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.