#61 December 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 five months in my attempt to further improve the glycemic control of my T1DM. These are the changes I made:

  1. Two meals per day: I continued eating breakfast at 7 AM and lunch at 3 PM. I like eating breakfast and given that my meal-time insulin requirements have always been greatest at breakfast, it makes me think that the breakfast Humalog dose is likely also contributing to compensating for the dawn phenomenon. Thus, eating later or skipping breakfast would likely result in morning hyperglycemia or require a larger basal insulin dose. Making my last meal at 3 PM immediately after weight training might help maintain my muscle mass according to some (not all) studies. But other reason to eat at that time is to allow for a 16-hour fasting period daily which might possibly have some metabolic benefits long-term. This also will probably never be formally studied, but I doubt it will hurt anything.
  2. In December, I tried taking Lantus three times daily at 7 AM, 3 PM and 11 PM (from December 1st through the 13th). The 3 PM and 11 PM doses ended up being very small (1-3 IU) and because I can’t measure it any more accurately than 0.25 IU with the insulin syringe, the % difference in dose (from say 1 IU to 1.25 IU i.e. a 25% increase) was rather large and not producing satisfactory result. So on December 14th, I changed to twice daily at 7 AM and 11 PM. So far, I am satisfied with this regimen and will continue it going forward.
  3. I will continue weighing my food on a kitchen scale. I plan to take it with me when I travel to maintain the consistency in food intake which I think is positively contributing to my glycemic control. Weighing food is no longer a bother now that I am seeing a benefit from it compared to years ago when I was using it to calculate carb intake which wasn’t helping at all. My breakfast macronutrient counts are: protein 63 grams, fat 60 grams, carbs 16 grams and lunch macronutrient counts are: protein 65 grams, fat 62 grams, carbs 28 grams. Daily macronutrient totals are: protein 129 grams (or 2.0 grams/kg/day), fat 125 grams, carbs 44 grams (of which 16 grams is fiber). The daily totals expressed as % of total calories are: 28% protein, 62% fat, 10% carbs.
  4. I continue taking metformin at 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. I forgot to take it for one meal in December and again noticed the unexpected rise in BG. 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, high blood pressure, cancer, and Alzheimer’s dementia. These chronic conditions constitute the leading causes of death amongst Americans.
  5. In December, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution. This way I could accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.

Glycemic Management Results for December 2018

My December glycemic results were improved in terms of mean blood glucose (BG) 97 mg/dl (97 mg/dl in October) and standard deviation (SD) 18 mg/dl (29 mg/dl in October). In fact, the SD of 18 mg/dl is a record low result. I just missed my desired BG goal of >70% of time spent with a BG value between 71 and 120 mg/dl.

The graphs below show the total daily insulin dose, and total Humalog and Lantus doses and my actual BG meter readings.

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

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage).

The table below shows the % Time spent in three BG ranges and what the mean BG was during those times.

My Goals For 2019

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

  1. Aim for a mean BG value of 96 mg/dl with a standard deviation of 12 mg/dl.
  2. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl.
  3. Aim for % Time in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but I believe if you aim low, you will likely get what you’re aiming for or conversely, if you aim high, you are more likely to hit the target you’re seeking.

How Will I Achieve These Goals

  1. I think estimating the Lantus insulin doses with the smaller 0.25 IU increments on my insulin syringes and diluting the Humalog 5-fold has helped get my resulting BG closer my target and I will continue doing this.
  2. I will continue Lantus dosing twice daily because that seems to be working.
  3. I am working on a mathematical method to predict my insulin doses based on prior responses. Haven’t found the right formula yet, but my search continues.

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

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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11 comments

  1. Svet Pavlovsky

    Hi Keith, Thank you for sharing your personal T1D management! I am wondering, what is the benefit of taking Lantus two or three times a day when it is supposed to be lasting for 24hr to 26 hours in the body?

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    • Keith Runyan, MD

      Hi Svet, Happy New Year and Thanks for being one of the first followers of this blog! In general, the duration of action of basal insulins can vary quite a bit from one person to the next. However without eliminating other variables such as varying meal macronutrient content, varying exercise type, duration, and intensity, and timing of meals, I was not able to determine that any given dose of Lantus given at 6 PM would or would not result in the correct morning BG AND the correct after-exercise BG. Either the morning BG was too low and the after-exercise BG was just right, or the morning BG was just right and the after-exercise BG was too high. After eliminating those variables, I concluded that the effect of Lantus, in me, as not as constant as I thought (for the past 13 years!). Thus dividing the total dose into about 2/3 in the morning and 1/3 at bedtime seems to be working much better in terms of the BG response. Unfortunately, figuring this out is a matter of trial and error which seems to be ongoing theme of T1DM. If my Lantus requirement (total daily dose) were higher, I think three times a day would have worked as well. That said, if two works well, why take an extra injection? The other advantage of twice daily over once daily is the ability to adjust each dose separately based on the morning BG vs the after-exercise BG. I think it is better to adjust each and every insulin dose based on the BG result rather than thinking that my insulin requirements never change and giving fixed doses (but that is probably already apparent).

      Liked by 1 person

    • Keith Runyan, MD

      Thanks Brian, I am definitely trying. First I want to see what is possible by keeping as many things constant as I can. I should also say I do not think it is necessary to have a perfectly normal BG and standard deviation to be healthy, but I do think the closer we can get to it, the better off we will be as long as hypoglycemia is avoided. Probably in February I will go back to olympic weightlifting (which I don’t want to give up permanently) and see if that was a source of glycemic variation or if it was the Lantus dosing all this time. Currently I am doing a machine weight exercise routine, same exercises, sets and reps with 1.25 lb. weight increases about once a week. I sure this won’t surprise you, but about half of the BG values below 70 mg/dl were the result of unplanned chores around the house like cutting the yard, cleaning, doing repairs, etc. Even though I see this over and over again, it still amazes me what a precise job the normal functioning pancreas does!

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  2. Laudine

    Hi! Happy new year !
    I have always been very curious about keto diet while being T1D. From the scientific point of view it has always made sense. But every doctor I asked about keto , has always discouraged me from trying ,scaring me with ketosis and preaching how carbs are so important. I have tried low carb diet and I felt so much better ! But then I was diagnosed with other diseases and went into depression – in result , sadly , I stopped following any dietary directives .. I feel stronger and better now and I am ready to follow keto diet. My only fear is – what do I do if my sugar level drops ? Would eating carbs to treat hypoglycemia ruin my nutritional ketosis? Are there any safe options ?

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    • Keith Runyan, MD

      Hi Laudine, There is a lot of free information on this blog. It will take time to read it. You should also read my book. The answer to your question is covered in Post #54. The very low carbohydrate ketogenic diet is a an excellent tool for type 1 diabetes. Best wishes.

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  3. thracion

    Hi Keith,
    I’ve been following your blog since I bought your ketogenic book about a year ago.
    The one thing that I consider might be beneficial to me is adding metformin.
    I am a 38yo, a bit overweight with BMI of 27-28%, albeit a muscular type and working out at the gym and also BJJ on an almost daily basis.
    On a very low-carb, high protein diet I still average about 50 units/day (pumping Fiasp).
    In Finland, we have public health insurance, and while it is great and practically free, it does come with downsides.
    Namely, a public health doctor who considers metformin an “alternative” treatment and not suitable for T1, due to the risk of hypos.
    With an A1c of 6% they already consider my management to be exemplary and anything on top of it would be too risky in terms of hypo. As for me, I know I am heavily insulin resistant.
    I am trying to make a convincing case for the next d-doctor meeting where I can convince her that trying out metformin medication would make sense.
    Do you think, as a doctor, can make a case that could convince a fellow colleague in the usefulness of that treatment?
    I can point to actual studies, blogs (such as yours), etc. but believe that could be a less effective approach.
    I’d be extremely keen on hearing what you have to say. Thanks!
    I love your meticulousness in your blog posts and the way you manage yourself with an iron hand. It’s inspiring and please keep those updates rolling! 🙂

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    • Keith Runyan, MD

      Thanks for your comment/question. Most doctors are reluctant to prescribe anything that is not “approved”, so I understand. I recommend reading my blog post #40. From which I copied this:
      A meta-analysis of eight randomized-controlled trials published in 2015 came to similar conclusions: “Metformin was associated with a reduction in daily insulin dosage, body weight, total cholesterol level, low-density lipoprotein level, and high-density lipoprotein level but an increase in risk of gastrointestinal adverse effects compared with placebo treatment in T1DM patients. No significant difference was found between the metformin group and the placebo group in HbA1c level, fasting plasma glucose level, or triglycerides level. No significant difference was found between the metformin group and the placebo group in the risk of severe hypoglycemia or diabetic ketoacidosis.”
      I also experienced a reduction in daily insulin dosage which is why I have continued it since Jan. 2017. It helps those with T1DM and insulin resistance become more insulin sensitive. You can point out that meta-analysis, the potential benefits, and the lack of hypoglycemia which is her concern. Tell her if she will prescribe metformin, you will be very careful about adjusting your insulin dose to avoid any excess hypoglycemia. I would be interested in her response. Here’s the reference: https://www.ncbi.nlm.nih.gov/pubmed/25369141
      Finally, you do not need metformin to lose excess body fat. You need to decrease your food intake and adjust your insulin doses (downward). Becoming lean will result in a dramatic improvement in your insulin sensitivity and reduction in insulin doses. As I mentioned in my last blog post, using cronometer.com will help you design a diet that is low in carbs, lower in calories, adequate in protein, and has all the micronutrients you need. My recent 22 lb. weight loss dropped my insulin dose from 40 to 20 IU/day which dwarfs the effect of metformin (although I will continue metformin for life unless something changes). Good luck.

      Liked by 1 person

      • thracion

        Wow, that was spot on. Thank you! I think I have enough to go on at the doctor’s even without quoting studies.
        About the weight loss, I haven’t given it probably enough thought, and though I know I should be much leaner without a proper plan it is incredibly hard to do so, even with an active after-work lifestyle. The 50% drop of insulin requirement sounds particularly encouraging. I’m already doing daily IF of about 14 hours (from 21:00 to 11:00), but now have decided to also replace the lunch at work with green smoothies/protein shakes in order to accommodate for further caloric deficit. It does seem to work already as I feel giant hunger pans about 20 minutes after my BJJ class. 🙂
        Thanks again!

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      • Keith Runyan, MD

        I know you did not ask a question, but I always get concerned when someone measures success in losing weight with becoming hungry. Now if you are only hungry immediately before a meal and at no other times, that’s OK. But if you have hours per day where you are resisting hunger, that is not fun and generally not sustainable. If that is the case, maybe you have chosen too much of a calorie deficit.

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