Can a Ketogenic Diet Cause Hypogycemia and Insulin Resistance?

Are there costs for eating low carb long term?

What are the consequences attached to being on a ketogenic diet long term?

Is the Atkins Diet, Nutritional Ketosis (LCHF), Keto, and other diets that restrict carbohydrates safe, or are there unforeseen consequences that might pop up from keeping your carbohydrate level very low for an extended period of time?

Can a long-term ketogenic diet actually cause insulin resistance and hypoglycemia rather than reverse them?

I was reading over at the Lowcarber forum and ran into something interesting in the Atkins' section. Someone over there was asking if a long-term ketogenic diet had the capacity to cause insulin resistance and hypoglycemia.

Her concern was due to an interview that Jimmy Moore had with Dr. Keith Berkowitz of the Center for Balanced Health.

Now, I'm not completely sure where this interview transcript came from because I only have dial-up and can't listen to Jimmy's podcasts. I'm just assuming that's what this is, a transcript from a podcast. The transcript is definitely an interview Jimmy had with Dr. Berkowitz a little while ago.

If you want to read that interview, so you'll understand what I'm talking about in this post, it can be found here; just scroll down to post #8. It's a little long, but worth the read.

My Gut Reaction to the Comments

Like many low-carb forums, the response to the interview posted over there was frustrating.

Dieters who would rather believe in and defend low-carb magic over science or biology tend to ignore what's really going on.

In this case, most of the comments were useless.

A lot of things that Dr. Atkins wrote in 1972 have not held up to the science, but that doesn't mean that a low-carb diet is not a useful tool to combat obesity and assist you in getting down to a healthier weight.

[I reread the interview this morning, November 2016, in order to update this post and found it interesting that those who fought hard against what Dr. Berkowitz was sharing never did make it to goal weight. While many people cast out personal experience as being unreliable, even in a medical setting, I'm surprised by the number of individuals who would rather bury the truth, rather than embrace it.]

Only ONE poster addressed the actual issue being discussed in that interview:

Hypoglycemia

Everyone else who responded to the original poster's question got hung up on the doctor's use of the term Insulin Resistance, and began arguing over whether or not he used the term correctly.

Since their insulin sensitivity improved on a low-carb diet, they didn't understand what the doctor was talking about.

For those of you who didn't follow the link to the interview, Dr. Berkowitz inherited several patients from Dr. Atkins shortly after Dr. Atkins died.

These people had lost 100 to 150 pounds of body fat, and then suddenly began to experience some wacky things, the same as I did.

Not only did they go into a weight-loss plateau, which they were unable to bust through, but they started experiencing symptoms of starvation:

• their hunger went through the roof,
• cravings suddenly returned,
• and their blood glucose started crashing after meals instead of rising

In view of what I understand today (2016), this makes perfect sense to me.

But at the time that I first read this interview, I didn't know much about:

• crashing leptin levels
• set points
• what the body does to reach equilibrium

Nor did I have a clear understanding of the role of insulin in stabilizing blood glucose.

Instead, I felt confused by the interview.

There seemed to be a lot of misunderstanding about insulin resistance, hypoglycemia, and even type 2 diabetes back then within the low-carb community.

Many believed insulin resistance and hypoglycemia were exactly the same thing.

What is Insulin Resistance?

In a normal metabolism, insulin is secreted by the pancreas into the bloodstream, whatever is needed to handle the rise in blood glucose from the meal before. The pancreas has no way to know what you are eating right now, so it uses your prior meal as a gauge to start with.

If the amount of insulin secreted isn't enough to bring the glucose down into normal range, because you just ate more carbohydrate or protein than you ate at your last meal or snack, the pancreas manufactures additional insulin and releases it.

Ordinarily, this second insulin response is enough to get the glucose into your cells and out of the bloodstream.

But in some individuals, it's not.

The body doesn't respond to the presence of insulin and either ignores it or misinterprets its presence.

If you're a type 1-1/2 diabetic, you will have a limited supply of beta cells and can't manufacture and secrete additional insulin fast enough to clear the bloodstream, so glucose builds up in the blood.

Either way, the pancreas will keep manufacturing and secreting insulin until it's able to bring the body back into balance. While this is happening, you have high insulin levels and high glucose levels at the same time.

What is Hypoglycemia?

Hypoglycemia is often due to insulin sensitivity, rather than insulin resistance.

The body sees the insulin that's secreted, and responds to it.

When you are sensitive to insulin, the insulin can work too well. Even a small amount can result in glucose entering your body's cells too quickly, causing your blood glucose level to drop below normal.

You end up with low insulin levels and low blood glucose at the same time because falling blood sugar will also cause insulin to go down. Low insulin always causes glucagon to be increased, which then tells the liver to convert glycogen into glucose and dump it into the bloodstream to correct the problem.

If too much glycogen gets broken down into glucose, the whole cycle gets repeated.

This condition is quite common in those who eat large amounts of sugar, especially between meals. The body secretes enough insulin at meal time to handle the high-sugar snack, which might be more than you need to handle the meal. Blood glucose will drop too low.

In some individuals, there is a tendency to over-produce insulin in response to meals, which can also cause hypoglycemia.

How Did Patients with Huge Fat Losses React to a Glucose Tolerance Test?

When restricting carbohydrates blood glucose
won't rise as high after meals

A very low-carb diet is often prescribed to reverse the dangerous effects of hypoglycemia and insulin resistance because restricting carbohydrates lowers basal insulin.

Since you aren't eating a lot of carbohydrate, less insulin is needed to usher blood glucose into body cells after meals and snacks.

As a result, blood glucose doesn't rise as high as it does on a typical diet.

The blood-stabilizing nature of a very low-carb diet also helps those with hypoglycemia because most of the over production of insulin stops, due to the type of foods allowed on low carb.

Many patients find eating 5 or 6 smaller meals to be essential as well, since it keeps insulin secretion lower, even though carbs are kept to a minimum.

For those who are insulin sensitive, patients can simply move to a higher rung of the Atkins Carbohydrate Ladder, supplying the right amount of carbs to balance the degree of insulin reaction to meals and snacks.

This prevents the blood glucose level from dropping too low.

Although, Dr. Berkowitz spoke about both of these corrections for hypoglycemia in the interview, the folks at the low-carb forum couldn't let go of their knee-jerk reaction to the doctor suddenly putting all of his patients through a glucose-intolerance test.

Without eating a high-carb diet for 3 days, a glucose intolerance test is not accurate for those on very low-carb diets.

However, the low-carb crowd didn't understand what the doctor was looking for. Nor did he say that he put those patients through a glucose test without taking the proper steps.

He wasn't trying to diagnose them with glucose intolerance.

Having inherited these people from Dr. Atkins, he already knew they had that. He just wanted to see how the body reacted to glucose after shedding 100 to 150 pounds.

The patients who had lost a lot of body fat had a more-than-healthy, over-reaction to the presence of glucose in the blood, causing their blood glucose level to be below normal within a mere two hours.

For patients who have been on carb restriction for a long time, the test result should have been the complete opposite.

If you are currently restricting carbs, your body won't produce enough insulin fast enough to confront a massive glucose exposure, so the expected result is high glucose levels at two hours.

But that isn't what happened.

These patients were suddenly overly sensitive to glucose instead of insulin resistant.

Even so, Dr. Berkowitz still called this phenomenon:

Insulin Resistance

The interview is a very interesting one, and it's well worth looking at if you haven't already. It hit close to home for me because these patients were experiencing many things that I have been.

Can a Very Low-Carb Diet Cause Insulin Resistance and Hypoglycemia?

Many of the participants at the low-carb forum I referenced above kept stumbling over the idea that a low-carb diet could cause insulin resistance and hypoglycemia.

They couldn't see past their own experience to consider the idea that someone else's experience differed from their own.

I found it very enlightening and reassuring to learn that others who have also lost over 100 pounds doing very low carb were experiencing something wacky with their blood sugar levels because I had been having similar symptoms the past 6 months myself.

Despite the opposition from the low-carb community, I think this is a real possibility, but not for the reasons these low carbers grabbed onto.

Most of their justifications for standing by a low-carb diet are pure fantasy.

They don't get it.

Up to this point in the weight-loss journey, I had chased after all kinds of things:

From Kimkins to thyroid issues to leptin resistance theories to the PSMF Diet, I was just trying to narrow down what was wrong with me.

Something wasn't right.

I just didn't know what it was.

Just like Dr. Berkowitz's patients, weight loss had come to a complete halt. I let the hunger and cravings get the best of me whenever I tried to go back on Induction, or anything close to low carb.

No matter what I did, I couldn't get back into ketosis either, not without suffering severe hypoglycemic attacks.

Or, I'm assuming they were hypoglycemic attacks.

In addition to increased vertigo, I got downright sick and felt:

• shaky
• weepy
• depressed

I craved things I hadn't been tempted to eat for over a year and a half.

Refeeds didn't cure the problem. At least, not so far.

I feel better eating 100 grams of carbs per day. On carbs, I have more energy than I know what to do with.

I feel great.

The vertigo essentially disappears, except when bad weather is on the way.

But whenever I tried to eat fewer carbs, whenever I tried to go back to low-carb dieting, I always got this kind of:

• blood-shaking
• buzzy type of feeling
• heart palpitations
• nausea

I crashed-and-burned every single time, without ever going back into the state of ketosis.

My body just didn't want to go there again.

Oddly enough, someone over at the Body Recomposition forum brought up similar symptoms and issues with dieting, back when I first wrote this post, and Lyle McDonald (the owner and founder of that forum) thought it sounded like liver issues to him.

While I've wondered the same thing about the vertigo, since a lot of my symptoms cleared up when we went to Texas for our vacation this past summer, reading the transcript again -- with a more open mind this time -- I saw something that I didn't notice the first time around.

Today's Thoughts - November 2016

It's obvious to me that at the time of the interview, Dr. Berkowitz didn't have a lot of experience with diabetes, or pre-diabetes even, since he said that fasting blood sugar should be the lowest of the day because you don't need much blood sugar during the night.

Glucose drops overnight, he said.

But, that's not how it works.

Metabolism actually has the largest draw on calories. Since the body is in a state of continuously breaking down and building up new cells and other body structures, while you sleep, your calorie needs don't go down all that much during the night.

Your basic metabolic needs stay the same.

Cortisol is secreted in the early morning hours to start waking you up, and high cortisol levels always pokes the liver, which results in glycogen being broken down into glucose and glucose being released into the bloodstream.

If that didn't happen, you would never wake up, and you would never have the energy to get out of bed because that first glucose dump is where you get the energy to do that.

Another odd belief this doctor had was that blood glucose doesn't peak for 2 hours. The patients were spiking at 30 minutes, peaking within an hour, and falling below normal by 2 hours. He couldn't figure out why, so he called it insulin resistance.

When your glucose response is normal, blood glucose peaks within an hour.

Whether you're eating a starchy breakfast or downing a swig of liquid glucose, if you are not diabetic, your blood glucose level will never go over 199 mg/dL by the end of the first hour. Preferably, it should be 140 mg/dL max because that is the level where damage and diabetic complications begin.

A healthy individual won't go above 120 mg/dL at one hour post-meal.

If your food is digested and absorbed properly, if insulin manages to speed up the process of getting glucose into your body's cells, then blood glucose will be back to normal within 2 hours.

At a very minimum, it should be below 120 mg/dL at the end of the second hour - not just barely peaking.

The doctor's comments make no sense to me.

He does offer a variety of symptoms of hypoglycemia to watch out for. Things like:

• dry mouth or feelings of dehydration
• A1C level below 5.0
• feeling hungry after eating
• huge cravings
• sweating
• clamminess
• fuzzy feeling in the head
• dizzy
• headaches
• heart palpitations
• extreme fatigue
• nightmares
• extreme anxiety

These are all signs of:

• severe stress
• high cortisol level
• starvation
• leptin resistance
• thyroid problems

The body isn't functioning normally because it has adapted to an emergency situation (carbohydrate deficiency) and is on high alert.

That alert gets more crazy the more body fat you lose.

Important body functions get shut off or slowed way down when the body is adapting to a low-carb diet. The main focus is on survival and bringing energy output into balance with energy input, and that's exactly what happened.

While the blood glucose profiles of those who lost over 100 pounds eating very low carb might look odd, this is how the body adapted to what it perceived as irregularities.

My best guess is that the liver took that glucose windfall and stored it as glycogen as quickly as possible because that's what the body does.

It's wired for survival.

Always.