#48 January 2018 Update on My T1D Management

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. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is 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 can reduce the 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 endogenous hyperinsulinemia in T2DM and exogenous insulin requirements in T1DM (i.e. reduced insulin doses).

In January, I was able to increase the dose of metformin to 500 mg three times daily. I am tolerating it without any side effects. As you may know metformin is the first-line medication for T2DM, but can also be useful for those with T1DM. Metformin acts on the liver to reduce glucose production by suppressing both glycogenolysis and gluconeogenesis. This is particularly useful for those with T1DM on a low carbohydrate diet, because the reduction in dietary carbohydrate reduces the insulin requirements and the reduction in insulin elevates glucagon levels reaching the liver from the alpha cells in the pancreas. It is glucagon that stimulates both glycogenolysis and gluconeogenesis. In addition, metformin stimulates muscle uptake of glucose independent of insulin. Hopefully over time, I will be able to determine if taking metformin either reduces my blood glucose (BG), insulin requirements, or both.

For the past several months I have detailed my treatment plan for my presumed left shoulder rotator cuff injury. Although it seems to be slow to recover, it has improved significantly. I continue doing snatch overhead, front, and back squats, snatch, clean & jerk, and deadlifts. In January, I continued once daily weightlifting workouts with only two exercises per day. I have previously discussed the change in BG with exercise. I still experience a significant, but variable, rise in BG during weightlifting. This rise in BG requires a correction dose of rapid-acting insulin (Humalog).

This past month I added a small post-workout (lunch) meal of meat after my workouts to increase my protein intake to 1.6 grams/kg/day which may promote some additional muscle growth. According to research done by Stuart Phillips, PhD and others, as one ages a “resistance” to building muscle develops which can be overcome somewhat by resistance exercise and increasing dietary protein intake to least 0.4 grams/kg/meal and 1.6 grams/kg/day.

Glycemic Management Results for January 2018

My January glycemic results were similar to previous time periods with more spikes in BG (hyperglycemia) and hypoglycemia than I would have liked that resulted in an elevation of all my measures of BG variability. Fortunately, I did not have any symptoms of hypoglycemia in January. I spent only 59% of the time with a BG between 61 and 110 mg/dl (my goal is >70%). My insulin doses had to be decreased steadily throughout the month especially the rapid-acting insulin (Humalog) dose to address the hypoglycemia. I had to decrease the total daily insulin dose from a peak of 70.5 to 38 IU/day by the end of the month. This oscillating pattern of insulin doses with a period of about 8 weeks continues for reasons that are not quite clear. I am beginning to think that I am creating this pattern by adjusting my doses too rapidly due to my desire to optimize by BG values. In other words, the very nature of exogenous insulin therapy does not accommodate rapid optimal BG regulation.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for January 2018 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 48 Means Table

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, yet more 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 two studies 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. 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 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 mild asymptomatic hypoglycemia adapts the brain to lower BG and reduces the symptoms of mild hypoglycemia and potentially the harm from hypoglycemia due to lack of activation of the sympathetic nervous system by reducing sympathoadrenal-induced fatal cardiac arrhythmia.

Below are my BG readings along with the Humalog (rapid-acting insulin) doses in January 2018. I adjust the breakfast (blue circles), post-workout lunch (black circles), and dinner (purple circles) meal-time doses based on the pre-meal BG reading and take extra correction Humalog doses (red circles) for high BG readings as needed. 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 BG at 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.

Post 48 Humalog Doses vs BG graph

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 do 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.

Post 48 Variability Table

The daily insulin dose totals and BG readings for January are shown in the graphs below. You can see a steady decrease in total daily insulin dose during the month to address hypoglycemia.

Post 48 Insulin Dose Totals and BG graph

 

The graph below is a new illustration of the distribution of BG values in the ranges indicated at various times of day. This could be useful to point out problems (hypoglycemia and/or hyperglycemia) at different times of day.

Post 48 BG Distribution During Day Graph

The graph below is also new and illustrates the percentage of time spent in three BG ranges for each day of the month of January. The numeric percentage is shown for the % of time BG was between 61 and 110 mg/dl.

Post 48 Daily % Time in Different Ranges

In February, I will continue olympic weightlifting every day with two exercises per day. I will also continue metformin 500 mg three times daily.

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 basic diet philosophy is to avoid processed foods especially those containing refined carbohydrates, sugar, and vegetable (seed) oils while enjoying whole foods (with just one ingredient) as close to their original state as possible. I think just knowing the guidelines in this paragraph would be a good start for those wanting to improve their diet. To treat diabetes, the additional step is to eliminate all foods with significant amounts of carbohydrate to keep the net carbohydrate total < 50 grams/day. Some may do better with < 30 grams/day, while others who exercise a lot may do well with < 100 grams/day.

My current version of ketogenic diet is as follows:

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, Leeks, Onions, Home-made Sauerkraut from Red Cabbage, Bok-Choy, Broccoli, Cauliflower, Yellow Squash, Zucchini, Cucumber, Lettuce (Iceberg & Romaine), and some others.
  • Fruit – Avocado, Tomatoes, Olives, lemon juice on fish and salads
  • Root Vegetable: Raw Carrots
  • Nuts & Seeds – Pepitas, Macadamia, Brazil, Pecan, Walnut, Pistachio, Cashew.
  • MCT oil – a few tablespoons on salads or cooked vegetables till current supply is finished.
  • 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 and most root vegetables – potatoes, sweet potatoes, yams
  • 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 – Canola, Corn, Soybean, Peanut, Sunflower, Safflower, Cottonseed, Grape seed, Margarine & Butter substitutes, Shortening.
  • All Processed Foods.
  • 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 – Although there is nothing bad about including butter, coconut & olive oil in a ketogenic diet, I have eliminated refined fats (except a small amount of MCT oil until my current supply runs out) from my diet to improve my body composition.

What I Don’t Drink

  • Colas (both sweetened and artificially sweetened).
  • Fruit Juice except small amounts of lemon juice.
  • Alcohol (can cause hyperglycemia or hypoglycemia in persons with diabetes).
  • No artificial sweeteners, don’t want or like them.

My exercise regimen negatively affects my glycemic control, but I enjoy exercising and feel it has health and lifespan-extending benefits which may compensate for the temporary increase in BG during/after exercise. Hopefully my BG values and variability as well as the relatively lower insulin doses that result from my ketogenic diet, exercise, and hopefully metformin (yet to be determined) are close enough to optimal to avoid any reduction in lifespan, diabetic complications, and harm from hypoglycemia, but only time will tell.

References

Efficacy and safety of metformin for patients with type 1 diabetes mellitus: a meta-analysis – here

A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults – here

Continuous Glucose Profiles in Healthy Subjects under Everyday Life Conditions and after Different Meals – here

Variation of Interstitial Glucose Measurements Assessed by Continuous Glucose Monitors in Healthy, Nondiabetic Individuals – here

Severe Hypoglycemia–Induced Lethal Cardiac Arrhythmias Are Mediated by Sympathoadrenal Activation – here

 

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4 comments

  1. raquelflorio gomes

    Dr Runyan, I finished reading your book and it changed my life!

    I have been a type 1 for 24 years, and a physician for 15 and it never crossed my mind that a low carb diet was a healthy one.

    Since that change I had to reduce the amount of insulin, Lantus from 20 to 10 units and a still use carbo and protein counting to correct the pre prandial dose with Humalog.

    I’m having difficulty in controlling my BG during the morning, it rises up to 50 mg/dL but not every day, so sometimes I have this surprise

    I run 6 to 8 Km early morning and my BG rises too much, i just drink coffee without sugar before the workout.

    Can you send me your post which you talked about exercise and BG?

    Thank you very much!!

    Raquel Florio, MD

    Excuse my english! Im brasilian

    2018-02-02 13:35 GMT-03:00, Ketogenic Diabetic Athlete

    Like

    • Keith Runyan, MD

      Raquel, I’m glad you found our book helpful.

      I haven’t done a blog post that covers all aspects of exercise and glycemic management with T1DM, but many of the older posts talk about one aspect or another of exercise and glycemic management.

      Blog post #3 https://ketogenicdiabeticathlete.wordpress.com/2015/11/17/insulin-analogs-carb-counting-and-exercise-2001-2011/ covers some of the aspects of the topic.

      In general, exercising first thing in the morning typically results in hyperglycemia due to the dawn phenomenon. Humalog could be taken before your run to prevent the rise in blood glucose (BG), but you will risk having hypoglycemia during the run which is not pleasant. Another option is to do your morning run and then take a correction dose of Humalog after the run or eat breakfast with Humalog after your run. A temporary rise in BG is not necessarily that bad if that is the only time you can get your run done. If you could do your run a few hours after breakfast when the breakfast Humalog has finished working, you will be less likely to have such a rise in BG. If that doesn’t fit your schedule, a run after work and before dinner would work well. You should avoid exercising immediately after a meal for which you took Humalog as that increases the risk of hypoglycemia. I hope that helps.

      Like

  2. looneyjohnniebelinda

    Dr. Runyan,
    I am not a diabetic (though it runs deeply throughout my family) but I have found your blog most helpful on following the Ketogenic diet for weight loss. Any suggestions or changes to the Keto diet for a non-diabetic?

    Like

    • Keith Runyan, MD

      John, using a ketogenic diet to lose weight i.e. excess body fat is relatively easier when you don’t have to adjust insulin or medications at the same time. The key points for weight loss include restriction of carbohydrates especially refined carbohydrates and sugar to a level that resolves any insulin resistance one may have. Since it takes special testing to determine whether or not one is insulin resistant, it is easier to assume that you are insulin resistant and restrict dietary carbohydrates to <50 grams/day. Then, make sure you get enough complete protein to prevent or minimize lean muscle loss (about 1.5 grams protein/kg ideal body weight/day) while producing a caloric deficit by adjusting healthy fats in the diet so that your body has to burn some body fat each day. The amount of calories or fat one needs can be estimated by formulas or one can adjust it up or down by trial and error. It is important to formulate your diet in a way that you enjoy it because if it cannot be followed for the rest of your life, the excess body fat will come back.
      Addendum on Feb. 20, 2018 – I assumed those looking at this comment would have been readings previous blog posts, but just in case they have not I should add the ketogenic diet I recommend is based on whole, real, unprocessed foods, composed of meat, (beef, chicken, lamb, or other animal foods) including organ meats, fish (or other seafood), eggs, non-starchy vegetables, small amounts of berries, avocados, olives, lemon juice, nuts, and seeds and avoiding all vegetable oils and even healthy oils like coconut and olive oil if excess body fast loss is desired.

      Liked by 1 person

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