Patient Information
By Phyllis Woodson, MS, RD, CDE

Hypoglycemia, or low blood glucose, may occur due to many reasons. If the individual has diabetes, too much medication or insulin, too much exercise, or too little food, hypoglycemia may occur. Other medical causes of hypoglycemia may be organic or metabolic or due to tumors. Excess alcohol may cause hypoglycemia. Alimentary hypoglycemia is due to prior upper GI surgery. Reactive hypoglycemia occurs when excess carbohydrate foods (sweets, starch, fruit or milk) elevate your blood glucose and cause excess insulin to be secreted, which may then cause hypoglycemia to occur two to four hours after eating.

Insulin is a hormone secreted by the pancreas, which helps excess glucose in the blood enter the liver, muscle and fat cells where it is either used as energy or stored as fat. The following illustration shows what can happen during reactive hypoglycemia.

A RECOMMENDED DIAGNOSIS OF REACTIVE HYPOGLYCEMIA is documentation of low plasma glucose (<60 with symptoms, <50 mg/dL without symptoms) associated with symptoms and relief of these symptoms by eating food or raising the glucose level. Physical symptoms include clammy, cold skin, shakiness, palpitation, dizziness and weakness. Central nervous system symptoms include confusion, headache, vision disturbances and motor and personality changes. Symptoms of anxiety — sweating, headaches, hunger and weakness — may suggest hypoglycemia but are not always confirmed by diagnosis. Hypoglycemia may be a risk factor for diabetes.

TREATMENT FOR LOW BLOOD GLUCOSE (usually below 70 mg/dL) includes 1/2 c orange juice or 1/2 c regular soda or 3 glucose tablets or 5-6 Lifesaver candies. Each of these foods has 15 grams of carbohydrate and will cause a gradual rise in blood glucose back to normal in about 15 minutes. For low blood glucose below 60 mg/dL it is recommended to treat with twice the amount of food suggested above.

PREVENTION OF LOW BLOOD GLUCOSE includes eating adequate "mixed" meals (starch, protein, vegetable, etc.), eating meals on time or at least avoiding long lapses between meals (most experts agree on four to five hours between breakfast and lunch, and five to six hours between lunch and dinner; if post-GI surgery, small, frequent meals are best), avoiding sweets, having regular meal/snack times, and being aware that extra activity or exercise may require more food in order to prevent low blood glucose. There are several snack bars available for the purpose of preventing low blood glucose, particularly at night or when exercising. They consist of uncooked cornstarch, protein and sucrose or fructose designed to provide a staged, time conversion to glucose during the next several to six hours or so. Three products available are Extend, NiteBite and Gluc-O-Bar (check with your physician or diabetes educator).

MANAGEMENT OF REACTIVE HYPOGLYCEMIA. If diagnosed with reactive hypoglycemia, the treatment includes avoidance of sweets and high sugar foods and eating meals at regular times. Snacks between meals, if necessary, will also help avoid low blood glucose. Each meal should include at least a starch (bread, potatoes, rice, corn, peas) and protein (lean meat, poultry, fish, egg, cheese or peanut butter), e.g., 1/2 to 1 turkey sandwich. Avoid eating more than 6 oz. lean meat, poultry, fish, cheese, or more than 1 egg on a given day, or more than a small amount of peanut butter — this could contribute to weight gain. One cup of low fat milk and a limited amount of fruit may be added to the meal. Vegetables, cooked or raw (salad, broccoli, cabbage, spinach, tomatoes, etc.), should always be added as desired. Protein and the fiber in the vegetables may stabilize the rate of absorption of glucose into the blood. These factors — regular meals with limited carbohydrate intake (avoidance of sweets, and limited to moderate starch, fruit, milk intake) — can help avoid high blood glucose.

READ THE NUTRITION FACTS FOOD LABELS. The average portion of carbohydrate (starch, fruit, or milk) has about 15 grams of carbohydrate per serving. Avoid or limit foods with more than 5 grams of sugar per serving (note: milk and fruit will normally contain between 12 to 15 grams of milk or fruit sugar per serving and this is ok - you will need some fruit, maybe 2 servings a day, and 3 servings of milk a day, but maybe smaller amounts at one time). Sugar alcohol or polyols originate from the hydrogenation of sugar or syrup and include sorbitol, zylitol, maltitol, mannitol, isomalt and starch hydrolysates - they have two to three calories per gram or about half the calories of sugar. If the grams of sugar alcohol listed on the food label are more than 5 grams, deduct half of this amount from the total carbohydrate grams on the label. Five or fewer grams of sugar per serving is considered a low sugar food and 10 grams of sugar alcohol is equal to about 5 grams of sugar. Sugar and sugar alcohol are listed under Total Carbohydrates on the food label. Sugar alcohol in excess may cause intestinal discomfort. Always try to limit intake to the portion recommended on the food label.

Snacks, if necessary to prevent low blood glucose, may include a small serving of starch or starch and protein food, e.g. crackers or crackers and a small amount of low-fat cheese or peanut butter. Caffeine and alcohol should be limited or avoided. Identifying low blood glucose by monitoring your blood glucose with a meter may be helpful. In some cases, your physician may find it necessary to prescribe pharmacologic agents such as insulin sensitizers or alpha-glucosidase enzyme inhibitors. In order to control weight and manage hypoglycemia with diet, consult with a registered dietitian experienced in diabetes or hypoglycemia management.

The following chart shows how reactive hypoglycemia can be prevented or controlled (blood glucose peaks and valleys are reduced). Remember, eat snacks only if necessary.