Wednesday, 16 April 2014

Carbohydrate

Gunnera
Groombridge Place, June 2013
After much deliberation, I decided to call the talk I gave at the weekend 'Carbohydrate'. It was part of a scheduled day of talks from healthcare professionals at a public awareness day organised by the local Diabetes UK voluntary group. Other speakers included doctors, podiatrists, eye specialists and a paediatric dietitian who was planning to talk about exercise (unfortunately I missed most of her talk because I was talking to someone about injection sites).

A colleague had sent me a presentation that she had recently delivered, so I based mine on hers and stole her case study. I started by reminding people that all types of Diabetes are characterised by blood glucose that is higher than it should be, and that the source of glucose in the blood is carbohydrate from the food we eat. As a Dietitian specialising in Diabetes, carbohydrate in food is my bread and butter (not so much butter, actually), and then posed the question: how do I decide what advice to give to patients about what they should eat?

This brought us on to the evidence-based nutritional guidelines published by Diabetes UK in 2011, and the changes that this document brought to the accepted picture of healthy eating for Diabetes. The trouble with the scientific method is that as more evidence is accumulated and new guidelines are researched and published, our total knowledge increases and conclusions can change from one day to the next.

The new guidelines advise that the primary nutritional strategy in Type 2 Diabetes should be weight loss above all else, and what's more, that there is no evidence to favour any one approach to weight loss over any other. Limiting energy intake overall is more important than where the calories come from. The document also says that low carbohydrate diets can be particularly effective at producing improved blood glucose control, especially when weight loss is achieved.

This is a drastic U-turn. Previously, guidelines suggested that a significant proportion of food eaten should be starchy carbohydrate - 50% or more of the total dietary intake. The potential consequences of restricting carbohydrate were perceived as deficiency of B vitamins, and increased fat intake leading to weight gain, higher blood cholesterol and an increased risk of cardiovascular disease. From one day to the next, our advice based on the best evidence goes from recommending fairly high carbohydrate portions to weight loss at all costs with a definite option of low carb. No wonder people are frustrated by reporting in the popular press, where advice seems to change every time a journalist sneezes.

One of my colleagues has thoroughly researched the low carb approach, and even converted her own diet to exclude carbs. She has converted the other Diabetes staff to the new low carb religion, and pioneered this method with her patients. We have two treatment groups increasing in numbers every month - a 'reducing carbs' cohort, and a 'very low carb' group.

'Reducing carbs' means limiting carbohydrate intake to 120g or less a day - 30g per meal and 30g for snacks. As an example, a slice of bread from a medium sliced loaf is 15g carbohydrate, as is a diet yogurt, or a portion of fruit. 30g carbohydrate equates to three tablespoons of cooked rice or pasta, or three egg-sized potatoes. Admittedly it usually involves a change in diet, but not necessarily a drastic change, and most people would find it manageable with a bit of forward planning.

'Very low carb' or VLC is a different kettle of fish, and this plan limits carbohydrate to just 40g or less per day. This means giving up all starchy carbohydrate - no bread, pasta, rice, cereal, potatoes or other starchy vegetables, with allowed carbs limited to a small amount of milk, berries and pulses and natural yogurt. Animal and vegetable protein features heavily, including nuts and seeds, along with less carb-heavy vegetables and salads. Saturated fats should be replaced with unsaturated as much as possible, and caffeine and artificial sweeteners should also be avoided.

The idea of both these diets is that the less carbohydrate you eat, the less glucose ends up in the blood. Consumption of lower calorie foods also increases, including vegetables and salad, so a very welcome by-product is weight loss. The VLC diet is also intended to change the body's metabolism from using carbohydrate to using fat as the main fuel for energy, which was once assumed to be a bad idea. It has now been shown not to have the undesirable effects that were once thought likely in the short term, although we still don't know the long-term consequences. Another very positive aspect of the change to fat metabolism is that it seems to have an appetite-suppressing effect.

For people with Type 2 Diabetes who are overweight, a VLC plan can bring about a miraculous transformation. High blood glucose levels start to drop straight away; medication can be reduced, appetite is reduced and weight starts to decrease. This allows medication to be reduced further, success reinforces motivation, and some people have even stopped taking the majority of their Diabetes medication, including insulin.

This is not to say it works for everyone. There are some who can't manage to construct an acceptable daily meal plan without carbohydrate, and others unable to tolerate the change to fat metabolism, which can result in headaches, constipation and fatigue over a transition period. Increasing emphasis on protein and vegetables can prove too expensive, although it is to be hoped that the reduction in total amount of food needed can offset the expense up to a point. Family circumstances are often the biggest barrier - it is not a suitable plan for children, other adults may not want to join in, and making separate meals can be impractical. I've thought about it for a while, and I'm not sure that I would be able to deal with the practicalities of this VLC option.

In between talking about the nutrition guidelines and explaining our low carb diets, I managed to include some audience participation, in the form of 'Find the Carbs'. I showed a selection of pictures of meals, and got people to tell me which components contained carbs, to illustrate how an acceptable diet might contain less carbohydrate than the traditional choices of toast, jam, cereal, fruit, yogurt and juice.

My talk seemed to go down well, and the whole event was very well attended. I met some more local Dietitians, which is always good to do, and the Diabetes UK local group committee and members actually talked to me a bit for a change. I still think I might not go to any more of their weird meetings, though.

Thursday, 10 April 2014

At last

In ski gear posing on mountain with ski village in the background
Les Deux Alpes, March 2014
I hope it's worth the wait, but just imagine my situation, each day knowing that there is no blog post waiting to be published. I have sinned, it's been a long month since my last confession. There has been a lot going on. I don't think there's ever been such a long gap between posts.

The last time I wrote was the week before my holiday. I went to the Snowdome to practise (what a good idea that was), dad went into hospital for his back operation, I went to work, badminton, the usual. Then it was off to France skiing for a week, home again and a lot of important admin stuff to catch up with, dad out of hospital, back to work, a Diabetes UK meeting. Last weekend was even more hectic: a friend over from Germany for a brief stay in order to sign paperwork so he could sell his house, and... The Hen Weekend.

Holiday


The holiday was great. It was a good group, almost everyone was congenial, and my biggest problems were a) the people who didn't look like their names, and b) breaking away to spend time on my own without appearing anti-social. In the end, I had to explain and apologise to the people who didn't look like their names because I kept calling them by the different names that I had conjured out of nowhere. I just resigned myself to appearing anti-social.

A vast amount of snow fell on our arrival day/night, which is heaven for experienced and skillful skiers. Since the instructor was an experienced and skillful skier, she took the group up where the snow was deep on our very first morning, when everyone was just getting the hang of skiing again after a long break. We were not experienced or skillful, and it was carnage. But nobody was hurt, and the rest of the week was fabulous. I am in two minds about repeating this type of holiday; I think on the whole I would prefer a less organised group and private lessons instead.

Work


The Structured Education sessions have been interesting. I missed week 2 because of skiing, which was a shame because it was the big one from the Dietetic point of view - focus on carb counting, weighing and measuring food. Week 3 involved talking about alcohol and eating out, and the nurses covered exercise. I am looking forward to when I start to lead sessions, which looks as though it won't be until June. Otherwise, consultations remain much the same, and I still find it fascinating to listen to people's stories about their lives, whether positive or negative. And the Diabetes department has already arranged its Christmas party.

Diabetes UK is dominating my thoughts at the moment, as I'm preparing my 30-minute talk for the weekend and attending another of their weird local meetings. My name is on the programme for Saturday's Diabetes Awareness Day, and at the meeting still nobody greets me with any glimmer of recognition. I did gain some understanding of the physiology of weight gain due to injecting insulin peripherally rather than having it released by the pancreas, so that was good. I left before the raffle. I really think I might not go to any more meetings.

Hens


Lola II, kayaking

Lola II decided to have a relatively low key hen weekend with just two of her friends and me. I was in charge of entertainments, although we agreed the basic agenda between us. Lola II put in some specific requests: Yorkshire puddings; a steamed chocolate and apricot pudding; sleeping in a tent; no veils, strippers or other tacky accoutrements of the vile and tasteless hen parties. With no time for blogging, I spent my weekday evenings making stew and puddings and cooking veg as well as preparing a guided tour of the delights of Leamington Spa based on the Discovering Britain website. Mr A put up the tent, which was christened the Hen House.

Lola I, kayaking
It went very well - we walked the walk, talked the talk, placed a bet on the Grand National, watched one of the worst movies I have ever seen (this was a mistake - it was well reviewed and featured quality actors like Terence Stamp and Vanessa Redgrave), ate stew and Yorkshire puddings and chocolate and apricot pudding, Lola II slept in the Hen House, and we went kayaking on the river. The highlight for me was none of these things - it was the revelation that Lola II needs reading glasses! After more than forty years, at last she can experience the interminable nuisance of not being able to see properly. I'm not gloating - I will definitely need bifocals at my next visit to the optician, and I'm thinking of getting reading glasses myself for when I wear contact lenses.

In other news...


The 'Couch to 5k' running programme continues to go well, despite interruption from skiing. I've completed Week 4 and am about to start Week 5 of 9; I have progressed from 60 seconds to 90 seconds to 3 minutes and now to 5 minutes 'running' at a time. I run on the circular path around the park, and this week there were a couple of women chatting and walking in front of me - as an indication of the speed I have achieved, I completely failed to catch up with them. I am concentrating on stamina and technique, I tell myself, I can work on speed later.

Lastly, you should know that the only reason I'm managing to produce this post is because I went to badminton (club #2) and the hall was locked up with nobody there. My loss is your gain on this occasion. I have a journal article to write after the weekend, so there may be another lengthy pause after this...

Two hens in sparkly spectacles

Sunday, 16 March 2014

Consultation skills

Leaves of a Swiss cheese plant in front of a window
National Botanic Garden of Wales, May 2013
It's been a good couple of weeks in the office and out of it. As highlighted previously, I have started the 'Couch to 5k' running plan and haven't yet missed a session. I didn't think I liked it much, except that I find myself almost looking forward to the sessions, and I can't work out what's going on. Lola II suggested it might be the dolphins (or 'endorphins' as they are more widely known). I have no idea. Anyway, I am now able to run, very slowly, for 90 seconds at a time. It is early days.

Patients come and go, and I have been enjoying hearing their stories and trying to encourage, guide and motivate them to achieve their goals. This idea of the patient owning and managing their chronic condition is not new or novel, but not often expressed. Because we often have lunch together, the team tends to share experiences of clinical situations quite a bit, and the underlying principle is often of the clinician 'treating' or 'managing' the patient, or generally telling or advising them what to do. I am making every effort, and getting increasingly more skilled at the opposite approach: not telling or advising them what to do. This takes an enormous amount of self-restraint on my part, but I think I am getting better at it.

For example, many of the patients I see have other conditions as well as diabetes. There are many different avenues I can follow in my dietary advice: a) general healthier eating (more veg, less saturated fat, lots of fluid, eating breakfast, less salt, oily fish twice a week etc), b) diet to influence blood glucose, c) dietary management of other conditions such as high cholesterol, high blood pressure, kidney failure, low calcium, anaemia and so on, and d) weight management - usually weight reduction, but not always. Looking at the patient's medical history and biochemical test results usually gives me an idea about what might ultimately have the greatest benefit on health.

But it is fruitless for me to decide what should be done and then do it. Diabetes is not like a broken bone - once diagnosed, it is not possible for a simple plan for treatment and review to be devised, implemented and followed up. It is a lifelong diagnosis where the majority of management and treatment takes place in the absence of any health professionals, done entirely by the patient. I even wince each time I write 'patient', because I spent a considerable amount of my career insisting that people are people and are not defined by their condition - they are not diabetics, they are people who have diabetes. Someone with diabetes is not ill, and is only defined as a patient when they turn up at the clinic. The rest of the time, they are in charge of their 'illness'. I don't have a better word yet, and would be viewed most oddly if I started to use the words 'client' or 'service user' in the NHS setting. But I digress.

The way it works is this. I invite the person into my room, introduce myself, and then ask either how it's gone since last time, or what's brought them to the clinic on this occasion? The idea is that they choose what we're going to talk about first. Obviously I might have issues that I'd like to raise, but my agenda is secondary.

For example, many people who see me are overweight, obese or morbidly obese. This may be the main 'problem' and if addressed, the majority of their other health conditions might be improved. But many people are happy with what they weigh and how they look, even though they are aware of the health implications. Many more are not happy but have tried many times to change and failed, or had succeeded, lost loads of weight and then put it all back on and more. Many are defeated. There is no point in me listening to their story and then telling them what to do. Nobody wants to be told what to do, especially by someone who only met you ten minutes ago and knows nothing about your life. They've tried over and over again, it didn't work, end of story.

Last week I felt my practising had paid off. An overweight lady was brought to me: "she needs to lose weight." This is often the first barrier - very few choose willingly to see a Dietitian, because they expect to be 'told off'. They know they have a problem, and they know the answer, everybody's told them they need to lose weight, they know they should lose weight but they've tried and failed and they don't see the point in having their noses rubbed in it, or exposing their weakness to a stranger. It's personal, uncomfortable, and emotionally painful.

The lady was happy to talk about her diet, but she didn't see what she could change. She told me about coming from a culture where being overweight is not a problem.

"So, you're happy with the way you are. That's good," I said.

Instead of agreeing with me, she continued to tell me about her diet, what she eats, how much she likes food.

"I get the impression that you don't really want to change anything at the moment. Is that right?" I asked.

Still no agreement. More information about her lifestyle. I must say, her cooking sounded amazing. A bit carb-heavy, but tasty.

"So, you don't feel that your weight is a problem. Would you like to talk about anything else? Do you have any other concerns about your diabetes?"

Again, she didn't really address the question I'd asked, but carried on chatting about her meals and her cooking. I felt like Jeremy Paxman that time he asked the prison chap the same question fourteen times. I just wanted her to agree that we could leave the weight thing alone, and then she could go.

But instead, she suddenly suggested a couple of things she might be able to cut out of her diet. I was genuinely amazed. I've always believed in this approach to consultations, where you get the patient to make the suggestions, but so often they hold back and hold back and eventually I give in. This time I think I was determined not to be directive, and for the first time, it really worked. We agreed on one or two goals, and arranged a follow up.

Whether she returns will perhaps be a test of success, and it's quite possible that she may not actually make the changes she suggested, or achieve the results she hopes for. But I would have suggested different changes, and she definitely wouldn't have taken those on board, and I definitely would never have seen her again. So we'll see.

Friday, 7 March 2014

What I've been reading

Image of the book cover

The Magical Maze: seeing the world through mathematical eyes
by Ian Stewart
"Enter the magical maze of mathematics and explore the surprising passageways of a fantastical world where logic and imagination converge. For mathematics is a maze - a maze in your head - a maze of ideas, a maze of logic."
This book is the basis for the Royal Institution Christmas Lectures of 1997 presented by the author. It has mostly familiar content (familiar to me, anyway) like the Monty Hall problem in the chapter about probability, and stuff about chaos and fractals. Some was new, particularly a chapter about why different four-legged animals have different gait, i.e. move their four limbs in a different order when walking/running. Despite the slightly weird story-like interludes between chapters, it is science that is well-explained without being patronising.


Image of the book cover

Bad Angels
by Rebecca Chance
"Step into Limehouse Wharf, the new, uber-luxury apartment building where Melody Down, an actress whose career is in tatters after too much plastic surgery has holed up to get her body and her boyfriend back. Aniela Jasicki, the nurse in residence, finds herself falling for the unlikely Jon Jordan, an assassin for hire who is also convalescing there."
Eleventh of my 12 Books of Christmas, and even the author describes it as a bonkbuster, so my expectations were low - but they were exceeded, as the writing was good and I can't complain that there was too much sex in it, given the genre. Obviously I won't be reading any more of her work if I can help it, but if you like that sort of thing, it's better than any of the others I've been subjected to since winning these 12 books. At the time I was pleased to have won, but my life has not been enhanced by the experience. Only one more to go, and it's a hardback, although I don't quite know what difference that will make.


Image of the book cover

Salvation of a Saint
by Keigo Higashino
"When a man is discovered dead by poisoning in his empty home his beautiful wife, Ayane, immediately falls under suspicion. All clues point to Ayane being the logical suspect, but how could she have committed the crime when she was hundreds of miles away?"
I read this one in just a day, mainly because I knew the truth would only be revealed at the end, and I couldn't bear to wait. It isn't as good as the first one (The Devotion of Suspect X) but still head and shoulders above other modern crime thrillers that I've read.


Image of the book cover

Dr Bradley Remembers
by Francis Brett Young
"John Bradley, aged seventy-five in 1937, reflects on fifty years as a general practitioner in Sedgebury in the Black Country, after being trained at North Bromwich Medical School. In the days before the National Health Service, he reveals how precarious the rewards of a practice could be and the parts played by chance and determination."
Based on a medical practice in a Black Country town from the 19th to early 20th century, the story covers the doctor's life including his marriage and the raising of his son, the growth of coal mining and the expansion of the small town into an industrial centre. It was easy to read, and quite an interesting historical account of 'medicine' as practised in rural England. The copy I have was given to my father as a prize at school - I don't know if he remembers reading it, perhaps he will comment?

Sunday, 2 March 2014

Running into the future

Lttle pink flowers
National Botanic Garden of Wales, May 2013
Looking back over the last couple of weeks, my diary is a desert; looking forward, it's a bit more interesting. I didn't have much to write about last time, and there's not much more this time, although I have been away on a two-day course intended to help me deliver the Structured Education for people with Type 1 Diabetes that we offer.

It was a good course, and I learned a few things, practised a few techniques, and gained confidence from the fact that I knew as much as anyone else about the subject. We were all Diabetes Specialist Dietitians and Nurses, as were the course facilitators. We all went out to dinner between the two days, and they managed to make it a learning experience by highlighting the difficulties of carbohydrate counting and insulin dosage and timing to those who'd never thought about it previously.

The team back home seem very easy-going about incorporating change into our course, and said before I went that they are looking forward to hearing about anything I think can improve our offering. I haven't yet observed our course so I don't know exactly what's in it and how things are done, but I'm looking forward to it now.

On the way I stopped off in London to surprise Lola II on her birthday, in collusion with Mr M. It is the first time that I have ever managed to avoid giving away a surprise; even Mr A managed not to spill the beans, so Lola II didn't suspect anything at all. When I tapped her on the shoulder she was so surprised that she said she couldn't quite understand what she was seeing - someone who looked a lot like me, but couldn't possibly be, because we were on the third floor of the Science Museum in London.

The Science Museum occasionally opens late in the evening with all sorts of activities - for adults rather than families on this occasion, and it was amazing to see throngs of people swarming around swigging from bottles of cider, taking part in a variety of science-related fun. The event that intrigued me the most was the advertised 'Silent Disco', where the music is conveyed via headphones. It wasn't quite as strange as I was expecting, because it was in a roped-off area in one of the main halls so there was quite a lot of ambient noise as well as the noise made by the dancers singing along. We didn't try it ourselves - there was a long queue for the headphones.

Disco moves with lights and headphones

That's about it for past activities; I try to avoid relating what is in the future, in case it doesn't happen after all, and in case it isn't worth writing about. But this is my 50th year, and this milestone has prompted me to make more plans than usual for things I both have and haven't tried before.

Many of my contemporaries are obviously reaching the same milestone, and it is interesting to see what some of them are doing, from a parachute jump to a trip to New York to a tea party to a first ski trip in Lapland. On my actual birthday I will be at home, but Mr A and I should be going to Cambridge Folk Festival shortly afterwards. In the meantime, I am planning to work up to running 5 kilometres using a set of 'Couch to 5k' podcasts from the NHS Choices website. I have also booked a ski trip for the end of March, which is making me unfeasibly excited. It is a trip for lone travellers (Mr A is not coming) and intended to help intermediate level skiers improve, and I'm looking forward to it a great deal.


Sunday, 23 February 2014

News of Lola II and Mr M

Perfect red rose with raindrops on petals
Groombridge  Place, June 2013
When things are going well, when there is no catastrophe to report, when all trots along in a routine and mundane manner, I am happy. But I am also at a loss to find anything to write about. There is no scandal, nothing to complain about, no disturbing incident with a patient at work, or a colleague. So you lose out, because I have nothing to write about me and Mr A and Lola Towers.

Although it is not true that nothing exciting has happened. Lola II and Mr M staged their second annual Film Festival, with eight films over the course of one weekend (Mr A and I attended four and it was excellent), and shortly afterwards announced that they are getting married. So that's nice. I am surprisingly enthusiastic about the event, although I think that it is a very thin veneer of enthusiasm that may be eroded surprisingly easily. I am going to host a very modest hen party and Lola II has promised that she will try not to tax my endurance by becoming a wedding bore.

This is one of the remaining weddings in my life that I must attend - the others are those of The Boy and my nephews and niece, but I hope they all wait until they are as old as Lola II and Mr M because then if I am still alive I will not be allowed to go because of chronic infirmity or serious eccentricity. They will all be glad that ancient Aunt Lola isn't coming because "she would embarrass everyone by lying down in the aisle to look at the ceiling, or singing lewd songs loudly at inappropriate times." I am looking forward to a time when I am able to be freely eccentric, because let's face it, there isn't much fun to be had when you can't play badminton any more.

Talking of badminton, I mentioned my difficulty with seeing patients in the consultants' clinics to some of the new club. One member used to be a GP before she retired, and she came up with a splendid idea which I shall try out. It involves coming up with a few questions on a piece of paper that the patient can answer while waiting, and this ought to help make my dietetic consultation more appropriate and potentially shorter. Now I just have to think of the right questions.

To finish this brief report, Mr A has written a blog post for a skibike website, reporting on our recent holiday. I have to warn you that it contains explicit images of Mr A's bare legs, so perhaps not suitable for the faint-hearted.

Monday, 17 February 2014

I like my job

Large thistle looking like a big pink flower
National Botanic Garden of Wales, May 2013
So far, I like my job.

I like the small team, the fact that we are mainly unsupervised and can do mostly what we like. I like the building, I like my office, I especially like the way that everybody comes together for lunch in the largest room. I can adjust 'my' heating, open 'my' window, and arrange 'my' furniture. I can always find somewhere to park on the site, even if not immediately outside the building. I can ask all sorts of people for all sorts of support, and so far they have not hesitated to do whatever they can to help.

Of course there are things that aren't so good. On Wednesday mornings I have to give up 'my' room to a renal Dietitian, but there are plenty of other places I can sit. We don't have any access to colour printing or copying in the building, but I believe we can go elsewhere if we really need it. These are small issues.

I have started to see more patients, and feel very pleased that I am almost keeping within the time limits allocated. One patient returned for a second appointment, and was extremely positive about how my advice had allowed him to make useful changes. There have been other patients who have not welcomed my input, but I have been content to leave them alone, and they may return for advice if they ever want it in future.

I've been given the job of reviewing the patient information leaflet that we offer on hypoglycaemia, and have included some of the great pictures that I produced last year. The draft leaflet is out with the rest of the team for comments at the moment; we'll see what they think.

A quick update on stuff outside work: no, there's nothing of any interest at all. I stupidly cut my finger on a tin can. I have a hurty arm, probably a result of the last wipe-out of the ski holiday and then exacerbated by badminton. My newest badminton club is very enthusiastic about the fact that I am eligible to play in matches; I am less enthusiastic, although I have said I will play if they are absolutely desperate. Mr A and I went dancing on Friday night; this is his latest plan to introduce some non-sedentary activity into his life. It was fun, but with two nights of badminton per week I'm not sure I will be accompanying him every time he wants to go dancing. The falconry centre has reopened after the 3-month winter break; it was interesting to see how the birds need reminding that they are expected to work for their living again. That's about it.

And it hasn't rained for two days!

Wednesday, 12 February 2014

Stuffed vine leaves

All the ingredients for stuffed vine leaves on the kitchen work surface
Ingredients
I don't think I've ever tried to show a recipe in one of my blog posts. For one thing, there are some great professional-looking food blogs that will make mine look very amateur indeed. But I did try to photograph my recent construction of stuffed vine leaves, thinking that it might be interesting. Let's see.

I took the recipe off a packet of vine leaves that I bought. It is slightly ambiguous, as I discovered when I attended a Vegetarian Society cookery course where they presented the same recipe. I decided that the rice should be raw; their version used cooked rice. I believe mine is the correct interpretation - cooking the rice inside the vine leaf wrappers swells and tightens the rolls nicely. Cooked rice just gets more soggy.
Two bowls with filling ingredients, one mixed, one not mixed8 oz / 225 g vine leaves
8 oz / 225 g white rice
2 to 3 tomatoes, skinned and chopped
1 onion, finely chopped
2 tbsp parsley, chopped
2 tbsp mint, chopped
¼ tsp ground cinnamon
¼ tsp ground allspice
salt and pepper
¼ pint / 150 ml olive oil
¼ pint / 150 ml water
1 tsp sugar
juice of 1 lemon
The packets of vine leaves I used to buy in our local health food shop matched the recipe, but the jars I now get from Lola II's local Asian shop contain twice as much, so I doubled up the quantities above. You can use brown rice, but the texture won't be as good.
First stage is to mix everything in the list from the rice up to the salt and pepper. Then roll the filling into the leaves.
The leaves are usually packed quite tightly in brine, so I tend to float them in a big bowl of water and gently rinse and separate them at the same time. So as not to have loads of filling or leaves left over at the end, I tend to divide them both up into three or four sections, keeping any scrappy leaves for repairing parcels that threaten to fall apart. My calculations didn't work so well this time, but I had some green cabbage festering in the fridge, so the last few rolls were in blanched cabbage leaves rather than vine leaves.

To get a good tight roll, I try not to put too much filling in the middle of the leaf. I fold the lower lobes up first, then tuck the sides in, rolling up and tucking in the sides alternately.



After rolling I pack them tightly in the largest pan I have, which happens to be a pressure cooker. I put them on a trivet to stop them sticking to the bottom of the pan. I forgot to photograph that bit, but you can see the packing arrangement below in the finished version.
Mix the olive oil, water, sugar and lemon juice and pour over the parcels in the pan. Simmer for 1 hour, cool before eating.
It is a lot of olive oil, so sometimes I'm a bit stingy with the oil and make up the volume with water. The total liquid needs to be enough so it doesn't boil dry during the simmering. I actually use the pressure cooker to reduce the cooking time to about 20 minutes, but it's not necessary. Nearly all the liquid should be gone by the end.

Cooked vine leaves in the pan with a few stuffed cabbage leaves

So what do you think? More cooking blog posts, or should I stick to the diabetes and the odd adventure with Mr A and Lola II?

Friday, 7 February 2014

Week two

Table, chairs, sink, desk and chair, window, filing cabinet, shelves
'My' office
The first day of my second week saw me thrown in well and truly at the deep end. I arrived bright and early, hoping to find time at last to get the room sorted, discover the contents of the filing cabinet, and look for all the official diet sheets or patient information or whatever I could find. Instead, I found a) a note from the main DSN saying she forgot to mention she and the other principal DSN wouldn't be around until lunchtime, b) a list of 23 patients who were due to be seen by the doctor that morning, of whom I could see as many or as few as I chose. I also found a small table had appeared in 'my' room, which was absolutely ideal for sitting with patients.

That was a difficult morning, because I didn't understand what was going on or what was expected of me. I tried to get an explanation from the Support Worker and the DSN working in the clinic, and they did tell me how the doctor worked and what all their roles were, but despite repeatedly asking for suggestions, I didn't get much help with what I was supposed to do. I did the best I could, and at the end I discussed how I'd found it a bit hard going, at which point the DSN said "Well, Dietitian X [one of my colleagues who comes over to participate in a joint renal and diabetes clinic] does it like [this], and it seems to work very well." That's what I wanted to know at the start of the day; I don't know why she didn't tell me then. It's all a very big learning curve.

Then on Wednesday I went to the meeting with four other Dietitians, three working in Diabetes in the big hospital and the community, and one working with obese patients. There are distinct differences in the services offered by this team compared with my previous team - for example, I used to offer support for a Very Low Calorie Diet (using meal replacements like SlimFast) to enable weight loss; this team advocates carbohydrate reduction and has two different programs to support this approach. My carbohydrate reference tables went down very well, but my hypo treatment illustrations provoked some discussion about whether the appropriate treatment should be 10g or 15g fast-acting carbohydrate followed by 15g or 20g slower acting carbohydrate.

The main problem through the meeting was that I had to interrupt them repeatedly to get them to explain all sorts of jargon and references to people, events, places, teams, programs and treatments that I wasn't familiar with. I didn't manage to get the full overview of the service that I was hoping for, but I can easily get back in touch to clarify and get more information at a later date.

I still haven't had time in 'my' office to get the hang of what goes on. I was looking forward to time on Thursday, when it didn't seem that there was anything scheduled. At the end of Wednesday, however, the DSNs mentioned that they wouldn't be around on Thursday because they were attending a study day on Type 2 Diabetes, so of course I asked if it would be suitable for me to attend, which it was. So that was where I went on Thursday.

It was a full day of talks from various doctors, nurses and researcher, but Ben Goldacre's views were thoroughly borne out when it became clear that the sponsor's products were featured heavily. It was useful to me anyway, because my knowledge of Type 2 and its features and treatments is a bit flaky. One of the strongest non-pharmaceutical messages that was delivered was that if you are diagnosed with diabetes and continue to smoke, then your risk of death is so enormously raised that if you understood the probabilities you would be thoroughly shocked. Maybe even shocked enough to stop smoking. I don't remember the numbers, but maybe I'll look them up when I get a spare minute. I have no idea when I will ever get a spare minute again.

I saw patients on Friday, which is my 'short' day, so I was home early. I had foolishly suggested to Mr A that we might go out on Friday night to a gig in which a friend was playing, and he was quite keen. I, however, had come to regret the suggestion and would have paid a considerable sum including body parts to be allowed to stay at home on the sofa. We went out, it was good, we came home very late indeed, and I slowly recovered over the course of the weekend. Then the working week started again...

Saturday, 1 February 2014

What I've been reading

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A Fatal Inversion
by Barbara Vine

narrated by William Gaminara
"In the long, hot summer of 1976 Adam, Rufus, Shiva, Vivien and Zosie are camping at Wyvis Hall. They don't ask why they are there or how they are to live; they simply scavenge, steal and sell the family heirlooms. Ten years later, the bodies of a woman and child are discovered in the Hall's animal cemetery."
I found this a rewarding experience, given my previous failures to choose suitable reading material (and I am looking warily at the last two books on my shelf from the 12 Books of Christmas from last year). The pace was good, it didn't confuse me with its characters or its flashback narrative, and I completely failed to anticipate what would happen. I had chosen it in the category of 'crime fiction', which I suppose it is, because you are told who the guilty parties are quite early on, it's just you're not sure exactly who's been killed and how. I'd certainly read another of hers.


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How to be a Woman
by Caitlin Moran
"It's a good time to be a woman: we have the vote and the Pill, and we haven't been burnt as witches since 1727. However, a few nagging questions do remain. Why are we supposed to get Brazilians? Should we use Botox? Do men secretly hate us? And why does everyone ask you when you're going to have a baby?"
Most of this book was about stuff I'm not interested in reading about - what society thinks about what women are and aren't interested in: feminism, periods, shoes, childbirth... Even the chapter that nearly corresponded to my own feelings about weddings wasn't enough to redeem the whole, even though she has a good turn of phrase. I know I should be reading more of the Forsyte Saga, because that always restores my faith in the pleasure of good writing, but it is too heavy and long for my current holiday mood.


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The Third Man
by Graham Greene

narrated by Martin Jarvis
"The British chief of police in a divided post-war Vienna is investigating the death of racketeer Harry Lime. Rollo Martins, a writer of Westerns, arrives in Vienna to visit his old school friend Harry, and gets inextricably involved in the mystery."
This only takes about twice as long to read than the film that was made of the story, a surprisingly short book, beautifully read by the master narrator Martin Jarvis. Audible only sells two Graham Greene novels, and it should get some more.


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The Color Purple
by Alice Walker

narrated by the author
"As a young black woman living in 1930s Georgia, Celie faces constant violence and oppression. Her story is told through a series of letters written firstly to God, and then to her sister Nettie."
At last, an engrossing and diverting book of quality. I hesitated to buy a book narrated by the author, because while authors are good at writing they aren't always good at narrating, but this was outstanding. Beautifully written, beautifully read, a story including some terrible subject matter but told with respect, subtlety and positivity. A joy to listen to, and unlike so many books I have read recently, I was sorry when it ended.


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Tuesdays with Morrie: An Old Man, A Young Man, and Life's Greatest Lesson
by Mitch Albom

narrated by the author
"Knowing Morrie was dying of ALS, or motor neurone disease, Mitch visited Morrie in his study every Tuesday, just as they used to back in college. Their rekindled relationship turned into one final 'class': lessons in how to live."
This is a really short book, and I'd read some very powerful reviews that prompted me to download it. Yes, it is good, but not THAT good.


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Bad Pharma
by Ben Goldacre
"Doctors and patients need good scientific evidence to make informed decisions. But instead, companies run bad trials on their own drugs, which distort and exaggerate the benefits by design. When these trials produce unflattering results, the data is simply buried."
Dr Goldacre writes very passionately and persuasively about the subject, but it is one that I find very tricky. As well as outlining the shocking distortion and withholding of the results of clinical trials, he also describes how healthcare professionals ought to behave in respect of their relationships with drug companies - basically, to steer clear of them in most circumstances. It is a situation, however, where the journey from here to there seems too difficult. If I want to go to a conference, it is highly unlikely that my NHS Trust employer will fund my attendance, but one of the drug companies might. The author's proposition is that industry would not spend its cash on this type of thing if it did not prove profitable overall, i.e. produce higher sales of a company's products. However, I am not a prescriber and have very little influence on pharmaceutical spending, so perhaps I can take the money? There is a training course that I would have attended if I had not left my last job, but the fee is more than £2,000. My colleague RSB was funded by a pharmaceutical company; I applied to the hospital charitable funds as an alternative, so there is a way forward, I suppose. It's certainly a complicated situation, and the problems are so deeply embedded that it is unlikely to be resolved for a long time, if ever. A recent editorial in the BMJ suggests some progress in Parliament, though.


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Swan Song
by John Galsworthy
"After years living in America with his mother Irene, Jon Forsyte is excited to be home and can't wait to show off his roots to his new bride. When Fleur Mont, his first love, hears of his arrival, she doesn't know what to feel."
I did return to the Forsyte Saga, which title I have found out refers to only the first trilogy; this second set of three books is officially called 'A Modern Comedy' and the whole thing including the third volume is 'The Forsyte Chronicles'. On holiday with time on our hands in the evening when the pistes are closed, I devoured it in no time. I don't think there's quite as much meat on the bones in this episode, but his description of Fleur's ambition and her devious plan is excellent. I have read that this is the end of the story of Soames and Fleur and Jon; the third volume deals with other cousins, but I'm looking forward to it nevertheless.