All low-carb diets ‘promise’ weight loss, which is what most people want. But I’m the exception. I’ve never had a weight problem in my life eating full fat and whole foods. I’m 67. I don’t want to lose any weight and wouldn’t mind gaining a couple of pounds.

All I’m trying to do with this way of eating is keep my blood sugar within normal range. Right now my fasting blood glucose is between 110 and 125 with spikes to 200 if I eat starchy foods like grains/potatoes, etc. – clearly pre-diabetic.

So my question is:

What adjustments would you suggest for a person like me to control blood glucose but keep the weight or even gain a few pounds?

Thank you so much!

Rosemarie

The diet my book promotes isn’t “about” weight loss but about reclaiming and expanding upon real health. I would expect weight normalization in time. High carbohydrate diets and certain forms of dysglycemia can also readily raise cortisol levels which can lead to muscle wasting and undesirably low weight issues in some. My book does discuss the mechanism for this. Whatever weight loss you might experience initially should be followed by an eventual normalization of healthy weight.

~ Nora

Primal Body Primal Mind

I’ll start with where I am now—I’m 23 years old, and 15 of those years I’ve spent as a type 1 diabetic. I am completely dependent on insulin injections, since I no longer make any insulin of my own. I use a combination of Lantus and Humulin R insulins (and Humalog very sparingly), which I inject 6-8 times per day to keep my blood sugar controlled. If I am cautious, I can normally keep my blood sugar between 70 to 85mg/dL all day. I use less than 20 total units of insulin per day. I have yet to meet another completely insulin-dependent person who uses less than 35 units of insulin analogs per day, and I know there are people that must use hundreds. My glycosylated hemoglobin (HbA1c) is at 5.5 and dropping. I have been following a low carb diet for five years, and a completely primal diet (80% calories from fat, 20% protein) for several months. I have absolutely no sign of any diabetic complications, and I am happier, healthier, and stronger than most of my non-diabetic friends (and way more energetic, people are so tired all the time!).

Blood Glucose Regulation

I monitor my blood glucose closely with around seven tests per day, but it’s not terribly inconvenient or stressful. Especially when 90% of my readings are perfect (and 99% are below 120mg/dL). I usually eat three meals per day, on no strict schedule, each about the same size and with equal protein content, so I just inject the same amount of insulin for each one (1.5 units of Regular right now). Any snacks I have are mostly fat, and still require a small dose (0.5-1.0 unit of Regular). Sometimes the standard meal dose will change—for breakfast I get about 2.5 units to account for the ‘dawn phenomenon,’ which manifests as slightly higher insulin resistance that lasts for a couple hours after waking. If I have exercised recently, I can usually skip my meal shot and let the long-acting Lantus take care of my blood sugar, since it is much more effective for about 3 hours after strength training. I treat any blood sugar over 95 with Humalog—a rapid-acting insulin analog that starts working in 5 minutes and quickly corrects high sugars (and is 1.5 times more potent than Regular). Meals are always treated with Regular insulin, as it starts working slowly and peaks in a couple hours, matching perfectly with the slow digestion of high-fat foods. Diabetics on a primal diet should not use Humalog for meals! It peaks too quickly, resulting in low blood sugar shortly after eating and high blood sugar later on, when the insulin wears off but the food is still being processed.

Many diabetics have trouble with hypoglycemia, some fearing low blood sugar episodes to the point that they purposely maintain higher sugars just to avoid them. For most, hypoglycemia is brought on easily by skipping a meal or getting a little too much insulin. In the past six months, I have discovered a truly remarkable phenomenon in myself, which has only ever worked with a very high fat/low carb diet (even moderate protein intake seems to negate it). I no longer suffer from the symptoms or effects of low blood sugar. My blood sugar may fall as low as 50mg/dL without any me noticing (or any real adverse effects, except a bit of tiredness), and it never seems to go any lower. I know that my dosing error, about ¼ unit, and external causes are enough that I would occasionally suffer blood sugars as low at 30-40mg/dL, but it just doesn’t happen. I have theories for both of these phenomena (but take them with a grain of salt, I could be wrong).

As for feeling no low blood sugar symptoms but mild tiredness at 55mg/dL, I believe that shifting my body to fat-burning has lessened the dependence of my other tissues (most importantly, my brain) on the level of glucose in my blood. Low sugar levels just don’t cause the shakiness, stumbling, and confusion that they used to. The tiredness may just be an effect of red blood cells starving and carrying oxygen less efficiently. This is probably also helped by my consistently low blood sugars—once a person adapts to a higher blood sugar levels, normal blood sugars can cause an adrenaline rush and hypoglycemia symptoms. Conversely, consistently low blood sugar diminishes hypoglycemia symptoms (this is the reason every endocrinologist I’ve visited has told me to keep my blood sugar higher). As for the mystery of my self-regulating blood sugars, my body seems to be able to raise my blood glucose slightly when it is lowered due to a tiny bit of extra insulin or exercise. This could happen in all diabetics, I suppose, but the tiny blood sugar increases are blown away by large insulin doses. I believe that my insulin levels are so consistently low that I am now enjoying a little extra help from my own system to keep my blood sugar in line.

Some Unique Challenges for a Primal Diabetic

There are some very important points that are relevant for people on a low carb/low insulin diet. These are things that no normal doctor or diabetes educator knows, because they only happen on extremely low carb diets, and are only important to people who want exceptionally tight blood sugar control. I discovered most of these through lots of trial and error, extensive research, and a little engineering innovation—hopefully I can save others some of the time I spent finding solutions to these problems. I owe thanks to Dr. Richard Bernstein, author of Dr. Bernstein’s Diabetes Solution, which I believe every diabetic (and everyone who knows a diabetic) should read. I wouldn’t have figured out any of this without it.

The first is about Lantus, the supposedly “24-hour” insulin. The truth is, as Dr. Bernstein pointed out, that the amount of time Lantus works is proportional to the size of the dose and its timing. Only large doses (20 units and higher) last the advertised 24 hours. A small dose taken at night lasts about 6 hours, and a small dose taken in the morning lasts about 12 hours. This makes it necessary for people like me to take two shots of Lantus every day, instead of one. I have found that one smaller injection at night (right before bed) and another within an hour or two of waking up works very well. I take 6 units at night at 9 units in the morning. The larger morning shot provides a fairly large ‘buffer’ of insulin throughout the day that allows me to get very small doses of regular for meals, which is perfect for slow-burning high fat meals. The phenomenon I mentioned earlier keeps my blood sugar from dropping low if I skip a meal or exercise (doing both can sometimes cause low blood sugars, though.)

Next, treating low blood sugars. I can function with blood sugars between 40-60mg/dL (badly controlled diabetics can fall unconscious at these levels), but I feel tired and a little sluggish. I’m usually in a great mood and have lots of energy, so if it starts to wane a little I know to check my blood sugar. Rather than using juice or sweets, which are usually inaccurate and unpredictable (and unhealthy), I use glucose as a drug administered to raise blood sugar. I have found glucose tabs to be the best option, available anywhere with a pharmacy in the diabetes section. They are 4g tablets, and chewing a whole one raises blood sugar 20mg/dL for a 150lb person. I break the tablets into one gram quarters, which allows me to choose my blood sugar elevation to within 5mg/dL. For example, if I test at 50mg/dL, I simply chew one and a quarter tablets. The glucose is absorbed directly through the mouth, and my blood sugar is at 75mg/dL within 10-15 minutes. Perfect.

The next issue I encountered was a financial one. If you have great insurance (which I do, but not for much longer), you can pitch ¾ of several bottles of insulin each month when they “expire,” 28 days after breaking the seal. In reality, if the vial is kept cold and unagitated in the fridge (on a shelf, not in the door), it will last for months, even if it is drawn out of once a month. Humulin R only comes in 10mL bottles—I use 250 units, or 2.5mL every month, at the very most. Humalog and Lantus can be ordered in 3mL pens, but I might use 50 units of Humalog (0.5mL) per month. I can usually use up a 3mL Lantus pen before it starts to lose activity. After trying a few unconventional methods, I found that the reservoirs from Medtronic Minimed pumps (essentially a tiny plastic bottle) are perfect for storing small volumes of insulin. I have extras from when I used the pump, and now I can make a single Humulin R vial last 4 months in the fridge. The reservoirs are designed to attach to an insulin bottle and draw up, but a large syringe can also be used (23 gauge, 3mL, can be found cheap online) to store insulin in any small sterile vial with a rubber stopper. I keep the small vials in the pouch I carry the rest of my supplies in, and draw up the insulin just like out of a regular vial (but without injecting air).

A quick note about insulin pumps. Almost all of the diabetics I know use one, and I used one for close to four years. You can make them work fairly well, but I do not recommend them for anyone on a primal or low carb diet. First, they use only Humalog, which is not ideal for anything other than quick blood sugar corrections. Second, the site where the cannula sits inside the skin is easily inflamed, causing a decrease in insulin effectiveness over a couple days. This makes very small dose corrections difficult and inconsistent. Lastly, you are constantly tethered to a little machine that is attached to a very sensitive open wound, essentially. Having the pump fall and tear out the cannula is extremely painful. I found that it interfered with my exercising, sleep, and everyday activities. I have found much more freedom and consistency with good old-fashioned injections.

Here’s another one that might be puzzling: dosing for only protein and fat—insulin is only for carbs, right? When I was on a low carb/high protein diet, I knew that I needed insulin for protein, since it could be converted to glucose. But I never got any insulin for fat, it was a freebie. This isn’t the case anymore. My blood sugar can be 75mg/dL, I drink a quarter cup of heavy cream for a snack, and then I feel a tiny bit of dry mouth and headache twinge that usually means slightly elevated blood sugar (more on this later). I usually don’t need more than 1 to 1.5 units of regular for a ‘fat snack,’ but I still need it to prevent blood sugar spikes in the 110-120mg/dL range. I’m not sure what the physiological explanation for this is, but it is consistent, and only seems to happen on a low protein diet. A meal that combines protein and fat (no more than 25% protein) is dosed depending on the number of grams of protein and how ‘full’ you will feel after a meal. Diabetics should avoid overfilling the stomach at any time, since it causes blood sugar to shoot up higher than expected. For me, a meal of 30g of meat with ¾ cup of tallow-fried broccoli and cheese, melted butter, and sour cream would need 1.5 units for the protein and fat, with an extra 0.5 unit fudge factor for the filling power of the veggies (for 2 units total). For the very rare berry or two, I get 1 unit of Regular for 8 grams of carbohydrate. It is mostly trial and error, but keeping meals at a consistent protein content and volume makes it easy to get the same dose for every meal.

I believe that every diabetic can develop a finely-tuned sense of their own blood sugars straying outside the normal range. It takes work and an awareness of your own body, but it is much easier to accomplish on a primal diet. When I am out of my optimal range, I can usually tell my blood sugar before testing it to within 10mg/dL. I say ‘usually,’ because sometimes I am completely wrong. This is why I always test before taking drastic action (more than 1 unit of insulin or half a glucose tab). Low blood sugar symptoms can vary from person to person (since it is the effect of adrenaline on you as an individual) but fatigue and mental fuzziness is usually the first sign—the severity of the low is usually proportional to the severity of the symptoms. For high blood sugar, I believe the universal first sign in dry mouth. This can be hard to tell from regular thirstiness, but it usually comes on suddenly (sitting quietly and then discovering the inside of your mouth is abnormally dry). I always test when I have a dry mouth. Interestingly, this happens because glucose is very soluble in water (and therefore the bloodstream), so when the concentration rises a little in the blood, it seeks to equalize the glucose concentration with the rest of the fluids in the body. There is an actual osmotic force that pulls water from the tissues of the body (and mouth) into the bloodstream to equalize glucose concentration (this explanation comes from my own experiences and knowledge). Being tuned into your body’s response really helps fine-tune control, but it must be used cautiously since it really isn’t always reliable.

The last problem I can think of for now—tiny doses. When I asked my pharmacist about a solution to dilute my insulins to a manageable level, he said that even small children use upwards of 3-4 units per meal, and that I should try asking at the local hospital. A hospital. The other pharmacies I went to had never heard anyone ask for insulin diluents, and had no idea how to order it. I regularly use fractions of units of insulin, and I need to be precise or risk blood sugars out of my control range. One unit of insulin is 10 microliters, a truly tiny volume, which must be drawn up into a 30 unit syringe, because they don’t make them any smaller. (I draw up all of my insulins into syringes, including the ones that come in pens. The pens don’t dial half or quarter units and are unusable for dosing, not to mention the insulin ‘bleeding’ that can result in up to an extra unit injected, terrible). I’m working on solving this problem now, since I really do need quarter unit precision for Humalog because it lowers my blood sugar by 50mg/dL per unit. I am going to contact the insulin manufacturer directly (Lilly) and try to get the diluent solution, since I know it is used for infants and laboratory experiments. Another note about tiny insulin doses: I have noticed that doses much less than 1 unit seem to have little to no effect. I believe that as the injection volume gets too small, the insulin either gets degraded or never diffuses from injection site, making ¼ unit corrections impossible without a diluent (½ unit doses can be a little unpredictable). I am managing for now with syringes that have ½ unit marks, and being very careful with the exact position of the plunger to get accurate doses.

Things Have Never Been Better

Completely adopting the Primal Body—Primal Mind diet and teachings, with no cheating and no exceptions, has truly changed everything for me. I feel like I have complete control over my life, in a way that I have never experienced before. It took 15 long years of doubt, criticism, small revelations, and gradual acceptance to come to the point that, when I finally read your book, I knew that it was exactly what I had been searching for. I actually cried partway through reading it for the first time. I’ve been a student of biochemistry and engineering for a long time, and every single word rang true. All the things I’d been trying to explain to people for so long were there, in perfect detail, as well as many things I’d never even considered.

I used to use excuses to eat grains and fruits and sugar, just ‘occasionally.’ Now that I am completely adapted and completely informed, I feel absolutely nothing when I see the sweets and treats that I used to crave. They don’t even register as food—I can taste how empty they are, and it’s almost repulsive. My cupboard is full of solid fats—palm oil, coconut oil, ghee, and grass-fed tallow. I have a cabinet of spices and herbs, and my fridge is stuffed with pasture butter, grass-fed cheeses and cream, and a bit of cabbage other veggies (all organic). In the freezer, I have grass-fed organs and meats from the healthiest cows I’ve ever seen, from a local farm. I have to spend a few hours on the weekend preparing enough food for the week, but it’s worth every minute. My roommates, also college students, think I’m insane, but I think they notice how happy and healthy (and in shape, and never sick) I am. I can’t join in their daily conversations about their ailments and sicknesses because I don’t have any—they all disappeared, along with my mild depression and fatigue.

This lifestyle, I think, creates a social gap because people don’t understand, or want to understand, why we live so differently from everyone else. Being diabetic as well just increases the isolation. I am extremely grateful to have had the tremendous love and support of my family through this long journey. My mother, father, (more recently, my little sister) and I all worked together for years, each finding out a little more, making suggestions and sharing personal revelations. Now, we all follow the exact same diet and wonderful way of life, even though I am the only diabetic among them. I feel such safety and security knowing that they will live happy and healthy for many years to come, free of disease and drugs. Without their help and support, I don’t think I would have had the courage to keep moving forward and face the criticism and worry of my friends, peers, and doctors for the “heart attack on a plate” I eat for every meal.

-Dana C. Matthews 3/25/2010