Happy New Year! I hope everyone had a joyous holiday with family and friends. Get togethers are always a challenging experience for those with type 1 diabetes (T1D) because of the ubiquity of food at social gatherings. I managed not to fall into any traps of temptation this month. I don’t like to mention that I have T1D, but sometimes I do in order to explain why I can’t eat foods that contain starch, sugar, or alcohol.
This is a monthly update on my glycemic management of type 1 diabetes (T1D) using lispro and Basaglar insulin injections, metformin, a ketogenic whole-food diet, and resistance and aerobic exercise (olympic weightlifting and walking). I did two interviews recently with Dr. Bret Scher at Diet Doctor here and Dr. Tony Hampton here.
For those who haven’t been following this blog, I was diagnosed with type 1 diabetes (T1D) in September 1998 and followed conventional advice to manage my diabetes for the next 14 years. While my HbA1c was 6.5 to 7% during those years, I suffered from frequent hypoglycemic episodes and grew to loathe them. I stumbled onto the use of a low-carb diet for diabetes in late 2011 and started my ketogenic diet on Feb. 8, 2012. The low-carb ketogenic diet greatly reduced my glycemic excursions and halved my insulin requirements from 58 to 28 IU/day and markedly reduced, but did not eliminate, my symptomatic hypoglycemic episodes. In 2019, in an effort to further reduce my hypoglycemic episodes, I added consistency of meals, exercise, and sleep to my blood glucose management strategy. As a result, I have had only 5 mildly symptomatic hypoglycemic episodes since 2019. In addition, my average blood glucose and standard deviation of blood glucose are equivalent to those without diabetes. This has kept me motivated to continue my regimented lifestyle (relative to most others). Although my lifestyle is regimented and consistent, it does not feel burdensome to me. The decision to make certain lifestyle choices is very individual and I can certainly understand if some might not to want to make all the changes that I have to obtain normal blood sugars. In addition to the avoidance of hypoglycemia, I am motivated to continue my current lifestyle as a result of having witnessed firsthand as a physician for 28 years the consequences of poorly controlled diabetes. It was not just witnessing the hospitalizations, surgeries, procedures, dialysis treatments, and infusions of medications, but most memorably, the suffering my patients with diabetes experienced until they met their death, 11 to 13 years sooner, on average, than those without diabetes. I realize that many with diabetes do not think these consequences will happen to them until they actually do. But if my mentioning these realities of poorly controlled diabetes motivates you to adjust your lifestyle habits to improve your glycemic control, then I will have served a purpose. Hippocrates (460 – 357 BC) said, “Before you heal someone, ask if he is willing to give up on the things that make him sick.” I think that applies to type 1 diabetes. Are you willing to give up refined dietary carbohydrates and sugar and haphazardly timed meals, exercise, and sleep that contribute to rollercoaster blood sugars?
My book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, explains in detail the strategies that need to be implemented to achieve normal blood sugars without hypoglycemia and is available in the U.S. on Amazon and internationally on your countries’ Amazon in Kindle, Paperback, and Hardcover versions. The book incorporates all the new strategies that I learned since my previous book that have allowed me to achieve truly normal blood sugars. It also describes why blood sugars can be so difficult to regulate with T1D without these strategies. The ‘Look Inside’ feature on Amazon will allow you to read the Table of Contents and some of the book contents. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.
If you feel you might benefit from some individual attention and suggestions for achieving success with blood sugar control for type 1 or type 2 diabetes and/or losing excess body fat, I can assist you with a personal consultation via Google Meet or Skype. See the Coaching page for more info.
Glycemic Results for December 2022
This month, my glycemic results were comparable to those of non-diabetic individuals (see below), but slightly short of my ultimate goal of no blood glucose values < 70 mg/dL. My average blood glucose for the entire month was 98 mg/dL and the standard deviation of blood glucose (SDBG) was 19 mg/dL. The top graph below shows all of my blood glucose measurements and the bottom graph shows the daily dose totals for bolus (lispro) and basal (Basaglar) insulin and the total daily insulin dose. Fortunately, I did not have any hypoglycemic episodes nor did I need to take any glucose (dextrose) tablets or Smarties™ this month.
My blood sugar goals are shown in Table 2.2 below. I decided to stop adjusting my target blood glucose (TBG) depending on my glycemic results. Instead, I have gone back to a TBG of 100 mg/dl. I have decided not to seek a TBG < 90 mg/dL because I have not found any compelling evidence that a lower TBG would further reduce the risk of diabetic complications or improve healthspan or lifespan, but the risk of having hypoglycemia definitely increases as the TBG is reduced.
The table below summarizes my glycemic results over the previous year. In the table, MBG = mean blood glucose, SDBG = standard deviation of blood glucose, BG COV = blood glucose coefficient of variation which equals SDBG ÷ MBG, MTDID = mean total daily insulin dose, MDBD = mean daily Basaglar dose, MDLD = mean daily lispro dose, HbA1c (%) is calculated using the formula, HbA1c (%) = (46.7 + mean BG mg/dl) ÷ 28.7. Additional columns include the percentage of blood glucose values < 70 mg/dL, between 70 and 130 mg/dL, and > 130 mg/dL, and body weight (kg). My goal is to have 100% of my blood glucose values in the range 70−130 mg/dL, but did not quite meet that goal this month.
The table below tracks my total daily meal macronutrients, body weight, insulin dosage, and the ketogenic ratio of my diet.
I am happy with my current caloric intake and body weight at ≈ 73 kg. The foods in my diet currently include eggs, salmon, parmesan cheese, cheddar cheese, broccoli, kale, spinach, unsweetened tea and water, and a dessert made with cream cheese, heavy whipping cream, coconut oil, unsweetened baker’s chocolate, allulose, chopped macadamia nuts, peanuts, and sunflower seeds, and water to adjust the consistency. The choice of these foods and the amounts I eat result in obtaining close to 100% of the RDA of 40 vitamins, minerals, and other essential nutrients. I do supplement with Morton Lite Salt added to my eggs for its sodium and potassium content and I also take magnesium chloride (300 mg/day) added to water. I also supplement with creatine monohydrate (2 grams/day), vitamin C (180 mg/day), vitamin B12 (0.5 mg/2 weeks because I take metformin), and vitamin D (5,000 IU 3x/week). In addition to Basaglar and lispro insulins, I take metformin 500 mg with each of 4 meals daily (2,000 mg/day). My meals are eaten at 7 am, 12:15 pm, 5:30 pm, and 10:45 pm, or as close to those times as possible. Each meal contains ≈ 0.45 grams/kg body weight of protein to help retain my muscle mass as I age.
Below is a photo of myself from April 2022 at 72.8 kg (160.5 lb.).
My best olympic lifts this month were 132.5 lb. snatch and 180 lb. clean and jerk, same as last month. These are less than December 2020 (147.5 lb. snatch and 200 lb. clean and jerk) prior to injuring my shoulder later that month. My shoulder is much better now, but I suspect I have a ligamentous type injury, e.g. rotator cuff, that will never fully heal. Although I would like to be able to lift those heavier weights, I still enjoy doing what I can. My daily exercise program is doing a good job of keeping my insulin sensitivity stable which contributes to achieving normal blood sugars with lower insulin doses.
Table 1.2 below shows the mean interstitial glucose (IG) of 732 non-diabetic subjects and standard deviation of the interstitial glucose (SDIG) of 708 non-diabetic subjects as measured by CGM from the seven studies referenced below. One of the studies, Sundberg, F, et al., 2018, was in 15 healthy, normal weight children, age 2−8. The mean CGM 24-hr IG was 95 mg/dL (5.3 mM) and SDIG was 18 mg/dL (1.0 mM). This study again confirms that children’s blood sugars are about the same as those of adults. The age of subjects in these seven studies ranges from 2−80 years. I think it is important for those with T1D to know the glucose results of metabolically healthy study subjects to be used as a reference for seeking normal blood sugars. Although achieving normal blood sugars with T1D is not an easy task, it can be made more difficult by choosing a target blood glucose that is too low and results in hypoglycemic episodes. The lower the target blood glucose, the more likely hypoglycemic episodes are to occur in those with T1D taking exogenous insulin. Having hypoglycemic episodes means that your target blood glucose is set too low. Achieving a normal mean blood glucose without hypoglycemia, requires that one’s glycemic variability as measured by the standard deviation of blood glucose is normal as well.
The references for these seven studies are shown below.
I’ll mention that the authors of Zhou, J, et al., 2011 above concluded that a SDBG <25 mg/dl should be considered to be normal because that was the 95th percentile of the metabolically healthy subjects in their study. The median SDBG in the study was 18 mg/dl which is what I am hoping to achieve each month. My goal moving forward is to eliminate all BG values < 70 mg/dL as part of managing T1D as safely as possible. Although I have yet to achieve this goal for an entire month, I am not discouraged and continue to strive for better results each day.
The purpose of this blog is to share my experience with a low-carb ketogenic diet and exercise to better manage my blood glucose as a person with T1D. A low-carb ketogenic diet also allows for lower daily insulin doses and normal body composition which I believe reduces the risk of developing insulin resistance (double diabetes) and the host of chronic diseases associated with insulin resistance including atherosclerosis, cancer, and neurodegenerative diseases. I also take metformin 500 mg with each of 4 meals daily (2,000 mg/day) to suppress liver glucose production which tends to be chronically elevated in those with T1D. This occurs due to the lower concentration of insulin around the pancreatic alpha-cells increasing the concentration of glucagon reaching the liver as well as the lower concentration of insulin entering the liver both of which increase liver gluconeogenesis, glycogenolysis and glucose production relative to those without T1D. Metformin also improves glucose uptake by skeletal muscle. Metformin, exercise, and a low-carbohydrate diet also improves glycemic control for those with glucose intolerance, prediabetes, type 2 diabetes, and double diabetes [T1D with insulin resistance]. As explained in detail in my book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, injecting insulin in the subcutaneous fat is just not the same as when it is secreted by the beta-cells in the pancreas according to the prevailing blood glucose concentration. I have accepted the fact that there will always be more variation in my blood glucose than I would like, but if I can continue to keep the mean and standard deviation of my blood glucose readings equivalent to that of non-diabetic individuals while avoiding hypoglycemia, I will be satisfied. I would appreciate those who want to purchase my book and derive some benefit from reading it to leave a positive review on Amazon so that others will see the book when they search for books on T1D. The search rankings in Amazon are based the number of books purchased and the reviews of the book. I hope 2023 will be everyone’s best year so far.
Comments or general questions are welcomed.
Till next time….
Ketogenic Diabetic Athlete 