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Functional Hypoglycemia

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Functional Hypoglycemia Andre Nadeau Functional Hypoglycemia: Facts and Fancies SUMMARY SOMMAIRE en bas d'un certain When blood glucose decreases below a given Lorsque la glycemie s'abaisse seuil, il y a apparition de sympt6mes de threshold, symptoms of cerebral dysfunction dysfonctionnement cerebral et/ou d'hyperactivite and/or adrenergic hyperactivity appear. If this adrenergique. Lorsque ceci survient apres le repas occurs postprandially in otherwise normal chez une personne par ailleurs normale, un subjects, a diagnosis of reactive or functional diagnostic d'hypoglycemie reactionnelle ou hypoglycemia may be proposed. However, fonctionnelle peut etre avance. Neanmoins, ces symptomes ne sont pas tellement specifiques, et ils symptoms are not specific, and they these devraient coincider avec des valeurs glycemiques should coindde with low blood glucose values basses et se corriger rapidement suite a l'ingestion and be rapidly relieved by glucose ingestion de glucose avant de porter le diagnostic before a diagnosis of hypoglycemia is d'hypoglycemie. L'epreuve d'hyperglycemie confirmed. The oral glucose tolerance test, provoquee par voie orale souvent utilisee dans often used in the evaluation of such patients, l'evaluation de ces patients peut egalement donner des r6sultats trompeurs, car beaucoup de sujets also may give misleading results, because normaux presentent des glycemies en bas de la many normal subjects have glucose values "normale" lors de ce test. Ceci explique sans doute below the 'normal' range during the test. This pourquoi le diagnostic d'hypoglycemie fonctionnelle may explain why functional hypoglycemia has a ete surutilise depuis plusieurs annees, amenant la probably been overdiagnosed during the last description du syndrome de non-hypoglyc6mie qui consiste a attribuer par erreur les symptomes a de years, giving rise to a description of several l'hypoglycemie, soit par le patient lui-meme ou the syndrome of non-hypoglycemia, in which meme par son medecin. Neanmoins, I'hypoglycemie the patient's symptoms are falsely attributed fonctionnelle existe et peut etre amelioree par un to hypoglycemia, either by himself or by his traitement approprie. physician. Nevertheless, functional hypoglycemia exists and can be improved by proper management. (Can Fam Physician 1984; 30:1333-1335) Dr. Nadeau is an associate the pathological counterpart to dia- glucose in the range of 70-100 mg/dl professor of medicine at Laval betes mellitus. Many years later, the is considered normal,3 more than five University, and Director, concept of hypoglycemia evolved into percent of normal subjects are ex- Laboratoires de Recherche en a broad classification encompassing pected to have values outside these Endocrinologie et Metabolisme, Le many different and unrelated patholog- limits. Furthermore, to be considered Centre Hospitalier de l'Universite ical entities.2 This is not really surpris- part of a disease entity, low blood glu- Laval, Ste-Foy. Reprint requests to: ing, because blood glucose is normally cose concentration should be asso- Le Centre Hospitalier de controlled by many biochemical fac- ciated with disturbance in some body l'Universite Laval, 2705, Laurier tors (enzymes) and physiological fac- functions. This is particularly impor- Blvd., Ste-Foy, PQ. GlV 4G2. tors (hormones) located in many dif- tant if glucose is measured after a glu- ferent organs. Various inherited or cose challenge, such as that done dur- acquired pathological processes can ing an oral glucose tolerance test. HORTLY AFTER the discovery of alter these factors. Studies conducted in large population insulin in 1924, Harris1 reported By definition, hypoglycemia is a samples2' 4 have shown that many nor- five nondiabetic subjects with symp- biochemical abnormality (i.e., a blood mal subjects may have plasma glucose toms similar to those occurring during glucose value below the normal values below 50 mg/dl without any an insulin reaction in insulin-treated range). Unfortunately, defining the symptoms. On the other hand, other diabetic patients. He was probably the normal range of blood or plasma glu- people may experience typical symp- first to postulate that hyperinsulinism cose is not as simple as it may seem. toms with values in the 50-70 mg/dl or dysinsulinism could well represent While for practical purposes, plasma range and even above 70 mg/dl. Thus, 1333 CAN. FAM. PHYSICIAN Vol. 30: JUNE 1984 diagnosis of reactive or post-prandial tion and then a rapid drop in blood glu- form a five-hour glucose tolerance hypoglycemia depends on more or less cose concentration and a typical hy- test, with blood samples taken at 30- subjective clinical manifestations. poglycemic attack.5 minute intervals after an overnight Although functional hypoglycemia fast. 5' 6 Unfortunately, as noted above, Clinical Manifestations is manifested more specifically by epi- many asymptomatic normal subjects Of Hypoglycemia sodes of the symptoms mentioned may have glucose values below the so- The clinical manifestations of hy- above, sometimes patients mainly called normal range; because of this, poglycemia can be grouped under two complain of more chronic disabilities probably many patients with non- headings: those caused by neurogluco- such as progressive fatigue, lack of en- hypoglycemia have been misdiag- penia, and those induced by adrenergic ergy, depressed mood or emotional in- nosed by their physician as suffering overactivity. stability. Although it is well known from reactive hypoglycemia. In such Glucose is the major fuel of the that functional hypoglycemia is asso- cases, failure to recognize non- brain. The central nervous system con- ciated with emotional disturbance and hypoglycemia may preclude further tinuously uses glucose and oxygen to personality disorder, it is not clear exploration of alternative diagnoses function. If the supply of glucose whether hypoglycemia is the cause or and treatments, and this should always diminishes, then symptoms of neuro- the consequence of such distur- be kept in mind when a diagnosis of glucopenia appear. Depending on the bances.6 hypoglycemia is proposed. severity of the glucose shortage, sub- jects may experience fatigue, head- Hypoglycemia Vs. Diagnosis Of ache, visual disturbances, faintness, 'Non-Hypoglycemia' Reactive Hypoglycemia difficulty with speech and thinking, Obviously, neither the neurogluco- Proper diagnosis of reactive hypo- confusion and even seizures and coma. penic nor the adrenergic symptoms glycemia (or any other type of hypog- Psychiatric manifestations such as out- mentioned above are specific and ev- lycemia) requires that there is a typical bursts of temper or bizarre behavior erybody has probably experienced symptomatic attack, which is asso- may also occur. 3 5 some of them. For many years, hypo- ciated with a low plasma or blood glu- Activation of the autonomic ner- glycemia has attracted the public cose, and that relief of symptoms is vous system and the ensuing release of press, which is always attentive to the rapid after glucose administration. epinephrine by the adrenal medulla public's desire for information about However, this triad, known as the triad cause the signs and symptoms of health matters.2 5 Often, after reading of Whipple, is rarely demonstrated adrenergic overactivity. These symp- a magazine article on the subject, a pa- spontaneously, and provocative tests toms include sweating, palpitations, tient will visit me with his own diag- are usually needed.5 Although the ap- tachycardia, shakiness, anxiety, ner- nosis of hypoglycemia. In the U.S., propriateness of the oral glucose toler- vousness or pallor.3' 5 the diagnosis of hypoglycemia seems ance test has been challenged,8 it re- Some subjects feel hungry, but nau- to have reached epidemic proportions mains the more standardized approach sea and vomiting also may be present. in recent years.7 Looking at this phe- to assess glucose homeostasis. To be While the neuroglucopenic symp- nomenon, Yager and Young described diagnostic of reactive hypoglycemia, toms usually predominate with the the syndrome of non-hypoglycemia.7 the appearance of symptoms during gradual onset of fasting hypoglycemia, These authors reported their own expe- the test should coincide with the nadir the adrenergic manifestations normally rience with many patients who ac- of plasma glucose. Measurements of predominate with the more rapid onset counted for their symptoms by falsely plasma cortisol and/or epinephrine of postprandial or reactive hypoglyce- attributing them to hypoglycemia. have been used to demonstrate the ac- mia. Nevertheless, both groups of Such a diagnosis has the obvious ad- tivation of the hypothalamic pituitary- symptoms, or either alone, may be ob- vantage of being more socially accept- adrenal axis in response to the central served in reactive hypoglycemia.5 able then a psychologic or otherwise neuroglucopenic stress. However, the With the functional type of reactive stigmatizing condition. Furthermore, significance of these measurements hypoglycemia, the symptoms typically the mere fact of having a medical diag- should be more clearly established be- develop 90 minutes to two hours after nosis for ambiguous and often perplex- fore their general use is advocated. Fi- a meal, most often after breakfast. The ing symptoms can provide some relief nally, although subjects with reactive symptoms are transitory and usually to these subjects. Finally, the more or hypoglycemia may, as a group, differ subside in 15-30 minutes. Convulsions less 'ritual' approach of adhering
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