Hi David, I had asked a question in class about hypoglycemia and wanted to restate it more clearly. I’ve always heard reactive hypoglycemia discussed in the context of early insulin resistance, but I’m trying to understand how you would interpret idiopathic hypoglycemia that presents primarily in a fasting state (not postprandial), begins early in life, and remains stable over time with normal A1C and glucose. When I was diagnosed, I was underweight, frail, and experiencing frequent dizzy spells, and it was specifically described as idiopathic, not reactive, and not connected to insulin resistance or type 2 diabetes. I haven’t seen hypoglycemia discussed much outside of the reactive/insulin resistance model, so I’m curious how you would interpret that kind of presentation. Would you consider it part of the same dysglycemia progression, or does it suggest a different underlying mechanism? I understand it's not a classic picture.

For example, I’ve always had a strong intolerance to fasting. I’m unable to fast for extended periods, like before a colonoscopy, without becoming symptomatic or passing out.

David said: Idiopathic means the cause is unknown, i doubt you would get that diagnosis today. It is no longer considered a real diagnosis. There are multiple possible causes including overproduction of insulin, oversensitivity to insulin, over production of catecholamines, excessive endogenous production of GLP-1. I suspect only a full endocrinological evaluation would truly reveal the underlying pathophysiology of your hypoglycemia.