The seriousness and severity of Hypoglycaemia

Managing blood sugar levels has its challenges. Low blood sugar can happen if the balance of diabetes medication you take (especially insulin), food you eat and physical activity you do sometimes isn’t right. A hypoglycaemic event, known as a hypo, is commonly defined as when blood sugar falls below 4mmol/l and is the most common side effect of taking insulin. It can happen quickly so it is important to recognise the signs. Everyone has different symptoms, but the common ones include:

  • Feeling shaky
  • Feeling disorientated
  • Sweating
  • Being anxious or irritable
  • Going pale
  • Palpitations and a fast pulse
  • Lips feeling tingly
  • Blurred vision
  • Being hungry
  • Feeling tearful
  • Tiredness
  • Having a headache
  • Lack of concentration
  • Night sweats

Hypoglycaemia is responsible for an estimated 70,000–100,000 emergency callouts in the UK per annum at up to £24million/annum; 7,000 non-elective long stays annually at a cost of £16.5million and 10,500 non-elective short stays annually at a cost of £4.5million. 10

Listen to someone's eyewitness statement on their emotions during their first experience of a severe hypoglycaemic episode of a friend.

Causes of Hypoglycaemia or abnormally low blood sugar

​Studies have identified a number of causes of severe hypos including: irregular or insufficient food, insulin dose miscalculation, physical exercise, stress and impaired hypo awareness. The last of these is believed to be a major risk factor, with people with impaired hypo awareness being nine times more likely to have a severe hypo. 11 12 13

Estimates vary but somewhere between 25-40% of people with type 1 have impaired hypo awareness. 14, 15

Such unawareness means there is an inability to detect the onset of a hypo, and consequently, a person is less likely to start corrective action sooner and more likely to go on to suffer severe episodes. Young age is also a risk factor due to lower awareness of the signs and symptoms. 16

In addition to significantly increasing the risk of severe hypos, impaired awareness of hypoglycaemia increases people’s reliance on others to manage their diabetes and can even lead to loss of driving privileges and employment.

Treating a Hypo

It is important to treat a hypo as soon as you notice the symptoms as they could get worse, beyond the initial confusion, to having a fit or becoming unconscious in what is called a severe hypo, when you need the help of others.

Diabetes UK offers the following guidance: 17

Treating a hypo is done by taking 10-15g of fast acting carbohydrates such as jelly babies, glucose gel, glucose tables, or a sugary drink.

If the hypo becomes severe, friends, family or people around you need to help you very quickly. It is important to:

  • Put you in the recovery position
  • Give you glucagon
  • Call an ambulance if you do not have glucagon or you do not recover within 10 minutes.

Care should be taken not to try to give you food or drink when having a severe hypo as you won’t be able to swallow.

Hypos can happen at night, so it is always good to have treatments by your bed.

The challenge of Hypos

Having a hypo is a reality of living with diabetes and affects one in seven people with the condition. It is more common in people with experience of severe hypos or those with impaired awareness.

This is most evident in the families of young children (‹ 6 years) who have a high risk of significant hypos who are unable to recognise the symptoms of hypoglycaemia quickly enough to counter it, and the fear is heightened at night. 19

Diabetes UK note that severe hypos are associated with: 20

  • impaired quality of life and emotional wellbeing
  • reduced engagement with diabetes management
  • impaired diabetes outcomes.

What is diabetes?

Diabetes is a serious, chronic condition that occurs when the body cannot produce enough insulin or cannot effectively use the insulin it does produce.

Type 1 diabetes is caused by an autoimmune process in which the body’s immune system attacks the insulin-producing beta-cells of the pancreas. As a result, the body produces very little or no insulin. The causes of this destructive process are not fully understood but a likely explanation is that the combination of genetic susceptibility and an environmental trigger such as a viral infection, initiate the autoimmune reaction 1, 2. Type 1 diabetes is the major type of diabetes in childhood but can occur at any age. It cannot be prevented. People with type 1 diabetes require insulin to survive.

Living with type 1 diabetes remains a challenge for a child and the whole family, even in countries with access to multiple daily injections or an insulin pump, glucose monitoring, structured diabetes education and expert medical care.

Besides the acute complications of hypoglycaemia (abnormally low blood glucose), suboptimal control may lead to poor growth and the early onset of circulatory (or ‘vascular’) complications affecting the heart, eyes, feet and kidneys.

Type 2 diabetes is the most common type of diabetes, accounting for over 90% of all diabetes worldwide. In type 2 diabetes, hyperglycaemia (or raised levels of sugar in the blood) is the result, initially, of the inability of the body’s cells to respond fully to insulin, a condition termed insulin resistance. With the onset of insulin resistance, the hormone is less effective and, in due course, prompts an increase in insulin production. Over time, inadequate production of insulin can develop as a result of failure of the pancreatic beta cells to keep up with demand. Insulin injections may be necessary to control hyperglycaemia to recommended levels if non-insulin medications fail to achieve glycaemic control.

According to the International Diabetes Federation (IDF), Hyperglycaemia in Pregnancy affects one in six pregnancies. Pregnant women with gestational diabetes can have babies that are large for gestational age, increasing the risk of pregnancy and birth complications for the mother and baby. With effective support and treatment from healthcare systems, these risks can be largely mitigated.

Diabetes is a global health issue

Diabetes has reached pandemic levels worldwide. With 1 in 10 adults living with diabetes, there is a heavy health and financial burden on every nation in the world. The recently published International Diabetes Federation (IDF) Diabetes Atlas3 states that over 537 million people are living with diabetes and this number is expected to rise to 643 million by 2030. The cost of treating diabetes and its complications is significant with an estimated global annual expenditure of $966 billion, $327 billion in the US alone. Expenditure is on the rise, increasing by 316% over the last 15 years.

In Europe, 9.2% of the population or 61 million are living with the condition, a figure IDF expect to rise to 67 million by 2030. Annual diabetes related expenditure in Europe is believed to be $189 billion which equates to $3,086 per person with diabetes in the region.

Estimates for the UK put the prevalence at 8.2% of those between 20-79 years. That equates to 4 million people diagnosed with the condition. Of these 10% or 400,000 live with type 1 diabetes and of these 32,000 are children and adolescents. Diabetes UK believe a further 850,000 live with type 2 diabetes and have yet to be diagnosed. 4

According to Diabetes UK, annual expenditure on diabetes is believed to be $5,589 per person and $23.4 billion in total, of which around £10/$13.2 billion is spent by the NHS; 80% goes on treating complications. 4

Useful Resources

References

  • 1. International Diabetes Federation. Diabetes Atlas 10th edition. Brussels, Belgium; December 2021 www.diabetesatlas.org Page 10
  • 2. Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet. 2014 Jan 4;383(9911):69–82
  • 3. Craig ME, Jefferies C, Dabelea D, Balde N, Seth A, Donaghue KC. Definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes 2014; 19(Suppl 27):7–19
  • 4. International Diabetes Federation. Diabetes Atlas 10th edition. Brussels, Belgium; December 2021 www.diabetesatlas.org Page 10-14
  • 5. IDF Care Prevention Gestational diabetes https://www.idf.org/our-activities/care-prevention/gdm
  • 6. International Diabetes Federation. Diabetes Atlas 10th edition. Brussels, Belgium; December 2021 www.diabetesatlas.org
  • 7. International Diabetes Federation. Diabetes Atlas 10th edition. Brussels, Belgium; December 2021 www.diabetesatlas.org Page78
  • 8. https://www.diabetes.org.uk/professionals/position-statements-reports/statistics
  • 9. NHS Condition definitions https://www.nhs.uk/conditions/low-blood-sugar-hypoglycaemia/
  • 10. Admissions avoidance and diabetes: guidance for clinical commissioning groups and clinical teams https://diabetes-resources-production.s3-eu-west-1.amazonaws.com/diabetes-storage/migration/pdf/admissions-avoidance-diabetes-0114.pdf
  • 11. Clarke WL, Cox DJ, Gonder-Frederick LA, Julian D, Schlundt D, Polonsky W. Reduced awareness of hypoglycemia in adults with IDDM. A prospective study of hypoglycemic frequency and associated symptoms. Diabetes Care. 1995;18(4):517–522.
  • 12. Gold AE, MacLeod KM, Frier BM. Frequency of severe hypoglycemia in patients with type I diabetes with impaired awareness of hypoglycemia. Diabetes Care. 1994;17(7):697–703.
  • 13. Hepburn DA, Patrick AW, Eadington DW, Ewing DJ, Frier BM. Unawareness of hypoglycemia in insulin-treated diabetic patients: prevalence and relationship to autonomic neuropathy. Diabet Med. 1990;7(8):711–717.
  • 14. Mechanisms of hypoglycemia unawareness and implications in diabetic patients
  • 15. Iciar Martín-Timón and Francisco Javier del Cañizo-Gómez World Journal of Diabetes, 2010 July 10
  • 16. Cognitions Associated With Hypoglycemia Awareness Status and Severe Hypoglycaemia Experience in Adults With Type 1 Diabetes Diabetes Care 2019 Oct; 42(10): 1854-1864. https://doi.org/10.2337/dc19-0002 Amelia J. Cook, Stephanie N. DuBose, Nicole Foster, Emma L. Smith, Mengdi Wu, Georgina Margiotta, Michael R Ricels, Jane speight, Nicole de Zoysa, Stephanie A Amiel
  • 17. https://www.diabetes.org.uk/guide-to-diabetes/complications/hypos/having-a-hypo
  • 18. Ogluo Patient Information Leaflet Date: Dec 2021
  • 19. Managing diabetes in preschool children Frida Sundberg, et al ISPAD Guidelines
  • 20. A critical review of the literature on fear of hypoglycaemia in diabetes: implications for diabetes management and patient education. Description: Based on a review of 34 papers, the authors have integrated the findings about fear of hypoglycaemia, predictors and correlates, its impact on behaviour and potential benefits of intervention to reduce fear. Source: Wild D, von Maltzahn R, et al. Patient Education & Counselling. 2007;68:10-15.