Low Carb Ketogenic Diet For Type 1 Diabetes - Blog Post 56 August 2018

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 low carb ketogenic 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. See below on the right.

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.

In August 2018, I made several changes to my diet, metformin, exercise, and thus insulin doses, all for the better I hope.

First, I traveled for two weeks which is always a challenge to my glycemic management. I did not lift weights during that two week period. I did some easy swimming and walking every day. As far as diet, I experimented with a further reduction in dietary carbohydrate intake, but I did not measure any exact quantities. Because I wasn't lifting weights, I did not eat lunch for two weeks, so I decided to continue the same after returning home with the reduction in dietary carbohydrates and an increase in meat (thus protein and fat) in the two meals I did eat. Although I was aiming to keep the calories about the same (without counting), I must have decreased them because I lost 6 lb. body weight (163 to 157 lb.). The little body fat I do have is around my waist and it did noticeably decrease along with my waist circumference from 34 to 33 inches. I also decided to increase my metformin dose to the maximum: 2500 mg/day divided in three doses: 1000 mg with breakfast, 1000 mg with a late afternoon lunch/early dinner, and 500 mg at bedtime. The metformin is definitely helping to control my post-meal BG. I know this because when I have forgotten to take it, my BG is almost invariably high. I also wanted to experiment with taking my basal insulin, Lantus, at bedtime instead of at dinner-time. I had tried this in the past without much difference noted, but thought I would try it again because I was noticing that I was having some asymptomatic hypoglycemia 3 hours after dinner on days when I was not taking any meal-time insulin, Humalog, but just taking metformin. Thus it was either the Lantus, metformin, or the combination of both causing this. So I thought either the dose of Lantus was too high, or it was being given too soon after my insulin-sensitizing exercise (weightlifting). Thus, I decided to take it at bedtime, and if the morning blood glucose was low, to reduce the dose. That is, in fact, what happened. But now that I have changed it to bedtime dosing, I will continue it for a while to see what happens.

Glycemic Results For August 2018

My August 2018 glycemic results were about the same as July 2018 and I did 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 (7% time) compared to most months with no symptoms of hypoglycemia. Below are my mean BG values, mean insulin doses, and BG frequency distribution for August 2018 compared to previous time periods. The predicted HbA1c uses the formula: AUC mean BG plus 88.55 divided by 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.”

Below are my BG readings along with the Humalog (rapid-acting insulin) doses for August 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.

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.

The total basal (Lantus), meal-time rapid-acting (Humalog), and total insulin doses along with the BG readings and are shown in the graphs below for August 2018. You can see I had to gradually decrease the basal insulin (Lantus) dose during August due to both the reduction in food intake (no lunch for the last 3 weeks of the month) and in body weight in response to my fasting BG results. The basal insulin (Lantus) dose decreased from 23 IU/day to 18 IU/day and the total daily insulin dose decreased from 32.5 IU to 21.5 IU/day.

The daily insulin dose totals for 2018 are shown in the graph below. You can see a reduction in insulin doses since the peak at the beginning of January 2018 followed  by a stabilization and more recently a gradual reduction in the total daily insulin dose. 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 (gluconeogenesis). 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.

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

The graph below illustrates the percentage of time spent in three BG ranges on each day of the month. The numeric percentage is shown on top of the green bars for the % of time BG was between 61 and 110 mg/dl. My goal is for this to be > 70% of the time.

The graph below  simply shows the change in BG that occurs after weightlifting during the month. I think that the increase is related to stress hormones secreted during intense exercise. However, the current basal insulin (Lantus) dose modifies the response as well. There are some days where the BG actually dropped. Thus, the change in BG is a function of both the exercise activity and the current basal insulin dose.

In September, my goals include a further reduction in the frequency of hypoglycemia (my goal is none) and an increase in strength.  I will continue olympic weightlifting every day with 2 exercises per day. I will also continue metformin 2500 mg daily with two meals per day for now.

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. Each person needs to determine their own level of carbohydrate tolerance to optimize their BG.

My Whole-Food Low Carb Ketogenic Diet

What I Cook & Eat

  • Beef  (85% lean)
  • Fish, wild Alaskan salmon
  • Chicken Eggs (two per day)
  • Non-starchy vegetables (about 5% carbohydrate content by weight) including Home-made Sauerkraut from Red Cabbage, dill pickles, and some others.
  • Fruit – 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 to further improve my body composition, 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 further 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, but for others they may act in the brain to fuel carbohydrate cravings and would be best avoided.

References

  1. Efficacy and safety of metformin for patients with type 1 diabetes mellitus: a meta-analysis – here
  2. 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
  3. Continuous Glucose Profiles in Healthy Subjects under Everyday Life Conditions and after Different Meals – here
  4. Variation of Interstitial Glucose Measurements Assessed by Continuous Glucose Monitors in Healthy, Nondiabetic Individuals – here
  5. Severe Hypoglycemia–Induced Lethal Cardiac Arrhythmias Are Mediated by Sympathoadrenal Activation – here

My Books Are Available in Downloadable PDF or in Print on Amazon.

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Both books are available as a PDF ebook and as a print book from Amazon. Note: Clicking on the links above will take you to the website of Ellen Davis, MS, my coauthor. Her website is ketogenic-diet-resource.com.

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