Reactive Hypoglycemia - my trial, error & research...

before I post, I want to say I'm not a Dr., Nutritionist or in the health career profession.  I've been dealing with reactive hypoglycemia for about 4 months now.  It started with severe periods of low blood pressure and blood sugar drops but I didn't know why.  I saw my RNY Dr. after it started and she ran blood work and an upper GI, both came back fine.  I saw my internal medicine dr. who also ran blood work which came back fine as well.  My endo said the same thing... Tests are coming back fine, add sodium to your diet and it will raise your blood pressure.  I added sodium, it raised my blood pressure, but the "crashes" affiliated with hypoglycemia didn't stop.   after eating, I would feel horrible, shakes would start, sweats, I'd feel like I wanted to pass out or if I hadn't eaten in a while I would feel the same symptoms so I decided to start a very detailed food journal.  In doing this, I started seeing that exactly 1.5 hours after eating white foods (potatoes, flours, rice, breads) the shakes would start, I checked my blood sugar and it was 47.  I learned about "reactive hypoglycemia" on the graduates board and immediately called the RNY Doctor and nutritionist, process of elimination, the pattern of symptoms after eating, they ruled it as Reactive Hypoglycemia (RHG).  Since then, I've been researching and learning as much as I can about it.  I hate the feeling of shaking uncontrollably, its a scary feeling not knowing when the shakes will start because your blood pressure has dropped so I continued my journal, writing times I ate, times shakes started, days I took all my vitamins, days I had caffeine and what my blood sugar recording was during a "crash" and here’s what I've found so far.. 1.  obviously simple carbs aren't the best decision for RHG, eating sweet potatoes instead of white, quinoa instead of rice/couscous and eating oatmeal as its a slow burning complex carb really help maintain a balance in your blood sugar for longer periods of time. 2.  Peanut butter is a life saver!  Since it isn't something that has to be refrigerated, you can keep it with you wherever you go.  I keep natural peanut butter at home, in my bedroom (incase I cant get to the kitchen during a "crash"), in my car, work, even in my tote bag.  Its protein and will help stop a crash in reactive hypoglycemics.   3.  keep a journal record EVERYTHING and if you're seeing a nutritionist (or your wls dr) show them what’s going on so you can figure out what the problem is.  4.  eat every 3 hours.  I found even after changing my diet to avoid white foods I was still crashing mostly on the weekends.  After looking back at my journal again, I found my times are off significantly on the weekends because I'm not driving to work having a protein shake and eating every 3 hours.  Instead I'm waking up at 10, my first meal around 12, no protein shakes, not all my vitamins and eating whatever’s available instead of my planned meals like during the week.  the following weekend, I set my alarm to the hours that I eat or have a shake, woke up long enough to have a protein shake, continued to eat every 3 hours during the day and didn't crash once all weekend.  Apparently "crashing" is more than just about eating the right foods, consistency helps. 5.  Use the glycemic index as a guide when food shopping.  Here’s a link to a food index http://www.southbeach-diet-plan.com/glycemicfoodchart.htm   this is a great website to learn more about it http://www.glycemicindex.com/  they also have a "database" you can search with thousands of foods to check the GI.  The higher the GI, the higher the probability is you'll "crash".  There are 3 GI levels low (55 and under), medium (56-69) and high (70 and above). 6.  Get informed!  There are some great books out there about hypoglycemia.  Finding books on RGH isn't as easy, but most books on hypoglycemia do have chapters on different types including RGH.  Here’s a list from the GI website http://www.glycemicindex.com/books.htm  The New Glucose Revolution 3rd Ed (isbn 1-56924-258-5) is very informative.  This is a cookbook (we all love new recipes right) that shows the GI per recipe The Low GI Diet - Cookbook (isbn 156924359X).  The New Glucose Revolution: Shopper's Guide to GI Values 2007(isbn 1569242801) is a good mini book you can keep with you.  It has a small GI index in the back which is great for food shopping trips.  Seek out books at your local library, they're there!  Most libraries now belong to a "network" where you can borrow books from other libraries (you order the book and its shipped to your local library).  Its a good way to sample books instead of buying them all.  While I'm on the book topic, there’s an AMAZING book out there called Sweet Deception by Dr. Joseph Mercola that EVERYONE who has ever used a sugar substitute should read.  Its a quick read and is very informative on the dangers of these products.  7.  take care of yourself.  we all had this surgery to lose weight.  in losing weight, we've slowed down or stopped the possibility of severe health risks that come with obesity.  Our "tool" is there for us, so be there for it!  Know what you're putting in your body, eat right, stay away from junk foods, artificial sweeteners that cause serious side effects including cancer, find ways to add protein to your meals, be creative so you're not bored with foods and snacking on the wrong things.  Last night I made "kfc popcorn chicken", the healthy way, a recipe I found from Devin Alexander, she has a healthy cooking show on cable.  Its made with chicken pieces, dipped twice in egg whites, panko bread crumbs with seasonings.  To not deprive myself I used mustard and sf honey (found at walmart) and made a honey mustard dipping sauce.  The food industry is realizing people out there want to be informed unlike years ago, because of that you can actually find healthy options out there like exotic fruits and vegetables, organic meats and healthier grains full of fiber.  Your pouch helped you lose, now help your pouch develop a healthier life style.  There’s a natural sugar out there that everyone should consider instead of poisoning our bodies with artificial sweeteners that have been made in science labs its called Stevia, its been used in other countries for hundreds of years, is natural and can be used for hot and cold drinks and/or baking.  Since the FDA is controlled by funding companies like Coke, Pepsi, Splenda, Equal, etc, etc, etc, Stevia is not FDA approved and can only be bought in vitamin stores.  You can buy it in different forms (liquid, powder, flavored liquids like the base of fruit 2O drinks),   Here’s a great 4 minute video about it http://youtube.com/watch?v=6079M5nPtsE  As you can tell, I hate the feeling of a crash and am doing everything to stop them from happening.  Not only are they a bad feeling, but since your blood sugar drops, it isn't sending enough insulin to your brain and is making your pancreas and liver work overtime, which is obviously dangerous.  Save yourself even if you can't get doctors to figure out the problem, we trust in them so much, don't wait around for them to figure out what the problem is if you can figure it out yourself.  My self diagnosis is what made me understand what RGH is all about.  Testing for hypoglycemia includes glucose tests, since we're post ops and some of us dump on high amounts of sugar, why put yourself through that misery.  Be happy you know what you have and find ways to prevent it, there are still so many people out there that aren't aware of why they crash, but think they're hypoglycemic, research it, test your blood sugar, journal and figure it out. 

Heres a few documets I've found online...

Reactive Hypoglycemia (RHG): FM/MPS Perpetuating Factor Devin Starlanyl, MD This information may be freely copied and distributed only if unaltered, with complete original content. There are three basic types of nutrients. Beef, fish, poultry, cottage cheese and tofu are foods that are largely protein. Butter, cream, and vegetable oils are fats. Vegetables, fruits, grains, pastas, and cereals are carbohydrates, and so are many so-called "junk" foods, such as candy. These junk foods have little if any nutritional value, and may carry fat as well as carbo.  People with reactive hypoglycemia (RHG) are often (but not always) overweight, and unable to lose the extra weight. A fat pad develops on the belly, and won't go away. The often-overlooked factor is that carbohydrates stimulate insulin production. Insulin enables blood sugar to move into our biochemical "factories" in the cells, where it is burned as fuel. If there is an excess of insulin as well as an excess of carbohydrates, the excess carbohydrates are stored as fatty acids in fat cells. The excess insulin also prevents the carbohydrates from being used. You not only gain fat, but you are also prevented from losing this fat because of the availability of excess carbohydrates. RHG is not the same as fasting hypoglycemia, which is low blood sugar that occurs when you do not eat. For this reason, RHG is not always picked up on routine medical tests. RHG 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. Adrenalin production should be measured as well as glucose, as occur at abnormal times. RHG is also called "insulin tolerance", "postprandial hypoglycemia", "carbohydrate intolerance" and in severe forms, "idiopathic adult-onset phosphate diabetes". This condition can lead to type II diabetes. RHG is common in people with FMS and FMS/MPS Complex. In FMS, it is enhanced by dysfunctional neurotransmitter regulation and other systemic mechanisms. With FMS, you crave carbohydrates but cannot make efficient use of them because of an electrolytic imbalance and other biochemical imbalances in your body. We produce adrenalin even when the blood sugar doesn't fall. We crave carbohydrates, because we need energy. Since our insulin level is high, our bodies take the carbohydrates and store them as fat, often in the belly. We can get the body balanced by eating a balanced diet, and teach it to metabolize our fat for energy. When you consume carbohydrates, your insulin production increases. If you have RHG, your body overcompensates. This results in low blood sugar. RHG can range from very mild to severe. Symptoms include headaches (usually in the front or top of the head), dizziness, irritability, chronic fatigue, depression, nervousness, difficulty with memory and concentration, nasal congestion, heavy dreaming, palpitations or heart pounding, tremor of the hands (especially if a long time elapses between meals), day or night sweats, anxiety in the pit of the stomach, anxiety, leg cramps, numbness and tingling in the hands and/or feet, flushing, and craving for carbohydrates (especially sweets). The hunger pangs experienced in reactive hypoglycemia can come in the form of acute stomach pain and nausea.  Severe RHG can cause hypoxic symptoms such as visual disturbances, restlessness, impaired speech and thinking, and blackouts. You can expect excess body fat, high triglycerides/cholesterol, fluid retention, dry skin, brittle hair/nails, dry small stools, decreased memory and ability to concentrate, fatigue or dips in energy, grogginess when waking, mood swings/irritability, and sleep disturbances. In cases of chronic MPS, the process of eliminating TrPs is hampered or even thwarted by the presence of hypoglycemia. TrP activity is aggravated and specific therapy response is reduced by hypoglycemia. Recurrent hypoglycemia attacks perpetuate TrPs. Many of these symptoms are caused largely by circulating adrenalin, which is also increased by anxiety. Hormones in a given system usually work in a set, called an "axis". The most important in RHG is the insulin-glucagon axis. Insulin drives down blood-sugar levels, while glucagon raises it. If insulin is too high or glucagon is too low, the result is hypoglycemia. Insulin resistance means that the insulin levels are elevated but blood sugar levels remain high, because the target cells no longer respond normally to insulin. This can eventually promote diabetes.  Insulin is a storage hormone. It takes excess glucose from carbohydrates in your food and stores them as fat. Then it locks the fat in place. Insulin drives down blood sugar. Glucagon, on the other hand, is a mobilizing hormone. It releases stored carbohydrates as glucose. Glucagon restores blood sugar levels. The release of insulin is stimulated by carbohydrates, especially heavy starches like bread and pastas. Glucagon is stimulated by dietary protein. If you eat a big carbo meal for lunch, by 3 pm you are ready for a nap. Excess carbohydrates have generated overproduction of insulin. As your blood sugar drops, your brain begins to fall asleep. Because the massive amount of carbohydrates you ate drove your insulin level up and your glucagon down, the fats stored in your body can't be released. But you feel fatigues, so you crave energy and more carbohydrates. This happens in 50% of all people. In 25%, the normal fat response is blunted, so they can get away with eating a lot of excess carbohydrates. Yet 25% of us have an extremely elevated insulin response to carbohydrates. Many of these people have FMS or FMS/MPS Complex. Hypoglycemic tendency is inherited, and often comes with a family history of diabetes. Remember, insulin triggers an adrenalin response. Coffee, tea and colas stimulate the release of adrenalin, as does nicotine. All carbohydrates stimulate the secretion of insulin. Fatty acids are actually the preferred fuel for building new muscles and for energy. A high-carbo diet means fat is deposited and it stays. Dietary fats decrease the flow of carbohydrates into the bloodstream and dampen the insulin response. Dietary proteins enhance the mobilization of fatty acids from fat cells and fat loss. We need a balance. Weight loss on a high carbo diet is mostly water and muscle loss. Any subsequent weight gain is fat gain. Also, the more carbohydrates you eat, the earlier adrenalin is produced as the blood sugar goes down. Blood sugar swings are more extreme and faster the more carbohydrates you eat, and your mood and energy swings go right along for company. Studies show that high carbo intake and resultant hyperinsulinism can contribute to every known disease process. The hormonal response from a balanced meal lasts 4 to 6 hours. Serotonin regulates the appetite for carbo-rich foods, and this neurotransmitter is often out of balance in FMS. Serotonin is also influenced by photoperiodism – the dark/light cycle. (Often carbo cravers overeat only at certain times of the day). The rate of conversion of tryptophan to serotonin is also affected by the proportion of carbohydrates in a person's diet. Dr. Barry Sears wrote a book with Bill Lawren, called Enter "The Zone",(Harper Collins N.Y.N.Y. 1995) It explains in detail why a ratio of 30/40/30 (the ratio of protein to fat to carbohydrate) is the healthiest balance for a majority of people. You are eating 30 percent of fewer calories as fat, and that fat is being used for energy. Every meal and snack must be balanced because there is a hormonal response very time you eat. 30/40/30 is an adequate protein, moderate carbo, low fat diet. At the same time, you will need to adjust your caloric intake and exercise to meet the needs of your body. In this diet, it is helpful to have minimal alcohol, sugar (in any form), fruit juice, dried fruit, baked beans, black-eyed peas, lima beans, potatoes, corn/popcorn, bananas, barley, rice, pasta, caffeine, or other heavy starches. Avoid caffeine, as its breakdown products tend to increase insulin levels. This is one tough diet, because if you need it, you REALLY crave carbohydrates.  You only have to try it for a few days and your body informs you, "Yes, this is what you must do," because you are attacked by whopping headaches and extreme fatigue as soon as your body begins its struggle for balance. Your excess fat will start to break down and release large amounts of toxic substances and waste material. It is not fun. As Dr. St Amand says, it is not for the faint of heart.  But "diet alone" is a treatment that works. When you start each meal, it is wise to eat some protein first. That allows its products reach your brain first. Exercise regularly to decrease the amount of insulin in your blood. Drink at least 8 ounces of water or a sugar-free decaf beverage with each meal or snack. If you are hungry and craving sugar 2-3 hours after a meal, you probably ate too many carbohydrates. Now that you are aware that sugar can ease your "carbo "withdrawal" symptoms in the short term, you may be tempted to cheat. If you do, you cheat yourself. If you don't cheat, in one month you will see considerable improvement. Within two months, the RHG symptoms should be gone. When all is in harmony, your body is your best doctor. Once you are in balance, it will tell you a great deal, if you listen. Learn to eat like a gourmet. Eat slowly, chew thoughtfully, and enjoy each bite.  Eat less, but eat mindfully, and you will be satisfied. You may have the bad habits of a lifetime to break, but if you succeed, you will have a better chance to live a longer and healthier life. Thanks to Drs. Lynne August, Barry Sears, Paul St.Amand, Janet Travell and David Simons and the Wurtmans for the basic research.   Devin Starlanyl, MD

Study Shows Low Blood Glucose Levels May Complicate Gastric Bypass Surgery BOSTON October 12, 2005 Physicians monitoring patients who have undergone gastric bypass surgery should be on the alert for a new, potentially dangerous hypoglycemia (low blood glucose) complication that, while rare, may require quick treatment, according to a new study by collaborating researchers at Joslin Diabetes Center, Beth Israel Deaconess Medical Center (BIDMC), and Brigham and Women’s Hospital (BWH).  The paper, recently published online by the journal Diabetologia and scheduled to be published in the journal’s November print edition, follows on the heels of a Mayo Clinic report on six similar case studies published in July in the New England Journal of Medicine. About 160,000 people undergo gastric bypass surgery every year.  The study details the history of three patients who did not have diabetes, who suffered such severe hypoglycemia following meals that they became confused and sometimes blacked out, in two cases causing automobile collisions. The immediate cause of hypoglycemia was exceptionally high levels of insulin following meals. All three patients in the collaborative study failed to respond to medication, and ultimately required partial or complete removal of the pancreas, the major source of insulin, to prevent dangerous declines in blood glucose.  “Severe hypoglycemia is a complication of gastric bypass surgery, and should be considered if the patient has symptoms such as confusion, lightheadedness rapid heart rate, shaking, sweating, excessive hunger, bad headaches in the morning or bad nightmares,” says Mary-Elizabeth Patti, M.D., Investigator in Joslin’s Research Section on Cellular and Molecular Physiology and Assistant Professor of Medicine at Harvard Medical School. “If these symptoms don’t respond to simple changes in diet, such as restricting intake of simple carbohydrates, patients should be evaluated hormonally, quickly,” she adds.  Dr. Patti and Allison B. Goldfine, M.D., also an Investigator at Joslin and Assistant Professor of Medicine at Harvard Medical School, were co-investigators of the study. The study reported on three patients – a woman in her 20s, another in her 60s and a man in his 40s. All three lost significant amounts of weight through gastric bypass surgery, putting them in the normal Body Mass Index (BMI) range. Each, however, developed postprandial hypoglycemia (low blood glucose after meals) that failed to respond to dietary or medical intervention. As a result, all patients required removal of part or all of the pancreas. In all three cases, it was found that the insulin-producing islet cells in their pancreases had proliferated abnormally. A potential cause of this severe hypoglycemia in these patients is “dumping syndrome,” a constellation of symptoms including palpitations, lightheadedness, abdominal cramping and diarrhea, explains Dr. Patti.  Dumping syndrome occurs when the small intestine fills too quickly with undigested food from the stomach, as can happen following gastric bypass surgery. But the failure to respond to dietary and medical therapy, and the conditions worsening over time, suggested that additional pathology was needed to explain the symptoms’ severity, Dr. Patti adds. “The magnitude of the problem was way beyond what doctors typically call dumping syndrome,” she says.  Other causes of postprandial hypoglycemia can include overactive islet cells sometimes caused by excess numbers of cells, a tumor in the pancreas that produces too much insulin or familial hyperinsulinism (hereditary production of too much insulin), which in severe cases can necessitate removal of the pancreas. In patients following bariatric surgery, additional mechanisms may contribute to overproduction of insulin. “First, insulin sensitivity (responsiveness to insulin) improves after weight loss of any kind, and can be quite significant after successful gastric surgery,” says Dr. Patti.  “Second, weight gain and obesity are associated with increased numbers of insulin producing cells in the pancreas, and so some patients may not reverse this process normally, leaving them with inappropriately high numbers of beta cells.”  Finally, after gastric bypass surgery, GLP1 (glucagon-like peptide 1) and other hormones are secreted in abnormal patterns in response to food intake, since the intestinal tract has been altered. High levels of GLP1 may stimulate insulin secretion further and cause increased numbers of insulin-producing cells. “In our patients, the fact that the post-operative onset of hyperinsulinemia was not immediate suggests that active expansion of the beta cell mass contributed to the condition,” Dr. Patti adds.  Other researchers participating in the study included S. Bonner-Weir, Ph.D., of Joslin; E.C. Mun, M.D., J.J. Holst, M.D., J. Goldsmith, M.D., D.W. Hanto, M.D., Ph.D., M. Callery, M.D., of Beth Israel Deaconess Medical Center.  Collaborating investigators from the Brigham and Women’s Hospital included R Arky, M.D., who also is a Joslin Overseer, G.T. McMahon, M.D., M.M.Sc., A. Bitton, M.D., and V. Nose, M.D. All participants are on faculty at the Harvard Medical School. Funding for the study was provided by the National Institutes of Health, the Julie Henry Fund of BIDMC and the General Clinical Research Centers.  Besides helping afflicted gastric bypass patients, the research has hopeful implications for treating people with diabetes, says Dr. Patti. The gastric bypass patients have what many of those with diabetes lack – ample insulin – and perhaps an understanding of this phenomenon could be harnessed to help those with diabetes. “If we can understand what processes are responsible for too much insulin production and too many islet cells in these patients, we may be able to apply this information to stimulate insulin production in patients with diabetes, who lack sufficient insulin,” Dr. Patti says.

Thank you so much for your post - You are my Angel.  I have been having problems with crashing after eating as well and didn't know what was causing it.  THANK YOU THANK YOU THANK YOU!!

Its an awful feeling (and has dangerous effects if untreated), I never heard about it before looking on the grads board and wasn't told of its side effect before surgery.   Be sure to mention your symptoms to your wls doctor (and nutritionist if you see one). 

Hello Stylz, I absolutely agree with you... it happened to me when i was a new post op. I was several months into my WL journey and I felt so sick ....after i ate. So i visit my surgeon , he said exactly the same thing that you have said! its because of what i was eating that caused me to react this way. I changed what i ate and ever since then ( now i am alittle over 3 years post op ) AND ....i have no more reactions. :-) thank you for posting this! your post is very helpful I do hope others will read your post. By the way, congrats on your success :-) hugss Lizzy

Thanks, congrats to you as well Lizzy!  I've read your profile before, you've done so well!   Its great you're able to keep it under control, I'm almost there, but still test the waters a little to see what will make me crash and what wont once and a while.  such a learning experience, but I'm staying positive.  The findings could have been worse, this will keep me eating healthy!