Last week, I began training for the London Marathon. It started with a run and ended in A&E. Marathon training with type 1 diabetes makes a difficult task not only more challenging, but potentially life threatening. So let’s talk about what happened.. and a rare complication called EDKA (Euglycemic Diabetic Ketoacidosis).
Background: I’m a massive fan of being in nutritional ketosis (A metabolic state which primarily burns fat for fuel instead of glucose. This happens by eating a very low carbohydrate diet (typically <20-50g/day). The benefits, for me, outweigh any initial struggle getting there. Ultimately, it’s a just a lifestyle that makes me feel most like a normal person and not like a person with a chronic illness.
The most common question or response I get to posting ketones as a diabetic is – ‘aren’t ketones bad?’ – and the answer is… not necessarily. Not if you’re in nutritional ketosis and not if those ketones are relatively low (I’m happy and feel healthy <~3 mM).
Last Thursday I woke up with reasonably high ketone levels (2.6 mM) and reasonably low BG (4.2 mM). I had a couple of coffees with cream, spent my morning pottering about doing household chores and then I got to the gym just before midday. I did a 2km row, followed by a (hard) 45 minute speedwork session on the treadmill. Then I thought I’d be sensible and call it a day, head home and refuel. I had some n’oat meal (unbolused).
An hour later, I felt really ill, so I darkened my room and crawled into bed. Unusually, my housemate came home from an interview about half an hour later, so I forced myself up to ask her how it went. That’s when I struggled to take in what she was saying and felt like I was going to throw up. Then it hit me: I re-tested my ketones. 5.4 mM. I swore in my head a few times. I got myself a pint of water. I drank it and got a second pint, trying not to throw up.
I was shaking, I’d turned grey, my lips were blue, my heart was racing and my breathing had quickened. I retested my ketones 30 minutes later. They’d gone up to 6.3 mM. That’s when I started to panic.
An hour later, in A&E, my ketones were 7.1 mM.
The line between nutritional ketosis and DKA isn’t well known or understood – if at all. I’m not sure anyone knows the point at which your blood becomes acidic if your blood sugar is normal. I sat in A&E for several hours, guzzling water, testing my ketones every half an hour and trying to google how long you can be in DKA before you go into a coma. The ketones remained high. 5 hours after my first high ketone reading and after 4 litres of water, a nurse finally took a blood sample. My blood sugar never went above 4.2 mM the entire day.
Today I met with my diabetes team (there were 5 other people in the room this time – including 2 consultants) and they agreed that I should have been admitted, and that I had Euglycemic DKA (DKA but with normal blood sugar).
But…I feel like this scenario is a brand new jigsaw puzzle that has never been put together. The pieces are there, but no one’s quite figured out how it all fits together yet. There’s a physiological explanation for what happened to me – but nobody knows what it is. I suspect a range of factors amalgamated together and produced a catastrophe. I suspect dehydration, high intensity anaerobic training, relatively high fasting ketones, my suspended pump and a fasted work out all contributed.
I can’t erase what happened last Thursday – but I can learn from it. I’m still in ketosis. I still text the dietitian, whilst in A&E, that I still planned on completing the marathons in ketosis (her reply was; ‘even if there’s not a hospital 8 minutes away?!’) and my answer is: yes, even then. The thing is, as type 1 diabetics, whatever we do carries a risk. I still believe that exercise is less of a risk, for me, whilst in ketosis. I just think that what happened can be avoided. Maybe with adequate hydration. Maybe with breakfast. Maybe with a temp basal instead of full pump suspension. The hospital are concerned about the lack of knowledge to help me, and I get it. I get the concern. I get that what I’m attempting is relatively unheard of. But that doesn’t mean that it’s not possible. Sometimes the best paths are the ones we make ourselves… and this isn’t a path I’m leaving any time soon.
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