Diabetic Neuropathy

Neuropathy may be diffuse, affecting many parts of the body, or focal, affecting a single, specific nerve and part of the body.

Diabetic neuropathy is a nerve disorder caused by diabetes.

Symptoms of neuropathy include numbness and sometimes pain in the hands, feet, or legs. Nerve damage caused by diabetes can also lead to problems with internal organs such as the digestive tract, heart, and sexual organs, causing indigestion, diarrhea or constipation, dizziness, bladder infections, and impotence.

In some cases, neuropathy can flare up suddenly, causing weakness and weight loss. Depression may follow.

While some treatments are available, a great deal of research is still needed to understand how diabetes affects the nerves and to find more effective treatments for this complication.

A 10-year clinical study that involved 1,441 volunteers with insulin-dependent diabetes (IDDM) was recently completed by the National Institute of Diabetes and Digestive and Kidney Diseases. The study proved that keeping blood sugar levels as close to the normal range as possible slows the onset and progression of nerve disease caused by diabetes.

The Diabetes Control and Complications Trial (DCCT) studied two groups of volunteers: those who followed a standard diabetes management routine and those who intensively managed their diabetes. Persons in the intensive management group took multiple injections of insulin daily or used an insulin pump and monitored their blood glucose at least four times a day to try to lower their blood glucose levels to the normal range.

After 5 years, tests of neurological function showed that the risk of nerve damage was reduced by 60 percent in the intensively managed group. People in the standard treatment group, whose average blood glucose levels were higher, had higher rates of neuropathy. Although the DCCT included only patients with IDDM, researchers believe that people with noninsulin-dependent diabetes would also benefit from maintaining lower levels of blood glucose.

People with diabetes can develop nerve problems at any time. Significant clinical neuropathy can develop within the first 10 years after diagnosis of diabetes and the risk of developing neuropathy increases the longer a person has diabetes. Some recent studies have reported that:

• 60 percent of patients with diabetes have some form of neuropathy, but in most cases (30 to 40 percent), there are no symptoms.
• 30 to 40 percent of patients with diabetes have symptoms suggesting neuropathy, compared with 10 percent of people without diabetes.

Diabetic neuropathy appears to be more common in smokers, people over 40 years of age, and those who have had problems controlling their blood glucose levels.

Scientists do not know what causes diabetic neuropathy, but several factors are likely to contribute to the disorder.

High blood glucose, a condition associated with diabetes, causes chemical changes in nerves. These changes impair the nerves' ability to transmit signals. High blood glucose also damages blood vessels that carry oxygen and nutrients to the nerves. In addition, inherited factors probably unrelated to diabetes may make some people more susceptible to nerve disease than others.

How high blood glucose leads to nerve damage is a subject of intense research. The precise mechanism is not known. Researchers have discovered that high glucose levels affect many metabolic pathways in the nerves, leading to an accumulation of a sugar called sorbitol and depletion of a substance called myoinositol. However, studies in humans have not shown convincingly that these changes are the mechanism that causes nerve damage.

More recently, researchers have focused on the effects of excessive glucose metabolism on the amount of nitric oxide in nerves. Nitric oxide dilates blood vessels. In a person with diabetes, low levels of nitric oxide may lead to constriction of blood vessels supplying the nerve, contributing to nerve damage.

Another promising area of research centers on the effect of high glucose attaching to proteins, altering the structure and function of the proteins and affecting vascular function.

Scientists are studying how these changes occur, how they are connected, how they cause nerve damage, and how to prevent and treat damage.

The symptoms of diabetic neuropathy vary. Numbness and tingling in feet are often the first sign. Some people notice no symptoms, while others are severely disabled. Neuropathy may cause both pain and insensitivity to pain in the same person.

Often, symptoms are slight at first, and since most nerve damage occurs over a period of years, mild cases may go unnoticed for a long time. In some people, mainly those afflicted by focal neuropathy, the onset of pain may be sudden and severe.

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