Curbside Consults

VOL 114 / NO 4 / OCTOBER 2003 / POSTGRADUATE MEDICINE

Is protein or sugar better for low blood glucose?

Q: If a patient with type 2 diabetes has a blood glucose level of 50 mg/dL and is coherent, should he or she be given orange juice with added sugar, orange juice alone, crackers with peanut butter, or milk? Is protein better than sugar for this condition?

Primary care physician, Mississippi

A: When a patient with either type 1 or type 2 diabetes has a blood glucose level of 50 mg/dL (2.8 mmol/L) or less, he or she should take 15 g of simple carbohydrate (one exchange, in the older terminology) whether or not symptoms are present. The carbohydrate can be taken in liquid form (eg, 4 to 6 oz of regular soda or orange juice without added sugar). An alternative is glucose gel (Glutose, Insta-Glucose, Insulin Reaction), which is absorbed orally and works well in patients with gastroparesis. Glucose tablets (B-D Glucose, Dex4 Glucose) also are available over the counter. Other alternatives include 1 tbsp of jelly, honey, or table sugar. Because they are all simple carbohydrates, they are easily absorbed and therefore act quickly, although they last only 15 to 20 minutes.

If the hypoglycemia occurs more than 15 minutes before the next scheduled meal, the patient should either eat the meal earlier or consume complex carbohydrates or protein to cover a longer period. Complex carbohydrates, such as bread or crackers (eg, six soda crackers), in combination with a protein (eg, cheese, peanut butter, 8 oz of milk) usually provide adequate nutrition, but blood glucose levels should be checked every 20 to 30 minutes until the next meal to avoid recurrent hypoglycemia. An 8-oz glass of skim milk has as much protein (8 g) and carbohydrate (12 g) as the same amount of whole milk.

If the patient is unconscious or unable to swallow without risk of aspiration, a glucagon injection (Glucagon Emergency Kit) can be given intramuscularly. Family members or friends can be taught how to deliver this medication to the patient.

Therefore, in the patient described here, I recommend orange juice for immediate correction of hypoglycemia, followed by a blood glucose check 20 minutes later if the patient has not eaten a complete meal. If the 20-minute blood glucose level is less than 70 mg/dL (3.9 mmol/L), the patient should drink more orange juice and consume a complex carbohydrate or protein to stabilize the blood glucose level until the next meal.

Robert G. Spanheimer, MD
Interim Head, Division of Endocrinology and Metabolism
University of Iowa Hospitals and Clinics
Iowa City

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