Knowing the warning signs of lows

You may notice when you’re having a low because you feel sweaty, confused, or just not right. A low may come on gradually, so you pick up on these symptoms. Or it may come on suddenly, so you don’t feel that different.

Here are common signs of low blood glucose:

• Shaking
• Nervousness or anxiety
• Sweating, chills, and clamminess
• Irritability
• Color draining from the skin
• Hunger and nausea
• Rapid heartbeat
• Weakness, fatigue, and sleepiness
• Headache
• Tingling or numbness in the lips or tongue
• Nightmares or crying out during sleep
• Lightheadedness, dizziness, or confusion
• Difficulty seeing or blurry vision
• Unusual behavior such as clumsiness or slurring of words
• Anger, sadness, and/or stubbornness

Some signs of severely low blood glucose include the following:

• Seizures
• Unconsciousness

People usually experience signs of lows, but the signs are a little different for each person. Make a point to tell your spouse, family, or friends about the signs of low blood glucose so they can look out for them and help you if the time comes. (We explain how to treat lows in the following section.)

If you think you’re low, check your blood glucose. Checking your blood glucose is the only way to know for sure whether you’re low (see Chapter 7).

Often people with diabetes can’t tell when they’re low, particularly when they’ve had diabetes for a long time. Hypoglycemia unawareness is a fancy term for when you can’t feel lows. Talk to your doctor if you suspect you might have this condition.

Treating lows with the Rule of 15

After you test your blood glucose to confirm that you’re low, then treat yourself right away. The goal is to raise your blood glucose. You can do this simply by eating or drinking.

Quickly and effectively raise your blood glucose using fast-acting carbohydrates, without fat or protein mixed in, which include the following:

• Four glucose tablets
• Four ounces of fruit juice or soda (not diet)
• Eight ounces of nonfat or 1 percent milk
• Two tablespoons of raisins
• Glucose gels, or liquids (more on these coming up)

Each of these foods has 15 grams of carbohydrates and is suitable for use with the Rule of 15.

What the heck is the Rule of 15? It’s an easy trick for treating lows. But before you use the Rule of 15, ask your doctor whether it’s right for you. Your doctor will tell you what to do if you shouldn’t use the Rule of 15 for some reason.

Here are the five steps for the Rule of 15:

1. Test your blood glucose (see Chapter 7).
2. If your blood glucose is below 70 mg/dL, eat or drink something containing 15–20 grams of carbohydrates.
3. Wait 15 minutes.
4. Test again. If your level is still below 70 mg/dL, eat or drink another 15 grams of carbohydrates.
5. Repeat until normal.

When using the Rule of 15, consider eating a snack if your planned meal is an hour or more away.

If you can’t always have fruit juice, milk, or raisins available to treat your lows, you can buy tablets, gels, and liquids that come prepackaged as exactly 15 grams of carbohydrates. They’re made just for people with diabetes. They work fast and are easy to have on hand. Pop them in your purse, car, or desk drawer so you have them when you need them. If you don’t have a supply on hand, drink a glass of milk or juice.

Generic or store-brand glucose products may be cheaper than brand-name versions, so shop around.

Having glucagon available

It’s rare, but sometimes people become so low that they pass out and can’t treat themselves. In this emergency, someone else must give them an injection of glucagon.

What’s glucagon? It’s a hormone that your body makes to raise blood glucose. But it’s also a medication in a portable kit for emergencies. The kit has a vial of powder and a syringe of saline that someone mixes together and injects, following the instructions.

Not everyone needs a glucagon kit, so ask your healthcare provider if you’re concerned. He can write a prescription for one if he thinks you might be at risk for lows. Teach family members and co-workers how to use the kit, and tell them to call 911 if they have any concerns.

Diabetic ketoacidosis

Diabetic ketoacidosis (DKA) occurs when you have consistent, extremely high blood glucose of 250 mg/dL or above. It happens more often in people with type 1 diabetes than in people with type 2 diabetes.

DKA usually happens when people are sick and their bodies make ketones in their blood and urine that build up and become toxic. It’s a dangerous situation that can cause breathing difficulties, shock, pneumonia, seizures, coma, and even death.

Ketones are chemicals that are produced when the body burns fat instead of glucose for energy. This process occurs when the body doesn’t have enough insulin for the amount of glucose it needs to use.

Luckily, you can test for ketones using a simple test strip from the pharmacy. Generally, you check for ketones by dipping a test strip into your urine stream, or you pee into a cup and dip a strip, and then you get a reading. However, follow the specific instructions that come with the test strips. Treating hyperglycemia in a timely fashion will usually prevent ketoacidosis when ketones are first present.

Some blood glucose meters also measure ketones, so check whether your meter has that option.

The warning signs of DKA include the following:

• Blood glucose of 250 mg/dL or above
• Nausea or vomiting
• Fruity breath odor
• Rapid breathing
• Flushed sensation
• Weakness
• Drowsiness
• Intense thirst
• Dry mouth
• Need to urinate frequently
• Lack of appetite
• Stomach pains

Ask your healthcare provider about if and when you should check for ketones. She may recommend checking every 4–6 hours if you’re sick or if you get a blood glucose reading above 240 mg/dL. She may also want you to call if you have ketones so she can give you further instructions.

Hyperosmolar hyperglycemic syndrome

Hyperosmolar hyperglycemic syndrome (HHS) is caused by extremely high blood glucose. It can be brought on by other conditions like not taking enough medication, infections, heart attack, or stroke. It usually happens over time. HHS can cause severe dehydration, seizures, coma, and even death.

You can develop HHS if you have high blood glucose and don’t drink enough fluids. People who are elderly and those who are in the hospital or a nursing home are at higher risk for HHS.

It can take days or weeks for HHS to develop, so always drink plenty of fluids — particularly when you’re sick.

Here are the warning signs that you may be developing HHS:

• Blood glucose of 600 mg/dL or higher
• Dry, parched mouth
• Extreme thirst (although this symptom may gradually disappear)
• Warm, dry skin with no sweat
• High fever
• Sleepiness or confusion

For caregivers: If your parent or an elderly relative with type 2 diabetes is in a nursing home or hospital, make sure drinking water is available, and encourage your loved one to drink water often. Some older people don’t recognize when they’re thirsty, so they may need extra reminders.

Hardening of your arteries

Atherosclerosis is the term for hardening of the blood vessels called arteries. Hardening can happen with a buildup of fat and cholesterol that stops blood flow. It can occur in arteries supplying your heart, brain, and other organs.

You may sometimes hear the term metabolic syndrome (or cardiometabolic syndrome) when you hear about diabetes and heart disease. Metabolic syndrome is a collection of various risk factors that tend to group together (obesity, high blood glucose, hypertension, high blood fat levels) and can lead to heart disease.

Heart attacks

A heart attack occurs when a blood clot forms in an artery and stops blood flow to your heart. Part of the heart muscle dies or is damaged during a heart attack.

Know the signs of a heart attack:

• Discomfort or pain in your chest, arms, back, jaw, neck, or stomach (yes, any one of these places)
• Shortness of breath
• Sweating
• Indigestion or nausea
• Lightheadedness
• Fatigue

Call 911 immediately if you suspect you or someone else is having a heart attack.

Strokes

The most common type of stroke, an ischemic stroke, occurs when a blood vessel gets clogged and stops blood flow to your brain, usually because of a blood clot. Another type of stroke, called a hemorrhagic stroke, occurs when a blood vessel leaks or breaks. During a stroke, brain cells die because they don’t have enough blood or oxygen.

The signs of a stroke include numbness in the face, arm, or leg (especially on just one side instead of both). Confusion, severe headaches, or difficulty speaking, seeing, or walking are also signs of a stroke. The American Stroke Association suggests the acronym FAST to remind you of these symptoms: F for face drooping, A for arm weakness, S for speech difficulty, T for time to call 911.

Call 911 immediately if you suspect you or someone else is having a stroke.

Getting a leg up on caring for your lower extremities

Keeping your blood glucose on target is the best way to keep your blood vessels healthy in your legs and feet and to protect your nerves (see the earlier section “Maintaining a Healthy Heart and Brain” for more about this). Controlling blood pressure is also very important. Exercise regularly and quit smoking to improve circulation in your legs and feet.

Because skin infections are more common in people with diabetes and often occur on the feet, preventing and treating foot problems is essential.

Protect your feet from calluses by wearing shoes that fit well. Buy comfortable shoes with low heels or thick soles to cushion your feet. If you get a callous, don’t try to remove it on your own, but instead see your doctor or nurse so it’s removed properly and doesn’t cause an infection.

Protect your feet from ulcers, which are sores or holes in the skin on the bottom or sides of your feet. Treat cuts and blisters immediately and see a doctor if you have any concerns. Visually check your feet regularly for any signs of infection because damage to your nerves could affect how much you feel pain.

You should also get an annual foot exam from your healthcare provider in which he checks the sensation, blood flow, and bone structure of your feet. It may sound funny, but take off your socks and shoes when you get to your checkup. That way, you’ll both remember to check out your feet.

Here’s a checklist that can help you keep your feet and legs healthy:

• Check both of your feet every day by comparing them and looking for cuts, blisters, ingrown toenails, or any other changes.

  If you’re elderly and can’t bend over or see well, use a mirror or ask a relative for help inspecting your feet.

• Keep your toenails trimmed or see a podiatrist for trimming if you can’t do it yourself.
• Get an annual foot exam.
• Keep your blood glucose on target.
• Wear comfortable socks and shoes that fit well.
• Quit smoking and exercise regularly to improve circulation.
• Talk to your doctor if you suspect peripheral artery disease (PAD; see the following section).

You’ll definitely see socks specifically marketed and sold as “diabetes socks.” These come as either over-the-counter socks that you can buy anywhere or prescription “compression” socks that your provider will prescribe to purchase online or at a medical supply store. These socks may have diabetes-specific features such as light to high compression (to reduce swelling) and antibacterial properties such as moisture-wicking fabric (to keep feet dry and prevent infections). Sometimes these socks don’t have seams, which helps to prevent rubbing, irritation, and sores from developing. You don’t need to buy “diabetes socks” unless your provider recommends it.

Amputation can be a risk for people with diabetes. People with diabetes are at least 10 times more likely to have a lower-extremity amputation than people without diabetes. And in most of those cases, the amputation occurred because of a pre-existing foot ulcer (an open sore or wound).

Why does this happen to people with diabetes? It’s a combination of factors. People with diabetes may have nerve damage that prevents them from feeling sores and cuts that other people may notice (see more on neuropathy in the following section). Circulation and swelling problems can reduce blood flow, which can slow healing of these wounds. High blood glucose can prevent the body from fighting off infection.

However, you can prevent this by following the checklist earlier in this section, including lowering your blood glucose, inspecting your feet daily for sores, and getting an annual foot exam.

Peripheral artery disease

Peripheral artery disease (PAD) happens when blood vessels to the periphery (such as your legs) get clogged and limit blood flow. The condition can be painful, causing leg cramps and difficulty walking. It may also lead to more infections in your legs or feet because circulation is limited.

Your healthcare provider can diagnose PAD using a test called the ankle-brachial index, which measures the blood pressure in your arm compared to your ankle. If you’re diagnosed with PAD, you’ll want to find out about treatments such as exercise routines that start very slowly.

Nerves that sense things

Peripheral neuropathy — nerve damage to your hands, feet, and legs — is the most common type of neuropathy. The damage can lead to numbness, tingling, or prickling sensations; shooting or stabbing pain; a sensation of bugs crawling on your skin or walking on a strange surface; or a complete loss of feeling.

A complete loss of feeling can be problematic because you may not be able to feel pain, heat, or cold in your feet, which means you may not notice infections or other pain you would normally sense. Wear water footwear when wading in water and wear shoes when walking on hot pavement or sand so you don’t get a cut or burn your feet. Check your feet visually every day for cuts and sores. We can’t stress enough how important this is.

Your healthcare provider can check for nerve function using vibrations or touch during your yearly exam.

Medications such as antidepressants and topical creams can ease neuropathy, so talk to your doctor if you’re experiencing pain or other symptoms.

Nerves that automatically do things

Autonomic neuropathy — nerve damage to involuntary body functions such as digestion, urination, or the function of your heart — can cause problems, too.

One form is called gastroparesis, which can cause heartburn, nausea, or lack of appetite. Diabetes is the most common known cause of gastroparesis, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Gastroparesis may also impede your best efforts to control your blood glucose because it causes a spike in blood glucose after eating. Nerve damage could cause diarrhea or constipation. Nevertheless, keeping your blood glucose in your target range is the best way to avoid damage to the nerves in your intestine and throughout your body.

Nerve damage can also affect your bladder’s ability to fully empty or other urination problems. This could, in turn, increase your risk for urinary tract infections. Autonomic neuropathy could affect your sexual organs, increasing your risk for erectile dysfunction and ejaculation problems for men and vaginal dryness and difficulty achieving orgasm for women (see more about sexual health later in the chapter). Although these aren’t fun topics to talk about, they’re important to bring up with your healthcare provider.

Acknowledging diabetes burnout and stress

Diabetes distress, also called diabetes burnout, is a term used to describe those feeling of worry, fear, and frustration that come with managing a chronic disease like diabetes. It is quite common, with 18–45 percent of people with diabetes reporting diabetes distress.

You may feel frustrated with your new self-care routine, which can include being more conscientious about what you eat, exercising regularly, taking new medications, or checking your blood glucose. You may feel fearful about potential complications such as blindness or heart disease. You may worry about how you’ll afford healthy foods, medications, or healthcare. You may feel like other people treat you unfairly because of your diabetes.

Stress is another common emotion for people with diabetes, and it can have similar triggers as those of diabetes burnout. Stress can affect your body and mind in various ways. For example, stress can raise your blood glucose or make it more challenging to stick to healthy foods or an exercise routine. Stress also interferes with sleep. You find out more about techniques for managing stress in Chapter 14.

Go easy on yourself. Recognize that other people with diabetes feel similarly. If you feel continually burned out or stressed, talk to your doctor or diabetes educator about your feelings. You may want to ask for a referral to a specialist such as a counselor or psychologist.

Recognizing depression

Depression is more common in people with diabetes. Although it may have similar symptoms to diabetes burnout and stress (see the preceding section), it is a distinct clinical diagnosis. If you feel sad or hopeless for more than 2 weeks, you may be suffering from depression.

Depression may or may not be related to diabetes. All kinds of things can cause depression, such as your life circumstances, the death of a person close to you, or medications you take for other conditions.

Talk to your doctor if you feel depressed. The doctor may prescribe an antidepressant or recommend that you see a psychiatrist, psychologist, social worker, or counselor. Depression is common and treatable, so don’t be afraid to talk to your healthcare provider.

Being mindful of your emotions

Whatever you do, don’t ignore your negative feelings about diabetes. Keep the following points in mind and talk to your doctor or a diabetes educator if you feel overwhelmed:

• Diabetes distress is common and can make you feel angry, frustrated, fearful, or burned out.
• Stress is common and can affect not just your feelings, but also your blood glucose and motivation to eat well and exercise regularly.
• Depression is more common in people with diabetes.
• Depression is a treatable condition with medications and/or therapy.

Talk to your doctor or nurse if you feel diabetes distress, stress, or signs of depression.