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Hello Dr.,

Could a gastric bypass patient die in their sleep if they have an episode of very low blood sugar after ingesting a large amount of sweets before going to bed?  I´ve woken up two hours after going to bed with low blood sugar after having a banana for dinner, for example. So I was wondering what would happen if someone had a tub of ice-cream (like many of us did pre-surgery).

Thank you for your time.

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Dear Blameithonthegenes,
 
A significant drop in blood sugar following meals or snacks is called reactive hypoglycemia. This phenomenon, also called late dumping, is seen in a substantial number of gastric bypass patients, and may also be seen occasionally after sleeve gastrectomy. At times blood sugars can drop dangerously low causing decreased mental status and even loss of consciousness. Fatal traffic accidents caused by decreased level of consciousness have been reported. Fatality from profound nighttime hypoglycemia is conceivable, but I have not seen it reported in the medical/legal literature. 
 
If a person is prone to reactive hypoglycemia, it would be wise to avoid eating anything for several hours before bedtime. Drinking water or other sugar free drinks is OK.  It would also be wise to avoid large carbohydrate loads any time of the day. Eating smaller, low glycemic meals seems to be best. Real success with weight control comes with a true commitment to lifestyle change. 
 
I've included several up to date summaries of medical studies for further information.
 
Dr. Callery
______________________________________________________________________
 
2016 Oct 17. pii: S1550-7289(16)30746-8. doi: 10.1016/j.soard.2016.10.007. [Epub ahead of print]

Overall and cause-specific mortality after Roux-en-Y gastric bypass surgery: A nationwide cohort study.

BACKGROUND:

Few population-based studies provide data on mortality after bariatric surgery. We hypothesized that hypoglycemia could be an underdiagnosed cause of death.

OBJECTIVES:

To examine perioperative, all-cause, and cause-specific long-term mortality in Roux-en-Y gastric bypass (RYGB) patients versus population comparisons.

SETTING:

Danish nationwide population-based cohort study.

METHODS:

We included all 9895 patients who underwent RYGB during 2006-2010, and a 1:25 age- and gender-matched comparison cohort (n = 247,366) (0.3% lost to follow up). We compared mortality rates and computed mortality rate ratios (MRR) for all-cause and cause-specific mortality using Cox regression analysis. For deceased RYGB patients (n = 91), we conducted a detailed medical record audit.

RESULTS:

The perioperative (30-days) mortality after RYGB was .04% (4/9895). After 4.2 years, RYGB-related mortality (deaths due to intestinal obstruction/intra-abdominal leakage) was .15% (16/9895). All-cause mortality was very similar in the 2 cohorts (median age, 40.2 years; 21.7% men): RYGB cohort, .89% (n = 91); comparison cohort, .92% (n = 2204); MRR = 1.03 (95% confidence interval [CI], .84-1.27). Mortality due to suicide (2.78; 95% CI, 1.44-5.33), accidents (2.29; 95% CI, 1.16-4.54), gastrointestinal diseases (2.01; 95% CI, 1.06-3.84), and infectious diseases (1.75; 95% CI, .98-3.17) was higher in the RYGB cohort versus comparison groups, but mortality from cancer was lower (0.43; 95% CI, .27-.70). Our medical record audit indicated that 8% of deaths after RYGB (n = 7) were possibly hypoglycemia related.

CONCLUSION:

Perioperative mortality after RYGB is low in Denmark, and subsequent all-cause mortality is similar to that of matched comparisons. After RYGB, patients have substantially increased mortality due to external causes such as suicide, accidents, and possibly hypoglycemia.

________________________________________________________________________________________
 
2017 Feb;13(2):345-351. doi: 10.1016/j.soard.2016.09.025. Epub 2016 Sep 28.

Postprandial hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass: an update.

Roux-en-Y gastric bypass (RYGB) is an efficient treatment for morbid obesity and reduces obesity-related co-morbidities. With the growing number of patients undergoing gastric bypass, complications now demand further attention. Postprandial hyperinsulinemic hypoglycemia (PHH) after Roux-en-Y gastric bypass is a complex condition, characterized by increased glucose variability including both hyperglycemic and hypoglycemic values. PHH seems to be more prevalent than previously suggested and is highly dependent on the choice of diagnostic tool, which has not yet been standardized. Questionnaires, an oral glucose tolerance test, a mixed meal tolerance test, and continuous glucose monitoring have been used, each with their own advantages. The condition is further complicated by a large group of asymptomatic cases. Patients with symptoms of PHH after gastric bypass are characterized by exaggerated insulin and glucagon-like peptide-1 responses compared to asymptomatic operated patients. The counter-regulatory mechanisms responsible for preventing hypoglycemia appear to be altered. The cause of these changes is not entirely understood, and it remains difficult to identify patients at risk of developing hypoglycemia. Known risk factors are female sex, longer time since surgery, and lack of prior diabetes. Management of the hypoglycemic episodes is difficult, and only dietary modifications consisting of frequent and less carbohydrate-rich meals seem to be efficient. Medical treatments and surgical procedures have been attempted in few studies and still warrant further examination.

_________________________________________________________________________________

 

2015 May-Jun;11(3):564-9. doi: 10.1016/j.soard.2014.11.003. Epub 2014 Nov 13.

Hypoglycemia after Roux-En-Y gastric bypass: detection rates of continuous glucose monitoring (CGM) versus mixed meal test

BACKGROUND:

Neuroglucopenic hypoglycemia might be an underestimated threat for roux-en-Y gastric bypass (RYGB) patients leading to fatigue, syncope, seizures or even accidental deaths. Different measurements can assess hypoglycemia such as a finger-stick glucometer, an Oral Glucose Tolerance Test, a Mixed Meal-Test (MMT) or, as introduced recently, continuous glucose monitoring (CGM).

SETTING:

University Hospital, Austria.

METHODS:

To assess the incidence of hypoglycemic episodes under real life conditions, 5-day CGM was performed in a series of 40 patients at a mean of 86 months after RYGB. The detection rates were compared to a mixed meal-test.

RESULTS:

Continuous glucose monitoring detected hypoglycemic episodes of <55 mg/dL or <3.05 mmol/L in 75% of the patients, while Mixed meal test indicated hypoglycemia in 29% of the patients. Continuous glucose monitoring also detected nocturnal hypoglycemic episodes in 15 (38%) of the patients. A mean of 3±1 hypoglycemic episodes per patient with a mean duration of 71±25 minutes were observed by CGM.

CONCLUSIONS:

Assessed under real life conditions by CGM, post-RYGB hypoglycemia was found more frequently than expected. CGM revealed hypoglycemic episodes in 75% of the patients while MMT had a lower detection rate. Thus, CGM may have a role for screening but also for the evaluation of dietary modifications, drug therapy or surgical intervention for hypoglycemia after RYGB.

 
__________________________________________________________________
 
2016 Jun;24(6):1342-8. doi: 10.1002/oby.21479.

Risk of post-gastric bypass surgery hypoglycemia in nondiabetic individuals: A single center experience.

OBJECTIVE:

The epidemiology of post-gastric bypass surgery hypoglycemia (PGBH) is incompletely understood. This study aimed to evaluate the risk of PGBH among nondiabetic patients and associated factors.

METHODS:

A cohort study of nondiabetic patients who underwent Roux-en-Y gastric bypass (RYGB) was conducted. PGBH was defined by any postoperative record of glucose < 60 mg/dL, diagnosis of hypoglycemia, or any medication use for treatment of PGBH. Kaplan-Meier analysis was used to describe PGBH occurrence, log-rank tests, and Cox regression to examine associated factors.

RESULTS:

Of the 1,206 eligible patients, 86% were female with mean age of 43.7 years, mean preoperative BMI of 48.7 kg/m(2) , and a mean follow-up of 4.8 years. The cumulative incidence of hypoglycemia at 1 and 5 years post-RYGB was 2.7% and 13.3%, respectively. Incidence of PGBH was identified in 158 patients and was associated with lower preoperative BMI (P = 0.048), lower preoperative HbA1c (P = 0.012), and higher 6-month percent of excess body weight loss (%EWL) (P = 0.001). A lower preoperative HbA1c (HR = 1.73, P = 0.0034) and higher 6-month %EWL (HR = 1.96, P = 0.0074) remained independently correlated with increased risk for PGBH in multi-regression analysis.

CONCLUSIONS:

The 5-year incidence of PGBH among nondiabetic individuals was 13.3% and was associated with a lower preoperative HbA1c and greater weight loss at 6 months following surgery.

 
______________________________________________________________________
 
2016 Nov;264(5):878-885.

Incidence and Predictive Factors of Postprandial Hyperinsulinemic Hypoglycemia After Roux-en-Y Gastric Bypass: A Five year Longitudinal Study.

BACKGROUND:

Postprandial hyperinsulinemic hypoglycemia (PHH) is often reported after Roux-en-Y gastric bypass (RYGB). In the absence of a prospective study, the clinical and biological determinants of PHH remain unclear.

OBJECTIVE:

To determine the incidence and predictive factors of PHH after RYGB.

METHODS:

Participants were 957 RYGB patients enrolled in an ongoing longitudinal cohort study. We analyzed the results of an oral glucose tolerance test (OGTT) routinely performed before surgery and 1 and/or 5 years after. PHH was defined as blood glucose < 50 mg/dL AND plasma insulin > 3 mU/L at 120 minutes post glucose challenge. Validated indices of insulin sensitivity (Matsuda index), beta-cell function (Insulinogenic index), and beta-cell mass (fasting C-peptide: glucose ratio) were calculated, from glucose, insulin, and c-peptide values measured during OGTT.

RESULTS:

OGTT results were available in all patients at baseline, in 85.6% at 12 months and 52.8% at 60 months. The incidence of PHH was 0.5% at baseline, 9.1% * and 7.9%* at 12 months and 60 months following RYGB (*: P < 0.001). In multivariate logistic regression analysis, PHH after RYGB was independently associated with lower age (P = 0.005), greater weight loss (P = 0.031), as well as higher beta-cell function (P = 0.002) and insulin sensitivity (P < 0.001), but not with beta-cell mass (P = 0.381). A preoperative elevated beta-cell function was an independent predictor of PHH after RYGB (receiver operating characteristics curve area under the curve 0.68, P = 0.04).

CONCLUSIONS::

The incidence of PHH significantly increased after RYGB but remained stable between 1 and 5 years. The estimation of beta-cell function with an OGTT before surgery can identify patients at risk for developing PHH after RYGB.

 

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Fatality from profound nighttime hypoglycemia is conceivable, but I have not seen it reported in the medical/legal literature. 

I have a question about that:

Wouldn't the brain be sending wake-up signals as soon as blood sugar drops low? Or is the body's ability to detect hypoglycemia during sleep impaired? (I'm thinking about undetected hypoglycemias in diabetic patients during sleep.)

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When blood sugar drops, people get an adrenalin surge. This causes rapid heart rate, sweating, and anxiety. People do often wake up if they are hypoglycemic. But sometimes they do not. The sugar can fall far enough and fast enough that the brain goes into a stupor, coma, sometimes convulsions, and death without fully awakening the patient. The patient could partially awaken, but not have the mental capacity to recognize the situation. Rare, but scary.

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