I wanted to write a technical post about a question I keep getting regarding the ketogenic diet and hypoglycemia. Even if you’re not into the keto diet, I think you may find some useful ideas to make low blood sugar less invasive in the short term. I recently shot a series of videos about the ketogenic diet and diabetes as part of my daily YouTube vlogging and you can check those out and subscribe here.

My general goal in my diabetes management is minimalism. Minimal intervention, treatment and daily impact. The most basic manifestation of this is to aim for the use of less insulin, which can create greater blood sugar stability. This strategy led me to a low carb diet. The need to have athletic performance in addition to the blood sugar stability led me one step further to the keto diet.

Using less insulin and eating fewer carbs means that lows do still happen but less frequently and they are easier to handle. Consider driving an empty truck down a hill. It’s going to be easier to stop than if it’s loaded down and has greater momentum. The same concept applies to insulin loads and slowing the “drop” of blood sugar. Simply lightening the load can simplify control of the vehicle.
When a low blood sugar occurs, the treatment ideally involves matching an increase in BG to the proportionate decrease in order to balance the two out. Therefore all hypo treatments are not created equal, or one treatment does not fit all lows– since different methods of raising blood sugar work differently.
One of the biggest obstacles to blood sugar stability is over correction of lows. Over correction can result from either the source of the treatment, the quantity of the treatment or a combination both factors. In other words, you don’t have to eat the entire pantry to overcorrect and spike. Sometimes following the 15×15 rule (eat 15g fast carbs, wait 15 minutes, test, repeat as necessary) can still yield the dreaded spike–which is now that much harder to bring down because you don’t want to overdo it and crash out–again.
The ideal treatment for a hypo is the smallest possible one. The hard part is figuring out how little you can get away with when you’re churning with adrenaline, in a cold sweat and panicking.
I’m suggesting that instead of always prioritizing the fastest treatment, prioritize the method of least intervention–when it’s possible to do so. There are certainly times when I’ll take glucose tabs or “fast sugar” of some kind, but those are typically emergency lows, not more benign lows. I classify my low blood sugars based on how fast I’m dropping because that correlates directly to the severity. Fast lows are treated as an emergency with emphasis on survival. Slow lows are treated with and emphasis on controlling the spike. In my 17 years I’ve used direct sugar sources (juice, glucose tabs, honey, candy, shot bloks etc)  about 10-12% of all my lows, probably fewer than 150 “fast-low” incidents.
I draw on that experience to inform me as to what methods I should use to treat lows. This allows me to still correct low blood sugars without having them bounce high. I should add that as I’ve been on the Keto diet in the last year I’ve had ONE low that required fast sugar. The rest were managed with slower treatments that better matched the insulin action, resulting in little or no rebound spike (over 180mg/dL)
My go to treatments are all ones that CDEs would reject for having too much protein or fat: cashews, peanut butter, dark chocolate, ice cream (if I need more sugar but with a slower release), beef jerky. Obviously these won’t work with large doses of insulin and their corresponding BG fluctuations. When you bring the doses down, fluctuations narrow down and you find that these types of foods will work better in parallel with the action profile of the insulin.
I’ve tried fast sugars in much smaller amounts but they always cause a spike and that rapid increase makes me feel like there’s a brick in my stomach.
The question of how various hypo treatments impact ketosis leaves room for simple sugars as well as my preference of slower sugar. The amount of sugar (fast or slow) that it takes to raise a low while eating keto is relatively small and should not do more than possibly diminish ketosis for a few hours. I can frequently use protein to treat a low on the keto diet. Remember, more than the minimum required intake of protein will get converted to glucose–this is a sneaky fact that often wreaks havoc on unsuspecting people with diabetes! Treating a low blood sugar suspends ketosis temporarily and doesn’t require you to go back through the arduous process of keto-adaptation. You can resume ketosis in 12 hours or less with no major adverse effects.
Treating diabetes is risk management. Tighter control creates its own risks as does loosening up and letting the numbers stray a little further from the ideal. Knowing when to shift gears is key and building the experience gradually and carefully is an important investment in long term health. This isn’t a magic wand that will fix your blood sugar. It’s self experimentation that will help you calculate your risk more effectively–but never eliminate it. I can’t overemphasize the importance of looking at this process as an experiment. I’m presenting my results to encourage your own experimentation, not to replace any portion of it.