#59 November 2018 Update on My Type 1 Diabetes 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 four months in my attempt to further improve the glycemic control of my T1DM. These include:

  1. I returned to two meals per day on 8/8/2018, but now eating breakfast (7 AM) and lunch (2 PM) instead of breakfast (7 AM) and dinner (6 PM). This has allowed me to administer Humalog at 7 AM and 2 PM and Lantus at 6 PM separately rather than Humalog and Lantus together at 6 PM as I had been doing for many years. 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). I did notice in November that although this improved my fasting BG readings, I was still have very different results with only tiny differences in the 6 PM Lantus doses. More on this shortly.
  2. I returned to weighing my food on a kitchen scale last month to more accurately balance the Humalog dose with food. The last time I did this was about 10 years ago when I was counting carbohydrates. I did it for two years with very unsatisfactory results. IMO carbohydrate counting does not work for T1DM (or for T2DM for that matter) primarily because eating a lot a carbs in those with diabetes does not work.
  3. Last month, 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 have been tolerating this maximal dose without any side effects. 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 as well. These are the known mechanisms of metformin in helping to control BG in diabetes. I believe metformin is helping me because on the several occasions when I forgot to take the dose my post-meal BG was significantly elevated (by 30 – 40 mg/dl) compared to the previous days when I took the metformin. It makes sense that metformin would help T1DM because 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 (and ketone production). Less liver glucose production by taking metformin 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 beneficial in terms of prevention of insulin resistance (and therefore “double diabetes”), cardiovascular disease, cancer, and Alzheimer’s dementia. These chronic conditions constitute the top causes of death amongst Americans.
  4. In November, I decided to try again to use smaller doses of my basal insulin, Lantus, given twice daily. But after three days, I decided to go ahead and try it three times a day which I have never tried before. This started just a few days ago (11/26/2018) so I will have to wait till next month to comment on the results. My rationale for this change was I had to change my weightlifting from the whole-body movements of olympic weightlifting (OWL) to bodybuilding type exercises on a machine due to a nagging hip discomfort that only occurs when standing up from a deep squat. However, OWL cannot be done without doing a deep squat. Interestingly I noticed that after the bodybuilding exercises, my BG was going up just as much as after OWL. These two types of exercises are completely different. The bodybuilding exercises, at least the way I have been doing them, are not at all intense. This made me suspect that the elevated BG values after both OWL and the easy bodybuilding exercises were more likely due to insufficient insulin onboard rather than release of stress hormones as I have thinking for quite a long time. This is why I decided to add a 7 AM morning Lantus dose to prevent the BG increase that occurs between 10:30 AM and 2 PM. After three days of twice daily Lantus, due to the above mentioned variation in fasting BG with small changes in the 6 PM Lantus dose, I decided to try giving the Lantus three times a day (at 7 AM, 2 PM, 10 PM) with smaller doses at 2 PM and 10 PM. I hope it works.

Glycemic Management Results for November 2018

My November glycemic results were about the same in terms of mean BG (97 mg/dl) and standard deviation (29 mg/dl) compared to October. Of course I was hoping for a reduction in standard deviation, but I did not achieve that. I did reach my desired BG goal of >70% of time spent with a BG value between 71 and 110 mg/dl and I had a reduced frequency of asymptomatic hypoglycemia. In November, my BG was calculated to be <71 mg/dl 10% of the time with a mean of 68 mg/dl during that time, 73% of the time BG was between 71 and 120 mg/dl with a mean of 89 mg/dl during that time, 17% were >120 mg/dl with a mean of 137 mg/dl during that time. No BG readings were in excess of 200 mg/dl. Preventing hypoglycemia is my top priority now so this reduction in asymptomatic hypoglycemia was encouraging.

The graphs below shows the total daily insulin doses of Humalog and Lantus and the total of both insulin doses and my actual BG readings.

The graph below shows each Humalog and Lantus dose taken during the month.

I had more fluctuations in insulin doses than I think is helpful. I think it reflects an impatience on my part to achieve normal BG as soon as possible.

My Goals For December 2018

I continue to strive for normal BG values and my goals are to:

  1. Achieve normal BG values including mean BG of 96 mg/dl with a standard deviation of 12 mg/dl or at least close to those values.
  2. Eliminate hypoglycemia i.e. BG < 71 mg/dl.
  3. In December, I am going to try my best to limit changing insulin doses to +/- 0.25-0.5 from one day to the next especially with the Lantus doses due to its longer half-life.

How Will I Achieve These Goals

  1. I think estimating insulin doses with the smaller 0.25 IU increments on my insulin syringes has helped get my resulting BG closer my target and I will continue doing that.
  2. I will try three times a day Lantus dosing to see if that helps.

I hope these measures will result in some improvements next month.

Published by Keith Runyan, MD

I'm a physician with type 1 diabetes who uses a ketogenic diet and exercise to manage my diabetes. The purpose of the blog is to describe the lifestyle changes I made that have resulted in near-normal blood glucose, reduction in hypoglycemic events and symptoms, and reduction in insulin doses.

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