Answer: E. The first step in treatment is to consume small, frequent (every 3 to 4 hours) meals/snacks. These meals/snacks should be high in fiber, low in sugar, and include a protein source. A regular exercise regimen has also been recommended to help with significant fluctuations in the blood glucose levels. Despite these current recommendations as a first step in treatment, there is little to no evidence in the literature that suggests that these changes are beneficial. However, patients can alleviate their symptoms with these dietary and lifestyle modifications. If the dietary modifications do not successfully reduce the postprandial hypoglycemia symptoms, then some literature suggests that the use of acarbose will delay carbohydrate absorptions and therefore reduce the insulin response to the meal. However, few studies support the efficacy of the use of acarbose in the treatment of postprandial hypoglycemia.

The best treatments for postprandial hypoglycemia in the gastric bypass patient are dietary and lifestyle changes. Patients should also be taught how to check their blood glucose at home, and they should know to check their blood glucose whenever symptoms first occur. They should also record food intake within the last 3 hours of the hypoglycemic event. The food log can be helpful for the provider or dietitian to make changes in the patients’ diet to reduce the hypoglycemic events. Patients should also test their blood glucose prior to operating a vehicle to avoid hypoglycemia behind the wheel.


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Recommendations

The most likely diagnosis for Mrs. Nelson is postprandial hypoglycemia. She should complete a mixed meal test in the lab for verification of the diagnosis. More importantly, she needs education regarding dietary and lifestyle changes and she should be seen by a dietitian who specializes in bariatric surgery patients. The focus of the visit with the dietitian is to teach Mrs. Nelson how to eat a mixture of foods that are low in sugars, high in fiber, and have adequate protein. She has already committed to regular exercise, which she should continue to help regulate her blood glucose values. She should start testing her blood glucose values whenever the symptoms of hypoglycemia occur or prior to operating a vehicle.

References

  1. Service GF, Thompson G, Service JF, Andrews J, Collazo-Clavell M, Lloyd R. Hyperinsulinemic hypoglycemia with nesidioblastosis after gastric-bypass surgery. N Engl J Med. 2005;353(3):249-254.
  2. Service JF. Postprandial (reactive) hypoglycemia. UpToDate. Available at: http://www.uptodate.com/contents/postprandial-reactive-hypoglycemia.
  3. Singh E, Vella A. Hypoglycemia after gastric bypass surgery. Diabetes Spectrum. 2012;25(4): 217-221.