Ketones & Low Carb Diets
Editor’s Note: It is important to note that not eating carbs DOES NOT put you at risk for DKA. It does however lead to ketogenesis/ketosis. With the combination of insulin omission and severe intercurrent illness, you are at a higher risk of acidosis (i.e. DKA).
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Testing for ketones is something that I am sure every person with Type 1 remembers doing shortly after diagnosis – constantly matching the color on that little square at the end of the urine stick to the color grid on the bottle. We all are taught that ketones can result from high blood sugar or illness, but what I have recently experienced has illuminated another cause of ketones – cutting out carbs.
It wasn’t until about three years after my Type 1 diabetes diagnosis that I had even considered the idea of a lower carb diet. I loved pasta. Pasta with butter and parmesan cheese had been a staple of my diet since I was old enough to eat solid foods. I loved hot dogs, paninis, the occasional pizza night and Starbucks pastries for breakfast. And really – who doesn’t regularly crave carbs?
The first few years of my T1D life were relatively seamless, albeit largely due to that lovely “honeymoon period.” I could eat as many carbs as I wanted and my blood sugar levels seemed to cooperate nicely no matter what I did or how often I snacked. And then suddenly, I started noticing the dreaded spikes and subsequent drops. It was getting more difficult to avoid the high blood sugars after those meals filled with complex carbs. One day my mom made grilled salmon – something new. My blood sugar behaved like a champ.
“I wonder what would happen if you cut out carbs completely,” my mother mused, mostly in jest. I shrugged my shoulders. I was willing to try more protein, at least.
Low and behold, more and more stable blood sugars resulted from less and less carb intake.
Soon I was off to Manhattan for college to live by myself for the first time. At that point, I definitely still ate carbs. I loved the occasional chicken parm sandwich from my favorite deli across the street, or the wontons from the vegetarian place I loved to order from. But the more it sunk in that I was on my own, (and in the days before CGMs were commonly used) – the more afraid I became of taking large amounts of insulin. I began to cut out carbs from my diet even more over the next handful of years, and eventually I cut them out all-together.
In addition to eating almost solely proteins and lower carb veggies, I found substitutes for the carbs that I used to love. For instance, shirataki (tofu noodles) in place of pasta have zero carbs per serving. I would make “pancakes” out of Quest protein powder. I became very inventive, and it worked well for me, or so I thought.
Although my blood sugars were always exceptionally steady, I never felt completely satisfied after eating, and the feeling only grew worse over time. I tried to ignore it – along with the gradual yet concerning loss of weight. Eventually I had to admit to myself that something was wrong. I began to feel so weak that a simple trip down the block to the grocery store seemed impossible. I was continually shaky and hungry (and no, I was not low!)
I knew I was going to be heading home to California soon and meeting with my endocrinologist, so I just had to hold on a little longer to find out what was going on with me. But I decided to do some research on my own. What I found out was that, although I was eating – I was starving myself.
Some bodybuilders and serious weightlifters evidently strive to get small amounts of ketones. This is because producing ketones can mean that your body is essentially eating and burning up the fat in your body for fuel because of the lack in carbs/glucose. This is what had begun to happen to me, which was proven by the “small” amount of ketones that appeared on the ketone urine sticks that I went out and bought for the first time since my diagnosis.
When I met with my endocrinologist a couple of days later, she confirmed that I was in desperate need of carbohydrates. She told me a story about one of her patients – another T1D who tried to cut out carbs completely. She began producing small ketones as I had, but after getting the flu she went into diabetic ketoacidosis (DKA) and had to be admitted to the ER.
My endo suggested that I slowly start incorporating them into my diet, starting out with approximately 20 carbs per meal and going from there. So that is what I did.
“Don’t worry,” she said, “That Dexcom will be sure to beep at you if anything goes wrong!”
In many ways, I now feel as if I am having to re-learn carb counting and some of the very basic things about living as a T1D that you go through when first diagnosed. But that’s okay. I am feeling much healthier, energized and confident taking larger amounts of insulin, and now with the reassurance of my CGM. It has empowered me in a unique way as a T1D.
There will be many times with this disease that we will all just have to “live and learn,” and for me – this was certainly one of those times.