Hypoglycemia Unawareness: The Silent Risk for People with Diabetes

Many people living with diabetes have hypoglycemia unawareness, which means their blood sugar can drop to considerably low levels, and they’d have no idea.

Let’s explore how hypoglycemia unawareness happens, its most detectable symptoms, and what you can do to protect yourself and your loved ones.

Hypoglycemia happens when blood glucose levels drop below the standard range. This range differs from one person to another, but anything below 70 mg/dL is generally considered too low.

When this happens, the body can’t properly function because it doesn’t have enough glucose, its primary energy source.

Depending on how low blood sugar levels get, the Endocrine Society breaks down the three levels of hypoglycemia:

• Level One (Mild Hypoglycemia): Below 70 mg/dL but higher than 54 mg/dL. Some people don’t experience the symptoms of hypoglycemia at this level, and it can be easily corrected by consuming simple carbs. 

• Level Two (Moderate Hypoglycemia): Below 54 mg/dL. At this level, the person may experience tremors, sweating, and even slipping in and out of consciousness. 

• Level Three (Severe Hypoglycemia): This level doesn’t require a blood sugar test to diagnose. Severe hypoglycemia manifests as fainting, delirium, or extreme fatigue, where the person needs assistance and time to recover. 

Hypoglycemia can happen to anyone, but it’s more common in people who suffer from diabetes mellitus. Here are some of the reasons blood sugar levels might drop:

• Insulin Dose: Taking too much insulin at one time or multiple insulin doses (dose stacking) within a short period.

• Food: Not eating enough carbs with anti-diabetic medication, especially insulin, can cause hypoglycemia. Also, the amount of protein, fats, and fibers in a meal can affect how fast the body absorbs glucose or carbs.

• Physical Activity: Vigorous or prolonged physical activity burns through glucose stores for energy, which can lead to low blood glucose levels if after replenishing them. 

• Alcohol: Drinking too much alcohol without eating can cause the liver to stop releasing glucose into the bloodstream.

• Weather: Hot and humid weather can cause hypoglycemia due to a more active metabolism and better insulin sensitivity. This is also the case for people living in warmer climates. 

Some common symptoms of hypoglycemia include:

• Shakiness, anxiety, or nervousness

• Sweats and chills

• Irritability, confusion, and impatience

• Nausea

• Blurry vision

• Pale skin (color-drained skin)

• Lightheadedness and dizziness

• A tingling or numb sensation, especially in the lips, cheeks, or tongue

• Miscoordination or clumsiness

• Nightmares or trouble sleeping

• Seizures

The symptoms of hypoglycemia are helpful because they let you know that your blood sugar is low. You should start acting as soon as you feel them and work to increase your blood sugar levels or eliminate these symptoms.

Some people don’t experience these symptoms, so their blood sugar levels might drop dangerously low without warning. This is called hypoglycemia unawareness.

If you have hypoglycemia unawareness, there’s very little chance you’ll be awakened at night when hypoglycemia occurs. You might have nightmares, wake up with headaches, and get night sweats.

Approximately one out of every ten people with insulin-dependent type 2 diabetes suffers from hypoglycemia unawareness.

This number is almost double for type 1 diabetes, with about one in every five people reporting hypoglycemia unawareness.

The risk factors for hypoglycemia unawareness include:

• Length of Diabetes Diagnosis: The longer you’ve had diabetes, the more likely you are to experience hypoglycemia unawareness. 

• Poor Diabetes Management: People who have poor diabetes management can experience low blood sugar episodes regularly. This makes it more difficult to sense hypoglycemia symptoms.

• Certain Medications: Some medications, such as beta-blockers (medication for high blood pressure), can cause hypoglycemia unawareness. 

The main problem with hypoglycemia is loss of consciousness when blood sugar levels get too low. This is especially dangerous if it happens while you’re driving, operating heavy machinery, or even crossing the street because you can easily hurt yourself or others.

Recurrent hypoglycemia can affect different organs, especially the brain and the heart. For example, a person is much more likely to experience a heart attack or stroke if their blood sugar levels constantly drop too low. It also increases their chances of developing high blood pressure and high cholesterol.

One of the simplest ways to avoid hypoglycemia is by staying on top of your blood sugar levels. Learn to monitor your blood glucose levels more frequently and at different times throughout the day.

You may notice patterns in your blood sugar that can help you make better diabetes care decisions.

If your blood glucose readings are usually low when you wake up, you can talk to your healthcare provider about adjusting your bedtime insulin dose.

The best times to measure your blood sugar include:

• Before and after meals

• Before and after exercise, as well as during, in case of long, intense sessions

• Right before you go to bed

• In the middle of the night, if you wake up

• Whenever there’s a change in your life, such as new insulin doses, a change in work schedule, or if you travel

A continuous glucose monitoring device ( CGM ) is a great way to monitor your blood sugar levels in real-time. Most CGMs measure your blood sugar every five minutes so they can show you your blood glucose fluctuations throughout the day.

Some CGMs can also give off alarms when you have low blood glucose or even before your blood glucose starts to drop.

If your blood sugar drops repeatedly, you should talk to your healthcare provider about adjusting your insulin therapy . It could be that you’re taking too much insulin or taking your insulin too frequently, which causes your blood sugar to drop.

Your doctor might change the type of insulin you’re taking. For example, they might shift you from short-acting insulin to rapid-acting insulin.

Your doctor might also prescribe newer insulins instead of NPH or regular insulins because the latter are more likely to cause blood sugar lows, especially overnight.

Sometimes, instead of changing your insulin therapy, your healthcare provider might lower your dose and add another anti-diabetic medication. They might start you on a weekly injection of GLP-1 agonists, like Ozempic or Wegovy .

In some rare cases, your insulin might not be the problem at all, but rather how you’re taking it. Insulin is supposed to be injected subcutaneously, which means it should only reach as deep as your skin layers.

If you inject insulin deep into the muscle tissue instead of just under the skin, the insulin can get absorbed too quickly, causing hypoglycemia.

If this happens often, your doctor might recommend a needle-free injector such as InsuJet  to ensure each injection is accurate.

Many diabetes educators offer structured, in-person training programs for people with diabetes. These programs teach you how to better identify hypoglycemia symptoms, how to take insulin properly, and other ways to avoid drops in blood sugar.

The American Association of Diabetes Educators (AADE) offers a free online tool to help you find your area's closest program. Some programs offer blood glucose awareness training for people with diabetes and their loved ones.

Most insurance plans cover around 10 hours of training with a diabetes educator. Other insurance plans, such as Medicare, may require you to pay 20% for your sessions.

Automated insulin delivery (AID) is a new technology for insulin pumps that saves you the trouble of monitoring your blood glucose levels and calculating your insulin doses accordingly.

AID devices are usually linked to a CGM and an insulin pump. The CGM measures your blood sugar level and tells the AID device how much insulin you need.

The AID device then programs the insulin pump to release enough insulin to regulate your blood sugar level without causing hypoglycemia. This technology is also known as an “artificial pancreas” because it mimics how the organ works.

An emergency hypoglycemia kit is one way to ensure your blood sugar levels don’t drop too low.

It can include things such as:

• Glucose tablets

• Sugary snacks or drinks

• Glucagon, either nasal or injectable, since glucagon is a hormone that can quickly raise your blood sugar levels

• A glucose monitor

• Emergency contact information

Let your friends and family know where your emergency kit is and how to use it if your blood sugar drops too low.

A sugary drink or glucose tablets should do the trick to treat hypoglycemia when your blood sugar is between 55 mg/dL and 69 mg/dL.

The American Diabetes Association recommends following the 15-15 rule for treating mild hypoglycemia.

This simply means taking 15 grams of carbs to raise your blood sugar level and then measuring it after 15 minutes.

Some examples of carbs you can take include:

• Glucose tablets

• Half a cup of juice or soda (but make sure it’s regular, non-diet soda)

• A tablespoon of honey or sugar

• Hard candy

Avoid foods that contain fats and carbs, such as chocolate, because fats can delay glucose absorption. This means reaching your bloodstream and raising your blood glucose levels will take longer.

If, after 15 minutes, your blood sugar is still below 70 mg/dL, take another 15 grams of carbs and wait another 15 minutes.

Repeat this several times until your blood sugar returns to normal.

However, if you get to the point of severe hypoglycemia or if you faint, the 15-15 rule won’t be enough, and you’ll likely need glucagon. Let someone close to you know how to spot these symptoms and how to administer a glucagon injection. This can potentially save your life.

Hypoglycemia unawareness is a serious condition. However, with the right knowledge, you can easily protect yourself and your loved ones.

As long as you’re prepared and you check your blood sugar regularly, you’ll be able to catch your blood sugar before it falls too low.

Lastly, being prepared with a hypoglycemia kit on your person at all times can prevent dangerous lows from negatively affecting your health in the long term.