082 Understanding Post-Bariatric Surgery Reactive Hypoglycemia

by reeger on April 16, 2017


episode 82

In this episode I talk with Jerry Ross about his experiences with post-bariatric surgery reactive hypoglycemia. Jerry had Roux-en-Y gastric bypass in 2002 when he was in his early thirties. Although the fact that Jerry had RYGB is central to this story, gastric bypass alone is not the reason Jerry and I recorded this conversation. We talked because Jerry wanted to share his experiences regarding Late Dumping syndrome, aka Reactive Hypoglycemia.


There is a lot of information in this episode so I wanted to give you a chronology of what we talked about and when, just in case you wanted to re-listen to a section and wanted to be able to find it faster than starting over. Happy listening.

Chronology of Topics Discussed
0:22 Reeger Thanks for Patreon supporters.
2:30 Jerry’s history of obesity and decision to have bariatric surgery.
6:35 Thoughts on food addiction.
8:00 Early days after bariatric surgery. The honeymoon period.
9:30 Jerry and exercise right after surgery and his advice to you.
12:30 Jerry’s early weight loss progress, weight regain, and feelings of frustration.
13:30 The tricky thing about hunger- physical hunger vs head hunger.
15:30 Jerry’s journey of testing and evaluation in the first 5-7 years after surgery.
16:50 The surgeons advice to Jerry and Jerry’s thoughts on “getting his head on straight.”
18:00 Jerry’s pre-op and post-op education.
19:20 The beginning of his symptoms of reactive hypoglycemia with a description of what his symptoms were, trying to figure out what was going on, and how he began to manage his symptoms.
27:47 Reeger goes over blood sugar values and symptoms of low blood sugar.
29:12 The Oral Glucose Tolerance Test (OGTT).
32:00 Jerry’s “wake-up call” that his bariatric surgery was not as benign as he once thought and that he could not live like a “normal” person and eat whatever he wanted to eat.
32:30: Reeger describes normal digestion of carbohydrates, blood glucose, gut hormones, insulin, GLP-1.
35:40 Reeger’s disclaimer of gut-endocrine over-simplification and violin metaphor.
36:30 Jerry and Hyperinsulinemic Hypoglycemia and why we call it “Reactive Hypoglycemia.”
38:22 Why might Reactive Hypoglycemia occur after RYGB, the role of GLP-1, and why it tends to get worse over time.
41:20 Nesidioblastosis: What it is and why it might happen after RYGB.
43:00 Acknowledging the frustration of limited understanding why reactive hypoglycemia might occur.
44:16 Incidents of Reactive Hypoglycemia from other bariatric surgeries.
44:50 How to Diagnosis Reactive Hypoglycemia: Blood glucose levels, Whipples triad, Mixed Meal Tolerance Test.
46:20 Excellent paper by Shantavasinkul titled “Post-gastric bypass hypoglycemia: a review”.
47:00 Jerry’s further evaluation and treatment: Food diary, possibility of surgical revisio (Rose procedure, reverse RYGB, partial pancreatectomy).
50:00 Behaviors Jerry changed to help manage his symptoms.
51:00 The foods Jerry now avoids.
53:30 The tricky thing about Jerry’s hunger.
57:00 Struggles with constipation and further weight loss.
58:00 With more weight loss his Reactive Hypoglycemia got even worse and his theory as to why.
1:01 Jerry’s use of a continuous glucose monitor (CGM).
1:04 What Jerry has learned from wearing his CGM.
1:08 Hypoglycemia Unawareness Syndrome.
1:09 A deep dive into treatment: One reference I looked at said that meals and snacks should not exceed 30 grams of carbs, excluding fiber, and some meals can have no carbs at all. Often meals sizes need to be reduced to smaller sizes, eaten more often, 5-6 times per day.
1:10 Understanding Glycemic Index and Glycemic Load.
1:12 Medication Used to treat Reactive Hypoglycemia: Acarbose, Calcium Channel Blockers, Diazoxide, Somatostatin Analogues.
1:14 Surgical Options: Partial pancreatectomy, Reversal of the RYGB, or placement of a gastric feedling tube.
1:15 An additional thought on the work-up of Reactive Hypoglycemia: Insulinoma.
1:16 The medication that did work for Jerry: GLP-1 receptor agonist.
1:18 Reeger’s pondering why a GLP-1 receptor agonist might given and Jerry helping explain how the medication has helped him.
1:22 Reeger goes back to the violin metaphor.
1:23 The GLP-1 agonist medications available: Exenatide (Byetta or Bydureon), Albiglutide (Tanzeum), Dula-glutide (Trulicity), Lixisenatide (Lyxumia), and Liraglutide (Victoza, and as an obesity medication it is sold under the name Saxenda). It should be noted, that using any of these GLP-1 agonist medications to treat Post-bariatric surgery reactive hypoglycemia would be considered an off-label use, so prescriber beware.
1:24 Jerry’s new normal of health.
1:25 Does Jerry regret having had RYGB?
1:26 Reeger talks about caring for patients who have presented in the office with symptoms of reactive hypoglycemia.
1:29 Reeger’s concluding thoughts.
1:32 Bonus Content.

Connecting with Jerry
Instagram ChunkyBoySlim
Email: Jerry@chunkyboyslim.com

Connecting with Reeger
WLSP Facebook

In Kindness,


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