World Diabetes Day 2023 - the road travelled

Hey there! How have you been. It's been a while eh? Sorry about that! Life, the universe, and everything. You know how it goes.

So this isn't the blog post I've been meaning to write about TBR hacks for the tSlim running Control IQ. It's not even the one about seeing if I can get funding for sensors, which I seem to be being promised, but which hasn't quite happened yet.

If those are of any interest, do let me know and I will try to get around to them. Honest!

No. Instead this is a little unexpected ponder I had earlier, when realising that it was WDD once again, as I saw lots of other more capable awareness-raising diabetes types sharing stuff on their social feeds. It came unbidden. And rather surprised me - so here it is...

"Wow. Diabetes has really changed since we started the blog!"

There. That's it. Groundbreakingly insightful as always.

But much as diabetes is still Very Annoying (TM), a bit of a drag, occasionally utterly terrifying, frequently exhausting, but on the whole relatively manageable most of the time... there have been some pretty big changes in the decade or more that I've been rambling semi-coherently on here.

Back then, Twitter (for diabetes types) was a sort of a cosy coffee shop. A place to connect with a few like-minded folk who were also, coincidentally pancreatically challenged (thanks ShootUp), and chat about something and nothing. Now it's not even Twitter any more!

Once 'low carb' to help managing T2 was viewed as some sort of crazy, lunatic idea and positively discouraged by pretty much all healthcare professionals. Now it's seen as a fairly mainstream management approach that works really well for some people, and is often mentioned by practice nurses from the very beginning. This was once unthinkable on the forums I was frequenting when I first started comparing notes with other people with diabetes. There are now whole NHS GP practices championing the approach, and even established NHS programmes to help people who want to give it a go.

When we started writing this blog, as far as the scientific and medical world was concerned T2 diabetes was an inevitably progressive condition (hardly a phrase that encourages self management!). You got it, and then it gradually got worse and worse, and needed more and more meds, until you expired either from it or from something related to it. Now thanks to the DIRECT trial, there is high quality evidence that many with T2 can get their diabetes in remission (keeping HbA1c below 48mmol/mol with no medication) though significant weight loss. And many folks who choose a low carb approach can achieve the same remission criteria too. And this that remission can be maintained for many years.

There are a bunch of fancy new insulins and meds available now too. Including some that could potentially prove complete transformative for people who struggle with overweight and obesity.

Way back in 2010, CGM was almost unheard of outside of the US. I was even invited to a thing where the company developing a product wanted to know whether or not many people in the UK had even heard of the idea. At the time the chance of getting a CGM funded in the UK was vanishingly small. But a torrent of advocacy effort, an expectation defying Prof, and a flurry of new technologies and options later, and now over 90% of people with T1 in the UK have access to funded full time CGM.

They are now embarking on the same transformation for Hybrid Closed Loops (where an insulin pump and CGM talk to each other and are able to make some gentle adjustments to help us out).

The pace of change is extraordinary. And it doesn't seem to be slowing down.

Plus in the background really quite staggering progress is being made with stem cell research and other avenues, edging ever closer to a possible cure.

I'm really hoping that some progress can be made around reducing diabetes stigma. And especially in increasing access to appropriate monitoring technology for those people with T2 who would value it and benefit from it. Possibly even a little sub-division of the T2 umbrella, so that more appropriate options can be offered to the different sub-types, rather than a blanket 'No' to so many people.

So cheers to old Fred Banting. And Charlie Best, and all the others. There really has never been a better time to have diabetes.

And maybe, just maybe, someday soon, nobody will.

Frestyle Libre available on prescription. Again.

It's with a certain sense of deja-vu that I mark World Diabetes Day this year with the news that Abbott's Freestyle Libre flash glucose monitor will become available to people with type 1 diabetes in the UK on prescription from April 2019. Cue inevitable Twitter meltdown.

Hang on... haven't we been here before?
Well yes. And no. You may remember me writing a post in September last year on this very subject.

Technically the Libre was made available on prescription on 1st November 2017, "subject to local healthcare economic approval". Prior to that 2017 announcement various Big Health and Diabetes Organisations (such as the Regional Medicines Optimisation Committee, NICE and a collaboration of Diabetes UK, ABCD, JDRF and INPUT) put together helpful documents, guidance and national position statements about what Libre was, who it might be useful for and the evidence to support its use.

What followed was an unholy scrabble of various different CCGs across the UK who either adopted Libre under RMOC criteria, published their own set of rules (which often had bizarre additional requirements that seemed to bear no relation to Libre and its use, such as blood pressure results) or denied access entirely saying that there wasn't enough evidence, or that they didn't like the colour of the packaging or any number of "Whatever we do, let's kick this can as far down the road as we can manage" strategies. And all the while those CCGs in the 'no' camp had meetings and re-reviewed the evidence that had already helpfully been reviewed for them, and invested time (and presumably money) into reinventing all the wheels they could see.

So what emerged was variously described as a 'postcode lottery', 'Libre lotto' and 'bloomin outrage' and across the country people living in the (at the last count) 51 CCGs to have said a big fat NO to prescribing Libre got together and organised themselves to petition, badger and generally make a fuss about it.

Meanwhile, in areas where Libre was more freely prescribed, the early results were overwhelmingly positive. HbA1c's tumbled, and importantly positive effects were seen at all starting points, with significant improvements being seen in those who hardly checked BG at all as well as those regularly checking 6-8 times every day.

And the results didn't begin to tail off after an initial positive surge either. As more data were added, the improvements were sustained and improved further.

Meanwhile the irrepressible, unstoppable force that is Dr Partha Kar was not for taking 'no' for an answer. If the evidence was sufficient for area A, why was it deemed insufficient for area B just down the road? Gentle pressure was applied with an NHS England behatted sledgehammer and a smile. Additionally everyone's second favourite Libre-prescribing-data-muncher Nick Cahm quickly became errant CCG's worst nightmare as he quietly and eloquently sifted through mountains of information to show how utterly nonsensical some of these local decisions were. And Diabetes UK weighed in to support and rally local people in their #fightforflash. The CCGs didn't stand a chance really.

And so today, the biggest of NHS bigwigs Simon Stevens joined in to announce that Libre will be available nationwide under RMOC guidance from April 2019:

“As the NHS prepares to put digital health and technology at the heart of our long term plan for the future, NHS England is taking important action so that regardless of where you live, if you’re a patient with Type 1 diabetes you can reap the benefits of this life improving technology.”

So who exactly will have access?
As far as I am aware this is the guidance (or something quite like it) that will be used to identify appropriate people with diabetes who will benefit from Freestyle Libre going forward:

It is recommended that Freestyle Libre® should only be used for people with Type 1 diabetes, aged four and above, attending specialist Type 1 care using multiple daily injections or insulin pump therapy, who have been assessed by the specialist clinician and deemed to meet one or more of the following:

1. Patients who undertake intensive monitoring >8 times daily
2. Those who meet the current NICE criteria for insulin pump therapy (HbA1c >8.5% (69.4mmol/mol) or disabling hypoglycemia as described in NICE TA151) where a successful trial of FreeStyle Libre® may avoid the need for pump therapy.
3. Those who have recently developed impaired awareness of hypoglycaemia. It is noted that for persistent hypoglycaemia unawareness, NICE recommend continuous glucose monitoring with alarms and Freestyle Libre does currently not have that function.
4. Frequent admissions (>2 per year) with DKA or hypoglycaemia.
5. Those who require third parties to carry out monitoring and where conventional blood testing is not possible. In addition, all patients (or carers) must be willing to undertake training in the use of Freestyle Libre® and commit to ongoing regular follow-up and monitoring (including remote follow-up where this is offered). Adjunct blood testing strips should be prescribed according to locally agreed best value guidelines with an expectation that demand/frequency of supply will be reduced.

It will be very interesting to see how this works in practice, and in particular whether this framework allows widespread adoption of Libre2 when that launches in the UK (at the same price as Libre1 apparently), which gives Libre users the option of alerts to prompt scanning when BG rises or falls to particular limits.

Roll on April!

Facebooking my diabetes for #WDD2016

Monday this week was World Diabetes Day. It's is one of those made-up things that come around every year and hope to raise awareness of something or other - World Sparrow Day... International Day of Happiness... World Toilet Day... One of my own favourites is 'International Talk Like A Pirate Day', but I digress... Aaaaarrrrrrrrr!

World Diabetes Day is held every year on November 14th, good ole Freddie Banting's birthday (one of the guys who was instrumental in the discovery of extracting and using insulin in diabetes treatment). It was nice to see a WDD themed Google Doodle make an appearance, something that us pancreas-impersonators have been asking for for many years.

A few years ago, inspired by something I saw on Twitter from Scott Hanselman, I decided to document a day's-worth of diabetes interactions on Facebook as they happened. People seemed surprisingly interested, and so having given them a few year's respite I thought it was time to Facebook my diabetes again. Here's how it went...

06:22 
Slightly early start to the day but the routine is the same. First thing, even before kettle goes on is to check blood glucose level. Make small hole in finger, squeeze out drop of blood and apply to test strip. Result: 8.3. Ideally this would be between 5.0 and 7.0. Give insulin for breakfast. Estimate single slice of toast as 15g of carbohydrate (12g for the bread, 3g for a dab of marmalade). Insulin pump suggests 1.3 units of insulin for the carbs, plus 0.6u to correct the slightly high BG level. In addition I also need an extra 1u for my liver releasing extra glucose when I get up (part of the body's Circadian Rhythm). Dose delivered I will now wait at least 30 minutes to eat breakfast.

Via comments:
Regarding the carb value of bread: I deliberately choose Burgen 'soya and linseed' as it is a) tasty b) slightly lower carb and c) relatively low GI

Regarding waking BG level: The official guidelines are 5-7, I think. The 7 is to give some wiggle room for a rise after eating. Usually pre-meal guides are 4-7, but at breakfast they make it 5, because regularly waking in the 4s is associated with increased risk of undetected nocturnal hypoglycaemia which can be a real problem. 

06:50
Check pump display to remind me when I had dosed for breakfast. I have been waiting 30 minutes to eat for so long I often instinctively get this right. I thought to check at about 28 minutes today which is about perfect. I need to leave a gap between dose and food because the 'rapid acting' insulin I use is not actually very rapid. I cannot afford getting distracted though as if I wait too long the insulin could start working before the food kicks-in and my BG levels could drop too far. It's a balancing act! 

07:17
Breakfast of champions. I have tried many things over the years but this seeded bread is fairly reliable for me (everyone's reaction to different foods is frustratingly and confusingly different). It has slightly fewer carbs than regular bread - 12g per slice vs the more usual 18g - and the seeds help to slow absorption. It is anything with carbohydrate that raises blood glucose levels, not just sweet things, so that's bread, rice, pasta, most fruit, anything made with flour, grains, root veg, and then all the sweet and sugary things too. My task is to match the carbohydrate I eat with doses of insulin. And then to match the speed of absorption of the food with the timings of the doses. I cannot hope to get that right all the time. But the lingering threat is that if I get that wrong too often I am at risk of blindness, heart attack, stroke, kidney failure, limb amputation (high levels) or unconsciousness, coma or death (low levels). Fun eh! Over the past 25 years I have spent more time thinking about the potentially disastrous outcomes of my efforts to manage my diabetes than is probably good for a person's mental health. 

07:57
Time to take this moppet out for a walk. Activity and exercise need more fuel than resting and tend to make insulin work more dramatically, so I need to allow for that, even when it's something as insignificant as a 35 minute wander. My insulin pump allows me to reduce my 'background' insulin level, so I am setting a 70% Temporary Basal Rate for 45 minutes. 

08:52
Back from dog walk, just checking to see how things are going. 11.5mmol/L. This is too high, it looks as though I could have done without the TBR I set (though tomorrow might yield different results even if I do exactly the same things). Ideally this should be no higher than 9mmol/L 2 hours after eating so I am adding .7u of insulin with the aim of getting me back to 9 and leaving the insulin already 'on board' to deal with breakfast as it continues to digest. 

09:14
It's 9:14 and I realise I have already forgotten to mention something. I had a shower, so I disconnected my insulin pump temporarily, capped the tubing and the cannula that is inserted, currently, on my back. After the shower I primed the tubing and reconnected. So many of these interactions are so automatic I barely even notice them any more. 

10:02 
WDD Update: (It's RELENTLESS isn't it?) 10am and feeling a little bit indigestion-y / dry-throated. This *might* be connected with my raised blood glucose levels, but my symptoms of high BGs are patchy to say the least. It is probably because I have just been thinking about it since breakfast and it's all in my head. Or maybe it isn't? Tempted to check my blood glucose level again, but the thought of another finger prick so soon after the others (and especially because I think it will be another high level) is not encouraging me. 

I am also feeling a bit hungry, but adding the complexity of something carby at this stage will just create even more confusion/uncertainty so I am having a handful of nuts and a cup of tea instead. It's not that I *can't* have a couple of biscuits - it's just that the mental effort, and potentially disastrous BG outcomes kinda drains the joy out of them.

Via comments
Regarding feeling hungry when BG is high: I think it's because you body knows you have fuel on board, but it also knows that the energy is trapped in the blood and not making it into the cells. So it asks for more fuel. Which potentially makes the problem worse. Which makes you hungrier. Rinse. Repeat...

The really REALLY irritating thing for me is that my clearest symptom of low blood glucose is ALSO 'feeling a bit hungry'. So every time I feel a bit hungry I have to work out whether my BG is too high because of what I've just eaten, too low because I've over-compensated or, perhaps, that I might be just 'a bit hungry'. Pah! 

10:40
My Twitter feed is ablaze with #wddchat16 today. A 24-hour curated international Twitter conversation with different countries hosting an hour and handing over to each other. Thousands and thousands of people connecting, sharing experiences and supporting each other. I find great support to help me manage my T1 by connecting with people online, but I am going to have to resist getting involved on Twitter today or I am *never* going to get anything done! 

12:30
Lunchtime beckons. As you can see, the carefully considered correction doses I have administered today have had absolutely no effect, even though all of those doses have now finished working (approx 4 hours). I am beginning to feel the sluggishness of high BGs emerge. Lunch is a 2 slice Burgen bread sandwich and an apple*. 25g carbs for the sarnie and allow 20g carbs for the apple, so 45g total. My lunch ratio is 1 unit of insulin for 11g carbs. Thankfully my pump can do the maths for me, along with calculating a correction based on 1u lowering my BG by 3.5mmol/L and the difference between my current BG and my ideal mid-range target. Confused yet? Dose for lunch is 4u, plus another 1.5u correction for the high BG. I will wait rather longer to eat this time, with the intention of being more in range before adding more carbs. A tricky timing challenge as the longer I leave it the more steeply dipping my BGs will be when I eat, and the food will take a while to get going itself. It can feel like trying to hit a perfectly weighted long-ball pass to a sprinting striker... in the rain... into a headwind. 

* I tend to eat the same things for breakfast and lunch week in, week out. Partly habit, but mostly to reduce the number of variables by sticking to things that have been 'fairly reliable' (Ha!) in the past. That way if results are not as expected I can discount carb-estimation and food-absorption-speed errors, and it becomes more likely that my insulin needs have changed again.

12:46
How long has that been? Ah. OK, my instinctive 30 minute recheck. Will leave it a while and BG check again.

Via comments
It must be exhausting being you: The thing is... I recognise how amazingly lucky I am to *only* have T1D to live with. And to live with it in the UK with access to insulin, tech and the unbelievably amazing NHS. If I'd been given a list of LTCs to pick from aged 21, it would have been a pretty good option.

13:12
Just checked again. #BGnow of 9.3 after a full hour. Not perfect, but it will have to do. If I don't eat now I'm likely to get too absorbed in what I'm doing and forget.

15:42
This is getting a bit annoying now. Walked to Coop without TBR as things have been running high and I'm still too high on return. If things were working I would already be back in range. Correcting with a further 2.5u. Pump recommended 0.7u as I still have 0.7u 'insulin on board' from lunchtime. Initially thought about 1.5u, but have added another unit. Essentially I am now dosing what I think is 'slightly too much' because 'enough' isn't doing anything. I will need to keep an eye on it towards eve meal time. Starting to feel a bit crabby/irritable.

Via comments
Could raised BGs be an issue with the infusion site? Good thought, Not sure though... Would expect a much more dramatic rise with a cannula fail rather than being held steady through subsequent meals. This just feels like walking the wrong way on a travelator. Have been expecting my basals/ratios to shift soon. Looks like this could be it?

Could it be degraded insulin, having got too warm?  No it's quite a fresh one. I will take a look at tomorrow's results and see whether it's a pattern or 'one of those days'

17:43
Yay! My first in-range result of the day. Must remember to change my insulin pump battery before I go out for the evening. Last thing I need is Threepio wailing away when I'm trying to play guitar.

17:56
Just prepping for evening meal. Here's my insulin pump working up the mathematics for the dose. Feel very lucky to have access to tech which can fine tune doses like this. And if I decide I want to up my insulin intake by 10% tomorrow I can adjust the settings and let it work out the new ones. My diabetes may not behave reliably/predictably, but at least I can wrestle it with some precision on one side of the equation!

19:54
Typical, just when you can't watch what is going on and just when you really don't want to dip low. Several handfuls of Skittles to the rescue. Don't want to repeat the brain-fog for the next lot of songs.

Via comments
Regarding hypo warning signs: The ones that sneak up on me at that level really scare me. I tend to get good signals at least between 3.5 and 3, this time I had lack of coordination and slight sweating as clues. Didn't get my more usual anxiety/hunger until on the way back up.

21:42
That's the thing about T1 diabetes. You really can't rely on it to behave consistently. Just when you have been running high all day, and without rage-bolusing for a meal you get an unexpected dip. I suspect a slight mis-estimate of carbs for my evening meal, and not quite enough of an insulin delay for noodles (some carbs take longer to hit my system and an insulin pump allows me to deliver the dose either fully or partially spread over a number of hours). Still surprised the handful of extra fast carbs I ate as a 'safety cushion' disappeared so completely. 

22:02
Another check, and as I half expected I slightly over-did the hypo correction. Always tricky treating a hypo when you have insulin active, and when you don't want to risk a double-dip. I added a 30 minute 0% temporary basal rate just in case. Looks like a few Skittles too many. Another correction delivered. Not my best day of BG control. But not my worst either!

23:36
This is the last of my posts as part of World Diabetes Day. I waited up to allow that last correction to settle in. 

In Sesame Street style, today has been brought to you by 9 blood glucose checks, 110g of carbs, 29.475 units of insulin (40% background, 60% meal/correction). Just an average day with T1D (with above average BG levels). 

Now wake up tomorrow and do it all over again. And the next day. And the next. And the next...

 

Tragedy, togetherness #insulin4all and WDD2015

Today is Frederick Banting's birthday and also, not quite by chance, World Diabetes Day.

I was planning to post something on the blog today, but the appalling, tragic events in Paris last night have completely taken the wind out of my sails.

It doesn't really feel the day to be marking or highlighting anything else. My heart goes out to anyone involved, however obliquely. Parisians who now live in fear as they go about their normal, everyday, uneventful lives. And also to the many hundreds of thousands of innocent people who will now live in fear of violent Islamophobic reprisals.

But life, as the say, goes on. Instead of focussing on the division, violence and horror that a tiny minority are so evidently able to inflict, I find myself trying to focus on the exact opposite.

People, on the whole, are nice.

People, generally speaking, look out for one another.

People, more often than not, want to help - even if they may not receive anything in return.

People care about each other.

Yes of course there is selfishness, self-interest and general all-round rubbishness in human experience. Yes *some* people, perhaps even quite a lot of people, are prepared to do absolutely awful things.

But not most.

Not most.

I can see this in the Diabetes Online Community all the time. People wanting to support and encourage. People wanting to help. Wanting to affirm, strengthen, build up. People wanting to understand other people's point of view. People from wildly different social, economic and cultural backgrounds wanting to improve each other's lives. People willing to give of themselves without expecting, or requiring anything back, save to be part of a bigger, wider, more connected whole.

Better together. Better. Together.

T1 International and The Pendsey Trust are an example of this - attempting to co-ordinate and bring together support for #insulin4all - tiny charities raising awareness about the lack of access to essentials (insulin, test strips, education, healthcare) that many people with type 1 diabetes face around the globe.

As difficult as it can sometimes be to manage life with type 1 diabetes in the UK, it is a complete doddle compared to countries in the world where insulin is unavailable or unaffordable. In this day and age no one should die because they cannot access the insulin they need to survive.

World Diabetes Day 2014 - #insulin4all, food and meeja mentions

The (diabetes) wisdom of Homer - with apologies to Matt Groening

Yesterday was the anniversary of Frederick Banting's birthday (one of the clever chaps behind the discovery of insulin) and, not coincidentally, World Diabetes Day. Here are a few things that caught my eye:

#insulin4all
Perhaps one of the most moving initiatives on the day came out of a collaboration between teeny tiny diabetes charity The Pendsey Trust and t1international.com who are seeking to break down the barriers across the world that prevent so many people from accessing insulin. Or which mean that they have to weigh life-saving medication against food or shelter for their families. The YouTube video clip explains it far more eloquently.

You can add your support on the insulin4all tumblr blog too.


Enjoy Food
Diabetes UK chose World Diabetes Day to launch their 'Enjoy Food' campaign. It's good to see an 'everything in moderation' and 'nothing is off limits' feel to this campaign - especially from a type 1 perspective. I confess I have a tricky relationship with some of the dietary advice that DUK have dished out over the years, particularly for people with type 2 diabetes. It is a great relief to see them backing off from their 'all carbs, all the time' mantra more recently and actively stating that all carbohydrate becomes glucose in the blood. Bizzarely DUK still seem to be stridently anti-fat despite much recent research (including this) and even the British Heart Foundation recently confessing that there was no longer any real evidence to support its historic 'avoid fat/go for polyunsaturated' guidance. But hey... one thing at a time.


tweet tweet
There was quite a lot of twitter action again this year including the amazing 24-hour #wddchat2014 which saw global DOC communities uniting again and passing the tweet-chat baton around the world. Pressures of work meant I was not able to take part much this year - but somehow it's good to know it's going on around you. Huge thanks to Cherise (@DiabetesSocMed) for organising it all.

Fame at last?
I was chuffed to be contacted by the lovely Amy Fleming at the Guardian newspaper a week or two back who was planning a story about the Abbott Freestyle Libre and was interested in including some of my ramblings on the subject. All I can say is that the picture desk must have been rather frantic (or all at the pub) when the story hit the website as they went with my ugly mug by way of illustration. Even more surprisingly the article is factually pretty spot on, and even carefully differentiates the type of diabetes in question. Given the number of horrendous diabetes gaffes in the media I have a sneaking suspicion that Amy Fleming might actually have diabetes herself, or have someone very close to her that does - either that or she's just very, very good at the ole journalism lark. You can read the article here.

World Diabetes Day 2013 - a late update

As you may or may not know, it was World Diabetes Day on 14th November - Thursday last week. It doesn't always get a huge amount of attention here in the UK, but early on Thursday morning I saw a tweet from someone who said that while they usually spare their Facebook friends and family any boring diabetes-related shenanigans they had decided to post something to Facebook every time they interacted with their diabetes care. That sounded like a brilliant and very simple way to help raise awareness so I shamelessly stole the idea and did just the same on my personal Facebook account. I was absolutely overwhelmed by the reaction from people, pretty much all of whom know I have diabetes (I've never hidden the fact) but who had not perhaps realised the amount of day-to-day faffing about that T1D management involves.

Better late than never - here's what I posted:

10.20 14 November 2013
Today is World Diabetes Day, so I've decided to bore you all senseless with some of the diabetes-based nonsense I have to do every day.
Before breakfast I checked my blood glucose level by taking a tiny blood sample from my finger and applying it to a test trip in my meter. The result at 7.10 this morning was 5.8mmol/L. That's pretty much spot-on. So I took some insulin, waited 30-40 minutes for it to get going, then ate some toast.

It's now a few hours later and I just felt unexpectedly hungry so checked again in case that meant my breakfast dose had been a little out and my blood glucose level was now running a little low. Nope. it was 7.8mmol/L.

That's a smallish rise after breakfast but within acceptable limits. I will need to check again at lunchtime.

12.32 14 November 2013
OK. So it's Diabetes time again. I need to get ready for lunch. At breakfast and lunchtime taking my insulin about 30-40 minutes before eating helps to keep my levels in check after those meals (bizarrely I don’t usually seem to need to do this for evening meals). I've tested at 5.8mmol/L again - this means my breakfast dose worked perfectly, bringing me back to my pre-breakfast level after the 4 hour duration of the insulin has passed.

I have not eaten anything since breakfast because, to be quite honest, juggling multiple overlapping doses of insulin in a short space of time to allow for the carbohydrate in a snack is such a hassle and provides such added complexity to my day that I find I'm better off just not bothering. It’s not that I can’t eat biscuits or cake if I want to... it’s just that the pleasure of those things is offset by the guesswork and calculations involved in trying to achieve good levels day to day.

I've estimated my lunch at 45g of carbs. I need to know pretty much exactly how many carbs are in *everything* I eat so that I can calculate insulin doses correctly. Fortunately I have a helping hand as my insulin pump does the maths for me. At 12.29pm I took 4.05u of insulin. I will have to keep an eye on the time now and aim to eat around 1pm otherwise the insulin will kick-in before my food and I risk my blood glucose level dropping too low.

Today is World Diabetes Day - this is what it's like living with Type 1 diabetes.

15.32 14 November 2013
More diabetes goings-on documented as part of World Diabetes Day. Just checked my BG (now you're used to the idea I'll slip into jargon) and it was 9.9. Not a disaster, but not ideal either. I should aim to be below 9.0 after meals to avoid future 'fun and games' like blindness, heart attack, kidney failure, amputation and so on (cheery!).

I had exactly the same lunch as yesterday (this makes things easier for me as it reduces the number of variables involved in my day to day decision making). But... I also made small changes to my 'background' insulin pattern yesterday to prevent some lower levels I’ve been having recently and it seems I've overcooked it a little.

I've added an extra unit to correct the high level and have re-tweaked my afternoon pattern again for tomorrow. This is one of the main advantages to an insulin pump (which I now use instead of multiple daily injections). The degree to which you can fine tune doses offers potentially amazing accuracy of doses and delivery. The drawback, of course, is that you have to be physically attached to a small pager-sized medical device 24 hours a day... But the benefits soon far outweigh any concerns you have over 24/7 attachment.


18.11 14 November 2013
World Diabetes Day again. Evening meal is pasta. And I'm still 9.1 despite the earlier correction which is well under way. Adding extra correction to meal dose.

18.50 14 November 2013
I’ve not just tested, but I am still thinking (worrying) about how this meal dose will work out. The carbohydrate in pasta usually digests fairly slowly for me, so sometimes I use options on the pump to 'spread' the insulin delivery over a longer period. This time however I have taken all the insulin up front as I'm high to start with and the insulin will probably struggle to keep pace with the food. Of course this means I will have to keep a closer eye on things this evening, just in case my guesswork as to what might happen between the food and insulin turns out to be completely wrong and I end up worryingly high or dangerously low. Today is World Diabetes Day - this is what it's like to live with T1 diabetes.

19.40 14 November 2013
Another update (are you all bored yet?) Tested an hour and a half after eating and BG was 10.3 Now even though this is *still* too high, it is actually encouraging because it suggests only a very small rise in BG level while the initial burst of glucose from food would be expected and insulin should be active. This means there is unlikely to be any issue with the cannula (the small tube under the skin through which the insulin is delivered) and/or the pump itself. If I had not eaten anything I would probably be well on the way back down now - possibly too quickly! Another check in an hour or two should provide a better picture.

Posted as part of World Diabetes Day. Millions of people all over the world - parents, children, teenagers and pensioners - are making similar judgements today and every day.

20.27 14 November 2013
More World Diabetes Day fun and games. Well, another test reveals my BG has now risen to 12.3mmol/L. Disappointing. I'm lucky in that occasional short-lived forays into double figures/teens don't make me feel awful like they do for some people, but it does mean that I don't necessarily feel it when my BG is rising and I'm expecting it to be falling. I have to find out by testing. I still have over a unit 'active' from my meal dose, but by now I should be approaching normal levels. I've corrected again, but this time I've dosed more than I should need in order to reduce my BG more quickly and will top up with some carbs later if I need to. Yesterday's adjustment which was intended to prevent low levels seems have been a little over enthusiastic for the afternoon and evening. I will be tweaking again it seems.

21.20 14 November 2013
Another hour further on... Another test. Still up at 11.9. Sometimes 'rapid acting' insulin can seem anything but. It would be tempting to add a little more insulin into the mix, but according to my pump I still have at least 1.8u still active. Of course, the pasta I ate earlier is probably still pushing BG upward to some extent, but it's often tricky to work out quite how much of a food's BG raising potential will already have passed. Today is World Diabetes Day, and I much preferred how stable my BG levels were this morning.

22.40 14 November 2013
Today is World Diabetes Day and I've decided to post something here every time I do something diabetes-related today. I haven't given you the full picture of course... These are just the edited highlights. I've not mentioned each time I've looked to check how long it was since I did ‘x’ or ‘y’, to see whether or not I now need to consider doing something else. Since about 3.30pm my blood glucose levels have been higher than I would like. When this happens I can use insulin to bring them down into a healthy range, but I can't overdo it as the body needs a minimum amount of glucose to function properly and if I overcorrect I could easily end up hypoglycaemic (where the brain is starved of glucose and begins to malfunction).
My efforts to correct my high levels so far this evening have been less than successful. I am currently cruising at 10.5mmol/L whereas by now I was expecting to need to be eating some top up carbs. It is difficult to work out exactly what has gone wrong and where all that extra insulin has wandered off to, but having waited and tested and waited and tested all evening I've decided it's time for one last gentle nudge. I still have around 0.5 of a unit circulating from earlier but I've overridden the pump's cautious suggestion and added another 1.25u to make 1.75u in total. I would expect 1u to reduce my blood glucose level by a smidge over 3mmol/L in about 4 hours which *ought* to bring me to the mid-5s by around 2am. That's the theory anyway - if you've been sticking with this from the start you'll know it's not quite been working out as expected so far this evening for one of several hundred possible reasons. I now have to decide whether to set an overnight alarm for 2-3am to check again. Or just hope for the best and see how things are in the morning. As a halfway house I'll probably wait up another hour or so to see what happens. Fun fun fun!

23.57 14 November 2013
My last post for the day - you will doubtless be very glad of that. Just tested again and I've dropped down to 8.4 with 0.7u or so still active. That's much more promising. Not quite sure what happened, but it could simply have been a slight error in dishing out the pasta earlier. Even though the amount of pasta we cooked was carefully measured a spoonful or two too many on my plate could have easily caused that sort of havoc from a highish starting point. On the other hand it may be nothing to do with that.

Today was not a particularly tricky one - I've eaten only tried and tested foods that I seem to be able to manage more often than not... I didn't do anything particularly strenuous or energetic that might have dropped my BG... I wasn't under undue stress or illness, both of which can cause BG upheaval... But I still managed to make a bit of a hash of it levels-wise nonetheless. Even relatively ‘normal’ days can involve a mind-bending number of conflicting and combining variables to navigate around.

On the plus side at least I didn't crash from too high down to too low and back again, but it has been a fairly frustrating 'wait and see' evening.

It won't be World Diabetes Day tomorrow, but I'll still be weighing food, calculating doses and trying to work out how to keep things in some sort of balance. There are around 3 million people living with diabetes in the UK, and something like 10% of them, around 300,000 have type 1. Thanks for reading, and congratulations on all having fully functioning pancreases you lucky lot!

Going blue for WDD and some pumping firsts

As many of you will know, November has been claimed by many Diabetes organisations as a month to raise awareness of the condition. We are marking World Diabetes Day, November 14th 2011 in our own small way by turning our pages blue for the month. All over the internet there are little blue circles appearing - the international symbol for diabetes. Yesterday I caught wind of a brilliant project being organised by Mike Young who runs the 'Diabetes in Spain' website. We are not the only ones, it seems laying claim to the month of November. A creative initiative called 'One Day on Earth' invites people to document their experience of 11-11-11 (the 11th of November 2011) through video or photography. Mike is encouraging those living with, or affected by Diabetes to share what it is like to live alongside the condition with the world by giving their submissions a diabetes twist. If you fancy taking part you can find details of how to sign up here: www.diabetesinspain.com/diabetes-11-11-11.

In other news...

At the risk of boring you senseless, wittering on about the first few hours of life as an embryonic pumper I can report the following:

First comfy cannula. When I went to see the DSN I was given some 'standard' 9mm Quick-Set cannulas. They seemed comfortable enough, though there was a constant low-level itch. I swapped one for another in case the first had gone in wrong somehow, and it felt pretty much the same. How was I to know how it was supposed to 'feel'? A few forum posts seemed to indicate that being constantly aware of the location of the set was not 'normal'. Last night I swapped the 9mm for a shorter 6mm cannula and bingo! About half an hour after insertion the initial tingly sensation has worn off and I cannot feel anything at all. No tenderness when I poke at the plastic surround on the skin. Nothing. I have not tried other varieties yet, but at least I know I can use these. Great!

First 'free roaming' night. The very first night I popped Artoo in the pocket of my pyjamas. I don't usually wear trousers under the duvet, but instinctively felt some sort of containment was the way to go. It wasn't bad, but my legs got hot and Artoo kept falling out. Last night I initially started with the clip fixed to a loop around my neck (another forum suggestion) but didn't like the sensation of being a bit tangled. Early on in the night I dispensed with the loop/clip and just let Artoo roam free. This was by far the comfiest so far, nestling in the dent in the mattres around waist height. As I turn over from side to side I just locate, grab and shift to the other side in my semi-comatose state.

First public display. I went to the gym for the first time this morning. Something I think every new pumper has to deal with is the attachment thing. How others might perceive you as different, even those you don't know, and whose opinion matters very little to you. I wondered if getting changed in front of others would make me feel a little self-conscious. It's normally fairly empty in the changing rooms when I am there but not today... oh no. The place was packed! Nevertheless when I lifted my shirt and detached Artoo no-one seemed to notice in the slightest. I've decided that since my workouts are usually under an hour I will, at least to begin with, detach Artoo and leave him in the locker while I exercise. I even used the little cannula cap thing this morning. But I'm not sure how long that attention to detail will last. Showered off with no problems... Man! that sticky tape stuff is strong. Buoyed by everyone's complete lack of interest on my way in, I decided to test the waters further as I changed after showering and deliberately struck up a conversation with someone while I primed the tubing and re-connected.

Not even a flicker of an eyebrow.

It seems that pumps, like injections in restaurants are protected by a Douglas Adams 'SEP field'. A cognitive filter which applies almost universally with perhaps the exception of some young children and a handful of adults. Because it is something inexplicable, odd and unexpected most people simply do not see the pump, even when you interact with it, merrily press buttons and make bleepy noises. Their brain edits it out of the visual field because it is Somebody Else's Problem and life is much easier without having to worry about what it is.

So there we go. Artoo and I are off and running. And I can't wait to get cracking with insulin next week.

UPDATE: Pumping for two months - a little bit of everything