Diabetes, Diabetes Treatment, Glucose monitoring, Understanding diabetes

Hypoglycemia/low blood sugar

In this article, we will talk about hypoglycemia/low blood sugar. Low blood sugar, in other words, hypoglycemia happens when blood sugars go below a .

In this article, we will talk about hypoglycemia/low blood sugar.

graphic of blood testingLow blood sugar, in other words, hypoglycemia happens when blood sugars go below a certain level. Everybody feels hypoglycemia/low blood sugar at different blood sugar levels depending on their baseline blood sugar level. We will talk about that later in this article. Medically, hypoglycemia/low blood sugar is defined as less than 70 mg/dL of blood sugar. Clinically significant hypoglycemia/low blood sugar is defined less than 55 mg/dL.

What are the symptoms of hypoglycemia/low blood sugar?

Most of the time for symptoms are typically shaking, sweating, anxiety, heart racing, feeling hot or nervous. These symptoms start early on with mild to moderate hypoglycemia/low blood sugar/low blood sugar.

When there is a severe low blood sugar patient may experience neurological symptoms such as severe dizziness, confusion, inability to talk, inability to hear, inability to move. At this point, patients may need help from someone else in order to correct the hypoglycemic symptoms.

What causes hypoglycemia/low blood sugar?

What causes low blood sugar?

For patients who do not have diabetes, prolonged fasting can cause hypoglycemia/low blood sugar. Normally the liver generates glucose for 8 to 10 hours during fasting. After that our body starts burning fat. However, if you are physically or mentally very active ketone bodies produced by fat may not be enough and blood sugar may go too low.

On the other hand, if you have diabetes and if you are on insulin or any medication that can increase insulin such as sulfonylureas(glipizide, glyburide, glimepiride) can cause hypoglycemia/low blood sugar if not taken correctly or if meals are missed.

In very rare cases, a tumor called insulinoma can cause hypoglycemia/low blood sugar in a nondiabetic patient. The good news is that insulinoma is an extremely rare condition.

Patients who have a history of gastric bypass surgery may also develop hypoglycemia/low blood sugar. This is a complication of gastric bypass surgery. Hypoglycemia/low blood sugar develops typically at least 5 years after surgery.

Some patients who do not have diabetes may have reactive hypoglycemia/low blood sugar. This happens when an individual is sensitive to carbohydrates. When they eat carbohydrates blood sugar spikes, which triggers insulin release. Blood sugar rapidly disappears due to simple carbohydrates however insulin stays in the system. As a result blood sugar may go low 1 to 2 hours after eating simple carbs such as cookies, crackers, cakes, bread or cereal. To avoid that mix your the diet with protein and fat. This will be the best thing to do.

Alcohol is another reason that causes hypoglycemia/low blood sugar. If somebody drinks alcohol especially without having any other nutrients, hypoglycemia/low blood sugar will happen in the next 8-10 hours. That can explain why alcohol makes a lot of people very hungry the next morning.  Alcohol stops the liver from making glucose in the fasting state. As a result, you will not be able to get help from the liver during fasting after alcohol as you would otherwise do without alcohol.

If you have severe chronic kidney disease or liver disease you may be more prone to have low blood sugar. That is because the liver and kidney contribute glucose generation in a fasting state.

Some patients who have a pancreatic disease may not be able to absorb glucose which can also cause low blood sugars.

How to treat hypoglycemia/low blood sugar?

First of all, anyone who feels that they may be having hypoglycemia/low blood sugar/low blood sugar if possible should check their blood sugar. Even if you have any continuous glucose monitoring system it is not a bad idea to confirm the low blood sugar with a fingerstick. Without losing time patients should eat simple carbs that can increase the blood sugar very fast. This is a totally opposite recommendation to what we normally recommend diabetic patients do on a daily basis in their diet. However, in the case of an emergency, patients need something that will increase blood sugar rapidly. This could be crackers, juice, candies, white bread, regular soda.

I advise patients to use 15-20 protocol. What that means is you eat 15 to 20 g of carbohydrates, recheck blood sugars in 15 to 20 minutes, if blood sugars are up 15 to 20 mg/dL, the protocol is complete. You can resume your normal routine. Most of the time patients will make the mistake of eating too many carbohydrates to find out that their blood sugars are in the 300-400 range 1 to 2 hours later. Do not do that. Even if you feel hungry stop eating if your blood sugars are in the normal range after 20 minutes of eating 20 g of carbs.

You should avoid treating hypoglycemia/low blood sugar, low blood sugar with food containing high fat such as peanut butter, chocolate. Anything that contains fat will delay the absorption which will cause a delay in the correction of hypoglycemia/low blood sugar.


When should I go to a hospital or call for an ambulance?

If you are able to correct hypoglycemia/low blood sugar you can as described above. If there is a family member around they can use glucagon if the patient is disabled or cannot correct the blood sugar themselves. If they follow the protocol and blood sugars continue to stay low then someone needs to call 911. Of course, if there is no glucagon nearby and the patient has passed out calling 911 should be the first step.
If you do have low blood sugar or have had low blood sugar and still having low glucose after correcting, it is not a good idea to drive to the hospital yourself. Someone can take you to the hospital if needed or an ambulance should be called.

How to avoid having hypoglycemia/low blood sugar?

For patients who are prone to have low blood sugar after fasting it is not a bad idea to eat frequently. The diet should consist of protein fat and carbohydrates instead of just simple carbohydrates.

Patients who have had gastric bypass surgery in the past and not experiencing low blood sugar should also follow the same principle and eat small portions with mixed meals( meals that have protein, fat, and carbs).

If alcohol is the reason for hypoglycemia/low blood sugar you should make sure that you mix alcohol with carbohydrates and or eat when you consume alcohol. If you have diabetes consuming alcohol is never a good idea.

If you have diabetes you may avoid using insulin or sulfonylurea such as glipizide, glimepiride, glyburide. You can ask your physician to possibly change his medications. If changing the medication is not an option or possible that you will need to understand how insulin works and how the medications work.

For example, if you take long-acting insulin such as Lantus, Levemir, Toujeo, Tresiba you should know have to and when to reduce insulin dose. If your blood sugar is normally in the 100-120 range in the morning, you should consider reducing the long-acting insulin dose by 20 to 30% on the days he has been physically more active.

If you are taking sulfonylurea agents you should stay on a strict and regular diet schedule. Missing a meal when you take sulfonylurea agents is definitely an invitation for hypoglycemia/low blood sugar/low blood sugars.

If you are on insulin or sulfonylurea agents and your doctor starts you on a new diabetic medication you should be careful as well. Even if the new medication would not cause hypoglycemia/low blood sugar, adding the new medication on top of insulin or sulfonylurea definitely can. See your diabetes specialist, an endocrinologist should be able to adjust other medications to avoid a hypoglycemic reaction.

If you are on mealtime insulin you should be very careful about being consistent on your carbohydrates if you are on a fixed-dose regimen.

If you are counting carbs, being right on in terms of your carbohydrate counting would reduce the chances of hypoglycemia/low blood sugar.

Why does hypoglycemia/low blood sugar symptoms start at different levels at different individuals?

That depends on the insulin resistance and average blood sugars any person experiences on a daily basis. For example, if your blood sugars are ranging from 90-120 which is a typical range for most normal people, then less than 70 blood sugar may make you feel irritable hungry or hungry. Most of the time people do not even know that their blood sugars are less than 70 but they know that they are having extreme hunger. Some patients will report shaking in the hands or even foggy mind. This can happen with prolonged fasting. That is not necessarily a medically serious condition.

For very skinny people that are very insulin sensitive low blood sugar definition is somewhat different. Some of these people can actually go down to 60 mg/dL blood sugar without any symptoms. On the other hand, insulin-resistant people will experience blood sugar differences even when they are in the normal blood sugar range. For example, the patient with diabetes may feel hypoglycemia/low blood sugar symptoms when blood sugar drops from 300 mg/dl down to 150 mg/dL. This is because the body differentiates the changes in the glucose medium/environment. So if someone’s blood sugar is running 200-300 on average then these glucose numbers change to 120-150 quickly, blood sugar would feel low for the person. The good news is that our body is very adjustable and the new normal will be established if the patient can maintain near-normal blood sugar levels. At the end of this period, hypoglycemic symptoms will disappear.

The bottom line, hypoglycemia/low blood sugar is a very complex phenomenon that can happen to anyone. It happens mostly in patients with diabetes due to complex medication regimens. The most common hypoglycemia/low blood sugar happens on patients taking multiple daily injections of insulin.
If you are on insulin or sulfonylurea it is very important to monitor blood sugars regularly. This could be done via fingerstick or continuous glucose monitoring systems. Regardless of the monitoring system, you are using someone has to monitor these blood sugars. That someone should be a diabetes specialist/endocrinologist. We believe remote glucose monitoring is the best way to manage patients on a day-to-day basis and be there to help patients “in the moment”. Keeping blood sugar logs are helpful however waiting months to see the doctor to show your doctor 20 different hypoglycemic episodes can be very costly. You can also be late because you may not be able to have time to see your doctor before a severe hypoglycemic reaction strikes.  Hypoglycemia is a serious event that can cause hospitalization, coma, and death.  Understand what causes hypoglycemia.  Understand how to treat hypoglycemia.  Make sure you have the latest technology to keep you safe.

Thank you for reading. Please feel free to contact us directly for any questions or concerns.


Ahmet Ergin, MD, CDE, ECNU



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