TABLE 7.

Observed Frequency and Recommended Management of Hypoglycemia

Lifestyle Medicine Practitioner	Frequency of Hypoglycemia	Management of Hypoglycemia (Glucose <70 mg/dL)	Considerations for Daytime Versus Nocturnal Hypoglycemia
M.M.M.	Infrequent	Commonly recommended care/treatment (rule of 15*)	Any hypoglycemia, particularly nocturnal, typically prompts de-escalation of insulin and SFUs.
J.H.K.	Infrequent	Educate patients to have ready access to healthy food to raise blood glucose (e.g., dates, an orange, or whole-grain crackers).	Risk of hypoglycemia is avoided during ITLC by holding or greatly reducing doses of diabetes medications. When these medications are deprescribed, there is essentially no risk of hypoglycemia.
G.E.G.	Infrequent	Check blood glucose; consume crackers, glucose tablets, or juice; use glucagon if needed.	Address nocturnal hypoglycemia with evening food and/or lower doses of long-acting insulin to prevent glucose from dropping too low overnight. For patients taking meal-time short-acting insulin, the correct basal dose will allow for more predictable meal-time responses and help to avoid hypoglycemia.
C.T.	Varies among patients	Commonly recommended care/treatment (4 oz fruit juice or glucose tablets and then eat a more substantial snack within 30 minutes; follow up for medication adjustment evaluation)	All hypoglycemia should be avoided. Attention to avoiding nocturnal hypoglycemia should be the first priority in determining which medication to deprescribe.
B.G.B.	Infrequent	Initially, correct blood glucose with 2 oz of a simple carbohydrate or juice, followed by 1 oz of nuts; patients are encouraged to follow up to assess the need to decrease medication	Hypoglycemia is just as important to monitor during the day as at night. I am much more inclined to decrease diabetes medications to allow for brief hyperglycemia into the 150-mg/dL range to prevent hypoglycemia.
J.F.	Rare	Deprescribing at <120 mg/dL (anytime) is emphasized for prevention of hypoglycemia. Patients are advised to have Medjool dates (16 g carbohydrate) available, but these have only been needed in one case in the past decade.	Hypoglycemia is an extremely unusual occurrence, as medications are rapidly discontinued in favor of nutritional therapy and exercise interventions that do not cause hypoglycemia.
S.L.	Infrequent	Educate patients on the importance of having quick access to drinks that can quickly increase blood glucose and notifying someone immediately if hypoglycemia and neurological status worsen.	To properly deprescribe medication, it is imperative to monitor glucose levels and patient symptoms to ensure that no daytime or nighttime hypoglycemic episodes occur.
J.F.L.	Infrequent	Educate patients to have access to something that can raise their blood glucose.	Avoid hypoglycemia in patients as they adopt a healthier lifestyle and we try to deprescribe their medications (especially insulin). I see the most dramatic drops in patients as they transition to a low-fat, high-fiber, whole-food, plant-based diet. I usually stop oral hypoglycemic medications and/or decease insulin doses proactively because I would rather see their glucose run a little high in the short run than have them develop hypoglycemia as their insulin sensitivity starts to improve and/or insulin resistance starts to resolve.
T.M.C.	Infrequent	Usual care/treatment (rule of 15*)	Varies according to patient type, prescribed medications, timing of insulin dosing, meal-time patterns, and baseline blood glucose control when I first meet a patient.

^*The “rule of 15,” a common guideline for hypoglycemia treatment, includes the following steps: 1) check blood glucose to confirm that it is <70 mg/dL; 2) consume 15 g carbohydrate; and 3) after 15 minutes, recheck blood glucose. If blood glucose is still low, repeat steps 2 and 3 until glucose is >70 mg/dL (51).