Very low carb diet

Low carb breakfast

As planned, I started my very low carbohydrate regime after the wedding. In brief, this involves: no sugar or starchy carbohydrates at all - no bread, pasta, cereals, rice, potatoes or flour, no cakes, biscuits, sweets or full sugar drinks. Fruit is limited to 100g per day (about a handful) of berries (strawberries, raspberries, blueberries, blackberries etc.), pulses are limited to 30g cooked per day (about 1 tbsp), nuts and seeds are limited to a small handful, and you can have 3 portions of dairy produce (to provide calcium) but not flavoured or sweetened yogurt. A multivitamin is required because of the exclusion of a whole food group. Lots of low carb vegetables are encouraged, ground almonds and coconut flour can substitute for wheat or cornflour (up to a point), and monounsaturated oils are recommended. Unprocessed forms of protein are deemed better than processed due to the potential for inclusion of carbohydrate fillers.

It has been easier than I thought it would be. I like protein and vegetables, so evening meals have been fairly straightforward: meat or fish and vegetables or salad. Lighter lunch meals have incorporated leftovers, or I've had vegetable sticks and dips like salsa or guacamole, or vegetable soup with a swirl of plain yogurt sprinkled with seeds. I thought breakfast would be the most challenging, especially on a work day when there isn't a lot of time, but it turns out that I like plain yogurt with berries and flaked nuts more than I thought I would. When there's time, breakfasts are egg-based - poached, fried, scrambled or an omelette with one or more of tomatoes, mushrooms, bacon, smoked salmon, cream cheese or herbs.

I thought I would miss pasta and rice, and when Mr A has cooked them for himself they smell lovely but I haven't been tempted. Luckily there has only been one cake at work, and it wasn't very attractive so not hard to resist. I've snacked on unsalted nuts or vegetable sticks, and a couple of squares of 85% cocoa chocolate are allowed, as well as 'Atkins bars' which I have felt obliged to try, but don't really like much. They're expensive, too.

The key to success has been planning, because I can't just grab a piece of toast or bowl of cereal if I'm in a hurry. So I have my week's meals scheduled, and at each meal time I consult the sheet of paper to find out what is on the menu. Tonight we're having mozzarella, some antipasti from a jar, a tomato and basil salad and grilled courgettes and peppers. Tomorrow it's haddock provençale from the BBC Food website. Mr A bulks out his meal with the carbohydrate of his choice.

Side effects can include headache, nausea, fatigue and constipation, but are usually mild and short-lived. I felt absolutely fine until about 10 days in, when I had a niggling headache for a couple of days - but it may be just a coincidence. I've lost a little bit of weight, only 1 kg, and I suspect it's because of not being able to tuck into the usual amount of work-based cakes and biscuits, and the odd slice of bread between meals, plus all the running that I'm doing. But I'm not the target candidate for this diet, which is squarely for the benefit of overweight people with Type 2 diabetes, in order to help them reduce their blood glucose and curb their appetite. I still haven't recruited any patients to actually start the very low carb diet for real, but I have produced a poster and some flyers that will be given to likely candidates during clinics, to see if I can rustle up some trade.

We had a Diabetes Dietitians' meeting this week, where we discussed exactly how much pulses to allow, and whether we should tell people about low carb bread, and what exactly is the recipe for ground almond pancakes. There are some recipes that the other Dietitians have tried, for linseed bread and low carb cake, but I'm not sure I can be bothered because I don't mind not having bread and I didn't bake cakes even when I was eating carbs. I did try to make the ground almond pancakes, but they just tasted like gritty omelettes, hence the discussion about the exact recipe. It was all very interesting - four out of five of us are on the diet, with one doing it seriously and the other three dabbling. I'm adhering to it strictly for these three weeks up to our holiday, but we'll see what happens when we're away, and when we come back.

Married

I have been quite exhausted. Everyday life has been taking its toll, plus assorted incompetencies and disorganisation, plus unnecessary enthusiasm for things that are just tiring but seem to be Worthy. Where to start?

Lola II and Mr M iz Married. This occurred at the end of a three-day period of celebration in which Mr A and I were given Too Many Things To Think About, which addled our brains to the extent that we were almost unable to remember our own names (even though we had multiple lists). In chronological order, Mr A left his suit at home and we had to go back and get it, we forgot two mackerels and a jumper at Lola II's house and had to go back and get them, I forgot my outfit at home and had to go back and get it (but we were a LOT further away than when we went back to get Mr A's suit), Mr A backed the car into a tree making a dent in the tailgate and breaking the rear window, we spent a BBQ variously phoning insurance and auto glass companies, I left my fleece at Lola II's house, we borrowed mum and dad's car while ours was being fixed, and Mr A and I were each entrusted with a secret thing from each of Lola II and Mr M that we were supposed to not tell the other until they were about to go off on honeymoon. Collecting wedding gift pledges was also my responsibility, but has been a trivial amount of effort compared to the rest of it.

But it was lovely really. There was a party for friends and family on the Saturday, we had a Dim Sum lunch before the ceremony and tea and cake afterwards, Sister D briefly played the piano in St Pancras station, there was a highly entertaining photographer, but the bit that made me laugh the most was the impossibly rude assistant Registrar who completely messed up the start of the ceremony itself by not being able to work the CD player. Mr M chose the music at the start, which was provided by a recording of some of Lola II's friends playing a string/piano piece, and Lola II chose the music at the end, which was 'Bring Me Sunshine' and we all had a little dance. Well, those of us with little or no dignity, anyway.

Enough wedding. The car survived. We survived. We got back a bit later than planned because of the car window repair, next day I had a diabetes meeting to go to in the evening (all about Insulin Pump Therapy), the next evening was the badminton association AGM, the next evening we had to go to meet friends that we're going on holiday with, and then it was Friday and I went to bed at 9 p.m. Which meant that when I woke up on Saturday it was early, and I could get to the start of the local Parkrun by 9 a.m. So I did, and it rained fairly hard throughout the event, but I only walked for about a minute on the steepest bit of hill and finished in 39 minutes and I wasn't last! Apparently, I came 11th in my category (Veteran Women aged 40-49 with dark curly hair wearing black socks). I haven't yet decided whether to nominate the primary endpoint as running 5 km, in which case I can stop now, or continue until I can do it in 30 minutes, or give up when I'm not improving my time any more. It was more fun running on a course with people about than in the park on my own. I'll probably do one more, especially if it isn't raining next week.

Which reminds me (how could I have forgotten) that my ipod has packed up, and it's the end of my world. I use that thing every single day, and I am feeling its loss acutely. My laptop has been pretty unwell for a while (its latest trick is to decide that it doesn't have a second monitor attached and just turn it off), and then the ipod started to skip tracks and parts of tracks so I tried to reset it, at which point it decided to successfully wipe its contents but refused to start up again. I have found a set of instructions to help me troubleshoot, but I might just go and get another one because I literally can't manage without it. Really, I might die.

Ketosis and ketoacidosis

National Botanic Garden of Wales, May 2013

When I was visiting Mr M and Lola II recently, Mr M and I had a brief discussion about ketones which made me think harder about exactly what happens when carbohydrate is restricted in ketogenic diets. Here is what I think.

Without diabetes

The body's fuel of preference is glucose, and its main source is from the digestion of carbohydrate foods which delivers glucose into the blood. Insulin is secreted from the pancreas in response to rising blood glucose, so when carbohydrate is plentiful and blood glucose levels are high, levels of insulin in the blood are also high. Insulin has a number of functions in the body, two of which are facilitating the uptake of glucose from the blood into cells so that it can be used as fuel or stored as glycogen or fat, and also preventing the breakdown of glycogen or fat in the liver and adipose tissue. It makes sense: if you've got fuel coming into the system from food, there's no need to retrieve fuel from stores.

In a non-diabetic person, in the absence of dietary carbohydrate the blood glucose is low, consequently insulin levels are low, and the inhibiting effect of insulin on the liver is reduced. The liver sends its stores of glucose into the blood and just enough insulin is secreted to allow uptake by cells to use for energy. When liver stores of glycogen start to run out, fat starts to be broken down for fuel. One of the byproducts of burning fat is the production of 'ketone bodies' or 'ketones', which are used for energy in a metabolic state known as 'ketosis'. This is entirely normal, especially when someone is deliberately trying to lose weight, and is variously called 'physiological ketosis', 'dietary ketosis' or 'starvation ketosis'.

In this situation, low levels of ketones are detectable in the blood and urine, and blood glucose and insulin levels remain at the low end of normal. If the level of blood ketones rises then insulin production is triggered, which halts the breakdown of fat and the formation of ketones. Through this feedback loop the level of ketones is kept within normal physiological limits while at the same time the body is supplied with sufficient fuel for its needs.

Type 1 diabetes

The word 'ketone' is a danger signal for people with Type 1 diabetes, because they are taught to test for ketones when blood glucose is high. A high level of blood ketones can be life-threatening, but this is because of ketoacidosis rather than ketosis.

In Type 1 diabetes it is possible for the level of insulin in the blood to be insufficient irrespective of the level of blood glucose. This could be because insulin has not been injected, or the insulin has been denatured or spoiled, or because of illness*, or for a number of other reasons. If insulin is lacking then glucose remains in the blood and cannot be taken up by the cells of the body, which mimics a state of starvation. So the liver starts to break down glycogen and fat to be used for energy, increasing the level of useless blood glucose and leading to the production of ketone bodies. Because this can only happen if you have Type 1 diabetes (or a very advanced stage of Type 2 Diabetes where the pancreas cannot produce any insulin), it differs from 'physiological ketosis' and is called 'diabetic ketosis'. The way to tell the difference is that with physiological ketosis blood glucose levels are low, but in diabetic ketosis blood glucose is high.

Ketone bodies are acidic, so in prolonged diabetic ketosis the blood becomes more and more acidic, which is definitely a bad thing. Because insulin is missing, the feedback loop to keep ketones within physiological limits doesn't work. Unless sufficient insulin is given, diabetic ketosis progresses fairly quickly to diabetic ketoacidosis, or DKA. DKA is what people with diabetes used to die from before insulin was discovered and isolated. People with Type 1 diabetes receive grim warnings that if they detect blood or urinary ketones above a certain level and are unable to reduce their blood glucose by injecting insulin, then they are to waste no time in getting to a hospital emergency department, especially if they have stomach pain or vomiting.

Ketogenic diets

This type of diet severely restricts the intake of carbohydrates in order to induce physiological ketosis. Ketogenic diets have come in and out of fashion, having been used to treat epilepsy since the 1920's, and rising in popularity more recently in the form of the Atkins diet. The current evidence suggests that they are safe, don't increase risk of cardiovascular problems as long as the type of fat is predominantly unsaturated, and seem to be an effective route to weight loss although it is not really known exactly why. A ketogenic diet is increasingly popular in improving glycaemic control in people with Type 2 diabetes, and can also be useful in Type 1 diabetes but needs to be very carefully managed so as not to result in DKA.

This is the basis for the very low carbohydrate diets that we promote to our patients. I have had little luck in 'selling' them to my patients so far, so in an attempt to become more familiar with the practical aspects I am planning to adopt a very low carb diet myself. I will be starting after the weekend, and probably ending after about three weeks when we go away on holiday. I will let you know how it goes!

* Illness completely messes up glucose metabolism in Type 1 diabetes in a way that I am not confident to write about yet.

Teaser

On my way to work, July 2013

There has been a whole lot less badminton and many fewer meetings in the last week, especially as there has been another Bank Holiday. Mr A and I travelled south for a lovely lunch in celebration of dad's birthday, followed by dinner separately with Mr M and Lola II, who wasn't well enough to go to the lunch. I spent most of the rest of my days off working on the gastroparesis article, which still needs more work, but is much nearer to being finished.

At work I observed the presentation used by the other Diabetes Dietitians to start people off on the very low carbohydrate diet, so that I could get a feel for how to 'sell' it in my own service. It was a useful experience and I am becoming better informed about it all, but I think eventually I will have to try it for myself. So far, none of my patients has committed to it, although one or two are thinking about it.

There was a bit of badminton business this week - as the season is ending, my second club held a tournament and I came second out of the ladies. Meanwhile it is AGM season, and as I am Secretary of my first club, there is more admin than usual. With very low expectations, I mentioned that I would be happy to give up being Secretary if a volunteer could be found, and lo! a volunteer appeared! This is unheard of among all badminton clubs where I have been a member (and that's quite a few), but very welcome indeed. Still two AGMs to attend before it's over, though.

I am trying to write quite a technical piece about ketosis which I was going to include in this blog, but it is taking much more time than I thought it would. It turns out that making metabolic pathways comprehensible to the average reader is pretty difficult, and I also found gaps in my own knowledge about the most technical bits. Rather than make you wait, I thought I'd just publish this short teaser, and come back to ketosis when I have more time. I have a 28-minute run to fit in this morning, followed by the first of a set of 50th birthday and wedding celebrations to attend!

Quality

National Botanic Garden of Wales, May 2013

Tuesday was a real throwback to my university studying. It's officially my day off but I've agreed to write an article about gastroparesis for a professional journal. I had thought the deadline was the end of May and had been procrastinating wildly, but decided it was time to start. When I checked the previous correspondence, I found that the original deadline I'd been given was 21st March...

Anyway, I settled down to get started on writing last week, and found all manner of distractions at home. Then I was told about a meeting on Tuesday. The Quality people (this is shorthand for all manner of administrators whose job it is to make sure that health professionals and associated personnel provide the best service possible to the public) recommended that the Diabetes Service in this Trust should have a multi-disciplinary meeting. Despite being another potentially tedious and time-wasting get-together, I actually think that this is a necessary evil, as change and improvement is very challenging when you don't know who the decision-makers are in your own service. It helps that a couple of new consultants have joined the team, who are young and dynamic and seem to be open to new ideas.

So the meeting was on Tuesday, my day off, in the main hospital of the Trust (not where I work), and I needed to get some work done away from the distractions at home. It made sense to work in the library at the hospital, which would give me the opportunity to go to the meeting too. I set my alarm for 'early', because my Couch to 5k run schedule usually includes a Tuesday morning.

The only problem was that I'd signed up for a badminton competition that took place last Sunday. It started at noon so I'd made some sandwiches, and then left them on the kitchen table. The teams were divided into groups, and we'd played everyone in our group by half past two, been soundly beaten by all but one team, and I was getting very hungry, so I was looking forward to going home without waiting to see the semi-final and final at the end of the competition (played by the top team in each group). Then they announced that we would be playing everyone in our group for a second time...

Needless to say we were beaten all over again (even by the team who had lost to us in the first round), and it was four o'clock and I was starving. I found out when I went to club night on Monday that the only team we had beaten were the eventual winners of the tournament, which was annoying. Having played six hours of badminton over the previous two days, it should have been no surprise that I decided not to respond immediately to my 'early' alarm heralding a 25-minute run on Tuesday morning.

An hour later I managed to get up and head off for the library, except that I had a couple of jobs to do first. One was straightforward, involving a signature on a form applying for a memory stick that is encrypted so that it can be used in Trust computers - obviously the risk of downloading and exposing confidential patient information means that ordinary memory sticks are not allowed. The Diabetes team in the hospital where I work is not particularly interested in technology, so we don't have a laptop or computer projector, and the old-style overhead projector with acetates is still used extensively. A laptop/projector combination can be borrowed from the Learning Centre, which I have done on a couple of occasions, but came up against the problem of transferring the file containing my presentation to the non-networked laptop.

The other job I had to do was around verifying my previous NHS service, which was a two year stretch in the 1990's. The only reason to bother with this is because length of service is one factor that determines how much annual leave you get, and those two extra years should give me an extra two days (or is it an extra five days? I can't remember any more). I had managed to extract a letter from the NHS Trust where I had worked, confirming the correct start date, but for some reason my record showed that I had worked there until 2006, which was clearly not true. Unfortunately, my contact in the HR department was still insisting that I get confirmation of the correct dates, and suggested that I use pension records (I didn't pay into the NHS pension in the 1990's) or tax records. I thought I would take the opportunity to visit the HR department in person, and see whether they could be brought round.

It was an interesting meeting - my HR contact had never personally dealt with the tax people, but seemed to accept my view that this was not going to be a desirable line of enquiry. It then transpired that a) she had thought we were talking about my previous employer rather than something that had happened two decades ago, and b) she hadn't realised I was asking for fewer years to be taken into account than were stated in my letter, rather than more. She is going to think again, and I hope that common sense will prevail.

So after all of this, I reached the library mid-morning, then found out that I couldn't access any work information from the library (again because of concerns that patient information might be left somewhere electronically insecure), then worked out (with assistance) how to get my laptop to access the Interwebs, and then, instead of knuckling down to work, I thought I'd do a bit of blogging. Just like my old student days.

The MDT meeting was a bit of an ordeal, all about how we can collect data to show whether we meet the 13 Quality Standards set out by NICE. Obviously it is important to provide patients with a service that includes all the things that contribute to high quality patient care. It is, however, an immense amount of work to record and then collate data to prove that we offered people structured education, foot clinics, retinopathy screenings and blood and urine tests even if they don't turn up for their appointments or provide samples and we can't actually deliver the structured education within current resourcing levels. Apparently, the Diabetes team in the community has a waiting list of 560 people for their structured education programme, which isn't actually being delivered due to lack of staff, or funding, or both.

We also have Quality Standards for clinical results like blood pressure and cholesterol levels as well as average blood glucose (HbA1c). Although I don't quibble with the targets, which are set at levels that ought to reduce patients' risk of cardiovascular disease, stroke and microvascular damage, I don't think the service should be held to account if patients don't achieve the targets - there's only so much that medications and health professionals can do. At the end of the day, if patients want to eat pies and burgers and drink Lucozade then the targets won't be met even if their doctors have dosed them up with as much medication as they dare, and done their best to let them know they're not doing themselves any favours.

I managed to do the run on Wednesday morning instead.

What I've been reading

This Is How It Ends
by Kathleen MacMahon

"Bruno is a middle-aged American banker who has come to Ireland to escape the financial meltdown in his own country. Addie is an out-of-work Irish architect. Addie and Bruno’s story is one of nationality and identity, of the power of optimism to defeat despair and the unstoppable march of time."

The very last of my 12 Books of Christmas, all finished in only 14 months or so. I chose the order to read them at random, so it's been interesting that I seemed to pick the worst ones to read first - this one was pretty good, even though lots of loose ends were left hanging, but I didn't much care in the end because I wasn't particularly interested in the story or the characters. It's been quite an experience, reading all sorts of books that weren't chosen by me, and finding out what sort of stuff can get published. Maybe when I retire I'll have a go myself.

The Blind Assassin
by Margaret Atwood

narrated by Lorelei King

"Laura Chase's older sister Iris, married at eighteen to a politically prominent industrialist but now poor and eighty-two, is living in Port Ticonderoga, a town dominated by their once-prosperous family before the First War. While coping with her unreliable body, Iris reflects on her far from exemplary life, in particular the events surrounding her sister's tragic death."

Here we are, a satisfyingly complex book by a skilful author, but I am in such a quandary about the story. It's more than 18 hours of (outstandingly good) narration, and for about 17 hours I wasn't sure why I was listening, or what the point of it all was - there seemed to be no arc to the story, no change in the pace or emotional quality. The characters behaved as people do, went about their business, sometimes life was eventful, sometimes not. I couldn't see how it had earned its reputation (and its Booker Prize). Then it all changed. The last hour and a half has set me to wondering whether I misunderstood the whole thing, and for the first time ever with an audio book I wished it were a print book instead so I could flick back and check what really happened throughout, whether the clues were there and I just didn't notice. I'm going to have to get a print or e-book version, because most online reviews are so cagey about giving away key aspects of the plot that they don't go into the aspects that I want to clarify.

Memento Mori
by Muriel Spark

"In late 1950s London, something uncanny besets a group of elderly friends: an insinuating voice on the telephone informs each, "Remember you must die." Their geriatric feathers are soon thoroughly ruffled by these seemingly supernatural phone calls, and in the resulting flurry many old secrets are dusted off."

When I started reading this, it felt like literature, with proper characters, long words and what seemed to be heading towards a proper story. But it never seemed to go anywhere. As a characterisation of old age maybe it has some merit, but the mystery of the voices on the telephone is never explained and the crimes and misdemeanours of the participants are uninteresting and almost embarrassing. So, a disappointment in the end.

The Innocence of Father Brown
by G. K. Chesterton

narrated by Frederick Davidson

"With his round face, pipe and umbrella, the shambling, bespectacled priest Father Brown is an unlikely detective - yet his innocent air hides a razor-sharp understanding of the criminal mind. The wise, worldly, clerical sleuth has an uncanny ability to bring even the most elusive wrongdoer to justice."

I have read these stories on and off since I was very young, and thought I liked them. In fact, they don't really stand the test of time, and I now think Father Brown is a rather sanctimonious prig. The solution to each mystery is often impossibly complicated and far-fetched, and to cap it all, the narrator gave Flambeau a very French accent, which I also found annoying.

Forty Stories
edited by Cal Morgan

This was a free download onto our new Nexus tablet, which now is not so new, showing just how long it has taken me to get through the book. I don't know whether I'm not appreciative of the short story format, or whether they're just not very good stories. I suspect the latter.

Mostly walking and a bit of running

Canterbury pub

As usual, quite a lot going on, but little inclination to document everything. I remember when I used to write a lot about social stuff and holidays, but for some reason I'm not doing this so much. I suppose I feel a little exposed because anybody at all can read this blog, and while my family and friends may like to know more personal stuff, those who are more interested in the professional stuff may be put off. I need to spend some time thinking about who my target audience is, and who I'd like it to be, and how comfortable people I know might be if I feature them here. But I don't think I use anyone's real name any more, so perhaps it doesn't matter.

Last week, on the spur of the moment, Mr A and I contacted our old friends Landrover Man and Bee Lady, whom we see approximately once a year (if you go by the number of mentions they get on this blog). It was a beautiful day and we had a nice long walk and a lovely pub lunch and it was brilliant. We're going to try and get them over here a bit sooner than in a year's time, but it may still be a month or two away. We're working on it.

My 'Couch to 5k' plan is still going quite well, and I'm on target to be able to run 5 kilometres by the end of May, all being well. It's an interesting programme, with just 60 seconds running at a time at the beginning, and I've now managed to run very slowly for 20 minutes in one go without ill effect. I'm starting to see how I will be able to run 5 km by the end of the series, which I always believed but didn't quite comprehend how it might be achieved.

On the other hand, badminton is going through a difficult period, with my Club C in abeyance due to hall refurbishment, and lots of end-of-season administration with Club A because I am Secretary. Club C doesn't play over the summer, but Club B (where I used to play a year ago) does - but I took a break from Club B because of a few annoying members. I shall be going back to Club B over the summer to see if I can put up with said annoying members, and then decide which of them to join for next season along with Club A. It's complicated.

Mr A and I have just returned from a few days camping in Kent. We went on Saturday, arriving quite late, and then it rained all day Sunday so we went for as much indoor activity as possible, starting in Rochester with their local museum. The highlight for Mr A was a camera mounted on top of the building which you could control from inside - eventually he had to relinquish control to a visiting child. Because it was still raining we spent the afternoon watching a film, then it was still raining and getting dark and we couldn't read any more in the tent and it was getting cold too, so obviously we went to a pub to get warm, which happened to have friendly locals and live music.

On Monday the sun came out, so we went to Whitstable for our traditional Guinness, oysters and crab sandwiches on the beach. We walked along the beach all the way to Seasalter, then went back to the campsite to take advantage of the better weather in order to sit and read. Unfortunately, it started to rain again on Monday night, and didn't stop all night. For some reason Mr A woke up very early this morning and decided to make tea without looking at the time. When he told me my tea was ready I asked him if he realised it was only 6.40 a.m? We packed everything up in the rain, loaded it into the car in the rain and drove back in the rain - there's going to be a fair bit of drying out needed when it's a bit less damp outside.

Carbohydrate

Groombridge Place, June 2013

After much deliberation, I decided to call the talk I gave at the weekend 'Carbohydrate'. It was part of a scheduled day of talks from healthcare professionals at a public awareness day organised by the local Diabetes UK voluntary group. Other speakers included doctors, podiatrists, eye specialists and a paediatric dietitian who was planning to talk about exercise (unfortunately I missed most of her talk because I was talking to someone about injection sites).

A colleague had sent me a presentation that she had recently delivered, so I based mine on hers and stole her case study. I started by reminding people that all types of Diabetes are characterised by blood glucose that is higher than it should be, and that the source of glucose in the blood is carbohydrate from the food we eat. As a Dietitian specialising in Diabetes, carbohydrate in food is my bread and butter (not so much butter, actually), and then posed the question: how do I decide what advice to give to patients about what they should eat?

This brought us on to the evidence-based nutritional guidelines published by Diabetes UK in 2011, and the changes that this document brought to the accepted picture of healthy eating for Diabetes. The trouble with the scientific method is that as more evidence is accumulated and new guidelines are researched and published, our total knowledge increases and conclusions can change from one day to the next.

The new guidelines advise that the primary nutritional strategy in Type 2 Diabetes should be weight loss above all else, and what's more, that there is no evidence to favour any one approach to weight loss over any other. Limiting energy intake overall is more important than where the calories come from. The document also says that low carbohydrate diets can be particularly effective at producing improved blood glucose control, especially when weight loss is achieved.

This is a drastic U-turn. Previously, guidelines suggested that a significant proportion of food eaten should be starchy carbohydrate - 50% or more of the total dietary intake. The potential consequences of restricting carbohydrate were perceived as deficiency of B vitamins, and increased fat intake leading to weight gain, higher blood cholesterol and an increased risk of cardiovascular disease. From one day to the next, our advice based on the best evidence goes from recommending fairly high carbohydrate portions to weight loss at all costs with a definite option of low carb. No wonder people are frustrated by reporting in the popular press, where advice seems to change every time a journalist sneezes.

One of my colleagues has thoroughly researched the low carb approach, and even converted her own diet to exclude carbs. She has converted the other Diabetes staff to the new low carb religion, and pioneered this method with her patients. We have two treatment groups increasing in numbers every month - a 'reducing carbs' cohort, and a 'very low carb' group.

'Reducing carbs' means limiting carbohydrate intake to 120g or less a day - 30g per meal and 30g for snacks. As an example, a slice of bread from a medium sliced loaf is 15g carbohydrate, as is a diet yogurt, or a portion of fruit. 30g carbohydrate equates to three tablespoons of cooked rice or pasta, or three egg-sized potatoes. Admittedly it usually involves a change in diet, but not necessarily a drastic change, and most people would find it manageable with a bit of forward planning.

'Very low carb' or VLC is a different kettle of fish, and this plan limits carbohydrate to just 40g or less per day. This means giving up all starchy carbohydrate - no bread, pasta, rice, cereal, potatoes or other starchy vegetables, with allowed carbs limited to a small amount of milk, berries and pulses and natural yogurt. Animal and vegetable protein features heavily, including nuts and seeds, along with less carb-heavy vegetables and salads. Saturated fats should be replaced with unsaturated as much as possible, and caffeine and artificial sweeteners should also be avoided.

The idea of both these diets is that the less carbohydrate you eat, the less glucose ends up in the blood. Consumption of lower calorie foods also increases, including vegetables and salad, so a very welcome by-product is weight loss. The VLC diet is also intended to change the body's metabolism from using carbohydrate to using fat as the main fuel for energy, which was once assumed to be a bad idea. It has now been shown not to have the undesirable effects that were once thought likely in the short term, although we still don't know the long-term consequences. Another very positive aspect of the change to fat metabolism is that it seems to have an appetite-suppressing effect.

For people with Type 2 Diabetes who are overweight, a VLC plan can bring about a miraculous transformation. High blood glucose levels start to drop straight away; medication can be reduced, appetite is reduced and weight starts to decrease. This allows medication to be reduced further, success reinforces motivation, and some people have even stopped taking the majority of their Diabetes medication, including insulin.

This is not to say it works for everyone. There are some who can't manage to construct an acceptable daily meal plan without carbohydrate, and others unable to tolerate the change to fat metabolism, which can result in headaches, constipation and fatigue over a transition period. Increasing emphasis on protein and vegetables can prove too expensive, although it is to be hoped that the reduction in total amount of food needed can offset the expense up to a point. Family circumstances are often the biggest barrier - it is not a suitable plan for children, other adults may not want to join in, and making separate meals can be impractical. I've thought about it for a while, and I'm not sure that I would be able to deal with the practicalities of this VLC option.

In between talking about the nutrition guidelines and explaining our low carb diets, I managed to include some audience participation, in the form of 'Find the Carbs'. I showed a selection of pictures of meals, and got people to tell me which components contained carbs, to illustrate how an acceptable diet might contain less carbohydrate than the traditional choices of toast, jam, cereal, fruit, yogurt and juice.

My talk seemed to go down well, and the whole event was very well attended. I met some more local Dietitians, which is always good to do, and the Diabetes UK local group committee and members actually talked to me a bit for a change. I still think I might not go to any more of their weird meetings, though.

At last

Les Deux Alpes, March 2014

I hope it's worth the wait, but just imagine my situation, each day knowing that there is no blog post waiting to be published. I have sinned, it's been a long month since my last confession. There has been a lot going on. I don't think there's ever been such a long gap between posts.

The last time I wrote was the week before my holiday. I went to the Snowdome to practise (what a good idea that was), dad went into hospital for his back operation, I went to work, badminton, the usual. Then it was off to France skiing for a week, home again and a lot of important admin stuff to catch up with, dad out of hospital, back to work, a Diabetes UK meeting. Last weekend was even more hectic: a friend over from Germany for a brief stay in order to sign paperwork so he could sell his house, and... The Hen Weekend.

Holiday

The holiday was great. It was a good group, almost everyone was congenial, and my biggest problems were a) the people who didn't look like their names, and b) breaking away to spend time on my own without appearing anti-social. In the end, I had to explain and apologise to the people who didn't look like their names because I kept calling them by the different names that I had conjured out of nowhere. I just resigned myself to appearing anti-social.

A vast amount of snow fell on our arrival day/night, which is heaven for experienced and skilful skiers. Since the instructor was an experienced and skilful skier, she took the group up where the snow was deep on our very first morning, when everyone was just getting the hang of skiing again after a long break. We were not experienced or skilful, and it was carnage. But nobody was hurt, and the rest of the week was fabulous. I am in two minds about repeating this type of holiday; I think on the whole I would prefer a less organised group and private lessons instead.

Work

The Structured Education sessions have been interesting. I missed week 2 because of skiing, which was a shame because it was the big one from the Dietetic point of view - focus on carb counting, weighing and measuring food. Week 3 involved talking about alcohol and eating out, and the nurses covered exercise. I am looking forward to when I start to lead sessions, which looks as though it won't be until June. Otherwise, consultations remain much the same, and I still find it fascinating to listen to people's stories about their lives, whether positive or negative. And the Diabetes department has already arranged its Christmas party.

Diabetes UK is dominating my thoughts at the moment, as I'm preparing my 30-minute talk for the weekend and attending another of their weird local meetings. My name is on the programme for Saturday's Diabetes Awareness Day, and at the meeting still nobody greets me with any glimmer of recognition. I did gain some understanding of the physiology of weight gain due to injecting insulin peripherally rather than having it released by the pancreas, so that was good. I left before the raffle. I really think I might not go to any more meetings.

Hens

Lola II decided to have a relatively low key hen weekend with just two of her friends and me. I was in charge of entertainments, although we agreed the basic agenda between us. Lola II put in some specific requests: Yorkshire puddings; a steamed chocolate and apricot pudding; sleeping in a tent; no veils, strippers or other tacky accoutrements of the vile and tasteless hen parties. With no time for blogging, I spent my weekday evenings making stew and puddings and cooking veg as well as preparing a guided tour of the delights of Leamington Spa based on the Discovering Britain website. Mr A put up the tent, which was christened the Hen House.

It went very well - we walked the walk, talked the talk, placed a bet on the Grand National, watched one of the worst movies I have ever seen (this was a mistake - it was well reviewed and featured quality actors like Terence Stamp and Vanessa Redgrave), ate stew and Yorkshire puddings and chocolate and apricot pudding, Lola II slept in the Hen House, and we went kayaking on the river. The highlight for me was none of these things - it was the revelation that Lola II needs reading glasses! After more than forty years, at last she can experience the interminable nuisance of not being able to see properly. I'm not gloating - I will definitely need bifocals at my next visit to the optician, and I'm thinking of getting reading glasses myself for when I wear contact lenses.

In other news...

The 'Couch to 5k' running programme continues to go well, despite interruption from skiing. I've completed Week 4 and am about to start Week 5 of 9; I have progressed from 60 seconds to 90 seconds to 3 minutes and now to 5 minutes 'running' at a time. I run on the circular path around the park, and this week there were a couple of women chatting and walking in front of me - as an indication of the speed I have achieved, I completely failed to catch up with them. I am concentrating on stamina and technique, I tell myself, I can work on speed later.

Lastly, you should know that the only reason I'm managing to produce this post is because I went to badminton (club #2) and the hall was locked up with nobody there. My loss is your gain on this occasion. I have a journal article to write after the weekend, so there may be another lengthy pause after this...

Consultation skills

National Botanic Garden of Wales, May 2013

It's been a good couple of weeks in the office and out of it. As highlighted previously, I have started the 'Couch to 5k' running plan and haven't yet missed a session. I didn't think I liked it much, except that I find myself almost looking forward to the sessions, and I can't work out what's going on. Lola II suggested it might be the dolphins (or 'endorphins' as they are more widely known). I have no idea. Anyway, I am now able to run, very slowly, for 90 seconds at a time. It is early days.

Patients come and go, and I have been enjoying hearing their stories and trying to encourage, guide and motivate them to achieve their goals. This idea of the patient owning and managing their chronic condition is not new or novel, but not often expressed. Because we often have lunch together, the team tends to share experiences of clinical situations quite a bit, and the underlying principle is often of the clinician 'treating' or 'managing' the patient, or generally telling or advising them what to do. I am making every effort, and getting increasingly more skilled at the opposite approach: not telling or advising them what to do. This takes an enormous amount of self-restraint on my part, but I think I am getting better at it.

For example, many of the patients I see have other conditions as well as diabetes. There are many different avenues I can follow in my dietary advice: a) general healthier eating (more veg, less saturated fat, lots of fluid, eating breakfast, less salt, oily fish twice a week etc), b) diet to influence blood glucose, c) dietary management of other conditions such as high cholesterol, high blood pressure, kidney failure, low calcium, anaemia and so on, and d) weight management - usually weight reduction, but not always. Looking at the patient's medical history and biochemical test results usually gives me an idea about what might ultimately have the greatest benefit on health.

But it is fruitless for me to decide what should be done and then do it. Diabetes is not like a broken bone - once diagnosed, it is not possible for a simple plan for treatment and review to be devised, implemented and followed up. It is a lifelong diagnosis where the majority of management and treatment takes place in the absence of any health professionals, done entirely by the patient. I even wince each time I write 'patient', because I spent a considerable amount of my career insisting that people are people and are not defined by their condition - they are not diabetics, they are people who have diabetes. Someone with diabetes is not ill, and is only defined as a patient when they turn up at the clinic. The rest of the time, they are in charge of their 'illness'. I don't have a better word yet, and would be viewed most oddly if I started to use the words 'client' or 'service user' in the NHS setting. But I digress.

The way it works is this. I invite the person into my room, introduce myself, and then ask either how it's gone since last time, or what's brought them to the clinic on this occasion? The idea is that they choose what we're going to talk about first. Obviously I might have issues that I'd like to raise, but my agenda is secondary.

For example, many people who see me are overweight, obese or morbidly obese. This may be the main 'problem' and if addressed, the majority of their other health conditions might be improved. But many people are happy with what they weigh and how they look, even though they are aware of the health implications. Many more are not happy but have tried many times to change and failed, or had succeeded, lost loads of weight and then put it all back on and more. Many are defeated. There is no point in me listening to their story and then telling them what to do. Nobody wants to be told what to do, especially by someone who only met you ten minutes ago and knows nothing about your life. They've tried over and over again, it didn't work, end of story.

Last week I felt my practising had paid off. An overweight lady was brought to me: "she needs to lose weight." This is often the first barrier - very few choose willingly to see a Dietitian, because they expect to be 'told off'. They know they have a problem, and they know the answer, everybody's told them they need to lose weight, they know they should lose weight but they've tried and failed and they don't see the point in having their noses rubbed in it, or exposing their weakness to a stranger. It's personal, uncomfortable, and emotionally painful.

The lady was happy to talk about her diet, but she didn't see what she could change. She told me about coming from a culture where being overweight is not a problem.

"So, you're happy with the way you are. That's good," I said.

Instead of agreeing with me, she continued to tell me about her diet, what she eats, how much she likes food.

"I get the impression that you don't really want to change anything at the moment. Is that right?" I asked.

Still no agreement. More information about her lifestyle. I must say, her cooking sounded amazing. A bit carb-heavy, but tasty.

"So, you don't feel that your weight is a problem. Would you like to talk about anything else? Do you have any other concerns about your diabetes?"

Again, she didn't really address the question I'd asked, but carried on chatting about her meals and her cooking. I felt like Jeremy Paxman that time he asked the prison chap the same question fourteen times. I just wanted her to agree that we could leave the weight thing alone, and then she could go.

But instead, she suddenly suggested a couple of things she might be able to cut out of her diet. I was genuinely amazed. I've always believed in this approach to consultations, where you get the patient to make the suggestions, but so often they hold back and hold back and eventually I give in. This time I think I was determined not to be directive, and for the first time, it really worked. We agreed on one or two goals, and arranged a follow up.

Whether she returns will perhaps be a test of success, and it's quite possible that she may not actually make the changes she suggested, or achieve the results she hopes for. But I would have suggested different changes, and she definitely wouldn't have taken those on board, and I definitely would never have seen her again. So we'll see.