Preparing for Lows With Type 2 Diabetes

From diatribe.org

Key takeaways:

• People with type 2 diabetes commonly experience low blood sugar that can be fixed with a quick snack, but taking insulin or sulfonylureas raises the risk of more serious hypoglycemia.
• It’s important to regularly monitor your blood sugar and prepare for unexpected lows with a kit that includes a sugary snack, a medical alert identifier, and ready-to-use glucagon.
• Glucagon is an essential part of any kit, so if you haven’t had a conversation about it, bring it up with your healthcare team.

It’s scary to think about severe hypoglycaemia, but it can happen to anyone who manages their diabetes with insulin or sulfonylureas. 

If you have type 2 diabetes and use one of these medications, you should know what severe hypoglycemia is, how to avoid it when possible, and how to treat it when it occurs. Ideally, these conversations should be happening during check-ups with members of your healthcare team.

“Unfortunately, I think the data tells us that more often than not, conversations about hypoglycaemia are not happening,” said Dr. Rozalina McCoy, an endocrinologist at the Maryland School of Medicine.

This is part of the reason so few people at risk of severe hypoglycaemia are prepared for it if and when it occurs. One study found that only 3.5% of people who treat type 2 diabetes with insulin filled a prescription for glucagon between 2019 and 2023. If no one on your healthcare team has mentioned severe hypoglycaemia or ready-to-use glucagon, it’s a good idea to bring up at your next visit.

Defining severe hypoglycaemia

A hypoglycaemic event is a problematic dip in your blood sugar. All lows should be taken seriously and treated appropriately, but some are more severe than others. Level 1 hypoglycaemia, the mildest form, is typically defined as a blood sugar level below 70 mg/dL. 

Symptoms like dizziness, shakiness, sweating, hunger, and anxiety may occur during hypoglycaemia, but they become more common when levels drop below the level 2 threshold of 54 mg/dL. It’s important to note that some people have impaired awareness of hypoglycaemia and never experience symptoms, leaving them unaware of lows unless they’re using a monitor to track their blood sugar.

Level 3 or severe hypoglycaemia is when your ability to function is impaired, and you require assistance from another person to return to normal blood sugar levels. Often, this is thought of as something that occurs after you’ve reached level 2, but everybody has a different tolerance for lows.

“You can have someone have a blood sugar of 20 mg/dL, and yet they’re young and resilient and able to self-treat,” McCoy explained.

On the other hand, she said that older people, especially those who have developed additional chronic conditions that make daily life more difficult, may require medical attention for blood sugar levels as high as 70 mg/dL. 

When does severe hypoglycaemia occur?

Most cases of severe hypoglycaemia are associated with insulin therapy or sulfonylureas. These medications are very effective at helping your body manage blood sugar, but it’s still easy to run into unexpected circumstances (maybe a delayed or missed meal or strenuous physical activity) that leave you with lower blood sugar than you were anticipating.

“It’s a mismatch between insulin requirements and insulin presence in the body, but it doesn’t mean it was anyone’s fault,” McCoy added.

Monitoring for lows

According to the American Diabetes Association’s (ADA) Standards of Care, everyone who takes insulin should wear a continuous glucose monitor (CGM). These devices help track changes in your blood sugar over time and alert you when you start to go low.

You should discuss your target range with your healthcare provider. Generally speaking, most people with diabetes should be aiming to spend most of their time between 70-180 mg/dL, but McCoy said she advises her older patients who might have a harder time handling a low to treat 100 mg/dL as their lower bound.

If you worry about being overwhelmed by all the CGM data, McCoy suggested thinking about it as an alert for lows. Even if you’re not looking at it that often, a CGM will tell you if you’re consistently going below your target range and may need to adjust your insulin therapy.

A CGM can be helpful for anyone with diabetes, but if someone isn’t taking insulin, then monitoring their blood sugar with fingerstick tests can be sufficient.

“If they’re on a sulfonylurea, they should check whenever they’re not feeling well or whenever they think they might be having a low,” McCoy said.

Hypoglycaemia preparedness

When you go low, the ultimate goal is to get more sugar in your body. Even if you have a severe episode that requires a trip to the hospital, healthcare providers will be treating you primarily with oral carbohydrates or an intravenous (IV) drip of sugar.

If you’re alert and able to eat, then candy, soda, juice, and even honey and sugar packets can all be effective options for raising your blood sugar back to normal levels. Wherever you are, you should always have some sort of sugary drink or snack on hand.

Regardless, there may be times when you go too low too quickly to raise your blood sugar with food. In these cases, emergency glucagon is necessary. There’s also a chance that a hypoglycaemic emergency will move so quickly that you won’t have time to react to it on your own. It’s important to educate people you’re close to about hypoglycaemia and glucagon. 

In case none of them are around when you need help, you should also wear a medical alert necklace or bracelet that clearly states you have diabetes and may be experiencing a low. If you have a car, then you could also put a medical alert cover on your seatbelt. 

When to use ready-to-use glucagon 

The ADA recommends self-administering ready-to-use glucagon if 15 grams of sugar hasn’t resolved your low within 15 minutes, if you can’t keep food down, or if you feel yourself becoming confused or on the verge of passing out. 

If you do need to give yourself glucagon, be prepared to feel sick. Also, make sure to call your healthcare provider or 911. You may still need emergency medical attention or your diabetes medications adjusted.

The ADA also recommends using glucagon if you pass out, but someone else needs to administer it at that point. Make sure your diabetes emergency kit includes glucagon and is accessible and clearly marked for other people. Once again, you should start by making sure that people you’re close to know what glucagon is, how to use it, and where your supply is stored, but you also have to anticipate times when people you’re less familiar with will need to help you.

Make sure your glucagon is clearly labelled as something to use when you’re unresponsive. If you also carry insulin with you, store the two medications in separate containers and make sure the insulin is clearly labelled as something that should not be given to you while you’re unresponsive.

It’s possible that the person who finds you might not be comfortable giving you glucagon. However, McCoy said that a dose of glucagon is unlikely to cause much harm, even if hypoglycaemia isn’t ultimately the reason a person with diabetes has become unresponsive. 

Actual instructions for using glucagon will depend on what type you have. There are currently three options. A traditional mixing kit includes a vial of glucagon powder and a syringe of liquid, and the powder must be dissolved into the liquid at the time of administration. This takes time and creates the possibility for mistakes, so traditional mixing kits are not the best option for an emergency situation.

Instead, it’s better to have ready-to-use glucagon. When you talk to your healthcare provider, ask about Gvoke HypoPens and Baqsimi nasal powders, both of which are readily administered with no mixing required.

How to get glucagon

Glucagon is a prescription medication, so you’ll need to talk to a healthcare provider to get it. Ideally, when you receive a prescription for insulin or a sulfonylurea, you should also get one for glucagon. However, getting started on any new medication may involve a steep learning curve, and discussions about glucagon often slip through the cracks at early medical appointments.

“I’m not perfect. I run out of time, or I start insulin, and then I’m like, ‘Okay, I’ll talk about glucagon at the next visit,’” McCoy said.

If the clinician who prescribed you insulin or a sulfonylurea didn’t discuss glucagon, then ideally your pharmacist would bring it up when you go to fill your prescriptions. Pharmacists are legally obligated to offer consultations to anyone picking up medications, and they should know all of the risks and benefits of medications they’re dispensing. 

If your pharmacist sees your insulin prescription come in without a glucagon prescription, then they should ask you about it. Your pharmacist can also ask your clinician to prescribe glucagon without waiting until your next appointment.

Other members of your healthcare team, including diabetes educators and dietitians, can also get the ball rolling on a glucagon prescription, but if no one brings it up, don’t be afraid to initiate the conversation. For many people, pharmacists may be the best starting point for these conversations because you can walk into a pharmacy and request a consultation without an appointment.

For most people in the U.S., McCoy said that insurance will cover a new prescription of an autoinjector pen or a nasal powder, but coverage varies. If your plan doesn’t cover ready-to-use glucagon and you can’t afford it on your own, you may be eligible for patient assistance programs offered by Baqsimi and Gvoke. 

In general, insurance will cover a glucagon refill every year or after every use. Glucagon doesn’t last forever, so even if you haven’t used yours, make sure to check the expiration date and replace it when necessary. You’ll need a replacement every two or two and a half years depending on which option you choose.

The bottom line

Any person with type 2 diabetes may experience low blood sugar, but people who take insulin or sulfonylureas are particularly at risk for severe hypoglycaemia, which a person cannot resolve on their own without assistance from someone else. It’s important to regularly monitor your blood sugar and prepare for unexpected lows by carrying sugary snacks, a medical alert identification tag, and clearly labelled ready-to-use glucagon. 

Members of your healthcare team should discuss hypoglycaemia and prescribe glucagon if you’re taking insulin or a sulfonylurea, but if they don’t, initiate the conversation yourself. For many people, it may be easiest to start by talking to the pharmacist, who is often the most accessible member of your healthcare team.

https://diatribe.org/diabetes-management/preparing-lows-type-2-diabetes 

A Doctor Explains What High Blood Sugar Can Do to Your Brain

From verywellhealth.com

A lot of people connect blood sugar with metabolic health and diabetes, but there’s less discussion about blood sugar and your brain. So we spoke to our chief medical officer, Sohaib Imtiaz, MD, about how poor blood sugar regulation affects the brain and what we can do now to protect it in the long term.

Severe blood sugar fluctuations over time can have lasting effects on your cognitive health.  FatCamera / Getty Images

*This interview has been edited and condensed for clarity.

Q: Why is managing your blood sugar so important for brain health?

Imtiaz: Your brain is actually the most metabolically demanding organ in the body. Even though it accounts for about 2% of your body weight, it consumes about 20% of your basal metabolic energy, and its primary fuel is glucose (sugar).

When you have diabetes or insulin resistance (a condition wherein your cells stop responding efficiently to the hormone that regulates blood sugar), it has a significant impact on your brain.

Some researchers have actually started calling Alzheimer’s disease “type 3 diabetes.” It’s an informal term, not an official diagnosis, but it captures just how important insulin signalling is in the brain.

Q: Is it just high blood sugar that is the problem?

Imtiaz: The constant swinging between high and low blood sugar readings, known as “glycaemic variability,” may be the biggest problem for brain health.

Ideally, your blood sugar should be between 70 and 180 mg/dL. Hyperglycaemia (high blood sugar) and hypoglycaemia (low blood sugar) occur when your glucose levels fall outside of the normal range.

Both high and low blood sugar contribute to cognitive dysfunction through different mechanisms.

Chronic hyperglycaemia causes inflammation in the brain and leads to a progressive decline in your brain cell connections, resulting in cognitive impairment. It also contributes to the loss of white matter in the brain, which can eventually lead to vascular dementia.

Since the brain relies so heavily on glucose, hypoglycaemia can disrupt brain functioning. Repeated episodes lead to structural brain changes affecting the brain’s prefrontal cortex, the region responsible for decision-making, and your hippocampus, the brain’s memory centre.

This is why it’s so important to work toward maintaining steady blood sugar levels rather than just aiming to keep it low.

Q: What are the top three simple habits you’d recommend to keep your blood sugar in check for better brain health?

Imtiaz: First, make balanced meals. Be sure to include protein, vegetables (fibre), and some healthy fat, such as olive oil, alongside carb-heavy foods. Fibre and fat are key to lowering glucose spikes from carbs.

Second, don’t sit down after you eat. Try to get up and walk around for a few minutes. It will help stabilize your blood sugar.

Third, get good sleep. When you’re sleep-deprived, you have a lot more blood sugar spikes the following day—even if you eat foods that don’t typically affect your blood sugar.

https://www.verywellhealth.com/how-blood-sugar-affects-brain-health-12007894 

11 Ways to Sleep Better With Type 1 Diabetes

From everydayhealth.com

Getting a good night’s sleep can be a challenge for people with type 1 diabetes. From navigating blood sugar highs and lows to equipment alarms and device discomfort, there’s plenty that can interfere with quality rest. 

Poor sleep isn’t just frustrating — it’s linked to suboptimal blood sugar management. People with type 1 diabetes who have poor sleep quality are more likely to have greater glucose fluctuations and more episodes of high and low blood sugar levels.

Fortunately, there are strategies for addressing the sleep problems that people with type 1 diabetes often face, to help ensure that nights are as restful as possible. 

1. Adjust Your CGM Alarm Settings

People who have a continuous glucose monitor (CGM) can set alarms that alert them when their blood sugar is too high or too low. However, these alarms can be disruptive to sleep.

Paediatric endocrinologist Kristin Arcara, MD, clinical codirector of the division of paediatric endocrinology and diabetes at Johns Hopkins Children’s Center in Baltimore, says that adjusting overnight alarms can help ensure that your sleep is interrupted less frequently: “Some CGM devices allow you to customize settings to make them different for daytime and night time.” 

It’s important to talk with your healthcare provider about how you customize your alerts for overnight use, she says, so that you can avoid alarm fatigue while remaining aware of blood sugar highs and lows.

2. Snack for Glucose Stability

“If your blood glucose levels are within target range but tend to drop overnight, having a snack that includes a quality carbohydrate and protein can help keep blood glucose levels steady,” says Toby Smithson, RDN, CDCES, senior manager of nutrition and wellness at the American Diabetes Association. 

But be careful with late snacks, because they can have the opposite effect: Too many carbohydrates can spike your blood sugar overnight, and snacks that require insulin can risk overnight blood sugar lows and roller coasters.

“The snacks that are better suited for bedtime are the things that are better suited for the rest of the day: fibre, protein, healthy fat, and complex carbohydrates, as opposed to high-sugar foods,” says Dr. Arcara.

3. Try New Device Locations

Not every CGM or insulin pump location is equally comfortable. It may sound like common sense, but if your device is uncomfortable overnight, consider putting it in a new location on your body.

“You have to consider how you sleep,” says Arcara. “If you sleep on your right side, don’t put it on your right arm, because it’s going to go off all night.” 

Your manufacturer’s instructions will tell you which parts of your body your device can attach to. Some people with diabetes choose to ignore these guidelines and stick their devices to different parts of their body, though this can’t guarantee optimal results.

“Devices are approved for certain sites, but patients certainly go outside of that and use them in different sites,” says Arcara. “It’s important to figure out what works for each patient.” For people who use an insulin pump and a CGM that communicate with one another, it may be helpful to put both devices on the same side of the body, she says. 

4. Don’t Overtreat Compression Lows

If your CGM has ever woken you up with a low blood sugar alert that didn’t make sense, you may have experienced a compression low. “Compression lows happen when a person puts weight on the CGM,” says Smithson. “For instance, if your CGM is on your upper arm and you’re sleeping on your arm, you may receive inaccurately low blood glucose results.”

If a compression low wakes you up, it can be tempting to reach for your bedside juice and go back to sleep. However, since these lows aren’t true lows, consuming fast-acting sugar will cause your blood sugar to rise — possibly way out of your target range — only to set off another alarm.

“If you get an alert for a low in the middle of the night ... and it doesn’t match how you’re feeling, it’s really important to do that finger stick,” says Arcara. “If it’s actually low, treat it, and repeat the finger stick in 15 minutes.” If the finger stick reads normal, go back to sleep.

5. Beware of the ‘Pizza Effect’

Sometimes, meals high in fat can lead to delayed blood sugar spikes, often occurring hours after eating. If you have a rich, starchy meal like pizza for dinner, it could result in blood sugar highs that present after you go to sleep, leaving you unable to respond with exercise or insulin. 

Pay attention to how different meals affect you. “Monitor glucose trends with what you eat, to understand which foods or combinations of foods affect your blood glucose levels,” says Smithson. 

If you’re using an insulin pump with automated insulin delivery, your system should take care of these blood sugar elevations automatically. Insulin pumps that aren’t connected to a CGM also allow you to preprogram doses of insulin if you know your blood sugar is likely to rise after bedtime.

If you’re not using an insulin pump or are not comfortable trusting those features and you plan to splurge on a richer meal, consider eating it earlier in the day, which could preserve your ability to react to subsequent blood sugar changes. 

“The approach might be different based on each person,” says Arcara, noting that some people may decide to avoid certain foods altogether, while others may choose to enjoy them only occasionally. 

6. Take a Tech Vacation

The constant barrage of information, warnings, and decision-making that sometimes comes with using diabetes devices can be emotionally draining or overwhelming. “For some people, taking a break from diabetes technology is helpful, although taking insulin and checking blood glucose levels is still required,” says Smithson.

If you want to take a tech vacation with type 1 diabetes, you need to be comfortable with giving yourself multiple daily insulin injections and testing your blood sugar via finger sticks.

For some people, the solution may be simpler. “If you’re feeling like you want a pump break, talk to your provider,” says Arcara. “Maybe a different pump would work better for you. Maybe taking a look at your continuous glucose monitor alerts would work better for you ... it really depends on what it is about the technology that’s causing you stress.” 

7. Strategize Your Exercise

While exercise can help improve sleep quality, people with type 1 diabetes need to be careful, as certain levels of activity can lower blood sugar levels both during and after a workout. Lowering blood sugar is usually one of the primary goals of diabetes management, but you still need to take care that a day of heavy exercise doesn’t drop your levels too low overnight.

“Having [an] idea of what your body does and how your body responds to different activities can help you make a proactive plan to avoid any issues with blood sugar overnight,” says Arcara. 

For instance, people on injections may decide to decrease long-acting insulin on nights that they exercise. People using pumps and automated insulin delivery systems will have special settings designed for exercise. “Turning that on while you’re exercising and leaving it on for a few hours afterward might be a way to avoid hypoglycemia overnight as well,” says Arcara. 

Timing exercise for the morning may also help, since evening and afternoon exercise may carry a greater risk of low blood sugar at night.

8. Keep Hypo Snacks Nearby

Like any time that you have low blood sugar, hypoglycemia that happens at night requires prompt treatment, but that can be tricky if what you need is located several rooms away from where you sleep.

“The last thing you want to do if your blood sugar is low and your brain is starving for energy is get out of bed and walk downstairs to the kitchen, because that’s not a safe thing to do sometimes,” says Arcara. 

Instead, it’s helpful to keep something to treat low blood sugar within easy reach. “Keep fast-acting glucose treatments like glucose tabs, hard candy, or juice boxes near your bedside,” says Smithson. 

9. Fine-Tune Your Basal Dose

If you’re frequently waking up to low or high blood sugar, it may be time to tweak the amount of basal insulin you’re using.

Basal insulin is the insulin that your body uses in the background over the course of a day, regardless of whether you’ve eaten a meal, to keep your metabolism running as it should. An insulin pump delivers a constant small trickle of insulin to serve as basal insulin, while those on injections use long-acting insulin that’s formulated to become bioavailable very slowly throughout the day.

Work with your provider if you think you need a change to your overnight basal rates, says Smithson. “It’s trial and error with finding the best basal rate for each person,” she says. 

“Depending on the pump system, there are different strategies you can use to ask the pump to be slightly more gentle with your blood sugar overnight,” says Arcara.

10. Switch to an AID System

An automated insulin delivery (AID) system allows your CGM and insulin pump to communicate with one another, with the goal being to keep your blood glucose in your target range, says Smithson. “It takes some of the constant thinking and adjustments of insulin dosing out of the picture, especially overnight when you should be sleeping,” she says.

For some people, an AID system can make sleep much better, since it can help prevent low blood sugar overnight and generally keep blood sugar more steady.

“Probably the most appealing feature of the automated insulin delivery systems is the overnight blood glucose management,” says Arcara, as they can decrease how often patients have to wake up in the middle of the night to address blood sugar.

11. Do a Safety Check as Part of Your Bedtime Routine

Needing to change an insulin or CGM site in the middle of the night can easily disrupt otherwise healthy sleep. 

A quick bedtime check of your status and diabetes equipment can help you avoid unnecessary overnight interruptions. “Have a routine of making sure that everything is in a safe spot for you to have a great night with your diabetes,” says Arcara. Before falling asleep, she suggests checking the following:

• Blood sugar level
• Insulin pump charge or pump battery level
• Insulin pump reservoir
• CGM status and time of expiration

The Takeaway

• Adjust CGM alarms for fewer night time interruptions, and place devices on parts of the body that you don’t sleep on, to prevent discomfort and compression lows.
• Stabilize overnight glucose with high-protein, high-fiber bedtime snacks, and be wary of the “pizza effect,” where high-fat meals cause delayed blood sugar spikes long after you’ve fallen asleep.
• Strategize the timing of exercise to avoid delayed hypoglycemia, and work with your doctor to adjust your basal insulin dose or pump settings on days when you’re more active.
• Establish a bedtime safety routine that includes checking all of your diabetes equipment and your blood sugar, and keep fast-acting glucose treatments like juice or tabs right next to your bed in case of an overnight low.

https://www.everydayhealth.com/diabetes/ways-to-sleep-better-with-type-1-diabetes/