Foods to eat when you have Hypoglycemia

Guide To Beating Hypoglycemia

Here's Just A Tiny Glimpse Of The Topics Covered: The 3 main types of hypoglycemia and which type you're most likely suffering from. How snacking on chocolate bars can actually make you Fat and worsen your condition! (If you thought those delicious dark brown bars were great energy- boosters.think again!) The No. 1 question most folks have when it comes to hypoglycemia and hyperglycemia. Why you should insist on a 6-hour Gtt and not a 5-hour one. ( Why it might not be a good idea to consult a doctor to confirm your hypoglycemia. Aside from taking a Gtt, what other methods can you use to determine whether or not you're suffering from this condition? Well, refer Chapter 4, Pgs. 23-26 to take a revealing 67-question test especially designed to find out if you've got the symptoms. An inspiring motivational exercise that will help you effectively banish all of your negative thoughts that prevent you from having peace of mind. 2 good reasons why you should keep a food journal. 3 powerful nutrients that limit the effect of glucose on your blood sugar level. This is vital to a hypoglycemic as it helps slow down the absorption of sugar in the food. The secret impulse that literally forces you to say 'yes' to a candy bar or chocolate whenever you feel the hunger pangs gnawing at you. 2 ingredients that are lethal to a hypoglycemic. 'Hidden sugars' you must know to avoid buying products that can easily worsen your condition. 8 essential rules of food planning that are crucial to your speedy recovery from hypoglycemia. Leave out one of them and it could hurt your chances of recovering. How to create a healthy food plan that's suitable for both vegetarian and non- vegetarian hypoglycemics. Most food plans only focus on non-vegetarians, but this one works great for everybody! Read more...

Guide To Beating Hypoglycemia Summary


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Frequency Of Hypoglycemia

Hypoglycemia is a fact of life for most people with established (i.e., C-peptide negative) type 1 diabetes (5,6). Those attempting to achieve some degree of glycemic control suffer untold numbers of episodes of asymptomatic hypoglycemia plasma glucose concentrations may be 50mg dL (2.8mmol L) 10 of the time. They suffer an average of two episodes of symptomatic hypoglycemia per week thousands over a lifetime of diabetes and episodes of severe, at least temporarily disabling hypoglycemia approximately once a year (Table 1). Indeed, an estimated 2 to 4 of deaths of people with type 1 diabetes have been attributed to hypoglycemia. Over a lifetime of diabetes, the incidence of iatrogenic hypoglycemia is considerably lower in type 2 diabetes than in type 1 diabetes. As discussed later, this likely reflects intact defenses against falling plasma glucose concentrations early in the course of the disease. Ascertainment of hypoglycemia is a challenge. Asymptomatic episodes will be missed...

Treatment of hypoglycemia

The vast majority of hypoglycemia cases are mild. You can treat hypo-glycemia with a small quantity of glucose in the form of 1 Two or three glucose tablets (Glucose tablets are available in any drugstore, and any person with diabetes who may develop hypoglycemia should carry them.) Keep the following tips in mind to aid in your treatment of hypoglycemia 1 You can easily overtreat hypoglycemia, causing your blood glucose to rise higher than you'd like. However, the high blood glucose resulting from overtreatment of hypoglycemia usually does not last long. You're better off not using a drug or insulin to bring it down, because doing so can result in alternate highs and lows. 1 Make sure that your friends or relatives know in advance what hypoglycemia is and what to do about it because your mental state may be mildly confused when you have it. Inform people about your diabetes and about how to recognize hypoglycemia. Don't keep your diabetes a secret. The people close to you will be...

The seriousness of hypoglycemia

One of the readers who wrote to thank me for the first edition of this book told me how her son had once gone on a blind date. He and his date went to a bar where they had a drink before dinner. As he sat there, he began to say, Sugar, baby, sugar, baby, sugar, baby. At first his date was offended until she realized that he had a glazed look in his eyes and found that he was wearing a bracelet identifying him as a person with diabetes. He was suffering from hypoglycemia and needed glucose. This story is amusing, but the subject is very serious. Hypoglycemia can ruin your day and leave you feeling dazed and exhausted afterwards. You also run the risk of overtreating it, leaving yourself with a very high blood glucose. Hypoglycemia is a barrier that prevents most patients with diabetes from achieving normal blood glucose levels. They can lower their blood glucose enough to prevent long-term complications such as eye disease, kidney disease, and nerve disease, but preventing heart...

Nocturnal Hypoglycemia

Nocturnal Hypoglycemia

Nocturnal hypoglycemia may be considered as the submerged part of the iceberg that constitutes hypoglycemia in insulin therapy. In a study of nocturnal glucose control in young children, episodes of hypoglycemia were observed in 45 of patients studied. The median glucose nadir was 1.9 mmol L (range 1.1-3.3) and the median duration of hypoglycemia was 270 min (range 30-630) (22). There are a number of risk factors for hypoglycemia that are specific to the night. First, the overnight period represents the longest time without food and glucose concentrations are maintained by mobilization of liver glycogen stores and, subsequently, through gluconeogenesis. Adults with diabetes studied during the course of a day during which three mixed meals were ingested were shown to synthesize only one-third of the amount of glycogen that was synthesized by nondiabetic controls (84). This may be, in part, the result of an imbalance in the portal glucagon insulin ratio, as rates of hepatic glycogen...

Hypoglycemia Unawareness

In diabetes, the best defense against a severe episode of hypoglycemia is the early subjective recognition of a low glucose concentration, prior to the onset of neuroglycopenia with so much congitive impairment that the individual is incapable of reacting in an appropriate way. For people with long-duration diabetes and for those aiming for tight glycemic control (see following subsection), hypoglycemia unawareness can become a clinical problem, as the inability to detect falling glucose concentrations is blunted or even lost. This predisposes the individual to unpredictable episodes of hypoglycemia that can be severe. Diabetic patients reporting themselves as unaware or only partially aware of their own hypoglycemia are three times more likely to experience severe hypoglycemic episodes (9) and patients with a history of recurrent severe hypoglycemia demonstrate defective counterregulation when challenged with intravenous insulin infusions in a laboratory setting (34). The etiology of...

Preventing and treating hypoglycemia

Preventing hypoglycemia may be time-consuming, but it's possible and entirely worth the effort Even if prevention doesn't work and your child still has episodes of hypoglycemia, you can treat it in several different ways, as you find out in the following sections. Preventing hypoglycemia The best way to prevent hypoglycemia is to be constantly aware of your child's blood glucose. Meters are being developed that can measure glucose every five minutes and beep if it falls below a set level. (See Chapter 7 for more on these meters and for general information on measuring blood glucose.) Unfortunately, these meters haven't been perfected quite yet, so it's still necessary to stick your child multiple times a day in order to know his blood glucose. But even periodic testing doesn't get around the problem of not knowing your child's glucose for seven to eight hours while he sleeps (unless you set your alarm to wake you for an occasional middle-of-the-night test). When your child is asleep,...

Physiological Response To Hypoglycemia

The physiologic counterregulatory response to hypoglycemia involves neuroendocrine, ANS, and metabolic processes. This includes the suppression of insulin release as well as secretion of glucagon and pancreatic polypeptide from the pancreas, epinephrine from the adrenal medullae, norepinephrine from sympathetic postganglionic nerve terminals and adrenal medulla, cortisol from the adrenal cortex, and growth hormone from the anterior pituitary gland (11-13). In humans, inhibition of insulin secretion is the initial defense against a falling glucose and occurs at a plasma glucose concentration of about 80 mg dL. The brain is one of the first organs affected and is most vulnerable to any glucose deprivation. In adults with T1DM, insulin levels do not decrease as glucose levels fall, because of persistent absorption of exogenous insulin. The lack of decline in plasma insulin concentrations as glucose levels fall constitutes the first deficit in the defense against hypoglycemia in T1DM....

Sulfonylureas And Hypoglycemia. Bmj 1988 296 949 -50

Ben-Ami H, Nagachandran P, Mendelson A, Edoute Y (1999) Drug-induced hypoglycemic coma in 102 diabetic patients. Archives of Internal Medicine, 159, 281-284. Blackman JD, Towle VL, Stuns J, Lewis GF, Spire JP, Polonsky KS (1992) Hypoglycemic thresholds for cognitive dysfunction in IDDM. Diabetes, 41, 392-399. Burge MR, Schmitz-Fiorentino K, Fischette C, Qualls CR, Schade DS (1998) A prospective trial of risk factors for sulfonylurea-induced hypoglycemia in Type 2 diabetes mellitus. JAMA, 14, 137-143. Burge MR, Zeise TM, Sobhy TA, Rassam AG, Schade DS (1999) Low-dose ethanol predisposes elderly fasted patients with Type 2 diabetes to sulfonylurea-induced low blood glucose. Diabetes Care, 22, 2037-2043. Cryer PE (1992) Iatrogenic hypoglycemia as a cause of hypoglyce-mia-associated autonomic failure in IDDM a vicious cycle. Diabetes, 41, 255-260. Cryer PE (1993) Glucose counter-regulation prevention and correction of hypoglycemia in humans. American Journal of Physiology, 264, E149-E155....

Antecedent Hypoglycemia And Hypoglycemiaassociated Autonomic Failure

Cryer earlier coined the term hypoglycemia-associated autonomic failure (HAAF) to describe the syndrome of acquired counterregulatory deficits associated with prior hypo-glycemia. This syndrome is experienced by individuals with T1DM and involves blunted neuroendocrine counterregulatory responses to hypoglycemia, lowered glycemic thresholds for activation of counterregulatory defenses, and HU. To test the hypothesis that hypo-glycemia itself causes reduced neuroendocrine and symptomatic responses to subsequent hypoglycemia, Heller and Cryer measured counterregulatory responses during repeated hypoglycemic clamp studies (13). These experiments determined that two episodes of antecedent moderate hypoglycemia (50 mg dL) resulted in significant reductions of plasma epinephrine, glucagon, pancreatic polypeptide, and cortisol responses to next day hypo-glycemia. Neurogenic and neuroglycopenic symptom responses were also reduced after antecedent hypoglycemia (13). Importantly, Dagogo-Jack et...

Cgm Trend Data Used To Minimize Postprandial Hyperglycemia And Avoid Hypoglycemia

Insulin Pump Catheter

Patients use the real-time glucose trend data displayed on the hand-held CGM monitor to make more appropriate clinical decisions regarding BG control (20,22,23). The Food and Drug Administration (FDA), however, does not currently allow the patient with diabetes to initiate a change in medical therapy (insulin or oral hypoglycemia medication) based solely upon CGM glucose sensor data. Diabetic patient are therefore required to adjust drug therapy according to traditional SMBG measurements. This limitation was imposed by the FDA to prevent the unsafe administration of insulin, due to the potential for inaccurate CGM sensor data ( However, patients given real-time access to CGM glucose sensor information have quickly learned to utilize the trend data to minimize postprandial hyperglycemia and avoid hypoglycemia. Most patients have not required extensive education to utilize the real-time BG data safely and effectively (22-24). In a randomized, prospective clinical trial...

Avoidance of Nocturnal Hypoglycemia

Most of the studies investigating hypoglycemia prevention have focused on nocturnal hypoglycemia. There have been a number of studies examining the effect of dietary intervention on the prevalence of nocturnal hypoglycemia. Most of these studies have involved the manipulation of the bedtime snack with uncooked cornstarch being used to provide part of the carbohydrate load. The beneficial effects have been variable. Some studies found a decrease in the rate of nocturnal hypoglycemia, but these studies only looked at one or two glucose concentrations overnight (150,151) or relied on self-reporting of overnight hypoglycemia (152). Other studies have found cornstarch to be less useful, although glucose concentrations did fall more slowly following a corn-starch snack (22,153). In one of these studies, hypoglycemia was avoided at the expense of hyperglycemia (22). The role of dietary fiber has also been examined with no beneficial effects on rates of hypoglycemia found (154). One study has...

Hypoglycemia Kills Brain Cells

Hypoglycemia (see Chapter 4) often comes on fast and leaves you with a headache or a general feeling of weakness and sometimes confusion. Because of this, people have believed that low blood glucose, especially if it occurs repeatedly, may destroy mental functioning. People who have had repeated episodes of hypoglycemia have shown no loss of mental functioning. Children may have different results because their brains are still developing. Fortunately, your body is supplied with hormones to reverse hypoglycemia. Some things you can do to prevent it include checking your blood glucose prior to heavy exercise and keeping a supply of rapidly absorbable glucose nearby. Also, let coworkers and loved ones know about your diabetes and how to recognize hypoglycemia. If you're prone to frequent low blood glucose, wear an ID bracelet.

The real risk of hypoglycemia in the workplace

A study in Diabetes Care in June 2005 represents an important accomplishment for people who take insulin. In this study, researchers looked at 243 employees (ranging in age from 20 to 69) who were taking insulin for diabetes. Over a 12-month period, researchers recorded the frequency, severity, and consequences of hypoglycemia occurring at work or elsewhere. (They focused on hypo-glycemia because it's the most common complication that employers point to as the reason they don't want to hire people with diabetes.) During the period of study, there were 1,995 episodes of hypoglycemia that were mild and could be treated by the patients. There were an additional 238 severe episodes that required help from someone else. Of the severe episodes, 62 percent happened at home, 15 percent occurred at work, and 23 percent occurred elsewhere. (Fifty-two percent of the severe episodes occurred during sleep.) As for the consequences of severe hypoglycemia, 14 percent of the patients being studied...

Clinical Aspects Of Hypoglycemia

Hypoglycemia constitutes a medical emergency and quick correction is important for survival of the individual. Recovery requires the appropriate glucoregulatory signaling from the brain, an enzmatically and structurally intact liver, and an adequate activation of the ANS and neuroendocrine systems. Normally, this acute physiologic counterregulatory response to hypoglycemia consists of suppression of insulin release and secretion of glucagon, epinephrine, and a host of other glucoregulatory substrates. However as discussed in detail, the response to hypoglycemia in adults with T1DM is altered. Treatment is often complicated by the dynamics of HU and HAAF and more fundamentally, by excessive action of exogenous insulin. This exogenous insulin that is delivered peripherally and not portally (as with endogenous insulin) is not responsive to change in blood glucose concentrations and has variable and nonphysiologic pharmocodynamics. There are several different challenges to preventing...

Distinguishing the severity levels of hypoglycemia

Hypoglycemia is divided into three levels of severity, depending on the symptoms and how difficult it is to get the patient to take some treatment (I discuss treatment in more detail later in this chapter) i Mild hypoglycemia, which is marked by a blood glucose of about 75 mg dl, is easily treated by the patient (or caretaker if the patient is a child). Glucose levels come back to normal with small amounts of carbohydrate. Mild hypoglycemia is usually well-tolerated, and the person can go on with his day after he's raised the blood glucose to normal. The diagnosis is usually made during routine testing of the blood glucose rather than by symptoms. i Moderate hypoglycemia, which is marked by a blood glucose of about 65 mg dl, is treated by the caretaker by giving two to three glucose tablets, waiting 20 minutes, and testing to make sure the glucose is back to normal. If it isn't normal, more glucose is given. It's recognized as the patient begins to feel the adrenergic symptoms,...

Subacute Effects of Hypoglycemia Cogntive Effects and Mood

Most research of the acute effects of hypoglycemia on cognitive performance has been performed in adults both with and without diabetes. A variety of neuropsycholog-ical tests have been used to assess cognition in these acute situations and there has been considerable variation among study results, depending on glucose nadir achieved and tests employed. The limitation of all of these studies is the difficulty in interpreting psychological test results. Although decrements may be demonstrated, the meaning of these in terms of brain processes is not unequivocal, and it is not clear to what extent they represent abilities that are important in everyday functioning (97). symptom generation (98). Studies have shown that cognitive function consistently deteriorates at a glucose concentration of about 2.8 mmol L in adults both with and without type 1 diabetes (99-101) but it can occur at a higher glucose concentration, which may indicate that some tests are more sensitive than others in the...

Mechanisms Of Counterregulatory Responses To Hypoglycemia In

Figure 2 Diagrammatic outline of defective counterregulatory responses to hypoglycemia in T1DM. Hence, the first defense against hypoglycemia is lost. Within a similar time frame (about 5 years), the glucagon response to falling glucose levels is also lost. Thus, an important second defense against hypoglycemia also fails. It should be noted that pancreatic alpha cells are present in equal numbers and size as compared to age and weight matched non-diabetic individuals. Glucagon responses to other physiologic stress such as exercise and amino acid infusion are preserved in T1DM. The mechanism of this selective and therefore functional (rather than anatomic) defect in glucagon secretion is controversial. Hypotheses, with supporting data, have included autonomic neuropathy and a failure of insulin shut off as the mechanism responsible for the lack of glucoagon release during hypoglycemia in T1DM (3,7-11,20). Epinephrine (not glucagon), therefore, constitutes the main defense against...

Causes of hypoglycemia

Hypoglycemia results from elevated amounts of insulin driving down your blood glucose to low levels, but an extra high dose of insulin or sulfonylurea medication isn't always the culprit that elevates your insulin level. The amount of food you take in, the amount of fuel (glucose) that you burn for energy, the amount of insulin circulating in your body, and your body's ability to raise glucose by releasing it from the liver or making it from other body substances all affect your blood glucose level. On average, hypoglycemia occurs about 10 percent of the time in people with type 1 diabetes, but it causes noticeable symptoms only about twice a week and is severe perhaps once a year. In people with type 2 diabetes, severe hypoglycemia occurs only one-tenth as often. The medications described in the next section are part of the reason that people with type 1 diabetes have to deal with hypoglycemia more often. Many people with type 1 diabetes (and some with type 2) rely on insulin...

Symptoms of hypoglycemia

Your body doesn't function well when you have too little glucose in your blood. Your brain needs glucose to run the rest of your body, as well as to function intellectually. Your muscles need the energy that glucose provides in much the same way that your car needs gasoline. So, when your body detects that it has low blood glucose, it sends out a group of hormones that rapidly raise your glucose. But those hormones have to fight the strength of the diabetes medication that has been pushing down your glucose levels. At what level of blood glucose do you develop hypoglycemia Unfortunately, the level varies for different individuals, particularly depending on the length of time that the person has had diabetes. But most experts agree that a blood glucose of 60 mg dl (3.3 mmol L) or less is associated with signs and symptoms of hypoglycemia in most people. Doctors traditionally put the symptoms of hypoglycemia into two major categories Adrenergic symptoms occur most often when your blood...

Hypoglycemia In The Nondiabetic State

Physiological Changes in Response to Hypoglycemia When exogenous insulin is injected into a non-diabetic adult human, peripheral tissues such as skeletal muscle and adipose tissue rapidly take up glucose, while hepatic glucose output is suppressed. This causes blood glucose to fall and triggers a series of counterregulatory events to counteract the actions of insulin this prevents a progressive decline in blood glucose and subsequently reverses the hypoglycemia. In people with insulin-treated diabetes, many of the homeostatic mechanisms that regulate blood glucose are either absent or deficient. Counterregulation The initial endocrine response to a fall in blood glucose in non-diabetic humans is the suppression of endogenous insulin secretion. This is followed by the secretion of the principal counterregu-latory hormones, glucagon and epinephrine (adrenaline) (5). Cortisol and growth hormone also contribute, but have greater importance in promoting recovery during exposure to...

Hypoglycemia In People With Diabetes Epidemiology

Most data on the frequency of hypoglycemia have been collected retrospectively in people with type 1 diabetes and predominantly focus on severe events, which are relatively robust to measure as they can be recalled with accuracy for up to 1 year in people with normal symptomatic awareness (12). Total amnesia of severe hypoglycemia is common, and obtaining an accurate estimate is often difficult in people who have impaired awareness of hypoglycemia relatives and friends may provide a more reliable history than the patient. Mild (self-treated) episodes are quickly forgotten and can be recalled by individuals for only about a week (12). However, prospective studies in Denmark and England that were performed 20 years apart, during which time insulin formulations and regimens changed considerably, have shown that the average incidence of mild hypoglycemia has remained unchanged at around two episodes per week (12,13). Prospective recording of hypoglycemic events over a defined period of...

Impact Of Hypoglycemia

There is little published information about the clinical impact of hypoglycemia in type 2 diabetes. While it is reasonable to extrapolate from the experience in type 1 diabetes, there are obvious differences. As noted earlier, episodes of hypoglycemia become familiar events early Iatrogenic hypoglycemia causes both physical morbidity (and some mortality) and psychosocial morbidity (6). While estimates of hypoglycemic mortality rates in type 2 diabetes are not available, deaths caused by sulfonylurea-induced hypoglycemia (like insulin-induced hypoglycemia) are well documented (14). The mortality of a given episode of severe sulfonylurea-induced hypoglycemia has been reported to be as high as 10 (14,15). The physical morbidity of an episode of hypoglycemia ranges from unpleasant neurogenic (autonomic) symptoms, such as sweating, hunger, palpitations, tremor and anxiety, to neuroglycopenic manifestations. The latter range from cognitive impairments and behavioral changes to seizures and...

Confusion Between Hypoglycemia and Intoxication

Intoxication in young people, whether from alcohol or drugs, is so common in many societies that people not knowing the youth with diabetes (and even those that do) may assume that he or she is intoxicated if they are showing dysfunctional behavior or diminished consciousness. This is particularly a risk if the young person has had some alcohol or is thought to use hallucinogenic or sedative drugs such as cannabis or LSD. Friends or family may let them sleep it off, endangering them further if, in fact, they are hypoglycemic. This risk further reinforces the advice to young diabetics that they should inform their friends about their diabetes and what to do if they may be hypoglycemic.

Hypoglycemic Alert Dogs

Assistance dogs for people who are blind, deaf, or have other physical challenges have become a familiar addition to the range of tools that help them live safely. Now, some dogs are being trained to help people with diabetes avoid the danger of low blood sugar. Especially for very young children or people afraid of becoming hypoglycemic without realizing it, these amazing dogs are proving their worth. These hypoglycemic-alert dogs cost at least twenty thousand dollars, and the training of dog and client takes about two years.

Treating Hypoglycemia

Treating hypoglycemia is fairly straightforward eat or drink any food that has a lot of glucose and is easily absorbed. Sources of glucose include glucose tablets and gels that you can buy at your pharmacy. Fruit juice and nonfat milk are also good sources. Foods with a lot of fat such as chocolate are not as good because the fat will delay the absorption of the glucose. Fructose does not raise the blood glucose, but most foods that have fructose, such as honey and fruits, also have a lot of glucose. After your hypoglycemia has been treated satisfactorily, you may want to trou-bleshoot. Think about why it happened and what you can do to avoid a similar situation in the future Does you insulin dose need to be adjusted Do you need advice from your medical team

Preventing Hypoglycemia

As you aim to get HbA1c levels (see Chapter 5) close to normal, the risk of hypoglycemia goes up. You can take the following measures to limit the risk Set realistic targets aim to keep premeal glucose levels between 90 and 130 rather than at 80. Also, if you have recently had a severe hypoglycemic reaction, then for about six weeks aim to keep your glucose around 150. This will help you recover your ability to sense hypoglycemia to some degree. Recognize behaviors that increase the risk of hypoglycemia and take steps to avoid them for example, adjust the insulin for exercise, and drink alcohol in moderation and with food. Monitor blood glucose levels frequently, especially if you have type 1 diabetes. You cannot achieve optimal glucose control with two or three checks a day. For tight control, check your blood glucose levels eight to twelve times a day (before meals and snacks, at bedtime, at 2 a.m., before and after exercise, before driving, and when you have symptoms of...

Driving and Hypoglycemia

Some of the medicines used to treat diabetes (insulin, sulfonylureas, repaglinide, and nateglinide) can cause hypoglycemia, which can affect reflexes and judgment. In addition, long-term diabetes complications, especially vision problems and neuropathy, may interfere with driving ability. There have been a number of research studies that have looked at the impact of diabetes on car accidents. Generally speaking, the impact appears to be modest if it exists at all. It does seem that the risk for future car accidents is increased if there has been a recent episode of severe hypoglycemia, hypoglycemic unawareness, or a history of past crashes. Hypoglycemia, or low glucose reactions, can occur in people with both type 1 diabetes and type 2 diabetes. Hypoglycemia occurs principally because of To prevent hypoglycemia Be vigilant for symptoms of hypoglycemia Treat hypoglycemic reactions with fast-acting carbohydrates such as juice or glucose tablets. Family members and colleagues should know...

Avoiding Exercise Induced Low Blood Glucose

You may need to eat during or after exercise if you work out hard or for a long time (an hour or more). Know that you may have a low blood glucose reaction up to 24 hours after exercising, depending on how hard and how long you exercised. If you suspect a low blood glucose reaction is coming on, stop exercising at once. Take some form of carbohydrate. Don't fool yourself into thinking you can last just 5 minutes longer. Always keep some form of glucose handy just in case you need it while exercising. This can be a soft drink or fruit juice, which will provide sugar and replace water. Or you can use glucose tablets, raisins, or hard candy. Be on the lookout for hypoglycemia not only while you are exercising, but up to 24 hours later. Keep monitoring your blood glucose levels to detect very low blood glucose. Monitoring your blood glucose levels is a great idea, even if you're not at high risk for hypoglycemia. It can be very motivating to see just how much exercise can reduce your...

Potential preventive and therapeutic options Oral Hypoglycemic Agents

The effect of oral hypoglycemic agents on endothelial function is controversial and probably relates to the agent and model of diabetes being evaluated. Metformin has been shown to improve endothelium-dependent function in the mesenteric arteries of insulin-resistant rats in vitro (165), and the ATP-dependent potassium channel blocker gliclazide ameliorated endothelium-dependent relaxation of the aortas of (alloxan-induced) diabetic rabbits (166). However, clinical studies evaluating the effect of oral hypoglycemics on endothelial function have shown either no difference (167) or diminished reactivity to acetylcholine once the agent is discontinued (120).

Avoiding Hypoglycemia

The elderly, who are already somewhat frail, are especially hard-hit by the consequences of hypoglycemia and are especially prone to it because of several factors In addition, their mental state may not permit them to recognize when they are becoming hypoglycemic. Intensive diabetes treatment may not be possible when hypoglycemia is a frequent problem. Using medications properly, as I discuss in the next section, is essential to helping avoid hypoglycemia. The hemoglobin A1c goal for healthy elderly adults is 7 percent. However, if the life expectancy is less than 5 years, the elderly person is frail or the risks of intensive therapy outweigh the benefits, the goal is 8 percent. This decreased level of control will help to avoid hypoglycemia.

Oral Hypoglycemic Agents

Oral hypoglycemic agents are not approved or recommended in the US for treatment of GDM. Older sulfonylureas, such as tolbutamide and chlorpropramide, cross the placenta and cause fetal hyperinsulinemia and macrosomia. They also have the potential to cause prolonged neonatal hypoglycemia. Minimal amounts of glyburide, however, cross the placenta (97). In a study of 404 women with mild GDM randomly assigned to receive either glyburide or insulin, the results demonstrated that the groups achieved similar glycemic control, with no differences in the frequency of macrosomia, neonatal hypoglycemia, and neonatal morbidity, or cord insulin concentration levels, between groups (98,99). The mean blood glucose was 105 mg dL in both groups. A number of other studies have described the use of glyburide in pregnancy (100-105). Though the results have been promising, more safety and efficacy data are needed before further recommendations can be made.

Hypoglycemia in Type Diabetes

HYPOGLYCEMIA THE LIMITING FACTOR Comprehensive treatment, including glycemic control, makes a difference for people with diabetes. Glycemic control prevents or delays the microvascular complications retinopathy, nephropathy and neuropathy of both type 1 diabetes (1) and type 2 diabetes (2) it may also reduce macrovascular events (3,4). However, because of the imperfections of all current treatment regimens, iatrogenic hypoglycemia is the limiting factor in the glycemic management of diabetes (5). Were it not for the potentially devastating effects of hypoglycemia on the brain which requires a continuous supply of glucose from the circulation diabetes would be rather easy to treat. Enough insulin, or any effective drug, to lower plasma glucose concentrations to or below the normal range would eliminate the symptoms of hyperglycemia, prevent acute hyperglycemic complications (ketoacidosis, hyperosmolar syndrome), almost assuredly prevent the long-term microvascular complications (1,2)...

Clinical Diagnosis Of Hypoglycemia

It is not possible to specify a plasma glucose concentration that defines clinical hypoglycemia in people with diabetes because the glycemic thresholds for the manifestations of hypoglycemia shift to higher than normal glucose levels in poorly controlled diabetes and lower than normal glucose levels in well controlled diabetes. The diagnosis is made most convincingly by Whipple's triad symptoms consistent with hypoglycemia, a low plasma glucose concentration and relief of those symptoms after the plasma glucose concentrations is raised to (or above) normal. Ideally, suggestive symptoms should prompt a monitor-measured glucose level to confirm that those symptoms are indicative of hypoglycemia. However, patients often self-treat on the basis of symptoms alone. On the other hand, low self-monitored glucose levels should not be ignored even in the absence of symptoms. The American Diabetes Association Workgroup on Hypoglycemia (11) recommended that people with diabetes should become...

Oral Hypoglycemic Pills and Illness

If you take oral hypoglycemic pills, you must watch for signs of low blood sugar during any illness that causes you to vomit or keeps you from eating and drinking normally. The hypoglycemic pills you took before your illness continue working to lower your blood sugar even when you do not increase it by taking in food. Try to replace missing carbohydrates by eating soup, crackers, or toast, or by drinking ginger ale or cola.

Exerciserelated Hypoglycemia

Exercise has numerous therapeutic benefits. Physical activity improves insulin sensitivity helps maintain body weight, and can reduce postprandial hyperglycemia. However, despite these and numerous other benefits, exercise often results in hypoglycemia in adults with T1DM. Counterregulatory hormones are activated during exercise in a similar fashion to hypoglycemia. However, norepinephrine levels are higher and epinephrine levels are lower during exercise as compared to hypoglycemia. Nevertheless, the metabolic role of counterregulatory hormones during exercise is to allow the individual to match glucose production to the needs of the working muscles. Therefore, neuroendocrine mechanisms are invoked to stimulate EGP, while simultaneously limiting glucose uptake in muscles. If glucose production cannot match glucose uptake then hypoglycemia will develop. Until recently, the mechanisms responsible for exercise-associated hypoglycemia in T1DM were thought to be due to a relative or...

Counterregulatory Hormone Responses To Hypoglycemia In Women

There is a large sexual dimorphism in counterregulatory responses to hypoglycemia. It has been clearly demonstrated that both healthy young men and women with T1DM have reduced neuroendocrine, ANS, and EGP as compared to age and body mass indexed matched men (39-43). Davis et al. (2000) (43) illustrated that healthy and T1DM women have lower catecholamine, glucagon, cortisol, growth hormone, EGP, and lactate responses compared to age and BMI matched men. On the other hand, women have increased lipolytic responses to hypoglycemia. This sexual dimorphism also occurs during exercise and is not due to differences in glycemic thresholds for activation of counterregulatory responses (43) (Fig. 5). In a series of separate glucose clamp studies at glycemic targets of 90, 70, and 50 mg dL, Davis et al. (2000) (41) demonstrated that reduced central nervous system drive is responsible for the sexual dimorphic responses to hypoglycemia occurring in women. In a subsequent study, Sandoval et al....

Counterregulatory Hormone Responses To Hypoglycemia In Older Adults

Insulin therapy is often problematic for older adults with T1DM and the risk of severe or fatal hypoglycemia associated with the use of insulin increases exponentially with age (44,45). Older adults using multiple medications are likely to have comorbidities and those who are frequently hospitalized are at greater risk for iatrogenic hypoglycemia (46). Meneilly et al. (44) investigated the effects of age on counterregulatory responses during hyperinsulinemic hypoglycemic clamp studies. They reported that older adults with diabetes had reduced glucagon and growth hormone responses during hypoglycemia, but reported increased epinephrine and cortisol responses when compared to age matched nondiabetic controls. Even with this mixed review, hypoglycemic symptom scores were similar in both the groups at all levels of glycemia (44). Matyka et al. (46), on the other hand, found differences in hypoglycemic symptom responses when comparing healthy older men, aged 60 to 70, with younger men,...

Adjusting for Hypoglycemia

In evaluating episodes of hypoglycemia, one must first establish whether the lows are explained or unexplained as this will impact whether or not insulin doses need to be adjusted as the corrective action of choice. An exploration of variables that may be causing the hypoglycemia should be undertaken. Is the hypoglycemia explained by a decreased food intake, e.g., skipped meal or bedtime snack an increase in the number of insulin doses taken, e.g., serial correction doses to treat a high an increase in the number of units of insulin taken in a dose, e.g., a large correction dose or by an increase in physical activity If the explanation was an isolated occurrence, then the corrective action is to try and avoid the circumstances that caused it, e.g., to carry a snack when it is likely a meal will be skipped. If it is known that the explanation is going to be an ongoing phenomenon, e.g., beginning of an effort to lose weight through a cut in caloric intake or initiation of a regular...

Understanding hypoglycemic unaWareness

If your child suffers from hypoglycemic unawareness, he doesn't feel the warning adrenergic symptoms that alert him that his blood glucose is too low. He may have a reduced or no adrenaline response as well as a reduced cortisol and growth hormone response this means that nothing is raising his blood glucose as it falls. Without the warnings of palpitations, anxiety, and hunger, Hypoglycemic unawareness occurs in about 25 percent of patients with T1DM. The occurrence of severe hypoglycemia is much more frequent in these patients than in those without the unawareness. It occurs more often when one of these risk factors is present Many years of diabetes Very tight control of the blood glucose Frequent and repeated hypoglycemia In order to deal with these frequent and severe hypoglycemic reactions, it may be necessary to allow the blood glucose to be higher than levels that prevent long-term complications, greater than 150 mg dl, for example. The risk is that long-term complications are...

Avoidance of Daytime Hypoglycemia

Good hypoglycemia awareness is the best defense against a severe episode of hypo-glycemia. Hypoglycemia awareness can be recovered by strict avoidance of hypo-glycemia (77). Intensive patient education can lead to improved self-management behavior and, thus, it is likely that some episodes of hypoglycemia may be avoided by a rigorous educational approach (144). One group was able to reduce HbA1c concentrations with a positive decrement in episodic severe hypoglycemia by virtue of a structured intensive teaching program, focusing on patient insulin adjustment (145). Regular snacking between meals may be necessary to reduce hypoglycemic excursions after meals, while allowing sufficient prandial insulin to be given to control the immediate postprandial blood glucose concentrations and maintain a near-normal HbA1c (146). There is also some early evidence to indicate that replacement of basal insulin by twice-daily isophane insulin may be beneficial, at least in adults, perhaps by reducing...

Intensive diabetes management means Ill have more hypoglycemic reactions

This, unfortunately, turns out to be true. When you've worked out a plan that narrows your range of blood glucose highs and lows, you're always closer to low than you were on standard diabetes therapy. Your room for error becomes much narrower. This doesn't mean you need to avoid intensive management, however, unless hypoglycemic reactions would aggravate other health conditions. You need to become an expert at telling when to pull out the meter and do a test and treat your hypoglycemia. The secret to keeping hypoglycemia from turning you away from intensive management is to prevent severe reactions. Act early, think clearly, and avoid letting your low level go so low that you need help to treat it. Here's a sample chart for treating hypoglycemia. It's based on your blood glucose result. This chart gives an average in general, each 5 grams of carbohydrate raises blood glucose about 15 mg dl. After treating, your blood glucose goal is about 120 mg dl. You'll need to figure out how much...

Levels of hypoglycemia

There are three levels of severity of hypoglycemia, defined by the level of the blood glucose 1 Mild hypoglycemia This level, corresponding to a blood glucose of around 75 mg dl, is easily treated by the patient himself. It does not cause the patient to change his routine and, in fact, is discovered not so much by symptoms as by the finding of a low blood glucose during routine testing of the blood. 1 Moderate hypoglycemia This level is achieved when the blood glucose is found to be around 65 mg dl. The patient begins to feel the adrenergic symptoms described above, especially anxiety and a rapid heartbeat. Patients who have moderate hypoglycemia may not recognize they need glucose and have to be helped by someone else. 1 Severe hypoglycemia This level occurs when the blood glucose is less than 55 mg dl leaving the patient severely impaired and thus requiring outside assistance to restore his or her glucose. An emergency injection of glucagon or intravenous glucose solution is...

Understanding Hypoglycemia

The condition of having low blood glucose is known as hypoglycemia. If you have diabetes, you can get hypoglycemia only as a consequence of your diabetes treatment. As a person with diabetes, you're in constant combat with high blood glucose, which is responsible for most of the long-term and short-term complications of the disease. Your doctor prescribes drugs and other treatments in an effort to fine-tune your blood glucose as it would be in the body of a person who does not have diabetes. (Part III explains many techniques that help you control your blood glucose levels.) But, unfortunately, these drugs and treatments aren't always perfect. If you take too much of a drug, exercise too much, or eat too little, your blood glucose can drop to the low levels at which symptoms develop. The following sections explain more about the seriousness of hypoglycemia as well as its symptoms, causes, and treatment.

Hypoglycemia In Diabetes The Clinical Context

Glycemic control is a fundamentally important component of the comprehensive management of diabetes mellitus because it prevents or delays the long-term specific complications of diabetes (retinopathy, nephropathy, and neuropathy) and may reduce its atherosclerotic complications (1-3). However, iatrogenic hypoglycemia is the limiting factor (4,5) in the glycemic management of both T1DM (1,2,6-8) and T2DM (3,9) both conceptually and in practice. Were it not for the potentially devastating effects of hypo-glycemia, particularly on the brain, glycemic control would be rather easy to achieve. Administration of enough insulin (or any effective medication) to lower plasma glucose concentrations to or below the nondiabetic range would eliminate the symptoms of hyperglycemia, prevent diabetic ketoacidosis and the nonketotic hyperosmolar syndrome, almost assuredly prevent retinopathy, nephropathy, and neuropathy, and likely reduce atherosclerotic risk. However, the devastating effects of...


Hypoglycemia, particularly severe hypoglycemia, represents the major limiting factor in achieving good glycemic control in patients with type 1 diabetes. People with diabetes are fearful of the risk for acute injury or death due to severe hypoglycemia and often alter their food and or insulin regimen so as to avoid it. An inverse relationship between glycemic control and risk of hypoglycemia was demonstrated in the DCCT, with a frequency threefold higher in the intensive versus conventional group (0.61 vs. 0.18 events per patient-year) (1). In a study of children with type 1 diabetes, those with average A1c less than 7 experienced a 4.3-fold increased risk of severe hypoglycemia when compared with those who had A1c levels greater than 10 . Fortunately, cognition and quality of life were not impaired in the intensively treated patients (4). The risk for hypoglycemia is reduced by the use of optimal basal-bolus therapy, using insulin analogues in multiple daily injection or insulin pump...

Bgat Hypoglycemia

American Diabetes Association Workgroup on Hypoglycemia. Defining and reporting hypoglycemia in diabetes. Diabetes Care 2005 28 1245-1249. 2. The Diabetes Control and Complications Trial Research Group. Hypoglycemia in the Diabetes Control and Complications Trial. Diabetes 1997 46 271-286. 17. ter Braak EWMT, Appelman AMMF, Van de Laak MF, Stolk RP, Van Haeften TW, Erkelens DW. Clinical characteristics of type 1 diabetic patients with and without severe hypoglycemia. Diabetes Care 2000 23 1467-1471. 20. Zammitt NN, Frier BM. Hypoglycemia in type 2 diabetes pathophysiology, frequency, and effects of different treatment modalities. Diabetes Care 2005 28 2948-2961. 22. Leese GP, Wang J, Broomhall J, et al. (for the DARTS MEMO Collaboration). Frequency of severe hypoglycemia requiring emergency treatment in type 1 and type 2 diabetes a population-based study of health service resource use. Diabetes Care 2003 26 1176-1180. 29. The DCCT Research Group. Epidemiology of severe hypoglycemia in...

Explain Hypoglycemia

,f you take either insulin or one of the sulfonylurea medications (see Chapter 10), you may become hypoglycemic. Occasionally, hypoglycemia can be so severe that you're unaware of the problem. At that point, someone in your environment needs to know the symptoms of hypoglycemia and how to treat it. Chapter 4 contains all that information. You may want to make a list of the signs and symptoms of hypoglycemia and pass it around to your family and friends. You should keep that list and an emergency kit to treat hypoglycemia at home and at work. You may even want to wear a medical alert bracelet so someone can identify your problem when none of these people are around.

Avoiding Illegal Drugs

I All cause you to lose your awareness of hypoglycemia so you don't treat it. i Some cause you to lose your appetite so you become hypoglycemic and malnourished with vitamin deficiencies. i Amphetamine (speed, Dex, crank) and ecstasy (derived from amphetamine and also called MDMA, E, X, adam, bean, and roll) increase the body's metabolic rate, resulting in hypoglycemia because the user often does not eat properly and is unaware of the onset of low blood glucose.

Risk Factor Reduction

The prevention of iatrogenic hypoglycemia is similar in advanced type 2 diabetes and type 1 diabetes (6,22). Hypoglycemia risk reduction involves Addressing the issue of hypoglycemia in every patient contact. Considering both the conventional risk factors and those indicative of compromised defenses against hypoglycemia, and adjusting the treatment regimen accordingly. Given a history of hypoglycemia unawareness, a 2- to 3-week period of scrupulous avoidance of hypoglycemia is advisable since that often restores awareness of hypoglycemia and improves the epinephrine response (18-20). The use of insulin analogues (e.g., glargine or detemir as the basal insulin and lispro, aspart of glulisine as the prandial insulin) reduces the risk at least of nocturnal hypoglycemia (22,24). Despite its theoretical advantages, continuous subcutaneous insulin infusion has not been found to cause less hypoglycemia than a bolus-based insulin regimen with insulin analogues in type 2 diabetes (25). Among...

Intensive Insulin Therapy

Intensification of insulin therapy commonly leads to a significant increase in the risk of severe hypoglycemia. In the intensively treated cohort of the DCCT, the risk of a first episode of severe hypoglycemia, defined as an episode requiring another person's assistance, increased by 27 for a 10 lowering in monthly HbAlc value (6). This risk was almost twofold greater in the adolescents taking part in the DCCT, despite the fact that they did not achieve the same degree of tight glycemic control as their adult counterparts (11). It is likely that most intensifications of insulin therapy for diabetes increase the frequency of exposure to mild hypoglycemia in daily life (83) and that this may create hypoglycemia unawareness as described earlier in the chapter, with its attendent increased risk of severe hypoglycemia. Young children seem to be at particular risk of severe hypoglycemia, which increases with intensification of insulin treatment (12,13,63). In a study examining the effect of...

Summary And Perspective

Iatrogenic hypoglycemia is the limiting factor in the glycemic management of diabetes, and a barrier to true glycemic control and its established long-term vascular benefits. Hypoglycemia is less frequent overall in type 2 diabetes, compared with type 1 diabetes, because glucose counterregulatory defenses remain intact early in the course of type 2 diabetes. However, iatrogenic hypoglycemia becomes a progressively more frequent problem, ultimately approaching that in type 1 diabetes, as patients approach the insulin-deficient end of the spectrum of type 2 diabetes because of compromised physiological and behavioral defenses against developing hypoglycemia. The syndromes of defective glucose counterregulation and hypoglycemia unawareness, and the concept of HAAF, in advanced (insulin deficient) type 2 diabetes are analogous to those that develop early in the course of type 1 diabetes. By practicing hypoglycemia risk reduction, i.e., addressing the issue, applying the principles of...

Can tell my blood glucose level without checking

However, you can learn more about sensing the clues your body or behavior gives about your blood glucose level by attending a class or series of classes on hypoglycemia prevention and recognition. This education can be very valuable to anyone with diabetes, but especially for people who have stopped recognizing symptoms of severe low blood glucose (hypoglycemia unawareness). Just as jet pilots can be trained to recognize and react to signs of oxygen deprivation, you can become better aware of your cues of possible hypoglycemia You are more likely to develop hypoglycemia if you have missed a meal, taken your insulin early, eaten later, or worked out harder or longer than normal. team about whether and how often you need to monitor. If you have gestational diabetes and take insulin, you need to monitor. Insulin and oral diabetes medications are powerful drugs that lower blood glucose. You can tell how well they are doing their job by keeping track of your blood glucose. It can help you...

Pathophysiology Of Glucose Counterregulation

While marked hyperinsulinemia alone can cause hypoglycemia, iatrogenic hypoglycemia is the result of the interplay of relative or absolute insulin excess and compromised physiological and behavioral defenses against falling plasma glucose concentrations in type 1 diabetes and in advanced (i.e., insulin-deficient) type 2 diabetes (Table 3) (5,6). Normally, decrements in insulin are the first physiological defense and increments in glucagon are the second defense against falling plasma glucose concentrations. Increments in epinephrine, the third defense, become critical when glucagon is deficient. Decrements in insulin and increments in glucagon and epinephrine increase endogenous glucose production epinephrine also limits glucose clearance in insulin-sensitive tissues. The sympathoadrenal response (largely the sympathetic neural response) to hypoglycemia causes neurogenic symptoms and thus prompts the

Monitoring Blood Glucose Levels

The risk of hypoglycemia goes up as you aim for glucose levels close to normal, and you will need to check your blood glucose frequently. You may end up checking eight to twelve times a day before each meal, midmorning, midafternoon, bedtime, before and after exercise, before driving, sometimes at 2 a.m., and anytime you have symptoms that suggest hypoglycemia. You cannot achieve a normal HbA1c value safely if you check your blood glucose levels only three or four times a day.

Potential Treatments For Adjunctive Therapy In Type Diabetes

It is nearly impossible to normalize postprandial glucose excursions with SC insulin alone, without causing hypoglycemia. Given the limitations of insulin therapy, there is a need for adjunctive therapies to safely improve glycemic control in people with type 1 diabetes. An ideal adjunctive agent would minimize postprandial glucose excursions, without increasing the risks for hypoglycemia and weight gain. Potential targets for pharmacologic intervention are listed in Table 2.

Failure to Adjust for Exercise

In Chapter 9, I explain why people with diabetes, especially type 1 diabetes, can find glucose control with exercise particularly challenging. Hypoglycemia can occur during or even several hours after exercise, and so glucose levels need to be monitored and food and insulin adjusted. Failure to do this can lead to hypoglycemia. Unexpected exercise can also be a challenge I remember seeing a sixty-eight-year-old woman with type 1 diabetes in my office, and during her visit the fire alarm

Toddlers Ages One to Three

With toddlers, it is best to establish a schedule with food and insulin injections. This can be challenging, especially with a child who refuses to eat or is a picky eater. Hypoglycemia is the biggest concern with this age group, and often it is best managed by giving insulin after a meal. Other steps that you can take include the following

Choosing Between Pancreas And Islet Transplantation As Treatments For Diabetes

Since pancreas transplantation has been shown to be very effective in controlling acute and chronic complications of diabetes over long periods of time, and islet transplantation has not, pancreas transplantation must be viewed as the more effective option. However, individual recipients who do not want to undergo the extensive surgery and potentially complicated postoperative course of organ transplantation may logically choose islet transplantation. This should be done, however, with the full knowledge that the majority of islet recipients need to return to insulin-based treatment and that intrahepatic islet transplant recipients do not have restored glucagon secretion during hypoglycemia. The latter is a significant issue given the number of islet transplant recipients who return to insulin treatment and are once again at-risk for hypoglycemia. There are few data that address the impact of islet transplantation on the secondary complications of diabetes mellitus. However, it can be...

Lack of Glucagon Response

In new onset diabetes, glucagon levels rise in response to a falling glucose level, and this is the most important factor preventing a further fall in the glucose level. People with diabetes longer than five years lose this glucagon response. As a result, these individuals are at a significant disadvantage in protecting themselves against falling glucose levels. People who have diabetes because of pancreatitis or pancreatic surgery also lack glucagon and so are at increased risk for hypoglycemia.

Human Insulin Preparations

Although undergoing some major improvements over the past several years, human insulin still has some limitations. The human insulins have variable and inconsistent absorption rates that cause erratic and unpredictable blood-glucose-lowering effects, resulting from the varying onset of actions, peak, and duration of action of these products. This is because when regular insulin is administered subcutaneously, its absorption into the circulation is slow, with a subsequent slow onset of action. Therefore, regular insulin should be administered 30-40 minutes before a meal to avoid a potential physiological mismatch, with subsequent hypoglycemia. This advance administration can become inconvenient or somewhat hazardous at times, particularly if the patient is unable to eat and has taken insulin (e.g., if the meal becomes surprisingly delayed or is not palatable to the patient). Additionally, when larger doses of regular insulin are given subcutaneously, the duration of action is...

Methods To Achieve Nearnormal Glucose Control

Treatment regimens should focus on safety and simplicity to minimize the risk for errors that may cause hypoglycemia. A program established by the United States Pharmacopoeia to track hospital drug errors reported that errors involving insulin delivery ranked second in number, and ranked first as the leading cause of patient morbidity (52). Simplicity is also required because overworked nurses and junior physicians often undertake bedside management. A variety of insulin delivery algorithms are currently used to manage blood glucose levels in the perioperative setting.

Adjusting Insulin for Changes in Activity Exercise

Increased levels of physical activity, including formal exercise, impact BG control by promoting movement of glucose into glycogen stores in the peripheral tissues. The entry of glucose into skeletal muscle is increased during exercise via an insulin-independent increase in the number of GLUT 4 transporters in muscle cell membranes. This increase in glucose entry persists for several hours after exercise and regular exercise training can produce prolonged periods of time where insulin sensitivity is increased. Exercise can precipitate hypoglycemia in diabetes not only because of the increase in muscle uptake of glucose but also because absorption of injected insulin is more rapid during exercise. Patients with diabetes will often need to either take in extra calories or reduce their insulin dosage when they exercise (5). If body weight is a concern, it is preferable to lower insulin doses in anticipation of exercise rather than to ingest extra calories to prevent hypoglycemia....

Studies in Type Diabetes

Several long-term, randomized, placebo-controlled trials of pramlintide in people with type 1 diabetes have shown consistent reductions in A1c accompanied by modest weight loss. In all of the studies, patients treated with pramlintide experienced a two- to threefold higher rate of nausea than those in the placebo group. Most of the nausea was described as mild to moderate and tended to decrease in frequency and severity with time (31-33). In one study, only 7.4 of subjects on pramlintide discontinued the study due to nausea (33). In a large 52-week trial, the SC administration of 60 g of pramlintide three or four times per day led to a reduction in A1c of 0.29 and 0.34 , respectively. Both groups treated with pramlintide experienced a modest weight loss of 0.4 kg, compared to weight gain of 0.8 kg in the placebo group. Those treated with pramlintide experienced a fourfold higher rate of severe hypoglycemia, the frequency of which decreased to levels below that of the placebo group...

Exercise and Your Blood Glucose Level

When you first start to exercise, your body uses the glucose stored in your muscles and liver for fuel. When these stores of glucose run low, your muscles recruit the glucose from your blood. So, during exercise, your blood glucose levels can fall. After you stop exercising, your body replenishes the stores of glucose in the liver and muscle cells. This can further lower blood glucose levels even hours after you have stopped exercising. Because of this, if you exercise in the evenings, you leave yourself vulnerable to hypoglycemia while you sleep. Regular exercise can be a tool for lowering blood glucose levels, but at the same time it puts you at risk for hypoglycemia. This is why monitoring blood glucose levels before and after exercise works to keep you in the game. Exercise-induced hypoglycemia is a concern for people who take insulin or a sulfonylurea or a meglitinide. els may drop too low during or after exercise. Like people with type 1 diabetes, you will want to avoid...

Target Glycemic Values

Women will need to be educated regarding the changing goals for blood glucose concentrations in pregnancy (Table 2). As they learn to manage their diabetes in pregnancy, they will learn when adjustments to therapy should be considered based on the number of out of target glycemic values obtained over the course of their monitoring. Providers should inform their patients that if greater than 15 to 20 of values are outside the target range they should call their physician and relay their glucose concentrations. Women with consistently elevated fasting glucose concentrations should be encouraged to obtain a glucose concentration between 2 00 a.m. and 3 00 a.m. to assess for a Somogyi effect that is discovered with maternal hypoglycemia in the early am with maternal hyperglycemia at the am fasting.

Incretin Based Therapies

Recently, a new class of pharmacologic agents that augment or mimic the effects of endogenous insulin secretagogues (incretins) were introduced. These include the parenteral drug exenatide, a glucagon-like peptide-1 (GLP-1) receptor agonist and oral drugs that inhibit the enzyme that degrades GLP-1, called DPP-IV inhibitors. Because these drugs enhance glucose-mediated insulin secretion, the risk of hypoglycemia appears to be small. The anorectic effect of exenatide, desirable for younger obese patients, has led to some concern about its use in the frail or malnourished elderly. The DPP-IV inhibitors (sitagliptin, vildagliptin) are weight neutral, with less pronounced effect on appetite and might be preferable for those patients.

Clinical Outcomes of Successful Pancreas Transplantation

The two most often used measures of glycemic control are the fasting glucose level and the hemoglobin A1c level. Typically, recipients of successful pancreas transplants have average fasting levels of 80 mg dL, which signals excellent glycemic control (5) (Fig. 3). Similarly, hemoglobin A1c levels are typically in the normal range, usually between 5.5 and 6 . The excellence of these outcomes can be appreciated by comparing hemoglobin A1c levels after pancreas transplantation with those obtained in the Diabetes Control and Complications Trial (DCCT) (5,6) (Fig. 4). Intensive insulin-based management augmented by frequent patient contact with physicians, nurses, and social workers was studied in the DCCT and outcomes were compared to less rigorous insulin-based management. The intensively treated patients were able to achieve average hemoglobin A1c levels of 7 . Attempts to achieve lower levels were met with an increasing incidence of clinical hypoglycemia. In contrast, hypoglycemia...

Favorable Glp Actions In Type Diabetes Beyond The Insulinotropic Effect

GLP-1 inhibits glucagon secretion (32,33). In type 2 diabetes, excessive glucagon secretion in relation to the plasma glucose aggravates fasting hyperglycemia by stimulating hepatic glucose output (34). Exogenous administration of GLP-1 in type 2 diabetic patients leads to a significant suppression of glucagon secretion together with a normalization in fasting plasma glucose (29). The counterregulatory response of glucagon secretion in hypoglycemia is unaffected by GLP-1 administration (35). GLP-1-based therapies will therefore not bear an intrinsic risk for hypoglycemia (36).

Working out with type diabetes

The person with type 1 diabetes has to avoid overdosing on insulin before exercise, which can lead to hypoglycemia, or underdosing, which can lead to hyperglycemia. If the body does not have enough insulin, it turns to fat for energy. Glucose rises because it is not being metabolized but its production is continuing. If exercise is particularly vigorous in a situation of not enough insulin, the blood glucose can rise extremely high. Reducing your insulin dosage prior to exercise helps prevent hypoglycemia. One study showed that an 80 percent reduction of the dose allowed the person with diabetes to exercise for 3 hours, while a 50 percent reduction forced the person with diabetes to stop after 90 minutes due to hypo-glycemia. Each person with diabetes varies, and you must determine for yourself how much to reduce insulin by measuring the blood glucose before, during, and after exercise. Another way to prevent hypoglycemia, of course, is to eat some carbohydrate (see Chapter 8). You...

Openloop Systems Csii

One of the most important aspects of starting pump therapy is a comprehensive education program. This should include explaining the principles of CSII and dosage adjustments, re-education about blood glucose self-monitoring, instructions for sport and exercise, action in case of hypoglycemia and hyperglycemia, intercurrent illness, ketonuria, pump malfunction, and infusion-site infection. Patients also should be supplied with insulin and syringes for emergency use. Moderate exercise, for example, can be performed without causing hypoglycemia by reducing the basal infusion rate by one-half for the duration of the exercise if this occurs more than 4 h after a meal or reducing the prandial insulin by one-half if exercise occurs shortly after a meal. Blood glucose monitoring after exercise is essential. The use of monomeric insulin as the pump insulin now offers further opportunities to improve control with CSII. A number of randomized crossover trials of lispro vs regular human insulin...

Evaluation Of Patients With Type Diabetes Prior To Surgery

The history provides essential information such as the presence of complications, duration of diabetes, adherence to treatment, and hypoglycemia unawareness. A complete and accurate drug history will allow the physician to rationalize management and decide which drugs need to be discontinued during hospitalization and which drugs may affect operative risk or mask the symptoms of hypoglycemia. Additional therapy such as P-blockade may be indicated perioperatively. The goals of glycemic control at this time are to provide reasonable control of blood glucose and therefore prevent unrestrained catabolism and ketoacidosis while avoiding hypoglycemia, which may have disastrous consequences in the unconscious patient. Most patients with T1DM now use intensive insulin therapy with multiple daily injections

Diabetes Management on the Airplane

If food will not be served on your flight, take food and fast-acting carbohydrate with you. If it is a long flight with a meal (and keep in mind that in-flight meals are rare these days), it is not necessary to order a special meal on the plane, but it is a good idea to have some food with you (two to three snacks) in case the meal is delayed. Inject your insulin dose after your meal arrives. Since the pressure in an airplane is different than the pressure on the ground, do not inject air into the vial before drawing up your insulin into the syringe. Check your blood glucose frequently during the flight. You may need a little more insulin because you are inactive. If you are traveling alone and are concerned that you might experience hypoglycemia, tell the flight attendants that you have diabetes so they can keep an eye on you.

Systemic Glucose Balance

Glucose is an obligate metabolic fuel for the brain under physiological conditions (4). (The brain can utilize other circulating substrates, including ketones such as P-hydroxybutyrate, but the blood levels of these seldom rise high enough for them to enter the brain in quantity and thus partially replace glucose, except during prolonged fasting.) Because of its unique dependence on glucose oxidation as an energy source and because it cannot synthesize glucose or store more than a few minute's supply as glycogen, the brain requires a continuous supply of glucose from the circulation. At normal plasma glucose concentrations the rate of glucose transporter (GLUT-1) mediated blood-to-brain glucose transport down a concentration gradient exceeds that of brain glucose metabolism. However, when arterial glucose concentrations fall below the physiological range blood-to-brain glucose transport falls and ultimately becomes limiting to brain glucose metabolism and thus its functions and even...

Nutritional Factors Affecting Blood Glucose Control

Blood glucose control, as measured by HbAlc, reflects the combined effect of fasting blood glucose levels, postprandial blood glucose excursions, and mean blood glucose values throughout the day. Nutrition interventions affect both fasting and postprandial values. Fasting blood glucose is determined by hepatic glucose production through the night and influenced by degree of insulin resistance and available insulin. Because individuals with type 1 diabetes produce little or no insulin, the amount and type of insulin provided during nighttime hours will determine fasting glucose levels. Previous days physical activity enhances insulin sensitivity, increases muscle glucose uptake, and, subsequently, may result in nighttime hypoglycemia. In turn, bedtime food intake in excess of insulin coverage can increase nighttime blood glucose levels.

Helping siblings be understanding

Being the brother or sister of someone with T1DM is a tough assignment. On the one hand, your other children envy all the time and attention that your child with diabetes gets from you (the parent). On the other hand, they may be fearful of getting it themselves. They also may witness a severe hypo-glycemic episode, which can be very scary. It's a good idea to educate your other children so that they know something about diabetes, especially how to manage hypoglycemia. You can certainly take non-diabetic children to diabetes education sessions.

Establishing Individual BG Goals and Times of Day for BG Monitoring

Individual targets must always be set for fasting and postprandial glucose and for HbAlc. It may be necessary to lay out stepwise goals for reaching targets over time, particularly if current levels of control are far removed from recommended values, or the patient has concerns regarding the recommended targets. Fear of hypoglycemia as a result of increase in insulin doses and not feeling right well if BG values are lowered to beyond a perceived threshold level are examples of reasons patients may cite as concerns regarding

Dipeptidyl peptidase IV inhibitors

That normally inactivates GLP-1, these agents prolong the glucoregulatory actions of GLP-1 23 . DPP-IV inhibitors modestly reduce A1C levels, are generally very well tolerated, are not associated with hypoglycemia, and are weight neutral 22 . Despite these attractive properties, which have been demonstrated in short-term studies, the long-term effects of these agents remain unknown. DPP-IV is present in other multiple biological systems, including ones involved in immunity and other hormones. This raises the theoretical risk that inhibition of DPP-IV may adversely affect functioning of other systems.

Outlook And Perspectives

The therapeutic principle of GLP-1 with the multiple mode of action besides its glucose-normalizing effect adds a new and attractive perspective to diabetes therapy. Since incretin mimetics and GLP-1 analogs are peptides, they have to be injected. This fact and their potential costs will probably give them a place in clinical practice for patients who have failed on oral therapy and in whom insulin therapy is not an alternative due to weight problems or possible hypoglycemia. Theoretically, GLP-1-like agents may be also

Inhospital Artificial Endocrine Pancreas

An artificial endocrine pancreas (AP) was commercialized in the 1970s (Biostator, Miles Laboratory) to automate the process of blood glucose monitoring and insulin delivery. The device contained a flow-through glucose sensor connected to an intravenous catheter. Glucose was measured every few minutes with accuracy similar to a laboratory glucometer. Insulin and glucose were infused according to a preprogrammed computer algorithm. The subsequent dose of insulin (or glucose) was based upon the absolute glucose concentration and the rate of change of blood glucose over time. Tight glucose control could be achieved without hypoglycemia in the majority of clinical situations. Unfortunately, the device was too large and complex for routine clinical application. The sensor required frequent manual re-calibration and greater than 200 ml blood loss per day (60). Researchers are attempting to develop more accurate glucose monitoring systems and a modern version of the AP that is safe and easy...

Continuous Subcutaneous Insulin Infusion Csii Therapy Using An External Insulin Pump

External insulin pumps have gained popularity because of increased flexibility of dosing, improved glycemic control and a lower incidence of hypoglycemia when compared with traditional insulin injection methods (5,6,45-48). However, CSII requires that patients count carbohydrates, SMBG frequently and carefully control caloric intake to avoid hypoglycemia and excessive weight gain. Failure to deliver rapid-acting insulin (due to pump malfunction, catheter occlusion or catheter disconnection) can lead to hyperglycemia and ketoacidosis within several hours, because of the small depot of sc insulin (two to four units) during typical basal CSII therapy (25,33,45). Doyle et al. performed a prospective randomized clinical trial in patients with type 1 diabetes comparing pump therapy with Lispro insulin (CSII) and multiple dose therapy using Lispro and Glargine insulin (MDI). Fifty percent of the patients managed with CSII achieved near-normal BG control (HbA1c 7 ), compared to only 12 of...

Focusing on your babys health

Also, keep in mind that the fetus was producing a lot of insulin to handle all the maternal glucose entering through the placenta. Suddenly, maternal glucose is cut off at delivery, but the high level of fetal insulin continues for a while. The danger of hypoglycemia exists in the first four to six hours after delivery. The baby may be sweaty and appear nervous or even have a Besides hypoglycemia, the baby may have several other complications right after birth

Monitoring Glucose Control

Regular self-monitoring of blood glucose (SMBG) allows the family and clinicians to keep up with the child's steadily increasing insulin needs. We request that blood glucose levels be checked at least four times per day (before each meal and at bedtime) and most families with children in the preadolescent age group comply with this request. The most important component of SMBG is the interpretation of the results. The parent or child must be taught what the target value is and what the relationship is among diet, exercise, and insulin. If the parent and or child grasp these concepts, they will make accurate adjustments aimed at achieving target goals. If they are unable to make accurate adjustments, they should be given guidelines of when to call the diabetes service for help. Day-to-day adjustments in the doses of rapid-acting insulin can be made based on the premeal blood glucose value, amount of carbohydrate in the meal, and the amount of anticipated exercise....

Brittle Diabetes Continued

Hypoglycemia Do you have frequent bouts of very low blood glucose Your body's natural defenses to this (glucose release from the liver) can be spoiling your insulin's work. Neuropathy Do you have nerve damage that affects your absorption of food Nerve damage can slow digestion or can produce unexpected bouts of diarrhea. Dehydration Do you have sustained periods of high blood glucose that drain your body of fluids The less water in your body, the harder it is for your insulin to flow into tissues.

Pramlintide How It Works

5-ml vial Type 2 patients on insulin start at 60- g containing dose 3 times a day (10 units on U100 0.6 mg ml insulin syringe) increase to 120 g 3 times a day (20 units) if no nausea for 3 to 7 days. Give immediately before meal. For type 1 patients, start at 15 g 3 times a day (2.5 units on U100 insulin syringe) and increase gradually to 60 g (10 units) 3 times a day. Reduce the insulin by 50 when you start to avoid hypoglycemia.

Monitoring Glucose Levels

With current therapies, it is difficult to achieve normal glucose levels when you have diabetes. Even when levels are below 100 mg dl before meals, they frequently go above the 140 range after meals. This is especially true if you take insulin, in which case aiming for normal glucose levels can significantly increase the risk of hypoglycemia (see Chapter 7). The only time doctors attempt to achieve normal glucose levels in insulin-treated patients is during pregnancy, when the target for premeal blood glucose level is 60 to 100 mg dl, postmeal peak level (usually about one and a half to two hours after a meal) is less than 130 mg dl, and bedtime and 2 a.m. levels are around 100 mg dl.

Quality Of Life And Obstacles To Care

The delivery of diabetes care and education has undergone a paradigm shift from giving advice and blaming the patient for failure to providing patients with the choice of aggressive, individualized treatment and an education plan tailored to their needs. This shift has melded health care providers and patients as partners in managing a devastating disease. The demands for daily self-management of diabetes are so formidable that each component of the diabetes education curriculum includes discussion of the psychosocial needs of the patient. The embarrassment of hypoglycemia and resultant fear, the social aspects of eating and dealing with well-meaning family members who comment on food choices, the

Determining an elderly patients ability to treat his own type diabetes

T1DM can cause a reduction in intellectual function resulting from reduced blood flow to the brain, inflammation often found in diabetes, and hypoglycemia. A reduction in brain function due to diabetes can lead to behaviors that are detrimental to the health of the patient, so it's very important to have an idea of the elderly patient's ability to perform self-care for his T1DM.

Selfmonitoring Of Blood Glucose Levels

Frequent SMBG monitoring has been shown to correlate closely with improved long-term BG control and decreased risk for hypoglycemia in patients with type 1 diabetes (8). The clinical benefit of frequent SMBG in patients with type 2 diabetes managed with diet and oral agents remain controversial (7,10). HbA1c levels decline when type 2 diabetics monitor their blood-glucose levels more than once per day and aggressively self-regulate their doses of insulin (11).

Artificial Endocrine Pancreas For Hospitalized Patients

In a landmark study, Van den Berghe et al. (52) demonstrated that control of glucose to near normal levels (90 to 110 mg dL) decreased morbidity and mortality following surgery and major illness in hospitalized patients. Numerous clinical trials have demonstrated the clinical advantage of controlling glucose levels in the near-normal range during major surgery and severe illness (53-55). Current hospital methods require frequent bedside glucose monitoring and careful titration of an intravenous insulin infusion to achieve tight BG control. Despite these precautions, the incidence of wide swings in BG and episodes of hypoglycemia remains high (4,52,54,55).

How Diabetes May Affect Your Family

Finally, your family should know what to do in an emergency. Make sure they understand the signs of hypoglycemia. Often people with diabetes having a low blood glucose episode will deny there is a problem or refuse treatment even though they may be in danger. Make sure your family members can recognize the signs of hypoglycemia and know how to deal with it.

Realizing the bodys reaction to pregnancy

In a nondiabetic pregnancy, the woman's body makes enough insulin to overcome the effect of pregnancy hormones (which block insulin action), and her blood glucose stays normal. But a woman with type 1 diabetes can't make more insulin, and during pregnancy she needs two or three times her usual dose to counteract the effect of her hormones. This increased need for insulin in a woman with type 1 diabetes usually stabilizes in the last several weeks of the pregnancy by the last one or two weeks, the mother-to-be may actually begin to have hypoglycemia. After the baby and the placenta are delivered, her insulin needs plummet immediately.

Using Expertise Available to

Don't neglect your family and friends as a helpful source. These are the people who love you and know that you would help them if the tables were turned. The problem is that they cannot help you if they do not know what you're dealing with. Tell them that you have diabetes and the risks, such as hypoglycemia, that you face. Tell them how to help you if the need arises. You will find that the result will be a much closer relationship.

Insulin Analogues in Children and Teens with Type Diabetes Advantages and Caveats

Although advanced complications are rare in youth, the demonstration of glycemic memory in follow-up studies of the Diabetes Control and Complications Trial cohort mandates the implementation of meticulous glycemic control in all individuals who have T1D as early as possible in the course of the disease 4 . This goal is particularly difficult to achieve in the pediatric population because of the increased risk for hazardous hypoglycemia 5-9 , fluctuating insulin requirements caused by exercise, illness, and variable carbohydrate intake, and psychosocial and physiologic issues related to age, puberty, and weight gain 10,11 . Adolescents who have T1D have higher average HbA1c levels compared with adults 8,11,12 , which is probably the result of a combination of biologic

Syndromes Of Insulin Resistance

Insulin resistance is an important feature of type 2 diabetes, and failure of insulin action in the peripheral insulin sensitive tissues, skeletal muscle, and adipose tissue is a major part of disease pathogenesis. Rare inherited syndromes of extreme insulin resistance have been vital in identifying genes involved in the insulin signaling pathway. One of these, Rabson-Mendenhall syndrome, consists of pineal hyperplasia, facial dysmorphism, phallic enlargement in males, short stature, acanthosis nigricans, and premature dentition. Diabetes mellitus presents between 3 and 7 yr of age, with death from ketoacidosis in the second decade. The diabetes is highly insulin resistant. Survivors develop later widespread microvascular disease (69). The syndrome is caused by insulin-receptor mutations leading to defective binding capacity (70). A model of treatment for this condition has been described, using monoclonal antibodies acting as a substitute for the normal ligand, thereby activating the...

Application Of Dcct Results In The Community

Neither group experienced a change in the rate of hypoglycemia and the three-injection regimen was as acceptable to the patients and the families as the two-injection regimen. In 1995, a cross-sectional nationwide study was conducted in 2579 children with type 1 diabetes receiving care in 206 treatment centers in France (53). Most of the children were still injecting insulin twice daily but reporting an average of almost three self blood glucose measurements daily. The mean HbAlc of the entire cohort was 9.0 (1.48 x ULN). Of these children, one-third had a HbAlc 8.0 , a value similar to the median HbAlc in the DCCT intensively treated adolescents however, almost one-sixth still had a HbAlc 11.0 , much higher than the median HbAlc of the conventionally treated adolescents in the DCCT. Despite the less than optimal degree of glycemic control, the rate of severe hypoglycemia was 45 per 100 person-years. Two years after the appearance of the DCCT results, a survey conducted in 1995...

Results of Clinical Islet Transplantation the International Islet Transplantation Registry

Through December 1998, a total of 405 islet allografts have been performed worldwide, including 306 since 1990, a relative increase in numbers related to the introduction of the automated method of islet isolation (47). Cumulative 1-yr patient and graft survival of 96 and 35 , respectively, were obtained in the 200 C-peptide negative, type 1 diabetic patients transplanted from 1990 through 1997. The persistence of graft function can be assessed by measurable levels of basal serum C-peptide, at a threshold of 0.5 ng mL. The observation that 32 of recipients lose graft function within 1 mo of transplantation (and 46 within 3 mo) indicates that primary nonfunction is a major cause of islet graft loss (47). In fact, we have shown that if early graft loss was excluded from the analysis of islet allograft survival (e.g., considering only grafts that maintain function for at least 1 mo posttransplant) after a state-of-the art islet transplant procedure, the results demonstrate an approx 80...

CSII by External Insulin Pump

Only rapid-acting or regular insulin is used in the insulin pump. Adjustments to the basal insulin infusion rate or changes in the size and timing of the insulin boluses generally allow more timely responses in BG concentration than are seen when adjustments are made to doses of intermediate-acting or long-acting insulin. All of these features confer a potentially greater flexibility for the patient in terms of lifestyle and insulin dosing. It has been suggested that use of lispro insulin may lead to a lower risk of hypoglycemia than the other rapid insulin analogs and or regular insulin in pumps (98,99).

Treatment of ketoacidosis

1 Your doctor gives you insulin intravenously to restore your insulin levels and reverse the abnormalities in your body. Your lack of insulin got you into this ketoacidosis situation in the first place. At some point, your blood glucose may fall toward hypoglycemia. If it does, your doctor gives you another IV made up of glucose and a solution of salt, potassium, and water.

Financial And Social Impact Of Type Diabetes

The impact of diabetes may also be felt in ways that are less easily quantifiable. The presence of type 1 diabetes, for example, is known to influence the insurance and employment experiences of affected individuals. Health, life, and sometimes automobile insurance are generally more difficult to obtain for a person with type 1 diabetes (106,112,113). Individuals may also face discrimination in the job application process (106,114) and often face limitations in the types of jobs available to them. Employment in commercial driving, for example, is limited out of concern for hypoglycemia (115).

Genetic and Tissue Factors Affecting Complications

Taken together, the above observations suggest the existence of genetic factors that could increase or decrease the susceptibility of tissue to hyperglycemic damage. When it becomes possible to easily and accurately determine each individual patient's vulnerability to diabetic complications, it will also be possible to determine each individual's relative need for intensive treatment of hyperglycemia. This, in turn, will enable us to focus our resources on those patients who absolutely require intensive treatment of type 1 diabetes and spare those patients, who may not require equally rigorous treatment in order to avoid long-term complications, from its burdens and hazards. Nonetheless, normoglycemia should be a goal for all patients, if it can be achieved without the hazards of hypoglycemia, the health and social burdens of obesity, and serious disruption of lifestyle.

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