Permission to follow a low carb diet (and fasting)

[Peppergirl]

Well, not really 'permission' as I don't need it, want it or looked for it. But I suppose I've kind of got it now

My diabetes consultation last week was a surprise to me. I was all set to argue how well low carb/keto was working for me and how fasting from breakfast to dinner also works great. However, the consultant firstly said how well my numbers are and I'm doing well. I really don't do this for praise . I confirmed that I low carb and fast. He then said, which surprised me, that he follows a low carb diet and knows how hard it is. He says that there are not many type 1's he knows who follow this so he's interested in it. I was expecting a negative conversation tbh. Discussed food - cheese and meat were mentioned along with my mostly egg, veggie and fish diet. No fruit apart from avocados. Funny as a dietician was sitting in to audit how well the Libre was working for me and did not mention anything about low carb!

He did ask me to increase my HbA1c from 34 to nearer 48. He says that there is no evidence that being nearer to 48 than 34 will give me a bigger risk of complications!? So I'm ignoring this point. Well, he had to criticise something.

I want an insulin pump so I can take less than full units of insulin (half units are the smallest I can manage for bolusing) but it's no go. I managed to get the Libre on prescription in September this year and it was a case of, do you want the pump or Libre? After self funding for a year and desperate for the Libre, I am made up to have this on prescription. But, consultant says I agreed to have the Libre to avoid moving to a pump!? Not sure it works like that but hey ho. I'm alright with it at the moment, but I'll keep trying.

FYI: all blood tests are normal eating low carb. Lots of butter.

 

[kokhongw]

He did ask me to increase my HbA1c from 34 to nearer 48. He says that there is no evidence that being nearer to 48 than 34 will give me a bigger risk of complications!? So I'm ignoring this point. Well, he had to criticise something.

And what is wrong with HbA1c @34 ???

 

[EllieM]

And what is wrong with HbA1c @34 ???

For an insulin dependant diabetic, the consultant is probably worried about loss of hypo awareness, which is a really big deal.
Other than that risk, it's sounds absolutely awesome to me. (I couldn't do it because once my hba1c goes below about 50 I do lose hypo awareness.) Mind you, I'm guessing/hoping that @Peppergirl gets less hypos on a keto diet and presumably she could get her libre to alarm if her blood sugars go too low (either with an add on or with the new version of the libre).

 

[kokhongw]

For an insulin dependant diabetic, the consultant is probably worried about loss of hypo awareness, which is a really big deal.
Other than that risk, it's sounds absolutely awesome to me. (I couldn't do it because once my hba1c goes below about 50 I do lose hypo awareness.) Mind you, I'm guessing/hoping that @Peppergirl gets less hypos on a keto diet and presumably she could get her libre to alarm if her blood sugars go too low (either with an add on or with the new version of the libre).

Yes. Dr Keith Runyan (T1D) has an insightful blog addressing this specific issue.
https://ketogenicdiabeticathlete.wo...-diabetes-mechanisms-avoidance-and-treatment/

 

[Member496333]

Surely to increase your HbA1c you’d need to increase carbohydrate intake and therefore the requisite bolus insulin, thus increasing the likelihood of mis-dosing and going hypo?

Genuine question. I’m far from educated on the ins-and-outs of type 1 management. I would asume you already have a set basal dose?

 

[Peppergirl]

And what is wrong with HbA1c @34 ???

exactly my thought!

 

[kitedoc]

Well, not really 'permission' as I don't need it, want it or looked for it. But I suppose I've kind of got it now

My diabetes consultation last week was a surprise to me. I was all set to argue how well low carb/keto was working for me and how fasting from breakfast to dinner also works great. However, the consultant firstly said how well my numbers are and I'm doing well. I really don't do this for praise . I confirmed that I low carb and fast. He then said, which surprised me, that he follows a low carb diet and knows how hard it is. He says that there are not many type 1's he knows who follow this so he's interested in it. I was expecting a negative conversation tbh. Discussed food - cheese and meat were mentioned along with my mostly egg, veggie and fish diet. No fruit apart from avocados. Funny as a dietician was sitting in to audit how well the Libre was working for me and did not mention anything about low carb!

He did ask me to increase my HbA1c from 34 to nearer 48. He says that there is no evidence that being nearer to 48 than 34 will give me a bigger risk of complications!? So I'm ignoring this point. Well, he had to criticise something.

I want an insulin pump so I can take less than full units of insulin (half units are the smallest I can manage for bolusing) but it's no go. I managed to get the Libre on prescription in September this year and it was a case of, do you want the pump or Libre? After self funding for a year and desperate for the Libre, I am made up to have this on prescription. But, consultant says I agreed to have the Libre to avoid moving to a pump!? Not sure it works like that but hey ho. I'm alright with it at the moment, but I'll keep trying.

FYI: all blood tests are normal eating low carb. Lots of butter.

Hi @Peppergirl, the point about too low HBA1Cs could be that the risk of hypos increase. Whilst high BSLs can affect diabetics over years, hypos can cause damage in hours. The lower you go the less you know, the higher you go the worse you become.
It is a catch-22 but that is diabetes for you !! Best wishes !!.

 

[kokhongw]

exactly my thought!

So the assumption seems to be that HbA1c of 30s means lots of hypos or loss of hypo awareness...is that what you are seeing with your Libre?

 

[kitedoc]

So the assumption seems to be that HbA1c of 30s means lots of hypos or loss of hypo awareness...is that what you are seeing with your Libre?

But is the Libre accurate enough to detect them ??

 

[SamJB]

It's part of the protocol that if you have a low HbA1c they will worry that you are going hypo, because not many T1s achieve that level of HbA1c without frequent hypos. As low carbing is such a rarity among T1s who don't frequent this board, they will naturally assume you are having regular hypos.

Regarding the HbA1c; there's been a few studies, in particular the DCCT trial, which show that the risk of complications is at unity with the non-diabetic population with an HbA1c of around 6.5% (48 mmol/mol). Anything lower is negligible in terms of reducing complication risk.

In the past, I've tightened my control to chase a lower and lower HbA1c. On reflection I was being vain. Anything in the 40s is a win for me and gives me a better quality of life without having to be so tight with my control. Just me personally, though.

 

[Peppergirl]

Surely to increase your HbA1c you’d need to increase carbohydrate intake and therefore the requisite bolus insulin, thus increasing the likelihood of mis-dosing and going hypo? YES! see Dr B.

Genuine question. I’m far from educated on the ins-and-outs of type 1 management. I would asume you already have a set basal dose?

I have to adjust it at a certain time of the month, but I'm OK at it now. I only need to adjust up to 4u. I usually take 8u at 8am.

Still have hypo awareness.

 

[KK123]

So the assumption seems to be that HbA1c of 30s means lots of hypos or loss of hypo awareness...is that what you are seeing with your Libre?

I think that the Drs prefer to advise you to keep your hba1c 'higher' than the 30s because the 'average' of a 30 plus result would indicate to them that you are spending much/some of your time hypo whether true or not. I think the problem is that most of us do not have libres and are therefore mostly guessing when we are low or high on this 'average' ergo they go off that, ie the 'average diabetic'. Even when they see before them a person who can prove (via libre) that they are not having hypos, I cannot imagine them saying to that person, yes, carry on aiming for the 30s, all you get from Drs is generic advice, the blurb from the text books. As individuals I think you should take responsibility for yourself on this issue, if you know your readings are fine throughout then you are the one managing your own risk, just don't expect a Dr to go along with it. Maybe if they give us all a libre their advice might change over time as we would have more accurate results. I feel like I'm guessing outside of the times of my finger pricks. By the way, THANK you for the Keith Runyan blog, just read it, massively useful.

 

[Deleted Account]

Surely to increase your HbA1c you’d need to increase carbohydrate intake and therefore the requisite bolus insulin, thus increasing the likelihood of mis-dosing and going hypo?

Genuine question. I’m far from educated on the ins-and-outs of type 1 management. I would asume you already have a set basal dose?

Not necessarily - when treated with insulin, we can adjust our insulin dose to achieve a higher target BG.

 

[Member496333]

Not necessarily - when treated with insulin, we can adjust our insulin dose to achieve a higher target BG.

But if you’re not consuming dietary glucose then surely your bolus dosing would already be minimal?

Not trying to be argumentative, just genuinely curious. I can see the logic in adjusting basal in order to get a higher baseline. That’s if I’m understanding the mechanics of T1 correctly.

 

[evilclive]

But if you’re not consuming dietary glucose then surely your bolus dosing would already be minimal?

Not trying to be argumentative, just genuinely curious. I can see the logic in adjusting basal in order to get a higher baseline. That’s if I’m understanding the mechanics of T1 correctly.

Dropping the dose of either will bring the HbA1C up. There's still bolus even for low carb. But yes, basal will probably be the better one to drop if running steady and wanting to bring it a little bit higher.

This is just the mechanics - I'm not suggesting it's necessarily a good idea.

 

[Robinredbreast]

Surely to increase your HbA1c you’d need to increase carbohydrate intake and therefore the requisite bolus insulin, thus increasing the likelihood of mis-dosing and going hypo?

Genuine question. I’m far from educated on the ins-and-outs of type 1 management. I would asume you already have a set basal dose?[/QUOTE

I normally have a small yogurt for breakfast ( 5 to 7 carbs) so, depending on what my BS is like before I eat, then I take 1/2 to 1 unit of Insulin and it also depends on how active or inactive I will be be ( normally active.
If I have scrambled eggs and a piece of bacon, protein, I will normally need 1 and 1/2 units of Insulin. It's a minefield at times and does need a lot of thought to get the right balance for the foods eaten + activity too.

 

[michita]

Thank you for sharing this. It's really good news. I'm also lowcarbing and keeping normal level, but haven't mentioned low carb diet to my consultants. I had a bad experience with doctors and nurses' negative reaction to low carb diet in the past, I feel very cautious. My driving licence is due for renewal this year, don't want to take any chance and I see different consultant every time it's difficult to build trust. To be honest none of the consultants Ive seen so far so far impressed me in any way ....

Anyway it's nice to hear about doctors understanding the benefit of low carb diet for type 1s.

 

[kitedoc]

I think that the Drs prefer to advise you to keep your hba1c 'higher' than the 30s because the 'average' of a 30 plus result would indicate to them that you are spending much/some of your time hypo whether true or not. I think the problem is that most of us do not have libres and are therefore mostly guessing when we are low or high on this 'average' ergo they go off that, ie the 'average diabetic'. Even when they see before them a person who can prove (via libre) that they are not having hypos, I cannot imagine them saying to that person, yes, carry on aiming for the 30s, all you get from Drs is generic advice, the blurb from the text books. As individuals I think you should take responsibility for yourself on this issue, if you know your readings are fine throughout then you are the one managing your own risk, just don't expect a Dr to go along with it. Maybe if they give us all a libre their advice might change over time as we would have more accurate results. I feel like I'm guessing outside of the times of my finger pricks. By the way, THANK you for the Keith Runyan blog, just read it, massively useful.

You have to remember that hypos can increase the risk of motor vehicle accidents. Would any doctor be prepared to sign a continuance of driver's license with such low HBA1Cs? They have a responsibility to the community at large to not certify drivers who may be at risk.
Doctors will not be using just knowledge out of a textbook but I agree not all are up-to-date !!

 

[kitedoc]

But if you’re not consuming dietary glucose then surely your bolus dosing would already be minimal?

Not trying to be argumentative, just genuinely curious. I can see the logic in adjusting basal in order to get a higher baseline. That’s if I’m understanding the mechanics of T1 correctly.

Surely is a dangerous word. It may assume too much. Protein intake can affect BSL also and the challenge is whether to use bolus or basal or both to deal with this. And insulin sensitivity may vary throughout the day so what is a 'good' basal rate and carb to insulin ratio (for boluses) in the am can differ from that in the pm. Also correction doses of short-acting insulin for dealing with high BSLs may differ in mmol/l BSL to insulin ratio over the 24 hours. Life was not meant to be easy !!

 

[Mbaker]

But is the Libre accurate enough to detect them ??

The Libre I think is good for trending. On Libre accuracy, my numbers can be ridiculously low, so I would not trust it, for the important decisions you need to make.

Libre 2 will at least have alarms.