“What does it feel like when you go low?” The question is asked often of diabetics. Our health care providers need to know if we can actually tell. Hypoglycemia is an extremely dangerous condition. Blood sugar levels below 70 milligrams/deciliter—informally known as hypos—can lead to unconsciousness, car and bike accidents, cognitive impairment both short and long term, damage to your cardiovascular system, possibly something akin to chronic traumatic encephalopathy, adrenal fatigue, burnt dinners, broken dishes, and regretted declarations.
The Latin roots of the term diabetes mellitus are, literally, to siphon sweet. The ancients realized that sometimes people became siphons for sweetness, would just up and melt into sugar water, in the process of which they would become lethargic, waste away, and, within a period of months, perish. The different forms, type 1, type 2 (contrary to what I thought, type 2 diabetes has been around for thousands of years, but in very small numbers, little clusters of wealthy people with excessive diets and sedentary habits who lifestyled themselves into insulin resistance) and gestational were all thought to be separate and distinct paths to the same no fun finish. Now it seems increasingly accepted that all forms are related and on a spectrum. Insulin dependence has elements of insulin resistance, and insulin resistance often engenders insulin dependence.
Just to clarify, insulin is a hormone, the messenger that tells your body what to do with sugar, that opens cells' walls to their only source of energy. Without it, your blood becomes sweeter than Pepsi Cola. Before the discovery of insulin in the 1920s, treatment options were so limited that some people were just told to stop eating. If you're starving, at least your blood sugar will be in range. Diabetes was a guaranteed death sentence. From then until the 1980s, people survived, but treatment was clunky and haphazard, and all insulin injected by humans was sourced from animals, primarily pigs and cows.
While the aim for centuries had been to lower blood sugar, it soon became obvious that the main side effect of insulin replacement therapy was hypoglycemia, caused by the difficulty in determining the exact amount of insulin needed for any given meal. It also was increasingly evident how dangerous hypos are—and how hard they are to avoid. Pioneering endocrinologist and educator Martha Kennedy of the University of California Medical Center in San Francisco was at the forefront of switching the emphasis in type 1 treatment from lowering blood sugar levels to avoiding lows. The American Diabetes Association's long term recommendation had been that diabetics strive for an a1c (the composite score of three months' blood sugars) of 6 to 6.5, in comparison with a non-diabetic a1c of 5 to 6. For most of us, this is nearly impossible without daily lows. Now, many endocrinologists are happy if their patients are in the vicinity of 7. There is the ideal world, and the one of limited will power, family dinners, and lots of compromise in which we all must live.
“At what number do you usually feel a low?” The answer is not an easy one. During my first months as a diabetic, in 2009, it was not a question. My adrenals were still involved. At about 80 mg/dl, I would get shaky, sweaty, confused, irritable, the blood would pulse in my head, often triggering a headache. By 2012, most of these symptoms were gone—except the headache. I have no adrenal response left at all—even when I drop to the 40s or 30s. What I do feel is a tightening of the muscles behind my eyes. Minor noises coalesce into an unbearable cacophony. I get annoyed more easily. If I am swimming laps, the pool seems interminably long, thick, the water leaden. My cognitive functions decline, turning unimportant decisions into quandaries. Sometimes my lips get numb. Vision blurs and pixelates. A protracted low feels like having all the disorientation of being really stoned, but with zero joy-giving endorphines. I have joked that the primary supportive partner of all type 1s should just once be injected with a few units of insulin so they could know what their loved one is dealing with, but that would be just too dangerous--and mean anyway.
On the plus side, when you're low food and water taste better than you've ever imagined them. Yesterday with my blood sugar plunging, I made a banana strawberry smoothie, the divinity of which I can not begin to describe. The problem then is having a little bit of that amazing treat—just enough to bring my numbers up. A big cup likely leads to a high, and then possibly another low, and another high, ad naseum. Will power is hard enough to come by in life anyway, just try to find it at 48 mg/dl.
I have never blacked out, never been taken to the ER because of a hypo, never used my glucagon kit (Google it), but that may be just blind luck, as I have been very close. On the other hand, I do have a high tolerance for low blood sugar, which I am proud of... in a stupid kind of way. I have been in the 30s dozens of times, in the 40s hundreds of times. Fortunately, I can't sleep through a low. Even if my continuous glucose meter doesn't rouse me with an urgent low alarm, I wake up, a tinny silent buzz behind my ears. When I first got diabetes, nighttime hypos were my biggest fear. I felt as if I were balanced on the blade of a knife, unconsciousness and coma on either side below.
Diabetes is the only condition in which a sugar pill is not a placebo. As soon as you feel a low coming on, you need glucose (also known as dextrose), the simplest sugar on a molecular level, the one that brings you back into the safe zone most rapidly. Sucrose works if glucose is not available, but it is slower, as the molecules need to be split before they become available glucose. Fructose is not helpful at all as it needs to go the liver to be broken down before it can enter the bloodstream. Maltose is pretty quick for me, but all the other forms of sugar on the market—and there are a lot—are slow. Glucose is sold in chalky tasting, artificially flavored tabs, gels, and liquids, specially over-priced for us diabetics.
I used to have a lot of hypos, some days more than one. For a period of nearly a year, I didn't have a single workout where I kept my blood sugar in range, even with lots of advance planning on the carb front. The astute observer will assume that I'm not managing my condition well. They will also assume that management is straightforward, that all one needs is a grasp of basic math and a lot of discipline. But that implies that there are only a few easily accounted for variables. The reality is exponentially different, far removed from theorizing and fourth-grade equations.
I could just be making excuses for my irresponsibility. I don't know. I used to try to guess my blood sugar number before I tested. I was close about as often as I was not. I stopped that mind game promptly. I continue to work out the variables, getting them pinned down just as new ones rear up. I go low perhaps 50% as much, and the lows aren't usually as deep, but, still, I dread those nights when I am alone, the only one in a big empty house.
Postscript: I recently discovered that Now Supplements sells unflavored powdered dextrose, in bulk, for much cheaper than the formulations available in drugstores, and with no artificial flavorings included. This form isn't convenient for carrying with you, but at home can be mixed into water or juice for the fastest recovery that I've found.
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