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Diabetic Neuropathy

Mary Vo, M.D. discusses diabetic neuropathy. She shares the cause of nerve damage and how it impacts patients with diabetes. She also discusses the latest treatments for the condition and how it can be preventable or reversible.

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Diabetic Neuropathy
Featured Speaker:
Mary Vo, M.D.
Dr. Mary Vo is an Assistant Professor of Neurology and Assistant Attending Neurologist at New York Presbyterian/Weill Cornell Medical College. 

Learn more about Mary Vo, M.D.
Diabetic Neuropathy

Melanie Cole: Welcome to Back To Health, your source for the latest in health, wellness, and medical care. Keeping you informed, so you can make informed healthcare choices for yourself and your whole family. Back To Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole. And I invite you to join us as we discuss diabetic neuropathy. Joining me is Dr. Mary Vo. She's an assistant attending neurologist at New York Presbyterian Hospital Weill Cornell Medical Center, and an Assistant Professor of Neurology at Weill Cornell Medical College Cornell University.

Dr. Vo, thank you so much for joining us today. I'd like you to start by helping us to understand the magnitude of the epidemic of diabetes on this country, what it means to patients and really what is diabetic neuropathy.

Dr. Mary Vo: Hi, Melanie. Thank you for having me. It's great to be here today. I wanted to address diabetic neuropathy. At current, it's estimated that at least 226 million people worldwide are affected with diabetes and it's estimated that one-third to one-half of those patients will eventually develop neuropathy of some form. And this number is only growing. So we are embarking on a growing and largely unaddressed public health issue.

Diabetic neuropathy takes many forms and the most typical and what most people think about is the most common what we'll call the length-dependent neuropathy. That constitutes about maybe 80% of all diabetic nerve disease.

This is a syndrome where patients experience some combination of pain, numbness, tingling, skin and bony changes in the feet and sometimes autonomic disturbances. It's seen in patients who have longstanding and poorly controlled diabetes. And how it starts is people develop sensory changes in the tips of their toes and the soles of their feet that gradually progress up the legs and can eventually develop in the hands and in the trunk as well. A large percentage of these patients also suffer from severe pain secondary to the nerve dysfunction. If unaddressed, this nerve injury can lead to certainly pain, poor balance, increased risk of falls, even weakness and muscle wasting in the legs that certainly contributes to morbidity.

Another common form of diffuse neuropathy is something called diabetic autonomic neuropathy. So in this form of neuropathy, which is also relatively common, the autonomic nerves that control things like your heart rate, sweating, body temperature regulation, and transit time of the gastrointestinal tract are affected.

So in this type of neuropathy, patients can develop things like racing heart rate, poor temperature regulation, inappropriate sweating or lack of sweating, dizziness, episodes of passing out. What's coming to attention is that a significant proportion of patients who develop this cardiac autonomic neuropathy that is associated with diabetes are at increased risk for myocardial infarction and arrhythmia.

So those covered the two broad and more common forms of diabetic nerve disease, but there are more. Diabetics are more prone to various forms of neuropathy. Some of the lesser common forms can include injury to the nerves that affect the face, facial cranial neuropathies as they're called. So in some of these cases, patients can have abrupt injury to a nerve controlling eye movement resulting in double vision. They can develop things like nerve carpal tunnels syndrome. And also among other things, injury to the nerve plexus, which is a big web of nerves in the proximal arm and leg that can affect pain and motor function.

Melanie Cole: It's so comprehensive, Dr. Vo. As you're telling us about these different types, how are they linked to diabetes? You said that if it's poorly controlled that the peripheral and even the autonomic, you know, are going to be complications that people can suffer from. How is this linked to diabetes? Why does this happen?

Dr. Mary Vo: Well, it's complicated. And the more we learn about diabetes, the more we're discovering how complex it really is. The basic answer is that it is a mix of both metabolic and vascular mechanisms that incur damage to the nerves. It's not one single mechanism. We think it's actually three or four different pathways that control nerve repair, nerve functioning and modulation of an inflammatory response that if they are out of balance can eventually culminate into sustained and progressive damage of the nerve.

Melanie Cole: So many complications are possible with diabetes. And as you say, we're learning more and more all the time about its relationship to obesity and heart disease and hypertension and all of these things. Can diabetic neuropathy be prevented, Dr. Vo?. And if so, how? Is it really just about good control of blood sugar levels? And if that's the case, tell patients what you tell them every day. Tell listeners what you tell patients every single day about the importance of controlling their diabetes.

Dr. Mary Vo: The majority of diabetes in the most common form that I described, the length-dependent neuropathy, once it's sets in, it can stabilize if one is very strict about glucose control or, for patients who have poor sugar control, it can get progressively worse. Patients with very early diabetic neuropathy or even those who are pre-diabetic, some people actually have very subtle and early involvement of the nerves in the form of small fiber nerves.

The way this manifests, particularly in patients with pre-diabetes or just glucose impairment, they can get very mild pure sensory involvement in the form of numbness, tingling in the tips of the toes. It can be painful or non-painful. If you catch it early in a patient who has not had established diabetes, there is some hope for nerve recovery. Certainly, the longer one has diabetes and the more severe the case is, it's harder to recover function.

And I'd also like to mention a question about vitamins, because I get asked this question all the time by my patients, whether vitamin supplements are helpful in diabetic neuropathy. I will highlight that there is evidence for one particular vitamin, alpha-lipoic acid in improving symptoms of early diabetic neuropathy, and that's borne out through studies. However, there's a lot of commercial advertising direct to the public about neuropathy cocktails that contain some combination of B vitamins, folic acid, and other "antioxidants." So some of these, while they certainly have their merits, I don't think should be necessarily taken indiscriminately because on occasion, some patients do take some of these B complex vitamins or B complex-containing vitamins and end up with excess of B6 vitamin, which can in turn actually aggravate or cause a neuropathy in and of itself. So I would say keep it simple.

We usually do a thorough check for any vitamin deficiencies that can contribute to neuropathy as part of our evaluation. And we specifically try to replete what's low, but we don't indiscriminately advise vitamin supplements because occasionally people do run into trouble with them.

Melanie Cole: Because the nerves are affected and the nerves in the feet, is that why people can maybe step on something and not realize they've done it and then they get a wound that doesn't heal? Are all of these kinds of things tied in together?

Dr. Mary Vo: Yes, they are. And I'm glad that you mentioned that. One of the most severe and concerning complications from my perspective is patients who aren't aware. They don't necessarily have a painful neuropathy and are therefore perhaps can be unaware that they're losing sensation in their feet. People who suffer from this condition can certainly sustain trauma or injury to the legs and not notice and, in that context, can develop ulcerations, infections, gangrene, and can even lead to non-traumatic amputation.

Melanie Cole: Certainly are scary complications. Dr. Vo, what would you like patients to know if they're living with diabetes about the best ways to care for their feet, to keep an eye on the red flags, the things that you want them to notice in cases of diabetic neuropathy?

Dr. Mary Vo: I think it's imperative for patients living with diabetes to have regular foot checks in foot clinics who take a look with careful attention to any evidence of trophic changes, tissue changes, including vascular changes in the feet or signs of deterioration of the skin or nails of the feet to make sure that there is no deterioration and, if one is found, to address it quickly. Secondly, it's important to have the right footwear, to have the right orthotic supports and shoes that reduce the risk of developing ulcerations in the foot.

Melanie Cole: What's your best advice as we get ready to wrap up this very informative podcast on something that not a lot of people might know about, Dr. Vo, with diabetic neuropathy. And you described the different types so very well. You're a very good educator. What would you like to tell listeners about controlling their diabetes, possibly preventing diabetic neuropathy and some of the other really severe complications of diabetes?

Dr. Mary Vo: I think first and foremost, I can't say it enough that strict control of one's blood sugar is imperative in reducing the progression of neuropathy and serious complications that can stem from it. Secondly, even before you get there, lifestyle interventions, such as regular exercise, a heart-healthy diet are imperative in keeping the body and particularly the nerves healthy before the symptoms of diabetic neuropathy sit in.

Lastly, I would like to emphasize that diabetic neuropathy isn't just the typical loss of sensation and pain in the feet, but it may take many other forms. So, checking with the neurologist to really take all of these things into account is imperative.

So I'd like to patients with diabetes or even glucose impairment to really pay attention to signs of numbness and tingling in the hands and feet or other parts of the body, visual changes, episodes of dizziness or palpitations that might be developing. And at this point, I think that they shouldn't hesitate to contact us at the peripheral neuropathy center at Weill Cornell to learn more.

Melanie Cole: Great information, Dr. Vo . Thank you so much for joining us today.

And Weill Cornell Medicine continues to see our patients in-person as well as through video visits and you can be confident of the safety of your appointments at Weill Cornell Medicine.

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