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Re: [IPk] Tighter control and hypo unawareness

Hi Melissa

Speaking from my own experiences, I test on average 8 times/day and can 
still miss a hypo until I hit about 2.5. Then I get the shakes and sweats 

When I was between pumps, I lost all of my hypo awareness... I wouldn't 
even sweat, so an outsider couldn't tell either ... very scary to be still 
functioning completely normally and oblivious at 1.1 (and I was there a 
number of times). My own hypo unawareness was caused by my incredible highs 
and lows (still had OK HbA1c's - not brilliant, but OK) but I was getting 
them from the massive bounces up and down. A typical day would see me go 
from 2.1 to 23.5 regardless of how often I tested or what I did - and 
*that* is what brittle diabetes is. Take my word for it, hypo unawareness 
is a VERY real thing, but tends to happen more to people who have been 
diabetic for over 20 years (there are thoughts that it is tied to 
deteriorating autonomic function, and I can dig out a few references if 
you'd like them). I find it odd that the two documented ways that hypo 
unawareness comes about are so completely opposite - tight control or 
hugely bouncing BGs. I would far rather run my BGs a little bit higher than 
the much-vaunted DCCT suggests than have the lauded "tight control" and 
hypo unawareness. Hypo unawareness in tightly controlled type 1s is very 
well documented, and may occur regardless of how often you test. My blood 
can drop 3mmol in 15 minutes, and if I start at 5.0, I am occasionally hypo 
before I know it (and in those instances usually get the warning symptoms 
*after* I have started coming out of the hypo). I know of many long term 
diabetics (20+ yrs) who have similar problems.

Even now, with control really good (last HbA1c was 7.2, have been at 6.5 in 
last 12mths), a hypo at 2.5 quite often feels less severe to me than one at 
4.2, and although I take your point that changing hypo symptoms may be 
somewhat causative in people feeling they are hypo unaware, certainly in my 
case, that was not the case. I didn't have changing symptoms... I had ZERO 
symptoms. I could be talking to my husband quite normally and within 
seconds be unconscious (and on one occasion like that, measured at 0.9).

I have regained my hypo awareness now, and my symptoms change almost week 
by week - sometimes headaches, sometimes confusion, sometimes clammy skin, 
rarely hunger,  often insomnia, occasionally nausea ... or any combination 
of these (and a few other things). Again, I suspect this is tied to the 
long term deterioration of the diabetic body in different areas (primarily 
autonomic and neurological functions).

It is definitely an art, but I think it's important we all bear in mind 
that it is a completely individualised disease that can change dramatically 
over duration as well . What works for one may not work for another, and 
what is "normal" for one is "abnormal" for another. That is why I feel it's 
so important we know what we are dealing with, rather than just assume that 
what we are told by "experts" is accurate. It's also why I choose to keep 
my BGs between 4 and 10, rather than aiming for what to me would be a 
dangerous 4-6 (or 6-9).

Just my fifteen dollars worth there ...


At 07:39 PM 19/03/2003, you wrote:
>Re the correlation between tighter control and hypo unawareness, I think 
>it might be worthwhile considering a another facet of the DCCT and what 
>has become less-than-unusual practice since. The DCCT recommended 'at 
>least four' bg tests/day. Many pumpers and several MDIers I know 
>personally do 7 or so. Four has become the guideline for people on 2 
>injections. The more often one tests, the more frequently one has the 
>chance to 'catch' a falling bg before it hits bottom.
>Also, I have run across some interesting anecdotal studies of hypo 
>symptoms (sorry, I don't have references). I think most of us who can 
>sense hypos would say that the ones with a bg of 4 are normally not quite 
>as incapacitating as the ones we get at 2.5: 4 is closer to 5 and so it 
>should take fewer carbs and less time to sort that one out. I have found 
>since being on a pump that I may not have the same hypo symptoms all the 
>time, but I am very rarely surprised to have a bg below 3.5. I am also 
>quite frequently 'aware' when my bg is above 12, though I can't always put 
>my finger on the exact reasons why I think I should test or just bolus a 
>unit even without testing.
>One thing we haven't really delved into as a list is how tighter control 
>may help us see what our bodies may do when they are functioning well. My 
>most typical hypo symptoms these days are intense hunger and slightly 
>slowed thinking. In the past, my hypos have been characterised by physical 
>shaking, intense headaches, stomachaches, inability to complete a 
>sentence, and tingling lips (usually some combination of 3). Judging from 
>the standard of diabetes education I have seen in the UK thus far, I bet 
>the idea that individuals have their own most likely--or even unique--hypo 
 >symptoms, and that those symptoms can change, hasn't made it far over here
>I do believe hypo unawareness exists; however, some people may discover 
>they are not necessarily as unaware as they thought if it is the case that 
>their symptoms have changed.
>As I am wont to mutter: diabetes is an art, not a science.
>IDDM 9+ years; MiniMed pumper 6+ years
>Co-ordinator, Oxford University Student Union Diabetes Network

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