#70 September 2019 Update on My T1DM Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with a ketogenic whole-food diet and resistance and aerobic exercise.

If you feel you might benefit from some individual attention and suggestions for achieving success with blood sugar control for type 1 or type 2 diabetes and/or losing excess body fat, I can assist you with a personal consultation via Skype. See the Coaching page for more info.

I wrote an article for DietDoctor in July titled “What you need to know about a low-carb diet and your kidneys“. You can read it here

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

After 13 months of specifically trying to achieve normal blood sugars, I was able to accomplish that goal this month. As mentioned in previous posts, I have had a normal mean blood sugar since I started my ketogenic low-carb diet in 2012. But last year I decided I also wanted normal blood sugar variability. I used as my measure of normality, a standard deviation of blood sugar of less than 25.2 mg/dl (1.4 mmol/l). This value was measured in 434 metabolically healthy subjects in China as reported in this study. My blood sugar goals are summarized in Table 3. below.

Glycemic Results For September 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), calculated HbA1c, body weight, and mean insulin dose totals for September 2019. You can see I am achieved both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Also note the decrease in average daily insulin dose compared to August. I attribute this to the fact that my body weight was stable throughout September as apposed to increasing in August. My current insulin dose is less than half (0.36 IU/kg/day) what it was (0.80 IU/kg/day) prior to starting regular exercise (in 2007) and a low-carbohydrate diet (in 2012).

The table below shows the percentage of blood glucose values in the indicated ranges of low, goal, and high values for September 2019. I just barely missed my stated goals for these parameters, but the low frequency of hypoglycemia is the most important one to me.

This month’s results were improved compared to August. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As shown in the Table 3. above, my goals are < 10% lows, > 80% normals, and < 10% highs. I am pleased with the relatively low frequency of hypoglycemia. My true goal is 0% of blood glucose values < 70 mg/dl, but I am trying to be realistic and thus have set the goal to less than 10%.

The graphs below show all of the daily insulin dose totals and all of the blood sugar (BG) readings for September 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

In olympic weightlifting, the goal is to lift as much weight as possible and to increase the weight over time. This means you are always looking to improve and you never arrive at a final destination. There is always more weight that can be added to the bar. I actually like this aspect of the sport. I like having a daily challenge. I think glycemic control in T1DM is similar to this concept. You can always seek a lower blood sugar variability. I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. I have one more month of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that insulin is very expensive and many people with T1DM do not have access to enough insulin. I plan to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

10 comments

  1. ÉRIC GONZÁLVEZ ESCOLANO

    Congratulations! And good thinking of not throwing Lantus until you finish it, ;-).

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  2. Svet Pavlovsky

    Hi Keith,
    I am struggling recently to calculate the amount of Humalog that needs to cover the meals. Do you have a “formula” that you use based on the nutrition of the meal? Or general guidance. For example, for breakfast of two eggs and cheese and two slices of low carb bread which is about two carbs but have a high amount of fat. Thank you, Svet

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    • Keith Runyan, MD

      Hi Svet, I have seen such formulas but they are used as a starting point. Each individual is different, so saying give x units of insulin for y grams of carbs and z grams of protein would not apply to everyone. The best suggestion I can give is to keep each breakfast the same from day to day and adjust the pre-meal insulin dose based on the pre-meal blood sugar reading. If the meal is kept constant, the variation in the post-meal blood sugar will be reduced. The same would apply to lunch and dinner as far as keeping them constant from day to day.

      Liked by 1 person

  3. Large Hadron Collider

    I’m definitely curious to learn what changing to Tresiba does to your glycemic control.

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    • Keith Runyan, MD

      Thanks for the article Thracion. I was not aware of this article. As a background, I found this article https://care.diabetesjournals.org/content/35/1/131 in June 2019 and decided to decrease my metformin dose from 2500 to 2000 mg/dy. The reduction in dose was also more convenient to take as 1000 mg with breakfast and dinner, rather than an additional 500 mg with lunch. I did not notice an increase in insulin dose after the reduction in metformin dose.
      Anyway, regarding the study you mentioned, I think Figure 2. shows that the difference between the placebo and metformin groups was small and there was a wide range of responses to the progressive resistance training amongst the study subjects. I don’t think I would use this study to make a decision one way or the other regarding the use of metformin. It is common that medications have both benefits and risks or downsides. Based on the research done to date, at least in those with diabetes, I think the benefits of metformin outweighs the potential decrements in response to resistance training.
      I found your new blog and am flattered that I inspired you to start it. I will subscribe to it as well. I hope your glycemic control continues to improve. You have done quite well so far. I am also glad that the metformin has helped you. Cheers.

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      • thracion

        Hi again Keith,
        I just put the article FYI, I myself would be the first one to admit that the benefits far outweigh the downsides. I also do strength training (and BJJ) and middle age is fast approaching, but the undeniable benefits of metformin in my T1 management just trump it all. It’s good for me also to know that you have limited by 500 mg, without insulin dose increase. I’m now taking 1000 mg, split into morning and evening, and probably will do for the foreseeable future (next D-doctor is in a year).
        Thank you for the kind words for the new blog, I’ll try to be more elaborate in future updates 🙂

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  4. Mark Young

    Great work.
    I was pleased to find your blog a few weeks back. I am a type 1 diabetic of similar age (47years) and weight (68kg), I was around the 73 kg mark before starting a ketogenic diet 3 months ago.
    I have been testing my ketones between 3 and 10 times a day in that time, also testing blood glucose around 20 times a day.
    I have seen a strong correlation between blood glucose and ketones (over 6 mmol/l usually lowers ketones).
    Did you find this?
    Exercise contributes to ketone production, so maybe with your training, ketosis was achieved more readily?
    I had a lot of difficulty getting into ketosis, but am having more success now.
    Did you find you slipped out of ketosis while trying to gain weight? I want to try to put some weight back on, but maintain ketosis.
    I’ve bought and read your book ‘The Ketogenic Diet for Type 1 Diabetes’, and greatly appreciate your blog.

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    • Keith Runyan, MD

      Thanks for the kind words, Mark. From 77 simultaneous measurements of blood glucose and ketones that I did in 2013, I found no correlation between the two. Exercise does increase ketosis. I had been on a ketogenic low-carb diet for almost a year before I started measuring blood ketones so I can’t say how long it took me to get into ketosis. I have not been out of ketosis since I started measuring ketones during both losing and gaining weight. I haven’t measured blood ketones in a while, but regularly check breath acetone with the Ketonix device just because I have the device. I have more ketone strips and plan to check blood ketones to see if they correlate with the Ketonix readings. I would not expect a tight correlation because they are measuring different ketones, but there should be some correlation there. As stated in the book, there are really only two reasons to check ketones, 1) to see if one’s carbohydrate intake is low enough to be in nutritional ketosis, and 2) if one becomes ill they should check to see if they might be heading toward DKA.

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