#16: January 2016 Update on My T1D Management

In the month of January, 2016, I am fortunate to remain in good health with type 1 diabetes (T1D). I have continued my daily exercise and in fact on Jan. 2nd I intensified my weightlifting schedule which resulted in some unwanted changes in blood glucose (BG). A recurring pattern I have noticed since starting regular exercise in 2007 is that a new exercise usually results in hypoglycemia at first and then over the next few weeks as I adapt to it, the BG normalizes. Once adapted, intensification of the same exercise either has no effect or results in hyperglycemia presumably from release of stress hormones epinephrine, glucagon, growth hormone, and cortisol. These stress hormones are released in non-diabetics as well to help mobilize both glucose from the liver via glycogenolysis and gluconeogenesis and fatty acids from adipose tissue (fat cells) to provide energy to exercising muscles. However in the person with T1D, there are no beta-cells to produce insulin to counteract the increase in BG. This can result in significant increases in BG after exercise in persons with T1D. So in the month of January, my average fasting BG was 97 mg/dl, my average post-breakfast BG was 93 mg/dl, my average pre-dinner (after exercise) BG was 138 mg/dl, and post-dinner BG was 82 mg/dl. This post-exercise BG increase has been going on since Jan. 2nd (unusually long) and I hope that I adapt soon because I really don’t want to take rapid-acting insulin at the start of exercise to prevent the increase in BG. As you might guess, I do not get a text message telling me when stress hormones will be released or not on any given day. I worry that if I start taking insulin to prevent the increase in BG that eventually I will end up with hypoglycemia during exercise (definitely want to avoid that). So for now I’ve decided to stay the course. In Jan. 2016, I made no changes to my ketogenic low carbohydrate high fat (KLCHF) diet. Shown below is a summary table with my results for Jan. 2016 in the last row.

Post 16 glucose insulin Table Jan 2016

My mean (average) BG (103 mg/dl) increased due to the previously mentioned increase in BG after exercise. My insulin doses have not changed significantly (total = 31.4 IU/day, basal = 22.2 IU/day, mealtime = 9.2 IU/day), but the percentage of hypoglycemic values (8%) did decrease and none of these episodes were symptomatic. I attribute this to brain utilization of ketones from nutritional ketosis due to my ketogenic diet rather than to hypoglycemia unawareness, although as pointed out in blog post #12, I will never be able to prove my case. The table below shows my BG variability data for Jan. 2016 in the last row.

Post 16 glucose variability Jan 2016

Most of the measures of BG variability were worse compared to the year 2015, but two were improved (interquartile range and Quintile 1). The meaning of these BG variability measures were defined in blog posts #5 and #10. The increased BG variability was due to the previously mentioned increase in BG with exercise and then the drop in BG after dinner due to mealtime insulin. The actual BG values and insulin doses are shown below.

Post 16 glucose insulin graphs Jan 2016

Note that on Jan. 26th I did increase my basal insulin dose from 22 to 23 IU/day, but so far it hasn’t had much effect. If you are curious to see the exercise that I think is causing my BG to shoot up, I posted a video of my snatch and clean and jerk on YouTube. I have to say that even though I think my weightlifting is currently adversely affecting my BG results, I am really enjoying this challenging activity and how I feel physically as a result. My current exercise schedule is two weightlifting sessions per day for 2 days, followed by an easy day of swimming or cycling for about 30 mins, then repeat. If I lift weights for a third day in a row, my knees will be too sore. If I don’t do the aerobic exercise (i.e. if I take a rest day), my insulin sensitivity will change enough to result in hyperglycemia by the evening of the rest day. Basically, any significant change in my diet or exercise routine has an adverse effect on my BG results. That’s diabetes! But keeping my KLCHF diet the same is definitely easier. In fact, I do want to change my weightlifting, i.e. I want to improve my results.

That’s all for now….

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7 comments

  1. BantiosThanassis

    Type 1 here, also on a ketogenic diet with probably < 5g carbs/day, and also a martial artist/strength athlete. I think this is a great blog with lots of useful information! Dr. Runyan what you write about insulin sensitivity changing for up to 36 days after exercise is probably one of my missing pieces to normal blood sugars. I have been following Dr. Bernstein's method for almost 2 years now, but I am unable to achieve normal blood sugars, and one of the reasons is that my insulin sensitivity is changing very rapidly. I exercise 5-6 times a week but each session is different in type, intensity (eg. wrestling, boxing, kettlebells strength session), and the effects on insulin sensitivity the days after each session may vary, according to your post. Do you think that the changes also have to do with the type/intensity of exercise, or the simple fact that you exercise on a single day will be sufficient to keep your insulin sensitivity constant? I saw the way you partition your workouts (2 strength days with 2 workouts each, followed by a light endurance day) and I will try this also, to see if it helps. It would be very helpful if you could share your workout details, again thank you for this wonderful source of information that you provide us!

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    • Keith Runyan, MD

      Thanks for your interest Bantios. I’m guessing that “Dr. Runyan what you write about insulin sensitivity changing for up to 36 days after exercise” is a typo. Maybe you meant “hours” instead of “days,” but I don’t recall writing that either. We can agree that exercise affects insulin sensitivity. From my own experience the type, duration, and intensity of exercise affects insulin sensitivity differently and I would venture to guess that it would vary from one person to the next.
      If you look at all my blog posts you will see that I really tried to achieve normal blood glucose soon after starting Dr. Bernstein’s plan on Feb. 8, 2012. I was training for and completed an ironman distance triathlon in 2012 which means my exercise was varying quite a bit from day to day. Since my diet varies little from day to day, I concluded that variation in my insulin sensitivity related to exercise must be one reason that I could not achieve normal blood glucose. When my mean blood glucose reached 85 mg/dl in 2014, I felt that was at the expense of increased episodes of hypoglycemia. And even though only 3 were associated with symptoms, I still feel that hypoglycemia is more dangerous than my frequency and extent of hyperglycemia. Dr. Bernstein has never published his blood glucose results so it is difficult to know how much variation he has, how much hypoglycemia he has, and it is clear that athletic performance is not one of his goals.
      I am happy to share my exercise routine but know that it is not necessarily something that you should try to emulate. Marital arts is an excellent exercise and you will need to sort out how that affects your blood glucose and insulin doses. I have no experience with marital arts.
      Currently, on day 1 of olympic weightlifting I do snatches for 1.5 hours in the morning with 2-3 minutes rest between the heavier lifts. In the afternoon, I do front squats, snatch pulls, and clean pulls for 1.5 hours with rests between sets. These last 3 exercises use heavy weights which currently is raising my blood glucose. On day 2, I do clean & jerk in the morning for 1.5 hours and in the afternoon, overhead snatch and clean squats, and jerks from the rack for 1.5 hours. Because my blood glucose has continued to remain elevated after these sessions, I have started taking insulin between the morning and afternoon sessions with some hamburger for extra protein (I would like to gain some more muscle). On day 3, I do cycling or swimming but this month increased the time to 45-50 mins because it was clear that this exercise was not as insulin sensitizing as the weightlifting.
      Bottomline, having normal blood glucose at all times with type 1 diabetes (T1D) is virtually impossible especially for those who feel that athletic goals are an important part of their life. But I also do not feel that it is necessary to have normal blood glucose all the time to have an enjoyable life free of diabetic complications. I will report if I do develop any complications in the future, but so far none after 18 years of T1D.
      To specifically answer your question, I do think that insulin sensitivity changes based on the type, duration, and intensity of exercise, but also that release of stress hormones (cortisol, glucagon, growth hormone, and epinephrine) varies as well and these hormones increase blood glucose. The reason I do aerobic exercise is not because it is the best way to balance insulin sensitivity, but because my body can’t do weightlifting every day without a break. Bantios, you will need to figure out how to balance your exercise and insulin doses to achieve the best blood glucose profile you can. I just think that the blood glucose profile will not be perfect and that we should not expect it to be perfect. In my opinion, the exercise has definite benefits even if they are difficult to measure.
      Hope that helps.

      Liked by 1 person

      • Thanassis Bantios

        Thank you for all the information, it is very helpful. I am too on Dr. Bernstein’s regimen, having read and appreciated his book almost two years ago. The only addition I made to Dr. Bernstein’s regimen is that I eat more on the ketogenic side, according to guidelines in books like “The art and science of low carb Performance” by Drs. Phinney and Volek. My macros are 5g carbs, 140 g protein and almost 300 fat /day. I eat two times/day, lunch and dinner (which are every day the same), with a bulletproof coffee before training which is in the evening, so I also practice Intermittent fasting (lunch is at 13:00, dinner at 22:00).
        Like you, I have arrived to the conclusion that exercise severely affects my insulin sensitivity. Strength exercise (like kettlebells or wrestling) almost always shoots my blood sugar up, sometimes as much as 100 mg/dl. (so if I start at 83 mg/dl, after only 15 minutes of hard sparring I may be at 180 mg/dl). It surely affects my immediate insulin sensitivity (eg. I need less insulin to cover a meal I eat exactly after my training session, probably due to the fact that I am more insulin sensitive at that time). The thing I did not know and discovered through your posts is that it also affects my insulin sensitivity for some hours after that, lets say 24 hours for convenience.Which complicates things a lot, because I am part of a training gym and every day is not the same. Some days are hard and some days are light, but there is no way to predict that, and also there is no way to force the other team members to work on a certain level of intensity so that I can have the benefits of constant insulin sensitivity :-).
        I am starting to suspect that the only way to get through that problem is work out alone. That way, you can standardise your training so that every workout is kind of the same, which will probably keep your insulin sensitivity level. Its is creating consistency in training, like we create consistency in food. But that is a major life decision, especially for someone like me who is a part of a team and a certain sport for over 15 years now. Another thing that troubles me is the long terms effects of a ketogenic diet and resistance training (this has no relation to type 1 diabetes). Do you think that glycogen depletion is an issue, when you train heavily on a keto diet? like what is described in this blog post.
        http://mostlymeatiswhatieat.blogspot.gr/2012/12/evolutionary-trade-offs-fast-versus.html

        Anyway, again thank you for the information. I have learned a ton of information from people posting their experiences and also the way they train and eat, as much as I have learned from studying books.

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      • Keith Runyan, MD

        Thanks for sharing your experience with increased blood glucose with intense exercise. If I am understanding your regimen correctly, you exercise in the evening and very soon after you take rapid-acting insulin with dinner. That means your blood glucose is elevated for a relatively short period of time (2-3 hrs at most). Although it is impossible to prove, I suspect that the benefits of your exercise outweigh the transient increase in blood glucose. It doesn’t seem like your sport is conducive to exclusively training alone and the social interaction with your training partners or competitors is one of the benefits of your exercise.
        Regarding glycogen, if you are feeling good during your exercise then I doubt there is a problem. Phinney’s study of cyclists showing a reduction in muscle glycogen was not replicated by Volek in his FASTER study. I think the difference was that the low carb athletes in the FASTER study had been on their low carb diets for many months prior to the start of the study where as the cyclists were on the ketogenic diet for only 5 weeks. Our bodies are remarkable in adapting to different conditions if given enough time. I don’t agree with several points made in the blog post you referenced. Rather than review each one, suffice it to say, if it’s not broken, don’t try to fix it.

        Liked by 1 person

      • Thanassis Bantios

        Ok thank you for all the advice. I feel very good during training, I was asking because I have read various posts on the internet about liver glycogen depletion on a keto diet+anaerobic exercise and I have not found any solid answer. The reason I am concerned is that, as far as I know, liver glycogen is what will save you in a case of a sever hypo. this is why I would rather not see it depleted. I understand what you write about the many benefits of training, and have no purpose in stopping anywhere soon 🙂

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      • Keith Runyan, MD

        I hope the FASTER study by Jeff Volek, RD, PhD will give you some reassurance about muscle glycogen not being depleted in athletes following a low carbohydrate diet (not necessarily ketogenic). However, a liver biopsy would be needed to measure liver glycogen, not likely that will be done in a study. Possibly another non-invasive technique will be developed to measure liver glycogen content.
        Please read my blog post #12 where I explain why having plenty of liver glycogen does not necessarily mean that a T1D has access to it during insulin-induced hypoglycemia. It’s called defective glucose counter-regulation. A KLCHF diet as explained in that post can help ameliorate insulin-induced hypoglycemia by several mechanisms. So I think a KLCHF diet does not make one more susceptible to hypoglycemia, but in fact makes it less of a problem.

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