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No account of dietetic treatment of hypoglycemia would be complete without a brief description of 'nonhypoglycemia', which has been described as a controversial illness and epidemic in the US. Clinically, the illness is indistinguishable from (idio-pathic) reactive hypoglycemia, except that the blood glucose level is never pathologically low during symptomatic episodes. Moreover, although transient 'turns' are often a major feature of the illness, only rarely, if ever, does the patient consider their health, between turns, as normal.

The attribution of these patients' illness to hypo-glycemia had its origins in the early 1950s with the appearance, in the US, of a book by Drs Abrahams and Pezet entitled 'Body, Mind and Sugar.' Other American practitioners, notably John Tintera, founder of the Hypoglycemia Foundation Inc., Stephen Gyland, Harry Saltzer and, others, including the medical writer Carlton Fredericks, publicized the concept. This led to 'hypoglycemia' being held, by a large section of the public, responsible for such diverse diseases as coronary artery disease, allergy, asthma, rheumatic fever, susceptibility to viral infections, epilepsy, gastric ulcer, alcoholism, suicide, and even homicide, as well as for a whole galaxy of symptoms in their own right. 'Hypoglycemia' was treated as though it were a disease entity and asserted by its advocates to be 'one of the most common illnesses in the United States' and that because of it 'thousands of Americans have forgotten, or perhaps never known, what it is like to feel completely healthy.' Diagnosis of 'nonhypoglycemia' generally depends upon the results of the 6-h oral glucose tolerance test, using venous blood, although some have dispensed even with this discredited formality in favor of just purely clinical criteria.

The appearance in the New England Journal of Medicine of an article entitled ''Nonhypoglycemia is an epidemic condition'' first drew international attention to the illness in 1974. It had previously been almost unknown outside the US and Australia, though known to a few fashionable medical practitioners in Britain.

Many patients with 'nonhypoglycemia' undoubtedly derive some benefit, probably through a powerful placebo effect, from severely restrictive dietary regimes. Although differing in details most of the diets emphasize the purported specifically detrimental effects of sugar (sucrose), salt, alcohol, and caffeine.

While the cause of illness in people with 'nonhy-poglycemia' remains unknown, and is unlikely to be the same in all cases, in a tiny proportion it is due to caffeine intoxication, which can be confirmed by a dietary history and, above all, by measurement of plasma caffeine levels. Such patients do benefit specifically from reducing their intake of caffeinated beverages, though not necessarily from avoiding them completely. Ironically, and probably significantly, caffeine restores hypoglycemia awareness to diabetic patients on insulin who have become insensitive to it. The possibility exists, therefore, that a combination of reasonable or normal caffeine intake occurring in combination with the normal rebound in arterial blood glucose to just below fasting levels that sometimes occurs 3-5 h after a meal in someone with an unusually low threshold for neuroglycopenia, might precipitate symptoms. This explanation must, however, be considered no more than speculative.

On the other hand such diverse illnesses as hyperventilation, panic attacks, unadmitted alcohol or drug abuse, and genuine food intolerances are all established as capable of producing the 'nonhypo-glyacemia' syndrome and should always be considered in the differential diagnosis.

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