My hands start shaking. Cold shivers creep in, despite the warm sweater I'm wearing. My vision blurs, to the point where I can't clearly see what's right in front of me...

These are just a few of the symptoms I experience when my blood sugar dips too low, or in other words, when hypoglycemia sets in. As someone living with type 1 diabetes since childhood, this is an all-too-frequent reality that I've learned to cope with. Technology can certainly help prevent these hypos, but it's not a guarantee and I still experience them quite often.

Not everyone feels the same symptoms when their glucose levels drop, and many T1Ds (myself included) don't always feel any symptoms at all to alert us of plummeting glucose levels. That's known as "hypoglycemia unawareness" and it's something I experience about 50% of the time, particularly overnight -- which is quite dangerous in case I don't wake up to consume some sugar.

The danger of low blood sugars doesn't get enough attention, and there's also a stigma associated with these situations -- since the general public and "diabetes police" folks often wonder what we "did wrong" to make our glucose levels drop.

Within the diabetes community, there are layers of conversation on this front -- from general Fear of Hypoglycemia (FOH) that leads people with diabetes (PWDs) to keep their glucose levels higher to avoid lows, to kids with diabetes hiding the fact that they even have hypos, to people with type 2 being afraid to take insulin because they're fearful of potential lows.

As someone now nearing four decades living with this chronic condition, it also intrigues (and scares) me to know that there are PWDs who don't actually know what the word "hypoglycemia" even means. There's a health literacy component here, of course, which should remind us that medical terminology can be confusing for many people. 


What is Hypoglycemia (aka Low Blood Glucose)?

Hypoglycemia is generally considered to be a glucose level less than 70 mg/dL (3.9 mmol/L). But believe it or not, there was no official consensus among healthcare professionals on the exact definition until 2018, when key diabetes orgs agreed on defining hypoglycemia for different types of hypo situations. Why different parameters for different patients in different situations? Risk is affected by other health conditions and treatments that patients may be undergoing.

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Alarmingly, stats from the Centers for Disease Control (CDC) show that hypos account for nearly 300,000 emergency room visits each year alone!

In people with diabetes, a low blood sugar can be cause by any one or a combination of these factors:

  • too much insulin or other glucose-lowering medication, whether that's a fast-acting bolus (mealtime) insulin or a too-high long-acting (background) insulin basal dose
  • delaying or missing a meal, or not consuming enough carbohydrates to match the amount of insulin taken
  • more intense-than-normal exercise or simply physical activity in combination with insulin on board (IOB) 
  • alcohol, which can lead to lower glucose levels hours after drinking, despite a higher glucose initially due to carbs in a mixed drink or beer
  • for some people, airplane travel or other unusual activity, that for some reason causes their glucose levels to drop


What Does Hypoglycemia Feel Like?

The official medical list of standard symptoms of a hypo includes:

  • weakness, trembling, shaking
  • sweating
  • light-headedness or dizziness
  • headaches
  • fatigue, sleepiness
  • inability to focus or lack of concentration
  • tearfulness, emotional behavior change
  • irritability
  • hunger
  • blurred vision
  • coldness or shivering

Personally, over the years, I've experienced most if not all of those at some point during a low.

A recent social media campaign coordinated by the non-profit org Diabetes Australia has been encouraging PWDs around the world to share their hypo stories and descriptions of what a low blood sugar experience feels like. It's called The LowDown (#thelowdown2019) and aims to raise awareness both within and outside the diabetes community.

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It's certainly helping to raise discussion on lows between those of us dealing with them, and we're all for that. Other possible uses will be sharing these testimonies with medical professionals or even in policy discussions, to underscore the real impacts of hypoglycemia in PWDs' lives. 

Of course, it's hard to describe the feeling of a dangerously low blood sugar. A few years back, DiabetesMine editor Amy Tenderich shared her POV , using the terms "weird" and "scratchy (not itchy)" to describe her symptoms. And who can forget D-peep Bill Woods (aka "1HappyDiabetic") who made a video to describing his lows as "Hunger + Fear + Head Rush"?

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That is a goal of #TheLowDown2019 campaign, to bring more of these real-life feels to the forefront to use as we continue discussing diabetes in general and what low blood sugars actually mean for us.


Taking Low Blood Sugar Seriously

A couple years back, the diabetes community kicked off a big push to expand beyond focusing solely on the A1C test as a benchmark of good diabetes management, to looking #BeyondA1C at other factors that affect diabetes health and well-being. Fortunately, hypoglycemia was part of those policy discussions.

I personally believe that hypos should be considered above all else because they can be so life-impacting on a daily basis. They can really mess with your job and daily existence, not to mention the fact that you may not wake up at night (!)

Growing up, I certainly wasn't hypo unaware; all of my symptoms were visible. But event at a young age, I'd have dramatic seizures or hallucinations where I'd envision strange things, like robot aliens attacking and trying to take over my mind in the form of my parents, for example. There were screaming fits where all they could do was hold me down, and force juice down my throat.

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That happened as an adult, too. After getting married and before starting on a CGM, I experienced some severe lows with hallucinations that caused aggressive behavior on my part. Once I even thought my wife was a Communist trying to poison me and I had to resist, too the point of chanting "USA, USA!" in my state of hypo-confusion. It was scary for both of us, and we agreed that our best course of action in these situations (aside from working hard to prevent them from happening in the first place) was to phone the paramedics, to avoid my wife having to attempt to hold me down herself to get juice or honey down my throat, or having to use the overly-complicated multi-step emergency glucagon injection.

Shuddering now... (not from a low, but just the vivid memories of this over the years).

With all of that in mind, I'm pleased to see more awareness-raising happening on the hypoglycemia front. It's possibly the most important issue facing people taking insulin, and should be discussed more often.