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 were, 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 lightheaded. 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 year’s 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 manageable 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).