Wellness

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According to the American Diabetes Association, up to 50% of diabetic peripheral neuropathies may be asymptomatic. This is called painless neuropathy and patients with this type of neuropathy are at risk of injuries and diabetic foot ulcerations. Previous research studies linking vitamin D deficiency and diabetic peripheral neuropathy did not distinguish between painless and painful diabetic peripheral neuropathy. The following study focuses on these distinctions and other confounding factors like sunlight exposure and patient activity levels.

Research was done on 45 white Europeans with type 2 diabetes along with 14 participants without. Participants with diabetes were separated into 3 groups: 17 had painful diabetic neuropathy, 14 had painless diabetic neuropathy, and 14 had no neuropathy. From July to September, lower limb skin biopsies were taken to measure 25-hydroxyvitamin D levels. Small and large nerve fiber function was tested using quantitative sensory testing. Daily activity was also measured in all volunteers.

Results showed vitamin D levels were significantly lower in the group with diabetic peripheral neuropathy. The group with painful diabetic peripheral neuropathy had an average of 34.9 nmol/l of 25-hydroxyvitamin D compared to healthy participants who had 62.05 nmol/L. The painless diabetic neuropathy group had an average of 53.1 nmol/l of vitamin D. After adjusting for age, BMI, activity level, and sunlight exposure, vitamin D was the only significant independent variable with an odds ratio of 1.11. An ANCOVA model was used to analyze the data. Also, participants with lower vitamin D levels also had lower cold detection thresholds and lower subepidermal nerve fiber densities. These results suggest vitamin D could play a role in nociceptor generation, which contribute to the development of painful diabetic peripheral neuropathy.

Many patients with diabetes go undiagnosed and live in pain because neuropathy can get overlooked as a major complication of diabetes. Even worse, some patients are never treated for neuropathy because they experience no pain. These patients could develop diabetic foot ulcerations and not be able to feel it since the pain receptors have greatly diminished. Current medications to treat diabetic peripheral neuropathy are very limited. Medications work on only 1/3 of patients and really can only numb or block the pain. There are significant side effects to these medications as well. If vitamin D deficiency is linked to nociceptor generation, then it can be corrected at a cellular level and mitigate the development of peripheral neuropathy or at least alleviate the pain with little to no side effects. More research needs to be done in this area considering the small sample size of this study. This emerging area of research will help patients live longer and better lives with diabetes.

Practice Pearls:

• Vitamin D deficiency is linked with painful and painless diabetic peripheral neuropathy despite age, BMI, activity level, or sun exposure.
• Cold detection was lower in participants who were vitamin D deficient.
• Educate patients on signs and symptoms of diabetic peripheral neuropathy and proactively screen for its development on patients who have diabetes.  

References:

Shillo, D. Selvarajah, M. Greig, R. Gandhi, G. Rao, I. D. Wilkinson, P. and, S. Tesfaye. Reduced vitamin D levels in painful diabetic peripheral neuropathy. Diabetic Medicine.(2018): https://doi.org/10.1111/dme.13798

Rodica Pop-Busui, Andrew J.M. Boulton, Eva L. Feldman, Vera Bril, Roy Freeman, Rayaz A. Malik, Jay M. Sosenko, Dan Ziegler. Diabetic Neuropathy: A Position Statement by the American Diabetes Association. Diabetes Care.  40(1) (Jan 2017): 136-154; DOI: 10.2337/dc16-2042

Angela Reyes, Pharm.D. Candidate, LECOM College of Pharmacy

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houlder ultrasound can predict, confirm type 2 diabetes

December 2, 2018

An ultrasound of the shoulder could be both a predictor and confirming tool for type 2 diabetes, according to study data presented at the Radiological Society of America in Chicago this week.


Steven Soliman
Steven Soliman, DO, a musculoskeletal radiologist at Henry Ford Hospital in Detroit, and colleagues observed that a disproportionate number of patients with diabetes or even prediabetes exhibited bright or hyperechoic deltoid muscle in musculoskeletal ultrasounds of the shoulder.

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A process that has become more popular in the past 2 decades, musculoskeletal ultrasounds are used to diagnose diseases of the muscles, tendons and ligaments across the musculoskeletal system. Patients with diabetes commonly require such procedures in the shoulder due to an increased risk for rotator cuff injury and pain, Soliman told Endocrine Today.

The researchers found that in questioning patients after an ultrasound, a large number confirmed that they had diabetes or prediabetes and were not yet taking medication. Soliman said the bright appearance was found in patients with diabetes regardless of obesity status.

“We believe this is something related to diabetes, not so much obesity, because we know that obesity patients can get increased fat in their muscles that can also appear bright like that, but we noticed it was kind of out of proportion with diabetics than it was with obese patients,” Soliman said. “That’s what got the idea that maybe we should take a look at this and see if this is something that is more pronounced in [patients with diabetes] than in obesity.”

The researchers enrolled 137 patients with diabetes and 49 with obesity and no diabetes for study. Shoulder ultrasound images were selected from each participant and then sorted by a radiologist not involved with the study. Two participating radiologists then examined each image to determine one of three endpoints: definite diabetes, suspected diabetes or no diabetes. A third radiologist served as an arbitrator when a consensus was not reached.

The ultrasound images were 89% predictive of definite diabetes, Soliman said. In addition, of the 13 participants with prediabetes in the cohort, all had an appearance in the deltoid muscle that correlated to definite or suspected diabetes.

“We were actually surprised that not only did [patients with diabetes] have this hyperechoic appearance of the deltoid muscle but [patients with prediabetes] showed that,” Soliman said. “It may be something that starts early and changes early within the muscle architecture.”

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n part 3 of this Exclusive Interview, Viswanathan Mohan talks with Diabetes in Control Publisher Steve Freed about the reasoning behind higher rates of diabetes in communities of color, especially in India.

Viswanathan Mohan, PhD, MD, DSc is the chairman of Dr. Mohan’s Diabetes Specialties Centre and president and director of the Madras Diabetes Research Foundation in Chennai, India.

Transcript of this video segment:

Freed:  Anyways, let’s get back to India. I have a philosophy or at least the knowledge I believe that people that have darker skins whether you’re Italian, Indian, American-Indian, African-American, Japanese, whatever, people with darker skins have more diabetes in their history.

Mohan:  Yes.

Freed:  What do you say to that?

Mohan: I think that is true in some way, because even if you look at the US population, if you look at the prevalence of diabetes in the white population in the US and compare them with virtually any other population, whether it’s the Pima Indians or the Asians, or the Black population, or the Non-Hispanic whites, you compare them with any other population, they have the lowest, the white population. Lowest, and every other ethnic group has higher. In India, there are other causes and one of them is consanguinity. People tend to marry into their own families. This traditionally has been to keep the wealth within the family. So, it’s not unusual for a girl to marry her uncle for example. The mother’s brother would be the first choice for marriage and then would be the cousins, the first cousins, and then the second cousins, and very rarely outside that. So, for centuries this has been going on particularly in some communities. And so, what happens is when you have a diabetes gene, it gets multiplied over and over and over again, and therefore everybody in the family then has the gene, and that’s why you get diabetes.

But if you go back to the time when my father started his work and when I joined him in the year 1971, the prevalence of diabetes – and at that time we didn’t have a national study, that’s being done by my daughter now, the whole country is being studied — but in my father’s days, we used to just study a city. So, in my city, Chennai, which the fourth largest city in India, the prevalence of diabetes is 2% of the adult population [then]. Today, it is 24% of the population. So, one in four of all adults about 20 years in Chennai have diabetes. And if you go to age, let’s say 50 or 55 in Chennai or Delhi, or Mumbai, both 40% have diabetes and 35% have pre-diabetes, so 75% of the population has either diabetes or pre-diabetes at that age and only 25% are normal. Now, these are highly — very, very worrying statistics. And it means that if you take a country with 1.3 billion people and then you talk about such high prevalence rates of diabetes, you’re talking about almost a hundred million people with diabetes in India. Currently it’s about 73 million, but the projection is that it’ll soon reach a 100 million, maybe in the next five years or so.

Freed:  So, I can quote — because I’m here in the US, I can say there’s 30 million people here with diabetes, 25% don’t know they have it, 10% of those people have type 1 diabetes. And we have a 100 million approximately. It keeps going up. We started at 70 but now we’re up to a 100 million people most likely with pre-diabetes and 90% of those people–

Mohan:  Don’t know.

Freed:   –don’t know they have it yet. So, what are the numbers in India?

Mohan:  The percentages? So, in India it would be much worse. The undiagnosed will be much worse because we don’t have systematic screening as you have here. So, I would say half of the people don’t know that they have diabetes. Among the pre-diabetics, I would say about nobody knows because it’s totally asymptomatic and nobody screens at that age and there are no symptoms. So, the number of people with pre-diabetes in India is about 80 million now. So, we have 73 million people with diabetes and 80 million people with pre-diabetes. And of course it depends on the definition that you use. If you use the American definition which is 100 milligrams and above, 100-125, then it’ll probably be more than 100 million in India. We use  110, the WHO criteria which is slightly stricter, and even with that we have 80 milion people. So, you’re right about that and so half the people really don’t know that they have the disease.

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Fasting for lab tests isn't good for patients with diabetes December 4, 2018, Michigan State University

Fasting before getting your blood drawn for cholesterol tests is common practice, but new research from Michigan State University shows it is a contributing factor of low blood sugar, or hypoglycemia, in patients who take diabetes medications.

The study, published in the International Journal of Endocrinology, shows that people with diabetes are more likely to experience FEEHD—fasting-evoked en route hypoglycemia in diabetes—than they would if they hadn't fasted. The "en route" comes from patients who have an episode while driving to a lab for blood work.

Saleh Aldasouqi, an endocrinologist in the College of Human Medicine, explained that eating before a lab test does not alter the results of the pivotal components of the cholesterol test as previously thought. In fact, fasting for these tests can incite hypoglycemia in patients with diabetes.

"Hypoglycemia is an overlooked problem that we see from time-to-time in patients with diabetes who show up for lab tests after skipping breakfast," Aldasouqi said. "Patients continue taking their diabetes medication but don't eat anything, resulting in low blood sugar levels that cause them to have a hypoglycemic event while driving to or from the lab, putting themselves and others at risk. Our new motto is 'Feed not FEEHD', to remind patients of this danger and get them to eat."

Hypoglycemia happens when blood sugar levels drop below 70 mg/dl and can cause faintness, confusion and even a loss of consciousness. Severe hypoglycemia can cause acute harm to the patient or others, especially if it causes falls or motor vehicle accidents.

Aldasouqi said that routine fasting is based off guidelines from the 1970s and newer studies show it may not be necessary anymore. Canada and Europe have already changed their guidelines and no longer require fasting for lipid tests, the most commonly ordered fasting labs. Similar U.S. guidelines have not yet become mainstream. In view of the risk of FEEHD, Aldasouqi hopes for diabetes organizations to take a lead in disseminating these emerging changes on lipid testing.

The study showed proper education about fasting and diabetes also is lacking. Only 35 percent of patients surveyed indicated having received any FEEHD prevention instructions from their doctor prior to their lab visit.

"We encourage patients who receive orders for a lab test to ask their doctor if fasting is really necessary, and if so, how they should handle their diabetes medications during the fasting period to account for the changes in their blood sugar levels," Aldasouqi said. "FEEHD is overlooked in clinical practice, and we aim to bring this problem to light and further educate doctors and patients about the consequences of fasting while on diabetes medications."

The study involved 525 patients with diabetes and was conducted at two endocrinology practices in Michigan. Patients completed a two-page survey and were excluded if data was missing or they reported no fasting labs in the previous 12 months. Aldasouqi plans to conduct a larger, population-based study to determine the prevalence of FEEHD in the general population.

Explore further: Pharmacists should counsel patients fasting for Ramadan

More information: Saleh Aldasouqi et al, Fasting-Evoked En Route Hypoglycemia in Diabetes (FEEHD): An Overlooked Form of Hypoglycemia in Clinical Practice, International Journal of Endocrinology (2018). DOI: 10.1155/2018/1528437