Walking the tightrope

“Problems are not stop signs, they are guidelines. Robert H. Schuller”
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The maintenance of strict glucose control is unassailable in diabetes, but hypoglycaemia (low blood sugar) is one of the major limiting factors on account of its morbidity and mortality. Though it is regarded as more common in Type I Diabetes, its occurrence in Type II Diabetes is often underestimated for a number of reasons, predominant of which is underreporting? Contemporary research, clinical experience and speaking to people with diabetes in non-clinical settings show that it occurs with much higher frequency than previously thought or reported. This has far reaching implications for safe management in the community and healthcare professionals and people alike sometime chose a guarded option and higher blood glucose levels are maintained which predispose people to more vascular complications.
In the UK hypoglycaemia means blood sugar levels less than 4 mmol/l. When this can be managed by the person themselves, it is regarded as mild and when third party intervention is needed it is regarded as serious. Though more common in people on insulin, it is also frequently associated with intake of sulphopnylureas (such as glibenclamide, gliclazide, glipizide, glimepiride, tolbutamide.With increasing use of insulin for Type II diabetes, the problem is likely to escalate. Though analog insulins do offer better protection, it is by no means absolute.

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The brain is extremely vulnerable to falling blood sugar levels as it neither has the ability to synthesise nor store glucose. When blood sugar falls, counterregulatory hormones of which glucagon and epinephrine (adrenaline) are the most potent are secreted and cognitive, physiological, and symptomatic changes occur. The recognition of symptoms is fundamental to self-management of hypoglycaemia. If (even mild) hypoglycaemia episodes recur often over time (e.g., once a day), symptoms are produced at a much lower blood sugar level. This is dangerous because symptoms are produced when the blood sugar level is precipitously low. In turn, failure to sense symptoms of hypoglycaemia (hypoglycaemia unawareness) increases the risk of prolonging duration and increasing frequency of hypoglycaemia. These events lead to a vicious circle leading to an increase in severe hypoglycaemia with brain dysfunction. Well-known risk factors for the development of hypoglycaemia include exercise, alcohol, older age, renal dysfunction, infection, decreased intake of energy, and mental health issues, including dementia, depression, and psychiatric illnesses. Though there is no conclusive evidence for long term deleterious impact of recurrent moderate hypoglycaemia on brain function, this is probably relevant for simple tasks, but may perhaps lead to impairment at times of performing complex tasks like driving. 

The challenge is to lower blood glucose to near normal values in order to lower the risk for long-term complications, but at the same time minimize hypoglycemia- and hypoglycemia- associated morbidity and mortality. The goal is also to manage most people with diabetes in the community. Continuous glucose monitoring is one of the methods used, which is constantly being evolved to be more accurate. In addition to this is the ability to transmit blood sugar readings from glucometers to the healthcare providers by using the internet (cloud services) via mobile devices in real time. This also has the ability to analyse and prepare trends which are useful for decision making. In addition to this, digital health has the ability to establish a two way communication between healthcare providers and people for providing advice by using multiple platforms like video link, text chat and messaging.

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An episode of hypoglycemia maybe quite miserable and have far reaching consequences. Often these people try to conceal these symptoms as these have social and economic implications. Thus they need both support regarding their lifestyles and emotional support. It is vital that they have lifestyle and mental health trained professionals to speak to and interact with for them to be further educated to make the necessary adjustments that are needed. Most importantly, it is important to win the confidence of these people that they live in a supportive community and there is help and correct guidance at hand. This can also be done remotely by using mobile health services and in the comfort of the person`s choice of place.
 
 
 
 

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