problem
Roughly 1.5 million lower-extremity amputations are performed worldwide each year, and diabetes accounts for an estimated 50 to 70 percent of them (Humphries, 2025). In the United States, age-adjusted amputation incidence among people with diabetes fell by about 43 percent between 2000 and 2010, yet that overall improvement has not been shared equally. A review of racial and ethnic disparities in diabetic foot management reported that diabetes-related amputations are two to four times more likely in Black, Native American, Hispanic, and other minority patients than in non-Hispanic White patients (Clayton et al., 2023). The same review notes that diabetes prevalence itself is higher in several of these groups, which increases the number of people at risk before any difference in care is considered.
Race, Ethnicity, and Amputation Level
Disparities are visible not only in how often amputation occurs, but also in how extensive it is. Clayton and colleagues summarized several large datasets. In a Medicare cohort of nearly 93,000 patients, hazard ratios for major amputation compared with White beneficiaries were 1.9 for Black and 1.8 for Native American beneficiaries. In another Medicare analysis of almost 69,000 patients with a diabetic foot ulcer, Black beneficiaries had an odds ratio of 2.18 for lower-extremity amputation within one year. Earlier work in the Veterans Affairs system found relative risks of 1.74 for Native American, 1.41 for Black, and 1.28 for Hispanic patients compared with White patients. The review also reported that minority patients were more likely to receive proximal, or higher-level, amputations, even after accounting for diabetes status (Clayton et al., 2023).
Why the Differences Persist
Humphries (2025) reviewed the social and structural determinants behind these patterns. Compared with non-Hispanic White individuals, Hispanic or Latino individuals had 46 percent higher odds of poor glycemic control and Black individuals had 28 percent higher odds. Minority patients and those with lower socioeconomic status were also less likely to receive guideline-directed therapy for peripheral artery disease. Importantly, the author notes that Black patients face up to a fourfold higher risk of major amputation even after adjustment for age and sex, suggesting that demographic factors alone do not explain the gap.
Geography and Neighbourhood Conditions
Where a person lives matters as well. In a cohort of 124,487 Medicare beneficiaries hospitalized with diabetic foot ulcers, the combined outcome of major amputation or death within 30 days of discharge occurred in 17.6 percent overall, 18.3 percent among rural residents, and 21.9 percent among Black patients. Among patients who were both rural and Black, the rate reached 28.0 percent, and the authors identified a significant interaction between race and rurality (Brennan et al., 2022). The pattern suggests that disadvantages can compound rather than simply add together.
Area-level economics show a similar gradient. Humphries (2025) reports that each $10,000 decrease in median household income was associated with a 4.4 percent increase in amputation rates, and that a 10-point increase on the Distressed Communities Index corresponded to a 3 to 16 percent rise. Living in a food desert was associated with roughly double the risk of postoperative wound complications, most often infection. Low health literacy was also strongly linked to amputation: in a 2024 study cited in the review, patients who required amputation were eight times more likely to have low health literacy.
Gaps in the Evidence
The available data have limitations. Much of the evidence is observational and based on administrative claims, which cannot fully separate delayed presentation, differences in referral patterns, insurance coverage, and clinician decision-making. Clayton and colleagues also observed that recent trials of new diabetic foot ulcer treatments in the United States rarely enrol racially diverse cohorts, which limits how confidently results can be generalized (Clayton et al., 2023). Most of the cited studies come from the United States, and findings may not transfer directly to other health systems.
Clinical Summary
Amputation risk in diabetes reflects both biology and social context. The evidence shows consistently higher rates of major and proximal amputation among Black, Native American, and Hispanic patients, compounded by rural residence, lower neighbourhood income, food insecurity, and limited health literacy. Differences in glycemic control and in access to guideline-directed vascular care appear to contribute. Because these contributors are largely modifiable, they are a recognized focus for epidemiological monitoring, early foot screening, and equitable access to limb-preserving care.
References
- Brennan MB, Powell WR, Kaiksow F, et al. Association of race, ethnicity, and rurality with major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers. JAMA Network Open. 2022;5(4):e228399.
- Clayton EO, Njoku-Austin C, Scott DM, Cain JD, Hogan MV. Racial and ethnic disparities in the management of diabetic feet. Current Reviews in Musculoskeletal Medicine. 2023;16(11):550-556.
- Humphries MD. Social and structural determinants of lower extremity amputations in diabetes. Current Diabetes Reports. 2025;25(1):40.
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