#33 December 2016 Update on My T1D Management

Happy New Year to all!

Before I get started, just a reminder about the upcoming Metabolic Therapeutics Conference, February 1-4 in Tampa, Florida. I’ll be speaking about The Management of Type 1 Diabetes with a Ketogenic Diet. This is the second annual conference featuring researchers and clinicians with expertise in ketogenic diet therapies, including Dr. Dominic D’Agostino, Dr. Colin Champ, Dr. Thomas Seyfried and many others. Click here to learn more and sign up.

Glycemic Management Results for December 2016

Below are my mean blood glucose (BG) values, insulin doses, and BG frequency distribution for current and previous time periods. I was aiming for less hypoglycemia which I accomplished, 15% vs 19% of BG values were < 61 mg/dl, but I would really prefer this to be less than 10%. For unknown reasons, I experienced a rather sudden increase in BG (32% of BG values were elevated to between 111 and 200 mg/dl) requiring additional insulin beginning on Nov. 21 that came under control by the end of December. And, no, I did not partake in any “holiday” food treats. For me, having the best BG control I can is worth any “sacrifice,” although I don’t view not eating treats as a sacrifice. Note: I immediately address elevated BG with extra doses of rapid-acting (Humalog) insulin and increase my basal insulin (Lantus) if the morning fasting BG is elevated, both of which I had to do this month.

post-33-means-table

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 target BG range at 61-110 mg/dl because values in this range are not likely to lead to harm or complications of T1DM. Your target BG range should be determined with your physician because one size does not fit all. 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 I believe are important in T1DM. Achieving a normal standard deviation or coefficient of variation in T1DM would be difficult, if not impossible, with current exogenous insulin therapy. I hope that adding a continuous glucose monitor (CGM) to my therapeutic regimen will improve my BG control. Monitoring the standard deviation and/or coefficient of variation and finding ways to improve them 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, insulin doses, and hypoglycemia. The ketogenic diet may also provide an alternate/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 I mentioned last month, having BG close to normal most of the time also minimizes symptoms of mild hypoglycemia 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.

Below are my BG readings along with exercise type and time. I had to take a few days off from weightlifting due to right lateral knee pain (probably due to ileotibial band syndrome which I have had several times before) which resolved spontaneously with rest. This may have contributed to hyperglycemia and the need to increase insulin doses, but probably does not explain it in entirety.

post-33-exercise-and-blood-glucose

The table below shows the BG variability results for current and previous time periods. In November, I converted time spent (hours) with BG < 61 mg/dl and time spent (hours) with BG > 110 mg/dl to % time by simply dividing each by 24 (hours in a day). I added a column for % time in target range (BG 61-100 mg/dl). I also added additional columns showing the 10th, 25th, 75th, and 90th percentiles of my BG readings and the Interquartile Range which is the difference between the 75th and 25th percentiles. The BG median shown in the previous table is identical to the 50th percentile. Thus, these percentiles show the spread of the BG readings about the median and are measures of BG variability. The other measures of BG variability were defined and explained in blog post #10. Compared to last month, most of the results were improved. I was particularly satisfied with % time with hypoglycemia of 7% (which is an all-time low) coupled with a normal mean BG of 97 mg/dl and % time in target of 65% (which is an all-time high). Overall, satisfactory.

post-33-variability-table

The actual daily insulin doses and daily insulin dose totals are shown in the graphs below. Similar to what occurred in November, I had to increase my total daily insulin dose from 32 IU/day to 49.5 IU/day over a 16 day period, an increase of 17.5 IU (a 55% increase) due to hyperglycemia for reasons that are unclear to me. Subsequently, I had to decrease the total daily insulin dose back down due to hypoglycemia to 32.5 IU/day over the next 11 days. I have been contacted by several individuals with T1DM who experienced a similar increase in insulin dose at different points in time after starting a ketogenic diet and thought this represented an insulin resistant state caused by the ketogenic diet. I told them that I do not think this is the case and that these increases (and decreases) just represent the usual variability that type 1’s experience. After all, a ketogenic diet is used to treat and reverse insulin resistance. I am aware of “physiologic insulin resistance” in non-diabetics used to describe slightly elevated fasting BG and an attenuated insulin response to a glucose tolerance test in those on a very low carbohydrate ketogenic diet. However, I do not think this would apply to those with T1DM on a ketogenic diet.

post-33-insulin-doses

My Ketonix breath acetone results since June 1, 2015 are shown below. There has been a gradual reduction in breath ketones. I suspect, but cannot prove, that this is related to an increased carbohydrate content of my meals. I have gradually increased the amount of berries, nuts, and seeds that I eat to help increase diet variety and add nutrients while at the same time decreasing added fats including coconut oil, olive oil, and butter. I occasionally supplement with MCT oil to help increase ketones and keep total calories about the same: 2,150 kcal/day due to the reduction in coconut oil, olive oil, and butter. I estimate I am now eating about 70 grams of carbohydrate per day of which 30 grams is fiber i.e. 40 grams of net carbs per day, 110 grams protein/day, and 170 grams of fat/day which is referred to as a 1:1 ketogenic diet. This is terminology used by neurologists who treat adults and children with epilepsy with ketogenic diets. They often use 4:1 or 3:1 ketogenic diets for epilepsy. The ratio indicates grams of fat to grams of carbohydrate plus protein. For me, for example, 170 grams fat ÷ (70 grams carbohydrate + 110 grams protein) ≈ 1:1. As you can image, a 4:1 diet would be more difficult (but not impossible) to follow long-term as it more severely restricts the quantity of foods that contain carbohydrates and protein.

post-33-ketonix-graph

In December, I achieved a new personal record (PR) in weightlifting in the snatch: increasing it from 150 to 155 lb. My clean & jerk PR is still stuck at 185 lb. since the end of March 2016. Fortunately, I don’t need to make a living from weightlifting, so any PRs are just plain fun.

In January, I will continue exercise daily (weightlifting and aerobic) with about 4 days/week of weightlifting. The aerobic exercise consists of swimming, rowing, or cycling at low intensity for ≈ 0.5 – 2 hours. I am using a heart rate (HR) monitor during cycling and rowing with the goal of not exceeding a HR of 124 bpm. This is derived from Phil Maffetone’s formula: 180 – age. 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. It also gives me a day to recover from weightlifting. I will see if this reduces BG reductions during cycling and the need for glucose supplementation during exercise (so far, so good).

Summary of Results Since Beginning The Ketogenic Diet

In the graph below, I have included all BG results since starting the ketogenic diet on Feb. 8, 2012 (indicated by the blue arrow) as well as some results prior to that for comparison with the one week moving average in black and my BG target range (BG 61-110 mg/dl) indicated in red. When I see the great variation in BG graphically, it is a wonder that I feel and function as well as I do. Again, I hope that the FreeStyle Libre CGM when it becomes available in the United States, will result in additional improvement in my BG control.

post-33-all-blood-glucose-values

In the graph below, I have included all insulin doses since starting the ketogenic diet on Feb. 8, 2012 (indicated by the red arrow) as well as some results prior to that for comparison with the one week moving average in black. Note that there is a lot of variability in the doses needed to control BG over time. With the exception of two periods of time (lasting 2 and 6 weeks respectively) after stopping exercise completely due to back injury, I don’t really understand why I have these recurrent peaks and valleys in insulin doses.

post-33-all-insulin-dose-totals

My Thoughts about Management of Type 1 Diabetes with a Ketogenic Diet

My goal of glycemic management in T1DM with a ketogenic diet is to keep BG as close to normal (≈ 90-95 ± 7-12 mg/dl (mean ± SD)) as is safely possible (i.e. avoiding hypoglycemia) to avoid diabetic complications, a reduction in lifespan, and unpleasant symptoms of as well as 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 BG 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 moderate degrees of hypoglycemia (see blog post #12 for more details). I also think that hypoglycemia unawareness (due to my frequent asymptomatic hypoglycemic episodes) contributes to my lack of symptoms of hypoglycemia. As pointed out in blog post #29, this may not necessarily be a bad thing. Exercise with its resulting varying insulin sensitivity and hormonal changes actually makes glycemic management more difficult i.e. challenging, but I enjoy exercise and feel it has other health and lifespan-extending benefits. Hopefully, my BG values and variability as well as my insulin doses are close enough to optimal to avoid any reduction in lifespan, diabetic complications, and harm from hypoglycemia. Only time will tell.

Till next time ….

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7 comments

  1. Laura

    Great article Keith! I think it is always nice to hear that other type 1 diabetics sometimes cant figure out why thier BG change randomly at times. For women I know it has a lot to do with hormones, for men I believe this is also the case but intersting that it only lasted a few weeks then you went back to where you were before. When mine randomly changes I just start a new basal setting on my pump incase I need to revert back to it. I also agree with the increased “safety” or less body response to lows when you are in keto. You should check out this article , it discuss low blood sugars and how hypoglycemia “unawareness” is not a simple thing to understand. Let me know your thought on this article 🙂 looking forward to seeing you at the conference in a few weeks :
    ]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3279554

    Like

    • Keith Runyan, MD

      Thanks for the article. I had not seen that one. It is a nice review of the problem of hypoglycemia in T1DM. Glad your coming to the conference. I will be discussing hypoglycemia in the talk and explaining hypoglycemia unawareness. At least this article mentions beta-hydroxybutyrate as an alternate fuel during hypoglycemia: most review articles that I have seen never mention it. Although completely anecdotal, I show that my blood glucose values before and after starting keto were not much different, yet my symptoms of hypoglycemia were absent during the first three months on the ketogenic diet compared to about 2-5 episodes per week prior. You will love the weather here: have the air conditioner on right now since it is warm and humid outside!

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      • Laura

        happy the article could give you some research to back up your (and mine) experience with keto and lower blood sugars. I did not know you lived in Florida, yes I am from out east Canada where it is very humid so hopefully it wont be too bad for me when I get there. You stated that quite a few type1 have contacted you, if any other ones are attending the conference I would love to offer to everyone for us all to meet up to hang out and discuss our experiences. I am attending with another local type 1 friend who also eats a low carb (Dr B)/ keto diet so either way would love to meet up and chat! I can show you all my kool little toys that I have built, like my night scout dexcom receiver.

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  2. Alex Romayev

    Hi Keith,

    Thanks for the posts. I’ve been managing my T1D with a ketogenic diet and sports for the last two years. Strangely enough I’ve had an increase of my total insulin from about 30 IU/day to about 40 IU/day recently, not as significant as yours, but still. I have also started some strength training and I know you’d mentioned before that strength training seems to require you to inject more insulin. Normally, when I play soccer my insulin sensitivity goes up, but the kettle bells had an opposite effect. Do you find that you need more insulin right after you lift weights or is the increase more evenly distributed during the day? Or both?

    Best,
    -Alex

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    • Keith Runyan, MD

      Hi Alex, good question. Problem is it is difficult to give a simple answer. I have noticed periods where I seem to understand a pattern in the blood glucose (BG) response to exercise. When I started lifting weights, my blood glucose shot up which I interpreted as a stress hormone response. Then months later, the increase stopped and then the BG started dropping during weightlifting to the point I had to take 6-12 grams of glucose during a two hour session. Then months later I did not take any glucose, and my BG remained stable even during the past 6 weeks when my insulin requirements were changing so rapidly. I suspect all this is contextual based on the basal insulin dose at the time or that I really don’t understand why it changes. I also notice a difference in BG response between aerobic and resistance exercise, but again, that response is contextual as well. Bottomline, for me, the BG response to exercise is not very predictable and the best way to deal with it is measure BG frequently, be prepared to treat hypoglycemia based on either symptoms or BG measurement, and not to let it bother you or stop you from pursuing exercise. Hope that helps.

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      • Alex Romayev

        Keith,

        What’s interesting is that prior to my keto switch, soccer used to raise my sugar level up to 300 mg/dl and I had to program my pump add extra insulin during the games. It is exactly the opposite now. If I start < 100 mg/dl, I could end up with glucose under 40 mg/dl. Note, by the way, back to your point about the "unawareness" in ketosis, many times I played with my glucose around 50 mg/dl and didn't even notice it (my performance did not get affected either). However, I could definitely feel it below 50 and even had to stop playing a few times and load up on glucose tablets.

        Anyway, I thought I'd share my experience. I'm definitely not giving up on my sports, but wish more research would be done or at least knowledge / experience sharing.

        Thanks again,
        -Alex

        Like

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