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!

Thursday, 1 May 2014

Quality

Garden view
National Botanic Garden of Wales, May 2013
Tuesday was a real throwback to my university studying. It's officially my day off but I've agreed to write an article about gastroparesis for a professional journal. I had thought the deadline was the end of May and had been procrastinating wildly, but decided it was time to start. When I checked the previous correspondence, I found that the original deadline I'd been given was 21st March...

Anyway, I settled down to get started on writing last week, and found all manner of distractions at home. Then I was told about a meeting on Tuesday. The Quality people (this is shorthand for all manner of administrators whose job it is to make sure that health professionals and associated personnel provide the best service possible to the public) recommended that the Diabetes Service in this Trust should have a multi-disciplinary meeting. Despite being another potentially tedious and time-wasting get-together, I actually think that this is a necessary evil, as change and improvement is very challenging when you don't know who the decision-makers are in your own service. It helps that a couple of new consultants have joined the team, who are young and dynamic and seem to be open to new ideas.

So the meeting was on Tuesday, my day off, in the main hospital of the Trust (not where I work), and I needed to get some work done away from the distractions at home. It made sense to work in the library at the hospital, which would give me the opportunity to go to the meeting too. I set my alarm for 'early', because my Couch to 5k run schedule usually includes a Tuesday morning.

The only problem was that I'd signed up for a badminton competition that took place last Sunday. It started at noon so I'd made some sandwiches, and then left them on the kitchen table. The teams were divided into groups, and we'd played everyone in our group by half past two, been soundly beaten by all but one team, and I was getting very hungry, so I was looking forward to going home without waiting to see the semi-final and final at the end of the competition (played by the top team in each group). Then they announced that we would be playing everyone in our group for a second time...

Needless to say we were beaten all over again (even by the team who had lost to us in the first round), and it was four o'clock and I was starving. I found out when I went to club night on Monday that the only team we had beaten were the eventual winners of the tournament, which was annoying. Having played six hours of badminton over the previous two days, it should have been no surprise that I decided not to respond immediately to my 'early' alarm heralding a 25-minute run on Tuesday morning.

An hour later I managed to get up and head off for the library, except that I had a couple of jobs to do first. One was straightforward, involving a signature on a form applying for a memory stick that is encrypted so that it can be used in Trust computers - obviously the risk of downloading and exposing confidential patient information means that ordinary memory sticks are not allowed. The Diabetes team in the hospital where I work is not particularly interested in technology, so we don't have a laptop or computer projector, and the old-style overhead projector with acetates is still used extensively. A laptop/projector combination can be borrowed from the Learning Centre, which I have done on a couple of occasions, but came up against the problem of transferring the file containing my presentation to the non-networked laptop.

The other job I had to do was around verifying my previous NHS service, which was a two year stretch in the 1990's. The only reason to bother with this is because length of service is one factor that determines how much annual leave you get, and those two extra years should give me an extra two days (or is it an extra five days? I can't remember any more). I had managed to extract a letter from the NHS Trust where I had worked, confirming the correct start date, but for some reason my record showed that I had worked there until 2006, which was clearly not true. Unfortunately, my contact in the HR department was still insisting that I get confirmation of the correct dates, and suggested that I use pension records (I didn't pay into the NHS pension in the 1990's) or tax records. I thought I would take the opportunity to visit the HR department in person, and see whether they could be brought round.

It was an interesting meeting - my HR contact had never personally dealt with the tax people, but seemed to accept my view that this was not going to be a desirable line of enquiry. It then transpired that a) she had thought we were talking about my previous employer rather than something that had happened two decades ago, and b) she hadn't realised I was asking for fewer years to be taken into account than were stated in my letter, rather than more. She is going to think again, and I hope that common sense will prevail.

So after all of this, I reached the library mid-morning, then found out that I couldn't access any work information from the library (again because of concerns that patient information might be left somewhere electronically insecure), then worked out (with assistance) how to get my laptop to access the Interwebs, and then, instead of knuckling down to work, I thought I'd do a bit of blogging. Just like my old student days.

The MDT meeting was a bit of an ordeal, all about how we can collect data to show whether we meet the 13 Quality Standards set out by NICE. Obviously it is important to provide patients with a service that includes all the things that contribute to high quality patient care. It is, however, an immense amount of work to record and then collate data to prove that we offered people structured education, foot clinics, retinopathy screenings and blood and urine tests even if they don't turn up for their appointments or provide samples and we can't actually deliver the structured education within current resourcing levels. Apparently, the Diabetes team in the community has a waiting list of 560 people for their structured education programme, which isn't actually being delivered due to lack of staff, or funding, or both.

We also have Quality Standards for clinical results like blood pressure and cholesterol levels as well as average blood glucose (HbA1c). Although I don't quibble with the targets, which are set at levels that ought to reduce patients' risk of cardiovascular disease, stroke and microvascular damage, I don't think the service should be held to account if patients don't achieve the targets - there's only so much that medications and health professionals can do. At the end of the day, if patients want to eat pies and burgers and drink Lucozade then the targets won't be met even if their doctors have dosed them up with as much medication as they dare, and done their best to let them know they're not doing themselves any favours.

I managed to do the run on Wednesday morning instead.

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