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

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. 

Ellen Davis is the creator and owner of, 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

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

Tuesday, August 18, 2015

Glucagon, The Forgotten Hormone In Diabetes.

Type 2 Diabetes is almost always thought of as a disease of simple blood sugar management.  In reality there is nothing simple about diabetes.   There are multiple factors involved on many levels.

In my experience with many Diabetics in my group settings there are always reports of crazy blood sugar swings when the person claims that they have not had any carbs or sugar,   Many report high blood sugar either at wake up or after wake up before eating.   It is not uncommon to see raised blood sugar after exercising, gardening, or fasting.  An argument or bad news can raise blood sugar.  What's going on here?

It isn't the most recognized hormone insulin that is the culprit behind these issues.  Insulin is the hormone that is supposed to lower blood sugar.   People often say "Your blood sugar went up due to an adrenaline response or a cortisol response".   But why and how?

I am no scientist but I spend a lot of time teaching others about managing blood sugar so I manage to learn from a lot of sciency people around me.   I pick up on a few things along the way.

There is the forgotten hormone Glucagon.   It seems that nobody talks about it.  Your doctor or diabetes educator won't.   They may know of it's use in patients who are passed out in a diabetic coma but that is the only time that they are going to think about it.

Glucagon is a major player in diabetes and blood sugar control.  One of the problems is that no one is able to figure out how to manage it.  Certainly drug companies would love to find a way to add an additional medication to control the over production of glucagon.   Many so-called Brittle Diabetics are thought to have a dis-regulation of glucagon.   

Glucagon is secreted into the bloodstream by the alpha cells, insulin is secreted by the Beta cells.  When insulin is produced, glucagon is suppressed.  (after a meal).  When glucagon is released it suppresses insulin.

In diabetics many of the beta cells are gone or are overworked so insulin is not working so well.  On the other hand the alpha cells are just fine and releasing lots of glucagon when signaled to do so.  Your insulin is not responding normally so your blood sugar does not come back down quickly like it would in a normal person.

Glucagon tells the liver to start churning out glucose and the next thing you know, for seemingly no reason that you can think of, you have an unexpected blood sugar high even while fasting!  What the heck. 


What are some reasons why glucagon is released?  Here are some:

Low Blood Glucose, even in a normal range when insulin levels are also low: Good normal blood sugar is great and that is what you want.  For many who are new to eating a low carb diet you may see some rises in blood sugar as glucagon is released to compensate.  Just keep going and things will level off.

Fasting:  Again while fasting insulin levels are low so the brain signals the pancreas to release glucagon. This is a normal response so don't panic.  This is why many see higher blood sugar in the morning. 

Protein-rich meals: stimulate both insulin and glucagon.  Too much protein will have to be stored as glycogen (sugar) in the liver and the hormone glucagon stimulates this process.  This is the reason that I always advise against large protein portions.   Your blood sugar goes up from both the carbohydrates and the protein you just ate.  Your body only needs an adequate amount of protein for the use of essential amino acids.  Glucagon, Dietary Protein, and Low-Carbohydrate Diets

Stress, Exercise, Bad News, an Argument or Injury:   Your body perceives all stress the same way. physical or mental stress cause the same release of various "fight or flight" hormones.   Beyond that, a person with chronic and long lasting fear or anxiety is in a constant state of stress.  Glucagon is stimulated by these various stress hormones.  As long as you are under the stressful condition the liver will receive it's instructions to provide more glucose to give you the energy you need to fight off the dangers around you, perceived or real doesn't matter.    This is all a good reason to try to discover what may be causing your stress and anxiety on a daily basis and try to find ways to combat it for your blood sugar health.
There isn't much you can do about illness and injuries but at least you will be aware of why it is affecting your blood sugar and you won't make matters worse by panicking and then adding to the stress!   In some cases there may be some natural remedies that will reduce pain and inflammation or you may have to rely on some medical help.

From: Minireview: Glucagon in Stress and Energy Homeostasis   Nov. 2011

"Evidence for glucagon release in a wide variety of stressful situations began to accumulate after improvements in glucagon assays made accurate measurement possible in the early 1970s. In animal models, large elevations in plasma glucagon are observed immediately after acutely stressful stimuli. Hyperglucagonemia is also well recognized in patients under a range of physiological stress states, including trauma , burns , surgery,  sepsis ), hemorrhage, acute myocardial infarction, cardiac arrest, and hypoxia including in neonates Very high plasma glucagon concentrations are seen in diabetic ketoacidosis and contribute to hyperglycemia in this setting."

While I have barely scratched the surface of this issue it is important to understand that glucagon may be affecting your blood sugar negatively and some changes may be in order in your life. Try to reduce stress, arguments, negative work environments, etc. 

My final word on this is that I hope you will remember not to beat yourself up over things that you can't control. Don't assume that every blood sugar rise must be due to something you ate or drank. Don't blame yourself and assume you must have "cheated" or eaten some forbidden food.  Give yourself a break! 

I will end by saying what I said when I started.  Diabetes is not a simple disease.  It is complicated and involves many hormones and various other factors.  Some you can control and others you may not be able to.   I am not an expert on diabetes.   I am growing and learning as I continue to discover how to manage diabetes with a ketogenic lifestyle. 

A good book to read that goes into these factors and hormones is one written by Dr. Richard David Feinman called
  "The World Turned Upside Down. The Second Low Carbohydrate Revolution".   

Please do not take anything you read here as medical advice or make changes to medications based on what you read on my blog.