Who doesn’t sometimes need help navigating life with diabetes? That’s why we offer Ask D’Mine, our weekly advice column, hosted by veteran type 1, diabetes author and community educator Wil Dubois. This week he’s offering some thoughts on diabetes and seizures, and… well, funky toenail concerns.

{Got your own questions? Email us at AskDMine@diabetesmine.com}

Marty, type 1 from Florida, writes: I’m 22 and I’ve been a diagnosed diabetic for 8 years. My A1C’s are always under 6%. I’ve been reading a lot of diabetic blogs and diabetic support group stuff, and I’ve noticed that a lot of type 1s have had seizures. I’ve never had one, but I did have an absolutely insane roommate that claimed that I might not even know if I had had one. Is there any reality to this? Could I have had a seizure and not known about it? I read that the seizures themselves do raise your blood sugar.

Wil@Ask D’Mine answers: Coma, seizure, and death. The three horsemen of the diabetes apocalypse. Google that trio of words and you’ll get around 8 million hits. That’s a whole bunch of comas, seizures, and deaths.

So we hear it a lot. As in, if your blood sugar goes too low it can result in coma, seizure, and death. That sounds pretty damn scary, but we rarely see any intelligent discussion around what it’s all about. What causes the seizure? What the f— is a seizure, really? Are all seizures created equal?

Here’s the deal. Sugar is brain fuel. Deprive the brain of sugar and weird things start happening. Of course, in medical circles, people in white coats and ties can’t look appropriately dignified talking about “weird things,” so they like to discuss “neuroglycopenic events” instead. In a nutshell, neuroglycopenia means not enough sugar for the brain, which in turn affects the function of neurons. That causes the brain to fire off strange signals it normally wouldn’t and weird things start to happen. Muscles twitch, jerk, jump, tighten. Gosh, it sounds a lot like an epileptic fit.

In point of fact, a diabetic seizure is a series of muscle convulsions similar to an epileptic seizure. Both are caused by confused neurons in the brain.

Now, for a hypo to trigger a seizure it has to be a pretty bad low, falling into the category of “severe.” And what about the coma and death part? Well, the seizure has nothing to do with it. Go low enough, long enough, and your brain will die. The seizure and the coma are just rest stops along the road between too-low too-long, and dead.

But where things really get complicated is that not all severe lows result in seizures, and not all seizures are created equal. Some people can have violent convulsions. Others might have only a momentary twitch.

Among folks who do have seizures, most happen at night. Most seizures wake the victim up. If you have even been “woken up” by a nocturnal low, odds are you’ve had a seizure of some sort, even though it’s unlikely you’ll remember it. And that’s the big difference between epilepsy seizures and diabetes seizures: people with epilepsy often report perfect memory of events, but are trapped in a body they can’t control; while we D-Folk often don’t recall our fits at all.

So your crazy roommate could be right. You might not know if you had had one. But there are clues. If you wake up with a pounding headache, sheets damp from sweat, and high blood sugar, you probably had a bad low in the night. Bad lows in the middle of the night can result in a seizure. Does that mean you had one? Not necessarily. Btw, the headache is your low blood sugar hangover. The damp sheets are from the night sweats that were the warning signs of the low that you slept through.

Now as to the high blood sugar, what you read was wrong. Seizures don’t raise blood sugar. A bad low will trigger the Somogyi Phenomenon, where your body, in a last-ditch effort to save itself from a bad low, will release glucagon, cortisol, and epinephrine to drive the blood sugar back upwards. And that’s what causes the morning-after high. Not the seizure. A seizure is just the side effect of some really bad lows. You’ll wake up high from a bad low that you live through, whether or not you had a seizure.

Are seizures dangerous? You bet your booties. There’s quite a bit of research that suggests that repeated seizures from lows can lead to brain damage.

And one last thought. I don’t like your A1C. What? Gasp, hundreds of readers. Sorry. Sub-six for a type 1 is bad news in my book. Given our current insulins and technology, it’s very, very, very hard to get A1Cs in the fives without having a lot of lows. And of course if you’ve having a lot of lows, a lot of them could be at night, and if they are at night, you could have seizures, and if you’re having seizures you might not know it, and your absolutely insane roommate could be right.

Or she could just be the fourth horsemen .

Bethany, type 1 from Illinois, writes: I’m 21 and I’ve had diabetes for 20 years. I’m in nursing school and what I’m learning about diabetes complications scares me. I’m not exactly sure if it’s opened my eyes, or if I am just over-thinking, but I’ve noticed that my feet are ALWAYS freezing cold. I can hardly ever walk around without socks on because they are literally like ice to the touch. And also, my skin on my toes is flaky/peely and my toenails have ridges in them and the nail flakes as well. I first thought neuropathy but I don’t really have symptoms that resemble that of neuropathy. No pain/numbness/tingling and I can feel everything with my feet – no loss of sensation. Could this be a vascular problem? I can’t find any literature that matches up to my experience.

Wil@Ask D’Mine answers: Hooray for you in nursing school! I totally think we need the absolute maximum number of PWD’s in the healthcare trenches. Who better to care for our kind than ourselves?

Of course, as you’re learning, knowing more about diabetes can prove… unsettling. It’s so much easier to live in ignorant bliss. If you don’t turn the light on, you don’t see the cockroaches, right?

But let’s talk about your cold feet before a cockroach scuttles across them. First, I agree that neuropathy seems unlikely. As you say, the symptoms don’t really fit. But I think the reason you can’t find any literature that matches your experience is because you’re suffering two unrelated problems that just happen to live in your feet.

Your flaky/peely toes with rough ridged flaky nails sounds suspiciously like a classic garden-variety case of nail fungus to me. I know. Eweeeeeeeeeew. Although it sounds straight-forward, nail fungus can actually be damn tricky to beat. Many over-the-counter creams are available, but the scientific literature seems to be in 100% agreement that they’re all worthless and that the best bet are powerful anti-fungal pills that need to be taken for months—and still fail in about half the cases. Make an appointment with your doc.

Now cold feet, on the other hand (or should I say on the other foot?), is most often the result of poor circulation. So yeah, I think some sort of vascular problem is the most likely culprit. The quick check for poor circulation is to test your capillary response. Press your finger firmly into the skin of your foot for a few seconds. The tissue around your finger should lighten, as you just pushed some of the blood away. Now, let go! Did the color return quickly or slowly? Normal refill is under two seconds. If it takes longer, your circulation is poor.

If you refill quickly, the next most common cause of cold feet is nerve problems, followed by under-preforming thyroid (in Bethany’s case she told me she does have well-controlled hypothyroid like many of us with diabetes, so that’s not likely to be the cause of her cold feet). Even though you don’t have any signs of neuropathy, as a 20-year vet of the diabetes wars, we can’t rule out some sort of nerve damage. And like the fungus, the cold feet, be it vascular or nerve, deserves a quick visit to your doctor.

Meanwhile, keep your socks on, and don’t let your literal cold feet give you metaphorical cold feet about staying in nursing school! We need you there! I’m passing the hat to buy you some heated socks…

“This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.”