#71 October 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.

This month I did an interview with Ross Wollen on asweetlife.org titled “Interview: Dr. Runyan is the Diabetic Ketogenic Athlete.” You can read it here.

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.

Last month, after 13 months of specifically trying to achieve normal blood sugars, I was able to accomplish that goal. This month, in addition to achieving a normal average and standard deviation of blood sugar, I was able to reach an additional blood sugar goal: the percentage of blood sugar values in the range 70 to 130 mg/dl of > 80%. This was despite having a back strain on 10/19/19 during olympic weightlifting that required changing my exercise regimen and insulin doses significantly. 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 October 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 October 2019. You can see I have achieved both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Note the increase in average daily insulin dose compared to September. As mentioned, I attribute this to the change in exercise due to the back strain. My current insulin dose (0.39 IU/kg/day) is still less than half what it was (0.80 IU/kg/day) prior to starting regular exercise in 2007 and a ketogenic 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 October 2019. I met two out of three of 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 last month. 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 October 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red. You can see the increase in insulin doses beginning after the back strain on 10/19/19. In contrast to times past, the increase in insulin doses was modest and stabilized much sooner. I think this why I was able to keep the blood sugars normal this month. You can also see the increase in blood sugars after 10/19/19 that prompted the increase in insulin doses. It took 3 days of insulin dose increases to resolve the high blood sugars. Had I known exactly how long it would take for my back to recover, I would have increased the basal insulin (Lantus) dose sooner. As of today, I still have not returned to olympic weightlifting, but my back is improving and I hope to start back on Monday, Nov. 4th. Note that the day after the back strain on 10/20/19, I increased my walk distance from 1.5 to 2.5 miles twice daily to try stay as insulin sensitive as I was while lifting weights. Clearly, walking is not as insulin sensitizing as lifting weights. On 10/27/19, I started doing bodybuilding type machine weight training and you can see the blood sugars and Humalog doses started decreasing.

This is a pattern I have observed over and over again. Each type, duration, and intensity of exercise results in different blood sugar, insulin sensitivity, and insulin dose requirements. I have found that keeping exercise constant from day to day has helped me achieve normal blood sugars, but when changes are required, as in the case of injury, at least devising a new exercise regimen and keeping that constant will allow blood sugars and insulin doses to again stabilize.

As I have mentioned in previous posts, I decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. I have received my order of Tresiba and it is in my refrigerator ready to go as soon as my last vial of Lantus is used up. I expect 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…

9 comments

  1. Brian Lucido

    Keith – Great work on achieving your goals this (and last) month! Your standard deviation of 24 is very good two months in a row. I see that you have had to reduce your exercise, and am sorry to hear about your injury. I just wanted to input that I just came back from a 2 month exercise intensive bike trip and decided to experiment with zero bike riding (but still doing household chores and gardening for exercise). I’ve been titrating my insulin DOWN, and in these 3 weeks of zero intensity exercise, my BG control has improved significantly. That seems counter-intuitive, right? I’m not losing weight, but I have been weighing my food and making sure not to eat too much. I know that earlier this year you had been losing weight and finally hit a point where you had to up the calories. Anyway, I once thought that my exercise was “insulin sensitizing,” but now I’m not 100% sure that this is the only pathway to insulin sensitivity. I’m thinking that carefully controlled caloric intake can do just as good of a job as exercise with the added benefit of greater stability.

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    • Keith Runyan, MD

      Thanks, Brian. Without knowing exactly what you were eating while biking versus what you are eating now, it is difficult to compare insulin doses from then versus now. I think all that biking was insulin sensitizing. I would guess you were eating more calories and maybe more carbs too which could explain the higher insulin requirement when biking. I think the reason to exercise is for the enjoyment of it and the health benefits that can’t be achieved with diet alone. I think by keeping exercise consistent from day to day, blood sugars can be normal. Any reduction in caloric intake will reduce insulin requirements. I don’t think that means insulin sensitivity has increased, although I understand the assumption that insulin sensitivity might always be inversely proportional to the total daily insulin dose. I’m not sure if I addressed your query. If not, let me know.

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  2. Svet Pavlovsky

    That is very nice, that you have normal blood sugars and deviation. Thank you for sharing all the details. It is very informative to see your daily insulin doses and body weight, at least to get a rough idea. I hope you are better and back to your exercise routine.

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  3. Eva

    I just received my book and I’m so grateful and happy for your work and sharing your experiences. I was diagnosed type one diabetic at age 33 and thought eating low-carb means less insulin. I am shocked that the ketogenic diet was never recommended in all of my experience. I’ve had a dramatic decrease in both NovoLog and Lantis but when I exercise I get hypoglycemia and have to force-feed myself orange juice or some other carbohydrate so it’s hard for me to lose weight. I keep an apple or glucose tablets on me. Thank you so much and everyone else who is sharing I finally don’t feel alone! I will continue reading and I’m working on taking further steps ahead without hypoglycemic episodes.

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    • Keith Runyan, MD

      This is common problem. In general, lowering basal insulin, keeping exercise consistent from day to day, and waiting several hours after the last bolus insulin dose before exercising will help decrease the likelihood of hypoglycemia. If you need specific help, see my Coaching page.

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      • Eva

        My blood sugar this morning was 111 and this is after having 13 grams max carbs per meal yesterday without Novolog!!! I took 11 units Lantus last night. I can’t believe it I thought my morning blood sugar was going to be awful. I will keep reading the book, having no carbs or very little takes discipline wish me luck 👍🏼.

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  4. insightoutdoors

    First of all, thank you for sharing your experiences. I have been diabetic for 18 years now and have been eating a ketogenic diet for the past 2 years with great success. I am however having difficulty finding any info on coming off of a keto diet with type 1. Is it safe to just up and eat slow carbs all of a sudden? Do you follow a true keto diet or are you eating more of a slow and low carb diet? My issue is that keto is tough to sustain 100% for long term. I feel like eating a lower carb diet but not being in ketosis may be easier to sustain and be able to eat a higher carb meal once in a while without needing to plan a day or two in advance to transition out of keto. What are your thoughts on this?

    Thanks!

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    • Keith Runyan, MD

      Hi there, I choose to eat a low-glycemic very low-carbohydrate ketogenic diet and have done so continuously for almost 8 years now. Only recently have I been able to normalize my blood sugars. What made the difference? Consistency in diet, exercise, and sleep. I think you could formulate a low-glycemic moderately low carb diet, say 75-100 grams of total carbohydrate per day or whatever you enjoy and can sustain long-term and still have very good blood sugar control. But I think having a higher carb meal once in a while (which I interpret to mean that your carb intake would change from day to day) would likely result in more blood sugar variability than I personally would like. You may be different. So to be clear, being in ketosis is not what reduces blood sugar variability, it is the lack of carbohydrates and day to day consistency in dietary protein, carbohydrates, and fat that reduces blood sugar variability, in my opinion. So I think of nutritional ketosis as a side-effect, albeit a good side-effect, of a very low-carbohydrate diet. I hope that helps.

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