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August 2007 - updated December 2008

Low blood sugar is an extremely common problem and I find myself talking about this subject more than any other! The body has a very difficult balancing act with respect to blood sugar. If levels drop too low, then this will cause unconsciousness and then death. On the other hand, if the blood sugar level goes too high, glucose will stick onto many other substances to create advanced glycation end products. This effectively causes an accelerated ageing. So the body goes to a great deal of trouble to keep the blood sugar tightly controlled between about 3mmols and 6mmols per litre. The mechanisms that achieve this are complicated and therefore there is great potential for things to go wrong.

This is complicated by the fact that 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. We all recognise this because the comfort-eating foods are carbohydrates. The second problem is that we have a "thermostat" for blood sugar (this is, if you like, 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.

What makes blood sugar go up?

Diet - carbohydrates are broken down into sugars which increase the blood sugar levels. Foods have been given a measure of this and it is called the "glycaemic index". It's a measure of the ability of a food to raise blood sugar levels. This can be affected by many factors, not just the food itself. Foods that are cooked will be more rapidly digested and therefore have a higher glycaemic index. Foods that are finely divided such as flours, again are more rapidly digested and therefore have a high glycaemic index. Carbohydrates that are very soluble such as sugars and alcohol again are rapidly absorbed. Any carbohydrates that are consumed should therefore be unrefined complex carbohydrates which are slowly digested, if possible eaten raw (although this is obviously impossible with some carbohydrates such as potato).

Foods should be slowly eaten. What causes insulin to be released is the rate at which the blood sugar level rises. A quick rise will produce a pulse of insulin which then hangs around for a long time and causes subsequent hypoglycaemia. So eat foods slowly, don't gobble them, and mix carbohydrates with high fibre foods, vegetables, meat and fats so that the absorption of carbohydrate is slowed.

It is easy to identify the carbohydrate addicts - they like their carbohydrates highly refined such as sugar, sweets, crisps, white bread, pasta and refined breakfast cereals and fruit juice. They tend to gobble their food. They are not content with a normal meal of meat and vegetables without the sweet sticky pudding to follow!

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.

Which factors affect blood sugar levels?

Stress - one of the stress hormones is insulin. This is because insulin drives sugar in the blood inside cells so it can be ready for immediate use. This means blood sugar levels will fall resulting in hypoglycaemia.

Poor digestion of foods - if proteins are not completely broken down into amino acids this may result in long chain polypeptides getting from the gut into the blood stream where they can have insulin-mimicking effects. This can be tested for by requesting Short chain polypeptides - another measure of protein digestion and absorption. Also see Hypochlorhydria and Pancreatitis - often a forgotten diagnosis.

Probiotics - having the right bugs in the gut means that fibre in the diet can be broken down into short chain fatty acids such as acetates, butyrates and propionates. When blood sugar levels run low, the body switches to short chain fatty acids for fuel. It is this which protects us from hypoglycaemia between meals especially where there is a long gap, for example at night. We can test for short chain fatty acids by measuring levels of acetate, propionate and butyrate in the blood first thing in the morning before breakfast. Low levels suggest a tendency to hypoglycaemia - see Probiotics - we should all be taking these all the time and double the dose following antibiotics and gastroenteritis

Candida and yeast problems - a yeast overgrowth in the gut means that any sugars, or carbohydrates which get digested to sugars, are then fermented by yeast. This produces carbon dioxide (and so bloating) together with alcohol. Alcohol is a high GI food, further destabilises blood sugar so rebound hypoglycaemia occurs. This makes the sufferer crave carbohydrate - a clever evolutionary ploy by candida to make the host eat the very food the yeast wants most!

Good micronutrient status - vitamins, minerals, essential fatty acids, vitamin C and D are all involved in blood sugar control. Two which seem to be particularly helpful are high dose niacinamide and chromium. I recommend taking them 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. 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.

I also suggest 2mgs of chromium daily. The usual daily requirement would be a tenth of this but with severe hypoglycaemia there is often severe chromium deficiency. Niacinamide and chromium work together synergistically.

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 - this is a diet which we all should follow and DIET FOR CFS.

Hormonal Effects

Hypothyroidism - can certainly cause hypoglycaemia. See Hypothyroidism - A Common Hormonal Problem in CFS

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 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 CFS and Adrenal gland problems - why they occur.

Sex hormones, The Pill and HRT

These hormones all have the effect of raising blood sugar levels. Indeed it is this mechanism which is responsible for gestational 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. See Contraceptive Pill and HRT - don't take them.

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). 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! See 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 toxicity).

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 problems in either of these departments 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. The cost to do each individual test is £52 for fructose-6-phosphate, £45 for short chain fatty acids and £90 for LDH isoenzymes. However if you order all three together the cost is £165 and you get a cell-free DNA free of charge.

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