Hypoglycemia is defined as:
The development of autonomic or neuroglycopenic symptoms. Autonomic symptoms include anxiety, trembling, sweating, hunger, tingling and anxiety. These are considered to be the early symptoms of a hypoglycemic episode. At this stage, you are mostly able to help yourself. (1)
The Moderate severity phase includes the neuroglycopenic and autonomic symptoms such as the confusion, weakness, drowsiness, difficulty concentrating and speaking and perhaps even vision changes. Most often you can treat yourself.(1)
The most severe stage is when you need the help of another person and loss of consciousness could occur. Usually the plasma glucose level is less than 2.8 mmol/L (50 mg/dl). For patients with type 1 or type 2 diabetes, the average incidence of severe hypoglycemia is 2.5 events/year. (1,2) Sadly, statistics tell us that only 34% of patients report severe hypoglycemia and that these same individuals were 1.9 times more likely to experience severe hypoglycemia. (2)
None of these are pleasant but for those of us who use insulin or oral medication that stimulates the pancreas to push out some extra insulin to meet our needs, hypoglycemia is inevitable as we go through this lifelong journey.
Speaking for myself, hypoglycemia has pretty well happened everywhere. I have been on planes, at conferences, at work, at home, at friends, during exercise and probably many more situations I prefer not to remember. Hypoglycemia episodes during the night are not fun and it can cause you to be afraid to go to sleep. If this happens to you at any point of time, please seek help in your diabetes management and/or someone to help with the stress and emotional side of hypoglycemia. Today I want to present some ideas of why low blood sugar might be occurring management of these events.
Do you think you might be at risk for hypoglycemia?
As per Diabetes Canada guidelines some of the risk factors include:
· Prior episode of severe hypoglycemia
· An A1C less than 6%
· Hypoglycemia unawareness
· Long standing kidney disease
· Age: adolescence, elderly, child
· Living alone
· Others mentioned in the above reference.
Hypoglycemia results from either too much insulin or not enough sugar in the body. After an episode, take time to look back and see if you can figure out why the hypoglycemia happened. Ask yourself some questions such as:
o Did I administer the correct dose of insulin or take the correct number of pills?
o Did I eat enough carbohydrate with my meal to match my medication dose?
o Did I eat later than normal? Did I eat as much as normal? If not, why?
o Do I feel unwell, am I anxious about something?
o Did I over exercise in both intensity and/or duration? Did I check my blood sugar after exercise?
o Did I eat enough after my last severe episode to restore the glycogen levels in my liver to come to my rescue? What did I eat or not eat before this low?
o How many times has this happened recently? What time of day is this happening? Is there a pattern?
o Did I not recognize or did I ignore the signs and symptoms? Why did I wait to treat?
o Did I not eat when I had that glass of wine with my friend? One should have food with alcohol.
o Did the new medication I started interfere with my diabetes management? I must call my pharmacist. This could be a drug interaction with the diabetes medication making it more potent.
o Why didn’t I have a fast acting form of carbohydrate with me? I know better.
o Why was I trying to hide my diabetes from my friend? She could have helped me if she had known what to do.
o How old is my vial of insulin ? When did I last change my pump set? Where did I inject my insulin? We know that for some injection sites, the insulin may be absorbed more rapidly especially if you exercise that area shortly after the injection.
o What was the temperature outside when I was gardening? Extreme heat improves blood flow and might have affected the insulin absorption rate.
Cautionary note: the hypoglycemic effect from exercise or alcohol may last up to 24 hours.
If you have had diabetes for a long time you are at a greater risk of hypoglycemia unawareness. “Hypoglycemia unawareness” or “impaired awareness of hypoglycemia” occurs when you don’t experience or perceive the symptoms of hypoglycemia. The body does not recognize the big drop in blood sugar and fails to trigger the secretion of epinephrine which generates the symptoms of hypoglycemia such as anxiety and sweating. More frequent monitoring, continuous monitoring and working with the health-care team to fine tune your insulin are all steps you can take to overcome this complication of long- standing diabetes.
The impact of hypoglycemia can create fear which can impact your quality of life. This fear may lead us to worrying about driving, staying home the next day, never staying or going anywhere alone (limits your ability to be independent), maintaining higher blood glucose levels which could contribute to other diabetes complications, eating extra (weight gain) and unwanted stress.
The goals of treatment are to detect and treat a low blood glucose (BG) promptly by using an intervention that provides the fastest rise in BG to a safe level. It is also important to avoid overtreating since this can result in rebound hyperglycemia and if frequent enough weight gain. To treat, use 15 grams of fast acting glucose source which is expected to increase BG by 2.1 mmol/L (38 mg/dl) within 20 minutes with adequate symptom relief in most cases. A 20 gram glucose load is expected to increase the BG level by 3.6 mmol/L (65 mg/dl)at 45 minutes.
3 to 4 glucose tablets (read the label on the package to see how much glucose each tablet contain)
3 packets of table sugar which can be dissolved in water
150 ml of juice or a regular soft drink. (not diet)
6 lifesavers
15 ml(1 tablespoonful) of honey
Step 2: Repeat the blood glucose test in 15-20 minutes. If the BG is less than 4 mmol/l (72 mg/dl) retreat.
Step 3: Once the hypoglycemia has been reversed eat your usual meal or snack that was scheduled for that time of day. If the next planned meal is over 1 hour away then have a snack including 15 grams of carbohydrate plus a protein source (ie. 3 arrowroots with peanut butter).
Other management options include the injection of glucagon or the intranasal administration of glucagon . Glucagon's effectiveness is reduced if you have had two or more alcoholic drinks in the previous few hours, after prolonged fasting or in individuals who have liver disease.(1)
Please be aware that products like chocolate bars take too long to work and are not the first choice for treatment. If it is the only thing you have and you are no where to choose another form of treatment then it will have to do but it could take you longer to recover from the hypoglycemic event and thus put you in danger of seizures or loss of consciousness. A product that is easily digested and gets into the blood stream fast works the best.
If the fear of hypoglycemia takes over your life, remember that is a normal response but extreme or overwhelming fear is a problem that could lead to poor diabetes management. This can impair your quality of life but also that of other family members. One idea to help with this emotion might be to start journaling (diary) of when these events took place, what you were doing before the event, and looking back at some of the questions in the first part of this blog.
Prevention is the key but we all know that is easier said than done. As a person with diabetes, there will be times of hypo and hperglycemia, but concern over repeated episodes can lead to serious health consequences.
ACTION PLAN
1. Always have some form of fasting acting glucose with you
2. Wear identification that you have diabetes
3. Keep your blood glucose meter handy all the time
4. Tell your family, friends, coworkers that you have diabetes and tell them what to do if you experience hypoglycemia
5. Ask your doctor for a prescription for glucagon (either format is good). Note the expiry date on packaging.
6. Communicate with your health-care team notifying them of these occurrences and ask for advice
7. Carry identification which includes who to contact if necessary. Review this information from time to time to be sure it has the right next of kin, the right doctor, the right phone numbers, etc.
On a personal note, my identification bracelet did save me one time. Because of this, I am a strong believer in having such an item.
Hypoglycemia is serious and should not be downplayed. It is a serious side effect of diabetes management and can have long terms effects on those of us with diabetes. I will discuss this more in Part II in the next blog. Stay tuned. Thank you for your time today.
References:
Can J Diabetes 42 (2018) S104-108
MDBriefcase-accessed on line September 11th,2020
diatribe.org accessed September 12th,2020
https://www.diabete.qc.ca/en/ accessed August 18th,2020
This blog is not intended to provide medical advice and does not replace medical advice from your physician and health providers.
excellent article on the stages and symptoms of hypoglycemia.