Saturday, 21 February 2015

Wet walls and Not Very Well

Signs of damp on the wall
Hall wall, February 2015
It's been busy, but when is it ever not busy? There was the 3rd Annual Gulloebl Film Festival (Random Chairs in a Darkened Room) - 1 screen, in 1 venue, across Europe. There has been badminton club, a badminton match, three different health-related issues, car stuff, a trip to the National Exhibition Centre in Birmingham to look at tents, and an evening out with work people. And work, of course, except I had the day off on Thursday for the NEC tent thing and to sit on the sofa feeling poorly watching Seven Psychopaths on DVD (confusing, odd, violent, but ultimately a film worth watching).

Health issue no. 1 is tennis elbow, which is new to me but many badminton players and the Interwebs gave me advice and suggestions which seem to have worked - ibuprofen, strapping, a bigger grip on my racquet, changing my computer mouse to the other hand, and resting the arm (guess which one I didn't do?) I'm about to have a week off badminton, so that may give it a chance to improve some more.

Health issue no. 2 is a small cold or flu which seems to be going around - it was quite bad for about 24 hours but is now just niggling in the background. I thought I was going to be proper ill for my skiing holiday, but with luck it will be gone in a couple of days.

Health issue no. 3 happened at the restaurant where we celebrated a work colleague's 65th birthday. The chair I sat on was broken, and when I pulled it towards the table I found the seat wasn't attached to the frame. I trapped my little finger which is now going purple and giving me problems typing the letter a (and q and z but I don't use them as much. I haven't been to any quizzes. Ouch).

On the bright side, Lola II and Mr M's film festival was a hit - I attended four screenings this time, and the previews, trailers and adverts before each film were of the usual high standard. I even helped to create several of the Chinema classics featured on the two 'Now That's What I Call Chinema' albums. My few moments of stardom are showcased here and here.

Most of the rest of the week was a bit less delightful, what with the elbow, and we lost the badminton match quite convincingly, and the cold/flu, and the finger, and I had to have the car windscreen replaced because of a long and growing crack, and the car is making a new rattling noise, and the burglar alarm has gone wrong so we can't turn it on, and the NEC show wasn't as good as I'd hoped. The show occupied 5 halls of the massive venue, but only one was showing tents and it was geared at the large family and glamping market so there was hardly anything in the smaller scale I was looking for. Sprayway Hood River 3 and Vango Aura 300 are the most likely contenders from the companies that were represented, but I'm going to have to do much more research because there's a lot more out there that wasn't at the show.

And my biggest achievement of the week - I've had the hall roof fixed! The blessed Alf is busy elsewhere, so I have found a substitute whom I shall call Elf. He came and had a look and diagnosed rotten felt, which he has replaced with a rubber membrane. He even provided pictures:


I think that Elf has done a good job, and there is plenty more for him to get stuck into. One of the ideas I have is for him to spend a day as my personal slave, fixing all the indoor things that are wrong, like re-hanging a door, fitting a pane of glass, that sort of thing.

Now it's time for me to get packing - I'll be back in about a week!

Friday, 13 February 2015

What I've been reading

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The Mysterious Stranger
by Mark Twain

narrated by Don Randall
"The stranger comes to a medieval village in the persona of a beautiful, lovable, yet exasperatingly amoral young man claiming to be the blameless nephew of the devil. Befriending a small group of boys, he expounds on the Moral Sense which distinguishes men from brutes, and changes the lives of many of the villagers."
This seems to be a fairly obscure work - Twain's last, published posthumously. My limited research suggests he'd had quite a bad time in his last few years, and perhaps this book reflects his disillusionment with his fellow man. The Stranger's philosophy is that humans are worse than animals, who do not deliberately inflict pain or death on each other in the name of religion or moral goodness, and that there is no god and all reality is an illusion. The narration is astonishingly bad for a commercial publication - there is an alternative version available so I don't know why I chose this one.


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A Brief History of Time
by Stephen Hawking
"Was there a beginning of time? Could time run backwards? Is the universe infinite or does it have boundaries? These are just some of the questions considered in an internationally acclaimed masterpiece by one of the world's greatest thinkers."
I went to see the film "The Theory of Everything" in between reading the previous science book "In Search of the Edge of Time" and starting this. The film is based on the book written by Hawking's wife and the science content is brief and tangential to the life story, but it made a nice trio. I first read this book not that long after it was published in 1986, and it's difficult to remember whether I found new information in it, but I can't deny the fine writing making the subject extremely accessible. It would be interesting to know how much of the content still holds true, and where our current knowledge of the subject differs.


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Slaughterhouse-Five
by Kurt Vonnegut

narrated by Ethan Hawke
"Billy Pilgrim is a man who becomes 'unstuck in time' after he is abducted by aliens from the planet Tralfamadore. We follow Pilgrim simultaneously through all phases of his life, concentrating on his shattering experience as an American prisoner of war who witnesses the firebombing of Dresden."
Although this was obviously written very much earlier and is set in a very different landscape, there are clear similarities with 'The Time Traveller's Wife', which is one of my favourite books. I wonder if the author of the latter has ever acknowledged the connection? Many of the reviews I've read compare this book to 'Catch 22', another of my favourite books, but that similarity is less clear to me - they say both books are funny, but I don't think they are. I'm sure this is fine literature, and it's certainly well written, but I was looking for meaning in the alien abduction, or some connection with the Dresden fire-bombing, but could find none. I find many 'classics' similarly unsatisfying. But then, 35 years ago I got an 'E' in my English Literature O level, so what do I know?


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On the Way to the Wedding
by Julia Quinn
"Unlike most men of his acquaintance, Gregory Bridgerton is a firm believer in true love - he is just biding his time until the right woman comes along. But when she appears in the rather lovely form of Lucinda Abernathy, Gregory is dismayed to discover that she is set to marry another man."
Another trashy Regency romance - I mooched three of them at once, so another two are on the shelf for easy reading when days are short and nights are long. Not in the least taxing, nicely written and so straightforward that I don't end up feeling that I've missed something. What I don't understand is how I can bear this type of book but can't stomach modern chick lit?


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The Pursuit of Love
by Nancy Mitford

narrated by Emilia Fox
"Longing for love, obsessed with weddings and sex, Linda and her sisters and cousin Fanny are on the look out for the perfect lover. But finding Mr Right is much harder than any of the young ladies thought."
This book is the first of the trilogy - I read the second one first (Love in a Cold Climate), which was a bit of a shame, but still enjoyed this immensely. The characters are so real! I didn't expect to like Nancy Mitford so much, but she does seem to have a habit of bringing the book to an end very abruptly. The story shows no sign of stopping even though the ipod says there's only 20 minutes to go, and then wallop! it ends. We'll see if the third book does the same thing.


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Londoners: The Days and Nights of London Now—As Told by Those Who Love It, Hate It, Live It, Left It, and Long for It
by Craig Taylor
"From the woman whose voice announces the stations on the London Underground to the man who plants the trees along Oxford Street; from a Pakistani currency trader to a Guardsman at Buckingham Palace - together, these voices and many more, paint a vivid, epic and wholly fresh portrait of Twenty-First Century London."
Lola II loaned me this book and it's very readable and rather good. Lots of different people talked to the author and he has simply transcribed their words into short chapters. He could have talked to a million more people and their stories would all have been as interesting as the ones he has chosen.

Monday, 9 February 2015

Continuing professional development

Close up of yellow stamens in a red flower
Peckover House, August 2014
It's blimmin' cold. This is, of course, not unusual in the winter, but it's always at February time that I start to get impatient for better weather. It may be that the house - Victorian, no cavity walls - gently cools so that the heating becomes less effective as winter progresses, but I tend to wear thermals or a duvet if I'm going to be indoors and stationary for any length of time - like when I'm constructing these blog posts, for example.

I have been keeping myself busy with a lot of curricular and extra-curricular activities. I went to a very interesting meeting one evening about the new guidelines on treatment of Type 1 Diabetes that are due to be published this year by NICE. It is fairly esoteric and a bit technical; I thought about summarising the changes for the blog but it really would be of interest to only a very few, so I summarised the changes for my colleagues who weren't at the meeting instead.

This sort of thing is very useful for my professional registration. Every two years, 5% of registrants (i.e. practising Dietitians) are selected for audit of their competence to practice. This is based on evidence of activity during the previous two years that demonstrates that they have kept up to date with best practice through continuing professional development (CPD). Attending meetings is one of the activities that count, but it helps if you can demonstrate that you have reflected on the things you learned and applied them to your practice. Just attending isn't enough.

I am a bit obsessive about my CPD portfolio. I cut out articles from professional magazines, print blog posts, include copies of diet sheets that I have worked on - I assume that pretty much everything that I do could be deemed as evidence of CPD. They are very keen on reflection, so every so often I will consider something that has happened within consultations, and write a short reflective piece: "What happened? So what? What next?" Some of those Dietitians selected for audit have to piece together two years of CPD from looking at their diary and working it out from scratch, which is time consuming and hard work. If I am selected, I'm hoping it won't be too much effort to construct my account of the evidence that's needed.

I digress. One lovely bit of CPD is my DESMOND educator accreditation. As mentioned in the last blog post, I have now had my first Mentor visit, which involved being observed in two sessions, one about activity and the other about food and cardiovascular risk (fats and calories). The observer provided some really good constructive advice that I couldn't have worked out on my own - for example, I was aiming for open questions but kept starting with "Do you know...?" or "Does anyone know...?" which are actually closed questions masquerading as open questions. Very interesting, and I hadn't spotted that I was doing it until it was pointed out. The next phase ends with a final assessment at the end of March, if I can get things together that quickly.

Aside from work, I spent a weekend watching badminton in Crawley - the English National competition. Nowhere near as mind-blowingly good as the international competition that takes place annually in Birmingham, but I left it too late to buy tickets for the internationals and there weren't any good seats left. I booked a cheap last minute room in a very posh hotel and was very unimpressed when the TV didn't work, so they switched me to a room where the TV was fine but the heating didn't work, and when I complained again they supplied a convection heater. On the positive side, they had a little fitness room and I did my first ever run on a treadmill, which was much easier than running outside, so I ran further and for longer than ever before.

I spent Sunday at the falconry centre, helping them to get ready to open to the public again - I applied teak oil to wooden benches and moved large rocks for a few hours. And as I still have a few minutes in my life that aren't full of work, badminton or running, a friend tried to persuade me to join a clarinet choir ("It's only once a month...") I dithered, but remembering that I'd thoroughly enjoyed the workshop that Lola II persuaded me to join, I gave in and signed up. It was good fun; I was by no means the worst despite having played so little over the past 30 years, and... it's only once a month...

Tuesday, 3 February 2015

Outcome measures and service development

Plants and a lantern on a sunny windowsill
July 2013
We have been encouraged for some time to try to establish a measure of the value of the work done by Dietitians. It is part of the ongoing 'modernisation' of the NHS, because we are all aware that if what we do does not appear to be of benefit (and when I write 'of benefit' what I mean is 'cost-effective') then our services will not be commissioned and we'll all be out of a job. For example, the Medicines Management people have latched on to the very low carb lifestyle as something that may help the Trust to save money because some patients with diabetes can reduce their medication, but against that must be balanced the cost of the Dietitian and Nurse time in helping them to succeed with the lifestyle.

With a surgeon or a physician it is sometimes possible to compile statistics on mortality and recovery from acute conditions; with a chronic condition like diabetes then improvement is unlikely - preventing progression is worthwhile, but difficult to measure. How can we tell whether the Dietitian made a contribution that made a patient better or saved the NHS money? Would the patient have got worse without the dietetic input? We have no way of knowing.

The Dietetics department has finally succumbed to the pressure to measure 'Outcomes', and my Dietitian colleagues and I have been trying out a set of four parameters specific to diabetes that have been proposed and are being used elsewhere. They are fairly easy to apply (although a bit of thought is needed), and we could conceivably start to record these Outcome Measures, but the next step is to find out how they will be used, and that subject will be discussed in a forthcoming meeting. It is a meeting that I will not have to attend, thankfully, but there are a number of questions that I hope will be answered - do we do this for every patient? What about those in groups? What will happen to the data that we generate - how will it be used?

There is also a change coming to the way that our services are organised, following the 'consultation' earlier in the year. It was a fairly token consultation given that the patients were not given anything like the information they would have needed to make informed choices, but if they had, most of them would have been unable to understand and process it (I am still not entirely sure what's going on - it's inordinately complicated). But the Clinical Commissioning Group (CCG) can state that it has consulted patients, and proposals for change towards an 'Integrated Diabetes Service' in the community have been made.

I have been to more than one meeting about this (I definitely don't intend to go to any more) and I still barely understand any of it. What does seem straightforward is that many people with well-managed Type 2 Diabetes should be discharged back to the care of their GPs instead of being seen by specialists such as those in the team where I work. Despite the fact that this message was delivered by the consultant who is working with the CCG on managing the change, he himself has failed to discharge any of such patients from his own clinics. So I am about 60% confident that little will change in my particular working area, but that leaves 40% of a chance that I am wrong. It's due to start in the new financial year, so we'll have to wait and see what happens then.

Not much more to say about work, although my full time hours have unofficially been extended to September. I don't yet have the paperwork to support the extension, so nothing is for certain. If it goes ahead, though, it should give me enough time to be fully certified as a DESMOND educator - an external assessor is attending my next course to provide some feedback towards my accreditation. I've also been standing in as an educator on a different course for people with Type 2 diabetes. DESMOND is for people who are newly diagnosed, but the other course is to promote the lower carb approach to people who've had diabetes for some time. It's much shorter in duration, and neither I nor the Diabetes Specialist Nurse who delivered it with me had done one of these before, so we launched ourselves at it and charged through at a gallop to make sure we squeezed everything in. Part 2 is this week, and perhaps we'll be able to moderate our speed. It was quite a ride.

If only I could tell you the details of some of my consultations! They have been particularly interesting in this post-holiday period, as people find different ways to explain how they really let things go over Christmas, but they are definitely going to get going again now. I had one afternoon when my input was more in the way of marriage guidance than dietetics; another appointment with a patient who had a lot to say and hardly gave me a chance to introduce myself. Occasionally I feel I can really make a difference with just one nugget of information.

But there are still a few patients who are baffling - their understanding of diabetes and their ways of managing it have been deeply embedded over many years, and trying to get to the bottom of what is going on can be frustrating, and sometimes futile. For these people it is a question of working within the parameters they set, and trying to find a way to ensure the best outcomes possible. Most of the time I would encourage the patient to plan just one or two small changes, although there is so much that could be done. But it is impossible to know what would have happened if I'd acted otherwise, and I do think that succeeding with one thing is better than being faced with too many challenges and not overcoming any of them.

Tuesday, 27 January 2015

Future holidays

A bench and a doorway in the sunshine
King's Lynn, August 2014
Every so often, I spend a week over the New Year holiday period with a group of friends at a large property somewhere in the UK (although one year we were in Ireland) - I have reported on this before (three times over the lifetime of this and the previous blog). Most of the previous holidays were arranged and booked by one particular couple. This year, during a weekend I spent meeting up with some of said friends including the couple who usually make the arrangements, I nobly volunteered Lola II to arrange another of the New Year shindigs.

Somehow it has turned out that the bulk of the work so far has fallen to me instead of Lola II. This is probably only fair, since she didn't have any say in the volunteering process. So off I went, getting people to commit to joining in, finding properties to house 21 people, discovering that the level of enthusiasm meant that we needed a bigger place, collating preferences for four different properties, and at last I hope we have reached a consensus on a suitable house for us. Now my fingers are crossed that it is still available, although we do have a backup option.

That took up quite a bit of time and headspace this week, alongside the usual badminton and work. So my outstanding jobs that are far less attractive (buying holiday insurance, breakdown cover, changing utility supplier, and - worst of all - clearing moss and mud off the hall roof and gutter) have been neglected, as they are likely to continue to be neglected until I have no choice but to knuckle down. The holiday insurance will probably be first, given that the date of the holiday is set and not far off now.

And on that very subject, I took myself off to the Snowdome to put in an hour's practice, so that my first turns on Italian snow are made with some confidence. It had to be at a weekend, so I thought I'd get in early on Sunday morning hoping to start before the main rush of the day, but no such luck, it was teeming. Quite a few were in groups being taught, so they weren't getting in the way too much, but no full speed zipping down the slope. It was still worth it, even though just for an hour on a tiny slope full of beginners. I came home buzzing with excitement and anticipation for my holiday, which is as it should be.

This holiday activity inspired me to consider what other plans I might make for the coming year, and I have two or three more ideas. One slight difficulty is that the lumbering hulk of bureaucracy that is the NHS manages annual leave for its staff through an electronic interface which deals in hours - in the current year, my allocation was around 273 hours, which includes Bank Holidays. I cannot assume next year will be the same because a) you get a different allocation when you work part time compared with full time, pro rata (last year I worked 6 months on 27 hours a week, and 6 months full time) and b) I have now completed 5 years service with the NHS, which entitles me to a few more days, and I can't remember exactly how many.

So now I have to a) find out how many hours I should get next year b) find out how many of these are taken up by Bank Holidays c) convert the remaining hours to days and thus determine what I can plan for. My current thinking is that it shouldn't make any difference about the part-time vs full-time working, because although my leave hours are reduced because of part time working, I will also need to take fewer hours as annual leave. It's complicated, but it's rather delightful to be considering some lovely trips over the next 12 months at this darkest, coldest time of year.

Sunday, 18 January 2015

Nothing much to report

Pink flowers against a background of leaves
Peckover House, August 2014
Nothing much has been happening that I can blog about. There's been badminton, a trip to London, a visit from a builder to look at the damp patches on the hall walls, an attempt at running which was curtailed by a very welcome phone call from Lola II, a second visit from the builder to look at the same problem in daylight, delivering a two-part DESMOND course, more badminton, renewal of the house insurance and another run - a proper 5k Parkrun this time. It was very cold - frosty and icy - and I cobbled together an outfit that I thought would do the trick. Only my elbows were cold, so I consider that a success, given that it started to snow at one point.

Nothing else of any particular interest, although the trip to London produced all the highlights: an urban fox jumping over the fence within a couple of feet of the window we were looking through, my first ever sighting of a jay (although my second sighting came within a week in a completely different location), and participation in the Gulloebl Chinema.

Work is still good, very good. I am practising and learning and practising some more, and reflecting on my performance and receiving and giving feedback. Some patients do very well, in which case their success comes from their own efforts. Some don't do so well, in which case I try to find a different way to help them help themselves. We discuss changing long-established dietary habits. "You're not going to tell me what to do, are you?" said one patient. "That's right," I replied. "You have to decide for yourself what you're going to do, because I'm not going to be there when you're faced with a choice."

The very low carb group is thriving - at least, those who attend seem to be getting on very well. I have had a quick look over my past blog posts, and I don't think I've written about the group before. It comprises all those people who have adopted the very low carb lifestyle to help manage their diabetes, and since September we have been meeting once a month to chat about various aspects of the diet - sometimes someone brings some food they've made for people to taste, we swap recipes, and we had a speaker talking about retinal screening at one meeting. My Broccoli and Stilton Soup was very well received, as were the cheese biscuits that one of the group had made.

I have been recruiting patients to the group at a fairly slow rate, and about half of them decide after the introduction that they aren't going to carry on, but we have about ten regulars now. Everyone is weighed and has their blood pressure measured, and one of our nurses is available to consult about medication changes. They seem to enjoy the meetings and, more importantly, most are enjoying the diet, losing weight, reducing medication and are keen to continue. Only one has dropped out so far, but may return now that the festive season is over.

I participated in a small meeting to discuss our pump clinics. An increasing number of people with diabetes are using insulin pumps, and our existing provision is inadequate, leading to lengthening waiting lists for clinic appointments. There were just four of us: the main diabetes doctor who leads on pumps, our two nurses and me. At the end of the meeting I felt that things were clearer than they were at the beginning, and that is such a rare event nowadays. It looks as though we have found a way to expand the pump service, and I may have a part to play which will also increase my knowledge and skills, which is just what I like.

Thursday, 8 January 2015

What I've been reading

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The Lie
by Helen Dunmore

narrated by Darren Benedict
"Cornwall, 1920: A young man stands on a headland, looking out to sea. He is back from the war, homeless and without family. Behind him lies the terror of the trenches. Daniel has survived, but will he ever be able to escape the terrible, unforeseen consequences of a lie?"
It was quite a good book, and the parts about the experience on the front line in WW1 were dramatic, gruesome, and evocative. The parts about the ex-soldier rebuilding his life but unable to shake off the traumatic reliving of the experience were also good, but his relationships with the people around him were a little sketchy. It ended as it had to, but was a little unsatisfying. Which was a shame.


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The Picture of Dorian Gray
by Oscar Wilde

narrated by B. J. Harrison
"After Basil Hallward paints a beautiful young man's portrait, his subject's frivolous wish that the picture change and he remain the same comes true. Dorian Gray's picture grows aged and corrupt while he continues to appear fresh and innocent."
Another classic of English Literature narrated by my US podcaster. I suppose there just aren't enough classics of American Literature that are out of copyright, but I wish there were. To be fair, he doesn't do a bad job with this one. It's interesting to be reminded that the picture in the schoolroom (not the attic) features alongside what I suspect was Wilde's main pleasure: writing about Art, Beauty, Love and the mores of the upper and lower classes in the late 19th century.


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The Siege of Krishnapur
by J. G. Farrell
"In the Spring of 1857, with India on the brink of a violent and bloody mutiny, Krishnapur is a remote town on the vast North Indian plain. The sepoys at the nearest military cantonment rise in revolt and the British prepare to fight for their lives with what weapons they can muster."
Set only about thirty years before the publication of Wilde's book above, this is a very different kettle of fish. I wasn't sure what to expect - it was a birthday present - and I'd read most of the book before deciding that it is more of a historical account than a story. If I were familiar with the history of India then I feel sure this would have provided colour and life to flesh out any dusty historical account. As it is, I now know a little bit more about the history of India.


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Love in a Cold Climate
by Nancy Mitford

narrated by Patricia Hodge
"Groomed from a young age for marriage by her mother, the fearsome Lady Montdore, Polly causes a scandal when she declares her love for her uncle, the lecherous lecturer, and runs off to France."
Outstanding narration of a great book - at last, my list of 'must read classics' has come up with something worth listening to. The characters all sound like real humans, even if raised in a social milieu quite different from anything I've ever experienced. Even though there isn't much of a story as such, in the hands of this author that doesn't matter - it's still fascinating and keeps me wanting to hear the next chapter, and Patricia Hodge reads superbly. It's the second of a trilogy, and I've already lined up the first to download soon. A sparkling, wonderful book.


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In Search of the Edge of Time
by John Gribbin
"The phenomena now known as black holes were described as early as 1783 and dismissed as idle speculation - invisible stars sounded just too implausible to be taken seriously. It was only with the development of radio astronomy, relativity theory and mathematical models of warped spacetime that their true significance became clear. "
As is usual in a book such as this, despite the clear writing, I feel very clever at understanding it up to about halfway, and then wallow about, hoping something will come into focus by the end. It usually doesn't. But I liked the first half, and even though I didn't really grasp the full impact of the argument, it says that time travel is possible, although seemingly not practicable. It was published in 1992 which is a long time ago in particle physics, but again I don't have the knowledge to determine what has been confirmed, ruled out or succeeded by more modern theory. The statement I liked the best was that our Universe might actually be located inside a black hole.

Thursday, 1 January 2015

SGLT2 inhibition

Red dawn sky over frosty bowling greens and clubhouse
Bowling greens at dawn, December 2014
All around are signs that a new year has started - empty roads, silent stations, Mary Poppins on TV and a host of New Year blog posts. I've been sitting on this post for a while, and as I don't have much to say about 2014 or the New Year, you can have this as my first gift of 2015.

The Diabetes Education Club meeting I attended recently featured an eminent speaker on SGLT2 inhibition in the management of high blood glucose. This is a relatively new treatment, although he described its origins in the 1800's when, following the isolation of salicylic acid from willow bark, people were mucking about with all sorts of tree bark to find something similarly therapeutic. A substance was found in apple bark, but all it seemed to do was produce glucose in the urine (glucosuria). This didn't seem useful at the time and it was even thought to cause diabetes (a symptom of which is glucosuria), so it was shelved.

More than a century later, the reality was understood - this substance inhibits the action of sodium-glucose co-transporter (SGLT) molecules which carry sodium and glucose across a cell membrane. In the gut, SGLTs enable the absorption of sodium and glucose from food into the body. In the kidney, they transport sodium and glucose from filtered blood back into the circulatory blood, and prevent glucose from being excreted in the urine.

There are two types, imaginatively named SGLT1 and SGLT2. SGLT1 works mostly in the gut but is found in the kidney as well, and SGLT2 is mostly found in the kidney. SGLT1 is a high affinity, low capacity transporter, so it catches glucose very effectively but works quite slowly. SGLT2 is a low affinity, high capacity transporter, so it lets a lot of glucose cruise on past but works very quickly. You can imagine that SGLT1 is good for low glucose concentrations, while SGLT2 works best with high glucose concentrations.


One of the functions of the kidneys is to filter the blood and get rid of waste products in the urine. Glucose in the blood passes through the kidneys and is normally totally reabsorbed back into the body; glucose is not normally found in the urine of a healthy individual. When blood glucose concentration is higher than normal, the kidneys still do a pretty good job and can cope with nearly double the usual blood glucose concentration, but eventually their capacity is exceeded and glucose is excreted in the urine.

The original apple bark extract (phlorizin) did not differentiate between the two types of SGLT. The phlorizin molecule sticks to the SGLT transporter molecules in the kidney and gut in place of glucose, and blocks the transport of glucose. The effect in the kidney results in glucosuria, and in the gut it leads to impaired absorption of glucose, with the remaining glucose fermenting in the lower intestine and causing pretty nasty side effects. Phlorizin was also too easily digested to be an effective oral treatment, so modifications were made to the molecule to inhibit digestion and to make it more selective for the SGLT2 transporter. This has resulted in the new SGLT2 inhibitor family of 'flozins', including dapagliflozin, canagliflozin and empagliflozin which are licensed in the EU (and some others are available in other parts of the world).

We burn about 250g of glucose per day, half of which is used by the brain. Some of this glucose will come from our diet, and the rest will be synthesized internally. About 180g of blood glucose a day passes through the kidney in a healthy person, and more if the blood glucose concentration is raised. Inhibiting the action of the SGLT2 transporters eliminates more than 50g of glucose per day, thus lowering the remaining blood glucose level. Although not its licensed purpose, this obviously eliminates more than 200 calories a day too, and so this treatment, unlike many diabetes treatments, has the potential to contribute to weight loss as well.

One of the disadvantages of many diabetes treatments is the risk of low blood glucose or hypoglycaemia. SGLT2 inhibition only works if blood glucose is high, because of its low affinity for glucose. If blood glucose is low it simply doesn't work very well, so there is little risk of a hypo. It also uses a different approach compared with all the other types of diabetes treatments, so can theoretically be combined with any of them, although licensing for UK prescription depends on having results of specific trials with each. Another factor in favour of the SGLT2 inhibiting treatment is that if the drug is either not effective or not acceptable (i.e. the patient doesn't take it) there will be no glucosuria, in which case it can be stopped without further ado.

Of course there are disadvantages. If kidney function is not good enough to filter blood effectively then this drug will not be effective. And glucose in the urine is all very well as long as bacteria and fungi don't take advantage. The doctors report that female patients are generally pragmatic about identifying and treating urinary tract infections and thrush, but they say that the male patients tend to either overreact or ignore the problem until it has got so bad it can't be overlooked any longer.

There doesn't appear to have been any direct comparison of treatment with SGLT2 inhibitors compared with dietary approaches to lowering blood glucose. The trials that have been done are comparing treatments with placebo, where sustained weight loss has been about 2kg and reduction in blood glucose has been demonstrated either with improved HbA1c results or a reduction in insulin dosage or a slowing of diabetes progression compared with a control group. There is also a small diuretic effect, which probably accounts for a slight improvement in blood pressure as well.

Because the inhibition affects sodium (the 'S' in SGLT) as well as glucose there are possible negative effects on sodium balance in the body. Recently, I attended a doctors' meeting (by accident) where the doctors raised this issue, but also questioned the size of the effect on HbA1c given the small amount of glucose that is actually eliminated in this way, and wondered what else might be going on. I am not entirely convinced either by the claims made or by the scepticism of the doctors. All I know is that it is another possible treatment for raised blood glucose, and I'll wait and see how it all turns out. That's the beauty of the Dietitian's job - all observation, very little responsibility, mostly trial and error.

Reference: Tahrani, Abd A et al. 'SGLT inhibitors in management of diabetes'. The Lancet Diabetes & Endocrinology, 1:2, p140-151. http://dx.doi.org/10.1016/S2213-8587(13)70050-0

Sunday, 28 December 2014

Media binge

Three frilly pink roses
Peckover House, August 2014
It's been full steam ahead self-indulgent media binge for days, ever since we were 'sent home' early on Christmas Eve. That's the difference between working in the diabetes service and the dietetic department - in dietetics we had to stay as long as it took in case a tube feeding patient arrived at 4pm on Christmas Eve. Things are more relaxed in diabetes, although there's no reason why they should be, as people are newly diagnosed with diabetes right through Christmas, and need more support than a feeding tube ever did. It's just a different approach.

Anyway, I've done a bit of cooking, a bit of cleaning, a bit of tidying up and admin, and the rest of the time I have been immersed in a sea of entertainment - radio, TV, iPlayer, audio books, real books, podcasts, blogs, DVDs and CDs. Starting with 8 out of 10 Cats (TV), Carols from Kings (CD) followed by Guys and Dolls (CD), then there was a bit of Cabin Pressure (iPlayer radio) - the final two episodes sustain the high quality of the whole series, and I can thoroughly recommend it. Especially the one when they go on their safety training.

What next? I've been reading J. G. Farrell's 'The Siege of Krishnapur' which is a bit heavy going, and listening to all my usual podcasts, including Oscar Wilde's 'The Picture of Dorian Gray'. I caught up on iPlayer (radio) with David Sedaris 'Santaland' in which he relates his time as an elf at Christmas in Macy's department store in New York, and an episode of 'The Museum of Curiosity' from a few years ago on Radio 4. There was a blast of St Matthew Passion as an interlude, and then I got stuck into TV films: 'Nanny McPhee', 'The Snowman', and then 'White Christmas', which I find I have never seen - I assumed that I had.

In between all of this I managed to nip to the Pub Next Door for a cheeky gin and tonic. And, of all things, I went out for a run. I haven't been running since the clocks changed and it got dark and cold and wet and I started working full time, but a couple of friends somehow managed to get me fired up again, even though they don't run with me and one doesn't even live within 200 miles. The power of the Interwebs, who'd have thought?  I wasn't that much slower than before despite my two months off, but I felt decidedly shaky after the event. Muscles not used for a while, that sort of thing.

The media binge continued on Boxing Day with 'Cool Runnings' and 'Back to the Future 2', followed by media bingeing of a different kind - updating the badminton club website with new pictures from our Christmas do this year. 'Big Fat Quiz of the Year' (TV), a couple of episodes of iPlayer radio 'Concrete Cow', and onwards to Saturday with 'Sunshine on Leith' (DVD), more podcasts, more St Matthew Passion (it's very long). By the end of Saturday my legs were feeling as if they had both been smashed with sledgehammers. Dad always told me exercise is a bad idea. I've also got a feeling that I am coming down with something chesty and headachey, but we'll see what develops.

Saturday finished with an episode of the Italian crime TV series 'Inspector Montalbano' which Mr A has been addicted to for some time. I had nearly had enough of media by Sunday, but I still managed to finish the audio and the real books and squeeze in the movie 'August: Osage Country' (warning to Lola II and Mr M: not only is there Julia Roberts but there's a whole ton of conflict), listen to the rest of the St Matthew Passion (it's really very long indeed), more podcasts (including the Mayo and Kermode film review show on 5 Live), and more 'Concrete Cow' on iPlayer radio. At the time of writing I was thinking of actually leaving the house to go and see 'Paddington' at the real live cinema, but if it is swarming with kids like it was earlier in the day I'll be giving that a miss and perhaps shorten my jeans, which is a non-media job that has been displaced for the whole four day holiday shindig.

And then it will be back to the real world again.

Tuesday, 16 December 2014

Christmas parties

Table strewn with crackers, streamers, bottles, glasses and other party debris

If you're waiting for the post about SGLT2 inhibition (and I'm not sure why you would be), it's on its way, but things more exciting and noteworthy have been cropping up to postpone the pleasure. The last few days have produced anecdotes that made me think "That would be great for the blog", and I'm writing this when I should really be working on the family calendar, and I've got to go to town in a bit, so time is short.

Short anecdote about a patient first: it was the first appointment of the day, the patient was slightly early, and as we walk from the waiting area to my room I generally ask how things are going in a general, casual everyday manner. The patient said "Pretty good, I've lost a stone [14 lb, about 6.4 kg]."

That's a good start to a consultation. When we're sitting down, I follow up with "So tell me, how did you manage to lose all that weight?" The patient looked at me in an odd way, as if I were a little bit dim, and said "I just did what you told me to do!"

So that was a good start to the day.

Further anecdotes result from the slew of Christmas parties that I've been at - the second and third were on Friday and Saturday nights. The second party was at a large hotel and conference centre, where at least three different events were being held concurrently, parking was being marshalled, and we were met at the entrance by a couple of burly security men asking to look in our handbags.

"What can they be looking for?" I wonder. "Has there been violence with weapons in the past? Do I look like someone who is hiding a knife in her bag? Are they expecting jihadists?" My naive questions are answered as I join our party in the main hall. One of my colleagues greets me with "Did they search your bag? I can't take my coat off yet, I've got a bottle of vodka in my pants" and she showed me the bulge in the front of her dress. Not only was she aware of the measures being taken to safeguard the takings of the hotel bar, but she had gone to great lengths to bypass them. I last saw her as she was being helped from the dance floor.

I am regarded as a mixture between an alien and a prude because I always drive to and from these parties, along with my other non-drinking (usually pregnant) colleagues. A different approach to alcohol applied to the third Christmas party with a different team, who had decided to use the teenage principle of 'pre-loading'. We were invited to pre-party cocktails, where I found a couple of colleagues who had rather overdone it. We all made it to the venue (a Masonic Hall) but they didn't last long enough to have their starters before having to be collected and taken home by a husband - I found out later that they had been pre-pre-loading with wine at another colleague's house even before the cocktails.

With two out of nine of our party already down and out, we enjoyed the meal and waited to see what would happen next. It was entirely organised by and for the hospital staff and was fundraising for dementia care, so I was expecting a live band and a raffle alternating with the disco, as is usual at this type of event. Instead, a tall, flamboyantly dressed woman introduced as 'Sabrina' entered the room and started to dance and mime along to the music. A surprisingly muscular, thick-waisted, slim-hipped woman...

As drag acts go, this was a corker. Not too naughty, very funny, it had me grinning and clapping and laughing until my face hurt. After the first number, one of my colleagues, a lovely chatty lady now wearing party antlers, stage-whispered to her neighbour "I think it's a man dressed as a woman!"

She and I were first on the dance floor when the disco started, and for a change the DJ had adopted the approach of playing music that made people want to dance - surprisingly rare in my experience. I've only got one more Christmas party coming up, and I doubt that it will be better than this last one.