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Why do hypos occur?

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D

Doddy

Well-Known Member
Relationship to Diabetes
Type 1.5 LADA
Sitting here thinking about random stuff, and this question just popped into my head.

If we dose our insulin according to how many carbs we are having, then hypos shouldn't occur should they? I understand if if skip a meal, then the background insulin will have nothing to work with and therefore a hypo can happen...but why do severe hypos occur?
 
There can be many reasons for a hypo because there are many more factors at play than just matching doses to insulin. With background insulin there might be little peaks which mean too much insulin to match the glucose being trickled out by the liver - or the liver will go through its own peaks and troughs according to how it is acted on by other hormones. Skipping meals is fine as the basal insulin is there to match the liver's output, not food.

With meal insulin, you also need to consider activity levels, which may increase your sensitivity, things like stress, the GI of the food may mean the insulin does not peak at the same time as the food. Also, the dose may not make its way into the bloodstream evenly - a cause of severe hypos can be where a dose suddenly gets into the blood, perhaps because an injection site is 'lumpy' through overuse. Sometimes there is no fathomable reason - I have had bad hypos over 7 hours after my injection, and that shouldn't happen! Injecting is a very crude solution to the problem - pumps are better, but there's a long way to go before we can mimic the fine-tuning by the human body 🙂
 
Basically too much insulin......

Which could be down to:

Miscalculation of carbs
Physical Activity
Too much background insulin
And others

If you background dose is right then you should not have a hypo, even if you don't eat anything...:D
 
The flipside of this is that if it's all just a case of dosing according to intake and basal flow, you shouldn't ever have high blood sugar either and we'd all have A1cs of less than 5.5.

The problem is that the insulins we use are extremely imperfect tools that don't adequately replace what our body needs.

In the first instance, there are actually 3 hormones that T1s don't produce because of islet cell destruction - amylin, c-peptide and insulin. Modern diabetes treatment only replaces insulin. Amylin has a role in modulating metabolism to prevent blood sugar spikes and stop you feeling hungry. C-peptide is believed to have an important role in vascular health. Whether any of these also have a further role to play in hypoglycaemia is unclear, but suffice to say, it should be obvious right from the get-go that we're patching up the equivalent of a massive mechanical failure with nothing but gaffer tape.

Secondly, the insulins we use aren't very good. Your bolus insulin has a specific action profile, that also varies according to when and where you inject. Unfortunately, your food doesn't digest in exact accordance with that action profile. In fact, the more cynical of us would suggest that the action profile of any bolus insulin doesn't match any meal known to man. And then of course, the digestion profile of your meal will vary according to any number of variables, whereas your dosing only involves two - your ratio, and the carb quantity.

It's even worse with basal insulins. Lantus and Levemir were celebrated because they don't have a peak action period. Unfortunately, your liver often does. It also has quieter times. Your basal glucose action can be dramatically altered simply by having a drink or running for a bit - whereas you're stuck with an insulin you can only alter every 12 hours at best.

If insulins matched your meal perfectly under all circumstances, then yes, you're right, you shouldn't have severe hypos. But they don't. Insulin injections are simply an imperfect solution that you have to make the best of, with a high margin of error.
 
Plus of course despite being touted as peakless, both Levemir and Lantus DO have peaks and not ones that it's easy to match by diet.
 
DeusXM said:
The flipside of this is that if it's all just a case of dosing according to intake and basal flow, you shouldn't ever have high blood sugar either and we'd all have A1cs of less than 5.5.

The problem is that the insulins we use are extremely imperfect tools that don't adequately replace what our body needs.

In the first instance, there are actually 3 hormones that T1s don't produce because of islet cell destruction - amylin, c-peptide and insulin. Modern diabetes treatment only replaces insulin. Amylin has a role in modulating metabolism to prevent blood sugar spikes and stop you feeling hungry. C-peptide is believed to have an important role in vascular health. Whether any of these also have a further role to play in hypoglycaemia is unclear, but suffice to say, it should be obvious right from the get-go that we're patching up the equivalent of a massive mechanical failure with nothing but gaffer tape.

Secondly, the insulins we use aren't very good. Your bolus insulin has a specific action profile, that also varies according to when and where you inject. Unfortunately, your food doesn't digest in exact accordance with that action profile. In fact, the more cynical of us would suggest that the action profile of any bolus insulin doesn't match any meal known to man. And then of course, the digestion profile of your meal will vary according to any number of variables, whereas your dosing only involves two - your ratio, and the carb quantity.

It's even worse with basal insulins. Lantus and Levemir were celebrated because they don't have a peak action period. Unfortunately, your liver often does. It also has quieter times. Your basal glucose action can be dramatically altered simply by having a drink or running for a bit - whereas you're stuck with an insulin you can only alter every 12 hours at best.

If insulins matched your meal perfectly under all circumstances, then yes, you're right, you shouldn't have severe hypos. But they don't. Insulin injections are simply an imperfect solution that you have to make the best of, with a high margin of error.
Click to expand...

That all sounds very appropriate *sighs*

Good answer Deus.
 
That is all helpful to know, even for a type 2 on pills
 
Im so glad I asked this question..thankyou all for your replies 🙂

It really is an art to get things "just right" isn't it!
 
Doddy said:
Im so glad I asked this question..thankyou all for your replies 🙂

It really is an art to get things "just right" isn't it!
Click to expand...

Like walking a tightrope sometimes, hanging onto a rollercoaster for dear life at others! 😱
 
It really is an art to get things "just right" isn't it!
Click to expand...

Precisely. How we manage diabetes is a bit like comparing doing a painting to taking a photograph to get the most realistic image. We're all trying to paint photoreal images with three colours of poster paint and a ceiling roller, whereas everyone with a working pancreas has one of those SLR cameras.
 
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