Hypoglycemia, Anyone have it?

So for the past several months I have been having issues with my blood sugar dropping. I had been telling my surgeon everytime I went for a checkup but all of my blood work came back normal. After a couple of really bad spells last week, I went to see my primary care doctor drew a bunch of bloodwork. My A1C level ( which test for diabetes) came back low. So now i'm almost 1 and 1/2 years post op bypass pt and now have hypoglycemia. M y surgeon says they have never heard of this. Has anyone else had this issue and if so what did you do? Please help!!!


Thanks,
Amanda

Yes,  First week post op for me.  I recognized it right away.  I fixed it by starting and ending my day with high protein mixed with some good complex carbohydrate.  This combination regulates your blood sugar longer.  I mix home prepared unsweetened and cooked fresh fruits with 2 oz. of Greek Yogurt.  I use Fage.  Fruits I've used are pureed yellow plums, and nectarines and peaches chopped fine and cooked soft with artificial sweetener and cinnamon.  It has made a huge difference for me.  You're way further out than I am so you can probably tolerate uncooked fruit.

Yeap, it's becoming quite commoningly known that it is an issue for RNY'ers to get hypoglycemia after their surgery.

That's why I'm chosing a DS.

Here is what I found in my research:

After doing research on many aspects of both, the DS is better not just for resolving diabetes but for keeping it away from your door down the road. I spent much time over on the RNY board and time after time, I saw threads about hypoglycemia. So I looked it up on my favorite diabetes format, the endocrinologists that TREAT diabetes.

Here is what I found:
Endocrine News
Patients who undergo Roux-en-Y gastric bypass surgery (RYGBP) experience many benefits such as dramatic weight loss and type 2 diabetes remission. Yet, they also face a risk for developing severe postprandial hypoglycemia due to gastric dumping.

Researchers have observed elevated levels of the incretin glucagon-like peptide 1(GLP-1) postsurgery, which has been linked to increased β-cell proliferation and differentiation. A research team led by Josep Vidal, M.D., Ph.D., at the Hospital
Clínic Universitari in Barcelona, Spain, investigated whether a rise in this hormone could over time cause this severe setback.

The team divided 24 women into three groups according to time after RYGBP (9–15 mo, 21–30 mo, and > 30 mo). Controls were 8 additional normal weight and 8 morbidly obese women. The subjects fasted overnight and ate a standardized test meal the following day. Blood samples to measure GLP-1, immunoreactive insulin, plasma glucose, and glucagon were taken beforeeating and 10, 30, 60, 90, and 120 minutes after the meal. The patients also underwent an intravenous glucose tolerance test to look for insulin secretion and insulin sensitivity and used a continuous glucose monitoring system to record their postprandial glucose profiles.

In an upcoming article in The Journal of Clinical Endocrinology & Metabolism,* the researchers report that although GLP-1 rose steadily after RYGBP, it did not eventually cause inappropriate insulin secretion. Additionally, their data did not reflect a link between asymptomatic postprandial hypoglycemia in the RYGBP-operated women and an unsuitable relationship between β-cell function and insulin sensitivity. The researchers called for further studies to examine why some patients develop severe postprandial hypoglycemia.

While that article says there wasn’t enough evidence at this time, it did give me pause in that they are even considering the issue.

Then there was a blog article from the EndocrineToday that intrigued me:

Hypoglycemia after Roux-en-Y surgery for weight reduction
Posted by Michael Kleerekoper, MD, MACE April 7, 2009 11:26 AM
Endocrine Today Blog

Seven years ago, my patient had a Roux-en-Y procedure to fight her obesity, and the result was just what she wanted — substantial weight reduction and “no more diabetesÂ" as she reported with a huge smile. Her weight had been stable for a few years, and she was comfortable with it. Four months before her office visit, and for reasons she could not explain, she felt the need to go on a weight-reduction diet during which she lost 12 lb. Two months before she was referred to me, she began to experience episodic hypoglycemia. In her early post-surgery period, she had experienced very typical “dumping syndromeÂ" symptoms, but they had finally cleared and the recent episodes of hypoglycemia seemed quite different.

At 10 p.m. one evening, she felt weak and her capillary blood glucose was 50 mg/dL. This was several hours after dinner. Over the next several weeks, she had a CBG of 53 at 7:45 p.m., 59 at 10:30 p.m., 45 at 3:30 p.m., and most worryingly to her, she woke at 1 a.m. one night feeling very unwell and disoriented, and her CBG was 45 mg/dL. She never experienced fasting hypoglycemia.

Physical examination was essentially normal aside from a suggestion of hyper-pigmentation of her abdominal scar and palmar creases. Pulse and blood pressure were normal as were visual fields and the thyroid examination. Her laboratory findings were also all normal, including electrolytes, fasting blood glucose of (89), insulin, C-peptide, cortisol and adrenocorticotropic hormone.

The history had many characteristics of the dumping syndrome, but several pieces of information did not quite fit. Dumping syndrome is not uncommon in the early months after a Roux-en-Y procedure, but patients generally adapt well by taking frequent very small meals, and over time, the syndrome seems to resolve. Additionally, why did the hypoglycemia occur only several hours after a meal and not sooner? She tried several approaches to changing her eating habits, but these episodes persisted.

I discussed this case with my colleague Dr. Anu Puttagunta, who had cared for a patient with much the same history. This late (post-weight-reduction surgery ) and delayed (post-meal) hypoglycemia has been reported,1, 2 but the mechanism remains elusive as far as I could tell from my reading. The articles reported that some patients did respond to frequent small meals that had little carbohydrate while others only responded when the diet change was accompanied by acarbose.

In some patients, it appears that acarbose alone was sufficient. Dr. Puttagunta’s patient did well with diet modification plus acarbose, so I have begun that same therapy on my patient. She had found those same articles on her own, had modified her diet and had no subsequent episodes of hypoglycemia, but that was not reassuring to her because they were so episodic. When adding the acarbose it was important to remind her to take the tablet (I started with 25 mg three times per day) as soon as she takes her first bite of food. I will report her progress after a few months.

1: Kellogg TA. Surg Obes Relat Dis. 2008;4:492-499. PMID: 18656831.
2: Moreira RO. Obes Surg. 2008;18:1618-1621. PMID: 18566871.

But was was the final straw that pushed me into the DS camp were the guidelines published for the Endocrine Society in March 2009.
Evaluation and Management of Adult Hypoglycemic Disorders:
An Endocrine Society Clinical Practice Guideline
First published in the Journal of Clinical Endocrinology & Metabolism, March 2009, 94(3): 709-728

Hypoglycemia can occur as a result of hyperinsulinism in the absence of previous gastric surgery or after Roux-en-Y gastric bypass for obesity. (pg8)

Some persons who have undergone Roux-en-Y gastric bypass for obesity have endogenous hyperinsulinemic hypoglycemia most often due to pancreatic islet nesidioblastosis, but occasionally due to an insulinoma (48–50). With nesidioblastosis, spells of neuroglycopenia usually occur in the postprandial period and develop many months after bariatric surgery. Spells of neuroglycopenia that occur in the fasting state soon after bariatric surgery are more likely due to a preexisting insulinoma (51). The predominance of women with post-gastric-bypass hypoglycemia may reflect the gender imbalance of bariatric surgery. The precise mechanisms of hypoglycemia remain to be determined (52–54). The incidence of this disorder is unknown, but at the Mayo Clinic the number of cases exceeds, by a considerable degree, that of insulinoma. Partial pancreatectomy is recommended for nesidioblastosis in patients who do not respond to dietary or medical (e.g. an a-glucosidase inhibitor, diazoxide, octreotide) treatments. (pg11)

I checked the document for any mention of the DS and there weren’t any but there were the two references to the RNY.

I have reactive hypoglycemia within my diabetes already. I don’t need a surgery that will make that worse.

Liz

"reactive hypoglycemia" can be a post-op comp.  

  I had two such similar attacks as you did, just earlier this week, when I hadn't been eating as much as usual during the day.  This quite surprised me, as I am 4 years out, as of 2 days ago.   However, I had thought it was odd that my most recent A1c test, done a couple of months ago, showed my A1c level at 4.8, which is as low as the scale goes, despite my eating more carbs/refined sugars than ever before since my surgery.  Before then, it had been 4.9 at the lowest, and averaged closer to 5.0.   Possibly this low level is attributable to developing reactive hypogly., although my family doc does not know as he is not a endo. and not familiar with r.h.       

  It's best to always keep some mints on you just in case you get hit with a hypo. episode.  In severe cases, part of the pancreas can be removed to resolve the condition, as that will then lower the insulin output. 

Rather than mints, get some glucose tabs to keep on you. Liz

Yes, I agree with this.  I keep some by my bed and in my bag.  I'm happy I haven't needed them but they're nearby just in case.

Paul, Paul, Paul.

You are the only person I know who's hell-bent and determined to "break" a DS.If you'd lay off the refined sugars and carbs you'd stop having these 'episodes', and you'd stop ****ting your pants and killing co-workers with your horrid gas. Not to mention that you'd lose the weight you've regained.

Folks---Paul is NOT a typical DSer. Please take anything he says with several grains of salt.

Hi Amanda!
Yes! I've been having trouble too and we're close to the same surgery dates. Melting Mama does a lot of research with this issue among others here on OH. She can probably help. Just now, 2 hours after eating a nice high protein meal, I got shaky and felt funny and my blood sugar was dropping..it was only 44. Two days ago, after eating, it dropped to 34!! I don't usually eat many carbs...two days ago, I had roast and about a third of a sweet potato. I would have never guessed it could drop like that over a high protein meal.

I'm glad you are talking to your primary care doc. From what I've heard here, some of them don't have a lot of knowledge about this issue.  I trust Melting Mama and the other experts here about this issue more than I would my primary care...lol!  Take care and keep a close eye on your body and the low blood sugar signals. I can see you have knowledge of low blood sugar..kinda your profession. Different when it happens to you! I eat a protein bar when it happens to me and it helps. Sometimes I eat a little bite of banana too (with the protein).      Connie

If Enochs hasn't heard of it, then he is a moronic imbecile or a liar.  Neither is exactly someone I play well with.

It is the 2nd most common issue post RNY, the first being anemia.

So again, I reiterate: moronic imbecile or liar?


Yes.  I have it.  Mine came on during my first pregnancy.  Back then, it was less commonly known.  Today, it's VERY well-known.  And any surgeon who doesn't recognize the symptoms and know how to treat it should be shot and sued for malpractice.  Perhaps in retrospect, it should be in reverse order.

The funny thing is, is that I just spoke with Enoch's nurse yesterday and asked her about it. My specific question was " Is this normal for post op bypass patients to become hypoglycemic?" The nurse said that she has never heard of it and that I must have been predisposed to it. Diabetes runs in my family not the hypoglycemia. I have an appt with a nutrionist in a couple of weeks but i'm so confused about what I can and can't eat. I have to do a low oxilate diet as well as the high protein low carb diet so the things that I am suppose to eat I can't eat because of that. And do to that I am having a hard time maintaing a normal blood sugar because of that. I didn't know that this was could happen. I had heard about the anemia and actually thought that was what I had and not the hypoglycemia. I'm not sure what to do..