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One Way to Achieve Normal Blood Sugar

Warning

This post contains links to the sources that helped me dramatically improve my blood sugar control as measured by average glucose, standard deviation, and HbA1c. If you want to improve, you have more work to do after reading this post. If you’re struggling with blood sugar, I wish that wasn’t a big deal but it is. It’s frustrating searching for good information not knowing the return on investment until you’ve spent time experimenting. Also, you might hate what you learn. Changing habits is hard. If you’re not ready for a way to achieve normal blood sugar that requires adapting how you think, eat, and live, skip reading this. Don’t waste your time.

My only sales pitch is that in two decades with this disease this is the information I wish someone gave me when I was diagnosed. I cry thinking about how much better off I’d be if I had this education then. Every time I hear of a kid getting diabetes, this is the information I give them. When I met a diabetic college student at the airport shuttle in Budapest, this is what I gave him. When coworkers tell me they’re prediabetic, this is what I give them. Now I’ll just give them this link. 

If you want to skip to what I learned and skip the why (i.e. how this helped me), go to Diabetes Education Resources.

Advice for Normals

Normals (nondiabetics), you can skip reading this post unless you want to understand me or diabetes better. If you get a yearly screening done at work, come back and read this and this if you see the trend below.  HbA1c isn’t the best measurement in the world, but the data you have is better than the data you don’t.  Most people in a wellness program get this test every year and have no clue how to interpret the results.  Many might not catch this trend as early as you’d want.  Check your data from the last two years.  If the trend is going up, find someone highly educated on diabetes to discuss how to proceed.  One of my students eliminated his coffee coolata sugar-bomb shakes to reduce his A1c in a few months and get off the path to diabetes.

HbA1c increasing over several years from 5 to 5.4 to 5.8 and predicted to become diabetic in a couple more years
If you see the upward trend in your A1cs over a few years, take action. You’ll wish you had earlier if you end up diabetic. Better to be proactive and reduce your risk. You might live ten to twenty more years and/or avoid heart attacks, amputations, lost kidneys, blindness.

My Recent Health

It’s 2019. I’ve been a diabetic twenty-three years. I’m not blind. No amputations. Both kidneys intact. Success. Almost.

My health tanked two years ago. Long story. Lots of issues. Almost too complicated for even my uber-smart neurologist who justs tells me “You’re complicated. If this is a bell curve, here’s you over there on the right, nope more right, yup the far-right side of complexity.”

Many of my issues are unrelated to diabetes. Several are directly or indirectly caused by living with diabetes for so long. Diabetes is one label for two different diseases, Type I and Type II. A better name for Type I might be autoimmune diabetes. That’s what I have. When I was around fourteen, my body started attacking the cells that make insulin. It never lets up. Those cells are gone. I don’t make insulin. If a post-apocalyptic hell ensues from climate change, my first stop is an insulin factory. Then we head north to keep the drugs cold. Type II might be called insulin-resistant-diabetes. I’m not a Type II expert but often you still make insulin, but your body doesn’t respond as well as a non-diabetic. Maybe over time, your body stops producing insulin. Maybe you make changes and regain insulin sensitivity. Maybe not. If you have ten people with diabetes, nine are Type II.

I’m living with diabetes until they find a cure or a targeted immune suppressant. So my goal for diabetes is simple: not losing weight, not getting off my meds, not stopping the insulin injections. My goal is to live as long as possible, as healthy and happy as possible. Simple goal. Hard to achieve two strikes down. If you want to know why I eat and train and do everything the way I do, it’s this. I woke up one day behind in the count without seeing a pitch. Diabetes feels to me like I’m rusting away faster than the average bear. When I talk about diabetes problems, sometimes people say “You’re just getting old.” Yes. Yes, I am. I’m also getting old quicker from insides rotting like a warm moist sandwich smeared with an extra tablespoon of sugar. So my strategy is to limit the damage. Keep my blood sugar as normal as possible. At least that’s my strategy now that I know that even mildly elevated blood sugar with high variance over a long period of time is not great for your health.

If you look at me, you’d never know I was a diabetic. You’d never think I had health issues unless you lived inside my skin, saw the world through my eyes. That’s a boring story. The short version: my physiology is wonky. My vision is wonky. My head is tight like Joe Pesci’s vice victim in Casino. A couple of years ago, I was lightheaded and dizzy all-the-time, couldn’t digest food well, slept but was always tired, and was hypersensitive to light and sound. Sounds like migraines? Except for the digestion and the lightheadedness and the vision and the…yeah, the neurologist said it’s more complicated than migraines. Still, I’ve fixed most of this. And a big part of it was tightening my diabetes game.

That Diabetes Feeling

Can you tell the difference between the two stick figures below?

Barely?

Twiggy on the left has a slight frown.

Twiggy on the right has a mild smile.

That’s it.

Stick figure on the left with uncontrolled diabetes and stick figure on the right with almost normal blood glucose

You don’t see diabetes. Except for the needle or blood drops, there’s not much to see. It’s a hidden disease all around you. In the US we may hit one in six people with the disease over the next several decades (source). But it feels awful. Many people with the disease feel bad much of the time, although they might be masters of ignoring it. Five years ago, I asked my wife “What’s a headache feel like?” I thought I hadn’t had a headache in a long time. Since I improved my blood sugar control recently, I noticed my head felt better. Now I notice when I get a headache from mildly high blood sugar. I realized I’d had headaches mostly non-stop for the last couple of decades. Headaches were so normal I thought I didn’t have them because I didn’t remember what not having them felt like. So the payoff for normal-like blood glucose is feeling better. Normal-like, not normal, because normal blood glucose is almost impossible for a diabetic. Even the most normal-like diabetics have something fail some of the time.

Now if you want to move from uncontrolled diabetes with blood glucose results that looks like a rollercoaster, you have to change. It’s hard. The image below has some experiments you can run. Try them for a month. See how you feel. The hardest part is you may have to add many things together before you start feeling better. One normally isn’t enough so it’s hard to tell what to keep and what to discard. My strategy – keep whatever you think might help. Measure your numbers frequently to get fast feedback. Discard behaviors when you know they don’t help.

Stick figure on the left with uncontrolled diabetes and stick figure on the right with almost normal blood glucose.  What got you to the left (your habits) what get you to the right.

My Old Diabetes Stats

Shortly after I was diagnosed with diabetes I started using a Medtronic insulin pump. I counted carbohydrates. I matched my insulin dose to the carbs in my food. I’m good at math. Easy, right? Ten grams of carbs equals one unit of insulin. Except I didn’t sleep well last night. I ate cheese with those carbs. I ran a mile. I’m sick. I’m stressed. I drank coffee. Your body figures this out. Mine doesn’t. My brain can’t. Not nearly as well as your body does automatically. When people know a little bit about diabetes, it seems simple. You don’t have enough insulin. Just give yourself insulin. Nope. Give yourself the exact right amount of insulin at the exact right time factoring in these and forty other variables – every – single – time. Plan your life four hours ahead every single moment. This complexity was lost on me for twenty years. I knew other things affected my blood sugar besides carbs but I just tweaked and adjusted and tested and tested and tested.

Before getting a continuous glucose monitor (CGM) I tested my blood sugar five to ten times per day. Now real-time CGM data helps me adjust whenever I’m headed high or low. But even that’s a guessing game. Yesterday, one unit of insulin lowered my blood sugar thirty mg/dL. Today it’s ten. This hour it’s fifty. Without constant monitoring, that wide variance in calculations would lead to death. Instead, I checked blood sugar constantly, especially when I ate a decent amount of carbs since that primarily lifts the height of the blood sugar rollercoaster.

Despite never getting this forty-variable equation right, my HbA1cs were in the high-fives to mid-sixes. HbA1c is like a diabetic report card. You get frowny faces or smiley faces from your doctor based on this number. Below 7 is great! My numbers are star-patient level. No doctor paid much attention to me. Normally, they hand me off to a nurse practitioner. Doctors have more complicated patients to treat. But what’s a normal HbA1c? Mid-fours to mid-fives. I’m one to two points above normal. That doesn’t sound like much but it’s a small scale. One to two is big. To me, anything above normal is rusting faster. A little above normal creates a little rust. Way above normal rusts rapidly. Either way, it’s worse than a normal person.

https://vimeo.com/70343177#t=12

Even with these good stats, my control was horrendous. No one told me this. Once I had a CGM the doctors even downloaded all my blood sugars every three months and never said a word about the dramatic peaks and valleys hour after hour, day after day. At this point, I assume no one said anything because others are worse and retraining behaviors in patients is hard in fifteen-minute appointments. I feel robbed of the time and money I spent going to these providers because I adjust behaviors easily. Just tell me what to do.

I learned to focus on my blood sugar variability from listening to Peter Attia, a non-diabetic doctor-engineer who wears a CGM for fun and tracks his blood sugar. Attia aims for an average around 80 mg/dL with a standard deviation of less than 10 mg/dL. I was nowhere near 10. I don’t know what my standard deviation was over the last twenty years but my guess is 40-50 mg/dL. Not good.

My New Diabetes Stats

Matt's Hemoglobin A1c showing 5.5

I got my latest HbA1c results recently and it was 5.5!

This report card image might hang on the fridge. If you were Type II, you might call yourself non-diabetic at 5.5 or at least normal. Diabetes is typically diagnosed after two A1cs over 6.5.

My average blood sugar over the last thirty days is 107 mg/dL. My standard deviation is 25 mg/dL which you can see in the Dexcom report below. That standard deviation is the bigger win. Less variability means more predictability and I feel better.

Dexcom report showing 107 mg/dL blood glucose and 25 md/dL standard deviation
Dexcom report from last 30 days. 5.9% is the glucose management indicator, which has results similar to HbA1c but not exactly the same. The rest of the data is a useful snapshot of my month.

Now with diabetes stats this low, many doctors would worry about low blood sugars, hypoglycemia. High blood sugar, hyperglycemia kills you slowly over many years. Low blood sugar, hypoglycemia can kill you quickly within minutes. So we want to avoid that. You may have felt these symptoms in the image below before. My average time low each day is only 3%. That’s low. Many diabetics are 5-10%. 3% is still almost 45 minutes per day. But most of those lows are mild in the 60s or 70s mg/dL. Also, since I’m eating low-carb I produce ketones. Ketones can mitigate the impact of low blood sugars.

Hypoglycemia symptoms like sweating, hunger on the left and hyperglycemia symptoms like headache, thirst, urination on the right.
If you notice these symptoms an hour or two after you eat a meal, you might be a diabetic, on the path, or maybe just sensitive. Talk to your doctor.

Not everyone is on board with ketones. It sounds like ketoacidosis. Death from hypoglycemia and ketoacidosis are a diabetic’s worst enemy. But producing ketones is good. I don’t need to eat as much. It’s an alternative fuel source. If you’re someone who feels like they HAVE to eat every few hours, you likely don’t produce significant ketones. You’re probably experiencing what I used to experience when I had a low blood sugar – tired, cranky, hungry. I don’t feel that way with ketones. And I don’t produce close to enough ketones to be anywhere near ketoacidosis. If I fast for twenty-four hours, my ketones might hit 1-2 mM. Your ketones need to be five to ten times that number to reach ketoacidosis as you can see in the image below. Unless I don’t give myself any insulin for days, I’m not getting anywhere near ketoacidosis. Like anything in life, the dose matters. Too much water kills you. Too little water kills you. Too much glucose kills you. Too little glucose kills you. Too much ketones kills you. Too little ketones…makes you hungry 🙂 If you’re worried about low blood sugar when eating fewer carbs, read this study which took research subjects down to <20 mg/dL while fasting and in ketosis. This experiment is not recommended but it’s amazing they suffered no negative impacts.

Graph of ketosis with nutritional ketosis starting at .5 mM and ketoacidosis starting at 10 mM
source – The Art and Science of Low Carbohydrate Performance, Jeff S Volek, PhD, RD and Stephen D Phinney, MD, PhD., p. 91

In addition, since I implemented these protocols in the spring, my deep sleep almost doubled. My heart rate variability (HRV) went up almost 25%. The Oura ring I used to pull these stats is more accurate on HRV but the relative change on deep sleep still seems significant even if the absolute measurement isn’t precise. HRV is important for me because I’m dealing with some amount of autonomic neuropathy. HRV is a proxy measurement for autonomic health and recovery. My resting heart rate continues to go down too.


Data from Oura ring.

Data from Oura ring.

Diabetic Education Resources

If you use only one resource below, read the Bernstein book. If you’re using an insulin pump and continuous glucose sensor and are uber-motivated, check out Looping. For Type Is, you will sleep better than you ever have since you were diagnosed. This type of diabetes technology should be available from mainstream medical device companies over the next several years. I tried Medtronic’s latest similar system, the 670g, and my blood sugar just went up, up, up. Loop gives you more control.

Bernstein

  • Browse Bernstein website (with some book excerpts)
  • Read Diabetes Solution book 
  • Watch Bernstein YouTube videos 
  • Join Type I Grit Facebook group
  • If you’re considering going to see the doctor, he works out of New Jersey, sees patients over three days, and charges $10,000 for the appointment. He’s in-demand and he’s old. We should all have such high rates on our time when we’re ninety. His office said to use the book, the groups, the videos and that anyone motivated can implement the program on their own.
  • My top learnings from the book
    • The Law of Small Numbers
      • Big inputs make big mistakes; small inputs make small mistakes. – Kanji Ishikawa
      • Essential to obeying the Laws of Small Numbers is to eat only small amounts of slow-acting carbohydrate when you eat carbohydrate, and no fast-acting carbohydrate. Even the slowest-acting carbohydrate can outpace injected or phase II insulin if consumed in greater amounts than recommended later in this book (Chapters 9–11). – Dr. Bernstein
    • Use a single (4g carbs), half, or quarter glucose tab for low blood sugar corrections
    • Use muscular injections for correcting high-blood sugars faster
    • Eat veg, protein, fat and skip other carbs – was already doing this but I’ve doubled down on skipping carbs
    • Hope for reversing early diabetic complications
    • A better disease understanding

DiaTribe

Attia Podcasts

Looping

  • Looping Main page (iPhone do-it-yourself hybrid closed loop pump/cgm system)
    • FAQs
      • This has a list of equipment and software needed.
      • Read this before you get too excited.  This is a do-it-yourself system.  There’s a lot of work to build, maintain, and run the system.  The same goes for OpenAPS below.  Otherwise, check out the systems from the manufacturers.
    • Facebook group
  • Nightscout
    • My blood sugar data (in case you want to know if I’m going to be cranky (high) or spacey (low) when I see you)
  • Autotune
  • Open APS (Android do-it-yourself system)
  • Systems from Medtronic, Tandem, Ominpod, etc (some coming soon – search for “company name” and “closed loop”)

My Current Habits

When you read all this, you might think it’s a lot of hard work. It is. But it gets easier. The hard part is reading, learning, implementing. Then it’s mostly automatic except for the occasional forty-two-headed-diabetes-dragon (image below) rearing its head.

List of 42 factors that affect blood glucose
This keeps me humble and reminds me of how hard diabetes is. Avoid it if you can.

source – https://diatribe.org/42factors, Adam Brown

This lifestyle requires effort to start. But you appreciate food more, moments of lemon-ricotta-pancake goodness, and waking up feeling like a normal person. If you want to know what I do to keep control, stay sane, and enjoy life, check out my current habits below.

Eat

Here’s a typical day of eating and a few others habits.

  • 7 am – wake-up, hot shower then cold shower, stretch, make coffee, lemon-mineral water, shake for post-lunch, maybe meditate or walk, fast until afternoon
  • 8 am – work until 6 pm, walk every 60-90 minutes outside when possible, stretch in hallway sometimes
  • 12-2 pm – break fast with big arugula salad with cucumbers, shaved carrots, olives, tuna, roasted red peppers, heavy salt, pepper, heavy olive oil
  • 3 pm – whey protein shake with cucumbers, avocado, 10g carbs worth of melon or berries, mint, basil, coconut milk, walk 10 minutes to mitigate blood sugar rise
  • 5 pm – macademia nuts and walnuts, maybe a keto brownie
  • 6 pm – exercise
  • 8 pm – 3-4 eggs, sage, bacon, mushrooms, tomatoes, basil, olive oil, heavy salt
  • 9 pm – stretching, icing, often yogurt and berries or dark chocolate and peanut butter, sometimes epsom salts, sometimes cold shower or bath
  • 11 pm – bedtime

You’re a sane person. If carbohydrate has this big of an impact on blood glucose and you need insulin to process glucose, would you eat a lot of carbs?
Easy to answer but hard to do. It’s taken a long time but I eat mostly protein and fat.
source – https://www.tandemdiabetes.com/blog/post/general/2018/01/04/carb-counting-1-food-and-blood-glucose

Treat

I’m not a complete zealot. Here are my current treats.

  • Trader Joe’s dark chocolate
  • Keto brownie bars, sometimes with almond butter
  • Peanut butter, cinnamon, and shaved dark chocolate, sometimes with cream cheese
  • High-fat, low-sugar Siggi’s yogurt with blueberries
  • Iced mineral water with fresh lemons
  • Homemade Darjeeling iced tea with lemon
  • Coffee anyway as long as its fresh ground, fresh made, and La Colombe or Madcap decaf
  • Weekend – lemon-ricotta-pancakes with high-protein mix – inspired by Mansour’s in Scranton
  • Weekend – sometimes a normal-carb meal with fresh bread or anything made with love

Move

My exercise plan was more ridiculous in the past. Now I’m approaching normalcy with a 39.5-foot pole.

  • Daily
    • Walk 5-10 minutes multiple times per day
    • Wake-up stretch
    • Bedtime stretch
  • Weekdays
    • Strength training 2-3x
      • Squats, lunges, or deadlifts (heavy 5×5, light plyometric, or bodyweight high-rep)
      • Vertical and horizontal push/pull like pull-ups, overhead press, bench press or push-ups, rows,
      • Double crunches, weighted crunches, GHDs
    • Boxing / kickboxing 10-20 minutes 1-2x
    • Row 10 minutes 1-2x
    • Walk 30 minutes 1-2x
    • Bike ride 20-30 minutes 1x
  • Weekend
    • Long CrossFit endurance workout + stretch
    • Hot yoga 90 minutes

What’s Next?

This is not the end. I can improve my control. I’m not stressing about it. That would defeat the purpose. I will time my walks to match my limited carbs, master late-night eating (I hope), and maybe even decrease exercise sometimes so I don’t need so many calories. That might sound crazy but I tell my wife my best strategy for controlling my blood sugar seems to be fasting. And she says “You have to eat.” I know, just not so often. Blood sugar control is not just a function of carbs, but calories in. Exercise is good but tactics to improve your health is not always as simple as good/bad, yes/no, 0/1. When you’re already exercising often, more exercise might improve performance, health, whatever a little but it might require more calories which must be processed, metabolized, and the sin wave of the blood sugar rollercoaster (image below) mitigated. Sometimes, the better option is a little less exercise and less input into the system like Dr. Bernstein’s Law of Small Numbers.

This is a relatively good image of the sin wave impact of carbs showing that more input (on the left) leads to more high blood sugar and low blood sugar. For me (Type I diabetic) glycemic index doesn’t matter as much as grams of carbohydrates. If I eat >10 grams of carbs I look more like the left. If I eat <10 grams of carbs, I look more like the right. Blood sugar variation is more forgiving for non-diabetics.
source – http://365fitt.blogspot.com/2013/01/the-glycemic-index-need-to-know-facts.html

Diabetes is a great example whereby, giving the patient the tools, you can manage yourself very well.

Clayton M. Christensen

The best tool I’ve found is not a drug, a glucose monitor, or an insulin pump. Learning a more accurate understanding of reality beats technology. If you’ve learned something impactful, please share.