Status from 2016-08-13

My morning blood sugar at 6:30 AM was 115. Normally I would do a pump bolus but today I decided to skip the extra Insulin. Three hours later (after my shower) the number is 138. I also lowered my basal amounts by 0.25 units an hour a few hours ago so that can account for some of the rise. I am going to once again not bolus (give more Insulin). Perhaps my body takes a while to kick in providing insulin on its own when it has been habituated to externally provided Insulin.

Also I have noticed that after a shower my blood sugar seems to be higher. Not advocating going European or some crazy thing but we do seem to take a lot of showers in the US. I’ve noticed that the Blood sugar after a shower tends to drop faster than the Insulin I have provided would indicate that it should.

If this is still a manifestation of the Dawn Effect then even that will decrease with time.

So I waited an hour and measured again (with no bolus at all this morning). Instead of seeing a high number I was back to 113. If I had given Insulin it would have not dropped so quickly.

INSULIN IS KILLING ME!!!

End of the Day 2016-08-13

Did a couple of things today. Decided to double down on my level of Insulin drop. Lowered at first to 12 units per day and then dropped to 8 units a day. Did no boluses in spite of a couple of “higher” numbers (130’s 2 hours after my LCHF meal). Decided to remeasure a little later and the numbers were down. End of the day my number was 125 which felt pretty good considering how far down I dropped my Insulin for one meal.

Let’s see how things look in the morning.

Am I in fat burning (ketosis)? (From Aug 2016)

Freeing up fat is the goal of any diet.

If your body has burned enough of the fat that you have eaten and it has freed up the easily accessed stores (the fridge in Dr Fung’s analogy) then it starts burning the fat from your cells.

This is called ketosis. From the WebMD site (What Is Ketosis?).

Ketosis is a normal metabolic process, something your body does to keep working. When it doesn’t have enough carbohydrates from food for your cells to burn for energy, it burns fat instead. As part of this process, it makes ketones.

The article continues.

For healthy people who don’t have diabetes and aren’t pregnant, ketosis usually kicks in after 3 or 4 days of eating less than 50 grams of carbohydrates per day. That’s about 3 slices of bread, a cup of low-fat fruit yogurt, or two small bananas. You can start ketosis by fasting, too.

There are ways to detect ketones. The most accurate measurement is a blood test. Another measurement is easier and cheaper, a ketone test strip. The ketone test strip is activated by your urine.

I got a box (with a bottle in it) of 50 Relion Ketone Test Strips at Walmart in the pharmacy for about $7. That’s less then 15 cents a test.

Here’s a good article on using the sticks to measure your state of ketosis (An Overview of Ketone Testing Products).

For me personally, there’s another way. Taste in my mouth. If I am in ketosis my mouth tastes metallic. This site includes that along with other symptoms (What is Ketosis?).

a metallic taste in mouth
strong smelling urine
random bursts of happiness (it’s weird, but it’s true!)
decreased appetite

If you are in doubt use the strips. I am in ketosis even after eating dinner (a LCHF dinner).

When the Strips stop working (Why You Need To Stop Worrying About The Color Of Your Ketostix).

 

Atkins Snacks as a way to get Low Carb? (Reprinted from Aug 12, 2016)

Walking down the Sam’s Club aisle (or the Pharmacy Aisle at Walmart) you can spot the Atkins snacks. This was my favorite.

I was eating those for lunch before I started the IF. I would typically eat two during the day. They didn’t send my sugars super high, but they didn’t let them drop down either. And I quickly found that I couldn’t use the net carbs of 3 grams listed on the label. It was just way too low when I was using the Insulin pump. I had to set the pump to the total carbs minus the fiber count to not have them mess me up. Trust your body over any label.

I think the reason is sugar alcohols. Atkins, likes other low sugar snacks, replaces sugar with sugar alcohols. Picking my favorite bar as an example, the Atkins Caramel Chocolate Nut Roll, they show the nutritional information as:

On the face of it this looks great. Let’s do the math.

  • 7g (Protein) * 4 cals/gram = 28 cals from Protein
  • 2 g carbs * 4 cals/gram = 8 cals from carbs

(My guess is Atkins doesn’t list the fat number on the front since most people still believe in Low Fat diets.)

Where are rest of the calories? Here is the detailed chart.

Fat presents 13 grams or 52 calories. Still short on calories. Turns out there are different numbers between Atkins and the nutritional label (forced by law). Atkins doesn’t count sugar alcohol as a carb in the Atkins Diet. They also don’t consider fiber as a carb. So from Atkins perspective the bar is only 3 net gram of carbs.

Atkins nutritionist writes (Ask the Nutritionist: The Scoop on Sugar Alcohols):

Sugar alcohols are not fully absorbed by the gut, which means they provide roughly half the calories that sugar does [ed: per weight]. Thanks to this incomplete and slower absorption, there is a minimal impact on blood sugar and insulin response. Because of this, sugar alcohols don’t significantly interfere with fat burning, which makes them acceptable on Atkins.

To calculate Net Carb count with sugar alcohols, simply subtract grams of sugar alcohols (including glycerin), as well as fiber, from total grams of carbs.

But I can tell you from my own experience the Sugar Alcohol used in these particular bars doesn’t act like that in my body.

Is it the fiber? The FDA estimates the amount of caloric contribution due to bacterial degradation of fiber at about 1.5 calories per gram of fiber. That would correlate to 1.2 calories from the fiber. Not enough there.

This article does a good job of analyzing the idea that Sugar Alcohols provide no net carbs (Can You Really Exclude Sugar Alcohols, Glycerin, Polydextrose, and Fiber?).

According to the article, the type of sugar alcohol matters. The label has two pieces of information with respect to sugar alcohols. This particular label lists 0 grams of glycerin. The sugar alcohol is hidden in the list of ingredients as Maltitol Syrup.

Some of the Atkins products use glycerin as the sweetening agent which the site says isn’t a problem. But this particular product uses Maltitol Syrup and the article says that is not a good sugar alcohol to use. The site states:

The glycemic index of one of their primary ingredients — maltitol — is higher than that of pearled barley or kidney beans.

Is there a solution?

The other ingredient glycerin had no glycemic load. The article concludes with:

You need to check which sugar alcohols are used in any low-carb products you buy. Just like different carbohydrates affect blood glucose to different degrees, so too do some sugar alcohols.

So, the other bar I would eat listed 5 grams of sugar alcohol and they were all glycerin.

Another article (Sugar-Free Labels Can Be Deceptive) reaches the same conclusions.

A Recommendation

I have also had the (Chocolate Peanut Butter Bar) and didn’t have a problem with my blood sugar rising. It also didn’t taste nearly as good. 8 of the 11 grams of sugar alcohol are glycerin. So the secret with Atkins bars is to look at the sugar alcohols and at the number from glycerin.

Status Aug 12, 2016 (Reprinted)

I had some good news this morning when I stepped onto the scale. My weight had dropped another 5 lbs. 10 lbs in 2 days. Looks like a switch got thrown to get rid of water weight. Plus, it’s been hot and humid here.

My insulin use was way down, too. Two days ago my insulin use was 42.0 and yesterday my insulin use was 29.2. My waking blood sugar was up a bit at 132 and it bounced up to 140 by a couple of hours later but that’s not abnormal for me.

My meal yesterday was satisfying. In fact, I ate until I felt sick of eating. Sick to my stomach of eating.  My total calorie count was too low at 1146 cals. I tried hard to eat Lower Carb and Higher Fat but only got to (% cals from source)

Carbs 11.6%
Protein 22.6%
Fat 42.3%
Alcohol 23.5%

I had less Craft beer than the day before (2 vs 3). However I did feel the effects a lot more than the day before. I attribute this to having less carbs to flatten out the response to the beer.

 

Status from Aug 11 2016

Great start today

My weight was down 3 lbs from yesterday.

Set a New Basal Rate of .25 units per hour less.

Woke up at 5 AM to a Blood Glucose of 111. Did the bolus to get me from 111 down to 105 (just a few tenths of a unit). Took my number two hours later and it had jumped to 143. Rather than doing a 3 unit bolus I decided to do 2 unit bolus. Will be interesting to see the results I get. Wonder what would have happened if I had not done the few tenths of a unit bolus.

Yesterday’s Meal

I did a (rare for me) calorie count of my dinner last night. At 1661 calories. Did the percent of calories from various sources and got:

Carbs – 16.9%
Protein 11.31%
Fat 36.6%
Alcohol 35.2%

That’s a day of counting calories and taking into account the types of calories.

 

Intermittent Fasting (IF) (Reposted from Aug 2016)

How does the Intermittent Fast work? Here’s another video by Dr. Jason Fung on Intermittent Fasting.

Dr Fung ties together some related points.

  1. The Biggest Loser TV program. Contestants have been admitting it didn’t work for most people. Eat less, move more diets. Problem with this approach is that it lowers your metabolism and you need less calories after the diet. Calories in excess of that lowered amount get added to the person as weight. They can’t also keep up with the 5 hours of exercise a day.
  2. Comparison group is people who have stomach stapling surgery. This procedure has dramatic cure rates for T2D. Difference is that it doesn’t reduce the metabolism like the Biggest Loser program. Metabolic slowdown has been well known for 100 years.
  3. Calorie model treats us as one storage location but we aren’t like that. Incorrect model.
  4. Two storage locations model (analogy: refrigerator vs freezer in the basement).
    Short term storage – Eat food > Increase Insulin > Store sugar in liver/produce fat in liver. Limited capacity.
    Deep storage – No food (Fasting) > Decrease Insulin > Burn sugar/fat in liver
  5. Fasting is the only way to access the deep storage (analogy: the freezer). Insulin is what stops the movement out of the cell.
  6. Insulin resistance locks away the deep storage in the cells.
  7. Reduced calorie “Women’s Study” showed the calories in/calories out model doesn’t work. It ignores the role of insulin.
  8. Fasting doesn’t burn muscle. It burns fat stores. It is against the way we were designed. Repeated fast/famine cycles in our history would have produced all fat people rather than thin people.
  9. Low Carb and fasting as the intervention which empties out the fridge which allows access to the fat in the cells.
  10. We were built to live through famines. We get energy from the fat stores in our bodies to go solve our famine issue.
  11. Fasting does not put you into starvation mode. Reducing calories does that, not fasting. Over four days of fasting metabolism increases.

Part 2

 

  1. You will lose weight when you fast. Even for intermittent fasts.
  2. Fasting is simple. Rather than doing something (buy special food, etc) you do nothing.
  3. Fasting is free. It’s what you are not spending money on.
  4. Fasting is simplicity. No efforts (shopping, cooking, cleaning).
  5. Fasting is flexible.
  6. Fasting can be added to any other diet. Low Carb and fast go along well.
  7. Should have the proper medical supervision (good luck with finding that). Dr Fung’s practice has a 9 month waiting list.
  8. Fasting has been done for 5000 years that we know about.
  9. All major religions practice fasting.

Dr Fung’s message really hits home for me. I’ve been looking around for evidence to the contrary. Dr Fung reached his conclusions after years of treating kidney patients the old fashioned way and watching them get sicker.

His key insight is that high levels of Insulin is the problem not the solution to T2D. His second insight is that Intermittent fasting is an effective treatment for T2D.

Case Studies

Dr Fung has videos of patients who have gone from 100 units of Insulin a day down to zero units. Other doctors have case studies as well but there’s something particularly appealing about Dr Fung’s patients. They are older and in declining health due to T2D. They are on 100 units a day or so. Not the easy cases other examples contain.

Mayo Advice #4 – Ask the doc for more pills (Aug 2016)

Here’s the full text of this next piece of advice (Avoid weight gain while taking insulin) from the Mayo Clinic website.

Ask your doctor about other diabetes medications. Some diabetes medications that help regulate blood glucose levels — including metformin (Fortamet, Glucophage, others), exenatide (Byetta), liraglutide (Victoza) and pramlintide (Symlin) — may promote weight loss and enable you to reduce your insulin dosage. Ask your doctor if these or other medications would be appropriate as part of your diabetes treatment plan.

I like the goal – reducing Insulin dosage. When I started Insulin my doctor wanted to take me off Metaglip. Only part of that made sense. The Glipizide part of Metaglip is a Sulfonylurea which stimulates the release of more insulin from the pancreas. But we’ve already determined that too much insulin is the problem. Sulfonylurea drugs also decrease insulin resistance which they would pretty much have to do in order to help the extra insulin work.

The diabetic care nurse knew more about the drug than the doctor did. I was able to convince the doctor to prescribe Metformin which the doctor was convinced could not help since my pancreas (he said) no longer produces insulin. He clearly had the meds mixed up. But he has told me since then that as long as it is working for me (and it is) that he will keep prescribing it.

I was on Byetta (Exenatide) which was getting decent results when the diabetic nurse recommended I go to the “gold standard” of care which is insulin with the pump. The mechanism of Byetta is (wikipedia source).

  1. Exenatide augments pancreas response
  2. Exenatide also suppresses pancreatic release of glucagon in response to eating…
  3. Exenatide helps slow down gastric emptying
  4. Exenatide has a subtle yet prolonged effect to reduce appetite…
  5. Exenatide reduces liver fat content

Byetta has some side effects that bother people enough to get them to stop taking it. It’s a shot, like Insulin, so there’s that inconvenience.

I have no experience with the other classes of drugs but if the drug’s net effect is to increase the level of insulin in your blood then it’s bad. Good that it is reducing your blood sugar. Bad that the insulin is what does the damage.

From what I can tell, Metformin is one of the best and it only gets you half way to normal. So yes, ask your doctor about these drugs but focus on the question of whether or not the drug increases the insulin level in your blood. If so, be skeptical.

 

Dietary Control Blood Sugar via Counting Calories (Reprint from Aug 2016)

The Mayo Clinic site we saw earlier recommends counting calories as a way of preventing weight gain when taking Insulin. Sounds good in theory. After all energy out has to match energy in. If you take in more energy than you put out you gain weight. If you take in less energy than you put out then you lose weight.

The only problem is that it is much, much more complicated than that. Here’s what I see as both sides of the question.

Positive Side of Counting Calories

  • Can be reduced to simpler terms, like exchanges.
  • Can eat until we reach our calorie limit and then stop for the day. This produces an extended fasting time which is good.
  • Being aware if how much we eat by logging can show we are eating a lot more calories than we think we are.

Negative Side of Counting Calories

  • Calories don’t take into account the type of calories consumed and their impact on blood sugar control. A packet of white sugar and a piece of lean chicken breast could have the same number of calories but a completely different response in a T2D. We don’t process them at the same rates (previous BLOG post on this).
  • As an example of the type of calories mattering a controlled study was performed which showed the higher protein and lower carbs group had improved insulin sensitivity and cardiometabolic profile in overweight women. So if the advice is to count calories with the goal of restricting calories then the type of calories need to be considered as very important.
  • The type of calories consumed also affected the bounce back after the diet (Study here: Diets with high or low protein content and glycemic index for weight-loss maintenance). Bottom line is higher protein is better.
  • Counting calories is the standard weight watchers approach and thousands of other companies which want to sell you books and meal plans. It doesn’t work in the long run except for getting repeat customers.
  • My own experience is that I still pick up stuff I buy and look at the labels to see what is in them. I don’t eat bread very often and stay away from most carbs and still have way too much weight.
  • Most of the people I know comment on how I never eat. It’s not like I am secretly binging either. I have been on many restricted calorie diets.
  • The Biggest Loser show does the most extreme intervention of restricted calories and exercise possible and many/most of the people gained the weight back. The ones that only had a modest gain were those who worked as trainers.
  • The biggest problem is the reduction in our metabolism that inevitably happens with a restricted calorie diet. This is a long term effect. That is my problem personally and with this sort of diet. In the case of the Biggest Loser show the study concluded:

By the finale, all their metabolisms had significantly slowed down due to the weight loss from diet and exercise routines, and their bodies were not burning enough calories each day to maintain their thinner frames. This was not a surprise to scientists, because studies have previously found that everyone’s metabolism slows down after a diet. But it was shocking that over the next several years, their metabolisms did not recover and return to the normal rate for a person of their size. Instead, their metabolisms became even slower, which caused the pounds to pack back on.

That is the key and the problem with the counting calories form of dieting. Sure you can lose weight but your metabolism drops.

The advice I give my own children is to not go on a diet to lose. Weight. They will gain the weight back and then more when they permanently alter their metabolism.

Reducing Insulin Results in Weight Loss (Reprinted from Aug 2016)

So if insulin causes weight gain then it would seem to logically follow that reducing insulin will result in weight loss. We know this is the case because if we just stopped taking our insulin we would lose a lot of weight fast*. However, getting rid of your need for external sources of Insulin is a great goal.

In my case, I lost 50+ lbs in six months before I was diagnosed with T2D. That was the body’s natural way of trying to handle the high blood sugar problem. Adding medications just pushed my weight up. That was true with just Metformin. Could this be because the study that the Metformin causes weight loss concept was built on a study of psychiatric patients not on diabetics? Other studies based on pre-T2Ds are equally questionable since their weight loss could be due to poorer control over their blood sugar levels.

This all makes the advice of the typical MD even more absurd when they tell you that “When you get your sugars in order you will be able to lose weight.” How is that even remotely possible when I have to use astronomical amounts of insulin to keep my sugar under control?

Standard Warning

*Stopping your Insulin cold turkey can be bad and people die from doing this. I feel like I need to say this because there are dumb people out there. Don’t drop your Insulin alone for weight loss even if that weight loss itself is good for you. There are other ways. Make sure you monitor your blood sugar level closely no matter what treatment you use.