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

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!