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HYPOGLYCEMIA: LOW BLOOD SUGAR

by Ed Bryant

(This article appeared in Voice of the Diabetic
Volume 16 No. 1, Winter 2001 Edition, published by the
Diabetes Action Network of the National Federation of the
Blind. Updated July 2001)

Diabetes mellitus, by definition, is inability to
properly process blood glucose. The untreated,
out-of-control diabetic has abnormally high blood sugars,
and the diabetic who wishes to keep his or her blood
sugars down in the normal range uses diet, exercise, oral
medications, and/or insulin to get them there. For
whatever reason, sometimes the sugars dip too low, and
hypoglycemia results.

A "hypoglycemic reaction," also called an insulin
reaction, insulin shock, or low blood sugar reaction,
occurs when blood glucose drops to a point where the
individual becomes confused and disoriented. At what
point a person is "low" varies; some health professionals
say any blood sugar level below 70mg/dL is hypoglycemic,
while others put the "trigger point" at 60mg/dL.
Individuals vary, and hypoglycemia can affect both
insulin-dependent and non-insulin-dependent diabetics,
though type 1s are more at risk. Safety is paramount.
Talk to your doctor about where your sugars should be
running, to keep you safe.

Prevention is the best treatment for low blood sugar
reactions! Though the personal "threshold" varies, and
some folks can function with their blood glucose down at
levels that would leave others disoriented or
unconscious, if your sugars stay up in the 70 to 110mg/dL
range, a hypoglycemic reaction won't happen. Although
exactly what is "normal" for a diabetic in good control
varies between individuals, the point is to provide
yourself a healthy range, while ensuring a margin of
safety against "hypos." "Tight control" means doing the
best possible job of keeping your blood sugar
fluctuations under control--it doesn't mean continuously
staying below normal range.

Don't just wait for symptoms of a "low" to clue you
in--all that shakiness, sweatiness, and confusion; too
often a reaction comes on without much warning. Frequent
blood glucose monitoring is the best way to warn yourself
of impending hypoglycemia. By observing your patterns of
low blood sugar, by learning how much medication,
exercise, and sustenance your body needs, you can make
the changes necessary to prevent a reaction. Remember
that meters are imperfect--they can vary by 10% either
way, and an indicated test result of 70mg/dl may in fact
be closer to an unsafe 63mg/dl. Home blood glucose
monitoring is not an exact science--to be safe, test
often, learn your individual "normal" range, and keep
your sugars in it, as best you can.

Although every effort should be made to prevent
hypoglycemia, almost every diabetic, especially those who
use insulin, will occasionally experience a reaction.
Common causes include straying from the prescribed diet,
taking too much insulin or oral medication, not eating
the proper amount at the proper time, or doing vigorous
exercise, especially at an unplanned time. Sometimes a
"low" comes on for no apparent reason at all. Alcohol
and certain drugs (certain sedatives, sleeping pills, and
the "beta blockers") can also lower blood sugar and bring
on a reaction. Individuals practicing strict "tight
control," holding to a low blood glucose level, increase
their risk of hypoglycemic episodes. Although the
long-term benefits of tight control are great, some
individuals may need to relax their numbers a bit,
trading higher glucose meter readings for an increased
margin of safety. THE GOAL SHOULD BE TO USE THE TIGHTEST
CONTROL THAT IS RIGHT FOR YOU.

Symptoms vary between people; learn what yours are
when you "get low." Studies suggest a diabetic's
awareness of his or her hypoglycemia is a learned
response, is taught, and can be improved by more
education. There's no substitute for your glucose meter,
but "when I feel like this my blood is doing that" is a
good line of defense. The old saying "know thyself!"
makes sense here. Once you recognize the symptoms, you
can take quick action to correct the condition.

Symptoms of low blood sugar reaction can be divided
into two general stages. The first stage, usually
occurring early in a reaction, can include shakiness,
sweating, nervousness, fast pulse, dizziness, headache,
and pale skin color. These symptoms may appear suddenly.
The second, more advanced stage of hypoglycemia, includes
mood/behavior changes, confusion, poor coordination, and
difficulty in speaking. If you think you might be going
into a reaction, have a snack, some simple carbohydrate,
now. Better safe than sorry.

Next to prevention, the best way to treat a low blood
sugar is to "nip it in the bud." To do so requires that
you realize it is happening. Many diabetics have learned
to recognize a reaction by the way they feel. For
example, I have learned to recognize that at the first
sign of a "low," I feel a kind of inner shakiness,
although it is not physically visible to anyone around
me. Although difficult to describe, it is a sensation I
have learned, and recognize as an early sign of low blood
sugar.

Note: Some people have "hypoglycemia unawareness,"
and cannot sense when a reaction is coming on, or even
that a reaction is in progress. There may be few initial
symptoms, or they may fail to recognize them. By the
time symptoms manifest, these individuals may be too
disoriented to help themselves. These folks should be
particularly careful to keep to their insulin and eating
schedules, and to monitor themselves for low blood
glucose levels. (Note: Studies suggest a long period of
euglycemia--normal blood sugar--achieved by tight control,
may restore some ability to perceive a "low.") When such
persons experience a reaction, it may appear at the
"second stage," with disorientation, confusion, or even
loss of consciousness. A diabetic in this condition,
while still conscious and able to swallow, needs sugar
immediately. CAUTION: DO NOT FORCE ANYTHING DOWN THE
THROAT OF AN UNCONSCIOUS PERSON--IT CAN BE ASPIRATED INTO
THE LUNGS!

Simple Carbohydrates/Sugars

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Doctors and Diabetes Educators recommend "The Rule of
Fifteens" -- 15 grams of simple sugar, immediately by
mouth and every 15 minutes after, until hypoglycemic
symptoms have cleared, and blood glucose has returned to
normal range. People vary -- learn what's best for you,
but note: -- taking more won't bring your sugars up any
faster!

Below are listed examples of simple sugars in appropriate
quantity:

3 or 4 Glucose tablets (available at your pharmacist)

5 or 6 Lifesavers candies

1 level tablespoon of granulated table sugar

1 tablespoon of honey

1 small tube of cake decorator's gel (sizes vary, one is
19gm, of which 12 gm are sugar)

Several companies make similar "glucose gel" products.

NOTE: Sugar-free, "low-cal" products provide no
benefit in treating a "low," and the fat in high-fat
"sweets" (like candy bars) can slow the absorption of
sugar!

What should you do then? Once symptoms of the low
have cleared (use your blood glucose monitor to be sure),
if your next meal is scheduled within 30 minutes or less,
be sure you eat on schedule. If it'll be more than 30
minutes, you should have a snack, more substantial food,
to cut the risk the hypoglycemia will reoccur. Food
containing complex carbohydrates, such as fruit,
crackers, or a lowfat peanut butter sandwich, should be
taken. Skim milk is particularly ideal, as it contains
both a simple sugar, lactose, and proteins. The complex
carbohydrates in the foods listed above enter the blood
more slowly than does refined sugar, but their effects
endure, helping re-establish euglycemia, proper blood
glucose level. Don't overtreat -- don't gorge yourself
here! You need to eat--but if you keep "stuffing it in,"
you may drive your blood sugar up above 300 or more! Eat
ENOUGH to re-establish euglycemia, and then STOP. If a
glucose meter is available, use it. (Note: The Diabetes
Control and Complications Trial suggested that diabetics
who had experienced a reaction stood a 50% risk of
another within 24 hours, and a 25% risk of another in the
next 24 hours.)

If a diabetic "misses the signals," if, for whatever
reason, no action is taken to bring the blood sugars back
up, the reaction will progress. The diabetic may shake
or sweat. When someone asks if something is wrong, the
response may be, "There's nothing wrong," or "I'm all
right." Confused, the diabetic may ask the speaker to
repeat himself, or may state that the question was not
understood. A person undergoing a low blood sugar may
appear distant, meditative, unusually quiet, "in another
world." He or she may stop conversing, or might respond
very slowly to questions. Some may become uncooperative
or belligerent, spewing obscenities at the offer of
assistance. The diabetic experiencing a "low" may seem
intoxicated. Unfortunately, every year a few diabetics,
thought by police to be drunk, are jailed overnight "for
drunkenness." Before morning, their untreated low blood
sugar reactions can lead to brain damage, even to death.

I strongly recommend that all diabetics wear medical
information jewelry, either a bracelet or necklace, and
carry a medical information card with them at all times.
I wear a bracelet, and my card is in my wallet. Such
information, available at most pharmacies, alerts law
enforcement and emergency personnel that the bearer is
diabetic, and is subject to low blood sugar reactions.
Because hypoglycemia is easily, quickly and inexpensively
treated, wearing a medical ID might help prevent an
expensive and unnecessary trip to the emergency room.

The diabetic should inform friends and fellow workers
about low blood sugar reactions. Relate symptoms and
remedies. Tell friends and fellow workers: "When in
doubt, give me something with sugar in it."

Occasionally a type 2 diabetic will experience a low.
If the individual is taking the oral medication acarbose
(trade name Precose), alone or in conjunction with a
sulfonylurea, table sugar will not be an effective
treatment for hypoglycemia. Oral glucose tablets or
lowfat milk are recommended.

When a diabetic is unconscious due to a "low," many
physicians recommend an injection of glucagon, a
prescription drug. It acts rapidly and causes the liver
to release stored glucose directly into the blood stream.
After an injection, the diabetic should regain
consciousness within 10 to 30 minutes. Expect a lot of
variation--no two diabetics, and no two reactions, are the
same.

After giving the injection, apprise the diabetic's
physician of the situation. The glucose released after
a glucagon injection burns off rapidly. To prevent
recurrence of the reaction, it is important for the
diabetic to take some food, especially complex
carbohydrates. Glucagon may make some diabetics
nauseated (there is a risk of vomiting--turn the patient's
head to one side and guard against choking). Some
individuals may need to wait 20 to 30 minutes after
glucagon is administered before having any food.
Incidentally, glucagon is expensive, but I recommend all
diabetics keep glucagon emergency kits on hand. Unmixed
glucagon keeps without refrigeration (mixed glucagon must
be used or discarded within 48 hours).

There seems to be no medical consensus regarding how
much time should elapse before emergency help is sought.
However, if a diabetic is not cognizant after two rounds
of sugar or two injections of glucagon, emergency medical
help should be summoned.

A diabetic walks a thin line between high and low
blood sugar. To keep diabetes under control, he/she must
follow the recommended diet and exercise, and must take
the proper dosage of medication, on time. DON'T OBSESS
OVER "TIGHT CONTROL." YOUR GOAL SHOULD BE TO USE THE
TIGHTEST CONTROL THAT IS RIGHT FOR YOU. Keep to your
schedule--it's your first line of defense. If and when
you experience a reaction, the best way to ensure your
safety is to know how to bring yourself out, keep the
tools close at hand (glucose tablets, cake icing, gel, or
sugary liquid, if consciousness is present; glucagon if
it is not), and tell your family, friends, and co-workers
what to do when you cannot help yourself. Discuss these
issues! A hypoglycemic reaction is an emergency
situation, and should be treated quickly to restore
normal blood glucose level. Plan, prepare, and be
rewarded!