Diabetes and Your Feet

Diabetes is a lifelong chronic disease that is caused by high levels of sugar in the blood. It can also decrease your body's ability to fight off infections, which is especially harmful in your feet. When diabetes is not properly controlled, damage can occur to the organs and impairment of the immune system is also likely to occur.

With damage to your nervous system, you may not be able to feel your feet properly. Normal sweat secretion and oil production that lubricates the skin of the foot is impaired, which can lead to an abnormal pressure on the skin, bones, and joints of the foot during walking and other activities. This can even lead to the breakdown of the skin of the foot, which often causes sores to develop. If you have diabetes, it is important to prevent foot problems before they occur, recognize problems early, and seek the right treatment when a problem does happen.

Diabetic Complications and Your Feet

When it comes to your feet, there are several risk factors that can increase your chances of developing foot problems and diabetic infections in the legs and feet. First of all, poorly fitting shoes are one of the biggest culprits of diabetic foot complications. If you have red spots, sore spots, blisters, corns, calluses, or consistent pain associated with wearing shoes, new proper fitted shoes must be obtained immediately. Additionally, if you have common foot abnormalities such as flat feet, bunions, or hammertoes, prescription shoes or orthotics from your podiatrist may be necessary to further protect your feet from other damage.
People who have long-standing or poorly controlled diabetes are also at risk for having damage to the nerves in their feet, which is known in the medical community as peripheral neuropathy. If you have nerve damage, you may not be able to feel your feet normally and you may also be unable to sense the position of your feet and toes while walking and balancing, which can cause even more harm to your feet.
Normal nerves allow people to sense if their shoes are too tight or if their shoes are rubbing on the feet too much. With diabetes, you may not be able to properly sense minor injuries, such as cuts, scrapes and blisters-all signs of abnormal wear, tear, and foot strain. The following can also compromise the health of your feet:
Poor circulation
Trauma to the foot
Infections
Smoking
Diabetes can be extremely dangerous to your feet, so take precautions now. You can avoid serious problems such as losing a toe, foot, or leg by following proper prevention techniques offered by your podiatrist. Remember, prevention is the key to saving your feet and eliminating pain.

Supplements for Diabetic Peripheral Neuropathy

Diabetes can affect the circulation of the feet (diabetic angiopathy), the nerves of the feet (diabetic peripheral neuropathy) or both.   Loss of circulation can make walking difficult and cause delays of healing to occur.  Diabetics with peripheral angiopathy often have difficulty healing trauma.  Diabetic peripheral neuropathy, can cause loss of feeling in the feet,  paresthesia (burning or tingling pain) or both.

Numbness of the feet can lead to the lack of ability to feel trauma such as cuts and scrapes. Additionally, numbness can make it more difficult to balance as the feel for the ground is lessened.

The type of diabetic peripheral neuropathy that leads to numbness can be insidious, causing a gradual loss of feeling.  The type of diabetic peripheral neuropathy that causes tingling or burning pains often keeps people awake at night and results in more visits to the doctor to seek remedies.

The cause of diabetic peripheral neuropathy is not certain but proposed causes include…
1) Direct damage to the small nerves of the feet caused by high blood sugar or hyperglycemia.
2) Narrowing of the small blood vessels that feed the nerves (vaso neurvorum).
3) Genetic factors, that is, the same factors that decrease function of the pancreas, having an effect on the nerves.
4) Oxidative stress on the nerves – polyol hypothesis.

Treatment of diabetic peripheral neuropathy involves tight control of blood glucose and use of drugs known as membrane stabilizing drugs.  Drugs used are only effective to control the burning, tingling type of neuropathy but have no effect on the progression of numbness itself.   Common drugs include gabapentin (Neurontin) and Lyrica.

A number of nutritional supplements have been shown to not only reduce the symptoms of  painful neuropathy but may have a beneficial effect on the progression of numbness.

Alpha lipoic acid

Alpha lipoic acid or ALA has enjoyed widespread use in mainstream medicine in Germany for some time before becoming popular in the US.   Alpha-lipoic acid is an antioxidant that is made by the body and is found in every cell, where it helps turn glucose into energy.  Antioxidants are substances that remove "free radicals," waste products created when the body turns food into energy or during stress. Free radicals cause harmful chemical reactions that can damage body tissues including nerve cells.   ALA can lower blood sugar levels and its intravenous  (IV) form has been used in Europe for years.   Patients with diabetic peripheral neuropathy may be started on IV ALA initially then switch to the oral form when the symptoms subside.

The dose of oral ALA is 800 to 1200 mg. per day.  Doses less than 800 mg. per day are ineffective. Alpha lipoic acid can cause some temporary gastrointestinal upset so it is best to start taking it gradually, say 300 mg.  three times a day with food.

It is important to be aware that supplements like ALA are not drugs so there effects are more subtle, occurring gradually over the weeks.

Side effects of alpha lipoic acid are few but since there is a possibility that it may lower blood sugar, one should make their physician aware of its use and blood glucose levels need be monitored.
Some references:
Ziegler D, Ametov A, Barinov A, et al. Oral treatment with alpha-lipoic acid improves symptomatic diabetic polyneuropathy: The SYDNEY 2 trial. Diabetes Care. 2006;29:2365-70.
Ziegler D, Gries FA. Alpha-lipoic acid in the treatment of diabetic peripheral and cardiac autonomic neuropathy. Diabetes. 1997;46 (suppl 2):S62–66.
Ziegler D, Reljanovic M, Mehnert H, Gries FA. Alpha-lipoic acid in the treatment of diabetic polyneuropathy in Germany: current evidence from clinical trials. Exp Clin Endocrinol Diabetes.1999; 107:421-430.

Benfotiamine

Benfotiamine became popular in Japan as a supplement to treat diabetic peripheral neuropathy while ALA was being used in Germany.   Benfotiamine is a lipid soluble form of vitamin B1 or thiamine.   B vitamins are water soluble vitamins.   Benfotiamine is a synthetic derivative of thiamine in which the molecule has been modified to change certain characteristics.   The patent for benfotiamine was awarded to Japanese researchers by the US Patent office in 1962.   Sankyo,  the Japanese pharmaceutical manufacturer attempted to market benfotiamine in the US but little interest was shown until about 2003 when the following article was written by Dr. Michael Brownlee,  of the Albert Einstein School of Medicine, http://benfotiamine.org/Brnlee.htm

Additional research was performed after the Brownlee article and benfotiamine gradually became available. A list of articles is here,  http://benfotiamine.org/Benfotiamine.htm There are beneficial effects of benfotiamine, not only on the the peripheral nerves but on diabetic retinopathy.

The popular dose is 300 mg. per day or 150 mg. twice a day.   Benfotiamine was significantly more costly than alpha lipoic acid for a number of years but the price has plummeted in the last couple of years.

Curcumin

Curcumin is a dietary pigment responsible for the yellow color of curry.  It is found in the Indian spice turmeric.   Turmeric has been use in traditional Indian medicine or Ayurvedic Medicine since about 1900 BC.   A number of studies have shown that curcimin  may have antitumor, antioxidant, anti-arthritic and anti-inflammatory properties as well as increasing insulin sensitivity;   http://endo.endojournals.org/content/149/7/3549.full

Common recommendations for curcimin dosing are from 600 to 800 mg.  three times a day.   Curcimin is not easily absorbed so, more recently, this has been addressed with novel preparations.   One such preparation is Meriva,  which is a combination of curcimin with soy lecithin, manufactured by Indena.

B Vitamins:  B12, folic acid, B6

Vitamin B12 preparations often contain cyanocobalamin but another form, methycobalamin, has been suggested as having more potential effect on peripheral nerves.   Methylcobalamin appears to be better absorbed and retained in higher amounts in tissues.   B12 is the only B vitamin which may not be easily absorbed by the body as it is dependent on stomach acid and intrinsic factor in the stomach.   Use of drugs which suppress stomach acid can reduce B12 absorption.   B12 can also be taken sublingually or by injection.

Folic acid is found in green leafy vegetables.  A potentially more active form is 5-methytetrahydrofolate (5-MTHF), the active, methylated form of folate, an essential B-vitamin. 5-MTHF requires no additional metabolic steps to be used by the body, thus it is often the preferred choice for this with absorption or metabolic defects. Methylfolate efficiently supports methylation, DNA biosynthesis, homocysteine metabolism, and nervous system function.


For more information on Diabetic Foot Care in the San Antonio, TX area, call Ed Davis, DPM, FACFAS. at (210) 490-3668 today!