Obesity Surgery

, Volume 30, Issue 1, pp 249–255 | Cite as

Insights from the Impact of Meal Composition on Glucose Profile Towards Post-bariatric Hypoglycemia Management

  • Ana Raquel Marques
  • Carolina B. Lobato
  • Sofia S. Pereira
  • Marta Guimarães
  • Sandra Faria
  • Mário Nora
  • Mariana P. MonteiroEmail author
Original Contributions



The need to improve post-bariatric hypoglycemia (PBH) diagnosis and clinical management is well recognized. Our aim was to evaluate the influence of meal nutritional composition on interstitial fluid glucose (IFG) profiles and symptom profile after Roux-en-Y gastric bypass (RYGB).


Seventeen subjects previously submitted to RYGB were allocated into two groups of symptomatic (n = 9) or control individuals (n = 8), according to spontaneous report of symptoms suggestive of hypoglycemia. Subjects were provided with a food and symptom diary (FSD) to record dietary intake and symptoms experienced, while using a flash glucose monitoring (FGM) system for 14 days.


Postprandial symptom reports occurred in 70.5% of subjects (88.9% vs 50.0%, p = 0.0790, symptomatic vs control), although symptoms with concurrent IFG < 54 mg/dL and within 54 to 69 mg/dL were only observed in 31.9% and 4.8% of the events in the symptomatic vs control group, respectively (p = 0.0110). Daily glucose profiles, total energy, and macronutrients intake were not significantly different between the groups. However, nutritional composition of meals preceding reported symptoms had lower protein (3.2 g ± 1.0 g vs 7.7 g ± 0.5 g, p = 0.0286) or higher sugar (11.6 g ± 2.4 g vs 4.3 g ± 0.9 g, p = 0.0333) content.


Postprandial symptoms are often in patients after RYGB. Concurrent hypoglycemia only occurs in up to a third of the symptomatic episodes being more frequent in patients that spontaneously reported complaints. Hypoglycemia is more likely to be triggered by meals with a low protein or high sugar content. These findings highlight the putative role of meal composition in eliciting PBH and reinforce the need to refine nutritional intervention.


Bariatric surgery Gastric bypass Post-bariatric hypoglycemia Interstitial fluid glucose profile Nutritional composition 


Funding Information

The UMIB was funded by grants from the Foundation for Science and Technology (FCT) Portugal (UID/ Multi/00215/2019).

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflict of interest.


All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.


  1. 1.
    Elder KA, Wolfe BM. Bariatric surgery: a review of procedures and outcomes. Gastroenterology. 2007;132:2253–71.CrossRefGoogle Scholar
  2. 2.
    Busetto L, Dicker D, Azran C, et al. Practical recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the post-bariatric surgery medical management. Obes Facts. 2017;10:597–632.CrossRefGoogle Scholar
  3. 3.
    Ruiz-Lozano T, Vidal J, de Hollanda A, et al. Timing of food intake is associated with weight loss evolution in severe obese patients after bariatric surgery. Clin Nutr. 2016;35:1308–14.CrossRefGoogle Scholar
  4. 4.
    Khwaja HA, Bonanomi G. Bariatric surgery: techniques, outcomes and complications. Curr Anaesth Crit Care. 2010;21:31–8.CrossRefGoogle Scholar
  5. 5.
    Eisenberg D, Azagury DE, Ghiassi S, et al. ASMBS position statement on postprandial hyperinsulinemic hypoglycemia after bariatric surgery. Surg Obes Relat Dis. 2017;13:371–8.CrossRefGoogle Scholar
  6. 6.
    Patti ME, Goldfine AB. The rollercoaster of post-bariatric hypoglycaemia. Lancet Diabetes Endocrinol. 2016;4:94–6.CrossRefGoogle Scholar
  7. 7.
    Lee CJ, Clark JM, Schweitzer M, et al. Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy. Obesity (Silver Spring). 2015;23:1079–84.CrossRefGoogle Scholar
  8. 8.
    Nor Hanipah Z, Punchai S, Birriel TJ, et al. Clinical features of symptomatic hypoglycemia observed after bariatric surgery. Surg Obes Relat Dis. 2018;14:1335–9.CrossRefGoogle Scholar
  9. 9.
    Sarwar H, Chapman 3rd WH, Pender JR, et al. Hypoglycemia after Roux-en-Y gastric bypass: the BOLD experience. Obes Surg. 2014;24:1120–4.CrossRefGoogle Scholar
  10. 10.
    Lee CJ, Brown TT, Schweitzer M, et al. The incidence and risk factors associated with developing symptoms of hypoglycemia after bariatric surgery. Surg Obes Relat Dis. 2018;14:797–802.CrossRefGoogle Scholar
  11. 11.
    Marsk R, Jonas E, Rasmussen F, et al. Nationwide cohort study of post-gastric bypass hypoglycaemia including 5,040 patients undergoing surgery for obesity in 1986-2006 in Sweden. Diabetologia. 2010;53:2307–11.CrossRefGoogle Scholar
  12. 12.
    Craig CM, Liu LF, Deacon CF, et al. Critical role for GLP-1 in symptomatic post-bariatric hypoglycaemia. Diabetologia. 2017;60:531–40.CrossRefGoogle Scholar
  13. 13.
    Salehi M, Prigeon RL, D’Alessio DA. Gastric bypass surgery enhances glucagon-like peptide 1-stimulated postprandial insulin secretion in humans. Diabetes. 2011;60:2308–14.CrossRefGoogle Scholar
  14. 14.
    Salehi M, Vella A, McLaughlin T, et al. Hypoglycemia after gastric bypass surgery: current concepts and controversies. J Clin Endocrinol Metab. 2018;103:2815–26.CrossRefGoogle Scholar
  15. 15.
    Tramunt B, Vaurs C, Lijeron J, et al. Impact of carbohydrate content and glycemic load on postprandial glucose after Roux-en-Y gastric bypass. Obes Surg. 2016;26:1487–92.CrossRefGoogle Scholar
  16. 16.
    Botros N, Rijnaarts I, Brandts H, et al. Effect of carbohydrate restriction in patients with hyperinsulinemic hypoglycemia after Roux-en-Y gastric bypass. Obes Surg. 2014;24:1850–5.CrossRefGoogle Scholar
  17. 17.
    Meijeren JV, Timmer I, Brandts H, et al. Evaluation of carbohydrate restriction as primary treatment for post-gastric bypass hypoglycemia. Surg Obes Relat Dis. 2016.Google Scholar
  18. 18.
    Kovatchev B, Cobelli C. Glucose variability: timing, risk analysis, and relationship to hypoglycemia in diabetes. Diabetes Care. 2016;39:502–10.CrossRefGoogle Scholar
  19. 19.
    Hill NR, Oliver NS, Choudhary P, et al. Normal reference range for mean tissue glucose and glycemic variability derived from continuous glucose monitoring for subjects without diabetes in different ethnic groups. Diabetes Technol Ther. 2011;13:921–8.CrossRefGoogle Scholar
  20. 20.
    Goios A, Martins ML, Oliveira AC, et al. Pesos e Porções de Alimentos. 2nd ed. UPorto Edições: Porto; 2016.Google Scholar
  21. 21.
    INSA. Tabela da Composição de Alimentos. 1st ed. Ministério da Saúde: Lisboa; 2007.Google Scholar
  22. 22.
    Fried M, Yumuk V, Oppert JM, et al. Interdisciplinary European guidelines on metabolic and bariatric surgery. Obes Surg. 2014;24:42–55.CrossRefGoogle Scholar
  23. 23.
    Ritz P, Vaurs C, Barigou M, et al. Hypoglycaemia after gastric bypass: mechanisms and treatment. Diabetes Obes Metab. 2016;18:217–23.CrossRefGoogle Scholar
  24. 24.
    Malik S, Mitchell JE, Steffen K, et al. Recognition and management of hyperinsulinemic hypoglycemia after bariatric surgery. Obes Res Clin Pract. 2016;10:1–14.CrossRefGoogle Scholar
  25. 25.
    Yumuk V, Tsigos C, Fried M, et al. European guidelines for obesity management in adults. Obes Facts. 2015;8:402–24.CrossRefGoogle Scholar
  26. 26.
    Handzlik-Orlik G, Holecki M, Orlik B, et al. Nutrition management of the post-bariatric surgery patient. Nutr Clin Pract. 2015;30:383–92.CrossRefGoogle Scholar
  27. 27.
    Moize VL, Pi-Sunyer X, Mochari H, et al. Nutritional pyramid for post-gastric bypass patients. Obes Surg. 2010;20:1133–41.CrossRefGoogle Scholar
  28. 28.
    Isom KA, Andromalos L, Ariagno M, et al. Nutrition and metabolic support recommendations for the bariatric patient. Nutr Clin Pract. 2014;29:718–39.CrossRefGoogle Scholar
  29. 29.
    Nguyen NQ, Debreceni TL, Burgstad CM, et al. Effects of fat and protein preloads on pouch emptying, intestinal transit, glycaemia, gut hormones, glucose absorption, blood pressure and gastrointestinal symptoms after Roux-en-Y gastric bypass. Obes Surg. 2016;26:77–84.CrossRefGoogle Scholar
  30. 30.
    Kandel D, Bojsen-Moller KN, Svane MS, et al. Mechanisms of action of a carbohydrate-reduced, high-protein diet in reducing the risk of postprandial hypoglycemia after Roux-en-Y gastric bypass surgery. Am J Clin Nutr. 2019;110:296–304.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Endocrine, Cardiovascular & Metabolic Research, Unit for Multidisciplinary Research in Biomedicine (UMIB)University of PortoPortoPortugal
  2. 2.Department of Anatomy, Institute of Biomedical Sciences Abel Salazar (ICBAS)University of PortoPortoPortugal
  3. 3.Department of General SurgeryCentro Hospitalar de Entre o Douro e VougaSanta Maria da FeiraPortugal

Personalised recommendations