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Introducing vitamin D

There is much controversy over the role of vitamin D in many diseases and conditions besides its effect on calcium intake and bone metabolism. This is a brief introduction to vitamin D. You can find much more concerning all aspects of vitamin D in my book Vitamin D for Dummies.

First of all, vitamin D is not actually a vitamin, but rather a hormone. A vitamin is, by definition, a food substance that cannot be made in the body and must be taken in from an external source. In fact, the human body exposed to sunlight can make all the vitamin D it needs. Unfortunately, the fear of skin cancer has resulted in avoidance of sun exposure, so that many people must take a supplement to achieve the necessary vitamin D level. In the winter and above certain latitudes you get very little ultraviolet B light, the kind that makes vitamin D, so you have to take a supplement then as well. It is difficult to get enough vitamin D from food.

Secondly, many conditions  have been shown to be reduced in people who have adequate lifelong blood levels of vitamin D. They include the following:

  • Cancers: Colorectal, prostate and breast
  • Infectious diseases: Tuberculosis, influenza, upper respiratory viruses
  • Autoimmune diseases: Multiple sclerosis, rheumatoid arthritis, systemic lupus erythematosis
  • Heart disease: Coronary artery disease, high blood pressure, heart failure
  • Metabolic disease: Types1 and 2 diabetes, metabolic syndrome, polycystic ovary syndrome
  • Other possible diseases prevented by adequate vitamin D: Asthma, psoriasis, autism, Alzheimer’s’ disease, Parkinson’s disease, depression, seasonal affective disorder

While the evidence for the role of vitamin D is stronger for some of these diseases than others, all of them are currently being studied to see if vitamin D can prevent their onset.

Thirdly, while the blood level of vitamin D necessary to prevent these diseases is not known, many experts feel that current government recommendations are woefully inadequate. Levels above 20 nanograms/milliliter (ng/ml) are considered sufficient because this is the level that prevents bone disease, but levels above 30 ng/ml or greater may be necessary for the prevention of the conditions listed above. Vitamin D is very inexpensive and daily intake of 2000 international units (IU) is not excessive.

Fourthly, it is very difficult to take an overdose of vitamin D, except in babies and small children. Adults who are deficient are often given 50,000 international units a week to make up for the deficiency without a problem.

While it is true that a major study is looking at the role of vitamin D and prevention of disease, I am not waiting around for the results of that study. As a physician in practice, I have always used the least amount of medication for my patients that is necessary, but I take my 2000 international units of vitamin D daily.

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Further Proof of the Importance of Exercise in Diabetes

In case you don’t believe it yet, here is some of the strongest proof of the place of exercise, both aerobic and resistance training, in prevention of diabetes.  A study published in the Archives of Internal Medicine on September 24, 2012 looked at 32,002 men from the Health Professionals Follow-up Study, who were observed from 1990 to 2008.  Weekly time spent on weight training and aerobic exercise was obtained from questionnaires at the beginning and every two years.

During the follow-up there were 2,278 new cases of type 2 diabetes (T2DM).  Those men who engaged in weight training or aerobic exercise for at least 150 minutes per week had a lower risk of  T2DM of 34% and 52% respectively.  Men who did both for at least 150 minutes total had an even lower risk of 59% compared to men who did neither.

Although they didn’t study it specifically, take my word for the fact that if you have diabetes already, doing 150 minutes of  both weight training and aerobic exercise will provide similar benefits in terms of controlling diabetes and its complications.

For everything you need to know about exercise in diabetes, see Chapter 9 in my book, Diabetes For Dummies.

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Could a Voucher System Work for Medicare?

In a voucher system (which the Republicans prefer to call “premium support”), you would be given a certain amount of money to spend on your health care.  You would choose your insurance.  Anything that your insurance did not pay would come out of your pocket.  Is such a system better for you than our current Medicare system?  The answer is unequivocally no.  Under the Medicare system, the government has huge leverage to reduce medical costs since it is a single payer.  It has already used that leverage successfully.  Payment for medical care in the hands of many different insurance companies has not been shown to reduce costs and there is no reason in such a system for them to even try since you cover everything they don’t.

In 40 years of medical practice, I have seen the cost of medical care rise dramatically.  New devices and new drugs are extremely expensive and the cost is passed on to the patient.  Numerous people have to choose between eating and medication.  Under a voucher system, the choice will be even more difficult.

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Do Statins Cause Diabetes

There is no more powerful drug for lowering cholesterol and reducing the risk of heart attacks than the class of drugs called statins.  Atorvastatin (Lipitor) is the best-selling statin and the best-selling drug in history, but others include lovastatin (Mevacor, Altocor), pravastatin (Pravachol, Lipostat), rosuvastatin (Crestor) and simvastatin (Zocor, Lipex).  Especially in susceptible people who have features of the metabolic syndrome (see that post) or abnormal fasting blood glucose levels, there is a higher incidence of diabetes in those who take statins compared with those who don’t.

The US Food and Drug Administration has required drug companies to add a warning to statin labels that “increases in glycosylated hemoglobin and fasting serum glucose levels have been reported with statin use”.  But they add that the “FDA continues to believe that the cardiovascular benefits of statins outweigh these small increased risks.”

Bottom line: don’t be afraid to take a statin if you need it, but work even harder at the lifestyle changes of weight loss and exercise to prevent the onset of diabetes.

For much more on controlling fats, the metabolic syndrome and prevention of heart disease, see my book Diabetes For Dummies, 4th Edition.

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Is Glargine Insulin Treatment Associated With More Cancer?

A study published in 2009 suggested that people who took higher doses of glargine insulin had an increased risk of cancers of all forms.  Other studies have not confirmed this association.

Two recent studies, the Northern European Database Study and the Kaiser Permanente California Cohort Study have found no increased risk.  The Northern European Study compared the risk of breast cancer in women, prostate cancer in men and colorectal cancer in both sexes who were given glargine insulin or human insulin.  17,800 cancers were diagnosed in these insulin users, but there was no difference in the frequency of these cancers between those who took glargine and those who took human insulin.

In the Kaiser Permanente Study, people who switched to glargine insulin from NPH insulin were compared as well as new insulin users who were started on NPH or glargine.  There was no difference in the occurrence of cancer in these groups.

Use of glargine insulin does not appear to be associated with more cancer.

For much more on the diagnosis and treatment of diabetes see my book, Diabetes For Dummies, which has just been published in its 4th edition.

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Omega-3 Fatty Acids: Do They Prevent Heart Attacks?

In the ORIGIN (Outcome Reduction With an Initial Glargine Intervention) study, over 12,500 people were given a supplement of omega-3 fatty acid or a placebo for at least 6 years.  All the participants had new or recently diagnosed diabetes, impaired fasting glucose, impaired glucose tolerance or other cardiovascular risk factors.  Those who received the drug (though they were unaware if they were receiving drug or placebo) were given 1 gram of omega-3 fatty acid daily.  Both groups had about the same baseline intake of omega-3 at the beginning and end of the study.

After 6 years, there was no difference in the rate of heart attacks in the group that received omega-3 fatty acids compared with those that did not.  Added fatty acids did not have a major effect on heart attack rates or rates of death.  They did not reduce strokes or heart failure either.  Cholesterol levels remained the same in both groups as well.

Should you take supplemental omega-3 fatty acids?  If you fall into any of the groups in this study, probably not.

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The Number One Problem in High Blood Pressure

The Number One Problem in High Blood Pressure

I have just returned from the scientific meetings of the American Society of Hypertension in New York City.  I was really surprised by what I confirmed there.   Many, if not the majority of measurements of blood pressure are not done correctly.  I say confirmed because I have had the information about the correct way to measure blood pressure in my book, High Blood Pressure For Dummies, for several years.  I guess I assumed that doctors, nurses and others had learned to measure it properly, but I was mistaken.

Consider the ramifications of this fact.  For the patient it means that he might not have high blood pressure after all.  If he does have high blood pressure, measurements that are taken to see whether treatment has worked are inaccurate.  If he doesn’t have high blood pressure but has been given that diagnosis, he is suffering the side effects of medication for no reason.

For the medical profession, it means that many of the journal articles that claim that a certain medication causes a certain amount of lowering of blood pressure are not accurate.  Conclusions that depend on accurate measurement of blood pressure are false.  Drugs that are highly touted by their manufacturer for their ability to lower blood pressure may not do so.

Before 1980, people with diabetes had no way to measure their blood glucose and had to measure the glucose in their urine.  This proved to be a highly inaccurate technique for controlling the blood glucose.  Thousands of medical papers had been published using urine glucose tests.  They were all wrong.  It was only with the advent of blood glucose monitoring that people with diabetes could reliably change their medication dosage, especially their insulin dosage.  The measurement of the blood pressure seems to be in a similar situation.

For a complete discussion of the proper way to measure the blood pressure, see Chapter 2 in my book mentioned above.

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Medical Procedures You Don’t Need

Medical Procedures You Don’t Need

A friend of mine went to see his doctor.  My friend was in good health but his doctor told him it might be a good idea to get a routine electrocardiogram (EKG-a test that measures the electrical signals in the heart) and a routine stress test (a test that by stressing the heart may disclose damage).  The stress test showed that he might have some blockage in his heart and he was advised to undergo surgery.  After the surgery, his kidneys failed, he had an acute gall bladder attack, he required over 20 blood transfusions and he still isn’t back to his state of health before seeing the doctor.  It was a medical procedure he didn’t need.  Sure, every now and then one of these unnecessary tests will turn up something important, but for every one like that, there are thousands that show nothing.

The American Board of Internal Medicine Foundation asked a number of the organizations that represent doctors in different specialties to recommend tests that were being performed on large numbers of people but that, except in certain circumstances, were unnecessary.  This is what they came up with:

Routine EKGs and Stress Tests

People who are at low risk for heart disease are 10 times more likely to have a false positive result than a real problem, resulting in millions of unnecessary surgeries or other treatments, which can threaten life.  If you have a risk factor such as diabetes, high blood pressure, obesity and others the test may make sense, but if you are well without risk factors, don’t let them do it to you.

Bone Scans for Women under 65 and Men Under 70

If you are a woman under 65 or a man under 70, a bone scan for osteoporosis is not needed unless you are a smoker, have used steroids, have low body weight, or have had a fracture.  You may end up taking medication you don’t need, worrying needlessly about your bones and taking medications with serious side effects.

Antibiotics for Mild or Moderate Sinus Infections

Most sinus infections (over 90%) are caused by a virus and do not respond to antibiotics.  You may be allergic to the antibiotic or develop a resistance to that antibiotic when you need it later.  If your infection lasts more than 7 days or becomes bacterial, you may need an antibiotic.

Nonsteroidal Antiinflammatory  Painkillers (NSAIDS) like Advil or Motrin for People with Heart Failure, High Blood Pressure or Chronic Kidney Disease

In these types of patients the NSAIDS, used for arthritis or headache, may raise the blood pressure, worsen the heart failure or increase the kidney failure.  They can also cause bleeding in the stomach.  People with these conditions have twice as many deaths from heart attacks and strokes when given those drugs.

CT Scans or MRIs for Uncomplicated Headaches

Not only is the test wasteful because it rarely shows anything important, but the radiation exposure is harmful.  Doctors may be concerned about malpractice should something turn up later.  It almost never does.  If you have symptoms like blurred vision, trouble speaking or weakness on one side of your body, it may be helpful.

Allergy Testing

A blood test called immunoglobulin for food allergies does not work.  If positive, it simply means that your immune system is working.  Also doing a large battery of blood and skin tests for seasonal allergies is not necessary.  Taking a careful history of the allergies from the patient will narrow the tests to just a few.

X-ray, CT scan or MRI for Low Back Pain

Most patients with low back pain get better regardless of the treatment.  The patient does not need the exposure to radiation and the expensive back surgery that doesn’t cure the problem.  If the doctor suspects that you have a serious condition, then these tests are indicated.

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Reducing Blood Pressure without Drugs

Reducing Blood Pressure without Drugs

There are many treatments that can lower the blood pressure without using drugs, which invariably come with the cost of their side effects, not to mention the monetary cost. This article will discuss the best of them.

Lifestyle modification

With or without drugs, lifestyle modification should be a primary method of lowering your blood pressure. If you combine the DASH diet (see another article in this site) with low salt, regular exercise and weight loss, you can reduce your systolic BP (the higher number) by more than 10 mm/Hg (millimeters of mercury). Reducing your alcohol intake if you drink 3 or more glasses of alcohol daily will lower it further. The value of stopping smoking should not even have to be mentioned.

Dietary supplements

Eating several dietary supplements will lower the systolic blood pressure. They include the following:

• Potassium

• Calcium

• Vitamin D

• Folate

• Fish oil

• Vegetable protein

• High fiber diet

Herbal/alternative techniques

Many herbal supplements are reputed to lower blood pressure but results are variable:

• Hawthorn

• Mistletoe

• Rauwolfia

• Acupuncture

• Meditation

Devices

Many devices you can use will lower the BP. They include:

• An implanted baroreflex stimulator (Rheos device), which has been tried in patients with intractable high BP and has lowered the BP as much as 44 mm/Hg.

• Symplicity catheter, which is used in patients with high BP due to chronic kidney disease and lowered the BP as much as 32 mm/Hg.

• Paced breathing by the RESPeRATE device, which slows the rate of breathing, leading to widening of blood vessels and lowered BP. The BP is lowered only 5 mm/Hg.

• Isometric handgrip exercises (Zona Plus device), which have only lowered BP by 5.7 mm/Hg.

If you are having trouble lowering your blood pressure, give one or more of these a try.

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New Exercise Discoveries For Diabetes

New Exercise Discoveries for Diabetes

You, of course, do both aerobic and resistance exercises.  Some people, however, skip the resistance exercises and others skip the aerobic exercises.  Is this wise?  And which should be done first?  Does it matter?

Two recent articles in Diabetes Care in April 2011 attempted to answer these questions.  The first study looked at the metabolic effects of performing one type of exercise before the other in patients with type 1 diabetes.  The scientists, from multiple centers in Canada, found that it does make a difference.   Subjects did 45 minutes of running before or after 45 minutes of weight lifting.  Those who did the weight lifting first were found to have much more stable blood glucose levels during and after the aerobic exercise.  They also have less frequent and less severe hypoglycemia after the exercise.

In a second study from Verona, Italy, patients with type 2 diabetes were put on a regimen of either aerobic exercise or weight training.  Both groups exercised 3 times per week for 60 minutes for 4 months.  Of course, the aerobic group ended up with more long-term stamina and the weight training group ended up stronger.  But the hemoglobin A1c was lowered the same in both groups, as were fat stores and insulin sensitivity.

Take Home Message: The effects of aerobic training and resistance training are different, are both highly beneficial, it’s better to do resistance training first, and my opinion is that doing both is at least twice as good as doing one or the other.

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New-Old Drugs for Type 2 Diabetes

There are two old drugs that have been found to lower the blood glucose when they were used for other purposes. The following information describes their properties. Discuss them with your doctor if you need a bit more control of your blood glucose.

Bile acid sequestrants

Bile acid sequestrants are drugs that are used to reduce the total cholesterol and the LDL (bad) cholesterol. When they were being used for that purpose it was noted that they also lowered the blood glucose and the hemoglobin A1c. Although the lowering of hemoglobin A1c is modest, about 0.5 percent, these drugs may have a place in prediabetes or mild type 2 diabetes. They do not cause hypoglycemia.

The FDA has authorized the use of colesevalam (brand name Welchol) for this treatment. It can be used for both type 1 and type 2 diabetes. Side effects include constipation and nausea. Colesevelam comes as 625 mg tablets as well as 1875 and 3750 mg powder packets. The dose is 3750 mg once daily. It may be used alone or with other oral hypoglycemic agents and does not cause weight gain.

Bromocriptine

Bromocriptine is another drug long used for a different indication that has been found to have glucose-lowering effects. It has been used to treat brain tumors that produce too much growth hormone or prolactin. It was discovered to lower the blood glucose and the hemoglobin A1c to a slightly greater extent (hemoglobin A1c reduced 0.6-0.7 %) then the bile acid sequestrants but by a different mechanism. It also reduces triglycerides and free fatty acids, without causing hypoglycemia or weight gain.

Side effects include nausea, dizziness and headache in less than 15 percent of patients. The dose of Bromocriptine (called Cycloset) is 1 0.8 mg tablet increased by 1 tablet per week up to a maximum of 4.8 mg. It may be used by itself or with other oral agents.

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Diabetic Neuropathy: Entrapment Neuropathies

Entrapment neuropathies are very common in people with diabetes, occurring in one in every three patients. These neuropathies result from squeezing of individual nerves as they pass through bony or ligamentous areas that do not allow expansion so the nerve is trapped if there is swelling for any reason. The entrapment neuropathies can produce symptoms similar to the mononeuropathies described in a previous post but they differ in several ways:

*  Onset of mononeuropathies is sudden while entrapment neuropathies have a gradual onset.

*  Mononeuropathies are self-limited, usually resolving over six weeks while entrapment neuropathies persist unless the nerve is released by surgery.

*  Mononeuropathies are painful from the start while entrapment neuropathies gradually get more and more painful.

The entrapment neuropathies include

*  Carpal tunnel syndrome: produces reduced sensation in the fingers and weakness touching the thumb to the fifth finger. The median nerve is trapped at the wrist.

*  Ulnar entrapment: produces reduced sensation in part of the fourth finger and the entire fifth finger as well as the hand between the fifth finger and the wrist. The ulnar nerve is trapped at the elbow.

*  Radial nerve entrapment: produces loss of sensation in the back of the hand and “wrist drop” from weakness of the muscles that straighten up the wrist. The radial nerve is trapped at the elbow.

*  Common peroneal entrapment: produces loss of sensation in the side of the leg and top of the foot and “drop foot” from weakness of the muscles that pull up the foot. The common peroneal nerve is trapped as it passes the head of the fibula, one of the two bones that begin at the knee joint and end at the ankle.

*  Tarsal tunnel syndrome: produces loss of sensation on both sides of the foot and wasting of the muscles of the foot resulting in decreased toe movement. It is like the carpal tunnel syndrome in the foot and results from trapping of the tibial nerve between two of the small foot bones.

Lateral femoral cutaneous nerve entrapment: produces loss of sensation on the outside of the thigh but no muscle weakness. It results from trapping of that nerve at the groin.

The entrapment neuropathies respond to rest, splints, drugs that promote water loss, injections of steroids and surgery if necessary. The important thing is not to confuse them with mononeuropathies

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Diabetic Neuropathy: Loss of Voluntary Movement Nerves and Automatic Nerves

Neuropathy can affect the muscles that you move voluntarily and the muscles that move automatically like the heart, diaphragm and intestines.  The signs and symptoms will depend on which nerves are involved.

Disorders of Movement: Mononeuropathy

Mononeuropathy means loss of movement of the muscle activated by a single nerve.  The cause is believed to be the sudden closing of the blood vessel supply to that nerve.  If, for example, the nerve to one of the eye muscles is affected, the patient will be unable to turn his eye to the side that the muscle is on.  If it is the nerve to a muscle to the mouth, he may not be able to smile on that side of his face.  There can be trouble with vision or hearing on the affected side.  The patient may not be able to focus his eye.

There is no specific treatment for mononeuropathy, but it tends to improve and disappear after several months.

Disorders of Autonomic  (Automatic) Nerves

Your body contains an entire system of nerves devoted to movement of automatic muscles.  As you read this, your heart is automatically pumping your blood, your diaphragm is automatically pulling air into your lungs, your intestines are automatically pushing that large lunch you ate down from your mouth to your esophagus to your stomach to your small intestine and large intestine.  40 percent of people with diabetes have been found to have some form of autonomic neuropathy using sensitive tests.

Here are some of the different conditions that result from loss of autonomic nerves:

  • Bladder abnormalities: the patient can’t tell when his bladder is full and he does not urinate regularly.  Urinary tract infections occur.  Treatment involves remembering to urinate every four hours and/or taking a drug that improves the force of contraction of the bladder muscles.
  • Abnormalities of sexual function: in 50 percent of males and 30 percent of females.  The males have loss of erections and the females have loss of sensation and lubrication.
  • Gastrointestinal abnormalities: The most common problem is constipation.  There is also delayed emptying of the stomach so that the food is not being absorbed while the insulin injection is active, resulting in brittle diabetes.
  • Failure of the gall bladder to empty resulting in gall stone formation.
  • Diabetic diarrhea and multiple (as many as 10) daily bowel movements.
  • Heart rhythm abnormalities so that the heart fails to speed up with exercise or the heart rate may be very fast and fixed, not slowing with rest.
  • Sweating problems, especially in the feet.  The body compensates from loss of sweating in the feet by sweating excessively in the face, arms and chest.

Key Advice

None of these disorders need ever occur if you keep your blood glucose in the normal range and maintain a hemoglobin A1c level of 7 percent or less.

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Diabetic Neuropathy: Loss of Sensation

There are many symptoms of diabetic neuropathy resulting from loss of sensation.  The following are the major types in the order of the frequency with which they occur.

Distal polyneuropathy

Distal polyneuropathy is the most common sensory neuropathy.  It involves the nerves of the feet and legs and often the hands as well.  It is believed to be caused by a metabolic abnormality, since other diseases that involve a metabolic abnormality can show evidence of a distal polyneuropathy as well (like kidney disease).

The primary signs and symptoms of distal polyneuropathy include the following:

  • Numbness of the feet and legs and inability to know whether the feet are bent forward or back due to loss of large fibers
  • Diminished ability to feel pain and heat or cold due to loss of small fibers
  • Mild weakness
  • Tingling and burning
  • Painful sensitivity to light touch such as the bed covers on your legs
  • Loss of balance and coordination
  • Worsening of symptoms at night

A patient with this condition may not know if he has been burned by hot water, for example, or has stepped on a tack.  Most patients who have this condition do not realize it and need to have studies of nerve conduction in order to evaluate it.

Key Advice

Get yourself a 10 gram filament and test your sensation at least monthly.  If you can’t feel your feet, you must use your eyes to discover lesions.  To avoid distal polyneuropathy you must achieve very good control of your blood glucose so that you have a hemoglobin A1c of 7 percent or less.  Once neuropathy is present, examine your feet regularly.  If you have it, ask your doctor to check your feet at each visit.

Polyradiculopathy-diabetic amyotrophy

Polyradiculopathy-diabetic amyotrophy is a combination of pain on one side from the hip to the thigh and loss of motor nerve activity to the upper leg so that the patient can’t straighten the knee.  It does not respond to improved blood glucose control but usually has a short course.

Radiculopathy-nerve root involvement

Sometimes the pattern of pain suggests that the whole nerve is affected from its beginning at the spinal cord.  The pain is felt along a horizontal line from the spinal column to the front of the chest or abdomen.  This pain can be confused with an internal abdominal emergency.  But the pain goes away in 6 months to 2 years and it does improve with better glucose control.

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What is Diabetic Neuropathy?

Diabetic neuropathy is the damage to nerves that occurs after ten or more years of exposure to high blood glucose (sugar).    It affects 60 percent of people with diabetes who have the disease that long.  The actual signs and symptoms can vary from loss of sensation in the feet and legs to inability to move muscles that are controlled by specific motor nerves.   Still another type of neuropathy is called autonomic neuropathy and refers to loss of nerves that control the automatic functions of the body like the movement of heart muscle, the movement of the diaphragm to bring air into the lungs and the movement of food through the intestines.

Just why the nerves are damaged is not clear.  The explanation varies from loss of blood supply to the involved nerve or nerves to damage from toxins (poisons) that result from years of high blood glucose levels.  Diabetic neuropathy can lead to foot ulcerations, foot infections and amputations.  This is completely preventable.

There are several conditions that make neuropathy worse in addition to high blood glucose.  These include:

  • Age: since neuropathy takes years, it is going to be worse in older people who have had the disease longer
  • Height:   taller individuals have longer nerve fibers to damage
  • Alcohol consumption: even small amounts of alcohol worsen diabetic neuropathy

Doctors check the various kinds of nerve fibers by testing with a tuning fork, hot and cold items and a filament that detects loss of light touch.  Here are the ways that this is done:

  • Vibration testing, using a tuning fork, for example, can bring out abnormalities of long nerve fibers when the vibration is not felt.
  • Temperature testing, using hot or cold items, tests for damage to small fibers, which are very important in diabetes.  When small fibers are damaged, the patient can lose his ability to realize that he is entering a burning hot bath.
  • Light touch testing, perhaps the most important test that is done, detects the inability of large fibers to detect light touch.  The test is done with a thin filament.  The thickness of the filament determines how much force is necessary to bend it so that it is felt.  For example, a filament that bends with 1 gram of force can be felt by normal feet.  If a patient can feel a filament that bends with 10 grams of force, it is not likely that he will fail to feel an irritant that could damage the feet.  However, if a patient can’t feel a filament that requires 75 grams of force to bend, that patient is considered to have lost all sensation in that area.

The next articles will deal with specific syndromes in patients with diabetes due to loss of various nerves.

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