Anemia is a health condition in which the Hgb levels, hematocrit and/or red blood cell (RBC) count are below normal and insufficient to carry enough oxygen to meet the body tissues’ physiological needs.[1] Anemia has a detrimental effect on the overall quality of life, impairing functional ability and labor productivity in adults, and affecting children’s cognitive and developmental growth, as well as anemia during pregnancy increases the risk of preterm birth, low weight in birth, ‎and possibly poor neonatal health.[1,2] According to the WHO’s gender-specific criteria, anemia is defined as men with Hgb levels of < ‎13 g/dL (7.7 mmol/l), non-pregnant women with < 12 g/dL (7.4 mmol/l) and pregnant women with <11 g/dl (6.83 mmol/l).[3]

The prevalence of anemia in diabetes is reportedly two to three times more common which could possibly be attributed to hyperglycemia, abnormalities in the renal functions and erythropoietin release, inflammation, oxidative stress, and autonomic dysfunction [4]. The microenvironment of the nerve is vital for its nutrition, circulation, and oxygenation. The resultant hypoxia due to anemia disrupts the microenvironment of the nerve and is a risk for neuropathy [5].

A decrease in hemoglobin levels due to anemia is linked to the pathophysiology of neuropathy. Because of its anti-inflammatory and anti-oxidant qualities, bilirubin, the breakdown product of hemoglobin metabolism, scavenges free radicals and shields nerves from the damage caused by oxidative stress. Additionally, hemoglobin deficiency causes red blood cells to become distorted and more susceptible to stress, which raises the risk of microvascular problems linked to diabetes[6].

Another important factor in the DPN linked to anemia in diabetics is gender. Research indicates that men are more vulnerable to a drop in hemoglobin levels than women since they have greater hemoglobin values [6]. Thus, neuropathy is anticipated to be a risk factor for male diabetics with anemia. It is imperative to identify diabetic neuropathy early in order to prevent problems related to diabetic peripheral neuropathy [7]. Moreover, anemia in diabetes is a generally ignored ailment that increases the risk of complications and neuropathy.

The current study was a five-month cross-sectional investigation carried out in an Indian tertiary care hospital (January to May 2024). The Institutional Ethics Committee approved the project. One hundred and sixty male Type 2 diabetics between the ages of thirty and seventy were involved in the study. Consenting subjects were included in the study and split into two groups: DPN (n = 90) and non-DPN (n = 70). The nerve conduction velocities (motor and sensory) were measured in 160 patients, split into those with and without anemia. The study excluded participants with a history of hypothyroidism, chronic liver and kidney problems, hemorrhoids, anemia therapy, smoking, alcoholism, and recent blood loss. The patients' 2-hour plasma glucose, HbA1C%, and fasting plasma glucose were recorded using recent investigations. The hospital's Central Lab's automated analyzer was used to record hematological investigations. To check for neuropathy, the patients were screened using the Michigan Neuropathy Screening Instrument (MNSI) [8]. Using Neuroperfect software and EMG/NCV equipment from the Medicaid System, nerve conduction velocities were measured.

Statistical analysis:

The data thus generated was analyzed Statistically using the student ‘t’ test to compare the mean of two groups. ANOVA for comparison of mean in more than two groups. Pearson’s coefficient of correlation was used to calculate the correlation between different parameters. P <0.05 was considered statistically significant.

Table 1 compares type 2 diabetics with and without DPN in terms of study characteristics.

Table 2: Diabetic neuropathy in individuals with or without anemia

Table 3:  Nerve conduction velocities differ between diabetics with and without anemia

The study's findings demonstrated that the mean age of participants with DPN (56.01±4.26) was considerably greater than that of those without DPN (43.24±4.11). In DPN individuals, there was a substantial increase in the mean duration of diabetes, fasting blood glucose, and HBA1C percentage. When compared to the non-DPN group, the hematological parameters Hb and RBC were considerably lower in the DPN group. Subjects with anemia had considerably lower motor and sensory nerve conduction velocities than subjects without anemia.Ninety of the 160 research participants had DPN, and 70 did not. Eighty of the 160 patients in total were anemic, while the remaining 65 were not. In the anemia group, 25 people lacked DPN and 59 had it. Of the non-anemic group, 25 had DPN and 40 did not. It was discovered that participants with DPN had longer diabetes durations and higher mean ages than those without DPN.

According to research, the percentage of diabetics with peripheral neuropathy can range from 19 to 100%, depending on how long the disease has been present. In other words, the proportion rises as diabetes gets worse. In our investigation, the average duration of diabetes (8.13±1.54) was greater in individuals with DPN (8.65±1.13) than in those without DPN (4.65±1.13), which could account for the greater proportion of people with peripheral neuropathy (i.e., 90 out of 160 research participants, or 56.67%). Age and length of diabetes are associated with increased reports of neuropathy[9].According to earlier research, the prevalence of anemia in people with diabetes ranges from 30 to 63%, depending on the length of the disease and glycemic control[5].

Research indicates that as the duration of diabetes increases, the conduction velocities of motor and sensory nerves decrease [10]. In our study, those with DPN had a longer mean duration of diabetes than those without DPN, and the findings also indicated a decrease in haematological markers in the DPN group. DPN was found in 59 out of 80 anemic individuals, or 73.75%. The results could be explained by the extended duration of diabetes and the decrease in Hb. Anemic diabetics had significantly lower median and ulnar nerve conduction velocities, according to previous study findings.

Previous studies have also demonstrated a decline in the motor nerve conduction velocity of the common peroneal nerve [11]. Early onset anaemia associated with the deficiency of erythopietin is reported in type 2 diabetics and is a risk for autonomic neuropathy [12].

Diabetes-related hyperglycemia causes sorbitol to accumulate, which raises osmolarity and causes neuronal swelling and a decrease in nerve conduction velocities. Our study's decrease in nerve conduction velocity is consistent with previous reports [13].

Anemia in diabetic patients needs to be properly evaluated because it is an early sign of renal impairment.

A decrease in hemoglobin also increases the risk of complications-related morbidity and death in diabetics. Research has demonstrated that diabetics are resistant to the stimulatory effects of erythropoietin because of inflammation, which causes anemia even before renal involvement develops [14]. The DPN group in our study had low mean hemoglobin levels, and 59 out of 80 anemic participants also experienced neuropathy. In comparison to the non-DPN group, the DPN group had lower hemoglobin levels and considerably higher fasting blood glucose and HBA1C%. The outcomes can be attributed to anemia and hyperglycemia as well as inadequate glycemic management in anemic diabetics.

The current study's findings indicate that diabetics with anemia have declining motor and sensory nerve conduction velocities. According to the research, anemia in diabetics is a condition that is often ignored and puts them at risk for problems like neuropathy. Therefore, to prevent long-term consequences, anemia in diabetics needs to be examined. Participants in the study and staff providing support are acknowledged.

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