Your Guide To Navigate Diabetes-Induced Neuropathy

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Thank you so much for having me, Will. It’s a pleasure to be at the summit and to share such an important topic. There’s nothing more important to help people with than diabetes because it’s a condition that affects a vast array of different health problems. For my background, I’m a Board Certified Chiropractic Neurologist. I’m also board-certified in functional medicine and integrative medicine. From my perspective, I’m looking at the big picture, because if we just focus on diabetes as simply a blood sugar problem, we’re going to miss a lot of other comorbid conditions that people may not be aware of that may also be plaguing them. So my background as a practicing Chiropractic Neurologist, is that I always see people with a lot of neurological symptoms. Now, this can be central nervous system symptoms like brain fog, depression, fatigue, anxiety, and memory issues, but it can also be peripheral nervous system symptoms such as sensory issues, numbness, and tingling. They may have a balance problem that’s a result of their peripheral neuropathy, although you can have a central-base balance problem like cerebellum issues. So that’s very common. When we see people with diabetes, my background is that we’re looking at this neuro-metabolic integration. That’s a term that I created 20 years ago because I saw what’s coming down the pipe in research. I saw this huge factor of metabolic conditions impacting nerve function. Diabetes, being a metabolic condition, has a tremendous impact on nerve function anywhere where you have nerves. But it’s not just in your brain; it’s not just in your feet. This is something that hopefully we can shed some more light on for people to be able to understand why they’re having symptoms that may or may not be diagnosed and may be plaguing them.

William Hsu, MD

Dr. Kan, it looks like you’ve taken care of so many patients with these issues, and maybe we should start from the beginning. A lot of our audience may be asking the question, Why do people with diabetes develop neuropathy, and what is neuropathy? Can you help us understand that a little bit?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

That’s a great question. A lot of people think of neuropathy simply as numbness and tingling in their hands and feet on the periphery. They can’t feel properly. Neuropathy simply means that there’s a pathological condition of the nerves. Some nerves are being damaged simply by speaking. When that happens in the sensory nerves in your hands and feet, then you’re going to have sensory symptoms, which is one of the most common complications of diabetes, Type 2 diabetes, and Type 1 is that you get neuropathy. But know that this glycation end product of diabetes, this high blood sugar condition, damages nerves wherever they are in the body, whether it’s peripherally or centrally, meaning in the brain. Your neurons rise because all nerve tissue, whether it’s in the brain or your sensory nerves, is composed of neurons, which are nerve cells. So there’s nothing that’s more inflammatory to nerve cells than having high blood sugar. Now, specifically, why is neuropathy so common in people with diabetes? These nerve cells that are at the hands and feet, specifically the sensory neurons that mediate light touch, pain, and temperature, are called type C nerve fibers. These are myelinated, which means that they don’t have a male, and she’s on the outer cover of the nerves that protect them, as well as the very small diameter nerve fibers. Because they’re very small, that means they’re very delicate. They’re the first ones to go when you have any inflammation or damage to the body. This is why they are very common in people with diabetes. In this inflammatory condition, you’re going to start to notice these sensory changes. However, I would say that other nerves are also very small in diameter. These are your A-delta fibers. These Delta fibers innervate your autonomic nervous system, and this is the part of the nervous system that controls everything that’s on autopilot. Those nerves, because they’re small, also get damaged easily. You can have neuropathy, which can affect a sensory nerve, causing sensational changes. But then you also have neuropathy, which damages the autonomic nerves, causing what’s called Dysautonomia. This may be something that’s very common, but the symptom can be very wide-ranging, sometimes subtle, and a very commonly missed diagnosis for people.

William Hsu, MD

Let’s come back to this to clarify for all of our audience here. There are different kinds of nerves in the body. There are sensory nerves that are responsible, as the name implies, the nerves in the senses. That touch was sensing the vibration. That’s one type of nerve. You mentioned that it could also be a motor component to that as well, is it? Then there are the nerves that connect to our organ systems, and that’s important to know. There’s not one single symptom. There are many different types of symptoms.

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

When you damage the nerves, depending on what type of nerve you damage, you can have symptoms in that area. Diabetes is not discriminatory as far as what type of nerve it will damage. It’s just a smaller fiber of nerves, like the sensory nerves and the autonomic nerves, they are the first ones that get damaged.

William Hsu, MD

Let’s go there. The sensory nerves. What are the symptoms people can expect? Some of our audience may be asking the question, How do I know if I have sensory neuropathy?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

In the early stages. Because you don’t get sensory neuropathy overnight. It’s a condition that develops over time. You don’t just wake up one day, and all of a sudden, have numbness and tingling. I don’t feel anything. You might just wake up and feel numbness and tingling, but, to be sure, that has developed over long periods until you finally feel numbness and tingling. But that disease process may have been going on for six months, a year, or two years before you even got to that stage. This is why early diagnosis and detection and being aggressive with treating these things are important because there’s a window of time for you to get that nerve function back, and too long without a nerve being damaged. There is a point of no return where you cannot get that function back anymore. then that neuropathy becomes permanent. But in the early stages, there’s a lot you can do.

William Hsu, MD

Dr. Kan, what’s the insight there? Why don’t nerves come back? Why do they not come back? Just like skin, when you have a cut, the skin can heal over what’s unique about the nerves that make it difficult to come back.

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

It depends on the type of nerve, by the way. In, the neurons in your brain, the central nervous system, are post-mitotic cells, which means that they don’t go through cellular division mitosis. So that’s what that means: whatever brain cells you came into this world with, that’s all you got. You don’t get to make more brain cells. This is why, if you have a spinal cord injury, you’re paralyzed for life. At least at this point, we don’t have a way to fix it. In your peripheral nerves, you have a time frame. If you have a compressed peripheral nerve, like in your pronator muscle or your brachial plexus, you have time to grow that nerve back, to decompress that nerve, so to speak, and let that nerve function come back. But if it’s been way too long, you start to notice trophic changes. You don’t get the nutrients that go to the nerves. You lose the capacity for that nerve function to come back.

William Hsu, MD

A lot of people probably think this is the easiest type of neuropathy for our audience to recognize because there are associated symptoms, either pain or numbness. Now, you mentioned another one. Our audience may not be familiar with it. That is autonomic neuropathy. Let’s go there. First, describe. Please help us understand what Romney means by apathy. What are the symptoms?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

For the layperson, the autonomic nervous system is something that is a concept that many are not familiar with. But it is the system that runs your body. 24 hours a day, whether you’re awake or not, whether you want it to or not, it’s doing its job to keep you alive. The autonomic nervous system controls everything that’s on autopilot, including blood vessel constriction and dilation, blood pressure control, heart rate, lung function, sweating response, pupil dilation, and digestion. These are all controlled by the autonomic nervous system. You can have neuropathy in the autonomic nervous system. When you have neuropathy of the autonomic nervous system, the symptoms can be very diverse because, typically, with the autonomic, you’re going to have cardiovascular. It’s going to impact blood vessel constriction and heart rate. You can have digestive issues because the enteric nervous system as well as the vagus nerve innervates the gut. If those systems are damaged, you’re going to have digestive issues such as gas, bloating, and reflux due to a lack of stomach acid production. You can have irritable bowel syndrome, constipation, and alternating diarrhea, so you can have GI problems. cardiovascular. It can manifest as lightheadedness, dizziness, cold hands, cold feet, high pressure, high blood pressure, low blood pressure, or unstable blood pressure. You can have an arrhythmia. These are cardiovascular. We talked about gas and gastrointestinal, and then you can also have pseudo-motor symptoms, which involve tearing or sweating abnormalities. Either you have dry eyes or a dry mouth, or you can have excessive tearing or excessive sweating; it just depends on how it’s impacted. Any urogenital, by the way, you can have, like urinary incontinence and urinary frequency. Symptoms can be all over the place, and that can lead some people to think, they are just falling apart. I had like 50 symptoms. What the heck is going on when in fact there’s one underlying thread, which is your autonomic nervous system being attacked by this neuropathy, and therefore you experience symptoms in a whole bunch of different places?

William Hsu, MD

This is such an important discussion because a lot of listeners may have been experiencing these unexplained symptoms for years. It’s difficult to know what they are. They have probably been through many different clinicians and tried to figure out what these are. Help us understand, then, how one makes an accurate diagnosis of either sensory or peripheral neuropathy versus autonomic neuropathy. How can we tell?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

The first step is to understand what is causing the problem. That’s why the summit that you’re holding is so important for the listener because they understand what’s going on with diabetes. Why is this metabolic disease such a devastating condition now? As we discuss, how is it so devastating for the nervous system? First, through understanding, the patient has to empower themselves with information. Then, secondarily, they have to go to a practitioner who can step back and look at the big picture. then a couple to ask the right question. The number one thing we learn in medical school is that history is everything. History is what leads us down to the working diagnosis. Then we run lab tests and do physical exams to confirm those things. doing the right history with a doctor, with a provider, and then doing the right physical exam for no sensory neuropathy, you got to do a sensory neurological exam to rule out things for autonomic neuropathy. Then you have to again; a lot of us sometimes. The astute doctor will be able to pick up on these. You have symptoms in a whole bunch of different areas. It sounds like it’s autonomic. Then we can do autonomic testing and then combine that with the history of diabetes, which may put a picture together. There’s some type of neuropathy issue. The autonomic.

William Hsu, MD

Maybe what could be very helpful for our listeners is to tell them what the patients are not asking when they see their practitioners.

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

That’s a great question.

William Hsu, MD

Because they can go to visit, and  I used to see this all the time. A patient goes home, and the wife or the husband asks, What did you guys talk about at the medical visits? And the patient just blanks out. So what advice do you have for our listeners? What are they not doing to be a good advocate for themselves at these medical visits?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

That’s a great question. There are two things that they need to advocate for or pay attention to during a medical visit or doctor visit. Firstly, you have to go in armed with some level of information. That’s what the summit would do, to help them understand some of the things that could be complications. In this particular session, where we’re talking about neuropathy, you need to be aware that you can develop sensory neuropathy. You can also develop autonomic neuropathy, which can manifest as what’s called dysautonomia, and that can show up for some people as POTS Postural Autonomic Tachycardia Syndrome, or orthostatic hypotension. It can manifest as cardiac autonomic neuropathy, which cardiac autonomic neuropathy is, once neuropathy hits the heart, all-cause mortality goes way up manyfold. It’s a bit of a dangerous complication. It’s something to be aware of. You have to know this information. If you recognize in yourself symptoms of dysautonomia, dizziness, or lightheaded. Your blood pressure is not stable. It’s one thing to have hypertension all the time. It’s another thing to have your blood pressure go up and down depending on your position. Changes like these are things you need to be aware of. Then you bring it up with your medical provider. Hey, I have these symptoms of blood pressure changes and dizziness, as well as my head and heart symptoms. Consider autonomic neuropathy. Would you please check on me for it?

William Hsu, MD

You were advocating for this, which is very interesting. You’re advocating by asking your practitioners.

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

But I ask for it because sometimes, with doctors, their time is limited. They may not know all the concerns that you have.  You know yourself best. You’ve got to be your doctor, working with your doctor. You’ve got to bring it up with them. The second thing is, on the way out, ask the doctor to summarize. What did you find? What are your findings? What is your assessment, not just the finding? I would say that knowing the diagnosis is one thing. Knowing the root cause is another thing. Ask the doctor, what’s the root cause. If it’s a good doctor, they’ll look for the root cause. Also, I would say that if there’s a good doctor, they don’t know the root cause. They’re just telling you; that I don’t know the root cause. I’m not in charge of the root cause. I’m just here to manage, or sometimes I go to another person for the root cause. If you’re being honest, that’s good.

William Hsu, MD

That’s transparency, at least. 

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Exactly.

William Hsu, MD

Since you brought up the idea of the root cause and love to talk to someone, spend a few minutes on what? Now we know what the symptoms are. We know that diabetes is linked to neuropathy. We know it’s related to sensory. Then we also know it’s related to this autonomic neuropathy, and we now know what to ask when we go to the doctor’s office. But to be armed with even more knowledge, tell us a little bit about the root cause of these very amorphous symptoms, which can range from pain to nausea to fluctuations in blood pressure. In your view, what are the root causes?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Well, in the case of diabetes, the root cause is high blood sugar. Now, if there’s Type 2, typically associated with lifestyle, and this is good news because of this lifestyle, that means you have a say. You have a choice in that you can make a different choice about your lifestyle. When I say lifestyle, that means what you eat, how you move, and what you put into your head. Stress management—all these things can have an impact on diabetes. So then there’s a root cause. In some people, the root cause of diabetes can be endocrine-disrupting chemicals. We know about BPA and fire-retardant materials, and all these. 

William Hsu, MD

People don’t talk about that enough. We look at obesity, but that’s not all the answer.

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

It’s something to be aware of. So for diet Type 2, there’s this chemical burden that can, over time, create insulin resistance. That’s something to be aware of. So that’s a route pass. But then the other side of that is the mechanism. The mechanism of neuropathy, which is the topic of this talk, is because of the diabetes-causing glycation end product. This glycated damage is damaging the nerve. That’s one of the primary reasons you get neuropathy. The second reason why people get neuropathy is due to autoimmune disease because once you get diabetes, your inflammation level is way higher at baseline than in people who don’t have diabetes. It’s an inflammatory condition. It’s a metabolic condition that results in inflammation. This inflammation can cause tissue damage and lead to increased cytokines. Then, when you have a lot of tissue debris and a lot of cytokines, that’s going to cause a lot of possibility for cross-reactions and molecular mimicry, where your immune system can develop antibodies to the tissue debris that’s floating around. Now you have immunity against your cell tissue. It’s very common because diabetes causes nerve damage. Now you have the proteins of nerves floating around. Then you can develop antibodies to those proteins floating around. You then get neuro-autoimmunity. If it happens to be autonomic nerve protein fragments floating around that you develop antibodies to, then you have autonomic autoimmune neuropathy. In that particular case, we need to manage it as an autoimmune condition. How do we do that? By dampening various immune pathways, modulating the immune system, identifying triggers that can cause cytokine release, and just dampening the inflammation response overall.

William Hsu, MD

This is an important discussion because, now we know the causes, but treatment is always, always what our audience wants to know. What are some of the conventional approaches to treating neuropathy? What are some of the more creative and emerging ways to look at the modalities that counter these terrible neuropathies, either conventional or what is expected as you go into the doctor’s office? Then what are some of the more emerging ideas around this?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Conventionally, it’s always about managing symptoms. When you have neuropathy, you have nerve damage. There are no drugs that cause your nerves to grow back. If you have high blood sugar and that’s damaging your nerves, no drug reverse that damage until you give your blood sugar control. I would say the treatment for neuropathy is to manage your blood sugar. In the conventional model, it’s going to be metformin, which is going to be all of your blood sugar-managing medications. If it’s Type 2, then we’re not talking about insulin here. But, in the early stages of neuropathy, if you can get that HbA1C under control and reverse diabetes, as you guys are talking about in the summit, then the neuropathy can improve in the early stages.

William Hsu, MD

So the key and key point number one is getting diabetes into remission. That has the potential to alter the course of neuropathy. That’s important. Dr. Kan, what else?

Well, then the other side of it besides, conventionally speaking, besides diabetes medication, from a neuropathy standpoint, it’s medication to treat neuropathic pain. It’s either pain medication or they may use Cymbalta or another type of neuropathy medication to dampen pain. But none of that’s addressing the root cause. Even if they can reduce symptoms, which is the right thing to do, sometimes you still need to work on the underlying root cause and the mechanism. There’s nothing more important in diabetes management than to not only watch out for conventional treatment and do that if it’s necessary but to concurrently do lifestyle things. Because if you’re taking diabetic medication, if you don’t exercise, if you only reduce carbohydrate intake, if you don’t manage stress, and if you don’t decrease inflammation, the medication is going to do, but it’s only going to take you so far, and if the goal is to reverse, then it’s lifestyle. If the goal is just to manage it, the medication will do just that. But managing it means keeping the disease in existence but not getting better. If we want to reverse that, we’ve got to work on our lifestyle. You’re saying that there is almost a complementary approach here: while we have to seek symptom relief because that’s what troubles the patient there, it also has to be a parallel approach to addressing the root cause through lifestyle changes. This may be a great way to tell us a little bit about your practice, and how you offer a different way of treating these very vexing health problems, such as diabetic neuropathy. What’s the difference in your approach? What’s your philosophy there?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Thank you for allowing me to share that because, for me, diabetic neuropathy, for anyone with any chronic condition, and not just diabetic neuropathy, is to help individual patients understand their condition to the point where they can become their own doctor. But that doesn’t mean their licensed health care provider can prescribe; it means the patient should be able to know what’s the underlying reason that’s driving their disease and the symptoms. Because if you just treat symptoms without understanding what’s causing them from a mechanistic perspective, then you’re just treating symptoms, and you’re just trying different things, and you can miss them, and you’re not even addressing the root cause. My main goal is to teach people at a very high level, as much as I can write for the layperson, for patients to understand at as high a level as possible, so then they can start to advocate for themselves. That’s the way that I do it. A lot of it is education, and a lot of it focuses on lifestyle changes. It’s going to be exercise. It’s going to be a diet change. Sure, some supplements can be very complementary and can have a great role in assessing the person’s functional, optimal, and physiological function. But it’s up to the person to decide how aggressive they want to be. So, once they’re armed with information, they’ll know that this is the target, and then they can decide how aggressive they want to be. But many times, people don’t understand the target. But when I say target, I don’t just mean a landmark or HbA1C target. That’s not the mechanism of what’s driving HbA1C, if somebody is just eating too much carb, then that’s what they need to do. They need to reduce their carbohydrate intake. Now, they may have cravings, they may have stress, or they don’t know how to do that. So we got to help them make these lifestyle changes. Supplements can help make that transition easier. But it’s always about teaching them the why behind what they’re doing and then giving them a reason to work hard towards something that can change their life.

William Hsu, MD

That’s very well said. Patient empowerment is the number one right of individuals, who can be armed with the knowledge and attitude to go into and seek solutions for themselves. At that point, is there anything else we haven’t covered that you think is relevant to a listener, or maybe a listener’s loved one? They’re struggling with diabetic neuropathy. Any additional advice or pearls that you can share with us?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

One thing that we haven’t touched on as much if anything, is autoimmune or neuropathy. This can mimic diabetic neuropathy because autoimmune neuropathy has the same symptoms of numbness, tingling, and pain in the extremities, but it can also be caused by gluten sensitivity. I see that very often in my practice where gluten can cause autoimmune neuropathy. I see people with environmental toxin exposure who end up with neuropathy. I see people with chronic infections that can cause autoimmune conditions that can drive neuropathy due to an inflammatory condition. So people need to be aware of the different ways that this can happen. With so many of these mechanisms, there’s a lot that individual patients can do to make things better through nutritional supplements, diet, and lifestyle changes. Finally, I want to leave people with that. Neuropathy is a progressive condition. You can’t reverse it in the early stages, but if you don’t get on the path of reversing this condition early, it’s going to get progressively worse. Then what that means is a permanent loss of function. That’s not something you want because, when you can’t feel your feet, the risk of falling increases dramatically. then that becomes a risk factor as older you get. When it becomes autonomic neuropathy, that also causes problems because autonomia in general increases all-cause mortality, increases cardiovascular risk so this is all something that people need to be aware of. Neuropathy is not simply the loss of sensation in the feet. There’s much more than that for people with diabetes. There’s a lot at stake, and there’s a point of no return. Get on it early.

William Hsu, MD

That’s an important message there. There’s good news and there is not so good news. The good news is that we have to catch it early and address it early, or else the consequences could be quite impactful if we’re too late. Dr. Kan, thank you so much for this fantastic conversation that we have. I hope our audience finds it helpful. If our audience wants to learn more about the type of medicine you practice and your approach and just simply wants to learn more, how can they find you?

Peter Kan, DC, DACNB, FAAIM, CFMP, CGP

Thank you for letting me share. They can find me online. I’m all over YouTube. There are a lot of free resources. There are videos. Just search. Dr. Peter Kan and you see the bald-headed Chinese guy pop up. Also on my website, askdrkan.com.

William Hsu, MD

Dr. Kan, thank you so much for participating in this fantastic episode of Reversing Type 2 Diabetes Summit 2.0. Thank you.