Ketones, potential illness and low carb diet

[Damian1991]

Hi all,

I started a low carb diet at the end of December to help improve my blood sugar control. I eat around 30g of carbs a day now and it really has helped me get my numbers under very good control.

I have a 1 year old son who goes to nursery and brings all sorts of illnesses home nearly every week it seems. I sometimes catch 1 or 2 of these illnesses which can impact my sugars but havent done so too dramatically so far. The latest one is a viral infection, cough and snotty etc, no vomiting or diarrhea. Although I am not outwardly showing any of these symptoms, I do feel a bit run down and a bit dehydrated (which i'm combating with plenty of water and some electrolyte effervescent tablets). I decided to check my ketones today just in case and they were 0.9, 1.1 & 1.0 at different points of the day. My BG's have been consistently between 4 and 7mmol for the past week at all times of the day with 0 spikes or anomalies, this is on a libre2 and backed up with many finger prick tests during the day.

My questions are, how much can i attribute those ketone numbers to perhaps nutritional ketosis from the low carb diet and how much to a potential illness (and should I be concerned about this with the threat of DKA)?

What do other low carbers do in this situation? At what point would you consider seeking medical help?

The daft thing is, in the past when my control hasn't been as good, I have had plenty of high BG numbers and not once thought to check ketones. But now I'm hyper focused on my control, I felt the need to check my ketones even though my sugars are perfect (for me). I think part of this is reading too much about euglycemic DKA.

Any thoughts and experiences appreciated

Thanks,
Damian

 

[Antje77]

With 30 grams of carbs a day, you're supposed to see ketones, you're following a keto diet.

One of the downsides of being in ketosis is that checking ketones doesn't tell you anything about ketoacidosis (unless you're measuring very high ketones perhaps).

Do you have a history of DKA?

From what I understand (I've never had DKA and never checked for ketones for that matter), DKA usually has some pretty noticable symptoms.
The problem arises if you catch a bug, which may give you similar symptoms, and it's hard to differentiate between an innocent bug with unpleasant symptoms, and DKA symptoms.

With ketones only at around 1, and symptoms only being feeling a bit run down and snotty, I wouldn't worry about DKA if it were myself.

I may or may not be eating low carb enough to hit ketosis sometimes, I have no idea. But I wouldn't think of DKA in the absence of typical DKA symptoms.

 

[Antje77]

I think part of this is reading too much about euglycemic DKA.

I just noticed a thread you posted about a year ago, and also the one on Lantus lows and switching to Tresiba you posted today.

Last year you were struggling with health anxiety, how have you been doing with those fears during the past year?
Can it be that this anxiety is rearing it's ugly head again, perhaps thanks to the Lantus Lows you've experienced? It's also very common to develop anxieties upon becoming a parent, which makes perfect sense if you're suddenly the one who has to protect such a vulnerable new person!

Reading too much and getting lost in the Google rabbit hole can be a real risk to mental health, especially if you have a tendency for health anxiety in the first place.

My questions are, how much can i attribute those ketone numbers to perhaps nutritional ketosis from the low carb diet and how much to a potential illness (and should I be concerned about this with the threat of DKA)?

What do other low carbers do in this situation? At what point would you consider seeking medical help?

With ketones at around 1, while on a keto diet, and no symptoms except those expected with the common cold, I wouldn't be worried at all.

 

[EllieM]

I've been T1 for 54 years and never had a DKA, but when my consultant insisted on giving me a glucose monitor that also checks for ketones, my understanding was that ketones are only an issue if you have a raised blood sugar. (Provided you're not on a flozin, where DKA can potentially occur at normal blood sugars).

Diabetic ketoacidosis

Find out about diabetic ketoacidosis (DKA), including what the symptoms are, when to get medical help and how to prevent it.

www.nhs.uk

If you have diabetes and have any of the symptoms of DKA, check your blood glucose. If it's high, test for ketones if you can.

 

[becca59]

Having had experience of high ketones when very ill last year, the medical profession only worry at 4 and above. As soon as mine dipped below they were unconcerned.

 

[Juicyj]

From dieting alone I would not be worried about this at all and neither should you, I would also only check for ketones if your levels are running higher than 11 mmol/l and you are clearly displaying ketone symptoms. The following info from NICE is a useful guide:

• Suspect diabetic ketoacidosis (DKA) in a person with known diabetes or significant hyperglycaemia (finger-prick blood glucose level greater than 11 mmol/L) and the following clinical features:
  • Increased thirst and urinary frequency.
  • Weight loss.
  • Inability to tolerate fluids.
  • Persistent vomiting and/or diarrhoea.
  • Abdominal pain.
  • Visual disturbance.
  • Lethargy and/or confusion.
  • Fruity smell of acetone on the breath.
  • Acidotic breathing — deep sighing (Kussmaul) respiration.
  • Dehydration, which can be classified as:
    • Mild — only just clinically detectable.
    • Moderate — dry skin and mucus membranes, and reduced skin turgor.
    • Severe — sunken eyes and prolonged capillary refill time.
  • Shock (resulting from severe dehydration). The person is severely ill with:
    • Tachycardia, poor peripheral perfusion, and (as a late sign) hypotension (indicating decreased cardiac output).
    • Lethargy, drowsiness, or decreased level of consciousness (indicating decreased cerebral perfusion).
    • Reduced urine output (indicating decreased renal perfusion).
• If DKA is suspected:
  • Assess for precipitating factors of DKA, such as:
    • Infection (for example pneumonia or a urinary tract infection).
    • Physiological stress (such as trauma or surgery).
    • Non-adherence to insulin treatment regimen or intentional insulin omission in order to lose weight (diabulimia).
    • Other medical conditions (such as hypothyroidism or pancreatitis).
    • Drug treatment (such as corticosteroids, diuretics, and sympathomimetic drugs [for example salbutamol]).
  • Test for ketones(produced by the liver when there is a lack of glucose [starvation ketones] and as an alternative energy source when there is a relative insulin deficiency).
    • In an adult with suspected DKA, test for urine or blood ketones even if plasma glucose levels are near normal.
    • In a child or young person with suspected DKA, test for blood ketones. If this is not possible, arrange immediate admission to a hospital with acute paediatric facilities.
    • Ketones are high if above 2+ in the urine or above 3 mmol/L in the blood.
• Consider the possibility of DKA in all people with type 1 diabetes who are unwell, bearing in mind that:
  • Hyperglycaemia may not always be present — children and young people on insulin therapy may develop DKA with normal blood glucose levels.
  • Low blood ketone levels (less than 3 mmol/L) do not always exclude DKA.

 

[KennyA]

I check maybe once or twice a week with a wee stick, just to make sure I'm still in ketosis. I'm on around 20-25g a day, sometimes less, and usually see something in the 1.5 - 4 range, hard to tell exactly with the sticks.

I have no worries about DKA - I was going to post the info JuicyJ posted above. As far as I'm concerned, ketosis and diabetic ketoacidosis are separate issues. Unfortunately there is often confusion on the internet and occasionally from clinical people who really should know better.

 

[Damian1991]

Hi all,

Thank you for all your replies

Antje77 - I don't have a history of DKA thankfully. The anxiety seems to always be there but changes to whatever the flavour of the week is and yes the Lantus low certainly didnt help with this. Since I started to really take control of my diabetes in December I felt it necessary to get as much information as possible on how to do this successfully which meant alot of reading and research around the low carb diet, Dr Bernstein etc. It really felt like I was starting the diabetes journey all over again after 10 years. It's proven very successful so far in terms of day to day numbers and control which sounds great but it's come at a price mentally. The price being a hyper obsession over my control, numbers and diet and the potential complications that can occur if I stray (even though largely I was able to push this to the back of my mind for 10 years). I keep telling myself that if i put the work in now, and my habits/new lifestyle stick, then the obsession will hopefully subside but the good habits will remain. I think the difference now is i have an incredibly strong motivation for this to stick for my 1 year old son and our future together. Day to day though currently, the obsession is a real problem for me as it fuels the health anxiety and seems to be a vicious cycle.

EllieM - Yes my understanding was ketones are largely only an issue with high sugars, unless under certain exceptional circumstances. The problem is the **** anxiety and hyper focus makes you think you are a part of this special 0.001% group that experience this Euglycemic DKA (I made that number up for dramatic effect i don't know what it actually is). I think it's a mindset change needed more than anything. Hearing people's thoughts and actual experiences on here helps alot.

becca59 - That's interesting to hear about 4 figure something to keep an eye on during sick times. Could this get blurred if on the low carb diet with ketones already in the blood due to nutritional ketosis during sick times do you think?

Juicyj - Thank you for sharing that information, I will keep the 11mmol figure in mind and think i will leave the ketone checking unless there is clear and obvious signs

KennyA - It does make logical sense to show ketones when on a 'keto' diet, i think because the diet is brand new to me (3 months nearly) the idea of any type of ketones is a scary thought (i find my mindset needs time to adapt with these things), especially when it is backed up by diabetes nurses in my area saying you shouldn't have more than 0.6mmol and that they have had people in DKA with just 10mmol glucose levels (I'm not sure if she was just trying to scare me at this point). They of course dismissed the idea about nutritional ketosis and the low carb diet altogether after telling them what I was doing and the results I was getting which was baffling.

Thanks again for all your replies, i would much prefer to build my knowledge base from people who have actually gone through this and live with this day to day, I also believe that is why Dr Bernstein is so revered.

 

[Juicyj]

Hi @Damian1991 I understand your anxiety but in all 13 years I have been diagnosed I haven't tested myself for ketones once, I think as I am acutely aware of DKA symptoms it would be easier for me to know that if any of the symptoms were present coupled with high BG levels and potentially an absence of any insulin on board that these key markers would tell me to visit A&E quickly, I use an insulin pump and if this fails these symptoms can present themselves very quickly (within 24 hours I believe) so have been trained how to respond with and pump failure and to recognise DKA if it presents itself. Simply telling you as a t1d to watch out for ketones is mis-leading and scare mongering.

 

[Antje77]

I think the main thing to take away from your original question and the replies is this:

The problem is the **** anxiety and hyper focus makes you think you are a part of this special 0.001% group that experience this Euglycemic DKA (I made that number up for dramatic effect i don't know what it actually is). I think it's a mindset change needed more than anything. Hearing people's thoughts and actual experiences on here helps alot.

If your anxiety starts running away with you again on whatever the day's flavour is, come back to the forum for another reality check, just like you did with this thread.

Are you working with a professional to help with your anxiety? It can be very helpful.
As for the hyperfocus on your diabetes, yes it makes for great numbers, but it also affects your quality of life. I hope that with time, you can find a balance where your diabetes is doing well enough without you feeling it has to be perfect all the time. Running full speed towards diabetic burnout doesn't help you.
If you're seeing someone about the anxiety, this could also be the person to talk through what you can do to manage your diabetes in a long time more workable way.
Many diabetes teams have a psychologist available, you might want to see if your team can help before you crash.

 

[Jordi77]

As I have just come out of hospital for a DKA the number that you have to look for is 1.5 and higher as the higher it is that is not good for you and your going to end up in hospital for a couple of days and I spent 7 days in hospital this time because my ketones were 6.5 and I was on 3 drips for a day and that is to get the ketones out of you and for you to feel better and this time I was in to have every test you can think of and a CT scan and MRI scan as well as a x-ray and that's just to check that the ketones didn't distroy anything inside of me and to check that my organ's were still okay and I am lucky because I caught them in time but I know what to look out for but most don't and as I get the ketones I don't get the symptoms of drinking loads of water or peeing loads I feel normal just my senses feel off slightly and my blood pressure goes down lots and I get dizzy because of it but not all the symptoms are like that

 

[Deleted member 99312]

Hi all,

I started a low carb diet at the end of December to help improve my blood sugar control. I eat around 30g of carbs a day now and it really has helped me get my numbers under very good control.

I have a 1 year old son who goes to nursery and brings all sorts of illnesses home nearly every week it seems. I sometimes catch 1 or 2 of these illnesses which can impact my sugars but havent done so too dramatically so far. The latest one is a viral infection, cough and snotty etc, no vomiting or diarrhea. Although I am not outwardly showing any of these symptoms, I do feel a bit run down and a bit dehydrated (which i'm combating with plenty of water and some electrolyte effervescent tablets). I decided to check my ketones today just in case and they were 0.9, 1.1 & 1.0 at different points of the day. My BG's have been consistently between 4 and 7mmol for the past week at all times of the day with 0 spikes or anomalies, this is on a libre2 and backed up with many finger prick tests during the day.

My questions are, how much can i attribute those ketone numbers to perhaps nutritional ketosis from the low carb diet and how much to a potential illness (and should I be concerned about this with the threat of DKA)?

What do other low carbers do in this situation? At what point would you consider seeking medical help?

The daft thing is, in the past when my control hasn't been as good, I have had plenty of high BG numbers and not once thought to check ketones. But now I'm hyper focused on my control, I felt the need to check my ketones even though my sugars are perfect (for me). I think part of this is reading too much about euglycemic DKA.

Any thoughts and experiences appreciated

Thanks,
Damian

Those ketone numbers are acceptable, and expected from eating low carb. 3.0 is where it becomes a medical emergency for T1 diabetics - make sure you have enough carbs throughout the day that you can take enough insulin to never get anywhere near that. Personally I would say 30g is a little low, you would give yourself a better safety margin by increasing to 40g or 50g which would reduce the chance of DKA significantly. Remember it only has to happen once and it could be your last time.

 

[Deleted member 99312]

I've been T1 for 54 years and never had a DKA, but when my consultant insisted on giving me a glucose monitor that also checks for ketones, my understanding was that ketones are only an issue if you have a raised blood sugar. (Provided you're not on a flozin, where DKA can potentially occur at normal blood sugars).

Diabetic ketoacidosis

Find out about diabetic ketoacidosis (DKA), including what the symptoms are, when to get medical help and how to prevent it.

www.nhs.uk

If you have diabetes and have any of the symptoms of DKA, check your blood glucose. If it's high, test for ketones if you can.

The NHS is wrong, unsurprisingly. DKA can and does occur in people with perfect blood sugar control, who aren't taking enough insulin.

Think about it, if DKA never occurred with normal blood sugar, why would we need to test our ketones? It would be redundant, because we would simply be able to look at our blood sugar, see it is normal, and conclude our ketones MUST be in a safe place also. Unfortunately this isn't the case.

The very first thing the NHS should tell us when we are diagnosed as type 1 is about DKA, what it is, what causes it and how to avoid or treat it. In my case I wasn't told anything at all and only learned about it from the internet. It is very common for GPs and even diabetes consultants and diabetes nurses not to know much about DKA, or to give incorrect advice. It is commonly believed that DKA is only an issue if you have very high blood sugar. But the high blood sugar is simply a side effect which sometimes occurs. The reason for DKA is there isn't enough insulin in your system to keep the ketones to a safe level.

Non-diabetics can eat low carb or even fast entirely for days, without any risk of ketoacidosis, because their pancreases work perfectly and will continue to produce insulin to control ketones. We do not have that luxury, so we must always be taking insulin even if we are eating very low carb. But we can't take much insulin if we eat very low carb, right? Because it would make our blood sugar go too low and we would be at risk of hypo. And so this is precisely why we need to make sure we eat enough carbs that this is not a danger or at least a very low one.

Not only do we need to make sure we keep taking our basal insulin even on very low carb, we also need to eat enough carbs during the day so we can keep taking some level of rapid insulin. The fewer carbs we eat, the less insulin we need to control our blood sugar, but this then increases the risk of there being insufficient insulin in our system to control ketones.

https://www.reddit.com/r/diabetes/comments/urtxpp
https://www.reddit.com/r/diabetes_t1/comments/17fogow/_/k6b6hml
https://www.reddit.com/r/Type1Diabetes/comments/10hhhqd/_/j58nwqy

 

[Antje77]

Those ketone numbers are acceptable, and expected from eating low carb. 3.0 is where it becomes a medical emergency for T1 diabetics - make sure you have enough carbs throughout the day that you can take enough insulin to never get anywhere near that. Personally I would say 30g is a little low, you would give yourself a better safety margin by increasing to 40g or 50g which would reduce the chance of DKA significantly. Remember it only has to happen once and it could be your last time.

Ketones aren't the problem in DKA, it's the acidosis. Those ketones are simply a byproduct which is easy to measure, and therefore used by T1's to rule out DKA or rule in the possibility of DKA. Having ketones without the acidosis is not DKA, it's simply ketosis, the thing anyone on a keto diet is looking for, hence the name.

There are many T1's using a keto diet to help manage their diabetes.
The main downside I see is that ketone testing won't tell you if you're at risk of DKA or not when you're in ketosis.

 

[Deleted member 99312]

I eat lowish carb also and have ketones above normal, I am aware that elevated ketones does not equal DKA and I don't think I implied it did. But people should keep them far away from 3.0 if they want to avoid DKA, which is not to be taken lightly I think we can all agree?

It can come on rapidly with little or no warning, and can kill. Serious warnings are warranted imo.

I would say that this is for people who exercise good control and are dedicated to keeping a good grip of their condition. People who are a bit more lax should be wary of playing with fire. That's my 2p, people can do with it as they wish. I will guess that every person who ends up in hospital with DKA did not expect it to happen to them.

 

[Melgar]

Just to add a different flavour to this thread, as I had an issue with ketones a few weeks back. I went on here and I yelled 'I have ketones in my pee, what's going?' after doing a pee dip test, while looking at my Leukoytes level (I had a mild UTI). @Antje77 put my mind at rest as I was not on any SGLT-2 inhibitors such as anything ending in Flozin, neither did my pee have any glucose traces. See I do listen! Like the eye of sauron my eyes now go straight to the ketones bit of the stick.

Firstly, I stopped the keto diet months back, as it wasn't working to bring my BS down and I didn't want to lose anymore weight. I test my urine at least twice a week. I can tell you I still have ketones in my pee every time I test. They very between 0.5 mmol/ls (trace) to 1.5 (small) mmol/ls. I did mention the pee ketones to my Dr who straight away asked if I had any glucose in my pee. When I said no , he said nothing to worry about. And that was that. No further discussion.

There are two things of note
a) I do a lot of cardio type exercises both aerobic and anaerobic. These types of exercise induce fat burn when you have exhausted all your glucose and thus ketones are produced.
and
b) I personally do not produce enough insulin.

It seems small amounts of ketones in your pee is nothing to worry about, even if you are not in nutritional ketosis, as already mentioned above. I just thought I would add my experience.

 

[SimonP78]

I eat lowish carb also and have ketones above normal, I am aware that elevated ketones does not equal DKA and I don't think I implied it did. But people should keep them far away from 3.0 if they want to avoid DKA, which is not to be taken lightly I think we can all agree?

I don't eat a low carb diet, so wouldn't expect to have higher than usual ketones, however, 4h after my last long ride I had ketones of 2.3 mmol/l and was none the worse for wear (aside from the ride that is.) A day later I was 0.4 mmol/l. I've no idea what I am normally, I should probably check as a baseline.