Neuropathy and Nerve Pain: Integrative Care for Tingling, Numbness and Burning Feet

Taking metformin for diabetes? Your tingling feet may partly be a vitamin B12 problem

Metformin, a common diabetes medicine, can lower vitamin B12 over time, and low vitamin B12 can itself cause pins and needles, numbness and burning in the feet, according to the UK medicines regulator (MHRA) [13]. In the long-term Diabetes Prevention Program study, each year on metformin raised the odds of B12 deficiency by about 13% [12], and in a one-year trial in people with diabetic neuropathy on metformin, bringing low-normal B12 back up improved nerve tests, pain and quality of life [14]. Diabetes also drains thiamine (vitamin B1): plasma thiamine was about 75% lower in people with diabetes, because the kidneys lose more of it [15].

• What this means for you: part of your nerve symptoms may come from a deficiency that a blood test can find and that can be corrected, while you keep taking your metformin [13].
• What we check: vitamin B12 (with its markers when needed), thiamine and vitamin D on blood tests, and magnesium from the overall clinical picture, read together with your sugar and lipid reports, then corrected as an add-on to your existing treatment.

What is peripheral neuropathy?

According to the NHS, peripheral neuropathy develops when the nerves in the body’s extremities, such as the hands, feet and arms, are damaged; the most common type, polyneuropathy, affects the longest nerves first, so symptoms usually begin in the feet [4]. About 1 in 100 people in the general population has polyneuropathy, rising to up to 7 in 100 older people [1].

• Sensory neuropathy: affects the nerves that carry feeling (touch, temperature, pain) [5].
• Motor neuropathy: affects the nerves that move muscles [5].
• Autonomic neuropathy: affects the nerves that control automatic functions such as blood pressure, digestion, sweating and the bladder [5].

Many people have more than one type at the same time; a mix of sensory and motor neuropathy is particularly common [5].

What are the symptoms of neuropathy?

According to the NHS, the main symptoms of sensory neuropathy are pins and needles, numbness, a burning or sharp pain usually in the feet, pain from a very light touch, and loss of balance [5].

• Feet first: symptoms often start in the toes and spread upwards, later in the fingers and hands, in a “glove and stocking” pattern [4].
• Worse at night: many people notice burning or tingling most in bed, when there is less to distract you.
• Muscles: cramps, twitching, weakness, or difficulty lifting the front of the foot when walking [5].
• Automatic functions: dizziness on standing, sweating changes, bladder or bowel problems, or digestion problems can mean the autonomic nerves are involved [5].
• Numb feet are at risk: if you cannot feel a cut or blister, it can turn into an ulcer [8].

What causes neuropathy?

Diabetes is the most common cause of peripheral neuropathy in the UK, says the NHS, and other causes include low vitamin B12, an underactive thyroid, long-term heavy drinking, kidney or liver disease, some medicines and immune conditions such as rheumatoid arthritis, lupus and Sjögren’s syndrome; in some people no cause is found [6].

• Diabetes and prediabetes: at least half of all people with diabetes develop neuropathy over time [2].
• High cholesterol and triglycerides: high triglycerides went with faster nerve fibre loss in people with diabetic neuropathy [10].
• Low nutrient levels: vitamin B12 deficiency is a recognised cause [6]; thiamine (vitamin B1) levels are often low in people with diabetes [15][32].
• Medicines: long-term metformin can lower vitamin B12 [12][13]; some chemotherapy, long courses of certain antibiotics and some other medicines can damage nerves [6].
• Autoimmune conditions: such as Rheumatoid Arthritis, Lupus and Sjögren’s Syndrome [6].
• No cause found: in 20 to 30% of people with polyneuropathy, no cause is identified [1].

Diabetes, cholesterol and nerve damage: how are they connected?

According to a review in Nature Reviews Disease Primers, neuropathy is the most common complication of diabetes and prediabetes, and blood sugar control alone has a more modest effect on it in type 2 diabetes than in type 1 [2].

• Blood sugar: in a Cochrane review, tighter glucose control clearly prevented neuropathy in type 1 diabetes, with a smaller effect in type 2 [9].
• Blood fats: in a study of people with mild to moderate diabetic neuropathy, high triglycerides went with faster nerve fibre loss over one year, independent of age, diabetes duration or sugar control [10].
• Inflammation and oxidative stress: research links diabetic nerve damage to oxidative stress, damage to the tiny blood vessels that feed the nerves, and low-grade inflammation [11].
• The disease and its medicines both drain nutrients: people with diabetes lose more thiamine in the urine [15], type 2 diabetes is linked to low magnesium [33], and long-term metformin and acid-reducing medicines can lower vitamin B12 [12][31]. These medicines protect your heart, kidneys and blood sugar and are not stopped; the lost nutrients are replaced instead.

Neuropathy or sciatica (a pinched nerve)? How to tell the difference

Neuropathy usually affects both feet in the same way and starts in the toes, while a pinched nerve in the neck or back (radiculopathy) usually causes pain that travels down one arm or one leg along the path of that nerve.

• Neuropathy: both feet, tingling or burning, numb toes, worse at night, slow to spread upwards [4][5].
• Sciatica or a pinched nerve: pain from the lower back or buttock down one leg, sometimes with numbness in one area. See Sciatica, Slipped Disc and Lower Back Pain.
• Arm and hand: tingling in the fingers can also come from the neck. See Neck Pain & Cervical Spondylosis.
• Heel pain on the first steps in the morning is more often plantar fasciitis; widespread pain with tiredness may be Fibromyalgia. A proper assessment tells them apart.

Which doctor treats neuropathy, and which tests are needed?

A family doctor or diabetologist usually diagnoses neuropathy first, and a neurologist may do further tests such as a nerve conduction test [36]. According to the American Academy of Neurology, the blood tests most likely to find a cause of polyneuropathy are blood glucose, vitamin B12 (ideally with its markers methylmalonic acid or homocysteine) and a blood protein test called immunofixation electrophoresis [28].

• Who: at Cure4Pain, Dr Krushal Pabari and AT. Chintan Dalal assess your symptoms, feet and blood work and plan your care in coordination with them.
• Check-ups: the American Diabetes Association advises checking for neuropathy at diagnosis of type 2 diabetes, 5 years after diagnosis of type 1, and at least once a year after that [3].
• What we usually test: fasting sugar and HbA1c, lipid profile (cholesterol and triglycerides), vitamin B12, vitamin D, thyroid and kidney function, and others depending on your history. Magnesium is assessed from your symptoms, diet, medicines and history rather than a blood test alone.
• If you take metformin: the UK medicines regulator (MHRA) advises testing vitamin B12 if new neuropathy appears, and considering regular checks in people at risk [13].

Can neuropathy get better, or is it lifelong?

It depends on the cause: some neuropathies improve when the cause is treated, while in other people the nerve damage lasts or slowly progresses, according to the NHS [4]. In people with diabetes or high blood fats (dyslipidaemia), neuropathy is a lifelong condition that needs lifelong management.

• The aim: keep correcting the deficiencies that keep coming back, keep sugar and blood fats steady, protect your feet, and slow further nerve damage.
• Why it is ongoing: diabetes and dyslipidaemia continue, and so do the medicines that manage them, so nutrient levels need checking and topping up over the years, not once.
• What can change: many people find symptoms such as burning, tingling and night pain become easier to live with, and sleep, balance and confidence improve. Individual results vary.

Our approach: finding and correcting nutritional deficiencies

Neuropathy, mostly from diabetes, is one of the conditions we manage most often. Our method is nutritional supplementation therapy: we find the deficiencies caused by the condition itself (diabetes, dyslipidaemia) and by the medicines used to manage it, and we replenish them at the right doses, set for you from your blood tests and adjusted over time, as a complementary add-on to your existing treatment.

1. Test first: blood tests show which nutrients, such as B12 and vitamin D, are low, and magnesium is judged from your overall clinical picture; we re-check over time and adjust.
2. Replenish what is missing: mainly vitamin B12, thiamine (vitamin B1), magnesium and a moderate, normal-range vitamin D, with omega-3 fatty acids for overall nutrition and blood fat health.
3. Keep your life-saving medicines: medicines for diabetes, cholesterol and blood pressure are never stopped abruptly. Any change is made under clinical guidance from Team Cure4Pain, in coordination with your diabetologist or cardiologist.
4. Calm inflammation over time: diet, weight, activity, sleep and stress, step by step (see below).
5. Protect your feet and balance: daily foot checks, good footwear, and safe exercise.

Clinic observation: in our practice, many people with diabetic or lipid-related neuropathy have low vitamin B12 or vitamin D on their blood tests, and signs of low magnesium in their clinical picture; we correct these as an add-on to their existing treatment. This matches published studies linking these deficiencies to neuropathy [12][18][19]; further studies are needed.

If you take medicines for nerve pain (NICE lists amitriptyline, duloxetine, gabapentin and pregabalin as first options [29]), any change is made under clinical guidance from Team Cure4Pain.

Which vitamins and minerals help neuropathy?

According to the NHS, vitamin B12 deficiency is a treatable cause of neuropathy [6][7]; for the other nutrients, the research supports correcting a measured deficiency rather than taking extra on top. Official daily intakes below are from the US National Institutes of Health; your own amounts are set from your blood work.

• Vitamin B12: in a one-year double-blind trial in people with type 2 diabetes on metformin and neuropathy, normalising low-normal B12 improved nerve conduction, pain and quality of life [14]. Official intake for adults: 2.4 micrograms a day, more in pregnancy and breastfeeding [31].
• Thiamine (vitamin B1): plasma thiamine was about 75% lower in people with diabetes in one study, because more is lost in the urine [15]. A 6-week trial of benfotiamine (a form of B1) reduced neuropathy symptoms, mainly pain [16], while a 12-month trial found no significant change in nerve measures [17]. Official intake: 1.2 mg a day for men and 1.1 mg for women [32].
• Magnesium: in a study of people with type 2 diabetes, low serum magnesium was linked to diabetic neuropathy and slower nerve conduction [18], and type 2 diabetes is linked to low magnesium [33]. According to the US National Institutes of Health, less than 1% of the body’s magnesium is in the blood, and blood (serum) levels do not accurately reflect total body magnesium [33], so we assess magnesium status from the overall clinical picture. Official intake for adults: 310 to 420 mg of elemental magnesium a day from all sources; the upper limit from supplements is 350 mg of elemental magnesium a day [33]. How well magnesium is absorbed depends on its form.
• Vitamin D: low vitamin D is linked to diabetic neuropathy [19], and in a small 8-week trial adding vitamin D to standard care reduced pain [20]. We aim for a moderate, normal-range level. Official intake for adults: 600 to 800 IU (15 to 20 micrograms) a day; the upper limit for adults is 4,000 IU [34].
• Omega-3 fatty acids: a 2025 Cochrane review found too few trials to judge their effect on nerve measures, and possibly little or no effect on symptoms [21]. According to the American Heart Association, prescription-strength omega-3 lowers high triglycerides [22], which matter in neuropathy [10]. Official intake (as plant omega-3, ALA): 1.6 g a day for men and 1.1 g for women [35].

Supplements can interact with medicines; please do not start high-dose supplements without medical guidance.

Calming inflammation over time: diet, lifestyle and nutrition

According to the Look AHEAD trial in 5,145 adults with type 2 diabetes, an intensive lifestyle programme with weight loss lowered neuropathy symptom scores, and changes in symptoms followed changes in weight, HbA1c and blood fats [23].

• Lifestyle helps nerves: in people with prediabetes and neuropathy, a year of diet and exercise counselling regrew small skin nerve fibres and reduced pain [24].
• Eating pattern: in a 20-week pilot trial, a low-fat, plant-based diet with B12 reduced nerve pain in type 2 diabetes [25]. We build a steady-sugar, triglyceride-friendly plan around your food culture: more vegetables, pulses, whole grains, nuts and seeds; fewer sugary drinks, sweets, refined flour, fried and ultra-processed foods; and less alcohol, which also damages nerves [6].
• Weight, sleep and stress: small, steady changes kept up over years matter more than strict short diets.
• Smoking: stopping protects the small blood vessels that feed the nerves; the NHS lists smoking as a risk factor in diabetic neuropathy [6].

What exercises help neuropathy?

A combination of endurance training (such as walking or cycling) and balance training is the most helpful exercise for diabetic neuropathy, a meta-analysis of exercise trials found [26].

• Balance: standing on one leg near a support, heel-to-toe walking, and sit-to-stand practice.
• Strength: calf raises, ankle and toe movements, and leg strengthening.
• Endurance: walking, cycling or swimming, built up gradually.
• Go carefully: check your feet before and after exercise, wear well-fitting shoes, and avoid barefoot exercise and long walks on hard ground if your feet are numb. If you have a foot wound, pause weight-bearing exercise and get it checked.

Why we avoid acupuncture and dry needling in diabetic neuropathy

According to the NHS, wounds on numb feet in people with diabetes heal slowly, can become infected and can lead to gangrene [8]. For this reason, needling is to be avoided in diabetic neuropathy: every needle is a small injury to skin that already heals poorly, and in our clinical experience it has not given a meaningful benefit for diabetic nerve pain. We use acupuncture and dry needling for other conditions, such as knee and joint pain, but not for diabetic neuropathy.

Neuropathy after chemotherapy

According to a review of 31 studies, about 68% of people have nerve symptoms in the first month after chemotherapy, about 60% at three months and about 30% at six months or more [27].

• What helps: balance (sensorimotor) training is the best-supported exercise after chemotherapy [26], together with foot care and checking nutrient levels.
• Your cancer team first: any supplement during or after cancer treatment is planned with your oncologist, because some can interact with treatment.

Burning feet at night: relief at home and daily foot care

Burning feet at night is most often a sign of peripheral neuropathy, and diabetes is its most common cause; low vitamin B12, an underactive thyroid, alcohol and some medicines are other causes [5][6]. If you have diabetes, the NHS advises examining your feet regularly for wounds, sores and blisters and having them checked by a podiatrist [6][8].

• Cool, not cold: cool water or a fan can ease burning; avoid ice and very hot water, because numb feet cannot judge temperature [5].
• Check every day: look at the soles and between the toes (use a mirror), and moisturise dry skin, but not between the toes.
• Shoes and socks: soft, seamless socks and well-fitting shoes; never walk barefoot.
• Bedtime: loose bedding over the feet, and a short walk or gentle calf stretch in the evening.
• Nerve pain medicines: common painkillers usually do not help nerve pain [7]; medicines are adjusted under clinical guidance from Team Cure4Pain.

When is nerve pain an emergency?

Go to a hospital or emergency service straight away if weakness or numbness spreads up your legs or arms over hours or days, or you have trouble breathing, swallowing or speaking (these can be signs of Guillain-Barré syndrome, which needs urgent hospital treatment [30]); if a foot wound is red, hot, swollen, smelly or turning black, or you have a fever with a foot wound [8]; or if you lose control of your bladder or bowels or have numbness around the groin with back pain.

Working in coordination with your existing consulting physician

We review your blood tests and nerve reports and share our findings with your diabetologist, cardiologist or neurologist. Medicines for diabetes, cholesterol, blood pressure and nerve pain are never stopped abruptly; any change is made under clinical guidance from Team Cure4Pain. If tests point to an autoimmune cause (such as lupus or Sjögren’s syndrome), your plan also includes the integrative rheumatology care described on our autoimmune pages.

What to expect

Your first consultation (in Mumbai or online) covers your history and medicines, your symptoms, a look at your feet and balance, a review of your blood tests and nerve reports, and a written plan with the tests we need. Because the care is built on nutrition, diet and lifestyle, most of it can be done online, with blood tests at a laboratory near you. Nutrient levels change slowly, so we plan in blocks of several weeks with regular reviews and repeat tests, and continue over the long term. Individual results vary.

Evidence: key studies

Who treats you

• Dr Krushal PabariMD, PGCP - Rheumatic & Musculoskeletal Diseases. Assistant Professor, Cooper Hospital; Guest Professor, CMP Homoeopathic Medical College.
• AT. Chintan Dalal, N.D.BNYS, R.AP. Functional nutrition and Coimbra Protocol practitioner.

Consultations look at the whole person: alongside the medical and nutritional plan, we bring a strong interest in behavioural science to counselling on stress, sleep and lasting lifestyle change.

How consultations work: Mumbai or online worldwide

Book through our patient portal. You can see us in person at our clinic in Malad West, Mumbai, or online from anywhere. Your first consultation reviews your history and tests; we then agree a plan together and set the monitoring schedule.

Related conditions and articles

• SciaticaPain running from the lower back down the leg.
• Slipped DiscA bulging or herniated disc; care without surgery where it is appropriate.
• Lower Back PainMuscle, joint and disc-related back pain.
• FibromyalgiaWidespread pain and fatigue; nutrients, sleep and pain care.
• Lupus (SLE)A whole-body autoimmune condition; vitamin D, magnesium and monitoring.

• Back, neck and joint pain

This page is for education and does not replace medical advice. Do not start, stop or change any medicine or supplement without medical guidance.

References

1. Hanewinckel R, et al. The epidemiology and risk factors of chronic polyneuropathy. Eur J Epidemiol 2016;31(1):5-20. doi:10.1007/s10654-015-0094-6

2. Feldman EL, et al. Diabetic neuropathy. Nat Rev Dis Primers 2019;5(1):42. doi:10.1038/s41572-019-0097-9

3. Pop-Busui R, et al. Diabetic neuropathy: a position statement by the American Diabetes Association. Diabetes Care 2017;40(1):136-154. doi:10.2337/dc16-2042

4. NHS. Peripheral neuropathy. nhs.uk/conditions/peripheral-neuropathy

5. NHS. Peripheral neuropathy: symptoms. nhs.uk/conditions/peripheral-neuropathy/symptoms

6. NHS. Peripheral neuropathy: causes. nhs.uk/conditions/peripheral-neuropathy/causes

7. NHS. Peripheral neuropathy: treatment. nhs.uk/conditions/peripheral-neuropathy/treatment

8. NHS. Peripheral neuropathy: complications. nhs.uk/conditions/peripheral-neuropathy/complications

9. Callaghan BC, et al. Enhanced glucose control for preventing and treating diabetic neuropathy. Cochrane Database Syst Rev 2012;(6):CD007543. doi:10.1002/14651858.CD007543.pub2

10. Wiggin TD, et al. Elevated triglycerides correlate with progression of diabetic neuropathy. Diabetes 2009;58(7):1634-1640. doi:10.2337/db08-1771

11. Zhu J, et al. Diabetic peripheral neuropathy: pathogenetic mechanisms and treatment. Front Endocrinol (Lausanne) 2024;14:1265372. doi:10.3389/fendo.2023.1265372

12. Aroda VR, et al. Long-term metformin use and vitamin B12 deficiency in the Diabetes Prevention Program Outcomes Study. J Clin Endocrinol Metab 2016;101(4):1754-1761. doi:10.1210/jc.2015-3754

13. Medicines and Healthcare products Regulatory Agency (MHRA). Metformin and reduced vitamin B12 levels: new advice for monitoring patients at risk. Drug Safety Update, 2022. gov.uk/drug-safety-update/metformin-and-reduced-vitamin-b12-levels-new-advice-for-monitoring-patients-at-risk

14. Didangelos T, et al. Vitamin B12 supplementation in diabetic neuropathy: a 1-year, randomized, double-blind, placebo-controlled trial. Nutrients 2021;13(2):395. doi:10.3390/nu13020395

15. Thornalley PJ, et al. High prevalence of low plasma thiamine concentration in diabetes linked to a marker of vascular disease. Diabetologia 2007;50(10):2164-2170. doi:10.1007/s00125-007-0771-4

16. Stracke H, et al. Benfotiamine in diabetic polyneuropathy (BENDIP): results of a randomised, double blind, placebo-controlled clinical study. Exp Clin Endocrinol Diabetes 2008;116(10):600-605. doi:10.1055/s-2008-1065351

17. Ziegler D, et al. Effects of benfotiamine treatment over 12 months on morphometric, neurophysiological and clinical measures in type 2 diabetes patients with symptomatic polyneuropathy (BOND study). BMJ Open Diabetes Res Care 2026;14(1). doi:10.1136/bmjdrc-2025-005773

18. Zhang Q, et al. Low serum phosphate and magnesium levels are associated with peripheral neuropathy in patients with type 2 diabetes mellitus. Diabetes Res Clin Pract 2018;146:1-7. doi:10.1016/j.diabres.2018.09.015

19. Qu GB, et al. The association between vitamin D level and diabetic peripheral neuropathy in patients with type 2 diabetes mellitus: an update systematic review and meta-analysis. J Clin Transl Endocrinol 2017;9:25-31. doi:10.1016/j.jcte.2017.04.001

20. Pinzon RT, et al. The benefits of add-on therapy of vitamin D 5000 IU to the vitamin D levels and symptoms in diabetic neuropathy patients: a randomized clinical trial. J Pain Res 2021;14:3865-3875. doi:10.2147/JPR.S341862

21. Britten-Jones AC, et al. Omega-3 fatty acid supplementation for distal symmetrical peripheral neuropathy in adults with diabetes mellitus. Cochrane Database Syst Rev 2025;9:CD014623. doi:10.1002/14651858.CD014623.pub2

22. Skulas-Ray AC, et al. Omega-3 fatty acids for the management of hypertriglyceridemia: a science advisory from the American Heart Association. Circulation 2019;140(12):e673-e691. doi:10.1161/CIR.0000000000000709

23. Look AHEAD Research Group. Effects of a long-term lifestyle modification programme on peripheral neuropathy in overweight or obese adults with type 2 diabetes: the Look AHEAD study. Diabetologia 2017;60(6):980-988. doi:10.1007/s00125-017-4253-z

24. Smith AG, et al. Lifestyle intervention for pre-diabetic neuropathy. Diabetes Care 2006;29(6):1294-1299. doi:10.2337/dc06-0224

25. Bunner AE, et al. A dietary intervention for chronic diabetic neuropathy pain: a randomized controlled pilot study. Nutr Diabetes 2015;5(5):e158. doi:10.1038/nutd.2015.8

26. Streckmann F, et al. Exercise and neuropathy: systematic review with meta-analysis. Sports Med 2022;52(5):1043-1065. doi:10.1007/s40279-021-01596-6

27. Seretny M, et al. Incidence, prevalence, and predictors of chemotherapy-induced peripheral neuropathy: a systematic review and meta-analysis. Pain 2014;155(12):2461-2470. doi:10.1016/j.pain.2014.09.020

28. England JD, et al. Practice parameter: evaluation of distal symmetric polyneuropathy: role of laboratory and genetic testing (an evidence-based review). Neurology 2009;72(2):185-192. doi:10.1212/01.wnl.0000336370.51010.a1

29. National Institute for Health and Care Excellence. Neuropathic pain in adults: pharmacological management in non-specialist settings (CG173). nice.org.uk/guidance/cg173/chapter/Recommendations

30. NHS. Guillain-Barré syndrome. nhs.uk/conditions/guillain-barre-syndrome

31. NIH Office of Dietary Supplements. Vitamin B12: fact sheet for health professionals. ods.od.nih.gov/factsheets/VitaminB12-HealthProfessional

32. NIH Office of Dietary Supplements. Thiamin: fact sheet for health professionals. ods.od.nih.gov/factsheets/Thiamin-HealthProfessional

33. NIH Office of Dietary Supplements. Magnesium: fact sheet for health professionals. ods.od.nih.gov/factsheets/Magnesium-HealthProfessional

34. NIH Office of Dietary Supplements. Vitamin D: fact sheet for health professionals. ods.od.nih.gov/factsheets/VitaminD-HealthProfessional

35. NIH Office of Dietary Supplements. Omega-3 fatty acids: fact sheet for health professionals. ods.od.nih.gov/factsheets/Omega3FattyAcids-HealthProfessional

36. NHS. Peripheral neuropathy: diagnosis. nhs.uk/conditions/peripheral-neuropathy/diagnosis