Conway McLean, DPM

An overused line from many an old gangster movie runs something like “You got a lot of nerve…” The comment had an obviously negative connotation. In the real world, those who don’t have enough functioning viable nerves have a problem. When most people think of nerve problems, they are usually referring to a neuropathy, the most common being those affecting the smaller nerves starting in the feet.

Many different neuropathies have been discovered, but because diabetes is epidemic in our society, any discussion pertaining to neuropathy is generally talking about diabetic neuropathy. Experts have labeled diabetic neuropathy the first step on the stairway to amputation. Many consequences of this condition can be devastating, including infection, hospitalization, and death. This “stairway” refers to the predictable chain of events leading to skin breakdown when someone can’t feel certain things properly.

An estimated 30 million Americans suffer from some form of neuropathy. Unfortunately, a clear majority are never informed of the presence of this condition, unaware they cannot trust how their feet feel. Simply because they are not experiencing pain does not mean there isn’t a problem. This concept runs counter to how we think about our body; if some limb or part doesn’t hurt…..then it must be okay.

There are two primary concerns when it comes to neuropathy. Certainly one component is pain. This can be an agonizing condition, producing strange and uncomfortable sensations, some common examples being burning, tingling, or a pins-and-needles feeling. As a generalization, these impressions are worse at night, often interfering with sleep, although some experience this 24-7. Because there is so much stimulation during the day, the brain is distracted and less likely to register these strange nerve impulses while at night these distractions aren’t present.

Perhaps the bigger concern is the reduced ability to feel some developing skin problem like a blister or cut. Confusing this issue for many individuals is that certain nerve receptors in the skin will be working just fine, leading one to conclude they all are. Only specialized nerve testing will reveal this deficit, although these tests are performed too infrequently. A diabetic needs to be informed when some skin trauma has occurred because of their reduced immune function, meaning they don’t fight bacteria well.

Diabetic neuropathy is one of the most prevalent complications of diabetes. Research has also revealed it develops in many individuals with prediabetes, as well as in young people with diabetes. One would think, given the tremendous complications ensuing from its presence, there would be beneficial therapies. And how many FDA-approved treatments are there for diabetic neuropathy? Zero. Exactly none. As is often the case, the therapy prescribed by established, ‘main-stream’ medicine is a band-aid, a psychiatric drug now utilized for all manner of painful conditions.

Many of these peripheral neuropathies can lead to other changes. As may be predictable, good sensory nerve function apparently is important to our balance and stability. These issues are a significant cause of falls and the fractures which ensue. This explains why some drugs which cause some nerve dysfunction (not working properly) are commonly associated with balance issues.

Our toes are kept straight because of a delicate balance of structures in the feet, an important one being the small muscles in the feet. Like all skeletal muscle, these are controlled by nerves. When innervation to these muscles is impeded, as in diabetic neuropathy, the toes tend to slowly drift out of position. Hammertoes are by far the most common result, which reliably leads to abnormal pressure to the skin.

If you will recall, our subject has neuropathy, which is why his toes are moving out of position. But with neuropathy, this chronic pressure to the skin, which should elicit discomfort, does not. Many of us don’t really “LOOK” at our feet. They seem quite far away to some of us. And covered up the majority of our lives. Without pain, all manner of pathology can be taking place, from infection to gangrene.

Many therapies have been developed to treat this ubiquitous condition. Generally, these have not been subjected to the clinical trials allowing definitive conclusions to be made regarding the benefit of some treatment. Clinical trials are exorbitantly expensive, affordable primarily to large corporations (e.g. pharmaceutical). One approach is the use of a specialized nerve vitamin. The B vitamins are well known to be important to nerve function, and indeed, many people have obtained relief with precision nutrition. This is the practice of treating some malady by ingesting foods and supplements known to improve the functioning of that system. Talk about a healthy approach, this appeals to many Americans.

A specialized form of electrical stimulation, far different than TENS or physical therapy units, seems to have merit. Several examples of this concept have been developed, with an important benefit being the absolute absence of any harm from this treatment. This stimulation causes the tiny blood vessels feeding our nerves to dilate (get wider), allowing greater flow to the nerves. As is the case so often in health and medicine, more blood flow to any unhealthy structure is probably a good thing.

Further evidence has recently come to light of the potential benefit of nutritional approaches to neuropathy. Well established in medicine is the success of the ketogenic diet for epilepsy and other seizure disorders. Based on the overlap between the mechanisms producing pain, and the effects of this nutritional plan, recent research efforts have been directed at how a ketogenic diet might aid those suffering from neuropathy.

This system of nutrition is based on shifting our energy sources from glucose, provided in carbs and sweets, to fats (hopefully healthy fats, not trans- or saturated). This encourages the body to get its energy from burning body fat. This produces an energy source known as ketones, reducing the body’s demand for insulin, of benefit to those with diabetes. Ketogenic diets are very effective at achieving two common aims of diabetes control, lowering blood glucose levels and reducing weight. The amount of carbs consumed per day, in order for a diet to be considered ketogenic, is 30 grams of carbs or less.

Although a ketogenic diet has been prescribed for various seizure disorders for decades, we are uncertain of how it works. How does this nutritional plan, markedly reducing carbohydrate intake and greatly increasing fat intake, alter nerve function and reduce neurogenic pain? Regardless, the studies have demonstrated a measurable reduction in those with symptomatic neuropathy. Another unanswered question is does this diet help improve nerve function? Will it lead to enhanced sensitivity to the outside world? Or, more precisely, the inside of your shoe?

Considering how few options for relief of neuropathic pain are available, the ketogenic diet would seem to be an exciting means of intervening in this debilitating condition. In conclusion, we have various treatments and approaches for this common affliction, yet these therapies are utilized too often too late. Unfortunately, like many diseases, the longer neuropathy is present, the worse it gets and the harder to treat.

New methods of diagnosing it earlier and more precisely are available. We simply need to detect sooner the too-common condition that is peripheral neuropathy. We must not, as a society, continue to fail those individuals with diabetes, by failing to educate them about the multiple dangers of neuropathy. The proclamation: better education for diabetics!