Hypoglycaemia (Hypo)
Hypoglycaemia or the more common name ‘hypo’ or ‘insulin reaction’ occurs when blood glucose (BG) level drops below 4.0 mmol/l (72 mg/dl). This is a result of too much insulin in the body for the amount of glucose available. For people who don’t have diabetes the body balances the insulin to glucose ratio exactly but for diabetics who have to administer insulin artificially it has to be balanced manually which can result in imbalances.
Hypoglycaemia is a serious and potentially life threatening complication of insulin treated diabetes. It doesn’t occur with other diabetes medications.
Hypos mainly occurs in type 1 diabetics (T1), but may also occur with type 2 (T2) depending on the medication taken. Most type 1 diabetics get them, especially if they keep good blood glucose (BG) control. If BG levels are near to normal a small dip may result in a hypo situation. They also occur in cases of poor control because BG levels are allowed to swing from high to low.
Hypos are my least favourite thing about diabetes. They take time to identify, treat and often leave unpleasant side effects for the remainder of the day or night. They can happen at the most inconvenient times (at work, while out and about or during the night). They can occur very quickly. People who get hypos are often on high alert for hypo symptoms. This can become stressful. The best way to reduce worry about hypos is to check BG regularly and deal with any low BG or symptoms of a hypo immediately. Knowledge is power, so learn about hypos and how your type of insulin works (the length of time it takes to work and how long it work for) and know how to count carbohydrates (as best you can).
Hypos vary from being very mild, only needing a small quantity of quick acting glucose to correct the BG level, to severe where the person becomes so disorientated that they need help to take glucose. The BG level can drop so low that the person becomes unconscious or unable to take glucose safely, due to the danger of choking.
Possible reasons for a hypo:
- Too much quick acting insulin administered for the amount of food eaten (estimated the carb count in the food incorrectly or ate less than intended).
- Too much background insulin (the amount you need can change from time to time).
- Gave too much insulin (background or quick acting) and didn’t realise it (e.g. thought 4 units was given when it was actually 6 units or gave quick action instead of background insulin. Can happen when you are distracted).
- Gave too much insulin to correct a high BG level.
- More exercise than usual.
- Alcohol consumed on an empty stomach – alcohol can reduce BG levels for up to 16 hours after it is consumed – a hypo at mid-day could be due to alcohol consumed the previous evening. If alcohol is consumed over a day (party etc.), it can result in BG issues even if food is eaten regularly and insulin given for the carbs in the alcohol).
- Illness can cause a drop in BG level, but more often it causes a rise in BG.
- Sometimes it’s a number of small things and you may not be able to find the exact cause.
Symptoms:
Symptoms vary from person to person and symptoms can be different on different occasions in the same person. A person’s awareness of hypo symptoms (feeling a hypo coming on) may decrease, which is dangerous because the person may become too ill to treat themselves and end up very ill or in a dangerous situation (won’t be able to judge everyday situations). This is something that I have had to keep a check on over the years. If you don’t notice hypo symptoms, talk to your Doctor. Carry out more BG checks until you have found a solution to this problem. When your BG goes below 4.0 mmol/l (72 mg/dl) symptoms may occur which include sweating, headache, sudden tiredness, feeling hungry, anxious and shaky.
If the low BG isn’t treated quickly, BG may drop further and symptoms will worsen and may include feeling disorientated, blurred vision, pins and needles, sudden mood swings and loss of concentration.
The reason for these symptoms is that a low BG level prevents the brain from getting enough fuel to perform its normal functions. If left untreated this will lead to unconsciousness and may be fatal.
Best hypo treatments are:
I have often over-corrected a low BG (took too much sugar to counteract the low BG) and ended up with high BG later. This can cause high and low BG levels for a couple of days. It’s best to treat a hypo in a controlled way. Easier said than done if you are feeling confused due to the hypo.
It’s best to plan how you are going to treat any potential hypos and always have sufficient supplies (often called a hypo kit) available. Make sure to replace any that you use. Chocolate is not a good hypo treatment because it contains fat which slows the rate in which the glucose is absorbed into the blood stream. If there is a possibility that other people will use your hypo kit it’s best to explain that you need it for medicinal purposes and also put a label on it as a reminder.
Once symptoms occur, test BG and if it is low (below 4.0 mmol/l (72 mg/dl), take 15-20g of carbohydrate. Examples are:
180ml of fruit juice (a small glass)
Carbs in both fresh & cartons of juice vary, so check the label or determine which fresh juice gives you the quickest result. The juice from 1 very large or 2 small oranges works very well for me. If you are near a juice bar, fruit juice is an ideal hypo treatment. It’s not a good idea to spend time preparing juices at home. I leave a manual juicer near the fruit bowl so that I can juice quickly. If I am very low I use an another treatment.
- 3 level teaspoons of sugar (approx 13g)
Little packets of sugar (most contain 4g of sugar per packet) are handy.
Sugar lumps (approx. 15g of carbohydrate in 5 sugar lumps).
Cheap and always available, no matter where you go! Sugar has fewer additives than sweets and fizzy drinks.
- Glucose
Pure glucose travels straight through the intestinal wall and into the blood stream quicker than any other carbohydrate. This is ideal, especially if BG is very low. Dextrose tablets, powdered glucose or Glucogel are ideal. I have been sick after taking it so I generally avoid it. When I used Glucogel I found it messy to take and was left with a sticky tube (the seal doesn’t go back on) in my bag.
- 3 – 6 jelly sweets (depending on the type)
These used to be one of my hypo treatments because they don’t spill, melt, go off once opened or in hot weather. They contain a lot of additives, so I rarely use them. Having said that they are very effective for hypos.
- Lucozade
Lucozade was another of my favourite hypo treatments but not anymore. In April this year, the manufacturers reduced the sugar content, to avoid the new sugar tax. Despite Lucozade being recommended by Doctors and Diabetic clinics and their many diabetic customers, they didn’t inform people of the change, in any meaningful way. The bottles look the same. Nobody reads the nutritional label of every single product they use, once they are familiar with the carb count. The old and new recipe bottles were side by side in supermarkets. This left people who treated hypos with Lucozade in danger of inadvertently taking too little and becoming fatally ill.
It now takes 200 ml of Lucozade to get 15g of carbohydrate and because it is diluted in so much water and other scary ingredients, it will not work as quickly as the old recipe. I don’t use it anymore. The manufacturers are definitely off my Christmas card list!
- Dried fruit bars
These are one of my favourites for treating hypos where my BG hasn’t gone very low.
Important: consult your Doctor for hypo treatment for children under 3 years of age.
If your BG is very low (e.g. 2.1) you will need to take 40g of quick-acting carbohydrate straight away, because the danger of becoming unconscious is very high once BG goes below 3.00 mmol. You should also take have something like a slice of bread or a couple of biscuits to prevent a further dip in BG. You should start to feel better in less than 15 minutes. If you don’t and your BG level hasn’t increased, take another 15g of carbohydrate.
If for example, you have given your insulin twice you will need to calculate how much you need to eat to balance the overdose. If it’s quick action insulin it can be corrected fairly quickly but it it’s long-acting insulin you will need to eat extra carbohydrate (quantity depends on overdose quantity) and monitor BG for up to 24 hours.
If the next meal isn’t in the next 30 minutes, I would also take 10/20g of slow acting carbs (e.g. a slice of bread or a small banana) to ensure that I didn’t go hypo again. The level of correction and monitoring afterwards depends on the severity of the hypo and if the cause is known or not. If the cause can’t be determined extra monitoring is needed until things settle.
If I get more than one unexplained hypo in a 48 hour period, particularly during the night I would look at my background insulin dose. The quantity of background insulin required can change for no particular reason and change back again in a few days or weeks later.
It’s a good idea to let your family and friends know about hypos and how they affect you. Sometimes during a hypo, you could get confused and be unable to get your glucose to correct it. It is far better for you and people around you to know how they can help you. After all, it can be frightening for them to see you having a hypo and not know what to do.
There have been many incidents of people with diabetes having a hypo and being unable to help themselves and people thinking they are drunk or taking drugs and refusing to help them. So always have your fast acting carbohydrate with you and don’t delay in taking it when needed. Never drive without checking your BG levels. See my article on driving.
Very severe hypos
If a diabetic becomes unconscious another person can administer a glucose injection (called GlucaGen) http://www.glucagenhypokit.com. and give the person quick acting glucose as soon as they become conscious again. It is advisable that family members, friends and colleagues are shown how to recognise the symptoms of low BG, where you always keep your quick acting glucose and how to give the GlucaGen injection (if the situation becomes very severe). If the hypo situation is even more severe the person will need urgent hospital treatment so the emergency services should be called immediately.
National Driver Licence Service (NDLS) regulations for drivers with insulin dependent diabetes:
Group 1 – drive a car, motor or tractor, you must inform the NDLS if:
You suffer more than one episode of severe hypoglycaemia (where you need someone to help you) within the last 12 months.
Group 2 – Driving a bus or truck, you must inform NDLS if:
You suffer one episode of severe hypoglycaemia or your medical team feels you are at high risk of developing hypoglycaemia or you begin to have difficulty in recognising warning symptoms of low blood sugar (impaired awareness of hypoglycaemia) or you suffer severe hypoglycaemia while driving.
https://www.ndls.ie/images/Documents/Forms/Diabetes-and-Driving.pdf
T1 = type 1 diabetes
BG = blood glucose or blood sugar
