How Many Hypo's Is Too Many?

Hi @James_Donnelly I average around 2-3 a week, however I normally am around 3.6 at the lowest, although have had a 2.6 in the last week which is rare.

The danger is having low hypos and then losing hypo awareness, I don't think the average number is so much of a concern it's simply avoiding going low low which is key.

If I was in your shoes then I would want to decrease this number so would be adjusting insulin and checking with my team to review, my priority is to maintain good hypo awareness and this is why it's best you check in for a review as soon as you can.

I've just checked my logs and I have had 8 hypos in the last 7 days. I have made massive changes to how I am dealing with the diabetes in the past month. I have gone from only ever testing my BG if I felt unwell to buying a Libre sensor and getting a little obsessed with checking it every half hour. From dosing the same amounts everyday because it worked ok yesterday to carb counting and working out myself what ratios I should be using.
Alot of these changes have been trial and error which is increasing the amount of hypos (guessing carb content on food without labels!)
I before I changed how I was dealing with the diabetes I would say I would hypo 2-3 times a month and would easily be able to spot a hypo as soon as I dropped below 4.
At the moment I don't tend to notice a hypo until my BG is around 2.5. sometimes when my BG is this low It's just a number and I know about of sugar will fix it quickly. sometimes it scares the hell out of me when I start to think what COULD happen with BG that low. Luckily I have been fine and the libre is helping me reduce the number of hypos. I have said to myself that if I don't get the hypos to a frequency I'm happy with and start to regain my awareness I will get a transmitter for the libre so I can get alerts

Hi @James_Donnelly, Thank you for posing this question, particularly when diabetes complications from high BSLs are emphasised so much. Based on my experience as a T!D for 52 years, not as professional advice or opinion:
Each hypo has the potential to do harm. And whilst my brain seems to have adapted to low BSLS so that I am less affected by a hypo than I used to be (all in subjective terms, of course)!! a hypo still matters.
And there is a difference I find between the 'sneaky' hypo where my BSL drops slowly and I may not pick it up until the 3.2 mmol/l mark, whereas a more rapid drop in BSL might trip my senses at the 4 mmol/l mark. The advent of CGM, Libre etc has of course made things easier - at least when such technology is accurate and active.
However it is the severity of some hypos which scares me. I have had one episode of going hypo and needing mouth to mouth resuscitation and 2 shots of glucagon given to get me through it. The cause was embarrassingly simple: I was tired, woke up for breakfast, had my insulin and fell asleep before having breakfast. My wife thinks I have not been affected by this episode (but she thinks I have the inferior intelligence of a male anyway)!!! This episode happened at the 45 year mark on insulin, at a time when I was having to take 6 + short-acting shots of insulin (plus 2 of long-acting) per day to try to get BSL under control but still suffering from night-time hypos in particular. Going onto an insulin pump was the best thing I have ever done and hypos are now mild and infrequent.
Interestingly from that episode it was also discovered that I had Obstructive Sleep Apnoea (OSA). I was not overweight but apparently had the type of airway (shape and structure of mouth, palate, throat) that predisposes to this condition). I was told that OSA and hypoglycaemia formed the double whammy which threatened my life.
I have never got hypo when I used to imbibe alcohol many years ago but I have heard enough horror stories of diabetics being thrown into jail as drunks when they were really hypo only, and of the fact that glucagon does not work when alcohol is present in the blood stream to steer well away from the stuff.
Some pundits think hypos over time might contribute to mental difficulties later in life.
Except for the one or two cases I have heard about where persons overdosed intentionally on insulin and suffered brain damage I have no real belief one way or the other about hypos and dementia being related.
My hypo awareness did improve after I was started on the pump. Hypo awareness is a term open to interpretation. If you have the 'adrenaline symptoms' of sweating, rapid heart beat, shakes as your first warning symptoms at a certain BSL level and over time that changes so that at about the same BSL your first noticeable symptoms are of confusion, clumsiness etc then is that a change in awareness or not? My point would be that hypo awareness has important situational and practical considerations.
If you are able to recognise the onset of a hypo in the latter case of confusion etc in the absence of the adrenaline caused symptoms and manage it that is all very well but will you be able to manage well enough if driving, up a ladder, crossing a busy street on foot etc? Hypos, my specialist reminds me have the potential to cause immediate harm, unlike high BSLs.

I have always said Diabetes is an equation.....
Food exercise and insulin........tinker with one and it affects the other and the more you tinker the greater the consequence.
If you intent to continue with the exercise then increase the food and lower the insulin as you have already started doing.
Eventually you will reach a happy medium.
Like @kitedoc I have been at it a while and you have the most incredible piece of technology available that we didn't have when we first started...........a blood glucose monitor.....

These things are underestimated in my humble opinion.

You have a change in routine then the only way to know scientifically whats going on is to do a test and you can test as many times as you like which will give you the most important thing in a diabetics life......

Peace of mind.

I hope I have made sense and wish you well

Tony

I was in a similar situation a couple of months ago, got back in to the fitness. My carb ratio at the time was around 1.5 units per 10 grams of carbs, through the intense exercise I lost around 20 pounds in 8 weeks and through that time had many hypos whilst adjusting insulin levels. Now my carb ratio is more like 1 unit per 13 gram carbs, so a big drop due to insulin sensitivity increase. Now I'm having a key focus on hypos, by understanding how long insulin takes to act in my body, when it reaches the peak and the best time to inject to counteract rise in glucose levels. This has all helped me understand where I should be at say a 2/3 hour mark after injecting.

My problem has always been to aim for 5 mmol/L level, but that on its own is a hypo in awaiting as even a unit of insulin can potentially drop it down to 2.5 mmol/L resulting in a hypo. So my aim is now to achieve a level of 6.5/7 following a meal, and this has helped me get a much better night of sleep as well. A lot of it is trial and error, but you want to make that trial and error as little as possible. In the short term its probably better to inject less, learn how much insulin affects you through monitoring and make change based on this, rather than injecting too much.

I agree with @Juicyj, you will lose your hypo awareness if you are having that many. I just checked my logs and I've not had a hypo for 2 weeks, but I'm probably averaging one mild one (in the 3s) per week.

Sounds like you're heading in the right direction by adjusting your basal and carb:insulin ratio. Always best to get the basal correct first, however. Two things reduced by hypo frequency - being dynamic with my basal and going low carb. Gary Scheiner's Think Like a Pancreas book is all about being dynamic with your insulin doses - I'd recommend reading it as I think it will help.

To answer the OPs question, the number of hypos you are prepared to tolerate has got to be a personal thing based on how much of an impact they have on your life.
I am on a pump and low carb so there tends to be less over dosing going on but keeping on top of carb ratios is the way to go and it is a great sign that your body is responding to exercise by needing less insulin. I do not believe that hypos are the price I must pay to have a good mean average (HBA1c); I could not live my life having daily hypos or living in fear of them. My HBA1c is not great though and I know I need to cartch the hypers quicker!
I just don't think I will ever be able to have a perfect set of rules for ratios etc. even with a pump that can adjust these things in time blocks so get frustrated when those not living with type 1 suggest that this is just a matter of data management. It probably is at the level of a workiing pancreas that makes real time adjustments, but I don't have the capacity to Think Like A Pancreas beyond the crude basics.
I think the new cgm/flash monitoring tech will help us record and adjust dosage better so that we look at 'time in range' as a metric rather than HBA1c (I guess that is a modal average rather than the mean average). Looking forward to getting my fsl this week to do some basal testing then back to test strips in between to manage that cost!

I hypo regularly - but it's at a particular time of day so as soon as i feel that slight wobble then the haribos are opened.

Novorapid seems to have a very long profile with me. I am very insulin sensitive and often hypo around 5:30pm when I start giving my horses their evening feed (think of it like 30 mins of gardening - there are wheelbarrows and manure involved!!). I will have injected around 1 for lunch & likely have been running high all afternoon and can fall from 13 to hypo in 30 mins.

I'm currently trying to manage it by eating low carb at lunch to minimise the novorapid on board.

I tried to discuss it with my consultant but she just focussed on the hba1c score of 49....despite the fact that hypos 5 times a week can't be a good idea.

I always say there's hypos and then there's hypos, a waking one where you've low a few hours is never good but for me bottoming out at 3.9 isn't a problem, I feel the drop coming and have a Dextrotab but both instances are hypos, and so there's no easy answer to your question

Dr Keith Runyan (T1D) had a pretty good blog post on the topic of Hypoglycemia.
https://ketogenicdiabeticathlete.wo...-diabetes-mechanisms-avoidance-and-treatment/

kokhongw said:

Dr Keith Runyan (T1D) had a pretty good blog post on the topic of Hypoglycemia.
https://ketogenicdiabeticathlete.wo...-diabetes-mechanisms-avoidance-and-treatment/

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"in addition spending less than 10% of time < 61 mg/d" - That's 3.4ish - quite low to be spending up to 10% of time under.

But later on he does say clinically significant is 3.0, which I'd instinctively agree with, though I'm aware my DSN hates anything under 4.

evilclive said:

"in addition spending less than 10% of time < 61 mg/d" - That's 3.4ish - quite low to be spending up to 10% of time under.

But later on he does say clinically significant is 3.0, which I'd instinctively agree with, though I'm aware my DSN hates anything under 4.

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That is because they consider only the glucose component and not the ketones.

Our brain function with glucose AND ketones. So if ketones avoidance is the main strategy, then there will be no ketones available when glucose drops too low. That is when diabetic coma typcially happens.

We can see that in a healthy individual during a 10 day fast. Glucose can drop below 3 mmol (~60 mg/dl) but there is sufficient ketones to keep the brain from shutting down. That is why those on ketogenic diet are able to function with much lower glucose levels.

Separately there was also a 2009 Yale experiment where 11 T1D subjects had their glucose dropped to 2.8 mmol, but given MCT. They remain conscious and able to complete cognitive test.

https://www.diabetes.co.uk/forum/bl...-transmission-during-acute-hypoglycemia.1914/


This shows that MCT/Ketones can be helpful for brain function.

And not forgeting this 1972 fasting experiment for obese individuals...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC332976/

This study was carried out to determine if, in fasting, an adaptation to utilization of ketones could prevent cerebral dysfunction during periods of acute, insulin-induced glucopenia.

After fasting 2 months, administration of weight-adjusted doses of insulin produced identical maximum insulin concentrations and disappearance curves. However, no insulin reactions nor significant rises in catecholamine excretion occurred despite equal extent and rate of glucose fall. Glucose concentrations as low as 0.5 mmoles/liter (9 mg/100 ml) failed to precipitate hypoglycemic reactions.

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So it has been known for quite a while that ketones can be neuro protective...but these days it would likely be deem unethical to perform such experiments...

I notice in the 2019 Standards of Medical Care in Diabetes by the American Diabetes Association that hypo’s in over 65s should be avoided in all patients. S140 notes that ‘severe hypoglycemia has been linked to increased risk of dementia (20).’ This is the first time I have read of this and could find any mention in the UK or Australian Standards. The standards make for an interesting read.

EllieM said:

Do you know if this includes T1s over 65? (Or maybe they don't have any T1s over 65 in the US because no one can afford 50 years of insulin supplies there?). I've reduced my number of hypos dramatically but I still get the occasional 3.3....

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Might be severe, ie unconscious ones?

So... if they discourage a moderate degree of ketosis in TIDs are dietitians, DSN and doctors making TIDs more susceptible to hypoglycaemic brain damage??