April 21, 2025 • 24 mins
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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
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:03):
Hi, welcome to your checkup.
We are the patient educationpodcast, where we bring
conversations from the doctor'soffice to your ears.
On this podcast, we try tobring medicine closer to its
patients.
I'm Ed Dolesky, a familymedicine resident in the
Philadelphia area.
Speaker 2 (00:17):
And I'm Nicole Rufo.
I'm a nurse.
Speaker 1 (00:19):
And we are so excited you were able to join us here
again today.
We're really bringing this toyou at the end of the night on a
Sunday.
You are the.
This is the biggest sportyou've been.
I'm pretty sure this is howthis went last Easter, is I kind
of like we went the whole dayand I was like but what about
the episode?
Speaker 2 (00:38):
It's like he's going to give me off.
It's a big holiday and hedidn't, so here I am.
Speaker 1 (00:44):
No, I am so incredibly lucky that, so I had
to work today.
But I came home and everyEaster growing up we would have
babka and it's a Polish dessertand that was the thing I would
look forward to it, and itseemed like I wasn't going to
get it this year.
And I come home and there is awhole babka Well, half of a
(01:08):
babka, because you took somewith you, homemade.
Speaker 2 (01:11):
I took some to my parents because it made a lot.
Speaker 1 (01:13):
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 themoment, and you FaceTimed me
immediately when you found outthat it happened.
And then your brother was thereand I didn't want to seem like
a wimp and so I didn't, but Iwas right there and it was just
(01:35):
so amazing.
And not only did you do it, youkicked ass and you made it
amazing as you always do.
Speaker 2 (01:43):
I was pretty impressed with myself.
I will say I was prettyimpressed with myself.
I will say that was the firsttime I made it and I haven't had
a lot of Bobcat in my life, butI feel like it was pretty good.
That like dense but flaky,consistent texture.
I guess it's really good.
Speaker 1 (02:00):
Yeah, it was amazing.
It still is.
We're going to probably go graba couple after we're done here,
but I just had to lead off withthat because that was just so
amazing.
All right, and then what elsedid we do this weekend?
Speaker 2 (02:14):
We had a wedding on Friday.
Speaker 1 (02:16):
We certainly did.
Speaker 2 (02:17):
That was fun.
One of us had a lot more funthan the other.
Speaker 1 (02:21):
Yep, definitely did.
Speaker 2 (02:23):
We'll let everyone guess who had the most fun.
Speaker 1 (02:27):
Still don't feel quite right, but congratulations
to Dylan and Maria.
Speaker 2 (02:31):
Yeah, allegedly Dylan is coming on our podcast to
talk about hypertension thatcame across our desk at the
wedding.
Not from him, from someone else.
Speaker 1 (02:40):
Yeah, From his friend from med school.
Speaker 2 (02:42):
Josh, that's what we hear is happening.
Speaker 1 (02:44):
So we'll send this, we'll let them know that he's
getting the shout out, at leastin the forefront, and then
eventually, if he ever wants tocome, on, We'll have our people
call his people yeah butbeautiful wedding, beautiful
venue, beautiful ceremony, nonotes all around.
It was great.
Cocktail hour was yeah greatcocktail hour.
Excellent.
Speaker 2 (03:05):
I feel like I judge a wedding based on its cocktail
hour no, it's phenomenal.
Speaker 1 (03:08):
And then when the groomsmen came in, they did the
um, that was cool, they likelined up, they announced them
all.
They lined up and they did thetush push and cj was the
quarterback and he was doinglike their anniversary, he was
yelling and then he was likesaying another name of like a
thing that Dylan would do incollege an inside joke, and so
that was fun.
But no one could hear thembecause, like the DJ place had
(03:30):
like everything going reallyloud.
So later it came to rise thatthat was a really cool moment.
So beautiful, beautiful day.
One of us had a lot more funbut, like you know, both of us
still had fun.
You know what I mean.
Let's see what else on the thedocket, or should we just dive
in now?
Speaker 2 (03:50):
let's see.
Do we have anything else totalk about that people didn't
ask to hear about?
Well growing up, we were a hamfamily for easter oh yeah, we
don't do.
We're not a ham family, we're alamb family.
So I brought him.
I came home it was like I wentgrocery shopping came home with
all this food for eddie and hehad lamb, which I don't know.
(04:14):
I really like lamb.
I feel like lamb is tastierthan ham, but I might just be
biased well, the way that you'resaying it, you're making it
seem like I don't come from aham family.
Speaker 1 (04:22):
I didn't like the lamb.
I I loved the lamb.
I know you loved it.
Yeah, I loved the lamb.
Speaker 2 (04:26):
I'm just saying like you didn't have your regular
Easter things like ham, but youhad lamb and it was so good.
Speaker 1 (04:33):
But I had lamb and like it was from, like from you
guys, and it's beautiful andlike it makes me you or Rufo's
have that, or maybe it's aBucciarelli special, but like I
haven't come across that soupbefore in my travels with your
family.
The pancake soup.
Speaker 2 (04:54):
Yeah, I feel like the last couple of years we were
like doing alternative things orlike you know why?
Because we would have it likeChristmas Day for dinner OK.
But we were with my family forChristmas morning and then last
year I stayed with my family.
You went to your parents.
Speaker 1 (05:16):
Yep, this tracks.
This makes much more sense.
All in all, it ended up being abeautiful day, and now I am
forcing our hand to put thisepisode together to make sure
that we get it out.
Speaker 2 (05:28):
It's going to be coming out hot.
Speaker 1 (05:29):
Coming out hot on Easter Monday.
Speaker 2 (05:31):
It's going to.
Let's see what time is it 8.30?
In about three and a half hoursit'll be live.
Speaker 1 (05:39):
Yeah, man right.
Well, why don't we just dive inhere?
What are we going to talk abouttoday, Nick?
Speaker 2 (05:45):
Today we're talking about hypoglycemia, or low blood
sugar.
Speaker 1 (05:51):
Exactly we are going to expand on this is mostly
related for people who havediabetes or know someone and
love someone with diabetes.
This happens to be a veryimportant episode for the loved
ones and the neighbors, becauseyou can recognize something
going wrong for someone whomight have really low blood
sugar and you can take action.
(06:11):
But all that to say, imaginewaking up feeling disoriented,
drenched in sweat and shaky.
That could be many things, butit could be hypoglycemia.
And so hypoglycemia, like youstated, means low blood sugar.
Glucose, or blood sugar, is theprimary energy source for our
bodies and when the levels droptoo low, various functions are
(06:35):
affected, and so mostlyhypoglycemia primarily affects
people who have type 1 diabeteswho are dependent on insulin,
and it can occur with people whohave type 2 diabetes and maybe
they use insulin or maybe theyuse specific other medications,
like we've talked about in priorepisodes sulfonylureas, like
(06:56):
glipizide or meglitinides, othermedications like that.
They can cause hypoglycemia.
This is something that you'veseen in your travels in
pediatrics quite a bit, I takeit.
Speaker 2 (07:09):
Oh yeah, A lot.
Speaker 1 (07:11):
Do you think that these themes run true for
children and adults, or is therea kind of a partition in how to
think about this for childrenand adults?
Speaker 2 (07:20):
I do think there is sometimes a little bit of a
divide.
Not that I really know whathappens in adults for the most
part, but I feel like a lot ofthe times, like little kids will
be very just like acting,normal and asymptomatic, which,
like we'll talk about likesymptoms of your blood sugar
being really low yeah but Idon't know if that happens in
(07:42):
adults all the time like I feellike an adult or like even just
like a bigger kid, like aschool-aged kid.
It's like easier to see liketheir symptoms of hypoglycemia
right like I always think ofthis one kid we had I won't say
his name, obviously, but he hadglycogen storage disease and he,
like his blood sugar was like acrazy for like however many
(08:06):
years, like all over the place,and he would just like regularly
be at like 28 oh geez and likerunning around the unit like a
nutcase while we're all chasinghim to try to put like apple
juice in his g-tube.
What?
Speaker 1 (08:20):
a scene.
Speaker 2 (08:21):
Oh man, all right, so this kid's bopping around at 28
, but then other people likekids are like regular I don't
know if regularly is the word,but more often just like
chilling with a really low bloodsugar.
But an adult, you feel crappy.
Speaker 1 (08:37):
Wow, yeah, so let's dive in a little bit more.
So it's important to have anormal blood sugar.
I mean, we've talked about thisin diabetes, that if it's too
high it can wreak havoc on thebody, but today we're going to
talk about what happens whenit'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
(08:58):
get in there.
And so a normal blood sugarrange for someone who hasn't
eaten or otherwise stated afasting blood sugar is somewhere
between 70 and 100 milligramsper deciliter, and these levels
may fluctuate throughout the daydepending on what you're eating
, what your activity looks likeand various other factors.
Speaker 2 (09:19):
So when someone checks their blood sugar, what
number are we looking at?
That would be consideredhypoglycemia.
Speaker 1 (09:26):
So usually the conversation starts when you get
to a blood sugar level of 70milligrams per deciliter or for
those listeners who are outthere, not from the United
States about 3.9 millimoles perliter.
That signifies potentialhypoglycemia.
That really should require someattention, and we should
probably take some steps toaddress that.
(09:47):
Now there's another thresholdwhere we talk about more serious
hypoglycemia, and this is whenblood sugar levels drop below 54
milligrams per deciliter, orthree millimoles per liter, and
that you really don't pass go.
You need to do something aboutthat right now, because at these
levels, the brain may notactually receive sufficient
(10:09):
glucose, and this may lead tomore severe complications.
And so it's important to knowthat people have individual
variation.
When they have hypoglycemia,their symptoms may appear at a
slightly higher glucose levelthan someone else.
Take someone who has a reallyhigh consistent blood sugar
(10:30):
level for an extended period oftime.
I'm thinking of someone whoseblood sugar is 300 all the time,
or 350.
When these people lower theirblood sugar, they may experience
symptoms of hypoglycemia athigher levels, making these
changes even more dramatic andnoticeable.
So, otherwise stated, even ifthey aren't at 70 milligrams per
(10:53):
deciliter, people with bloodsugar levels that high may
experience symptoms ofhypoglycemia.
So this leads us to the nexttopic of what are the causes of
hypoglycemia.
Very often this can happen whensomeone has too much insulin or
diabetes medication.
There are certain medications,like we mentioned, has too much
insulin or diabetes medication.
(11:14):
There are certain medications,like we mentioned earlier, like
insulin or glipizide, that canlead to lower blood sugar levels
.
If someone isn't eating enoughfood, they can have low blood
sugar.
So, otherwise stated, it'simportant to have enough
carbohydrates to balance theeffect of insulin.
If you're taking it and alsoskipping meals can lead to some
disruptions and affect yoursugar balance.
There's also a situation where,if you have vigorous exercise
(11:39):
and you don't make properadjustments, so exercise
increases the glucose uptake bythe muscles and this in itself
can significantly lower theblood sugar.
So when you take that andcombine it with insulin and
other medications, you may needto adjust a snack beforehand or
adjust the medication dose andsomething to talk about with
(12:00):
your doctor.
Irregular eating patterns arealso something to think about If
you have inconsistent mealtimes.
I have a guy who routinely seesme and I think about him with
this.
He like skips breakfast andthen he's away from where he's
living and then maybe he has totake his insulin and then boom
low blood sugar.
And people who drink alcohollike a lot of alcohol
(12:23):
consumption can interfere withthe liver's ability to release
stored glucose and that can leadto problems with hypoglycemia.
Especially if someone'sdrinking alcohol on an empty
stomach or exercising, thenalcohol and insulin all
problematic things.
Speaker 2 (12:42):
Can you tell us about the symptoms of hypoglycemia?
Speaker 1 (12:45):
So there are early symptoms and then there can be
more severe symptoms.
Early symptoms are along withcommon warning signs like
sweating, trembling, hunger,anxiety.
Pay attention to these thingsbecause they can be subtle cues
to tip you off that maybe youshould measure your blood sugar.
And then there are more severesymptoms that can come up at
(13:08):
lower thresholds, like peopleget difficulty walking, weakness
, blurred vision or unusualbehavior, even personality
changes and confusion, faintingand, yeah, even seizures can
happen from low blood sugar, andso it's important to recognize
these symptoms early.
But it's also important torecognize that sometimes people
(13:31):
have hypoglycemia and they don'thave symptoms.
This is a whole other entitycalled hypoglycemia unawareness,
and it's a dangerous conditionwhere individuals don't
experience the typical warningsigns that we just talked about,
and it means that their bloodsugar can drop dangerously low
and they won't even realize it.
(13:52):
And the people who are at riskfor this are people with
longstanding type 1 diabetes I'mtalking like 5 to 10 years of
symptom burden.
And there are othercontributing factors, like
people who get hypoglycemia alot, especially with severe
episodes like below 54.
(14:12):
People who are on a lot ofinsulin we mentioned alcohol
before people who have fatigue,and sometimes, with the balance
of assessment from your doctor.
Beta blockers can also increasethe risk of hypoglycemia
unawareness, and so it'simportant to even think about
(14:32):
these, because they can lead tocar accidents, injuries, coma
and even death.
A special brand of hypoglycemiaunawareness is nocturnal
hypoglycemia, and this is lowblood sugar.
That happens when you're asleepand it can be really challenging
to detect, but I think morepeople are picking it up because
more often, even if you justhave one insulin in your life,
(14:54):
you're probably having acontinuous glucose monitor.
Nocturnal hypoglycemia can causerestlessness, nightmares,
sweating during sleep andoverall poor sleep quality, and
so people may feel tired and notrecognize why, and it might be
a contributing reason.
So, because it's a brand ofhypoglycemia unawareness, it
(15:15):
goes in that same bucket that itmight be challenging to
diagnose and it's all importantto think about.
So we mentioned people withnocturnal hypoglycemia might be
able to track it more and reallythe core piece of if you're
feeling these symptoms, weshould be proactive with blood
glucose monitoring, and so ifyou have insulin, especially, or
(15:36):
if you're on a medicine thatmight lower your blood sugar,
this is really an importantreason to do those blood sugar
checks, and if people have a CGMall the better, because you'll
be able to get notifications ifyour blood sugar drops too low,
and you might even be able tolet loved ones or neighbors know
by pairing them into yoursystem as well.
Speaker 2 (15:58):
How are we treating hypoglycemia?
Speaker 1 (16:01):
Luckily, the treatment is pretty simple, but
it's really important to beproactive about it and do it
quickly, because delays intreatment can lead to more
severe symptoms andcomplications.
So if someone's not having anysymptoms of hypoglycemia, it
might be reasonable to check itif it's low and then recheck it
again sometime later, maybe 15,20 minutes afterwards, but to
(16:23):
avoid activities like drivingand maybe have some
carbohydrates.
But really the best way to goabout this is the 15-15 rule,
and I explain this to patientsin the office and we're going to
learn about it here today.
So it's the act of consumingfast-acting carbohydrates once
you realize that you havehypoglycemia.
(16:45):
So if you are feeling theseearly symptoms, that's when it's
ideal to check your blood sugar.
If your meter isn't readilyavailable, then you should go
ahead and get started with thistreatment anyway.
So the 15-15 rule is the ideathat you would consume 15 grams
of fast-acting carbohydrates andthen recheck your blood sugar
(17:08):
15 minutes after and, if theblood sugar isn't improved,
repeat this process.
And so something important tothink about is what fast-acting
carbs can you have around?
You can use something like threeto four glucose tablets.
You can use a hard candy orhalf a cup of fruit juice.
These are important becausethey're quickly absorbed in the
(17:29):
bloodstream.
But a couple caveats to note isthat initially, you should
probably avoid foods that havefat and protein, because they
can slow the absorption of theglucose, and really focus on
simple carbs.
And also, I happen to remembera few patients who go through
the hypoglycemia a lot and theytend to have very large amounts
(17:52):
of food to counteract thehypoglycemia.
And then this starts, thisroller coaster where someone has
low blood sugar and then theyeat a lot and then they spike up
and they go from like 50 to 250in just a matter of moments.
And that is a roller coaster,because then they're like, oh, I
need insulin again, boominsulin, then low blood sugar,
(18:14):
and then it's up and down anddown do people do that a lot?
Speaker 2 (18:18):
I see this pretty frequently, and one gentleman in
my head is coming to mind andwhenever I would be like doing
teaching, like you do like the15 thing and then do that until
you're chill and you have a goodnumber, and then you know,
worry about like eating and whenyou're going to cover yourself
for insulin, like don't try tofix your low blood sugar with a
(18:41):
huge meal, because then thatwill happen right?
Speaker 1 (18:43):
no, but this is happening and that's why, like
it's, I think it's importantthat we highlight that like 15
grams is not a lot.
Like you're, if your doctor'sgiving you some glucose tabs,
it's three to four of them.
We're talking about a hardcandy, half a cup of juice, not
even a full cup.
But know that the 15-15 rulethere is for a reason Start low,
(19:04):
go slow, be measured and takeyour time.
Now, however, if you havesevere symptoms, like anything
we were discussing before,sometimes you need to move
faster, and food or 15 grams ofsugar isn't going to get the job
(19:24):
done.
And you and I were talking,before this episode was
happening, about the medicationthat you can use.
It's kind of like a once in aday type thing, if it needs to
be done, of glucagon, andglucagon is a hormone that
rapidly raises the blood sugar.
It's available in two differentflavors or methods of
administration.
It is given as an injection or,more recently, a nasal spray,
(19:49):
and it can be available inemergency kits with a
prescription.
And so what thought you'vegiven glucagon before?
Right, I actually physicallyhaven't given it to someone, but
I prescribe it.
Um, do you have any?
Like what are you?
What's your experience withglucagon?
Speaker 2 (20:05):
Um, I mean, it works.
Speaker 1 (20:07):
There you go, like how quickly I mean honestly like
a couple of minutes.
That's awesome, yeah, andpeople tolerate it pretty well.
Speaker 2 (20:16):
Yeah, I mean like, if a kid can tolerate it, sure, an
adult can tolerate it.
There you go, and I thinkpeople are moving toward um, at
least in peds are moving towardthe um, what's it called?
Speaker 1 (20:32):
Nasal.
Speaker 2 (20:33):
Yeah, baximi.
It was like the big brand name.
They didn't really ever likestock that on the floor or a pen
.
We had to like draw it up in avial.
But it gets the job done.
Speaker 1 (20:46):
Sure, and so one thing to mention is that
sometimes people do have areaction to the glucagon,
specifically vomiting, and so ifyou are going to be
administering this, or you havea loved one who has diabetes,
that you might put them on theirside if you're going to give
them the glucagon, have you seenanyone vomit from this
specifically?
Speaker 2 (21:04):
I don't think so.
Speaker 1 (21:06):
Comes up in the literature.
Shout us out in the fan mail ifyou happen to have experienced
this in the past.
And truthfully, the last stepis that this is the important
part of the episode where, ifyou are a loved one or a
neighbor and someone'sunconscious and they're not
responding, call for help.
911 exists and it's true.
Maybe they'll get better afterGoogle gone.
(21:27):
Maybe you are so facile insomeone's life with diabetes
that you know what to do in thatmoment, but it's never a bad
idea to just reach out for helpwhen you feel like you need it.
So there is follow-up careafter having hypoglycemia.
Hypoglycemia itself can worsenblood sugar control overall,
because your body kind of shutsdown and it's like, wow, we
(21:49):
didn't like that at all, we justneed to hold on to as much
sugar as we possibly can.
So people with hypoglycemia canhave A1Cs that are worse and
more uncontrolled.
So it's important to go back toyour doctor and let them know
that this is happening, becauseadjustments probably need to be
made or maybe some extraeducation.
It's also important torecognize that after someone's
(22:10):
had hypoglycemia, for about 48to 72 hours after that event,
someone's ability to recognizelow blood sugar might be
diminished and so someone mightflick into that hypoglycemia
unawareness symptom.
It's always a better idea tocheck your blood sugar more
frequently if you're worried and, at the end of the day, make
your doctor a part of thedecisions for your treatment
(22:32):
plan, because that is what'sgoing to help you most overall.
Any last thoughts abouthypoglycemia before we wrap up
here on an Easter Sunday.
Speaker 2 (22:41):
Nope.
Speaker 1 (22:42):
Wonderful.
So, for our loyal listeners outthere, I have two requests for
you.
If you found this episodehelpful, share it with a loved
one or a neighbor, and my secondrequest is that you go to our
little description there andthat you sign up for our email
list, where we're sendingnotifications weekly as we
release the episodes.
(23:02):
These emails will come on aWednesday.
We're going to build out ourservices and provide some
written materials as well, so ifyou give us that email, you'll
be on that list and we'll lookforward to being in contact with
you.
We're putting out more blogposts on Substack that you can
find.
If you're interested, find usat our website or email us at
yourcheckuppod at gmailcom.
(23:24):
But, most importantly, stayhealthy, my friends, until next
time.
I'm Ed Dolesky.
Speaker 2 (23:30):
I'm Nicole Rupa.
Speaker 1 (23:31):
Thank you and goodbye .
This information may provide abrief overview of diagnosis,
treatment and medications.
It's not exhaustive and is atool to help you understand
potential options about yourhealth.
It doesn't cover all detailsabout conditions, treatments or
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This is not medical advice oran attempt to substitute medical
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You should contact a healthcareprovider for personalized
(23:51):
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We explicitly disclaim anyliability relating to the
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This content doesn't endorseany treatments or medications
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Always talk to your healthcareprovider for complete
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In short, I'm not your doctor,I am not your nurse, and make
sure you go get your own checkupwith your own personal doctor.
Hi, welcome to your checkup.
We are the patient educationpodcast, where we bring
conversations from the doctor'soffice to your ears.
On this podcast, we try tobring medicine closer to its
patients.
I'm Ed Dolesky, a familymedicine resident in the
Philadelphia area.
Speaker 2 (00:17):
And I'm Nicole Rufo.
I'm a nurse.
Speaker 1 (00:19):
And we are so excited you were able to join us here
again today.
We're really bringing this toyou at the end of the night on a
Sunday.
You are the.
This is the biggest sportyou've been.
I'm pretty sure this is howthis went last Easter, is I kind
of like we went the whole dayand I was like but what about
the episode?
Speaker 2 (00:38):
It's like he's going to give me off.
It's a big holiday and hedidn't, so here I am.
Speaker 1 (00:44):
No, I am so incredibly lucky that, so I had
to work today.
But I came home and everyEaster growing up we would have
babka and it's a Polish dessertand that was the thing I would
look forward to it, and itseemed like I wasn't going to
get it this year.
And I come home and there is awhole babka Well, half of a
(01:08):
babka, because you took somewith you, homemade.
Speaker 2 (01:11):
I took some to my parents because it made a lot.
Speaker 1 (01:13):
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 themoment, and you FaceTimed me
immediately when you found outthat it happened.
And then your brother was thereand I didn't want to seem like
a wimp and so I didn't, but Iwas right there and it was just
(01:35):
so amazing.
And not only did you do it, youkicked ass and you made it
amazing as you always do.
Speaker 2 (01:43):
I was pretty impressed with myself.
I will say I was prettyimpressed with myself.
I will say that was the firsttime I made it and I haven't had
a lot of Bobcat in my life, butI feel like it was pretty good.
That like dense but flaky,consistent texture.
I guess it's really good.
Speaker 1 (02:00):
Yeah, it was amazing.
It still is.
We're going to probably go graba couple after we're done here,
but I just had to lead off withthat because that was just so
amazing.
All right, and then what elsedid we do this weekend?
Speaker 2 (02:14):
We had a wedding on Friday.
Speaker 1 (02:16):
We certainly did.
Speaker 2 (02:17):
That was fun.
One of us had a lot more funthan the other.
Speaker 1 (02:21):
Yep, definitely did.
Speaker 2 (02:23):
We'll let everyone guess who had the most fun.
Speaker 1 (02:27):
Still don't feel quite right, but congratulations
to Dylan and Maria.
Speaker 2 (02:31):
Yeah, allegedly Dylan is coming on our podcast to
talk about hypertension thatcame across our desk at the
wedding.
Not from him, from someone else.
Speaker 1 (02:40):
Yeah, From his friend from med school.
Speaker 2 (02:42):
Josh, that's what we hear is happening.
Speaker 1 (02:44):
So we'll send this, we'll let them know that he's
getting the shout out, at leastin the forefront, and then
eventually, if he ever wants tocome, on, We'll have our people
call his people yeah butbeautiful wedding, beautiful
venue, beautiful ceremony, nonotes all around.
It was great.
Cocktail hour was yeah greatcocktail hour.
Excellent.
Speaker 2 (03:05):
I feel like I judge a wedding based on its cocktail
hour no, it's phenomenal.
Speaker 1 (03:08):
And then when the groomsmen came in, they did the
um, that was cool, they likelined up, they announced them
all.
They lined up and they did thetush push and cj was the
quarterback and he was doinglike their anniversary, he was
yelling and then he was likesaying another name of like a
thing that Dylan would do incollege an inside joke, and so
that was fun.
But no one could hear thembecause, like the DJ place had
(03:30):
like everything going reallyloud.
So later it came to rise thatthat was a really cool moment.
So beautiful, beautiful day.
One of us had a lot more funbut, like you know, both of us
still had fun.
You know what I mean.
Let's see what else on the thedocket, or should we just dive
in now?
Speaker 2 (03:50):
let's see.
Do we have anything else totalk about that people didn't
ask to hear about?
Well growing up, we were a hamfamily for easter oh yeah, we
don't do.
We're not a ham family, we're alamb family.
So I brought him.
I came home it was like I wentgrocery shopping came home with
all this food for eddie and hehad lamb, which I don't know.
(04:14):
I really like lamb.
I feel like lamb is tastierthan ham, but I might just be
biased well, the way that you'resaying it, you're making it
seem like I don't come from aham family.
Speaker 1 (04:22):
I didn't like the lamb.
I I loved the lamb.
I know you loved it.
Yeah, I loved the lamb.
Speaker 2 (04:26):
I'm just saying like you didn't have your regular
Easter things like ham, but youhad lamb and it was so good.
Speaker 1 (04:33):
But I had lamb and like it was from, like from you
guys, and it's beautiful andlike it makes me you or Rufo's
have that, or maybe it's aBucciarelli special, but like I
haven't come across that soupbefore in my travels with your
family.
The pancake soup.
Speaker 2 (04:54):
Yeah, I feel like the last couple of years we were
like doing alternative things orlike you know why?
Because we would have it likeChristmas Day for dinner OK.
But we were with my family forChristmas morning and then last
year I stayed with my family.
You went to your parents.
Speaker 1 (05:16):
Yep, this tracks.
This makes much more sense.
All in all, it ended up being abeautiful day, and now I am
forcing our hand to put thisepisode together to make sure
that we get it out.
Speaker 2 (05:28):
It's going to be coming out hot.
Speaker 1 (05:29):
Coming out hot on Easter Monday.
Speaker 2 (05:31):
It's going to.
Let's see what time is it 8.30?
In about three and a half hoursit'll be live.
Speaker 1 (05:39):
Yeah, man right.
Well, why don't we just dive inhere?
What are we going to talk abouttoday, Nick?
Speaker 2 (05:45):
Today we're talking about hypoglycemia, or low blood
sugar.
Speaker 1 (05:51):
Exactly we are going to expand on this is mostly
related for people who havediabetes or know someone and
love someone with diabetes.
This happens to be a veryimportant episode for the loved
ones and the neighbors, becauseyou can recognize something
going wrong for someone whomight have really low blood
sugar and you can take action.
(06:11):
But all that to say, imaginewaking up feeling disoriented,
drenched in sweat and shaky.
That could be many things, butit could be hypoglycemia.
And so hypoglycemia, like youstated, means low blood sugar.
Glucose, or blood sugar, is theprimary energy source for our
bodies and when the levels droptoo low, various functions are
(06:35):
affected, and so mostlyhypoglycemia primarily affects
people who have type 1 diabeteswho are dependent on insulin,
and it can occur with people whohave type 2 diabetes and maybe
they use insulin or maybe theyuse specific other medications,
like we've talked about in priorepisodes sulfonylureas, like
(06:56):
glipizide or meglitinides, othermedications like that.
They can cause hypoglycemia.
This is something that you'veseen in your travels in
pediatrics quite a bit, I takeit.
Speaker 2 (07:09):
Oh yeah, A lot.
Speaker 1 (07:11):
Do you think that these themes run true for
children and adults, or is therea kind of a partition in how to
think about this for childrenand adults?
Speaker 2 (07:20):
I do think there is sometimes a little bit of a
divide.
Not that I really know whathappens in adults for the most
part, but I feel like a lot ofthe times, like little kids will
be very just like acting,normal and asymptomatic, which,
like we'll talk about likesymptoms of your blood sugar
being really low yeah but Idon't know if that happens in
(07:42):
adults all the time like I feellike an adult or like even just
like a bigger kid, like aschool-aged kid.
It's like easier to see liketheir symptoms of hypoglycemia
right like I always think ofthis one kid we had I won't say
his name, obviously, but he hadglycogen storage disease and he,
like his blood sugar was like acrazy for like however many
(08:06):
years, like all over the place,and he would just like regularly
be at like 28 oh geez and likerunning around the unit like a
nutcase while we're all chasinghim to try to put like apple
juice in his g-tube.
What?
Speaker 1 (08:20):
a scene.
Speaker 2 (08:21):
Oh man, all right, so this kid's bopping around at 28
, but then other people likekids are like regular I don't
know if regularly is the word,but more often just like
chilling with a really low bloodsugar.
But an adult, you feel crappy.
Speaker 1 (08:37):
Wow, yeah, so let's dive in a little bit more.
So it's important to have anormal blood sugar.
I mean, we've talked about thisin diabetes, that if it's too
high it can wreak havoc on thebody, but today we're going to
talk about what happens whenit'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
(08:58):
get in there.
And so a normal blood sugarrange for someone who hasn't
eaten or otherwise stated afasting blood sugar is somewhere
between 70 and 100 milligramsper deciliter, and these levels
may fluctuate throughout the daydepending on what you're eating
, what your activity looks likeand various other factors.
Speaker 2 (09:19):
So when someone checks their blood sugar, what
number are we looking at?
That would be consideredhypoglycemia.
Speaker 1 (09:26):
So usually the conversation starts when you get
to a blood sugar level of 70milligrams per deciliter or for
those listeners who are outthere, not from the United
States about 3.9 millimoles perliter.
That signifies potentialhypoglycemia.
That really should require someattention, and we should
probably take some steps toaddress that.
(09:47):
Now there's another thresholdwhere we talk about more serious
hypoglycemia, and this is whenblood sugar levels drop below 54
milligrams per deciliter, orthree millimoles per liter, and
that you really don't pass go.
You need to do something aboutthat right now, because at these
levels, the brain may notactually receive sufficient
(10:09):
glucose, and this may lead tomore severe complications.
And so it's important to knowthat people have individual
variation.
When they have hypoglycemia,their symptoms may appear at a
slightly higher glucose levelthan someone else.
Take someone who has a reallyhigh consistent blood sugar
(10:30):
level for an extended period oftime.
I'm thinking of someone whoseblood sugar is 300 all the time,
or 350.
When these people lower theirblood sugar, they may experience
symptoms of hypoglycemia athigher levels, making these
changes even more dramatic andnoticeable.
So, otherwise stated, even ifthey aren't at 70 milligrams per
(10:53):
deciliter, people with bloodsugar levels that high may
experience symptoms ofhypoglycemia.
So this leads us to the nexttopic of what are the causes of
hypoglycemia.
Very often this can happen whensomeone has too much insulin or
diabetes medication.
There are certain medications,like we mentioned, has too much
insulin or diabetes medication.
(11:14):
There are certain medications,like we mentioned earlier, like
insulin or glipizide, that canlead to lower blood sugar levels
.
If someone isn't eating enoughfood, they can have low blood
sugar.
So, otherwise stated, it'simportant to have enough
carbohydrates to balance theeffect of insulin.
If you're taking it and alsoskipping meals can lead to some
disruptions and affect yoursugar balance.
There's also a situation where,if you have vigorous exercise
(11:39):
and you don't make properadjustments, so exercise
increases the glucose uptake bythe muscles and this in itself
can significantly lower theblood sugar.
So when you take that andcombine it with insulin and
other medications, you may needto adjust a snack beforehand or
adjust the medication dose andsomething to talk about with
(12:00):
your doctor.
Irregular eating patterns arealso something to think about If
you have inconsistent mealtimes.
I have a guy who routinely seesme and I think about him with
this.
He like skips breakfast andthen he's away from where he's
living and then maybe he has totake his insulin and then boom
low blood sugar.
And people who drink alcohollike a lot of alcohol
(12:23):
consumption can interfere withthe liver's ability to release
stored glucose and that can leadto problems with hypoglycemia.
Especially if someone'sdrinking alcohol on an empty
stomach or exercising, thenalcohol and insulin all
problematic things.
Speaker 2 (12:42):
Can you tell us about the symptoms of hypoglycemia?
Speaker 1 (12:45):
So there are early symptoms and then there can be
more severe symptoms.
Early symptoms are along withcommon warning signs like
sweating, trembling, hunger,anxiety.
Pay attention to these thingsbecause they can be subtle cues
to tip you off that maybe youshould measure your blood sugar.
And then there are more severesymptoms that can come up at
(13:08):
lower thresholds, like peopleget difficulty walking, weakness
, blurred vision or unusualbehavior, even personality
changes and confusion, faintingand, yeah, even seizures can
happen from low blood sugar, andso it's important to recognize
these symptoms early.
But it's also important torecognize that sometimes people
(13:31):
have hypoglycemia and they don'thave symptoms.
This is a whole other entitycalled hypoglycemia unawareness,
and it's a dangerous conditionwhere individuals don't
experience the typical warningsigns that we just talked about,
and it means that their bloodsugar can drop dangerously low
and they won't even realize it.
(13:52):
And the people who are at riskfor this are people with
longstanding type 1 diabetes I'mtalking like 5 to 10 years of
symptom burden.
And there are othercontributing factors, like
people who get hypoglycemia alot, especially with severe
episodes like below 54.
(14:12):
People who are on a lot ofinsulin we mentioned alcohol
before people who have fatigue,and sometimes, with the balance
of assessment from your doctor.
Beta blockers can also increasethe risk of hypoglycemia
unawareness, and so it'simportant to even think about
(14:32):
these, because they can lead tocar accidents, injuries, coma
and even death.
A special brand of hypoglycemiaunawareness is nocturnal
hypoglycemia, and this is lowblood sugar.
That happens when you're asleepand it can be really challenging
to detect, but I think morepeople are picking it up because
more often, even if you justhave one insulin in your life,
(14:54):
you're probably having acontinuous glucose monitor.
Nocturnal hypoglycemia can causerestlessness, nightmares,
sweating during sleep andoverall poor sleep quality, and
so people may feel tired and notrecognize why, and it might be
a contributing reason.
So, because it's a brand ofhypoglycemia unawareness, it
(15:15):
goes in that same bucket that itmight be challenging to
diagnose and it's all importantto think about.
So we mentioned people withnocturnal hypoglycemia might be
able to track it more and reallythe core piece of if you're
feeling these symptoms, weshould be proactive with blood
glucose monitoring, and so ifyou have insulin, especially, or
(15:36):
if you're on a medicine thatmight lower your blood sugar,
this is really an importantreason to do those blood sugar
checks, and if people have a CGMall the better, because you'll
be able to get notifications ifyour blood sugar drops too low,
and you might even be able tolet loved ones or neighbors know
by pairing them into yoursystem as well.
Speaker 2 (15:58):
How are we treating hypoglycemia?
Speaker 1 (16:01):
Luckily, the treatment is pretty simple, but
it's really important to beproactive about it and do it
quickly, because delays intreatment can lead to more
severe symptoms andcomplications.
So if someone's not having anysymptoms of hypoglycemia, it
might be reasonable to check itif it's low and then recheck it
again sometime later, maybe 15,20 minutes afterwards, but to
(16:23):
avoid activities like drivingand maybe have some
carbohydrates.
But really the best way to goabout this is the 15-15 rule,
and I explain this to patientsin the office and we're going to
learn about it here today.
So it's the act of consumingfast-acting carbohydrates once
you realize that you havehypoglycemia.
(16:45):
So if you are feeling theseearly symptoms, that's when it's
ideal to check your blood sugar.
If your meter isn't readilyavailable, then you should go
ahead and get started with thistreatment anyway.
So the 15-15 rule is the ideathat you would consume 15 grams
of fast-acting carbohydrates andthen recheck your blood sugar
(17:08):
15 minutes after and, if theblood sugar isn't improved,
repeat this process.
And so something important tothink about is what fast-acting
carbs can you have around?
You can use something like threeto four glucose tablets.
You can use a hard candy orhalf a cup of fruit juice.
These are important becausethey're quickly absorbed in the
(17:29):
bloodstream.
But a couple caveats to note isthat initially, you should
probably avoid foods that havefat and protein, because they
can slow the absorption of theglucose, and really focus on
simple carbs.
And also, I happen to remembera few patients who go through
the hypoglycemia a lot and theytend to have very large amounts
(17:52):
of food to counteract thehypoglycemia.
And then this starts, thisroller coaster where someone has
low blood sugar and then theyeat a lot and then they spike up
and they go from like 50 to 250in just a matter of moments.
And that is a roller coaster,because then they're like, oh, I
need insulin again, boominsulin, then low blood sugar,
(18:14):
and then it's up and down anddown do people do that a lot?
Speaker 2 (18:18):
I see this pretty frequently, and one gentleman in
my head is coming to mind andwhenever I would be like doing
teaching, like you do like the15 thing and then do that until
you're chill and you have a goodnumber, and then you know,
worry about like eating and whenyou're going to cover yourself
for insulin, like don't try tofix your low blood sugar with a
(18:41):
huge meal, because then thatwill happen right?
Speaker 1 (18:43):
no, but this is happening and that's why, like
it's, I think it's importantthat we highlight that like 15
grams is not a lot.
Like you're, if your doctor'sgiving you some glucose tabs,
it's three to four of them.
We're talking about a hardcandy, half a cup of juice, not
even a full cup.
But know that the 15-15 rulethere is for a reason Start low,
(19:04):
go slow, be measured and takeyour time.
Now, however, if you havesevere symptoms, like anything
we were discussing before,sometimes you need to move
faster, and food or 15 grams ofsugar isn't going to get the job
(19:24):
done.
And you and I were talking,before this episode was
happening, about the medicationthat you can use.
It's kind of like a once in aday type thing, if it needs to
be done, of glucagon, andglucagon is a hormone that
rapidly raises the blood sugar.
It's available in two differentflavors or methods of
administration.
It is given as an injection or,more recently, a nasal spray,
(19:49):
and it can be available inemergency kits with a
prescription.
And so what thought you'vegiven glucagon before?
Right, I actually physicallyhaven't given it to someone, but
I prescribe it.
Um, do you have any?
Like what are you?
What's your experience withglucagon?
Speaker 2 (20:05):
Um, I mean, it works.
Speaker 1 (20:07):
There you go, like how quickly I mean honestly like
a couple of minutes.
That's awesome, yeah, andpeople tolerate it pretty well.
Speaker 2 (20:16):
Yeah, I mean like, if a kid can tolerate it, sure, an
adult can tolerate it.
There you go, and I thinkpeople are moving toward um, at
least in peds are moving towardthe um, what's it called?
Speaker 1 (20:32):
Nasal.
Speaker 2 (20:33):
Yeah, baximi.
It was like the big brand name.
They didn't really ever likestock that on the floor or a pen
.
We had to like draw it up in avial.
But it gets the job done.
Speaker 1 (20:46):
Sure, and so one thing to mention is that
sometimes people do have areaction to the glucagon,
specifically vomiting, and so ifyou are going to be
administering this, or you havea loved one who has diabetes,
that you might put them on theirside if you're going to give
them the glucagon, have you seenanyone vomit from this
specifically?
Speaker 2 (21:04):
I don't think so.
Speaker 1 (21:06):
Comes up in the literature.
Shout us out in the fan mail ifyou happen to have experienced
this in the past.
And truthfully, the last stepis that this is the important
part of the episode where, ifyou are a loved one or a
neighbor and someone'sunconscious and they're not
responding, call for help.
911 exists and it's true.
Maybe they'll get better afterGoogle gone.
(21:27):
Maybe you are so facile insomeone's life with diabetes
that you know what to do in thatmoment, but it's never a bad
idea to just reach out for helpwhen you feel like you need it.
So there is follow-up careafter having hypoglycemia.
Hypoglycemia itself can worsenblood sugar control overall,
because your body kind of shutsdown and it's like, wow, we
(21:49):
didn't like that at all, we justneed to hold on to as much
sugar as we possibly can.
So people with hypoglycemia canhave A1Cs that are worse and
more uncontrolled.
So it's important to go back toyour doctor and let them know
that this is happening, becauseadjustments probably need to be
made or maybe some extraeducation.
It's also important torecognize that after someone's
(22:10):
had hypoglycemia, for about 48to 72 hours after that event,
someone's ability to recognizelow blood sugar might be
diminished and so someone mightflick into that hypoglycemia
unawareness symptom.
It's always a better idea tocheck your blood sugar more
frequently if you're worried and, at the end of the day, make
your doctor a part of thedecisions for your treatment
(22:32):
plan, because that is what'sgoing to help you most overall.
Any last thoughts abouthypoglycemia before we wrap up
here on an Easter Sunday.
Speaker 2 (22:41):
Nope.
Speaker 1 (22:42):
Wonderful.
So, for our loyal listeners outthere, I have two requests for
you.
If you found this episodehelpful, share it with a loved
one or a neighbor, and my secondrequest is that you go to our
little description there andthat you sign up for our email
list, where we're sendingnotifications weekly as we
release the episodes.
(23:02):
These emails will come on aWednesday.
We're going to build out ourservices and provide some
written materials as well, so ifyou give us that email, you'll
be on that list and we'll lookforward to being in contact with
you.
We're putting out more blogposts on Substack that you can
find.
If you're interested, find usat our website or email us at
yourcheckuppod at gmailcom.
(23:24):
But, most importantly, stayhealthy, my friends, until next
time.
I'm Ed Dolesky.
Speaker 2 (23:30):
I'm Nicole Rupa.
Speaker 1 (23:31):
Thank you and goodbye .
This information may provide abrief overview of diagnosis,
treatment and medications.
It's not exhaustive and is atool to help you understand
potential options about yourhealth.
It doesn't cover all detailsabout conditions, treatments or
medications for a specificperson.
This is not medical advice oran attempt to substitute medical
advice.
You should contact a healthcareprovider for personalized
(23:51):
guidance based on your uniquecircumstances.
We explicitly disclaim anyliability relating to the
information given or its use.
This content doesn't endorseany treatments or medications
for a specific patient.
Always talk to your healthcareprovider 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 checkupwith your own personal doctor.
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