The serious long-term complications of high blood sugar levels are much publicised. But for some people living with diabetes, it is the fear of very low blood sugar levels that can cause crippling anxiety.
One such person is Ben, a self-employed 41-year-old who was diagnosed with diabetes 12 years ago.
He was initially managed with oral medications but required insulin therapy after four years, when the oral medications stopped being effective.
He had to inject himself with insulin before every meal. He wasn't sure of the amount of insulin to inject and often used too little or too much.
His life became a daily roller coaster of high and low blood sugar levels as he grappled with the right balance of insulin and carbohydrates.
By the time Ben was referred to the Diabetes Centre at Khoo Teck Puat Hospital a year ago, his drastic high and low blood sugar levels were causing him a lot of anxiety.
He tested his blood sugar levels 20 times a day and often woke up at night in panic, worried that he was having a low blood sugar attack or hypoglycaemia.
A hypo, or hypoglycaemia attack, occurs when blood sugar levels fall too low because of a mismatch between the body's insulin level and the amount of food (carbohydrates) eaten.
It results in unpleasant symptoms such as shakiness, sweating, palpitations, confusion and blurred vision.
If left untreated, a hypo is a medical emergency as it can cause a coma and even death.
This condition can happen to a person with diabetes, depending on the types of medication he is taking. It is often more common in those taking insulin, although certain oral medications can also result in hypoglycaemia.
Other than too much insulin or diabetes medications for the amount of carbohydrates consumed, other causes of hypoglycaemia include delayed or missed meals, unplanned strenuous physical activity or exercise, or alcohol consumption.
TOO FEARFUL TO SLEEP
Patients will often share that they dread the short-term consequences of having a hypo more than the serious complications, such as kidney failure and blindness, which can develop over time from consistently high blood sugar levels.
Some are so fearful of having a hypo that they can barely sleep, as they are afraid that they will go into a coma or die in their sleep.
The usual responses to hypoglycaemia - such as sweating, palpitations and shakiness - are reduced during sleep, so it is harder for them to realise that their blood sugars are low and treat the hypo.
Therefore, the risk and consequences of having a severe hypo are higher during sleep.
However, it is possible for people with diabetes to swop the daily ups and downs of this blood sugar roller coaster ride for more stable blood sugar control with only occasional hypos.
Normal daily activities such as eating, having a drink and exercise can impact diabetic control, so the key to success is patient empowerment.
Ben's journey to improved self-care took commitment, self-discipline and the support of a multidisciplinary team.
After determining that he required insulin injections for diabetes management, we went back to basics, teaching him how to estimate his carbohydrate intake at meal times and adjust his insulin dosage.
Over the course of several months, he would send in his blood sugar charts for weekly reviews and recommendations.
As his control improved, Ben suffered fewer blood sugar peaks and hypos, resulting in less anxiety.
His confidence grew and he started playing badminton three times a week, which helps to improve both his blood sugar control and overall fitness.
Diabetes technology has also improved Ben's control.
Six months ago, he moved from administering insulin injections four to six times per day to using insulin pump therapy.
An insulin pump is an insulin delivery device worn 24 hours a day. It delivers a small and steady rate of background insulin into the body through a fine plastic tube inserted below the skin, which is changed every three days.
This avoids the need for insulin injections before every meal.
During mealtimes, the user estimates the amount of carbohydrates to be consumed and keys it into the pump.
The pump will then deliver a surge of insulin to cope with the carbohydrate load.
Some insulin pumps are connected to a continuous glucose monitoring device, which senses glucose levels and alerts the user to high and low blood sugar levels.
It can also stop insulin delivery from the pump if a hypo is predicted, thereby preventing a hypo even before it happens.
This feature is particularly useful for patients who are no longer able to sense their hypo symptoms (due to repeated exposure to hypos) and to prevent overnight hypos during sleep.
Diabetes technology continues to advance rapidly and it's hoped that an artificial pancreas that mimics the function of a healthy pancreas will soon become a reality.
In the meantime, with the right knowledge, skills and tools, people with diabetes can adapt and manage their condition to fit their lifestyle, rather than allowing diabetes to control what they do.
• Dr Ester Yeoh is a consultant endocrinologist at Admiralty Medical Centre, a new specialist outpatient and day surgery centre of Khoo Teck Puat Hospital.
The Straits Times © Singapore Press Holdings Limited. Reproduced with permission.
ST ILLUSTRATION: ADAM LEE