Hypoglycemia means low blood sugar, and the condition occurs primarily as a result of diabetic treatment. Some people with diabetes never experience hypoglycemia. The incidence, however, has increased significantly since the advent of intensive control of blood sugar. Tight control is now recognized as the best way of avoiding or delaying long-term complications. In the landmark research trial on diabetes control, the Diabetes Control and Complications Trial (DCCT), 65 percent of patients getting intensive treatment (compared to 35 percent of those receiving conventional treatment) had at least one episode of severe hypoglycemia over a 6.5-year period.
The Need for Glucose
The body, and particularly the brain, is highly dependent on energy from sugar in the blood. Blood sugar, or blood glucose, comes not only from sweet foods, but also from the breakdown of carbohydrates such as fruits, vegetables, rice and potatoes. Insulin is a hormone secreted by the pancreas. It is the key that allows cells to take in glucose to use it for energy and store what is left in the liver and muscles for future use.
In a person with diabetes, blood sugar becomes elevated because the pancreas is unable to produce enough insulin or because cells are unable to use it effectively. Because of a lack of insulin, excess glucose lingers in the blood, eventually damaging nerves and small and large blood vessels and leading to the common complications of diabetes. We give diabetes medication to allow movement of sugar into cells. But sometimes diabetes treatment takes too much sugar out of the blood. A certain amount of blood sugar is needed, particularly by the brain, to carry on routine activities. The goal of diabetes treatment is to provide the right amount of insulin to balance the patient’s diet and physical activity. Too much insulin coupled with too much physical activity or too little food can cause blood sugar to drop fairly dramatically. For a person with diabetes, hypoglycemia, or low blood sugar, can also occur because the liver doesn’t react as it should to the signals of low blood sugar.
Symptoms
Mild symptoms of hypoglycemia include intense hunger, nervousness, sweating, weakness, trembling and rapid heart beat. A person without diabetes might experience similar symptoms as a result of prolonged fasting, but this is not as dramatic as with diabetes. For a diabetic, the need to raise blood sugar is truly urgent and requires quick consumption of a simple sugar that can be easily absorbed.
Treatment
The general rule for mild hypoglycemia is to take 15 grams of glucose; that is the equivalent of 6 lifesavers, a tablespoonful of raisins, or a half a glass of regular soda or juice. Contrary to what many with diabetes would like, desserts such as cookies, candy bars, or brownies are not recommended. These sweets include simple sugars combined with fat and protein. As a result, they take longer to be absorbed.
After the immediate symptoms of low sugar resolve, a longer acting carbohydrate plus fat and/or protein snack–such as half a peanut butter sandwich is usually recommended to stabilize blood sugar. If there’s no improvement of symptoms or an increase in blood sugar after 15 minutes, however, the patient should take another 15 grams and repeat the process no more than three times before calling an ambulance.
Without prompt attention, a diabetic’s blood sugar will continue to drop and symptoms will become more severe: confusion, slurred speech, blurred vision, difficulty concentrating, behavioral changes, seizures and eventually loss of consciousness.
People with diabetes who are at risk of frequent hypoglycemic attacks should check their blood sugar before driving a car, operating machinery or taking part in strenuous physical activity. A reading of 70 mg/dL is considered mild hypoglycemia, requiring action even though it might not produce symptoms. A reading of 50 mg/dL or below is severe and requires urgent attention. For persons at risk of suffering severe attacks, glucagon kits for home use may be an alternative to an emergency room visit. Glucagon must be approved and prescribed by a physician.
Who Is at Risk?
Mild hypoglycemic attacks now occur fairly frequently among those with type 1 diabetes on intensive therapy. Sometimes people with type 2 diabetes are at risk if they take insulin or other intensive treatment. Elderly patients are particularly at risk because they may have other medical conditions or be taking medications that affect blood sugar. They may also be prone to memory lapses regarding medication or have difficulty measuring their insulin doses because of failing vision. Also at risk are active young children, adolescents with eating disorders and those who participate in vigorous physical activity. Smoking and excess alcohol intake (particularly on an empty stomach) also increase the risk of hypoglycemia.
To prevent hypoglycemia, athletes are advised to plan workouts at times when insulin effects are low and blood glucose is on the rise, such as shortly after a meal. It’s important to check blood sugar not only before exercise but 15 minutes after exercise and sometimes even during a workout if it lasts more than 30 minutes. Carbohydrate snacks should be kept readily available.
Awareness must be high at all times since hypoglycemic attacks can occur several hours after exercise–or even the next day. It’s important for patients to learn to recognize the signs of a mild attack and carry with them glucose tablets or food for quick treatment. Signs may vary from person to person but are usually fairly consistent within the same person.
Good education is essential so that fear of hypoglycemia does not lead a patient to over-eat in anticipation of an attack or neglect efforts to keep blood sugar under tight control. The long-term complications that develop because of uncontrolled blood sugar are at least as life threatening as a severe hypo attack. Both must be avoided.
If you or someone you know needs help with understanding or controlling diabetes, call us at Bremo Diabetes Lifecare 804-285-8055 ext 128. We offer diabetes education, which is frequently covered by health insurance.
Michelle Herbert Thomas, PharmD, CDE
Clinical Director, Richmond Apothecaries Incorporated
