Wednesday, May 23, 2012

Avoiding Lows? Or Managing Them?

For a few years now, I've been hearing a "buzz" among medical professionals (mostly endocrinologists) about the danger of low blood sugars. I was invited to participate in a research study through Washington University about low blood sugars in Type I diabetics; there have been a slew of personal stories on low blood sugars causing car accidents, including two articles in scientific journals synthesizing some of the data on car accidents following low blood sugars; and CGMs are targeted to individuals who are no longer able to feel low blood sugars coming on ("hypoglycemic unawareness"), and justified to insurance companies on that basis.

It's certainly a problem. Low blood sugar causes people to be stupider, and people do stupid things when they're feeling stupid. While death is frequently mentioned as a "worst-case scenario" for people with a low blood sugar, as far as I can tell, most people who have died from hypoglycemic incidents were actually trying to commit suicide.

Here are a few stupid things that I've done (actually ranging from hilarious to hazardous to my health) while my blood sugar is low:
  •  Lie down on the sidewalk at a bus stop. I was in late middle school, maybe high school, and I didn't have anything with me for a low. I stumbled up to the bus stop, with my knees collapsing underneath me each step on the way, and laid down. The bus driver kindly got out of the bus, helped me to my feet, and helped me get something to eat.
  • Yell and fight whoever is trying to help me. A few times, and most notably when I was being force-fed cake frosting from a tube (that stuff is nasty). This one time, at band camp (hold the snickers), I kept protesting the juice and granola bars offered to me at 6:00 in the morning, claiming that I "have to be on my flute at 12. I have to be on my flute at 12!" (Yes, I played flute at band camp. And yes, I have been fielding offensive jokes ever since.)
  • Hit my husband. I took the juice rather submissively, but seriously resented the fact that he woke me up to treat it. I smacked his arm to register my displeasure.
  • Take a Sunday afternoon nap that ends up in a sweaty, subconscious state from which I am revived with cake frosting from a tube. Did I mention that stuff is nasty? Anyway, I woke up with a tube of cake frosting in my mouth and immediately hoped that it was a bad dream. Unfortunately, it wasn't. This was the closest my husband came, about 4 or 5 years ago, to calling an ambulance for help.
  • Break a dish in the kitchen at my office, collapse on the floor in a heap, and gratefully accept the help of another Type I diabetic who happened to work in our small office. That one is pretty self-explanatory. It happened after I took a longer-than-average run on my lunch break. Bad idea, because I was already running on empty and a suspended basal rate just wasn't enough to keep the low away.
  • Take a bath. You can read about that here. It was horrible, and the closest I have ever been to dying from stupid behavior secondary to a low blood sugar. In fact, it gave me a serious dose of humility (I didn't even need the harsh treatment provided by my endocrinologist!), and I have treated low blood sugars much more cautiously ever since.
So there's the problem. Low blood sugars make you do stupid things. If you happen to be driving a car when your blood sugar gets low, you might get into an accident. If you happen to be lying in bed, you might get really sweaty and mad when someone tries to wake you up to help you treat the blood sugar. If you happen to draw yourself a bath, you might pass out and drown. If you happen to be pregnant, you might do something stupid that hurts both yourself and your unborn baby.

I've had endocrinologists fret over the fact that lows happen at all, but as far as I can tell, I think it's more important to face the reality that they WILL happen, and do our best to arrange the circumstances of our lives to protect ourselves against the serious consequences. According to my mother, who is an emergency room physician, "everyone knows that people who control their blood sugar well are at greater risk for lows." It's apparently common knowledge among medical professionals. They want us to control our blood sugars well, and they are aware that sometimes, in the effort to avoid highs (which are well-known to cause long-term damage to blood vessels in the eyes, feet, heart, and elsewhere, as well as damage to kidneys), we dip low.

As you can tell from the title of the post, I don't think that avoiding lows is the whole answer. Endocrinologists and I can adjust my insulin rates until we're blue in the face, but every now and then, I'm going to have an exercise session that sends me lower than expected. Or I'm going to overestimate my carbs and give a too-large bolus. Or I'm going to have an unexplained change in my metabolic rate (weight loss of even just 3-5 pounds, as during postpartum breastfeeding, often has this effect), resulting in a few more lows than normal and requiring wholesale changes to my basal rates and bolus ratios. Or I'm going to get a stomach bug that makes it impossible for my stomach to absorb anything I eat to bring the blood sugar up. Every diabetic knows these things happened, which means that low blood sugars cannot be absolutely avoided.

First of all, because this is a blog about pregnancy, let me just say that pregnancy is only tangentially related to low blood sugars. If you work harder at tight blood sugar control during pregnancy, you may experience lows more frequently. But that doesn't mean pregnancy is the problem. Because if you did what you were supposed to and kicked your butt into gear to get tight control when weren't pregnant, you'd have the same problem!

So after adjusting my insulin rates to avoid at least a few lows, here's what I do to work around the fact that lows will happen, and how I prepare for them.
  • Carry Gatorade, and I mean, everywhere. At times, I've looked in my purse and the kids' diaper bag and between the two, I had 3 bottles of Gatorade. I'm packing a lot of extra weight, but it's saved my butt on dozens of occasions. Gatorade is GREAT because it's absorbed in your stomach (instead of juice, which is absorbed in your intestines), and so I feel better in 5 minutes. That means I can start driving, changing my kids' diapers, and keeping us moving throughout our day a whole lot faster. It doesn't last me beyond an hour, but an hour is usually plenty of time to find some real food.
  • Figure out what the best way to bring up a low blood sugar is, and fast, and not too high. I've heard Starbursts and lemonade works well for some. :) You'll probably need to stop eating before you feel better. Wait 15 or 20 minutes, and check again. It will only take you a few weeks to figure out what and how much you need to eat to raise a low, and then you can be confident that food will work every time (or at least, most of the time) without giving you a rebound high, even when you don't feel better right away.
  • If I'm having lows persistently at one time during the day, I try to avoid going out of the house at that time, or at least making sure I have a snack AND Gatorade with me, or eat a meal right beforehand. This happened during the second trimester of this pregnancy. After a heart-to-heart with my brother and sister-in-law, I decided I needed to hang around the house more after breakfast, because my 2-hour post-breakfast was very consistently low and still dropping. After a week, I figured out what was wrong, and was able to resume my normal morning activities. Staying home had the added bonus of giving me time to pay attention to what I was feeling, and I was even able to detect not just when my blood sugar was already low, but when it was dropping!
  •  Eat smaller meals. I'm trying to keep it less than 60 carbs. The problem with high-carb meals is that if your carb count is off, your insulin bolus is going to be waaaay off. Especially when you're pregnant, and your bolus ratios are very low. That means an overestimation of 10 carbs will result in a low that's even harder to bring up. If your meals are small and you need to eat a snack in between meals to bring your blood sugar up and stave off hunger, so be it. Isn't everyone always saying that eating frequently throughout the day is healthier, anyway?
  • Check your blood sugar all the time. Every two hours and more frequently if you think you're low.
  • Check your blood sugar every two hours.
  • Check your blood sugar whenever you think it's low.
  • Check your blood sugar before you get in the car, especially if you're going to be on an interstate or in the car for more than 15 minutes.
  • Check your blood sugar whenever you think you might not have a good opportunity to do so in the next hour.
  • Check your blood sugar when you wake up in the middle of the night, even if you don't feel low.
  • Check your blood sugar whenever you're worried about it.
  • Just suck it up and ask for help. Especially because this is a blog about pregnancy, do this one especially when you're pregnant. When I'm lying in bed at night, and I'm just about the fall asleep, and I can tell that I'm not just tired but that my blood sugar is, in fact, low, I ask my husband to get up and get me juice. It pains me, because I hate not being self-sufficient, but you know what? He's never said "no." And if your spouse does, then maybe you should let him or her read my post about taking a bath with a blood sugar of 20. That's what happens when you test-drive self-sufficiency with a low blood sugar, and it can have ugly consequences.
I'm apparently not the only diabetic who is skeptical about the hysteria over low blood sugars. So my recommendation is: avoid lows as best you can, which may involve working with your doctor, diabetes educator, and so forth. But in the end, it's equally (and possibly, more) important to manage them when they do happen.

What are your tips, especially you pregnant diabetics out there?

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