Random thoughts on Hypos.

[PattiEvans]

This morning I was posting on the "7 day Waking average" thread that my FBG was 5.7 this morning but that the Libre 2 had alerted me that I was 4.2 half an hour earlier. I had just munched a Dextrose and fallen asleep again.

That incident and reading up the posts the thread where many people were reporting eating Jelly Babies during the night led to some random thoughts on the subject of hypos and remedies. I first joined the online diabetes community in 2004. Back then there was little in the way of forums as we know them now. It was mostly .alt.newsgroups which required special bits of software in order to read them properly. Then a couple of USA based forums sprouted which were a lot easier and more comfortable to read. Even so, the alt.newsgroups had some very experienced and wise members. From them I learned that Dextrose (or Lucozade) tablets were pure glucose which would be absorbed through the cheek linings and under tongue membrane right away. I was warned that sweeties were slower because they contained sucrose which needed to be digested before making it's way into the blood stream. For a while, some years later, I became keen on Jelly Beans as hypo remedies, but they took noticeably longer to bring me up than the Dextrose and I had a tendency to eat too many as they tasted nice. I notice these days lots of people using Jelly Babies as hypo cures so I looked the nutrition up. They do include some pure glucose syrup so, unlike other sweeties, they will start working right away. This set me thinking and it seems that going back people were reporting much higher incidence of "serious" hypos, accompanied by fits and requiring medical assistance, than we do these days. Now people seem to be able to deal with their own hypos and we rarely have people posting about being rushed into hospital or paramedics being called out. So I was thinking "why?". I concluded that it's probably due to a combination of more accessible self testing, better diabetic education and probably more common use of devices such as CGMs/FlashGMs (Libre). Anyone have any thoughts?

 

[nonethewiser]

Probably down to combinations you mentioned more than hypo treatments, easy to spot low levels coming now with likes of libre & cgms.

 

[Ivostas66]

I discussed this with one of my students a few years ago; an eleven year old type 1. Her smartwatch pinged an alarm and she grabbed a few jelly babies from her bag. She did not have any symptoms of hypo, but had a reading of 3.2. About 10-15 minutes later she was feeling rough and when she checked she was around 4. It was the end of the lesson so I offered her space in my room with a friend to relax and access to my stash of hypo treats from my cupboard if she needed them. She said she usually used a carton of apple juice with a straw so that it does not damage her teeth, but had used the one in her bag the day before and forgot to replace. She also said that's why she swallowed jelly babies whole as she does not want to damage her teeth with too much sugar. It sounded like this was advice given to her at primary school and also from friends. I also told her that when I was diagnosed I was specifically told that if I treated with sweets such as jelly babies that I should always chew them for a long time next to my cheek otherwise they would not work properly.

She no longer follows the advice given to her at primary school (thankfully) and it is something that I discussed with her parents that very day.

 

[rebrascora]

I must admit that I sort of expected hypos to be horrendous, once or maybe twice a year occurrences, which might need assistance, rather than the almost daily mildly inconvenient truth that I experience. Yes my first few hypos were pretty scary, but now that I have more stable BG levels and rarely go above 10, the hypos aren't really a big deal and oddly, nocturnal ones, which I was very anxious about, are less of an issue than daytime ones.

I can usually feel them coming on at low 4s or high 3s and the vast majority of the time I just pop a JB in my mouth and chew whilst I continue what I am doing.... be that mucking out a stable, walking or sleeping. In fact I can be back to sleep within a minute of treating a hypo during the night, it causes me so little worry. I am aware that it is dangerous to be too casual about them but I also think the fear of them can be really debilitating and affect people's everyday (and night) lives quite significantly. I do wonder if the fear of them can be worse than the reality.

I think sharing experiences via the likes of this forum is a huge benefit in understanding the wide range of normal that hypos cover and perhaps being more comfortable with my own experience and having a more realistic expectation and most importantly feeling reassured. I remember having 2 in a fortnight the first summer I was diagnosed and posting about it as I was really worried and Juliet @TheClockworkDodo said she regularly had 2 a day which was unbelievably reassuring for some reason. I now consistently average just under 1 a day (69 in the last 90 days), admittedly that is according to Libre and we all know it exaggerates 🙄 but that seems to be my normal. I take action when necessary and regularly adjust my basal and I have really good TIR with Libre currently 96% (1% above and 3% below) so it isn't that I am careless or cavalier, because I put a lot of effort into managing my diabetes, it is just the way my body works with my diet. I no longer worry about it and my consultant is fine with it.
I sometimes feel a bit of a fraud that my hypos are usually so "undramatic" but i think a big part of that is not panicking and just treating it and getting on with life.
Of course Libre etc makes a huge difference but I do not feel any urge to upgrade to Libre 2 with alarms as I am comfortable with my own body's ability to sense it. There was a time when I was really anxious about nocturnal hypos and researched CGMs with alarms because I was so frightened, but having now experienced quite a number of mid sleep hypos, I have gained confidence in my body responding. What I find interesting is that I tend to have hypos when I am having really deep restful sleep and yet my body still wakes me, I scan, munch a JB or two depending on the readings and go straight back to that deep restful sleep. I don't even wait the 15mins to retest. I am out like a light, it causes me that little concern. If I drop low an hour later or so, I wake up again and repeat and back to sleep. Obviously, the next night I adjust my basal but otherwise it is no big deal.
I think it may be that my low carb way of eating means that I have more stable levels and that enables my body to be more attuned to high and low levels. As well as waking up when I get a bit low, I usually have very poor sleep and toss and turn when levels are 8+ during the depths of the night and I will eventually wake up and inject a correction unit on 8 in order to sleep better.

Anyway, that is my thoughts and experience.

 

[helli]

This set me thinking and it seems that going back people were reporting much higher incidence of "serious" hypos, accompanied by fits and requiring medical assistance, than we do these days. Now people seem to be able to deal with their own hypos and we rarely have people posting about being rushed into hospital or paramedics being called out. So I was thinking "why?". I concluded that it's probably due to a combination of more accessible self testing, better diabetic education and probably more common use of devices such as CGMs/FGMs (Libre). Anyone have any thoughts?

Is it also likely to be due to the basal bolus insulin regime?
In them there olden days, it was a mixed insulin which was much less flexible. If you ate your dinner an hour or so later or had something with less carbs in it, you had too much active insulin onboard with insufficient carbs to "mop it up".

 

[PattiEvans]

Probably down to combinations you mentioned more than hypo treatments, easy to spot low levels coming now with likes of libre & cgms.

Yes of course, that was part of the random thoughts... people do seem far more motivated to take charge of their own care now though. It's not just something they expect their HCPs to be in charge of, or at least I suppose a few still do, but much less than when I first came online seeking information.

She no longer follows the advice given to her at primary school (thankfully) and it is something that I discussed with her parents that very day.

Good for you! A win!

 

[eggyg]

In the eight years I’ve been on insulin I’ve only had two horrendous hypos, the type that you just feel so ill and the numbers won’t go up however hard you tried. Both times have been after strenuous walking. I do go low but deal with it and get on. I think it’s partly the fact I learnt so much on my DAFNE course, having the Libre and just generally experience gained over the years. We have the tools, we have the educational courses and we have the forum.

 

[everydayupsanddowns]

I was involved in the PPI panel of a recent clinical trial which was investigating a new intervention for people who continue to struggle with severe hypos, despite having had access to the ‘standard’ things that often help (including pump and CGM)

Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc): protocol for a group randomised controlled trial of a novel intervention addressing cognitio

It seems there are relatively few individuals who account for a pretty large proportion of the total number of severe hypos / ambulance callouts, A&E visits etc.

Something like 10% of the T1 population accounting for 70% of events.

 

[TheClockworkDodo]

I remember having 2 in a fortnight the first summer I was diagnosed and posting about it as I was really worried and Juliet @TheClockworkDodo said she regularly had 2 a day which was unbelievably reassuring for some reason.

That's nice to know! I'm currently averaging just over 2 a day, and would very much like to have fewer! (It's a timing thing, I've had more since the clocks went forward and I'm still trying to adjust everything accordingly.) But they are still generally a minor nuisance rather than a major event.

In 11+ years I've only had one really severe hypo when I went to bed for a rest during the afternoon and R had to wake me up 4 hours later and make me test (and I didn't know who he was or what he was talking about), one fairly severe one (in the middle of dinner, my fault because I knew my bgl was dropping but mistakenly thought it would quickly come up again because I'd just eaten lots of carbs, as it sometimes does this during breakfast if I get the timing of my morning pre-bolus slightly wrong, so I wasn't going to bother doing anything about it until R saw I was getting very rapidly very much more hypo and insisted), and a tiny handful of not severe but nasty plummety ones when I'm glad he was around and could pass me the glucose so I could lie on the floor for a bit, but if he hadn't been there I'd have managed. I've also had a couple where the numbers just wouldn't go up, like @eggyg - last one of those was walking round the Botanical Gardens of Wales, and after I had several glucoses and finally got my bgl over 4, I went to the cafe, bought a large flapjack and two enormous pieces of shortbread, injected for half the flapjack and ate the whole of it and one of the shortbreads - and then had another hypo on the way home to where we were staying 🙄

I've never been admitted to hospital with a hypo or had a fit or any very severe symptoms like that though. I hardly ever have them in the night, but when I do my body normally just deals with it and I sleep through it - only very occasionally do I wake up, scan, eat something, and go back to sleep. If it's shortly before I'm going to get up anyway and it's high 3s I might just have half a Hobnob rather than a proper hypo treatment, to try to avoid adding to the fotf spike. I do always keep glucose syrup by my bed in case I need it in the night, but I can't actually remember the last time I did - I tend to need it when I'm on my way to bed and I'm getting the last kick of the Novo-notso-rapid I had with my evening meal.

I don't use alarms, I've turned off all the noises on my Libre and meter as I'm too sensitive to noise to cope with things beeping at me! I hated it when I had a CGM for a week and it kept alarming - especially as it alarmed when it got to the number (I think it was 3.9) on the way back up as well as on the way down! Aargh, I know I've had a hypo, I dealt with it ten minutes ago, keep the noise down!!

Having the Libre really has changed things for a lot of people - for those of us who used to test 8-10 times a day and undoubtedly miss a lot of what was going on with our blood sugar, it's great to be able to scan 30+ times a day, and to have the arrows so we're not constantly guessing whether that's a 6 which is about to become an 8 or a 6 which is about to become a 4.

I think @helli is right though, basal-bolus must have been the huge game-changer before that, which stopped people having such bad hypos - the Libre has just helped us refine things a bit more. Useful as I find the Libre, I managed perfectly well without it for years - but I can't imagine how I'd have survived on fixed insulin: I have to change at least one of my doses every few days, especially when the weather is changing rapidly. And there are (occasional) days when the ME makes me too ill to chew or swallow, sometimes at very short notice, that would have been a nightmare if I'd already injected for a set amount of carbs.

 

[nonethewiser]

Yes of course, that was part of the random thoughts... people do seem far more motivated to take charge of their own care now though. It's not just something they expect their HCPs to be in charge of, or at least I suppose a few still do, but much less than when I first came online seeking information.

Quite agree, so much info out on web which helps newbies & oldies alike learn new skills.

Another thing to consider, 20+ years ago hardly knew anyone using insulin pump, today taking this forum for example there are many of us using pumps, from own experience they decrease amount of hypos experienced, especially night time ones by being able to fine tune basal rates, cant remember last time had night hypo & hypos in general are far & few between, aided of course by using libre as well.

Think as more & more get access to pumps & tech like libre cgm hospital admissions will fall further, well hopefully so.

 

[PattiEvans]

Is it also likely to be due to the basal bolus insulin regime?
In them there olden days, it was a mixed insulin which was much less flexible. If you ate your dinner an hour or so later or had something with less carbs in it, you had too much active insulin onboard with insufficient carbs to "mop it up".

When I was first diagnosed MDI was around, but because I was diagnosed as T2 by a DSN who had never met me, I was put onto mixed insulin. Apparently the surgery nurse phoned the DSN and despite the dramatic weight loss - I looked like something out of a concentration camp - and the extremely high BGs, she made her diagnosis on the strength of my age. It was hopeless, I was never one to have a strictly regimented life, so I ended up with multiple nasty hypos. I was lucky to get online and find some advice - there wasn't much in the way of online resources then. So I advocated for myself and got the surgery DN to prescribe MDI. I taught myself to carb count, because that wasn't on offer to T2s either. Eventually I had to kick up a fuss to get the tests where I was re-diagnosed by an Endo. All that to say that mixed insulin was a blooming nightmare! For that matter I hear Insulatard was as bad.

Something like 10% of the T1 population accounting for 70% of events.

That's very interesting! Of course not everyone is gifted with the ability or the will to manage well, diabetes isn't particular who it is given to!

And there are (occasional) days when the ME makes me too ill to chew or swallow, sometimes at very short notice, that would have been a nightmare if I'd already injected for a set amount of carbs.

Oh dear, you have an extra condition that impacts on your ability to manage - that must make things exceptionally difficult for you.

I'm so glad awareness has increased so much for sufferers.

 

[TheClockworkDodo]

It's shocking that you had to go through all that to get a proper diagnosis, Patti - even more shocking that we regularly read on the forum about similar things happening now. I'm so glad they decided I was type 1 right away, despite my age at the time (44). Getting a correct diagnosis as an adult with type 1 is such a lottery, and shouldn't be.

I have four or five different conditions/sub-conditions, diabetes is the easiest to manage despite all the hypos!

 

[trophywench]

I had a few when I was fairly newly diagnosed - but so very little information or help was available 50 years ago, I was more than happy to be carted off in an ambulance secure in the knowledge they'd see me OK in the local A&E, and they did.

After that it was well over 20 years before I had a couple of hypos whilst driving - lack of knowledge of the times of effectiveness of Humulin I & S.

Then another gap until a really bad one that scared me to the core in 2008 ish. I could hear and understand everything that anyone said either to me or each other. I could not see, speak or move. It was then I very much appreciated the paramedic saying he was testing my BG, (TG for that) that it would not register on his glucometer (Oh sheet) and he was going to set a glucose drip up (Get on with it FFS then mate!)

Don't remember having a bad one since then.

 

[YE2GATHER]

I must admit that I sort of expected hypos to be horrendous, once or maybe twice a year occurrences, which might need assistance, rather than the almost daily mildly inconvenient truth that I experience. Yes my first few hypos were pretty scary, but now that I have more stable BG levels and rarely go above 10, the hypos aren't really a big deal and oddly, nocturnal ones, which I was very anxious about, are less of an issue than daytime ones.

I can usually feel them coming on at low 4s or high 3s and the vast majority of the time I just pop a JB in my mouth and chew whilst I continue what I am doing.... be that mucking out a stable, walking or sleeping. In fact I can be back to sleep within a minute of treating a hypo during the night, it causes me so little worry. I am aware that it is dangerous to be too casual about them but I also think the fear of them can be really debilitating and affect people's everyday (and night) lives quite significantly. I do wonder if the fear of them can be worse than the reality.

I think sharing experiences via the likes of this forum is a huge benefit in understanding the wide range of normal that hypos cover and perhaps being more comfortable with my own experience and having a more realistic expectation and most importantly feeling reassured. I remember having 2 in a fortnight the first summer I was diagnosed and posting about it as I was really worried and Juliet @TheClockworkDodo said she regularly had 2 a day which was unbelievably reassuring for some reason. I now consistently average just under 1 a day (69 in the last 90 days), admittedly that is according to Libre and we all know it exaggerates 🙄 but that seems to be my normal. I take action when necessary and regularly adjust my basal and I have really good TIR with Libre currently 96% (1% above and 3% below) so it isn't that I am careless or cavalier, because I put a lot of effort into managing my diabetes, it is just the way my body works with my diet. I no longer worry about it and my consultant is fine with it.
I sometimes feel a bit of a fraud that my hypos are usually so "undramatic" but i think a big part of that is not panicking and just treating it and getting on with life.
Of course Libre etc makes a huge difference but I do not feel any urge to upgrade to Libre 2 with alarms as I am comfortable with my own body's ability to sense it. There was a time when I was really anxious about nocturnal hypos and researched CGMs with alarms because I was so frightened, but having now experienced quite a number of mid sleep hypos, I have gained confidence in my body responding. What I find interesting is that I tend to have hypos when I am having really deep restful sleep and yet my body still wakes me, I scan, munch a JB or two depending on the readings and go straight back to that deep restful sleep. I don't even wait the 15mins to retest. I am out like a light, it causes me that little concern. If I drop low an hour later or so, I wake up again and repeat and back to sleep. Obviously, the next night I adjust my basal but otherwise it is no big deal.
I think it may be that my low carb way of eating means that I have more stable levels and that enables my body to be more attuned to high and low levels. As well as waking up when I get a bit low, I usually have very poor sleep and toss and turn when levels are 8+ during the depths of the night and I will eventually wake up and inject a correction unit on 8 in order to sleep better.

Anyway, that is my thoughts and experience.

whats libre 2?

 

[Lily123]

whats libre 2?

It’s a sensor that’s worn on the back of the arm and can be scanned to tell you your blood glucose and has alarms you can set and choose the number you want to be alarmed at for both high and low numbers

 

[rebrascora]

whats libre 2?

The Libre system is a means of monitoring your glucose levels via a sensor applied to your arm. It is stuck to your arm for a fortnight and samples your glucose levels every few minutes and stores the data. You scan it with a phone or a reader to get your results and it gives you the reading at that time similar to a finger prick test but quicker and easier but it also transfers all the date from the past 8 hours of testing in the sensor to your phone or reader so that you can see what your glucose levels are doing throughout the day and night. For those of us on a variable insulin regime this enables us to adjust our insulin doses to suit our bodies needs on an almost daily basis if necessary and that is the thing about our bodies..... they need more at some times of the day and less on others. If you have been really active one day, you will likely need less insulin that night and the next day than if you had been siting at a desk or watching TV all day. If you are more active for several days in a row then your insulin needs can really drop quite a bit and if you keep taking the same amount of insulin as normal, you are likely to hypo..... this may be what happened to you when you experienced the hypo you mentioned in your other thread. Walking and gardening are two activities which can really drop your levels unless you reduce your insulin or snack to push your levels up a bit when they are dropping.
If I give a couple of examples of graphs from my Libre it might give you a better idea...

This was a day when I was very active all day. The blue band is the range I want to stay within (BG between 4-10) and as you can see it wiggles along the bottom of the band and just dips into the red (a hypo) about 4pm. All those wiggles are where my activity is using up glucose and dropping my levels and then I am eating a jelly baby or a piece of dried fruit to push it back up a bit. The spike at the end is where I had a late evening meal.

This was a day when my levels were less stable. I probably didn't exercise much, if at all this day, and was using my insulin to try to bring levels down but they kept rising again. I don't like days like this because I feel like I am battling my diabetes.. I will have slept badly because my levels were high overnight and that means I start my day tired and irritated and that alone can affect my BG levels. Good sleep is really helpful to diabetes management..... talking of which it is past time I was gone...

 

[YE2GATHER]

The Libre system is a means of monitoring your glucose levels via a sensor applied to your arm. It is stuck to your arm for a fortnight and samples your glucose levels every few minutes and stores the data. You scan it with a phone or a reader to get your results and it gives you the reading at that time similar to a finger prick test but quicker and easier but it also transfers all the date from the past 8 hours of testing in the sensor to your phone or reader so that you can see what your glucose levels are doing throughout the day and night. For those of us on a variable insulin regime this enables us to adjust our insulin doses to suit our bodies needs on an almost daily basis if necessary and that is the thing about our bodies..... they need more at some times of the day and less on others. If you have been really active one day, you will likely need less insulin that night and the next day than if you had been siting at a desk or watching TV all day. If you are more active for several days in a row then your insulin needs can really drop quite a bit and if you keep taking the same amount of insulin as normal, you are likely to hypo..... this may be what happened to you when you experienced the hypo you mentioned in your other thread. Walking and gardening are two activities which can really drop your levels unless you reduce your insulin or snack to push your levels up a bit when they are dropping.
If I give a couple of examples of graphs from my Libre it might give you a better idea...
View attachment 20626
This was a day when I was very active all day. The blue band is the range I want to stay within (BG between 4-10) and as you can see it wiggles along the bottom of the band and just dips into the red (a hypo) about 4pm. All those wiggles are where my activity is using up glucose and dropping my levels and then I am eating a jelly baby or a piece of dried fruit to push it back up a bit. The spike at the end is where I had a late evening meal.
View attachment 20627
This was a day when my levels were less stable. I probably didn't exercise much, if at all this day, and was using my insulin to try to bring levels down but they kept rising again. I don't like days like this because I feel like I am battling my diabetes.. I will have slept badly because my levels were high overnight and that means I start my day tired and irritated and that alone can affect my BG levels. Good sleep is really helpful to diabetes management..... talking of which it is past time I was gone...

dont let me keep you.