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).
Recent Interviews and Videos
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. There are other interviews and lectures of mine which appear on YouTube. My weightlifting videos are also on YouTube.
Introduction
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.
My Glycemic Results for October 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. In fact, I have yet to go a month without at least 3 blood glucose values < 70 mg/dL. My average blood glucose for the entire month was 104 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 insulin 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 spreadsheet below is what I use to track my total daily meal macronutrients, micronutrients, and other items that may not be of interest to all of you. For those who are interested, it does provide more information than I have ever presented before.
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 are shown in the table below.
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.
Exercise
I resumed olympic weightlifting with light weights (95 lb. snatch and 135 lb. clean & jerk) until my right lateral thigh muscle/fascia heals. I strained it presumably during olympic weightlifting 4 months ago. I increased my walking to 2 miles twice daily. 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.
What are average blood sugars in persons without diabetes?
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.
A new method to calculate my correction factor for use in calculating my mealtime insulin doses
Although most of the following is covered in detail in Chapter 5 of my book, Master Type 1 Diabetes: The Simple, Low-Cost Method to Normalize Blood Sugars, I have developed a new method to calculate the correction factor (CF) which is used to adjust the mealtime insulin dose based on the pre-meal blood glucose (pre-BG). Just to review what I explained in my book, I calculate the mealtime bolus insulin dose using the formula, BIDE = MI + CI, where BIDE is the bolus insulin dose estimate, MI is the meal insulin, and CI is the correction insulin used to lower a high preBG or raise a low preBG toward one’s target blood glucose (TBG). The formula for CI = (preBG − TBG) ÷ CF, where TBG is your chosen target blood glucose (mine is 95-100 mg/dl) and CF is the correction factor. In my book I give guidance and a formula used to estimate your CF based on your total daily insulin dose. However, I have experimented with different ways to determine my CF based on my actual BG and insulin dose data. I have determined that the CF can be estimated by plotting insulin/hour (INS/hr) on the y-axis and change in BG/hr (ΔBG/hr = (postBG – preBG)/time in hours) on the x-axis and computing the slope of the line through the data (by eye) as shown below for the breakfast meal. The graph includes 270 data points from Jan. 2, 2023 through September 28, 2023. Fewer data points would work as well, but I had the data, so I used it.
I then simply select two points on the black line that I drew through the data using Keynote for Mac (or powerpoint for Windows). I chose two (x/y) data points, -20/1.95 and 20/0.75, on the black line and calculate the negative reciprocal of the slope of these two points. In this case, the slope is -0.0300 and the negative reciprocal of the slope is 33 mg/dl/IU, where slope (b) = (y₂ – y₁)/(x₂ – x₁). I do the same calculation for lunch, dinner, and bedtime. In essence, if my preBG at breakfast is 133 mg/dl and I, of course, want to lower it to 100 mg/dl, then I will give an extra 1 IU of bolus insulin: Correction Insulin (CI) = (133 mg/dl – 100 mg/dl) ÷ 33 mg/dl/IU = 1 IU. If the preBG at breakfast is 84 mg/dl, then I want to raise it to 100 mg/dl, so I will give less insulin as follows: CI = (84 mg/dl – 100 mg/dl) ÷ 33 mg/dl/IU = -0.5 IU. I have been using 36 mg/dl/IU as my breakfast CF for a long time, so it is interesting to see that this method yields such a similar value. My lunch CF calculated to 43 mg/dl/IU, dinner CF calculated to 41 mg/dl/IU, and bedtime CF calculated to 33 mg/dl/IU. I decided to just stick with my current CF values since my overall results are pretty good and a small difference in the CF wouldn’t change the bolus doses significantly. My current CF values are: breakfast CF = 36 mg/dl/IU, lunch CF = 40 mg/dl/IU, dinner CF = 40 mg/dl/IU, and bedtime CF = 40 mg/dl/IU. I realize this is pretty nerdy stuff and most of you would not want to fool with such shenanigans, but I thought some might be interested to know that one’s actual blood glucose and insulin dose data could be used to calculate one’s correction factors (CF). Finally, the y-intercept can be used as the meal insulin (MI) which is used to calculate the bolus insulin dose estimate (BIDE). The formula is BIDE = Meal Insulin (MI) + Correction Insulin (CI), where CI = (PreBG – TBG) ÷ CF of BIDE = MI + (PreBG – TBG) ÷ CF. Using the graph method, BIDE = y-intercept × time between meals + (PreBG – TBG) ÷ CF. I use the previous 30 days of data to calculate the MI and CF since insulin dose averages vary over time. If one’s insulin sensitivity is not very stable, then either a shorter time frame than 30 days can be used or a different method altogether could be used to provide a more accurate BIDE.
Closing Thoughts
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 4 meals daily (2,000 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 on the number of books purchased and the number and ratings of the reviews of the book.
Comments or general questions are welcomed.
Till next time….
Ketogenic Diabetic Athlete 