Reactive Hypoglycemia After Bariatric Surgery: What You Need to Know

Thank you so much for being with us today, Danielle. We're very, very grateful and we're really excited for this. So we would just love it if you would just share what's brought you to this particular point in your career. Well, thank you for the opportunity. You know, it's been a long time coming since we first met, so thank you for your patience, but happy to be here. I guess, look, Barry at Trick Dietetics was my first job as a graduate and I fell in love with it straight away. And I guess the reason I fell in love with it straight away was that it was really nice to be part of someone's journey to watch them go from, you know, feeling a little flat about where their health status was to blossom in and embrace in life. And as a dietician and as a health professional, it's an absolute pleasure to watch that change and that progression. So I thought, yes, this is definitely the specialty for me. And I grew to love it and grew to learn more about it. And here I am almost 20 years later, but don't tell anyone I love that. And so look, a lot has changed in that 20 years since 2004, you know, a lot of like bands were being inserted and the sleeve hadn't really been thought about and the bypass was a big scary operation that, you know, you'd rather avoid. And here we are down the track where we know now that the band really doesn't help or encourage a good relationship with food. It can lead to all kinds of, you know, issues and I think food is such a pleasure in life and it should be enjoyed. And so if the band is not doing that, then it's not right for us. So then the sleeve was determined to be a possible option. It was originally the first part of a bypass whereby if someone needed a bypass, but perhaps we're at risk during surgery, they would get a sleeve, loosen weight and then go and get the bypass performed. And then they, you know, surgeons found that there was some successful weight loss with the sleeve and, hey, let's just leave it at that. Now we're learning more about the sleeve and amongst the mix over the past, you know, a few years has come, the mini bypass, which although it uses the term mini, perhaps from a nutritional point of view, not so mini. So it's been amazing over, you know, a 20-year period to see how much it's evolved and how much it's changed and how much the bariatric community, particularly the medical community has embraced our light health and understood the importance of diatetics and exercise physiology and absolutely psychology. So then I found that, look, hey, you know, there's so much research done on everything that can change in the first 12 months after bariatric surgery, but what about those people that have had a great 12 months, 18 months, but then have vined in some problems, 18 months thereafter. So that's when I thought, hey, you know, we need to live into some of the things that have been in here and that's when I found out about, you know, some of these issues around reactive hyperglycemia. So I thought when there was an opportunity to do a PhD on this topic, I thought, yes, why not? For it. And we are just, well, I know for myself anyway as somebody that lives with this condition day in and day out, any developments are heartily and warmly embraced because it's such an incredibly confronting condition when it first re-sits ugly head and then learning to live with it afterwards. So we're very, very grateful that there are brilliant minds like yourself who are looking into these things. Shall I find a big part and make a difference that will learn something that will be groundbreaking for people like yourself and just help kind of get on top of this? Yeah. So could you tell us, and I guess for people that may never have even heard of the term before, can you break down what reactive hyperglycemia is? Yeah. Yeah, look, well, how long have we got? Yeah. So, look, reactive hyperglycemia is definitely a term that has been used for a long time. We're evolving into a term more like post-bariatric hyperglycemia or hyperglycemia. Largely because reactive hyperglycemia, I guess, is a general term that refers to changes in blood sugar levels, but I'd like for my research in particular to focus on why it happens and how it happens in the bariatric community. So I guess for the sake of not getting time-tied, we'll go with reactive hyperglycemia, but I'd like to focus on it specific to the bariatric community. And it is different from a fast-in-hypoglycemia, you know, that may be a type one diabetic might get, or you know, if you kind of drop your blood sugars because you have an eaten for a while because this actually happens after eating. Now normally we find that there's a hyperglycemia after eating, in other words, your blood sugars will rise. But in this scenario, in a bariatric population, particularly with the bypass, we don't find this problem to this to be too much of a problem with the sleeve patients. And I guess in my experience it anyway, I haven't found to be too much of a big difference in the mini bypass population, but the mini bypass really has only been done for a short while and we have very little data on that. So my focus is definitely the raw and wide gastric bypass, but there's no doubt the information will evolve and I'm sure we'll find out more about the future. But essentially, you know, well, usually we find that this problem is around 18 months to three years and up to five years after all my gastric bypass surgery. Can be as soon as 12 months. I do have a patient at the moment that has it at around the 12 month mark. And so there's no real time frame, which it can happen, but usually it's around the 12 to 18 month time post-operative. Usually occurs around one to three hours after eating. And so it is different than a lot of the research and even some of the papers that I've read from 2023 are still using Lake Dump in Syndrome and re-addipiboglycemia as an interchangeable term. In my opinion, it's very, very different and the biggest difference is really that Lake Dump in Syndrome, yes, your blood sugar levels fall and there is a blood sugar kind of component to it, but it will never fall low enough to develop what we call neuroglochopenia. And neuroglochopenios, when your blood sugar is fall below three and you're at risk of maybe 2.7 something like that and you're at risk of having seizures and all kinds of things. Now that's reactive hypoglycemia. If you have Lake Dump in Syndrome, your blood sugars will never go low enough to really be at risk of a neurological event like passing out or having a seizure of something along those lines. So hopefully we can chat more about that throughout today's session. But so you know, usually one to three hours after eating, you know, what essentially happens from what we understand is that your insulin levels overshoot and become a little bit too high. And therefore, as a result, you have excess glucose been removed from the blood stream and as a result of that, you feel pretty lousy. One of the main reasons they are thinking this might happen is because of the hormonal changes that occur after the bypass surgery. And in particular, there's a hormone that's probably become in a bit more popular, the GLP1 and the reason why that might be more popular these days is through ozempic and during those kind of weight loss medications. But essentially what that does is it encourages the release of insulin. So if you've got this higher concentration of GLP1 as a result of a bypass surgery and it's encouraging the release of insulin after a meal to higher than normal levels, then you will have the job of insulin is to draw the sugar out of the bloodstream and store it in the muscle or the liver. So if you've got an excess amount of this particular hormone, you will end up having lower than normal blood sugar levels. Right. The unique thing about Reactive Hypoglycemia versus late dumping is that it can happen overnight, whereas late dumping usually happens because we've had a very decadent hot chocolate with a nice serum, that's maybe a little bit too quickly. Reactive Hypoglycemia is sometimes occurs during the night as well. Yeah. It can be, it can definitely be very terrifying. - I can only imagine, absolutely. - And it strikes. - I bet, Tush, I bet. And the other thing that can be quite scary is that someone with reactive hypoglycemia are probably having more hypoglycemia events than they actually give themselves critical because your body develops a bit of an adaptation to it. So you can develop what's called hypoglycemia unawareness where your blood sugar levels are a little bit low, but you're just not aware of it. And if we wear things like continuous glucose monitoring and devices, you can see exactly how many times it occurs during the day. And that is definitely not late dumping. If it's occurring regularly to a point where your body's developing an adaptation to it, then you need to have a lower blood sugar level to actually be aware that it's happening. And that can get quite dangerous and you know. - Well, so should someone who is having our hates, should they maybe look at getting a continuous glucose monitor so that they can just, you know, at least know when they're blood sugar level. - Yeah, absolutely. I'm a big fan. If they really do feel that, you know, they've, the whole concept of late dumping, it's definitely not associated with that. And there's something more to it. I really like the idea of continuous glucose monitoring, monitoring, it gives us a lot of information and it gives the patient a lot of information as well. - Mm-hmm. - And it also tells us whether the problem is occurring during the night, you know, which can be quite dangerous. It's hard as a non-diabetic to get your hands on a continuous glucose monitor, but if your surgeon is on board, then, you know, for $15, you know, you can get one for two weeks and you can monitor your blood sugar levels. You just need a letter from your surgeon that allows for the company to, you know, to provide you with that monitor. But there are some companies that for $99 a month or for $15 for two weeks. And I usually find two weeks of data is more than enough to give us the information of whether it's happening or not. - Yeah, that's very, very good to know. - That's great. - I actually got, I had one for a couple of weeks 'cause I got type two diabetes, which came back in all its deathly glory last year. And my HBA1C was like 15 and, you know, I was really unwell and in the doctor put me on a couple of different insulins. And so I got one because I just didn't think I was managing it that well. And it was so interesting the data that came from it. And I was able to take that to my endocrinologist, you know, he said it's really helpful in working out what strategy and what was actually, what was actually happening. - I agree. And although it's a bit tedious, taking a food diary and trying to see the trends between what you're eating and how your blood sugars have responded is really great as well. But yeah, good on you for doing that. I think it's very insightful. - I know for me was, I was at, right at the 18 month mark post-bipast when all of this started for me. But it was a challenging time because that was during COVID. So there was a lot of difficulty, as you would imagine, particularly living in Melbourne during, or in Victoria during that time. So it probably took a little bit longer to diagnose than what I was hoping it would. But it affected me to a point where I was not allowed to drive, finily eagier, because my blood sugar was really above full. So it was just such a hard, it was such a hard, hard time. And yeah, I ended up with a glycogen pen and all of those things because I was passing out so frequently. And it was a very terrifying time for my family. Funnily enough, with me, red meat really affects me. - Which is extremely strange. But if I just avoid it, which is hard when you need protein, and it's such a wonderful source, if I just steer clear, then I can pretty much guarantee that my blood sugars stay quite okay. Still low, very low. But yeah, so it's odd because we wouldn't necessarily think that that would trigger anything. But I guess you're right. It's a good source of, you know, iron and B12 and protein and all those things. But to be able to narrow it down just to the one food item, as opposed to a group of foods that, you know, it doesn't kind of restrict you too much. But what it takes in a lot of hard work and a lot of trial and error to get to that point. And, you know, to have your license taken away, it goes to show how much of an impact it is, not only on your health, but on your life, on the things that you can do and how easy it is. - That's right. - And it's about how it is to do. And, you know, then that gets you down at an emotional point of view. So it's a real mind-body soul kind of issue. - It's just, it was such a strange journey for me anyway, because it was the very last thing that I would have thought. I also have celiac. So I already have a whole lot of things that I just simply can't have. I was at that time quite, well, I'd been through a plastic, my first plastic surgery procedure, my hemoglobin was very low. So my body, I needed protein. And for me, it felt like my whole world was falling apart because he's the meat that I need to have for the protein. But now every time I have it, my blood sugar is dropping to 1.7, 1.9. So it was, and we didn't really link it for quite a while. Me and my endocrinologist, we were very, it was just odd, it was strange. But anyway, we did get there in the end. But yeah, it is a difficult, difficult condition to manage and I really wouldn't wish it on anybody. But do we know why? Do we know why that switches on at the 18 month mark? Do we know what it is yet? - Not really in a word, but I can give you a few ideas of what might be happening. - Okay. - I mean, there's lots of theories out there. And one of the biggest theories is, it tends to occur and I'm being touched to hear if this relates to yourself, but it tends to occur mostly in people that are pretty diabetic before surgery rather than diabetic before. - I was? - Okay, yeah. And the reason for that is, there's cells in your pancreas called beta cells and the beta cells release insulin. And when you've got an insulin resistance, then those cells can sometimes expand, I guess, in a way that your body's trying to upregulate the amount of insulin that it's releasing so it can deal with the higher blood sugar levels. And so if you can imagine you go into surgery as a pre-divide, because if you're a diabetic, then you've probably been treated and these beta cells haven't probably expanded quite as much. So you go into surgery and you have a significant loss of weight in a very short space of time. If you go into remission with diabetes slowly, then those cells tend to get smaller and that hyper-insulemia or that excess release of insulin is great. But when you have a significant loss in a short period of time, those cells haven't had an opportunity to get smaller. And therefore, they are oversecreted in the insulin. - Makes perfect sense. It makes perfect sense. - Yes, it really does. - It's felt to me like I was receiving the same type of insulin that I probably once would have needed, but now no longer need. And it absolutely just knocks me out because I did lose 100 kilos. - What we're thinking is happening and why the hyper-insulemia is happening. And then of course, you've got a suppression of what we call counter-regulatory hormones. So you mentioned earlier that you had a glucagon pen. If your blood sugars did go a little bit low, you would inject yourself with a hormone called glucagon, which encourages a release of carbohydrate from your liver and your muscles to bring your blood sugars back up. Unfortunately, one of the, that glucagon is like the opposite to insulin. If you like, insulin brings your blood sugars down, glucagon will bring it up. But with this reactive hypoglycemia, you have a problem counter-regulatory hormones. So not only do you have an excess release of insulin, but you, you can't have that counter regulatory gluteagon, influencing your blood sugar levels because that system has kind of failed and broken down a little bit. So that's what we're thinking is happening at the moment. - Yeah. - That's fascinating. It makes sense. And it lines up exactly. I can manage things if I eat very much within the range of foods that I know are safe for me. So if I stick within that killer scope, then things remain quite balanced. If I eat outside of that, then. - No. - So all of that makes such good sense and I'm so glad that that's actually what the research points to and it's not just that I'm crazy. - That's still crazy. - I might be. - I'm sorry, but it's not your cue to agree. (laughing) - Yeah. - So look, there's still a lot of research to be done. I think we need to appreciate that it's not the same as dumping. I think that's the first thing. And like I said, still to this day, some of the latest papers are using those terms interchangeably and they're really not. - No, it's nothing like that. - And it really takes away from what people are going through because to me it's like, oh, you're here dumping. Well, maybe I shouldn't have had those three scoops of ice cream as a snack and then this wouldn't be happening. But when it. And people. I know people have sort of said that to Tasha, it's obviously something you ate. And so I will. As far as a brisket, shouldn't do that to someone. And it really takes away from what someone might be going through to almost feels like a bit of gaslighting that it's your fault anyways. - Yeah. - On the mission, I'm advocating. I just want to go around the whole world and tell everyone this is a real thing. And you're right with the health. You know, surgeons, GPs, some endocrinologists, they understand that reactive hypoglycemia is a condition that how it relates specifically to bariatricis is not well known. - Yeah. - So doctors that are listening, listen. - Please, please, please, please do that because it's such a debilitating thing and terrifying for people when they're going through this and we see it all the time on bariatric support Australia when people's blood sugars are just dropping and they're really higher than four and their bodies are in crisis and they are in crisis and their life can literally just come to a grinding halt because they can't work or they can't interact with their family like they would have once and it can be such a frightening thing because you don't necessarily understand why it's happening. - Yeah. No, no, you do reach out for help. You're not getting people who are understanding as well. So then it comes back to, you know, is this maybe, you know, - Yeah. - You're dieting. - Is it something I'm doing? Am I overreacting? You know, jeep, the medical profession doesn't know about it or is wondering what it is as well. Maybe it's, you know, yeah. - Well, then even the term sort of eating disorder gets thronicked. - That happened. - That definitely happened to me. - It does cause that mental health sort of issues because when you've got a, you know, a doctor sitting there going, no, this is actually in your head and you know, you need to see a psychologist. When really, no, you need to see an endocrinologist and, you know, a dietician that can help you through this. You know, it's really hard. So with the people that you treat for this condition, are you seeing good progress? And in terms of longer term outcomes, what does it look like? And obviously I understand that the research is, you know, relatively new. So of course, we don't really know what longer term outcomes are yet. You know, does this impact on the potential for diabetes in the future? My mind's racing with all of the questions. - Absolutely. Well, I guess because it's not known or not popular or, you know, not popular. What I mean by not popular is, you know, because people are unsure how to interpret their symptoms. You know, you don't hear a lot about it or they perhaps, if they're out of the loop because otherwise doing well, they're unlikely to reach out. So I guess I haven't had a lot of patience. I've probably only had two. And one at the moment who is in the process of doing the continuous glucose monitoring. So I really, I'm working closely with Michael Talbot to hopefully get on top of exactly what's happening here. So I really can't help you if I may be honest. I really can't help you with how the outcomes are going to be the interventions going at the moment because we're still kind of a working progress. There's no doubt that nutrition plays a role. That's usually the first port of call looking at nutrition. And as you say, you know, we can't be always looking at carbohydrates and glycemic index and these kind of things because a piece of red meat has no glycemic index at all. Yet my nose. How does it do that? - Exactly. And I think we underestimate how insulin is a hormone that is released after eating to regulate not only your blood sugar levels, but it is released as a result of that and protein intake as well, which we can underestimate. And for those type one diabetics who are, you know, have a sliding scale of insulin, they do need to take into account, you know, the protein and the fats and those kind of things in the diet as well. So we need to really think more, literally, a move away from carbohydrate and glycemic index because it's not just a carbohydrate issue. The carbohydrate issue occurs because it's a hyperinsulemic issue. In other words, too much insulin is being released and that can be released for any macronutrient. So I guess there was a second part to your question, Tasha. And I'm terribly sorry. I forgot what it is. You mentioned something that was really interesting and I've forgotten entirely what it was as far as treatment and that kind of thing. Yes, yes, yes, yes, my apologies. So yeah, usually, usual nutrition therapy is definitely the first port of call because what we don't want to do is we don't want to reverse the surgery. We don't want anything in invasive. We don't want to go down those kind of paths. You've already had a big operation. We don't want to have another one. You know, ideally, we don't want to burden you with as well, you know, where you can try and avoid pharmacotherapy, then that's great as well. So definitely medical nutritional therapy and working with the patient and getting that continuous glucose monitoring so that we can find out, you know, for that specific patient, what their triggers are. But if the nutritional therapy just isn't working as well as you'd like, or perhaps it's working, but there's still that little bit of a concern or issue there, then pharmacotherapy would definitely be the next port of call. And there are a number of medications on the market there that work on, you know, insulin and trying to, you know, essentially inhibit the insulin secretions so that you don't get these high-bokelycemic events. And then the third point of call, if the medical nutritional therapy and the insulin reduction in insulin secretion through medication isn't working, then what we do is we can put a peg tube into the remnant stomach. Now this is where we start to get a little bit more invasive with our treatment approach. But a peg tube is essentially a tube that's inserted from the outside of your body into the stomach. And as you know, with the raw and Y gastric bypass, you get quite a small stomach around the size of an egg. But the rest of your stomach that's been bypassed continues to have a blood supply and continues to be viable and is connected to the smallest iron stills. So what we tend to do is we put a tube from the outside of your body into that part of your stomach that is remaining, not the part that's part of the actual bypass. And we feed you nutrition through that tube into that remnant stomach. And the concept there is that if it goes into that remnant stomach, then the flow of food will go back into its original flow. So if you did a bypass in the first part of your intestine, then the food or the nutrition or the macronutrients will flow back into that first part of your small intestine, the jawadena. And we find that that will then next to no time will fix the problem. So there's, yeah, there's something there that when you, when you bypass the jawadena, then part of the jujuna, which the jawadena is the first part of your small intestine. intestine and the jujune is the second part of your small intestine and usually with a row and y we tend to bypass about a meter and a half of your small intestine. So if you go back to using that upper small intestine that's been bypassed then the problem goes away. So we need to worry. But having a long tube and being fed through a tube into your stomach is not why we have this bypass. It's to be the healthiest version of yourself with less invasive pharmacotherapy and medicine and all kinds of things. So I guess if you get really, really good results with the pectube then reverse in the bypass is the other option because if we can get the digestive system back into its original kind of anatomy then we know that this reactive hypochloric email will no longer be a problem because we've tested the theory with the pectube and inserting things back into the original digestive tract. Wow. Who came up with that idea? I'm going to have to get back to you with that one because that's all right. I'm fascinated. Just like yeah. Such an intricate procedure and you know just let's just try this and see how it goes. It's amazing. It's amazing. Well I guess the theory is that okay you didn't have this condition before the surgery. You have this condition after the surgery. So since you've still got your organs within your body let's try and see if the problem still occurs by using the old digestive system. Wow. And yeah it usually more often than not and very quickly will become much, much better. I mean something that I found, well and I really wasn't expecting it because obviously after bariatric surgery we're not advised to not eat carbs and I certainly do eat carbs. Eating carbohydrates system is what has really helped me which is quite strange and was nearly counterintuitive to the advice that I was given back when I first had my bypass but now that I do eat carbohydrates in a balanced way consistently throughout the day my blood sugar is far better than what it used to be which again is it still seems strange to me but it actually seems to be working which is wonderful. It's great. My times are being or collapsing are very very few and far between. I think it's happened once in the last six months and it was daily. Wow okay well that is a significant improvement and look I guess what's happening in there is I'm only guessing so any doctors or other dietitians out there please correct me if I'm wrong but I'm guessing what's happening in their tashes that because your oral intake is quite small. You don't have a lot of carbohydrate or glycogen in reserve so if you do go to a point where you don't have a lot of carbohydrates and your body is looking for maintaining your blood sugar levels by using that counter regulatory kind of glucagon scenario and they don't have any in reserve then you just your body goes into a spin but by having that small frequent intake of carbohydrate means that you'll never get your body into a spin trying to look for reserves in your liver and your muscles and therefore you don't get that you know hormonal response that can lead to a low blood sugar reading so I think that is a brilliant result and again credit to you and your team for the severe and for the trial and error that you've been through to find your way to going from daily high-brose to one in six months I mean that is a life change improvement. Yeah it was difficult mentally it was a difficult challenge mentally because it required such frequent meals and that again was a departure from that initial advice you know those those three three meals a day that this the no snacking thing and all of that but I eat probably eight times a day and and I keep I keep it balanced I try very very hard to make sure that I'm having protein fats and carbs every time that I do eat and I I really I really did have my doubts about it all I thought oh my goodness what if this makes me worse I was very scared but it seems to have helped which has been so good because it was such an exhausting thing to be going through and I did do you know a few of the different pharmaceutical drugs that are out there for you know for this type of thing and well there there was some improvement but it was still happening we started looking for what else what else can I do so yeah I'm I'm pleased that that I'm now at this point it would be lovely if it never happened but once every six months is certainly much more manageable than once or twice a day absolutely do you feel it coming on do you feel when it's yeah okay so I do I do you know yes and my dog also also knows which is yeah they're and you know he's not he's not a trained he's not a trained animal like for alerting for those kinds of things but we worked out that that's what he was doing so he obviously knew when my when my blood sugar was dropping and he would come and he would start pouring me and and doing that um while I while we were going through this whole process of trying to work out exactly what was happening and how to help it he he was very helpful um in that regard because I would sort of um eat when he would indicate that something was was happening and over time it started improving it's it's very strange but but I think thank you for sharing that I think that's an amazing story and and it goes to show that you need to just be open to any anything anything everything all the help you know I didn't have the blood glucose monitoring back then I have done it since but I didn't have it back at the start as I said it was during COVID and it was yeah very crazy time but I was testing my blood sugar so frequently you know six times a day or something like that it was a lot and and every time every time my my dog would come and do his little thing it was always low so we just we just worked out over the last few years that yes that's definitely what it was yeah we've been able to slowly come up with what seems to be working for now of course I've always got that concern in my mind that something in my body might change and suddenly I will be at its mercy again but hopefully not. Hopefully fingers and toes crossed in all the hard work that you've done and and it just sounds like it's been an extremely you know like a roller coaster ride you know some that I'm really glad that with all that that you've learned along the journey that it's made such an impact and I can't really ask is it just read me that's a problem or is it chicken and fish is it any type of animal meat that tends to set it off? it it seems to be those more dense proteins I've had it happen to me with kangaroo yeah I've had it happen to me mainly with with with umbreath but it seems to be those particular those two particular things not with chicken and not with fish okay so that's that's good you've got that still in your diet and you know what um sometimes we we can't question it if that you know we found a trend just go with it you know um and it's it's odd and and I've asked myself all of the same questions what am I missing is there is there something else that it could possibly be um you know could it I I thought for a time maybe it was seasoning maybe it was this or that but no no it's just it is just predictably those things well look I'm just rep that you found you know you you come to a conclusion and it's made a difference I think that's that's really important because um we don't want to reverse your surgery we we don't want to have you you know top up your nutrition by a peg tube um you know no no well what would you say to somebody that that is having these symptoms so what firstly I suppose what should people look out for and then what should they do if they believe that this is what's happening yeah well yeah what to look out for is things like the sweats and the trimmers and you know the the bogginess in the mind and you know all those things that we hear about that and that are type one diabetic you going into a hypo might feel they're all they're all the same and reactive hypoglycemia. The nasty thing is if it goes really below a blood sugar of 2.7 and that really high risk of having a seizure, that's where you know and the fact that if you are having regular mini-hypose that your body determines that to be the new norm and that you have to have an extreme hypoglyphial body to actually alert you to the fact that this is not good. So that hypoglycemic unawareness is a real concern and and that's where the Tinois glucose monitoring is really handy at indicating just how often it happens and to try and you know alerts someone to a hypoglyphial much sooner so that you can maybe have something to eat with some carbohydrate or that will bring the blood sugars back up without what you don't want though is a rebound hypoglycemia so you know yes nutrition does play a role and and having some carbohydrate to bring your blood sugars back up will certainly make you feel better but what you don't want to do is feel so terrible that you have a whole packet of jelly beans instead of just real poor jelly bean because what can happen is your blood sugar levels can spike again and then you get another hyperinsulemic event in other words you get another influx of insulin that brings you back down to an extra low level and it can be a real a real cycle if you do that so as yucky as you feel you really do need to be quite particular with how much carbohydrate you have so you don't create another scenario but I guess what you really need to do is find a GP or specter surgeon or get a referral to a endocrinologist or find a bariatric specific dietician because there's there's dieticians generalist dieticians fantastic there's then bariatric dieticians those dieticians that specialize in bariatric surgery and and all the nutrition related to that but then there's the bariatric dieticians that kind of been in the area for a long time seeing a lot of scenarios and can kind of pick it a little bit better so I guess you know taking the box seen a dietician it's really all about seeing the dietician that you think might be able to help you as opposed to just seeing a dietician you know we all have 100% I 100% agree with you there are and our dieticians are wonderful they're they're so well trained I mean I love and appreciate all the work that dieticians do and and then there are our bariatric dieticians and then there are the dieticians as you've just said who have been around bariatrics for a long time they've seen these conditions and they understand them in a different way they're the people that that you need in your corner when you have this kind of condition you're definitely 100% and off of the GP is a little bit unsure and and we're we as with the dietician and you know it's great when you've got a team that all speak to one another and all open to each other's thoughts and opinions and and and and then can take their own specialty into into into considerations so that you know that that we're all doing the right thing by the patient at the end of the day so yeah if you do approach a GP your surgeon a dietician and they really just aren't giving you what you feel you need or because no one knows their body better than they do and if you feel that they are giving you feedback and it's just not specific to you or it's you know sometimes sometimes there's a bit of troll in error where you know we we are on the side of caution a little bit and then if things aren't working we implement option B and C so but what we really need to do is understand that if you are feeling these signs and symptoms and you think it is different from late dumping you haven't really had anything that could have led to a late dumping episode and the way late dumping an early dumping differ is that early dumping is more of a gastrointestinal issue that happens maybe 20 30 minutes after consuming something quite high in yeah in sugar or fats or maybe drinking too soon after eating whereas a late dumping episode is more something that will occur a couple of hours after eating and usually affects your blood sugar rebels as opposed to a gastrointestinal like loose bowel action you know they can be interchangeable the signs and symptoms can be a little bit interchangeable but the main distinctive thing is that with early dumping you don't get a huge blood sugar response whereas with late dumping you get more of a blood sugar response so yeah look having the right team in your corner and you know starting off with the more basic things in the hope that that will fix things before going to you know into endocrinologists and medications which you all want to try and avoid so you know take your own diet history away which you can really help the health professional is to take a diet history and maybe even in that diet history have how you feel after eating within an hour or two after eating and you know that way we can see any trends that okay you feel particularly late and not quite yourself an hour after eating and read me okay well that's a trend that we can't deny so taking that kind of information into when you see your health care professional will really help with because it's highly likely they'll ask you to you know take a diet history and and a symptom diary and and get back to them so if you've got that already leading into the consultation it just saves a bit of time but look ultimately you absolutely need an endocrinologist I think in in your corner because they are by far the specialists in the area of hormonal changes and and anything hormone related and this is definitely a large owner of this is this hormone hormonal related as a result of the gastric bypass surgery look there has been some extremes where even part of the pancreas has been removed because these cells the beta cells that we were speaking of before have enlarged and aren't really regressing and so if we take away that part of the pancreas then you've got less beta cells and they're more less insulin being released but that is really something that you don't want to have to do and it's not something that they're doing moving forward it's it's definitely something from the past and and what it can do is make a difference to your reactive hypoglycemia then create issues around blood sugar control in other ways so I guess really what you want to do is we as with your GP you search and find a really good bariatric dietitian an endocrinologist and and and hope that they understand the condition and and can guide you accordingly amazing amazing so for any of you know listen to your gang you know what I think that's me but I don't have a dietitian that I can go to or I'm not comfortable are you taking new patients on? I would love to try and help anyone that's awesome so you know you've got this issue I'm on based in Melbourne I'm not sure if but I'm happy to do video calls and tell you how from that kind of thing um I really I really like to advocate for the patient I think that um that's really important and if we if we do need continuous glucose monitoring we do need the medical team involved to be able to and allow for that to to occur or for that to be released if they especially they're non-diabetic so yeah it'd be a pleasure to to help anyone. I'm thankful thank you so much. Well include your um your website in the in the video and in our description and that so for anyone who is listening um the the website will be there. I just this is just so amazing and the the information you know I've stuff that I've never heard and you know it's questions that we've asked and so much so much of what you've said has just confirmed for me what what what I thought was happening and what I felt happening and it makes sense it all makes sense which is for somebody like me that's um I don't know I ever since I was a tiny child I always wanted to know why why why is it happening and when I I don't know for me when I can understand why I can I I can at least get some peace even in the situation because it's the unknown that that I find scary so thank you because I have no doubt that people will feel a lot of comfort just understanding that it's not just in their head. Thank you Tash. I can actually relate to exactly what you've said and it is a life-bomb moment when you hear that someone understands and can somewhat explain even though it's not entirely explainable just yet um yeah I get where you come in from and I think that's not necessarily just a bariatric thing, I think that that's just a human trait that is really important. And we need to be validated when we're concerned about our health and when you say, - Yes, that's right. - That's right. And they're saying, look, I think that, you know, you haven't done this well enough or you haven't done that or you haven't considered that or you might think it's that, but it's really not. Well, you know what, I really, really believe that you know your body better than anyone. And it's, I entered in this profession to listen to people and help them. And that is, you can't turn someone away when they truly believe something is not right with themselves. - Thank you. Thank you so much. - Thank you so much for joining us. - No worries, look, thank you. - We love this. - Yeah, we love this. And I know that so many people are going to be able to access the correct information for themselves and hopefully be able to get the help that they need. - I hope so. Fingers and toes cross well. I'm here advocating for everyone. And hopefully in the next few years it'll be something that will be common knowledge as opposed to what's that. So, thank you. - Yes, thank you. - And for the opportunity. Thank you. Have a fabulous day.