February 2019

Diabetes Updates:  Amputations Increasing; Insomnia as Risk Factor

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Amputations on the Rise

After decades of decline, diabetes-related lower-extremity amputations appear to be on the rise in the United States, according to new data from the Nationwide Inpatient Sample of the US Healthcare Cost and Utilization Project and the National Health Interview Survey of the National Center for Health Statistics, part of the US Centers for Disease Control and Prevention. What’s most disturbing is that the increase is in young (18 to 44 years) and middle-aged (45 to 64 years) adults—2 groups more likely to be uninsured than adults older than  65 years, who are eligible for Medicare.

The study,1 published recently in Diabetes Care, evaluated hospitalization rates for nontraumatic amputations of the lower extremity among people with and without diabetes from 2001 to 2015.

Researchers found that:

  • Between 2000 and 2009, the age-adjusted amputation rate for every 1000 adults with diabetes decreased 43% (from 5.38 to 3.07) (P<.001).
  • Then, between 2009 and 2015, the same rate surged by 50% (from 3.07 to 4.62) (P<.001).
  • In adults who did not have diabetes, the age-adjusted amputation rate for every 1,000 decreased 22% (from 0.23 to 0.18) from 2000 to 2015 (P<.001).
  • The increase in the diabetes-related amputation rate was driven by a 62% increase (from 2.03 to 3.29) in the rate of minor or partial amputations for every 1000 adults (P<.001).
  • Smaller (but still statistically significant) was a 29% increase in major amputation (from 1.04 to 1.34).
  • The rate of amputation was most pronounced in young and in middle-aged adults.
  • The rate was more pronounced in men.

Although the study was not designed to provide insights on changes in diabetes treatment that occurred during the study duration, the authors note that the United States appears to be experiencing a reversal in progress made in the fight against amputation. They conclude that diabetes patients need 1) more support in keeping their blood glucose level under control and 2) more education about foot care and warning signs of potential problems.

Insomnia Can Increase Risk of T2D

In a 4-year study2 of 81,233 persons with prediabetes, nearly 30% experienced insomnia some time during the observation period. Of those who experienced insomnia, nearly 28% were more likely to develop type 2 diabetes (T2D), compared to those who did not experience insomnia. This work follows studies showing that sleep deprivation can lead to hyperglycemia and that quantity and quality of sleep can be significant predictors of T2D.

The authors note that establishing an association between insomnia and T2D increases the at-risk population and that the clinical diagnosis of insomnia might be more easily applied than patient-reported sleep questionnaires. The good news, they note, is that treating sleep problems might serve as a strategy to prevent T2D.


  1. Geiss LS, Li Y, Hora I, Albright A, Rolka D, Gregg EW. Resurgence of diabetes-related nontraumatic lower extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2018. pii: dc181380. [Epub ahead of print, November 8, 2018]
  2. LeBlanc ES, Smith NX, Nichols GA, Allison JM, Clarke GN. Insomnia is associated with an increased risk of type 2 diabetes in the clinical setting. BMJ Open Diabetes Res Care. 2018;6(1):e000604.

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