Hypoglycemia (Low Blood Sugar)

How is sugar normally used in the body?

When you consume carbohydrates (bread, fruit, sweets, etc.), enzymes in the mouth, stomach and pancreas begin breaking it down into its most basic part: glucose.
Cells will take in glucose, either directly, or, most frequently with the help of insulin secreted by the pancreas.
When the body is hungry, insulin is barely made at all. When the body has just been fed, insulin production is high, to help your cells use glucose.
People who do not have diabetes can tolerate blood sugar levels that go quite low. Women especially are evolved to handle blood sugars even as low as 35.
All of the processes involved in normal glucose action are extremely well regulated.

What do NORMAL sugars usually look like?

What happens during HYPOglycemia?

As blood sugar falls, insulin production slows down, and a different hormone called glucagon is made in the pancreas.
Glucagon makes the body use the back-up supplies of sugar (called glycogen) in the liver and muscles.
The body notices this drop in blood sugar and “feels hungry.” If blood sugar continues to fall, the body will feel more symptoms: rapid heart rate, sweating, anxiety, shakiness, confusion and in severe cases, it’s possible to faint.

What causes hypoglycemia? There are many!

Lab interference – what we call “artifactual hypoglycemia”
Illness – certain infections, chronic diseases, severe illness, etc.
Medications – various publications show us that about 175 different types of prescriptions can cause low blood sugar! Everything from antibiotics to blood pressure medications.
Alcohol – large quantities of alcohol can block the body’s ability to restock its glucose stores.
Malnourishment – either from starvation or deficiencies in the body’s ability to absorb nutrients from the gut. Sometimes from bariatric surgery for weight loss.
Low cortisol – this is a very serious consideration, because the body MUST have cortisol in order to live.
Excess insulin – has many different forms
- Receiving insulin injections when the body doesn’t need it.
- Pancreatic tumors that make extra insulin (VERY rare!)
- Overactive pancreas cells that make more insulin than they should.
Autoimmune causes – when a patient has antibodies to insulin or the insulin receptor

How do we diagnose the cause(s) hypoglycemia?

Having a low blood sugar isn’t enough!
We have to fulfill Whipple’s Triad:
- Symptoms of low blood sugar
- Lab-verified low blood sugar concentration
- Symptoms get better when glucose rises again
It’s important to identify WHEN blood sugar becomes low: when fasting? After a meal? Both?
- If a person only has low blood sugar after eating, it could be a normal reaction, or will require a Mixed Meal Test to try and prove the low blood sugar.
- If a person only has low blood sugar when fasting, diagnosis usually will require a 72 hour Diagnostic Fast, and this requires time in the hospital.

How does a 72 Hour Diagnostic Fast work?

The patient will eat a light dinner, then starting at 6pm, will not eat or drink anything except water.
The following morning, the patient is admitted to the hospital and blood tests are performed.
The patient continues to fast for a total of 72 hours, while going about typical daytime activities, and fingerstick blood sugar is tested every 2-4 hours.
If at any time the patient feels their typical symptoms of low blood sugar, the fingerstick is performed. If number is less than 60, the patient’s blood is drawn.
If the blood draw confirms the blood sugar is < 55, more labs are drawn immediately,
After labs are complete, the patient is given a glucose rescue and resumes eating.
We analyze the lab data to determine if the patient has excess insulin in the bloodstream when they have low blood sugar.

What happens if the Diagnostic Fast is POSITIVE?

The patient will require ultrasound or CT scan to look for a tumor that is making the extra insulin.
Sometimes they are really difficult to find, and the ultrasound may have to be done through an endoscope passed into the stomach through the mouth.
If we can prove there is a tumor, we remove it by surgery, or “suffocate” it with enucleation.

What happens during a Mixed Meal Test?

The patient is given a prescribed meal, and after eating, waits for the onset of symptoms.
When symptoms begin, the lab draws the blood tests, and provides a glucose rescue afterward.

Resources

www.mayoclinic.org section on Hypoglycemia
www.webmd.com section on Non-Diabetic Hypoglycemia
Univ of Michigan: https://www.uofmhealth.org/health-library/rt1054

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