#76 February 2020 Update on My T1DM Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and now Tresiba 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.

In October 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

Glycemic Results For February 2020

My February 2020 glycemic results were excellent except for having more blood sugars < 74 mg/dl than my goal of < 5%. My monthly blood glucose variability, as measured by standard deviation, was a new low at 16 mg/dl, since my diagnosis of type 1 diabetes in 1998.

The graph below shows all the blood glucose measurements and daily insulin dose totals for February 2020.

My blood sugar goals are shown in Tables 2.3 and 2.4 below. I used as my measure of normality, a standard deviation of blood glucose (SDBG) of less than 18 mg/dl (1.0 mmol/l). This value was measured in 434 metabolically healthy subjects in China as reported in this study.

The table below shows my monthly mean body weight, mean total daily insulin dose, mean basal insulin dose, mean bolus insulin dose, and the mean bolus insulin dose for each meal and the bedtime bolus insulin dose which I started using a few months ago to try to improve my fasting blood sugar while keeping the basal insulin dose constant. Despite this I did have to decrease my Tresiba dose by 1 IU this month to address fasting low blood sugars. Diluting my Humalog 5:1 helps to give precise doses with meals and at bedtime.

The table below shows my blood glucose variability data including the monthly mean blood glucose, the standard deviation of blood glucose (SDBG), the coefficient of variation (COV), the calculated HbA1c, and the percentage of blood glucose values < 74 mg/dl, between 74 and 126 mg/dl, and > 126 mg/dl. As mentioned, my percentage of blood glucose values < 74 mg/dl was higher than my goal of < 5%. I did not need to take any glucose tablets (or Smarties) this month.

My total daily insulin dose was lower this month and on par with previous months.

Table 2.2 below shows the mean and 95th percentile of the interstitial glucose (IG) and standard deviation of the interstitial glucose (SDIG) of 564 nondiabetic subjects as measured by CGM from the five studies referenced below.

The references for these five studies are shown below.

In February, I tinkered with a mathematical model to predict insulin doses. This month, I will test it and hope that it will be the final version. It is clear that there will always be some inherent variability in blood sugars when treating T1DM with exogenous insulin, but as long as normal blood sugars can be achieved while being safe, i.e., with minimal hypoglycemia, then I will be satisfied. I expect this mathematical approach will only be useful after one has established a consistent schedule of meals, exercise, and sleep, i.e. factors known to affect insulin sensitivity.

Till next time….

14 comments

  1. Brian Lucido

    Hey Keith – Nice work again this month. I wanted to point out that you are probably doing even better than the “metabolically healthy Chinese” people. I had a CGM (Dexcom G5) for one year. The interstitial blood glucose measure is delayed by about 20 minutes, and being a frequent tester, I often compared my capillary blood glucose with the CGM. The CGM absolutely “softens” variability, often giving me a SD of 12mg/dL… but real life (I.e Capillary readings, like you do) I’d be up in the mid to low 20’s for Standard deviation.

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    • Keith Runyan, MD

      Hi Brian, thanks for the props. Interesting CGM observation. I think CGMs are excellent tools for those with T1DM, but I have heard lots of complaints about accuracy from patients despite the excellent published results. I can’t explain the difference between the study results and actual patient results. Maybe those who are satisfied with their CGM don’t say anything about how good they are so I’m getting a biased or skewed assessment. I would have to say a standard deviation in the low 20’s is exceptional, so props to you too!

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      • Sometime

        Keith, see the article “Biological Variation in HbA1c Predicts Risk of Retinopathy and Nephropathy in Type 1 Diabetes”. It would be useful for you to check and compare it with your estimated values.

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      • Sometime

        I would like to see if your exceptionally good blood glucose control do translate into exceptionally low A1c or not. This is because we know that A1c is a better indicator of glycation than the blood glucose numbers.

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      • Sometime

        We already know that A1c is a measure of glycation of red blood cells. The study above shows it’s more correlated to diabetic complications than average blood glucose. What more evidence do you want than this? It seems clear to me.

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      • Keith Runyan, MD

        The point you are missing, Sometime, is that all of the subjects in the DCCT had high blood sugars which is what causes retinopathy and nephropathy. My blood sugars are normal and even if I am a high-glycator, there has been no study done, to date, to determine the risk of developing long-term diabetic complications with normal blood sugars as a high-glycator. After having had T1DM for 22 years, I have no retinopathy or albuminuria. Your suggestion that I lower my HbA1c further, at the risk of having hypoglycemia, to avoid the potential for long-term complications that, so far, I have not even begun to develop, is potentially dangerous and deadly. At this point, I will stick with my current management goals. Thank you for your concern about my future development of long-term diabetic complications.

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      • Sometime

        Keith, I’ve not asked you to lower your blood glucose targets (they’re perfect) nor I’m concerned about your health. But I think it would be beneficial to known your real A1c to evaluate the approach you’re advocating for management of T1 and T2.

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  2. Someone

    The benefit is that we can see how much your diet and exercise program reduce glycation. Is it as good as the blood glucose numbers would suggest? Let’s see. Another biomarker to see is fructosamine. Then we can evaluate your results.

    You don’t have to do it for me or for yourself, you’ve to do it for science. 🙂

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    • Keith Runyan, MD

      Well, Sometime, I’m glad you have a sense of humor. Read my blog post #23. You can enter #23 into the search box to bring it up quickly. After carefully reading it, spend some time reading the references and learning about all the factors that determine HbA1c and its limitation in the management of diabetes. You don’t have to do it for me, you have to do it for yourself. 🙂

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