Managing hypoglycaemic anxiety

Dr Paula Diab discusses hypoglycaemic anxiety, its impact on diabetes management and provides practical strategies to help take control and reduce it.

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Living with diabetes can present numerous challenges, including daily glucose monitoring; paying careful attention to what you eat and when you eat; and compensating for normal, everyday lifestyle challenges such as stress, exercise and hormonal changes. Added to these challenges is the ever-present danger of low blood glucose levels (hypoglycaemia). While hypoglycaemia can be concerning in itself, it can also trigger hypoglycaemic anxiety and stress which may even exacerbate glucose levels further.

Understanding hypoglycaemic anxiety

Hypoglycaemic anxiety refers to the fear or worry experienced by people living with diabetes regarding the possibility of experiencing low blood glucose levels. This anxiety can stem from concerns about the physical symptoms as well as potential complications associated with hypoglycaemia.

Symptoms associated with hypoglycaemia include dizziness, confusion, and even loss of consciousness. These may often be misinterpreted as an anxiety attack or exacerbated by associated anxiety.

A previous experience of hypoglycaemia will also have a significant impact on future decision-making. Additionally, the fear of not being able to manage or control these episodes can contribute to heightened anxiety levels.

This is particularly true for the elderly; people who live alone and those who have poor or unstable support systems. Even an adult living with a spouse at home may feel unsupported and anxious if the spouse’s work demands irregular working hours or shift work. Children who have unpredictable daily routines where one day involves a two-hour sport practise after school and the next day is more sedentary or when sports practise is suddenly cancelled, or the time moved, or some aspect of the exercise changed.

Even those who rely on served meals (old age homes, hospitals, boarding schools, work conferences, travel, etc.) may experience anxiety at not being in control of what food they have access to at any time.

Impact on diabetes management

Hypoglycaemic anxiety can have a significant impact on diabetes management. Anxiety and stress can lead to hormonal changes that affect blood glucose levels, potentially triggering a vicious cycle of unstable glucose control.

Fear of hypoglycaemia may also result in intentionally maintaining higher blood glucose levels to avoid low episodes, which can lead to long-term health complications. It’s crucial to address hypoglycaemic anxiety to maintain a balanced and healthy approach to diabetes management.

Strategies to prevent hypoglycaemia

As with most challenges in diabetes, awareness and education are key to gaining control. Understand the signs and symptoms of low glucose levels and discuss them with your healthcare team.

Learn to recognise your individual triggers and identify the steps to prevent and treat low blood glucose effectively. This may differ for each and every individual.

Insulin

The most common culprit is short-acting insulin as this is exactly what it’s designed to do. Long-acting basal insulins don’t generally have a high risk of hypoglycaemia. Particularly the newer basal analogue insulins are very stable and don’t have a high risk for hypoglycaemia.

Pre-mixed insulins may also cause hypoglycaemia as they have a short-acting component in them and if you haven’t eaten enough to compensate for the insulin, your glucose levels will drop. Try to opt for newer insulins that have a lower risk profile.

Delayed food intake

Skipping meals, delaying meals, or inadequate carbohydrate intake can cause a drop in blood glucose levels. It’s important to maintain a regular eating schedule and include balanced meals and snacks to provide a steady supply of glucose to your body. When planning and scheduling isn’t in your control (boarding schools, catered meetings, travel), make sure that you speak to your healthcare team and mitigate this risk as best you can.

Physical activity

Engaging in physical activity or exercise can lower blood glucose levels, particularly if you aren’t properly fuelling your body before and after exercise or if the activity level is more intense than usual.

Once again, a change in scheduling of exercise, may enhance your risk of hypoglycaemia so try to mitigate the risk as best you can and understand what changes can be made if necessary.

The combined anxiety of a change in routine added to the risk of hypoglycaemia with exercise may well be a perfect storm so try to plan your exercise and stick to the regime as best you can.

Alcohol

Alcohol can interfere with the liver’s ability to release stored glucose, leading to hypoglycaemia. It’s important to consume alcohol in moderation and with food to help prevent low blood glucose.

Again, an honest discussion with your healthcare team can prepare you for this risk and help you to make the necessary adjustments rather than being afraid of a potential glucose low and making incorrect decisions around your medication.

Illness

Factors such as illness, hormonal changes (during menstruation), and stress can affect insulin sensitivity. These changes can result in increased insulin activity, potentially leading to hypoglycaemia. Education and awareness are the key ways to understand how these events will impact you and what you need to do to avoid hypoglycaemia.

Mistakes

You are human. You make mistakes. Sometimes you may confuse your long and short-acting insulins or miscalculate a carbohydrate intake. Such errors often result in glucose lows. Know how to correct your mistakes and have emergency plans in place.

Insulin pump malfunctions

If you use an insulin pump for diabetes management, a malfunction or infusion site issue can lead to improper insulin delivery. This usually results in glucose levels to rise but the corrective action may be a bit too severe and you may end up with a rebound hypoglycaemia. Many of the newer pumps have cut-off alarms and suspend functions that can now predict hypoglycaemia and switch off insulin delivery to prevent the event occurring.

However, a past experience of hypoglycaemia may tempt the user to override the pump actions and this generates artificial machine learning. Disconnecting your pump and allowing it to deliver insulin outside of your body or manually overriding settings aren’t encouraged as this will result in incorrect decision-making in the future. Speak to your pump specialist about individualising these settings and ensuring they work best for you. Too many alarms and alerts can also result in alarm fatigue where users ignore warning signs and don’t act appropriately.

Medications

Certain medications, such as those used to treat other health conditions like beta-blockers or some antibiotics, can mask the symptoms of hypoglycaemia or affect blood glucose regulation, increasing the risk of low blood glucose. If you’re taking other medications, make sure that they aren’t compounding the problem and be aware of additional signs and symptoms to look out for.

Test, test and test again

Regular monitoring of blood glucose levels empowers you to detect and address potential fluctuations promptly. There is unfortunately no easy and cheap way around this. Regular finger-pricking and interpretation of the numbers can give you important information as to how various lifestyle events, medications and situations affect your blood glucose levels. The more often you test, the more you can predict future patterns.

As an example, if you test regularly before going to bed and know that you’re generally safe if your levels are around 7 – 8mmol/L, then you can be assured that your levels will remain at that level overnight and not drop low.

Not testing leads to too many unknowns and consequent anxiety that a potential hypo will occur which, in turn, leads to false decision-making. By keeping a close eye on your glucose levels, you can gain confidence in managing your diabetes and reduce anxiety associated with hypoglycaemia.

Managing anxiety

Once you’re aware of the nuances of diabetes management and have educated yourself on the effects of daily food intake, activity and hormonal changes, then you can start to plan and make the necessary adjustments that are required.

Try to build a strong support network which can provide a valuable source of encouragement and assistance. Identify one (maybe even two) person/s that you trust (and who you have educated on diabetes) who can call you out and alert you to signs of potential danger.

One of the many downsides of hypoglycaemia is that it affects your executive brain function and decision-making abilities. It can also make you irrational, irritable and angry. Very often, people who are experiencing a severe low glucose level will make decisions that they would not normally make simply due to the physiological changes in their body as a result of the low glucose. Have a trusted friend who can very directly comment on your behaviour and enforce correct decision-making.

Try to find your tribe. Connect with other people living with diabetes through support groups or online communities. Sharing experiences and seeking advice from peers who understand your challenges can help alleviate anxiety. Very often these community groups can provide sound advice and understanding when healthcare professionals are unable to. It’s difficult to empathise with the fear associated with a severe hypoglycaemic episode if you have never experienced it yourself.

Mitigate stress

We are all far too stressed. At this time of year, we’re usually mentally exhausted. Having navigated the cold winter months, the onslaught of public holidays in the first half of the year that wreak havoc with business practices and still just too many months left until the end of the year. Medical aid funds are often depleted at this time and people are unwilling to invest time and money into healthcare.

Although the end of the year may rehabilitate your medical aid benefits, it will do no more than that. There will be more breaks in business function, more stress, more curveballs. Try to incorporate stress management techniques into your daily routine, such as regular exercise, meditation, deep breathing exercises, or engaging in hobbies you enjoy.

Reducing overall stress levels can positively impact both your mental well-being and your blood glucose control and will go a long way to improved diabetes management in the long run.

If hypoglycaemic anxiety significantly impacts your quality of life and ability to manage diabetes, don’t hesitate to seek professional help. Mental health professionals with expertise in diabetes care can provide guidance and support to address anxiety-related challenges effectively.

Questions to ask yourself are:

1. How confident are you that you can stay safe from hypoglycaemia when:

• Exercising
• Sleeping
• Driving
• Social situations
• Alone

If you feel that you lack confidence in any of these situations, then seek professional assistance from your diabetes team before you encounter the problem. Ensure that you know how to avoid and respond to hypoglycaemia and this will greatly diminish your anxiety. Involve your family and friends and ensure that those close to you are also well-equipped to support you.

Conclusion

Hypoglycaemic anxiety is a common concern among people living with diabetes. However, by understanding the condition, implementing effective strategies, and seeking support when needed, you can regain control over your diabetes management and reduce anxiety surrounding hypoglycaemia. Remember, managing diabetes is a journey, and with time, patience, and support, you can overcome hypoglycaemic anxiety and live a fulfilling life while effectively managing your condition.

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