#62 January 2019 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 now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes. See the Coaching page for more info.

I have made several changes over the past six months in my attempt to further improve the glycemic control of my T1DM. These are the changes I have made:

  1. Two meals per day.
  2. More than one basal insulin dose per day.
  3. Achieved a leaner body composition which in turn dramatically reduced my insulin requirement per kg of body weight which reflects an improved insulin sensitivity.
  4. Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. By standardize, I mean the same exercises with the same duration and only minor occasional increases in intensity over time.
  5. Emphasized avoiding hypoglycemia as a more important goal compared to achieving any particular mean BG level. Hypoglycemia (BG < 71 mg/dl) is both unpleasant to experience and is life-threatening, whereas, mild transient hyperglycemia (BG > 120 mg/dl) is very unlikely to cause any problems.
  6. Using cronometer.com to design different meal plans that I enjoy and can eat over and over again, each composed of the same amounts of macronutrients (protein, fat, and carbs) and each containing > 100% of the RDA for all vitamins and minerals. Since I do feel I get the best results from a low carb ketogenic diet and I feel a higher protein intake will best preserve my muscle mass as I age (currently 58 years old), I chose to design each meal so that I get a daily total intake of 2.2 grams protein/kg BW/day and 57 grams of carbohydrate. If I could meet the > 100% RDA goal with fewer total grams of carbs I would do that, but non-starchy green vegetables do contain a fair number of carbs. Also, the fact that included in that 57 grams of carbs is 22 grams of fiber/day which reduces the BG impact of those carbs. Another way of saying that is I eat 35 grams of net carbs/day.
  7. Weighing my food on a kitchen scale helps to precisely follow my own meal plan.
  8. The combination of 6. and 7. above also makes achieving a lean body composition a lot easier.
  9. Taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with dinner really reduces my meal-time insulin requirements.
  10. In December 2018, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution to use as my meal-time insulin. This way I can accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.

I have greatly simplified my data presentation down to the bare essentials. At this point in time, I think the four most important metrics are: mean BG, standard deviation (SD) of BG, % of BG meter reading in the normal range (71 – 120 mg/dl), and % of BG meter reading < 71 mg/dl (a rough measure of the frequency of hypoglycemia). 

Glycemic Management Results for January 2019

First, note I made an error in reporting my SD results last month. I stated it was 18 mg/dl and I was pleased since it was the lowest I had ever achieved. Unfortunately, I had unknowingly introduced an error in my spreadsheet program which I use to calculate the SD. My actual SD for December 2018 was 28 mg/dl which was unchanged from previous months.

My January 2019 insulin doses and BG results were about the same as last month.

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 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) as well as my current body weight and mean insulin dose totals. My height is 5’8″.

The table below shows the % of BG meter reading in three BG ranges. 

My Goals For 2019

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

  1. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl. 
  2. Aim for a mean BG value of 96 mg/dl with a standard deviation of 12 mg/dl.
  3. Aim for % of BG meter reading in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but having a challenging target is motivating to me.

How Will I Achieve These Goals

  1. I will continue Lantus dosing twice daily and make small infrequent changes in dose based on my BG responses.
  2. I will continue using the 5-fold diluted Humalog to more precisely adjust my meal-time insulin dose.
  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 experimentation continues.

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

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15 comments

  1. Brian Lucido

    This is good that you are continuing to (nearly) reach your glucose goals with very little insulin. I have read online that the most common connection between people who have survived a long time with type 1 diabetes is a low insulin dose. Your TDD is about what mine was when I was doing well (and eating approximately the same as you). Now I have been bike touring in Latin America for 2.5 months and my TDD has increased 50% due to a combination of insulin being exposed to constant high temps, and poor food selection. Oddly, this all day exercise only lowers my insulin needs if there is a fairly hard effort for an extended period. So with your weight loss, are you hungry often? If so, how do you manage? Again, good work on your numbers! I was a little bummed to see your SD was miscalculated- but it is still a very good number.

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    • Keith Runyan, MD

      Bike touring in Latin America sounds very challenging! Not really surprised your diabetes metrics have changed. I think living life is important as well and as long you are avoiding serious hypoglycemia, you will still be OK.

      Part of the reason my BG results are not improved is because I have been experimenting with different insulin dosing regimens and at the same time adjusting my daily total calories. I am seeking the maximum number of calories that will still result in a body weight of 66 kg. I did experience hunger for the first time when my daily caloric intake bottomed out at 1900 kcal/day (my BW also dropped to 64.8 kg). I have increased my caloric intake twice since then, to 2560 kcal/day for now. Eventually, I will get both the daily caloric intake and insulin doses right and then hopefully stick with it for a long time. I don’t like the BG swings that result from these frequent changes. I do like the regimen I have implemented. If nothing else, I feel like I am doing everything possible to optimize my BG control, minimize my insulin doses, and stay safe by minimizing hypoglycemia.

      I will be interested to see how low I can get the SD. I consider that to be my fourth highest priority, but I do not feel I can really say my BG results are “normal” unless the SD is also normal or very close to normal. My priorities are 1) minimizing hypoglycemia, 2) normalizing mean BG, 3) minimizing insulin doses, and 4) normalizing BG SD.

      BTW, I have enjoyed reading your blog as well and I encourage others to check it out here. https://www.brianlucido.com

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  2. thanassisBantios

    Hello! In regards to that:

    “Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. ”

    I have found that the best way to have predictable Blood sugars is not only to standardise the workout sequence, intensity etcr, but also to work out every day using the same workout. This may sound very, very limited, and in some cases not a good thing exercise – wise, but I have seen the best results using that regimen.

    For example, lets say that you work out 3 days/week, weightlifting, each workout consists of 12 sets. One way will be to workout every day, 6 days a week, using only 6 sets per day.

    As I said , I have tried this and had extremely predictable blood sugars. I abandoned it only because strength training was difficult in this way. I think aerobic training can be done better this way (eg. Running for 30 minutes every day, or something like that). The idea is to keep the insulin sensitivity as constant as possible.

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    • Keith Runyan, MD

      I agree with you 100%. I started doing the same 6 months ago. The only difficulty has been finding a low enough dose of exercise that I can recover from. One or two days a month I just have to take a day off. Also, that low dose is not very conducive to achieving any sort of competitive competency. But at this stage of life, my priority is my BG management over being competitive, so it’s OK.

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      • thanassisBantios

        Interesting! Would it be possible for you to share your workout regimen? so we get ideas! I remember you practice Olympic weightlifting, so what would a low dose be for every day?

        I strength train 3 times per week, 12 set each workout. 3-5 repetitions, 2-3 mins rest between each set. The other regimen I have tried (and abandoned although I had much better BS management – thinking getting back into it) is workout every day, 6 sets each day, again 3-5 reps and 2-3 mins rest. When I did this, I used a Push-Pull-Legs split, so Monday/Thursday was Push, Tuesday/Friday Pull and Wednesday/Saturday Legs.

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      • Keith Runyan, MD

        My olympic weightlifting is on hold while my hip heals. Should be back to it soon. Right now I am doing machine (Universal type machine) resistance exercises. I do 3 sets of 10 reps of 1) arm curls, 2) triceps extension, 3) leg extensions, 4) leg curls, 5) lat pull-downs, 6) calf raises, 7) superman low back extensions, 8) leg raises. The weights I’m using wouldn’t mean much because it is machine dependent, but I increase the weight by 1.25 lb. once per week on all exercises assuming I am able to complete all reps and sets and it doesn’t feel terribly challenging. That is a pretty slow rate of progression which is my method to being able to recover by the next day. I also walk 2 miles before I lift weights and another 2 miles after I lift weights for sun exposure, a little cardiovascular exercise, and to chat with the neighbors. I have a treadmill in the event of rain. Nothing magic about it, the amount of exercise from which I can recover was determined by trial and error just like insulin doses and everything else related to diabetes management.

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  3. Billy

    Hi Keith i recently found your blog and I would be interested to know why you are using such a potent bolus insulin especially as you are insulin sensitive? Have you tried Human insulin in the past and not found it suitable.?

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    • Keith Runyan, MD

      Good question, Billy. After I read Dr. Bernstein’s book in 2012, I switched from Humalog to Regular insulin per his recommendation. I found that it took a long time for my blood glucose (BG) to return to the pre-meal level again. I gave it two months to confirm that it was a consistent finding. So I switched back to Humalog. Humalog has a faster onset, 15 mins, peaks in about 1-1.5 hrs, and lasts 3-5 hours total. I can’t say exactly why it works better for me, but it could be that I do not have any gastroparesis or I just digest faster than others. When the dose of Humalog gets low, having the diluted Humalog really comes in handy so that it can be accurately dosed. Having written two books on diabetes, I can say it is difficult to give specific recommendations because the optimal treatment for diabetes varies from individual to individual. That is why it really helps to both carefully experiment with different approaches and to have a doctor to consult with to help customize solutions. I hope that helps.

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      • Billy

        Many thanks for such a comprehensive reply Keith. I have read both your book (for type 1) and also Dr Bernstein’s and I have had Type 1 since 1989 (21 years old at diagnosis). I agree that we all have different requirements when it comes to managing T1D the best we can. I seem to be the opposite to you in the respect that if I was to use humalog for my meals I would be hypo within a very short time after injecting and sometimes even regular can be too fast!. (especially at lunch time) I have wondered if I have gastroparesis, however my response to food and insulin is fairly predictable nowadays after 4 years low carbing.

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  4. Rien

    Hi Keith, you are doing a wonderful job! I have tried keto to manage my type 1 a few years ago. Unfortunately I had to stop it, as my total serum cholesterol went from 3.3 to > 10 mmol/L (128 mg/dl to 387 mg/dl). Most of it was LDL. How are you managing your cholesterol?

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    • Keith Runyan, MD

      Fortunately, I did not have to “manage” my cholesterol. Having read about the beneficial effects of the diet on cardiovascular risk markers particularly lowering of triglycerides and raising of HDL-C, I stopped taking pravastatin (statins are recommended for everyone with diabetes due to the increased risk of cardiovascular disease) on the day I started my low carb diet. Four months later after having started my low carb ketogenic diet on Feb. 8, 2012, my LDL-C had increased from 100 to 162 mg/dl. I did not panic and rechecked it 6 months later at 136 mg/dl. But my triglycerides were 78, HDL-C was 91 mg/dl, and ApoB100 was 100 mg/dl. After six years on the diet, I checked my CAC score on April 24, 2018. My score was zero, indicating no coronary artery calcium. Given that my glycemic control and hypoglycemia had improved so much, I felt that continuing the diet would be more beneficial that stopping it even if my LDL-C had increased by more than it did. Remember that the increased risk of heart disease in persons with diabetes is due to lack of glycemic control and a high exogenous dose or endogenous insulin level. The low carb diet improves all of those. Also, note that LDL-C is not a strong risk factor for heart disease in the first place and that its weak association with heart disease was primarily in males with known heart disease and while eating a high carb standard American diet. It has not been studied in persons following a low carb diet. I think there is good evidence that the high carb, high glycemic load, standard American diet is very likely a causative agent in heart disease. Thus, rather than eating porridge, oats, honey, raisins, sugar and milk for breakfast, for example, it would be better to eat a low carb ketogenic diet, have close to normal blood glucose with lower insulin requirements (whether that is endogenous or exogenous). Finally many who follow a low carb diet whose LDL-C did increase markedly, have been able to lower it by replacing dairy with olive oil, nuts, and seeds. At the end of the day, each person needs to learn as much as they can about their disease and come up with their own decision about their path. Best of luck with your path.

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      • Rien

        Thanks for your detailed response, Keith. It is food for thought. Porridge does send my BGL to dizzying heights. Still, my last A1c was 5.8%, higher than it has been. Too low, according to my endo. Sigh.

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      • Keith Runyan, MD

        Rien, your endo thinks your HbA1c is too low because he/she assumes you are having a lot of hypos. I don’t know if that is the case or not. However, even if you don’t want to try a ketogenic diet again because of the LDL-C, you certainly don’t need to pick out the high glycemic index carbohydrates to include in your diet. Low glycemic carbs around 100 grams per day might markedly improve your glycemic variation and likely reduce your insulin requirements. Just saying.

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