Understanding Impaired Awareness of Hypoglycemia

Q&A with Anika Bilal, MD
Postdoctoral Research Scientist
AdventHealth Translational Research Institute

Hypoglycemia, or low blood sugar, is a serious and potentially life-threatening condition that can affect people with diabetes when they use insulin to manage their diabetes. Since people with Type 1 diabetes depend on insulin for their survival, they are more susceptible to hypoglycemia than those who do not use insulin. Hypoglycemia occurs when the blood sugar level drops below 70 mg/dL. It can cause a range of symptoms, from headache, sweating, irritability, blurred vision, dizziness, and confusion to seizures and coma. It is estimated that, on average, a person with Type 1 diabetes has two episodes of hypoglycemia per week. In the Q&A below, Doctor Anika Bilal talks in-depth about the difference between hypoglycemia and impaired awareness of hypoglycemia, along with the risks, symptoms, and treatments.

Question: What are the differences between hypoglycemia and impaired awareness of hypoglycemia?

Dr. Bilal:

Both hypoglycemia and impaired awareness of hypoglycemia are conditions related to low blood sugar levels. Most people recognize the onset of hypoglycemia by symptoms like headache, trembling, sweating, irritability, blurred vision, and anxiety. As a result, they intervene by ingesting carbohydrate-rich food. If the blood glucose level continues to drop, it can result in severe hypoglycemia, which requires a third-party intervention to manage it. Severe hypoglycemia is a medical emergency as it may result in loss of consciousness, seizures, and brain damage.

People who suffer from repeated episodes of hypoglycemia, over time, lose their ability to recognize the warning signs and symptoms of hypoglycemia. This condition is called impaired awareness of hypoglycemia. This reduced ability to recognize the signs and symptoms of onset and progression of hypoglycemic episodes predisposes them to severe hypoglycemia. Research shows that people with Type 1 diabetes and impaired awareness of hypoglycemia are predisposed to more episodes of life-threatening severe hypoglycemia as compared to those who have normal awareness of hypoglycemia.

Question: What causes hypoglycemia and impaired awareness of hypoglycemia?

Dr. Bilal:

Hypoglycemia can be caused by various factors, such as taking excess insulin or certain diabetes medications, eating too little or skipping meals without adjusting insulin, strenuous exercise without adjusting insulin or carbohydrate intake, or hormonal imbalances. Multiple factors, like repeated episodes of hypoglycemia, longer diabetes duration, old age, and the use of insulin, cause impaired awareness of hypoglycemia. One in four people with Type 1 diabetes develops impaired awareness of hypoglycemia.

Question: How can hypoglycemia and impaired awareness of hypoglycemia be managed?

Dr. Bilal:

Both hypoglycemia and impaired awareness of hypoglycemia can be managed through a combination of lifestyle changes and interventions. Consistent blood sugar monitoring is essential for individuals with diabetes. This involves regular checks throughout the day to identify potential fluctuations and adjust treatment as needed. A well-balanced diet that includes regular meals and snacks can help stabilize blood sugar levels and reduce the risk of hypoglycemia. Regular physical activity can also improve insulin sensitivity and control blood sugar. Additionally, continuous glucose monitors (CGMs) can provide real-time data on blood sugar levels, allowing for more proactive management and early detection of hypoglycemia. Similarly, automated insulin delivery systems can play a vital role in managing impaired awareness of hypoglycemia.

For people with Type 1 diabetes, it is important that they can perceive the commencement of their hypoglycemic event. If they are not usually aware of their low blood glucose level or are only aware of it when the blood glucose level is too low, they are at high risk of developing impaired awareness of hypoglycemia. Therefore, identifying the problem plays a vital role in its management. There are various educational programs focused on behavioral, psychological, and cognitive therapy, which can be used to manage impaired awareness of hypoglycemia. It's important to consult with a healthcare professional for personalized guidance on managing hypoglycemia and impaired hypoglycemia. They can help develop a treatment plan that is tailored to your individual needs and monitor your progress.

Question: What are the risk factors for impaired awareness of hypoglycemia?

Dr. Bilal:

Several factors can increase the risk of impaired awareness of hypoglycemia, including the longer duration of diabetes, frequent hypoglycemic episodes, use of glucose-lowering agents like insulin, which can predispose a person to hypoglycemia, old age, and a defective autonomic nervous system of the body. People who are diagnosed with Type 1 diabetes for many years are more likely to develop impaired awareness due to repeated episodes of low blood sugar desensitizing the body's natural warning signals. Frequent hypoglycemic episodes can also make it harder to recognize the symptoms of hypoglycemia. Some types of insulin, particularly rapid-acting insulin, may increase the risk of hypoglycemia and impaired awareness, especially at higher doses. As people age, their body's sensitivity to changes in blood sugar levels may decrease, making it more difficult to recognize the symptoms of hypoglycemia. Decreased autonomic nervous system response to hypoglycemia could be another factor that can affect the ability to sense the symptoms of hypoglycemia. Additionally, certain medications, such as beta-blockers, can mask the symptoms of hypoglycemia. It's important to note that these are just some of the risk factors for impaired awareness of hypoglycemia. If you have diabetes, it's crucial to work with your healthcare provider to manage your blood sugar levels and monitor for any signs of impaired awareness.

Question: Why is it important to recognize impaired awareness of hypoglycemia?

Dr. Bilal:

Recognizing impaired awareness of hypoglycemia is crucial for several reasons. First, individuals with impaired awareness are at a significantly higher risk of experiencing severe hypoglycemia, which can lead to seizures, coma, or even death. This is because they may not notice the early warning signs of low blood sugar, allowing the condition to progress to a dangerous level before they seek help. Second, early recognition and management of impaired awareness can help to improve the quality of life for people with diabetes. By understanding their risk and taking steps to prevent severe hypoglycemia, individuals can reduce their anxiety and live more independently. Third, severe hypoglycemia can have long-term consequences, such as brain damage and cognitive impairment. Individuals can help prevent these complications and maintain their overall health by recognizing and addressing impaired awareness. Finally, understanding impaired awareness can help individuals and their healthcare providers develop a more effective diabetes management plan. This may involve adjusting insulin doses, monitoring blood sugar levels more frequently, or implementing additional strategies to prevent hypoglycemia.

Question: What are some potential treatments for impaired awareness of hypoglycemia?

Dr. Bilal:

Current research suggests that several approaches may help restore hypoglycemia awareness. It is believed that avoiding hypoglycemic episodes for a prolonged period can potentially improve the awareness of hypoglycemic symptoms. Therefore, educational and psychological interventions, such as programs that teach people with diabetes about the signs and symptoms of hypoglycemia and how to manage hypoglycemia in a timely manner, can improve their ability to recognize and manage low blood sugar. Additionally, new technologies like continuous glucose monitors (CGMs) can provide real-time information about blood sugar levels, aiding in early identification and response to hypoglycemia. Lifestyle changes and appropriate psychosocial interventions to prevent hypoglycemia can also contribute to improved hypoglycemia awareness.

Question: What are the future directions for research on impaired awareness of hypoglycemia?

Dr. Bilal:

Researchers are actively exploring new ways to improve the detection and treatment of impaired awareness of hypoglycemia. This may involve developing more advanced technologies, such as artificial intelligence-powered systems that can analyze CGM data and predict hypoglycemia. Additionally, the role of hybrid closed-loop systems is being explored in the management of impaired awareness of hypoglycemia. Further clinical trials are needed to evaluate the effectiveness of different treatment approaches, including new medications, devices, and educational interventions. Understanding the underlying mechanisms that contribute to impaired awareness, such as changes in the brain's response to low blood sugar levels, may lead to the development of more targeted treatments. Tailoring treatment plans to individual patients based on their specific risk factors and characteristics may improve the effectiveness of interventions. Additionally, research is focused on developing strategies to prevent impaired awareness of hypoglycemia, such as identifying individuals at high risk and implementing early interventions. By exploring these areas of research, scientists hope to improve the lives of people with diabetes who are affected by impaired awareness of hypoglycemia.