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.