#41 - Jake Kushner, M.D.: How to thrive with type 1 diabetes and how everyone can benefit from the valuable insights
Dr. Jake Kushner, a pediatric endocrinologist, discusses managing Type 1 Diabetes (T1D) with diet and exercise, emphasizing how lower insulin levels reduce risks for T1D patients and have implications for non-diabetics. The episode covers T1D pathophysiology, increasing prevalence, and practical strategies.
Deep Dive Analysis
15 Topic Outline
Jake Kushner's Path to Pediatric Endocrinology
Pathophysiology of Type 1 Diabetes (T1D)
Increasing Prevalence and Risk Factors for T1D
Genetic Contribution to Type 1 Diabetes
Hemoglobin A1c and its Role in Diabetes Management
Discovery of Insulin: Banting and Best's Story
Insulin's Metabolic Role and High Cost
Diabetes Control and Complication Trial (DCCT) Findings
Microvascular Complications of Diabetes
Dangers of Glucose Volatility and Cognitive Load in T1D
Jake's Radical Shift in Clinical Approach for T1D
Exercise and Insulin Sensitivity in T1D Management
The Bernstein Method: Low Carb, Protein, and Insulin
Challenges of Ketogenic Diet for T1D Patients
Lessons from T1D for the Non-Diabetic Population
9 Key Concepts
Type 1 Diabetes (T1D) Pathophysiology
T1D is an autoimmune condition primarily driven by T-cells, with B-cell involvement, leading to the progressive destruction of insulin-secreting beta cells in the pancreas. This results in a profound catabolic state due to the body's inability to produce insulin.
Diabetic Ketoacidosis (DKA)
A life-threatening metabolic state where the body, lacking sufficient insulin, breaks down fat for energy, producing ketones that make the blood acidic. It is a common and dangerous presentation of undiagnosed T1D, especially in young children.
Insulin's Anabolic Role
Insulin acts as a master regulator of metabolism, signaling cells to store nutrients in a 'feast' state. It promotes glucose uptake into skeletal muscle via GLUT4 transporters and regulates fat storage and breakdown in adipose cells.
Hemoglobin A1c (HbA1c)
A measure of the amount of glucose attached to hemoglobin in red blood cells. It provides an estimate of average blood glucose levels over the preceding 2-3 months, reflecting the lifespan of red blood cells.
Diabetes Control and Complication Trial (DCCT)
A landmark clinical trial conducted in the mid-1980s to 1993, which definitively showed that tight blood glucose control in T1D patients significantly reduces the risk of long-term microvascular complications like kidney disease, eye damage, and nerve damage.
Cognitive Load in T1D
The immense mental burden and constant anxiety associated with managing type 1 diabetes, which includes continuous monitoring of blood sugar, precise insulin dosing, and the pervasive fear of complications like hypoglycemia. This cognitive load contributes significantly to high rates of depression and anxiety among T1D patients.
Insulin-Independent Glucose Uptake
A pathway for glucose entry into skeletal muscle that does not rely on insulin. This process is primarily activated by exercise and muscle work through the AMP kinase (AMPK) pathway, and can dramatically reduce insulin requirements in T1D patients.
Bernstein Method
A low-carbohydrate, higher-protein dietary approach for T1D patients, championed by Dr. Richard Bernstein. It aims to reduce blood glucose volatility by minimizing carbohydrate intake and carefully dosing insulin (often regular human insulin) to cover protein and basal metabolic needs.
Euglycemic DKA
A rare but dangerous form of diabetic ketoacidosis where blood glucose levels are not significantly elevated. It is observed in some type 1 diabetes patients, particularly those using SGLT2 inhibitors, and can delay the recognition of life-threatening insulin deficiency.
11 Questions Answered
The typical age of onset for Type 1 Diabetes is around 9 years old, but it can occur as early as five or six months of life. Children often present with increased drinking and urination, weight loss, and in about 30% of cases, with life-threatening diabetic ketoacidosis (DKA).
Type 1 Diabetes affects approximately 1 in 300 people and has doubled in incidence since 1960. This increase may be due to environmental factors like obesity or improved diagnostic capabilities.
Individuals with a direct relative who has T1D have an approximately 6 to 10-fold greater risk than the general population. While identical twin concordance approaches 80% by adulthood, it's still unlikely for any individual child to develop the disease.
The cost of a vial of insulin has increased from about $25 in 2000 to $300-$400 today, significantly outpacing inflation. This is largely attributed to the federal government's willingness to pay whatever sellers charge, indicating a lack of market influence to drive prices down.
T1D patients are at high risk for microvascular complications such as diabetic retinopathy (leading to blindness), nephropathy (kidney failure), and neuropathy (contributing to amputations). They also face increased risk of cardiovascular disease and premature death.
The DCCT trial demonstrated that achieving tighter blood glucose control (e.g., an HbA1c of 7% compared to 9%) significantly reduces the risk of microvascular complications. Furthermore, benefits in cardiovascular disease and mortality persist for decades even after initial tight control periods.
The 'cognitive load' refers to the immense mental burden of constantly thinking about diabetes management, including blood sugar monitoring, insulin dosing, and the fear of hypoglycemic episodes. This constant stress contributes to high rates of depression and anxiety, affecting nearly half of T1D patients.
Intense or prolonged exercise, particularly distance activities, can dramatically reduce insulin requirements in T1D patients. This is due to the activation of insulin-independent glucose uptake into skeletal muscle via the AMP kinase (AMPK) pathway.
Dr. Bernstein advocates a very low-carbohydrate, higher-protein diet to minimize blood glucose excursions. He recommends using smaller, more precise doses of insulin, often regular human insulin, to cover protein intake and basal metabolic needs, thereby reducing blood sugar volatility.
A strict ketogenic diet can pose risks for T1D patients, primarily the danger of diabetic ketoacidosis (DKA), including euglycemic DKA where glucose levels remain normal despite dangerously high ketone levels. This can delay the recognition of life-threatening insulin deficiency.
The observed weight gain and increased cardiovascular risk associated with hyperinsulinemia in T1D patients suggest that the standard American diet, which often leads to chronically high insulin levels, may be a significant contributor to cardiovascular disease in the general population.
17 Actionable Insights
1. Optimize Insulin Levels
Aim to control blood sugar with lower levels of insulin, as high circulating insulin (whether from injections or your own body) is linked to higher health risks, including cardiovascular disease.
2. Precise Carb & Protein Management
For Type 1 diabetes, meticulously manage carbohydrate and protein intake to reduce insulin requirements and minimize blood glucose fluctuations, following Dr. Richard Bernstein’s method.
3. Embrace Low-Carb for T1D
Significantly reduce carbohydrate intake, focusing on vegetables and avoiding enriched carbohydrates, to lower insulin needs and stabilize blood glucose, thereby reducing volatility and associated health burdens for Type 1 diabetics.
4. Leverage Continuous Glucose Monitoring
Utilize a Continuous Glucose Monitor (CGM) as an essential tool to gain real-time understanding of your glucose excursions, which is crucial for making informed decisions to stabilize blood sugar and reduce overall insulin exposure.
5. Prioritize Distance Exercise for T1D
Engage in consistent, long-duration exercise like walking 6-10 miles daily, as this can dramatically reduce insulin requirements and improve glucose control for individuals with Type 1 diabetes by promoting insulin-independent glucose uptake.
6. Seek T1D Education & Community
Actively seek out educational resources like Dr. Bernstein’s ‘Diabetes Solution’ book, the ‘Type 1 Grit’ Facebook group, and low-carb focused media (e.g., Low Carb Down Under, Adam Brown’s ‘Bright Spots and Landmines’) to learn practical strategies for managing Type 1 diabetes.
7. Insulin Dose for Protein (T1D)
Recognize that protein can convert to glucose over several hours (gluconeogenesis), requiring insulin coverage (often regular insulin due to its slower action) to prevent delayed blood sugar spikes in Type 1 diabetes.
8. Avoid Prolonged Fasting (T1D)
Do not engage in prolonged fasting if you have Type 1 diabetes, as it can lead to dangerously high levels of ketones and diabetic ketoacidosis, even if blood glucose appears normal (euglycemic DKA).
9. Boost T1D Early Detection
Be vigilant about the signs and symptoms of Type 1 diabetes in children (e.g., increased thirst, frequent urination, weight loss) and educate others to ensure early diagnosis and prevent life-threatening diabetic ketoacidosis.
10. HCP: Allocate More Patient Time
Healthcare providers should allocate more time for patient appointments, especially for complex conditions like Type 1 diabetes, to foster deeper understanding, build rapport, and provide more effective, personalized care.
11. HCP: Practice Active Listening
As a healthcare provider, make a conscious effort to listen more and ask open-ended questions to patients, especially those with chronic and complex conditions, to build rapport and facilitate deeper understanding.
12. Patience & Empathy for Teenagers
When interacting with teenagers, especially those managing chronic illnesses, offer patience and understanding without judgment, as building trust and rapport is crucial for long-term support and positive outcomes.
13. Minimize Glucose Variability
Strive to minimize both your average blood glucose and its fluctuations (standard deviation), as this serves as an indirect indicator for reducing your body’s overall insulin production or requirement, which is beneficial for health.
14. Practice Quantified Self
Actively monitor and understand your body’s physiological responses to different inputs, using tools like CGMs, to become ‘dialed into your physiology’ and optimize your health.
15. Maintain Child’s Normal BMI
Encourage children to maintain a normal BMI, as there’s a subtle population-level association between higher body weight and an increased risk for Type 1 diabetes.
16. Early Peanut Exposure
Introduce peanuts to children early in life, as current evidence suggests this practice can help prevent the development of anaphylactic peanut allergies.
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6 Key Quotes
If people with type 1 diabetes are at risk for terrible complications... cardiovascular disease and kidney disease and diabetic retinopathy and blindness and limb amputations... The DCCT really figured this out.
Jake Kushner
The problem is you can't just throw in a bunch of insulin and then normalize glucose because you will cause somebody to go low. And with type 1 diabetes, the crux of the problem is the volatility in blood glucose.
Jake Kushner
This is somebody who figured out like the ultimate biohack. She's trying to make her blood sugars near normal all the time. She discovered a group of foods that she needs to avoid. And so she avoids them.
Jake Kushner
I think of it as a cognitive load. It's the burden of having to think nonstop about your diabetes. And if you can imagine that volatility, the rollercoaster blood sugars that are going up and down, you're going to have to think about it nonstop.
Jake Kushner
More carbohydrate means more insulin, more insulin means more vacillation.
Jake Kushner
If you could wave a magic wand and have something that doesn't exist, what would it be? And my first answer is a metabolic signature for autophagy. My second answer would be every night I'd like to go to bed and have a little readout that says, this is the total amount of insulin your pancreas made in the last 24 hours.
Peter Attia
1 Protocols
Dr. Bernstein's Method for Type 1 Diabetes Management
Jake Kushner (describing Dr. Richard Bernstein's method)- Minimize carbohydrate intake to reduce blood glucose excursions.
- Use medium and long-acting insulin to cover basal metabolic requirements, fat, and protein.
- Utilize regular human insulin (not rapid-acting analogs) to cover protein, as its slower kinetics (peak onset 1-2 hours, lasting 6-8 hours) better match the delayed glucose conversion from protein.
- By consuming fewer carbohydrates, require less insulin, thereby reducing the opportunity for dosing mistakes and minimizing blood sugar volatility.