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Ketogenic Diet and Hypoglycemia

ketogenic-diet-and-hypoglycemiaGrief had me wide awake at 3 a.m. on Saturday, I was trying to figure out which chores I could cram into the 14 hours before I returned to the land of migraine disability. I had admitted defeat with the ketogenic diet. One more meal was all I had left on the diet; dinner would take me back to migraine as usual.

Ketogenic Diet and Hypoglycemia: Cause and Effect

Frustratingly, even though the ketogenic diet reduced my migraine attack severity and enabled me to be more functional, it also caused hypoglycemia—which is in itself a migraine trigger. Despite a month of various fixes, I couldn’t get it under control. (I’ve actually been wrestling with it for two months. That awful nausea I attributed to dehydration was actually hypoglycemia. The wrung out feeling I woke up with each day was the fallout from hypoglycemia-triggered migraine attacks that came on while I slept.)

How I Discovered Hypoglycemia Was the Problem

After increasing to 2500 calories to gain some weight back, I woke up each day ravenous and shaky. This seemed odd—how could I be hungrier than when I ate 1700 calories a day? Knowing that a ketogenic diet could cause hypoglycemia, I began researching. Not only did I discover that it was likely I had hypoglycemia, but the nausea and accompanying symptoms of the previous month fit the pattern of reactive hypoglycemia perfectly.

Reactive Hypoglycemia

Reactive, or postprandial, hypoglycemia occurs two to four hours after eating. It’s usually a crash after eating a meal high in carbohydrates. Although I wasn’t eating many carbohydrates, my blood sugar was so low the rest of the time that I’d crash after my meal each day. It would start two hours after the meal, but I’m so used to ignoring vague physical symptoms that I didn’t notice until they got bad. Which they did like clockwork six hours after eating every night.

Treating Hypoglycemia

The treatment of mild hypoglycemia is relatively easy: eat small, frequent meals and eat a dose of carbs whenever your blood sugar dips too low. The latter was obviously out (it’s hard to dose up with carbs when you are limited to 15 grams a day). The former didn’t work for me either, since I still had a migraine attack every time I ate, so I could eat no more than two meals a day.

Desperately Searching for Fixes

I spent a month trying every possible fix I could imagine: increasing from one to two meals a day, eating the same ratio with less protein and more carbs, a lower ratio, 100 calorie snacks that didn’t seem to trigger migraine attacks (they did, the attacks just built slowly), eating more in the morning, 1 gram doses of sugar, more calories… Nearly everything worked for a day, then became ineffective. I tested my blood sugar so often that my fingertips developed callouses.

Magical Thinking

An idea came to mind a couple weeks ago that sounded like pure magical thinking: What if I increasing my ratio to 4:1 (that’s 90% fat) made the diet more effective and enabled me to eat small meals without triggering migraine attacks? I ran it past Hart and my naturopath. They both agreed with the magical thinking hypothesis.

Going for Broke

I didn’t give up on Saturday. I was clinging so desperately to the good hours that I decided to give the 4:1 ratio a shot before calling it quits. I began yesterday by cutting my protein in half so I could keep a relatively high carbohydrate content for the transition period. By evening, I felt remarkably good. I managed three 114 calorie snacks in less than three hours without a migraine attack. A migraine attack didn’t even come on in the night.

Today’s meal plan increased the protein and decreased the carbs some. Four 114 calorie snacks later, no migraine attack ensued and my blood sugar was fine (still on the low end, but manageable). Things went downhill when I ate an actual meal—it triggered a migraine attack and my blood sugar tanked. Several small snacks helped me recover and I’m up and thinking again.

Research Soothes My Worries (a Bit)

Today I learned that a person’s blood sugar range tends to be lower on a ketogenic diet than it normally is. Anything below 70 mg/dL is typically considered hypoglycemic, but 55-75 mg/dL is typical on a 4:1 ketogenic diet. This isn’t a cause for concern as long as the person doesn’t have hypoglycemia symptoms. Also, it can take a full week for one’s blood sugar to stabilize when starting on or changing a ketogenic diet. That means all my dietary tweaks have probably done just the opposite of what I intended. (I am not a medical professional—PLEASE don’t take my word for any of this information. If you’re struggling with a ketogenic diet and hypoglycemia, work with health care professionals to determine the best approach for you. I’m being very careful and consulting with doctors and dietitians as I attempt this unorthodox experiment. Still I worry my low blood sugar is causing long-term harm to my brain. I’m seeing an endocrinologist next week and am going to try get yet another opinion from a neurologist at an epilepsy clinic. Maybe then I’ll find peace of mind.)

Optimism

Obviously, there are a lot of kinks to work out, but I feel like I’m getting closer to getting them sorted. Although most of my earlier fixes didn’t last long, they were all focused on increasing my carbohydrate content. Eating more frequent meals is a far more sustainable option—and one that seems like it could work. I’ve come close to admitting defeat countless times in the last two weeks. I have shed so many tears that I’m distrustful of possible indications of success. But the signs are promising, so I’m still hopeful.

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Ketogenic Diet for Migraine: A Comprehensive Introduction

I’ve told you about my difficulties starting a ketogenic diet for migraine and have tried to assess whether it is working for me, but haven’t told you how the diet works or why I decided to try it. Here’s a comprehensive introduction to using a ketogenic diet for migraine. It’s based on five months of research and more than three months of living with the diet.

Why a ketogenic diet?

Diet and headache was one of the presentations at the American Headache Society conference last November. Topics included biogenic amines (including tyramine and histamine), MSG, food allergies (actual immune responses rather than food sensitivities), gluten, low fat diets, a ketogenic diet, a high omega-3/low omega-6 diet, and a low-sodium diet. The research on a ketogenic diet for migraine was small and the results weren’t overwhelming. But I’d tried almost everything else the presenter mentioned and was feeling desperate. In the last couple years, I’ve heard more anecdotal evidence of it being effective for migraine and my naturopath recommended I look into it.

This was not my first flirtation with a ketogenic diet for migraine. I’ve looked into it multiple times over the last decade, but couldn’t find enough information to do one on my own. Until recently, the information was tightly controlled by doctors and dietitians who work with epilepsy patients. That’s because ketogenic diets are not nutritionally complete and can have serious side effects. As ketogenic diets have become really popular for weight loss, more information has become available. Simultaneously, some of the gatekeepers of the diet for epilepsy began to share details. Here’s what I’ve learned.

What’s a ketogenic diet?

Ketogenic diets shift the body’s fuel source from carbohydrates to fat. Burning fat for fuel causes the body to produce a substance called ketones, which is why the diets are called ketogenic (keto = ketones, genic = producing). When you produce ketones, you are in a state called ketosis and your metabolism mimics fasting or starvation. While that doesn’t seem like it would be a good thing, it works pretty well for treating epilepsy. Medically, ketogenic diets have been in use for epilepsy for nearly 100 years. They are increasingly being used for other conditions, like brain tumors, traumatic brain injuries, and autism, and have recently become popular for weight loss.

What are the different types of ketogenic diets?

ketogenic diet percentagesThe classic medical ketogenic diet is 90% fat. It’s referred to as a 4:1 ketogenic diet—which means that for every four grams of fat, you eat one gram of protein+carbohydrate. This is not a high-protein diet; the goal is to just meet your recommended daily allowance of protein. Your carb count is whatever is leftover in the protein+carbohydrate equation.

That’s the classic ketogenic diet, but there are many variations. For epilepsy, a 3:1 ratio tends to be the starting point for infants and teenagers. The Modified Atkins Diet is becoming increasingly popular for epilepsy, particularly for adults; it contains about 63% of calories from fat. Ketogenic diets for weight loss aren’t as strict in their breakdown. They range from about 60% to 75% calories from fat, 15% to 30% calories from protein, and 5% to 10% calories from carbohydrates. A quick internet survey found that the typical weight loss formula is 75% fat, 20% protein, and 5% carbohydrates.

[click on chart to enlarge]

What’s the best ketogenic diet for migraine?

It depends on the person. Some people see results at lower levels of fat, while others need higher amounts. Start with the lowest ratio you can and work your way up. Readers have reported success on the Modified Atkins Diet. I didn’t get noticeable relief until I worked up to a 3.5:1 ratio; my migraine attacks were worse when I increased to a 3.75:1 ratio (possibly because my blood sugar got too low).

How long does it take to see migraine improvement on a ketogenic diet?

Some people see improvement within a week of starting the diet or increasing their ratio. Almost everyone who sees improvement sees it in the first month. However, it takes about three months for the metabolism to fully shift, so some people don’t see results until a few months in.

It’s also important to manage adverse effects, which could worsen migraine attacks. I became hypoglycemic on the diet and hypoglycemia is a migraine trigger. Since I got the hypoglycemia (mostly) under control, my migraine attacks have been less severe. I can even eat small amounts without triggering an attack.

How long do you have to say on a ketogenic diet for migraine?

Kids with epilepsy can often be on the diet for a year or two, then return to a fairly normal (though generally lower carbohydrate) diet. My dietitian said it often functions as a sort of reset, but does not require a permanent change. Less is known about how adults respond to the diet. In one book I read, a woman in her early 20s with epilepsy had been on the diet nine years with no plan to stop. In naturopathic circles, it is often talked about as a lifelong change. For now, I think it’s an individual thing depending on the severity of your symptoms, your triggers, and how long your migraine attacks have been at their current level.

Why are medical ketogenic diets successful?

Almost all the research is on epilepsy. No matter the illness, the answer is that no one actually knows. Researchers have tested many hypotheses in the last century, but have not come to any conclusions. Ketosis is the probable cause, but that hasn’t been proven. Some researchers speculate that ketosis isn’t actually what’s responsible for improvements, it’s just the visible marker of some other physiological change. In the study on a ketogenic diet for migraine presented at AHS, the benefit could have come from weight loss rather than ketosis.

Why are the risks of ketogenic diets?

Ketogenic diets are not nutritionally complete. Carbohydrates are so restricted that you can’t eat enough vegetables and fruit to get adequate nutrition, so supplementation is imperative. Side effects can range from mild annoyance to death. Although highly unlikely, patients have died in multiple studies of ketogenic diets for epilepsy. Those deaths are typically attributed to hidden metabolic disorders, but it’s still important to be aware of the potential risk.

Please, please do a lot of research before jumping into a ketogenic diet and consider working with a dietitian. I’ve had a DIY approach to my diet for years and would have done this one on my own had I thought I could safely manage the 4:1 ratio without a dietitian. I’m so glad I didn’t. Even working with two dietitians and a naturopath, having blood work every month, and being hypervigilant, I’ve had issues with my blood becoming too acidic, hypoglycemia (that went undiagnosed for five weeks despite the best efforts of my health care team), and wildly fluctuating liver enzymes and inflammation markers. While my migraine attacks have been better on the diet, I overall feel less healthy than before I started it.

The popular version of the diet is less potentially damaging to health than the classic medical version, but I’ve heard enough scary stories from smart people who have educated themselves on the diet to urge anyone considering it to work with a dietitian, at least to start.

What about weight loss?

This diet is popular for weight loss for a good reason—it works. Because the diet mimics starvation, it suppresses hunger. And if you’re doing a 4:1 or 3:1 ratio, you have to weigh everything you eat, so you know exactly how many calories you’re getting. Even though my dietitian kept increasing my calorie intake, I lost 20 pounds unintentionally. My weight finally stabilized when I got to 2,300 calories a day—600 calories more than my dietitian thought I should need and more than I’ve eaten in years. I have yet to gain any of the weight back.

Learn More About Ketogenic Diets

Google “ketogenic diet” or search for it on Amazon and you’ll find information for bodybuilders and people who want to lose weight. That might be the best approach for you, but I recommend starting with the epilepsy-related information. It provides a foundation that explains the medical uses for the diet, is based in solid science (whereas much of the popular information is from not-quite-accurate interpretations of research), includes rational assessments of risks, and explains how to follow the diet in a way that doesn’t otherwise compromise your health. The following resources contain excellent information and were my sources for this post.

Even if you read nothing else, start with these:

More good resources include:

  • The Charlie Foundation and Matthew’s Friends (Nonprofits started by parents of children with epilepsy who have benefited from ketogenic diets. Both sites have good introductions to the diets and helpful guidance. The Charlie Foundation’s information is written or reviewed by a leading dietitian in the field.)
  • Fighting Back With Fat (A book by two moms who have implemented ketogenic diets to treat their children’s epilepsy. *Amazon affiliate link)

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Ketogenic Diet for Migraine: Too Much Weight Loss

ketogenic diet for migraine weight lossElementary school is the last time I weighed this little. I’m not bragging, I’m worried. I was at my ideal weight when I began the ketogenic diet for migraine in January. My dietitian wanted me to lose a couple pounds at first to kickstart ketosis. 17 pounds disappeared in two months. I knew I was too thin, but the weight loss seemed temporary and manageable. Until I lost three more pounds in the last couple weeks and crossed from too thin to frighteningly so.

You may be thinking I’m lucky or that this is a problem you wish you had. I expect you’d reconsider if you saw me without a shirt on. My sternum is pronounced and my ribs are clearly countable. I look sick. I do not feel lucky. I feel sick.

Talking about unintentional weight loss is a strange thing. I used to think it was the same as unintended weight gain, just in the opposite direction. Then I gained weight on cyproheptadine and discovered how different the two are. Weight gain is almost always reviled in this culture; weight loss is typically celebrated. I see a skeleton reflected back at me in the mirror, but people keep telling me how good I look.

I am on the ketogenic diet for migraine—that is, I’m on the diet to become healthier. Yet I keep losing weight that I’m trying to keep and am likely malnourished. Neither of these things is entirely unexpected. A less extreme version of the diet is popular for weight loss and it’s well known that ketogenic diets are not nutritionally complete. The surprise is in how much difficulty I’m having managing the diet. I didn’t expect so many different, complex variables. I certainly didn’t expect to drop to a pre-puberty weight.

P.S. I’m working with my dietitian and naturopath to increase my weight and correct nutritional deficiencies. The problems I’m having with the diet are solvable. Right now I’m feeling overwhelmed by how quickly the issues escalated and expect I will be on edge until the numbers on the scale increase.