Professional fear of hypoglycemia

Continuing the discussion from @Terry4 - a stroke survivor:

My first reaction to the almost universal attitude amongst medical professionals toward their overpowering philosophy that acute lows trump everything. They assiduously avoid acute lows such that it markedly degrades any attempt to keep overall glycemia in any semblance of normalcy.

I think they lack the experience of living with the constant threat of debilitating and dangerous low blood glucose (< 54 mg/dL) yet still manage to balance the fear of the immediate acute danger with the very real, yet somehow invisible danger of the cumulative effect of hyperglycemia (> 140 mg/dL).

The medical professional mindset quickly and easily trades away long-term health for the immediate benefit of avoiding glycemia anywhere close to < 54 mg/dL. Some would even counsul correcting, adding sugar, to any measured glucose under 100 mg/dL.

I do understand playing this game short-term while the new insulin using diabetic learns the ropes. Yet many teach their patients to hew to this outrageous standard indefinitely.

I also concede that we insulin using diabetics contribute to this attitude. Our inattention to our blood sugar while we consume risky foods often plays a role.

But not all insulin users fall into this category. The more widespread use of CGMs has enabled many insulin users to negotiate well the path between acute low blood sugars and healthy levels.

Is there anything more that we can do to teach health our providers to not be so hyper-phobic about hypo-glycemia?

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Yeah, this is always a topic of discussion with every medical professional. And yes, my doctor looks at my reports and comments if my extreme low is up or down from last visit. I don’t get the lecture, it’s just a passing comment if it’s up and high five if it’s lower. He knows I have this. He knows I know what to do. He knows that just a little adjustment can mess things up. 3 grams of carbs can send me up and .2 bolus can send me crashing. So just letting the pump do it’s things sometimes makes the lows a little lower for a little longer. But I always acknowledge the alarms and do what I must.

But this fear from a medical professional standpoint comes from their liability if something bad happens to the patient or someone else. Which is why people lose their drivers license for too many lows. And that conversation with one of my favorite doctors was very intense. I said, so if I am telling you I a, having lows that cause me to pass out, looking for help on fixing this problem, I could end up without my license? And she said , yes, it could happen. So then I said, so that means I come to you looking for answers but am now afraid to ask these important questions. Yup! So very, very messed up. But now with CGMS this has just stopped happening.

But hospital stays, that is another whole nightmare. They just want to keep you safe enough, so they can get you on your way. And for them higher is better because it’s less work, less problems and easier for the employees. But very shortsighted on the fact that higher blood sugars make recovery times go up.

But some hospitals are waking up. I had to sign my life away to keep all my equipment on and in my control last time I was overnight. And the big University hospital here is testing putting CGMS on all people with diabetes when they are in the hospital! Changes are coming but as with everything, very slowly!

Hope and pray you are doing well. I know he are very proactive on everything diabetes and you know yourself better than all of those darn medical professionals. Keep standing up for your rights! Love you!

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Are the health care providers following the standards published by ADA? I agree that as individuals we should specify strategies for our BG that are much better for our health than the ADA standards. However I think the ADA is the responsible party for the current one size fits all approach taken by some medical providers. They are saying TIR of 50% should be the goal for people over 65 years of age…makes no sense to those of us on the forum but provides a low risk standard that supports a “hypoglycemiaphobic” approach to BG.

ADA Issues Time-in-Range Targets for CGM Use (ajmc.com)

Type 1/Type 2 Users

  • The target of 70 mg/dL to 180 mg/dL should be maintained at least 70% of the time.
  • CGM users should allow low blood glucose levels of at least 70 mg/dL for less than 4% of the day, or about 1 hour, and very low levels of less than 54 mg/dL for no more than 1% of the day, or 15 minutes.
  • Users should allow blood glucose of more than 180 mg/dL for less than 25% of the time, and very high levels of more than 250 mg/dL for less than 5% of the time.

Older/High-Risk Users, Both Type 1 and Type 2

  • The target of 70 mg/dL to 180 mg/dL should be maintained more than 50% of the time.
  • Avoiding hypoglycemia is a priority in this population, so CGM users should allow low blood glucose levels of less than 70 mg/dL for less than 1% of the day, or 15 minutes.
  • Users should allow blood glucose of more than 180 mg/dL for less than 50% of the time, and very high levels of more than 250 mg/dL for less than 10% of the time.

You make a good point, @John58. Your citation of the TIR and low blood glucose numbers provides much that I don’t agree with. I particularly object that all CGM user over age 65 spend no more than 1% of the time below 70 mg/dL.

Do we automatically become frail at age 65? I feel that the standards became much too conservative for all people over 65.

Are these groups really trying to help all of us? Do they even consider the unintended consequences of their actions?

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I am a 71 yr old type 1. It sounds like since I am over 65, that I don’t have much life left, so poor control isn’t going to affect me? I plan on living for a long time in the best health I can manage.

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[quote=“Marilyn6, post:5, topic:90023”]
I plan on living for a long time in the best health I can manage.
[/quote]birthday party.

Go girl!!! We all love you and support you. I hope you invite us all to your 100th birthday party.

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Ohhhh, so nice CJ. You will be there with me for sure! You are pretty amazing at 74!

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When I was diagnosed it was made clear to me that I would most likely make it to age 60 and if I really take care of my diabetes and have sufficient luck, might make it to age 65. On the one hand, I guess I am on borrowed time, yet feel better than I did 30 years ago. My mom, had her 100th birthday early this year and still lives alone so good family genes must also help.

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Yes, I think good genes definitely help. Both my mom and dad lived until 89, so I should have a long life too. I remembered that your mother is 100, but living on her own just says so much about her health. Good for her!
I am glad that you outlived predictions! I don’t remember ever being told that I would have a short life. I do remember a pharmacist telling me that I would probably outlive him, because people with diabetes had to take such good care of themselves. It was very thoughtful of him to tell a young teen that.

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Years ago my endo stressed a bit when I had A1c’s in the low 5’s and once in a blue moon in the high 4’s. This was prior to reliable CGM numbers and she worried about too many lows. And yes, I probably had too many lows although never debilitating. But it wasn’t uncommon to eat a whole tube of glucose tabs on the days that I was active.

Fast forward to now. She still indicates that I could relax my targets at bit and be confident of having good health. But she says “Good Job” when she sees my A1c’s. And although I often chafe at Control IQ, she looks at my tracings and we both marvel at how good Control IQ is at preventing lows below 70.

I wrote this blogpost a few years ago after there was a “definitive” report on the standards for seniors with diabetes.

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Thanks for including your take on aging with diabetes, @Laddie. I share with you the sense that any general guidelines makes me feel that they’re not talking to me.

I don’t fit into the standards. Since I eat a low carb diet and take small insulin doses, my exposure to hypoglycemia is small. I spend less than 1% of my time at < 54 mg/dl, a standard that I seriously consider still applies to my 68-year old self!

I pay fairly close attention to my blood sugar levels and wear all the technology that is not shy about alarming if I go out of range. My A1c is in the low 5’s and high 4’s range and more importantly, my glucose variation in < 21 mg/dL range. In short. my BG control is excellent and general guidelines don’t seem to apply.

What gripes me, again, is that the standards writers just don’t think that people like me even exist. I know we’re not very common yet there more of us than the general advice notices.

With my recent adverse health events, I don’t think that I can just write these issues off. I’m trying to calibrate to a world that takes into account my increasing age and health status but the general advice seems so out of step with me.

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@Laddie I loved your article!

@Terry4 I think it really depends on your endo, internist or PCP doctor. My endo never says a bad word about my numbers, it’s mostly about what do I need or if I have any questions. I usually have an A1c of 5.1-5.2 % and 98 TIR. So I have great control and she recognizes that. My last A1c was 4.9, I still maintained a 96% TIR. and I wondered if she was going to say anything.

She wasn’t, I brought it up at the end and told her I had wanted to be under 5% once, but I didn’t care if I stayed there. That I was happy because I hadn’t had to try. That I thought it was the Afrezza and she agreed. And that was it. I just saw my internist pcp and she is the one that warned me 4 years ago when I was 5.1% to not go any lower, but after that first year she has never said anything one way or the other about it again. And she didn’t this time either.

But I think a hospital would be different. I remember reading once that a pcp will likely only have one type 1 as a patient their whole career, maybe 2. Given that most doctors at the hospital are going to go by “textbook” treatment. Worry about the low, which can cause seizures or kill someone. The high numbers usually don’t suffer immediate consequences and let your pcp treat whatever ends up happening. That falls in line pretty much how they are taught, you have this problem, this is what we can do for it. Hospitals really aren’t about that this is the long term goal, it’s more about getting you through whatever is going on, like surgery, illness etc, send you home and let your regular doctor deal with it. And they have no way of knowing how well you know what you are doing or how good at it you are. And face it, a majority of people don’t come close to to even reaching the recommended guidelines.

I just assume when I end up in the hospital for some reason, I will need to maintain a higher number, hopefully not ridiculously high but…hopefully I will be successful in doing so!!! Like @Laddie said in her article, I’m not sure how good I will be at it!

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At the same time we expect every medical personnel we deal with to be a diabetes expert. As diabetics, no 2 of us are exactly the same with the same desires and requirements. Most of the medical staff that treat us have very limited knowledge of diabetes and certainly little to no experience with all the different diabetic scenarios a patient may have. At the same time they are prepping or treating several other patients with a host of different medical issues.

This means that most personnel need a one size fits all approach and for the most part don’t have the time or interest to learn how YMMV.

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@MapleSugar posted about a free book on AMAZON KINDLE, Sick to Death. This line still seems fitting in this day and age.

It a British police procedural written in 1971. The murder was done by somehow adulterating the victim’s insulin.

‘But I still think that if the ordinary quacks don’t know all that much about diabetes, we’re going to find it as hard as little nuts to get to grips.’

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I never expected to die young.

I was able to get life insurance 20 years ago at an inflated rate but I still got it.
The insurance guy told me, “you aren’t at a high risk of dying young. You are at a high risk of being blind in a wheelchair on dyalisys. And we don’t pay out on that”

I think that cast a shadow about longevity and why I try to keep good control as best as I can.

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Back around 1960, a diabetic died age 48. My father said it was a shame, if diabetics took care of themselves, they could live well past 70, but (he said) none of them ever did, so they died in their 40s or 50s.
Back then, no blood sugar meters, only urine strips, and diabetics were advised to have the lowest positive amount of urine that the strip could measure, to ensure no hypoglycaemia. Of course, that’s around 180 mg/dl or 10 mmol/l, which is now considered much too high. Diabetics were given a very strict diet to follow, and few managed to follow it.
Insulin back then was either porcine or bovine, no human equivalents out.
We’ve come a long way since then.

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I have lived with T1D for 76 years and I am 82 years old. I do not have any serious complications. I do have to use a catheter for urination, but I have adjusted to that. It is easy to do.

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I just got home from the hospital. Not only is the food served totally not diabetic-friendly, but Doctors left me with sky high blood sugars the entire 7 days that I was there. My normal target goal is 100. I hope I will be able to get back on track soon now that I’m finally home. It’s an atrocious situation to say the least.

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It doesn’t have to be. There are several topics here regarding hospital stays, and when possible getting more involved in your own diabetes care. But as you learned, the normal hospital stay doesn’t make bg control a priority. Having a family member to assist often helps, and hospitals usually get you to sign acknowlement of taking over your own care.
Many have food from home brought for more accurate dosing. If use pump, need to plan ahead on what options you may have to keep your own dosing with pump.

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I agree with @MM1. You don’t have to let the hospital staff run the glucose. Not eating food that you know will run your sugars high can be tough in a hospital situation, but definitely doable.

When I was in the hospital recently, I ordered the same thing for breakfast every day: scrambled eggs with four strips of bacon and a hard-boiled egg on the side. I delayed it until 10:30 am, the latest that breakfast could be served.

Luckily, I was in control of the timing of my insulin because I wear a pump. So I controlled all the factors necessary for good post-meal glucose. I wished I had more collaboration from hospital staff because my brain was stroke impaired, but I had enough brain power to make good glucose decisions. It wasn’t easy but it was manageable.

It would be a much better situation if you could join efforts with hospital professionals to manage the diabetes but that is not usually the reality.

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