Keith Runyan transcript

Written by Christopher Kelly

Nov. 11, 2016

[0:00:00]

Christopher:    Hello, and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I'm joined by Dr. Keith Runyan. Hi, Keith.

Keith:    Hi, how are you?

Christopher:    I'm very good. I'm very excited to have you. Delighted, in fact. Keith got in touch to tell me about a mistake in one of my Keto Summit interviews. And that made me very happy because I love learning from my mistakes. Keith, tell me about the Keto Summit. How could I have made it better?

Keith:    Well, I haven't listened to all of them but I've probably heard 80% or 90% of them and I thought they were very good.

Christopher:    Can you not think of a way that I could have made it better?

Keith:    Well, I haven't even thought about that. I've just been enjoying the various conversations you've had with people who have different backgrounds and approaches and uses for ketogenic diet. And I'm glad today we're going to get to talk about how it can be used for type I diabetes because that wasn't really covered in the Keto Summit.

Christopher:    There you go. That's like a very important topic that I didn't cover. Dr. Keith is a medical doctor and a type I diabetic and he has been managing his condition with a ketogenic diet and exercise. That's going to be the main focus of this particular interview. But the Keto Summit is still going. Tommy and I are going to do a Q&A webinar. We've been collecting questions from the people who have the All Access pass. I'll put a link in the show notes for you to get an All Access pass and then you can take part in the Q&A webinar.

    We've had 34,000 people sign up for the Keto Summit. I'm so grateful to everyone that's been sharing this content. Thank you, Dr. Keith, and everyone else listening who has made the Keto Summit such a success. I'm really, really grateful to you. So, Dr. Keith, tell us about your background. How did you arrive at this place where you are diagnosed with type I diabetes?

Keith:    Well, in around 1998, I had been losing weight for quite a few months. Initially, when I was losing the weight, I said, "Oh, this is great." Most people who reached the age of 38 are putting on weight. And now I've got a little bit of tummy fat that's going away. So, I thought this is good. But then after several more months of that, I started to develop some symptoms of this sort of intermittent diarrhea and I thought, "Well, it must be something I'm eating." And so, basically, fast forward, the problem just wouldn't go away. Everything I tried to not eat didn't seem to matter.

    So, eventually, got some blood tests and saw a doctor and my blood sugar was 489. And so, since I had really never been overweight and I had been losing weight, which is a typical symptom of diabetes, and I had the other symptoms too -- frequent urination, being thirsty, being very hungry. I mean, I was eating a lot of food and yet losing weight at the same time. It all, in retrospect, fit exactly with diabetes.

Christopher:    You were working as a doctor yourself at that time?

Keith:    Yeah, at that particular time--

Christopher:    You did not recognize the symptoms that you see in your patients?

Keith:    No. No, I didn't. I don't know whether it's just complete denial or what but I didn't feel really horribly bad interestingly. I just thought this is just some minor thing and it should go away and when it didn't I finally broke down and got some tests. But I really was shocked when I got the blood sugar that's 489 back.

Christopher:    Right. And you've never tested that for yourself? You never got one of those finger stick test and done it at home yourself?

Keith:    No, no.

Christopher:    Wow. And so what happens next then? What's the standard of care when you get diagnosed with type I diabetes in your late 30s?

Keith:    Well, I was pretty sure that this was a version of type I and it took me a few weeks or months of reading to actually figure out what I had was called LADA, which is latent autoimmune diabetes in adults. It's basically just like type I diabetes in children except the beta cell destruction from the autoantibodies occurs at much slower rate. And so, usually, children will be sick for weeks or six weeks or maybe even two weeks. So, their beta cell destruction happens much more rapidly.

    And so they will get to the point where they often or quickly hospitalized for diabetic ketoacidosis and that sort of thing. So, it presents differently but it's basically the same problem. I was losing beta cells and the ability to produce insulin as time went on.

[0:05:03]

Christopher:    And have you any idea what might have trigged the autoimmunity?

Keith:    No. No. I have researched as far as what they think might be causing it. What I came up with was they think that viral infections can do it. They think that oral antibiotics can do it. They also think that if you give children less than one year of age cow's milk that they can develop autoantibodies to the casein in the cow's milk. And then also cereals, if you give children less than one year old cereals, either gluten or non-gluten type cereals. And these are what are called association or epidemiologic studies.

    So, it's not 100% that that's really a cause. They just noticed an increased frequency of children developing diabetes who had these exposures. But you can't really put your finger on this is the cause in this particular person. The other interesting thing I learned though was that the incidents of type I diabetes has been increasing sort of in step with the increase in type II diabetes. So, it kind of makes you think that there must be some dietary factor that is causing more cases of type I diabetes.

Christopher:    Right. And so you've never had a problem with cereal grains, for example, as a dietary sensitivity? You'd not noticed anything?

Keith:    Not cereals. But I did develop -- Remember, I said I had the diarrhea. What I noticed was that that was much more frequent when I had any kind of milk or ice cream. So, one of the foods I eliminated many months before I developed diabetes was milk and ice cream. So, god knows, maybe it was the casein. I don't know.

Christopher:    Right. I mean, it seems to me like that's almost going to certainly be a multifactorial problem and it's not going to be just a single thing that causes it.

Keith:    Probably. That's true.

Christopher:    So, let's talk about the standard of care then. What was recommended to you once you had your diagnosis?

Keith:    I started on NPH insulin and regular insulin.

Christopher:    Okay. One of the nice things about me doing this interview is I'm a complete dummy when it comes to type I diabetes. So, can you explain to me what that insulin is?

Keith:    Regular insulin at that time I was diagnosed, which was 1998, was actually a synthesized human insulin. So, they trick bacteria into producing the insulin. And that was actually a great advantage compared to what the diabetics in 1920s and all the way up until the 1990s. They had to use animal insulin so they would take pancreases from butcher factories and then isolate the insulin. So, most diabetics had to take pork or beef insulin. That had some negative side effects. So, fortunately, I never had to experience that. So, the regular insulin is identical to human insulin. That's what I started on mainly for when I ate a meal.

    And then the NPH insulin is the same structure except that they add zinc and protamine to it. And what that basically does is it delays the absorption of the insulin from the site where you inject it into your body, which is typically under the skin, that's called the subcutaneous injection, and so that delays the absorption of that insulin. And so, it's therefore used like a basal type insulin because the pancreas are your beta cells, secrete insulin impulses continuously throughout the day and night.

    And then, of course, when you eat a meal, those pulses become larger and more frequent. And so the idea of injecting those two different types of insulin is to try to mimic those two different functions of how the beta cells actually work. And one of the things that I didn't even know as a physician was how far off those two types of injections are from how intricate and how well designed -- it's maybe not a good word -- but how well the beta cells and the alpha cells work together to keep your blood sugar pretty close to normal 24 hours a day whether you're eating or fasting or whatnot. And that's why it's so hard to manage blood sugar in type I diabetes because these injections of insulin are just not -- It's not the same thing.

[0:10:01]

Christopher:    Right. The alpha cells secrete glucagon, the beta cells insulin, and they belong in the same tissue so that when one secretes opposes the other and that's something that you can't mechanistically mimic with an injection, am I right in thinking that?

Keith:    That's exactly right, yeah. In fact, the beta cells and alpha cells sit right next to each other in the islet of the pancreas. And so when the beta cell is secreting insulin it tells the alpha cell not to secrete glucagon. And, of course, when you have type I diabetes, there's nothing to tell the alpha cell not to secrete glucagon. So, for instance, if a type I diabetic eats a piece of steak that has no carbohydrate in it and that's all they eat, the blood sugar will go up significantly, 40, 50 milligrams per deciliter.

    And that's because the amino acids are actually stimulating the alpha cell to make glucagon. And then the glucagon goes straight over to the liver and tells the liver to make glucose or break glycogen down into glucose. So the blood sugar goes up. And I don't think I knew that before I had type I diabetes. Or if I did, that was first year medical school stuff and I had already forgotten it by then. So, it's just a very intricate thing and understanding how all of it works actually makes managing the diabetes more manageable, I'd say.

Christopher:    Right. And what do they tell you with respect to your diet? So, they prescribed two different types of insulin. Did they say anything about your diet?

Keith:    Not one word.

Christopher:    Wow. And so, would you disagree with that lack of recommendation now?

Keith:    Well, I didn't disagree with it for 14 years, I'll have to admit because I didn't know any better. I mean, in medical school, we had about two weeks of nutrition classes or lectures in another course. I forgot what the course was. But basically they talk about the metabolism of protein, carbohydrate and fat. You'll learn all that stuff. And then you'll learn about what rickets is and pellagra and all these vitamin deficiency diseases, which we never see. I've never seen one, at least here in America. I mean, you can see in other parts of the world. But basically, they're sort of giving you a background. But in terms of what should you eat to avoid the diseases that you're going to see for the rest of your career, that was never ever mentioned. I assume it's because they didn't know to mention it.

Christopher:    Right, obviously. And then, so what drove you, after 14 years then of just not really thinking too much about your diet at all, what was it that drove you to the point where you did start thinking about it?

Keith:    I guess, that was 2011. But if we back up to 2007, I knew I had this blood sugar that were kind of all over the place. My doctors were happy with my blood sugars. My hemoglobin A1C ranged between six and seven, which is kind of right where they recommended. But I was not happy. My blood sugars could be anywhere from 40 to 300. And I was having these frequent, what I thought were frequent hypoglycemic attacks or episodes. They're really kind of very uncomfortable, scary, and because I'm a doctor, it's like embarrassing.

    

    It's like, why can't you control your diabetes? I mean, that's what I kind of imagined people might say if that were to happen right in front of them. So, it was pretty bad. I said maybe there's something I ought to do to try to prevent myself from getting these long term complications of diabetes. So I had started to exercise and I picked triathlon as a sport to train for, to try to get my heart in fitness so to speak. And so then I would go out and ride around, meet other people and turns out they were eating these like sugar based sports products.

Christopher:    Yes. I know them very well.

Keith:    Yeah. They said, "Well, you need to eat these things or else you'll run out of energy." And so I said okay. And then also I had actually already experienced by that point some low blood sugars while running and biking and I said, "Well, I probably need to take some of this sugar to prevent a low blood sugar." So, I had a couple of reasons to do it.

[0:15:00]

    So, I started doing that kind of prophylactically. I take it quite from the beginning of the exercise and then periodically while I was doing these rides. And I kept increasing the time I spent doing it, the distance I was going. I didn't really realize at that time it but I was getting higher and higher blood sugars as a result of eating these gels and stuff.

    I got the idea it would be really neat if I could do this Ironman triathlon. That would sort of show that, yes, I'm a type I diabetic but not a lot of people are able to do triathlons. So, I figured, well, if I could do a triathlon that would sort of show myself that I was doing okay, so to speak. But I was concerned that what if I got a low blood sugar? I mean, it takes all day to do this event? What if I get a low blood sugar? I just happened to be listening to a podcast that was about triathlons. It was called Iron Talk. You're not really into triathlons, I guess.

Christopher:    I'm not personally a triathlete but many people that we work with are.

Keith:    Okay. Well, anyway, so they interviewed Loren Cordain.

Christopher:    Of course. Who I do know of, yes.

Keith:    Yeah. He was talking about how -- Remember, earlier I mentioned that in medical school -- I didn't mention that your diet has a lot to do with what chronic diseases you end up with? Well, that's where I first heard that, was from Loren Cordain's interview. And I said, "Geez, it seems like that's something I should have learned before now." So that was it. Then I started reading. I said I need to learn about this. So I started reading, started listening to more podcasts. And then I got on to Jimmy Moore's Livin' La Vida Low-Carb show.

Christopher:    Of course, yes, I know Jimmy too. I interviewed Robb Wolf for the Keto Summit and Robb trained underneath Loren Cordain. And, of course, I've interviewed Jimmy Moore for my podcast and he was a Keto Summit expert too.

Keith:    Right. Anyway, so he interviewed Dr. Richard Bernstein who has type I diabetes and he figured out, I think, it was in the late 1960s, early '70s, because his wife is a physician and she got him a glucose meter. It was like a three pound thing that they used in emergency rooms. And he was an engineer and he started measuring his blood sugars and he figured out that if he didn't eat very many carbohydrates his blood sugar was much easier to control. And he was able to drop his insulin dose to one-fifth of what he had been taking. And so he wanted to write it up, spread the word and nobody would accept anything he wrote. And so he said, "Well, I guess, I'll have to go to medical school."

Christopher:    Isn't that amazing? That's the most amazing story in the whole world ever.

Keith:    He went to medical school so he could do this. Anyway, I got his book and devoured that. And that was pretty much how I got going on improving my blood sugars to the point that I felt like I could do the ironman.

Christopher:    Yeah. So, did you get through an Ironman without using those sugar products that we talked about earlier?

Keith:    Yeah, yeah. So, as a matter of fact, I mean, I had no idea how it's going to go because you can't actually train for the whole Ironman. I mean, it's so long. You can't do it all in one day. I mean, I didn't know exactly how it's going to all work out. So, I just had to take a guess. My first guess was, well, I'm going to skip the insulin that I would normally take with breakfast and just eat a very small breakfast because I didn't want a stomach full of food during the swim. And I didn't want to get a low blood sugar during the swim.

    Basically, that's what I did. And so I started at 98 in the morning and by the swim and by the end of the swim I was like 212, a combination of not taking the insulin, eating breakfast and then that swim, where you got these guys that are just whacko swimming all over you. I don't understand what their hurry is at the beginning of an Ironman.

Christopher:    It's a race. That's the hurry.

Keith:    Yeah, but all you get at the end is a medal and a pat in the back.

Christopher:    I don't care. It's still a race.

Keith:    So, anyway, because my blood sugar was like 212, there was no reason to eat anything.

[0:20:01]

    So, basically, I just kept checking my blood sugar and saying any minute now it's going to go down but it didn't change much for the whole thing. So, I ended up with a blood sugar at the end of 150 which is still high. But, basically, that's the reason why I didn't eat anything during the whole time, just drank water and that was it.

Christopher:    And how long did it take you to complete the race?

Keith:    That was about 15 and a half hours.

Christopher:    Wow. That's a long time. So, you didn't eat anything at all the whole time?

Keith:    No, no.

Christopher:    That's amazing. I can tell you from personal experience I don't have diabetes but I've been wearing a continuous blood glucose monitor recently and at a cyclocross race at the weekend -- it's only 60 minutes but it's obviously very intense -- my blood glucose went up to 175 milligrams per deciliter. That's a delayed response, right? The gun goes off and initially blood glucose starts to drop presumably as you start using it.

    And then your body responds with cortisol starts mobilizing energy and then you suddenly stop and your body is not expecting it and then you see this huge peak of glucose that happens afterwards. But mine comes back down to 83 within 30 minutes, maybe an hour at the most of that peak. But it's really interesting to see those dynamics with exercise. I want people listening to know that it's not just about the food. There's other things that affect blood glucose.

Keith:    Yeah, yeah. Especially if you go out for like a very easy ride, your glucose response would be a lot different. You might have a slight reduction in blood sugar and then it might come right back to normal and that would be it. But when you do intense exercise, your body says, "Oh, we need a lot of nutrients to fuel this type of activity." And so it releases, like you said, cortisol, glucagon and epinephrine. And so those hormones tell the liver to release glucose and it tells the fat cells to release fatty acids so that your muscles have that energy to do that activity. So, that's a very normal response that it goes up like that. But you see how quickly it comes back down because you've got working beta cells to correct the high blood sugar.

Christopher:    Right. Well, you've done an amazing job of cataloging your experiment and your experience on your blog, which is ketogenicdiabeticathlete.wordpress.com. And I will of course, link to that in the show notes. And then I also have some fantastic questions from a wonderful Facebook group called Typeonegrit. And two very kind gentlemen by the name of [0:22:45] [Indiscernible] gave me some fantastic questions. I think these questions are going to be much better than the ones that I could pose to you just because I've never lived it.

    So, maybe we'll get stuck into some of their questions. The first one that's more obvious and, I think, I probably could have thought of this one is: Can you slowly walk me through a 24-hour period? Just a normal day. I want to know just a normal day looks like for you. What do you eat for breakfast? What kind of exercise are you doing? How do you take the insulin? How does it all fit together?

Keith:    Okay. Sure. I use to get up around 7:30, 8 o'clock, and the first thing I do is check my blood sugar. And I eat breakfast. I don't do any of this postponing eating until lunch like you hear a lot because with type I diabetes that just doesn't work because of this thing called dawn phenomenon. And that's basically everybody in the early morning hours releases cortisol from the adrenal glands to kind of wake you up and make you active in the morning.

    But that also increases blood sugar. If you have working beta cells, the blood sugar will normalize. But if you don't have that, if you have diabetes and you're not making insulin in response to the cortisol, the blood sugar goes up. So, if I got up and didn't eat breakfast and didn't take insulin my blood sugar would just progressively get higher, if I were to, say, postpone and eat a lunch, for example. so, breakfast is kind of varied but the thing I like to do is keep my meals very constant in terms of how many grams of protein, how many grams of carbohydrate, how much fat, from day to day.

    So, breakfast will be like some homemade fermented sauerkraut, some black olives and then I eat one spoonful of six different nuts, pecans, walnuts, macadamia nuts, pistachios, cashews and pepitas, which are actually a seed. But, anyway, that would be a breakfast.

[0:25:00]

    And so, in another day, I might have pork sausage with non-starchy vegetables cooked with it. Another day would be liverwurst, which is already prepared by a company called US Wellness.

Christopher:    Yes, I know it. I enjoy it too. It's a good product.

Keith:    Yeah. Well, then you know the product. But it has liver, kidney and heart and then what they call trim. I guess, it's just skeletal meat. All mixed together. But the way they make it, it actually doesn't taste bad at all. And so I'm able to eat it and not have a nauseous feeling that I get from eating just plain liver. So, that's another breakfast. And then sometimes scrambled eggs with some coconut oil and some vegetables, just spinach, or just whole variety of different vegetables. I eat a lot of vegetables.

Christopher:    Right. And then do you need insulin to cover this meal?

Keith:    Yeah. So, I'll just take a small dose of -- I told you originally I took NPH and regular. In the years that followed, they came out with what they call insulin analogs, which are where they've made minor substitutions of the amino acid structure of the insulin molecule. And so when you inject those it affects how quickly it gets absorbed into the bloodstream. So now, I take Humalog for meals, which is absorbed and starts working quite rapidly. So, it starts working in 15 minutes and it's finished, in my case, in about two and a half hours, which is perfect for a meal, as close to perfect as you can get.

Christopher:    Right, right.

Keith:    So, I take a small dose of Humalog for breakfast. And then I learned actually in the year 2001 when I started private practice in nephrology after I finished with emergency medicine, I learned to skip lunch because eating lunch means taking insulin and taking insulin means a chance to have a hypoglycemia. And I did not want to have hypoglycemia while I was at work. So, I quit eating lunch in 2001 just to avoid hypoglycemia. And I still do that now.

    And then as far, you asked about exercise, so I have also learned since the middle of 2015 that if I can manage to exercise every day that smoothes out the fluctuations in my insulin sensitivity because exercise has a big influence on my insulin sensitivity. So, for instance, if I were to stop exercising, which I have had to do a couple of times due to like a back injury, if I stop exercising, in 24 hours, I have to start increasing my insulin doses. And that will go on for the next couple of weeks until it finally levels off again. But I'll end up having to take, say, ten units a day more than what I normally would.

    I normally take about 30 units a day. So, if I quit exercising, I'll end up having to take 40 units a day. It has a big influence on the insulin sensitivity. So, I have to exercise every day. And currently, I alternate swimming one day with weight lifting the next day. So, I go back and forth between those two. And then when I'm done with the exercise I don't eat anything.

    I just wait until dinner time, around 6 o'clock, and then I take two types of insulins. I take the Humalog for the meal and then I take Lantus insulin, which is a basal insulin that lasts about 24 hours. So, I take that at dinner time. And then dinner is usually ground beef from US Wellness Meat. So, that's grass fed beef. And then an entire dinner plate full of vegetables either cooked or raw. So, sometimes I'll have a big salad or I'll have, say, three different non-starchy vegetables. And that's pretty much it for dinner.

Christopher:    Wow. And is there any particular type of exercise that has the greatest impact on your insulin sensitivity?

Keith:    Well, the two that I'm doing now are different. And the swimming doesn't drop my blood sugar much immediately after. But the next morning my blood sugar is typically lower compared to what weightlifting does which will drop the blood sugar more immediately within hours.

[0:30:11]

    And then the next morning the blood sugar is not as low. I also cycle and do other things, but not as frequently as swimming and weightlifting, but those affect differently too. So, I mean, the sort of frustrating part about diabetes is it's like a constant flux and you just have to keep checking and adjusting and you just have to have patience for it and not blame yourself if your blood sugar is high or blame yourself if it's low.

Christopher:    Right. It could become a self perpetuating problem if you do that.

Keith:    Yeah. I mean, you just have to say, okay, well, I'm just going to deal with it. And then get on with my life. That's sort of how I look at it.

Christopher:    And what do you think the key things are for controlling your blood sugar?

Keith:    Well, I think some of the things I've already mentioned. I think having a regular schedule really helps because, for instance, let's say you eat meals at different times a day. Well, those exact same meals would then require different amounts of insulin because the body's insulin sensitivity varies depending on the time of day. And some people have no choice because of, for instance, their work schedule requires that they eat at different times and different days. So, it makes it really tough.

    I've been fortunate in that I've always been able to eat at the same time every day because my job just allowed that. But keeping the meals at the same time every day helps. Keeping the meals as far as the calories, the macronutrients, keeping that constant for each meal. Now, breakfast doesn't have to equal dinner. But you want a breakfast to be the same breakfast, the same breakfast every day and you want your dinner to be the same dinner every day. So, reducing that variable.

    And then the one I've learned most recently is the exercise part, trying to keep the exercise as constant as possible. I mean, if I could do the exact same exercise every day I would do that. But my body just can't take it. It can't take -- I would like to lift weights every day if I could but my body just can't take it. My knees would get achy and stuff. So, I have to alternate different exercises. But you just do the best you can basically to try to keep things constant.

Christopher:    Right. And you don't find that the weightlifting causes a chaotic spike like the one that we talked about earlier?

Keith:    You mean like the spike you were talking about?

Christopher:    Exactly. So, if I know that I can repeat what I did in the cyclocross race by doing other types of intense exercise like kettlebell swings, for example.

Keith:    Well, the response I get out of weightlifting has actually varied. When I first started weightlifting, it didn't really seem to be affected much. And then when I started getting heavier weights then I noticed my blood sugar would actually go up just like you were talking about with the cyclocross. I had that response. It would go up as much as 100 points. And then more recently, my blood sugar has been dropping during the weightlifting.

    And it could be that difference between when it was going up and now is that my basal insulin dose is three units higher. So, that could have something to do with it. Or it could be that I'm just sort of getting used to the activity and my body is not perceiving it as such a stress. So, I don't know the answer but I'm just saying that anytime I come to the point where I think I can predict what's going to happen to my blood sugar it changes.

Christopher:    I think that might be true for all things in health is a constantly changing target. Every time you think you've got it nailed it's like something changes and then you're back to the drawing board.

Keith:    Yeah. Well, that is sine qua non for diabetes is everything about it seems to be constantly changing. And so that's why I really try to emphasize keeping as many things that are under my control constant as possible. Because there are certain aspects that are not under my control and they never will be.

Christopher:    Right, of course. Of course. Talk to me about the intensity of the endurance training that you do. So, I interviewed for the Keto Summit Phil Maffetone and Phil has also been in my podcast. I've had tremendous results following his approach of polarized training, is what it is. So, you spend most of your time sub 140 beats, say, and then occasionally you smash it. At the moment, that's the weekends when I ride cyclocross. Have you tried that sort of approach or what approach do you take?

[0:35:11]

    

Keith:    Well, first, I have to tell you I basically transitioned from calling myself a triathlete to now I'm calling myself a weightlifter.

Christopher:    I think that might be a good idea as you get older. You need to hang on to those type IIA fibers. You need them.

Keith:    Yeah, yeah. Well, it's a combination of factors but, first of all, I actually over trained for that Ironman that I did. And I was exhausted five miles into the bike ride. So, I just sort of, thinking about that whole process of training for the Ironman and and then doing the Ironman, which is why it took me five and a half hours because I was pretty much knackered. For some reason, at mile 13 of the marathon, I felt like something had lifted and I started feeling better.

Christopher:    I think your brain just gets to the point where it's like, okay, he's just going to ignore me. Whatever I do now, he's just going to ignore it. I'll give up. You can go ahead and keep doing this stupid thing. See if I care.

Keith:    Well, I don't know. I sort of thought that mile 13, I think I decided that I was going to be able to finish this stupid thing and so I think I felt better.

Christopher:    Yeah, it's that as well. Yeah, exactly, the barn door syndrome where you can see the end.

Keith:    Yeah, yeah. But anyway, I kind of concluded after finishing that that probably doing lots of these Ironman events was probably not a very healthy activity. And basically, what I did for the next two years was I swam, bike and ran but I did it at more of an aerobic type pace because I really wasn't training for anything. I did actually learn about Phil Maffetone quite a while ago. And so I basically used his 180 minus age and I do wear a heart rate monitor and I just try to stay aerobic when I bike. I don't do it at swimming but when biking and running and jogging and walking, whatever. I just try to stay in that kind of aerobic zone. I had no real reason to do intense aerobic activity anyway.

    And then in 2014, at the end of December 2014, basically beginning of 2015, that's when I got the barbell and the weights. My intention was actually to do power lifting. So, I started power lifting and then got some terrific pain in my elbow and my shoulder so then I said, "Well, I guess, I'll try Olympic weight lifting." And boy are those two sports quite a bit different. And I really enjoy the Olympic weightlifting. It is fun and it's very technical and it's very challenging. So, I'm really enjoying that.

Christopher:    That's awesome. Awesome. Do you have any good resources? Would you direct anyone any place in particular if they're interested in starting Olympic weightlifting?

Keith:    Yeah. There's a website called Catalyst Athletics.

Christopher:    Okay. I will find that and link to it in the show notes.

Keith:    Greg Everett is the coach. He's an Olympic weightlifting coach and, I think, he probably got the most prominent website for Olympic weightlifting. He's got tons of articles that talk about the technique. He has written some books. I think I bought one of his. And then he's got lots of videos that show you actually how to do the exercises. So, yeah.

Christopher:    I'll link to that.

Keith:    Yeah, I'm sure it's not for everybody. But I have to say even with Olympic weightlifting there's times I've had a sore elbow. I think anybody that does sports realizes that you're going to have a niggle and a tendonitis or all this injury that happens from time to time. But they get better. I think, overall, exercising is much better than not exercising.

Christopher:    Of course. And do you have any thoughts about specifically timing carbohydrates for this type of activity? So, you might assume that Olympic weightlifting was quite glycolytic in nature. So, do you ever take carbohydrates to improve your performance?

Keith:    No. I only take them to try to keep my blood sugar normal. So, yeah. I'm just sort of ruled by my blood glucose meter honestly.

Christopher:    Okay. And do you ever get carb cravings or have any advice for people that get carb cravings?

[0:40:02]

Keith:    My carb cravings, I had them when I started this ketogenic diet on February 8 of 2012. I'm treating diabetes. If I go and respond to my cravings to eat something that's not on the diet, well, I'm going to have immediate adverse results from that. So, I never felt like I should pay any attention to my cravings. I just try to put it out of my mind and go on to the next thing. So, yeah, I mean, there's lots of foods that I used to really enjoy that I haven't eaten since 2012. But I really don't care because my life is so much better now. I don't want to go back to that old way.

Christopher:    Right. Yeah. I can certainly sympathize with that and I've eliminated some things especially gluten and dairy from my diet. And my response to that was so awful. There's no way that I'm going go back to that for any tasty birthday cake I can resist.

Keith:    Right, right. It's just not worth it.

Christopher:    Exactly. Well, Corey's got an interesting question here that I'm not sure I fully understand but I'll ask it anyway. Do you have any thoughts on the new dual function insulin pumps?

Keith:    You mean the one that just came out?

Christopher:    I think that must be what he's talking about. Is it right that they're secreting both glucagon and insulin? Am I right in thinking that? It sounds like they're saying it.

Keith:    Well, I've read about that they're going to have one, yeah. And then the other one that's also very recent is they've actually come out with an artificial pancreas. So, it just got approved by the FDA. And so the idea is that you will tell it, your insulin to carb ratio and you will tell it how much insulin to give per meal. But it's tied up or it's connected to a continuous glucose monitor, like the one you have.

    And so, when your blood sugar goes up above a certain set point, it will give insulin without your having to do anything. And to bring your blood sugar back down or if it goes low, it will stop giving you insulin until the blood sugar rises back up again. It's got two set points. So, its' set for either 120 milligrams per deciliter or 150 milligrams per deciliter. Well, neither one of those are normal. So, they wouldn't really help me. My blood sugar is around 90 on average. Unfortunately, unless they allow the patient to pick their own target, I won't be able to use that device. Currently, that's not part of their algorithm.

Christopher:    Right. And one other thing that I would mention is that it sounds to me like your quality of life improved tremendously when you started getting involved in such a serious way, right?

Keith:    I'm glad you mentioned that because I didn't even mention the most dramatic and beneficial effect of going on this ketogenic low carb diet and that was I stopped having those hypoglycemic episodes. So, that was, as I said, February of 2012. So, I was having two to five of those things a week and then all of a sudden, wham, they stopped. And I actually started researching why is that? Because my blood sugars really weren't much different. So, why was it? I stopped having them. And that's when I started to learn about what ketones were. And I am today of the opinion, and I say opinion on purpose, I'm of the opinion that those ketone bodies actually supply my brain with an alternate fuel so that when my blood sugar does go low I don't actually feel it.

Christopher:    Right. So, the ketones are picking up the slack where the glucose would normally operate.

Keith:    Right.

Christopher:    And you're measuring -- I know I've seen on the blog that you're measuring ketones using breath acetone and blood beta-hydroxybutyrate, is that correct?

Keith:    I'm just using the acetone and the breath. I measured it in the blood for almost two years and the results were kind of all over the place. I used as low as 0.2 and values as high as 6.9 millimolar. And I couldn't make a correlation between what the blood level for ketones was and whether or not I was having any symptoms related to low blood sugar. And this is another thing I don't really hear anybody talking about is the blood level of beta-hydroxybutyrate, it represents the difference between your ketone production rate and your ketone oxidation rate.

[0:45:13]

    And what you really are interested in is what rate am I oxidizing or burning the ketones towards? How am I able to use them? The thing that we're really interested in can't be measured. So, all I was measuring is the difference. So, I'm not really sure what the value of measuring the blood levels are other than someone who's not even sure if they're following the diet correctly.

    I've never had a doubt about that. I mean, I know how to follow the diet. I think it would be a value to some people if, for instance, let's say they had been following the diet for months and let's say they started measuring the ketones in their urine and they were positive. And so he said, "We'll, I'm following the diet correctly." And then all of a sudden they noticed their ketones in the urine are negative but they're still following the same diet.

    And so that, I think, can occur in a small percentage of patients or people because the kidneys actually get better at reabsorbing the acetoacetate from the urine so that it doesn't appear in the urine. And so that might be that they're in ketosis but the urine ketones are negative. That's where the blood really would come in handy if they were concerned that they were not in ketosis.

Christopher:    Right. And then so measuring breath acetone doesn't get us any closer to solving the problem of am I burning ketones or not?

Keith:    Well, no, I think if you have positive breath acetone that means that you're making ketones, yes.

Christopher:    Right. But it doesn't tell you whether or not you're burning them.

Keith:    It doesn't tell you the extent to which you're burning them.

Christopher:    Right, right. Can you talk to me a bit about the diabetic kidney pathology? So, as a nephrologist, you probably know more about this than most people. Explain what's going wrong in diabetes and the kidneys?

Keith:    Yeah. It's primarily that the proteins in the kidneys that have to do with how the kidney filters the blood, they become glycated from the chronically elevated blood sugars. And that glycation is also associated with inflammation. Inflammation is important part of having uncontrolled diabetes. I had actually measured my CRP, my C-reactive protein, prior to starting the diet and it was high. And then after three months after starting it, it dropped down to a very low level that most people who follow the diet have.

    It's that combination of glycation and inflammation in the kidney that slowly damages the kidney and makes it unable to filter the blood after periods of years. And that leads to kidney failure. And that was part of my specialty, was treating people with kidney failure, with dialysis, who are getting kidney transplant, that sort of thing.

Christopher:    Right. How would you advise change for younger people? Most people with type I diabetes are not going to be diagnosed in their late 30s. They're going to be diagnosed much younger. And you've obviously done an amazing job managing your situation and achieving what looked like very normal blood sugars using this diet. Would you recommend it to children? I know you can't practice medicine over the internet. I should make that clear. But this is an opinion.

Keith:    Yeah, yeah. I mean, I'm not making any recommendations. But that's one of the things that Dr. Bernstein does, is he actually takes care of children. And the Typeonegrit, that whole group with thousands of people and their children too. So, yes, I think a ketogenic diet is very useful and children can follow it. I understand that the ketogenic diet for type I diabetes is not nearly as strict as the one for epilepsy. The epilepsy apparently requires higher ketone levels to be effective.

    But the main point of using that for diabetes is just to minimize the carbohydrate intake because it's the carbohydrate in the diet that causes the biggest fluctuations in blood glucose. But there's really no reason to restrict protein particularly. So, I would say children with type I diabetes could just have a normal protein intake, let's say, 1.2 grams per kilogram body weight per day.

[0:50:08]

    So, that's not really restrictive. They need the protein to help with growth and that sort of thing. So, yeah, I think it's very good for children. And it might be more difficult especially when they go to school and such and they would have to learn about it. Children are not dumb.

Christopher:    Right. There's nothing wrong with my three-year old but she definitely eats differently from most other kids and one of her favorite things to do is go through somebody else's lunch box and like, "What's this thing I've never seen before?"

Keith:    Yeah. I mean, if I had a child with type I, I would definitely make the effort to change them over. Because it had such a positive effect both in the short term and, I think, in the long term. And for a child, of course, you know they got their whole life ahead of them. And if they could avoid those complications that I spend a career taking care of some very uncomfortable and very sick people related to these complications of diabetes that they just honestly did not need to have.

Christopher:    What is your vision for spreading this new diet as a way of treating diabetes? I mean, obviously, you've started the blog. I just wonder, do you have a vision?

Keith:    I have actually spent over the last few years contacting endocrinologist who do research in diabetes and I sort of try to summarize what we've been talking about in this podcast and email. And I say I'd like to talk to you about this and I'd like to see if you might be interested in doing some research because that's kind of what doctors like to see. They want to see a study that shows that this is effective. And then they want the Diabetes Association to say, "Hey, this is a good idea and this is the standard of care." I mean, that's kind of what we would like, is to happen. But medicine is kind of like an oil tanker. You're trying to turn, it just happens so slowly. So, I haven't really gotten much response. They just give me various reasons. They say, "Well, it seems like you're doing a good job there but…"

Christopher:    But my research grant depends on me doing this other study that's already funded.

Keith:    Yeah. That's really a problem because how do you make money on eating a different food? It seems like money is a big part of the whole system. So, if somebody can't profit off of it, how does it move forward as a therapy?

Christopher:    Yeah, it's hard. It is a difficult problem.

Keith:    Yeah.

Christopher:    Well, Dr. Keith, this has been fantastic. I must extend some thanks towards the Typeonegrit group for providing me with some excellent questions. And they're an amazing resource. So, if you have a child with type I or if you've developed type I in your later life then I highly recommend the Typeone facebook group. And I encourage anybody listening, if you know somebody with type I and they're still on the -- how can I describe it -- the glucose roller coaster then the Typeone Facebook group, Typeonegrit Facebook group, I think, is a fantastic place to add that person, maybe willing or unwilling, I'm not quite sure. But Dr. Keith, is there anything else that -- I will, of course, link to your blog in the show notes. Is there anything else that you'd want people to know about?

Keith:    Well, I've written two books.

Christopher:    Of course. I'm so sorry I forgot about your books.

Keith:    It's okay. Yeah, I've got a book that talks about how to use this diet and general guidelines on how changes in the insulin are needed to accommodate the ketogenic diet, a book just for people with type I diabetes. And then I wrote another one for people with pre-diabetes or type II diabetes or glucose intolerance because they're basically all different degrees of the same problem, and how this diet is fantastic for type II diabetes.

Christopher:    Right, of course.

Keith:    And the type II diabetes book, I was over all the medicines that people may be taking and some are not so good with a ketogenic diet versus others. And it kind of goes through the whole thing and we try to make it as condensed as we could but keeping all the important information in it. I wrote both of those books with Ellen Davis who runs the website ketogenicdietresource.com. And if you ever type in ketogenic diet in to Google, the first that comes up is her website because she's been running that website for a number of years and she's got a ton of information about ketogenic diets on her website.

[0:55:08]

Christopher:    Excellent. And I will, of course, link to all of these things in the show notes. And there is a full transcription as well. So, if there's something that Keith said during this interview and you'd like to read it, then come and find the transcript which is also linked from the show notes. Well, Keith, this has been fantastic. I really hope that we've helped some people with type I out there. I'm sure we have. Congratulations on everything you've achieved. I think it's amazing and I think you've done an amazing job in writing everything up on the blog as well. I'd highly recommend people go and have a look at that.

Keith:    Yeah. Can I just say one more thing?

Christopher:    Of course.

Keith:    The phrase normal blood sugars. That's a phrase that I first heard from Dr. Bernstein that patients with type I diabetes deserve normal blood sugars. I have to say I don't consider my blood sugars to be normal. If you take an arithmetic mean of all my blood sugars, yes, it's normal. But it's really not normal. So, I've got ups and downs, ups and downs, up and downs and every day. And do I think I'm going to be better off with my blood sugars now than the way they were before? Of course. But that up and down of the blood sugars is not normal. And like I said, I'm doing everything I can to try to make it be normal but it's just not, the technology of those insulin analogs that I take and injecting them into the subcutaneous space, just will not mimic what the pancreas and the beta cells and the alpha cells, it will not mimic that perfectly. So, I just don't want to make a claim that my blood sugars are normal. I just want to say that.

Christopher:    But they are as close to optimal as you could get them.

Keith:    I'm doing the best I can, yes.

Christopher:     I think you're doing a fantastic job.

Keith:    And the ketogenic diet is the major change that has resulted in that. I told you I changed my exercise too. I'll change anything to try to improve. But I just wanted to say that they're not normal, so to speak.

Christopher:    Okay. Well, thank you. This has been fantastic. I really appreciate you.

Keith:    I enjoyed talking to you. That was fun.

Christopher:    Thank you.

[0:57:36]    End of Audio

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