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How do you hypo on a ketogenic diet?

LucySW

Well-Known Member
Messages
1,959
Location
Denmark
Type of diabetes
LADA
Treatment type
Insulin
Can anyone eg @Spiker explain how hypos can happen once we're eating ketogenically, i.e. once we're up and running on ketones?

Could being in ketosis possibly mean either that 1) things have to go a lot more wrong for a hypo to happen, or that 2) BG changes slowly? (@smidge raised this on the T1 Libre thread.). Or both?

This just occurred to me after wasting incredible amounts of time today fussing around over my Libre, and seems important. I guess I'm asking, does ketosis actually make life safer for T1s (and LADAs)?

Bored and fed up with diabetes, Lucy
 
Hmmm, no one interested? I suppose I've answered my own Q and that both things do happen, to varying extents. I've never seen anyone claim this for ketogenic diets, though.

(I suppose implicitly this is part of Bernstein's point.)

Loose the Moose
 
What I've found with Ketosis as a T1 is that it generally gives me more stability - my BG variance has definitely dropped.

Being low carb, I'm still taking a decent amount of basal insulin but my boluses are practically non-existent.

I find that the most likely low BG occurrences come first thing in the morning following a previous evening's gym session (and I'm working out how best to dose my late evening Lantus to manage this), but that typically my BG changes far more slowly.

I'm not sure whether I'd say it is safer. I didn't really suffer major hypos beforehand and I've always had warning signs, so I don't think I've had fewer hypos than previously.
 
Hi Lucy,

I think that they would happen just as they do when not in ketosis; when you have more insulin than glucose your blood sugar levels will drop.

You would expect the peaks and troughs of normal carb/bolus matching to even out so I would agree that falls would be slower.

Don't forget that when in ketosis you are not glucose free; you are still converting protein to glucose and if you were not a diabetic your blood sugar levels would still be constant albeit possibly lower.

Anecdotally, I find that I need to be much lower to get the full on hypo symptoms; shakes, sweats etc., I can still tell that my bloods are too low before that happens and so can test/correct but I have haven't had a full on hypo (by which I mean confusion/loss of control) for years. So, on those grounds perhaps a ketogenic adapted brain will be able to cope much better than a normally glucose burning brain?

I'm not sure if I would class myself as ketogenic though as often I don't detect any in my urine and I'm eating about 30 grams a day of carb, sometimes less (sometimes more...).

I read about someone yesterday who was severely overweight (about 200kg+) and just stopped eating and under medical supervision wanted to see what would happen; he didn't eat for more than a year and towards the end he was running blood sugar levels of about 2 mmol/l which is well below the 'hypo' level we have in mind without suffering from any noticeable consequences. He wasn't a diabetic I hasten to add. Interesting though?

Best

Dillinger
 
Very interesting. Makes you speculate that starvation is good for us T1s - as @runner2009 was saying recently (on this thread: http://www.diabetes.co.uk/forum/threads/managing-the-bernstein-eating-plan.63042/ ). Or to put it another way, in evolutionary terms, is normal eating over-eating?

Lucy
 
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Amazing, and extremely interesting. Hmmmm ...
 

Hi Lucy,

My own anecdotal evidence is that my experience of a low blood-sugar event is utterly different, depending upon whether I am in Ketosis or out of Ketosis.

When I am out of Ketosis, I get the regular warning signs when my blood-sugar drops low (shaking, sweating) and this proceeds to a loss of brain function (double-vision, loss of balance, confusion) if I do not treat this in time. This can be a very unpleasant event.

When I am in Ketosis, I do not get any warning signs when my blood-sugar drops low, but then I do not get any loss of brain function either. I just notice the low level at the time of my next test, and "correct" this with some Glucose tablets. It's rather a non-event.

My own opinion is that being in Ketosis makes me very very much safer than otherwise. I am a T1 that lives alone, and I have come to rely on the Keto diet as a strategy to manage my Diabetes and keep me safe.

My regular routine has put me in a nice position to compare the Ketosis / non-Ketosis models for my own body. I stick mostly to a Ketogenic diet (13 days out of each 14) and generally measure positive for Ketones (I have the Ketonix breath-analyzer to easily check for Ketones). At the end of each fortnight I treat myself to a Sunday afternoon of chocolate eating and come out of Ketosis. It takes me around 36 - 48 hours to fall back into Ketosis and during that time I am vulnerable to 'normal' hypos (i.e. loss of brain function when blood-sugar is low). For the remainder of the time, Ketosis offers me a very nice protection that brain function is not lost when blood-sugar is low.

I've mentioned this in a few other Posts that I've made. As always, I make clear that I'm not advocating that people shoot for low levels. My target is always to maintain a normal (non-Diabetic) blood-sugar level. But I have developed a lot of confidence in the Keto diet; I now know that if I make any mistake and my levels drop low, I will not get any loss of brain function, so it won't be an unpleasant or dangerous event.

My own experience does seem to match the findings of a few published medical studies that I have found (i.e. that brain function is not lost during a low blood-sugar event when in Ketosis).

But you don't hear about this idea very often, which I always find surprising - I would have thought that this is a priceless piece of information for T1s that try to maintain non-Diabetic levels. Perhaps this is because there's just not many T1s using the Keto diet? Or perhaps most T1s on the Keto diet do not get this experience of protection from Ketosis? Would love to know this . . .

Regards
Antony
 

Thanks, Antony. That is amazing. I suspect the reason we don't hear this much is that people self-censor because they know it's too controversial. Also, perhaps, because it might lead to nasty outcomes if relied on. It may differ very much from person to person and particular circs to particular circs. What you say sounds completely convincing.

@Spiker, won't you pontificate here? I know you had a major hypo experience, and you low-carb, no?

On controversy, look at how much trouble low-carbers get into over on the Type 1 forum. That's why I posted this here, where low-carbing LADAs feel a little safer.

Lucy
 
Hi Anthony,

That's interesting and backs up what I understand of Ketosis for someone without diabetes.

Once you are in Ketosis, your body functions on fatty acids and the liver can metabolise the small amounts of glucose still needed for brain function from protein. In a fully ketogenic state, you do not have any glycogen stored so there is nowhere to turn other than protein and your entire metabolism functions differently.

The key difference for T1s is that we are adding in insulin (which manages the release of those fatty acids - lack of it causes ketoacidosis - as well as taking glucose into storage) and it sounds as though you have found a nigh on perfect balance.

When I am in full on ketosis, I still get warning signs that I am low, however I have found that it is much easier to maintain concentration and continue to do things that I can't when not in that state, however when dropping below 2.2 mmol/l, I was getting impaired brain function. I hadn't paid that much attention to it before now, but your post makes a lot of sense.
 
@LucySW I tend to stay out of ketosis most of the time, but am definitely low-carb, rarely eating the big 5 carbs. I get the full range of hypo symptoms but can function pretty well down to about 2.2 - although it's pretty unpleasant and I'd rather correct once I've fallen below 3.5ish. What I have noticed and commented on many times is that my BG does not fall quickly it can fall into the mid 3s and hang around for hours, so I know I don't actually need to rush to correct. I have had quite a lot of bad comments from some people on this forum when I've said this though. However, my use of the Libre for the past week has shown me beyond any doubt that my BG generally moves very slowly, drifting up and down rather than rising and plummeting - I have hardly seen anything other than the horizontal arrow on the Libre reader. (TBH I've just scanned and I have a very strong vertical up arrow at the moment, presumably due to the mountain of mashed swede I ate an hour ago and the not-so-rapid-acting Apidra failing to keep up.) Anyway, mountains of mashed swede aside, I managed to go 3 days without seeing anything but a horizontal arrow. The only times I have seen them was after bread, after ryvita and after a tiny chocolate used to correct a hypo the other day - oh, and now the swede! So, I am coming more and more to the conclusion that low-carb means my BG rises and falls far more slowly.

Smidge
 
Whilst I'm reliant on good old finger sticks, I have noticed that Novorapid gets to work more quickly than brown rice carbs get into the blood stream. Even taken 20mins after lunch, 4iu of Novorapid causes a low on 70g o brown rice carbs about an hour after taking it. Now I know I'm currently much more sensitive because I used to eat 100g of carbs and take 12 iu....

Sent from my D6603 using Tapatalk
 

Ditto here. With three days on the Libre, I've got only one slow rise arrow and one fast rise arrow after a big breakfast. I'm only on teeny basal doses and not fully developed type 1 yet, but that has to be good.

To look at it another way, the absence of carbs is bound to mean a slower rate of change.

Bernstein's Law of Small Numbers?
 
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Hi Anthony,

Thought that I'd undertake a little experiment today and have run with my blood sugar in what is normally classified as a diabetic hypo.

My blood sugars have been between 2.4 and 3.3 all afternoon on a carb free day. I have been generating ketones in my urine, so I'm fairly sure I'm in ketosis.

Now the acid test of this is what my other half says to me as she always picks up on hypo signs as I usually become confused and unco-ordinated. I also lose my temper and shout at the dogs when they are being difficult.

During this period, I have been calm, cool and fully normally functioning. My other half didn't notice I was low, which is the topper.

Now I know this is unscientific and wholly anecdotal, but I think it replicates what you have experienced. For me what I think it identifies is that once you have spent long enough ina ketongenic state, your brain is used to running on fatty acids and small amounts of glucose, and not just glucose, so in a classic hypo state, your brain is not actually suffering a hypo.

While this is not revolutionary on here, it's the kind of thing that will scare the NHS witless, and the DVLA even more so, as I'd argue it can't be classified as a hypo if you are fully in control.

What are others' thoughts on this phenomenon?

**Disclaimer. I don't recommend doing this kind of experiment on your self unless you know what you are doing, or think you do at least...
 
@tim2000s - glad you're OK. I've had a situation once where I had a little chocolate (which usually corrects me instantly), a whole little carton of orange juice and a kitkat and I was still hypo'ing. Sorted it eventually and I didn't collapse, but it was scary. That was after a couple of glasses of red wine the evening before.

Smidge
 
Sorry for the very late response @LucySW

My experience is similar to Anthony (@diamondnostril) and @tim2000s. Hypo warnings occur at a lower level and I am fully functional at a lower level. I don't do it deliberately, I just notice that it's the case. Hypos are noticeably much less severe. In general for me and probably others it is the fast dropping hypos that are the most dangerous and hard to deal with. In ketosis I get only slow dropping hypos that are gentle and easy to deal with. I find it much easier to avoid over treating the hypo by "eating the kitchen" until I feel ok. In turn this means rebound hypos are avoided.

To be honest though I always assumed that the milder hypos during ketosis were simply due to the much smaller amounts of insulin being used. After all it is insulin that causes hypos, invariably, and hence big insulin doses are required for any rapid blood sugar drops.

Whether there is something in the ketosis itself that affects the nature of the hypo, I can't say personally, though of course there is a body of research showing better toleration of low blood glucose by the brain when in a ketogenic state.
 
if you are eating mainly protein and fat which metabolize slowly, it makes sense that you will not see the fast peaks and falls which carbs create. Ali
 
Hey, this is all new to me (not diabetes - have been T1 for 29 years) but I have not heard of being in ketosis - I thought this was a bad thing having ketones in your urine? Are you all speaking about having a low carb diet - mainly fats and protein and is this the ketogenic diet? Is there some risk to this diet, do you consider the nutrients you are consuming and are you getting enough? My hypos vary widely, sometimes I lose motor function, sometimes brain function as in it causes confusion and affects vision and there have been times when I measure my blood and am low with no symptoms - I cannot explain why it varies, I have not seen a pattern. I think when I am extremely busy I am less likely to be aware of what is going on inside and may not recognise symptoms. My insulin needs vary -sometimes it seems for no reason, it is affected by the temperature / weather but I cannot predict when it will change and sometimes it seems to change for no reason. Ali
 
There is a huge difference between dietary ketosis and ketoacidosis (which alters the pH of you blood and is life threatening). As a low-carber, my ketones are usually between 1.5 - 3.0 mmol and I have enough insulin to keep normal blood sugars. Ketoacidosis starts at around 10 mmol and is usually caused by a lack of insulin and high blood sugars. If you are not following a ketogenic diet then, as a Type 1, you need to be wary of ketones and follow sick day rules if ketones appear.
 
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