#34 January 2017 Update on My T1D Management

January’s post was delayed because I attended and spoke at the Metabolic Therapeutics Conference on February 3rd in Tampa, Florida on The Management of Type 1 Diabetes with a Ketogenic Diet. My talk was videoed and I will post a link when it is available on YouTube. It was an excellent conference and I would highly recommend it to anyone interested in ketogenic diets.

Glycemic Management Results for January 2017

Below are my mean BG values, insulin doses, and BG frequency distribution for January 2017 compared to previous time periods. I am always aiming for less hypoglycemia, but I had more this month 23% vs 15% of BG values were < 61 mg/dl last month. My goal is less than 10%. The increase in hypoglycemia was I suspect related to the increase in insulin doses that began last month to treat hyperglycemia. Thus, most of this month I had to reduce the insulin doses to address the hypoglycemia. Fortunately, none of the hypoglycemia was associated with symptoms.

post-34-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 96 ± 12 mg/dl (mean ± standard deviation (SD)) and coefficient of variation is 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. I plan to get the FreeStyle Libre CGM as soon as I becomes available in the U.S. 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.

post-34-exercise-and-blood-glucose

The table below shows the BG variability results for current and previous time periods. The percentiles (10th, 25th, 75th, 90th) on the right show the spread of the BG readings about the median. The interquartile range, the difference between the 75th and 25th percentiles, is a measure of BG variability. In the middle of the table are the %Time in three BG ranges: %Time BG < 61 mg/dl and the mean BG during that time, then %Time BG 61-110 mg/dl, and %Time BG > 110 mg/dl and the mean BG during that time. The other measures of BG variability were defined and explained in blog post #10. Compared to last month, glycemic variability increased and frequency of as well as %Time with BG < 61 mg/dl increased, but I do not expect this to persist next month. Overall, satisfactory.

post-34-variability-table

The actual daily insulin doses and daily insulin dose totals are shown in the graphs below. The decline in my insulin requirements that began on 12/22/2016 continued in the month of January. The total daily insulin dose came back down to my prior level in the low 30’s IU/day by the end of the month.

post-34-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: 2,250 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 divided by the grams of carbohydrate plus protein. For me, for example, 170 grams fat ÷ (70 grams carbohydrate + 110 grams protein) ≈ 1:1. As you can imagine, a 4:1 diet would be more restrictive to emphasize foods high in fat and to avoid foods high in carbohydrates and/or protein.

post-34-ketonix-graph

In January, I achieved a new personal record (PR) in weightlifting in the clean & jerk increasing it from 185 lb. to 195 lb. The snatch remained the same at 155 lb.

In February, I will continue to exercise daily alternating olympic weightlifting and aerobic exercise (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).

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 i.e. 96 ± 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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5 comments

  1. Heather Burt

    Hello, Dr. Runyan ~

    I’m a 51-year-old recreational athlete living with T1D (dx at 21) and am very pleased to have discovered your fantastically detailed blog (and book, which I read with great interest) as I conduct my own experiments with a ketogenic diet. I’d be curious to know your thoughts on a couple of keto-related issues:

    1) Do you have any experience with or theories about the “keto rash” that some people experience on a VLCK diet? (I experienced an extreme version when I first tried VLCK eating, a couple of years ago, and I eventually increased my carbs, thus exiting ketosis, to get rid of it.)

    2) With regard to athletic performance, do you think it’s possible to be in a metabolic state in which you aren’t sufficiently ketotic to fuel your workouts through fat burning but also aren’t consuming enough carbohydrate for optimal glucose-based performance (and thus feel chronically fatigued when working out)? I think Phinney and Volek might address this topic in one of their books — in just enough detail to have made me worry about the phenomenon!

    Thanks again for the great blog/resource and all the best with your various life-enhancing strategies!

    Heather

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    • Keith Runyan, MD

      Thanks for your comments and questions, Heather. I had one patient with the keto rash. It was itchy as I recall and went away with increasing the carbs. I researched it and found a series of 10-15 cases in the literature. I appears to be a real phenomenon, but the mechanism is unknown. You might try decreasing the carbs more slowly over several weeks instead of all of a sudden or over days and see if the rash comes back or not. As far, as athletic performance, I think the reduction in energy is related to the quick transition from plenty of carbs to very few carbs, so again, a gradual reduction in carbs would probably prevent a noticeable change in energy. For those with T1DM, the gradual transition also allows time to adjust the insulin doses, so multiple reasons to make the transition slowly. Hope that helps and I would interested in hearing how you do with both of these issues.

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      • Heather Burt

        Thanks very much for your reply, Dr. Runyan.

        Yes, I’m hoping that a more gradual entry into ketosis will keep the rash at bay this time (I have minor signs of it, but it’s not terribly itchy). It’s reassuring to know that it is, as you say, a real phenomenon.

        The other issue, as I’m thinking of it, is somewhat different from the common low-carb “induction” fatigue; it’s more a chronic condition. I’ve found in the past that, despite my best dietary efforts, I have trouble staying in full-on ketosis. Hormone fluctuations and other variables that affect blood sugar regularly give me high-ish BGs and undermine my efforts to keep my insulin levels low, with the result (if I’m not misunderstanding the phenomenon) that my blood ketones often dip below 0.5 mmol/L. I remember reading in one of the Phinney/Volek books that hanging out in a low-ketone range can feel lousy, and I suspect that I’ve yet to experience the full potential of ketogenic performance.

        In any case, I’m motivated to keep up the experiment and will keep my focus on maintaining the best blood sugar control possible (aiming to get my A1c under 6%). I look forward to more of your management reports and other blog posts, both for information and inspiration!

        Cheers and thanks,
        Heather

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      • Keith Runyan, MD

        I have heard others say they have “trouble” staying in ketosis, more commonly in menstruating women. I do not recall Phinney/Volek mentioning not feeling well when blood ketones are < 0.5 mM, only that 1.0 to 2.0 mM is "optimal." I think the value of blood ketone measurements is simply to confirm that one can follow the diet properly. I do not think blood ketones should necessary be in a certain range all the time. Blood ketone levels represent the difference between ketone body production and oxidation rates and thus low ketones does not necessarily mean one is not utilizing ketones.
        IMO, persons with T1DM should take enough insulin to achieve as near-normal blood glucose values as they can safely (i.e. with hypoglycemia) accomplish. In my previous blog post from December 2016, you can see my insulin doses vary quite significantly for reasons I cannot explain. Finally, I don't know what to make of the "chronic fatigue" on a ketogenic diet. Perhaps, a review of your diet with someone knowledgeable in ketogenic diets might pick up a deficiency or an area of improvement. No one wants to live "chronically fatigued."

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  2. Heather Burt

    Thanks, again. 🙂 Fortunately, I’m not “chronically fatigued” in any global way — I’m thinking mainly of my performance in the gym and in rowing (my main sport). It’s not terrible when I’m eating a VLCK diet, but nor do I feel as powerful as I do when I’m consuming more carbs (and, of course, dealing with all the crap that goes along with carb-fuelling!). Yes, it would be wonderful to consult in person with an expert who knows both T1D and ketosis. You’d think Vancouver would be a good place to find such a person, but I’m still searching!

    Your Dec. 2016 comments about insulin dose variability are reassuring (especially in the context of Richard Bernstein’s somewhat rigid argument that T1 diabetics can — and even must — maintain non-diabetic glucose levels at all times).

    Have a great weekend!

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