Diabetic peripheral neuropathy care is improving

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Adapted from BMJ 16 May 2026

Diabetic peripheral neuropathy affects up to 50% of people living with diabetes. It results in sensory and gait dysfunction as well as a liability to foot ulceration that can lead to amputations. It can give pain that is difficult to treat with drugs. Both metabolic derangements and high blood sugars contribute to getting neuropathy. Apart from normalising the metabolic and blood sugars, there is no treatment that modifies the course of the disease.

People who get diabetic peripheral neuropathy (DPN) have higher mortality rates than those without.

Diabetes now affects 10.5% of the worldwide population. DPN affects 20-50% of those with type 2 diabetes and 17-54% of those with type 1. The younger you are when you are diagnosed, the more likely you are to get it. Not everyone with DPN gets the pain.

The duration and the severity of the diabetes influence who gets DPN. Hyperinsulinaemia, and low insulin sensitivity increase the risk. Metabolic syndrome also increases the risk. The factors involved are high blood sugar, abdominal obesity, abnormal lipid profiles, high triglycerides, and hypertension.

Having a larger BMI and waist circumference increases the risk of DPN. People who are socio-economically disadvantaged have higher risk of DPN. Their foot ulcers are more likely to get infected too.

The symptoms tend to start with numbness, tingling and/or pain starting in the toes and going up the legs. Pinprick sensation, temperature variation, and vibration and proprioception can be affected, and measured clinically. Reduced reflexes and weakness are later findings. The first ability lost is usually the ability to extend the toes. Alcoholic neuropathy can also cause neuropathy of the feet and legs.

If these things are reported or discovered, a FBC, metabolic panel, vitamin B12 and protein electrophoresis should be done. Electrical testing and MRIs are not recommended because they are expensive tests and rarely alter the diagnosis or treatment. Skin biopsy is also not recommended but it is wise to examine the eyes to see if there is evidence of neuropathy there, and also to take HBA1c.

Things that can help are to get good glycaemic control, particularly in type 1 diabetes. Weight loss can help. Exercise is recommended but is not proven to help.

The sorts of drugs used to treat the pain of this condition are many. These include tricyclic anti-depressants, SNRIs, and gabapentinoids. Sodium channel blocker may have a modest effect. One study showed that amitriptiline, duloxetine and gabapentin were all equally effective. Combining drugs can also be more effective. Another study showed that nortriptiline and duloxetine were superior to pregabalin and mexiletine for neuropathic pain.

Some studies have shown that cognitive behavioural therapy, and acupuncture (separately) improved painful DPN. All of these options are preferred to opiods, as these can cause misuse, addiction, overdose, fractures and myocardial infarction.

Some of the new weight loss injections have been tried, but there haven’t been many trials and so far results are mixed.

The American Diabetes Association recommends that type 2s are screened for DPN on diagnosis and type 1s are screened 5 years after diagnosis. Thereafter foot assessment should be annual.

Some guidelines recommend carbamezepine and oxcarbamezepine and some promote the use of capsaicin and some lidocaine topically. Opiods tend to be used after trying other drugs first.

If someone has peripheral neuropathy but does not have retinopathy there is a case for more extensive investigations such as electrodiagnostic testing.

The ECG can also reveal abnormalities in conduction in diabetics. Postural hypotension may be a symptom of autonomic neuropathy that co-exists with peripheral nerve damage and retinopathy. Renal damage may also be evident. The necessity for haemodialysis is associated with three times the risk of diabetic foot ulceration and a six fold risk of major amputation.

Although monofilament testing of the foot is the commonest test done to show DPN, there is a wide discrepancy between clinicians in picking up the problem. Very good news, is that as multidisciplinary foot care clinics have expanded, the rate of amputations has reduced from 9.1 per 10,000 people with diabetes to 7.7 between 2010 and 2021.

You need to do more than take calcium and vitamin D supplements to prevent fractures and falls

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Adapted from BMJ 30 May 2026

I have been prescribing calcium and vitamin D, and latterly just vitamin D, to my patients to prevent fractures. New evidence would suggest that this strategy has been a dead loss.

A study shows that taking any combination or singular element of calcium and vitamin D provides no clinically meaningful benefit over no supplementation. The study involved 69 clinical trials overing almost 154,000 participants. 87% lived in the community and 73% were not at high risk of fractures or falls.

About 30% of people aged 65 or older and over half of those living in nursing homes experience falls at least annually. 5% of these will result in a fracture. A fracture can be the end of that persons ability to live independently. This happens in 17% of adults who are admitted to hospital after a fracture after a fall.

Low body mass index and low bone density increase the risk of fractures from falls. Calcium and vitamin D supplements are a cheap and safe intervention. Sadly the study showed that these just did not work, even in a sub-group analysis of people aged 80 or over, living in a care home, who had a previous history of fractures or falls, osteoporosis, and low vitamin D levels.

In this study, the planners aimed to see if a 2% reduction in fractures, a 0.7% reduction in hip fractures and a 2% reduction in vertebral fractures could be achieved. They didn’t rely on “statistical significance”.

The authors suggest that interventions such as balance and resistance exercise, and hazard assessment, which have been shown to reduce falls and fractures, are undertaken instead of relying on supplementation.

Which: Is there such a thing as a healthy crisp?

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Adapted from Which Magazine July 2026

It is certainly debatable whether there is such a thing as a healthy crisp. We all know that crisps are bad for our waistlines and health. They can be very moreish and can be difficult to consume in small amounts. In recent times alternatives made from other vegetables such as lentils have hit the market. But are they any healthier at all?

Which scored 66 crisp products out of 100. The rating was based on how much fat, salt, sugar, fibre and protein was contained in the crisp, using the Nutrient Profiling Model and a University of Oxford equation. These systems are used by the government and various health groups. 63 or above was considered a pass and under this was considered a fail.

Brands often advertise using a single positive attribute that their product has or doesn’t have. They use this “halo effect” to urge you to buy their crisps. The trouble is that the single redemptive feature doesn’t usually make for an overall healthy product.

For instance, Mini Cheddars scored 20, the lowest of the series. These are baked rather than fried, but they still contain a lot of saturated fat. (My comment: I’m not concerned by eating saturated fat but it is a metric used in the evaluation.)

Also scoring rather low at 36 was Proper Chips Barbecue Lentil Chips. A problem was that although lentils do have more fibre than potatoes in their natural state, the processing to make chips takes a lot of this out, and they still have high sugar and salt levels.

Fried crisps like Tyrrells score relatively highly because the manufacturers remove some of the oil.

Here were the best scoring items:

Kettle Chips Lightly Salted 74

Holland and Barrett Carrot and Beetroot Lightly Sea Salted Crisps 72

Holland and Barrett Simply Roasted Sea Salt and Cider Vinegar Crisps 72

Tyrrells Sour Cream and Onion Lentil Crisps 72

Tyrrells Sweet Chilli and Red Pepper Lentil Crisps 72

These scores don’t appear on the packets, so keep your eyes open as to what you are buying and eating when you see crisps marketed as a healthy option.

More physical activity is needed in high income countries

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Adapted from BMJ 4-11 April 2026

A new study in Nature Medicine indicates that when it comes to physical activity, more people achieve physical activity targets through the nature of their work or from their usual mode of travel or commuting. The World Health Organisation population household survey also noted that there were large discrepancies in overall physical activity between genders and nations. The most sedentary were wealthy men in high income countries, and the most active were women in low income countries.

More than 80% of the population in low income countries meet WHO physical activity guidelines. Just over 60% of people in high income countries make this target. Only 40% of wealthy men in high income countries manage this.

About 70% of the population meet this target just from the work they do in low income countries. 40% of the population in high income countries manage adequate activity from work alone. (My comment: not too shabby!)

Just over 60% of the population meet physical activity goals during transport such as walking or biking in low income countries. This fell to 20% in high income countries.

About 7% of the population in low income countries had active leisure pursuits compared with about 25% of the population in high income countries.

Medium income countries performed in between the high and low income countries on all measured outcomes.

My comment: What does this tell us? I think this tells us that what you have to do almost every day regarding physical activity, matters more than what you can do now and again. If you have an active job and an active commute, great for you. You probably don’t need to be a gym bunny, or member of a sports club. or go hillwalking at weekends, and ski in the winter unless you want to. But 60% of us in high income countries don’t have active jobs. (I was surprised it wasn’t higher than this.) 80% of us drive or get to work by other means than our feet or bikes. Only 25% of us bother with active leisure pursuits. Maybe it would be easier overall if we did get more routinised physical activity in every day by getting off a stop earlier, parking further away, or going for a walk at lunch time or after work. Meanwhile governments and councils could do more to make walking or biking safer and more available to the working population.

Which: Best tinned fish for omega-3

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Adapted from Which Magazine June 2026

Tinned fish is a simple, affordable way to boost your intake of high quality protein and nutrients including vitamin D and B12. Oily fish are also high in omega-3 fats which are essential for heart, immune and lung health.

Mackerel, sardines, and salmon are the top three fish for dietary omega-3s. From 80 tins of fish, Which researchers found that the best sources seem to be mackerel, then sardines, then salmon. It should be noted that mackerel is being overfished.

Fish in tomato sauce or spring water are lower in calories and salt than those in sunflower oil or brine. Richly sauced options such as sweet chilli flavour, were found to have high amounts of added sugar and salt.

Eating “with bone” varieties give more calcium. Smaller fish species such as sardines naturally accumulate less mercury than bigger fish like tuna.

The UK government recommend at least two portions (140g) of fish a week, one of which should be oily. The NHS advises that girls and women planning a pregnancy should not eat more than two portions of oily fish a week. Everyone else can have up to four portions of oily fish a week.

Which’s top picks are:

Mackerel: Sainsbury’s Taste the Difference smoked Scottish mackerel with black pepper. This contains 4,700mg of omega-3 per 100g and costs £3.20 for a 110g tin.

Sardines: Fish4ever sardines in organic piri piri sauce contains 4,200g per 100g and costs £3.35 for a 120g tin from Ocado.

Salmon: Marks and Spencer’s wild Alaskan red salmon contains 2,000mg of omega-3 per 100g. This costs £.3.65 for a 213g tin and Sainsbury’s wild pacific red salmon contains the same omega-3 and costs £3.50 for a 212g tin.

Preventing cognitive decline as you age.

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Adapted from BMJ 2-9 May 2026

A Japanese study has linked home cooked meals to a reduced risk of dementia.

Among 11,000 adults over the age of 50, those who prepared meals at least once a week were a third less likely to be diagnosed with dementia over six years of follow up. Whether cooking itself is protective or simply indicates a more active and independent life is hard to say. Perhaps those who cook are less dependent on highly processed foods?

Several studies have shown that exposure to green space improves well being, but a randomised study from Zurich, Switzerland, indicates that this is dependent on getting away from traffic noise as well as getting out into a green environment.

Financial insecurity has long term consequences for higher mental function. In a US longitudinal study of more than 7,500 adults aged over 50 years, worsening material circumstances were linked to poorer memory and faster cognitive decline. The associations were strongest in older participants and in those whose circumstances had deteriorated the most.

Grip strength also reflects mental health. In a cross sectional study of more than 500 participants, people who had schizophrenia or depression had lower grip strength than healthy controls.

Strength was lowest in those who had current or past depression and did not fully recover with remission. In schizophrenia, weaker grip correlated with negative symptoms. The researchers think that reduced physical strength may be a marker for impaired motivation and motor function.

Although physical inactivity, hypertension and hyperlipidaemia are well established as risk factors for cognitive decline, a multicentre randomised controlled trial of more than 500 older adults failed to show that dealing with them made much difference.

Neither a programme of aerobic exercise, intensive pharmacological lowering of blood pressure and LDL cholesterol, nor a combination of both interventions, improved global function over 24 months.

My comments: So what can we make of all this? Make healthy home cooked food several times a week. Maybe ask your friends round to share it, and vice versa. Get out for walks in green spaces and say away from the noise and pollution of cars and roads if you possibly can. It will benefit you more. Keep active and balance your walks with strength training. Keep your blood pressure under control, but you don’t need to go great lengths to have the blood pressure of a teenager. And don’t worry too much about your LDL. Low triglycerides and high HDL are much better markers of lipid health and can be achieved by a low carb diet that includes naturally saturated fat.

How much money you have as you age depends on many factors. Did your family have money? What lessons in finance were passed down or learned by you? What was your job and your spouses job? What economic situations have occurred during your lifetime? What are your spending habits? Have you invested carefully? All these things build up over time, and I would say that what you do when you are young to improve your situation is going to matter the most long term. If you are getting on in age, are you getting all of the benefits that you are entitled to?

There are many resources that can help you to manage your money optimally for your circumstances and needs, plan meals, cook, walk and exercise, and particularly if you are young, getting into good habits and sticking with them will reap great rewards later on.

Adoption into loving homes improves life for the children and their offspring.

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Adapted from BMJ 2-9 May 2026

If a child from parents who have psychiatric or behavioural problems is adopted into a favourable home environment, this has lasting benefits for that child, but also for the children of that child.

Researchers in Sweden used national registers to compare full siblings and half maternal siblings born between 1950 and 1980 who were adopted before the age of ten, compared with their biological siblings who were not adopted. The children of these children were also compared. The outcomes included psychiatric, social, educational, cognitive and non-cognitive measures.

Adopted children showed a lower risk of psychiatric disorders: 29.8% compared to 36.1%.

Fewer criminal convictions: 26.1% compared to 34%

Fewer social welfare recipients: 37.8% compared to 48.5%

Higher mean intelligence scores: 4.5 compared to 3.8

Better cognitive skills scores: 4.8 compared to 3.9.

More likely to attend university: 26% compared to 15.2%.

The measures between the future offspring were less marked but still showed some improvement with higher psychosocial functioning. Regarding psychiatric disorders the figures were 29.6% compared to 32.3%.

The early environment in early life plays a central role in shaping health, educational, and labour market outcomes over the life course. Disadvantaged children who suffer from poverty, poor neighbourhoods, and who don’t get good nursery or maternal care have worse outcomes in adulthood.

Sweden has a particularly good social welfare system so results could be different in other countries. The results do seem to indicate that if a child’s environment can become more stable, and adequate resources and support are given to caregivers, the child’s outcome should improve.

My comments: I wondered how these figures compared with “normal families”. I asked ChatGTP.

Around 25% of working age adults have some form of criminal conviction. This includes minor offences such as motoring offences or not having a television licence. When these are excluded the figures are 25% of men and 10% of women have some sort of conviction.

In the UK 22-23% of adults of working age get some sort of disability or health related support, get benefits due to low income, receive housing assistance or are carers. 10% of UK adults get some sort of health support.

About 50% of UK adults go to university. 40% go immediately after school and the rest go later. More women go than men. 42-46% of working age adults have a higher education qualification such as degrees, HNDs or nursing qualifications.

These figures tend to indicate that children adopted from difficult home circumstances still don’t do as well as “average” children, although the UK is a different country and the times periods are not directly comparable.

Anti-amyloid drugs don’t improve memory in Alzheimer’s patients.

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Adapted from BMJ 2-9 May 2026

Unfortunately a Cochrane study has revealed that new drugs for dementia that target amyloid protein in the brain, just don’t make a clinical difference to the patient.

Although amyloid beta protein accumulates in the brain in Alzheimer’s dementia, and the drugs do help to clear this up, there is no significant difference to the mental functioning of the patients. In addition the drugs increase the risk of swelling and bleeding in the brain. The findings were reported by Francesco Nonino the lead author, who is a lead author, neurologist and epidemiologist.

The review examined 17 randomised controlled trials, involving 20,342 participants aged 70-74 with mild cognitive impairment or mild dementia from Alzheimer’s disease. Seven different monoclonal antibody drugs were tested and the outcomes assessed against placebo. The drugs all have different mechanisms of action. The studies lasted 18-24+ months. Two of the drugs, donanemab and lecanemab are licenced in the UK.

Disappointingly, there was no difference in cognitive function between the groups. There were small increases in brain swelling and bleeding, but no other side effects.

As as result there could be changes in the prescription guidance of these drugs, particularly as they are very expensive. They can cost up to £32,600 for each patient in the USA per year.

The authors recommend that other pathways be looked at for the development of new drugs and that the amyloid hypothesis be put to rest.

My comment: These drugs, particularly Donezepil, have been prescribed for quite a few years. I did see one man who had a great response to the drug. He was being cared for by his wife. He would hide under the bed thinking that he was back in the war and under attack. He got the drug and his response was fantastic. He was so good that he became her carer when she got dementia. Unfortunately he was the only patient from whom there was any noticeable change when I was a GP. In the UK the drug is only £18-30 per patient per year. I would imagine that a three month trial of the drug may be reasonable and if there is no clinical response it could be stopped. Money would be better spent on social and nursing care. No doubt clinical guidelines will be changed after this important study. Already there are calls to delay the onset of Alzheimer’s and other dementias by recommending population approaches such as measures to prevent obesity, increase exercise, decrease smoking, improve sight and hearing, and encourage social meetings and lifelong learning. If you have diabetes, good control will also reduce your risk.

Public toilets are becoming hard to find in the UK

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Adapted from BMJ 2-9 May 2026

The number of public toilets in England has fallen by 14% in a decade. There are now 15,481 people for each public toilet in England. Let’s hope they all don’t want to go at the same time!

In Scotland the level is 8,500 people per toilet and in Wales it is 6,748.

The shortage is causing people to have to urinate in public, according to the Royal Society of Public Health (RSPH). They say, “Access to a public toilet can be the difference at to whether someone can comfortably leave their house. For others, they can only go out if they deliberately reduce fluid intake.”

Whether councils provide public toilets or not is discretionary. Their funding power has dropped by 26% since 2010 and this has affected spending on public toilets. My comment: In my own area there has been a noticeable drop in activities for young people, libraries, and community hubs for people of all ages matched by increased expenditure on home care for the elderly.

The RSHP wants adequate toilet facilities to be funded centrally. They also want developers to include public toilets when they build non-residential buildings. They say, “We need to give local authorities the resources they need to provide the facilities we all rely on.”

My comment: People who have diabetes or other disabilities can obtain a key to unlock public toilets under the RADAR scheme. These are big blue keys and they cost £7.50. You register for one of them online. Google RADAR. One problem is that there are not that many toilets that are available under the scheme. An App that helps is Where is Public Toilet. This covers most of the world. It’s best to look for available toilets before you leave your home or hotel. Most places that serve food and drink provide toilets and they may let you use their facilities if you pay them, even if you are not a customer.

Your genetic inheritance determines 50% of your life expectancy.

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Adapted from BMJ 21-28 March 2026

Estimates of the genetic contribution to human lifespan have been surprisingly low and often show rates of 20% or less.

A re-analysis of Scandinavian twin cohort studies now puts this figure at 50%.

The reason for lower figures is that mortality rates are distorted by external causes that often have a familial effect such as infection, violence and other unintentional harms such as eg road traffic accidents or natural disasters or building collapses.

When these deaths are excluded the heritability of the intrinsic life span rises to around 50%.

This is similar to other complex traits such as body mass index, blood pressure and general cognitive ability.

My comments: Recently a friend who is adept at trawling ancestry sites discovered information about my family tree. There was a great deal of poverty and early death. I added up the ages of death of my parents and grandparents and divided the figure by six. According to this, my heritable life expectancy is 54.8 years. I’ve already lived 12 years longer than this. Here is a list of the ages and causes of death:

Women: Jeannie, my mother’s mother : Age 38 Lobular pneumonia and heart failure due to Pneumococcal Pneumonia – now has effective anti-biotics and vaccination. Ellen my mother: Age 46 Myocardial Infarction due to Ischaemic Heart Disease – now would have substantial chance of success after a stent operation and modern drugs. Sarah my father’s mother : Age 71 Heart Failure due to Pernicious Anaemia- now treatable with vitamin injections and drugs.

Men: Thomas, my father’s father: aged 29 Burns and Pneumonia due to Industrial Accident- chances of this very much reduced now with Health and Safety at Work Legislation. Robert, my mother’s father aged 66. Head injury due to fall from a height at work due to Industrial Accident – chances of this very much reduced due to Health and Safety at Work Legislation and practices around scaffolding. Tommy my father aged 79: Cardiac Failure due to Hypertension. Would still have died of this but modern drugs slow down the progression and he could possibly have added up to a further five years of life, though not without debility.