Chasing Zebras in Diabetes

Got questions about life with diabetes? So do we! That’s why we offer our weekly diabetes information column, Ask D’Mine, hosted by our snarky diabetes expert Wil Dubois, a veteran type 1 and diabetes author.

This week, Wil is carrying on a question about what seems to be false blood glucose levels… or are they all? Do fainting spells with diabetes consistently point to overeating?

Jess, type 1 in Utah, writes: I have a worker who has had type 1 for 10 years. Actually, we have had type 1 for the same timeframe. So we understand each other.   She’s had these fainting spells. In fact, she passed out on her first day of work. Day, eventful. Anyway, when she gets faint, she turns ashen grey, gets super confused and uncoordinated and weak. I haven’t had her struck the floor again because the first day, but it has been shut, trying to get her to a chair quickly enough.

We check her blood glucose every time this occurs because your initial assumption is really a low. She generally has tested before it occurs, we examine during and then check again after. I truly can’t find any consistent amounts I can correlate and say Aha! That’s the cause. She’s been anywhere from 105-400 when this occurs. Now, everybody wants to point fingers at her control being less than perfect. She tests at least five times every day. She uses an insulin pump plus she stays pretty on top of it. Her blood sugars do swing and she does her best to chase them. She is a stressed-out student who’s working her way through school.

So I ran across information that prolonged hyperglycemia can cause a type of neuropathy that affects the heart. But medical people usually say it is probably not the “” (exotic identification). She does not appear to have some other complications up to the point. At least, none that were recognized.   But still, what do you think? Is it the Zebra?

Wil@Ask D’Mine answers: For readers who’ve just seen zebras at the zoo, allow me to give you some background. In medical school, budding young docs are taught that if they are walking in the woods in Vermont and hear hoof beats, then it is probably not a zebra. It is a method of telling them although anything else is possible, the most likely is, well, the most likely. So if their first thought is their patient’s symptoms match , they ought to probably rethink their identification, as pseudomyxoma peritonei is among the rarest diseases on earth.

In general, I think that the Zebra lesson is a good one for doctors, particularly new ones with more knowledge than experience. It helps avoid wasted time peeling empty trees. It is probably even better information for average citizens today that we all live in the Age of Google. As an example, if I noticed my waistline was gradually expanding, I had been having stomach aches, and my appetite was down, Uncle Google might lead me to believe I’d pseudomyxoma peritonei, as those are some of its symptoms.

Of course they are also the indicators of eating bad corn dogs and two hundred million other things, including Zebraititus Hypochondriasis, all of which are more likely than pseudomyxoma peritonei.

OK, I made that one up. There is nothing as Zebraititus.

So I can’t mistake the docs for looking to low blood glucose as the cause of a young T1’s fainting spells. It is the most probable cause. Still, the hoof beats in the Vermont forest could be a Zebra. Perhaps a circus train derailed, freeing all the critters. Maybe misguided eco terrorists freed one out of a zoo. After all, simply because pseudomyxoma peritonei is one of the rarest diseases in the world does not mean people do not get it. They do.

For years I had a zebra Xing sign above the doorway of my clinic office. It was a method of thumbing my nose at medical tradition and a reminder to keep an open mind in any way times. I am aware that Zebras happen. I have seen it.

But even working beneath a zebra crossing sign, I would nevertheless seem to blood glucose as the secret to your young worker’s woes. It sure seems to fit the bill, even or even all the evidence. So the first thing I had troubleshoot before I went zebra searching is her meter. Is your meter working correctly? Is it giving us good, dependable data? There are a whole lot of crap yards out there and health insurance plans are forcing a growing number of PWDs into using these shady pieces of gear.

And it is worth noting that many of the poorer meters give the least accurate information in the very low blood glucose range.

My first advice to you would be to enlarge your struggling college student’s employee benefit plan to add a single really good meter and 100 strips to go with it. Consider it as a possible investment in enhanced productivity. Let’s not eliminate the most probable cause until we’re really sure it is not the issue. Keep in mind that none of us possess a worldwide lights-out point. Each and every hypo affects each and every one of us otherwise. Some of the contributing factors are the rate of the blood sugar drop, the sum of active insulin in the blood, the type, nature, quantity, and timing of the latest meal, and the baseline average blood glucose of the PWD. That list does not even include things like stress, sleep hygiene, illness, and a million other things. My point being, do not assume somebody has to be at 35 mg/dL to pass out.

But if the tree I’m barking up turns out empty, until I looked at heart neuropathy, I would look to another place in the bloodstream, and that is quantity and pressure. Why? If the hoof beats were not out of a white-tailed deer (common in Vermont), the next most likely hoof beater in the Vermont woods is a moose.

Low blood pressure is a common cause of syncope–a Zerbra-esque word for a temporary loss of awareness. It occurs when the blood pressure drops low enough that the brain does not get quite enough oxygen. Why would that happen in a young, healthy-ish individual?

I can think of two common causes. Is she on the “recommended” ACE inhibitor that all D-folk are assumed to take if they need it or not? It is the standard of care : All of us sugar-impaired men and women take this med, as it may protect our kidneys out of the ravages of elevated sugars. But they are blood-pressure lowering meds. In case her dose is just a little too large, it might trigger syncope from time to time.

Another common cause of syncope, which may exist together with the ACE inhibitor, is dehydration. Does she drink a lot of water? And java does not count. Consuming considerable amounts of caffeine may have a diuretic effect, mildly dehydrating the body and lowering the blood pressure. As a struggling, working school student, I imagine your woman might be a caffeine addict.

But if that is not it either, well, what on your Zebra? The neuropathy of the heart? Could this be the cause? Yes, but… Well, I’ll get back to the “but” in a second. This sort of neuropathy is known as cardiac autonomic neuropathy. And you’re correct it may trigger fainting.

Why am I so quick to rule out something that seems to fit the bill?

Since I really don’t think she’s had diabetes to get this “side effect” She’s just had diabetes 10 years and you told me that is she is “pretty on top of it” Even in poorly controlled type 1 diabetes, ten years is your earliest you’d see some long-term complication pop up, and the autonomic neuropathies aren’t typically in that wave.

It takes a whole lot of high sugar over a long time to make that kind of harm.

So to answer your question, exactly like a zebra could be in the Vermont woods, she could have this negative effect sooner than many men and women get it.

But my money is on it being the bull. Or the moose.

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge in the trenches. But we’re not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are just a small portion of your whole prescription. You still need the expert advice, treatment, and care of a licensed medical professional.

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This content is made for Diabetes Mine, a consumer health blog focused on the diabetes community. The content isn’t medically reviewed and does not adhere to Healthline’s editorial guidelines. To learn more about Healthline’s partnership with Diabetes Mine, please click here.

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