Culture bound hypoglycemia symptomatology.

Dear Editor,

Symptomatology of various disorders may vary from culture-to-culture. This is evident from the acceptance of culture-bound syndromes in current academic discussions.[1] In diabetes, too, perception of hypoglycemia has been found to differ among different linguistic groups.[23] Certain symptoms of neuroglycopenia, with a religious perspective, have also been reported.[4]

We report a case of culture-bound symptoms of hypoglycemia, which we recently encountered in clinical practice. SS, a 58-year-old Hindu priest, of normal weight, well-educated in English, Hindi, and Sanskrit, with 2 years history of diabetes, presented for a routine checkup. His glycemic parameters suggested fair control (fasting plasma glucose 141 mg% HbA1c 6.6%) on a regime of glimepiride 1 mg and metformin 500 mg twice a day, in fixed dose combination. Lipid profile, renal hepatic, and thyroid functions were normal. This noncelibate priest led an austere life, which included waking up at 4 am, and performing prayer meetings with continuous incantation of holy verses for up to 6 h at a stretch.

The patient proffered no complaints upon history taking, but upon questioning regarding quality of sleep, volunteered that he frequently had dreams in which God appeared, asking him to eat sugar. The patient did not take sugar, as it was “prohibited” by the dietician, and woke up with a feeling of guilt and remorse, not having “listened to God.” This situation led to a mental dilemma in which the patient was unable to decide whether to follow God's advice or the dietician's. Upon detailed questioning, the priest explained that he earlier used to experience a feeling of bliss (“anand”), while conducting prayers. In the recent past, he had noticed a “loss of bliss” or “inability to concentrate during meditation,” which would begun suddenly just as he reached a point of “extreme bliss.” He correlated this with his disobedience to God in his dreams. He was unable to follow a 3 + 3 pattern (three major meals, with three snacks, including a late night glass of milk), and noticed that these symptoms occurred when he missed breakfast.

The patient was requested to perform a seven point profile, which revealed low glucose values dipping up to 44 mg%. The concept of neuroglycopenia was explained, and the prevention and management of hypoglycemia discussed with the patient.

SS was prescribed a fixed dose combination of vildagliptin 50 mg and metformin 500 mg twice a day, and advised to take small frequent meals. This was done as a precautionary measure, as he had experienced hypoglycemia with very small doses of glimepiride. The patient mentioned that he could not eat solids or “proper food,” while in the temple, or during prayers, as it would be considered socially inappropriate. Methods of taking socioculturally acceptable snacks during long prayer meets were suggested, such as taking sips of sweetened water, dry fruits or nuts as “Prasad” or Holy Communion. A fortnight later, he reported that his dreams had disappeared, and that he had begun enjoying his prayer sessions.

This case highlights the existence of religion-specific symptoms of hypoglycemia, viz; “dreaming of God” and “loss of bliss,” while meditating. It also sensitizes diabetes care professionals to take a complete history related to hypoglycemia, using questions appropriate to religion and culture, and be cautious while prescribing drugs, which may cause hypoglycemia.