Glycogen stores, hypos and low carb/keto diets

[EllieM]

(This question is inspired by the discussion in the thread "crazy hypo in the morning"
https://www.diabetes.co.uk/forum/threads/crazy-hypo-in-the-morning.178164
but I didn't want to take the thread too off topic_)


OK, a bit of googling suggests that the people on low carb or keto diets have less glycogen in the liver? So what's the implication of this for those of us T1s who rely on a bit of help from their livers when they go hypo?

 

[Jaylee]

Hi, thanks for the topic @EllieM ,

I'll tag in @MarkMunday ,

Because from my understanding the "100 to 130gees" estimated in the liver is by non D sporting types rumnning about for a few hours.. (Done a little Googling too.)
Where as I personally scoot up 3mmol with "foot on the floor" after something like a dog walk & prep for work within 2 hours of getting up, then stay there if I don't correct? So I am looking at something like the equivalent 10g of carbs...

I low carb too.. & never do breakfast opting for a "brunch" or lunch.. & also use a calibrated sensor CGM set up.

 

[DCUKMod]

I'm neither T1, nor insulin user, but my very basic take on this is that our liver will do what it can to help us ("us" being everybody, not necessarily the assembled few, if you know what I mean) out where it can, but that help comes without a sure-fire assurance of it being efficient or adequate.

If the liver dump were full-proof, there would be no deaths by hypo, which we know is tragically untrue.

My look on it is that for those with very disrupted, natural, metabolic blood glucose control relying on liver dumps is a bit like playing Russian Roulette with most of the chambers blank, but a random number of bullets on randomly placed chambers.

Are you feeling lucky? Were I in that particular position, I'd probably rather not take the gamble.

Our local Diabetes UK group received a couple of very significant donations of money raised after the death of a young man locally, who had died, in his sleep as a result of a sever hypo. The situation was a bit complex, due to alcohol in the mix, and therefore perhaps another bullet in the (Russian Roullette) gun, but nevertheless very, very tragic indeed.

The quantum and number of the donations received went some tiny way to demonstrate the devastation his passing caused to a far wider community than his family.

 

[EllieM]

My look on it is that for those with very disrupted, natural, metabolic blood glucose control relying on liver dumps is a bit like playing Russian Roulette with most of the chambers blank, but a random number of bullets on randomly placed chambers.

Not going to disagree with you there, but I am actually wondering if a decreased liver dump is a factor if you go low carb.... There are lots of low carb pros, is this a low carb con for a T1?

 

[MarkMunday]

Generally, death where hypos are suspected are often caused by something else. There is no way of telling post-mortem what blood glucose was at the time of death, so when hypoglycemia appears on a death certificate, it is guesswork. With the so-called dead-in-bed syndrome, death is now thought to be caused by an otherwise benign congenital heart defect.

People on ketogenic diets are thought to have 50% less glycogen in their livers. That could just be speculation, but in any case, such people have a much smaller need for glycogen. Simply because fat is the main source of energy. Bolusing is much smaller and basal is reduced too. Even the brain learns to use use fat for energy. I guess the implication of reduced liver glycogen capacity in people doing Kato is that they should avoid injecting large amounts of insulin. But that is like preaching to the converted ...

 

[DCUKMod]

Not going to disagree with you there, but I am actually wondering if a decreased liver dump is a factor if you go low carb.... There are lots of low carb pros, is this a low carb con for a T1?

I have been low carbing for 7 years now, and I still have a liver dump. I'm one of those odd people who can feel when it's happening - not anywhere close to my liver, but all I can describe as an odd feeling in my throat.

(Yes, I am that odd!)

 

[DCUKMod]

Generally, death where hypos are suspected are often caused by something else. There is no way of telling post-mortem what blood glucose was at the time of death, so when hypoglycemia appears on a death certificate, it is guesswork. With the so-called dead-in-bed syndrome, death is now thought to be caused by an otherwise benign congenital heart defect.

People on ketogenic diets are thought to have 50% less glycogen in their livers. That could just be speculation, but in any case, such people have a much smaller need for glycogen. Simply because fat is the main source of energy. Bolusing is much smaller and basal is reduced too. Even the brain learns to use use fat for energy. I guess the implication of reduced liver glycogen capacity in people doing Kato is that they should avoid injecting large amounts of insulin. But that is like preaching to the converted ...

But surely in the insulin dependent person, the amounts of insulin injected are governed by underlying blood glucose, eating/drinking in prospect, exercise, hormonal issues, carb counting and all the rest.

I appreciate that taking all of those things into account several times a day must be brain frying, but by and large, surely the major factors are carb ratios/prospective, historic eating/drinking and current blood glucose numbers. For low carbers, I believe there is a consideration that smaller amounts of insulin are likely to lead to "smaller" erros, but of course, I have no personal experience of this.

So, extremely simplistically, if an individual's blood glucose is 6, they intend eating 20gr carb, with a ration 1:10, they take 2 units, then review a while later? If they have no idea about carb counting or ratios, then it is more of a lottery.

Of course, I am massively, hugely over simplifying things.

As I read it, for T1 (and others in a similar position), hypos are part of life's rich pattern. How much the individual person then depends on their liver to rescue them is just as individual as they are, I'm sure. The good old Dirty Harry saying "Do you feel lucky ****?" comes to mind if they intend to serially allow their liver to save them.

 

[EllieM]

There is no way of telling post-mortem what blood glucose was at the time of death, so when hypoglycemia appears on a death certificate, it is guesswork.

Thanks for posting. I agree there is no way to prove that dead in bed is caused by hypos, but I can confirm from personal experience that hypos can cause seizures and unconsciousness, which can't be good for the body. And when I googled there was a hospital case where a woman died because the hospital injected her with too much insulin (40 units instead of 4 so unlikely to be accidentally injected).

BBC NEWS | UK | Scotland | Death followed wrong insulin dose

On a personal level, having had a couple of lantus lows and an injection of bolus instead of basal, I find the vertical blood sugar descent caused by excess insulin absolutely terrifying, and I would like to think that my liver gives me as much help as possible. On the other hand, you're certainly right that low carb means less insulin which gives less opportunities for sudden cliffside drops, but it's good to know all sides of the low and not so low carb arguments.

 

[EllieM]

And I''m going to retry posting a really interesting article about (long discontinued) insulin shock therapy for schizophrenia.

Insulin Therapy for Schizophrenia (priory.com)

Basically they started with 20 units and kept increasing the daily dose until the patients went into comas, with coma rates as low as 40 and as high as 600 units (guess there were T2s with schizophrenia).

Massed figures gathered in the United States give a mortality of 90 deaths in 12,000 patients treated, of which about half were due to hypoglycaemic encephalopathy, which is thus seen to be the most serious risk of treatment; it is, on the other hand, an avoidable risk and is the rarer the more skilled the operator. In this series there were also twelve deaths from heart failure, nine from aspiration pneumonia, seven from pneumonia occurring otherwise, some of which were probably also avoidable.

 

[EllieM]

hypoglycaemic encephalopathy

I guess that's death by hypo for .75% of the patients, with additional deaths by hypo induced heart failure etc....

 

[bulkbiker]

Not going to disagree with you there, but I am actually wondering if a decreased liver dump is a factor if you go low carb.... There are lots of low carb pros, is this a low carb con for a T1?

Well my FBG was 5.9 this am 4.9 yesterday go figure.. about 15 g of carbs both days before (naughty oppo) ...

I even had a 6.1 a couple of weeks ago so for me ultra low still get liver dumps.

 

[EllieM]

The good old Dirty Harry saying "Do you feel lucky ****?" comes to mind if they intend to serially allow their liver to save them.

I think most T1s allow their liver to save them in the sense that brittle diabetes can occur in those people who don't have a working glucagon/glycogen loop. Mild hypos occur very often for T1s who are trying to keep their bgs at normalish levels, but sudden severe bg drops can be catastrophic and life destroying. I hate hypos more than anything else about T1, but if I want to maintain good bgs I'm stuck with occasional mild ones. Brittle diabetes would be a nightmare.

 

[DCUKMod]

I think most T1s allow their liver to save them in the sense that brittle diabetes can occur in those people who don't have a working glucagon/glycogen loop. Mild hypos occur very often for T1s who are trying to keep their bgs at normalish levels, but sudden severe bg drops can be catastrophic and life destroying. I hate hypos more than anything else about T1, but if I want to maintain good bgs I'm stuck with occasional mild ones. Brittle diabetes would be a nightmare.

Yes, I appreciate that situations like high 3s, with food in near prospect aren't likely to be too high risk.

I'm just clarifying my thoughts, and trying to be as simplistic as possible.

My concerns are, obviously, for those who aren't very knowledgeable, reading it's OK to ignore hypos, because we have a great safety net, when the reality is that living with T1 (as an example) doesn't guarantee the safety net will always be robust enough to catch and hold.

 

[EllieM]

My concerns are, obviously, for those who aren't very knowledgeable, reading it's OK to ignore hypos, because we have a great safety net, when the reality is that living with T1 (as an example) doesn't guarantee the safety net will always be robust enough to catch and hold.

I agree with you there, which is why I find a cgm with an alarm that goes off at 4,4 so valuable. (Before that I had to keep my levels much higher). Of course, I can't count on the alarm working 100%, but since self funding my dexcom my hypos have drastically reduced. Loss of hypo awareness is a real risk for T1s who have too many hypos, and though the liver may or may not protect us from death by hypo, it certainly doesn't protect hypo unaware T1s from unconsciousness and trips to hospital (plus seizures and/or loss of driving licenses).

But back to my original question, I'm pretty sure that my liver partially mitigates the effects of mild and bad hypos, so I was wondering about the trade off between lower carb and less mitigation but less insulin to require that mitigation....

But as a T1, you have to learn to live with hypos. Too much hypo fear can be as debilitating as the hypos themselves. (Think of it this way, you always look both ways before crossing the road to avoid being hit by a car, but don't refuse to ever leave your house because you're afraid you might be hit by a car.) Always, always carry glucose or equivalent if you're on insulin.

 

[PeteN11]

OK, a bit of googling suggests that the people on low carb or keto diets have less glycogen in the liver? So what's the implication of this for those of us T1s who rely on a bit of help from their livers when they go hypo?

I do not believe we can ever rely on our Livers helping out. Just one sniff of Insulin in the body and it just wont happen anyway. I am fortunate though to not have to worry about it as I do not believe I have ever had a night time Hypo.

Reducing the amount of carbs should also mean a drop in Insulin which may mean the Liver helps out more to begin with but the body should adapt to using stored fat instead.

I have been playing with low carbs for 3 months with 50g to less than 80g a day. I feel better for it now but the first couple of weeks I felt very tired and lethargic. I have now reduced my Basal Insulin by half and my Bolus by much more. The trouble with me is I am not strict enough with it so probably have not ventured too far into the Ketososis phase although I did lose over a stone in weight.

My BG levels used to fluctuate wildly with varying highs between 8 & 15, probably due to my bad management but with low carb the average was around 6 with whole days of between 5-6 readings including night time. I have never been able to do that before.

This you tube video is a discussion with Dr Ian Lake a T1 from age of 30 who is an advocate of low carb diet. There are so many interesting points in it. The main one for me is that only 10% of T1's in the UK reach a Hba1c of 7% or lower whereas those on a Keto diet it is 90%!

He also talks about his (and others) recent "Zero 5 100" event. No food for 5 days running/walking 100 miles. Around the 40 min mark he says that many of those taking part were regularly showing BG of 3 with no adverse effect or any of the usual Hypo symptoms.

 

[PeteN11]

I agree with you there, which is why I find a cgm with an alarm that goes off at 4,4 so valuable. (Before that I had to keep my levels much higher). Of course, I can't count on the alarm working 100%, but since self funding my dexcom my hypos have drastically reduced. Loss of hypo awareness is a real risk for T1s who have too many hypos, and though the liver may or may not protect us from death by hypo, it certainly doesn't protect hypo unaware T1s from unconsciousness and trips to hospital (plus seizures and/or loss of driving licenses).

But back to my original question, I'm pretty sure that my liver partially mitigates the effects of mild and bad hypos, so I was wondering about the trade off between lower carb and less mitigation but less insulin to require that mitigation....

But as a T1, you have to learn to live with hypos. Too much hypo fear can be as debilitating as the hypos themselves. (Think of it this way, you always look both ways before crossing the road to avoid being hit by a car, but don't refuse to ever leave your house because you're afraid you might be hit by a car.) Always, always carry glucose or equivalent if you're on insulin.

If you do watch that video I suggested above I would be very interested to see if it has changed your thoughts or fears.

 

[EllieM]

If you do watch that video I suggested above I would be very interested to see if it has changed your thoughts or fears.

Thanks, I did watch it (though would much prefer a transcript as I read fast and hate having to devote 50 minutes to something I could read in 10) . Really, really interesting, though I see he used 18g of glucose to control hypos so wasn't strictly 100% keto.. Don't think I'm worried about low carb causing brittle hypos now.

I'm currently low carb (probably less than 80g per day), would consider going lower though am not sure I would want to go full keto. As I have T2 in my family I have some insulin resistance and extra weight, so would love to be able to reduce both of those.

I might try some fasting....

And going off topic, does he say anything about lipid levels anywhere? (Currently under pressure from GP because after going lower carb my total cholesterol is up, though my ratio is still fine at total/HDL of 3.5. NZ guidelines have a chart where the lowest ratio shown is 4 and I'm deemed to need statins just because of my age (over 55). I'm concerned that they may make my T2 tendencies worse and push up my bgs)

 

[MarkMunday]

... Basically they started with 20 units and kept increasing the daily dose until the patients went into comas, with coma rates as low as 40 and as high as 600 units (guess there were T2s with schizophrenia). ...

A doctor in Dunedin murdered his wife using this approach. She was ill but not a diabetic and he injected insulin every day until she died. It took three weeks. A single insulin dose is seldom fatal, though, and attempted suicide using insulin is usually not successful.

 

[EllieM]

It took three weeks.

I hope he went to jail for a long time....

Given my experiences with hypos, I've never thought that an insulin overdose would be a good way to commit suicide (not that I've ever been that way inclined, but if I had a reason to need to do so I'd find another way.)

 

[MarkMunday]

... brittle diabetes ...

That term raises various reasons. What exactly is brittle diabetes? Why don't T1s eating low carb or keto ever have it? What is the difference between poorly controlled and brittle diabetes? And what evidence backs up the assertion that these people don't make glucagon when required?