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Reactive Hypoglycemia E-mail
Written by Jeff Behar, MS, MBA   

 

Reactive Hypoglycemia
Reactive hypoglycemia is a medical term describing recurrent episodes of symptomatic hypoglycemia occurring 2-4 hours after a high carbohydrate meal (or oral glucose load).

Reactive hypoglycemia is also called "insulin tolerance", "postprandial hypoglycemia", "carbohydrate intolerance" and in severe forms,” idiopathic adult-onset phosphate diabetes". This condition can lead to
type 2 diabetes.

Reactive Hypoglycemia  vs. Fasting Hypoglycemia
Reactive hypoglycemia is not the same as fasting hypoglycemia, which is low blood sugar that occurs when you do not eat. For this reason, reactive hypoglycemia is not always picked up on routine medical tests. Reactive hypoglycemia occurs within 2 to 3 hours after a meal of excess carbohydrates, when there is a rapid release of carbohydrates into the small intestine, followed by rapid glucose absorption, and then the production of a large amount of insulin.
Insulin is a protein hormone produced by the beta cells of the pancreas. Insulin is an anabolic hormone that stimulates the uptake of glucose into fat and muscle and promotes the formation of glycogen. Insulin stimulates protein synthesis and inhibits protein degradation. Glucose, amino acids, and certain pancreatic and gastrointestinal hormones (eg, glucagon, gastrin, secretin) stimulate the pancreas to secrete insulin. Insulin secretion is inhibited by hypoglycemia and somatostatin. In healthy individuals insulin is secreted in a pulsatile fashion that is closely controlled by glucose levels. Insulin levels can be useful predicting susceptibility to the development of type 2 diabetes, although C-peptide has largely supplanted insulin measurement for this role.

Reactive hypoglycemia is thought to represent a consequence of excessive insulin release triggered by the carbohydrate meal but continuing past the digestion and disposal of the glucose derived from the meal.

Types of Reactive Hypoglycemia

Different types of reactive hyperglycemia include:

  • Alimentary Hypoglycemia (consequence of dumping syndrome; it occurs in about 15% of people who have had stomach surgery)
  • Pre-diabetes
  • Hormonal Hypoglycemia (due to lack of some hormones; i.e., hypothyroidism)
  • Helicobacter pylori-induced gastritis (some reports suggest this bacteria may contribute to the occurrence of reactive hypoglycemia)
  • Congenital enzyme deficiencies (hereditary fructose intolerance, galactosemia, and leucine sensitivity of childhood)
  • Idiopathic reactive hypoglycemia
  • Late Hypoglycemia (Occult Diabetes; characterized by a delay in early insulin release from pancreatic B cells, resulting in initial exaggeration of hyperglycemia during a glucose tolerance test)[3]
Symptoms
Although symptoms vary according to individuals' sensitivity to the elevation and decline of glucose levels. If you recognize any three of these symptoms in yourself over a period of time, you are probably at risk for reactive hypoglycemia. 

  • Fatigue
  • Irritability
  • Nervousness
  • Inner Trembling and Pounding Heart 1-4 Hours after a Meal
  • Palpitations/Irregular Heartbeat  
  • Weight Gain in Abdominal Area  
  • Nightmares
  • Depression
  • Insomnia
  • Flushing
  • Leg or foot cramps
  • Memory and concentration problems
  • Anxiety 
  • Hypertension
  • Headaches
  • Dizziness, and sometimes even actual fainting
  • Blurring of vision
  • Nasal congestion
  • Rhinitis
  • Tinnitus (ringing ears)
  • Numbness and tingling of the hands, feet or face 
  • Bloating
  • Abdominal cramps
  • Bowel problems
  • Craving sweets
  • Increased appetite
  • Epileptic-type response to rapidly flashing bright lights
  • Impotence and inability to maintain an erection
  • Loss of libido

If there is no hypoglycemia at the time of the symptoms, this condition is called Postprandial Syndrome. It might be an "Adrenergic Postprandial Syndrome" - the glycemia is normal, but the symptoms are caused through autonomic adrenergic counter regulation. Often, this syndrome is associated with emotional distress and anxious-behavior of the patient. Note: Dietary recommendations for reactive hypoglycemia can help to relieve symptoms of postprandial syndrome.

Causes
Most hypoglycemia, or low blood sugar, occurs while fasting. But reactive hypoglycemia is low blood sugar that occurs after a meal — usually one to three hours after eating. Reactive hypoglycemia can occur in people who do not have diabetes. The cause of most cases of reactive hypoglycemia isn't clear.
Some researchers suggest that certain people may be overly sensitive to the normal release of the hormone epinephrine, which causes many of the symptoms of hypoglycemia. Others believe that deficiencies in glucagon — a hormone that normally protects against low blood sugar — may cause reactive hypoglycemia.

Less commonly, reactive hypoglycemia results from excessive production of insulin by the pancreas (hyperinsulinemia) due to a tumor (insulinoma) or high numbers of insulin-producing cells (nesidioblastosis). Reactive hypoglycemia may also occur after stomach surgery or due to certain enzyme deficiencies, which may interfere with the balance between nutrient absorption and insulin secretion.

The Effect of Carbohydrates

Carbohydrates are not a part of the natural, prehistoric diet of humans, and they are very difficult for the body to handle because they demand so much from the pancreas and other glands. Overtime it overworks the pancreas.

The Effects of High Blood Glucose
High untreated blood sugar is related to many longterm health problems including the kidneys, nerves, eyes and vision, risk of heart disease and stroke, and erectile dysfunction in men and pregnancy complications in women. Reactive hypoglycemia can lead you down the path to Type 2 Diabetes if left untreated. The following are just a portion of the potential health effects that can one can expect if this occurs:

Diabetes can cause heart disease. Cardiovascular disease is the leading cause of early death among people with diabetes. Adults with diabetes are two to four times more likely than people without diabetes to have heart disease or experience a stroke. At least 65% of people with diabetes die from heart disease or stroke. About 70% of people with diabetes also have high blood pressure.

Diabetes can affect your vision.
In diabetic eye disease, high blood glucose and high blood pressure cause small blood vessels to swell and leak liquid into the retina of the eye, blurring the vision and sometimes leading to blindness. People with diabetes are also more likely to develop cataracts – a clouding of the eye’s lens, and glaucoma – optic nerve damage. Laser surgery can help these conditions. Keeping your blood glucose level closer to normal can prevent or delay the onset of diabetic eye disease. Keeping your blood pressure under control is also important. Finding and treating eye problems early can help save sight. Here is the important oint regarding the importance of controlling blood sugar levels, diabetic eye disease may develop without symptoms. For this reason, regular eye exams are important for finding problems early. Some people may notice signs of vision changes. If you’re having trouble reading, if your vision is blurred, or if you’re seeing rings around lights, dark spots, or flashing lights, you may have eye problems. Be sure to tell your health care team or eye doctor about any eye problems you may have.

Diabetes can cause kidney disease.
Diabetic kidney disease happens slowly and silently, so you might not feel that anything is wrong until severe problems have developed. Therefore, it is important to get your blood and urine checked for kidney problems each year. All is not lost however, as studies show that controlling your blood glucose can prevent or delay the onset of kidney disease. Keeping your blood pressure under control is also important. Your doctor can learn how well your kidneys are working by testing every year for microalbumin (a protein) in the urine. Microalbumin in the urine is an early sign of diabetic kidney disease. Your doctor can also do a yearly blood test to measure your kidney function.

Diabetes can damage nerves and body systems.
Having high blood glucose over time can damage the blood vessels that bring oxygen to some nerves, as well as the nerve coverings. Diabetic neuropathy is the medical term for damage to the nervous system from diabetes. The most common type is peripheral neuropathy, which affects the arms and legs. This can cause numbness, pain, and weakness in the hands, arms, feet, and legs. Problems may also occur in various organs, including the digestive tract, heart, and sex organs (hence why impotency may develop). Regarding the stomach gastroparesis, otherwise known as delayed gastric emptying, can occur due to nerve damage. In this case the stomach takes too long to empty itself. Symptoms of gastroparesis include heartburn, nausea, vomiting of undigested food, an early feeling of fullness when eating, weight loss, abdominal bloating, erratic blood glucose levels, lack of appetite, gastroesophageal reflux, and spasms of the stomach wall. The good news is that you can help keep your nervous system healthy by keeping your blood glucose as close to normal as possible though diet, getting regular physical activity, not smoking, and having your health care provider examine for nerve damage at least once a year

Diabates can affect dental health.
Because of high blood glucose, people are more likely to have problems with their teeth and gums. And like all infections, dental infections can make your blood glucose go up.

Diagnosis
The prevalence of this condition is difficult to ascertain and controversial, because a number of stricter or looser definitions have been used, and because many healthy, asymptomatic people can have glucose tolerance test patterns said to be characteristic of reactive hypoglycemia. It has been proposed that the term reactive hypoglycemia be reserved for the pattern of postprandial hypoglycemia which meets the Whipple criteria (symptoms correspond to measurably low glucose and are relieved by raising the glucose), and that the term idiopathic postprandial syndrome be used for similar patterns of symptoms where abnormally low glucose levels at the time of symptoms cannot be documented.

Diagnostic Tests:
Fasting glucose test – measures blood sugar after an 8- hour fast. This should be measured before starting ARV treatment and checked every 3-6 months after switching treatment. Fasting plasma glucose should be below 6.1 mmol/l (110 mg/dl). Fasting levels between 6.1 and 7.0 mmol/l (110 and 126 mg/dl) are borderline ("impaired fasting glycaemia"), and fasting levels repeatedly at or above 7.0 mmol/l (126 mg/dl) are diagnostic of diabetes.

Random glucose test
  - This test is used to evaluate blood glucose levels. It may be used to diagnose or screen for diabetes and to monitor control in patients who have diabetes.  A random serum glucose test can be done at any time of the day, as the name implies however, results will depend on what you drink or eat before the test, as well as activity therefore unfasted glucose levels are less accurate. Typically if results are greater than 5.17 mmol/ L other tests are run. Diabetes is over 11.1 mmol/L.

Oral glucose tolerance test
– Monitors levels of glucose every 30-60 minutes for two hours after fasting for 8-hours and then drinking a measured glucose drink. The test should not be done during an illness, as results may not reflect the patient's glucose metabolism when healthy. A full adult dose should not be given to a person weighing less than 43 kg (94 lb), or exaggerated glucoses may produce a false positive result. Healthy glucose on this test should be less than 3.62 mmol/L. If it is greater than 5.17 mmol/L other tests are run. Diabetes is over 11.1 mmol/L.

Hemoglobin A1c – Also known as: Hemoglobin A1c, HbA1c, Glycohemoglobin, Glycated hemoglobin, Glycosylated hemoglobin, this test determines how much glucose adheres to red blood cells. It is used to determine average glucose levels over several months. Normal range for someone without diabetes is 4-6% and managed treatment for someone with diabetes should aim to keep this fewer than 7%. One drawback to the A1c test is that it will not reflect temporary, acute blood glucose increases or decreases. The glucose swings of someone who has “brittle” diabetes will not be reflected in the A1c. Additionally,  if you have an abnormal type of hemoglobin, such as sickle cell hemoglobin, you may have a decreased amount of hemoglobin A. This will affect the amount of glucose that can bind to your hemoglobin and may limit the usefulness of the A1c test in monitoring your diabetes. If you have hemolysis or heavy bleeding, your test results may also be falsely low. If you are iron deficient, you may have an increased A1c measurement.

Fasting insulin test – This test is primarily used to measure insulin in the evaluation of individuals with fasting hypoglycemia. Insulin levels tend to be inappropriately elevated in individuals with insulin-secreting tumors. Fasting hypoglycemia in association with markedly elevated serum insulin levels is considered the determinate for insulinoma. The results are used to calculate HOMA-IR (homeostasis model assessment of insulin resistance) score. Measuring glucose is generally preferred to measuring insulin directly.

Rapid insulin tolerance test (also called glycemic clamp, ITT) – This is a medical diagnostic procedure during which insulin is injected into a patient's vein to assess pituitary function, adrenal function, and sometimes for other purposes. This is expensive and again is rarely used.


Treatment
Reactive hypoglycemia is actually the earliest stage of Type II diabetes. Reactive hypoglycemia usually doesn't require treatment. When needed, treatment may include dietary changes such as:

  • Eating several small meals and snacks throughout the day — no more than three hours apart.
  • Avoiding or limiting high-sugar foods, especially on an empty stomach.
  • Eating a variety of foods, including meat, poultry, fish, or non-meat sources of protein, foods such as whole-grain bread, fruits, vegetables, and dairy products. Although some health professionals recommend a diet high in protein and low in carbohydrates, studies have not proven the effectiveness of this kind of diet for reactive hypoglycemia.
  • Fasting from carbohydrate foods can be a good way to get control of the oversupply of insulin.
  • When consuming carbohydrates, choosing high-fiber foods and food with a moderate-to-low glycemic index.
  • Avoiding or limiting foods high in sugar, especially on an empty stomach.
  • Avoiding alcohol, caffeine, and highly starchy foods such as white rice, potatoes, corn, and popcorn (all very high on the glycemic index).
  • Adding soluble fibers (e.g., 5 to 10 grams of hemicellulose, pectin, or guar gum) to a meal may help to relieve symptoms, especially in dumping syndrome.
  • If the diet does not provide a relief in symptoms, there are some medications which can be useful in reactive hypoglycemia, and that should be administrated only by a physician.

Carbohydrate Fasting
By removing carbohydrates from the daily diet and making the change permanent, an individual relieves the burdensome metabolic stress on the body, specifically the pancreas.

The older you are (especially if you are a woman) the harder this will be to accomplish.  Post-menopausal women have a tendency to thickened middles anyway, as a result of the secondary estrogen secretor role of their abdominal fat. If you fast for any length of time and not only don't lose, but continue to gain, the chances are very good that more than your sugar metabolism is at fault.  If this happens, get an adrenal and thyroid panel from your doctor.  Sometimes hidden problems like hypothyroid or cortisol disturbances can be behind your metabolic problems.  Don't hesitate to ask for these tests, and follow your doctor's instructions.

Carbohydrate fasting when followed diligently can be successful form of treatment for reactive hypoglycemia.  Without the carbohydrates that would normally be in the diet, insulin receptor sites gradually begin to reappear; the insulin is there to take the sugar into the cell for energy. 

In the first few days, the receptors on the muscle cells will begin to reappear, slowly at first, but soon in large numbers.  The individual might feel some fatigue or lethargy at this time.  This is normal.  The body is trying to force itself to switch from consumed sugar to its own sugar, which will take a couple of days. During this adjustment period, glucagon will be released once again and the switchover will be complete.

Once the body starts to burn fat, rather than glycogen (stored glucose) the body will stop craving carbohydrates as a energy source stopping the vicious carbohydrates craving more carbohydrates cycle. Once this metabolic change takes place reactive hypoglycemia symptoms will disappear, and the blood sugar will move into the normal range  (80-120mg/dl). 

This process can take days, weeks, or even months, depending on the fat blanket and the amount of insulin stored, but if the individual is diligent, the fat will come off and the blood sugar will normalize. When the blood sugar normalizes, energy is restored, and body temperature is back to normal.  It is important to note that even a small sugar/starch carbohydrate feeding during the fast will shut down the process for approximately 24 hours and cause the carbohydrates to be stored as fat once more.  Only diligent attention to the diet will return the body to the fat-utilization stage.

Caution, once the body sugar metabolism is back to normal this does not mean that the individual can go back to a high-carbohydrate diet. It is important to note that the individual’s sugar metabolism is broken due to years of overworking the pancreas, and will most probably never be fixed.  As long as you have stored insulin in your fat cells, you will continue to have hypoglycemia. The stored insulin spells "no room" in the blood to newly secreted insulin, which means new fat cells must be stimulated for more insulin and fat, and so on ad infinitum.  Only by not stimulating any new insulin (such as when you eat carbs) can the individual begin to use up the fat/insulin stores.  This return to "normal" in regarding to blood sugar levels is only because of the stringent die.

Note: The more strictly the sufferer follows the fast, the more relief he will get. The individual will immediately know if he has taken in insulin-stimulating foods because he will again feel hunger pangs, something that disappears completely when the body is utilizing its fat stores.  Without insulin, the body has no "feed me!" signal.   

Tips
Check your blood sugar once or twice daily with a glucometer to get an idea of what is going on.  For hypoglycemics, it will be highest in the morning and lowest in the evening.  When it gets down around 90 mg/dl and stays there, you can call your fast a success.

The diet must be very strictly adhered to. Do not consume vegetable oils or shortenings however do not be afraid of animal fats in your diet in moderation your diet. Once the normal blood-sugar level is reached, you should be able to add small amounts of other foods (vegetables and small servings of fruits) back into your diet.   Non-starchy vegetables like broccoli and cauliflower may be eaten in small amounts, as well as green beans, cabbage, and asparagus. Eat sparingly, if you wish, but don't starve.

Summary/Prognosis
Reactive hypoglycemia will never go away.  It is yours forever, probably as a result of a family history of defective sugar-metabolism genes. Careful attention to diet however can keep it under control and reduce the many health threatening risk factors associated with diabetes.







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