Leg cramps and diabetes

Here’s a scary stat: More than 30 million people in the U.S. have diabetes, according to the Centers for Disease Control and Prevention (CDC)—and 25 percent don’t even know they have it.

But it gets worse: 84 million more Americans have pre-diabetes (a.k.a., almost diabetes, when your blood sugar levels are high, but not high enough for full-blown diabetes)—and 90 percent of those people don’t know they have it either, per the CDC.


Back up—remind me what diabetes is again.

Diabetes isn’t just one disease. There are actually three types of diabetes: type 1, type 2, and gestational diabetes. Most people with diabetes have type 2—it happens when your body doesn’t use insulin well and is unable to keep your blood sugar stable, per the CDC.

Type 1 diabetes is much less common—only about 5 percent of those with diabetes have type 1—and it’s essentially an autoimmune disease where your body stops making insulin at all (and as such, can’t regulate blood sugar).

And gestational diabetes occurs in pregnant women—it usually goes away after you give birth, but it can increase your likelihood of developing type 2 diabetes later on, according to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

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All three types of diabetes can easily be detected though a blood test. The test, essentially, checks to see if your blood glucose (a.k.a. blood sugar) is too high. But be warned: You can’t diagnose yourself—not even with an OTC blood glucose meter, per the NIDDK.

Unfortunately, many people are walking around with undiagnosed diabetes or prediabetes because the symptoms are super-subtle, says Poorani Goundan, M.D., an endocrinologist at Boston Medical Center.

These sneaky diabetes symptoms might indicate that it’s time to head into your doctor’s office for a test.

1. You have to pee all the time.

When you have excess sugar coursing through your blood stream, your body instinctively tries to get rid of it, says Mary Vouyiouklis Kellis, M.D., an endocrinologist at Cleveland Clinic. “Water follows sugar, so you end up having high-volume urine loss,” she explains.

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If you notice you’re suddenly peeing a lot, and more often, for no real reason—especially if you’re waking up a few times during the night to go—it’s time to talk to your doctor, she says.

2. You never stop drinking water.

With all that peeing, dehydration is a very real possibility. And, to make matters worse, “some patients who don’t know they have diabetes quench their thirst with sugary drinks like soda or juice, which adds to their blood sugars,” Goundan says. Signs of dehydration include dark-colored urine, a drop in (water) weight, and extreme thirst.

Sound familiar? Talk to your doc about this potential symptom of diabetes, especially if it occurs in tandem with lots of bathroom breaks.

3. Your breath smells awful.

Diabetes-related dehydration contributes to dry mouth, and the bad breath that can accompany it. (After all, with dry mouth, there’s not enough spit to wash away bacteria and balance the pH in your mouth, Kellis says.)

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What’s more, undiagnosed or uncontrolled diabetes can trigger ketosis, a process in which the body uses fat, rather than glucose, for energy. Ketosis releases a chemical byproduct called ketones, which can make your breath smell unpleasantly sweet or fruity, she says—sometimes it might even smell like acetone, since that’s a type of ketone.

Unless you’re on a keto diet (which is designed to put you into ketosis), it’s worth talking to your doctor.

4. Your vision’s getting increasingly blurry.

Blurry vision is a common—and often ignored—diabetes symptom in women. What does diabetes have to do with your vision? Kellis explains that fluid can form in your eye’s lens as sugar levels increase (remember: fluid follows sugar).

Diabetes can cause significant, unexplained weight loss. Think: 10 or 20 pounds.

A buildup of fluid in the eye blurs vision, causes nearsightedness, and sends many people to the optometrist for a new glasses or contacts prescription.

Fortunately, getting your blood sugar levels under control can clear up blurred vision, she adds.

5. Your hands and feet fall asleep a lot.

Neuropathy—a condition characterized by numbness or weird sensations like pins and needles in your arms, legs, hands, and feet—occurs in more than half of people with type 2 diabetes, according to a 2017 Diabetes Care review.

Why so common? Diabetes reduces blood flow to your extremities and, over time, damages your blood vessels and nerves, Kellis says.

6. Your cuts and bruises take forever to heal.

Reduced sensation in your extremities makes you more prone to injuries. “You’re less likely to notice a cut because you can’t feel it, which means you’re less likely to take care of it and it’s more likely to get infected,” says Goundan.

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Then, once you do have an injury, uncontrolled diabetes can make it harder for your body to heal. “High blood sugars provide a good environment for bacteria to grow,” she says. That’s because diabetes is also often accompanied by high blood pressure and high cholesterol, and the resulting plaque buildup can narrow blood vessels, reducing blood supply and leading to slow healing.

Diabetes can also weaken the T-cells that make up your immune system—your body’s defense against infection. “When you have high blood sugar, it’s like delaying your body’s army to go to the wound to heal it,” says Kellis.

7. You’re losing weight…but aren’t trying to.

Unexplained weight loss can happen for lots of reasons, and diabetes is one of them. Goundan explains that insulin helps your body move sugar from your blood to your cells, so when you have an insulin resistance, you don’t get enough energy into your cells despite all that sugar flowing through your body. “Because you’re unable to get enough energy from sugar, your body burns your own fat and muscle for energy,” Kellis says. “Weight loss can be pretty significant, sometimes 10 to 20 pounds.”

Generally, doctors recommend visiting the doc if you unintentionally lose between 5 to 10 percent of your body weight over the course of six months.

8. You get enough sleep, but you’re still so tired.

Carbohydrates, which your body breaks down into glucose, are your body’s main source of energy. But your body can’t effectively use that source of energy when you have diabetes, explains Goundan. (And diabetes-related dehydration can also bring on fatigue.)

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Of course, there are tons of other reasons you could be feeling exhausted, including your diet, stress levels, and how much you’ve been sleeping.

Still, if you can’t think of any other good reason for your extreme fatigue, and your low energy levels are accompanied by some of these other diabetes symptoms, it’s worth getting checked out.

9. You get a surprising number of yeast infections.

High blood sugars create an environment in your vagina that’s ripe for yeast infections. “Glucose is fuel for yeast. The more that’s around, the more they can multiply,” says Kellis.

If you’re having two to three yeast infections every few months or if the standard treatments just aren’t working, it’s time to see a doctor. “Once blood sugar is controlled, the frequency goes down,” says Goundan.

10. You’ve got weird dark spots on your skin.

Darkening skin around the nape of your neck, under your armpits, or even in your groin area is a surprising and common early sign of insulin resistance, the precursor to diabetes—the medical name for the condition is acanthosis nigricans (AN).

“We see this often in women with polycystic ovary syndrome (PCOS),” says Kellis, who notes that women with PCOS are at an increased risk of insulin issues. If you notice new dark spots on your skin, they’re worth checking out with your doctor.

11. You feel really itchy all the time.

Those with diabtetes often experience itching due to yeast infections (which can occur on the skin, too), dry skin, or poor circulation, according to the American Diabetes Association. If poor circulation is to blame, your legs will be the itchiest area.

Per the ADA, you can try to treat the itching yourself by limiting how much you bathe (especially in less humid climates), using soap with a built-in moisturizer, and remembering to apply lotion immediately after washing up.

Colleen de Bellefonds Colleen de Bellefonds is an American freelance journalist living in Paris, France, with her husband and dog, Mochi.

Is Diabetes Causing My Nausea?

Nausea comes in many forms. Sometimes it can be mild and short-lived. Other times, it can be severe and last for a long time. For people with diabetes, nausea is a common complaint. It can even be a sign of a life-threatening condition that requires swift medical attention.

5 common causes of nausea

Factors related to your diabetes may cause you to feel nausea.


Metformin (Glucophage) is one of the more common medications used to treat diabetes. Nausea is a potential side effect for people taking this medication. Taking metformin on an empty stomach may make nausea worse.

Injectable medications used to treat diabetes, such as exenatide (Byetta), liraglutide (Victoza), and pramlintide (Symlin), may also cause nausea. The nausea may go away after extended use. Your doctor may also start you on a lower dosage to try to reduce or eliminate nausea.

Hypo- and hyperglycemia

Hyperglycemia (elevated blood sugar levels) or hypoglycemia (blood sugar levels that are too low) may cause nausea. Check your blood sugar and respond appropriately if you suspect abnormal blood sugar levels.

To avoid hypo- and hyperglycemia, stick to your diabetes meal plan, monitor your blood sugar, and take your medication as prescribed. You should also avoid exercising in extreme temperatures and keep cool by drinking cold liquids during outside activities, advises Sheri Colberg, PhD, author, exercise physiologist, and expert on diabetes management.

Diabetic ketoacidosis

Severe nausea may be a sign of diabetic ketoacidosis. This is a dangerous medical condition that must be treated to avoid coma or even death. Symptoms include:

  • nausea
  • excessive thirst
  • frequent urination
  • abdominal pain
  • weakness or fatigue
  • shortness of breath
  • confusion
  • fruity-scented breath

If you suspect diabetic ketoacidosis, seek immediate medical attention.

To prevent diabetic ketoacidosis:

  • monitor your blood sugar levels
  • take medication as prescribed
  • test urine for ketone levels during periods of illness or high stress


Gastroparesis is a gastrointestinal complication. It prevents normal emptying of the stomach, which delays digestion of food and can cause nausea. If you have diabetes, you may have an increased risk for developing gastroparesis. Symptoms of gastroparesis include:

  • nausea
  • heartburn
  • loss of appetite
  • upper abdominal pain
  • swollen abdomen
  • changes in blood sugar levels
  • malnutrition

There is no cure for gastroparesis, but there are things you can do to control the symptoms.

Try eating several small meals during the day instead of three large meals. Avoid lying down after meals. Instead, take a walk or sit. This will help with digestion. Your doctor may also adjust your insulin dosage or recommend taking insulin after a meal instead of before eating.


People with uncontrolled diabetes have a higher chance of developing pancreatitis. Pancreatitis is a swelling and inflammation of the pancreas, and may cause nausea. Vomiting, abdominal pain, and high triglyceride levels often accompany the nausea.

Maintaining a low-fat, healthy diet may help prevent or control pancreatitis. Avoiding alcohol and smoking may also help.

Artificial sweeteners and sugar alcohols

In an attempt to control blood sugars, many diabetics turn to artificial sweeteners and sugar alcohols to minimize their regular sugar intake. However, a common side of added sweeteners like xylitol is nausea, as well as other digestive symptoms. When someone has more than one serving a day, the side effects may be amplified. The U.S. Food and Drug Administration (FDA) has compiled a list of reactions to aspartame that includes nausea.

Know the signs to stay on track

If you have diabetes, nausea can be a sign of something more serious. Knowing the potential causes and how to treat or prevent this uncomfortable side effect is key to keeping your diabetes management on track.

Most, if not all of us will be familiar with the feeling of nausea, which is basically the feeling of needing to be sick, felt in the stomach area.

Both nausea and vomiting can be a sign of a number of underlying health conditions, including diabetes.

When there is an issue that can affect the stomach or gastric system of their body, people can feel sick.

Even if it is a fairly tenuous connectio, such as angina affecting blood flow, the sufferer may still feel queasy.

Causes of nausea

Both type 1 diabetes and type 2 diabetes can cause nausea or vomiting in several ways.

Hyperglycemia and Hypoglycemia

As the blood glucose levels rise and fall, the body’s metabolism can get interrupted and confused which can lead to a mixed feeling of nausea.

Low blood pressure (Hypotension)

Low blood pressure often leads to dizzy spells which, for some people, can induce a feeling of nausea as the world appears to spin around them.

Certain medications

The side effect of a lot of drugs is a feeling of nausea, and even vomiting. Metformin, the most widely used diabetes drug, is known to have nauseating side effects


Due to neuropathy, the body may not be able to move food from the stomach or along the intestines

This can cause a back log of food, which can result in sickness.


Bezoars are stone like formations created from undigested food matter, which can block the gastro-intestinal track and stop food processing and digesting.

This can eventually cause nausea and vomiting.

When to see your doctor

If you are having recurrent or consistent bouts of nausea or vomiting, then it is a good idea to go and see your doctor to get the issue sorted as soon as possible.

Keeping a diary of nausea or vomiting episodes and what you ate or were doing beforehand may help the doctor in determining the underlying cause of your nausea.

Diabetes Basics


Coping with diabetes at work has similarities to coping with it at home. Of course, much of this depends on the type of work one does. People with “desk jobs” who get very little physical activity at work would do best by taking advantage of walking steps instead of riding the elevator or intentionally parking further away than necessary. Even this moderate amount of additional exercise can improve glucose levels and for many improve stress.

For people who take insulin, it is important your supervisor knows you need to eat at specific times. If this is not possible, you can discuss with your physician different strategies to avoid problems. With the newer insulins, there are many ways to be creative about this. For everyone with diabetes, it is important not to “hide” your diabetes from your co-workers. This is especially true if you take insulin.

Some people have difficulty discussing their diabetes with others. Occasionally, this is such a problem that self-management tasks are not performed (blood sugar testing, for example). These fears need to be addressed and occasionally require the help of a psychologist.

Family and friends

Another important but complicated topic is the effect of diabetes on different types of relationships.

For children, diabetes can affect their relationships with parents, siblings and friends. Kids often feel “different” and this can create significant problems–occasionally resulting in behavior changes. It is important for parents to make sure their child with diabetes does not feel “different.” The most important example is to make sure a different type of food is not served to the child with diabetes compared to the rest of the family. Everyone should be served the same food.

In teens with diabetes, issues pertaining to dating are often a concern. Both girls and boys often have difficulty in dealing with their diabetes when confronted with the opposite sex. Again the key is for the family to be supportive of an open discussion of any concerns that the teen may have. This may include discussions about the effects of alcohol on diabetes control.

Diabetes can affect relationships in adults as well. Issues can be just as complicated: relationships at work, at church and at the golf course can all be affected by diabetes. Many of these problems are due to others being uneducated about diabetes. Explaining to others about diabetes can be the most important solution to problems that may arise.

Adaptive aids

There are a variety of different “adaptive aids” to help with the various aspects of diabetes. Perhaps the most common one is the use of the specialized shoes to protect the feet in people with severe peripheral neuropathy. Feelings of sensation in the feet are lost and special protective shoes can protect these feet from developing an ulcer. These ulcers often become infected and cause many problems, but the special shoes can assist in preventing this. Similarly, the use of “orthotics” for the feet help to redistribute the weight so that areas that are prone to callus formation have a better opportunity to heal.

There are a variety of new aids for actual blood glucose management. Home blood glucose meters have become quite simple to use, requiring small amounts of blood. Several meters can use blood from the arm or thigh, so there is no more pain from the fingersticks which tend to cause more pain. We are also using more sophisticated software systems to download the meters to help assess trends in blood glucose readings. This is particularly helpful for people who test frequently and most of the meter software can be purchased directly from the company for your PC.

Insulin pump use continues to grow. In the US, there are over 120 000 people using pumps and this is also growing in people with type 2 diabetes. The pump delivers small amounts of fast-acting insulin–usually lispro (Humalog) or aspart (Novolog)– continuously around-the-clock and a “bolus” of insulin is infused by pressing a button before a meal. The amount of insulin to infuse is based on the blood glucose reading at the time and the amount of anticipated carbohydrate intake. Obviously, exercise also has an influence in how much insulin to administer. In our experience at the University of Washington with pumps for 107 patients for a time period of 3 years, we saw a 74% reduction in hypoglycemia.


Stress can have a major impact on blood glucose control as it causes an elevation of adrenalin (also called epinephrine), in addition to other hormones. Adrenalin makes one more resistant to the effects of insulin, so no matter if you have type 1 or type 2 diabetes, stress can raise the blood glucose levels. One recent study showed that if one can relieve stress, the HbA1c can decrease on average by 0.5%.

The best strategy for relieving stress is to learn how to avoid the emotional upset that may occur. This is easier said then done, as it takes time to change the way one reacts to stress. For some people, getting exercise works well. This is particularly helpful for people with diabetes as the exercise directly works against insulin resistance. For many, it also makes the stress less bothersome.

For others, the main problem is lack of sleep–the stress keeps people awake, and the next day, the stressed-out person has difficulty functioning due to lack of sleep. It would be important to discuss this with your physician as there are safe medications that could be used for a short period of time to help with this problem. For people with type 2 diabetes, there is a higher rate of sleep apnea (due to obesity). If you snore and are exhausted during the day, also ask your doctor about this possibility.

For many with overwhelming stress, it may be best to discuss with your physician. Divorce, loss of a loved one, loss of a job are all major “stressor events” which may require more formal treatment either by discussing with a psychologist or with anti-anxiety medication.


There are a variety of important resources for people with diabetes. The largest American organization is the American Diabetes Association (ADA). Based in Alexandria, Virginia, the ADA funds diabetes research, has extensive education programs for patients with diabetes and health-care professionals, and manages camps for children with diabetes. They have a monthly journal “Diabetes Forecast” and a regular e-newsletter for important updates in relevant news. The ADA can be reached at 1-800-DIABETES or www.diabetes.org.

Other important resources include:

  • Juvenile Diabetes Research Foundation: 1-800-533-CURE or jdf.org. The JDRF is the world’s leading nonprofit, nongovernmental funder of diabetes research. JDRF is the only major diabetes organization focused exclusively on research.
  • Taking Control of Your Diabetes: www.tcoyd.org. A nonprofit organization started by Dr. Steven Edelman at the University of California in San Diego, this group strives to motivate and improve the lives of everyone with diabetes. The programs this group runs are tremendous and if one comes close to you, please make time to attend!
  • American Association of Diabetes Educators: http://www.diabeteseducator.org/
  • The Diabetes Mall: www.diabetesnet.com. Provides reviews of all of the latest research and new products.
  • The Diabetes Monitor: www.diabetesmonitor.com. “Monitors everything about diabetes in cyberspace.”
  • Diabetes Self-Management: www.diabetesselfmanagement.com. Comprehensive journal regarding all aspects of diabetes care.
  • Diabetes Interview: www.diabetesworld.com. An excellent newspaper.

Condition research

For both type 1 and type 2 diabetes, research is focusing both on prevention and cure. Another major focus of research is improvements in current therapies.

For type 1 diabetes, a large study asking if small doses of insulin could prevent type 1 diabetes in high-risk individuals showed this strategy did not work. Scientists are now looking at other strategies, perhaps an “immunization”. For example, a group from Israel showed that injecting a small protein could slow the progression of diabetes in newly diagnosed individuals with type 1 diabetes. More research on this is anxiously awaited. As far as a cure in concerned, some progress has been made with islet cell (the cells that make insulin) transplants. Newer ways to prevent rejection of the transplanted tissue are now being studied.

For type 2 diabetes, a large prevention study showed that intense diet and exercise could reduce the risk of diabetes by 59% in high-risk people. The drug metformin could also reduce this risk but by only 31%. This makes sense since weight loss and metformin also improve insulin resistance, one of the main mechanisms for type 2 diabetes.

Research has also resulted in an explosion of new drugs and technologies for the treatment of diabetes. This explosion shows no sign of a slow-down as we expect more new pharmaceutical agents to be released over the next five years. This will include new classes of oral agents to improve both insulin resistance and insulin secretion in type 2 diabetes and new insulins for those both with type 1 and type 2 diabetes. It is also hoped there will be better weight-loss drugs as our understanding of obesity improves. It is also likely glucose sensors will become more often used as telemetry-based glucose sensors should be available by 2003. This would allow a sensor placed under the skin to relay “real-time” blood glucose readings to you on a monitor you could wear on your belt or like a watch. Another development, the “Glucowatch” by Cygnus, will work similar to this and should be available in the near future. It is hoped that the sensors will progress to the point they can be attached to an implantable pump and thus work like a normal pancreas.

Non-surgical research

The study of exercise and its effects on blood glucose is one of the earliest types of diabetes research. Dietary research also continues to evolve especially as we learn more about heart and kidney disease. There have been tremendous advances in our understanding in dietary recommendations as mentioned above.

There is also better understanding on the impact of anxiety and depression on the impact of diabetes. People with diabetes tend to have more mental health challenges than those without diabetes and effective management of these often tends to improve diabetes care. For example, some people when stressed or depressed tend to eat more. Others find it difficult to measure their blood glucose during these times. Treating any mental health problems often makes diabetes management easier.

Since diabetes is treated surgically only in a very small minority of patients, treatment programs are based on many other factors: appropriate diet, regular exercise and a variety of medications which often includes insulin. As opposed to many other conditions, diabetes is a chronic medical condition that first and foremost requires active patient participation to result in good outcomes (blood glucose control).

Surgical research

At the current time, the possibility of programming cells with new genes to produce insulin or perhaps stem cells (early types of cells which can “differentiate or transform into islet cells, the cells that make insulin) is a goal of many scientists. Of course, there are both technical and political barriers with this type of research. Nevertheless, diabetes, especially type 1 diabetes, is a condition for which gene therapy or stem cell research could produce a breakthrough advance.

Summary of diabetes basics

The five most important facts about diabetes are as follows:

  • Diabetes is not one disease but rather is at least two diseases grouped as type 1 and type 2 diabetes. In actuality, there are many other types of diabetes, but the vast majority can be classified into these two types. Type 1 diabetes which usually presents in children or teens can present at any age. It is caused by the body destroying the cells in the pancreas that make insulin (the B-cells of the islets), and therefore insulin is required for survival. In type 2 diabetes which affects Hispanics, Blacks, Asians and American Indians more frequently, one must have both a resistance to the effects of insulin (so more insulin is required to maintain a normal glucose) and some degree of insulin deficiency. People with type 2 diabetes are usually (but not always) overweight and often have other risk factors for a heart attack or stroke including high blood pressure and dyslipidemia (high triglycerides low HDL cholesterol). People with type 2 diabetes often have their disease for years before they are diagnosed which is why the American Diabetes Association recommends screening for all high-risk individuals which would include everyone over 45 years of age, people with a strong family history of type 2 diabetes, and women who had diabetes during a pregnancy (gestational diabetes).

  • Control of blood glucose for both type 1 and type 2 diabetes can reduce the risks of complications especially those involving the eyes (retinopathy), the kidney (nephropathy) and the nerves (neuropathy). The American Diabetes Association recommends maintaining the HbA1c below 7% which would be an average blood glucose of 150 mg/dL.

  • Treatment of blood pressure below 130/80 and LDL-cholesterol (“bad cholesterol”) below 100 mg/dL has been shown to prolong life in people with diabetes. For the blood pressure, there are advantages to using the class of drugs called ACE inhibitors. Also a daily aspirin has been shown to reduce risks of a heart attack.

  • People with diabetes should have the following tests performed on a regular basis by their doctor:

    • a dilated eye exam each year to assess for diabetic retinopathy (the leading cause of adult blindness in the U.S.)
    • a yearly assessment for urine albumin or urine protein which is the first sign of diabetic kidney disease (nephropathy which is the leading cause of kidney dialysis or transplant in the U.S.)
    • a yearly measurement of cholesterol levels
    • Two HbA1c levels measured each year if you are well controlled, not receiving insulin, and four per year if you are receiving insulin.
    • have a yearly comprehensive foot exam by your doctor, assessing for the presence of neuropathy and vascular disease (the leading cause of lower extremity amputation in the U.S.).
    • consider some type of heart stress testing if you have diabetes and any other risk factors for a heart attack. Although 2/3 of people with diabetes die from heart disease it often presents without any symptoms and testing for it early may lead to finding a problem before it leads to a heart attack.
  • If despite following the physician’s advice, a person with diabetes still cannot meet the specific HbA1c blood pressure or cholesterol goals noted above, or the physician refuses to perform the standards of care from the ADA outlined above (they can also be read at www.diabetes.org), he or she might consider getting a second opinion or finding another physician. Doctors specializing in diabetes are called endocrinologists and it may be wise to consider seeing an endocrinologist if this situation occurs.

Diabetes-related Foot and Ankle Problems

Is age a factor among patients who have diabetes?
Dr. Onosode: Age is not necessarily a factor. The most important prognostic indicators are diet, exercise, and family history. We become especially concerned when the patient is very young, their diabetes is not controlled, and they have diabetic-related complications.

What role does a patient’s professional life or activities play in the development of diabetic-related foot and/or ankle problems?
Dr. Onosode: Lifestyle and physical activity plays an important role. The patient’s profession can be an indicator to determine what their prognosis may be. For example, patients with sit down or stand up jobs. Here the amount of time spent on the feet is important. Patients who do not spend a lot of time on their feet tend to do better than the patient who spends 8 to 12 hours a day on their feet. The wrong kind of shoe and/or a shoe that does not appropriately accommodate the bony and soft tissues of the feet, can cause problems to develop.

What types of diabetes-related complications do you see?
Dr. Onosode: In my practice, the types of diabetic foot and ankle problems seen are multifactorial. The most common complication is peripheral neuropathy, which I’ll discuss next. However, we also see patients with diabetes who have foot and/or ankle deformities.

Now you may wonder why a diabetic-related foot/ankle problem may progress to such a serious state. It is often because patients with long-standing diabetes, who have peripheral neuropathy, may not have adequate feeling in one or both feet or ankles, to know early that something is wrong.

How does diabetes contribute to peripheral neuropathy?
Dr. Onosode: As physicians, we worry about peripheral neuropathy, which is an abnormal or lack of sensation in the foot or feet. When a healthy person steps on a nail causing a break in the skin, their body sends signals through the central nervous system (eg, pain, swelling). However, someone with peripheral neuropathy doesn’t feel or sense those warning signals, and the wound may go untreated.

I had a patient in my office who stepped on a nail more than a month prior. He didn’t realize he had stepped on the nail, and he kept walking on the foot. Unfortunately, the small puncture wound became a full-fledged infected ulceration (see image below).

How does peripheral neuropathy develop?
Dr. Onosode: In my patient’s case, peripheral neuropathy started as a burning and tingling sensation, which can be easily ignored. The problem progresses from burning and tingling and becomes numbness. When a lower extremity is numb, the person cannot feel microtrauma, and when left untreated, the sore(s) become ulcerated and infected.

Please Note: If you have diabetes, please talk with your treating physician about a referral to a podiatrist. A podiatrist is an essential member of your diabetes care team.

Updated on: 07/23/18 Continue Reading Diagnosis and Treatment of Diabetes-related Foot and Ankle Problems

If you are diabetic, you need to worry about a lot more things like heart diseases and leg swelling. This causes peripheral edema in some cases and can be painful. If you see symptoms of swelling in your ankles, lower legs or feet, it is time to pay your physician an emergency visit.

Diabetes expand blood circulation in an inappropriate way, which can cause swelling in the lower leg region. However, there could be other reasons as well that would cause the swelling. So a visit to the doctor is a must. Diabetes is a serious disease which gives rise to many further complications; swelling in the legs is one of them. Let’s discuss a few reasons that could be contributing to the swelling and its cure.

What can lead to leg swelling?

For any diabetic patient, it is a must to consult a doctor in case you notice any changes in the body. A patient who’s been living with diabetes for several years needs to be extra careful because this disease comes with so many attached risks.

If you are diabetic and have noticed some leg swelling recently, the following could be a few reasons for it.

  1. The main reason for leg swelling in diabetes is peripheral edema. Fluids collect in the feet, ankles and leg and this condition can become quite severe if left untreated. A consultation with a doctor is a must.
  2. Sometimes, a diabetic may suffer from diabetic neuropathy. This is a condition that leads to numbness in legs and feet. As a result, the diabetic may not be able to feel an injury, maybe something even as severe as a sprain or a fracture and continue to use the limb. But the swelling caused by the injury is what will raise concern, which is why a consultation with the doctor becomes very important.
  3. Diabetics have low immunity towards infections and your swelling could very well be a sign of an infection in the leg. Further signs that you may have an infection can be mild fever and redness along with the swelling.
  4. Sometimes a high blood pressure can also result in leg swelling as fluids begin to build up within the tissues of the body. These are symptoms of a congestive heart failure and if you also feel like you have trouble breathing and are fatigued, you should rush to the nearest hospital.
  5. While most of us know about Diabetes Type 1 and Type 2, very few people are aware of the risks of gestational diabetes. This is a unique kind of diabetes that only affects pregnant women and usually disappears once the woman gives birth to the baby. Swelling in the legs is often associated with gestational diabetes, though the pregnancy itself can contribute largely to the collected fluids in the legs, causing a swelling.
  6. If you have Diabetes Type 2 and have been prescribed Thiazolidinediones, they can be the reason for your leg swelling. Talk to your physician if your leg swelling is severe and maybe he can change your prescription to give you relief from the swellings.

10 ways to reduce leg swelling

So now that you know what is causing your leg to swell, it is time to find out how to get rid of the swelling. The fact is that, for most diabetics leg swellings become a part of life. They come and go, and some lifestyle changes and exercises can bring a lot of relief. Though your doctor may give you a prescription to reduce swelling, it is best to adopt more holistic methods as medicines may have certain side effects. And as a diabetic, you are already ingesting enough medicines to take care of normal insulin functioning of your body and should refrain from taking any more.

Self-help measures to reduce leg swelling in diabetics:

  1. Twice a day, lie down with pillows under your legs to bring them above your heart levels.
  2. Make sure you get regular exercise to reduce risks of fluid build-up in legs.
  3. Wear compression stockings if you are prone to leg swellings.
  4. Eating a low-sodium diet will help symptoms of leg swellings.
  5. For diabetic women, wearing low-heeled or flat shoes is the best way to avoid leg swelling.
  6. Don’t stand in one spot for too long. Take breaks to sit down. If your job requires you to stand for long hours, keep one leg bent at the knee and then repeat the same with the other leg to keep them moving.
  7. Get regular leg massages to improve blood circulation in the entire leg. Start with the lower legs and move downwards to the toes. This will redistribute any accumulated fluids throughout the leg.
  8. Wear well-fitted shoes that are never tight, even when your feet feel slightly swollen. If you must, buy shoes one size bigger. It is better to buy shoes with ties to be adjusted as per foot condition.
  9. Never sit cross-legged because it stops circulation of blood to the lower leg.
  10. If you smoke, consider quitting because a diabetic who smokes is at increased risk of leg swelling.

With the above mentioned self-help tips, you can deal with leg swellings easily and get relief easily. However, we’d like to stress once more that at the slightest hint of leg swelling, visit a doctor because, as a diabetic, it always helps to be safe rather than sorry.

People who don’t know they have Type 1 diabetes may account for a surprising number of deaths from one complication of the condition, a new study says.

Nearly a third of people in Maryland who died over a six-year period from diabetic ketoacidosis, a condition of severe insulin deficiency, had no known history of diabetes, the study of autopsy results found.

While the researchers weren’t able to definitively tell whether those who died had Type 1 or Type 2 diabetes, their high blood sugar levels suggest they probably had Type 1, said study researcher Dr. Zabiullah Ali, the assistant medical examiner for the Office of Chief Medical Examiner in Maryland.

The finding highlights the need for regular physicals that include checking blood sugar levels, especially if warning signs of diabetes are present, the researchers said.

The study was published in the September issue of the American Journal of Forensic Medicine and Pathology.

What happens when the body runs out of sugar

Diabetic ketoacidosis is a complication of diabetes that occurs when body cells don’t have enough glucose (sugar) to use for energy, so they switch to burning fat instead. (Body cells need insulin in order to take up sugar from the bloodstream; in people with Type 1 diabetes, little or no insulin is produced.)

Breaking down fat for energy produces molecules called ketones, which are acids and can build up in the blood. If ketone levels climb too high, they can poison the body, causing chemical imbalances that can lead to coma, or death.

In the study, Ali and colleagues looked at 20,406 autopsies and found 107 people who had died from diabetic ketoacidosis, although only 92 had data available for further review.

Out of the 92 cases, they found that 60 people were previously diagnosed with diabetes, while 32 were not.

Nearly half of those who died with no history of diabetes were in their 40s. The researchers also found that 84 percent of these cases were men, and 53 percent were African-American.

Adults can be diagnosed with Type 1 diabetes too

Type 1 diabetes was long referred to as “juvenile diabetes,” because people tend to be diagnosed with the condition during childhood.

But now, “physicians are becoming more aware of the possibility of a diagnosis of Type 1 diabetes in the adult population,” said Dr. Mark S. Segal, a nephrologist at the University of Florida, who was not involved in the study.

“It’s relatively new that we’re seeing more adults are being diagnosed with Type 1,” Segal said.

Ali emphasized that people should pay attention to any warning signs that point to diabetes, such as needing to urinate frequently, constant thirst, nausea and vomiting.

People newly diagnosed with Type 1 diabetes may go through a “honeymoon period,” in which they may be able to function even though they aren’t making insulin — but that period doesn’t last long, he said.

“Once the period ends, they get into trouble fast,” Ali said. Healthy people should have their blood sugar checked one or twice a year.

“But if you have symptoms, you should go to the doctor immediately,” he said.

Pass it on: Getting blood sugar levels checked could help prevent diabetes complications, such as diabetic ketoacidosis.

This story was provided by MyHealthNewsDaily, a sister site to LiveScience. Follow MyHealthNewsDaily on Twitter @MyHealth_MHND. Find us on Facebook.

Summary of recommendations

Diabetes impacts on every facet of life in the person living with diabetes and this included when that individual is dying. The management of diabetes and the associated risks and side effects related to diabetes can complicate the dying process and make the experience more difficult and unpleasant. Simple measure can be put into place to ensure that the diabetes does not get in the way of a peaceful death; staff need to be trained and competent in the management of diabetes to ensure that this final act of caring is in place.

Dame Tessa Jowell; a British Member of Parliament has the last word when she stated in the House of Lords just prior to her death from cancer in May 2018 (27), “In the end, what gives a life meaning is not only how it is lived, but how it draws to a close”.


Dr. Rob Gregory, Dr. Jean MacLeod, Dr. James Burton, Professor Alan Sinclair.


Conflicts of Interest: The author has no conflicts of interest to declare.

Cite this article as: James J. Dying well with diabetes. Ann Palliat Med 2019;8(2):178-189. doi: 10.21037/apm.2018.12.10

Diabetes-Related Leg Cramps: How to Prevent and Treat

Being suddenly woken up by a painful knot in your calf—or frozen toes—isn’t fun. Here’s what diabetes has to do with it and what you do to stop the pain. Written by Julia Telfer, MPH 14

Some research suggests diabetes is linked to an increased frequency of painful leg cramps.

Perhaps you’ve been there—in the middle of a perfectly restful night of sleep you are abruptly woken up by an intense pain from a cramping muscle, typically in your foot or calf.

Although the exact cause of muscle cramps is still up for debate, they are frequently linked to poor flexibility and muscle fatigue. A smaller body of research also suggests that diabetes can increase your risk of experiencing leg cramps, potentially due to swings in blood sugar levels, certain medications, and long-term complications such as diabetic neuropathy (nerve damage).1,2 With or without diabetes, these cramps are characterized by the sudden, involuntary, and painful tightening (contraction) of a muscle. They occur most frequently in the evenings in the following muscle groups:

  • Calf muscles (back of the lower leg)
  • Hamstrings (back of the thigh)
  • Quadriceps (front of the thigh)
  • Cramps can also occur in the hands, feet, arms, neck, and abdomen

What causes these painful cramps and how can I prevent them?

“Although the exact cause of muscle cramps remains unknown, they are not inevitable,” says Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE. While cramps may seemingly come on without warning, knowing the factors and situations that can cause muscle cramps can help you understand them, prevent them, and treat them. Here, some reasons for cramps and what you can do to avoid them:

  • Uncontrolled blood sugar levels. Glucose is required for muscles to contract and relax, so if your blood sugar levels are too high or low, it impacts the body’s ability to regulate these activities properly.1 Controlling your blood sugar levels is important in preventing muscle issues. One study found that 75% of participants with type 2 diabetes reported experiencing leg cramps, compared to 39.5% in participants without diabetes.2
  • Dehydration. If you don’t consume enough water, it can lead to an imbalance in your electrolyte levels, which can trigger muscle cramps. Remember to stay ahead of your thirst and drink water regularly to avoid dehydration.
  • Medications. Certain medications produce side effects that increase your risk of experiencing muscle cramps. Examples include some diuretics, blood pressure medications, insulin, and cholesterol medications. Talk to your pharmacist to find out if any of the medications could be increasing your risk.

  • Lack of nutrients. Low levels of potassium, calcium, and other vitamins and minerals can cause an imbalance that contributes to muscle cramping. Eating a well-balanced diet can help. Supplements are also an option, but check with your doctor before adding any to your health routine—some aren’t recommended with specific medications you might be taking for your diabetes or the associated complications.
  • Diabetic nephropathy. Kidney damage caused by diabetes, also known as diabetic nephropathy, has been associated with muscle cramps.
  • Diabetic neuropathy. Diabetic neuropathy is nerve damage caused by high blood sugar levels over time. Roughly 70% of people with diabetes experience some form of neuropathy.3 Symptoms include: numbness, tingling, or pain in the extremities.This nerve damage can contribute to muscle cramping. Talk to your doctor about ways to prevent or manage neuropathy.
  • Tight muscles. If you partake in more physical activity than usual and overwork a particular muscle group, you might experience some muscle tightness or cramping. Even if you’re not exercising more than usual, staying loose is important.

How can I stop the pain?

OnTrack Diabetes editorial board advisor Amy Hess-Fischl, MS, RD, LDN, BC-ADM, CDE has two techniques you can try:

  • Stretch before bed. “Place your hands against a wall at shoulder height. Place the leg you want to stretch behind you, toes facing forward and heel on the floor. Lean forward, with the front leg bent and the back leg straight, until you feel a stretch in the calf. Hold the stretch for 30 seconds, without bouncing, and do one to two repetitions with each leg.”
  • Massage to stop the pain. If you do experience a cramp, try to “gently stretch and massage the cramping muscle, holding your joint in a stretched position until the cramp stops,” Hess-Fischl recommends. For example, if your calf muscle is cramping, try pulling your toes toward the top of your foot.

Home remedies abound all over the internet and include everything from taking a swig of dill pickle juice, placing a bare, cramping foot on a cold floor and even, pinching the skin under your nose very tightly! None of these techniques are based in science but you can certainly try them at your own risk.

How serious are muscle cramps?

In many cases, muscle cramps are infrequent and relatively harmless, but it’s important to recognize that other complications and conditions can be confused with muscle cramps.

  • Frequent leg pain can signal worsening diabetic neuropathy. Research suggests that painful peripheral neuropathy occurs in 1 out of every 4 people living with diabetes.4
  • Leg pain can also be a sign of peripheral artery disease (PAD), characterized by a plaque buildup in the arteries, which prevents blood flow throughout the body.5
  • Severe cases of restless leg syndrome (RLS) may cause painful aches, often in the lower calves and other extremities. RLS is more common in those with diabetes than the general population.6

If you continue to experience frequent muscle cramps or pain, talk to your doctor. Either you’ll have peace of mind that it’s nothing serious, or you’ll be one step closer to figuring out what’s happening with your body and how to best address it.

Updated on: August 8, 2017 View Sources


Brown, TM. Sleep-related leg cramps: A review and suggestions for future research. Sleep Medicine Clinics, 2015;10(3):385-392.

Rabbitt L, Mulkerrin EC, and O’Keeffe ST. A review of nocturnal leg cramps in older people. Age and Ageing, 2016;45:776-782.

Wyatt LH and Ferrance RJ. The musculoskeletal effects of diabetes mellitus. J Can Chiropr Assoc, 2006;50(1):43–50.

Continue Reading The Do-Anywhere Workout

Diabetes can lead to certain complications if blood sugar levels are not kept in safe ranges. One of these potential complications is joint and muscle problems. Diabetes-related damage to the small blood vessels, connective tissue, and nerves can all cause these musculoskeletal conditions.

The good news is that they are all treatable conditions. But the longer you have diabetes that goes untreated, the more likely you are to experience them. Here’s what you need to know about joint and muscle complications with diabetes, from head to toe.

The shoulders: tendonitis and frozen shoulder

Rotator cuff tendonitis

The rotator cuff is made up of four muscles. Rotator cuff tendonitis occurs when a tendon from one of these muscles becomes inflamed. This is more common in people with diabetes.

Shoulder pain that worsens when the arm is raised is a hallmark of rotator cuff tendonitis. Early treatment includes icing, rest, physical therapy, and a non-steroidal anti-inflammatory drug (NSAID) like ibuprofen (Advil, Motrin). If the pain remains after 4 to 6 months, your healthcare provider may refer you to an orthopedic surgeon to talk about surgery options.

Frozen shoulder

Frozen shoulder is a condition that starts with pain in the shoulder but progresses to limited mobility and stiffness with little pain. It is more common in people with diabetes. Treatment for frozen shoulder includes home exercises, steroid injections, and physical therapy. Surgery is only necessary if the initial treatments don’t help.

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The arms and hands: numbness, pain, and finger cramps

Dupuytren’s contracture

A Dupuytren’s contracture is a hard round knot on the palm of your hand, usually close to your ring or pinky finger. Over time the knot can become long and chord-like, and pull your fingers into a bent position. The nodules and chords are caused by a buildup of connective tissue.

Treatment options include seeing a healthcare provider for a steroid injection and possibly surgery, if necessary.

Trigger finger (Flexor tenosynovitis)

A common symptom of trigger finger is a locking sensation when you try to bend and straighten your finger. You may also feel a hard knot due to thickening of the tissue surrounding a tendon in your finger. The ring finger, middle finger, and thumb are most often affected. Treatment starts with splinting and NSAIDs. If those options don’t help, steroid injections followed by surgery are your next steps.

Carpal tunnel syndrome

The early symptoms of carpal tunnel syndrome start in the hand as pain, numbness, and tingling. Carpal tunnel syndrome is caused by a compressed median nerve. This is the main nerve in the front of the forearm.

Carpal tunnel syndrome is more commonly diagnosed in people with diabetes as a result of damaged connective tissue. Treatment for mild symptoms starts with nighttime wrist splints or a steroid injection and occupational therapy referral for hand therapy. Carpal tunnel release surgery is your next step if symptoms are still present.

The feet: tingling, numbness, and pain

Diabetic neuropathy

Diabetic neuropathy is one of the potentially serious complications of diabetes. Neuropathy, or nerve damage, can cause a burning pain in the feet and lower limbs. Once your healthcare provider is certain the pain in your feet is from diabetic neuropathy, treatment is focused on pain control, although carefully controlling blood sugar levels is also important.

Oral medication options for managing nerve-related pain in people with diabetes include:

  • Pregabalin (Lyrica)
  • Valproic acid (Depakene)
  • Amitriptyline (Elavil)
  • Duloxetine (Cymbalta)
  • Venlafaxine (Effexor)

Topical treatments include capsaicin cream and lidocaine (Lidoderm) patches.

Note: Providers used to prescribe gabapentin (Neurontin) for diabetic neuropathy, but the American Diabetes Association has since updated their treatment guidelines and they longer recommended it.

– – –

Hope this helps.

Dr. O

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  • Are Leg Cramps Caused by Diabetes?

    Leg cramps/muscle cramps/charley horses are a frequent manifestation of diabetes mellitus (DM). The subject of debate: are these leg cramps caused by DM or not? Straight from the horse’s mouth: Yes, they can be! (1), ( 2)

    There could be many reasons of leg cramps due to diabetes. Some of the most common being

    • Dehydration and electrolyte (mineral) imbalance secondary to high blood glucose levels (hyperglycemia) prompting excessive urination (polyuria) and the subsequent passage of glucose (glycosuria) and electrolytes in urine (scroll down)
    • Peripheral neuropathy
    • Peripheral vascular disease
    • Hypoglycemia secondary to insulin and oral anti-diabetic medications

    So, how do you define leg cramps? Leg cramps are instantaneous, involuntary (automatic, not under your control), and sustained painful contractions of one or more groups of muscles. These are usually felt in the calves and can extend up to the feet. Diabetics usually describe pain being worse at night (nocturnal leg cramps).

    A) Leg Cramps Secondary to Polyuria and Consequent Electrolyte Disturbances

    Dehydration secondary to polyuria causes leg cramps via inducing electrolyte disturbances, most commonly hyponatremia (a decrease in blood sodium levels). Glucose is an osmotic substance; when the blood sugar levels rise high enough, the glucose starts excreting into the urine (glycosuria), and along with it, it carries sodium and water, predisposing to hyponatremia (5). This is hyperglycemia-induced-osmotic-diuresis (i.e. increased blood glucose causing an excessive excretion of glucose in urine along with electrolytes and water).

    Diuresis is the excessive production of urine. Osmotic diuresis is excessive urination due to the presence of osmotic substances within the kidney tubes. This osmotic diuresis draws out the fluid from the spaces between the cells (called interstitial fluid) including the muscle cells, thereby increasing the osmolarity of the extracellular fluid (the fluid outside the cells; aka ECF). As a rule of thumb, an INCREASE in the ECF osmolarity (the solute concentration of a solution), SHRINKS the cells (muscle cells here) and vice versa (as the water will move out of the cells to compensate for the increased ECF solutes (or less ECF water).

    The purpose of this detailed description is that these sequences of events will eventually culminate in muscle cramps. Let us see how! Because of the osmotic shifts, the calcium pump inside the muscle becomes malfunctioned, so that the calcium remains bound to troponin, resulting in a sustained muscle contraction (i.e. muscle cramp). FYI: In order for a normal muscle contraction to occur, the calcium ion needs to bind to a protein of the muscle, called troponin C. However, when this calcium detaches from troponin, the muscle is relaxed.

    The other proposed mechanism of electrolyte imbalance-inducing leg cramps in DM is hypomagnesemia (reduced magnesium levels in the blood). The occurrence of hypomagnesemia in DM has a multifactorial basis. Some of the common factors include:

    • Hyperglycemia-induced-osmotic-diuresis
    • Insulin deficiency: Because insulin enhances the reabsorption or re-uptake of magnesium (Mg) via the kidneys so that more Mg is available in the blood: ↓Insulin = ↓Mg (6)
    • Various other causes

    How does Hypomagnesemia Contribute to Leg Cramps in Diabetes

    Since magnesium is imperative for the normal neuromuscular transmission, a deficiency of magnesium is likely to cause leg cramps (7). Mg deficiency also results in potassium deficiency (hypokalemia), further adding an insult to an injury. This hypokalemia aggravates the leg cramps additionally.

    B) Leg Cramps Secondary to PVD

    Peripheral vascular disease (PVD) or peripheral arterial disease (PAD) is a narrowing of the arteries of the legs, which leads to severe muscular cramps in the calves, thighs, or hips while walking, mounting stairs, or exercising, popularly called as intermittent claudication. However, claudication is not similar to the resting nocturnal leg cramps.

    When leg cramps result from diabetic PVD, they are because of the lack of sufficient blood being supplied to the arteries of the legs due to the narrowing of the arteries by atheromatous (fibrous fatty) plaques containing cholesterol, LDL, fatty acids, inflammatory cells, and a protein called collagen.

    Secondly, diabetics with poorly controlled blood glucose levels tend to have elevated levels of C-reactive protein (CRP). CRP is a heralding inflammatory marker and a major culprit behind atherosclerosis (hardening of the arteries) and PVD (3). This CRP binds to the oxidized LDL in atheromatous plaques and induces further inflammatory damage to the arterial wall. To boot, CRP also stops the production of a substance called nitric oxide (a vasodilator substance that widens and relaxes the arteries). Hence, it is quite evident that the diameter of the arteries, including the leg arteries, will reduce more leading to more claudication initially and then as the disease progresses, more resting legs cramps, specifically at night (4). It is crucial to note that although PVD can give rise to the resting leg cramps; these cramps are different from those due to intermittent claudication (a hallmark of PVD).

    C) Leg Cramps secondary to Peripheral Neuropathy

    Peripheral neuropathy is damage to the peripheral nerves traveling from the spinal cord up to the peripheries (rest of the body). Because of damage to the peripheral nerve/nerves, the messages sent from the brain to the periphery go haywire and the diabetics end up getting intense, burning pain sensations in the legs and or feet in the absence of a stimulus (allodynia). Albeit, diabetic peripheral neuropathy usually causes numbness (loss of sensation), tingling (pins and needles), and muscle weakness, sharp pains or cramps are also one of the reported symptoms of diabetic neuropathy (called as painful diabetic neuropathy). It has a preference to feet and legs (affected before) than hands and arms.

    The Anatomy of Leg Cramps

    Anatomically speaking, a cramp occurs due to constant stimulation of the reflex arc. A reflex arc is a neural pathway, which regulates a reflex action. It comprises of a sensory nerve (a nerve that conveys messages from the periphery to the central nervous system), a motor nerve (a nerve that carries information from the central nervous system to the periphery), with the muscle that it supplies, and a junction called synapse in between the two nerves. Let us get this straight! Imagine what happens when a pin pricks your foot. Your foot gets an alarm through the sensory neuron that you have encountered a painful stimulus and you suddenly withdraw your foot from the painful stimulus. This is what makes up a reflex arc. The proposed mechanism for a muscle cramp is that the repetitive stimulation of a muscle that is already contracted sets off a reflex arc that is constantly conveying contraction signals back and forth from the muscle and then back to it, which ultimately culminates in a sustained, involuntary contraction of the muscle (i.e. a cramp).

    If you are a diabetic and suffering from leg cramps, do not take it with a pinch of salt. Consult your doctor to detect the possible etiology (cause) of your leg cramps and managed accordingly.


    • Are Leg Cramps Caused by Diabetes?

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