Disease: Hypoglycemia

    What is hypoglycemia?

    Hypoglycemia is the clinical syndrome that results from low blood sugar. The symptoms of hypoglycemia can vary from person to person, as can the severity. Classically, hypoglycemia is diagnosed by a low blood sugar with symptoms that resolve when the sugar level returns to the normal range. The medical term for blood sugar is blood glucose.

    Who is at risk for hypoglycemia?

    While people who do not have any metabolic problems can complain of symptoms suggestive of low blood sugar, true hypoglycemia usually occurs in people being treated for diabetes (type 1 and type 2). Individuals with pre-diabetes who have insulin resistance can also have low blood sugars on occasion if their high circulating insulin levels are further challenged by a prolonged period of fasting. There are other rare causes for hypoglycemia, such as insulin producing tumors (insulinomas) and certain medications. These uncommon causes of hypoglycemia will not be discussed in this article, which will primarily focus on the hypoglycemia occurring with diabetes mellitus and its treatment.

    Despite advances in the treatment of diabetes, hypoglycemic episodes are often the limiting factor in achieving optimal blood sugar control, because many medications that are effective in treating diabetes carry the risk of lowering the blood sugar level too much, causing symptoms of hypoglycemia. In large scale studies looking at tight control in both type 1 and type 2 diabetes, low blood sugars occurred more often in the patients who were managed most intensively. This is important for patients and physicians to recognize, especially as the goal for treating patients with diabetes becomes tighter control of blood sugar.

    I thought high blood sugar was bad. Why is low blood sugar also bad?

    The body needs fuel to work. One of its major fuel sources is sugars, which the body gets from what is consumed as either simple sugar or complex carbohydrates in the diet. For emergency situations (like prolonged fasting), the body stores a stash of sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to "make new sugar") and converts these stores of glycogen to sugar. This backup process emphasizes that the fuel source of sugar is important (important enough for human beings to have developed an evolutionary system of storage to avoid a sugar deficit).

    Of all the organs in the body, the brain depends on sugar (glucose) almost exclusively. Rarely, if absolutely necessary, the brain will use ketones as a fuel source, but this is not preferred. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. If for some reason, the glucose level in the blood falls (or if the brain's requirements increase and demands are not met) there can be effects on the function of the brain.

    Can the body protect itself from hypoglycemia?

    When the circulating level of blood glucose falls, the brain actually senses the drop. The brain then sends out messages that trigger a series of events, including changes in hormone and nervous system responses that are aimed at increasing blood glucose levels. Insulin secretion decreases and hormones that promote higher blood glucose levels, such as glucagon, cortisol, growth hormone, and epinephrine all increase. As mentioned above, there is a store in the liver of glycogen that can be converted to glucose rapidly.

    In addition to the biochemical processes that occur, the body starts to consciously alert the affected person that it needs food by causing the signs and symptoms of hypoglycemia.

    What are symptoms of hypoglycemia and how low is too low?

    The normal range of glucose in the bloodstream is from 70 to 100 mg/dL when the individual is fasting (that is not immediately after a meal). The body's biochemical response to hypoglycemia usually starts when sugars are in the high/mid 70's. At this point, the liver releases its stores and the hormones mentioned above start to activate. In many people, this process occurs without any clinical symptoms. The amount of insulin produced also declines in an attempt to prevent a further drop in glucose.

    While there is some degree of variability among people, most will usually develop symptoms suggestive of hypoglycemia when blood glucose levels are lower than 50 mg/dL. The first set of symptoms are called adrenergic (or sympathetic) because they relate to the nervous system's response to hypoglycemia. Patients may experience any of the following;

    • nervousness,
    • sweating,
    • intense hunger,
    • trembling,
    • weakness,
    • palpitations, and
    • often have trouble speaking.

    In most people, these symptoms are easily recognizable. The vast majority of individuals with diabetes only experience this degree of hypoglycemia if they are on medications or insulin. People (with diabetes or who have insulin resistance) with high circulating levels of insulin who fast or change their diet to lower their carbohydrate intake drastically should also be cautioned. These individuals may also experience modest hypoglycemia.

    People being treated for diabetes who experience hypoglycemia may not experience symptoms as easily as people without diabetes. This phenomenon has been referred to as hypoglycemic unawareness. This can be dangerous as blood sugars may approach extremely low levels before any symptoms are perceived.

    Anyone who has experienced an episode of hypoglycemia describes a sense of urgency to eat and resolve the symptoms. And, that's exactly the point of these symptoms. They act as warning signs to tell the body to consume more fuel. At this level, the brain still can access circulating blood glucose for fuel. The symptoms provide a person the opportunity to raise blood glucose levels before the brain is affected.

    If a person does not or cannot respond by eating something to raise blood glucose, the levels of glucose continue to drop. With further drops in blood glucose, patients progress to neuro-glyco-penic ranges (meaning that the brain is not getting enough glucose). At this point, symptoms progress to confusion, drowsiness, changes in behavior, coma, and seizure.

    How is hypoglycemia treated?

    The acute management of hypoglycemia involves the rapid delivery of a source of easily absorbed sugar. Regular soft drinks, juice, lifesaver candies, table sugar, and the like are good options. In general, 15 grams of glucose is the dose that is given, followed by an assessment of symptoms and a blood glucose check if possible. If after 10 minutes there is no improvement, another 10-15 grams should be given. This can be repeated up to three times. At that point, the patient should be considered as not responding to the therapy and an ambulance should be called.

    The equivalency of 10-15 grams of glucose (approximate servings) are:

    • Four lifesavers
    • 4 teaspoons of sugar
    • 1/2 can of regular soda or juice

    Many people like the idea of treating hypoglycemia with dietary treats such as cake, cookies, and brownies. However, sugar in the form of complex carbohydrates or sugar combined with fat and protein are much too slowly absorbed to be useful in the acute treatment of hypoglycemia.

    Once the acute episode has been treated, a healthy, long-acting carbohydrate to maintain blood sugars in the appropriate range should be consumed. Half a sandwich is a reasonable option.

    If the hypoglycemic episode has progressed to the point at which the patient cannot or will not take anything by mouth, more drastic measures will be needed. In many cases, a family member or roommate can be trained in the use of glucagon. Glucagon is a hormone that causes a rapid release of glucose stores from the liver. It is an injection given intramuscularly to an individual who cannot take glucose by mouth. A response is usually seen in minutes and lasts for about 90 minutes. Again, a long-acting source of glucose should thereafter be consumed to maintain blood sugar levels in the safe range. If glucagon is not available and the patient is not able to take anything by mouth, emergency services (for example 911) should be called immediately. An intravenous route of glucose administration should be established as soon as possible.

    With a history of recurrent hypoglycemic episodes, the first step in treatment is to assess whether the hypoglycemia is related to medications or insulin treatment. Patients with a consistent pattern of hypoglycemia may benefit from a medication dose adjustment. It is important that people with diabetes who experience hypoglycemia check blood glucose values multiple times a day to help define whether there is a pattern related to meals or medications. Some people who experience recurrent hypoglycemia will benefit from changes in their dietary patterns; for example, eating multiple small meals and frequent small snacks throughout the day rather than three larger meals.

    I thought high blood sugar was bad. Why is low blood sugar also bad?

    The body needs fuel to work. One of its major fuel sources is sugars, which the body gets from what is consumed as either simple sugar or complex carbohydrates in the diet. For emergency situations (like prolonged fasting), the body stores a stash of sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to "make new sugar") and converts these stores of glycogen to sugar. This backup process emphasizes that the fuel source of sugar is important (important enough for human beings to have developed an evolutionary system of storage to avoid a sugar deficit).

    Of all the organs in the body, the brain depends on sugar (glucose) almost exclusively. Rarely, if absolutely necessary, the brain will use ketones as a fuel source, but this is not preferred. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. If for some reason, the glucose level in the blood falls (or if the brain's requirements increase and demands are not met) there can be effects on the function of the brain.

    Can the body protect itself from hypoglycemia?

    When the circulating level of blood glucose falls, the brain actually senses the drop. The brain then sends out messages that trigger a series of events, including changes in hormone and nervous system responses that are aimed at increasing blood glucose levels. Insulin secretion decreases and hormones that promote higher blood glucose levels, such as glucagon, cortisol, growth hormone, and epinephrine all increase. As mentioned above, there is a store in the liver of glycogen that can be converted to glucose rapidly.

    In addition to the biochemical processes that occur, the body starts to consciously alert the affected person that it needs food by causing the signs and symptoms of hypoglycemia.

    What are symptoms of hypoglycemia and how low is too low?

    The normal range of glucose in the bloodstream is from 70 to 100 mg/dL when the individual is fasting (that is not immediately after a meal). The body's biochemical response to hypoglycemia usually starts when sugars are in the high/mid 70's. At this point, the liver releases its stores and the hormones mentioned above start to activate. In many people, this process occurs without any clinical symptoms. The amount of insulin produced also declines in an attempt to prevent a further drop in glucose.

    While there is some degree of variability among people, most will usually develop symptoms suggestive of hypoglycemia when blood glucose levels are lower than 50 mg/dL. The first set of symptoms are called adrenergic (or sympathetic) because they relate to the nervous system's response to hypoglycemia. Patients may experience any of the following;

    • nervousness,
    • sweating,
    • intense hunger,
    • trembling,
    • weakness,
    • palpitations, and
    • often have trouble speaking.

    In most people, these symptoms are easily recognizable. The vast majority of individuals with diabetes only experience this degree of hypoglycemia if they are on medications or insulin. People (with diabetes or who have insulin resistance) with high circulating levels of insulin who fast or change their diet to lower their carbohydrate intake drastically should also be cautioned. These individuals may also experience modest hypoglycemia.

    People being treated for diabetes who experience hypoglycemia may not experience symptoms as easily as people without diabetes. This phenomenon has been referred to as hypoglycemic unawareness. This can be dangerous as blood sugars may approach extremely low levels before any symptoms are perceived.

    Anyone who has experienced an episode of hypoglycemia describes a sense of urgency to eat and resolve the symptoms. And, that's exactly the point of these symptoms. They act as warning signs to tell the body to consume more fuel. At this level, the brain still can access circulating blood glucose for fuel. The symptoms provide a person the opportunity to raise blood glucose levels before the brain is affected.

    If a person does not or cannot respond by eating something to raise blood glucose, the levels of glucose continue to drop. With further drops in blood glucose, patients progress to neuro-glyco-penic ranges (meaning that the brain is not getting enough glucose). At this point, symptoms progress to confusion, drowsiness, changes in behavior, coma, and seizure.

    How is hypoglycemia treated?

    The acute management of hypoglycemia involves the rapid delivery of a source of easily absorbed sugar. Regular soft drinks, juice, lifesaver candies, table sugar, and the like are good options. In general, 15 grams of glucose is the dose that is given, followed by an assessment of symptoms and a blood glucose check if possible. If after 10 minutes there is no improvement, another 10-15 grams should be given. This can be repeated up to three times. At that point, the patient should be considered as not responding to the therapy and an ambulance should be called.

    The equivalency of 10-15 grams of glucose (approximate servings) are:

    • Four lifesavers
    • 4 teaspoons of sugar
    • 1/2 can of regular soda or juice

    Many people like the idea of treating hypoglycemia with dietary treats such as cake, cookies, and brownies. However, sugar in the form of complex carbohydrates or sugar combined with fat and protein are much too slowly absorbed to be useful in the acute treatment of hypoglycemia.

    Once the acute episode has been treated, a healthy, long-acting carbohydrate to maintain blood sugars in the appropriate range should be consumed. Half a sandwich is a reasonable option.

    If the hypoglycemic episode has progressed to the point at which the patient cannot or will not take anything by mouth, more drastic measures will be needed. In many cases, a family member or roommate can be trained in the use of glucagon. Glucagon is a hormone that causes a rapid release of glucose stores from the liver. It is an injection given intramuscularly to an individual who cannot take glucose by mouth. A response is usually seen in minutes and lasts for about 90 minutes. Again, a long-acting source of glucose should thereafter be consumed to maintain blood sugar levels in the safe range. If glucagon is not available and the patient is not able to take anything by mouth, emergency services (for example 911) should be called immediately. An intravenous route of glucose administration should be established as soon as possible.

    With a history of recurrent hypoglycemic episodes, the first step in treatment is to assess whether the hypoglycemia is related to medications or insulin treatment. Patients with a consistent pattern of hypoglycemia may benefit from a medication dose adjustment. It is important that people with diabetes who experience hypoglycemia check blood glucose values multiple times a day to help define whether there is a pattern related to meals or medications. Some people who experience recurrent hypoglycemia will benefit from changes in their dietary patterns; for example, eating multiple small meals and frequent small snacks throughout the day rather than three larger meals.

    Source: http://www.rxlist.com

    The body needs fuel to work. One of its major fuel sources is sugars, which the body gets from what is consumed as either simple sugar or complex carbohydrates in the diet. For emergency situations (like prolonged fasting), the body stores a stash of sugar in the liver as glycogen. If this store is needed, the body goes through a biochemical process called gluco-neo-genesis (meaning to "make new sugar") and converts these stores of glycogen to sugar. This backup process emphasizes that the fuel source of sugar is important (important enough for human beings to have developed an evolutionary system of storage to avoid a sugar deficit).

    Of all the organs in the body, the brain depends on sugar (glucose) almost exclusively. Rarely, if absolutely necessary, the brain will use ketones as a fuel source, but this is not preferred. The brain cannot make its own glucose and is 100% dependent on the rest of the body for its supply. If for some reason, the glucose level in the blood falls (or if the brain's requirements increase and demands are not met) there can be effects on the function of the brain.

    Source: http://www.rxlist.com

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