Low carb diet, ketone query

My understanding is that high ketones AND high blood sugars are dangerous as they are a strong symptom of DKA.
Unfortunately, the blood sugar level that indicates DKA differs from person to person. Hence, the focus on the ketone level.

Howell_595 said:

Hi everyone

My name's David and I type one diabetic and have been for 20 plus years. I'm on Nova rapid and levemir insulin and use a freestyle Libra 2 cgm.
I've wanted to lose weight so I decided to start a low carb diet or keto. I lost 10lb in water weight Which I was so pleased with but recently I've been checking my ketones after speaking to my diabetic nurse to advise that She didn't like the idea of keto but I stuck to it a little.

I think I'm in ketosis As I've had the symptoms of it but I've recently been really concerned about my ketones. My diabetic nurse said anything above 0.6 is raised ketones and I should monitor them. I've read things on the internet And it mentions anything above 1.5 and I should contact my doctors.
I had ketones of 1.3 yesterday but the thing is my sugar levels from being on a low-carb diet have been 4 mmol or less so not high sugars.
I'm worried about ketoacidosis but am I right in understanding it only occurs with high sugar levels?

Sorry for the long post Just need some advice

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Hi,

Safety first.. Ketones. Double check using your meter to corroborate what your Libre 2 is telling you on the BG levels.
If it does? Then it mearely suggests you are in "nutritional Ketosis" & not DKA.

Here is what the NHS say about the DKA.. https://www.nhs.uk/conditions/diabetic-ketoacidosis/

Nutritional ketosis starts at about 0.5mmol/l. I switched to a very low carb diet before I started having to use insulin. I have had ketones in the 3 to 5 mmol/l range regularly - these are high enough to be worrying if I were on a high carbohydrate diet but are not on a very low carbohydrate diet.

The ketone levels have been with blood glucose in the 4 to 5mmol/l range (certainly less than 7mmol/l), I would be concerned if the high ketones are in combination with high blood glucose. I would also be concerned with ketones approaching 8 to 10mmol/l irrespective of blood glucose levels.

I think the highest ketone reading while being on insulin has been 6.2mmol/l (corresponding blood glucose was 4.9mmol/l). I think the highest ketones reading about 7 months before I started using insulin was 3.7mmol/l (with a corresponding blood glucose reading 3.8mmol/l - no diabetic medication at the time).

It's probably worth watching this if you have not done already.

Ed: I'd respond to the symptoms irrespective of the ketone meter readings

Have you found typeone grit on Facebook. They are also type 1 doing keto and could have some great resources for you. Dr Bernstein is a type 1 himself treating others with keto and can be found widely on the internet. He may have something to say on ketone levels if you search.

Howell_595 said:

That's interesting as my partner has smelt a sweet smell on my breath when I've been talking to her. When I first lost all the water weight on keto I did have muscle ache just like I had 'keto flu'
I'm just getting concerned as I've read if your ketones are above 1.5 you should seek medical attention. I know keto can be different for everyone But I just don't want to be doing something that may harm me while dieting.

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What are your BG levels doing in all this? Not just with the Libre. But the meter too?

I also low carb and I’ve seen my ketone level range from anything up to 3.5. I no longer test for ketones as I don’t have the test strips on my repeat proscription list and I’m not worried. I just try to keep close monitoring of my bs level and keep fit in general. Ketosis and ketoacidosis are different.

Howell_595 said:

Since I've been on keto/low carb, my blood glucose levels have been fairly low anywhere from 4.5 to 2.8.

I understand nutritional ketosis is probably 1 to 1.5 ketones but then I start getting concerned like I say because my diabetic nurse said that is a concerning level for a type 1.

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To be frank. If I was hovering around the "2.8" level for too long. I'd be concerned about losing basic hypo awareness?

Howell_595 said:

Since I've been on keto/low carb, my blood glucose levels have been fairly low anywhere from 4.5 to 2.8.

I understand nutritional ketosis is probably 1 to 1.5 ketones but then I start getting concerned like I say because my diabetic nurse said that is a concerning level for a type 1.

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According to the famous Phinney and Volek graph ketoacidosis starts at ketone levels well over 5 mmol/l


With your low blood sugar levels and assuming you are just taking insulin you should be fine.

Howell_595 said:

Since I've been on keto/low carb, my blood glucose levels have been fairly low anywhere from 4.5 to 2.8.

I understand nutritional ketosis is probably 1 to 1.5 ketones but then I start getting concerned like I say because my diabetic nurse said that is a concerning level for a type 1.

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2.8mmol/l blood glucose could be a problem. You are probably not getting any hypo symptoms because ketones are high enough at the time. Most of your body can run on fatty acids and ketones but there are parts which still require glucose ... I'd probably target 4mmol/l as a low and be doing something to raise blood glucose if it drops to 3.5mmol/l.

I did have a number of 3.6mmol/l glucose readings before I started taking insulin ... but they may have been after a couple of days fasting

Howell_595 said:

the impression dka only happened with higher blood sugars not low

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That is indeed exactly how I understand it too unless you are taking SGLT-2 inhibitors (mainly a T2 medication) which can also lead to DKA.

Howell_595 said:

Since I've been on keto/low carb, my blood glucose levels have been fairly low anywhere from 4.5 to 2.8.

I understand nutritional ketosis is probably 1 to 1.5 ketones but then I start getting concerned like I say because my diabetic nurse said that is a concerning level for a type 1.

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your BS level of 2.8 to 4.5 mmol/l is too low? and not having hypo awareness is a problem. Can you adjust your insulin to be not go below 4? Is this 2.8 to 4.5 range based on actual finger pricked readings ? Libre always gives me lower reading than actual finger pricked readings quite often about 2.0 lower.

Howell_595 said:

That's an interesting chart thank you for posting it. I am taking a basal insulin which is levemir once in the morning and once at night and my nova rapid is carb controlled so one unit per 10 grams of carbs. At the moment though the food I eat is usually bang on or under 10 g It's not really taking little to any Nova rapid.
I assume the levemir would still do its job though.
I'm just a little confused with the ketone results I'm getting and what the diabetic nurse said. I was always under the impression dka only happened with higher blood sugars not low.

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Also worth having a conversation with the nurse about her knowledge of nutritional ketosis as a result of low carb v ketoacidosis and the differences between them. She may or may not be aware of them!

Howell_595 said:

That's the thing when doing a low carb/keto diet I found that if I get low sugars I don't get the usual hypo warning, You know trembling agitation hunger. I just seen in control and feel normal which in a way is good but in another way I don't want to lose like you say that hypo awareness.

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Hi David,
I'm a low carber myself. But would not be happy cruising at 2.8.

Sub 3.5? I still know when I'm low. (Even without a sensor alarm.) now don't ge me wrong, I've had some doozies in my 45 years, the porcine insulin hypos were horrendous. (& I didn't even have a meter back then.)
I'm pretty passive when low. To the onlooker I seem bored with a bit of a disinterested attitude.
I'm certainly not a trembling sweaty mess I was in the early days. (Real "Steel magnolia" symptoms.)
But my eyes (in their perception.) are one give away with shimmering flashes of light in the lower field of vision or a gosemer map of France in the central field, light sensitive & a little colourblind? Then my thought process can go on a tangent.
Forgetting my train of thought during conversation. Maths becomes tricky.

I'm going to level with you. I sing in a band. For practical reasons & to stay at optimal levels when performing I can't sing on a stomach digesting food. (Neither can I deal with any errant BG levels whilst doing so.) So I can fast for 12 hours? I will eat after the gig. A nominal amount of sugar in liquid form can fix a low quickly if they happen during a gig.
In short. The reality is, we are using exogenous insulin. To my mind 4.5 to 7.8 is a nice place to be at any one time on my personal scale.
If I was consistently "captain hypo." I would personally be revising my insulin. Starting with the basal if I was flying that low?

I agree with @michita on her comment about the low BGs. But the Libre for me has a discrepancy of 0.6mmol. Lower than my meter.