All people with type 1 and some people with type 2 diabetes will experience an episode of hypoglycemia (low blood glucose) sometime during the course of their disease. For some people with type 1 this can be become an every day occurrence, especially if they are attempting near normal control. For most of these people, the physical symptoms of low blood glucose will alert them to the impending drop in their blood glucose level.
That isn’t true for everybody though. Over 20 percent of people with type 1 diabetes have hypoglycemic unawareness, a condition where you lose the ability to tell your blood glucose is declining before it becomes dangerously low. The longer you have diabetes the more likely it is that the intensity of your symptoms will wane. One theory proposes that damage to the nerve fibers from years of high blood glucose causes impairment in the release of the hormone epinephrine, which is responsible for many of the physical symptoms. In addition, repeated episodes of hypoglycemia can also blunt these symptoms and increase the risk for more hypoglycemia.
Symptoms of hypoglycemia can be roughly divided into three categories: physical, mood and mental. Physical symptoms vary among individuals but manifest as dizziness, clumsiness, shaking, tingling around the mouth, hunger, sweating, palpitations. Mood symptoms also vary among individuals but can include feeling irritable, nervous, frustrated, depressed and giddy. People may also experience mental (neuroglycopenic) changes such as confusion, difficulty concentrating, slurred speech and slowed mental processing and inability to do calculations.
For people with hypoglycemia unawareness, the physical and mood-related symptoms may be blunted. Fortunately, the ability to detect mental changes during low blood glucose episodes is usually preserved. Paying attention to the sometimes subtle changes that happen to your thinking can help you recognize and treat the condition before you become incapacitated. Untreated hypoglycemia can result in loss of consciousness, seizures and possibly even death, not to mention the possible loss of property and life if low blood glucose happens while driving.
Hypoglycemic unawareness can be more than just physically dangerous, though. It can create tension and conflict with loved ones. Family and friends may begin to live in fear of a severe episode and become hypervigilant. Family and friends may start to feel that the person with diabetes isn’t taking responsibility for the disease and blame them for not taking proper care of themselves..
That is why attempting to reestablish physical symptoms is so important. To do this it is crucial to avoid episodes of hypoglycemia for several weeks.
Blood Glucose Awareness Training (BGAT) as well as continuous glucose monitoring can help in this process. BGAT, which was originally developed at the University of Virginia, is currently only offered at the Joslin. BGAT is a program that helps people understand the relationship between food, insulin and physical activity to better predict when they might be at risk for lows. It teaches patients and family members to focus on mental cues. This coupled with the security of knowing glucose levels on a constant basis from a CGM can make living with the risk of hypoglycemia less frustrating.
If you or a family member has hypoglycemic unawareness contact the behavioral health unit at the Joslin for a schedule of upcoming BGAT programs.