My son has type I diabetes recently diagnosed, and he is 9 years old, and small (50 pounds) and without much fat supply on him. He is also in the "honeymoon phase" where his blood sugar is easily managed because his pancreas has temporarily regained most function because is got a break from the insulin injections. He gets a minimal insulin.
Now the doctor told me that while the traditional approach of medicine is to eat 80% carbs with as little fat and protein as needed/possible, kids will range anywhere from 80% to as low as about 40% of their calories from carbs in some case.
I found that lower carbs with more fat kept his blood sugars perfectly normal with the insulin doses (he is between 70-135 all the time in the honeymoon phase) while higher carbs required an increasing ratio of insulin and actually there was no way to prevent highs when he was getting more than about 65 grams of carbs at a meal.
So I worked on getting him about 50% carbs, 35% good fat (whole milk, butter) and 15% protein.
And he is getting 125-150 grams of carbs a day BUT
He wakes up in the morning with a "medium" amount of ketones even though his blood sugar is around 90 (unlike typical diabetic ketoacidosis where blood sugar is 300+ and you have a problem because your not getting insulin to move the carbs into the liver).
He eats dinner early (5 pm) and has a small 15 gram carb snack with fat and protein at 8 pm, and doesn't get down for breakfast until 7:00 am so he is really in the range of near fasting conditions for around 11 hours.
So go ahead and throw out ideas. Is it bad?
Why does he get into ketosis on 150 grams of carbs for a 50 pound kid when his insulin is clearly enough to move glucose into the liver?
Does milkfat before bed trigger ketones once the carbs are used up? If you eat MCTs will you get ketosis rather than beta oxidation?
Is it better to get fats during the day when you can burn the ketones for fuel rather than at the end of the day when they might build up?
Why isn't it just beta oxidized, in other words does ketosis have to mean that liver glycogen is low?
Why don't I get ketosis if I eat dinner early and sleep late? (more liver, more liver glycogen?)
Can a kid grow if they wake up in the morning with medium ketones?
Will people adjust to more fat, less carbs over time with gluconeogenesis and better beta oxidation and so not go into ketosis as easily.
Being small and lean again, does ketosis mean that he is catabolic, or can it be the result of consuming dietary triglycerides before bed?
Is there a way to avoid ketosis without upping carbs given that his blood sugar is not high. It seems that ketosis is the natural effect of not having a lot of circulating insulin, but well, that's because he is not on the super high carb diet that doctors used to push.
It also opens the door to a possibility I had considered that onset of type 1 diabetes might be quickened by hepatic insulin insensitivity. He is getting very little fructose, about 10-15 grams of net fructose a day which I mention because fructose can rebuild liver glycogen without insulin.
My goal is to find a solution that lets him stay at around 150 grams of carbs or less to optimize sensitivity and keep his pancreatic function for as many months as possible, and to let him gain some weight and grow properly, and avoid any risk of "high" ketones again usually associated with high rather than low blood sugar.
If he was larger I would not really be concerned about the medium ketones with good blood sugar in the morning. Mild ketosis actually has a few health benefits. One is that it activates the immune system to destroy precancerous or damaged/dysfunctional cell masses. Another is that if blood sugar gets low, having some ketone capacity can protect the brain at lower blood sugars than without ketones. Studies have shown that people can avoid unconsciousness/disorientation/confusion with blood sugar 10-15 points lower if they have some ketones to support the brain. Also having glycogen stores a little low really seems to improve insulin sensitivity and prevent blood sugar highs because there is plenty of room to put the carbs from meals, while with full glycogen, you may have the insulin needed, but just no place to put them, especially if you have very little fat as well.