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!

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!

here's a story about why I'm trying a modified Ketogenic diet

Why I'm trying a modified Ketogenic diet

A little over a year ago I was bored. I was working in an office environment and not able to get out climbing. I wanted to try something to shake up my routine despite the obvious constraints. I decided to do an experiment with a vegan diet, which ultimately led me to try the complete opposite--a ketogenic diet. This bit of skylarking wound up taking off and got this humble blog ranked #1 in Google for the search terms "type 1 diabetes and the ketogenic diet". This happy accident has brought many of you here no doubt although it's left me with a burden of continuing to write about a topic that I feel has been wrapped up (at least in my life). The notable exception is the modified Ketogenic diet which I am currently following.

There is one loose end, however--and that is the issue of high cholesterol. I also have the dubious honor of ranking very highly in Google searches for ketogenic diet and high cholesterol--a pleasure that I'd prefer to postpone indefinitely. I am still working on sorting out the details on my high cholesterol and what it means for my adherence to a low carb, high fat ketogenic diet. There is a dearth of information available that gives simple, clear insight into the topic of cholesterol--and much less still when you add type 1 diabetes into the mix. Half of the discussion resembles this: "Cholesterol is not a problem! Eat more butter and stop listening to the man!" The other half resembles this: "Cholesterol is a HUGE problem! Eating that butter is going to kill you!" I would like to believe that a modified ketogenic diet could win the middle ground between these two viewpoints.

The ketogenic diet stabilizes and controls my blood sugar without technology. This fact alone makes it an asset that could revolutionize the impact of diabetes if given the chance--especially significant for the millions of people who can't afford higher tech solutions. It gives me the simplicity and freedom that allows me to live out from under the burden of diabetes about 90% of the time. Still, living with the cholesterol monkey on my back is a concern.

I feel as though I can choose to either optimize cholesterol or blood sugar--but not both.

I choose to optimize blood sugar because there is no lack of conclusive clinical evidence showing what uncontrolled blood sugar does. There is also no shortage of anecdotal evidence showing how much harder it is to be active, creative, happy and productive while riding the glucoaster. Without getting all morose, let me just say that I have chosen my priority. It's not an easy choice and it gives me a lot of stress and grief--but it's the best I know to do and I am prepared to live or die with the consequences.

Welcome to my life with diabetes and climbing. These types of decisions are par for the course.

What I have learned with the help of my doctor (he is an amazing endocrinologist who is supporting my blood sugar management despite its unorthodox approach) is that I am most likely a hyper-responder to saturated fat. This is a genetic anomaly that causes my body to produce exponentially more cholesterol in the presence of saturated fats. The detriment of that cholesterol is still undetermined--along with the possibility or being able to reduce it.

Thanks, genes! The diabetes was a sweet offer--but wait, there's more...

In light of this hypothesis, I am not abandoning a low carb, high fat diet but I am following a modified ketogenic diet. I believe that most people have to modify whatever diet they follow in order to accommodate their specific needs. A modified ketogenic diet can, of course, mean many different things--it is not imply any one specific modification. I am trying to add more unsaturated fats in place of saturated fats. In simplest terms that means that I am eating more olive oil, macadamia nuts and fish. I am eating less red meat, eggs and coconut oil. In a lot of ways it's closer to hybrid mediterranean diet. It's really hard to sell this approach since it doesn't fit with the self congratulatory memes of the vegan "path" nor the devil-may-care tropes of the ketogenic community. Oh well.

My cheese intake is still predictably unaltered. I will be buried with my block of Coastal Cheddar and a paring knife if need be. Nuff said there.

I recently started swapping out olive oil in my coffee rather than coconut oil. Before you gag and click away, I have to tell you that it's actually delicious if you put it in a blender. I'm still putting heavy cream in my coffee with the olive oil. Additionally I am eating more leafy greens and cruciferous vegetables (red cabbage, brussel sprouts) as vehicles for more olive oil and more fiber. I've cut out a lot of red meat--not to complete exclusion but I'll eat a steak or some lamb once a week rather than twice or three times weekly. Meat ends and deli meats which I love--have been largely replaced with macadamia and Brazil nuts. I am also increasing fiber intake through the vegetables and adding chia seeds to just about everything I can.

I'm not on statins currently--but I am taking fish oil, vitamin D and Berberine as part of my normal supplement routine of magnesium and potassium.

I don't have any solid numbers yet to indicate the effectiveness of the modified ketogenic diet on my cholesterol. In terms of its impact on my blood sugar and energy, I feel like it takes a little more olive oil to get into ketosis. It's lower caliber--but it still seems to be getting the job done. I've been taking more insulin recently--but I am not sure if this is because I am back living in Massachusetts or because of the dietary modifications. I have always found a dramatic decrease in my insulin dosage when I am out west (10-15% consistently). On the flip side, I have more time and space to focus on my diet and supplementation here than I did when we were living on the road.

ketogenic diet and hypoglycemia

Ketogenic diet and hypoglycemia

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 15x15 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.

Ketogenic climbing | low carb athletes with T1D

I am considering doing a video series in the near future for low carb athletes with T1D about my dietary approach, trial and error and adapting the ketogenic diet to give greater blood glucose stability and athletic performance. I still feel like this is all in the "test phase" because the results I have had are not extensive. That said, I will be sharing developments as they occur in hopes of pushing the limits of what we are able to do with our diabetes.

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Losing control, gaining influence

Somewhere between pride and despair lies acceptance. I could only hear the sound of wind whistling past my ears as I stepped delicately around the airy corner; about 1500 feet of nothingness separated me from the ground. The fact that I was actually able to stand on the sloping, sandy ledge beneath my feet seemed to defy what I'd come to learn about physics. 'Here goes literally everything' I thought for the 1,336th time since starting to climb "Cowboy Ridge" that morning. I shifted my weight forward to test the only viable handhold that would grant me access to the ledge above. I tried to weight the hold gradually because I didn't want to ricochet off into the void if it popped. I pulled back a handful of sand as the rock disintegrated in my hand.

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Climbing Cowboy Ridge in Zion National Park

I've spent a lot of time in Zion National Park over the last few years and it's no secret that the climbing here is outside my comfort zone. Maybe that's why I keep coming back--because there are "easy" climbs like Cowboy Ridge that have mocked me from afar. It's a 5.7 filled with route-finding, loose rock and lots of elevation gain. It's a long day and it's far from civilized comforts should poor planning or blood sugar fluctuations interfere. It's not the dark side of the moon, but it's more involved than lowering down off a single pitch climb and 'calling it a day'. Maybe this is part of getting back into the swing of things, but I've been more intimidated by this "loose end" than I'd like to admit, so I decided to tie it off ASAP.

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How does the keto diet work on the road?

In the last few posts I've been focused on the challenges (read: chaos) of getting adapted to living in a tiny home (trailer). That process is far from complete and while we are waiting I thought I would touch on a question I've been getting from a few people regarding the keto diet that I am using to control my type 1 diabetes and improve my climbing. Having to manage blood sugar can complicate even the simplest tasks and I can honestly say that dealing with the stress of this move would be impossible for me to tolerate if I had to devote more of my focus to erratic blood sugar swings. I've written a lot about how the keto diet has worked for me (including failures and challenges) but in this post I want to focus on how living on the road has impacted my ability to eat a low-carb high-fat diet.

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New tweaks to the keto diet and updates to the vlog

In the last week or so I have been forced to reckon with the fact that my cholesterol is high and the keto diet that has enabled me to dial in my blood sugar--may be the culprit that is creating chaos in a different area of my bloodwork. Since I ultimately may have to choose between the lesser of two evils, I have decided to tweak my ketogenic diet to see if my elevated cholesterol may be due to specific items within this diet rather than the entire way of eating. Here are the steps that I have taken:

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