Maybe……

[WD5CW]

1. I feel at a total loss. I have been keto for 4 years; at the beginning things where going well I was seeing good progress; weight moved, depression fell away, and my BG was under control.
   I now find myself the same weight (don’t really care), depression is off and on (hoping one thing lead to another), and my BG is slightly out of control. The reason I say slightly is because if you look at my BG (I wear a CGM) it starts 120-140 and goes as high as 250 then falls off at the end of the day. Now I know what your thinking Dawn Phenomenon? Well maybe. But I have had cortisol checked and it’s been normal. Isn’t it supposed to fall of or go away after a few years? Something clearly isn’t right. After 4 years of keto shouldn’t it regulate better? We went down the Cushings rabbit hole and if I was at one time I’m not now.
2. The times I have had normal BG was: after a 4 day fast (not currently sustainable), working out like a crazy person (3 hours a day 4 times a week), and doing all the things they tell you not to do with fat and keto products. (Butter and cheese, salts and mct oil)
3. Because of the high BG they wanted me on a new medication. GLP-1’s are out of the picture because of sleeve surgery, I had a sever (TMI) yeast infection from invokana (but it did work), so my Endo gave me jardiance. Which work Beautifully the first day; highest registered BG 250 then it plummeted to 85 within 3 hours. (It made my head spin literally) but by the 3rd day I was eating every 2 hours feeling awful and registered a low of 54. I was pale and out of it (cognitively). I had done some research but I didn’t find out till after I stopped it that it’s not uncommon to have DKA with low carb or keto people. Oops.
   This really put me at my wits end. I really don’t know where to go from here. I don’t know what to try and I’m trying to find a reason it’s worth it.(it’s the depression talking; not suicidal) so I’m throwing it here and hoping for some thoughts, encouragement, and advice. I know no doctor-patient relationship is formed. But experiences are welcomed. Maybe I’m the only one?

P.S. I’m glad the dudes are back I really needed this right now.

[richard]

The problem with extended fasting is it’s a short term strategy only. For me it was an eye opening epiphany, that I could do it. That in fact I can function without needing to eat for a few days if I had to. In fact I think the most lasting benefit was that I came to a new relationship with my own body fat. A lean person can’t fast, they have to eat consistently and go downhill quickly when they don’t. I know I can not eat for 4 days and cycle 100km. I’ve done that many times, and every time I am amazed at how adaptive my body is with this buffer of energy.

Let’s look at what worked for you to get you glucose control - I believe that glucose control is the most important thing, and hopefully getting some control over that will help with the other issues. Fasting did, but it was a short term strategy. The higher fat end of keto did. And exercise did. All these things switch your glucose homeostat from pancreatic insulin to hepatic glucose. I suspect with these strategies your glucose slowly dropped to whatever your safe lower level was and stayed there. No hypoglycemia, right?

Empagliflozin (jardiance) apparently made a difference but it was like cracking an egg shell with a sledgehamer. It inhibits reuptake of glucose and sodium in the kidneys, causing you to pee out a lot of excess glucose and sodium in your blood. At best that is a symptomatic treatment, with nasty side effects (hypoglycemia, UTIs like bladder infections or genital fungal infections, hypotension, hyponatremia - sodium deficiency, gangrene in low places). I suspect your endocrinologist is seeing the high blood sugars as the problem to fix, and the sledgehammer is probably only going to work with someone who is supplementing their diet with extra glucose (paradoxically enough). It may be that the problem is further upstream with insulin resistance, and fixing just the chronically high glucose is only painting over the cracks in your walls and not addressing the cause of the cracks.

I think we can rescue something from the strategies that you found that did work. Hit up @Karen Ogilvie for some advice. She’s a professional nutritionist who runs a free group program (patreon supported) who combines basic keto with alternate day intermittent fasts and exercise. I helped her build her program so I’m not going to endorse it, but it may be something that might help.

[ctviggen]

Warning: most of these are guesses. Do with them what you will.

A blood glucose of 250 is very high…no matter what diet you’re on. I’ve been LC/keto 7.5 years, and don’t get blood sugar that high…ever, even eating meals of high carb. For instance, eating Thanksgiving dinner with bread, mashed potatoes, and stuffing (bread) gets me to around 180.

As for cortisol, I don’t know enough about that. I have a cortisol test at home, but keep forgetting to take it. (You send it to a lab.) But it would only be one value anyway, which is basically useless.

To me, the most important thing is the depression. Many (like me) report much better results with depression while on keto. Have you tried modifying fat, taking ketone measurements, and correlating ketones (or not) with your mood? Some seem to get better results with higher ketones, higher fat. Though I’ve seen others say they like higher protein better, at least for seizure control. I’d take a few weeks and test higher/lower fat (animal fat) to see if this helps at all. (Warning: after 7.5 years, my ketones, BHB, are so low, running 0.1-0.2 mmol/l every morning, that I stopped taking them. I can’t get them up, even eating fat. You may or may not be the same.)

Have you tried an elimination diet, such as Whole 30 or carnivore? Maybe you’re one of those people (like Amber O’Hearn) who can’t eat plants or can only eat selected plants? (This is for depression, not necessarily blood glucose.)

Also, when you are exercising, does your blood sugar go up or down? Mine goes up, but yours seems to go down.

I had a theory for a while that high exercisers – those exercising a lot – following low carb would have higher blood sugar, such as for glycogen replacement; But Shawn Baker put a hole in that theory when he started dropping his blood sugar into the low 50s after exercise. I still think it makes sense as a general rule, though.

Keep us informed, if you would kindly do so.

[amwassil]

You say you’ve been eating keto for 4 years - this fails to compute. I don’t know how you can be consistently in ketosis for 4 years and have daily swings of over 100 points in BG. If you’re spiking BG to 250 regularly, then something’s seriously haywire, not ‘slightly out of control’. Consistently in ketosis you should not have to fast 4 days to get your BG down to normal. If it were me, I’d start eating fatty beef and water only for a few months to see if the BG goes down and stays down or at least more consistent. Continued depression also indicates something’s amiss. A brain on ketones becomes a healthy brain.

[WD5CW]

Empagliflozin (jardiance) apparently made a difference but it was like cracking an egg shell with a sledgehamer. It inhibits reuptake of glucose and sodium in the kidneys, causing you to pee out a lot of excess glucose and sodium in your blood. At best that is a symptomatic treatment, with nasty side effects (hypoglycemia, UTIs like bladder infections or genital fungal infections, hypotension, hyponatremia - sodium deficiency, gangrene in low places). I suspect your endocrinologist is seeing the high blood sugars as the problem to fix, and the sledgehammer is probably only going to work with someone who is supplementing their diet with extra glucose (paradoxically enough). It may be that the problem is further upstream with insulin resistance, and fixing just the chronically high glucose is only painting over the cracks in your walls and not addressing the cause of the cracks.

That’s kinda how I feel about it as well. I was trying to find the mechanism of how it worked. I was going to see if I could help by replacing the electrolytes lost to see if I felt any better.

[WD5CW]

To me, the most important thing is the depression. Many (like me) report much better results with depression while on keto. Have you tried modifying fat, taking ketone measurements, and correlating ketones (or not) with your mood? Some seem to get better results with higher ketones, higher fat. Though I’ve seen others say they like higher protein better, at least for seizure control. I’d take a few weeks and test higher/lower fat (animal fat) to see if this helps at all. (Warning: after 7.5 years, my ketones, BHB, are so low, running 0.1-0.2 mmol/l every morning, that I stopped taking them. I can’t get them up, even eating fat. You may or may not be the same.)

I don’t really have the money to check blood ketones like that. I have on occasion tested and have seen ketone levels within ranges that are normal within the community. I found out that keto mojo will except a trade in and have ordered their new meter. I’ll have ability to test more then but I’m not sure I can afford the replacements.

[WD5CW]

Also, when you are exercising, does your blood sugar go up or down? Mine goes up, but yours seems to go down.

After about 30 min of exercise it starts to drop.

[WD5CW]

The problem with extended fasting is it’s a short term strategy only. For me it was an eye opening epiphany, that I could do it.

I only fated that long because at the current time that’s where the community was it was before Dr Jason Fung’s recommendation to not go over 48 hours. But it’s the only time my BG was normal and steady. I was also driving truck at the time and it helped me to focus on the driving.

[WD5CW]

You say you’ve been eating keto for 4 years - this fails to compute.

I’m with you which I why I’m seeking the help. It’s obvious it’s something wrong and I just can see it anymore.

[PaulL]

If you’re spiking BG to 250 regularly, then something’s seriously haywire, not ‘slightly out of control’.

It could possibly be a problem with glucagon. I believe that glucagon levels can be tested, though most physicians never order the test.

I know that in rodent studies, rats and mice bred to produce no insulin become diabetic if their pancreas still produces glucagon, but their blood sugar remains normal when their ability to produce glucagon is also destroyed. (Glucagon is produced by the α-cells and insulin by the β-cells in the Islets of Langerhans in the pancreas.) Dr. Robert Lustig talks about some of these rodent studies in his more recent lectures on metabolic disease.

[fitbod]

I agree with @ctviggen that you should prioritize the depression. I was on Paxil (or equivalent) for most of the 15 years or so prior to keto. It was amazing the way I felt “normal” within a month or two of going keto and quit the meds. For me the mood effects are 100% correlated with ketone levels. So for me “chasing results = chasing ketones”.

If you don’t test ketones it could be something to start. Like a lot of people my ketones fell - i started having some return of mood issues which really scared me - i hadn’t tested for a while and sure enough i was in the 0.2 mmol area. But I was able to get them up. I was encourage hearing that Peter Attia was able to maintain 1.7 mmol fasted throughout a 3-year keto journey.

I had to dial in the diet and pay attention to fasting windows and protein intake.

I also have gotten frustrated with my BG levels although mine were lower but stuck above 100. I am on day two of a berberine trial and I have had my two lowest FBG levels ever so I am hopeful. I am sure my muscles don’t want to use glucose at this point but my liver thinks it needs to pump it out.

[richard]

I was trying to find the mechanism of how it worked.

Both Invokana and Jardiance have the same mechanism, they inhibit the SGLT2 transporter. That has two effects, we have that transporter in the gut and in the kidneys. In the gut it reduces the amount of glucose you absorb. And in the kidneys we filter out a lot of large molecules mechanically and then have selective uptake transporters that drag nutrients back in from the filtride - essentially the liquid that will become urine.

It’s like a second gut that selectively grabs nutrients back that the kidneys have filtered out. Normally your body grabs glucose back from the urine because it’s an important nutrient. But your endocrinologist is apparently using this to dump excess glucose in urine by inhibiting this transporter.

The problem is that treatment is usually calibrated for someone eating the prudent diet with 300g of carbohydrates a day. And even then it’s just treating a symptom - high glucose. Without treating the upstream cause - insulin resistance.

[WD5CW]

The problem is that treatment is usually calibrated for someone eating the prudent diet with 300g of carbohydrates a day. And even then it’s just treating a symptom - high glucose. Without treating the upstream cause - insulin resistance.

I ask the Dr about a more targeted approach; taking it ever over day or half a dose or only when I have a BG higher then a certain level. Fay 3 so far and I haven’t heard from him.
I remember hearing Dr Nally say if you haven’t reverse IR within 1.5 years it will never reverse.

[WD5CW]

I was on Paxil (or equivalent) for most of the 15 years or so prior to keto. It was amazing the way I felt “normal” within a month or two of going keto and quit the meds. For me the mood effects are 100% correlated with ketone levels. So for me “chasing results = chasing ketones”.

I was on fluoxetine prior to keto. Depression resolved and so I stopped taking the meds with no side effects. I’ll start working on “Chasing Ketones” again.

[WD5CW]

So the day I wrote this I got labs drawn.
Glucose: 201 by lab measurement 137 by CGM
A1c: 7.6
Direct LDL: 201
HDL: 39
Trig: 112
B12: 1633
Insulin: 13.8

[WD5CW]

I got my Keto Mojo meter in yesterday and this morning I was 204 BG and 0.8 ketone level.

I’ve decided to experiment with 5mg of jardiance in order to attempt to keep my BG lower. My CGM seems to be 50 points off. I had 1/2 cup of pistachios last night with my meal and that’s the only explanation I can see for the rise in BG last night but it seems to have stayed high all night.

[ctviggen]

That is…bizarre.

For comparison,here’s my Thanksgiving, 2017 data, think bread, potatoes, stuffing (more bread) (the 9.7, about 176), then dessert (cheesecake?, before the 6.3), then more at dinner (the 8.2). Between each two lines is 1 hour:

This is eating low carb, with exercising Tuesday morning, which is what causes the higher blood sugar that morning:

Odd that your fasting insulin is really not that high.

I just don’t get the swings in blood sugar. You get pretty low, then go relatively high for a very long time.

Sad to say, but this is out of my league. Could you be a T1 (or close?)? That might explain things.

[WD5CW]

I would think that if I was getting close to T1 then my fasting insulin would be low. Dr Nally said on a podcast once that fasting insulin should be 5 or below.

[WD5CW]

This is yesterday. Day 2 of chasing ketones. New sensor (old one expired). Keto mojo

[WD5CW]

Still taking the jaurdiance. So I imagine that’s why I’m falling so fast still. Overall I’m feeling better using the MCT oil and butter in my coffee. And I feel a little more energized.