ALOHA: A lack of hypo awareness
By Registered Nurse and Credentialled Diabetes Educator Carolien Koreneff
ALOHA is an acronym for A Lack Of Hypo Awareness – more commonly referred to as hypoglycaemia unawareness. In this article we discuss how to talk to your clients about hypoglycaemia, and what recommendations you can make if your client loses their sensitivity to the signs of a hypo.
What are hypos?
Hypoglycaemia, or hypo for short, is a low blood glucose level. It usually means a blood glucose level below 4 mmol/L.
Hypos can happen in people who take insulin or other glucose lowering medications, called sulphonylureas. This includes medications such as:
- gliclazide (Diamicron or Glyade)
- glibenclamide (Daonil)
- glimepiride (Amaryl or Dimirel)
- glipizide (Minidiab)
In some cases, hypos can also happen when the glucose level drops very rapidly from a high level into the target range. For example, if your client’s levels have been around 20-25 mmol/L for some time, they start or change treatment and suddenly drop to 6 or 7 mmol/L within an hour or less.
Hypos are not pleasant and can make the person feel really unwell.
Most people know when they are going low due to warning signs, or symptoms, of hypoglycaemia.
Symptoms of a hypo
Most of the time hypos cause symptoms, these include:
- Weakness, trembling or shaking
- Sweating
- Light headedness/dizziness
- Headache
- Fatigue/tiredness
- Lack of concentration
- Behaviour change
- Tearfulness/crying
- Irritability
- Hunger
- Numbness around the lips or finger tips
- Fast heart beat
- Blurred vision
If an individual feels any, or a combination of, these symptoms it is important they act on them straight away.
Causes of hypoglycaemia
Hypoglycaemia can be caused by one or more of the following:
- Too much insulin or diabetes medication
- Delaying or missing a meal
- Not eating enough carbohydrate foods
- Unplanned physical activity
- More strenuous exercise than normal
- Drinking too much alcohol
- Drinking alcohol without eating
- Illnesses such as diarrhoea and vomiting
Sometimes the cause of a hypo may not be all that clear to the client and that is where you come in. Talk to your client about what preceded the hypo, as knowing the cause can help prevent future hypos.
Treatment of hypoglycaemia
Hypos need to be treated as soon as the person experiences symptoms and/or their blood glucose is below 4mmol/L. They will not recover without treatment.
Step 1
Quick-acting carbohydrate (that the person finds easy to swallow) such as:
- 1/2 a glass (125mL) or a popper of fruit juice OR
- 6–7 regular jellybeans or 4 large glucose jellybeans OR
- 1/2 a can (150mL) of regular (not ‘diet’) soft drink OR
- glucose tablets equal to 15 grams of carbohydrate OR
- 1 tube of oral glucose gel (equal to 15 grams of carbohydrate) OR
- 100mL of Lucozade® OR
- 3 teaspoons of sugar or honey
After 10–15 minutes, the person should check their blood glucose level to make sure it has risen above 4mmol/L. If it hasn’t, they should repeat step 1 and check their level again another 10-15 minutes later.
Step 2
If their next meal is more than 20 minutes away, they should eat some longer-acting carbohydrate food such as:
- 1 slice of bread OR
- 1 glass (250mL) of milk or soy milk OR
- 1 piece of fruit OR
- 4 dried apricots OR
- 1 tablespoon sultanas OR
- 1 small tub (100g) fruit yoghurt
Eating a snack that contains around 15g of longer-acting carbohydrate will prevent the glucose level from dropping again a little later, as the carbohydrates taken in step 1 will not hang around for long.
For individualised advice on hypo treatment in small children or for people who use an insulin pump and/or a continuous or flash glucose monitoring (CGM) device, talk to the person’s diabetes nurse practitioner or diabetes educator about how to treat and manage hypos in that scenario, as it will be a little different. For example: people who are on an insulin pump for the management of their diabetes do not necessarily need to follow step 2.
Risk factors for ALOHA
Some people with diabetes have difficulty detecting hypos or have no warning signs at all, which is known as hypoglycaemia (hypo) unawareness, a lack of hypo awareness (ALOHA) or impaired hypoglycaemia awareness.
People with hypo unawareness are at a greater risk of severe hypoglycaemia, this is where blood glucose levels can drop dangerously low (down below 2 mmol/L).
Hypo unawareness is more common in people with type 1 diabetes and the risks can be increased by:
- Going low frequently, whether during the day or overnight while sleeping
- Having diabetes for a long time; as this might mean more episodes of hypoglycaemia over time, which can contribute to hypo unawareness
- As we age, autonomic symptoms like shaking, hunger or sweating can be slowed down and make it harder to feel a hypo
- Alcohol consumption in the short term can lower the ability to feel a hypo and weaken the liver’s ability to release glucose when glucose levels start to drop
- Some prescription medications such as some beta blockers or antidepressants may reduce the ability to feel a hypo.
People with type 2 or other types of diabetes may also be at risk of ALOHA, as it can also be caused by the body’s ability to make adrenaline due to nerve damage. Adrenaline is a hormone produced in the adrenal glands and by a small number of neurons in the brainstem. It prepares the body for strenuous activity or in response to fear, anger or stress. Sometimes also called Epinephrine, adrenaline gives the body a surge of energy by stimulating glucose release from the liver.
And although a higher Time in Range helps reduce the risk of diabetes-related complications, if levels rarely go above 7 or 8 mmol/L, the person’s body’s ability to feel a drop in levels can be dulled.
What can you do?
First of all, talk to your clients who are on sulphonylurea medication or insulin about hypoglycaemia. Give them a copy of the NDSS Hypoglycaemia fact sheet and make sure they know about this acute complication of diabetes.
If you suspect that your client has hypo unawareness it is very important to raise this with them. They should not drive a motor vehicle as this may put the client and others around them at risk if they have a severe hypo.
Instead, get them to:
Do more frequent blood glucose monitoring
Your client should check their glucose levels more frequently if hypoglycaemia unawareness is suspected. This will help identify patterns in blood glucose levels and prevent hypoglycaemia.
Tell your client to always treat for a hypo if their blood glucose level is below 4mmol/L, even if they feel fine.
Consider continuous glucose monitoring
Continuous glucose monitoring (CGM) provides glucose readings in real-time and over a period of time. The CGM system will receive glucose readings from the glucose sensor every five minutes or so, this means less finger pricks are needed, but a better overview of glucose levels throughout the day and night is obtained.
Alarms can be set to alert the user if their levels are going too high or too low, this can help prevent hypoglycaemia.
However, it is important that you remind your clients not to rely on their CGM solely, as sensor glucose levels can remain low for up to an hour after a hypo. A good slogan to use is: “if in doubt, get your meter out!”
Avoid any hypoglycaemia for some time
By deliberately running glucose levels a little higher, for example by setting a target of 6-10 mmol/L rather than 4-8 mmol/L, the person can (hopefully) avoid hypos for a month or two. If they do not get any hypos for a couple of months it will help “reset” their system and improve hypo awareness.
Consult the diabetes healthcare team
Get the person to see their doctor or credentialled diabetes educator if you suspect they have hypo unawareness so they can make treatment adjustments.
The diabetes team can review insulin doses, identify any causes of hypoglycaemia, adjust glucose target ranges and help initiate new technology that can be of benefit, such as insulin pump therapy, continuous glucose monitoring or new insulins on the market.
Driving and hypoglycaemia
Hypoglycaemia can impair a person’s ability to drive safely. If a person has hypo unawareness it is recommended that they do not drive, as they have a higher risk of having a severe hypo and this can be life threatening when driving a motor vehicle.
A severe hypo is a hypo that someone else has to help the person to treat, either because they don’t feel or recognise their hypo and/or because they are unable to treat themself. Severe hypos increase the risk of fitting and may lead to unconsciousness.
Having a severe hypo also means the person is at risk of having further episodes of severe hypos, and this can be dangerous when driving.
You should recommend that your clients with diabetes always check their blood glucose level before driving and that they make sure it is over five to drive.
For further information on driving and hypoglycaemia call the NDSS helpline to speak to a health professional on 1800 637 700.
Interested in learning more about hypo- and hyperglycaemia?
Our Hypo- and hyperglycaemia course bite provides practical guidance on managing diabetes, helping you support your patients with confidence. By completing the course you can:
- Describe the signs and symptoms and causes of hypo- and hyperglycaemia and how they are managed.
- Describe what diabetic ketoacidosis is and the factors that cause it.
Enrol today and gain valuable knowledge, CPD points, and practical skills to enhance your professional practice.