#67 June 2019 Update on My T1D Management

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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.

This month I want to review a study I recently discovered, but was actually published in 2009. Not sure how I missed it, but I think it is related to the search terms put into Google. Anyway, here goes.

The study was conducted on 434 nondiabetic male and female subjects, age 20−69 years old, at 10 academic hospitals throughout China in which their BG was measured by 3-day CGM and 4 finger-stick blood glucose (BG) measurements daily. Before applying the CGM to the study subjects, they were confirmed to be metabolically healthy (nondiabetic) using a medical history, physical exam, and extensive laboratory testing. The subjects were not taking any medications, had normal body weight, blood pressure, fasting BG and HbA1c, fasting insulin or C-peptide level, homeostatic model assessment of insulin resistance (HOMA-IR), and oral glucose tolerance tests (OGTT). HOMA-IR is simply the fasting insulin level multiplied by the fasting BG. If either value are slightly elevated, then the product of the two will be elevated and indicative of insulin resistance, a precursor to diabetes. The OGTT measures several BG values after consuming a 75-gram glucose solution. If any of the values exceed a predetermined level, this too is indicative of insulin resistance, pre-diabetes, or diabetes. Subjects with any abnormal results were excluded from the study.

The total calorie intake from the three daily meals was 30 kcal/kg􏰉/day during CGM, with 50% carbohydrates, 15% proteins, and 35% fats. Comparing the  interstitial glucose (IG) values at times when the finger-stick BG readings were also obtained, the mean IG was 103 mg/dl and mean BG was 103 mg/dl. For the 434 healthy subjects, the mean 24-hour IG was 104 mg/dl and the mean standard deviation (SD, a measure of glucose variability) of IG was 14.2 mg/dl. The 95th percentile of mean 24-hour IG was 119 mg/dl (6.61 mmol/l). This means that 95% of the metabolically healthy subjects had a mean 24-hour IG as high as 119 mg/dl. The authors of this study considered any mean 24-hour IG ≤ 119 mg/dl to be normal. Interestingly, impaired fasting glucose is defined by the ADA as a fasting plasma glucose between 100−125 mg/dl (5.56−6.94 mmol/l). It should be noted that the World Health Organization (WHO) and numerous other diabetes organizations define the impaired fasting glucose cutoff at 110 mg/dl (6.11 mmol/l). 

Two years later, another paper was published on the same 434 subjects. This paper focused on the glucose variability as measured by standard deviation (SD) of interstitial glucose (IG). The median SD of IG was 13.5 (0.75 mmol/L). The 95th percentile of the SD of IG was 25.2 mg/dl (1.40 mmol/L). Again the authors of this study considered any SD of 24-hour IG ≤ 25.5 mg/dl to be normal.

I included data from three other studies that I have previously reviewed on this blog in Table 2. below.

Glycemic Results For June 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 June 2019. I did not feel well at a body weight of 67 kg. I felt a slight lack of energy and was thinking about food a lot. I was not hungry, but at the end of each meal, I felt like I wanted to eat more. Therefore, I decided to just eat an amount of food that would satisfy me and let my weight be whatever it turns out to be. If I have to go back to the 73 kg weight class to compete in olympic weightlifting, then so be it. Thus, my total daily insulin dose had to be increased a bit during June.

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

I did experience a reduction in hypoglycemia, but an increase in hyperglycemia compared to the previous month. Overall, I was pleased with my results, particularly with the reduction in standard deviation of BG. The graphs below show all of the daily insulin dose totals and all of the BG readings for June 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red. 

In July, I will continue to seek normal mean blood glucose and normal glycemic variability results. I appear to be getting ever closer to achieving that goal. Table 3. below shows my goals from this point forward in light of the results of the two studies presented above.

References:

Zhou, J., et al., (2009). Reference values for continuous glucose monitoring in Chinese subjects, Diabetes Care, 32: 1188–1193.

Zhou, J., et al., (2011). Establishment of normal reference ranges for glycemic variability in Chinese subjects using continuous glucose monitoring, Med Sci Monit, 17(1): CR9-13.

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4 comments

    • Keith Runyan, MD

      I agree. Many who follow a low-carb diet read that 83 mg/dl is a normal blood sugar. This I believe can lead to an increased frequency of hypoglycemia without any expectation for benefit.

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  1. Brian Lucido

    Keith- that is interesting about the study of the people on China. The numbers seemed high until I looked at my conversion chart. 103mg/dL is an A1c of 5.2%, and 119 would be about 5.6% – so “normal.” The 119 would be on the edge of normal, of course. So, I’m curious as to your take on this. As an aside, I spot check my friends when they ask. I’ve seen plenty of athletic friends at 155mg/dL to 180mg/dL – who don’t have diabetes. I also did a search on endurance athletes and diabetes and found a study with CGM graphs where the 10 subjects were almost continually above our target range! Yet they didn’t have diabetes!?!? If you can’t find it, I can post the link to that study when I get home tomorrow. I got the link to the research from an Outside Online article about diabetes in athletes.

    Also, do you have any info on your plan to reduce Lantus and use Humalog every few hours to bridge the gaps and give you more adjustability? I had been eagerly awaiting that project.

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    • Keith Runyan, MD

      Hi Brian, I reread the study so I would recall it correctly. None of the athletes were tested for diabetes, they just put CGMs on them and took the readings. They found that “When the sensor glucose profiles of 10 trained, sub-elite athletes were analyzed over a 6-day monitoring period 4/10 athletes studied spent more than 70% of the total monitoring time above 6 mmol/L even with the 2-hour period after meals removed.” The basic conclusion was athletes are probably eating too many carbohydrates and sugar and they are not as carbohydrate tolerant as one might assume athletes to be. For those interested here is the reference: Blood Glucose Levels of Subelite Athletes During 6 Days of Free Living, Journal of Diabetes Science and Technology 2016, Vol. 10(6) 1335–1343.

      Regarding my insulin dosing, I started at 7 IU Lantus and found I had to increase it progressively over several months to get consistently normal fasting BG. I was also concerned about taking a large bedtime Humalog dose for fear of hypoglycemia which did happen once. The point of that experiment was to have the Lantus low enough so I could take a Humalog dose of at least 0.4 IU at each meal, which seems to be the case for now anyway. So I take Humalog at 7 AM, 12 noon, 5 PM, and 10 PM and take Lantus at 10 PM. I do not take insulin at any other times.

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