Does a healthy ketogenic diet cause irreversible insulin resistance?

(Michael - When reality fails to meet expectations, the problem is not reality.) #102

@SunnyNC @Corals

Maybe this is relevant to what you’re experiencing:

Above and several following posts from myself and @amber. Maybe it’s not IR causing the steadily rising BG but low ketones coupled with GNC trying to keep the brain supplied with glucose.

I note that in the article cited by @PaulL , Peter says “I spend rather a lot of my life in mild ketosis” and I suspect that the fasting blood glucose rise noticed by Peter and others might in fact be due to having insufficient ketones available for the brain to max out, so it’s demand for glucose remains. As long as the brain says “feed me!” gluconeogenesis is there to do just that. When the brain stops asking for more glucose, I think gluconeogenesis stops making so much.

Just a thought. Unless I misunderstood her, I think Amber would suspect it’s due primarily to increased protein intake, ie a lower fat:protein macro ratio as one stays in ketosis long term and loses fat mass. Maybe she will clarify if I’ve misinterpreted.

PS: I keep saying/intending to purchase another Free Style Libre sensor and monitor glucose for couple of weeks. I’ve been in ketosis continually for 5 consecutive years. I’ve also maintained a 2:1 fat:protein macro ratio the whole time, except for a several month-long test of slightly higher protein. So it would be pertinent to see where my glucose is.

(Michael - When reality fails to meet expectations, the problem is not reality.) #103

You may find this of interest and might find something useful. There’s a nice list of citations following. There is also a critical discussion with one of the commenters and the author which is worth reading.


I only mentioned it because I am prone to similar eating patterns, despite the evidence by folks like Sachin Panda around circadian rhythms showing eating earlier in the day is likely superior for hormones.

(Doug) #105

Sunny, it will be interesting to see what your next A1C test result is. How much of a history of the readings, there, do you have? Several readings ~5.5 before keto?

Your concern is one of the most interesting things, here, lately, IMO. I’d like to see more results, i.e. many other people doing the same thing and taking the same readings. I wonder how prevalent it is - initial decline in A1C and blood sugar but then an increase while eating ketogenically.

It’s pretty common to have the body adjust to whatever we’re doing. To see the rate of improvement decline, or even outright reversals occur - this stuff happens. Family history of diabetes - perhaps you’re fighting this battle more than many people. Certainly more questions than answers at this point; whether or not your next A1C test confirms projections from your blood sugar readings is one.

There’s often variability from one person to another. For you, personally, another question is if the ‘higher’ current range of blood sugar is harmful. I don’t know how well established any consensus about a ‘hard number’ for average blood sugar is, i.e. “Above this line is bad, below it is good.” I think there’s a continuum, and if there’s individual variation in tolerance then it’s a tough thing to nail down. Not at all saying that your higher fasting blood sugar is magically okay, but also not saying that it’s definitely bad and worthy of treatment - my ‘not a doctor’ opinion.

There are well-known chronic, long-term bad effects from “high blood sugar.” I wish there were shorter-term, measurable effects where we could say, ‘Sunny’s averaging 104 mg/dL blood sugar and this is (or is not) harming him.’ If it is, then I hear you on approaches like possibly taking Metformin. For now, I think it’s a question. Here too, I am not sure how much this varies, person by person, but with many things a given level of a substance will be a problem for one person but not another.

One thing that seems odd to me is on your CGM report where it says, “Each 5% increase in time in range (70-180 mg/dL) is clinically beneficial.” I guess that is allowing for higher readings after eating, but IMO it’s oversimplified (it needs to take the average into account) - somebody doesn’t go above 180 but averages 170 and they’re thinking, “Oh, I’m good…” :smile:

(SunnyNC) #106

Doug - Its refreshing to read a response that finally does not say high BG is OK on keto for XYZ reasons and vehemently defend keto diet.
I dont remember all the past A1Cs. I am fairly young, healthy and fit, so it was not something I even thought about. I do know that my highest pre keto lab measured A1c was 5.5 (fasting BG was 85 at that time). That was in Nov 2020. 5.5 was shocking to me, that when I started keto and serious running and fitness regimen. 3-4 months into clean keto, it dropped lab A1C dropped to 5.2, but fasting BG was upper 90s. 5.2 is what my CGM was estimating. So I know CGM data is good. When they called me to discuss the results, high fasting BG was the only concern they mentioned, other than LDL having gone up. but HDL and TG was the best it has been so I was not concerned about LDL, even though my Doc was. She is definitely not up to date on new science, for sure. 3 months after that, my (CGM) A1C jumped to 5.6, a month later it 5.7 officially putting me in pre-diabetes range. I will now look like an idiot if I go to my Doc complaining about my high FB and increasing average as she clearly stated I need to “add more carbohydrate and eat at least one extra meal” when my Fasting BG and LDL went up.

Yes, my family is plagued with diabetes. I am guessing its mostly due to poor lifestyle choices and diet. Genetics may have a role, who knows! That is the reason I proactively went keto. My pre keto A1c of 5.5 was after a bout of crappy eating, parties, binging and not exercising. (got a house and was dealing with construction for a year) I knew I was going down a bad path, that is the reason I got my base lab work done and started keto. I have a feeling, if I had gone back to my normal healthy eating and exercise patterns, that also would have dropped my A1C after 3 months, so I definitely cannot credit keto alone for the initial drop in A1C. But I do know I can credit keto for the high HDL and low TG as I know my HDL was not good even when I was eating super healthy and working out 6 times a week preketo.

I totally agree with you on comment “above this avg BG, it is bad as this is when glycation starts” but that have not seen that data anywhere. According to Lusting, we are all constantly glycating/browning… compare a low flame to high heat, both eventually brown, low just takes longer. So I believe lower BG still causes glycation but at much lower rates. So lower the BG the better, that’s where being in ketosis has an advantage. With ketones powering most of the energy demand, we can allow BG to go lower than the typical 70 and still feel great. In the beginning “honeymoon phase” of keto, I have had BG in 60s at night and I still felt just fine. It even went to 57 one time. I only knew I was that low because the reader alerted me, I felt great. BG always returned to 70s, 80s in a few minutes.

Regarding - "**“Each 5% increase in time in range (70-180 mg/dL) is clinically beneficial.” – this is because that report is geared for diabetics. For a diabetic that would be a great target. You are right, they have the range all the way up to 180 to account for post prandial spikes. In my case, post prandial is pretty much the same as fasting a I eat less than 5% to no net carbs during my meals.

my new update is -
I am suspecting my high fiber and/or moderate (but on the higher side) protein (causing high GNG) could be an issue. This definitely was not an issue in the past. So if I can confirm through further monitoring and tracking that high fiber/protein on keto is bad, for me, then keto is not for me. I love my high fiber and protein, in the lack of carbs. This past week, I have eaten the healthiest foods, tracked everything on my fitness pal, ran every day, did some HIIT, been in calorie deficit, tracked ketosis, ate minimum protein for my height/weight/BF%. The only difference all that made so far is my BG is lower at night, when I sleeping. Average BG dropped 3 points, not a lot for all the sacrifice but I want to give it a 2 week shot. It still starts going up at early mornings (dawn effect, ofcourse) and continues to stay high all day long. If I go for a long walk or jog, BG goes down to 80s but it goes to 100s within 30 mins. I am guessing this is due to glucagon dominating in absence of insulin or due to hepatic IR induced by keto diet. If I have to resort to medication to control my FBG, then I might as well do a regular non-keto healthy diet and I am pretty sure my physiological IR will vanish and I will have good BG control. This is the reason I am getting another round of bloodwork done end of Jan to get a new baseline before I stop keto. However, given all the other benefits of Keto, I am willing to consider metformin as it is supposed to have other benefits (longevity, gut microbiome, higher HDL etc).Another option I am considering is CKD or TKD. This is all more trouble and work than what I “signed up” for when I went keto. I have 3 more weeks to continue tracking and researching before I decide my next approach. I would love to hear from others who have done some research around this issue or have some data to share.

(SunnyNC) #107

Thanks. My blood ketone when I wake up is at least 0.5. usually between 0.5 and 1.
It used to be higher the first few months. According to what I have researched, after being fat adapted, body learns not to waste ketones so 0.5 to 1 is the norm and indicates fat adaptation.

Regarding I don’t have enough ketones so liver puts out sugar via GNG, I would not argue with that because I know that my BG is high because my liver is dumping out sugar. I cannot control ketone amounts, I can only cut out all carbs. I am not interested in taking exogenous ketone supplements. The fact that my liver is dumping glucose via GNG but my muscles are not using it coz of physiological IR, my fasting BG, average BG and A1C are all going up. My only question is why this high BG ok when it is driving up my average BG and A1C. High BG is toxic to organs regardless of the reason why BG is high. I have probably repeated this question a dozen times and no body is able to directly answer my specific question. Perhaps it because we have all been repeatedly brain washed to believe high BG is OK in keto. There never say how higher A1C as a result will not cause glycation and associated damages

(SunnyNC) #108

Thanks, I had ready that article before. I read the comments section now and it does not answer my question unfortunately. The solution that worked as per the comments are not really applicable in my situation :frowning:

  1. Lose weight - I don’t have any weight to lose. I am already at 15-20% body fat and very lean. I am athletic so weight has never been a problem.
  2. Combine keto and IF: I already am. I do 18:6 usually. I have done 48 hrs fast here and there for longevity purpose. Right when I started keto a year ago, I did FMD to get I into ketosis quickly. Everything was great the first 9 months.

(Laura) #109

My numbers drive me crazy too. My fasting BG is always over 100. The last test a few weeks ago was 105. My a1c is 6.1, but when I test my BG all day long, it never goes above 126 and usually hangs around down in the low 100’s and mid 90’s.

My doctor knows that I follow low carb/keto and he approves of that and he is unconcerned by my numbers. It makes no sense to me what is going on, but if he says that I am fine, then I am not going to worry about it. I would feel better if the numbers were all lower though.

(Butter Withaspoon) #110

Hi Sunny, it sounds frustrating and I hope you can figure it out. I have some thoughts but no data or studies so maybe not helpful… but here I go.

You said you are lean and athletic with low body fat. I’m in the same category. I had an initial period of keto diet with very low carbs, to experience it fully and see how my body responded. I became leaner and my muscles seemed to grow a bit, or at least be more visible. I felt great.

Some months passed then I found that
my blood pressure had gone up a bit which was worrying me. How could that happen when I look and feel healthy and lean? I considered that I was possibly pushing a little too hard from more than one direction, thus raising cortisol and adrenaline. When eating mainly meat and fat it can be hard to eat enough after a 6hour hard hike. Maybe my body was having a mild stress response. :woman_shrugging:

Longer term, I’ve added some fresh unprocessed carbs back in, and somehow this feels relaxing, easy, comfortable. My blood pressure was better recently. But since I haven’t had BP tracking at home with more data I’m only guessing.

So my thought is- for a lean athletic type who exercises- consider eating more, aiming for a higher level of carbs with plenty of variety. Consider a stress response

(Butter Withaspoon) #111

Also: I don’t fast anymore. A pretty generous Time Restricted Eating pattern is all.

(Michael - When reality fails to meet expectations, the problem is not reality.) #112

I’m starting my CGM ‘adventure’ part 2 - now! 2 weeks of data coming your way. I’ve posted today’s meals and summary as start data. For reference, I’ve been in continuous ketosis for 5 consecutive years as of Jan 03, 2022.

(Michael - When reality fails to meet expectations, the problem is not reality.) #113

I’ll be posting today’s glucose plot either in the evening or tomorrow morning here, although I will post a partial plot in this topic later today.

Just to keep anyone who’s interested up-to-date, though, I charged the CGM reader overnight, activated the sensor at 07:10 this morning and just took my first reading. This 1.25 hours after getting out of bed after a 13 hour overnight fast:

2022:01:09::08:14 = 3.2 mmol/L.

Mike’s Excellent Glucose Monitor Adventure 2
(Michael - When reality fails to meet expectations, the problem is not reality.) #114

As promised:

2022:01:09 glucose plot (partial)

(SunnyNC) #115
  1. A1C is BAD if you are not diabetic. I would change my doc is he or she says 6.1 is ok for a non diabetic. If your A1C was lot higher preketo and came down to 6.1 post keto then its OK as keto is helping… maybe you can ask your doc why 6.1 is ok on LC/keto, wont it cause same glycation damage as 6.1 on SAD…?

(SunnyNC) #116

Hi Hallie - thanks for sharing! that is also my guess. Along with physiological IR, it exuberates my fasting/baseline BG . This is why I am planning on changing my diet after getting my blood work done. Luckily I had full lab done each time I changed my diet, so I will at least know what works for me. the issue is it takes time to adapt, so it takes time and $.
Regarding blood pressure, mine dropped after keto. It used to be slightly above normal the year before I started Keto as I was eating crap and not at all exercising much of 2018/19. Its almost normal now, not sure if its due to me getting back to working out several times a week and eating 100% healthy or due to Keto. I have a feeling my BP would have normalized on any any healthy diet and working out. All I know is keto did not make my BP worse! I think over all keto has been great, it simplified my shopping/cooking. I am never hungry. That is why I am desperately trying to find out why I can continue on keto and justify high BG. So far, I have been biased towards keto. That’s starting to change because in my books and speaking for myself, high BG is so bad and damaging in the long term, that it offsets all the other positive changes that Keto diet brings. I envy folks who are on keto and have normal FBG! Still trying to figure out my next lifestyle/diet, maybe CKD/TKD or just LC. Suggestions welcome!

(SunnyNC) #117

Thanks again Hallie. I am glad you found something that works for you. I have been considering adding breakfast back, I tried a few times and I find that I over consume calories. BTW, I love BF, it is my favorite meal of the day so it was pretty hard to give up. So no bias there :slight_smile: I don’t miss BF now. I can easily eat 2000 calories in 2 hours and feel great and go for a walk or a jog. So eating 3 meals, I tend to over eat. I was doing 20:4 for 3 months, then I changed it to 18: 6 on a more liberal side, meaning I will eat after 16 if I work out or feel like it. I am going to try your suggestion and make my eating window even more generous (maybe 14:10) and track my BG response. Thank God for CMG technology!

(Bob M) #118

Be very careful with A1c. It’s not an actual measure of blood glucose, it’s a measure of glycation of red blood cells, which depends at least on how long your blood cells live. See this for instance:

He recommends fructosamine, which I have had done in the past. Maybe I should get it again?

But the best really is a CGM. They are, sadly, too dang expensive.

Edit1: Also, he likes post-meal glucose, but for me when I’m eating keto, my post meal glucose = my pre meal glucose. It’s a useless measure.

Edit2: Also, I have the theory that red blood cells can liver longer on keto over time, at least for some, leading to a misleading “increase” in HbA1c, when one does not exist.

(SunnyNC) #119

Hi James, I love Satchin Panda. I have been following him ever since I saw him on Rhonda Patrick’s Found My Fitness channel.
Its going to be hard but I am going to try to stop eating after sun set for a couple of weeks and track the results. I have a feeling it will definitely work. But then why on earth I am doing a diet that increasing my BG and then do all these other things just to bring it back to normal when it was normal to begin it, before I went keto :slight_smile: See my dilemma here, lol!
P.S: Regardless of keto or SAD or vegan or whatever lifestyle, I think Satchin Panda’s research is very convincing. Circadian rhythm is so important and under appreciated. So maybe this is an opportunity for me to start implementing some of his suggestions. :slight_smile:

(Bob M) #120

Whoa, your blood sugar varies much more than mine does. Consider these random 3 days:

Pretty much dead flat, except for a rise in the morning.

Edit, one more since this month had my oral glucose tolerance test:

The big hump in the morning is my response to 75 gram glucose. I know I ate at least twice that day after my OGTT. When did I eat? Even I can’t tell.

(SunnyNC) #121

So true. My post meal BG = pre meal, so I am 100% with you on why that is useless for keto folks. In my case, I dont think I have any weird hemoglobin issue and A1C trending up or down is still a reasonable indicator of where I am headed. Moreover I use CGM and A1C and CGM data correlate pretty well. I am going to ask my doc to order a fructosamine. Wish me luck, for some reason she seems reluctant to order anything other than standard tests. I had to convince her to order a NMR as I was concerned with LDL going up since starting keto. She said I need to reduce my LDL when going over the results but did not want to order an NMR test but instead “eat more carbohydrates and add a extra meal”. Finally when I got my NMR, it shows that my lipid profile is indeed great and in the top 25 percentile despite LDL-c being higher. When I discussed the results, her response was “I still recommend that you add more carbohydrates to your diet and eat an extra meal”.

It will be interesting is folks can share their A1C vs Fructosamine results to see if Keto does indeed produce falsely higher A1C for them.