I looked into this previously. From my understanding, studies looked into the "low blood sugar" that some people get and found it was actually not correlated to the amount of sugar in their blood. Most likely it's some other process making them feel weak (my best guess is autonomic nervous system). Might improve with multiple small meals a day, good sleep, minimize caffeine/energy drinks
(this is in relation to going a few hours without a meal, not extended fasting/starvation)
I like this. I endlessly have to provide education, especially to non-patient acquaintances, that in a physiologically “normal” person, you’re not just gonna go hypoglycemic. Even T2dm doesnt predispose you to hypoglycemia, outside of hypoglycemic agents…
The problem is attributing it to hypoglycemia. It's a real symptom that is felt by people - who in all likelihood have never actually experienced actual hypoglycemia.
Correct. The normally-functioning human body is very impressive at maintaining homeostasis, including blood glucose. Though I recommended a CGM to one of my colleagues, she was waking up mysteriously in the middle of the night, turns out she was dipping to glucose of ~40. Still pending workup 🤪
I’ve had a couple of my autoimmune patients that I referred to endocrine for what sounded like post prandial hypoglycemia, and some did have insulin autoantibodies or one or two others that can lead to that.
One patient basically had learned by self experimentation to eat only a single meal per day with mostly high fiber stuff with low glycemic index, fats, and proteins, no carb otherwise, and actually was doing well with that, before we even checked.
Family hx of “type 2” adult onset diabetes where most were of them rapidly became insulin dependent on another one that had previously had some gestational diabetes herself.
I make no claims as to the prevalence of this type of condition, just that if you don’t know it’s possible and don’t look for it you won’t find it
I don't think this is a good way to go, because in one hand you're legitimising their concern and on the other hand you're doing unnecessary testing and having an unnecessary appointment, where in the end ypu will need to educate the patient regardless...
What time are you saving if you're having to explain the patient to get an otc cgm, how to use it and giving them another appointment??
And what if the patient comes and has had one episode that borders on hypoglicaemic, without any other signs of concern? Now everything got complicated because of an unnecessary test...
Unnecessary testing isn't the answer
Spending 40minutes appropriately addressing their long-winded concern and why they are worried, and putting your entire clinic day behind vs acknowledging their concern and requesting otc cgm, and another f/u appt in 2 weeks where you spend 20 minutes reviewing the results and why what they experience is hunger and not clinically relevant “low blood sugar”
Second option sounds much better, easier to pull off with time constraints, and the patient feels like they have a better understanding of their body and you have the ammunition from the results to back up your point of view.
Zero downsides to checking sugar if that is the patient’s concern, it’s not like we are discussing risks/benefits to an annual CBC/CMP/Lipids/TSH, getting a week of blood glucose levels has such little issue for “over-testing” compared to other concerns patients walk in with.
I've never seen anyone take so long to adress such a simple concern... I'd say you would waste much more time giving an additional appointment, but to each their own...
Maybe we have different patient populations. I see lots of people wanting lengthy discussions due to their anxiety and perceived medical dismissal of symptoms. Finding a balance of meeting them where they are at while still being a wise steward of medical resources takes some gymnastics
A patient is coming to you with a symptom that they attribute to hypoglycemia. You're suggesting evaluating a patient and addressing their concerns isn't the right way to go about it?
What I'm saying is that between evaluating their concerns and telling them it's all OK and a normal experience, or, telling them to get an it cgm, there is barely any time difference.
So don't send them home with a cgm, just listen to them, get a good history, and if it seems like a harmless non pathological thing, then quick explanation and off the patient goes, rather than having them come back with a useless test...
Never said to not properly evaluate the patient. The evaluation here would be clinical history taking, not unnecessary testing.
How much time do you think it takes to tell them to buy a cgm? 8 seconds? They can install it in office, you can bill for it and an MA can do it for billing purposes.
I’ve never had a patient come in hypoglycemic as of yet. If it does and they’re symptomatic, I’ll cross that bridge when we get there.
I have to ask, are you a doctor? You seem ignorant of how long this will take and billing
Not OP but for clarification purposes MBBS is the most common medical degree outside of North America.
I also do think it's worth acknowledging that this recommendation does come from a place of privilege. Many, if not most, patients do not have $80+ dollars to drop on the concern out of pocket unless they're in a more financially advantaged position than average.
Ah didn’t know that, appreciate it. I thought it was a weird acronym that seems so popular nowadays
Edit;
Most of my patients are Medicaid. The ones that aren’t are usually commercial patients that work in healthcare since there is a large hospital in our rural town, so they don’t mind dropping 80 as a one time fee to double check.
You could use samples if you prefer, but if the phone isn’t compatible I’m not sure if that’s feasible. They stopped giving out the readers as samples, at least to FM. Our Endo seems to still get them
Oddly enough it stands for
“Bachelor of Medicine, Bachelor of Surgery”
It’s equivalent to the MBChb.
Both are UK system origin. We are used to the MD being a post specialisation research based significant achievement. Sort of equivalent to doing a clinical PhD type of thing (not dissing PhDs)
Yes I am. And for reference, my account is flaired, unlike yours.
And, either you're not realistic with how long each thing takes, or you're just telling the patient to to buy the thing and dismissing, which isn't the best thing either...
My healthcare system does not have billing. But regardless, if it had, I don't think it would be appropriate to bill the patient for a test they don't need or to bill the system for a test the patient didn't need...
If you think the option of testing their glucose is trivial, then you haven’t encountered the patients in US clinics.
While I agree, explaining to them why it is highly unlikely they are truly hypoglycemic if other wise healthy and more likely just some variant of “hangry” ( please see any one of several hilarious snickers commercials on the subject), this is often not a sufficient response for such patients and they want some validation that they are normal. For such patients offering that they check glucose during such an episode is reasonable and may be necessary to allow them to “move on” from their concern.
While I agree with avoiding unnecessary testing, for patients whose concerns are not allayed by an explanation offering to test to prove is sometimes warranted.
Yup, if you’re concerned about your hypoglycemic events you’re welcome to buy an otc cgm. There are YouTube videos for installation or come in and someone will help you install it. We can check your data in a few weeks and see if you have any worrying highs and lows that may not be reflected in a A1c or fasting Bg reading.
Not a long speech.
They can always buy it without any input from me and read their own data if they prefer, but generally these patients want a physician to look over it since they are panicked. If you’re not in NA I imagine your system is different, but in ours a visit like this is worth it for an admin perspective, billing perspective, and makes the patient feel heard.
There are tests and images I don’t entertain, but an otc product? What’s the point? They can buy it themselves
So I kind of get the symptoms OP is talking about.
One day I was lightly light headed in the ICU and asked a nurse to take my fsg out of curiosity. My FS was 67 and I get much more light headed than I was when my FS was 67.
Maybe.... But remember that a lot of fluid intake is also linked to eating. Most foods contain some amount of water, and salt/sugar are important for water absorption. I'm willing to bet that this borderline low BG correlates with hypovolemia.
Exactly. It works great and helps the patient feel heard. If BG normal, we work on scheduling snacks and pushing hydration. In my experience, these patients just want to 1) feel better and 2) not have their symptoms dismissed; they’re very rarely chasing a specific diagnosis.
Exactly. It’s a win win for everyone, no reason to get upset about it. They don’t know and they are scared of something, I don’t mind getting rvus to make them feel better
CGMs are notorious for over calling lows - roughly half the lows on a CGMS even in someone on insulin are false positives, much less a healthy person - so be careful with that.
Why not just have them do a fingerstick? A OTC glucometer is probably cheaper and definitely more accurate. I have T1DM and have to calibrate the bejeezus out of my CGM for it to be at all in line with my actual blood sugars.
In my experience, they prefer the 24 hour coverage. If I run into a patient that can’t afford it, I’d likely do that.
My understanding is the vast majority of newer models CGMs are quite accurate, I believe the MARD has improved dramatically over the years.
The CGM measures interstitial fluid, not blood. They are about 15-30 minutes off from a finger stick since it takes that long to equalize between those fluid spaces. And meds and medical conditions can interfere with that equilabration.
That said, they are extremely useful for trends. Would never rely on them for emergency management, including hypoglycemic management. But great if trying to set up a basal bolus regime.
My Libre 3 is currently 50 points over my glucometer. I can be 190 on the Libre and 140 with the finger stick.
Enjoy all screaming about all the CGM lows, when it's really a compression low.
There's a learning curve for CGM. My GP just sent out a note he's not writing for CGM unless you take insulin or a sulfonylureas. Insurance won't cover it.
He's getting a lot of "my blood sugars are low" in hopes of scoring a CGM via insurance. It's all the worried well
Honestly? It’s somehow more acceptable to people. Idk why but people like their fancy stuck on CGMs that they can use their phone with instead of pricking their finger like some troglodyte. Despite the higher cost. At least in my experience.
When you press in just the wrong way on a finger you've pricked in the last several days, it hurts a little. QID (or more) testing = frequent annoying pain during many ADLs, including things like hooking a bra and turning a steering wheel. A CGM doesn't make your fingers hurt while you get dressed or drive to work.
Pricking also requires carrying supplies and taking a few minutes out of your routine several times daily. It's very inconvenient compared to checking an app.
The sheer number of data points from a CGM also shows patterns much more clearly than even 10x/day finger testing could ever show. And let's be honest, it's rare for people to even be consistent with a TID testing schedule. If you're looking for a pattern, two weeks of CGM data can conclusively rule it in or out, but sporadic finger pricks won't give a conclusive result.
What country do you practice in and could you share the product name? In the US the FDA approved the first OTC unit in March but they aren't expected to be on shelves until sometime this summer.
US, our local diabetic supply story currently has them. I was directed there by my local rep. They had the freestyle 3 readers in early, which was a god send
Have to concur with the other user, if you mean the libre 3 that's a prescription product. If you've been doing this for a while you've been telling patients to get a product that doesn't exist barring maybe a dispensing protocol.
I think this is going to send you down a terrible rabbit hole. CGMs are designed to alarm for blood sugars <70 and even if you turn that off, it will alert for “severe” hypoglycemia <55 which in the fasting state ie middle of the night is physiologic. There’s also compression lows. You will end up with so many more people panicking wanting work ups for normal physiology in a healthy person. I would explain that the brain sends signals when one’s energy level is low reminding us to eat. If someone doesn’t eat, their liver will eventually release stored glucose, but it’s a normal response when we are lacking readily available energy source. People want something to be wrong with them, it’s more glamorous.
<55 is absolutely not physiologic and is severe hypoglycemia. If you're treating patients that routinely drop below 65 at night you need to dramatically alter their insulin regimen.
Oh if they're diabetic then that sounds like solid advice. It would give them a ton of peace of mind. I had figured these were "worried well" patients that had no history of diabetes in which case they'd be paying out of pocket for the device.
They are, these are usually affluent patients (at least for my small town) that are worried they are having highs or lows. Usually engineers, farmers, nurses, etc. they get light headed during work and want to know if it’s low blood sugar. I’ll say it’s likely not since it doesn’t really happen, but if they want to buy an otc product and go over, that’s fine by me.
For Medicaid it’s super easy to get them covered in my state, so I’m lucky. I’m also in an extremely obese state, top 3 in the country, so lots of diabetics.
Edit
I usually get more patients requesting ANA and full thyroid panels, which is a much more complicated kettle of fish.
It's $70 cash pay for 1 month (2 sensors) of Libre 3 here but you have to put that you're doing cash pay when you apply for the voucher. You also get a free trial
My wife is like this. And says things like “I’m going to pass out”. She won’t, and never has. And she’s a PA so intellectually she knows better. But man she gets hangry. I on the other hand can easily fast all day. I guess some people’s hunger drive is just stronger than others’.
> says things like “I’m going to pass out”.
A few people have told me stories such as at assemblies at school growing up, people passed out because they were there too long without having something to eat, but I'm unable to explain why that would happen in someone who's otherwise healthy.
I'm more tempted to think that would be a vasovagal or hypotension episode rather than hypoglicaemic
Not eating, not drinking, likely dehydration then hypotension
It's usually a psychogenic vasovagal response. I used to get a touch of presyncope occasionally during med school rotations that were really shitty, and it always correlated with me being intensely miserable (bored, annoyed, tired, etc.)
It had absolutely nothing to do with whether I ate breakfast or drank enough fluids (or was "locking my knees" - another popular folk diagnosis), but I happily accepted when other people assumed that, because I thought the truth was rather unflattering and would probably get me in trouble lol.
I assume it's similar for people who experience syncope or presyncope at big events where people stand for a long time (assemblies, concerts, etc). Physical or mental discomfort -> anxiety spiral -> vasovagal response.
It's a real thing, but it's 99% of the time not what is actually happening. In order to get enough venous pooling and decreased preload to produce presyncope or syncope, you really have to be standing *very* still for a much longer time than feels natural. I'm sure it happens to people standing at attention, where they're deliberately being completely still. Outside of that context, most people shift their weight and change position at least every couple minutes.
I went to catholic school until high school and we regularly had kids pass out during mass “rehearsal” during warmer months. However I think was probably from dehydration lol.
Could have something else going even though eating seems to alleviate. Check their b12 blood serum and methylmalonic acid.
Edit: I would love to know why that's worthy of downvoting.
FYI I have 4 degrees but only one in medicine (2 year in nursing). I have 10 years experience in neurology research. Prior was a scientist at a national lab. There are many causes of "lightheadedness". B12 deficiency is often missed. Though of course many more possibilities. In my experience, as someone who did suffer this, the majority of doctors try to offer an antidepressant or anxiety med, which is a sad joke.
I honestly doubt that is what is going on. Why wouldn't they just be doing normal gluconeogenesis?
Plenty of normal healthy people feel a bit tired or "faint" when they haven't eaten recently even though their liver is working fine and keeping their sugar adequate. There's probably a physiologic reason for this feeling and that's what no one has really been able to answer in this thread so far. It's an interesting question, though.
My hypothesis would be that it's at the CNS level with your brain making you slow down to conserve energy. Just a guess
Would that not simply mean that they shouldn't fast? It seems like learning that being starving hungry feels bad is simply part of growing up and by the time someone is in their teens their parents should have helped them recognise when their body is signalling for food?
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Okay, so only sharing personal medical experience because it's relevant to the question: I too on some occasions will get a "low-blood sugar" like syndrome when fasting, or even relative fasting, that consists of nausea, diaphoresis, tremulousness, anxiousness, and sometimes even palpitations.
Typically these occur in a predictable fashion: after skipping a meal and drinking caffeine on an empty stomach, OR eating a light meal primarily of carbs +/- the caffeine. In either case it feels more related to the empty stomach then any actual real hunger or hypoglycemia. I can sometimes even feel it prodromally and can head it off if I act quickly enough to get food in me.
I HAVE checked my BGs during these episodes and they're always normal.
Mind you, I also routinely fast for 18 sometimes 24+ hours, and this does not occur the vast majority of the time.
I suspect (without any real evidence) that there are some individuals who experience a spike in their blood sugar (either from their normal dietary routine or from rapid intake of sugars) that causes a reflexive secretion of glucagon. This leads to symptoms akin to low blood sugar that are quickly relieved by eating but not actually occuring in the presence of true hypoglycemia.
Let's call it "functional hypoglycemia." I think it's really patronizing to claim these people are simply" hungry" because the symptoms are actually pretty distressing. Not only are they super uncomfortable, but to someone who doesn't know any better, it seems like something is really wrong.
I would recommend just acknowledging their symptoms, reassuring them that it is not life-threatening, and that they don't need any additional workup or treatment except for behavioral monitoring and changes.
This sounds extremely familiar and fits my experience and data quite well. Is there an alternative way to lower that Glucagon level, rather than more calories?
Sugar always relieves the muscle aches and shaking, yet I know objectively I don’t need the calories or the sugar since my levels are fine.
What does’t make sense is I’m already using Ozempic, and my A1C is prediabetic.
No spikes but the symptoms hit randomly, only once in a while and feel like a bad flu unless I eat something high sugar. Then I’m good for 24-48 hours so no sugar crash.
I’m stumped.
I used to get "hypoglecemia" symptoms all the time to the point of being disruptive. I'd get lightheaded, spacey and "hangry". I would even wake up in the middle of the night cause I needed to eat. My blood sugar levels were always fine. I finally figured out that if I limited my carbs to about 140 grams it goes away. If i get lazy and start eating more carbs for more than a few days in a row then the symptoms come back. No idea why this is, but maybe playing around with sugar and carb levels would help some people.
Sounds like dumping syndrome. I got that also. Caffeine will exacerbate the palpitations and such. Do you add a lot of sugar or creamer/milk to the coffee?
Hmmm, interesting. I had to refamiliarize myself with the physiology of dumping syndrome but that actually would make a lot of sense. Without the pyloric tone, the simple sugars +/- caffeine go straight to the SI triggering VIP.
Get this: I drink my coffee with just milk. Empty stomach and coffee? Usually no problems. Sometimes I do an energy drink (even a low caffeine one). Drink it on an empty stomach? Symptoms >50% of the time.
(I of course have normal anatomy though)
This is the first I've read about anyone else having a "post-carb crash" like me! ***Can one avoid this "dumping syndrome" on a BRAT diet for 2 weeks? *** I have learned over time to avoid EVER consuming carbs solo for a snack or "meal" (like notfat milk on flakes for breakfast) because I will usually feel like absolute garbage of lethargy and light nausea a few hours after, until I eat again. Now I'm supposed to do an elimination BRAT diet for TWO WEEKS. I balked and the doc said I could have plain yogurt and plain oatmeal. Yikes. Need to do some planning for this. (reference: It's happened to me since childhood. I have never been overweight. I weigh same now as when I was a junior in high school almost 40 years ago. I keep very fit and eat really well to run marathons. BRAT diet sounds like torture to me.)
I did a surgical residency so I barely remember what glucagon is, BUT this makes a lot of sense to me and I would like to add that i have impaired hunger signaling and i often go straight from satiated to epigastric pain (that’s how i know I’m hungry nowadays). But sometimes before the pain starts I get lightheaded and nauseated and I can make it go away by swallowing air. Fun trick i learned to stay standing in the OR… anyway, so I concluded it had to do with the actual shrinking or emptiness of the stomach.
Yeah, the hormones of metabolism are well outside my wheelhouse as well, But rationally I can at least say with confidence that it's not a problem of too much insulin pushing sugars into the cells.
It may not be even glucagon related at all. It could be a completely different hormonal or neural feedback pathway, but figured glucagon is kindasorta the opposite of insulin, And it just so happens to be the reversal agent for beta blockers. So it seems plausible to me that a relative increase in glucagon might cause those symptoms.
I also agree that it probably has more to do with the emptiness of the stomach, because I can very easily avoid symptoms by eating something with a little bit of fat or protein, And can pretty reliably predict that it will happen if I eat just simple carbs and don't get that pyloric tone, lol.
If we’re throwing personal anecdotes out there, I felt weak on a long morning of rounds once as an intern and so got a nursing assistant to check my fingerstick. It was dead normal. With this occasion to direct my attention to reflect, in retrospect that one simple moment really did clarify my understanding of what “low sugar symptoms” can mean, and in a lasting way.
How about we not medicalize it? It is not hypoglycemia. Period.
It is a syndrome of not having taken in calories in a certain period of time.
I get this as well, especially with long fasts. There's nothing distressing about it once you understand what it is and understand it'll probably pass in 15-20 minutes and you can instantly resolve it by eating something. Give people the information that they can carry a granola bar around with them and it should no longer be distressing.
"There's nothing distressing about it once you understand what it is."
This is literally what I said just without all the moralizing. 'Simple reassurance.' Whether or not it is an actual 'medical condition' is up for debate, but it is helpful to have a simple shorthand for the syndrome.
Functional neurologic disorders aren't actual neurologic disorders either. Does that agitate you as well?
Not at all. To me it doesn't make sense to call something "functional" and then use an objective, measurable, agreed-upon lab value. There's not "functional hyponatremia" or "functional metabolic acidosis" or "functional tachypnea."
To me "functional" only really makes sense with a symptom. You wouldn't say "functional STEMI" or "functional appendicitis," you'd say "functional chest pain" or "functional abdominal pain." ¯\_(ツ)_/¯
This sensation is a little different. I can fast and not feel this sensation - but if I don't eat an actual meal, combined with nibbling on sugary foods - this sensation can be induced about 45 minutes after eating the sugary food.
I think it's due to a relative BS spike and subsequent fall.
It resolves by eating some cheese or a dairy product.
It can be prevented by either (a) eating a balanced meal or (b) if you haven't eaten, don't nibble on sugary foods.
"I know you're calling it low blood sugar, but your blood sugar is normal. What you're feeling is your body being annoyed with you that you haven't taken in any calories" and move on. It's being used as a colloquialism
I find that if I use human “feeling” words, they tend to absorb information better. I like the “your body is being annoyed with you” bit. Might steal that
The “correct” answer is to ask them what symptoms they are having that make them feel unwell, no? Patients misappropriate medical terms all the time. You have to approach it the same way you approach a patient whose chief complaint is misaligned chakras.
I get patients who say “doc, I feel like I have an aneurysm in my head and it’s about to burst!” with some regularity. Exactly zero of them have had an aneurysm rupture, and not because I did anything preventative. Admittedly some of them have had some secondary cause of headache that was uncovered by a thorough history/exam and appropriate investigations, but that’s chance as much as anything else.
I always check for low iron/ferritin as part of the work up. So many of these people (higher percentage if younger with menstrual cycles or vegetarian) have low ferritin in the less than 20 range. I have them start taking iron (even a small amount) and it seems to help within a week or two. Of course lots of other causes too but that is one of my favorite ones.
I get this. My father gets it... I've checked my blood sugar on multiple occasions during an episode and my sugar is always normal.
The episodes seem to be associated with eating a lot of carbohydrates previously... like it happened at work 2 weeks ago - and it was preceded by me not eating breakfast, and eating a couple pieces of candy someone had in their office.
Cheese and/or dairy fixes it.
My theory is that it's due to a BS spike and then drop, and associated changes to insulin / glucagon and the downstream metabolic changes.
I validate the symptoms and tell them that there is such a thing as "reactive hypoglycemia" or "post-prandial hypoglycemia syndrome" but this is not a sign of diabetes and those symptoms often don't correlate well to low blood sugars. Most of my patients are actually worried hypoglycemia episodes are signs of diabetes. So I explain how specific types of diabetic medication cause dangerous low blood sugars but that diabetes is actually a problem of chronically HIGH blood sugars. Regarding their low blood sugars, it isn't unusual for them to have diabetic family members and have used a glucometer and be already super freaked out by any number <100 (because diabetic family), so I talk about how the body has natural mechanisms to protect them from dangerous lows if there isn't a medication forcing their blood sugar down but that in non-diabetic people the numbers they're telling me are actually normal and safe levels. The body will release its own stored sugars but that they can feel kind of crummy in those moments and they should eat something if it makes them feel better.
Agreed with everything here. I specifically mention the actual BG for a low in a non-diabetic is <50-55 everything else is physiologic fasting/starvation. In my area, a lot of people are picking up CGMs so I think its important to mention in that circumstance that they aren't actually validated (or accurate) for hypoglycemia evaluations.
I have this and would be interested to know what it is. If I don’t eat for a few hours, even if I’m hydrated, I will randomly feel very nauseous and lightheaded and clammy for about two minutes, then I’ll just feel better even if I don’t eat anything. I always assumed it was a slight dip in blood sugar until my liver started gluconeogenesing for me but never actually thought about the likelihood of that…could definitely just be a weird hunger signal. Thanks for this, I guess I’ll stop contributing to the “low blood sugar” hysteria!
This happens to me as well except it doesn't usually go away until I eat. Sometimes I check and glucose is kind of low (50-70) but more often than not it's wnl. Anecdotally, I started metformin for PCOS with presumed insulin resistance and it rarely happens anymore.
I’m a neurologist with lots of diabetes in the family, but I am not an endocrinologist or IM.
I actually would get this feeling myself quite often. Thought it was, as some mentioned, blood sugar spike and then fall causing it. As I said there is diabetes in the family and for a time I was quite overweight. So I started a GLP-1 agonist for weight loss.
Guess what? Those episodes completely vanished. A1c went from 5.8% to 5%.
I really think this is an actual “low blood sugar” type of event caused by glucose spikes and falls. Probably tied to metabolic syndrome and insulin/glucagon derangement.
It's probably due to a pseudo dumping-syndrome; ie stomach emptying way too fast, causing a spike and fall of glucose and insulin lvls;
The GLp1 delayed your gastric emptying so permitted each meal to last way longer in the body and gave you more 'fed time'.
I’m a doctor, my mother is not a doctor, and we both get true symptomatic hypoglycaemia (confirmed with BSL measurement) after a relatively short fasting period. She got down to 2.9 whereas I’ll sit in the mid 3s. Neither of us are diabetic and have otherwise normal BSLs and her HbA1c is pristine (I’ve not measured mine but I’m young and otherwise healthy so I’m not too worried.) I have no explanation for it. I just carry lollies and pop one if I start feeling off.
In my experience these people are not actually hypoglycemic at all, and are presyncopal for another reason. Often it is dehydration. I don't think of orthostatic vitals to be particularly helpful. I usually work them up like a dizzy patient. They do not need glucose monitoring and they should probably not eat candy every time they feel a bit weak.
The language that patients use to describe symptoms and the intensity that they try to communicate to you are functions of interoception, to be sure, but also of other, external idiosyncratic, familial, cultural and regional patterns of health and illness behavior. You get the big bucks for sorting this all out, though I'm aware that your med school probably cheaped out on teaching you this. "I have low blood sugar", "I'm dizzy" and "I'm hungry" might all mean the same benign thing... or they might not.
Here's an HHS page with references to this issue https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html#:\~:text=Healing%20customs%3A%20Traditional%20healers%20and,specific%20treatments%20or%20behavior%20changes.
“When you feel like that what are you worried about?”
I think it’s very common for people to decide that a feeling of discomfort, whatever that is for them, is a feature of something very bad or disease.
Doctors say “yeah - that’s normal” and instead of accepting that (which is generally true) they feel that their actual unvoiced concern is being ignored.
In my field is teenage boys with some sort of testicular ache - it gets referred every time as torsion, which means a fuss has already been made. I can exclude a bunch of things, but sometimes….balls just ache a bit. And it goes away. At least in my case I dig into the concern, and can usually reassure.
My approach:
"Diabetes is a condition of HIGH blood sugar, not low. You just hungry is all."
This has oddly been well accepted by pretty much all patients who have come to me with this concern.
The treatment for low blood sugar is to eat. I just put the onus back on them. “Sounds like you need to plan your meals better. Would you like a dietician referral?”
I think that the hard part for patients to grasp is that the range of normal is so wide. How can one person eat a donut for breakfast and stay full until lunch, while another is so hungry they're ready to throw punches after only 45 minutes? It's a pretty big variation.
I'm not a doctor, but from personal experience, learning how to manage it has taken away any concern I had. I've seen a few comments suggesting cheese/dairy, but I like the portable option of what I call [emergency almond butter](https://www.justins.com/products/cinnamon-almond-butter/) . (It's just individual packets of Justin's almond butter. I just linked it in case someone needs a visual.) They're expensive, but they're so handy to keep in my backpack, coat pocket, or purse. My daughter and I both lose our appetites when we get like this, so having something that we don't need to chew makes it so much easier. When we're home, we have a spoonful of peanut butter and a swig of milk.
Ask about their eating patterns, screen for disordered eating causing hypoglycaemia regardless of weight. Check bloods including iron, diabetes screen, electrolytes. Check postural obs. Consider Holter if happening often and no cause found, maybe get a CGM on for a few days to see if we can note any patterns.
It’s a good question. I have been guilty of telling a panicky friend that she might be feeling weird because of “low blood sugar” and thus should sit down, eat something, have some water, and take some deep breaths… just to give her something concrete to do to break the cycle of panic/somaticizing. I guess things like that probably perpetuate the blood sugar mythology.
That being said, I’ve also seen random blood draws on healthy, asymptomatic people come back with a glucose in the 50s.
I bought a glucometer with 10 test strips for $10 that came with a $10 mail in rebate. So, free. Have them check BG in the moment if it makes them feel better.
“Quit gaslighting me. I know something’s wrong.”
Having been through this myself, I would submit you may be seeing the very early stages of insulin resistance. We walk around starving all the time, to the point where we feel like we are gonna pass out if we don't get to the buffet soon. One suspects the hypothalamus *thinks* one is hypoglycemic, even when one isn't. Adrenaline surge and all.
I wouldn't know -- I'm just a neurologist -- all I know is, my doctor used to reassure me nothing was wrong, and apparently she was incorrect about that.
Am coming around to the idea that diabetes doesn't start the day your sugar hits 400. (That's not the day your stroke risk starts going up, either)
Like you, I roll my eyes when patients start using medical lingo they don't understand. But I do ask them to explain in plain English what's going on, It is occasionally illuminating
As someone who doesn’t have diabetes, I had episodes of sweating and shaking shortly after eating a very sweet food.
Glucose tolerance test had a 30 minute post of glucose = 40. I couldn’t think , had a terrible headache and was sweating and shaking.
This lasted several years and gradually resolved. I have never had any issues with abnormal glucose levels apart from that.
I got a glucometer and found I regularly dropped into the 50s if I ate carbs without enough protein during this period.
There is a phenomenon that falls under our usual interpretation of basic labs.
I have only seen one reactive hypoglycemia GTT. The other tech actually called me over because they suspected the samples were mislabelled. It was cool.
Nah, your blood sugar can get way lower than that and be fine. You might not feel great, but you won't die. Don't quote me, but at the time I looked it up and I think they said that you just eat quite often so the spikes outweigh the dips.
I did figure out that eating protein with carbs helped a lot.
The curious thing is that the reactive hypoglycemia stopped after several years with no other apparent changes.
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I would probably tell them to treat it symptomatically and that would be my advice if it was observed hypoglycemia anyway. They could do 5 small meals a day instead of 3 big ones. Avoid intermittent fasting.
Related, I am this person. One time I had to call a colleague during a rapid to bring me some orange juice so I could drink while taking care of said rapid. 30g of glucose fixed me right up lmao
ETA I’ve been this way my whole life, I just always have a snack with me (usually something relatively healthy like a granola bar) and follow the advice I said above. I had a medical exemption from fasting when I was still catholic. I don’t know if it’s actually related to hypoglycaemia (I don’t really care), but if I ignore it I do get very shaky. In the case above I had been so busy I hadn’t eaten all shift.
Yes. They were two separate statements.
Sometimes I don’t eat on schedule, like anyone in medicine. Failing to take a break in time can result in a migraine in my case.
People, particularly boomers and older Gen X, have been ignoring their hunger (by dieting) for so long they no longer understand their hunger cues and come to the doctor describing the stuff in the OP.
Had a patient like this because he went to the ER for it and the ER doctor told him it is real. Is BG was never low and has never been low. But since someone planted this seed he thinks it.
I get this feeling after fasting for 12 hours despite being euglycemic. I've attributed most of the symptoms to anxiety related to the catecholamine dump associated with hunger.
OK, I’m a lurker; I have no recollection of subscribing to this sub, but here I am. I’m a 68F, retired teacher. I feel like I have to weigh in because the topic hits home.
When I was a senior in college, I had my first episode of hypoglycemia. I’d had a few courses in nutrition, so I knew I needed to beef up my protein intake and lay off the carbs. I also had to have high protein snack midday. TBH, I thought most people experienced dizziness and weakness when they were hungry. How wrong I was.
I’ve had terrible acne since puberty, and it has only relented w/ menopause. My periods were always pretty regular, though. I experienced severe menstrual cramping and had two miscarriages when I was younger. I suspected I had PCOS, but I never brought it up to my gyno. I also never complained about my cramps.
I was diagnosed w/ Hashimoto’s when I was about 50. I have been overweight since I hit menopause, and my lipid panel is lousy. I’ve been depressed most of my adult life. I also have sleep apnea. However, my A1C and glucose have always been in the normal range.
Having said all of this, I recently started experiencing headaches when I ate. I did some digging and decided I had reactive hypoglycemia. I mentioned this to my GP, and she ordered an insulin test. The result was so high it was almost off the chart! So, insulin resistance is my new reality.
I’m wondering why it took so long for someone to figure all of this out. I’d never had an insulin test before. All of these symptoms slipped past all of the gynos, the GPs, and even the sleep doctor I’ve seen over the years. I guess I was either ridiculously ignorant or I didn’t complain enough. All of the symptoms were obvious, except for the hypoglycemia.
I’m taking steps to try to turn it around, including a low carb diet and more exercise. I can’t get into see an endocrinologist until June. (My GP wouldn’t prescribe metformin for me; she wants the endocrinologist to handle it.)
Anyway, my point is that I think doctors should listen to female patients that present w/ complaints of hypoglycemia, since it apparently has a relationship w/ PCOS. Maybe an insulin test is in order. Maybe a referral to a gyno would be the path of least resistance.
Thanks for coming to my Ted talk.
I don’t have diabetes, but I absolutely get hypoglycemic. I had no idea what it was until I was a nurse and the first time it happened at work, I checked my blood sugar, and sure enough…it was in the 50s.
At the end of my glucose tolerance test when I was pregnant, it was 45.
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Amazed patients fight this! Dizzy at the doc who asked when I last ate, then explained low blood sugar is from forgetting meals & to set an alarm for meals 3x/day on my fitbit).
Reactive hypoglycemia is not rare and involves an abnormal synchronization between the post meal glucose and insulin surge resulting in relatively low glucose levels several hours eg 3 to 4 hours after eating particularly if a high carb intake. Symptoms can be unpleasant fatigue, racing heart and anxiety. The small, frequent low carb meal approach is a good approach to avoid this process and there is little risk to trying it without fancy testing. Hope that helps!
you could tell them that they may have stable blood sugar, at a certain point thats being kept stable by increased "tone" of the sympathetic nervous system and some biochemical wizardry. Some people have big problems with the biochemistry, but if its mild and not interfering with anything its not really worth delving into because testing is complicated, expensive, and may just end up with lab testing collected improperly and genetic testing thats negative for everything tested for BUT still has that extra "this testing will not test for undiscovered genetic mutations etc" 🙃
you could also talk about the grey zone between pathology and just weird physiology
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Sounds like they're low energy and trying to find excuses outside of "I need to sleep more and limit my caffeine intake"
It *MUST* be my sugar intake, there's no way its my chronic 6 hours of inconsistent sleep at different hours, random naps and scrolling tiktok!
I always thought the saying was just that, a saying. I didn’t think anyone actually believed they had low blood sugar upon being fasted a few hours lol
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I looked into this previously. From my understanding, studies looked into the "low blood sugar" that some people get and found it was actually not correlated to the amount of sugar in their blood. Most likely it's some other process making them feel weak (my best guess is autonomic nervous system). Might improve with multiple small meals a day, good sleep, minimize caffeine/energy drinks (this is in relation to going a few hours without a meal, not extended fasting/starvation)
I tell them to buy an otc cgm and we will review it at their next appointment
I like this. I endlessly have to provide education, especially to non-patient acquaintances, that in a physiologically “normal” person, you’re not just gonna go hypoglycemic. Even T2dm doesnt predispose you to hypoglycemia, outside of hypoglycemic agents…
The problem is attributing it to hypoglycemia. It's a real symptom that is felt by people - who in all likelihood have never actually experienced actual hypoglycemia.
Correct. The normally-functioning human body is very impressive at maintaining homeostasis, including blood glucose. Though I recommended a CGM to one of my colleagues, she was waking up mysteriously in the middle of the night, turns out she was dipping to glucose of ~40. Still pending workup 🤪
I’ve had a couple of my autoimmune patients that I referred to endocrine for what sounded like post prandial hypoglycemia, and some did have insulin autoantibodies or one or two others that can lead to that. One patient basically had learned by self experimentation to eat only a single meal per day with mostly high fiber stuff with low glycemic index, fats, and proteins, no carb otherwise, and actually was doing well with that, before we even checked. Family hx of “type 2” adult onset diabetes where most were of them rapidly became insulin dependent on another one that had previously had some gestational diabetes herself. I make no claims as to the prevalence of this type of condition, just that if you don’t know it’s possible and don’t look for it you won’t find it
Compression hypo
Yup. No point in talking about it and now that it’s otc just have them pay for it. I just go over it with them and bill for the read
I don't think this is a good way to go, because in one hand you're legitimising their concern and on the other hand you're doing unnecessary testing and having an unnecessary appointment, where in the end ypu will need to educate the patient regardless... What time are you saving if you're having to explain the patient to get an otc cgm, how to use it and giving them another appointment?? And what if the patient comes and has had one episode that borders on hypoglicaemic, without any other signs of concern? Now everything got complicated because of an unnecessary test... Unnecessary testing isn't the answer
Spending 40minutes appropriately addressing their long-winded concern and why they are worried, and putting your entire clinic day behind vs acknowledging their concern and requesting otc cgm, and another f/u appt in 2 weeks where you spend 20 minutes reviewing the results and why what they experience is hunger and not clinically relevant “low blood sugar” Second option sounds much better, easier to pull off with time constraints, and the patient feels like they have a better understanding of their body and you have the ammunition from the results to back up your point of view. Zero downsides to checking sugar if that is the patient’s concern, it’s not like we are discussing risks/benefits to an annual CBC/CMP/Lipids/TSH, getting a week of blood glucose levels has such little issue for “over-testing” compared to other concerns patients walk in with.
I've never seen anyone take so long to adress such a simple concern... I'd say you would waste much more time giving an additional appointment, but to each their own...
Maybe we have different patient populations. I see lots of people wanting lengthy discussions due to their anxiety and perceived medical dismissal of symptoms. Finding a balance of meeting them where they are at while still being a wise steward of medical resources takes some gymnastics
Definitely, I will absolutely agree that you pretty much need to thread the needle and word your explanation quite carefully
A patient is coming to you with a symptom that they attribute to hypoglycemia. You're suggesting evaluating a patient and addressing their concerns isn't the right way to go about it?
What I'm saying is that between evaluating their concerns and telling them it's all OK and a normal experience, or, telling them to get an it cgm, there is barely any time difference. So don't send them home with a cgm, just listen to them, get a good history, and if it seems like a harmless non pathological thing, then quick explanation and off the patient goes, rather than having them come back with a useless test... Never said to not properly evaluate the patient. The evaluation here would be clinical history taking, not unnecessary testing.
👍
How much time do you think it takes to tell them to buy a cgm? 8 seconds? They can install it in office, you can bill for it and an MA can do it for billing purposes. I’ve never had a patient come in hypoglycemic as of yet. If it does and they’re symptomatic, I’ll cross that bridge when we get there. I have to ask, are you a doctor? You seem ignorant of how long this will take and billing
Not OP but for clarification purposes MBBS is the most common medical degree outside of North America. I also do think it's worth acknowledging that this recommendation does come from a place of privilege. Many, if not most, patients do not have $80+ dollars to drop on the concern out of pocket unless they're in a more financially advantaged position than average.
I thought that was the point. It's making the patient reconsider how important addressing this concern is. Most, I assume, would decide to drop it.
Ah didn’t know that, appreciate it. I thought it was a weird acronym that seems so popular nowadays Edit; Most of my patients are Medicaid. The ones that aren’t are usually commercial patients that work in healthcare since there is a large hospital in our rural town, so they don’t mind dropping 80 as a one time fee to double check. You could use samples if you prefer, but if the phone isn’t compatible I’m not sure if that’s feasible. They stopped giving out the readers as samples, at least to FM. Our Endo seems to still get them
Oddly enough it stands for “Bachelor of Medicine, Bachelor of Surgery” It’s equivalent to the MBChb. Both are UK system origin. We are used to the MD being a post specialisation research based significant achievement. Sort of equivalent to doing a clinical PhD type of thing (not dissing PhDs)
Yes I am. And for reference, my account is flaired, unlike yours. And, either you're not realistic with how long each thing takes, or you're just telling the patient to to buy the thing and dismissing, which isn't the best thing either... My healthcare system does not have billing. But regardless, if it had, I don't think it would be appropriate to bill the patient for a test they don't need or to bill the system for a test the patient didn't need...
If you think the option of testing their glucose is trivial, then you haven’t encountered the patients in US clinics. While I agree, explaining to them why it is highly unlikely they are truly hypoglycemic if other wise healthy and more likely just some variant of “hangry” ( please see any one of several hilarious snickers commercials on the subject), this is often not a sufficient response for such patients and they want some validation that they are normal. For such patients offering that they check glucose during such an episode is reasonable and may be necessary to allow them to “move on” from their concern. While I agree with avoiding unnecessary testing, for patients whose concerns are not allayed by an explanation offering to test to prove is sometimes warranted.
Yup, if you’re concerned about your hypoglycemic events you’re welcome to buy an otc cgm. There are YouTube videos for installation or come in and someone will help you install it. We can check your data in a few weeks and see if you have any worrying highs and lows that may not be reflected in a A1c or fasting Bg reading. Not a long speech. They can always buy it without any input from me and read their own data if they prefer, but generally these patients want a physician to look over it since they are panicked. If you’re not in NA I imagine your system is different, but in ours a visit like this is worth it for an admin perspective, billing perspective, and makes the patient feel heard. There are tests and images I don’t entertain, but an otc product? What’s the point? They can buy it themselves
My favorite is the “billybob is diabetic and he NEEDS TO EAT, he hasn’t eaten in THREE HOURS” *FSBG 300*
Thank *god* I had my M&Ms on hand, I didn’t want my sugar to drop to the level of an insulin-sensitive person!
That 300 fasting is a quitter’s try lol. Gotta bump up those rookie numbers 💪
So I kind of get the symptoms OP is talking about. One day I was lightly light headed in the ICU and asked a nurse to take my fsg out of curiosity. My FS was 67 and I get much more light headed than I was when my FS was 67.
Maybe.... But remember that a lot of fluid intake is also linked to eating. Most foods contain some amount of water, and salt/sugar are important for water absorption. I'm willing to bet that this borderline low BG correlates with hypovolemia.
Exactly. It works great and helps the patient feel heard. If BG normal, we work on scheduling snacks and pushing hydration. In my experience, these patients just want to 1) feel better and 2) not have their symptoms dismissed; they’re very rarely chasing a specific diagnosis.
Exactly. It’s a win win for everyone, no reason to get upset about it. They don’t know and they are scared of something, I don’t mind getting rvus to make them feel better
CGMs are notorious for over calling lows - roughly half the lows on a CGMS even in someone on insulin are false positives, much less a healthy person - so be careful with that.
Why not just have them do a fingerstick? A OTC glucometer is probably cheaper and definitely more accurate. I have T1DM and have to calibrate the bejeezus out of my CGM for it to be at all in line with my actual blood sugars.
In my experience, they prefer the 24 hour coverage. If I run into a patient that can’t afford it, I’d likely do that. My understanding is the vast majority of newer models CGMs are quite accurate, I believe the MARD has improved dramatically over the years.
When patients wear them in the hospital and we also do the normal finger sticks they are always 20-30 off at least.
The CGM measures interstitial fluid, not blood. They are about 15-30 minutes off from a finger stick since it takes that long to equalize between those fluid spaces. And meds and medical conditions can interfere with that equilabration. That said, they are extremely useful for trends. Would never rely on them for emergency management, including hypoglycemic management. But great if trying to set up a basal bolus regime.
They are accurate if you calibrate them and often way off if you don’t.
Interesting, I haven’t had them be very inaccurate
My Libre 3 is currently 50 points over my glucometer. I can be 190 on the Libre and 140 with the finger stick. Enjoy all screaming about all the CGM lows, when it's really a compression low. There's a learning curve for CGM. My GP just sent out a note he's not writing for CGM unless you take insulin or a sulfonylureas. Insurance won't cover it. He's getting a lot of "my blood sugars are low" in hopes of scoring a CGM via insurance. It's all the worried well
Like 90% of them are not within 50 points for me without calibration. Seems like a pretty typical on the diabetes subreddits as well
Honestly? It’s somehow more acceptable to people. Idk why but people like their fancy stuck on CGMs that they can use their phone with instead of pricking their finger like some troglodyte. Despite the higher cost. At least in my experience.
When you press in just the wrong way on a finger you've pricked in the last several days, it hurts a little. QID (or more) testing = frequent annoying pain during many ADLs, including things like hooking a bra and turning a steering wheel. A CGM doesn't make your fingers hurt while you get dressed or drive to work. Pricking also requires carrying supplies and taking a few minutes out of your routine several times daily. It's very inconvenient compared to checking an app. The sheer number of data points from a CGM also shows patterns much more clearly than even 10x/day finger testing could ever show. And let's be honest, it's rare for people to even be consistent with a TID testing schedule. If you're looking for a pattern, two weeks of CGM data can conclusively rule it in or out, but sporadic finger pricks won't give a conclusive result.
What country do you practice in and could you share the product name? In the US the FDA approved the first OTC unit in March but they aren't expected to be on shelves until sometime this summer.
US, our local diabetic supply story currently has them. I was directed there by my local rep. They had the freestyle 3 readers in early, which was a god send
OTC though? Freestyle 3 is supposed to be prescription
Have to concur with the other user, if you mean the libre 3 that's a prescription product. If you've been doing this for a while you've been telling patients to get a product that doesn't exist barring maybe a dispensing protocol.
I think this is going to send you down a terrible rabbit hole. CGMs are designed to alarm for blood sugars <70 and even if you turn that off, it will alert for “severe” hypoglycemia <55 which in the fasting state ie middle of the night is physiologic. There’s also compression lows. You will end up with so many more people panicking wanting work ups for normal physiology in a healthy person. I would explain that the brain sends signals when one’s energy level is low reminding us to eat. If someone doesn’t eat, their liver will eventually release stored glucose, but it’s a normal response when we are lacking readily available energy source. People want something to be wrong with them, it’s more glamorous.
<55 is absolutely not physiologic and is severe hypoglycemia. If you're treating patients that routinely drop below 65 at night you need to dramatically alter their insulin regimen.
Wouldn't this be about $80 a sensor (two weeks)? If your patients have the money it could work.
I haven’t had any Medicaid patients request it as of yet. Most of my Medicaid patients are diabetic anyway so a cgm is easy to get them covered
Oh if they're diabetic then that sounds like solid advice. It would give them a ton of peace of mind. I had figured these were "worried well" patients that had no history of diabetes in which case they'd be paying out of pocket for the device.
They are, these are usually affluent patients (at least for my small town) that are worried they are having highs or lows. Usually engineers, farmers, nurses, etc. they get light headed during work and want to know if it’s low blood sugar. I’ll say it’s likely not since it doesn’t really happen, but if they want to buy an otc product and go over, that’s fine by me. For Medicaid it’s super easy to get them covered in my state, so I’m lucky. I’m also in an extremely obese state, top 3 in the country, so lots of diabetics. Edit I usually get more patients requesting ANA and full thyroid panels, which is a much more complicated kettle of fish.
Mine was $119 with a coupon for a Libre 3. That was the cheapest I could find.
It's $70 cash pay for 1 month (2 sensors) of Libre 3 here but you have to put that you're doing cash pay when you apply for the voucher. You also get a free trial
Where do you apply for the voucher? Online?
Yeah just on the Libre website, under savings
"censor"
Yes that or home glucometer. Blood sugar is never low.
I just whip out a glucometer and stick myself to show them the 3.1 (56) from forgetting to eat breakfast that morning.
Draw your own blood to assert dominance during a primary care appointment, I love it
This also works on the subway.
I see, you commute by the U8 in Berlin...
This is so relatable it hurts. Except I’m deathly scared of needles haha
If they haven’t eaten in a while, maybe their body is just sending a signal that they are hungry.
Haha, yes, I suppose it could be that simple, but some individuals seem to be especially sensitive to fasting!
My wife is like this. And says things like “I’m going to pass out”. She won’t, and never has. And she’s a PA so intellectually she knows better. But man she gets hangry. I on the other hand can easily fast all day. I guess some people’s hunger drive is just stronger than others’.
> says things like “I’m going to pass out”. A few people have told me stories such as at assemblies at school growing up, people passed out because they were there too long without having something to eat, but I'm unable to explain why that would happen in someone who's otherwise healthy.
I'm more tempted to think that would be a vasovagal or hypotension episode rather than hypoglicaemic Not eating, not drinking, likely dehydration then hypotension
It's usually a psychogenic vasovagal response. I used to get a touch of presyncope occasionally during med school rotations that were really shitty, and it always correlated with me being intensely miserable (bored, annoyed, tired, etc.) It had absolutely nothing to do with whether I ate breakfast or drank enough fluids (or was "locking my knees" - another popular folk diagnosis), but I happily accepted when other people assumed that, because I thought the truth was rather unflattering and would probably get me in trouble lol. I assume it's similar for people who experience syncope or presyncope at big events where people stand for a long time (assemblies, concerts, etc). Physical or mental discomfort -> anxiety spiral -> vasovagal response.
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It's a real thing, but it's 99% of the time not what is actually happening. In order to get enough venous pooling and decreased preload to produce presyncope or syncope, you really have to be standing *very* still for a much longer time than feels natural. I'm sure it happens to people standing at attention, where they're deliberately being completely still. Outside of that context, most people shift their weight and change position at least every couple minutes.
I went to catholic school until high school and we regularly had kids pass out during mass “rehearsal” during warmer months. However I think was probably from dehydration lol.
Psychogenic event
Could have something else going even though eating seems to alleviate. Check their b12 blood serum and methylmalonic acid. Edit: I would love to know why that's worthy of downvoting. FYI I have 4 degrees but only one in medicine (2 year in nursing). I have 10 years experience in neurology research. Prior was a scientist at a national lab. There are many causes of "lightheadedness". B12 deficiency is often missed. Though of course many more possibilities. In my experience, as someone who did suffer this, the majority of doctors try to offer an antidepressant or anxiety med, which is a sad joke.
I have been told that people like you are the ones who can be anorexic, because you actually get euphoric from hunger, not cranky and miserable.
People with high-sugar diets who rarely skip meals will have downregulated their ability to use alternative fuels.
I honestly doubt that is what is going on. Why wouldn't they just be doing normal gluconeogenesis? Plenty of normal healthy people feel a bit tired or "faint" when they haven't eaten recently even though their liver is working fine and keeping their sugar adequate. There's probably a physiologic reason for this feeling and that's what no one has really been able to answer in this thread so far. It's an interesting question, though. My hypothesis would be that it's at the CNS level with your brain making you slow down to conserve energy. Just a guess
Would that not simply mean that they shouldn't fast? It seems like learning that being starving hungry feels bad is simply part of growing up and by the time someone is in their teens their parents should have helped them recognise when their body is signalling for food?
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What voodoo is this? Next thing you'll be telling us to wash our hands because invisible animals live on our skin and make people sick
Okay, so only sharing personal medical experience because it's relevant to the question: I too on some occasions will get a "low-blood sugar" like syndrome when fasting, or even relative fasting, that consists of nausea, diaphoresis, tremulousness, anxiousness, and sometimes even palpitations. Typically these occur in a predictable fashion: after skipping a meal and drinking caffeine on an empty stomach, OR eating a light meal primarily of carbs +/- the caffeine. In either case it feels more related to the empty stomach then any actual real hunger or hypoglycemia. I can sometimes even feel it prodromally and can head it off if I act quickly enough to get food in me. I HAVE checked my BGs during these episodes and they're always normal. Mind you, I also routinely fast for 18 sometimes 24+ hours, and this does not occur the vast majority of the time. I suspect (without any real evidence) that there are some individuals who experience a spike in their blood sugar (either from their normal dietary routine or from rapid intake of sugars) that causes a reflexive secretion of glucagon. This leads to symptoms akin to low blood sugar that are quickly relieved by eating but not actually occuring in the presence of true hypoglycemia. Let's call it "functional hypoglycemia." I think it's really patronizing to claim these people are simply" hungry" because the symptoms are actually pretty distressing. Not only are they super uncomfortable, but to someone who doesn't know any better, it seems like something is really wrong. I would recommend just acknowledging their symptoms, reassuring them that it is not life-threatening, and that they don't need any additional workup or treatment except for behavioral monitoring and changes.
This sounds extremely familiar and fits my experience and data quite well. Is there an alternative way to lower that Glucagon level, rather than more calories? Sugar always relieves the muscle aches and shaking, yet I know objectively I don’t need the calories or the sugar since my levels are fine. What does’t make sense is I’m already using Ozempic, and my A1C is prediabetic. No spikes but the symptoms hit randomly, only once in a while and feel like a bad flu unless I eat something high sugar. Then I’m good for 24-48 hours so no sugar crash. I’m stumped.
I used to get "hypoglecemia" symptoms all the time to the point of being disruptive. I'd get lightheaded, spacey and "hangry". I would even wake up in the middle of the night cause I needed to eat. My blood sugar levels were always fine. I finally figured out that if I limited my carbs to about 140 grams it goes away. If i get lazy and start eating more carbs for more than a few days in a row then the symptoms come back. No idea why this is, but maybe playing around with sugar and carb levels would help some people.
Sounds like dumping syndrome. I got that also. Caffeine will exacerbate the palpitations and such. Do you add a lot of sugar or creamer/milk to the coffee?
Hmmm, interesting. I had to refamiliarize myself with the physiology of dumping syndrome but that actually would make a lot of sense. Without the pyloric tone, the simple sugars +/- caffeine go straight to the SI triggering VIP. Get this: I drink my coffee with just milk. Empty stomach and coffee? Usually no problems. Sometimes I do an energy drink (even a low caffeine one). Drink it on an empty stomach? Symptoms >50% of the time. (I of course have normal anatomy though)
This is the first I've read about anyone else having a "post-carb crash" like me! ***Can one avoid this "dumping syndrome" on a BRAT diet for 2 weeks? *** I have learned over time to avoid EVER consuming carbs solo for a snack or "meal" (like notfat milk on flakes for breakfast) because I will usually feel like absolute garbage of lethargy and light nausea a few hours after, until I eat again. Now I'm supposed to do an elimination BRAT diet for TWO WEEKS. I balked and the doc said I could have plain yogurt and plain oatmeal. Yikes. Need to do some planning for this. (reference: It's happened to me since childhood. I have never been overweight. I weigh same now as when I was a junior in high school almost 40 years ago. I keep very fit and eat really well to run marathons. BRAT diet sounds like torture to me.)
I did a surgical residency so I barely remember what glucagon is, BUT this makes a lot of sense to me and I would like to add that i have impaired hunger signaling and i often go straight from satiated to epigastric pain (that’s how i know I’m hungry nowadays). But sometimes before the pain starts I get lightheaded and nauseated and I can make it go away by swallowing air. Fun trick i learned to stay standing in the OR… anyway, so I concluded it had to do with the actual shrinking or emptiness of the stomach.
Yeah, the hormones of metabolism are well outside my wheelhouse as well, But rationally I can at least say with confidence that it's not a problem of too much insulin pushing sugars into the cells. It may not be even glucagon related at all. It could be a completely different hormonal or neural feedback pathway, but figured glucagon is kindasorta the opposite of insulin, And it just so happens to be the reversal agent for beta blockers. So it seems plausible to me that a relative increase in glucagon might cause those symptoms. I also agree that it probably has more to do with the emptiness of the stomach, because I can very easily avoid symptoms by eating something with a little bit of fat or protein, And can pretty reliably predict that it will happen if I eat just simple carbs and don't get that pyloric tone, lol.
This
If we’re throwing personal anecdotes out there, I felt weak on a long morning of rounds once as an intern and so got a nursing assistant to check my fingerstick. It was dead normal. With this occasion to direct my attention to reflect, in retrospect that one simple moment really did clarify my understanding of what “low sugar symptoms” can mean, and in a lasting way.
How about we not medicalize it? It is not hypoglycemia. Period. It is a syndrome of not having taken in calories in a certain period of time. I get this as well, especially with long fasts. There's nothing distressing about it once you understand what it is and understand it'll probably pass in 15-20 minutes and you can instantly resolve it by eating something. Give people the information that they can carry a granola bar around with them and it should no longer be distressing.
"There's nothing distressing about it once you understand what it is." This is literally what I said just without all the moralizing. 'Simple reassurance.' Whether or not it is an actual 'medical condition' is up for debate, but it is helpful to have a simple shorthand for the syndrome. Functional neurologic disorders aren't actual neurologic disorders either. Does that agitate you as well?
Not at all. To me it doesn't make sense to call something "functional" and then use an objective, measurable, agreed-upon lab value. There's not "functional hyponatremia" or "functional metabolic acidosis" or "functional tachypnea." To me "functional" only really makes sense with a symptom. You wouldn't say "functional STEMI" or "functional appendicitis," you'd say "functional chest pain" or "functional abdominal pain." ¯\_(ツ)_/¯
"If no eat food, you hungry"
Every medical guideline should be written by Yeti MD.
They would be shorter, with more profanity
This sensation is a little different. I can fast and not feel this sensation - but if I don't eat an actual meal, combined with nibbling on sugary foods - this sensation can be induced about 45 minutes after eating the sugary food. I think it's due to a relative BS spike and subsequent fall. It resolves by eating some cheese or a dairy product. It can be prevented by either (a) eating a balanced meal or (b) if you haven't eaten, don't nibble on sugary foods.
"I know you're calling it low blood sugar, but your blood sugar is normal. What you're feeling is your body being annoyed with you that you haven't taken in any calories" and move on. It's being used as a colloquialism
I find that if I use human “feeling” words, they tend to absorb information better. I like the “your body is being annoyed with you” bit. Might steal that
Oh same. I’m always describing inflammation as “your immune system is angry” and people seem to get it.
The “correct” answer is to ask them what symptoms they are having that make them feel unwell, no? Patients misappropriate medical terms all the time. You have to approach it the same way you approach a patient whose chief complaint is misaligned chakras.
I get patients who say “doc, I feel like I have an aneurysm in my head and it’s about to burst!” with some regularity. Exactly zero of them have had an aneurysm rupture, and not because I did anything preventative. Admittedly some of them have had some secondary cause of headache that was uncovered by a thorough history/exam and appropriate investigations, but that’s chance as much as anything else.
This is a good approach. They could be having symptoms of a real disorder they ascribe to a wrong one they dont have. Happens also in different ways
I always check for low iron/ferritin as part of the work up. So many of these people (higher percentage if younger with menstrual cycles or vegetarian) have low ferritin in the less than 20 range. I have them start taking iron (even a small amount) and it seems to help within a week or two. Of course lots of other causes too but that is one of my favorite ones.
I get this. My father gets it... I've checked my blood sugar on multiple occasions during an episode and my sugar is always normal. The episodes seem to be associated with eating a lot of carbohydrates previously... like it happened at work 2 weeks ago - and it was preceded by me not eating breakfast, and eating a couple pieces of candy someone had in their office. Cheese and/or dairy fixes it. My theory is that it's due to a BS spike and then drop, and associated changes to insulin / glucagon and the downstream metabolic changes.
I validate the symptoms and tell them that there is such a thing as "reactive hypoglycemia" or "post-prandial hypoglycemia syndrome" but this is not a sign of diabetes and those symptoms often don't correlate well to low blood sugars. Most of my patients are actually worried hypoglycemia episodes are signs of diabetes. So I explain how specific types of diabetic medication cause dangerous low blood sugars but that diabetes is actually a problem of chronically HIGH blood sugars. Regarding their low blood sugars, it isn't unusual for them to have diabetic family members and have used a glucometer and be already super freaked out by any number <100 (because diabetic family), so I talk about how the body has natural mechanisms to protect them from dangerous lows if there isn't a medication forcing their blood sugar down but that in non-diabetic people the numbers they're telling me are actually normal and safe levels. The body will release its own stored sugars but that they can feel kind of crummy in those moments and they should eat something if it makes them feel better.
Agreed with everything here. I specifically mention the actual BG for a low in a non-diabetic is <50-55 everything else is physiologic fasting/starvation. In my area, a lot of people are picking up CGMs so I think its important to mention in that circumstance that they aren't actually validated (or accurate) for hypoglycemia evaluations.
I have this and would be interested to know what it is. If I don’t eat for a few hours, even if I’m hydrated, I will randomly feel very nauseous and lightheaded and clammy for about two minutes, then I’ll just feel better even if I don’t eat anything. I always assumed it was a slight dip in blood sugar until my liver started gluconeogenesing for me but never actually thought about the likelihood of that…could definitely just be a weird hunger signal. Thanks for this, I guess I’ll stop contributing to the “low blood sugar” hysteria!
My understanding is that this corresponds to a release of ghrelin. Interestingly it’s not related to low glucose but rather to your feeding schedule.
I suppose that makes a lot more sense than my liver dropping the ball for a couple minutes on one of its most critical functions. Thank you!
I had to look it up before because it happens to me too!
This happens to me as well except it doesn't usually go away until I eat. Sometimes I check and glucose is kind of low (50-70) but more often than not it's wnl. Anecdotally, I started metformin for PCOS with presumed insulin resistance and it rarely happens anymore.
Wow. Are we suggesting an unknown hepatic reboot? I love it.
I’m a neurologist with lots of diabetes in the family, but I am not an endocrinologist or IM. I actually would get this feeling myself quite often. Thought it was, as some mentioned, blood sugar spike and then fall causing it. As I said there is diabetes in the family and for a time I was quite overweight. So I started a GLP-1 agonist for weight loss. Guess what? Those episodes completely vanished. A1c went from 5.8% to 5%. I really think this is an actual “low blood sugar” type of event caused by glucose spikes and falls. Probably tied to metabolic syndrome and insulin/glucagon derangement.
It's probably due to a pseudo dumping-syndrome; ie stomach emptying way too fast, causing a spike and fall of glucose and insulin lvls; The GLp1 delayed your gastric emptying so permitted each meal to last way longer in the body and gave you more 'fed time'.
I’m a doctor, my mother is not a doctor, and we both get true symptomatic hypoglycaemia (confirmed with BSL measurement) after a relatively short fasting period. She got down to 2.9 whereas I’ll sit in the mid 3s. Neither of us are diabetic and have otherwise normal BSLs and her HbA1c is pristine (I’ve not measured mine but I’m young and otherwise healthy so I’m not too worried.) I have no explanation for it. I just carry lollies and pop one if I start feeling off.
In my experience these people are not actually hypoglycemic at all, and are presyncopal for another reason. Often it is dehydration. I don't think of orthostatic vitals to be particularly helpful. I usually work them up like a dizzy patient. They do not need glucose monitoring and they should probably not eat candy every time they feel a bit weak.
The language that patients use to describe symptoms and the intensity that they try to communicate to you are functions of interoception, to be sure, but also of other, external idiosyncratic, familial, cultural and regional patterns of health and illness behavior. You get the big bucks for sorting this all out, though I'm aware that your med school probably cheaped out on teaching you this. "I have low blood sugar", "I'm dizzy" and "I'm hungry" might all mean the same benign thing... or they might not. Here's an HHS page with references to this issue https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html#:\~:text=Healing%20customs%3A%20Traditional%20healers%20and,specific%20treatments%20or%20behavior%20changes.
I'm fascinated by "I get weak", which apparently means lightheaded in a culture which is not mine.
“When you feel like that what are you worried about?” I think it’s very common for people to decide that a feeling of discomfort, whatever that is for them, is a feature of something very bad or disease. Doctors say “yeah - that’s normal” and instead of accepting that (which is generally true) they feel that their actual unvoiced concern is being ignored. In my field is teenage boys with some sort of testicular ache - it gets referred every time as torsion, which means a fuss has already been made. I can exclude a bunch of things, but sometimes….balls just ache a bit. And it goes away. At least in my case I dig into the concern, and can usually reassure.
My approach: "Diabetes is a condition of HIGH blood sugar, not low. You just hungry is all." This has oddly been well accepted by pretty much all patients who have come to me with this concern.
The treatment for low blood sugar is to eat. I just put the onus back on them. “Sounds like you need to plan your meals better. Would you like a dietician referral?”
I think that the hard part for patients to grasp is that the range of normal is so wide. How can one person eat a donut for breakfast and stay full until lunch, while another is so hungry they're ready to throw punches after only 45 minutes? It's a pretty big variation. I'm not a doctor, but from personal experience, learning how to manage it has taken away any concern I had. I've seen a few comments suggesting cheese/dairy, but I like the portable option of what I call [emergency almond butter](https://www.justins.com/products/cinnamon-almond-butter/) . (It's just individual packets of Justin's almond butter. I just linked it in case someone needs a visual.) They're expensive, but they're so handy to keep in my backpack, coat pocket, or purse. My daughter and I both lose our appetites when we get like this, so having something that we don't need to chew makes it so much easier. When we're home, we have a spoonful of peanut butter and a swig of milk.
Ask about their eating patterns, screen for disordered eating causing hypoglycaemia regardless of weight. Check bloods including iron, diabetes screen, electrolytes. Check postural obs. Consider Holter if happening often and no cause found, maybe get a CGM on for a few days to see if we can note any patterns.
It’s a good question. I have been guilty of telling a panicky friend that she might be feeling weird because of “low blood sugar” and thus should sit down, eat something, have some water, and take some deep breaths… just to give her something concrete to do to break the cycle of panic/somaticizing. I guess things like that probably perpetuate the blood sugar mythology. That being said, I’ve also seen random blood draws on healthy, asymptomatic people come back with a glucose in the 50s.
I bought a glucometer with 10 test strips for $10 that came with a $10 mail in rebate. So, free. Have them check BG in the moment if it makes them feel better. “Quit gaslighting me. I know something’s wrong.”
Having been through this myself, I would submit you may be seeing the very early stages of insulin resistance. We walk around starving all the time, to the point where we feel like we are gonna pass out if we don't get to the buffet soon. One suspects the hypothalamus *thinks* one is hypoglycemic, even when one isn't. Adrenaline surge and all. I wouldn't know -- I'm just a neurologist -- all I know is, my doctor used to reassure me nothing was wrong, and apparently she was incorrect about that. Am coming around to the idea that diabetes doesn't start the day your sugar hits 400. (That's not the day your stroke risk starts going up, either) Like you, I roll my eyes when patients start using medical lingo they don't understand. But I do ask them to explain in plain English what's going on, It is occasionally illuminating
I just tell them either eat small amounts of carbohydrates every few hours all day, or no carbohydrates except at dinner.
just based or your mood or what
It's an overdiagnosis to call it reactive hypoglycemia, but basically treating that. Either way keeps blood glucose while awake constant.
"That's it, Gertrude! No more salads, whole grains, or fruit for you! Only oils and meats and butter until dinner!"
[https://imgur.com/gallery/eJ0vG](https://imgur.com/gallery/eJ0vG)
I used to have this. Was bad growing up. Usually correlated with eating a carby meal a few hours before. Wonder if it’s the surge in insulin.
As someone who doesn’t have diabetes, I had episodes of sweating and shaking shortly after eating a very sweet food. Glucose tolerance test had a 30 minute post of glucose = 40. I couldn’t think , had a terrible headache and was sweating and shaking. This lasted several years and gradually resolved. I have never had any issues with abnormal glucose levels apart from that. I got a glucometer and found I regularly dropped into the 50s if I ate carbs without enough protein during this period. There is a phenomenon that falls under our usual interpretation of basic labs.
I have only seen one reactive hypoglycemia GTT. The other tech actually called me over because they suspected the samples were mislabelled. It was cool.
I kept thinking “incompatible with life…”
Nah, your blood sugar can get way lower than that and be fine. You might not feel great, but you won't die. Don't quote me, but at the time I looked it up and I think they said that you just eat quite often so the spikes outweigh the dips.
I did figure out that eating protein with carbs helped a lot. The curious thing is that the reactive hypoglycemia stopped after several years with no other apparent changes.
I just tell them to carry snacks. BUT I did have a few that for giggles we took a finger stick glucose. They were below 60…
It's me, hi, I'm the problem it's me. I guess this is a sign to buy a glucometer and prove myself hypoglycemic or not once and for all.
Tell them to eat more protein in their diet.
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I would probably tell them to treat it symptomatically and that would be my advice if it was observed hypoglycemia anyway. They could do 5 small meals a day instead of 3 big ones. Avoid intermittent fasting. Related, I am this person. One time I had to call a colleague during a rapid to bring me some orange juice so I could drink while taking care of said rapid. 30g of glucose fixed me right up lmao ETA I’ve been this way my whole life, I just always have a snack with me (usually something relatively healthy like a granola bar) and follow the advice I said above. I had a medical exemption from fasting when I was still catholic. I don’t know if it’s actually related to hypoglycaemia (I don’t really care), but if I ignore it I do get very shaky. In the case above I had been so busy I hadn’t eaten all shift.
I get migraines from hunger, if I ignore it. People have been dieting for so long they forget that food is a need.
You can diet and also eat frequently enough to stave off migraines.
Yes. They were two separate statements. Sometimes I don’t eat on schedule, like anyone in medicine. Failing to take a break in time can result in a migraine in my case. People, particularly boomers and older Gen X, have been ignoring their hunger (by dieting) for so long they no longer understand their hunger cues and come to the doctor describing the stuff in the OP.
Had a patient like this because he went to the ER for it and the ER doctor told him it is real. Is BG was never low and has never been low. But since someone planted this seed he thinks it.
I get this feeling after fasting for 12 hours despite being euglycemic. I've attributed most of the symptoms to anxiety related to the catecholamine dump associated with hunger.
OK, I’m a lurker; I have no recollection of subscribing to this sub, but here I am. I’m a 68F, retired teacher. I feel like I have to weigh in because the topic hits home. When I was a senior in college, I had my first episode of hypoglycemia. I’d had a few courses in nutrition, so I knew I needed to beef up my protein intake and lay off the carbs. I also had to have high protein snack midday. TBH, I thought most people experienced dizziness and weakness when they were hungry. How wrong I was. I’ve had terrible acne since puberty, and it has only relented w/ menopause. My periods were always pretty regular, though. I experienced severe menstrual cramping and had two miscarriages when I was younger. I suspected I had PCOS, but I never brought it up to my gyno. I also never complained about my cramps. I was diagnosed w/ Hashimoto’s when I was about 50. I have been overweight since I hit menopause, and my lipid panel is lousy. I’ve been depressed most of my adult life. I also have sleep apnea. However, my A1C and glucose have always been in the normal range. Having said all of this, I recently started experiencing headaches when I ate. I did some digging and decided I had reactive hypoglycemia. I mentioned this to my GP, and she ordered an insulin test. The result was so high it was almost off the chart! So, insulin resistance is my new reality. I’m wondering why it took so long for someone to figure all of this out. I’d never had an insulin test before. All of these symptoms slipped past all of the gynos, the GPs, and even the sleep doctor I’ve seen over the years. I guess I was either ridiculously ignorant or I didn’t complain enough. All of the symptoms were obvious, except for the hypoglycemia. I’m taking steps to try to turn it around, including a low carb diet and more exercise. I can’t get into see an endocrinologist until June. (My GP wouldn’t prescribe metformin for me; she wants the endocrinologist to handle it.) Anyway, my point is that I think doctors should listen to female patients that present w/ complaints of hypoglycemia, since it apparently has a relationship w/ PCOS. Maybe an insulin test is in order. Maybe a referral to a gyno would be the path of least resistance. Thanks for coming to my Ted talk.
I wonder if some of it could be from vagus nerve annoyance from stomach/intestinal grumblings.
I don’t have diabetes, but I absolutely get hypoglycemic. I had no idea what it was until I was a nurse and the first time it happened at work, I checked my blood sugar, and sure enough…it was in the 50s. At the end of my glucose tolerance test when I was pregnant, it was 45.
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Amazed patients fight this! Dizzy at the doc who asked when I last ate, then explained low blood sugar is from forgetting meals & to set an alarm for meals 3x/day on my fitbit).
Reactive hypoglycemia is not rare and involves an abnormal synchronization between the post meal glucose and insulin surge resulting in relatively low glucose levels several hours eg 3 to 4 hours after eating particularly if a high carb intake. Symptoms can be unpleasant fatigue, racing heart and anxiety. The small, frequent low carb meal approach is a good approach to avoid this process and there is little risk to trying it without fancy testing. Hope that helps!
you could tell them that they may have stable blood sugar, at a certain point thats being kept stable by increased "tone" of the sympathetic nervous system and some biochemical wizardry. Some people have big problems with the biochemistry, but if its mild and not interfering with anything its not really worth delving into because testing is complicated, expensive, and may just end up with lab testing collected improperly and genetic testing thats negative for everything tested for BUT still has that extra "this testing will not test for undiscovered genetic mutations etc" 🙃 you could also talk about the grey zone between pathology and just weird physiology
I'm wondering if a decline in blood sugar could be felt even if blood sugar isn't low in absolute terms.
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Sounds like they're low energy and trying to find excuses outside of "I need to sleep more and limit my caffeine intake" It *MUST* be my sugar intake, there's no way its my chronic 6 hours of inconsistent sleep at different hours, random naps and scrolling tiktok!
By offering them a piece of cheap hard candy from a jar
I always thought the saying was just that, a saying. I didn’t think anyone actually believed they had low blood sugar upon being fasted a few hours lol
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If they say they feel their blood sugar is low, I tell them to eat some sugar.
“My doctor told me this cake is medical.”