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 seen that some patterns are emerging. So, now that I have found some patterns, it is an excellent 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 Type 1Type me.
I have never wholly 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 definite 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 an 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 possibly can. And the best way to do that is through a ketogenic diet.
And what of physical activity? We all have our 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 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 tasks. 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 colon, 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 are 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 a 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 glucose all night, a flat trace, but higher than 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 continuously.
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. 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 merely 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 amounts. 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 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 hypothalamus, 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, two major hormones involved in glucose regulation. Glucagon increases blood glucose, and insulin does the opposite. Some people have suggested that it is the glucagon that drives diabetes by increasing glucose levels. It is the inability of insulin to function correctly 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 a more significant response to insulin production.
So, the vagus nerve is vital in diabetes control. 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.
I had recovered sufficiently the stress in the previous six weeks to be feeling okay about the run. The 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 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? Okay, 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 four laps around 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 causing 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 essential 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 ravenous. A habit, I suppose.
So, there we are—possibly the best control ever. In total, 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. Sufficient and straightforward 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 just extended fat burning. Boring beta-oxidation. Consuming only 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 were 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, try starting with high glucose levels in the teens, reduce nighttime basal dose, and take regular gels after an hour. I haven’t done that for a while. Back to ‘extreme diabetes’ it is!