Saturday, August 22, 2015

Low Blood Sugar Protection for Insulin Dependent Diabetics - Ellen Davis of the Ketogenic Diet Resource


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.

In the overall evolutionary design of the human body, the ability of the liver to produce ketones is an elegant solution for providing an alternate body fuel when food is unavailable. Fasting and starvation cause the same elevation in ketone production, and in fact, most people wake up each morning in mild ketosis because they haven’t eaten for the past 8-12 hours. If dietary carbohydrate is restricted to 20 – 50 grams per day over several weeks and dietary protein is not excessive, the liver will produce ketones, and blood ketone levels will rise moderately. However, it’s important to note that blood ketone levels don’t typically rise as high during nutritional ketosis (0.5 – 3  mM) as they do during prolonged fasting (5 – 8 mM) so this protective effect may be more pronounced during times of total food fasts.


[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.



6 comments:

  1. 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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  5. I 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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