Elevated pulse rate.
Always carry a watch with a sweep second hand.
Knowyour maximum restingpulse rate.
When possiblesymp toms of hypoglycemia appear and youhave no handymeansof testing your blood sugar (a sign of gross negligence), measure your resting pulse.
Many people find it more convenient to measure the temporal pulse (at the temple, on the side of the head between eyebrow and hairline) or carotid pulse (on the side of the neck just below lower edge of jaw and about 1-3 inches forward of the ear) than the radial, or wrist, pulse.If restingpulseexceeds your maximum restingvalueby more than one-third, assume hypoglycemia.
This measurement may be normally elevated if you've been walking about during the prior 10 minutes.
Yourhealth care professional can help you learn how to mea sure your pulse.
This exercise should never be necessary since, of course, you haveyour blood sugar meter with you at all times.
How to Preventand Correct LowBloodSugars 321
Nystagmus.
This symptom may be demonstrated by slowly moving your eyes from side to side while keeping your head immobile.
If an other person is asked to watchyour eyes, shewillnotice, when your blood sugar is low, that they may jerk briefly in the reverse direc tion, or "ratchet," insteadof moving smoothly.
You can observe the ef fect of this by looking at the sweep second hand of your watch.
If it seems occasionally to jump ahead, you are experiencing nystagmus (actually, asyour eyes jumped to the sidefor brief instants,you missed seeing bits of motion of the second hand).
Absence of erections. For a man, a fairly reliable sign of early- morning hypoglycemia is awakening without an erection, assuming that he ordinarily experiences morning erections. Failure to experi ence an erection when sexually stimulated likewise suggests hypo glycemia if this is not a usual problem.
Denial. As hypoglycemia becomes more severe, or if blood sugarhas been dropping slowly, many patients will be certain that their blood sugars are fine. An observer suspecting hypoglycemia should insiston a blood sugar measurementbefore accepting the diabetic's denial.
TREATING MILD TO MODERATE HYPOGLYCEMIA, WITHOUT BLOOD SUGAR OVERSHOOT
Historically, the advice for correction of lowblood sugar has been to consume moderately sweet foods or fluids, such as candybars, fruits, cookies, hard candies, peanut butter crackers, orange juice, milk, and soda pop.
Such treatment has never worked properly, for reasons you canprobablyguess, knowing whatyou nowknowabout variousfoods and how they affect your blood sugar.
These moderately sweet foods contain mixtures of slow- and rapid- acting carbohydrates.
If,forexample, youeator drink enoughthat the rapid-acting carbohydrate in these foods raises yourbloodsugarfrom 40mg/dlup to your targetof 90mg/dloverthe course of halfan hour, you may havesimultaneously consumed so much slow-acting carbo hydrate that your blood sugarwill go up by 300 mg/dl several hours later.
In the old days, beforeI learnedto maintainmyblood sugarin nor-
322 Treatment
mal ranges, my physicians insisted that very high blood sugars after hypoglycemic episodes were due to an"inevitable" hypothetical effect they called rebound,or the Somogyi phenomenon.*Once I learnedto avoidthe usual foods fortreatinglow blood sugar, I never experienced blood sugar rebound. Nevertheless, the scientific literature does de scribe occasional mild insulin resistance that lasts up to 8 hours fol-
SIGNS AND SYMPTOMS OF HYPOGLYCEMIA
Signs andsymptomsof hypoglycemia include the following: • Confusion (e.g., inabilityto read the time or to find things) • Headache • Hand tremors • Tingling sensation in fingers or tongue • Buzzing in ears • Elevated pulserate • Dilated pupils • Great hunger • Tight feeling in throat or near rear of tongue • Numbness or strangesensations in lips or tongue • Clumsiness • Impaired ability to detect sweet tastes • Stubbornness • Inappropriate laughter or joking • Irritability • Nastiness • Anxiety or panic • Pounding hands on tablesand wallsor kicking the floor or other objects • Miscellaneous visualimpairments, such asblurred or double vision, seeing spots,visualhallucinations (e.g., letters or numbers seem to be printed in Chinese)
If your physician stillbelieves whathe learnedin medical schoolabout this fic tional phenomenon, ask him to read "The Somogyi Phenomenon , Sacred Cow or Bull?," Arch Intern Med 1984; 144:781-787.
How toPrevent andCorrect Low Blood Sugars 323
lowing anepisode of very low blood sugar. This isnotthedramatic re bound caused byeating the wrong thing tobring upblood sugar. Hypoglycemia can be hazardous, as the list of its progression on page 318 demonstrates. We therefore want to correct it as rapidly as possible. Complex carbohydrate, fructose, lactose (in milk), and even sucrose, which is used in most candies , all must be digested or
• Poor physical coordination (e.g., bumping into walls and dropping things) • Tiredness • Weakness • Sudden awakening from sleep • Shouting while asleep (or awake) • Rapid shallowbreathing • Nervousness • Light-headedness • Faintness • Hot feeling • Cold or clammy skin, especially on the neck • Resdessness • Insomnia • Nightmares • Pale complexion • Nausea • Slurred speech • Nystagmus (page 321) Several ofthese symptoms may occuratthe sametime. One symptom alone may be the only indicator. In some cases, there may be no clearly apparent early signs or symptoms at all.
324 Treatment
processed by the liver before theywill fully affect blood sugar. This de laymakes these types of carbohydrate poor choices for treating hypo glycemia. Furthermore, you need to know exacdy how much your blood sugar will rise after eating or drinking something to raise it. With most of the traditional treatments you must continually check your blood sugar many hours later to gauge the unpredictable effect.
Raising Blood Sugars Predictably What, then, can we use to raiseblood sugars rapidly with a predictable outcome?
The answer,of course, is glucose.
Glucose, the sugar of blood sugar, does not have to be digested or converted by the liver into anything else.
Unlike other sweets, it's ab sorbed into the blood directiythrough the mucous membranes of the mouth, stomach, and gut.
Furthermore,aswediscussed in Chapter 14, "Using Exercise to Enhance Insulin Sensitivity," we can compute pre ciselyhow much a fixed amount of glucose will raise blood sugar.
If you havetype 2 diabetesand weigh about 140pounds, 1 gram of pure glucose will raise your blood sugar about 5 mg/dl , provided that your blood sugar is below the point at which your pancreas starts to make insulin to bring it down.
If you weigh 140 pounds and have type 1 diabetes, 1 gram of glucose will raise your blood sugar about 5 mg/dl no matter what your blood sugar maybe, becauseyou cannot produce any insulin to offset the glucose.
If you weigh twice that, or 280 pounds, 1 gram will raise your blood sugar only half as much.
A 70-pound diabetic child, on the other hand, will experience double the blood sugar increase, or 10 mg/dl per gram of glucose consumed.
Thus, the effect of ingested glucose on blood sugar is inversely related to your weight.
Table 20-1 gives you the approximate effect of 1 gram glucose upon lowblood sugarfor variousbody weights.
If you have handled glucose tablets,be sure to wash your hands be fore recheckingyour blood sugar.If a source of water is not available, lick the fingeryou intend to prick to remove any residualglucose.
You can dry the finger by wiping it on your clothing or a handkerchief.
Do not keep glucose tablets near your blood sugar meter or test strips!
Many countries have available as candies or confections products that contain virtually all of their nutritive ingredients as glucose.
These glucose tablets are usually sold in pharmacies.
Some countries even have glucose tablets marketed specifically for the treatment of
HowtoPrevent andCorrectLow Blood Sugars 325
TABLE 20-1 EFFECT OF 1 GRAM GLUCOSE UPON LOW BLOOD SUGAR
1 gram glucose will raise Body weight low blood sugar
35 pounds 16 kilograms 20 mg/dl 1.11 mmol/1 70 32 10 0.56 105 48 7 0.39 140 64 5 0.28 175 80 4 0.22 210 95 3.3 0.18 245 111 3 0.17 280 128 2.5 0.14 315 143 2.2 0.12
hypoglycemia in diabetics.
Table 20-2 lists a few of the products with which we are familiar.
Of the glucose tablets listed, I personally prefer Dextrotabs because they're veryeasy to chew, raise blood sugar quite rapidly, taste good, are convenientiy packaged, and are inexpensive.
They are also small enough that they usuallyneed not be broken in halves or quarters to make small blood sugar adjustments (except for children).
Each jar of 100 Dextrotabs* comes with a small plastic envelope that holds 20 tablets flat.
This envelope fits easily into your pocket or purse and can be refilled as often as needed.
For smaller children I prefer Smarties* or Winkies because of their tiny size.
Most glucose tablets begin to raise blood sugar in about 3 minutes and finish after about 45 min utes, if you don't have gastroparesis (if youdo, see Chapter 22).
With thisbackground in mind,howshould you proceed when you encounter a low blood sugar?
*Available at Rosedale Pharmacy, (888) 796-3348.
326 Treatment
TABLE 20-2 GLUCOSE TABLETS USED FOR TREATMENT OF HYPOGLYCEMIA BY DIABETICS
1 tablet will raise blood sugar of Grams of 140-pound person Country of Name of glucose with low blood sugar manufacture product per tablet approximately
USA Dextrotabs 1.6 8 mg/dl 0.44 mmol/1 USA Sweetarts or 2* 10 0.56 WackyWafers USA, UK, B-D Glucose 5 25 1.40 Canada Tablets USA, Canada Smarties or 0.4 2 0.11 Winkiest USA, Canada Dex4 4 20 1.10 UK, Canada Dextro Energy 3 15 0.83 FRG Dextro-Energen 4 20 1.10
Tablet size may vary. 'Availableat kosher stores and at Rosedale Pharmacy or at www.smartiesstore.com. Ideallysuited for children because of their smallsize.