Edited by Lahle
Source: NIH Publication No. 02–3185, May 2002
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ADA Complete Guide to Diabetes: Perhaps the most complete and authoritative resource on diabetes, American
Diabetes Association Complete Guide to Diabetes covers everything from how
to manage types 1 and 2 and gestational diabetes, to traveling with insulin,
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Gary Scheiner, CDE
Think Like a Pancreas:
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pump, hypoglycemia—the best ways to avoid it and treat it , the impact
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For More Information, contact the following organizations:
American Diabetes Association
National Service Center
Alexandria, VA 22311
Phone: 1–800–232–3472 or
1–800–DIABETES (1–800–342–2383) Fax: 703–549–6995
American Foundation for Urologic Disease
1128 North Charles
Baltimore, MD 21201
Phone: 1–800–242–2383 or 410–468–1800
American Podiatric Medical Association
9312 Old Georgetown
Bethesda, MD 20814–1698
Centers for Disease Control and Prevention
National Center for
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Division of Diabetes
Mail Stop K-10
4770 Buford Highway, NE.
Juvenile Diabetes Research Foundation International
Street, 19th floor
New York, NY 10005
Phone: 1–800–533–2873 or
Lower Extremity Amputation Prevention Program
East-West Highway, 9th floor
Bethesda, MD 20814
National Diabetes Education Program
1 Diabetes Way
National Digestive Diseases Information Clearinghouse
Bethesda, MD 20892–3570
National Heart, Lung, and Blood Institute Information Center
Bethesda, MD 20824–0105
National Institute of Neurological Disorders and Stroke
Bethesda, MD 20824
National Kidney and Urologic Diseases Information Clearinghouse
Bethesda, MD 20892–3580
Pedorthic Footwear Association
7150 Columbia Gateway Drive, Suite
Columbia, MD 21046–1151
Phone: 1–800–673–8447 or 410–381–7278
A Diabetic Doctor Looks At Diabetes: Written from the unique perspective of a doctor who has lived with diabetes for
the past 30 years, A Diabetic Doctor Looks at Diabetes has been updated
to give people with diabetes the up-to-the-minute tools and information they
need to understand, cope with, and live with the disease.
W. H. Polonsky
Diabetes Burnout: Diabetes Burnout is an interactive book that addresses the emotional
issues that contribute to poor glycemic control and provides guidance to
overcoming the barriers to good self-care. Worksheets help readers assess their
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101 Medication Tips for People with Diabetes by University of New Mexico Diabetes Care Team.
Caring for the Diabetic Soul: This new book is a collection of articles from the award-winning
Diabetes Forecast magazine. Each chapter offers practical suggestions for
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want to discover how to balance the emotional ups and downs or offer support and
care for the child with diabetes. Caring for the Diabetic Soul provides
insight, guidance, and most of all, peace of mind.
NIDCH NIH Publication 02-3185 May 2002
back to main "Complications" page
Complications of Diabetes
Symptoms, Causes, Diagnosis, Treatment, and Prevention
John A. Seneff
Numb Toes and Aching Souls: This is, in
a nutshell, the best current work on the subject of neuropathy for lay people.
It explains the problem, goes through the rational for treatment, and discusses
the treatments one by one. In addition to the use of PO medication, it covers vitamin therapy, physical therapies, psycho- therapy and
for patients who fail standard treatments, it covers alternative therapies such
as plasmapheresis and hyperbaric oxygen.
Mini Site Index
Diabetic Neuropathies: The Damage of Nerves
Causes of Neuropathy
Symptoms of Neuropathy
Types of Diabetic Neuropathy
Neuropathy Affects Nerves Throughout the Body
Preventing Diabetic Neuropathy
Treatment for Neuropathy
Points to Remember
Hope Through Research
For More Information
Diabetic Neuropathies: The Nerve Damage of Diabetes
Diabetic neuropathies are a family of nerve disorders caused by diabetes.
People with diabetes can, over time, have damage to nerves throughout the body.
Neuropathies lead to numbness and sometimes pain and weakness in the hands,
arms, feet, and legs. Problems may also occur in every organ system, including
the digestive tract, heart, and sex organs. People with diabetes can develop
nerve problems at any time, but the longer a person has diabetes, the greater
An estimated 50 percent of those with diabetes have some form of neuropathy,
but not all with neuropathy have symptoms. The highest rates of neuropathy are
among people who have had the disease for at least 25 years.
Diabetic neuropathy also appears to be more common in people who have had
problems controlling their blood glucose levels, in those with high levels of
blood fat and blood pressure, in overweight people, and in people over the age
of 40. The most common type is peripheral neuropathy, also called distal
symmetric neuropathy, which affects the arms and legs.
Causes of Neuropathy
The causes are probably different for different varieties of diabetic
neuropathy. Researchers are studying the effect of glucose on nerves to find out
exactly how prolonged exposure to high glucose causes neuropathy. Nerve damage
is likely due to a combination of factors:
- metabolic factors, such as high blood glucose, long duration of diabetes,
possibly low levels of insulin, and abnormal blood fat levels,
- neurovascular factors, leading to damage to the blood vessels that carry
oxygen and nutrients to the nerves,
- autoimmune factors that cause inflammation in nerves,
- mechanical injury to nerves, such as carpal tunnel syndrome,
- inherited traits that increase susceptibility to nerve disease,
- lifestyle factors such as smoking or alcohol use.
Symptoms depend on the type of neuropathy and which nerves are affected. Some
people have no symptoms at all. For others, numbness, tingling, or pain in the
feet is often the first sign. A person can experience both pain and numbness.
Often, symptoms are minor at first, and since most nerve damage occurs over
several years, mild cases may go unnoticed for a long time. Symptoms may involve
the sensory or motor nervous system, as well as the involuntary (autonomic)
nervous system. In some people, mainly those with focal
neuropathy, the onset of pain may be sudden and severe.
Symptoms may include:
- numbness, tingling, or pain in the toes, feet, legs, hands, arms, and
- wasting of the muscles of the feet or hands,
- indigestion, nausea, or vomiting,
- diarrhea or constipation,
- dizziness or faintness due to a drop in postural blood pressure,
- problems with urination,
- erectile dysfunction (impotence) or vaginal dryness,
In addition, the following symptoms are not due to neuropathy but
nevertheless often accompany it:
Types of Diabetic Neuropathy
Diabetic neuropathies can be classified as peripheral, autonomic, proximal,
and focal. Each affects different parts of the body in different ways.
- Peripheral neuropathy causes either pain or loss of feeling in the toes,
feet, legs, hands, and arms.
- Autonomic neuropathy causes changes in digestion, bowel and bladder
function, sexual response, and perspiration. It can also affect the nerves that
serve the heart and control blood pressure. Autonomic neuropathy can also cause
hypoglycemia (low blood sugar) unawareness, a condition in which people no
longer experience the warning signs of hypoglycemia.
- Proximal neuropathy causes pain in the thighs, hips, or buttocks and leads
to weakness in the legs
- Focal neuropathy results in the sudden weakness of one nerve, or a group of
nerves, causing muscle weakness or pain. Any nerve in the body may be affected.
Neuropathy Affects Nerves Throughout the Body
- heart and blood vessels
- digestive system
- urinary tract
- sex organs
- sweat glands
- facial muscles
- pelvis and lower back
|Peripheral neuropathy affects the nerves in your arms, hands,
legs, and feet.
This type of neuropathy damages nerves in the arms and legs. The feet and
legs are likely to be affected before the hands and arms. Many people with
diabetes have signs of neuropathy upon examination but have no symptoms at all.
Symptoms of peripheral neuropathy may include
- numbness or insensitivity to pain or temperature,
- a tingling, burning, or prickling sensation,
- sharp pains or cramps ,
- extreme sensitivity to touch, even a light touch,
- loss of balance and coordination
These symptoms are often worse at night.
Peripheral neuropathy may also cause muscle weakness and loss of reflexes,
especially at the ankle, leading to changes in gait (walking). Foot deformities,
such as hammertoes and the collapse of the midfoot, may occur. Blisters and
sores may appear on numb areas of the foot because pressure or injury goes
unnoticed. If foot injuries are not treated promptly, the infection may spread
to the bone, and the foot may then have to be amputated. Some experts estimate
that half of all such amputations are preventable if minor problems are caught
and treated in time.
|Autonomic neuropathy affects the nerves in your lungs, heart,
stomach, intestines, bladder, and sex organs.
Autonomic neuropathy affects the nerves that control the heart, regulate
blood pressure, and control blood glucose levels. It also affects other internal
organs, causing problems with digestion, respiratory function, urination, sexual
response, and vision. In addition, the system that restores blood glucose levels
to normal after a hypoglycemic episode may be affected, resulting in loss of the
warning signs of hypoglycemia such as sweating and palpitations.
Unawareness of Hypoglycemia
Normally, symptoms such as shakiness occur as blood glucose levels drop below
70 mg/dL. In people with autonomic neuropathy, symptoms may not occur, making
hypoglycemia difficult to recognize.
However, other problems can also cause hypoglycemia unawareness so this does
not always indicate nerve damage.
Heart and Circulatory System
The heart and circulatory system are part of the cardiovascular system, which
controls blood circulation. Damage to nerves in the cardiovascular system
interferes with the body's ability to adjust blood pressure and heart rate. As a
result, blood pressure may drop sharply after sitting or standing, causing a
person to feel light-headed—or even to faint. Damage to the nerves that control
heart rate can mean that it stays high, instead of rising and falling in
response to normal body functions and exercise.
Nerve damage to the digestive system most commonly causes constipation.
Damage can also cause the stomach to empty too slowly, a condition called
gastroparesis. Severe gastroparesis can lead to persistent nausea and vomiting,
bloating, and loss of appetite. Gastroparesis can make blood glucose levels
fluctuate widely as well, due to abnormal food digestion.
Nerve damage to the esophagus may make swallowing difficult, while nerve
damage to the bowels can cause constipation alternating with frequent,
uncontrolled diarrhea, especially at night. Problems with the digestive system
may lead to weight loss.
Urinary Tract and Sex Organs
Autonomic neuropathy most often affects the organs that control urination and
sexual function. Nerve damage can prevent the bladder from emptying completely,
allowing bacteria to grow in the bladder and kidneys and causing urinary tract
infections. When the nerves of the bladder are damaged, urinary incontinence may
result because a person may not be able to sense when the bladder is full or
control the muscles that release urine.
Neuropathy can also gradually decrease sexual response in men and women,
although the sex drive is unchanged. A man may be unable to have erections or
may reach sexual climax without ejaculating normally. A woman may have
difficulty with lubrication, arousal, or orgasm.
Autonomic neuropathy can affect the nerves that control sweating. When nerve
damage prevents the sweat glands from working properly, the body cannot regulate
its temperature properly. Nerve damage can also cause profuse sweating at night
or while eating.
Finally, autonomic neuropathy can affect the pupils of the eyes, making them
less responsive to changes in light. As a result, a person may not be able to
see well when the light is turned on in a dark room or may have trouble driving
Proximal neuropathy, sometimes called lumbosacral plexus neuropathy, femoral
neuropathy, or diabetic amyotrophy, starts with pain in either the thighs, hips,
buttocks, or legs, usually on one side of the body. This type of neuropathy is
more common in those with type 2 diabetes and in older people. It causes
weakness in the legs, manifested by an inability to go from a sitting to a
standing position without help. Treatment for weakness or pain is usually
needed. The length of the recovery period varies, depending on the type of nerve
Occasionally, diabetic neuropathy appears suddenly and affects specific
nerves, most often in the head, torso, or leg. Focal neuropathy may cause
- inability to focus the eye
- double vision
- aching behind one eye
- paralysis on one side of the face (Bell's palsy)
- severe pain in the lower back or pelvis
- pain in the front of a thigh
- pain in the chest, stomach, or flank
- pain on the outside of the shin or inside the foot
- chest or abdominal pain that is sometimes mistaken for heart disease, heart
attack, or appendicitis.
Focal neuropathy is painful and unpredictable and occurs most often in older
people. However, it tends to improve by itself over weeks or months and does not
cause long-term damage.
People with diabetes also tend to develop nerve compressions, also called
entrapment syndromes. One of the most common is carpal tunnel syndrome, which
causes numbness and tingling of the hand and sometimes muscle weakness or pain.
Other nerves susceptible to entrapment may cause pain on the outside of the shin
or the inside of the foot.
Preventing Diabetic Neuropathy
The best way to prevent neuropathy is to keep your blood glucose levels as
close to the normal range as possible. Maintaining safe blood glucose levels
protects nerves throughout your body.
Neuropathy is diagnosed on the basis of symptoms and a physical exam. During
the exam, the doctor may check blood pressure and heart rate, muscle strength,
reflexes, and sensitivity to position, vibration, temperature, or a light
The doctor may also do other tests to help determine the type and extent of
- A comprehensive foot exam assesses skin, circulation, and
sensation. The test can be done during a routine office visit. To assess
protective sensation or feeling in the foot, a nylon monofilament (similar to a
bristle on a hairbrush) attached to a wand is used to touch the foot. Those who
cannot sense pressure from the monofilament have lost protective sensation and
are at risk for developing foot sores that may not heal properly. Other tests
include checking reflexes and assessing vibration perception, which is more
sensitive than touch pressure.
- Nerve conduction studies check the transmission of electrical
current through a nerve. With this test, an image of the nerve conducting an
electrical signal is projected onto a screen. Nerve impulses that seem slower or
weaker than usual indicate possible damage. This test allows the doctor to
assess the condition of all the nerves in the arms and legs.
- Electromyography (EMG) shows how well muscles respond to
electrical signals transmitted by nearby nerves. The electrical activity of the
muscle is displayed on a screen. A response that is slower or weaker than usual
suggests damage to the nerve or muscle. This test is often done at the same time
as nerve conduction studies.
- Quantitative sensory testing (QST) uses the response to
stimuli, such as pressure, vibration, and temperature, to check for neuropathy.
QST is increasingly used to recognize sensation loss and excessive irritability
- A check of heart rate variability shows how the heart responds
to deep breathing and to changes in blood pressure and posture.
- Ultrasound uses sound waves to produce an image of internal
organs. An ultrasound of the bladder and other parts of the urinary tract, for
example, can show how these organs preserve a normal structure and whether the
bladder empties completely after urination.
- Nerve or skin biopsy involves removing a sample of nerve or
skin tissue for examination by microscope. This test is most often used in
The first step is to bring blood glucose levels within the normal range to
prevent further nerve damage. Blood glucose monitoring, meal planning, exercise,
and oral drugs or insulin injections are needed to control blood glucose levels.
Although symptoms may get worse when blood glucose is first brought under
control, over time, maintaining lower blood glucose levels helps lessen
neuropathic symptoms. Importantly, good blood glucose control may also help
prevent or delay the onset of further problems.
Additional treatment depends on the type of nerve problem and symptom, as
described in the following sections.
People with neuropathy need to take special care of their feet. The nerves to
the feet are the longest in the body and are the ones most often affected by
neuropathy. Loss of sensation in the feet means that sores or injuries may not
be noticed and may become ulcerated or infected. Circulation problems also
increase the risk of foot ulcers.
More than half of all lower limb amputations in the United States occur in
people with diabetes—86,000 amputations per year. Doctors estimate that nearly
half of the amputations caused by neuropathy and poor circulation could have
been prevented by careful foot care. Here are the steps to follow:
- Clean your feet daily, using warm—not hot—water and a mild soap. Avoid
soaking your feet. Dry them with a soft towel; dry carefully between your
- Inspect your feet and toes every day for cuts, blisters, redness, swelling,
calluses, or other problems. Use a mirror (laying a mirror on the floor works
well) or get help from someone else if you cannot see the bottoms of your feet.
Notify your health care provider of any problems.
- Moisturize your feet with lotion, but avoid getting it between your toes.
- After a bath or shower, file corns and calluses gently with a pumice stone.
- Each week or when needed, cut your toenails to the shape of your toes and file the edges with an emery board.
- Always wear shoes or slippers to protect your feet from injuries. Prevent
skin irritation by wearing thick, soft, seamless socks.
- Wear shoes that fit well and allow your toes to move. Break in new shoes
gradually by wearing them for only an hour at a time at first.
- Before putting your shoes on, look them over carefully and feel the insides
with your hand to make sure they have no tears, sharp edges, or objects in them
that might injure your feet.
- If you need help taking care of your feet, make an appointment to see a foot
doctor, also called a podiatrist.
For additional information on foot care, contact the National Diabetes
Information Clearinghouse at 1–800–860–8747. Materials are also available at http://ndep.nih.gov/resources/health.htm.
To relieve pain, burning, tingling, or numbness, the doctor may suggest
aspirin, acetaminophen, or nonsteroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen. (People with renal disease should use NSAIDs only under a doctor's
supervision.) A topical cream called capsaicin is another option. Tricyclic
antidepressant medications such as amitriptyline, imipramine, and nortriptyline,
or anticonvulsant medications such as carbamazepine or gabapentin may relieve
pain in some people. Codeine may be prescribed for a short time to relieve
severe pain. Also, mexiletine, used to regulate heartbeat, has been effective in
treating pain in several clinical trials.
Other pain treatments include transcutaneous electronic nerve stimulation
(TENS), which uses small amounts of electricity to block pain signals, as well
as hypnosis, relaxation training, biofeedback, and acupuncture. Walking
regularly or using elastic stockings may also help leg pain.
To relieve mild symptoms of gastroparesis—indigestion, belching, nausea, or
vomiting—doctors suggest eating small, frequent meals, avoiding fats, and eating
less fiber. When symptoms are severe, the doctor may prescribe erythromycin to
speed digestion, metoclopramide to speed digestion and help relieve nausea, or
other drugs to help regulate digestion or reduce stomach acid secretion.
To relieve diarrhea or other bowel problems, the doctor may prescribe an
antibiotic such as tetracycline, or other medications as appropriate.
Dizziness and Weakness
Sitting or standing slowly may help prevent the light-headedness, dizziness,
or fainting associated with blood pressure and circulation problems. Raising the
head of the bed or wearing elastic stockings may also help. Some people may
benefit from increased salt in the diet and treatment with salt-retaining
hormones. Others may benefit from high blood pressure medications. Physical
therapy can help when muscle weakness or loss of coordination is a problem.
Urinary and Sexual Problems
To clear up a urinary tract infection, the doctor will probably prescribe an
antibiotic. Drinking plenty of fluids will help prevent another infection.
People who have incontinence should try to urinate at regular intervals (every 3
hours, for example) since they may not be able to tell when their bladder is
To treat erectile dysfunction in men, the doctor will first do tests to rule
out a hormonal cause. Several methods are available to treat erectile
dysfunction caused by neuropathy, including taking oral drugs, using a
mechanical vacuum device, or injecting a drug called a vasodilator into the
penis before sex. The vacuum and vasodilator raise blood flow to the penis,
making it easier to have and maintain an erection. Another option is to
surgically implant an inflatable or semirigid device in the penis. A
constriction ring or penile sling may be helpful.
Vaginal lubricants may be useful for women when neuropathy causes vaginal
dryness. To treat problems with arousal and orgasm, the doctor may refer the
woman to a gynecologist.
Points to Remember
- Diabetic neuropathies are nerve disorders caused by many of the
abnormalities common to diabetes, such as high blood glucose.
- Neuropathy can affect nerves throughout the body, causing numbness and
sometimes pain in the hands, arms, feet, or legs, and problems with the
digestive tract, heart, and sex organs.
- Treatment first involves bringing blood glucose levels within the normal
range. Good blood glucose control may help prevent or delay the onset of further
- Foot care is another important part of treatment. People with neuropathy
need to inspect their feet daily for any injuries. Untreated injuries increase
the risk of infected foot sores and amputation.
- Treatment also includes pain relief and other medications as needed,
depending on the type of nerve damage.
- Smoking significantly increases the risk of foot problems and amputation. If
you smoke, ask your health care provider for help in quitting.
Hope Through Research
The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
and the National Institute of Neurological Disorders and Stroke (NINDS) conduct
and support research to help people with diabetes, including studies related to
diabetic neuropathy. A complete listing of clinical research studies can be
found at http://ClinicalTrials.gov.