Hypoglycemia is a medical term to describe a situation where the amount of circulating useful blood sugar is lower than normal—a level low enough to cause symptoms in a person. Generally, hypoglycemia is defined as a serum glucose level below 70mg/dL. Symptoms of hypoglycemia can vary from person to person, from a common dizziness to having frank seizures.

Persons without any metabolic problems can complain of symptoms suggestive of low blood sugar, but true hypoglycemia occurs in persons with diabetes. Hence, it is important to educate the people we are treating for diabetes and help them recognize signs and symptoms of low blood sugar, and treat hypoglycemia when a patient develops the symptom.

In diabetes treatment, our goal is to maintain blood sugar at normal levels, but we also have to watch out for those times when the levels go below normal. Sugar or glucose is the fuel which our bodies run on. If a situation occurs, wherein person is under stress due to illness or has not taken enough food during meals, the blood sugar levels go down. During these times, when the body does not get enough fuel to maintain its needs, a protective mechanism will be activated. The first organs to be affected when the blood sugar levels go down are the sympatho-adrenal nervous system and the brain. As the levels of sugar go down, the brain senses this drop and sends out messages that will trigger a series of events aimed at increasing the levels of blood sugar.

Once the level of blood sugar drops down below 70mg/dL, the pancreas is signaled to produce a hormone called glucagon. Think of glucagon as the Mr. Hyde to insulin’s Dr. Jekyl. Glucagon’s role is to produce sugar from several sources in our body like fat muscle tissue and stores glucose called glucogon. This process of making sugar available is called gluconeogenesis. Other messengers activated are called epinephrine, cortisol, and growth hormone. Epinephrine, for example, is responsible for most of the symptoms you get when blood sugar goes down like palpitations, sweating and trembling.

These symptoms are easily recognizable and are called adrenergic response to hypoglycemia (see box on next page). These are great telltale signs, giving people an opportunity to correct the problem. If correction is not done at this point, the blood sugar levels may continue to go down further. Somewhere in the 50 mg/dL range, most patients progress to neuro-glycopenic ranges (the brain is not getting enough glucose).

Symptoms then progress to confusion, drowsiness, changes in behavior, coma, and seizure. It is important to note that patients with nerve damage or have repeated bouts of hypoglycemia may have no warning symptoms.

Recognition of the signs and symptoms is important, as well as knowing those persons who are at risk for developing hypoglycemia. Earlier, it was mentioned, stress as a precipitant to the development of hypoglycemia. Stress on the body include infections, or missing a meal while continuing to take diabetes medications.

Other causes include an increase in physical activity above the usual routine, meals or snacks that are too small, delayed, or skipped, or taking alcoholic beverages.

Preventing hypoglycemia
By knowing the cause of hypoglycemia, we can set our sights on prevention, and discussion of the adverse effects of diabetes medications that should be taught to people with diabetes (see a short list of medications bottom right). Patients should be reminded to take medications at the right dose and time, as well as to not take additional medication if a dose is missed.

Patients should eat regular meals following dietary advice, to take note of the quantity, and to not miss any of the meals and snacks. A visit to a dietitian can be useful in making a diet plan suited for an individual person’s needs.

For those people with diabetes who are physically active, the following is advised. First, check blood glucose levels before undertaking sports or physical activity, and at intervals during a prolonged activity and after the activity. Snacks may be taken if the blood sugar levels fall below 100 mg/dL.

Frequent blood sugar level testing is also recommended when illness develops, such as having diarrhea, a bad cough, or an infected wound which can put a strain on the body leading to hypoglycemia.

Treatment
If you suspect a person of having hypoglycemia, immediate action must be taken to increase the blood sugar level. The blood glucose can be raised to normal within a few minutes by taking 10-20 grams of carbohydrates. You can always give sugar at least once to a diabetic patient with symptoms of low blood sugar. If their blood sugar is already high, then the small amount given will not do any harm. If the blood sugar is low, giving it can be lifesaving.

If the person is awake and alert, give orange juice (or any available sugary juice). Water with added sugar also works (a couple of teaspoons or sugar packets per four ounces). A half a glass of regular (non-diet) soda will also work. Other forms of starch, such as a slice of bread or four crackers may work as well. Symptoms should begin to improve within five minutes, but full recovery may take 10-20 minutes.

Other useful therapies include cake icing, glucose gel, glucose tablets, instant glucose, or several candies. People with diabetes should routinely carry this remedy for potential emergency use.

Call for a doctor or bring the patient to the doctor if the patient develops a change in behavior, weakness, or drowsiness. Consider bringing the patient to the hospital if despite intake of emergency sugar, the symptoms do not change, or there is a return of hypoglycemic symptoms after being treated.

Summary
Hypoglycemia can be preventable and if attacks do occur, it can be easily be reversed. Here are some pointers when teaching about hypoglycemia:

1. Symptoms of hypoglycemia may vary. If in doubt, take the blood sugar levels.
2. Low blood sugar can be caused by too much medicine, too much stress, or too little food.
3. If you don’t have access to a glucose level test kit, eat now! Test later.
4. Stick to the plan, that is, stay on the recommended medications and diet plan.

Diagnosis of true hypoglycemia consists of three important features (known as Whipple’s triad):

• symptoms consistent with low blood sugar
• low plasma glucose (blood sugar) on testing
• relief of symptoms with sugar intake

It would be best to have regular blood sugar monitoring when doing more than the average activity, when starting new medications, and when another illness develops.

When do we advise that a person with a possible hypoglycemia be brought to the doctor? As a rule of thumb, it is best to inform the attending physician when hypoglycemia occurs as soon as they can and medication dosage can be switched, discontinued, or the physician can find out the cause of hypoglycemia.

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