hypo - keytone (relatively low carb) query

[grantg]

couple of questions if ketosis what levels of keytones would you expect to have?
the other query i have is regarding being told recently not to treat hypo's ... currently unless VERY low.

Low Glucose Average duration 298 Min. 14 so far over the last 2 weeks (daytime hours). have tested blood keytones (regularly 2+)a few times after fingerprick confirm glucose <3. Have been given advice what to do if high keytones alongside high sugars... but no advice on if not high sugars. drinking helps to lower them a bit but can't appear to get them within normal levels recently. dsn says not to worry too much. have had dka before.. not wanting a repeat is there anything in particular should be looking at doing or indeed not doing

most of time when tested keytones has been after some exercise eg 30min to 60min swimming, or after a small hike, testing again a few hours later. lowest blood keytone result at the moment for the last week has 1.9 highest 3.8. dsn emailed advice which isnt relevant has only states guidelines for high glucose levels with keytones. nothing to do with low glucose & keytones.

 

[ianf0ster]

I'm not an expert on this since I'm a Type 2 and don't measure my ketones.
Eating (very) Low Carb (between 20gm to 40gm of Carbs per day) for over 6yrs means that much of the time my body is running on ketones. In fact even non-diabetics often go into ketosis when they haven't eaten (carbs) for several hours e.g. during sleep or if fasting.
But I'm a Type 2.
I've heard some Type 1's dispute it, so I may be wrong, but my understanding is that (for all Types) ketones are only a problem in conjunction with high Blood Glucose (talking mid teens and above here).
High ketones in somebody who isn't Low Carbing are due to the body desperately trying to get energy to where it's needed when either suffering lack of insulin or extreme insulin resistance, so you would only expect this to be associated with high Blood Glucose.

 

[Westley]

Ketoacidosis can occur with normal or low blood glucose levels - known as Euglycemic Diabetic Ketoacidosis. It is rarer than the more usual DKA with high glucose, but still very serious, and potentially even fatal.
It seems like there are various factors which can make it more likely, including use of SGLT2 inhibitors like dapagliflozin.

Euglycemic Diabetic Ketoacidosis - StatPearls - NCBI Bookshelf

I'm no expert and don't have first hand experience of this, but I think if ketones are high and there are other signs of DKA, like vomiting, shortness of breath or abdominal pain, it calls for a visit to the emergency room, even without high BG.

 

[Antje77]

the other query i have is regarding being told recently not to treat hypo's ... currently unless VERY low.

I don't understand this advice at all.
How are you treaing hypos? I'm thinking along the lines of her going very high every time you treat a hypo, in that case they could have a bit of a point. But I'm not sure this is what is going on. If it is, it just tells you she usually needs a less agressive hypo treatment.
Do you verify hypos with a fingerprick, and check again after about 15 minutes? In my experience, sensors can be very slow to register a rise after a hypo so I rely on figerpricks.

have tested blood keytones (regularly 2+)a few times after fingerprick confirm glucose <3.

What has she eaten and has she dosed insulin in the hours prior to those tests?
If she's not eating many carbs and doesn't have any symptoms associated with ketoacidosis, ketones are expected and not a problem.
Different story if she has symptoms of course.

 

[SimonP78]

I think the level that A&E consider to be high is not the same as the NHS guidance page though. The former appears to be something along the lines of >4 (and probably higher than that), while the NHS guidance is much more conservative. In A&E they also check blood pH afaiu before they move to action unless the ketones are significantly higher.

IMO (not a medical professional) your numbers look fine (with the caveat that I assume you are taking some insulin whether basal or basal + bolus - for people on pumps it can be quite easy to not have any IoB with a diffusion set failure which is why there is a renewed concern I think).

You're low carb and you've been exercising. If you feel fine don't worry about it would be my (not-a-medical-professional) suggestion. I've posted some numbers that I've had here (post exercise, and I'm definitely not low carb): https://forum.diabetes.org.uk/boards/threads/normal-ketone-values.110801/

I should also add that before getting this meter, as I was interested in why everyone was so worried all the time and thought I should have some numbers of my own, I'd not tested in the previous 25-odd years.

 

[grantg]

I don't understand this advice at all.
How are you treaing hypos? I'm thinking along the lines of her going very high every time you treat a hypo, in that case they could have a bit of a point. But I'm not sure this is what is going on. If it is, it just tells you she usually needs a less agressive hypo treatment.
Do you verify hypos with a fingerprick, and check again after about 15 minutes? In my experience, sensors can be very slow to register a rise after a hypo so I rely on figerpricks.

What has she eaten and has she dosed insulin in the hours prior to those tests?
If she's not eating many carbs and doesn't have any symptoms associated with ketoacidosis, ketones are expected and not a problem.
Different story if she has symptoms of course.

zero insulin currently haven't had for umpteen weeks. yes verified low via fingerprick told not to treat unless other symthons unless very low dizzy/confused/shakey not to worry too much. eg earlier today cgm 2.9 straight down arrow fingerprick at 2.5 which treated 10g fast carbs + 6g slow. restested ~30 mins later BG 4.9. keytone test was done on second test same area with a wee squeeze to get more blood, 2.3 . extra 30odd minutes cgm 8. something.

 

[SimonP78]

Interesting that you're not taking insulin and yet have low blood glucose, at which point my comments on ketone levels are no longer standing on particularly firm ground. How long have you been diabetic out of interest - presumably your pancreas is still producing some insulin?

Are you able/willing to eat at least a few more carbs (to stave off the low blood glucose)?

 

[EllieM]

My understanding is that blood sugars can run lower on people on ketogenic diets

What Causes Hypoglycemia (Low Blood Sugar) Without Diabetes | NOVI Health

Low blood sugar (Hypoglycemia) can occur in people who are not diabetic. Learn about the symptoms, causes of Hypoglycemia, and when you should see a doctor.

novi-health.com

(Disclaimer, the above ref doesn't give any references for its claims).

@grantg have you had antibody and cpeptide tests to confirm LADA or was it just via DKA?

One reason I don't do a keto diet is that I don't want to have to worry about whether my ketones are normal dietary ketosis or the prelude to DKA, though on low carb I normally run very low levels (less than 1, usually less than 0.6)

 

[grantg]

Interesting that you're not taking insulin and yet have low blood glucose, at which point my comments on ketone levels are no longer standing on particularly firm ground. How long have you been diabetic out of interest - presumably your pancreas is still producing some insulin?

Are you able/willing to eat at least a few more carbs (to stave off the low blood glucose)?

no idea how long, diabetic symtons for years... which i ignored fear of needles, looking after family members etc ... not for want of trying and gp tried umpteen times to help bending over backwards.. january dka diagnosed type1 told insulin dependant. honeymoon phase currently (dsn & consultant have said). I asked the DSN at what levels should i be taking more carbs/glucose to possibly reduce ketones, her reply was as not taking insulin at present ... dont worry about lows and dont treat lows unless symptomatic alongside very low <2.5 was given as example , not to worry about ketones (even though showed glucose monitor ketone results) been back and forth now for several weeks asking. usually takes them a few days to reply recently dsn cancled in person appts swapping to telephone calls... dsn i think is getting peeved off. i hassled the dsn when sugars kept dropping whilst taking insulin was arguements every few days about lowering as was sick of eating so much, first few weeks after injecting was fine, glucose was inititally all over the place then stablised somewhat. slowly less and less insulin required dsn arguing each step of way whilst decreased. was more or less always chasing insulin with sugars from maybe the 7/8th week or so was having to eat 200g+ per day to prevent lows :O

hba1c at diagnosis was 162.

i haven't went low carb. less carbs than prior to diagnosis sure. still i think would be maybe a 'normal' amount carbs. breakfast usually between 26 and 30g. lunch between 26 and 35g. evening meal 28-40g when swimming or hike for couple of miles usually 10-15g more during.

total carbs for last few days: sat: 97g sun: 122g mon: 132g tues: 104g wed 113g

pancreas was not producing any insulin on diagnosis. its producing fine at the moment, depending on carbs consumed for a particular meal. over 45g stay relatively high for several hours.

 

[grantg]

My understanding is that blood sugars can run lower on people on ketogenic diets

What Causes Hypoglycemia (Low Blood Sugar) Without Diabetes | NOVI Health

Low blood sugar (Hypoglycemia) can occur in people who are not diabetic. Learn about the symptoms, causes of Hypoglycemia, and when you should see a doctor.

novi-health.com

(Disclaimer, the above ref doesn't give any references for its claims).

@grantg have you had antibody and cpeptide tests to confirm LADA or was it just via DKA?

One reason I don't do a keto diet is that I don't want to have to worry about whether my ketones are normal dietary ketosis or the prelude to DKA, though on low carb I normally run very low levels (less than 1, usually less than 0.6)

c-peptide test been done 3 occassions so far. (twice during stay in hospital) something to do with lipids preventing results as too high on the first one, second result no idea. last c-peptide test i haven't been told result other than am definately producing some insulin , its honeymoon phase which can last days/weeks/months or in some cases even years, that was a non fasted c-peptide test, the one directly prior was fasted. the only thing that tells them is that body is that currently producing insulin which they knew anyway from the cgm readings. i had expected to of seen the consultant for appt by now. hospital lost some of the other bloods that were done.. i put in a formal complaint, since then there has been issues with communicating with the dsn. have not had gad antibody test (or if i have they are not in hospital notes)

 

[grantg]

'As a general guide, you may consider taking 3-5g of carbohydrate per kilo of body weight per day. This is for those who exercise 3-4 times a week for 30-60 minutes per day. Roughly that’s about 180g-300g of carbohydrates per day for someone who is 60kg.'

Above quoted from @EllieM link.

Approx 1 hour 5 days a week swim (occasionally 30min need to leave pool) currently weigh 67kg . 67x3 = 201g carbs??

Still reading link.


Current thinking is maybe slightly larger breakfast before swim and possibly slice of toast or something before bed to see if that helps reducing ketones.

 

[EllieM]

'As a general guide, you may consider taking 3-5g of carbohydrate per kilo of body weight per day. This is for those who exercise 3-4 times a week for 30-60 minutes per day. Roughly that’s about 180g-300g of carbohydrates per day for someone who is 60kg.'

Sounds to me like a standard NHS recommended high carb diet. I don't think I've ever had that much even when I wasn't low carbing, though admittedly they are quoting it for athletes, though not massively energetic ones. Pretty sure there are keto athletes out there?

Maybe that wasn't the best link?

Having said all that, you aren't currently on a keto diet so I am slightly puzzled as to what is going on. I think you need a chat to an endocrinologist. (There are also other types of diabetes than T1/LADA and T2 though there's no particular reason to suppose you aren't LADA with a nice (hopefully long) honeymoon.) At least a consultant should be able to answer some of your questions. (I cynically suspect the DSN just doesn't know because they aren't standard questions?)

Current thinking is maybe slightly larger breakfast before swim and possibly slice of toast or something before bed to see if that helps reducing ketones.

Sounds like worth a try at least.

Good luck.

 

[grantg]

Sounds to me like a standard NHS recommended high carb diet. I don't think I've ever had that much even when I wasn't low carbing, though admittedly they are quoting it for athletes, though not massively energetic ones. Pretty sure there are keto athletes out there?

Maybe that wasn't the best link?

Having said all that, you aren't currently on a keto diet so I am slightly puzzled as to what is going on. I think you need a chat to an endocrinologist. (There are also other types of diabetes than T1/LADA and T2 though there's no particular reason to suppose you aren't LADA with a nice (hopefully long) honeymoon.) At least a consultant should be able to answer some of your questions. (I cynically suspect the DSN just doesn't know because they aren't standard questions?)

Sounds like worth a try at least.

Good luck.

link imo was fine. waking up several times a night to pee at least that will be passing ketones maybe fluid intake should be higher daytime and less towards bedtime (which already trying to do) brightside appears kidneys are working well otherwise wouldnt be peeing so much lol

going to try chase up endo appt, was promised one a couple of weeks after last blood tests were done... was also told would start on some more education so they had the right plan in action. still no appt. last hba1c they have 46 1/5/25. last c-peptide test 7th of july '25. where they managed to lose lipids. january trigylcerides were Very High 63.2 miles better 1st may 2.3 rest of lipid profile showed great improvement although still above ranges.

i chose the lower end nhs do indeed appear to recremmend a fairly high carb diet. i was interested in low carb ketones to see how that would compare to current ketone levels.

 

[SimonP78]

'As a general guide, you may consider taking 3-5g of carbohydrate per kilo of body weight per day. This is for those who exercise 3-4 times a week for 30-60 minutes per day. Roughly that’s about 180g-300g of carbohydrates per day for someone who is 60kg.'

Above quoted from @EllieM link.

Approx 1 hour 5 days a week swim (occasionally 30min need to leave pool) currently weigh 67kg . 67x3 = 201g carbs??

Still reading link.

Current thinking is maybe slightly larger breakfast before swim and possibly slice of toast or something before bed to see if that helps reducing ketones.

I don't think you need to chase a carbs target, eat what works for you and adjust (insulin if and when, eventually, needed) to match that. The level of ketones you have is because you're burning fat, I don't think the levels are anything to worry about however I would keep an eye on it as your pancreas will presumably eventually stop helping at which point you're at risk of DKA again (I wonder if taking a couple of units of background basal would stave that off somewhat and not require vast amounts of extra food intake?).

It would be interesting (for you to) to keep track of your weight, which is the ultimate measure of whether your intake is sufficient.

Sounds to me like a standard NHS recommended high carb diet. I don't think I've ever had that much even when I wasn't low carbing, though admittedly they are quoting it for athletes, though not massively energetic ones. Pretty sure there are keto athletes out there?

Maybe that wasn't the best link?

I used to eat more along those lines when I was younger, I don't eat so much any more - but I'm obviously older so my metabolism is somewhat slower (or is that a proverbial "old wives tale"?) - I certainly do less (though longer total duration in terms of riding a bike, but less generally rushing around going out/etc. which does have a massive effect on BG/carb burn).

For reference my typical daily carb intake is 260g, which is almost exactly 3g/kg of body weight. If I'm riding a lot (100s of kms) that might go up to 3.5g/kg, though I don't tend to do this for many days back to back, if I did, I'd probably end up eating more to avoid weight loss.

And likewise good luck, please keep us up to date

 

[grantg]

I don't think you need to chase a carbs target, eat what works for you and adjust (insulin if and when, eventually, needed) to match that. The level of ketones you have is because you're burning fat, I don't think the levels are anything to worry about however I would keep an eye on it as your pancreas will presumably eventually stop helping at which point you're at risk of DKA again (I wonder if taking a couple of units of background basal would stave that off somewhat and not require vast amounts of extra food intake?).

It would be interesting (for you to) to keep track of your weight, which is the ultimate measure of whether your intake is sufficient.


I used to eat more along those lines when I was younger, I don't eat so much any more - but I'm obviously older so my metabolism is somewhat slower (or is that a proverbial "old wives tale"?) - I certainly do less (though longer total duration in terms of riding a bike, but less generally rushing around going out/etc. which does have a massive effect on BG/carb burn).

For reference my typical daily carb intake is 260g, which is almost exactly 3g/kg of body weight. If I'm riding a lot (100s of kms) that might go up to 3.5g/kg, though I don't tend to do this for many days back to back, if I did, I'd probably end up eating more to avoid weight loss.

And likewise good luck, please keep us up to date

seems like sensible suggestion to record weight which i have been doing recently looks stablish (always same way recorded in morning after loo) appear slowly losing so presume not enough to maintain weight. will keep a closer eye on.

05/09/2025 67.3 Kg
28/08/2025 67.6 Kg
22/08/2025 67.8 Kg
07/08/2025 69.2 Kg
20/07/2025 70.4 Kg
24/06/2025 71.2 Kg
19/01/2025 88.3 Kg


risk of DKA: when was discharged from hospistal was told the majority of patients usually readmitted within 6months to a year with same issue.

from a small amount of limited research have done normally a few units could be given to help elongate honeymoon period. however can't find any data that verifies backing up said claims. will see how get on if manage to chase up endo appt, been waiting most of yesterday for a calls back.. Brightside i did make some progress with needlephobia assistance .. chased up mental health side for help with that. still bad at bloods getting done. dont always manage fingerprick either although much better at fingerpricks now than was initially (small wins eh)

 

[EllieM]

dont always manage fingerprick either although much better at fingerpricks now than was initially (small wins eh)

Small wins are worth celebrating. Are you using a cgm to minimise fingerpricks?

Unfortunately if you become insulin dependent you will need to get over that phobia a bit. Maybe a pump would be easier?

I know that you aren't the only one with a needle phobia and I'm pretty sure the NHS have programs to help such people?

If the issue is that they can't get any blood out of your arms I assume you've tried drinking lots and lots of liquid before the tests???

 

[grantg]

Small wins are worth celebrating. Are you using a cgm to minimise fingerpricks?

Unfortunately if you become insulin dependent you will need to get over that phobia a bit. Maybe a pump would be easier?

I know that you aren't the only one with a needle phobia and I'm pretty sure the NHS have programs to help such people?

If the issue is that they can't get any blood out of your arms I assume you've tried drinking lots and lots of liquid before the tests???

yes using cgm

takes a good while to do. slowly getting better at it. used to get someone to help... they got a scare when inserted and lots of blood once blaming themselves for doing it wrong. did try tell them its ok happens wasnt their fault dont want to put them in that position again. besides was intended as a short term stop gap after gp nurse didnt have time.

panic attack hyperventalate pass out heart rate is issue.. not allowed to take if passed out dont understand that as gave prior consent they try a few times then say cant try again. i fail to understand their logic why cant they just take when have consent whilst passed out? if someone in a car accident or something losing blood they'd take that persons blood to get crossmatch etc done...

local hospistal has refused to even try now. dr's surgery nurse refused takes too long. they do have another nurse that was more patient... shes on materinity leave. i liked that nurse gave up lunchbreak etc didnt feel rushed etc was so much easier and definately a lot less stressful than feeling rushed/in the way

i would agree that when or if need arises a pump maybe a better option. saying that another small win was that i never once missed (on purpose) injections. there was a couple of times when i thought i had injected but needle on the bd autosheild duo didnt look like changed dsn advised -- just run higher dont try to inject if your not 100% sure. that was before given info on correctional doses.

 

[grantg]

I know that you aren't the only one with a needle phobia and I'm pretty sure the NHS have programs to help such people?

there is mental health services... was refered the community mental services refused on grounds that should of went NEXT DOOR litterly the next room, within the SAME hospistal "primary care mental services". they stated the asked gp to re-refer to the correct part that was in feb. I chased up the appt yesterday.. dr's surgery swear they never got letter ... community mental health swear they sent dr an email and letter. progress has been made on that side of things, managed to get the primary care team to phone the dr's surgery, and the gp was going to email yesterday referal. was called back from the primary care mental health team saying they will discuss on wed and will receive an appointment for evaluation within a 'short time' whatever a short time happens to be. I've requested to be notified of the appt via txt message hospital on a few occassions forget to frank letters... and have ended up having to pay for collecting the letters at the local sorting office.

hospital physcologist prescibed temezapan alongside diazapan to try settle nerves. since out of hospistal diazapan only been given. 6mg doesnt appear to help too much.

 

[EllieM]

a pump maybe a better option. saying that another small win was that i never once missed (on purpose) injections.

That is a massive win IMO.

 

[grantg]

That is a massive win IMO.

I'd of called it a big win... If didn't take 30mins to an hour+ to do.

Thinking about things a little more it's prob why DSN argued each step of the way on reducing insulin marked in hospital notes big letters needing to keep on things and on umpteen pages of notes. Discharge letter also had marked clearly needlephobic. I think if hospital let me do own fingerpricks or use what they gave .e to take home would of found lots easier rather than. Having to rely on the safety lancets. Can't yet bring myself to use the pen with lancet at all. Nor could use other safety lancets that the hospital didn't use every few hours. Wasn't allowed during hospital to inject insulin myself either imo if they had allowed that even with supervision would of made returning home a lot easier