I just had my endo visit today and he noticed from my meter that I was having about one to two lows per week. He said I should only have one or two lows per month. I am currently on MDI and as you know it's a balancing act. My A1c's are in the mid to high 5's for which he attributes to those lows.I don't agree. I am vigilant about my food and insulin intake and work very hard to strike the proper balance and keep my blood glucose in a healthy range. In any event, I was curious what people who actually live with this disease think about an acceptable number of lows per week/month. Of course I do not want to become hypo-unaware. On the other hand, going into a blood glucose range that is higher than I am normally used to worries me. Would love to read what others think.
Hi -
If most of your lows are in the 60s with perhaps one or two per month in the fifties, I'd say you are doing fine. If your one or two lows per week are in in the fifties and forties, I'd try to find a pattern (easier said than done) and loosen up a bit.
My endo once looked at my logs with a bunch of 60s and said that they come with the territory if you A1c is going to be in the 5s. On the other hand, he looked at my logs one visit and saw a lot of 50s and suggested that I see a CDE to help me cut the number. The visit helped.
Maurie
I agree. Unless they are severe lows, one or two a week seems very moderate to me. It's easy for endos to come up with "shoulds" like that when even the best of us don't have that kind of perfect control. As long as you test and treat, that is certainly not frequent enough to create hypo unawareness.
There was another thread recently where people listed how often they get lows, though I don't remember the name of it. My own page with three weeks of numbers has 6 lows on it which is also two a week and I'm fine with that. I wish I could reduce my highs to that number. I think you are doing great especially for MDI!
There was also a thread recently about how doctors overreact to lows and anyone with an A1C in the 5's they immediately jump on re this.
Yes I feel as you do Zoe. I think we all find numbers we can live with when considering the end game. Of course i hate lows...who doesn't? But I still have a bit of emotional sensitivity when it comes to highs...or what I may consider high for me.
I don't give any credence to lows in the 60s. Treat it and move forward.
Everything I've read says BGs in that range are not only not harmful, some non-diabetics dip down there routinely as well (very few, but it's not considered an issue).
Beating a dead horse, a CGM is the solution here. I change my low alert setting several times a day depending on various factors. I usually bump it up from 70 to 80 after meals so I can catch the downswing and make sure it flattens out. I shoot for 80-85 fasting, and this gives me a chance to schlorp up some skittles if it looks like I might have a bit too much insulin from the bolus.
I've had maybe 3 in the 50s in 4 months, and one in the 40s, back when I was doing MDI and learning. Man, that one was an experience. Don't ever want to go through that again.
I feel like it's all pretty subjective and situational.
My thinking is along the same lines as still_young_at_heart. It's an atypical week for me if I have not dipped into the 60s, which generally happens during a workout or if I go a little too long without eating. Since a low in the 60s from a workout can easily turn into a low in the 50s, I don't usually worry about those at that time either.
Between the different activities I engage in that can drop my BG like a rock, it becomes more of a question of how often I find myself doing those activities every week.
Random lows are a different issue and I take those much more seriously. One or two random overnight lows in a week will cause me to make immediate changes to deal with them before I can even get to a third or fourth.
The depth of the lows is what matters to me.... low 40's , my endo warned me, given the errors in our BG meters, can mean you are very close to seizing or passing out. You probably don't want to visit that area often. 60's are less worrisome to me, though I do correct them.
Everyone's reaction to lows is different...some people pass out in the 50s.
A couple of consequences of too many lows : (1) Your ability to sense the lows will be degraded...numerous studies from places like Yale and others show this. Fortunately, this can be restored, usually, by avoiding lows for a couple of weeks.
(2) You are essentially starving your brain of fuel during a low.... not much different than someone asphyxiating you. Hypoglycemia can kill neurons
http://www.ncbi.nlm.nih.gov/pubmed/15554413
Also the Joslin center says "It is equally important to avoid unconsciousness and seizures caused by hypoglycemia, not only because of the increased risk for accidents, but because of the potential for brain damage related to repeated severe hypoglycemia."
http://www.joslin.org/info/is_low_blood_glucose_hypoglycemia_dangerous.html
Where they define severe as needing assistance to treat yourself.
Thanks for the info. I suppose part of my struggle comes from being on MDI and balancing bolus amounts without going to high or low. I feel I have my basal pretty well nailed. However, I do long distance running and that definitely plays with the amount of bolus insulin for me. I am concerned about hypo unawareness as I have only had diabetes going on five years. But like many have mentioned, I don't feel too concerned about the 60's. I treat with a small amount and go on. I suppose some of my question has an emotional component. I think I have this fear of highs...and what is happening to my organs when that happens. Something I think I need to work on.
Unfortunately, we live our lives balancing on a tight wire....highs, over the long term, can cause damage, while extreme lows can cause immediate damage.
It's all about striking the correct balance. It is helpful to look at the curves of A1c vs complication rates... below 6.5 or so the curves are not as steep...so you have to decide whether the marginal benefit you are gaining is worth the added risk. Each of us makes that tradeoff at a different point.
Yes I understand that intellectually. It's the emotional side of me that needs to come to terms with a few higher numbers.
A few times a week sounds completely reasonable to me, as long as they aren't severe lows. I do find endos worry a lot about lows, though. Often more than highs.
I've been having way too many lows lately, and lowering pump settings as a result. According to my meter, over the past month I've had 56 lows in the 60s or below, 27 lows in the 50s or below, and 9 lows in the 40s or below. A few of those are from extended lows that were really only one "episode" but spanned multiple tests, but that's still way too many.
In my thinking, 60s and steady arent truly low at all. Non diabetics wake up in the 60s often. The issue is that 60 and dropping is a potential problem… Which can be tricky when taking insulin… But to answer your question-- real “lows” which I don’t believe can be defined by a single number but rather whether they affect the individual, I believe can be completely avoided
I think it's more than just about the number of lows. I think it matters when they happen. I don't want to be driving with my BG under 80-100, and don't want a diabetic driver next to/behind me (or my family) with a low BG. I know I perform better mentally when BG is >80, so that's my goal.
I do have 2-3 lows (60-70) per week, but mostly at night time, and my CGMS wakes me, so I don't think that's a problem. During the day, I run a bit higher, because it's more likely to unexpectedly go down, with just minimal activity.
My endo will check for, and comment on BGs <70, but doesn't make a big deal about it. I think it's in their job description.
I don't use a "number", I use the %ages, 70-130 is "goal", > 130 is "high" and <70 is "low". I like to have 5-10% low and 5-10% high. When I'm "on", I can do that decently and things work great. My old endo who moved was ok w/ it and the new one didn't know what my A1C was. They had a tape readout that was hard to read, she guessed 6.2, which is up like 20% and was like "that's uh, ok..." to which I thought "uh, no it's not..." so I have an appointment with a new endo on Monday. That's a bit of a concern as, for whatever reason, maybe eating lower carb or something, I've got a 8 low, 81% "within limits" and 11% high, which is ok for 1 day average (ha ha...). When I stretch it out to 7 days, it goes to 17/75/8 which I don't like as much, as I'm sure the doctor will be all "that's extremely dangerous, I'll have the dietitian get you a pizza stat..." but, in terms of progress, I made some adjustments and hopefully they'll work out.
I have lows every day, but they are manageable and my Dexcom warns we about them. I probably get a low every day in the 60’s, but with eating low-carb and using a Dexcom G4, I only see occasional lows in the 50’s and 40’s.
It has been almost ten years since I have had a low I needed help with. My endo is OK with my regimen, but my internist thinks I’d get rid of all the lows if I just had a bigger bedtime snack. He doesn’t understand that because my insulin is so tightly controlled that I can eat nothing with a bolus. A bolus at bedtime isn’t the best plan…
With an A1c of 6.2 you will most likely not develop complications. So the endo is not wrong with his remark. Your personal goal might be different but statistically his remark is not that questionable. In fact there is also room for the argument that below 6 can be seen as overachieving the goal of good control. This is valid because statistically there is little payback of all the effords. The risk of complications does not change much but the risk of lows increases the lower the A1c. So if the overachievement leads to a high number of lows the overal result can be seen critical. Now I know and see that you keep that in balance. Your deviation is also excellent no question about that. With an A1c between 6.2 and 5.7 I also follow the same goals. But with too many lows we should question our goals.
Perhaps a ranking will help.
70 < x < 60 mg/dL: mild low = can happen often. With low A1c's these are hard to avoid. If they happen every second day you should do something about it.
60 < x < 50 mg/dL: normal low => maybe one per week would be acceptable. They should be catched earlier. Is this systematic? I:C, basal? Is the frequency of glucose tests high enough?
50 < x mg/dL: dangerous low. Due to the accuracy of meters and the uneven distribution of blood glucose these numbers are not reliable anymore. These events should be avoided. Stacking of insulin? Guestimation of carbs? Physical activity? What led to this situation and how can it be prevented in the future?
I blathered about this elsewhere but the endo was wrong b/c it wasn't 6.2, it was 5.2 but they didn't check the number anywhere, e.g. online where I'd checked and where it was legible. To me, if you are "betting" you're whole timeframe on a single number and the number isn't clearly legible, you should douple check. Particularly, after it jumped up 20% over where it had been previously, which made me think either they just look when they walk in the room with you or if they looked, they didn't care about the spike, seemingly at all. Now however I've had a blip and will be interested to see what the new doctor makes of it.
RE the complications, I agree that the result is useful to have, but I still see glimmers of complications (hair loss on my legs, slow healing of scrapes, cuts, etc...).
I have about two Low BG excursions a week, and this can be anything from 69mg/dL to 29mg/dL. The cause can be blamed on dosing errors, but most are brought on by unscheduled activity. My A1c was 5 .0 to 5.7 for over 5 years until my Cancer diagnoses, treatment, and transplant, it has climbed up to around 6.5 and I have no more or less Hypos just a higher BG average, my Hypos are still caused by my dosing errors and activity. I lost my Hypo awareness 20+ years ago and cannot detect a low BG until it has dropped into the 40's. My Doctors understand that everyone is going to make a few mistakes, they are a consistently reminding me that a low BG could be fatal.
My doctors have also called me a overachiever and they are probably right, I spent years upon years saying, because of my excellent BG control I can expect to retire with good health. This was not the case, at 58 I was diagnosed with (HCC Cancer) and received a Liver transplant. I can't say what someone else should/ should have chosen for a BG goal, but for me it was probably a little excessive... You know the old saying...hind sight is always 20/20...;-)
Like many here, I don’t consider it a “low” unless it’s below 60. I measure my lows using CGM data and my goal is to not exceed 5% below 70 and 1% below 60. One of my goals that’s closely related to hypo-management is to keep a standard deviation at 30 or less. If I do this then my lows will be of the “drifting” variety, low slope excursions that slowly sink.
If I’m surprised by a low or one that drops preciptously, then that suggests a need for a change. That change may be a change to the insulin to carb ratio, insulin sensitivity factor, or basal rate.
I’ve mentioned this before. Gluco-normal people spend 5% of their time below 70 and only 0.2% below 60. 60 is the line that I will defend and take action. I discount/ignore any medico advice to draw that line at 70. I need that buffer zone to keep my overall average at a reasonalbe level. I’m happy with an average of 100-110. Gluco-normals aveage out at 90.