More Diabetes Answers

Why is NOT being an "early adopter" uncomfortable but might be a good thing?

You have probably seen lots of adverts on TV for new drugs to help improve your sex life, lower your cholesterol, allow you to eat salty, spicy, food without heartburn, and generally make your life better.  The adverts often show everyone looking happy and have actors dressed as earnest, sincere doctors in white coats advising you in reassuring tones that you should, "Ask you doctor about fill-in-the-blank." Then at the very end of the advert in an incomprehensibly fast rush a different voice blurts out all the fine print (including side effects, or the fact that a new fat-lowering drug actually hasn't been shown to prevent heart attacks and strokes and might in fact increase your risk of stomach bleeding... check out the website at www.lovaza.com ) 

What's a person to do when the main message is that more is better and than anything new is most likely a huge scientific advance forward and therefore a good thing.

But often it takes years before we really know if a new therapy will actually improve real health outcomes that matter to people.  There have been many examples of drugs that seemed like they were doing good but ended up causing more harm than good.  Back in the 1970s and 1980s there was a big push to give people drugs to stop the heart developing irregular rythmns after a heart attack.  Seemed like a no-brainer.  If you've just had a heart attack you wouldn't want your heart to suddenly go into irregular rythmns.  And these drugs (like encainide and flecainide) did work to make the electrical tracings of the heart (the ECGs or EKGs) look better.  But unfortunately when researchers looked at the outcomes in patients who received the new "miracle" drugs more of them died than patients who did not receive the drug.  Sometimes a drug that helped lower blood pressure (like short-acting nifedipine) can actually increase the risk of heart attacks or stroke.  Sometimes pain killers (like Vioxx) that appear to be better because they cause less risk of stomach bleeding can actually cause an increase in heart attacks.

As I have talked about in other blog postings the story with the thiazolidinediones is another example of a class of drugs that looked promising but may be causing more harm than good.  We won't know for sure for another few years.

I work for a health care organization (Group Health in Washington State) that holds itself to a very high standard.  Before we add any drug to our formulary so that our patients can get it we try to wait until there are long-term studies that show clearly that the drug is beneficial.  When those studies are published we move very fast to contact all of our patients who might benefit and offer them the drug.  But it also means that when a new drug is being hyped up by the drug companies but before we truly know if it will be beneficial we do NOT add it to our formulary.  For patients (and some of our doctors) who buy-in to the hype I often have to deal with some unhappy and angry phonecalls.  It often feels uncomfortable to be cautious and conservative.  We take a lot of heat for not being out front with "cutting edge" drugs. 

But despite the discomfort of fielding angry phone calls in the early years of new drugs, I take comfort in this.  We never had Vioxx on our formulary at Group Health.  We never had Rezulin or Avandia or Actos on our formulary either.  I don't know how many hundreds of patients are alive today because of our cautious approach because they did not get heart attacks or die as a result of taking these drugs but it does probably run into the hundreds at least.

Again, let me be clear:  I have nothing against the company who makes Lovaza and I don't know whether it will turn out to cause more good than harm.  I hope it will.  But none of will know that until larger long-term trials are done.  We do know that it causes significant side effects.  Once we know for sure that the benefits outweigh the risk we will jump on it and prescribe it widely.  But not until then.

What will history say about the thiazolidinedione class of diabetes drugs like Avandia and Actos?

Every time I hear another piece of bad news about rosiglitazone (Avandia) or pioglitazone (Actos) I feel as though I am watching another piece of diseased flesh falling off a bloated and dying giant.  The thiazolidinediones (or TZDs or glitazones) was the juggernaut new "blockbuster" diabetes drug class of the past ten years.  Despite having no research studies showing long term benefit these drugs were pushed very persuasively onto the market.  But as I have detailed in previous posts the longer we looked the longer the list of problems and side effects grew while the evidence of meaningful benefit remained elusive.

http://gomeworld.typepad.com/morediabetesanswers/2010/06/why-would-you-ever-want-to-use-avandia-or-even-actos.html

This weeks brings more bad news.  The FDA has issued a warning that pioglitazone (Actos) may cause an increased risk of bladder cancer, especially with prolonged use of the drug.  We already know that the risk of developing bone-thinning (osteoporosis) with these drugs gets worse the longer you stay on them.

http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm226257.htm

Another announcement today states that rosiglitazone (Avandia) is being taken off the market in Europe because of the likely increased risk of heart attacks, strokes and deaths associated with taking Avandia.  Avandia will, of course, still be available in the USA market.  Although sales in the USA are dropping Avandia still brings in annual revenue of over a billion dollars.

http://link.email.washingtonpost.com/r/BZYGW4/A7M5IB/30Y38H/VMINCB/Q0A68/E4/h

Why is it that the USA seems so much slower to act as Europe just did?  This is eerily reminiscent of the situation back in 1997 when troglitazone (Rezulin), the first drug in this class, was taken off the market in the UK with most of Europe quickly following suit, but was left on the US market for another full two years before the rising toll of deaths from liver failure convinced the FDA to remove it.  I wonder how long we will need to wait before we see the last of Avandia in the USA.

I do not write this with pleasure or malice.  I have nothing against pharmaceutical companies that work to develop new treatments that might benefit people with diabetes.  Far from it.  I applaud their efforts.  In the past few decades some other classes of drugs (like ACE-inhibitors and statins) have been proven over time to be dramatically beneficial for people with diabetes.  What concerns me is how easily fooled many doctors and patients are, and how readily we all want to believe the early hype about new drugs.  How impatient we all are.  We are rarely willing to do the rigorous long-term trials that can truly prevent us from allowing millions of people to be exposed for years to drugs that cause more harm than good.

The power of groups: why one plus one is wa-a-a-ay more than two!

I spent the morning with one of my favorite colleagues, Dr. Jeff Gelgisser.  Jeff is a family practice doctor in Redmond, Washington who looks after a lot of people who have diabetes. 

A few years ago Jeff went through his list of diabetic patients and found a dozen or more who didn't come in very often and who had blood glucose levels and blood pressure levels that were too high and who weren't getting their eyes and feet screened as often as they should. 

 

When he called them up he found:

• Some of these people just preferred to ignore their diabetes. 
• Others just didn't like the way they were treated when they came in to the clinic. 
• Some felt lonely and isolated as if no-one understood how hard it was for them to deal with diabetes along with everything else in their lives. 

They had stopped coming in because they knew that the doctor or nurse who saw them would lecture them about how "bad" they were at looking after themselves.

Jeff then did a rather brave thing.  He invited them to come in as a group and vent their frustrations to him and his staff.  He encouraged them to share ideas with each other and he took the time to explain things to them that they were frustrated about and didn't understand. 

 

And something magic started happening.  Many people in the group changed from feeling hopeless and angry to feeling motivated to change things about how they were living their lives.  They shared positive ideas with each other.  They set new goals for themselves. 

 

They wanted to keep meeting.  They celebrated each other's successes and supported and comforted each other when new difficulties arose. Most all of those people now have lower blood glucose and blood pressure levels, are eating healthier, exercising more, are taking their medicines better and feel much better about their overall lives.

 

Jeff and his team have held group meetings like this for several years now.  Once a year they ask me to join them to answer questions about new research findings in diabetes or anything else that is on their minds.  I am honored to attend.  I always leave feeling more positive and optimistic about my life, too.

There are lots of different types of "group visits" for people with diabetes and other chronic illnesses.  One very successful and popular program was started by Dr. Kate Lorig and colleagues at Stanford. 

It is called "Living Well with Chronic Conditions"

 

You can search for that phrase on the Internet to see if there is a group near where you live. Another great resource for learning how to set up and organize group visits is at www.improvingchroniccare.org.

Is lower always better? (Part 1 - blood glucose control)

Even though I have been studying diabetes and helping people with diabetes to live better with it for over thirty years, I still get surprised constantly when a new study challenges my firmly held assumptions!  One message that has been pushed down our throats for over twenty years at least is that the lower your blood glucose levels are the better.  Yes, we are told, it can be a nuisance pushing your blood glucose levels closer and closer to normal because you run the risk of feeling weird or even passing out from a too low blood glucose (hypoglycemia) and you may need to check your blood glucose more often and may gain weight but over the long haul you will stay healthier if your average blood glucose levels are kept as close to normal as you can.  It is a simple message to push.  Organizations like the American Diabetes Association have pushed the message hard.  All the big pharmaceutical companies who make drugs that help push your blood glucose lower and lower have a vested interest in pushing the message that "lower is always better, and even lower is better still!"  But some recent research studies have challenged this simple message.

The ACCORD trial is a large randomized controlled research trial carried out in many different medical centers around the world.  In the study 6,779 people with type 2 diabetes were randomly assigned to a "standard" approach to lowering their blood glucose where they aimed to get their HbA1c between 7-8% and keep it there or to an "intensive" approach where they tried to get their HbA1c as low as they could get it and keep it there (You can read the full study results in the journal Diabetes Care 33:721-727, 2010).  These subjects had had their diabetes for several years and many of them had had heart disease already (angina, or a heart attack) or had risk factors for heart disease (like high blood pressure or a history of smoking or heart disease in their family).  After about five years of follow up the standard therapy group achieved an average HbA1c of 7.5% whereas those in the intensive treatment group kept their HbA1c at 6.4%.

The surprising results of the study were that after 4-5 years of follow up there were more deaths in the intensive therapy group than in the standard therapy group.  This was even more noticeable in people who had had very poor HbA1c levels to begin with and in people who had worse nerve damage (neuropathy) at the start of the study.

Another study published in the Lancet this year (Currie, CJ, et al.  Lancet 375:481-489, 2010) looked at over 50,000 people with type 2 diabetes treated in general practice in the United Kingdom.  The researchers followed what happened to those people after they had their diabetes treatment intensified by having an extra blood glucose lowering pill or insulin added to their treatment.  As you would expect their HbA1c levels dropped lower after the new treatments were added.  But when they looked to see how those people did in the next few years they found that those whose HbA1c levels stayed high were more likely to die and that those with a lower HbA1c did better... but only up to a point.  It was bad to have a HbA1c of over 9.0% for example.  Those who got it down to 8.5% did better and those at 8.0% or 7.5% did better still.  However, if the new treatment pushed the HbA1c down below 7.0% the outcomes started to get worse with more people dying if their HbA1c was at 6.5% and even worse if it was 6.0%.

So what does this mean for you?  There is no doubt that high blood glucose levels (HbA1c over 9.0%) are bad for your long term health and working to bring it down is a good thing to do.  However, how low to push it is more complicated.  I think it depends on what type of diabetes you have, how long you have had it, what your average blood glucose levels (HbA1c) have been for the past few years and whether or not you have risk factors for heart disease.  For people with type 1 diabetes or people with type 2 diabetes who have always had HbA1c levels that are below 8.0% and who don't have risk factors for heart disease then pushing to keep your HbA1c level down below 7.0% is probably a good thing to prevent long term problems from your diabetes.  But if you have had heart disease (or have several risk factors for heart disease like smoking or having high blood pressure and high cholesterol) and if your HbA1c has often been above 8.0% in the past few years then these research studies suggest that a better target for you might be to keep your HbA1c around 7.5%

Should I worry about my triglycerides, too?

Most everyone worries about their cholesterol these days.  Even when you are relaxing watching a sports game on TV it seems like every other advertisement seems to mention heart disease and cholesterol levels and tells you which pills you should ask your doctor about to lower your cholesterol level.  There is good reason for this.  Cholesterol is a kind of fat that floats around in your blood and can become deposited in the lining of your arteries to increase your risk of getting heart attacks, and strokes, and other bad things.  So in addition to eating a healthy diet and getting exercise it is important for many people with diabetes to take a drug that can lower the LDL cholesterol (often called the "bad cholesterol").  The most common, powerful and effective types of drug to lower LDL cholesterol and protect you from getting heart attacks and strokes are the statindrugs (like simvastatin [Zocor], atorvastatin [Lipitor] and others).  Most people with diabetes who are over age 40 should consider taking a statin drug.

But there is another type of fat that floats around in our blood called triglycerides and that can sometimes cause problems, too.  The normal range for triglycerides in your blood is less than 150 mg/dl (1.7 mmol/L).  If the triglyceride level gets very high (above 500 mg/dl, or 5.6 mmol/L) it can cause a very dangerous inflammation of your pancreas (called pancreatitis) and so most doctors know that they should treat very high levels of triglycerides.  But what if your triglyceride is just a bit higher than normal but not really high?  Suppose your triglyceride level is between 150-350 mg/dl.  Should you take drugs to bring that down into the normal range?  Another part of the famous ACCORD trial looked at this question and came up with a very interesting results.

I have written about the ACCORD trial in several other posts in this blog. In this part of the ACCORD trial 5,518 people with type 2 diabetes (at an average age of 62), many of whom already had heart disease or two or more risk factors for heart disease were studied.  These patients were already taking simvastatin, one of the powerful statin drugs to help lower their LDL cholesterol and protect them from having heart attacks and other bad cardiovascular events in the future.  Many of these people also had triglyceride levels that were in the 150-350 mg/dl range.  The ACCORD researchers wanted to know if outcomes would be even better if they added another type of drug called fenofibrate.  Fenofibrate is a drug that can lower triglyceride levels.  So half the subjects got fenofibrate added to their drug treatment while the other half got "dummy pills" (or placebos) that looked like the fenofibrate pills but didn't contain any active drug.

After almost five years of follow up the levels of triglyceride in the blood were quite a bit lower in the group who were taking fenofibrate than in the group taking the placebo pills.  However, the number of bad cardiovascular events (like heart attacks and strokes, some of which were fatal) was notany lower in the subjects who took fenofibrate compared to those who took the dummy pills.  In fact among women in the study the overall rate of bad events was higher(9.1%) in those taking the fenofibrate compared to those taking the placebos (6.6%)!

What lesson can we learn from this study?  First of all it teaches us that focusing on an improvement in a lab test is much less important that focusing on outcomes that really matter to us (like preventing heart attacks,strokes and deaths).  It also teaches us that sometimes the side effects of a drug cause more harm than the condition it is trying to treat.  So if you have diabetes and are already taking a statin drug to get your LDL cholesterol under 100 mg/dl and if your triglycerides are only slightly above the upper end of the normal range then taking a drug like fenofibrate is not likely to protect you from heart attacks in the future and may even increase that risk, if you are a woman.

Is lower always better? (Part 2 - blood pressure control)

In The Diabetes Answer BookI talk a lot about heart disease.  The biggest risk to your future life and health if you have diabetes is from heart disease.  If you have diabetes it is incredibly important that you do everything you can to lower your risk of heart disease.  If you smoke do everything you can to quit.  If you are over age 40 talk to your doctor about whether you should be taking a statin drug, or an ACE-inhibitor drug, or low dose aspirin.  Ask to get your cholesterol checked and try to keep the LDL cholesterol level below 100mg/dl (2.6 mmol/L).  And keep track of your blood pressure.  High blood pressure increases your risk of getting a heart attack.  Doing things to lower your blood pressure will keep you healthy and alive longer.  Nothing that I have said so far is surprising, new, or controversial.  The controversial part is to ask the question, "How low should we push the blood pressure level?"

When someone measures your blood pressure they give you two numbers.  The first number is higher.  This is called the systolic blood pressure and tells you how much pressure your heart generates when it is pumping. There is no doubt that having your systolic blood pressure at 150 is better for your long term health than having it at 170, for example.  Having your systolic blood pressure below 140 is better still, and we have been told for years that if you have diabetes you should try to get it below 130.  But would an even lower number be better still.  If you took enough medicines, drugs, and pills to push your systolic blood pressure below 120 would you live a longer and healthier life?

This very question has recently been asked in a large, well-designed, randomized controlled research trial called ACCORD.  In this study 4,733 people with type 2 diabetes, whose average age was 62 and who had had heart disease or at least two risk factors for heart disease were given two different approaches to treating their blood pressure.  Half of them were treated to get their systolic blood pressure below 140.  This group kept their blood pressure at an average of 133 for the next 4-5 years.  The second group were treated to try to get their blood pressure below 120.  they kept it at an average of 119 for the next 4-5 years.  In order to get their blood pressure at this lower level the people in this more intensive treatment group needed to be on more drugs and in bigger doses than the people in the less intensive treatment group.  Because of that the intensive group had more side effects from their treatment.  But the big question was, would they do better when they were followed up?  Would they have fewer heart attacks, and strokes? Would more of them stay alive and well during the 4-5 years of follow up? Surprisingly, the answer to those questions was NO!  Both groups did equally well.  About the same number died or developed a new cardiovascular disease (like a heart attack or a stroke).

So where does this leave us? Does the ACCORD trial tell us what the ideal systolic blood pressure is if you have diabetes?  Well, it does confirm that high blood pressure is not good for you if you have diabetes.  Getting the systolic below 140 is definitely a good goal to go for.  And, in fact, the people in the ACCORD trial who were trying to get their blood pressure below 140 ended up at 133, which is a lot closer to 130 than 140. So maybe a target of less than 130 (which is what the American Diabetes Association and other international group recommend right now) is the right target.  I wish the ACCORD trial had had a third group who were targeted to get their systolic blood pressure below 130, but they didn't.  What the study reminds us is that when taking drugs to treat any medical condition there is a balance between the drugs doing good and causing harm.  Sometimes adding more drugs and pushing the dose higher and higher only results in more cost and more side effects and may not always result in more benefit.

Do I really have to check my blood glucose?

In Chapters 13 and 14 of The Diabetes Answer BookI talk a lot about testing your own blood glucose levels.  Pricking your finger one or more times every day can be a "real pain."  Some people get so frustrated about it that they wonder why they even bother testing at all if they feel fine.  In fact some recent research studies have challenged the idea that blood glucose testing is necessary at all.  O'Kane and colleagues published an interesting study in the British Medical Journal a couple of years ago (O'Kane, MJ, Bunting, B, Copeland, M, et al. Efficacy of self monitoring of blood glucose in patients with newly diagnosed type 2 diabetes (ESMON study): randomised controlled trial.  BMJ 336:1174-1177, 2008).  They studies 184 people with newly diagnosed type 2 diabetes who were not requiring insulin but could manage their diabetes by improving their lifestyle and taking one or more pills.  They were all given educational advice about how to eat healthier and get more exercise but while half of the subjects were also taught to check their own blood glucose levels several times a day the other half did no self blood glucose monitoring.  The results of the study were surprising: after one year both groups had improved their overall blood glucose control to the same amount.  The average HbA1c level in both groups had fallen from 8.7% to 6.9%.  Both groups had lost about the same amount of weight and the number of episodes of hypoglycemia (low blood glucose levels) was the same in both groups.  In fact the only difference between the groups was that the subjects who had done no blood glucose testing were significantly less depressed than the group who did lots of blood glucose testing!

What are we to make of these results?  On one hand they shouldn't surprise us.  Thirty years ago, before the techniques for testing blood glucose levels at home had been invented, people with diabetes still managed to lower their overall blood glucose levels by eating healthier, getting more exercise and taking pills.  After all, testing your own blood glucose level isn't a treatment that improves your diabetes control.  It is simply a tool that allows you to know what your blood glucose level is an any particular time.  It is like being given a flashlight on a pitch dark night to help you get where you want to get to more safely.  You might be able to get where you want to go without the flashlight but you may trip or bump into more trees if you try to move forward in the darkness.  The key thing about the O'Kane study is that the people they enrolled in the study were not in much danger of having their blood glucose go too low.  They simply needed to lose some weight, eat healthier and exercise more.  Some people might be motivated to see their blood glucose levels dropping in response to their improved lifestyle but other people are just as happy to make the changes and not worry about what is happening to their blood glucose.

The key thing about testing your blood glucose is to learn from the information that you get.  So if you want to know what happens to your blood glucose after going for a thirty minute walk test your blood glucose before hand and then again when you are done with the walk.  If you want to know how much higher your blood glucose goes after eating a baked potato compared with a piece of grilled fish then test your blood glucose before and one hour after eating each type of food.  If you have had a really stressful day and are feeling "weird" or tired when you get home you might be interested to know what your blood glucose level is.

So do you really have to check your blood glucose?  If you won't use the information to change anything you are doing to manage your diabetes then it is probably a waste of time to check.  But if you learn something useful that gives you insight about how to manage your diabetes better then testing your blood glucose can be very helpful.  Maybe I'm just not very brave and not much of a risk-taker but if I was asked to run down the street on a pitch dark night when the power was out I would prefer to have a flashlight in my hand!

What is glycosylated hemoglobin (or hemoglobin A1c, HbA1c)?

As I said in The Diabetes Answer Book (page 83):

Hemoglobin is a protein inside all of your red blood cells.  It helps carry oxygen to your tissues to keep you healthy.  Every day your body makes a few million new red blood cells in your bone marrow.  These get pumped round and round your body for the next two or three months.  When the red blood cells get old, your body destroys them in your spleen.  Since the hemoglobin is floating around amongst the glucose in your blood, a small amount of glucose gets attached to the hemoglobin.  Hemoglobin with glucose attached to it is called glycosylated hemoglobin or hemoglobin A1c (HbA1c).  Brand new red cells have no glucose attached to them, but the longer they stay in your bloodstream, the more glucose gets attached.  The higher the glucose level in your blood, the more HbA1c you form.

We can measure what percentage of your hemoglobin has glucose attached to it.  This tells us what the average glucose level was in your blood for the previous ten to twelve weeks.  To give you an idea of how to use this information, a non-diabetic person's blood glucose will vary between about 20 and 160 mg/dl (3.9-8.9 mmol/L) throughout the day.  Over time about 4 to 6 percent of the person's hemoglobin will get glycosylated.  So the normal range for HbA1c is about 4 to 6 percent.  Now, imagine the worst possible blood glucose control.  If someone let his or her blood glucose average remain at 400 to 600 mg/dl (22-33 mmol/L) for months on end, the HbA1c could rise above 20 percent.  I have never seen HbA1c higher than 25 percent, but it can almost get to that level if someone leaves his or her diabetes completely untreated for long enough.

Doctors pay so much attention to HbA1c that it is important for you to understand what it is and how to interpret it.  I will refer back to this in other blog posts. 

Do the benefits of good blood glucose control ever wear off?

Keeping your blood glucose close to normal will definitely make you less likely to get eye damage or heart disease in the future.  But doing everything to keep your blood glucose close to normal is really hard work.  Watching what you eat, checking your blood glucose a lot, making adjustments in your food, exercise, pills or insulin... the constant grind of paying attention to every little detail can wear you out.  Some people can manage it for months or years on end, but others find that they can't keep it up all of the time.  They worry that if their blood glucose levels drift up that they will have lost all the benefit of those years when they kept it close to normal.  Some recent research studies give very encouraging results about this.

The biggest study looking at the effect of blood glucose control on long term complications for people with type 1 diabetes was the Diabetes Control and Complications Trial (DCCT).  After six and a half years of the study the people who kept their blood glucose closer to normal had a lot less eye damage, kidney damage and nerve damage than those whose blood glucose levels were higher.  At the end of the study the difference in blood glucose control between the two groups (those with "intensive management" and those with more regular treatment) was lost in a year or two.  In other words those who had been managed intensively to keep their blood glucose control close to normal "slacked off" a little while those in the less intensive group tightened up their efforts a bit.  So for the next several years all the people who had been in the DCCT had about the same level of control as each other.  The surprising thing was that the group who HAD kept their blood glucose levels closer to normal for the six and a half years of the study continued to have lower rates of eye damage, heart disease and other problems.  The benefits of their years of hard work continued even when they had "slacked off."

Just recently the same thing has been found for people with type 2 diabetes.  The largest study to look at the effects of blood glucose levels on diabetic complications for people with type 2 diabetes was the United Kingdom Prospective Diabetes Study (UKPDS).  That study showed that people who kept their blood glucose closer to normal had fewer problems with their eyes and blood vessels and heart.  It has been over ten years since the UKPDS finished.  Within a year the blood glucose levels for the people in that study had drifted closer together so that for the next eight to ten years they all had about the same level of blood glucose.  But once again, those who HAD kept their blood glucose closer to normal during the study continued to have healthier eyes and hearts than those who had had higher blood glucose levels during the study.

I think the follow up results from the DCCT and the UKPDS are very encouraging.  What they tell us is that if you can keep your blood glucose levels close to normal for many months or years that the benefit you get from this lasts for a very long time.  So if you drift for a while and can't keep things as close to normal as you used to don't beat up on yourself.  There are times when your life circumstances change and it is harder to do everything right.  Maybe you got divorced.  Maybe you lost a job.  Maybe you are looking after a family member who is ill and it takes up all of your time.  If your average blood glucose levels are not as good now as they used to be don't be discouraged.  Your body is still getting the benefit from all those years when you kept your blood glucose levels close to normal.  And if you can get back on track and bring your average back down again you will get even more benefit.

Nerve Damage: Less Common Forms

Here are the questions I answered in chapter 12:

Chapter 12: Nerve Damage: Less Common Forms

Why do my fingers feel swollen when I try to make a fist?

What is Carpal Tunnel Syndrome?

Why is Carpal Tunnel Syndrome more common in people with diabetes?

How can Carpal Tunnel Syndrome be treated?

Is erectile dysfunction inevitable for men with diabetes?

How do I explain erectile dysfunction to my spouse or partner?

What can be done to treat erectile dysfunction?

What is gastroparesis?

What treatments are available for gastroparesis?

Why do some people with diabetes have bad breath?

Can diabetes cause diarrhea or constipation?