Hypos

[Satan’s little helper]

I was wondering if you were taking your gliclazide in the evening with a low carb meal so it would not have had enough carbs so your pancreas would have been producing more insulin than it had carbs to work on.k
Can you give some examples of the meals you have.

From what I understand Gliclazide acts as a catalyst to “turbo charge” the Pancreas insulin output? As an insulin user, I can take (roughly) into account how much is on board or whether the basal is to blame? But a pancreas triggered by Glic. Is where I walk away on the guesswork.

 

[rebrascora]

@Newbie777 Are you aware that Libre are prone to what we call "compression lows" which are false lows recorded when you lie on the arm with the sensor for any length of time. As a result you should always double check any low Libre alarm during the night with a finger prick before treating and then only treat with a hypo treatment if you are genuinely low.

It may well be that you are eating all those carbs during the night unnecessarily but in any case a hypo treatment should be 15g of fast acting carbs which is 4-5 glucose tablets or 3 jelly babies and then retest after 15 mins with a finger prick. You cannot rely on Libre for hypo recovery because it will almost always show your levels having gone lower still 15 mins after treatment whereas a finger prick will generally show you are recovering. An apple is not a suitable hypo treatment because the sugar in it is bound up in fibre which makes it slower to release. People sometimes then need some slower follow up carbs like a digestive biscuit, but I would be in double figures if I had 3 Jelly Babies plus a digestive, every time let alone an apple as well. Basically you are over treating if they are genuine hypos but it is entirely possible you are not having nocturnal hypos at all and Libre is just suffering from false compression lows.

Often you can tell from the graph if it is a compression low as it dips quite suddenly whereas a genuine nocturnal hypo will usually be a slow and steady descent into "the red".

 

[Newbie777]

Breakfast 8.00am 2 boiled eggs and two pieces of high low bread with French butter tea with inweestend almond milk, sometimes have scrambled egg on bread. Sometime have 45g of high protein Surreal cereal

Lunchtime 12.00pm I have battered haddock fish but remove most of the batter.
Sometimes have cauliflower curry or lentil curry eat with a fork or spoon.
Sometimes have 4 pieces of high low bread with cheddar cheese or full fat cream cheese or peanut butter.

Evening meal no later than 6pm
Grilled chicken breast cooked with herbs and spices, with green beans and grilled mushrooms

Snack 4 times.a day on Walnuts, almonds, peanuts cashew nuts and brazil nuts.

Also have Greek yogurt with blueberries or strawberries as a mid afternoon snack

 

[harbottle]

Trans/Saturated fats are the ones to avoid. Others are fine.

 

[Newbie777]

I think there is a lot of debate currently regarding how true this is vegetable oils aso have other issues so all is not clear, in moderation may be better

 

[Leadinglights]

Sorry do you know which medications where they don't work as well on low carbs, thanks

Sorry I didn't notice your post. Gliclazide is a medication which encourages the pancreas to produce more insulin so needs carbs to work post effectively, it usually suggests you take it 30 mins before food so it has a head start to deal with the carbs.
The 'flozin' medication encourages the kidneys to work harder to excrete excess glucose via urine but with a low carb diet there is a risk of euglycemic DKA however nobody seems to know how low is too low but 130g is suggested as being OK but it is only something you would know by experience.
It could be your hypos are due to the gliclazide acting over a longer period of time but it seems puzzling that they are at night rather than during the day when you take the medication.
Have you tried having a higher carb meal when you have your dinner or have one of your snacks later in the evening.

 

[Proud to be erratic]

Are you fully hydrated, @Newbie777? Particularly during the night.

Libre is sampling your interstitial fluid, not quite the same blood that you take a drop from for your fingerprick test. If you are not fully hydrated then it is likely your brain will give hydration priority to actual blood at the expense of interstitial fluid. Many people, as they get older, deliberately or subconsciously cut back on liquids in the evenings to reduce their need to pass urine in the middle of the night and the conseuent aleep disruption. This is particularly so for males with prostate enlargement (and Urology advice for such males specifically includes instructions to stop fluid intake well before bedtime).

True hypo is medically set at 3.5 mmol/L. We use the figure of 4 partly because it's historic; a convenient round number ("4 is the floor" is easy to remember); and it provides an initial factor of safety when our mental capacity is impeded during very low BG.

Also home blood testing is done using mass produced equipment for a limited market (people with Diabetes) yet available at an affordable price; there is an inevitable degree of inaccuracy within all blood testing at home. While a screen displays a number to within one decimal point, in practice the equipment is simply not that accurate. CGM worsens the perception of accuracy, yet CGM does give accurate graphs for showing predicted trend. CGM is sampling every single minute, displaying something every 5 minutes and using a "secret" (commercially sensitive) algorithm (mathematical trickery) to derive the best (manipulated) average with secret adjustments to compensate for the known (10-15 minutes) lag of interstitial fluid behind actual blood glucose. The permitted tolerances for both home testing BG meters or CGM is +/- 15%; these are Internationally agreed tolerances, arrived at after clever medical and commercial people have wrestled long and hard at accepting a compromise between medical safety and commercial viability.

So it is sensible and practical to use the numerical data with a degree of caution and to take steps to simply avoid hypos. Why go near 4 mmol/L when you have tech that can "Alert" you from 5.6 that your BG is falling? Why an "Alarm" that panics you at 4.2 (or any number close to 4) when you might already be in or very close to a hypo state?

Your body will run perfectly well if you had a target to be above 5.5 (but below 10) and the older you get the more you can allow that figure to increase. Hypos are best avoided in the short term (day by day) because they are downright inconvenient and unoleasant; but also because of the long term potential for cognitive impairment with age.

If your CGM tells you that you are aporoaching a hypo state, VERIFY that with a finger prick, unless of course your own internal hypo awareness signals are already telling you. We can all be guilty of over- reacting. Indeed we have to some extent primed ourselves to need to overreact by using the "Alarm" response process; modern lifestyles are built around last minute planning, decision making - encouraged by smart phone tech sending reminders by endless texts, emails etc plus gadgets/widgets/apps providing notifications.

Treat hypos initially ONLY with high glucose rapid response treatments. An apple does not provide that. Dextrose, jelly babies or high carb drinks like orange juice & coke @ 8-10% do. WAIT 15 minutes, confirm with a finger prick that recovery is happening and if not, REPEAT. Once the hypo has ended it often helps to consolidate with a small amount of medium level carbs, such as a biscuit or a round of toast. But do NOT DILUTE the high glucose response with low or medium glucose extras - at the same time. Give the high glucose response time to work, then consolidate that success. It is very tempting to overdo things (and when our BG is truly low the mental confusion it causes makes us want to empty the cupboards/larders/fridges) - right now.

Reading your posts, @Newbie777, leaves me thinking you are setting yourself up for high Glycaemic Variability: most of the time you are trying to be low carb, then your hypo response is excessive leading to that inevitable hyper backlash.

All of this is just my (middle of the night) non-medical opinion. We are all different, with different detailed medical responses and different social and familial influences/constraints.

 

[Newbie777]

It's okay, you have been most helpful, did not know about Glicizide 30 mins prior, do have the florizin 1st thing in morning though before food.

I do snack all day and in the evening also, so perhaps till 8pm, but then I do ike to keep a 12 hour fast.

My evening meals has always been high protein, low fat and low carb, but last night I had battered fish, 2 chicken strips and two beef patties, the key thing to note is I ate the batter on both the chicken and fish and my blood sugar went up from 10.8 to 15.3. This morning, however, it was 6.9 which I would accept anytime.

So for now will carry on with a higher carb meal at my evening meal.

BTW. In the past at night used to eat an apple with peanut butter, but at that time my blood sugars were a lot more normal!

 

[Newbie777]

Are you fully hydrated, @Newbie777? Particularly during the night.

Libre is sampling your interstitial fluid, not quite the same blood that you take a drop from for your fingerprick test. If you are not fully hydrated then it is likely your brain will give hydration priority to actual blood at the expense of interstitial fluid. Many people, as they get older, deliberately or subconsciously cut back on liquids in the evenings to reduce their need to pass urine in the middle of the night and the conseuent aleep disruption. This is particularly so for males with prostate enlargement (and Urology advice for such males specifically includes instructions to stop fluid intake well before bedtime).

True hypo is medically set at 3.5 mmol/L. We use the figure of 4 partly because it's historic; a convenient round number ("4 is the floor" is easy to remember); and it provides an initial factor of safety when our mental capacity is impeded during very low BG.

Also home blood testing is done using mass produced equipment for a limited market (people with Diabetes) yet available at an affordable price; there is an inevitable degree of inaccuracy within all blood testing at home. While a screen displays a number to within one decimal point, in practice the equipment is simply not that accurate. CGM worsens the perception of accuracy, yet CGM does give accurate graphs for showing predicted trend. CGM is sampling every single minute, displaying something every 5 minutes and using a "secret" (commercially sensitive) algorithm (mathematical trickery) to derive the best (manipulated) average with secret adjustments to compensate for the known (10-15 minutes) lag of interstitial fluid behind actual blood glucose. The permitted tolerances for both home testing BG meters or CGM is +/- 15%; these are Internationally agreed tolerances, arrived at after clever medical and commercial people have wrestled long and hard at accepting a compromise between medical safety and commercial viability.

So it is sensible and practical to use the numerical data with a degree of caution and to take steps to simply avoid hypos. Why go near 4 mmol/L when you have tech that can "Alert" you from 5.6 that your BG is falling? Why an "Alarm" that panics you at 4.2 (or any number close to 4) when you might already be in or very close to a hypo state?

Your body will run perfectly well if you had a target to be above 5.5 (but below 10) and the older you get the more you can allow that figure to increase. Hypos are best avoided in the short term (day by day) because they are downright inconvenient and unoleasant; but also because of the long term potential for cognitive impairment with age.

If your CGM tells you that you are aporoaching a hypo state, VERIFY that with a finger prick, unless of course your own internal hypo awareness signals are already telling you. We can all be guilty of over- reacting. Indeed we have to some extent primed ourselves to need to overreact by using the "Alarm" response process; modern lifestyles are built around last minute planning, decision making - encouraged by smart phone tech sending reminders by endless texts, emails etc plus gadgets/widgets/apps providing notifications.

Treat hypos initially ONLY with high glucose rapid response treatments. An apple does not provide that. Dextrose, jelly babies or high carb drinks like orange juice & coke @ 8-10% do. WAIT 15 minutes, confirm with a finger prick that recovery is happening and if not, REPEAT. Once the hypo has ended it often helps to consolidate with a small amount of medium level carbs, such as a biscuit or a round of toast. But do NOT DILUTE the high glucose response with low or medium glucose extras - at the same time. Give the high glucose response time to work, then consolidate that success. It is very tempting to overdo things (and when our BG is truly low the mental confusion it causes makes us want to empty the cupboards/larders/fridges) - right now.

Reading your posts, @Newbie777, leaves me thinking you are setting yourself up for high Glycaemic Variability: most of the time you are trying to be low carb, then your hypo response is excessive leading to that inevitable hyper backlash.

All of this is just my (middle of the night) non-medical opinion. We are all different, with different detailed medical responses and different social and familial influences/constraints.

Thank yiu very much, this is quite interesting.

Regarding hydration, I have suffered from dehydration many times and yes do not drink too much water after 6pm.

Howver I also know that Invokana has two main side effects 1. Low blood pressure and 2. Dehydration and it has been 3 weeks where I have now reduced my dosage from 300mg to 100mg. My low blood pressure has now stopped!

As well as water, I do drink Robinson barley cordial and I also have celtic salt which I also mix with water, sometime I have mineral water too. But I agree I need to drink more, especially in the evening.

Regarding the CGM, initially I thought it was the best device out there and it has really helped, now I am a bit more cautious and think it is very useful but agree not as accurate as it should be, sowill start to use the old blood sugar tester, so I get a more accurate result when required.I will increase the low level alarm to 5.0 now.

Rrgarding hypo, I have ordered a hypo gel kit from Amazon, I will eat either 5 dextrose sweets, or drink small amount of orange juice and test again after 15 mins, once all OK with have 1 piece of toast.

I fe at the moment I am going through a lot of change and I can change my diet, but ideally want to go to the gym also and with my blood sugars sporadic that is not an option at the moment.

Personally I am demoralised, I love high carbs, especially potatoes and would argue my favourite would be some nice freshly baked bread and butter!! So going low carb has been very difficult for me.

f am now thinking if I took out the Trajenta and had the 3 medicines and stuck to say120g carbs a day and then maybe 150 to 180 carbs for the odd going out day and NO hypos then I would be happy.

After I stabilise my blood sugars I can increase my car intake again as will be going to the gym.

Thanks again for the helpful advice

 

[Proud to be erratic]

Thank you for all the above. So while I understand that you feel demoralised Niaz (@Newbie777), I wonder, [now in normal daylight (!)], if you are somewhat overthinking all of this. But I have noted you've been grappling with your T2 for over 20 years, currently on a raft of medications and have some D complications, highish cholesterol, a bit overweight and currently feel vulnerable to re-starting exercise; plus you want to avoid taking insulin.

I am out of my depth and can offer no medical advice, not just because the Forum rules preclude this, but I am not medically qualified and I simply don't understand the interactions, effects and consequences of your current medications. However, I don't really see why you feel you shouldn't return to the gym straightaway. You are T2 and the only thing that might cause your hypos, rather than routinely being too high, are the medications you are taking to boost your insulin production, to help reduce your natural insulin resistance and perhaps help you pass excess glucose with your urine.

One prompt start point could be to shed those last few kilos, partly by your already good diet and partly by letting exercise help your metabolism. With reduced weight and hopefully reduced visceral fat that could/should give your hard worked pancreas some respite.

Your concern about frequent hypos is appropriate IF they are real hypos or very low BGs and not a consequence of your Libre 2 being over enthusiastic, or compression lows. I've tried reading back, but struggling to see the wood for the trees. I've deduced that you haven't previously (ie before you started this thread yesterday) confirmed your CGM declared hypos with finger prick (FP) tests? We're you experiencing any hypo awareness directly, at those times? This is a potentially dangerous question because when we see a hypo alarm it's remarkably easy to mentally convince ourselves we are going hypo, until an FP reveals this is not the case. I have twice had a CGM showing me very low and I've frozen, treated etc, thought I really was hypo, before finally bothering to FP and realise there was a Libre sensor issue. (Then of course I got the inevitable and self-influcted hyper rebound).

If you were to start exercising straightaway, you could carry hypo treatment with you (and your lancer and meter) and respond accordingly. With your Libre set at 5 (your compromise between Alarm and Alert!) you should have ample time to detect your falling BG and respond. That response would be better from 5.6 (the Libre limit); I would certainly not immediately go to full on hypo response at 5.6, I'd just have a suitable reasonably quick acting snack such as a Graze bar or a Nakd bar (various flavours from c.13 to 16 carbs each). There are plenty of equivalents and if one snack type isn't right for your metabolism you can experiment - ie "Trial and Learning". Avoid chocolate based snacks at this mid 5 level; the fats can slow down your metabolism. You might even do well with your apple and peanut butter combo, again trial and learning. But I'm hoping everything you are doing already will be already taking you away from the hypo issue!

You don't necessarily need to go to the gym. A full on workout is far more likely to elevate your BG, triggering a release of glucose from the liver's glucose store. A steady 20+ minute walk 2 or 3 times a day is kinder on your muscles as exercise gets reintroduced into your routine and if shortly after each main meal that can be a great help to the digestion and metabolism of that meal. The trick is to not over exercise at this point. Any intensive exercise can create a degree of inner stress and stress, in any form, can elevate BG by triggering different hormones to send messages to the liver and hey presto mor unwanted glucose gets released! If it's raining, or the timing is inconvenient any steady active task is a decent equivalent form of exercise for this purpose.

Once again I caveat my remarks: we are all different and what works for one person may not work for another.

I must break off here, got a lot going on to get our nearly empty new house ready for the arrival of our possessions from storage, some necessary DIY repairs and lots of time to be wasted on sorting utility accounts as well as some personal overdue admin. I'll be monitoring any response from you, but not necessarily responding quickly. But you are in a lengthy marathon and already making changes, so it will be interesting to see how you get on over the next few weeks. Good luck.

 

[Proud to be erratic]

Sorry @Newbie777 , I've just caught up with a speed read of the thread on Triglycerides and seen your remark:
"My cholesterol is fine but my triglycerides are high 28, this due to a low carb but higher fat food regime. Cant have it both ways."
So my opening paragraph above is slightly askew.

 

[Newbie777]

Thank you friend and you are absolutely right in what you are saying.
I work on the process of elimination and have a plan..

Short term plan is to get the hypo under control and get the medication right.
Medium term is start gym and also adjust carbs and eating plan.
Long term., want to try Berbefine to replace Metformin, also reduce my Atorvastatin from 80mg to 40mg.

Yes, you are also correct will avoid insulin at all costs!!

Good news I I have decided will be going gym from tomorrow, thanks. The main reason for not going is actually to do with low blood pressure and not to do with my Diabetes.

I suffer from high blood pressure and have been taking Lisonipril 10mg, but for the last few years now, I get low blood pressure, which is okay but going from usual 140!/85 to 90/50, is not good at all, it is THE big drop in units and yes I feel it, like my head is spinning and I am going to fall.
Been to see GP many times and they said it is Posterioc? Also mentioned at hospital too, no joy, GP advised to reduce medicine to 5mg, still happening until 3 weeks ago,.. WHEN I was looking into all my meds and looked further into Canagilflozin and side effects there were three main issues..

1. Leg and toe amputations,inqcreases research from America, banned there?
2. Low blood pressure!
3. Dehydration!
It is point number 2 that really hit me, as I think the low blood pressure drops started when I started to take 300mg Canagilflozin from 100mg.so from this told GP will trial 100mg for 4 weeks, GP not happy, guess what no low blood pressure and will now stick to 100mg.

Also been to A&E a few times in the past and it was dehydratkon, could not understand why though as was having plenty of water and salt too, well found out Canagilflozin drains water out of you!

Regarding my weight loss, it is happening but am not losing much weight but losing fat, Also by taking Glicizide you put on weight.
Thereis a big difference in me all round losing fat everywhere, buthappy to lose another 10kg or so in gym, as long as I feel energised.

Also another key reason to go back to the gym is my triglycerides are high and this is important that I manage this going forward with my food and exercise.

So I agree I am guilty of not managing my T2 over the years and have suffered mainly with my eyes and now kidneys, but I am strong natured, positive, don't easily give up and determined, will get through this and thanks to people like yourself and everyone else who have been so kind and helpful, the experience has been less painful.

Kind regards
Niaz

 

[helli]

A full on workout is far more likely to elevate your BG, triggering a release of glucose from the liver's glucose store.

Can you provide a reference for this as it is contrary to my experience and what I have read?

In my experience, a full on cardio work out significantly reduces my BG.
High intensity interval training or resistance training will raise my BG as the liver releases the glucose store but if I maintain the activity for more than 15 minutes, the outcome is definitely a reduction as my body is more efficient at using insulin which overcomes the liver release.
But even the type of exercise that raises BG (in my case, this is climbing - short burst of activity with a big bonus of adrenaline thrown in) will reduce my BG/increase my insulin sensitivity over the next 24 to 48 hours.

 

[Newbie777]

So it's 4.05pm and my CGM is showing 6.1 and dropping.
Had 10pmv and 80mg Glicizide 30 mins before breakfast, and 500mg metformin with breakfast, breakfast was two pieces of good life bread and scanbled egg and tea.
Lunchtime was away from so eat at 1.30pm and had donner and chicken dinner meat and salad and took 5mg Trajenta.
Had some nuts at 3pm,
Will see how much it drops, as tea is 5.30pm and will not be usual low carb, only medicine willbe 500mg Metformin

 

[Newbie777]

Now at 5.00pm CGM showing as 5.2, checked with blood sugar strip and it is 6.1, wow what a difference!!

 

[Newbie777]

Have the hypo kit at hand just in case!

 

[rebrascora]

Now at 5.00pm CGM showing as 5.2, checked with blood sugar strip and it is 6.1, wow what a difference!!

That is about par for the course for me with Libre. It is usually about 1mmol lower than finger prick.

Have the hypo kit at hand just in case!

These kits are really just a money making business. A tube of Glucose tablets costs less and doesn't need a special case. A packet of jelly babies are cheaper still, although they are liable to melt if left in a hot car.

Your hypo kit should include your testing kit though to double check any lows reported by Libre and to check your recovery 15 mins after treatment.

 

[Newbie777]

I agree expensive but fine for emergencies.

 

[Newbie777]

When I get the hypo. I eat a red apple so about 40 to 50g, 2 malted biscuits 30 g? and 3 dextrose tablets?not sure, but looks I may be looking at 70 to 90g if carbs!

Unless ‘red apple’ is some sugar-coated toffee apple type thing, then an apple (red or green) is around 15g carbs not 40 to 50g! It sounds like you’re over-estimating the carbs a lot. The best treatment for a hypo is something like Dextro tablets followed by a digestive biscuit or two.

Sorry just seen this now, oh OK, then I will eat the dextrose tablets 5 of them and a biscuit or the gel and a biscuit, will be trial and error, but will get it right

 

[rebrascora]

You only need 5 glucose tabs if it is a full hypo ie below 4 and dropping. If you have your alarm set at 5 and it goes off and you are dropping slowly, you might just need 1 glucose tab or half a biscuit and then keep an eye on your levels and maybe have another glucose tab if they are still dropping half an hour later.
I find very small amounts of carbs are all I need to gently nudge my levels back up a bit. As you say, you learn by trial and improvement, but don't feel the biscuit 15 mins after recovery is essential. Some people need it to prevent levels dropping again because they have excessinsulin in their system, but this is unlikely to be the case with gliclazide but try it and see assuming you are actually having real hypos and not just compression lows caused by lying on the sensor in your sleep. It is about being disciplined and taking as much as you need but not too much, particularly if you are trying to manage your diabetes with diet as well as meds and trying to lose weight. No point in taking meds to lower your BG and then having to regularly eat extra carbs to counteract any lows that the meds cause.
First you need to be sure that you are having genuine hypos by double checking with a finger prick, particularly the nocturnal ones and then consider if you need to discuss reducing medication if they are a regular occurrence.