Study day - Diabetes technologies

Adhisthana, June 2018

The study day I recently attended was a good one, including many interesting and relevant presentations. It was organised by the Association of UK Dietitians (BDA) Diabetes Specialist Group, and focussed on diabetes technologies as well as some of the usual business when Diabetes Specialist Dietitians get together - whingeing about nurses and other colleagues, comparing notes on difficult patients, who has been asked the most ridiculous 'what can I eat' question, whining that the lunch provided is a bit carb-heavy while demolishing all the crisps and three puddings etc etc. A bonus for me was that two previous colleagues were also there and it was lovely to catch up with them, and there was also a Dietitian from a nearby Trust whose previous Team Leader is my new Team Leader. So we had a good exchange of views on that situation, too.

After the AGM, the presentations started with someone from Diabetes UK updating us on what they've been up to in the way of nutritional news. This included information and new videos about 'Diabulimia', which is a term often used (but just as often criticised) describing the practice of someone with Type 1 Diabetes withholding insulin in order to lose weight.

Then a doctor ran through all the current technologies available at the moment, including insulin pumps, CGM systems, Flash GM systems, sensor-augmented pumps, closed loop and artificial pancreas systems, and something called Diaport which delivers insulin into the peritoneal cavity. There wasn't really anything new here for me, but it was nice to appreciate that my knowledge is way ahead of many Dietitians who don't come into contact with these technologies in their usual work setting.

Quite a few Diabetes Dietitians are working at national policy level with Diabetes UK and the All Party Parliamentary Group on Diabetes. This year the old evidence-based nutrition guidelines from 2011 were updated with a new document, which has shifted away from nutrients (recommended proportions of protein, fat and carbohydrate in the diet) in favour of real foods. The overarching recommendations haven't changed: the first line treatment of Type 2 Diabetes should be weight loss of 5%, a Mediterranean style of eating, education and exercise. For Type 1 Diabetes it is still about matching insulin to carbohydrate intake to regulate blood glucose levels. The advice about prevention of cardiovascular disease is now aligned with the NICE guideline, and progress has been made on the thorny question of fat - is it in fact irrelevant, or should we still advise restriction? The conclusion is now that the quantity of fat is less important than the type of fat, and whatever level of fat we choose to eat it should be more unsaturated than saturated.

The 'James Lind Alliance Research Priorities' were also new to me - the ten highest priority research topics in various clinical areas, including diabetes. Not that it makes any difference to my workload, but interesting to see what questions are thought to be most important at this time. A couple of the priorities relate to diet, and one is the old chestnut about the role of fat, protein and carbohydrate in the diet for Type 2 Diabetes, and what the evidence tells us we should specifically be advising people to eat. This has been addressed by the finest minds in the UK Dietetic profession, and the answer is that we have no idea. Another question that still remains unanswered is what we would initially advise someone with Type 2 Diabetes who is not overweight.

Those same fine minds have also come up with a policy statement about low carbohydrate diets (defined as between 50g and 130g carbohydrate per day) in the management of Type 2 Diabetes. It was published in the week following the study day, and it's handy to be able to see a summary of the available evidence even if that evidence is scanty. Essentially, we can say that in the time frame of 12 months, adopting a low carbohydrate diet is as good as any other approach to improving blood glucose levels, and it probably works because restricting carb tends to result in a reduction in total energy intake and therefore weight loss. We don't have any evidence beyond 12 months because it seems to be quite a difficult diet to sustain.

The next presentation was all about trying to be more prescriptive about how to manage exercise with Type 1 diabetes. I have written about this before (June 2016), and said at that time that it's one of the most difficult aspects of diabetes. A Dietitian from Birmingham Children's Hospital has worked on this for a while, and come up with a spreadsheet that allows you to enter six parameters: what kind of exercise; what intensity; the duration; how long since your last insulin bolus; whether you want to reduce your insulin or increase your carb intake; and whether you use an insulin pen or a pump. It then comes up with its best guess (based on published evidence) on how to manage blood glucose, food and insulin before, during and after the activity. You can print that recommendation for the patient to try, but it may need adjusting subsequently.

The most interesting presentation was from a Dietitian involved with the DiRECT trial, which has attracted the largest amount of research funding that Diabetes UK has ever awarded. The trial is intended to follow up an earlier 'Proof of Concept' trial that suggested that Type 2 Diabetes could be reversed with rapid weight loss, and this time they want to try and find out how it works, how much weight loss is needed, how long does reversal last, who might benefit the most from this approach and whether it can be achieved in primary care. Weight loss is achieved through Total Diet Replacement for 12 to 20 weeks (the Cambridge Weight Plan meal replacement products) with weekly or fortnightly review, followed by structured food reintroduction with fortnightly review, and there is also support in increasing physical activity. Monthly monitoring and support is provided to stabilise weight and prevent weight regain for two years.

There were relatively few participants (n=157) and the trial is not yet finished, but early results are impressive. Of the cohort who managed to lose 15kg or more, irrespective of their starting weight, 86% achieved remission from their diabetes at 12 months, defined as normalised blood glucose results (there are ongoing discussions about the definition of remission). Results were better for younger participants, lower starting HbA1c results and when the duration of diabetes was shorter. Unfortunately this exactly defines the people I don't see - in secondary care we generally see people who have had Type 2 Diabetes for some time and whose medication regimes are escalating and/or who are starting to get complications.

The last presentation of the day was from the doctor who leads the Diabetes service at the hospital we visited over the summer, talking about interpreting the data that we are starting to see coming from all these technological wonder-gadgets. One key point: we often advise a minimum of 4 blood glucose tests a day, but the evidence suggests this can generally only get people down to an HbA1c of about 69mmol/mol (8.5%). The target is often 53mmol/mol (7%) which would take at least 8 fingerprick tests a day, and for anything lower than this you're looking at micro-management using a CGM and pump or artificial pancreas system.

It was an interesting and informative day, but I continue to remind myself that despite the worth of the ideas being presented, there is in reality a negligible chance of making any changes to the service we offer, given that nothing has changed even after the whole team's visit to London.

What I've been reading

The Iliad
by Homer

"Homer has created a timeless, dramatic tragedy out of a single episode in the Tale of Troy - Achilles' withdrawal from the fighting and his return to kill the Trojan hero Hector. His characters are heroic but their passions and problems are human and universal, and he presents them with compassion, understanding, and humour against the harsh background of war."

All I knew about the siege of Troy was the story of the wooden horse, which isn't even part of the story in the Iliad. My recently acquired knowledge about this Greek heroic epic poem, however, is extensive. Firstly, given that the poem was originally transmitted entirely orally before eventually being written down long after it was first composed, 'Homer' is by no means an identifiable person. More likely, Homer was the name associated with the style of both the Iliad and the Odyssey when they were finally transcribed. Secondly and much more esoterically, the poem is written in iambic hexameter with 95% of feet being dactyls (DUM-diddle) and the remainder spondees (dum-dum).

The book I actually read is a prose translation that makes no attempt to reconstruct the poetic nature of the work, and it's been much more interesting to read than I was expecting. For instance, after describing exactly how each person meets his death in battle (where the spear or arrow or sword hits them and what the damage is), a brief biography is given, usually including where he came from, what his previous employment was, who his parents were and sometimes also details of his wife and children. This certainly slows down the narrative pace of the battle. The gods are portrayed as imperfect beings who operate much like any family in their preferential treatment of their favourites and unfair treatment of mortals they aren't keen on, although their ability to transform into other shapes and pass messages to humans and to skip back and forth between the battlefield and Olympus is decidedly godlike.

The poem actually describes only 51 days in the siege of Troy, a single episode resulting from a spat between the Greek King Agamemnon and his compatriot Achilles. A woman who was given to Achilles following some victory in battle is taken from him by King Agamemnon, and Achilles has an epic tantrum and refuses to fight any more. Eventually his best mate Patroclus borrows Achilles' armour, goes off to fight and gets himself killed, at which point Achilles goes utterly mental, culminating in him killing Hector, the best Trojan warrior and favourite son of Priam, the king of Troy. Achilles not only ties dead Hector's body to his chariot and drags it round the city walls in triumph and revenge against the killing of his best mate, but then drags the body around Patroclus's funeral site every day subsequently (the god Apollo protects Hector's body so it doesn't rot or get damaged). Eventually Achilles gives the body up to Priam in return for a ransom, and the book ends with Hector's funeral. Not entirely what I was expecting, but better than many of the 'classic' books I've been reading.

Becoming a Writer
by Dorothea Brande

"A unique and genuinely inspirational guide to creative writing, constantly in demand with writers and students of writing. She believes that there is such a thing as the writer's magic, that everybody has it in differing degrees and that it can be taught."

This is an old book, written in 1934, but also one of my older books, acquired and first read by me in 1988. It isn't about the technique of writing, plotting, character or any aspect of writing, it's about how a person becomes a writer - how to coax the material out of your conscious and unconscious brain, how to make sure your thoughts are successfully transferred to paper, how to avoid your style being contaminated by other authors - how to write, not what to write. I want to follow its instruction and exercises, but it's one more activity that I have to fit into the scanty 24 hours available to me every day. I'm working towards it, and when I start to see the light at the end of the tunnel I will definitely come back to this small book and its inspirational and practical advice.

The Essex Serpent
by Sarah Perry

narrated by Juanita McMahon

"It is 1893. Cora is a well-to-do London widow who moves to the Essex parish of Aldwinter, and Will is the local vicar. They meet as their village is engulfed by rumours that the mythical Essex Serpent, once said to roam the marshes claiming human lives, has returned."

This is a recently published book which received a good deal of praise and sounded interesting in a Gothic sort of way. It wasn't bad but the narration was odd; sometimes the narrator delivered a sentence that seemed to indicate she wasn't familiar with English idiom. Again, I hoped for too much of the ending. It was fine, but not fully satisfactory in the way I want an ending to be.

The Rose of Tibet
by Lionel Davidson

"A filmmaker is reported dead near Mount Everest. His brother, Charles Houston, is convinced he's alive and is determined to find him. He travels from India to the Yamdring monastery in the forbidden land of Tibet."

This is a bleak tale but told very well. It came from one of those piles of books that someone shows you to give you the option of taking any that you fancy before they are taken to some charity shop. Someone who knows more about China-Tibet situation in the 1950s would perhaps have a head start on feeling at home with part of the plot at least.

The Prestige
by Christopher Priest

narrated by Simon Vance

"In 1878, two young stage magicians clash in the dark during the course of a fraudulent séance. From this moment on, their lives become webs of deceit and revelation as they vie to outwit and expose one another."

It's a confusing mixture of Victorian reality and science fiction, and I must have read it before because I somehow knew what was going on, which helped a great deal to untangle the prose in the first section. I've seen the film too, and I actually think the film is slightly better, which is unusual.

The Three-Body Problem
by Cixin Liu (translated by Ken Liu)

"Beijing police ask nanotech engineer Wang Miao to infiltrate a secretive cabal of scientists after a spate of inexplicable suicides. Wang's investigation will lead him to a mysterious online game and immerse him in a virtual world ruled by the intractable and unpredictable interaction of its three suns."

The first book of an odd science fiction trilogy loaned to me by a friend who has spent some time in China, and who commends this book as conveying a sense of the original language. As someone who has never been to China I don't think I got as much out of it as my friend did, but I will still be going ahead with the next one.

Kitchen Goddess and Mega Marshal

Run Forest Run, November 2018

My last trip to London combined a study day for work, staying with Lola II and Mr M, and a gathering for mum's birthday. I'm writing about the study day separately, and because it's taking ages and I've been rather busy, I'll do a quick round of other news in this post.

Mum's birthday gathering was slightly marred by Lola II losing her handbag, but the story ended happily when it was handed in without loss. The following day I accompanied Lola II and Mr M to a Games Cafe in Richmond where we tried out three new games: Quirkle, Exploding Kittens, and Sushi Go! We liked Quirkle best.

Between then and now I had a busy week with the usual work, a District Council meeting on Monday evening, a car mini-service, chimney sweep visit and meditation on Tuesday, a trip to Birmingham on Wednesday evening, badminton club on Thursday evening and a match on Friday evening (we lost, but it was good fun with friendly opposition, which isn't always the case).

The Council meeting was about the proposed replacement of a decaying car park combined with the relocation of elderly Council offices. Many local businesses are dismayed at the 'parking displacement plan' and feel that shoppers will be put off by a potential reduction in car parking spaces in the town. Residents are also up in arms at the loss of 42 mature trees (although more saplings will be planted in their place) plus the failure of their planning proposal to follow the Council's own guidelines of including 40% affordable housing. By attending the meeting I achieved my aim of understanding what all the fuss is about while being depressed by the poor standard of debate and the attitudes and arrogance of the Council leader and officers.

The trip to Birmingham was much more fun: I went to a meeting of 'Skeptics in the Pub' at which The Angry Chef was speaking. As the name suggests he is a chef, and I have been following and been hugely entertained by his profanity-filled blog for some time. He writes very eloquently and at length about the rubbish that is promoted by celebrities and others aimed at telling people how and what to eat, or 'nutribollocks' as he terms it. I enjoyed the meeting a great deal - he talks a lot of sense backed up by proper levels of evidence, and I bought his book and he signed it for me.

This weekend was the fifth annual 'Run, Forest, Run' event in Surrey, where this year there were more runners than ever. Lola II and Mr M were marshalling out in the forest along with J from Family JJL&J, and another two J's actually did the 10k plus obstacle course. I was again put in charge of the kitchen, and apart from running out of bacon and teabags it all went very well. I was very proud to be awarded the 'Mega Marshal' trophy for services rendered to mass catering.

Weight loss has stalled, but it has remained 4kg below what it started at (rather than the 5kg I was aiming for), so I'm going to take that as a win. Nothing new with the LTRP except that I briefly went into a carpet shop and now I need to decide who to invite to estimate for the job and whether to choose wool or synthetic fibre (any opinions from readers would be very welcome).

The television saga continues - the price of the TV I am after did drop to a level where I was happy to buy, but by the time I got to the website in a secure WiFi zone there were no more in stock. Stock suddenly appeared a week or so later, but the website claimed that delivery was not possible to my postcode, and when I followed that up with the retailer we agreed that there was actually no stock and it was a website error. However, I guessed that the American phenomenon of Black Friday might influence prices, and so it did. The television appeared on the website at an even lower price on Thursday evening, I placed an order successfully, and all being well it will be delivered today.

A poem

Flysch rock formation, Playa de Sakoneta, September 2018 (photo by Mr M)

While the writing of my epic three-part saga of the holiday progressed, life went on in the background with more mundane everyday activities - the usual work, badminton, meditation, films and trips to see people and places. I have travelled to Nottingham, Altrincham, Woodford and Lea (near Ross-on-Wye), played in a couple of matches, supervised another student for an afternoon, met the new Dietitian hired to replace the last one that left, and attended a meeting about a potential diabetes app.

One of my work colleagues (a Diabetes Nurse not a Dietitian) attended some sort of event where she was encouraged to submit an idea for a phone app. She chose to include a half-baked idea about weight management, and then when the company asked to meet up to discuss her idea she came to me. I have no interest in her idea, but this seems to cut no ice. As with everything else at work nowadays, I will try to just sit back and see what happens.

Usually the result is 'nothing happens', but in one department the Clinical Commissioning Group have succeeded in taking a positive step forward. The Structured Education for Type 2 Diabetes, DESMOND, had all but lapsed in our area, mostly due to staff changes. The CCG stepped in, and despite our scepticism they have set up a new procedure which looks like it may work. We have advance notice that they will soon turn their attention to Type 1 education, so we're on our toes now and paying attention.

Home news: the washing machine engineer arrived to diagnose the fault with the washing machine. Despite everything we tried it refused to perform, and consistently and reliably failed to demonstrate any water leak whatsoever. The engineer kindly noted that the reason for the callout was that the packaging had not been correctly removed, otherwise I would have had to pay for his visit. So the good news is that the washing machine is not leaking, and the bad news is that I wasn't hallucinating when I found water on the floor so I fear it will start leaking again at some future time. When it does, I will take pictures.

I went to visit Landrover Man and Bee Lady, and because they actually read this blog I have been instructed to report on the visit. There was cake, dinner, a film, breakfast, a walk, a Sunday roast, plenty of talk and all of it was wonderful. There, that's slightly more than the "I went to see them and it was nice" that I threatened to write. Bee Lady still has bees (it's winter so they don't go out much) but Landrover Man no longer has Landrovers.

BL and LRM in front of Big View West

On my visit to Altrincham, cousin H showed me two poems he has written and gave permission for me to share them. I know as much about Poetry as I do about Art, but here is my favourite of the two:

Alzheimer's

It works like this. Each time he sees a thing
That's just the start. He has to process it
Through several departments of the brain.
To recognise it. Work out what it is.
Give it a name, and know how it fits in.
Responding needs another set of functions -
Making a choice from several office menus,
While holding all the options in a list.
Then he can send a message in reply
Not yet though. First he has to formulate
The answer, and then put it into words
And (in a separate office) make the sounds.
I sometimes think he recognises me.