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Hypo Unawareness: Can it be reversed?

“I didn’t know my blood sugar was low” can often present a dangerous scenario for someone with diabetes. In this blog, we’ll break down what hypoglycemia unawareness is, what factors increase the likelihood of experiencing it, and the steps you can take to reduce your risk.

What is Hypoglycemia Unawareness?
Most people with diabetes know when their blood sugar levels are low, but others may struggle to detect it or are completely unaware. This is known as “hypoglycemia unawareness” or “impaired hypoglycemia awareness.”

Hypoglycemia unawareness occurs when someone does not recognise or experience the symptoms of hypoglycemia, which typically prevail when blood sugars fall below 54 mg/dl (3.0 mmol/L). This causes the body to quickly respond to the very low blood sugar, which could potentially prove dangerous.

Studies show that those with hypoglycemia unawareness are at much higher risk for experiencing “severe hypoglycemia” because they are less likely to recognize early “alert” signs, such as shakiness, hunger, or sweating (these symptoms are also known as “autonomic” symptoms).

Can hypoglycemia unawareness be reversed?

Signs of hypoglycemia

  • Sweating

  • Shakiness

  • Hunger

  • Palpitations

  • Dizziness

  • Confusion

  • Sleepiness

  • Difficulty speaking

  • Clumsiness or jerky movements, muscle weakness

  • Nausea

Factors for Hypoglycemia Unawareness

About one in five people with type 1 diabetes and one in ten with insulin-treated type 2 diabetes report experiencing hypoglycemia unawareness.

Several factors increase this risk, including:

  • Going low while sleeping. Many people develop hypoglycemia while they are asleep and are not able to perceive the symptoms or treat the low. If this happens frequently, it can affect the ability to detect hypoglycemia warning symptoms while awake.

  • Exercise. The likelihood of hypoglycemia is increased both during and after exercise, when the body’s tissues are more sensitive to insulin. This effect can be delayed and occur up to 15 hours later, especially if the amount of exercise was unusually strenuous.

  • Having diabetes for a long time. Those who have had diabetes for longer are more likely to have been exposed to multiple episodes of hypoglycemia, which has been shown to contribute to hypoglycemia unawareness.

  • Age. As people age, they start to experience “cognitive” symptoms like slowed thinking, confusion, and difficulty speaking at the same time as “autonomic” symptoms like shakiness, hunger, or sweating. The cognitive symptoms can therefore interfere with recognition of hypoglycemia. At younger ages, people typically recognize hypoglycemia more frequently because they experience “autonomic” symptoms before “cognitive” symptoms.

  • Consuming alcohol. This can, in the short term, lower your ability to recognize typical symptoms and impair your liver’s ability to release glucose when your blood sugar is too low. These effects typically last as long as it takes your body to process the alcohol. There is no evidence that alcohol increases hypoglycemia unawareness in the long term unless chronic, heavy drinking leads to permanent liver damage. That in turn increases the risk of severe hypoglycemia.

What Classify as Normal Blood Glucose Levels?

• Fasting: Official ADA recommendation for someone with diabetes: 80–130 mg/dl (4.4–7.2 mmol/L).

• 2 hours after meals: Official ADA recommendation for someone with diabetes: Less than 180 mg/dl (10.0 mmol/L).

• HbA1c: Official ADA recommendation for someone with diabetes: 7.0% or less.

How Can I Prevent Hypoglycemia Unawareness?

Research has shown that hypoglycemia unawareness can reversed, in other words, people can become aware again of low blood sugars. In order to do so it is vital to reduce the time spent with low glucose levels by avoiding frequent lows. The following tips may be helpful:

1. More frequent blood glucose measurement (fingersticks)

By measuring blood sugar several times daily, many people with impaired awareness can identify potential hypoglycemia and reduce the risk of developing low levels without warning.

2. Continuous glucose monitoring (CGM)

A number of clinical trials have shown that seeing your glucose levels in real-time (via measuring tissue fluid) may help prevent hypoglycemia. While fingersticks give a snapshot at a single point in time, CGM provides a glucose value every five minutes as well as trend information and optional alarms, alerting users of lows when they start or even before they happen.

3. Set Targets
By setting target levels just a bit higher and adjusting insulin doses to help achieve these target levels, you can become more alert to any lows occurring after a few weeks’ time.

4. Avoid Alcohol
Another way to help prevent hypo unawareness is to avoid alcoholic beverages or at least limit them. After drinking alcohol in the evening, delayed hypoglycemia can be common. Alcohol is a recognised risk factor for hypoglycemia in patients with type 1 diabetes.

5. Re-train Habits
It is important to re-train your mind and to measure your blood sugars frequently to know when you are low. By preventing lows for up to two weeks, you will begin to notice the symptoms associated with low blood sugar once again. After three months, it is common to have full ability to recognize the symptoms.

6. Seek Medical Advice

If you are struggling to prevent low glucose levels, seek medical guidance. Meeting with a doctor, nurse, or diabetes educator will offer you guidance on how to improve insulin use and on how to anticipate an increased risk of low blood sugar. They also help manage mental barriers associated with going low.

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