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Hypoglycemia

Hypoglycemia is a medical term referring to a pathologic state produced by a lower than normal amount of sugar (glucose) in the blood. The term hypoglycemia literally means "low blood sugar". Hypoglycemia can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose as fuel to the brain, resulting in impairment of function (neuroglycopenia). Derangements of function can range from vaguely "feeling bad" to coma and (rarely) death. Hypoglycemia can arise from many causes, and can occur at any age. The most common forms of moderate and severe hypoglycemia occur as a complication of treatment of diabetes mellitus with insulin or oral medications. more...

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Endocrinologists (specialists in disorders of blood glucose metabolism) typically consider the following criteria (referred to as Whipple's triad) as proving that an individual's symptoms can be attributed to hypoglycemia:

  1. Symptoms known to be caused by hypoglycemia
  2. Low glucose at the time the symptoms occur
  3. Reversal or improvement of symptoms or problems when the glucose is restored to normal

However, not everyone has accepted these suggested diagnostic criteria, and even the level of glucose low enough to define hypoglycemia has been a source of controversy in several contexts. For many purposes, plasma glucose levels below 70 mg/dl or 3.9 mmol/L are considered hypoglycemic, but these issues are elaborated in more detail below.

Defining hypoglycemia: what's normal and what's low?

Although 70 mg/dl (3.9 mmol/l) is commonly cited as the lower limit of normal glucose, different values may be defined as low for different populations, purposes, or circumstances. The precise level of glucose considered low enough to define hypoglycemia is dependent on (1) the measurement method, (2) the age of the person, (3) presence or absence of effects, and (4) the purpose of the definition. This article expresses glucose in milligrams per deciliter (mg/dl or mg/100 ml) as is customary in the United States, while millimoles per liter (mmol/l or mM) are the SI (International System) units used in most of the rest of the world. Values in mg/dl can be converted to mmol/l by dividing by 18 (e.g., 90 mg/dl = 5 mmol/l or 5 mM).

Measurement method: different methods can yield different values

Glucose levels discussed in this article are venous plasma or serum levels measured by standard glucose oxidase methods used in medical laboratories. For clinical purposes, plasma and serum levels are similar enough to be interchangeable. Arterial plasma or serum levels are slightly higher than venous levels, and capillary levels typically in between. This difference between arterial and venous levels is small in the fasting state but is amplified and can be greater than 10% in the postprandial state. On the other hand, whole blood glucose levels (e.g., by fingerprick meters) are about 10-15% lower than venous plasma levels. Furthermore, available fingerstick glucose meters are only warranted to be accurate to within 15% of a simultaneous laboratory value. In other words, a meter glucose reading of 39 mg/dl could be properly obtained from a person whose serum glucose was 55 mg/dl.

Two other factors significantly affect glucose measurement. The disparity between venous and whole blood concentrations is greater when the hematocrit is high, as in newborns. High neonatal hematocrits are particularly likely to confound meter glucose measurement. Second, unless the specimen is drawn into a fluoride tube or processed immediately to separate the serum or plasma from the cells, the measurable glucose will be gradually lowered by in vitro metabolism of the glucose.

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Alcohol and risk of hypoglycemia in type 1 diabetics - Diabetes - Brief Article
From Nutrition Research Newsletter, 12/1/01

The consumption of alcohol is an established risk for hypoglycemia in patients with type 1 diabetes. It has been estimated that as many as one-fifth of severe hypoglycemic episodes are directly related to alcohol. Some researchers have reported an increase in risk of hypoglycemia in the morning hours, following evening consumption 12-16 hours prior. The exact mechanism of this observation is unknown, however it is thought that reduced cortisol levels play a role.

Both the British and American Diabetes Associations provide guidelines that recommend limiting alcohol consumption to no more than the equivalent of 2 servings of alcohol at one sitting.

The British and the US researchers teamed up to perform a controlled study to further examine both glucose control and hormonal responses through to midday following the consumption of alcoholic beverages in the evening. Six men with type 1 diabetes served as subjects. The mean age of the subjects was 33 years with the mean duration of diabetes being 13 years. All subjects had controlled diabetes with out complications, with the exception of background retinopathy. All subjects were being treated with a basal-bolus regimen of pre-meal regular insulin and bedtime NPH insulin. Subjects underwent detailed evaluation of their day-to-day glucose control for purposes of optimization of glycemic control prior to the initiation of the study.

The subjects were admitted to the study center for a 20-hour period beginning at 5:00 p.m. on two separate occasions. Subjects injected themselves with regular insulin at a dose of 70 percent their usual evening meal dose to reduce the likelihood of hypoglycemia between 6:00 and 9:00 pm. The subjects then ate a meal that provided 50 percent of calories from carbohydrate, 30 percent from fat, and 20 percent from protein. The carbohydrate content provided matched the average evening meal carbohydrate level given in the prestudy food diary. At 9:00, the subjects were given either dry, white wine or an equal volume of mineral Water (as a control) and were instructed to drink steadily over a 90-minute period. A volume was measured to provide 0.75 grams ethanol per kg body weight. Blood pressure and pulse were measured during drinking. At 11:00 p.m. an intravenous insulin infusion was initiated. A rate was chosen to provide a basal insulin level sufficient to maintain near-normoglycemia under the control conditions. No subcutaneous insulin was administered at bedtime. Upon waking in the morning, breakfast containing a carbohydrate content equivalent to the subjects' average breakfast was served. Blood samples were collected for immediate glucose analysis every 30 minutes while the subjects were awake and every hour while they were sleeping. Insulin, cortisol, glucagons and growth hormone were also regularly monitored. Subjects were then readmitted to perform the routine again, substituting either water or alcohol for the beverage that they had previously been tested for.

Blood ethanol reached a mean peak of 19.1 mmol/l and was undetectable in all subjects by 8:00 a.m. Fasting and postprandial blood glucose levels were significantly lower following consumption of wine than following consumption of mineral water. Five subjects required treatment for hypoglycemia after 10:00 am the morning following intervention with the alcohol. None of the subjects experienced hypoglycemia following consumption of Water. Growth hormone secretion was significantly reduced between midnight and 4:00 a.m. after consumption of wine. Levels of insulin or other hormones showed no differences between the control and intervention trials.

It appears that reduced nocturnal growth hormone secretion is responsible for predisposing type 1 diabetics to hypoglycemia after breakfast following an evening of excessive alcohol consumption.

B. Turner, E. Jenkins, D. Kerr, et al. The effect of evening alcohol consumption on next-morning glucose control in type 1 diabetes. Diabetes Care; 24: 1888-1893 (November, 2001) [Correspondence: Dr. Benjamin C. Turner, Diabetes and Endocrine Day Centre, 6/F North Wing, St. Thomas' Hospital, Lambeth Palace Rd., London, Sel 7EH U.K. E-mail: ben.turne@gstt.sthames.nhs.uk]

COPYRIGHT 2001 Frost & Sullivan
COPYRIGHT 2002 Gale Group

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