The Hungry Place

There is indeed such a thing as a very hungry place. And fortunately for Rajan he found it at his home. At 5 pm, as he burst open his door, and stormed inside, he thanked his lucky stars.

Time to rewind, and know Rajan a little bit. Rajan was 36 years old, and has had Type 1 Diabetes for the last 25 years. People with Type 1 Diabetes cannot make insulin, a hormone needed to keep the blood glucose in check. As a consequence, they need to take insulin treatment lifelong for survival. Rajan took a long acting insulin injection at bedtime to give him a minimum required insulin throughout the day, this is called basal insulin. In addition, to cover the meal- related spikes of insulin, he took 3 boluses of rapid acting insulin with the 3 major meals of the day. He worked in a private company and talked to clients all day long. He was single and had his breakfast and lunch in the office. Dinner was at home. Every day, at 11 am and 3 pm, he would have a cup of tea, usually whilst discussing business matters with a client. He checked his blood glucose using a simple glucometer, and was not keen on tech advancements such as insulin pumps and continuous glucose monitors.

Fast forward to the day of the hungry place.

The first half of the day was unremarkable. Rajan took his rapid acting insulin shots as usual prior to breakfast and lunch. He had already taken the 24 hour long-acting insulin at bedtime the previous night and this was expected to cover the insulin requirements between meals. To avoid evening hunger, Rajan usually had a cup of tea at 3 pm with some snacks. But today, one of his clients had declined the offer of tea, and soon there was a flow of client after client. Rajan kept talking as usual. Though at the back of his mind he knew he had not taken his evening snack, he soon forgot all about his food. Such was his immersion in work-related matters.

At 4.15 pm, Rajan realized that his usual office bus had left for the city, where he lived. His office was in a forest-laden suburb of the city, and the last bus would leave at 4:20 pm. He sprinted towards the bus and got in just as the bus was starting. Inside the bus, he started feeling pangs of hunger, and soon his hands and feet began to tremble. As the bus stopped outside his society building, Rajan broke out into a sweat. He remembered his doctor's words:

“Remember, insulin injection does not just bring down your high blood glucose to normal, it can also push glucose levels into the dangerously low range. When you are on insulin injections, and then feel sweaty, hungry or begin to tremble, you could be having adrenergic symptoms, which are due to the release of a hormone called adrenaline, and such symptoms are early indicators of “hypoglycaemia” or very low blood glucose readings. If you don't take glucose at this stage, you will go into the neuroglycopenic stages of hypoglycaemia when damage to the brain occurs: in this stage, fainting, coma, convulsions and even fatality can occur.”

This neuroglycopenia was exactly what happened to Rajan as he climbed the stairs in a rush, to enter the house and eat something. The combination of the missed snack and the heavy sprint towards the bus had caused his blood glucose to dip low. Very low. Rajan felt as if he was about to faint. And thus, dear reader, there is indeed such a thing as a very hungry place. And fortunately for Rajan he found it at his home. At 5 pm, as he burst open his door, and stormed inside, he thanked his lucky stars.

Having reached his study table, he tore open a small sachet and consumed glucose powder. In a few minutes he was fine. He could feel the glucose levels rising, and feeling better. He confirmed that his blood glucose reading was good, by measuring it with a small home glucometer.

Snacking at the right time with the right amount of carbohydrates is important for people with Diabetes, when they are on certain medications like insulin. Some patients wait till the glucose begins to dip and then take a snack, but this can be dangerous for 2 reasons: firstly, when you wait till you are extremely hungry, you will eat a lot more, and for a person with diabetes, this can lead to spikes of high blood glucose. But secondly, and more importantly, it can lead to a fainting-like situation which happened to Rajan above. And imagine if this were to happen when you are crossing the road or riding a cycle- it could lead to an accident, and could even be fatal. Hence the importance of snacking at the right time with the right amount. A common time that patients need to snack is in the evening, when the glucose levels that have risen during lunch have begun to dip, and dinner is quite some time away. The right approach is to snack on time, before or just when the hunger has set in, not too early, not too late. Not that difficult, if you put your mind to it. You can even confirm the right time by checking with your glucometer.

In this issue of Diabetes Health, we hand- hold you, step by step, into a world of smart snacking. So that you never end up in a hungry place like Rajan. At Diabetes Health the focus has always, and will always be on impact-making articles and news that you can use.

Diwali is just around the corner, and we wish you a peaceful and blessed festive season!

Dr Unnikrishnan AG

Editor