The Lowdown on Hypoglycemia (Dangerously Low Blood Sugars)

My hands start shaking. Cold shivers creep in, despite the warm sweater I'm wearing. My vision blurs, to the point where I can't clearly see what's right in front of me...

These are just a few of the symptoms I experience when my blood sugar dips too low, or in other words, when hypoglycemia sets in. As someone living with type 1 diabetes (T1D) since childhood, this is an all-too-frequent reality that I've learned to cope with. Technology can certainly help prevent these hypos, but it's not a guarantee and I still experience them quite often.

Not everyone feels the same symptoms when their glucose levels drop, and many T1Ds — myself included — sometimes don't feel any symptoms at all to alert us of plummeting glucose levels. That's known as "hypoglycemia unawareness" and it's something particularly dangerous overnight, as we don't always wake up to treat a low with necessary sugar, which can lead to a seizure or even death.

Fear and avoidance

It is well-noted by experts that the danger of hypoglycemia doesn't get enough attention. There's also a stigma associated with it, since the general public and even our friends and family often don't understand, but rather wonder what we "did wrong" to make our glucose levels drop.

Within the Diabetes Community, there are layers of conversation on this topic — from common Fear of Hypoglycemia (FOH) that leads people with diabetes (PWDs) to keep their glucose levels higher to avoid lows, to kids with diabetes hiding the fact that they even have hypos, to people with type 2 diabetes being afraid to take insulin because they're fearful of potential lows.

As someone now nearing four decades living with this chronic condition, it also concerns me greatly to know there are PWDs out there who don't actually know what the word "hypoglycemia" even means. That's a health literacy component, of course, which should remind us that medical terminology can be confusing for many people — and that many face a misdiagnosis scenario or medical professionals who don't educate them properly upon diagnosis.

Meanwhile, alarmingly, stats from the Centers for Disease Control (CDC) show that hypos alone account for more than 200,000 emergency room visits each year!

It's a huge issue that our D-Community is addressing through advocacy and awareness campaigns. To help shed light on this important topic, we've compiled the following overview.

What is hypoglycemia?

Hypoglycemia is generally considered by both patients and doctors to be a glucose level less than 70 mg/dL (<3.9 mmol/L).

But believe it or not, there was no official consensus among healthcare professionals on the exact definition until 2018, when key diabetes orgs agreed on three levels of hypoglycemia that can be tracked with continuous glucose monitors (CGMs) in various studies:

Level 1: A glucose value of <70–54 mg/dL (3.9–3.0 mmol/L) with or without symptoms.

Level 2: A glucose level of <54 mg/dL (3.0 mmol/L) with our without symptoms. This should be considered "clinically significant" hypoglycemia requiring immediate attention.

Level 3: Severe hypoglycemia, which "denotes cognitive impairment requiring external assistance for recovery but is not defined by a specific glucose value."

Why these different parameters? It turns out that risk of hypoglycemia is affected by other health conditions and treatments that patients may be undergoing.

In PWDs, a low blood sugar can be caused by any one or a combination of these factors:

  • too much insulin or other glucose-lowering medication, whether that's too much fast-acting bolus (mealtime) insulin or long-acting basal (background) insulin
  • delaying or missing a meal, or not consuming enough carbohydrates to match the amount of insulin taken
  • more intense-than-normal exercise or simply physical activity in combination with insulin on board (IOB) 
  • alcohol, which can lead to lower glucose levels hours after drinking, despite a higher glucose initially due to carbs present in the drink
  • for some people, airplane travel or other unusual activity, that for some reason causes their glucose levels to drop
  • interaction with other drugs being taken, such as heart medications 

What does low blood sugar feel like?

The official medical list of standard symptoms of a hypo includes:

  • weakness, trembling, shaking
  • sweating
  • light-headedness or dizziness
  • headaches
  • fatigue, sleepiness
  • inability to focus or lack of concentration
  • tearfulness, emotional behavior change
  • irritability
  • hunger
  • blurred vision
  • coldness or shivering

Personally, over the years, I've experienced most, if not all of the symptoms at some point during a low.

Of course, it's hard to fully describe the feeling of a dangerously low blood sugar. A few years back, DiabetesMine Editor Amy Tenderich attempted to "describe the indescribable" low blood sugar sensation using the terms "weird" and "scratchy... the opposite of itchy." And then there was diabetes advocate and YouTuber Bill Woods (aka "1HappyDiabetic") who described his lows as "Hunger + Fear + Head Rush." 

Treatment options

The rule of thumb for treating non-emergency lows is something called the rule of 15: PWDs should consume 15 grams of fast-acting carbohydrates, wait about 15 minutes, and then check blood glucose. If still low, take another 15 grams of carbs and recheck 15 minutes later.

Any sort of simple sugar will do, but most people treat with glucose tabs, fruit juice, or simple candies like Skittles.

My own hypo trauma

Speaking of personal experience, I wanted to share that I believe hypoglycemia should be a No. 1 priority in diabetes education because it is so life-impacting on a daily basis. Lows can really mess with your job and daily existence, not to mention the fact that you may not wake up at night(!).

Growing up, I certainly wasn't hypo unaware; my symptoms were always clearly visible. But even at a young age, my lows would cause dramatic seizures or hallucinations where I'd envision strange things, like robot aliens attacking and trying to take over my mind in the form of my parents, for example. There were screaming fits where all they could do was hold me down and force juice down my throat.

That happened to me as an adult, too. After getting married and before starting on a CGM, I experienced some severe lows with hallucinations that caused aggressive behavior on my part. Once I even thought my wife was a Communist trying to poison me and I had to resist, to the point of chanting "USA, USA!," in my state of hypo-confusion.

It was scary for both of us, and we agreed that our best course of action in these situations (aside from working hard on prevention) was to phone the paramedics rather than have my wife attempt to hold me down herself to get juice or honey down my throat, or having to use the overly-complicated multi-step emergency glucagon injection that was the only option at the time.

I'm shuddering now... (not from a low, but just the vivid memories of this over the years).

With all of that in mind, I'm grateful to see more awareness-raising happening on the hypoglycemia front. It's possibly the most important issue facing people taking insulin, and should be discussed more often.

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Originally published on DiabetesMine

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