Assessing the Risks

Hi, Lemming here.

Before I started to go keto, I was worried about complications. I still am of course. But I think things have changed for me. Since going keto I feel that I might have a glimmer of hope. Before this there was none. I get the impression reading online that I am going to die early, probably as a result of a heart attack or stroke. Risk factors talk of 2-3 times the risk with diabetes. And the length of time you have had it is the best predictor of complications. So, it doesn’t look good. That was why I decided to take a look at changing things fundamentally.

When I was considering keto I decided to take a look at what this was going to mean in terms of my diabetes. Is it safe enough? I had had lots of warnings. A powerful one was that if you are taking insulin you must back this up with carbohydrate. Otherwise you risk hypo’s. Balancing insulin and carbohydrate is fundamental to managing type 1 diabetes.  The position statement from the American Diabetes Association is quite clear on carb counting in management and the level of evidence, B, is impressive:  “Monitoring carbohydrate intake, whether by carbohydrate counting or experience-based estimation, remains a key strategy in achieving glycemic control. (B)”(*).

Quite right.  If you are eating carbohydrate and have diabetes it is definitely a good idea to monitor it! But there is no research that I can find that has looked at carbohydrate and insulin with respect to whether you need carbohydrate. Clearly insulin lowers blood sugar. So if you have made the wrong judgement call on how much insulin to inject and inject too much, then it is certain that you will have a hypo, Every type 1 diabetic needs to inject insulin, and that keeps us alive. In fact everyone needs insulin, diabetic or not for  ‘background’ metabolic functions.  Lemming Test-Pilot is using background insulin, long acting, to replace the amount of insulin needed just for the body to carry out these background metabolic functions.  Lemming Test-Pilot also used to  inject extra insulin, rapid-acting, at mealtimes depending on how many carbohydrate portions he or she counted. That is standard carbohydrate counting and insulin management that we are all familiar with. But, if  we eat no carbs with meals, how much extra insulin do we then need? Well, the answer is none, surely. No extra insulin beyond background. If your meal carbohydrate count is zero, the required insulin is then zero. It’s looking appealing already.

Lemming Test-Pilot in their reading has come to the conclusion that the diet recommendations for people with type 1 diabetes are exactly the same as the recommendations for the non-diabetic population in terms of the proportions of carbohydrate, fat and protein. Despite the obvious fact that one is a condition of abnormal metabolism and one isn’t.  So, the current state of the art whether you have diabetes or not, is this. Eat your carbs as complex carbs and starchy carbs  (often called healthy grains or unrefined carbohydrate). This is because carbohydrates in this form are not absorbed too quickly and so will not raise glucose as dramatically. Eat a reasonable amount of protein up to 1 gram per kg of body weight, and eat no more than 30% fat, and make sure that only 10% of this is saturated. If you have type 1 diabetes, do exactly the same, but of course you must accurately count the carbs in the meal and inject the appropriate amount of insulin at the appropriate time. That is pretty well what Lemming Test-Pilot has been doing for the past 20 years with patchy success but in the main a general decline in health in line with the common observation that your complications are more likely the longer you have had the condition. And that is why Lemming Test-Pilot has decided to look at diabetes again. If people with type 1 diabetes have a defective metabolism that means they cannot handle carbohydrate, why on earth is Lemming Test-Pilot being recommended to eat carbohydrate? It is not essential in the diet. And, reducing carbohydrate fundamentally changes the way that rapid -acting insulin is perceived and used in practice.

I have had so many dire warnings about fat. People just can’t get their head round it. But we now know that all the research points to saturated fat in the diet NOT causing heart disease(*)(*) (*)There is only one study left(*) that gives hope to those clinicians who are suspicious of fat.  And that was really fiddling round the edges, by altering the proportions of saturated and unsaturated fat. But the percentage of total fat in the diet was the same at around 30%, as was the percentage of carbohydrate, which was about 50% of the energy in the diet. So, whatever conclusions were drawn from that trial, they don’t apply to me. I’m on around 10% carbs and 75% fat. And it is the same with cholesterol.  There seems to be a relationship between cholesterol and heart disease but it is not due to cholesterol in the diet(*). I was looking at a recent study showing that people on statins ( which are cholesterol lowering medicines) with Type 1 have less heart attacks and strokes than those not on the drugs. That sort of headline catches the attention. But when I took the time to look at the data, it seemed that this was in an environment of high HbA1c (64 mmol/mol) and a ‘healthy balanced’ diet. So that is 55% or more carbs. So that doesn’t really apply to me either. Although it would have done before I changed my diet. Cholesterol levels might have importance in other ways which involve receptors in cells that clear cholesterol from the blood.  Some people  are short of those. But that is a rare condition. And of course it is now not just total cholesterol that is a problem. That is so like 10 years ago. The new culprit is a sub-fraction of total cholesterol  called small dense LDL(sdLDL).  But this is not cholesterol even. It is called low density lipoprotein  but is only a cholesterol containing structure which carries all fat soluble nutrients round the body. It also contains omega fats and vitamins as well as fatty acids. Lipoproteins move fats around the body. We subdivide them according to density then measure the cholesterol in the heaviest fraction and estimate the rest. Then we infantilise the whole process and call it ‘good’ cholesterol and ‘bad’ cholesterol. Medically that is HDLcholesterol and LDLcholesterol. Even though LDL do not just contain cholesterol.  Anyway, to my knowledge no one has ever measured sdLDL in me, so I haven’t a clue what my true risk is.

So, I don’t think that anyone has done much research with 10% carbs 75% fat. But where does that leave me? I keep being given medical and dietary advice based on evidence that does not apply to me. However much I protest, the guidelines are the be-all and end-all. Surely science has not been corrupted by dogma? Well, I think yes, and no. On the one hand it would seem that the current dietary recommendations, especially on fat avoidance, have become accepted as a basic fact. Like it was once accepted as a basic fact that the Earth was at the centre of the universe. Look in any NHS staff-room and you will see confirmation of that in the ubiquitous gesture of faith in low fat ‘healthy living’; the semi-skimmed milk in the fridge door.  But on the other hand there are some clinicians out there who have managed to slip in some helpful advice in the guidelines. Both in the NICE guidelines “Provide nutritional information sensitive to personal needs and culture”(*), and the American Diabetes Association “Individualized medical nutrition therapy is recommended for all people with type 1 diabetes as an effective component of the overall treatment plan. (A)”(*). That last statement is high quality evidence. So, even though the ketogenic diet is way out on the fringe of mainstream science, there are people out there who, it would seem, are happy for me to give it a go. And that is encouraging.

So, saturated fat does not seem harmful, dietary cholesterol is irrelevant. Carbohydrate is not essential. It is really perplexing to understand how the guidelines on ‘healthy balanced’ diet managed to get published at all. And, more bizarrely, how the medical profession seemed to buy the story even though there was little science in it. For 50 years! In fact, I was also reading that if you attach radio-active tracers to sugar and feed it to people, about 20% will be found in fat. That fat is called palmitic acid. And that is one of the worst ones you can have according to the scientists. Apparently it is a good fat for providing energy, so is a storage fat. And OMG, it is saturated! So, ‘healthy grains’ are passing into the body as saturated fat? Well, that doesn’t fit the story. So, it is probably best to avoid ‘healthy grains’ as well, then.

So, if it’s not the dietary fat, ‘healthy’ grains or cholesterol, what about sugar? It seems to have been known for ever and a day that if you have high HbA1c then you are likely to have increased risk of diabetes complications. HbA1c it seems is linked to heart disease in people with diabetes, but also in the non-diabetic population. If you have HbA1c at the top end of normal you are far more likely , 75% more likely, to have a heart attack than of you were at the bottom end of the normal range. And it gets worse the higher you go. So, it would seem that we are onto something. Is the sugar sticking to tissues the real risk factor? I found this in the EPIC Study(*). The population came from the UK and HbA1c was a risk factor even when you allowed for age, smoking, weight, cholesterol, and exercise.

The one trial I have found that has been done with low carb in type 1, showed that a low carb diet gave improved HbA1c over 4 years, with 1.2% reduction. So that one applies. It would seem that getting good glucose control is desirable.

So I have decided to go with the principles in Richard Bernstein’s book, Diabetes Solution. And Keith Runyan’s  Ketogenic Diet. They are both Doctors and they both have type 1 diabetes. And in Richard Bernsteins book he reversed a lot of his complications. That alone is good enough for someone in my situation.  A diet of fat and protein should be okay. I will be getting all of the essential nutrients. I will be likely improving my HbA1c and therefore improving my chances of avoiding complications. And I will be complying with the guidelines!

In fact, fast forward to 1 year on.  That has proved to be the case. My own HbA1c went from a value 57 when  trying really hard on conventional diet at that point with reduced carbs,( it has been a lot worse than that), to 47 after just 3 months on a ketogenic diet and then  45 just 3 months after the previous reading. It is currently 43, just a fraction above the normal value.  I am hopeful of getting normal values soon as I get slick with this diet. I reckon it takes 2 years to get really slick.

So, I can justify my actions based on googling the information. It is so disappointing that there is none of this information in the NHS. I wonder what would have happened had I not had some initial luck in finding this information online.

Let’s get back to applying the science and have fun pushing the boundaries.