Q I've always been afraid to ask

But knowledge is power, right?

What is the deal with otherwise healthy type I's dying in their sleep from hypos? I had kind of assumed (or maybe convinced myself) that there had to be more to the story, like drugs or drinking, but I'm losing my resolve. Is it really just a crap shoot to go to sleep every night? Is it a Q of glycogen stores in the liver -- and if so, how does one make sure they're stocked up?

I've gone into shock a few times, during my sleep. I've never lived alone, so there was always someone to rescue me, though.

An endo told me that glycogen will eventually bring you back. I don't know if that's true or not. I found this horrible article while searching for answers:


I'm guessing ketones will keep the body going, but not the brain. If you use a pump, set your auto off! Mine is @ 14hrs.

Terrible story. :(

I think I've had dozens, maybe even hundreds of lows in my sleep and I think I've slept through maybe half or more. When I wake up my bloodsugar is usually in the high 300's. That's usually my only clue that I've been low.

I'm also curious as to how many of these there are? Occasionally there are reports of kids, etc. which are extremely sad. With smaller bodies and greater variability, I could see the danger there. At the same time, whenever I've googled it, it's not clear exactly how many of these there are? dozens? hundreds? thousands? I can't tell...

Fat stores in the liver will usually save you from dying of a hypo. An exception might be if you were drinking alcohol and the liver is distracted by getting rid of it.

Very low glucose levels can cause cardiac arrhythmia. Given the glucose deprivation of the brain it wouldn't be surprising that it would mess with the nervous system. One blessing is that we are all somewhat different. Having had lows come on suddenly that reduce me to oatmeal it was a sobering thought. I got a CGM and it has been very helpful. It misses my lows A LOT and I will wake up in old fashioned shaky/starving/weak symptoms I know that I'm in my 20s. I keep glucose shots (the little bottle thingy, not the mix and jab) by the bed for those over night issues. I hate having to chew through 4 tablets or more depending upon the low.

A bit of a protein snack before you hit the hey can bring a lot of piece of mind. I'm a huge proponent of CGM technology. I found it very useful when I was doing MDI. If you can get one, I would urge you to run, not walk. My experience has been pretty good. I've had discussion with other members who have had the Dexcom and had lots of bumps in the road. At this point, I can't imagine leaving the house without it. I also sleep a bit easier.

I've also been very fortunate to have my liver release glucose when I got very low and sleep through it. I wake up with a BG of 380 but I'm a little thankful that I get to wake up at all.

Based on what I've read, it has to do with lows causing disruptions in heart rhythm, and for some people this disruption turns into a fatal heart rhythm if the low continues long enough. I don't know if there is any way to tell who is at risk and who isn't, but it's definitely scary.

Same here SF Pete.. I wake up with wet night clothes ( from the shakes and sweeats accompanied by a a high glucose) when I have been really low at night; say under 35 or so.. Fortunately, it does not happen very often, maybe 2x a year. I usually wake up from my lows before the shakes and sweats come on, say when I am in the 50's high 40's.
I agree that low blood glucose produces the sometimes fatal cardiac arrhythmia. I think that maybe the reported deaths from lows at night may have happened to the type one kids or youth because they have had many, many severe lows and the liver is depleted of glucose. as I said before, I am Like SF Pete: my body does release glucose if I am very low.. But Every type one body doesn't. I do not know why.

God Bless.

And your liver only has to ignore the trigger just once. I am truly thankful for my CGM. I've been keeping myself a bit more steady and I'm finding I'm getting hypo symptoms at a much safer level. I never thought I'd be so happy to find myself having a Noah's Flood level body sweat at 46. I really do appreciate the smaller victories.

I'm working from memory but I remember reading that most of these episodes involve long sustained multi-hour lows. They've happened to me more than once and I'm sure glad my liver responded well.

I live alone and sleep with two Dexcom receivers (stereo alarms) and a low blood sugar alert dog. Sometimes I think he cheats and just listens for the Dex to alarm and then wakes me up when I've been sleeping through it! He gets his treat just the same.

This is a frightening phenomena but you can't protect yourself from everything. Take reasonable precautions. As far as protecting yourself from this, the best practice is to have as few lows as possible so that you don't lose the awareness and symptoms that help alert you to your falling blood sugar. Not making too many demands on the emergency liver sugar should help preserve it for when you need it.

Do people around you know how and when to give a glucagon shot? Do you even own one?

I'm not sure, honestly. But I have always seemed to wake up from my hypos. I'm usually not on TuD at 4am.. but I just got woken with a 55 bloodsugar. For me, it seems strange that someone could sleep through a low. I guess that as long as I keep my hypo awareness (14 years and counting!) Then I feel pretty confident that if I go low at night, I WILL wake up. So I won't lose any sleep worrying about lows...

(the lows themselves, yes I'll lose some sleep there, but not the worrying)

I actually would not say that the auto off killer that poor young woman, the improper settings on her pump were her demise. Read this excerpt:

On Oct. 25, 2000, a Wednesday, Sylvia met with Emily Holing, a diabetes educator at the UW clinic. Holing hooked up Sylvia's pump and showed her how to use it.

This same afternoon, Holing documented two episodes of hypoglycemia for Sylvia, 15 minutes apart. Each time Sylvia needed to drink orange juice.

Holing didn't activate the Auto-Off on Sylvia's pump. She understood the feature, Holing said later, but didn't think Sylvia should use it. "I don't want the insulin interrupted during pregnancy," Holing said in a deposition. She advised Sylvia to use a "buddy system," with a friend or relative making regular checks on her. Sylvia had pizza that evening, then drove home. She wouldn't be heard from for three days.

As far as I am concerned, her diabetes educator set her pump up WRONG! She had two hypos while meeting with her educator!

The most aggressive estimates of rates of death for people with type 1 diabetes from hypos is 2-4% by Cryer in 2003. His estimates lump in a wide range of causes of death (including a range of cardiovascular problems) and probably are way too high.

In practice, hypoglycemia awareness and counterregulation protect us against harm. With a harsh low, even most T1s will countreregulate and dump glucose to fight against a potentially harmful low, this is why you see a high blood sugar after a hypo episode. And while it is true that as you get older, you have autonomic problems, etc, and you do become more vulnerable to really dangerous lows, I have just not seen studies suggesting that lots of people are passing because of hypos.

If hypos were truly taking us at high rates, I think we would hear it here from our thousands of members.

The "dead in bed" story is relatively new. If it was going to happen with any frequency, it would have happened a lot more with those of us raised on NPH. And we were never scared to go to sleep. I'm sure there is a grain (very small) of truth to this story, but I believe that these sorts of things are incredibly rare.

The "dead in bed" syndrome is not new (though our collective awareness of this phenomena is new) and educated estimates as to its incidence are significant. Here's an abstract of the findings of an Irish study published in 2010:

""Dead in bed" is a tragic description of a particular type of sudden death in type 1 diabetes mellitus (DM). Patients are typically found dead in the early morning, lying in an undisturbed bed, having been well the previous evening. The incidence of "dead in bed" syndrome is not known but studies suggest figures of between 4.7 and 27.3% of all unexplained deaths in type 1 DM. The pathogenesis is unclear but patients typically have a preceding history of recurrent severe hypoglycaemia. We describe two cases of "dead in bed" syndrome which occurred at our institution within a 12-month period."

I was able to look through the paper. The two cases displayed are perhaps extreme. The first case, the woman had a long history of severe hypos and unawareness and was described as requiring 3-4 injections of glucagon every month. The second was poorly controlled with an A1c 9-11% and "significant complications" including a history of severe hypos and excess alcohol intake.

The 27.3% figure is actually misrepresented from an earlier study of 3228 type 1 patients (children), of whom 10 died. 5 deaths were due to accidents and the other 5 were attributed to "diabetes." There are not many "unexplained" deaths and the mortality found in the study (only 0.75/1000 patient years) was not high to begin with.

Thanks for these details, bsc. It looks like you have good access to the medical literature.

What did you think of the JDRF claim in a full page ad in The New York Times last year that claimed that 1 in 20 Type 1 diabetics dies from hypoglycemia?

Thanks for reading that article, bsc, because I don't think I could stand to. I find it scary that there's a name for it, even if it is a catchy one.

That's interesting about waking up with a bs of 380. Mine is always right around 380 after an overnight low.

Maybe it is time to get a CGM.

Let's all say together:
I will test before going to bed. I will raise my BG above 100 if it's below.
I will not go to bed after an alcohol binge.
I will not depend on only my glycogen stores.
The rest of the day I will keep my average BG above 100 so hypo plunges are minimized.
And I will set the pump's mechanisms to stop pumping as its default condition.

Once again, bsc, excellent point. Unfortunately, it seems this happens too often, but rarely with such tragic results. Clearly the whole thing should have been avoided, but would she have come to if auto off had been enabled?