#288 Defining Diabetes: Ketones
Scott Benner
Defining Diabetes: Ketones
Scott and Jenny Smith, CDE define the terms that are at the center of your type 1 diabetes care. This episode is a companion to episode 287.
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Scott Benner 0:00
Hey everybody, welcome to Episode 288 of the Juicebox Podcast. Today's show is a defining diabetes episode that is a companion piece to Episode 287. So Episode 287 is a diabetes pro tip with Jenny Smith, about illness injury and surgery. This defining diabetes episode is all about ketones, they go together. So if you're having sickness and illness, you might have ketones. And that would make all this important to understand. Today's episode of the podcast is sponsored by the merch store at Juicebox podcast.com. That's right. Juicebox Podcast merchandise is sponsoring this episode, which is to say that I am now why am I taking the time to tell you about this large price drops on all of your favorite stuff. The merchandise supplier I'm using has dropped their prices, which allowed me to pass that savings on to you some of the drops in cost are significant. So go take a look. Juicebox podcast.com, you click on the link in the like, so what do you do? Maybe I don't even know Juicebox podcast.com then there's a little thing in the top corner top left corner, it's like three little lines. That's a menu. You guys know that. And then it gives you a little drop down emerges one of the things you can choose. And there you'll see some reductions. 3421 of them's down like $6, maybe me say, well, there's some shirts that went from 2490 to $16. So check it out. All of the money that I make on this stuff goes back into the podcast, I have recently upgraded audio equipment, and your new computer. And I have to add a microphone, because I think Arden is going to come on the show in 2020. So I'm gonna need another mic. Anyway, all that stuff that you guys buy goes towards helping me with that. I really appreciate it Juicebox podcast.com. And now defining diabetes with Jenny Smith, you know, Jenny from integrated diabetes, right? If you want to hire Jenny, go to integrated diabetes.com Check her out, send her an email, her email addresses also right there in the links in your show notes. And you can find it also at Juicebox podcast.com. Alright, ready, defining diabetes Episode 288, the companion piece to 287 with Jenny Smith.
This one's gonna be really appropriate because some of the stuff we've done recently. I'd like to define ketones. Hmm. And then explain to people when they happen and why they happen and how they change your insulin needs. So in the reason that this throws me for a bit of a loop, is because there's the keto diet that works off of ketones, but those aren't that no not for ketones. There's a keto diet that works off of ketosis, and there's nutritional ketosis, okay. And there's ketones that you get from not having enough insulin because you've been put into ketosis for not having enough insulin, but Betty being put into ketosis for not having enough insulin is not the same as being put into ketosis because of your nutrition. And I don't understand why that sounds like something. My wife said to me that I didn't understand. And I just nodded along with because I didn't want to get yelled at. Right like that. Totally. When, when, like, I was talking to Vicki on the podcast the other day, and about her ketone diet and how or her see it throws note about her keto diet and how she bonuses for it. And when she explained that part of it. I am not gonna lie to you. I nodded along like Vicki and I were married. How's it go? I get that I completely understand. Yeah, sure. That makes a lot of sense. Thank you. I
Jennifer Smith, CDE 3:41
looked at your like, a Ha ha ha.
Scott Benner 3:44
I asked the question, I was gonna ask the wrong question. And then I was gonna look like an idiot. And I didn't want to do that. So I thought I will just talk to Jenny about this. So I guess let's break it down into ideas. First, type one diabetes, I don't have enough insulin is one of the reasons I could produce ketones. Is that right?
Jennifer Smith, CDE 4:04
Right. And so in name wise, you're right. It's kind of like ketosis versus ketoacidosis. Two different things. Right, keyed ketoacidosis essentially reverse to decay. It could be a potential complication of you know, having type one diabetes, because we are at a complete insulin deficit, right. That's the reason we either pump it, inject it, inhale it, whatever you're going to do, you got to have your insulin right. And essentially, if you are in DK a, it essentially makes your blood too acidic. And that changes the normal function of many of organs in your body like your kidneys and whatnot. I mean, you have to get treatment for DK you do. Hydration is a huge part of it. And DK A is a result of a A significant deficit of insulin. It can happen for lots of reasons, either, you know, your pump site has failed and you didn't realize it and you're sleeping overnight, and you don't have a CGM, and you didn't get an alert for it or could be because of illness, and high blood sugars and not eating. And sometimes starvation, ketosis can lead in illness, to DK A, B, because of the way that the body isn't getting enough food and the potential for higher blood sugars and not correcting them and whatnot. So ketoacidosis is not what you want, right
Unknown Speaker 5:34
at all.
Jennifer Smith, CDE 5:36
And it can happen very quickly, I mean, in less than 24 hours, you know, you can in a body that doesn't make any insulin, you can be in decay very quickly. So, ketosis is difference, it's essentially the presence of ketones, which aren't harmful. And I will say that, again, ketones are not harmful. In fact, most people I mean, who who has diabetes has regularly tested their ketone level, unless they're ill or have a high blood sugar. That's when you're told to test your ketones, right? Right. ketones, however, are very common. If you test first thing in the morning, you are in a fasting state. Okay. And so in the morning, if you tested ketones, even if you're not on a ketogenic diet, or a low, low carb diet, many people wake up with ketones low level very low level in the morning, because they're in a fasting state. And in a fasting state, your body is essentially relying on fat stores to keep you going, as overnight, you're not eating in any fasting state, you're not technically eating, but your body still needs to get energy or derive energy from something. Right. So it resorts to fats.
Scott Benner 7:04
So basically, and that is God I'm sorry. that produces Yeah, go ahead. I was. Basically, when you wake up in the morning, had you gone to say you went to bed at 10pm, and you woke up at eight? For the last 678 10 hours? You've been at the beginning of your low carb diet? Because you haven't you? That's right, right, you have you haven't taken a carb. So the body begins to do what it does in a low carb situation.
Jennifer Smith, CDE 7:30
Yes, and your body is essentially tapping into your stored fat to burn something for energy in a place where there is no food coming in. Unless you're the person who sleep walks to the fridge and eats overnight, I can guarantee you're not going to be in, you know, you're not going to have low level ketones, fasting ketones in the morning. But in terms of people who do choose the ketogenic diet, essentially, you are teaching your body to no longer rely on carbohydrates for energy, but you're not doing it in a deficit of insulin. People with diabetes who are following a ketogenic diet, and are eating very low carb, and by defining low carb on a ketogenic diet, it's typically less than 50 grams of carbs a day, most are following less than that usually more around like 30 grams or less a day to maintain nutritional ketosis. And so what does the body revert to? It burns fat. And so those those diets on a kind of a flip side of what we the ABA typically teaches, which I will say it here is has tended in the past to be very carb heavy. Um, that's where I'll leave that. But the flip is the is true for a ketogenic diet, they essentially consume about 70 to 80% of their nutrition calories from fat, right? And very little from carbohydrates, somewhere between, you know, maybe five to 10%. And then protein is also very lean. In a ketogenic diet. It's not a high protein, high fat, it's a high fat, mild to moderate protein and very low carb intake. Do you in that diet? Vicki told me that you get the glucose because your body turns the protein into glucose, if you ever heard that before. Yeah, yes, actually. So with that's why you have to be kind of really conscious of what you're taking in. If you're aiming for a true ketogenic diet. If you're truly maintaining ketosis, you can't have a lot of protein, you have to look at how much is coming in because you're so low carb that in a low carb environment, your body will resort to protein conversion.
Scott Benner 9:59
Okay, today glucose,
Jennifer Smith, CDE 10:01
okay, so if you're taking in too much protein in such a low carb intake your bodies instead of taking in the fat and using it for fuel and being in true ketosis, your body is going to say, hey, there's some protein here in excess of what I need. Let's just use that for glucose. So it's it's a fine line of managing, which is why, you know, when somebody comes to me and wants to talk about ketogenic diet, I, you know, there's nothing specific about any diet that I'm like, nope, don't do that. Don't try it at all, whatever. I'm happy and willing to work with whatever kind of plan you want to work on. But you have to understand the difference between all of the things that are out there, you have to do your homework, and it takes work. It takes upfront work of really understanding, healthy and safe, nutritional ketosis.
Scott Benner 10:53
I put the I put Vicki's episode talking about bolusing for her keto, for keto diet and your my episode about fat and protein, I put them up on the same day, because in my mind, they looked at two different things from the same angle and different with different theories, like but they they all fit together to me correct. I thought you really needed to hear both of them to understand. So okay, so two things I want to go back to the first thing is, if my blood sugar is very low, and I feel like you said this before, but I want to make sure I'm clear, but I'm sick. I could still end up in ketosis because I'm likely not eating. And am I getting? Am I getting a mixture then of ketoacidosis?
Jennifer Smith, CDE 11:34
If you're? Yeah, yeah, you're right. If you're, it's a it's a fine line. And it's one that we talk about a lot with people now, on low carb diets and talk we in talking about illness and illness management. If you're already in ketosis, and you are then not really eating and blood sugars aren't necessarily going to be excessively high unless there may be an infection. We know that infections are such a stress on the body that you will likely have higher blood sugars, but high that's typically defined with the worry for DK a is greater than 240. And that's why many meters and pumps and whatever you put in a blood sugar is more than 240. It says check for ketones, you know, right? Right, I probably remember that from you know, PDM, it tells you right away check for ketones with the blood sugar. But if you are ill, and you're running higher blood sugars than normal, let's say you are typically running at 90 because you're on a new, you know, ketosis type of diet. Now your blood sugars are running at 141 40 might not be a bad blood sugar. But it's and I hate the word bad. But you know, for somebody who 90 is normal 140 is like oh my gosh, I'm you know, at 140. And quite honestly an illness, you may end up getting yourself into the potential for trouble with ketoacidosis, even at a number that doesn't look, quote unquote high. So again, what goes into that is the management of hydration, the management of the amounts of insulin that you need, if you're typically running at a 90 blood sugar, but your blood sugar's now 140 or 150 and you're not eating and you have normal ketones floating around in your body, those ketones could get higher than they should be in nutritional ketosis leading you into decay. So that's, that's again, we're defining like ketosis versus ketoacidosis. Those ketone levels are very, very different in ketoacidosis. If you're doing a blood glucose or a glucose, blood based ketone test, not a urine but a blood based ketone test with a monitor, you will have very high ketone levels, I mean, four or five, six, on the scale of measurement. in ketosis, typically, ketosis is, depending on what you need, could be anywhere between a value of like 1.5 to three ish for normal ketone levels in nutritional ketosis, and people who are really trying to follow a ketogenic diet. They typically follow their ketones if they're trying to maintain that they're doing a good job about maintaining and once once they have a pretty standard to what they're eating and taking in and whatnot through the day. They may do it less often, unless something changes again for them. But for the most part, they they really try to follow their ketone levels to make sure that they're in that safe, like nutritional ketosis range.
Scott Benner 14:42
Okay. Jenny was probably stunned like watching me think, but she I don't think she does very often. Usually, I'm just waiting, listening.
Jennifer Smith, CDE 14:51
You were looking at the ceiling at a viewer
or something, you're like what's coming
Scott Benner 14:57
to absorb what you're saying. I and I have one little Last question wrapped around this. And I am wondering if I'm not seeing what I think I'm saying. So I have one real clear memory of Arden having the flu. Yeah. And she, her blood sugar was low. This is prior to CGM, her blood sugar was always around like 75 or 80. While she had the flu, sometimes she'd be low, she was sucking on candy for days ever, I'd be like, Here, put this in your mouth, you know, and she'd sock on it, I'd reach it. I don't give it back. You know, like I was literally like, just trying to get sugar and, but then all of a sudden she's got ketones. And they're like to on the blood glucose meter that we have, or the blood ketone meter that we have. And I call the hotline to the, you know, the hospital, and they're like, you have the Bolus for those ketones. And I said, What do you mean, they said, but she's two units, one unit for each number, like she was one if she was one on the ketone meter, we'd have you given one unit if she was to have to. So her blood sugar's by five. She's like six years old, she weighs nothing. And they want me to give her two units of insulin. And so I was just like, You're sure. And they're like, yeah, I had the flu. So I was probably like, Yeah, all right. Well, I mean, I guess if this is how we go out, like, let's try this, you know, and I like, and I gave her, they what they're telling me to do, I'll blame this lady at the funeral is what I was thinking, right, like, so I gave her the two units, and it worked. And she didn't get low. And till To this day, I can't explain that. Like, I don't understand that well enough to explain that to anybody. I know what happened, I watched it happen. So
Jennifer Smith, CDE 16:37
right, and what it deals with, like on a physiologic level, I to explain it, I guess in a simplified way, because I don't I don't know all of the physiology completely behind it. But in a setting of ketones from like a DK, or you know, ketoacidosis kind of setting, the body requires more insulin to overcome the ketone level in the body. And so even at what what was looking like a normal level of glucose for her, in fact, on the lower end right at and you're thinking, Oh, my gosh, she's not eating anything, and I'm going to give her two units of insulin, what you needed the insulin for was clearing of the ketones. And along with that comes hydration as well. And I would expect they probably were encouraging you to kind of be a force as much fluid as possible, right, get it in. But, I mean, there are some very defined ketone management strategies for how much extra insulin you should be given based on where your glucose is, what your ketone level is. It has to do with how much insulin do you currently use from a base basal amount, and how much extra should you give to a correction for blood sugar to overcome the ketones that are also there along with that blood sugar. So typically, let's say blood sugar of 200, you would use one unit to bring you down to your target of 100. With ketones, there's a there's a percentage extra that you would need to incorporate to say, okay, 200, to also clear, the ketones along with bringing this blood sugar down, you're going to need a certain amount extra to that one unit you would normally take to actually start bringing it down and get rid of the ketones. So
Scott Benner 18:34
when they tell you your bolusing, for the ketones, there's really a much bigger physiological thing going on. It's just sort of how we are. Right? Correct. Okay. So is this attached to the concept of if my blood sugars been say, I'm not sick? And you know, it's a regular day, but my budget has been 300 for a few hours. And where you would hear me say, high blood sugars require more insulin? This is why is it possible? Is this part of it? Do you think or, like what, you know, when your blood sugar is high, it's stuck, and you need more? Do you think you have ketones at that moment? You don't realize? Or no,
Jennifer Smith, CDE 19:13
because I don't, you know, I don't think most people really are again, testing. If they've got a one off high blood sugar for eating the whole cake versus only eating one slice, you know, I mean, in that setting, the high blood sugar that requires a little bit more insulin, I think that there are more variables there potentially, again, a miscalculation to carbs, right. So of course, you're probably going to need some extra insulin, not just to correct the blood sugar but to correct for food that you didn't account for before in the original Bolus. Also, I mean, and I kind of call them sort of sticky blood sugars right sticky and the fact that you just you have to take more insulin and thus, the strategy of sometimes even using a temporary bazel increase around a house Blood Sugar along with a bolus to get it to start moving more effectively? You know, that's a really good question. If ketones are maybe potentially in the picture there already, or, you know, how quickly do ketones really start to kind of develop, I mean, they're more so in the picture of like a true ultimate insulin deficit, right? I have a feeling that it has more to do with kind of what we actually just talked about a little earlier is like that resistance.
Scott Benner 20:29
I was just thinking,
Jennifer Smith, CDE 20:32
is that like, a resistance is there, you know, some, um, but for most people, I would say people recognize that above about a 250, blood sugar, it takes a bit more insulin, for whatever reason to bring the blood sugar down.
Scott Benner 20:50
Yeah. So with all these, you, if your brain can wrap around all this, bless you, I think that's great. And if you can think of all this stuff in the moment and make better decisions within something, that's great. But just in case, you're like me, Scott has very kindly boiled this all down to more insulin. So just I know, it's, that's just the day when I realized there were all of these different factors happening. And I couldn't figure out what they all were, I just thought I don't I just resolved myself to the fact that this requires more insulin. And I'll use a more and that'll work. And it does. So. All right, cool. Wow, that one I don't even know I don't even think I can call that a defining divide. That was like a mini like, pro tip episode on like a bunch of words that are all sound the same. That By the way, again, when people use a develop language, don't make one thing ketone, the other thing ketosis, and then the diet keto, you confuse people, I go right back to the looping thing. If I want my my, my sensitivity factor to be more powerful, the number should get larger, not smaller, whoever said that way, wasn't thinking about me in my regular life. And I feel, I felt that we're thinking
Jennifer Smith, CDE 22:00
about math, we're not thinking about the regular layman brain. It's great. I got a lot
Scott Benner 22:05
of engineers telling me how to think about my insulin. So I just I'm just telling you that you don't say keto ketosis and ketoacidosis expect people to keep that all straight. But anyway, try. Try. That's kind of the same
Jennifer Smith, CDE 22:17
reason that that Dexcom uses the GI instead of a one C in their prediktor. In their clarity reports, they had to get rid of that being an A one c because it technically a one C is specific to the hemoglobin and whatnot from a test in the bloodstream and whatnot. So they, I would assume legally, they couldn't use a one c this and they had to figure out a new fancy word for it. So glucose management indicator was the next best like term, whatever,
Scott Benner 22:49
doesn't even realize she just teased another episode for you. So we're not talking about that. Oh, but that is definitely one of the things we're going to talk about eventually. Thank you Jenny Smith for being here with me today and talking about ketones Don't forget go to integrated diabetes comm To find out more about Jenny, and to hire her to help you with your blood sugar's and etc. Thank you also to me for sponsoring the episode, which is to say I'm thanking you for considering buying some merchandise Juicebox podcast.com, upper left corner, click on the menu go to merge, you're going to see a huge drop in costs for almost every item that's available. proceeds go to me, I pay taxes on those proceeds. And whatever's left, I'm going to buy a computer with a microphone. So this episode came out at the beginning of the week when it normally would come out on Friday, but there will still be an episode on Friday, don't you worry. And look where we're at December 2019 388 episodes into this podcast. So let me say you're going to get one more on Friday. And then I might start going to a Monday Thursday schedule instead of a Tuesday, Friday schedule. I'm thinking about that. So anyway, there's gonna be one on Friday the 13th. And you'll get the 16th and 19th. And I don't let up just because of the holiday, you're gonna get one of the 23rd. And then the day after Christmas, to for like five more. And then on the 36 there's six more left in this year. I could have just said there are six more episodes left in December. But you know, what am I gonna do? You don't want a shirt and you still want to give me a gift. You can donate to the podcast. Again, I'm not a charity, so I'll pay taxes on it and whatever is left computer payment, or if you can't afford any of that, but you still really want to help help my soul by leaving an amazing review. Like go to Apple podcasts, you know, and your podcast player whichever one you're using, wherever you can, like leave a review. And if the show has been truly helpful to you, please describe to others how it has been, because that might make them think maybe that could be like that for me. And then maybe they would come check out the show. And of course you can always Just share the show with a friend or an acquaintance, somebody who you think may enjoy it. Last thing, if you're a thoughtful person about your management, and you try to stay away from the drama about type one diabetes, but you're looking for community, may I suggest the private Facebook group for the podcast, the juice box discussion group, you have to answer like a couple quick questions like, you know, what my connection to diabetes is, basically to make sure you're not like a robot. And then once you're in, you'll have a community of now 1800 people who are answering questions to each other. It's a very collaborative and supportive group. If you're into something like that, you know, no drama, no head games. Check it out. All right, there's gonna be links to all of this in your show notes, and then the episode guide at Juicebox podcast.com. Today, links for Jenny Smith links for the merge links for the private Facebook group. You know, I said that was the last thing but but one more last thing. I am incredibly just looking proud to say that this podcast ran at six new episodes in 2019 86 new episodes. And I believe that in 2020, that number will be more like 100. This really cool, because obviously, these episodes wouldn't exist. If the interest wasn't there. I wouldn't be here like pumping out all these episodes. If no one was listening, I'd be like, oh, okay, I guess nobody cares. And then I might stop. But it's clear that you guys care. The downloads are insane. In the time, it took me to tell you about the 90 some episodes that ran when I say 86 episodes that ran in 20 1940 people downloaded the podcast. Again, that time frame. It's incredibly cool. So I appreciate your support. Appreciate listening to old episodes telling other people about the podcast really is absolutely our warming. All this makes me incredibly excited to start season six right away in January. When Let's take a look. Pulling up my calendar. Looks like you'll get one in January right around the second right after New Year's for the first time. I even think I know what episode I'm going to give you that. I think I have something uplifting for the new year. We'll start off strong.
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If you're interested in see me live, my event schedule is at the Juicebox Podcast bold with insulin Facebook page, so it's bold with insulin on Facebook. Go to the event link. There's also artist a.com scroll to the bottom and click on events coming up Oklahoma City that's coming soon. January 11. Dallas February 16. That's it the greater Dallas type one nation event, Georgia type one nation event February 29. I'm going to be doing an evening in Appleton, Wisconsin or right around that. Yeah, Appleton, Wisconsin. I'm pretty sure it's exactly where it's at March 26. It's a Thursday night, I think from like five to 8pm. Just Scott talking, not one of those type one diabetes events, sort of a Juicebox Podcast live event, just for you, Wisconsin, that on May 30. I'll be down in Orlando, Florida for the touch by type one event from dancing for diabetes. And on August 22, Richmond, Virginia type one nation event. And I think I think we're still in talks in Indianapolis. somewhere else, I'm not sure but if I do many more of these, my wife's going to shoot me. So I think this might be it for the short term. But I'm always interested in hearing about 2020 at the end of the year 2021. If you know somewhere you'd like me to be, reach out. I'd like to be there.
About Jenny Smith
Jennifer holds a Bachelor’s Degree in Human Nutrition and Biology from the University of Wisconsin. She is a Registered (and Licensed) Dietitian, Certified Diabetes Educator, and Certified Trainer on most makes/models of insulin pumps and continuous glucose monitoring systems. You can reach Jenny at jennifer@integrateddiabetes.com
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