Remember your first hypoglycemia when you first got diabetes? I do. I felt everything, intensely. I felt that feeling of “the energy being sucked out of my body,” the sweat, the shakiness, the confusion in my brain. I felt like I was about to faint. 
Whether you hated it, loved it (because you could eat everything that’s forbidden) or you didn’t care for it, it was clear that you were in hypoglycemia.
Fast forward one or several decades of life with diabetes. Now, for some reason, you’ve lost the capacity to detect most, if not all, your low blood sugar levels. These are some of the things that happened to me. Maybe some of them are familiar to you too.
I found myself driving (car or motorcycle) with my glucose level ridiculously low, and, even if I got to destination, I didn’t remember how I got there. Other times I found myself in places I didn’t remember driving to.
I started mumbling on the job or during business meetings, repeating things without finishing sentences, or going off on tangents. Everyone who’s not aware of my diabetes thought I was drunk or high. (Someone got curious about what kind of drug I might’ve been on.)
I found myself shifting from happy to angry or sad, while with friends, or family.
While playing a sport, my coordination went out, my reflexes got slow, I became silent and passive, I made mistakes, but I didn’t say anything.
I woke up soaked in sweat, my PJs and linens drenched, I couldn’t talk. Sometimes I couldn’t even walk and I had to crawl to the kitchen for sugar.
Not aware of my descending sugar level, I fell to the ground during my morning yoga and went into a seizure.
In these and other situations I was unaware of my low blood glucose level and I just kept going, until I either took glucose, carbs or sugar, or I fell in hypoglycemic coma.
What happened that made me become unaware of hypoglycemia and its symptoms? Well, very simply, I just got used to being in hypoglycemia.
This is the case for the majority of people with hypoglycemia unawareness (unless the cause is autonomic neuropathy).
This happens frequently when we tend to keep our blood sugar levels in a tight and low range, which easily creates frequent low blood glucose levels. The more we experience hypoglycemia the more we become used to it. Our brain learns to function at low sugar levels, and we bypass the symptoms. (For a clinical explanation of how hypoglycemia unawareness works you can find a good explanation here http://en.wikipedia.org/wiki/Diabetic_hypoglycemia#Hypoglycemic_unawareness.) The more we do this, the more unaware we become, until we place our life, and sometimes other people’s life, in danger.
Is our awareness gone forever? No (in most cases). More importantly, we can do things to turn the awareness switch back on. How much hypoglycemia awareness can be restored depends on several factors. But even a slight increase in awareness can make a life changing difference, for the person with diabetes and everyone around them. (There’s even been a program that has scientifically proven that hypoglycemia awareness can be reactivated, the Blood Glucose Awareness Training, or BGAT.)
Here are five things I did that restored my hypoglycemia awareness.
- For three months, I raised my optimal range higher than I was used to, from 70-140mg/dl to 80-180mg/dl. I agreed that I wouldn’t take insulin until my blood glucose level went over 180. I was very afraid of pushing my A1C to a high level, as a result of this adjustment. But the fact that it was going to be temporary made it doable for me. Getting used to having higher blood glucose levels is essential to restoring hypoglycemia awareness. It doesn’t have to continue forever, just as long as the body re-learns to secrete epinephrine and other substances to create the symptoms and for our brain to relearn to detect them.
- I made an agreement with my wife (you can do it with anyone you live with whom you trust to have your best interest at heart). I looked at my wife in the eyes, shook her hand and said, “We both want my health to be at its best. As soon as I feel, see or hear the signs of hypoglycemia I immediately take action and compensate for it. If you tell me to do it, I will follow your direction.” Point 1. and 2. were recommended by my diabetes nurse, and they worked like magic. Particularly at night, when often I have not listened to my wife telling me to check my blood glucose level or take glucose, because I was in a dream-like state and I didn’t think it was necessary.
- I said a mantra (I basically made the same agreement with myself). The mantra is, “As soon as I feel, see or hear the signs of hypoglycemia I immediately take action and compensate for it.” For the first three months I said the mantra three times as soon as I woke up, three times before falling asleep and anytime during the day when I remembered to do it. This also worked like magic. Anytime I feel that I might be slacking off on awareness, I repeat the mantra, and my hypoglycemia sensors are reactivated.
- I took note of any “new symptoms” of hypoglycemia. After decades of life with diabetes the symptoms might change a little bit, and you might get some specific ones that I don’t get, and vice-versa. For example, I’m an actor and memorizing lines is an integral part of my work. Anytime I feel my lines are slipping, I now know to check my blood glucose level. Also, anytime my mood swings, there’s a good chance my blood glucose level is low, or getting low (or high, or rising). If I keep thinking that I should say something, but I don’t say it, there’s a great chance I’m low or on my way to a low. If thoughts are looping in my mind, it’s likely I’m in or getting to hypoglycemia. If I walk back and forth (in the kitchen for example) with thoughts looping in my brain, without really doing anything, I’m definitely low. And so on and so forth for other situations.The important thing is, take note of these behaviors (make a mental or written note, whatever is more effective for you). Thus doing your brain will become aware and alert you next time you experience one of them, and you will connect it to “I’m in hypoglycemia, I need to compensate for it.”
- Do anything that increases your awareness. For example keep a log of mood swings, mind confusion, lack of coordination, sweat, and similar in connection with blood sugar levels. You can do it with pen and paper or with an app or device that makes it fun for you.Having a continuous blood glucose monitoring system (CGM) also helped restore hypoglycemia awareness. Not in and of itself, but because I continuously compared my awareness of how I am feeling with the levels and trends shown. Often the CGM system is wrong and I found myself saying, “I don’t feel low now,” or “It shoes 140, but I’m feeling low.” Sure enough, I checked with a blood meter and 99% of the times I was right.Something that’s fun and has great impact on my awareness is to guess what my sugar level is, anytime before checking it. Either high or low, I guess what I feel my glucose level is and then compare it with the actual number. This has been very effective for my awareness and its accuracy.
These are five tools that restored my hypoglycemia awareness. They will help you increase your awareness by connecting “how you feel” to your blood glucose levels.
Now I feel the hypoglycemia eight times out of ten in perfect timing, and the remainder twenty percent of the time I still feel it, just slightly delayed, but never when it’s at a dangerous level.
After the first three months I continued with the higher range set for a few more months. Now I brought it back to where it used to be. With my restored awareness I can keep my A1C around 5.6% without any dramatic or dangerous hypoglycemic events.
The most important thing is to want to switch your awareness back on and to be consistent and honest with yourself in doing the work. There’s not a lot of work required, but the pay-off is big.
This has been really good for me, when by myself, with friends, or on the job. My increased awareness has drastically improved our family life. My wife and I feel a lot safer and trusting.
Very importantly, as soon as I slack off with my nutrition, insulin and overall diabetes management, I have to go through the process again and reactivate my awareness. Not as much work as the first time, but certainly the mantras, the simple awareness tools and a new determination to keep my levels, nutrition and physical activity in check. Like everything else, it’s a work in progress.
Even though it worked very well for me, make sure to first check with your doctor and diabetes team, and coordinate with them based on your specific lifestyle and condition. If you decide to try it, I hope it generates positive results for you too. I wish you all the best and I look forward to hearing about your experience.
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(*) Based on the original version of this article appeared on Diabetes Daily Post on 3/27/2014.
