So what is low?

Type 1 and LADA
1

I likely tend to the introvert, I do not hide my diabetes but I do not talk about it much, and then only with people I know well. When I first found Tudiabetes I wrote a long introduction under the question “how did you get diabetes?” But while I was writing, I was reading every discussion on the site. By the time I finished, I was humbled out of my enthusiastic introduction. My own experience; a diagnosis on January 28 of this year preceded by a viral infection that left me a (temporarily) paralyzed vocal cord; several months of sliding into DKA imagining I had the flu; three days in intensive care; a miserable 41 days on the ADA diet; then finding Bernstein and the immense relief of a low carb diet which I still follow; all of this now seems thin, limited, under fed and likely just my honeymoon. I have been looking for an opening to the conversation and I have found it in the many ways that we show our concern about going low.

So what is low? In the “Recommendations for Standardizing Glucose Reporting,” from Diabetes Technology and Therapeutics, 70-180 mg/dl is labeled “In Range” and 60-70 mg/dl is labeled “Low.” 50-60 is labeled “Very Low” but “Dangerously Low” does not begin until one slips under 50 mg/dl.

I have only been in the 50’s a few times since I was diagnosed. Once under the ADA diet while I was driving, the other times involved extensive physical activity and a missed meal. My drifts into the 60’s also revolve around manual labor but I can correct most of these by simply changing my BG meter. (A note of irony!) My Abbott Freestlye is consistently 3-10 mg/dl higher than my NIPRO TRUEresult. So, it takes more than a reading in the mid-60’s to cause me concern. I need to consider the time of day with reference to my last bolus, meal time, and physical labor. When I correct, I rarely take more than 2 grams, 1/2, of a Dex4. When I am in the 70’s, I work indoors. Besides the one time under the ADA diet, I have not had any trouble driving. I would like to see the data on amputations and hypoglycemic auto accidents!

Because of Tudiabetes I began to treat my BG readings as statistics. I am on MDI and my doctor allows me 8 tests a day. The question then, what is the most significant way to use 8 tests? Using them for driving or exercise seemed too specific. I need a sense of where my BG is going, not a one time reading. By rule of thumb, before each meal’s bolus and 2 hours after gives 6 times. Limited to 8, I chose (7) when I get up in the morning and (8) 1:00 AM when I take 5 units of Lantus. I believe that I need a 9th test for a better analysis, and that is bed time. Of course I have to buy the extra strips.

I ran these 9 tests each day for the month of August and one day I took my blood every 30 minutes from 5:00 AM until 10:00 PM to see how the 9 tests would measured against 34. The 9 did a good job and I can still make good estimates based on the 8 my doctor allows. To get concrete; I take 4 units of Lantus at 5:00 AM and the 5 units at 1:00 AM. I usually take 1 unit of Humalog with each meal but my doctor gave me a Lilly pen that allows 1/2 unit discretion. During the first 13 days of November I have gone into the 60’s on 4 days, each time in the afternoon. (Is this too many? And why?) On each occasion I corrected with from 1 to 3 grams of Dex4. For these 13 days, based on my TRUEresult meter, my daily average is 96 mg/dl, my daily average HgbA1C is 4.6 and my daily average Standard Deviation is 11.98. My highs were in the 130’s, 136 and 130, both at 1:00 AM. My lowest reading was 61. Before I found Tudiabetes I thought this control was my own doing, now I tend to dismiss my role and chalk-it-up to the honeymoon. However, I cannot imagine such control as I have on the recommended ADA diet. I have tried that. Not only did I have swings into the 200’s, I was on edge and I gained weight. Meals were no fun. And it drove my wife to distraction. But that is another discussion.

So what is low? And why?

2

That I'll never know because there are no concrete barometer to determine what is actually considered LOW....

3

Unhelpful though it may be, I understand the official definition of “low” in the UK is a BS below 4 mmol (70mg/dl) and symptomatic. I appreciate this does not make perfect sense, particularly for those with hypo unawareness. I tend not to feel low until about 3.5 (low 60s).

4

I agree with the low gradients listed in the study you reference with < 70 low, <60 very low, and < 50 dangerously low. While we all may differ somewhat from person to person and even within the same person, from time to time, I consider a valid solid low as one that elicits a counter-regulatory response involving adrenaline, glucagon, and subsequent glycogen release from the liver. This often marks the start of the oscillating gluco-coaster.

Time is another important factor when dealing with lows. If I can correct a low within 20 minutes or so of its onset, then I can often avoid the over-reaction of my counter-regulatory system.

You are very well informed for a recently diagnosed T1D. Your recognition of the help that your partially working pancreas gives you is closer to reality than taking all the credit yourself. But don't be too humble. Your embrace of T1D and all that it means will stand you in good stead over the long haul. You may tire of the regimented schedule that you've set up but at least you know what you are capable of and can return to that when your metabolism becomes less cooperative. Good luck; it's good to read your story.

5

What is low? The number under which you’re considered to be low is an arbitrary number. By the time neuroglycopenia sets in, however, it isn’t arbitrary to say that you’re low.

For me, whether I treat a number as a low depends upon the circumstances. I don’t have a set number. Let’s say that I have a meal when my BG is 170. 30 minutes later it’s 90. In that situation, I’ll treat it as if it is low.

Whether or not I consider a number to be low also depends on my future plans. For instance, if I plan on exercising, I’d consider a greater range of numbers to be too low.