Hypoglycemia Mini-FAQ, prepared by Miryam Williamson 

1. Article by R Paul St. Amand, MD 
2. Comment by Miryam Williamson 
3. Thoughts on panic attacks by Miryam Williamson Revised: 12/18/95 


1. HYPOGLYCEMIA by R. Paul St. Amand, M.D., Assistant Clincial Professor of Medicine Endocrinology - U.C.L.A.. 4560 Admiralty Way, Suite 355, Marina del Rey, CA. 90292, (310) 577-7510 <fmsdoc@aol.com>

'Hypoglycemia' is a word often used to denote a disease when it is actually only a symptom. The term means "low blood sugar" but often symptoms occur without a particularly low value. This syndrome is better defined as carbohydrate intolerance resulting in symptoms due mainly to an overzealous neuro-endocrine response. Alternatively, it is the inability to effectively use certain carbohydrate loads without adverse consequences.

When one eats sugar or complex carbohydrates blood sugar rises and triggers insulin release from the pancreas. This hormone facilitates entry of some carbohydrates into various parts of the body for utilization or storage. The liver converts the excess to fatty acids and insulin drives deposits into fat cells as triglycerides, our fuel reserve. In hypoglycemics, insulin cut-off is inadequate,or hormonal release excessive or inappropriate for the situation. This creates a system-wide stress which results in the endocrine 'fatigue' syndrome we call "hypoglycemia".

The standard for diagnosis has been the five hour glucose tolerance test. A certain sugar solution is given, and blood is drawn and tested at various intervals. Such tests were done in 1994 by Genter and Ipp(1) on a group of young, healthy people who had no symptoms of hypoglycemia. Blood was sampled every ten minutes in order to measure the timing and amount of various hormones which are released to counter-balance insulin. These secretions attempt to prevent excessive decreases in blood sugar. One-half of these test subjects developed acute symptoms of hypoglycemia near the peak epinephrine (adrenaline) release which coincided with the lowest blood sugars. Each reacted at very different sugar levels, often at values we have considered normal. This informative study shows that each of us will tolerate only a certain fall in blood sugar before our neuro- endocrine system perceives danger, and releases adrenaline.

The symptoms of 'hypoglycemia' (the term we will continue to use here) are many. They consist of fatigue, irritability, nervousness, depression, insomnia, flushing, impaired memory and concentration. Anxieties are common as are frontal or bitemporal headaches, dizziness, faintness or actual syncope. There is often blurring of vision, nasal congestion, ringing in the ears, numbness and/or tingling of the hands, feet or face. Excessive gas, abdominal cramps, loose stools or diarrhea are common. Many complain of leg or foot cramps. These are the chronic symptoms of this condition and are present even during periods of normal blood sugar.

Most telltale however are the acute symptoms which occur at certain lower blood sugar levels. These include hand tremors or an inner shakiness which accompany hunger. Often these are accompanied by sweating anywhere on the body, sometimes most intensely during the night. Frequent is heart pounding or 'palpitations' and acute anxiety in the pit of the stomach. Nightmares are common. This combination disturbs sleep and causes more fatigue. More frightening however is the accentuation of these symptoms into full-blown "panic attacks". These acute events last fifteen to thirty minutes and are induced by the sudden release of larger amounts of adrenaline.

We have performed many glucose tolerance tests during which patients listed their symptoms. These often developed at times when no blood test was due, and sampling frequently missed the lowest blood sugar which had triggered the acute, adrenaline-induced symptoms. We now rarely perform the test since symptoms are obvious merely from the patient's history.

Only a perfect diet will control hypoglycemia. It is not what one adds to daily food intake but rather what one removes. Patients must eat no table sugar, corn syrup, honey, sucrose, glucose, dextrose or maltose. All heavy starches must be avoided including potatoes, rice, pasta etc. (see below). Excessive fructose is provided by the several pieces of fruit needed to make one glass of juice, and therefore none is allowed. Caffeine intensifies the action of insulin and is likewise forbidden. Certain carbohydrates such as sugar-free bread are permitted but we must limit intake. For example, only one slice of such bread or one piece of fruit can be eaten in a four-hour period.

In my experience improvement begins in about seven to ten days on this restricted diet. Considerable relief is afforded within one month, and total clearing of symptoms occurs within two months but only if the diet has been followed perfectly! During the first ten days of the diet one might experience headaches from caffeine withdrawal or fatigue induced by changing the body's basic source of fuel.

Consider the entire dietary process as if one were building a checking account. First, deposits must be made to achieve surplus funds. Only at this point should one begin writing checks knowing that the account is variably lowered with each check written. Similarly the hypoglycemia diet builds energy reserves until the patient is well. Only then can experimentation with a forbidden carbohydrate begin. Each such 'cheat' draws on the account and one cannot over-spend without developing symptoms anew. Thus, over time, this hunt and peck system will define the ultimate, required, dietary restrictions.

Having entered the cheating phase one will slip occasionally by overindulging in carbohydrates. Close observation should detect the first symptom which develops after such excessive intakes. Often this will be merely fatigue, but in other cases it will be frontal, pressure headaches. Gradually most hypoglycemics learn exactly what they can allow themselves. They find they must resume a perfect diet with added emotional or physical stresses since these place greater demands on their energy banks. At such times it becomes more difficult to maintain an adequate account. Since no physician or dietician can adequately predict the final, habitual diet only the patient can make this judgement.

Some hypoglycemics suffer simultaneously from another condition, fibromyalgia. This illness also causes chronic symptoms similar to hypoglycemia but not the acute ones listed above. This is the subject of another paper we have prepared. Suffice it to say that the fibromyalgic has many areas of contracted muscles, ligaments and deranged metabolism which constantly burn fuel. This translates into energy deprivation system-wide. For those with a predisposition to hypoglycemia, this provides the final push to make them symptomatic. These are ill patients with intense symptoms of both diseases.

There is no compromise with the carbohydrate intolerance syndrome. One either eats correctly or the illness continues. The reward is great however since well-being is exhilarating when contrasted with the disabling symptoms of hypoglycemia. It is yours to control.

Dietary Restrictions The Hypoglycemic Must Follow:

Sugar in any form, including soft drinks 
Fruit juices and dried fruits 
Baked beans 
Black-eyed peas (cowpeas) 
Garbanzo beans (chickpeas) 
Refried beans 
Lima beans 
Pasta of any kind 
Dextrose, Maltose, Sucrose, Glucose, Honey, Corn syrup Starch 

May 1996.

Reference: (1) Genter, P. and Ipp, E. Metabolism, Vol. 43, No. 1 (January), 1994, pp 98-103


2. Comments by Miryam Williamson

What you have here are the comments on Dr. St. Amand's article by someone with lots of personal experience with hypoglycemia, who has been symptom-free for the past 7 years. Take them for what they are worth, if you take them at all. Our responses are unique; your experience may differ from mine.

I was one of those people with 'dramatic manifestations': I passed out cold 90 minutes into a five-hour glucose tolerance test during which period my blood sugar level dropped from 100 (dead-on normal) to 65.

At one time or another I had experienced all of the symptoms Dr. St. Amand lists with the exception of nasal congestion. I fainted several times; in all cases, I believe, the fainting was brought on by an adrenaline rush in valid response to an external stimulus. Before this hypoglycemic episode began, I had already stopped eating refined sugars as far as I could identify them.

There is no history of diabetes anywhere in my family, nor have I ever shown any signs of diabetes. 

Dr. St. Amand omits from his list one very common symptom, and the one that alerted me to the possibility that I was hypoglycemic -- an overwhelming sleepiness after I ate anything remotely 'sugary' (fruit juices, for example -- remember, I wasn't eating sugar per se.) The feeling was one of having been drugged, and I have seen many people affected with this on those occasions when I have been a conference presenter at an after-lunch session.

I agree completely with Dr. St. Amand's recommended diet for overcoming hypoglycemia. In my own case, however, it took much longer than two months to get over it -- more like four or five years, as a matter of fact. This may have to do with the fact that my hypoglycemia came on after a prolonged period of severe stress, preceded by 10 of the most hectic work years in which my occupation virtually demanded that I be an adrenaline junkie. The combination of fibromyalgia, hypoglycemia, and what almost certainly was adrenal exhaustion probably lengthened my recovery.

Without knowing of Dr. St. Amand, I followed his restriction list to the letter for about four years, then I began experimenting. As he recommends, sugar and caffeine came back last, and today I can tolerate small amounts of refined sugar on occasion as long as I am exercising aerobically on a daily basis.

Only you can tell whether any of Dr. St. Amand's information applies to you, and whether the benefits of following his suggestions outweigh the costs of being hypoglycemic. 


3. On panic attacks and nightmares (by Miryam Williamson)

I believe that panic attacks are caused by a rush of adrenalin, because the physical sensations are the same as those experienced when adrenalin is released into the bloodstream in response to a real emergency. Adrenalin's function is to trigger the release of stored sugar reserves from the liver (there are technical terms for what actually happens but I don't remember them from the time I was studying this phenomenon) to provide the energy needed for fight or flight.

In normal sugar metabolism, insulin burns sugar to provide energy. In many people, when a quantity of sugar arrives in the bloodstream (e.g., in the case of eating a candy bar or, for some, after any refined sugar is ingested) the pancreas responds by secreting too much insulin, with the result that the amount of blood sugar burned is greater than the amount that was dropped into the bloodstream, for a net loss of sugar in the bloodstream. This phenomenon is known as reactive hypoglycemia, a condition common among PWFM.

I believe that nightmares, the kind that make you wake up in a panic, are caused by this phenomenon. You eat or drink something in the evening that causes a sudden drop in blood sugar a few hours later. Your adrenalin kicks into action to release sugar stored in your liver, and you experience it as a reaction to an emergency. We've all had dreams in which a bell or phone was ringing in the distance and nobody was paying any attention to it, and then awakened to discover that the phone or alarm clock is ringing. Such dreams are sleep's way of trying to keep you asleep. Similarly, I believe that a nightmare is a way to explain the panic that you are experiencing so that you can keep on sleeping.

There's no reason why this can't happen during the day, as well, in response to having eaten something earlier that caused the blood sugar roller coaster (sugar in-insulin overburn-adrenalin flood to bring the blood sugar level back up) that happens at night. In the daytime there's no dreaming allowed, so your're flooded with adrenalin and explain it to yourself as a panic attack -- which it is, because you feel the panic that precedes an adrenalin rush, only this time the adrenalin rush was triggered by a sudden drop in blood sugar and you must explain it to yourself in the only way you know.

When I arrived at this theory, I took steps to eliminate the cause of the panicky feeling: I eliminated (completely for as long as it took, and then almost completely even now) the rapidly absorbed refined sugars that cause the adrenalin rush that I interpreted as panic. For a while, even fruit juices had this effect on me, so if I had a panic attack I talked myself through it, reminding myself that there obviously wasn't anything to be panicked about, so it must be a chemical process that was causing the feeling of panic. I also, when I could, drank a glass of milk (not skim milk; the butterfat is what I was looking for) to help stabilize my blood sugar. If I had thought of it, I would have had a glass of milk at bedtime, but I never did think of it until the episodes of panic had disappeared.

This approach worked for me, for one of my daughters, and for several friends I have told about it. Not all of them are likely to have FM, but to a one they found relief from panic attacks this way. I don't know if it has been field tested or written up anywhere, but for what it's worth, it works for some people. I hope it helps you, too.

Copyright ©1997, Miryam Ehrlich Williamson - ALL RIGHTS RESERVED


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