type 2 diabetes slurred speech

Type 2 Diabetes

9 warning signs of low blood sugar.

Hypoglycemia can cause both short- and long-term complications. Know the symptoms of low blood sugar so that you can treat the condition as soon as you’re aware of it.

If you’re living with diabetes, you know how important it is to reduce blood sugar when it is too high, a phenomenon called hyperglycemia . But blood sugar that is too low, or hypoglycemia , is equally critical to avoid.

What Does Low Blood Sugar Mean in People with Diabetes?

Also, pay attention to these telltale symptoms of dipping blood sugar levels to make sure yours stays under control.

1. Ravenous Hunger

2. feelings of anxiety, 3. restless nights.

“Symptoms include night sweats , nightmares, episodes of waking suddenly and crying out, and feelings of unrest and confusion upon waking,” says Palinski-Wade. “A  snack before bed  can reduce the frequency and severity of sleep disturbances.”

4. Shakes and Tremors

5. sweating, 6. lightheadedness, 7. difficulty concentrating.

RELATED: Tired All the Time? Diabetes Could Be to Blame

8. Vision Problems

9. slurred speech and poor coordination, what to do during a hypoglycemic episode, the takeaway.

Hypoglycemia affects the body by causing shaking, sweating, blurred vision, and mood changes. People with low blood sugar may feel suddenly anxious, lightheaded, or hungry.

Recognizing the signs of hypoglycemia can support the return of blood sugar levels to normal as well as a person’s overall diabetes treatment plan. Speak to a physician about the best way to manage your blood sugar levels long-term.

Resources We Trust

• Cleveland Clinic: Blood Glucose (Sugar) Test
• Centers for Disease Control and Prevention: Treatment of Low Blood Sugar (Hypoglycemia)
• DiabetesSpectrum: Living With Hypoglycemia: An Exploration of Patients’ Emotions: Qualitative Findings From the InHypo-DM Study, Canada
• University College of San Francisco: Treating Low Blood Sugar
• Nemours KidsHealth: Hypoglycemia and Diabetes for Parents

Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy . We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

• Hypoglycemia. Harvard Medical School . December 15, 2022.
• Hypoglycemia. Mayo Clinic . November 18, 2023.
• Heller SR et al. Hypoglycemia in patient with type 2 diabetes treated with insulin: it can happen. BMJ Open Diabetes Research & Care . June 15, 202.
• Understanding and Managing Low Blood Glucose (Hypoglycemia). American Diabetes Association .
• Hypoglycemia (Low Blood Sugar). Cleveland Clinic .
• Carb Counting and Diabetes. American Diabetes Association .
• Panic Attacks & Panic Disorder. Cleveland Clinic . February 12, 2023.
• Fear of Hypoglycemia (and Other Diabetes-Specific Fears). American Diabetes Association .
• Hypoglycemia: Nocturnal. Johns Hopkins Medicine .
• Avoiding Nighttime Hypoglycemia. Joslin Diabetes Center .
• Lin YK. Hypoglycemia Detection Using Hand Tremors: Home Study of Patients With Type 1 Diabetes. JMIR Diabetes . April 19, 2023.
• Hillson R. Sweating in diabetes. Practical Diabetes . May 19, 2017.
• Symptoms of Low Blood Sugar. Kaiser Permanente . October 2, 2023.
• Hypoglycemia: Diagnosis and Treatment. Mayo Clinic . November 18, 2023.
• Jackson DA et al. Prevention of Severe Hypoglycemia-Induced Brain Damage and Cognitive Impairment With Verapamil. Diabetes . May 3, 2018.
• Why Does Diabetes Cause Blurry Vision? Optometrists Network . September 23, 2020.
• Low blood sugar (hypoglycaemia). National Health Service . August 3, 2023.

Understanding and Managing Low Blood Glucose (Hypoglycemia)

Throughout the day, depending on multiple factors, blood glucose (also called blood sugar) levels will vary—up or down. This is normal. If it varies within a certain range, you probably won’t be able to tell. But if it goes below the healthy range and is not treated, it can get dangerous.

Low blood glucose is when your blood glucose levels have fallen low enough that you need to take action to bring them back to your target range. This is usually when your blood glucose is less than 70 mg/dL. However, talk to your diabetes care team about your own blood glucose targets, and what level is too low for you.

Low blood glucose may also be referred to as an insulin reaction, or insulin shock.

Signs and symptoms of low blood glucose (happen quickly)

Each person's reaction to low blood glucose is different. Learn your own signs and symptoms of when your blood glucose is low. Taking time to write these symptoms down may help you learn your own symptoms of when your blood glucose is low. From milder, more common indicators to most severe, signs and symptoms of low blood glucose include:

• Feeling shaky
• Being nervous or anxious
• Sweating, chills and clamminess
• Irritability or impatience
• Fast heartbeat
• Feeling lightheaded or dizzy
• Color draining from the skin (pallor)
• Feeling sleepy
• Feeling weak or having no energy
• Blurred/impaired vision
• Tingling or numbness in the lips, tongue, or cheeks
• Coordination problems, clumsiness
• Nightmares or crying out during sleep

The only sure way to know whether you are experiencing low blood glucose is to check your blood glucose levels, if possible. If you are experiencing symptoms and you are unable to check your blood glucose for any reason, treat the hypoglycemia.

A low blood glucose level triggers the release of epinephrine (adrenaline), the “fight-or-flight” hormone. Epinephrine is what can cause the symptoms of hypoglycemia such as thumping heart, sweating, tingling, and anxiety.

If the blood sugar glucose continues to drop, the brain does not get enough glucose and stops functioning as it should. This can lead to blurred vision, difficulty concentrating, confused thinking, slurred speech, numbness, and drowsiness. If blood glucose stays low for too long, starving the brain of glucose, it may lead to seizures, coma, and very rarely death.

Treatment—The "15-15 Rule"

The 15-15 rule—have 15 grams of carbohydrate to raise your blood glucose and check it after 15 minutes. If it’s still below 70 mg/dL, have another serving.

Repeat these steps until your blood glucose is at least 70 mg/dL. Once your blood glucose is back to normal, eat a meal or snack to make sure it doesn’t lower again.

This may be:

• Glucose tablets (see instructions)
• Gel tube (see instructions)
• 4 ounces (1/2 cup) of juice or regular soda (not diet)
• 1 tablespoon of sugar, honey, or corn syrup
• Hard candies, jellybeans, or gumdrops—see food label for how many to consume

Make a note about any episodes of low blood glucose and talk with your health care team about why it happened. They can suggest ways to avoid low blood glucose in the future.

Many people tend to want to eat as much as they can until they feel better. This can cause blood glucose levels to shoot way up. Using the step-wise approach of the "15-15 Rule" can help you avoid this, preventing high blood glucose levels.

• Young children usually need less than 15 grams of carbs to fix a low blood glucose level: Infants may need 6 grams, toddlers may need 8 grams, and small children may need 10 grams. This needs to be individualized for the patient, so discuss the amount needed with your diabetes team.  
• When treating a low, the choice of carbohydrate source is important. Complex carbohydrates, or foods that contain fats along with carbs (like chocolate) can slow the absorption of glucose and should not be used to treat an emergency low.

Severe hypoglycemia

When low blood glucose isn’t treated and you need someone to help you recover, it is considered a severe event.

Treating severe hypoglycemia

Glucagon is a hormone produced in the pancreas that stimulates your liver to release stored glucose into your bloodstream when your blood glucose levels are too low. Glucagon is used to treat someone with diabetes when their blood glucose is too low to treat using the 15-15 rule.

Glucagon is available by prescription and is either injected or administered or puffed into the nostril. For those who are familiar with injectable glucagon, there are now two injectable glucagon products on the market—one that comes in a kit and one that is pre-mixed and ready to use. Speak with your doctor about whether you should buy a glucagon product, and how and when to use it.

The people you are in frequent contact with (for example, friends, family members, and coworkers) should be instructed on how to give you glucagon to treat severe hypoglycemia. If you have needed glucagon, let your doctor know so you can discuss ways to prevent severe hypoglycemia in the future.

Steps for treating a person with symptoms keeping them from being able to treat themselves.

• If the glucagon is injectable, inject it into the buttock, arm, or thigh, following the instructions in the kit. If your glucagon is inhalable, follow the instructions on the package to administer it into the nostril.
• When the person regains consciousness (usually in 5–15 minutes), they may experience nausea and vomiting.

Don’t hesitate to call 911. If someone is unconscious and glucagon is not available or someone does not know how to use it, call 911 immediately.

• Inject insulin (it will lower the person's blood glucose even more)
• Provide food or fluids (they can choke)

Causes of low blood glucose

Low blood glucose is common for people with type 1 diabetes and can occur in people with type 2 diabetes taking insulin or certain medications. The average person with type 1 diabetes may experience up to two episodes of mild low blood glucose each week, and that’s only counting episodes with symptoms. If you add in lows without symptoms and the ones that happen overnight, the number would likely be higher.

Too much insulin is a definite cause of low blood glucose. One reason newer insulins are preferred over NPH and regular insulin is that they’re less likely to cause blood glucose lows, particularly overnight. Insulin pumps may also reduce the risk for low blood glucose. Accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle (instead of just under the skin), can cause low blood glucose.

What you eat can cause low blood glucose, including:

• Not enough carbohydrates.
• Eating foods with less carbohydrate than usual without reducing the amount of insulin taken.
• Timing of insulin based on whether your carbs are from liquids versus solids can affect blood glucose levels. Liquids are absorbed much faster than solids, so timing the insulin dose to the absorption of glucose from foods can be tricky.
• The composition of the meal—how much fat, protein, and fiber are present—can also affect the absorption of carbohydrates.

Physical activity

Exercise has many benefits. The tricky thing for people with type 1 diabetes is that it can lower blood glucose in both the short and long-term. Nearly half of children in a type 1 diabetes study who exercised an hour during the day experienced a low blood glucose reaction overnight. The intensity, duration, and timing of exercise can all affect the risk for going low. 

Medical IDs

Many people with diabetes, particularly those who use insulin, should have a medical ID with them at all times.

In the event of a severe hypoglycemic episode, a car accident or other emergency, the medical ID can provide critical information about the person's health status, such as the fact that they have diabetes, whether or not they use insulin, whether they have any allergies, etc. Emergency medical personnel are trained to look for a medical ID when they are caring for someone who can't speak for themselves.

Medical IDs are usually worn as a bracelet or a necklace. Traditional IDs are etched with basic, key health information about the person, and some IDs now include compact USB drives that can carry a person's full medical record for use in an emergency.

Hypoglycemia unawareness

Very often, hypoglycemia symptoms occur when blood glucose levels fall below 70 mg/dL. As unpleasant as they may be, the symptoms of low blood glucose are useful. These symptoms tell you that you your blood glucose is low and you need to take action to bring it back into a safe range. But, many people have blood glucose readings below this level and feel no symptoms. This is called hypoglycemia unawareness.

People with hypoglycemia unawareness can't tell when their blood glucose gets low so they don’t know they need to treat it. Hypoglycemia unawareness puts the person at increased risk for severe low blood glucose reactions (when they need someone to help them recover). People with hypoglycemia unawareness are also less likely to be awakened from sleep when hypoglycemia occurs at night. People with hypoglycemia unawareness need to take extra care to check blood glucose frequently. This is especially important prior to and during critical tasks such as driving. A continuous glucose monitor (CGM) can sound an alarm when blood glucose levels are low or start to fall. This can be a big help for people with hypoglycemia unawareness.

Hypoglycemia unawareness occurs more frequently in those who:

• Frequently have low blood glucose episodes (which can cause you to stop sensing the early warning signs of hypoglycemia).
• Have had diabetes for a long time.
• Tightly manage their diabetes (which increases your chances of having low blood glucose reactions).

If you think you have hypoglycemia unawareness, speak with your health care provider. Your health care provider may adjust/raise your blood glucose targets to avoid further hypoglycemia and risk of future episodes.

Regaining hypoglycemia awareness

It’s possible to get your early warning symptoms back by avoiding any, even mild, hypoglycemia for several weeks. This helps your body re-learn how to react to low blood glucose levels. This may mean increasing your target blood glucose level (a new target that needs to be worked out with your diabetes care team). It may even result in a higher A1C level, but regaining the ability to feel symptoms of lows is worth the temporary rise in blood glucose levels.

Other causes of symptoms

Other people may start to have symptoms of hypoglycemia when their blood glucose levels are higher than 70 mg/dL. This can happen when your blood glucose levels are very high and start to go down quickly. If this is happening, discuss treatment with your diabetes care team.

How can I prevent low blood glucose?

Your best bet is to practice good diabetes management and learn to detect hypoglycemia so you can treat it early—before it gets worse.

Monitoring blood glucose, with either a meter or a CGM, is the tried and true method for preventing hypoglycemia. Studies consistently show that the more a person checks blood glucose, the lower his or her risk of hypoglycemia. This is because you can see when blood glucose levels are dropping and can treat it before it gets too low.

If you can, check often!  

• Check before and after meals.
• Check before and after exercise (or during, if it’s a long or intense session).
• Check before bed.
• After intense exercise, also check in the middle of the night.
• Check more if things around you change such as, a new insulin routine, a different work schedule, an increase in physical activity, or travel across time zones.

Why am I having lows?

If you are experiencing low blood glucose and you’re not sure why, bring a record of blood glucose, insulin, exercise, and food data to a health care provider. Together, you can review all your data to figure out the cause of the lows. 

The more information you can give your health care provider, the better they can work with you to understand what's causing the lows. Your provider may be able to help prevent low blood glucose by adjusting the timing of insulin dosing, exercise, and meals or snacks. Changing insulin doses or the types of food you eat may also do the trick.

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Hypoglycemia vs. Hyperglycemia

Causes and risk factors, complications.

Hypoglycemia and hyperglycemia refer to blood sugar levels that are too low or too high, respectively. A fasting blood sugar level below 70 milligrams per deciliter (mg/dL) is referred to as hypoglycemia, while a fasting blood sugar level over 125 mg/dL is called hyperglycemia.

Blood sugar changes, whether a dip or a spike, can cause symptoms and serious complications. These conditions are common in people with diabetes but can also be caused by other factors and occur in people without diabetes.

Halfpoint / Getty Images

Unbalanced diet

Skipping meals

Medications

Family history

Major illness

Hyperglycemia Causes

Hyperglycemia occurs when there is too much sugar in the blood. This happens either when your body has too little insulin (the hormone that transports glucose into the blood) or if your body can't use insulin properly like in the case of type 2 diabetes.

The causes of hyperglycemia in people with diabetes include:

• The dose of insulin or oral diabetes medication that you are taking is not enough.
• The amount of carbohydrates you are taking in when eating or drinking is not balanced with the amount of insulin your body is able to make or the amount of insulin you inject.
• You are less active than usual.
• Physical stress from an illness, such as a cold, the flu, or an infection, is affecting you.
• Stress from family conflicts, emotional problems, or school or work is affecting you.
• You are taking steroids for another condition.
• The dawn phenomenon (a surge of hormones the body produces daily around 4 a.m.–5 a.m.) is affecting you.

Other possible causes of hyperglycemia include:

• Endocrine conditions, such as Cushing's syndrome , that cause insulin resistance
• Pancreatic diseases, such as  pancreatitis , pancreatic cancer, and cystic fibrosis
• Certain medications, such as diuretics and steroids
• Gestational diabetes (diabetes in pregnancy)
• Surgery or trauma

Hypoglycemia Causes

Hypoglycemia occurs when there is too much insulin in the body, resulting in low blood sugar levels. It is common in people with type 1 diabetes, and it can occur in people with type 2 diabetes taking insulin or certain medications. 

For people without diabetes, hypoglycemia is rare. Causes of hypoglycemia in people without diabetes can include:

• Having prediabetes or being at risk for diabetes, which can lead to trouble making the right amount of insulin
• Stomach surgery, which can make food pass too quickly into your small intestine
• Rare enzyme deficiencies that make it hard for your body to break down food
• Medicines, such as salicylates (such as aspirin), sulfa drugs (an antibiotic), pentamidine (to treat a serious kind of pneumonia), or quinine (to treat malaria)
• Alcohol, especially with binge drinking
• Serious illnesses, such as those affecting the liver, heart, or kidneys
• Low levels of certain hormones, such as cortisol, growth hormone, glucagon, or epinephrine
• Tumors, such as a tumor in the pancreas that makes insulin or a tumor that makes a similar hormone called IGF-II

For people with diabetes, accidentally injecting the wrong insulin type, too much insulin, or injecting directly into the muscle (instead of just under the skin) can cause low blood sugar.

Other causes of hypoglycemia in people with diabetes include:

• Being more active than usual
• Drinking alcohol without eating
• Eating late or skipping meals
• Not balancing meals by including fat, protein, and fiber
• Not eating enough carbohydrates
• Not timing insulin and carb intake correctly (for example, waiting too long to eat a meal after taking insulin for the meal)

Vision changes

Excessive thirst

Fruity breath

Increased hunger

Nausea, vomiting

Fast heartbeat

Hyperglycemia Symptoms

While hyperglycemia symptoms can start small and insignificantly, the longer your blood sugar is high, the worse these symptoms can become. Typically, hyperglycemia starts with fatigue , headache, frequent urination, and increased thirst. Over time, symptoms can progress to nausea and vomiting, shortness of breath, and coma.

Recognizing the symptoms of high blood sugar and treating them early are key to avoiding serious complications.

Hypoglycemia Symptoms

Hypoglycemia symptoms also tend to start slowly and may not be recognized at first, but without treatment, symptoms tend to become more serious.

The common symptoms related to low blood sugar include shakiness, hunger, fast heart rate ( tachycardia ), and sweating. They also can include irritability, inability to concentrate, and dizziness.

If your blood sugar levels are dangerously low (below 54 mg/dL), severe symptoms can occur. These symptoms can include confusion, behavioral changes, slurred speech, clumsy movements, blurred vision , seizures, and loss of consciousness.

Fast-acting insulin

Regular exercise plan

Weight loss

Eating carbohydrates in moderation

15 grams of carbohydrate

Glucose tablets

Dietary changes

Hyperglycemia Treatments

For nonemergency episodes of hyperglycemia, a person can turn to fast-acting insulin to reduce blood sugar. Another quick way to lower blood sugar is with exercise.

Prevention should come first to ensure these spikes in blood sugar don't happen to begin with. Some ways to ensure that blood sugar stays level and doesn't go too high include following a regular exercise plan and eating a balanced diet. Maintaining a healthy weight, quitting smoking, and limiting alcohol intake can help prevent future hyperglycemic episodes.

Hypoglycemia Treatments

Hypoglycemia can usually be treated in a pinch with snacks or drinks you have on hand. The 15-15 rule states that you should raise your blood sugar gradually by first eating 15 grams of carbohydrate, waiting 15 minutes, and checking your blood sugar level. If your blood sugar is still below 70 mg/dL, repeat the steps until you feel better.

Glucagon can be used along with emergency treatment to manage low blood sugar. It comes in liquid form in a prefilled syringe or an auto-injector device for you to inject just under the skin. Glucagon is also available as a powder that can be mixed with a provided liquid to be injected into the skin, muscle, or vein. It also is available as a nasal spray.

After injecting glucagon, the patient should be turned onto their side to prevent choking if they vomit. Use glucagon injection exactly as directed. Do not inject it more often or inject more or less of it than prescribed by your healthcare provider.

To avoid low blood sugar symptoms and complications, discuss any changes and concerns with your healthcare provider. Some ways to avoid low blood sugar include keeping emergency medication or glucose tablets on hand, discussing your condition with loved ones, empowering them to assist you if needed, and wearing a medical identification card in case of an emergency.

If you don’t feel better after three tries of the 15-15 rule or if your symptoms get worse, call your healthcare provider or 911. Healthcare providers can use a medication called glucagon. They inject it with a needle or squirt it up your nose. 

Kidney damage

Peripheral neuropathy (nerve damage outside the brain and spinal cord) and autonomic neuropathy (damage to nerves controlling involuntary bodily functions)

Loss of consciousness

Falls or accidents

Hyperglycemia Complications

Complications of hyperglycemia can affect various body systems, from your eyes to your nerves. Additionally, ongoing high blood sugar can lead to worsening heart disease and peripheral arterial disease.

Treatment and outlook depend on the person's individual needs and circumstances. If hyperglycemia happens during pregnancy, it is considered serious since it can cause damage to the fetus and mother.

Pregnancy can change how the body regulates blood sugar levels. Gestational diabetes is a complication of pregnancy and should be closely monitored.

Parents of children experiencing high blood sugar should work closely with a healthcare provider. High blood sugar, especially when chronic, is a sign of worsening diabetes.

Hypoglycemia Complications

Low blood sugar levels can lead to serious complications as well. The most common complications of severe hypoglycemia include seizures, loss of consciousness, and death. It should also be noted that people experiencing low blood sugar can fall or have accidents due to the shakiness and dizziness that the condition causes.

Hyperglycemia and hypoglycemia both can cause symptoms and serious complications if left untreated. While they can't be completely prevented, symptoms can be managed so you can get your blood sugar back to normal when they do occur.

Blood sugar levels may be out of sight, out of mind for people without diabetes. However, it's still important to know the signs of hyperglycemia or hypoglycemia so you can take action or seek help immediately when symptoms start. Symptoms are treatable without medical attention most of the time, but if symptoms recur, aren't changing with treatment, or become severe, talk to your healthcare provider.

American Diabetes Association. Hyperglycemia (high blood glucose) .

Kumar JG, Abhilash KP, Saya RP, Tadipaneni N, Bose JM. A retrospective study on epidemiology of hypoglycemia in Emergency Department . Indian J Endocrinol Metab . 2017 Jan-Feb;21(1):119-124. doi:10.4103/2230-8210.195993

American Diabetes Association.  Hypoglycemia (low blood sugar) .

National Institute of Diabetes and Digestive and Kidney Diseases. Low blood glucose (hypoglycemia) .

MedlinePlus. Glucagon injection .

MedlinePlus. Long-term complications of diabetes .

By Kimberly Charleson Kimberly is a health and wellness content writer crafting well-researched content that answers your health questions.

• Patient Care & Health Information
• Diseases & Conditions
• Hypoglycemia

Hypoglycemia is a condition in which your blood sugar (glucose) level is lower than the standard range. Glucose is your body's main energy source.

Hypoglycemia is often related to diabetes treatment. But other drugs and a variety of conditions — many rare — can cause low blood sugar in people who don't have diabetes.

Hypoglycemia needs immediate treatment. For many people, a fasting blood sugar of 70 milligrams per deciliter (mg/dL), or 3.9 millimoles per liter (mmol/L), or below should serve as an alert for hypoglycemia. But your numbers might be different. Ask your health care provider.

Treatment involves quickly getting your blood sugar back to within the standard range either with a high-sugar food or drink or with medication. Long-term treatment requires identifying and treating the cause of hypoglycemia.

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If blood sugar levels become too low, hypoglycemia signs and symptoms can include:

• Looking pale
• Hunger or nausea
• An irregular or fast heartbeat
• Irritability or anxiety
• Difficulty concentrating
• Dizziness or lightheadedness
• Tingling or numbness of the lips, tongue or cheek

As hypoglycemia worsens, signs and symptoms can include:

• Confusion, unusual behavior or both, such as the inability to complete routine tasks
• Loss of coordination
• Slurred speech
• Blurry vision or tunnel vision
• Nightmares, if asleep

Severe hypoglycemia may cause:

• Unresponsiveness (loss of consciousness)

When to see a doctor

Seek medical help immediately if:

• You have what might be hypoglycemia symptoms and you don't have diabetes
• You have diabetes and hypoglycemia isn't responding to treatment, such as drinking juice or regular (not diet) soft drinks, eating candy, or taking glucose tablets

Seek emergency help for someone with diabetes or a history of hypoglycemia who has symptoms of severe hypoglycemia or loses consciousness.

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Hypoglycemia occurs when your blood sugar (glucose) level falls too low for bodily functions to continue. There are several reasons why this can happen. The most common reason for low blood sugar is a side effect of medications used to treat diabetes.

Blood sugar regulation

When you eat, your body breaks down foods into glucose. Glucose, the main energy source for your body, enters the cells with the help of insulin — a hormone produced by your pancreas. Insulin allows the glucose to enter the cells and provide the fuel your cells need. Extra glucose is stored in your liver and muscles in the form of glycogen.

When you haven't eaten for several hours and your blood sugar level drops, you will stop producing insulin. Another hormone from your pancreas called glucagon signals your liver to break down the stored glycogen and release glucose into your bloodstream. This keeps your blood sugar within a standard range until you eat again.

Your body also has the ability to make glucose. This process occurs mainly in your liver, but also in your kidneys. With prolonged fasting, the body can break down fat stores and use products of fat breakdown as an alternative fuel.

Possible causes, with diabetes

If you have diabetes, you might not make insulin (type 1 diabetes) or you might be less responsive to it (type 2 diabetes). As a result, glucose builds up in the bloodstream and can reach dangerously high levels. To correct this problem, you might take insulin or other medications to lower blood sugar levels.

But too much insulin or other diabetes medications may cause your blood sugar level to drop too much, causing hypoglycemia. Hypoglycemia can also occur if you eat less than usual after taking your regular dose of diabetes medication, or if you exercise more than you typically do.

Possible causes, without diabetes

Hypoglycemia in people without diabetes is much less common. Causes can include:

• Medications. Taking someone else's oral diabetes medication accidentally is a possible cause of hypoglycemia. Other medications can cause hypoglycemia, especially in children or in people with kidney failure. One example is quinine (Qualaquin), used to treat malaria.
• Excessive alcohol drinking. Drinking heavily without eating can keep the liver from releasing glucose from its glycogen stores into the bloodstream. This can lead to hypoglycemia.
• Some critical illnesses. Severe liver illnesses such as severe hepatitis or cirrhosis, severe infection, kidney disease, and advanced heart disease can cause hypoglycemia. Kidney disorders also can keep your body from properly excreting medications. This can affect glucose levels due to a buildup of medications that lower blood sugar levels.
• Long-term starvation. Hypoglycemia can occur with malnutrition and starvation when you don't get enough food, and the glycogen stores your body needs to create glucose are used up. An eating disorder called anorexia nervosa is one example of a condition that can cause hypoglycemia and result in long-term starvation.
• Insulin overproduction. A rare tumor of the pancreas (insulinoma) can cause you to produce too much insulin, resulting in hypoglycemia. Other tumors also can result in too much production of insulin-like substances. Unusual cells of the pancreas that produce insulin can result in excessive insulin release, causing hypoglycemia.
• Hormone deficiencies. Certain adrenal gland and pituitary tumor disorders can result in an inadequate amount of certain hormones that regulate glucose production or metabolism. Children can have hypoglycemia if they have too little growth hormone.

Hypoglycemia after meals

Hypoglycemia usually occurs when you haven't eaten, but not always. Sometimes hypoglycemia symptoms occur after certain meals, but exactly why this happens is uncertain.

This type of hypoglycemia, called reactive hypoglycemia or postprandial hypoglycemia, can occur in people who have had surgeries that interfere with the usual function of the stomach. The surgery most commonly associated with this is stomach bypass surgery, but it can also occur in people who have had other surgeries.

Complications

Untreated hypoglycemia can lead to:

Hypoglycemia can also cause:

• Dizziness and weakness
• Motor vehicle accidents
• Greater risk of dementia in older adults

Hypoglycemia unawareness

Over time, repeated episodes of hypoglycemia can lead to hypoglycemia unawareness. The body and brain no longer produce signs and symptoms that warn of a low blood sugar, such as shakiness or irregular heartbeats (palpitations). When this happens, the risk of severe, life-threatening hypoglycemia increases.

If you have diabetes, recurring episodes of hypoglycemia and hypoglycemia unawareness, your health care provider might modify your treatment, raise your blood sugar level goals and recommend blood glucose awareness training.

A continuous glucose monitor (CGM) is an option for some people with hypoglycemia unawareness. The device can alert you when your blood sugar is too low.

Undertreated diabetes

If you have diabetes, episodes of low blood sugar are uncomfortable and can be frightening. Fear of hypoglycemia can cause you to take less insulin to ensure that your blood sugar level doesn't go too low. This can lead to uncontrolled diabetes. Talk to your health care provider about your fear, and don't change your diabetes medication dose without discussing changes with your health care provider.

If you have diabetes

Continuous glucose monitor and insulin pump

A continuous glucose monitor, on the left, is a device that measures your blood sugar every few minutes using a sensor inserted under the skin. An insulin pump, attached to the pocket, is a device that's worn outside of the body with a tube that connects the reservoir of insulin to a catheter inserted under the skin of the abdomen. Insulin pumps are programmed to deliver specific amounts of insulin automatically and when you eat.

Follow the diabetes management plan you and your health care provider have developed. If you're taking new medications, changing your eating or medication schedules, or adding new exercise, talk to your health care provider about how these changes might affect your diabetes management and your risk of low blood sugar.

Learn the signs and symptoms you experience with low blood sugar. This can help you identify and treat hypoglycemia before it gets too low. Frequently checking your blood sugar level lets you know when your blood sugar is getting low.

A continuous glucose monitor (CGM) is a good option for some people. A CGM has a tiny wire that's inserted under the skin that can send blood glucose readings to a receiver. If blood sugar levels are dropping too low, some CGM models will alert you with an alarm.

Some insulin pumps are now integrated with CGMs and can shut off insulin delivery when blood sugar levels are dropping too quickly to help prevent hypoglycemia.

Be sure to always have a fast-acting carbohydrate with you, such as juice, hard candy or glucose tablets so that you can treat a falling blood sugar level before it dips dangerously low.

If you don't have diabetes

For recurring episodes of hypoglycemia, eating frequent small meals throughout the day is a stopgap measure to help prevent blood sugar levels from getting too low. However, this approach isn't advised as a long-term strategy. Work with your health care provider to identify and treat the cause of hypoglycemia.

• AskMayoExpert. Unexplained hypoglycemia in a nondiabetic patient. Mayo Clinic; 2021.
• American Diabetes Association. Standards of medical care in diabetes — 2021. Diabetes Care. 2021. https://care.diabetesjournals.org/content/44/Supplement_1. Accessed Nov. 11, 2021.
• Hypoglycemia (low blood sugar). American Diabetes Association. https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hypoglycemia. Accessed Nov. 11, 2021.
• Low blood glucose (hypoglycemia). National Institute of Diabetes and Digestive and Kidney Diseases. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/low-blood-glucose-hypoglycemia. Accessed Nov. 22, 2021.
• Cryer PE. Hypoglycemia in adults with diabetes mellitus. https://www.uptodate.com/contents/search. Accessed Nov. 23, 2021.
• Vella A. Hypoglycemia in adults without diabetes mellitus: Clinical manifestations, diagnosis, and causes. https://www.uptodate.com/contents/search. Accessed Nov. 23, 2021.
• Hypoglycemia. Merck Manual Professional Version. https://www.merckmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-metabolism/hypoglycemia?query=Hypoglycemia#. Accessed Nov. 29, 2021.
• What is diabetes? Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/basics/diabetes.html. Accessed Nov. 29, 2021.
• Kittah NE, et al. Management of endocrine disease: Pathogenesis and management of hypoglycemia. European Journal of Endocrinology. 2017; doi:10.1530/EJE-16-1062.
• Vella A (expert opinion). Mayo Clinic. Dec. 2, 2021.
• Castro MR (expert opinion). Mayo Clinic. Jan. 7, 2022.
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Hypoglycaemia (low blood sugar)

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If you or someone you are with develops signs of hypoglycaemia, call triple zero (000) and ask for an ambulance. State that it is a diabetes emergency. If the person can’t swallow, don’t try to give them anything to eat or drink.

• Hypoglycaemia is when you have too little glucose (sugar) in your blood.
• People with diabetes can be at risk of becoming hypoglycaemia (hypo).
• Symptoms of a hypo include trembling, feeling lightheaded, sweating or irritability.
• If a person with diabetes is having a hypo, they need to quickly have some glucose.
• If hypoglycaemia gets worse, you can become unconscious.

What is hypoglycaemia?

Hypoglycaemia (hypo), is when you have diabetes and have too little glucose (sugar) in your blood. A blood glucose level lower than 4 mmol/L is considered hypoglycaemic.

What causes hypoglycaemia?

A hypo can happen for many reasons such as:

• using too much insulin or too much of your glucose lowering medicine
• delaying or missing a meal or snack
• being more active or exercising more than usual
• a hypo can happen 12-15 hours after exercise
• a hypo can happen while you are asleep
• not eating enough carbohydrates
• carbohydrates are found in potatoes, bread and pasta
• drinking alcohol, especially without much food
• feeling unwell and unable to eat or drink
• vomiting or diarrhoea
• breastfeeding

Sometimes there is no clear reason for why you have hypoglycaemia.

If you have diabetes, you should stay alert for the signs of a hypo and carry a treatment kit with you.

What symptoms are related to hypoglycaemia?

Hypoglycaemia can affect different people in different ways. If you have diabetes you will learn over time how it feels for you.

If you are having a hypo, you might:

• be trembling or shaking
• feel sweaty
• feel dizzy or light-headed
• have a headache
• feel tearful or like crying
• feel hungry
• have tingling lips, tongue or cheeks
• feel that your heart is beating faster
• have blurred vision
• feel irritable or nervous

If your hypo gets more severe you could:

• become confused
• find it hard to concentrate
• have slurred speech
• behave strangely, or look like you are drunk
• have a seizure (fit)
• become unconscious

If you feel any of these symptoms, check your blood glucose level. If your blood glucose level (BGL) is below 4 mmol/L you should have some quick acting glucose.

If you cannot check your blood glucose level , treat these symptoms as if you are having a hypo.

CHECK YOUR SYMPTOMS — Use the Symptom Checker and find out if you need to seek medical help.

How is hypoglycaemia treated?

It is important to treat hypoglycaemia straight away. This will stop your blood glucose level from dropping even lower. Untreated hypos can be dangerous.

Follow these steps to have some quick acting glucose.

Have about 15 grams of quick acting carbohydrate. Choose something that is easy to swallow such as:

• glucose tablets equal to 15 grams carbohydrate OR
• 6 or 7 regular size jellybeans OR
• half a can (150mL) of regular soft drink (not ‘diet’) OR
• half a glass (150mL) of fruit juice OR
• 100mL of Lucozade OR
• a tube of oral glucose gel equal to 15 grams carbohydrate OR
• 3 teaspoons of sugar or honey

Wait for 10 to 15 minutes. Check your blood glucose levels again to see if your blood glucose level has risen above 4 mmol/L.

If your blood glucose level is still below 4 mmol/L, repeat Step 1 with another 15 g of glucose.

If your blood glucose level has risen above 4 mmol/L go to Step 2.

Now you should eat a snack or meal with longer acting carbohydrate, such as:

• a slice of bread OR
• a glass of milk or soy milk (250mL) OR
• a piece of fruit OR
• 2 or 3 pieces of dried fruit such as apricot OR
• a tub of yoghurt OR
• a meal including pasta or rice

When should I see my doctor?

If you are unconscious, drowsy or unable to swallow this is a diabetic emergency. Your support person should not try to give you anything to eat or drink. You should be put into a recovery position , and they should call an ambulance (dial 000).

If you have had a severe hypo, tell your doctor as soon as you can. They can help you to find the cause of your hypo and update your diabetes management plan.

FIND A HEALTH SERVICE — The Service Finder can help you find doctors, pharmacies, hospitals and other health services.

ASK YOUR DOCTOR — Preparing for an appointment? Use the Question Builder for general tips on what to ask your GP or specialist.

How is hypoglycaemia diagnosed?

When you are diagnosed with diabetes you will be given a blood glucose meter. If your blood glucose level is lower than your target range, this is low blood sugar. If the blood glucose level is below 4mmol/L this is hypoglycaemia.

It is normal for your blood glucose levels to vary at different times during the day

Can hypoglycaemia be prevented?

Tell the people close to you that you have diabetes. Make sure that they know what to do if you are showing signs of a hypo.

Have a meal that includes carbohydrates if you plan to drink alcohol.

If you are using insulin or some other glucose lowering diabetes medicines, you may be at increased risk of hypoglycaemia. You may need an individual plan to manage hypoglycaemia. Follow the advice of your doctor or diabetes nurse.

If you have diabetes, you should keep a hypo treatment kit. Carry it with you when you are out. The kit should contain:

• a way to check your blood glucose level
• 2 or 3 quick acting glucose treatments
• a snack that contains longer acting carbohydrate

If you have a glucagon injection add it to the kit.

Complications of hypoglycaemia

If hypoglycaemia is not treated your blood glucose levels will continue to drop. This can lead to a severe hypo. You will feel very drowsy and won’t be able to swallow. You will need help from someone else.

If you have a severe hypo, you can become unconscious or have a seizure. The brain may not be getting enough glucose.

Resources and Support

If you are concerned about your symptoms, you can use healthdirect's online Symptom Checker . This tool can give you advice on what to do next.

Visit Diabetes Australia to learn more about blood glucose monitoring

The National Diabetes Services Scheme website has information about living with diabetes in multiple languages.

You can also call the healthdirect helpline on 1800 022 222 (known as NURSE-ON-CALL in Victoria). A registered nurse is available to speak with 24 hours a day, 7 days a week.

Learn more here about the development and quality assurance of healthdirect content .

Last reviewed: December 2022

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Prolonged Cerebellar Ataxia: An Unusual Complication of Hypoglycemia

Jonathan p. b. berz.

1 Evans Department of Medicine, Boston University School of Medicine, Boston, MA USA

2 Boston Medical Center, Boston, MA USA

Jay D. Orlander

3 VA Boston HealthCare System, Boston, MA USA

A 51-year-old male with a history of insulin-dependent diabetes and polysubstance abuse presented after overdose on insulin. Soon after resuscitation, he displayed a severe ataxia in all 4 limbs and was unable to walk; all of which persisted for at least 5 days. Laboratory testing was unrevealing, including relatively normal brain magnetic resonance imaging. He had recovered full neurologic function 3 months after the event. This report describes a case of reversible cerebellar ataxia as a rare complication of severe hypoglycemia that may occur in patients with abnormal cerebellar glucose metabolism. Thus, this phenomenon should be included in the differential diagnosis of patients with a history of hypoglycemia who present with ataxia. In this context, the differential diagnosis of cerebellar ataxia is discussed, as is the proposed mechanism for hypoglycemia-induced cerebellar dysfunction.

INTRODUCTION

The neurologic manifestations of hypoglycemia include behavioral change, confusion, loss of consciousness, and seizures. Rarely, neuroglycopenia can present as ataxia, and prolonged and potentially irreversible deficits may occur with repeated episodes of hypoglycemia. 1 , 2 This phenomenon is thought to be because of abnormal glucose metabolism in the cerebellum. 3 In this paper, we report the case of a 51-year-old male with diabetes and polysubstance abuse who experienced prolonged but reversible cerebellar ataxia after a severe hypoglycemic episode. His case highlights a seldom-reported cause of ataxia and, in addition to providing an opportunity to review the differential diagnosis of ataxia, serves as a reminder that a history of severe hypoglycemia should be assessed in patients presenting with these findings.

CASE PRESENTATION

A 51-year-old African-American male with a history of diabetes presented with gait ataxia and slurred speech 12 hours after being found unconscious with a blood glucose level of 30 mg/dL. He had injected 80 U rather than his usual 8 U of insulin and regained consciousness after receiving glucose from local emergency response personnel. He denied visual disturbances and any previous gait disorder, and admitted to hearing voices telling him to hurt himself. He was initially taken to another hospital where he was found to have a serum screen positive for cocaine, benzodiazepine, and alcohol (his blood alcohol level was not available). His brain CT was reported by the outside hospital as negative.

His medical history included active polysubstance abuse (benzodiazepines, alcohol, cocaine, and tobacco), schizophrenia, hepatitis C, hypertension, and myeloid leukemia in remission. He had a history of multiple hospital admissions for alcohol and illicit drug detoxification, although none documented for a similar presentation. His medications, in addition to his insulin, included felodipine, fosinopril, hydrochlorothiazide, metoprolol, omeprazole, prazosin, risperidone, quetiapine, sertraline, tramadol, and calcium. His glycosylated hemoglobin was 6.4% 1 month before.

On transfer to this hospital, his blood pressure was 163/79, pulse 89, and temperature 97.5°F. In general, he was alert and oriented to person, place, and time, and was acting appropriately. Cardiac and respiratory exam were normal. Abdominal exam revealed no organomegaly. On neurological exam, he was profoundly dysarthric. His pupils were reactive and he had full extra ocular muscle testing with mild endpoint nystagmus bilaterally. Cranial nerves were intact; he had normal strength and sensory testing, and had trace deep tendon reflexes throughout. On coordination testing, he had moderate to severe dysmetria in all 4 limbs (finger to nose and heel to shin), and a wide based unsteady gait that prevented ambulation. His repeat glucose was 106 mg/dL, and additional laboratory studies revealed the following: creatinine 0.9 mg/dL, sodium 137 mmol/L, potassium 4.7 mmol/L, chloride 102 mmol/L, bicarbonate 28mmol/L, white blood cell count 6.6 K/μL, hematocrit 39.8%, and international normalized ratio 1.2. A lumbar puncture was not performed. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain was requested.

The differential diagnosis of symmetric cerebellar ataxia can be classified into acute, subacute, and chronic. Acute causes include cerebellar hematoma, viral cerebellitis, drug or alcohol ingestion, vertebrobasilar ischemic attacks, Wernicke’s encephalopathy, and post infectious syndrome, especially after varicella. Subacute presentations may also include chemotherapeutic agents, paraneoplastic syndromes, and nutritional deficiencies including thiamine and vitamin B-12. Inherited causes including ataxia–telangiectasia and spinal cerebellar atrophy are important considerations in progressive ataxia. When this patient initially presented to care, it was evident that his ataxia was acute or subacute as he had a documented normal neurological examination 1 month before. Given his diabetes and hypertension, he was at risk for cerebral ischemic events and intracerebral bleeding. He was also at risk for alcoholic and nutritional causes. Wernicke’s was considered, as only one third of patients actually have the classic triad of ataxia, ophthalmoplegia, and confusion. However, the patient was not in a confusional state and 90% of patients with Wernicke’s are thought to have disturbances of consciousness and mentation. 4 In addition, he was reported to have been eating regularly thus making it less likely that he had severe thiamine deficiency. MR can be helpful in the diagnosis, and findings may include lesions of the paraventricular regions of the thalamus and hypothalamus, the periaqueductal region of the midbrain, and the mammillary bodies. However, the sensitivity of MR has been shown to be only 53% in 1 case control study. 5 The neurologic manifestations of cocaine use include coma and seizures, and focal neurologic deficits are also possible from subarachnoid hemorrhage or cerebral infarction. We are not aware of prolonged cerebellar ataxia as a manifestation of cocaine toxicity in the absence of infarction. Alcohol can cause acute ataxia, which resolves with resolution of intoxication, and can also cause chronic ataxia as a result of damage to the cerebellum (especially the superior vermis) from chronic alcoholism. There was no history to suggest an infectious etiology and he had no known malignancy to cause a paraneoplastic syndrome. However, ataxia as a result of the latter can be the first presentation of a malignancy. 6 Inherited causes are most often progressive in nature and would have been suspected had his ataxia slowly progressed over time.

Review of his MRI and MRA of the brain was notable for a prolonged T2 signal seen in the white matter consistent with mild microvascular disease and 60% stenosis of the right internal carotid artery (Fig.  1 ). Hematoma and evidence for vertebrobasilar infarction were not present. Mammillary bodies were not visualized. Mild prominence of the cerebellar folia was noted at the midline. Other laboratory testing revealed anti-Hu and Purkinje cell antibodies to be negative, both of which can be seen in the paraneoplastic syndrome of small cell lung cancer.

Brain MRI shows prolonged T2 signal consistent with mild microvascular disease. No hematoma or infraction. Mild prominence of the cerebellar folia was noted at the midline. Mammillary bodies were not visualized.

During his course, he was monitored on a Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) for alcohol withdrawal for which he required minimal benzodiazepines, 7 as he was noted to exhibit little evidence of withdrawal. He also received thiamine and folate in addition to his usual antihypertensive and psychiatric medications. Frequent blood glucose measurements showed a range of 93–271 mg/dL on insulin NPH 12 U/day. Four days into his hospital admission, he continued to display severe ataxia, inability to walk, and slurred speech.

Upon discharge on hospital day 5, he had persistently slurred speech and gait ataxia and was discharged to a nursing facility with the diagnosis of hypoglycemia-induced cerebellar dysfunction. A follow-up MRI was not performed.

The patient signed himself out of the nursing facility 11 weeks later against medical advice as he felt he no longer required a wheelchair to ambulate safely. Two weeks later, a normal abbreviated neurological exam performed by a physician assistant is documented in the record.

Hypoglycemia-induced cerebellar dysfunction is a rare complication of severe hypoglycemia. The neurological findings of hypoglycemia include behavioral change, confusion, loss of consciousness, and seizures. 6 The cerebellum is normally protected from hypoglycemia, and several studies in rat and in man have shown differences in glucose metabolism in the cerebellum compared to the cerebrum, providing a physiologic explanation for such protection. 3 , 8 , 9

Few other cases have been reported on hypoglycemia-induced cerebellar dysfunction. In those cases, myelinolysis appears to be associated with continued neurologic dysfunction. By contrast, in the single case reported in which the patient did not have myelinolysis, the neurologic dysfunction was transient, as was the case in our patient. Rajbhandari et al. describe a 24-year-old female type I difficult-to-control diabetic with HBA1c as high as 21.7% who presented to a diabetes clinic with slurred speech and mild cerebellar ataxia of the limbs. 1 Shortly before, she had had an episode of hypoglycemia where she was found unconscious and resuscitated by an emergency physician with glucagon. MRI findings revealed changes typical for central pontine myelinolysis. This patient had gradual improvement in her symptoms at 6 months with normal speech although she had residual impairment of heel/toe walking.

Schwaninger et al. report on a 41-year-old male who presented with a 2-year history of recurrent severe hypoglycemia and was found to have cognitive impairment, motor neuropathy, and cerebellar gait ataxia. 2 On workup, he was found to have an insulinoma. MRI showed prolongation of T2 relaxation time in the middle cerebellar peduncle and the anterior limb of the internal capsule, consistent with extrapontine myelinolysis. Four months after removal of the insulinoma, the gait ataxia had partially improved although the MRI lesions were still apparent.

Kim et al. report on a 52-year-old female diabetic who presented with hypoglycemia and was found to have transient cerebellar ataxia that resolved after 12 hours. 3 Workup was otherwise unrevealing including a normal brain MRI. Using insulin and glucose administration along with PET scan evaluation of the brain, this patient was then studied to compare the glucose uptake and metabolism kinetics of her cerebrum and cerebellum compared to that of normal controls. In normal controls, glucose uptake was higher in the cerebellum relative to the cerebrum, but the rate of glucose metabolism was lower in the cerebellum. In the case patient, by contrast, the rate of glucose uptake was lower in the cerebellum and metabolism was similar to that of her cerebrum. This metabolic difference would seem to make their case patient more susceptible to hypoglycemic cerebellar injury, whereas in the controls, the cerebrum is more likely to be adversely affected by prolonged and severe hypoglycemia.

In summary, glucose uptake and utilization in the cerebellum appear to be protective with regard to hypoglycemia. Hence, cerebellar dysfunction is a rare complication of hypoglycemia. This disorder may occur in patients with altered cerebellar glucose kinetics. In the case reported above, we present a diabetic with prolonged and severe cerebellar ataxia after an episode of severe hypoglycemia. These abnormalities persisted after a 5-day hospitalization but had normalized by 3 months. In contrast to the other reported cases of prolonged ataxia from hypoglycemia where MR imaging of the brain showed pontine myelinolysis, our patient had no abnormalities of the brainstem or cerebellum seen on brain MRI. The only other patient in the literature with normal MRI findings in the setting of hypoglycemia-induced cerebellar dysfunction had normalization of her ataxia within 12 hours of onset. 3 It appears that the neuronal damage in our patient was severe enough to cause prolonged ataxia, however, the damage was reversible as evidenced by the normalization of his ataxia. A question that remains unanswered is whether the relatively normal MRI findings in the setting of hypoglycemia-induced cerebellar dysfunction predict complete recovery as occurred in our patient.

This case highlights a seldom-reported cause of ataxia and reviews the likely mechanism for hypoglycemia-induced cerebellar dysfunction and why most patients do not manifest neuroglycopenia in this manner. In addition, the differential diagnosis of ataxia is reviewed and serves as a reminder that a history of hypoglycemia should be assessed in patients presenting with ataxia.

Acknowledgements

We would like to thank Dr. Carlos S. Kase, Department of Neurology, Boston Medical Center, for his review of the manuscript.

Conflict of Interest None disclosed.

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How Diabetes Changes Your Voice, and Why It Could Be Very Useful

By Ross Wollen October 25th, 2023

Diabetes can affect just about every part of your body, from your toes to the very top of your head . A new study claims that it can change your voice , too.

Don’t worry — the changes were not enough to be detected by the human ear. But a recognition of these shifts could prove to be very useful. The study was the work of a digital health startup named Klick Labs, which is developing voice-recognition software that may be able to diagnose type 2 diabetes simply by listening to adults speak a few sentences.

Klick scientists took the recordings of several hundred adults, both with and without diabetes, and fed them to an artificial intelligence (AI) model capable of analyzing each snippet. By examining the acoustic features of each voice, the AI system learned that factors such as vocal pitch (in women), strength (in men), and variability (in both) seem to differ meaningfully in people with diabetes. This allows the program to make a surprisingly accurate guess as to whether someone has diabetes — and it only needs to hear you talk for 10 seconds.

The results: The AI model “has 89 percent accuracy for women and 86 percent for men,” according to a press release . The designers hope that their innovation could become a useful tool for the diagnosis of type 2 diabetes, which currently relies on blood tests that are more invasive and time-consuming. Voice recognition could potentially be a faster and less expensive screening alternative, one that could be done even without an office visit.

“Current methods of detection can require a lot of time, travel, and cost. Voice technology has the potential to remove these barriers entirely,” states Jaycee Kaufman, a research scientist at Klick Labs and the primary author of the new paper.

Diabetes, Nerve Damage, and the Throat

Actually, this isn’t the first research to consider the effect that diabetes can have on the voice.

• A 2012 study found that people with diabetes have a higher degree of hoarseness — though only those “with poor glycemic control and with neuropathy.”
• A 2019 systematic review found that 12.5 percent of people with diabetes (1 in 8) have “voice problems,” far higher than in the general population, ranging from hoarseness and straining to excessive throat clearing, annoying coughing, and the sensation of a lump in one’s throat.

Such issues appear to be more common in people with neuropathy (nerve damage). A 2022 review explains that chronically elevated blood glucose levels cause nerve dysfunction throughout the entire body — including the throat and neck. The nerve fibers of people with diabetes experience “progressive destruction,” with consequences such as weakness, reduced sensation, and ataxia (loss of coordination). This dysfunction, presumably, can alter your voice.

Some voice or throat problems may also be related to gastroesophageal reflux disease (GERD) , which is more common in people with diabetes.

More Experimentation Needed

Klick Labs’ innovation is not ready for prime time yet. Medical authorities will need to see a much more robust proof of accuracy before they can consider recommending the voice recognition program. Yan Fossat, vice president of Klick Labs, says that follow-up validation studies will require “individuals with different characteristics than our original study, with different demographics, from different regions of the world.”

It also seems reasonable to guess that, like other complications, voice changes are more prevalent and substantial in people with diabetes of longer duration. The shifts may be far more subtle (or completely nonexistent) in people with recently developed type 2 diabetes, which might reduce the voice-recognition technique’s efficacy as a tool for screening or diagnosis. Kaufman told Diabetes Daily that “we have also considered this question and, to address it, we are looking to perform the same study on people with prediabetes.”

With more than 200 million people worldwide unaware that they have type 2 diabetes, there is an immense demand for simpler screening techniques.

Read more about artificial intelligence , neuropathy , throat , type 2 diabetes , voice .

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• Slurred Speech

6 Causes of Slurred Speech

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What is slurred speech?

Slurred speech quiz.

Take a quiz to find out what's causing your slurred speech.

6 most common cause(s)

Slurred speech is when you have trouble speaking, your words are slow or garbled, or your words run together. When you talk, many components of your nervous system work together to form words. When these parts don’t work correctly, your speech can become distorted, or “slurred.” The medical term for slurred speech is dysarthria.

Slurred speech includes problems pronouncing words and regulating the speed or pace of your speech. It can range from a barely noticeable problem to one that’s so severe that others can’t understand what you’re saying.

People often describe slurred speech as feeling like you’re trying to talk with your mouth full of marbles.

Common causes of slurred or slow speech include drinking too much alcohol and not getting enough sleep. In these cases, the slurring will stop once you’re sober again and have gotten rest, respectively.

There are also other causes of slurred speech such as a stroke (a medical emergency), brain tumor, Bell’s palsy, or a serious migraine.

Does slurred speech always need to be treated?

"People often think slurred speech is a minor symptom that does not need a medical evaluation. As our speech and ability to speak is our main form of communication, it is important to look for correctable causes." — Dr. Karen Hoerst

Should I go to the ER for slurred speech?

You should call 911 if:

• Your slurred speech starts suddenly.
• You have other symptoms, such as a sudden or severe headache and weakness or numbness of one side of your body.
• Your tongue, face, or lips are swelling, which could mean you’re having an allergic reaction.

Slurred speech emergency quiz

Take a quiz to find out if your symptoms are an emergency.

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1. Stroke or TIA (transient ischemic attack)

• Slurred speech
• Drooping of one side of the face
• Weakness or trouble controlling one side of the body
• Numbness in the face , arm , or leg
• Difficulty walking
• Sudden loss of vision or double vision
• Sudden, severe headache

A stroke occurs in the brain because the blow flow in a blood vessel is blocked. It can also happen when a blood vessel ruptures or leaks. This affects the blood supply to parts of the brain, which leads long-term damage. If it affects the area of the brain responsible for speech, it can cause slurred speech.

A transient ischemic attack , or TIA, is sometimes called a "mini stroke." A TIA is a temporary interruption of blood flow that causes the same symptoms as a stroke, but improves without any permanent damage to the brain or symptoms.

For example, if you have slurred speech because of a TIA, once the blood flow is restored to that area of the brain, the slurred speech goes away. But people who have a TIA are at a high risk of having a stroke in the future, especially if their risk factors are not treated. Risk factors are the same for stroke and TIA and include smoking, obesity, and cardiovascular disease.

It’s extremely important to call 911 right away if you suddenly have slurred speech. Getting immediate treatment is critical to minimizing permanent damage. Paramedics can begin treating you in the ambulance on the way to the hospital, so it’s better to call 911 than go to the ER yourself.

Treatments for strokes and TIAs include medications to break up blood clots and surgery to remove blood clots from the vessels. If your stroke is from bleeding in the brain, you may need surgery to repair a blood vessel.

Following treatment, your doctor will recommend medications to prevent another TIA or stroke. These typically include drugs that prevent clots from forming in the blood (like aspirin or other blood thinners) and cholesterol medication to prevent plaque from building up on the walls of the blood vessels. You may also need to take medication to control your blood pressure.

Speech therapy is recommended to help treat problems with speech.

It may not be a stroke

"There are so many possible causes of slurred speech. Most of the time we need a detailed history and physical exam to guide the diagnosis and treatment." — Dr. Hoerst

Take symptoms quiz

2. Bell’s palsy

• Drooping of the face
• Drooping of the eye
• Changes in taste or hearing

Bell’s palsy is a relatively common condition that affects the facial nerve, which is responsible for movement of your face.

In Bell’s palsy, the nerve gets inflamed typically because of a recent viral infection. This inflammation can cause the facial nerve to not work as well, leading to drooping and slurred speech.

Bell’s palsy usually improves in a few months, but medications such as steroids and antiviral drugs are typically given to help speed the process. If nerve problems continue, physical therapy is recommended. In rare instances, surgery may be needed to help improve facial muscle function.

3. Brain tumor

• Slurred speech or speech difficulties
• New or changing headaches
• Weakness or coordination and balance problems
• Abnormal vision

A brain tumor is an abnormal growth of cells in the brain. A brain tumor may be cancerous (malignant) or noncancerous (benign). Both types can cause symptoms including slurred speech.

The diagnosis of a tumor in the brain or spinal cord is based on an exam and imaging of the brain, such as an MRI or CT scan. A biopsy (tissue sample) may be needed to determine what type of tumor it is.

Some tumors, such as a small noncancerous tumor, do not need treatment, though your doctor will recommend periodic MRI scans to make sure it hasn’t changed.

Most larger or cancerous tumors do require treatment, which may consist of chemotherapy, radiation, or surgery. If you develop physical or cognitive (mental) problems from the tumor, rehabilitation such as physical therapy, occupational therapy, or speech therapy may be needed.

4. Multiple sclerosis

• Blurred vision or decreased vision, typically in one eye
• Weakness or trouble walking
• Numbness or pins-and-needles sensation on your face, arm, or leg (typically on one side)
• A band-like squeezing sensation around the chest or abdomen
• Difficulty focusing

Multiple sclerosis, or MS, is a central-nervous system disease that affects the cells of the brain and spinal cord. In MS, a fatty tissue that surrounds nerve fibers (myelin) is attacked. Myelin helps to insulate the electrical signals sent through the nerves. When there is a problem with this fatty tissue, information sent to and from the brain can be disrupted.

MS is most common in young adults between the ages of 20 and 50, according to the National MS Society .

MS is not curable , but treatments have dramatically improved the ability to control MS, so people usually have fewer symptoms and less disability.

Treatment includes medications that may be taken orally or injected or infused through an IV line. Physical therapy and speech therapy are commonly used to help in physical recovery, and medications can be used to treat other symptoms, such as depression, pain, and fatigue.

5. Amyotrophic lateral sclerosis (ALS)

• Difficulty with speech, including slurred speech
• Progressive weakness and difficulty balancing
• Muscle cramps, twitching, and stiffness
• Difficulty swallowing

Amyotrophic lateral sclerosis (ALS) is also known as Lou Gehrig’s disease. It affects nerve cells called motor neurons that control your movement.

The disease primarily causes a loss of strength, impaired swallowing and speech, and in most cases, difficulty breathing because of impaired respiratory muscles. It is a progressive disease, meaning that symptoms are mild at first and worsen over time.

Previously, it was thought that ALS doesn’t affect a person’s mental ability. But it’s now known that people with ALS can get a specific type of dementia called frontotemporal dementia (FTD). That condition can affect behavior, mood, and speech.

Symptoms of ALS can develop in adults of any age, but it’s most commonly diagnosed in people who are between the ages of 40 and 70, according to the ALS Association .

While there are some medications that can be used to delay the progression of the disease, there is currently no cure for ALS. Treatment includes rehabilitation with physical therapy, occupational therapy, speech therapy, and respiratory therapy.

6. Migraine

• Sensitivity to light and sound
• Visual disturbances

A migraine causes a severe headache that is often accompanied by nausea and sensitivity to light or sound. But some migraines don’t cause head pain.

Other symptoms that involve the nervous system can occur. Some of these sensory symptoms are called “auras.” These distortions can cause visual changes , including flashing lights or distorted vision. People may feel tingling or numbness of their face, arm, or leg.

In some types of migraine, people may even develop slurred speech and weakness of the face, arm, or leg. These are also symptoms of a stroke, so it may be hard to figure out which condition you have. If you develop sudden slurred speech or weakness, go to the ER immediately.

In an acute migraine attack, medications can be used to stop a migraine that has already started, such as triptans or newer medications called CGRP inhibitors. These medications can be in pill form, inhaled form, or injectable medications.

Migraine prevention can include taking medications for blood pressure, anticonvulsants, or even antidepressants. In some instances, Botox treatments are used to prevent migraine.

Behavior and lifestyle changes such as exercise, improved sleep, and healthy diet or weight loss are also often recommended to help decrease the number of migraine headaches you experience.

Other possible causes

Slurred speech may occur from alcohol intoxication or tiredness. It can also be a side effect of medications like high dose pain medications, antipsychotic medications or even some allergy medications like antihistamines. Other causes include:

• Infections such as urinary tract infections or electrolyte imbalances (particularly in elderly people).
• Brain infections such as meningitis or encephalitis.
• Problems that affect your mouth or throat, such as poorly fitting dentures, dental infections, dental numbing medications, swelling in your throat, or muscle or nerve problems.
• An allergic reaction , especially if you notice slurred speech along with tongue swelling , lip swelling, or shortness of breath.

"Early speech therapy can not only help with early improvement but also with diagnosis. Speech-language pathologists have special training in detecting the various types of slurred speech, which helps to determine the possible causes."— Dr. Hoerst

Specialty treatment options

• Speech therapy is the most common treatment for slurred speech.
• Injected medications such as Botox are sometimes used, depending on the cause of slurred speech.
• Medications to improve nerve and muscle function.

While it's important to follow your healthcare provider's guidance, here are some over-the-counter (OTC) options that might provide extra support.

• Proper nutrition supports overall health, including nerve function. Supplements like B vitamins may support neurological health.
• Staying hydrated is key, especially if speech difficulties make it hard to drink. Consider a no-spill, easy-sip water bottle designed for easy grip.
• Engaging in exercises to improve speech clarity can be helpful. Explore speech therapy tools and resources that you can use at home.

Slurred speech treatment quiz

Take a quiz to find out how to treat your symptoms.

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Learn About the 50 Essential Biomakers that Determine Your Health, Energy, and Lifespan

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Slurred speech

• Thread starter Steven76
• Start Date Oct 31, 2010
• Guest, we'd love to know what you think about the forum! Take the Diabetes Forum Survey 2024 »
• Diabetes Discussion
• Ask A Question
• Oct 31, 2010

I've been diabetic now for 20 years,insulin controlled.my sugar levels are never stable it's uncontrollable.I've been running very high for weeks now then I panic shoot insulin and end up low then eat the food cupboard lol.what concerns me is at times,not neccessarily when my sugars are at extremes my speech gets slurred and my wife accussed me of drinking or taking drugs or something.I don't do either and really would like know what causes this slurred speech.thanks  

As there are over 250 possible causes of slurred speech which can include side effects of some Medications it is important that you seek medical advice ASAP for this. Whilst it can be humourus to some it can be signs of a serious problem. Please see your GP and discuss.  

Steven, Like Ken says, it's best to get this investigated as there are many other causes for slurred speech and may well not be diabetes related. Hypoglycemia can cause confusion and make some people talk disorientated, but as you say your levels are high when you slur this obviously isn't the case, so for peace of mind do see your gp. Nigel  

I've been to doc got tested I'm on blood pressure mess but all else fine.my mouth gets very dry when bloods unstable.does anyone else experience this?  

Steven76 said: I've been to doc got tested I'm on blood pressure mess but all else fine.my mouth gets very dry when bloods unstable.does anyone else experience this? Click to expand...

No I've not tested for ketones in about a year.  

Steven76 said: No I've not tested for ketones in about a year. Click to expand...

Dry mouth ..Check for thrush in your mouth..  

That's great thanks it all makes sense.no haven't got thrush but the rest fits  

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• Open access
• Published: 13 August 2024

Disability-related disparities in health outcomes among newly diagnosed diabetic patients: A retrospective cohort

• Sujin Kim 1 &
• Boyoung Jeon 2  

BMC Public Health volume  24 , Article number:  2207 ( 2024 ) Cite this article

85 Accesses

Metrics details

A distinct gap in the literature persists regarding the health outcome of individuals with Type 2 diabetes who also have disabilities. This study aimed to investigate potential disparities in events occurrence among diabetes patients across various disability stages.

We conducted a retrospective cohort study on patients newly diagnosed with diabetes in 2013 and 2014, aged ≥ 18 years, and followed them until December 2021, using data from the Korean National Health Insurance database. All-cause mortality and hospitalization for diabetes mellitus and cardio-cerebrovascular diseases (CVD) was assessed.

The study included 26,085 patients, encompassing individuals without disabilities and those with physical, visual, hearing and speech, intellectual and developmental, and mental disabilities. After adjustment, individuals with disabilities had a higher risk of all-cause death (adjusted hazard ratio [aHR]: 1.25, 95% CI: 1.07–1.48) compared to those without disabilities. In particular, severe disabilities and hearing and speech disabilities showed significantly higher risks of all-cause death (aHR: 1.40, 95% CI: 1.06–1.85 and aHR: 1.58, 95% CI: 1.17–2.15, respectively), with marginal significance for mild disabilities (aHR: 1.20, 95% CI: 0.99–1.45) and mental disorders (aHR: 1.92, 95% CI: 0.98–3.73). Patients with disabilities also had significantly increased risks of CVD-related first admissions (aHR: 1.30, 95% CI: 1.07–1.56) and diabetes-related first admissions (aHR: 1.31, 95% CI: 1.20–1.43) compared to those without disabilities.

Conclusions

This study underscores the urgent need for public health policies to prioritize individuals with disabilities and diabetes, addressing the disparities in health outcome.

Peer Review reports

The global prevalence of diabetes among the 20–79 year old demographic in 2021 was estimated at 10.5%, encompassing approximately 530 million people, with Type 2 diabetes accounting for over 90% of cases worldwide [ 1 ]. This epidemic is responsible for 6.7 million deaths worldwide and increases the risk of cardiovascular disease and mortality [ 2 ]. Concurrently, 1.3 billion people, constituting 16% of the global population, living with significant disabilities [ 3 ], among whom a higher prevalence of diabetes is observed. Given well-documented disability-related health inequalities [ 3 ], the burden of diabetes is particularly pronounced among persons with disabilities. Factors such as harmful behavior, limited access to healthy diets, and quality care, as well as delayed detection, may exacerbate this burden [ 4 ]. In addition, persons with disabilities may exhibit poor compliance with medical treatment due to physical limitations, socio-economic conditions, as well as hard to finding adequate physicians heightening the risk of diabetes complications and mortality [ 5 , 6 , 7 ].

While an existing study has reported an association between disabilities and poor health outcome among diabetic patients, it only focused on vision impairments and hearing disorders and fail to differentiate between disabilities caused by diabetes itself. Although patients with diabetes have a higher risk of death and hospitalization, the nuanced landscape of disability-related health inequalities has been overlooked among diabetic patients [ 8 ]. Furthermore, although an emerging body of literature has highlighted the importance of continuity of care (COC) and medication adherence in reducing diabetes-related complications and mortalities [ 9 ], their impact on the health outcomes of persons with disabilities and diabetes remain inadequately explored [ 10 , 11 , 12 ].

Despite existing research on health outcome of individuals with disabilities attributed to diabetes, a distinct gap in the literature persists with respect to comparisons based on disability itself, as well as its characteristics and types. In addition, studies integrating the elements of COC and medication adherence (proportion of days covered, PDC) into their analysis remain considerably limited. Addressing this gap is essential for understanding the health outcomes of persons with disabilities and diabetes and developing effective interventions. Thus, this study aimed to investigate potential disparities in the occurrence of fatal and non-fatal events among patients with diabetes across various stages of disability, while examining the influence of factors such as continuity of care and medication adherence. Utilizing national cohort data from the Korean National Health Insurance Service (NHIS) database, we specifically aimed to explore the association of disability status, severities, and types with mortality among adults with Type 2 diabetes, as well as hospitalization due to diabetic and cerebrovascular diseases (CVD).

Database and study population

The study population was derived from the NHIS database. The NHIS provides mandatory health care coverage for almost all Koreans, including National Health Insurance (NHI) enrollees (97%) and Medical Aid beneficiaries (3%), and covers most forms of health services, including emergency, inpatient and outpatient care, and medication prescriptions. The NHIS database contains the insurance claims of medical institutions and enrollee information, including disability type and severity, health coverage type, NHI contributions, and death records. A key advantage of the NHIS is that it is managed by a single insurer under the government, ensuring the databases includes nearly all medical use information recorded during the claims process [ 13 ].

For this study, 10,413,089 participants, representing 20% of the 2012 population, were sampled considering the sex, age, and region distribution from the NHIS database, which contains the insurance claims of medical institutions and enrollee information. We collected data from the NHIS database between January 2012 and December 2021 (data number: NHIS-2022-1-629) [ 13 ]. Disability status, including primary type of disability and severity of disability, health coverage type, and NHI contributions, was examined as of January of each year. Because this study used de-identified data provided by the NHIS after anonymization according to strict confidentiality guidelines, the requirement for ethics review was exempted by the Institutional Review Board (IRB) of Korea Institute for Health and Social Affairs (IRB number: 2022-004).

We defined the study population as newly diagnosed diabetes (E12) patients aged ≥ 18 years in 2014 and 2015, excluding those with internal organ impairments and epilepsy disability (who are more likely to be hospitalized unavoidably due to the disability itself) and those with facial disfigurement (a low proportion). Patients with newly diagnosed diabetes did not visit healthcare institutions for type 2 diabetes (E11) during the previous two years, but did visit with a diabetic diagnosis code in 2014 or 2015 with an oral antihyperglycemic prescription according to the International Classification of Disease 10th revision codes. The inclusion criteria included patients with a primary diagnostic code while the exclusion criteria included those with a whole diagnostic code. Among 31,331 newly diagnosed diabetic patients, we excluded 3,949 subjects who had medical records of CVD (I20-I25, I60-I64, I67 and I69) for the two years before the diagnosis. We also excluded 447 patients with diabetes who were hospitalized for 90 days or longer during the two years immediately after the diagnosis, which reflects a serious condition and affects PDC and COC assessment [ 12 ]. Then, 379 patients with diabetes were excluded because of missing values for the covariates. Finally, we excluded patients who experienced each event during the first two years depending on dependent variables (Fig.  1 ). All participants were followed from diagnosis until the outcome event or December 31, 2021, whichever came earliest.

Study population

Classification of disabilities

The level of disability was categorized into mild and severe according to the Ministry of Health and Welfare (MOHW) definition. We included eight types of disability based on the MOHW definition and categorized them into the following five groups: (1) physical disability–orthopedic impairment and brain injury; (2) visual disability; (3) hearing and speech disability; (4) intellectual and developmental disability–intellectual disability and autism spectrum disorder; and (5) mental disability (schizophrenia, schizoaffective disorder, bipolar affective disorder, recurrent depressive disorder, organic psychiatric disorder due to neurological damage, obsessive-compulsive disorder, Tourette’s disorder, and narcolepsy) [ 14 ].

COC and PDC variables – modifying factors

We calculated the COC and PDC during the 2 years after the diagnosis to ensure longitudinal continuity and medication adherence. First, we used the Bice–Boxerman continuity of care index score (COCI), which is influenced by the distribution of visits to different healthcare providers, i.e., the total number of visits, total number of providers, and number of visits with each provider. This index measures the degree to which patients visit several providers by counting the total number of visits (N), the total number of visits to the i th provider ( \(\:{n}_{i}\) ), and the total number of providers (j) using the following formula:

The COCI has a value between 0 and 1, with 1 indicating that all visits were to the same provider and 0 indicating full discontinuity of care. In this study, providers were defined as healthcare institutions.

Next, we assessed medication adherence using the PDC, the recently preferred method of measuring medication adherence [ 12 , 15 , 16 ]. The PDC was calculated based on the Anatomical Therapeutics Chemical (ATC) Code. Oral antihyperglycemic agents included biguanides (A10BA), sulfonamides, urea derivatives (A10BB), combinations of oral blood glucose-lowering drugs (A10BD), α-glucosidase inhibitors (A10BF), thiazolidinediones (A10BG), dipeptidyl peptidase 4 (DPP-4) inhibitors (A10BH), and other blood glucose-lowering drugs, excluding insulin (A10BX) [ 10 , 12 ].

Although people with disability may have limited access to regular care, at least four and two visits are essential for calculating the COC and PDC, respectively. Thus, we created a combined variable of COC and PDC (COC–PDC), defining values ≥ 0.8 as high COC and high PDC, and classified them into five categories, creating another category for subjects with four or fewer visits: four or fewer outpatients visits, low COC and low PDC, high COC and low PDC, low COC and high PDC, and high COC and high PDC.

Confounding factors

Age, sex, health coverage type, income, and comorbidities were included as covariates. Age was employed as a continuous variable with age square. Healthcare coverage included NHI enrollees and Medical Aid (a subsidy program for the poor). Income level was categorized into the following five groups using contribution quintiles: Medical Aid and first, second, third, fourth, and fifth contribution quintiles. We calculated the Charlson Comorbidity Index (CCI) using the primary diagnosis codes in healthcare use records from 2018 to evaluate the level of comorbidities (0, 1, 2, or ≥ 3), referring to the definition of Charlson and colleagues [ 17 ].

The primary outcome was all-cause mortality. The secondary outcomes were hospitalization for diabetes for patients with diabetes and CVD. Hospitalization was determined when patients received medical services as inpatients with a primary diagnosis code for diabetes (E11) and CVD (cardiovascular: I20-I25 and stroke: I60-I64, I67, I69). All outcomes were recorded as dichotomous variables.

Statistical analysis

The chi-square test and analysis of variance were conducted for categorical and continuous variables, respectively, to compare the differences in the baseline distributions of covariates by disability status, severity and types. Multivariate Cox proportional hazard regression analyses with competing risk models were conducted to evaluate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for outcomes. The proportional hazard assumption was validated by including time-dependent covariates, which were created with interactions between the predictors and survival time, in the Cox proportional hazard regression models [ 18 ]. Stratified analyses of the association of disability types with outcomes were conducted according to the COC–PDC subgroups. All multivariate models were adjusted for the covariates listed above. Data analyses were performed using SAS Enterprise Guide 7.1 (SAS Institute, Cary, USA).

Characteristics of the study population

Table  1 shows that most participants had no disability (92.7%). Among those with disabilities, 67.8% had mild disabilities, and 32.2% had severe disabilities. The distribution of disabilities included physical (64.3%), visual (11.3%), hearing and speech (12.1%), intellectual and developmental (5.6%), and mental disabilities (6.7%). The average age of individuals without disabilities was 53.4 years, while those with disabilities had a higher mean age of 58.7 years. As for COC–PDC, 19.1% of those without disability had less than four outpatient visits while 34.0% had a high COC and PDC. In contrast, among those with disabilities, 20.0% had less than four outpatient visits and 37.1% had a high COC and PDC (Table  1 ). Supplementary Table 1 presents the characteristics of the study population for each event (Table S1 ).

Cox proportional hazards regression analysis

Table  2 presents the results of the Cox proportional hazard regression analysis for death, first admissions related to diabetes, and CVD. After adjusting for factors including sex, age, monthly contribution, insurance type, medical institution type, CCI score, and COC–PDC, individuals with disabilities showed a significantly increased risk of all-cause death (aHR: 1.25, 95% CI: 1.07–1.48) compared to those without disabilities. When differentiating disability severity, individuals with severe disabilities exhibited a significantly higher risk of all-cause death with aHR of 1.40 (95% CI: 1.06–1.85) compared to those without disabilities. Mild disabilities demonstrated a marginally significant increase in the risk of all-cause death (aHR: 1.20, 95% CI: 0.99–1.45). Patients with hearing and speech disabilities showed an increased risk of death (aHR: 1.58, 95% CI: 1.17–2.15) while those with mental disabilities did so with marginal statistical significance (aHR: 1.92, 95% CI: 0.98–3.73). Those with other disabilities did not exhibit a significant association (Table  2 ).

Patients with disabilities showed a significantly increased risk of CVD-related first admissions (aHR: 1.30, 95% CI: 1.07–1.56) compared to those without disabilities. Patients with diabetes with mild disabilities had an increased risk of CVD-related admissions (aHR: 1.30, 95% CI: 1.07–1.56), while those with severe disabilities showed no significant association (aHR: 1.28, 95% CI: 0.94–1.80). In addition, patients with visual disabilities, but not those with other disabilities, showed an increased risk of CVD-related first admissions (aHR: 1.59, 95% CI: 1.02–2.48) (Table  2 ).

Moreover, patients with diabetes and disabilities had an elevated risk of diabetes-related first admission compared to those without disabilities (aHR: 1.31, 95% CI: 1.20–1.43). Both mild and severe disabilities showed higher risks of diabetic hospitalization (mild: aHR: 1.22, 95% CI: 1.04–1.43; severe: aHR: 1.59, 95% CI: 1.22–1.50). In addition, patients with diabetes with physical, visual, and intellectual and developmental disabilities had an increased risk of diabetes-related first admission (aHR: 1.31, 95% CI: 1.17–1.46; aHR: 1.46, 95% CI: 1.15–1.84; and aHR: 1.70, 95% CI: 1.22–2.36, respectively), whereas those with hearing and speech disabilities and mental disabilities showed no significant association (aHR: 1.09, 95% CI: 0.77–1.55) (Table  2 ).

For explanatory analyses, we incorporated interaction terms between disability severity and COC–PDC groups, which were categorized into three groups: (1) the low COC-PDC group, representing four or fewer outpatient visits or low COC and low PDC; (2) the middle COC-PDC group, comprising high COC and low PDC or low COC and high PDC; and (3) the high COC-PDC group, characterized by both high COC and PDC. The low COC-PDC group was associated with an increased risk of diabetes-related first admission for individuals without disabilities (aHR: 1.09, 95% CI: 1.03–1.16), but not for those with mild or severe disabilities (aHR: 1.00, 95% CI: 0.79–1.26; aHR: 1.03, 95% CI: 0.73–1.45, respectively). Similar associations were found for CVD-related admissions and death, where the low and middle COC-PDC groups were significantly associated with increased risk for individuals without disabilities, but not always for those with disabilities (Fig.  2 ).

Association of COC-PDC with diabetes- and CVD-related hospitalization and mortality risk by disability severity

COC: continuity of care; CVD: Cardio-cerebrovascular disease; PDC: proportion of days covered

In this study, we examined the relationship between disability and the risk of all-cause death and admissions related to diabetes and CVD. After adjusting for COC and PDC, as well as demographic and health factors, individuals with disability were found to have an elevated risk of all-cause death compared to those without disability. In particular, individuals with severe disability exhibited a 40% increased risk of all-cause death compared to those without disability, while those with mild disability showed a less significant increase in risk. Among specific disabilities, hearing and speech impairments were associated with an elevated risk of death, with marginal significance observed for mental disabilities. For CVD-related admissions, mild and visual disabilities indicated an increased risk, whereas severe disability did not. The risk of diabetes-related admission remained elevated among persons with physical, visual, intellectual, and developmental disabilities. Our explanatory analyses showed that low COC-PDC was associated with a greater risk of all-cause death, diabetic and CVD hospitalization not consistently among those with disabilities.

In the present study, disability was associated with fatal results among newly diagnosed patients with diabetes, independent of major potential confounding factors. Considering that a large cohort study reported smoking and physical activity as the strongest predictors of death among patients with type 2 diabetes [ 19 ], a low physical activity rate among people with disabilities may be a significant risk factor for mortality among persons with disability and diabetes [ 20 ]. The heightened mortality risk observed among patients with diabetes and hearing and speech disabilities, as reported in this study, aligns with findings from previous research [ 8 , 21 ]. Prior studies have suggested that the simultaneous presence of hearing loss and diabetes may synergistically increase the risk of all-cause and CVD mortality. Furthermore, a recent systematic review highlighted potential mechanisms linking hearing loss to mortality, including aversion to physical activity, frequent falls, depression, anxiety, cognitive impairment, and social isolation [ 22 ]. Concerning mental disorders, existing literature has pointed out barriers to receiving appropriate care. These barriers include an inadequate training in health professionals, limited mental health literacy among non-mental health providers, and poor socio-economic conditions exacerbate these challenges [ 23 ]. These factors collectively may contribute to higher mortality rates among patients with diabetes and hearing and speech disabilities, as well as mental disabilities.

When we consider CVD hospitalization, patients with disability had an increased risk of CVD hospitalization. Furthermore, additional analyses showed a high risk of hospitalization due to ischemic heart disease in people with disability (Table S2 ). While body mass index, glycated hemoglobin and physical activity are significant risk factors for these events among persons with type 2 diabetes (19), persons with disabilities and diabetes are more likely to have uncontrolled diabetes and undesirable daily lifestyle choices. In the context of varying levels of disability severity, there was no significant higher risk of CVD hospitalization for severe disability, which differs from all-cause mortality. Patients with severe disability may face challenges in accessing hospitalization even for significant health conditions. For example, a previous examination on disability and incident coronary heart disease reported that disability was associated with fatal events, but not non-fatal events such as hospitalization due to angina pectoris or myocardial infarction [ 24 ]. This implies that health care disparities and the limited ability of persons with disability to cope with an acute event increases their risk of death.

In this study, an increased risk for CVD-related admissions but not all-cause mortality in persons with visual disabilities was partially consistent with a previous study that showed that vision impairments increase the risk of cardiovascular events and death in patients with type 2 diabetes [ 8 ]. In contrast, a previous study included any patients with diabetes and thus may have also included those with visual disabilities due to worsened diabetes, as well as those with worsened diabetes-related diseases [ 25 ]. Similar to the current study, a previous study showed that a visual acuity problem was not associated with diabetes-related mortality or longer-term all-cause mortality among patients with newly diagnosed type 2 diabetes [ 25 ].

Patients with diabetes with mild or severe disability had an increased risk of hospitalization. In addition, patients with physical, visual, intellectual, and developmental disabilities had a higher risk of diabetes-related hospitalization. Individuals with mental, intellectual/developmental, and physical disabilities showed a higher risk for avoidable hospitalizations for hypertension and diabetes-related conditions in Korea because they had access problems in primary care [ 6 ]. Persons with disabilities face a higher risk of adverse health outcomes due to barriers in accessing healthcare services and engaging in healthy behaviors. For example, previous studies have suggested that physical barriers to health screening or primary care access, difficulties in communicating with medical staff, and a lack of a healthy diet and regular exercise can lead to high rates of avoidable hospitalizations in these populations [ 6 ]. Another study indicated that visual acuity problems were not associated with diabetes-related mortality or longer-term all-cause mortality in patients with newly diagnosed type 2 diabetes [ 26 ].

The present study found a diminished significance of COC-PDC among individuals with disabilities, relative to their counterparts without disability. This is in contrast to the consistent evidence of COC and PDC in the management of type 2 diabetes in the general population. When we used the Usual Provider Index instead of COC, another frequently used measure to assess care continuance, the results remained similar (Table S3 ). One explanation for this discrepancy is that COC and PDC did not accurately reflect appropriate diabetic care in individuals with disability. Although previous studies consistently suggested that better COC may have positive effects on health outcomes by ensuring better information sharing and higher medication adherence [ 10 , 27 ], COC may not be linked to these positive benefits in patients with diabetes and disabilities. For example, a study on patients with diabetes with intellectual disability suggested that communication with health professionals about diabetes did not seem to occur [ 28 ]. In addition, although PDC represents the intention to treat and is directly linked to better medication adherence in the general population, individuals with disabilities are more likely to experience additional barriers to medication adherence. Even if individuals have been prescribed certain drugs, it does not confirm medication adherence or proper dosage management. They may not keep the proper frequency or dosage of medication at home because of a lack of health literacy or medication information provision [ 29 ]. This is particularly salient for persons with disabilities who need to manage complex and multimorbid conditions that may involve polypharmacy, thereby complicating medication adherence. Another explanation for the insignificant COC and PDC is the missed opportunity for early intervention to treat hyperglycemia, implement lifestyle changes, and address cardiovascular risk factors because of a delayed diagnosis of diabetes in individuals with disabilities. Inadequate care access and under-screening, both of which contribute to the prevalence of undiagnosed diabetes [ 30 , 31 ], have been reported in individuals with disability.

Therefore, rigorous further analysis is necessary to ensure the effectiveness of maintaining continuity of care and high medication compliance across different types and severities of disability in reducing hospitalizations and mortality. Tailored interventions for improving diabetes self-care among people with visual impairment (TID-VI) and the holistic, patient-centered Integrated Personalized Diabetes Management (iPDM) model hold promise for enhancing self-care and optimizing treatment outcomes [ 32 , 33 ]. To improve health outcomes and mitigate mortality risk among individuals with diabetes and disabilities, it is crucial to regularly manage blood glucose, blood pressure, cholesterol, and undergo annual screenings for complications. Lifestyle modifications, and adherence to necessary medications are also important [ 1 ].

Meanwhile, we excluded individuals with hospitalizations lasting 90 days or longer, potentially resulting in less pronounced associations within the subgroup of disabilities experiencing high hospitalization rates. Additional analyses incorporating these patients showed significant mortality and diabetic hospitalization and marginally significant CVD hospitalization for patients with mental disorders. We also found a significant high risk of mortality for persons with developmental disabilities when we included patients with long-term hospitalization (Table S4 ). This may be due to persons with severe conditions are more likely to be hospitalized; alternatively, the limited number of persons with these disabilities may weaken the statistical power. Future studies based on larger observations may improve our understanding. In our additional analysis, which included interaction terms between disability status encompassing both mild and severe disabilities and PDC-COC, we observed consistent results. Specifically, individuals with disabilities and high PDC-COC exhibited a lower risk of CVD hospitalization compared to those with low PDC-COC (Table S5 ). We acknowledge that studies with larger sample sizes would likely yield more robust results.

A notable limitation of the current study lies in its reliance on claims data analysis, which may not accurately capture the actual health behaviors of individuals with disabilities which can be potential influencing factors. For instance, although COC indicates regular interaction between patients and their physicians, the social support by family or caregivers of patients with severe disabilities may regularly visit physicians on the patient’s behalf to obtain medicine prescription, meaning that there is no continuous patient–physician interaction. In addition, the claims data also lack details on essential aspects of daily health management, such as levels of physical activity, exercise regimes, dietary habits, and blood glucose or HbA1c levels, which are critical determinants of health outcomes in this population. This study also could not include the specific information of the duration and the type of hospital admissions, such as emergency department visits. Future studies should address these limitations. Moreover, mental health conditions like depression could contribute to reduced patient interest in self-care practices [ 34 ].

This comprehensive study deepens our understanding of how disability status, severity, and various types of disabilities relate to the risks of all-cause death and hospitalization for diabetes and cardiovascular disease among newly diagnosed diabetes patients. Our findings underscore that individuals with disabilities face a heightened risk of all-cause death compared to those without disabilities, with particular emphasis on those with severe disabilities, hearing and speech impairments, and mental disabilities. In addition, physical, visual, intellectual, and developmental disabilities were associated with increased rates of diabetes-related hospitalizations, while mild and visual disabilities were associated with a higher risk of CVD-related admissions. Our results also highlight the role of COC-PDC, in that lower COC-PDC levels were identified as potential risk factors for adverse outcomes among individuals without disabilities, but less consistently so for those with disabilities. Therefore, public health policies should prioritize individuals with disabilities and diabetes to address the disparities in health outcomes between those with and without disabilities. Moreover, there is an urgent need for a better understanding of the unique risk factors for diabetes among persons with disabilities.

Data availability

The datasets analyzed during the current study are not publicly available due the restrictions apply to the use of data by NHIS. The use of current NHIS datasets is limited only for the permitted study and is not publicly available.

Abbreviations

Cardio-Cerebrovascular diseases

Continuity of care

Proportion of days covered

National health insurance service

Ministry of health and welfare

Continuity of care index score

Charlson comorbidity index

Adjusted hazard ratios

Confidence intervals

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This work was supported by the Korea Institute for Health and Social Affairs [research number 2022-33, 2022] and the National Research Foundation of Korea (NRF) [NRF-2022S1A5C2A03092307]. The funders had no role in the design or execution of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

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Kim, S., Jeon, B. Disability-related disparities in health outcomes among newly diagnosed diabetic patients: A retrospective cohort. BMC Public Health 24 , 2207 (2024). https://doi.org/10.1186/s12889-024-19690-5

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Did Donald Trump have a stroke? His new lisp and slurred speech, explained

In retrospect, we should have predicted that the much-hyped interview between Donald Trump and Elon Musk would be a non-event, with Musk playing the fawning yes-man to Trump’s nonsensical blather. And, for a while, it seemed the only major news story arising from it would be the humiliating sight of Musk’s X Spaces immediately collapsing under the traffic.

But, after 40 minutes of brain-numbing muzak, this great meeting of the minds finally commenced. Trump’s statements — apart from his unexpected assertion that Kamala was “beautiful” and him comparing her to Melania — were boilerplate campaign speeches. But for many it was a curious way he said them that’s raised eyebrows.

A thpeech impediment?

Why does Trump sound like Donald Duck? This lisp thing is distracting #ElonXTrump pic.twitter.com/jJ1AHhi5t7 — sidney (@hcesd) August 13, 2024

Throughout the interview, Trump had a strong lisp and his speech was slurred. Veteran voice actor Billy West (Fry on Futurama ), who knows more about the particulars of speech than most, dismissed claims that this could be a case of loose dentures, saying that it sounds like Trump may be suffering from “certain types of brain damage or stroke.”

Trump talking to Musk did not sound like loose dentures. That you can fix. He could’ve straightened that out before he did the interview. Nope. It sounds like aphasia. Symptoms from certain types of brain damage or stroke. THAT’S who people are gonna riot for if they don’t get… — Billy West (@TheBillyWest) August 13, 2024

Trump has been suspiciously light on campaigning compared to previous presidential runs and last week took an uncharacteristic week away from his adoring fans. Trump is 78, so it wouldn’t be particularly uncommon for a man of his age to suffer a stroke. And, given that his campaign put so much focus on Joe Biden being too old and infirm to be president, it’d put them in an awkward position if Trump was even slightly incapacitated.

Skeptics might point to the fact that Trump continues to work to a busy schedule and certainly doesn’t appear to be suffering a medical episode, but it’s common to have a “silent stroke” or ministroke and display symptoms so minor you can be unaware it’s happened. And, after a peek at MedicalNewsToday , common symptoms include slurred speech.

I randomly got a Trump ad is his left eye like… okay isn't drooping on one side of the face like a sign of a stroke? This is odd pic.twitter.com/UnWIbf32gC — Marie (@MarieMoments_) August 9, 2024

Just a tech glitch?

best part of this interview is how x’s audio compression has given me an hour plus of trump sounding like daffy duck — wake (@wakewilder) August 13, 2024

Trump’s defenders were quick to blame Elon Musk. According to them, the shift in Trump’s voice is either due to X’s audio compression mangling the feed or potentially due to the type of lapel-mounted microphone he was using. We will concede that it’s plausible that Musk would be responsible for a glaring technical oversight in one of his products. Even so, if this were the case, we imagine Trump isn’t best pleased that Musk’s inept tech has everyone theorizing he might have brain damage.

It really is striking to hear Trump’s frequent vocal issues in this event. It sounds like some combination of slurring and an audible lisp. If it was audio compression issues, it would be happening to the host as well, but it’s not. Whatever it is, it’s not good. #TrumpIsDone — Matt Butler, LISW-S, LICDC-CS (@apooltoswim) August 13, 2024

Trump is constantly in the public eye so if he is slurring his speech more than normal and lisping everybody is going to notice soon enough. If so, Trump’s attacks on Joe Biden’s age and health making him unable to be president will come back to haunt him in a big way .