Managing Type 1 Diabetes: Exercise, Plant-Based Diet & CGM

Many individuals may unknowingly have diabetes, a silent killer that increases the risk of cardiovascular disease and other metabolic issues. Drew Harrisburg, an exercise physiologist, sports scientist, and type 1 diabetic, shares his journey of understanding and thriving with diabetes. Diagnosed at 22, Drew has become an educator through his platform, Drew's Daily Dose, and frequent appearances on Simon Hill's podcast, "The Proof."

Drew's Personal Story and Diagnosis

Drew grew up in Bondi, Australia, pursuing a career in music. Life was carefree until he noticed a gradual decline in his health over 6 to 12 months. Despite having a degree in exercise physiology, he didn't immediately recognize the signs. He experienced significant weight loss, dropping from his usual 83 kg to 70 kg, despite no changes in diet and intense rugby training.

The most alarming symptom was extreme fatigue. During an interview for a clinical placement at a cardiac rehab facility, he struggled to stay awake. This fatigue escalated to micro-sleeps while driving, culminating in a near-accident in the Cross City Tunnel. This incident prompted him to call his parents, both doctors, for immediate blood tests.

His mother, a general practitioner, ordered a comprehensive panel of tests. While most results were normal, one marker, HbA1c (a three-month average blood glucose), was significantly elevated at 6.6%, placing him in the diabetes territory (normal is below 5.5%). This was the first red flag.

His father, an ophthalmologist working with a leading diabetes clinic, consulted a professor there. Further tests revealed high levels of autoimmune antibodies (Gad and IA2), which are markers of the immune system attacking the body. With no family history of type 1 diabetes, these results indicated a 25% chance of developing the condition.

Drew was given a blood glucose meter and instructed to track his blood sugar for two weeks. He experienced the classic "four Ts" of undiagnosed diabetes: excessive thirst, frequent urination, extreme hunger, and exhaustion. One morning, his fasting blood glucose was 7.7 (normal is below 7), which he initially dismissed as a mistake.

During a follow-up appointment, a diabetes educator tested his blood glucose with a new, more accurate meter. The result was 16 (approximately 350 mg/dL), four times the normal range. This confirmed his diagnosis of type 1 diabetes. The news was devastating, feeling like a life sentence. He was told his life expectancy would decrease, and his risk of cardiovascular disease and other long-term complications would increase.

Understanding Diabetes: Type 1 vs. Type 2

Diabetes is an umbrella term for conditions characterized by high blood glucose (hyperglycemia), but the underlying mechanisms differ.

Type 1 Diabetes

Type 1 diabetes is an autoimmune condition where the immune system attacks and destroys the insulin-producing beta cells in the pancreas. This means the body cannot produce insulin, requiring exogenous insulin administration (via pen or pump) for life. Insulin is needed to move glucose from the bloodstream into cells. Drew, for example, must calculate carbohydrates in his meals and administer the correct insulin dose.

Most people with type 1 are diagnosed after being rushed to the hospital in ketoacidosis, a severe complication of prolonged high blood sugar. Drew's diagnosis was unusual because his lifestyle, particularly his physical activity, likely delayed the onset of severe symptoms.

Type 2 Diabetes

Type 2 diabetes is primarily characterized by insulin resistance, where the body's cells do not respond effectively to insulin. The pancreas initially produces more insulin to compensate, but over time, it can become exhausted, leading to beta cell destruction and insulin dependence. Type 2 diabetes is often considered a metabolic disease, distinct from the autoimmune nature of type 1.

Globally, 537 million people have diabetes, with 50% undiagnosed. This highlights the silent and insidious nature of the condition.

The Power of Exercise and Lifestyle

Initially, Drew felt his life was over. However, a pivotal moment occurred shortly after his diagnosis. After eating a carbohydrate-rich meal, his blood glucose spiked to 25. He then went to the gym, and after his workout, his blood glucose dropped to 5, a normal range. This experience sparked hope and a sense of agency.

This phenomenon is explained by non-insulin mediated glucose uptake, also known as contraction-mediated glucose uptake or exercise-induced glucose uptake. When muscles contract, they send signals within the cells to activate glucose transporters (GLUT4) that move to the cell wall, allowing glucose to enter the cells independently of insulin. This is a crucial backup mechanism, especially in situations like fight-or-flight, where immediate energy is needed.

The effectiveness of this mechanism is site-specific; a full-body workout is more effective than isolated exercises because it activates more muscle groups, leading to greater glucose uptake.

Drew's initial success with exercise led him to believe it was a universal solution. However, he soon learned that different types of exercise have different effects. High-intensity sprint training, especially in a fasted state with caffeine, could actually raise his blood glucose due to the liver releasing stored glucose. This taught him the importance of understanding the nuances of exercise and its impact on blood sugar.

Dietary Evolution: From Paleo to Keto to Whole Food Plant-Based

Drew's journey to manage his diabetes became a continuous experiment. He meticulously tracked his blood glucose with 15-20 finger pricks daily, initially avoiding continuous glucose monitors (CGMs) due to a desire to hide his condition.

His first dietary shift was to a Paleo diet, which he discovered through a simple Google search. Compared to his previous standard diet, Paleo brought significant improvements. His daily carbohydrate intake was around 150 grams, and he focused on whole foods, eliminating grains, legumes, and dairy, while consuming plenty of meat, eggs, chicken, fruits, and vegetables. Within four weeks, his insulin requirements decreased by 50-60%, and his insulin sensitivity improved. He also regained the weight he had lost, though initially, he became "fluffy" due to insulin's anabolic effects. This led to a period of disordered eating, a common issue among type 1 diabetics, particularly women.

Next, Drew explored the Keto diet after receiving numerous inquiries about it. He adopted a Paleo-style keto diet, focusing on whole foods, leafy greens, and non-starchy vegetables, with 75% of calories from fat (olive oil, avocado, salmon, nuts, seeds, eggs, coconut oil, fatty meats). For the first two months, his blood glucose levels were stable, and his insulin requirements were minimal. He became an advocate for the diet, documenting his experience on social media.

However, after two months, he hit a "brick wall." His fasting blood glucose began to rise daily, indicating that his liver was releasing glucose into his bloodstream overnight, and there was no effective way for it to be cleared. His insulin doses increased, but his blood glucose remained high, leading to concerns about insulin resistance. This prompted him to seek a new approach.

This is where Simon Hill introduced him to the Whole Food Plant-Based (WFPB) diet. Drew, initially unaware of this dietary approach, was intrigued by the idea of managing diabetes with a high-carbohydrate diet, which seemed to contradict conventional wisdom. He decided to go "all in" with WFPB, despite fears of losing muscle and experiencing high blood glucose spikes.

To his surprise, within a few weeks, his insulin requirements and insulin sensitivity improved dramatically, becoming the best they had ever been. His muscles effectively absorbed glucose, and his insulin-to-carbohydrate ratio improved significantly. He maintained his muscle mass and athletic performance, dispelling his initial fears.

Drew emphasizes that while a keto diet can achieve good diabetes management for some, it often masks the underlying issue of insulin resistance. When carbohydrates are reintroduced, the body's inability to metabolize glucose becomes apparent. A WFPB diet, by contrast, focuses on improving insulin sensitivity through low saturated fat intake, high fiber, and healthy body composition, allowing the body to tolerate carbohydrates effectively.

The Role of Continuous Glucose Monitors (CGMs)

CGMs are vital for diabetics to monitor blood glucose levels in real-time. However, their increasing use by non-diabetics for "biohacking" raises concerns. While knowledge is power, misinterpreting CGM data can lead to demonizing healthy foods and adopting restrictive diets based on short-term blood glucose fluctuations rather than overall metabolic health.

The Double-Edged Sword of CGM Use

Many healthy individuals use CGMs as a "badge of honor" or a fashion accessory, demonstrating their commitment to health. While this dedication is commendable, the utility of the data collected is questionable if not properly understood. A common pitfall is using CGMs to justify restrictive diets, such as low-carb or keto, by focusing solely on blood glucose fluctuations without considering broader metabolic health indicators like insulin sensitivity. This can lead to demonizing certain foods based on isolated spikes, without understanding the full physiological context.

The "gamification" of blood glucose levels, where the goal is to keep the line as flat as possible, can lead to dietary choices that may not be optimal for long-term health. Education is crucial to interpret CGM data effectively. While some users report learning valuable insights, such as how specific foods or lack of sleep impact their glucose levels, the clinical significance of these individual data points for healthy individuals remains debated.

Drew notes that the goal of "flattening" blood glucose curves, often promoted by CGM users, may not be clinically meaningful. Studies on HbA1c (a three-month average of glucose levels) in healthy populations show an inflection point around 5.5%. Below this, the risk of chronic disease is largely similar, whether HbA1c is 4.1% or 5.5%. Only when levels go outside this range do risks increase. This suggests that striving for an "as flat as possible" glucose curve in healthy individuals, based on CGM readings, may not be an evidence-based approach and that minor "spikes" might not be clinically meaningful.

Who Benefits Most from CGMs?

The individuals who would most benefit from CGMs are often not the ones currently using them. There's a significant rise in metabolic disease, with many people being pre-diabetic or at risk of type 2 diabetes. These individuals could gain crucial insights into their glucose regulation. CGMs could be a powerful tool in stemming the tide of type 2 diabetes, especially considering projections that nearly 50% of Americans could suffer from it by 2030.

Elite athletes also find CGMs valuable for optimizing nutrition and performance, particularly in endurance sports where understanding glucose stability in challenging conditions is critical.

Accessibility and Cost Concerns

A significant concern is the potential for a shortage of CGMs for those who genuinely need them, such as individuals with diabetes. If healthy "biohackers" are using devices that are essential for managing a life-threatening condition, it raises ethical questions.

In Australia, CGMs are subsidized by the government, making them affordable for people with diabetes. However, in other regions like the US, there are reports of accessibility issues. The argument for increased scale leading to lower costs is often raised, but the current market dynamics, especially when considering the pricing of essential medications like insulin, suggest this isn't a guaranteed outcome.

A Powerful Diagnostic and Educational Tool

One compelling potential use for CGMs is in diagnosing undiagnosed diabetes. Many individuals live with diabetes unknowingly, increasing their risk of cardiovascular disease and other metabolic issues. If CGMs were widely accessible and affordable, they could help diagnose millions of people who are currently unaware of their condition.

The real-time feedback provided by CGMs can be incredibly empowering. Seeing the immediate impact of food choices or lifestyle factors on blood glucose levels can create a strong connection with one's body and foster a sense of agency, leading to more engaged and healthier choices. This is akin to the motivation provided by a step tracker, where simple data input can snowball into broader positive lifestyle changes.

For individuals with diabetes, CGMs offer a far more comprehensive picture than traditional finger pricks. Finger pricks provide only a snapshot, missing the dynamic fluctuations in blood glucose throughout the day. CGMs, on the other hand, display real-time trends and patterns, allowing users to understand how their glucose levels respond to various factors, including natural physiological rhythms (like morning cortisol spikes) and dietary choices.

Personal Insights from CGM Use

One user shared an experience of how CGM data revealed the negative impact of eating a large dinner late at night. The CGM showed a significant blood glucose spike around 2 AM, coinciding with waking up. This phenomenon, often seen in individuals with type 1 diabetes who consume large, fatty meals close to bedtime, can lead to a mismatch between glucose entering the bloodstream and available insulin. This insight led the user to adjust their eating habits, opting for smaller meals throughout the day, which resulted in better sleep and more stable glucose levels.

Intermittent Fasting and Type 1 Diabetes

Intermittent fasting can be a useful tool for managing blood glucose, especially when levels are already in range. However, for individuals with type 1 diabetes, it requires careful management. Overeating during the eating window, particularly large meals, can lead to delayed gastric emptying and a mismatch between insulin and glucose, similar to the late-night dinner scenario. Scaling back meal sizes is crucial for successful intermittent fasting in this context.

Different intermittent fasting protocols exist, such as backloading calories (fasting in the morning and eating from noon onwards) or frontloading calories. The optimal protocol can vary between individuals. For those who prefer to train fasted in the morning, a post-workout breakfast can be a practical approach.

Holistic Plant-Based Nutrition for Longevity

Drew's initial motivation for adopting a WFPB diet was purely health-driven. However, he soon became exposed to the ethical and environmental aspects of plant-based living. He realized the contradiction between his love for animals and his consumption of animal products. This ethical awakening, combined with the health benefits, solidified his commitment to the WFPB lifestyle.

A key principle for a healthy, whole-food, plant-based diet is plant diversity. Aiming for a wide variety of unique plants ensures a broad spectrum of nutrients and supports gut health. The recommendation of consuming 30 different plants per week is easily achievable with a robust plant-based diet.

For individuals with diabetes, macronutrient balance is critical. Each meal requires careful consideration of carbohydrate, protein, and fat content to determine appropriate insulin dosages. A target of 30 grams of protein per main meal, sourced from tofu, tempeh, legumes, nuts, and seeds, is a good guideline. Whole grains provide carbohydrates, and a large base of low-calorie density, nutrient-dense leafy greens and non-starchy vegetables contributes volume and satiety.

Protein supplements can be used post-workout to meet protein targets, especially for active individuals. The goal is to achieve approximately 1.5 grams of protein per kilogram of body weight.

Essential Nutrients and Supplementation

While a plant-based diet can provide many essential nutrients, supplementation can "bulletproof" the diet. For Omega-3s (DHA, EPA), consuming flax meal, hemp seeds, and chia seeds is beneficial, but an algae oil supplement is recommended to ensure adequate intake. A daily multivitamin containing B12, vitamin D, and algae oil can cover other essential nutrients. Regular blood work helps monitor nutrient levels and overall health.

Addressing Misconceptions about Plant-Based Diets

Common misconceptions about plant-based diets include concerns about protein intake and carbohydrate levels. It's a myth that animal products are necessary for sufficient protein; plants offer ample protein. While plant-based diets tend to be higher in carbohydrates, attempting a low-carb plant-based diet can be challenging as many plant protein sources also contain carbohydrates.

He also addresses common myths, such as the fear of lectins in grains and legumes. He explains that cooking effectively neutralizes lectins, and populations with the longest lifespans consume these foods regularly. He highlights that the "alpha male" narrative often associated with meat consumption is often disconnected from the reality of modern food production.

The long-term benefits of a plant-based diet, including ethical and environmental considerations, satiety, nutrient density, muscle building, and reduced risk of chronic diseases like cardiovascular disease, are compelling. Even an 85% plant-based diet can offer significant health benefits.

Drew's journey demonstrates that a WFPB diet can support an active lifestyle, build lean muscle, and provide optimal health outcomes, challenging the notion that animal products are essential for strength and vitality.

Embracing a Plant-Based Lifestyle

Transitioning to a plant-based diet can be approached gradually. Starting by reducing the portion size of animal products and replacing them with plant-based alternatives (like beans, tofu, or tempeh) can be an effective strategy. Exploring a diverse range of fruits and vegetables can reignite enjoyment in food.

Making plant-based meals delicious is crucial for sustainability. Marinating tofu, experimenting with recipes, and creating homemade dressings and sauces can transform potentially bland ingredients into enjoyable dishes. Learning basic culinary skills is also important, as plant-based dining options may not always be readily available when eating out.

Navigating Social Situations

The social aspect of dietary changes can be challenging. While individuals with diabetes may have a "built-in excuse" for specific dietary needs, it's empowering to own one's choices without relying on the condition as a crutch. Being assertive and politely requesting plant-based options at restaurants can lead to pleasant surprises, as others may also be curious about healthier alternatives.

Resources and Community

For those interested in learning more, resources like "Drew's Daily Dose" offer a five-pillar protocol covering nutrition, exercise, mindfulness, and blood glucose management. Online training programs, ebooks, and retreats provide further guidance and community support. These initiatives aim to educate and empower individuals to manage their health effectively, particularly those living with diabetes.