Hypoglycemia occurs when blood glucose levels fall below 4 mmol/L (72mg/dL).

Whilst many of us do think of diabetes as being a problem of high blood sugar levels, the medication some people with diabetes take can also cause their sugar levels to go

too low

and this can become dangerous.

What is hypoglycemia?

Hypoglycemia occurs when the level of glucose present in the blood falls below a set point:

• 
  Below 4 mmol/L
  
  (72mg/dL)

Being aware of the early signs of hypoglycemia will allow you to treat your low blood glucose levels quickly – in order to bring them back into the normal range.

It is also recommended to make close friends and family aware of the signs of hypoglycemia in case you fail to recognise the symptoms.

What are the symptoms of hypoglycemia?

The main symptoms associated with hypoglycemia are:

• Sweating
• 
  Fatigue
• Feeling dizzy

Symptoms of hypoglycemia can also include:

• Being pale
• Feeling weak
• 
  Feeling hungry
• A higher heart rate than usual
• 
  Blurred vision
• Confusion
• Convulsions
• Loss of consciousness
• 
  And in extreme cases, coma

Who is at risk of hypos?

Whilst low blood sugar can happen to anyone, dangerously low blood sugar can occur in people who take the following medication:

• 
  Insulin
• 
  Sulphopnylureas
  (such as glibenclamide, gliclazide, glipizide, glimepiride, tolbutamide)
• 
  Prandial glucose regulators
  (such as repaglinide, nateglinide)

If you are not sure whether your diabetes medication can cause hypos, read the patient information leaflet that comes with each of your medications or ask your doctor.

It is important to know whether your diabetes medication puts you at risk of hypos.

What are the causes of hypoglycemia?

Whilst medication is the main factor involved in hypoglycemia within people with diabetes, a number of other factors can increase the risk of hypos occurring.

Factors linked to a greater risk of hypos include:

• Too high a dose of medication (
  
  insulin
  or hypo causing tablets)
• Delayed meals
• 
  Exercise
• 
  Alcohol

You can take steps to minimise the risk of these factors causing hypos.

How is hypoglycemia diagnosed?

Hypoglycemia is detected by measuring blood sugar levels with a glucose meter. Any

blood glucose level below 4.0 mmol/L

indicates that the individual has hypoglycemia. Urine tests do not detect hypoglycemia.

If taking a blood test is not possible or would take too much time, it may be better to treat the hypo straight away.

How do I treat hypoglycemia?

A mild case of hypoglycemia can be treated through eating or drinking 15-20g of fast acting carbohydrate such as

glucose tablets, sweets, sugary fizzy drinks or fruit juice.

Some people with diabetes may also need to take 15-20g of slower acting carbohydrate if the next meal is not due.

A blood test should be taken after 15-20 minutes to check whether blood glucose levels have recovered. Severe hypoglycemia may require an ambulance, for example if loss of consciousness occurs or a seizure persists for more than 5 minutes.

Severe hypos can be treated with glucagon if a

glucagon injection kit
is available and in date.

• Read more detail on
  
  how to treat hypoglycemia

How serious is hypoglycemia?

Hypoglycemic episodes can range from mild to severe.

Mild hypoglycemia can usually be treated by the individual and are to be expected to some degree in people on insulin. Mild hypos are not associated with significant long term health problems unless they are occurring very regularly or for long periods of time.

Severe hypoglycemia, however, will require treatment from someone else and may require an ambulance. Severe hypos can lead to immediate danger if not treated immediately. Whilst rare, severe hypos can potentially lead to coma and death.

• What is
  
  dead in bed syndrome
  ?

Do symptoms always occur before hypoglycemia?

Most people experience some warnings before the onset of hypoglycemia. However, some diabetics may experience little or no warning before the onset of sudden or severe hypoglycemia.

An impaired ability to spot the signs of hypoglycemia is known as loss of hypo awareness (or

hypo unawareness
).

Preventing hypoglycemia

The key to preventing hypos is understanding why hypos occur and then taking actions to stop this happening. If you know that a hypo is likely to occur soon, carbohydrate can be taken to raise sugar levels and prevent the hypo.

If your doctor is happy for you to adjust your medication doses, you can also lower your dose during or following certain activities (eg exercise or after having alcohol) to prevent a hypo occurring.

Testing blood sugar levels
regularly can help you to understand when your sugar levels are dropping too low.

Your diabetes health team can help you with making changes to your diabetes management.

Are hypos catching you without warning?

Join the Hypo Awareness Program for a comprehensive guide towards recovering your hypo awareness »

A hypo (hypoglycemia) is triggered when blood sugar levels fall under 4 mmol/L.

Too much insulin or too little food can spark a hypo.

This guide details what

hypoglycemia
is, how to recognise hypo symptoms, and what to do when you or your child is suffering from a hypo (hypoglycemia).

What are the symptoms of hypo?

Symptoms of hypoglycemia vary from person to person, but people with diabetes should learn to recognise their own signs in order to treat the hypo as quickly as possible.

Some of the most

common symptoms
of a hypo include:

• Feeling dizzy
• 
  Feeling hungry
• A change in mood
• Feeling sweaty
• Trembling
• Finding it hard to concentrate

What to do if you think you/your child is having a hypo?

If you, or your child, may be having a hypo, it’s often worth checking

blood sugar levels
as soon as the symptoms are noticed.

However, if testing could delay treating the hypo by more than a minute or two, it is better to treat the hypo immediately and test as soon after as you can.

Someone I know is having a hypo, what should I do?

If someone with diabetes is having a hypo and is conscious, they should initially treat a hypo with 15-20g of fast acting sugary food or drink, such as:

• 5 glucose tablets
• 150 to 200ml of a sugary fizzy drink (eg full sugar cola or lemonade)
• 4 to 5 sugar lumps or teaspoons of sugar
• 150 to 200ml of fruit juice

The priority is to bring blood glucose levels back up to normal as quickly as possible.

Chocolate can be used if little else is available. However, note that the fat in chocolate slows down how quickly the sugar gets broken down, so use sugary foods without fat in where possible.

If someone is unconscious or has a seizure this is a severe hypo. Read more on the symptoms and

treatment of a severe hypo

So in the case of serious hypo what should be done?

• The patient should be put into recovery position
• Emergency services should be contacted
• Glucagon should be given as advised

What does glucagon do to a hypo patient?

Glucagon causes blood glucose levels to rise within 10-60 minutes after an injection. Following glucagons, standard instant hypo treatment (glucose tablets, Lucozade, fizzy drinks). Vomiting may occur during the first hour of glucagon injection.

How much glucagon should be given to hypo patients?

Standard glucagon dose is:

• Half a vial – 0.5mg
  
  (Children younger than 8 years)
• Full vial – 1mg)
  
  (Children 8 years and above)

Directions for use should be included with the product or your

healthcare professional
should be able to advise you.

The prefilled

syringe
should be injected into the glucagon vial, this should then be shaken until contents dissolve, the solution should then be drawn into the syringe with all air removed.

The technique for injection is to inject about ¼ inch into the outer thigh at an angle of 90 degrees.

Low blood glucose levels can cause us to feel exceptionally hungry. If you’ve had that feeling of “I could eat the whole fridge right now” then you’re not alone.

Intense hunger as a result of hypos can lead to overeating, so we’ve written a guide to address treating hypos without over doing the calories.

Why do hypos make us hungry?

The intense hunger we can feel is down to our blood sugar levels and it’s not so difficult to control.

It just takes a bit of understanding of what your body really needs and a bit of faith that the extreme hunger will go once your sugar levels have recovered back to normal.

When you’re low on sugar, you get hunger cravings because your body wants you to get sugar.

You may feel like eating meat, cheese or a fifteen course meal, but the bottom line is that all your body usually needs is a certain amount of glucose to bring your sugar levels back to normal.

It’s not uncommon for us to eat more than we would normally when hypoglycemic, which can present problems for those of us that are

watching our weight

Treating a hypo and beating the hunger

The best way to reduce the hunger cravings is to get your blood glucose levels back to normal levels.

The faster you can get your blood sugar up, the less time you’ll spend being very hungry.

Glucose tablets raise blood sugar levels very quickly and are therefore a recommended way of treating low blood sugar levels.

Most glucose tablets contain about 3-4 grams of carbohydrate and so it is recommended to take 3 to 4 glucose tablets to raise blood sugar levels. Test your blood sugar levels after 15 minutes to see how your blood sugar levels have responded.

• Buy glucose tablets from the
  
  Diabetes Shop

If you don’t have glucose tablets, then sweets, sugary soft drinks or fruit juice should also raise your blood glucose levels quickly. You can eat other sources of

carbohydrate
such as bread, chocolate or cereal bars but these will take longer to raise your glucose levels.

Preventing further hypos

Once your sugar levels get back above 4 or 5 mmol/l, the hunger cravings should then subside.

If you’re watching your weight, the best way to treat a hypo is with glucose tablets as these will raise your blood sugar quickly and therefore end the hunger cravings sooner.

If it is some time before your next meal, you may need to take some longer acting carbohydrate in addition to prevent your blood glucose levels dropping low before the next meal.

• Read more on
  
  how to treat a hypo

People with diabetes on insulin or certain tablets, such as solfonylureas, will have an increased risk of experiencing

hypoglycemia

To be able to prevent hypos from occurring, it’s important to understand why you are experiencing low blood glucose levels.

Identifying regular low blood glucose levels

It is useful to find out whether there are patterns that could indicate why you might be going hypo.

You may find it useful to ask the following questions:

• Do your blood sugar levels go low at similar times each day?
• Do you get hypos after particular activities?
• Do your hypos follow after periods of stress or illness?
• Do you get hypos in warmer or colder environments?

Preventing hypos at similar times of day

If you find you go low at specific times of day, say just before lunch, you may want to change your routine to prevent the lows from happening.

In this case you may be able to take lunch slightly earlier or have a small snack before lunch.

Another option available would be to

adjust your insulin
If you are not confident in adjusting your own insulin doses, speak to your diabetes team who will be able to help you.

Preventing hypos after certain activity

Certain activities can cause hypos to occur later in the day or even on the following day in some instances.

If you take part in energetic exercise, this can cause us to be more sensitive to insulin for up to 48 hours.

This could lead to

experiencing hypos at night
following exercise or even the next day. Alcohol is another factor that is also known to lead to a higher chance of hypos over night

If you find you are getting hypos following specific activities, you can take action to prevent hypos occurring the next time. Remedial action may include reducing one or more

insulin doses
or taking carbohydrate prior to the times you’d expect to go hypo.

For example, if playing football causes you to go hypo overnight, you might want to reduce your background insulin when you play football or take some carbohydrate before going to bed.

Speak with diabetes team if you need help with adjusting your own insulin doses.

Preventing hypos after illness or stress

When we experience stress or illness, we may need to take more insulin to help keep our blood glucose levels from going too high. When stress or infection is over, the body will revert back to its previous insulin requirements and this can mean a higher risk of hypos if we do not adjust insulin levels back to what they were before

illness
or

stress

During periods of stress, it is recommended to test your blood glucose levels more often than usual. The University of Birmingham Medical School advises testing more often until your blood glucose levels stabilise.

Preventing hypos when temperatures change

Many people report that their blood glucose levels are affected by significant changes in temperature. If you find your blood glucose levels vary in response to temperature changes, you may need to consider altering your

insulin
doses.

If you keep records of blood glucose results, you may be able to detect whether any episodes of hypoglycemia may be linked with changes in temperature and take precautions to prevent hypos under similar conditions in the future.

Fear of hypoglycemia is a commonly reported problem and can affect most types of diabetes. It is particularly common in

type 1 diabetes
but it can also affect women with

gestational diabetes, type 2 diabetics on certain oral medications.

Being afraid and worried about hypos is not only something that people with diabetes experience, it is also a feeling frequently shared by their friends and loved ones.

Managing the fear of hypoglycemia

In situations where you are worried, or even scared of having hypos, some people may decide to run their

blood sugars higher than usual
and others may abstain from a particular activity, such as certain sports or driving.

How you cope with concerns about hypoglycemia is a matter of individual taste and it could come down to a play off of what is most important to you; good blood glucose control, the freedom to have fun or the safety of moderation.

Worrying about hypoglycemia

Where worry of hypoglycemia is prevalent, it’s well worth

performing regular blood tests

Whether you’re an athlete, frequent driver or the partner of a concerned spouse, blood testing can help you to understand why you may be going low and change your management routine to help prevent it in future.

Over treating hypos

If you have had a serious or uncomfortable hypo experience, it can be a natural reaction to over treat a hypo, just to make sure. Generally most hypos can be treated with 10 to 15 grams of quick acting carbohydrate, and where a meal is not due, an additional longer acting source of carbohydrate.

Over treating hypos can therefore result either from taking too large an amount of short acting

carbohydrate
or taking too much long acting carbs. Short term carbohydrate will typically take around 10 to 15 minutes to sufficiently raise blood sugar levels, but it can take longer. If sugar levels do not appear to rise, it can be tempting to keep eating glucose.

Unless a large

insulin dosage
error occurred, it is best to be patient and allow sugar levels to rise. If you are worried, perform a test every 10 or so minutes.

Night time hypoglycemia

Hypos at night can be a particular worry for some people, especially if you wake up during a hypoglycemic episode.

Less severe hypos during the night are relatively common. More serious hypos will usually be a result of over dosage. If you are having regular or severe hypos during the night, your healthcare team can advise how to change your regime.

• 
  Nocturnal hypoglycemia

Hypoglycemia and your social life

When you just want to kick back, relax and have fun, the last thing you want to worry about is hypoglycemia. Where alcohol is involved, the problem can be worse as alcohol makes it harder to recognise when you are low.

• 
  Diabetes and alcohol

Parents

Managing the threat of hypoglycemia in

your children
can be very stressful, particularly if your child has suffered from severe hypos in the past. It can be difficult to strike a balance between keeping blood sugars from being too high whilst preventing hypos.

Keeping a comprehensive set of blood testing records for your child will certainly help with getting a good understanding of your child’s control and help to ensure your child is hitting the right numbers.

Be aware that is common for children who self test to lie about their numbers.

• 
  Parenting and diabetes

Hypoglycemia and relationships

Friends and family may also worry about hypoglycemia.

They may want to try and protect you by asking you to keep your sugars higher.

If you are committed to keeping tight control this can present an issue.

No-one should force you into making a change but make sure you listen to their concerns and try not to be stubborn.

• Hypoglycemia can affect
  
  sport,
  
  driving
  and even your
  
  sex life

Hypo unawareness is used to describe a situation where people with diabetes, usually type 1 diabetes, are frequently unable to notice when they have low blood sugar, hypoglycemia.

Loss of hypo awareness can be troubling, and at times dangerous, so taking steps to regain awareness of your hypo warning signs is strongly recommended.

Most people are able to recognise the symptoms of hypoglycemia, which include:

• Feeling weak
• Confusion
• Tingling in the fingers or mouth

However, the

symptoms
tend to vary in different people and can also vary in the same persons at different times.

Diabetics who have lost their hypo awareness may not notice any symptoms until they go into

severe hypoglycemia
which includes:

• Convulsions (fitting)
• Unconsciousness
• In rarer cases, coma

It is possible to regain hypo awareness.

Join the Hypo Awareness Program for a comprehensive guide towards recovering your hypo awareness »

Causes of hypo unawareness

Hypo unawareness can be common in people who have had diabetes, particularly

type 1 diabetes, for a number of years.

Having a period of frequent hypoglycemia and hypo unawareness can also be caused by a recent hypo in the last day or two.

Hypos can also be harder to spot when they follow a rapid drop in blood sugar levels. Some

medications
including beta blockers can also lead to hypo unawareness.

Other factors that can contribute to reduced hypo awareness are:

• 
  Stress
• Depression
• 
  Consuming alcohol

Can hypo unawareness be dangerous?

Reduced hypo awareness can potentially be dangerous. If you suffer hypoglycemia you should be careful to test before putting either yourself or others in any potential danger.

Examples when hypoglycemia and unawareness of it could be particularly dangerous include driving, operating dangerous machinery

at work
and even day to day tasks such as cooking or even crossing the road.

Improving hypo awareness signs

If you are suffering from impaired hypo unawareness, you may be advised to increase your window of

blood glucose control
for a period of time to get your numbers higher and prevent hypos from occurring so often.

Studies have found this method to be successful.

If you have frequent hypos you may need to test your blood sugar more often, to help get better control as well as to catch hypos earlier. Try to record which events lead to hypos so you can spot trends and prevent them in future.

Improving your hypo awareness

Hypo awareness can also be improved by consciously making your mind more aware of hypoglycemia. If you have trouble thinking, speaking or performing a task, don’t allow yourself to dismiss it for other reasons – I’m tired, I’m not having a good day etc.

Instead, allow hypoglycemia to be a possible cause, see if any other

hypo symptoms
are present and where possible do a blood test to make sure.

Helping to prevent hypoglycemia

If you are hypo unaware take the following steps:

• Help family, friends and colleagues with recognising your hypo signals and let them know how best to treat it
• Always carry
  
  glucose tablets
  or sweets with you
• Carry diabetes identification with you

As people with hypo unawareness are more susceptible to severe

hypoglycemia, glucose sweets come highly recommended as they are more effective than normal sweets for treating hypos.

Consider doing more

blood tests
This will help you to get a better understanding of why you may be experiencing low blood sugars. You may need to review or alter your treatment regime and your healthcare should be able to help you with this.

Hypo unawareness and bizarre or violent behaviour

In some cases people with hypo unawareness may be prone to acting out of character when their

blood sugar levels
run very low.

This behaviour can include violence, irritability, silliness, inappropriate laughing, becoming highly emotional or very stressed.

Diabetics who have lost their hypo awareness may insist they’re fine even when acting very unusually.

Is pork insulin better than human insulin for hypo awareness?

Some people have found a change onto

pork insulin
to be of benefit when suffering from frequent hypo unawareness.

Hypo unawareness and driving

Driving with impaired hypo awareness can and does kill people. Don’t take the risk.

If you have difficulty recognising your

hypos whilst driving
you should not drive and should inform the DVLA.

Nocturnal hypoglycemia or night time hypos are common in people who treat their diabetes with insulin. Symptoms are usually only realised once waking up from a hypo.

Due to their nature, you will usually only find out about having a hypo during the night after waking up from a hypo.

Therefore people may not even be aware that they are having night time hypos, so it’s useful to be able to spot the signs and symptoms of when nocturnal hypoglycemia may be taking place.

Whilst nocturnal hypoglycemia is most common in

insulin users, it can also occur for people who take oral anti-diabetic drugs.

Symptoms of night time hypoglycemia

Sometimes you may wake during an episode of nocturnal hypoglycemia.

However, if you don’t, you may notice one or more of the following indications that

hypoglycemia
may have occurred whilst you were asleep.

• Waking with a headache
• Experiencing seemingly unprovoked sleep disturbance
• Feeling unusually tired
• Waking with damp bed clothes and sheets from sweating

Having a clammy neck can be a particular indication of night time hypoglycemia.

Nocturnal hypoglycemia in children

For parents of children with diabetes, nocturnal hypoglycemia can be particularly worrying.

Parents of diabetic children
may wish to check their child’s neck whilst they are sleeping if they are worried that night time hypoglycemia may be occurring.

Causes of nocturnal hypoglycemia

The chances of having night time hypos may be increased by the following:

• Too high a level of basal (background) insulin
• Physical activity during the day can increase insulin sensitivity which can lead to night time hypoglycemia, particularly for the first night after a sustained session of activity
• Following
  
  alcohol consumption
• Absence of a night time snack when one is usually taken
• Missing out dinner
• Following a period of illness if basal insulin was increased

Treating night time hypos

The treatment for night time hypos is the same as the general advice for

treating hypos

That is to take 10 to 15g of a quick acting sugary food (such as sweets or glucose tablets) and some slower acting carbohydrate such as a slice of bread to prevent a further hypo taking place.

Have some quick acting carbohydrate next to your bed so that if a hypo occurs, you can treat it as quickly as possible.

Preventing night time hypoglycemia

A useful first step towards preventing hypoglycemia is to test your blood glucose levels before bed.

For people on two or more insulin injections per day can help prevent hypos over night keeping blood glucose levels above 6.5 mmol/l before going to bed.

If over night hypos are suspected, carry out a test at 3am. Together with a before bed and first thing in the morning test, this can help to understand how your sugar levels are behaving over night.

If sugar levels are dropping too low over night, you may need to adjust your insulin doses. Speak to your doctor if you need help with correctly

adjusting your insulin

The other way to prevent sugar levels going too low is to take some

carbohydrate
before bed.

Hypos can also be prevented by:

• Ensuring you basal insulin dose is not too high
• Reducing your night time/evening long acting insulin following exercise
• Taking carbohydrate before bed following an evening/night of drinking
• Not missing out dinner or any snacks you would usually have

Concerned about hypos?

Join the (free) Hypo Awareness Program for a comprehensive guide towards improving hypo awareness »