#36 February 2017 Update on My T1D Management

February 2017 turned out to be the best one month glycemic control that I have achieved to date. Another highlight was my first olympic weightlifting meet on Feb. 12th in Palmetto, FL where I lifted 70 kg in the snatch and 89 kg in the clean & jerk for a total of 159 kg. I made 5 of 6 lifts to achieve that total. I have another meet scheduled later this month.

Glycemic Management Results for February 2017

Below are my mean blood glucose (BG) values, insulin doses, and BG frequency distribution for February 2017 compared to previous time periods. I had the least hypoglycemia so far with 11% of BG values < 61 mg/dl this month vs 23% last month. None of these hypoglycemic values were associated with symptoms. My goal is less than 10%. The decrease in hypoglycemia was accompanied by an increase in hyperglycemia with 33% of BG values > 110 mg/dl this month vs 21% last month. My goal is less than 20%.

post-36-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 for February 2017.

post-36-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 decreased and frequency of as well as %Time with BG < 61 mg/dl decreased, to record low levels. Overall, I hope this continues next month.

post-36-variability-table

The actual daily insulin doses and daily insulin dose totals are shown in the graphs below. I had to take multiple extra rapid-acting insulin doses to correct hyperglycemia and the breakfast and dinner rapid-acting insulin doses increased in the second half of the month. I made small changes in my basal insulin doses based on the fasting BG results as usual. I still find it interesting that my insulin doses vary so much over time for reasons that I largely do not understand. Again, this is IMO due to the very nature of exogenous insulin therapy.

post-36-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.

post-36-ketonix-graph

In March, I will continue to exercise daily but will try olympic weightlifting six days a week and aerobic exercise (swimming, rowing, or cycling at low intensity for ≈ 0.5 – 2 hours) one day a week.

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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2 comments

  1. Thanassis Bantios

    Hello mr. Runyan, I enjoy reading your blog because you are one of the few persons that follow a keto diet that talk about insulin sensitivity and variable absorption, which is really one of the key elements in diabetes management. I also follow a keto diet and am very strictly committed to Dr.Bernstein’s regimen (fixed meals, eating the same things every day etcr) which is something that many people find too extreme, but still, I face the same problems. The same lunch with the same dose of insulin everyday may result to different outcome (although the variability is much minimised due to the doses being very small), for reasons that I too do not understand. Increased/decreased insulin sensitivity, not constant absorption of insulin or food and also a host of other reasons make this a challenge by itself.
    I purchased a Freestyle Libre and indeed, my control is a little better, it helps catch trends and highs/lows as soon as they start to happen. Dexcom would be a better choice as you can set alarms during your sleep (Freestyle Libre does not have this choice as you have to manually scan yourself). But my biggest problem is this, a variability in insulin sensitivity, which inserts uncertainty as to what dose should I inject for basal and for my every meal.

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    • Keith Runyan, MD

      I agree 100%. Every dose of rapid-acting insulin is a guess and usually I am undecided as to whether it should be 0.5 units more or less because of the previous days responses. It is a common occurrence that the exact same meal with the exact same dose of rapid-acting insulin yields a post-meal BG that can vary by 40, 50, to 60 mg/dl. I think understanding that it is not my fault helps. I also agree that the CGM will allow me to catch and correct lows sooner particularly since I do not usually have symptoms. Hopefully, our FDA will speed up the approval process for the FreeStyle Libre system.

      Like

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