Tuesday, 28 April 2015

Pump clinic

Snowy mountains, blue sky and white clouds
Courmayeur, February 2015
I am lucky enough to have a pleasantly varied job which includes so many different aspects of diabetes. I work with Doctors, Nurses and other Dietitians, we see people with Type 1 and Type 2 Diabetes who are on medications alone, medications and insulin and insulin alone, using fixed doses, varying their dosage by carb counting using multiple daily injections or insulin pumps. We see them for individual consultations, in my very low carb group and in group education sessions, sometimes in the hospital as outpatients, in a community clinic and at a GP surgery. And that doesn't include the courses, conferences, study days and meetings with colleagues. Not forgetting that I don't have to do things that I find less congenial, like ante-natal clinics or paediatrics.

One recent meeting was all about updating our service to increase our capacity to see patients who are using insulin pumps, all of whom have Type 1 diabetes (because you don't qualify for NHS funding for a pump if you don't have Type 1). Very few people stop using a pump after they have started, so obviously numbers are increasing, and more children are being started on pumps who then transition to the adult service.

In our service, adults have to attend our structured education before they can have a pump, because it's an expensive and sophisticated bit of kit and we want people to get the best out of it. There's no point having a pump if all you do is give fixed amounts of insulin three times a day with meals; you might as well use a straightforward insulin pen. The pump can give fractions of a unit of insulin; you can extend a bolus over a period of time; you can set up different rates of background insulin over the course of 24 hours; you can adjust the background insulin up or down by a percentage for a period to allow for exercise or illness and much more. So we want people to be able to count their carbs and make informed decisions about adjustments in order to get the most out of the equipment.

This means that our pump clinics contain patients who are generally the most knowledgeable and skilled in carb counting and insulin adjustment. Their level of knowledge and skill does vary, because for example the young people moving from paediatric to adult clinics may have been given pumps without the specialist education if they were too young at the time. But some may have had diabetes for upwards of 50 years; I have been a diabetes dietitian for less than two and a half years. This fact has made me wary of intervening with most patients in the pump clinic.

My colleagues tell me that there is more I could be doing in terms of helping people to use their pumps to manage their diabetes, but before I feel confident to do more I have asked for two things. The first is to attend some sort of insulin pump training for healthcare professionals, and the second is to visit a Diabetes department in a different Trust where they manage pumps, so I can learn from the Dietitian there.

My colleagues are more experienced than I am, but they still feel they could do with knowing a bit more about the range of pumps on the market. Our service tends to favour one particular pump brand, although there are a few others that we support because patients using those brands have moved into our area. So we are setting up an afternoon when the five or six main manufacturers will be asked to demonstrate their products one after another, and we will compare features and costs.

Then there is the way that our pump clinics are organised. With three different overlapping roles - Nurse, Dietitian, Doctor - there can be some duplication. For instance, in order to analyse whether any changes are needed, the data about blood glucose levels, carbs and insulin delivery stored by the insulin pump can be downloaded and manipulated on a computer, which is much easier to do than using the handset. It is also easier to spot trends using graphs, and rates of insulin delivery can be adjusted by drag and drop. But it makes little sense for the Nurse and the Doctor to download and view the same data each in their separate rooms, so they are thinking working together. With two Doctors and two Nurses per clinic it is clear how things might be organised for them, but there is only one Dietitian. I'm not yet sure what I will be doing, but maybe when I've seen what other services do I will come up with some ideas.

Monday, 20 April 2015

What I've been reading

Image of the book cover

Auschwitz: A Doctor's Eyewitness Account
by Miklós Nyiszli
"A Hungarian Jew and a medical doctor, Dr. Miklós Nyiszli was spared from death for a grimmer fate: to perform 'scientific research' on his fellow inmates as a research pathologist under the supervision of the infamous Dr. Josef Mengele."
My goodness, this book was difficult to read. The author describes what happened in Auschwitz, what he saw, heard and experienced, and it is more direct and real than any other account I have read. Of course we know what went on, but this brought home the cruelty and the scale of the killing - thousands upon thousands of human beings murdered every day, week after week, month after month. I could only manage to read about two chapters at a time. But we must remember these events, for although it seems inconceivable that such a crime could be repeated, it did happen once, and nobody then thought it conceivable until it was upon them.

Image of the book cover

Queen Lucia
by E. F. Benson

narrated by Nadia May
"England between the wars was a paradise of utter calm and leisure for the very, very rich. But into this enclave is born Mrs. Emmeline Lucas - La Lucia, as she is known - a woman determined to lead a life quite different from the pomp and subdued nature of her class."
Unfortunately the village is populated by shallow small-minded pretentious snobs, except for the lovely and sensible Olga who settles in their midst and brings a welcome dose of reality to the ludicrous 'romps' and dinner parties and garden parties with which the residents occupy themselves. There are some wonderful characterisations though, narrated to perfection. I particularly loved Mrs Weston in her bath chair with her long-winded accounts of who said what and when they said it. But Lucia herself is awful, and her friend and rival Daisy Quantock is just as bad, and Georgie Pillson not much better. Time will tell whether I am inclined to read more in the series...

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Maid in Waiting
by John Galsworthy
"The Cherrells are cousins by marriage to the Forsytes. When Elizabeth 'Dinny' Cherrell's brother faces extradition to South America, falsely accused of murder, and her cousin is threatened by her mentally unstable husband, Dinny does everything she can to shield them from harm."
This is the seventh book of the nine in the series, and moves away from the Forsyte family, although Fleur still features. Galsworthy writes very sound women as well as men, and the women in this book are at least as important as the men, and much more interesting. It's also fascinating to read how upper class families of the day had access to powerful government officials if they knew the right people - the Home Secretary in this case - and yet complain how they are not given any special status in the eyes of the law: "... one must be careful not to give an impression of favouring privilege -" "I think that's so unfair," interrupted Dinny, hotly.

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Thank You, Jeeves
by P. G. Wodehouse

narrated by Jonathan Cecil
"The manager of the building in central London has issued an ultimatum to either give up the music or clear out, and Jeeves resigns over Bertie's dedicated but somewhat untuneful playing of the banjolele. In high dudgeon, Bertie disappears to the country as a guest of his chum Chuffy."
I'm gradually working my way through the Wodehouse books - this is the first he wrote featuring Jeeves and Wooster, and it is heart-warming that the relationship between the two seems so strong and yet completely understated. Wooster is an ass as usual, and Jeeves saves the day, and they are together at the end and What Ho! all is well with the world.

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A Study in Scarlet
by Sir Arthur Conan Doyle

narrated by Simon Vance
"Dr. John Watson, discharged from military service after suffering severe wounds, is at a loose end until a chance encounter leads him to take rooms with a remarkable young man. The arrogant, irascible Sherlock Holmes is a master chemist, a talented musician, and an expert on all aspects of crime."
I've invested in the Complete Sherlock Holmes in one audiobook - 58 hours of narration, and tremendous value when you have a yearly subscription. This is the first of all his books, and I've read it many times before, although it struck me this time that Mormons are portrayed very negatively indeed. I didn't check before I bought the whole omnibus, but Simon Vance is a fine narrator, so that's good.

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The Girls of Slender Means
by Muriel Spark

narrated by Juliet Stevenson
"It is 1945; a time of cultural and political change, and also one of slender means. Spark's evocative and sharply drawn novel focuses on a group of women living together in a hostel in Kensington who face new challenges in uncertain times."
Not a long book, and I was a bit concerned about choosing it because I was so disappointed by Memento Mori, but it turned out well. It is set immediately after the war, when London was a mess of bomb damage, everything was rationed and people were somewhat traumatised. The description of a young ladies' hostel in Kensington was perfect, the characters drawn with care and attention, even if there wasn't much of a story to be told.

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The Sign of Four
by Sir Arthur Conan Doyle

narrated by Simon Vance
"As a dense yellow fog swirls through the streets of London, a deep melancholy has descended on Sherlock Holmes, who sits in a cocaine-induced haze at 221B Baker Street. His mood is only lifted by a visit from a beautiful but distressed young woman - Mary Morstan, whose father vanished ten years before."
Second of the Sherlock Holmes books, and a little pedestrian in its pace and length. Darkly atmospheric though, reprising Holmes' violin playing and introducing his cocaine habit, Watson's eventual wife, and all sorts of exotic travelling types and natives of far-flung islands. The narrator really is good.

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Arsène Lupin, Gentleman-Burglar
by Maurice Leblanc

narrated by B. J. Harrison
"Witty and urbane, Lupin stole from the rich through elaborate capers and gave to the poor in bursts of generosity. An inventive genius, a master of disguise and an accomplished actor, Lupin operates in the choice chateaux and salons."
I hadn't heard of this character, who might be described as the French Sherlock Holmes except that he is on the side of the baddies. It's not a bad read, and the great Holmes even makes an appearance in the last story - a little surreal, when one fictional character comments on another created by a completely different author.

Monday, 13 April 2015

Ten things

Outdoor tables and chairs under large umbrellas in the sunshine by the sea
Greece, June 2014
This post is pretty close to a rant. It's true that I have been feeling a bit stressed and the four-day weekend for Easter was very welcome. Normal service should be resumed very soon with calm, considered blogs of an informational and entertaining nature. I hope so, anyway.

1. Sensational media reports based on a flawed interpretation of a journal article or on something made up by a journalist or a celebrity

"Did you see the TV programme last week about how eating saturated fat is good for you? I've switched back to butter."

"I read in a magazine about how you will lose weight if you eat nothing at all after 5 p.m."

"I cut this article out of the newspaper about kale smoothies reversing diabetes."

"This website says that chia seeds will melt fat."

"The Daily Mail says that eating blackberries brings your blood glucose down."

"It says there's a new cure for diabetes."
FACT: It's all rubbish, ignore it. If you are overweight and want to reduce your blood glucose and improve your diabetes control, then eat less carbohydrate and lose weight. If you want to lose weight, you need to eat less, and ideally move more. The dietitian's job is to help you find a successful way to do all this, not spend half a consultation explaining how journalists are perfectly free to MAKE STUFF UP and are paid handsomely for it.

2. I can't possibly eat any less

The patient declares that there's no way they can eat any less than they already do. "I don't have any appetite," they say. "I eat like a bird. My two-year old grandson eats more than I do." The account they give of their daily diet consists of a small bowl of cereal for breakfast, half a tin of soup for lunch, and one slice of toast and a tin of sardines for supper. Between meals: black tea and coffee with sweetener. "I can't understand it," they say.

FACT: You are eating more than this, and you know it. Or maybe you don't know it. Either way, you're eating more than this or you wouldn't weigh 20 stone.

3. Artificial sweeteners

"Aren't they as bad as sugar? I read they cause cancer. They're full of chemicals, really bad for you. I wouldn't touch them."
FACT: Artificial sweeteners are safe. They're calorie-free. They're carb-free. THEY ARE FINE, STOP BEING STUPID.

4. Exercise

"I would lose all this weight if I could exercise, but I can't."

"I'd love to go out for a walk, but my back/hip/knees are too painful."

"My dog died and I put on 10 pounds."
FACT: exercise is incredibly good for us - it brings down high blood glucose levels, makes us feel good, strengthens muscles and helps stabilise joints - but the amount of calories burned by ordinary people who increase their activity level is about equivalent to a sandwich. If you're a typical overweight person you won't lose weight by exercise alone, and you'll probably reward yourself with more calories than you used up. But go out for a walk anyway, because the other benefits of activity are so worth it. And then start eating less.

5. Honey

"I've cut out all sugar, I don't have any now. I put honey in my tea and on my porridge instead."

"Honey's natural so it must be better than sugar."
FACT: Sugar is processed from plants by people; honey is processed from plants by bees and then people. Honey will have the same effect on your blood glucose and your waistline as sugar. Sorry to disappoint you, but YOU ARE DELUDING YOURSELF.

6. Fruit and fruit juice

"Fruit juice is healthy, isn't it? It's natural."

"I buy the fruit juice labelled 'no added sugar.'"

"I've stopped snacking on biscuits, and I'm having lots and lots of fruit instead."
FACT: fruit juice has more sugar in it than lemonade, and nearly as much as Coke or Pepsi. Why would a manufacturer need to add more sugar to a product that's already 10% sugar? Yes, whole fruit is better, but you're not helping your blood glucose levels if you have more than a handful at a time. And the 'five-a-day' message? Well, it's perfectly OK to have five portions of vegetables and no fruit at all.

7. 'Full of sugar'

"I stopped having ketchup on my chips - it's full of sugar."

"Those pasta sauces are full of sugar."

"I don't eat grapes or bananas any more; the nurse told me they are full of sugar."

"I have muesli now - cornflakes are full of sugar."
FACT: There's far more 'sugar' in your chips than in your dollop of ketchup, more in your large bowl of pasta than in the couple of tablespoons of pasta sauce, and no less in your bowl of muesli than there was in your cornflakes. It's all about the carbs. Grapes and bananas are fine, but have a handful of grapes or a small banana, not the whole punnet or a banana the size of a baseball bat.

8. The Menu Plan

"Just tell me what to eat."

"Can you just give me a menu plan?"
The lifestyle magazines are always printing "a menu plan for a week". We love them. I love them. If only we could just follow the plan to the letter, it would be so easy and we'd reap the promised benefit. But then we look through them - one muffin? Half a grapefruit? 300g kale? What do we do with the five other muffins that came in the pack of six, or the other half grapefruit, and I'm not allowed grapefruit anyway, and kale comes in 500g packs, and I don't like kale, and it's too expensive to eat all that fish, and I don't like fish except tinned tuna. What do I do in week 2 - just repeat week 1? My wife does all the cooking and we eat curry and chapatti not sausages and potatoes...

FACT: Menu plans are useless, and I don't have one for you. You'll have to work it out for yourself. Sorry.

9. "You're telling me I can't have..."

Honey. Rice. Sugar puffs. Fruit juice. Potatoes.

NO, I'M NOT TELLING YOU WHAT YOU CAN AND CAN'T HAVE. What I'm telling you is the effect that it will have on your weight, or your blood glucose. You can have whatever you like, whenever you like, because it isn't me that will put on weight or need to inject insulin, it's you. If you want to start the day with a Pepsi, that's fine, but if I were you, I wouldn't do it, like I wouldn't walk into the road without looking, or swim in the sea when there's a red flag flying. But if you want to, you go ahead.

9a. 'Good' and 'Bad' food

There is no such thing as good or bad food - nothing is forbidden. It's good to eat a lot of some foods and a little of others, and hey! it's bad to eat a lot of some foods and a little of others. Eat what you like, it's your decision and you will have to live with the consequences. My job includes making sure you are aware of what those consequences might be.

10. Low blood sugar

"I had to have a sandwich because my blood sugar was low."

"I can't sleep unless I have a glass of milk and a biscuit before bedtime."

"I need a snack to keep me going."
FACT: if you 'need' a regular snack then your insulin needs adjusting down. If you're not on insulin (or gliclazide or another insulin-stimulating medication) then you don't 'need' a snack, you just want one - you will never have low blood sugar. Grow up, you're not a toddler any more.

Tuesday, 7 April 2015

Drawing class

The class with their drawings
Drawing class, March 2015
Mr M's birthday was in February, and long before that date Lola II had been planning a surprise. Ever since they both went to a Members' Event at the British Museum and were encouraged to make a pencil drawing under the guidance of a drawing teacher. Lola II considered Mr M's drawing to be very fine, and it is now framed and hanging on the wall. So the surprise was to be a drawing lesson with this same teacher, Anna, but at their home and together with six other people, of whom I was one.

Anyone can tell you that keeping secrets is not my strong point. Admittedly I am better at it than Mr A or mum, who given a chance will be certain to say the wrong thing - I just find it very difficult to lie when faced with a direct question. Which is why I feel proud to say that I did not give the game away, even when asked a week before the big day by Lola II in the presence of Mr M: when would I next be in London? I said it was a secret, which was true.

The surprise had to include the provision of lunch, as Lola could not be seen to assemble food for nine people when Mr M was expecting to go out to a drawing class somewhere else. An online food order was delivered to me ahead of time and I brought it with me. There were also undercover assignations in a local cafe, secret bedmaking and no doubt more subterfuge that I was unaware of. Anyway, it all went swimmingly and Mr M was surprised and we had a full day of lessons, in which we were taught how to draw faces.

Drawing anything is pretty difficult. I am no expert, but I've had a go at drawing things (long ago, admittedly) and no face I've ever drawn looks like a human face, let alone the person whose face it is. After a day being taught how to do it, I think the drawings I produced are not bad, and with practice I can see how it could be possible to achieve a proper likeness. I had a fantastic time.

Before hints and tips
Same face, later
First we were given pencils and told not to judge our own work but to move on if things got sticky. We had a couple of warm-up exercises with the pencil, and then were given a slightly out-of-focus face to copy, and some charcoal. I've never used charcoal before, but it was such fun. Teacher commented on our work, and told us about tricks and techniques to use, and I produced a face. My first face belonged to a man, which was a pity because the picture I was copying was of a woman, but using the advice provided I remodelled it and suddenly it transformed into a female face. I still don't know how that happened.

After lunch we had a different face to copy, using pencil this time. That was fun too, and I drew a respectable face (the one in the picture at the top of the blog), but I love the charcoal one much more - in fact, I love it so much that I may frame it. Of course Mr M and Lola II drew lovely faces too, but this is my blog all about me. Oh all right, here's Lola II and her drawing, from pretty early on in the day.

Unfortunately we don't have a picture of Mr M and his drawing except in the group photo at the top. Happy Birthday Mr M!

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