Keto and DKA

Type 1 & LADA
1

I’m really confused right now. I had been doing keto for a week and was getting amazing results just a few days in. I stayed 100% within my target blood sugar range (3.9–7.9) most of the week. That’s a huge deal for me—I’ve struggled with blood sugar management and food for the past 15 years.

Then, the night before last, I started feeling unwell—nauseated, headachy, and too sick to eat dinner. I went to bed with blood sugars still looking great. But the next morning, I felt like I had the flu: weak, spacey, nauseous, strong headache, and like I might faint. I had to go to an appointment anyway, and during it, my heart felt like it was pounding and fluttering.

When I got home, I decided to check my blood ketones, since I’ve had DKA before and this felt similar. My ketones were 2.7, but my blood sugar was only 9. I double-checked with my glucose meter and it said 11.4. That’s when I emailed my endocrinologist. I asked if keto could be causing this, and told him I was going to eat an apple and take a bolus plus a correction dose.

But I kept feeling worse, so I called the nurse hotline. They were concerned because my ketones were over 1.5 and advised me to go to the ER. I didn’t, but a tel-doctor called me soon after and told me she would NOT recommend keto for someone with type 1 diabetes who has had DKA a few times before—especially since I once went into DKA with normal blood sugars (I was on Invokana at the time, which may have played a role). She said if my blood sugar goes over 13 AND my ketones are above 1.5, I should go to the ER.

Later, my endocrinologist called back and gave me completely different advice. He said that ketones around 2.7 are totally normal on keto, and I shouldn’t worry unless they go above 4. He told me if my blood sugars go over 10, I should follow the sick day protocol: eat some carbs and take insulin. He also congratulated me on how well I’d managed my blood sugars that week and said keto can do wonders for blood sugar control.

So now I’m stuck, not sure who to listen to.

By the next morning, my blood sugars had normalized, but I still had large ketones (measured with urine strips since I ran out of blood ketone strips—they were the second darkest color). I drank water and electrolytes, then pre-bolused by 20 mins for a Starbucks ham and swiss croissant (27g carbs), which I usually tolerate well. But it’s now 4 hours later, and I’ve been correcting and walking during that time just to get my blood sugar down. It peaked at 14.6 and is finally down to 7. My ketones are still showing as moderate (again, on urine strips). I am going to eat keto for lunch and dinner I think.

Should I try low carb instead? I am feeling really defeated, I was loving the good numbers and just feel like I don’t know what to even try eating.

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If you are doing keto I don’t think they will get worried about anything unless your BG goes above 250. Ok, so you hit 14.6 but seriously? If I hit one of those fetid carb monsters from StarButts I’d be heading into 300. When I eat half a (US) croissant I do 45g (in fact I do this quite regularly) and I peak out at 150 at present but couldn’t blaime 250.

So here’s the deal; eating carbs bumps our BG. A pre-bolus helps but can overshoot. However it’s a bump; if you start from “only 9” (the only number you quoted) a bump by 5 is believable.

So, yeah, do what they say; they both said the same thing.

Or don’t over-engineer it. It is what it is. If you really did do keto (or low carb - they’re the same thing) 2.7 is expected. That means if you are doing close to 0 carbs (<20 per day) and you are getting some moderate amount of exercise. I don’t go that high; I don’t like my blood ketones going must over 1! All of us (not just T1s) can feel those ketones and they’re not pleasant. For us T1s of course anything over 1 is suspicious; bent canula maybe? So, yeah, the high ketones are “fine” but the high BGs with them are really suspicious. Hence your warnings.

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I would trust your endocrinologist over a nurse hotline, for sure.

When I tried keto/super low carb in the past, if I ever tried to eat carbs, my blood sugar would spike high and stay high, even with lots of fact-acting insulin. I think it’s because there is more fat/protein circulating in the body and it’s harder to get that sugar into the cells.

It makes sense that you would have ketones in your body, but the question for diabetics is, are you getting insulin? There is a difference between DKA and ketosis: Ketosis vs. Ketoacidosis: What’s the Difference?

For me, it wasn’t worth doing low carb/keto, because when I would go off-script and eat something I enjoyed, it would spike too much. Keto just didn’t work with my lifestyle. I just eat what I want and bolus appropriately.

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@PP777 You’re the best judge of the background and trust factor of the folks. The questions I’d ask are: What are their backgrounds and experience with T1? How long have you been seeing them? Sounds like the doc has the inside track and knows you best, but I once saw a PA that knew way more than the doc I saw at the time, so a more advanced title may not be the deciding factor.

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Maybe jumping into keto was too much of a change from what you were eating before from a learning-on-the-fly or adaption perspective. Croissants aren’t a good fit with keto, but it was your first week. :slight_smile:

If you feel more comfortable with low carb this might be a better transition to start with. Then later you might become curious and want to experiment with keto again, or something else.

Research as much as you can to feel confident in change, knowing the tricks and traps as much as you can. Then experiment and adapt to fit with what works for you, “n=1”.

It took me reading Dr Bernstein’s book 5 times to get my head around low carb before committing myself to launching into it one day. That day was pure T1D magic for me. Not to mention, IMHO, life saving and changing. Since then I upped the ante to keto and shortly after to VLC which is where I’m at now. I’m still cyclically ketogenic (aka metabolically “flexible”) and importantly without skimping on protein. My ketones are typically 0.2-1.5mmol/L, highest 3.5. I tend to consider BG + BK as a “total energy state” and try to keep that within a range. Most importantly I always have IOB, which is not negotiable with T1D.

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I found this paper of a study to explore the long term use of the keto diet on insulin resistance. Evidently most of the earlier studies were short term.

This from the discussion on the study.

DISCUSSION

High-fat, low-carbohydrate KD have been associated with beneficial effects on body weight and epileptic seizures. However, their effects on pancreatic endocrine cells and glucose metabolism on the long term are less clear. The main results of our study show that long-term KD in mice causes glucose intolerance and a reduction in both β- and α-cell mass, but no weight loss. This indicates that long-term KD leads to features that are also associated with the metabolic syndrome in humans and an increased risk for type 2 diabetes.

https://journals.physiology.org/doi/full/10.1152/ajpendo.00453.2013

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