I have three main purposes for my website and one is to help educate consumers on the connection between nutrition and health, secondly to describe the philosophy of my counseling services to potential patients to distinguish it from other dietitians/nutritionists and thirdly, to act as a portal for people with type 1 diabetes and those interested in the care for type 1 diabetes to connect, communicate and learn.
That said, I am honored to share the experiences from Keith R. Runyan, MD, a physician in Florida, about his journey with type 1 diabetes.
So often I can write how the paleo diet has changed my life (diabetes), yet, when I see another fellow T1 experiencing similar things, I am inspired to share the story with my audience. Thank you Dr Runyan for allowing me to post this information and keep up the great work with your diabetes and helping your patients.
Dr. Runyan’s story goes something like this…
In medical school, I learned a tremendous amount of information about anatomy, histology, embryology, physiology, biochemistry, cell biology, and genetics, as well as most of the pathologic conditions that affect mankind. Interestingly, the topic of how nutrition influences or causes disease was lacking. Of course, we learned about vitamin, mineral, fatty acid, and protein deficiencies and their clinical presentations, but the idea that a diet which deviates from that on which humans evolved to thrive can cause numerous major chronic diseases was not covered or adequately emphasized. So, over most of the past 20 years, I have been treating these diseases with medications and advice to see a dietitian, thinking that the dietician would be dispensing correct information about what my patients should be eating.
In 1996, I gradually became ill with weight loss initially, then later fatigue, polyuria (excessive urination), polydipsia (excessive thirst), and diarrhea. Through the powers of denial, of which mine were strong, I was able to ignore these symptoms and continue working. Even though my wife, other physicians, and nurses noticed the weight loss, I continued to believe the problem would go away on its own. Eventually, in 1998, having lost 40 lbs. from my originally normal body weight, I could no longer deny I had a problem. I saw a physician and had some tests run. My blood sugar was 489 mg/dL, and obviously I had diabetes mellitus, type 1 in my case. I started on insulin that same day with resolution over the next 2 weeks of the fatigue, polyuria, and polydipsia, but the diarrhea which turned out to be caused by diabetic autonomic neuropathy involving the intestinal tract would take another two and a half years to resolve. With treatment of the diabetes with insulin and improved blood sugar control came the onset of severe and diffuse peripheral neuropathy with pain and numbness over most of my body. I could not decide which was worse, the whole body pain or the diarrhea up to 20 times per day. Fortunately, I did not have eye, vascular, or kidney involvement and that remains the case today. The neuropathic pain gradually resolved over the next year, and the neuropathic numbness gradually went away after 2-3 years. But, I did want to discuss the difficulty I had with controlling blood sugars while following the recommendations of the ADA (American Diabetes Association). Ever since I was diagnosed with type 1 diabetes mellitus in 1998, the ADA has recommended a low fat diet in line with the dietary fat-heart disease hypothesis since heart and vascular disease is the most common cause of death of the diabetic patient. Specifically, a dietary intake of 50 – 60% of calories from carbohydrates (carbs) has been recommended, some of which may be simple sugars. In theory, I thought this seemed plausible, since the ADA recommended counting carbohydrate grams in the diet to be balanced with insulin, in my case, or other diabetes medications (for those with type 2 diabetes). However, after 2 years of weighing my food or otherwise calculating the grams of carbohydrates eaten with each meal, there was no significant improvement in blood sugar control and no improvement in the number or severity of hypoglycemic episodes (low blood sugars). So, I abandoned the carb counting and just tried to keep the intake of carbs constant with each meal. At some point along this journey, I heard about the book “Dr Richard Bernstein’s Diabetes Solution”. I did not read the book at the time, but found out about the “drastic” reduction in carbohydrates in the diet as the main feature of his approach. The thought of giving up so many foods that I liked did not appeal to me. I thought the fluctuations in blood sugar, hypoglycemic episodes, and my HgbA1c values of 5.6 to 6.9% were an inevitable part of having diabetes. In addition, I assumed that if his approach was scientifically based and clinically effective, that the medical authorities (including the ADA – American Diabetes Association) would have also embraced this approach. But the fact that they did not, added to my reluctance. Well, I should have looked into that more at the time and actually read his book. In 2008, the ADA for the first time acknowledged the use of a low carbohydrate approach for the purpose of weight loss in diabetics for up to one year, based on a recent study published in the medical literature. They did not, and have not, embraced the low carbohydrate diet for all diabetics long term.
In 2007, my wife trained for and did her first triathlon. I watched her first triathlon race and saw how she and so many others appeared to enjoy it. I had not exercised on any regular basis since high school and since I had a chronic disease that might be helped with exercise, I decided to give triathlon a try. I enjoyed the exercise and having a goal to work toward gave me the motivation I needed. After a few years of increasing the distance of the triathlon events, I contemplated doing the full ironman distance triathlon. I started looking into how to keep my body fueled and blood sugars near normal for the 12+ hours it might take me to do such a race particularly since sugar is the primary, if not sole, fuel used by athletes during a long distance triathlon. This is what motivated me to discover the dietary change that I am currently enjoying.
In 2011, I reexamined my diet and studied the Paleo Diet (Loren Cordain, PhD), the low carbohydrate ketogenic diet for diabetes (Richard Bernstein, MD), and the low carbohydrate ketogenic diet for athletes (Stephen Phinney, MD, PhD, Jeff Volek, PhD, RD and Eric Westman, MD). I have combined portions of both of these diets for myself. The essence of the low carbohydrate ketogenic approach for diabetes is as follows. Diabetes is a disease of carbohydrate intolerance. Carbohydrates in the diet are not essential to the diet, only protein and fat are essential. Near elimination of carbohydrates from the diet will maximally improve diabetes control, reduce insulin doses needed to control blood sugars in type 1 or insulin dependent type 2 diabetes, and in the case of pre-diabetes or early type 2 diabetes can normalize blood sugars without medications. See Athletes page for more details.
I transitioned to this low carbohydrate ketogenic diet to address both of my issues, namely diabetes control and fueling endurance exercise with excellent results. My blood sugars are better controlled and hypoglycemia is quite unusual. I have had several blood sugar readings in the range of 46 to 60 mg/dl without any symptoms of hypoglycemia. Readings this low prior to the ketogenic diet would have caused symptoms of hypoglycemia. On the ketogenic diet, however, these symptoms are absent presumably due to the use of ketones by the body and brain. I am able to exercise with no apparent loss of energy or power while consuming relatively little sugar during exercise to prevent hypoglycemia. I measure my blood sugar while exercising usually every 60 – 90 mins or if I feel my blood sugar might be low. My blood tests have improved in the typical pattern seen on a ketogenic diet. Triglycerides decreased from an average of 76 to 65 mg/dL, HDL cholesterol increased from an average of 61 to 90 mg/dL, the triglyceride/HDL ratio decreased from 1.31 to 0.72, the calculated LDL cholesterol increased from an average of 103 to 162 mg/dL. The hsCRP (high sensitivity C-reactive protein, a marker of inflammation) decreased from 3.2 to 0.7 mg/L. Of note, in my case, exercise did not result in a significant change in any of these lipid values, nor did niaspan or pravastatin (taken during different time frames). The niaspan was discontinued 16 months prior to and the pravastatin was discontinued 4.5 months prior to these latest results. Seeing that this diet actually worked for me and the scientifically proven health benefits of a well formulated low carbohydrate diet for treatment of obesity and numerous chronic diseases, I decided to add nutritional therapy to my medical practice. In addition to review of books and literature, I am using the resources of the ASBP (American Society of Bariatric Physicians) in preparation for the board certification examination in obesity medicine (by the American Board of Obesity Medicine) in Nov. 2012.
What Does Dr Runyan Eat?
1. Macronutrient Composition
Protein – about 0.7 grams protein per pound of body weight per day, currently 163 lbs X 0.7 = 114 grams per day. This is close to what I ate prior to starting a ketogenic low carb diet. This is in the range recommended for athletes (0.6 to 1.0 grams per pound of body weight per day). I chose the lower end of this recommended range for two reasons. First, I am doing endurance exercise rather than body building exercise and therefore need less protein. Second, too much protein in the diet can interfere with maintaining nutritional ketosis since protein in excess of the body’s needs for production of enzymes, hormones, structural components, etc. can be converted to glucose which in turn would require more injected insulin and suppress fat burning and ketone production. The protein in my diet comes from grass-fed beef, lamb, and pork (which is higher in omega-3 fatty acids than grain-fed), range-fed chicken, omega-3 enriched eggs (currently not range-fed), cheese (extra sharp cheddar, feta, and cream cheese primarily), fish (primarily wild caught Alaska salmon, but other varieties as well) and shrimp, plain Greek yogurt (10% milk fat), and nuts (primarily macadamia and pistachio).
Carbohydrates – about 40 – 50 grams carbohydrate per day. I aim for about 30 – 40 grams from my diet, and during long exercise sessions (> 2 hrs) which generally occurs 2 days/week, I may take up to 24 grams of carbohydrate per hour while exercising to prevent hypoglycemia. Carbohydrates in my diet come from vegetables (kale, collard greens, yellow squash, zucchini squash, brussels sprouts, lettuce, etc), and the small amount of carbohydrates contained in cheese, yogurt, nuts, cream, and 2 tbls lemon juice for salads. I avoid all grains and foods made from grains, fruits (except tomato and avocado), potatoes, and legumes. I take sugar (glucose) only to treat hypoglycemia or prevent it during exercise.
Fats – about 230 grams fat per day (about 100 grams saturated fat, 100 grams monounsaturated fat, 30 grams polyunsaturated fat, 6600 mg of omega-3 fatty acids, omega-6/omega-3 ratio of 3.6 to 1, and 600 mg of cholesterol). Fat in my diet primarily comes from meat, tallow, eggs, fish, cheese, nuts, butter, heavy whipping cream, coconut oil, olives and olive oil.
Totals Calories = (114 grams protein x 4) + (45 grams carbohydrate x 4) + (230 grams fat x 9) = 2700 calories. From a caloric perspective, 17% of calories come from protein, 7% from carbohydrates, and 76% from fat.
2. Micronutrient Composition
I used the USDA nutrition data tables primarily to calculate the micronutrient content of my diet. Using the Recommended Dietary Intake (RDI) values for my sex and age, I compared them to my daily intake. My diet met or exceeded the RDI values.
My daily dietary fiber intake is about 18 grams/day, which is less than the recommended 30 grams/day. This recommended figure is based on the belief that dietary fiber will prevent colon cancer. I believe that colon cancer is not causally related to dietary fiber, but more related to a carbohydrate predominate diet since colon cancer is one of the many diseases of Western civilization.
In summary, I have combined most of the tenets from the Paleo Diet as outlined by Loren Cordain, PhD (except for the use of some dairy products, inclusion of more fat, exclusion of fruit) with a ketogenic low carbohydrate approach as detailed by Richard Bernstein, MD which I believe is optimal for those with diabetes. This lifestyle has resulted in the best control of my diabetes to date and has the potential to minimize the many complications of diabetes.