Keto and Type 1 diabetes--A controversial duo not paired together quite as often as Keto and Type 2. With the knowledge that some of our customers use Genteel to track their ketones, we became curious to learn more about the potential health implications of this approach for those living with type 1 diabetes.

According to our recent anonymous Instagram polls, much of our active community live with type 1 diabetes, while the next largest subset have MODY & LADA  (Maturity-onset diabetes of the young and Latent autoimmune diabetes in adults). With misdiagnosis being a common story in our community, it’s safe to assume that dietary information for different kinds of diabetes is being simultaneously consumed by this population at some point. Knowing how these dietary strategies might impact different kinds of diabetes could be useful information for people researching a treatment plan that works best for them.

Anonymous IG poll results: T1D: 61.04% MODY: 11.69% LADA:10.57% T2D: 6.4% Non Diabetic: 6.4%  3C: 3.9%

(Out of 47 participants)

Before moving any further, it's important to mention that managing dietary needs while living with any kind of diabetes or chronic illness is an extremely individual experience. One that not only requires the close supervision of your primary care physician, but also needs to be sustainable. While one individual may thrive following a strictly controlled diet like the ketogenic diet, others feel they might spiral out of control when presented with limitations. One common theme discussed among our friends in the online diabetes space is that they deserve to be able to eat what they want, without judgement or input from outsiders. That is certainly understandable, especially considering the large amount of misinformation and stigma associated with food and diabetes. As briefly mentioned in one of our recent Instagram Lives, many who echo these sentiments feel they are well equipped to manage their needs, and strive to live a lifestyle that has room for their favorite foods (albeit with a little extra insulin and math). While it is true that any type of diet can be mentally and emotionally triggering for many, it’s difficult to completely dismiss the health implications of contemporary research. Just as checking your blood sugars with the Genteel lancing device empowers you to make decisions that are right for you, so does reviewing recent findings by experts in the field.

Jessica Turton, an Accredited Practicing Dietitian & PhD completed a systematic review published in the Austrailian National Library of Medicine titled, Low Carbohydrate Diets for Type 1 Diabetes. In her research, she notes that many are struggling to keep their sugars in range, at no real fault of their own. For reference, long term glycemic control is determined by hemoglobin A1C, and should be less than 7%, which is considered the primary target for all types of diabetes. Data from over 300,000 people across 19 different countries reported that only 16% of patients with type 1 could achieve this metric. This leaves 84% of patients with type 1 who are at risk of developing fatal complications from diabetes. Increasing insulin is not always the answer either. It can lead to insulin excess, which can cause a host of other medical complications. With diet being the main controllable variable, Turton posits that it only makes sense to harness its power. She takes us through an example of this in action with a theoretical meal coming in at 90g of carbs. After administering the correct amount of insulin, one might think they’re done managing their glucose levels for that meal. However, something that is often not considered is the margin for error. Nutrition information on labels are not always accurate. In many instances, manufacturers refer to online databases to estimate the calories per gram, and are not required to do use bomb calorimetry to test the exact carbohydrate content to the gram. This is not to mention the inaccuracies due to human error. If estimated that the total margin for error is about 20%, our theoretical meal could be between 72-108g of carbs. If dosing insulin for 90 grams of carbs, but consuming 72g, we are now at a high risk of experiencing hypoglycemia, or too much insulin. A reversal of the situation could put someone at risk of hyperglycemia. This everyday example could be indicative of what those 84% of our aforementioned population are experiencing.

By reducing dietary carbohydrate with a ketogenic diet, the error rate in determining the amount of insulin needed is also reduced. Let’s look at her previous example with a lower carb count. In this instance, the meal is 15g. The 20% of margin for error is still present, but ranges between 12-18 grams. In this scenario, even if the patient miscalculates, they're likely only miscalculating by around 3g of carbs, instead of 36g. This greater safety-net leaves room for human error without the serious medical implications. Turnton concludes that this could lead to more predictable sugars, and tighter ranges overall. Theory is great, but what about actual research? In her meta analysis, she notes that 6 of 9 studies included (Knight 2016, Chantelau 1982, Krebs 2016, Ireland 1992, Neilsen 2012 and O'Neil 2003) found statistically significant improvement in the A1C levels of participants following low-carb diets. The other three studies didn’t find significant improvements in A1C levels, but they did find them in other areas such as number of hypoglycemic episodes, and total daily insulin used.

While research like this wildly compelling, it’s important to consider the limitations. The studies included did not have very large sample sizes, and each one defines "low carb" slightly differently. However, it does highlight the pressing need for more research on the matter, especially if it has the potential to help people reach their target A1C levels. So why is low carb or keto such a controversial topic among health experts? The most common concerns are difficulty sustaining the diet, the potential for ketoacidosis, and increased the risk of hypoglycemia. Nutritional ketosis is a state in which the ketone levels are moderate (less than 3mmol/l) with normal insulin and blood glucose levels. It is the aim of the ketogenic diet. DKA on the other hand is a buildup of acids in your blood, and can happen when your blood sugar is too high for too long. Some experts maintain that as long as people with type 1 diabetes monitor their blood glucose levels regularly and treat as needed, nutritional ketosis shouldn't put those with type 1 diabetes in danger. While this may be true for some, there are a handful of case reports which conclude that a ketogenic diet triggered DKA for individuals. However, we must also consider that many of these case reports involve a slue of unique variables such as intensive diets, pregnancy and lactation. Some may even be familiar with Dr. Bernstein as being the oldest person living with type 1 diabetes. At 77 years old, he continues to see patients 6 days a week for diabetes, and has been an advocate for a low carb diet to manage type 1 for much of his life.

The conflicting information presented is not meant to further confuse you, but to highlight the importance of letting your doctor know if you are choosing to follow any specific diet. A keto diet could be a lifestyle change that makes navigating diabetes much easier for you! It could also be potentially dangerous. We care deeply about your individual health, so we urge you to discuss this decision with your care team before implementing anything new. No matter what you use Genteel for, whether it's to check ketones or glucose, we are here to make it less painful for you. By continuously reviewing the research and offering valuable information, we hope to empower you to live your best life possible with diabetes. We promise to continue asking the questions that drive our future (& share the answers we find along the way).

Sources

Turton JL, Raab R, Rooney KB. Low-carbohydrate diets for type 1 diabetes mellitus: A systematic review. PLoS One. 2018 Mar 29;13(3):e0194987. doi: 10.1371/journal.pone.0194987. PMID: 29596460; PMCID: PMC5875783.

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