Ketogenic diet for Diabetes: Part 2

In October 2020 I began a very successful experiment with the ketogenic diet to control my  reactive hypoglycemia. I wrote this post in April 2021 outlining the initial phases of this experiment. Since then, a lot has changed, so I wanted to give an update on how it's working for me now.

Even though I had been "keto" for a year and a half, I had been pretty loosey-goosey with my carb limits. As long as I stuck under 60g carbs/day I could see that I was producing a little bit of ketones (using a ketone meter) and this kept my glucose relatively stable. After a few months of keto, my A1c dropped dramatically from 6.2 down to 5.2. I'm holding steady now at around 5.3.

But because I was a little lax with my carbs, especially between the end of 2021 and the beginning of 2022, I would regularly get hypoglycemic crashes once every couple of weeks which I required a rescue remedy (a half of a cube of maple sugar). So recently I've gotten much more strict with my carb intake, and the results have been excellent. My ketones are in optimal range almost all the time, my energy and digestion is great, and my blood sugar is in better control than ever before.

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Optimizing Ketosis
On a ketogenic diet we want to make sure we have enough fat in our diet from which to produce ketones, but the amount of fat we eat in excess of our needs for ketosis just leads to fat storage. I didn't understand this until recently.

One way to tell if we're eating too much fat while in ketosis is to check the blood ketones using a ketone meter. Ideally the ketones should be between 1.0 and 1.5 mmol/L if we're in adequate ketosis. If they're above that, like say in the 3.0 range, it could mean that we're producing plenty of  ketones but they're not getting used up in exercise! The point of ketones is for energy, but if you're not using that energy, they're just laying around and building up. High ketones is not a health concern as long as they're under 8.0 or so. Having a moderate ketone level while being physically active means that we're using up the ketones we produce, and this is great! In fact, if we have high or moderate ketones before a workout, and then drop down to 0.5-1 mmol/L afterward, you'll know it's working!

In the initial stages of transitioning to a ketogenic diet, or maintaining a steady state ketosis, it's probably a good idea to have the fats relatively high. For therapeutic ketosis where you want the ketones as high as possible for benefiting the brain (such as in epilepsy), a keto diet can get 70-80% of its calories from fat. For the rest of us who are not using it to treat a neurological condition, that percent is unnecessarily high. When my metabolism was slow, I think I was at about 70% calories from fat, which for me was too high. Now that I've increased my protein intake (which allows me to build muscle in the context of strength training) my fat intake is around 60% of daily calories, protein around 27%, carbs 13%. I now believe that once the body has successfully transitioned into ketogenic fat burning, it's a good idea to reduce fat intake slightly so that the body chooses to burn body fat instead of dietary fat (the fat from food). For those CFers (or anyone else) who don't want to lose weight, it'd be best to keep dietary fats high. But I'm no longer worried about weight loss as a CFer due to Trikafta, which has caused me to put on a bit of pudge.

Calories and Macronutrient Ratios
Caloric intake should depend on our level of exercise and our basal metabolic rate (the baseline calories burned just being awake and doing normal daily  activities). The BMR varies depending on multiple factors like hormone dominance, season/climate, diet, health status, and constitution type. You can calculate your basal metabolic rate using several calculators online. I like this one which is specific for ketogenic diets. For non-therapeutic ketogenic diets (i.e. those used for fitness and/or body recomposition) the macronutrient amounts or ratios should depend on our health goals. We don't need to pay attention to % of the calories from different macronutrients so much. By macronutrients I mean proteins, fats, and carbs. According to Ketogains, protein intake should be a goal (related to have much muscle you want to gain), carbs are a limit (which we should not exceed if we want to stay in ketosis), fat is a lever (with which we can control body weight). The amount of carbohydrate is somewhat fixed around 40g/day max total carbs (though I can be in ketosis eating 50g or less), but the protein and fat amount shifts depending on our needs. When it comes to calculating carb limit, use total carbs NOT net carbs. Total carbs is the scientific standard, while net carbs is largely used as a marketing gimmick by companies wanting to sell fancy keto snacks.

Foods to Eat on Keto Diet
There are many, many resources on how to start a keto diet, so I'm not going to write about that here. However, I want to say that I do not recommend packaged foods sold for the keto diet. This is just catering to the health fad and often has way more carbs than is logical. Plus, packaging is harmful to the environment, and whole foods are always healthiest. Whatever you decide to eat, please please please favor local, organic, and grass-fed/pasture-raised foods. I get my foods almost exclusively from my garden, farmer's market, or my farmer-friends. I also recommend following some version of a Paleo diet for extra health benefit. It is absolutely possible to be a junk-food-keto person, just like it's possible to be a junk-food-vegan (the most common kind). So make sure that your keto diet is rooted firmly in ancestral health principles such as the Paleolithic diet or Weston A. Price. Diets should focus on mimicking as closely as possible how our ancestors ate in pre-industrial societies, because these diets are the most nutritious and the least toxic. Eating foods produced locally and in season is always best for our health and the health of the environment, reducing the carbon emissions associated with food production, food shipping, and also benefiting local businesses and farmers.

And yes, it's possible to be keto on a budget! In fact, for the first month eating this strictly I saved a lot of money on food because I really didn't need to eat very much -- when properly implemented keto reduces appetite and at the same time favors nutrient dense foods of smaller volume compared to other diets. And just because the keto health fad tries to sell us ridiculously expensive and trendy products it doesn't mean that is needed! Remember, many of our hunter gatherer ancestors were in ketosis a good amount of the time, and they didn't have any packaged foods or supplements available to them! There are some supplements that I think are decent though, like grass fed collagen powder or MCT oil. These supplements are not necessary however, whole foods are enough.

Remember also that we're not just eating organic and local and pasture-raised for our own health benefit. In my opinion, the primary reason to do this is for the benefit of the natural environment. I think lots of people make the mistake of thinking that they should go organic primarily because it will make them healthier. Sure, it's a good idea to limit exposure to pesticides, hormones, genetically modified foods, and untested chemicals, but the organic movement is at its roots an attempt to limit the ecological devastation perpetuated by agribusiness and mainstream agriculture. Please don't forget this. It's not just about you or about humans generally. It's easy for us anthropocentric westerners to forget this.

Stable Blood Sugar
I firmly believe that there is nothing, NOTHING, more effective for blood sugar regulation than a ketogenic diet. While I'm not yet sure of the safety of ketosis in type 1 diabetes, I firmly believe it should be the first line of defense and treatment for type 2 diabetes, CF-related diabetes (as long ass it doesn't cause unwanted weight loss), metabolic syndrome, pre-diabetes, glucose intolerance, hypoglycemia, and other blood sugar disorders. The point is that by reducing the amount that our endocrine pancreas is stimulated to produce insulin (to deal with meal time carbohydrates) we prevent spikes and crashes in blood sugar (as I described happened to me regularly in my previous post), increase insulin our sensitivity, reduce dependence on pharmaceuticals, and prevent all the harmful effects of blood sugar dysregulation like cardiovascular disease, obesity, kidney damage, eye damage, diabetic ulcers, etc.

So in this more advanced stage of ketosis that I'm now in, my blood sugar is amazingly steady and I very rarely get hypoglycemic anymore. Sometimes I am slightly hypo in the morning when I wake up (in the 60s) but 2 grams of carbs in my dandelion morning tea can correct this. Plus, when we're in ketosis our bodies can do this crazy thing called gluconeogenesis. This means that we can produce glucose from protein, fat, or lactate without needing to eat carbs, and this can keep our blood sugar steady without triggering insulin production! Specifically, in a fastest state, if we produce lactate through exercise-induced lactic acid build up (when our muscle start to burn due to lifting weights, for instance) gluconeogenesis can convert that lactic acid into glucose! This explains how I can workout and actually raise my blood sugar about 10 points, but only if it's intense enough to "feel the burn". Moderate or low intensity exercise like walking will not do this--walking will normally drop my blood sugar.

In this new diet change, I also made note that breakfast is really important to have very low carb. Eating more than 10g carbs will send me into a crash within a couple of hours, and yet these breakfast carbs can only be from fiber. So, for example, my usual breakfast is two hard boiled eggs and two teaspoons of miso. The miso has 5-8g of carbs per two teaspoons, and much of it is fiber. Yet if I add vegetables to that (even kale!), I can push myself over the edge and get hypo in a little while. I am very sensitive in the mornings, so I only eat veggie carbs later in the day.

I have also noticed that while in deep ketosis, I can sometimes accidentally have a blood sugar spike (like if I eat too many carbs at a potluck), but I don't get the post-meal crashes that I did before! In these situations, the blood sugar naturally  comes back to balance in a timely fashion. This has never happened to me before! However, if I allow myself to eat too many carbs or let my blood sugar to rise above 130 mg/dL more than twice in a couple of days, my blood sugar will lose its steady state (probably due to a disruption in ketosis) and I'll begin to get cyclic crashes again. If you have volatile reactive glycemia like me, watch out for this! For you and me, our keto diet has to be very strict to prevent reactive hypoglycemia.

What I Eat Presently
My diet is constantly shifting as my caloric needs shift (since I'm now working out more and muscle gain increases caloric need), however, here is a daily snapshot of my diet right now. I offer this because when I've started out on a new diet, I find it helpful to see what others are doing in order to judge how hard it's going to be. This is not a hard diet to maintain once you get used to it. 

Breakfast (after workout): two hard-boiled eggs plus two teaspoons of miso. Sometimes I'll add a tablespoon of sunflower seed butter (unsweetened) and/or 2 oz. of deli meat.

Lunch: 4-5 oz. grassfed local ground beef with either a salad or a veggie stir fry (kale, mushrooms, zucchini, onion, garlic, other seasonal veggies from my garden, optional tofu, plus tamari and green curry paste), 1 tbsp of sunflower seed butter for dessert.

Snack: cucumber or pickle.

Dinner: Pea and hemp protein shake with MCT oil. Or I may eat at a community potluck favoring meat and veggies.

That's it. Pretty simple. I don't have a huge amount of variety in my diet but that's mostly because I'm not a very creative cook and my food budget is small. I don't miss my old diet though. I have zero food cravings on this diet, which is a great relief! My body is getting all the nutrients it needs and the keto diet controls hunger so that I'm rarely hungry and can go without food for many hours (as long as my ketones are high enough and blood sugar is stable).

Possible Side Effects
I strongly believe that the keto diet is the most effective treatment for reactive hypoglycemia and many types of diabetes. There are a few possible side effects I have experienced, however. One is that since going keto I have gotten many more kidney stones than before. After doing a lot of research on this topic, I've come to the conclusion that keto is not entirely to blame for this. Primarily cystic fibrosis is to blame, for we have the unfortunately luck of having excess excretion of calcium in our urine, and this may have to do with the faulty CFTR ion channel. Secondly, a keto diet is low in phytic acid because we eat little to no grains or legumes. Phytic acid is an anti-nutrient in these foods, and while we don't want too much of it in our diet, it is sometimes helpful in that it binds to dietary oxalates and calcium (the combo of oxalate and calcium from the diet lead to calcium-oxalate kidney stones). Thirdly, unless we're paying attention, it's very easy to eat too many veggies or nuts high in oxalic acid. Now I'm on a very low oxalate diet. Fourth, we must make sure to drink enough fluids, at least 70 oz. daily. Lastly, eating small amounts of dietary calcium can help bind with food oxalates, and taking potassium citrate supplements can help prevent stone formation.

I also suffer from gout (uric acid build up), but again, this is more the result of CF than keto, as I had gout before going keto. While gout can happen when we eat too much meat, I've found that it's more triggered by ingestion of fructose. As long as I have ZERO fructose in my diet (yes, this means I cannot eat any fruits) then I never get gout, no matter how much meat I eat. I also take a small dose of allopurinol (100mg) to take the edge off of the uric acid build up, but that will not help me prevent gout if I eat fructose. So if you get gout on a keto diet, I suggest limiting fructose to as close to zero as possible.

If anyone is interested in my research on both kidney stones and gout, please let me know and I'll write another post about it. In the mean time, check out this rich resource from Dr. Fred Coe. I am indebted to him for his amazing educational work, all presented for free!

I hope this was helpful to you and that if you're like me trying to stabilize your blood sugar, please consider the keto diet. If you have any questions, please post them in the comments. Be well!