I want to thank my friend Ellen Davis for addressing the ketogenic diet for use in insulin dependant diabetics. This is not an area of expertise for me so I am thankful that she has agreed to post here!
I use her wonderful websites often. She does fantastic work and is extremely knowledgeable. She has written a book for type 2 diabetics and just finished another one for the type 1 diabetic.
On to Ellen's post!
The Ketogenic Diet: Low Blood Sugar Protection for Insulin Dependent Diabetics
Diabetes, as the readers of this blog probably know, is
a group of diseases in which high levels of glucose or sugar build up in a
person’s bloodstream because insulin, a pancreatic hormone which manages blood
sugar, is either not available (type 1 diabetes), or is not working correctly (type
2 diabetes).
Some people tend to underestimate the implications of a
diabetes diagnosis, but make no mistake, diabetes is a deadly disease. When high blood sugar (hyperglycemia) goes uncontrolled,
diabetics can suffer from a range of serious complications including loss of
eyesight, limb amputations, kidney failure, heart disease and death. And while high blood sugar is damaging,
there’s an even more immediate health risk associated with low blood sugar
(hypoglycemia).
For those with type 1 diabetes and insulin reliant type
2 diabetes, the lack of sufficient internal insulin requires injecting insulin
from outside. Since this external
process is much less efficient than normal pancreatic function, diabetics on
insulin must engage in a moment-to-moment guessing game of judging how much
insulin to inject to offset food intake, while taking into account the sugar
burning effect of normal activity and exercise.
The scary part is that a wrong guess can have serious
consequences. Injecting too little insulin to compensate for food
intake allows blood sugar to climb high enough to cause body damage. But
injecting too much insulin can cause
blood sugar to plummet to levels low enough to be lethal. In fact, the issue of dangerously low blood
sugar is the greater danger for diabetics who inject insulin. About 10 % of type 1 diabetics die each year
from hypoglycemia, and many of those are children who perish when their blood
sugar crashes while they are asleep.[1]
While imprecise insulin dosing
is the major factor, food choices also play a large role in the frequency of diabetic
hypoglycemic episodes. This is because each of the three food macronutrients (carbohydrates,
proteins and fats) have very different effects on blood sugar and compensating insulin
needs.
[1] Cryer, PE. Death during intensive glycemic therapy of diabetes: mechanisms and implications. Am J Med. 2011 Nov;124(11):993-6. Accessed August 8, 2015 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3464092/pdf/nihms397850.pdf
In particular, carbohydrates,
which are found in all sweet and starchy foods, have the greatest effect on
blood sugar. Ingested carbohydrates in any
form or amount will raise blood sugar swiftly and require insulin to counteract
the rapid blood sugar elevations.
More importantly, the
relationship between carbohydrate intake and compensatory insulin is not a
linear one, but is instead an exponential one[1]. In other words, if 15 grams of carbohydrate
is consumed in one meal, it will require a certain amount of insulin, say one
unit, to counteract the blood sugar rise. But if 5 times that amount (75 grams
of carbohydrates) is consumed at one sitting, more than 5 times the amount of insulin will be needed to
lower blood sugar back to a baseline level.
These larger doses of insulin increase the likelihood of driving blood
sugar down below baseline and causing a dangerous low blood sugar episode.
In addition, protein, which
is found in foods such as meats, eggs, poultry, and fish has a moderate effect
on blood sugar. Whereas carbohydrate raises blood sugar immediately, protein tends
to raise blood sugar several hours after a meal, and extra insulin may be
needed then. This “protein effect” is
not usually discussed by the American Diabetes Association because their
guidelines direct people with diabetes to eat large amounts of carbohydrate at
each meal. The amount of insulin needed to counteract this
high carbohydrate intake tends to mask the associated blood sugar rise from
protein. This is an important point to remember for any diabetic who decides
to lower carbohydrate intake.
In contrast, dietary fats
have little to NO stimulatory effect on blood sugar, so the need for compensatory
insulin is low, and blood sugar stays steady. As you can now understand, meals
which are low in carbohydrate and higher in fat are less likely to result in
hypoglycemia.
Furthermore, macronutrient
choices also determine what type of fuel will be predominantly used by the
body. If one eats a diet high in
carbohydrates, then the body cells will utilize the large amounts of sugar or
glucose created as the primary fuel. If
one eats a diet low in carbohydrates and higher in fat and protein, the body will
generate and utilize fuels created from stored and dietary fat. (Protein is mainly used a construction and
repair material, rather than a fuel source.)
[1]
Marran KJ, Davey B, Lang A,
Segal DG. Exponential increase in postprandial blood-glucose exposure with
increasing carbohydrate loads using a linear carbohydrate-to-insulin ratio. S
Afr Med J. 2013 Apr 10;103(7):461-3.
This is why a low carb, high fat ketogenic diet can
help people with diabetes take control of their disease. Over time, when carbohydrate intake is
restricted and fat intake is increased, the liver adapts to the dietary change by
breaking down stored and dietary fat into substances called ketone bodies and
releasing them into the bloodstream. This is called being “in ketosis” and when
blood ketone levels get into a certain range, the brain, heart and other body
systems can use them as an alternate fuel source when blood glucose levels are
low.
However, while our brains can run on both glucose and
ketone fuels, there’s a balancing act involved. This issue of balanced fuel
sources for brain function is crucial to understanding the positive effect of a
ketogenic diet on diabetic hypoglycemia and overall health. The difference is whether
carbohydrates or ketones are being used as a primary fuel. In other words, is one’s brain “carb-adapted”
or “keto-adapted?”[1]
Carb-Adapted or Keto-Adapted Brain?
Our brain cells MUST have a constant fuel source to
stay alive. Any interruption in fuel availability is a critical emergency for
the brain, and it doesn’t take long for our brains to shut down permanently
when brain cells don’t get enough fuel.
Having a carbohydrate-adapted brain versus a keto-adapted brain
highlights this weakness because there are differences in fuel availability
while in these various states. Let’s explore these differences.
We’ll discuss the carb-adapted brain first, because
that’s the typical state for someone consuming a standard American diet.
When a person consumes a high-carbohydrate diet, ketone
production in the liver is essentially shut off due to the presence of large
amounts of stored and circulating glucose and insulin. Since ketones are
unavailable, the brain becomes dependent on glucose as its primary fuel source.
We call this a carb-adapted brain since it relies greatly on glucose from
carbohydrate intake to function and thrive. The problem will bring carb-adapted is that
the human body can’t store a lot of glucose for future use, so unless food is
ingested every 3-4 hours, it quickly runs out of fuel, and blood sugar begins
to drop.
[1]
(Keto-adaptation is a term coined by Drs. Jeff Volek and Steve Phinney,
authors of the Art and Science of Low Carbohydrate Living.)
When a carb-adapted brain senses that blood glucose is
becoming scarce (such as when food is
scarce, or too much insulin is injected) it takes counter measures and frantically
signals the liver to break down stored energy to glucose and dump it into the
bloodstream. An adrenalin rush ensues, and is experienced by the brain’s owner
as the symptoms of hypoglycemia or low blood sugar.
The signal is frantic because at this point, glucose
MUST be made available to the brain. Otherwise, very bad things happen. For
example, the liver may not be able to break down enough stored carbohydrate to
counteract an excessive insulin dose. As blood glucose levels continue to drop,
the carb-adapted brain starts losing consciousness. Without an intervention of sugar
(juice, glucose tablets or candy) from outside, blood sugar can drop to a level
which results in a coma or death. As you now understand, going on high alert
when blood sugar drops is definitely warranted for a carb-adapted brain.
Now consider a person consuming a ketogenic diet.
Carbohydrates are restricted and ketone production in the liver increases over
time as this person enters a state of “nutritional ketosis.” Blood ketone levels are in a range of 0.5 – 3
mmol/L (mM), and at this level, the ketones act as an alternate fuel source for
the brain. This brain is keto-adapted and low blood sugar becomes less of an
emergency since the brain cells now have an alternate fuel source. For the diabetic in a state of nutritional
ketosis, this is not to say that lower blood sugars shouldn’t be corrected if
discovered, but it is logical and there is experiential and researched based
evidence[1]
that the brain is afforded an extra measure of protection from symptomatic
hypoglycemia when blood ketones are available.
[1]
Cahill GF Jr. Fuel metabolism in starvation. Annu Rev Nutr. 2006;26:1-22. Review.
This alternate fuel effect is a great reason for people
with diabetes to eat less carbohydrate and more fat, but being in ketosis also
brings other significant benefits. Not
only does ketosis provide an alternative fuel for the brain and heart, blood
sugar normalizes, and the spikes and crashes associated with a high
carbohydrate diet and compensatory insulin are minimized. This translates into a much lower risk for
diabetic complications down the road, a reduction in dangerous hypoglycemic
episodes and better overall health.
The ketogenic diet is arguably the best diet for
diabetics, and if you have diabetes and are not on a ketogenic diet, I hope
this post has given you some compelling reasons to change your diet in that
direction.
BIO-
Ellen Davis is the creator and owner of www.ketogenic-diet-resource.com, a website devoted to sharing information on the health benefits of ketogenic
diets for diabetes and other health conditions.
She also has a wealth of free information at her other website www.healthy-eating-politics.com
Ellen has a Master’s degree in Applied Clinical Nutrition from New York Chiropractic College. She recently wrote and released two books detailing how to treat diabetics with a ketogenic diet. Both books were co-authored with Dr. Keith Runyan, a physician who successfully treats his own type 1 diabetes with a ketogenic diet, and both books are available on her website. Ellen lives in Cheyenne, Wyoming and can be contacted at ask.ellen.davis@gmail.com.
She also has a wealth of free information at her other website www.healthy-eating-politics.com
Ellen has a Master’s degree in Applied Clinical Nutrition from New York Chiropractic College. She recently wrote and released two books detailing how to treat diabetics with a ketogenic diet. Both books were co-authored with Dr. Keith Runyan, a physician who successfully treats his own type 1 diabetes with a ketogenic diet, and both books are available on her website. Ellen lives in Cheyenne, Wyoming and can be contacted at ask.ellen.davis@gmail.com.
Great post Ellen! As you say a ketogenic diet would provide the type 1 or insulin dependent type 2 with an alternate fuel source for the brain freeing them from the wild swings of a high-carb diet. Also lowering their daily insulin needs. And as you say when the brain burns primarily ketones the risk for dangerous hypos is greatly reduced.
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ReplyDeleteI have been below 20 carbs for 16 days. Yesterday I took 20 Units of Humulin of insulin because even without carbs my BS was at 200. I had a large salad at lunch of greens, boiled eggs, cheese, blue cheese, bacon, cucumbers, and tomato and then water walked for an hour and tread water for a half and floated for another. When I got out I felt my tongue getting numb and perspiration coming off my head. The cool water hid my symptoms. I drove home, drank 8 ounces of oj . I awoke with a high 175 at 4:30 am and took 14 U of insulin. Again at 6;30 120. I had not taken Pruvit exogenous ketones as usual.. Possibly I would not have experienced this low if I had!
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