Learning, changing jobs and home news

National Botanic Garden of Wales, May 2013

It's one of those times when I think I've written all that I can about everything, and there's nothing left to blog about. I have an interesting and fulfilling life, it's true, but there's nothing particularly interesting to write about. Living in two places, work, badminton, family, the house and the blessed car - nothing you need to know. Mr A and I have a new boiler, the brakes on the car have been fixed, I have been on a course, that's it.

OK, so let's try harder.

I handed in my assignment for the module I'm doing for a Masters degree. It was a case study, all about a patient who was newly diagnosed with Type 1 diabetes at a relatively late stage of life, but who also is very overweight and has other health problems too. As usual, I write this on the basis that there's no reason at all to think that the patient isn't reading along with us, which makes it difficult to describe much more about the situation. I learned quite a bit about various aspects of diabetes by reading up on the evidence base, but it seemed to take an enormous amount of time. I'm not sure that doing more modules towards a Masters is how I would like to carry on with further professional development.

I have had my exit interview with my current employer - I think the administrator whose job it is to arrange these things was a bit enthusiastic, seeing as it's more than a month until I finish. It's also ironic that I haven't yet been able to complete the mandatory training associated with my induction. Anyway, I fed that back, which gave us something to talk about, along with the difficulties of having a fixed term contract working in a Diabetes department that often feels like it's in a continuous crisis situation. I would have no hesitation working with any of the Dietitians in the hospital - not just the Diabetes Dietitians - but I'm not sure I'd want to work in this Diabetes department again.

Luckily, I was allowed to continue with the training I'd been booked to do before I handed in my resignation, which took place last week. It focused on behaviour change (level 1), and covered much of the same ground as the Communication Skills module I did while at university. If done well, it can transform a difficult interview, and can help patients to achieve the results they are after. At the moment, I can see the potential and know in principle what I should be doing, but achieving it is another matter. It is something that I plan to practise as much as possible.

The new boiler was installed in my weekend home without fuss, according to Mr A who was there at the time. I played in a badminton match for the 1st ladies team of my weekday home, which is well above my standard, so losing 6-3 was a good result. I failed to get my hair cut through lack of booking ahead, mostly because I couldn't remember the name of the hairdresser. I'm busy making extravagant plans for the nearly three weeks I will have between the old and the new jobs, but will probably just sit around, as usual.

Gestational Diabetes

Cardiff castle, May 2013

I started writing this post some considerable time ago, which is a little ironic. Not many posts have needed incubation.

Every week, I see a few patients who have just been diagnosed with Gestational Diabetes Mellitus (GDM). And when I say 'just diagnosed', sometimes it's been in the last hour or two. Some have had it before, some take it in their stride, and some are completely freaked out.

For each of these women, I aim to give them basic dietary information in 30 minutes, and then they can have lots more input the following week if they need it when they come back for a scan and a full check-up. When I started writing this post, the shortest time I had managed was about 40 minutes, and when I first started in the job it was more like an hour. Now I've got it down to a well-practised routine.

The diagnosis is made by screening women who have one of several risk factors, including pre-pregnancy BMI over 30 kg/m², a previous baby that weighed 4.5 kg or more, previous gestational diabetes, a first degree relative who has diabetes, or one of several ethnic backgrounds that have a high prevalence of diabetes. Screening is usually done at around 26 weeks into the pregnancy. The fasting blood glucose is measured, then they are given a measured dose of glucose to drink, and after two hours their blood glucose is measured again. In our Trust, if the fasting level is greater than 5.4 mmol/L or the 2-hour level is greater than 7.7 mmol/L, then bingo - the diagnosis is Gestational Diabetes. Even if the fasting level is 5.5 or the 2-hour level is 7.8 mmol/L.

For most of the time when I see people in the general diabetes clinics, I have to respond to what the individual brings to the consultation. It could be anyone, with any type of problem, or no problem at all. For this ante-natal clinic, it's always a woman, it's always gestational diabetes, and the advice is always the same at this initial stage. So it's an opportunity for me to hone things over the weeks, to get the right messages delivered as well as I can do it.

My first inclination was to do a bit of research, to make sure that my advice is based on the best available evidence. Two documents were the obvious starting point: the NICE guidelines, and a Diabetes UK document, both from 2008. I also found a couple of academic papers.

There are two main reasons that diabetes in pregnancy needs to be addressed. High maternal blood glucose means that the baby will receive more glucose than necessary via the placenta, and will secrete higher levels of insulin to compensate. Any energy that isn't needed for growth will be laid down as fat, generally around the middle and the shoulders. This can complicate delivery, with a higher risk of the baby getting stuck (shoulder dystocia) and trauma to the mother. The other issue is that after the baby is born, its blood glucose will drop to normal levels, but it may still be producing a lot of insulin. Hence there is a risk of post-natal hypoglycaemia, to the extent that the baby might need a glucose drip for a day or two until it sorts itself out.

After delivery of their baby, mothers are offered a six-week follow up glucose tolerance test, and the good news is that for most mothers the diabetes will have gone away. According to the US National Diabetes Education Program, however, 5 to 10% are found to have diabetes at this point, usually Type 2. Those who don't have diabetes at this stage still have a seven times higher risk of developing Type 2 later in life than if they hadn't had GDM.

I work with a specialist midwife in the clinic, and we take it in turns to deliver our messages. She covers the clinical information, and provides a meter so that the mother can test her blood glucose seven times a day: before each meal, one hour after meals and once before bedtime. Seven times a day, every day until the end of the pregnancy. Some women have had to do this before, some women take it in their stride, some women... well, you can imagine.

So what is my dietary input? In 30 minutes, I cover the following:

• An explanation of Gestational Diabetes, and how food affects blood glucose.
• Reassurance that they haven't developed GDM through eating too much sugar or too many pies.
• The treatments available (diet, tablets, insulin, in that order) and that if you progress to tablets and insulin it's not necessarily because you're doing anything wrong, but this is a progressive condition.
• What is their 'normal' or 'typical' diet? [I love a good diet history, you find out such interesting things]
• Foods that don't significantly affect blood glucose (protein, fat, vegetables/salad, diet drinks, sweeteners, vinegar, herbs, spices) and those that do (sugary and starchy carbohydrates, including fruit, milk and yogurt).
• The difference between sugary and starchy carbohydrate in terms of their effect on blood glucose, and the difference between a lot and a little carbohydrate.
• What a reasonable portion size of carbohydrate should be.
• Check that they are aware of advice on food safety and hygiene, avoiding liver, pate, uncooked shellfish and eggs, blue, soft and unpasteurised cheese, limiting intake of certain fish (swordfish, marlin, tuna), and the suggested restriction on caffeine.
• The benefit of activity on general health and particularly blood glucose control.
• And... any questions, at which point I have an eye on the clock and hope that they are completely overwhelmed with the information so far and will keep their questions for another day.

One of the reasons for clock-watching so closely is that the only time the midwives can run this clinic is on a Friday afternoon, when up to four women are scheduled. Run over a few minutes on each, and we're not going home on time. I can fill an A4 sheet with drawings, graphs and lists of food in clear handwriting faster than you can imagine.

The evidence behind the dietary advice for GDM principally supports a focus on a healthy balanced diet containing low glycaemic index carbohydrate food that is digested quite slowly. I often use the analogy of a sink with a blocked drain, where the level of water in the sink is the blood glucose level. Turn the tap on full blast and the sink overflows; put in the same amount of water (carbs) at a slow trickle and the level will only rise a little. It is all meant to limit the period of time when blood glucose is above the optimum level.

Women often ask how much carbohydrate is enough, or whether cereal A or B is better. I can give a generic answer based on population studies and determination of glycaemic index and glycaemic load (which is the index multiplied by the amount of food). The easiest way to address this question, however, is to point out that they will be testing their blood glucose before and after meals, and after just a few days they will know what 'too much' looks like. 

My dietetic advice differs slightly from the usual 'healthy eating' messages, because short-term glycaemic control is much more important than long-term cholesterol levels, for example. So a high protein, low carb cooked breakfast isn't such a bad thing for the few final weeks of pregnancy, because eggs, bacon, sausage, mushrooms, tomatoes and baked beans hardly contain any carbs at all. Crisps are a comparatively good choice of snack compared with sweets, cake or chocolate, but nuts are even better (as long as there is no history of nut allergy in the family). Reduced fat houmous with vegetables is probably the best choice for a snack that I can think of - low in fat, high in fibre with minimal effect on blood glucose.

Follow up in clinic consists of reviewing the blood glucose numbers recorded, and seeing a) if there are any above the target levels and b) whether these are occasional and random or frequent and showing a pattern. The woman may want advice on better choices for a particular meal, or she may have been experimenting to find the best type and amount of cereal for breakfast. There has been only one woman I can remember who seemed to deliberately ignore dietary advice and who changed nothing. Most are prepared to put up with everything because it's usually for only three months, and it's clearly worth it for an easy delivery and a healthy baby.

New job

Munich Viktualienmarkt, March 2013

All the different employment options have finally coalesced into a nearly certain situation. I have a leaving date and a start date that are very nearly three weeks apart; I will be in a permanent job for nearly three days a week and there will be temporary work for definitely one other day and possibly two, all with the same employer. I got in touch with the other employer that was offering one day of Type 2 education, and they said extremely nice things and even suggested that they keep the post open until I start the new job, because the extra days cannot be put in writing (it's complicated) and may disappear into thin air.

The new job is probably very similar to my current job except without the pregnant women, which is fine by me. It is in a much smaller hospital than my current one or the previous one, with a much smaller team where I will be the only Diabetes Specialist Dietitian. I'm guessing the journey time will be about half an hour, compared with the current time of nearly two hours due to ongoing 'improvements' to motorway junctions.

I met my future boss (who is also my previous boss) at a Coeliac UK meeting on Saturday and had a nice chat. In the line for tea and cake I stood next to a lady who recognised me, and thanked me for giving her a recipe for gluten-free lemon drizzle cake three years ago. I thanked her for complimenting me on my gluten-free lemon drizzle cake three years ago in front of the Dietitian who I was hoping would give me a job - and who eventually did become my boss.

In other news: the heating company phoned Mr A and postponed the boiler replacement for another week - we are thinking of going away next weekend just in case it doesn't last that long. The car really does need more attention on the brakes, which I had been trying to ignore. I finished the module for the Masters degree with days to spare, by dint of working in the library every night until 8 p.m. last week. It was painful, but worth it, because I didn't have to work all through this weekend. But when I finally got round to attacking the task of switching gas and electricity suppliers, the website containing all my bills was closed for maintenance so I couldn't get started after all.

After the last mammoth blog post, I think this will do for the time being!

Dressmaking

I've been making a dress for Lola II. This is something I rashly offered to do after she had to return a dress that she really liked because it was such an unflattering colour. I'm not talking about a shade that didn't bring out the vivid colour of her eyes, I'm talking about a dress that made her look like she had a fatal disease. Seriously.

Dressmaking is something I used to do quite often when I was younger (a lot younger), and I used to rather enjoy it, so instead of doing a jigsaw puzzle on my Solitary Holiday back in May, I thought I'd make the dress.

It was touch and go whether we would find both a pattern and fabric that would do, but we managed it. Then Lola II said that she'd like to have a go a dressmaking herself, but wasn't sure a) what it entails, b) whether she'd like it, and c) whether she'd be able to manage it. So then I foolishly offered to blog my progress so she could see how it works. This is the consequence of all that foolishness.

Very shortly after this, she attempted a basic dressmaking operation (sewing a hem or something similar) and decided that there was no way on earth that she was going to do any dressmaking after all. Given that this post was already well on the way to completion, I thought I might as well carry on regardless.

A dress pattern comes on large sheets of tissue paper. The cover tells you how much fabric to buy, and there's a plan of how to lay the pieces out, usually with the fabric folded in two (right side inside) so the symmetrical pieces can be aligned to the fold and you can cut two identical (but mirror images) of the other pieces.

The 'nap' of the fabric matters (that's the direction parallel to the longitudinal threads in the material), especially if the printed design is asymmetrical (so all your Christmas trees point upwards in the finished piece), and the pattern pieces are printed with a line that has to be aligned to the nap. You measure from the line to the edge or the fold of the fabric to make sure it's straight.

Quite early on you have to decide exactly what dress size you are, which isn't as easy as it sounds. A pattern generally comes with different cutting lines for different sizes. That's one of the beauties of self-made clothes - if you are a non-standard size, you can adapt very easily. [It turned out that Lola II comprises four different
clothes sizes.]

Day 1

The first step is to cut out the pattern pieces roughly, and pin them (usually to the back of the fabric) according to the plan. Sometimes it helps to iron the pattern sheets and/or the fabric to make sure they're properly flat. It helps to have a table large enough to spread all the fabric out, but I didn't. Never mind.

Don't feel bad if you have to pin and unpin the pieces several times. I'm so out of practice that I think I made every mistake in the book - I looked at the wrong layout plan more than once - the main thing is that everything is as it should be before you pick up the scissors, because once the first cut is made, it's much harder to put mistakes right. In fact, it took me so long to get this bit right that I had to switch over to music from the dramatisation of Bleak House that I was listening to, just so that more of my brain was concentrating on the sewing. I unpinned and re-pinned some of the pieces three or four times.

That first cut with the scissors is scary, but necessary. I cut the pieces out roughly first, because I wanted to mark out the changes that would accommodate different sizes at bust, waist and hip, and also because then it's more easy to be accurate about cutting along the lines. I tend to do the final cut on just the pieces I'm working with, and leave the rest until their turn comes.

The next step is the one I find most tedious, which is to transfer the markings from the pattern to the fabric, both on the side where the pattern is pinned, and the other side. These marks are to help line up various points accurately when it comes to stitching, e.g. centre front and back on both bodice and skirt. There are various chalks and carbon papers available that will serve this purpose - I used an HB pencil.

A word about interfacing - this is a fabric used to stiffen the garment, like in a collar or cuff. It doesn't have a grain, which removes some complication, and nowadays it's usually got iron-on adhesive - we used to have to tack (roughly stitch) the interfacing on. Usually, you use one of the pattern pieces to cut the interfacing where directed. These instructions were a bit vague about the interfacing, which was annoying, so I made an educated guess. If the interfacing covers up any of the pattern markings then you have to mark them on the interfacing. If you make a mistake and have to move the interfacing, then iron it again and peel it back while the glue is warm. This dress seems to use interfacing to reinforce the V-neck at the front.

Before you start to sew a fabric for the first time, it's a good idea to test the thread colour, tension and size of stitching with a spare bit of fabric. For this pattern, the darts in the back of the bodice were the first thing to stitch. Always pin first, using as many pins as you think you'll need (it doesn't matter if it's hundreds) and align them at right angles to the seam. Sew over the pins and take them out afterwards. Sew as fast or as slowly as you're comfortable with.

Day 1 ends with interfacing in place and darts sewn in back of bodice.

Day 2

No dressmaking. I went to London.

Day 3

It occurs to me that there are many dressmaking words I take for granted, like 'nap'. This morning starts with 'baste', which just means sew roughly. I used to do it by hand, but now I generally use a larger stitch on the machine. There's an extra reinforcing piece that finishes the neckline at the back, it's a bit fiddly, so they get you to sew it roughly first. In fact, for the final 'topstitching' (which is stitching that isn't hidden but shows on the finished garment) I did sew by hand to baste, because as I've said the basting was fiddly and also needed to be removed after the final stitching was done.

Don't be afraid to unpick things if they don't go right. I wasn't happy with how I stitched the neck first time round, so unpicked the seam and had another go. Obviously, this gets very tedious and time-consuming, so if it isn't too bad, I would just live with it. Like the time I sewed the cuffs of a shirt onto the wrong sleeves. I had to live with cuffs that did up at the back rather than the front for the lifetime of that shirt.

Next is the pleating at the bottom of the bodice. Again, I pinned it all wrong before I worked out how it was supposed to be done - I blame the wording and the picture in the instructions. I needed to pin and sew each pleat individually.

Day 4

Shoulders. Another complicated part, but following the instructions and with a bit of intuition, I think I've got it right. It's useful to remember that things are often sewn and then turned inside out - if this is the case, the seams that end up on the inside need to be trimmed a bit so they aren't too bulky.

Next, the two pleated front pieces of the bodice need to be sewn together. Nothing terrible here, I just found that I had ironed the pleats in the wrong direction, which was easily fixed. Once that's done, there's some gathering needed to the front of the skirt - this is done by sewing two parallel lines of the longest stitches and then pulling on the threads to gather the fabric. Then it's time to sew the skirt to the bodice: front first, then the back.

There are a number of sewing equivalents to the toast always landing butter side down. On the trickiest seam, when it's taken you hours just to work out what should be sewn to what, and fiddled about getting it pinned just right - something like the top of a sleeve, a collar or a cuff - you will inevitably find (usually after you've taken the pins out with relief) that you've either caught some of the underlying fabric in the stitching by mistake, in which case all or part of the seam has to be unpicked and redone, or that the lower thread on the bobbin ran out at the start of the seam and you've got to fiddle about pinning it all up again. I can report that, up to this point, neither of these events has taken place, but now that I've typed these words, I'm expecting the worst.

Day 5

I forgot to take photos of this bit, and with hindsight I'm not sure they would be helpful. It involved constructing the decorative band that goes across the front, with two interlocking sections and a twist. I'm pretty sure I followed the instructions properly, but it seems to leave the edges of the band completely unfinished. Maybe this is OK with jersey fabric, which is what is recommended, but I took the initiative here and made a small change so that no frayed edges would be visible. The last thing I did during the holiday was to baste the band to the front of the dress. I'm sure it should also be sewn to the front so it doesn't sag in the middle, but I can wait to see how it works in the end before making this 'improvement'.

Due to a small mixup, the measurements that Lola II gave me for her waist turned out to be inaccurate, and the next step in the instructions was to sew the sides together (including a zip). To be on the safe side, I thought it would be a sensible idea to do this after Lola II had the chance to try it on, and we could measure her properly.

Day ?

So I didn't do any more on the dress until I dropped in on Lola II and Mr M on the way back from holiday. That gave us the chance to try it for size, and it was pretty good, so I sewed the full side seam on one side, and the zip into the other side.

Of all the different operations necessary, this was probably the most tricky, and I took no pictures of the procedure. It didn't work brilliantly the first time, mainly because I didn't follow the instructions exactly to the letter, but I had to undo it again anyway, because I'd made it too small. Better the second time, and that's as far as I got in the holiday week.

Day ??

Coming back from holiday to the real world, the dress took a back seat for a month or so, while I moved into my new weekday accommodation and acclimatised to the new lifestyle. But the sleeves and the hem still remained to be finished. The sleeves are stitched into a tube first, then the outside edge (armhole) needs finishing. The instructions assume a jersey fabric, but I felt the need to prevent it fraying by creating a hem. I could have done an invisible hem by hand, but I don't think the machine version is too bad.

Then one of the most fiddly operations - fitting and stitching the sleeves into their sockets. It didn't go too badly, I'm pretty sure I sewed them in the right way round, it all looked OK. So, time to try the almost-finished dress on.

Disaster! It appears that the one place where the stretchy jersey fabric was needed was the sleeves. Both my arms got stuck with the dress half on and the sleeves not much further than my elbows, and it was a devil of a job to extricate myself. Eventually the garment and I were separated, and I could survey the scene.

A couple of options are possible. I could split the sleeves along the outside, which would be fairly difficult to do, or I could remove them and create new ones, which would also be difficult. So I did nothing, for quite a long time.

Day ???

A long time later, following much thought, discussion and borrowing a T-shirt from Lola II that had the sort of sleeves we were looking for, I returned to the dress on our Yorkshire holiday in September.

I found that the T-shirt template wasn't going to work unless I unpicked the sleeve to use it as a template, but as the T-shirt was still a viable garment, I decided not to do that. What I did was to copy the pattern piece onto newspaper (it would have been tissue paper but I forgot to bring any), then split it and re-drew it in a way that I hoped would fit the same armhole but wouldn't need stretch jersey to work.

And it did! So the dress is nearly complete, with only the hem to finish. I can't do that without Lola II, because I will need her to model it and check that the skirt is the same length all the way round.

Days ???? and ?????

When I met up with Lola II after the holiday, we spent some time with me lying on the floor measuring the height of the hemline. It shouldn't have been necessary, but it's been a while since I did any dressmaking before this marathon effort, and the hemline definitely wasn't straight. That took ages.

I knew I'd be seeing her again this weekend, and all that was needed was to sew the hem and a bit at the front, so in between getting to weekend home from weekday home and setting off again for school reunion, I managed to haul out the sewing machine for the hem and then sew the front bit by hand.

Finished! It was fun. I really enjoyed it, and it brought back the satisfaction of creating something both beautiful and practical by hand. I'm going to do it again, but I have so many more pressing things on the agenda, it might be some time before I get round to this little project.

Lola 2013

Burda 7082

An account of the past week or two

National Botanic Garden of Wales, May 2013

Let's start with some good news. Here are some bad things that haven't happened: the boiler hasn't broken down. The car hasn't needed any attention for nearly a week. There have been no work-related disasters.

My list of everyday tasks expands and contracts but never goes away. There has been progress of sorts - we have a date for installation of a new boiler, I have a certificate to prove I am not a criminal, and I have even managed to get proof of previous employment in the NHS back in the 1990's. This is useful because the amount of annual leave that one is entitled to depends on duration of employment, and it doesn't matter when that employment took place, so I should get a few more days holiday as a result.

On the down side, I haven't had any firm offer of employment so I haven't been able to give my notice in, and it is now looking as though I will therefore have to work through Christmas; I am nowhere near dealing with the Will or the Power of Attorney that I have been determined to set up for several years now, and there are some other jobs that look like they will be pushed further and further into the future. Income tax self-assessment form? Forget it.

The employment situation becomes ever more complicated. Why is it never straightforward? I got a call last thing on Friday as I was driving home last week, saying that there were more hours available to add to the 20 hours in one of the prospective new jobs, and then the voicemail message was cut off. An exciting prospect - perhaps this would be enough to make up a full time job together with the one day I've been offered by the other employer?

I had to wait until Monday to get more details. It took nearly a whole day of phoning and leaving a message, followed by not being able to answer the phone when it rang, then leaving another message, then being with a patient again when the return call came through, and so on throughout the day. Eventually we managed to find a time when both of us could speak, and of course the extra hours turned out to be on the same day as I had been offered for the one-day job.

Pros: four days with one employer is better than three with one and one with another, and it would cut out all the travel. Cons: the one day job would be doing education for people with Type 2 diabetes which is something a bit different that I'd actually like to do; I've said I'll take the one day job and don't like to mess people around; the extra hours tacked on to the 20-hour job would have to be taken on trust because that offer can't be put in writing. Watch this space.

I have been given the extension to the deadline for my Masters module that I asked for, and spent the whole of last weekend working on it. Really and truly, the whole weekend, except for a couple of hours watching La Vie En Rose, a biopic of the life of Edith Piaf, and a trip to the shops for provisions. I was able to do this due to the absence of Mr A, who is on a Bulgarian Biking Bonanza for a week. He returns very soon, and I await the thrilling tales of excitement and adventure. As far as I know, he hasn't broken anything, but I doubt that he would mention it if he had - he would just return home in plaster as a lovely surprise.

There is more to do for the stupid Masters module, which is taking up a disproportionate amount of leisure time, to the extent that I have decided to use work time to do it as well. Studying as a full time student was wonderful; combining it with a full time job is not so much fun. Just a couple more weeks of pain and it will be over - I do wonder whether I can be bothered to put myself through this for all the other modules necessary for the degree, but I imagine when the memory of this module has faded I shall miss the learning experience.

I am doing a fair bit of learning through everyday work, because I always want to make sure I'm on top of the game. A chance remark by one of the nurses set me thinking about the effect of caffeine on control of blood sugars in diabetes, and I chanced upon a recent paper which investigated just that. In case you're interested, it concludes that caffeine is bad for blood glucose control in Type 2 diabetes, and probably also in Type 1 and gestational diabetes. I'm not sure whether the paper is freely available because I accessed it through my university account, but if you're interested then look for "Whitehead N. & White H. (2013) Systematic review of randomised controlled trials of the effects of caffeine or caffeinated drinks on blood glucose concentrations and insulin sensitivity in people with diabetes mellitus. J Hum Nutr Diet." Or ask me, and I'll email it to you.

Speaking of gestational diabetes, those ladies keep on coming. I have had to deal with a glut of interpreters recently, some of whom have been truly awful, along with some very difficult patients who have been struggling both to understand what is being asked of them and to put it into practice. But some good news to finish with: at the end of today's clinic there was a lovely smiley lady whose interpreter hadn't arrived, but whose blood sugar record was near perfect and who indicated (with the help of family present) that she actually felt much better having made the recommended changes to her diet. That hardly ever happens, but so nice when it does!