Category: Living with diabetes

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.

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.

Adapted from BMJ 11 October 2025

About half of all patients with diabetes will develop a symmetrical polyneuropathy but several other atypical nerve conditions can also occur.

Treatment induced neuropathy of diabetes is an acute and severely painful small fibre neuropathy that occurs with a steep drop in glycated haemoglobin levels.

Radiculoplexus neuropathies include lumbosacral, cervical, and thoracic forms, in which pain and weight loss are followed by weakness and sensory loss in the distribution of a single anatomical region.

Monophasic cranial neuropathies are caused by non-inflammatory microvascular ischaemia and present acutely followed by slow improvement.

Compressive neuropathies are when nerves are compressed.

There is more chronic inflammatory demyelinating polyneuropathy in patients with diabetes than in the general population, but definitive diagnosis is difficult to ascertain when diabetes is also present.

Diabetes now affects 9.3% of the world’s population, and half of them have typical symmetric neuropathy. Carpal tunnel syndrome affects 20-30% of diabetics. Cranial neuropathies affect 1% of the population which is ten times higher than in the general population. Over a five year period, about 10% of diabetics will get a treatment induced neuropathy. Lumbosacral neuropathy will eventually affect 1% of diabetics. Chronic inflammatory demyelinating neuropathy affects 0.7 to 10.3 people for every 100,000 people. It is the rarest type.

Treatment induced neuropathy is associated with a high rate of damage to the retina and kidney. It is thought that neuronal ischaemia and the release of cytokines damage the small blood vessels to the nerves.

Prior high blood glucose is the main risk factor for this type of neuropathy. Pain, and autonomic symptoms occur such as low blood pressure, gut dysmotility and sexual dysfunction. The usual age of onset is 25 in type one diabetes and 51 in type two diabetes. The faster the rate in improvement in blood sugars, the higher the risk.

The usual presenting problem is pain in the arm or leg within six to eight weeks of rapid blood sugar correction. The pain is usually in the glove and stocking distribution. Unfortunately the pain is often difficult to treat even with modern drugs such as tricyclic antidepressants, SSRIs, gabapentinoids, and sodium channel blockers. The condition and pain usually stablise over three years if the blood sugars can be kept in control and stable. Foot ulceration can become a common problem if the condition becomes recurrent due to blood sugar swings.

Radiculoplexus neuropathy is caused by a vasculitis of affected nerve roots, plexus and individual nerves in the back. Most people have pain. Rapid glycaemic control can be a pre-disposing factor. Leg weakness, foot drop, numbness and autonomic symptoms can occur. It usually stays one sided.

Post surgical inflammatory neuropathy is typically defined as a neuropathy occurring within 30 days of a surgical event. It occurs in non diabetics too, but more often in diabetics.

Multiple mononeuropathies can also occur in diabetics. This tends to affect the lower arm or lower leg.

Figuring out what type of neuropathy is occurring may be done on clinical history and examination, electrodiagnostic testing, MRI scans, blood tests, lumbar puncture, and nerve biopsy.

Most neuropathies require good blood sugar control to improve, may worsen for a period of time before improvement, and may need drug or other treatments and supportive aids such as braces and wheelchairs. Sometimes residual motor deficits such as foot drop can persist long term.

For Facial mononeuropathy a short course of oral steroids starting within 72 hours of onset may improve recovery.

GLP-1 based treatment for diabetes, weight control, and fatty liver disease is rapidly increasing. These agents also rapidly reduce HbA1c levels. A study was done to specifically look at the effects on type two diabetics and polyneuropathy risk on these agents. One group got the weight loss injection and the other got metformin and insulin. Over five years there was no difference in neuropathy diagnoses.

Adapted from BMJ 24 August 2024

An Australian study has shown that people with both type one and type two diabetes are hospitalised for injury more often than the general population.

Most of these injuries happened due to falls.

People using insulin have 60% more chance of being hospitalised for injury. Type two diabetics who take sulphonylureas have also a raised risk.

My comments: These findings tend to indicate that hypoglycaemia is a cause of falls. There could also be other reasons. I recall visiting a woman who had two broken wrists. She had fallen in the street and had fallen off the kerb. I asked why she thought she fell. She said, “I can’t feel my feet.” As a fractured hip in older age is a major reason for losing independence it is important for diabetics to aim for as best blood sugar control as appropriate for them, but also to take care to reduce hypoglycaemia.

Adapted from BMJ 3 Feb 2024

No excess prostate cancer has been found in hypogonadal men who were treated with replacement testosterone over 20 months follow up.

A randomised trial of 5,000 men found no difference in genital problems between the treated group and the untreated group.

The incidences of prostate cancer, acute urinary retention, prostatic surgery, and drug treatment for urinary symptoms were all low and no different between the groups.

My comment: This should be reassuring for those men who need to take testosterone for sexual health reasons and also to correct their hormonal status, as testosterone deficiency can be one cause of type two diabetes in older men.

Adapted from BMJ 4 Nov 2023 The Bottom Line: The time to tackle rising type 2 diabetes is T2DaY by Partha Kar consultant in diabetes and endocrinology Portsmouth Hospitals NHS Trust.

England’s 18-40 year olds with type two diabetes now exceed those with type one. In the not too distant past, type two diabetes was associated with middle age rather than youth. Causes for this increase include lifestyle, environmental and societal factors.

About 4% of people with type two diabetes are now under 40 years of age. Worryingly, this rise in type two diabetes is accelerating fastest in the under 40s. It tends to affect people who are socioeconomically deprived, are in minority ethnic groups, and in those with obesity. And the complications are aggressive.

There tends to be a greater risk of the vascular complications of diabetes compared to later onset type two diabetes. There are poorer pregnancy outcomes compared to type one diabetes. If you are diagnosed at the age of 30, you can expect to live 14 fewer years of life. At diagnosis, multi-morbidity is common and even if not present, can develop rapidly.

The 18 to 40 age group are often in education or working. They face transitions from the family home, to university or the workplace. Money tends to be tight. They are considering buying homes or renting. They may pairing off with partners, and they may already have a young family or be planning to start. Increasingly they can’t afford to buy a home, and put off having children till older ages.

There are now about 140,000 young adults with type two diabetes. It is important that the correct diagnosis is made at the outset, and that pregnancy planning and outcomes are prioritised. Dr Shivani Misra from Imperial College London, has published a Type 2 Diabetes in the Young programme that she hopes will be adopted in order to improve the outlook for these young people and their families.

Meanwhile, Government initiatives are needed to reduce socio-economic deprivation, improve healthy food options, improve space for exercise, and improve people’s motivation to look after themselves.