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Covid, Keto and Insulin

A personal Covid experience. 

Given the complexities of Type 1 diabetes management, one would think that a level of competency would be required before people were to be trusted with ownership of this disease. Even as a medically qualified person, I would agree with that statement. I would have also failed the test. It is not in my nature to be so thoroughly organised or disciplined to be trusted with Type 1 diabetes daily. But like most of you readers, I have got it and have to get on with it. I get through each day mostly unscathed. I’m still here. I can still refer to the Frank Sinatra song ‘I did it my way in the present tense’. We all do it our way. So please take the following blog as a personal account. I hope you pass this on to your clinical teams. Some individuals still have learning needs around keto management of diabetes. It will help them to understand our lives. And rest assured, many of those would fail the Type 1 test, too. 

This is about how Covid provides opportunities for learning about Insulin in Type 1. 

‘Have you had Covid?’ people would ask? 

‘Of course not, I have a keto cloak of invincibility!’ would come the reply. 

Doctors above all should know that such puffed-up confidence is never likely to end well. 

I expected it would be bad if and when I got Covid and likely finish me off. Bravado is never a proxy for certainty. In theory, Keto should help me against Covid. Even in Type 1, Keto reduces insulin needs and downregulates the cellular receptors that Covid latches on to. Keto reduces inflammation and, in theory, should confer some protection against Covid. But there might be other mechanisms that exert a countereffect and are the driver of bad outcomes. Who knows. But I felt well prepared for this fight partly because of the keto lifestyle. I am also triple vaccinated against Covid. I did this more as a gesture of solidarity with my fellow citizens than a personal life-saving exercise. The Covid Vaccine seems to reduce symptoms were I to get Covid. 

I have not had Pneumovax as that is not a Public Health issue. It is a personal risk assessment. But I have had every other vaccine and booster offered.

But I don’t get ill these days ( there I go again!) I recover quickly from injury, and overall, this keto lifestyle suits me. 

It does help my T1 diabetes control. And, let’s face it, glucose control is so important in diabetes of all types. I even got approval from my diabetes specialist after they warned me, erroneously, that normal HbA1c is dangerous in Keto. It isn’t. Glucose control is an essential determinant of day-to-day well-being and long-term complications. Keto makes it easier and safer. 

In stark detail, a sobering paper presented at the EASD in 2020 showed that fact. It turns out that for every year that HbA1c is above 7.5% or 58mmol/mol, 100 days of life are lost. Over a lifetime from diagnosis, that adds up to 8 years on average.

If you start counting from the 1st of January, you will lose every day until the 10th of April. I could miss January, the first two weeks of February and November. But I don’t think there is a choice. 

Now, at a Public Health level, this might just about be acceptable if a few people with complex needs were poorly controlled to this level. We could focus on specialist teams to work with this group. But, no. According to the Diabetes audit for England and Wales 2017-2018, a whopping 70% of people with Type 1 diabetes are in this situation. 

Seven out of every ten people are losing a third of every year they live. The only saving grace is that we don’t know how long we have left. And this figure hasn’t changed for years. Is anyone bothered? I am. Because research on keto lifestyles has shown that HbA1c can be normalised such that the vast majority of people can get their 100 days back. 

In 1752 in England, the fabled ‘Calendar Riots’ occurred when an attempt was made to remove just a measly 11 days as a one-off from the existing calendar to account for the perturbations of celestial mechanics. Over the years, such tiny errors had led to the European and British calendars getting out of synchronisation. Unlike today, scientific reason prevailed despite self-interested attempts to fool the public over the loss of benefits such as festivals, pay, and the like. We live in the hope that science will prevail in our times one day. Imagine if all people with Type 1 diabetes found out they were not given complete information about their options. They might start demanding their 100 days back. Modern riots are often carried out more quietly in courtrooms. I fear this will be no different when the ‘mob’ get organised. Adding life to years becomes an urgent priority when your year is only 265 days. And there’s no better way to add life when you have good diabetes control. 

Raised glucose as the first sign of Covid. 

 One morning, my blood glucose gradually rose and plateaued at around 14 mmol//mol for no explicable reason. I felt well on waking, but I had symptoms of headache, mild sore throat, and light dry cough over a few hours. A Covid lateral flow test was positive. The rest of that day was spent feeling more tired with some myalgia. My glucose levels had been a Covid early warning sign. 

I was already on a keto diet and had no appetite, but my sense of smell and taste was usual. So, despite around 50% fewer calories and increased bolus injections of Novorapid, I could not drive the glucose down. This was the situation for the next three days. It seems intuitive to want to correct glucose with Insulin. At the end of this article, I have suggested another way for the non-infected body. But, back to Covid.

My usual total daily Insulin is eight units of Tresiba twice a day and two units of Novorapid in the mornings. This goes in fasted to counter the dawn effect where blood glucose rises due to stress hormones. Typically four units for evening meal, on a 16 to 18 hour fast and two meals a day strategy. So I use around 22Units of Insulin, give or take, every day. And this level of Insulin keeps a good glucose profile to keep my HbA1c within the non-diabetes range.

On day one of Covid, I injected  12 units of Tresiba in the morning and 14 units at night, with 4,6,6,6 units of Novorapid throughout the day. 

My day 2 was 14 units of Tresiba twice a day, six units of Novoapid fasted, and then another eight units 30 minutes later. Overall, I injected 54 units of total Insulin, close to that volume the next day, 38 units on day four and today on day five; it looks like around 28 units. Today the glucose will be back to normal. In fact, on reflection, I wonder what would have happened if I had injected my usual volumes. Please read on. My glucose eventually settled into the normal range, but my Covid test remains positive. I have added the CGM graphs. You can immediately spot the crazy lines when the glucose sensor was malfunctioning; it was then a manual reset. I tested several times a day manually because of sensor issues. They are indispensable but not without flaws. 

Apart from cold symptoms and tiredness on day 1, I was slightly better on day 2; I was 90% better on day three, fully recovered by day four, and symptom-free. My glucose told a different story by 24 hours; it normalised on day 5. 

Day 2
Day 3. Sensor failure! Erratic levels.The gap in readings is the time to coax it back to life, decide it is dead, then remove,refit and recalibrate
Day 4. This sometimes happens when sensors are settling down! Gradual return to normal.Dots are fingerprick calibrations when the meter is reset. Hence the ‘unnatural ‘drops in glucose.
Day 5 settling down. Flat line abnormal as can be deduced from red calibration dot at 1200
Day 6, normal.

I felt it necessary to dust off the ketone meter. I was in and out of ketosis, but mostly out. On one occasion, I had a glucose of 16.6 mmol/l  and ketones of 0.8. Hospital admission levels. I could detect the glucose level physically but wasn’t too bothered about the ketones as the glucose came down to its plateau high after a few hours. But if both had kept rising after a few hours, the story might have been different. I might have been entering Diabetic Ketoacidosis. Diabetic Ketoacidosis is a risk for all Type 1. Especially during infection. But not as a result of a keto diet. 

So, what on earth is going on here? An almost tripling of Insulin with little effect on control. For me, one unit of Insulin reduces glucose by two mmol/l, yet here I was shooting up 14 units with no food cover and not a flicker on the glucose needle. It is the situation of acute insulin resistance caused by inflammation caused by Covid infection.  I have noticed the same effect with constant snacking on keto foods. The glucose goes up to 11-12 mmol/l and refuses to budge. It seems that whatever metabolic processes are happening, Insulin is not working. Or, if it is working, it has reset the glucose threshold and parked it there for some reason. You might notice that this level is just about the level at which the kidneys fail to recover all of that filtered glucose and at which glucose then spills into the urine. I had no means of checking this as I had no urine glucose strips. However, in the absence of carbs, the glucose rise can only be through glucagon. Glucagon is a counter hormone to Insulin that responds to stress hormones and raises blood sugar. And in the absence of carbs, the glucose level could be maintained at a plateau through the kidney dumping the excess glucose. And this is probably what was happening. 

Start adding carbs to this situation where Insulin is not that effective, and you can see how all of this will get out of control. The system’s self-regulating capacity will be overwhelmed by glucose from carbs and stress hormones. It would likely keep on rising. 

Of course, Insulin doesn’t just have a role in glucose control, though that is one of its significant functions. Insulin interacts with at least 23 different hormones at my last count. Glucagon is the obvious counter hormone to Insulin. Insulin lowers glucose, and glucagon raises it. But thyroxine, oestrogen,  testosterone, vitamin D, growth hormone, cortisol, adrenaline, and many digestive hormones interact with Insulin and affect how it is expressed and vice versa. It’s a proper old chemical soup but as tightly regulated as a Swiss watch. You can see that Insulin has many interactions. Pouring in huge glugs of the stuff without respect for these subtle interactions isn’t going to help. Insulin also leads to the production of pro-inflammatory signalling molecules called cytokines. Cytokines perpetuate inflammation, and stress hormones continue to rise. Glucose rises, and Insulin doesn’t work well. What this is doing to all the other hormones is anyone’s guess! It is all code red until the immune system kicks in or the inflammation stops. Lobbing in a few carbs at this point is surely unwanted provocation? 

 Type 1 diabetes helps us explore how this insulin requirement changes during infection. It was surprising that I used almost three times the usual dose of Insulin to maintain, let’s face it, rubbish control. 

I expect this type of metabolism to happen in everyone, diabetes or not. Lack of Insulin and the need to inject just highlights it. Those who do not need Insulin will never know. Type 1 might be of use after all! 

Finally, I knew that I would recover from the infection at some point. And I might become insulin sensitive very quickly. At this point, and it can happen in hours, any excess insulin will drive down the glucose from its plateau. And it can be dramatic from experience. I was injecting large volumes of Insulin and getting nowhere. I had to bear in mind that a massive hypo might be imminent. As soon as I felt better, I knew it was time to start tapering the insulin injection. I would have done this also if my glucose trace had normalised. Being ever vigilant but with patience was the key here. A CGM is so helpful. I was timing nearly all my rapid insulin dosing to ensure the previous dose had worn off before reinjecting. Three hours to five hours is quoted. Everyone will have their own figures. I think that if I had day three again ( and I’m sure that I will get the chance someday!) I would not be quite as bold with insulin dosing. Insulin wasn’t working because the trace was flat whether I chose to inject or not. You might question the need to increase the Insulin at all? I guess it depends on whether the glucose plateaus or rises. I was reacting out of habit, plus I wasn’t in the best frame of mind with a headache and a temperature. Excuses, excuses!

I never used more than 2 unit corrections at night—big doses when asleep would have been reckless. Fourteen units need around 140 g of carbs in an Insulin sensitive person. I knew I was Insulin resistant on day three, so I had more safety. The CGM graph confirmed it. Had I not had an infection and high glucose, I would have taken a different approach: do vigorous exercise and hoover the glucose up by that route. Bypass the long process of waiting for the gut and liver to get their act together. I’m not sure it works in inflammation. And also,  when ill, it is something you just don’t want to do.

The crisis is over, and it is now back to the usual round of fasting, Keto diet, physical activity, daily monitoring, and daily injections. The irony is that the more control you have, the more time you have to keep injections going if you have a pen. That extra eight years is 12000 of them! But a small price to pay to stay well.  

I don’t know how others manage. Please share your story. Every one of the 400,000 people in the UK with Type 1 diabetes will have a different account of how they manage the infection and the insulin demands on the body that goes with it. Those with kidney disease will have a vastly different experience. Those whose diabetes has reduced glucagon sensitivity will have another story to tell. As will those on day 1 compared to those on day 1000. I hope my account will encourage you to tell yours.