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Hypoglycemia
Too much insulin to the rescue
Hypoglycemia refers to the state of low blood sugar and the negative health effects it can cause. In an attempt to manage the influx of the glucose, or blood sugar, the body releases insulin into the bloodstream to bring the glucose into the blood cells for energy. However, too much insulin then creates low blood sugar. Blood sugar can become too low in other ways, too, such as when the blood cells use glucose too rapidly or when sugars stored in the liver are not released quickly enough. The resulting state, called hypoglycemia, can cause weakness, irritability, palpitations, and confusion.
In conventional medical circles, hypoglycemia is not regarded as a disease itself but a dysfunction caused by disease or the side effect of some medical treatments. For instance, hypoglycemia most often occurs when someone with diabetes uses too much medication to reduce his or her blood sugar level at a certain time. People with diabetes need to be sensitive to low-blood-sugar signals so they can adjust their medication.
Others believe that hypoglycemia is more widespread and that it accounts for many chronic complaints of hypoglycemic symptoms. Simple refined sugars can comprise up to 30% of the calories in an average person's diet, the logic goes, so hypoglycemic symptoms like confusion and irritability are often the result. Since not everyone subscribes to this belief, some controversy still surrounds hypoglycemia when it is diagnosed for these reasons.
Synonyms
Different types of hypoglycemia include the following:
- Reactive hypoglycemia
- Functional hypoglycemia
- Alimentary hypoglycemia
- Postgastrectomy hypoglycemia
- Alcohol-induced hypoglycemia
- Factitious hypoglycemia
- Exogenous hypoglycemia
- Congenital hypoglycemia
Detailed Description
Hypoglycemia refers to low blood sugar, which can happen when too little sugar is supplied or too much is taken out of the blood. Excess insulin often causes too much glucose to be taken up. Excess insulin can occur when someone with diabetes administers too much for his or her blood-sugar control or when the body itself produces too much. Insulin oversecretion is also caused by some diabetic medication. When sugar is digested, insulin is normally released into the blood to bring the glucose (sugar) into the cells for energy.
Low blood glucose doesn't always produce measurable hypoglycemia symptoms. When symptoms do occur, ingesting sugar or food often relieves them. Medications used to control diabetes -- insulin, sulfonylurea, and others -- are the most common cause of hypoglycemia.
The categories of hypoglycemic reactions include the following:
- Fasting hypoglycemia: occurs about five hours after eating, typically at night
- Pharmacological hypoglycemia: a serious drop in blood sugar in response to mistimed or miscalculated drug or alcohol ingestion
- Idiopathic reactive hypoglycemia: a milder form of hypoglycemia that may resolve quickly with treatment
- Hypoglycemia in critical illness: liver failure, kidney failure, heart failure, or overwhelming infection
- Hypoglycemia in hormone-deficiency states: Cortisol, growth hormone
- Autoimmune hypoglycemia
- Hypoglycemia from insulinoma: a rare tumor of the pancreas that causes excessive production of insulin
- Alimentary hypoglycemia: when surgery involving the stomach has been done, the stomach may empty too quickly into the small intestine. Glucose is then absorbed too rapidly, and more insulin is released
Characteristics of Hypoglycemia
Hypoglycemia stems from having too little glucose in the blood and causes mental symptoms such as confusion, irritability, and mood swings. Hypoglycemia may also bring on other characteristic signs, including sweating, faintness, headaches, palpitations, trembling, impaired vision, and hunger. Not everyone will experience all of these symptoms. In fact, low-blood sugar can make someone so mentally confused that they don't feel hunger. Consequently, they don't receive one of the critical signs that could help them correct the condition themselves.
Paradoxically, eating too much sugar, including sugary snacks or carbohydrate-laden meals, can actually cause low blood-sugar levels. As insulin rushes in to transport incoming glucose, it actually does its job too well, dispersing the glucose too quickly and causing a drop in blood sugar levels.
Hypoglycemia can be caused by drug miscalculations, liver disease, surgical absence of the stomach, tumors that release excess amounts of insulin, and a prediabetic state. In some people, hypoglycemia symptoms occur during fasting (fasting hypoglycemia). In others, symptoms occur after meals (reactive hypoglycemia). And in still others, they occur in response to an influx of too much alcohol, which compromises the liver's ability to process glucose efficiently (pharmacological hypoglycemia).
While it's possible to self-diagnose hypoglycemia by its symptoms, it's wiser to undergo blood and glucose tests that specify tolerance levels to determine the suspected cause of the hypoglycemia. Diagnosing hypoglycemia -- particularly the fasting and reactive types -- can be difficult, so one of several tests could be helpful.
Depending upon its cause, hypoglycemia may be treated with diet, medication, or surgery.
How Common Is Hypoglycemia?
The number of people in the United States affected by this disorder is not precisely known. Diabetes-associated hypoglycemia affects all ages. Nondiabetic hypoglycemia tends to affect older adults and is found equally in men and women.
What You Can Expect
Without treatment, hypoglycemia can either continue as mild symptoms or provoke serious consequences. Much depends on the cause. Hypoglycemia is seen in critical illnesses (overwhelming infection, liver/kidney/heart failure) that need immediate treatment. When hypoglycemia is due to drugs, stopping the medications may relieve symptoms. When glucocorticoids are lacking, replacement therapy can help. Insulin-producing tumors must be removed surgically.
Established Causes
Many things can cause low blood glucose levels, or hypoglycemia, including the following:
- Early diabetes mellitus
- Too much insulin or too high a dose of a hypoglycemic drug
- Side effect of certain medications
- Abnormalities in pituitary, adrenal glands or the liver, including severe liver disease
- Infants and children with abnormal liver enzyme functioning
- People who have had their stomachs removed surgically or have undergone stomach surgery
- Tumor of the pancreas
- Kidney failure
- Cancer
- Excess alcohol intake with long periods of fasting
- Prolonged fasting
- Shock
- Hormone deficiencies (cortisol, growth hormone)
- Severe infection
Risk Factors
Several risk factors are associated with different types of hypoglycemia. These include the following:
- People with diabetes who take too much insulin or too high a dose of a hypoglycemic drug
- Side effects of certain medications
- Abnormalities in pituitary, adrenal glands or the liver, including severe liver disease
- Infants and children with abnormal liver enzyme functioning
- People who have had their stomachs removed surgically or have undergone stomach surgery
- Tumor of the pancreas
- Kidney failure
- Cancer
- Excess alcohol intake with long periods of fasting
- Prolonged fasting
- Shock
- Severe infection
Risk factors are traits or behaviors that may make you statistically more likely than others in the general population to have a certain condition. They are not necessarily "causes" of the condition.
Symptoms
Hypoglycemia symptoms fall into two main categories: the autonomic response and the central nervous response. The autonomic response is caused when the body secretes too much epinephrine and norepinephrine (hormones produced by the adrenal gland) and when neuroglycopenia (the brain being deprived of glucose) occurs. If hypoglycemia occurs gradually, the autonomic response may sometimes be masked by symptoms of the central nervous system. However, when blood glucose levels drop further, autonomic symptoms become very noticeable.
Symptoms associated with the autonomic response include the following:
- Sweating
- Tremor
- Anxiety
- Hunger
- Weakness
- Irritability
- Tingling of the fingers and/or mouth
- Rapid heartbeat and/or palpitations
Symptoms associated with the central nervous response include the following:
- Dizziness
- Headache
- Clouding of vision
- Loss of fine motor skills
- Confusion
- Abnormal behavior
- Convulsions
- Loss of consciousness
Conditions That May Be Mistaken for Hypoglycemia
Hypoglycemia's varied symptoms can cause it to be confused with other conditions, including the following:
- Reaction to emotional problems
- Adverse reaction to a drug
- Depression
- Heart conditions
- Hyperthyroidism
How Hypoglycemia Is Diagnosed
Testing for hypoglycemia typically involves blood and urine tests, which may involve a period of fasting beforehand. Occasionally, X-rays may be ordered. The tests are used to diagnose whether or not you have hypoglycemia and, if you do, what type.
The following tests may be conducted for people without diabetes:
- Oral glucose tolerance
- Plasma glucose (preceded by overnight fasting)
- Plasma glucose (preceded by 72 hours of fasting)
- Insulin radioimmunoassay
Lab tests
- Plasma glucose test: This blood test determines how low your glucose level may be. You will need to fast overnight (or 12 hours) beforehand, though your doctor may extend this up to 72 hours. A separate test is usually done following this to see if you have evaluated insulin levels.
- Oral glucose tolerance test: This is a five-hour test that follows a 12-hour fast on the heels of several days of a 150- to 300-grams-per-day carbohydrate diet. Avoid anything that may mislead the test results, including alcohol, caffeine, vigorous exercise, or smoking. This test is given to determine what type of reactive hypoglycemia you may have. Lab technicians will give you a sweet, syrupy solution. Drink the entire thing. Afterwards, your blood and sometimes urine will be tested during certain intervals. Report any hypoglycemic symptoms promptly.
- C-peptide test: This blood test requires no preparation. If you have already been diagnosed with fasting hypoglycemia, it helps distinguish whether you may be miscalculating insulin injections or whether you may have an insulinoma (an insulin-producing pancreas tumor).
Imaging
For people without diabetes, an abdominal CT - computed tomography, a special type of cross-section X-ray -- or endoscopic ultrasound may be used to rule out abdominal tumors as the cause of hypoglycemia.
Goals of Treatment
For many people, hypoglycemia and its symptoms can be treated effectively through diet and medication. Depending upon it severity, hypoglycemia can be either relatively easy or difficult to manage. Learning more about this condition and how to treat it can be very helpful in its management.
If the hypoglycemia is caused by excess insulin or antidiabetic medication, reducing the dosages may cure the problem. If it is caused by an insulin-secreting tumor, the condition can be cured through surgery.
Specific treatment goals include stabilizing blood-sugar levels when they are in crisis and learning as much as possible about the condition so that hypoglycemic episodes can be avoided. Training family members so that they can help in the event of a hypoglycemic episode is also good.
Treatment Overview
The treatment of hypoglycemia varies, depending on its cause. Most often, treatment involves changes in diet, accompanied by medication, which help manage the condition and stave off hypoglycemic episodes. For people with diabetes who have frequent hyperglycemic episodes, more attention to insulin dosing and blood-sugar management may be needed.
Drug therapy
The use of drugs varies with the underlying cause of hypoglycemia.
- When there are mild symptoms in an alert person, sugar (either glucose or dextrose) in tablet form is available, but fruit juice, milk, soda, or candy may serve the purpose.
- If someone with hypoglycemia is unable to take sugar orally, glucagon injected under the skin or into muscle, as well as intravenous glucose, may be used.
- In the case of hormone deficiencies, hormone replacement may be used.
- When insulin-secreting tumors cannot be removed surgically, Proglycem (diazoxide) and Sandostatin (octreotide) have been used.
Surgery
If your hypoglycemia is caused by an insulinoma (an insulin-secreting tumor), surgery is an option. About 90% of these tumors are benign; however, they can be difficult to diagnose because they usually stimulate the pancreas to produce excess insulin intermittently.
Appropriate Healthcare Setting
Treatment involving blood tests and then diet and medication modifications is usually done on an outpatient basis. Inpatient treatment may be necessary during severe hyperglycemic episodes or if surgery is needed to correct the problem.
Healthcare Professionals Who May Be Involved in Treatment
The following healthcare providers may be involved in the care of hypoglycemia:
- Internists
- Pediatricians
- Family medicine physicians
- Endocrinologists
- General surgeons
Activity & Diet Recommendations
Activity
Be attentive to your exercise routine. Plan around your glucose cycles. If you have fasting hypoglycemia, don't exercise for five hours after a meal-- you're more likely to dip into a hypoglycemic state. If you have reactive hypoglycemia, avoid exercising two to four hours after a meal.
Exercise with a partner. Glucose levels can drop dramatically and swiftly during exercise. You can slide into the classic glucose-starved stupor and not be able to help yourself. Having others around you aware of your condition can be helpful. Carry fast-acting carbohydrates with you when you exercise.
Hypoglycemia caused by medication is difficult to handle with the sort of calorie and glucose burns that come with exercise. Check with your doctor for guidelines and a schedule that fits your particular case. Remember not to exercise a part of your body that you recently injected with insulin.
Diet
Eating right to help regulate blood sugar levels takes planning. The diet of choice is high in fiber, protein, and complex carbohydrates and low in sugar. Avoid skipping meals and carry a snack in case symptoms appear.
If hypoglycemia is a problem for you, consider the following diet notes:
- Fiber: Fiber is the indigestible residues of fruits and vegetables. Fiber from wheat, legumes, oat bran, nuts, seeds, psyllium-seed husks, pears, apples, and most vegetables actually sustains steady blood-sugar elevations. Eat about 50 grams of fiber a day. You can get it by choosing the most natural form of a food possible, for example, an apple instead of apple juice.
- Protein: Diets high in protein can stabilize blood sugar levels. By providing calories with a low-glycemic index, protein tends to produce much less of an insulin response than do carbohydrates. For instance, nuts (high in protein) have a glycemic index of 13, whereas corn flakes have an index of 80. Compare that to pure glucose, whose glycemic index is 100.
- Chromium: The use of chromium has been suggested by some for keeping blood glucose levels more steady and reducing hypoglycemic symptoms.
- Alcohol: The use of alcohol should be curtailed.
Quality of Life
Hypoglycemia can be a challenge to manage. Since you need to consider it whenever you eat, living with this condition requires vigilance and dietary awareness.
Considerations for Women
Some suspect that hypoglycemia may sometimes be linked to premenstrual syndrome (PMS). Experiment with this to see if you can correct your PMS with diet and attention to exercise.
Considerations for Children and Adolescents
If your child has diabetes, make sure he or she wears a Medic-Alert bracelet in case a hypoglycemic episode occurs when you can't be there.
Considerations for Older People
The brain is the first organ affected by low glucose levels, which can cause confusion, distraction, and disorientation. Because these symptoms can be mistaken for aging, emotional or mental diseases, be sure to have elders tested for hypoglycemia if they are present. Caretakers should be notified if an older person is prone to hypoglycemia.
Diet
The importance of diet in the management of hypoglycemia can hardly be overemphasized. Eat frequent, small meals of low-sugar, high-protein, high-fiber foods that are low in fats and refined carbohydrates. Avoid alcohol and caffeine.
Supplements
Nutrients suggested by some to help relieve hypoglycemia include the following:
- Chromium picolinate
- Vitamin B complex
- Magnesium
- Vitamin E
Relaxation Techniques
Stress can alter blood sugar levels. Relaxation techniques like yoga, meditation, and others, along with a personal plan for stress reduction, can help bring emotional relief and prevent drastic swings in blood glucose.
Preventing Hypoglycemia
Regulating blood sugar levels takes planning. The diet of choice is high in fiber, low-fat protein, and complex carbohydrates, and low in fats and sugar. The following self-help measures can help reduce the chances or severity of hypoglycemia.
- Educate those around you. Make sure your family, friends, and co-workers are aware of your hypoglycemia condition. If they can alert you to initial symptoms, you can correct your glucose levels swiftly before they get any worse.
- Eat a high-fiber diet. Fiber is the indigestible residue of fruits and vegetables. Fibers from wheat, legumes, oat bran, nuts, seeds, psyllium-seed husks, pears, apples, and most vegetables actually sustain steady blood-sugar elevations. Eat about 50 grams of fiber a day. You can get it by choosing the most natural form of a food possible. For example, instead of choosing apple juice, eat an apple.
- Eat low-fat proteins. Diets high in low-fat protein can stabilize blood sugar levels. By providing calories with a low-glycemic index, protein tends to produce much less of an insulin response than do carbohydrates. For instance, nuts (high in protein) have a glycemic index of 13, whereas corn flakes have an index of 80. These are both in relationship to glucose, whose glycemic index is 100. Limit your consumption of meat and dairy foods in favor of low-fat protein sources like beans, tofu, nuts, and whole grains.
- Avoid alcohol. The use of alcohol should be curtailed.
Websites & Organizations
American Diabetes Association
National Office
1660 Duke Street
Alexandria, VA 22314
Phone: 703-549-1500 or 800-342-2383
American Dietetic Association
National Center for Nutrition and Dietetics
216 West Jackson Boulevard
Chicago, IL 60606-6995
Phone: 800-366-1655 or 312-899-0040
Diabetes Monitor
Health Answers
Hypoglycemia Discussion Group
Hypoglycemia Support Foundation, Inc.
P.O. Box 451778
Sunrise, FL 33345
Juvenile Diabetes Foundation International
432 Park Avenue South
New York, NY 10016-8013
Phone: 800-533-2873
National Diabetes Information Clearinghouse
1 Information Way
Bethesda, MD 20892-3560
Email: ndic@info.niddk.nih.gov
National Institutes of Health
Institute of Diabetes, Digestive, and Kidney Disorders
9000 Rockville Pike
Bethesda, MD 20892
Phone: 301-496-3583
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