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#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.

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#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.

 

 

#57 September 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 two 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 (7:30-8 AM) and late lunch (3 PM) instead of breakfast and dinner. This will result in a 16 hr daily fast. It has also allowed me to administer Humalog and Lantus separately rather than together at dinner time. 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). So now I take Humalog at breakfast (7:30-8 AM) and late lunch (3 PM) and take Lantus at 6 PM. I check my blood glucose (BG) five times a day at 7:30 AM (fasting i.e. before breakfast) and 10:30 AM, at noon I exercise, another BG check and lunch at 3 PM, check BG 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 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).
  • 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 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. I know this because on the occasions when I forgot to take the dose my post-meal BG was significantly elevated 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. Less liver glucose production 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 a benefit.
  • 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. I am sure the reduction in body weight contributed somewhat 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. The lower the dose, the better the insulin sensitivity (assuming BG control is the same). 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 either the weight reduction or the small increase in metformin dose from 2,000 mg/day to 2,500 mg/day, or both combined. Either way, this is the lowest dose of insulin I have taken since my diagnosis in 1998.
  • The last change I made 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, so hopefully the reduction will correct the GI problem. I will discuss this in more detail next month once I’m sure the GI problem has resolved (it is an intermittent problem so it will take some time to sort out). I will review my new diet menu and include the macronutrients and micronutrients next month. Since non-starchy vegetables are mainly composed of carbohydrates some of which are fiber as well as important vitamins and minerals, reducing them has resulted in a reduction in total carbohydrates which could additionally have contributed to the reduction in insulin requirements.

Glycemic Management Results for September 2018

My September glycemic results were somewhat improved compared to previous time periods. I reached my desired BG goal of >70% time spent with a BG value between 61 and 110 mg/dl. I had about the same frequency of asymptomatic hypoglycemia this month compared to last month. Preventing hypoglycemia is my top priority now. I think I can figure out a way to make it a rare event.

Below are my mean BG values, mean insulin doses, and BG frequency distribution for September 2018 compared to previous time periods. The predicted HbA1c uses the formula: AUC mean BG plus 88.55 divided 33.298. This formula is the least squares fit using my own personal mean BG versus measured HbA1c over many years. My particular HbA1c values are higher than many other individuals with the same mean BG. This is referred to as being a “high glycator.”

Post 57 Means Table

Below are my BG readings along with the Humalog (rapid-acting insulin) doses in September 2018. I adjust the breakfast (blue circles) and post-workout lunch (black circles), doses based on the pre-meal BG reading and take extra correction Humalog doses (red circles) for high BG readings as needed.

Post 57 BG Humalog Doses.png

The table below shows the BG variability results for current and previous time periods. The percentiles (10th, 25th, 75th, 90th) on the right show the spread of the BG readings about the median. The interquartile range, the difference between the 75th and 25th percentiles, is a measure of BG variability. In the middle of the table are the %Time in three BG ranges: %Time BG < 61 mg/dl (hypo) and the mean BG during that time, then %Time BG 61-110 mg/dl (target) and the mean BG during that time, and %Time BG > 110 mg/dl (hyper) and the mean BG during that time. Both the %Time with hypoglycemia and hyperglycemia are probably overestimates because they do not account for the corrections with glucose tablets for hypoglycemia or rapid-acting insulin (Humalog) for hyperglycemia. Measuring my BG more frequently than 5 times per day or using an accurate CGM would result in a more accurate estimate.

Post 57 Variability Table

The daily insulin dose totals started at 19 IU and ended the month at 16 IU with a bump up in the middle of the month. As mentioned above, 16 IU is the lowest dose since my diagnosis so I hope that continues and wasn’t just a fluke.

Post 57 BG Insulin Dose Totals

The daily insulin dose totals for 2018 are shown in the graph below. You can see a steady reduction in insulin doses since the peak at the beginning of January 2018. I outlined above the measures I have taken this year to reduce my insulin requirements. Included in that list is regular exercise which I continue daily.

Post 57 2018 Insulin Dose Totals

I will skip the section on my current diet because it is still being adjusted until my GI issue is resolved. I am experimenting with which and how much non-starchy vegetables I can tolerate and still come close to 100% of the RDA values for each nutrient.

That’s all folks…..

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

#56 August 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 posted the blog post on my new website lowcarbdiabetesdoctor.com and the new blog post is here.

Post-56-Variability-Table

#55 July 2018 Update on My T1DM Management

Dear Blog Followers, I am happy to reveal my new website, lowcarbdiabetesdoctor.com that also will house my blog posts. The purpose of the new website is to make it easier to find more information about using lifestyle changes including the low carb ketogenic diet and exercise for not only type 1 diabetes (T1DM), but also for many related metabolic conditions including insulin resistance, prediabetes, type 2 diabetes, dyslipidemia, cardiovascular disease, and many more.

Please sign up for the newsletter on the new website which is the mechanism by which I can announce new blog posts and new articles that I will be writing. I just started the new website about 6 weeks ago, so many of the articles I have planned are not written, but they will be forthcoming. Thanks for your interest and support. You can find my latest blog post here.

#54 June 2018 Update on My T1DM Management

Dear Blog Followers, I am happy to reveal my new website that also will house my blog posts. The purpose of the new website is to make it easier to find more information about using lifestyle changes including the low carb ketogenic diet and exercise for not only type 1 diabetes (T1DM), but also for many related metabolic conditions including insulin resistance, prediabetes, type 2 diabetes, dyslipidemia, cardiovascular disease, and many more.

You can find my latest blog post here. Please sign up for the newsletter which is the mechanism by which I can announce new blog posts and new articles that I will be writing. I just started the new website two weeks ago, so many of the articles I have planned are not written, but they will be forthcoming. Thanks for your interest and support.

#53 May 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.

Although glycemic management in T1DM will always be challenging, the low carb ketogenic whole-food diet definitely improves it by reducing average blood glucose (BG) and variations in BG as well as insulin requirements. Many of the diseases (cardiovascular disease, cancer, Alzheimer’s, and many more) associated with T2DM and “double diabetes” as part of T1DM are due to insulin resistance and hyperinsulinemia. The low carbohydrate ketogenic whole-food diet directly improves both insulin resistance and endogenous hyperinsulinemia in T2DM and exogenous insulin requirements in T1DM (i.e. reduced insulin doses).

May 2018 was the third full month of taking metformin at a dose of 2000 mg/day (started that dose on Feb. 15, 2018). I am tolerating it without any side effects. As you may know metformin is the first-line medication for T2DM, but can also be useful for those with T1DM. Metformin acts on the liver to reduce glucose production by suppressing both gluconeogenesis and glycogenolysis. I think this may be useful for those with T1DM on a low carbohydrate diet because the reduction in dietary carbohydrate reduces insulin requirements which in turn stimulates glucagon secretion by the alpha cells in the pancreas which in turn increases glucose production by the liver. This increase in glucose production occurs primarily from increased gluconeogenesis, but also some increase in glycogenolysis is suggested in some studies. In addition, metformin stimulates muscle uptake of glucose independent of insulin. Hopefully over time, I will be able to determine if taking metformin either reduces my blood glucose (BG), insulin requirements, or both. I am estimating that I will need to take it for 6 months to be able to make a before and after comparison as far as the insulin dose comparison is concerned. There is a possibility that metformin could increase the incidence and severity of hypoglycemia while on a ketogenic diet, so caution should be exercised. A possible mechanism for this is the fact that gluconeogenesis plays a more important role in maintaining BG in those on a ketogenic diet than on a balanced macronutrient diet. If metformin reduces gluconeogenesis, then hypoglycemia could result if insulin doses are not appropriately reduced. 

Glycemic Management Results for May 2018

My May glycemic results were somewhat improved compared to previous time periods although I did not reach my desired BG goal of >70% time spent with a BG value between 61 and 110 mg/dl. I had less hypoglycemia this month, but one was symptomatic. This time I developed skin numbness while walking. I have had this particular symptom before and took two glucose tablets immediately and the symptom resolved in about 30 mins. This occurred when I was out of town. Travel usually adversely affects my glycemic control so I stay on high alert. Below are my mean BG values, mean insulin doses, and BG frequency distribution for May 2018 compared to previous time periods. The predicted HbA1c uses the formula: AUC mean BG plus 88.55 divided 33.298. This formula is the least squares fit using my own personal mean BG versus measured HbA1c over many years. My particular HbA1c values are higher than many other individuals with the same mean BG. This is referred to as being a “high glycator.”

Post 53 Mean BG Table

As discussed previously, exogenous insulin cannot mimic normal insulin secretion, so persons with T1DM should not expect to have truly normal BG values at all times. They just need to be low enough to prevent long-term complications and not so low as to cause unpleasant hypoglycemic symptoms or less common, yet more dangerous, consequences including brain damage, seizure, injury, coma, or death. I have set my target BG range at 61-110 mg/dl because values in this range are not likely to lead to harm or complications of T1DM. Your target BG range should be determined with your physician because one size does not fit all. Normal BG is 96 ± 12 mg/dl (mean ± standard deviation (SD)) and coefficient of variation is 13% which is the weighted mean from two studies of continuous glucose monitoring in healthy subjects (see references at the end). The standard deviation and coefficient of variation are measures of BG variability which I believe are important in T1DM. Clinical outcomes in T1DM (i.e. microvascular and macrovascular complications) have only been documented to correlate with measures of mean BG, particularly HbA1c. This does not mean that BG variability is not important, but it just has not been documented to correlate with outcomes and complications of T1DM. Achieving a normal standard deviation or coefficient of variation in T1DM would be difficult, if not impossible, with current exogenous insulin therapy (injected or pumped). Monitoring the standard deviation and/or coefficient of variation and finding ways to improve them to the best of one’s ability is desirable in my opinion. Following a low carbohydrate ketogenic diet is one such method of reducing BG variability, mean BG, insulin doses, and hypoglycemia. A ketogenic diet may also provide an alternate or additional brain fuel in the form of ketones to protect the brain when BG does go low. The alternative energy that ketones supply to the brain may prevent or blunt the sympathoadrenal response to hypoglycemia which in turn reduces or eliminates the symptoms of and harm from hypoglycemia. This hypothesis needs to be tested before it can be stated as fact. Having mild asymptomatic hypoglycemia adapts the brain to lower BG and reduces the symptoms of mild hypoglycemia and potentially the harm from hypoglycemia due to lack of activation of the sympathetic nervous system by reducing sympathoadrenal-induced fatal cardiac arrhythmia (see references at the end).

Below are my BG readings along with the Humalog (rapid-acting insulin) doses in May 2018. I adjust the breakfast (blue circles), post-workout lunch (black circles), and dinner (purple circles) meal-time doses based on the pre-meal BG reading and take extra correction Humalog doses (red circles) for high BG readings as needed. I continued my previous pattern of high BG readings after weightlifting which I correct with my lunch-time Humalog dose.

Post 53 Humalog Doses and BG graph

The table below shows the BG variability results for current and previous time periods. The percentiles (10th, 25th, 75th, 90th) on the right show the spread of the BG readings about the median. The interquartile range, the difference between the 75th and 25th percentiles, is a measure of BG variability. In the middle of the table are the %Time in three BG ranges: %Time BG < 61 mg/dl (hypo) and the mean BG during that time, then %Time BG 61-110 mg/dl (target) and the mean BG during that time, and %Time BG > 110 mg/dl (hyper) and the mean BG during that time. Both the %Time with hypoglycemia and hyperglycemia are probably overestimates because they do not account for the corrections with glucose tablets for hypoglycemia or rapid-acting insulin (Humalog) for hyperglycemia. Measuring my BG more frequently than 5 times per day or using an accurate CGM would result in a more accurate estimate.

Post 53 Variability BG Table

The daily insulin dose totals ranged from 23 to 33.5 IU/day in response to the BG readings and are shown in the graphs below for May 2018. You can see a fairly steady total daily insulin dose during the month with a 2 to 4 day intervals of increased insulin doses to address hyperglycemia. The basal insulin dose was more stable and ranged from 20 to 22 IU/day.

Post 53 Insulin Dose Totals and BG graph

The daily insulin dose totals for 2018 are shown in the graph below. You can see a steady reduction in insulin doses since the peak at the beginning of January 2018. The measures I have taken to reduce this variation in insulin dose have included keeping meals and exercise as constant as possible and adding metformin to suppress liver glucose production. Specifically, I try to keep all meals constant in terms of portion size, macronutrient composition and timing of my meals. In addition, I try to keep exercise constant including frequency (daily), type (the type of weightlifting exercises, mainly compound movements), intensity (gradually increasing weight over time as tolerated), and volume (repetitions). That said, keeping exercise intensity constant from day to day is quite difficult.

Post 53 Insulin Dose Totals 2018

The graph below illustrates the distribution of BG values in the ranges indicated at various times of day. This could be useful to point out problems (hypoglycemia and/or hyperglycemia) at different times of day.

Post 53 Percent BG values in Ranges at Times of Day

The graph below illustrates the percentage of time spent in three BG ranges for each day of the month of May. The numeric percentage is shown on top of the green bars for the % of time BG was between 61 and 110 mg/dl.

Post 53 Daily Time in Range

In June, I will continue olympic weightlifting every day with 3 exercises per day. I will also continue metformin 2000 mg daily (1000 mg every twelve hours).

My Thoughts About Management of Type 1 Diabetes With A Ketogenic Diet

My goal of glycemic management in T1DM with a ketogenic diet is to keep BG as close to normal i.e. 96 ± 12 mg/dl (mean ± SD) as is safely possible (i.e. avoiding hypoglycemia) to avoid diabetic complications, a reduction in lifespan, and unpleasant symptoms of as well as injury and death from hypoglycemia. For me, a well-formulated whole-food nutrient-dense ketogenic diet, daily exercise, frequent BG measurements, and lower insulin-analog doses (Humalog/Lantus) have improved my glycemic control, hypoglycemic reactions, and quality of life. My basic diet philosophy is to avoid processed foods especially those containing refined carbohydrates, sugar, and vegetable (seed) oils while enjoying whole foods (with just one ingredient) as close to their original state as possible. I think just knowing the guidelines in this paragraph would be a good start for those wanting to improve their diet. To treat diabetes, the additional step is to eliminate all foods with significant amounts of carbohydrate to keep the net carbohydrate total < 50 grams/day. Some may do better with < 30 grams/day, while others who exercise a lot may do well with < 100 grams/day.

My current version of ketogenic diet is as follows: 

What I Cook & Eat

  • Beef, grass-fed, including meat (85% lean), heart, liver, and kidney (liverwurst)
  • Fish, mainly wild Alaskan salmon
  • Lamb, Chicken & Turkey occasionally
  • Chicken Eggs (one per day)
  • Non-starchy vegetables (about 5% carbohydrate content by weight) including Cabbage (Red, Green, Napa), Kale, Collard Greens, Home-made Sauerkraut from Red Cabbage, Bok-Choy, Broccoli, Cauliflower, and some others.
  • Fruit – Avocado, Olives, lemon juice on fish
  • Nuts & Seeds – Pepitas, Macadamia, Brazil, Pecan, Walnut, Pistachio, Cashew.
  • Note: I developed an intolerance to milk prior to my diagnosis of T1D. I did try heavy whipping cream after starting my KLCHF diet, but am also intolerant of it. I do tolerate butter, but wanted to decrease my fat intake, so eliminated all dairy including cheese and yogurt.

What I Drink

Water (filtered by reverse osmosis), Unsweetened Tea & Coffee

What I Don’t Eat

  • Grains – Wheat, Corn, Rice, Oats (there are many more) or anything made from them, which is too numerous to list here. Gluten is a protein present in a number of grains (all varieties of wheat including spelt, kamut, and triticale as well as barley and rye.) which can cause a number of medical problems for a significant portion of the population with gluten sensitivity or celiac disease. In my case, I avoid them due to their carbohydrate content.
  • Starchy and most root vegetables – potatoes, sweet potatoes, yams
  • Legumes – peas, beans, lentils, peanuts, soybeans
  • High sugar fruits – includes most fruits except berries, see above.
  • Sugar and the fifty other names used to disguise sugar.
  • Vegetable Oils – Canola, Corn, Soybean, Peanut, Sunflower, Safflower, Cottonseed, Grape seed, Margarine & Butter substitutes, Shortening.
  • All Processed Foods.
  • I avoid restaurants except when traveling, and then order fish or steak with plain steamed non-starchy vegetables (no gravy or sauces that typically contain sugar, cornstarch, or flour) or salad.
  • Refined, but healthy, fats – Although there is nothing bad about including butter, coconut & olive oil in a ketogenic diet, I have eliminated refined fats from my diet to improve my body composition.

What I Don’t Drink

  • Colas (both sweetened and artificially sweetened).
  • Fruit Juice except small amounts of lemon juice occasionally.
  • Alcohol (can cause hyperglycemia or hypoglycemia in persons with diabetes).
  • No artificial sweeteners: I don’t enjoy them.

My exercise regimen often results in post-exercise hyperglycemia which is a normal response to intense exercise. However due to having T1DM, my body is unable to correct this without taking exogenous rapid-acting insulin (Humalog). The exercise I choose negatively affects my glycemic control to some extent. I’m sure I could find an exercise that has less impact on glycemia, but I enjoy weightlifting and feel it has health-span and life-span extending benefits which may compensate for the temporary increase in BG during/after exercise. Hopefully my BG values and variability as well as the relatively lower insulin doses that result from my ketogenic diet, exercise, and hopefully metformin (yet to be determined) are close enough to optimal to avoid any reduction in lifespan, diabetic complications, and harm from hypoglycemia, but only time will tell.

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