Very low carb diet and BG levels

Hi all,

Just for anyone interested I thought I could post my experience on changing to a low carb diet (<40g per day max). I have done this before but got side-tracked by...carbs. So here are some results/comments for those interested:

Week before 7-day average = 12mmol/l
First week of <40g carbs ed = 6.7
Last 5 readings:7.0, 6.1, 5.8, 8.2, 6.6

Previous insulin regime: 24IU lantus/glargine (basal bolus) ed during week; 28IU on weekend. Novorapid with carbs/as needed
Current inslulin regime: no insulin during week. 2-4IU on weekends

Exercise regime (remained the same): Every weekday 1hr in morning consisting of 30min weights, 30 min cardio OR 45min weights + 15min cardio in morning with 30 min cardio at lunchtime (cardio is usually running @ 12kph)

Diet: Pervious was carb heavy, typical diet although tried to remain healthy. Low on fats and trying to avoid simple carbs. New diet only has carbs from vegetables, higher fat content overall. No milk (but do have other dairy products).

Noticable effects
- Digestion - an improvement in bloating (reduced), fewer bowel movements however no issues with constipation (!). Was worried about less fibre from things like oats/rice etc, but this has not been an issue.
- Satiable - can go longer between meals without eating. Feel fuller.
- Cravings - now down to 0. Had a really tough time from days 5-7 however this is expected at this time and also it was the weekend (where I'm used to being a little less strict with diet!). Do not get the ravenous feelings that were associated with a little bit hypo or hyper
- Energy levels - feel far more awake in morning and evening - completely different to how I was eating carbs and on isulin. Feel like I need less sleep. With carbs and poor BG management I got extremely tired, have a long commute which was difficult. Lacked much energy especially in afternoons. Hard to get up and took longer to wake compared with low carbs/no insulin
- Hypos/Hypers - none. highest been was 12mmol/l however this was at start of diet. Regularly around 7mmol/l and lowest has been 5.3.
- Attitude - much more mellow, less easily angered or getting in bad moods.

Overall, the range of BG levels I achieve using this approach for me is very stable which has led to me feeling 100x better in general. Almost how I felt before I was diagnosed although this was a long time ago so my memory may be skewed!! My BG levels are excellent, there are no hypos as no insulin used and no hypers as combination of very low carbs and high exercise means my levels stay stable. I feel it is very positive for me and hope to be able to maintain long term. I have lost 2kg of weight however I imagine this will stablise. I am around 10-12% body fat so have no need to lose excessive amounts of weight.

I would not recommend this diet to everyone or this approach (i.e. please do not stop taking insulin hearing this!) as you really have to know how your body reacts to insulin (both long and short), know how your body reacts to exercise, and in combination with insulin, and have a good knowledge of carb levels in food to keep tight under the 40g amount. You also have to be well prepared as it is difficult to just pop to the shop and buy some food if you are sticking to this. Finally, to be able to eliminate insulin you have to dedicate a decent amount of time to a good level of somewhat intense exercise most days of the week.

Hopefully some will find this interesting! I will have to see what my HbA1c levels are although having moved recently I have been rubbish at getting to the hospital for diabetic appointments...!

JD

Scardoc - no I have IDDM so am fully type 1. My previous readings I regularly tested over 20mmol/l with carbs (and stress from work!) and had much variation (drops and rises - but rarely any bad hypos as I have very good hypo awareness).

This is the amazing thing - that I am type 1, have had no insulin for 10 days (apart from a few IUs of basal bolus on weekend) and can sustain an average blood sugar level in those 10 days now at 6.6mmol/l.

This is why I said this approach is certainly not for everyone. I respond very well to exercise which is why previously on weekdays I took less basal bolus than weekends (when I do not do as much exercise). I exercise a lot - often twice a day but also importantly (something I think is overlooked by GPs and specialists) I have a higher than normal muscle mass from 13 years of weight training every week day. Combining this with cardio means I can completely ditch my insulin whilst on this diet. I eat about 20-30g carbs per day, at most 40g and since the 2nd day on the diet I have not tested above 8mmol/l nor below 5.3mmol/l and most readings are in the 6's.

People underestimate how muscle mass can influence blood sugar levels and how more (particular fibers associated with short bursts of energy often preferentially laid down by weight lifters) muscle when trained and exercised, can result in better blood glucose control and lowering abilities. I remember having an argument with a specialist about this who was quite obnoxious to me about it - then he found out I had a PhD in cell biology and shared lab research with a diabetes group which was an international leading lab in the field and he decided to somewhat accept my points. Exercise does not simply affect insulin sensitivity - there is a completely separate pathway to insulin for transport of glucose from the blood into muscle cells (via GLUT4 transporter translocation to the membrane if you wish to read more about it) which involves different proteins and has different effects. The point is exercise does not need insulin to alter (lower) blood glucose and with increased muscle mass this can result in greater blood-lowering properties. I feel I am human proof of that.

J

Hi Sam,

That is why I was careful to say:

"I would not recommend this diet to everyone or this approach (i.e. please do not stop taking insulin hearing this!) "

I certainly would not recommend anyone stop taking insulin - was just passing on my experience.

From a personal point of view, the research I have done suggests to me that insulin is not necessary for a healthy functional body as long as blood glucose is in control. There are numerous mechanisms by which amino acids can be transported into muscle cells and insulin is not the only method for this. There are plenty of other anabolic hormones that will do this. I assume you are referring to mitosis and not meiosis? I have worked in oncology research for over 5 years and personally again, have no concern with the lack of insulin - but again I must emphasise this is my own personal thoughts and am certainly not ever recommending any IDDM remove an insulin dosing regime. Wiki can be misleading and most of the properties listed are covered by other hormones and molecular functions within the body. Furthermore, there is plenty of research going into alternatives to insulin (e.g. the approach of leptin) with the mindset to remove the need for a Type 1 to inject insulin thus if there was real concern that no insulin would be very harmful that research would be flawed from the outset and should not be taking place.

Furthermore based on the research I have done over time on this issue, my feeling is that a stable blood glucose level (every time I have measured this week I have been over 6.0mmol/l and under 7.0mmol/l) with no insulin poses to me less health risk than large flucuations regularly in my BG levels. This is where the real damage is done and I struggle with carb-centred diets (and if I take insulin with the amount of exercise I do on a carb-low diet).

I have heard and known of others who have also stopped insulin but it is difficult to find anything in the literature about it, although my busy schedule has not allowed me to spend the few hours searching journal articles to find case studies like this!

All in all, you make a good point about potential risks and the very good point that people should not read this and think they can or should do the same as I have - that is why I was careful to state that in my original post and again emphasise it here. I repeat - I would not recommend that anyone come off insulin in any circumstance without first consultation with a professional physician who recommends it is safe to do so.

No need to apologise - important to remember people are influential by what is written on places like these and to emphasise the need for individual caution! Certainly is well such an extreme approach should not be considered at all for those who have not stopped their development and reached adulthood.

There are a few studies on leptin relating to diabetes, most are animal models with the hope to bring it to the clinic from what I remember. EG:

http://www.nature.com/nrd/journal/v11/n ... d3757.html

http://www.sciencedaily.com/releases/20 ... 161835.htm

I'm sure there are others!

J

Hi VickiT,

My profile must be very much out of date!? I've been a type 1 for 6 years but it was quite late onset for me as was in my mid-20s.

I went through the honeymoon phase as all type 1's do, where I was initially on less insulin then almost suddenly, had to massively increase. I remember it well - was in Paris and went out for a meal, nothing too carb-y and came back to the hotel, felt like **** and checked my readings - the monitor said "hi". Despite at first thinking it was just being friendly, I soon found out this meant it was >33mmol/l! So I took 20IU of novorapid. 1hr later, and about 10 toilet trips it was still saying "hi" so I took another 20IU. About an hour later and still feeling so awful it read 32.5mmol/l. I took another 20IU and in the morning I woke up and it was in the 6's. 60IU of insulin needed!!

I do believe I was pre-diabetic for a while, and kept it at bay with my lifestyle of heavy exercise and high protein diet I had adopted as a weight-lifter. It all happened after a bout of Epstein-Barr Virus in which I developed hepatospleenomegaly, insane tiredness and abnormal blood panels (lipids, Liver markers, etc). I have always behaved like a type 1 since the diagnosis following the downward trend from pre- to full-blown type 1.

I sincerely believe that the ability to go very low carbs (20-40g ed) and still not need insulin for me personally while reamaining between 6-7mmol/l at all tests I have done since day 3 of the diet, is down to exercise and my muscle mass. I have always said for a while that I believe the more muscle you have, the more impact exercise has on your blood glucose levels. I exercise a LOT, often twice per day during the week plus my lean body mass is above average (e.g. I tend to be classified as obese/overweight by BMI despite having a 30-32" waist...) due to 12-13 years of heavy weight lifting.

In fact, something I have believed for years due to the mechanisms of exercise on BG levels independent of insulin seems to be apparent now in more recent research. Have a read of this article:

http://www.eurekalert.org/pub_releases/ ... 040413.php

It certainly advocates the use of developing fast-twitch "white" muscle fibers through resistance training as a beneficial approach to helping control diabetes.

Every aspect of the analysis of my various clinical tests over the last 6 years since diagnosis with Type 1 has confirmed that I am a type 1 so have no reason to believe that is not true. However I am sure we are often very limited by classifying people so rigidly when perhaps in the field we do not as fully understant the various subtle differences from person to person with this disease. Therefore I must return to what seems to me to be the most logical explanation as to why I can control it like this - exercise and muscle composition.

To add further proof I guess to my theory, when I take off a week from exercising my BG goes very high and I have to prepare for this by massively increasing my basal bolus and novorapid insulins.

Hope that makes sense,
J

Interesting read there Phoenix, thanks for that. I would agree potentially with a lot of what was said in that article, disappointing that there are only about 6 references in the paper though.

With regards to GLUT4 receptors - I used to work in a lab that extensively and practically soley worked on this protein and its trafficking. I saw with my very own eyes the effects insulin has on its translocation to the plasma membrane. There is always some GLUT4 at the surface of the membrane but there are large internal stores. Insulin causes these internal stores (which make up the majority of GLUT4 in the cell) to dramatically translocate from the storage compartments to the cell surface, and take up glucose. Now whether experimentally these insulin levels used in such experiments are too high to be above thresholds these authours mention I do not know. Thus I wish that paper offered more references.

Perhaps I still have some residual endogenous insulin production - many people may well have this. However if that is the case then others who have had type 1 a similar amount of time as me would in theory be able to see similar results that I have. I would say my insulin requirements when not on a low-carb diet match what many other diabetics/long-term type 1's need, implying that I cannot be too different to them in terms of endogenous insulin production. However very simply, someone with more muscle cells will have more GLUT4 by definition therefore more glucose transport anyway. As exercise stimulates GLUT4 trafficking to the surface and increases its presence there, it stands to reason someone with higher muscle mass will clear glucose from the blood. Now the effects of exercise on glucogon and perhaps the gluconeogenesis that occurs in the liver must also be considered, and I would say these are favourable in states of exercise, to the diabetic.

Vicki - I think higher muscle mass does help however it is also the type of muscle mass and even the type of exercise you do. If you get a chance read the link I posted above. I personally do not follow anyone's diet in particular and have always had my own training regimes, but would advocate High-Intensity Interval Training for extended blood glucose lowering effects, along with weight training. You do not have to pack on a lot of muscle to see effects, and despite what many women think, most women will find it hard to put on "bulk" given their hormonal expression.

In terms of diet an example day would be something like this for me:
5am breakfast: 2 eggs scrambled with Almond milk (unsweetened), grated cheese, smoked salmon. coffee with almond milk
Gym from 6:30-7:30 - weights mainly, some cardio
8:30 - whey protein shake in water
10:30 - coffee with almond milk
12pm - cardio for 45min.
1pm - roast veg in olive oil and spices (swede, turnips, courgettes, mushrooms), few olives, tuna-mayonnaise, home-made soup
4pm - 2 tomatoes sliced with basil, oreganno, sea salt and olive oil. 1 piece of smoked mackeral
7:30pm - chicken with full-fat creme-fraiche and pesto sauce, broccoli or stir-fried vegetables

If I get hungry in between I might have a few nuts, another protein shake, or some reduced fat cheese. Just an example of a typical weekday for me.

J

By the way I forgot to mention - I regularly have been checking my blood ketones lately and they vary between 0.6 and 1.1 so nothing dangerous or suggestive of anywhere near ketosis etc.

J

I thought it was also worth pointing out this review of ketones, low carb diets and textbook myths. It is very informative and useful:

http://www.jissn.com/content/1/2/7

The author makes some very interesting points and observations from the literature.

In comparison with glucose, the ketone bodies are a very goodrespiratory fuel. Whereas 100 g of glucose generates 8.7 kg of ATP,100 g of 3-hydroxybutyrate can yield 10.5 kg of ATP, and 100 g ofacetoacetate 9.4 kg of ATP [5].

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As diabetics we are taught to view ketones as bad – but they are only bad in the context of hyperketosis and hyperglycaemia. As well as the dehydrating nature of both states, the diabetic ketoacidosis only occurs at very high levels of blood ketones. For someone with well-regulated blood glucose (healthy OR diabetic), ketones in theblood is certainly not a bad thing and actually is a good source ofenergy alternative to glucose.

Interestingly, Volek et al. recently reported that avery-low-carbohydrate diet resulted in a significant reduction in fatmass and a concomitant increase in lean body mass in normal-weight men[8]. They hypothesized that elevated β-hydroxybutyrate concentrationsmay have played a minor role in preventing catabolism of lean tissuebut other anabolic hormones were likely involved (e.g., growthhormone).

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Despite what we read in so many articles and what many dieticians and health professionals say, there is good evidence that a low carb diet does not result in muscle wastage. Protein is utilised as energy but so is fat; and the point of ketogenic/low carb diet is to raise fatand proteins. If you are not raising these, then you are starving yourself of calories and a starvation state will always result in muscle wastage whether glucose (carbohydrate) is involved or not.

Diabetic patients know that the detection in their urine ofthe ketone bodies is a danger signal that their diabetes is poorly controlled. Indeed, in severely uncontrolled diabetes, if the ketonebodies are produced in massive supranormal quantities, they areassociated with ketoacidosis [5]. In this life-threatening complication of diabetes mellitus, the acids 3-hydroxybutyric acid andacetoacetic acid are produced rapidly, causing high concentrations ofprotons, which overwhelm the body's acid-base buffering system.However, during very low carbohydrate intake, the regulated and controlled production of ketone bodies causes a harmless physiologicalstate known as dietary ketosis. In ketosis, the blood pH remains buffered within normal limits [5].

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This emphasises my first point – ketosis is not inherently bad at all (in fact from an evolutionary point of view if you want to go downthat road it is likely our ancestors had preferential energy use through ketones and the insulin-glucose pathways developed later on).So again I emphasise, in diabetic patients who are not regularly achieving hyperglycaemia, ketosis of the normal low amounts is not bador dangerous. And the beauty of it is that it is harder to become hyperglycaemic when you are on a low carb diet.

Interestingly, the effects of ketone body metabolism suggest that mild ketosis may offer therapeutic potential in a variety of different common and rare disease states [11]. The large categories of disease for which ketones may have therapeutic effects are: 1)diseases of substrate insufficiency or insulin resistance; 2) diseases resulting from free radical damage; and 3) disease resulting from hypoxia [11].

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Ketones can have beneficial effects on health – in the context of diabetes (let us not forget insulin resistance is not a phenomenon restricted to Type II diabetics, but many type I’s develop this moreover time too) it has a positive effect on insulin resistance, reportedly.

Although some studies suggest that pre-exercise muscleglycogen stores determine capacity for prolonged exercise [12], thereis no clear requirement for dietary carbohydrates for human adults[13]. Current carbohydrate recommendations are based on 1) preventingketosis, and 2) providing glucose beyond minimal needs. However, it isclear that ketosis is not harmful [14-16], except in the high levelsseen in type 1 diabetes. Also, the need to provide glucose aboveminimal needs is exactly what has never been demonstrated [14].Indeed, the National Research Council has not established Recommended Dietary Allowance (RDA) for carbohydrates, probably because the humanbody can adapt to a carbohydrate-free diet and manufacture the glucoseit needs. Nevertheless, some nutritionists contend that thecarbohydrate is an essential nutrient. For example, Mcdonald claimed that healthy, moderately active adults require at least 200 g ofcarbohydrate daily to sustain normal brain metabolism and musclefunction [17]. However, the author did not provide any evidencesupporting this recommendation.

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Again, the author points to a fact that many of us often state on this board – the over-emphasis of carb requirements drilled into us from a young age. The body can live happily without glucose, yet this is what we are told throughout our life I the western world should form the biggest parts of our diets. We are taught to view fat as “bad” whereas this is not the case – it is based on out-dated studies and wrongful assumptions. Note the last sentence in the above quote…

Low-carbohydrate diets have been avoided because of thehigh-fat nature of the diets and the "predicted" associatedhypercholesterolemia. However, serum lipids generally improve with thelow-carbohydrate diet, especially the triglyceride and HDLmeasurements. In sharp contrast, high-carbohydrate diets, which reducehigh-density lipoprotein (HDL) cholesterol and raise triglyceridelevels, exacerbate the metabolic manifestations of the insulinresistance syndrome [18]. Finally, all fats raise HDL cholesterol. Therelative potency of fatty acid classes in raising HDL cholesterol issaturated > monounsaturated > > polyunsaturated [19]. Thus, it isclear that replacement of total fat (of any fatty acid distribution)with carbohydrates results in significant reductions in HDLcholesterol [19]. Indeed, recent studies of carbohydrate intake andits relationship to the development of CHD and type 2 diabetes havebeen rather revealing, showing that an increase in carbohydrate intakeis related to increases in both conditions [20].

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All fats raise HDL. HDL is seen in the medical field as an independent predictive marker of cardiac disease. Thus although we used to focus much in the past on LDL, HDL is a very good predictor too. Low HDL is bad and we should not neglect this marker. Yet here the author statesthat all natural fats (not speaking of unnatural fats which have been modified, eg. Trans etc) will raise the good cholesterol, in the expected order (polyunsaturated has the greatest HDL-raising power).With diabetics who are prone to higher LDL and lower HDL it makes most sense then to adopt a lower-carb, higher fat diet.

Contrary to popular belief supported by the leading physiologyand biochemistry textbooks, there is sufficient population of glucosetransporters in all cell membranes at all times to ensure enoughglucose uptake to satisfy the cell's respiration, even in the absenceof insulin [21]. Insulin can and does increase the number of thesetransporters in some cells but glucose uptake is never truly insulindependent. Even under conditions of extreme ketoacidosis there is nosignificant membrane barrier to glucose uptake – the block occurs"lower down" in the metabolic pathway where the excess of ketonescompetitively blocks the metabolites of glucose entering the citricacid cycle.

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This is something that was pointed out earlier in this thread and is a good point to make. It seems then that the issue is controlling the liver’s production of glucose less than what we are classically taughtas the “model” of insulin in diabetes and human endocrinology.

Finally:

It has also been claimed that carbohydrate provides the onlymacronutrient substrate whose stored energy generates ATPnon-aerobically. This is not the case, however, since several studieshave shown that amino acid catabolism also provides a source ofanaerobic energy production [23], Aspartate, for example, can befermented to succinate or propionate [24]. Interestingly, Ivy et al.[25] and Saunders et al. [26], reported that the addition of proteinto a carbohydrate supplement enhanced endurance performance above thatwhich occurred with carbohydrate alone.

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Relating to exercise – this would suggest that even in the lack of a carbohydrate source, anaerobic respiration is not an issue. Certainly that is what I feel from my training, but am careful to supplement with enough protein to prevent potential catabolism of muscle due to excess exercise.

If you get a chance the article is worth a read (although I have quoted half of it here!) and makes some excellent referenced points.Unfortunately I believe a lot of Drs and even endocrinologists are not fully clued up on some of these sorts of reviews although many specialists and endocrinologists are very good here, I would hope most.

I spoke with a colleague of mine I work with who is a qualified MD about my approach and he seemed to think that the important issuesare:
-      I have regularly checked (excessively so) my BG levels and they are always in a very good range (no hypers/hypos even after eating)
-      I have regularly checked blood ketones and they are all acceptable (from 0.6-1.1mmol/l which is fine)
-      I feel better overall, therefore perceived health tells us a lot about how a change could be for better or worse

All in all he seemed very positive about my approach and did not see any issues with cessation of insulin based on these parameters. Still however, I am to book into the clinic to get extensive bloods done. I am in particular interested in seeing my lipid panels, blood triglycerides, electrolytes, liver markers and blood counts. Just have to convince them to run these tests!!!

J