Half Marathon 12. Injury Time, Posture and Health

If an actor can project emotion through body posture do you think that the reverse might be true? Can posture affect emotion? I think that it might. If I look like an old man with hunched shoulders and shuffling gait, will I turn out to be grumpy old man? There is lots on the internet about posture and pain, and some articles on posture and hormones. An aggressive person has a certain body language and a lot of hormonal activity. So does the victim! Do our genes in part dictate our posture and because of this our character? And, can we alter our posture to alter our character? Are our lifestyles causing more than just aches and pains and the occasional heart attack? Are our lifestyles affecting our basic sense of self? I will be googling this over the months to learn more.

I got into this by accident really. You see, I picked up an injury just 3 days after my last run. It was an insignificant enough event. Lifting a heavy bulky load out of the back of the car on a slope. A slight rotation on the right knee as it took the weight. I felt only tiny twinge. I didn’t even have to stop and recover. It was trivial, but it got worse through the day and was there the next day, and the next… Hmm, this was not going to go away. I diagnosed bursitis and took a week off running. But the pain was beginning to get worse. There was an ache at night and swelling in the lower quads. I was beginning to limp. A complete disaster. With just 3 weeks to my last run, I could barely walk let alone run.

My usual cure for just about everything is to go for a run. Bad back, high glucose, sore throat, go for a run. It sorts most things out. Running is great for aerobic fitness. I also find it remarkably meditative. I can free my mind when running. It is mobile yoga as far as I am concerned.

Over the past few months though, I have been aware of the need to do more all round exercise than just pounding the streets and paths. Everyone is talking about high intensity training with weights at the moment. Richard Bernstein talks about it too. I needed to look at expanding my exercise regime.

It must have been one of those moments of just good fortune that I had contacted a personal trainer a few weeks before my knee injury. My first appointment was a week after it. I was intending anyway to try improve my all round fitness in order to see what would happen on my 12th and last run of my challenge. I wanted to build on the aerobic fitness of the last 11 runs. That was going to be compromised by an inability to run now but I turned up at the gym anyway. I am not a gym bunny. In the past I could never see much improvement of working out at the gym. Despite all of that huffing, puffing and grunting I never seemed to get better. But Dave was good. He took the time to listen to my needs. These were that I needed to learn exercises that I could do at home. And to reverse the decline of years of office-type work, which was starting to cause some low back pain. A simple task for him!

Just changing to Low carb had improved things enormously with respect to aches and pains, but I knew I had a way to go. Dave got me to do a few exercises then diagnosed where I might need improvement. Tight pelvis and hips caused by hamstring and quads being relatively underused because of all that sitting. Over-developed quads, weak shoulder girdle. Leading to back pain. It all made enough sense for me to want to try it. I had only mentioned my knee as a trivial problem as I was keen to start all round improvement.

So over the next 3 weeks I got down to some serious training.

One thing was certain. I was going to do this final run. It was not a serious injury and I would not in the long term destroy the joint. But the issue was, how could I run 2 hours when I could barely walk 100 metres? It was painful. I trained at home and went weekly to see Dave, where the ante was upped relentlessly. I was sweating buckets just moving weights. Far more than if I went running. But the thing was that the knee pain eased on each session. I was stretching the muscles of the thigh and taking the load off the bursa. Ok, they tightened up again later but it was instructive. My pelvis getting freed up and I had more flexibility in my hips. I could feel the change over the weeks. That slow re-awakening of the body when it gets the chance. Spring was following winter. I felt energised and lively. I could walk better, my posture was subtly improving. It felt just like the time when I gave up carbs. At that time my body breathed a sigh of relief. And I recognised the same thing with this training. Just when I didn’t think it could get much better, it did! I am converted!

So this is significant. One of the 4 pillars of health talked about by Dean Ornish. Eat well, Move well, Sleep well. Love well. Moving well. I was moving by running that was not in doubt. But was I moving well? In my case probably not. So I now have to somehow incorporate this into my daily life. Having a sedentary job is not ideal, but there is no way round that unless I change my job. However, there are plenty of opportunities to practice stretching and warm up during the day. I just need to get on and do it. I regard gym work as needing preparation and a dedicated time slot. That is the case, but I know that there are opportunities throughout the day too. After a few weeks it will become second nature anyway and I know that it will help a lot. After all who would say no to improved posture, improved movement, improved happy hormones?

My final run.

I was pleased to have discovered moving well as I entered my final run. Actually taking part turned out to be a last minute decision. I had booked everything and turned up the day before. I knew how to stretch the leg to relax the quads, but I was in pain 2 days before. I was concerned. But as if by a miracle the pain eased the next day and I was in with a chance. I had decided to run on maximum pain relief. A knee brace might have been useful but I never got round to it. I am not a great fan of these sort of things. The knee was not unstable, the bursa was inflamed that was all.

I had injected my usual now only 18 units of ‘designer’ Tresiba. I only use this once a day and it seems ok. I might one day look at just rapid acting injections and cut out the background stuff, but my body is not there yet. I need to crack the problem of insulin resistance. There is a piece of knowledge still missing. I cannot yet work out how to approach this, but something will come up. It always does if you keep looking. It is something I will try when the time is right.

I was fancying a full English breakfast so I indulged. 500 or so calories from fat and protein. I am now more mindful of protein. Dave my trainer likes protein, not too much but twice my current input. Mind you, where I am lifting a few kilograms here and there, you can multiply it by 10 with him. But my muscles are building so I might need to increase for a while. My morning glucose was 4mmol/l on waking and went up to 9.6 after breakfast and just before the run.

I am a slow learner. Using a sensor for 3 weeks when it is only meant to last a week is asking for trouble. And, knowing for a couple of days that this was giving up and needing tweaking, was not a good sign. I never got another reading out of that sensor. It fell off just after the start. and was confident that I would not need to top up with rapid acting. On many occasions in the past I had needed top ups of carbs. 9.6mmol/lit was not ideal, but I would have been pleased with that before I decided to go keto. And at this level I could totally relax knowing that I would be very unlikely to have a problem with low glucose. I had glucose tablets anyway but no monitor. But I did have good hypo awareness. I was not worried. I was trying to think what it would have been like in the pre keto days, but I couldn’t. I am used to being near ‘normal’ when running now. The bad old days are becoming a distant memory. Nowadays on keto, diabetes is just a minor irritant that can be largely ignored. Sure I have to work hard at it, but this diet has become my normal way of eating, I don’t have to think about it. Even if I do get a hypo it is weedy. Not like a proper hard-core hypo when I was carb counting. In those days the vision would go patchy and I would start gobbling loads of glucose in the vain hope that more might act more quickly. And the sweating, the squinting to try to clear the blind spots, and the thought that this might be ‘the one’ that might put me in hospital. Ah, the memories! No, after the last run when I realised I had been planning like a diabetic, I decided to get this in perspective. The proper way to treat diabetes is by following a ketogenic diet. Everything becomes possible then.

Anyway, I had other concerns. The knee needed some attention. It had about 13,000 flexion and extensions to do in the next 2 hours. So it needed to sort itself out. It did as well. I was very lucky. There was some pain and it was persistent, but it did not really spoil things.

I enjoyed the run. A good first half and an equally good second half. My third best time with no training other than the gym. Could it have been that? I think it might.

God only knows what my glucose levels were. I needed no glucose supplements, or at any rate didn’t take them. I never felt hypo or even light headed. I met my nephew afterwards and didn’t get to check it until 3 hours later. To be honest, I can’t even remember what it was, but I know it was okay. Such is the relaxed way I do things now. So, bearing in mind the lack of training, it was a great end to the challenge I set myself a year ago. At that time it was a huge personal challenge. Now my perspective has changed. I am no longer a half marathon person. I reckon anything is possible. I could never have even contemplated even saying that 2 years ago. When I did things the current guideline way I could only see a bleak future health wise. That may still turn out to be the case, but while I am here I am vital, and get the most out of every day. That after all is all I can ask for. I can now look forward with optimism.

This has been a great journey for me. I know that this ketogenic lifestyle is perfect for type 1’s and will promote it at every opportunity. Change will only come from the ground up. If there is anyone out there reading this, please pass on the information. I arrived here by total accident. It changed my life for the better. It may change someone else’s.

Half-Marathon 11. Paleo-Keto and training like a non-diabetic

 

Having HbA1c in the non- diabetic range is the norm. It is a gift so late-on in my life with diabetes that I am eternally grateful for the moment that I discovered keto.

I have become pretty slick at using a keto diet over the months. If I do get high glucose levels it is usually my own fault. Occasionally genuine error reading the labels, but mostly, laziness and indulgence.

 Imagine my surprise, then,when I became aware of the Paleolithic Ketogenic Diet. (PKD). I had sent some of my work on keto for a review by Csaba Toth, a Doctor in Budapest who understands low carb diets. He works with a biologist, Zsofia Clemens and they run a clinic called Paleomedicina. Csaba was an intensive care doctor when he discovered that autoimmune diseases such as T1 might be triggered by food in the gut breaking through into the blood stream. The idea is that certain foods that we were not genetically set up to eat, can cause irritation in the gut. In turn this opens up the cell walls lining the gut to allow food particles to get into the blood stream. This then sets up an immune reaction by the body. The antibodies produced sometimes then mistake parts of the body as ‘foreign’ for example the pancreatic cells that make insulin and attack and destroy them to create a chronic disease such as type 1 diabetes.

The assumption is that humans are not genetically programmed to cope with many foods we now see as parts of a normal, health diet. We were genetically made to eat meat and fat, with modest amounts of vegetables. Csaba and Zsofia have treated people in the early stages of type 1 diabetes and have written up some scientific papers to share their results. Some would take this as evidence for their methods, others would find alternative explanations for their results. Have a look and see what you think www.paleomedicina.com https://www.researchgate.net/profile/Csaba_Toth9

https://www.researchgate.net/profile/Zsofia_Clemens

In any event, it was an intriguing idea. It would be easy to dismiss as a fringe idea. But if Richard Bernstein had gone with orthodoxy, where would I be now? (And him?!). There is not a lot of point becoming dogmatic about LCHF for it’s own sake. My interest was piqued. I needed to take a look.

So, off I went to Hungary. A 3 hour drive west is the small town of Zalaszentgrot where Paleomedicina run a residential week to teach PKD. They provide all of the food and do personal consultations alongside communal teaching.

To be fair, I wasn’t expecting much personally. I am so far down the line of autoimmune disease that my insides must be pretty furred up. Just running diabetic range blood sugars all those years must have stuck everything together inside. The years and years of high glucose levels must have bonded sugar to just about every tissue. If there was added inflammation from the diet also, along the lines of leaky gut, well, just multiply all of that by a factor of n. If I were a kettle I would have been replaced years ago as furred up beyond use. But I am still having fun and feel vital every day. Living in the now is everything and I have a second chance. So, I am going to take a look and see what happens.

It was not to be the best start in trying to be scientific about it, unfortunately. I was going to get some pre diet bloods done at the clinic. But I happened to turn up on a National holiday, so this was not possible. Getting them arranged privately in the UK via the local hospital lab when I got home was a lot hassle and delay. I gave up in the end. And also I had by then been on the PKD diet for too long for the tests to have any real meaning. It was shame as it would have been good to experiment. All manner of tests less familiar to the routine NHS monitoring of diabetes.were planned. GAD antibodies ( newly diagnosed can get them, not me, too far gone), ditto C-peptide. Vitamin D? Ditto. Etc etc. Magnesium is another intriguing test in diabetes. I wasn’t aware that this metal was vital to proper functioning of cell energy pathways. There also a direct test of leaky gut where you drink a clear liquid containing small indigestible beads of a plastic substance called polyethylene glycol. These beads are sized so that they will not pass through a healthy gut. But if the gut is inflamed and leaking then they will get into the body. They can then be measured in the urine a few hours later.

For someone just diagnosed. I’m sure these would be fascinating to do.

What was the diet like? Well, it consists of fat from animals, 4 legs preferred, fish, less acceptable in small amounts. Eggs okay, raw veg, such as saurkraut, turnip, cabbage, swede, mainly. Ideally the animals would be pasture fed. Offal was encouraged. The ratio of fat to protein was 2 grams of fat to 1 gram of protein. So, that was a hefty protein hike for me. Water only.

In reality it was a more than acceptable diet. The meals prepared in the hotel were superb. Surprisingly the fat was manageable without veg to help to eat it. I have now eaten my first brain,and tasty it was too. Bone broth was also excellent and prepared with a few root vegetables.

Two meals a day were recommended with no snacks if possible. This was easy for me as I do that anyway. And of course I had already cut out carbs. Out went dairy, nuts, nightshade foods ( peppers, aubergines, tomatoes potatoes). Out too went spices other than salt and pepper, alcohol, and too much leafy veg ( because of insecticides, herbicides etc ). Coffee and tea were out too.

But I felt well on it. I found more difficult to adapt to the diet when I got home and my usual routine. Boredom somehow makes me want to switch on the kettle. Getting home late from work makes me go straight for the fridge, having fasted all day. A bad habit. But that aside, I found that getting enough fat and moderating the protein was a big ask. I frequently went into double figures because of the protein which I was overestimating. So, for me personally it a mixed result. I started to crave carbs for some reason for the first time in 2 years but was able to resist. I did 6 weeks as intended. I weakened on the coffee, and the occasional alcohol. But overall I managed it. Because of the problems with blood tests this time I will never really know how effective it was. But it was a good experience and one I might revisit in the future. Instinctively I felt better off dairy, and continue that. Vegetables are back but those from the nightshade family are still out. So I have actually made some significant dietary adjustments as a result of learning about PKD. My glucose levels are now back on track.

I now think about glucose control in the context of inflammation in addition to carb restriction. I never thought about it like that before. No inflammation and normal glucose, excellent. Inflammation and high glucose, not good and what current dietary guidelines in diabetes are not addressing. And everything inbetween. It is a fascinating idea.

I did my month 11 half-marathon 2 weeks later. This one involved a few laps of a wood with some uphill sections. My dietary preparation was fasted as usual. I just took long acting but it was slightly different. You see I had changed to a so called ‘designer insulin’. It has an ultra long action over 30 hours. I think it is designed with Type 2 in mind. Fire-and-forget with a steady state insulin level that would be good in insulin resistance. I am not a huge fan of insulin in T2 as in the main I don’t believe the model. Most people don’t run out of insulin because the pancreas dies of exhaustion through overwork. I was at a professional meeting the other day and heard this very thing. How then I asked, does the pancreas miraculously recover just days after bypass surgery in obese people with diabetes to enable them to stop using insulin? Of course it doesn’t and the insulin producing cells never died off in the first place. Insulin resistance is a simple response to poisoning with carbs. It is biochemistry and physiology pure and simple. You don’t need to invent theories based on a disease model to explain this. Just stop the poison. Which, in diabetes, is carbohydrate. Then you don’t need the insulin in the vast majority of cases. Good for the person, but a potential disaster for the manufacturer.

This designer insulin seems okay at this early stage. I use slightly less overall than my previous long acting insulin and if I am strict with the meter can go up to 30 hours between doses. I know that I must try to inject the correct dose of insulin for me and it is not good if I use less. I risk high glucose and ketoacidosis if I go down that route. I will always need insulin. But I am anxious not to have too much on board. I am keen to get just the right amount. There are some chilling graphs of insulin levels in relatively well controlled T1’s where the levels are well above normal. As I have mentioned before, that is creating conditions for resistance. So, any reduction to optimal is good. I am still striving to control T1 without the insulin resistance of T2. If I can do that I will be very happy indeed.

The run

The first 6 miles were a breeze and I felt good, the last 6 were ones to forget. It was a total wipeout on the hills and feeling tired on the flat. I just ran out of stamina. My finishing time was 8 mins above average. Glucose levels were good throughout maxing at 9, troughing to 4. I think that a change to PKD was not the problem. But I do think I am just a bad runner because I am not preparing like a runner. I am still preparing like a diabetic. Diabetes has dominated my exercise for so long that it has taken 2 years of keto for me to start thinking about non-diabetic preparation! I have now proven what I set out to do with respect to insulin and carbs. I have shown conclusively that if the insulin dose is correct that carbs are not needed. In fact, that is so obvious to me that it always surprises me that health care professionals still send me letters at work which clearly show that they take the opposite view. So, it is now time for me to move on.

I have been running with little thought for muscle building, and more concern with fat burning. This particular run was a routine run based on what I have found to work. Basically, fast , inject, and run. But, looking back, my past 3 runs have not been good. Have my fasts made me slow? ( sorry). I think I am just wearing myself out . Just pounding the trails hour after hour with no thought for doing any other sort of training to vary it a bit. I still cycle when I can but that is the same sort of thing. Aerobic, cardio type training.

But I mentioned several months ago that I needed to get some more thorough preparation with a varied exercise regimen beyond just running. I have decided to get a trainer and sort myself out. I will get no fitter just by running alone. I hate the gym but it is time to act. I need to know what exercises will suit me best. The internet is awash with exercise plans, but I have no clue which might help me. I need to know more about increasing my overall fitness in a progressive way and not just trying to heave weights at random. That is the way to a rupture, and I don’t want that, thank you very much. I have tinkered with internet fitness programmes with no success.. So, about 6 months after I thought about it, I have decided to act. With me, being slow to act is the way it is. I can only change when I am ready. Slow learner? Maybe. But I think it is more a case of doing the work to get to this point. I cannot now improve by just doing more of the same. Change will not happen unless I put some effort in to make that change happen. And it is not just physical. I might also now try to optimise my diet by increasing my pre-run protein. I often need a few grams of glucose supplement towards the end of a run, so the delayed glucose rise with a protein meal might be the perfect solution. I will never be taking carbs again unless I need to rescue a hypo, but I will be looking at diet from an athlete’s perspective. Time also to get Stephen Phinney’s book on althletic performance on keto. This journey just gets more intriguing!

Half-marathon 10: Considering Carb-loading

 

The guidelines produced by my local diabetes team state the following: ‘

The evidence to support the use of low-carbohydrate diets in people with Type 1 diabetes is limited. The Diabetes Control and Complication Trial showed that lower carbohydrate, and higher saturated, monounsaturated and total fat intake were associated with higher HbA1c levels (Delahanty et al, 2009). There is a lack of robust, good quality and long term evidence to support the universal use of low carbohydrate diets as a standard approach (<50g/day) for all individuals with diabetes……

…The local policy for the management of Type 1 diabetes is within the Secondary care Specialist Diabetes Team where they have access to a multidisciplinary team including a specialist dietitian…’

Well, there you go! Lower carb diets raise HbA1c. If you want to go low carb, then you have to see a specialist who will give you evidence-based advice which is that it is not recommended! But they might make exceptions for ‘difficult’ patients like me. (lack of evidence to support universal use). But you get the drift of the thinking.

Low carb diets don’t raise HbA1c in me or dozens of other T1. There is evidence that low carb in T1 not only improves control, but that it can be sustained for at least 4 years ( the length of the trial),https://dmsjournal.biomedcentral.com/articles/10.1186/1758-5996-4-23 with a reduction in hypo’s and a longer percentage of time spent in the normal range of blood glucose. https://www.ncbi.nlm.nih.gov/pubmed/28345762 . My HbA1c had been in the diabetic range before I decided to go keto, and has been in the non-diabetic and even normal range post keto. Anecdotal? N=1. Yes but N=1 times many people. Take a look at the NICE guidelines CG17 on Type 1.

‘...the diabetes professional team should develop with and explain to the adult with type 1 diabetes a plan for their early care. To agree such a plan will generally require:….environmental assessment to understand:….the social, home, work and recreational circumstances of the person and carers..their preferences in nutrition and physical activity..cultural and educational assessment to identify prior knowledge and to enable optimal advice and planning about..treatment modalities.’

So, my current choice of management fits within the guidelines. My preference in nutrition is nutritional ketosis. But I am in this strange world where on the one hand as a doctor I am under pressure to tow the line and on the other as a patient ( and doctor) I know that the current recommendations are badly flawed. I do not think it is ethical to toe the line. The irony is that there is long term robust research on high carb diets and it doesn’t inspire me as someone with Type 1 diabetes to follow that research. I will just decline in health. Inevitably. Keto has given me a chance I might not. Better to take the chance than succumb to the inevitable. Even worse, the quoted evidence in local guidelines isn’t even low carb! Unless you take 210g a day as low carb. Which of course is nowhere near. I have written to them about it but they are sticking with their original statement.

That is by way of introduction. Ranting aside, I was planning to do this 10th run on a ‘heritage’ fully-carbed diet. After all, current local and national guidelines would favour carbs and insulin management. My local team would seem to recommend it. In preparation for carbing up for physical activity, I decided to do some research.

diabetes.org.uk suggest frequent monitoring, carrying ID, and letting someone know where you are if running alone. And also talk to my specialist team for advice.

Ditto diabetes.co.uk plus considering reducing short acting insulin later in the day to prevent night time hypos.

Runners World suggest talking to specialist to discuss training regimen and goals, taking 15-30g glucose per 30-60 mins, ( that is my day’s allowance OMG!) and to adjust both carbs and insulin. There is then a discussion on glucose gel mixtures. Oh, and if you are out for over an hour, don’t go alone.

Jerry, an ultra-marathon runner turns down his basal in the days pre run then increases food to stock up glycogen using granola, bagels and bananas.

Many bloggers and chat rooms on T1 give their personal ‘recipes’ for success just like Jerry. The regimens are specific to them, but the bottom line is that it is trial and error.

Hmm. Mainly trial and error, then. So nothing earth shattering there. Of course, that can only be as good as it gets, low carb or high carb. We each have our own type of diabetes and must manage it accordingly. I respect most of the recommendations anyway, whether running or not. That is standard practice amongst us Type 1’s. It is simply sensible. My main problem is that I have not injected more than 4 units of rapid-acting insulin at a time for nearly 2 years. I am out of practice. To take the recommended 30g carb up to every 15 minutes is 240g or 1000 calories in the run times that I do. That would be the right amount of calories for the run. But how on earth would I plan for that with carb-counting alone?

Truth is, I was nervous about this. Being used to just going out and running with little planning has become a habit. How on earth was I going to work this one out?

240g carbs without exercise is 24 units of insulin roughly according to my personal insulin carb ratio. Minus of course the exercise. I would be burning all of that carbohydrate up as I ran so really any extra insulin would be unnecessary in practice.

But, If I was going to be burning glucose, I would need to ensure I had enough insulin to get that glucose out of the blood and into the tissues. Otherwise we are talking the dreaded ketoacidosis. Would the long-acting insulin be enough on it’s own? Possibly, as I would not be producing much glucagon, but would be producing more adrenaline and cortisol. 10 years ago when I did a series of once a year half-marathons I opted for 4-6 units but mostly ran glucoses in the teens for most of the run, with low glucoses a few hours later. Some people even mention monitoring into the night to anticipate late hypos. That has never been a problem for me.

To be honest, I have got my body into reasonable shape. Considering that my insulin resistance was 3 hours just 18 months ago, measured by the time to act of rapid insulin, getting this down to near normal is remarkable. I consider that I have done well but mindful of the fact that I have work to do. I need to look at how fats affect insulin resistance. They certainly do. I can have perfectly flat glucose levels for hours after a high fat meal at whatever level it ‘sets’ at. It can be 4mmol/l , or 9mmol/l ,but will only budge with physical activity, not with injecting rapid acting insulin (well, it does eventually of course). A strange one that. But, even though my HbA1c is in or near the normal range, and I am used to good control, it is by no means the end of the story. So, there is still something about my own T1 that is proving difficult to work out. I have found that fasting for 18-24 hours is helpful and I do this a lot. But when I get stressed or bored I find that it is difficult to fast. Lifestyle and not just diet seems to be fundamental.

In the end I chickened out of carb-loading for this run. I was out late the night before and had an early start and a 2 hour drive to the venue. It was a cold day, and I was just not in the mood for all of that planning and monitoring. So, I just turned up and ran. It was all routine. I decided on an omelette this time, not a fast. I rustled it up on a camping stove on arrival. A mug of black coffee, and off we went. A lovely run in the countryside round a reservoir. Glucose control was okay. There was a slight rise of glucose to 11mmol/l at the start but it trickled down to 6mmol/l at the end. I decided on no rapid on this run. Perhaps a unit at the start would have been better, but to be honest, I was a bit bored. I wasn’t in the mood that day.

So much for ‘extreme’ diabetes then. This was the usual routine run that I am now used to. No fuss, no surprises. I know my local specialist would not have recommended it but then how can you make life so easy for a diabetic when you start with the wrong dietary model? No. I am sticking with keto. It makes complete sense in theory, and that is borne out in practice. But I am going to do some work on other aspects of Type 1. I am going to Hungary to learn about the Paleo-Keto diet. It sounds promising. That is for the next run.

Half-Marathon 9. 26 hour fast, 13 mile run. It’s not all about food.

 

If only diabetes were just about insulin and carbohydrate. All of us Type 1’s would have had it sorted years ago. Inject the basal and cover the carbs with rapid. Job done!

I guess I have known for ages that it is far more complicated. Infection of course is the more obvious indication that glucose can go up due to more than just food alone. But, even when I don’t have an infection I have noticed that the glucose does not always obey the food/insulin model, keto or not. Ever since I have had a continuous meter, I have noticed that there are some patterns emerging. So, now that I have found some patterns, it is a good time to look at these.

Food, Sleep, Physical Activity and Happiness, (or possibly more accurately inner contentment). These are all things that influence my particular diabetes. My own Type 1/Type me.

I have never completely sorted the sleep thing. It is not the hours alone, though less sleep does seem to make the effects of stress more pronounced. But I cannot be categorical on that. What I can say is that researchers have looked at sleep and measured all sorts of hormones that regulate sleep. http://care.diabetesjournals.org/content/31/6/1183 . The conclusion was that there were alterations in the patterns of sleep, with deep sleep being less in Type 1, and there was elevation of stress hormones, adrenaline(epinephrine) and cortisol, and also hormones released from the pituitary gland in the brain; thyroid stimulating hormone, growth hormone, and prolactin, compared to people without diabetes. What was striking from the graphs provided in the paper were the high levels of insulin throughout the night and the high levels of glucose ( around 7mmol/lit compared to 4mmol/l). The researchers commented on this, saying that it reflects the difficulties of getting normal insulin levels, even with sophisticated insulin regimens. You bet! If you take a look at the graph the overnight insulin level is shockingly high. They further suggest that it might be the levels of glucose and insulin that drive up the overall levels of the stress hormones.

That research suggests to me that it is wise to use the lowest possible dose of insulin that I can possibly get away with. And the best way to do that is through a ketogenic diet.

And what of physical activity? We all have our own peculiar reactions to physical activity. I have yet to fully sort mine out despite hundreds of miles of running this year. Mostly my blood glucose goes up, especially in the first 30 minutes, then it mostly drifts down as a result more of the Lantus than the exercise I reckon, which is augmented by any rapid-acting insulin I choose to shoot up. What has been weird though is the improved sensitivity to exercise over the past month. I think I have the answer to this and it seems to be related to the vagus nerve. Folks, for me this is a breakthrough, Vagal tone is driving some of my insulin resistance. And it IS possible to do something about it. Sometimes I marvel at my own inability to join up the dots. And even when I get close I still can’t see the bigger picture. Like… derr!

The vagus nerve, of course is the nerve that controls gut function, as well as myriad other functions. It supplies the whole bowel and affects not just the digestive functions, which are of immediate interest to us with diabetes, but also interacts with the bacteria in the bowel, the microbiome, and therefore the immune system. How amazing is that? I really can’t wait to explore this, but that is for another run. Gut function and diabetes is planned for the run after next.

But the vagus nerve has many ‘background’ functions. You don’t have to think about choreographing your digestion, it just happens. It also can be over-ridden by you and me, just by our mood. Think singing in public, interviews, and all that stress and what happens? The stress interferes with the vagus function and we might spend lot more time in the loo than we would otherwise. So, relaxation and inner contentment might be useful here. But, what I have found is that it is the intermittent fasting that gives the most benefit. Just by keeping the gut empty seems to control the glucose perfectly. And, linking in with sleep I try never to eat anything late in the evening. That is sometimes difficult but when I do, I pay for it with higher glucoses all night, a flat trace, but higher that I find acceptable. Because I can get a flat trace at night, running at 7mmol/l of higher is just not the ticket if I can run at 4-5mmol/l constantly.

You see I found this out because I took to nibbling throughout the day. No more food overall but spread out in tiny, more frequent portions. And I found that this elevated the blood glucose for hours, and a few units of rapid insulin here and there made little difference to glucose levels. But if I went for a run, the glucose would fall rapidly. In fact I began to use running to kick start the insulin sensitivity. This is classic insulin resistance, I reckon. Too much insulin in the blood suddenly cutting in when the insulin resistance goes. So for me insulin resistance is variable and not simply a response to long term poor control, even though it might ultimately be driven by this. No, I can affect changes in my insulin resistance throughout the day if I control my vagus nerve.

Bullish! But it works. And there is some evidence for this.

Some people opt to have gastric bypass surgery. The Roux-en-y type of operation, which is considered the best in type 2 diabetes, reduces the volume of the stomach. This means that people cannot physically eat large volumes. But what it also does is to bypass the gut near the pancreas and the liver, so little actual food goes there. It has been speculated that the alteration in gut hormones locally has a significant part to play in helping to resolve diabetes, because the diabetes improves far earlier than the weight loss. And where does that leave the classic insulin resistance model of long term chronic change? Because this operation can improve control in weeks? And a lot of Type 2’s can come off insulin. But are we not told that the pancreas fails? Back to the drawing board for some I think.

The flow of information through the vagus nerve is that 90% of the nervous activity is due to the vagus sending signals to the brain,to the hypothlamus, which is the control centre of appetite and regulation of metabolism. The brain will then send instructions back according to what it receives. The vagus nerve affects how we secrete insulin and glucagon, 2 major hormones involved in glucose regulation. Glucagon increases blood glucose, and insulin does the opposite. Some people have suggested that it is the glucagon which drives diabetes by increasing the glucose levels. It is the inability of insulin to function properly that sustains it. https://www.ncbi.nlm.nih.gov/pubmed/27115412. In this paper, Diabetic mice were cured if the glucagon secreting cells, the alpha cells, in the pancreas were destroyed as well. Interesting that. Also tests on stimulating the vagus nerve in dogs produced a response in both glucagon production and bigger response to insulin production.

So, the vagus nerve is vital in diabetes. My current solution to this is to allow it to rest by not stimulating it in the first place. That means keeping the gut around the liver and pancreas empty. It works for me.

The Run.

I had recovered sufficiently from all that stress in the previous 6 weeks to be feeling okay about the run. Training was slowly building up and glucose control was back to my new, ketogenic normal.

It was @jen_unwin who put me up to it. She tweeted before and after glucometer readings from a 20 hour fast 10k run. That got me thinking, 13 hour fasts are pretty sorted, why not extend a bit? Double it. To 26 hours. Fine. Let’s do that. And so it was. Water, tea and coffee all day and overnight. I went to bed with a glucose of 4mmol/l and opted for the usual 10 units of long acting. Black coffee brewed up on a stove by the car pre-run, on a crisp sunny but frosty morning. And off we went. My blood glucose had nudged up to 10mmol/lit overnight. Mmm. Tantalising. Far too high these days. That was likely to be the morning stress hormones waking up. Hello. Will I get an adrenaline spike today? Who knows! I opted to shoot up 8 units of Lantus as that was worked out in a previous run as being my minimum insulin requirement. And what about the rapid acting? Ok just one unit. It would at worst take the glucose down 3mmol/lit.to no less than 7. Safe enough.

It was a flat run and 4 laps round a lake. Pleasant. Glucose on crossing the line was a manageable 3.6mmol/lit. I think that this was due to the rapid acting insulin, the effect of exercise and possibly some Lantus adding to the glucose lowering at the end. I had a possible hypo sensation in the last half mile, but opted to finish anyway. To be safe, it is important to be safe, I took 10grams of glucose as soon as I had crossed the finish line, knowing that there is a CGM lag of about 20 minutes. About an hour later I got round to eating though I wasn’t really hungry. Habit I suppose.

So there we are. Possibly the best control ever. In total a 29 hour fast. 13 hour run, Type 1 Diabetes.

So my new model for half marathons based on my last 5 is: Don’t eat, shoot up and then run. Simple and effective for me.

Of course, it sounds impressive to the uninitiated, but if you have followed the blog so far you will know that it is really just extended fat burning. Boring beta oxidation. Consuming just 1200 calories of the 40,000 I have available. What on earth is extreme about that? I could have probably gone on for hours if I was fitter.

No, we need to spice things up a bit. Next up is a conventional guideline run. I have been doing some research. The words ‘experimental’ and ‘trial and error’ seem to crop up a lot. So do starting with high glucose levels in the teens and taking regular gels. I haven’t done that for a while. Back to extreme diabetes it is!

Half Marathon 8. Stress

 

Every December sky must lose it’s faith in leaves and dream of the spring inside the trees. So sang Beth Neilsen-Chapman. She wasn’t singing  about diabetes of course  but the same lyrics applied to this run. Just 3 days after my ‘Easy Street’ marathon I went down with a cold. A pretty straightforward viral- type cold only lasting a week and not enough to need to go to bed, just to take things quietly and not exercise for a while until the slight muscle aches went away. It just doesn’t seem right to run with muscles that themselves are struggling. But I do often run through early sore throats though, it is my treatment for sore throat based on the assumption that exercise improves immunity. It seems to work okay if you can get out within a day of getting that sore throat sensation. But once an infection gets hold I tend to back off the exercise. Running is also a good treatment for muscular back ache. After about a mile of pain, the muscles fall into line and as if by magic, back-ache gone! You might think I run in a hair shirt running vest, but I don’t. If the back pain is just muscle pain it works. Anyway, that is to digress. This cold took hold.I missed the window of opportunity to get out for a run. But, while it only lasted a week, it had a bad effect on glucose levels for 6 weeks overall. It was quite shocking. I had to double my rapid acting insulin for at least 4 weeks in order to get even modest control. I even had to give lots of added injections between meals as a sort of damage limitation exercise. Only a couple of units here and there in an attempt to keep the glucose reasonable. But despite this, glucose levels would frequently get into double figures and stubbornly stay there, even with additional doses of rapid acting. I’m sure many people have been there. It is not good. With the addition to mental stress on top, and disturbed sleep, things were pretty dire indeed. Of course it is all relative. Back in the day when I was carbohydrate counting I would have been pleased to have achieved such profiles even on a good day. But I had got used to doing better than that. Complacent almost. I was doing fine with a simple diet adjustment. And having had a long period free of illness I wasn’t paying much attention to other aspects of diabetes. But I knew just by observing glucose levels that there was more going on than just reaction to diet, and that insulin resistance was still there. I was also aware of the effect of general stresses of day to day life were having on glucose control. I suppose the relief of just being in control for the first time in over 20 years on dietary change alone and the improvement in everything diabetes related does allow one to just carry on doing the same thing. There is far more to life than a ketogenic diet. That is just a tool to enable life to be fun again. Lemming Test-Pilot reckons they are pretty slick at ketogenic dieting. It helps enormously and is life-transforming. A ketogenic diet is  fundamental in managing Type 1 diabetes.

But this stress reaction of course was way beyond the insulin-diet model. If only diabetes were that easy! The problem of gaining control here was related to infection and mental over- stimulation in a negative way. We are talking stress reactions. Acute stress on top of chronic stress; infection and mental stress for a short time on top of a background of the long-term low level stress of diabetes.

Stress! A great word that means many things. It can have both positive as well as negative meanings. What we are talking about here is the negative one. Infection and mental stress can affect the immune system. As can the sleep deprivation that often goes with it. The internet is awash with advice and information on stress. And perhaps it is no surprise that there is often a supplement being sold to treat it. There are endless antioxidants and super-foods, pills and potions, that are claimed to reduce inflammation caused by stress. Not to mention all of the medicines for mental health that identify a single molecule that is causing the damage and invent a pill for it. Lemming has been interrogating the internet and decided that one needs a brain the size of a planet to understand the biochemistry of stress. The end result of all of that research, has led Lemming to the conclusion that stress reactions are nothing more than a consequence of the condition the body finds itself in.

Anyone who has read the blog this far (and you might benefit from this explanation of stress as a result, well done and thank you!) will have a reasonable grasp of how carbohydrate, real food and lifestyle can transform Type 1 diabetes). That in itself is a great start. Type 1 in a low-stress environment responds to a ketogenic diet and relatively low levels of stress are manageable. But ramp up the stress and it is another challenge entirely. Lemming has discovered so many stress-related biochemical pathways and biological compounds that it is difficult to work out what is significant, and what has less importance in the grand scheme of things. There is the acute stress reaction to infections, and reactions to lower level persistent stresses in such things as chronic disease including the metabolic upset of Type 1 diabetes, through to inflammatory effects of external agents such as food and the air we breathe. And don’t forget emotions and the brain. Stress reactions can raise levels of stress hormones such as cortisol and adrenaline, which are best known, but there are also others such as growth hormone, prolactin and even insulin. Just about every response to stress operates through the immune system of B-cells, T cells ,which can be subdivided into Regulatory, Helper and Killer cells. Chemicals interacting with the immune system include cytokines, interlukeins ( a whole series), thromboxanes, and prostaglandins. The omega 6 and omega 3 fats work at this level. It is complicated by the fact that there are subfamilies omega fats and that they can have both pro-inflammatory and anti inflammatory effects. There is evidence that the ratio of omega fats 6 and 3 can influence inflammation. Because these fats are only obtained through the diet (the body cannot make them by conversion of other fats), it is thought important that the omega 3 to 6 ration is close to 1:1. In many diets it is multiples of 10’s to 1 which might be driving inflammation in the body. Omega fats are also major components of brain tissue.

Inflammatory reactions can cause cell death which leads to the appearance of altered phospholipids on the cell membranes. These then stimulate the liver to produce a specific binding protein which binds to these. It is called C-reactive protein, (CRP), and is one of the commonest markers of inflammation that is measured in blood samples. Autoimmune diseases such as Type 1 diabetes and Rheumatoid Arthritis can also raise the levels of CRP.

Chemical reactions of inflammation (and just normal metabolism), result in the production of reactive chemicals called free radicals that can damage tissue including DNA. It is not a surprise then that the body has a robust system for mopping these up. They are the naturally occurring antioxidants, such as the perhaps better known Glutathione and Superoxide Dismutase. That is the level at which the antioxidant food and supplement industry operates. Then there is the whole business of the Nitrogen cycle. All Lemming knows about this is that it is important!

The gut also has a way of nurturing the bacteria that exist in it, the microbiome. The microbiome has been shown to influence health and there is a lot to learn. There is a huge nervous and immune system in the gut and special nerve cells called dendritic cells recognise healthy and potentially unhealthy bacteria. These dendritic cells interact with the local immune system and no doubt play a very significant role in health. Vitamin D is thought to operate here, as a modulator of inflammation among it’s many functions, the most well known being maintenance of bone health.

Confused? Lemming Test Pilot is overwhelmed by the complexity of the body in how it copes with stress. And that is only scratching the surface no doubt. We have only recently been able to rapidly identify bacteria but there is no technology yet to identify viruses. When we do, GP’s will no longer be able to use viruses as the fall guy for every unexplained short illness.

It seems likely that some people are more vulnerable to stress reactions as a result of genetics. Unless you are able to choose your parents that is a tricky one, but there are 4 things that can be changed; diet, sleep, happiness and physical activity. So, for practical purposes, that is what Lemming is sticking to. If you stick with the basics the body will regulate itself. A little more tricky when you have a metabolic condition such as diabetes, but a good philosophy nevertheless.

The Run.

This was the worst prepared run so far. By a mile, ‘scuse the pun. No training at all for 2 weeks, then the occasional 3 and 6 mile run. This was going to be another fasted run as there was less preparation to do. Just don’t eat. Then run. Fat oxidation. Simple. And as nature intended. Blood glucose was 9mmol/lit (for mg/dl multiply by 18, or roughly double it and add a zero) in the morning. It was decided to inject 10 units of long acting despite the fact that 8 units had been worked out on the last run. This was because of frequently raised glucoses of 10-15 mmol/lit in the past few weeks. So I decided to inject only one unit of rapid acting insulin. If the rapid acting reduces glucose by 2-3 mmol/lit per unit then the glucose would be about 6mmol/lit after an hour or so. Plus whatever the stress would contribute. It was a cold grey day with fine drizzle so fluid balance was easy. 400ml/hour.

This was 2 laps of open countryside with a gentle few hills. It was a club run and the only one I could find.

Competitors were serious and some had that haunted look of inner torture that one only sees in the eyes of people in competition with themselves. Now that is stressful.

It was a good start to 5 miles. Then came the low glucose at half way. I must have injected too much insulin with little thought of the improved insulin sensitivity that comes with exercise. It was a bad hypo with intermittent vision loss, tiredness and a slight feeling of confusion. The continuous monitor glucose monitor unhelpfully decided to call it a day ( it was in it’s third week), so it was a desperate attempt to get the glucose up and keep running. I needed about 20g of glucose at that time, then ended up low again at 11 miles. This was like the old, pre-keto days. It was so, so lucky that it was a 2 lap event. I was able to stop at the car and get supplies, there was no food provided on the run. So I was saved the embarrassment of needing to get help. The second lap was more of a stagger. The leg muscles were tightening and I was all in. Crossing the line couldn’t have come too soon.

What went wrong?  I reckon that it  was the excess of insulin being injected to counter high blood glucose levels I must have had some increased insulin resistance caused by stress. While blood glucose was not falling in response to more insulin, it was reduced by the effect of exercise. In fact I had noticed the more dramatic sensitivity to exercise when I did get a chance to get out and run in the weeks before the event. It was, if I had paid more attention, a very good example of reduced insulin resistance with exercise. The higher levels of insulin in the blood at the time ( which I had injected in addition to usual diet requirements to try to reduce glucose raised by stress) became available once the resistance reduced, to give a much more dramatic drop in blood glucose. It is obvious on looking back. What else goes past me that I don’t pay attention to?

So the lack of opportunity to keep well trained finally took its toll in this run, with an awful experience, accompanied by fatigue, poor glucose control and muscle pain. This was truly the end of Easy Street. But it was a run put down to experience with plenty of learning in the process. It will get better from here.

Half-Marathon 7. Insulin Resistance

Half-Marathon 7. Deliberately running into ketoacidosis

Everything has been going so well so far that one run seems to blend into another with ease. Training is fun. Glucose control is good, injuries are non-existent and times are improving. I am feeling good. I have without doubt shown that carbohydrates are not necessary if one can get the insulin dose correct. I have shown that fat burning allows fasting to be done safely. It makes exercising so much more fun as planning is a doddle. I am on a roll down Easy Street! In fact I did this 7 th run in cruise control.

I got away with minimal training and ran with my friend, Joanne. She is a fellow low-carber and a tireless campaigner for the cause. She does not have diabetes but as a clinician she was interested in ketogenic diets in Type 1. In fact the run was a long natter about all things low carb and was the best meeting in the best location of low hills and coast. What a great day at the office! All days should be like this.

The Plan for the Run.

I was on another 13 hour fast, I find it the easiest way to prepare. But there was a variation in the preparation this time. You see, I have become pretty much obsessed with insulin resistance. I have been looking it up and it is not just my unique view. There was a study on fit young people who did not have diabetes but were given intravenous infusions of insulin. [*] The glucose levels were controlled with intravenous doses of glucose as needed. The result was that there was evidence of insulin resistance after just 40 hours compared to controls. 40 hours! I have been over-injecting insulin for nearly 22 years in an attempt to balance the carbs, which I now know I didn’t need to do. That adds up to 191,555 hours of possibly avoidable insulin resistance. In spite of that I have been lucky so far. Insulin has prolonged my life and quality of life beyond all measure compared to a century ago. If I were around then, I would barely have lasted a year, with recurrent episodes of ketoacidosis that would eventually cause my demise. But, as they say. If I knew 21 years ago what I know now I would have done differently. I didn’t. I did what I was told, and did to others what I was taught. I believed in carb counting, DAFNE, statins. I swallowed it all, hook, line and sinker. Once you ‘get it’ of course, it is a lightbulb moment and you wonder how it was possible to see things any other way. But that remains a minority view. I am eternally grateful to have googled into Richard Bernstein. He changed my life, possibly saved me from future problems. We will have to see. Of course, the diabetes is still there. That’s going nowhere. And I feel lucky to have found fellow clinicians who also ‘get’ low carbing and are sharing knowledge in the hope that one day we can do better for all people with diabetes. But, I still reckon that there are plenty of clinicians who think I am completely bonkers. They will listen politely, then say something like, ‘Well, good for you if it works,for you. I do see genuine enthusiasm sometimes, but I guess you are only truly interested if you have the condition. All clinicians are truly interested in something. That keeps us going.

For us that have Type 1, it is more of a desperate search to survive. We have to be interested. And we need quality information. Thank God for the internet. Change will come from the ground up, not top down. And this run was done to raise funding for the Public Health Collaboration who are campaigning to make that change happen https://phcuk.org/.

To find that I have 0.2 million hours of insulin resistance is not only a nerdy fact, it is chilling!

Type 1 managed by keto is pretty straight forward. I instinctively think that there is more to learn about therapy, but keto is good for now. It frees me up, makes me feel good and, most significantly I now feel in control of my diabetes. But where Type 1 seems straight forward, what about Type 2? No one wants Type 2! There is a view out there that somehow taking tablets over insulin makes it less of a condition. Threatening to add insulin (why, in 99% of cases I don’t know, but go with it) in people with Type 2 really wakes those people up. Some people think it is really serious then. Actually adding insulin in type 2 is really serious, but for a different reason. But we are Type 1’s. I don’t want to indulge myself by ranting. The metabolic mayhem caused by insulin resistance is such a profound change in the body because it affects so much. The complex inter-dependent hormonal and chemical reactions are altered by insulin resistance. So, insulin resistance is a metabolic state caused by diet that started possibly with genetic vulnerability. In type 2 insulin resistance is caused when the body produces it’s own insulin. In Type 1 it is caused by injected insulin over and above what is essential replacement that Type 1 will always need. Insulin resistance, if sustained, will eventually cause true disease. Once the blood vessels start popping and the nerves get damaged, things get very tricky indeed. I have finally controlled my glucose levels well and am approaching the optimal doses of insulin that I will need for life. But I know that things could be even better if I could get round insulin resistance. Timing of injections, stubborn slightly highs, slow to come down glucoses. This is all insulin resistance, I’m sure.

The Run.

So for this run I would start the process of estimating insulin resistance. The plan for this run was to reduce my insulin injection to a level which would not be able to cope with my internal glucose production (gluconeogenesis). Then the blood glucose would rise relentlessly and not peak because there would be insufficient insulin to do this. That would stimulate unregulated fat burning because insulin reduces glucose levels partly by stimulating the cells to take in glucose and partly by making fat from excess carbohydrate. The opposite happens if there is insufficient insulin. Glucose cannot enter cells so stays in the blood, and glucose levels rise. The body then has to burn fat for energy. Unregulated fat burning because of insufficient insulin will generate more ketones eventually into the ketoacidosis zone. Regulated fat burning with sufficient insulin would never cause ketoacidosis, just nutritional ketosis. So, if I could get into unregulated fat burning I would know that I had injected too little insulin. Extreme diabetes in one way. But, in the bad old days when I was getting my carb-counting wrong, this was undoubtably going on all the time but not bad enough to qualify for a hospital bed. Plus I was never offered ketone testing so never knew whether I had early ketoacidosis or not.

On the morning of the run I woke with a good glucose of 6mmol/l which had been steady at 4mmol/l through the night. I would normally go for 10 units of long-acting insulin here, and possibly one unit of rapid-acting insulin, maybe two if the insulin after one hour of being awake showed signs of climbing. But this morning glucose was stable. 10 units of long -acting insulin is the current figure for combined Type 1 and 2 and this keeps glucose levels stable. But I want to try to estimate how much of this dose is for Type 1. And how much for Type 2. This is practical diabetes, Lemming-style. I’m going for 6 units. But I wanted to do this safely so took the rapid-acting insulin with me on the half-marathon. Just in case. For me the rapid-acting insulin is now working at around 40 minutes compared to 3 hours before I decided to go keto. So I hope that this represents less insulin resistance now.  What actually happened was that the glucose rose at about half the rate compared to eating glucose tablets so was probably representing internal glucose production, gluconeogenesis, not quite controlled by 6 units. I had the luxury of continuous monitoring so total control.) CGM really should be available to all Type 1’s. Sign the petition https://petition.parliament.uk/petitions/151064 ).

 At a glucose level of 14mmol/l, I baled out and injected 4 units of rapid-acting insulin half way through. At 2.2mmol/l reduction per unit of insulin which I know is the particular rate for me,  that should get to around 6mmol/lit. It did after 3 hours. So with 10 units of long-acting insulin  giving good control and sometimes slight hypo, and 6 units showing a tendency to ketoacidosis, I reckon that 7-9 units twice a day represents Type 1 and the rest is due to acquired insulin resistance. Less than I thought but I am pleased. The less resistance the better. I now have a target. But after all that experimentation, I reckon that sensitivity to insulin action is just as good in practically. Getting from 3 hours for rapid-acting to act to currently 40 mins is a good enough measure of resistance.  If I keep on the ketogenic diet, I am hoping eventually to get back to true Type 1 and get rid of the insulin resistance for ever.

Half -Marathon 6: Double Diabetes And Doing Something Mo Farah Will Never Do.

In Lemming Test-Pilot’s grandparents generation, double pneumonia was something to be feared. Even today few people are exactly sure what that was, presumably infection in both sides of the lung. The 70’s pop group 10cc even had a lyric with double pneumonia in it. Lemming reckons that they have acquired another medical double to be equally feared, Double Diabetes.

To Explain. Lemming developed Type 1 diabetes over 20 years ago. The diagnosis was made on the basis of symptoms alone ( there were no C-peptides and GAD antibodies in those days), and the response to insulin was good. In fact, during the honeymoon period Lemming stopped insulin and tried a sulphonylurea which was no good at all. So Type 1 it was. Over the next 20 years of injecting extra insulin to cover carbohydrate, which was unnecessary as we now know, Lemming Test-Pilot has become insulin resistant. This is what is called an iatrogenic illness. Induced by clinicians.  Jason Fung has written on this and has written about persuasive research in which   insulin resistance was caused by giving infused extra insulin to non-diabetics and keeping the glucose levels stable. After just 96 hours the insulin resistance was 40% higher than those not being given insulin. And the insulin resistance reversed on stopping the insulin. There is also an insulin secreting tumour ( insulinoma) that makes insulin in an unregulated way. That causes all sorts of problems with hypoglycaemia but there is again evidence of increased resistance to insulin. Presumably the body is trying to protect itself against the harmful effects of too much insulin. When the tumour is removed, the body recovers. Similarly in type 2 diabetes with the insulin resistance that is a hallmark of that disease, removing carbohydrate from the diet improves insulin sensitivity and in many cases a person continuing a low carb lifestyle can be considered non-diabetic as long as they remain on the diet. If type 2 are injecting insulin, they can often stop it.

In type 1 with added type 2, the dreaded Double Diabetes, which a lot of people with type 1 for any length of time probably have, it is not quite straight forward. The trouble is that type 1’s cannot simply stop insulin without getting into severe difficulty. Not a good idea at all, in fact.It can lead to  ketoacidosis which is a potentially serious condition. The amount of insulin that Type 1’s inject can be reduced a lot by removing carbohydrate from the diet, therefore adopting a ketogenic diet. But then what? What about the basal insulin? Can we reduce that as well? Basal insulin is thought of as the amount of insulin needed to replace the insulin that the body no longer makes in order cover the gluconeogenesis that is happening frequently in various organs, especially the liver. We need basal insulin.  But, thinks Lemming Test-Pilot, in Double Diabetes, what proportion of the basal insulin is necessary for type 1 and what proportion for type 2? It is difficult to know and difficult to sort out. Lemming foolishly bought a triglyceride meter and is finding mostly high triglyceride levels. The triglyceride readings are above normal mostly with only the occasional excursion into the normal range. Those triglycerides must be coming from the liver in Lemming’s case. So that is likely to mean that the local cellular conditions of insulin resistance are playing out in the liver. There is fat congestion in the liver. Fatty liver, medically speaking. So even though L T-P feels pleased that the glucose is under control, and weight is in the normal range, all of that extra insulin over 2 decades has caused fat build up in the liver. It should have been obvious really. After all insulin orchestrates the removal of glucose from the blood by parking it as fat in the liver and adipose tissue. So, it shouldn’t come as a surprise if a Type 1 will have some fat in the liver. The only surprise is that it is not talked about much in medical circles. Because if it was, surely Lemming would not then have a metabolic illness on top of a hormone deficiency state. That puts Lemming right in the middle of heart attack territory. But you don’t have to have diabetes to have fatty liver. Some people are more prone to it. If Lemming did not have diabetes they would be one of those thin people who occasionally get a mention on a quiet news day, when they drop dead in a marathon. The journalists love people who die in sports events. It gives their inner couch potato a (false) sense of security.

So, there is work to be done on this presumed fatty liver. Lemming has read a scientific paper about MRI scans of fatty liver and this showed that there is improvement to be had at BMI approaching 20. Lemming has only reduced BMI by 1.5 units in 12 months to a BMI of 22 by losing 7 kg so this is a big ask. But in extreme diabetes we roll up our sleeves and get on with it. The only way is dietary energy reduction to tease the fat out of the liver. Lemming has tried to lose weight , but it is hard. You see, insulin pretty well sets Lemming’s weight. At the present dose that weight is giving Lemming a BMI of 22. That should be good by most standards, but if this is causing insulin resistance then it is not good at all. Apart from weight loss there is little that Lemming can do. Lemming is maxed-out on carbohydrate restriction and maxed-out on physical activity. So the only way is to lose weight. It will be a long term project. But Lemming has lost 2kg in the month leading up to this Half-Marathon, it is a start.

The Run. This was the local Half-Marathon on a flattish route. Lemming has done this run 6 times before, but never on a ketogenic diet. It is a well supported run with an enthusiastic crowd and is always one to look forward to.

This was another fasted run. Fasted runs are just so easy. One cup of coffee, 300ml water. 10 units of basal insulin. A mile walk to the start in cool but not cold conditions, a bit of sun. Glucose was 6mmol/lit pre -run. Perfect. No rapid -acting insulin injection for this run. So off Lemming went. And at a good pace. Lemming failed to spot the 1 mile marker and came to the 2 miles with a sub 9 minute pace. At 6 miles Lemming was cruising at 9 mins pace waiting for the inevitable slow down. It came and went between 8 and 9 miles. Fluid was taken at 7 miles so Lemming had had 800mls by then and topped up at 11 miles. Dehydration was unlikely. Lemming likes Tim Noakes formula of 4-800ml/hour depending on conditions. The continuous glucose meter packed up at 6 miles with a last reading of 6.3. So that meant that the first half of the run had pretty well flatlined the glucose level. The last 2 miles were all good. No pain, not short of breath. But a little light headed. What could that be? Was this a hypo? It got worse at 12 miles when Lemming turned to wave to a friend and almost fell over with dizziness. The pulse was good but fast ( it is always above 160). But it was regular. Because this part of the run could be heart attack territory, there was no way a journo was going to dine out on another running death story as far as Lemming was concerned. Having done a basic assessment Lemming decided it was probably nothing. Possibly an impending hypo. But there were only 5 minutes to go and amazingly Lemming was on for 2 hours. That was plain ridiculous. 9 minutes off this years personal best. Something Mo Farah would never do!

So in true Lemming style with only a few minutes to go it was a dash for the line. Glucose supplements could wait, if they were needed at all. Having injected only a few units of basal insulin and no rapid acting insulin this would be a slow lazy hypo at worst. Completely different to back in the day when they would dive bomb in from nowhere. There was no sprint but a good pace to the end. Just 18 seconds over 2 hours. Truly remarkable! Lemming had not achieved this time for 7 years.

So, what has been learned from this? When the glucose was tested about 10 minutes after the run it was 4.3mmol/l. So starting at 6, ending at 4.3. That counts as a success. Possibly low at the end. The glucose should go up if there is no insulin at all. Or insufficient insulin. But this was going down. Too much insulin? Possibly. But 10 units of basal works most of the time. This was a second successful fasted half. But there will need to be some reduction of basal before the next run to prevent the low at the end of the run. Lemming reckons that the next run might be a good time to look at the amount of insulin needed for type 1 and the amount for type 2. Start to explore Double Diabetes. Shake things up a bit. So, Lemming will reduce the insulin to levels so low that it will elevate the glucose. So low in fact that there will be insufficient to handle the glucose raising effects of gluconeogenesis, glucagon, cortisol, growth hormone and adrenaline.Plus all of the other hormones Lemming forgot to mention (or just forgot). Lemming will need to estimate the basal insulin dose required to just start to raise the glucose towards the end of a run. It may take a while to perfect but it will be a useful exercise. Rising glucose in a fasted person can only mean one thing. That the insulin in the body is barely sufficient and is struggling to handle the gluconeogenesis. Of course they are the conditions for ketoacidosis if allowed to get out of control. So, in anticipation Lemming will obtain a suitable meter that tests blood ketone levels. There will need to be some ketoacidosis but it will be easy to correct at such an early stage with the sort of monitoring Lemming is planning. As a result of this there will be enough information to calculate roughly what dose is needed for type 1. And that will highlight how much surplus is being used to service the useless insulin resistance of Type 2. Of course it might be all type 1 after all. But Lemming doubts it. What about the triglycerides? And what of the delayed response to rapid acting which has fallen over the year from 3 hours to under an hour? Insulin resistance almost certainly. Then comes the difficult task of continually working away at reducing insulin resistance without raising the glucose, and at the same time losing weight to get rid of the fatty liver. Lemming is keen to reduce insulin to levels that are required to control the Type 1 only. Type 1 is managable on a ketogenic diet. Type 2 has no place in Type 1. In fact, Lemming is a bit miffed that doctor-induced illness gets such an easy ride in chronic disease. Because Double-Diabetes really does add insult to injury. And 22 years of insult is possibly too long a time period to rein in. We are talking damage limitation if indeed that is at all possible. Double Diabetes will possibly do Lemming in. But Lemming practices medicine as well and has been rushing to the cliff with everyone else.  Something has gone wrong in diabetes medicine.  Lemming had a stroke of luck in finding the book that changed their life. But being done for is for another day. There is still plenty of life to be lived. Carpe diem! Carpe DM? !(groan).

Half-Marathon5 :13 hour fast,13 mile run.

Generally, if someone is planning to do any significant physical activity they normally have a good meal first. This is obviously to build up energy stores in anticipation of using them throughout the activity. We have all done it, be it a day out in the countryside, a days walking or whatever. Athletes obsess about it and there are all sorts of sports nutrition protocols hopefully containing that magic formula to get you over the line first. The last trend I heard of, and I expect I am way behind, was pasta and bananas, with various electrolyte formulas containing glucose in an isotonic mix. The pre- run information pack advised me to take 60-70% of my energy as carbohydrate in the 3 days before the event.

But, not being an athlete, competitive or carb-loading, and certainly not likely to get over the line first, that sort of thing is irrelevant for me.

I have managed to show in previous blogs that a Type 1 can run for around 2 hours without any carbohydrate at all. The last half-marathon a month ago was on almost 100% fat to supply about half of the energy I anticipated I would burn up on the run. I relied on my body to supply it’s own fat to meet the remaining energy balance needed.

So that got me thinking. If I can do half the distance using my body’s own fat reserves, why not the full distance? We are talking only a couple of hours. I need about 1200 calories . Body fat can supply 7000 calories per kg, so 1200 calories is around 170g. Nothing in the grand scheme of things. After all what exactly is a ‘fast’? If we eat say, a couple of hours before a run, does that make the following couple of hours of not eating a ‘fast’? The body will need to get it’s energy from somewhere in that time. ‘It will get that energy from food’, you say. Possibly, and ultimately yes. But it has to be processed first. So, yes, you need energy, of course you do. But it is also true that most of us have enough energy already stored as body fat. I know I have. Even though I am right in the middle of the range of BMI,  I have some spare fat. I can see it. Just a hint of a wobble in the mirror. But it is there. And I think too much. If it’s on the outside it is also on the inside. I need to work on that. But that is for another blog at another time. Today is fast day. I have decided just to extend the fast time a bit, from a couple of hours up to 13 hours. I have plenty of on-board energy, no need to eat to take more in. There is no science in this amount of time. 13 hours and 13 miles  has a catchy ring to it. Nothing more than that. 13 hours of not eating to allow the ‘tank’ of body fat to empty a bit. It will empty a little because I will still need some energy to burn in order to stay alive whilst not eating! Then I plan to run which will just up the energy expenditure for 2 hours and so will make that fat burn a bit more fiercely. That seems totally logical to me. Everyone I have spoken to thinks this is risky. Mostly because of the diabetes. But diabetes is not a problem if you ignore the carbohydrate. Being a type 1 on a ketogenic diet and then running is about insulin management. Get the insulin right and the body will look after itself. I already know that my basal insulin dose is more than adequate. The challenge here will be injecting exactly the right amount of rapid -acting insulin.

So is there any science here? Well, yes there is! I have not managed to find anything about diabetes and fasting before activity. But there are studies on exercise in fasted non-diabetic athletes trained in LCHF diets. (*). They have found that the body will prioritise metabolism to keep glucose levels in the blood within a constant narrow range. The liver and kidneys will make glucose from scratch if needed. If the demand exceeds supply, all sorts of nutrients are brought in to shore up the situation. Of course fat can be burned to provide energy to tissues that are not glucose dependent. It usually does that anyway. Muscle protein can go to the liver and kidneys and be converted to glucose. Lactic acid produced during physical activity can be converted to glucose ( how good is that?), as can the glycerol part of triglyceride ( the form of fat that is transported in blood plasma). It’s all about getting the right nutrients at the right time. In some of those metabolic pathways, there will be a net energy loss in order to provide the correct nutrient. Making glucose is sometimes expensive in terms of energy, but these metabolic pathways all work out to keep us alive. Insulin is nowhere to be seen. Hormones such as glucagon, cortisol, growth hormone and adrenaline come into play. Of course that is a bit harsh on insulin. It doesn’t just do damage and skulk away. All of those hormones are in a continuous state of balance and tension so when one goes down the other goes up. It is all harmonious. Insulin anyway is just a fall-guy for the wrong foods we put in our mouths. It just does what it does. Insulin does get a bad rap these days, but are we not just shooting the messenger?

Back to the point. What the experiments on the athletes also showed were that, regardless of whether one is eating a low carbohydrate or high carbohydrate diet, the rate of production of glucose, (or gluconeogenesis), does not alter. The amount of glycogen stores did not alter before exercise or after recovery. But the rate of fat burning was higher in the low carbohydrate athletes. And, (And!), muscle will burn fat even if there is an adequate supply of glucose.(*) Well, there you go! Fat burns by preference. So, my body will sort itself out. It will make enough glucose for my needs. Eating is irrelevant for this run. All I have to do is manage the insulin. I am beginning to realise that this way of managing diabetes is not extreme diabetes at all! Exactly the opposite as it happens. The current advice that recommends eating carbs before running with type 1 is the real extreme diabetes! So, I have been preparing for this run thinking that it was I who was taking a risk by fasting. That was reinforced by everyone I knew, medically qualified people included. And now we have a total anticlimax! It will be all of those people with diabetes and who are still carbohydrate counting that are taking all of the risks. I will just be blending into the crowd playing it safe. That’s not how it should have been. But every run so far has taught me that, by following the science of metabolism, I can make decisions on my diabetes that make glucose control predictable and I can be safer by avoiding large glucose swings that are a frequent problem with carbohydrate counting. At least for me it works, and I am sure it will work for others as well. I am curious to see how the fasting works out.

The run itself started in the most bizarre way.  My daughter joined me as it was her home-town run. The course was lovely and flat and weaved through a town route, ending with a wide open countryside section at the end. The problem was that the roads were closed from 6 am for a 9 o’clock start. We had planned to meet at her house then cycle the last couple of miles to the starting line.  With the roads closed we couldn’t even get to the house. So, the closure of the roads for the run ended up with the runners being unable to get to the start to actually run along the closed roads. Farcical . In the end we had to abandon the car and run 2 miles to the start! We started 20 minutes late. But is was okay as hundreds of people started late. It felt like an organised run rather than a lonely sunday morning slog. It was to be a 15 mile half-marathon today.

Preparation with respect to diabetes was therefore rushed. I had injected the usual reliable 10 units of long- acting insulin before setting out.  But in the hour before the run I was so pre-occupied with actually getting to the start that I forgot to manage the rapid- acting insulin. When we arrived at the venue my continuous glucose meter was showing 6mmol/l and a relatively flat trace.  The glucose level had not gone up significantly during our 2 mile dash to the start, so possibly wouldn’t. I always expect a bit of a bit of a spike in the mornings and usually shoot up a couple of units of rapid-acting on waking. I had not done that today because of the circumstances. So, what to do with the rapid acting? One unit of insulin reduces glucose by 2.2 mmol/lit. Could I risk dropping any further from 6mmol/l? Possibly the long acting would be cutting in right at the end as well. It usually just keeps the glucose levels flat but can dip throughout the day at a very slow rate. Not a big issue generally but it might be today. In the end I went with 1 unit. That would take the glucose down to just under 4 towards the end of the run. When you are rushing, though, all sorts of untoward things happen. I had decided to take my rapid-acting pen with me just in case the glucose went up. I had an idea it wouldn’t but was unsure. But, having grabbed a pen from my bag to take with me, I had forgotten the needle! So it was a couple of hundred metres run  back to the bag drop building. Of course the needle was not in the bag,(it was later found on the floor of the car).  But luckily the long-acting pen was there.   So I unscrewed the needle from the long-acting pen and used that. Welcome to a day in the life of a person with diabetes.

Once settled in, the run itself was enjoyable. I had good energy levels, and with some one to talk to throughout the miles just reeled away. Glucose levels were okay up to about an hour and a half when it trickled down to 3.5mmol/l at 10 miles. I had a hypo awareness just before the continuous glucose monitor squawked to tell me so. It was no big deal, just an increased sense of exhaustion really. Over the next mile I used 15g of glucose tablets to top up. No drama at all. I opted to walk a couple of hundred metres and use that time to top up with the rest of the fluid. (400ml pre run and 400 en-route). Then off I went. In 10 minutes I felt back to normal despite the squawking of the continuous glucose meter. This is the problem with continuous sensors. They lag a bit by about 20 minutes. But I know it well and like using it. And I felt good so ignored it. At times like this I usually turn it off but as I was in a fasted state I was curious to see what would happen. It took about half an hour for the sensor to register the upswing due to the glucose tablets. But it all was okay to the end of the run. I even managed a small sprint at the end. I felt really good. Type 1 diabetes, 13 hour fast , 15 mile run. Job done! I picked up my medal and kept that. The goody bag I gave away. Grain and honey-based energy bar, Lucozade Sport drink, Banana, Popcorn, and some Good Stuff ‘naturally delicious’ jelly sweets. I had no need of that. In fact I didn’t feel like eating for another couple of hours. So I didn’t.

So, what have I learned? Well, the most important for me is that my rapid-acting insulin is now reliably cutting in at just over an hour and a half. Before I started using a ketogenic diet this was around 3 hours. It has been coming down gradually for several months. It is something to monitor. It might be that I am finally reducing my insulin resistance. Activities like sustained running need a degree of accuracy of management in diabetes so it is wise always to be vigilant. I have also learned that tiny doses of insulin that I now use do not lead to dramatic hypos, just enough symptoms to alert me . I had on this occasion over-injected by just a single unit, but the rescue of that hypo was easy. Also, the science of LCHF in physical activity seems sound. It worked in my case. I have shown that it is possible to fast in Type 1 diabetes and exercise quite safely for a couple of hours.

I have shown over the last 5 half-marathons that what is currently thought of as extreme is in fact the very opposite in reality. Real hard-core extreme diabetes is carbohydrate counting! Fasting before a run is a walk in the park compared to that. I have no doubt about that at all. And, because this blog is about extreme diabetes I will need to join the real crazy gang and carb-load for at least one race. . But at the present time the thought of injecting more than 4 units of rapid acting insulin makes me shudder to think about it. There is still lots to test with the ketogenic diet. I will stick with that. I am not brave enough to take carbs!

Half-Marathon 4 : Fat Only

We need to shake things up a bit if these runs are to have any meaning. I have done 3 runs on high fat and protein, each meal totalling around 500 calories, and relying on body fat to provide the deficit. I am reasonably happy but need to refine because of the glucose spikes in the run.  I am sure that I will be able to get the balance right by adjusting timings of insulin and the blend of fat and protein in the meal. But more of the same and fiddling about at the edges is for another time. I need to press on with testing the ketogenic diet and have some ideas based on the past runs. Today’s run has no challenges as far as the route is concerned. It is relatively flat on quiet tarmac roads. No hills, no rough trails underfoot. I can concentrate on experimenting with diabetes. As usual, please read the warning section. 

My training has been more dedicated and I feel a bit fitter generally but not yet feeling fully-fit. I can put in a bit of a sprint at the end. But stamina for hills is not there. I still think a lot of it is mental, but the engine is a bit lacking I think. What to do to increase stamina without becoming completely obsessed about it? I have been reading about high intensity training (HIT), where you train in intensive bursts rather than prolonged aerobic exercise. A lot of personal trainers I have met do that. It seems to be the ‘latest thing’, the must-have answer to fitness for the next few years. I have bought the programme to give it a go, but it is hard to find the motivation to do it. To be honest I find it a bit boring. But the time has come to discipline myself to do this if I am going to improve my times. I will start HIT after this run.

For today the pre-run diet will explore energy just from fat. I think Richard Bernstein’s approach to take regular protein loads throughout the day to help improve control is sound and I will go back to that. But I need to sort out that unacceptable morning glucose peak. So, out with the protein today.

But how much fat will I go with? A half–marathon is just 1200 calories of energy in addition to my usual daily requirements . I am keto-adapted so am fat-burning anyway. I could just do the run and use some on-board reserves. I will, but another time. But I want to run on a fat-burn today. People obsess about saturated fat and cholesterol. They even talk about fat and cholesterol as if these are the same entities . Of course they are totally different compounds, their only common characteristics are their solubility in a fatty environment. They hang around together because that is the most efficient way for the body to move them around. In fact they also associate with vitamins A,D, E and K , because these are fatty substances as well. And of course the media-cuddly omega fats snuggle up with cholesterol on their ride through the blood stream. But none of these fatty substances are unhealthy components of the diet. Despite just about every recent statement from guideline bodies saying that saturated fat and cholesterol in the diet do not affect heart disease, this is the official advice we are still given. It of course makes little sense if you know the biology. Mainstream Medical Science really does need to catch up!

Our liver makes most of our cholesterol and this is partly regulated by insulin. A quarter of our total body cholesterol is found in the brain and acts to facilitate nerve function. More cholesterol is produced at night when we are asleep. Is that a coincidence or is it serving a vital maintenance function?

We are fat-burning naturally a lot of the time. Resting muscle thrives on it and so does intestine.  And  our body produces  glucose in enough quantity  for crucial tissue needs. We know that we do not need to eat glucose to get that energy as we make it from other metabolites and also from proteins, in the kidney, liver and  intestine.  And of course, insulin ensures a normal glucose level in the blood.  Any excess glucose is parked away so that blood glucose levels can remain stable. It is parked away as fat.  Excess carbohydrate in a meal will lead to the production of fat under the control of insulin. This is saturated fat as we know. Saturated fat is a very efficient fuel and the end-product of fat metabolism is ketones, which are themselves fuel, perhaps better fuel than fat. It seems then, that the body just needs us to eat the correct nutrients and then it can look after it’s own needs. It can convert everything to everything else if you see what I mean. But an incorrect blend of  nutrients might direct that metabolism into an unhealthy state. Feeding myself carbohydrate when my metabolism cannot process it has led to all sorts of problems. I am pleased to have stopped it when I realised. It seems that fat and protein suit my defective carbohydrate metabolism.  

So, on this run what type of fat will I take? Well, clearly something from a healthy source, so that will be fat from pasture grazed animals, or oil processed by pressing with no industrial processes such as dissolving in hexane, and washing out ‘impurities’, (that means nutrients to me and you) in caustic soda(*). That is important. Industrially processed fats have little nutrient value and contain trans fats. And will I eat saturated fat or unsaturated fat? Most will know that few foods are pure saturated fat or unsaturated fat. Olive oil has 10% saturated fat, but is mostly mono-unsaturated, pork has 25% mono-unsaturated fat but twice as much saturated fat. I am not too worried about omega fats today. Sure they have anti-inflammatory effects, but I just want to simplify it to fats that provide energy. Oily fish is a good source of omega fat but it has protein as well and I want to avoid the protein today. I have decided that I will go with coconut oil and unsalted butter. I have found a recipe you see for Bulletproof Coffee. Well a derivative of that. Double strength coffee, 30g coconut oil and 20g of butter whisked up. Coconut oil is 100% sat fat. Coconut oil has 850 cals/100g. And butter 734cals/100g, 82% fat 52% of which is saturated, 0.6% carb and protein. That makes a total of 430Cals all as fat. It seems to be the ideal fuel package today. I will reserve the right to add some fibre if I feel sick! I will allow my body to provide the other energy, which is only 88grams (3.1 oz) of body fat. I can give that up okay.

Preparation.

It was to be an early start and a 40 minute drive to the venue. I woke up tired after a short sleep of only 6 hours. I was out until late but took care with alcohol, consuming only one glass of red wine. I woke with a glucose approaching 7mmol/l and allowed just one unit of insulin rapid-acting to nudge the glucose down a couple of mmol/l. Remember that one unit of insulin in someone of my weight 75kg reduces glucose by 2.2mmol/l. I used the same amount of long acting insulin, 10 units. That is my reliable dose. And took a glass of 300ml plain water.

We arrived 1 hour pre-run so brewed up the coffee in the car park and blended it with the pre-weighed 30g coconut oil and 20 g butter. A vigorous shake and it was done. A creamy,greasy, black mix. I think I had done a reasonable job. Not too much of the separation that this drink is supposed to be prone to. It tasted quite reasonable. Oily on the palate but the coffee and coconut came through strongly with notes of butter following.  And another 250 ml fluid as coffee. So I have had half of my allowance already. I work on 4-500ml/hr in normal conditions in this country. 

My blood glucose level was 6.3mmol/l in the 20 minutes before the run. At the half way point it was approaching 7mmol. This was looking really good and bang on the glucose prediction. Exciting, and to boot I had yet another good time at 7 miles. But predictably this tailed off mile after mile towards the end. There were plenty of hills which I had not expected and a nasty one at 11 miles. But the thing was, I was not needing to walk on the hills. That was progress indeed. Ok, I was being overtaken by walkers, but I was doing what would be recognised as running, however slow.

The glucometer sensor fell off at the 8 mile mark with a glucose of 7.3mmol/l. But I felt good. I could stop worrying about a hypo. One unit of rapid acting was not going to do much. The main concern now was, had I injected enough insulin? Because if I was insulin-deficient then my glucose levels would start to rise. It has happened to me before when exercising.  One of the functions of insulin is to remove glucose from the blood into the cells of the tissues where it can be used as energy. Even if you are burning fat though, you are still making glucose and using it for energy. The body makes it by converting other substances, notably protein, but also by reversing biochemical pathways if necessary. Red blood cells for example can only use glucose as fuel and they work hard in exercise. So, there is a need to make glucose. If I had not injected enough insulin, there would be no way to reduce the levels of glucose made by the body. The glucose would not be able to get into the cells, because that process is largely insulin driven.  If the cells could not access glucose because there was no insulin to enable that to happen, the glucose in the blood would rise, and the cells would then take their energy from fat and ketones.  Ketones are just the natural end-product of fat breakdown but they can then be used as well to provide energy. If you have insulin in sufficient amount, then fat burning and producing ketones is not a problem at all as the glucose levels will be controlled. Insulin pretty well orchestrates metabolism and fat burning  will also be controlled in a precise way. But if there is no insulin then fat burning also gets out of control and therefore so do the levels of ketones. Very high, unregulated levels of ketones make the blood more acidic. High levels of ketones, high levels of glucose, and increased acidity in the blood equal ketoacidosis. And all that glucose in the blood makes you pee so much that you become severely dehydrated.   So if I had injected insufficient insulin,  I could be at risk of the dreaded ketoacidosis. And worse, with no insulin in the body, potassium levels build up in the blood. That can lead to heart rhythm problems.  High glucose, high potassium, acidic blood and dehydration are a potentially fatal combination. So it was a worry. That is why if you have gastroenteritis it is still important to take insulin. It is vital if you are going to avoid ketoacidosis. But with enough insulin, everything is fine.  Regulated fat burning,  normal, healthy levels of ketones and business as usual with normal glucose levels. The ketogenic diet is  safe in type 1 therefore if one injects sufficient insulin. Ketosis in a ketogenic diet is not related to keto acidosis in any way apart from the letters k-e-t-o and o-s-i-s.

 And that is what it turned out to be. A glucose of 3.9mmol/l just after the run. It was vindication of the theory that you can inject insulin and not need carbs if you plan it right. 

What Have I learned?

I have managed to demonstrate that basal insulin is sufficient to meet the metabolic needs of the body during a 2 hour period of moderate intensity exercise when no carbohydrate is eaten. And beyond as well. Because after the run it was completely stable between 4mmol/l and 7mmol/l into the night.

So, there you have it. If you don’t eat carbs you don’t need extra insulin. What I had thought all along. I feel good about this but not bullish. To be honest, I knew what should happen and it did. But I had a nagging doubt for an hour that I could be getting into early ketoacidosis. Very early admittedly and easily managed, but not safe enough to make it routine practice. So I am going to do this again. Probably twice more. It is so important to me that I cannot rely on one run to make that judgement. But that was exciting. The hard work of research is paying off. But I want to keep exploring the boundaries even further. This run was all about whether fat alone could provide the energy. It did. But logically there is no reason why some of that fat has to come from the diet an hour or so before exercise. My body can provide it possibly, I am fat burning after all. I have relied on fat from the body for the second half of the last 2 runs and that has been okay with respect to glucose. But my performance has tailed off. Is that cause and effect? Well, we shall see another time. I think I might do a run on body fat alone with just black coffee for breakfast. That seems like a fair challenge.

Half-Marathon 3: Keto and Mental Attitude

A flat course along quiet lanes with part of the run done in a private estate It is an impressive country house owned by the National Trust, with equally impressive gardens. Before you read further, please go back to the menu and read the warning if you haven’t done so already.

I had only 3 weeks in which to train and one of these was a recovery week. Circumstances were such that I did only 3, 6-mile runs over consecutive days with an hour’s road biking somewhere in the middle. The last run was exhausting and was clearly over-training for my fitness level, so I decided to give the rest of the week a miss and ‘wing it’. Winging it has been my modus operandi of life and has worked so far. So, wing-it it was. The last half-marathon was the second half-marathon in 2 months that I had done. That  was already new ground for me, so this third one was completely uncharted territory. My main concern now was not a worry about cramping up or any injury like that. I was more concerned that I might have a heart attack or something. Us diabetics are prone to heart attacks and all things related to blood vessel disease. I had 20 years of damage in the ‘clockwork’ by doing things in the wrong way, so things could blow up at any time.  Steady running seems OK, except for a nagging ache on the left side on some occasions. I reckon that it might be spasm of the gullet or something as it comes and goes and is no worse really than a couple of years ago. It might be heart. But I don’t think it is. I have never had a heart attack but this did not feel like it might be. All this talk of uncharted territory and the like  is a mental thing, I guess. In reality this half-marathon is a completely manageable couple of hours running just a week slightly earlier than I wanted. And nothing more. I guess we are all limited by our own sense of what is possible. If we think 10K then that is probably us. I have some fridge magnets all with inspirational messages. They talk about our own sense of limitation. Try this from Sir Edmund Hillary ‘It’s not the mountain that we conquer but ourselves’. Or T.S.Eliot ‘ Only those who risk going too far can possibly find out how far one can go’. And of course, challenging oneself in the end is exciting. I have done my fair share of risky things in adventure sorts over the years. The dare, the apprehension, the decision to commit and the adrenaline rush are addictive.  In adventure sports, other brave people have ‘been there’ before and have learned from mistakes to improve safety. All I have to do  is to do what I am told by my instructor, and be taught how to assess the risk. Then do it. In this series of experiments with diabetes, I am constantly warned that what I am attempting to do is against all scientific consensus. In it’s own way, stepping outside the norm of medical practice is just as daunting as risk sports. If not more so. There are of course pioneers in the field of keto who have laid the groundwork. And I am keen to reinforce that work in my own way.  I feel sure that my  guideline diet of high carbohydrate and low fat has brought me to the brink of a personal health disaster. So, where with risk sports you make a positive decision to take the risk, in these experiments I am making a positive decision to reduce the risk. The short-term experiments like this series of runs are a challenge. But I am pretty sure I have a sound knowledge of the biochemistry, and it will work. Risky, possibly, but I am sure that the gains will be found in the longer term.  The experts will tell you that it is risky. There is little evidence for the benefits of keto in the longer term.  But the biggest risk I take is doing the same thing as I have for 20 years. I am just declining in health by doing that. Ironically there is plenty of good evidence to say that decline in health will happen!  Doing the same thing over and over and expecting different results  seems doomed to fail. Ask Einstein. He defined insanity like that.
So, from now on, I have determined to see beyond what I currently think of as normal. I will make more progress that way. My new normal will be what I previously thought as not possible.  Otherwise I might become a 10K man forever.
Now that I am doing longer training runs I can concentrate more on posture and how my body is tense in some areas. I can work on that slight ache in the chest. The hips can also get achy until I fix my mind on relaxing them, and my upper arms and shoulders seem to be quite fixed. I am learning to rotate my arms from side to side which seems to help. It seems to give forward momentum. Carrying my glucose monitor in the left hand might make it worse, I cannot tell. And the increased effort of breathing when tired, I am discovering is just tightness in the neck muscles. It is quite interesting actually discovering all of these things. Honestly, who would have thought running was such a palaver?  We just got up and did it when we were kids. I guess years of bad habits such as sitting in a car for half an hour on the way to work , then sitting at a desk for 8 hours, then back in the car takes its toll. So, now that I am less concerned about race timings, and more on experiments with diet and insulin, I can concentrate on that. And I can also practice shifting posture and see what feels good.
This was a run to get out of the way before my holiday. It was one of only 4 organised runs in the UK that day. The most local one was fully subscribed so it was a 2 hour trip to the venue the night before. This was the closest one. I could have simply just churn out the miles of my local half marathon route alone.  But I needed a medal!
It was to be a club-type run. Minimal facilities but functional. Plenty of serious club runners, polite but not humorous. Not a Fun-Run atmosphere and not much chatting en-route. But that was OK. It was just perfect for my needs. I was only here for the business of running. And it was flat. I needed flat.

Preparation.
After the last run which required quite a lot of carbohydrate during the run itself, I felt that a bit more preparation was needed. Waking up  with a glucose of 4.5mmol/l was encouraging but I had no dawn phenomenon again.  However, I knew that my glucose levels would go up when I started the run. I knew it from experience. But I was caught out last time and wary of a repeat of that. I decided to go for 2 eggs and streaky bacon 4 rashers one and a half hours pre-run. 500 calories including creamy coffee. That left a 600 calorie deficit. 9 calories per gram of fat this was equivalent to only 66g of fat ( 2.4oz) I had that available on board round my waist to give up. I still have a thin spare tyre. More a racing bike these days, but it is there. So I decided to donate some of that. Isn’t that what it is for after all? I injected the usual basal insulin, 10 units, on getting up, and decided not to inject any rapid acting insulin at that time. A glucose of 4.5 with no intake of carbs would be very risky indeed. I would see how things went closer to the run. My breakfast included an 20g protein load, some of which might convert to glucose, which I had to bear in mind.
40 minutes to go and glucose was 6.7 and rising. That was the protein, possibly some cortisol and adrenaline. What to do? I could have waited and saw what happened in the subsequent hour or so. If I did this I would take my insulin pen with me on the half-marathon. There was room in my running belt for insulin which I could take mid-run if needed to bring the glucose down to normal after the run. In the event, with 30 minutes to go I decided though to go for a 4 unit rapid acting . Why? I thought it was likely from experience that the glucose would go up more. And high glucose is not good. Because of the way my insulin worked for me I knew it would be a couple of 2 hours before it kicked in. The time delay before action is reducing and I hope this is due to insulin resistance decreasing. So, if I injected 4 units, that amount of insulin would lower my glucose by 8.8 mmol/lit ( roughly 2.2 mmol/l per unit in someone of my size according to Richard Bernstein in his book Diabetes Solution ). By 2 hours that 4 units of rapid-acting insulin would have kicked in. Through experience I know that the rate of action of rapid-acting insulin (not including a potential 30% variability in absorption!), is to bring the glucose down by  6 mmol/l/hour for me personally. So, if my glucose was 7mmols/l 30 mins before the start, it would have likely stayed there until half and hour to go and then would fall at 6mmol/l/h. So, by the time it kicked in, that final 30 mins would reduce the glucose by 3 mmol/l and it would then be 4mmol/lit at the end. Safe enough and covered with continuous monitoring. So I gave it a go. When I finished, I would be able to sort any low out at leisure with glucose tablets. The great thing though about continuous monitoring is the luxury of sorting out on the go so this was less of a big deal than if I were to use a standard glucometer. I am lucky to have one.

The Run.
A nice gentle start in cloudy but warmish conditions, perfect for running perhaps slightly too warm. Working on the fluid formula of 400-800 mls per hour from research done by Tim Noakes, I reckoned 500mls of water would do it per hour. So I took 300ml  pre-run  and topped up twice on the way round. At half way, feeling good. I was on for 1 hour 50, way too quick. Ridiculous. And it was to prove to be the case. I finished outside 2 hours. Slightly disappointing but realistic. And my best time in this series. I got the usual light-headedness and ache in the chest, but put this down to tension. I could feel that I was tensing up. My pulse was regular so I assumed the heart was OK. I did some in-run relaxation. It seemed to help. I had to walk a couple of times to settle a sense of exhaustion, but did manage to speed up at the end.  At the one hour mark, so about half way, my blood glucose peaked at a way too high 13mmol/l.  Then it started to fall at a predictable rapid insulin rate of 6mmol/l per hour. So, I reckoned that, with one hour left to run I would finish at a glucose of 7 or so. That was the theory and that is what happened. I took slightly longer to run the distance and the final glucose was just under this. But it all worked out. These small insulin doses are great. You just feel so safe. At less than half way into a run I could totally relax and ignore my diabetes! Think about something else. What a luxury that is. If you have Type 1 you will connect with this. It can be difficult to remember forgetting diabetes.

What did I learn from this?
I was pleased to have completed this half-marathon in the way I did. Carb free and with reasonable control. I now know that the practice of injecting insulin and not covering with carbs can be done. I am loving the keto! There is still much to learn, but I reckon that less protein and more fat will be the way to go on the next run. I have got into splitting up protein in equal amounts throughout the day. It smooths out control on a normal day, and it has become a habit. But I think I can get better control when running if I cut out the pre-race protein. Just go with the fat. I think it will be less complicated and make preparation easier. I will do that in my next run in 5 weeks time. But first a holiday. I am looking forward to my Italian holiday and 2 weeks running in the lovely scenery of Tuscany. It will be very hot and that will be a challenge in itself. I am beginning to find out that I can safely cut the carbs, just as I had predicted at the start of all this. I reckon that with nine Half-Marathons to go, that I can perfect my glucose control and have time to experiment more radically on a few of the runs. I will try omitting the pre-run meal completely and just keep burning the fat. Perhaps a longer fasting period??  And, if can bear to, I might also try a ‘heritage’, DAFNE-style run. Fully carbed-up and injecting to suit. It makes me shudder just to think of it.