Managing a 'hypo' in type 1 diabetes

In type 1 diabetes, a low blood glucose (hypoglycaemia) or a ‘hypo’, can occur due to the use of insulin. People with type 1 diabetes should always carry glucose or some form of sugar to take immediately if their blood glucose level goes low, which for most people is below 4mmol/L. It is recommended to wear a medical alert bracelet or carry identification that lists your normal insulin use. If hypos occur often, talk to your diabetes specialist.

What is a low blood glucose level?

People will feel symptoms of low blood glucose at different levels, but most people and doctors agree that your blood glucose is low once it drops below 4mmol/L.

Some groups of people (eg. the elderly, children, or people who can't recognise if they are going low) may be advised to keep their blood glucose levels well above 4mmol/L. Take the advice of your diabetes specialist team on this.

What are the symptoms of low blood glucose (hypo)?

Symptoms of a hypo can include:

• feeling shaky, sweaty, or suddenly unwell
• a 'racing' heart
• tingling around your mouth and tongue
• suddenly a little 'strange' as if you are unable to concentrate
• suddenly feeling very hungry
• your friends may notice you have gone pale.

Over time you will come to recognise the feelings you get when your blood glucose goes low.

Treating low blood glucose levels

If you feel you have time (if you are not feeling too 'hypo') check your blood glucose on your meter. Sometimes it may be something else that has made you feel unwell. But if in doubt, or if you are feeling very unwell, go ahead and treat your low blood glucose anyway. Always remember 'if in doubt, treat'.

Immediately take some glucose or sugar by mouth.
Eat or drink one serving of a quick-acting carbohydrate:

• 3 teaspoons of glucose powder in water, or
• 3 Dextro Energy tablets, or
• 3 Vita Glucose tablets (available from pharmacies), or
• 3 teaspoons of honey or jam or sugar, or
• a small glass (150ml) of sugar-sweetened lemonade [not diet] or cordial, or
• 6 large jelly beans.
• Each of the above represents one serving, eg, 6 jelly beans = one serving.

After 10 minutes test your blood glucose again. If it is still less than 4mmol/L, eat another serving of quick-acting carbohydrate (see list above).

Once your blood glucose is above 4mmol/L - if it is your mealtime, eat your meal. Otherwise eat or drink a snack such as:

• a slice of bread, or 
• a pottle of yoghurt.

How to avoid low blood glucose levels

Test and record your blood glucose levels often and visit your medical team if you notice that your blood glucose levels are often low.

What usually causes a low blood glucose level?

Factors include:

• not eating enough carbohydrate with your meal (eg. steak and salad with no bread or potato)
• missing or delaying a meal
• missing snacks
• doing physical activity without either adjusting your insulin (downwards) or taking more carbohydrate before, during or after physical activity
• taking too much insulin
• drinking alcohol in excess or without taking carbohydrate food and/or adjusting your insulin downwards.

Understanding insulin and how it works

When we eat carbohydrate foods (starches and sugars) they are broken down to glucose in our stomach and gut. They are then absorbed into our bloodstream. Once in the bloodstream this glucose is called blood glucose.

Blood glucose is circulated to every part of our body. The glucose needs to get out of the bloodstream and into our body's cells so it can be burned up for energy. To do this we need insulin.

Insulin a natural body hormone
Insulin is produced by our pancreas. It is a natural body hormone. One of the main jobs it does is to act on the wall of our body's cells and muscles to make them let glucose through. Glucose is also produced by the liver from fat and protein. This is to prevent hypoglycaemia when not eating. About half of the insulin we need is for the purpose of switching off the liver when blood glucose levels are high enough.

In type 1 diabetes our blood glucose levels get too high because we either have no insulin or only a minimal amount. But it is important to remember that it is just as bad to have a blood glucose that is too low, as too high.

Why is a very low blood glucose bad for us?

Our brains need glucose all the time, just as much as our brains need oxygen. If you cut off the supply of oxygen to a person's brain (say by drowning) they will become unconscious. It is just the same with glucose. Our bodies are designed to make sure that our blood glucose never goes low (otherwise we'd fall over every time we skipped breakfast).

In response to the lowering of blood glucose, our body lowers the amount of insulin it is putting out. This does two things. Firstly, it slows down the movement of glucose out of the bloodstream and into our cells (which starts to keep our blood glucose more steady).

Secondly, our liver recognises we have now got a low insulin level and starts releasing stored glucose (from the liver) out into the bloodstream. This acts to keep the blood glucose level up. So this is how our bodies normally protect us against having low blood glucose levels.

Injected insulin can produce hypos
All this changes when you have diabetes and are taking insulin. You can still get the same low blood glucose level if you run out of glucose coming in from your food. But, when the body senses that the blood glucose is becoming lower it tries to switch off its insulin, but it can't. This is because you have injected your insulin (and you can't switch this off).

If your blood glucose is low and your insulin can't be switched off, what happens?

The insulin continues to move the glucose into the body's cells. The liver doesn't start releasing stored glucose (remember, it only does this when it senses your insulin levels are low). So, your blood glucose level keeps going down and can soon be dangerously low. The liver does not correct your low glucose.

What is a serious low blood glucose level?

A serious low blood glucose level is classified as one you need the help of another person to correct. If you have serious low blood glucose levels you should visit your diabetes specialist team.

What is the treatment for serious low blood glucose levels?

If you are conscious, the treatment for a serious low is the same as above. Sometimes people who are having a serious low find it easier to suck on a teaspoon of honey rather than suck glucose tablets. Dextrose gel that can be taken by mouth is available through Diabetes Supplies Ltd.

Call an ambulance if person unconscious

If a person is unconscious with serious low blood glucose levels the treatment is different. Get the person into the recovery position (lying on their left side with right leg hooked over the top of the left leg so they are leaning over, chin extended). DON'T give them anything by mouth (an unconscious person can choke if you put something in their mouth). Call an ambulance.

Glucagon injections

There is an injection called glucagon that can be given to someone who is unconscious with a low blood glucose level. Glucagon raises blood glucose levels. Family members need to be taught how to administer it. It is usually recommended that parents of children with type 1 diabetes carry this medication, as children often tend to be more erratic in their eating and activity levels.

Talk with your specialist diabetes team about whether they recommend this medication for you. If glucagon is supplied to your family or partner they should be taught how to use it.

Wear identification

If you are on medication that may cause you to go low, wear or carry some form of identification that clearly states you have diabetes and you are on insulin. Medic Alert bracelets are good. Otherwise Novo Nordisk NZ produce a small ID card that you can keep in your wallet. If you go low and are unable to help yourself, identification is essential.

Women who are on insulin and breastfeeding sometimes find they often get low blood glucose levels. This is usually because they are losing a lot of calories through their breast milk.

Manage hypos early

Low blood glucose levels can happen even during those times when you're working really hard to actively manage your diabetes. Although many times you can't entirely prevent them from happening, low blood glucose levels can be treated before they get worse.

Related topics

Also see: Insulin for people with type 1 diabetes and Home blood glucose testing

Original material provided by Diabetes New Zealand, 2008. Edited by everybody, August 2011.