Ketogenic Diabetic Athlete

#43 August 2017 Update on My T1D Management

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This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic real-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print.

In August 2017, I continued using sweet potato once daily primarily at dinnertime to see if it might improve my weightlifting performance. I will have to wait to see if my performance changes, if any, after stopping sweet potato on August 24 to understand if it was effective. I changed my weightlifting schedule on August 3rd from every other day to once daily in the hopes of improving my glycemic control. My improved insulin sensitivity from weightlifting only lasts 24 hours, so daily exercise of the same type might help stabilize my insulin sensitivity and blood glucose (BG). I had previously experimented with daily weightlifting in the past but it resulted in overtraining. This time I cut the number of exercises down to just two per day. That seems to be working for now in terms of not too much or too little. Along with the change in exercise schedule, I ate a half of a sweet potato weighing about 150 grams or 30 grams of total carbohydrate each evening until August 24th. Since stopping the sweet potato I have not felt any reduction in energy, but I will reserve judgement for a few more weeks.

Glycemic Management Results for August 2017 

August 2017 glycemic results were noteworthy for more hyperglycemia with increasing insulin doses during the month. Some of this increase in insulin dose and hyperglycemia for that matter could have been related to the sweet potato. Fortunately, I had fewer low BG values and they were not 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. This is accomplished 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. In fact, I had to take 25 correction doses this month due to hyperglycemia.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for August 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.”

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 at all times. 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 consequences 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 T1DM (i.e. microvascular and macrovascular complications) have only been documented to correlate with measures of mean BG, particularly HbA1c. This does not mean that 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 the Humalog (rapid-acting insulin) doses I used to address hyperglycemia in August 2017. You can see below that most of the hyperglycemia occurred either in the morning (fasting at 8 am – blue circles) or after weightlifting (at 2 pm – black circles or at 6 pm – magenta circles). The morning hyperglycemia was addressed with increasing basal insulin doses. The hyperglycemia after weightlifting could be related to inadequate basal insulin and/or as 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 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, so hopefully increasing the basal insulin dose will help reduce it. However, it beats the alternative of hypoglycemia 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.

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.

The daily insulin dose totals and exercise type and time are shown in the graphs below. You can see that I had to increase my insulin doses progressively during the month from a total in the mid 30’s IU/day to the mid 50’s IU/day. In fact, these insulin dose totals are the highest I have had to use since starting the ketogenic diet in Feb. 2012. It will be interesting to see if this persists or goes back down to previous dose totals.

In September, I will continue olympic weightlifting every day to the extent that I can with the current two exercises per day.

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, 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

What I Drink

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

What I Don’t Eat

What I Don’t Drink

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.

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