Unequal Cut in Limb Amputations: Diabetes and Health Disparity in the United States

This paper discusses the diabetes “epidemic” (U.S. Centers for Disease Control and Prevention, [herein after CDC] https://www.cdc.gov/diabetes/library/features/diabetes-stat-report.html) in the United States. Specifically, the paper will discuss the racial disparity in diabetes disease prevalence and impacts between African Americans and Whites in the United States. The disproportionate prevalence, impacts, treatment, and care of diabetes between African Americans and Whites is particularly manifested in the diabetes related lower extremity amputations (LEA) undergone by African Americans compared to their White counterparts pertinent to causal, predisposing, and preventive factors. Through comparative analysis and using diabetic amputation rates, extant LEA encounter studies and data in the literature will be used to analyze and demonstrate “The Black American Amputation Epidemic” with implications for public policy and public health. Methodically, the paper conducted systematic review and meta-analysis of observational studies, government reports, secondary data, PubMed articles, Google Scholar Databases, published references. Consistent with existing empirical literature, the paper find and conclude that African Americans and other racial minorities suffer disproportionate preventable diabetes induced LEAs and deaths compared to Whites, further widening racial health care disparity problem. In addition, the paper adds to the body of knowledge and awareness of the increasing problem of diabetes on the African American population health germane to public policy intervention to reduce, if not totally eliminate the problem. Policy interventions including robust diabetes mitigation policy and leadership in the American health care system, more funding, research, education, better management, and preventive care for all patients at risk of amputation should be pursued, especially focusing on the historically underserved population. In this paper, the terms “Black (s),” “Black Americans,” “African Americans,” “racial minorities” and “people of color” are used interchangeably.


I. Introduction
Globally, according to the World Health Organization [herein after WHO] the number of people with diabetes increased from 108 million in 1980 to 422 million in 2014, while the prevalence of diabetes among adults over 18 years of age rose from 4. 7% in 19807% in to 8.5% in 20147% in (WHO, 2020. In 2016, worldwide, an estimated 1.6 million deaths were directly caused by diabetes, and between 2000 and 2016, there was a 5% increase in premature mortality from diabetes (WHO, 2020). Aside being the major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation (WHO, 2020), diabetes exacerbates major infectious diseases such as tuberculosis (TB), malaria and HIV/AIDS (WHO, 2012). People with diabetes are three times more likely to develop TB when infected and approximately 15% of TB globally is thought to be due to diabetes (WHO, 2012). The economic costs of diabetes is also enormous.
In its "Global Report on Diabetes 2016" the WHO stated: "Diabetes and its complications bring about substantial economic loss to people with diabetes and their families, and to health systems and national economies through direct medical costs and loss of work and wages. While the major cost drivers are hospital and outpatient care, a contributing factor is the rise in cost for analog insulins 2 which are increasingly prescribed despite little evidence that they provide significant advantages over cheaper human insulins" (p. 6). The United States is not immune to the global diabetes problem.
There are 34.2 million people (10.5% of the population) in the United States with diabetes (CDC, National Diabetes Statistics Report 2020, p. 2), 88 million with pre-diabetes (34.5% of the population), and 1.5 million diagnosed new cases of diabetes every year (American Diabetes Association, https://www.diabetes.org/resources/statistics/statistics-about-diabetes). (Table 2). Diabetes is a source of considerable cost to the health care system (Rayman, et al. 2004(Rayman, et al. , p. 1892. In the United States, diabetes and related complications are estimated to result in direct medical costs totaling $237 billion, and $90 billion of   What is Diabetes Diabetes Symptoms Diabetes Risk Factors Diabetes is a chronic disease that affects how the body turns food into energy and uses blood sugar (glucose). When blood sugar rises, it prompts the pancreas to release insulin. Insulin acts like a key to let the blood sugar into the body cells for use as energy.With diabetes, your body either doesn't make enough insulin or can't use it as well as it should.
Family history, age, overweight, inactivity, race or ethnicity, high blood pressure, environmental factors, geography.

Types of Diabetes
Complications Diabetes Tests There are Type 1, Type 2, and gestational diabetes. With Type 1 diabetes, the body immune system which normally fights harmful bacteria or viruses, attacks and destroys the insulin-producing cells in the pancreas. This leaves your body with little or no insulin. Instead of being transported into your cells, sugar builds up in your bloodstream.With Type 2 diabetes your cells become resistant to the action of insulin, and your pancreas is unable to make enough insulin to overcome this resistance. Instead of moving into your cells where it's needed for energy, sugar builds up in your bloodstream. Gestational diabetes is pregnancy related. It occurs when the body cannot make enough insulin during pregnancy.
If you are diabetic you are more likely to have: cardiovascular diseases (e.g. heart attack, coronary artery disease with chest pain, stroke and narrowing of arteries); nerve damage (neuropathy -if left untreated could cause loss of feelings in limbs, for men it may lead to erectile dysfunction); kidney damage (nephropathy -can lead to kidney failure or permanent end-stage kidney disease, which may require dialysis or kidney transplant); eye damage (retinopathy -can cause cataracts and glycoma, and potentially lead to blindness); foot damage (nerve damage in the feet can cause infections to heal poorly, and if left unreated can lead to toe, foot, or leg amputation; hearing impairment (more common in people with diabetes); Alzeimers's disease (diabetes may increase the risk of dementia).
A1C Test (hemoglobin A1C or HBA1c test) measures your average blood sugar level over the past 2 or 3 months. An A1C below 5.7% is normal, between 5.7 and 6.4% indicates you have prediabetes, and 6.5% or higher indicates you have diabetes.

III. Determinants of Diabetes Prevalence
While the reasons for racial disparities in diabetes prevalence are not clear, or "not well understood" (Golden et al. 2019), it has been suggested that behavioral, environmental, socioeconomic, physiological, and family history are risk factors (Signorello et al., 2007;Harris, 1990;Cowie et al., 1993;Harris et al., 1998;Carter, Pugh, & Monterrosa, 1996). These risk factors are collectively referred to as social determinants of health. For the sake of space and brevity, four risk factors of diabetes will be discussed beginning with socioeconomic factor, followed by obesity, environment, and discrimination.

A. Socioeconomic Status
Several studies have found that socioeconomic status is not only strongly correlated with diabetes, but also, diabetes is more prevalent in deprived and depressed minority areas (Link & McKinlay, 2009;Lord, Roberson, & Odoi, 2020;Connolly et al., 2000;Rabi et al., 2006;Jamil et al., 2008;Cunningham et al., 2008;Signorello et al., 2007). Wachtel (2005, p. 334) "family poverty accounts for differences in lower-extremity amputation rates of minorities." One study (Link & McKinlay, 2009), for example, in the Boston Area Community Health (BACH) epidemiology based survey of 5,503 Boston (in the State of Massachusetts, United States) residents aged 30-79 (1,767 Black, 1,877 Hispanic, 1,859 White; 2,301 men and 3,202 women), on socioeconomic status (education and income) covariate, found that "Blacks and Hispanics have statistically significantly increased odds of having diabetes compared to Whites:" Blacks (12.8%), Hispanics (11.6%), and Whites (7.5%). Also, a 2020 study in the State of Florida, United States, based on the state's Behavioral Risk Factor Surveillance System respondents found that "disparities of pre-diabetes and diabetes exist in Florida" but most importantly "income level is a significant predictor of diabetes" (Lord, Roberson, & Odoi, 2013). Another study (Marley & Metzger, 2015) concluded that the "higher rates of obesity and type 2 diabetes in the American Indian young adults than in the general U.S. population can be partially explained by neighborhood poverty" and economic "stress." Piccolo et al. (2014) found "it is likely that non-genetic factors, specifically socioeconomic factors, account for much of the reported racial/ethnic disparities in type 2 diabetes mellitus (T2DM) incidence" and "childhood obesity overweight prevalence" ( Stamatakis & Cole, 2010). Butler (2017) investigation concluded "low family income and parental education…are common negative social determinants of health (SDOH) among families of youth with type 2 diabetes mellitus (T2DM)." Piccolo et al. (2016) study of "joint contributions of competing risk factors for T2DM" found that "socioeconomic factors had the greatest impact on explaining the excess prevalence of T2DM among racial/ethnic minorities." In addition, in a study of the "50 most populous US cities," Rosenstock et al (2014, p. 883) found that "nearly 75 % of the disparity in diabetes mortality rates between African Americans and Whites was explained by economic inequality and segregation." The WHO summarized it neatly in its "Global Report on Diabetes 2016" (p.4): …"diabetes and its complications impact harshly on the finances of individuals and their families, and the economies of nations. People with diabetes who depend on life-saving insulin pay the ultimate price when access to affordable insulin is lacking." B. Obesity Obesity can be defined as an excessive amount of fat that increases the risk of medical illness and premature death (Fock & Khoo, 2013). According to WHO, obesity has nearly tripled since 1975 (WHO, 2020). In 2016, more than 1.9 billion adults aged 18 years and older were overweight, with 13% being obese (WHO, 2020). In addition, in 2019, at least 40 million children under the age of 5 were overweight or obese (WHO, 2020). According to WHO, the main drivers of obesity include poor and misaligned diet, insufficient physical activity, sedentary lifestyle, changing mode of transportation, increasing urbanization (WHO, 2020). The United States is no exception.
In the United States, it is forecast "a 33% increase in obesity prevalence and a 130% increase in severe obesity prevalence over the next 2 decades (Finkelstein et al., 2012). Also, in the United States (and globally) obesity has been found to be a major risk factor for diabetes (CDC, 2019; Alonso, Decora, & Bauer, 2019; Bhupathiraju & Hu, 2016;Chobot et al., 2018;OECD, 2019), especially among "African Americans compared with all other race and Hispanic origin groups" (Hales et al. 2020). The close relationship between obesity and diabetes has led to the connotation 'diabesity,' meaning that the majority of individuals with diabetes are overweight or obese (Leitner et al. 2017). Tajik et al. (2019) "being classified as overweight and obese increased the risk of T2DM in comparison with normal weight. Metabolically unhealthy (MUH) individuals are at higher risk of T2DM in all categories of body mass index (BMI) compared with metabolically healthy individuals." In concordance, Janghorbani et al. (2017) "obesity is a risk factor for T2D with individuals who are metabolically healthy obese (MHO), metabolically unhealthy overweight (MUOW), and metabolically unhealthy obese (MUO) in excess risk of T2D." The economic costs due to obesity can be burdensome (Loureiro & Nayga, 2005).
In the United States, for example, in 1990 the total economic cost of diabetes associated disease was put at estimated $68.8 billion, with direct cost of $45.8 billion and indirect cost of $23 billion (Wolf & Colditz, 1994). Five years later in 1995, the total cost attributable to obesity amounted to $99. 2 billion (5.7% of U.S. national health expenditure), out of which nearly $52 billion were direct medical costs, and approximately $4 billion in lost productivity, reflecting 39.2 million days of lost work (Wolf & Colditz, 2012). Currently in the United States, medical costs attributed to obesity were estimated $149.4 billion (Kim & Basu, 2016). In contrast, if obesity in the United States were to remain at 2010 levels, the combined savings in medical expenditures over the next 2 decades would be $549.5 billion (Finkelstein et al., 2012). Comparatively, the economic cost of obesity in the United States is similar to what is obtainable in "other industrialized countries which indicate that the cost of obesity is between 2% to 5% of the total cost of health care in industrialized nations" (Levy, Levy, & Basdevant, 1995). A recent report by the Organization for Economic Cooperation and Development (OECD), a body of industrialized economies, found that OECD spend estimated $311 billion annually to treat obesity induced diseases (OECD, 2019, p. 75). Overall, obesity will cost the 52 OECD countries $425 billion per year, equating to average of 3.3% lower GDP, and 8% of total health spending (OECD, 2019, p. 75). Obesity is linked to environmental risk factor. C. Environmental Risk The influence of neighborhood and environmental factors on health is increasingly being recognized and studied in the recent years (Dendup et al, 2018;Diez Roux & Mair, 2010;Black & Macinko, 2008;Marshall, Brauer, & Frank, 2009;Hankey & Marshall, 2017;WHO, 2018). According to WHO, 24% of all global deaths are linked to environmental risk factors, roughly 13.7 million deaths annually (WHO, 2016). Also, more than one quarter of the 6.6 million under-five child deaths every year are associated with environment-related causes and conditions (WHO, 2016, p. 13). In addition, exposure to ambient air pollution is thought to increase the risk of premature birth, low birth weight and infant mortality (WHO, 2016, p. 44). And diabetes is no exception. A recent Global Burden of Disease study covering 194 countries and territories found that PM2.5 3 air pollution is associated with "increased risk of diabetes…with the burden skewed more heavily towards lowincome and lower-to-middle-income countries" (Bowe et al., 2018, p. e301). The study estimate the attributable burden of disease (ABD) and disability-adjusted life-years (DALYs) of diabetes cases linked to environmental air pollution are highest in the ten most populous countries in the world (Table 6), China with the highest ABD of 600,000, followed by India with an ABD of 591,000, and the USA third, with an ABD of 150,000 (p. e305). Prior, the U.S. Environmental Protection Agency (EPA), found "people living with diabetes are considered at high risk for adverse health effects from exposure to harmful particles, or air pollution found both indoors and outdoors" (EPA, 2007). The poor air quality situation is worse in the communities and neighborhoods of racial/ethnic minorities in the United States (Ash & Boyce, 2018). In the "United States," argued Lambert (2019) "pollution, much like wealth, is not distributed equally," or, as Brown et al. (2013) put it, "collective illness experience in the United States" is not the same for African Americans and Whites. Bullard (1993, p. 15) "Communities are not created equal. In the United States, for example, some communities are routinely poisoned while the government looks the other way. Environmental regulations have not uniformly benefitted all segments of society. People of color (African Americans, Latinos, Asians, Pacific Islanders, and Native Americans) are disproportionately harmed by industrial toxins on their jobs and in their neighborhoods." The foregoing quotes go a long way to support the "charge that poor and minority communities are dumping grounds for environmental hazards" (Northridge & Shepard, 1997, p. 730). Concurring, Downey and Hawkins (2008, p. 759), "racial minorities are disproportionately burdened by environmental hazards." Some scholars and analysts have called this phenomena "pollution inequity" (Tessum et al., 2019, p. 6001), "environmental racism" (Northridge & Shepard, 1997;Newkirk, 2018;Grossman, 1993, p. 326;, "ecology of toxic inequality" (Sampson & Winter, 2016, p. 3), and "environmental injustice" (Brulle & Pellow, 2006), thereby reinforcing the health disparity gap between minorities and Whites. Many studies have explored this disparity (Gwynn & Thurston, 2001;Olden & White, 2005;Downey & Hawkins, 2011). More recently, according to the American Lung Association (2020a, p.44), "The burden of air pollution is not evenly shared. Poorer people and some racial and ethnic groups are among those who often face higher exposure to pollutants and who may experience greater responses to such pollution" and vulnerability to health problems.
The most recent EPA review of the research on the health effects of particle pollution (American Lung Association, 2020b) concluded that "there is strong evidence demonstrating that black and Hispanic populations, in particular, have higher risk exposures than non-Hispanic white populations'' (U.S. EPA, 2019, section 12.5.4) and that ''there is consistent evidence across multiple studies demonstrating an increase in risk for nonwhite populations" (U.S. EPA, 2019, pp. 12-38). [See also Federal Register, vol. 85, no. 84, April 30, 2020, p. 24114]. Also, due to decades of residential segregation and redlining, African Americans tend to live where there is greater exposure to air pollution (Nardone, et al., 2020) and by implication are more susceptible to health risks including diabetes. A 2019 study by the American based Union of Concerned Scientists, a nonprofit science advocacy, found "inequitable exposure to air pollution from vehicles in American Northeast and Mid-Atlantic regions, with communities of color breathing 66 percent more air pollution than White residents." Another 2016 study found that long-term exposure to airborne pollution is associated with racial segregation, with more highly segregated areas suffering higher levels of exposure (Bravo et al., 2016). As also, racial segregation is suspected in the prevalence of lead poisoning in the African American neighborhoods and has contributed to the legacy of Black disadvantage in the United States (Sampson & Winter, 2016).
In Louisiana, for example, the region between Baton Rouge and New Orleans has been infamously called the "Cancer Alley" 4 (Pezzullo, 2003;Berry 2003;Taylor 2014) because this area, particularly "predominantly Black and poor communities" (Baurick, Younes, & Meiners, 2019) "host a disproportionate number of hazardous and noxious facilities" (Taylor, 2014, p. 2) including "about 135 petrochemical plants" (Taylor, 2014, p. 20), that tend to release "air toxins and pollutants known or suspected to cause cancer or other serious health problems" (Louisiana Department of Environmental Quality, Air Toxics Monitoring, n.d.). In fact, it has been found that "numerous cancer cases occur in the Cancer Alley" 5 (Taylor, 2014, p. 20), as people living in the Cancer Alley are "more than 50 times as likely to get cancer than the average American" (Pasley, 2020), and "while air quality has improved for decades across the U.S., but Louisiana is backsliding…a crush of new industrial plants will increase concentrations of cancer-causing chemicals in predominantly black and poor communities" (Baurick, Younes, & Meiners, 2019).The federal cancer picture mimic Louisiana's.
A CDC and National Cancer Institute study of cancer death rates from 2013 to 2017 indicates that African Americans are more likely to die from cancer than any other racial group in the United States (CDC & National Cancer Institute, 2020). In the 2013-2017 study period, the death rate from all cancers was 181.7 per 100,000 for African Americans (compared to 158.3 per 100,000 nationally), 159.0 per 100,000 for Whites, 98.9 per 100,000 for Asian and Pacific Islanders, 106.2 per 100,000 for Native Americans, and 112.3 per 100,000 for Hispanic (CDC & National Cancer Institute, 2020). Cancer is the second leading cause of death in the United States, after heart disease. One of every four deaths in the United States is due to cancer (CDC & National Cancer Institute, 2020). In 2017 (latest incidence data available), in the United States, 1,701,315 new cases of cancer were reported, and 599,099 people died of cancer. For every 100,000 people, 438 new cancer cases were reported and 153 people died of cancer (CDC & National Cancer Institute, 2020). Accordingly, the long association of environmental inequity with minority communities in the United States continue to reinforce health disparity, not the least diabetes occurrence and impact. Environmental inequity is linked to racial discrimination with implications for diabetes risk factors. D. Discrimination Nwagbara (2020) found that racial discrimination is partly to blame for African Americans health disparity problem in the United States. Another recent report found that close to "25% of African Americans avoid medical care even when in need, for fear of discrimination" (Harvard T.H. Chan School of Public Health, Robert Wood Johnson Foundation, and National Public Radio, 2017, p. 1). The literature further reveal that due to racial discrimination African Americans tend to receive low quality of care for basic hospital services (Ayanian, 1999;Noonan, Velasco-Mondragon, & Wagner, 2016;Scott & Wilson, 2011;Gerend & Pai, 2008;Hostetter & Klein, 2018). Pinderhughes (1996, p. 231) "most common victims of environmental hazards and pollution are minorities and the poor. Disproportionate exposure to environmental hazards is part of the complex cycle of discrimination and deprivation faced by minorities in the United States" including health inequity. The impact of discrimination/racism on diabetes outcomes is no exception.
Robert Anderson (1998, p. 689) observed "in the United States racism and diabetes are in the heart of darkness." Tull and Chambers (2001) echoed similar sentiments, "internalized racism is associated with glucose intolerance among Black Americans…may also contribute to the unexplained excess of type 2 diabetes in that group." Wagner et al. (2011, p. 224) found that "African American women believed that racism affects their diabetes self-management and control…with exposure to novel racial stressors." Bacon et al. (2017) "Black Women's Health Study" of 59,000 African American women spanning 16 years period found "exposure to 'every day racism' (interpersonal racism in daily life) and 'lifetime racism' (treated unfairly due to race with respect to police, housing or work) increased risk of type 2 diabetes." Moody-Ayers et al. (2005) study of "perceived societal racism in African Americans aged 50 and older with type 2 diabetes mellitus" found that "patients' day-to-day experiences of societal racism can influence the patient trust in the medical system and their adherence to medical advice or engagement in self-management of their chronic conditions." Auslander et al. (1997) investigation concluded, "mothers of children with diabetes who reported greater perceptions of racism were significantly less satisfied with their children's medical care than those from less stressful environments." Nowhere is the health complications 6 of diabetes more pronounced than in the disparity in limb amputation risks between ethnic minorities and Whites. To put it vividly, Presser (2020) " they [African Americans] are disproportionately diabetic…put at risk by an array of factors, from unequal health care access to racist biases to cuts in public health funding. These elements have long driven disparities, particularly across the South. One of the clearest ways to see them is by tracking who suffers diabetic amputations, which are, by one measure, the most preventable surgery in the country" [America].

IV. Diabetic Amputations: The African American Experience
According to WHO, the global cases of diabetes rose more than 290% in 2014 from 1980, representing 422 million patients (WHO, 2020). This has led to increasing number of individuals with diabetic foot disease, up to 75% of lower extremity amputations (LEAs) being performed in these patients (Narres, 2017, p. 2). The United States is no exception. Back in 2001 Wrobel, Mayfield, and Reiber found that in the United States "patients with diabetes were 10 times more likely to undergo major amputation" (p. 861). Nearly twenty years later in 2018, a major report in the Diabetes Care, the official journal of the American Diabetes Association reached a similar conclusion, indicated that diabetic related "lower-limb amputations may be rising in the United States after decades of decline" (Caffrey, 2018). According to the study which covered the years between 2009 and 2015, the rate of amputations in the United States grew 50% during the period under review (Geiss, et al., 2018). In the United States, diabetics undergo about 120,000 amputations each year (Geiss, 2018, p. 53), often in low-income and underinsured neighborhoods (Presser, 2020). The problem is worse in the African American population. Table 7 shows the outcomes of patients admitted to the hospital from 2003-2015 7 for diabetic foot infections (DFIs) across various racial/ethnic groups including Whites, African Americans, Hispanics, and Native Americans (Tan, et al., 2019). Applying multivariable logistic models, the researchers studied the association between racial and ethnic groups and outcomes, including major (lower extremity amputation above the ankle) and minor (amputation below the ankle) amputations, endovascular intervention, and open surgery (Tan, et al., 2019). Major amputations were highest for African Americans (7.6%), followed by Native Americans (7.1%) and Hispanics (6.9%), than it is for Whites (5.4%). Similarly, the number of minor amputations were highest for African Americans (31.6%), followed by Hispanics (31.5%), than Whites (29.3%), and Native Americans (27.8%).  (Lefebvre & Lavery, 2011). African Americans (AAs), Hispanics, and Native Americans (NAs) have a higher prevalence of diabetes than Whites (Spanakis & Golden, 2013;CDC, n.d.;Cheng, et al., 2019). Consequently, the incidence of DFUs and amputations are disproportionately higher in AAs, Hispanics, and NAs (Lavery et al. 1996;Margolis, et al., 2011, Data Points #1 and #2;Tan, et al., 2019). 7 The study utilized National Inpatient Sample (NIS). The NIS is part of the Healthcare Cost and Utilization Project (HCUP), is the largest publicly available all-payer health care database and collects data for more than 7 million hospital stays every year (Tan, et al., 2019). Journal of Health, Medicine andNursing www.iiste.org ISSN 2422-8419 An International Peer-reviewed Journal Vol.95, 2021 Other studies have also reached similar conclusions. According to a recent Dartmouth study, Black patients' amputation rate is nearly three times higher than the rate among others (Goodney, et al., 2014, p. 12). "Racial and ethnic minorities" wrote Fakorede (2018) not only "have a higher prevalence and greater burden of diabetes compared with Whites," but also, "African Americans are 4 times more likely to experience diabetes-related amputation than Whites." "Blacks and Hispanics with…diabetes experience a greater incidence and odds of amputation when compared with Whites" (Lefebvre & Lavery, 2011;Margolis, et al, 2011;Goldberg, et al. 2012;Fakorede, et al., 2019;Girijala & Bush, 2018). Earlier, Feinglass et al. (2008) census data analysis of racial disparities in lower extremity amputation rates in Northern Illinois, 1987Illinois, -2004 found that "despite progress in reducing the overall major amputation rate in northern Illinois, racial disparities have remained remarkably constant." The "predominantly African American area of the South and West sides of Chicago, with less than 15% of the area population, accounted for 27% of all amputation discharges." Rucker-Whitaker, Feinglass, and Pearce (2003) analysis of "population-based hospital data indicate that African American patients undergo major lower extremity (LE) amputation 2 to 3 times more frequently than white patients." The disparity is because "African American patients undergo repeat major amputation at a significantly higher rate than Whites." Goldberg et al. (2012) exploration of Medicare diabetic patients 23,976 amputations between 1999 and 2006, found that "high-risk patients represent a minority of Medicare diabetic patients but account for 50% of all amputations, and this effect is magnified in African Americans." Lavery et al. (1997) found "African Americans diabetes higher prevalence or severity of risk factors may explain the excess mortality observed in African-Americans following lower extremity amputations." In all, Presser (2020) has called it "The Black American Amputation Epidemic." Mississippi Delta -"Black American Amputation Epidemic" Epicenter Geographic variation cluster analysis in the rate of diabetic prevalence, amputation, and mortality is in order. The Mississippi Delta region 8 is a case in point. The region has the highest concentration of diabetic amputations, prevalence, and mortality in the United States (Figures 1, 2, and 3). Mississippi has been called the "amputation capital of the United States" and it is considered the epicenter of the diabetic "Black American Amputation Epidemic" (Presser, 2020). Also, Mississippi has a large African American population, 9 it has one of the highest rates of diabetes (rank number 3, Table 8), and the highest poverty rate at 19.1% (same as Louisiana) in the United States. 10 Consequently, Mississippi 11 can be generalized as representative of the diabetes induced "Black American Amputation Epidemic" with its "dire implications for disability and mortality" (Wrobel, Mayfield, & Reiber, 2001, p. 862). The "Black American Amputation Epidemic" toll is so heavy in the Mississippi Delta that one Dr. Foluso Fakorede, "a crusading cardiologist" and the "only cardiologist in Bolivar County, Mississippi" (Presser, 2020) has envisioned building a lab called "Amputation Prevention Institute" (Presser, 2020)   Adapted from Lizzie Presser (May 19, 2020). "The Black American Amputation Epidemic." PROPUBLICA. https://features.propublica.org/diabetes-amputations/black-american-amputation-epidemic/. Lower extremity amputation (LEA) in patients with diabetes results in high mortality, reduced quality of life, and increased medical costs (Narres, et al., 2017, p. 1). Diabetic persons have a 15 times higher risk of LEA than nondiabetic individuals (Most & Sinnock, 1983;Bild et al., 1989) and elevated risk of foot ulcer as a result (Paisey, et al. 2018). African Americans and other historically underserved populations are less likely to get lower extremity amputation alternative attention such as, "prior arterial intervention and peripheral vascular intervention (PVI) than Whites" (Fakorede, et al. 2019). In the same breath, African Americans are more likely to undergo primary amputation than revascularization to improve arterial blood flow than Whites (Tan, et al., 2019). Furthermore, it is widely believed that African-American patients experience worst quality of life after PVI, than their White counterparts (Fakorede, et al., 2019;Zaitoun, et al., 2017), leading to more health comorbidities. Also, it has been shown that "African American are less likely to be evaluated with an angiogram than are White patients" (Henry, et al., 2011), leading to the "conclusion that physicians should not be dissuaded from treating African-American patients with PVI when appropriate" (Fakorede, et al., 2019).

V. Conclusion and Policy Recommendations
This paper examined the diabetes "epidemic" in the United States and its devastating impact on African