Ketogenic Diabetic Athlete

#46 November 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 whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. Although glycemic management in T1DM will always be challenging, the low carbohydrate ketogenic whole-food diet definitely improves it and just as importantly reduces insulin requirements and frequency of symptomatic hypoglycemia. Many of the diseases (cardiovascular disease, cancer, Alzheimer’s, and many more) associated with T2DM and “double diabetes” as part of T1DM are due to insulin resistance and hyperinsulinemia. The low carbohydrate ketogenic whole-food diet directly improves both insulin resistance and hyperinsulinemia in T2DM and in T1DM via reduced insulin doses.

Last month I detailed my treatment plan for my presumed left rotator cuff injury. Although it seems to be slow to recover, it has improved significantly throughout the months of October and November. I started back doing snatch overhead squats on October 27th and snatch and clean and jerks on November 26th. So far no shoulder pain during exercise, but some soreness with certain arm movements in daily life. I interpret this as much improvement, but not as yet complete recovery. In November, I continued once daily weightlifting workouts with three exercises per day lasting about 2 hours including warmup, rest between lifts, and cool down. I have previously discussed the change in blood glucose (BG) with exercise. I have and still experience a significant rise in BG during weightlifting which I felt was due to stress hormone release from intense exercise. However, I am thinking that more likely the BG response to exercise is primarily related to the adequacy or inadequacy of the basal insulin dose. What I have noticed is that when the fasting BG is normal (BG 61-110 mg/dl), the BG rises during weightlifting. But when the fasting BG is low (BG < 61 mg/dl), the BG does not rise during weightlifting and when the fasting BG is high (BG > 110 mg/dl), the BG rises even more dramatically during weightlifting. Of course, there is a lot of variability and these are general observations, not rules or predictable responses. For me, there does not seem to be one basal insulin dose that will result in both a normal fasting BG and a normal post-exercise BG. Several years ago I tried splitting up the basal insulin dose to a morning and dinner-time dose to address this issue with no improvement. For safety reasons, I think it is best to adjust the basal insulin dose (Lantus) to achieve a normal fasting BG and accept and treat an elevated post-exercise BG with a correction dose of rapid-acting insulin (Humalog). I have taken a small correction dose of rapid-acting insulin (Humalog) (about 1-2 IU) to correct a high post-breakfast BG prior to exercise with success most of the time. Once this month, I took glucose during exercise because I was not feeling well (dizzy after lifts) without first checking my BG. That was a mistake: my BG was over 200 mg/dl post-exercise and it took all day to correct. Also, on November 6th I had a symptomatic hypoglycemic episode. This one occurred a couple hours after dinner. My pre-meal BG was 45 mg/dl so I did not take any rapid-acting insulin (Humalog) and took one less IU of basal insulin (Lantus), 29 IU instead of 30 IU, because I have had hypoglycemia in the past just from the basal insulin dose post-exercise (improved insulin sensitivity). The symptoms of this month’s hypoglycemic episode were sweating and a feeling of impending doom. This latter symptom led to my over-treating it with glucose tablets. I took 5 or 6 instead of 2 or 3 for this symptomatic episode. My bedtime post-treatment BG was 83 mg/dl, but I suspected it would be high the following morning. Sure enough, it was 211 mg/dl in the morning and elevated most the next day requiring 4 extra Humalog correction doses. I’m not sure what I could have done differently other than increase the carbohydrate content of the dinner meal. Taking fewer glucose tablets would have helped, but only those who have experienced hypoglycemia can understand the desire to correct the BG ASAP when there is a fear of impending doom.

Glycemic Management Results for November 2017 

My November glycemic results were similar to previous time periods with more hypoglycemia and hyperglycemia than I would have liked. I only spent 51% of time with a BG between 61 and 110 mg/dl (my goal is >70%). My insulin doses varied up and down in response to high or low BG in the range of 29 to 50 units/day with a slight downward trend during the month.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for November 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 discussed previously, 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). 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 and MCT oil used on salads or vegetables at dinnertime 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 in November 2017. I adjust both the morning and evening meal-time doses based on the pre-meal BG reading and take extra correction Humalog doses (green circles) for high BG readings between meals. I continued my previous pattern of high BG readings after weightlifting. This is primarily controlled by the basal insulin (Lantus) dose taken at dinnertime but that dose is determined by the fasting BG reading and thus cannot be adjusted to optimize all times of day. In those with T1DM the basal insulin dose may be enough to compensate for the increase in BG with intense exercise, but may also require a rapid-acting insulin dose to lower a high post-exercise BG.

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. Both the %Time with hypoglycemia and hyperglycemia are probably overestimates because they not account for the corrections with glucose tablets (for hypoglycemia) or rapid-acting insulin (Humalog) (for hyperglycemia). Measuring my BG more frequently or using a CGM would result in a more accurate estimate. In November, the BG standard deviation and coefficient of variation and %Time with hypoglycemia were higher than usual.

The daily insulin dose totals and BG readings for November are shown in the graphs below. You can see a slight downward trend in total daily insulin dose with several spikes (for hyperglycemia) during the month.

The daily insulin dose totals and 7-day moving average for 2017 are shown in the graph below. You can see an oscillatory pattern with a period of about 8 weeks. In October and November there was some stabilization of insulin doses. I think it is too early to say that I have solved the problem of oscillating insulin doses, but I did change the procedure of drawing insulin from the vial into the syringe by not injecting air into the vial with a reused needle and I have been adjusting my basal insulin (Lantus) dose less frequently and to a smaller degree.

In December, I will continue olympic weightlifting every day with three exercises per day one of which will be either snatch or clean and jerk (alternating days) as long as I don’t have any shoulder problems.

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.  For the past two months, I have stopped using berries to correct asymptomatic hypoglycemia because the response is too unpredictable compared to glucose tablets. I also found I was intolerant of spinach (diarrhea), bell peppers, and eggplant (diarrhea, nausea).

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

When my entire diet is analyzed, 26% of my fat intake is from polyunsaturates (mainly from nuts and seeds), 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 makes glycemic management more 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, but only time will tell.

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