I am pleased to announce the 2nd Annual Conference on Nutritional Ketosis and Metabolic Therapeutics to be held in Tampa, Florida, February 1-4, 2017. I would like to thank the organizers, Angela Poff, PhD and Dominic D’Agostino, PhD, for inviting me to speak on the “Management of Type 1 Diabetes with a Ketogenic Diet.” I think anyone interested in ketogenic diets would enjoy this conference. You can see some of the talks from the inaugural event at the Epigenix Foundation YouTube channel. You can register for the event here.
In August 2016, I achieved a personal best in glycemic control. Although glucose management in diabetes is subject to many factors that are difficult to quantify, I attribute this month’s results to my most recent exercise schedule. Starting the second week of August, I changed to an alternating schedule of weightlifting with swimming or cycling. This facilitated recovery from each activity and the daily exercise hopefully stabilized my insulin sensitivity and improved glycemic control. I hope this continues and results in some improvement in the weights I am able to lift. Currently, I’m at 135 lb. snatch and 175 lb. clean and jerk which is just short of my personal bests of 140 lb. and 185 lb., respectively. There has been no significant change in my low carb healthy fat ketogenic lifestyle.
The summary table of current and previous mean blood glucose (BG) and insulin doses is shown below. Compared to July 2016, my mean BG decreased from 101 to 95 mg/dl in part as a result of an increase in mean total daily insulin dose from 28.1 to 30.4 IU/day due to an increase in basal insulin (from a mean of 21.2 to 21.8 IU/day Lantus) and an increase in rapid-acting insulin (from a mean of 6.9 to 8.5 IU/day Humalog). I had 3 of 130 (2%) BG readings < 51 mg/dl, but all were without symptoms due to either nutritional ketosis or hypoglycemia unawareness (see blog post #12 for more details). I had 102 of 130 (79%) BG readings between 51 and 120 mg/dl, 24 of 130 (18%) between 121 and 200 mg/dl, and 1 of 130 (1%) > 200 mg/dl.
Below are my BG readings along with exercise type and time so you can see how the type and duration of exercise affected my glycemic control.
The table below shows the summary of current and previous BG variability results. Most of the results were improved compared to previous months and years with improvement in the following variability measures: standard deviation = 32, coefficient of variation = 34%, mean daily BG range = 66, mean time of hyperglycemia = 3.7 hr/day, mean time of hypoglycemia = 0.1 hr/day, interquartile BG range = 47. The measures of BG variability were defined and explained in blog post #10.
The actual daily insulin doses and daily insulin dose totals are shown in the graphs below.
The Ketonix breath ketone (acetone) monitor results beginning June 2015 are shown below (see blog post #19 for more details). I have been in continuous nutritional ketosis due to my low carbohydrate ketogenic diet. There is a noticeable gradual decline in the readings. I would guess this is related to a gradual increase in carbohydrate intake from nuts and seeds.
The graphs below show the change in BG that results from mealtime rapid-acting insulin. On the x-axis is the Breakfast and Dinner mealtime insulin dose (Humalog) plotted against the change in BG, i.e. Post meal BG minus Pre meal BG on the y-axis. Thus positive values represent an increase in BG and negative values represent a decrease in BG after the meal. Also, note that I removed 3 of 31 Breakfast points and 3 of 31 Dinner points from the graphs where the Post meal BG was not in the range of 51-120 mg/dl. The rationale for this is to eliminate graphing mealtime doses that were “incorrect” so to speak. This way the graph shows both that larger doses of insulin reduce BG more (obvious), but more importantly even when the resulting Post BG was in an acceptable range, that there is a wide variation in the amount of BG reduction for any given dose of insulin. This variation can be due to varying absorption of injected insulin, variation in insulin sensitivity from exercise, or variation in food consumed during the meal from one day to the next. Reducing this variation is an important goal of mine.
I required quite a few doses of rapid-acting insulin (Humalog) to correct hyperglycemia this month. The resulting change in BG is shown in the graph below. Negative values represent a decrease in BG. Note that I removed 2 of 15 correction doses from the graphs where the Post meal BG was not in the range of 51-120 mg/dl. The rationale for this is to eliminate graphing correction doses that were “incorrect” so to speak. Again, the main feature is variability and unpredictability of the BG response to insulin injections. In contrast to the mealtime insulin doses, this may be an over interpretation. To make this statement, I would have to recheck the BG about 3 hr. after the correction dose. This occurred the minority of the time. Instead in most instances, I wait until my next “usual” time to check the BG. Thus, other factors can affect the subsequent BG result other than the correction dose of Humalog.
The graph below shows the change in BG due to weightlifting. On the y-axis, positive values represent an increase in BG due to weightlifting. There were thirteen positive values representing an increase in BG due to weightlifting, but the degree of increase declined through the month (red linear regression line). The main feature is that intense resistance exercise stimulates catabolic hormones (epinephrine, cortisol, glucagon) to release nutrients into the blood stream and to stimulate muscle contractions. In a person with T1DM who cannot make insulin to correct the rise in BG, this results in hyperglycemia as shown in the graph.
Since I did more swimming this month I decided to graph the change in BG due to swimming. On the y-axis, positive values represent an increase in BG whereas negative values represent a decrease in BG due to swimming. There were four negative values representing a decrease and five positive values representing an increase in BG due to swimming. As I have mentioned before, changes in BG with exercise are not very predictable, i.e. sometimes up, sometimes down. It really keeps you on your toes so to speak. The red linear regression line indicates a general increase in BG with swimming during the month, but the changes in BG were rather modest.
In September, I will continue weightlifting and aerobic exercise on alternate days. Thus I will continue weightlifting to 3.5 days/week and aerobic exercise to 3.5 days/week. The olympic weightlifting consists of only 4 exercises (snatch, clean and jerk, snatch overhead squat, front squat) which takes about 2 hours to complete including warmup, cool down, and stretching to maintain mobility. The aerobic exercise consists of swimming or cycling at low intensity for 0.5 – 2 hours. The goal is to exercise consistently to maintain insulin sensitivity while avoiding injury and overtraining.
The goal of glycemic management in type 1 diabetes is to keep BG as close to normal (83 mg/dl) as is safely possible (i.e. avoiding hypoglycemia) to avoid both diabetic complications and a reduction in lifespan. For me, a nutrient-dense whole food low carbohydrate ketogenic diet (see blog post #9 for more details) combined with insulin analogs (Humalog/Lantus) have been the best tools so far in accomplishing this goal. I also feel, but cannot prove, that this eating plan and the resulting nutritional ketosis reduces the symptoms of hypoglycemia and protects the brain from the consequences of mild degrees of hypoglycemia (see blog post #12 for more details). Exercise with its resulting varying insulin sensitivity and hormonal changes actually makes glycemic management more difficult, but I both enjoy it and feel exercise has other health and lifespan extending benefits. Hopefully, my BG values and insulin doses are close enough to normal to avoid both a reduction in lifespan and diabetic complications. Only time will tell.
Till next time ….