Abstract

Lower-extremity amputations related to diabetes and Peripheral Artery Disease (PAD) continue to disproportionately affect populations in the southern United States, a region often referred to as the “Diabetic Belt.” This article synthesizes key insights presented by Dr. Luso Bakari in a recent public health lecture focused on amputation prevention, highlighting the clinical, socioeconomic, and systemic factors driving the amputation crisis. The discussion underscores the significant cardiovascular burden among diabetic patients, the urgent need for early PAD detection, and the critical role of multidisciplinary, community-centered care models. This paper aims to promote awareness, inform primary care providers, and encourage policy-level change to reduce avoidable amputations and improve cardiovascular outcomes across high-risk populations.

Introduction

The southern United States exhibits some of the highest rates of diabetes, cardiovascular disease, and diabetes-related amputations in the nation. This cluster of disproportionately high risk has led researchers to label the region the “Diabetic Belt.” Despite advances in vascular medicine, early detection strategies, and interventional treatments, thousands of preventable amputations occur annually—many among minority and underserved communities.

In his presentation for the Tennessee Heart Health Network, Dr. Luso Bakari emphasized the urgent need to redesign care pathways for diabetic patients at risk of PAD and lower-limb complications. He detailed how structural inequality, clinical oversight, and delayed diagnosis contribute to unnecessary amputations—procedures associated with an 80% five-year mortality rate among diabetic patients.

The Burden of Amputation in the Diabetic Belt

1. High Prevalence of Diabetes and PAD

The southern states—particularly Tennessee, Mississippi, Alabama, Georgia, and Louisiana—show elevated rates of:

• Type 2 diabetes
• Hypertension
• Obesity
• Smoking
• Social vulnerability (poverty, limited access to specialty care)

Peripheral Artery Disease, a progressive narrowing of peripheral arteries, is common among diabetic patients yet often underdiagnosed until advanced stages.

2. The Mortality Connection

Amputation represents the end stage of systemic vascular disease. Dr. Bakari highlighted that:

• Up to 80% of diabetic patients undergoing major amputation die within five years.
• The primary cause of death is cardiovascular disease.
• Early detection of PAD significantly lowers mortality risk but is often missed in primary care settings.

Systemic Factors Driving Preventable Amputations

1. Underinvestment in Prevention

The U.S. spends substantially more on amputation procedures and postoperative care than on preventive screening and early intervention for PAD.

2. Delayed Diagnosis

Many high-risk patients do not receive essential evaluations such as:

• Ankle-brachial index (ABI) testing
• Vascular assessments
• Routine foot examinations
• PAD symptom education

This delay allows ischemia and diabetic ulcers to progress until amputation is the only option.

3. Geographic and Racial Disparities

The Diabetic Belt overlaps with:

• Rural regions lacking specialists
• Counties with high Black American populations
• Historically underserved communities

These populations face disproportionate risk of delayed treatment, misdiagnosis, and limb loss.

Advances in Limb Preservation

Dr. Bakari’s work in Mississippi showed that aggressive screening, multidisciplinary collaboration, and prompt intervention can reduce amputation rates by up to 88% in four years.

1. Early PAD Screening

• ABI testing
• Toe-brachial index
• Duplex ultrasound
• Routine foot inspection

2. Rapid-Response Vascular Care

Timely endovascular procedures restore blood flow, prevent ulcer progression, and avoid major amputation.

3. Community Education

Public health programs teaching patients to recognize early symptoms—such as rest pain, color changes, or non-healing wounds—significantly increase early intervention.

4. Multidisciplinary Collaboration

Effective models bring together:

• Primary care physicians
• Cardiologists
• Interventional vascular specialists
• Podiatrists
• Endocrinologists
• Wound care teams
• Community health workers

Policy and System-Level Recommendations

Dr. Bakari has advocated federally for improved PAD care standards, contributing to the establishment of the first bipartisan congressional PAD caucus. Key recommendations include:

1. National PAD Screening Standards

Mandatory ABI testing for high-risk diabetic patients.

2. Coverage Expansion

Ensuring Medicare, Medicaid, and private insurance reimburse preventive screening at levels comparable to amputation procedures.

3. Community-Based Prevention

Investing in local clinics, mobile vascular units, and targeted public health campaigns.

4. Data-Driven Accountability

Tracking amputation rates across hospitals and counties to identify disparities and intervene earlier.

Conclusion

Amputation prevention in the Diabetic Belt is both a medical and moral imperative. Evidence presented by Dr. Bakari demonstrates that early detection, interdisciplinary care, and systemic reform can dramatically reduce preventable amputations and improve cardiovascular survival.

Reducing diabetes-related limb loss requires:

• Empowered primary care providers
• Informed patients
• Improved reimbursement policies
• Community engagement
• Coordinated vascular care

By adopting these strategies, the United States can significantly reduce the impact of preventable amputations and improve long-term outcomes for millions of high-risk individuals.