#65 April 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 and/or weight management. See the Coaching page for more info.

April 2019 was an interesting month with more changes. I now believe I have tried every possible combination of Lantus dosing. I have given it at 4 different times of the day 7 AM, 12 PM, 6 PM, and 11 PM once daily. I have given it twice daily and three times daily. I have changed the doses up and down the entire spectrum from A to Z. This month I changed back to my original regimen of once daily at 6 PM. I originally started experimenting with other Lantus regimens in about September last year because I was having problems with not being able to control my BG both fasting and later during the day with exercise without one being too high (6 PM) or the other being too low (7 AM). I was also afraid to give doses of Humalog either before exercise and at bedtime for fear of hypoglycemia. However, now that I have diluted Humalog I can give as little as 0.2 IU of Humalog either before exercise or at bedtime if needed. So, this month I finally decided that there is no regimen of Lantus that will accomplish both goals. Instead, I decided to choose a single 6 PM Lantus dose that would not necessarily result in a normal BG at any time of the day, but would simply be a low enough dose to avoid hypoglycemia 24 hours a day. Then I would be willing to give Humalog 4 times a day at 7 AM, 12 PM, 6 PM, and 11 PM to make up the difference between the Lantus and my actual insulin needs. As usual, I would figure out the Humalog dose by trial and error in small increments or decrements. I also decided to change from 2 to 3 meals a day. I have learned from Donald Layman, PhD and Stewart Phillips, PhD (you can Google those names to find their publications on dietary protein and muscle protein synthesis if you’re interested) that more frequent meal boluses of protein is the best way to avoid sarcopenia of aging especially when combined with resistance exercise. I have no idea whether or not increasing from 2 to 3 meals per day will work and doubt I never will know, put since I will likely need to take Humalog anyway at 12 PM before exercise, I might as well try it. I just got started on this new regimen so I won’t be able to report on the results until next month. I also reduced my daily calorie intake from 2300 kcal/day to 2000 kcal/day in 3 steps of 100 kcal/day with a week between each change to see if I can get down to 67 kg for the purpose of competing in masters olympic weightlifting. If I can’t get down to that weight, I will have to compete at 73 kg.

Glycemic Results For April 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for April 2019. I experienced a slight reduction in insulin doses, but otherwise not much different compared to March.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for April 2019

Note that I changed my target BG range from 71-120 mg/dl to 71-130 mg/dl and my target BG from 95 to 100 mg/dl in order to further reduce the frequency of hypoglycemia which was improved in April. I would like it to continue to reduce it even further. I deleted the other two columns of % of BG readings for the previous months because I did not have time to go back and recalculate the % in range values for Jan. to March 2019.

The graphs below show all of the daily insulin dose totals and all of the BG readings for April 2019.

On April 27th, I think I forgot to take my 6 PM Lantus dose since I had been in the habit of taking it at 11 PM. I am not 100% sure of that, but it was the only explanation I could come up with to explain the sudden jump in BG the following day. I took an extra 3.5 IU of Lantus to try to catch up, but did not want to give a big dose in case I had not forgotten it. Anyway, my BG seemed to have straightened out afterwards.

In May, I will continue with Lantus at 6 PM and I have no plans to change it again. I will tweak the doses of Humalog up to 4 times a day to see if I can further improve my glycemic control. Currently, I feel like 2,000 kcal/day is about the minimum number of calories/day I can eat to feel satisfied. Therefore, I am going to stick with that for several weeks and see what happens to my body weight. This weight loss experiment has been an interesting process having never purposely tried to lose weight before. I am already pretty lean, so I’m not sure if I have much more body fat to give up. Given what happened two months ago when my weight dropped to 65 kg and I got cold, fatigued, and hungry on 1,900 calories/day, I’m not sure if 67 kg will work for me long-term.

I saw an interesting YouTube video of a lecture this past month https://www.youtube.com/watch?v=3RlxpKzoiY8 given by biochemist, Richard Hanson, PhD. Near the end, he describes an experiment with mice that accelerated their ability to burn fat. At the very end, he showed a quote attributed to Winston Churchill that I thought fit perfectly with my pursuit of normal glycemic control.

“Success is going from failure to failure with enthusiasm.”

Thus by Churchhill’s estimation, I have been very successful! Well, I think that is about all I have to share this month. I hope possibly something in these posts will help others with the very challenging task of managing T1DM.

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3 comments

  1. Billy

    Hi Keith you may be interested to read these two web pages regarding the use of Lantus:
    https://www.diabettech.com/diabetes/lantus-lethal-or-lifesaver-doc-gbdoc/
    https://www.diabettech.com/lantus/hypoglycaemia-and-long-acting-insulin-the-switch1-trial-and-why-you-should-try-tresiba-if-youre-on-lantus/
    I used Lantus for some 10 years and could never get consistent results especially during the night, one night I would end up hypo the next I would have optimal BG right through the night. There appeared to be no rhyme or reason for this until I was offered the chance to try a different basal insulin. I changed to Levemir and the overnight hypo’s stopped within a few days, at a later date I changed diabetes consultants and managed to change my basal insulin to Tresiba which I take twice per day and I find its profile to be amazingly flat/stable. If you have the opportunity to trial another basal you might just find that Lantus has been the reason for your issues.

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    • Keith Runyan, MD

      Thanks for that, Billy. I did try Levemir with no real change. I haven’t tried Tresiba yet. I think this month I will know if the problem is Lantus or not. If I don’t get the results I want this month, I will get Tresiba when my Lantus runs out. Thanks so much.

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  2. thanassisBantios

    Hello! This was a very informative post. Regarding the Basal dose, I have come to similar conclusions after doing a lot of basal testing, and following the principles in these two articles:

    https://www.diabetesdaily.com/forum/articles-by-members/16675-basal-testing-mdi/
    https://www.diabetesdaily.com/forum/articles-by-members/15495-getting-most-out-mdi-using-other-insulins/

    As it seems, my basal needs are flat all day (and could be covered by one shot of exactly 14 units of Tresiba), except for about 8 hours, starting from the morning at 04:00 and lasting until 12:00. So I have decided to give an extra shot of Regular when I wake up in the morning.

    In the beginning, I gave myself two shots (one at 04:, and one at 08:00). But then I decided that the extra effort of cutting my sleep in half is worse than having my blood sugar go up a little bit. So what happens now: I may sleep with a good blood sugar (lets say 90-100 mg/dl), wake up at 08:00 with a raised blood sugar (usually no more than 150 mg/dl, usually around 130 mg/dl), correct myself with apidra (eg 2 units), and also give myself a dose of regular to fill the gap (usually 3-4 units). This has worked quite well for me, and my blood sugar is quite stable in the morning hours.

    The most important thing, though is that all the other times of the day a single dose of Tresiba can keep me flat without fluctuations.

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