Thursday, 31 July 2014

Half a century


Empty barrack with columns, beams, paned windows
Block C, Bletchley Park
I can't believe it's a week since I last wrote something. Maybe time is passing more quickly, or more likely, there's much less that I feel like sharing publicly.

I have reached my half century without serious setbacks, and I feel most thankful. I enjoy what I do most days, and have been taking a bit more care to pursue activities that are both mentally and physically satisfying. Watching films and reading books as well as working, learning, writing and listening to music fulfil the intellectual criteria, and I've continued to play badminton twice a week even through the recent heatwave, when drinking more than a litre of water over two hours is often not enough.

Then there's the running. I completed my challenge of learning to run, and wrote about doing two Parkruns, so I knew I could run for 5 km. Looking back, I wrote at the time that I wouldn't rule out doing more, and in the last couple of weeks I've been out running on my own and did another Parkrun, and faster than before. It's incomprehensible. I still don't really like running, but I'm still doing it, even when it means getting up early at the weekend. If you'd told me even six months ago that I'd be running for the joy of it, I would have laughed in your face. I'll let you know when I've worked out what's going on.

Just to add to all of this, I decided not to let a whole summer go by without skiing, so I took myself off to the Snowdome to have a bit of a practice, thinking that it would be pretty quiet on a midweek day in July. It wasn't that busy, but still a few groups learning to ski. I found I hadn't got as rusty as I expected, and that an hour on the slope was enough to get me back in the swing of things. Time to book the next holiday?

Mr A has got a contract job, which is very good news, but as with all things relating to Mr A, it is stressful. There is a major deadline imminent, and no doubt some other deadlines to follow, which always puts the pressure on. He has, however, been getting some very good results in his latest Open University module. No particular news to report from Lola II and Mr M, who continue to get up to mischief at every opportunity. No news from the pub next door, and our house is still shabby but functional. The garden is even more overgrown than before, which is to be expected since I haven't been out there except to pick some mint and unblock a drain after a thunderstorm.

Main entrance to Bletchley Park mansionWe still have no working doorbell, and our (landline) telephone system relies on four handsets with rechargeable batteries, of which three seem to have stopped recharging. The batteries seem to be custom models soldered into the handsets, making replacement complicated. Note to those who telephone the house - if you leave a message we can play it back on the base station and then hunt down a handset that works, or phone back using a mobile. There is very little chance of us actually finding a working handset in time to answer your call. Or if we do, the handset will probably fail within a minute, cutting you off. And our mobile phones will probably not be in the same room as us...

Other recent events: a trip oop north to a barbeque with H&B, which was lovely. The mid-season falconry centre barbeque, which was pretty good considering most people there communicate better with birds than with strangers (I don't necessarily exclude myself from that description). A trip back to Bletchley Park, which has developed enormously since my last visit back in 2008. Re-reading that post, I learned a lot more detail on that visit about the actual decryption methods, presumably because I was part of a small academic group. This time the information was much more general: how the place was run, who was there, how it felt to be one of the workers rather than the exceptional genius of Turing, Welchman and the rest. The entry fee allows repeat visits for a year, and although I was there for about five hours I didn't see all that I wanted, so I'm planning to go back next week before my holiday ends.

Woodworking in the woodland
Mr A and I have also visited our southern friends who have bought a nearby area of forest, and are working to restore it to its original state by gradually getting rid of the planted softwoods and allowing native woodland to regenerate. They are also having fun camping there, and have started to create a mountain bike track and an obstacle course as well as hosting the annual 'Run Forest Run' (which, for those who have not seen the Tom Hanks film, is a rather amusing reference to Forrest Gump).

That's it. I've got stuff to do, packing for my birthday treat: a weekend at the Cambridge Folk Festival, where I have previously spent my 30th and 40th birthdays (and possibly also my 20th, although it's too far back for me to have recorded that attendance). Here's to the next half century!

View of Bletchley Park mansion across the lake

Thursday, 24 July 2014

Outpatients and inpatients: clinics and wards

Honeysuckle
Groombridge Place, June 2013
The consultant-led clinics have been a bit like a roller coaster for a week or two. One of our regular consultants has been ill, and sometimes another doctor has provided cover, and sometimes the admin staff have had to try and contact everyone to cancel at short notice, and sometimes patients have turned up and been seen or not seen depending on who's available and what's needed.

For one particularly busy pump clinic (where patients with Type 1 Diabetes who are using insulin pumps usually spend much more time with the Diabetes Specialist Nurse than in most clinics), we only had one DSN, and the consultant delegated the clinic to two subordinates, neither of whom was familiar with how to manage a patient using a pump. This meant that the poor DSN had to support the doctors as well as trying to do her own job. The whole thing provided a pretty unsatisfactory experience for the patients - none of whom complained, despite having to wait ages.

The whole scenario was relayed back to the consultant, who overcompensated the following week by bringing three doctors with him. Unfortunately we don't have enough rooms in the building to house all these doctors as well as ourselves, and consequently neither the DSNs nor I were able to see patients and we had to squeeze into rooms occupied by researchers and secretaries. There were also far fewer patients booked into this clinic than the previous week, which meant all these doctors had long gaps between patients. At one point, a patient with a baby and a toddler was dealing with a nappy change in the room I was in, and the only place left for me to sit was in the waiting room.

This is unusual - most of the time the clinics run pretty efficiently and on time, and most times I get to see the people I think I should be seeing. I have taken to advertising the very low carbohydrate lifestyle with a few posters on the wall, and flyers given to the patients that I think might benefit. This has rustled up a few candidates, and I am starting to build towards a group that can meet regularly to share experiences and recipes and generally keep each other motivated. There are plenty of others who don't need or want to follow that diet, and I am still seeing new people all the time. It is always very interesting, even if I sometimes end a consultation thinking that I could have done better. There are plenty where I feel I did well.

And in between all this interesting and rewarding outpatient contact, for the last five weeks I have had to spend a day a week on the wards. I've disliked this type of dietetic work from the start, and now I've come to hate it. I would rather spend hours with a recalcitrant diabetic who has no intention of taking any advice from me or anyone else while ignoring spiralling blood glucose, than 15 minutes trying to get a confused malnourished inpatient to drink a sickly sweet milky supplement because that's all we have to offer. I would rather be resigned to the inevitability of diabetic-related complications than despair at the likelihood of hospital-acquired pneumonia.

I have enormous respect for the nurses and healthcare assistants on the wards, who are frequently doing three or four things at the same time, often unpleasant and involving bodily fluids or orifices or both, and who listen to me with patience and good humour even while I'm telling them what they already know. But despite my regard for ward staff and their dedication to doing the best they can, the institutional setting thwarts most of their best efforts. I heard today about a patient with Type 1 Diabetes - elderly, frail - who kept having hypos while in hospital, so the doctor stopped their insulin. Just stopped it. Two days later, the patient had to be transferred to the main hospital for life-saving treatment in intensive care.

Our health service is amazing - the care that is offered without additional payment in NHS establishments is incredible. But I would do almost anything to avoid having to spend even one night in a hospital ward.

Monday, 14 July 2014

Diabetes services

Sunset over harbour and hills
Greek sunset, June 2014
I've got a half-written blog post that I've been trying to finish, but it's taking ages because it needs a bit of thinking time and I'm just not getting round to it. So I'll do some writing off the top of my head, just to keep things ticking over.

I'm still working five days a week, being paid for about five hours on that fifth day doing general dietetics on the wards, which means mostly nutrition support. The hospital is a small one with only six wards, and holds patients who are not acutely ill and/or who live in the area. They are generally old and not actually needing further treatment but cannot go home until some sort of provision is arranged to make sure they can cope (a 'Package of Care'). Nearly all those who need dietetic input are not eating or drinking well, usually because they have dementia. I absolutely hate it. I have two weeks to go before the Dietitian who has been off sick is due to return, and I shall do everything in my power after that to be completely unavailable for this type of work in future, although there will be a lot of moral pressure to 'help out' if a similar situation happens again.

My real job is still very interesting. I have managed to start two people on the very low carb plan, but unfortunately one did not return for the follow up appointment and wasn't answering the phone when I rang. My first Structured Education course for people with Type 1 Diabetes finished this week. This is designed to give people a lot of information and practical experience of how to best manage their diabetes, and we run it one day a week for four weeks. We had eight attendees, and all of them seemed to get a lot out of it. I found it a little stressful to have so much responsibility for delivering material that is so critical to the course.

At least half of the course is about carbohydrate counting. This is a skill that is fundamental to good control of Type 1 Diabetes for those who want to have the flexibility of eating what they like when they want to. Teaching carb counting is a core skill for a Diabetes Specialist Dietitian, and I would say I have reached an intermediate skill level - not too bad, but I've only been doing it in earnest for a few years. Nearly all of the people on the course have had diabetes for much longer than that.

Despite my nervousness, it went quite well, although I think I can improve with practice. We cover all sorts of ways of estimating the carbohydrate content of food - using food labels, weighing food and using reference tables, using apps, websites and pictures, and plain and simple educated guesswork. The part that makes me a little bit uncomfortable is that while my estimates are based on my experience with a number of different people as a day job, I don't actually act on the data and inject insulin, so I don't get any personal feedback about the accuracy of my estimates. When I get it wrong, it's someone else that suffers. I take this responsibility very seriously, so I often lose sleep worrying about whether someone I've seen in the day is going to end up with very high or very low blood glucose as a result of something I've said.

As well as the course and the individual consultations, there has been some discussion in the Trust and the Clinical Commissioning Group about funding to expand the very low carb programme that we offer. This has caused some controversy, because we haven't any solid evidence for its value in our service. We have lots of anecdotal evidence of patients who have found it life-changing (in a positive way), and we have a spreadsheet with lots of data, but the data hasn't been analysed and there's been no data collection from those who haven't found it helpful, nor have we sought views from anyone who may have experienced negative effects.

There are a number of healthcare professionals in our Diabetes service who are positively messianic about the plan, and they are all in favour of the expansion in funding because they have seen so many people find it beneficial. Having joined the service so recently I am more sceptical, and feel that we must carry out some analysis of our data to provide evidence of benefit and investigate any negative aspects properly. Our Team Leader has very sensibly defused the situation with an eminently rational proposal, including the view that we should be offering people choices rather than putting all our energies into selling the low carb idea.

Whenever I have met up with other Diabetes Dietitians, I have asked them their views on very low carb diets. So far I haven't met any that are offering anything like our plan, but they have all been very interested in hearing about what we do. I would like our next stage to be a proper audit of what we have, if not a research project culminating in a peer-reviewed publication, but I'm not volunteering for the job.

Wednesday, 25 June 2014

Sailing

Fishing boat moored
Ionian sea, June 2014
We were on holiday and now we're back, have been back for a week or more, and where has all the blogging gone? It's gone to work, that's where, with five-day full-time working for three weeks and the realisation that I had taken my extra spare time for granted over the last five months. I'd got used to being able to play badminton on Monday and Tuesday and have a lie-in on Tuesday and Wednesday, thus allowing me to function when necessary at work for the remaining week.

Coming back from holiday on Sunday, then straight into full-time hours for a week has also reminded me how old I am. One of the very young badminton players (i.e. under 30!) was talking about where she would be going to party on her birthday after badminton finished on Tuesday at 9.30 p.m. It made me remember that I used to do that once. It was lovely being young, and the observation that youth is wasted on them is becoming a common refrain. And no young person has ever or will ever understand.

Saturday morning was the first opportunity for lie-in, and what time do you think I woke up? 6 a.m, that's what time. Birds singing, sun shining, bin lorries reversing, distant trains and nearby cars and even more nearby snoring. I finally gave in at 7 a.m.

Back to the holiday - it was in the Ionian sea off the coast of Greece, in a very large catamaran with four other friends, and we stopped off on the coast of Ithaca and Cephalonia and probably some other places. I wasn't paying attention, really - I wasn't in charge, and there was nothing much to see that was memorable or of historical note in any of the villages or towns we saw, except a couple of presentation boards in the town square of Stavros on the island of Ithaca, suggesting that Odysseus's palace had been found. We didn't go to the site, though. It wasn't that kind of holiday.

Golden sunset over the harbour

Instead we sailed, and while our friends Mr and Mrs Captain who have their sailing qualification did the driving, the rest of us sat in various shady (or sunny) corners of the boat and read books or surveyed the scenery. It was a great holiday for reading. I thought there would be more swimming, but the water was still fairly cold. I did swim twice, and was reminded how buoyant the sea is - I think the last time I swam in salt water would have been in the King Alfred baths in Brighton when I learned to swim as a child with Auntie Sylvia. You can just float if it all gets too tiring.

Mr A became a knot specialist. We were all expected to help with the mooring, which is the trickiest manoeuvre in a sailing holiday when you don't want your enormous catamaran to come into contact with any rocks, jetties or other boats. This is quite important, I came to understand, a bit like the importance on land of not coming into contact with railway bridges or other cars or, in the sky, with other aeroplanes. I'm quite confident with my half hitches and clove hitches, and I could do a bowline at a push, but by the end of the week Mr A could do a bowline upside down while suspended from the dinghy. He actually practised tying knots with his eyes closed.

Mr Captain did most of the steering and played with the sails when there was wind, Mrs Captain was in charge of the anchor, and my special skill turned out to be driving the dinghy, which is needed if you have to moor at a short distance from the shore because the mooring is too shallow for your enormous boat. I only had a couple of goes at it, but they went quite well. Our other two friends on board were in charge of swimming and smoking roll-ups if these were needed, which they mostly weren't. In fact, Mr and Mrs Captain did 90 percent of what needed to be done, Mr A did 5 percent (mostly knots) and the remaining three of us did virtually nothing. I did cook lunch twice, so that was a small contribution. The other two did quite a lot of washing up.

The other notable highlights of the holiday:
- The three male members of the party had become friends through their participation in various off road motorcycle events and rallies. They found it impossible to walk down any street without stopping at least 1000 times to look at and discuss some form of motorised transport. A seemingly ordinary conversation about, e.g. the merits of a hat could suddenly veer off into tales of foolhardiness on some desert rally in Africa.
- I found a Factor 50 suntan spray (called P20) that doesn't contain poison, doesn't smell like rotting vegetable matter, and works so well that on a day when my arms were exposed to the Ionian sun for the full eight hours I still looked as though I'd spent an overcast day walking in Scotland. I am tempted to write to the manufacturer. It was the day we rented scooters and whizzed about on the island of Ithaca: great fun. The disadvantage of the wonderful P20 is that weight for weight it costs more than gold.
- Greek salads. Every day. And lots and lots of reading.

Table and chairs on the sea front

Thursday, 19 June 2014

What I've been reading

Image of the book cover

One Day
by David Nicholls

narrated by Anna Bentinck
"She peered up at him through her fringe as he leant against the cheap buttoned headboard and even without her spectacles on it was clear why he might want to stay exactly this way. Eyes closed, the cigarette glued languidly to his lower lip, the dawn light warming the side of his face through the red filter of the curtains, he had the knack of looking perpetually posed for a photograph."
Unusually, it's been a while since finishing this book before writing my review - but there's been a lot going on. It was interesting enough, and I enjoyed the concept of relating the events of one day over a period of years - a lot can be implied and you don't have to hear the detail, it certainly maintains the pace of the story. But in the end the characters weren't drawn sympathetically enough, and I didn't much like either of them, so it felt a bit shallow. Not bad though, and much better than my choices over the previous month.


Image of the book cover

Let's Explore Diabetes With Owls
by David Sedaris

narrated by the Author
"A guy walks into a bar. From here, the story could take many turns. A guy walks into a bar and meets the love of his life. A guy walks into a bar and finds no one else is there. When this guy is David Sedaris, the possibilities are endless, but the result is always the same: he will delight you with twists of humour and intelligence."
I like David Sedaris, and that's all that's needed for this collection of readings, some live to an audience, others narrated in the studio. There isn't much diabetes in it - in fact I don't remember any - but I do remember the owls, which are stuffed. He appeared live in Leamington Spa in March, and I would have gone to the show, but I was away skiing.


Image of the book cover

The Mask of Dimitrios
by Eric Ambler

narrated by Tony Gardener
"English crime novelist Charles Latimer is travelling in Istanbul when he makes the acquaintance of Turkish police inspector Colonel Haki. It is from him that he first hears of the mysterious Dimitrios - an infamous master criminal, long wanted by the law, whose body has just been fished out of the Bosphorus."
A title from my list of 'Classics' but from an author I hadn't heard of before. It's a historical thriller in the mould of John Le Carre, but written earlier last century, and includes historical detail about the politics of Eastern Europe between the wars that was wasted on me. A quality read, though, and worth the time spent.


Image of the book cover

The Alchemist
by Paul Coelho

narrated by Jeremy Irons
"Here is the magical story of Santiago, an Andalusian shepherd boy who yearns to travel in search of a worldly treasure as extravagant as any ever found. From his home in Spain he journeys to the markets of Tangiers into the Egyptian desert where a fateful encounter with the Alchemist awaits him."
Another book that appears on the 'Classic' list, quite short and poetically written, although that might be down to the translation. I think there is a sub-text in the story, but I'm too dense to pick it up - parables are not my thing. On the surface, a straightforward tale with a likeable hero and a happy ending.


Image of the book cover

Counselling People with Diabetes
by Richard Shillitoe
"This book takes you through the steps in the helping process; forming a relationship with the patient, agreeing goals for care, giving advice and information, supporting patients and families and helping them through difficult times."
This is a library book from work, not all that recent, but reiterating messages that are only refined and improved in newer textbooks. I'm attending the level 2 Behaviour Change course next week, so this has helped to remind me of the areas that I'm aware need more attention.


Image of the book cover

Relics of the Dead
by Ariana Franklin
"Medieval Glastonbury - human remains have been uncovered. Are these the bones of King Arthur and Guinevere? On hearing of this momentous discovery, King Henry II demands evidence that the legendary Arthur is dead. So he calls upon his Mistress of the Art of Death, anatomist Adelia Aguilar, to examine the bones."
I like the way this writer puts her mysteries together, making for a book that I end up reading at a wild gallop, reaching the end, and thinking, "I should have read that more slowly, I'm sure I would have enjoyed it even more." But when there's a plot to untangle I can't slow down - one reason that audio books are so satisfying for me: they make me read at a pace that forces me to absorb every word without skipping through.

Saturday, 7 June 2014

Shopping and running

Two croquet players and a garden urn with flowers
Just a nice picture from 2004

Good news

The gastroparesis article is finished, the editor seems to like it, and has sent a pro-forma invoice for me to submit. They are going to pay me! Given the amount of time it took, the hourly rate probably works out at less than the minimum wage, and I ought to declare it for tax, but on the whole I think this qualifies as good news. Finishing the writing has freed up my Tuesdays for more interesting things.

I have been on a shopping spree. Nearly all online, of course, but still, it felt like going into the street and throwing money at things that I've wanted to get for a very long time but it was just too much effort to go into shops. Quite ordinary things mostly: a dish drainer tray, oven gloves, electronic kitchen scales, a new kitchen bin. The bin is not ordinary because it is a luxury touch-top item from Brabantia and cost more than all the other purchases put together, but it is a thing of beauty while being utterly functional.

I also bought a new mobile phone, or more accurately, a phone contract that comes with a new mobile phone. It had taken me two years to bump up against the limitations of my first smartphone, but eventually I realised that I should be able to download more than two apps and use the camera without it seizing up. It took a few long sessions on the Internet and a fairly extended discussion in a shop, but my new mobile has changed my views on smartphones, and has excelled in an entirely unexpected field - my running.

I downloaded an app that used the GPS signal to track my location and speed. This was hopeless on the old mobile, but the new one coped very well. I turned the app on at the start of the run and then examined it at the end and it told me all about my route and speed and it was great. Then it emailed me a link to create a Spotify playlist, so I thought that would be fun. I no longer need or want the plinky-plonky music that came with the Couch to 5k podcast, but it's much less boring to run when listening to music.

The revelation came when I managed to put all these things together for my second Parkrun. The phone was robust enough to access and play the music, and I started up the running app alongside it and they both worked together, and I plugged in the earphones and I could listen as I ran. It wasn't even raining. All of a sudden, a few minutes into the run, the music was interrupted for a second and the running app gave me an update on how I was doing - how far and how fast I had run. I'm no newcomer to the power of the Interwebnets, but this was a combination of utility and ease of use that I found astounding.

So my running career has culminated in a time of 35-and-a-bit minutes for 5 km, which I am very pleased with. A friend was also there on Saturday, and speaking to him afterwards I was sure that I wasn't going to do any more runs, because all the way through I'd been thinking how tedious it all was, and how much more fun it is playing badminton. Subsequently, however, I looked back on the event with some pleasure, and now I'm not so sure that I won't do it again. I think our holiday will get in the way, but we'll see.

Lastly in the good news category, I spent the best part of a whole day cleaning the oven. Not good news in itself, but it doesn't half look nice when it's clean. That should last about a week.

Bad news

I mentioned that my ipod died and was revived - well, it has died again. Rather than ending my life, Mr A has generously lent me his, which is so far performing as it should, unlike my laptop. The poor laptop has been groaning and shuddering for a while, taking about 20 minutes to boot up and generally being more sluggish than a snail without a home. Mr A bought me a new hard disk and operating system, and once the gastroparesis article was finished I started installing it. Unfortunately, the new and powerful hard disk seems to overtax the geriatric laptop (born in 2009) so that after about 10 minutes of usage the fan fires up noisily and within a minute or two it shuts down without further ado. That's as far as we've got with the laptop. Mr A is experimenting with my ipod to see if he can keep it alive for a bit longer.

Meanwhile at work, there is bad news masquerading as good news. The Dietetic Manager is juggling her many fecund female staff who seem to come back from maternity leave for all of three minutes before admitting to being pregnant again, and that's not counting the ones whose family members require their immediate attention or are themselves needing some time away from the office. Not to make light of a distressing situation, one of the two hospital Dietitians where I work is unavoidably absent, and the Manager is taking none of my excuses or suggestions, and requires me to spend some time On The Wards.

I have tried to keep this to the minimum that is ethically possible, but I notice that I seem to think patients need a lot less attention than the Dietetic Manager does. I am going to have to see people in hospital beds who need nutrition support, and it is not the area of dietetic practice that interests or attracts me, which strongly suggests I am not going to be very good at it. Let's hope my attitude and out-of-date skill set doesn't land me in trouble. I really don't like ward work.

As a carrot dangling before my eyes, however, the same Dietetic Manager has suggested that more paid work may be available in Diabetes. This has been mentioned before, and timescales are vague, as are the actual content and location of the extra work required. I'm not holding my breath. I've started to enjoy my Tuesdays and I'm not quite so keen as I used to be to rejoin the world of full time work.

Ten foot thistle among the roses with me for scale
Also in the bad news category is the garden. I have done absolutely no work in the garden this year, which has left us with an attractive meadow instead of a lawn, an enormous amount of foliage covering every inch of soil, most of the walls, and causing the 'paved' area to resemble, well, more garden. We are about to go away for a week, and it keeps raining, so the plants may well have staged their bid to take over the house as well by the time we get back. If you look closely, the picture shows the dominance of the ten-foot thistle over the puny efforts of the human race. Although its two colleagues were broken by wind/rain, it has latched itself on to the rose bush and shows no signs of halting its assault on humanity. Luckily, its legs have not yet formed so we may yet be able to conquer it when the time comes.

Lastly in the bad news category, you may have noticed a lack of book reviews (good news for some, I believe). I have picked on the book 'Middlemarch' for leisure reading, and it is proving to be hard going. I've found a few good audio books though, and shall take some less heavy duty reading on holiday next week. I wonder how many I should pack?

Oh yes, our doorbell has stopped working too.

Saturday, 31 May 2014

Very low carb diet

Scrambled egg with dill, creme fraiche and tomato salad
Low carb breakfast
As planned, I started my very low carbohydrate regime after the wedding. In brief, this involves: no sugar or starchy carbohydrates at all - no bread, pasta, cereals, rice, potatoes or flour, no cakes, biscuits, sweets or full sugar drinks. Fruit is limited to 100g per day (about a handful) of berries (strawberries, raspberries, blueberries, blackberries etc.), pulses are limited to 30g cooked per day (about 1 tbsp), nuts and seeds are limited to a small handful, and you can have 3 portions of dairy produce (to provide calcium) but not flavoured or sweetened yogurt. A multivitamin is required because of the exclusion of a whole food group. Lots of low carb vegetables are encouraged, ground almonds and coconut flour can substitute for wheat or cornflour (up to a point), and monounsaturated oils are recommended. Unprocessed forms of protein are deemed better than processed due to the potential for inclusion of carbohydrate fillers.

It has been easier than I thought it would be. I like protein and vegetables, so evening meals have been fairly straightforward: meat or fish and vegetables or salad. Lighter lunch meals have incorporated leftovers, or I've had vegetable sticks and dips like salsa or guacamole, or vegetable soup with a swirl of plain yogurt sprinkled with seeds. I thought breakfast would be the most challenging, especially on a work day when there isn't a lot of time, but it turns out that I like plain yogurt with berries and flaked nuts more than I thought I would. When there's time, breakfasts are egg-based - poached, fried, scrambled or an omelette with one or more of tomatoes, mushrooms, bacon, smoked salmon, cream cheese or herbs.

I thought I would miss pasta and rice, and when Mr A has cooked them for himself they smell lovely but I haven't been tempted. Luckily there has only been one cake at work, and it wasn't very attractive so not hard to resist. I've snacked on unsalted nuts or vegetable sticks, and a couple of squares of 85% cocoa chocolate are allowed, as well as 'Atkins bars' which I have felt obliged to try, but don't really like much. They're expensive, too.

The key to success has been planning, because I can't just grab a piece of toast or bowl of cereal if I'm in a hurry. So I have my week's meals scheduled, and at each meal time I consult the sheet of paper to find out what is on the menu. Tonight we're having mozzarella, some antipasti from a jar, a tomato and basil salad and grilled courgettes and peppers. Tomorrow it's haddock proven├žale from the BBC Food website. Mr A bulks out his meal with the carbohydrate of his choice.

Side effects can include headache, nausea, fatigue and constipation, but are usually mild and short-lived. I felt absolutely fine until about 10 days in, when I had a niggling headache for a couple of days - but it may be just a coincidence. I've lost a little bit of weight, only 1 kg, and I suspect it's because of not being able to tuck into the usual amount of work-based cakes and biscuits, and the odd slice of bread between meals, plus all the running that I'm doing. But I'm not the target candidate for this diet, which is squarely for the benefit of overweight people with Type 2 diabetes, in order to help them reduce their blood glucose and curb their appetite. I still haven't recruited any patients to actually start the very low carb diet for real, but I have produced a poster and some flyers that will be given to likely candidates during clinics, to see if I can rustle up some trade.

We had a Diabetes Dietitians' meeting this week, where we discussed exactly how much pulses to allow, and whether we should tell people about low carb bread, and what exactly is the recipe for ground almond pancakes. There are some recipes that the other Dietitians have tried, for linseed bread and low carb cake, but I'm not sure I can be bothered because I don't mind not having bread and I didn't bake cakes even when I was eating carbs. I did try to make the ground almond pancakes, but they just tasted like gritty omelettes, hence the discussion about the exact recipe. It was all very interesting - four out of five of us are on the diet, with one doing it seriously and the other three dabbling. I'm adhering to it strictly for these three weeks up to our holiday, but we'll see what happens when we're away, and when we come back.

Leek and mushroom soup with yogurt and mixed seeds

Sunday, 25 May 2014

Married

Lola II and Mr M with an intricate handmade card

I have been quite exhausted. Everyday life has been taking its toll, plus assorted incompetencies and disorganisation, plus unnecessary enthusiasm for things that are just tiring but seem to be Worthy. Where to start?

Lola II and Mr M iz Married. This occurred at the end of a three-day period of celebration in which Mr A and I were given Too Many Things To Think About, which addled our brains to the extent that we were almost unable to remember our own names (even though we had multiple lists). In chronological order, Mr A left his suit at home and we had to go back and get it, we forgot two mackerels and a jumper at Lola II's house and had to go back and get them, I forgot my outfit at home and had to go back and get it (but we were a LOT further away than when we went back to get Mr A's suit), Mr A backed the car into a tree making a dent in the tailgate and breaking the rear window, we spent a BBQ variously phoning insurance and auto glass companies, I left my fleece at Lola II's house, we borrowed mum and dad's car while ours was being fixed, and Mr A and I were each entrusted with a secret thing from each of Lola II and Mr M that we were supposed to not tell the other until they were about to go off on honeymoon. Collecting wedding gift pledges was also my responsibility, but has been a trivial amount of effort compared to the rest of it.

But it was lovely really. There was a party for friends and family on the Saturday, we had a Dim Sum lunch before the ceremony and tea and cake afterwards, Sister D briefly played the piano in St Pancras station, there was a highly entertaining photographer, but the bit that made me laugh the most was the impossibly rude assistant Registrar who completely messed up the start of the ceremony itself by not being able to work the CD player. Mr M chose the music at the start, which was provided by a recording of some of Lola II's friends playing a string/piano piece, and Lola II chose the music at the end, which was 'Bring Me Sunshine' and we all had a little dance. Well, those of us with little or no dignity, anyway.

Enough wedding. The car survived. We survived. We got back a bit later than planned because of the car window repair, next day I had a diabetes meeting to go to in the evening (all about Insulin Pump Therapy), the next evening was the badminton association AGM, the next evening we had to go to meet friends that we're going on holiday with, and then it was Friday and I went to bed at 9 p.m. Which meant that when I woke up on Saturday it was early, and I could get to the start of the local Parkrun by 9 a.m. So I did, and it rained fairly hard throughout the event, but I only walked for about a minute on the steepest bit of hill and finished in 39 minutes and I wasn't last! Apparently, I came 11th in my category (Veteran Women aged 40-49 with dark curly hair wearing black socks). I haven't yet decided whether to nominate the primary endpoint as running 5 km, in which case I can stop now, or continue until I can do it in 30 minutes, or give up when I'm not improving my time any more. It was more fun running on a course with people about than in the park on my own. I'll probably do one more, especially if it isn't raining next week.

Which reminds me (how could I have forgotten) that my ipod has packed up, and it's the end of my world. I use that thing every single day, and I am feeling its loss acutely. My laptop has been pretty unwell for a while (its latest trick is to decide that it doesn't have a second monitor attached and just turn it off), and then the ipod started to skip tracks and parts of tracks so I tried to reset it, at which point it decided to successfully wipe its contents but refused to start up again. I have found a set of instructions to help me troubleshoot, but I might just go and get another one because I literally can't manage without it. Really, I might die.

Mr M and Lola II during the ceremony

Friday, 16 May 2014

Ketosis and ketoacidosis

Pink fluffy flowers
National Botanic Garden of Wales, May 2013
When I was visiting Mr M and Lola II recently, Mr M and I had a brief discussion about ketones which made me think harder about exactly what happens when carbohydrate is restricted in ketogenic diets. Here is what I think.

Without diabetes


The body's fuel of preference is glucose, and its main source is from the digestion of carbohydrate foods which delivers glucose into the blood. Insulin is secreted from the pancreas in response to rising blood glucose, so when carbohydrate is plentiful and blood glucose levels are high, levels of insulin in the blood are also high. Insulin has a number of functions in the body, two of which are facilitating the uptake of glucose from the blood into cells so that it can be used as fuel or stored as glycogen or fat, and also preventing the breakdown of glycogen or fat in the liver and adipose tissue. It makes sense: if you've got fuel coming into the system from food, there's no need to retrieve fuel from stores.

In a non-diabetic person, in the absence of dietary carbohydrate the blood glucose is low, consequently insulin levels are low, and the inhibiting effect of insulin on the liver is reduced. The liver sends its stores of glucose into the blood and just enough insulin is secreted to allow uptake by cells to use for energy. When liver stores of glycogen start to run out, fat starts to be broken down for fuel. One of the byproducts of burning fat is the production of 'ketone bodies' or 'ketones', which are used for energy in a metabolic state known as 'ketosis'. This is entirely normal, especially when someone is deliberately trying to lose weight, and is variously called 'physiological ketosis', 'dietary ketosis' or 'starvation ketosis'.

In this situation, low levels of ketones are detectable in the blood and urine, and blood glucose and insulin levels remain at the low end of normal. If the level of blood ketones rises then insulin production is triggered, which halts the breakdown of fat and the formation of ketones. Through this feedback loop the level of ketones is kept within normal physiological limits while at the same time the body is supplied with sufficient fuel for its needs.

Type 1 diabetes


The word 'ketone' is a danger signal for people with Type 1 diabetes, because they are taught to test for ketones when blood glucose is high. A high level of blood ketones can be life-threatening, but this is because of ketoacidosis rather than ketosis.

In Type 1 diabetes it is possible for the level of insulin in the blood to be insufficient irrespective of the level of blood glucose. This could be because insulin has not been injected, or the insulin has been denatured or spoiled, or because of illness*, or for a number of other reasons. If insulin is lacking then glucose remains in the blood and cannot be taken up by the cells of the body, which mimics a state of starvation. So the liver starts to break down glycogen and fat to be used for energy, increasing the level of useless blood glucose and leading to the production of ketone bodies. Because this can only happen if you have Type 1 diabetes (or a very advanced stage of Type 2 Diabetes where the pancreas cannot produce any insulin), it differs from 'physiological ketosis' and is called 'diabetic ketosis'. The way to tell the difference is that with physiological ketosis blood glucose levels are low, but in diabetic ketosis blood glucose is high.

Ketone bodies are acidic, so in prolonged diabetic ketosis the blood becomes more and more acidic, which is definitely a bad thing. Because insulin is missing, the feedback loop to keep ketones within physiological limits doesn't work. Unless sufficient insulin is given, diabetic ketosis progresses fairly quickly to diabetic ketoacidosis, or DKA. DKA is what people with diabetes used to die from before insulin was discovered and isolated. People with Type 1 diabetes receive grim warnings that if they detect blood or urinary ketones above a certain level and are unable to reduce their blood glucose by injecting insulin, then they are to waste no time in getting to a hospital emergency department, especially if they have stomach pain or vomiting.

Ketogenic diets


This type of diet severely restricts the intake of carbohydrates in order to induce physiological ketosis. Ketogenic diets have come in and out of fashion, having been used to treat epilepsy since the 1920's, and rising in popularity more recently in the form of the Atkins diet. The current evidence suggests that they are safe, don't increase risk of cardiovascular problems as long as the type of fat is predominantly unsaturated, and seem to be an effective route to weight loss although it is not really known exactly why. A ketogenic diet is increasingly popular in improving glycaemic control in people with Type 2 diabetes, and can also be useful in Type 1 diabetes but needs to be very carefully managed so as not to result in DKA.

This is the basis for the very low carbohydrate diets that we promote to our patients. I have had little luck in 'selling' them to my patients so far, so in an attempt to become more familiar with the practical aspects I am planning to adopt a very low carb diet myself. I will be starting after the weekend, and probably ending after about three weeks when we go away on holiday. I will let you know how it goes!

* Illness completely messes up glucose metabolism in Type 1 diabetes in a way that I am not confident to write about yet.

Saturday, 10 May 2014

Teaser

View over a low wall into a sunny cemetary
On my way to work, July 2013
There has been a whole lot less badminton and many fewer meetings in the last week, especially as there has been another Bank Holiday. Mr A and I travelled south for a lovely lunch in celebration of dad's birthday, followed by dinner separately with Mr M and Lola II, who wasn't well enough to go to the lunch. I spent most of the rest of my days off working on the gastroparesis article, which still needs more work, but is much nearer to being finished.

At work I observed the presentation used by the other Diabetes Dietitians to start people off on the very low carbohydrate diet, so that I could get a feel for how to 'sell' it in my own service. It was a useful experience and I am becoming better informed about it all, but I think eventually I will have to try it for myself. So far, none of my patients has committed to it, although one or two are thinking about it.

There was a bit of badminton business this week - as the season is ending, my second club held a tournament and I came second out of the ladies. Meanwhile it is AGM season, and as I am Secretary of my first club, there is more admin than usual. With very low expectations, I mentioned that I would be happy to give up being Secretary if a volunteer could be found, and lo! a volunteer appeared! This is unheard of among all badminton clubs where I have been a member (and that's quite a few), but very welcome indeed. Still two AGMs to attend before it's over, though.

I am trying to write quite a technical piece about ketosis which I was going to include in this blog, but it is taking much more time than I thought it would. It turns out that making metabolic pathways comprehensible to the average reader is pretty difficult, and I also found gaps in my own knowledge about the most technical bits. Rather than make you wait, I thought I'd just publish this short teaser, and come back to ketosis when I have more time. I have a 28-minute run to fit in this morning, followed by the first of a set of 50th birthday and wedding celebrations to attend!