Written by Michelle Archer, RD, CDE of Diabetes Training 101 Inc.

New Classification of Hypoglycemia in Canada

I attended the Vascular 2023 conference in Montreal, PQ and wanted to share and highlight that there was a significant update to the 2023 Diabetes Canada Clinical Practice Guidelines (CPG)-Hypoglycemia Chapter. Hypoglycemia, often also referred to as low blood sugar, is a significant risk factor and burden to people living with diabetes who use insulin or sulfonylurea diabetes drugs.  The big changes with the hypoglycemia chapter are a new classification system that was adopted from the International Hypoglycemia Study Group as well as related recommended approaches to education, prevention, and treatment.

In the previous Hypoglycemia Chapter found in the 2018 Diabetes Canada Clinical Practice Guidelines, hypoglycemia was defined by (1) types of autonomic or neuroglycopenic symptoms, (2) low plasma glucose levels in any type of diabetes treated with insulin or an insulin secretagogue, and (3) symptoms related to the administration of carbohydrate. Severity of hypoglycemia was defined by descriptions of mild, moderate, or severe. The 2023 update moves us toward a standardized definition of hypoglycemia adopted by other diabetes organizations around the world.

New Classification of Hypoglycemia

Hypoglycemia is a major obstacle to achieving recommended blood sugar targets in individuals with Type 1 or Type 2 diabetes (T1D/T2D) treated with insulin and/or insulin secretagogues. Increased frequency and severity of hypoglycemia can cause Fear of Hypoglycemia (FoH) and it can negatively impact individuals’ health outcomes and quality of life (QOL).  This fear often leads to people preferring to keep their blood sugars slightly higher in an effort to avoid hypoglycemia. While this move makes complete sense as a measure to avoid any episodes or symptoms of low blood sugar by an individual, the downside is that overall blood sugar control often worsens, which therefore increases the risk of long-term risks associated with hyperglycemia.

As you can see in the chart above that’s taken from the updated CPGs, the severity of hypoglycemia is no longer strictly defined by the individual’s glucose number, but by the severity of the associated symptoms of hypoglycemia and the need for assistance to treat, as defined by the International Hypoglycemia Study Group. The adoption of a 3-tiered, numbered classification system helps standardize the diagnosis of hypoglycemia and outline the treatment response according to the severity of symptoms irrespective of actual glucose readings. While levels 1 and 2 may be recognized and treated by the individual experiencing hypoglycemia, level 3 is defined by the presence of neuroglycopenic symptoms and the necessity of external assistance to treat the low blood glucose.

The Impact of Hypoglycemia on People with Diabetes

Hypoglycemia has neurological (memory, reaction time), cardiovascular (increased mortality: etiology uncertain), musculoskeletal (falls and fractures) and psychosocial implications (QOL impacts, places significant burden and limitations on individuals and those who care about them). Its impact on the daily lives of people living with diabetes should not be underestimated.

What Hypoglycemia Means for Health Care Providers

The frequency and severity of hypoglycemia has a significant impact diabetes care and management and on the individual’s daily activities and their quality of life. It’s important for each of us as health care professionals and diabetes educators to ask our patients with diabetes at each visit if they are having any hypoglycemic episodes, how often they are experiencing them, and then for us to dig deeper and identify if their pharmacological management has anything to do with causing their hypoglycemia. If we find a source of the hypoglycemia, we need to reflect on what could be done differently, and offer suggestions, make adjustments, or make recommendations for medication changes to their primary care provider. Our role is to improve the quality of life of people living with diabetes and by addressing hypoglycemia causes we are decreasing the risk of hypoglycemia and can improve an individual’s quality of life and overall health.

In my next blog post, I will discuss the Fear of Hypoglycemia (FoH) and is impacts on diabetes management and discuss current hypoglycemia treatment options.

Until next time,


Michelle Archer, RD, CDE


Reference: Diabetes Canada Clinical Practice Guidelines Expert Working Group: Iliana C. Lega MD, MSc, FRCPC; Jean-François Yale MD, CSPQ, FRCPC et al. Diabetes Canada 2023 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Hypoglycemia in Adults. https://guidelines.diabetes.ca/cpg/chapter-14-2023-update Accessed January 25, 2024.