Hypoglycemia is not only a risk for people with type 1 diabetes, but also for many people with type 2 diabetes—especially older individuals who are treated with insulin. The danger is not limited to acute effects such as loss of concentration or consciousness. With each hypoglycemic episode, the perception of and counterregulation against the next episode deteriorate. In addition, severe hypoglycemia can lead to accidents involving danger to oneself and others, as well as lasting damage to brain structures, thereby increasing the risk of developing dementia.
A distinction is made between mild hypoglycemia, which patients can treat independently by consuming carbohydrates, and severe hypoglycemia, in which affected individuals require assistance from others.
Defining hypoglycemia by a specific blood glucose threshold (previously often 50 mg/dL or 2.8 mmol/L; in the United States below 70 mg/dL or 3.9 mmol/L) is currently being controversially discussed. What is clearly established, however, is the association between low therapeutic targets and an increased frequency of hypoglycemic episodes.
Every third to fourth person with type 1 diabetes has problems with hypoglycemia—around 100,000 people in Germany. Severe hypoglycemic episodes occur in people with type 1 diabetes on average every two to five years. The associated risk depends on the type of treatment and the targeted therapeutic goal (HbA1c level).
Below are factors associated with higher risk of any hypoglycemia (including mild/non-severe events) in people with type 1 diabetes, with supporting study evidence.
1) Intensive glycemic targets / lower HbA1c (tighter control)
2) Longer duration of Type 1 diabetes (and insulin dependence over time)
3) Impaired awareness of hypoglycemia (IAH) and blunted counterregulation (HAAF physiology)
4) Prior hypoglycemia (recurrence/“hypoglycemia begets hypoglycemia”)
5) Alcohol consumption (especially evening intake → next-morning risk)
6) Reduced glucose monitoring / lack of CGM (more time spent low)
Even when patient-level risk markers are present, mild hypoglycemia is often triggered by day-to-day mismatches such as insulin dose vs. carbohydrate intake, missed/delayed meals, and unplanned physical activity—these are widely recognized precipitants and are clinically important when you are discussing “any hypoglycemia,” not only severe events. (Online Library)
Hypoglycemia (Low Blood Sugar)
Hypoglycemia is not only a risk for people with type 1 diabetes, but also for many people with type 2 diabetes—especially older individuals who are treated with insulin. The danger is not limited to acute effects such as loss of concentration or consciousness. With each hypoglycemic episode, the perception of and counterregulation against the next episode deteriorate. In addition, severe hypoglycemia can lead to accidents involving danger to oneself and others, as well as lasting damage to brain structures, thereby increasing the risk of developing dementia.
A distinction is made between mild hypoglycemia, which patients can treat independently by consuming carbohydrates, and severe hypoglycemia, in which affected individuals require assistance from others.
Defining hypoglycemia by a specific blood glucose threshold (previously often 50 mg/dL or 2.8 mmol/L; in the United States below 70 mg/dL or 3.9 mmol/L) is currently being controversially discussed. What is clearly established, however, is the association between low therapeutic targets and an increased frequency of hypoglycemic episodes.
Hypoglycemia in Type 2 Diabetes
Whereas the risk of hypoglycemia in people with type 2 diabetes was often underestimated in the past, it is now clear that many individuals with type 2 diabetes are also at risk. Up to 14% of patients (i.e., about 150,000 per year) treated with sulfonylureas or insulin experience severe hypoglycemia. In type 2 diabetes, the frequency and danger of hypoglycemia increase with age and duration of the disease, duration of insulin therapy, alcohol consumption, liver dysfunction, dementia, kidney dysfunction, and lack of diabetes education. Impaired awareness of hypoglycemia is also a significant risk factor in type 2 diabetes.
Causes of Hypoglycemia in Diabetes
Hypoglycemia is always the result of an absolute or relative excess of insulin. This can be caused by insufficient carbohydrate intake (skipped meals), unaccustomed physical activity, confusion of insulin type or dosage, alcohol consumption, or improved insulin sensitivity.
Recognizing and Treating Hypoglycemia Immediately
Recognizing hypoglycemia in time can be difficult. In many people with diabetes, the time window in which hypoglycemic symptoms are noticed—before slowing of reactions and impaired concentration lead to inability to act—is short. A distinction is made between “warning signs” and “deficiency signs”:
If a person with diabetes is still able to act independently and can eat or drink:
If a person with diabetes is conscious and able to swallow but not able to act independently:
If a person with diabetes becomes unconscious:
In all cases:
After self-treatment, do not immediately correct temporarily elevated blood glucose levels with insulin. After severe hypoglycemia, target values should be increased for some time.
Nocturnal Hypoglycemia in Diabetes
To prevent nocturnal hypoglycemia, doses of rapid-acting insulin (regular insulin or rapid-acting analogues) late in the evening or at night should be avoided whenever possible. During the day, consider whether factors such as physical activity, small meals, alcohol consumption, or insulin or tablet intake might cause blood glucose levels to fall at night. As a precaution, blood glucose should always be checked shortly before going to bed. Target value: at least 120 mg/dL (6.7 mmol/L).
Do not go to bed with a blood glucose value below 120 mg/dL (6.6 mmol/L): danger during sleep.
Fast-acting carbohydrates and the blood glucose meter should be kept within reach on the bedside table. Occasional blood glucose measurements during the night are also part of monitoring. If nocturnal hypoglycemia occurs, it is essential to discuss with a physician whether a change in therapy is necessary (e.g., reducing long-acting insulin).
Learning to Recognize Hypoglycemia
In some patients, severe hypoglycemia occurs repeatedly, leading to significant insecurity in everyday life and even serious conflicts in partner relationships. For such patients, special training programs are available at specialized practices or clinics.
In these programs, patients learn to observe themselves closely and to evaluate signs of hypoglycemia. What sounds simple requires a great deal of practice—especially for patients whose impaired hypoglycemia awareness begins only at blood glucose levels below 50, 40, or even 30 mg/dL (2.7, 2.2, or 1.6 mmol/L), emphasizes Dipl.-Psych. Dr. phil. Bernd Kulzer, educational director of the training center at the Diabetes Clinic Bad Mergentheim. Patients must understand that preventing dangerous hypoglycemia requires several steps.
According to Cox’s hypoglycemia model, these steps are:
At each of these stages, something can go wrong—for example, noticeable signs may occur with delay; or symptoms such as sweating and trembling are noticed but not interpreted as hypoglycemia; or the person is no longer fully responsive; or sugary food is not available to counteract the episode quickly.
Hypoglycemia Awareness Training Provides Safety
Training concepts such as HyPOS (Hypoglycemia Positive Self-Management) are designed specifically to prevent hypoglycemia. HyPOS is aimed at patients at risk due to recurrent and severe hypoglycemia, patients with impaired awareness, and those who suffer from constant fear of hypoglycemia. The HyPOS program trains self-management of hypoglycemia in five double sessions with four to eight participants. The course includes group discussions, homework, and exercises using blood glucose meters, with measured values processed further on a computer. Developed by the Diabetes Clinic Bad Mergentheim and Berlin-Chemie, the concept integrates education and counseling and is therefore suitable for use in outpatient diabetes care facilities.
Further information and addresses can be found at www.hypos.de