Friday, 20 November 2015

Study Day

Round, ivy-clad decorative brick tower
Part of Rugby School, May 2015. I really like the slanty windows
I have mentioned carbohydrates on here so many times - they are the mainstay of the British diet in the form of cereal, bread, potatoes, pasta, rice, pastry and flour as well as all the sweet and sugary food and drink, fruit, milk and yogurt. Carbohydrate is also the dietary component that raises blood glucose in people who have diabetes, which can cause poor health in the long term. For this reason, we are coming round to the idea that it makes no sense to encourage people with diabetes to eat lots of carbohydrates.

A reduction in consumption of sugary food and drink has always been advocated, and not just for people with diabetes. This is why the 'traffic light' labelling system on the front of some food packets includes the amount of sugar. But starchy carbohydrate and natural sugars in fruit and dairy products were not restricted in the past, despite the fact that they are also converted to blood glucose when they are digested. Glucose from starchy food, fruit, milk and yogurt enters the bloodstream a bit more slowly than glucose from sweet things, that's all. But if you don't have diabetes, you only really need to care about sugar.

So when people with diabetes come to see me, they always know that they're not supposed to have sugary foods, and they commonly mention that they have been told that brown, wholemeal or granary bread is good for you, as well as lots of fruit. Sometimes they say they can't have bananas or grapes. They have usually picked up this information from non-specialist Dietitians or nurses in their GP practice, or from friends and relations with diabetes.

It now seems to be accepted among Dietitians that limiting all types of dietary carbohydrate (not just sugars) is a valid and beneficial approach for people with diabetes, and very recently Diabetes UK seems to have accepted this idea and at last - at last! - the dietary advice on its website has changed. It used to recommend that carbohydrate foods should make up a third of your diet, or up to 14 portions of starchy carbohydrate a day. Now the same web page suggests you should 'try' to have some wholegrain carbohydrate every day, but acknowledges that you may be advised to reduce the amount of carbs that you eat.

Carbohydrate intake is only half the story; the other factor that leads to raised blood glucose in Type 2 diabetes is insulin resistance, which is often caused by excess weight around the waistline. Most people with Type 2 diabetes are overweight or obese, so I try to recommend that my patients replace the carbs with vegetables that are lower in calories than carbs, which should result in a calorie deficit and very welcome weight loss. Reducing carbohydrate intake reduces blood glucose levels on a day-to-day basis, and losing weight lowers blood glucose in the long term by reducing insulin resistance,

There are some who are not particularly overweight, and therefore cutting the calories from carbohydrates needs to be balanced by an increase in calories beyond what vegetables can provide. For these people we have up to now suggested protein and healthy unsaturated fats: monounsaturated (from olive and rapeseed), polyunsaturated (from sunflowers and corn) and omega 3 (from oily fish, nuts and seeds).

Diabetes Specialist Dietitians are generally a mild-mannered lot (as are most Dietitians). However, there is a militant faction of Dietitians who declare that not only is there no evidence of harm from saturated fats (derived from animal sources), but that these fats are positively beneficial. They promote a low carb high fat (LCHF) diet, and not just any fat, but saturated fats.

The difficulty is that these LCHF people are either deluded or they are visionaries, and we have no certain evidence to tell us which. On Friday I attended a study day where one of the highlights was a debate between a leading proponent of LCHF and a respected academic research Dietitian. Both argued their case admirably, although unfortunately the advocate of the LCHF diet was a little less articulate and let herself down with a couple of poor examples that weakened her case for me. In the end, the consensus is still that we believe saturated fat promotes cardiovascular disease, but there's a chance that it doesn't. Unfortunately it is impossible to conduct human trials that are sufficiently long-term, randomised or blinded to give us the evidence we need, especially as people eat food not nutrients.

The study day also included discussions about the pros and cons of weight reduction through surgery or extreme calorie restriction, the 5:2 fasting diet, a protocol for adjusting diabetes medication in a weight loss programme, and the AGM of the Diabetes Dietitians' Specialist Group.

The session about the 5:2 diet was presented by the Dietitian who invented it within the setting of breast cancer management, and she made the point that there are now three times as many books about the diet than there were participants in the trials that supported it. The diet she invented involved two consecutive days of very low calorie intake separated by five days of 'normal' eating, whereas the common version now in the public domain has separated these two fasting days. Evidence is scanty, trial participants were all women (breast cancer, remember), and the end message was that we have no long term evidence about either benefit or harm. It's pretty unlikely to do any damage (unless there is blood glucose lowering medication or insulin in the mix) so if it works and people lose weight then we're fine with that.

The other diet discussed was the 'Diabetes Reversal' diet pioneered in Newcastle, which involves restriction to 800 calories a day. The rationale for this was because people who have bariatric surgery for weight loss and who have Type 2 diabetes often experience sudden remission in their diabetes and normal blood glucose levels immediately post-surgery. The researchers wanted to investigate whether this outcome was due to extreme caloric restriction alone, or something else to do with the surgery.

Their original study put people on the diet for 8 weeks and required a portion of vegetables every day alongside meal replacement products, and it showed impressive results. They have followed this up with a bigger study - the biggest research grant ever awarded by Diabetes UK - which is for 12 weeks' restriction with meal replacements only. All the information about the original diet is in the public domain on their website, so anyone can try it, and a number of our patients have done so. We are now considering how to support our patients if they were to choose this option for weight loss.

The other sessions I attended at the study were interesting but not remarkable. Back at work, this blog comprises the main reflection I have carried out on the day's experiences. My colleagues are working on a way to offer people a choice of weight loss pathways and I'm planning to use their approach in my service, once they have ironed out the wrinkles.

Saturday, 14 November 2015


A selection of obscure Indian vegetables
Southall, November 2015
Our new data projector has been installed at work!! All those months of nagging and chasing have paid off, and at last we are able to display Powerpoint in our education room, along with videos and other Internet content. It's only taken about 18 months to achieve, and I'm delighted. My joy is somewhat diminished by the others in the department commenting that now they'll be able to watch TV at lunchtime. I'm hoping that they're joking, but I'm not sure that they are...

Meanwhile, I have been to That London again, this time entirely avoiding the horror of M&M World and instead having a lovely time celebrating Diwali with food and fireworks. For a few years Lola II and Mr M have made an annual pilgrimage to Southall which puts on a fine show for the festival of lights, and I joined them in an absolutely delicious Indian meal followed by standing on the railway bridge playing with sparklers and watching all the many different fireworks displays that are visible from that standpoint. I ignored Guy Fawkes night this year but I do enjoy a firework display, and ten simultaneous displays is even better.

I got there slightly early, and being the kind of obsessive Dietitian that I am, I made a point of checking out some of the specialist produce on offer in the local emporia. While I know a fair amount about Indian produce, the fresh green veg is a bit of a mystery, so I took lots of photos and I will have to do a bit of research later.

Lola II with a sparkler

Friday, 6 November 2015

What I've been reading

Image of the book cover

The Valley of Fear
by Sir Arthur Conan Doyle

narrated by Simon Vance
"A brutal murder in an English country house leads Sherlock Holmes to unravel the grim and gruesome story of the Valley of Fear."
I imagine Conan Doyle still resisting the pressure to produce yet more of these dratted Sherlock Holmes stories, so in this book he created a mystery murder that is solved by the end of the first half of the book, and then spends the second half writing a story that he actually wants to write. Which is perfectly fine by me, even though the fact that it is set in America makes the narrator's job a bit more difficult.

Image of the book cover

by Stephenie Meyer
"When Isabella Swan moves to the gloomy town of Forks and meets the mysterious, alluring Edward Cullen, her life takes a thrilling and terrifying turn. With his porcelain skin, golden eyes, mesmerizing voice and supernatural gifts, Edward is both irresistible and impenetrable."

I picked this up on a whim from a big box of free books, because in its day it gained a reputation for being as good as Harry Potter and because the films made of the story are supposed to be excellent. Well, it is not as good as Harry Potter, nowhere near as good. It is actually quite boring for 80% of the way through, then there is one huge exciting action-packed event for about 20 pages, and then it gets boring again. I really won't be reading any more of the series and I will be putting it back into the box of free books where it came from.

Image of the book cover

Equal Rites
by Terry Pratchett

narrated by Celia Imrie
"Right before the wise old wizard Drum Billet died, he passed on his magical staff of power to the newborn eighth son of an eighth son. Unfortunately, Drum Billet never bothered to check the gender of the newborn baby, and it turns out it was a girl."
After all those years of attempting but failing to read his works, I've turned into someone who actually likes Terry Pratchett. However, Audible should be ashamed of the audio quality of this book, which sometimes sounds like it was recorded at the bottom of a well, and at other times includes strange pauses in the narration. Despite these issues I did enjoy the overt and the implied humour - at one point I got the distinct impression that he was describing Discworld magic in the same terms as particle physics.

Image of the book cover

The War of the Worlds
by H. G. Wells

narrated by B. J. Harrison
"Giant cylinders crash to Earth, disgorging huge, unearthly creatures armed with heat-rays and fighting machines. Amid the boundless destruction they cause, it looks as if the end of the world has come."
To be honest, it isn't really a very good book, even though it's well known enough to be called a Classic. The story is told in a rather pedestrian way, nothing much happens and there's virtually no change of pace from start to finish. I wouldn't have minded much if the Martians had won, I didn't care about the narrator's missing wife, and it wasn't even a War - certainly the native humans did nothing but get killed or run away. It highlighted a bit about life at a time when horses pulled buses and flying machines hadn't been invented, but that's all it has to commend it.

Image of the book cover

Reverse Your Diabetes
by David Cavan
"Based on the latest research and proven results, this clear and effective programme outlines the key steps you need to take to turn around your health, and tackles the myths and misinformation that surround type 2 diabetes."
Obviously this is a work book, but it recommends something that is causing some controversy in the world of diabetes and lifestyle - reducing or limiting dietary carbohydrate. [I think the subject might need its own blog post quite soon, maybe after a study day I'm attending this week.] Apart from the carbohydrate thing, it covers every relevant aspect of Type 2 diabetes in a readable and not over-long book, and encourages people with the disease to take control by learning what they can do to improve their own situation, and then planning and making sustainable changes where they can. This is the textbook for my approach to diabetes. If only change were as simple as reading a book.

Tuesday, 3 November 2015

Nothing interesting at all

Mr M took this photo somewhere, August 2014
I'm sitting here thinking about what to write, but I can't talk about the main things I'm involved with at work and at home, either because of professional confidentiality or just because they're not appropriate for a public blog. So I'm left with a few inconsequential happenings - the boiler's had its annual service, I've made lentil soup, I took some garden rubbish to the tip, I had a massage. I sewed a bit more of the dress I'm making for sister D. I met a friend in Birmingham and saw the remodelled station with its John Lewis (good) and new branch of Wasabi food outlet (better).

I've written enough about badminton and running, books get their own post, and the films I've watched have been OK but nothing special. So what's left? Honestly, I don't know. I haven't done anything particularly interesting recently. The new car is running fine. The garden is running wild. The house still needs loads of work doing. I haven't been on holiday. The clocks went back so it's dark really early.

Lola and Mr M and vertical tubes of coloured M&Ms
M&M World. Just Don't.
I did go down to That London for a family event, and Lola II and Mr M took the opportunity to expose me to M&M World, which is four enormous floors of M&M branded tat right next to Leicester Square in the heart of the West End. They justified this 'experience' by saying that they are educating me in the ways of London folk, but I would prefer to stay thoroughly provincial and never see M&M World ever again. But I've given you a nice picture of Lola II and Mr M in front of the rainbow of pick 'n mix M&Ms.

All of a sudden, out of the blue, something slightly interesting happened at work - the IT guy turned up with four large monitors for us to replace the tiny ones we've been using and which work perfectly well. We beg, plead and pray for a data projector, but without even asking we get replacement monitors; it's very peculiar. And not really that interesting after all. Sorry about that. If we're lucky, something properly interesting will happen next week.

Sunday, 25 October 2015

Two busy weeks

Skyscrapers and blue sky
View of Chicago, June 2015
Remind me - what day is it? What am I supposed to be doing? Where should I be?

I like it when my days are full and it's busy, lots to do, people to see. A long afternoon stretching out with nothing scheduled and I get a little twitchy. But I have made a rod for my own back and overdone it a bit recently.

Of course, part of the problem is the extra-curriculars. If I hadn't agreed to be part of both Ladies and Mixed badminton teams, and continued to attend two different clubs, there would be a bit less badminton in the evenings. If I hadn't volunteered to do this 10k + obstacle course run in November, I wouldn't be doing so much running (although I haven't had time or strength to run for about two weeks). I've joined the work choir again this year, and we're having weekly rehearsals again. The basics of the choir practice haven't changed - a lovely leader with much more enthusiasm than musical knowledge who has again chosen carols that are pitched a bit too high for any of us to sing comfortably. I've admitted that I can play the piano in the hope that she will let me at least pick out the notes to help those singing the harmonies, but she hasn't yet called on me for assistance so I sing along with the rest.

So that's Monday to Thursday evenings fully committed most weeks - when I'm not playing or singing I'm too tired to run or even cook. At the weekends I sometimes run (I am very excited that I've now managed to do Parkrun 5k in under 30 minutes for the first time!), and plan and prepare meals for the whole week, assisted by the fact that I don't eat much on badminton nights and we've managed to get sponsorship for our structured education so that some Thursday lunches are provided. Which brings me on to work - there's quite a lot happening there too. The main thing is that we've been Windows Sevened. Is Windows 7 a verb? Yes, it is.

Apparently a few key people were aware this was in the pipeline but I was notified by email one afternoon that it was happening that night, so the next morning the Windows 7 tech team turned up to make sure everything was running as it should. Of course it wasn't. The basics were in place so we could use email, MS Office and most of the systems used everywhere in the Trust, but the specific diabetes systems were all over the place. The Windows 7 team asserted that they hadn't been told about any of those systems, while our team claimed that everything had been fully declared in advance.

Most of it has now been sorted out, the one remaining issue being an application that is used to download the data from a certain type of blood glucose meter and insulin pump, which is needed on six computers but is only working on one - mine. So every time a download is needed, my computer has to be used - actually that's not quite true, some of the meters can be downloaded onto a laptop, but only some of them and then we can't print anything. Chasing the Windows 7 team about this has been entirely fruitless - they are refusing to fix anything until the manufacturers of the software have sorted out how to download the data to a secure networked drive. It's very frustrating.

Would you like an update on progress towards having a ceiling-mounted data projector connected to a net-enabled computer? This is something that I asked about shortly after I started working in the Centre nearly two years ago. I started to make more of a fuss about it a year ago, and those holding the reins of power finally caved in and we started to apply for funding in December last year. The funds we targeted are in a specific charitable account that is managed entirely within the Diabetes service, which contained enough money to pay for the equipment, and our application met all the necessary criteria. Despite all this, we were up against a particular 'Jobsworth' character in hospital management - during the ten months that has elapsed one episode that stands out was when this person sent all the forms back to us by post because one box had not been ticked.

We were told, finally, that the whole scheme could go ahead about a month ago, but nothing has happened yet. Up to this point I have managed to resist becoming involved, mainly because I have no status with this charitable fund so could play no part in the application, but also because I knew the whole thing would wind me up - and it certainly has done that. I could hold off no longer, so now I am phoning our IT department and the equipment supplier at least twice a week until the ruddy thing is installed. I'm aiming to get it done before the first anniversary of the application starting. I am not confident that this is possible, not least because the quote is nearly a year old and I expect prices may have changed.

Meanwhile, my weighing scales have broken. I got in touch with people in the relevant department who arrived commendably promptly but were unable to fix the problem, so the scales have gone away with them. They were incredibly pessimistic about them ever coming back, and told me not to expect anything for a number of weeks. The scales were also provided by the Friends of the Hospital's charitable funds. It is sad to think that a department in a teaching hospital uses charitable funds for weighing scales and data projectors, but there are far worse troubles in the NHS than these minor issues. The NHS is pretty much broke, as far as I can tell from media reports.

My joy at having Tuesdays off has abated, but again it's my own fault. The DESMOND education that I am now qualified to deliver is also delivered by a different team, and I have long wanted to sit in on one of their courses to see how they do it and steal any good ideas. The disadvantage to this plan is that they deliver their courses on Tuesday mornings, so my lovely free Tuesdays have disappeared for the last two weeks while I watched them perform. I did get a few good ideas, but I'm still looking forward to a lie-in on a Tuesday. This coming Tuesday I've arranged for the boiler to be serviced at 9 o'clock. I should have asked for an afternoon appointment...

Alongside all of this bureaucratic mayhem I am still seeing patients, and our group education continues. Some of the patients on the very low carb diet are doing really well, everyone else is struggling as people will struggle when they try to changes habits of a lifetime. I'm getting a bit more proficient with insulin pumps, and was edged out of my comfort zone when I was asked to stand in for a nurse with one patient - this means advising on changing insulin dosage based on results of blood glucose monitoring, and is a bit scary. Luckily a nurse was around - in fact she was in the room using the software that only works on my PC - and helpfully chipped in now and again to agree with the advice I was giving, so that helped my confidence a lot.

Friday, 16 October 2015

Vroom beep beep

The car-buying ordeal is over. I have a car. It is a SEAT Ibiza, and it is white. At this point, I should include a stylish photo of me and the car, but for some reason I have not been taking many photos lately and I keep forgetting to do it during the daytime. So instead, I bring you a scarecrow dressed as a chef with a sheep under one arm.

A scarecrow dressed as a chef with a sheep under one arm
Harrogate, July 2015
It only took about six weeks to buy the car, and a lot of that was waiting because the most suitable was one being returned by a customer who replaces their car every year. I cannot believe that some people go through this every year, but maybe it's easier if all you have to do is choose the colour and accessories and hand over the cash on a monthly basis.

I got through three different salesmen in the week before taking delivery of my white car. I liked the first chap best, but he suddenly disappeared without trace (they weren't telling me where he went) and I got his manager next. He then delegated to a third salesman, who actually warned me in advance that he was leaving - he said it wasn't my fault when I asked. He told me that before this job he'd played rugby to a pretty high level, so he was moving to a job where he'd only have to work normal hours 5 days a week. Car salesmen work ridiculously long hours.

Cars, then. I'm not really interested in cars, I just want them to start up reliably when I turn the key, drive where I want to go without breaking down, and play my ipod through their speakers. So my total requirements included 5 doors, petrol engine, ipod connection. One reaches a compromise on age, mileage and cost. Fact: new SEAT Ibiza cars come in red unless you pay extra for another colour. Whoever first bought mine paid a premium for it to be white, and added mudflaps. I think the rest is standard.

Despite being standard specification, this car is more technologically advanced than anything I have in my house, including the laptop computer I'm typing on. I needed help to set it up and a lesson in how to use it before I drove it away. I will have to practise using the various features, especially the satnav thingy that also controls the music system and even lets me use my phone handsfree. There is a manual for the car, a manual for the satnav and a manual for the radio. I will be doing some more reading this weekend, except it is a bit boring so it may take a few weeks before I am competent to Bluetooth successfully. Whatever that entails.

The particular surprises I discovered when eventually I was shown 'my' car were not only the fancy shmancy satnav (which I'd been told about), but it also has parking proximity beeping sensors, and cruise control! This is a basic small car - cruise control used to be the domain of the travelling salesman doing 50,000 miles a year on motorways, not commuting up the road or the odd trip to Sainsburys. I have a proper long motorway journey coming up soon, so I'll give it a try then.

Update a few days later: I have now used the satnav thingy in earnest to find the location of my most recent badminton match, and it was rather good, unlike the match which we lost fairly comprehensively. Another good thing is that I have discovered one of the numbers on the fascia display tells me how many miles it will be before my fuel runs out (I don't yet know how accurate it is). More good news: the rear windscreen wiper works and all the interior controls light up with the headlights - these things are good because they are things that the previous car had stopped doing. I wouldn't be surprised if there is a beep if I open the door before I've turned the headlights off - I haven't tried it yet, but the Golf stopped doing that years ago.

A slightly less good thing is that as soon as the car is put in reverse the audio is muted in favour of the beepy parking proximity sensors. This is fine when you're listening to music or the radio, but I don't want to miss bits of my latest audio book just because I'm going backwards, so now I have to stop the ipod before putting the car in reverse gear. But maybe it will stop me hitting things when going backwards. I have never hit anything going backwards before, but you never know.

I very much doubt that in just under a week I have discovered all the things that this miracle of modern engineering can do. In future posts I may be moved to add footnotes of this variety: "You know my new car, well you'll never guess what it did yesterday..."

Friday, 9 October 2015

Getting things done

Close up of pink flower with yellow stamens
Peckover House, August 2014
The garden has been in need of attention for months now. It's not work that I particularly enjoy, although after everything has been cut back to within an inch of its life I take satisfaction in the brief period of orderliness before everything gets out of control again or the weather turns nasty and I don't go into the back garden for six months. It's a blessing that I don't have a front garden. Anyway, this was the weekend when I made a start, and managed about a quarter of the work needed. I could imagine making a resolution to do just an hour a day to keep things ticking over, but it's the sort of resolution that I know is worthless.

Not much else that is blog-worthy has happened. I have continued to do too much in the way of exercise, but have curbed my worst excesses and even left badminton much earlier than usual on Thursday. It occurred to me that I have been playing competitive badminton for about 25 years, first in Manchester and then here, and it isn't until now that I have regularly been picked for the 1st team. And it isn't because I have improved compared with my peers, it's more a reflection of the decline in popularity of badminton, and perhaps also my choice of club which contains rather a lot of 'veteran' players. Anyway, we won our first match despite my partner and I having met only a week ago.

At last I have returned to four-day working, and I have a long list of things that are awaiting my attention because I can't get round to them at the weekend. For my first day I took the garden waste to the tip, spent a long time continuing the process of buying a car (at least one further instalment will be forthcoming in this saga), spent an age on the hideous process of sorting out car insurance, did some cooking, some paperwork and that's all there was time for. Not many things get crossed off a long list in a single day, but it felt good.

On the list of other things going on: an update on the clarinet group. We had a bit of a hiatus after the hugely successful open air summer concert we put on in the rectory garden together with the flute and the saxophone group. First week back, and some new music (including top Christmas hits), with some parts specially written for me! It was lovely to play something a little bit challenging, and I may even try to fit in some practice, which I didn't need for any of the previous pieces. It's such good fun that I even imagined one day I might find time to source a new mouthpiece for my mothballed saxophone and join that group as well. Maybe one day.

Friday, 2 October 2015

What I've been reading

Image of the book cover

The Book of You
by Claire Kendal
"Being selected for jury service is a relief. The courtroom is a safe haven, a place where Rafe can’t be. But as a violent tale of kidnap and abuse unfolds, Clarissa begins to see parallels between her own situation and that of the young woman on the witness stand."
Absolutely not a book I would have chosen, but at the place where I worked one day a week they get through a lot of books so they offered a few to me. I gave this one a try and got away with it, but I don't enjoy reading about cruelty and abuse and feeling really tense, and the story isn't that good anyway - I didn't like any of the characters, not even the 'good' guy or the heroine. I avoid horror films for the same reason - some people must like feeling scared, but it would just give me nightmares. I won't be trying this experiment again.

Image of the book cover

The Return of Sherlock Holmes
by Sir Arthur Conan Doyle

narrated by Simon Vance
"The great Sherlock Holmes is back from the dead and devoting his life once more to examining the criminal complexities of the capital."
Poor old Conan Doyle wasn't allowed to kill off his hero, and here he is writing another lot of short stories to the same formula. Holmes: crime-solving genius, Watson: well-meaning duffer, with a side order of wily criminals and desperate clients and bumbling policemen. I love it.

Image of the book cover

Ten Things I Love About You
by Julia Quinn
"Annabel Winslow is in a pickle. Having newly arrived in London for her first season and being in possession of a voluptuous figure, is being openly courted the the Earl of Newbury, who is at least 75 and a nasty brute to boot."
Another ridiculous mock-Regency romance. Half way through I was determined to give up this author because all her books are fundamentally the same, and I may still pack it in. But I did enjoy it in the end. It's just that there are much more worthy and thoughtful books on my shelf waiting to be read, and spending time on this insubstantial fluff feels like a wasted evening.

Image of the book cover

Rabbit, Run
by John Updike

narrated by William Hope
"At twenty-six Harry 'Rabbit' Angstrom is trapped in a second-rate existence, stuck with a fragile, alcoholic wife, a house full of overflowing ashtrays and discarded glasses, a young son and a futile job."
What an excellent writer, and what a shame he has written such a horrible book. I was transported by the imagery he uses and his skill with words - wonderful, brilliant writing - but the people he has created and imbued with life are so mean, selfish and ignorant. Nobody is given any generosity of spirit and the lives they lead are bleak. Maybe this was the reality of life in 1959, and maybe I'm limiting my horizons by not wanting to read about it but I do want just a little bit of joy in my reading matter, and this has close to none.

Image of the book cover

Tom Brown's Schooldays
by Thomas Hughes
"The book is semi-autobiographical and is based on Hughes’ own experiences at Rugby school, including his respect for his schoolmaster Dr Thomas Arnold, who is portrayed as the perfect teacher in Hughes’ novel."
When I started this book it felt very much like reading a set text for English at school: a worthy book with plenty of material for O level essays. Despite the language and attitudes to class and religion typical of a book written in 1857, it improved no end as I went along. I enjoyed setting the scenes of school life into the same Rugby School I visited earlier this year, and relished the detailed descriptions of the life of public schoolboys so different from my schooldays forty years ago, and even more different from what I imagine schools are like today. It is a historical document as much as anything else, and that is the most fascinating part - how our values and attitudes have changed, and how much our present has derived from its past! I am almost ready to write that O level essay...

Sunday, 27 September 2015

Pumping insulin - Part 2

View of the hotel beyond a meadow
Coombe Abbey, June 2015
In part 1 I wrote about the basics of how a pump works in comparison with using insulin pens and MDI - multiple daily injections. Now we come to how I got on with the course, and some fancy features of the pump in more detail.

Tube or Not Tube?

The course I attended was run by a company whose pump delivers insulin to the cannula via a tube. Other pumps, like Mr M's, combine the pump and cannula in one unit and you stick the whole lot onto your body and control it from a separate handset. The pumps that we were using also had a handset that duplicated the interface on the pump and communicated with it via Bluetooth. The benefit of this approach is that when you administer insulin you can leave the pump in whatever inaccessible place you have stashed it - such as in your pants. Some pumps don't have this convenience, so you have to retrieve the actual pump in order to deliver insulin. You probably don't want to be fishing down the front of your trousers at the dinner table so your options for carrying the pump are more limited, and slinky dresses present a similar problem.

Here's a slightly blurry picture - the handset is on the left, and the pump with its tube is on the right.

There are a few different cannula types to choose from, but they all require you to stick a needle into your body. We were given the opportunity to try two types, one inserted manually and one using an insertion gadget, and I was very surprised that I hardly felt the insertion at all. You load the insulin into the pump either using a pre-filled cartridge or by filling the reservoir yourself with a syringe and a vial of insulin. Then you have to prime the tubing to fill it with insulin, connect the tube to the cannula and fill the cannula with insulin, and then it's all set and ready to go. The whole process takes a few minutes, which isn't long, but I imagine could be very annoying if it needs to be done at an inconvenient time.

Cannula, tube and pump connected to yours truly
Obviously I wasn't delivering any insulin through the cannula (I produce my own very nicely, thank you), and we weren't given strips to test our blood glucose. But we were given a pump to wear and encouraged to go through the process of estimating carbohydrate and programming a dose of insulin using the pump or its handset. This is something I'm pretty familiar with given that I've been interested in diabetes for some time above and beyond what the job requires.

12 hours connected to a pump

At dinner we were encouraged to estimate the carbohydrate portions and pretend to bolus insulin using the pump. I tend to forget that most normal people don't do this every now and again just for fun - for some it was actually the first time! We shared our guesses about the carbs in various dishes, and established the kind of variation in estimation that you get when there's no correct answer. But then one of the most enthusiastic pump reps suggested that to try and estimate carbs more accurately we should ask the chef, and then went as far as to haul the chef out of the kitchen to talk to us.

I had a problem with this. "Do you expect the chef to be more skilled at carb counting than a room full of diabetes healthcare professionals, including Diabetes Specialist Dietitians?" I wanted to know. Undaunted, the rep persisted in asking the chef his opinion on the goat's cheese tartlets. The chef obligingly came up with a figure. I continued to make myself unpopular. "What are you basing that figure on?" I asked. "Is it the pastry? How much does the pastry weigh?"

At this point there was a murmur from the room. My questions were perceived as 'a bit much' by some of the other delegates, and sympathy was building for the chef. He was prepared to take me on, though. He said, "I'm basing it on the pastry, and the cheese, and the onion."

"The cheese? But cheese doesn't contain any carbs..."

At this point the enthusiastic pump rep proposed a vote of thanks to the chef, we all complimented him on the delicious spread, and he was hastily bundled out of the room, poor man. Nobody wants a smartarse Dietitian making a chef look like he doesn't know his carbs from his elbow.

Pump features

Lots of the two-day course covered the range of sophisticated features available on this particular pump, many of which are possible on most pumps on the market. These features are designed to help the user decide on the dose of insulin, and deliver it over a period of time rather than in a single injection.

There are quite a number of factors that influence the delivery of insulin in addition to the quantity of carbs eaten - the type of carbohydrate (sweet, starchy, liquid) what is being eaten alongside the carbs (especially fat, protein and fibre content of food and drink), the size and duration of the meal (quick breakfast before work or three leisurely courses at a dinner party), time of day, ambient temperature, whether the user is ill or well, the menstrual cycle, the site of the cannula, planned activity or alcohol, recent past activity or alcohol, whether there has been low blood glucose in the last 24 hours... the list goes on. All of this should be considered before you can even take a bite. It's a massive overhead for something that most of us take for granted as we tuck into our food without a second thought.

The help that most pumps give is confined to the maths involved in applying a ratio of insulin to carbs and adjusting it for the factors given above. The 'bolus advisor' comes up with a suggested number of units of insulin to be injected, which the user can accept or overrule. Then the user can decide how those units should be delivered.

There are three different ways to deliver the insulin. A standard bolus just squirts all the insulin required over a few seconds, much as an insulin pen or syringe would. An extended bolus allows you to spread out the insulin over a longer period of time. You can have it delivered at a constant rate for the whole period of time you select, or you can combine the standard and extended bolus and specify 30% (or 50% or 70%) to go in straight away as a standard bolus and the rest extended over however many hours you want. This type of  'multiwave' or 'dual wave' bolus is for foods that are digested quite slowly (low glycaemic index or low GI), usually because a large amount of carbohydrate is combined with a lot of fat and protein. Fish and chips, pizza, pasta in a cheesy or creamy sauce and curry are the main culprits.

The third insulin delivery option is the super bolus. It's used less than the other bolus types, and is a more extreme version of the multiwave bolus for food that is digested quickly (high GI). It's a little bit complicated because it involves the background insulin that is usually not included in calculations around food. Remember, the background level is programmed automatically to feed insulin dripwise over 24 hours. For these high GI meals (think candyfloss, Halloween or birthday party) you calculate the insulin needed for the food, then you add on the amount of insulin that you'd be getting from background insulin for the next 2 (or 3) hours and give that whole amount up front. Then you turn off the background insulin for 2 (or 3) hours. It gives you a big 'kick' of insulin with the sugary food then turns it off so you don't go low later on.

Other features that may be used more often than the different bolusing options are the different basal profiles and temporary basal rates. The basal insulin is the background 'dripwise' insulin, and the rate it is delivered is programmed into the pump as a 'basal profile'. This generally varies hour by hour, giving a little more insulin in the early hours of the morning for example, when blood glucose naturally rises as the body prepares for waking. You may have different basal profiles if you work different shifts, for example, or if your routine and pattern of activity varies between weekdays and weekends. Temporary basal rates (TBR) can be handy if you are ill and you need more insulin, or if you are exercising and you need less. A TBR is selected for a number of hours rather than for a whole day.


Writing this pair of posts has reminded me just how much is involved in managing diabetes day-to-day, with or without a pump. It's a lifetime's work - I have left out far more in these 'essays' than I have been able to include. For example, how do we decide on how much background insulin to program into the pump, or how much to give for food? How do people manage sport or illness or pregnancy or holidays or airports? What if you get it wrong, or drop the pump or handset in the toilet, or run out of insulin or needles or test strips? What if you can't do maths, or read, or you live in prison, or are homeless? These are all matters for other blog posts on other days.

I complained to the last group we had for structured education that they had an advantage over me, because I can't experiment and test out my dietary theories. I can estimate carbs in meals and suggest matching insulin doses and bolus types as much as I like, but I will never know if I am right. Obviously they showed no sympathy (and I expected none), but having diabetes is a process and a lifestyle and a challenge as much as a diagnosis, and one that takes a lot of effort and commitment to master.

A pump doesn't cure diabetes, but it can help. There are other technologies being developed including the holy grail of the 'Artificial Pancreas' which is intended to match the natural pancreas even more closely, but even that won't detect blood glucose or deliver insulin in the non-diabetic physiological manner. Glucose-detecting contact lenses or wrist-watches have been proposed, but these are all sticking plasters on the gaping wound that is Type 1 diabetes, and we are nowhere near any sort of cure, or even identifying a cause.

Tuesday, 22 September 2015

Pumping insulin - Part 1

Garden and fountain in courtyard of hotel
Coombe Abbey Hotel and Conference Centre, June 2015
This pair of posts have been brewing for a very long time, mainly because it's an interesting but a complicated subject, and I wanted to make sure I covered as much as possible in one go. Mr M has written a guest post about his insulin pump, and reading back over that gives quite a comprehensive view of pumping. On the course I attended I discovered there is much more to say, and I won't even be covering everything in these two posts. For more information from people with greater expertise, go to the INPUT website.

The insulin pump course I attended took place almost immediately after my extended (TEN DAYS!) U.S. holiday and before my Solitary Holiday, and was held in a very posh hotel and conference centre constructed within a former Abbey with adjoining Country Park. There were no bedrooms, only 'bedchambers'. Initially I wasn't going to be staying overnight because it is well within commuting distance of home, but the company who organised the whole event contacted me shortly beforehand to say that some attendees had dropped out but their rooms were booked and paid for, so I might as well use one. Which was nice, because dinner was included and I probably wouldn't have stayed for that if I weren't staying overnight.

Insulin Pumps and Insulin Pens

In the UK, insulin pumps are only available to people with Type 1 diabetes, i.e. their pancreas is completely broken and not producing any insulin. As a Type 1 without insulin you end up dead before too long, so you have to inject a modified synthetic insulin into subcutaneous fat, which most people do using 'pen' devices. There are different types of synthetic insulin which have been designed to enter the bloodstream from the subcutaneous depot at particular rates. There are a rare few people who haven't moved on from bovine or porcine insulin and some who even use old-fashioned hypodermic syringes, but these are a tiny minority.

A working pancreas responds automatically to blood glucose levels, secreting exactly the right amount of insulin to maintain blood glucose within the ideal range. The person with diabetes has to take on the role of the pancreas by measuring capillary blood glucose via a finger-prick, then guessing at what blood glucose levels will do next, and injecting insulin according to their guess. Insulin pen users inject a long-acting insulin once or twice a day and rapid-acting insulin at mealtimes or with snacks, or else a twice-a-day mixture of long- and short-acting insulins.

The insulin pump is designed to try and mimic the physiological action of a working pancreas more closely. It contains a reservoir of rapid-acting insulin, and a background rate is programmed to inject this dripwise at an adjustable rate instead of the daily or twice-daily injections of long-acting insulin. With food there is the same process of estimation and guesswork about what blood glucose is likely to do, and the user tells the pump how much insulin to deliver from the same reservoir of rapid-acting insulin.

The pump delivers its insulin into subcutaneous fat via a cannula, which is a hollow needle made of metal or teflon that you insert into your body. The cannula stays in place for only two or three days otherwise you risk irritation around the insertion site and the formation of lipohypertrophy, which is a lump caused by insulin being delivered into a specific location for too long. Available sites are round the abdomen, the top of the buttocks, back of arms and sides of legs as long as there is a decent covering of fat - the same locations as for standard insulin injections.

Benefits and drawbacks

We often come across people in our service who are desperate to have a pump because they think it will make their diabetes management easier. In fact a pump is no easy option, and if you don't put any effort into managing diet and insulin and lifestyle then your outcomes will be as bad or worse than on multiple injections with an insulin pen. None of the benefits I list below relate to doing less work in managing calculations and all the rest of the overheads associated with doing the job of your defunct pancreas.

So what are the pros and cons of pump vs pen? The obvious disadvantage of the pump is that you're attached to it 24 hours a day, although you can remove some pumps for bathing or swimming or sports for up to an hour. Some people don't have any sort of a problem with having a pump attached to them day and night, at work, in bed, on holiday, doing sport - everywhere. Some people just don't like the idea, and ladies who want to wear figure-hugging clothing or a bikini may not be keen to display their condition. It's a very individual choice.

Disconnect the pump for more than an hour and you start to risk rising blood glucose levels, because you don't have any long-acting insulin in your system. After about four hours insulin-free there is the further risk of developing ketoacidosis, which is unpleasant at best and life-threatening at worst. So another disadvantage is that if anything goes wrong with the pump or your cannula or your insulin, you'd better have a back-up option handy or you might find yourself in A&E. If you're away from home, even on a short trip, you may find the journey cut short or have to make a whole lot of calls or trips to hospitals or pharmacies unless you carry spare equipment with you.

One clear advantage of the pump is fewer injections - in the three days that one cannula lasts you might expect to give at least 12 injections using a pen, and probably more. Another advantage of the pump is the ability to reduce your dose of insulin as well as increase it - with a pen, once the injection is given you can't dial the dose down. The third main advantage is that the background dose can be varied in a diurnal pattern that better matches the body's requirement for insulin, and the fourth advantage is that insulin to match food can be delivered in an adjustable dose over a period of time, which better mimics the action of a working pancreas compared with one or more isolated injections. Lastly, insulin pens only allow administration of insulin in whole (or occasionally half) units, while the pump can deliver much smaller amounts.

Other pump features

The pumps on the market also have no end of other features that are useful rather than necessary, like alarms, and the ability to download data from the handset and pump for viewing in all sorts of different ways designed to help you improve your carb counting and insulin delivery. The software for the pump that nearly all our patients use has some further features such as the ability to create a new profile by adjusting the background insulin up or down by a percentage - the alternative would be to change each of the 24 hourly settings using the pump or handset menus. The main feature that this pump lacks is the ability to upload all its data to the Internet so that it can be accessed anywhere. In our department we can only view the data on the specific computer that it's downloaded to, although we're working on a networked option so at least we can see the data on more than one computer in the building.

Mr M has a number of objections to the way the the software for his pump works that are probably a bit too technical to discuss here. I expect there are annoying features with every pump and handset. We recently held a session where we invited all the different pump manufacturers to show us their wares in an afternoon, and while they all do roughly the same job they are all quite different.

Coming soon: Part 2 of the Pumping Insulin series covers my own experience on the course, including wearing a pump myself for 12 hours.