What Is A Hypo?

Most regular readers of the blog (there are at least six of you I think) will be experts on the whole diabetes 'thing' through either living it or living very closely to someone with it.  So asking the title question of this blog might seem a little strange.  But it's been puzzling me for a while so I thought I'd take this moment to have a ponder and think it through.

In true high school essay stylee I'll start by looking at the dictionary definition and then break this down as to why it might not be the case.  So using the modern equivalent of the OED we shall see what Wikipedia has to say on the matter:

"Hypoglycemia, hypoglycæmia or low blood sugar (not to be confused with hyperglycemia) is an abnormally diminished content of glucose in the blood. The term literally means "low sugar blood" (Gr. υπογλυκαιμία, from hypo, glykys, haima). It can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose to the brain, resulting in impairment of function (neuroglycopenia). Effects can range from mild dysphoria to more serious issues such as seizures, unconsciousness, and (rarely) permanent brain damage or death."

Blimey, that's a bit scary! But having such a clear definition should make it easy to answer the standard clinician's question asked in many appointments: "How many hypos do you have?" or "When was your last hypo?" But that's the problem, for me, and I'm guessing other people with diabetes, it's not that simple.  In a 24 hour period I may bounce a few times into a state that might be medically classed as 'hypo' but a quick treatment with either a couple of sweets or my scheduled meal means that it doesn't really cause a pulse on my 'that was a hypo' radar. More that it was a low that needed dealing with in a mild and not overly urgent way. 

For me answering the question I'd search my not vey brilliant memory for moments where I had to either take time out of what was occurring at the time or be in such a state that it's noticeable to others. And I think that's my trigger to acknowledge. If my waffy moment (for definition of 'waffy' see here) needs the assistance of other people or triggers a 'what's he doing?' by other people then I'll classify it as a hypo.  Indeed the DVLA in the UK are primarily interested in those events they classify as 'severe hypos' that require the assistance of another person to judge whether you are a fit and proper person to drive a car. 

It may be just me but I also think it depends on the circumstances as to your judgement on the question.  As I have relatively good hypo awareness I feel able to self-classify my 'attacks' - I really hate that word by the way as it conjures up images of me waving a knife around whilst trying to find some coke to drink.  However a parent or carer can only use the numbers from the machine and behaviour judgements and so much more simply classify. i.e. 4.8 mmol/l (86 mg/dl) - "Oooo, that's a hypo. Eat!" 5.2 mmol/l (94 mg/dl) "Well done, excellent score". And here we are also ignoring the vagaries of blood glucose meters to provide an accurate yet reliable and consistent result. Read an excellent piece here for further analysis of the unreliability of BG meters results.

For me I think it comes down to a hypo being more about a feeling and brain squiggle rather than a number on a machine.  I think I've mentioned before the flaws in the judgement provided by a single HbA1c reading and similar rules apply to BG readings.  I was discussing Adam (my pump) with a friend at the weekend who is a teacher and I was giving an example of the bolus wizard to show how it calculates insulin dosage based on carbs and BG.  So I did an obligatory test and it came out at 9.9 mmol/L.  To which the teacher exclaimed that that seemed very high and wasn't I concerned?  I then explained that it was a couple of hours after a bran loaded breakfast, I'd lowered my basal because of having an active morning, I was being pretty active on the touchline and IOB suggested it was pretty good.  So as always it's everything in context.  A 4.2 just before dinner for me is slightly lower than I'd like but not overly bad.  But a 4.8 an hour after I've eaten with plenty of insulin stacking up is a much bigger worry.

So in summary, and to answer my opening question; I don't really know.  I know you've read this far hoping for the magic answer but I must apologise and explain I truly believe its a personal judgement.  As always 'your diabetes my vary' so if a doctor asks you how many hypos you've had ask them to clarify what they mean before giving them an answer close enough to the truth so that you can both work on reducing them even further.  For me it will still remain classified by the treatment type:
*1 Fruit Pastille (FP) = 3g carbohydrate
Four FPs or less = waffy. 
Five to seven FPs = mild hypo. 
Eight FPs or more or a can of Coke (not Diet) + abusing random people = hypo worthy of note + apologies aplenty required.

I hope that was helpful although I'll admit it was lacking in ultimate clarity and guidance.  Sorry. 


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Finally today I'd like to dedicate this blog to an old friend of mine that sadly passed away just before the weekend. Back in my youth I took a year out before heading to university to help look after a wonderful man called Mayo who had Duchenne Muscular Dystrophy and was studying at Leeds University.  As a country lad who'd just turned 18 he gave me a whole new slant on life and always had a positive outlook even if he'd been dealt a very bad hand of cards from the start.  His disease meant he was restricted in movement but not in any why in his mind.  He was at true gent who always looked for the best in everyone and I feel honoured to have had a chance to share a part of his life with him.  My thoughts and prayers at this time go to his wonderful family who were also some of the most friendly and warm people I have ever met.

It's at times like this when as a diabetic of the modern era i must take the time to realise that it's not all bad and the medicine and technology of the modern age make my condition something I can manage in a relatively unobtrusive way.

Dave xxx