Ketosis questions and type 1 diabetes

Diet and Nutrition
1

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.

2

I really and truly wish I could help you better, as what I have is terribly minimal and the need is so important. I simply haven’t ever at any time put any focus into Type 1 diabetes and so I know scarcely anything. Your questions have considerable depth.

The main thing that seems worth thought is that the doctor’s idea of diet seems very, very group-think.

There is absolutely no way that throughout human history there hasn’t been a very major percentage of kids who grew up just fine without anything like so much carbs, simply out of availability in many areas. No way.

Although there’s a huge problem in my not understanding, from flat not knowing, the metabolic disturbances that may be present in Type 1 diabetes as opposed to Type II or metabolic syndrome, let alone for growing up. Too much lack of knowledge! That said I don’t see (maybe because of not knowing something key?) why a diabetic child should get more carbs than any number of children in history who have grown up fine in areas and times that did not have much carbs. I’m not saying extreme low carb, it sounds like your ideas are balanced and the doctor’s idea of norm, is not.

3

Kids with type 1 diabetes did not live for more than months or a couple years after onset before insulin was isolated. They typically died from ketoacidosis. Insulin supresses ketone production in the liver, so type 1 kids do need insulin whether they need carbs or not. In fact even if they don’t eat carbs, they eventually can get high blood sugar because glucagon is signalling the liver to release sugar, and gluconeogenesis will produce sugar, but it can’t get back into the liver.

They tried to extend lifespan by feeding kids low carb diets before we had insulin.

So they need some insulin to move carbs back into the liver and keep it from getting chronically depleted. Or perhaps they could some eat fructose, to rebuild liver glycogen, or adapt to make more from gluconeogenesis. Bill, I am not asking anyone for a prescription to follow. I am really just trying to get specific answers to some of the specific questions. Forget that we are talking about a type 1 diabetic kid for a minute. Do you have any ideas about some of the other questions?

Here are the main ones:

  1. Does milkfat or coconut milk before bed trigger ketones once the carbs are used up? If you eat MCTs will you get ketosis rather than beta oxidation?

  2. 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?

  3. Why isn’t it just beta oxidized, in other words does ketosis have to mean that liver glycogen is low?

  4. Why don’t I get ketosis if I eat dinner early and sleep late? (more liver, more liver glycogen?)

  5. Can a kid or anyone grow if they wake up in the morning with medium ketones?

  6. Will people adjust to more fat, less carbs over time with gluconeogenesis and better beta oxidation and so not go into ketosis as easily.

  7. Being small and lean again, does ketosis mean “catabolic”, or can it be the result of consuming dietary triglycerides before bed?

  8. 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.

4

My thought was that if someone gets enough carbs to meet their basic glucose/glycogen replenishment needs without becoming insulin resistant, and they get insulin to match, and maintain good blood sugar that they should be able to get the rest of their calories from other sources. It could be that the developing brain needs more carbs though. He has done great with blood sugars averaging 100 for 10 weeks without highs or lows. And he just had 1 morning with medium level of ketones which went away within a short time after eating.

I think he probably just didn’t eat enough total food for dinner. He had 37 grams of carbs which has worked well, but he didn’t get as much fat an protein because I made chicken soup with rice noodles, and he basically ate all the noodles, and half of the broth, but didn’t eat much of the protein, and it only had a little fat. I just need to make sure he downs around 400 cals for dinner but keep the carbs where they are I think.

5

Again wanting to emphasize my limitations on this, your thinking makes complete sense to me.

6

It looks like my sons morning “medium” ketones were the result of a mild viral infection. He ended up having a 100-101 temp in the evening. So the good news is that the 150 grams carb ceiling that worked so well to control blood sugar still looks good.

In fact the morning ketones showed he was getting sick 12 hours before he had any temperature.

7

[quote]mertdawg wrote:

  1. Does milkfat or coconut milk before bed trigger ketones once the carbs are used up? If you eat MCTs will you get ketosis rather than beta oxidation? [/quote]

I don’t think there’s a major effect here if any at all for any type of fat consumption. The driving factor is the low carb state, perhaps further driven by protein catabolism if that is occurring.

Some evidence towards there being some effect would be (depending on how one evaluates it) a rat study where on refeeding after high fat/low carb or more typical diet, increased fat intake on the refeeding gave a rise in ketones. That might be explained by enzyme upregulation perhaps. Another explanation likely could be partitioning of absorbed glucose towards glycogen synthesis rather than oxidation.

In human evidence, and not refeeding after caloric restriction but rather ongoing diet, a study found no effect of increased fat intake itself on ketone production provided that intake was supported by quality protein (albumin instead of gelatin).

I don’t think there’s a problem with either timing so long as there is no ketoacidosis. If it was occurring, then your idea seems to me to be a potential solution or aid and worth trying.

There’s always some production of ketone bodies, but it’s high only when when liver glycogen is low.

On a normal-carb diet, glycogen stores are large enough to allow not only for time of sleeping, but even for 90 minutes or more of hard work, which is more calories than RMR times the period of sleep.

I would surely tend to think so though I have not studied it. At the least Eskimo kids for example surely grow. But might they have a greater adult height had they had more carbs? I don’t know.

Ketosis is fine, it’s ketoacidosis that’s a problem. Rate of production of ketones won’t decrease with adjustment to the diet.

Ketone bodies in the blood are actually anticatabolic. However, catabolism while sleeping could promote the production of ketones.

[quote]8) 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.
[/quote]
I am extrapolating but quality protein might well help, both from the standpoint of decreasing catabolism, perhaps therefore the production of ketone bodies, and because it supports gradual conversion to glucose at a rate that would be relatively easy on your son’s natural insulin production he still, I’m very glad to hear, has.

8

Thanks Bill. This is useful info and opinion.