T2s in remission from keto - how quickly did you adjust insulin dosage?

[Cocosilk]

Hi,
I'm just curious, if you have T2 and have eaten very low carb or ketogenically, how quickly did you find after entering and maintaining ketosis did you have to reduce your insulin dosages?

I know this is going to be completely different for every individual so I'm not going to copy what anyone else is doing but I'm just curious about your experiences.

I've only been taking nightly insulin doses (currently at 22 units) for the past few weeks with gestational diabetes and I can get into ketosis really quickly at 35 weeks pregnant, almost accidentally really, but I'm not sure I need to change anything in my insulin dose just yet, but may experiment if I manage to keep my fasting levels as low as they were this morning: 4.4 mmol.

This really only happened overnight after eating pretty low carb for one day - that's pregnancy for you. I still ate a few carbs but not sure how to measure how many. Half a slice of a homemade sourdough rye bread that my husband makes, even with a heaped tablespoon of thawed raspberries on top. Then later in the day 2 tbspn of lentils in homemade tomato/mince pasta sauce (minus the past though!)

And lastly there was a tiny bit of carrot in a cow tongue soup (my husband is Serbian and likes to cook

The rest of what I ate yesterday was mostly without carbs so I woke up with 4.4 mmol blood glucose. I stayed low after eating more tomato/ mince / sour cream for breakfast (4.9 mmol 2 hours after that).

I ate a small half slice of sourdough rye with about a 1/4 of an apple and a coffee mid morning. And then pork belly with one slice of sweet potato for lunch. I felt so lacking in energy all day, but full (not hungry). Then at 4pm, 3 hours after lunch I decided to check my ketones and they were between 1.5 and 4 mmol, which is higher than they need to be for nutritional ketosis and I really only accidentally got there. I checked my BG levels straight after that and they were 4.6 mmol.

So I ate some cheese, pistachio nuts and a tiny bit of apple and red capsicum with a cup of tea.
Two hours later when I checked ketones again, they were between 0.5 (trace) and 1.5 (weak), which is preferable for me I think. And BG was 5.6 mmol then.

Tonight for dinner I've eaten eggs with mince, tomato and mushroom and a spinach salad.
If my BG is in the high 5s before bed, I'll stick to my current dose of insulin because I'll need it to get it down again by morning. If I'm lower though, like in the 4s, I'm not sure whether to take a bit less insulin or not. I know a hypo would be worse for baby... We only have 2 and a bit weeks to go till the baby is born so not long anyway. I could just give up on really low carb and easily eat more carbs and take more insulin, but neither situation feels ideal. My OB is fine with me doing low carb, but last time I saw him, I was still sneaking extra carbs in since my insulin dose kept being put up because my morning fasting levels were not budging. Now it seems I have to be in proper ketosis for that to change. Do I stick with really low carb for the next couple of weeks and watch my insulin doses carefully? Or just eat extra carbs to stay out of ketosis and just keep injecting whatever insulin I've been assigned? It's all such a balancing act, isn't it? Which is why I'm curious how it works for non-pregnant T2 diabetics as well.

 

[Squire Fulwood]

I notice that no-one has replied and I notice that you ask the question of T2's. The vast majority of T2's do not take insulin so maybe they feel they cannot respond.

 

[Resurgam]

I can't comment on the insulin requirement, but I notice that you are eating high carb foods, such as bread, sweet potato, apple - rather than low carb choices which would give you far more to eat.

 

[britishpub]

if you have T2 and have eaten very low carb or ketogenically, how quickly did you find after entering and maintaining ketosis did you have to reduce your insulin dosages?

Whilst by no means being an "expert" on the subject, I would think that for a T2D to start a Ketogenic diet, they would be looking to dramatically reduce their need to inject Insulin quite quickly.

Again I am no expert, but I doubt whether too many T2D will have made the move to this kind of diet if they were already on an insulin regime so you may not get too many answers to your original Q

 

[becca59]

Just to point out this is gestational diabetes and the OP is 35 weeks pregnant.
@Cocosilk surely your insulin dose has been set by your medical team and any food you are eating should be reflecting your pregnancy.

 

[Krystyna23040]

I'm just curious, if you have T2 and have eaten very low carb or ketogenically, how quickly did you find after entering and maintaining ketosis did you have to reduce your insulin dosages?

Hi - have been out all day and have just read your post. I Initially hesitated before replying because you have gestational diabetes and should only take advice from your medical team.

So my reply just sets out how I came off insulin - it isn't offering advice to you.

50g of carbs a day didn't affect the insulin injections. When I dropped down from 50g carbs to 20g of carbs I assume I went into ketosis but never checked. Very quickly I had to cut down Lantus which I took at night. I think it was literally in days.

I was in a bit in a panic and did ring the diabetes clinic for advice as I was dropping down into the 3s. The Novorapid after meals was easier to sort because it was matched to the carbs eaten so I was injecting tiny amounts. It was the lantus that was the problem. The advice from the DN was to keep testing and to keep adjusting the insulin down.

I also found that I had to move the Lantus to the morning because even a very small amount at night was dropping me into the 3s.

That was September 2016. I came off all insulin for a while but then early in 2017 I had to go back on small amounts of Lantus. This kept happening until September 2017 when I finally came off all insulin completely - and haven't injected since. I still keep to the 20g carbs.

So it was a bit of a roller coaster - sometimes my need for insulin dropping dramatically and sometimes it would increase dramatically.

Actually it is no different now. Sometimes I am in the 7s two hours after a low carb meal and other times I am in the low 4s two hours after the identical meal.

I am assuming that - because you are pregnant - you will not be dropping your carbs as low as I did and should definitely follow the advice of your medical team.

Edited to correct the date I came off all insulin. It was September 2017 not 2018.

 

[Cocosilk]

I can't comment on the insulin requirement, but I notice that you are eating high carb foods, such as bread, sweet potato, apple - rather than low carb choices which would give you far more to eat.

I only quoted the high carb foods to illustrate which carbs I included in my low carb meals and I ate them in very small quantities along side the meats, eggs and vegetables. If I avoid them altogether I will end up with ketones closer to 8 mmol, which I had a few weeks ago after only one day of practically zero carbs. Pregnancy puts you in ketosis much faster and because I am taking insulin, I'm trying not to go into a deeper ketosis than around 1.5 mmol. But most of what I ate yesterday was not carbs and I was not hungry or craving because I was full up on pork belly with all the fat/lard, and the mince and sour cream in the straight pasta sauce (minus the pasta). I'll cut out the carbs completely one day when I'm no longer pregnant or breastfeeding I think.

 

[Cocosilk]

Whilst by no means being an "expert" on the subject, I would think that for a T2D to start a Ketogenic diet, they would be looking to dramatically reduce their need to inject Insulin quite quickly.

Again I am no expert, but I doubt whether too many T2D will have made the move to this kind of diet if they were already on an insulin regime so you may not get too many answers to your original Q

I guess people just do what they are told by their doctors really, don't they? I just keep reading more and more that while T1s absolutely need insulin injections, T2s have too much insulin floating around usually and their insulin resistance makes them not use it properly so injecting more, while it fixes things in the immediate term, it's not addressing the problem of having too much insulin in your body and the problems that can cause. But I guess if most doctors aren't told to encourage people to try eating no carbohydrates to see if they can reduce their insulin doses, it's easier for people to keep eating what they've always eaten and just take the insulin, isn't it? I know how hard it is to change eating habits.

There are a few T2s on this forum who have put themselves in remission by eating low to zero carbs and some of them may have been on insulin before they did it, but perhaps they were only diet controlled or on Metformin only.

 

[Cocosilk]

I notice that no-one has replied and I notice that you ask the question of T2's. The vast majority of T2's do not take insulin so maybe they feel they cannot respond.

Is that true that the vast majority of T2s do not take insulin? I thought insulin was still routinely given to T2s if they have a severe enough problem controlling their blood glucose levels. Is everyone either diet controlled or on Metformin these days?

 

[Cocosilk]

Hi - have been out all day and have just read your post. I Initially hesitated before replying because you have gestational diabetes and should only take advice from your medical team.

So my reply just sets out how I came off insulin - it isn't offering advice to you.

50g of carbs a day didn't affect the insulin injections. When I dropped down from 50g carbs to 20g of carbs I assume I went into ketosis but never checked. Very quickly I had to cut down Lantus which I took at night. I think it was literally in days.

I was in a bit in a panic and did ring the diabetes clinic for advice as I was dropping down into the 3s. The Novorapid after meals was easier to sort because it was matched to the carbs eaten so I was injecting tiny amounts. It was the lantus that was the problem. The advice from the DN was to keep testing and to keep adjusting the insulin down.

I also found that I had to move the Lantus to the morning because even a very small amount at night was dropping me into the 3s.

That was September 2016. I came off all insulin for a while but then early in 2017 I had to go back on small amounts of Lantus. This kept happening until September 2017 when I finally came off all insulin completely - and haven't injected since. I still keep to the 20g carbs.

So it was a bit of a roller coaster - sometimes my need for insulin dropping dramatically and sometimes it would increase dramatically.

Actually it is no different now. Sometimes I am in the 7s two hours after a low carb meal and other times I am in the low 4s two hours after the identical meal.

I am assuming that - because you are pregnant - you will not be dropping your carbs as low as I did and should definitely follow the advice of your medical team.

Edited to correct the date I came off all insulin. It was September 2017 not 2018.

Thanks for answering this question!
It's good to know that it can be a rollercoaster ride with the same meal giving you 7 one day and 4 on another. That's not as much control as I would want being pregnant - getting into the 3s with a baby on board would panic me) and you are correct that I don't intend on going to zero carb while I am still pregnant because after just one day of eating like that, I had ketones up to 8 mmols, which I think is a but higher than it needs to be. So I will continue eating some carbs. Last night I didn't change anything with my insulin dose anyway because after my meal (lots of protein rather than carbs) I was still at 6.4 after 2 hours (which is well under the target of 6.7 but high enough that I would still stick to the insulin dose I was on) and this morning I woke up at 6am and my BG was 4.5 mmol and ketones were at 1.5 mmol, which I think is about where I would want them.

Despite the insulin I've been on (and it's only been a few weeks starting at 6 units for a few days, then going up to 10 units, 14 units, 20 units and now finally 22 units) I've only really had 3 days in the last week where my morning fasting glucose was under 5.0 mmol, which is where they want it. Otherwise it's been between 5.1 and 5.6 mmol, which is not terrible but still higher than the new guidelines want pregnant women (in Australia at least) to be at.
And it definitely has affected baby's growth even just being a bit over 5.0 mmol because he is measuring a good 2 weeks ahead with his estimated weight. It could also be that I had the odd post meal spike between 8 and 10 a few times as well before I worked out what not to eat.
So even if these BG levels seem tame compared to a fully fledged T2, they do still affect baby so I think it's a good thing more women will be flagged with the condition in pregnancy now and hopefully more of them take it seriously enough to change the way they eat and not let it go on to T2 if they are still in a situation to be able to prevent it after pregnancy.
From what I've read on the Gestational Diabetes thread on this forum, I think too many women take for granted that gestational diabetes will go away after pregnancy and it's not their fault they got it; it's simply the pregnancy hormones. I think it's foolish to assume that you don't already have a higher level of insulin resistance if you got gestational diabetes and eat accordingly to try to correct that. If it were just about pregnancy hormones, every pregnant woman would get gestational diabetes. But that's not the case. Being a lucky one who doesn't go on to get T2 probably only happens for those who do change their diet post pregnancy and stick to something more low carb for the rest of their lives. Or perhaps for those who only ate and craved more sweet things in pregnancy but then went back to more moderate carb consumption. Anyway, I should probably post that rant on another thread.. ha ha

I'll just continue with my balancing act to try to keep my fasting glucose under 5.0 mmol now that it's been there for the last 2 days, and if I wake up one morning with something under 4.0, I'll probably just eat a few more carbs again for the rest of pregnancy.

 

[Stephen Lewis]

I am T2 and I was on insulin but as you see from the photo I am not having a baby. We are all different and can manage different levels of carbs to keep our blood glucose levels within tolerance. I was put on a mixed fast/slow insulin with 30 units per day in February 2018. The dose went up over about 4 months to 68 units per day. My bg only came down a little during that time. In July I went on a low carb diet using the Low Carb Program. This was not ketonic though the fat levels did increase - mainly bacon. I gradually reduced the carbs and was able to slowly reduce the insulin to zero in December. I try to keep the carbs to below 20 gms per meal and my A1C dropped from about 9.5 in Feb 2018 to 6.9 in February 2019. I am aiming for under 6 in May and will try to reduce the carbs further if necessary. I hope all goes well for you in a few weeks and you may find that your pancreas returns to normal function afterwards. If not, stick to the low carbs but I think that bg in the low 4s is too low for safety unless your pancreas can stimulate your liver to produce the glucogens quickly to prevent hypo. Mine kicks in with strength at about 4.5 and my body seems to want to average about 7.0 for the whole day so I'm not sure if cutting carbs further will help. You need to work out what is best for you both now and in a few weeks with hopefully good professional medical information.

 

[Squire Fulwood]

Is that true that the vast majority of T2s do not take insulin? I thought insulin was still routinely given to T2s if they have a severe enough problem controlling their blood glucose levels. Is everyone either diet controlled or on Metformin these days?

Yes it is true that the vast majority of T2's do not use insulin. That's why I thought you were asking the wrong people. There are some that use insulin but usually the more severe cases. Traditionally T2's were given some pills and told they were going to get worse and then die. Using diet to help with sugar control is relatively new for the majority and the health service seemed blissfully unaware of it until a few years ago. Dr. Malcolm Kendrick said that when he was at medical school he didn't think they spent more than one hour on nutrition.

People who control their sugar level with diet have had great success. Some of them have come off of all diabetes medication.

 

[NiccyW]

I have been type 2 (?) since I was 28 (in 1975!) so I have seen many advances in the treatment of diabetes, especially for women during pregnancy. I became pregnant at 36 and immediately went onto long acting and short acting insulins.It took quite a lot of effort to keep in control with the increase in weight and hormones during the pregnancy and I was worried about harming the baby. But what I wanted to say was dont be too hard on yourself during these last weeks and during breastfeeding - you will need energy for the birth so make sure your balance of carbs is right for you and increase a little if necessary. Breastfeeding too uses and requires energy. One or two short hypos are very unlikely to harm your baby (I'm not talking about a major event requiring help) so relax your worries a bit. I have been there too, worrying over the pressure to keep really good control which actually made my pregnancy quite stressful and probably increased my blood pressure which in turn meant a month in hospital before the birth. Take it easy - you can tighten up later if it is necessary and your gestational diabetes doesn't fade away. Good luck!

 

[Cocosilk]

I have been type 2 (?) since I was 28 (in 1975!) so I have seen many advances in the treatment of diabetes, especially for women during pregnancy. I became pregnant at 36 and immediately went onto long acting and short acting insulins.It took quite a lot of effort to keep in control with the increase in weight and hormones during the pregnancy and I was worried about harming the baby. But what I wanted to say was dont be too hard on yourself during these last weeks and during breastfeeding - you will need energy for the birth so make sure your balance of carbs is right for you and increase a little if necessary. Breastfeeding too uses and requires energy. One or two short hypos are very unlikely to harm your baby (I'm not talking about a major event requiring help) so relax your worries a bit. I have been there too, worrying over the pressure to keep really good control which actually made my pregnancy quite stressful and probably increased my blood pressure which in turn meant a month in hospital before the birth. Take it easy - you can tighten up later if it is necessary and your gestational diabetes doesn't fade away. Good luck!

I'm having a bit of a spike as we speak after having low carb meals for the last couple of days. I was feeding my kids a bit of spaghetti and thought I'd have a bit myself since I'd hardly eaten any carbs today and have only seen readings from the mid 4s to the mid 5s today. Well, I think I'm becoming even more glucose intolerant as this pregnancy progresses because I really didn't eat that much spaghetti but I'm sitting at 8.5 mmol two hours after eating it. I must have been 9 or 10 at the spike. But as you say, it won't kill anyone to have a spike here and there. I've been having this scenario once or twice a week since 29 weeks pregnant (35 weeks now) but hopefully it's not too serious. I do feel like I need some sort of carbs while pregnant. I've been trying to harvest colostrum and if I stick to very low carbs, it makes that even harder so I can imagine how it might affect breastmilk supply later. I never had a problem with my supply with the first 2 but I ate whatever I wanted then, and I ate a lot because you just get so hungry, don't you?
But you are right that stress is a big factor. I had my blood pressure scares in previous pregnancies. This time I'm on low-dose aspirin to reduce pre-eclampsia risk (had it in my first pregnancy), and it seems to be working because my BP just before was 111/61. Almost as low as it was before I started having babies.

Thanks for the reassurance!