A 42-year-old man with uncontrolled type 2 diabetes came to us complaining of persistent fatigue, tingling hands and feet, and suffering from walking. This meant that his blood sugar had begun to hurt his nerves. As expected, his HBA1C count (average blood glucose level over the course of three months) was 9.2% (inadequate diabetes). But what surprised me was his vitamin count: Vitamin B12: 123 pg/ml (severe deficiency), Vitamin D3: 8 ng/ml (deficient), Magnesium: 1.5 mg/dl (low).
So, what was he wrong? The man had been taking metformin for years without B12 supplementation. His diet was free of dairy and fruits due to misconceptions about managing blood sugar levels. After starting vitamin B12 injections and vitamin D supplementation, symptoms of neuropathy improved significantly over four months, along with improved diet and diabetes control.
This case highlights the importance of looking beyond blood glucose levels, as vitamin deficiencies can mimic or exacerbate complications of diabetes. Beyond the direct effects on glucose metabolism, diabetes can interfere with nutrient absorption and lead to several micronutrient deficiencies. Over time, these defects can exacerbate diabetic complications such as neuropathy, poor wound healing, and cardiovascular problems.
Why do people with diabetes develop vitamin deficiencies?
This is due to an increase in urinary loss. High blood sugar levels cause a condition called the osmotic membrane, which allows the kidneys to excrete more water, and in addition to water-soluble vitamins such as vitamin B1 (thiamine), vitamin B12, and vitamin C.
Diabetes can slow gastroparesis or stomach leakage, which affects the digestion and absorption of nutrients. Long-term use of metformin, a common diabetes drug, is also known to interfere with the absorption of vitamin B12 in the intestine. Chronic low-grade inflammation in diabetic patients increases the body's need for antioxidants such as vitamin C, vitamin E and selenium. However, these nutrients often deplete faster than they can be replenished.
Type 2 diabetes is generally associated with obesity and fatty liver, both of which impair fat metabolism. This affects the absorption of fat-soluble vitamins such as A, D, E, and K.
Dietary restrictions or poor diet
Diabetics often limit food choices and sometimes avoid fruits and certain carbohydrates due to the fear of sugar spikes. This can lead to unintentionally inadequate essential vitamins and minerals.
Most common defects
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Vitamin D deficiency is common as it is associated with insulin resistance and immune dysfunction. Vitamin B12 deficiency, especially those using metformin, is common and can cause fatigue, memory loss, and worsening neurological disorders. Thiamine (vitamin B1) deficiency can lead to worsening diabetic neuropathy and heart problems. Magnesium is an important cofactor of insulin signaling. However, this is often lost through urine in diabetic patients.
What can patients and caregivers do?
Don't miss out on our daily screenings, especially for B12 and vitamin D in long-term diabetics or metformin patients. Include nutrient-rich foods such as green leafy vegetables, low-sugar fruits, dairy products, nuts and seeds.
Under the supervision of a healthcare provider, proper supplementation can prevent long-term complications. Also, regular evaluation of the side effects of diabetic medications is essential. Diabetes management is not just about sugar, but about complete nutritional care.
(Dr. Chaturvedi is a senior endocrinologist at Apollo Hospital, New Delhi)
©The Indian Express Pvt Ltd
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