Saturday, November 13, 2010

Hypoglycemia is a myth?

Parents worry their child might have hypoglycemia (or low blood sugar). They notice that when their child has not eaten for a while they get really mean and cranky. Or their teenager (who skips breakfast and lunch) becomes low on energy, possibly even feeling dizzy in the afternoon. Parents worry that this could mean their child has diabetes. It looks the same as when the child's diabetic grandparent seems "out of it" when their blood sugar level drops. Then they have to get the grandparent to drink orange juice to bring the level back up.

This concern brings itself to my office with a parent asking that their child's sugar be checked, or asking for a diabetes check, or simply with questions about hypoglycemia. Many believe this is a very common condition, and some think that it is a sign of diabetes.

My goal in this blog post is to dispel the myths--the myth that hypoglycemia is a sign of diabetes (it definitely is NOT), and the myth that hypoglycemia is a common and likely explanation for children being mean, cranky, low on energy, or dizzy.

First lets talk about diabetes. The main problem in diabetes is either lack of insulin, or decreased ability to respond to insulin. Insulin is a chemical that is made in the body by the pancreas. Its purpose is to make glucose (sugar) available and usable as a source of energy. Without the important, life-sustaining effects of insulin the result is HIGH blood sugar, or HYPERglycemia. In that case there is lots of sugar circulating in the blood, but it is useless to the body as energy. If a blood test is done, the blood sugar level will be very high.

Diabetes comes in two forms. Type I is insulin dependent--meaning that insulin must be injected into the body--and usually starts at a young age. Type II is not usually insulin dependent, is often controlled with diet or pills, and is traditionally thought to start in adulthood. The SIDE EFFECT of insulin or pills used in diabetes can be HYPOglycemia. If a diabetic person has low blood sugar it is usually an undesirable, and sometimes unavoidable, side effect of the medication they are using to treat their diabetes.

Is that point clear? Having diabetes means you will have HIGH blood sugar levels. Treatment of diabetes could have the occasional side effect of low blood sugar (hypoglycemia), but this is a result of the treatment, not the diabetes itself.

But, now that you know that hypoglycemia (or low blood sugar) does not suggest your child has diabetes, I must go on to dispel the myth that hypoglycemia is a common symptom.

Blood sugar levels are very tightly regulated by your body. Think of this as an algorithm: Levels get high and more insulin is released so the sugar can be processed as energy. Levels start to drop and natural body chemicals stimulate your body to release glucose from various places where it is stored (the liver is a big storage center for glucose). If blood sugar levels are starting to drop there might be a feeling of hunger or thirst as your body is stimulating you to replace your energy stores.

We could not live without this tight regulation of blood sugar levels. If our blood sugar levels were constantly getting low we would be passing out, having seizures, becoming brain damaged, and having terrible things happen to us. Our bodies are so sensitive and so good at preventing low blood sugar that we can often feel the effects of just a slight drop in an otherwise normal blood sugar level. This might be a feeling of hunger, crankiness, headache, or jitteriness. If we tested our blood sugar at that time it would likely be in a "normal" range! Yet the slight drop stimulated the symptoms we are having.

Similarly we might respond to rapid metabolism of simple sugars by feeling a quick boost in energy, followed an hour later by the "crash" as the sugars are absorbed from the blood stream. However, if we test the blood sugar level during the "sugar high" and the "crash", it will most likely fall into a medically normal range. We feel the tiny changes as the sugar is used and then leaves the blood stream, but these changes do not show up on a blood test. And, these adjustments are a NORMAL part of the process of using the energy we put into our bodies. Your body makes you hungry and cranky so you will EAT, and replace the energy you are using.

Is your child feeling jittery, hungry, cranky, low on energy, and mean? Obviously these are unpleasant symptoms. Possibly they are related to the body's metabolism of sugar, but they almost never translate into hypoglycemia that we can identify on a blood test. Other explanations for these symptoms could be fatigue, poor sleep, sensory overload, need to exercise or play, thirst, hunger, illness, or need for some quiet alone time.

It is definitely possible to smooth out the feelings we have as our body makes slight adjustments in our blood sugar levels. Protein, especially, helps even out the ups and downs of otherwise normal blood sugars. The body will first use the simple sugars in the blood, as they are the easiest to digest, then move on to other sources, such as protein, to help maintain smooth blood glucose levels. Some protein at breakfast, lunch, and snack can go a long way toward helping your child feel better throughout the day. An all carbohydrate diet (such as a breakfast pastry in the morning, followed by graham crackers for snack, and then a granola bar at lunch) sets your child up to feel bad, noticing all those little ups and downs as the body tries to maintain normal blood glucose levels.

You don't believe me? You were diagnosed with hypoglycemia, you say? I'm not saying it's impossible to have hypoglycemia--I'm just saying it's much more likely that your child is feeling the effects of normal body metabolism, and that if we check the blood sugar levels they will look normal!

As a physician, I have had patients and parents who did not believe me, who needed proof their child was not hypoglycemic. I have sent blood glucose monitoring units home with families, to check blood sugars throughout the day and record symptoms. Years ago one teenager did a beautiful job with this. He monitored his levels throughout the day, recorded his cranky, weak, and hungry symptoms, checked levels before and after eating, upon getting up in the morning, after exercise, etc. Despite having many symptoms he thought were attributable to hypoglycemia, ALL of the blood sugar levels recorded were in the medically normal range!

So, when you think about it, were you really diagnosed with hypoglycemia? Or did someone offer that diagnosis to you as an explanation for the symptoms I have described, without explaining in detail how the body works to maintain normal sugar levels? It would be easy for a health care provider to offer hypoglycemia as an explanation for such symptoms (it's hard to explain, after all), and then put the focus on improving the diet to help minimize those unpleasant symptoms.

Now that I have hopefully dispelled the common myths around hypoglycemia, I do have to mention some true examples of hypoglycemia! Newborn babies are at risk for hypoglycemia. Through the pregnancy the fetus makes its own insulin to respond to its mother's blood sugar levels. So the newborn baby sometimes comes out of the womb making much more insulin than it will end up needing, and there will be low blood sugars for a period of time. These levels can be very low, and sometimes need to be treated for a few days after birth.

There is also a condition that can affect young, usually tiny, toddlers and preschoolers. They might have true hypoglycemia after a long fast (often over night). Their symptoms are pretty dramatic--a seizure or loss of consciousness, inability to wake up--not just cranky. There are some rare conditions that can affect older kids, as well. Again, the symptoms will be dramatic--loss of consciousness, seizures, inability to wake up. Usually these symptoms are on a level that an ambulance must be called to take the patient directly to the hospital.

And, by the way, symptoms of Type I, childhood, insulin dependent, diabetes (which is HIGH blood sugar, remember?) are excessive thirst, excessive urination, excessive appetite, and weight loss.

Please keep in mind that the comments in my blog are meant to provide you with useful information and things to think about, but not to diagnose or rule out any particular medical condition in your child. My blog is not meant to be a comprehensive analysis of any particular condition. For that you need the personal attention of your child's own doctor.

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Robyn said...

What is the rare condition that causes seizures and inability to wake up? There is a case of a boy I learned about on Facebook, his name is Noah- something like that happened to him 70 days ago and they don't know what's wrong. His page is Prayers for Noah Facecchia.

Steph said...

I don't know the exact condition you mention here. There are a number of rare conditions that can cause serious hypoglycemia, which will result in seizures and loss of consciousness.

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