High Insulin vs High Blood Glucose

There was a very important study done which reflects on the question of which is a better predictor for CHD, a high insulin level or high blood glucose level.

This is important since the standard treatment for advanced diabetes is to increase insulin with the goal being to keep the blood glucose levels low. But is this the smartest strategy? Results from the Helsinki Policemen Study cohort indicate that reducing blood glucose at the cost of increasing insulin levels is not a wise approach (Acta Med Scand Suppl. 1985;701:38-52. Plasma insulin as coronary heart disease risk factor: relationship to other risk factors and predictive value during 9 1/2-year follow-up of the Helsinki Policemen Study population. Pyörälä K, Savolainen E, Kaukola S, Haapakoski J.).

The test subjects were.

982 men aged 35—64 years and free of coronary heart disease (CHD) at entry plasma insulin level (fasting, 1-hour and 2-hour plasma insulin after oral glucose load) … during a 9½-year follow-up

The result was.

Plasma insulin levels showed positive correlations, besides to blood glucose levels, to body mass index, plasma triglyceride level and blood pressure and inverse correlations to leisure time physical activity and objectively measured physical fitness.

So all of that makes some sense if you understand insulin sensitivity. But here is the unexpected part.

In multivariate analyses the predictive value of high plasma insulin with respect to CHD risk was found to be independent of other risk factors, including blood glucose levels.

Insulin levels are a better predictor than blood glucose levels. That sounds exactly the opposite of conventional wisdom. What I find particularly disturbing is that this study was done in 1985.

A similar study which looked at other studies concluded (The American Journal of Clinical Nutrition, Volume 98, Issue 6, 1 December 2013, Pages 1543–1554, https://doi.org/10.3945/ajcn.113.065565. Fasting insulin concentrations and incidence of hypertension, stroke, and coronary heart disease: a meta-analysis of prospective cohort studies. Pengcheng Xun Ying Wu Qianchuan He Ka He).

A higher fasting insulin concentration or hyperinsulinemia was significantly associated with an increased risk of hypertension and CHD but not stroke.


Ketosis and Insulin Levels – Status 2016-08-14

Noticed this morning that my body was out of ketosis. My detection method is the metallic taste in my mouth when I am in ketosis. Now, 2 hours later I am back in Ketosis. My pump delivers .5 U/hr between 4 AM and 12 PM. The rest of the time I am pumping .25 U/hr.

I am not adding any bolus today so that I can try to understand the effects. I took a Metformin 850 mg when I got up so part of the following effect may be from the Metformin. Numbers were up early on but I am watching the numbers over the day.

  • 7:20 – 130
  • 8:20 – 154
  • 9:20 – 130
  • 10:20 – 116
  • 11:20 – 118
  • 12:30 – 127 (physically active – working in the kitchen)
  • 1:20 – 118
  • 2:20 – 108
  • 3:20 – 111
  • 5:40 – 113

I have gotten pretty much the same response when I used Insulin so why use Insulin?


How much Insulin Does the Pancreas Produce? (Reprinted from Aug 2016)

According to (Diabetes Care 1980 Mar; 3(2): 270-273. “Normal” Insulin Secretion: The Goal of Artificial Insulin Delivery Systems? R Philip Eaton, Richard C Allen, David S Schade and James C Standefer).

In the present study, we have determined prehepatic insulin production in six normal men throughout a day that included three typical 750-cal meals. Total insulin secretion for the 24 h was 45.4 ∪, secreted as 10.6 ∪ with breakfast, 13.4 ∪ with lunch, and 13.8 ∪ with dinner. The remaining 7.6 ∪ was secreted during the 9 h night at a rate of 0.85 ∪/h.

This may be why the transition down from 20 units a day to 8 units a day has been a more stressful one (with a couple of “higher” Blood Glucose levels) than any of the previous steps. I am now down into the range my body needs as a baseline.

If my LC-HF diet is keeping me from needing mealtime insulin then the remaining rate of approx .85 U/h would mean approx 20 U/day are needed for the background rate. I am far from a normal man (in so many ways) but I have to imagine that these were people substantially smaller than myself. Maybe 2/3 my weight so my requirements should be proportionately higher. Not a biologist so who knows?

An interesting additional factor is the question of gluconeogenesis during fasting. There was a study done on this as well (Metabolism
Volume 50, Issue 1, January 2001, Pages 47-52. Quantitative contributions of gluconeogenesis to glucose production during fasting in type 2 diabetes mellitus. Alexandre Wajngot, Visvanathan Chandramouli, William  C. Schumann, Karin Ekberg, Paul K. Jones, Suad Efendic, Bernard R. Landau).

Contributions of gluconeogenesis to glucose production were determined between 14 to 22 hours into a fast in type 2 diabetics (n = 9) and age-weight-matched controls (n = 7); ages, 60.4 ± 2.3 versus 55.6 ± 1.2 years and body mass indices (BMI) 28.6 ± 2.3 versus 26.6 ± 0.8 kg/m2.

The results were interesting.

Thus, gluconeogenesis contributed more to glucose production in the diabetic than control subjects. Production and the contribution of gluconeogenesis declined more in the diabetic subjects during the fast.


Status from 2016-08-14

IF was complicated yesterday which means I broke my fasting window a bit. Knew I was going over to visit family/friends but didn’t want to risk high carb food choices (and there were some but some LC choices as well) so I made a Tex-Mex casserole to bring along. Ate at 5 and got home after 10:30 so I had two beers at the very end and past the end of my window. Blood glucose was 125 at bedtime and I didn’t bolus.

Woke up this morning to a bit of a Blood Glucose high of 141. Not too bad at all considering my total Insulin usage yesterday was 12.1 Units down from 100 units day average before IF+LC-HF.

Didn’t do a single extra bolus yesterday and set the pump to only give out 8 units a day now.

What is the typical Insulin dosage for a T1D? That could help answer the question of how well my own pancreas is now producing Insulin and how much more it is being asked to do not that I am not taking as much Insulin.

According to this site (Calculating Insulin Dose).

The general calculation for the body’s daily insulin requirement is:

 Total Daily Insulin Requirement (in units of insulin)
= Weight in Pounds ÷ 4

So for me, that would be about 70 units of Insulin needed per day. They estimate half being for basal and half being for bolus. That means they are expecting to pump 35 units a day for basal. If you are doing LC-HF the bolus component could be ignored. Yet, I am thriving on 8 units a day and not perfect LC-HF. This implies to me that there’s nothing wrong with my pancreas it’s the overtaxing I’ve done to it over the years that made it not be able to keep up with the demand.

Going to keep a close eye on my Blood Glucose today. I don’t see it likely that it will skyrocket up but this big change downward might be a problem because it’s asking a lot more from my pancreas than it has done in years. Or maybe my pancreas has always been working fine but even added with Insulin the cell resistance has been so profound that neither of them are working all that well.

Pumping Insulin with IF

I have been pumping (using short term insulin) but only doing a basal. My pump has a syringe in it that only holds 300 units of Insulin. My Insulin usage rates have dropped from an average of 100 units a day down to less than 20 a day now. Last time I filled the syringe 5 days ago I took into account the lower Insulin usage and only filled up the pump syringe with 200 units. Problem is now the pump still has 80+ units in it. The infusion sites are supposed to be changed every 3-4 (at the most) days.

Still tastes in my mouth like I am in ketosis but not as much as some mornings. Probably the late night beers.

Two Weeks into IF + LCHF (From Aug 2016)

My goal was to reduce my Insulin from the pump and not mess up my blood sugars. I went on Intermittent Fasting and it’s working great. My insulin usage over the past 45 days is:

If diabetes is really a chronic irreversible disease then this should have led to some very bad Blood Glucose numbers from what I have done to my drop my Insulin levels over the last 2 weeks. I have cut my numbers from around 100 to around 25 units. The drop down has been fairly smooth.

The one pop up was my trip to the Frozen Custard shop for a pretty big frozen custard cone. I pumped a lot that day to counteract the custard. Perhaps I should have tried to leave it alone (eat the custard and not pump for it) but old habits die hard.

SO what are my Blood Glucose levels? Glad I asked.

No more erratic highs. Daily average Blood Glucose level before IF was 159. Average after is 122. Very steady numbers and nothing over 150.

So is it working? By every test I have at my hands IF is working fantastically well.

Your mileage may vary.

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.


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.

Is Low Carb Unhealthy?

There was a study done to determine the safety and effectiveness of a Low Carb (LC) diet vs a Calories Restricted Low Fat (CR-LF) diet (J Clin Endocrinol Metab. 2003 Apr;88(4):1617-23. A randomized trial comparing a very low carbohydrate diet and a calorie-restricted low fat diet on body weight and cardiovascular risk factors in healthy women. Brehm BJ1, Seeley RJ, Daniels SR, D’Alessio DA.).

The study was on fifty-three healthy, obese female volunteers.

The LC diet was more than twice as effective compared to the LF diet.

The very low carbohydrate diet group lost more weight (8.5 +/- 1.0 vs. 3.9 +/- 1.0 kg; P < 0.001) and more body fat (4.8 +/- 0.67 vs. 2.0 +/- 0.75 kg; P < 0.01) than the low fat diet group.

OK, so the Low Carb diet lost more weight and fat but was it safe? The study looked at the cardio risk factors and concluded.

Mean levels of blood pressure, lipids, fasting glucose, and insulin were within normal ranges in both groups at baseline.

Their conclusion?

A very low carbohydrate diet is more effective than a low fat diet for short-term weight loss and, over 6 months, is not associated with deleterious effects on important cardiovascular risk factors in healthy women.

So no, not only is Low Carb more effective than Low Fat, but it is also not any less healthy.


McDonald’s $1 Breakfast Burritos

Here is the nutritional information for McDonald’s $1 Egg and Sausage Burrito:

  • 300 Calories
  • 16 g Total Fat 25 %
  • 12 g Protein
  • 26 g Total Carbs 9 %

Up until 2 weeks ago (today) was eating two of these for breakfast. Not a bad deal at $2. Tasty, too.

Let’s double the numbers and see what we get:

  • 600 Calories
  • 32 g Total Fat 50 %
  • 24 g Protein
  • 52 g Total Carbs 18 %

A couple of observations here.

  1. Removing the 600 calories a day would result in under one pound a week of weight loss. I should have only lost 2 lbs in the past two weeks. But I’ve lost 14 lbs. Calorie counting doesn’t work.
  2. The claim that the two burritos are half my day’s fat is based on the old “low fat” diet model.
  3. No recommended daily amount of protein. Interesting.
  4. Most disturbing is the suggestion that I should eat more than 250 grams of carbs a day.

The Recommended Daily Allowance (RDA) numbers are (The Recommended Daily Intake of Calories, Carbs, Fat, Sodium & Protein).

Carbohydrates – 45 to 65 percent of your total calories
Saturated fats to no more than 10 percent of calories
Protein 0.8 grams of protein per kilograms

So if you eat 2000 calories a day they are recommending 900-1300 calories from carbohydrates. That’s 225 – 300 grams of carbs a day. This is deadly advice and the government should get it by now. There’s more than enough evidence that this level is just way too high. And telling Americans to get their carbs from non-refined sources doesn’t match what they see in the supermarket. Substituting wheat bread for white doesn’t do it.