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The Three Levels of Hypoglycemia

measuring blood sugar
Measuring blood sugar / Photo: Adobe Stock Photos

A Steering Committee made up of representatives from the American Association of Clinical Endocrinologists, the American Association of Diabetes Educators, the American Diabetes Association, the Endocrine Society, JDRF International, The Leona M. and Harry B. Helmsley Charitable Trust, the Pediatric Endocrine Society, and the T1D Exchange formed a decision-making group for the Type 1 DiabetesOutcomes Program.

Their goal was to develop a consensus on definitions for hypoglycemia, hyperglycemia, time in range, DKA, and patient reported outcomes and while their decisions were informed via input from researchers, industry, and people with diabetes they relied on published evidence, their own clinical expertise, and Advisory Committee feedback.

The Steering Committee defined three levels of hypoglycemia.

Level 1 Hypoglycemia

Level 1 is defined as a measurable glucose concentration of <70 mg/dL (3.9 mmol/L) but ≥54 mg/dL (3.0 mmol/L) which “can alert a person to take action”, they wrote.

In those without diabetes, a blood sugar of 70 mg/dL (3.9 mmol/L) is known as low blood sugar.

People with diabetes (with “altered counter regulatory hormonal and neurological responses”) don’t have any way of naturally raising blood sugar when it is low and the main risk with a blood sugar at this level is that in may drop further.

Not only that but “Recurrent episodes of hypoglycemia lead to increased hypoglycemia unawareness, which can become dangerous as individuals cease to experience symptoms of hypoglycemia, allowing their blood glucose levels to continue falling,” writes the committee.

So blood glucose at <70 mg/dL (3.9 mmol/L) are relevant and “clinically important” despite a lack of severe symptoms.

Level 2 Hypoglycemia

Level 2 hypoglycemia is defined as a measurable glucose concentration of <54 mg/dL (3.0 mmol/L) which requires immediate action.

At this stage, “neurogenic and neuroglycopenic hypoglycemic symptoms begin to occur, ultimately leading to brain dysfunction at levels <50 mg/dL (2.8 mmol/L),”

At this level, symptoms like behavioral changes, visual changes, seizure, and loss of consciousness occur due to “central nervous system neuronal glucose deprivation,” the committee writes.

Level 3 Hypoglycemia

“Level 3 hypoglycemia is defined as a severe event characterized by altered mental and/or physical status requiring assistance.”

At this level, a persons symptoms are such that they require help from others. For some, this level may occur during the aforementioned level 1 or 2 for hypoglycemia.

They’ve classified this state as it’s own level because people differ and while some might function at a certain low blood sugar level, others may not.

They also noted that there are other symptoms of hypoglycemia that are “important for consideration of individuals with hypoglycemia unawareness and variations in the presentation of hypoglycemia among different demographics.”

Also, if hypoglycemia comes on fast like with a significant insulin overdose, level 2 or 3 hypoglycemia can have a quick onset without much warning.

More Research Needed

The committee report states that with more information these days like from CGM devices, decision-making abilities are enhanced regarding when one can correct a low blood sugar. They agree that, “More information on the impact of level 1 and level 2 hypoglycemia—both physiologically and with regard to impairment in how patients feel and function—is needed.”

Also, there needs to be more research into links regarding level 1 and 2 hypoglycemia and long-term outcomes as well as the “underlying factors” behind hypoglycemia-associated autonomic failure and changes to how one responds to repeated lows over time.

Originally published by Sysy Morales at Diabetes Daily


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