What do you use for second-wave treatment for hypos?

I understand that Dr. B recommends dextrose tabs for first-wave treatment of hypos, but what do you have after that?

I am trying to follow a fairly strict interpretation of a “clean” low carb diet (kind of Paleo/Bernstein) to get my BG’s under control and to lose weight. I’ve gotten almost all of the sugary, starchy, carby stuff out of my house (there wasn’t much left, but still).

I realize that I have plenty of emergency gels and dextrose tablets on-hand for hypos, but what am I going to eat for the second wave of treatment, after I get the initial boost from the dextrose? I don’t want to go flying off my diet by keeping a bunch of tempting junk in the house, but I also don’t want to sit there yo-yo-ing up and down on dextrose tabs all night in the event of a miscalculation or unforeseen drop in my insulin resistance, either (this happens sometimes a day or two after strenuous exercise.) I do have a bunch of emergency Ensure (in case of the flu or an earthquake) but…yuck.

In the past I would have made a sandwich, grabbed a stack of crackers with cheese or microwaved starchy leftovers. I guess I could keep some plain canned yams on hand or something like that, but that seems kind of brutal at 1:30 in the morning.

Any ideas on moderate carb snacks that are Bernstein approved for treating hypos, preferably with a Paleo spin, i.e. no bread, pasta, peanut butter or yogurt?

All I can think of are starchy vegetables like pumpkin, but how do you make pumpkin snack-worthy in a hurry?!? Just heat it up with a pinch of salt? I guess I could do that.


I’m not sure what you mean by second wave. i use jelly beans (not a choice for you) until my BG’s at target. Don’t understand why anything else is needed. Once BG is where it should be, there’s no need to eat anything. If you continue to drop, more glucose not anything starchy.

After BG is back up, I eat a small amount of protein, either cheese or nuts, to keep it stable. I usually go with cheese since it’s hard for me not to pig out on nuts.

Hey JeanV:
What type of insulin dosage do you use? Needles or pump? When I was on needles, I would have the second low blood sugars (sometimes). If that be the case … it was a watch game. But always followed with protein, & a little fat.

Now that I use a pump … the jelly beans (Gerri’s suggestion) & protein is a good trick.

I remember the 911 calls & the perimedics would refer to the “dual wave” as a “low blood sugar rebound.”

Ooops, see below…

That’s what I meant, the cheese/nuts stabilization phase of your hypo treatment.

I’ve been told by several docs (and the EMS guys who treated my hypo where I couldn’t use my arms or legs) that after the glucose phase (raise it immediately) one needs a second phase of something to eat that will keep it from dropping again – I’m T2, remember, so I could get a second drop from whatever caused the first drop, e.g. an unplanned for, temporary remission of my insulin resistance while I still have, temporarily, “way too much” Lantus on-board. Or I might have injected too much Novolog (this would be true of any diabetic, insulin resistant or not). I want to go back to sleep, not sit up all night testing and eating dextrose tabs every 30 minutes.

The more I read these boards, Gerri, the more I realize that treating T2 with insulin is very different from treating T1. My body doesn’t just respond to insulin/food the way a T1 body responds to insulin/food unless that T1 has some pretty severe insulin resistance, too (a T3…?)

If I have a hypo, it’s often because of something I did 24 to 48 hours earlier, and it lasts for a while (several hours). It’s not a quick-fix thing; it’s a ride that wave to shore thing. What I’ve done up till now (if the hypo is at night) is just eat way too much higher-carb food so I could get off the roller and get some sleep. I don’t know what else to do.

If your meaning that carb after glucose to keep you going, you dont really need it. Once you get going on this way of eating, there isnt a need for starch post LBS. Theres no carbs to zigzag you around. Your diet sounds pretty restrictive. How far along into it are you? I noticed after my first few weeks real LBS isnt as much of an issue. You know the whole “law of small numbers” thing. I have a 50± mg/dl maybe 2-3 times a week. Most days if any I dip into the 60s and a small bump brings me back up.

If I need some glucose and I see that Im trending down on my CGMS, peanut butter, cream cheese, and a kavli crisp do the trick for me. Its about 7 carbs total and takes roughly 1/2-1 hour to do its magic. Although on your strict interpritation I dont think that is an option. Possibly nuts alone )20 is worth 8g carbs)? Are nuts not paleo? Maybe natural almond butter? Plus you’ll have to consume a cup of pumpkin to get 12 carbs. I may have 5 pound in the freezer, but Im not sure Ill eat that raw for LBS. =^)

I can only answer as T1, but I believe that glucose followed by protein would also work for you. I’ve had lows that continued to drop, but just continue to take more glucose until stable. Too easy to overtreat eating something too carby & ending up high. We’ve all been there.

How low is low? .

One of many things I learned the hard way is to ignore the 15-15 guideline because 15 glucose grams can be too much & it can take longer than 15 minutes to know the full effect. Another thing is that healthcare people would always rather see us high.

Yes, I’m on shots – once the Lantus is in, it’s in. There’s no getting away from it until it wears off or the insulin resistance kicks back in to its “normal” level.

I’ve seen this happen every time I try to eat better and walk more, at some point I can’t keep ahead of the insulin resistance remission and the Lantus is too much – boom, hypo – but usually not while I’m exercising. It hits later, perhaps 24 to 48 hours after a “big” walk. I can’t really predict it because it doesn’t happen at a predictable time after a predictable amount of exercise. I think there’s a certain amount of hormonal voodoo in the mix, as I also have PCOS and I’m in the late stages of perimenopause.

I think it’s important to work to improve my insulin resistance, but now that I’m injecting insulin, it’s challenging to keep up with the weird, unpredictable fluctuations in insulin resistance in relation to long-acting insulin. When I went down to 36 and couldn’t move, I was on Lantus only, a dose that had been keeping me a bit too high for weeks up until that hypo. Then I improved my diet and started walking a bit more and one morning I’m sitting at my desk, checking my e-mail, still in my bed-clothes, an hour after injecting my usual Lantus (half my daily split dose) and…BLAMO…36 mg/dl and unable to move.

Lantus–ugh. I had staggering Lantus lows.

OK, so next time I wake up shaking, sweating and 52 or 53, I’ll take a few glucose tabs (4 grams of carb each) and test again in 5 minutes (I can’t stand waiting). If it’s going up, I’ll test again in 15 minutes and in the meantime, resist the urge to eat the world. If it’s above 70 and rising, I’ll eat some protein/fat (e.g. turkey roll-ups and some almonds, or some scrambled eggs with onion) and give it 15 to 30 minutes and test a few more times. If it’s above 90 and sticking/rising I’ll go back to sleep.

Does that sound like a plan?

However, if I’m really dropping and can’t control it with this modest approach, all bets are off and I’m diving into the Ensure. :0\ Sometimes, the adrenaline just gets the best of me.

…Theres no carbs to zigzag you around…

I wish this were true for me, onesaint, but my insulin resistance seems to be capable of zigzagging me around all by itself.

Maybe when I get some of this weight off and get used to exercising on a more regular basis (my goal right now is 5,000 steps per day, 6 days per week), my zigzagginess will settle down.

I think nuts are a fine idea. I can have raw almonds or raw walnuts around the house – I’ll eat them but I won’t be tempted to binge on them. (Roast them with salt or soy sauce and I might be tempted to eat the whole bag.)

I could have some frozen berries, thawed in the microwave, too. A half-cup (unsweetened) is 7 or 8 gm of carbs. Nuts and berries might be just the thing.

I’ve been known to make blueberry omelets, too. They’re surprisingly good. I just heat the frozen berries in the pan with a little bit of olive oil until they’re good an hot, whisk the eggs and then pour them over the heated-up berries. It tastes like a Bernstein-friendly blueberry pancake.

Butternut squash (9 gm per half cup) or sweet potato (a high-fiber 20 gm per half cup) are also things I can keep in the freezer and heat up in the microwave in a hurry.

Do you know how much 1 glucose tab raises you?

Testing in five minutes won’t show much & you’ll be tempted to take more glucose tabs. Do your best to wait to get accurate results. This will give you an idea what to expect in the future. It can take up to an hour to see the full effect.

Yep, resisting the urge to empty the fridge is a plan, as is knowing exactly how much glucose to take:)

Tell yourself that it’s just a low & you can handle it. Know it feels like an eternity waiting. Deep breaths, calming your thoughts & trying to remember the name of your second grade teacher helps.

If you’re talking about using berries, nuts or squash to treat a low, these work too slowly because of the fiber (& fat in nuts).

LOL on the second grade teacher: Mrs. Duncan and she ruined my love of math for the next thirty years or so. She was scary, but in perfect hind-sight, I think she and all the other staff at my Catholic grade school were grieving pretty hard that year for President Kennedy. I took their grim faces and irritability way too personally, I’m sure.

I don’t have a consistent, reliable response to x gm of carbs or to y amount of insulin. It really does vary – wildly – depending on my insulin resistance at any given moment. How much x gm of carbs will raise me is a roll of the dice. I just have to keep testing to see what happens.

The waiting is the hard part – I usually am pretty strung out on adrenaline. I think I’m getting better at talking myself through one. I did much better last time than I have in the past, but it was only 63 when I caught it, so perhaps I didn’t dump as much adrenaline. In fact, I’m pretty sure I didn’t because I didn’t sweat during this last one like I’d taken a shower in my clothes. When I was 36, 52 and 53 (previous hypos) I soaked my clothes and my hair was soaked, too.

My body thought I was being chased by a polar bear or something.

You’re right that testing at 5 minutes is probably counter-productive. But if I’ve gone up even 1 md/dl (and not down 10!!!) then somehow I feel better. But you’re right, I’m tempted to treat again right away and that is counterproductive. Oh for that perfectly accurate CGMS, eh? I’d give my whole kingdom for one of those. :0(

Sorry, Gerri, I was talking about the second-wave treatment (the consolidation phase.)

Sorry I misunderstood. I like sticking with just protein because it keeps me from dropping & I don’t want any surprise spikes overnight. I’m really carb sensitive, aka no native insulin. Carbs make me hungry.

For our general edification. I thought this was interesting.

Hypoglycemia: Differential Diagnosis

Exogenous insulin administration is the most common cause of hypoglycemia
–Most commonly occurs in patients with known diabetes mellitus
–May occur with inadequate food ingestion or excessive exercise after an insulin injection
–May occur with delayed absorption of food (e.g., diabetic gastroparesis)
–Rarely, may occur as part of attention seeking behavior (i.e., factitious)

Oral hypoglycemic medications (e.g., sulfonylurea)
–This is especially common with severe liver disease, which prevents gluconeogenesis

Other medications (e.g., salicylates, sulfonamides, tetracyclines, warfarin, MAO inhibitors, phenothiazines)

Reactive hypoglycemia occurs 2–4 hours after meals, due to delayed and exaggerated insulin release (associated with a family history of type II diabetes)

Insulinoma/islet cell hyperplasia
Alcohol consumption
Renal failure
Pituitary or adrenal insufficiency
Congenital hormone or enzyme defects
Severe hepatic dysfunction (e.g., hepatitis, hepatic toxins, hepatic necrosis)

That’s OK. What you say makes sense, but I’m back to trying to find a way to uncoil my anxiety enough to go back to sleep without lifting the fridge and dumping it into my mouth. 10 to 20 grams of carbs in the form of something like meat and squash or sweet potato would probably do the trick – much better than the way I handled my first self-treated midnight hypo:

Gel, gel, gel, balance bar, Ensure, balance bar…something like 120-130 grams. Not good.

For me I find fatty foods take longer to breakdown and give me a generally smooth ride. Protein lasts me about 5 hours where as fat is more like 7 or so. Jean, I think you need to try monitoring your trends for a few days to see how those two food groups effect you. We know carbs just play havoc and Im not so sure fibrous carbs are any good for LBS stabilization.

In a carb based diet they tell you to eat carbs to raise BGs, then eat protein / carbs to stabilize your BG. In our WOE, the fat and protein are what stabilizes our BGs. Maybe and I know this is going to suck, but maybe try one night at your first low, eatting protein, then wake up every 2 hours and test. Adversely, try with a more fatty low carb snack. I dont think though that you can treat your lows the same as when you were a carb eater. Your metabolism has changed.

Bleech, gel. I used that & felt sick. Think gel scared the low away. Nasty stuff.

Honestly, I think eating 10-20 carbs in addition to glucose tabs once you’ve raised BG to a good level is over treating a low.

Once you feel comfortable in knowing you can handle a low precisely (a plan), you won’t have anxiety. The feeling of panic will disappear. There’s anxiety about the anxiety. Wish there was an easy answer, but it’s simply experience & knowing you can do it. Mentioned this before. I tell myself-- It will pass. We all hate lows. They suck.