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Diabetes Download: What If I No Longer Feel My Lows Like I Used To?

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In Diabetes Download, Nalani Haviland, a board-certified physician assistant and diabetes expert who has type 1 diabetes herself, answers the Mighty community’s questions.

Editor's Note

If you’ve been living with diabetes for a long time, you may not feel hypoglycemia like you used to. Here, Nalani Haviland, PA-C, explains how to cope with “hypoglycemia unawareness.”

This column is solely for general education and information. It is not intended to provide any medical advice and cannot replace or be a substitute for your relationship with your healthcare provider. Always talk to your clinician for any issues or questions.

The Mighty community asked: “I’ve had diabetes for about 25 years now, and I’ve noticed that I don’t feel my lows like I used to. Sometimes I don’t feel any hypo symptoms until I’m in a dangerous situation. Why is this happening?”

Excellent question! This is a dangerous state called hypoglycemia unawareness and can happen in people who have had diabetes for a long time and/or have been experiencing a lot of lows. Let me explain further…

Hypoglycemia is not only one of the most dangerous challenges we face as PWD, but it is also one of the scariest. Hypos can be caused by many things: exercise, excess insulin, alcohol, or a sulfonylurea (glipizide) just to name a few. These lows make us feel shaky, dizzy, irritable, sweaty, and weak because our brains depend solely on glucose for fuel.

When there is an inadequate amount of glucose available, the body reacts! This reaction acts not only as a physical warning, but also helps to stimulate physiologic mechanisms that raise blood glucose levels. Due to these mechanisms, people without diabetes rarely get hypoglycemia. The pancreas and the liver work together to balance the release of insulin and glucose depending on the body’s needs. When PWD take drugs such as insulin or sulfonylureas (glipizide/glimepiride) to help lower the blood glucose (BG) or if they have a history of frequent hypos, neurohormonal responses can be impaired causing hypoglycemia unawareness.

Why is this dangerous? Because if a PWD is unaware of a low BG, then they may not treat it!

In people without diabetes, the first defense mechanism against hypoglycemia is a decrease in the secretion of insulin. This mechanism is completely impaired in people with type 1 diabetes and becomes impaired over time in people with type 2. The second response is a release glucagon from the liver. This response, although usually normal at onset of DM, decreases over time. Lastly, epinephrine increases delivery of glucose and inhibits its use in the periphery. This allows for the little glucose that is available to be used by the more vital organs.

These mechanisms are impaired in PWD and even more so in people who experience hypoglycemia frequently. In fact, the lower the average BG, the higher the risk of hypoglycemia unawareness.  This can be very dangerous, especially overnight! If a person’s body does not warn them of a severe hypo, they may not wake up to treat it. Therefore, a continuous glucose monitor (CGM) in someone with hypoglycemia unawareness is especially important.

What can we do?

People who experience this can regain some awareness by avoiding lows. Alcohol ingestion can also contribute to hypo unawareness by decreasing the liver’s ability to release glucose (it is too busy processing alcohol). Alcohol avoidance is important in someone suffering from hypoglycemia unawareness or trying to regain some of that awareness. For someone with hypoglycemia unawareness, a CGM and access to glucagon are a must! With a CGM, the person can be alerted before severe lows occur.

Glossary of Terms

Type 1 Diabetes: A chronic condition that occurs when the pancreas produces little to no insulin. As a result, the body is unable to properly process glucose for energy. It is primarily managed with frequent blood glucose monitoring, diet, exercise, and either insulin pump therapy or multiple daily injections.

Type 2 Diabetes: A chronic condition resulting from insulin resistance and/or an inadequate response to insulin secretion. This results in the body’s inability to properly process glucose. It is managed with frequent blood glucose monitoring, oral or injectable medications, diet, exercise, and sometimes insulin.

Blood Glucose: Another name for blood sugar. Having blood glucose levels that are too high or too low is the hallmark sign of diabetes.

Insulin: A hormone produced by the pancreas. Insulin allows for the regulation of blood glucose and without it, the body cannot process glucose for energy. People with diabetes must get their insulin either through injection or insulin pump therapy.

Diabetic Ketoacidosis (DKA): A complication of uncontrolled diabetes caused by an insufficient amount of circulating insulin. This usually leads to high blood glucose levels and a buildup of blood ketones, byproducts of the breakdown of fatty acids. Untreated diabetic ketoacidosis can lead to coma and death.

PWD: Person with diabetes

Basal Insulin: Also called “background insulin.” In people without type 1 diabetes, the pancreas supplies consistent basal insulin to maintain blood glucose levels between meals. People with type 1 diabetes must inject long-acting insulin to maintain correct blood glucose levels.

Bolus Insulin: Insulin made by the pancreas in response to glucose consumed in food. People with type 1 diabetes must inject rapid-acting insulin immediately before a meal to maintain correct blood glucose levels.

Glucagon: A hormone that treats severe low blood sugar.

Continuous Glucose Monitor: A system that allows PWD to track their glucose levels throughout the day. A small sensor wire is inserted under the skin, and a reusable transmitter connects to the wire and sends readings in real-time to a receiver and/or smartphone app.

Follow me on Instagram at @diabetes_pa, on YouTube, and on my website.

Originally published: April 14, 2019
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