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Hypoglycemia: What Do You Feel In Your Body? What Do You Feel In Your

Mind?

King, Editor-in-Chief

1 May 2008

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We originally wrote this article for our September 1994 issue. Now it is

an " Archive Favorite " as it has not gone out of date, and is still very

helpful.

Not much has changed about hypoglycemia or its treatment in the last 14

years. Am I right or wrong? For me, Learning all I can about Lows makes

it easier

to recognize and manage them (before I go too Low). I've used this

article to help understand what I am feeling so I can recognize a Low

early on! Please

use the Comment feature below to share your experiences of success, or

tell us about your worst Low, what happened and what you learned.

A word of caution about the values used below. This study was conducted

using people without diabetes. Some people with diabetes experience

symptoms at

higher glucose levels than the study suggests. Other people with

diabetes appear to function well with blood sugars in the 30's and 40's

(mg/dl). Therefore,

the values in the study should only be used as an approximation. This

study also used plasma glucose levels. Your values done at home might be

20 percent

lower or higher than these lab values. For example, epinephrine release

in someone without diabetes would begin at about 63mg/dl with a home

blood glucose

meter.

More caution: Many people with long-standing type 1 diabetes completely

lose some of these responses. The glucose counter-regulation system

becomes impaired

sometime during the first few years of diabetes. This impairment is

unusual in that it seems to be hypoglycemia-specific: the ability of

glucagon and epinephrine

to respond to other stimuli is basically unchanged, but is reduced or

absent when dealing with hypoglycemia. The cause of this is not known,

but it is

closely linked with the lack of insulin production.

SIDE BAR:

HYPOGLYCEMIA, What Happens As Your Blood Glucose Levels Fall*:

at 69 mg/dl Epinephrine is released into the bloodstream

at 68 mg/dl Glucagon release begins

at 67 mg/dl The brain conserves glucose by reducing glucose uptake

at 66 mg/dl The body releases the growth hormone Somatotropin, which

tells the body to reduce its use of glucose and burn fat instead

at 58 mg/dl Cortisol, a steroid that promotes the conversion of glycogen

into glucose

at 54 mg/dl Full-on hypoglycemic body symptoms may start including

shaking, pounding heart, nervousness, sweating, tingling and hunger

at 49 mg/dl Thinking becomes impaired. The Mind symptoms start:

confusion, drowsiness, weakness, feeling too warm, difficulty speaking,

impaired coordination

and odd behavior

*Many type 1s don't have all these responses.

In this age of tight control, hypoglycemia has become a major concern

for people with diabetes. How much do you really know about it? This

article details

symptoms, causes, and the body's responses to hypoglycemia. The more you

know about hypoglycemia, its progression, and its causes, the more

likely you

will be to control or prevent it.

" I'm drenched in sweat and everything is getting on my nerves. My face

feels tight and my lips feel numb. I know I should check my blood sugar,

but I can't

think well enough to get it together. Finally I get my finger stuck, my

blood drop on the strip, wait... Blood sugar reads 40mg/dl. I eat 4

Dex4's and

start to feel better in about 10 minutes. My health practitioner calls

this hypoglycemia, but I call it pure hell. "

I know many type 1's actually get used to this, and learn to feel, test

and correct by eating very effectively. Others, like me, get the

" Diabetic Werewolf

Syndrome " where I have to keep eating everything in site until my blood

glucose raises back up, usually about 20 or 30 minutes until we stop

shaking. But

of course every hypo can be different. I have friends that can get quit

querulous when they are low. I have seen some skinny type 1's who, when

low,

may even " fight off " a husband who tries to get them to eat. Many of us

have spent our whole lives AVOIDING Sweets, so their subconscious

eschews sweet

even when low. Everyone had heard of some Low diabetic doing something

REALLY wacky. Like running out to the parking lot at work and urinating

while standing

on the bosses car. Can't you just hear him later, " Wow, I did that?

Sorry Boss, I must have had a real bad Low! "

At some level, hypoglycemia as the ability to let our unconscious

thoughts come out. Kind of like being drunk and doing something

embarrassing you don't

remember later. Has anyone here ever woke-up with paramedic surrounding

your bed asking you what day it is? Maybe yours was running naked our

the front

door one night mumbling something about the ice-cream man coming? This

can happen to anyone as it is really very easy to et too much insulin.

No one has to tell most people with diabetes that low blood sugar or

hypoglycemia is one of the most common and potentially dangerous

problems of diabetes.

Mild hypoglycemia is annoying and embarrassing; severe episodes can lead

to brain damage, seizure, coma, or, even death.

Although the famous 1993 DCCT study showed conclusively that reducing

blood glucose levels also reduces long-term diabetes complications, it

also found

that people who keep their blood sugars close to the normal range have a

three times greater chance of hypoglycemia. Some of the 27 centers

involved in

the DCCT were able to achieve nearly normal average blood sugar readings

with very little hypoglycemia. However, a significant risk remains when

tight

control is attempted.

Hypoglycemia is dangerous because it impacts the brain or nerve center,

which derives almost all of its energy from glucose. The brain depends

on the bloodstream

for a continuous supply of glucose because it can only store a few

minutes' worth of energy as glycogen. Any change in blood glucose levels

can quickly

and seriously affect thinking and coordination.

Hypoglycemia can usually be detected by the brain, but the brain relies

heavily on warning signals generated by the central nervous system as

the blood

sugar drops. Signals like sweating and shaking are produced by the

release of stress hormones in a process called glucose

counter-regulation. This release

starts the slow return of the blood sugar to the normal range. The

liver, interestingly, is directly involved as well in sensing and

correcting low blood

sugars. Remember that some type 1s lose this response (the body's own

ability to raise BG's) altogether over the years.

Non-diabetics can count on the body's backup systems for raising a low

blood sugar. In a research paper done by Dr. Philip Cryer at the

Washington University

School of Medicine, these recovery systems were outlined in non-diabetic

volunteers. Physical responses that generate recovery are triggered at

different

glucose levels.

The first response, which occurs at around 83 mg/dl, is a reduction of

insulin production, while the second, the release of epinephrine into

the bloodstream,

begins at 69 mg/dl, but plays a minor role unless the supply of glucagon

becomes deficient. Glucagon release begins at 68 mg/dl, followed at 67

mg/dl by

a reduced glucose uptake into the brain. And at 66 mg/dl, the body

releases the growth hormone somatotropin, which tells the body to reduce

its use of

glucose (so this defense mechanism is trying to keep us form going too

Low). Somatotropin also tells the body to increase the use of fats as

fuel.

As the blood glucose level reaches 58 mg/dl, cortisol, a steroid that

promotes the conversion of glycogen into glucose, is released to assist

in raising

the body's glucose levels. For these test subjects, when the glucose

level fell to 54 mg/dl, the body's hypoglycemic symptoms started. At 49

mg/dl thinking

becomes impaired, as now the brain is low on glucose too.

Long term type 1s who lack a good epinephrine and glucagon response, are

25 times more likely to experience severe hypoglycemia than those who

respond

normally.

Two types of symptoms are associated with hypoglycemia: neurogenic

(body) symptoms, which originate in the nervous system, affect the body,

and are usually

noticed by the person with diabetes himself; and neuroglycopenic (mind)

symptoms, which affect the mind. The latter are a direct result of

glucose deprivation

in the brain, and are frequently noticed by others but not by the person

with diabetes.

In the controlled study of non-diabetics, the neurogenic symptoms occur

at around 54 mg/dl and include shaking, pounding heart, nervousness,

sweating,

tingling, and hunger, while the neuroglycopenic symptoms which occur at

49 mg/dl are confusion, drowsiness, weakness, feeling too warm,

difficulty speaking,

impaired coordination, and odd behavior (and, of course, coma, seizures,

and death).

Risk Factors for Hypoglycemia:

1-an excessive insulin in the blood (due to either high injected dosage

or missed meals),

2-an increase in the use of insulin (as seen during exercise),

3-a decrease in glucose production (as occurs after drinking alcohol),

or

4-an increase in insulin sensitivity (also seen during exercise).

5-a history of severe hypoglycemia,

6-having type 1 diabetes for over 9 to 12 years,

7-any lowering of HbA1c levels, and

8-an increase in your insulin dose.

9-Any hypoglycemia can impair the body's detection of hypoglycemia for

up to 3 days. This means glucose levels must go even lower to produce

hypoglycemic

symptoms and activate glucose counter-response after any hypoglycemia.

Hypoglycemia unawareness, the clinical condition in which people no

longer experience the neurogenic symptoms of low blood sugars, affects

many people

with type I diabetes and a few with type 2. The glucose levels needed to

trigger glucose counter-response are lower in people with hypoglycemia

unawareness

and the first symptoms they usually experience are neuroglycopenic, a

sign of blood sugars of 49 mg/dl or less.

Recent studies indicate that avoiding hypoglycemia for a period of time

as short as a few weeks may reverse hypoglycemia unawareness. (See the

Uncomplicating

Column in the March, 1994, issue of Diabetes Health.) People who suffer

from hypoglycemia unawareness should monitor their blood sugar levels

very closely.

Hypoglycemia unawareness itself increases the risk for hypoglycemia by

seven times.

Hypoglycemia is dangerous. As a complication of diabetes, it is perhaps

the most easily treated, but can also be the most immediately dangerous.

Awareness

of the signs, symptoms, and risks of hypoglycemia, and diligent

monitoring of blood sugars allows hypoglycemia to be controlled and even

avoided. This

can be vital, because like many things about diabetes, hypoglycemia is a

self-perpetuating problem.

This article was refined from a review article called " Hypoglycemia "

which appeared in the July, 1994 issue of Diabetes Care.