Ad: 0:00

Blog Talk Radio.

J Basser: 0:04

It's time for the Exposed Vet Radio Show. The Exposed Vet Radio Show, we discuss issues affecting today's veteran. Now here's your host, john and Ray. Welcome, ladies and gentlemen, to the Exposed Vet Radio Show. Today's the third day of July 2024. It's going to be an interesting show. Today's the third day of July 2024. We'll get an interesting show. We got Bethany Spangenberg from Valley Corvette she's on and we got Mr Ray Cobb, our trustee co-host, who, by the way, last week went to the VA's version of Harold's House of Pain and couldn't talk too much. He got a few words in, but I think he was kind of snaggletooth a little bit Today he's doing a whole lot too much.

Ray Cobb: 0:46

He got a few words in, but I think he was kind of snaggletooth a little bit. I had no teeth, they just took them all out, man.

J Basser: 0:52

Well, I told you you could have come up here. I could have done it with paraplyers and a ball-peen hammer. You've been all right.

Ray Cobb: 0:57

I'll tell you what it would not have hurt anymore. I can guarantee you that.

J Basser: 1:02

I don't know what you mean, buddy. I don't know exactly what you mean, but today Beth is going to discuss a condition that's near and dear to me and some other folks. It can be a bad side effect of diabetes. It's called diabetic or autonomic neuropathy. I know it's kind of hard to understand and digest, but I think she can explain it to us. Bethany, how are you doing?

Bethanie Spangenberg: 1:30

I'm doing well, thank you. I'm excited for tonight's topic. I know that you've been poking me about talking about it for a little bit, so I'm glad that we're able to knock it out tonight.

J Basser: 1:42

That's good. That's good. It's good. I know a lot of vets are affected by this. A lot of them don't even know what it is.

Bethanie Spangenberg: 1:53

Yeah, and I know you know we'll talk a little bit tonight about different symptoms and things that your provider should be looking for, but from even the clinical side of things, it's not a topic that's readily discussed. It's something that normally we call a diagnosis of exclusion. So basically, if you're concerned with it or if we're concerned with it, we put you through all these different tests, and if none of those other tests show that you have a condition or a different condition, then we say, oh okay, well, it must be diabetic autonomic neuropathy. And so when we look at it from the clinical side of things, it's usually the bottom on our list of concern and so a lot of times it goes without diagnosis or a misdiagnosis, and the statistics are actually pretty significant for those with diabetes.

Bethanie Spangenberg: 2:46

In the presence of diabetic autonomic neuropathy, now I will say I prefer to say the whole diabetic autonomic neuropathy, but in a lot of the medical literature they call it DAN. So if we talk about DAN today, dan is diabetic autonomic neuropathy. So hopefully there's no confusion about having somebody else I don't know you pull things up your sleeve. There might be other people on this phone call that I don't know about.

Ray Cobb: 3:24

There may be. We may have lost him.

Bethanie Spangenberg: 3:28

Exactly.

Ad: 3:29

So we're going to talk to Dan that's not here, yeah.

Ray Cobb: 3:34

Dan, that's what I'm thinking. I have a question for you that this has to do with if I understood correctly what little I read about it this week. If I understood correctly what little I read about it this week, does this have to do with the nerves control over certain muscles or certain reaction that normally the body or the brain doesn't? That does it automatically. Yeah, such as heart rate or things like that.

Bethanie Spangenberg: 4:03

So I'm just going to use that as an opportunity to just dive right in and talk about what it is and what it isn't.

Bethanie Spangenberg: 4:09

But I think, before we get too far into what it is, I really want to explain the nervous system a little bit and try to make it clear as mud for everybody. So when we look at our nervous system, we look at it as two components. We have a central nervous system, which is the brain and the spinal cord, and then everything that is not the brain and the spinal cord is the peripheral nerves. So we've got our central nervous system and then our peripheral nervous system and then if we divide the peripheral nerve system, it is divided into other components. So one of those is somatic and the other one is autonomic.

Bethanie Spangenberg: 4:55

So when we look at somatic, it's the nerves that are associated with intentional movements or voluntary movements. So our muscles, our muscle, control us moving our arms. That's the somatic nervous system. If we put our hands on something that's hot or that's cold, that is the somatic nervous system, because we are intentionally grabbing and feeling the pressure or adjusting to the temperature pressure or adjusting to the temperature. There is part of that temperature regulation that is in the automatic or the autonomic system.

Bethanie Spangenberg: 5:31

And so when we look at, when we hear the term diabetic peripheral neuropathy that we normally hear about, or we hear about it more readily, that is going to affect the somatic nervous system and we're not talking about that type of peripheral neuropathy today. So this is something different. That is not those muscles and skin that we're intentionally controlling. The autonomic nervous system is those involuntary reactions or those involuntary actions such as your heart rate, your blood pressure, breathing, digestion, and that's just to name a few, because it's pretty extensive of what the autonomic system does. But these are things that we do or that are controlled subconsciously, and so you asked about, did you ask about blood pressure? Is that what you were asking about?

Ray Cobb: 6:34

Well, there's some of the things that well, one thing that's similar to blood pressure. I was wondering about AFib. You know, when your heart goes into irregular beat, which is referred to as AFib, is that a part of it or is that a sign of it?

Bethanie Spangenberg: 6:54

It can be so. If that nerve system or those communication systems don't effectively communicate, then it can create either a high heart rate, it can cause disruption within the regular rhythm. Sometimes it has to do with electrolyte imbalance. So when we look at AFib we don't think first of diabetic autonomic neuropathy. We think of something else, some type of blood vessel disease or muscle disease of the heart. But it can cause some disruption in that heart rhythm.

Ray Cobb: 7:33

Okay.

Bethanie Spangenberg: 7:36

So autonomic nerve go ahead.

J Basser: 7:39

Dan's brother can ain't it.

Ad: 7:44

Yes yes, absolutely.

Bethanie Spangenberg: 7:46

It is abbreviated Any type of autonomic neuropathy that is affecting the cardiovascular system. They call it Can. So we have Dan and Can and Dan and a few other ones coming through. I do want to mention all the different organ systems that are controlled by the autonomic nervous system, because it's pretty extensive and we again, these are not things that we actively control. These are things that our body does on its own. So the autonomic nervous system controls our eyes, has some components of the eyes, the skin, the salivary glands, the heart, the lungs, the stomach, the pancreas, the adrenal glands, the liver, the gallbladder, the bladder and the genitals. So they have a lot of control over things that we are not actively thinking about.

Bethanie Spangenberg: 8:57

About the autonomic nerve, the diabetic autonomic neuropathy can affect both type 1 and type 2 diabetes. When type 2 diabetes is diagnosed, it's typically something that's been going on for a while, and we're just now meeting the criteria for the blood sugar level to be diagnosed as type 2 diabetes. So statistics show that at diagnosis of type 2 diabetes that 7% have some type of diabetic autonomic neuropathy, which I found that striking. Normally with type 1, because it's more of an abrupt onset of sugar dysregulation that autonomic neuropathy doesn't present itself until five years or more after the onset of diabetes. So I found that to be interesting, that 7% at time of diagnosis of type 2 diabetes has some type of diabetic autonomic neuropathy.

J Basser: 10:03

I read that too.

Ray Cobb: 10:03

It makes sense. Yeah, it is a diabetic type 2 diabetic and if you're just learning about this, what are some signs or what are some things that indicate that you need to bring up to your doctor?

Bethanie Spangenberg: 10:20

So that's the tricky part, because sometimes you don't have to have any symptoms whatsoever and they call this subclinical findings or things where you're not experiencing symptoms but we can see it somewhere in your vital signs. Or if we look at cardiac function we may be able to find it. So the most common types of neuropathy affect the heart and blood vessels, the gastrointestinal system, the bladder, the skin and even some metabolic and sleep dysfunction. Those are your primary things. That it can affect Not everybody is the same. That it can affect Not everybody is the same. There's not a group of symptoms that one diabetic can have to say, oh, that's diabetic.

Bethanie Spangenberg: 11:14

Autonomic neuropathy Again, like I said earlier, it's usually a diagnosis of exclusion and that's really because sometimes those symptoms can be vague and they can make a clinician believe that it might be something different and so they have to rule that the more common probability out first before they really get to the autonomic neuropathy diagnosis. But if we like, for example, if we look at the cardiovascular system, you can have a heart rate above 100 at rest and that's a concern that the autonomic nerves aren't doing what they're supposed to do at stabilizing that heart rate. You can have decreased exercise intolerance, meaning you go to exercise and you start to develop pain in your legs. From running or even just lifting your arm to put in a light bulb, you can develop burning in your arms because the body cannot adjust to the increased need for oxygen so those vessels don't dilate to allow increased blood flow to those muscles and so those muscles are deprived of oxygen and so it starts to trigger a burning sensation in the arm of them or the legs. You can have tension or low blood pressure if you change position.

Ray Cobb: 12:40

I think that is something, yeah, I think I've heard that one before.

Bethanie Spangenberg: 12:46

That would be so we call that orthostatic hypotension, and that is probably one of the more common diabetic autonomic neuropathy findings that occur in diabetes. And then you can get things like POTS, which is very similar too. So rather than the blood pressure changing or malfunctioning, I guess in position, the heart rate in POTS does not adjust appropriately with position change. And so to diagnose those cardiovascular autonomic neuropathies there's special testing to do, and Ray what kind of testing have you had?

Ray Cobb: 13:30

Well, good point. I'm not for sure what all testing I've had. I haven't had any recently, but back in 2011, when I had my open heart surgery, they ran all type of tests there and then, when they were checking my legs for neuropathy in my hands and arms, I had all type of electrical type where they, you know, use the little shock and see how fast you react to the and at what level the electricity causes your muscles to relax. But I think that's the only test that I can relate to that I've had, and that's why I was wondering is there some that I should be asking the doctors to look at or just kind of let it go by? When you were talking about the heart and the standing up and the blood pressure, all of mine seem to be fairly regulated as long as I take my medication, and medication might be what. Does that help regulate it or not?

Bethanie Spangenberg: 14:37

Well, John, I think that's your cue.

J Basser: 14:44

Great To answer the question on that. They regulate a lot of these arrhythmias and things like that with pretty high-powered beta blockers. I've been taking one for years. We just increased it here last year. The issue that you know it's kind of hard to find but if you start having issues like Bethany said, it's kind of a you know you have to check the boxes on it to get a diagnosis. You know you need more than one issue and I can tell you, for example, when you, if you take this medication I've been taking for years, every time you go to see a heart doctor you have to get an EKG. That's kind of I guess a clinical standard for like solo.

J Basser: 15:28

All right, bethany, yes. And so you start looking at EKG results and you start seeing crazy things like, for example since 2017, I've had probably 20 to 30 EKGs and 16 or 17 of them have this thing called poor R wave progression, which is the R-axis on your EKG as always low and it's below the threshold of 30, so it's like a minus 15 or minus 13 or minus 12. That's a giveaway. Another issue is, if you have arrhythmias, you've got HVAB, you have other arrhythmias and things like that. That could be a part of it too.

J Basser: 16:10

The big issue is blood pressure. If your blood pressure say, for example, I'm sorry, it's like hypertension, okay, on Monday, my blood pressure will be 175 over 132. On Tuesday, it'll be 160 over 99. On Wednesday, it'll be 90 over 70. There's no control there. It's either or you hardly ever see a regular blood pressure reading. Then, when you stand up and your blood pressure drops, say 30 points or more, and especially if your blood pressure is near normal or low, that's when, especially, blood pressure is near normal, low, that's when you're going to have your syncope. So you're going to open status, going to wipe you out, happens to me a whole lot.

Bethanie Spangenberg: 16:54

So, and you, you're able to talk about this because you've walked that path and you've had these tests done and they've done the the tilt table test for you, and that's where they check your blood pressures at different positions.

J Basser: 17:08

I don't know years ago. I had it a couple weeks ago when a kid sort of worked up and the cardiologist said that I could not do the tilt table test. It's too dangerous.

Bethanie Spangenberg: 17:22

So when we look at the cardiovascular side of things, if we're concerned with an autonomic involvement, we definitely look at the EKG. We do some tilt testing, the exercise intolerance. That's hard to diagnose. It's really based off of clinical symptoms and you rule out like a large nerve fiber neuropathy or a somatic nerve disease, like we talked about earlier, and so they can do an EMG in your legs, you know, and your nerves in your legs, and they'll tell you.

J Basser: 17:55

You know that your big nerves are basically okay, there's a little issue but usually they can find the small fiber, neuropathy, which is actually another giveaway, and things like that.

Bethanie Spangenberg: 18:09

So one thing that I found valuable when I was reviewing this material for tonight is they were talking about heart rate variability, and I knew that heart rate variability is a sign of cardiac health, but I never realized how it plays out in autonomic neuropathy. So I know. John, you talked about getting a smartwatch. Do you have one? Do you wear one, Ray? Do you wear a smartwatch?

J Basser: 18:35

I've been wearing one for years.

Ray Cobb: 18:37

No, I try to get him to.

J Basser: 18:39

I've tried to get him to. Ray's, I mean he's, he's one of the time X boys. Well, you know it's.

Ray Cobb: 18:50

in listening to this I've been beginning to think that, um, I am not anywhere near as severe or have as much of any of this, because my heart rate is pretty regulated, of course, with medication. My blood pressure when I take my medication is fine. I have normal readings all day long. If I come off of it for a day or two, yeah, then the readings get out of whack, but on a daily basis, as long as I take my medication, I mean, I'm going to be somewhere around the 120, over 63 or 19, over, you know, 61.

Bethanie Spangenberg: 19:41

We've covered a little bit of the cardiovascular system, but we've got one, two, three, four, at least five more systems to touch base on. So okay keep an open mind you might have to start asking your provider questions.

J Basser: 19:54

Well, she wants to be made quick and that would be good. Get a smartwatch.

Bethanie Spangenberg: 20:05

So, if you look at the data on your heart rate variability, you can have a subclinical sign in that heart rate variability that says maybe I am experiencing some diabetic autonomic neuropathy and so when you look at the heart rate variability, for a healthy adult you should sit somewhere between 40 and 45. If it gets lower, it can go lower with age, but if it gets much lower then it's going to be abnormal and then you should be asking your provider questions. Ranges can go from 19 to 75 on the heart rate variability. Your higher numbers are going to be your professional athletes, your endurance runners. They're going to have a different heart rate variability. So for a healthy adult, you're going to sit somewhere between 40 and 45. Anything lower and you've been diabetic.

Bethanie Spangenberg: 21:06

You need to start asking questions about what does it mean? And is there something else we should be looking for as it relates to autonomic neuropathy? Okay, so I thought that was interesting. I never really put the two together as how I could use my smartwatch, the heart rate variability and looking for subclinical signs of diabetic autonomic neuropathy. And if you're new to listening, I'm also a diabetic and I have been for 25 years and based on these statistics, it shows that some studies have shown, up to 50% of diabetics have some type of autonomic neuropathy after 15 years. So the chances just go up every year that you have this disease. So it's kind of a striking number, say that again.

J Basser: 22:04

Pay attention to your high heart rate. Notifications at rest.

Bethanie Spangenberg: 22:09

Yes. So other than the heart and the blood vessels, the autonomic neuropathy can affect your gastrointestinal system. It can cause troubles with motility in the esophagus. It can cause dysphagia or difficulty swallowing. It can mimic reflux disease. It can cause slowing of the bowels to where your bowels don't empty like you're constipated. It can actually cause diarrhea like you're constipated. It can actually cause diarrhea and it can cause loss of sphincter control where you have fecal incontinence and there's no other nerve damage, not had any back issues.

Bethanie Spangenberg: 22:50

So those are different things that can occur with gastrointestinal autonomic neuropathy, intestinal autonomic neuropathy. The other thing to consider is there's a big push or a lot of news out there about like Ozempic and Wagovi and a lot of diabetes medications or weight loss medications, and one thing I think it's important to understand is if you're on those medications for either weight loss or for diabetes, you need to understand that that medication is designed to slow stomach motility. So with those medications you can have nausea because your food isn't digesting as quickly. You can have what they call early satiety or you can't eat as much as you used to. You get fuller quicker.

Bethanie Spangenberg: 23:42

You can have constipation because your bowels aren't moving the same. So some people or some diabetics who experience the gastroparesis or the decreased motility of the GI system, they do have weight loss and that is the purpose of that medication. So if you're like, oh, I'm on Ozempic and I have these same symptoms, it's probably the Ozempic mimicking the slowing of the motility than it is gastroparesis.

J Basser: 24:13

So, just keep that in mind. I'm assuming you had it before you started taking Ozempic.

Ray Cobb: 24:18

Yeah, yeah, right, I mean, mine came on since I've been taking Ozipic and as far as weight loss, I have gone from 320 pounds down to, right now, about 247 last week. Whoa buddy Good deal, that's good.

J Basser: 24:42

It's a good deal, that's good, that's really good. But also, I mean in defense of all the veterans out here even if you are taking your service for your diabetes and it's causing you to have that, and still if it's causing this due to a service-needed medication, you know all better still aren't every sniff of medication is.

Bethanie Spangenberg: 25:01

You know, I'll bet they're still on it and you know of all the complications related to autonomic dysfunction. Gastroparesis is in the rating schedule, so the only. There's no DBQ for autonomic neuropathy. There's no diagnostic code in the rating schedule for autonomic neuropathy. You have to break it down to what system it affects. And gastroparesis is in the rating schedule. And they even put that orthostatic hypotension in. I've seen it under peripheral vestibular disorders, which is an ear condition. Yeah, right.

Bethanie Spangenberg: 25:44

When it's really an autonomic thing. So it's interesting how they have to kind of work with their rating schedule to fit the symptoms.

J Basser: 25:56

You look at the vascular system too, it's, you know, it's basically the same. I mean, you know, because it causes vascular issues too, as well as feet issues. So you know, I mean it's a big for it, that stuff, there's a lot of stuff involved with it. So, but the VA doesn't have that. The right-hand side is not, what do you call it? It doesn't cover enough. You know, it doesn't diseases. So they just had a loop and it's similar to it.

Bethanie Spangenberg: 26:19

Right, yeah, and before we leave too far from that medication, the ozempic Wagovi there's several of them out there the long-term effects we really don't know. So some people who have stopped the medication have continued to experience some of that gastric motility slowing and there is some concern. You know what it does for long-term effects because we haven't seen you know, we don't have the 10-year study on these medications yet so just keep that in mind as you take that medication or if you stop that medication. Just keep that in mind as well. If we move on to the genitourinary section, some of the autonomic dysfunction can be erectile dysfunction, female sexual dysfunction. You can have urinary incontinence or urinary frequency and then you lose the distress signals. So when your bladder gets distended and tells you, oh hey, there's pressure here and you need to go to the bathroom, the autonomic neuropathy can block that signal to where the nerves aren't functioning correctly and you don't know that your bladder is full, and it can result in the urinary incontinence.

Bethanie Spangenberg: 27:52

Some of the skin changes that can occur you can have dry skin, you can have swelling and this is outside of what we talked about about the peripheral vascular diseases. This is different. You can have swelling in the skin itself. You can also have heat intolerance and sometimes in the patients that I've had, this is one of the first symptoms that they have and it really comes down to hey, I was outside on a hot day and I just couldn't tolerate the heat and I got really nauseous and I got sick. And here their body is not sweating, so they don't have the temperature regulation because their body is not sweating to lower the skin temperature. And there's actually a test we call it a sweat test to see how much you sweat and they can look at the conduction of the sweat to see what is occurring in your sweat glands.

Ray Cobb: 28:54

Okay question on that line. You're talking something I have noticed recently. For example, outside today I was not sweaty, although as soon as the sun hits I do have a lot of dry skin, and Pam made the comment this morning she needs to start putting more lotion on. Putting more lotion on and with the dry skin. I was outside today when the sun hit my skin. It felt like a thousand little needles hitting me. Is that an?

Bethanie Spangenberg: 29:34

indication that I need to have it looked at, or a question. I would be more concerned with the dry skin rather than the sensation that you're getting. I've not other than getting sunburned, which you're going to be susceptible to. I'm not sure. To me that doesn't correlate with some type of skin nerve disease.

Ray Cobb: 29:58

Okay, nerve disease.

Bethanie Spangenberg: 30:01

A couple other things that we can see or appreciate in patients with diabetic autonomic neuropathy is that they lose their pupillary reflex with light.

Bethanie Spangenberg: 30:15

And some patients will say you know, I really struggle at nighttime with driving because it hurts my eyes when I see the bright lights. So what happens is you're at night and your pupils are big and then when you get light from other cars, your pupils are supposed to constrict to control that light function, to control that light function, and with autonomic neuropathy your pupils can lose the ability to constrict and relax to adjust to light accommodation. And so some people with diabetes experience that and then they go see the eye doctor and they also because glaucoma and cataracts can mimic similar symptoms and they're at higher risk because they're diabetic. So if you have any type of eye symptoms related to driving, whether it's painful or a glare, you should talk to your symptoms or your concerns with your eye doctor and they can do some testing for complications of diabetes, as it relates to the eye, I've heard to tell you that you know they've actually told me to quit driving.

Ray Cobb: 31:27

I mean, you know I actually one person said it was laser, too much laser in one eye. The other said it was an eye stroke and the other said it was just abnormal blood cells around my retina that ruptured, but sufficiently legally. In my left eye I'm blind. I'm actually 20 over 2,000 in the left eye and the right eye is still 20, 25. But you're hit head on when you said driving at night, which I don't do. But even if I'm riding and the car lights are coming at me, it actually hurts my eyes. You know pain, so I can relate to that. And another thing I brought up another topic what if I'm outside and then come into a darker room and it takes a while for me for my eyes to adjust so I can even see in what I'm going to call normal light in a room? Would that be also an indication?

Bethanie Spangenberg: 32:39

That can be a sign or a symptom of pupillary dysfunction. That's a good example. If we look at a different metabolic autonomic neuropathy and some of you out there listening it's probably one of the most common up there with orthostatic hypotension, but it's hypoglycemia, unawareness. So if you've ever experienced a low blood sugar, you get shaky, you get sweaty, your heart rate increases, kind of get confused or your thoughts are slow. And if you have autonomic neuropathy, you start to not feel those symptoms. You don't have the heart rate increase, you're not getting sweaty, you're not experiencing that autonomic, normal, autonomic response to a low blood sugar, and so that is a common symptom, I guess, symptom of autonomic neuropathy. They even make dogs out there that are able to tell from the sweat on your skin whether your blood sugar is low. You put off a scent, you put off a certain like sweat or I don't know the term to use, but the dogs are able to sense that you have low blood sugar but that's how common it is.

Bethanie Spangenberg: 34:24

Yes, thank you so they have dogs out there that are trained to sense a low blood sugar, and those with long-standing diabetes may experience the hypoglycemia unawareness or low blood sugar unawareness, and they can actually qualify to get one of these dogs as a companion dog because it's life-saving for them.

J Basser: 34:50

That should be a situation like this. It should be a prereq for the VA for aid and attendance.

Ray Cobb: 35:01

I would think it would be yeah.

J Basser: 35:04

Yeah well, you must not be in my world buddy.

Ray Cobb: 35:09

Yeah, Understand that one yeah.

J Basser: 35:14

You know what I mean. I've had a cat save my life before.

Bethanie Spangenberg: 35:22

Related to diabetes or something different?

J Basser: 35:30

Yes, I had a little over a few years ago. I dropped pretty high and didn't catch it and my test of my sugar. I was down in the 30s, heading toward the 20s and the cat saw me and got up there and next thing you know, she's licking me all over the head and face and woke me up.

Bethanie Spangenberg: 35:42

Oh my gosh.

J Basser: 35:47

She sure did. It's bad stuff, people, really bad stuff.

Bethanie Spangenberg: 36:00

So the last couple things that I want to mention, as it relates to things like systems. They have. This in the other category is diabetic. Autonomic neuropathy can contribute to sleep apnea because of the decreased respiratory signal or the restriction in the breathing. You're supposed to adjust your breathing throughout the night, related to your sleep cycles, related to your heart rate. They're trying to regulate your acid levels in your blood system and your body does that through breathing, so you can see some increased carbon dioxide retention. On lab levels or even during a sleep study, you can see some changes.

Bethanie Spangenberg: 36:54

Sometimes the brain doesn't tell your body to breathe also, and that can contribute, and it's specifically diabetes. So diabetes over time can affect the brain to where it doesn't tell the brain to breathe, and those are, you know, complications of long-standing diabetes. The last one is anxiety and depression, and it can contribute to those. Because you don't have the, your emotional response is suppressed. So when we get excited, our heart rate normally increases and we're sad, our heart does different things. Well, if you're running at a hundred heart rate all day, you're going to feel more anxious. So it can contribute to those conditions indirectly. Specific testing as it relates to each body system.

Bethanie Spangenberg: 38:00

Now, there's not a lot that we can do. When it comes to the hypoglycemia unawareness, Again that's a symptom. We can't do a test to say you know, this test result shows that you have autonomic neuropathy, For those types of things.

Bethanie Spangenberg: 38:19

it's purely based off of your symptoms and the history that you're telling your provider. When it comes to the gastrointestinal motility slowing, there is imaging that they can do. They can do a gastric emptying or a barium swallow. When they do the barium swallow, you drink it and then they take images of you at certain time intervals and they can show how fast the material is moving through your system. When it comes to some of those urinary symptoms, the urinary incontinence they can scan your bladder to look and see how much urine is being retained, if you're completely emptying your bladder or not, and then they can also do some CT imaging to kind of look and see how quickly dye is moving through your body.

Bethanie Spangenberg: 39:16

There's no one test that. If you're concerned with having diabetic autonomic neuropathy, there's no one test that allows a clinician to put their finger on it. It's typically something that you present the symptoms to your provider. Your provider has to be aware of what symptoms and kind of group them together or kind of separate them out. They have to be able to have the clinical skills to make autonomic neuropathy in their differential diagnosis or concern for it, and then they put you through all kinds of testing. So it's a diagnosis of exclusion. Usually it takes a while to capture the diagnosis. It's not something that's typically done on a first or second visit. Maybe it's three or four visits with special testing and even a specialist or cardiologist to get involved. So if someone is listening and they're concerned with it, just know that it is a process and it's not a quick answer for you.

Ray Cobb: 40:25

Is there any treatment for it?

Bethanie Spangenberg: 40:28

That's a great question. So there is no medication. There isn't anything specific to treat diabetic autonomic neuropathy. What happens is the treatment from the clinical side is optimizing your blood sugars and treating or trying to prevent complications, so to get your blood pressure under control, so that you don't develop a stroke from your elevated blood pressures. When you decide to go. You know your blood pressures decide to be what did you say, john? 170 over 132 or something?

J Basser: 41:15

like that.

Bethanie Spangenberg: 41:20

So we try to give you medications so that you don't have a stroke. We give you aspirin to try to prevent any type of stroke or cardiac ischemia that may arise. We try to give medications to protect your kidneys because those high and low blood pressures really put your kidneys to work and that can cause some damage. Try to get your cholesterol under control. If you get your cholesterol lowered and in control, you're less likely to have a stroke, less likely to have a blood clot. You're less likely to have a heart attack.

Bethanie Spangenberg: 41:56

Heart attack stroke and blood clots, heart attack, heart attack, stroke and blood clots, and so there is some literature out there that says that exercise can help to improve autonomic neuropathy.

Bethanie Spangenberg: 42:10

The exercise forces your body to trigger some autonomic function. So if you think about what happens when you exercise, your heart rate goes up, your blood pressure has to adjust, which also involves your kidneys talking to your heart, the blood flow increases to those autonomic nerves in the body and it also helps to force or trigger the production of your sweat glands. And so that exercise has been shown to, or some studies have shown that it helps to reduce the severity, not necessarily treat it, not necessarily make it go away, but it does improve some of the symptoms. So does that answer your question?

J Basser: 43:05

Yeah, it's great. Let's get up and hobble around the block you want to.

Bethanie Spangenberg: 43:14

So I will say that I have struggled with the exercise intolerance for about the last 10 years. When I had my daughter about 10 years ago, I almost died with her and that triggered a lot of stress on my body, and shortly after that I noticed that even walking up the stairs and running around the track was difficult for me.

Bethanie Spangenberg: 43:47

I was an athlete prior to having my daughter. I ran track, I went to state and track, I went to a Division II school for cheerleading. I went to a Division II school for cheerleading and we stunted and tumbled and all this crazy stuff. But after I had her, I was not capable of tolerating any exercise and I really struggled to get that back. And so, for me personally, I started to take supplements to try to help. I started. I had some panic attacks with that as well, because you don't have again your heart rate's going 100 miles an hour and you just you can't relax.

J Basser: 44:32

And so it's been.

Bethanie Spangenberg: 44:33

It's taken me a while, but I've got back to you know, to where I can run more comfortably. I can't run consistently for long periods of time because I start to get that pain and burning in my legs. I've had my blood vessels tested so I know it's not a matter of peripheral arterial disease, but my body's not responding to the exercise. I'm not getting the dilation within the muscle structure to feed the oxygen in my muscles. But for me personally, in trying to recover.

Bethanie Spangenberg: 45:10

It has taken me a long time and it's a matter of running for 30 seconds and walking and then running. You know it's taken a while to recover from that, but it has improved for me. So I know that, john and Ray, I know it's not on your agenda to start running, but that movement, even walking, starting somewhere, can kind of help to build that tolerance.

J Basser: 45:38

Ray and I are both athletes At a much younger age. Of course, football players Played baseball, even shot up for the Reds. Even tied up for the red cord. That's been a few years ago, but this issue is kind of dangerous, you know. I mean you know, you don't know, you've got it, you know, and it goes to the heart and the cardiac involvement.

Bethanie Spangenberg: 46:26

I mean, I see reports all the time. I guess sudden death and things like that can occur too, you know yeah, I didn't want to go that morbid, but it can happen. That's the silent cardiac distress signal, that malfunction. So I talked a little bit about the distress signal of the bladder, but that's the same with the abdomen. If you get abdominal distension whether, let's say, you have an appendix rupture and your abdomen distends, you don't necessarily feel that pain from the abdominal distension. Same with the heart. You don't necessarily feel the distress signal that the body is putting out. Hey, with the heart, you don't necessarily feel the distress signal that the body is putting out. Hey, you know, the heart's not getting enough oxygen and so the distress signal is an autonomic signal. And so some people who have diabetic autonomic neuropathy find themselves having a heart attack and never having any symptoms find themselves having a heart attack and never having any symptoms.

J Basser: 47:22

That's one. Another symptom is the silent heart attack, because you don't feel the heart attack. That's another symptom of it. I'll tell you how they found mine. They found mine on my legs and they started looking and started putting stuff together and started talking about heart rate and done tests for heart rate, things like that. Over time. This Apple Watch I didn't know too much about the health app. You know, when I first got to watch I started out with a 6 and we changed over and of course my brainiac son helped me finally get it set up here about a year and a half ago and you watch the symptoms and and it's pretty sharp, but you start looking at 350 to 360 heart rate notifications at rest in a year's time or something along. That was kind of the one that kind. That was the kind of the one that kind of let the cat out of the bag.

Bethanie Spangenberg: 48:23

So so I've actually seen those smart watches. I had a relative that was going in and out of AFib and that watch is what saved his life, because it signaled an abnormal rhythm and he was kind of panicking because it went off a few times like in the same day and so he was able to call his family doctor. Family doctor got him in, ended up seeing a cardiologist and here he had 35% heart function. He was in heart failure and he ended up having to have a valve replacement. His valve replacement or his valve malfunction was causing heart failure which led to the arrhythmia, and it's all because of that watch. He had no symptoms. So that watch was a lifesaver.

J Basser: 49:13

It is. I wish they would work it out with the company that did the uh oh, two, seven meters and bring that back to the watch. I'd be like you know, that's the thing, you know what I'm doing. So he's got the apps. Not that it's kind of hard to you know, it's pretty good, functional to keep it charged up, right, you need to get you one of these. I'm serious, we didn't we.

Bethanie Spangenberg: 49:46

I don't know if you guys can hear this rain.

Ray Cobb: 49:49

Yeah, how loud this rain is.

Bethanie Spangenberg: 49:50

I'm trying to it's raining and you know what I praise the Lord. I've needed rain for my garden for two weeks, and this is the first rain, and so I'm excited. But what timing, oh my goodness. No-transcript.

J Basser: 50:35

Talk to my outside VA doctor a lot about it, because he's the first one to catch it, you know, and the VA finally catches on, you know it's kind of like a day late and dollar short situation.

Bethanie Spangenberg: 50:44

We haven't seen that before, though, have we?

J Basser: 50:47

Too much. But I don't know. We've got to figure this thing out. I mean, it's you know, I file claims for the statics and they keep denying it. Last time they sent me down, they sent it to California for a terror thing due terrifying exposure to asbestos and radiation. I'm still scratching my head on that one. So we'll see. I'm just going to get something put together so we can show them what it's all about.

Bethanie Spangenberg: 51:15

But you know, so far nobody's listening. John, how long have you been diabetic?

J Basser: 51:23

I was diagnosed with diabetes, started insulin in 2006. I was pre-diabetic for several years before then. I was on metformin and then started the shot in 2006, so it's been almost 18 years ago. So even what we just talked about, tonight.

Bethanie Spangenberg: 51:41

So it's been almost what 18 years ago, 20 years. So, even what we just talked about tonight. The statistics are against you. You know you should be sitting at 50-plus percentage at risk of having, you know, a peripheral or an autonomic neuropathy, and so I'm surprised that you've struggled this far, you know to get that that orthostatic hypertension service connected.

J Basser: 52:05

Well, they're just, uh, I think they made a mind they're not going to do it. You know I did the same thing with Bill Sheeker. What he did is put me in hypertension years ago. He's like you know, we know you got it and we know what it's from, because he's already serviced for, uh, I guess it's COPD, and I said you can't do that. You know, I said we're not going to do that. Well, he, finally, they finally did it. You know, after the right. You know he spent a lot of money to, you know, the attorney and stuff, but you know it didn't do much good?

J Basser: 52:31

no, it didn't.

Bethanie Spangenberg: 52:40

Well, what's interesting about it too is if they're rating the orthostatic hypotension under the vestibular conditions, it's a 10% rating. So they're fighting you over a 10% rating for orthostatic hypotension.

J Basser: 52:46

Keep switching up and they don't want to rate it, period, you know. So it's kind of crazy, but I don't know, I'm probably going to have to, at least one day, get an IMO Somebody knows what they're talking about because these folks don't know nothing much about it at all. I mean, I can understand that, you know, because it's not you know you don't hear people talk about this every day and you know, and so.

J Basser: 53:09

But you look through the past history and the rest of the stuff, you know we've talked about it before, bethany, I think. Maybe you know I need to get something done with this because I'm just getting fed up. But with that and the diabetic lows and the falls, I mean I'm serious. I mean I broke my S5 vertebrae. You know, with the S5, s4, I broke one of them. I fell in the concrete and hit pretty hard and I had to go through a bunch of tests and x-rays and I hurt my arms, I hurt my shoulder twice, and so you know, you stand up and for about two minutes you walk up somewhere and the next thing, you know, you get real dizzy.

J Basser: 53:52

And the next thing you know you're on the ground and you know you wake up pretty much shortly afterward, but still you know you're on the ground.

Bethanie Spangenberg: 54:04

Well, if you got this, guys sell your slab house and buy something with a padded floor Bubble wrap works too.

J Basser: 54:11

I think I know it does. But you know, and they're like well, this and then how to plan some clothes.

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They're like well, why?

J Basser: 54:15

don't you call 911 and go to the hospital? I?

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don't have to I said.

J Basser: 54:20

there's a new study I went on today in a class that there's a major percentage of vets and people by itself are avoiding going to the hospital now. And guess why? They're not going to the hospital With hypoglycemia Because of the dexcoms, because the dexroms catch it.

Bethanie Spangenberg: 54:42

Absolutely you know, I was actually earlier today I was talking about the rating schedule for diabetes. You know, part of the rating schedule talks about weekly visits to a diabetic care provider and it's like I don't ever have to go weekly anymore because my insulin pump data goes straight to my endocrinologist. My blood sugar data goes straight to my endocrinologist and if there is a flag on my chart because something's abnormal, she calls me.

J Basser: 55:14

There you go, there you go. Look, I'd like to see an endocrinologist. I haven't seen one yet.

Bethanie Spangenberg: 55:24

They actually they are hard to get to. I will tell you that our local VA, their pump therapy is done by a clinical pharmacologist and not necessarily an endocrinologist, and not necessarily an endocrinologist.

J Basser: 55:42

For PharmD? Yes, For PharmD, right? Okay, they're smart. You know I've been, that's who I go visit. I mean, I do biowiches visits because of hypoglycemia and I've been doing this for a long time. We started back in November doing it because, you know, I mean I always been dropping but since I decided to keep an eye on it.

J Basser: 56:01

no matter what I do, it still drops. So it dropped this morning. It was in the 50s, but it's. You know what I mean. I hope we lost right, or not, did we? I'm going to double check the screen here, but do you think they have any treatment for stuff? Have you done any independent medical opinions on this stuff, Becky?

Bethanie Spangenberg: 56:39

We have. Normally it's the gastroparesis or the orthostatic hypotension that we get asked to do opinions on. I will say that some of the urinary incontinence is more readily recognized. The pupillary dysfunction, that's not my wheelhouse. I'll never see that. That's going to be, you know, ophthalmology or an eye specialist, the hypoglycemia unawareness if you know a patient has that, I'm sending them to an endocrinologist. You know there's not much on the clinical side that I can do other than getting them a continuous glucose monitor and some glucagon. Any orthostatic hypotension concerns or tachycardia concerns always go to cardiology and we haven't done a lot of opinions on the cardiac stuff.

J Basser: 58:03

All right, I see Ray's back in there. I can barely hear you guys.

Ray Cobb: 58:09

I don't know what's going on with my phone?

J Basser: 58:12

Probably the weather. Betsy, could you give us your contact information before we shut it down and Valor for Vet and plug in for them.

Bethanie Spangenberg: 58:21

Valorfor Vet. You can plug in for them ValorforVetcom. Valor V-A-L-O-R, the number 4 Vet V-E-Tcom. There's a lot of helpful information that you can research and look at and then, if you have any questions, you give us a call. 888-448-1011, 888-448, 448- 888-448-1011.

J Basser: 58:43

Well, listen, guys, that's all the time we have for tonight. Bethany, thank you for coming on, we'll do this again. Stay tuned. Next week, guys. We've got a major show coming up. We've got Alex Graham and Peter D'Ancelli out of California. We'll discuss the latest lawsuit, or the Supreme Court ruling that turned over the Chevron deal that Reagan put in, and that's going to be a big deal. Have you heard about that one, bethany?

Bethanie Spangenberg: 59:14

I have, but I'm not sure how exactly that impacts VA stuff, so I'll be definitely listening next week. Okay, well, that will be shutting down.

J Basser: 59:20

So I'll be definitely listening next week. Okay, well, that will be shutting down. We'll see you guys next week, and this is John, on behalf of Bethany Spangenberg and Mr Ray Cobb. We will be signing off. For now, you have been listening to the Exposed that Podcast. Any opinions expressed on the show are the opinions of the guest speakers and not necessarily the opinions of Exposed that, exposed Thatcom or Blog Talk Radio. Tune in next week for another episode of the Exposed that podcast. Thanks for listening.

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