December 17, 2008

Diabetic Nerve Pain and What You Can Do About It

One of the saddest statistics about diabetes is that, at the time of their diagnosis, fully 48% of those newly diagnosed with diabetes already have signs of diabetic nerve damage.

You can see this documented in this table where "impaired foot sensitivity" is a diagnostic sign of neuropathy:

Prevalence of microvascular complications at the time of diagnosis in diabetic patients identified by screening and in general practice

which is taken from this study:

Microvascular Complications at Time of Diagnosis of Type 2 Diabetes Are Similar Among Diabetic Patients Detected by Targeted Screening and Patients Newly Diagnosed in General Practice: The Hoorn Screening Study

It is known from studies of people with Type 1 diabetes that it takes a decade of exposure to elevated blood sugars to produce neuropathy. But high blood sugars creep up on people with Type 2 diabetes, and it turns out that even blood sugars in the "prediabetic" range can cause it.

You can read more about the research that documents the relationship of high post-meal blood sugars to neuropathy HERE.

Doctors miss the early diagnosis of Type 2 diabetes in these people because they rely on the fasting glucose test, or perhaps the A1c test, to screen for diabetes.

Unfortunately, neurologists who have researched the topic have found that the incidence of neuropathy correlates entirely to rising post-meal blood sugars, not fasting glucose or A1c. As soon as post-meal blood sugars (or GTT blood sugars) go over 140 mg/dl (7.7 mmol/L) the incidence of neuropathy starts to rise. It starts with small nerve fibers and with extended exposure to high blood sugars, extends to the thicker fibers.

But even after they diagnose people with Type 2 diabetes, the treatment that doctors give their patients ensures that even those who did not have neuropathy at diagnosis will develop it over time, because most doctors who are not specialists follow the treatment guidelines provided by the American Diabetes Association (ADA). These guidelines focus entirely mainly on lowering A1c using oral drugs and when they mention post-meal blood sugars at all--which is not often, they recommend post meal blood sugar levels that are way over the blood sugar level where science has found neuropathy begins.

Symptoms of Neuropathy

Neuropathy starts out with pain and tingling in your feet. It usually is present in both feet, which can help you distinguish it from similar foot pain that can be caused by compressed nerves due to bad vertebral discs or piriformis syndrome which is likely to be present on only one side of your body.

The damage to your nerves is being caused by glucose blocking up the tiny capillaries that feed your nerves so that they do not receive the nourishment they need and start to die. Though you feel the pain in your sensory nerves, neuropathy also affects your autonomic nervous system--the nerves that control involuntary functions like heart beat and sexual response. It also turns out that the autonomic nervous system, through the vagus nerve, controls your immune system. So when your nerves are dying your immune system may not get the message that invaders have attacked your feet, which is part of what leads to the devastating infections that lead to diabetic amputations.

Treatment for Neuropathy

If you go to your doctor complaining about tingling or numbness in your feet, you are likely to be given a prescription for an expensive drug like Lyrica or Topomax. These drugs do not have any effect on the progress of your neuropathy. Instead, what they do is disrupt the pain signals being sent to your brain so that you don't feel them. They have also been linked to suicidal thinking and actions and the FDA just today published new guidelines warning of this devastating side effect in people taking these drugs.

But while you take these drugs, even though you might feel better, the nerve damage continues. Eventually your nerve pain goes away to be replaced by numbness, which is easier to live with but much worse for your health. Once your feet are numb, infection can easily take root and since your immune system is weakened, it can lead to tissue death requiring amputation.

This is very scary especially for those of you who have seen relatives lose their limbs. But the good news is that you can reverse neuropathy by lowering your post meal blood sugars.

Doctors may not tell you this because after years of urging their patients to shoot for the dangerously high ADA blood sugar targets, they have observed most of their patients develop neuropathy. This convinces them that "tight control" (as defined by the ADA) cannot prevent neuropathy. Since they assume that all people with diabetes will eventually develop it, they give you your pain pills and shoo you out of the office.

Effective Treatment for Neuropathy

Everything changes when you define "tight control" to mean "Maintaining post-meal blood sugars below the level where neuropathy begins." That level turns out to be 140 mg/dl (7.7 mmol/L). Lower your blood sugar to this level, meal after meal, and your nerves sill start to heal.

This is a good 40 mg/dl lower than the dangerously high 180 mg/dl two hours after eating which the ADA officially defines as "tight control." And when you bring your blood sugars down below 140 mg/dl and keep them there for a few months, your feet will get better.

In fact, people who have done this have reported on web discussion groups that once they get into truly good control, they can tell when their blood sugar has gone over 140 mg/dl because their feet begin to hurt. If they bring it back down, the pain stops.

If you have been living with much higher blood sugars for a while and have neuropathy that has progressed to numbness, there is one bump in the road you should be aware of. If your nerves are so damaged that they have become numb, when you start to heal them, they may hurt.

Regenerating nerves always hurt, itch or tingle. This is true whether they are regenerating from glucose poisoning or mechanical damage. If your feet start to hurt after you have lowered your blood sugar, remind yourself that this is good not bad.

It is a sign that your nerves are healing and that, even more importantly, your immune system is learning that you have feet again and will get back on the job of fighting off invaders.

If you think it is impossible to get your post-meal blood sugar down below 140 mg/dl after eating, be assured it is not. Thousands of people with diabetes--both Type 2 and Type 1--who are active on online discussion groups are doing it.

The secret is to follow a strategy like the one described here:

How to Get Your Blood Sugar Under Control

If you are taking insulin or a sulfonylurea drug like Amaryl that can cause hypos, you will have to work slowly and carefully cut back on your doses of medication as your blood sugars come down to avoid hypos. Talk to your doctor or diabetic educator about how to do this if you don't already know how.

No matter how bad your blood sugars might be now, there is some combination of dietary change, oral medication, or insulin, properly prescribed, that will bring your post-meal blood sugars down to the safe zone.

If your doctor or educator is not supportive of your desire to achieve truly safe blood sugars targets, and does not respond with enthusiasm to your desire to lower your post meal blood sugars to the safe range, find a new one who is better trained and more up-to-date, who will.

The take-away lesson here is this: It is post meal blood sugars that cause neuropathy. People can get identical A1cs with very different post meal blood sugars which is probably why the research finds there is no clear correlation between A1c and the presence of neuropathy, especially when A1c is below 8%.

Your fasting blood sugar, which is the only blood sugar many out-of-date doctors monitor, is also worthless in evaluating your neuropathy risk, because it is possible to have extremely high post meal blood sugars and completely normal fasting blood sugars. I did that myself years ago when I had fasting blood sugars of 98 mg/dl and post meal blood sugars at every meal over 250 mg/dl.

This 140 mg/dl post meal blood sugar target is very mainstream--the American Association of Clinical Endocrinologists has been recommending it for five years now and I have heard rumors that some of that organization's members would like to see it lowered even further.

I personally try to keep my blood sugar under 120 mg/dl at all times, though that is not always possible. But even with eating quite a few meals that missed that target, I have been able to maintain my A1cs in a range between 5.5% and 5.8% over the past decade, and has been enough to keep me from developing any signs of diabetic neuropathy.

I do periodically experience neuropathy caused by compressed nerves in my spine, thanks to some ruptured vertebral discs. But as long as I keep my blood sugar in the safe range, I have found that over time those nerve injuries are able to heal up, too.

Do Supplements Help?

People often write to me asking about whether there are supplements that can help with neuropathy. As is the case with any painful, chronic condition, diabetes attracts flocks of vultures eager to prey on the desperation of sufferers. These vultures will gladly sell you herbs and potions at inflated prices with the promise they will heal you.

Save your money. There are very few supplements that appear to have any affect on neuropathic pain and the evidence for them is underwhelming. You can read what researchers have found about these supplements here:

Useful Supplements for People with Diabetes

But after years of reading the discussion boards, my impression is that very few people find these supplements worth the expense, while everyone who follows the advice about modifying their diet experiences improvement. So your best bet is to put the money you would have wasted on expensive herbs and supplements into buying the foods that lower your blood sugar. It's a much better investment.


Anne said...

I have small fiber PN. My doctors gave me a GTT twice, but told me I did not have diabetes even though my blood sugar rose to over 200 at 2 hours. They shrugged their shoulders and prescribed Neurontin.

In a way I am glad that they missed the blood sugar PN connection as that caused me to continue my search. I found a link between gluten and PN. To make a long story short, I tested positive to antibodies to gluten, stopped eating gluten, and my symptoms greatly improved. At the time I went gluten free the tingling and numbness was extending up my arm and legs. I had vibrating pains and lightening bolt pains. Walking was becoming very painful.

Five years later and my pain is nearly gone(no pain meds). I still have some mild numbness of my feet. I now have hope that my nerves will heal even more by following the guidelines outlined by Jenny. I have been low carbing and checking my BG for the past 6 months.

Sometimes there is more than one cause of a health problem.

Trinkwasser said...

Keep at it, I had neuropathy to the extent of numbness and tingling/foot going to sleep rather than pain on "not diabetic yet" blood sugars and it has reversed *unless* I go over 140 - 150, it took a while and I also use the DPN cocktail

The really interesting one is, I still have some autonomic neuropathy affecting my digestive system/gut motility BUT for a long time my heart was stuck at 60 - 80 bpm and would beat harder, to the extent it felt like it was about to burst out of my chest, instead of speeding up.

NOW after a few years it has suddenly started to respond normally to stress again, and my ED is also somewhat improved. So some forms of neuropathy may respond quickly to BG control while others may take a long time, probably as long as they took to be caused, but *keep at it*!

And for anyone whose medical professionals write off this or other sites as "amateur" try this one

Katharine is a real live doctor and has a very similar approach as many successful "amateurs"

Marie said...

Hi I have been having neurpathic pains (pins and needles in my lower legs and sometimes arms), and a burning sensation-pain in both my feet. I had a EMG and NCT to rule out neuropathy. I consider myself "pre-diabetic" even though my THREE doctors ,2 PCP and Neurologist say Im not pre-diabetic. My A1C back in 3/11 was 5.7. 6 mos later it went down to 5.3 (starting watching my carbs and portions), 3 mos later it went to 5.4 and last month it jumped to 5.8. My 1 hour post meal have been under 140 and 2 hour under 120. Sometimes I miscount the carbs and my 1 hour post meal will go up as high as 154 and 167 but it always goes back down to below 120 by two hours. My fastin BG are good always below 90 closer to 85. I am convinced that have some small nerve Neuropathy (even though the Doctor says its normal) based on my after meal spikes and my A1C.
I am in pain and feel helpless. I feel my Doctors do not take me seriously. They gave me a script for Neurotin for my pain, but im afraid to take it because of the side effects. If ths is "Diabetic" Neuropathy , will it go away if I continue to keep my BG from spiking over 140 after meals? Desperate, in pain and depressed.

Jenny said...


Sorry to hear you are having such a tough time finding help for your nerve pain.
If it is caused by higher than truly normal blood sugars, lowering your blood sugars will reverse the damage if you stick to it for many months. It's worth a try.

However, there are other causes for nerve pain and some of what you describe does not ound all that much like the classic way in which early diabetic nerve damage manifests. This may be why your doctors don't think that the most likely explanation.

I have heard from other people who have similar symptoms to yours along with normal or near normal blood sugars and they share your frustration at not being able to get a real diagnosis.

Christina said...

I have the exact same issue as you have. I have been checking my sugars and A1C is always like yours. The only thing I noticed was in the middle of the night I checked it some times and it would jump up to like 148... and it freaked me out. I researched all about the Dawn Phenomenon and that is when I started doing a few A1C ... My doctor says I'm ok. not to worry. So My toes started tingling in both my toes and my left one became more numbing. So I thought maybe I need orthotics. Just went to a pediatrist and he thinks I have Neroma and gave me prednisone (small dose for 6 days ) and oh boy my sugars are going quite higher. Nurse said they will go back down but last night, on day 3 i woke up at 2:30 with extremem tingling and pains in my legs and I got up and checked by BP was 158. I wonder if I am borderline diabetic. Anyone else come accross this issue AC1 normal - my last one was 5.1

Jenny said...

Christina, The A1c is a poor tool for screening for diabetes. If you are at all anemic or if you have certain genetic varients of your red blood cells it will give a falsely low reading. A glucose tolerance test is a much better measure of your blood sugar control. If you keep having problems, demand that your doctor order one. If he resists, you need to find a doctor more knowledgeable about diagnosing diabetes.

Lee Robbins said...

I too discovered, with the help of a very smart internist friend, an open-minded neurologist, and the ability to purchase blood-sugar meters, that I got significant blood sugar spikes (e.g., 250 after a bagel or 2 slices of pizza) even though by HbA1c was 5.8 and FP under 100. Controlling carbs and thus spikes led to cessation of neuropathy increase and, after 2-3 years, improvement in neuropathy (it takes years for the fibers to regenerate from the spine). Now, some 10 years later, things remain comfortable and under control though 750 mg. of metformin, 8-10% weight loss and lots more exercise has also aided the situation. Thanks for your wonderful site.

Jenny said...


So glad to hear that lowering blood sugar reversed your neuropathy. It often will if people have enough patience.

Reeva Milstein said...

Thank you for this site. I have been suffering for 2 years with neuropathy and was recently diagnosed with Type 2 Diabetes. Although I have lost 50lb since March and have started to exercise, my feet have been really painful. I was getting really depressed over it, as I was making a real effort to correct my problem but was still suffering. I am so grateful to discover that I need to monitor my post-meal glucose levels. I am going to begin that today and will make sure to keep it under 140. I feel as if I have been sent a lifesaver. I will keep you posted...

Jenny said...


Give it some time, as it isn't a quick process, but I have heard from so many people for whom it has worked, it probably will for you.

Elango Devy said...

Few pre cautionary measure that can be taken patiently Regular walking, warm water bath or taking proper care of your feet is considered as some of the effective ways to treat this problem. thanks for the information.

Luke Tyrrell said...


My mother has just been diagnosed with type 2 diabetes, they say she may have had this for quite some time without knowing, her inital reason for visiting the doctor was complaints of numb and tingling feet. after blood tests has come back with type 2 diabetes, she is rather taken back by the news as she is awfully scared of needles and is worried it will progress to that stage, She is only on day 2 of the meds prescribed by her doctor and her blood sugar level reads a 23... she drops to 16 and times during the day, this is all very new to us and also a very scary subject when amputation and needles are involved. she still has the numbness in her feet and is very worried about the whole amputation senario.. i have been trying to research on the internet as much as i can although i am getting a bit lost in it all, How do we insure the reversal of any nerve damage that may have been caused before diagnosis? and also any other help you may be able to provide on the above would be greatly appreciated as we are only on day 2 since diagnosis and its a little overwhelming.

Thank you.

Jenny said...


It is overwhelming at first, but the good news is that there is a great deal your mom can do besides taking drugs that don't work very well. I'd suggest you have her try the technique described on THIS PAGE. It has helped quite a few people get back into control who started with very high blood sugars.

To reverse the numbness in her feet she will have to get her blood sugar down under 7.8 as much as possible, which though it sounds impossible, is not. What pushes up blood sugar is the starch and sugar we eat. If you cut back on them, the sugars will drop, and at a certain point they will drop a lot, since the higher sugars might be, the more insulin resistant the body becomes.

If the technique explained on that page doesn't lower her blood sugar then it is a sign she might need insulin. Don't be afraid of it. It works very well when used properly.

For now, you both need to read up on the subject.Gretchen Becker's book, The First Year: Type 2 diabetes, Dr. Bernsteins book, "Dr. Bernstein's Diabetes Solution, and yes, my book, Blood Sugar 101, will all help you get a better idea of what you are dealing with.

P1 said...

How long would it typically take - best and worst case - for a neuropathy to heal?

You mentioned that high glucose will block the capillaries that feed the nerves. Does this action ever destroy or damage the capillary itself? Is that capillary damage something that can also heal over time?

Jenny said...


My understanding from people who have reversed neuropathy is that it is a slow process that can take up to a year. I don't have any hard data as to how well nerves can heal, but I do know that nerves are able to slowly regrow (at a rate measured in mm) and new capillaries also are able to grow in living tissue.