Hypoglycaemia - the full story
It is critically important for the body to maintain blood sugar levels within a narrow range. If the blood sugar level falls too low, energy supply to all tissues, particularly the brain, is impaired. However, if blood sugar levels rise too high, then this is very damaging to arteries and the long term effect of arterial disease is heart disease and strokes. This is caused by sugar sticking to proteins and fats to make AGEs (Advanced Glycation End-products) which accelerate the ageing process.
Normally, the liver controls blood sugar levels. It can create the sugar from glycogen stores inside the liver and releases sugar into the blood stream minute by minute in a carefully regulated way to cope with body demands which may fluctuate from minute to minute. Excess sugar flooding into the system after a meal can be mopped up by muscles, but only so long as there is space there to act as a sponge. This occurs when we exercise Exercise - the right sort. This system of control works perfectly well until we upset it by eating the wrong thing or not exercising. Eating excessive sugar at one meal, or excessive refined carbohydrate, which is rapidly digested into sugar, can suddenly overwhelm the muscle and the liver’s normal control of blood sugar levels.
We evolved over millions of years eating a diet that was very low in sugar and had no refined carbohydrate. Control of blood sugar therefore largely occurred as a result of eating this Stone Age diet and the fact that we were exercising vigorously, so that any excessive sugar in the blood was quickly burned off. Nowadays the situation is different: we eat large amounts of sugar and refined carbohydrate and do not exercise enough in order to burn off this excessive sugar. The body therefore has to cope with this excessive sugar load by other mechanisms.
When food is digested, the sugars and other digestive products go straight from the gut in the portal veins to the liver, where they should all be mopped up by the liver and processed accordingly. If excessive sugar or refined carbohydrate overwhelms the liver, the sugar spills over into the systemic circulation. If not absorbed by muscle glycogen stores, high blood sugar results, which is extremely damaging to arteries. If one were exercising hard, this would be quickly burned off. However, if one is not, then other mechanisms of control are brought into play. The key player here is insulin, a hormone secreted by the pancreas. This is very good at bringing blood sugar levels down and it does so by shunting the sugar into fat. Indeed, this includes the "bad" cholesterol LDL. There is then a rebound effect and blood sugars may well go too low. Low blood sugar is also dangerous to the body because the energy supplied to all tissues is impaired. When the blood sugar is low, this is called "hypoglycaemia". Subconsciously, people quickly work out that eating more sugar alleviates these symptoms, but of course they invariably overdo things; the blood sugar level then goes high and one ends up on a rollercoaster ride of blood sugar level going up and down throughout the day.
Ultimately, this leads to metabolic syndrome or syndrome X (effectively, this is the loss of control by the body of blood sugar levels) - a major cause of disability and death in Western societies, since it is the forerunner of diabetes, obesity, cardiovascular disease, degenerative conditions and cancer.
Sugar and fast carbs are addictive
The problem is that people feel boosted by a high level of blood sugar. This is because they have a good energy supply to their muscles and brain - albeit short-term. The problem arises when blood-sugar levels dive as a result of insulin being released and energy supply to the brain and the body is suddenly impaired. This results in a whole host of symptoms: the brain-symptoms include difficulty thinking clearly, feeling spaced out and dizzy, poor word finding ability, foggy brain and sometimes even blurred vision or tinnitus. The body-symptoms include suddenly feeling very weak and lethargic, feeling faint and slightly shaky, rumbling tummy and a craving for sweet things. Sufferers may look as if they are about to faint (and indeed often do) and have to sit down and rest. The symptoms can be quickly alleviated by eating something sweet; if nothing is done, then the sufferer gradually recovers. These symptoms of hypoglycaemia can be brought upon by missing a meal (or one’s usual sweet snack top-up such as a sweet drink), by vigorous exercise or by alcohol. Diabetics may become hypoglycaemic if they use too much medication.
So the brain likes sugar. Running a high blood-sugar allows the brain to function efficiently and also releases the happy neuro-transmitters such as GABA and serotonin which have a calming effect. See Edge effect. We all recognise this because comfort-eating foods are carbohydrates. The second problem is that we have a “thermostat” for blood sugar (this is, a measure against which blood-sugar levels are compared and controlled), which I suspect gets set upwards if blood sugars run consistently high. I believe this because I’ve seen several people with diabetes who run consistently high blood-sugar levels but feel hypo if their blood sugars drop below 7 or 8. So, whatever interventions one makes to control high blood sugars must be done slowly so that this “thermostat” can be gradually reset.
The fermenting gut
This is a major cause of hypoglycaemia because sugars (or carbohydrates that are digested to sugars) are fermented to produce various alcohols. These destabilise blood sugar levels. See Fermentation in the gut and CFS
Energy supply to the brain
The brain's preferred fuel supply is fat. See Brain fog - poor memory, difficulty thinking clearly etc. Eating a low fat diet and relying on sugar to nourish the brain is a little like running your car on the reserve petrol tank rather than a full tank. The brain goes into panic mode at the prospect of the fuel supply running short and produces adrenaline which results in all the symptoms of hypoglycaemia. This ensures a petrol station is just round the corner as one rushes for a carbohydrate snack! Also see Phospholipid exchange for the right fats to consume.
We have a sugar addiction gene
This makes perfect evolutionary sense. We evolved eating a Stone Age Diet. But every so often there would be a carbohydrate bonanza - perhaps the banana tree would ripen. The only way primitive man could take advantage of this would be by eating the lot! Bananas do not store well and one is at risk of someone else eating them. Once he started eating, the carbohydrate addiction gene would switch on and he would go on eating until there was none left. He would gain weight, which would give him energy for other tasks such as building the house, fighting the neighbours, getting the wife pregnant or whatever!
The carbohydrate gene is switched on when just 3% of the diet contains sugar. The trouble with Western diets is they are high in sugar and refined carbohydrate and so the sugar addiction gene is permanently switched on. See Wikipedia:Sugar addiction. When you can get your sugar intake low, the gene is switched off and you stop craving.
Disturbed sleep is a common symptom of hypoglycaemia
When blood glucose levels fall for any reason, glycogen stores in the liver may be mobilised to prop them up. Another rapid and very effective way in which the body repletes the low glucose is by conversion of short chain fatty acids to glucose. In a healthy person on a good balanced diet the only time this is of importance is during the night because of the long break between food intake. Short chain fatty acids are used to prop up circulating glucose and prevent a fall below whatever that person’s usual fasting glucose level is. Short chain fatty acids are made in the gut by bacteria fermenting fibre (and such starch as escapes small intestinal digestion). Production is maximised from about 3 hours after food intake. That is to say, short chain fatty acids are highly protective against the dips we see in blood sugar.
Therefore, a key symptom of a hypoglycaemic tendency is disturbed sleep. This occurs typically at 2 – 3 am, when blood sugar levels fall and there are insufficient short chain fatty acids to maintain a blood sugar. Low blood sugar is potentially serious to the brain, which can only survive on sugar and, therefore, there is an adrenalin reaction to bring the blood sugar back up, but this wakes the sleeper up at the same time.
Alcohol – the commonest symptom of alcohol causing hypoglycaemia is sleeplessness. Initially alcohol helps one to go to sleep, but then it wakes one up in the small hours with rebound hypoglycaemia.
Insulin is a stress hormone
There is a final twist to the hypoglycaemic tale which complicates the situation further. When one becomes stressed for whatever reason, one releases stress hormones in order to allow one to cope with that stress. Insulin is such a stress hormone and has the effect of shunting sugar in the blood stream into cells. This produces a drop in blood sugar levels and also causes hypoglycaemia. Therefore, hypoglycaemia can be both a cause of stress and the result of stress, indeed, another one of those vicious cycles that are so often seen in disease states.
So, we have:
One becomes stressed => stress hormones [including insulin] released => sugar is shunted out of the blood stream into cells => blood sugar falls [ie hypoglycaemia] => one becomes stressed => etc
Symptoms of hypoglycaemia
Hypoglycaemic symptoms and manifestations can be divided into those produced by the counter-regulatory hormones (epinephrine/adrenaline and glucagon) triggered by the falling glucose, the neuroglycopenic effects produced by the reduced energy delivery to the brain and the fatigue from reduced energy delivery to the body.
- Adrenergic manifestations
Shakiness, anxiety, nervousness, palpitations, tachycardia, sweating, feeling of warmth, pallor, coldness, clamminess, dilated pupils (mydriasis), feeling of numbness "pins and needles" (parasthaesia).
- Glucagon manifestations
Hunger, borborygmus (rumbling or gurgling noise made by the movement of fluid and gas in the intestines), nausea, vomiting, abdominal discomfort, headache.
- Neuroglycopenic manifestations - reduced energy delivery to the brain
Foggy brain, impaired judgment, nonspecific dysphoria (a state of unease or generalized dissatisfaction with life), anxiety, moodiness, depression, crying, daydreaming, negativism, irritability, belligerence, combativeness, rage, personality change, emotional lability, poor quality sleep, automatic behavior, also known as automatism,ataxia, incoordination, sometimes mistaken for "drunkenness", focal or general motor deficit, paralysis, hemiparesis (weakness of the entire left or right side of the body), paresthesia (‘pins and needles’), headache, stupor, coma, confusion, amnesia, dizziness, delirium, staring, "glassy" look, double vision, difficulty speaking, slurred speech, abnormal breathing, generalized or focal seizures
These symptoms are very similar to being drunk with alcohol - which results again in poor energy delivery to the brain.
- Poor energy delivery to the body
Fatigue, weakness, lethargy, poor stamina, blurred vision and many others!
Treatment of hypoglycaemia
- Low glycaemic index diet Treatment is to avoid all foods containing sugar and refined carbohydrate.One needs to switch to a diet which concentrates on eating proteins, fats and complex (and therefore slowly digested) carbohydrates. Initially I suggest doing a high protein, high fat diet, but include all vegetables (care with potato), nuts, seeds, etc. Fruit is permitted but rationed, since excessive amount of fruit juices or dried fruits contain too much fruit sugar for the liver to be able to deal with. I suggest one piece of fruit at mealtimes. See Stone Age Diet and Low glycaemic index diet. In fact, more often I now prescribe the ketogenic diet - please see Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.
- Nutritional supplements - Nutritional Supplements - what everybody should be taking all the time even if nothing is wrong
- The brain's preferred fuel are ketones which the liver synthesises from medium chain fatty acids. The best source of these is coconut oil. This fuel source is much more constant than glucose and highly protective against hypoglycaemia. Coconut oil 10-20ml twice daily is often very helpful! See Brain fog - poor memory, difficulty thinking clearly etc. The brain loves fat!
If the brain runs short of fats and ketones, it can swap to short chain fatty acids (which come from the large bowel fermenting soluble fibre and can provide up to 500kcals a day) or worst, sugar. The trouble with sugar is that it is a short term fuel, like running on reserve tank. The brain is constantly assessing the fullness of the tank and if the tank starts to run low, the brain stimulates the release of adrenaline - this will bring blood sugar up for the brain but one then suffers from the adrenaline effects.
- Prebiotics (as soluble fibre in vegetables especially pulses, vegetables, nuts and seeds or as fructo-oligosaccharides). Prebiotics feed bacteroides in the large bowel which ferment to produce short chain fatty acids ("SCFAs") – when blood sugar levels fall, mitochondria happily swap to SCFAs as a fuel source. Indeed over 500kcals a day can be generated in this way. SCFAs help to prevent hypoglycaemia especially during sleep.
- Probiotics - my view is that probiotics have not lived up to their potential. However they may be useful by displacing unfriendly bacteria or yeast. Kefir for example produces a toxin that kills yeast in the gut. The best and cheapest way to do this is to brew your own – see Probiotics - we should all be taking these all the time and double the dose following antibiotics and gastroenteritis and Kefir.
- Fermentation in the gut and CFS - a fermenting gut produces alcohol which further destabilises blood sugar levels.
- Additional supplements - niacinamide and chromium are particularly helpful. I recommend taking a high dose for two months. Both these supplements have a profound effect on blood sugar levels to stabilise them but sometimes have to be given in high doses initially to kick start the necessary mechanisms. By this I mean niacinamide 500mgs, 3 daily at mealtimes and possibly double this dose. Chromium 2mgs daily (2,000 mcg) for 2 months. Rarely, niacinamide in these doses can upset liver enzymes but this is accompanied by nausea – so if you feel this symptom, reduce the dose to 500mgs daily. Niacinamide is a really interesting vitamin – it shares the same action as diazepam (Valium) to produce a calming effect which is not addictive. I suspect it works because so much anxiety is caused by low blood sugar and niacinamide helps prevent this.
- Allergies to foods - this can certainly cause hypoglycaemia – the top three allergens are grains, dairy products and yeast. But one can be allergic to any food! See Stone Age Diet.
- Hypothyroidism - see Hypothyroidism
- Adrenal problems and cortisol - the job of the adrenal gland is to produce the stress hormones to allow us to move up a gear when the stress comes on. Cortisol raises blood sugar levels. It is largely excreted during mornings and declines as the day progresses - this is why we should feel at our best early in the day, and blood sugar problems get worse as the day progresses. Often people compensate for this by eating more as the day goes on and this explains why many hypoglycaemics do not need or eat breakfast, with supper being the largest meal of the day. Changing all of the above will help. But it may be appropriate to do an adrenal stress profile and actually measure output of the stress hormones cortisol and DHEA since a small supplement may be very helpful. See Adrenal Gland - the gear box of the car (DHEA and cortisol) – underactive and Common Hormonal Problems in CFS - Adrenal
- Sex hormones, The Pill and HRT. These hormones all have the effect of raising blood sugar levels. Indeed this is the mechanism which is responsible for gestational (pregnancy) diabetes. The problem is that stopping these hormones then causes hypoglycaemia and one gets withdrawal symptoms. I suspect it is part of the mechanism that makes these hormones so addictive.
- Toxins and pollutants. There was a fascinating paper in the Lancet that showed that the biggest risk factor for diabetes (and this is the end product of years of hypoglycaemia as insulin resistance results) is the level of pollutants in the body (pesticides, volatile organic compounds and heavy metals). (Please see Environmental pollution and diabetes: a neglected association) The paper showed that chemical pollutants were a greater risk factor than being overweight! It was suggested that the overweight problem reflected a larger chemical burden as the body tried to “dump” chemicals where they would be out of the way. When people who have the highest levels of POPs in the blood were compared to the people with the lowest levels of POPs in the blood, they were found to be 38 times more likely to be diabetic.
The chemicals literally get in the way of many biochemical processes and prevent the body functioning normally. So for some people doing detox regimes is very helpful – ie far infra red sweating/saunaing and improving liver detox with vitamins and minerals. We can easily test for pollutants in fat by doing a fat biopsy – this is a simple test, easier than a blood test! Please see Fat biopsy for pesticides or Volatile Organic Compounds and also Detoxification - an overview and Detoxing - Far Infrared Sauna (FIRS)
- Nickel toxicity. Nickel toxicity is a very common problem and nickel is a substance often found stuck onto DNA. See DNA adducts. Nickel biochemically looks very much like zinc and so enzymes which normally incorporate zinc into them, in the presence of zinc deficiency, will take up nickel instead. This prevents the enzyme or the hormone from functioning normally. Clinically nickel toxicity often presents with hypoglycaemia. See Nickel - a nasty toxic metal.
- Fructose intolerance. Fructose is fruit sugar generally perceived to be a healthy alternative to glucose. No problem if one is tolerant of fructose or if it is taken in small amounts, but intolerance of fructose or excessive intake can result in hypoglycaemia. This is because the control mechanisms that apply to glucose are bypassed if the system is awash with fructose. In fructose intolerance (aldolase type B deficiency), fructose-1-phosphate builds up because it inhibits glycogen phosphorylase which is essential for the provision of glucose from glycogen and it also inhibits fructose-16-biphosphatase which is essential for provision of glucose from protein and fat. This combination can result in severe hypoglycaemia because it means effectively the body cannot mobilise glucose from stores in the liver for when blood sugar levels fall. This combination can lead to severe hypoglycaemia.
Even if the enzyme works perfectly well, excessive fructose intake will stress the same pathways. Sugar stores in the liver cannot be mobilised. Because liver uses up short chain fatty acids for the production of glucose to try to avoid this hypoglycaemia, this tendency can be measured by looking at short chain fatty acids in the blood and also measuring levels of fructose-6-phosphate which gets induced in this situation. These three metabolic problems i.e. levels of short chain fatty acids, levels of fructose-6-phosphate and LDH isoenzyme (indicative of liver damage), can help diagnose this problem.
I recommend people avoid tropical fruit (high fructose), and go for berries which are low fructose but rich in goodies!
Failure to tackle hypoglycaemia will result in Diabetes. Indeed diabetes is an inevitable consequence of Western diets and lifesyles. On current figures 50% of the UK population will be diabetic by the year 2030.
Initial complications. The problem for the established hypoglycaemic is that it may take many weeks or indeed months for the liver to regain full control of blood sugar and therefore the symptoms of hypoglycaemia may persist for some time whilst the sufferer continues to avoid sugar and refined carbohydrate. This means that when you change your diet you will get withdrawal symptoms and it may take many weeks of a correct diet before these symptoms resolve. This type of addiction is very much like that which the smoker or the heavy drinker suffers from.
With time the regime can be relaxed, but a return to excessive sugar and refined carbohydrate means the problem starts again. Finally, many sufferers of hypoglycaemia may need something sweet to eat immediately before and during exercise, until the body learns to fully adapt.
Test for hypoglycaemia
Measuring blood sugar levels is not a terribly useful test for hypoglycaemia, partly because the levels fluctuate so much and partly because by the time one gets the symptoms of hypoglycaemia, the blood sugar levels have started to correct. A much better test would be to measure short chain fatty acids in blood collected in the morning before breakfast. The test should be done as follows:
- It is important to continue your usual diet – indeed, there are no special dietary instructions for the test, but the blood sample must be taken between 9 –12 hours after a meal;
- 2 ml of blood taken into a fluoride oxalate tube and posted off in an envelope to Acumen.
DIET - More often I now prescribe the ketogenic diet - please see Ketogenic diet - the practical details and My book The PK Cookbook - Go Paleo-ketogenic and get the best of both worlds.
- Exercise - the right sort
- Nutritional Supplements
- Edge Effect
- Fermentation in the gut and CFS
- Brain fog - poor memory, difficulty thinking clearly etc
- Phospholipid exchange
- Stone Age Diet
- Low glycaemic index diet
- Probiotics - we should all be taking these all the time and double the dose following antibiotics and gastroenteritis
- Adrenal Gland - the gear box of the car (DHEA and cortisol) – underactive
- Common Hormonal Problems in CFS - Adrenal
- Nickel - a nasty toxic metal
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