#42 July 2017 Update on My T1D Management

I continued my trial of metformin in July 2017. Unfortunately, I had two common side-effects: diarrhea and fatigue despite reducing the dose to 500 mg/day. Although I have not ruled out giving it another try at some point in the future, I decided to stop because I did not like feeling fatigued.

After stopping the metformin I decided to experiment with carb-loading prior to weightlifting with sweet potato beginning on July 15th. I tried 250-320 grams of sweet potato in a meal (either the breakfast just prior to weightlifting or at dinner the evening before). Sweet potatoes are about 20% carbohydrate by weight with about 16% of the carbohydrate being dietary fiber. Thus a 300 gram sweet potato has about 60 grams of total carbohydrate. I have wanted to do this experiment for a while as I started olympic weightlifting Feb. 2015 after having been on the ketogenic for three years. Because olympic weightlifting is an intense exercise it is possible that performance may be improved with additional muscle glycogen reserves that could possibly be low on a ketogenic diet. Of course without doing muscle biopsies, there is no way to know what my glycogen reserves are on a ketogenic diet, how much glycogen is used during olympic weightlifting, and whether or not my performance is adversely affected. Thus the reason for the experiment. So far it appears that the 60 grams of carbohydrate from sweet potato is helping my performance unless the placebo effect might account for the improved performance. Another confounding factor is that my left shoulder pain resolved during the last 6 workouts after starting sweet potato. However, during 9 workouts prior to taking metformin, my average max snatch was 145 lb. compared to 143 lb. during the last 9 workouts on metformin. I stopped metformin and started sweet potato. My average max snatch while taking sweet potato over 9 workouts was 152 lb. Similarly, my max clean and jerk prior to metformin was 178 lb., while on metformin was 183 lb., and with sweet potato was 191 lb. I have to take an additional 1 – 1.5 IU of Humalog with the meal to which I add sweet potato. I really can’t evaluate whether the sweet potato alone has adversely affected my overall glycemic control, but I will be looking at that as well.

Glycemic Management Results for July 2017

July 2017 glycemic results were noteworthy for both more hypoglycemia and hyperglycemia with decreasing insulin doses during the month. Fortunately none of the low blood glucose (BG) values were associated with symptoms this month. Hypoglycemia in a person with T1DM who is conscientiously trying to control BG is a real danger that should be minimized. Although not always avoidable, hypoglycemia can be reduced by considering the many factors that affect BG response to exogenous insulin including dietary carbohydrate and protein, exercise, sleep (lack of sleep increases insulin resistance) and by slightly underestimating the insulin dose (e.g. by 0.5 IU) to be administered (in my opinion). Additional insulin correction doses can always be given later to correct hyperglycemia.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for July 2017 compared to previous time periods. I have changed two columns to indicate the AUC mean BG and predicted HbA1c. AUC mean BG is the mean BG by calculating the area under the curve (AUC) of BG versus time. The predicted HbA1c uses the formula: AUC mean BG plus 88.55 divided 33.298. This formula is the least squares fit using my own personal mean BG versus measured HbA1c over many years. My particular HbA1c values are higher than many other individuals with the same mean BG. This is referred to as being a “high glycator.”

Post 42 Means Table

As presented in blog post #15 exogenous insulin cannot mimic normal insulin secretion, so persons with 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 or less common but dangerous consequence including 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. Normal BG is 96 ± 12 mg/dl (mean ± standard deviation (SD)) and coefficient of variation is 13% which is the weighted mean from these two studies (here  and here) of continuous glucose monitoring in healthy subjects. The standard deviation and coefficient of variation are measures of BG variability which I believe are important in T1DM. However, be advised that clinical outcomes in type 1 diabetes (i.e. microvascular and macrovascular complications) have only been documented to correlate with measures of mean BG, particularly HbA1c. This does not mean BG variability is not important, but it just has not been documented to correlate with outcomes and complications of T1DM. Achieving a normal standard deviation or coefficient of variation in T1DM would be difficult, if not impossible, with current exogenous insulin therapy (injected or pumped). I hope that adding a continuous glucose monitor (CGM) to my therapeutic regimen will improve my BG variability and thus the standard deviation and coefficient of variation. I plan to get the FreeStyle Libre CGM as soon as it 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 in my opinion. Following a low carbohydrate ketogenic diet is one such method of reducing BG variability, mean BG, insulin doses, and hypoglycemia. A 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. Having BG close to normal most of the time (some of which are hypoglycemic) also minimizes the 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 July 2017. You can see below that most of the hyperglycemia occurred after weightlifting (at 2 pm – black circles or at 6 pm – magenta circles). I have explained in prior blog posts that this may be related to stress hormones which are normally released during intense exercise that serve to increase both BG and fatty acid levels in the blood to provide exercising muscles with additional energy. Because those with type 1 diabetes (T1DM) cannot make insulin, BG can rise with intense exercise and will need to be corrected with exogenous insulin. I don’t like the fact that my BG increases so much with weightlifting. However, it beats the alternative of hypoglycemia and loss of performance during the workout. I have not used exogenous insulin prior to a workout in anticipation of hyperglycemia for fear of hypoglycemia. Hopefully, any adverse effects from these temporary rises in BG will be mitigated by the benefits of the exercise itself. Those without diabetes also experience a similar increase in BG with intense exercise, see here.

Post 42 BG Exercise Graphs

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 (hypo) and the mean BG during that time, then %Time BG 61-110 mg/dl (target) and the mean BG during that time, and %Time BG > 110 mg/dl (hyper) and the mean BG during that time. The other measures of BG variability were defined and explained in blog post #10.

Post 42 Variability Table

The actual daily insulin doses and daily insulin dose totals are shown in the graphs below. You can see that I had to decrease my insulin doses progressively during the month from a total in the upper 40’s IU/day to low 30’s IU/day. I have yet to understand why my doses vary so much over time other than the simple fact that exogenous insulin therapy does not mimic endogenous insulin secretion. Nor have I found a way to make the insulin doses more stable while still enjoying the exercise that I know contributes to glycemic variability. I had to take multiple extra rapid-acting insulin doses to correct hyperglycemia during the second half of the month and I had to decrease both basal and mealtime bolus insulin doses during the month.

Post 42 Insulin Totals Doses Graphs

I measured blood ketones twice after adding eating the sweet potato in July at 0.2 and 0.4 mM and once prior to eating sweet potato at 0.7 mM. Thus from this limited data, it appears that the 60 grams of extra carbohydrate knocks me out of ketosis and that I’m back in ketosis ([BHB] > 0.5mM) less than 48 hours after eating the sweet potato. Note: I do olympic weightlifting every other day and took the sweet potato either just prior to or the evening before weightlifting. In August, I will resume using the Ketonix acetone monitor to get a better idea of how the extra carbohydrate affects my time in ketosis.

In August, I will continue olympic weightlifting every other day. I am continuing to take a break from regular aerobic exercise and instead I am stretching and foam-rolling every other day as well as doing rotator cuff exercises to further strengthen my left shoulder which I injured in March 2017. Fortunately I am no longer having left shoulder pain, so I think the rotator cuff rehab exercises were helpful. The foam-rolling has been effective in resolving trigger points (along with two rounds of trigger point dry needling) in my IT bands which has resolved the IT band syndrome in my right knee.

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. My current version of ketogenic diet has changed slightly since I last wrote about it in detail in blog post #9.

My current diet looks like this.

What I Cook & Eat

•Beef, grass-fed, including meat (85% lean), heart, liver, and kidney (liverwurst)

•Fish, mainly wild Alaskan salmon

•Canadian bacon (uncured pork loin)

•Lamb occasionally

•Chicken & Turkey occasionally

•Chicken Eggs

•Non-starchy vegetables (about 5% carbohydrate content by weight) including Cabbage (Red, Green, Napa), Kale, Collard Greens, Spinach, Bell Peppers, Raw Carrots, Leeks, Onions, Brussels sprouts, Home-made Sauerkraut from Red Cabbage, Bok-Choy, Broccoli, Cauliflower, Yellow Squash, Zucchini, Cucumber, Lettuce (Iceberg & Romaine), and some others.

•Fruit – Avocado, Tomatoes, Olives, Strawberries, Blueberries, Blackberries, lemon juice on fish and salads

•Root Vegetable: Sweet Potato and raw carrots.

•Nuts & Seeds – Pepitas, Macadamia, Brazil, Pecan, Walnut, Pistachio, Cashew.

•Note: I developed an intolerance to milk prior to my diagnosis of T1D. I did try heavy whipping cream after starting my KLCHF diet, but am also intolerant of it. I do tolerate butter, but wanted to decrease my fat intake, so eliminated all dairy including cheese and yogurt.

What I Drink

Water (filtered by reverse osmosis), Unsweetened Tea & Coffee

What I Don’t Eat

•Grains – Wheat, Corn, Rice, Oats (there are many more) or anything made from them, which is too numerous to list here. Gluten is a protein present in a number of grains (all varieties of wheat including spelt, kamut, and triticale as well as barley and rye.) which can cause a number of medical problems for a significant portion of the population with gluten sensitivity or celiac disease. In my case, I avoid them due to their carbohydrate content.

•Starchy vegetables – white potatoes

•Legumes – peas, beans, lentils, peanuts, soybeans

•High sugar fruits – includes most fruits except berries, see above.

•Sugar and the fifty other names used to disguise sugar.

•Vegetable Oils (really seed oils) – Canola, Corn, Soybean, Peanut, Sunflower, Safflower, Cottonseed, Grape seed, Margarine & Butter substitutes, Shortening.

•All Processed Food-like Substances i.e., most of what is in the grocery store.

•I avoid restaurants except when traveling, and then order fish or steak with plain steamed non-starchy vegetables (no gravy or sauces that typically contain sugar, cornstarch, or flour) or salad.

•Refined, but healthy, Fats – I have eliminated refined fats from my diet including butter, coconut & olive oils.

What I Don’t Drink

•Colas (both sweetened, artificially sweetened, and unsweetened).

•Fruit Juice except small amounts of lemon juice.

•Alcohol (can cause hyperglycemia or hypoglycemia in persons with diabetes).

•No artificial sweeteners, don’t need or like them.

A large part of my fat intake comes from nuts & seeds which hypothetically could result in potential adverse consequences from omega-6 polyunsaturated fats in the opinion of some low carb advocates. However, I have yet to see any studies that show harm from eating nuts & seeds. As a reference, the average fat breakdown of the seven nuts & seeds that I eat daily is 33% polyunsaturated, 52% monounsaturated, and 15% saturated fat. However, when my entire diet is analyzed, 26% of my fat intake is from polyunsaturates, 56% is from monounsaturates, and 18% is from saturated fats. When my diet is broken down by macronutrients, I consume 170 grams of fat (or 68% of my total daily calories), 70 grams of carbohydrate, 30 grams of which is dietary fiber (or 12% of my total daily calories), and 110 grams of protein (or 20% of my total daily calories). In calories, it totals to 2,250 kcal/day.

My exercise regimen and 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 lower insulin doses that result from my ketogenic diet and exercise are close enough to optimal to avoid any reduction in lifespan, diabetic complications, and harm from hypoglycemia. Only time will tell.

Till next time ….