Eat to Beat Low Blood Sugar

The Nutritional Plan to Overcome Hypoglycaemia, with 60 recipes

Martin Budd and Maggie Budd

Contents

Cover

Title Page

Introduction

Part One Low Blood Sugar - Facts and Figures

Chapter 1 – So what exactly is low blood sugar?

Chapter 2 – The causes of low blood sugar

Chapter 3 – The symptoms of low blood sugar

Chapter 4 – The diagnosis of low blood sugar

Part Two Treating Low Blood Sugar

Chapter 5 – The low blood sugar diet

Chapter 6 – The Glycaemic Index

Chapter 7 – Case histories

Part Three The Recipes

Chapter 8 – Introduction

Chapter 9 – Breakfasts

Chapter 10 – Lunchtime snacks and sandwiches

Chapter 11 – Salads

Chapter 12 – Soups

Chapter 13 – Main meals

Chapter 14 – Desserts

Chapter 15 – Between-meal snacks and drinks

Chapter 16 – Baking

Part Four Taking it Further

Chapter 17 – Supplement use

Glossary

Resources

Index

Copyright

About the Publisher

Introduction

Since the publication of my first book, Low Blood Sugar, in 1981, the established medical attitude to the diagnosis and treatment of low blood sugar has radically changed. For many years doctors viewed sudden falls in the blood sugar as a relatively harmless cause of the sort of transient symptoms that we can all at times experience. The recommended treatment at the time was usually sugar cubes or a bar of chocolate.

These days, low blood sugar, or hypoglycaemia to give it its proper name, is seen by many doctors, naturopaths and researchers as an important clue that indicates a general inefficiency in our sugar regulation system. This faulty control has been termed dysglycaemia.

A host of symptoms and health problems are now known to develop as a result of poor blood sugar regulation. These include obesity, high blood pressure, anxiety, depression, fatigue, late onset diabetes, gout, heart disease, thyroid and adrenal deficiency and a recently defined group of abnormalities known as Syndrome X, or the metabolic syndrome.

While some of the technical aspects of the diagnosis and treatment of low blood sugar will be briefly discussed, this book essentially offers dietary advice to readers with low blood sugar to enable them to help themselves. Correct eating to minimize the adverse effects of dysglycaemia can reduce the distressing symptoms of low blood sugar, and lessen the risk of the many health problems associated with a high sugar diet that can develop in later life.

Part One looks at what low blood sugar means, its causes and symptoms. Part Two concerns itself with diet, providing guidance on what you should and should not be eating and the importance of timing meals well, as well as an easy-to-follow low blood sugar diet. Low blood sugar can cause a wide range of problems and the solution is not always the same. For this reason, a range of case histories is provided to illustrate some of the problems and solutions involved.

Part Three is where we get practical with the Eat to Beat Low Blood Sugar recipes. Here you will find a selection of recipes appropriate for a low blood sugar diet - both in terms of their content and when they are designed to be eaten. Part Four, entitled Taking it Further, outlines the value of specific nutritional supplements used to treat low blood sugar.

Towards the end of the book you will also find a glossary that explains the terminology currently in use in the field of blood sugar imbalances - for instance, Syndrome X, insulin resistance, glycaemic index and dysglycaemia. Please note, low blood sugar, low blood glucose and hypoglycaemia are one and the same, so in order to avoid confusion I describe the condition as low blood sugar throughout this book.

PART ONE Low Blood Sugar – Facts and Figures

CHAPTER 1 So what exactly is low blood sugar?

Low blood ‘sugar’ refers to a low level of glucose in the blood. There are no rigid criteria for diagnosing low blood sugar, as considerable individual variations can exist. However, a blood glucose level of below 3.5mmol/litre will usually cause the typical symptoms of low blood sugar. This is not a rare condition – everyone reading this book will have experienced the symptoms of low blood sugar at some time in their lives.

However, for such a widespread problem, it is surprisingly misunderstood. Indeed for many people almost every aspect of the low blood sugar condition is either contradictory or confusing. This is well demonstrated by the questions that I am frequently asked, examples being:

‘If diabetics with high blood sugar need to avoid sugar, why do those with low blood sugar also need to avoid sugar?’

‘Why are the symptoms and causes of low blood sugar on the increase, yet most of us eat too much sugar?’

‘Why do many people with low blood sugar develop high blood sugar [type II diabetes] in later life?’

‘My doctor has advised me to suck a sugar cube whenever I feel shaky or dizzy between meals [low blood sugar symptoms]. You advise me to avoid sugar, who is correct and why?’

‘We are told that all the carbohydrates in our diet end up as glucose in the blood. Do I therefore need to avoid all forms of carbohydrate for the remainder of my life?’

The answers to these and other questions will become apparent as you read this book.

The beginning – the discovery of low blood sugar

Perhaps low blood sugar should be termed ‘Seale Harris Syndrome’ after the American GP who first defined its symptoms in 1924. Dr Harris – a contemporary of Banting and Best, the co-discoverers of the role of insulin in diabetes – noticed that many diabetic patients attending the new insulin clinics developed symptoms of low blood sugar. Given that diabetes is characterized by a high blood sugar level, caused by the lack of insulin (a hormone that controls the level of glucose in the blood), this observation was surprising. The reason, however, was simple – many diabetics have difficulty in accurately judging their insulin requirements and often overdose themselves, producing a condition known as hyperinsulinism, which consequently causes low blood sugar (or hypo).

Crucially, Dr Harris noted that he also had several patients in his regular practice who exhibited symptoms of the ‘hypo’ reaction on a regular basis, but who were not diabetic and were therefore not taking insulin. He accurately concluded that these patients probably experienced the unpleasant symptoms of hypoglycaemia as a result of an inefficiency or imbalance in their sugar-regulating apparatus. This complex mechanism involves the islet glands of the pancreas that release insulin, the liver, to some extent the pituitary, thyroid and adrenal glands and other functions that play a part in sugar metabolism.

Dr Harris discussed his ideas with Dr Banting, who agreed that the role of insulin in non-diabetic low blood sugar offered a new aspect to the study of blood sugar balance. No papers on the topic had appeared in medical literature prior to Seale Harris’s work, but his discoveries led to numerous similar papers appearing in journals all over the world.

CHAPTER 2 The causes of low blood sugar

You may ask why many people who eat and drink excessive amounts of sugar-rich foods do not suffer from low blood sugar, while others who follow a near-perfect low sugar diet experience low blood sugar symptoms. The answer appears to lie in the many background health influences that can predispose an individual to dysglycaemia and low blood sugar.

This is a very complex subject but a brief list will serve to highlight the chief causative factors:

Excessive sugar intake, leading to pancreatic overstimulation, hyperinsulinism and insulin resistance.

Adrenal under-production, leading to adrenal deficiency or hypoadrenalism.

Imbalance and subsequent deficiency of the thyroid.

Excessive use of tobacco (each cigarette smoked raises the blood sugar equivalent to 2½ teaspoons of sugar).

Excessive use of alcohol and caffeine – both serve to stress the adrenal mechanism.

Inability to handle prolonged or excessive stress, leading to adrenal debility and inefficiency (known in the US as adrenal exhaustion or adrenal fatigue).

Food allergies or intolerances, which can be caused by, but also aggravated by, low blood sugar.

Mineral deficiencies. These include chromium, which is now deficient in the soil of Western nations. The minerals zinc, vanadium, magnesium, manganese and potassium are also essential for optimum blood sugar control.

Hereditary factors, in particular a family history of diabetes, hypothyroidism, asthma, epilepsy, clinical depression or chronic fatigue.

When attempting to treat blood sugar disorders one key question that must always be considered is whether the patient’s low blood sugar is only a symptom, or is itself a cause of symptoms.

Fasting hypoglycaemia

When low blood sugar is simply a symptom, it is generally the result of fasting, or transient, hypoglycaemia – low blood sugar that is caused by a delayed or missed meal. This is something we have all experienced; the symptoms include shakiness or dizziness and fatigue, perhaps a mild headache or a feeling of ill temper. Usually the symptoms are coupled with a strong urge for chocolate or something sweet.

Those who experience such symptoms on waking each morning usually have a background health problem. However, there are very few health problems that can cause us to feel worse on rising than we feel upon retiring. The list includes adrenal exhaustion, hypothyroidism, drug addiction and alcoholism. Those with severe food intolerances can also feel tired, thickheaded and irritable on waking – the reason for this is thought to be the early onset of withdrawal symptoms resulting from the night fast.

Reactive, or functional, hypoglycaemia

This problem is the main subject of this book. It defines a type of chronic low blood sugar that usually requires an appropriate dietary strategy and supplement use. The symptoms can occur at any time and, for many unfortunate sufferers, can be virtually continuous.

WHAT HAPPENS TO THE BLOOD?

The symptoms of low blood sugar can develop as a result of two principle changes in the blood sugar. These changes can involve either the actual low level of the blood sugar or the speed of fall in the blood sugar. Unfortunately the human brain cannot store glucose, so even a five per cent fall in the available glucose supply to the brain and nervous system can produce an adrenal response with subsequent symptoms.

WHAT ARE THE IDEAL GLUCOSE LEVELS?

The normal level of our fasting blood sugar (fasting refers to food avoidance for 12 hours) is 4–7mmol/L. Many diabetic clinics define a patient’s symptoms as ‘hypo’ if a patient’s blood falls below 4mmol/L. However, I have frequently seen great symptom variations in a patient’s response to low blood sugar levels, although generally I have found that a blood sugar level below 3.5mmol/L can predictably cause symptoms to surface.

The American doctor and nutritionist Carlton Fredericks, a renowned authority on low blood sugar, stated “when blood sugar drops as little as 0.25mmol/L below the normal for the patient, a profound glandular compensation may start’. However, as mentioned above, a low level of blood sugar is not the only cause of low blood sugar symptoms – an inappropriately rapid fall in the blood glucose can also give rise to symptoms.

SPEED OF FALL IN BLOOD SUGAR

A rapid fall in the blood sugar level (for whatever reason) in excess of 1.5mmol/L in one hour can produce symptoms of low blood sugar. These changes occur irrespective of the actual level of blood sugar, for example a fall from 7mmol/L to 5mmol/L in 30–45 minutes can often cause low blood sugar symptoms to develop.

Both of the trigger factors that cause low blood sugar symptoms – i.e. speed of fall and a general low level – are subject to individual variations. I have seen patients who appeared to be symptom-free with a blood sugar level of 2.5mmol/L and others with levels around 3.5mmol/L who could barely walk or talk.

Insulin-dependent diabetics can ‘hypo’ when they overdose on their insulin requirements in relation to food and/or activity. Glucometers are used to check their blood glucose levels. Early models were designed to measure high blood sugar levels, however the more recent glucometers can measure blood sugar levels as low as 1.5mmol/L with a finger-prick blood sample. Accurate results can be achieved within 6–60 seconds, depending on the model used.

The problems caused by too much sugar

The high-carbohydrate Western diet provides sugar far in excess of our energy needs. Consumption of sugar alone in Great Britain amounts to 27kg (60–65lb) per person per year. If you include the sugar-rich refined carbohydrates we eat (for example, sweets, chocolates, cookies, cakes, cereals, soda and cola drinks) then our total sugar ‘load’ can be as high as 90kg (200lbs) per person (the figures in the US follow close behind). In terms of calories, one teaspoon of sugar per day equals 100 calories per week, so the amount of calories consumed by someone at the top end of the sugar-intake scale is vast.

When we eat sugar, we either use it for energy needs, or it is stored as glycogen or fat. Marathon runners know that they need to consume extra carbohydrates three to four days before a race to provide stored fuel for gradual release during the race. Likewise, those who do heavy manual work can often avoid weight and health problems as a result of converting all their food (fuel) directly to energy.

The experience of the explorer Sir Ranulph Fiennes clearly demonstrates how important it is that we match our energy intake to our output. On an Arctic trek, Fiennes lost weight despite consuming 5000 calories a day. In spite of his high calorie diet, his energy requirements meant he utilized a total of 11,000 calories each day. His subsequent weight loss was therefore inevitable. Perhaps we could justify our high sugar diets with marathon running or polar exploration – not popular choices. Fortunately there are other solutions (these are discussed in Part Two).

Insulin

Central to the problem of low blood sugar is the hormone insulin. Any rise in our blood sugar requires an insulin response. Insulin is a hormone secreted by the pancreas to lower blood glucose levels; it does this by transporting the glucose to the muscle cells and other tissues. Insulin is uniquely the only hormone to promote food (fuel) storage for future use. For this reason it is often termed the storage or fattening hormone.

This storage facility was essential for human survival several thousand years ago, for the early hunter-gatherers were very similar to the present day big cat carnivores in Africa and India. Their eating habits consisted of large meals perhaps every three to four days. The ability to store food was therefore a vital survival strategy. Unfortunately 21st-century men and women follow a largely sedentary lifestyle yet they often eat carbohydrate-rich meals and snacks three to six times daily. Our metabolism can only convert a small amount of excessive sugar to glycogen, which is stored in the liver and muscle cells. The remainder is stored as fat. Our food is our fuel and if the fuel is not required it is stored and excess weight is the result.

However, a sugar-laden diet does not only lead to the storage of fat. Because the insulin response is constantly being overworked, it can become less efficient as the cells become less sensitive and resistant to the effect of the insulin.

INSULIN RESISTANCE

This gradual loss of sensitivity to the blood insulin results in an increase in the level of insulin as the pancreas secretes more and more in an attempt to normalize the blood sugar balance. The end result is an on-going high level of blood insulin (hyperinsulinaemia). This excess insulin promotes more fat storage at the expense of available energy. High-sugar and high-carbohydrate eating can eventually lead to obesity, high blood fats, high blood pressure and fatigue (this group of disorders is known as Syndrome X, or metabolic syndrome). Such inappropriately high levels of blood insulin can cause chronic irritable bowel syndrome, adrenal exhaustion and disturbances to the female hormonal balance (as in Polycystic Ovary Syndrome).

The adrenal response

Although the brain and nervous system rely on blood sugar as the chief nutrient, excessively high levels of blood sugar can cause damage to nerve cells.

The temporary fall in the blood sugar caused by the insulin response to food triggers adrenal compensation, where adrenaline is released to counter the effect of the low blood sugar. This yo-yoing of the blood sugar levels can lead to a chronic imbalance in the blood sugar control (dysglycaemia), causing adrenal deficiency and a reduced thyroid hormone output. The thyroid gland reflects our metabolic rate and mild hypothyroidism can result from adrenal exhaustion.

The role of the adrenal hormone adrenaline in the blood sugar narrative highlights a design fault in our body chemistry. This vital hormone has two major functions. These are stress-handling (the so-called fight or flight response) and raising our blood sugar when the level falls too low.

As any athlete knows, adrenaline increases the metabolic rate, the heart rate, the blood flow to muscles and the oxygen intake. In a primitive society this would prepare us to either run or attack. However, for those of us who suffer from low blood sugar (which causes our brain and nervous system efficiency to be compromised), the adrenaline response that occurs is identical to our reaction to any type of stress. This explains why so many sufferers of long-term low blood sugar experience episodes of aggression and mood changes – examples being women with pre-menstrual syndrome and diabetics or non-diabetics who ‘hypo’. Our metabolism cannot identify the reason for the adrenal surge, hence the stress response that occurs with low blood sugar.

Summary

The modern high carbohydrate/sugar diet, coupled with our sedentary lifestyle, has lead to an increase in many low blood sugar symptoms, including obesity, fatigue and poor stress handling. The subsequent adrenal compensation and exhaustion can result in mild hypothyroidism, high blood pressure and subsequently Syndrome X. Anxiety, depression, elevated blood fats and metabolic depression can be the consequence.

In the next chapter we look at the many symptoms that can result from low blood sugar.

CHAPTER 3 The symptoms of low blood sugar

One of the main problems in accurately diagnosing low blood sugar is that many of the symptoms of the condition can have other causes.

General symptoms and problems

To discuss the diversity of symptoms caused by low blood sugar would take up most of this book. However, the list below is a representative selection of the most common symptoms that can be caused in part or wholly by low blood sugar.

Fatigue | Anxiety | Depression
Irritability | Forgetfulness | Poor concentration
Indigestion | Breathlessness | Panic feelings
Headaches | Migraine | Asthma
Overweight | Food cravings | Excessive smoking
Alcoholism | Vertigo | Sweating
Pre-menstrual tension | Muscular stiffness | Phobias
Numbness | Blurred vision | Cold extremities
Joint pain | Fainting and blackouts | Convulsions
Nightmares | Lack of sex drive | Allergies
Angina | Suicidal tendencies | Irritable bowel symptoms
Epilepsy | Stomach cramps | Stomach ulcers
Hyperactivity | Neuralgia | Agoraphobia
Narcolepsy | Tinnitus |

I am sure there will be many eyebrows raised at the great variety and number of symptoms I have listed and, at first sight, it is difficult to imagine that there is a common theme to all these conditions.

Interestingly though, many of the symptoms of low blood sugar are classed by doctors as ‘stress disorders’ and I hope to show, by describing the effect of sugar on the nervous system, that many of these symptoms are in fact due to nutritional imbalances and not ‘personality failings’. You may see several of your own symptoms on the list; but simply to scan this list, recognize your symptoms and blame low blood sugar is not the answer. As previously stated, many of these symptoms may have other causes, not least of which could be stress.

Self-diagnosis is therefore not advisable; a naturopath or sympathetic doctor should be able to offer more objective diagnostic methods. These can include, in addition to detailed case-history taking, the six-hour glucose tolerance test, the measurement of adrenal and thyroid hormones and a blood insulin test (these will be discussed in due course).

At some time in their lives most people experience one or more of the symptoms listed above. They are usually caused by transient low blood sugar – a temporary or passing fall in the blood sugar level. This is rapidly rectified by the body’s own sugar regulation mechanism. Once a balance is achieved, the symptoms usually disappear. If, however, there is a chronic imbalance in our sugar regulation, the symptoms may well improve or change, but they will always return if the actual imbalance is not corrected.

Now let us look more closely at the way in which a drop in the blood sugar directly affects the various organs and systems of the body, giving rise to the symptoms outlined. In this way you will begin to understand why the blood sugar level is so important to the normal running of the body. The effects of low blood sugar can be classified as follows:

Nervous system changes

The main nutrient needed by the nervous system is glucose. There is no really adequate substitute and, although other substances are involved, they cannot replace glucose. Unfortunately, it is not fully understood just how glucose acts on the nervous system, but it has been noted that when a healthy patient is injected with insulin (the opposite of glucose), profound and sudden changes in the efficiency of the nervous system occur within minutes. This is completely reversed by an injection of glucose. This tends to confirm that the nervous system requires a continuous supply of glucose in order to function efficiently.

Although the weight of an adult brain is only two per cent of the total body weight, the activity of the brain, in terms of utilization of glucose, may amount to 20–25 per cent of the total body activity. In spite of this, the total amount of glucose concentrated within the brain at any one time would, under normal conditions, be exhausted in 10–15 minutes. The effects of glucose starvation on the brain and nerve tissue as a result of a low level of blood sugar are as follows:

1 Insufficient oxygen.

2 Reduction in specific substances within the brain that are essential for nervous activity.

Let us look at the symptoms that can result from such changes.

CIRCULATORY CHANGES

Not surprisingly, the system first affected by a drop in the blood sugar level is the blood circulatory system. This, of course, includes the heart and blood vessels. When the blood sugar falls, the body automatically reacts in an attempt to restore balance to the system. This response involves the release of adrenaline from the adrenal glands, to raise the blood sugar. Adrenaline is also released in stressful situations. This means that if an individual has persistent low blood sugar, they may have symptoms similar to those produced by chronic stress. These can include:

1 An irregular increase in the heart rate, causing palpitations and breathing difficulties.

2 Angina-like symptoms involving a reduction in circulation to the heart muscle, chest cramp and pain in the chest and arms.

3 A general withdrawal of blood to deal with the ‘stress effects’, causing coldness of the hands and feet, muscular cramp and a poor adaptation to temperature changes.

GLANDULAR CHANGES

The changes involved in the glandular system following a drop in the blood sugar level are widespread and could well provide sufficient material for another book. However, in this context, it is adequate simply to briefly look at the glands affected.

1 Pituitary gland. This is the master control gland influencing the thyroid and adrenal glands.

2 Adrenal glands. These glands produce adrenaline, cortisol (hydrocortisone), DHEA and other hormones. It is the persistent stimulation of these glands in a patient suffering from low blood sugar that provides the causative link between blood sugar and rheumatoid arthritis. Overactivity, with subsequent exhaustion of the adrenal glands, can cause a reduction in the availability of cortisol and the ‘mother’ hormone DHEA, which provide protection against joint pain and inflammation.

3 Thyroid gland. Changes that occur with thyroid activity are of less significance than other glands. Although, like the adrenal and pituitary glands, the thyroid secretions are essentially antagonistic to insulin and thus thyroid imbalance can contribute to a blood sugar imbalance. A vicious cycle may be established whereby a mildly deficient thyroid causes low blood sugar and the subsequent adrenal stress can further depress the thyroid.

DIGESTIVE CHANGES

The changes in gastric (stomach) activity that occur with low blood sugar are mainly caused by the increased insulin level in the blood, rather than the actual deficiency of blood sugar. A standard hospital test to assess the efficiency of digestive activity involves administering to the patient an injection of insulin. This prompts a rapid and predictable increase in the amount of stomach acids, which are then measured. It follows that if this test has such an effect, the fluctuations of the insulin level in the blood – as occurs in low blood sugar and insulin resistance – would have a similar effect. Indeed, in practice, I find that many patients suffering from stomach ulcers, heartburn, hiatus hernia and other digestive ailments frequently have an underlying blood sugar imbalance.

Those with food intolerances may suffer symptoms that are partially caused by low blood sugar. Unfortunately, as a result of symptom similarity the two conditions are often confused.

PSYCHOLOGICAL CHANGES

As I discussed previously, changes in blood sugar can have a significant impact on the brain and nervous system – it is hardly surprising then that many patients suffering from low blood sugar also have personality problems. The most common symptoms found in low blood sugar patients are depression, anxiety and mental confusion. Many researchers, particularly in the US, consider chronic low blood sugar to be a contributing factor in such serious personality problems as schizophrenia and manic depression (bipolar disorder).

We know that low blood sugar can lead to fatigue of the adrenal glands, and that the adrenal glands are the body’s main defence mechanism against stress. It therefore seems likely that those with chronic low blood sugar can suffer a vicious circle of adrenal exhaustion, which causes anxiety, and with the anxiety comes further exhaustion and stress. Unfortunately, many people suffering from stress often overeat or comfort-eat the wrong foods. They also tend to miss meals, relying on caffeine, tobacco and alcohol for their fuel, thus further aggravating any blood sugar imbalance.

Respiratory changes

Surprising as it may seem, low blood sugar can also affect the respiratory system. The reason for this is a substance called histamine. This compound is naturally present in all the cells of the body and has a variety of uses – not least is its role in controlling osmosis (passage of water) between the body membranes. It is well known that if the histamine level increases, the characteristic symptoms can include hay fever, skin rashes and asthma. The link between histamine and the blood sugar exists because histamine and glucose are on separate ends of a seesaw. If the glucose level drops, the histamine level rises and vice versa. It follows that a patient who has low blood sugar may, under certain conditions, also have asthma or hay fever.

It is an interesting fact that diabetic patients rarely develop asthma; there are also very few cases on record of an asthma patient also having diabetes. (The main exception is the condition known as cardiac asthma, which is associated with heart disease). Many asthma patients find to their delight in their late 40s and 50s that their asthma symptoms improve. The reason for this is that they are developing late onset diabetes and their blood sugar has become raised above normal level, thus protecting them from asthma.

It should be said that low blood sugar is not the only cause of asthma; there are certain types of asthma caused by stress or extreme sensitivity to various allergens, vigorous exercise, infections and various irritant particles. A good medical dictionary will list more than 30 different types of asthma, usually defined according to their cause.

Musculo-skeletal changes

The other system of the body that is frequently affected by low blood sugar is the musculo-skeletal system – in other words, the muscles and joints. As already explained, the effect of the adrenal glands and, in particular, Cortisol on joint inflammation is well documented, hence the apparently miraculous symptom-relief afforded to rheumatoid arthritis patients when Cortisol is taken or injected. If the adrenal glands are overworked and fatigued as a result of prolonged low blood sugar, and the efficiency of steroid hormones that protect the joints from inflammation is compromised, joint pain, stiffness and swelling may result. This link between musculo-joint symptoms and stress is known to all of us. The expressions ‘pain in the neck’ or ‘pain in the butt’ illustrate the connection. Whether any adrenal exhaustion is caused by stress alone or indirectly caused by low blood sugar, the resulting joint and muscle symptoms are the same.

General symptoms of low blood sugar – the two stages

STAGE ONE SYMPTOMS – FALLING BLOOD SUGAR

The immediate symptoms that follow a fall in blood sugar result from a reduction in the brain and nervous system fuel (i.e. glucose). These first stage symptoms generally include mental and physical lethargy, partial or total loss of concentration, headaches, trembling and/or dizziness, a tendency to yawn, paleness of lips and face with either a skin coldness or heat with perspiration, unexplained anxiety and a sudden urge for chocolate or anything sweet.

STAGE TWO SYMPTOMS – ADRENAL COMPENSATION

The second stage symptoms are caused by the adrenal response to the low blood sugar level. For many people these symptoms are more distressing than those of the first stage.

The surge of adrenaline that occurs in response to low blood sugar causes symptoms identical to the body’s response to stress. The metabolism is literally revved up for action. The heart rate increases and the blood flow to muscles is stepped up. This can be likened to pulling out the choke on a car to increase the available fuel. Heavy sweating can occur, with breathlessness and unpleasant palpitations.

A frequent consequence of the stress reaction is a degree of irritability or even aggression – a good example being the mood swings of the diabetic patient. Those readers who have a diabetic friend or relative will know only too well that when a ‘hypo’ occurs the victim becomes both irritable and aggressive. Many people with low blood sugar symptoms show a degree of anxiety, irritability or depression – symptoms that often improve as their problem is resolved.

All this is part of our body’s normal reaction to stress. If we are confronted by an angry bull as we cross a field we need to increase our oxygenation, heart rate and muscle strength to hastily flee. Most athletes and competitive sports people know the value of this adrenaline effect, for the power and speed increase it can provide. They learn to control and at times to override the adrenal response to further their sporting goals.

For most of us this alarm-response by our body is in direct proportion to the intensity of the threat or stress. However, many who suffer with chronic low blood sugar lose their fine control and an adrenal hair-trigger response to stress of any kind leads to frequent and often unnecessary alarm-responses. When adrenaline is released on a regular basis for trivial reasons, many distressing symptoms can develop. Some sufferers, for instance, are frequently awakened at 3–4am bathed in sweat, anxious, with a rapid pulse and short of breath. This occurs because the adrenal response to their nocturnal low blood sugar is being inappropriately triggered and their metabolism is stressed.

Unfortunately, even when we sleep changes in the blood sugar can activate the adrenal response. Professor Hans Selye, who wrote the definitive first description of our response to stress in his landmark 1956 book The Stress of Life, described sleep as follows: ‘No one is ever absolutely at rest, while alive. Even during sleep, your heart, your respiratory muscles, your brain continue to work. It makes no difference that you are not conscious of this and that these activities require no voluntary effort on your part’.

Our management of stress is a very individual quality that depends on many factors. The amount and type of activity appropriate to a five-year-old child would be very stressful for a 75-year-old man and vice versa. Our stress load and our stress handling are unique to each of us. Stress can, of course, be on many levels, psychological, chemical, structural or environmental. It does not always need to be unpleasant or unexpected to give rise to symptoms. Enjoyable, planned events can also be stressful – excited children becoming sick at parties and sports people suffering asthma attacks are examples of this.

Trigger factors

The most common triggers that can cause low blood sugar symptoms include one or more of the following:

Excessive sugar consumption.

Unexpected shock from any cause.

Unaccustomed or excessive exercise.

A delayed or missed meal.

Excessive caffeine intake (e.g. cola drinks or coffee).

Excessive alcohol.

The 3- to 5-day pre-menstrual time for women.

CHAPTER 4 The diagnosis of low blood sugar

I have diagnosed and treated patients with low blood sugar for 35 years, and over this time I have learnt that a simple diagnosis of ‘low blood sugar’ is rarely helpful for the patient and not always accurate. Indeed the diagnostic challenge with low blood sugar symptoms is to provide satisfactory answers to the following questions:

1 Are the symptoms of low blood sugar seen in a patient the result of poor stress handling or a faulty diet, and therefore transient and probably reversible? or

2 Are the symptoms the result of a chronic glandular imbalance, long-term stress, excessive reliance on caffeine, tobacco, alcohol and other drugs, or the many other factors associated with dysglycaemia?

In fact, many people with the symptoms of low blood sugar have several causes running parallel. As low blood sugar masquerades as so many different conditions, and can create such a diversity of symptoms, diagnosis can be difficult. For this reason, and others that will be discussed later, it is not wise to diagnose low blood sugar without professional help. Low blood sugar mimics very many serious diseases and it is therefore essential that the possibility of more serious causes for the symptoms is ruled out.

The clinical diagnosis of low blood sugar falls naturally into several stages.

Family history

Low blood sugar disorders can pass from generation to generation. It therefore follows that a detailed evaluation of a person’s family health is of considerable diagnostic value.

Table 1 – The family connection, 25 patients

Table 1 illustrates the family history of 25 patients with confirmed low blood sugar. These patients have been selected because they are typical low blood sugar cases. You will see that characteristic disorders pass through each family. The majority of patients with low blood sugar symptoms tend to show a previous history in their family of either asthma, migraine, hay fever, diabetes, obesity, chronic fatigue or depression.

Present symptoms

As we know, the symptoms of low blood sugar can be misleading to the diagnostician. Often of more significance than a list of symptoms are the pattern of cause and the time of onset of symptoms. One patient, Mr A, may experience headaches when reading or watching television, while another patient, Mr B, may develop headaches only in the early morning or when he drinks certain types of wine. In the case of Mr A, he may well have eyestrain, but Mr B could be suffering from low blood sugar.

Fatigue at the end of the day may be caused by overwork, anaemia or a variety of ailments. Fatigue on rising, which improves towards the end of the day, offers a strong clue to the possible diagnosis of low blood sugar. A subjective evaluation is never easy, for unless one is familiar with the diagnostic value of symptom patterns, it is very difficult to diagnose one’s own problems.

One of the chief characteristics of low blood sugar sufferers is the combination of physical and mental symptoms coupled with considerable variation in the symptoms. Sometimes the patient may feel on top of the world; at other times he or she may feel exhausted and depressed for no apparent reason. Remember, we are not dealing with a predictable organic disease such as arthritis or anaemia, but an imbalance in the nervous, circulatory, digestive and endocrine systems. Therefore any symptoms may be the expression of a great number of interrelating and fluctuating causes. These causes can include diet, emotional state, menstruation, time of day, stress, fatigue, the side effects of drugs and many other factors.

Past health

No illness suddenly arrives. There are always changes in the body before the symptoms become apparent to the patient. With low blood sugar the early symptoms are usually vague and difficult to identify. The commonest symptoms are fatigue associated with a dulling of concentration, irritability and mild anxiety or depression, feeling thick-headed on waking and a distinct loss of zest before mid-morning.

Early symptoms may also include transitory feelings of panic or breathlessness with cold sweating and headaches, often accompanied by a craving for something sweet. Such symptoms are often diagnosed as being due to overwork, stress or just ‘nerves’. The usual sedatives and relaxants are prescribed, but if symptoms are caused by low blood sugar, any relief will be only temporary. The fatigue will still be there, often without excessive effort or work, and the anxiety will persist, despite a lack of stress.

It is unfortunate that many people with low blood sugar suffer their symptoms because of a false diagnosis. Often they are classified by doctors and family as neurotic when, in fact, the cause of their symptoms is physiological and not psychological.

When looking into a person’s history, disorders often feature that provide clues to future low blood sugar. These include hepatitis, jaundice, morning sickness during pregnancy, biliousness and intolerance of fats, a history of gall bladder trouble, chronic fatigue and overweight. The role of the body’s early warning system is to indicate the development of a biochemical imbalance or damage of some kind. If the early symptoms of low blood sugar are accurately diagnosed before the obesity, fatigue, migraines and diabetes develop, a great deal of pain and distress may be avoided.

Dietary habits

Faulty nutrition is the single most important cause of low blood sugar. The modern Western diet, with its high sugar content, refined starches, artificial additives and low nutritional value, provides an appropriate formula for causing blood sugar imbalances. If we also consider the modern habits of snack meals, frequent coffees and the excessive use of drugs, alcohol, cola drinks and tobacco, it is no surprise that the incidence of high and low blood sugar conditions is increasing at an alarming rate.

As poor diet is a key factor in the development and maintenance of low blood sugar, it is obviously an important clue in the diagnosis of the problem. I find in practice that most low blood sugar sufferers have characteristic dietary habits that provide important leads to the cause of their symptoms. It must be remembered that, for these patients, meals are not simply a question of choice, for the pattern of meals and type of food is strongly influenced by the underlying low blood sugar. Sugary foods and drinks and caffeine-rich or alcohol-rich drinks all provide temporary relief to the symptoms of low blood sugar. Not surprisingly, the diet reflects this and is usually high in these items and in particular there may be cravings for sweet foods far in excess of normal consumption. One of the most significant clues is a person’s sugar intake – two to three teaspoonfuls in either tea of coffee is not unusual. Smoking can also be a clue, as many tobacco addicts experience low blood sugar symptoms.

Because our blood sugar is linked to the appetite, a frequent symptom is hunger. This is not a general feeling of hunger, but more often a craving for a certain type of food. However, the low blood sugar patient, because of the symptoms produced by his condition, often cannot face food. This usually occurs at breakfast time as the blood sugar drops overnight. The thought of breakfast can make a person with low blood sugar feel physically sick. Usually a coffee or cigarette starts the day, and the inevitable ‘high’ provided by the caffeine produces a mid-morning ‘low’ as the blood sugar drops again. So the day consists of small frequent ‘shots’ of sugar or caffeine to maintain the energy level and the concentration at a tolerable level.

When the blood sugar has sunk to a low level, usually around 3–5am, the low blood sugar sufferer often wakes with stomach cramp, indigestion or just hunger – for this reason they are often night nibblers.

The two diets listed below are those of two patients seen in my practice. Every characteristic of the typical eating habits associated with low blood sugar can be seen here.

Example 1

Breakfast: Cereal with sugar and milk, 4–5 cups of tea with 1 teaspoonful of sugar in each cup

11 am: Tea with a biscuit or cake

Lunch: Sandwich with tea and biscuit

4pm: Cake with tea

Dinner: Meat and vegetables with sweet dessert, cup of tea

Supper: Crackers, cheese, biscuits and tea

Tea: 12–14 cups daily

Coffee: rarely

Cigarettes: 20–30 a day

Sweets and chocolate: 100–175g (4–6oz) a day

Alcohol: 20–25 units weekly

Example 2

Breakfast: 2 coffees with 2 1/2 teaspoonfuls of sugar in each

11am: Coffee with biscuits

Lunch: Toast with egg or cheese, 2 coffees

4.30pm: Cake with coffee

Dinner: Meat and vegetables followed by coffee

Supper: Cake with coffee

Tea: nil

Coffee: 8–10 cups daily

Cigarettes: 10–12 a day

Sweets and chocolate: 50g (2oz) a day

Alcohol: 15–18 units weekly

Physical examination

There is only one physical sign linked to low blood sugar – a tenderness over the pancreas in the left upper quadrant of the abdomen, often extending as low as the umbilicus. This tenderness is felt just below the ribs, or at times round the side of the ribcage. It is caused by pancreatic sensitivity due to hyperinsulinism. (The functions of the pancreas include the secretion of various substances including insulin to lower blood sugar, and glucogon to raise the blood sugar.) In practice, I find that if I press most patients’ abdomens hard enough they are tender in most places. It is important therefore to press with the same gentle pressure all over the stomach, liver and pancreas areas – and then ask the patient, ‘which is the most tender?’ The fingers encounter a feeling of tightness, or even hardness, accompanying the discomfort. This sign usually disappears as treatment progresses and provides confirmation that the situation is normalizing.

Although the patient’s weight, colouring, blood pressure and so on are all significant in low blood sugar, they are all influenced by many other disorders and are therefore not of special value in diagnosing low blood sugar.

The six-hour glucose tolerance test (GTT)

Often a two to three hour GTT is requested by doctors and hospitals, but although this shortened test maybe sufficient for a diagnosis of diabetes, it is virtually valueless as a means of establishing a diagnosis of low blood sugar. The important evidence of low blood sugar can often only occur after more than two hours.

The six-hour GTT test is a far more appropriate method of diagnosing low blood sugar. However, in my opinion it is only a valid diagnostic tool if the following conditions are met:

1 It is combined with a physical examination.

2 A detailed case history is recorded before the test.

3 The patient has described and listed his own diet and symptoms.

4 The patent’s reactions and symptoms during the test are noted and timed.

5 The glucose dosage and timing of blood sample taking is standardized for every test.

6 No dramatic changes have recently been made to the diet.

7 The physician is fully aware of any drugs being taken by the patient.

It must be remembered that some people show mild symptoms while other patients show pronounced symptoms even with a ‘normal’ blood sugar level, hence the need to standardize the test procedures and to know each patient as thoroughly as possible before the test.

TEST PROCEDURE (AUTHOR’S PROTOCOL)

The patient is requested to undergo a 14-hour fast (water only permitted), and to attend the surgery at 9.00am. The fast is no great hardship as only breakfast is missed. Obviously it is important that no food or drink (except water) is taken until the test is completed at 3.30pm. As cigarettes and certain drugs influence the blood sugar it is essential not to smoke during the test, and patients are requested to provide information at least a week before the test on their current medical treatment.

During the course of the test, seven small blood samples are taken. The first sample, taken at 9.15am, shows the level of fasting blood sugar (FBS). At 9.30am the patient is given 50g (2oz) of soluble glucose dissolved in approximately 500ml (16fl oz) of water. The remaining six blood samples are then taken to monitor the effects of the glucose on the patient’s blood sugar level. The amount of glucose used in the GTT can vary, 100g (4oz) being the usual test dose in the US. This higher dose can occasionally make the more sensitive patients nauseous or faint, and it is not normally used in the UK. (There is no available evidence to suggest that the higher dose improves diagnostic accuracy.)

The blood sugar level is constantly changing and even with seven samples taken in six hours, one obtains only a guide to the dynamics of blood glucose activities. For this reason, the highest reading may in fact lie between two samples. If I suspect that this has occurred and the speed of the patient’s insulin response has been so rapid that the GTT has not confirmed a diagnosis, a repeat test is carried out. This is a shorter version, also using 50g (2oz) of glucose, but with a sample taken every 15 minutes over a 1¹/2-hour period. In this way the all-important upper figure is more precisely assessed.

The timing of when the samples are taken is obviously at the convenience of the practitioner. I find the following schedule most suitable.

Patient arrives |  | 9.00am
Sample 1 | FBS taken | 9.15am
| 50g glucose taken(drunk quite rapidly with 2 glasses of still mineral water)

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