A Diabetes Connections Extra! We take a deep dive into low blood sugar with a frank talk about what hypoglycemia means, what the dangers are, how to treat and more

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This is the extended, full version of our conversation about lows. As with all of our “Extra” episodes, an excerpt ran in the episode just before the this one. Look for Extras the last week of each month.

Stacey talks to Shannon Johnson, who was diagnosed with LADA in her early 20s.  Shannon is also a CDE and a pump and CGM trainer.

Low blood sugar basics (JDRF)

Low blood sugar info (ADA)

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Interview Transcription:

 

Stacey: Shannon thanks for spending some time with me today. I think this is a really interesting topic that we think we know about but I’m really interested to learn more. Thanks for being here. 

Shannon: Absolutely. Thanks for having me.

Before we even jump into lows and all the physiology and everything behind them. Can you share your story a little bit? You live with type 1 when were you diagnosed? 

Shannon: I was diagnosed at a older age, actually I was 22 and they thought I had type 2 diabetes in the beginning. I actually have what’s considered latent autoimmune diabetes in an adult (LADA). But it acts more like a type 1, so that’s why I can actually say, you know, I have type 1 diabetes as opposed to type 2. Because like a type 1, I also have to have insulin every day to continue on. And so I juggle all of those things that all my patients have to juggle as well. So I’ve been living with it now for about 25 years. This might be 26 years now. So, been a very long time.

Dumb question because we’ve talked about LADA on the show, as you said. Is is that something that stays LADA? Do they still consider it that or do you eventually say no, I just have type 1 in terms of the medical diagnosis, not how you live your life?

Well, so yeah, I mean if, I saw a provider they would document that I have LADA but for you know, say for Medicare, those kinds of things, insurance purposes, they are going to say that I have type 1 diabetes.

Got it. I was just curious if LADA and again, this is probably a really dumb question. I know it’s kind of slow going when it’s first raising its ugly head, but I was wondering if it kind of becomes just general regular old type 1 if the different diagnosis or the differentiation in language matters after 26 years.

Right. Yeah, I mean I’m not real too concerned about which diagnosis it is. It’s just I know that I don’t make insulin and I have to have insulin to live. So yeah.

It doesn’t matter what you call it. You know what you have to do with it. 

Exactly. That’s exactly right.

When you were diagnosed, were you already on a healthcare track to get those degrees? 

I was actually. I was in my first year of nursing when I was diagnosed. So a lot of stress already with just being diagnosed with or going to school as a nurse and all of that. And then being that diagnosed with diabetes as well. I’ve done several presentations and at this point my PowerPoint picture is like a tornado has taken out a whole house. That’s how I felt. Totally devastated when I was first diagnosed. You know your whole life changes. It’s a life-changing disease for sure.

Well, it’s always great to talk to somebody who’s had the amount of health care experience that you have because you know, you talk to people, you train people in the pumps and CGMs and everything, but to actually live with it as well just gives that other layer of understanding. So let’s just jump right in because when I talk about low blood sugars, I think we all think we know what we’re talking about. But you know, I’ve learned in these deep dive episodes that even after 12 years, I’m just scratching the surface. So let’s just start with the basics. When we say somebody has a low blood sugar what’s happening in the body?

An actual low blood sugar is a blood sugar below 60. However, we like to think of it, we start treating it and start teaching people to treat it when it starts to become below 70. There are a couple of things that are happening when you actually have a hypoglycemic episode. One is you have too much insulin for whatever reason – whether it’s you took a too much insulin for your carbs or you got maybe some extra exercise or you know, you skipped a meal and you had already taken your insulin. But for some reason you have too much insulin and then you don’t have enough glucose or sugar in your body to use that insulin. Because the insulin is like a key that’s what we use to get the glucose to the cells to be used for energy. So if we have extra insulin going there in throughout the body then our glucose can’t get to where it needs to go. Because we don’t have enough. So that’s when it you start to feel shaky. You might feel drowsy, might not feel real clear-headed those kinds of things and then your body lets you know, what’s going on most times. So those are the couple of things that are happening when you’re experiencing low blood sugar.

I guess in people who don’t have diabetes, their bodies are grabbing that extra emergency glucose that they can. But when you have type 1 you don’t have those sources. You know, I’ve heard that it starts in your body and then it kind of goes to grab the glucose from your brain and does that even make sense?

Yeah, I mean because our body uses lots and lots of glucose. Our liver stores glucose for times when we need that. And so when you know, our body gives us as much as it can afford to and then to the point where it can’t give it any more it’s told not to do that. So then that’s when we start to feel those lower blood sugar symptoms.

How exact are the numbers? You mentioned below 70s when you start to treat. Below 60s when it’s really low. But my understanding is that the lower the blood sugar reading on a meter is or even on a CGM, the less accurate it is and the same thing for the highs, you know, we get to the extremes, it’s less accurate. Is that true, and should we be concerned about that? 

Well, the the FDA will approve a system as long as the values that they’re getting anywhere from 95% of the time to 99% of the time, the values have to be within the lab values, 20% either way. So what that means is, so let’s say you check your blood sugar on your meter and it says 190 it’s still considered accurate if it’s 152 or up to 228 on your meter. Okay, but your labs even though the lab says 190, it’s still considered accurate. So when your blood sugars are higher, because the number’s higher, that 20% is, whether it’s lower higher than your lab number is quite extensive. There’s more space in between your 20%. But when you have let’s say a 70, your 20% below is 56 and your higher range is 84. So it’s not quite as inaccurate.

Got it.

As for your higher range, I used to get really concerned about that. I thought, you know 20% that’s huge living with type 1 diabetes, if I only take .25 units or whatever. I just I used to think that was not acceptable. But then I started looking at it and started thinking about it. Let’s say again, I check a blood sugar and it comes up of 190 and actually it could be 152 to 228 with my correction scale. Am I really going to do anything that much different if it’s 152 as opposed to 190? Probably not. You know, so that’s how I kind of have come to accept that discrepancy. So best-case scenario, we get this question all the time. I get this all the time, you know as you get older when you have type 2 this especially, you make less and less insulin, everybody does that’s just the way of the of the body. So I hear all the time, I don’t think my meter is working. I don’t think my meter’s working. So that’s the first thing they think of so the only way that you really can tell if that meter is accurate is when you check a blood sugar, have a lab draw the blood sugar as well and then compare it to that lab draw and if it’s within twenty percent either way then your meter is accurate.

So you’ve got to bring it with you when you go to the lab for your blood test?

Right? Yeah. Yeah, and we have a lot of people will do that especially if they think there’s something wrong with it. A lot of times they’ve just gotten older they’re making less insulin, you know, maybe they haven’t been following their regimen or they need a different regimen. But that’s always a first concern for my patients and then we just put that to rest and then we move on to see what’s really causing the higher blood sugar readings.

Got it. You know, I think we were very fortunate because at the very beginning our endocrinologist told me, “Look diabetes is as much of an art as it is a science and you can’t worry about the exact numbers.”

Right.

We were really lucky that way because I do have a lot of people and parents that I talk to who you know, they’ll check a finger three times to get three different numbers and be really concerned. So I’m glad to hear you say that you know to explain it the way you did.

We’ve also learned to kind of go off feelings if that makes sense, because sometimes Benny, my son, he can be 65 and feel great, but then he can be like 95 and say, “I’m low and I need to treat” and he’s almost always right. Even if the arrow isn’t showing up on the Dexcom up or down. Do you find that a lot of people and yourself tend to do that? That at some numbers sometimes you feel okay and at other times when you should be quote “in range” you’re really, you’re not. 

Yeah, I find sometimes I’ll sit down to eat a meal and check my blood sugar and it’ll say you know 52 and I’m like wait a minute. I don’t feel 52 and my sensor is not saying 52, you know, or maybe arrows aren’t going down. So I’ll check it again. I always double check to make sure if I have a question. But yeah, I’ve had that happen and then other times I feel like I’m low and I’m not low. So I always want to make sure that I know what my blood sugar is with the meter. But I I think one of the things that’s happening is it’s just the rate of change. You could be dropping very quickly and at 60, maybe you have just dropped from let’s say 90 to 60 very quickly and your body’s just telling you that you know, you’re dropping or you have dropped quickly and maybe your 95 is a little bit more stable or slowly dropping or slowly rising. So I think that’s the difference that one can feel that little rate of change.

Yeah that makes sense. Again, this may sound like a silly question, but why are lows dangerous? Could you talk to me about, we mentioned what’s going on in the body, but why is it something to be concerned about and to treat quickly? 

Well our bodies have to have glucose for energy and to continue, you know, our brain function, our heart function, everything that functions needs glucose. And so if your insulin levels are high and your sugar levels are low, then your vital organs are not getting what they need and they start to deteriorate. Eventually it can lead to – and that’s why if you start not having enough sugar for the brain – that’s where you start with the loss of consciousness and then maybe into a seizure and then maybe even to a coma. So that’s the part that we worry about with the lows. The other thing is, as people get older, not just our kids but we have and older population now that is becoming more and more type ones. We have to worry about when they’re low when their blood sugars are low, that can cause some arrhythmias in their heart. And their hearts are very fragile. You know, 79-years-old, 82-years-old. So we want to make sure that we really avoid the lows with those people. And as a matter of fact, we teach them, you know, we drill in their head, your A1C has to be less than 7. But then as they get older, we have to change that behavior and actually try and get it a little bit higher. We keep them around 7.5% to 8%. And that’s really difficult for them, ‘Well, you told me I have to be less than 7% all the time. And now you’re telling me I have to be higher, that doesn’t make sense.’ So then we have an opportunity for education there. But there’s lots of different things that can happen from those low blood sugars.

I’ve actually I heard very recently some statistics about how as we get older many people feel their lows less. That many people over the age of 65 are spending more time under 70. Which you don’t want to do.

Right.

You know, how do you get people to, is it just checking more often? Using a CGM? How do you try to tell your older people to, I don’t know, to pay more attention to it?

You know as you get older and especially if they’ve had really, really tight control, that ability to feel those lows because maybe they’ve had so many or because everything declines as you get older. It becomes kind of a mystery to them like, ‘Well this has never happened to me in the past.’ So that is one of the best things that ever came out of Medicare is the coverage of the CGM. So pretty much all of our type ones in the older generation especially, are on CGM. There are several different systems out there. But the one that we prefer is the Dexcom for our older folks just because it will alert them if they have lows or if they’re trending down and especially if they don’t feel them then they will get that alert. Other systems not quite so much will do that. But we really, really use a lot of Dexcom here. Type twos we use the Libre a little bit more. But the Dexcom is is one of our favorites and so Medicare just started covering that for those folks and then they can only have the G5 right now, but hopefully they can get the G6 soon, now that it’s been approved. (Note: G6 is now available for Medicare)

Sensors are just game-changing whether you’re two-years-old or 82-years-old. Not checking quite as much, being able to see where your blood sugars are. When I first started working with sensors, I would always tell people because they had to calibrate – they don’t have to do that so much anymore, but when they had to I had to kind of help them through. They’d ask, why would I want this system? I just would compare it to like an insurance policy or a GPS system. Because right now without the arrows telling me where I’m at, if I get into a car and my blood sugar is 99 and I’m going to take a trip three hours away. How do I know if I’m going to make it without a low blood sugar or if I’m going to have a high blood sugar? So that’s kind of like how I compare my GPS system. This is telling me where I’m going. I’ll know if I’ll make it there without a snack or I’ll know if I need to take a snack, you know. I also compare it to an insurance policy, whereas now you have a little bit more leniency to check those blood sugars and make sure that you have something that’s backing you up as well. So but they’ve evolved a lot since then, so they’re only getting better.

It’s great. No, we’re thrilled. Obviously, we’ve used Dexcom for several years and it really has been a game-changer all around. You know, you mentioned seizure and coma, things like that. I’m not trying to scare anybody but this is an episode about low blood sugar. So let’s talk about that if we could. The risk of seizure, again, I’m a lay person, seems different for different individuals. I know people mostly parents of children with type one whose child has had a seizure and it hasn’t always been because of a low blood sugar. It hasn’t happened at a number that you’d expect. And then I know many, many more, I mean, I have 600 parents in my local Facebook group whose children have been down to 20 and 25, you know 17, and not had a seizure. Can you speak to what’s going on there?

We had a type one of several years walk into the clinic with a blood sugar of 19. We check blood sugar every time somebody comes in. Totally talking, alert, you know, he was starting to get a little ornery but he was fine. But then as time went on he couldn’t remember being that low. So, you know, the threshold is different for each individual. You can see somebody has a 10 blood sugar and they recover very well. Somebody else might have 32 and they are just deathly afraid of ever getting that low again. But it’s just dependent upon the threshold of where their brain is saying, ‘Okay, I need more sugar and I’m not getting it.’ And then that will put them into to that seizure as you have more lows, you know, you don’t get those early signs and symptoms if you’re used to getting several lows so it might be you know that you’re getting to not getting the early signs and it’s getting to the later signs a little bit quicker than what you think it is. But it’s just your whole body, your brain is just really needing that sugar. Everybody’s individual.

So that last part – everybody’s an individual – that’s what I wanted to ask about. Once you’ve had a seizure are you more at risk of other seizures or is there anything in the literature or studies that have said well this this person is at less risk. I mean, are there any through lines or commonalities that we can look for?

You know, I’m not really sure about that. I haven’t really looked into that so much.

Because I’ve never heard of any. And you know, we get that question a lot especially from the newly diagnosed families. Some people seem to think, well if my son hits this number he’s going to have a seizure or pass out. 

Right.

Where that’s not something that we ever talk about. 

Yeah. That’s not really something that we teach people. I’ve had to teach my children because they’ve asked ‘If I find you unconscious what should I do?’ It could be that my blood sugar is too low so you might want to give me a shot of glucagon, but it could be that I’m too high and I’m you know in a coma or whatever because my blood sugar is you know, 800 or 900, 1,000, whatever my threshold would be there too. So it’s kind of a check and a balance all the time. So like I said, I haven’t really read much on the levels of where people will actually have a seizure. I get that question a lot. ‘Well, where will I actually get a seizure’ and my answer is always it’s individual, you know, if you feel like you’re having a symptom, check your sensor, check your blood glucose, whatever you have to do. And just to make sure that you’re safe.

And that is another part of low blood sugar. It’s not just the risk of these we’re so terrified of seizures and coma but it’s what can happen when you’re low people could fall, you know, simple things like that. 

Right.

That was the first thing my son did – it was two weeks into diagnosis, maybe three weeks and he got clumsy and fell while he was playing. We know now, of course I would know but we kind of said, ‘oh, wow, I wonder what that’s about’ and didn’t think to check his blood sugar until he really was almost falling asleep. I mean, he was a toddler. And of course then he was really low. But that to me is almost more of the danger, right, is the regular activities. Can you speak to that a little bit?

Exactly. And that is one of the things that we really push at our clinic is safety. It’s not always about the numbers, and the seizures and the heart attacks and all that kind of yucky stuff. We want people to be safe. You know, if you come in with a 12.7 A1C, you’re not safe. You know, you’re going to be falling asleep at the wheel and you’re not going to be productive. If you’re a basketball player, you’re not going to play your best. But if you also come in with an A1C of 4.8 you’re not safe, you’re having low blood sugars that maybe you’re not catching. Or you know, someday will catch you while you’re sleeping or might not wake you up. So the most important thing when you’re teaching somebody about diabetes whether it’s type one, type two, gestational is to keep them safe, you know, keep their blood sugars well-controlled, but to the point where they’re not unsafe.

Okay, so let’s talk about how to treat low blood sugar because it’s simple, but it’s not that simple.

Right.

I was amazed, I remember and I’ll go back to that first story. I think my son was 52 or some crazy number when he was stumbling on the playground and we you know, we ran and we got the juice and we got everything we needed and then I called the Endo because we were three weeks in and I said, ‘Okay, what else do I have to do?’ And they said ‘What do you mean?” By then his blood sugar was 120. He was fine. He felt good. He was kind of hungry. I think we got him some lunch but they said, ‘you don’t have to do anything.’ and I was amazed it was the power of this simple sugar. Oh, so this is a miracle drug. You know and all it was, was juice. But he was fine. And to me it was absolutely amazing, but it’s not really that simple. Can you explain how we’re supposed to treat low blood sugars? 

Well what we teach our people, our patients is the rule of 15 just because it’s just it’s kind of an easy, you know when your blood sugar’s low you’re not thinking very clearly. And your body is starving, it needs sugar. So it’s telling you to eat, eat, eat. I’ll tell my patients, ‘I know you want to go to the pantry and eat till you feel better or drink till you feel better or go to the refrigerator and eat and drink till you feel better. But then, you’re blood sugar is going to come up obviously, but then you’re going to go from feeling crappy, you know, 52 or whatever 48 to feeling really yucky again now over 300 probably from everything that you’ve eaten.’

It does take longer and I think people don’t like it because it does take longer, but it’s, I’ll say again, it is the safe way of bringing that blood sugar up and and getting you back to feeling better, of course. So the rule of 15 is our common rule. Of course, you can change that a little bit based on the age of the child or the adult. Children don’t need as much sugar because they don’t have as much blood and mass so they don’t really need as much sugar. But typically, a good rule of thumb has been the rule of 15.

So what you do is you check your blood sugar and then if it’s less than 70 you’re going to treat it with 15 grams of fast-acting carbs. That’s when people you’ll hear that’s when I get to have my Snickers or that’s when I get to have my M&Ms. That’s not the best time to do that because actually chocolate doesn’t work as well, as say like a Lifesaver would just because of the fat content it takes longer. It’ll work but it’s going to take longer and we want to bring that sugar up. So the best thing that that works is a liquid like maybe four ounces of juice. Whether it’s orange juice, grape juice, regular soda works well. But I always encourage my patients to carry the glucose tablets because they’re portable, you tend not to cheat on them. You know, if you have a bag of Skittles sitting in the bottom of your purse, you might tend to see those and take a few here and there so you’re not going to do that with glucose tablets. They have lots of different flavors. But what I find is people don’t take enough. I’ll come into the clinic and I’ll hear, ‘Yeah, I had a low blood sugar last week and then I took one glucose tablet and then later that night I was low again. Well, they didn’t bring that blood sugar up high enough. One glucose tablet has about 4 grams of carb in it. So they have to take, the literature says about three to five. I always tell them to do 4, that’s 16 grams and then you can refill them as you need to at any pharmacy. It’s really easy. They’re portable. So that’s typically what we do.

So you would take the 15 grams of fast-acting glucose. And then this is the hardest part, you got to stop what you’re doing wait 15 minutes and then check it again. And it doesn’t matter and I have to tell people this all the time. It doesn’t matter if you eat 15 grams of carb or 50 grams of carb. It’s still going to take you 15 minutes before you start to feel better because that’s how long it takes for sugar to get to your bloodstream. So then after that 15 minutes of waiting then you check it again and if it’s come up above 70 that’s good. Then you want to eat something like a sandwich or you know, something like that. If not, then you want to treat it again. You do the 15 grams, wait, 15 minutes and treat it again. So sometimes when you’re not thinking very clearly because of the low that’s a little bit easier to grasp.

Okay, so you mentioned little kids who might not need quite 15 carbs and older people who might need more or bigger people who might need more, but that’s a great way to just start and then go from there. So if you find that 15 carbs is skyrocketing you up you can always cut back a little bit but I’m curious and I’m always biased as a parent here. So let’s kind of try to take people treating themselves and talk about people who are treating themselves because frankly it’s a lot easier for me to say to my son. You have to wait 15 minutes, right? I mean, you just make him wait. But when you’re in a room by yourself and you want to eat the entire refrigerator – you must go through this yourself.  How do you cope with any tips or tricks to kind of get yourself out of that mindset when you’re not even thinking clearly?

Right yeah. So what I’ve had to do and what I usually tell them to do what works well is just go lay down if you can. That works for me like I will I will if I have let’s say a low in the middle of the night. This is how unclear I think, I have a bottle of glucose tablets right on my bedside table, but I wake up if my sugar is low, I automatically think I have to get something to eat. Well when my glucose tablets are right beside my bed. So I go, you know have a fruit snack or whatever my 15 grams and I’m still not feeling well, so I want to keep going but what I’ll do is I’ll go lay back down because I tend to, when my blood sugar comes up I tend to get cold and then I will shiver a little bit. So I’ll lay down for about 15 minutes. Just don’t do anything whether it’s sitting in the recliner, just remove yourself from that situation as much as you can and just relax and do nothing. And then after 15 minutes, I will check it again. The CGMs have helped a lot with the low as you know, we automatically think it’s the 15 grams that will bring you up it sometimes it doesn’t take as much and so we’re learning a lot more with those continuous glucose monitoring systems. And I think they’re really helpful for patients to see, you know, if I just have this little bit of cookie, you know without insulin I’m going to be fine. But really if you they take that and they see what happens then they learn a lot more. Well, then maybe it doesn’t take quite as much to fix a low blood sugar either. So the CGM’s are great teachers too.

They really are. We’ve learned so much from that and there’s something soothing at least as a parent, I can’t obviously speak as person with diabetes, when you’re you see the number of maybe going up slowly but the arrow has turned so that at least I know okay, something’s going on. Here it comes. Here comes the arrow. So it does make you feel better about that. 

Yeah. Absolutely.

You’ve mentioned hypoglycemia unawareness a couple of times. Let’s talk about that a little bit and let’s start in children. I’ve got to tell you I kind of thought my son had that when he was very little but then I realized it was just that a four-year-old isn’t communicating well about anything, and so I realized that I think most kids and this is a generalization on my part, most kids really can’t tell you how they’re feeling until they’re at least seven-year-old. Is there a true hypoglycemia unawareness among children or does that really take longer? 

Yeah, that is something that comes over time unless your child has lows constantly then that can, they can lose that feeling but it’s usually the protective hormones. So when your blood sugar gets low your body kicks out some hormones that protect us like epinephrine, glucagon, adrenaline, and lots of other things but over time if especially if you’re telling those to be kicked out a lot from low blood sugars, those stores will get depleted and then it’s not able to tell you when your blood sugar is low. So you typically, I will tell people we don’t see as much of it until you’ve had diabetes for you know, at least 10 years or so. Unless you’re running a lot lower too. So, I think the I would agree with you as far as the hypoglycemia unawareness in children is just more of, I really can’t tell you how I feel because I’m just a child, you know? Bugt the unawareness really comes, in my experience anyway, as they get older.

And then you mentioned if someone’s having a lot of lows. They may stop feeling them. Can you quote unquote “fix” that by running a little bit higher or more in range for a while? 

Yeah. Absolutely. When your blood sugar is low but you’re not telling your body to release all those hormones and they start to you know, get back to where they’re working better again. And yeah, you can get that back. Sometimes not always but sometimes.

That’s interesting.  Okay. Let’s talk about emergency treatment for lows. Let’s touch on glucagon and how that works and what we’re supposed to do. First, as you listen, you’re probably familiar, this is a red or orange emergency kit and you’ve got to have a couple of steps to put it together. Your endocrinologist or educator probably has had you practice once or twice hopefully. But what does the glucagon do Shannon? Let’s talk about what it’s actually doing in the body because it’s not a sugar shot, right? You’re not putting glucose in your blood.

Right, exactly. The liver is storing the sugar or glucagon. So for times when you need glucose, so a person without diabetes, when they have the fight or flight response, your body needs this surge of energy we get the energy from sugar. But if you’re not eating anything at the time you have to get it from somewhere and one of those places is the liver.  So when you have type 1 or type 2 diabetes though, the liver’s not working the way it should be. And the pancreas is doing lots of things but they’re just not working as well as they should be, they’re not talking to each other. So what happens then is you take the glucagon when you have a low blood sugar if your liver has given you sugar but it’s given you as much as it wants to give you, because it doesn’t want to give you all of it. When you take the glucagon what you’re doing is you’re just telling the liver to release all that it has in it. All that it can possibly give. And it does. So that’s what the glucagon does.

I have fortunately have never had to have a glucagon shot. So I don’t really know what that feels like, but I have heard that you don’t feel well and I’m sure you don’t. It’s probably just the opposite of just kind of like when you eat a whole bunch of food for a low, you don’t feel really well. So what I teach my patients, I always teach the significant other, the mom, or the dad, you know, I’ll show it to the patient, but they’re really very rarely going to use it. So I usually show it to the support person and tell them how to use it. Always tell them to put the person on their side if they have to, if the patient’s unconscious. Give them the shot. Put them on their side because you know, a lot of times people will throw up when they start to feel better. Then they have to get something to eat. I mean, they just really don’t feel well, but that’s what that medication is for. So that’s the worst case scenario, you know, blood sugar, somebody finds you unconscious. They give you the glucagon, somebody else has to administer.

Usually we give about half the dose for kids who are between like 5 and 16 or 5 and 15 we’ll only give them the half the dose. We’ll give anybody over 15 usually the full dose and then the little guys we use about a third of the dose. So like 30 units for a little guy, five or less, 50 for 5 to 15, and then over 15, we will give them the 100 units of that.

Do you talk about mini glucagon shots in your clinic? I know that’s an off-label use, you know, it’s not FDA approved but do you talk about that at all? 

Yeah, we do. And actually I had a pregnant mom calling me the other day who has type 1 diabetes, had some pretty aggressive settings in her insulin pump, but couldn’t keep anything down and she was throwing up and she was having low blood sugar. So I did have her take just a little bit of that glucagon because if you can’t, if you can’t eat or if you can’t drink anything you got to do something. So the low dose glucagon works pretty well. What we teach patients is one unit for every year of age until you’re about 15 and then you can use the 15 units or so.

For a mini dose, you mix up the glucagon kits but you use a syringe right? You’re not using the big needle that comes with the glucagon kit for the mini dosing?

Right. That’s exactly right. Then I tell them that it only they can only have it for 24 hours and then they’ll have to get rid of it because it does tend up to gel up. And then they just get a refill for their kit.

I’ll put a link in here for more if you want to look at a chart or some more information because more hospitals are putting out information about mini glucagon shots. Although again, that is an off-label use. I talk to Lily about glucagon almost two years ago now and they wouldn’t even address it because they can’t.

Right.

We should also touch here that there are some other more stable glucagon methods and brands that are in front of the FDA right now. So maybe this summer will have some alternatives which I think is very exciting. I mean we look at the glucagon that’s a total in case of emergency thing. We’ve never broken it out in 12 years. Thank God. But there’s a there is a line of thinking that if we could use glucagon easier,  if we had more access to it and it was more stable, that if you were 50 and you didn’t feel like eating, you were nauseous or you were ill, you know, take a shot. Not a huge glucagon shot, a mini shot maybe it would be better. So I know that’s kind of a different subject but I’m excited for that personally. I don’t know if you are. 

Yeah. And with my patients, because the the glucagon will expire as well I always tell them, don’t throw it away. It’s still going to work a little bit. We tell them to put it, you know, put it in your glove box because up here we get lots of snow and if you take your insulin are you have your pump running and you get stuck in the snow storm and you don’t have anything at least you could take a little bit of that glucagon. So, you know, it will help you get through that hopefully. So yeah, I mean, there’s just kind of little nuances. Of course that’s off label, too. But  little nuances that you learn along the way.. So yeah if we could have glucagon orally or you know, something a little bit easier that would be great.

I want to ask you about alcohol and low blood sugars because my understanding is that you’ve got to really change the way you treat them. Can you speak to that?

Alcohol is difficult, or can be very difficult, because some of it will raise blood sugars. But what happens is we worry when somebody’s on insulin or medication is the early am lows. Your body when it’s busy processing the alcohol because alcohol gets metabolized by your liver, you know, just like some medications will. So when it’s busy doing that then it can’t, if your blood sugar happens to get low then then it can’t give you the sugar that it’s storing. So that’s how those lows tend to come about because it’s too busy working on the alcohol and not being able to do two things at once by giving you the sugar. So then that’s when people get low.

So what we recommend, what I always recommend, of course is check your blood sugars. Sensors help a lot too. I mean, they really, really will tell on you if you drink. But you know, I always tell people have something to eat, take a little insulin if you have to but have something to eat with your alcohol. And of course, they’ll say well can I have nuts? Well, you can but it’s not going to do anything. So I encourage them to have before they go to bed, maybe just a cracker with a little bit of peanut butter on it. Or a cracker with a little bit of cheese. It doesn’t take much but you got to have something there in case that alcohol is metabolized.

Yeah. That’s something that I do worry about as my son gets older. You know, he’s 14 now we’ve talked about it, but I do think I’ve talked to a lot of adults with type one who they pay attention. They’re careful, but to me, that’s it’s such an unknown factor. 

Yes. It’s very scary. Very, very scary. Especially, when kids get into the college age and their binging and not eating like they should or like Mom and Dad had them eat, or just kind of eating on the run. It can be very, very scary.

So I have a question. I’m not sure I’m going to leave in but I want to ask you anyway. So this is actually not about diabetes, but I have experienced low blood sugar several times and I’m curious. I don’t have diabetes, you know, what’s going on with me? And I’ve had it to the point where you know, we have meters all over the place now, and I’ve checked my blood sugar and one time just at home by myself, I was like 62 which isn’t that low. But then I was at “Friends for Life” at that conference and I didn’t feel well, of course, I’m surrounded by people with diabetes, so everybody’s shoving a meter at me and I was 51. So you know, I ate some gummies and…  

Whoa.

Oh now I’m nervous. So what happens to people who are not diabetic who have low blood sugar? I mean, do I just need to be careful and eat more?

Well, wouldn’t that be nice? No, it’s actually the choice, what we have to add to your diet is protein. So what’s happening is called hyperinsulinemia. When you eat carbs, your body is kicking out insulin, but for some reason it’s kicking out too much. So you’re getting more insulin than your body needs. And then as the as the food is digested and the glucose is used, your insulin is still active and you have too much in your bloodstream and that’s causing your low. So one of the things that helps with that is protein. Adding protein to breakfast, lunch, supper, making sure you’re having, you know an egg with your slice of toast in the morning and you know a grilled cheese sandwich.

The protein helps. So what that does is it helps keeps the carbs in your blood stream just a little bit longer. So they get digested a little bit slower. And then that insulin is used for that glucose from your food. Having said that you want to get a handle on that because that can lead to type 2 diabetes because when we’re born we’re only born with as much insulin as we’re making to make. And if you’re, if we’re eating high glycemic foods, you know cereals, juices, regular pops, Gatorades telling our pancreas to work overtime all the time, eventually you’re going to you may run out. Okay? I mean you deplete anyway as you get older, it’s just the natural progression of getting older, but if you have predisposition for diabetes like a family member with diabetes or you have the hypoglycemia, of course, then what’s happening is you’re telling that pancreas to kick out even more insulin and then in the back of my mind it says well you’re going to run out very quickly and then what’s going to happen? Which is a reason we don’t use sulfonylureas anymore, which is a medication that you probably I don’t know if you’re familiar with it, but it’s used for type 2, and it tells the pancreas to kick out more insulin. Well that to me is like, why would we do that when we already know they’re going to be making less insulin anyway? Why are we telling them to kick out more? So that’s a whole another subject. But yeah, the sulfonylureas will do that.

One of the things that we tell our patients is no cereal. I mean, we think even the really healthy cereals like the Special K’s and the Honey Bunches of Oats and even you know, if it’s not sugary, we think it’s real healthy and it’s got its very highly glycemic. So we take we take the cereals away if we can. And then change them to toast and peanut butter, or toast and eggs, toast and cheese or you know something that’s a little bit less glycemic. Pasta, rice all of those things that you know will really spike up those blood sugars.

So this might be a dumb question, but I’ve actually never heard that. I thought the pancreas makes insulin or you know, the beta cells make insulin. Not that you’re just born with all of the insulin you’re ever going to have. 

Yep. Yeah. That’s what I mean. That’s where they’re they the insulin comes from is the islet cells in the pancreas. But in the end yeah it, what happens is your pancreas as you get older the the beta cells stops functioning.

I see.

And then and that’s the part of the type 2 diabetes as well. It’s not it’s a little bit easier, I guess to say you just sort of run out of of insulin than telling people all your beta cells don’t work. Well, what does that mean? So that’s how I get to that.

I know this is not where most people’s minds would go, but in my head I’m thinking and I’m sorry parents this now rated PG-13. I’m thinking that does not mean it’s like women are born with all of the eggs that they’re ever going to be able to fertilize. This is not it’s not the same right? That’s not really what you mean.

No.

Okay, just checking. That’s the first place my mind went. Sorry.

That’s Ok.

I was trying to think of a part of the body that does that. Was there anything that I didn’t touch on about low blood sugars that you wanted to mention?

The only other thing that I usually teach when I’m doing a hypoglycemia session with a patient is I strongly encourage them to obtain medical ID. A lot of people will say, ‘Well I have my pump.’ Well, you know, not everybody knows what an insulin pump is. Or, ‘I have an ID card.’ Well, when a paramedic finds you unconscious, they’re not going to go rummaging through your purse to see an ID card. So I strongly encourage people to get a bracelet or a necklace because that’s typically where they’re going to look. Just let them know, and it doesn’t have to be anything fancy. It doesn’t have to have your doctor’s name or anything all it has to say is diabetes so that they will at least have some inclination to draw, at least check a blood sugar or give you glucagon or something that they can do. I think something that we as practitioners miss a lot for our patients is to tell him that. But I think it’s very, very important especially as a kid.

Then the other thing that I also tell patients is, especially if they’re going if they’re going on a pump is does somebody around you know you have diabetes? You know and with kids that’s a little bit difficult because they don’t want people, they don’t want to be different and other kids think it’s contagious, you know that they’re going to catch it those types of things but I strongly encourage that they find somebody or have somebody that they know, knows that they have diabetes. So if they are acting, you know, not themselves they can you know, hopefully quickly act on that.

I think a good support group – I don’t mean a formal support group with folding chairs and graham crackers – but you know good friends, good support, that’s got to be what you need with something like diabetes. So, that’s a great. 

Absolutely. Yeah. It’s a team effort. That’s for sure. Definitely. I mean you really you think of a disease as well, this is my disease. I’ll take care of it and do everything, but it really is a team effort. If you have a good team then you’ll do fine.

Well Shannon, thank you so much for spending so much time with me today. I’d love to have you back on this was really informative, and it was fun to talk to you. Thank you so much. 

Absolutely. Thanks for having me.

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