Balance. What could be nicer? It’s what keeps us from gaining too much weight, overdrawing our checking accounts, and plunging to our deaths when walking tightropes. For those with diabetes, balance is intrinsic to everything we do to keep our glucose levels in a healthy range. Balance your food and hormones against your physical activity and meds/insulin, and voilà!
Unfortunately, balance isn’t achievable 100% of the time. Given the almost unlimited number of factors that influence glucose levels, it is inevitable that we will experience our share of highs and lows. In fact, even subtle changes to food intake, physical activities, moods or emotions, and medication types and doses can send blood glucose careening upward or downward. Heck, even the weather can affect glucose levels! Anyone who takes insulin or a drug that stimulates the pancreas to secrete extra insulin (including glyburide, glipizide, glimepiride, chlorpropamide, tolazamide, tolbutamide, repaglinide, nateglinide, and combination medicines that contain these drugs) is at risk for low blood glucose, or hypoglycemia.
Every bout of hypoglycemia has the potential to become quite dangerous if it is not treated promptly and properly. Most people with diabetes are instructed to treat hypoglycemia with something called the “rule of 15,” meaning they should consume 15 grams of unspecified carbohydrate and then wait 15 minutes to see if the blood glucose level has returned to normal; if it hasn’t, you treat with another 15 grams. It doesn’t matter who you are, what you’re doing, or how low you are — the combination of 15 grams and 15 minutes is the magical elixir.
Unfortunately, those of us who treat patients and live with diabetes on a daily basis know that this procedure rarely works. Every person is unique, and every situation is different. Improper treatment of hypoglycemia can lead to prolonged or severe lows as well as prolonged or severe highs. It’s time to develop a more customized approach to dealing with hypoglycemia.
An individualized approach
Proper treatment of hypoglycemia is something you should think about and prepare for now, not when your levels are low and you can’t think all that clearly. I’ve found that when I don’t have access to my prepared, planned treatments, I turn into a ravenous wolf ready to consume everything I can get my hands on. Even my kids run the other way when they know my levels are low and I’m looking for food.
The fact is that, besides compromising our judgment, hypoglycemia makes us really, really, really hungry, and just about everything tastes good — even stuff you wouldn’t normally touch with a 10-foot pole. So do yourself a favor: Don’t wait until a low is staring you in the face to figure out what to do. Identify appropriate food types and quantities now, and put them where you can access them easily.
First, let’s think in terms of quantity. The amount of carbohydrate needed to treat hypoglycemia varies based on a number of factors, including your body size, target glucose level, how low your level is, and how quickly it is dropping.
Body size. Every gram of carbohydrate will raise a small child’s blood glucose much more than that of a fully grown adult, because bigger people have more blood volume into which the glucose will dissolve. Now, we could break down the amount of blood each person has and do some very complicated math, but that would get a bit messy. Suffice it to say that the bigger you are, the more carbohydrate it takes to raise your blood glucose level. The chart here summarizes observations conducted at our clinic about the amount that each gram of carbohydrate raises a person’s blood glucose based on his or her weight.
Blood glucose level. The lower your glucose level, the more grams of carbohydrate you will need to consume to get back up to target. And if you define “target” as 120 mg/dl (6.7 mmol/l), you’ll need more than if you define “target” as 100 mg/dl (5.6 mmol/l). The table here provides a guide based on body size, with a goal of raising the glucose to approximately 120 mg/dl.
Another way to determine the amount needed is to use this formula: (target BG – current BG)/blood glucose rise per gram of carbohydrate. For example, if your target is 100 mg/dl, your current blood glucose level is 60 mg/dl, and each gram of carbohydrate raises you 4 mg/dl, then you need (100-60)/4, or 10 grams of carbohydrate.
The rate of change. This is easily seen on a continuous glucose monitor (CGM), if you’re lucky enough to have one. If your glucose level is low and dropping quickly, you will need more carb than the “standard” amount. If your level is low and leveling off, the standard amount should work fine. One way to determine your rate of change is by observing the directional arrows on the screen. A diagonal direction arrow indicates a relatively slow rate of decline. One down arrow represents a moderate decline, and two down arrows equals a rapid fall. My rule of thumb is to treat with the usual amount of carb if there is a diagonal arrow or no arrows, but to add extra carb for each down arrow: 5g carb for each down arrow if you weigh less than 100 pounds (47 kg) and 10g for each down arrow if you weigh more than 100 pounds (47kg).
Of course, you can also simply look at your trend graph. If your BG is accelerating downwards, take an extra 5–10g carb. If your BG is dropping very gradually or leveling off, the standard treatment should work fine.
If you don’t have a CGM to show the current rate of change, there are several ways to determine whether the standard treatment amount needs to be adjusted. If you have a considerable amount of insulin on board from a previous mealtime dose, taking in extra carb is probably necessary. Since rapid-acting insulin has its greatest effect one to three hours after injection (or infusion if you use an insulin pump), a low that occurs in this time frame is probably still dropping quickly. A low that takes place more than three hours after you take mealtime insulin is probably dropping less rapidly.
Muscle activity can cause blood glucose levels to drop very rapidly as well. If the low occurs during or right after exercising, increase the amount of carb to treat the low.
Food eaten in the past couple of hours can also affect the direction your blood glucose is headed. If you had a meal or snack that consisted of slowly digested foods — legumes, dairy products, pasta, salad veggies, or high-fat items such as chocolate — there is a very good chance that the carbs in the food are still being digested, so the blood glucose is dropping at a slow rate. This doesn’t mean that you should ignore the low, but the usual amount of carb should work fine. In some instance, less than the usual treatment amount may suffice.
Not all carbohydrates are created equally when it comes to raising your blood glucose level. Some will raise it very quickly, while others will take their own sweet time. When hypoglycemia hits, choose a food that will raise blood glucose as quickly as possible.
Dextrose is the form of carbohydrate that raises blood glucose levels the fastest. Glucose tablets, gels, and drinks are made with dextrose, as are several candies, including Smarties, SweeTarts, Nerds, Runts, AirHeads, Spree, and Pixy Stix. Check the ingredient labels on candies to see if dextrose is the first item listed.
If you don’t have ready access to foods containing dextrose (or you don’t care for the taste), several ordinary foods will work almost as quickly: grape juice, dry cereal, pretzels or crackers, sports drinks, and regular (sugar-sweetened) soda. Dairy products like milk, yogurt, and ice cream tend to take a long time to raise the blood glucose. Likewise, foods that are high in fat or fiber tend to be digested slowly. These are not good choices for treating a low. Fruits and juices, because they contain a certain amount of fructose (a relatively slow-acting sugar), fall somewhere in the middle.
How long will it take?
Many people overtreat their lows by continuing to eat until their symptoms disappear completely. It usually takes 10 to 15 minutes for rapidly digested foods to start raising blood glucose and 30 to 90 minutes for them to finish the job. Foods that are digested slowly take even longer. Be patient! It’s fine to check your blood glucose level 15 minutes after treatment, but don’t be surprised if it hasn’t risen all the way to target. As long as your glucose level has begun to rise, you should be fine. If it has not risen at all (or has dropped further), then go ahead and treat again according to the standard treatment chart.
One note: If you use a continuous glucose monitor, do not trust it while you are recovering from a low. Because CGMs measure glucose in the fatty layer of tissue below the skin and not in the blood directly, they tend to take a long time to show a blood glucose rise after hypoglycemia has been treated. Instead, use finger-stick readings to measure your progress during recovery from a low.
One other note: If you happen to go overboard when treating a low (and everyone does on occasion), cover the excess carbohydrate with insulin. For example, if you normally take 1 unit of rapid-acting insulin for every 10 grams of carbohydrate, and you overtreat your low by 40 grams, give yourself 4 units of insulin once your glucose has risen to a safe range. Otherwise, your blood glucose is virtually guaranteed to rise well above your target in the next couple of hours.
Do as I say
None of us is perfect when it comes to treating lows. I’ve had my share of hypoglycemia-induced chocolate binges over the years, but I’ve learned from them. Take it from me: Prepare to treat your lows the right way, and follow your plan when the time comes. It will save you a lot of grief and aggravation, not to mention about a zillion unnecessary calories.