Diabetic Neuropathy – Part 5

In the last blog, alternative treatments for diabetic neuropathy were mentioned. Now it is time to discuss the alternative treatments as some are quite effective, but again it is worth pointing out that not everything will work for everyone.

Capsaicin is the chemical that gives hot peppers their bite. When applied to the skin, capsaicin creams can reduce pain sensations in some people. Side effects may include a burning feeling and skin irritation. Alpha-lipoic acid (ALA) is one of the most interesting developments in pain research is the discovery that alpha-lipoic acid, a powerful antioxidant found in food, may be effective at relieving the symptoms of peripheral neuropathy.

Your doctor may prescribe transcutaneous electrical nerve stimulation (TENS) therapy, which can help prevent pain signals from reaching your brain. TENS delivers tiny electrical impulses to specific nerve pathways through small electrodes placed on your skin. Although safe and painless, TENS does not work for everyone or for all types of pain. TENS may be prescribed in addition to other treatments.

Acupuncture may help relieve the pain of neuropathy, and generally does not have any side effects. Keep in mind that you may not get immediate relief with acupuncture and will likely require more than one session. Biofeedback therapy uses a special machine to teach you how to control certain body responses that reduce pain. You then learn how to control these same responses yourself. Biofeedback techniques are often taught in medical centers and hospitals.

The above are all worth investigating and may be of value for you. You may need to use a combination or use in combination with prescription medications. If one treatment does not work in a reasonable time, try another treatment.

The best way to control diabetic neuropathy, and what it does, is to keep your blood glucose tightly managed, taking good care of your feet, and maintaining a healthy lifestyle. Yes, maintaining tight management of your diabetes requires a big commitment on your part, but the rewards are worth it. Whether you are on oral medications or insulin, by watching the foods you eat and monitoring your blood glucose levels is the only way to help avoid or prevent neuropathy and other complications of diabetes.

I would like to remind everyone to reread part one of this series about the four main types of neuropathy. This is because peripheral neuropathy is the most common form, but also because it is the most talked about. Foot care of foot problems is so important I want everyone to know how important this is. I do not wish to seen people needing an amputation because they did not take care of their feet.

First, have a comprehensive foot examination at least a minimum of once a year and more often if possible. Check your feet daily. No, do not just take a glance at them, but really look and examine them. If you are unable the bottoms of your feet, use a mirror or ask a family member or even a friend to examine your feet for blisters, cuts, bruises, cracked and peeling skin, redness and swelling.

Please wash your feet everyday with lukewarm water and mild soap. If you cannot tell the temperature of the water with your feet, use a dampened washcloth and touch it to an area of your body that is still sensitive to temperature. Wash thoroughly and rinse before drying. Be careful when drying as rubbing too vigorously can damage your skin. Dry between your toes and if necessary moisturize your skin liberally, but it is not good to put the lotion between your toes. This applies especially to men to avoid fungal growth.

Trim your toenails regularly and carefully to avoid cutting into the skin. Use a toenail clipper and with an emery board round off the corners not filing into the skin. If you are unable to reach your feet, ask a family member to assist or schedule a regular appointment with your podiatrist to get this done.

Wear clean and dry sock and preferably ones that have a cushion on the bottom to assist in keeping the moisture away from your feet. Avoid socks that are too tight or have a tight elastic at the top or thick seams. You will only harm your feet with this type of sock.

The last, and I want to emphasize this, is to wear shoes that fit your feet properly, are cushioned and comfortable. A podiatrist can be very helpful in teaching you how to buy properly fitting shoes that will help in preventing problems such as corns and calluses. Never buy new shoes in the morning. Wait until later in the afternoon when your feet are more swollen to ensure the shoes are not too tight. Shoes that fit well can be costly. If you are on Medicare, your plan may cover one pair of shoes per year. Your doctor and possibly your diabetes educator may be able to help you. Never buy shoes that pinch your toes or that do not support your feet. Just because it may be the latest fashion, does not mean they are for you.

Please read these articles for additional information, article 1 and article 2.  Part 5 of 5.

Diabetic Neuropathy – Part 4

In case you are not aware of this, diabetic neuropathy has no known cure. Treatment focuses on slowing the progression of the disease, relieving the pain, and managing the complications.

As you should know, management of your blood glucose readings is important. Maintaining these in a narrow range is the best solution for slowing the progression of neuropathy. I will give you the American Diabetes Association's (ADA's) recommendations, which I think are too lax.

They claim this is intense management.

Time                                                           ADA                       Rest of the World

Blood glucose level before meals               70 to 130 mg/dl          3.9 to 7.2 mmol/L

Blood glucose level two hours after meals  less than 180 mg/dl    10 mmol/L

after meals

Hemoglobin A1c less than                          7 percent

People that do not have diabetes generally maintain an A1c between 4 and 6 percent. To help slow nerve damage be sure to follow the recommendations of your doctor for good foot care and keep your blood pressure where it should be. Also, follow a healthy food plan, get plenty of exercise, if needed, get to a healthy weight, and avoid smoking and alcohol.

How do you effectively get pain relief from diabetic neuropathy? There are several medications that are used to relieve nerve pain, but they do not work for everyone. They also have to be weighed against the side effects and balanced to the benefits offered. This is the most difficult part of finding what works for you most efficiently and may require some trial and error.

Some of the prescription medications that may be prescribed include the following: anti-seizure medications, antidepressants, lidocaine patch, and opioids. You may read about them here. There are a few alternative therapies, such as capsaicin cream and acupuncture that may help with pain relief. Doctors do use them with prescribed medications, but some can be effective on their own.

Other neuropathy complications can have specific treatments for restoring functions. Urinary tract problems for both men and women have specific treatments and can have a combination of therapies that can be the most effective. Digestive problems can be treated and gastroparesis, diarrhea, constipation, and nausea may be helped with dietary changes and medications.

Low blood pressure on standing can often be helped with lifestyle measures. Medications can also be used alone in combination to treat orthostatic hypertension. There are many alternative medications and devices to help men with erectile dysfunction and women may get help with vaginal lubricants.

There are also lifestyle and home remedies that may help reduce the risk of diabetic neuropathy. First, people with diabetes generally have high blood pressure and with diabetes can greatly increase your risk of complications. It is important to maintain your blood pressure in the range that your doctor recommends. Read the advice of the Mayo Clinic here.

Second, regardless of whether you think your current food choices are healthy, many people find out once they have diabetes that the foods are not as healthy as thought. Make sure that you attempt to eat a balanced diet. Third, if possible, achieve a healthy weight and stay as active as your condition permits. Select an activity that you enjoy and can continue. If possible, try to do at least 30 minutes per day five days per week or 15 minutes seven days per week. Fourth, if you smoke, realize that with diabetes you are more likely to suffer a heart attack or stroke. Find ways to stop smoking as this increases your chances of neuropathy.

Finally, do all you are able to tightly manage your diabetes. This will help prevent or delay complications for many years.  Part 4 of 5.

Diabetic Neuropathy – Part 3

Seeing a doctor is very difficult for many people. They do not like to admit something is wrong that they cannot handle. Others just will not see a doctor until they have to. Neuropathy is not something to take lightly and does need to be seen by a doctor. It is better to see a doctor sooner than later with neuropathy. I hate to say this, but if you can manage your diabetes, neuropathy may be managed as well. Neuropathy is still possible whether we like it or not.

If you have a cut or sore on your foot or lower legs that does not seem to be healing, is infected or is getting worse, seek medical care. If you have a burning sensation, a tingling, weakness, or pain in your hands or feet that bothers you doing your daily tasks, be sure to see a doctor. If you have dizziness, or changes in your digestion, urination, or sexual function, seek medical care quickly.

These symptoms do not always mean nerve damage, as they may indicate other problems needing medical care. Regardless of the symptoms, record them and get an appointment with your doctor, as this is your best opportunity to prevent more serious complications. If fact, any problems with your feet should be seen by a doctor. This is the best method to prevent any problems from becoming severe enough to cause amputation.

Anyone can develop neuropathy, but people with diabetes are more susceptible if they have these risk factors. Number one is poor blood glucose management as this is the greatest risk factor for every complication of diabetes. Keeping your blood glucose levels consistently within goals is the best way to protect the health of your nerves and blood vessels.

Another factor is just the length of time you have had diabetes. This is especially true if your blood glucose levels are poorly managed. Peripheral neuropathy is most common in people who have had diabetes for 25 years. Others who are successful in their management of their diabetes may never develop peripheral neuropathy.

Kidney disease is another factor that can be caused by poor management of diabetes and can increase the toxin in your blood and contribute to nerve damage. Finally, smoking causes your arteries to narrow and harden, reducing the blood flow to your legs and feet. This makes it more difficult for cuts and wounds to heal.

People with type 2 diabetes should prepare for their appointments by being prepared. Your preparation will depend on the doctor you are seeing. Unless your doctor is very knowledgeable about diabetes, expect to be referred to an endocrinologist as they specialize in treating metabolic disorders, such as diabetes. You may also be referred to a doctor who specializes in treating the nervous system (neurologist). Here are some tips to help make the best use of the time you have to spend with the doctor.

When you make the appointment, be sure to ask about special preparations necessary, such as fasting or diet restrictions. Next write down any symptoms you are experiencing. Be sure to include any symptoms even if they seem unrelated to the reason for seeing this doctor. Make a list of all (this is important) medications you are taking and include all vitamins and supplements you are taking. While this may seem unimportant, record any major stresses or recent life changes that have happen, such as illnesses, family deaths, major accidents, etc.. Depending on what you can find out, it may be wise to take your blood glucose meter with you as well as your daily log of blood glucose readings.

If possible, ask a family member or a friend to come with you. Instruct them to record potential important information to assist you in remembering everything all the information you will receive during the appointment. Also write down the questions for your doctor. List the most important one first in case time expires before all are asked. Some doctors will accept a list of questions and send a follow-up letter with answers, but this is not to be expected.

If you cannot get a referral to a neurologist, check with your medical insurance company to see what they will allow or suggest. Some will offer a list of two or three that are in proximity to you. A neurologist will give you an examination to check your muscle strength and tone, tendon reflexes, and sensitivity to touch, temperature and vibration.

Other tests may include a filament test using a monofilament and electromyography (EMG) which measures the electrical discharges produced in your muscles. Other tests may be a quantitative sensory testing to assess how your nerves respond to vibration and temperature changes and a nerve conduction studies that measures how quickly the nerves in your arms and legs conduct electrical signals. Finally autonomic testing may be done if you have symptoms of autonomic neuropathy to determine your blood pressure in different positions and assess your ability to sweat.

The American Diabetes Association recommends all people with diabetes have a comprehensive foot exam, either by a doctor or by a foot specialist (podiatrist), at least once a year. In addition, your feet should be checked for sores, cracked skin, calluses, blisters, and bone and joint abnormalities at every office visit. If you already have diabetic neuropathy, you will likely be referred to a podiatrist or other specialist for monitoring and treatment.

The next blog will be on treatment. Part 3 of 5.

Diabetic Neuropathy – Part 2

Knowing how to manage your diabetes helps prevent many of the complications of neuropathy. In other words, know how to tightly manage your blood glucose levels. It is also important to know when to see your doctor when there are signs and symptoms of neuropathy as discussed in my previous blog.

The signs and symptoms may not always indicate neuropathy damage; however, they may be an indication of other problems that require medical care. This is where many people make a mistake of thinking – oh this is really nothing and do not seek the medical advice they should have sought. Then it can be too late and damage can be done that can cause more serious problems.

Read the article here for more detail and follow the advice to prevent more severe problems. The damage to nerves and blood vessels can be caused by several variables, and chief among them for those of us with diabetes is prolonged exposure to high blood glucose levels. High blood glucose can damage delicate nerve fibers, causing diabetic neuropathy.

While the exact reasons are not fully understood, a combination of variables are likely involved. High blood glucose interferes with the nerve communications and it weakens the walls of the small blood vessels (capillaries) that supply the nerves with oxygen and nutrients. Other variables that may contribute as well include inflammation in the nerves, genetic factors, and smoking and alcohol abuse.

If you have diabetes, you can develop neuropathy and there are variables that make you more likely to have nerve damage. Topping the list is poor blood glucose management followed by the length of time a person has had diabetes, but do not forget that people with type 2 diabetes sometimes develop peripheral neuropathy before diagnosis. Kidney disease and smoking are also risk factors for neuropathy.

The complications of diabetic neuropathy include loss of a limb, charcot joint, urinary tract infections and urinary incontinence. Low blood pressure can be caused by neuropathy, as can digestive problems. When you feel faint or dizzy when coming to a standing position can be the result of low blood pressure and should be looked after by a doctor. Digestive problems can cause what seems a myriad of problems, from constipation to diarrhea and nausea, vomiting, bloating, and loss of appetite.

Autonomic neuropathy often damages the nerves that affect the sex organs in men and women. This leads to erectile dysfunction in men and problems with lubrication and arousal in women. Neuropathy can also cause the sweat glands to not function properly so your body is not able to regulate body temperature properly. This can be life threatening. Even worse, for the elderly, neuropathy caused pain, disability, and embarrassment – robbing them of their independence, leaving them increasingly isolated and depressed.

More serious is hypoglycemia unawareness. Normally when your blood glucose level drops below 70 milligrams per deciliter (mg/dl) or 3.9 millimoles per liter (mmol/L) you develop symptoms like shakiness, sweating, and an increase in heart rate. These alert you to the problem so that you can take steps to raise your blood glucose quickly. Autonomic neuropathy may interfere with your ability to have these symptoms. This is extremely dangerous as hypoglycemia can be fatal.

Next blog is about seeing your doctor. Part 2 of 5.

Diabetic Neuropathy – Part 1

One of the more problematic complications of diabetes is diabetic neuropathy. It is a type of nerve damage where high blood sugars can damage the nerves most often in your feet and legs. Diabetic neuropathy can affect nerves in your entire body ranging from mild problems to painful that can be disabling or fatal.

There are four main types of diabetic neuropathy. All are the result of neglect of or poor diabetes management. You may have just one type or symptoms of several types. Most develop gradually, and you may not notice problems until considerable damage has occurred. For some people with type 2 diabetes, symptoms of neuropathy develop before diabetes is ever diagnosed. How well I know this as I had this at least four years before I was diagnosed.

Peripheral neuropathy. Peripheral neuropathy is the most common form. It affects the very ends of nerves first, starting with the longest nerves. That means your feet and legs are often affected first, followed by your hands and arms.

Signs and symptoms of peripheral neuropathy include - numbness or reduced ability to feel pain or changes in temperature, especially in your feet and toes. It can be a tingling or burning feeling or a sharp, jabbing pain that may be worse at night. It may be a pain when walking, extreme sensitivity to the lightest touch, and for some people, even the weight of a sheet can be agonizing. It can be muscle weakness and difficulty walking, serious foot problems, such as ulcers, infections, deformities, and bone and joint pain.

Autonomic neuropathy. The autonomic nervous system controls your heart, bladder, lungs, stomach, intestines, sex organs and eyes. Diabetes can affect the nerves in any of these areas, possibly causing - a lack of awareness that blood sugar levels are low (hypoglycemia unawareness). Bladder problems, including frequent urinary tract infections or urinary incontinence, constipation, uncontrolled diarrhea or a combination of the two may also happen. Slow stomach emptying (gastroparesis), leading to nausea, vomiting and loss of appetite is not uncommon. Erectile dysfunction in men, vaginal dryness and other sexual difficulties in women, increased or decreased sweating, and the inability of your body to adjust blood pressure and heart rate. This leads to sharp drops in blood pressure when you rise from sitting or lying down (orthostatic hypotension) that may cause you to feel lightheaded or even faint, and problems regulating your body temperature. It may cause changes in the way your eyes adjust from light to dark, difficulty exercising, and increased heart rate when you're at rest.

Autonomic neuropathy is most likely to occur in people who have had poorly controlled diabetes for many years.

Radiculoplexus neuropathy (diabetic amyotrophy). Instead of affecting the ends of nerves, like peripheral neuropathy, radiculoplexus neuropathy affects nerves closer to your hips or shoulders. Also called diabetic amyotrophy, femoral neuropathy, or proximal neuropathy, this condition is more common in people with type 2 diabetes and older adults. Though the legs are affected more often, this type of neuropathy may affect nerves in the arms or even the abdomen. Symptoms are usually on one side of the body, though in some cases symptoms may spread to the other side too. Most people improve at least partially over time, though symptoms may worsen before they get better.

This condition is often marked by - sudden, severe pain in your hip and thigh or buttock; eventual weak and atrophied thigh muscles; difficulty rising from a sitting position; unintentional weight loss; abdominal swelling, if the abdomen is affected.

Mononeuropathy. The term mononeuropathy means damage to just one nerve. The nerve may be in the arm, leg or face. Mononeuropathy, which may also be called focal neuropathy, often comes on suddenly. It's most common in older adults. Mononeuropathy can cause severe pain, but it usually does not cause any long-term problems. Symptoms usually diminish and disappear on their own over a few weeks or months.

Signs and symptoms depend on which nerve is involved and may include - difficulty focusing your eyes, double vision or aching behind one eye; paralysis on one side of your face (Bell's palsy); pain in your shin or foot; pain in the front of your thigh; chest or abdominal pain.

Mononeuropathy occurs when a nerve is compressed. Carpal tunnel syndrome is a common type of compression neuropathy in people with diabetes. Signs and symptoms of carpal tunnel syndrome include - numbness or tingling in your fingers or hand, especially in your thumb, index finger, middle finger and ring finger; a sense of weakness in your hand and a tendency to drop things; worsening of symptoms upon awakening or while gripping something.

Sources for this information include article 1, article 2, and article 3. Part 1 of 5.

Are We Going to Allow A Sugar Tax?

I have to end the week with this. This study is about imposing a “Sugar Tax” on our sugar-sweetened beverages. This is proposed on the basis that it will cut into our current obesity epidemic. The proposal is for a one cent per ounce tax. Buy a 20-ounce bottle of your favorite sweetened beverage and pay a tax of $0.20.

Does this seem steep? Not enough to stop sales is what I think. But, let them pass this, and the tax will continue upward until is could be much more expensive. These people will never stop in their crusade.

What is humorous is their estimates. They don't have accurate data, so we are seeing guesstimates. They say this and the claim that, but I don't believe their guesstimates. All that will happen will be more income generated for bloated government.

Read this doctor's blog and notice his humor. Please read article he refers to and then read this press release. Yes, this needs to be rejected, but will it.

Other Doctors Could Learn From This Doctor

This doctor apparently is teaching other doctors as an instructor, but he does have some excellent points for discussion. His one thought of “How can I be a better doctor?” really drew my attention. He then describes the 4 C’s, which he says he learned from his mentors, colleagues, and patients. This makes him a doctor I would like to meet and get to know in a doctor-patient relationship. Whether he would be my doctor could be doubtful, but just getting to know him could be a worthy experience.

The four C's he lists are – competency, communication skills, compassion, and convenience. He states that there was a fifth C, but that has been resolved some decades ago and it was confidentiality. I'm sorry to mention this doctor, but this needs a revisit. Electronic medical records are making this even more important with the hackers breaking into medical records at an ever-increasing rate. While most record keepers are doing what they can, medical records are being exposed and accessed at every turn. Not only is it by insiders looking for the latest gossip, but by outsiders wanting access to expose confidential information and obtain money for their efforts.

In addition, I am sure he is referring to The Health Insurance Portability and Accountability Act of 1996 (HIPAA). This for manual records has been great for doctors and hospitals and allows for discipline of staff that gets too curious and then collect the latest gossip about patients. The new electronic health records are supposed to covered, but as above they are being compromised.

He uses a very interesting discussion to emphasize doctor competency. This is why doctors should not be hesitant to consult with other doctors. We as patients are not supposed to be able to rate the competency of doctors, but we can often sense when a doctor is having problems with a diagnosis. We can also notice when doctors do not read the detail and ask the right questions, do some necessary testing, and sometimes we can sense by their tone of voice that they are just trying something hoping it will work.

Communication skills is a subject this doctor seems well versed in and knows what is necessary. He again uses a vivid example of lack of communication skills. We as patients need this communication. I makes us pay closer attention to the doctor and without it even the author agrees we are likely to seek doctors that will communicate with us.

Compassion can be difficult for some doctors especially if they lack communication skills. When my first wife was near death from cancer, the attending physician was probably the most compassionate doctor I have dealt with in my life. He knew her family was grieving and probably used his arsenal of communication skills to let us know that he was there for us and understood our grief. He answered our questions with compassion and described quite accurately what was ahead, but in a caring way.

The last C he covers is convenience. This is a difficult one to explain, as it will not always be convenient to get a referral even with your doctor’s intervention. Often in some rural areas, the specialist needed may be several hours away and booked up for a month or more. If you know your doctor is doing his best to get you in to see the specialist, and it is not an emergency, have patience. I have seen doctors refer patients to the emergency room to bypass logistical headaches, and get his patient taken care of, but I know this is frowned on heavily unless it is an actual emergency.

Surprise, Statins Not Shoved at Us!

This is a pleasant surprise, at the least the part of not having statins shoved at us. I am surprised that this study was allowed to go forward or even be published since statins are not mentioned. It is going to be very interesting to see how long this study stays posted before people are asking that it be pulled because statins are not mentioned or recommended.

Now, to the study, which says patients have time to learn lifestyle changes before drugs may become necessary. This is for people diagnosed with diabetes and hypertension. It could have included prediabetes and should include this. The savings for cost analysis would have been greater and possibly easier for the patients to adjust their lifestyles.

While the study mentions diabetes, it on the control of high blood pressure as the key for the time allowed before medications are needed. Yes, some people are able to manage diabetes without medications and this should be the goal for all patients. Some may need medication assistance until lifestyle changes are made to prevent potential complications from developing, but the goal should be to get off medications if possible.

This study is important as it shows there is a potential window available without severe consequences for people to adopt lifestyle changes to reduce the effects of hypertension before high blood pressure medications are necessary. To quote the study statement, “The consequences of delaying effective hypertension treatment for up to a year were small - a two-day reduction in quality-adjusted life expectancy - according to a study by University of Chicago researchers published online for the Journal of General Internal Medicine. But as the delay gets longer, the damages multiply. A ten-year delay decreased life expectancy by almost five months.”

While no mention is made about cholesterol and statins, this can be a good thing as too often this is an automatic thing for doctors to prescribe especially when diabetes and hypertension exist in the same patient. If lifestyle changes can be accomplished within one year, then it should also be possible to avoid the need for statins as the cholesterol readings generally follow the blood pressure readings brought on by lifestyle changes.

The study also emphasized the importance of working with the patients to learn how to make the lifestyle changes and receive the support for making them. The American Diabetes Association (ADA) recommends only allowing a three-month trial of medication-free lifestyle therapy for patients with moderately elevated hypertension. This is a good reason for doctors to know of this study and allow the patients up to a year for making the lifestyle changes.

“This study argues that caregivers should work with patients to help them gain the knowledge and develop the necessary skills gradually rather than rushing to drug treatment, especially if their blood pressure is only mildly elevated. It suggests that patients and providers "have more time," the authors write, "at least up to one year, to focus on diabetes self-management and lifestyle modification."”

The ideas put forth from this study are needed, but I would agree that sometimes it might be necessary for medications to be used when the test results are in excess of the upper limits. Patient safety should be exercised to bring diabetes and hypertension under good management while the patient is taught how to use and manage lifestyles changes to the fullest.