Ketogenic diets (KDs) are gaining popularity for managing diabetes, yet they're linked to increased hypoglycemia (low blood sugar). Ketotic hypoglycemia, characterized by low blood sugar and high ketone levels, commonly affects toddlers, especially when they haven't eaten for extended periods or are ill. This article explores the relationship between ketogenic diets and hypoglycemia, examining causes, symptoms, treatments, and precautions.
Understanding Ketosis and Hypoglycemia
Ketosis occurs when the body breaks down fats instead of carbohydrates for energy, producing ketones. Hypoglycemia happens when blood sugar levels drop too low. Ketotic hypoglycemia is when these two conditions occur together. A healthy blood glucose range is typically 70 to 150 mg/dL, though lab ranges may vary. Ketones indicate fat breakdown, detectable through urine or blood tests.
Ketotic Hypoglycemia: A Closer Look
Ketotic hypoglycemia is the most common cause of hypoglycemia in children in emergency departments, often due to illnesses reducing food intake or fasting/vomiting. Children with this condition may experience irritability, tiredness, and shakiness. Treatment involves administering sugar, which usually alleviates symptoms quickly, followed by monitoring if necessary.
Causes and Risk Factors
While the exact cause of ketotic hypoglycemia remains unclear, the Pediatric Endocrine Society points to two potential issues: increased use of liver-stored energy and a quicker switch to fat breakdown, and sometimes, an inability to effectively store fat and muscle energy to maintain blood glucose levels. Children are more susceptible due to higher energy demands and lower glucose reserves. Common causes include reduced food intake due to illness, especially gastrointestinal issues with vomiting, and prolonged fasting. Most children outgrow this condition by ages 5 to 6 as their bodies improve blood sugar management. However, rare cases can occur in adults.
Ketogenic Diets and Hypoglycemia: The Link
Ketogenic diets (KDs), very low carbohydrate diets that induce nutritional ketosis, have become a popular weight loss strategy. They are also increasingly used by diabetes patients and healthcare professionals due to their effectiveness in reducing HbA1c, body weight, and improving lipid profiles. However, KDs have been associated with an increased frequency of hypoglycemia in both type 1 and type 2 diabetes.
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Research Findings
One study tested the effects of consuming a KD on physiological responses to neuroglucopenia and insulin-induced hypoglycemia in mice. The results indicated that both responses were significantly altered in mice fed a KD.
Mice fed a KD for either 7 or 21 days had lower fasting blood glucose levels and experienced ketosis, indicated by increased serum levels of BHB (beta-hydroxybutyrate). 21-day KD mice showed a significant blunting in the physiological response to 2DG-induced neuroglucopenia, reflected by decreased serum glucagon levels and blood glucose. Despite similar hypoglycemia exposure, 7-day KD mice experienced reduced hypoglycemia-induced glucagon release and increased corticosterone release.
Implications for Diabetes Management
KDs are touted as a highly effective treatment for metabolic syndrome and diabetes. However, concerns remain about whether KDs increase the risk of hypoglycemia in both type 1 and type 2 diabetes. Research suggests that consuming a KD may lead to altered hypoglycemia-induced glucagon and corticosterone release.
Hypoglycemia on Keto: A Case Study
A 69-year-old woman on a strict ketogenic diet for nearly a year presented with malaise, sugar cravings, and mental fogginess. After consuming alcoholic beverages, she was hospitalized with hypoglycemia (39 mg/dL). She had elevated beta-hydroxybutyrate and low insulin and C-peptide, consistent with starvation ketosis. This case illustrates that prolonged adherence to a ketogenic diet, combined with alcohol intake, can disrupt glucose homeostasis and result in significant hypoglycemia.
Factors Contributing to Hypoglycemia on Keto
The most significant aspect of the ketogenic diet is achieving ketosis. A standard ketogenic diet derives 65%-75% of calories from fat and only 5%-10% from carbohydrates, typically 20-50g per day, to ensure ketosis. This restriction leads to decreased blood glucose and insulin levels, causing the body to synthesize ketone bodies through hepatic oxidation of fatty acids.
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While generally safe in the short term, ketogenic diets carry risks, including nausea, vomiting, dehydration, and hypoglycemia. The case above shows that severely reduced caloric intake, illness, lactation, and dehydration during a ketogenic diet can lead to ketoacidosis.
The Role of Alcohol
The patient in the case report ingested alcohol before presenting with hypoglycemia. Alcohol metabolism involves the oxidation of ethanol to acetaldehyde and then to acetic acid, reducing nicotinamide adenine dinucleotide (NAD+) to NADH. An increased NADH/NAD+ ratio suppresses hepatic gluconeogenesis and reduces free glucose, potentially worsening ketogenesis and hypoglycemia.
Counterregulatory Responses and the Brain
The lack of typical hypoglycemic symptoms in the described case raises questions about the ketogenic diet's effect on brain response to hypoglycemia. The hypoglycemia-associated autonomic failure (HAAF) syndrome describes hypoglycemia unawareness, where individuals don't perceive neurogenic warning symptoms.
Studies in mice have shown that a ketogenic diet can blunt glucagon release in response to hypoglycemia, increasing the risk of low blood sugar. However, the ketogenic diet may also protect against hypoglycemia-induced neuronal damage by inducing molecular adaptive mechanisms, stabilizing cellular metabolism, and reducing neuronal excitability.
Avoiding Common Low-Carb Diet Mistakes
Consuming a low-carb diet can help people with type 2 diabetes effectively manage their blood sugar levels. When starting out, it’s important to avoid some common low-carb diet mistakes, such as not focusing on carb quality and not drinking enough fluids, so that your diet can work most effectively to protect your health. Work with your healthcare team to determine which type of low-carb diet may be right for you. Too few carbs can make it tougher to stick to your diet, while dehydration can lead to uncomfortable symptoms, such as dizziness and fatigue.
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Communication with Healthcare Team
Your diabetes care team can help you determine the right low-carb approach for you. It’s also important to notify them of any diet or lifestyle changes to avoid any potential side effects. In fact, they may recommend lowering or changing your medications to avoid very low blood sugar levels (hypoglycemia), cardiovascular complications, and diabetic ketoacidosis (DKA), which is a health emergency. This is especially true if you’re taking insulin, insulin-promoting drugs, or blood pressure medications. Ideally, they’ll be able to offer ongoing nutritional advice and support.
Monitoring Blood Sugar
While a low-carb diet can help stabilize your blood sugar, it’s still important to monitor it carefully to prevent periods of hyperglycemia or hypoglycemia. When you go on a low-carb diet, monitoring your blood sugar can provide important information that you can use to adjust meal portions as well as medication dosages. To get the most complete info and make the most informed decisions, use a continuous glucose monitor (CGM), which takes a blood sugar measurement every 5 minutes or less.
Carb Quality and Distribution
A low-carb diet shouldn’t just be about what you cut. It should also be about what you add into your nutrition plan, Zanini says. When following a low-carb diet, the more you can focus on whole, unprocessed foods, the better. These foods can include healthy high-fat foods, such as olive oil, avocado, walnuts, and salmon. But the exact amount of fat you should eat depends on whether you are following a keto diet or trying to build lean muscle through an increase in dietary protein, Urbanski says.
If you become too focused on reducing carbs, you may end up replacing them with high-calorie fats, as well as sugar-free foods that contain artificial sweeteners, which may encourage you to eat more. If you eat too few carbs at each meal, you may have difficulty sustaining this diet long-term, Urbanski says. You may end up reaching for high-carb snacks during the day, which can cause large dips and spikes in your blood sugar levels. Evenly distributing carb intake throughout the day can prevent these dips and stabilize your levels. Sheth recommends that most people with type 2 diabetes aim to consume 30 to 45 g of carbs per meal. To figure out the right balance for you, divide your goal number of daily carbohydrates by the number of meals and snacks you plan to eat throughout the day.
Fiber Intake and Hydration
Fiber is critical to overall health: It lowers blood pressure, improves insulin health, and encourages weight loss by stabilizing blood sugar and increasing satiety. The recommended daily amount of fiber for adults up to age 50 is 25 g for women and 38 g for men. Women and men older than 50 should have 21 and 30 g daily, respectively. When following a low-carb diet, try to add plenty of high-fiber foods to your meals. Low- to moderate-carb options include leafy greens, berries, legumes, and low-carb, high-fiber breads and tortillas, Sheth says.
Following a low-carb, high-protein diet, such as the keto diet, can increase the risk of dehydration, as well as electrolyte imbalances. This happens because when the body stores carbohydrates, it stores water along with it. In response to reduced blood sugar levels, the body doesn’t produce as much insulin. In turn, the kidneys expel both water and sodium from the body, she says. Proper hydration helps support steadier blood sugar levels. If you’re aiming to eat less food as part of your low-carb plan, this can lower your sodium levels even more. Dehydration and too-low sodium levels can cause lightheadedness and dizziness, and prevent your cells from functioning optimally, she says. These dehydration symptoms are a part of the so-called keto flu that often afflicts new low-carb dieters.
General Hypoglycemia Information
Low blood sugar (hypoglycemia) occurs when blood sugar drops below 3.9 mmol/L (70 mg/dL). It's more common in individuals with diabetes, but can also affect those without the condition. Symptoms include dizziness, fatigue, hunger, and difficulty concentrating. Common causes in non-diabetics include high carbohydrate intake, low-carbohydrate diets, prolonged physical activity without adequate carbohydrate replenishment, alcohol consumption, and certain medications.
Managing Hypoglycemia
In most cases, consuming small amounts of carbohydrates (e.g., fruit) can resolve hypoglycemia symptoms. However, if symptoms persist or worsen, seek immediate medical attention.
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