How many lows per day / week are too many?

Hi all.

I have always thought that I am quite good at my diabetes control- I get good HBA1Cs, always try to keep my numbers from going too high. When I was pregnant doctors were really happy with my control and my daughter was born normal size and healthy.

Recently, however, doctors have suddenly changed their opinion about my control- they think that I have too many lows.
I normally get 1 low per day, sometimes 2. My consultant says I should not have more than 2-3 lows per week.

My consultant says that if I get lows as often as I do, I might lose my sensation of getting low. At the moment I do get the symptoms of being low once my BG goes 3.5.

My consultant advised me to focus only on reducing my lows to 2-3 per week and relax my control, where my target range is 5-10 ( not 4-9), and I compensate with extra insulin only after my BG reaches 13.

I find it really hard to get down to only 2-3 lows per week. I am also worried that relaxing my control might lead to diabetic complications.

How many lows per week do you have? Do you agree with my consultant? Any ideas and responses would be greatly appreciated :slight_smile:

Do you have a CGM?

What sort of medical qualifications does your consultant have?

I think there is a big difference between mild low and a harsh low. And it matters how long you stay low. If I dip down to 65 mg/dl (3.5 mmol/L) a dozen times a week but treat promptly get back up to normal quickly and don’t have any harsh lows then I don’t have any concerns about the risks of lows. Hypounawareness comes about when you have harsh lows or spend too much time low and become accustomed to being low.

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Yeah i don’t like to run too low. If I’m having a low every day I start trying to figure out why and fix it, especially if it’s at the same time every day. I don’t completely understand the conversion to mmol/L, but based on Brian’s math above, I usually get early symptoms at a 4.5 or 5, I might treat under 5 depending on the time of day, and don’t like to go to bed under 10.

Factor of 18.

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I agree with this wholeheartedly.

I also think it’s odd your consultant is suggesting not to treat with “extra” insulin until after you’re at 13(230). Maybe I misunderstand the context (perhaps there’s already a lot of IOB?), but in general I’d say there’s no reason to wait that long if your bg is on the way up.

If you’re using a cgm or doing lots of measurements during these events it doesn’t sound there’s a significant reason to depart from your “regular” target range.

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Thank you all for commenting. I do feel I have hypoglycemia when my BG goes 3.5 and lower, and when it is 4 I already feel it is going down, but it has happened in the past not to wake up for mild lows.

It feels a bit like I have to be choosing between a good control (always being below 10), and staying away from hypos…I feel that in my case keeping ‘good’ BGs almost inevitably involves more than 3 lows per week. This is logical, because if my BGs stay averagely at 6, they can much quicker get down to 3.5 than from let’s say 9.

I live in England and I can only guess that my consultant is well qualified. I just think that sometimes professionals’ expectations of our diabetes management are a bit unrealistic.

I am using the Freestyle Libre, which I find very helpful. I have cut down on lows recently, but my sugars have been running higher and that makes me worry a bit.

I guess the ideal would be to just stay in my target range- not get low and not get high- I can only try to keep in range a bit harder and see whether I will achieve it.

Before I got a pump, I was having daily lows 1-2 times every day. Adjusting my basal even one unit resulted in high fasting BGs and rising numbers throughout the day. Switching to a pump helped me all-but eliminate the lows. Last year, I changed my eating habits to a much lower carb approach. That has been the rest of the ‘fix’ – Control is easier most of the time. and I rarely, if ever, see lows below 65 (3.6) – and mostly (almost 90% of the time) stay between 70 and 125 (3.9 and 6.9).

Last A1c was 5.5 - and yes, I was asked to prove to an endo that I was doing that without a lot of lows – even though my Dexcom reported ZERO lows in 90 days!

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Since you use a Libre, I suggest that you focus on blood glucose variability as measured by Standard Deviation (SD). If you want to increase time in range, lower average BG, without increasing hypos, you’ll need to lower your SD first. Using mmol/L, try to keep your SD <= 1.7 (30 mg/dL).

Lowering SD to <= 1.7 mmol/L will allow you to lower your average without increasing your exposure to hypos.

In order to lower SD, I would concentrate on using a pre-bolus time to allow matching up the rise caused by food as well as eating fewer carbohydrates. Many people find that the canned advice of 15 minutes between dosing and eating is too short, especially in the morning. Some do not so this is something you need to personally test. Always keep emergency sugar at hand when doing a personal experiment like this. I found eating a lower carb diet to be key in lowering SD. Good luck!

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Perhaps that is a term (“consultant”) that does not translate properly in the US when used in this context.

lol. For Sure !!!
Totally depends on the particular food obviously but for a fast acting breakfast carb, more like 50 minutes for a predose if avoiding a spike is the desired outcome.

I’ve interacted with several folks from U.K. on other support group forums who use the word “consultant” when folks in the US would use the word “specialist”.

I was also wondering about the term, “consultant,” too. I thought it might be a certified diabetes educator or CDE. In the US, we do often “consult” with our doctors.

If you know what times you are likely to go low, and view your Freestyle data at these times, paying attention to the trend, and treating your downward trends with just a few carbs, you can flatten out your curve, and reduce the number of lows you are having.

Using a CGM and paying attention to the data 6-8 times per day, my son has been able to reduce both his A1c and the number of lows he is having. Much to the delight of his medical team who believe that these items act like a seesaw and can’t both be optimized.

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For me, breakfast needs to be ~1 hour after morning dose

Consultant (UK) is the term for the senior doctor in charge of a hospital department. In the case of the OP, he/she would have the title Consultant Diabetologist or Consultant Endocrinologist, in US terms Endo. I would hope that he/she knows his/her stuff.

I take on board the point that mild hypos (3.7/65) are probably not harmful. However, I do agree with the OP’s Consultant about the need to avoid hypos and the risk of developing hypo-unawareness. Consistently or frequently running levels of around 3.0 (55) although these levels are not in themselves dangerous, heightens the very real risk of loss of warning signs Being able to run BGs at under 2 (36) without any warning symptoms, is not something I would personally recommend.

I would say that 2+ hypos per day are too many. 2-3 per week seems like a reasonable aspiration, although like all targets, not necessarily achievable.

Don’t forget, a bad low can kill you in an instance. Slightly looser control may shorten your life a bit at the end or not…