Hypoglycemia After Gastric Bypass Surgery

What is hypoglycemia?
Hypoglycemia refers to low blood sugar. Low blood sugar can be dangerous since your brain
requires normal blood sugar levels to function normally, so if untreated, severely low blood
sugars can cause passing out (loss of consciousness), seizures, car crashes, or other more serious
outcomes. Normal levels of glucose are typically always above 70 in the fasting state (first thing
in the morning before eating), and usually range from 70-120 other times of the day in people
without diabetes.

The major organs in your body important for maintaining normal blood sugar levels are your
pancreas and your liver. The pancreas makes and releases insulin into the blood stream.
Normally, when you eat a meal, the pancreas makes insulin and helps to keep blood sugar levels
normal. The liver is also very important to help maintain blood sugar levels, since it actually
makes glucose, particularly between meals and overnight when you are not eating.

There are two broad categories of hypoglycemia:

(1) Fasting – low blood glucoses in morning, or when no food has been eaten for many
hours
(2) Postprandial, or after meal (also called reactive) hypoglycemia is when blood sugar
levels drop too low within a few hours after eating.

Hypoglycemia may occur due to many medical conditions. The more common type of
hypoglycemia in people who have had gastric bypass surgery is postprandial hypoglycemia,
and may occur because a lot of insulin is released in response to eating, and the insulin removes
too much sugar from the blood. In some cases, this may be very severe if the pancreas is
making too much insulin (hyperinsulinemia due to overproduction of insulin from the islets of
the pancreas).
What are the symptoms?
Some or all of the following symptoms are felt 1-4 hours after eating:
 Weakness
 Nausea
 Extreme hunger
 Headaches, especially first thing in the morning (may indicate a low blood sugar has
occurred overnight)
 Dizziness
 Sweating
 Difficulty concentrating or thinking
 Racing or rapid heartbeat
 Nightmares or bizarre dreams – may indicate a low blood sugar while you are sleeping
 Importantly, you may have NO symptoms, but others may notice that you are staring,
not paying attention, seemingly less attentive, “not looking quite right.”

How can I TREAT a low blood sugar?

Even though you may experience dumping syndrome (abdominal cramping, lightheadedness and
diarrhea), it is critical to treat a low blood sugar quickly so that your brain has enough glucose to
function normally, and to prevent you from passing out. Here we need to use sugars to bring the
glucose level up quickly.

1. Stop what you are doing - sit down.

2. Test your glucose, if possible, to verify that it is low.

3. Eat 15 grams of carbohydrate in the form of one of these “hypoglycemia treatments”:

 4 oz of juice (small juice box works great)
 3 tsp sugar
 3 tsp jelly
 1 small box of raisins
 3 glucose tablets or 4 dextrose tablets
 7-8 lifesavers (chew and swallow)
 5-15 jellybeans (carb content varies from 1-3 g/bean – need to check label)

4. Retest after 15 minutes. Repeat treatment if glucose is under 80.

 5. After you treat the low, eat a protein food (but NOT low fat ones) to prevent the low from
returning – this is a critical step. Some examples include:

a. roast beef (1 ounce),

b. cheese (1 ounce)
c. cottage cheese (1/4 cup)
d. ricotta cheese (1/4 cup)
e. peanut butter (1 tablespoon)
f. nuts (1ounce)
g. milk (1 cup)

6. Keep glucose tablets or glucose gel with you at all times. These are available at any
pharmacy and do not melt or require refrigeration. Keep some in your pocket or purse,
next to your bed, and in your car for emergency use. You don’t want to take the time to
search for a glucose source when you are having a low blood sugar! You may also find
peanut butter tubes and juice boxes convenient for the car.

How can I PREVENT reactive hypoglycemia?

It is really crucial to prevent lows – your brain needs glucose to function normally, so we would
like to keep your brain healthy and happy. It is always better to prevent a low, rather than rely
on treatment, which (despite our best efforts) can result in a “roller-coaster” pattern (alternating
high and low blood glucoses). Note that prevention focuses on using slowly digested foods – as
opposed to treatment, which requires simple sugars to get the blood glucose up quickly once it
has dropped.

Modify your diet.

At meals, eat controlled portions of low glycemic carbohydrates together with a protein
food. Low glycemic carbohydrates are digested slowly. The fat in the protein food also slows the
digestion of the carbohydrate. This will lead to less of a “spike” in blood glucose and less
stimulus for insulin secretion (which is what you are trying to avoid).

Carbohydrates that are high in fiber are typically slowly digested. Read labels and seek
products that are made with whole grains and whole grain flours rather than enriched flour,
which has the bran and much of the fiber removed.
Avoid high carbohydrate foods by themselves or in excess amounts (>30 g per meal).

When you are eating carbohydrate, pick from this list (low glycemic carbs)

brown rice
yams/sweet potatoes
beans and legumes: navy, kidney and pea beans, chick peas, soybeans (edamame), lentils
some fruits: berries, grapefruit, oranges, cherries, lemons, limes, apples, pears
whole grain crackers: RyKrisp, RyVita, Wasa
products made with 100% whole grains and/or unprocessed bran: stone ground whole wheat
breads, steel-cut oats, wheat and oat bran cereals.
most vegetables: broccoli, green beans, asparagus, lettuce, Brussels sprouts, cabbage, raw
carrots, celery, tomatoes
bean products: tofu, hummus

AVOID

some fruits: bananas, pineapple, watermelon, raisins, cantaloupe, grapes, plums

all fruit juices
refined cereals: Corn flakes, Rice Krispies
pasta
short grain rice
rice cakes or popped corn
refined crackers: Saltines, Ritz
white bread, rolls, bagels
Pretzels ,starchy vegetables: potatoes, corn, winter squash
sweets: candy, cakes, cookies, syrups, Soda

 Avoid sugar substitutes made with sugar alcohols such as Sorbitol or Mannitol.

 Include a high protein food with each meal and snack. High protein foods include
fish, chicken, turkey, meat, ham, eggs, nuts, and cheese.

 Include healthy fats in your diet. Fat from soybean oil, olive oil, canola oil, nuts, seeds,
soybeans, and avocado. Fish, such as mackerel, salmon and blue fish, not only contain
high quality protein but also contain healthy fats.

 Include high fiber, non-starchy vegetables with most meals. Examples are romaine
lettuce, broccoli crowns, asparagus tips, summer squash (yellow, zucchini & spaghetti
 squash), tomato, carrots, turnip, spinach, cauliflower, eggplant, green beans, cabbage, and
cucumbers.

 Try eating 3 small volume meals a day, rather than 3 larger meals. If you eat snacks
between meals, choose non-carbohydrate foods.

 Eat carbohydrate with protein before exercise. Some examples may be whole-wheat
crackers with milk, cottage cheese, or peanut butter.

 Drink liquids primarily between meals.

1. Learn how to monitor your blood glucose level to gain awareness of how low your blood
glucose levels are dropping and to identify patterns of low blood glucose, particularly in
relationship to meals, exercise, and alcohol (all of which may provoke or aggravate low
glucose levels).
 Always, always PLEASE test your blood glucose before driving – you don’t want to hurt
yourself or someone else.
 Test your blood glucose before exercise and before bed.
 Purchase and wear a medical ID bracelet, which says that you have hypoglycemia.
Always wear it. This can be lifesaving! Medic-Alert (www. Medicalert.com) and other
companies make these.

2. Ask your doctor for a prescription for a glucagon emergency kit. Have someone in your
family who lives with you learn how to use it. This is a hormone which can be injected
under the skin into the muscle to raise your glucose level if you are unable to treat a low
blood sugar yourself – for example, if you have passed out.

3. Educate family and friends about low blood glucose, so they may be able to recognize
signs and symptoms in you and assist you if necessary.
If, despite the above treatments, you continue to have low blood glucose, you may need to
be evaluated by an endocrinologist with expertise in post-gastric bypass hypoglycemia. You
may have an excess number of insulin-producing cells in your pancreas requiring additional
testing and therapy to improve blood glucose levels. This may include additional medications
and/or surgery to decrease the amount of insulin your body produces.

Mix-and-Match Snacks
Remove all tough skin and chop seeds and nuts

1. Hummus and pita

1 oz whole-wheat pita with 2 TBS hummus

2. Extend Bar (www.extendbar.com)

These are made with uncooked cornstarch, a very slowly absorbed carbohydrate, and can
prevent low blood glucose levels. It may be useful to eat one at bedtime (to prevent low
blood glucose in the middle of the night) and one in the mid-morning (to prevent low in
late afternoon).

3. Yogurt and chopped nuts

4 oz light low fat yogurt topped with 1 TBS chopped nuts

4. Apple and peanut butter

1 medium apple and 1 TBS peanut butter

5. Toasted cheese and tomato on wheat

Top 1 slice whole wheat bread with 1 oz cheese or avocado and 2-3 slices tomato. Toast
in toaster oven.

6. Cottage cheese and berries

½ cup strawberries or blueberries and ½ cup cottage cheese topped with 1 TBS chopped
soybeans. Sweeten with Splenda if desired.

7. Veggies with dip

1-cup raw baby carrots or broccoli florets and 1/3-cup cottage cheese vegetable dip

8. Mexican tortilla wrap

Top an 8-inch whole-wheat tortilla with ¼ cup refried beans, ¼ cup shredded cheese, and
1 TBS salsa. Microwave for 15-20 seconds and roll.

9. Celery and peanut butter

4 3- inch raw celery sticks and 1 TBS peanut butter

10. Ricotta cheese dessert

 ½ cup part skim ricotta cheese mixed with 1 packet sugar substitute. Sprinkle with
cinnamon and 1 TBS almonds.

11. String cheese and crackers

1 mozzarella string cheese and 1-2 RyVita or Wasa whole-wheat crackers

12. Tuna salad pita

1/2 (1oz) whole-wheat pita filled with ½ cup tuna, 1 TBS mayo, and alfalfa sprouts

13. Tomato and cottage cheese

1 small tomato cut in wedges topped with ½ cup cottage cheese and sprinkled with
chives

14. Smoked salmon and cream cheese

1 slice whole-wheat bread topped with 1 TBS cream cheese, 1 thin slice red onion and 1
oz smoked salmon

15. Egg and spinach salad with chick peas

1 sliced hard cooked egg, 1cup baby spinach, ¼ cup canned chickpeas, 1 TBS olive oil
and balsamic vinaigrette. Toss spinach with vinaigrette, place in serving dish, sprinkle
with chickpeas and place sliced egg on top.
6 of 6

Nutritional Guidelines for Reactive Postprandial Hypoglycemia

What is Reactive Hypoglycemia?

Hypoglycemia means low (hypo) blood glucose (glycemia).

Reactive hypoglycemia can occur due to over-secretion of insulin in response to a meal. This
increase in insulin causes the blood glucose level to fall. If the blood glucose level falls below
normal, certain symptoms may occur. These symptoms may include sweating, shakiness,
weakness, hunger, headache, and irritability.

Reactive hypoglycemia is diagnosed when blood glucose falls below 55 mg/dl and symptoms
occur at the same time. Recording blood glucose measurements during the time of the
symptoms is necessary to establish the diagnosis.

Treating Reactive Hypoglycemia

The goal of treatment is to prevent the over-secretion of insulin into your blood. You can
accomplish this by limiting the amount of carbohydrate in your meals and by eating meals that
are digested relatively slowly. Consider the following guidelines to help you choose foods that
will decrease your risk of experiencing low blood glucose levels after eating:

1. Eat smaller meals and eat more frequently during the day.
This will help spread carbohydrate foods throughout the day and keep
blood glucose levels more stable.

2. Control the amount of total carbohydrate in your meal or snack.

A Registered Dietitian can help you to develop a personal meal plan with
carbohydrate goals that meet your needs.

3. Increase your intake of fiber-rich carbohydrates.

Fiber is the indigestible part of fruits, vegetables, grains and nuts.
Fiber, if eaten in adequate amounts, helps to slow the absorption of
carbohydrates into your blood. Sources
of fiber include: beans, lentils, peas, vegetables, nuts, seeds,
and whole-grain breads and cereals.

4. Include a small amount of healthful fat at each meal.

A small amount of healthful fat (olive oil, canola oil, nuts) can help to
stabilize blood glucose levels because fat slows the digestion of
carbohydrates.

5. Avoid or limit alcoholic beverages.

Alcohol can lower blood glucose levels, especially when taken on an empty stomach.

6. Avoid or limit foods and beverages containing caffeine.

Caffeine can cause the same symptoms as hypoglycemia.
Examples: regular coffee and tea, cola-type sodas, dark chocolate.
Better choices include water, seltzer, decaf coffee and herbal teas.
SAMPLE MEAL PLAN FOR HYPOGLYCEMIA

Exchanges Carbohydrate Sample Menu

Grams

Breakfast

2 starches 30 5 ½ cup oatmeal & 1 slice whole grain

toast
1 fruit 15 1 ½ grapefruit
½ milk or 0-6 ½ cup skim milk
1 lean protein or 2 Tbsp peanut butter
1 healthy fat _____ ____ 1 tsp. tub margarine
45-51 6
Morning Snack

1 starch 15 1 3 whole wheat crackers

1 lean protein with 10 peanuts
or 1 healthy _____ ____
fat
15 1
Lunch

2 oz. lean 2 oz. turkey

protein
2 starches 30 2 1 6” whole wheat pita
1 vegetable 5 1 lettuce & tomato salad
1 fruit 15 3 1 small apple
½ milk 6 ½ cup skim milk
1 healthy fat _______ ____ 1 Tbsp. light mayonnaise
56 6

Afternoon Snack

1 starch 15 3 3 cups microwave light popcorn

1 lean protein or 6 saltines w/ ½ cup lowfat cottage
or 1 healthy fat ____ ____ cheese
15 3
 Dinner

3 oz. lean 3 oz. grilled chicken

pr
ot
ei
n
2 starches 30 2 1 medium sweet potato
2 vegetables 10 4 1 cup cooked broccoli
½ milk 6 ½ cup skim milk
2 healthy fats ____ ____ 2 tsp. olive or canola oil
46 6

Bedtime Snack

1 starch 15 5 ½ cup oatmeal

½ milk 6 ____ ½ cup skim milk
21

Carbohydrate: 204 grams

Protein: 84 grams
Fat: 54 grams
Fiber: 27 grams
Total calories : 1640

Reviewed October 2014 Copyright © 2014 by Joslin Diabetes Center (www.joslin.org). All rights
reserved.This document may be used for personal, noncommercial use only. For permission for
other use call 617-226-5815. PEMRAC 0143-0508-001-0000