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[IP] (Fwd) E-News 10/05/01

This may be of interest to those of you who participated in the 
discussion on uncontolled sweating, etc...

------- Forwarded Message Follows -------
Date:          Fri, 05 Oct 2001 02:30:00 -0700
To:            (Recipient list suppressed)
From:          "Dr. Joe, The Diabetes Doctor" <email @ redacted>
Subject:       E-News 10/05/01

This is a soon to be published article by Dr. Joe.

Autonomic Neuropathy: Diagnosis and Treatment
by Joseph Prendergast, M.D.

Ask most people with diabetes what neuropathy means and they'll
quickly refer to symptoms of burning feet or numbness in the
extremities. But these well-known manifestations of peripheral sensory
neuropathy only tell half the story; in fact, as many as 60 percent of
people with diabetes may suffer from autonomic neuropathy, another
less-mentioned form of peripheral neuropathy. And while autonomic
neuropathy may actually be considerably more deadly than its more
familiar cousin, awareness of the condition and its dangers is only
beginning to grow among doctors and patients alike.

While diabetic sensory neuropathy damages the sensory nerves in the
extremities, diabetic autonomic neuropathy involves damage to the
nerves serving the heart, all internal organs, and other processes
that are not under direct conscious control. Impairment of the nerves
serving the bladder or genitalia may cause urinary incontinence or
erectile dysfunction. Sweat gland function may be affected, leading to
uncontrolled perspiration, or a lack of it, resulting in overheating
and dry skin. Autonomic neuropathy may also affect the nerves that
internally sense blood pressure, leading to blood pressure that is too
high or too low. Yet another complication is gastroparesis, a
dysfunction of the stomach's autonomic nerves that may lead to slowed
digestion, bloating, constipation, diarrhea, nausea, and vomiting.

Recent research indicates that autonomic neuropathy's most common and
life-threatening consequences may be cardiac. Cardiovascular autonomic
neuropathy can affect both heart rate control and cardiovascular
dynamics. Add these effects to the already-serious tendency of
diabetes to raise blood lipids and you have a condition ripe for
disaster. Studies indicate that the onset of later-stage, symptomatic
diabetic autonomic neuropathy is associated with a 50 percent
mortality rate over the following five years.

Early detection and intervention are of prime importance in heading
off the potentially serious consequences of autonomic neuropathy. Yet
surveys indicate that as few as 8 percent of diabetes patients know
what autonomic neuropathy is, and only 2 percent believe they have
undergone screening. To compound the awareness problem, diabetic
neuropathy has a slow and insidious onset, and many patients may
suffer from the condition unknowingly for years. Case reports abound
in which autonomic neuropathy has gone undetected in patients with
other chronic conditions such as Parkinson's disease. Studies indicate
that as many as 60 percent of all people with diabetes have some form
of neuropathy, although an estimated 30 to 40 percent of those are in
the pre-symptomatic stage and are therefore unlikely to know of their

In our practice, we make a concerted effort to quickly identify
patients with pre-symptomatic and symptomatic autonomic neuropathy,
and then use a variety of interventions to get their condition under
control. We routinely measure patients' heart rate variability, which
research shows can help detect diabetic autonomic neuropathy in its
early pre-symptomatic stages.

The American Heart Association and the American Association of
Clinical Endocrinologists both recently declared heart rate
variability as a recommended test for detecting autonomic dysfunction
in diabetes. Heart rate variability testing has previously been
limited to the research lab setting due to the fact that it called for
customized and computerized analysis of electrocardiograms, but today
physicians nationwide can incorporate a heart rate variability test,
such as the AnscoreV Health Management System, into a single office

Using the Anscore System, we look at heart rate variability responses
to three easy exercises: 1) the patient takes controlled breaths at a
constant rate for 60 seconds; 2) the Valsalva test, in which the
patient blows forcibly for a brief period; 3) the patient stands up
from a lying position. We look for reduced variability (less of a
change in heart rate), a sign that the patient's heart response, as
provided by the body's autonomic control center, is not adequate. At
least two tests must be performed in order for the test to be
conclusive. Sometimes one test result may be abnormal, but the second
test result turns out normal. This is because some heart rate
variability tests are more sensitive to earlier autonomic nervous
system dysfunction than others. This is also due to the fact that test
results are based on a combination of activities within the body,
which are influenced differently in each patient. As a general rule,
the more tests that result in abnormal results, the more severe the
end organ damage is to the autonomic nervous system.

With the Anscore heart rate variability test and other test results as
our guide, we can quickly set an individualized treatment regimen. The
Anscore System also enables us to track patients' heart rate
variability over an extended period of time. People with diabetes
should be tested for heart rate variability at least once per year as
part of their personal diabetes management routine.

More than 25% of diabetics achieve heart rate variability test scores
below the 5th percentile (and therefore abnormal) for a healthy
population. Therefore, this form of testing identifies a large group
with autonomic dysfunction.

When we detect diabetic autonomic neuropathy, the first and most
important focus of treatment is blood sugar control. We find that many
of our patients, particularly those with Type 2 diabetes, have not
been under tight control for some time. Until recently, researchers
were unsure as to whether high blood sugar levels were actually
responsible for complications of diabetes. In 1993, the results of the
Diabetes Control and Complications Trial (DCCT) largely put those
doubts to rest. The nationwide study looked at 1400 people with Type 1
diabetes, half of whom followed their regular self-treatment regimen,
and half who adopted a tighter standard for blood sugar control. Early
signs of kidney and eye disease were significantly lower in the
tighter-control group, and their rates of diabetic neuropathy were 60
percent lower. Tight blood sugar control appeared so beneficial that
the study was stopped a full year early so that the results could be

Tight blood sugar control is now the standard treatment for Type 1
diabetes, and additional studies from Japan and Europe indicate that
controlling blood sugar slows the development of complications in
people with Type 2 as well. Patients with Type 2, however, must walk a
finer line; tight blood sugar may have the somewhat paradoxical effect
of increasing weight in many patients, and weight gain exacerbates
diabetes. Maintaining healthy blood sugar levels while controlling or
reducing weight remains a challenge for many people with diabetes.
Most diabetologists recommend that people who want to avoid neuropathy
should work with an endocrinologist, a dietician and a diabetes nurse

We begin our intervention by introducing the patient to the use of an
insulin pump, which we have found extremely effective in helping to
control even the most "brittle" diabetic patients. The pump can
deliver a slow, steady dose of insulin, mimicking the role of the
pancreas, which normally supplies the body with insulin. At the same
time, the pump can be set to deliver large "bolus" doses of insulin at
mealtimes, again, just as the pancreas does. Our goal is to
consistently bring patients' glycoslated hemoglobin levels below 7.0%,
and using the pump, we can usually achieve this within one month.

We also use a number of other interventions to ward off coronary
artery disease, including administration of 800 mg of the antioxidant
vitamin E per day, and l-arginine, an amino acid that smooths the
internal lining of blood vessels.

Perhaps the most important things we can do for our patients with
diabetes are to make them aware of autonomic neuropathy, to let them
know whether they have it, and to help them keep blood sugar levels in
an acceptable range. Doing so not only helps reduce the risk of heart
disease, but also lowers the risk of diabetic eye, kidney and nerve
disease, each of which patients dearly want to avoid.

Diabetic autonomic neuropathy has been called a "silent killer,"
because so few patients realize that they suffer from it, and yet its
effects can be so lethal. With a brief, 15-minute test that we can
administer in the office, and some relatively modest interventions, we
can help many patients live longer, healthier lives.

Dr. Joseph Prendergast, M.D. is an endocrinologist and founder of the
Endocrine Metabolic Medical Center in Atherton, California. For more
information on diabetic autonomic neuropathy and heart rate
variability testing, visit www.anscore.com


Vinik, Al, MD, PhD, and Suwanwalaikorn, S, MD: Autonomic Neuropathy,
In deFronzo, R.M. (ed). Current Therapy of Diabetes Mellitus. Yearbook
Inc. 1997; 165-176.

NFO Research, Inc.: The Diabetic Autonomic Neuropathy Awareness
Survey, commissioned by Boston Medical Technologies, Wakefield,
Massachusetts. March 2001.

Ziegler D. Diabetic cardiovascular autonomic neuropathy: prognosis,
diagnosis and treatment. Diabetes Metab Rev 10:339-383, 1994

The American Association of Clinical Endocrinologists Medical
Guidelines for the Management of Diabetes Mellitus: The AACE System of
Intensive Diabetes Self-management 2000 Update, Endocrine Practice
2000; 6(1): 43-84; American Heart Association, 1999. AHA Scientific
Statement; Diabetes and cardiovascular disease. Circulation

Ewing D, Martyn R, Young R, and Clarke B. The value of cardiovascular
autonomic function tests: 10 years experience in diabetes. Diabetes
Care 8:491-498, 1985.

The DCCT Research Group. The effect of intensive treatment of diabetes
on the development and progression of long-term complications in
insulin-dependent diabetes mellitus. The New England Journal of
Medicine 329: 977-986, 1993.

E-News is written by Dr. Joe Prendergast and his staff at Endocrine
Metabolic Medical Center.  It is sent out Monday through Friday

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