Hypoglycemia (Low Blood Glucose)
Throughout the day, depending on multiple different factors, blood glucose (also called blood sugar) levels will vary – up or down. This is normal. If it varies within a certain range, you probably won’t be able to tell. But if it goes below the healthy range and is not treated, it can get dangerous.
Low blood glucose (hypoglycemia) is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL. However, talk to your diabetes care team about your own blood glucose targets, and what level is too low for you.
Low blood glucose may also be referred to as an insulin reaction, or insulin shock.
Signs and Symptoms of Low Blood Glucose (happen quickly)
Each person's reaction to low blood glucose is different. Learn your own signs and symptoms of when your blood glucose is low. Taking time to write these symptoms down may help you learn your own symptoms of when your blood glucose is low. From milder, more common indicators to most severe, signs and symptoms of low blood glucose include:
- Feeling shaky
- Being nervous or anxious
- Sweating, chills and clamminess
- Irritability or impatience
- Fast heartbeat
- Feeling lightheaded or dizzy
- Color draining from the skin (pallor)
- Feeling Sleepy
- Feeling weak or having no energy
- Blurred/impaired vision
- Tingling or numbness in the lips, tongue, or cheeks
- Coordination problems, clumsiness
- Nightmares or crying out during sleep
The only sure way to know whether you are experiencing low blood glucose is to check your blood glucose, if possible. If you are experiencing symptoms and you are unable to check your blood glucose for any reason, treat the hypoglycemia.
A low blood glucose level triggers the release of epinephrine (adrenaline), the “fight-or-flight” hormone. Epinephrine is what can cause the symptoms of hypoglycemia such as thumping heart, sweating, tingling, and anxiety.
If the blood glucose level continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, it may lead to seizures, coma, and very rarely death.
Treatment - The "15-15 Rule"
The 15-15 rule—have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes. If it’s still below 70 mg/dL, have another serving.
Repeat these steps until your blood glucose is at least 70 mg/dL. Once your blood glucose is back to normal, eat a meal or snack to make sure it doesn’t lower again.
This may be:
- Glucose tablets (see instructions)
- Gel tube (see instructions)
- 4 ounces (1/2 cup) of juice or regular soda (not diet)
- 1 tablespoon of sugar, honey, or corn syrup
- 8 ounces of nonfat or 1% milk
- Hard candies, jellybeans, or gumdrops—see food label for how many to consume
Make a note about any episodes of low blood glucose and talk with your health care team about why it happened. They can suggest ways to avoid low blood glucose in the future.
Many people tend to want to eat as much as they can until they feel better. This can cause blood glucose levels to shoot way up. Using the step-wise approach of the "15-15 Rule" can help you avoid this, preventing high blood glucose levels.
- Young children usually need less than 15 grams of carbs to fix a low blood glucose level: Infants may need 6 grams, toddlers may need 8 grams, and small children may need 10 grams. This needs to be individualized for the patient, so discuss the amount needed with your diabetes team.
- When treating a low, the choice of carbohydrate source is important. Complex carbohydrates, or foods that contain fats along with carbs (like chocolate) can slow the absorption of glucose and should not be used to treat an emergency low.
When low blood glucose isn’t treated and you need someone to help you recover, it is considered a severe event.
Treating Severe Hypoglycemia
Glucagon is a hormone produced in the pancreas that stimulates your liver to release stored glucose into your bloodstream when your blood glucose levels are too low. Injectable glucagon is used to treat someone with diabetes when their blood glucose is too low to treat using the 15-15 rule.
Glucagon kits are available by prescription. Speak with your doctor about whether you should buy a glucagon kit and how and when to use it.
The people you are in frequent contact with (for example, friends, family members, and coworkers) should be instructed on how to give you glucagon to treat severe hypoglycemia.
Steps for treating a person with symptoms keeping them from being able to treat themselves.
- Inject glucagon into the buttock, arm, or thigh, following the instructions in the kit.
- When the person regains consciousness (usually in 5-15 minutes), they may experience nausea and vomiting.
- If you have needed glucagon, let your doctor know so you can discuss ways to prevent severe hypoglycemia in the future.
- Inject insulin (it will lower their blood glucose even more)
- Provide food or fluids (they can choke)
Causes of Low Blood Glucose
Low blood glucose is common for people with type 1 diabetes and can occur in people with type 2 diabetes taking insulin or certain medications. The average person with type 1 diabetes may experience up to two episodes of mild low blood glucose each week, and that’s only counting episodes with symptoms. If you add in lows without symptoms and the ones that happen overnight, the number would likely be higher.
Too much insulin is a definite cause of low blood glucose. One reason newer insulins are preferred over NPH and regular insulin is that they’re less likely to cause blood glucose lows, particularly overnight. Insulin pumps may also reduce the risk for low blood glucose. Accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle (instead of the just under the skin), can cause low blood glucose.
What you eat can cause blood glucose, including:
- Not enough carbohydrates
- Eating foods with less carbohydrate than usual without reducing the amount of insulin taken.
- Timing of insulin based on whether your carbs are from liquids versus solids can affect blood glucose levels. Liquids are absorbed much faster than solids, so timing the insulin dose to the absorption of glucose from foods can be tricky.
- The composition of the meal—how much fat, protein, and fiber are present—can also affect the absorption of carbohydrates.
Exercise has many benefits. The tricky thing for people with type 1 diabetes is that it can lower blood glucose in both the short- and long-term. Nearly half of children in a type 1 diabetes study who exercised an hour during the day experienced a low blood glucose reaction overnight. The intensity, duration, and timing of exercise can all affect the risk for going low.
Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times.
In the event of a severe hypoglycemic episode, a car accident, or other emergency, the medical ID can provide critical information about the person's health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can't speak for themselves.
Medical IDs are usually worn as a bracelet or a necklace. Traditional IDs are etched with basic, key health information about the person, and some IDs now include compact USB drives that can carry a person's full medical record for use in an emergency.
Very often, hypoglycemia symptoms occur when blood glucose levels fall below 70 mg/dL. As unpleasant as they may be, the symptoms of low blood glucose are useful. These symptoms tell you that you your blood glucose is low and you need to take action to bring it back into a safe range. But, many people have blood glucose readings below this level and feel no symptoms. This is called hypoglycemia unawareness.
People with hypoglycemia unawareness can't tell when their blood glucose gets low so they don’t know they need to treat it. Hypoglycemia unawareness puts the person at increased risk for severe low blood glucose reactions (when they need someone to help them recover). People with hypoglycemia unawareness are also less likely to be awakened from sleep when hypoglycemia occurs at night. People with hypoglycemia unawareness need to take extra care to check blood glucose frequently. This is especially important prior to and during critical tasks such as driving. A continuous glucose monitor can sound an alarm when blood glucose levels are low or start to fall. This can be a big help for people with hypoglycemia unawareness.
Hypoglycemia unawareness occurs more frequently in those who:
- Frequently have low blood glucose episodes (which can cause you to stop sensing the early warning signs of hypoglycemia)
- Have had diabetes for a long time
- Tightly control their diabetes (which increases your chances of having low blood glucose reactions)
If you think you have hypoglycemia unawareness, speak with your health care provider. Your health care provider may adjust/raise your blood glucose targets to avoid further hypoglycemia and risk of future episodes.
Regaining Hypoglycemia Awareness
It’s possible to get your early warning symptoms back by avoiding any, even mild, hypoglycemia for several weeks. This helps your body re-learn how to react to low blood glucose levels. This may mean increasing your target blood glucose level (a new target that needs to be worked out with your diabetes care team). It may even result in a higher A1C level, but regaining the ability to feel symptoms of lows is worth the temporary rise in blood glucose levels.
Other Causes of Symptoms
Other people may start to have symptoms of hypoglycemia when their blood glucose levels are higher than 70 mg/dL. This can happen when your blood glucose levels are very high and start to go down quickly. If this is happening, discuss treatment with your diabetes care team.
How Can I Prevent Low Blood Glucose?
Your best bet is to practice good diabetes management and learn to detect hypoglycemia so you can treat it early—before it gets worse.
Monitoring blood glucose, with either a meter or a continuous glucose monitor (CGM), is the tried and true method for preventing hypoglycemia. Studies consistently show that the more a person checks blood glucose, the lower his or her risk of hypoglycemia. This is because you can see when blood glucose levels are dropping and can treat it before it gets too low.
If you can, check often!
- Check before and after meals
- Check before and after exercise (or during, if it’s a long or intense session)
- Check before bed
- After intense exercise, also check in the middle of the night
- Check more if things around you change such as, a new insulin routine, a different work schedule, an increase in physical activity, or travel across time zones
Why Am I Having Lows?
If you are experiencing low blood glucose and you’re not sure why, bring a record of blood glucose, insulin, exercise, and food data to a health care provider. Together, you can review all your data to figure out the cause of the lows.
The more information you can give your health care provider, the better they can work with you to understand what's causing the lows. Your provider may be able to help prevent low blood glucose by adjusting the timing of insulin dosing, exercise, and meals or snacks. Changing insulin doses or the types of food you eat may also do the trick.
If you or your child has recently been diagnosed with type 1 diabetes, order our FREE Courage-Wisdom-Hope Kit for children and their families.
If you're new to type 2 diabetes, join our free Living With Type 2 Diabetes program to get help and support during your first year.
Personal Stories from The Type 1 Diabetes Self-Care Manual by Jamie Wood, MD and Anne Peters, MD
Rush and Fog
There are the slow lows, where blood sugars drop ever so slightly over time until you are symptomatic. There are the crashing lows, where due to insulin or exercise (or both), I’m crashing down at a rapid pace and feel terrible. These are the ones that make me feel weak, shaky, nervous, not want to talk to anyone, and give me a ravenous need to eat everything around me until I feel better. It’s like an adrenaline rush and brain fog mixed into one. I hate this feeling. My husband knows to leave me alone when I’m low (it’s the only time I don’t like to be touched or talked to), unless I ask for help. I do like that he will bring me a juice box or something to treat at night. It helps to have a little bit of the burden shared by someone else.
—Natalie H. Strand, MD, is a pain management specialist, a mother of two, and was a member of the first two-woman team to win The Amazing Race.
Many people say that I’m brave because I poke myself multiple times in a day with fingersticks or syringes. But many don’t understand that the hardest, scariest, and most paralyzing moments have nothing to do with a needle.
Usually I notice it with a shift of my head. It will feel like things move slightly slower than they should. I’ll mentally calculate, “When did I last eat? How much insulin did I take?” And even though neither of these things matter because they could have nothing to do with my low blood sugar, I try to rationalize that I’m fine.
I can feel my heart beating out of my chest, and it becomes difficult to hear and see. Check blood sugar level, get sugar. Except I forgot to replace the sugar in my purse the last time I used it, so now I’m a fool without the one thing I need. I start rummaging through my purse, hoping for some random piece of candy, something, anything, that can bring my levels up. I can go get a soda from the machine, but I don’t have any cash.
I need someone to help me, but in this intense moment of fear, my brain becomes incapacitated and all logical ideas are gone. Everything is so blurry, I can hardly make out what I’m even looking at now.
The only way to move past the fear is to robot-like move forward. Get up and go find something or someone to help. Saying to someone “I have low blood sugar and need juice” becomes the hardest sentence I’ve ever said; shame overwhelms me and the effects of the low make it difficult for me to even move my mouth, let alone say something that makes sense...
When I finally obtain the sugar I need, I can’t turn off the panic coursing through my veins. I’ll inhale the food and guzzle the soda quicker than I can even realize. Often I’ll try to drink the soda again, confused why the bottle is empty. The world is still spinning for me, my heart still feels like it’s beating so quickly that it’ll explode. It can take me 30 minutes to convince myself that I’m not dying, that I have pulled through this again.
This experience never gets easier. Knowing that I’ve survived it a million times before doesn’t help me believe I’ll get through in again. After 16 years of this, I still struggle to hold back the tears and shame and to fight for myself in that moment. It all seems so simple: If it’s an emergency, ask someone to help and very likely, they will! But it’s hard to remember in that moment...
Every diabetic has their story (or stories)... These are the moments that make us brave. These are the moments where we must have a stronger sense in us to live and fight for it than to let go and let the dizzying wheel take us away. These are the moments that no matter how much you love a diabetic, you will never truly understand.
...No one sees the chemical, hormonal, emotional scars. So brave, yes, but for so many reasons others may never understand.
—DeAnna Wendland, 33, teaches middle school history, English, and religion, and plans her road trips around craft beer and delicious wine.
Featured Book Set
Are you struggling with managing your blood glucose? With the Complete Guide to Carb Counting, 3rd ed, you’ll learn tools and techniques for counting carbs including new chapters that cover how to build a personal carb count database, carb counting for insulin pump users, a whole week of meal plans, and much more. You’ll learn basic and advanced carb counting to manage blood glucose or commonly known as blood sugar, how to count carb in meals, and how to count carbs using food labels and restaurant menus. Pair it with the fifth edition of Diabetes Carbohydrate & Fat Gram Guide, which includes nutrition information for thousands of food and menu items.
The American Diabetes Association Guide to Insulin and Type 2 Diabetes will give you complete insulin information, and you’ll hear from the experts—people with type 2 diabetes who use insulin. Their advice, support, and practical tips will help you fit insulin into your lifestyle. Use the ADA Log Book to stay organized and on track.