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Your Checkup: What You Wish Your Doctor Explained
Ever leave the doctor’s office more confused than when you walked in? Your Checkup: What You Wish Your Doctor Explained is your health ally in a world full of fast appointments and even faster Google searches. Each week, a family medicine physician and a pediatric nurse sit down to answer the questions your doctor didn’t have time to.
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Because better understanding leads to better care—and you deserve both.
Your Checkup: What You Wish Your Doctor Explained
Understanding Hypoglycemia Could Save Someone's Life
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We dive deep into hypoglycemia (low blood sugar), exploring its causes, symptoms, and critical treatment options for patients with diabetes and their loved ones. This episode provides essential knowledge that could potentially save lives in emergency situations.
• Hypoglycemia defined as blood sugar below 70 mg/dL, with severe cases below 54 mg/dL
• Common causes include excess insulin/medication, inadequate food intake, vigorous exercise, irregular eating patterns, and alcohol consumption
• Early symptoms include sweating, trembling, hunger and anxiety, progressing to confusion, unusual behavior, and potentially seizures if untreated
• Hypoglycemia unawareness occurs when individuals don't experience warning symptoms, putting them at serious risk
• The 15-15 rule for treatment: consume 15g of fast-acting carbs, wait 15 minutes, recheck blood sugar
• Emergency glucagon (injection or nasal spray) for severe cases when a person cannot safely consume sugar
• Children may sometimes appear asymptomatic with dangerously low blood sugar levels
• Post-hypoglycemia follow-up with healthcare providers is essential to adjust treatment plans
Share this episode with loved ones who have diabetes or anyone who might benefit from understanding how to recognize and respond to low blood sugar emergencies. Sign up for our email list at our website for notifications and additional written materials, or email us at yourcheckuppod@gmail.com.
Production and Content: Edward Delesky, MD & Nicole Aruffo, RN
Artwork: Olivia Pawlowski
Hi, welcome to your checkup. We are the patient education podcast, where we bring conversations from the doctor's office to your ears. On this podcast, we try to bring medicine closer to its patients. I'm Ed Dolesky, a family medicine resident in the Philadelphia area.
Speaker 2:And I'm Nicole Rufo. I'm a nurse.
Speaker 1:And we are so excited you were able to join us here again today. We're really bringing this to you at the end of the night on a Sunday. You are the. This is the biggest sport you've been. I'm pretty sure this is how this went last Easter, is I kind of like we went the whole day and I was like but what about the episode?
Speaker 2:It's like he's going to give me off. It's a big holiday and he didn't, so here I am.
Speaker 1:No, I am so incredibly lucky that, so I had to work today. But I came home and every Easter growing up we would have babka and it's a Polish dessert and that was the thing I would look forward to it, and it seemed like I wasn't going to get it this year. And I come home and there is a whole babka Well, half of a babka, because you took some with you, homemade.
Speaker 2:I took some to my parents because it made a lot.
Speaker 1:On the counter and it was like one of the purest forms or demonstrations of love, and I was left speechless. I could have cried in the moment, and you FaceTimed me immediately when you found out that it happened. And then your brother was there and I didn't want to seem like a wimp and so I didn't, but I was right there and it was just so amazing. And not only did you do it, you kicked ass and you made it amazing as you always do.
Speaker 2:I was pretty impressed with myself. I will say I was pretty impressed with myself. I will say that was the first time I made it and I haven't had a lot of Bobcat in my life, but I feel like it was pretty good. That like dense but flaky, consistent texture. I guess it's really good.
Speaker 1:Yeah, it was amazing. It still is. We're going to probably go grab a couple after we're done here, but I just had to lead off with that because that was just so amazing. All right, and then what else did we do this weekend?
Speaker 2:We had a wedding on Friday.
Speaker 1:We certainly did.
Speaker 2:That was fun. One of us had a lot more fun than the other.
Speaker 1:Yep, definitely did.
Speaker 2:We'll let everyone guess who had the most fun.
Speaker 1:Still don't feel quite right, but congratulations to Dylan and Maria.
Speaker 2:Yeah, allegedly Dylan is coming on our podcast to talk about hypertension that came across our desk at the wedding. Not from him, from someone else.
Speaker 1:Yeah, From his friend from med school.
Speaker 2:Josh, that's what we hear is happening.
Speaker 1:So we'll send this, we'll let them know that he's getting the shout out, at least in the forefront, and then eventually, if he ever wants to come, on, We'll have our people call his people yeah but beautiful wedding, beautiful venue, beautiful ceremony, no notes all around. It was great. Cocktail hour was yeah great cocktail hour. Excellent.
Speaker 2:I feel like I judge a wedding based on its cocktail hour no, it's phenomenal.
Speaker 1:And then when the groomsmen came in, they did the um, that was cool, they like lined up, they announced them all. They lined up and they did the tush push and cj was the quarterback and he was doing like their anniversary, he was yelling and then he was like saying another name of like a thing that Dylan would do in college an inside joke, and so that was fun.
Speaker 1:But no one could hear them because, like the DJ place had like everything going really loud. So later it came to rise that that was a really cool moment. So beautiful, beautiful day. One of us had a lot more fun but, like you know, both of us still had fun. You know what I mean. Let's see what else on the the docket, or should we just dive in now?
Speaker 2:let's see. Do we have anything else to talk about that people didn't ask to hear about? Well growing up, we were a ham family for easter oh yeah, we don't do. We're not a ham family, we're a lamb family. So I brought him. I came home it was like I went grocery shopping came home with all this food for eddie and he had lamb, which I don't know. I really like lamb. I feel like lamb is tastier than ham, but I might just be biased well, the way that you're saying it, you're making it seem like I don't come from a ham family.
Speaker 1:I didn't like the lamb. I I loved the lamb. I know you loved it. Yeah, I loved the lamb.
Speaker 2:I'm just saying like you didn't have your regular Easter things like ham, but you had lamb and it was so good.
Speaker 1:But I had lamb and like it was from, like from you guys, and it's beautiful and like it makes me you or Rufo's have that, or maybe it's a Bucciarelli special, but like I haven't come across that soup before in my travels with your family. The pancake soup.
Speaker 2:Yeah, I feel like the last couple of years we were like doing alternative things or like you know why? Because we would have it like Christmas Day for dinner OK. But we were with my family for Christmas morning and then last year I stayed with my family. You went to your parents.
Speaker 1:Yep, this tracks. This makes much more sense. All in all, it ended up being a beautiful day, and now I am forcing our hand to put this episode together to make sure that we get it out.
Speaker 2:It's going to be coming out hot.
Speaker 1:Coming out hot on Easter Monday.
Speaker 2:It's going to. Let's see what time is it 8.30? In about three and a half hours it'll be live.
Speaker 1:Yeah, man right. Well, why don't we just dive in here? What are we going to talk about today, Nick?
Speaker 2:Today we're talking about hypoglycemia, or low blood sugar.
Speaker 1:Exactly we are going to expand on this is mostly related for people who have diabetes or know someone and love someone with diabetes. This happens to be a very important episode for the loved ones and the neighbors, because you can recognize something going wrong for someone who might have really low blood sugar and you can take action. But all that to say, imagine waking up feeling disoriented, drenched in sweat and shaky. That could be many things, but it could be hypoglycemia. And so hypoglycemia, like you stated, means low blood sugar. Glucose, or blood sugar, is the primary energy source for our bodies and when the levels drop too low, various functions are affected, and so mostly hypoglycemia primarily affects people who have type 1 diabetes who are dependent on insulin, and it can occur with people who have type 2 diabetes and maybe they use insulin or maybe they use specific other medications, like we've talked about in prior episodes sulfonylureas, like glipizide or meglitinides, other medications like that. They can cause hypoglycemia. This is something that you've seen in your travels in pediatrics quite a bit, I take it.
Speaker 2:Oh yeah, A lot.
Speaker 1:Do you think that these themes run true for children and adults, or is there a kind of a partition in how to think about this for children and adults?
Speaker 2:I do think there is sometimes a little bit of a divide. Not that I really know what happens in adults for the most part, but I feel like a lot of the times, like little kids will be very just like acting, normal and asymptomatic, which, like we'll talk about like symptoms of your blood sugar being really low yeah but I don't know if that happens in adults all the time like I feel like an adult or like even just like a bigger kid, like a school-aged kid.
Speaker 2:It's like easier to see like their symptoms of hypoglycemia right like I always think of this one kid we had I won't say his name, obviously, but he had glycogen storage disease and he, like his blood sugar was like a crazy for like however many years, like all over the place, and he would just like regularly be at like 28 oh geez and like running around the unit like a nutcase while we're all chasing him to try to put like apple juice in his g-tube. What?
Speaker 1:a scene.
Speaker 2:Oh man, all right, so this kid's bopping around at 28, but then other people like kids are like regular I don't know if regularly is the word, but more often just like chilling with a really low blood sugar. But an adult, you feel crappy.
Speaker 1:Wow, yeah, so let's dive in a little bit more. So it's important to have a normal blood sugar. I mean, we've talked about this in diabetes, that if it's too high it can wreak havoc on the body, but today we're going to talk about what happens when it's too low. And, as we were talking about, glucose is essential for energy production inside of our cells, and that's why it's important to get in there. And so a normal blood sugar range for someone who hasn't eaten or otherwise stated a fasting blood sugar is somewhere between 70 and 100 milligrams per deciliter, and these levels may fluctuate throughout the day depending on what you're eating, what your activity looks like and various other factors.
Speaker 2:So when someone checks their blood sugar, what number are we looking at? That would be considered hypoglycemia.
Speaker 1:So usually the conversation starts when you get to a blood sugar level of 70 milligrams per deciliter or for those listeners who are out there, not from the United States about 3.9 millimoles per liter. That signifies potential hypoglycemia. That really should require some attention, and we should probably take some steps to address that. Now there's another threshold where we talk about more serious hypoglycemia, and this is when blood sugar levels drop below 54 milligrams per deciliter, or three millimoles per liter, and that you really don't pass go. You need to do something about that right now, because at these levels, the brain may not actually receive sufficient glucose, and this may lead to more severe complications. And so it's important to know that people have individual variation. When they have hypoglycemia, their symptoms may appear at a slightly higher glucose level than someone else. Take someone who has a really high consistent blood sugar level for an extended period of time. I'm thinking of someone whose blood sugar is 300 all the time, or 350. When these people lower their blood sugar, they may experience symptoms of hypoglycemia at higher levels, making these changes even more dramatic and noticeable. So, otherwise stated, even if they aren't at 70 milligrams per deciliter, people with blood sugar levels that high may experience symptoms of hypoglycemia. So this leads us to the next topic of what are the causes of hypoglycemia. Very often this can happen when someone has too much insulin or diabetes medication. There are certain medications, like we mentioned, has too much insulin or diabetes medication. There are certain medications, like we mentioned earlier, like insulin or glipizide, that can lead to lower blood sugar levels.
Speaker 1:If someone isn't eating enough food, they can have low blood sugar. So, otherwise stated, it's important to have enough carbohydrates to balance the effect of insulin. If you're taking it and also skipping meals can lead to some disruptions and affect your sugar balance. There's also a situation where, if you have vigorous exercise and you don't make proper adjustments, so exercise increases the glucose uptake by the muscles and this in itself can significantly lower the blood sugar. So when you take that and combine it with insulin and other medications, you may need to adjust a snack beforehand or adjust the medication dose and something to talk about with your doctor.
Speaker 1:Irregular eating patterns are also something to think about If you have inconsistent meal times. I have a guy who routinely sees me and I think about him with this. He like skips breakfast and then he's away from where he's living and then maybe he has to take his insulin and then boom low blood sugar. And people who drink alcohol like a lot of alcohol consumption can interfere with the liver's ability to release stored glucose and that can lead to problems with hypoglycemia. Especially if someone's drinking alcohol on an empty stomach or exercising, then alcohol and insulin all problematic things.
Speaker 2:Can you tell us about the symptoms of hypoglycemia?
Speaker 1:So there are early symptoms and then there can be more severe symptoms. Early symptoms are along with common warning signs like sweating, trembling, hunger, anxiety. Pay attention to these things because they can be subtle cues to tip you off that maybe you should measure your blood sugar. And then there are more severe symptoms that can come up at lower thresholds, like people get difficulty walking, weakness, blurred vision or unusual behavior, even personality changes and confusion, fainting and, yeah, even seizures can happen from low blood sugar, and so it's important to recognize these symptoms early. But it's also important to recognize that sometimes people have hypoglycemia and they don't have symptoms. This is a whole other entity called hypoglycemia unawareness, and it's a dangerous condition where individuals don't experience the typical warning signs that we just talked about, and it means that their blood sugar can drop dangerously low and they won't even realize it. And the people who are at risk for this are people with longstanding type 1 diabetes I'm talking like 5 to 10 years of symptom burden. And there are other contributing factors, like people who get hypoglycemia a lot, especially with severe episodes like below 54. People who are on a lot of insulin we mentioned alcohol before people who have fatigue, and sometimes, with the balance of assessment from your doctor. Beta blockers can also increase the risk of hypoglycemia unawareness, and so it's important to even think about these, because they can lead to car accidents, injuries, coma and even death.
Speaker 1:A special brand of hypoglycemia unawareness is nocturnal hypoglycemia, and this is low blood sugar.
Speaker 1:That happens when you're asleep and it can be really challenging to detect, but I think more people are picking it up because more often, even if you just have one insulin in your life, you're probably having a continuous glucose monitor.
Speaker 1:Nocturnal hypoglycemia can cause restlessness, nightmares, sweating during sleep and overall poor sleep quality, and so people may feel tired and not recognize why, and it might be a contributing reason. So, because it's a brand of hypoglycemia unawareness, it goes in that same bucket that it might be challenging to diagnose and it's all important to think about. So we mentioned people with nocturnal hypoglycemia might be able to track it more and really the core piece of if you're feeling these symptoms, we should be proactive with blood glucose monitoring, and so if you have insulin, especially, or if you're on a medicine that might lower your blood sugar, this is really an important reason to do those blood sugar checks, and if people have a CGM all the better, because you'll be able to get notifications if your blood sugar drops too low, and you might even be able to let loved ones or neighbors know by pairing them into your system as well.
Speaker 2:How are we treating hypoglycemia?
Speaker 1:Luckily, the treatment is pretty simple, but it's really important to be proactive about it and do it quickly, because delays in treatment can lead to more severe symptoms and complications. So if someone's not having any symptoms of hypoglycemia, it might be reasonable to check it if it's low and then recheck it again sometime later, maybe 15, 20 minutes afterwards, but to avoid activities like driving and maybe have some carbohydrates. But really the best way to go about this is the 15-15 rule, and I explain this to patients in the office and we're going to learn about it here today. So it's the act of consuming fast-acting carbohydrates once you realize that you have hypoglycemia. So if you are feeling these early symptoms, that's when it's ideal to check your blood sugar. If your meter isn't readily available, then you should go ahead and get started with this treatment anyway. So the 15-15 rule is the idea that you would consume 15 grams of fast-acting carbohydrates and then recheck your blood sugar 15 minutes after and, if the blood sugar isn't improved, repeat this process. And so something important to think about is what fast-acting carbs can you have around?
Speaker 1:You can use something like three to four glucose tablets. You can use a hard candy or half a cup of fruit juice. These are important because they're quickly absorbed in the bloodstream. But a couple caveats to note is that initially, you should probably avoid foods that have fat and protein, because they can slow the absorption of the glucose, and really focus on simple carbs. And also, I happen to remember a few patients who go through the hypoglycemia a lot and they tend to have very large amounts of food to counteract the hypoglycemia. And then this starts, this roller coaster where someone has low blood sugar and then they eat a lot and then they spike up and they go from like 50 to 250 in just a matter of moments. And that is a roller coaster, because then they're like, oh, I need insulin again, boom insulin, then low blood sugar, and then it's up and down and down do people do that a lot?
Speaker 2:I see this pretty frequently, and one gentleman in my head is coming to mind and whenever I would be like doing teaching, like you do like the 15 thing and then do that until you're chill and you have a good number, and then you know, worry about like eating and when you're going to cover yourself for insulin, like don't try to fix your low blood sugar with a huge meal, because then that will happen right?
Speaker 1:no, but this is happening and that's why, like it's, I think it's important that we highlight that like 15 grams is not a lot. Like you're, if your doctor's giving you some glucose tabs, it's three to four of them. We're talking about a hard candy, half a cup of juice, not even a full cup. But know that the 15-15 rule there is for a reason Start low, go slow, be measured and take your time. Now, however, if you have severe symptoms, like anything we were discussing before, sometimes you need to move faster, and food or 15 grams of sugar isn't going to get the job done.
Speaker 1:And you and I were talking, before this episode was happening, about the medication that you can use. It's kind of like a once in a day type thing, if it needs to be done, of glucagon, and glucagon is a hormone that rapidly raises the blood sugar. It's available in two different flavors or methods of administration. It is given as an injection or, more recently, a nasal spray, and it can be available in emergency kits with a prescription. And so what thought you've given glucagon before? Right, I actually physically haven't given it to someone, but I prescribe it. Um, do you have any? Like what are you? What's your experience with glucagon?
Speaker 2:Um, I mean, it works.
Speaker 1:There you go, like how quickly I mean honestly like a couple of minutes. That's awesome, yeah, and people tolerate it pretty well.
Speaker 2:Yeah, I mean like, if a kid can tolerate it, sure, an adult can tolerate it. There you go, and I think people are moving toward um, at least in peds are moving toward the um, what's it called?
Speaker 1:Nasal.
Speaker 2:Yeah, baximi. It was like the big brand name. They didn't really ever like stock that on the floor or a pen. We had to like draw it up in a vial. But it gets the job done.
Speaker 1:Sure, and so one thing to mention is that sometimes people do have a reaction to the glucagon, specifically vomiting, and so if you are going to be administering this, or you have a loved one who has diabetes, that you might put them on their side if you're going to give them the glucagon, have you seen anyone vomit from this specifically?
Speaker 2:I don't think so.
Speaker 1:Comes up in the literature. Shout us out in the fan mail if you happen to have experienced this in the past. And truthfully, the last step is that this is the important part of the episode where, if you are a loved one or a neighbor and someone's unconscious and they're not responding, call for help. 911 exists and it's true. Maybe they'll get better after Google gone. Maybe you are so facile in someone's life with diabetes that you know what to do in that moment, but it's never a bad idea to just reach out for help when you feel like you need it. So there is follow-up care after having hypoglycemia.
Speaker 1:Hypoglycemia itself can worsen blood sugar control overall, because your body kind of shuts down and it's like, wow, we didn't like that at all, we just need to hold on to as much sugar as we possibly can. So people with hypoglycemia can have A1Cs that are worse and more uncontrolled. So it's important to go back to your doctor and let them know that this is happening, because adjustments probably need to be made or maybe some extra education. It's also important to recognize that after someone's had hypoglycemia, for about 48 to 72 hours after that event, someone's ability to recognize low blood sugar might be diminished and so someone might flick into that hypoglycemia unawareness symptom. It's always a better idea to check your blood sugar more frequently if you're worried and, at the end of the day, make your doctor a part of the decisions for your treatment plan, because that is what's going to help you most overall. Any last thoughts about hypoglycemia before we wrap up here on an Easter Sunday.
Speaker 2:Nope.
Speaker 1:Wonderful. So, for our loyal listeners out there, I have two requests for you. If you found this episode helpful, share it with a loved one or a neighbor, and my second request is that you go to our little description there and that you sign up for our email list, where we're sending notifications weekly as we release the episodes. These emails will come on a Wednesday. We're going to build out our services and provide some written materials as well, so if you give us that email, you'll be on that list and we'll look forward to being in contact with you. We're putting out more blog posts on Substack that you can find. If you're interested, find us at our website or email us at yourcheckuppod at gmailcom. But, most importantly, stay healthy, my friends, until next time. I'm Ed Dolesky.
Speaker 2:I'm Nicole Rupa.
Speaker 1:Thank you and goodbye. This information may provide a brief overview of diagnosis, treatment and medications. It's not exhaustive and is a tool to help you understand potential options about your health. It doesn't cover all details about conditions, treatments or medications for a specific person. This is not medical advice or an attempt to substitute medical advice. You should contact a healthcare provider for personalized guidance based on your unique circumstances. We explicitly disclaim any liability relating to the information given or its use. This content doesn't endorse any treatments or medications for a specific patient. Always talk to your healthcare provider for complete information tailored to you. In short, I'm not your doctor, I am not your nurse, and make sure you go get your own checkup with your own personal doctor.
