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#67 June 2019 Update on My T1D Management

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 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.

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

This month I want to review a study I recently discovered, but was actually published in 2009. Not sure how I missed it, but I think it is related to the search terms put into Google. Anyway, here goes.

The study was conducted on 434 nondiabetic male and female subjects, age 20−69 years old, at 10 academic hospitals throughout China in which their BG was measured by 3-day CGM and 4 finger-stick blood glucose (BG) measurements daily. Before applying the CGM to the study subjects, they were confirmed to be metabolically healthy (nondiabetic) using a medical history, physical exam, and extensive laboratory testing. The subjects were not taking any medications, had normal body weight, blood pressure, fasting BG and HbA1c, fasting insulin or C-peptide level, homeostatic model assessment of insulin resistance (HOMA-IR), and oral glucose tolerance tests (OGTT). HOMA-IR is simply the fasting insulin level multiplied by the fasting BG. If either value are slightly elevated, then the product of the two will be elevated and indicative of insulin resistance, a precursor to diabetes. The OGTT measures several BG values after consuming a 75-gram glucose solution. If any of the values exceed a predetermined level, this too is indicative of insulin resistance, pre-diabetes, or diabetes. Subjects with any abnormal results were excluded from the study.

The total calorie intake from the three daily meals was 30 kcal/kg􏰉/day during CGM, with 50% carbohydrates, 15% proteins, and 35% fats. Comparing the  interstitial glucose (IG) values at times when the finger-stick BG readings were also obtained, the mean IG was 103 mg/dl and mean BG was 103 mg/dl. For the 434 healthy subjects, the mean 24-hour IG was 104 mg/dl and the mean standard deviation (SD, a measure of glucose variability) of IG was 14.2 mg/dl. The 95th percentile of mean 24-hour IG was 119 mg/dl (6.61 mmol/l). This means that 95% of the metabolically healthy subjects had a mean 24-hour IG as high as 119 mg/dl. The authors of this study considered any mean 24-hour IG ≤ 119 mg/dl to be normal. Interestingly, impaired fasting glucose is defined by the ADA as a fasting plasma glucose between 100−125 mg/dl (5.56−6.94 mmol/l). It should be noted that the World Health Organization (WHO) and numerous other diabetes organizations define the impaired fasting glucose cutoff at 110 mg/dl (6.11 mmol/l). 

Two years later, another paper was published on the same 434 subjects. This paper focused on the glucose variability as measured by standard deviation (SD) of interstitial glucose (IG). The median SD of IG was 13.5 (0.75 mmol/L). The 95th percentile of the SD of IG was 25.2 mg/dl (1.40 mmol/L). Again the authors of this study considered any SD of 24-hour IG ≤ 25.5 mg/dl to be normal.

I included data from three other studies that I have previously reviewed on this blog in Table 2. below.

Glycemic Results For June 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for June 2019. I did not feel well at a body weight of 67 kg. I felt a slight lack of energy and was thinking about food a lot. I was not hungry, but at the end of each meal, I felt like I wanted to eat more. Therefore, I decided to just eat an amount of food that would satisfy me and let my weight be whatever it turns out to be. If I have to go back to the 73 kg weight class to compete in olympic weightlifting, then so be it. Thus, my total daily insulin dose had to be increased a bit during June.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for June 2019.

I did experience a reduction in hypoglycemia, but an increase in hyperglycemia compared to the previous month. Overall, I was pleased with my results, particularly with the reduction in standard deviation of BG. The graphs below show all of the daily insulin dose totals and all of the BG readings for June 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red. 

In July, I will continue to seek normal mean blood glucose and normal glycemic variability results. I appear to be getting ever closer to achieving that goal. Table 3. below shows my goals from this point forward in light of the results of the two studies presented above.

References:

Zhou, J., et al., (2009). Reference values for continuous glucose monitoring in Chinese subjects, Diabetes Care, 32: 1188–1193.

Zhou, J., et al., (2011). Establishment of normal reference ranges for glycemic variability in Chinese subjects using continuous glucose monitoring, Med Sci Monit, 17(1): CR9-13.

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#66 May 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

May 2019 was an interesting month with more changes. I now believe I have tried every possible combination of Lantus dosing. I have given it at 4 different times of the day 7 AM, 12 PM, 6 PM, and 11 PM once daily. I have given it twice daily and three times daily. I have changed the doses up and down the entire spectrum from A to Z. This month I changed my BG check times to 7 AM, 12 PM, 6 PM, and 10 PM. I also decided to change my insulin-dosing strategy and add a fourth meal daily. The reason for the fourth meal was two-fold. First, based on research in the sports science field that I mentioned last month which shows that muscle protein synthesis (MPS) is maximized by consuming 0.4 – 0.55 grams of protein/kg/meal in each meal. This stimulation of MPS is not as powerful as that produced by resistance exercise, but the benefits of exercise on MPS is also dependent on eating enough protein within the next 3-4 hours. Eating more protein than 0.55 g/kg/meal does not further increase MPS. Each meal results in net MPS over and above the muscle protein breakdown that occurs during fasting between meals and especially fasting overnight. Adding the fourth meal at bedtime potentially results in more net MPS per day. This is a hypothesis rather than a proven fact. Understand that the number of studies in humans is small and the ones that do exist are all short-term studies. Most of the studies on MPS were done in animals, primarily rats, and they too are short-term studies. However my decision to add the fourth meal was not just related to this potential, but uncertain, benefit on MPS. My second purpose was to test a different insulin-dosing strategy. The idea was to take my basal insulin (Lantus) dose with the bedtime meal, now 10 PM, such that I inject a dose of Humalog with each of the four meals daily. This means taking a total of five injections daily and no more. The Humalog dose would now have three purposes. 1) cover the meal, 2) correct for either high or low BG readings, 3) supplement my basal insulin needs for 20 of the 24 hours per day. The 20 hours represents the duration of action of Humalog of 5 hours x 4 doses daily. This last purpose is the new part. I am specifically choosing the basal insulin (Lantus) dose to cover my insulin needs between 3 AM and 7 AM, the time period where all Humalog is done. The hope is that the Lantus dose required to accomplish this will be low enough to never cause hypoglycemia at any other time of the 24-hour day. Another way of stating this is that I hope I can find a Lantus dose that is low enough that I always have to take greater than or equal to 0.4 IU of Humalog with each meal. If the Humalog dose at a meal is less than 0.4 IU, then the accuracy of drawing up my 5-fold diluted Humalog is questionable. I thing this approach makes sense because rapid-acting insulin doses can be precisely adjusted daily whereas any change in a Lantus dose takes 3-5 days to take full-effect. This method does not require eating 4 meals per day. If one chooses 3 meals per day, then Humalog could be given at 10 PM with the Lantus without eating a meal. I figured why not use the Humalog for both of the purposes stated above. I started this new regime on May 14 with 7 IU Lantus at 10 PM. I had to subsequently increase to 8, 9, 10, 11 IU, and back down to 10 IU. I hope that 10 IU at 10 PM will do the trick from this point forward. My BG values started looking pretty good on May 24th and the two lows I had subsequently is what prompted the reduction in Lantus from 11 IU to 10 IU.

This month I reached my goal weight of 67 kg at 2000 kcal/day, but today, June 1, I got hungry and fatigued again and increased my caloric intake back to 2100 kcal/day. Hopefully my weight will stay close to 67 kg so that when it comes time to compete in olympic weightlifting, I won’t need to cut much weight. An interesting observation I have had with this body weight adjustment process is that the symptoms of insufficient caloric intake is delayed. In other words, I can feel fine on the caloric intake that leads to the weight loss for several weeks before any symptoms develop. This sounds like the observation noted by overweight persons who lose weight. They find it is easier to lose the weight than to maintain the weight loss. This might be why. I think that covers all the new developments in May 2019.

Glycemic Results For May 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for May 2019. I experienced a slight reduction in insulin doses, mean BG, SD, and CV compared to April.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for May 2019. Two of the three values were improved compared to April.

The graphs below show all of the daily insulin dose totals and all of the BG readings for May 2019. HUM = Humalog, LAN = Lantus, INS = total daily insulin dose. Note: I accidentally forgot to take a Lantus Dose on May 8th. I attributed that to a “senior moment” and to my frequent changes in dosing schedules. I don’t expect that to continue.

In June, I will continue with the above plan. I do not have plans for any more experiments. I think I need to give the current plan some time to settle out and see if I can get normal blood sugars in June.

I found a new study I plan to review next month regarding measuring interstitial glucose in nondiabetic subjects. It was published in 2009, so I don’t understand why it took me so long to come across it, but I guess better late than never. It is a better study than any of the others I have come across on this topic and involved 434 metabolically healthy nondiabetic subjects.

Finally, I would appreciate your comments on the idea of using inhaled insulin for the sole purpose of eating candy “as a treat.” I assume that means not very often, but I’m not sure how often that is. For me, I’m afraid that would send me down a path of having “treats” more and more often. I believe I was once addicted to chocolate and sweets in general. My low-carbohydrate diet fixed that, thank goodness. Also, not sure if this matters, but the person doing this is an endocrinologist with T1DM who states he/she follows a “not very strict low-carbohydrate diet.” To me, this means he/she understands the purpose of the low-carbohydrate diet. To me, the purpose of eating carbohydrates is to get nutrients from plant foods that are difficult to get, or are not available, in animal foods. The nutrients in my diet that come almost exclusively from plants include vitamin C, vitamin K1, manganese, lutein, and zeaxanthin. The nutrients from plants in my diet that make up at least 40% of my daily requirements include folate, vitamin E, copper, magnesium, and potassium. I would be interested in hearing your thoughts on the idea of eating candy as a “treat” with T1DM.

Well that is all I have for this month. Wishing you smooth blood sugars in June 2019.

#65 April 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

April 2019 was an interesting month with more changes. I now believe I have tried every possible combination of Lantus dosing. I have given it at 4 different times of the day 7 AM, 12 PM, 6 PM, and 11 PM once daily. I have given it twice daily and three times daily. I have changed the doses up and down the entire spectrum from A to Z. This month I changed back to my original regimen of once daily at 6 PM. I originally started experimenting with other Lantus regimens in about September last year because I was having problems with not being able to control my BG both fasting and later during the day with exercise without one being too high (6 PM) or the other being too low (7 AM). I was also afraid to give doses of Humalog either before exercise and at bedtime for fear of hypoglycemia. However, now that I have diluted Humalog I can give as little as 0.2 IU of Humalog either before exercise or at bedtime if needed. So, this month I finally decided that there is no regimen of Lantus that will accomplish both goals. Instead, I decided to choose a single 6 PM Lantus dose that would not necessarily result in a normal BG at any time of the day, but would simply be a low enough dose to avoid hypoglycemia 24 hours a day. Then I would be willing to give Humalog 4 times a day at 7 AM, 12 PM, 6 PM, and 11 PM to make up the difference between the Lantus and my actual insulin needs. As usual, I would figure out the Humalog dose by trial and error in small increments or decrements. I also decided to change from 2 to 3 meals a day. I have learned from Donald Layman, PhD and Stewart Phillips, PhD (you can Google those names to find their publications on dietary protein and muscle protein synthesis if you’re interested) that more frequent meal boluses of protein is the best way to avoid sarcopenia of aging especially when combined with resistance exercise. I have no idea whether or not increasing from 2 to 3 meals per day will work and doubt I never will know, put since I will likely need to take Humalog anyway at 12 PM before exercise, I might as well try it. I just got started on this new regimen so I won’t be able to report on the results until next month. I also reduced my daily calorie intake from 2300 kcal/day to 2000 kcal/day in 3 steps of 100 kcal/day with a week between each change to see if I can get down to 67 kg for the purpose of competing in masters olympic weightlifting. If I can’t get down to that weight, I will have to compete at 73 kg.

Glycemic Results For April 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), body weight, and mean insulin dose totals for April 2019. I experienced a slight reduction in insulin doses, but otherwise not much different compared to March.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for April 2019

Note that I changed my target BG range from 71-120 mg/dl to 71-130 mg/dl and my target BG from 95 to 100 mg/dl in order to further reduce the frequency of hypoglycemia which was improved in April. I would like it to continue to reduce it even further. I deleted the other two columns of % of BG readings for the previous months because I did not have time to go back and recalculate the % in range values for Jan. to March 2019.

The graphs below show all of the daily insulin dose totals and all of the BG readings for April 2019.

On April 27th, I think I forgot to take my 6 PM Lantus dose since I had been in the habit of taking it at 11 PM. I am not 100% sure of that, but it was the only explanation I could come up with to explain the sudden jump in BG the following day. I took an extra 3.5 IU of Lantus to try to catch up, but did not want to give a big dose in case I had not forgotten it. Anyway, my BG seemed to have straightened out afterwards.

In May, I will continue with Lantus at 6 PM and I have no plans to change it again. I will tweak the doses of Humalog up to 4 times a day to see if I can further improve my glycemic control. Currently, I feel like 2,000 kcal/day is about the minimum number of calories/day I can eat to feel satisfied. Therefore, I am going to stick with that for several weeks and see what happens to my body weight. This weight loss experiment has been an interesting process having never purposely tried to lose weight before. I am already pretty lean, so I’m not sure if I have much more body fat to give up. Given what happened two months ago when my weight dropped to 65 kg and I got cold, fatigued, and hungry on 1,900 calories/day, I’m not sure if 67 kg will work for me long-term.

I saw an interesting YouTube video of a lecture this past month https://www.youtube.com/watch?v=3RlxpKzoiY8 given by biochemist, Richard Hanson, PhD. Near the end, he describes an experiment with mice that accelerated their ability to burn fat. At the very end, he showed a quote attributed to Winston Churchill that I thought fit perfectly with my pursuit of normal glycemic control.

“Success is going from failure to failure with enthusiasm.”

Thus by Churchhill’s estimation, I have been very successful! Well, I think that is about all I have to share this month. I hope possibly something in these posts will help others with the very challenging task of managing T1DM.

#64 March 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes and/or weight management. See the Coaching page for more info.

March 2019 was an interesting month. Having reduced my body weight from 75 kg to 65 kg over the past six months, this past month I suddenly developed symptoms of excessive calorie restriction and/or excessively lean body composition. These symptoms included feeling cold, generalized fatigue, lack of desire to exercise, hunger, and frequent thoughts of food. Fortunately, it did not take long to recognize the cause of the symptoms and take corrective action. I progressively increased my daily caloric intake from 1900 kcal/day to 2700 kcal/day over about a 7 day period. The cold feeling resolved first, followed by my energy level and desire to exercise, and finally the feeling of hunger and thoughts about food ceased. My weight increased pretty quickly as well and went beyond my goal of 67 kg which is the olympic weightlifting weight class I would like to compete in at some point in the future. My weight has peaked and stabilized at 69.9 kg. I am now slowly reducing my caloric intake and adjusting my insulin doses to try and get back to 67 kg more slowly without the return of any symptoms. My current daily calorie intake is 2300 kcal/day.

Glycemic Results For March 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), and coefficient of variation (CV), and mean insulin dose totals and body weight for March 2019.

The table below shows the percentage of BG values in the indicated ranges of low, goal, and high values for March 2019.

The graphs below show all of the daily insulin dose totals and all of the BG readings for March 2019.

You can see I have not met my BG goals. I am aiming for a lower BG SD, fewer BG values < 71 mg/dl, and fewer BG values > 120 mg/dl. I think the fluctuating caloric intake, body weight, and travel made my BG management more challenging. I hope that this will improve in April. Seems my goals are just out of reach each month for one reason or another. However, I will not be deterred. I will keep trying until I get it right. You can probably guess the dates of my travel from the BG graph above. If you want to guess the dates, you can leave a comment. Hint: it was a 5-day trip. Travel has always been challenging for my BG management, but this too I want to conquer.

My goal for April 2019 is to find the correct caloric intake to bring my body weight down to 67 kg, and this will likely require some slight reduction in insulin doses. Because I am eating the same breakfast and dinner everyday, I am not really “counting calories” in the usual sense of the term. I am simply using calories as a measure of food quantity. Keeping each meal constant allows me to identify a bolus insulin dose that will hopefully result in a post-meal BG in my desired target range. In April, I hope to improve my BG variability i.e. BG standard deviation and % of BG values in my target range of 71 – 120 mg/dl. Till next time ….

#63 February 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes. See the Coaching page for more info.

I have made several changes over the past seven months in my attempt to further improve the glycemic control of my T1DM. Many of the changes have not been successful. However, I don’t think it is possible to predict their success in advance and at least I now know what doesn’t work at this time in my life. For example during these past seven months, I have tried multiple different basal insulin schedules and doses trying to exactly match my changes insulin sensitivity throughout the day (due to exercise). I still have not solved this puzzle unfortunately. All of the different basal insulin combinations seem to result in the same problem. When my fasting blood glucose (BG) is normal, I will get hypoglycemia after exercise 25-33% of the days. In the past I had problems with hyperglycemia as well. This, I believe, was corrected by adding a 2-mile walk before and after weightlifting. Below are the changes that I feel have been helpful (I am leaving out the unhelpful ones):

  1. Two meals per day. This prevents overlapping meal-time insulin doses and frees up time for other activities.
  2. Achieved a leaner body composition which in turn dramatically reduced my insulin requirement per kg of body weight which reflects an improved insulin sensitivity.
  3. Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. By standardize, I mean the same exercises with the same duration and only minor occasional increases in intensity over time.
  4. Emphasized avoiding hypoglycemia as a more important goal compared to achieving any particular mean BG level. Hypoglycemia (BG < 71 mg/dl) is both unpleasant to experience and is life-threatening, whereas, mild transient hyperglycemia (BG > 120 mg/dl) is very unlikely to cause problems.
  5. Using cronometer.com to design different meal plans that I enjoy and can eat over and over again, each composed of the same amounts of macronutrients (protein, fat, and carbs) and each containing > 100% of the RDA for all vitamins and minerals. Since I do feel I get the best results from a low carb ketogenic diet and I feel a higher protein intake will best preserve my muscle mass as I age (currently 58 years old), I chose to design each meal so that I get a daily total intake of about 2.2 grams protein/kg BW/day and less than 40 grams of total carbohydrate and less than 30 grams of net carbs.
  6. Weighing my food on a kitchen scale helps to precisely follow my own meal plan.
  7. The combination of 6. and 7. above also makes achieving a lean body composition a lot easier.
  8. Taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with dinner really reduces my meal-time insulin requirements.
  9. In December 2018, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution to use as my meal-time insulin. This way I can accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.
  10. The past few months I have developed a spreadsheet to estimate my Humalog doses. For the past 20 years, I have been using the “experienced guessing” approach. I have always been uncomfortable with this approach, but did not have an alternative until now. The approach is simple in principle, using least squares linear regression of insulin versus change in BG. The spreadsheet is customized to a fixed number of BG measurements and insulin (basal and rapid-acting) dosing opportunities per day. I would say it is still in the testing phase and would not call it a true success until I have reached my BG control goals.

I have greatly simplified my data presentation down to the bare essentials. At this point in time, I think the four most important metrics are: mean BG, standard deviation (SD) of BG, % of BG meter reading in the normal range (71 – 120 mg/dl), and % of BG meter reading < 71 mg/dl (a rough measure of the frequency of hypoglycemia). 

This image has an empty alt attribute; its file name is post-63-bg-and-insulin-dose-graphs.png

Glycemic Management Results for February 2019

My February 2019 insulin doses and BG results were a bit worse compared to last month due to multiple changes in calorie intake and experiments with different basal insulin schedules and doses. Oh well.

The graphs below show the total daily doses of Humalog (blue) and Lantus (green) individually and the total of both insulin doses (red) and my actual BG readings (purple) below. The increase in insulin doses started on Jan. 27, 2019.

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage) as well as my current body weight and mean insulin dose totals. My height is 5’8″.

This image has an empty alt attribute; its file name is post-63-variability-table.png

I should mention that I believe the increase in insulin dose for February was related to an increase in calorie intake that was needed due to a two-week period of feeling hungry, cold, and tired. My calorie intake was increased from 1900 kcal/day to 2600 kcal/day in 100 kcal/day increments during the month of February.

The table below shows the % of BG meter reading in three BG ranges. 

This image has an empty alt attribute; its file name is post-63-means-table.png

Lessons Learned From Different Basal Insulin Schedules and Dosing

I have been experimenting with numerous different basal insulin (Lantus) schedules and doses (one to three doses per day, given at four different times of the day, with a wide range of doses at each time: that is a lot of different combinations). Because basal insulin is by design, long-acting, the main lesson I have learned after all these experiments is that the amount of basal insulin released from the injection site can not be varied enough to adjust for changes in insulin sensitivity due to exercise. I think if I did not exercise at all, my BG would be much better regulated (although my total daily insulin dose would be significantly higher). This is why I have returned to once daily Lantus dosing. I am choosing bedtime to administer it because my basal insulin requirements appear to be the most while sleeping. During the day, there are two 5 hour periods that are covered by Humalog from meals, and there is one 6-hour period influenced by exercise (lower basal insulin requirement). In other words, this 16-hour period does not require as much basal insulin as the overnight sleeping period. I should also mention that I think the marked increases in BG during olympic weightlifting (OWL) that occurred in the past are currently being compensated for by doing a 2-mile walk before and another 2-mile walk after the OWL. For March 2019, I will find a dose of Lantus at bedtime that results in a fasting BG between 71-120 mg/dl say 80% of the time. I no longer feel that perfection is a realistic goal, at least for me. So I will be OK with occasional mild lows (60s mg/dl) and highs (<200 mg/dl). Any fasting BG < 60 mg/dl has and will prompt a Lantus dose reduction. As stated above, I anticipate whatever bedtime Lantus dose I come up with will cause hypoglycemia 25-33% of the days during or after exercise if my post-breakfast i.e. pre-exercise BG is 95 mg/dl (which has generally been what I aim for). This month, my approach will be to reduce the breakfast Humalog dose (by setting the post-target BG higher) to try to compensate for the exercise-related improved insulin sensitivity and thus avoid the exercise-related hypoglycemia.

I should mention there are many different ways to approach this problem of changing insulin sensitivity with exercise. I have heard Dr. Richard Bernstein say that he lifts weights one or two days a week. He takes multiple doses of liquid glucose during his workout to compensate for the improved insulin sensitivity rather than making any adjustments in basal insulin. This is certainly a valid approach, but I was hoping to find a method that did not require much or any glucose supplementation (my personal preference) particularly since I am exercising daily rather than 1-2 days/week. After all, I am trying to remain in nutritional ketosis.

More on Blood Glucose Standard Deviation

In doing simulations with random numbers between 71 and 120, the mean is about 95 with a standard deviation of about 15. And, of course, any numbers lower than 71 or higher than 120 will result in even higher standard deviations. Therefore, my goal of achieving a standard deviation of 12 mg/dl is quite unlikely. Oh well.

My Goals For 2019

I will continue to strive for normal BG values and my goals are to:

  1. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl. 
  2. Aim for a mean BG value of 96 mg/dl with a standard deviation as close to 12 mg/dl as possible.
  3. Aim for % of BG meter reading in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but having a challenging target is motivating to me and I am not discouraged by the fact that I have not yet achieved all of them.

How Will I Achieve These Goals

  1. This month, I will will go back to once daily Lantus at bedtime, but use my spreadsheet to calculate the breakfast Humalog dose using a higher post-breakfast BG target to thus avoid exercise-related hypoglycemia.
  2. I will continue using the 5-fold diluted Humalog to more precisely adjust my meal-time insulin dose.
  3. I will continue refining my mathematical method to predict my insulin doses based on prior BG responses. I think this will be a useful tool for me. I think it could be expanded to include a multiple linear regression model that uses meal protein, carbohydrate, and fat grams as independent variables along with changes in BG to predict insulin doses. That said, I think keeping meal macronutrients constant is a better approach so I will continue that for now.

I hope these measures will result in additional improvements next month.

#62 January 2019 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I now also offer online coaching for those who need some individual attention in optimizing their glycemic control for either type 1 or type 2 diabetes. See the Coaching page for more info.

I have made several changes over the past six months in my attempt to further improve the glycemic control of my T1DM. These are the changes I have made:

  1. Two meals per day.
  2. More than one basal insulin dose per day.
  3. Achieved a leaner body composition which in turn dramatically reduced my insulin requirement per kg of body weight which reflects an improved insulin sensitivity.
  4. Standardized my exercise regimen to hopefully improve the predictability of the blood glucose (BG) response to insulin. By standardize, I mean the same exercises with the same duration and only minor occasional increases in intensity over time.
  5. Emphasized avoiding hypoglycemia as a more important goal compared to achieving any particular mean BG level. Hypoglycemia (BG < 71 mg/dl) is both unpleasant to experience and is life-threatening, whereas, mild transient hyperglycemia (BG > 120 mg/dl) is very unlikely to cause any problems.
  6. Using cronometer.com to design different meal plans that I enjoy and can eat over and over again, each composed of the same amounts of macronutrients (protein, fat, and carbs) and each containing > 100% of the RDA for all vitamins and minerals. Since I do feel I get the best results from a low carb ketogenic diet and I feel a higher protein intake will best preserve my muscle mass as I age (currently 58 years old), I chose to design each meal so that I get a daily total intake of 2.2 grams protein/kg BW/day and 57 grams of carbohydrate. If I could meet the > 100% RDA goal with fewer total grams of carbs I would do that, but non-starchy green vegetables do contain a fair number of carbs. Also, the fact that included in that 57 grams of carbs is 22 grams of fiber/day which reduces the BG impact of those carbs. Another way of saying that is I eat 35 grams of net carbs/day.
  7. Weighing my food on a kitchen scale helps to precisely follow my own meal plan.
  8. The combination of 6. and 7. above also makes achieving a lean body composition a lot easier.
  9. Taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with dinner really reduces my meal-time insulin requirements.
  10. In December 2018, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution to use as my meal-time insulin. This way I can accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.

I have greatly simplified my data presentation down to the bare essentials. At this point in time, I think the four most important metrics are: mean BG, standard deviation (SD) of BG, % of BG meter reading in the normal range (71 – 120 mg/dl), and % of BG meter reading < 71 mg/dl (a rough measure of the frequency of hypoglycemia). 

Glycemic Management Results for January 2019

First, note I made an error in reporting my SD results last month. I stated it was 18 mg/dl and I was pleased since it was the lowest I had ever achieved. Unfortunately, I had unknowingly introduced an error in my spreadsheet program which I use to calculate the SD. My actual SD for December 2018 was 28 mg/dl which was unchanged from previous months.

My January 2019 insulin doses and BG results were about the same as last month.

The graphs below shows the total daily insulin doses of Humalog and Lantus and the total of both insulin doses and my actual BG readings.

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage) as well as my current body weight and mean insulin dose totals. My height is 5’8″.

The table below shows the % of BG meter reading in three BG ranges. 

My Goals For 2019

I will continue to strive for normal BG values and my goals are to:

  1. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl. 
  2. Aim for a mean BG value of 96 mg/dl with a standard deviation of 12 mg/dl.
  3. Aim for % of BG meter reading in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but having a challenging target is motivating to me.

How Will I Achieve These Goals

  1. I will continue Lantus dosing twice daily and make small infrequent changes in dose based on my BG responses.
  2. I will continue using the 5-fold diluted Humalog to more precisely adjust my meal-time insulin dose.
  3. I am working on a mathematical method to predict my insulin doses based on prior responses. Haven’t found the right formula yet, but my experimentation continues.

I hope these measures will result in additional improvements next month.

#61 December 2018 Update on My T1D Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I have made several changes over the past five months in my attempt to further improve the glycemic control of my T1DM. These are the changes I made:

  1. Two meals per day: I continued eating breakfast at 7 AM and lunch at 3 PM. I like eating breakfast and given that my meal-time insulin requirements have always been greatest at breakfast, it makes me think that the breakfast Humalog dose is likely also contributing to compensating for the dawn phenomenon. Thus, eating later or skipping breakfast would likely result in morning hyperglycemia or require a larger basal insulin dose. Making my last meal at 3 PM immediately after weight training might help maintain my muscle mass according to some (not all) studies. But other reason to eat at that time is to allow for a 16-hour fasting period daily which might possibly have some metabolic benefits long-term. This also will probably never be formally studied, but I doubt it will hurt anything.
  2. In December, I tried taking Lantus three times daily at 7 AM, 3 PM and 11 PM (from December 1st through the 13th). The 3 PM and 11 PM doses ended up being very small (1-3 IU) and because I can’t measure it any more accurately than 0.25 IU with the insulin syringe, the % difference in dose (from say 1 IU to 1.25 IU i.e. a 25% increase) was rather large and not producing satisfactory result. So on December 14th, I changed to twice daily at 7 AM and 11 PM. So far, I am satisfied with this regimen and will continue it going forward.
  3. I will continue weighing my food on a kitchen scale. I plan to take it with me when I travel to maintain the consistency in food intake which I think is positively contributing to my glycemic control. Weighing food is no longer a bother now that I am seeing a benefit from it compared to years ago when I was using it to calculate carb intake which wasn’t helping at all. My breakfast macronutrient counts are: protein 63 grams, fat 60 grams, carbs 16 grams and lunch macronutrient counts are: protein 65 grams, fat 62 grams, carbs 28 grams. Daily macronutrient totals are: protein 129 grams (or 2.0 grams/kg/day), fat 125 grams, carbs 44 grams (of which 16 grams is fiber). The daily totals expressed as % of total calories are: 28% protein, 62% fat, 10% carbs.
  4. I continue taking metformin at 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with lunch. I have been tolerating this maximal dose without any side effects. I am convinced that even though I am relatively insulin sensitive, the metformin helps control post-meal BG by suppressing liver glucose production in response to meals and may be increasing muscle glucose uptake as well. These are the known mechanisms of metformin in helping to control BG in diabetes. I believe metformin is helping me because on the several occasions when I forgot to take the dose my post-meal BG was significantly elevated (by 30 – 40 mg/dl) compared to the previous days when I took the metformin. I forgot to take it for one meal in December and again noticed the unexpected rise in BG. It makes sense that metformin would help T1DM because exogenous insulin is at a relatively low concentration around the pancreatic alpha-cells compared to normal and thus glucagon secretion is chronically elevated and particularly elevated after meals since amino acids (from the protein in the meal) directly stimulate alpha-cell glucagon secretion. Glucagon in turn stimulates liver glucose production (and ketone production). Less liver glucose production by taking metformin in turn means either lower BG or since my BG is low already, means lower insulin doses. I think lower insulin doses while BG is controlled is beneficial in terms of prevention of insulin resistance (and therefore “double diabetes”), cardiovascular disease, high blood pressure, cancer, and Alzheimer’s dementia. These chronic conditions constitute the leading causes of death amongst Americans.
  5. In December, I obtained Humalog diluent from Eli Lilly (they kindly sent it to me for free) and I made a 5-fold diluted Humalog solution. This way I could accurately deliver Humalog in 0.1 IU increments or decrements which translates to 0.5 IU on my insulin syringe.

Glycemic Management Results for December 2018

My December glycemic results were improved in terms of mean blood glucose (BG) 97 mg/dl (97 mg/dl in October) and standard deviation (SD) 18 mg/dl (29 mg/dl in October). In fact, the SD of 18 mg/dl is a record low result. I just missed my desired BG goal of >70% of time spent with a BG value between 71 and 120 mg/dl.

The graphs below show the total daily insulin dose, and total Humalog and Lantus doses and my actual BG meter readings.

The graph below shows each Humalog and Lantus dose taken during the month.

The table below shows the mean BG, standard deviation (SD) of BG, coefficient of variation of BG (which is simply SD divided by mean BG expressed as a percentage).

The table below shows the % Time spent in three BG ranges and what the mean BG was during those times.

My Goals For 2019

I will continue to strive for normal BG values and my goals are to:

  1. Aim for a mean BG value of 96 mg/dl with a standard deviation of 12 mg/dl.
  2. Minimize or eliminate hypoglycemia i.e. BG < 71 mg/dl.
  3. Aim for % Time in the range of 71-120 mg/dl of > 80%.
  4. I realize these are lofty goals, but I believe if you aim low, you will likely get what you’re aiming for or conversely, if you aim high, you are more likely to hit the target you’re seeking.

How Will I Achieve These Goals

  1. I think estimating the Lantus insulin doses with the smaller 0.25 IU increments on my insulin syringes and diluting the Humalog 5-fold has helped get my resulting BG closer my target and I will continue doing this.
  2. I will continue Lantus dosing twice daily because that seems to be working.
  3. I am working on a mathematical method to predict my insulin doses based on prior responses. Haven’t found the right formula yet, but my search continues.

I hope these measures will result in additional improvements next month.

References

Efficacy and safety of metformin for patients with type 1 diabetes mellitus: a meta-analysis – here

A systematic review, meta-analysis and meta-regression of the effect of protein supplementation on resistance training-induced gains in muscle mass and strength in healthy adults – here

Continuous Glucose Profiles in Healthy Subjects under Everyday Life Conditions and after Different Meals – here

Variation of Interstitial Glucose Measurements Assessed by Continuous Glucose Monitors in Healthy, Nondiabetic Individuals – here

Severe Hypoglycemia–Induced Lethal Cardiac Arrhythmias Are Mediated by Sympathoadrenal Activation – here

#60 The American Diabetes Association Has Shifted Its Stance On The Low-Fat Diet For Diabetes

I have just read the 2019 Standards of Medical Care in Diabetes (Ref. 1). This is a comprehensive document produced annually by the American Diabetes Association (ADA). I have read this document each year since 2008. To their credit, the ADA has gradually changed their dietary recommendations in the right direction, in my opinion. Yes, their changes have been exceedingly slow. And, yes, I believe they have not given any special credence to a very low carbohydrate ketogenic diet (VLCKD) for the treatment of both type 1 diabetes (T1DM) and type 2 diabetes (T2DM). To date, they haven’t mentioned that a low carbohydrate diet can place T2DM in remission. In this study (Ref. 2), 65% of participants were able to achieve a HbA1c < 6.5% with either no medications (25%) or metformin alone (35%). I believe this missing knowledge would motivate many to adopt the VLCKD as a lifestyle. Of course, I am biased in favor of the VLCKD. I am also aware that some persons with T1DM who follow a VLCKD to improve their glycemic control have received discouraging words from their health care provider (HCP) about this choice. In this study (Ref. 3), 20% of the participants felt that their HCP was not supportive of their choice to use a VLCKD.

However, I believe this latest 2019 ADA document makes it quite clear that a variety of dietary choices are acceptable as long as they result in improved glycemic control. Additionally, this is the first time that “shared decision making” has been emphasized. This represents a significant shift from the idea that the HCP knows best and dictates what the patient should do without any input from the patient. This document makes it clear that HCPs should listen to and respect the patients’ individual preferences regarding their own diabetes care including which diet they feel is best. Therefore, I think it is fair to refer this document to your HCP if they do not agree with your dietary choice.

Below I have listed quotes from the 2019 Standards of Medical Care in Diabetes rather than paraphrase or summarize their words. I have added bold lettering to some words and my own thoughts in brackets that are particularly relevant to those who follow the VLCKD for treatment of their diabetes.

  1. This document is an official ADA position, is authored by the ADA, and provides all of the ADA’s current clinical practice recommendations. 
  2. The field of diabetes care is rapidly changing as new research, technology, and treatments that can improve the health and well-being of people with diabetes continue to emerge.
  3. A new figure from the ADA-European Association for the Study of Diabetes (EASD) consensus report about the diabetes care decision cycle was added to emphasize the need for ongoing assessment and shared decision making to achieve the goals of health care and avoid clinical inertia. [Just to clarify: shared decision making means that your health care provider should be listening to your desires about your own medical care. Avoiding clinical inertia means the provider should stop just doing the same old thing and be more nimble by updating their medical knowledge. Were they to do so, they would see that the body of published research on the effectiveness of a VLCKD for improved glycemic control continues to grow which is the primary goal of both the patient and the provider.]
  4. Evidence continues to suggest that there is not an ideal percentage of calories from carbohydrate, protein, and fat for all people with diabetes. Therefore, more discussion was added about the importance of macronutrient distribution based on an individualized assessment of current eating patterns, preferences, and metabolic goals. [This is the ADA’s way of saying that their previously recommended low fat diet is clearly not the best choice for treating diabetes. This should alert physicians that the ADA no longer recommends the low fat diet as the best way to eat. Therefore, there is no reason to discourage a patient from following a VLCKD if he/she so chooses.]
  5. Additional considerations were added to the eating patterns, macronutrient distribution, and meal planning sections to better identify candidates for meal plans, specifically for low-carbohydrate eating patterns and people who are pregnant or lactating, who have or are at risk for disordered eating, who have renal disease, and who are taking sodium–glucose co- transporter 2 inhibitors. [see my notes in 14. below]
  6. There is not a one-size-fits-all eating pattern for individuals with diabetes, and meal planning should be individualized. 
  7. A recommendation was modified to encourage people with diabetes to decrease consumption of both sugar sweetened and nonnutritive-sweetened beverages and use other alternatives, with an emphasis on water intake. 
  8. The sodium consumption recommendation was modified to eliminate the further restriction that was potentially indicated for those with both diabetes and hypertension. 
  9. In addition, in response to the growing literature that associates potentially judgmental words with increased feelings of shame and guilt, providers are encouraged to consider the impact that language has on building therapeutic relationships and to choose positive, strength-based words and phrases that put people first. [This is applicable to any provider who reacts negatively about the patient’s choice to follow the VLCKD.]
  10. People with diabetes and those at risk are advised to avoid sugar-sweetened beverages (including fruit juices) in order to control glycemia and weight and reduce their risk for cardiovascular disease and fatty liver and should minimize the consumption of foods with added sugar that have the capacity to displace healthier, more nutrient-dense food choices. 
  11. Data on the ideal total dietary fat content for people with diabetes are inconclusive, so an eating plan emphasizing elements of a Mediterranean-style diet rich in monounsaturated and polyunsaturated fats may be considered to improve glucose metabolism and lower cardiovascular disease risk and can be an effective alternative to a diet low in total fat but relatively high in carbohydrates.
  12. Studies have demonstrated that a variety of eating plans, varying in macronutrient composition, can be used effectively and safely in the short term (1–2 years) to achieve weight loss in people with diabetes. This includes structured low-calorie meal plans that include meal replacements and the Mediterranean eating pattern as well as low-carbohydrate meal plans.
  13. Studies examining the ideal amount of carbohydrate intake for people with diabetes are inconclusive, although monitoring carbohydrate intake and considering the blood glucose response to dietary carbohydrate are key for improving postprandial glucose control.
  14. Providers should maintain consistent medical oversight and recognize that certain groups are not appropriate for low-carbohydrate eating plans, including women who are pregnant or lactating, children, and people who have renal disease or disordered eating behavior, and these plans should be used with caution for those taking SGLT2 inhibitors due to potential risk of ketoacidosis. [See the warnings from the Food and Drug Administration (FDA) (Ref. 4). I agree with avoiding the use of SGLT2 inhibitor drugs for those with T1DM or those with type 2 diabetes (T2DM) who require exogenous insulin especially if they follow a VLCKD. Although very few persons with T1DM would be prescribed any of these drugs since they are not FDA approved, doctors can prescribe them off-label at their discretion. In those with T2DM (not on insulin) who follow a VLCKD, caution should also be used if an SGLT2 inhibitor drug is prescribed. The rationale for this caution is that some persons with T2DM have an impaired ability to make insulin somewhat like a person with T1DM. Additionally, a VLCKD significantly reduces insulin requirements as does an SGLT2 inhibitor due to its ability to cause the kidney to excrete glucose. Therefore, combining the VLCKD with an SGLT2 inhibitor drug results in low insulin levels and increases the risk of euglycemic diabetic ketoacidosis (EDKA). During EDKA the same symptoms (abdominal pain, nausea, vomiting) develop, but the patient may not cognate that DKA is a possibility due to the normal or near-normal blood glucose level caused by the SGLT2 inhibitor. Thus, it is best to avoid SGLT2 inhibitor drugs while following a VLCKD.

As far as children with T1DM using a VLCKD, Dr. Richard Bernstein and numerous other physicians have been treating children with a low carb diet for many years. The facebook group, TYPEONEGRIT, has thousands of children using Dr. Bernstein’s approach, and a research study of this group has been published (Ref. 3).

I have read several case reports of pregnant women who developed ketoacidosis and reported following a low carb diet. However in each of these case reports, there was no careful analysis of what the women were eating prior to hospital admission, but more importantly each of them also had a superimposed illness that caused them to be unable to eat for several days. Thus, they likely had superimposed starvation ketoacidosis, not related to the prior low carb diet. I would argue that these case reports certainly do not settle the issue about using a low carb diet with pregnancy or lactation. That said, I do admit that the use of a low carb diet with pregnancy or lactation has hardly been studied. Thus, caution should be exercised in using a VLCKD during pregnancy or lactation.]

  1. There is inadequate research about dietary patterns for type 1 diabetes to support one eating plan over another at this time. 
  2. However, for special populations, including pregnant or lactating women, older adults, vegetarians, and people following very low-calorie or low-carbohydrate diets, a multivitamin may be necessary. [A well-formulated VLCKD should not require a multivitamin supplement IF one chooses whole, real (not processed) foods rich in micronutrients. I suggest using cronometer.com to calculate the micronutrient content of your VLCKD. IF after entering and adjusting your VLCKD foods in cronometer.com, you determine you cannot meet your micronutrient needs, then a multivitamin or individual supplement with the specific deficient micronutrient(s) is indicated. Although vitamin supplements in general can be useful, they are not regulated in the U.S. and likely other places around the world. That means you can never be sure that the supplement contains the vitamin/mineral you are needing, it may contain more or less than what the label states, or it may contain toxic substances not listed on the label. Also, real food likely contains other nutrients which have not necessarily been identified by nutrition science. Thus, you should really make the effort to get as many of your micronutrients (vitamins/minerals) from food rather than supplements if you can.]

I hope anyone contemplating or following a VLCKD can use the above information from the ADA to discuss their approach with their HCP without fear of criticism.

For more information about using the VLCKD to improve glycemic control for those with type 1 diabetes (T1DM) consider purchasing my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

References

  1. American Diabetes Association, Standards of Medical Care in Diabetes, 2019 http://care.diabetesjournals.org/content/suppl/2018/12/17/42.Supplement_1.DC1
  2. Effectiveness and Safety of a Novel Care Model for the Management of Type 2 Diabetes at 1 Year: An Open-Label, Non-Randomized, Controlled Study https://www.ncbi.nlm.nih.gov/pubmed/29417495
  3. Management of Type 1 Diabetes With a Very Low-Carbohydrate Diet. http://pediatrics.aappublications.org/content/early/2018/05/03/peds.2017-3349.
  4. https://www.fda.gov/Drugs/DrugSafety/ucm446852.htm.

#59 November 2018 Update on My Type 1 Diabetes Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I have made several changes over the past four months in my attempt to further improve the glycemic control of my T1DM. These include:

  1. I returned to two meals per day on 8/8/2018, but now eating breakfast (7 AM) and lunch (2 PM) instead of breakfast (7 AM) and dinner (6 PM). This has allowed me to administer Humalog at 7 AM and 2 PM and Lantus at 6 PM separately rather than Humalog and Lantus together at 6 PM as I had been doing for many years. Turns out my basal Lantus dose was too high and my dinner-time Humalog dose was too low (many days I was not even taking Humalog at dinner-time). I did notice in November that although this improved my fasting BG readings, I was still have very different results with only tiny differences in the 6 PM Lantus doses. More on this shortly.
  2. I returned to weighing my food on a kitchen scale last month to more accurately balance the Humalog dose with food. The last time I did this was about 10 years ago when I was counting carbohydrates. I did it for two years with very unsatisfactory results. IMO carbohydrate counting does not work for T1DM (or for T2DM for that matter) primarily because eating a lot a carbs in those with diabetes does not work.
  3. Last month, I increased my dose of metformin to the maximum of 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with lunch. I have been tolerating this maximal dose without any side effects. I am convinced that even though I am relatively insulin sensitive, the metformin helps control post-meal BG by suppressing liver glucose production in response to meals and may be increasing muscle glucose uptake as well. These are the known mechanisms of metformin in helping to control BG in diabetes. I believe metformin is helping me because on the several occasions when I forgot to take the dose my post-meal BG was significantly elevated (by 30 – 40 mg/dl) compared to the previous days when I took the metformin. It makes sense that metformin would help T1DM because exogenous insulin is at a relatively low concentration around the pancreatic alpha-cells compared to normal and thus glucagon secretion is chronically elevated and particularly elevated after meals since amino acids (from the protein in the meal) directly stimulate alpha-cell glucagon secretion. Glucagon in turn stimulates liver glucose production (and ketone production). Less liver glucose production by taking metformin in turn means either lower BG or since my BG is low already, means lower insulin doses. I think lower insulin doses while BG is controlled is beneficial in terms of prevention of insulin resistance (and therefore “double diabetes”), cardiovascular disease, cancer, and Alzheimer’s dementia. These chronic conditions constitute the top causes of death amongst Americans.
  4. In November, I decided to try again to use smaller doses of my basal insulin, Lantus, given twice daily. But after three days, I decided to go ahead and try it three times a day which I have never tried before. This started just a few days ago (11/26/2018) so I will have to wait till next month to comment on the results. My rationale for this change was I had to change my weightlifting from the whole-body movements of olympic weightlifting (OWL) to bodybuilding type exercises on a machine due to a nagging hip discomfort that only occurs when standing up from a deep squat. However, OWL cannot be done without doing a deep squat. Interestingly I noticed that after the bodybuilding exercises, my BG was going up just as much as after OWL. These two types of exercises are completely different. The bodybuilding exercises, at least the way I have been doing them, are not at all intense. This made me suspect that the elevated BG values after both OWL and the easy bodybuilding exercises were more likely due to insufficient insulin onboard rather than release of stress hormones as I have thinking for quite a long time. This is why I decided to add a 7 AM morning Lantus dose to prevent the BG increase that occurs between 10:30 AM and 2 PM. After three days of twice daily Lantus, due to the above mentioned variation in fasting BG with small changes in the 6 PM Lantus dose, I decided to try giving the Lantus three times a day (at 7 AM, 2 PM, 10 PM) with smaller doses at 2 PM and 10 PM. I hope it works.

Glycemic Management Results for November 2018

My November glycemic results were about the same in terms of mean BG (97 mg/dl) and standard deviation (29 mg/dl) compared to October. Of course I was hoping for a reduction in standard deviation, but I did not achieve that. I did reach my desired BG goal of >70% of time spent with a BG value between 71 and 110 mg/dl and I had a reduced frequency of asymptomatic hypoglycemia. In November, my BG was calculated to be <71 mg/dl 10% of the time with a mean of 68 mg/dl during that time, 73% of the time BG was between 71 and 120 mg/dl with a mean of 89 mg/dl during that time, 17% were >120 mg/dl with a mean of 137 mg/dl during that time. No BG readings were in excess of 200 mg/dl. Preventing hypoglycemia is my top priority now so this reduction in asymptomatic hypoglycemia was encouraging.

The graphs below shows the total daily insulin doses of Humalog and Lantus and the total of both insulin doses and my actual BG readings.

The graph below shows each Humalog and Lantus dose taken during the month.

I had more fluctuations in insulin doses than I think is helpful. I think it reflects an impatience on my part to achieve normal BG as soon as possible.

My Goals For December 2018

I continue to strive for normal BG values and my goals are to:

  1. Achieve normal BG values including mean BG of 96 mg/dl with a standard deviation of 12 mg/dl or at least close to those values.
  2. Eliminate hypoglycemia i.e. BG < 71 mg/dl.
  3. In December, I am going to try my best to limit changing insulin doses to +/- 0.25-0.5 from one day to the next especially with the Lantus doses due to its longer half-life.

How Will I Achieve These Goals

  1. I think estimating insulin doses with the smaller 0.25 IU increments on my insulin syringes has helped get my resulting BG closer my target and I will continue doing that.
  2. I will try three times a day Lantus dosing to see if that helps.

I hope these measures will result in some improvements next month.

#58 October 2018 Update on My Type 1 Diabetes Management

This is a monthly update on my glycemic management of type 1 diabetes (T1DM) using Humalog and Lantus insulin injections with resistance exercise and a ketogenic whole-food diet as described in my book, The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print. My other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print. I would appreciate anyone who has read and benefited from either of these books to leave a review on Amazon. The number and ratings of the reviews are used by Amazon to order the search results when people are looking for books on diabetes.

I have made several changes over the past three months to further improve the glycemic control of my T1DM. These include:

  • I returned to two meals per day on 8/8/2018, but now eating breakfast (8 AM) and late lunch (3 PM) instead of breakfast and dinner. This will allow me to administer Humalog at 8 AM and 3 PM and Lantus at 6 PM separately rather than Humalog and Lantus together at 6 PM as I had been doing for many years. Turns out my basal Lantus dose was too high and my dinner-time Humalog dose was too low (many days I was not even taking Humalog at dinner-time). I check my blood glucose (BG) five times a day at 8:00 AM (fasting i.e. before breakfast) and 11:00 AM, at noon I exercise, another BG check and lunch at 3 PM, another BG check at 6 PM and take my dose of Lantus, then check BG at 10 PM (bedtime).
  • I returned to weighing my food on a kitchen scale last month to more accurately balance the Humalog dose with food. The last time I did this was about 10 years ago when I was carbohydrate counting. I did it for two years with very unsatisfactory results. IMO carbohydrate counting does not work for T1DM (or for T2DM for that matter) primarily because eating a lot a carbs in those with diabetes does not work.
  • Last month, I increased my dose of metformin to the maximum of 2,500 mg/day, 1,500 mg with breakfast and 1,000 mg with lunch. I have been tolerating this maximal dose without any side effects. I am convinced that even though I am relatively insulin sensitive, the metformin helps control post-meal BG by suppressing liver glucose production in response to meals and may be increasing muscle glucose uptake as well. These are the known mechanisms of metformin in helping to control BG in diabetes. I believe metformin is helping me because on the several occasions when I forgot to take the dose my post-meal BG was significantly elevated (by 30 – 40 mg/dl) compared to the previous days when I took the metformin. It makes sense that metformin would help T1DM because as I reviewed in other articles on my website lowcarbdiabetesdoctor.com, exogenous insulin is at a relatively low concentration around the pancreatic alpha-cells compared to normal and thus glucagon secretion is chronically elevated and particularly elevated after meals since amino acids (from the protein in the meal) directly stimulate alpha-cell glucagon secretion. Glucagon in turn stimulates liver glucose production (and ketone production). Less liver glucose production by taking metformin in turn means either lower BG or since my BG is low already, means lower insulin doses. I think lower insulin doses while BG is controlled is beneficial in terms of prevention of insulin resistance (and therefore “double diabetes”), cardiovascular disease, cancer, and Alzheimer’s dementia. These chronic conditions constitute the top causes of death amongst Americans. See the section below about euglycemic diabetic ketoacidosis where exogenous insulin doses can be too low!
  • Last month, all of the above resulted in a reduction in total daily insulin dose from 24.5 IU/day on 8/8/2018 to 16 IU/day on 9/30/2018 as well as a reduction in body weight from 163.4 to 150.6 lb. (over a 10 week period). I am sure the reduction in body weight contributed greatly to the reduction in insulin dose. However, insulin dose is usually expressed as IU/kg body weight and when expressed this way it is a reflection of insulin sensitivity. In general the lower the dose, the more insulin sensitive (assuming BG control is the same) the person is. Expressed this way, my total daily insulin dose decreased from 0.33 IU/kg BW/day on 8/8/2018 to 0.23 IU/kg BW/day on 9/30/2018. Thus, my insulin sensitivity improved due to the weight reduction and the increase in metformin dose from 2,000 mg/day to 2,500 mg/day. This is the lowest dose of insulin I have taken since my diagnosis in 1998. Fortunately, my insulin doses remained just as low in October, on average 15.7 IU/day, and my weight declined slightly more as well to 147.3 lb. Thus, the total daily insulin dose based on body weight was 0.24 IU/kg/day which is almost one-fourth the amount I was taking prior to starting my low carb ketogenic diet.
  • The last change I made last month was to decrease the volume of vegetables I was eating. This was due to some GI disturbances after meals. I was really eating more than I needed in terms of getting my micronutrients and fiber. I am glad to report that the GI disturbances resolved completely in October.

Glycemic Management Results for October 2018

My October glycemic results were about the same in terms of mean BG (96 mg/dl) and standard deviation (30 mg/dl) compared to September. Of course, I was hoping for more improvement (a reduction in standard deviation), but I did not achieve that. I did reach my desired BG goal of about 70% of time spent with a BG value between 61 and 110 mg/dl. I had a reduced frequency of asymptomatic hypoglycemia this month compared to last month. In October, 8.4% of my BG meter readings were less than 61 mg/dl, 61.3% were between 61 and 110 mg/dl, 30.3% were between 111 and 200 mg/dl, and none were in excess of 200 mg/dl. Preventing hypoglycemia is my top priority now so this reduction is asymptomatic hypoglycemia was encouraging.

The graph below shows my actual BG readings and the total daily insulin doses of Humalog and Lantus insulin and the total of both insulin doses.

Post 58 BG Insulin Totals Graph

The graph below shows the BG readings and the Humalog doses given.

Post 58 BG Humalog Doses Graph

I had more fluctuations in insulin doses this month compared to prior months. Hopefully this will smooth out in November.

The graph below shows the % Time spent in different ranges of BG on each day of October.

Post 58 %Time in Range

The graph below shows the % Time my BG was low, in target, or high and the mean BG value in those intervals for the month of October.

Post 58 %Time BG Low, BG in Target, and BG High

The graph below shows the % of meter BG readings in three different ranges at each of the five times of day that I measure it for October.

Post 58 %BG in Range Different Times of Day

New Diet Regimen beginning October 2018

The table below shows my new diet menu.

Daily Menu

Note: the MCT oil is only to be used if my body weight falls below 66 kg or 145 lb. I haven’t needed to use it yet.

From the table above you can see I eat different breakfast menus on Sunday Tuesday Thursday Saturday (beef and egg) compared to Monday Wednesday Friday (salmon). The weight of food and macronutrients are almost identical. Pictures of the meals are shown below. I realize I am not a professional food photographer. LOL.

Breakfast Beef and Egg on STTSBreakfast Salmon on MWF

Below is lunch at 3 PM everyday.Lunch Beef and Egg Photo

The macronutrient counts are as follows:

Macronutrient Table

Note that I am consuming 2.1 grams of protein/kg body weight/day. This is more protein than many who follow a ketogenic diet might consume. I am doing this due my age and and athletic goals as I desire to hold on to as much lean muscle mass as I can as I age. Aging has been shown to create some resistance to dietary protein in promoting skeletal muscle synthesis as well as resistance to the muscle building effects of resistance exercise. Stuart M Phillips, PhD in the Department of Kinesiology, McMaster University, Hamilton, Canada, based on his meta-analysis of multiple studies recommends a dietary protein intake of 1.62 grams protein/kg/day. However the 95% confidence interval is 1.03 to 2.20 grams protein/kg/day,  so I decided to consume protein at the higher end of his recommendation since I have no contraindications to doing so. The paper is here for your reference. At this level of protein intake, my blood ketones last month on two occasions were 0.5 and 0.6 mM.

You may wonder if eating the same menu over and over each day is difficult. For me it is not. I realize not everyone would be satisfied with the monotony. However, I did pick foods that I really enjoy and secondly, for me anyway, the lack of hunger produced by a ketogenic diet eliminates all cravings for other foods. If the above diet will result in the type of BG control that I am seeking, then the lack of variety will be worth it. Additionally, I can change the menu in small ways from time to time as long as I do so infrequently.

The graph below is a pictorial version of the above macronutrient table.

Macronutrient Pie Chart without MCT Oil

The graph below shows the % of the RDA (Recommended Daily Allowances) of vitamins provided by my diet. This was to confirm that I am getting all the micronutrients in adequate amounts. So as not to make this post too long, I will skip for now the meaning of RDA. Turns out that the confidence one should place on the RDA amounts is not very high.

Percent of RDA for Vitamins

The graph below shows the % of the RDA (Recommended Daily Allowances) of minerals provided by my diet.

Percent of RDA for Minerals

I would like to give credit to cronometer.com as an easy to use application to enter foods and determine both the macronutrient and micronutrient components of a menu.

Side Bar Regarding Euglycemic Diabetic Ketoacidosis

I have written on this blog in a prior post about nutritional ketosis as apposed to diabetic ketoacidosis (DKA). I think nutritional ketosis is a desirable state in general, but that the ketone levels do not need to be particularly elevated and in fact probably should not be particularly elevated, e.g. > 4 mM. I recently heard a talk by Jake Kushner, MD (a pediatric endocrinologist) at the Low Carb Houston conference where he said that persons with T1DM using a ketogenic diet to help manage their BG should be aware that nutritional ketosis may in rare cases increase the likelihood of euglycemic diabetic ketoacidosis (EDKA). DKA and EKDA are both pathological and potentially life-threatening states where the liver is overproducing ketones due to a high glucagon to insulin ratio in the blood, but in contrast to DKA, in EDKA the BG is not particularly elevated (generally less than 200 mg/dl). The fact that the BG is not particularly elevated makes the person with T1DM not be on the lookout for DKA. This phenomenon of EDKA has become more prominent recently due to some persons with T1DM being prescribed an SGLT2 inhibitor drug (which include the following: canagliflozin (Invokana), dapagliflozin (Farxiga), empagliflozin (Jardiance), empagliflozin/linagliptin (Glyxambi), empagliflozin/metformin (Synjardy), dapagliflozin/metformin (Xigduo XR)) off label to improve BG control and subsequently developed EDKA. SGLT2 inhibitors are FDA approved for T2DM and more commonly used for T2DM. The number of cases of EDKA has also increased in those with T2DM. Thus, this problem is not limited to just T1DM.

Dr. Kushner explained that nutritional ketosis has some physiological similarities to the effect of SGLT2 inhibitors. One is that SGLT2 inhibitors lead to chronically elevated glucagon levels and an elevated glucagon to insulin ratio. This elevated glucagon to insulin ratio occurs in those with T1DM (even not taking an SGLT2 inhibitor) because exogenous insulin does not adequately suppress alpha-cell glucagon production and I believe that nutritional ketosis and the resulting lower exogenous insulin doses probably magnifies this effect (although I don’t think it has been actually measured). So first, in my opinion, SGLT2 inhibitors should not be used in T1DM especially if a low carb ketogenic diet is being consumed. The second condition that can lead to an elevated glucagon to insulin ratio and the potential risk for EDKA in persons with T1DM is restriction of food intake either voluntarily (intentional fasting) or involuntarily due to an illness like gastroenteritis. The reduction in food intake requires a further (beyond what the low carb diet requires) reduction in exogenous insulin doses to avoid hypoglycemia. However, because as mentioned earlier exogenous insulin at very low doses does not adequately suppress alpha-cell glucagon production, the liver receives a signal (a high glucagon to insulin ratio) to overproduce ketones. This would not occur normally in a non-diabetic person who intentionally fasts or does not eat due to illness. So the take home message is that very low (or large reductions in) exogenous insulin doses in persons with T1DM should be a waving red flag. The blood ketone levels should be monitored along with BG and exogenous insulin doses need to be increased to keep blood ketones below, say 4 mM, even if that requires eating a significant amount of dietary carbohydrates. Obviously, illnesses can and do occur and cannot necessarily be avoided. However, voluntary fasting or significant reductions in caloric intake for the purpose of body fat loss, or other potential benefits (e.g. autophagy) can be moderated or avoided in those with T1DM. The benefits of fasting for autophagy and improvements in lifespan or health-span has only been studied in microorganisms and small animals, not in humans. Thus, implementing fasting for these purposes given the potential risks in those with T1DM is unwarranted in my opinion. As far as body fat loss is concerned, achieving a normal amount of body fat is important, but it must be achieved gradually with a modest caloric deficit (e.g. 100 – 200 kcal/day) to be safe in those with T1DM.

My Goals For November 2018 and Beyond

I am going to raise the bar further in terms of my glycemic management. I am not, by any means, sure that I will be able to achieve these lofty goals, but without goals, there is no direction to move toward. These are my goals:

  • Achieve near-normal BG values including mean BG of 96 mg/dl with a standard deviation as close to 12 mg/dl as possible.
  • Adjust my target BG range up from 61 – 110 mg/dl to 71 – 120 mg/dl and spend 80% of the day in this new higher range, 71 – 120 mg/dl. Honestly, with the elevation in BG that results from olympic weightlifting, this will be difficult to achieve. I do not feel the temporary elevation in BG that results from exercise is harmful. The elevation in BG is a normal response to exercise. The part that is not normal is that without exogenous insulin, the BG would remain elevated. This is why I eat lunch and take insulin right after I finish exercising. The main purpose of increasing the target BG range is to encourage me to avoid hypoglycemia. However, this elevation in BG after olympic weightlifting increases both the mean BG and the standard deviation. Thus, normalizing both of these parameters may not be compatible with olympic weightlifting.
  • Eliminate hypoglycemia or make it a rare event. I my case, my odds of developing long-term diabetic complications due to hyperglycemia are quite small, but I think my risk of having adverse effects of hypoglycemia are significantly higher. I want to eliminate that risk. This is my highest priority.

How Will I Achieve These Goals

In addition to the changes made in the past two months enumerated above, I am going make smaller adjustments in insulin doses by using 0.25 IU increments or decrements on my insulin syringes. This is because my total insulin doses are smaller than in the past and thus I need to have finer adjustments to the doses so the % change remains small. I have become aware that this applies to my basal insulin, Lantus, dose as well. I have noticed that changes in the Lantus dose have significant BG implications the following morning. I had been operating under the assumption that because it was “long-acting” it would take larger adjustments and require several days to have an effect. This is not the case. So any changes in my Lantus dose will be smaller than I have used in the past.

I hope next month I will have some improvements to report.