Hypoglycemia (low blood sugar)

Symptoms Of Hypoglycemia

Low blood glucose level presents different symptoms from person to person. It tends to come quickly and can worsen if not treated in time. These symptoms include:

Mild to moderate

• Anxiety

• Feeling shaky or having jitters

• Sweating 

• Hunger 

• Dizziness/lightheadedness

• Feeling confused

• Increased irritability 

• Unsteady heartbeat

• Heart palpitations

• Unable to see or speak properly

• Tiredness

Prolonged hypoglycemia can affect brain functioning since the brain will stop receiving optimal glucose levels. This is a severe condition and needs immediate treatment. The symptoms include:

• Loss of consciousness 

• Seizures 

Note: If hypoglycemia is severe and prolonged, it can be life threatening.

You can also experience a drop in glucose levels during your sleep. This results in low blood sugar that lasts for several hours and can cause serious issues. Even if you don't wake up or notice these signs, low blood glucose levels can interfere with your sleeping pattern and affect your quality of life, work, and mood. Low blood sugar during sleep makes it tougher to notice the signs and symptoms of low blood glucose during the day. These symptoms include:

• Feeling irritated or foggy after waking up 

• Sweating through your clothes or leaving your sheets damp

• Crying out or having nightmares

Causes Of Hypoglycemia

Your body gets glucose from food rich in carbohydrates which are broken down by acids and enzymes into smaller pieces. In this process, glucose is absorbed from the intestine and passed into the bloodstream. 

Insulin, a hormone made by the pancreas, moves glucose from the bloodstream into the cells, where it is used for energy and storage. The body should be able to maintain a constant state of blood glucose to facilitate normal functioning. After you eat, pancreatic cells release insulin to ensure that various body cells can uptake that sugar and use it optimally. The brain specifically relies on glucose to help it process information and work efficiently. 

After the body uses an optimal glucose level, it stores the excess in the form of glycogen that can be used later when needed. When the blood sugar drops, the pancreas signals the liver to break down the stored glycogen and convert it into glucose. This travels through the bloodstream and replenishes the energy supply. Some conditions can disturb the blood sugar regulation and cause hypoglycemia, including:

1. Diabetes

Blood sugar is supposed to circulate in the body and supply it with constant fuel. However, in conditions like diabetes, the body fails to produce enough insulin to move glucose into the cells or the cells themselves become resistant towards insulin. In type 1 diabetes, the body cannot produce enough insulin, whereas, in type 2 diabetes, the cells become less responsive towards the hormone. This results in high glucose levels in the blood that can lead to severe damage to your kidney, nerves, eyes, and other organs. However, in diabetic patients, hypoglycemia can occur when the blood glucose levels drop to below 70 milligrams per deciliter. The causes for the same are:

• To manage diabetes, patients are prescribed insulin or other medications that can effectively lower their blood sugar levels. Diabetic drugs such as sulfonylureas and meglitinides boost insulin in the body that absorbs blood glucose. 

• However, if a patient takes excessive insulin or other drugs, the blood sugar can drop too low and lead to hypoglycemia. 

• Skipping meals and exercising more than usual can also lead to the body using more glucose than usual, which can further cause hypoglycemia in diabetic patients.  

• A diabetic patient taking insulin during fasting is also likely to develop hypoglycemia. If you are sick, you may not eat as much as needed to combat the insulin, lowering your blood glucose further.

• Drinking alcohol can also have a detrimental effect and cause hypoglycemia. Alcohol makes it more challenging for the body to maintain its blood glucose levels, especially if there has been no food intake in a while. Alcohol also prevents you from identifying the symptoms of low blood sugar, leading to severe complications. 

It is essential for people diagnosed with diabetes to be educated about diabetes and accordingly balance their food intake, insulin and daily activities. Working with a doctor is the best way to prevent the occurrence of hypoglycemia. 

2. Specific medications 

Hypoglycemia can be a side effect of certain medications such as:

• Quinine, which is used to treat malaria is a potent stimulator that leads to the release of insulin from the pancreatic beta cells. It increases the uptake of glucose by muscles and cells. Quinine also stimulates the production of glycogen that stores up glucose. This can lead to low blood glucose levels. 

• Antibiotics such as fluoroquinolones used to treat pneumonia and urinary tract infections also cause low blood sugar or high blood sugar. 

• Medications including clarithromycin, linezolid, and doxycycline are other antibiotics linked with hypoglycemia. 

• When diabetic patients take sulfonylureas and antimicrobials such as ciprofloxacin and  metronidazole are at a high risk of developing hypoglycemia.

• Children and people with kidney failure are at an increased risk of developing medication-induced low blood glucose.

• Other commonly used drugs that are associated with hypoglycemia are antihypertensive medications including angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta blockers, and painkillers like indomethacin.

3. Alcohol

If a person consumes excessive alcohol every day for a few days which is coupled with less intake of food, it can lead to alcohol induced hypoglycemia.

4. Hepatitis 

Hepatitis is a medical condition that causes inflammation of the liver. The liver is responsible for breaking down stored glycogen and converting it into glucose when the body needs energy. If the liver fails to produce or release ample insulin, it can be difficult for the body to maintain blood glucose levels leading to hypoglycemia. Any type of liver disease can lead to insulin resistance. 

5. Adrenal or pituitary gland tumour

Disorders and tumours of the pituitary or adrenal gland can disturb the balance between the hormones that influence blood glucose levels and hence cause hypoglycemia. 

6. Pancreatic tumours 

Pancreatic tumours (especially insulinoma) cause the organ to release too much insulin that can cause the cells to take up excessive glucose. If the insulin levels are too high, the blood glucose level will decline and lead to hypoglycemia. This tumour continues to produce insulin even when the blood sugar level is too low. This can lead to serious side effects of hypoglycemia. 

7. Kidney disorders 

The kidney is responsible for excreting waste and toxins from the body. Kidney failure can affect the clearance rate of waste products and cause the build-up of medications that can lead to hypoglycemia. Diabetic patients who are on insulin should be particularly cautious after development of diabetic nephropathy as they have higher chances of development of hypoglycemia due to reduced clearance of insulin. Hypoglycemia, at times, can be the initial presentation of new onset diabetic nephropathy.

8. Critical illness

Among hospitalised patients, serious illnesses such as kidney disease, liver disease, cardiac failure and sepsis are common causes of hypoglycemia. 

9. Reactive hypoglycemia 

Sometimes, if you eat food that has a high sugar quantity, your body can end up producing excessive insulin to manage the extra sugar. This excessive insulin can lead to hypoglycemia and is called postprandial or reactive hypoglycemia. It can also occur in people who have had stomach bypass surgery. 

Risk Factors For Hypoglycemia

You may be at a higher risk of developing hypoglycemia, if you:

• Use insulin or take oral anti-diabetic drugs such as sulfonylureas

• Are above 60 years of age

• Have an impaired kidney or liver function

• Are unaware of the symptoms of hypoglycemia

• Take multiple medications that interact with each other

• Suffer from any disability

• Consume excess alcohol

• Suffer from diabetes from a long time

• Have pancreatic tumour

• Suffer from eating disorders such as anorexia

• Have diabetic autonomic neuropathy

Diagnosis Of Hypoglycemia

1. Blood glucose monitor (glucometer)

If you have diabetes and suspect that you have hypoglycemia, check your blood sugar level right away. Diabetic patients are usually provided with a glucometer which is a small electronic device. These devices can check your blood glucose level within a minute. To use this device, prick your finger for a small drop of blood and place it on the test strip. This test strip will be inserted in the glucometer that will evaluate your blood glucose level. If you don't have your glucometer, talk to your doctor about getting one. These glucometers are great tools that help diabetic patients balance their insulin and food intake. 

If you experience repeated episodes of low blood glucose, visit your doctor to determine the reason. Your doctor can help you devise a more efficient plan to keep your diabetes in check without leading to hypoglycemia. 

2. Physical examination

If you don't have diabetes but suspect that you have signs and symptoms of hypoglycemia, talk to your doctor. Your doctor will perform a physical exam.

Whipple's triad which is a collection of three criteria that can suggest the presence of a pancreatic insulinoma can also be looked into. It consists of assessing :

• Fasting hypoglycemia (<50 mg/dL)

• Symptoms of hypoglycemia

• Immediate relief of symptoms after the administration of intravenous (IV) glucose

3. Random blood glucose test 

A random blood glucose test measures the glucose level in the blood at the time of the test. The results of this test depend on the last time you ate and doesn't require fasting. For people with normal blood sugar regulation, the blood glucose level should be relatively stable at any time. But if you have a disorder that is disturbing your blood sugar level, then the random blood glucose test will help your doctor determine the cause. 

4. Fasting blood glucose test

A fasting blood glucose test measures the blood glucose level present in your blood after an overnight fast. Usually, a fast of 10-12 hours is recommended before the test, and it can help diagnose diabetes, prediabetes and hypoglycemia. A fasting blood glucose level below 70 mg/dL is an indication of hypoglycemia. 

Learn how to use blood glucose monitors and various tips to buy a glucometer.
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Prevention Of Hypoglycemia

The key to preventing hypoglycemia is managing your diabetes.

• Understanding the link between insulin and food will help you prevent a hypoglycemic episode. 

• It requires following the instructions of your healthcare provider and not skipping your meals.

• Follow your doctor's orders about daily exercise and don't exceed the advised limit.

• Diabetic patients should also measure their blood sugar before and after meals, exercise and before sleeping. Maintaining a log book for the same can be very handy.

• In case you have a hypoglycemic event, note down what you ate before that and the amount of insulin you took, along with other details. This will help your doctor decide on a more effective plan for managing your diabetes. 

If you don't have diabetes and have infrequent hypoglycemia episodes, make sure not to skip meals. Take in plenty of fruits and carbohydrate-rich foods so that your body has enough carbs to burn. In case your symptoms don't improve, talk to a doctor to rule out any medical condition. 

Specialist To Visit 

You should visit your doctor if you are experiencing symptoms such as jitters, anxiety, lightheadedness, confusion, brain fog, lethargy, heart palpitations, difficulty in seeing or speaking, and unconsciousness. These symptoms might indicate the possibility of hypoglycemia and should be treated right away. You can consult the following doctors for a diagnosis.

• General physician 

• Endocrinologist 

Sometimes, a patient may present with loss of consciousness which requires emergency medical care and hospitalisation and also administration of intravenous glucose to maintain glucose levels in the normal range.
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Treatment Of Hypoglycemia

Hypoglycemia can be managed through various methods. The best approach is decided on an individual's age, overall wellbeing, symptoms, underlying cause, and severity of the disorder.

1. Carbohydrate-rich diet   

If your blood glucose level is low, immediate treatment would be eating something rich in carbohydrates. So, keep snacks high in carbs such as glucose tablets, juices, honey, jelly beans, hard candies, gumdrops or non-diet soda, with you all the time. The American Diabetes Association suggests that the snacks should have around 15 grams of carbohydrates.

Diabetic patients can take glucose tablets that act rapidly and increase the blood sugar level. After taking a carbohydrate-rich snack, wait for 15 to 20 minutes and check your glucose level. If your blood glucose levels haven't increased, take another 15 grams of carbohydrate and repeat the procedure until the blood sugar starts to rise. Don't overeat to ensure that your blood sugar level doesn't increase too high. 

2. Glucagon hormone 

Glucagon is a hormone that is administered in emergencies. It raises blood sugar levels rapidly and can be life-saving for someone who is unconscious or unable to eat and drink. It is only available as prescription medicine. Glucagon comes in an emergency syringe kit (for subcutaneous or intramuscular routes) or as a nasal spray. After 15 minutes of being given glucagon, the person should be alert enough to eat. In case someone isn't alert even after 15 minutes of administering glucagon, call emergency medical care. 

3. Octreotide 

This somatostatin analogue can be used to suppress insulin secretion in sulfonylurea induced hypoglycemia. It raises plasma glucose concentrations only transiently and the patient should therefore be urged to eat as soon as possible to replete glycogen stores.

4. Treatment of underlying conditions

A tumour in the pancreas is treated by surgical removal of the tumour. In some cases, partial removal of the pancreas might be required.

Home-care For Hypoglycemia

Tips for diabetics

• Check your blood glucose level before and after a meal.
• You should also check your blood sugar before going to bed.
• Follow your doctor's instructions and take your insulin as and when instructed.
• Do not take extra insulin without your doctor's advice.
• In case you exercise more than usual, make sure to balance out the loss of glucose by taking in the required carbohydrates. 

Tips for non-diabetics

• List down the food you ate, the amount you exercised, the symptoms you experienced and the time it took you for the signs to go away. These records will help your doctor diagnose your problem. 
• The best way of handling hypoglycemia is to determine the cause behind it.
• Along with that, make sure not to skip meals and get an ample amount of carbohydrates. 

Learn about the 15-15 rule and much more about prevention and emergency management of hypoglycemia.

Complications Of Hypoglycemia

Untreated hypoglycemia can affect brain functioning and lead to severe side effects.

1. Seizures 

The brain needs glucose to function. Any significant change in blood sugar directly influences the signalling mechanism of the brain. This allows seizures to occur quickly. Prolonged hypoglycemia can give rise to a seizure known as a tonic-clonic seizure. This involves the entire body and leads to loss of consciousness and violent muscle contractions. 

2. Diabetic coma 

When the brain doesn't receive enough glucose to function properly, it can cause you to pass out and lose consciousness. A diabetic coma occurs when a person with diabetes loses consciousness. Hypoglycemia as a result of excessive insulin or not getting enough food can be critical. Passing out due to hypoglycemia is an emergency medical situation and needs attention right away. 

The symptoms of diabetic coma include headache, confusion, heart palpitations, vomiting, weakness, and dizziness. If you are diabetic and at risk of developing hypoglycemia, it is advisable to talk to your loved ones and friends and teach them how to administer treatment in such cases. 

Losing consciousness due to hypoglycemia means that you will be unable to eat or drink emergency glucose tablets. In such cases, injections like glucagon can be life-saving. After gaining consciousness or if there is no response to glucagon injection, call your doctor immediately. 

3. Hypoglycemia unawareness

The symptoms that help alert you about hypoglycemia may be unpleasant, but they are also instrumental. These symptoms tell you to drink or eat carbohydrates that bring up your glucose levels to normal. But several people are unable to identify these symptoms. This is called hypoglycemia unawareness. It can primarily occur in people who have had repeated episodes of hypoglycemia. This results in the body adapting to the early warning signs and subsequently ignoring them after repeated episodes. 

Hypoglycemia unawareness is especially dangerous since your body will stop telling you when your blood sugar level drops, and hence you won't be able to treat it. People with hypoglycemia unawareness are also less likely to wake up when their blood sugar drops at night. They need to be extra careful and check their blood sugar frequently. This step is significant when carrying out tasks that require attention such as driving. Such patients can have a continuous glucose monitor that will sound an alarm when the blood sugar drops. Hypoglycemia unawareness is reversible by as little as 2-3 weeks of scrupulous avoidance of hypoglycemia in most affected patients.

Alternative Therapies For Hypoglycemia

1. Diet

Your diet plays the most critical role in managing your blood sugar levels. Diabetic or non-diabetic, you need to have a balanced diet and not skip meals in between. If you are diabetic, keep carbohydrate-rich food in hand to avoid hypoglycemic food. Increase your soluble fibre intake and eat foods such as flax seeds and oat barns. Soluble fibre can help slow down the rate at which sugar enters the bloodstream and helps manage blood sugar throughout the date. 

2. Supplements 

You can address nutritional deficiencies by taking a daily multivitamin containing vitamin A, E, C and B complex. You can also take omega-3 fatty acids and alpha-lipoic acid for antioxidants. Make sure to consult your doctor before taking any supplements. 

3. Mid-meal snacking 

In cases of reactive hypoglycemia, the body reacts to meals with excessive sugar by releasing more insulin than required. This results in hypoglycemia. To avoid such conditions, it is advisable to cut down on eating high sugar meals. Instead, you can have small frequent meals that are balanced and rich in protein and carbohydrates. 

4. Fuel during exercise

Light exercises are a great way to manage your blood sugar. In patients with diabetes, ADA recommends 150 minutes of moderate physical activity per week for at least 3 days & with no gaps longer than 2 days. Follow your doctor's advice about your daily exercise limit. If you work out more than usual, make sure to eat after your workout or have a small snack between your workout to ensure that your blood sugar stays up. If you are diabetic, it is essential to avoid overdoing your workout until you have a good handle on balancing your sugar level and insulin dosage. 

Living With Hypoglycemia

Having episodes of hypoglycemia can cause stress and anxiety. Complications like losing consciousness are especially scary to go through. Diabetic patients who have repeated episodes of hypoglycemia may become scared of taking insulin in the future and try to reduce the dosage without proper medical advice. This can result in further complications that can be life-threatening. Recognising the signs of hypoglycemia and taking timely action is the best way of preventing hypoglycemic episodes. 

Teach people how to help

Inform and teach the people around you such as your co-workers, friends and family, about hypoglycemia. If the people around you can identify and look out for signs of hypoglycemia, they can lend you support and alert you about the signs. It's equally vital to teach them how to administer emergency glucagon so they can avert a potentially life-threatening situation. 

Plan your meals ahead
If you are on a trip or aware of a busy day ahead, make sure that you plan your meals ahead of time. Do not skip meals in between. 

Carry glucose-rich snacks 

Always carry a sugar candy or bar handy while travelling or place one near bed to avoid panic during a hypoglycemia episode. If you are diabetic, then carrying glucose-rich snacks that you can eat after taking insulin, can help maintain the glucose level.

Wear a medical ID 

If you are prone to develop hypoglycemic episodes, your doctor may advise you to wear a medical ID to help people identify that you have diabetes. This will help quick medical administration, especially if you are not around the people who know you. 

Take extra care when you are sick 

Being sick might make you feel like eating less food or may not be able to keep the food down due to nausea and vomiting. Make sure to adjust your insulin level according to your food intake.