The nerves controlling heart rate, blood pressure, digestion, sweating and bladder function are damaged by diabetes too. Patients rarely connect the symptoms to their feet, and clinicians rarely ask.
Why it goes unrecognised
Nothing about it looks like neuropathy. A patient reports dizziness on standing to one doctor, early fullness after meals to another, and unexplained sweating to a third, and each is investigated separately. The unifying explanation is rarely reached because nobody asks all three questions in the same room.
What it actually produces
Cardiovascular
Dizziness or graying-out on standing, from blood pressure that fails to compensate. A resting heart rate that stays high and does not vary. Reduced exercise tolerance. Most importantly, reduced or absent chest pain during a cardiac event — silent ischemia is a recognized danger in diabetic autonomic neuropathy, and it is the reason unexplained breathlessness or fatigue in this group is taken seriously.
Digestive
Gastroparesis — delayed stomach emptying — causing early fullness, bloating, nausea and unpredictable glucose. That last part is a genuine trap: food absorbed unpredictably makes insulin timing nearly impossible, and the resulting swings are often blamed on adherence. Diarrhea, particularly at night, and constipation both occur.
Sweating and skin
Reduced sweating in the feet, which dries and cracks skin and raises ulcer risk. Compensatory heavy sweating elsewhere, often the upper body, and sometimes sweating triggered by eating.
Bladder and sexual function
Incomplete emptying, reduced awareness of a full bladder and recurrent urinary infections. Erectile dysfunction is frequently the earliest autonomic sign in men and is often the one nobody mentions.
Why the glucose connection runs both ways
Autonomic damage also blunts hypoglycemia awareness — the tremor, sweating and palpitations that normally warn of a low. Losing those warnings is dangerous, and it changes how aggressively glucose should be targeted. If you have stopped feeling your lows, that is important information for whoever manages your diabetes.
What can be done
- Glucose stabilization, which slows progression and is the only thing that addresses the cause.
- Orthostatic symptoms — rising slowly, adequate salt and fluid where appropriate, compression stockings, and reviewing medications that lower blood pressure.
- Gastroparesis — smaller lower-fat meals, and coordination with whoever manages your diabetes, because insulin timing has to change.
- Foot skin — active moisturizing where sweating is reduced, because dry cracked skin is an entry point.
- Medication review, since a great many drugs worsen orthostatic symptoms and several worsen gastric emptying.
We treat the pain side of diabetic neuropathy and coordinate on the autonomic side rather than managing it alone — cardiology and gastroenterology have the relevant tools. What we can do is recognize it, name it, and make sure it is not being investigated as four unrelated problems. See diabetic neuropathy.
To be assessed, call (314) 310-5577 or text (314) 886-5902. We are at 12174 Natural Bridge Rd, Suite 110, St. Louis, MO 63044.
Common questions
Is autonomic neuropathy reversible?
Progression can be slowed with glucose stabilization. Established damage generally does not reverse, which is why recognizing it early matters.
There is more on this in The Stages of Diabetic Neuropathy.
Why does my blood sugar swing so much?
If your stomach is emptying unpredictably, food and insulin no longer line up. That is gastroparesis and it is worth identifying rather than assuming poor adherence.
Diabetic Neuropathy goes through it in detail.
I have stopped feeling my hypos. Is that related?
Very likely. Loss of hypoglycemia awareness is an autonomic effect and it is important — tell whoever manages your diabetes.
There is more on this in The Stages of Diabetic Neuropathy.
Could my dizziness be from this?
Possibly, and it is worth measuring lying and standing blood pressure. Medication is also a common contributor and both can be true.
This is set out in Diabetic Neuropathy.
Sources
- Eleftheriadou A et al. Cardiovascular autonomic neuropathy in diabetes: an update with a focus on management. Diabetologia, 2024. PubMed 39120767
- Agashe S et al. Cardiac Autonomic Neuropathy in Diabetes Mellitus. Methodist DeBakey cardiovascular journal, 2018. PubMed 30788010
- Dineen J et al. Autonomic Neuropathy. Seminars in neurology, 2015. PubMed 26502768
- Zilliox LA et al. Is there cardiac autonomic neuropathy in prediabetes?. Autonomic neuroscience : basic & clinical, 2020. PubMed 33011523
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