Can you REALLY tell when your blood sugar is low?

For many, the perception that they suffer from low blood sugar, or “hypoglycemia,” may prevent them from taking advantage of strategies that can improve health and help to slay the beast for good. To help provide some clarity on this issue, and to keep it from undermining your success, Dr. T addresses some of the myths and misconceptions around the topic of hypoglycemia.


The Study: “Training to estimate blood glucose and to form associations with initial hunger.”

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Welcome to another episode of The Miracle Moment. In today’s episode I’m going to be talking about hypoglycemia or also known as a low blood sugar. Now, this is a word that gets thrown around quite a bit, often times as an explanation for all manner of symptoms, and that includes migrainers who often attribute migraines or other symptoms to hypoglycemia. That oftentimes leads to a whole set of behaviors that are believed to be either necessary to prevent it or reverse it.

As we’ll discuss sometimes, those behaviors or the beliefs that motivate them can stand in the way of you making progress. Because of that, I think this is a topic that’s really important to understand, especially given that there’s also a whole lot of mythology and misunderstanding that’s built up around it.

In this podcast, we’re going to try to tease out the fact from fiction in this area and give you a little clarity on the whole issue of low blood sugar and hypoglycemia. Now, before we get there, have a few announcements. Our next key Keto Blast Challenge launches this weekend, which is October 21st. This will actually be our last Keto Blast Challenge of the year, our next one is scheduled for February 2019.

For those who don’t know, the Keto Blast is our 30 day challenge. The ketogenic diet has really taken off in the past couple of years as a therapy for many things, most notably obesity and diabetes, and some of you are likely aware it can also be a weapon against migraines. I’ve personally been using it off and on with great success for almost eight years in addition to the primary Migraine Miracle Plan, and have used it with great success with many patients and folks in our community.

The Keto Blast challenge gives people a migraine friendly way of implementing a ketogenic diet. There is no one single ketogenic diet and there are many ways of getting into nutritional ketosis, and it’s entirely possible to eat a ketogenic diet that will be quite bad for migraines. One reason for creating a Ketoblast was to help folks do so in a migraine friendly way, not in a way that might undermine their migraines.

If you’d like to take part in it, you can learn more about it That’s, and if you are listening and you’ve missed the sign up, you will find information on when our next one is taking place and you can go ahead and register then.

There are a couple of ways of taking part, one is to sign up directly for the challenge. The other is by becoming a member of Migrai-Neverland as one of the benefits of membership is that you have unlimited access to all of our 30 day challenges among the other things that you get with becoming a member. You can learn more about Migrai-Neverland by going to

You can also see all nine of our primary resources for migrainers by going to and just selecting the resources tab at the top. Also, if you do choose to become a member of Migrai-Neverland, don’t forget to enter the discount code moment. That’s MOMENT to get $30 off your first six months as a thank you for being a podcast listener.

All right, and before we dig into the topic of the day, let me first share a success quote that we recently received. This one came by way of an Amazon review and we’ve had some really nice reviews lately, a big thanks to any of you out there who’ve left a review on Amazon we really do appreciate it. This one comes from Sharon and I’ll summarize it a bit. She writes, “I don’t usually leave reviews, but I wanted to leave a review for this book because it has helped me so much. Maybe if I leave this review, I can help someone else who has suffered with headaches.

First, let me say that I’ve had headaches for as long as I can remember. They got worse when I became an adult, and even worse over the last several years. I’ve talked to every doctor I’ve ever had about my headaches, the best I could get with a prescription for the really bad days. I did the blood test to see what foods I might be sensitive to, I’ve been on an elimination diet for well over a year, but could never pinpoint any particular trigger.

Sometimes, I would get a headache from eating something and sometimes I wouldn’t, it was frustrating. I had given up so much without results. Then a friend was telling me that she was doing the ketogenetic diet. I started searching and came across this book, I had given up gluten and sugar, but still had higher carb foods in my diet, and that was certainly not eating enough fat.

Slowly I changed over to eating low carb, moderate protein, and moderate fat. I’m absolutely amazed at the difference. I feel so much better, I’m not tired or hungry all the time. I highly recommend this book as a place to begin solving your headache issues. I have done more research into the ketogenic diet and have decided that this is the lifestyle for me.

My friends say they could never give up sugar alcohol, but for me it is worth it to not have a daily headache. Sugar is highly addicting and just does nothing for the body. Fat is the ticket to feeling satisfied with virtually no hunger. I have been hesitant to admit this, but I just really can’t deny it anymore. I feel for the first time that I can control my headaches and I’m “cured” of the daily fatigue and pain associated with the headaches.”

Thank you Sharon for taking the time to share your experience. I think it’s one that many people listening can relate to, especially those who have made the change to the Migraine Miracle Plan and who we’ve even implemented the ketogenic diet. I’ve said before that while I don’t think longterm Ketosis is necessary, we’ve had multiple folks now, who have gone through the Keto Blast and felt so great, that they don’t want to change anything or rock the boat.

They plan to continue that way indefinitely because of the way they feel and it certainly sounds like that’s been sharing his experience as well. Also, I liked that she mentions having to sort of admit to herself that not only was sugar eat more evil than she’d maybe let herself believe, but also that eating more fat was the ticket to getting to where she wanted to be.

Speaking of sugar, let’s get into the topic of the day, which, as I mentioned is hypoglycemia. This is a term I hear mentioned quite a lot, many times as a stand in for feeling weak or shaky or light headed so much so that many people will say, “I’m feeling hypoglycemic.” As a shortcut for those symptoms, which I think in and of itself is kind of illustrative of the problem here. That’s because in that case we’re actually describing what we think to be the cause of those symptoms, and we’re making a self diagnosis that’s not grounded in any data.

That’d be fine if we were right about this most of the time. If indeed when people said that they were experiencing hypoglycemia or feeling hypoglycemic, that they were actually experiencing a low blood sugar and experiencing symptoms from low blood sugar. The question is, is that true? Are we actually able to determine when we were hypoglycemic?

Now, you may wonder why does this matter at all? Well, as I discussed in a recent episode about hunger headaches, the perception that our blood sugar is falling influences our behavior oftentimes in ways they can undermine our health and that can inadvertently strengthened the beast. Also, the use of the term reinforces this idea that we are dependent on sugar or carbohydrates for energy. We’ve discussed many times the benefits of carbohydrate reduction when it comes to health and migraines in addition to the benefits of intermittent fasting.

Oftentimes I’ll hear people say, “well, I know I need to eat every two hours or I’ll get hypoglycemic, or I have to eat at least three meals a day.” And, so on. They use this idea of hypoglycemia as a justification for some unhealthy behaviors or as a reason why they can’t do things that might otherwise health their migraines or help their overall health and other ways.

The more accurate statement in those situations would be, “I currently depend on carbohydrates, to not feel hungry or tired or fatigued or irritable every few hours.” Which would then prompt the question of why that is and how best to address it? Which, in most instances is going to be an issue with metabolic flexibility.

In other words if that’s the case, if you’re experiencing those kinds of symptoms, if you feel like you’re dependent on an eating every few hours or carbohydrates every few hours, that should prompt an investigation as to the root cause. Which is almost never going to be an insufficient amount of carbohydrates in the diet. These ideas are driven by this belief that goes something like, “Number one, when I get hungry, it’s because my blood sugar is low and number two, if my blood sugar is low and I don’t eat bad, things will happen because of low blood sugar.”

Let’s dig in here to this issue. When it comes to self diagnosing with low blood sugar, there are really two things that must be true for that diagnosis to be correct. The first is that the blood sugar is actually low or in a range where symptoms could at least conceivably occur and the second is that if the blood sugar is low, is that actually the source of the symptoms? For example, two people could have the same exact blood sugar and one person experienced true symptoms and the other person doesn’t. How could that be? Well, that’s because sugar isn’t our only source of energy.

As I’ve discussed in the past, we have two primary sources of fuel, glucose or sugar and fatty acids, and if you go extended periods of time with restricting carbohydrates or with eating a ketogenic diet, then the proportion of energy that you’re deriving from fats is increasing. It’s not uncommon at all for people who have been ketogenic for extended periods of time, to have blood sugars in the range of 40s with a zero symptoms.

In fact, quite the opposite, they may feel more energy than ever, and that’s because they’re deriving their fuel, the majority of their fuel from elsewhere, not from their blood sugar, this is totally normal. But, for someone who is carbohydrate dependent, such as eating a standard western diet, a sugar of 40, would typically be insufficient to maintain consciousness so they probably be passed out.

This alone illustrates that there’s a lot more complexity and nuance surrounding this topic than I think most people realize. As I mentioned, for us to even be able to accurately self diagnosed hypoglycemia, the first requirement is that we can actually determine when our sugar is low and it turns out this is something that’s been studied.

One of those studies was published in 2006 in the journal of Nutrition and Metabolism. There they took 158 people who were having some GI symptoms and they divided them into two groups, a control group in a study group. Over the course of seven weeks, half of the people were trained on how to identify low blood sugar by checking their sugar about 15 minutes before meal times. Then the other half they didn’t test their blood sugar during that seven week period.

Also, the group that received the training was told to eat only based on feelings of hunger rather than by the clock, so not according to mealtimes, but instead according to hunger. Incidentally, within a few days, they were no longer adhering to our typical meal time routine. Also, with the train group, when they check their sugar, if it was over 85, they were instructed to delay their meal. And, if it was under 85, they were instructed to remember those feelings that they would associate with a lower blood sugar and then to eat.

What they did was then at the end of the training, test how well the subjects could determine what their blood sugar was. What they found when they brought them back into the lab at the end of the training was that far more of the control subjects are the ones who hadn’t been a testing their sugar. Not only said that they were hungry, but they also on average estimated their blood sugar to be far lower than it actually was.

Then far fewer people in the train group said that they were hungry, and the ones who did were very accurate at estimating or about what their blood sugar was. In other words, the group that had gotten the training, their hunger was more directly tied to blood sugar levels, and the untrained group which essentially represents a typical person, their hunger was not directly tied to that blood sugar levels.

The key takeaway here being that the untrained group was unable to predict when their blood sugar was low. In particular, when they were feeling hungry and predicted that their blood sugar was low or that they are hypoglycemic, their sugar was typically normal. It also means that the eating behavior and those who were untrained, the control group was driven by factors other than their energy needs.

They were eating and becoming hungry for reasons other than the fact that they needed more energy. Obviously that’s a key driver when we’re thinking about things like obesity because one of the problems with obesity is that we’re taking in energy into the body when it isn’t needed, in that case it will be stored in the fat tissue.

What this study shows, and which is also what I found in the clinic is that we aren’t good at estimating our own blood sugar. In that unless we’ve been trained to recognize it when we say we’re feeling hypoglycemic, we actually aren’t experiencing low blood sugar. Whatever feelings were experiencing that we’re attributing to low blood sugar are not from that but from something else. That also means that eating and specifically eating carbohydrates in that scenario is not the right course of action even though that’s the one that’s commonly taken.

How come we aren’t very good at knowing when we are hypoglycemic? Also, why don’t we realize that we’re not very good at it? Well, it turns out that there are a number of things that contribute to our feeling of hunger. Yet our typical idea I think most people have is that hunger is primarily driven by our blood sugar levels, so we essentially equate hunger to low blood sugar. We know from the neuroscience of hunger that feelings of hunger actually based on a number of different inputs.

Hunger itself is a feeling generated by our hypothalamus, that’s a structure in the brain that some of you may know is of special importance to the migrainer. The role of the hypothalamus has to maintain homeostasis or stable conditions inside of the body and that includes energy levels. One of the ways it helps us to maintain homeostasis is by generating feelings, and those feelings then provoke us to change our behavior. For example, if we’re staying out in the sun too long and our bodies get into hot, the hypothalamus will generate that feeling we associate with heat, so that will then seek cooler conditions and lower our body temperature.

In addition, it also makes us feel hungry if it thinks that we are in need of food for some reason, but when our hypothalamus is deciding whether or not to generate that hunger signal, it’s actually tracking many different parameters. For example, it tracks how far the stomach is distended, which is transmitted from nerves there.

If your stomach is bigger, it typically means there’s food in there so it will inhibit your hunger. It’s also tracking the levels of a variety of hormones. Things like Insulin which is released in the presence of carbohydrates, Ghrelin which is released when the stomach is empty, Leptin which is released from the fat tissue, as a marker of energy stores, and yes, it also does track blood sugar.

Though the studies indicate that the rate of change of blood sugar may be as or more important than the actual level in terms of the contribution of blood sugar to hunger. On top of that, there are all sorts of psychological factors that play a role through conditioning into whether or not we feel hungry. We all know we can smell fresh popcorn or freshly baked brownies, and suddenly we feel like eating and yet nothing has changed in that scenario with our blood sugar or energy levels. This is entirely a conditioned to response and one big way we’re all conditioned, which was reflected in the results of this study is with mealtimes.

With the standard three meals a day routine, we learn to feel hungry at certain times of day and again that conditioned hunger has nothing to do with whether or not we actually need to eat, and again, nothing to do with our blood sugar. I think anyone with a pet will know this phenomenon very well, that you can pretty much a condition your pet to get hungry, whatever time of day you want based on the time or times when you decided to feed them. They will soon start eating by the clock if you keep that timing consistent every day and we are no different.

Suffice to say that, the regulation of hunger is an extraordinarily complex process and it has to do with many things beyond blood sugar. It’s also happens to be a system that’s screwed up big time in the context of our modern diet and lifestyle because it’s these signals that are given to the hypothalamus. Our hypothalamus response to those signals was calibrated in an environment that’s very different than the one we find ourselves in now. Not only are those feelings of hunger and satiety based on much more than just blood sugar, the entire system for energy regulation, the fidelity of that system is compromised considerably, at least in the context of a modern diet.

If most people are under the impression that hunger is mainly a product of our blood sugar, and if the reality is that it’s the culmination of many different factors, only one of which is blood sugar, and some of which like conditioning aren’t even connected at all to our energy needs. Then you’d predict that humans wouldn’t be very good at predicting when their blood sugar is low, and you’d predict that they would primarily have a lot of false positives, which is exactly what the study found.

As I mentioned earlier, the reason that hypoglycemia is a thing in the first place, is something we care about is because we think that it explains certain feelings we have like hunger, but others as well. Also, because we think that it’s inherently a bad thing that’s in need of immediate correction. Now, we’ve already established that we’re generally wrong on the first count, we aren’t very good at correctly self-diagnosing hypoglycemia unless we’ve specifically been trained to do so, but the second part of this is also inaccurate.

We can derive, as I mentioned earlier, we can derive our energy from multiple sources and that includes glucose or sugar. If our blood sugar is dropping, we do have stored glucose in the form of glycogen and we can also manufacturer glucose in the process known as Gluconeogenesis. We have hormones that respond to drops in blood sugar, that allow us to tap into those sugar stores or manufacturer it to try to maintain stable blood sugar levels.

On top of that, we have loads of energy stored inside of the fat tissues that can keep the typical person with a normal amount of body fat, a meeting their energy needs without food at all, for well over a month. Furthermore, as many of you know, in the presence of a low carbohydrate diet or without any food in the diet, the brain will also start running on ketones. We can turn stored fat into ketone bodies that can then be sent to the brain and used as an alternative energy source to glucose.

Now, once again, the reason I think all of this matters to the migrainer in particular is because it often leads to counterproductive behaviors, like feeling an urge to eat when you’re feeling what you think is hypoglycemic, and the tendency to prefer a simple carbohydrates when you do choose to eat. Eating too frequently and eating the wrong kinds of foods when you do so leads to eating behaviors that undermine health and increase our vulnerability to the beast. It also leads to people avoiding things like carbohydrate restriction or intermittent fasting, that we also know to be beneficial.

While it’s true that significant hypoglycemia can occur and can be a serious thing and cause brain injury. It is a rare thing and really not seen outside of pathological situations. I’ve been a practicing neurology since 2001, and I’ve only seen the very rare cases of brain injury from low blood sugar and every single one of those was in the setting of a diabetic who was administering a drug to lower blood sugar, usually insulin.

In this case, the only situations where I was seeing a hypoglycemia severe enough to injure the brain, was in cases where we were doing things that deliberately interfered with our body’s own mechanism for regulating blood sugar. If someone is experiencing symptoms that they truly believe are from hypoglycemia, the first step would be to make sure that’s the right diagnosis, and if so, it should then prompt an investigation as to the root cause. There really isn’t anything more important to our survival than sustaining a stable supply of energy to the brain. We have many different safety mechanisms in place to ensure that, that happens.

True hypoglycemia, while incredibly over diagnosed is pretty rare, and if it’s occurring in the context of daily food intake, would definitely indicate a pathological condition that’s in need of further investigation. Again, if you suspect any issues with hypoglycemia, the first step would be to test it. Glucometers are pretty inexpensive and can be obtained at the drug store at the very least. If you do track your blood sugar for a period of time, you’ll be able to train yourself to accurately recognize when your blood sugar is low on the low side, like those who were in the study.

That wraps up this episode of The Miracle Moment, remember that you can find this and all other episodes of The Miracle Moment There you’ll also find the transcripts for each of the episodes along with the links that are mentioned. Thank you so much for listening, if you enjoy this podcast and you want to help others find it, it’d be great if you left a rating and review in iTunes. It really does help, I do read each, and every one of them and they really mean a lot to me.

Finally, as a reminder, our next Keto Blast Challenge starts this coming weekend. You can learn more and sign up or find out when our next one is happening by going to Keto for Migraine. That’s Okay. Now, it’s time to go out and slay the beast.