Hypoglycemia in young women: The science behind "hangry"

Symptoms of hypoglycemia or low blood sugar include light-headedness, headaches, and anxiety. Hypoglycemia can even feel like panic attacks. 

In this episode, Lara discusses:

• why young women are more prone to hypoglycemia,
• the importance of the autonomic nervous system and a "blunted glucagon response," and 
• what you can do to feel better. 

Links:

• Prevalence of self-reported symptoms attributed to hypoglycaemia within a general female population of the UK
• Hypoglycemic symptoms in the absence of diabetes: Pilot evidence of clinical hypoglycemia in young women

Transcript

Symptoms of hypoglycemia or low blood sugar include light-headedness, headaches, and anxiety. Hypoglycemia can even feel like panic attacks. “I used to feel like I was dying,” said my patient Shelby, “until I figured out that what I thought was a panic attack was really just low blood sugar.”

Women seem more prone to hypoglycemia, particularly young women. And in this episode, I’m going to explore why.

Welcome back to the podcast. I’m your host, Lara Briden, a naturopathic doctor and author of the books Period Repair Manual, Hormone Repair Manual, and a new book about metabolic health called Metabolism Repair for Women in most parts of the world and The Metabolism Reset in Australia and New Zealand. Two titles, the same book. 

And a huge thank you to everyone who has been sharing their reviews. One of my favorite reviews so far was from Australian podcaster Alexx Stuart, who observed that the book manages to troubleshoot so many different situations  that "no one is left behind."  I'm grateful for Alexx’s feedback because that's what I was going for! Different diets, types of movement, and treatments work for different people. But there's always a way forward. As I’ve said in all my books, trust your body. 

Now, onto hypoglycemia, and let’s start with this: In a healthy state, blood sugar should never drop below a certain threshold—even with skipping meals or fasting. That’s because the body has several strategies for boosting blood sugar, such as glycogenolysis, which is the breakdown of stored glycogen into glucose, and gluconeogenesis, which is the production of glucose from amino acids, lactate, and glycerol, which happens primarily in the liver. As an aside, gluconeogenesis can be impaired by alcohol. The other process that boosts blood sugar is lipolysis, which is the breakdown of stored fat into glycerol and free fatty acids. The glycerol can be made into glucose via gluconeogenesis, and the fatty acids can be burned directly as energy. As another aside, in a healthy resting state, the body should be burning mostly fat, not glucose—that’s metabolic flexibility, as I describe in my book. But even when fat-burning, glucose is maintained in the normal range. 

As yet another aside, there’s also ketogenesis, which is the production of significant amounts of ketone bodies from the fatty acids and the burning of them as a partial alternative to glucose, with the understanding that, even in nutritional ketosis, lipolysis and gluconeogenesis are also ongoing, and so blood glucose remains in the normal range. We’ll save a discussion of ketogenesis for another day because it really only applies to people doing a ketogenic diet. 

More commonly, for most people, the dominant processes are glycogenolysis, gluconeogenesis, and lipolysis. Those processes are boosted by the hormones glucagon, made by the pancreas; cortisol, made by the adrenal glands; and adrenaline, made by the adrenal glands and the nervous system.

Working in the opposite direction to all of that is, of course, insulin, which lowers glucose. That’s why Type 1 diabetics who take insulin are at such risk of hypoglycemia. It’s also why people with insulin resistance and, therefore, chronically elevated insulin are at risk of reactive hypoglycemia, which is hypoglycemia within a few hours after a meal—which makes sense because just after a meal is when insulin is highest, and all of that insulin pushes down on glucose. Chronically high insulin is also why women with PCOS tend to have a higher risk of reactive hypoglycemia. For more about insulin resistance, see my new book, Metabolism Repair for Women.

More broadly, though, hypoglycemia can also occur in people without insulin resistance. In that case, it’s largely due to what researchers call “a blunted or delayed glucagon response,” and that can be largely downstream from what is going on with the autonomic nervous system, which, honestly, is one of the most interesting parts of physiology. 

The autonomic nervous system should probably be called the “unconscious nervous system,” and it affects so much, including mood & sleep, heart rate, blood pressure, breathing, immune function, digestion, hormone balance (including thyroid and female hormones), and hunger, satiety (which means being not hungry), and energy expenditure—which makes the autonomic nervous system, or as I call it in my book, the “metabolic nervous system,” a major player in metabolic health, energy balance, and weight loss. Finally, of course, the autonomic nervous system controls blood sugar. 

As you probably remember, the autonomic nervous system is supposed to oscillate between the sympathetic “fight or flight” mode and the parasympathetic “rest and digest” mode. The sympathetic side is associated with adrenaline and glucagon, both of which work to increase blood sugar. In contrast, the parasympathetic side is associated with the vagus nerves, acetylcholine, oxytocin, and insulin—all of which (in addition to their many other effects) work to decrease blood sugar. To be clear, we need both sympathetic and parasympathetic to be healthy, and a flexible oscillation between them can support healthy blood sugar. 

Now, what’s interesting is that young women (as in, younger than 35) tend to have a more sensitive or reactive autonomic nervous system compared to men and older women and tend to be more parasympathetic dominant—which is not always a good thing because it can be associated with higher insulin and lower glucagon. Plus, when young women do experience sympathetic activation—such as with stress or a drop in blood sugar, it tends to result in a steeper sympathetic activation, which means a bigger rush of adrenaline. So, not only are young women more likely to experience hypoglycemia, but are also more likely to experience distressing symptoms from it. 

On top of all that, there is the menstrual cycle, which also affects blood sugar regulation via several mechanisms, including by directly influencing the autonomic nervous system. In particular, the drop in estrogen at the end of the menstrual cycle tends to destabilize blood sugar and increase adrenaline. 

With mild dysfunction of the autonomic nervous system, sometimes referred to as an instability of the autonomic nervous system or dysautonomia, there can be symptoms such as:

• blunted glucagon response and an increased tendency to low blood sugar—our topic today.
• headaches and irritable bowel syndrome or IBS
• delayed stomach emptying
• cold hands and feet
• fatigue, 
• exercise intolerance, 
• fainting, 
• heart palpitations, 
• POTS (which is the condition where standing up causes a significant increase in heart rate), and 
• low blood pressure. 

Both low blood pressure and low blood sugar can cause symptoms such as dizziness and light-headedness. And because the autonomic nervous system controls both, some people can get relief from using electrolytes, especially sodium, to increase blood volume and prevent blood pressure from bottoming out. 

You might recognize that list of symptoms (just mentioned) as sounding a lot like what some practitioners call “adrenal fatigue.”  Autonomic dysfunction is arguably a better term to describe the symptoms, given that the adrenal glands interact very closely with the autonomic nervous system. Furthermore, the common conditions of hypermobility and high histamine or mast cell activation are closely tied in with autonomic dysfunction, low blood pressure, and low blood sugar. 

So, how common is all of this? How common is hypoglycemia in young women? Well, one study suggested it affects up to 38 percent of young women. We’ll look at that study in a minute. I was one of that 38 percent. For anyone watching the video, this is a photo of me at about age 27 or 28. Back then, I was healthy in lots of ways but had low blood pressure and was prone to blood sugar crashes to the point that I always kept trail mix in my bag or car for an emergency snack. Looking back, I should not have been trying to manage low blood sugar with nuts and dried fruit but should instead have been filling up on high-protein foods in the morning, which we’ll come to. You can learn from my mistakes. Twenty-seven years later, my blood sugar is way more stable, which is probably largely because I now eat more protein. I think it’s also because I’m older, so I now have a more stable autonomic nervous system, plus no menstrual cycles thanks to menopause. But if you’re older or in menopause and thinking, “Wait, but I have more hypoglycemia,” again, please consider whether that could be driven by insulin resistance. And see my new book. 

Sticking with the hypoglycemia of young women, it wasn’t until 2019 that scientists finally decided to investigate with a study called “Hypoglycemic symptoms in the absence of diabetes: Pilot evidence of clinical hypoglycemia in young women.” The link is in the show notes. The participants were all women, with an average age of 29, and they were asked to wear continuous glucose monitors or CGMs. For the results, researchers classified hypoglycemia as a glucose level below 70 mg/dL or 3.9 mmol/L. And they classified clinically significant hypoglycemia as a glucose level below 54 mg/dL or 3.0 mmol/L. Of the participants who reported symptoms of hypoglycemia, such as dizziness, all of them had corresponding low blood glucose readings below 70 milligrams per decilitre or 3.9 mmol/L. And about half of them had clinically significant readings below 54 mg/dL or 3.0 mmol/L. So, it’s a real phenomenon. Plus, all the participants reported that they tried to manage hypoglycemia by eating snacks or avoiding exercise. The study proposed a “blunted or delayed glucagon response” as the main mechanism of hypoglycemia in these women. It’s so great to see this research! 

Okay, but what can you do to feel better? What are the solutions for preventing low blood sugar? The first and simplest strategy, as mentioned, is to eat more protein, especially animal protein, and especially in the morning. Protein supports glucagon. It also dramatically improves satiety and insulin sensitivity. To be clear, though, a tablespoon of nut butter or one egg on toast is not enough protein. You want to aim for 30 grams of protein by 10 am, which will require either five large eggs—which is a lot—or maybe two eggs plus cheese or fish, or 100 grams of cooked chicken, for example, or 120 grams of fish. Or, protein powder is another option. 

When I finally talked one of my patients into eating chicken for breakfast, she observed that her sugar crashes completely disappeared. “Protein has been so effective,” she said, “that it almost feels like cheating.” 

Beyond the simple strategy of protein, the supplement magnesium can be very helpful. It works by modulating the release of insulin and calming the nervous system. It can also stabilize the nervous system throughout the menstrual cycle, so you’re less sensitive to the ups and downs of estrogen and progesterone. 

You also want to be fully nourished with other nutrients, especially B vitamins, zinc, and iron. You want to stay hydrated and maybe take electrolytes, especially sodium or salt, to maintain blood volume and prevent that interaction between low blood pressure and low blood sugar that I mentioned earlier. You want to avoid alcohol because of how it can impair gluconeogenesis. You’ll need to identify and address insulin resistance—see my new book. Finally, you’ll need to identify and address any underlying issue, condition, or medication that could be destabilizing your autonomic nervous system. 

Possible drivers of autonomic dysfunction include:

• chronic stress, 
• a history of trauma,
• autoimmunity, especially thyroid disease and chronic fatigue syndrome
• food sensitivities, including wheat and dairy, 
• digestion and microbiome problems, 
• high histamine or mast cell activation,
• nutrient deficiencies, and 
• medications, including hormonal birth control.

Another potential driver of autonomic dysfunction is hypermobility, which I mentioned earlier. Women who are genetically hypermobile seem to have a differently calibrated nervous system. And can be more prone to low blood sugar.

As mentioned, the menstrual cycle can also affect the autonomic nervous system and blood sugar control. The trickiest time is the late luteal or premenstrual phase, but those premenstrual symptoms should respond to the protein and magnesium we’ve just discussed, the autonomic support we’re about to cover, plus all the treatments for hormonal resiliency that I discuss in my books and episode 7 of the podcast, which is all about premenstrual symptoms. 

Finally, for reasons that should be abundantly clear by now, you want to support and regulate your autonomic nervous system. That should help to normalize hunger, satiety, energy expenditure, insulin resistance, and blood sugar. It can also help to address many of the underlying issues just mentioned, including autoimmune disease and mast cell activation. 

Key nutrients for the autonomic nervous system include magnesium, B vitamins, choline, zinc, and iron. Herbal medicines can also be very helpful, including tonics and adaptogens like ashwagandha. Many of the adaptogens are also traditionally described as “adrenal tonics” because, as mentioned, “adrenal fatigue” is a common descriptor for autonomic dysfunction.  

To support the autonomic nervous system and blood sugar, you also want to think about “signals of safety.” The phrase was coined by neuroscientist Stephen Porges and refers to all the cues or signals that tell the autonomic nervous system that you’re safe and okay. In my metabolism book, I expanded Porges’ “signals of safety” to “signals of safety and satiety.” Signals of safety include but are not limited to being with loved ones, spending time outdoors, breathing exercises, yoga, meditation, massage, singing, and, of course, nourishing food.
There are plenty of other ways to support the autonomic nervous system, so please chime in with your favorite. You can leave a comment on the YouTube video, on the blog post associated with this episode at LaraBriden.com, or in my forum—on the topic that I’ll create for this episode.  I hope that’s been helpful, and thanks so much for listening. Please share and leave a review. And I’ll see you next time when I’ll discuss three tips for endometriosis and pelvic pain.