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Ironic, isn’t it? Diabetes in its purest sense is an excess of sugar in the bloodstream, but the greatest immediate threat to life and limb with diabetes is the exact opposite: Not enough sugar in the bloodstream. Called hypoglycemia, low blood sugar is often caused by the very medicines we use to avoid excess blood sugar.

In its more severe manifestations, hypoglycemia can trigger bizarre or violent behavior, impair driving enough to land PWDs (people with diabetes) in jail, and increase the risk of injury or even result in death.

Luckily, reversing a low or dropping blood sugar level is a simple matter of consuming some fast-acting sugar, and all manner of emergency glucose products have been created to help us. There are glucose tablets, glucose powders, glucose gels, and glucose liquids.

But while a lot of thought has gone into the products themselves, very little thought — it seems — has gone into how these life-saving emergency products are packaged.

It’s also ironic that while these emergency glucose products are made to help a person experiencing the confusion and “brain fog” of a dangerously low blood sugar, the packaging is typically quite complex to open — even for a person whose brain is at full capacity.

Glucose tabs, for example, come packaged in a plastic vial or container that is tightly sealed with form-fitting plastic, which can take many long minutes to break and unravel. Glucose liquids typically have squeeze tops that require strength and dexterity to pop. And the plastic pouches that contain glucose gel are, by definition, difficult to rip open.

The problem here isn’t just the “Apple factor” — the idea of making packaging beautiful and elegant for its own sake. Rather, when it comes to emergency glucose, the functional issue MUST take precedence: It needs to be easy to open in an emergency. Because when people experience hypoglycemia, their mental acuity is severely degraded, and their physical dexterity is impaired.

The result is acting like a bumbling fool because your brain and hands aren’t working right. So why in the world isn’t the packaging for these emergency products designed to be simpler to access?

This is a question that PWDs have been asking publicly for nearly a decade.

DiabetesMine reached out to all the major manufacturers of glucose products and asked exactly that question, and the silence was nearly deafening. Only Annmarie Ramos, Trividia Health’s Senior Manager of Product Marketing, responded. Never heard of Trividia? Founded in 1985, they are the largest manufacturer of store-branded diabetes products in the U.S.

Trividia TRUEplus liquid glucose

Its portfolio includes blood glucose meters and strips, sharps, diabetic skincare products, and glucose tablets, gels, and liquids — all under the brand name TRUEplus.

Its glucose tablets come in large plastic jars, smaller travel tubes, and pouches of four “soft tabs.” Its gel is packaged in a soft envelope squeeze pouch, and its liquids in the Dex4-style mini bottle. All have the typical tight plastic seals previously described.

Ramos says her company’s products “have packaging that is easy to open,” but she provided no details on whether this has been tested by PWDs in any real-life scenarios.

The company’s main message was this: “We suggest that the product be opened after purchase so it is ready to be used in emergencies.”

On the larger bottles, she says “the perforated safety seal should be removed after purchase. Same for our 10-count tablet tubes, which have a tab on the cap for ease in popping off to open.”

She also insists that “for our Glucose shot bottles, the large caps are easy to twist off.”

I personally have been living with type 1 diabetes since 2004 and have found that “liquid shot” products from Dex4 and others have gotten more difficult to open over the years — presumably because the companies think this is a safety issue. At first, it was just a matter of applying a little extra “elbow grease.” But by late 2019, I found I had to use a pair of pliers to break open the twist cap. Then the day came in early 2020 that, even with pliers, and not even hypoglycemic, I couldn’t get the darn thing open. In fact, one effort to pre-open a bottle triggered a hypo.

Also, if you choose to pre-open the liquid vials, as Ramos recommends, you, of course, increase the risk of leakage.

This might be a reason to switch to gel pouch glucose. Ramos tells us that Trividia’s TRUEplus pouches have “a notch at the top of the pouch for ease in opening.” While it’s true that most glucose pouches are easier to open with hands or teeth than the bottles, that doesn’t mean the true needs of PWDs were considered in the development of the product’s packaging. There’s still a big risk of leakage, and they’re not always ideal to carry. Read on.

We checked in with diabetes designer Sara Krugman of Healthmade Design — who worked on Tidepool’s diabetes data interface and also the future iLet Bionic Pancreas system — to see if she knew anything about the world of glucose packaging.

Krugman says, “I only know this kind of production vaguely, but I do know there are quality tests — probably a machine dropping something on the goo packet to see when and how hard the impact needs to be to break it.”

Well, I personally have had any number of these packets rupture in my pocket, which is an unnaturally gross feeling sticking your hand into your own pocket and encountering a sea of slime. And don’t get me started on the embarrassing stain, smell, and stickiness… not to mention that when your gel packet ruptures, you no longer have the glucose you need in an emergency to keep from shouting at your spouse, staying out of jail, avoiding an injury, or dropping dead.

I also had a first-time negative experience with a gel pouch recently. It cut me. I was wearing a pair of slacks with thin-lined pockets, and the sharp edges of the pouch actually cut several long, painful lacerations in my skin, right through the cloth!

That highlights the other side of the coin with emergency glucose packaging that’s going unaddressed: Not only does it need to be easily opened by fools, but it also needs to be carried with ease, 24/7/365, so that we have it at the ready when we need it.

Long-time diabetes blogger Bernard Farrell has been an outspoken critic of glucose product packaging. He tells DiabetesMine that this came up again recently, “as I struggled to unwrap a vial of glucose tabs.”

He dreams of something “more like a circular jelly belly that also had 4 to 5 grams of very fast-acting carbs per serving. Then you could use a similar cylinder as the current one for a pack of 10 to 12 and a larger refill container to replenish those packs.”

“Ideally,” says Farrell, we need “something that works to dispense one gel cap at a time with a button push, so you don’t risk losing the lid, and don’t drop them when you try to get a few out of a container.”

He also points out the need to have dispensers cheap enough that PWDs can have multiples around. “If those are inexpensive enough, then I can keep one in each coat pocket, and each car. Also, in my gym bag, and my office drawer.”

It’s wonderful that so many companies have put a lot of thought into our biological needs when it comes to glucose, it’s just too bad that the same amount of effort hasn’t been put into practical and easy-to-carry and to-open packages to hold the glucose until we need it.

Given that, is it any wonder that many PWDs just carry hard candy, or opt to reach for a juice box when a hypo hits?

Glucose tabs and other medical glucose products are supposed to be better than candy because they provide the same controlled “dose” of sugar each time, helping to reduce the risk of over-treating. But until the packaging is revamped, they may have a run for their money against easy-grab treatments like dried fruit or Skittles.

Wil Dubois lives with type 1 diabetes and is the author of five books on the illness, including “Taming The Tiger” and “Beyond Fingersticks.” He spent many years helping treat patients at a rural medical center in New Mexico. An aviation enthusiast, Wil also works as a private flight instructor. He lives in Las Vegas, New Mexico, with his wife and son.