#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.

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.

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.

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.

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.

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.

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.

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 ….