Is it reactive hypoglycemia

[Pirkar]

Hello everyone

I'm new here and I look for your advise if I may have reactive hypoglycemia and what is the cause of it. I have read that lean women with PCOS often have it, along with high insulin, and 70% of them may have insulin resistance. I'm not diagnosed with PCOS but have had all symptoms all my life. However, I'm not sure I have insulin resistance because my fasting insulin seems very low. I calculated HOMA-IR and QUICKI based on my fasting glycose and insulin, and the result is insulin sensitive. My HbA1 is 5.3. However, considering that I've been on sugar free, low GI diet for decades, my fasting sugar seems a bit on high side.

Since my childhood and especially since teenager I've have bad reaction to carbs, especially high GI and sugar, about 2 hours after meal I get all hypo symptoms, so I've not eaten these foods for decades. My endo said 2 h GGT test results were normal, but 3 hours after test I almost collapsed (trembling, sweat, hunger, dizzy, etc.) and I felt weak even on the next day. Therefore, I'm not willing to take an extended GGT for 4-5 hours, because this experience was terrible.

My main question is: doctors diagnose reactive hypo by postprandial glycose 3 mmol/l; anything above this level is not considered hypo. However, 2 h GGT shows that my glycose is lower at 2nd hour (4 mmol/l) than fasting (5,3 mmol/l). In addition, I am sure at 3rd hour it was even lower - because I developed the worse symptoms after I left the hospital, at home. Are these results enough to say I have reactive hypo, and why did my endo said the "test was normal" and I don't have insulin resistance and glycose intolerance?

Given that my fasting insulin is low, what is the mechanism that it spikes at hour 2 and 3 after 75 ml oral glycose? Does this lead to insulin resistance in the future? I'm now on paleo, light keto - trying to transfer to full keto.

fS-C-pept reference 298-2350, my results: 394 pmol/l
Fasting glycose reference <6,1, my results: 5,3 mmol/l
After 2 hours reference <7,8, my results: 4,0 mmol/l
Fasting S-Ins reference < 29,1, my results: <2,00 mIU/l

Thank you!

 

[kokhongw]

Are these results enough to say I have reactive hypo, and why did my endo said the "test was normal" and I don't have insulin resistance and glycose intolerance?

Because the insulin and glucose data is not available for the 3rd/4th hour to substantiate a clinical assessment. It doesn't matter how you feel after that. Unfortunately Dr's don't make the diagnosis just based on how we feel. They need the data for confirmation. So until the extended OGTT is done, there will be no diagnosis.

 

[Pirkar]

FYI: This is from a medical textbook "Patients have symptoms suggestive of increased sympathetic activity, including anxiety, weakness, tremor, sweating or palpitations after meals. Physical examination and laboratory tests are normal. Previously, many of these patients underwent a 5-hour oral glucose tolerance test and the detection of glucose levels in the 50–60 mg/dL (2.8–3.3 mmol/L) range was thought to be responsible for the symptoms; the recommended treatment was dietary modification. It is now recognized that at least 10% of normal patients who do not have any symptoms have nadir glucose levels less than 50 mg/dL (2.8 mmol/L) during a 4- to 6-hour oral glucose tolerance test. In a study comparing responses to oral glucose tolerance test with a mixed meal tolerance test, none of the patients who had plasma glucose levels less than 50 mg/dL on oral glucose had low glucose values with the mixed meal. It is not recommended that patients with symptoms suggestive of increased sympathetic activity undergo either a prolonged oral glucose tolerance test or a mixed meal test. Instead, the patients should be given home blood glucose monitors (with memories) and instructed to monitor fingerstick glucose levels at the time of symptoms. Only patients who have symptoms when their fingerstick blood glucose is low (less than 50 mg/dL) and who have resolution of symptoms when the glucose is raised by eating rapidly released carbohydrate need additional evaluation. Patients who do not have evidence for low glucose levels at time of symptoms are generally reassured by their findings. Counseling and support should be the mainstays in therapy, with dietary manipulation only an adjunct."
Thus, 4-5 H GGT is not recommended.

 

[Pirkar]

And this is the second possible cause for postprandial hypo:
Occult Diabetes

This condition is characterized by a delay in early insulin release from pancreatic B cells, resulting in initial exaggeration of hyperglycemia during a glucose tolerance test. In response to this hyperglycemia, an exaggerated insulin release produces a late hypoglycemia 4–5 hours after ingestion of glucose. These patients are often obese and frequently have a family history of diabetes mellitus.

Patients with this type of postprandial hypoglycemia often respond to reduced intake of refined sugars with multiple, spaced, small feedings high in dietary fiber. In the obese, treatment is directed at weight reduction to achieve ideal weight. These patients should be considered to have prediabetes or early diabetes (type 1 or 2) and advised to have periodic medical evaluations.

 

[Lamont D]

And this is the second possible cause for postprandial hypo:
Occult Diabetes

This condition is characterized by a delay in early insulin release from pancreatic B cells, resulting in initial exaggeration of hyperglycemia during a glucose tolerance test. In response to this hyperglycemia, an exaggerated insulin release produces a late hypoglycemia 4–5 hours after ingestion of glucose. These patients are often obese and frequently have a family history of diabetes mellitus.

Patients with this type of postprandial hypoglycemia often respond to reduced intake of refined sugars with multiple, spaced, small feedings high in dietary fiber. In the obese, treatment is directed at weight reduction to achieve ideal weight. These patients should be considered to have prediabetes or early diabetes (type 1 or 2) and advised to have periodic medical evaluations.

That is not quite right.
I suppose it is possible.
My problem as is with most RH patients is the overshoot of insulin after eating carbs.
It is the insulin response either initially or secondary that causes the hypoglycaemic episodes.
I have been diagnosed with ' Late Reactive Hypoglycaemia'
There are many types of Hypoglycaemia.
There are other conditions similar to Hypoglycaemia or RH.
Then there are conditions that have similar symptoms akin to Reactive Hypoglycaemia, rebound effect or false hypos, because of the many conditions that are hormonal, only specific tests can establish diagnosis.
If I like you, had a two hour OGTT, my results would be classed as normal, because my fasting would be normal, as my Hba1c levels, I would perhaps have a little too high spike and my levels after two hours would be still above normal levels.
It is after this, at the three to four hours that the symptoms of a hypoglycaemic episode would start and your blood sugar levels would drop below normal levels.
I have had the mixed meal test, the breakfast test, allergy tests, the 72 hour fasting test and numerous eOGTT.
These tests are done to eliminate other conditions.
Until most of these tests are done, you cannot get a true diagnosis.

In my opinion, because you have been on a very low carb diet for quite a long time, your blood sugar levels, hba1c levels are normal, you won't have high background insulin levels, your fasting insulin levels should be normal. And something like 75ml of glucose would be a tremendous shock to your system, no wonder you had terrible symptoms afterwards. You can have glucose intolerance with many conditions. And it is atypical reactive hypoglycaemia to have intolerance to many foods.
Looking at your results it would have been helpful to monitor yours after the two hours. And of course we cannot say it is this or that, we can only go by our experience.

The report you quoted, is just that, a different view of how to treat Hypoglycaemia, without having the experience of those who have really good control of their condition, and avoiding carbs as much as possible.
In the normal views of these doctors, we have to eat such as complex carbs, regularly eat fibre and have small portions every couple of hours.
This is not right and it causes more problems as the patient is constantly having fluctuating blood sugar levels. Which is not treatment that works.
Initially it does work, and it does help with insulin resistance and hyperinsulinaemia.
But over a long period it doesn't stop the high Insulin levels, and symptoms.
As you have found, the only treatment is dietary, avoiding foods that causes the hypoglycaemic episode. Again, as you have found, having a higher than normal blood sugar, causes an overshoot of insulin and the symptoms worsen.
My advice, would ask to be referred to an endocrinologist who will help with the correct diagnostic tests. If you wish to take that course, or carry on with the very low carb diet and be as healthy as is possible.

 

[kokhongw]

And this is the second possible cause for postprandial hypo:
Occult Diabetes

This condition is characterized by a delay in early insulin release from pancreatic B cells, resulting in initial exaggeration of hyperglycemia during a glucose tolerance test. In response to this hyperglycemia, an exaggerated insulin release produces a late hypoglycemia 4–5 hours after ingestion of glucose. These patients are often obese and frequently have a family history of diabetes mellitus.

Patients with this type of postprandial hypoglycemia often respond to reduced intake of refined sugars with multiple, spaced, small feedings high in dietary fiber. In the obese, treatment is directed at weight reduction to achieve ideal weight. These patients should be considered to have prediabetes or early diabetes (type 1 or 2) and advised to have periodic medical evaluations.

This is actually the most common undiagnosed condition leading to RH...see Dr Joseph Kraft's study on Hyperinsulinemia, plus the countless researches and Banting award lectures since the 80s...routinely it is dismissed as just being hungry. Go eat something.

Basically we have lost our phase 1 insulin response and depends on faulty glucose sensor to send out a huge compensatory phase 2 insulin response....in an attempt to clear the glucose overload.


There is a more worrying condition leading to RH and that is insulinoma. That is the real reason to seek medical confirmation, to exclude the possibility that the RH experienced is due to insulinoma.

Otherwise a generally carbs lite fats friendly insulin lite lifestyle would suffice to modulate the condition.

 

[Lamont D]

To add to @kokhongw post.
Quite a few pancreatic conditions can cause Hypoglycaemia and the symptoms of reactive hypoglycaemia, along with insulinoma, pancreatitis, pancreatic cancer, hyperinsulinaemia, that is why testing is necessary and there is also hypoglycaemic conditions, such as gastric dumping, post prandial syndrome, inherited fructose intolerance, and quite a few disorders. Heliocobacter Pylori, a bacterial infection in the gut is known as a cause. It is a cause of RH symptoms in stomach surgery and gastric banding due to the quick digestion due to the smaller stomach.

It is widespread, it is not as rare as it is often quoted because of the lack of research, teaching and experience for GPs and some endocrinologists. It is a specialist endocrinologist who has experience in research and experience that will help you the most.
I was lucky to get my second endocrinologist, because my first didn't have a clue!

 

[Pirkar]

Hi Lamont, and @kokhongw, thanks for your reply! Lamont, what is your fasting insulin? Today I took another blood test - fasting glucose 4.7; fasting insulin 2.5 (normal range 3-25mlU/l. I understand the late reactive hypogl but what is the cause? It has to do with b-cells not functioning as well as they should, at least in the beginning. Have your endos explained you the mechanism - what is the cause in your pancreas for this reaction? Thanks

 

[Lamont D]

Hi Lamont, and @kokhongw, thanks for your reply! Lamont, what is your fasting insulin? Today I took another blood test - fasting glucose 4.7; fasting insulin 2.5 (normal range 3-25mlU/l. I understand the late reactive hypogl but what is the cause? It has to do with b-cells not functioning as well as they should, at least in the beginning. Have your endos explained you the mechanism - what is the cause in your pancreas for this reaction? Thanks

Hi again,
My endocrinologist did not exactly know-how or why I ended up with RH.
He told me that there could be many ways it could happen but no exact tests could prove it. Between us, my endocrinologist and I have extensively discussed the role that the bacterial infection in my stomach known as heliocobacter pylori could be the cause. He even hinted it could have happened regardless of my previous health issues and had RH for many, many years, there was no trauma, no surgery, no abuse, my body just developed RH of its own accord, which is quite rare itself, if you look at the probable causes that I have read. (I am just weird!)
From three eOGTTs my fasting insulin is above normal, my initial insulin response is weak. It could be that my previous diet (recommended) was carb heavy, rendering high insulin levels, high insulin resistance and higher blood sugar levels. A viscous circle of elevated hormones. My balance of hormones became insulin heavy. Hence, every time I ate carbs, the reaction to it, would first rocket my blood sugar levels, then because of a secondary insulin response which is called an overshoot because it is too much insulin, would send my blood sugar levels down into Hypoglycaemia.
It cannot only be the beta cells, because since I got complete control, my reaction to food without carbs has all my blood panel results as normal.
My body has decided that I'm carb intolerant and doesn't like it when I have too much.
It does like, being in ketosis, my health has improved so much.
The years I was ill, and didn't know what was going on, continuous health issues and weight gain regardless of all the diets I tried, not until I was directed by my endocrinologist to this site could I understand what so called healthy foods were doing to me. It helped me realise, that, it was these healthy foods that were making me ill.
It's not finding the cause that made me feel better, but finding a lifestyle choice that actually made me healthy.

If you think that you could have some symptoms of hypoglycaemia, getting your balance of protein, good saturated fats and a low carb diet will help you anyway.

Best wishes

 

[Pirkar]

Thank you Lamont D! This short article explains very well insulin response, but does not deal with insulin overshoot: https://www.lchf-rd.com/2018/11/29/...xIF1T0nZloUPeDFbS2kDIxgRujokoE2nDMWEjuQPHxYu8

 

[Lamont D]

Thank you Lamont D! This short article explains very well insulin response, but does not deal with insulin overshoot: https://www.lchf-rd.com/2018/11/29/...xIF1T0nZloUPeDFbS2kDIxgRujokoE2nDMWEjuQPHxYu8

There is very limited research that has been done on gastric dumping and the secondary insulin response overshoot.
What I would get from the link is about hyperinsulinaemia.
Hyperinsulinaemia is a major cause of diabetes/endocrine system conditions.
If I would have got an insulin test, it would have changed so much of my health issues over the last twenty years or so.

Best wishes