Hypos milder whilst on keto - is there any scientific evidence?

[kokhongw]

Came across this abstract today...
https://www.ncbi.nlm.nih.gov/pubmed/16454166

 

[bulkbiker]

@ratherbegliding

You may find the work of Paleomedecina interesting too

https://www.paleomedicina.com/en/pa...n_chronic_diseases_clinical_and_research_data

 

[kokhongw]

This is interesting but I notice it says "twenty two patients with type 1 diabetes with symptomatic fluctuating blood glucose started on a diet limited to 70 - 90g carbohydrates per day and were taught to match the insulin doses accordingly."
So, not only was this a very small sample of people, the results maybe as much due to being taught how to dose correctly as due to the lower carb intake.
My personal experience of being taught how to dose corrrectly significantly reduced the number of hypos I experienced without limiting my carb intake.

Perhaps it is just a matter of learning how to dose correctly...or it could be as Dr Bernstein suggested, smaller dose, smaller margin of error...But what is notable and interesting to the OP may be that the hypo events reduced almost 6 fold, from 6 times in 2 weeks to 1 time in 2 weeks...

After three and 12 months the rate of hypoglycaemia was significantly lowered from 2.9 +/- 2.0 to 0.2 +/- 0.3 and 0.5 +/- 0.5 episodes per week respectively

 

[tim2000s]

Now, to put this in perspective, I test 7 times a day and in the most recent month of readings data I supplied I had 5 readings of 3.5mmol/l or less. So that's about 1 a week. I feel they are missing the point that whilst these events are technically a hypo, the fact I am on a keto diet means that they are mild and easily treatable - nothing like what life used to be like before!

The issue is that a capillary glucose test of lower than 3.5mmol/l is typically representative of a lower arterial glucose level, which can mean cognitive dysfunction.

As the studies on people eating a keto diet have very small numbers, they aren't powered enough to drive any form or regulatory decision, and greater study would be required. While the papers shown here suggest ketones provide fuel to the brain in place of glucose (and my experience of ketogenic diet supports this view), they have to consider that your low glucose levels are too low.

 

[ratherbegliding]

@kokhongw , @bulkbiker - Thanks for the links to some very interesting reading.

Much appreciated!

So in view of the CAA's response, my new plan is to get in contact with the diabetes consultant I see annually and see if I can convince him to write a letter explaining the effects of being in ketosis on hypoglycemic reactions.

Interestingly, the medical review board consisted of just two CAA doctors - neither of which were endocrinologists or diabetes specialists. It's not much of a chink in their decision, but I've got to try - you miss 100% of the shots you don't take and all that.

That said, the senior practice nurse who deals with all CAA medicals at the GP's said she'd never heard of an appeal being successful.
:/
Will be back with an update in due course.

Thanks again,
RBG

 

[NicoleC1971]

@DCUKMod , @Rachox - thanks for the lead. I'm in New Zealand, so the rules aren't quite so enlightened here.

@bulkbiker - Yes, it was Dr Bernstein's book which got me started with keto. Awesome bit of literature which should be required reading for all newly diagnosed diabetics.

@Robbity - Yup, came across that one too.

@kokhongw - thanks for that, really interesting read! Will spend a bit more time with that blog. Although as he says, there doesn't seem to be a wealth of studies into the effects of a keto diet on T1's.....

So, the medical review panel have declined my application for a medical waiver. Their opinion, in it's entirety, reads as follows:

"The medical experts note the history of hypoglycaemia and recent glucose logbook readings. They consider the risk of hypoglycaemia to exceed that which is considered to be compatible with CAA NZ medical certification."

Now, to put this in perspective, I test 7 times a day and in the most recent month of readings data I supplied I had 5 readings of 3.5mmol/l or less. So that's about 1 a week. I feel they are missing the point that whilst these events are technically a hypo, the fact I am on a keto diet means that they are mild and easily treatable - nothing like what life used to be like before!

Hence I'm trying to find reliable/scientific evidence to support the above.

Apparently I have the right to appeal, but not sure if that's going to achieve anything without some sort of suitable material.

Thanks for the help so far everyone - keep 'em coming!

RBG

I do mainly low carb too and have asked the question of a diabetic consultant whether given the experience of being less sensitive to lower blood sugars when you have more numbers 'in range' via keto, what the research says about any dangers of having lower blood sugars than the higher average which is preferred for those treated with insulin. She said that increased incidence of blood sugars under 4 would produce reduced sensations of hypos and therefore be potentially dangerous. She would not or cold not answer the question about what level of blood glucose represents an absolute danger ( e.g. a recent thread here mentioned someone feeling symptoms of hypo when going under 20!).
I had heard of an experiment in which healthy men were put on a ketogenic diet and improved their tolerance of having lower blood sugars i.e. they went lower than normal but were completely asymptomatic and functional (will wrack my brains to remember the book in which this was mentioned - possibly Taubes The Case Against Sugsar....
It makes sense to me that if you are not taking high doses of insulin and are a 'fat burner' , you will have less roller coaster peaks and troughs. The law of small numbers as Dr Bernstein says.
In my experience clinicians have very little experience of how type 1 s react to ketogenic diets and less experience of type 1s achieving normal and stable blood sugars so will therefore assume that a low HBA1c = peaks and troughs rather than a steady line of low ish numbers!

 

[bulkbiker]

will wrack my brains to remember the book in which this was mentioned

See post 15 on this thread..

 

[ratherbegliding]

@NicoleC1971 , (1971? DoB by any chance? makes us the same age )

You hit the nail on the head. My appeal will live or die based on that very point - does a keto diet merely delay the symptoms (and hence the same risk of incapacitation exists) or does it actually reduce incapacitation levels altogether, and thus the risk that goes with it.

Everyone's different, and the sugar level at which one person suffers visible impairment can be quite different to another's.
I met one Doctor a few years ago who was also T1D and he told me he just runs his blood sugars high all the time - like between 15 and 20 mmol/l. He said he started 'going hypo' at around 6 mmol/l!

Which approach is better? Who knows. I think there is no one right solution that fits everybody (although this example was pretty extreme).

Just finished writing my letter to my consultant... let's see what he says.

RBG

 

[NicoleC1971]

See post 15 on this thread..

Found a Cahill paper summarising his life works

@NicoleC1971 , (1971? DoB by any chance? makes us the same age )

You hit the nail on the head. My appeal will live or die based on that very point - does a keto diet merely delay the symptoms (and hence the same risk of incapacitation exists) or does it actually reduce incapacitation levels altogether, and thus the risk that goes with it.

Everyone's different, and the sugar level at which one person suffers visible impairment can be quite different to another's.
I met one Doctor a few years ago who was also T1D and he told me he just runs his blood sugars high all the time - like between 15 and 20 mmol/l. He said he started 'going hypo' at around 6 mmol/l!

Which approach is better? Who knows. I think there is no one right solution that fits everybody (although this example was pretty extreme).

Btw I think this is the George Cahill study to which BikeBulker referred and I recalled -
file:///C:/Users/Nicole.Walker/Downloads/Fuel-Metabolism-in-Starvation_ReviewArticleTIMM2008-9Lazar-1.pdf
which discusses the brain function on keto:
How does the brain function using mainly β-hydroxybutyrate and acetoacetate? Intellect-wise it is indistinguishable from glucose. Many studies have shown reversal of hypoglycemic signs and symptoms by ketone bodies. However, some changes do occur. Gonadotrophins decrease, but these also decrease in other caloric deficits without elevated ketone levels, as in patients with anorexia nervosa who eat some 100 grams or less of carbohydrate daily (23). Yet, there are metabolic alterations, as is well known in the world of epilepsy. As popularized by the Hopkins group of John Freeman and Ellen Vining and associates (22, 26), about one third of the children with multidrug-resistant epilepsy improve dramatically on a strict ketogenic diet, another one third improve to some extent, and the remainder experience little or no effect. The problem is that the diet has poor palatability, and patients may experience gastrointestinal problems as well as a degree of osteoporosis, delayed growth, delayed puberty, and some changes in potentially atherogenic blood lipids, although this last point is not accepted by all. Adherence to the diet is clinically difficult (61).

So as others have pointed out research evidence is limited to small numbers and you may have to be a pioneer in your field.
I'd rather have a ketogenic pilot than a high carb one personally!

 

[Fndwheelie]

Now, to put this in perspective, I test 7 times a day and in the most recent month of readings data I supplied I had 5 readings of 3.5mmol/l or less. So that's about 1 a week. I feel they are missing the point that whilst these events are technically a hypo, the fact I am on a keto diet means that they are mild and easily treatable - nothing like what life used to be like before!

I maybe sticking my nose in where it doesn’t belong here, but surely the blood sugar numbers should be less important than the number of times you required outside assistance in treating a hypo due to (confusion or unconsciousness) being unaware of the hypo yourself. If your able to function safely at 3.5 and act accordingly treat hypo and continue with what you were doing, that should be what counts.

 

[ratherbegliding]

@Fndwheelie - I know right?
The last time I needed any sort of assistance was a decade ago.....
Unfortunately the standards were drawn up in the 60's when treatments of diabetes and their success rate at avoiding serious hypoglycaemic events weren't what they are today.
I woke up this morning at 3.0 mmol/l - no drama, had breakfast and a smaller dose if insulin than normal, was at 7.5 mmol/l two hours later. Perfectly fine, no issues.
They just don't see that.
Very frustrating.
RBG

 

[ert]

Hi everyone,

I've been a T1D for 30 years now but only discovered the joys of a keto diet 3 years ago.
Many thanks,

RBG

DAFNE doesn't agree with keto diets because of the increased levels of ketones you will run as a type 1. It's the risk is DKA, which is life-threatening.
If you constantly blood sugars above 13 mmol/l, or if you are ill with normal blood sugars or higher blood sugars, check for blood ketones. With high blood sugars, if blood ketones are between 1.5 - 3 mmol/l then you should take 10% of your daily insulin every 2 hours with non-carb liquids. If your blood ketones are above 3 mmol/l then take 20% of your daily insulin every 2 hours with non-carb liquids and contact your diabetes team.

 

[Jaylee]

DAFNE doesn't agree with keto diets because of the increased levels of ketones you will run as a type 1. It's the risk is DKA, which is life-threatening.
If you constantly blood sugars above 13 mmol/l, or if you are ill with normal blood sugars or higher blood sugars, check for blood ketones. With high blood sugars, if blood ketones are between 1.5 - 3 mmol/l then you should take 10% of your daily insulin every 2 hours with non-carb liquids. If your blood ketones are above 3 mmol/l then take 20% of your daily insulin every 2 hours with non-carb liquids and contact your diabetes team.

Hi,

From my understanding, a Keto diet will produce keytones ("nutritional Ketosis.") even when BGs are stable. (This includes non Ds.)
However that is not the same as Ketoacidosis, which is ketones produced from dangerously prolonged high BGs associated with uncontrolled diabetes.

No correction with insulin would be needed if the BGs are actually in normal range, regardless of the dietary choice to manage it & thus any presence of keytones as a result..?

 

[ert]

Hi,

From my understanding, a Keto diet will produce keytones ("nutritional Ketosis.") even when BGs are stable. (This includes non Ds.)
However that is not the same as Ketoacidosis, which is ketones produced from dangerously prolonged high BGs associated with uncontrolled diabetes.

No correction with insulin would be needed if the BGs are actually in normal range, regardless of the dietary choice to manage it & thus any presence of keytones as a result..?

A normal person on keto will run their ketones between 1.5 and 3 mmol/L quite happily. But they have a homeostasis mechanism which type 1's do not. That's why they advise for type 1's not to run their ketones this high. It's very easy for your ketones to keep building past 3 mmol/L and your blood PH to change, which is the beginning of DKA. This is why all consultants here are against type 1's being on keto.

As I said, no correction of ketones is required unless your blood sugars are constantly over 13 mmol/L. The exception is if you are ill. You can go into DKA with normal blood sugars if you are unwell. My DAFNE nurse has had cases of this.

The main issue is the dosing is different for Keto to dosing for carb counting. I follow Bernstein and his insulin calculations are higher than Dafne for keto meals to keep the ketone levels down. For example, my lunch yesterday, Bernstein calculation was 5 units of fast-acting insulin but the DAFNE calculation was just 1 unit. If I took the one unit, then my ketones build up. If I follow Bernstein's calculation then my ketones are trace. So the warning is, don't simply follow carb counting if you are on keto. Bernstein counts 50% of protein and all carbs (Dafne has carbs you don't count, for example from vegetables and legumes.)

 

[ScottyD]

I can only speak regarding the UK CAA. Canada, Austria and Ireland are the other countries that allow pilots who are insulin dependant to fly commercially. The FAA in the US has been recommended to uptake a protocol for insulin dependant pilots but I’m not sure if that’s official yet. On the recreational front, many other countries do allow it. It’s not an area I’m up to speed with sadly. I do think NZ is for pilots with diabetes who are not on insulin. I made contact with an ex Qantas pilot who lost his career due to being diagnosed with T1D. He retrained as a doctor and now flies solo to remote destinations in Australia to provide a medical service to remote areas. He is trying very hard to get the Australian CAA onboard.

I’m have 6 monthly meetings with the UK CAA. This includes bloods to the same requirements that the NHS have. Retinopathy checked once a year. The only difference being a stress ECG every 5 years. I believe this is a requirement for HGV drivers too.
On the hypo front, I’ve had a number. None whilst flying. So long as I’ve felt it, corrected it, retested and back in range, all is well. For each value out of range, the CAA goes over the and documents what I did to correct to ensure the protocol is working. The UK CAA looking to implement CGM very shortly in association with Dexcom.

Sorry I can’t be on much help. I hope I’ve given you at least a little insight into what’s expected.

 

[ratherbegliding]

Hi everyone and apologies for the delay in coming back.

@ert @Jaylee - I use the Dr Bernstein method. My BG gets above 13mmol/l about once a month!
Generally really stable, between 4 and 10. Hardest part is coping with changes post exercise (I run 2-3 times a week for about 40 minutes a time).
My meter also does keytones and I check those very irregularly because they seem very stable....I'm always <1.

@ScottyD - Hello! Here in NZ we have what is known as a Recreational Pilot's Licence which I believe is similar to the old NPPL in the UK. So I can still fly but it's the restrictions that are annoying (and somewhat arbitrary) eg no aerobatics, no night flying, no flying over built up areas except for the purposes of taking off and landing etc...
I appreciate I'll never get a Class 1 and fly commercial, but in my view the restrictions which come with an RPL are designed for people with high blood pressure or previous heart conditions, of which I'm neither!

I occasionally (once or twice a week) get a reading <3.5mmol/l (and never whilst flying, driving or riding my motorcycle) but since I've gone keto it's really not a drama - I feel a bit tired and hungry, I test, I eat a piece of chocolate and I'm all good.

Going keto is the key here. Prior to going keto I didn't have this degree of stability.

I'm told there is a precedent of diabetics who are NOT insulin dependent being granted Class 2's over here.

Update on progress - I'm going to appeal the decision. I've been in email contact with my consultant and he's willing to help put together a detailed response to directly address the only concern raised - my 'risk' of hypoclycaemia.
The reality is though I'm told these decisions are rarely over-turned on appeal.....

 

[bulkbiker]

Update on progress - I'm going to appeal the decision. I've been in email contact with my consultant and he's willing to help put together a detailed response to directly address the only concern raised - my 'risk' of hypoclycaemia.

Best of luck with the appeal... what bike do you ride?

 

[ratherbegliding]

2008 Ducati Monster