You might have heard any of your family members who are diabetic, saying “I didn’t grasp when my sugar went low. How’s that possible??” Let me share an incident with you all. There was a girl, let’s name her X. She had type 1 diabetes and stayed in USA with her parents till she turned 18 years. Subsequently, she moved out and stayed separate. One fine day, X’s sister merely thought of just checking on her and she finds that phone calls are unresponsive, door bells are unresponsive. X’s sister, then calls up her dad, they then try to somehow open the door and realize that X went in coma. From hospital reports it came out that she had severe hypoglycemia and was untreated.

This is one of those incidents which explain why awareness about hypoglycemia is so important. For people with diabetes, hypoglycemia is fact of their life. So first let us know what’s hypoglycemia?

Hypoglycemia or low blood glucose levels occur when blood sugar level drops below normal, i.e. below 68 mg/dl (<3.8 mmol/L). There are several reasons a diabetic can go into hypo such as:

Insulin

Oral anti-hyperglycemic medications

Skipping meals or long intervals between meals

Excess physical activity

Having alcoholic beverage after a diabetic medication (e.g. metformin)

What are the signs and symptoms of hypoglycemia?

Usually when a person goes into hypo, he/she can have any few of these symptoms:

Blurred vision

Irregular heartbeat

Excess hunger

Headache

Dizziness and irritability

Confusion

Sweating

Patients experiencing the above symptoms have perception to hypoglycemia.

Severe Hypoglycemia

The main energy source for our brain is glucose and low blood glucose can create havoc on a person’s physical and mental health. This is one of the crucial factors which make hypoglycemia so important in the management of diabetes. Impedance in the continuous supply of glucose to brain cells can damage the central nervous system, creating a weaker sense of perception and understanding things. A further drop in blood sugar may eventually lead to coma. This is observed in severe hypoglycemia (BG <51 mg/dl). Patients may also experience seizures and might require someone’s assistance to correct it. Severe hypoglycemia is associated with increased death rate.

Severe hypoglycemia is treated by injecting dextrose (a mixture of glucose and water) intravenously (into the vein). Rarely, glucagon ( hormone produced by pancreas that stimulate the liver to release stored glucose, when levels go down ) can also be injected into buttocks, arm or thighs. Glucagon kits are available by prescription. Please do not put anything in mouth if the person has passed out, since it increases the risk of choking.

What is Hypoglycemia unawareness (HU)?

“Hypoglycemia unawareness” or “impaired awareness of hypoglycemia” can be simply defined as failure to recognize hypo when blood glucose concentration drops too low (< 54mg/dl), at which warning signs normally occur. Hypoglycemia unawareness is observed in type 1 diabetes and long standing type 2 diabetes. You can have severe hypoglycemia whether or not you have hypoglycemia unawareness. But if you have hypoglycemia unawareness, you are more likely to have frequent episodes of severe hypoglycemia over a few weeks or months. HU can occur at any time during the day or even at night during sleep.

Normal mechanism is that when the blood glucose falls below 65-68 mg/dl, hypoglycemia is sensed in various parts of the brain. This causes release of anti-insulin hormones like glucagon and epinephrine, which prompt the liver to release stored glucose. These counter regulatory hormones also give sign of low blood glucose. This is a protective response to hypoglycemia, since these hormones are responsible for classic symptoms such as sweating, irregular heartbeat, etc. In most studies, it is observed that in type 1 diabetes this response is impaired after 4-5 years of duration and therefore hypoglycemia unawareness. If a patient having HU goes untreated, it can lead to further drop in blood sugar resulting in coma and sometimes even death.

Who can experience HU?

Type 1 diabetes

Patients with long standing type 2 diabetes

Recurrent hypoglycemic episodes

Patients trying to achieve tight glycemic control

Intensive therapy to achieve good blood glucose control

Advanced age

How to regain hypoglycemia awareness?

If you have diabetes or have had any hypoglycemic episode, it is a must for your diabetes educator/physician to discuss with you about hypoglycemia and its management as routine part of assessment. The thumb rule is:

Check your blood sugars. If it’s < 68 mg/dl, you should have any one from the below options which will provide 15 grams of carbohydrate to raise blood glucose by 50mg/dl.

3-4 glucose tablets

½ cup of any fruit

½ cup of regular soft drink or fruit juice

1 tbsp of sugar or honey

5-6 pieces of hard candies (e.g. mango bite)

Wait for 15 minutes and re-check your blood sugar. If it’s in the normal range, eat some complex carbohydrate rich food such as oats/dalia so that it doesn’t go low again. If it’s still low, repeat the above process.

If you have experienced hypoglycemia without any symptoms, things that need to be kept in mind are:

Be sure to discuss it with your health care provider

Need to adjust / raise glycemic target in order to avoid further hypoglycemic episodes

raise glycemic target in order to avoid further hypoglycemic episodes Frequent monitoring of your blood sugar should be considered

Always carry glucose tablets / fruits / hard candies along with you

fruits hard candies along with you Can consider continuous glucose monitoring system (CGMS- a coin sized monitor which continuously records blood sugar with food, medication and exercise). Blood sugar patterns are noticed after removal of the monitor

Keep a record of your diet, physical activity and medication and / or insulin

or insulin Carry a medical alert ID of “ I am Diabetic”

To sum up, in the fewest possible words, hypoglycemia is far more dangerous than hyperglycemia. It can kill you if ignored. Testing blood sugar often might be tedious, but if you’re having hypoglycemia, you can address it before it becomes serious.

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