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How is reactive hypoglycemia diagnosed?

A blood sugar level of less than 70mg/dL along with the symptoms will confirm the diagnosis for reactive hypoglycemia.

To diagnose reactive hypoglycemia, your doctor may follow this routine:

• Ask you about the symptoms and signs.
  
• Test your blood sugar while you are feeling the symptoms.
  
• Check if the symptoms get back to normal after your blood sugar returns to 70 or above (that is, after drinking or eating).
  

What is the treatment for low blood sugar or reactive hypoglycemia?

Here are the steps that some health care professionals recommend to relieve reactive hypoglycemia:

• Regularize your exercise routine.
  
• Eat snacks and small meals every 3 hours.
  
• Include a variety of foods in your diet like fish, meat, poultry or non-meat sources of protein, such as fruits, vegetables, dairy products and whole-grain bread.
  
• Avoid or limit foods that are rich in sugar (especially on an empty stomach).
  
• Avoid the intake of caffeine, alcohol and foods that are rich in starch such as potatoes, corn, white rice and popcorn.
  
  

Preventing Reactive Hypoglycemia

If you think you might have reactive hypoglycemia, there are a few lifestyle changes you can make to prevent reoccurring reactive hypoglycemia bouts. For example, to keep yourself from crashing, eat several small meals a day. This will prevent your body from experiencing a blood sugar drop after a large meal. These meals should be eaten no more than three hours a part.

Another way to prevent reactive hypoglycemia is by limiting the number of sugary foods that enter your system. Too much sugar can throw of your body's balance and launch you into a reactive hypoglycemia spell. High sugar foods do not just include candy, ice cream and other traditional sweets. Many breads, soups and sauces also include sugar. So, if you suffer from reactive hypoglycemia, eat minimal amounts of these foods.

Reactive Hypoglycemia, my trials, tribulations and errors...

1.  Obviously simple carbs aren't the best decision for RHG, eating sweet potatoes instead of white, quinoa instead of rice/couscous and eating oatmeal as its a slow burning complex carb really help maintain a balance in your blood sugar for longer periods of time.

2.  Peanut butter is a life saver!  Since it isn't something that has to be refrigerated, you can keep it with you wherever you go.  I keep natural peanut butter at home, in my bedroom (incase I cant get to the kitchen during a "crash"), in my car, work, even in my tote bag.  Its protein and will help stop a crash in reactive hypoglycemics.  

3.  Keep a journal record EVERYTHING and if you're seeing a nutritionist (or your wls dr) show them what’s going on so you can figure out what the problem is. 

4.  Eat every 3 hours.  I found even after changing my diet to avoid white foods I was still crashing mostly on the weekends.  After looking back at my journal again, I found my times are off significantly on the weekends because I'm not driving to work having a protein shake and eating every 3 hours.  Instead I'm waking up at 10, my first meal around 12, no protein shakes, not all my vitamins and eating whatever’s available instead of my planned meals like during the week.  the following weekend, I set my alarm to the hours that I eat or have a shake, woke up long enough to have a protein shake, continued to eat every 3 hours during the day and didn't crash once all weekend.  Apparently "crashing" is more than just about eating the right foods, consistency helps.

5.  Use the glycemic index as a guide when food shopping.  Here’s a link to a food index http://www.southbeach-diet-plan.com/glycemicfoodchart.htm  
this is a great website to learn more about it
http://www.glycemicindex.com/  they also have a "database" you can search with thousands of foods to check the GI.  The higher the GI, the higher the probability is you'll "crash".  There are 3 GI levels low (55 and under), medium (56-69) and high (70 and above).

6.  Get informed!  There are some great books out there about hypoglycemia.  Finding books on RGH isn't as easy, but most books on hypoglycemia do have chapters on different types including RGH.  Here’s a list from the GI website http://www.glycemicindex.com/books.htm 
The New Glucose Revolution 3rd Ed (isbn 1-56924-258-5) is very informative.  This is a cookbook (we all love new recipes right) that shows the GI per recipe The Low GI Diet - Cookbook (isbn 156924359X).  The New Glucose Revolution: Shopper's Guide to GI Values 2007(isbn 1569242801) is a good mini book you can keep with you.  It has a small GI index in the back which is great for food shopping trips.  Seek out books at your local library, they're there!  Most libraries now belong to a "network" where you can borrow books from other libraries (you order the book and its shipped to your local library).  Its a good way to sample books instead of buying them all.  While I'm on the book topic, there’s an AMAZING book out there called Sweet Deception by Dr. Joseph Mercola that EVERYONE who has ever used a sugar substitute should read.  Its a quick read and is very informative on the dangers of these products. 

7.  Take care of yourself.  we all had this surgery to lose weight.  in losing weight, we've slowed down or stopped the possibility of severe health risks that come with obesity.  Our "tool" is there for us, so be there for it!  Know what you're putting in your body, eat right, stay away from junk foods, artificial sweeteners that cause serious side effects including cancer, find ways to add protein to your meals, be creative so you're not bored with foods and snacking on the wrong things.  Last night I made "kfc popcorn chicken", the healthy way, a recipe I found from Devin Alexander, she has a healthy cooking show on cable.  Its made with chicken pieces, dipped twice in egg whites, panko bread crumbs with seasonings.  To not deprive myself I used mustard and sf honey (found at walmart) and made a honey mustard dipping sauce.  The food industry is realizing people out there want to be informed unlike years ago, because of that you can actually find healthy options out there like exotic fruits and vegetables, organic meats and healthier grains full of fiber.  Your pouch helped you lose, now help your pouch develop a healthier life style.  There’s a natural sugar out there that everyone should consider instead of poisoning our bodies with artificial sweeteners that have been made in science labs its called Stevia, its been used in other countries for hundreds of years, is natural and can be used for hot and cold drinks and/or baking.  Since the FDA is controlled by funding companies like Coke, Pepsi, Splenda, Equal, etc, etc, etc, Stevia is not FDA approved and can only be bought in vitamin stores.  You can buy it in different forms (liquid, powder, flavored liquids like the base of fruit 2O drinks),   Here’s a great 4 minute video about it http://youtube.com/watch?v=6079M5nPtsE 

As you can tell, I hate the feeling of a crash and am doing everything to stop them from happening.  Not only are they a bad feeling, but since your blood sugar drops, it isn't sending enough insulin to your brain and is making your pancreas and liver work overtime, which is obviously dangerous.  Save yourself even if you can't get doctors to figure out the problem, we trust in them so much, don't wait around for them to figure out what the problem is if you can figure it out yourself.  My self diagnosis is what made me understand what RGH is all about.  Testing for hypoglycemia includes glucose tests, since we're post ops and some of us dump on high amounts of sugar, why put yourself through that misery.  Be happy you know what you have and find ways to prevent it, there are still so many people out there that aren't aware of why they crash, but think they're hypoglycemic, research it, test your blood sugar, journal and figure it out. 

Reactive Hypoglycemia (RHG): FM/MPS Perpetuating Factor
Devin Starlanyl, MD

This information may be freely copied and distributed only if unaltered, with complete original content.

There are three basic types of nutrients. Beef, fish, poultry, cottage cheese and tofu are foods that are largely protein. Butter, cream, and vegetable oils are fats. Vegetables, fruits, grains, pastas, and cereals are carbohydrates, and so are many so-called "junk" foods, such as candy. These junk foods have little if any nutritional value, and may carry fat as well as carbo. 

People with reactive hypoglycemia (RHG) are often (but not always) overweight, and unable to lose the extra weight. A fat pad develops on the belly, and won't go away.

The often-overlooked factor is that carbohydrates stimulate insulin production. Insulin enables blood sugar to move into our biochemical "factories" in the cells, where it is burned as fuel. If there is an excess of insulin as well as an excess of carbohydrates, the excess carbohydrates are stored as fatty acids in fat cells. The excess insulin also prevents the carbohydrates from being used. You not only gain fat, but you are also prevented from losing this fat because of the availability of excess carbohydrates.

RHG is not the same as fasting hypoglycemia, which is low blood sugar that occurs when you do not eat. For this reason, RHG is not always picked up on routine medical tests. RHG occurs within 2 to 3 hours after a meal of excess carbohydrates, when there is a rapid release of carbohydrates into the small intestine, followed by rapid glucose absorption, and then the production of a large amount of insulin. Adrenalin production should be measured as well as glucose, as occur at abnormal times. RHG is also called "insulin tolerance", "postprandial hypoglycemia", "carbohydrate intolerance" and in severe forms, "idiopathic adult-onset phosphate diabetes". This condition can lead to type II diabetes.

RHG is common in people with FMS and FMS/MPS Complex. In FMS, it is enhanced by dysfunctional neurotransmitter regulation and other systemic mechanisms. With FMS, you crave carbohydrates but cannot make efficient use of them because of an electrolytic imbalance and other biochemical imbalances in your body. We produce adrenalin even when the blood sugar doesn't fall. We crave carbohydrates, because we need energy. Since our insulin level is high, our bodies take the carbohydrates and store them as fat, often in the belly. We can get the body balanced by eating a balanced diet, and teach it to metabolize our fat for energy.

When you consume carbohydrates, your insulin production increases. If you have RHG, your body overcompensates. This results in low blood sugar. RHG can range from very mild to severe. Symptoms include headaches (usually in the front or top of the head), dizziness, irritability, chronic fatigue, depression, nervousness, difficulty with memory and concentration, nasal congestion, heavy dreaming, palpitations or heart pounding, tremor of the hands (especially if a long time elapses between meals), day or night sweats, anxiety in the pit of the stomach, anxiety, leg cramps, numbness and tingling in the hands and/or feet, flushing, and craving for carbohydrates (especially sweets). The hunger pangs experienced in reactive hypoglycemia can come in the form of acute stomach pain and nausea. 

Severe RHG can cause hypoxic symptoms such as visual disturbances, restlessness, impaired speech and thinking, and blackouts. You can expect excess body fat, high triglycerides/cholesterol, fluid retention, dry skin, brittle hair/nails, dry small stools, decreased memory and ability to concentrate, fatigue or dips in energy, grogginess when waking, mood swings/irritability, and sleep disturbances. In cases of chronic MPS, the process of eliminating TrPs is hampered or even thwarted by the presence of hypoglycemia. TrP activity is aggravated and specific therapy response is reduced by hypoglycemia. Recurrent hypoglycemia attacks perpetuate TrPs. Many of these symptoms are caused largely by circulating adrenalin, which is also increased by anxiety.

Hormones in a given system usually work in a set, called an "axis". The most important in RHG is the insulin-glucagon axis. Insulin drives down blood-sugar levels, while glucagon raises it. If insulin is too high or glucagon is too low, the result is hypoglycemia. Insulin resistance means that the insulin levels are elevated but blood sugar levels remain high, because the target cells no longer respond normally to insulin. This can eventually promote diabetes. 

Insulin is a storage hormone. It takes excess glucose from carbohydrates in your food and stores them as fat. Then it locks the fat in place. Insulin drives down blood sugar. Glucagon, on the other hand, is a mobilizing hormone. It releases stored carbohydrates as glucose. Glucagon restores blood sugar levels.

The release of insulin is stimulated by carbohydrates, especially heavy starches like bread and pastas. Glucagon is stimulated by dietary protein. If you eat a big carbo meal for lunch, by 3 pm you are ready for a nap. Excess carbohydrates have generated overproduction of insulin. As your blood sugar drops, your brain begins to fall asleep. Because the massive amount of carbohydrates you ate drove your insulin level up and your glucagon down, the fats stored in your body can't be released. But you feel fatigues, so you crave energy and more carbohydrates. This happens in 50% of all people. In 25%, the normal fat response is blunted, so they can get away with eating a lot of excess carbohydrates. Yet 25% of us have an extremely elevated insulin response to carbohydrates. Many of these people have FMS or FMS/MPS Complex. Hypoglycemic tendency is inherited, and often comes with a family history of diabetes.

Remember, insulin triggers an adrenalin response. Coffee, tea and colas stimulate the release of adrenalin, as does nicotine. All carbohydrates stimulate the secretion of insulin. Fatty acids are actually the preferred fuel for building new muscles and for energy. A high-carbo diet means fat is deposited and it stays. Dietary fats decrease the flow of carbohydrates into the bloodstream and dampen the insulin response. Dietary proteins enhance the mobilization of fatty acids from fat cells and fat loss. We need a balance.

Weight loss on a high carbo diet is mostly water and muscle loss. Any subsequent weight gain is fat gain. Also, the more carbohydrates you eat, the earlier adrenalin is produced as the blood sugar goes down. Blood sugar swings are more extreme and faster the more carbohydrates you eat, and your mood and energy swings go right along for company. Studies show that high carbo intake and resultant hyperinsulinism can contribute to every known disease process.

The hormonal response from a balanced meal lasts 4 to 6 hours. Serotonin regulates the appetite for carbo-rich foods, and this neurotransmitter is often out of balance in FMS. Serotonin is also influenced by photoperiodism – the dark/light cycle. (Often carbo cravers overeat only at certain times of the day). The rate of conversion of tryptophan to serotonin is also affected by the
proportion of carbohydrates in a person's diet.

Dr. Barry Sears wrote a book with Bill Lawren, called Enter "The Zone",(Harper Collins N.Y.N.Y. 1995) It explains in detail why a ratio of 30/40/30 (the ratio of protein to fat to carbohydrate) is the healthiest balance for a majority of people. You are eating 30 percent of fewer calories as fat, and that fat is being used for energy. Every meal and snack must be balanced because there is a hormonal response very time you eat. 30/40/30 is an adequate protein, moderate carbo, low fat diet. At the same time, you will need to adjust your caloric intake and exercise to meet the needs of your body. In this diet, it is helpful to have minimal alcohol, sugar (in any form), fruit juice, dried fruit, baked beans, black-eyed peas, lima beans, potatoes, corn/popcorn, bananas, barley, rice, pasta, caffeine, or other heavy starches. Avoid caffeine, as its breakdown products tend to increase insulin levels.

This is one tough diet, because if you need it, you REALLY crave carbohydrates.  You only have to try it for a few days and your body informs you, "Yes, this is what you must do," because you are attacked by whopping headaches and extreme fatigue as soon as your body begins its struggle for balance. Your excess fat will start to break down and release large amounts of toxic substances and waste material. It is not fun. As Dr. St Amand says, it is not for the faint of heart.  But "diet alone" is a treatment that works.

When you start each meal, it is wise to eat some protein first. That allows its products reach your brain first. Exercise regularly to decrease the amount of insulin in your blood. Drink at least 8 ounces of water or a sugar-free decaf beverage with each meal or snack. If you are hungry and craving sugar 2-3 hours after a meal, you probably ate too many carbohydrates.

Now that you are aware that sugar can ease your "carbo "withdrawal" symptoms in the short term, you may be tempted to cheat. If you do, you cheat yourself. If you don't cheat, in one month you will see considerable improvement. Within two months, the RHG symptoms should be gone. When all is in harmony, your body is your best doctor. Once you are in balance, it will tell you a great deal, if you listen.

Learn to eat like a gourmet. Eat slowly, chew thoughtfully, and enjoy each bite.  Eat less, but eat mindfully, and you will be satisfied. You may have the bad habits of a lifetime to break, but if you succeed, you will have a better chance to live a longer and healthier life.

Thanks to Drs. Lynne August, Barry Sears, Paul St.Amand, Janet Travell and David Simons and the Wurtmans for the basic research.  

Devin Starlanyl, MD

 Study Shows Low Blood Glucose Levels May Complicate Gastric Bypass Surgery
BOSTON October 12, 2005

Physicians monitoring patients who have undergone gastric bypass surgery should be on the alert for a new, potentially dangerous hypoglycemia (low blood glucose) complication that, while rare, may require quick treatment, according to a new study by collaborating researchers at Joslin Diabetes Center, Beth Israel Deaconess Medical Center (BIDMC), and Brigham and Women’s Hospital (BWH). 

The paper, recently published online by the journal Diabetologia and scheduled to be published in the journal’s November print edition, follows on the heels of a Mayo Clinic report on six similar case studies published in July in the New England Journal of Medicine. About 160,000 people undergo gastric bypass surgery every year. 

The study details the history of three patients who did not have diabetes, who suffered such severe hypoglycemia following meals that they became confused and sometimes blacked out, in two cases causing automobile collisions. The immediate cause of hypoglycemia was exceptionally high levels of insulin following meals. All three patients in the collaborative study failed to respond to medication, and ultimately required partial or complete removal of the pancreas, the major source of insulin, to prevent dangerous declines in blood glucose. 

“Severe hypoglycemia is a complication of gastric bypass surgery, and should be considered if the patient has symptoms such as confusion, lightheadedness rapid heart rate, shaking, sweating, excessive hunger, bad headaches in the morning or bad nightmares,” says Mary-Elizabeth Patti, M.D., Investigator in Joslin’s Research Section on Cellular and Molecular Physiology and Assistant Professor of Medicine at Harvard Medical School. “If these symptoms don’t respond to simple changes in diet, such as restricting intake of simple carbohydrates, patients should be evaluated hormonally, quickly,” she adds.  Dr. Patti and Allison B. Goldfine, M.D., also an Investigator at Joslin and Assistant Professor of Medicine at Harvard Medical School, were co-investigators of the study.

The study reported on three patients – a woman in her 20s, another in her 60s and a man in his 40s. All three lost significant amounts of weight through gastric bypass surgery, putting them in the normal Body Mass Index (BMI) range. Each, however, developed postprandial hypoglycemia (low blood glucose after meals) that failed to respond to dietary or medical intervention. As a result, all patients required removal of part or all of the pancreas. In all three cases, it was found that the insulin-producing islet cells in their pancreases had proliferated abnormally.

A potential cause of this severe hypoglycemia in these patients is “dumping syndrome,” a constellation of symptoms including palpitations, lightheadedness, abdominal cramping and diarrhea, explains Dr. Patti. 

Dumping syndrome occurs when the small intestine fills too quickly with undigested food from the stomach, as can happen following gastric bypass surgery. But the failure to respond to dietary and medical therapy, and the conditions worsening over time, suggested that additional pathology was needed to explain the symptoms’ severity, Dr. Patti adds. “The magnitude of the problem was way beyond what doctors typically call dumping syndrome,” she says. 

Other causes of postprandial hypoglycemia can include overactive islet cells sometimes caused by excess numbers of cells, a tumor in the pancreas that produces too much insulin or familial hyperinsulinism (hereditary production of too much insulin), which in severe cases can necessitate removal of the pancreas.

In patients following bariatric surgery, additional mechanisms may contribute to overproduction of insulin. “First, insulin sensitivity (responsiveness to insulin) improves after weight loss of any kind, and can be quite significant after successful gastric surgery,” says Dr. Patti. 

“Second, weight gain and obesity are associated with increased numbers of insulin producing cells in the pancreas, and so some patients may not reverse this process normally, leaving them with inappropriately high numbers of beta cells.” 

Finally, after gastric bypass surgery, GLP1 (glucagon-like peptide 1) and other hormones are secreted in abnormal patterns in response to food intake, since the intestinal tract has been altered. High levels of GLP1 may stimulate insulin secretion further and cause increased numbers of insulin-producing cells. “In our patients, the fact that the post-operative onset of hyperinsulinemia was not immediate suggests that active expansion of the beta cell mass contributed to the condition,” Dr. Patti adds. 

Other researchers participating in the study included S. Bonner-Weir, Ph.D., of Joslin; E.C. Mun, M.D., J.J. Holst, M.D., J. Goldsmith, M.D., D.W. Hanto, M.D., Ph.D., M. Callery, M.D., of Beth Israel Deaconess Medical Center. 

Collaborating investigators from the Brigham and Women’s Hospital included R Arky, M.D., who also is a Joslin Overseer, G.T. McMahon, M.D., M.M.Sc., A. Bitton, M.D., and V. Nose, M.D. All participants are on faculty at the Harvard Medical School. Funding for the study was provided by the National Institutes of Health, the Julie Henry Fund of BIDMC and the General Clinical Research Centers. 

Besides helping afflicted gastric bypass patients, the research has hopeful implications for treating people with diabetes, says Dr. Patti. The gastric bypass patients have what many of those with diabetes lack – ample insulin – and perhaps an understanding of this phenomenon could be harnessed to help those with diabetes. “If we can understand what processes are responsible for too much insulin production and too many islet cells in these patients, we may be able to apply this information to stimulate insulin production in patients with diabetes, who lack sufficient insulin,” Dr. Patti says.

 Nov 22, 07
Day full of more trial and error, unfortunately on Thanksgiving no less..  

journaling, I found that taking a quick nap yesterday (throwing my 3 hour eating pattern off) made me crash.  

When I woke up I had 1/2 a bagel (kind of like a multi grain, 11gr fiber and tons of protein) with sf strawberry jam and 2 peanut butter balls.  Obviously that wasnt enough protein after missing a meal because 1.5 hours later, crash and burn.....  blood sugar 51, had 4 peanut butter balls to stop the crash, less than 20 minutes later my blood sugar went up to 87, but I was still feeling the shakes a little.  continued feeling shakes and my speech and motor skills were a little slow.  I didnt feel comfortable driving home, the last thing I needed was to get pulled over for OUI and explain why I decided to drive knowing I was RGH and semi-crashing (hell during my cop days I probably wouldn't have believed the "crash" story either lol).  Got home, went to bed around 3a, woke up around 10 (meaning no morning protein shake and late for breakfast).  I had a protein bar, but it was too late... Crash started, had peanut butter with a banana cookie (made with banana, egg white, stevia and oatmeal) and it stopped.

Thanksgiving began with family at a relatives house, I continously grazed all day to avoid a crash.  Grazing isn't the best option but I knew if I didn't I would crash and didn't want to go through that with everyone around. 

tomorrow is a new day.. going to set my alarm for 6:30 to have my shake like i do every day and every 3 hours til I wake up to see how the day goes, hopefully crash less!

If you're going through this and still haven't figured out your pattern, you should really journal to see if its your foods, the time pattern or both thats making you crash.  Its important to find the root of the problem and stop it from happening, crashing is dangerous.

heres a paragraph about the hypoglycemia effecting the brain from www.intelihealth.com
Hypoglycemia is an abnormally low level of blood sugar (blood glucose). Because the brain depends on blood sugar as its primary source of energy, hypoglycemia interferes with the brain's ability to function properly. This can cause dizziness, headache, blurred vision, difficulty concentrating and other neurological symptoms. Hypoglycemia also triggers the release of body hormomes, such as epinephrine and norepinephrine. Your brain relies on these hormones to raise blood sugar levels. The release of these hormones causes additional symptoms of tremor, sweating, rapid heartbeat, anxiety and hunger.

1. Simple carbohydrates and concentrated sweets: All carbohydrates can be broken down into glucose in the body. Some carbohydrates have a simple structure that easily breaks down into glucose. These are simple carbohydrates, commonly known as sugars. Table sugar, corn syrup, and honey are simple carbohydrates. Simple carbohydrates also occur naturally in fruits, milk, and other foods. They are digested rapidly, and this allows glucose to be absorbed into the bloodstream quickly. Therefore, meals that are high in simple carbohydrates can contribute to reactive hypoglycemia. Concentrated sweets such as candy, table sugar, soft drinks, cookies, cakes, and ice cream are mainly simple carbohydrates. Avoid these foods unless they are made with sugar substitutes. Read package labels to avoid foods containing sugars. Look for terms such as sugar, corn syrup, corn sweetener, or high fructose corn syrup.
   
2. Complex carbohydrates and proteins are important in the diet. They are a basic source of energy. Complex carbohydrates are many molecules of simple sugars linked together like beads on a string. They take longer to break down in the intestine, and this helps to keep blood glucose levels more consistent. Pasta, grains, and potatoes are complex carbohydrates. Proteins are made of amino acids that the body needs for growth and good health. Foods from animal sources contain protein, but so do legumes, nuts and seeds. Most food protein can be converted into glucose by the body, but since this process takes some time, the glucose gets into the bloodstream at a slower, more consistent pace. That is why people with reactive hypoglycemia should eat complex carbohydrates and protein for their energy needs, instead of simple carbohydrates.
   
3. Choose high fiber foods. Fiber is the indigestible part of plants. Insoluble fiber, such as wheat bran, does not dissolve in water. It adds bulk to the stool and causes it to pass through the intestine more quickly. Soluble fiber does dissolve in water, forming a sticky gel. It is found in the fibrous coatings of foods such as legumes, oat products, and pectin found in fruit. Soluble fiber delays stomach emptying, digestion, and absorption of glucose. Therefore, it helps to prevent hypoglycemia symptoms between meals. When making fruit choices, choose whole fresh fruits or those canned without added sugar instead of fruit juice. The added fiber helps to slow down the absorption of sugar.
   
4. Size and frequency of meals is very important for managing hypoglycemia. The body really can't tell the difference between the glucose in a candy bar and the glucose in a whole grain roll. The object is to manage the diet so glucose is released into the bloodstream slowly and evenly. Many people skip meals, and this is certainly not good for people with reactive hypoglycemia. Start out with three well-balanced meals. Include a small mid-morning, afternoon, and evening snack. If symptoms are not relieved, it may be necessary to divide the daily food intake into five or six smaller, well-balanced meals evenly spaced throughout the day. Include an evening snack. Choose more complex carbohydrates over concentrated sweets, and try to include some insoluble fiber and protein with each meal.
   
5. Fats like those in whole milk, cheese, and meats should be limited. A low-fat diet has been shown to help in treating hypoglycemia. When selecting dairy products and meats for protein; choose lean meat, skim milk products, and eggs in moderation. Use oils sparingly.
   
6. Sweeteners such as sorbitol, saccharin, and aspartame (Equal® and Nutrasweet®) do not contain sugar or calories and may be used in a hypoglycemia diet. If you have questions about them, consult your physician or a registered dietitian.
   
7. Alcohol is high in calories and can cause hypoglycemia all by itself. Therefore, people with reactive hypoglycemia should avoid or limit alcohol.
   
8. Caffeine should be avoided. Caffeine stimulates the production of adrenaline. So does reactive hypoglycemia. Therefore, caffeine in the diet can make symptoms worse because the production of adrenaline is increased.
   
9. Body Weight: Excess weight has been shown to interfere with the body functions that regulate glucose. So if you are overweight, reducing to the proper body weight could help to control reactive hypoglycemia.
   

Day full of more trial and error, unfortunately on Thanksgiving no less..  journaling, I found that taking a quick nap yesterday (throwing my 3 hour eating pattern off) made me crash.  When I woke up I had 1/2 a bagel (kind of like a multi grain, 11gr fiber and tons of protein) with sf strawberry jam and 2 peanut butter balls.  Obviously that wasnt enough protein after missing a meal because 1.5 hours later, crash and burn.....  blood sugar 51, had 4 peanut butter balls to stop the crash, less than 20 minutes later my blood sugar went up to 87, but I was still feeling the shakes a little.  continued feeling shakes and my speech and motor skills were a little slow.  I didnt feel comfortable driving home, the last thing I needed was to get pulled over for OUI and explain why I decided to drive knowing I was RGH and semi-crashing (hell during my cop days I probably wouldn't have believed the "crash" story either lol).  Got home, went to bed around 3a, woke up around 10 (meaning no morning protein shake and late for breakfast).  I had a protein bar, but it was too late... Crash started, had peanut butter with a banana cookie (made with banana, egg white, stevia and oatmeal) and it stopped.Thanksgiving began with family at a relatives house, I continously grazed all day to avoid a crash.  Grazing isn't the best option but I knew if I didn't I would crash and didn't want to go through that with everyone around.  tomorrow is a new day.. going to set my alarm for 6:30 to have my shake like i do every day and every 3 hours til I wake up to see how the day goes, hopefully crash less!If you're going through this and still haven't figured out your pa