Feeling low sugar before lunch? How to stop diabetes medication energy crashes

 

Written by: Dr Saptarshi Bhattacharya

Source: https://indianexpress.com/article/health-wellness

A patient of mine described his blood sugar fluctuations despite being on medication and a physical activity routine. “I walk 10,000 steps daily. I take metformin 500 after dinner but I experience an energy crash and low sugar levels before lunch and evening. What does it indicate?”, he asked me.

How many of you have gone through similar experiences? Symptoms mimicking low blood glucose before lunch and in the evening while being on drugs suggests a possible mismatch between physical activity, meal timing and medication. It indicates that the current regimen may need review and adjustment.

Understanding Low Blood Glucose (Hypoglycemia)

Hypoglycemia occurs when blood glucose levels drop below 70 mg/dL. Symptoms include shakiness, dizziness, sweating, hunger, irritability, confusion or even loss of consciousness in severe cases. Given your proactive approach to managing diabetes with exercise and medication, it’s crucial to understand why these episodes might be happening.

Possible Causes of Low Sugar Levels

1. Medication review: Metformin works by decreasing glucose production in the liver and increasing insulin sensitivity, but hypoglycaemia is an unusual side effect of metformin. Among the medicines used for treating diabetes, the sulfonylurea group of medicines and insulin carry a risk of hypoglycemia. Review with your doctor that you are taking the right medicine. Also, ensure that you are not taking some indigenous supplements which are sometimes mixed with drugs that can cause hypoglycaemia.

2. Reactive hypoglycaemia: Reactive hypoglycemia refers to a drop in blood glucose occurring 2–4 hours after a meal. It is usually related to an exaggerated insulin response in early stages of diabetes following carbohydrate intake, particularly meals high in refined carbohydrates and low in fibre content. Blood glucose may fall to low levels before lunch or in the late afternoon or evening if you have a snack rich in simple carbohydrates in between your meals.

3. Diet and Meal Timing: Infrequent meals or not adjusting food intake with exercise could lead to hypoglycaemia.

What Does This Indicate?

Your body is signalling that your current diabetes management plan might need tweaking. Your doctor might review your medicine requirement. Hypoglycaemia is not a usual complication of metformin but still this might require a relook. Additionally, some medications can slow carbohydrate digestion and help in such situations.

Eating smaller, balanced meals with complex carbohydrates, protein and healthy fats can help stabilise blood glucose levels. Regular blood glucose checks and strategic snacking before exercise or when you feel low can help manage hypoglycaemia.

The primary reason behind reactive hypoglycaemia is insulin resistance, mismatch in insulin secretion timing and blood glucose excursion following food intake. Weight loss can help decrease insulin resistance and consequently such episodes.

Preventing Hypoglycaemia

Always monitor blood glucose levels. Regular checks can help identify patterns and triggers. Eat balanced meals complete with complex carbohydrates, proteins and healthy fats. Drink water throughout the day. Eat a snack before or during prolonged exercise. Carry glucose tablets; it’s better to be prepared for hypoglycaemic episodes. Given your proactive approach to managing diabetes, it’s essential to work with your healthcare provider to adjust your treatment plan.

 

High fasting blood sugar in young adults: Why you need that 20-minute walk after dinner

 

Written by Dr V Mohan

Source: https://indianexpress.com/article/health-wellness

One of my patients was worried about the high fasting glucose levels in his 22-year-old son. He was worried if the dawn phenomenon, when hormones in the body naturally makes every morning and elevates blood sugar, could be worrisome for non-diabetic people like his son, too. Is it indicative of diabetes in the future?

Yes, the dawn phenomenon can affect both individuals with and without diabetes. The human body experiences the lowest level of blood sugar at 3 am. Then the body releases hormones like cortisol, growth hormones and adrenaline to prepare us to wake up, usually between 3 am and 10 am. They signal the liver to boost the production of glucose, which provides energy that helps you wake up. In non-diabetic individuals, insulin works efficiently and brings the blood sugar back to normal. But in people with diabetes — or those with insulin resistance — the body cannot counteract this hormone-driven rise effectively, leading to high fasting blood sugar levels.

Does a slightly high fasting sugar mean a non-diabetic person will get diabetes?

Not necessarily. For non-diabetic individuals, it can be an early warning sign rather than a diagnosis. It tells us that lifestyle changes are needed now to prevent diabetes later. The occasional morning high will have little impact on your HbA1C, average blood glucose count over three months, which is an indication of whether your blood sugar management is effective enough. But if those highs become consistent, they could push up these levels too.

What is the best way to manage the dawn phenomenon for both groups?

The most effective and safest strategy is lifestyle management, especially physical activity. A simple 20–30-minute walk after dinner is one of the best activities to combat the dawn phenomenon in both diabetic and non-diabetic individuals. It helps muscles use glucose, improves insulin sensitivity and reduces the overnight rise in sugar levels.

Is walking really enough, even for people with diabetes?

Yes. Walking is sustainable and highly effective. Consistency matters more than intensity. Even light activity after dinner makes a meaningful difference.

What about morning exercise?

Morning exercise is good for overall health but when focusing on the dawn phenomenon, intense early morning workouts can sometimes increase blood sugar temporarily due to stress hormones. Gentle activities like yoga, stretching, or a calm walk are better choices in the morning. A Chinese study showed that moderate-intensity aerobic exercise before breakfast reduced the morning rise of blood glucose in diabetes patients. It significantly reduced blood glucose fluctuations and improved blood glucose control throughout the day.

I usually eat dinner late and go straight to bed. Could that worsen the problem?

Late dinners followed by immediate sleep reduce glucose utilisation overnight for both diabetic and non-diabetic individuals. Ideally, dinner should be light and finished at least two to three hours before bedtime, followed by light movement.

What to do if lifestyle changes don’t work for people with diabetes?

If fasting sugars remain high despite walking, timely meals and good sleep in people with diabetes, we may need to adjust night-time treatment. This can include increasing the dose of long-acting insulin at night or modifying night-time oral hypoglycaemic agents (OHAs). These changes help control the early morning hormone-related sugar rise.

Should patients adjust insulin or tablets on their own?

They can make adjustments with the guidance of their healthcare professional. This helps ensure changes are safe, effective and based on fasting blood sugar trends and the risk of low blood sugar.

Can technology help understand this better?

Continuous Glucose Monitoring (CGM) tracks glucose levels day and night, clearly showing when sugar starts rising. It helps us confirm the dawn phenomenon, adjust insulin or medication safely, and also shows how effective walking and meal timings are.

Is CGM useful as a predictive tool for non-diabetic people?

CGM helps non-diabetic individuals identify hidden sugar spikes related to late meals, poor sleep or stress, long before diabetes develops.

Whether someone has diabetes or not, managing the dawn phenomenon requires timely meals, regular post-dinner activity, good sleep and stress control. For people with diabetes, medication adjustment and CGM add precision. Small daily habits make a big difference to long-term blood sugar health.

 

IT professional ignored borderline cholesterol at 25, had heart attack at 35: How you shouldn’t ignore even mild spike in LDL

 

Source: https://indianexpress.com/article/health-wellness

At 25, Aadya Waadiyar (name changed) had to undergo a pre-employment medical screening before she could settle into her new IT job. Her numbers were borderline high, her total cholesterol being 220 mg/dL, (the normal being less than 200 mg/dL). Total cholesterol is a sum of low-density lipoprotein (LDL) or bad cholesterol, high-density lipoprotein (HDL) or good cholesterol and triglycerides or blood fats from excess calories. “I didn’t know anything about why their single scores also mattered. Or why I couldn’t roll back the readings with a few extra runs. At 25, you are young and you think these slightly elevated figures won’t make much of a difference. Except it did, when I had a heart attack at 35, exactly a decade later,” she says.

“People can have high cholesterol for years, decades even and not experience any discomfort till it piles up as plaque in the heart vessels, blocks the blood flow and triggers a heart attack,” says Dr Ranjan Shetty, lead cardiologist and medical director at Sparsh Hospital, Bengaluru, who did an angioplasty (a medical procedure to open blocked arteries). “She was a fit person and had no other risk factor. So I asked her about her family history. Then she told me that her father had had a heart attack, that too at age 50. And suddenly everything became clear,” he adds.

When you have a family history of young heart attacks, it means you can inherit genes that lead to high cholesterol, high blood pressure, or other risk factors for heart disease. “Some patients have familial hypercholesterolemia, a hereditary disorder where your body can’t effectively remove LDL cholesterol from your blood, leading to its build-up in the bloodstream,” says Dr Shetty. “Aadya had a total cholesterol of 220 mg/dL at 25. Though she didn’t know it then, that figure in her early 20s was actually very indicative. Anything above 180 mg/dL in your early 20s usually means you have a family history of risk factors. It is a red flag to do follow-up tests and monitor your condition regularly to prevent a heart attack,” he adds.

Why cholesterol management needs to begin early

Cholesterol takes a long time to get to dangerous levels in the body. “Plaque formation typically begins from a person’s childhood. Then it takes a long time, usually a decade and actually gives you time to rectify yourself with lifestyle correction. Once it reaches high levels, then you would need medication to bring it down,” says Dr Shetty. “I wish I had known basic facts about cholesterol and my family history. Then perhaps I could have prevented my heart attack,” says Aadya.

When should young people do a cholesterol test?

Adolescents, says Dr Shetty, should have their cholesterol checked between ages 18 and 21. Children who have obesity or diabetes may need to be screened earlier and monitored more frequently. Those with family history and co-morbidities should go for annual check-ups. Those with normal readings and without co-morbidities should go for their next test within a four to six-year window.

What do the numbers in a cholesterol test mean?

“Since Indians are more prone to heart attacks a decade earlier than other populations and 31 per cent of them have high LDL (bad) cholesterol, while being genetically predisposed to low HDL (good) cholesterol, the checks and balances ought to be calibrated very well,” says Dr Shetty. So LDL, according to him, should ideally be under 70 mg/dL while the minimum HDL should be no less than 40 mg/dL. Triglycerides should be less than 150 mg/dL. Simultaneously, check and balance other components of heart health, like blood sugar and blood pressure.

Dr Shetty focusses on LDL and triglyceride levels to assess risk. “The two together are a potent combination. One must also measure lipoprotein-A or Lp(a), which carries cholesterol in the blood. About 25 per cent Indians have high levels, which should ideally be lower than 30 mg/dL. That’s why it should be tested at least once to eliminate risk factors,” he says.

What to do for preventive heart health?

Looking back, Aadya realises that long hours of sedentary work had limited her physical activity while work stress had fuelled her desire for convenience foods. “I didn’t realise that I was piling up new risk factors with diet and low exercise,” says the IT professional, who now has low-fat, low calorie food. She has more fruit and vegetable salads as the soluble fibres in them bind to the cholesterol in the digestive system and remove it from the body. She gets her Omega 3 fatty acids from almonds, walnuts and flaxseeds.

Dr Shetty has advised her strength training and she does them at least twice a week, doing five-minute squats and lunges at her workplace. Her cholesterol is now within range.

 

Why blood sugar readings may look confusing: Patient had slightly high fasting blood glucose of 107 mg/dL but HbA1c was too high, above 7%

 

Source: https://indianexpress.com/article/health-wellness

Blood glucose tests are important tools to understand how well your body is managing glucose. Sometimes, though, the results can be confusing. For example, a patient showed me he had a fasting blood glucose of 107 mg/dL (which looks only slightly above normal), but the HbA1c (average blood sugar count of three months) was above 7 per cent (which is clearly in the diabetic range, the normal being 5.7 per cent). How can this happen and what does it mean? Let’s break it down in simple terms.

Fasting Blood Glucose (FBS): This test measures your blood glucose at a single point in time, after you have not eaten for at least eight hours.

Normal: less than 100 mg/dL

Prediabetes: 100–125 mg/dL

Diabetes: 126 mg/dL or higher

So, a fasting glucose of 107 mg/dL means the person is in the prediabetes range.

HbA1c (Glycated Hemoglobin): This test reflects your average blood glucose over the past two to three months. It shows how much glucose has been sticking to your red blood cells.

Normal: less than 5.7%
Prediabetes: 5.7–6.4%
Diabetes: 6.5% or higher

An HbA1c of over 7 per cent indicates sub-optimally controlled diabetes, with average blood glucose around 170–180 mg/dL.

Why do the results differ?

This mismatch happens more often than you might think. Remember that blood glucose rises after meals or what we call post-prandial spikes. Fasting glucose may look almost normal but after eating, the person’s glucose may rise very high. These repeated spikes raise the HbA1c, even though fasting numbers look okay.

Fasting glucose is just one snapshot and may reflect recent improvement in glucose levels. HbA1c shows the bigger picture over months and will be influenced by the glucose pattern of the last three months. Some people first develop high glucose after meals (postprandial hyperglycemia) before fasting glucose goes up.

Rarely, conditions like anemia, thalassemia, kidney disease or certain medications can affect HbA1c readings.

What does this mean for the patient?

The HbA1c reading of over 7 per cent cannot be ignored. It means that overall blood glucose has been consistently high, even if the fasting reading looks only mildly elevated. This person does have diabetes and needs lifestyle changes and possibly medication. Fasting glucose of 107 mg/dL may give a false sense of security, but HbA1c is more reliable for long-term risk.

Why is this important?

Uncontrolled blood glucose, reflected in a high HbA1c, increases the risk of heart disease and stroke, kidney damage, nerve problems (neuropathy), eye damage (retinopathy) and slows down wound healing. Early diagnosis and management can prevent these complications.

What should be done?

Sometimes doctors repeat the tests or add an Oral Glucose Tolerance Test (OGTT) to be sure. Review your lifestyle. Eat a balanced diet with less glucose and refined carbs. Exercise at least 30 minutes a day, five days a week. Maintain a healthy weight. If lifestyle changes alone don’t help, doctors may prescribe medicines like metformin or others depending on the case. Keep checking blood glucose and HbA1c to track progress. Fasting tests can sometimes miss the bigger picture but HbA1c reveals how glucose behaves over months.

 

Blood sugar double risk you didn’t know about: How black coffee and no sleep can push up levels

 Source: https://indianexpress.com/article/health-wellness

Getting less than six hours of sleep regularly can interfere with your body’s ability to regulate blood sugar.

A young patient of mine reported that her blood sugar levels were not quite in range despite keeping herself active and eating clean. We had suggested lifestyle correction as the first step to control her body weight but she said her regular exercises were tiring her out. Meanwhile her blood sugar levels showed an uptick. What was going wrong?

Then I asked her if she was sleeping enough. “Honestly, I sleep about five hours a night, sometimes less. I have a lot of daily deadlines to meet, so I rely on coffee — maybe five or six cups a day — to stay alert,” she told me. There lay my answer. Poor sleep and caffeine are bad news for blood sugar.

Sleep and blood sugar spikes

Getting less than six hours of sleep regularly can interfere with your body’s ability to regulate blood sugar. Poor sleep stresses the body. This means your body produces more cortisol, a stress hormone. Cortisol makes it harder for the sugar-regulating hormone insulin to do its job, which means your blood sugar levels can rise. Even if your diet doesn’t change, sleep deprivation can push your blood glucose up. Your body becomes less sensitive to insulin, and your liver might release more glucose into the bloodstream thinking you’re in stress mode.

But isn’t black coffee good for diabetes?

Only in moderation. One or two cups a day usually don’t cause problems. But having five or six cups can backfire, especially when you’re not sleeping enough. High caffeine intake increases adrenaline and cortisol levels, just like lack of sleep does. Together, they create a double impact on your glucose control. So, caffeine indirectly raises your blood sugar, too.

Plus, excessive caffeine can lead to poor sleep quality — even if you do manage to get to bed on time. It becomes a cycle: less sleep, more coffee, more stress hormones, and higher blood sugar.

Studies suggest that in some people, especially those with prediabetes or type 2 diabetes, high caffeine consumption can reduce insulin sensitivity. This means that their bodies require more insulin to bring blood sugar levels down after meals, putting extra strain on the pancreas and increasing the risk of hyperglycemia.

Sleep is essential for glucose metabolism. And caffeine, though helpful in small doses, should be limited—especially if you’re using it to compensate for inadequate rest.

The ideal combination

Start by aiming for at least seven to eight hours of sleep per night. Try reducing your caffeine to two cups a day — preferably before 2 pm. Then monitor your blood sugar. You’ll likely see improvement within a week or two. These small lifestyle changes can go a long way in protecting your health — especially if you’re at a risk for diabetes or already managing it.

 

What’s spiking BP in women in their early 30s and 40s faster than men?

 Source: https://indianexpress.com/article/health-wellness

Women between 30s and 40s often begin transitioning through perimenopause, a phase marked by fluctuating and gradually declining estrogen levels. (Representational)

Lately, I have been seeing a lot of women in their 30s and 40s with complaints of hypertension or high blood pressure. And I noticed that most of them lived in some of Mumbai’s most polluted areas. While the impact of pollution is generally associated with respiratory health, in women it can impact their biology and hormones.

Pollution and Blood Pressure

Research indicates that women may experience more pronounced cardiovascular responses to air pollution than men. Exposure to pollutants like fine particulate matter (PM2.5) and nitrogen dioxide (NO₂) has been linked to steeper blood pressure spikes in women. This is because of two reasons. One, women typically have smaller airways, which may allow pollutants to exert a greater physiological impact and obstruct them further. Second, their hormonal cycles and stress levels heighten their sensitivity to environmental triggers.

Hormonal Shifts and Cardiovascular Risk

Women between 30s and 40s often begin transitioning through perimenopause, a phase marked by fluctuating and gradually declining estrogen levels. Estrogen, known for its protective effects on the cardiovascular system, helps maintain blood vessel flexibility and suppresses inflammation. Pollutants like PM2.5 damage cells and trigger inflammation, which, in the absence of adequate estrogen, can damage walls of blood vessels—a precursor to chronic high blood pressure.

Pollutants of Concern

PM2.5 stands out as the most hazardous. These microscopic particles can penetrate deep into the lungs and even enter the bloodstream, igniting inflammation and damaging blood vessels. Nitrogen dioxide (NO₂) from vehicle exhaust leads to arterial stiffness. Carbon monoxide (CO) interferes with oxygen transport, forcing the heart to work harder, while ozone (O₃)—though less studied—has been shown to exacerbate cardiovascular and respiratory conditions. In urban areas, where traffic, construction, and industrial emissions converge, daily exposure to this toxic mix becomes unavoidable.

Many offices and homes suffer from poor ventilation, leading to constant exposure to indoor air pollutants as well. Combined with chronic stress, irregular routines, and limited physical activity, this creates a high-risk environment for cardiovascular problems.

Urban working women also often deal with long screen hours, shift work and low sun exposure — factors that further disrupt metabolic balance and vitamin D levels, both of which are closely linked to blood pressure regulation.

Taking Control: Prevention and Management

Since hypertension is a silent killer, women must do the following:

• Monitor regularly: Schedule routine check-ups for blood pressure, cholesterol and lipid profiles.

• Stay protected: Use indoor air purifiers and wear N95 masks when pollution levels are high.

• Eat smart: Adopt an anti-inflammatory diet rich in antioxidants, fibre and Omega-3 fatty acids.

• Move daily: Engage in regular physical activity, preferably indoors or in clean-air zones like parks.

• Manage stress: Practise mindfulness techniques such as yoga, breathing exercises, or meditation.

• Track the air: Use air quality index (AQI) apps and avoid outdoor activity during peak pollution hours.

 

Doctors revive heart attack patients in remote TN pockets with a little help from WhatsApp: How a hub and spoke model works

 Source: https://indianexpress.com/article/health-wellness

A study conducted by the Institute of Cardiology at Madras Medical College connected 188 smaller hospitals, which do not have catheter labs for angioplasty procedures, to 18 big hospitals in Tamil Nadu as part of a “hub and spoke” therapy model.

What if a person suffers a heart attack in a remote village and the local health centre doesn’t have a cardiologist or the infrastructure to do an angioplasty — a procedure to remove blood clots from heart arteries? The patient can still live and recover if the centre is connected to a bigger hospital through a chat platform, where specialists can recommend clot-dissolving drugs to local healthcare personnel and buy some time for the patient to get to a bigger hospital for surgical interventions.

A study conducted by the Institute of Cardiology at Madras Medical College connected 188 smaller hospitals, which do not have catheter labs for angioplasty procedures, to 18 big hospitals in Tamil Nadu as part of a “hub and spoke” therapy model. Cardiologists at bigger hospitals read the ECG, patient history and test results, suggested drugs and procedures, all through WhatsApp, improving the odds of patients at smaller centres surviving a heart attack.

What a pilot study shows

The study, which covered 71,000 people over five years, was able to demonstrate that just by providing guidance to the smaller hospitals on WhatsApp, more lives could be saved. Within five years, nearly one in five patients treated for heart attack in the hub hospital came from a spoke hospital, indicating how the linking system improved access. In the second phase of the study done with six hub hospitals, the doctors saw a remarkable increase in the proportion of people who got any intervention from 52.6 per cent in 2019 to 87.1 per cent by 2022.

The findings, which were recently published in the Indian Journal of Medical Research, are significant because they lay the template for broad-basing cardiac care to cover the last mile. With more Indians experiencing heart attacks in their early years, such a public health intervention can make heart care accessible even during emergencies. The data is from the cardiac care policy implemented by the government of Tamil Nadu.

Why this model can reduce deaths from heart attacks

“The sooner a person can undergo a procedure to open up a heart blockage or at least get a medicine that can help in dissolving the clot, the more muscles we end up saving. Sadly, a very small proportion of people receive these timely interventions,” said Dr G Justin Paul, professor at the Madras Medical College who designed the model. He also leads the state government’s heart attack management programme team.

“There are two types of heart attacks. A STEMI (ST-elevation Myocardial Infarction) is a major heart attack where the clot blocks blood flow completely to a part of the heart, resulting in muscles dying. Non-STEMI is referred to as a minor heart attack. Once the heart muscles die, there is no way of reviving them. However, there is now enough evidence to show that giving the clot-dissolving drug immediately and then doing the procedure within 24 hours is also equally effective. While most hospitals may not be able to do the procedure, they can certainly give the drug and then move the patients to the bigger hub hospital,” said Dr Paul.

In fact, the WhatsApp chat platform also helps the smaller centres share transfer protocols and coordinate patient care with the bigger hospitals. “This system of care worked in Tamil Nadu because of the availability of cardiologists in several Government hospitals, even in those that did not have a catheter lab prior to the study. This may not be true for all of India. However, the model may be modified and adopted,” said Dr Paul.

Benefits in numbers

In the first cluster with 12 hub hospitals, including the key Madras Medical College, the proportion of patients undergoing the stenting procedure after getting the clot dissolving medicine streptokinase increased from 9.1 per cent to 33.2 per cent. The proportion of patients able to receive the procedure within hours of heart attack also increased from 5.7 per cent to 9.7 per cent.

“The cost of angioplasty in a private hospital — which can range from Rs 1.5 lakh to Rs 6 lakh — can be a deterrent. But, more importantly, not all hospitals have the facility to conduct the procedure. This is the reason many may not be able to get the procedure within a few hours of the heart attack,” reasoned Dr Paul.

The results from the second cluster were even more impressive. While the proportion of patients undergoing the procedure immediately remained the same, those getting the procedure after having received the medicine increased from 0.9 per cent to 5.3 per cent. The proportion of deaths also reduced from 8.5 per cent to 5.8 per cent.

While the study used the less costly streptokinase that is given as an infusion, newer drugs can also be used. “These one-shot injections are costly at present, but the price may be brought down by governmental action, much in the same way as the stent prices were lowered,” said Dr Paul.