Melanie Cole, MS (Host): 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 joining me today to highlight treating and managing diabetic nerve pain is Dr. Mohammad Piracha. He's an Assistant Professor of Clinical Anesthesiology at Weill Cornell Medical College-Cornell University and an Assistant Attending Anesthesiologist at New York Presbyterian Hospital Weill Cornell Medical Center.

Dr. Piracha, it's a pleasure to have you join us today. As we get into this topic, can you help us a little bit to understand the magnitude of the epidemic of diabetes and what it means to patients as far as the prevalence, the burden? What are you seeing as far as diabetes in the trends?

Dr Mohammad Piracha: It's great to be here. I am happy to share as much information as I can with everyone. To go back to your question, the general prevalence unfortunately has been continually increasing over time. Diabetes has reached epidemic proportions globally, particularly in the United States. But also globally, its prevalence steadily continues to rise. The latest data shows somewhere around the realm of 400 to 500 million adults, so between the ages of 18 and 80 typically, are suffering from diabetes. But the scarier part of that is it's projected to rise almost double to 700 to 800 million in the next 10 to 15 years. And that increase is mainly a complex interplay of various factors, mainly the unhealthiness that a lot of us are living sedentary lifestyle, the increase in rise of obesity, and then aging populations all play a major role in that.

Melanie Cole, MS: What staggering statistics those are, Dr. Piracha. And I agree with you that it's such a multifactorial reason for why we're seeing this increase. Now, I'd like you to explain diabetic neuropathy, what that is; there are different types, the most common type that you see. Can you explain a little bit about what that is, what it means?

Dr Mohammad Piracha: So, it's a very common complication of diabetes unfortunately, and it's characterized by mainly nerve damage, primarily affecting the peripheral nerves. It tends to vary, but most frequently affects the most distal parts of our body. So, the typical symptom that people have is in their fingertips and hands and lot of the feet, and that tends to be kind of the worst part of it. It is something that really impacts people's life, not only because of symptomatic reasons, but the secondary Issues that arise as a result of losing sensation of what we are using daily, regularly and depend on on a day-to-day basis.

Melanie Cole, MS: Well, so then what is the cause of it? How is it linked to diabetes, Dr. Piracha? Why is diabetes so precarious, especially for the feet? Tell us a little bit about what we know about why it's linked to diabetes.

Dr Mohammad Piracha: It's one of those things that also happens to have a multifactorial reason. Generally speaking, the nerves that are very distal to our body tend to be the ones most vulnerable, mainly because of the blood supply is sparse compared to those that nerves that are located centrally in our body. As a result, what happens chronically over time, the inflammatory process that's associated with the high levels of sugar in our blood and those that have diabetes tends to cause microvascular damage to these nerves. And the resulting issue that most people unfortunately are faced with is as those nerves get damaged, they start instituting these symptoms of numbness, tingling, burning pain and, in drastic cases, they lose sensation completely. And this can happen rapidly depending on how people's sugars are being controlled, or it can happen slowly over time depending on how compliant patients are with their regimens associated with their diabetes.

Melanie Cole, MS: Before we get into treatment and how patients can best advocate for themselves and keep track of these sorts of things, can it be prevented, Dr. Piracha?

Dr Mohammad Piracha: The main source of prevention is going to be actually monitoring the primary diagnosis of diabetes. We have a variety of ways to do that, but most frequently people are measuring blood sugar levels and what we are in the medical world following mostly is hemoglobin A1C, which tracks longer term control of our diabetes and how our sugars average over longer periods of time. So, the primary prevention is actually controlling the diagnosis of diabetes, not so much the secondary characteristics of this. The better sugar control you have over a longer period of time, the less likely you are to develop complications of diabetes. And the poorer control you have with lower compliance, the more likely you are to have a more severe spectrum of these symptoms.

Melanie Cole, MS: So, what would they recognize and what can you help them do about that? If they're starting to do things as their doctors have told them, like checking their feet quite often, or they're starting to feel some of the symptoms, then what's next? So, tell us a little bit about what they would notice and what comes next.

Dr Mohammad Piracha: I tend to categorize diabetic neuropathy into kind of three broad categories. And depending on your source, they can be divided into more nuanced categories, but I think these three buckets really address the main issues patients have. And to simplify things, I put them into these three buckets because they're generally the ones that are accepted to be the things that people are faced with most regularly.

So, the first one is going to be sensory symptoms. That's the one that patients tend to notice first and also tend to be the most troublesome. It typically revolves around three aspects. Numbness and tingling is very common. Patients often experience numbness and tingling or pins and needle sensations in their distal extremities, toes, feet, hands. This is due to damage of the sensory nerves that I had mentioned earlier. That also can include changes in the way patients perceive touch, temperature, and pain. And I'll get more into that because the pain part is actually very important. The loss of sensation occurs over time, and that's basically a symbol of progression of that disease process. And the ability to feel pain and temperature also changes. And then last, eventually, people will develop shooting and burning pain as well concomitantly with these problems. And that can be very troublesome since it can be somewhat difficult to manage. So, that's kind of the first broad bucket.

The second bucket would be motor symptoms. So, people can develop muscle weakness and muscle wasting because the damage is not isolated to just peripheral sensory nerves, but could also involve motor nerves. And this can result in that weakness as well as. muscle wasting or atrophy medically described. And that can occur as well depending on how poorly controlled the diabetes are.

The last one is a little bit more nuanced, but will occur in patients, but tends to be harder for patients to identify mainly because the symptoms vary in spectrum a lot. And that's the autonomic disturbances. Our autonomic system is basically in charge of controlling all of our unconscious functions, things like digestion, things like urination, things like our blood pressure. And unfortunately, diabetes impacts the nerves that are responsible for those functions as well. So, people can develop things like orthostatic hypotension, which is essentially misregulation or dysregulation of our blood pressures when we go from a sitting to a standing position or from a lying to a sitting position. Nerves, usually, in healthy or well-controlled diabetics respond very quickly, we don't get lightheaded or dizzy. But these patients who do have some peripheral nerve damage will have issues and may feel dizzy or faint when they're having rapid change from a lying sitting or sitting to standing position. Gastrointestinal symptoms that are normally regulated by the autonomic system can also be affected. So, this can result in things like nausea, vomiting, bloating, also gastroparesis, which is the stalling of the stomach, being able to actually digest and move food forward to go through the colon. And then, urinary symptoms can also occur. And urinary retention incontinence, recurrent urinary tract infections are also things that can occur in the autonomic bucket. So as you can see, there's a variety of symptoms with typically the most troubling being diabetic peripheral neuropathy since it's the one that's closely associated with the pain.

Melanie Cole, MS: So then what? If people do have that peripheral neuropathy, which as you said is the most common and that you see quite often, and I've seen it in so many years of doing what I do. So, can you tell us what we do about it? You want people to really keep track of their blood sugars. You've mentioned that. What else? Can these nerves be healed? Is this something that is only going to get worse over time or not get better? What happens?

Dr Mohammad Piracha: So, it sort of depends where people land on the spectrum. As far as reversal, it tends to not be reversible. However, the closer and more carefully you monitor your exercise, your diet, and your diabetes in general, the less likely it is to progress, or at least you can slow the progression substantially.

As Far as what do we do about the pain, now, fortunately we live in the modern medical world where we have a slew of options that help treat the pain. They don't actually reverse any of the peripheral diabetic neuropathy symptoms, but they can really subdue what's troublesome for patients, which is that sense of numbness, tingling, burning. And more importantly, secondarily to the loss of sensation comes the likelihood of injury to the feet. We're so used to feeling our feet all the time that we don't realize that all these little nicks and bumps that we can develop, unfortunately, in peripheral diabetic neuropathic patients, they don't feel those nicks and they're at high risk for infection since they don't have any way of really monitoring. Other than visually monitoring, they don't get that pain feedback anymore.

So as far as symptomatic treatment goes, we have a variety of them. We can use neuropathic pain medicines, which typically fall into broad classes of neuropathics, which include anti epileptics, tricyclic medicines, as well as some newer technologies we have. So, one of the newer, more technologically advanced things that we can do now is we do have spinal cord stimulation that can be used to actually help reduce not only the numbness and pain, but prevent progression as well from there, that point forward. So, we do live at a point in time where we can actually really mitigate some of these symptoms that patients are feeling.

Melanie Cole, MS: This has been such an eye-opening, informative episode, Dr. Piracha. As we wrap up for people that are living with diabetes, what's the best way to take care of their feet? Can you give us some of your best tips? Walking, you mentioned exercise, things that might be good for their neuropathy, keeping track of their blood sugar. What about socks, shoes? We hear about diabetics shoes. Can you speak just a little bit with your best advice, doing what you do and the expert that you are? And tell people living with diabetes what you'd like them to take away from this episode.

Dr Mohammad Piracha: In general, exercise is always going to be recommended. Not only is it great for preventing progression of your diabetes, but it's great for your cardiovascular health. And we now know a very close association exists between cardiovascular disease and diabetes. So, the actual act of exercise or physical therapy and staying active is going to be a great way to prevent some of these more drastic things that we worry about when it comes to peripheral neuropathy.

In terms of socks and shoes and so forth, I think the main reason people ask that question is because I don't want them to get misled to think that that prevents any progression. But what it does do is it protects the feet and that's really important. So, you reduce the risk of having wounds, cuts, things that can lead to infections or hard-to-treat, long-term injuries to the foot and that's why the shoes and socks can be helpful. They themselves though will not prevent progression or prevent improvement of the nerve pain and/or nerve injury people have. The thing that's going to most likely prevent that progression and help patients in the long term is going to be very close glycemic control. And that can be medicinal, that can be exercise, but it's going to require quite a bit of effort to help reduce that progression. But I would still recommend things that prevent injury to the feet because we're really worried about people developing chronic infections that can be hard to heal in these patients.

Melanie Cole, MS: Great information, doctor. Thank you so much for joining us today and really sharing your incredible expertise. 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. That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, Pandora, and Google Podcasts. And for more health tips, please go to weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast, so many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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