What I've been reading

Who Needs Mr Darcy?
by Jean Burnett

"Mr Wickham turned out to be a disappointing husband in many ways, the most notable being his early demise on the battlefields of Waterloo. And so Lydia Wickham, nee Bennet, still not twenty and ever-full of an enterprising spirit, must make her fortune independently."

Well, they were free, and I wasn't expecting classic literature, but my 12 Books of Christmas are proving to be a great disappointment. This is number seven, a sequel to Pride and Prejudice, and it just isn't very good. Hard to say why, but there's no depth to the characters, and some of the situations are simply unrealistic and hardly credible. And the story doesn't finish with the end of the book, so there was no satisfaction there either. Five more of these books to go, and I'll be most pleasantly surprised if any of them turns out to be any good.

The Man Who Mistook His Wife for a Hat
by Oliver Sacks

"These are case studies of people who have lost their memories and with them the greater part of their pasts; who are no longer able to recognize people or common objects; whose limbs have become alien. In Dr Sacks’s splendid and sympathetic telling, each tale is a unique and deeply human study of life struggling against incredible adversity."

This is an old favourite book that I started because the book above was so bad that I couldn't read more than two chapters at a time, and needed something good to read at the same time. The two couldn't be more different, especially in the quality of writing. A book about neurological conditions written in 1985 for the general rather than specialist reader was, I think, somewhat unusual. The proliferation of books about the brain has increased along with our knowledge and insight, although I find it fascinating that we are on the brink of creating quantum computers and describing the origins of the universe, but we actually know so very little about the meat that is inside our own heads, let alone how to fix it when it goes wrong.

Stranger in a Strange Land
by Robert A. Heinlein

narrated by Christopher Hurt

"Many years in the future, Valentine Michael Smith's upbringing is exceptional. Orphan child to two astronauts killed in space, he is raised on Mars. Twenty-five years later he is rescued and brought back to earth."

I remember reading books by this author when I was young, along with Arthur C. Clarke, Isaac Asimov and other science fiction writers of the day. None of those books was as allegorical as this one, at least if they were, it didn't impact on my young teenage consciousness. The man from Mars arrives as a young adult, has supernatural powers, attracts a devoted following, and sacrifices himself to the mob in order to save the others - sound familiar? Still, it was well narrated and much more interesting than the free books - another one of those on the way...

Avenger's Angel
by Heather Killough-Walden

"Four thousand years ago, four archangels were cast down to Earth in human form. God's favourites, they came to find their mates, the other half of their souls made only for them. But after centuries of fruitless searching, the archangels - and their enemy - have all but given up hope."

Eighth of my 12 Books of Christmas, another supernatural thriller, including not one but two vampires and a set of good and bad angels. The story runs at such a pace that there's hardly time to breathe - the whole thing takes place over about a week and there are at least two crises every day, making it rather tiring to read. At least it isn't badly written, and only a very little bit too much sex.

Back to school

Deutches Museum, Munich, March 2013

I spent two days last week at university: "Learning Beyond Registration - Diabetes 1". The registration that I'm learning beyond is that issued by the Health and Care Professions Council, which is the regulatory body for the Dietetics profession. The module can stand alone, or can form part of a Masters qualification.

Teaching is done at the university where I studied for my Dietetics degree, and the campus has changed surprisingly in two years. There is a big hole where one building used to be, there is a whole new building where there used to be an open space, there is a brand new cafe and shop, and various other upgrades to facilities, including pay and display parking which used to be free. It was also quite sunny and the cherry blossom was in full bloom, showing off the beauty of the countryside campus to full effect.

There are five of us taking this module, where in previous years there have been many more (I think a previous class of more than thirty was mentioned). Five was a good number, and three of the others had less experience than I do; we all had lots of opportunities to ask questions. In fact, day 2 was spent with an experienced diabetes Dietitian doing nothing but asking question after question.

Day 1 was more structured. The morning covered the evidence base, including a very useful document that summarises all the evidence behind the nutritional guidance that is applicable to diabetes. In the afternoon we went over the evidence of increased cardiovascular risks associated with both Type 1 and Type 2 diabetes with a very knowledgeable Dietitian from London, as well as looking at the different medications available and some of their side effects. We ran out of time at the end and skipped through insulin pumps, which was fine because I know quite a lot about pumps.

Day 2 was my perfect day. From 9 am until 4 pm we talked about anything and everything about diabetes - insulin, weight management, carbohydrate counting, glycaemic index, alcohol, physical activity, renal function and lots more. The role of the multi-disciplinary team, prescribing, low calorie and very low calorie diets, low carb vs low fat diets, the latest 5:2 'Fast' diet, glucose metabolism and competitive sport, glycaemic rebound following a hypo, the dawn phenomenon, glycaemic profile after alcohol or activity, matching insulin profiles against individual requirements, the use of 'old' vs 'new' insulins and their cost, the comparative cost of other medications, working with difficult patients (and colleagues), gestational diabetes, enteral and parenteral feeds with insulin, educational resources, new technologies like Skype clinics, different blood glucose meters, issues to consider on holiday (especially an activity holiday), and there was probably more.

After some careful discussion, I think I have got to the bottom of the meaning of the statement that if the same total amount of carbohydrate is consumed, then "sugar does not raise blood glucose levels any higher than starch". What it seems to mean is that the total amount of glucose that reaches the bloodstream is the same for a portion of sugar and a portion of starch that contain the same amount of carbohydrate - the body does not distinguish between the glucose that is derived from digestion of sugar compared with the glucose derived from the digestion of starch. But sugar is digested faster and reaches the bloodstream quicker than starch, so produces a sharper peak in blood glucose post-ingestion, especially if in liquid form, even if the total impact on blood sugar (the area under the graph of blood glucose plotted against time) is the same for both curves. This post-prandial peak seems to be the most harmful aspect of glycaemic control in diabetes, according to the experts, and subcutaneous insulin isn't quick enough to deal adequately with a sugar peak.

Having said all that, the total amount of sugar in most foods we eat is usually less than the total amount of starch - compare a serving of honey (1 tbsp = 15g) with the serving of bread (1 slice = 40g) that accompanies it. Even with bread at 50% carbohydrate and honey at 85%, you're still getting a bigger hit of starch than sugar overall. So having a little bit of honey on your toast isn't too bad, but drinking non-diet Coke is not advised. Except to treat a hypo.

The next stage in the module, after I've properly consolidated what we learned (more formally than just writing a blog post), is to find myself a case study and start writing it up. We have another two days taught in July including an assessed presentation, then the case study has to be ready in October.

There will now be a short break while Mr A and I go on holiday...

Writing letters

Basilica of Esztergom, Hungary, October 2012

I have a half-finished post written about gestational diabetes, but in my obsessive way I have facts to check before I can publish it, and I'm not getting round to it at the moment. It is quite busy at work and at home, and very soon Mr A and I will go on holiday for a week, which I expect will get in the way of blogging.

There has been nothing exceptional in the last week. I have seen some patients, and started writing letters. It appears that no letters have been written following dietetic patient consultations for quite a long time, so this is more exciting than it sounds. I think that letters should have been written, at least for the first consultation following a referral, and for any significant change of treatment or discharge. I am now familiar enough with the department to be confident that my opinion that letters should have been written is correct; therefore, I am now going to have to write some.

Of course, there is no 'writing' involved in writing letters. There are two options: one is a word processing system whereby I call up an appropriate template and type the thing myself, then print copies for file, referrer, GP and patient, and attempt to ensure that all copies go to the correct destination. This is the option I have been using for my first few attempts at letters, because I don't really know what I'm going to say when I start, and the alternative is a dictation system. I've never done dictation before, and am not looking forward to it. Eventually I shall move to dictation, because then all the formatting and printing and filing and envelope-stuffing and posting will be done by the admin staff rather than me, and this will make up for the amount of time it is likely to take me to dictate a letter in an effective way.

However, it has not gone unnoticed by the admin staff that the Dietitians who previously were not writing letters are now writing letters, and this suggests an increase in the volume of work that they will have to do. There appears to be some ambiguity about the status of Dietitians in the Diabetes administrative setup, which accepts Doctors and Nurses as entitled to dictate letters, but is not sure about Dietitians. So we will see how many dictated letters it will take before there is a revolt, and the Managers are invoked, and Dietitians will temporarily have to return to the word processing template system while people argue about budgets.

Meanwhile, the cell that RSB and I share by way of an office has suddenly become a sauna. We have no window or air conditioning, so there is nothing we can do except turn on the fan on the filing cabinet and blow hot air around. At home I wear jumpers and fleeces and Mr A and I sit on the sofa under a duvet, and at work I wear thin tops, anti-perspirant, and look forward to my clinics (where it is not so hot). The important meeting to decide the future location of the Diabetes service has taken place, and unsurprisingly, no decision was made, although the process by which a decision might be made was laid out. So I don't anticipate that we might have a more habitable office any time soon.

A post that very nearly isn't about diabetes

Sculpture in Austrian monastery garden, October 2012

Anyone would think that the only things I get up to are work, reading and blogging. But there are a few other aspects to life, although I have to admit, they are mainly based around badminton and commuting.

I played in a one-off Ladies doubles handicapped competition, which means that there were teams of all standards playing one another with an attempt to even things up by giving one side lots of points to start with. We were given a head start of 12 (out of 21) and didn't do too badly, although we didn't win any prizes. Then there was the local badminton League dinner dance, which is a social evening that includes presentation of all the trophies for teams that have come first in their divisions and in competitions. Our club has won nothing this year, not even the plate for the friendliest club, but we occupied more than one table and more than our fair share of the dance floor. And just to follow up this enthusiastic participation, the club actually held an AGM this year (primarily because I am the club Secretary at the moment), and people were keen enough to attend, and even vote! And, even better, there are volunteers to attend the League AGM, which I would probably have had to do if nobody had volunteered, and which I hate.

Moving on to life that is not badminton, we have started to take steps towards resumption of house preservation and restoration. Not the most enthusiastic pair when it comes to DIY, Mr A and I have reviewed the battleground and made progress in attempting certain tasks ourselves while delegating others to the reliable Alf and a badminton-playing friend who has business cards calling herself 'Lady Decorator', which I find most amusing. Mr A is hoping to build a new door for the airing cupboard, while I will permanently shorten the curtains that I tacked up temporarily ten years ago, and attempt to descale all the bathroom fixtures and fittings. We have also performed some DIY support to Lola II and Mr M, who are similarly disinclined to do it themselves, and who also lack some essential skills. Mr A provided sawing, screwing and wood shaping support, while I made Lola II strip the wallpaper that was coming away from the wall rather than painting over it. Mr A made things look much better, and I made things look much worse, but I am confident they will be better in the long run.

In relation to work, I am finding the commute to be long but tolerable, especially when I have a good book to listen to, although the car is wheezing a little at the moment and will need some attention this week. I attended a talk given by our specialist obesity dietitian, which confirmed much of what I already know. The consensus of evidence seems to be that it doesn't much matter how one loses weight (as long as nutritional balance is not compromised), but the focus must always be how that weight loss can be maintained. And that it is almost impossible for most people to use exercise and activity alone to lose weight, because we simply don't have the time - but activity is highly effective in supporting weight loss that is achieved by eating fewer calories.

That's about it when it comes to stuff that isn't about diabetes. I can report that I attended another local Diabetes UK meeting, and Mr M has kindly donated some insulin pump supplies for me to stab into my fleshier parts as an experiment, because he is getting a new pump. I have commissioned a blog post from him and Lola II about the new pump, and some photos were taken at the weekend, but we'll have to wait and see whether they can find enough time to fulfil the commission.

Ketones

Brixham harbour, August 2012

Warning to readers: more of the technical diabetes stuff coming up.

I do try to simplify the descriptions and explanations of what I'm learning about diabetes. Firstly because I want people to be able to understand what I write, and secondly because it's good to practise what I would say when there's a patient in front of me. I want them to be able to understand the information I provide, and it helps to think about it in the writing of this blog.

So this post is about what happens when things don't go quite right with diabetes. 'Ketones' are a by-product of fat metabolism, i.e. when fat rather than carbohydrate is used to generate energy, a state known as 'ketosis'. The main reasons why this would happen are a) if less carbohydrate is eaten than the body needs for fuel, which might be if someone is deliberately trying to lose weight or is on a low-carb diet, or b) if there is a lack of insulin, in which case the blood glucose just can't get into the cells to fuel carbohydrate metabolism. The two types are sometimes respectively called 'starvation ketones' and 'diabetic ketones'.

Starvation ketones don't generally build up to significant levels, and aren't a problem. Diabetic ketones, on the other hand, are an indication that all is not well.

Diabetic ketones arise when there is a deficiency or lack of insulin in relation to blood glucose. The most common scenarios are either when a person with Type 1 diabetes stops injecting insulin for one reason or another, or when they get ill, which tends to result in higher blood glucose levels. If this glucose isn't available to be used for energy - if it can't get out of the bloodstream into the cells due to the lack of insulin - it will hang around in the blood, keeping levels high, and be excreted in the urine, potentially causing dehydration.

Because the body isn't aware that the reason for lack of carbohydrate fuel is that it's all in the blood and not in the cells, this will provoke the breakdown of fat, leading to a rise in blood ketone levels. In people with Type 2 diabetes who are still producing endogenous insulin, the presence of the insulin inhibits fat breakdown, which produces a protective effect, so Type 2's generally don't become ketotic. But their livers will keep chucking more glucose into the blood, not realising that there's plenty there already, keeping blood glucose levels high as can be.

Ketones in excess are damaging to the body because they are acidic, and acidic blood is not a good thing. The body responds to raised ketones by excreting them in the urine, but also via the lungs, which is what causes ketotic diabetics and slimmers on the Atkins diet to have breath that smells of pear drops or nail varnish remover. Historically, ketones were measured in the urine, which gives an indication of ketone levels over the period that the urine has been accumulating in the bladder. It is now more routinely possible to measure blood ketones, which are a more immediate indication of the current situation.

Raised ketones with normal blood glucose suggests starvation ketones - a lack of carbohydrate - and is not immediately worrying. Raised ketones with raised blood glucose is an indication of diabetic ketosis, and depending on the level of ketones, an individual may just monitor the situation, inject extra insulin, or take themselves to the Emergency Department of the nearest hospital. If ketosis has progressed so that the blood is acidic (known as diabetic ketoacidosis or DKA), it is usually necessary to start medical intervention, often with an IV infusion of insulin. If the illness (or the DKA) has caused vomiting and dehydration as well, then glucose and re-hydration will probably be needed too. It's a life-threatening condition if left untreated.

As well as illness, there are potentially many other causes of DKA resulting from disruption to the delivery of insulin: faulty insulin pumps, blocked or kinked cannulas, bubbles in pump tubing, forgetting or neglecting to give injections, hitting 'lipohypertrophy' when injecting so the insulin is poorly absorbed, insulin that is out of date or has been inactivated through heat or cold, being an inpatient or unconscious and not being given insulin, and there are probably more reasons that I haven't immediately called to mind.

In contrast with these unintentional insulin deficiencies, 'diabulimia' is the informal name given to a type of behaviour that involves injecting less insulin than is needed, in order to excrete glucose instead of utilising it, and thereby remaining both slim and constantly on the brink of DKA.

Within all the education and empowerment and interaction we have with diabetic patients, especially those with Type 1 diabetes, 'Never Stop Taking Insulin' is probably the most important central message that we offer.