by Ann S. Williams, MSN RN CDE
This column focuses on providing information to help people make their diabetes care fit their needs and their lives.
Last issue’s column focused on what hypoglycemia, or “low blood sugar,” is, and on how to treat it. This month’s column focuses on how to prevent hypoglycemia.
First, let’s look at what keeps blood glucose in balance. When blood glucose is normal, the factors that make the blood glucose go up and the factors that make it go down are in balance. The biggest factors that make blood glucose go up are:
1. Carbohydrates, which are starches or sugars, from food the person has
eaten.
2. Stress.
3. Stored glucose being released into the blood.
The biggest factors that make blood glucose go down are:
1. Insulin.
2. Oral medications that make the body make more insulin.
3. Exercise or other physical activity.
4. Losing weight.
5. Anything else that makes the body burn glucose.
In people who do not have diabetes, these factors are naturally kept in balance
throughout the day. The blood glucose stays between 70 to 140, even when the
person has eaten a large meal with lots of carbohydrates. In people who do
have diabetes, it’s best to keep blood glucose as close to normal as
possible, through diet, exercise, and appropriate medications. Many people
who have diabetes can come close to these "normal" levels, can “achieve
euglycemia,” if they can learn the skills of avoiding too much hypoglycemia.
Preventing hypoglycemia can make the difference between good or poor blood
glucose control.
In general, if a person is having hypoglycemic events often, the hypoglycemia
can be prevented by increasing the factors that raise blood glucose, or decreasing
the factors that lower blood glucose. This is most often done by changing the
amount or timing of eating, changing the amount, timing, or type of medication,
or changing the amount or timing of exercise.
Now let’s look at some typical ways hypoglycemia can happen in people who are using insulin or oral medications. Here are three true situations, with some comments about what these individuals did to prevent hypoglycemia:
Situation 1
Rebecca takes a combination of rapid insulin and NPH insulin twice a day. She usually wakes up at 6:00 AM, takes her insulin, and has breakfast about 6:30 AM. Then she goes to work at her job as a secretary, where she sits at a desk all day. She takes a break at about 10:30 AM, and has a cup of tea. Almost every morning, she has low blood sugar at about 11:00 AM.
In this situation, Rebecca’s hypoglycemia is caused by a mismatch between her insulin and her eating schedule. At about 11:00 AM, the NPH insulin is peaking. Rebecca’s breakfast has been completely digested and absorbed, and she has not eaten anything else. So the insulin is causing her blood glucose to drop.
Rebecca spoke with a diabetes educator about ways to prevent this almost-daily hypoglycemia. She learned she had several choices. She could decrease the factors that lower her blood sugar, or increase the factors that raise her blood glucose. Specifically, the choices her diabetes educator discussed with her were:
1. Decreasing the morning insulin dose. However, this would have meant she would also have a lower dose of rapid insulin in her insulin mixture, so she would have had to eat a smaller breakfast. She likes to have a large breakfast, so this was not a good choice for her.
2. Use a different insulin regimen. What the diabetes educator suggested was a long-acting insulin without a peak (Lantus) as a background insulin, with a rapid-acting insulin at every meal. But this would mean that Rebecca would have had to carry insulin to work, and give herself an injection before lunch. She did not like this idea, so this also was not a good choice for her.
3. Increasing the factors that raise blood glucose, either by eating more at breakfast, or by eating a small snack during the mid-morning, before the time of her hypoglycemia. Rebecca realized that if she ate a larger breakfast, her blood glucose would be higher all morning, and she did not like that idea. So she chose to eat a small snack at her 10:30 AM break. She began bringing a piece of fresh fruit to work for an easy, healthy snack with some, but not too much, carbohydrate.
Situation 2
Carlos had type 2 diabetes and was using 10 mg of Glucotrol twice a day to control it. For many years, this had worked well for him. Lately, Carlos has been taking action to lose weight. He has been exercising every day for about one half hour in the late afternoon, and has cut back on how much he has been eating. He has lost about six pounds already, and would like to lose about 20 more. He has noticed that for the last week, at about 5 PM every day, he has been feeling very shaky and lightheaded. This feeling went away if he has a snack. But he has been worrying that all that snacking is going to undermine his efforts to lose weight.
The cause of Carlos’s hypoglycemia in this situation involves several factors working together. He is exercising more, eating less, and he has lost weight. The oral medication he takes, Glucotrol, works by making the pancreas put out more insulin, whether Carlos actually needs more insulin or not. Carlos now has too much insulin in his system.
Carlos talked with his doctor about his situation. His doctor congratulated him on increasing his exercise and eating less, and on his weight loss. She encouraged Carlos to continue with the weight loss. She also pointed out that both the exercise and the weight loss were helping Carlos to decrease his high blood pressure and his high cholesterol. In addition, she noted that Carlos’s exercise time, late afternoon, occurred when all the carbohydrates from his lunch had already been absorbed, so it would be easy for his blood glucose to drop.
Carlos’s doctor agreed with Carlos that having a snack before exercise would prevent hypoglycemia, but it also would make it harder for Carlos to lose more weight. So the doctor advised him to reduce his dose of Glucotrol to 5 mg twice a day. She also pointed out it would be better to exercise in the early afternoon, when he would still have plenty of carbohydrate in his system from his lunch.
Finally, Carlos’s doctor asked Carlos to be sure to let her know if he had more hypoglycemia as he lost more weight. She pointed out that it was possible, with further weight loss, that Carlos might eventually be able to have good control of his diabetes without taking any medications.
Situation 3
Marian has worked as a nurse in an intensive care unit, a very high-stress
position.
She did not get along well with her supervisors, which only increased her stress
levels. In addition, she was raising two teenagers, and one of them was having
some serious problems in school. Even though she used an insulin pump to manage
her diabetes, she often had blood glucose levels that were higher than her
goals.
As Marian grew more unhappy, she decided she needed to see a mental health counselor to help her deal with the high stress in her life. She chose to see a social worker. As she worked with the social worker, she realized that she had more choices about how she reacted to her situation than she realized. She learned how to do deep relaxation exercises, decreasing her physical and emotional response to the stress in her life. She learned better communication skills, improving her relationship with her teenagers. And she found a new job, in a lower-stress environment.
As Marian made all these changes in her life, she began having frequent episodes of hypoglycemia. Since she was eating more, to correct all that hypoglycemia, she began gaining weight. She did not like that, so she consulted the endocrinologist who had prescribed the insulin pump for her.
Marian’s endocrinologist agreed that high stress levels had increased her blood glucose. Her previous insulin doses had been based on these higher blood glucose levels. Complicating matters even more, the increase was different from one day to the next, frustratingly unpredictable. In addition, because she had been almost constantly upset, Marian hadn't had the energy to figure out the best use of her insulin pump to control her diabetes. Now that she had less stress in her life, and was handling the remaining stress better, she could take some time and energy to find out exactly how her body was reacting, and adjust her insulin pump settings to match her insulin need.
Marian’s endocrinologist asked her to see a diabetes educator, to work out better settings for her insulin pump, and achieve better control of her diabetes. The diabetes educator guided her through a series of systematic, step-by-step procedures for checking all the settings on her insulin pump. Marian checked out both the basal, or background, rates, and also the bolus rates, which are the rates at which she gave insulin after meals, or to correct high blood glucose. Although the entire series of checks took about six weeks to be completed, they were well worth the effort. After she had done this, she was able to maintain near-normal blood glucose, and she had hypoglycemia only rarely.
As you can see from these three true stories, preventing hypoglycemia is a very individualized effort. Each person, and each situation, calls for a clear analysis of the factors that raise or lower blood glucose. Furthermore, it is very important to consider what else is going on in the person’s life. In many situations in which a person has a problem with hypoglycemia, there are several possible solutions. By thinking through all the possible choices, a person has the best chance of finding a solution that prevents hypoglycemia and also fits well in his or her overall life.