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#69 August 2019 Update on My T1DM 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.

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.

I wrote an article for DietDoctor last month titled “What you need to know about a low-carb diet and your kidneys“. You can read it here.

My books are available for purchase: The Ketogenic Diet for Type 1 Diabetes also available on Amazon in print, and my other book, Conquer Type 2 Diabetes with a Ketogenic Diet, is also available on Amazon in print.

This month I continued making adjustments even though I was hoping to keep everything constant for a change. I decided to go ahead and increase my weight to 73 kg, the masters olympic weightlifting class I would like to compete in. Changes in body weight are accompanied by changes in food intake, insulin doses, and blood sugar responses to those changes. Despite all these changes, I was pleased with my blood sugar results this month even though I did not reach my goals which are shown in the table below.

Glycemic Results For August 2019

The table below shows my mean blood glucose (BG), standard deviation (SD), coefficient of variation (CV), calculated HbA1c, body weight, and mean insulin dose totals for August 2019. You can see I am close to achieving both normal mean (average) blood sugar and variability of blood sugar (standard deviation). Now that I am at goal body weight, I might be able to achieve my blood sugar goals in September. If not, perhaps changing Lantus to Tresiba, which is scheduled to begin in November, will do the trick. Also note the increase in insulin dose that accompanies a larger body weight even when calculated as IU/kg/day. A higher body weight requires more daily food intake and more tissue that requires insulin. Still, this is a relatively low daily insulin requirement as most with T1DM require about 0.80 IU/kg/day which was my insulin requirement prior to starting regular exercise and a low carbohydrate diet.

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

This month’s results were about the same as in July. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As mentioned in previous posts, my goals are < 10%, > 80%, and < 10%, respectively. That said, the reduction in hypoglycemia is my highest priority so I am pleased with that. In addition, I needed to take glucose tablets on only 1 occasion in the month of July which is a new record low.

The graphs below show all of the daily insulin dose totals and all of the blood sugar (BG) readings for August 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

Even though the range of BG excursions continues to improve (I’m not complaining), there still appears to be a significant number of BG swings.

I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. Note that the study that found the largest difference in day-to-day variability was conducted and paid for by the maker’s of Tresiba, so we must take the results with a grain-of-salt. Nevertheless, the best way to know if something works better – or not – is to test it for myself. I have two more months of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that many people with T1DM do not have enough insulin. So I should be able to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

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#68 July 2019 Update on My T1D Management

I wrote an article for DietDoctor this month titled “What you need to know about a low-carb diet and your kidneys“. You can read it here. 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 continued making adjustments even though I was hoping to keep everything constant for a change. Unfortunately, my earlier decision to drop my body weight to make the 67 kg weight class in olympic weightlifting was a mistake. I had reduced my calories to the point that I felt a lack of energy, was thinking a food too frequently, was wishing for more food at the end of each meal, and I suspect that my energy expenditure went down to compensate for the lack of calories. Not only was this not pleasant, but I could not train enough to be able to lift the weights needed to be competitive. So during July, I progressively increased my caloric intake in steps and each time having to readjust insulin doses upward (see graph below). This process of adjusting food intake, insulin doses, and exercise results in less than optimal blood glucose control.

Glycemic Results For July 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 July 2019.

The standard deviation of BG was about the same as June, but I did not reach my goal of < 25 mg/dl was considered normal in the study reviewed last month (Post #67).

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

This month’s results were about the same as in June. I reached only one of my three goals for % of blood glucose readings in the three ranges above. As mentioned in previous posts, my goals are < 10%, > 80%, and < 10%, respectively. That said, the reduction in hypoglycemia is my highest priority so I am pleased with that. In addition, I needed to take glucose tablets on only 4 occasions in the month of July.

The graphs below show all of the daily insulin dose totals and all of the BG readings for July 2019. HUM = Humalog in blue, LAN = Lantus in green, INS = total daily insulin dose in red.

Even though the range of BG excursions continues to improve (I’m not complaining), there still appears to be a significant number of BG swings.

I have decided to change from Lantus to Tresiba because of the reported lower day-to-day variability of Tresiba compared to Lantus. Note that the study that found the largest difference in day-to-day variability was conducted and paid for by the maker’s of Tresiba, so we must take the results with a grain-of-salt. Nevertheless, the best way to know if something works better – or not – is to test it for myself. I have three more months of Lantus left in the refrigerator and I can’t bear to throw it out given the fact that many people with T1DM do not have enough insulin. So I should be able to start Tresiba in November 2019.

If you have questions or topics you would like me to write about, leave them in the comments. Till next month…

#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.

#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. 

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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.