[Taking It Off]

First, I want to thank all of those who offered advice to my last post. Your advice was dead on. Mini meals every 2-3 hours, ultra low carb diet, test blood sugar level often. That's my future, basically that of a diabetic, but without medications that can help me.

Well, I had a 3-week follow-up with my endocrinologist & dietician this week, took in my blood sugar & diet logs, and just sat there as her eyes got wider reading it. Clearly, my numbers were much worse than she had anticipated. This practice deals with alot of WLS patients (they also do weight management and it is where I did my 6 month pre-op education). She said she has a few other patients with reactive hypoglycemia... but that mine is pretty severe. There was some discussion of trying Prandin with meals to help with the carbs (Doc, does this makes sense to you?), but they wanted me to try reducing my carbs to 10-15 max at meals, 5-10 for snacks, and to keep very detailed logs for another 7-10 days, then I will fax them in, and they will decide if we need to try the Prandin.

I wish I had some way of knowing if this will improve/resolve. As it stands now, she feels that my body is in a "starvation" mode due to my chronically low blood sugar levels, and that it will be very difficult to lose additional weight, unless this somehow resolves or at least improves. (Note: I haven't lost any weight at all since early November!) Whoever heard of weight loss stopping only 5 months post-op?!

You know, we all go into this surgery with this little voice in the back of our heads saying "Will it really work for me??? Will *I* be the first person to not lose weight after WLS?". Well.... that voice is screaming at me these days... that I have failed, and now have this whole new problem on top of it! I'm angry, depressed, frustrated..... after all I've been through in the past few months with my husband's head injury, this seems like the final blow. It seems so unfair to come this far and NOT lose the weight!

[DocSanae]

How was your glucose level in relation to meals? Not just when you are having hypoglycemic episodes, but the peak level. Personally, depending on how your glucose level (and insulin level, too) changes in relation to the meals, I am not sure that insulin-secretion inducing medication (which Prandin is) is the best choice. I don't want to disagree with your endo, as she knows you better than I do, but what I was thinking that might work is an alpha-glucosidase inhibitor, which slows down the absorbtion of glucose and elongates the time of absorbtion. What happens is, the peak will be lower but last longer with this medication. This will slow down the rush of insulin secretion and prevent a crash, if the initial glucose level is high and triggers the insulin overproduction and release that leads to the glucose crash.

Also, how much of your carb intake is complex carbs in comparison to the simpler carbs? Do you do better with complex carbs, or is it that it doesn't make a difference?

[BreeChick]

Hang in there girl! and see if you can shut the 'voice' down hon. Tell it that it is just trying to brainwash you into believing you are a failure when you are NOT!!

Listen to Doc and talk a lot with you endo and all that..Logging/journaling IS so important to help understand what works/doesn't work.

It's good reminder to me to start keeping an actual notebook and not just do it all online!

[Taking It Off]

Originally Posted by DocSanae

How was your glucose level in relation to meals? Not just when you are having hypoglycemic episodes, but the peak level. Personally, depending on how your glucose level (and insulin level, too) changes in relation to the meals, I am not sure that insulin-secretion inducing medication (which Prandin is) is the best choice. I don't want to disagree with your endo, as she knows you better than I do, but what I was thinking that might work is an alpha-glucosidase inhibitor, which slows down the absorbtion of glucose and elongates the time of absorbtion. What happens is, the peak will be lower but last longer with this medication. This will slow down the rush of insulin secretion and prevent a crash, if the initial glucose level is high and triggers the insulin overproduction and release that leads to the glucose crash.

Also, how much of your carb intake is complex carbs in comparison to the simpler carbs? Do you do better with complex carbs, or is it that it doesn't make a difference?

Thanks for your reply Doc, I figured you'd have an opinion on the Prandin. My after-meal sugars range typically 130-160. With some as high as the 180 range. I try very hard to use only complex carbs, but a few whites do sneak through, as well as a few corn products. The dietician had no issues with my food journal, and agreed that I am eating right for the most part. I do know that white rice, even 1/4 cup, will trigger a bad attack (50 one hour after a meal), but I haven't "challenged" it since I've been testing, so I can't tell you how high it would get before dropping.

Last week I had a really bad low (40) about an hour after eating breakfast. My breakfast was a 3" whole grain waffle, SF syrup, and 2 oz. of ham. I was really in disbelief that this would cause such a low, so the following day, I had the EXACT same breakfast. This time, no problem (mid-80's at one hour). Go figure! The only difference I could think of was maybe I had more coffee (50/50 decaf) the first morning, but honestly, I drink coffee every morning. (I know, my bad, but I have cut back significantly... and I am still having alot of migraine/headache issues, so I'm not ready to cut back any more, yet.)

Can you tell me some names of alpha-glucosidase inhibitors? From what you describe, that does sound exactly like what I would need. I told her I had gotten advice from this board on the blood testing/frequent meals issue, and she agreed that I had gotten the right advice, she seemed very open to suggestions I made as well. She even encouraged me to keep talking with other post-ops with these issues, so I'm sure she would be open to discussing a different meds option - she's actually one of my favorite medical providers because she is so open to discussion on things.

Thank you again for your help.

[Taking It Off]

It means alot coming from you, since I know you are battling your own post-op health demons, even more than I am.

Originally Posted by BreeChick

Hang in there girl! and see if you can shut the 'voice' down hon. Tell it that it is just trying to brainwash you into believing you are a failure when you are NOT!!

Listen to Doc and talk a lot with you endo and all that..Logging/journaling IS so important to help understand what works/doesn't work.

It's good reminder to me to start keeping an actual notebook and not just do it all online!

The paper logs definitely are a good thing. I noticed even when printing out the results logs from my meter, that it's not as black-and-white as having it on paper - it "analyzes" the data in ways that may be great for diabetics, but not necessarily for us. And, since I now have two meters, the computer can't consolidate the data. yup, paper logs.

Aren't we lucky to have Doc to bounce this stuff off of.... she's awful smart when it comes to us post-ops (and other things too.... but it's just really nice when someone has a true interest and understanding of your condition, beyond the routine). Thanks, Doc! Your advice is truly helpful and appreciated.

[BreeChick]

You're welcome hon..it is actually encouraging me to really talk this one out at the consult. I need to really start tracking my glucose counts but as the PA will not prescribe me the supplies I'm having to pay out of pocket for the strips which as most know is quite cost prohibitive! When I had more $$ coming in that wasn't such a bad problem but right now things are very very tight!

So it's encouraging ME to track things better too!

[DocSanae]

180 at peak doesn't seem all that high, but the normal post meal peak is considered below 140, so you may be having delayed insulin release, so the peak insluin amount comes after your glucose level starts coming down which means you will have excess insulin in your blood stream, which results in lowering your glucose level lower than it should be.
If this is the case, I can understand your endo suggesting Prandin, as that will give the insulin release a kick start. The question here is, will the insulin release stop as soon as your glucose level goes down, or, will the reduction be delayed, and cause further glucose drop anyway.
This also is the reason that in your case, I think your insulin level should be monitored in relation to your meal, along with your glucose level. This will show whether the insulin level is in tune with the glucose absorbtion, but overshoots, or, the insulin release itself is delayed, so the there's a time lag between the glucose peak and the insulin peak resulting in the glucose drop. Which it is, may affect the choice of medication, too.

Acarbose (Precose), Miglytol (Glyset) and Voglibose are classified as alpha GIs. However, I think only the first two are approved by the FDA, though Voglibose is available in other countries.

[Taking It Off]

Doc - how does one monitor the insulin level? The meter only tests the Blood Glucose Level, correct? I did alot of reading today on the AG Inhibitors - the internet is a wonderful thing - and found alot of info that was encouraging, but also some that is discouraging.

In reading on other sites, one thing I noticed is that nearly everyone posting about post-RNY Reactive Hypoglycemia is much further out than I am.... like Years.... not just a few months. It did reinforce for me that I will need to really tighten up on those carbs though... because I won't get the insulin release if I don't eat the carbs... correct? Boy, my diet is so 100% different than one year ago... and now I will have to change it a whole lot more. I positively LOVE fruit... and I still fight the bread cravings constantly, so some of these things are going to be very hard to give up completely. I HOPE I don't have to give them up completely!!!

Jody

[DocSanae]

Originally Posted by Taking It Off

Doc - how does one monitor the insulin level? The meter only tests the Blood Glucose Level, correct?

I know. This is the glitch. It has to be done through blood labs, which means you'll have to stick around your dr's office for multiple blood draws--just before meal, 30 mins, 1, 2, and 3 hours. You don't have to do this all the time, once should be enough, even if you don't end up with hypoglycemia the particular time, how the insulin level changes should be good reference for an experienced endo.
I know this is a toughie, but this is like a glucose tolerance test of sorts. When we want to be sure of the insulin movement of the patient, we do a glucose tolereance test and take the glucose and insulin levels simultaneously, so we can see if the patient has enough insulin secretion but the pattern is off, or the insulin level is low, so it's better to intervene early with insulin injections--well, not just only for that, as GTT is a diagnostic test, but you get the idea, it's a good way to see if your pancreas is producing enough insulin in a timely manner, or if it's kinda off kilters.

[BreeChick]

I personally think this issue is a bigger one than anyone has ever thought for posties..that it does happen early on but no one attributes it to being the 'reactive hypoglycemia' they just think it's the regular hypoglycemia.

that's just my 2 cents on the whole deal!