Prevalence of and risk factors for hypoglycemic symptoms after gastric bypass and sleeve gastrectomy: Postsurgical Hypoglycemic Symptoms
Open accessAbstract
OBJECTIVE: To determine the prevalence of and risk factors for postprandial hypoglycemic symptoms among bariatric surgery patients. METHODS: A questionnaire including the Edinburgh hypoglycemia scale was mailed to patients who underwent either Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) at a single center. Based on the questionnaire, the patients were categorized as having high or low suspicion for post surgical, postprandial hypoglycemic symptoms. RESULTS: Of the 1119 patients with valid addresses, 40.2% (N = 450) responded. Among the respondents, 34.2% had a high suspicion for symptoms of post bariatric surgery hypoglycemia. In multivariate analyses, in addition to female sex (P = 0.001), RYGB (P = 0.004), longer time since surgery (P = 0.013), and lack of diabetes (P = 0.040), the high suspicion group was more likely to report pre-operative symptoms of hypoglycemia (P < 0.001), compared to the low suspicion group. Similar results were observed when the high suspicion group was restricted to those requiring assistance from others, syncope, seizure with severe symptoms, or medically confirmed hypoglycemia (N = 52). CONCLUSIONS: One third of patients who underwent RYGB or VSG reported postprandial symptoms concerning for postsurgical hypoglycemia, which was related to the presence of pre-operative hypoglycemic symptoms. Pre-operative screening for hypoglycemic symptoms may identify a group of patients at increased risk of postbariatric surgery hypoglycemia.
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Among 450 patients who underwent a Roux-en-Y gastric bypass or sleeve gastrectomy, approximately one-third (34.2%) reported postoperative symptoms consistent with postprandial hypoglycemia.
“Among 450 patients who underwent a Roux-en-Y gastric bypass or sleeve gastrectomy, approximately one-third (34.2%) reported postoperative symptoms consistent with postprandial hypoglycemia (12).”
From Dumping syndrome after esophageal, gastric or bariatric surgery: Pathophysiology, diagnosis, and management (2017) · cites this paper as [12]
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Background7. Obesity Management for the Treatment of Type 2 Diabetes
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“In one study, it affected 11% of 450 patients who had undergone RYGB or vertical sleeve gastrectomy (67).”
BackgroundInfluentialThe rollercoaster of post-bariatric hypoglycaemia.
Patti, M., & Goldfine, A. (2016) · The Lancet Diabetes and Endocrinology · doi:10.1016/s2213-8587(15)00460-x · Cited by 23 · see citing works
Prevalence and possible mechanisms of reactive hypoglycemia in polycystic ovary syndrome.
Mumm, H., Altinok, M. L., Henriksen, J., Ravn, P., Glintborg, D., & Andersen, M. (2016) · Human Reproduction · doi:10.1093/humrep/dew046 · Cited by 22 · see citing works
Effects of GLP-1 on counter-regulatory responses during hypoglycemia after GBP surgery.
Almby, K., Abrahamsson, N., Lundqvist, M., Hammar, U., Thombare, K., Panagiotou, A., Karlsson, F., Sundbom, M., Wiklund, U., & Eriksson, J. C. (2019) · European Journal of Endocrinology · doi:10.1530/eje-19-0171 · Cited by 21 · see citing works
Sun, W.-W., Zhang, Y.-W., Shen, Q.-W., Zhang, W., Yao, Q.-Y., & Yang, Y. (2019) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2019.06.026 · Cited by 21 · see citing works
Zanley, E., Shah, N., Craig, C. M., Lau, J., Rivas, H., & McLaughlin, T. (2020) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2020.09.026 · Cited by 19 · see citing works
Clinical features of symptomatic hypoglycemia observed after bariatric surgery.
Hanipah, Z. N., Punchai, S., Birriel, T. J., Lansang, M., Kashyap, S., Brethauer, S., Schauer, P., & Aminian, A. (2018) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2018.02.022 · Cited by 19 · see citing works
Hypoglycemia after gastric bypass: An emerging complication
Millstein, R., & Lawler, H. M. (2017) · Cleveland Clinic journal of medicine · doi:10.3949/ccjm.84a.16064 · Cited by 19 · see citing works
Brazilian guide to nutrition in bariatric and metabolic surgery
Pereira, S., Rossoni, C., Cambi, M. P. C., Faria, S., Mattos, F., de Campos, T. F. D., Petry, T., da Silva, S. A., Pereira, A. Z., Umeda, L. M., et al. (2023) · Langenbeck's archives of surgery (Print) · doi:10.1007/s00423-023-02868-7 · Cited by 18 · see citing works
“…in counterregulatory hormone responses may perpetuate recurrent hypoglycemia in the affected individual [59] Generally, the presentation of reactive hyperinsuline-mic hypoglycemia occurs after the first year of surgery and almost exclusively in the postprandial period [62] (class II; grade B).”
Ames, A., Lago-Hernandez, C., & Grunvald, E. (2019) · Journal of the Endocrine Society · doi:10.1210/js.2019-00097 · Cited by 18 · see citing works
Emous, M., Wolffenbuttel, B., van Dijk, G., Totté, E., & van Beek, A. V. (2018) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2018.04.011 · Cited by 18 · see citing works
“However, Lee and co-workers [27] studied late dumping by means of questionnaire, with .012 I feel anxious or insecure by above-mentioned complaints (”
Poitou, C., Bouaziz-Amar, E., Genser, L., Oppert, J., Lacorte, J., & Beyec, J. L. (2018) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2018.03.014 · Cited by 17 · see citing works
Attenuation of Insulin Action by an Allosteric Insulin Receptor Antibody in Healthy Volunteers
Johnson, K. W., Neale, A., Gordon, A., Roessig, J. M., Bezwada, P., Vukelich, S., Goldfine, I., & Rubin, P. (2017) · Journal of Clinical Endocrinology and Metabolism · doi:10.1210/jc.2017-00822 · Cited by 16 · see citing works
IS TESTING FOR POSTPRANDIAL HYPERINSULINEMIC HYPOGLYCEMIA AFTER GASTRIC BYPASS NECESSARY?
Aubry, E., Gasser, M., Meier-Estermann, C., Herren, S., Steffen, R., & Stanga, Z. (2017) · Aktuelle Ernãhrungsmedizin · doi:10.1016/j.clnu.2017.11.013 · Cited by 16 · see citing works
Carpentieri, G. B., Gonçalves, S. E. A., Mourad, W. M., Pinto, L. G. C., & Zanella, M. (2023) · Archives of Endocrinology and Metabolism · doi:10.20945/2359-3997000000598 · Cited by 15 · see citing works
“The risk factors for this condition are lower age, female sex, greater loss of excess body weight after surgery, and higher betacell function (6,7).”
The Structural Refinement of Glucagon for Therapeutic Use.
Chabenne, J. R., Mroz, P., Mayer, J., & DiMarchi, R. (2019) · Journal of Medicinal Chemistry · doi:10.1021/acs.jmedchem.9b01493 · Cited by 14 · see citing works
Marques, A., Lobato, C., Pereira, S., Guimarães, M., Faria, S., Nora, M., & Monteiro, M. (2019) · Obesity Surgery · doi:10.1007/s11695-019-04147-1 · Cited by 13 · see citing works
Wysocki, M., Szopa, M., Stefura, T., Dudek, A., Torbicz, G., Gajewska, N. A., Pędziwiatr, M., Małczak, P., Pisarska, M., Budzyński, A., et al. (2019) · Obesity Surgery · doi:10.1007/s11695-018-03684-5 · Cited by 13 · see citing works
Hypoglycemia after bariatric surgery: Management updates
Iqbal, A., & Makin, V. (2025) · Cleveland Clinic Journal of Medicine · doi:10.3949/ccjm.92a.24033 · Cited by 13 · see citing works
“…Use with caution in patients with history of pancreatitis Safe to use in renal impairment but avoid dehydration Expensive Dipeptidyl peptidase 4 inhibitors 25,26 Sitagliptin 100 mg once daily Nausea, constipation Inconclusive results—not recommended GLP-1 antagonist 32–34 Avexitide 30 mg SC…”
Patience, N., Sheehan, A., Cummings, C., & Patti, M. (2022) · Current Obesity Reports · doi:10.1007/s13679-022-00482-0 · Cited by 12 · see citing works
Defining clinically important hypoglycemia in patients with postbariatric hypoglycemia.
Craig, C. M., & McLaughlin, T. (2021) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2021.06.013 · Cited by 12 · see citing works
Zweck, E., Hepprich, M., & Donath, M. (2021) · Obesity Surgery · doi:10.1007/s11695-021-05277-1 · Cited by 12 · see citing works
Post-Bariatric Hypoglycemia: an Impaired Metabolic Response to a Meal
Aydin, Ö., Meijnikman, A., de Jonge, P. D., van Stralen, K. V., Börger, H., Okur, K., Iqbal, Z., Warmbrunn, M. V., Acherman, Y., Bruin, S., et al. (2024) · Obesity Surgery · doi:10.1007/s11695-024-07309-y · Cited by 11 · see citing works
“Finally, although it was suggested that insulin resistance might be protective against PBH [26], we did not observe differences in HOMA-IR between the PBH and non-PBH groups. is reported as asterisk (* p < 0.05 and ** p < 0.01) after correction for multiple testing according to Benjamini–Hochberg…”
InfluentialRamos-Leví, A., Rubio-Herrera, M., Matía-Martín, P., Pérez-Ferre, N., Marcuello, C., Sánchez-Pernaute, A., García, A. T., & Calle-Pascual, A. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12134295 · Cited by 11 · see citing works
“However, its prevalence may grow up to 30% of patients when specific questionnaires are used, [9] and more than 50% when dynamic tests such as an oral glucose tolerance test (OGTT) or a mixed meal tolerance test (MMTT) are used [5].”
Potential contribution of the gut microbiota to hypoglycemia after gastric bypass surgery
Zhou, L., Deng, M., & Xiao, X. (2020) · Chinese Medical Journal · doi:10.1097/cm9.0000000000000932 · Cited by 10 · see citing works
Incidence and risk factors of post-metabolic and bariatric surgery hypoglycemia: a systematic review
Zheng, H.-J., Sun, L., Wang, L.-J., Zhao, Y.-X., Gong, F.-Y., & Zhu, H.-J. (2024) · International Journal of Obesity · doi:10.1038/s41366-024-01651-y · Cited by 10 · see citing works
“…and 88% speci fi city [30]), higher insulin sensitivity [28], and elevated fasting glicentin after surgery (AUC 0.81, 95% CI 0.64 – 0.98; a cut-off 17.2 pmol/L with 85.7% sensitivity and 53.8% speci fi city [29]) (speci fi c related risk factors and corresponding data can be found in Table 3).”
InfluentialFactors associated with quality of life and weight regain 12 years after Roux-en-Y gastric bypass
Bauraitė, K., Mikuckytė, D., Gudaityte, R., Petereit, R., & Maleckas, A. (2021) · Surgical Endoscopy · doi:10.1007/s00464-021-08778-3 · Cited by 10 · see citing works
Karimi, M., & Gargari, O. K. (2024) · Frontiers in Surgery · doi:10.3389/fsurg.2024.1449012 · Cited by 9 · see citing works
Weight loss maintenance after bariatric surgery
Cho, Y., Lee, Y., Choi, J. I., Lee, S. R., & Lee, S. Y. (2023) · World Journal of Clinical Cases · doi:10.12998/wjcc.v11.i18.4241 · Cited by 8 · see citing works
Hepprich, M., Antwi, K., Waser, B., Reubi, J., Wild, D., & Christ, E. (2020) · Case Reports in Endocrinology · doi:10.1155/2020/4510910 · Cited by 8 · see citing works
Dadheech, N., Garrel, D., & Buteau, J. (2018) · Islets · doi:10.1080/19382014.2018.1513748 · Cited by 8 · see citing works
Diabetes in Native Populations and Underserved Communities in the USA
Joseph, J. J., & Golden, S. H. (2016) · Springer eBooks · doi:10.1007/978-3-319-41559-8_14 · Cited by 9 · see citing works
Lüscher, A., Vionnet, N., Pasquier, J., Chartoumpekis, D., Mantziari, S., Wojtsusizyn, A., & Favre, L. (2024) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2024.06.006 · Cited by 7 · see citing works
Hemmingsson, J. U., Leijonmarck, C., & Klingvall, M. (2022) · BMJ Open Diabetes Research & Care · doi:10.1136/bmjdrc-2021-002572 · Cited by 7 · see citing works
Grover, A., Farahmandsadr, M., Saeed, H., Cummings, C., Sheehan, A., Pei, L., Simonson, D., & Patti, M. (2024) · Clinical Endocrinology · doi:10.1111/cen.15169 · Cited by 6 · see citing works
“While the prevalence of PBH differs according to assessment methodology, up to 38% of individuals post ‐ RYGB report symptoms consistent with hypoglycemia [3, 4].”
Recommendations for the diagnosis and treatment of hypoglycaemia after bariatric surgery.
Vilarrasa, N., Bretón, I., Ballesteros-Pomar, M., Lecube, A., Goday, A., Pellitero, S., Sánchez, R., Zugasti, A., Ciudin, A., de Hollanda, A., et al. (2022) · Endocrinología Diabetes y Nutrición · doi:10.1016/j.endien.2021.09.005 · Cited by 6 · see citing works
Is Bariatric Surgery Brain Surgery?
Sewaybricker, L., & Schur, E. (2021) · Diabetes · doi:10.2337/dbi21-0022 · Cited by 6 · see citing works
“Accompanying these benefits, however, is symptomatic hypoglycemia, reported by up to one-third of post–bariatric surgery patients (2,3).”
Inpatient Glycemic Protocol for Patients with Diabetes Undergoing Bariatric Surgery
Machnica, K., Pannain, S., Schulwolf, E., Bartfield, J. K., & Emanuele, M. (2015) · Obesity Surgery · doi:10.1007/s11695-015-1860-y · Cited by 6 · see citing works
Postprandial hypoglycaemia in adults: pathogenesis, diagnosis and management
Sulaiman, R. (2021) · Journal of Laboratory and Precision Medicine · doi:10.21037/jlpm-20-102 · Cited by 5 · see citing works
“PPH is a well-known late complicat ion of upper gastrointestinal surgery (18-22).”
BackgroundPrevalence of post-bariatric hypoglycemia in the United States.
Craig, C. M., Ramanujan, S. A., & McLaughlin, T. L. (2026) · Surgery for Obesity and Related Diseases · doi:10.1016/j.soard.2026.03.013 · Cited by 4 · see citing works
Marin, R., Ianculescu, M., Costescu, M., Mocanu, V., Mihăescu, A.-G., Fulga, I., & Coman, O. (2025) · Nutrients · doi:10.3390/nu17152542 · Cited by 4 · see citing works
“Indeed, up to a third of RYGB patients experience post-prandial hypoglycemia or dumping episodes, which continuous tracking can identify early and mitigate through dietary or supplementation adjustments [78].”
Papamargaritis, D., Zacharoulis, D., Sioka, E., Zachari, E., Bargiota, A., Koukoulis, G., & Tzovaras, G. (2016) · Obesity Surgery · doi:10.1007/s11695-016-2187-z · Cited by 4 · see citing works
“hypoglycaemia after LSG is very limited and poorly understood [5, 6, 8].”
BackgroundPost-bariatric Hypoglycemia Management: A Gulf Cooperation Council Consensus Statement
Abdelgadir, E., Rashid, F., Awadi, F. A. A., Busaidi, N. A., Alfaris, N., Hadad, M. A., Alkaabi, J., Kharusi, A. A., Al-Ozairi, E., Alromaihi, D., et al. (2025) · Journal of the Endocrine Society · doi:10.1210/jendso/bvaf225 · Cited by 3 · see citing works
Soliman, A., Ahmed, R., Meligi, A. E. E., Abdelmoaty, A., Hegazy, M., Saad, A. M., Alwakil, S., Sherif, N., Abdelghaffar, S., Fahmy, E., et al. (2025) · Cardiovascular Diabetology · doi:10.1186/s40842-025-00234-8 · Cited by 3 · see citing works
“Nesidioblastosis is controversial [44–46].”
Yukina, M., Chernova, M. O., Troshina, E., Evdoshenko, V., & Platonova, N. (2020) · Almanac of Clinical Medicine · doi:10.18786/2072-0505-2021-49-029 · Cited by 3 · see citing works
Mariën, I., Block, C. D. D., Verrijken, A., Dessel, K. V., Peiffer, F., Verhaegen, A., Hubens, G., van Gaal, L. V., & Dirinck, E. (2020) · Diabetes, obesity and metabolism · doi:10.1111/dom.14130 · Cited by 3 · see citing works
“2020;22:2107–2119. wileyonlinelibrary.com/journal/dom © 2020 John Wiley & Sons Ltd 2107 a minimum of 1 hour after a meal.4,6,7 It usually develops 6 months or later after RYGB.3,4,8,9 Hypoglycaemia after RYGB is only provoked by oral intake of glucose, not by intravenous administration of glucose.10,11 The hypoglycaem…”
BackgroundInfluentialStill, C., Benotti, P., Hangan, D., & Zubair, F. (2018) · Springer eBooks · doi:10.1007/978-3-319-75841-1_2 · Cited by 3 · see citing works
Anabela, L. M., Salsabila, S., Huang, W., Fathoni, M. I., Sumardi, A. Q. A., & Parameswari, C. (2025) · Journal of Gastrointestinal Surgery · doi:10.1016/j.gassur.2025.102288 · Cited by 2 · see citing works
Liu, Y., Zhang, W., Qian, J.-L., Huang, C.-X., Yao, Q.-Y., Sun, W.-W., Shen, Q.-W., & Yang, Y.-H. (2025) · Obesity Surgery · doi:10.1007/s11695-025-08151-6 · Cited by 2 · see citing works
“Literature reports postprandial hypoglycemia prevalence ranging from 0.1% to 41.4% [17, 22–25].”
InfluentialEfficacy of Lisosan G (fermented wheat) on reactive hypoglycemia after bariatric surgery
Moriconi, D., Pucci, L., Longo, V. G., Antonioli, L., Bellini, R., Tricò, D., Baldi, S., & Nannipieri, M. (2024) · Obesity Research & Clinical Practice · doi:10.1016/j.orcp.2024.11.004 · Cited by 2 · see citing works
Artsitas, S., Artsitas, D., Smparounis, S., Theodorou, D., & Zografos, G. C. (2023) · Bulletin of the National Research Centre · doi:10.1186/s42269-023-01145-3 · Cited by 2 · see citing works
“Additional insights from Lee et al. (2015) were focused on the clinical implications of PBSH.”
Zhou, M., Wang, L., Zhou, L., Chang, X., & Zhu, X.-B. (2022) · Experimental and clinical endocrinology & diabetes · doi:10.1055/a-1708-3214 · Cited by 2 · see citing works
Patient involvement to inform the design of a clinical trial in postbariatric hypoglycaemia
Hepprich, M., Donath, M. Y., & Hemkens, L. G. (2020) · BMC Medical Research Methodology · doi:10.1186/s12874-020-01171-z · Cited by 3 · see citing works
- Authors
- Lee, C. J., Clark, J. M., Schweitzer, M., Magnuson, T., Steele, K., Koerner, O., & Brown, T. T.
- Affiliations
- Johns Hopkins University (US)
- Corresponding author
- Lee, Clare J.
- Venue
- Obesity
- Publisher
- Wiley
- Published
- 2015-04-10
- Volume
- 23
- Issue
- 5
- Pages
- 1079-1084
- ISSN
- 1930-7381 (ISSN-L)
- PMC
- PMC4414701
- OpenAlex
- W1942344902
- Cited by
- 159
- References
- 26
- Citations by year
- 2026: 11 · 2025: 16 · 2024: 8 · 2023: 16 · 2022: 10 · 2021: 16 · 2020: 15 · 2019: 14 · 2018: 14 · 2017: 13 · 2016: 21 · 2015: 5
- FWCI
- 17.81
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Licence
- Locations
- Obesity (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (5KL2TR001077)
- Topics
- Health Sciences › Medicine › Surgery › Bariatric Surgery and Outcomes
- Health Sciences › Medicine › Surgery › Minimally Invasive Surgical Techniques
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Keywords
- postprandial hypoglycemia, bariatric surgery, Roux-en-Y gastric bypass, sleeve gastrectomy, hypoglycemic symptoms, risk factors, prevalence, preoperative screening, syncope, seizures
- MeSH terms
- Adult, Female, Gastrectomy, Humans, Hypoglycemia, Insulin Resistance, Male, Middle Aged, Obesity, Morbid, Risk Factors, Gastric Bypass, Prevalence, Postprandial Period
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