Diabetes and the hypoglycemic syndrome

Guide To Beating Hypoglycemia

Here's Just A Tiny Glimpse Of The Topics Covered: The 3 main types of hypoglycemia and which type you're most likely suffering from. How snacking on chocolate bars can actually make you Fat and worsen your condition! (If you thought those delicious dark brown bars were great energy- boosters.think again!) The No. 1 question most folks have when it comes to hypoglycemia and hyperglycemia. Why you should insist on a 6-hour Gtt and not a 5-hour one. ( Why it might not be a good idea to consult a doctor to confirm your hypoglycemia. Aside from taking a Gtt, what other methods can you use to determine whether or not you're suffering from this condition? Well, refer Chapter 4, Pgs. 23-26 to take a revealing 67-question test especially designed to find out if you've got the symptoms. An inspiring motivational exercise that will help you effectively banish all of your negative thoughts that prevent you from having peace of mind. 2 good reasons why you should keep a food journal. 3 powerful nutrients that limit the effect of glucose on your blood sugar level. This is vital to a hypoglycemic as it helps slow down the absorption of sugar in the food. The secret impulse that literally forces you to say 'yes' to a candy bar or chocolate whenever you feel the hunger pangs gnawing at you. 2 ingredients that are lethal to a hypoglycemic. 'Hidden sugars' you must know to avoid buying products that can easily worsen your condition. 8 essential rules of food planning that are crucial to your speedy recovery from hypoglycemia. Leave out one of them and it could hurt your chances of recovering. How to create a healthy food plan that's suitable for both vegetarian and non- vegetarian hypoglycemics. Most food plans only focus on non-vegetarians, but this one works great for everybody!

Guide To Beating Hypoglycemia Summary


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Definitions of hypoglycemia have changed over the years and the acceptable level of blood sugar has risen in the last decade, driven in part by medico-legal concerns. The ''paper that launched a thousand law suits'' described changes in sensory-evoked brain stem potentials in neonates with blood sugars less than 2.6micromoll 1 (45mgdl1) (Koh et al., 1988). Because of this report most neonatalogists now treat any newborn that is shown to have a blood glucose level less than this. This leads, in many cases, to increased (and sometimes unnecessary) medical intervention in normal term breastfeeding newborns. In the case of an IUGR infant delivered from a pregnancy complicated by PIH (pre-eclampsia or superimposed pre-eclampsia) an aggressive approach is appropriate. Most neonatal units employ bedside capillary glucose monitors to screen for hypoglyce-mia. These are generally innacurate at the lower range of blood sugar recordings, which is the area of most interest to neonatologists and a...

Indications and Testing

Pancreas transplant provides tight glucose control without insulin reactions and hypoglycemic episodes. However, it does this at a cost. Immuno-suppression renders the recipient at risk for the development of certain cancers and many types of infection. For this reason, pancreas transplantation is only performed when the quality of life has become seriously impaired.

Exercise and Activity Guidelines

For a woman with a normal pregnancy there are no known contraindications to exercise during the pregnancy. Recent reviews have documented the benefits of exercise during pregnancy (Agnostini, 1994 Artal, 1996 Clapp, 2000). The incidence of infertility, spontaneous abortion, congenital malformation and placental abnormalities is not increased in women who continue a strenuous weight-bearing type of exercise (running, aerobics, crosscountry skiing, stair stepping, and so forth) throughout early pregnancy. The concern that continuing a strenuous exercise program or beginning to exercise in mid to late pregnancy might lead to preterm labor or premature rupture of the membranes is not supported by current data. Previous concern about exercise during pregnancy has been related to the hypothetical risks of strenuous maternal exercise, including resulting in fetal stress, competing for blood flow and depriving the fetus of oxygen, fetal hypoxia and thermal stress resulting in neural tube...

Acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) is a condition characterized by microvesicular fatty infiltration of the liver, developing in the latter half of pregnancy. The incidence is approximately 1 12,000 deliveries. Clinical disease severity varies with some patients having only mild right-upper quadrant discomfort associated with prodromal nausea and vomiting. Others develop fulminant liver failure leading to coma. A depressed level of consciousness may arise from either hypoglycemia or the onset of hepatic encephalopathy. Hypoglycemia is a common feature of AFLP and should alert the clinician to the possible diagnosis. More than 50 of affected patients will have mild hypertension and pro-teinuria, making the distinction from HELLP syndrome difficult. Jaundice is often present at the time of diagnosis. Liver enzymes are increased and transaminases may rise above 1000 IUl1 in severe cases. Liver failure leads to severe coagulo-pathy and a prolonged partial thromboplastin time and INR....

Insulin Products for Travel

Patient and physician should discuss the objectives of insulin therapy during long, complicated flights and foreign travel. Should they aim for very tight glycemic control (intensive insulin therapy) during the trip, with the potential for hypoglycemia Or should they settle for conventional therapy with programmed dosing throughout the day, based upon the length of day and other factors related to travel

New Insulin Delivery Systems for Travelers

There are several advantages for travelers who gain familiarity with this rapidly acting insulin (Noble et al., 1998). Because there is a strong tendency for travelers with diabetes to take their insulin immediately before a meal, rather than the 30-45 min before a meal required for regular insulin to become absorbed, the inconvenience of timed administration leads to poor control of glycemia. There is a mismatch between postprandial carbohydrate absorption and the 2-4 h postinjection peaking of regular insulin. In addition, there will still be circulating insulin present as the peripheral blood glucose is falling. This predisposes such patients, particularly those who exercise, to late postprandial hypoglycemia. mers. The peak serum concentrations of insulin lispro occur within 30-90 min following administration, regardless of the site of administration. There is a better match between carbohydrate absorption and insulin availability with less chance for late-peaking regular insulin...

Travel Across Time Zones

Suggested regimens had become excessively complicated in well-meaning attempts to achieve nearly perfect glycemic control during travel. We prefer the method outlined by Sane et al. (1990). It calls for a 2-4 adjustment in insulin dosing for each time zone crossed. For instance, a traveler going west over 10 time zones would have his or her day lengthened and require about a 30 increase in long-acting insulin dose. Adjustments to that regimen can be more finely tuned using insulin lispro as needed, based upon more frequent blood glucose monitoring. Individualization of advice by expert nursing personnel, informing airlines about diabetes and the potential for hypoglycemia, carrying carbohydrates during flights, avoiding airlines' largely nonstandardized diabetic meals, frequent monitoring of blood glucose, and detailed tips for planning insulin regimens are all useful. Unexpected delays during trips should be anticipated, such that extra food and insulin doses are carried.

Respiratory distress syndrome

Prompt resuscitation of at-risk infants to prevent hypoglycemia and cold injury, both of which inactivate surfactant, is vital. It is now accepted that exogenous surfactant should be administered early in high-risk infants rather than waiting until there is established atelectasis (Verder et al., 1999). There is still debate as to whether this means elective intubation of every baby less than 29 weeks at birth, or if surfactant should be given only to those infants who truly require intubation at birth. There are two types of exogenous surfactant available for treatment. Natural surfactant harvested from pigs or cows (e.g. Curosurf, Survanta) contain varying amounts of the different surfactant proteins in comparison to artificial surfactant (e.g. Exosurf). The presence of these surfactant proteins is thought to explain the superior results seen with the administration of a natural surfactant (Halliday, 1996).

PET Scanning in Cardiology

Heart Pet Scan

Cardiac PET scanning is perhaps the most complex and time-consuming of the three main clinical groups. The patients are prepared slightly differently depending on whether they are non-diabetic, insulin dependent diabetic (IDD) or non-insulin-dependent diabetic (NIDDM). All categories of patients should be asked to refrain from caffeine-containing products for at least 24 hours prior to their appointment time. This minimizes both the inherent stress effect of caffeine and also lowers the free fatty acid level that might otherwise compete with the 18F -FDG for provision of the myocardium's energy source. Non-diabetic patients should be asked to fast (water only) for six hours prior to their appointment time. The noninsulin dependent diabetics should fast for six hours but if their appointment is booked for the afternoon they are encouraged to have breakfast and take their normal morning oral hypoglycemic as usual. The insulin-dependent diabetics are instructed to eat and take their...

Intrauterine growth restriction

Hypotonia, apnea (magnesium sulfate) Hypoglycemia (Labetalol) Hypotension, renal failure (ACE inhibitors) Prematurity with surfactant deficiency Asphyxia with surfactant dysfunction is conserved. After birth examination shows a baby with a large head relative to body size. There is soft tissue wasting, reduced muscle bulk and large hands and feet. IUGR newborns are at risk of both early and late complications. Initial problems are an increased risk of perinatal asphyxia, polycythemia, hypoglycemia and hypothermia. The late complications of short stature and fetal programming of adult-onset disease will be discussed later in this chapter.

Gastrointestinal laboratory findings

AFMP is a multisystem syndrome characterized by abdominal pain, malaise, confusion or encephalopathy, hypertension and proteinuria that characteristically has its onset in the third trimester. In contrast to pre-eclampsia, these women are clinically jaundiced and have severe hepatocel-lular dysfunction. This hepatocellular dysfunction frequently manifests itself not only by elevated transaminases but also by obvious coagulopathy and hypoglycemia. This latter finding is ominous and associated with an increased mortality risk. Up to 50 of these women will also develop renal failure and pancreatitis. As with pre-eclampsia, the only known cure for AFMP is delivery. LCHAD deficiency can produce a clinical syndrome resembling AFMP or HELLP syndrome, particularly if the fetus is affected. It can sometimes also resemble persistent hyperemesis gravidarum (Wilcken et al., 1993).

Pyrimethamine with sulfadoxine Fansidar

Travel to a chloroquine-sensitive area. Treatment for travel to a choloquine-sensitive area is chloroquine. For severely ill pregnant travelers with life-threatening infections, intravenous quinine or quinidine gluconate is the drug of choice. Hypoglycemia must watched for and prevented. In areas of pyrimethamine sulfadoxine-sensitive malaria this combination is an option for pregnant women if they are not allergic to either component. Although not first line, mefloquine may be given in doses of 750-1250 mg as single dose for treatment. Malarone may also be used for treatment.

IRKassociated PTPs A Key Therapeutic Target

The recognition that the in vivo administration of pVs to rats induced hypoglycemia led to studies in diabetic animals. It was shown that in insulinoprivic BB Wistar diabetic rats the parenteral administration of pV but not vanadate returned blood glucose levels to normal and fully abrogated the associated ketoacidosis (Fig. 8) (Yale et al., 1995). This established the concept that inhibition of the IRK-associated PTP

Whole Body Imaging in Oncology

Full Body Tomography

Tained blood pool tracer activity can occur. It is relatively easy to measure serum glucose prior to FDG administration, and this is routine in many centers. Use of exogenous insulin to reduce serum glucose immediately prior to FDG administration is not generally indicated, as this will result in accelerated FDG uptake in muscle and the liver. It is much preferred to manage known diabetic patients such that at the time of FDG administration, serum glucose levels are under roughly 150 mg dL. This must be arranged in consultation with the patient and the physician treating their diabetes, as the strategy used will depend on the patient's treatment regimen and history of serum glucose control. For example, patients who are non-insulin requiring may present with an acceptable serum glucose levels with an overnight fast, while insulin requiring patients may need a fraction of their usual morning dose of short acting insulin in addition to the overnight fast. For patients with poor serum...

Late Term or Near Term Infants Born at the Upper Border of Prematurity

Although their outcomes are better than outcomes of preterm infants with gestational ages of less than 32 or 33 weeks, late preterm infants remain vulnerable to the complications of prematurity. They are more likely than fullterm infants to experience cold stress, hypoglycemia, respiratory distress syndrome, jaundice and sepsis, yet there are wide variations among hospitals in treatments and resource use for late preterm infants (Amiel-Tison et al., 2002 Laptook and Jackson, 2006 Lewis et al., 1996 McCormick et al., 2006 Wang et al., 2004a). Despite a relative lack of information regarding longterm outcomes, retrospective studies of children with cerebral palsy report that 16 to 20 were born between 32 and 36 weeks gestation (Hagberg et al., 1996 MacGillivray and Campbell, 1995).

Complications for Near Term or Late Preterm Infants

For many years, attention has focused on high-risk obstetric and neonatal intensive care for extremely preterm infants and infants born at the lower limit of viability, although very little attention has been paid to the majority of preterm infants who are born near term (also called late-preterm infants). Although many deliveries of near-term infants are spontaneous or are indicated for maternal or fetal circumstances, it is important to keep in mind that these larger preterm infants born near term are more vulnerable to complications and disabilities than full-term infants. Although complications in near-term infants are not as frequent as they are in more-preterm infants, near-term infants have more perinatal and neonatal complications than full-term infants (Allen et al., 2000 Amiel-Tison et al., 2002 Wang et al., 2004). One study found that the incidence of RDS was as high as 15 percent among infants born at 34 weeks of gestation, whereas it was 1 percent among infants born at 35...

Intraoperative Management

Blood glucose levels may be elevated in diabetics, in which case an insulin infusion may be necessary. Once the incision is made, hypoglycemia is generally not a problem due to catecholamine-induced glycogenolysis. Cachectic patients with long-standing poor nutrition may be hypoglycemic and not respond to sympathetic outflow if glycogen stores are minimal. Small amounts of glucose are generally sufficient to maintain blood glucose levels near normal. The major additional task in these surgical patients is to manage glucose levels. Hypoglycemia must be avoided, as it can lead to brain damage. Similarly, uncontrolled hyperglycemia can lead to dehydration and electrolyte disturbances. Ketoacidosis can also occur and should be avoided. Since the signs of hypoglycemia can be masked by general anesthesia, blood, not urine, glucose levels need to be measured. Glucose levels should be checked 30-60 minutes after insulin administration and every hour, for 4 hours. After the pancreas is in,...

The Effects of Changes in Glucocorticoid Availability

A deficiency of endogenous glucocorticoids produces overt clinical symptoms, including weakness, fatigue, hypoglycemia, hyponatremia, hyperka-lemia, fever, diarrhoea, nausea and shock. This condition, also known as Addison's disease, is most often caused by autoimmune destruction of the adrenal cortex. However, it is important to note that abrupt withdrawal from exogenous corticosteroids or ACTH can also induce an Addisonian crisis, because the exogenous administration of these compounds suppresses endogenous HPA axis activity. This is why tapering of the dose of adrenal steroids is essential before discontinuation. Glucocorticoid deficiency may also produce mild to severe depression or, less commonly, psychosis.

Glutamate Receptor Channels

Glutamate receptor activation to neuronal death involves excessive Ca2+ influx. Overactivation of the glutamate receptors, particularly NMDA receptors, has been implicated in a number of neurological disorders, including ischemia, hypoglycemia, seizure, and mechanical trauma. In the case of cerebellar granule cells, glutamate toxicity resulted in early necrotic cell death in a population of cells, and delayed apotosis in the others. On the other hand, controlled Ca2+ influx through the NMDA receptor blocked apoptosis induced by serum withdrawal in NG108 neuroblastoma cells. This is consistent with a view that NMDA receptors may or may not induce apoptosis, depending on the amplitude and duration of Ca2+ signals.


Dementia may be reversible or irreversible. Reversible causes include brain tumors, subdural hematoma, slowly progressive or normal-pressure hydro-cephalus head trauma endocrine conditions (such as hypothyroidism, hypercalcemia, hypoglycemia) vitamin deficiencies (of thiamin, niacin, or vitamin B12) thyroid disease ethanol abuse infections metabolic abnormalities effects of medications renal, hepatic, and neurological conditions and depression. Irreversible dementia is more common in the elderly. Irreversible causes of dementia include diseases of the brain such as Alzheimer's, Parkinson's, Pick's, Creutzfeldt-Jakob, and Huntington's diseases human immunodeficiency virus (HIV) infection vascular dementia and head trauma.

Metabolic System

Metabolic derangements may be multitudinous and severe. Electrolytes may be abnormal for many reasons, such as fluid overload, and cardiac and renal dysfunction. Hyponatremia is quite common, and rapid correction of significant hyponatremia should be avoided as it can lead to central pontine myelinolysis (CPM). Potassium concentrations may be either elevated or depressed depending on renal dysfunction and types of diuretics used. Mild hypocalcemia is common and usually of little clinical concern. However, if there is significant blood transfusion, calcium therapy may be required to maintain hemodynamic stability, since the diseased liver may not be capable of clearing the preservative citrate, which binds calcium, from the banked blood. Blood glucose concentrations are usually normal to elevated, depending on the presence of diabetes, and the patient's diet and hepatic function. Hypoglycemia may be seen in cases of fulminant hepatitis. Many patients arrive in the operating room with a...

Neurologic Issues

Neurologic complications occur in 12-20 of patients after liver transplantation. Eighty-five percent of these complications occur in the first postoperative week. The symptoms and signs range from seizures to disorientation, to agitation, to coma, and are more likely in older patients and those with severe encephalopa-thy preoperatively. The causes include toxic-metabolic processes, hypomag-nesemia, hypoglycemia, hypercalcemia, hypo- and hypernatremia (central pon-tine myelinolysis), poor graft function, drug reactions, infections, and intracranial hemorrhage. Medications should be carefully reviewed in order to identify agents that may be the cause of the neurologic changes. These include amantadine, cyclosporine, steroids, narcotic analgesics, histamine type 2 blockers, acyclovir, antibiotics (e.g., Imipenem), benzodiazepines, and tacrolimus. There should be a low threshold for obtaining blood, urine, and sputum cultures, and a computerized tomographic (CT) scan of the head and an...


Phenomenon of physiological jaundice. In an IUGR infant there is an increased bilirubin load from the extra red cells, often impaired liver function from in-utero hypoxemia, and the possibility of a compromised newborn. There is then concern that bilirubin levels will rise to harmful levels and phototherapy and exchange transfusion may be required to prevent kernicterus. The increased red cell mass may have other harmful effects relating to increased blood viscosity. These include hypo-glycemia, hypocalcemia, decreased glomerular filtration, and decreased gastrointestinal perfusion leading to gut mucosal ischemia. The hematocrit can be lowered by a partial exchange transfusion using saline. There are risks from this procedure and in the author's experience this is rarely required. It is essential, however, that a venous hematocrit is checked, as capillary samples will often be falsely raised. Ensuring that the newborn is not dehydrated (by giving judicious intravenous fluids) and...

Maternal drugs

Drugs used in PIH can have detrimental effects on the fetus. Labetalol, in rare instances, may result in neonatal hypoglycemia, and an infant born to a mother prescribed labetalol should be monitored for hypoglycemia as outlined in Figure 33.1. Magnesium sulfate, when used in high doses, can cause hypotonia and apnea in the newborn. Angiotensin-converting enzyme inhibiting drugs (ACE inhibitors) can result in a dramatic decrease in renal function in both newborns and the fetus. In the neonatal intensive care unit this class of drugs would initially be introduced in a greatly reduced dose and slowly increased. Fetal and neonatal renal failure have been reported after prenatal use of ACE inhibitors.

Abnormal Bowel Loop

Pink Sock Inverted Colon

Functional immaturity of the colon is a common cause of neonatal obstruction, particularly in premature infants and in those whose mothers were treated during labor with magnesium preparation or high doses of opiates or other sedatives. The condition has also been encountered in children of diabetic mothers, or children with septicemia, hypo-thyroidism, or hypoglycemia (CoHen 2003). The term includes meconium plug syndrome and small left colon syndrome. Both entities are associated with dysmotility of the colon. The etiology remains unclear, although they are thought to be associated with immature myenteric plexus ganglia (BurgE and Drewett 2004). These infants have difficulty in initiating evacuation, abdominal distension, and sometimes vomiting, but, in general, bowel distension usually is less severe than in organic obstruction. The condition is both diagnosed and treated with contrast material enemas (De BAcker et al. 1999).

Useful Links

Stanley CA, Thornton PS, Finegold DN, Sperling MA. Hypoglycemia in neonates and infants. In Pediatric Endocrinology, second edition, Ed. Sperling MA. Saunders, pp. 135-159. Cornblath M, Hawdon JM, Williams AF, et al. Controversies regarding definition of neonatal hypoglycemia suggested operational thresholds. Pediatrics 2000 105 1141-1145.


Pentamidine is another alternative that has been widely used. It is effective but quite toxic (Thakur et al., 1991). It can result in hypotension if infused too rapidly. It is also associated with bone marrow suppression, nausea, vomiting, reversible azotemia and damage to pancreatic B cells, resulting in the release of insulin and life-threatening hypoglycemia. Those affected may later develop insulin-dependent diabetes mellitus, a potential fatal complication for someone living in an area without electricity, refrigeration or access to insulin. Less frequent side-effects are acute pancreatitis, rash and allergic reactions, including anaphylaxis.


Historically, insulin is an early and classic example of a biotechnology product, illustrating the general problems that are associated with peptide drugs and how modern technology leads to improved therapy. Prior to the production of human insulin by cell-based fermentation processes, treatment was with pancreatic extracts of porcine or bovine origin. Insulin resistance correlated with effective, specific antibody responses in many diabetics, who had a 'career' of increasing insulin dose, punctuated by hypoglycemia when changing from one animal source to another without changing dose size. Some patients became so competent at clearing bovine or porcine insulin that they needed extracts from exotic species such as whales. The modification of recombinant chi-meric or pure cell lines to secrete human insulin, the development of large-scale fermenters to multiply such cultures, and the ability to purify cell-free insulin from other materials in the broth, has led to a sufficient supply...

HELLP syndrome

Coagulopathy is an uncommon feature of HELLP syndrome but thrombocytopenia and impaired platelet function both give rise to impaired coagulation. Prolonged partial thromboplastin times and INRs are more likely to occur in association with acute fatty liver than HELLP syndrome. Hypoglycemia may occur in some cases but is more characteristic of acute fatty liver of pregnancy.