How do you hypo on a ketogenic diet?

alisonhe said:

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

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Hi Ali

It is quite common to not notice hypo symptoms as easily when busy. Also quite common that many different factors can affect insulin needs. So really you are quite normal.

Losing hypo awareness however is quite dangerous and you should probably bring this up with your diabetes care team. They may be able to help, for example slightly raising your average BG tends to restore losses in hypo warning ability.

@Spiker
@tim2000s
@robert72
@LucySW

Just an observation which may be useful/interesting, following on from Spiker's first Post . . .

I mentioned above that my routine is to eat Ketogenic for 13 days out of 14, and have a chocolate binge on the Sunday at the end of each fortnight.

Over time I have noticed that even when my blood-sugar is very low on the morning of the post-binge Monday, the "Ketosis rules" (no warning signs; no loss of brain function) still seem to apply.

I was intrigued by this, so I started to test for Ketones more frequently. I found that I still had Ketones on the Monday morning. It takes 12 - 18 hours (after I start my binge) for my Ketones to disappear. And until they disappear, the "Ketosis rules" still apply. I guess the body does not waste an energy resource which is already available.

I conclude from this that the Ketosis itself is what protects the brain from problems with low blood-sugar. On Sunday afternoon/evening I have injected very large amounts of Rapid Insulin, and before bed on Sunday night I have injected a much larger amount of Basal Insulin. But still I get the protection on the (first part of) Monday.

I agree with you @Spiker that the smaller amounts of Insulin being used with Keto/LCHF are extremely helpful. But my results explained above suggest that Ketosis itself is protective. This fits with the few medical studies I have found, where people in Ketosis were infused with amounts of Insulin that had previously triggered Hypoglycaemic symptoms.

There was a particularly good example of this, a month or so ago. I switched my binge day to the Saturday, as I wanted to combine my binge with watching the Rugby. On the Sunday morning, my girlfriend and I went to the Felsenmeer to climb the rocks (pic below). After a couple of hours climbing up, I measured my blood-sugar at 25mg/dl (1.4mmol/l). Did not have any balance/brain problems with that. We climbed down.

During the drive back home around midday (not me driving, by the way), I started to notice a sweatiness and double-vision, my classic Hypo signs. I measured at 30mg/dl (1.7mmol/l).

I thought this was a very neat demonstration of what goes on. When in Ketosis, my body tolerates low blood-sugar levels without problems. When out of Ketosis, such low levels cannot be tolerated. Here was an example where my blood-sugar level had hardly changed at all, but my Ketotic state had changed. As I transitioned from Ketosis to non-Ketosis, my Hypo warning signs started to show themselves.

Regards
Antony

I can corroborate that experience. I have seen similar myself, although I haven't been down to quite such low levels.

Do GP's/medics recommend this state of ketosis? I live in the UK and my nurse has never mentioned it.

Hi alisonhe - no, they don't generally. The NHS is still recommending a high carb, low fat diet to diabetics - it beggars belief really - the attitude is changing slowly, and some medics are beginning to break rank, but low-carb high-fat is by no means a mainstream NHS recommended diet. A ketogenic diet is simply a lower-carb version of a LCHF diet. Many diabetics use this way of eating very successfully. If you want to learn more about it so that you can make up your own mind, get a copy of Dr Bernstein's 'The Diabetes Solution'. Dr Bernstein is a US medic who has had Type 1 for most of his life. He is in his 80s now, keeps normal blood sugars and has managed to reverse many of the complications he suffered before swapping to a ketogenic diet. Well worth a read.

Smidge

alisonhe said:

Do GP's/medics recommend this state of ketosis? I live in the UK and my nurse has never mentioned it.

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Most GPs, diabetic specialists even, have never even heard of it, let alone recommend it.

LucySW said:

Me too, at a very much lesser level. I've actually never had hypo symptoms yet (despite dropping to 3.1 a couple of times after too much insulin/not enough food. I see that as the result of being in ketosis all the time - which I can check it on my sweet little Ketonix).

But Tim, what happened then that time with the dramatic Lantus experience? Were you not in ketosis then? That was a trad hypo.

Lucy

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@LucySW At the point where I collapsed, I suspect my bg levels were sub 1mmol/l. The fact is that I remained conscious, got up eventually and walked away without assistance and was able to consider doing a test to see where my bg was when I was at 1.2 mmol/l. I'd say that it worked pretty well.

tim2000s said:

@LucySW At the point where I collapsed, I suspect my bg levels were sub 1mmol/l. The fact is that I remained conscious, got up eventually and walked away without assistance and was able to consider doing a test to see where my bg was when I was at 1.2 mmol/l. I'd say that it worked pretty well.

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Wow! Superstar!

(Don't try this at home, kids!) ;-)

Spiker said:

Wow! Superstar!

(Don't try this at home, kids!) ;-)

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This is why I have very considered opinions relating to Hypos in relation to a low carb diet. I guess it is probably linked to the same reasons that the ketogenic diet works for epilepsy. (My phone wanted to call it a keto genie diet)

And I agree, as a one off, it proves an interesting point. As a regular thing I wouldn't go there.

My problem with all this is that I can also tell you that I function well at most things when I have very low glucose levels.
I eat 150g of carb a day, if I'm more active it can be more ( the exception is sometimes when walking or running , when I run out of oomph going up hills )
I remember playing a reaction game once to 'prove' it and I used to do mental arithmetic and had no problems (something I read early on to judge if you were hypo). As I've written before I have been riding a bike ,tested and found that I was 'lo' twice in a week. I didn't feel bad and I certainly thought that I was perfectly compos mentis. (just a bit shocked at the result; I retested to make sure)

It's only since I was more careful to keep an eye on things that I get obvious signs at the 3-4mmol/l area. They aren't as obvious as those you read about in books or on websites. If I have a few days with frequent levels below 3.5mmol/l those signs definitely diminish.
In terms of feelings, it feels better to be unaware because there are no slightly unpleasant symptoms; but what is the tipping point for me not on a ketogenic diet or for someone on a ketogenic diet? I don't think that there is any data, just anecdote.
Utimately, I think that it's better to be aware. Collapsing, like Tim above might result in injuries to yourself or someone else.

(I think I've given this link before in a similar discussion. It discusses other fuel though specifically lactate as possibly being protective in recurrent hypoglycaemia but also discusses whether ' recurrent hypoglycemia-induced brain adaptations that enhance lactate uptake and preserve glucose metabolism are ultimately beneficial or maladaptive' http://www.jci.org/articles/view/69796 )

phoenix said:

My problem with all this is that I can also tell you that I function well at most things when I have very low glucose levels.
I eat 150g of carb a day, if I'm more active it can be more ( the exception is sometimes when walking or running , when I run out of oomph going up hills )
I remember playing a reaction game once to 'prove' it and I used to do mental arithmetic and had no problems (something I read early on to judge if you were hypo). As I've written before I have been riding a bike ,tested and found that I was 'lo' twice in a week. I didn't feel bad and I certainly thought that I was perfectly compos mentis. (just a bit shocked at the result; I retested to make sure)

It's only since I was more careful to keep an eye on things that I get obvious signs at the 3-4mmol/l area. They aren't as obvious as those you read about in books or on websites. If I have a few days with frequent levels below 3.5mmol/l those signs definitely diminish.
In terms of feelings, it feels better to be unaware because there are no slightly unpleasant symptoms; but what is the tipping point for me not on a ketogenic diet or for someone on a ketogenic diet? I don't think that there is any data, just anecdote.
Utimately, I think that it's better to be aware. Collapsing, like Tim above might result in injuries to yourself or someone else.

(I think I've given this link before in a similar discussion. It discusses other fuel though specifically lactate as possibly being protective in recurrent hypoglycaemia but also discusses whether ' recurrent hypoglycemia-induced brain adaptations that enhance lactate uptake and preserve glucose metabolism are ultimately beneficial or maladaptive' http://www.jci.org/articles/view/69796 )

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Hi @phoenix . . .

May I ask, why is it that you have a "problem with all this" ??

Surely your experiences, and the experiences of others on this thread, can easily co-exist ? . . .

Your experiences (and your link) show evolution's solutions to low blood-sugar when the body is not in Ketosis . . . warning signs are given so that raising blood-sugar is encouraged, and if these warning signs go constantly unheeded then further adaptations are pursued so that the brain gets sufficient fuel to function.

My experences (and the links I posted here http://www.diabetes.co.uk/forum/threads/driving-a-wedge.72495/#post-778944) show evolution's solution when the body is in Ketosis . . . brain is fuelled primarily with Ketones so that blood-sugar becomes far less relevant.

We know that brain metabolism is working very differently in and out of Ketosis. I think it's no surprise that evolution should find different solutions to the problems encountered by these two different ways of operating.

Regards
Antony

@phoenix, just to be clear, the collapse occurred after normal warning signs and dosing with dextrosol tabs more than once. Whilst in the state, the warning signs remained. The deep Hypo occurred in spite of all of this due to massively excess insulin. I was just able to come out more quickly due to the keto adaptation.

diamondnostril said:

Hi @phoenix . . .

May I ask, why is it that you have a "problem with all this" ??

Surely your experiences, and the experiences of others on this thread, can easily co-exist ? . . .

Your experiences (and your link) show evolution's solutions to low blood-sugar when the body is not in Ketosis . . . warning signs are given so that raising blood-sugar is encouraged, and if these warning signs go constantly unheeded then further adaptations are pursued so that the brain gets sufficient fuel to function.

My experences (and the links I posted here http://www.diabetes.co.uk/forum/threads/driving-a-wedge.72495/#post-778944) show evolution's solution when the body is in Ketosis . . . brain is fuelled primarily with Ketones so that blood-sugar becomes far less relevant.

We know that brain metabolism is working very differently in and out of Ketosis. I think it's no surprise that evolution should find different solutions to the problems encountered by these two different ways of operating.

Regards
Antony

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the last link of your 4 had this observation below. Am I reading this right that they took the male subjects down to 0.5 on our glucose meter scale?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC332976/
full pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC332976/pdf/jcinvest00637-0253.pdf
" However, no insulin reactions nor significant rises in catecholamine excretion occurred despite equal extent and rate of glucose fall. Glucose concentrations as low as 0.5 mmoles/liter (9 mg/100 ml) failed to precipitate hypoglycemic reactions. "

jack412 said:

the last link of your 4 had this observation below. Am I reading this right that they took the male subjects down to 0.5 on our glucose meter scale?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC332976/
full pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC332976/pdf/jcinvest00637-0253.pdf
" However, no insulin reactions nor significant rises in catecholamine excretion occurred despite equal extent and rate of glucose fall. Glucose concentrations as low as 0.5 mmoles/liter (9 mg/100 ml) failed to precipitate hypoglycemic reactions. "

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Yes, that's right . . . it was the 1970s and I suppose the health-and-safety mentality hadn't yet taken over. The few studies on this topic are all decades old and have the perception of being out-of-date . . . and this will always remain the case, because nobody will ever get permission to perform a similar study these days. Shame!

9mg/dl is the lowest I've seen in the few studies available.

diamondnostril said:

Yes, that's right . . . it was the 1970s and I suppose the health-and-safety mentality hadn't yet taken over. The few studies on this topic are all decades old and have the perception of being out-of-date . . . and this will always remain the case, because nobody will ever get permission to perform a similar study these days. Shame!

9mg/dl is the lowest I've seen in the few studies available.

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I hereby volunteer to be a subject in a repeat of these ultra low blood glucose, ketone-infused clamp studies.

Spiker said:

I hereby volunteer to be a subject in a repeat of these ultra low blood glucose, ketone-infused clamp studies.

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In the next months I will return to the UK, to pursue my mid-life crisis dream of taking a Bachelor of Medicine degree and eventually becoming a Diabetes specialist. If I ever get the chance to run a study, then I already have my first volunteer

diamondnostril said:

Surely your experiences, and the experiences of others on this thread, can easily co-exist ? . .

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Of course they can, but we cross the line when anyone suggests or implies that very low bg levels are not a concern when following a particular diet, low bg levels are dangerous and the long-term effects of frequent and prolonged episodes of hypoglycaemia are still unknown.

noblehead said:

Of course they can, but we cross the line when anyone suggests or implies that very low bg levels are not a concern when following a particular diet, low bg levels are dangerous and the long-term effects of frequent and prolonged episodes of hypoglycaemia are still unknown.

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One thing we do know is that in the short term, frequent hypoglycemic episodes impair hypo awareness, sometimes permanently. So that is already not a good thing, regardless of whether there may be other as yet undiscovered long term negative effects.