Sunday 27 January 2019

New approaches to diabetes management

Close up of orange lily
Lily, June 2018
There is much in the diabetes news about developments for people with Type 1 diabetes (Flash Glucose Monitoring using the Libre device) and Type 2 diabetes (Very Low Calorie diets leading to diabetes remission). The Trust where I work, however, is not forward thinking, innovative or dynamic, so we still haven't done much to make either of these available to our patients.

In our little team we were hoping that the doctors and/or the Clinical Commissioning Group (CCG) would feel the pressure from patients and organisations like Diabetes UK with all the media announcements that FGM (an unfortunately acronym) technology is now available on NHS prescriptions. Not in our area, it isn't. It has made it onto the local 'Formulary', which is a list of things that can be prescribed, but no protocol or procedure was forthcoming which would make it actually possible to prescribe it. In the end we gave up on the idea that the doctors would do anything at all, so the nurses and I have tried to come up with our own local protocol to put forward for approval Trust-wide.

It is quite an interesting process, because the device is so different from what you normally get when you hand over a prescription to your pharmacist. The Libre consists of a handset as a one-off device at the start, and disposable sensors that last two weeks at a time. At the moment we also believe that users should have some initial training (or at least guidance) about how to make best use of the device. The CCG has defined the criteria that have to be met before the device can be prescribed at all, and other criteria that have to be met if it is not to be withdrawn after six months. A bit different from a prescription for a 10-day course of antibiotics or a tube of ointment.

The criteria for prescription are quite restrictive - Type 1 only, appropriate blood glucose monitoring 8 or more times daily, and one of the following: where success with the Libre would avoid the need for an insulin pump; impaired awareness of low blood glucose; more than 2 admissions a year; or where a third party is needed (e.g. learning or physical disability). And the prescription has to be for a six-month trial period, during which we have to collect data on eight different indicators, and if fewer than two indicators have improved then the trial is discontinued and no more sensors on the NHS.

The Pharmacists have said that they don't want to have anything to do with it, thank you very much, which is fine for the first prescription - we would be happy to handle that, given that we want to have a role in starting people off with some training. After that, though, we aren't in a position to be dispensing sensors every month, so we've got to try to persuade the pharmacists to take that job on. And the Procurement people will have to decide how exactly the handset and sensors will be ordered and recorded, and the Finance people will need to define how the budgets will work and how we will charge the cost to the CCG (because although it's prescribable, it comes from a different budget than for 'normal' prescriptions). And the Doctors are clinically responsible for the prescription so they have to fulfil the criteria set by the CCG. So all of these people have to approve our proposal.

Can you imagine trying to arrange a meeting with people from five different professional groups, at least three of whom are not in the least interested in the extra work that this might entail?

We have started by finding a date convenient to ourselves and our paediatric colleagues (at least the paediatric nurses; I doubt whether there will be a dietitian involved). None of the doctors has replied to the invitation, and we know and work with them (update - one doctor thinks he can probably be there). The Head of Procurement has said that he will find someone to attend; Pharmacist representation is still unconfirmed - we don't have any routine contact with these guys, so I'm not expecting much -  and I have no idea about Finance. I'll let you know.

The other issue all over the news is the effect of rapid weight loss on Type 2 diabetes, which in some cases can induce diabetes 'remission' - a return of blood glucose to non-diabetic levels. The research trial that has generated all the stories is not yet finished, but many people seem to want to try the diet. There's also Michael Mosley who keeps making TV programmes, and the family behind 'Fixing Dad' which also led to a TV programme and more, and every two minutes there's something else in the Daily Mail or on ITV about how you can live forever if you adopt some version of a simplistic and entirely unrealistic lifestyle.

The trouble is that the Calorie* restricted diet used in the (unfinished) research trial was not the sole intervention that led to remission - there was a whole team approach within GP practices, supported by the research team, including dietitians. And not everyone who tried it achieved remission. But the main concern for me is that we know weight loss is difficult to sustain, and the research has not yet uncovered what happens to people who lose the weight but then regain it again. If they experience more serious consequences than if they had done nothing then that changes the complexion of the outcome considerably. We just don't know.

It's still worth losing weight, though, and not eating (or drinking) excessive carbohydrate if you're at risk of Type 2 diabetes, or if you already have it. Even if you do it in a more measured way than by cutting down to 600 or 800 Calories* per day.

(* I tried to write 'calories' because that's how we generally refer to kilocalories, but I couldn't, because it's not accurate and I am a pedant. It's either kcal or Calories with a capital C.)

Three out of five of my team of adult diabetes dietitians are new, and with fresh eyes they have pointed out that we don't really provide much support to people who want to lose weight. We obviously can't compete with successful and rigorous programmes like Slimming World or WeightWatchers (now stupidly rebranded to be just WW), but we don't even have any leaflets that could help people think about losing weight, let alone provide the intensive and expert dietetic input to a rapid weight loss programme for diabetes remission. So we're going to have a couple of new leaflets, and we'll follow the course of the research and maybe work out how to apply the results within our practice. At some point. Maybe.

Tuesday 15 January 2019

Square eyes

Jewish memorial
Jewish memorial, Dachau, December 2018
Many, many movies have been watched. On the weekend before Christmas Lola II and Mr M have a screening of a Christmas-themed movie, and this year it was Love Actually and I went all that way to see it. Then mostly on my wonderful huge TV screen at home: Leave No Trace, Bros: When the Screaming Stops, Swimming With Men, Phantom Thread, Bohemian Rhapsody (at the cinema), A Quiet Place, Hell or High Water and 20 Feet from Stardom. And some David Attenborough nature documentaries, both current and from long ago.

I've also worked out how to stream video from my mobile phone to the TV, so I watched the first episode of the American series Breaking Bad which Landrover Man loaded onto my phone, but when I tried to watch the second episode I couldn't take the unpleasantness of the content so I'm back looking for a quality episodic drama. All this screen time means I haven't done very much reading lately.

Something that has kept me hooked up to the computer is that I decided it was time to change all my passwords. While a specific app that encrypts and saves passwords would be the ideal solution, it's unlikely that I'd be able to use it at work, so I decided to do the job manually and it turns out that a) I have an awful lot of passwords, and b) it takes quite a lot of time to change them all. And it turns out that, annoyingly, some sites require you to have certain characters in your password, and some specifically forbid those characters. One site wouldn't even let me have a sequence of two numbers or two letters the same (e.g. 'gg' or '22'). I think I've very nearly finished them all, but this is a job that has to be 100% finished or I won't remember which ones I've changed and which I haven't.

Christmas and New Year came and went. I worked most of the time but also went to London because my cousin from Seattle was visiting with her son and other friends. I've been moving furniture around upstairs, but also in the Auditorium because of the carpet fitting. The carpet estimator came and was very helpful, so I have that to look forward to.

Actually there's quite a lot to look forward to - January and February are chock full of assignments, meetings, trips, visits as well as the usual badminton club nights and matches. The Buddhist group is running a four-week introductory course, and while they do that in the usual venue it was proposed that the regular members might meet somewhere else - so I offered my house. We've done this twice, and it has been rather lovely. I have also volunteered to join the committee that runs the group. I want to generate more social activity within this group, and hopefully promote its growth.

And a man came to service the boiler. The only reason I mention this is that he offered to check and bleed the radiators, and we discovered that the bedroom radiator essentially contained air rather than water, which neatly explains why it has been so cold in there. Very timely for the arrival of visitors this weekend, but reminds me how very obvious the solution to some problems are.

Tuesday 8 January 2019

Lola II to the rescue

Excess goods in the kitchen awaiting disposal
Stuff, December 2018
I only took one day off work apart from Christmas Day, Boxing Day and New Year's Day, and spent three out of those four days away from home so I'm still very behind on reporting my pre-Christmas activity, and it's 2019 already! Happy New Year!

Lola II paid me a mercy visit for a day in December because I had (and still have) so many niggling jobs to be done and was finding it almost impossible to concentrate on making a start on them. She was very effective - not by doing anything much more than making it more interesting for me to do all these jobs, although she did come up with a few really useful suggestions.

We started by sorting out some of the stuff in boxes that have been in my hall for about a year, waiting for me to decide whether to take them to a car boot, or auction them on eBay, or give them away through Freegle, or sell them with shpock, Facebook marketplace or NextDoor. So many choices, so much procrastination. What I actually did with Lola II's support was take them to the municipal tip, where there is an Age UK shop. They took the good stuff and I sent the rest into landfill or recycling. There is still more to do on this front, but at least some of it has disappeared from my hallway.

Then we went off to the carpet shop to confirm my preferences for the Auditorium and find out why there were no online options to book a visit for estimation purposes. The man in the huge showroom was difficult to pin down - all his colleagues were away and he was responsible for the whole warehouse on his own - and he winced when I told him my postcode. With some difficulty he found someone to come out just after Christmas, in the evening, and I handed over a deposit. Result.

Lola I gazing at carpet salesman in showroom
Carpet salesman confused at why we would want to take a photo of him
Subsequently I received a call saying that there had been a mistake and unfortunately the estimate couldn't be done that day, but they would re-arrange a visit. Which they did, scheduling it for 9.30 a.m. on New Year's Day. So I had to rearrange it again.

Coming back to Leamington from the carpet showroom I left the car with the car wash people because of an unfortunate incident with some dog poo outside my garage. Lola II and I had lunch in a new steakhouse in town, returning to the car wash via the cake shop. The beef industry has coined the term 'surf and turf' in order to pair steak with seafood; the Lola department has found a better combination in 'steak and cake'.

In a nicely cleaned car I drove Lola II to an art supplies shop so she could buy something for this year's Christmas card manufacturing effort - despite this being a day all about me, I felt it was only fair to give her just a moment for herself. Then it was back home and more of my odd jobs until it was time to stop working and have some fun. We watched a film in the Auditorium, wrapped in a duvet because without any flooring or carpet the room is seriously draughty, and ate chestnuts.

Two rather large pieces of cake


Wednesday 2 January 2019

What I've been reading

Image of the book cover

This is Going to Hurt
by Adam Kay
"Welcome to 97-hour weeks. Welcome to life and death decisions. Welcome to a constant tsunami of bodily fluids. Welcome to earning less than the hospital parking meter. Wave goodbye to your friends and relationships. Welcome to the life of a junior doctor."
I haven't done this for a long time - bought a book I haven't read in order to give it to someone as a present, and then read the whole thing very carefully trying to make it look like it hasn't been read. It's not a difficult book to read but the black humour of the subject matter is not far off what I would expect, even though my experience comes from very limited access to non-emergency inpatient care and a few years in diabetes. Why anyone intelligent and ambitious would train to be a doctor nowadays is a mystery to me - yes, after thirty years of unimaginable stress you could probably command a good income in private practice, but... thirty years??


Image of the book cover

The Circular Staircase
by Mary Roberts Rinehart

narrated by B. J. Harrison
"Wealthy spinster Rachel Innes is persuaded by her niece and nephew Gertrude and Halsey to take a house in the country for the summer. Rachel is unaware that the house holds a secret, and soon unexplained happenings and murder follow."
This was pretty good, published in 1908, and is a murder mystery novel when these were not a recognised genre. There were perhaps too many twists and interconnected plotlines for me, but I enjoyed listening.


Image of the book cover

The Angry Chef
by Anthony Warner
"Assembling a crack team of psychiatrists, behavioural economists, food scientists and dietitians, the Angry Chef unravels the mystery of why sensible, intelligent people are so easily taken in by the latest food fads, making brief detours for an expletive-laden rant."
The book by the chef whom I met in Birmingham in November when he did a talk to the Skeptics in the Pub. He was a good talker, and it's a good book too, which is a relief. And nothing in there that I disagreed with professionally either. I look forward to his next book coming out in January, which I believe will be about fat and fatness.


Image of the book cover

The Stars My Destination
by Alfred Bester

narrated by Gerard Doyle
"Imagine a future in which people "jaunte" a thousand miles with a single thought, where the rich barricade themselves in labyrinths and protect themselves with radioactive hit men - and where an inarticulate outcast is the most valuable and dangerous man alive."
I think this is a good book which I spoiled by listening with long gaps between short bursts. So I didn't entirely follow the plot. I should really listen again, but there are so many other books awaiting my attention!

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