Hi, changes after 12 years....low BG and high ketones

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Ducks at Sea

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Type 2
Hi
I was diagnosed T2 12 years ago and up to late 2022 controlled by low carb and no medication. Was considered as in remission for last 9 years or so, HaB1c under 33 for last 11 and half years.
Had a severe chest infection late 2022, ended up in hospital for 2 weeks due to DKA.
In hospital BH levels went very high, HaB1c over 100. Discharged With basal insulin, Metformin and Dapagliflozin.
Once discharged I returned to low carb diet and reduced insulin slowly, completely off insulin within 5 weeks. Stopped the Dapagliflozin as had side effects and the risk of DKA was too high (not recommended if already had DKA and low carb not recommended whilst taking it).

HaB1c reduced to 46 within 6weeks, still on Metformin.
Issue now is BG are within range but ketones are raised (was issued with a dual meter). Hospital diabetes team don't know why.
I have a urine Cpeptide test Monday so hopefully that might help.
Increased my carbs from under 30g a day to about 50g any higher and BG levels increase a lot.
 
Could they be ketones from your low carb diet @Ducks at Sea ? How high are they? Did you ever test your ketones when you were eating low carb previously?
 
Inka said:
Could they be ketones from your low carb diet @Ducks at Sea ? How high are they? Did you ever test your ketones when you were eating low carb previously?
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I didn't check ketones before, but they were checked during the annual check up at GP and never an issue.
Currently between 0.9 & 2.8.

I am vegetarian, previously and since discharged from hospital (hospital food is terrible and they don't offer low carb vegetarian) once home, returned to my normal eating, I aimed for less than 30g of carbs a day.
I weigh and measure everything, and make a record of all food and drink including black coffee.

When HbA1c had reduced so quickly Hospital consultant was concerned with ketones I am measuring at home, adviced to increase carb levels above 30g a day.
It's been hard to do that, but now carb intake is over 50g a day. Following lots of testing with my meter I have a lower carb breakfast and higher lunch & dinner. Too many carbs at breakfast raises BG into reading of 9 or 10 even after 2 hours.
Trying to keep my BG levels as stable as possible without increased risk of DKA (don't want that again).

Been advised to have a carb heavy meal before doing the urine cpeptide test, no idea how much is carb heavy?

I feel like all the rules have suddenly changed after being in control for many many years
 
I maybe think that it’s the keto diet. I never ever have zero ketones I do about 50g-70g carbs a day. I’m usually about the 0.4-0.8 ranges. I know in the fitness world those who do keto for its perceived health benefits and weight loss would aim for ketones in your range. On the American diabetes forums they regularly post their fasting blood sugar and their ketones, to them the higher ketones the better. (This is type 2’s)I think without raised BG it’s ok, but please don’t quote me on that. With raised bg over 14 and ketones in those ranges I think it would be more worrisome
 
Hopefully the cPeptide result will provide reassurance @Ducks at Sea and point towards a way forward

I can understand the clinicians caution given that you have already experienced DKA.

Ketones in the absence of sufficient insulin (and especially with elevated BG levels I think) are worrying. If you don’t have sufficient insulin my understanding is that you can’t metabolise the ketones so they build up in the bloodstream and increase acidity risking DKA.

It would be helpful to chat with the hospital team about your low carb approach, and see if between you you can find a balance that keeps you safe and well, even if that involves taking a little insulin alongside a slightly higher carb intake?
 
everydayupsanddowns said:
Hopefully the cPeptide result will provide reassurance @Ducks at Sea and point towards a way forward

I can understand the clinicians caution given that you have already experienced DKA.

Ketones in the absence of sufficient insulin (and especially with elevated BG levels I think) are worrying. If you don’t have sufficient insulin my understanding is that you can’t metabolise the ketones so they build up in the bloodstream and increase acidity risking DKA.

It would be helpful to chat with the hospital team about your low carb approach, and see if between you you can find a balance that keeps you safe and well, even if that involves taking a little insulin alongside a slightly higher carb intake?
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So if I understand correctly elevated ketones have the potential to be dangerous even when BG isn’t high?
I never really checked mine until I was specifically asked to by a consultant once. I told him that my sugars were never over 14 but he still asked me to check them and that he would call me after a few weeks to check on me, that never happened and a different consultant guy called about 6 months later and when I told him about the elevated ketones he just said those are your starvation ketones and instructed me to eat more. Now I eat way more calories and have put on about a stone but the ketones are still always there. I just assumed this must be the lack of carbs about 60g a day. I must say I don’t check that often though as I only get 10 strips a month but when I do test they are always there 🙄
 
EmmaL76 said:
So if I understand correctly elevated ketones have the potential to be dangerous even when BG isn’t high?
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I think (and I am no expert, and have no medical training) it depends on whether there is sufficient insulin available?

I believe some people with T1 who got Covid badly in the early days were showing DKA at lower BG levels, but I’d have to check back through some old emails with a diabetes professor I was in contact with about something else.

Nutritional ketosis seems to be OK, as long as you have sufficient insulin in circulation is my understanding.

But personally I’m not sure high levels of ketones that aren’t being metabolized are a great idea?
 
EmmaL76 said:
So if I understand correctly elevated ketones have the potential to be dangerous even when BG isn’t high?
I never really checked mine until I was specifically asked to by a consultant once. I told him that my sugars were never over 14 but he still asked me to check them and that he would call me after a few weeks to check on me, that never happened and a different consultant guy called about 6 months later and when I told him about the elevated ketones he just said those are your starvation ketones and instructed me to eat more. Now I eat way more calories and have put on about a stone but the ketones are still always there. I just assumed this must be the lack of carbs about 60g a day. I must say I don’t check that often though as I only get 10 strips a month but when I do test they are always there 🙄
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Ketones can be dangerous with normal bg, particularly on some medications. I had DKA with normal bg when I took empagliflozin.
 
everydayupsanddowns said:
I think (and I am no expert, and have no medical training) it depends on whether there is sufficient insulin available?

I believe some people with T1 who got Covid badly in the early days were showing DKA at lower BG levels, but I’d have to check back through some old emails with a diabetes professor I was in contact with about something else.

Nutritional ketosis seems to be OK, as long as you have sufficient insulin in circulation is my understanding.

But personally I’m not sure high levels of ketones that aren’t being metabolized are a great idea?
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Thanks @everydayupsanddowns @Lucyr. Just when I think I’ve got this whole thing worked out I’m back to a confused state. Apologies if I may have given incorrect information to the OP it’s just what I was told by my most recent consultant. Admittedly there have been mixed messages amongst my consultants though. If I’m totally honest the battery in my meter ran out a good while ago and I haven't tested for a while. I have been feeling dog rough though for a long time and I’ve tried everything. Vitamins, more food even HRT! Nothings working, sometimes I struggle to leave the house! Thing is I wasn’t like this before diagnosis when my sugars were high. Sometimes I tell myself … Emma this is all in your head, pull yourself together but the only way I can describe it is like walking through treacle. I get quite emotional when I think of my old life the one where I did everything for everybody , ran miles everyday and maintained my house and garden whilst working full time…. Sorry that was a bit of an offload, feeling a bit emotional this morning… maybe it’s this darn HRT. When I get reincarnated, I’m coming back as a man !
 
EmmaL76 said:
Thanks @everydayupsanddowns @Lucyr. Just when I think I’ve got this whole thing worked out I’m back to a confused state. Apologies if I may have given incorrect information to the OP it’s just what I was told by my most recent consultant. Admittedly there have been mixed messages amongst my consultants though. If I’m totally honest the battery in my meter ran out a good while ago and I haven't tested for a while. I have been feeling dog rough though for a long time and I’ve tried everything. Vitamins, more food even HRT! Nothings working, sometimes I struggle to leave the house! Thing is I wasn’t like this before diagnosis when my sugars were high. Sometimes I tell myself … Emma this is all in your head, pull yourself together but the only way I can describe it is like walking through treacle. I get quite emotional when I think of my old life the one where I did everything for everybody , ran miles everyday and maintained my house and garden whilst working full time…. Sorry that was a bit of an offload, feeling a bit emotional this morning… maybe it’s this darn HRT. When I get reincarnated, I’m coming back as a man !
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With normal glycemic control
 
EmmaL76 said:
So if I understand correctly elevated ketones have the potential to be dangerous even when BG isn’t high?
I never really checked mine until I was specifically asked to by a consultant once. I told him that my sugars were never over 14 but he still asked me to check them and that he would call me after a few weeks to check on me, that never happened and a different consultant guy called about 6 months later and when I told him about the elevated ketones he just said those are your starvation ketones and instructed me to eat more. Now I eat way more calories and have put on about a stone but the ketones are still always there. I just assumed this must be the lack of carbs about 60g a day. I must say I don’t check that often though as I only get 10 strips a month but when I do test they are always there 🙄
Click to expand...

Yes, it even has a name: euglycaemic DKA. It’s why I get freaked out when I have a stomach virus and can’t eat. It’s not common but it’s certainly possible. Some information here:

https://www.statpearls.com/ArticleLibrary/viewarticle/61065

.
 
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