#118 July 2023 – Keith Runyan, MD – My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1D) using lispro and Basaglar insulin injections, metformin, a ketogenic whole-food diet, and resistance and aerobic exercise (olympic weightlifting and walking).

I was recently interviewed by Nayiri Mississian @Low Carb and Fasting on YouTube here. We talked about normalizing blood sugars in those with T1D using a ketogenic diet with consistent meals and exercise. She has other interviews that will no doubt interest those with T1D.

For those who haven’t been following this blog, I was diagnosed with type 1 diabetes (T1D) in September 1998 and followed conventional advice to manage my diabetes for the next 14 years. While my HbA1c was 6.5 to 7% during those years, I suffered from frequent hypoglycemic episodes and grew to loathe them. I stumbled onto the use of a low-carb diet for diabetes in late 2011 and started my ketogenic diet on Feb. 8, 2012. The low-carb ketogenic diet greatly reduced my glycemic excursions and halved my insulin requirements from 58 to 28 IU/day and markedly reduced, but did not eliminate, my symptomatic hypoglycemic episodes. In 2019, in an effort to further reduce my hypoglycemic episodes, I added consistency of meals, exercise, and sleep to my blood glucose management strategy. As a result, I have had only 5 mildly symptomatic hypoglycemic episodes since 2019. In addition, my average blood glucose and standard deviation of blood glucose are equivalent to those without diabetes. This has kept me motivated to continue my regimented lifestyle (relative to most others). Although my lifestyle is regimented and consistent, it does not feel burdensome to me. The decision to make certain lifestyle choices is very individual and I can certainly understand if some might not to want to make all the changes that I have to obtain normal blood sugars. In addition to the avoidance of hypoglycemia, I am motivated to continue my current lifestyle as a result of having witnessed firsthand as a physician for 28 years the consequences of poorly controlled diabetes. It was not just witnessing the hospitalizations, surgeries, procedures, dialysis treatments, and infusions of medications, but most memorably, the suffering my patients with diabetes experienced until they met their death, 11 to 13 years sooner, on average, than those without diabetes. I realize that many with diabetes do not think these consequences will happen to them until they actually do. But if my mentioning these realities of poorly controlled diabetes motivates you to adjust your lifestyle habits to improve your glycemic control, then I will have served a purpose. Hippocrates (460 – 357 BC) said, “Before you heal someone, ask if he is willing to give up on the things that make him sick.” I think that applies to type 1 diabetes. Are you willing to give up refined dietary carbohydrates and sugar and haphazardly timed meals, exercise, and sleep that contribute to rollercoaster blood sugars?

My book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, explains in detail the strategies that need to be implemented to achieve normal blood sugars without hypoglycemia and is available in the U.S. on Amazon and internationally on your countries’ Amazon in Kindle, Paperback, and Hardcover versions. The book incorporates all the new strategies that I learned since my previous book that have allowed me to achieve truly normal blood sugars. It also describes why blood sugars can be so difficult to regulate with T1D without these strategies. The ‘Look Inside’ feature on Amazon will allow you to read the Table of Contents and some of the book contents. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

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.

Glycemic Results for July 2023

This month, my glycemic results were comparable to those of non-diabetic individuals (see below), but slightly short of my ultimate goal of no blood glucose values < 70 mg/dL. My average blood glucose for the entire month was 100 mg/dL and the standard deviation of blood glucose (SDBG) was 19 mg/dL. The graph below shows all of my blood glucose measurements for the month in both mg/dl and mmol/l (mM) units of measure.

The graph below shows all of the daily dose totals for bolus (lispro) in blue, basal (Basaglar – glargine) in green, and the total daily insulin dose in red. I did not experience hypoglycemia nor need to take glucose for a low blood sugar this month. Note: When needed, instead of glucose tablets or liquid, I use Smarties™ candy which contains 6 grams of dextrose (glucose) per roll.

My blood sugar goals are shown in Table 2.2 below. My target blood glucose (TBG) is 100 mg/dl. I have not found any compelling evidence that a TBG < 89 mg/dL has any benefits in terms of reducing the risk of diabetic complications or improving healthspan or lifespan, but the risk of having hypoglycemia definitely increases as the TBG is reduced.

The table below summarizes my glycemic results over the previous year. In the table, MBG = mean blood glucose, SDBG = standard deviation of blood glucose in both mg/dl and mmol/l (mM), BG COV = blood glucose coefficient of variation which equals SDBG ÷ MBG, MTDID = mean total daily insulin dose, MDBD = mean daily Basaglar dose, MDLD = mean daily lispro dose, HbA1c (%) is calculated using the formula, HbA1c (%) = (46.7 + mean BG mg/dl) ÷ 28.7. Additional columns include the percentage of blood glucose values < 70 mg/dL, between 70 and 130 mg/dL, and > 130 mg/dL, and body weight (kg). My goal is to have 100% of my blood glucose values in the range 70−130 mg/dL, but did not quite meet that goal this month.

My Ketogenic Meal Plan

The table below tracks my total daily meal macronutrients, body weight, insulin dosage, and the ketogenic ratio of my diet.

I decided to return to ≈2,000 kcal/day. I don’t have a specific bodyweight goal. I’m continuing on three meals/day. The foods in my diet currently include 2 large eggs and 38 grams of 73% lean ground beef scrambled together and cooked in microwave with salt, 38 grams canned salmon with 4 grams lemon juice and 12.5 grams homemade sauerkraut, and 1 oz Cabot cheddar cheese at each meal. Fluid intake is 10-12 cups/day consisting of unsweetened tea and water. At lunch and dinner I eat 27 grams canned spinach, 29 grams canned diced tomatoes, and 30 grams of canned asparagus. My dessert recipe is now made with 42 grams unsweetened Baker’s chocolate, 15 grams each of allulose, erythritol, and xylitol, 4 oz of Philadelphia cream cheese, 220 grams chopped macadamia nuts, 120 grams chopped sunflower seeds, and 120 grams Smucker’s natural peanut butter (contains only peanuts and salt), and 135 grams coconut oil. I make up the dessert once a week and portion it out of the container by weight on my kitchen scale 3 times daily. The choice of these foods and the amounts I eat result in obtaining ≥ 100% of the RDA of 40 vitamins, minerals, amino acids and other essential nutrients except for folate (vitamin B9) at 93% of the RDA and calcium at 99% of the RDA. Other daily nutrient totals that I track include 64 grams (28% of daily energy or calories) of monounsaturated fatty acids, 65 grams (29% of daily energy or calories) of saturated fatty acids, 14 grams (6% of daily energy or calories) of polyunsaturated fatty acids which includes 12.2 grams (5.4% of daily energy or calories) of the omega-6 fatty acid linoleic acid and 1.6 grams (0.7% of daily energy or calories) of the omega-3 fatty acids, DHA (docosahexaenoic acid), EPA (eicosapentaenoic acid), and DPA (docosapentaenoic acid). The omega-6 to omega-3 ratio is 7.5 to 1. Some folks online argue that this ratio should be very low. I have heard and read ratios of 1 to 1 (1:1) up to 3 to 4 to 1 (3-4:1) as a target, but I have been unable to design a ketogenic diet with low enough omega-6 fatty acid content to achieve these ratios while also providing enough protein, vitamins, and minerals. Eggs and sunflower seeds are the major sources of the omega-6 fatty acids in my diet (each with 4 grams of linoleic acid). Eggs contain omega-6 fatty acids that originate from the soybean and corn meals in their diet. See here for more information on omega-3 and omega-6 fatty acids. I do supplement with Morton Lite Salt added to my eggs and beef for its sodium and potassium content and I also take magnesium chloride (300 mg/day) added to water. I also supplement with creatine monohydrate (2 grams/day), vitamin C (180 mg/day), vitamin B12 (0.5 mg/month because I take metformin), and vitamin D (5,000 IU 3x/week). In addition to Basaglar and lispro insulins, I take metformin 500 mg with each of 3 meals daily (1,500 mg/day) to reduce my total daily insulin dosage. My meals are eaten at 7 am, 12:30 pm, and 5:30 pm, or as close to those times as possible. Each of my 3 meals per day contain ≈ 38 grams (0.5 grams/kg body weight) of protein along with daily resistance training to help retain my muscle mass as I age. Because the subtitle of my book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, mentions “low-cost,” I decided to calculate the cost of my food each day. My daily food cost from Walmart is $6.27 per day. I took the estimated annual cost of food for Floridians (here) $2,801 to $3,200 and divided by 365 to get $7.67 to $8.77 per day. My cost is considerably less than this range. So a minimally processed-food ketogenic diet can indeed be less expensive than the average Floridian’s food cost. I should also specifically mention that the number of “keto” ultra-processed foods has exploded since I started my ketogenic diet in 2012. I think all of these products should be rarely consumed if at all. Personally, I have never tried them so I can’t claim that they are harmful especially if they make following a ketogenic diet easier/feasible for you. But just looking at the ingredient lists, I suspect they would not be healthful in the long term.

Blood Ketones

I have blood ketone strips that will eventually expire so I decided to do periodic checks of my blood beta-hydroxybutyrate levels. My recent results include 2.2 mM on April 3, 2023 at bedtime, 2.9 mM on May 6, 2023 at bedtime, and 2.2 mM on June 2, 2023 at breakfast. I forgot to check my ketones this month, but will do so in August. For persons with T1D following a ketogenic diet, checking blood, urine or breath ketones can help inform one if they are in fact restricting dietary carbohydrates sufficiently and not consuming dietary protein to excess. Checking blood ketones can also establish a baseline blood ketone level that can be compared to blood ketones during an illness to alleviate the fear of developing diabetic ketoacidosis if the blood ketone level is close to baseline. Alternatively if blood ketones are well above baseline along with elevated blood glucose, one can increase insulin doses appropriately to lower blood glucose and ketones in consultation with their physician to avoid developing diabetic ketoacidosis.

Below is a photo of myself from April 2022 at 72.8 kg (160.5 lb.). I will update this photo once my bodyweight stabilizes.

My best olympic lifts this month were 110 lb. snatch and 150 lb. clean and jerk which I reduced to recover from overtraining. My fatigue has now resolved and I plan to slowly increase the amount of weight lifted over time. I went back to twice daily walks of 1 mile each.

Table 1.2 below shows the mean interstitial glucose (IG) of 732 non-diabetic subjects and standard deviation of the interstitial glucose (SDIG) of 708 non-diabetic subjects as measured by CGM from the seven studies referenced below. One of the studies, Sundberg, F, et al., 2018, was in 15 healthy, normal weight children, age 2−8. The mean CGM 24-hr IG was 95 mg/dL (5.3 mM) and SDIG was 18 mg/dL (1.0 mM). This study again confirms that children’s blood sugars are about the same as those of adults. The age of subjects in these seven studies ranges from 2−80 years. I think it is important for those with T1D to know the glucose results of metabolically healthy study subjects to be used as a reference for seeking normal blood sugars. Although achieving normal blood sugars with T1D is not an easy task, it can be made more difficult by choosing a target blood glucose that is too low and results in hypoglycemic episodes. The lower the target blood glucose, the more likely hypoglycemic episodes are to occur in those with T1D taking exogenous insulin. Having hypoglycemic episodes means that your target blood glucose is set too low. Achieving a normal mean blood glucose without hypoglycemia, requires that one’s glycemic variability as measured by the standard deviation of blood glucose is normal as well.

The references for these seven studies are shown below.

I’ll mention that the authors of Zhou, J, et al., 2011 above concluded that a SDBG <25 mg/dl should be considered to be normal because that was the 95th percentile of the metabolically healthy subjects in their study. The median SDBG in the study was 18 mg/dl which is what I am hoping to achieve each month. My goal moving forward is to eliminate all BG values < 70 mg/dL as part of managing T1D as safely as possible. Although I have yet to achieve this goal for an entire month, I am not discouraged and continue to strive for better results each day.

The purpose of this blog is to share my experience with a low-carb ketogenic diet and exercise to better manage my blood glucose as a person with T1D. A low-carb ketogenic diet also allows for lower daily insulin doses and normal body composition which I believe reduces the risk of developing insulin resistance (double diabetes) and the host of chronic diseases associated with insulin resistance including atherosclerosis, cancer, and neurodegenerative diseases. I also take metformin 500 mg with each of 3 meals daily (1,500 mg/day) to suppress liver glucose production which tends to be chronically elevated in those with T1D. This occurs due to the lower concentration of insulin around the pancreatic alpha-cells increasing the concentration of glucagon reaching the liver as well as the lower concentration of insulin entering the liver both of which increase liver gluconeogenesis, glycogenolysis and glucose production relative to those without T1D. Metformin also improves glucose uptake by skeletal muscle. Metformin, exercise, and a low-carbohydrate diet also improves glycemic control for those with glucose intolerance, prediabetes, type 2 diabetes, and double diabetes [T1D with insulin resistance]. As explained in detail in my book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, injecting insulin in the subcutaneous fat is just not the same as when it is secreted by the beta-cells in the pancreas according to the prevailing blood glucose concentration. I have accepted the fact that there will always be more variation in my blood glucose than I would like, but if I can continue to keep the mean and standard deviation of my blood glucose readings equivalent to that of non-diabetic individuals while avoiding hypoglycemia, I will be satisfied. I would appreciate those who want to purchase my book and derive some benefit from reading it to leave a positive review on Amazon so that others will see the book when they search for books on T1D. The search rankings in Amazon are based the number of books purchased and the reviews of the book.

Comments or general questions are welcomed.

Till next time….