#57 September 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. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I have made several changes over the past two months to further improve the glycemic control of my T1DM. These include:

  • I returned to two meals per day on 8/8/2018, but now eating breakfast (7:30-8 AM) and late lunch (3 PM) instead of breakfast and dinner. This will result in a 16 hr daily fast. It has also allowed me to administer Humalog and Lantus separately rather than together at dinner time. Turns out my basal Lantus dose was too high and my dinner-time Humalog dose was too low (many days I was not even taking Humalog at dinner-time). So now I take Humalog at breakfast (7:30-8 AM) and late lunch (3 PM) and take Lantus at 6 PM. I check my blood glucose (BG) five times a day at 7:30 AM (fasting i.e. before breakfast) and 10:30 AM, at noon I exercise, another BG check and lunch at 3 PM, check BG at 6 PM and take my dose of Lantus, then check BG at 10 PM (bedtime).
  • I returned to weighing my food on a kitchen scale to more accurately balance the Humalog dose with food. The last time I did this was about 10 years ago when I was carbohydrate counting. I did it for two years with very unsatisfactory results. IMO carbohydrate counting does not work for T1DM (or for T2DM).
  • I increased my dose of metformin to the maximum of 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with lunch. I am convinced that even though I am relatively insulin sensitive, the metformin helps control post-meal BG by suppressing liver glucose production in response to meals and may be increasing muscle glucose uptake. I know this because on the occasions when I forgot to take the dose my post-meal BG was significantly elevated compared to the previous days when I took the metformin. It makes sense that metformin would help T1DM because as I reviewed in other articles on my website lowcarbdiabetesdoctor.com, exogenous insulin is at a relatively low concentration around the pancreatic alpha-cells compared to normal and thus glucagon secretion is chronically elevated and particularly elevated after meals since amino acids (from the protein in the meal) directly stimulate alpha-cell glucagon secretion. Glucagon in turn stimulates liver glucose production. Less liver glucose production in turn means either lower BG or since my BG is low already, means lower insulin doses. I think lower insulin doses while BG is controlled is a benefit.
  • All of the above resulted in a reduction in total daily insulin dose from 24.5 IU/day on 8/8/2018 to 16 IU/day on 9/30/2018 as well as a reduction in body weight from 163.4 to 150.6 lb. I am sure the reduction in body weight contributed somewhat to the reduction in insulin dose. However, insulin dose is usually expressed as IU/kg body weight and when expressed this way it is a reflection of insulin sensitivity. The lower the dose, the better the insulin sensitivity (assuming BG control is the same). Expressed this way, my total daily insulin dose decreased from 0.33 IU/kg BW/day on 8/8/2018 to 0.23 IU/kg BW/day on 9/30/2018. Thus, my insulin sensitivity improved due to either the weight reduction or the small increase in metformin dose from 2,000 mg/day to 2,500 mg/day, or both combined. Either way, this is the lowest dose of insulin I have taken since my diagnosis in 1998.
  • The last change I made was to decrease the volume of vegetables I was eating. This was due to some GI disturbances after meals. I was really eating more than I needed, so hopefully the reduction will correct the GI problem. I will discuss this in more detail next month once I’m sure the GI problem has resolved (it is an intermittent problem so it will take some time to sort out). I will review my new diet menu and include the macronutrients and micronutrients next month. Since non-starchy vegetables are mainly composed of carbohydrates some of which are fiber as well as important vitamins and minerals, reducing them has resulted in a reduction in total carbohydrates which could additionally have contributed to the reduction in insulin requirements.

Glycemic Management Results for September 2018

My September glycemic results were somewhat improved compared to previous time periods. I reached my desired BG goal of >70% time spent with a BG value between 61 and 110 mg/dl. I had about the same frequency of asymptomatic hypoglycemia this month compared to last month. Preventing hypoglycemia is my top priority now. I think I can figure out a way to make it a rare event.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for September 2018 compared to previous time periods. 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 57 Means Table

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

Post 57 BG Humalog Doses.png

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 than 5 times per day or using an accurate CGM would result in a more accurate estimate.

Post 57 Variability Table

The daily insulin dose totals started at 19 IU and ended the month at 16 IU with a bump up in the middle of the month. As mentioned above, 16 IU is the lowest dose since my diagnosis so I hope that continues and wasn’t just a fluke.

Post 57 BG Insulin Dose Totals

The daily insulin dose totals for 2018 are shown in the graph below. You can see a steady reduction in insulin doses since the peak at the beginning of January 2018. I outlined above the measures I have taken this year to reduce my insulin requirements. Included in that list is regular exercise which I continue daily.

Post 57 2018 Insulin Dose Totals

I will skip the section on my current diet because it is still being adjusted until my GI issue is resolved. I am experimenting with which and how much non-starchy vegetables I can tolerate and still come close to 100% of the RDA values for each nutrient.

That’s all folks…..

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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