Ketosis for Type 1 Diabetes – dispelling the myth on ketoacidosis - PART 1

Thanks for reading my February post on ketones, ketosis, and ketoacidosis. I decided to split this post into 2 part. The first here goes into what ketosis and ketones are, what diabetic ketoacidosis is and its causes and symptoms.

Please read part 2 of this post for my personal experience with ketosis and how it has benefited my type 1 diabetes.

What is keto – what are ketones?

If you are reading this post, you’ve probably already heard of keto, or the ketogenic diet. How else did you land here? There is so much buzz and information out there about keto, that it can honestly be overwhelming to sift through it all. Believe me, I know! I myself have been experimenting with keto for over 4 years now, and by listening to experts with differing opinions in the space, I’ve dived deep into the science, nutrition, and different protocols and have found what works for me and my type 1 diabetes (T1D) management. Now, let’s get into the meat and “potato-substitute” of the subject: what is keto and how can it work for managing T1D, and what is diabetic ketoacidosis and how does it relate to a ketogenic diet?

Simply put, keto is our ability to function in the absence of carbohydrates. This happens to us all in a daily capacity when we wake up and before we eat, in long breaks between meals, and after long bouts of exercise when we’ve depleted our stored glycogen (stored glucose). The state of “ketosis” as it’s called, is a natural metabolic state we have all evolved to function within. Nutritional ketosis is a way of achieving this metabolic state through diet. In ancestral terms, we lived through periods of feast and famine thanks to seasonal eating, hunting and gathering. Thanks to this, our bodies evolved the ability to survive long periods of “famine” or fasting, by dialing into our backup of stored energy – fat cells. When a fat cell is broken down by the liver, the process creates a compound called a ketone body. Our brains and bodies developed the ability to function on ketone bodies as fuel so that we, as a species, could survive periods of starvation. This could be over winter, over poor crop yields, or just in between meals.

Ok, so are we simply talking survival here? That doesn’t sound very appealing does it?! As it happens, throughout the last century and especially within the last 20 years, there have been many benefits that have been discovered by following a ketogenic approach. These include, but are not limited to, creating a systemic anti-inflammatory response, increased neurotransmission and cognition, increased mitochondrial function, decreased oxidative stress, decrease in cancer cell proliferation, weight loss and a decrease in glycaemic variability.

Some medical uses for keto

It was discovered in the 1920s that eating a high fat, low carbohydrate diet – aka a keto diet, significantly improved the symptoms of Epilepsy. Some people saw up to a 50% reduction in seizures, and for 15% of sufferers, the impact was unbelievable – life 100% seizure free. There is ongoing research to fully understand the impact that a ketogenic diet can have on neural function, as improvements for people living with Parkinson’s Disease and Alzheimer’s Disease have been noted both in research and anecdotally. As outlined by Russel and Swerdlow in their 2011 paper, Alzheimer’s disease is associated with impaired glucose utilization in the brain and mitochondrial dysfunction. Ketone bodies can therefore be utilized as a backup fuel source, providing the brain with energy and thus slowing down the effects of the neuro-degenerative disease.

Another fascinating area where use of nutritional ketosis is being experimented with for medical uses is in slowing down (and as it’s been discovered, reversed!) the growth of certain cancers. Cancer cells live off of glucose, so it has been hypothesized and now proven that by shifting the body’s metabolism to use ketones as energy, the result is starvation of the cancer cells while healthy cells in the body get energy from an alternate source – ketones!

Ok I digressed away from diabetes for a minute there. I just find this all so dang fascinating!

So ketones, these fat-converted compounds, are backup energy sources that can be utilized by the body when carbohydrates, or glucose in their broken down state, are absent. How does this affect a person with type 1 diabetes? Well, ketones don’t need insulin to be absorbed by the tissues that need them. This of course is in stark contrast with glucose, or carbohydrates. As you probably know by now, in order for the body to mobilize and utilize its glucose stores, it needs insulin. Insulin, which we know isn’t produced in the pancreas of a person with T1D and is needed to be injected exogenously.

Also, just saying that in animal models, a ketogenic diet leads to improved metabolic profiles, extended lifespans and improved neurological responses – longer life! Of course the research hasn’t been around long enough to show this in human models.

What is diabetic ketoacidosis or DKA?

The term “diabetic ketoacidosis”, or DKA, is often thrown around as a warning against ketones, or choosing to enter a state of ketosis for a person living with T1D. It’s understandable, but frustrating at the same time that the line of distinction between the two isn’t commonly understood. I’ve noticed (anecdotally) that when discussing ketosis, I’m often “informed” that my choice to live this way is a danger to my diabetes because elevated levels of ketones cause DKA. This just isn’t true. It is true that when a T1D develops DKA, they have highly elevated levels of ketones in their blood. It is not the ketones alone, mind you, that cause the acidification of the PH in the blood. It is actually the malabsorption of glucose – therefore the excess floating through the bloodstream, that causes the shift in PH. It is the high blood glucose level, in combination with the high ketone levels, that cause the acidification of the blood, causing DKA.

Causes of DKA

So in a nutshell, Diabetic ketoacidosis is caused by:

The body’s response to glucose malabsorption
Defective insulin release and impaired glucose uptake
Excess ketone bodies being made by the liver because energy (from glucose) is not being absorbed thanks to insufficient or defective insulin levels.
Insulin resistance

With poorly controlled diabetes, increased levels of ketones along with high levels of blood glucose may lead to diabetic ketoacidosis. Because of their acidic pH, elevated concentrations of ketone bodies affect the electrolyte balance, causing cell damage and dehydration. Untreated diabetic ketoacidosis can be very serious and can cause coma and even death.

Symptoms of DKA

Anyone with T1D has likely experienced one or more of the following with hyperglycemia (high blood sugar). If you experience one or more of these, make a treatment decision immediately following your doctor’s guidelines.

high blood glucose (BG) levels
rising levels of ketones in the urine
excessive thirst
frequent urination
exhaustion
dry or flushed skin

Untreated symptoms (the above) can lead to more serious DKA. As ketoacidosis progresses, symptoms can include:

nausea
vomiting
stomach pain
lower back pain
trouble breathing
a fruity odour in the breath
confusion
loss of consciousness

Experiencing any of these symptoms should result in a visit to the emergency room. Treatments will likely include intravenous (IV) insulin therapy with IV hydration and electrolyte therapies.

How to avoid DKA

You will notice that in the bullet points above listing the causes of DKA, almost every point mentions or infers excess glucose present in the blood. How do we as T1Ds manage this? By taking insulin. By adhering to a proper insulin regime and carefully monitoring your blood sugar levels, you should be able to keep BG in the safe zone where the blood’s PH won’t be affected. Does this mean that if you overdo your consumption of chicken wings and your BG goes above 10.0 (180 in the USA) you need to go to the ER? No it doesn’t. Just monitor your levels and don’t let yourself stay high for extended periods of time. Good practice should always include checking BG levels after a meal to make sure you gave adequate insulin to cover the meal – low carb or not. If it’s high, just treat it to bring it back into range.

So really it’s a simple formula: test frequently, and take insulin regularly.

Be sure to read PART 2 to discover the benefits of a ketogenic approach for T1D through my personal experience!