Are ketones dangerous?

Are ketones dangerous? The answer to that question is it depends. I think it's important to note that ketones still may pose a risk for those of us on a ketogenic diet, pursuing nutritional ketosis. I have blogged a lot over the years about the benefits of a ketogenic (low carb, high fat) diet for type 1 diabetes. I even wrote an eBook about it. I began my dietary experimentation after 15 years of living with diabetes so my discussion of this topic often assumes that readers are also aware of their own limits and responsibility to establish their limits before inviting complex experimentation. As exciting as the results of a ketogenic diet are, risks must be understood in order to proceed safely.

Ketones can indicate diabetic keto-acidosis or DKA, which is life-threatening insulin deficiency, for someone with type 1 diabetes. Sadly, far too many people with type 1 diabetes die from DKA every year. Although the risk is pretty low on an annual basis, there are large numbers of people who actually die from DKA. So, you can easily see why the medical system believes that ketones (or the condition it is associated with) can absolutely can be dangerous.We all enter into experimentation with ketosis having had the "ketones are dangerous" doctrine drilled into our heads from the time of diagnosis. When you have type 1 diabetes, assuming a standard carbohydrate driven diet, the appearance of ketones in any concentration suggests DKA (diabetic keto acidosis) which is life threatening! DKA occurs as a result of insulin deficiency and correlates with elevated blood glucose. In response, usually over a period of hours, the liver dumps ketones which accumulate in the bloodstream at levels approaching 20 mmol/l . At this level of concentration the blood acidifies and the symptoms of DKA set in. This condition requires insulin to slow the production of ketones and correct the elevated blood glucose.

The problem is that ketones in a standard carbohydrate diet only appear in response to this critical insulin deficiency and so their association is purely negative and tantamount to danger. The idea of pursuing ketone production on a much lower level as a means of health and energy isn't even in the picture. If I go to the hospital as a Type 1 Diabetic, I have to be very careful to let them know that I am in nutritional ketosis NOT DKA. Often times the mere presence of any ketones is a red flag since it's the primary marker for DKA. Few nurses or doctors will say, "Yes but how high are his ketones? Only 3 mmol/l? Oh--he might not be in DKA, we should see if he's in nutritional ketosis!" They are not testing to see how high the ketones are; they are only testing for presence or absence.

To be honest, there are SO FEW people pursuing nutritional ketosis that it is unrealistic to expect that every medical provider will be “hip” to T1D and/or nutritional ketosis. Frankly, even many national experts on T1D believe that nutritional ketones might cause DKA in high enough doses. Whether this is true or not remains to be seen, but you get the idea of the challenges a keto-friendly T1D person faces when intersecting with the carb-burning non-T1D world. Here is an example of the kinds of “cognitive dissonance” you should expect in the mainstream medical world:

I got a concerned email from a person who had been hospitalized with misdiagnosed "Keto Flu" after starting the ketogenic diet. Her blood glucose tested in normal range but feeling the flu-like symptoms that often times coincide with fat adaptation (requiring electrolytes and salt) alarmed her. She decided to play it safe and at the emergency room the staff only focused on her type 1 diabetes and the presence of ketones. They treated for DKA when she was actually not in DKA but had been producing lower levels of ketones through nutritional ketosis.

I experienced these same symptoms when I first started on the ketogenic diet (many people do-it's called the "Keto Flu") and I had the same concerns of DKA. I did some research and discovered that this was commonplace and not a danger so long as blood glucose was within acceptable range (which it was). I drank some bullion soup to get some extra salt, went to bed early and the next day the symptoms were gone and I was adapted to burning fat as my main source of energy! Still, it can be a tough call to make given the consequences and prudence is always the better part of valor.

Nutritional ketosis introduces ketones at a low level the body can use for energy and at a concentration that does not acidify the blood. Nutritional ketosis usually refers to ketone levels between 0-3 mmol/l whereas DKA sets in around 20mmol/l. However, without the black and white back drop of "no ketones=good, some ketones=danger" things can get a bit murky. When inviting an increase in blood ketones through nutrition it's important to note that this CAN contribute (even if only slightly) to slight head start for DKA in an insulin deficient scenario. In the fairly extensive research I have done about the question of "are ketones dangerous" I have not heard of anyone being able to generate anything even close to 20 mmol/l of ketones through nutritional ketosis. Still, that does not mean it's impossible or that we can afford to be complacent.

Many studies have associated insulin pump use with increased rates of DKA. The convenience of pump use may sadly come at a cost. If you are concerned about DKA and pumps, one possibility is to use long acting and a pump at the same time. This is one of many reasons I choose not to use an insulin pump. Bad sites, occlusions, cooked insulin from hot yoga, kinked tubing, empty insulin cartridges or dead batteries can all put you in a situation where you're headed for DKA and if you're already in nutritional ketosis--that very well may serve to grease the rails! If you already have a higher blood ketone level from nutritional ketosis it's also likely that you can go into DKA at a lower blood glucose level since less extreme highs and less duration of time would seem to be necessary to increase ketones to 20 mmol/l--a point that's relevant regardless of your chosen method of insulin delivery.

The flip side of this is that vigilance and attention to blood sugar will help interpret the appearance of ketones if you're prepared for more nuanced information. Nutritional ketosis alone (assuming "normal" titration of insulin and blood glucose levels) will not raise ketones to the point of DKA. Also, when on a low carb diet, blood glucose excursions are much smaller and much less frequent. Assuming the insulin one takes is reaching it's delivery target, the likelihood of going high enough to enter DKA is very low. Awareness of the change in risk management strategy is key-specifically in the first week or two of adapting to a ketogenic diet.

I'm not writing this to scare anyone or to back-pedal from my usually laudatory discussion of ketones. I'm sipping coffee with butter and beta hydroxybutyrate in it and preparing to go to the gym for a fasted training session later this afternoon. As beneficial as ketones are when understood fully and used properly, they are equally dangerous when approached without proper preparation and caution. I believe that there are not enough disclaimers in the world to replace common sense and individual responsibility. I am frequently torn between a desire to share the nearly magical properties of ketosis and to keep silent about them. Attention to detail is imperative; the ketogenic diet isn't something you wake up one morning and do haphazardly.

The keto-T1D community is a small slice of a small fraction of the US population. When you enter the carb-burning non-T1D world that most of us live in, be prepared to experience some misunderstanding.

I posted a photo on my facebook page recently discussing some of the benefits of ketosis relating to hypoglycemia. I received a comment complaining that I should offer more disclaimers or else people would take my post as being "prescriptive" leading to dangerous outcomes for the uninitiated. I pointed out that literally the first words of my post read: "First, a couple of disclaimers"

To this the commenter replied, "Oh well it's on Facebook, so I can't actually take the time to read anything but the teaser text"

Again, the first words were a disclaimer. Despite all of my best efforts, there will never be enough precautions to replace simply reading and researching. Common sense. Personal responsibility. Still, I wanted to have some information available for those willing to read about the points of caution that I have adhered to in my experiments. I am a big believer in ketogenic eating for type 1 diabetes but that doesn't mean I throw caution to the wind, much less advocate for others to do so.

  • Go gradually. Test often. Be aware of how your body feels. Insulin puts the brakes on ketone production; if you're having second thoughts, eat carbs and take insulin.
  • Cut carbs and replace those calories with fat-gradually, over time. Cut carbs by 20% every week or so until you're fully in the ketogenic zone (less than 50 grams daily). Once you're comfortable eating around 50 grams of carbs or fewer each day, then experiment with shifting calories from protein to fat while testing for ketones. A slower approach means smaller errors and smaller corrections to the process.
  • Going from high carb to low carb may take a month. Going from low carb to fat adapted (ketogenic) may take another month. Patience and a methodical approach will help it "stick" in the long run.
  • When shifting the majority of calorie intake to fat sources (ketogenic diets are usually a 75/25 ratio of fat to protein) prepare to supplement electrolytes (salt will do in an emergency) with magnesium, potassium and sodium. Failure to do this will lead to the "Keto flu". I learned this the hard way-stay hydrated and up the electrolytes!
  • Don't try to workout with any intensity until you're fully past the point of fat adaptation. It can be hard to resist the feelings of stable blood glucose and energy, but be patient and give it a couple of weeks. If you must, do very limited, low intensity exercise like walking. This helps you deal proactively with changes in insulin sensitivity and allows your body to learn this new "metabolic language" gradually.
  • Exogenous ketones can make a good thing better, but personally I did not try them within my first year on the ketogenic diet. I believe that the benefits are fantastic but the risks are much more significant given my type 1 diabetes. Being totally solid on a ketogenic diet is an important step to really understand how your body responds and if ketosis is something you want to venture deeper into.
  • Never get complacent. It only takes a skipped dose of insulin or a pump site gone bad overnight to put you in range of DKA. This is one reason why a full on keto diet might not be a great idea for teens or those who are more likely to be distracted.

It's not all bad news though. Plenty of people manage the risks of ketones with no problems. Plenty of people drive their car to work despite the obvious risks that require management. It's important to point out that a ketogenic diet is a low carb diet but not all low carb diets are ketogenic. Simply eating lower carb without getting into nutritional ketosis can be a much simpler way to gain 70-80% of the benefit of glycemic control with only 20% of the effort--but that's a topic for another post!

The takeaway from this discussion is that DKA kills many people, year after year. Don’t be complacent. The benefits of nutritional ketosis do not justify a lower level of vigilance against the dangers of diabetic keto-acidosis.


For the love of exogenous ketones!

You read that correctly. I love ketones and I am actively pursuing ways to increase my bodies ability to produce them through the use of exogenous ketone supplements. Ketones are a dirty word in the world of diabetes because of the confusion surrounding their appearance as the harbinger of doom through DKA (diabetic ketoacidosis). Unfortunately many healthcare providers actively discourage their diabetic patients from attempting to achieve nutritional ketosis because they don't fully understand the difference between nutritional ketosis and DKA. That difference is NOT the focus of this post, other than to establish the fact that there IS a difference.

It's important to note that the means of detecting DKA is typically the presence of ketones in the blood. Adding them through exogenous supplementation or nutritional ketosis is useful (I would even argue beneficial), but not without some risk. In case of insulin deficiency (bad pump site, occlusion, skipped dose etc) while in ketosis one would be without the means to clearly identify DKA. You'd only be able to guess based on blood glucose level to infer how insulin deficient you are. The risk can be mitigated through vigilance and attention to insulin dosing but shouldn't be taken lightly.

I've recently started using exogenous ketones to help put me into nutritional ketosis more readily and I wanted to report the initial findings since I've been asked about them so many times. Up till this point I didn't feel compelled to spend the time and money on exogenous ketone supplements--which are not cheap! I took the plunge and got some delicious, chocolate-flavored betahydroxybutyrate or (BHB) for short. I am not going to attempt to get into the science behind the impacts of BHB on my blood sugar, energy and metabolism-just share what I have observed happening in my own blood sugar management and health since I've started using it.

Why ketone supplements?

I spent several years feeling pretty ambivalent about supplementing ketones. I got good results in balancing my blood sugar and maintaining energy from simply consuming the standard macronutrient balance (75% fat/25% protein) so I never felt the need to optimize the process. Boredom got me to experiment with the ketogenic diet in the first place and ironically it's what inspired me to try to kick it up a notch. Also, due to recent life changes, I haven't been climbing. Instead, I've returned to normal weight training (which is more affordable and accessible given my situation) and I found that my power in standard lifting techniques to be...lacking. I needed something to kickstart better performance.

Nutritional ketosis, when achieved strictly through endogenous ketone production is a little bit squirrelly. It doesn't always occur at the times or to the extent that you want it to. You may be in deeper ketosis at night when you're sleeping--but in the morning after you eat breakfast it falls off for several hours after eating, for example. One solution to this problem is intermittent fasting--delaying that breakfast for the sake of longer fat-burning ketosis (which I've been doing as well, but I don't want to lump that discussion in here). The other solution is introducing external or exogenous ketones to kickstart nutritional ketosis even when the internal production mechanisms are moving a little behind your desired pace.

The introduction of ketone supplements has given me a greater control of when I am in ketosis (and how deep I go) and it's also hinted at some other benefits of ketosis that I didn't expect or understand--besides the energy increase. It seems as though exogenous ketones can have a blood glucose suppressant effect. I have noticed that the increase in blood glucose (after meals where I have taken exogenous ketones) is much less prevalent. Unfortunately my CGM broke and I have been without the continuous data to prove this, but I have been consistently surprised when testing one or two hours after a meal where I would normally have had to take a unit or two of insulin (having taken none) and finding my blood glucose to be in the mid-high 80s rather than 130-150 as I would have expected.

This could be part of the explanation of why ketones build up in the presence of extremely high blood glucose. Ketones are not simply the "bad guy"; they are dumped into the blood stream as part of an emergency response to enhance the role of insulin during high blood glucose events. Obviously ketones cannot replace insulin all together, which would explain the feedback loop of increasing blood glucose and dangerously high levels of ketones in the blood or DKA (which cannot occur strictly through nutritional ketosis with insulin on board). This is my hypothesis based on a couple weeks of personal observation--please note that I'm not suggesting that anyone stop taking insulin and replace it with betahydroxybutyrate.

Another thing I've noticed since being on the ketogenic diet is that my body responds differently to low blood glucose and insulin. It's felt as though the insulin works harder and faster when my blood glucose is higher and then backs off as my sugar normalizes--almost like the ketones are educating my insulin to create a "smart insulin" performance. Since supplementing exogenous ketones and seeing the glucose suppressant effect that I noted earlier, I have had to deal with more low blood sugars-and I am in the process of tweaking my basal insulin dose to fix this. These undesirable hypoglycemic events actually have presented me with an opportunity to observe the way that ketones mitigate the symptoms of low blood sugar which is also exciting!

I want to be clear that I am not talking about hypoglycemia unawareness--which is dangerous and not something I know how to cultivate or would advocate for if I did. During lows I have been totally aware of the fact that my blood sugar is low and needs to be treated BUT notably absent are the sweating, shaking and panic-induced hunger that makes a low so scary and difficult to handle. It's as though the increased ketones blunt the symptoms of a low to the extent that you still are aware of it--but do so while taking the bite out of the symptoms and allowing you to function fully normally. Imagine a hypoglycemic event without the panic-eating and corresponding blood glucose spike!

In terms of athletic benefits of the BHB supplement, the jury is still out. It will take more time for me to observe and report. The initial blood glucose indications are encouraging however not written in stone.

Where do exogenous ketones fit in the mix--specifically for people with diabetes? I'm not a doctor so I can only share my experimental philosophy--that's what this stuff is at this point--an experiment. Go gradually. Starting from a "normal" diet, gradually reduce carbs by 20% per week. Get under 100g carbs and get comfortable there. Then get under 50. Then get the protein and fat right and dial in the ketogenic diet and learn how ketosis feels. Exogenous ketones aren't something that you just try on for size over a week or two (at least that's not how I have approached them) but they seem to be a really exciting way to enhance an already established low carb, high fat diet.

Stephen Richert is a photographer and filmmaker who happens to live with type 1 diabetes. You can see his professional portfolio here.

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with your friends, it would be greatly appreciated!


Share your story about insulin access

Banting's Ghost has gotten enough funding to begin the documentary process thanks to 36 amazing Patreon supporters (and we still have room for more)! Without stories to document however, there is no documentary. That's where I need your help. Do you have a story-or have you heard someone tell their story and feel like it needs to be heard? Insulin access stories seem to be everywhere until you pull out a camera and notepad; then everyone sort of puts their hands in their pockets and start kicking rocks. There is a bit of a time constraint for capturing the first round of stories as I am enrolling in a nursing program this fall and will have additional responsibilities which will limit my ability to travel freely this fall.

If you're wondering what kind of stories I'm looking for, let me clarify: stories of people impacted or involved in issues which relate to insulin access. This could mean anyone from the CEO of Lilly and JDRF who are on one end of the access pipeline to someone on the complete opposite end, living in rural Utah and unable to qualify for medicaid AND unable to afford insurance premiums. Maybe you've lived off of samples from your doctor--or maybe you're the doctor. Maybe you're the pharmaceutical rep who delivers the samples to the doctor and you see all this very differently than those of us who are outside the industry.

This is a complex story with many perspectives. All of them are important to understand. I realize that people sharing their stories are putting themselves at risk and I am willing to be discreet and conceal identities if need be in order for my subjects to feel comfortable about opening up. I am committed to an honest representation of what my subjects share; I am not creating a hit piece against the industry nor a puff piece for it. I want to capture the struggle of people all along the chain of this issue.

Providing a platform and inviting you--that's all I can do. Now it's your turn:

  • Visit our contact page linked HERE or email me directly: steve@livingvertical.org
  • Share your name and relative location (I won't share this information publicly)
  • Give a brief summary of your story (doesn't have to be in depth, just bullet points about the main conflict you're experiencing
  • Let me know how you prefer to be contacted if we can work together.
  • Please note: I'm not looking to promote other blogs or personalities within the diabetes community through Banting's Ghost. This project isn't about sharing your workout and diet program or promoting your speaking tour or book.
  • If you have a blog or a book or whatever but you also have a story that relates to insulin access--then by all means reach out and get in touch. I'm not trying to exclude anyone--just trying to focus on stories about insulin access.
  • THEN SHARE THIS POST!

I'm excited to see how far this can go and what we can create together. It won't be easy and it may not even be successful. Documentaries are lots of work and sometimes they fizzle out. Still, the only way to know is to try hard.

Stephen Richert is a photographer and filmmaker who happens to live with type 1 diabetes. You can see his professional portfolio here.

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with your friends, it would be greatly appreciated!


High cholesterol meets ketosis: an update

A couple of years ago I started using the ketogenic diet to manage my blood sugar as a type 1 diabetic and to enhance my athletic performance. I wrote a series of blogs and an ebook to share that experiment because adopting a low carb high fat (ketogenic) diet has become the single most beneficial thing that I've done for my diabetes management and my ability to be active in the 20 years I've been living at this difficult metabolic crossroads. Eating ketogenic has improved my life and my ability to make photography, climbing and moving around in the outdoors the center of my life rather than fleeing the complications of diabetes.

I didn't expect those posts to take off because I'm not a dietary blogger. I just wanted to share the ups and downs of what I was trying in hopes that it would help other people. One of the major issues I encountered was the sharp increase in my LDL ("bad") cholesterol and initially I considered abandoning the ketogenic diet because I feared that I was just trading one risk factor for another. If you want to read that post and the comment thread check it out here!

I am writing this post to update you since two years have passed and I have found some information that I believe is useful. I also want to clarify my current position on the cholesterol issue and why my LDL is still high and why I'm not letting that fact deter me from eating ketogenic. In fact, I am going to share a couple more blog posts in the future detailing some new experiments I've been doing using intermittent fasting and exogenous ketones which has been nothing short of mind-blowing!

Exhibit A: Biohacker's Lab podcast (non-iTunes) or Biohacker's Lab (iTunes) : Ep8: High Cholesterol Levels on a Keto Diet Experiments by Dave Feldman

If you have concerns about the impact of high cholesterol on your health--specifically if your cholesterol values have increased as a result of a ketogenic diet that has otherwise improved all the "other" health markers you monitor then this podcast has some very important considerations to add to your risk management assessment.

If you've done even a tiny bit of searching about the topic of cholesterol and it's impact on health you'll know that it's incredibly complex and there's a great deal that is not known. There's also a lot of passionate exploration of opinion and theory without true authority because very few cholesterol studies have been done on people who are ketogenic. These are the realities of the murky water in which we swim as we make life and death decisions.

My own position is what I'm sharing here. This isn't my advice to others determining their position. I have measured the risk of high cholesterol against the risk of high and/or unstable blood glucose and I am willing to accept the worst case outcomes of high cholesterol over the worst case outcomes of high blood glucose. I don't say this to be flippant about risk but to clarify that risk cannot be avoided, it must be managed. I don't eat to live forever, I eat to live well first and to live long secondly. I'd like to think that eating to live well would enable me to live for a longer time but that exact dichotomy is what we are wrestling with when we discuss high cholesterol and the ketogenic diet.

I've gotten angry emails predicting my demise from people accusing me of preaching recklessness since my "cholesterol numbers are s--t". I'm still here and I'm not changing the way I eat for the sake of my cholesterol levels. I briefly tried swapping out saturated fats for unsaturated fats in hopes that this would allow me to stay ketogenic and bring my LDL down. It didn't make a huge impact on my cholesterol-and it made ketosis much less effective and it cause my blood sugar to fluctuate more. I chose to refocus my efforts on stable blood glucose, ketosis and energy production instead of sacrificing all of those markers for a minimal reduction in my cholesterol.

I made that choice long before finding the podcast I recommended above. The podcast presents evidence that would seem to validate my choice and shed light on it. I will summarize a couple of the most significant points below.

Hyperresponders are people who experience significant spikes in their cholesterol after adopting a ketogenic lifestyle for no apparent reason. Many people eating an identical diet will experience the opposite--an improvement in their lipid profile after going ketogenic. (I happen to be a hyperresponder in case that wasn't apparent thus far.)

The overwhelming majority of cholesterol hyperresponders encountered seem to be thin and athletic (like me), which would fly in the face of expectations associated with a "high cholesterol" diagnosis. This makes sense when you consider the fact that a fat adapted athlete needs to mobilize LDL for energy rather than glucose. In the absence of stored body fat the body produces more LDL to satisfy the need for energy.

The presence of cholesterol means different things depending on the context. Elevated blood cholesterol in a fat-adapted athlete signifies an up-regulated metabolism that is geared to meet higher energy demands associated with diet and activity. Elevated cholesterol in a non-fat adapted, non-athlete would signify something totally different since that cholesterol wouldn't be there for energy. It could indicate some sort of inflammation or reparative event that would correspond to atherosclerosis and cardio vascular disease--thus explaining the correlation between elevated cholesterol and heart disease.  LDL isn't the culprit itself--it's the event triggering the production of LDL that is more telling.

Looking at other factors which would illuminate the context and significance of LDL elevation (A1C, belly fat accumulation, blood pressure, inflammatory markers etc) can help us more accurately assess if our cholesterol is indicative of risk or not.

These are a few brief takeaways that really stood out to me because they offered an explanation beyond the typical refrain of "it's the particle size that matters" and looks at the different contexts that can lead to increased LDL for very different reasons. My understanding of the concepts is certainly truncated and incomplete, however these points made a great deal of sense to me given my own experience and the experiences I've had with others. I encourage others to assess and manage risk carefully according to their own research and so I hope that I have added some more perspective to consider.

I am a big fan of simplicity. I believe in working with what we know to surmise about what we don't know. As a diabetic I know what happens when my blood glucose is elevated and volatile. As an athlete I know what happens when I am sedentary and unable to exercise effectively. There is very little question about these things. Making use of a questionable diet to mitigate two very clearly known risk factors seems like a good call. To put it otherwise, if I eat a diet that helps me maintain a healthy body weight, good blood pressure, stable blood sugar in  a normal range and energy enough to train hard and often--how could that possibly be bad for me?

Anything is possible, but it seems unlikely.

Stephen Richert is a photographer, filmmaker and climber who happens to live with type 1 diabetes. You can see his professional portfolio here.

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with your friends, it would be greatly appreciated!


Crowdfunding with Patreon: why it's right for "Banting's Ghost"

There are 5 days left to see if crowdfunding with Patreon will successfully launch the Banting's Ghost documentary project. My Patreon is at $391/month pledged by 29 backers. We need to reach $500/month in order to launch. I have gotten some questions about the way I am attempting to fund this project--specifically if it wouldn't be more beneficial to use a platform like Kickstarter which would allow one-time contributions of a larger amount rather than seeking the smaller, monthly pledges by crowdfunding with Patreon. Here are some facts about this project that you may not have known--and that I hope will clarify the choices I've made in funding it.

  • Banting's Ghost Documentary Project is an ongoing effort; a series. This isn't a one time production of one piece of media or even a predetermined number of pieces. It's an ongoing effort to document the lives of real people who are wrestling with the challenges of access to insulin. I believe that the greatest impact this project can have is if it's responsive. Light and fast. Guerrilla media--not one monolithic production that simply takes a position and holds it. I've chosen this kind of delivery of the documentary not only because it's what I can do best but because it's aligned most closely with how people consume media today.
  • Fewer and fewer people  sit down to watch a 90 minute documentary on Netflix. Everyone has the time to watch a 1-3 minute short on social media--or a series of stills that bring an issue to life. Sharing happens and on it grows. Shorter, episodic projects leave more flexibility and room for failure. Even the best effort sometimes misses the mark. When you're telling an ongoing story you have many more opportunities to explore different perspectives and even take risks because you'll have more chances to try again and connect with a variety of people.
  • The problem we are attempting to address through this project is complex. The solution must also involve complexity and the episodic approach is better adapted to this.
  • Having done a handful of successful and unsuccessful crowdfunded projects I know how incredibly hard fund raising is. I also know that I'm not naturally gifted at sales, specifically when I have to sell the value of my work. I want to DO the work, not sell the work. Still, unless the funding is there, nothing can be done. Patreon (monthly contribution model) allows me to do the fundraising once and then gives me a sustainable outlook for future funding which allows me to use more of my time as a documentary storyteller and less as fundraiser. If I have $750 pledged in monthly support, I can make a plan for the best work I can do with that funding. One time contributions can give a bigger bump in support but can't really be factored into planning.

support livingvertical

So why not accept one-time donations in addition to monthly support? What's the harm in adding more ways for people to give?

At the time of this writing I am not certain that Banting's Ghost will "go" since we are close to the end of the launch funding window and we haven't hit our target. If we can't cover the base costs then I will hold the contributions via Patreon and pause the campaign until we decide how to move forward--and no one gets charged in the meantime, no refunds have to be processed and all the support for Banting's Ghost will be managed through ONE platform. The alternative of having to chase down individual contributors and return funds adds more complexity to the endeavor.

If the project gets funded and is growing, then accepting one-off donations is no problem because I wouldn't need to be focused on building a base level of support but rather on growing the already established project.

Stephen Richert is a photographer and filmmaker who happens to live with type 1 diabetes. You can see his professional portfolio here.

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with your friends, it would be greatly appreciated!


Insulin access before incremental advancement

I've always wondered how a cure for diabetes might have any hope of actually being delivered broadly enough to make an impact in the lives of those who need it most. Today there are thousands of people who are grappling with the untenable reality of insulin access while paying the ever-escalating prices attached to 22 year-old insulins like Humalog. The idea that developing the biggest ticket item ever put forth by the pharmaceutical industry would somehow lead to accessibility without a prohibitive price tag is unrealistic under the current model. Driving people to support incremental advancements that are increasingly hard to afford with no meaningful check and balance to the industry is at best misguided.

What's a documentary project going to do to fix this? An absence of voices that express the position of the silent majority is largely why I'm discussing this issue and asking for support for the Banting's Ghost documentary project. If you haven't yet guessed, the majority of people with diabetes aren't on twitter or blogging or making movies about their condition. They're not invited to attend conferences that guide the future of research, technology or policy. They are not heard in those gatherings and it's no surprise that their best interest is not represented. They are working multiple jobs, sacrificing good nutrition and leisure time that could be spent exercising or not sitting at a desk. They are worrying about how they will pay their rent AND buy their insulin. Homeless or sick? Homeless or sick? 

This is the silent majority and they don't care about the fancy new insulins that are 5% better than the "old" insulins that they still can't afford. They've never had a CGM and wonder what it would be like to know what their blood sugar is all the time so that they could relax a bit more. If this narrative sounds exaggerated or unfamiliar-that's only due to the inherent difficulty of building a successful PR campaign around the access before advancement credo. I'm done waiting for a big "community" organization to act in a way that promotes the interest of all the community--and give a voice to those who are unheard.

I know that I've spent many years of my life as part of that silent majority. When I first peeked into the world of the vocal minority (read: Diabetes Online Community) I found it to be largely well intentioned but unmistakably tone-deaf and out of step with the reality faced by most people with diabetes. I don't say this to be critical but rather to explain why I'm sticking my neck out to execute this documentary project. If it seems like I'm stirring the pot--I absolutely am. Telling these stories will raise issues to the surface that tend to be ignored--and that's really all I'm after.

Better yet, the Banting's Ghost documentary project is not about my story or perspective. Sure you'll get some of my views when it's my turn to talk but I only want to use my platform to shine a light on the stories of others who are always swept under the rug. Not just one story, but every last one of them--until the presence of the silent majority becomes too uncomfortable to ignore at the galas and the conventions--and eventually the board meetings.

Insulin access isn't a problem that I can solve with my camera but media and stories are an important step along the path to a solution. I'd argue that we haven't had a solution up till this point because those who really experience the biggest problem aren't meaningfully included in the discussion. That's something I think I can solve with my camera.

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If any part of this writing resonates with you, please support the Banting's Ghost documentary project. I'm working to get it operationally funded by the end of June and we are just over half way to our goal. If we reach July and the funding isn't there then I can accept "no" as the collective answer without feeling any sense of failure. This isn't an easy thing to sell--if it was, I'd be competing with other artists for this job. Ranting is more cathartic, inspiration is more pleasant. Reality is utilitarian, plain--and in some cases, just plain ugly.

If no one names the problem and humanizes its impact--how can we ever expect to change it?

Stephen Richert is a photographer and filmmaker who happens to live with type 1 diabetes. You can see his professional portfolio here

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with people who might want to share their story, it goes a long way!


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Banting's Ghost: an insulin access documentary project

It might not work. These are some of the scariest words in the vocabulary of any creative and they are responsible for stifling the launch of countless projects that might have changed the world if they'd only gotten out of the front yard. As much as I've tried to turn my creative focus away from diabetes and towards the things that inspire, I feel like there is unfinished business. Inspiration means nothing without insulin when it's literally keeping you alive. That's why I'm using the platform and the talent that I have to try to make a ruckus about insulin access through a documentary project called Banting's Ghost--that will amplify the humanity in this otherwise very data heavy issue.

Banting's Ghost is the working title for this project and it will document the people who are struggling with access to insulin--not in a far off land but right here in the United States. I named this project for Frederick Banting, one of the lead researchers who discovered insulin in 1923 and promptly sold his share of the patent for $1. He was quoted as saying "Insulin does not belong to me--it belongs to the world".

Our current situation has departed significantly from Banting's altruistic vision. The system has run amok. The pharmaceutical industry has escalated prices that are untenable for insurers--who have responded by covering fewer and lesser quality options which is untenable for people living with diabetes who would like to survive. Community organizations cry, 'research for a cure' over the wailing of those people suffering because they can't afford access to 20 year old drugs.

We are expected to believe that advancements will lead to access rather than the other way around.

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Who are these people suffering and struggling you might ask? Maybe you--like me and most of those who are vocal and have time and following to share our opinions online--are still able to bear the weight of the dysfunctional system and are struggling forward under the burden in hopes that the finish line is at hand. I've got news for you. It's not. People who are struggling are not represented in diabetes advocacy--which is funded by the industry--directly and indirectly swaying those who might otherwise stand up and provide a check and balance.

I don't have all the answers. I have the ability to tell stories. It's a start. It's a missing piece of the puzzle and I'd argue that it's a really important one. I don't think that homebrewing insulin is the answer or that the diabetes industry should be decimated. I think that productive conversations begin with some empathy--or at the very least the inability to ignore a public relations fecal hurricane of stories that amplify the value of people over the pursuit of the status quo. There are a lot of data, graphs and charts out there to show that this crisis is out of control. What's missing is the living, breathing human element and that's what I'd like to amplify through the Banting's Ghost documentary project.

It might not work. How will it get funded?

True, it might not even get enough funding to leave the station, let alone gain the momentum it needs to create impact down the line. It's a bigger task than I can execute on my own, I know that much. I'm asking that if you believe this project to be a worthy endeavor that you back it with a small financial contribution. That's the only way it will fly. With a family to support and limited resources at hand--addressing a topic that is inherently unfriendly to the industry it's not difficult to see that the "fly by the seat of my pants" approach won't work this time around.

Still, I want to unfurl the Banting's Ghost documentary project in stages, according to the financial support that is available as we progress rather than waiting until all the necessary funds are in place. The first stage is a photo documentary project (inspired by Humans of NY) which is the most time efficient manifestation. My goal is for that to lead into a series of mini documentaries in video format as well as podcast episodes.

It might not work. It's something I've always wanted to try to contribute to the conversation in the diabetes community and the public and I am not afraid to fail--at least not so afraid that I won't try. Will you help?

Stephen Richert is a photographer and filmmaker who happens to live with type 1 diabetes. You can see his professional portfolio here

To support this project and all the creative efforts of LivingVertical become a Patron and get prints, ebooks and early access to media as part of the group of insiders driving the creative efforts of LivingVertical also please know that non-monetary support is always greatly appreciated. If you can share our work or connect us with people who might want to share their story, it goes a long way!

 


Here's why I'm thankful for film this Thanksgiving

I returned home to wade through plenty of my own personal baggage that I encountered during my time at Standing Rock. It's been heavy and not at all comfortable witnessing this unfolding of events. I went there with questions, seeking answers--and came back with more questions. I have a few more posts that I am working on which will extrapolate the details of the time I spent there and show you the images I made--but right now, I want to share something seemingly unrelated that has helped me find my center in the midst of all this tension: gratitude for film photography.

My emotional baggage wasn't the only thing that was waiting for me when I arrived home. I had sent a years worth of film in to be developed before I left for North Dakota and just as I had done while shooting it--I let it slip from my mind. As I was in the process of unpacking my bags and cleaning up my camera gear I got an email with a link to the scanned negatives. Clicking through these "lost" moments from the preceding months was like a reprieve from the inexorable passage of time. It filled me with gratitude for everything I've been able to experience and share--and that feeling of gratitude lifted the burden of baggage. It's enough of a privilege to live my life enjoying technology and travel--adventure and photography--it's even more of a gift to have the opportunity to create little time capsules that distill the journey. It's also a complete privilege to have you reading this because as I've said before, no one is entitled to an audience.

As I clicked through, I  found pictures of my friends Rob and Chris--just being themselves. I found pictures of Lilo from when she was much smaller. I found pictures of Stefanie from little moments that had held no great significance other than the fact that they'd never come again. I found the last photographs of my friend Pittman before he took his life. Looking at each image I was taken back to a moment in the past that I felt something worth capturing--usually a sense of tension and finality as I pushed the shutter button. I didn't know what I'd make or how the photograph would turn out. Once you push that button it's too late to edit or second guess. It's done. I was afraid of trying to capture something intangible and just barely missing it--tasting the success just enough to make the failure that much more sour.

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I know that people are afraid of a lot of things in these uncertain days. I am too, I guess. Regardless of your social or political views, things are pretty dark out there. That's something we can all agree on. I don't know that pointing a camera at things will make anything better objectively. I don't even know what is better objectively. I do know that I have a lot to be thankful for and that fear and ignorance are not good enough reasons to stop creating and exploring. Diabetes taught me over the years that life is what we make it and that creation is the opposite of destruction. That is, and will always be the truth that drives me to keep creating even if I miss the mark by miles. It's not the mark that matters in the end--goals, targets and objectives always change. It's the willingness to take aim and try that I'm thankful for.

Film photography isn't about perfection. It's simply not the best way to make the most technically precise photographs. There is too much left to chance and variables that are difficult, if not impossible to predict with regularity. Still, the process of letting go and eventually getting a return is incredibly satisfying. Maybe it's because there are no guarantees or do-overs. You get one chance to get it right and when you do, it feels that much better.


Standing Rock: Examining my bias

As a photographer it's my job not just to re-create what I see in the world around me but to take some responsibility for my interpretation of it. This fact made the task of remaining unbiased while photographing at Standing Rock--exceedingly difficult. The inherent tension between accuracy and interpretation is something that thrills and terrifies me. It's a tenuous balance of being entrusted with a sensitive story--wanting to do it justice while avoiding being swept away by my own raw emotion gathered through the experience.

If you have no idea what is going on at the Standing Rock Sioux Reservation or why I went there, I urge you to do a little digging to find sources who have reported on this conflict and its background context. The story is almost invisible in the mainstream media and I am not a reporter as such. My hope is that my sliver of shared experience and photographs from the Oceti Sakowin camp on the Standing Rock Sioux Reservation this past week will help create enough tension that you may look into the facts and form your own opinions. It's an historic moment in our history, with over 200 tribes from all over the United States represented--the largest such gathering in modern times, catalyzed in response to the Dakota Access oil pipeline (DAPL) which is slated to run through treaty land, just upstream from the reservation water supply. The pipeline also will run through sacred native burial sites. These are the facts--not my opinion about them.

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Speaking of opinions.

I hadn't really encountered a situation in my photography where I was pointing my camera at something so socially charged without the security of knowing how and why I felt about it. My previous work in diabetes advocacy is something I live daily so my work was my opinion in that context. I knew where I fit in.

How could I form a valid opinion on the Standing Rock situation? It's barely a hiccup in the mainstream media and furthermore it has deep racial implications. I'm on the outside. I'm white. I've never lived on a reservation. I don't know what it's like living in a community with 80% unemployment where the Dollar Store is literally the only grocery store for miles around. Growing up, colonization to me, simply meant the process through which we got here. To many indigenous people it means an ongoing process through which their culture was largely decimated and the lever by which they were displaced from their homeland.

There is an obvious chasm between my world, which is largely insulated from this struggle, and the perspectives I encountered at the Oceti Sakowin camp. I will be wrestling with this disparity for a long time to come--possibly without any clear resolution. Not looking away from difficult realities is where I can begin. I don't make apologies for who I was born or where my ancestors originated. During my time at Standing Rock I didn't feel as though I was expected to do that. I was accepted as a guest and often greeted kindly as a non-native relative. Receiving respect in the face of so many generations of sadness and injustice made me want to find a way to just make it all better. Staunch the bleeding. It also made me more determined to not let my feelings interfere with my photographs. Still, those feelings are what drove me to travel from Massachusetts to North Dakota over 3 days to make those photographs.

Clear as mud, yes?

I've had some people take offense at the fact that I've even been willing to look at this story in the first place--as if recognizing that the situation exists is tantamount to taking sides. There are certainly others who feel as if anything other than explicit activism for the NoDAPL cause is irresponsible or exploitative. I don't share either of those views--but still, they aren't wrong.

To whit:

The presentation of lethal force against peaceful, prayerful demonstrations that I experienced is not business as usual. I learned as a child that you never point a loaded weapon at something (or someone) unless you fully intended to pull the trigger. Yet, at one point, I stood at the police blockade with two other journalists and a Marine combat veteran--only four people armed with questions and cameras--who asked respectfully to speak with the commanding officer. We were met with mockery, a drone hovering overhead and more than 10 heavily armored men watching us through the scopes on their weapons. I still don't know if they were police or military. No one would identify the agency under whose authority they were operating. I made their photograph as I am certain they made mine. I would have greatly appreciated a chance to tell the other side of the story, but all I saw of the other side was armored vehicles and the business end of a lot of big guns. I wouldn't say I took sides in that moment--more like I was forcibly relegated to a side.

I was walking back into camp after this incident took place and I was confronted by a young woman with a camera of her own. She asked me who I was reporting for and I explained to her that I ran my own website and was out there on a self-directed project to document the situation. I shared that a lot of this was a learning experience for me because I felt strangely trapped between two worlds. It didn't take her a long time to explain that unless I had plans to report on every oil pipeline on native lands--not just the one that was trending on Twitter that I was just a looky loo. Part of the problem. Another tourist out on a camping trip taking snapshots. Perpetuating genocide, she said.  Maybe she was just being overly sensitive towards a competing photographer.

I still worry that somehow I was actually taking more from the native community than I could give back despite my best efforts and she unwittingly put her finger on the truth.

Hello, uncomfortable tension.

I went to Standing Rock without a fully formed opinion, knowing that I would begin to assemble one through my experience--which would ultimately not even scratch the surface. I went there and saw things. I felt things that impacted my views. I'm human, flawed and willing to empathize with people I don't agree with or understand. I don't know if it's possible to look at people suffering with dignity and feel nothing. My purpose in breaking up these posts on the blog is to compartmentalize some of these competing reactions that I had internally. I don't intend for the sum of my opinions to be the ultimate takeaway so it's important to give my feelings some outlet that is distinctly separate from the photographs themselves. Dealing with this tension through the creative process--that's the takeaway.

If all this duality makes you uncomfortable--I assure you it only gets worse from here. Or better.


I'm going to Standing Rock, ND--here's why.

I'm not political but I'll give it a whirl for a moment.

I don't rant incessantly about who is ruining the country or who should fix it. I'm pretty sure that's what voting is for--a place to contribute a meaningful impact (as opposed to berating people on social media who disagree with you for seeing the world differently). The truth is that your opinion doesn't matter--only your actions do. This wildly unpopular view is the only hope have we have as a society of self-rescue--because the worst leadership wouldn't be able to capsize a nation of people who were humble enough to link arms across various lines of race, ethnicity and politics.

Ok, now that's out of my system:

A few days ago I felt like I should go to Standing Rock in North Dakota to do a photo-project documenting the protest about the Dakota Access Pipeline there. I don't have an axe to grind. I'm not a protester. I'm a photographer who believes that pretty images aren't necessarily the most important. For those of you joining me in the Ugly Camera Challenge I wrote about recently--I absolutely will be continuing to participate in that (and I hope you will too!) It feels as though something deep and significant is under way in the Standing Rock conflict right now and for the last few weeks we've heard almost nothing about it in the media. Nothing from our political leaders who are selectively concerned about the dire implications of climate change but refuse to even acknowledge this debacle that is unfolding on our own soil.

You may agree or disagree with my decision to go to Standing Rock, North Dakota and point my camera at something that no one seems to want to deal with. I'm writing this to articulate my purpose in going. I'm not attempting to shame others who can't or won't join in this journey. I have the privilege of time and opportunity to travel. I have the freedom (risk) of no allegiance to a commercial sponsor or assignment other than my own self direction and those of you who are supporting me on Patreon (thank you!!!). I have a supportive family who is making it possible for me to step out and do this. I'm thankful for those gifts and I don't deserve them any more than anyone else does. I don't believe we are given gifts in life to squirrel the benefits away away while turmoil engulfs others who have drawn a different card.

I have no idea what I will find out at Standing Rock. I'm not going with any opinion other than this: my opinion doesn't matter. What matters is that there is not a public and transparent discussion of a militaristic-type of force being used on civilians who are peacefully protesting corporate development that directly impacts their land. I suspect that as with most conflicts in life there is a combination of people doing the right things for the wrong reasons--and people doing the wrong thing for the right reasons.

One of the cop-outs of the photographer is that the camera doesn't have an opinion. It's not biased. It accepts us as we are--the good and the bad. The humanity. I'd like to think that I will return with some images that may make us think about this conflict from a more personal standpoint. Because that's all any of us are, after all. We're just people. If we can only use our technology to start arguments rather than conversations then we have already failed, utterly. On some level that's the hurdle that I now have to clear as I go out to photograph.

I feel a lot of creative tension around this.  I don't know the outcome and I am fairly certain that this choice will alienate more than a few people who I consider important in my life. I feel real risk. Some fear. I don't know that I can do this without making an ass of myself or getting in the way of a cause that isn't my own. I know that this might not work.

I know that it still feels right to go and try.

I'm not sure what will come from this effort in terms of deliverables. My primary goal is still images. Interviews, stories, video assets and the like will be a bonus that I hope to capture as well. I'll update via LivingVertical social media channels as I can. Cell and data service are reputed to be lacking within a 20 mile radius of the reservation so I may be quiet for (the first time in my life) a while. If you'd like to support this work I'm doing, you can contribute via my Patreon page. If you'd like to tell me to go _______ myself, sound off in the comments below--or better yet do it in person.