#71 October 2019 Update on My T1DM Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with a ketogenic whole-food diet and resistance and aerobic exercise.

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 Skype. See the Coaching page for more info.

This month I did an interview with Ross Wollen on asweetlife.org titled “Interview: Dr. Runyan is the Diabetic Ketogenic Athlete.” You can read it here.

I wrote an article for DietDoctor in July titled “What you need to know about a low-carb diet and your kidneys.“ You can read it here

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

Last month, after 13 months of specifically trying to achieve normal blood sugars, I was able to accomplish that goal. This month, in addition to achieving a normal average and standard deviation of blood sugar, I was able to reach an additional blood sugar goal: the percentage of blood sugar values in the range 70 to 130 mg/dl of > 80%. This was despite having a back strain on 10/19/19 during olympic weightlifting that required changing my exercise regimen and insulin doses significantly. As mentioned in previous posts, I have had a normal mean blood sugar since I started my ketogenic low-carb diet in 2012. But last year I decided I also wanted normal blood sugar variability. I used as my measure of normality, a standard deviation of blood sugar of less than 25.2 mg/dl (1.4 mmol/l). This value was measured in 434 metabolically healthy subjects in China as reported in this study. My blood sugar goals are summarized in Table 3 below.

Glycemic Results For October 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), calculated HbA1c, body weight, and mean insulin dose totals for October 2019. You can see I have achieved both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Note the increase in average daily insulin dose compared to September. As mentioned, I attribute this to the change in exercise due to the back strain. My current insulin dose (0.39 IU/kg/day) is still less than half what it was (0.80 IU/kg/day) prior to starting regular exercise in 2007 and a ketogenic low-carbohydrate diet in 2012.

The table below shows the percentage of blood glucose values in the indicated ranges of low, goal, and high values for October 2019. I met two out of three of my stated goals for these parameters, but the low frequency of hypoglycemia is the most important one to me.

This month’s results were improved compared to last month. As shown in the Table 3 above, my goals are < 10% lows, > 80% normals, and < 10% highs. I am pleased with the relatively low frequency of hypoglycemia. My true goal is 0% of blood glucose values < 70 mg/dl, but I am trying to be realistic and thus have set the goal to less than 10%.

The graphs below show all of the daily insulin dose totals and all of the blood sugar (BG) readings for October 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red. You can see the increase in insulin doses beginning after the back strain on 10/19/19. In contrast to times past, the increase in insulin doses was modest and stabilized much sooner. I think this why I was able to keep the blood sugars normal this month. You can also see the increase in blood sugars after 10/19/19 that prompted the increase in insulin doses. It took 3 days of insulin dose increases to resolve the high blood sugars. Had I known exactly how long it would take for my back to recover, I would have increased the basal insulin (Lantus) dose sooner. As of today, I still have not returned to olympic weightlifting, but my back is improving and I hope to start back on Monday, Nov. 4th. Note that the day after the back strain on 10/20/19, I increased my walk distance from 1.5 to 2.5 miles twice daily to try stay as insulin sensitive as I was while lifting weights. Clearly, walking is not as insulin sensitizing as lifting weights. On 10/27/19, I started doing bodybuilding type machine weight training and you can see the blood sugars and Humalog doses started decreasing.

This is a pattern I have observed over and over again. Each type, duration, and intensity of exercise results in different blood sugar, insulin sensitivity, and insulin dose requirements. I have found that keeping exercise constant from day to day has helped me achieve normal blood sugars, but when changes are required, as in the case of injury, at least devising a new exercise regimen and keeping that constant will allow blood sugars and insulin doses to again stabilize.

As I have mentioned in previous posts, I decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. I have received my order of Tresiba and it is in my refrigerator ready to go as soon as my last vial of Lantus is used up. I expect to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

#70 September 2019 Update on My T1DM Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with a ketogenic whole-food diet and resistance and aerobic exercise.

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 Skype. See the Coaching page for more info.

I wrote an article for DietDoctor in July titled “What you need to know about a low-carb diet and your kidneys“. You can read it here

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

After 13 months of specifically trying to achieve normal blood sugars, I was able to accomplish that goal this month. As mentioned in previous posts, I have had a normal mean blood sugar since I started my ketogenic low-carb diet in 2012. But last year I decided I also wanted normal blood sugar variability. I used as my measure of normality, a standard deviation of blood sugar of less than 25.2 mg/dl (1.4 mmol/l). This value was measured in 434 metabolically healthy subjects in China as reported in this study. My blood sugar goals are summarized in Table 3. below.

Glycemic Results For September 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), calculated HbA1c, body weight, and mean insulin dose totals for September 2019. You can see I am achieved both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Also note the decrease in average daily insulin dose compared to August. I attribute this to the fact that my body weight was stable throughout September as apposed to increasing in August. My current insulin dose is less than half (0.36 IU/kg/day) what it was (0.80 IU/kg/day) prior to starting regular exercise (in 2007) and a low-carbohydrate diet (in 2012).

The table below shows the percentage of blood glucose values in the indicated ranges of low, goal, and high values for September 2019. I just barely missed my stated goals for these parameters, but the low frequency of hypoglycemia is the most important one to me.

This month’s results were improved compared to August. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As shown in the Table 3. above, my goals are < 10% lows, > 80% normals, and < 10% highs. I am pleased with the relatively low frequency of hypoglycemia. My true goal is 0% of blood glucose values < 70 mg/dl, but I am trying to be realistic and thus have set the goal to less than 10%.

The graphs below show all of the daily insulin dose totals and all of the blood sugar (BG) readings for September 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

In olympic weightlifting, the goal is to lift as much weight as possible and to increase the weight over time. This means you are always looking to improve and you never arrive at a final destination. There is always more weight that can be added to the bar. I actually like this aspect of the sport. I like having a daily challenge. I think glycemic control in T1DM is similar to this concept. You can always seek a lower blood sugar variability. I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. I have one more month of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that insulin is very expensive and many people with T1DM do not have access to enough insulin. I plan to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

#69 August 2019 Update on My T1DM Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet.

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 Skype. See the Coaching page for more info.

I wrote an article for DietDoctor last month titled “What you need to know about a low-carb diet and your kidneys“. You can read it here.

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

This month I continued making adjustments even though I was hoping to keep everything constant for a change. I decided to go ahead and increase my weight to 73 kg, the masters olympic weightlifting class I would like to compete in. Changes in body weight are accompanied by changes in food intake, insulin doses, and blood sugar responses to those changes. Despite all these changes, I was pleased with my blood sugar results this month even though I did not reach my goals which are shown in the table below.

Glycemic Results For August 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), calculated HbA1c, body weight, and mean insulin dose totals for August 2019. You can see I am close to achieving both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Now that I am at goal body weight, I might be able to achieve my blood sugar goals in September. If not, perhaps changing Lantus to Tresiba, which is scheduled to begin in November, will do the trick. Also note the increase in insulin dose that accompanies a larger body weight even when calculated as IU/kg/day. A higher body weight requires more daily food intake and more tissue that requires insulin. Still, this is a relatively low daily insulin requirement as most with T1DM require about 0.80 IU/kg/day which was my insulin requirement prior to starting regular exercise and a low carbohydrate diet.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for August 2019.

This month’s results were about the same as in July. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As mentioned in previous posts, my goals are < 10%, > 80%, and < 10%, respectively. That said, the reduction in hypoglycemia is my highest priority so I am pleased with that. In addition, I needed to take glucose tablets on only 1 occasion in the month of July which is a new record low.

The graphs below show all of the daily insulin dose totals and all of the blood sugar (BG) readings for August 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

Even though the range of BG excursions continues to improve (I’m not complaining), there still appears to be a significant number of BG swings.

I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. Note that the study that found the largest difference in day-to-day variability was conducted and paid for by the maker’s of Tresiba, so we must take the results with a grain-of-salt. Nevertheless, the best way to know if something works better – or not – is to test it for myself. I have two more months of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that many people with T1DM do not have enough insulin. So I should be able to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

#68 July 2019 Update on My T1D Management

I wrote an article for DietDoctor this month titled “What you need to know about a low-carb diet and your kidneys“. You can read it here. 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 Skype. See the Coaching page for more info.

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet.

This month I continued making adjustments even though I was hoping to keep everything constant for a change. Unfortunately, my earlier decision to drop my body weight to make the 67 kg weight class in olympic weightlifting was a mistake. I had reduced my calories to the point that I felt a lack of energy, was thinking a food too frequently, was wishing for more food at the end of each meal, and I suspect that my energy expenditure went down to compensate for the lack of calories. Not only was this not pleasant, but I could not train enough to be able to lift the weights needed to be competitive. So during July, I progressively increased my caloric intake in steps and each time having to readjust insulin doses upward (see graph below). This process of adjusting food intake, insulin doses, and exercise results in less than optimal blood glucose control.

Glycemic Results For July 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for July 2019.

The standard deviation of BG was about the same as June, but I did not reach my goal of < 25 mg/dl was considered normal in the study reviewed last month (Post #67).

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for July 2019.

This month’s results were about the same as in June. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As mentioned in previous posts, my goals are < 10%, > 80%, and < 10%, respectively. That said, the reduction in hypoglycemia is my highest priority so I am pleased with that. In addition, I needed to take glucose tablets on only 4 occasions in the month of July.

The graphs below show all of the daily insulin dose totals and all of the BG readings for July 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

Even though the range of BG excursions continues to improve (I’m not complaining), there still appears to be a significant number of BG swings.

I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. Note that the study that found the largest difference in day-to-day variability was conducted and paid for by the maker’s of Tresiba, so we must take the results with a grain-of-salt. Nevertheless, the best way to know if something works better – or not – is to test it for myself. I have three more months of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that many people with T1DM do not have enough insulin. So I should be able to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

#67 June 2019 Update on My T1D Management

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 Skype. See the Coaching page for more info.

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet.

This month I want to review a study I recently discovered, but was actually published in 2009. Not sure how I missed it, but I think it is related to the search terms put into Google. Anyway, here goes.

The study was conducted on 434 nondiabetic male and female subjects, age 20−69 years old, at 10 academic hospitals throughout China in which their BG was measured by 3-day CGM and 4 finger-stick blood glucose (BG) measurements daily. Before applying the CGM to the study subjects, they were confirmed to be metabolically healthy (nondiabetic) using a medical history, physical exam, and extensive laboratory testing. The subjects were not taking any medications, had normal body weight, blood pressure, fasting BG and HbA1c, fasting insulin or C-peptide level, homeostatic model assessment of insulin resistance (HOMA-IR), and oral glucose tolerance tests (OGTT). HOMA-IR is simply the fasting insulin level multiplied by the fasting BG. If either value are slightly elevated, then the product of the two will be elevated and indicative of insulin resistance, a precursor to diabetes. The OGTT measures several BG values after consuming a 75-gram glucose solution. If any of the values exceed a predetermined level, this too is indicative of insulin resistance, pre-diabetes, or diabetes. Subjects with any abnormal results were excluded from the study.

The total calorie intake from the three daily meals was 30 kcal/kg􏰉/day during CGM, with 50% carbohydrates, 15% proteins, and 35% fats. Comparing the  interstitial glucose (IG) values at times when the finger-stick BG readings were also obtained, the mean IG was 103 mg/dl and mean BG was 103 mg/dl. For the 434 healthy subjects, the mean 24-hour IG was 104 mg/dl and the mean standard deviation (SD, a measure of glucose variability) of IG was 14.2 mg/dl. The 95th percentile of mean 24-hour IG was 119 mg/dl (6.61 mmol/l). This means that 95% of the metabolically healthy subjects had a mean 24-hour IG as high as 119 mg/dl. The authors of this study considered any mean 24-hour IG ≤ 119 mg/dl to be normal. Interestingly, impaired fasting glucose is defined by the ADA as a fasting plasma glucose between 100−125 mg/dl (5.56−6.94 mmol/l). It should be noted that the World Health Organization (WHO) and numerous other diabetes organizations define the impaired fasting glucose cutoff at 110 mg/dl (6.11 mmol/l). 

Two years later, another paper was published on the same 434 subjects. This paper focused on the glucose variability as measured by standard deviation (SD) of interstitial glucose (IG). The median SD of IG was 13.5 (0.75 mmol/L). The 95th percentile of the SD of IG was 25.2 mg/dl (1.40 mmol/L). Again the authors of this study considered any SD of 24-hour IG ≤ 25.5 mg/dl to be normal.

I included data from three other studies that I have previously reviewed on this blog in Table 2. below.

Glycemic Results For June 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for June 2019. I did not feel well at a body weight of 67 kg. I felt a slight lack of energy and was thinking about food a lot. I was not hungry, but at the end of each meal, I felt like I wanted to eat more. Therefore, I decided to just eat an amount of food that would satisfy me and let my weight be whatever it turns out to be. If I have to go back to the 73 kg weight class to compete in olympic weightlifting, then so be it. Thus, my total daily insulin dose had to be increased a bit during June.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for June 2019.

I did experience a reduction in hypoglycemia, but an increase in hyperglycemia compared to the previous month. Overall, I was pleased with my results, particularly with the reduction in standard deviation of BG. The graphs below show all of the daily insulin dose totals and all of the BG readings for June 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red. 

In July, I will continue to seek normal mean blood glucose and normal glycemic variability results. I appear to be getting ever closer to achieving that goal. Table 3. below shows my goals from this point forward in light of the results of the two studies presented above.

References:

Zhou, J., et al., (2009). Reference values for continuous glucose monitoring in Chinese subjects, Diabetes Care, 32: 1188–1193.

Zhou, J., et al., (2011). Establishment of normal reference ranges for glycemic variability in Chinese subjects using continuous glucose monitoring, Med Sci Monit, 17(1): CR9-13.

#66 May 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

May 2019 was an interesting month with more changes. I now believe I have tried every possible combination of Lantus dosing. I have given it at 4 different times of the day 7 AM, 12 PM, 6 PM, and 11 PM once daily. I have given it twice daily and three times daily. I have changed the doses up and down the entire spectrum from A to Z. This month I changed my BG check times to 7 AM, 12 PM, 6 PM, and 10 PM. I also decided to change my insulin-dosing strategy and add a fourth meal daily. The reason for the fourth meal was two-fold. First, based on research in the sports science field that I mentioned last month which shows that muscle protein synthesis (MPS) is maximized by consuming 0.4 – 0.55 grams of protein/kg/meal in each meal. This stimulation of MPS is not as powerful as that produced by resistance exercise, but the benefits of exercise on MPS is also dependent on eating enough protein within the next 3-4 hours. Eating more protein than 0.55 g/kg/meal does not further increase MPS. Each meal results in net MPS over and above the muscle protein breakdown that occurs during fasting between meals and especially fasting overnight. Adding the fourth meal at bedtime potentially results in more net MPS per day. This is a hypothesis rather than a proven fact. Understand that the number of studies in humans is small and the ones that do exist are all short-term studies. Most of the studies on MPS were done in animals, primarily rats, and they too are short-term studies. However my decision to add the fourth meal was not just related to this potential, but uncertain, benefit on MPS. My second purpose was to test a different insulin-dosing strategy. The idea was to take my basal insulin (Lantus) dose with the bedtime meal, now 10 PM, such that I inject a dose of Humalog with each of the four meals daily. This means taking a total of five injections daily and no more. The Humalog dose would now have three purposes. 1) cover the meal, 2) correct for either high or low BG readings, 3) supplement my basal insulin needs for 20 of the 24 hours per day. The 20 hours represents the duration of action of Humalog of 5 hours x 4 doses daily. This last purpose is the new part. I am specifically choosing the basal insulin (Lantus) dose to cover my insulin needs between 3 AM and 7 AM, the time period where all Humalog is done. The hope is that the Lantus dose required to accomplish this will be low enough to never cause hypoglycemia at any other time of the 24-hour day. Another way of stating this is that I hope I can find a Lantus dose that is low enough that I always have to take greater than or equal to 0.4 IU of Humalog with each meal. If the Humalog dose at a meal is less than 0.4 IU, then the accuracy of drawing up my 5-fold diluted Humalog is questionable. I thing this approach makes sense because rapid-acting insulin doses can be precisely adjusted daily whereas any change in a Lantus dose takes 3-5 days to take full-effect. This method does not require eating 4 meals per day. If one chooses 3 meals per day, then Humalog could be given at 10 PM with the Lantus without eating a meal. I figured why not use the Humalog for both of the purposes stated above. I started this new regime on May 14 with 7 IU Lantus at 10 PM. I had to subsequently increase to 8, 9, 10, 11 IU, and back down to 10 IU. I hope that 10 IU at 10 PM will do the trick from this point forward. My BG values started looking pretty good on May 24th and the two lows I had subsequently is what prompted the reduction in Lantus from 11 IU to 10 IU.

This month I reached my goal weight of 67 kg at 2000 kcal/day, but today, June 1, I got hungry and fatigued again and increased my caloric intake back to 2100 kcal/day. Hopefully my weight will stay close to 67 kg so that when it comes time to compete in olympic weightlifting, I won’t need to cut much weight. An interesting observation I have had with this body weight adjustment process is that the symptoms of insufficient caloric intake is delayed. In other words, I can feel fine on the caloric intake that leads to the weight loss for several weeks before any symptoms develop. This sounds like the observation noted by overweight persons who lose weight. They find it is easier to lose the weight than to maintain the weight loss. This might be why. I think that covers all the new developments in May 2019.

Glycemic Results For May 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for May 2019. I experienced a slight reduction in insulin doses, mean BG, SD, and CV compared to April.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for May 2019. Two of the three values were improved compared to April.

The graphs below show all of the daily insulin dose totals and all of the BG readings for May 2019. HUM = Humalog, LAN = Lantus, INS = total daily insulin dose. Note: I accidentally forgot to take a Lantus Dose on May 8th. I attributed that to a “senior moment” and to my frequent changes in dosing schedules. I don’t expect that to continue.

In June, I will continue with the above plan. I do not have plans for any more experiments. I think I need to give the current plan some time to settle out and see if I can get normal blood sugars in June.

I found a new study I plan to review next month regarding measuring interstitial glucose in nondiabetic subjects. It was published in 2009, so I don’t understand why it took me so long to come across it, but I guess better late than never. It is a better study than any of the others I have come across on this topic and involved 434 metabolically healthy nondiabetic subjects.

Finally, I would appreciate your comments on the idea of using inhaled insulin for the sole purpose of eating candy “as a treat.” I assume that means not very often, but I’m not sure how often that is. For me, I’m afraid that would send me down a path of having “treats” more and more often. I believe I was once addicted to chocolate and sweets in general. My low-carbohydrate diet fixed that, thank goodness. Also, not sure if this matters, but the person doing this is an endocrinologist with T1DM who states he/she follows a “not very strict low-carbohydrate diet.” To me, this means he/she understands the purpose of the low-carbohydrate diet. To me, the purpose of eating carbohydrates is to get nutrients from plant foods that are difficult to get, or are not available, in animal foods. The nutrients in my diet that come almost exclusively from plants include vitamin C, vitamin K1, manganese, lutein, and zeaxanthin. The nutrients from plants in my diet that make up at least 40% of my daily requirements include folate, vitamin E, copper, magnesium, and potassium. I would be interested in hearing your thoughts on the idea of eating candy as a “treat” with T1DM.

Well that is all I have for this month. Wishing you smooth blood sugars in June 2019.

#65 April 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

April 2019 was an interesting month with more changes. I now believe I have tried every possible combination of Lantus dosing. I have given it at 4 different times of the day 7 AM, 12 PM, 6 PM, and 11 PM once daily. I have given it twice daily and three times daily. I have changed the doses up and down the entire spectrum from A to Z. This month I changed back to my original regimen of once daily at 6 PM. I originally started experimenting with other Lantus regimens in about September last year because I was having problems with not being able to control my BG both fasting and later during the day with exercise without one being too high (6 PM) or the other being too low (7 AM). I was also afraid to give doses of Humalog either before exercise and at bedtime for fear of hypoglycemia. However, now that I have diluted Humalog I can give as little as 0.2 IU of Humalog either before exercise or at bedtime if needed. So, this month I finally decided that there is no regimen of Lantus that will accomplish both goals. Instead, I decided to choose a single 6 PM Lantus dose that would not necessarily result in a normal BG at any time of the day, but would simply be a low enough dose to avoid hypoglycemia 24 hours a day. Then I would be willing to give Humalog 4 times a day at 7 AM, 12 PM, 6 PM, and 11 PM to make up the difference between the Lantus and my actual insulin needs. As usual, I would figure out the Humalog dose by trial and error in small increments or decrements. I also decided to change from 2 to 3 meals a day. I have learned from Donald Layman, PhD and Stewart Phillips, PhD (you can Google those names to find their publications on dietary protein and muscle protein synthesis if you’re interested) that more frequent meal boluses of protein is the best way to avoid sarcopenia of aging especially when combined with resistance exercise. I have no idea whether or not increasing from 2 to 3 meals per day will work and doubt I never will know, put since I will likely need to take Humalog anyway at 12 PM before exercise, I might as well try it. I just got started on this new regimen so I won’t be able to report on the results until next month. I also reduced my daily calorie intake from 2300 kcal/day to 2000 kcal/day in 3 steps of 100 kcal/day with a week between each change to see if I can get down to 67 kg for the purpose of competing in masters olympic weightlifting. If I can’t get down to that weight, I will have to compete at 73 kg.

Glycemic Results For April 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for April 2019. I experienced a slight reduction in insulin doses, but otherwise not much different compared to March.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for April 2019

Note that I changed my target BG range from 71-120 mg/dl to 71-130 mg/dl and my target BG from 95 to 100 mg/dl in order to further reduce the frequency of hypoglycemia which was improved in April. I would like it to continue to reduce it even further. I deleted the other two columns of % of BG readings for the previous months because I did not have time to go back and recalculate the % in range values for Jan. to March 2019.

The graphs below show all of the daily insulin dose totals and all of the BG readings for April 2019.

On April 27th, I think I forgot to take my 6 PM Lantus dose since I had been in the habit of taking it at 11 PM. I am not 100% sure of that, but it was the only explanation I could come up with to explain the sudden jump in BG the following day. I took an extra 3.5 IU of Lantus to try to catch up, but did not want to give a big dose in case I had not forgotten it. Anyway, my BG seemed to have straightened out afterwards.

In May, I will continue with Lantus at 6 PM and I have no plans to change it again. I will tweak the doses of Humalog up to 4 times a day to see if I can further improve my glycemic control. Currently, I feel like 2,000 kcal/day is about the minimum number of calories/day I can eat to feel satisfied. Therefore, I am going to stick with that for several weeks and see what happens to my body weight. This weight loss experiment has been an interesting process having never purposely tried to lose weight before. I am already pretty lean, so I’m not sure if I have much more body fat to give up. Given what happened two months ago when my weight dropped to 65 kg and I got cold, fatigued, and hungry on 1,900 calories/day, I’m not sure if 67 kg will work for me long-term.

I saw an interesting YouTube video of a lecture this past month https://www.youtube.com/watch?v=3RlxpKzoiY8 given by biochemist, Richard Hanson, PhD. Near the end, he describes an experiment with mice that accelerated their ability to burn fat. At the very end, he showed a quote attributed to Winston Churchill that I thought fit perfectly with my pursuit of normal glycemic control.

“Success is going from failure to failure with enthusiasm.”

Thus by Churchhill’s estimation, I have been very successful! Well, I think that is about all I have to share this month. I hope possibly something in these posts will help others with the very challenging task of managing T1DM.

#64 March 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

March 2019 was an interesting month. Having reduced my body weight from 75 kg to 65 kg over the past six months, this past month I suddenly developed symptoms of excessive calorie restriction and/or excessively lean body composition. These symptoms included feeling cold, generalized fatigue, lack of desire to exercise, hunger, and frequent thoughts of food. Fortunately, it did not take long to recognize the cause of the symptoms and take corrective action. I progressively increased my daily caloric intake from 1900 kcal/day to 2700 kcal/day over about a 7 day period. The cold feeling resolved first, followed by my energy level and desire to exercise, and finally the feeling of hunger and thoughts about food ceased. My weight increased pretty quickly as well and went beyond my goal of 67 kg which is the olympic weightlifting weight class I would like to compete in at some point in the future. My weight has peaked and stabilized at 69.9 kg. I am now slowly reducing my caloric intake and adjusting my insulin doses to try and get back to 67 kg more slowly without the return of any symptoms. My current daily calorie intake is 2300 kcal/day.

Glycemic Results For March 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), and coefficient of variation (CV), and mean insulin dose totals and body weight for March 2019.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for March 2019.

The graphs below show all of the daily insulin dose totals and all of the BG readings for March 2019.

You can see I have not met my BG goals. I am aiming for a lower BG SD, fewer BG values < 71 mg/dl, and fewer BG values > 120 mg/dl. I think the fluctuating caloric intake, body weight, and travel made my BG management more challenging. I hope that this will improve in April. Seems my goals are just out of reach each month for one reason or another. However, I will not be deterred. I will keep trying until I get it right. You can probably guess the dates of my travel from the BG graph above. If you want to guess the dates, you can leave a comment. Hint: it was a 5-day trip. Travel has always been challenging for my BG management, but this too I want to conquer.

My goal for April 2019 is to find the correct caloric intake to bring my body weight down to 67 kg, and this will likely require some slight reduction in insulin doses. Because I am eating the same breakfast and dinner everyday, I am not really “counting calories” in the usual sense of the term. I am simply using calories as a measure of food quantity. Keeping each meal constant allows me to identify a bolus insulin dose that will hopefully result in a post-meal BG in my desired target range. In April, I hope to improve my BG variability i.e. BG standard deviation and % of BG values in my target range of 71 – 120 mg/dl. Till next time ….

#63 February 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes. See the Coaching page for more info.

I have made several changes over the past seven months in my attempt to further improve the glycemic control of my T1DM. Many of the changes have not been successful. However, I don’t think it is possible to predict their success in advance and at least I now know what doesn’t work at this time in my life. For example during these past seven months, I have tried multiple different basal insulin schedules and doses trying to exactly match my changes insulin sensitivity throughout the day (due to exercise). I still have not solved this puzzle unfortunately. All of the different basal insulin combinations seem to result in the same problem. When my fasting blood glucose (BG) is normal, I will get hypoglycemia after exercise 25-33% of the days. In the past I had problems with hyperglycemia as well. This, I believe, was corrected by adding a 2-mile walk before and after weightlifting. Below are the changes that I feel have been helpful (I am leaving out the unhelpful ones):

  1. Two meals per day. This prevents overlapping meal-time insulin doses and frees up time for other activities.
  2. Achieved a leaner body composition which in turn dramatically reduced my insulin requirement per kg of body weight which reflects an improved insulin sensitivity.
  3. Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. By standardize, I mean the same exercises with the same duration and only minor occasional increases in intensity over time.
  4. Emphasized avoiding hypoglycemia as a more important goal compared to achieving any particular mean BG level. Hypoglycemia (BG < 71 mg/dl) is both unpleasant to experience and is life-threatening, whereas, mild transient hyperglycemia (BG > 120 mg/dl) is very unlikely to cause problems.
  5. Using cronometer.com to design different meal plans that I enjoy and can eat over and over again, each composed of the same amounts of macronutrients (protein, fat, and carbs) and each containing > 100% of the RDA for all vitamins and minerals. Since I do feel I get the best results from a low carb ketogenic diet and I feel a higher protein intake will best preserve my muscle mass as I age (currently 58 years old), I chose to design each meal so that I get a daily total intake of about 2.2 grams protein/kg BW/day and less than 40 grams of total carbohydrate and less than 30 grams of net carbs.
  6. Weighing my food on a kitchen scale helps to precisely follow my own meal plan.
  7. The combination of 6. and 7. above also makes achieving a lean body composition a lot easier.
  8. Taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with dinner really reduces my meal-time insulin requirements.
  9. In December 2018, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution to use as my meal-time insulin. This way I can accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.
  10. The past few months I have developed a spreadsheet to estimate my Humalog doses. For the past 20 years, I have been using the “experienced guessing” approach. I have always been uncomfortable with this approach, but did not have an alternative until now. The approach is simple in principle, using least squares linear regression of insulin versus change in BG. The spreadsheet is customized to a fixed number of BG measurements and insulin (basal and rapid-acting) dosing opportunities per day. I would say it is still in the testing phase and would not call it a true success until I have reached my BG control goals.

I have greatly simplified my data presentation down to the bare essentials. At this point in time, I think the four most important metrics are: mean BG, standard deviation (SD) of BG, % of BG meter reading in the normal range (71 – 120 mg/dl), and % of BG meter reading < 71 mg/dl (a rough measure of the frequency of hypoglycemia). 

This image has an empty alt attribute; its file name is post-63-bg-and-insulin-dose-graphs.png

Glycemic Management Results for February 2019

My February 2019 insulin doses and BG results were a bit worse compared to last month due to multiple changes in calorie intake and experiments with different basal insulin schedules and doses. Oh well.

The graphs below show the total daily doses of Humalog (blue) and Lantus (green) individually and the total of both insulin doses (red) and my actual BG readings (purple) below. The increase in insulin doses started on Jan. 27, 2019.

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage) as well as my current body weight and mean insulin dose totals. My height is 5’8″.

This image has an empty alt attribute; its file name is post-63-variability-table.png

I should mention that I believe the increase in insulin dose for February was related to an increase in calorie intake that was needed due to a two-week period of feeling hungry, cold, and tired. My calorie intake was increased from 1900 kcal/day to 2600 kcal/day in 100 kcal/day increments during the month of February.

The table below shows the % of BG meter reading in three BG ranges. 

This image has an empty alt attribute; its file name is post-63-means-table.png

Lessons Learned From Different Basal Insulin Schedules and Dosing

I have been experimenting with numerous different basal insulin (Lantus) schedules and doses (one to three doses per day, given at four different times of the day, with a wide range of doses at each time: that is a lot of different combinations). Because basal insulin is by design, long-acting, the main lesson I have learned after all these experiments is that the amount of basal insulin released from the injection site can not be varied enough to adjust for changes in insulin sensitivity due to exercise. I think if I did not exercise at all, my BG would be much better regulated (although my total daily insulin dose would be significantly higher). This is why I have returned to once daily Lantus dosing. I am choosing bedtime to administer it because my basal insulin requirements appear to be the most while sleeping. During the day, there are two 5 hour periods that are covered by Humalog from meals, and there is one 6-hour period influenced by exercise (lower basal insulin requirement). In other words, this 16-hour period does not require as much basal insulin as the overnight sleeping period. I should also mention that I think the marked increases in BG during olympic weightlifting (OWL) that occurred in the past are currently being compensated for by doing a 2-mile walk before and another 2-mile walk after the OWL. For March 2019, I will find a dose of Lantus at bedtime that results in a fasting BG between 71-120 mg/dl say 80% of the time. I no longer feel that perfection is a realistic goal, at least for me. So I will be OK with occasional mild lows (60s mg/dl) and highs (<200 mg/dl). Any fasting BG < 60 mg/dl has and will prompt a Lantus dose reduction. As stated above, I anticipate whatever bedtime Lantus dose I come up with will cause hypoglycemia 25-33% of the days during or after exercise if my post-breakfast i.e. pre-exercise BG is 95 mg/dl (which has generally been what I aim for). This month, my approach will be to reduce the breakfast Humalog dose (by setting the post-target BG higher) to try to compensate for the exercise-related improved insulin sensitivity and thus avoid the exercise-related hypoglycemia.

I should mention there are many different ways to approach this problem of changing insulin sensitivity with exercise. I have heard Dr. Richard Bernstein say that he lifts weights one or two days a week. He takes multiple doses of liquid glucose during his workout to compensate for the improved insulin sensitivity rather than making any adjustments in basal insulin. This is certainly a valid approach, but I was hoping to find a method that did not require much or any glucose supplementation (my personal preference) particularly since I am exercising daily rather than 1-2 days/week. After all, I am trying to remain in nutritional ketosis.

More on Blood Glucose Standard Deviation

In doing simulations with random numbers between 71 and 120, the mean is about 95 with a standard deviation of about 15. And, of course, any numbers lower than 71 or higher than 120 will result in even higher standard deviations. Therefore, my goal of achieving a standard deviation of 12 mg/dl is quite unlikely. Oh well.

My Goals For 2019

I will continue to strive for normal BG values and my goals are to:

  1. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl. 
  2. Aim for a mean BG value of 96 mg/dl with a standard deviation as close to 12 mg/dl as possible.
  3. Aim for % of BG meter reading in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but having a challenging target is motivating to me and I am not discouraged by the fact that I have not yet achieved all of them.

How Will I Achieve These Goals

  1. This month, I will will go back to once daily Lantus at bedtime, but use my spreadsheet to calculate the breakfast Humalog dose using a higher post-breakfast BG target to thus avoid exercise-related hypoglycemia.
  2. I will continue using the 5-fold diluted Humalog to more precisely adjust my meal-time insulin dose.
  3. I will continue refining my mathematical method to predict my insulin doses based on prior BG responses. I think this will be a useful tool for me. I think it could be expanded to include a multiple linear regression model that uses meal protein, carbohydrate, and fat grams as independent variables along with changes in BG to predict insulin doses. That said, I think keeping meal macronutrients constant is a better approach so I will continue that for now.

I hope these measures will result in additional improvements next month.

#62 January 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes. See the Coaching page for more info.

I have made several changes over the past six months in my attempt to further improve the glycemic control of my T1DM. These are the changes I have made:

  1. Two meals per day.
  2. More than one basal insulin dose per day.
  3. Achieved a leaner body composition which in turn dramatically reduced my insulin requirement per kg of body weight which reflects an improved insulin sensitivity.
  4. Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. By standardize, I mean the same exercises with the same duration and only minor occasional increases in intensity over time.
  5. Emphasized avoiding hypoglycemia as a more important goal compared to achieving any particular mean BG level. Hypoglycemia (BG < 71 mg/dl) is both unpleasant to experience and is life-threatening, whereas, mild transient hyperglycemia (BG > 120 mg/dl) is very unlikely to cause any problems.
  6. Using cronometer.com to design different meal plans that I enjoy and can eat over and over again, each composed of the same amounts of macronutrients (protein, fat, and carbs) and each containing > 100% of the RDA for all vitamins and minerals. Since I do feel I get the best results from a low carb ketogenic diet and I feel a higher protein intake will best preserve my muscle mass as I age (currently 58 years old), I chose to design each meal so that I get a daily total intake of 2.2 grams protein/kg BW/day and 57 grams of carbohydrate. If I could meet the > 100% RDA goal with fewer total grams of carbs I would do that, but non-starchy green vegetables do contain a fair number of carbs. Also, the fact that included in that 57 grams of carbs is 22 grams of fiber/day which reduces the BG impact of those carbs. Another way of saying that is I eat 35 grams of net carbs/day.
  7. Weighing my food on a kitchen scale helps to precisely follow my own meal plan.
  8. The combination of 6. and 7. above also makes achieving a lean body composition a lot easier.
  9. Taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with dinner really reduces my meal-time insulin requirements.
  10. In December 2018, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution to use as my meal-time insulin. This way I can accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.

I have greatly simplified my data presentation down to the bare essentials. At this point in time, I think the four most important metrics are: mean BG, standard deviation (SD) of BG, % of BG meter reading in the normal range (71 – 120 mg/dl), and % of BG meter reading < 71 mg/dl (a rough measure of the frequency of hypoglycemia). 

Glycemic Management Results for January 2019

First, note I made an error in reporting my SD results last month. I stated it was 18 mg/dl and I was pleased since it was the lowest I had ever achieved. Unfortunately, I had unknowingly introduced an error in my spreadsheet program which I use to calculate the SD. My actual SD for December 2018 was 28 mg/dl which was unchanged from previous months.

My January 2019 insulin doses and BG results were about the same as last month.

The graphs below shows the total daily insulin doses of Humalog and Lantus and the total of both insulin doses and my actual BG readings.

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage) as well as my current body weight and mean insulin dose totals. My height is 5’8″.

The table below shows the % of BG meter reading in three BG ranges. 

My Goals For 2019

I will continue to strive for normal BG values and my goals are to:

  1. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl. 
  2. Aim for a mean BG value of 96 mg/dl with a standard deviation of 12 mg/dl.
  3. Aim for % of BG meter reading in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but having a challenging target is motivating to me.

How Will I Achieve These Goals

  1. I will continue Lantus dosing twice daily and make small infrequent changes in dose based on my BG responses.
  2. I will continue using the 5-fold diluted Humalog to more precisely adjust my meal-time insulin dose.
  3. I am working on a mathematical method to predict my insulin doses based on prior responses. Haven’t found the right formula yet, but my experimentation continues.

I hope these measures will result in additional improvements next month.