Does a healthy ketogenic diet cause irreversible insulin resistance?

#14

@Fry
I don’t think there’s any cause for alarm. LC and especially keto are fantastic for improving insulin sensitivity and reversing diabetes, and none of the information given or linked above is in contradiction to that. Once we’re super insulin sensitive and if we have long stretches of keto/vlc, some folks find that their blood glucose levels rise (a bit - not much) though their A1C stays low and their other health markers are still fantastic. “Adaptive glucose sparing” sounds like a better phrase, and I’m just hoping to understand that phenomenon a bit better.

#15

@Madeleine

Thank you. What about this selection of a comment by the author of the article:

"I’m presuming you’ve read Steve Cooksey? He is an example of a perfectly controlled T2 diabetic, drug free. He is fully healthy (as far as any of us can tell), but he can’t eat pizza after years of LCHF. Something changes permanently…"

So it causes chronic prediabetic blood sugar and may be irreversible. This sounds like a serious concern.

This comment conversation is also noteworthy:

"freakingout said…
I don’t know whether this post is still active. I was doing ultra low carb for 5 months (30 grams or less a day). During that time I had a FBG of 96 on a random test which gave me concern, as I’m usually in the low 80s. I quit doing ultra low carb over 3 months ago, and my fasting blood glucose is now 100-118. Post-prandial has gone as high as 162. So have I permanently made myself diabetic by this low carb diet? I would think that 3 months after going back to a more balanced diet, my glucose levels would have recovered.

5 AUG 2013, 02:47:00
freakingout said…
I was on an ultra low carb (ULC) diet for 5 months. A random blood test showed fasting blood glucose (FBG) at 96, which concerned me, as I’m usually in the low '80s. Since then, I have quit the ULC diet. I’ve been eating moderate carbs for 3 months now. Yet my FBG is now 100-120 and post-prandial can get as high as 162. Have I given myself diabetes from this ULC diet? It seems it is not reversing itself once I stopped ULC. I’m very worried that I’ve impaired my ability to eat carbs permanently.

5 AUG 2013, 02:50:00
Peter said…
Hi freakingout,

I think it is quite clear that there is zero evidence base for your having given yourself diabetes by carbohydrate restriction. The physiology is quite straight forwards, I see no reason why it should happen.

There are a stack of unknowns about your circumstances. I would be very concerned about a BG over 160mg/dl post prandially and would do whatever was needed to stop it going there. You have only two tools, LC and drugs. You need to know if you need drugs. You do need LC, on the most simplistic of generic observations…

Peter"

Peter states that there is zero evidence that carbohydrate restriction can give someone diabetes. However in his article he states that one would fail a glucose tolerance test and would be diagnosed diabetic and that his fasting glucose is pre diabetic. The in the above, first comment by peter, he states that “something changes permanently” and if this “something” is a permanent insulin resistance which would presumably cause permanent high blood sugar, isn’t that very close to diabetes caused by carbohydrate restriction?

Finally, don’t prediabetic blood sugar levels and a diabetic response to a glucose tolerance test strongly contradict LC and keto improving insulin sensitivity and reversing diabetes since these are symptoms of impaired insulin sensitivity and diabetes?

EDIT:

One more thing, this directly contradicts the idea that LC and keto are fantastic for improving insulin sensitivity:

From the article:“Well, the first thing is that LC eating rapidly induces insulin resistance.”

I am so lost. This is the opposite of everything I have learned about keto!

#17

@Fry
Deep breath… it sounds like Steve Cooksey was a T2D and even though he’s doing great, he isn’t insulin sensitive enough to be able to handle pizza, and the answer to FreakingOut makes sense to me.

A lowcarber failing a GTT just means that they’re not used to those extreme levels of sugar hitting the system. Richard’s preferred phrase “glucose sparing” kind of answers this one.

When someone who is already insulin sensitive dramatically lowers their carb intake, the glucose sparing mechanism is more likely to kick in, and even then it doesn’t seem to be a problem (which I think is the point of his article, right?).

I’m not sure where you are health/insulin-resistance-wise, but insulin resistant folks have a very different path.

Edited to take out references to the blog post (which I haven’t actually read!!)

#18

@Madeleine
Thank you. Doesn’t insulin sensitivity improvement include those that are insulin resistant? The diet is supposed to improve these things for diabetics and those that are pre diabetic and/or insulin resistant as well as those with normal insulin sensitivity. Yet if the diet rapidly induces insulin resistance this is utterly impossible and contradictory.

Also there is the issue of whether or not chronic pre diabetic blood sugar levels as mentioned by the author (he said his were above 100 when fasting which is pre diabetic) is detrimental to ones health and begs the question: do they keep getting higher until one’s fasting glucose levels are straight diabetic?

(Todd Allen) #19

The temporary physiological insulin resistance of a keto diet makes sense to me. However, my personal experience differs somewhat. I had very poor post prandial blood glucose response to most carby foods before keto as well as a nearly diabetic fasting blood glucose.

After a year of keto my fasting blood glucose is healthy, ~80 mg/dl, and lately I’ve been able to eat increasing amounts of carbohydrate with post prandial blood glucose remaining below 100 mg/dl, my somewhat arbitrary target. I’m not interested in doing OGTTs to establish my degree of insulin sensitivity compared to others and am content with how this is working for me so far. I did get my fasting insulin measured and it is now quite low. Most of my gains I attribute to fasting and losing weight, especially visceral fat. Eating keto is what makes fasting possible for me.

However we are all different and your keto diet is different from mine and everyone else’s. Even if keto works for most it could still make you diabetic and destroy your health. I don’t think there is any good substitute for monitoring as best you can how your body is responding to your diet and adjusting as needed.

Also, there are many many factors known to affect insulin resistance beyond diet macros: sleep quality, chronic stress, exercise, gaining/losing fat - especially visceral fat, muscle quality and quantity, a wide variety of toxins, numerous micronutrients, therapeutic thermal stress, etc.

#20

Yes, I think it includes especially those who are insulin resistant. Folks who are already insulin sensitive find that cycling in some carbs sometimes can be useful for various reasons, one of which might be to keep up the glucose -burning end of a flexible metabolism (? I have no idea… I’m just speculating here).

I’ve never heard of anyone getting diabetes from LC; there’s a lot that I can’t answer in detail about your questions but that - becoming diabetic from restricting carb intake - just doesn’t happen.

Here’s a question: how do we explain 100 fbg (in the blog author) but a 4.something A1c? Since the a1C is an average glucose reading over the longer term, I would take that as a very reassuring indication that the guy is not headed in a dangerous direction.

I’m pretty sure that Richard has gone into this question in depth at some point. Have you dug around the forum a bit? There’s something about this in Mark Sisson’s new keto book. I’ll type it out for you if it makes you feel better.

#21

I hope I’m not violating some copyright laws here, but @Fry, you sound really worried. Here’s something to tide you over. Mark Sisson goes into a number of long-term strategies once someone’s spent 6 weeks or so in keto. His favorite for those who are active and metabolically healthy is in and out of ketosis, with some activity and low carb but not 100% keto all the time (where as his recommendation for those who are metabolically damaged or compromised is long-term keto).

Here’s what he says at the end of a section where he goes into a few strategies that different people sometimes use:

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(Todd Allen) #22

Jeff Volek video - keto reverses insulin resistance

(Jen ) #23

Just curious if you have consulted an endocrinologist or keto-friendly nutritionist about your concerns?

(You've tried everything else; why not try bacon?) #24

The kind of insulin resistance discussed in the article is a healthy adaptation to fat-burning, in which (as I understand the article to be saying) muscle cells resist the insulin’s instructions in preference to burning fat, so the glucose level in the blood rises somewhat. That this is a healthy adaptation is shown (again, according to the article) by the fact that HbA1C remains low. This means that the hemoglobin in the red blood cells is not being glycated at a significant rate, despite the somewhat elevated serum glucose. It is not the same thing as diabetes, which is an insulin problem, not a glucose problem (although too high a glucose level becomes a metabolic emergency for the body). The fact that glucose levels decrease after only three days of eating carbs is another sign that this is neither a problem nor the type of insulin resistance that is the result of eating too much carbohydrate.

From the blog article, here is the blogger’s explanation of the phenomenon:

What is happening? Well, the first thing is that LC eating rapidly induces insulin resistance. This is a completely and utterly normal physiological response to carbohydrate restriction. Carbohydrate restriction drops insulin levels. Low insulin levels activate hormone sensitive lipase. Fatty tissue breaks down and releases non esterified fatty acids. These are mostly taken up by muscle cells as fuel and automatically induce insulin resistance in those muscles. . . .

This is patently logical as muscle runs well on lipids and so glucose can be left for tissues such as brain, which really need it. Neuronal tissue varies in its use of insulin to uptake glucose but doesn’t accumulate lipid in the way muscle does, so physiological insulin resistance is not an issue for brain cells.

However, while muscles are in “refusal mode” for glucose the least input, from food or gluconeogenesis, will rapidly spike blood glucose out of all proportion. This is fine if you stick to LC in your eating. It also means that if you take an oral glucose tolerance test you will fail and be labelled diabetic. In fact, even a single high fat meal can do this, extending insulin resistance in to the next day.

. . . . .

This now fits in to an overall pattern. Elevated non esterified fatty acids induce physiological insulin resistance and a higher than expected FBG level. A simple switch to higher carbohydrate eating (in myself) allows the normal underlying pancreatic and muscle function to show. It also fits in with the FBG of 3.5mmol/l found in the carbohydrate fuelled natives in the Kitava studies.

So do I worry about a FBG of over 5.5mmol/l?

Not while my HbA1c is 4.4%.

So the author, himself a Type II diabetic, has concluded that the rise in fasting serum glucose is perfectly normal, and that he is perfectly healthy, despite appearances.

P.S.—I edited the quotation slightly and added emphasis that seems relevant.

#25

@JayBee

I have had my a1c and fasting sugar tested and the results were normal.

Thanks for the suggestion but I have terrible insurance and it doesn’t cover anything but an md unless it was deemed necessary, so I cannot talk to either of those types of specialists. I am also poor.

#26

@PaulL

Thank you. I suppose then it would just depend on whether or not it actually is healthy to walk around with higher than normal blood sugar regardless of how one defines such a state in regards to one’s hba1c. I would like to find some actual science or studies or both that make it crystal clear that there is

A) no negative health effects from running technically pre diabetic blood sugar levels a lot of the time

and

B) That this is reversible.

Further, what if a non keto person had a fasting blood sugar level of 110 but a low Hba1c? Is this healthy as well? I am feeling like it is my lack of education that makes me confused but I imagine a standard trained md might be out of sorts here too. Pre diabetes is commonly diagnosed with this blood sugar reading. I imagine if one’s md who was not into keto saw one’s fasting blood sugar, as the author put it, “creeping up” to pre diabetic levels, regardless of what kind of diet one was on, they would be concerned. Further the author states in the comments that there are some kind of permanent changes possible (though he is not clear on what he means by this). I so wish there were more studies!!!

#27

@Madeleine

Thank you so much. That is very kind of you to try to watch out for my stress level lol!

The page you posted certainly makes me feel better. I am still a little perplexed by the section where he states “The rationale for refeeding is that if you maintain low insulin levels for a long time, your cells may become somewhat resistant to insulins signals…like a muscle atrophying from lack of use.” He doesn’t quite clarify why one would need to do this at all, particularly in light of his later statement …there are simply and absolutely no health objections to long-term keto…"

If there are no health objections to long-term keto, why is refeeding needed to balance insulin sensitivity?

Also interesting to note is that he flatly contradicts the statement by the author of the article (Peter) that “LC eating rapidly induces insulin resistance”. “a long time” is not rapid!

Is the author of the page an actual doctor and the article writer (Peter) just some guy? That would be convenient as I am fine with taking a doctors reassuring words over some guys concerning statements. However if both are legitimate doctors then it is a bit tougher to decide who to listen to…

(You've tried everything else; why not try bacon?) #28

Yes, more studies would be a good idea. Be aware, however, that even if nutritional science should suddenly become rigorous and data-driven, there is no such thing as certainty in science. At best we can say things such as, “The preponderance of the evidence appears to indicate . . .” and “In 820 cases out of a thousand, we observed . . .”

If your assessment of the evidence as you’ve discovered it, and in particular from blog posts such as this one, leads you to doubt that keto is safe, then I would strongly encourage you to do what you need to do to stay safe and to adopt some other way of eating. For myself, I like having lost 60 pounds and six inches around the waist, even if I never lose any more. I like the way I feel. I like being free of my sugar/carb addiction. I will keep eating keto regardless, unless my metabolic markers fail to improve, in which case I will be looking around for another way of eating. Keto, however, is the only one I’ve seen so far that I like the looks of.

#29

@PaulL

Thanks, I agree with your sentiment but this idea of irreversible insulin resistance is what scares me!

I have had similar fantastic results on the diet and found nothing but good studies and the bad ones talked about reversible problems. I always felt like the diet was basically keeping one’s body in safe mode so to speak. Protects against diabetes and a lot of other ailments.

Now I am looking at a diet that has wonderful results but may permanently impair my bodies ability to handle glucose and may keep my blood sugar chronically high which may be a very bad thing.

Could you please explain your view on how this is not a concern?

#30

@brownfat

This Volek thing you posted is precisely what I have always understood and it is supported by studies. Perhaps this article is flawed and incorrect? All studies I know of show keto reversing insulin resistance, reversing diabetes, etc. This author is the first I’ve heard say “LC eating rapidly induces insulin resistance”. It is the exact opposite of what studies show. If this were true then LC eating could not reverse diabetes or insulin resistance. Unless I misunderstand something, diabetes is caused by insulin resistance, so if someone with insulin resistance started a diet that rapidly induces insulin resistance then this would simply worsen their condition and may even be fatal for those already having these kinds of problems. It certainly wouldn’t help them!

That said, assuming this resistance is not actually rapid at all and so it would help diabetics, what of the high fasting blood sugar? He said it creeps up. Does it stop at some point? What would that mean for a diabetic? They get on keto, it reverses their insulin resistance, lowers their blood sugar, but then it starts creeping back up as their insulin resistance reappears?

I have seen studies that show the insulin sensitivity improvement is temporary. So maybe this author is simply experiencing a return to his pre keto health problems? Maybe cycling keto is the best way to keep these numbers low?

(Richard Morris) #31

Yep. It’s normal. It’s like if you reduce sugar in your diet, eventually slightly sweet food tastes cloying. It doesn’t mean you can’;t eat the food, it just means that you have adapted to having less sweet food. If you were to eat sweet food for a few weeks you will reverse the adaptation. It is similar with physiological glucose sparing.

Dr Joseph Kraft who did over 15,000 oral glucose tolerance tests and developed the oral glucose insulin test in order to identify hidden diabetes described the pattern when people make insufficient insulin such as in the case of type 1 diabetes as pattern 5

image

Interestingly, Kraft also shows that sometimes people on low carb diets can show this pattern temporarily. It’s not that they are unable to produce insulin, it’s just more likely that they can take up glucose into cells (eg, brain) without insulin in the first instance. These people return to Pattern 1 after a period on a higher carb diet. I think this is also consistent with the finding that people on LCHF diets typically have a temporary diagnosis of peripheral insulin resistance which is resolved after a large carb meal. It’s likely that the body adapts to preferentially shunt the available glucose to the brain first. So Pattern 5 with a low carb diet is OK, its just the same physiology as Pattern 1 but adapted to low carb.

There are Vegan activists (like Dr Michael Greger) who use this to make their case that a ketogenic diet is unhealthy. IMO It’s a willful misrepresentation of the data in order to make their case that eating animals is unhealthy. Those are the only people I have ever seen make the case that a low carb diet causes diabetes.

Have the keto experts talked about negative effects of "intramyocellular lipids" (IMCLs)
#32

There are a number of people on here, who preKeto had FBG of 120 or more. They now have FBG of 80 or 90. For those people it does not matter whether they will ever be able to process carbs because they could not do it before, its like the joke, Doctor will I ever be able to play the violin, after surgery and the doctor says of course only to have the patient say, that is funny because I could not play it without the surgery. So since they were headed down a medicated path and are now on unmedicated one, they are happy as long as their numbers do not creep back up. I am not sure if that does or does not happen. Some people mention it happens but I do not know how strict they are being. Most have accepted that they will not be having crumb cake anytime soon or possibly ever.

[quote=“Fry, post:30, topic:23257”]
I have seen studies that show the insulin sensitivity improvement is temporary.
[/quote] I would be curious to see the studies that prove this

If someone is healthy, insulin sensitive who has a few pounds to lose but is not prediabetic, then I might do my own research

#33

The author of the page I put up is Mark Sisson and I don’t know anything about the blog fellow. Mark Sisson and a few other prominent health writers and scientists like Chris Kresser, Peter Attia, Robb Wolf, etc. who have been low carb for a long time, are insulin sensitive, and are particularly fit (resistance training seems to do something really great for metabolism) find that they do best mostly keto, but they cycle in some carbs or some periods of bumping up their carbs a bit. Not a ton, and they’re careful about the quality of the carbs (not pizza and donuts! more like sweet potatoes and squash). I think Attia spent several years strictly keto before he did that and you could check out his blog to read about how/why he started adding in more carbs.

I would read Richard’s post several times and then do some digging around to reassure yourself.

(Jen ) #34

Are you in the US? If you are obese or have metabolic syndrome, you can definitely be referred to a nutritionist by your doctor (covers medical necessity- my past job was getting authorization from insurance companies and out of the hundreds of patients referred to a nutritionist zero were denied). I hope my posts aren’t coming across as hostile- I’m just trying to help!