Hiking the Appalachian Trail with Type 1 Diabetes, Afrezza, and Keto Food

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We found Mike Joyce in the famous TypeOneGrit Facebook group, where he was advising on the best ways to stay low carb on long wilderness trips. When Mike switched to a low carb diet to help manage his Type 1 diabetes, he lost about 100 pounds and discovered that he had an aptitude for extreme endurance sports. In just a short time, he’ll take on the Appalachian Trail. We talked about his amazing lifestyle changes, his preference for Afrezza insulin, and how to maintain a low carb diet on the trail. 

Can we start at the beginning? When were you diagnosed?

February 2nd, 1996, Groundhog Day. At 9 years old, I began my journey with Type 1 diabetes. Like in the movie with Bill Murray, I kept trying to get things right so that life could go on.

For the most part I did well. My parents were very supportive and gave me every tool they could at the time.

What did your management look like in the past, especially with regard to carbohydrate consumption?

Initially I started with R and NPH twice a day. Carb consumption was a necessity and my life revolved around eating. Since both those insulins were relatively unpredictable, especially NPH, I was eating every 2 hours due to fear of hypoglycemia. No one really knew any better.

In the beginning, it was just carb exchanges with a sliding scale of “fast” acting. This changed to carb counting and ratios with the pump and Humalog. All while eating a “balanced” diet of moderate carb consumption.

When did you make the switch to the Dr. Bernstein approach?

I overheard a couple people talk about the Bernstein diet in the diabetes online community, but I was skeptical and unwilling to part with certain lifestyle choices (I really dove into the craft beer scene after college). Also it was hard to wrap my mind around the idea of nutritional ketosis, after being taught to fear ketones for so long.

Before and After

However, I was really blowing up like a balloon, exercise was next to impossible without having to eat calories to treat lows, and I finally got a CGM. Once I could visualize the impact food (and drink) had on my blood sugars, I decided it was time to let go of some of the comfort I was finding in food. I actually started implementing it in 2016.

And what was the result?

My first goal was to get a <7.0% A1C without using a pump. It had taken a lot of work to get down to 6.6% on my “balanced” diet. When I cut the carbs I dropped down to 5.6% almost immediately, without doing much different. So improved blood sugars were the instantaneous reason to stick with what I was doing.

Two years later, my A1C is at 5.0% and I have lost almost 100 pounds. I now have a better relationship with food, seeing it more as fuel than treatment for feeding excess insulin. My ability to focus improved and my overall mood seemed to stabilize. Some could claim this to be the result of ketosis, but I think it was so noticeable because I had spent 20 years on a roller coaster of blood sugars. I finally got off the ride and the turbulence settled.

Can you tell me what your diet looks like? Are you doing the full Dr. Bernstein – very low carb, plenty of protein?

I mostly eat a pretty high protein ketogenic diet. A lot of red meat, chicken, fish and eggs. Veggies like zucchini, cauliflower, broccoli, dark greens, avocados. My fats come from a mix of avocado oil, butter, bacon fat, and animal protein. I often do intermittent fasting (from 8:00pm to noon) and only rarely eat both lunch and dinner unless I’m running or hiking big miles or working out hard.

And I understand you primarily use Afrezza. I find that surprising, as most people pair the high-protein high-fat diet with Regular insulin, the slowest “fast” insulin. But you’re using the very fastest. Can you explain why you prefer Afrezza?

Afrezza’s action curve is the closest available to natural, endogenous insulin. The onset of action is incredibly quick, and its tail is so short that I don’t have to worry about stacking or calculating insulin on board.

Typically I dose Afrezza “as-actually-needed” not “as-predicted-to-need.” Using CGM data, Afrezza allows me to implement Dr. Ponder’s method of Sugar Surfing in real-time.

Mike Joyce - Agrezza

Can you detail your bolus strategy?

I typically dose soon after eating, watching my CGM and waiting to see the line bend upward. Since the insulin peaks in 15 minutes, the dose usually stops the incline and the line flattens out. Then when the protein starts bending the line up again, I hit it with another dose to flatten it back out. Depending on how much fat slows down my digestion, that can be anywhere between one and four hours after the meal. I just have an alert vibrate my watch as soon as my blood sugar hits 110, and I usually get it back down to 80-100 within the hour.

Fascinating, so you use the Afrezza in a purely reactive manner, giving little boluses as necessary.

With Afrezza, I don’t really count carbs anymore. It works fast so that I don’t have to predict, only react. It frees up my headspace to focus on the things I love like running and hiking and playing soccer. Until I started using Afrezza, I never realized how much of my mental space was taken up by planning and anticipating what might happen with my blood sugar. This is a much smaller part of my management now. I don’t think I can emphasize more how much Afrezza allows me more time to live. 

Let’s talk about your big miles. How long are the runs and hikes you go for?

Typically I run about 6-8 miles two or three times a week and then a long run 10-20 miles on the weekend, and I did some 50K trail races locally this winter.

This summer I’ll be hiking the Appalachian Trail. My days will range from 12 to 30 miles depending on how I’m feeling.

How do you find your body responds to this type of heavy cardio on the low-carb diet?

Most runs over 5 miles do require me to eat some carbohydrate for blood sugar maintenance. So, I usually carry a small honey bear in the breast pocket of my running vest. Honey can get into my blood stream quickly, and a little goes a long way.

Does Afrezza offer any unique advantages when you’re exercising?

The lack of tail on Afrezza’s action curve is what makes exercise much easier. I don’t have to consider insulin on board before running 10 miles after work. I know my bolus from lunch, or a correction at 2pm is totally out of my system come 5pm. Previously I struggled with bad lows during exercise.

How the heck do you plan on sticking to a low-carb diet on the Appalachian Trail?

This is the biggest difficulty and my focus currently. I’m buying bulk supplies of freeze dried ingredients and making my own meals.

I’m also going to do protein shakes. I can add a quarter cup of oil to a shake and get some 600 calories in to fuel me through the morning with little need for insulin

Snacks are fun. With keto becoming so popular over the last few years there are so many new options out there. I’ll also supplement with some almonds, cheese, pepperoni, tuna, and chicken salad from grocery stores along the trail.

I know that at least a handful of people with T1D have thru-hiked the AT. Have you leaned on any of them for advice?

There are quite a few T1Ds that have hiked the AT, and I have talked to some of them. My approach to diabetes is a bit different than theirs when it comes to diet, but overall we shared the fact that insulin needs are cut drastically when out there. There’s the worry of having a hypo snack on you in bear country, how resupplying is extra complicated. There are also people (non-diabetics) who are following keto on the trail so I’ve also been reaching out to them.

How can we follow your progress on the trail?

I’m using Instagram @sweet.hiking and I’ll be blogging for thetrek.co for my thru hike.

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