A balanced and articulate summary of ketogenic eating

I realize that this topic has been covered a lot here and elsewhere online. And marketing forces have latched on to the word “keto” and plastered it everywhere.

I also realize that people don’t like to re-examine how they eat with an eye toward making changes, especially if some outside influence is campaigning for social change.

This topic is for people who are familiar with the term “ketogenic eating,” but aren’t conversant in just what that means. If you are comfortable with another eating style and the blood glucose performance it gives you, this video is not for you.

Mark Sisson, according to Wikipedia is “an American fitness author, food blogger, and a former distance runner, triathlete and Ironman competitor.” He is the same age as me but looks a generation younger.

Sisson is interviewed by Dr. Mark Hyman, best selling author and founder of The UltraWellness Center, a clinic that takes a functional and integrative approach to setting the stage for good health and not merely throwing drugs at symptoms. He has an extensive selection of YouTube health topic videos and is an able and articulate interviewer. I’ve learned a lot from watching him.

So, if you’re not quite sure what the term “ketogenic” really means and how that affects your health, this is worth your time. Or if you’re familiar with the term and have been enticed by how it might improve your health, especially your glucose metabolism, but have not been able to get past the idea of limiting some of your favorite carbohydrate-rich foods, this discussion might help.

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Ketogenic diets scare the crap out of me. So much so that it was the core of my grad school thesis, when Atkins was king. I wanted to know my ketones killed my friends, but not all these people on a ketogenic diet. My advisor gave me the most rueful look and asked, “what makes you think they’re NOT?” Most of the byproducts of ketogenesis are harmless, but beta-hydroxybutyrate is not. It evolved to be an emergency fuel for short terms of starvation, but not without significant risk.

I know it’s futile to try to convince “successful” keto people of the danger, but I always fail to understand why diabetics who were raised to FEAR ketoacidosis ever think, “hey, I think it would good for me to put myself into a mild form of something I know kills my brethren.”

Most reputable medical sources, doctors who are banking their business on selling a keto-approach excluded, specifically say a keto-genic diet is NOT for anyone with disorders of the PANCREAS, kidneys, liver, heart, thyroid, and/or more. It’s hard on the body and potentially toxic to many systems.

I know people loose fat following such a plan, and people will always jump on anything promising to be a quick fix for that. I know you can achieve beautiful flat-line glucose data doing so, too But those are only TWO befefits weighed against the much longer list of risks.

What is the point of the beautiful glucose data if you’re risking your heart and kidneys anyway? How do you not fear the tiny slip into ketoacidosis, since you’re already part-way there? An illness on top of that intentional ketosis could do it. Too much alcohol could do it An unforseen swing in glucose or failure to receive insulin could most definitely do it.

I’m honestly asking for feedback here as to WHY some diabetics choose keto, because I just can’t comprehend it. Am I just more scared of ketoacidosis and the other complications than the typical diabetic? I remember the memorial services growing up for my summer camp mates who didn’t make it through the year I lost my boyfriend to ketoacidosis when I was 16. We talked on the phone one night, and he was gone by the next. I remember vividly my own incidences, though it’s been more than 20 years since the last, of my lungs hurting so bad I’d hold my breath until I passed out, rather than take that next agonizing breath. How are others not equally terrified?


Your fear of ketoacidosis is justified and understandable. I believe your conflation of nutritional ketosis with ketoacidosis has clouded your assessment of a well balanced ketogenic diet.

Check out this graph:

If you investigate the credentials and work of Drs. Volek and Phinney, the creators of this graph, you’ll find that they’ve done their homework.

The point of the graph is that nutritional ketosis is orders of magnitude removed from ketoacidosis. Ketoacidosis absolutely demands our full respect. But ketosis is natural and nothing to be feared. Most people wake up from a good night’s sleep at some level of ketosis. Nutritional ketosis is one of the reasons our species has been able to survive.

The last time I checked my blood ketones a few weeks ago, I measured 0.8 mmol/L.

I choose to live using a diet that often puts me into nutritional ketosis because it helped me lose weight, satiates my appetite, significantly reduces my insulin needs, gives me plenty of sustainable energy and contributes to blood glucose lines like this.

This is not an everyday occurrence for me but is not unusual either. A line like this represents metabolic sanity and peace to me. I spend over 90% of my time in range (65-140 mg/dL), with little to no time < 54 mg/dL, with glucose variability as measured by standard deviation in the low 20’s mg/dL and an average in the 92-102 mg/dL range.

I live with much less risk now than when I was eating a standard American high carb, high fat diet using industrial-sized doses of insulin and intense glucose variability that switched between skyrocketing post-meal glucose followed by over-corrections and screaming descents that I usually could pull up before BG disaster, until I didn’t.

Being able to use ketones for some of my daily energy needs grants me metabolic flexibility. My body can convert dietary and physical fat into ketones and also use the glucose derived from the carbohydrates and protein in my diet. I eat twice per day and I can easily skip a meal without needing to exert lots of willpower.

Please explain how I am risking my heart and kidneys.

I’m curious if you watched the video.


Only the first few minutes. I accept that it’s conceited of me, but I don’t believe an intro to keto video is going to offer any insights I didn’t uncover myself in my thesis research. It was obviously not directed at diabetics, they stated it was about fat loss and curing hunger/cravings. They lost me there, because keto is WIDELY criticized for not being a safe way to do that, backed by years of my own clinical research. And honestly, I’m not interested in their credentials, either. They fall into the subset I specifically excluded when I said :

Most definitely not. I know full well that there is a vast difference between ketosis and ketoacidosis. My concern is that I think you, and potentially other diabetics following keto, misunderstand how easily it is to fall off that slippery slope. Ketosis is a symptom of metabolic distress. There are many potential causes of ketosis, besides diet. It takes sustained distress to induce ketosis (approx three days by diet alone, but could be much faster/slower by other factors. Can happen really quickly for diabetics), think of that as like a degree of protective resistance and safety barrier. That “safe” level of low ketosis has you living on the wrong side of that barrier. My concern is for all the unforseen circumstances that also induce ketosis, and from which you no longer have that safety barrier to protect you from. While I fully acknowledge that it would be difficult to produce too many ketones by diet choice alone (though not impossible for the determined over-achievers), the progression into full blown ketoacidosis can happen frighteningly fast in the presence of OTHER metabolic distressed. As diabetics, we’re particularly prone/susceptible to metabolic distress.

Am I crazy, or weren’t you hospitalized yourself in recent months with Ketoacidosis? I’m pretty sure I remember reading that, regarding a loop and/or pump glitch. I would definitely consider you a model for a good diabetic. I know I’ve drooled over your flat CGM graphs. I have to question what part the low-level ketosis played in that. (I’m really hoping it was you, and not one of the other loopers, or I look like a total heel :slight_smile: )

I’ll defer to you on that it’s working for you. We always say around here to do whatever works for you. I can’t help but feel afraid for you, though, because I read some nievety in your words Ketosis is most definitely not safe. It’s only “natural” in extreme circumstances to prevent death. It’s a last resort, not clean energy.

A simple Google search will provide a sea of articles showing that ketones can damage your heart, kidneys, and brain. A ketogenic diet has it’s own pitfalls. When you sacrifice balance, you need to lean heavier on fat and protein. Cardiologists cry over high fat diets, nephrologists cry over high protein diets. One can only eat so many leafy greens. From my experience, keto people also love their artificial sweeteners which are just plain scary in their own right.

My food philosophy is simple, eat FOOD, and all things in balance. If it had to be synthesized in a lab, it’s not food and shouldn’t be put in your face. It’s the moderation part most people struggle with. Carbs aren’t bad, they’re not the enemy… they’re just cheap, shelf stable, over-abundant, and decadent. They’re too easy to over-indulge in. We’re omnivores. We evolved to eat a balance of carbs, protein, and fat from a variety of sources. I just don’t abide by any extremes in diet, unless something necessitates it.

For the record, I’m proud of my numbers, too. It may not be perfect and my lines are rolly-polly, but my A1c is 5.8, and most days are 98% in range. I’ve only had a few elusive 100% TIR days, because even touching a toe to 70mg/dl and the data changes to 98%/0%/1%, I guess 1% is a sacrifice to the data gods.

I hope you know I don’t mean any of this as an attack. I know there’s value in the peace of finding something that works for you. Like I said, keto just really scares me.

As I understand it, high blood sugars are the cause of ketoacidosis - irrespective of what you are eating

If you eat a well planned keto diet and keep your blood sugars in the normal range there’s zero chance of ketoacidosis, just the same as if you were following a tradtional diet

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Thank-you for your thoughtful reply.

I disagree with your characterization of ketosis as a symptom of metabolic distress. I understand that babies are born in mild ketosis and remain in ketosis if they are breast-fed. People who fast, a very common condition during the millennia of our evolution, enter into ketosis. All the world’s great religions feature fasting as one of their practices. I’m not religious but do respect that human institution as one that brings comfort to people. I don’t think that fasting tradition would have developed or survived if it was unhealthy for human beings.

Your wariness with nutritional ketosis is shared by dietitian’s professional associations over the years. I don’t share your belief that mild ketosis is a slippery slope toward DKA.

I did report here about my brush with DKA last February. I did not go to the hospital. I did not fall into DKA but was heading that direction when I took successful counteraction. I think the six hours sleeping without adequate insulin delivery was the main driver of that event. I believe that I would have taken the same path whether I started that event in mild ketosis or not. The peak glucose I measured at 262 mg/dL was the result of too little insulin. When I administered sufficient insulin and hydration, I was able to reverse the 4.7 mmol/L blood ketone level fairly quickly. DKA is described as blood ketone levels closer to 10 mmol/L.

I am interested in the details of your clinical research that have a bearing on this discussion.

I don’t accept your assertion that my belief about ketosis is naive. I could assert the same as to your belief but I will not. Ketosis is a tactic and strategy evolved over millions of years to help us survive. It is not rare as many people experience it every night when sleeping. I think nutritional ketosis is a tactic well-suited to people with diabetes. I think the “carb-up, shoot-up” philosophy common in the medical community advice has been a disaster for our kind. If that was a good tactic, it would be easy to point at all the good outcomes for diabetics.

You missed this observation in the video I linked to. There are essential amino acids, essential fatty acids, but there is no such thing as an essential carbohydrate. The term, “essential” has a specific meaning in nutritional science.

As humans, we can survive well without carbohydrates. I don’t avoid carbs; I limit them but do avoid processed carbs. I don’t believe that there is such a thing as “heathy whole grains.” Wheat, for instance, has only been a significant part of the human diet for about 10,000 years, a mere blip of time over the millions of years that our species evolved.

I’d be happy to read your reply to this comment but I’ll likely choose to not respond as I suspect our differences are not reconcilable. And that’s OK :slightly_smiling_face:. I’d like to make room for others to chime in, if they want.


No that is inaccurate—DKA actually has nothing to do directly with blood sugar level. It’s the absence of insulin that is key—if, as a T1 diabetic, you are neither eating anything nor taking any insulin, your blood sugars might not be that high, but you could still go into DKA. Similarly, you can have be taking enough insulin so that your cells have adequate energy, but then drink a huge amount of sugar, spike over 1000, be in direct danger from the level of glucose in your system, but not necessarily be in DKA.


You’re right and the key word you used is “directly.” It’s easy to look at the blood glucose level as an indicator of the presence or absence of insulin, but that relationship doesn’t correspond 100% and could mislead.

There’s also the more recent occurrence with something known as euglycemic DKA often associated with the use of the SGLT2 meds. These are the drugs can cause the kidneys to excrete “excess” glucose at a relatively low threshold. Most of us do this when glucose exceeds about 180 mg/dl (10) but the SGLT2 drugs reduce that threshold to a lower number.

So someone taking these drugs can experience a normal blood sugar and still go into DKA.

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The other big example is being sick, especially with a stomach bug of some sort. That’s how I ended up in DKA, and while my blood sugars were somewhat elevated (200-300s), those are levels at which normally I don’t even produce ketones, let alone risk DKA, so the glucose itself was not a good indicator of concern.

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Fair enough, I’m hsppyb to agree to disagree and bow out of the conversation… With one last comment:

Yes, absolutely yes. By all means call me naive. Call me me ignorant, too. I most definitely am. Whereas many, dare I say most, people take offense to those words, I see them as mere universal truth. WE ARE ALL IGNORANT.

That is what drew new to the natural sciences in the first place. I’ve always been awe struck by the complicated, convoluted nature of physiology, and that is just one tiny facet of greater complicated, convoluted multiverse.

The thing is, the more scientists discover about the world, the more we realize that we will never comprehend the sheer magnitude of what we DON’T know. What we “know” today, is much different then what we “knew” yesterday. What will we “know” tomorrow? We live in an age where just enough information is available to be dangerous. I think we all need to accept and acknowledge that the so called “experts” are ignorant, too. It is easy to cherry pick arguments to defend any stance. And it’s soooo easy to believe them when they’re presented with “fact”, but it’s up to us to take everything with a grain of salt and look for the fatal flaws in information. Case in point: “You missed this observation in the video I linked to. There are essential amino acids, essential fatty acids, but there is no such thing as an essential carbohydrate.” That even gave ME pause to think. It sounds like an astute revelation when presented with JUST ENOUGH INFORMATION that it’s easy to believe, and is an excellent opportunity to practice looking for the logical flaws in the information presented to us.

I accept some people want to do a ketogenic diet and I truly believe everyone should have the choice to choose.

I wasn’t going to say a word, lol…until you said wheat/grains were bad for you!

Just don’t say grains are unhealthy lol…Grains have been proved to be very healthy in all sorts of ways. There is more research pro whole grains than the few doctors that are anti whole grains because they have decided so. If you choose not to eat them, that’s your choice. And it doesn’t matter that wheat has only been around 10,000 years. Many animals people eat have been around less. Dairy and meat from cows come to mind. And if you go by what your ancestors ate that would be only the food grown and happily alive running free in the area you live/lived.

Wheat is only unhealthy in the people that can’t eat wheat, because of an intolerance or celiac disease.

I have eaten wheat all my life and been tested repeatedly by “normal” doctors because of type 1 and also by natural doctors and I have no issues with wheat. And my non ketogenic eating numbers are very good.

A1C 5.1%
TIR 98%-99% between 65-160
18-22 standard deviation
My BG number average is usually between 104-107
I never go below 54, I rarely go below 65 (less than 1%)

For me I eat what I want as long as it’s vegan, high fat, high carb I don’t care, it depends on what I want to eat for the day. I am fully satisfied with my food. I just almost always try to prebolus and use my exercise bike to help control my numbers. I am retired and realize it is easier for me because of that. I don’t take any medications other than Humalog.

But my diet is full of whole grains, veggies, fruits, beans.


If anyone cites themselves as an studied expert. It would help if you post the peer review of your work.
Keto is how we survived and there are populations where all they’ve ever eaten was keto, since the dawn of age.

Comparing keto with dka shows exactly what you don’t know

Starch can be detrimental for diabetics. The fibre and germ of a grain is very good for you. The starch not so much. It’s turns to a glucose and too much is bad for me is a metabolic resistant T2 or a T1 with unstable blood glucose.

I’ve come to believe that the only right way to eat is to avoid processed foods.

I don’t think carbohydrates matter, as long as you’re being careful to bolus in a way that minimizes the after-meal blood glucose spike. This is, of course, easier when not eating processed foods. But there certainly are people out there who achieve very tight control even while eating carbohydrates.

I went through a cardiac rehabilitation program last year (for an arrhythmia; I don’t have heart disease). That program was the first exposure to modern (as in the past decade or so) nutritional recommendations that I have had, beyond diabetes clinics that focus solely on glucose control. Here is some of what the dietitian recommended:

  • Limit cheese to two times per week
  • Limit red meat to two times per week
  • Compose meals of a variety of foods
  • Fill half the plate with a variety of veggies
  • Fill a quarter of the plate with meat/protein
  • Fill a quarter of the plate with “starchy” foods
  • Avoid processed products and don’t drink juice
  • Avoid added sugar and salt in products and on plates
  • Avoid fast-food, eat out rarely, make healthy choices when doing so
  • Steel-cut oats rather than (processed) rolled/quick oats
  • Limit oils and only use small amounts of healthy oils

How many people are actually following those types of recommendations (much of which is based on the Canadian Food Guide)? Eating cheese and red meat just twice a week? Avoiding processed products? Eating out rarely and choosing healthy options when they do so? I would say the vast, vast majority of people are not following these guidelines. Heck, I don’t even follow them, because they are hard!

Would we as a society be a lot healthier if people followed these guidelines? It’s hard to tell without people actually doing it. But I think it would improve public health tremendously. Interestingly, when I did follow these guidelines for a while, I lost 15 pounds for the first time in years (including years I spent eating a low-carbohydrate diet). I do need to get back on track in that regard.

I don’t think anyone knows what diet is the best, because our knowledge is constantly evolving. At least the committee of professionals who come up with the dietary guidelines update their advice over time in accordance with what research is showing. It will likely change again in the future. That doesn’t mean that it’s bad advice, just that our knowledge is continuing to evolve over time.


If your blood glucose and weight is good, then your diet is working for you.
I should add health to that.

Starches cam be fine for a diabetic, unless you particularly have a problem with them. I eat bananas, sweet potatoes, potatoes and I have no issues with them. The tricky part can be eating a potato with a lot of fat. I have to extend my dosing when I do that.

The diets of a good portion of modern America has a lot of pure junk food. Donuts, cookies, soda. Instead of something being a treat now and then, too many eat it all day, all the time. Look at the popularity of coffee shops and the 500 calorie caramel frappucino type drinks and the 1,000 calorie cinnamon roll.

I’m not even saying you can’t have one off and on as a treat, it’s not good for you but something once in a while isn’t likely to hurt you. It’s the reliance of daily eating on mostly total junk.

@Marilyn6 follows the Mastering Diabetes guidelines and the Mastering Diabetes program is designed to lessen insulin resistance with high carbs, low fat and it includes starches.

Ketogenic diets work well for some people, everyone should choose what works for them. I even know some people that do ketogenic vegetarian diets.

But this goes back to for me, don’t condemn grains, fruits, veggies and beans!!! If you don’t want to eat something don’t eat it!!!


It is accurate, but I would consider a blood glucose over 120 to be on the high side of things, you may not

If you blood glucose level is in range, DKA will not happen

What applies to a T2, isn’t the same with a T1.
I can’t eat those starches. It blows my BG. I’m insulin resistant and overweight.
My BG meter and bathroom scales tell me how I’m going and how much carb I can eat.

Again, that’s simply not true. Unlikely, yes, but it’s definitely happened for people.

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You will need a link to diabetic DKA with good BG numbers. I’ve never come across it other than the drugs peeing sugar, and T1