Measuring Ketones

I finally started doing something that I should have done a while ago - measure my ketones.  It's something that I initially thought I was doing by using ketostixs, which are cheap and easy to use.  All you do is pee on a stick, wait 15 seconds and then match a color.  But there's more to it than this.

The method above is quite crude.  It's actually not too far from how they used to measure blood sugars not too long ago.  Measuring anything in the urine can be easily thrown off by hydration levels - and considering that I have a sweat rate measured to be more than twice the standard person, it can really get thrown off. Plus anything measured in the urine is old data if you're really concerned about what going on in the blood.  

And finally - ketostix actually measure Acetoacetate (AcAc), which is only one of the three types of ketones produced by the body.  When I initially began my ketogenic journey I was measuring very high levels on the ketostix, but after a couple of weeks, my ketones barely registered.  This is likely due to the fact that over the first couple of weeks of ketoadaptation, things change.  It seems that initially AcAc is produced, but eventually you start to make a greater proportion of the ketone called beta-hydroxybutyrate (BOHB).  The kidneys also change their ability to filter out or hold in different ketones.  Together this may explain why I wasn't seeing much for ketones in my urine, but judging by my performance I'm rather confident that I was still making them.  

While ketostix measure AcAc, a blood ketone detected such as my newly acquired Precision Xtra measure the blood concentration of BOHB.  BOHB is the ketone that is preferentially used by the muscles.  Much of this info I learned from the Phinney & Volek books "Art & Science of Low Carb..."  I also learned the actually levels that I should be aiming for.  

It appears that there is a physiological curve where ketones are most useful.  Most people produce some level of ketones - pretty sure that less than 0.2mM.  In order to be considered to be benefiting for the physiological benefits of ketosis, a person should be targeting a concentration between 1-5mM with 5mM being the peak of benefit, but then the benefit tapers off beyond that. Ketone levels supposedly aren't as variable as blood sugar levels, but I'm still learning how they vary as an effect of both diet and exercise.

I've been testing for a week now.  My first test was last week after I ran 18 mile over the course of two runs during the day.  That test showed 2.3mM.  Bingo!  Then I continued to test over the course of the week - still running each day - distances ranging from 6 to 12 miles, but each day the ketones in the evening measured less and less.  0.9mM, 0.6mM, and then last night 0.4mM.  

While I'm very relieved that the numbers are on the conservative side, I was concerned that I might be doing something wrong.  I'm able to run for 2-3 hours at a time without carbs, with stable blood sugar and consistent energy (all done at an easy aerobic pace). I'm confident I'm in ketosis - and I feel very good, but 0.4mM is pretty low.  

But then today I got in a 5 hour ride.  Easy pace again, reduced my temp basal to 0.1U/hr and achieved very steady blood sugar numbers ranging from 75 to 90 mg/dL - energy felt fine.  I haven't been spending much time on the bike since I've been focusing on my running lately - so I didn't feel incredibly strong on the bike, but I felt good.  I should could have stopped for more water and perhaps packed some salt, but I managed fine in the cooler weather.  It was just an easy ride - a good opportunity to finally log some miles on the tri bike.

I ate some dinner post-ride since I was hungry.  I'm learning to manage my habit of post ride eating.  I'm still used to the urge to have to eat right when I finish riding, even when I'm not actually hungry.  I have to be careful with what I eat post workout since my insulin levels are much lower than usual, even a small amount of carbs would spike me - I would love to have a nice green juice but even the carbs in that would spike me pretty quickly.  So I found a nice dinner with plenty of fat.  And then I enjoyed a nice cup of home made chicken broth to replace some of my electrolytes.  Feeling good now!

What did the long ride mean for my blood ketones?  3.2mM!  Boom.  From 0.4mM last night up to that.  Now higher isn't always better - their is no benefit to running blood ketones higher than 5mM.  But I'm also nowhere near the levels that would be a concern as far as the dreaded diabetic ketoacidosis, which can be found in the range of 15-20mM.  

I had planned to run afterwords, but I'll save figuring out how to transition from bike to run for another day.  That task is going to have some nuance to it as well.

Inspiration & Research

It's the week after Ironman Wisconsin - an inspiring event for sure.  I did not race this event this year - this year was about coaching for me.  The whole week leading up to the event is full of excitement.  It's a celebration of ambition - certainly a cause I can get behind.

The weekend was a great success.  I am very happy with how my clients did.  Very, very happy.  If I had to compare the nerves of actually doing the race myself, verses coaching, cheering, and spectating - I will definitely admit that I was more nervous on race day about how every would.  I guess I've always found it easier to stay calm when I'm the one actually doing the work.  As a coach I was anxious - hoping that I properly prepared my athletes for the day.

In a sense I'm much more relaxed when I'm the one actively working towards the goal.  I'm approaching my third year as a coach - and I'm gaining confidence in my abilities.  However, like many others with high ambition I set a high standard for myself and even when things go very well I am always thinking of ways that they could go even better.  

It's such an inspiring event.  I started the day at 4:30am scoping out a spot to cheer on the helix and stayed at the finish line until just after midnight!  I'm so glad I stuck around.  Without even knowing the story I witnessed a very inspiring moment.  Father and Son duo, Dan and Zack Rotert respectively dove across the finish line 7 seconds after the finish-line clock showed the 17 hour cut off.  Why do you never quit?  Because sometimes the finish line clock is wrong.  That night it was running 9 seconds fast.  Regardless of the technicality of it all - the can rightfully call themselves both Ironman.  The back story here is that Zack had a very had day - it was his first time racing the Ironman distance.  And he's a fellow Type I.  Can't find anything more inspiring than that. 

That said and not to be critical because we are all coming to this sport with different levels of ability - my goal is to NOT suffer in the same way that Zack did.  If I had the same difficulties and put myself through that same amount of suffering when it comes time for me to race my next race - to be honest I'd pull out.  Don't get me wrong, for Zack to claw his way across the finish line was amazing.  That was his goal and he laid it all out there to get there.  However, for me my goal (bigger than racing) is to be healthy.  This has been a realization that has been difficult for me to come to terms with.  It's in my nature to push as hard as I can - but in reality I know that that thinking is very dangerous.  

Perhaps after I build on a couple racing successes I'll trust my body enough to push it harder, but until then I am only willing to push at a safe level.  Some might call that wimping out - others might call it maturity.

Regardless of it all - man it was exciting!  Even with the approach of Ironman Wisconsin I was inspired to really take my own training back into my own hands.  I've experienced some spectacular success with my nutrition and my training.  I've even managed to knock out approximately 70 miles of running this week - where did that come from?!  I'm amazed at my bodies ability to perform aerobically and recover well.  I really have some amazing endurance considering that I haven't really been focusing on it.  I truly feel that I have unlock a key to endurance that I never would have expected.   

My running has still all been on the treadmill (for safety and for controlling conditions), and my running has not been fast.  I've been walking plenty, but I'm laying down some good distance.  It's mostly 10 minute miles for now, but I'm listening to my body.  Right now it feels great.  I've never recovered from a 16 mile run so well in my life. Today I'm taking my first rest day in 12 days - tomorrow I'll be back at it.

And while all this inspiration surrounds me, I hate to not mention the 'Research' part of the title of this blog.  My recent reading list has consisted of "Good Calories, Bad Calories" by Gary Taubes - which has been doing a rather in depth review of the flaws in modern dietary thinking.  It's the detailed book before his much easier read "Why we get fat & what to do about it" which was a much easier read.

The other two books that I'm excited about are from a pair of researchers,  Jeff Volek & Stephen Phinney.  I just finished "The Art & Science of Low Carb Performance".  Pretty easy read that does a great job of discussion the how to's and benefits of low carb.  Very nicely organized and it does a great job of keeping things simple.  I'll probably be digging through their cited resources for a good long while now.  I'll also be reading their prior book "The Art & Science of Low Carb Living".  Judging by the one I read first, it's telling where my priorities are at!

New Paradigm - and success: and a bunch of details that are probably only important to me.

I'll be honest.  I have a few unpublished blogs that I'll be saving for myself.  It's been a tricky summer with the management of my diabetes.  I had things well figured out - as I had it with both my riding with HHH and my birthday ride.  But as I'm learning as a diabetic novice - things change.

The paradigm-shift:  I must have been honeymooning.

Turns out that I likely was 'honeymooning', meaning that my body was still making a trace amount of insulin.  Likely, but not proven.  Ideally I could get all the necessary tests done to measure the levels of endogenous insulin production vs what my pump provides - but in reality I could not convince my health care provider to pay for additional tests.  I look back at my initial test of my insulin levels and I guess it seems fair to assume that I held onto my ability to produce a very slight amount of insulin.  And this makes sense when I consider my ability to ride and swim for long workouts with my basal pump rate set to zero.

I am always open to learning more.  I have been doing well on my high fat, moderate protein, low carb nutrition.  But despite that my stability took a nose dive at the start of July - it took me a while to figure it out.  I questioned whether it could have been my choice of the ketogenic diet, whether it was something specific I ate, stress or lack of rest, etc.  In restrospect I really can't be sure.  But regardless of the cause I've got the train back on the tracks.  And honest confession, I feel some guilt believing that my instability was a result of an overindulgence of chocolates and sweets - but whatever the cause the result is what it is.  My body now seems to make absolutely no insulin.  (Again, I'd like to get this tested but that request is denied).

I make this assumption because of the changes which I've had to make to level things back out.  Previously I would set my daily basal rate to 0.2U/hr.  During my period of instability I had to get to 10x that - it was crazy.  But now I've been settled for over a month at a rate of 0.8U/hr.  And I'm stable.  My insulin sensitivity has lowered a bit, and that could be due to my low carb diet - something I just read about on Mark's Daily Apple.  But assigning reasons is really just educated guessing without the ability to test myself.  All I can really say is that 1U of insulin does not seem to go as far as it used to.  (It used to be 1U:40grams).  I don't really know what it is now since I don't plan to test - since I don't really ever eat that many carbs anymore - but I'd guess I'm about 1U:25g judging by my corrective use.  I guess I could do those tests at some point.

Lets get to the success:

But back to my successes - it's always fun to talk about what works.  Running has been the biggest challenge for me.  I attribute it to my size.  There is no way around the fact that I'm 6'5 and 225#, although my weight ranges lately and I was much leaner a few months ago.  I don't put too much stock in my body-weight but that is a topic for another day.  Running more so than swimming and biking has a greater physical demand due to gravity.  Swimming can be done at very low intensities and lots of breaks at the walls, cycling provides a range of gears.  Plus I'm much more efficient mechanically as a swimmer and a cyclist.

Running has always been my favorite discipline, but for those reasons above, also one of my more challenging.  I was just starting to build confidence in my abilities.  I had broken into the 19:3X's for my 5k, gotten my mile time to 5:20.  Most of that progress I made without doing much for actual speed work.  I was focused on running economy and ultra distance running - not only was it a low injury risk for me to run the trails in Vancouver at slower than 12min/mile pace, it was great fun.  It was supposed to be NOW that I was planning on increasing my intensity, hitting hard track workouts and finally building to long set goals such as a sub-40 10k, hoping that those increases would translate into faster marathon times.

But running has been the discipline that my diabetic diagnosis affects the most.  Most of my runs have caused me to destabilize.  At first my runs would cause the expected drop in blood sugar values, but now that I've become very fat adapted the reverse has actually been the issue.  Due to the greater physical demands of running my body, through whatever mechanism, would actually produce more blood sugar than it needed.  Total mind bender on that one - and the only way around that would have been to head out running with my full basal rate flowing - not something I wanted to get wrong alone... so I put those trials off until now.

But as I said, there has been success.  I've had to relegate myself to the safety of the treadmill, but it's been working.  Right now I'm doing a lot of walking, which provides opportunities to test my sugars as I go, as well as let my body's fat metabolism catch up to the demand.  And I'm just running slowly for now.  Logged a total of 16 miles today!  That's on top of 10 miles last night, and a few shorter runs of 3-6 miles earlier this week.  I don't want to ramp too fast, but I'm on a cushioned treadmill running very slowly so I'm not too concerned about doing too much too soon - but I do know better.

Details....

What worked today in case anyone is interested, but more for my own record, was:

Started running at the same time I turned my basal down from 0.7U/hr to 0.35U/hr.  Kept repeating segments of walking 5 minutes at 3mph and running 10 minutes at 6mph.   Like I said, not fast but I'm focusing on building the base right now and need to be very patient - stability is way more important.

What I was hoping for was that by started to run at the same time I turned my insulin down, the insulin that was in my system would cover the BG spike that I'd been seeing when my body adapts to the demand.  And it worked, perhaps a little too well.  My body's response (spike in BG) seems to increase when I start running too fast too soon.  So this 5 min walk - 10 min run seemed to mitigate that.

I figured it would take about an hour for the reduced basal rate to start to balance out, so I wasn't too shocked to see that after 30 minutes my BG was down to 71. I was feeling fine so I kept on going in hopes of figuring out where my bottoming out point would be.  This is assuming that my fat metabolism would kick in at some point as my insulin level reduced.  I tested my BG during every walking break.

I noticed a few other things worth recording.  My heart rate while walking at 3mph would drop to 120bpm after one minute and would be down to about 100bpm after 5 minutes.  My HR while running at 6mph would stay between 148 and 150.  The longer I kept running, the lower it would actually be (which I'm contributing to fat adaptation.   As for nutrition:  My breakfast was 6 slices of bacon, 2 eggs (4 yolks) served over a bed of lettuce 4 hours prior to running.  No calories were consumed during my run, just 3 bottles of water.

After my initial drop to 70mg/dL each successive test was steady in the mid-60's.  After about 90 minutes I had a reading of 62, but since I felt very good I decided to turn my insulin down further from 0.35U/hr to 0.10/hr and keep going.  Sure enough I kept repeating my 10 minute miles and despite no calorie input my numbers started to balance out closer to 70.  Luckily I find this whole process entertaining since I did spend upwards of 3 hours on the treadmill - thank goodness for podcasts too.

It was a fun experiment.  3 hours of running without carbs sounds rather crazy - and not something I recommend, but I never got hungry.  I actually spent the entire run breathing through my nose as well - which has become my fun way of ensuring that I'm training at an aerobic level.  I counted my breathing rate to be about 24 breaths per minute - too bad I couldn't quantify my 02 vs C02, as I'm confident that my fat adapted state is much more efficient on that front (RQ).

I'm still not all that hungry afterwards.  Normally I'd be ravenous after a long run.  Normally I'd be much more sore as well.  I've been trying a new treat which fills my chocolate cravings and fills me up very well.

4 spoonfuls of chia seeds (30g)
1 cup of water
microwave for 2 minutes
mix in 4 heaping tablespoons of cocoa powder
1 pat of grass-fed butter.

It makes for a chocolate oatmeal sort of thing - hey I know it's not normal, but I like it.  I've had it pre-run too and it sits very well.

This time I added a little bit of raw green leaf stevia, but have also sweetened it with some almond butter and or sprinkled a bunch of powdered pecans or walnuts in with it.  This is my new treat now that I've been trying to limit my usage of dairy, specifically the heavy whipping cream - another experiment for another day.