#31 October 2016 Update on My T1D Management

In October 2016 as usual, I had more low and high blood glucose (BG) values than I would have liked. However compared to last month, my results in October were improved.

Below are my BG values using the new target ranges mentioned last month. The mean BG was 87 mg/dl at a lower mean insulin dose of 27.5 IU/day compared to 31.5 IU/day last month. Both the mean basal insulin dose and mean mealtime insulin dose decreased from 24.5 IU/day to 22.8 IU/day and from 7.0 IU/day to 4.6 IU/day, respectively. The percentage of BG values < 61 mg/dl decreased from 25% to 21% whereas the percentage falling in my goal range of 61-110 mg/dl increased from 52% to 61%, and the percentage of BG values > 110 mg/dl decreased from 22% to 18% compared to last month.


As presented in blog post #15 exogenous insulin cannot mimic normal insulin secretion, so persons with type 1 diabetes (T1DM) should not expect to have truly normal BG values. They just need to be low enough to prevent long-term complications and not so low as to cause unpleasant hypoglycemic symptoms, brain damage, seizure, injury, coma, or death. I have set my goal BG range at 61-110 mg/dl because values in this range are not likely to lead to harm or complications of T1DM. As mentioned last month, normal mean BG is in the range 90-95 ± 7-12 mg/dl (mean ± standard deviation (SD)) and coefficient of variation is 8-13% as a frame of reference. The standard deviation and coefficient of variation are measures of BG variability which are important in T1DM. Achieving a normal coefficient of variation in T1DM would be difficult, if not impossible, with current exogenous insulin therapy. Monitoring the coefficient of variation and finding ways to improve it to the best of one’s ability is desirable. Following a low carbohydrate ketogenic diet is one such method of reducing BG variability, mean BG, and insulin doses. The ketogenic diet may also provide additional brain fuel in the form of ketones to protect the brain when BG does go low. The alternative energy that ketones supply to the brain may prevent or blunt the sympathoadrenal response to hypoglycemia which in turn reduces or eliminates the symptoms of and harm from hypoglycemia. This hypothesis needs to be tested before it can be stated as fact. And as mentioned last month, having BG close to normal most of the time and dipping into the 50s and 60s sometimes also minimizes symptoms of mild hypoglycemia (hypoglycemia unawareness) and potentially the harm from hypoglycemia as well due to lack of activation of the sympathetic nervous system and adrenal gland responses to hypoglycemia i.e. sympathoadrenal-induced fatal cardiac arrhythmia, see here. Although asymptomatic hypoglycemia is not a goal of therapy, it is an expected consequence of near-normal glycemia in those with T1DM on exogenous insulin therapy. My goal is to reduce the frequency of these asymptomatic hypoglycemic episodes from 21% currently to <10%.

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 = 31, coefficient of variation = 36%, mean daily BG range = 57, mean daily time of hypoglycemia = 3.0 hr/day, interquartile BG range = 40. The measures of BG variability were defined and explained in blog post #10.


The graph below shows that the various measures of BG variation in the table above correlate well with the coefficient of variation. Because the coefficient of variation is easy to calculate (standard deviation ÷ mean X 100 expressed as percent) and compare to normal values, it is the best measure of BG variability for persons with diabetes in my opinion.


The actual daily insulin doses and daily insulin dose totals are shown in the graphs below.


In November I will continue weightlifting and aerobic exercise, but hope to increase the frequency of weightlifting as I feel I can now tolerate it more than every other day. The aerobic exercise consists of swimming or cycling at low intensity for ≈0.5-2 hours. I am using a heart rate monitor during cycling with the goal of not exceeding a heart rate of 130 bpm. This is derived from Phil Maffetone’s formula: 180 – age, see here. The purpose is to exercise aerobically so as to burn mainly fat and to minimize utilizing glucose for muscle energy which can result in hypoglycemia in those with T1DM. I will see if this reduces the number of low BG readings after cycling and/or the need for glucose supplementation prior to cycling (typically 6-12 grams of glucose).

My Thoughts on T1DM Management

The goal of glycemic management in type 1 diabetes with a ketogenic diet is to keep BG as close to normal (≈ 90-95 mg/dl) as is safely possible (i.e. avoiding hypoglycemia). More specifically the purpose is to avoid diabetic complications, a reduction in lifespan, and unpleasant symptoms, injury and death from hypoglycemia. For me, a well-formulated whole-food nutrient-dense ketogenic diet (see blog post #9 for more details), daily exercise, frequent blood glucose measurements, and lower insulin-analog doses (Humalog/Lantus) have improved my glycemic control, hypoglycemic reactions, and quality of life. 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 challenging, but I 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.

I have written two ebooks with Ellen Davis, MS of ketogenic-diet-resource.com that explain how to use a real-food low carbohydrate ketogenic diet to manage type 1 and type 2 diabetes. They also explain how insulin, oral, and other injectable diabetes medications need to be adjusted or discontinued at your physician’s direction after changing to the ketogenic diet. In addition, they explain how the ketogenic diet can be used to support exercise while improving body composition by decreasing fat mass and increasing muscle mass. Recipes, food tables with carb, protein, and fat quantities, and tips for avoiding side-effects are provided to help formulate and sustain a ketogenic diet long-term. Links to relevant scientific literature are included as well.




Till next time ….


  1. heri

    Quite interesting. Do you time your workouts with blood glucose? for e.g. go for a long run when BG is low (or high)

    Or you are following a predetermined training plan


    • Keith Runyan, MD

      Yes Heri, I wait at least 2.5 hours after taking Humalog with breakfast to start exercise. If BG is low I take glucose to correct it first. If BG is high, I take Humalog to correct it first. Thus, I have to wait another 2.5 hours. Depending on how my BG has changed during exercise recently, I will or will not take glucose before or during exercise. Currently, I take 6-12 grams glucose before exercise. But a few months ago, I took none and BG was going up during exercise. My basal insulin dose was 2 units less at that time, but could have been due to other factors. The BG response to exercise changes frequently. Anticipating the response is difficult. I do the best I can. Yes, I follow a predetermined training plan for each type of exercise. That at least gives some constancy on which I might have a chance of anticipating the BG response. It would not necessarily be incorrect to start exercise with a mildly high BG if the prior responses had been a reduction in BG. However, I prefer to start with a near-normal BG since I have flexibility in my schedule.

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      • heri

        Thanks. Insightful. A small point, do you have alerts on certain thresholds on your phone or BGmonitor during exercise or you just remind yourself to check it every X minutes?

        Wishing all the bests for the training and BG “maintenance”


      • Keith Runyan, MD

        I mainly go by how I feel. If I don’t feel right, I take 4 grams of glucose. If 4 or 8 grams of glucose doesn’t correct any abnormal feelings, then I check BG with the meter. I no longer do prolonged exercise. Back when I did long distance triathlons, I checked BG every 2-3 hours as long as I felt well, or sooner if not feeling well after taking glucose tablets. Again, not feeling well almost always means low BG, so I take glucose tabs if I don’t feel well.

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