Diabetes and the hypoglycemic syndrome

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!

Guide To Beating Hypoglycemia Summary


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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...

Treatment Of Hypoglycemia

Fear of hypoglycemia is a real concern of patients receiving insulin therapy. Intensive glycemic goals may make this concern a reality because there is a threefold greater incidence of severe disabling hypoglycemia for patients striving to achieve near normal glycemic targets as compared to conventional insulin replacement therapy (4,6). Education regarding all aspects of diabetes care will be paramount in equipping the patient to prevent and treat hypoglycemia. Carbohydrate counting, insulin dosing, concomitant medications, alcohol intake, exercise, and even driving should be included in the discussion. Reducing iatrogenic hypoglycemia will involve the patient, their support system, and health-care provider. The health-care providers will take on the role of facilitator as they educate and empower the patient to achieve diabetes self-care practices that will reduce diabetes-related complications (acute and long-term). Education will help alleviate fear of hypoglycemia that may impede...

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...

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...

Hypoglycemia Unawareness

HU is a major limiting factor in the management of adults with T1DM. Recommendation of strict glycemic goals may not be appropriate for patients experiencing HU because it may contribute to an increased prevalence of severe hypoglycemia. HU is characterized by the loss of autonomic warning symptoms that defend against the development of neuroglycope-nia. This failure to perceive autonomic warning signals like sweating, anxiety, or tremor, has been proposed to contribute to the increased frequency and severity of hypoglycemia in patients with T1DM. Duration of diabetes, antecedent hypoglycemia, and tight glycemic control are known risk factors for HU. The mechanism responsible for HU remains controversial. Work from Boyle et al. (21) has demonstrated that somewhat paradoxically, brain glucose uptake during hypoglycemia is increased in intensively treated patients with T1DM as compared with patients with poor metabolic control or healthy subjects. The explanation for this finding is...

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...

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...

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.

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...

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 (www.fda.gov). 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.

What you need to know about low blood glucose hypoglycemia

(( Tell your doctor if you have hypoglycemia often, especially at the same time of the day or night several times in a row. < K Tell your doctor if you've passed out from hypoglycemia. (( Ask your doctor about glucagon. Glucagon is a medicine that raises blood glucose. If you pass out from hypoglycemia, someone should call 911 and give you a glucagon shot. Hypoglycemia happens if your blood glucose drops too low. It can come on fast. It's caused by taking too much diabetes medicine, missing a meal, delaying a meal, exercising more than usual, or drinking alcoholic beverages. Sometimes, medicines you take for other health problems can cause blood glucose to drop. Hypoglycemia can make you feel weak, confused, irritable, hungry, or tired. You may sweat a lot or get a headache. You may feel shaky. If your blood glucose drops lower, you could pass out or have a seizure. CC Tell your doctor if you have hypoglycemia often, especially at the same time of the day or night several times in a...

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...


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.

Exercising with Diabetes

In general, the best time to exercise is when glucose peaks, about sixty to ninety minutes after eating. This timing provides enough energy, allows calories to be burned, and avoids high blood sugar after eating. Also important is to learn how to determine the right insulin dosages before, during, and after exercise. Why Too much insulin before a workout can lead to too-low blood sugar, or hypoglycemia, while not enough insulin can cause too-high blood sugar, or hyperglycemia. Stress and heat can affect the blood glucose insulin balance, so these factors must also be taken into account. A good idea is to have some carbohydrates available during exercise in case blood sugar needs to be raised quickly. Eating carbohydrates helps to prevent hypoglycemia. And exercising with a partner who knows what to do in case of a diabetic emergency can add a safety factor as well as make exercise more fun.

Future Perspectives For Young Children With Type Diabetes

Frequent daily BGM is necessary in young children because hypoglycemic episodes, especially nocturnal ones, are asymptomatic and difficult to detect, predict, and prevent. Nocturnal glucose sensors detecting hypoglycemia with an alarm are urgently needed for young diabetic children. These techniques seem to be close to becoming clinically applicable. The ultimate resolution of the difficult problems in managing diabetes in a preschool child will require closed-loop devices or cure via islet transplantation in the future.

What Should My Glucose Levels Be

In people without diabetes, glucose values can be in the 60 to 70 mg dl range or even lower with prolonged fasting. The problem with diabetes is that if you are taking medicines that can cause hypoglycemia, like insulin and sulfonylureas, a glucose level around 60 is of concern because it could go down even further. The ADA defines a glucose level of 70 mg dl or less as hypoglycemia, even if you feel fine and show no symptoms. Thus, if you are on medicines that can cause hypoglycemia, you should take action if the glucose level is below 70. If, however, you are controlling your diabetes with diet only, then values in the 60 to 80 range are fine and do not need treatment. Table 7-1 Typical Hypoglycemic Symptoms

Glycemic Effect of Protein

Plasma as free amino acids and are transported to muscle and other tissue. Protein is not converted immediately into glucose and, as a result, does not immediately raise postprandial blood glucose levels. Consuming as much as 9 oz of protein in a mixed meal elevated postprandial blood glucose levels only slightly at 3-5 h after eating in persons with type 1 diabetes when compared to a standard meal with 3-4 oz of protein (39). Plasma glucagon levels appear to be stimulated by protein consumption in type 1 diabetes and mirror the delayed glucose elevation (40). Thus, increased hepatic glucose output, secondary to elevations in glucagon, during the latter half of the postprandial period appear responsible for the effect of protein when consumed along with carbohydrates. This attribute has led to the assumption that protein is required at every meal and in bedtime snacks to prolong the blood glucose response and prevent nighttime hypoglycemia. Little evidence exists to support or refute...

Clinical Presentation of Type Diabetes

Blood Glucose Control High Risk of Hypoglycemia A major characteristic of metabolic control in type 1 preschool children is the unstable glycemic control with its accompanying risk of severe hypoglycemia. An international cross-sectional study of around 3000 children and adolescents has shown that the highest rate of severe hypoglycemia (60 episodes), resulting in unconsciousness or seizures, was observed in the younger children, aged less than 5 yr compared to the older children (10-20 episodes per 100 patients-years) (13). In this study, the only variables with a significant effect on the incidence of severe hypoglycemia were age, which led to a decrease of 8.4 per year, and HbA1c, which led to a decrease by 21 for each increase of HbA1c by 1 . Nocturnal hypoglycemia events are also more frequent in young children than in older, as reported in two recent studies (14,15). Thus, the frequency of nocturnal hypoglycemia was twice as high in children aged under 5 yr than in children aged...

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.

Identifying Neurocognitive Phenotypes

The interpretation of the early onset literature is complicated by the fact that in a number of studies, investigators have stratified their diabetic samples in terms of presence or absence of severe hypoglycemic events rather than earlier or later age at onset (14, 51). As a consequence, cognitive dysfunction has been attributed to severe hypoglycemia, but that may be in error insofar as severe hypoglycemia and onset age tend to be interrelated. Data from both epidemiologic (52) and cross-sectional studies (53) show that children with an early onset of diabetes have a greatly increased risk of severe hypoglycemia when compared to those with a later onset (45 vs. 13 ). The use of more intensive therapeutic regimens further increases the risk of severe hypoglycemia (54), particularly in those with an earlier onset of diabetes (55), perhaps because of a heightened sensitivity to insulin in young patients (56). slowed neural activity, measured at rest by electroencephalogram (EEG) and in...

If your blood glucose isEat this much carbohydrate

Of course, the goals mentioned previously are guidelines only. Discuss your needs with your health care team to create a plan that will work for you. Your target glucose levels may change over time. For instance, you could find it harder and harder to detect hypoglycemia. This would call for increasing your target range and perhaps new training at recognizing your symptoms. You'll probably want to check your blood glucose often at least as often as you inject insulin (or take your bolus dose via a pump) and sometimes more. You could be monitoring seven times a day before your three meals, after each meal, and before bedtime. You may even check at 3 a.m. once or twice a week. For instance, you will not want your blood glucose level to become too low during the night. But if you have experienced several severe hypoglycemic reactions, you may want to aim for a higher overnight blood glucose level. Every bit of testing gives you more knowledge of how your body reacts to food, exercise,...

Competing against others

1 Test his glucose several times in the hours after he competes. The exercise will make him very sensitive to the insulin and prone to hypoglycemia. 1 Should he become hypoglycemic, he shouldn't hesitate to stop and treat it. Not finishing is not the worst thing that can happen. Allowing his body to be damaged because he can't think clearly is. There will be many more competitions.

Results Of Studies Of Glycemic Control And Microvascular Disease

The Diabetes Control and Complications Trial (DCCT) was a landmark trial that was designed to finally answer the glycemic control and complications question (22). This was a large multicenter trial with enough statistical power to answer the issue conclusively. The study involved 1441 patients with type 1 diabetes who were randomized to either intensive glucose control or conventional treatment. The intensive therapy regimen was designed to achieve blood glucose levels close to the normal range as possible with three or more daily injections of insulin or an insulin pump. The conventional therapy consisted of one or two insulin injections. The cohorts were studied to answer two different questions that were related to the control and complications debate. One of the study questions was, whether intensive therapy would prevent the development of diabetic retinopathy (primary prevention) and the other whether intensive therapy would affect the progression of early diabetic retinopathy...

Alphaglucosidase Inhibitors

Like bigaunides, this class of agents is considered to be antihyperglycemic, since when used as mono-therapy they do not result in hypoglycemia. Another potential advantage of AGIs when used as mono-therapy is that there is no associated hyperinsulinemia or weight gain. However, if patients are treated with a combination of an AGI and a hypoglycemic agent such as insulin or a sulfonylurea, glucose should be used to treat the hypoglycemic reactions since sucrose or a complex carbohydrate will not be readily effective. Hypoglycemia is a major concern and limiting factor in treating elderly patients with Type 2 diabetes. Considering the favorable tolerability and safety profile of AGIs, some diabetologists therefore choose these agents as first-line therapy in elderly Type 2 diabetic subjects with fasting blood glucose levels < 11.0 mM (Johnston et al 1998). However, the relatively higher cost of these agents, the need for multiple daily dosing and the gastrointestinal side-effects...

Therapeutic implications

Consideration of the derangements in platelet function, the coagulation system, and the fibrinolytic system and their contributions to exacerbation of macrovascular disease in type 2 diabetes gives rise to several therapeutic approaches. Empirical use of aspirin (160-325 mg per day in a single dose) seems appropriate in view of the high likelihood that covert CAD is present even in asymptomatic people with type 2 diabetes and the compelling evidence that prophylactic aspirin reduces the risk of heart attack when CAD is extant. Because many of the derangements contributing to a prothrombotic state in diabetes are caused by hyperglycemia, rigorous glycemic control is essential. Accordingly, the use of diet, exercise, oral hypoglycemic agents, insulin sensitizers, and if necessary insulin itself is appropriate to lower HbA1c to 7 . Because other derangements contributing to a prothrombotic state such as attenuation of fibrinolysis appear to be related to insulin resistance and...

Comments on figure

The weight of the food inputs was not as well controlled as in home-prepared meals also the meals were eaten in late afternoon after only 4 hours of fasting, however, due care was exercised to try to make valid comparisons. The food was purchased at Wendy's and then consumed at home where the effects of a red wine (Merlot) on the meal could be determined. Merlot was found to reduce BG, that is, it acted as an oral hypoglycemic agent in these tests. Further tests with Merlot, shown in figure 5-7, support this finding.

Foods That Reduce Blood Sugar

Alcohol and onions were reported in the Diabetic mailing list at Lehigh as two substances that reduced BG level under some conditions. These reports illustrate the power of the Internet for people to share their experiences. The test conditions were not defined exactly by those reporting, but because the tests were not immediately after overnight fasting, it is quite possible that the BG reduction came from inhibited protein conversion effects as indicated by Bernstein 1 . My tests show a small hypoglycemic effect for both red wine (Merlot) and onions when ingested after overnight fasting.

Following up and treating your diabetes

The need for insulin diminishes immediately or within days of a transplant. It's important to measure your blood glucose frequently to know when you may reduce your insulin shots. Hypoglycemic episodes and brittleness of the diabetes (frequent and unexpected ups and downs in the blood glucose) improve within one month of the transplant.

Rationale for the Use of Human Insulin During Pregnancy

Maternal anti-insulin antibodies may contribute to hyperinsulinemia in utero and thus potentiate the metabolic aberrations in the fetus. Although insulin does not cross the placenta, antibodies to insulin do cross the placenta and may bind fetal insulin this necessitates the increased production of free insulin to reestablish normoglycemia. Thus, the anti-insulin antibodies may potentiate the effect of maternal hyperglycemia to produce fetal hyperinsulinemia. Human and highly purified insulins are significantly less immunogenic than mixed beef-pork insulins (45). Human insulin treatment has been reported to achieve improved pregnancy and infant outcome compared to using highly purified animal insulins (45). Recently, the insulin analog lispro (which has the amino acid sequence in the P-chain reversed at position B28, B29) has been reported to be more efficacious than human regular insulin to normalize the blood glucose levels in gestational diabetic women. This insulin rapidly lowered...

Taking charge of your health

Prior to developing diabetes, he was a very active person, participating in vigorous sports and doing major hiking and mountain climbing. At the time, his doctor warned him that he would have to give up many of the most strenuous activities because he would never know his blood glucose level and it might drop precipitously during heavy exercise. He ignored this advice and continued his active way of life. He found that he could do with much less insulin than his doctor prescribed and rarely became hypoglycemic. He has been able to continue these activities without limitation. His blood glucose level is generally between 75 and 140. His last hemoglobin A1c was slightly elevated at 5.7 (see Chapter 7). A recent eye examination showed no diabetic retinopathy (see Chapter 5). He has no significant microalbuminuria in his urine and no tingling in his feet (see Chapter 5).

Role of Early Pancreas or Islet Cell Transplantation in the Prevention or Reversal of Diabetic Nephropathy

Pancreas transplantation provides essentially euglycemic control in type 1 diabetes patients. The glycosylated hemoglobin levels usually average 5.5 with almost no hypoglycemic episodes (212). Conversely, the glycosylated hemoglobin levels achieved on intensive insulin regimen in the DCCT study were only 7 and two-thirds of such patients had progression of nephropathy (190). As there appears to be no minimum threshold for glycemia that prevents progression of diabetic nephropathy, the near-normal glycemic control achievable with pancreas or islet cell transplantation may be necessary to prevent or reverse diabetic nephropathy.

Species of Plants Reported to Be Used Traditionally to Treat Diabetes

Farnsworth, 1995) Mixture of coumarins including fraxidin, isolated from aerial material show hypoglycemic activity (Fort et al., 2000) Decreases blood glucose in STZ-treated rats (Ojewole and Adewunmi, 2004) Extracts alleviate hyperglycemia in STZ-diabetic rats (Amer et al., 2004)

No of antihypertensive agents Trial Target BP mm Hg

The choice of hypoglycemic therapy (as discussed in detail in another article in this issue) should be influenced by consideration of multiple factors including body mass index, renal function, comorbidities, financial issues, and patient preferences. In general, in the absence of contraindications, overweight individuals should initially be treated with metformin. The TZDs, an important therapeutic drug class, are effective in reducing blood sugar. Their hypoglycemic action is mediated by increasing muscle uptake of glucose, thereby decreasing insulin resistance. They also reduce hepatic glucose production. The primary action of these drugs is mediated through activation of the peroxisome proliferator-activated receptor-y receptor, a nuclear receptor with a regulatory role in differentiation of cells. This receptor is expressed in adipocytes, vascular tissue, and other cell types. These drugs improve endo-thelial function, reduce intra-abdominal adipose tissue, improve pancreatic...

Epidemiology Of Typical Type Diabetes In Various Populations

However, it also might reflect a range of professional practice regarding the use of insulin with pediatric patients, since most epide-miologic studies define Type 1 diabetes by the use of insulin therapy. In the latter situation, different proportions of Early 2 subjects might be included in epidemiologic studies of type 1 diabetes, according to whether local standards permit oral hypoglycemic agents to be used in diabetic children. For example, several groups have found early Type 2 diabetes to be more frequent among females. Wagenknecht et al. (33) identified three girls with Type 1 diabetes for every boy among African Americans in Jefferson County, Alabama (US), while the sex ratio for whites in the same study was 1.0. If female sex is truly a risk factor for Early 2, then misclassification would be suspected in the Alabama study. Alternatively, it is certainly possible that real differences in the risk of atypical, non-Type 1 diabetes exist among ethnic groups...

Prevention of Diabetic Nephropathy General Considerations Glycemic Control

Intuitive, the intensive insulin therapy used in the DCCT (28) was associated with a fourfold increase in the incidence of severe hypoglycemic episodes (defined as coma or need for medical assistance) and an average gain of 4.6 kg in weight after 5 yr of intensive therapy. However, despite these concerns in the DCCT study, a 33 reduction in the development of nephropathy occurred in type 1 diabetics. Also, both the DCCT Research Group and the UKPDS concluded that there was not a minimal glycemic threshold above normal for the development of the microvascular complications of diabetes and, thus, recommended that patients attempt to achieve as tight glucose control as possible (28,29,190).

Impact Of Lipidlowering On Cardiovascular Endpoints

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in patients with diabetes, and their risk is similar to that of non-diabetics with prior myocardial infarction (MI) (24). Improved glycemic control alone seems not to be sufficient to improve the CVD risk profile of patients with diabetes. In this regard, in the UKPDS, more intensive hypoglycemic therapy was associated with a 25 risk reduction in microvascular end points compared with conventional therapy (p 0.01), whereas risk reductions in fatal or nonfatal MI did not reach significance (fatal MI, 6 risk reduction, p 0.94 nonfatal MI, 21 risk reduction, p 0.06) (25).

Treatment Of Hyperglycemia

Results from the GIST-UK trial in stroke patients (mean contrast in plasma glucose between the groups 0.57 mmol L 17 ) as well as the results from trials in other medical emergencies (121, 129, 130) also demonstrate that without a significant effect of tight glycemic control on the mean glucose level no benefit on clinical outcome was found. In contrast, most, but not all (131,132), trials that targeted glucose values in a lower physiological range (4.4-6.1. mmol L), with intensive glucose control and or that accomplished a contrast in the mean glucose levels between the treatment and control group, demonstrate a beneficial effect on clinical outcome when patients are treated for more than 2 days (3,120,122,123). We therefore suggest that for future clinical trials in stroke patients to be effective on clinical outcome, adequate glycemic control and targeting glucose levels in the lower physiological range are of paramount importance. Caution, however, is warranted as maintaining...

Diet and Modification of Nutrient Absorption

In diabetic children the caloric needs depend on the rate of growth and activity pattern. Children 4-6 years old require 90 cal kg day and children 7-10 years old require 80 cal kg day. It is important to allow an adequate caloric intake in juvenile diabetes. Caloric requirement in children may also be calculated by adding to the baseline value of 1,000 cal day the amount of 100-125 cal for every year of age up to 12 years. Youngsters should consume 3 meals daily with 2 or 3 snacks (eaten at the same time each day) to minimize glycemic fluctuations and the risk of hypoglycemic episodes. After the caloric content and the composition of the diet are established, the prescription of a diet was in the past made by utilizing the data in the Exchange Lists for Meal Planning published by the American Diabetes Association. A more useful approach might be to use the precalculated diets (of various caloric content) prepared by several diabetes associations or other authoritative sources....

Prevention Of Stroke In Patients With Dm

The influence of the mode of antihyperglycemic treatment on the risk of stroke is uncertain. Mortality from cerebrovascular disease increased to a similar extent in patients treated by oral hypoglycemic medications or insulin compared to those on diet only (160). Although the incidence of stroke was higher in diabetic subjects treated with insulin than in those receiving oral medications or diet this difference disappeared after adjustment for other confounding factors (11). Stroke incidence did not differ in patients treated with chlorpromamide, glibenclamide, or insulin in the UKPDS. However, in overweight diabetic patients, intensive therapy with metformin was more effective in preventing stroke compared to other intensive treatment modalities, achieving a stroke reduction by 42 compared to the conventionally treated group (161). Although in the UKPDS an early addition of metformin in sulfonylurea-treated patients did not lead to an increased stroke incidence (161), another study...

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.

Symptoms Of Menopause

Women with diabetes has not been systematically studied. Women with diabetes may attribute their menopausal hot flashes or sweats to hypoglycemia and inappropriately take in calories leading to weight gain. On the other hand, these women may also attribute sweating from hypoglycemia to menopause symptoms and not appropriately treat episodes of hypoglycemia. Urinary incontinence increases in frequency at menopause. In a study of over 1,000 postmenopausal women, there was no difference in urinary incontinence in women with diabetes as compared to those without. Severe incontinence was more common in women with diabetes although that may be in part explained by higher BMI (14).

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

You Can Tell the Level of Your Blood Glucose by How You Feel

Many of my patients have claimed that they can tell their blood glucose level by how they feel, and I have challenged them to prove it. Guess who wins every time with the exception of significant hypoglycemia Sure, if your blood glucose is below 50 mg dl and you are sweaty and have palpitations and a headache, you know that you are low but even then, you don't know how low. Therefore, you don't know how much treatment to give yourself to bring it back up, but not too high.

Management of Ketoacidosis

In young children, frequent blood glucose monitoring (BGM) is critical in order to navigate within acceptable targets of glycemic control by minimizing the risk of severe or frequent hypoglycemia. Usually five to six BGMs per day and two urine tests per day for urine glucose and ketone bodies are performed by parents or caregivers. Measurement of blood glucose level at the parents' bedtime must be encouraged in order to detect asymptomatic hypoglycemia or to give a snack when BG is below a specified level (15). Nocturnal hypoglycemia should be suspected in children under conventional therapy with frequent fasting BG values below 120 mg dL (15). It must be noted that systematic carbohydrate intake at supper did not consistently prevent nocturnal hypoglycemia (14). Needle length has to be carefully considered in young children, as their role in the risk of hypoglycemia has been shown. Alternating intramuscular and subcutaneous injections can occur from one day to another and from one...

Overestimation of Carbohydrate Intake

One of the most common reasons for recurrent hypoglycemia is injecting too much insulin or taking too much oral medication for the amount of carbohydrates ingested. You may overestimate the amount of carbohydrate in the food or eat less than planned, or you may be delayed in eating after taking the insulin or medicine. For example, a number of times, I have had patients inject a dose of insulin in the car before they went to a restaurant. At the restaurant, the food did not come at the expected time, and so their glucose level went low. Another example is when patients are asked to fast for a lab test (such as a lipid profile) they do not realize that they should delay taking their insulin or diabetic medicine until after the test. Drinking alcohol in excess (see Chapter 8), especially on an empty stomach, can also cause hypoglycemia.

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...

AGlucosidase inhibitors

Acarbose and miglitol are the two agents in the a-glucosidase inhibitor (AGI) class of antihyperglycemic compounds. AGIs reduce the rate of digestion of polysaccharides in the proximal small intestine. When used before meals, they delay the absorption of complex carbohydrates and blunt postprandial hyperglycemia, resulting in modest reductions in A1C. They are not associated with weight changes or hypoglycemia. AGIs are infrequently used in the USA. The main limitations to their widespread use are the need for frequent dosing, poor tolerability due to frequent gastrointestinal side effects, and only modest antihyperglycemic effects.

Rationale For Control Of Blood Glucose

Normal metabolism should be mimicked as closely as possible. Therapeutic goals include the avoidance of hypoglycemia, hyperglycemia, lipolysis, ketogenesis, proteolysis, dehydration, and electrolyte imbalance. Type 1 diabetic patients should receive a continuous supply of insulin to avoid ketosis. Sufficient insulin should be supplied to counterbalance the hyperglycemic effects epinephrine, norepinephrine, cortisol, glucagon, and growth hormone

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.

Training of School Personnel

Diabetes care training for school nurses and other school personnel should be developed and implemented by diabetes educators, school nurses or other qualified health care providers, and school administrators. School nurses and nonmedical school personnel can be trained to perform and assist with blood glucose and ketone monitoring insulin, oral medication, and glucagon administration and recognition and treatment of hypoglycemia or hyperglycemia. There are three levels of training appropriate for school personnel 1) Training for school personnel who will actually perform diabetes care tasks, such as blood glucose monitoring, insulin administration, glucagon administration, and recognition and treatment of hypoglycemia or hyper-glycemia. Training should address the following areas general overview of diabetes and explanation of type 1 and type 2 diabetes, recognition and treatment of hypoglycemia and hyperglycemia, blood glucose monitoring, insulin and glucagon administration,...

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...

Physiology of Glucose Counterregulation

The physiological postabsorptive arterial plasma glucose concentration in healthy humans is approx 70-110 mg dL (3.9-6.1 mmol L). Falling plasma glucose concentrations normally elicit a characteristic series of responses (14-16) (see Fig. 1). Insulin secretion decreases (favoring increased hepatic and renal glucose production and decreased glucose utilization by tissues other than the brain) as plasma glucose concentrations decline within the physiological range. The arterialized venous glycemic threshold for decreased insulin secretion is approx 80-85 mg dL (approx 4.4-4.7 mmol L). Decreased insulin secretion is the first defense against hypoglycemia (3). The secretion of glucose counterregulatory (plasma glucose raising) hormones glucagon and epinephrine as well as cortisol and growth hormone increases as plasma glucose concentrations fall just below the physiological range. The arterialized venous glycemic thresholds for their secretion are approx 65-70 mg dL (approx 3.6-3.9 mmol...

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.

Coronary Artery Disease

Coronary artery disease can be further complicated by maternal hypoglycemia. Strict glycemic control in the type 1 diabetic has been associated with increased episodes of hypoglycemia in pregnancy. This phenomenon is seen primarily in the first half of pregnancy. The concern revolves around the activation of the counter-regulatory responses with the release of catecholamines that lead to tachycardia and increased demand on the myocardium. These changes can result in acute myocardial infarction in the patient with underlying coronary artery disease. 5. Aggressive glycemic control with frequent self-monitored blood glucose levels and avoidance of maternal hypoglycemia. Targets for blood glucose levels may have to be adjusted to attempt to further avoid maternal hypoglycemia.