Showing posts with label hypoglycemia. Show all posts
Showing posts with label hypoglycemia. Show all posts

Thursday, December 19, 2019

Minimizing Hypoglycemia in Diabetes


Minimizing Hypoglycemia in Diabetes
Dr KK Aggarwal

President CMAAO and HCFI

December 11 in the Journal of Clinical Endocrinology and Metabolism: The US Department of Health and Human Services has identified hypoglycemia as one of the top three preventable and measurable adverse drug events.

Hypoglycemia is defined in

  • Level 1: Glucose < 70 mg/dL and ≥ 54 mg/dL
  • Level 2: Glucose < 54 mg/dL that needs immediate action.
  • Level 3: A severe event characterized by altered mental and/or physical status requiring assistance.

Remember the three measures

Measure 1: Identify high risk patients
·        First, if the patient has experienced a previous Level 2 or Level 3 hypoglycemic event within the past year. If not, then:
·        Second, if the patient has a prescription for insulin and/or insulin secretagogues and has an A1c < 7% documented within the past 6 months. If not, then:
·        Third, if the patient has a prescription for insulin and/or insulin secretagogues and at least one relevant comorbidity.

Measure 2: Educate patients ( 65+) and care givers at greater risk for hypoglycemia

Measure 3: Patient report hypoglycemic events

A Starting Point...



Sunday, August 18, 2019

Mera Bharat Mahan 2- Hypoglycemia, starvation and Chandogya Upanishad



Dr KK Aggarwal

As per Chandogya Upanishad, liquid in the food makes urine, blood and Prana; solid food makes stool, muscles and manas; fatty foods make bone, bone marrow and karmendriyas (elimination, procreation, movement, grasping and speech).

Manas in Upanishad means Jnanindriyas (smell, taste, seeing, touch and hearing) along with mind, intellect, ego and chitta or pure intelligence (Fourfold mind or antahkarana chatushtaya).

Ahamkara is derived from the earth tanmatras; Chitta consciousness from jala tanmatra; buddhi discriminative mind from agni tanmatra; manas finite mind from vayu tanmatras and heart from akasha tanmatra.

The Upanishad says that a person can stay without solid food only for 16 days on liquids.

There is a saying in modern medicine that a person can stay without air for 3 minutes, without water for 3 days and without food for 3 weeks.

The symptoms of hypoglycemia will start once the food is not taken. The symptoms are mainly in the mental functions and sensory organs.

Once a person is in food starvation, even a small amount of food will take care of the mental symptoms.

Let us read the dialogue between Svetaketu with his father Udlaka in Chandogya Upanishad.

Chapter 6.7
6.7.1: षोडशकलः सोम्य पुरुषः पञ्चदशाहानि माशीः काममपः पिबापोमयः प्राणो नपिबतो विच्छेत्स्यत इति
ṣoḍaśakalaḥ somya puruṣaḥ pañcadaśāhāni māśīḥ kāmamapaḥ pibāpomayaḥ prāṇo napibato vicchetsyata iti||


O Somya, a person has sixteen parts, [and all your sixteen parts are intact]. Do not eat anything for fifteen days, but drink as much water as you like. Life is dependent on water. If you do not drink water, you will lose your life.

The mind consists of food, the prana consists of water and speech consists of fire.

6.7.2:   पञ्चदशाहानि नशाथ हैनमुपससाद किं ब्रवीमि भो इत्यृचः सोम्य यजूंषि सामानीति  होवाच  वै मा प्रतिभान्ति भो इति:
sa ha pañcadaśāhāni naśātha hainamupasasāda kiṃ bravīmi bho ityṛcaḥ somya yajūṃṣi sāmānīti sa hovāca na vai mā pratibhānti bho iti||

Śvetaketu did not eat anything for 15 days. After that he came to his father and said, ‘O Father, what shall I recite?’ His father said, ‘Recite the Ṛk, Yajuḥ, and Sāma mantras.’ Śvetaketu replied, ‘I can’t recall any of them, sir’.

6.7.3: तं होवाच यथा सोम्य महतोऽभ्या हितस्यैकोऽङ्गारः खद्योतमात्रः परिशिष्टः स्यात्तेन ततोऽपि  बहु दहेदेवंसोम्य ते षोडशानां कलानामेका कलातिशिष्टा स्यात्तयैतर्हिवेदान्नानुभवस्यशानाथ मे विज्ञास्यसीति
taṃ hovāca yathā somya mahato'bhyā hitasyaiko'ṅgāraḥ khadyotamātraḥ pariśiṣṭaḥ syāttena tato'pi na bahu dahedevaṃsomya te ṣoḍaśānāṃ kalānāmekā kalātiśiṣṭā syāttayaitarhi vedānnānubhavasyaśānātha me vijñāsyasīti ||

The father said to Śvetaketu: ‘O Somya, from a blazing fire, if there is but a small piece of ember left, the size of a firefly, it cannot bum anything bigger than that. Similarly, O Somya, because only one small part of your 16 parts remains, you cannot remember the Vedas. Eat something and then you will understand what I am saying’.

6.7.4:  हशाथ हैनमुपससाद तं  यत्किंच पप्रच्छ सर्वंह प्रतिपेदे  
sa haśātha hainamupasasāda taṃ ha yatkiṃca papraccha sarvaṃha pratipede ||

Śvetaketu ate something and then went to his father. Whatever his father asked him, he was able to follow.

6.7.5: तं होवाच यथा सोम्य महतोऽभ्याहितस्यैकमङ्गारं खद्योतमात्रं परिशिष्टं तं तृणैरुपसमाधाय प्राज्वलयेत्तेन ततोऽपि बहु दहेत् 
taṃ hovāca yathā somya mahato'bhyāhitasyaikamaṅgāraṃ khadyotamātraṃ pariśiṣṭaṃ taṃ tṛṇairupasamādhāya prājvalayettena tato'pi bahu dahet ||

The father said to him: ‘O Somya, from a blazing fire, if there is but a small piece of ember left, the size of a firefly, the fire can again blaze up when you add some grass. The fire, in fact, can then blaze up even more than it did before’.

6.7.6: एवं सोम्य ते षोडशानां कलानामेका कलातिशिष्टाभूत्सान्नेनोपसमाहिता प्राज्वाली तयैतर्हि वेदाननुभवस्यन्नमयंहि सोम्य मन आपोमयः प्राणस्तेजोमयी वागिति तद्धास्य विजज्ञाविति विजज्ञाविति 
evaṃ somya te ṣoḍaśānāṃ kalānāmekā kalātiśiṣṭābhūtsānnenopasamāhitā prājvālī tayaitarhi vedānanubhavasyannamayaṃhi somya mana āpomayaḥ prāṇastejomayī vāgiti taddhāsya vijajñāviti vijajñāviti ||

‘In the same way, O Somya, of your sixteen parts, only one remained. But that, when nourished by food, has revived, and by that you are now able to follow the Vedas. O Somya, this is why I said that the mind was nourished by food, prāṇa was nourished by water, and speech was nourished by fire.’ Śvetaketu now understood what his father was saying.

The 16 kalas are mentioned in the Prashna Upanishad 6.4.

 प्राणमसृजत प्राणाच्छ्रद्धां खं वायुर्ज्योतिरापः पृथिवीन्द्रियं मनः अन्नमन्नाद्वीर्यं तपो मन्त्राः कर्मलोका लोकेषु  नाम    
sa prāṇamasṛjata prāṇācchraddhāṃ khaṃ vāyurjyotirāpaḥ pṛthivīndriyaṃ manaḥ annamannādvīryaṃ tapo mantrāḥ karmalokā lokeṣu ca nāma ca ||

He created Prâna; from Prâna faith, âkâsa, air, fire, water, earth, senses, mind and food; and from food, strength, contemplation, mantrâs, karma and worlds; and in worlds name also.

1.     Prana or the life force
2.      Faith or Shraddha
3- 7. The Five Elements: Space, Air, Fire, Water and Earth.
8.     The Senses: The organs of knowledge and the organs of action.
9.     Mind, the Antahkarana or thought process
10. Food – that which sustains the gross body or the “Food-sheath”.
11. Veerya, or strength, mental and physical
12. Tapas or austerity
13. Mantra
14. Karma, the performance of actions
15. The World, the manifested world provides the field and the means to fulfill the actions undertaken.
16. The Naming of all the different items in creation.

See related link

Mera Bharat Mahan 1: May you live for 100 years...


Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA


Sunday, June 23, 2019

Bihar children deaths: Could refeeding syndrome precipitated by litchis be the cause?




Dr KK Aggarwal

What do we know so far about these deaths: Mostly malnourished children < 10 years old, linked to lychee orchids, convulsions early in the morning, no fever, high mortality the same day, all had low sugar but mortality still high even after infusing sugar.

This only means that some other metabolic factor is also at play apart from the sugar.

What might be happening? If significantly malnourished children, who have not eaten food for more than 3 days eat oral carbohydrates (litchi in this case), it can cause electrolyte and fluid shifts that may precipitate disabling or fatal medical complications.

This is the so-called refeeding syndrome characterized by hypophosphatemia, hypokalemia, congestive heart failure, peripheral edema, rhabdomyolysis, seizures, fever and hemolysis.  The hallmark feature is hypophosphatemia.

Rapidly treating hypoglycemia with lychee will harm, if phosphate levels are not managed. The best food in such situations is sugarcane juice and not litchi. Remember, sugarcane is the juice used to break all starvation fasts.

The risk of hypophosphatemia during refeeding appears to be greater in patients who are more severely malnourished and at lower percent of ideal body weight. 

Stores of phosphate are depleted during episodes of starvation. When nutritional replenishment starts and patients are fed carbohydrates, glucose causes release of insulin, which triggers cellular uptake of phosphate (and potassium and magnesium) and a decrease in serum phosphorous levels. Insulin also causes cells to produce a variety of depleted molecules that require phosphate (adenosine triphosphate and 2,3-diphosphoglycer1ate), which further depletes the body’s stores of phosphate.

The subsequent lack of phosphorylated intermediates causes tissue hypoxia, myocardial dysfunction, respiratory failure due to an inability of the diaphragm to contract, hemolysis, rhabdomyolysis and seizures.

Risk factors for the re-feeding syndrome include low baseline levels of phosphate, potassium, or magnesium prior to re-feeding the patient; and little or no nutritional intake for the previous 5 to 10 days. Patients are at the highest risk for the re-feeding syndrome in the first 1 to 2 weeks of nutritional replenishment and weight gain.

Generally, the risk progressively dissipates over the next few weeks if there has been consistent forced intake and weight gain.

Excerpts from Dr T Jacob John, Retired Professor of Virology from CMC Vellore

·         All it would have taken was to ensure that the children had a meal the preceding night
·         The disease is not encephalitis but encephalopathy.
·         Encephalitis results from a viral infection, unless proved otherwise. The pathology is primarily in the brain. Encephalopathy is a biochemical disease, unless proved otherwise.
·         Encephalopathy is eminently treatable.
·         Hypoglycemia is usually due to an overdose of insulin in children with diabetes. It is easily corrected with oral sugar or intravenous glucose. The easily available 5% glucose solution suffices. Hypoglycaemic encephalopathy, however, is different from simple hypoglycemia.
·         The disease broke out during the months when litchi was harvested, i.e. April, May and June. The illness started suddenly; children were found vomiting, displayed abnormal movements, were semi-conscious, and were convulsing between 4 a.m. and 7 a.m. The disease progressed fast — children went into coma and died within a few days. When sick children were tested, the blood glucose level was always below normal.
·         This disease was reminiscent of the Jamaican Vomiting Disease, a form of hypoglycaemic encephalopathy. It is triggered when unripe cake fruits are eaten. These fruits contain a substance, ethylene cyclopropyl alanine, which blocks a biochemical process called fatty acid oxidation, or gluconeogenesis.
·         There are two essential steps: gluconeogenesis is turned on and is then blocked midway by methylene cyclopropyl alanine. The back-up molecules of the unfinished process are certain amino acids that are highly toxic to the brain cells. Ackee and litchi belong to one plant family. We found generous quantities of methylene cyclopropyl glycine in litchi fruit pulp.
·         The disease affected only malnourished children between the ages of two and 10.
·         A majority of them were from families camping in orchards for fruit harvesting. No child from the nearby towns fell ill. Children of well-to-do families never fell ill.
·         Litchi harvest usually begins by 4 a.m., which means that families are awake before that. They go to sleep early. If children go to sleep without dinner, parents usually do not wake them up and feed them. Litchis are collected in bunches and sent to the collection points, but single fruits fall to the ground. Children are free to collect and share the fruits with their friends.
·         After prolonged fasting, malnourished children slipped into hypoglycaemia in the morning. Since they had very little reserve glycogen in their livers, they were unable to mobilise glucose from liver glycogen, unlike well nourished children. The brain needs glucose as a source of energy. As a result of lack of liver glycogen, gluconeogenesis was turned on. Had there not been litchi methylene cyclopropyl glycine, the glucose levels would have been maintained, and the children would have come to no harm. As the children had consumed litchis the previous day, gluconeogenesis had been blocked, aminoacidemia had developed, and brain functions had been affected. Hypoglycaemic encephalopathy had set in.
·         We were unable to demonstrate aminoacidemia in children with hypoglycaemic encephalopathy, but that was done by investigators from the US Centers for Disease Control and Prevention (CDC). The only missing piece in our studies was filled in by CDC colleagues.
·         The disease can be prevented if children are well nourished, but that is not possible in the immediate term. It can also be prevented by ensuring that children eat a meal at night. All families were taught to provide a cooked meal to children before going to sleep at night. Preventing children from eating litchis is not easy, but the quantity of the fruit can be restricted with parental supervision. With all this health education, I was told that the disease number had come down drastically in 2016-18 compared to what it was in 2014-2015. I don’t know what went wrong this year.
·         In 2015, all primary health centres were supplied with glucometers to check the blood glucose levels of sick children. Doctors were instructed to take a blood sample for glucose estimation and, irrespective of the results, infuse 10% glucose intravenously. To correct mild hypoglycaemia, 5% glucose is enough, but here the problem is not hypoglycaemia alone, but aminoacidemia as a result of blocked gluconeogenesis. To prevent any further back-up amino acid from accumulating, the fatty acid oxidation process has to be turned off quickly. That requires raising blood glucose level to abnormally high levels so that insulin secretion is stimulated, and that in turn turns off the gluconeogenesis.
·         If ill children are infused with 10% glucose within four hours of onset of brain dysfunction, recovery is fast and complete. If only 5% glucose is given, or if 10% glucose is not administered within four hours, recovery is unlikely.
·         Glucometers have not been maintained well. Health education was not sustained. New doctors are not familiar with all the information. Instead of 10% glucose, 5% is given.
·         Ambulances take more than four hours to reach the city hospitals from many rural clinics.

The final answer

·         Refeeding syndrome
·         Shortened duration added with litchi toxins
·         Prevention: Evening mid-day meal
·         In hospital, treat low sugar, low phosphates, low magnesium, low potassium


Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of Medical Associations in Asia and Oceania   (CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of India
Past National President IMA

Wednesday, August 31, 2011

Emedinews:Makesure: A patient on 10 units of insulin developed hypoglycemia after taking a light breakfast.

Situation: A patient on 10 units of insulin developed hypoglycemia after taking a light breakfast.
Reaction: Oh my God! Why was the insulin dose not reduced?
Lesson: Make sure that insulin dose is correct. The formula is 500/total daily dose. The value will be the amount of sugar fluctuation with ten grams of carbohydrates.

Saturday, August 6, 2011

Emedinews: Makesure: A patient after receiving 40 units of insulin developed severe hypoglycemia.


Situation: A patient after receiving 40 units of insulin developed severe hypoglycemia.
Reaction: Oh my God! The order was 4 units.
Lesson: Make sure that 4 unit is not written as 4.0 units as it may be read incorrectly as 40.

Monday, July 25, 2011

Dr KK Answers: What is optimal insulin dose?

June 23 in Diabetes Care.
Weight-based insulin dose up to 0.6 units per kilogram is associated with a low risk of hypoglycemia. 
ADA recommendation: 
1. provide 0.6 units/kg of subcutaneous insulin to non-ICU patients 
2. Basal-bolus insulin: low rates of hypoglycemia with doses less than or equal to 0.6 units/kg