Hypoglycemia guide

One of the biggest fears people with diabetes face is hypoglycemia, a blood sugar low. And rightfully so, because the most severe forms of hypoglycemia lead to seizures, coma and in the worst cases, death.

Every person with diabetes (and under ideal circumstances, their family members) needs to know how to recognize and manage unpredictable hypoglycemic episodes.

Let’s agree on some definitions first.

What is hypoglycemia?

Simply put, hypoglycemia is when your blood glucose (BG) dips below normal levels.

Experts disagree on whether 60 or 70 defines a true low. It is very helpful to be aware of how your body feels when it gets to those numbers to guide you in how aggressive the treatment should be. We will use 70 as the definition of a low in this article since it appears to be more widely accepted among healthcare providers and national guidelines. The definition of a severe low is the point at which you require assistance to be treated.

Hypoglycemia causes

insulin hypoglycemia

Hypoglycemia can be caused by a variety of factors.

Your body has 2 main hormones that regulate glucose levels in the body – insulin, and glucagon.  These hormones have opposite functions. Insulin’s job is to tell your body to move glucose out of the bloodstream and into the cells where it can be used as fuel.  Glucagon’s job is to sense when BG levels are low and to tell the liver to release some glucose to fuel your body. In type 2 diabetes, these signaling mechanisms may not work properly. When combined with some of the factors listed below, blood sugar values can drop quickly.

These are some of the most common causes:

  • Medications – Medications are certainly intended to lower blood sugar, but sometimes you get more than you need. This is true of both insulin and some oral medications.
  • Food – Skipping meals and eating fewer carbs than usual can mean less glucose is available to be converted to energy.
  • Exercise – When there is an increase in physical activity, the muscles use up their supply of glucose and go to the bloodstream to get more energy.  Pulling the glucose from the blood can lead to hypoglycemia. (Does this mean exercise is bad? Definitely not! It just means you need to be properly fueled for whatever activity you plan to do.)
  • Alcohol – Drinking excessive alcohol without eating is not advised!
  • Kidney dysfunction – Kidneys are responsible for clearing insulin from the body.  When they aren’t working at full capacity, the insulin stays around longer and can lead to higher insulin concentrations, thereby lowering the glucose.
    What are the signs and symptoms of hypoglycemia?

If you’ve ever experienced the shakiness, weakness, nausea, sweating, intense hunger, fast heartbeat, confusion, and overall feeling crummy, you don’t need any further description of the symptoms of hypoglycemia!

Or, if you’ve ever awakened in the middle of the night sweating like crazy and felt super confused and frightened, you know all about hypoglycemia. You’ve heard stories of other people going into a hypoglycemic coma, or maybe you’ve even had the terrible experience of passing out. In that moment, the only thing important in life is getting your blood sugar UP and doing so FAST.

The ability to recognize these symptoms and check your blood sugar quickly will go a long way toward treating the low and preventing it from progressing.  Can you have a low and have none of these symptoms? Yes, you can. It’s called hypoglycemia unawareness or asymptomatic hypoglycemia which may require the use of a continuous glucose monitor to treat it.

How to treat hypoglycemia

So what should you do when you start to feel a little bit shaky or nauseated? Check your blood sugar!

It is important to know the BG value because that number will help you determine how the situation should be managed. When the value is <70, treatment should begin.

Rule of 15

To treat a true low – BG of 70 or less – the Rule of 15 is followed.  This rule says that you should consume 15 grams of fast-acting carbs. Wait 15 minutes and recheck your BG.  If you’re still less than 70, eat 15 more grams of fast-acting carbs. Repeat that up to 3 times. If this isn’t doing the job of getting you to 100 or more, seek emergency medical treatment for more intense intervention.

Foods to treat hypoglycemia

What do 15 grams of fast-acting carbs look like? Simple carbs or straight glucose.

Can I just eat chocolate or peanut butter?  Chocolate and peanut butter are not recommended in this scenario because they contain plenty of fat and protein.  You don’t want to have to digest fat and protein when you really need a fast-acting carbohydrate! So, even though the candy bar looks great, it won’t provide you sugar fast enough to meet your body’s needs in this situation.

Examples of 15 g of carbohydrates

½ C fruit juice
½ C regular soda (Coke, Sprite, etc)
1 C milk
3 glucose tablets
1 tube glucose gel
5 hard candies
1 Tablespoon of honey, sugar or corn syrup

The caution in treating lows is to not overdo it with simple carbs.  Because the symptoms are so troublesome, you will want to chug an entire gallon of juice just to feel better.  Don’t do that. You’ll end up with the opposite problem for the rest of the day! Your goal is to bring your sugar back to a normal range, not overshoot it. Once you have brought your sugar back to 70 or above, at that point it is a good idea to eat a snack with fat or protein to stabilize your BG.

Don’t use hypoglycemia as permission to go on a carb binge for the rest of the day.  It’s not worth it!

Treating a “false low”

If you are experiencing some of the symptoms of hypoglycemia, but your BG is >70, this is called a false low.  You will definitely want to do something to fix the unpleasant symptoms, but this is not a potentially life-threatening event.  The symptoms likely won’t go away until you eat some carbs, but here’s where the advice is different from a true hypoglycemic event.

WIth a false low (feeling symptoms but blood sugar is >70), your body has likely become accustomed to a higher BG.  When you start to get back into normal BG range, your body will think it’s in a low state, and those feelings will be triggered to signal your body that it wants carbs.  What is happening here is that you are resetting your body’s blood sugar “thermostat” to know what a normal “temperature” (BG) truly is.

Here’s an example to illustrate the point.  Let’s say your A1C is 10%. That translates into an average blood sugar number of about 240 most of the time.  When you start to bring that down, even to 150ish, your body is going to think that it’s low because you’ve trained it to believe that 240 is normal.

In this case, the symptoms of lows will occur, even though your body isn’t in a hypoglycemic crisis.  So, what do you do? You should eat just enough carbs to make the symptoms go away, but also be very careful not to overshoot and end up back in the 250’s for the rest of the day.  It’s tricky to treat because the hypoglycemic symptoms are triggered.

In this case, it’s okay to eat some carbs mixed in with protein and fat.  It’s actually a good idea because it won’t spike your blood sugar too quickly.  The protein and fat will slow down how fast the carbs will be absorbed. You’ll start to feel better, but your blood sugar won’t be sky high for the next several hours.

hypoglycemia management

Preventing hypoglycemia

It’s rarely possible to predict a low.  Some people with diabetes are fortunate enough to rarely if ever have the experience.  For others, it’s a constant battle of watching for the symptoms and treating them.

The first step of prevention is to eat and take your medications on a regular schedule. Skipping meals, over medicating or taking too much insulin are the most common contributing factors to lows. If you’re going to be out all day, take snacks with you! If you need to clarify your medication dose, call your healthcare team to get it figured out. If you are taking insulin and are in the process of adjusting the number of units to get you to a normal blood sugar range, stay on top of glucose checks so that you aren’t taken by surprise.

Many times your BG number may look normal, but be on a downward slide, where a low is right around the corner. Some drugs are more prone to causing lows, just by the way that they work, so even at normally prescribed doses, the risk is still there.  This is most common with sulfonylureas (ex: glipizide, glyburide, glimepiride) or insulin.

Other things that can contribute to lows are alcohol and illnesses.  When alcohol is consumed, especially in large quantities over time, your liver is unable to convert stored glucose into glucose that can be used by the cells to regulate your BG.

With the introduction of continuous glucose monitors over the last few years, people who have frequent lows can benefit from this technology.  The current products on the market (Dexcom, iPro, Freestyle Libre) each have different benefits, features, and costs. The devices are designed to alert you of low BG numbers and tell you the rate at which they are going down so that you can be proactive. Not experience the low in the first place is the easiest way to treat it!

Finally, educating friends and close family members on how to treat lows is also very important. This is crucial for Type 1 diabetics but also advised for Type 2s, especially for those on insulin.  Family members or close friends should know where your quick sources of sugar can be found. In an emergency situation where you are not able to consume real food, honey, syrup or glucose gel can be given to you by a loved one while they are waiting for emergency medical treatment to arrive.


Most people will not forget the experience of a hypoglycemic episode! Prevention is always better than treatment.

What has been your experience? How have you been successful in preventing or treating lows? Tell us in the comments.

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