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Diabetic Foot Self-Inspections and the Variations of Performance in Different Racial Groups

May 16, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Deonna Andrews, PharmD Candidate 2020 of Florida Agricultural & Mechanical University College of Pharmacy and Pharmaceutical Sciences 

With the increase in lower limb amputations due to diabetes, researchers look into how specific racial groups manage nonpharmacological modalities like foot self-inspections in prevention.  

Although lower limb amputation is a preventable risk complication of diabetes, more than thirty million Americans who have diabetes are at an increased risk of it. Lower limb amputation is associated with a substantial negative impact on functioning and the quality of life. Minor trauma, cutaneous ulceration, and wound-healing failure are all common pathways that lead to people with diabetes undergoing a lower limb amputation. Also, there factors that contribute to wound-healing failures such as neuropathy, ischemia, and infection. Prompt self-recognition of the early signs of diabetic foot complications and self-referral to a diabetes specialist can reduce the severity of diabetic foot complications and the chances of amputation. This is primarily why guidelines recommend patient education and daily foot monitoring.  


 Considering geographic and racial/ethnic variation in lower limb amputations, there is a substantial difference that is indicative of socioeconomic and healthcare-related factors that contribute to this variation. More specifically, African-Americans have lower limb amputation rates that are 1.5 to 4 times greater than rates in Caucasians. This disparity is proposed to be due to biological and sociocultural factors. The purpose of this study was to assess the differences in foot self-inspection among people with diabetes by race/ethnicity. Previous studies generally found that patients at high risk for a lower limb amputation were more likely to check their feet daily than those classified as low risk; however, the studies were not consistent.  

Researchers of this study used data from the Centers for Disease Control and Prevention from 2015 to 2017 Behavioral Risk Factor Surveillance System. Individuals were included in this trial if they lived in a state or territory that included the diabetes module, reported being told by a doctor, nurse, or other health care professional that they had diabetes, and answered the questions on race and ethnicity. Individuals were excluded if they reported being told that they had diabetes during pregnancy, or borderline diabetes, or refused to answer the questions on checking their feet or race.  

For statistical analysis, a descriptive analysis was conducted first assessing the frequency of daily foot inspection overall and within subgroups. Furthermore, these analyses were accounted for by the complex survey design of the Behavioral Risk Factor Surveillance System as well as nonresponse by using survey commands and Centers for Disease Control and Prevention calculated weights. Prevalence ratios and the associated 95% confidence intervals were estimated using log-binomial linear regression models. An iterative approach was used to assess confounding by examining whether factors included in multivariable models changed the PR for daily foot inspection of African-Americans, Hispanics, or Asian-Indian/Alaska Native versus Caucasians by >10%. The presence of effect modification through the inclusion of interaction terms was assessed through multivariable models. Finally, the primary outcome was defined as daily foot inspections that were determined based on responses to a questionnaire provided to the participant.  

While analyzing the results, researchers found that when compared to Caucasians, who had a weighted prevalence of daily foot self-inspections of 57%, the other ethnicities had a higher prevalence of daily foot self-inspection. African-Americans reported a weighted prevalence of 67%, prevalence ratio of 1.25, 95% confidence interval 1.14 and 1.23. Asian Indians/Alaska Natives reported a weighted prevalence of 66%, prevalence ration of 1.15, and 95% confidence interval 1.07 and 1.25. Pacific Islanders and self-proclaimed Hispanics reported a prevalence of 71%, prevalence ratio of 1.25, and a 95% confidence interval 1.03 and 1.52. Additionally, there was a significantly lower prevalence of daily foot inspections among Asians with a prevalence of 35%, prevalence ratio of 0.62, and a 95% confidence interval 0.48 and 0.81. Researchers also were able to determine that there wasn’t an association variation by insulin use, years since diabetes diagnosis, or having received diabetes self-management education.  

In conclusion, researchers were able to quantify that the higher frequency of foot self-inspection in racial and ethnic groups who are at an elevated risk of diabetes-related lower limb amputation is not sufficient to terminate lower limb amputation disparities. Furthermore, a grave amount of additional interventions will be needed to achieve this aim.  

Practice Pearls: 

  • Daily foot self-inspections are thought to decrease the amount of lower limb amputations in various racial groups. 
  • When comparing the data, various racial groups had a higher incidence of daily foot self-inspections than Caucasians.  
  • More research is needed in order to assess the importance of this study.  


Littman, Alyson J., et al. “Associations Between Racial and Ethnic Groups and Foot Self-Inspection in People With Diabetes.” Diabetes Care, Apr. 2020, p. dc191486., doi:10.2337/dc19-1486. 


Deonna Andrews, PharmD Candidate 2020 of Florida Agricultural & Mechanical University College of Pharmacy and Pharmaceutical Sciences 


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