The Link Between Blood Sugar and Anxiety

Worried woman from the blood sugar test results

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Low blood sugar and anxiety are linked, but the relationship is complicated. Symptoms of low blood sugar can mirror anxiety's symptoms, or worsen existing anxiety. Shakiness, fast heart rate, irritability, nausea, difficulty concentrating, and panic are all shared symptoms.

Some people, especially those who have diabetes, may also experience anxiety about regulating their blood sugar levels. This may manifest as a consistent and overwhelming fear that you will become hypoglycemic or anxiety about managing your condition.

Low blood sugar occurs when a person's blood glucose falls below normal levels. This state is also called hypoglycemia, insulin shock, or insulin reaction. For a person with diabetes, this is below 70 milligrams per deciliter (mg/dL). For a person without diabetes, low blood sugar is considered to be below 55 mg/dL.

Symptoms of Low Blood Sugar and Anxiety

Many of the symptoms of low blood sugar and anxiety overlap. Without checking blood sugar levels, it may be difficult to differentiate between the two states.

Symptoms of low blood sugar (hypoglycemia) include:

  • Shakiness
  • Hunger
  • Anxiety or panic
  • Sweating
  • Headache
  • Irritability
  • Nausea
  • Dizziness
  • Fast heart rate
  • Confusion
  • Blurred vision
  • Loss of consciousness

Symptoms of anxiety include:

  • Excessive worry, disproportionate to the situation and difficult to control
  • Dry mouth
  • Irritability
  • Difficulty concentrating
  • Muscle tension or tension headache
  • Tremors or shakiness
  • Nausea
  • Fast heart rate
  • Sweating
  • Insomnia
  • Overly cautious behavior
  • Panic attacks

Low Blood Sugar Mimics Anxiety

The mutual symptoms of low blood sugar and anxiety are not coincidental. There is a shared physiological base of the two conditions.

When low blood sugar occurs, the body attempts to normalize levels by bringing blood glucose up. It does this through epinephrine (adrenaline) excretion, which triggers glucose production in the liver.

Increased adrenaline levels, however, trigger a "fight or flight" response in the body. This same biochemical process is also linked to anxiety.

A longer-term or chronic low blood sugar state can also cause the body to produce cortisol, which is the "stress hormone." Cortisol helps tissues in the body be less reactive to insulin, which helps increase glucose circulation in the bloodstream.

While this may help raise and normalize blood sugar levels, higher cortisol levels are also linked to anxiety. For this reason, many of the warning signs and symptoms of low blood sugar are shared with that of anxiety.

Who Gets Low Blood Sugar?

Low blood sugar can occur in diabetes mellitus, but may also be seen in people without diabetes for other reasons.

People With Diabetes

Low blood sugar is most commonly discussed in the context of diabetes. People with diabetes have difficulty regulating blood sugar, due to issues with insulin production or utilization. They may experience abnormally high blood sugar, and also low blood sugar at times.

Low blood sugar is most common in people with type 1 diabetes, who may experience mild low blood sugar about two times a week. People with type 2 diabetes who take insulin or other medications may also experience low blood sugar on occasion.

People with diabetes also have higher rates of anxiety than the general public. This finding was supported in a systematic review of 12,626 people with diabetes. However, it is not clear if this higher rate of anxiety is due to physiological causes, or other stressors around living with this chronic health condition.

People Without Diabetes

Having diabetes is not a prerequisite for experiencing low blood sugar. People without diabetes can still have low blood sugar, although this is rare. Conditions that can lead to hypoglycemia in people without diabetes include gastrointestinal surgery, pancreatic tumor, anorexia nervosa, overuse of alcohol or aspirin, liver disease, liver cancer, and more.

"Relative" low blood sugar in people without diabetes might also be linked to anxiety, meaning a true low blood sugar of less than 55 mg/dL isn't necessary to experience anxiety symptoms or exacerbation.

This was first suggested in a seminal 1966 paper by Dr. Harry Salzer, titled "Relative hypoglycemia as a cause of neuropsychiatric illness." His theory has since been supported, such as in a 2016 case report on lowering the glycemic index of a participant's diet to regulate blood sugar, which also resulted in lowered anxiety levels.

What Causes Low Blood Sugar

There are various causes of low blood sugar. The most common causes of low blood sugar include:

Diabetic Medication

Medications for diabetes lower blood sugar, and too high of a dose may lead to a hypoglycemic state. People who take insulin are at particularly high risk for low blood sugar episodes. This risk is increased if the wrong type of insulin is injected, too much insulin is injected, or if the insulin is accidentally injected into the muscle rather than under the skin.

Oral diabetes medications, particularly the sulfonylurea group drugs, also increase the risk of low blood sugar episodes.

Increase in Exercise

Exercise lowers blood sugar. If someone with diabetes increases their exercise regimen, they may experience low blood sugar as a result. People with type 1 diabetes are at particularly high risk for exercise-induced low blood sugar.

Diet

What and when you eat also can cause low blood sugar. Generally, food raises blood sugar. Going for a long time without eating (such as in skipping a meal, religious or intermittent fasting, dieting, or anorexia) can cause low blood sugar. Lack of carbohydrates in the diet can also cause low blood sugar.

Preventing Low Blood Sugar

For someone with diabetes, the best way to prevent low blood sugar is to check your blood sugar often. You can check your blood sugar with a continuous glucose monitor (CGM) or glucometer. Discuss with your doctor how often you should be checking your blood sugar.

Your doctor might suggest checking before and after meals, before and after exercising, when changing your routine or schedule, when traveling across time zones, and more. By checking your blood sugar, you can identify when your sugar is falling and enact steps to normalize your levels.

For people both with and without diabetes, another tried-and-true way to prevent low blood sugar is to eat regular meals. Avoid skipping meals or fasting. When you do eat, research indicates that eating a diet low in refined carbohydrates, and inclusive of omega-3 fats and adequate protein, can help regulate blood sugar and lower anxiety levels.

In Case of a Low Blood Sugar Episode...

If you have diabetes or otherwise at risk of hypoglycemic episodes, it is important to keep an emergency kit with you in case of an unexpected episode to help bring your blood sugar back up to a safe level. This kit might include:

  • Sugar cubes
  • Candy
  • Sugar paste
  • A glucagon injection kit

Anxiety and Diabetes Overlap in Other Ways

People with diabetes can experience anxiety for other reasons related to their condition.

Anxiety Over Low Blood Sugar

A low blood sugar episode, which can include anything from confusion and shakiness to nausea, loss of consciousness, and seizures, can be very scary. It therefore makes sense that some people with diabetes also experience anxiety related to possibly having a low blood sugar episode—and not just as a physiological reaction to low blood sugar levels.

This anxiety is so common that the term "fear of hypoglycemia" (FoH) is commonly used among physicians and researchers. Research has found that a history of experiencing mild hypoglycemia increases FoH in people who have diabetes.

Anxiety Over Diabetes Management

Managing your blood sugar and other aspects of your health when you have diabetes can be time consuming and stressful, and also contribute to anxiety.

For people with diabetes, monitoring blood sugar usually involves a home finger prick test. Fear of needles, as well as fear of the results, may lead to anxiety.

One study found that 33% of people with diabetes experience anxiety specific to the finger prick method of glucose testing. Thirty percent of people with diabetes in this same study had generalized anxiety related to their diabetes management.

Other areas of diabetes management may also lead to stress and anxiety. This includes monitoring potential symptoms of vision loss (diabetic retinopathy), nerve damage (diabetic neuropathy), slow-healing wounds on the feet or extremities, kidney damage, and more.

Managing Diabetes Anxiety

If you have diabetes, know that your worries around managing your condition are very valid. However, there is a line between normal feelings of worry, and levels of anxiety that interrupt your thoughts or daily activities and relationships. Speak to your doctor if you believe you are experiencing anxiety.

In addition to educating you and helping you feel prepared to manage your diabetes, your doctor may also recommend a treatment plan or lifestyle changes for coping with your anxiety. This could include:

A Word From Verywell

Low blood sugar and anxiety are interrelated, but it is unclear on the exact direction of the relationship. The symptoms of low blood sugar mirror the symptoms of anxiety, due to a similar biochemical process that occurs in the body. Psychological, emotional, and environmental factors around managing your diabetes can also contribute to anxiety.

If you are concerned about your blood sugar, anxiety, or both, talk to your doctor. Together, you can come up with a holistic plan that addresses both the symptoms and causes of your low blood sugar and anxiety.

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Article Sources
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