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.

Plus ça change

DUK Towers E1, tomorrow.

I shouldn't be writing this.

It's too late. I've been to the pub and had a couple of beers (as my Libre trace would gleefully tell you). I've just poured a rather tasty Japanese whisky.

By rights there are at least 3 blog posts that have been patiently waiting in line for me to finally get around to writing and posting them.

But tomorrow.

Tomorrow.

Tomorrow is the start of a new chapter.

Jane always liked new chapters.

Tomorrow I will be up early to breakfast, to walk the dog, and then potter to the train station to travel to a meeting at Diabetes UK's HQ in East London where I will begin a new part time digital peer support role with the UK's second favourite national diabetes charity.

I've been a volunteer moderator on the Diabetes UK sponsored forum for almost a decade, but this will be a change for me, and the first time I've been employed by anyone except me for more than 15 years. I am really looking forward to the challenge and to growing, encouraging and nurturing the peer-support interactions which I know from my own experience are SO vital, in a thriving community, over the coming years.

2020 has always felt like quite a momentous year. Perhaps because of the position in life in which I find myself. Perhaps simply because of the neatness of the numbers.

It will be very interesting to see where we are at the end of it.

64 Days with the Medtronic 640G: Ep 7 Overnight Hypoglycaemia

Those of you who can remember way back when this blog started (if you even exist, you have my undying affection for your extraordinary stickability) may recall that we were prompted to start writing a blog about my diabetes as a family after a particularly nasty overnight hypo. It was the beginning of me realising that I was *nothing* like as good at the whole 'pretending to be my own pancreas' lark as I had managed to convince myself that I was. I began to realise how much I didn't know, and that one event led me to connect with literally thousands of others wrestling their own diabetes into submission every day. My life, and particularly my diabetes management are very much the better for it.

Overnight hypos have been a bit of a recurring theme throughout my 25 years of living with type 1 diabetes. I am lucky in that I have never needed paramedic callouts, but there were many times along the way when Jane had to step in at breakfast time to 'bring me round' in the years before we started writing this blog. I look back at those early posts and am bewildered and ashamed that it took me quite so long to realise how much effect this was having on everybody else in the family. How unfair it was on them. At the time though, I guess I had convinced myself that my management was 'as good as could be expected'. I knew I was having 'A few too many highs... a few too many lows'. But doesn't everyone?

If you are the sort of person who approaches anywhere near 8 hours a night when you live with type 1 diabetes, you are spending fully a third of every day in the land of nod. That is an awful lot of time for things to go wrong - especially if your basal insulin dose is not adjusted correctly* or your requirements have moved since you last checked. You may be lucky enough to get clanging warning signs when you dip below 4.0mmol/L - enough to wake you up and sort yourself out. But you can't rely on them. And the more and longer the periods you spend below 4 during the night, the more of a hammering your hypo awareness will take and the less you will feel them. A classic vicious circle.

I am coming toward the end of my 64 days with the MiniMed 640G now (Medtronic have kindly allowed me to keep hold of their toy for a little while longer as there are a couple more posts I'd like to put together). Today seemed like a good opportunity to gather some of the snippets of video that I've been filming since the beginning and edit them into a 'SmartGuard vs Overnight Hypoglycaemia' post. Has Smartguard made any difference? Has my overnight hypoglycaemia reduced at all?

Watch the video below to find out what has been happening over the last 9 weeks. As always, I'd love to hear your comments or any questions, please leave them below or post on my Youtube channel.



*During the video, I mention how important I have found the concept of basal testing over the last few years, both on MDI (multiple daily injections) and also on a pump. Systematically testing and adjusting my basal insulin on an ongoing basis helps me to keep my meal doses and corrections working more or less as I expect them to (ha!). It was one of the most significant 'new concepts' I discovered when I first started comparing notes with other people with type 1 diabetes online. If you'd like to know more read this post by Gary Scheiner (Think Like a Pancreas) which explains the principle. It is written for pump users, but would be easy to adapt for once- or twice-daily basal insulin injection on MDI.

Diabetes Week 2013 - A question of research

It was great to be invited to submit a guest post for Diabetes UK's blog to mark Diabetes Week (9-15 June) this year. I'm a little late with it, so it may not make it onto their site this week, but here it is anyway.

"What aspect of your diabetes would you fund research into if you had the choice?"

Some of you may know I've been pottering off to London every so often recently as part of the Guideline Development Group that is updating the NICE Type 1 Diabetes Guidelines. I'm on the Group as one of two 'punters', part of the Patient and Public Involvement programme that seeks to include a grass-roots perspective from patients during the development of NICE guidelines. As a result I've had a bit of homework to do and have come into contact with a whole stack of research papers on all sorts of topics.

I have good reason to be thankful for NICE Guidelines. As a patient, well written guidelines give you a meaty, authoritative document to wave in front of your clinic or GP that says, "Look, this is what the NHS says is the very best way to treat my condition, and that's what I want". NICE prides itself on being 'evidence based' and looks into all sorts of different approaches/treatment options to try to evaluate the very best options in terms of efficacy, balanced with cost-effectiveness. Thankfully 'cost effective' is not a euphemism for cheap here. Even very expensive options, such as an insulin pump, can be recommended provided that the research demonstrates quantifiable benefits to the patient.

At the risk of offending researchers everywhere, to my simple mind the research papers I've been looking at seem to divide roughly into two camps. One is 'I wonder what...' and the other 'I reckon...'. The second camp also appears to include studies with a vested interest in demonstrating a particular outcome, sort of 'Can we show...'. It is a good job that published research is peer-reviewed and some considerable effort is taken to ensure that studies are designed fairly, but nevertheless there is a part of all of us, I think, that looks slightly sideways at research into how marvellous a new drug is that was paid for by the company that makes the product. NICE even have a special method for reviewing research papers to assess their reliability 'grade'.

So what of my own 'I wonder what...' question? To be honest, it's probably a bit more of an 'I reckon...', but only because of my own experience over the last few of years. I also suspect (given some of the online questionnaires I have been invited to complete recently) that there is already a growing body of work on the subject. Best of all, there is no Big Pharma organisation lurking in the shadows looking to make squillions from a new wonder drug. What would I like to see researched? It is simply this: "The use of internet forums, social media interaction and blogs (the Diabetes Online Community) for improved patient outcomes with T1 Diabetes".

Now I'm not for a minute suggesting that posting a couple of threads on a diabetes forum replaces the expertise of dedicated healthcare professionals or attending regular screening or clinic appointments, but diabetes is a frustratingly individual condition and can be quite isolating. Time and again I see new people join diabetes forums, or begin tweeting who have lived with type 1 for decades but rarely, if ever, met or compared notes with anyone else living with the condition. I'm a passionate believer in the power of peer support and have seen its transformative power at work in the lives of many individuals. Successful diabetes forums are huge resource of pooled experience, knowledge and can instantly put you in touch with approaches, techniques and suggestions from clinicians all over the world. Diabetes blog posts that mirror your own experience from another's perspective can give you a real sense of connectedness and help you realise that it is not just you. Conversely, another post might make you realise that anything is possible. Social media channels and interactions provide very genuine and in some cases almost instantaneous support and encouragement when diabetes is not 'playing nicely'.

There is a new breed of Healthcare Professional learning to embrace and value these resources, and it would be nice for them to have some good hard research numbers to back up their enthusiasm. Hopefully we can move away from the time when HCPs never looked at online diabetes resources and suggested that their patients never read them.

If you are living with type 1 diabetes you are not alone. There are 1,000s of others facing the same daily battles and together we can make each other's days just that little bit easier.

Not cool - insulin storage problem

I'm still waiting to write that post extolling the virtues of Colin, my Accu-Chek Expert, but even his shrewd bolus-calculating savvy was not up to coping with the BG craziness of the last seven days.

Things just went bonkers.

And it made me realise that this is not unusual. Since I started putting a lot more effort into my diabetes a year and a bit ago I've noticed a definite repeating pattern in what I previously thought was just diabetes randomness:

1. Finally work out the rules
2. Good numbers for a few days. Yay!
3. Wow that was an AMAZING day. Woo hoo!
4. Errrrr hang on where did that come from
5. Right something's definitely not right here...
6. So the rules have changed again then. Great, thanks for that.
7. Erm... try this?
8. Nope. That was annoying.
9. What about this?
10. Right OK not that either...
11. OK that's looking a bit better
12. Definitely on to something here...

....aaaaand repeat. Given enough trips around the cycle the doses/ratios/splits/timings begin to repeat themselves and off we go again.

But this one wasn't like that. This one was off the scale.

Looking back over recent records I'd had a spectaculatly good patch. Over a fortnight with 75% of readings between 4 and 8 (including several 1hr/2hr post meals). Anything over 10 was a bit of a surprise. I was also having almost no hypos during this period. In short it felt like I was winning. It felt amazing.

I started having a few hypos to tentatively dropped my Lantus by 1u to see if I'd settle just a notch higher up. I only lasted 2 days first with a prefectly acceptable 6.9 average, the second constantly fighting highs and averaging at 10.8.

The next two days, Lantus back up by 1u were not too bad, but the following few days were a complete disaster. Countless corrections were having little or no apparent effect. One morning despite a 2u correction the previous night (at 14.x) I woke to 16.6. I went for broke decided on double my usual breakfast insulin:carb ratio +20% for 'stress', injected 8u and waited for it to come down. 5 hours passed and I still hadn't eaten anything other than a lump of cheese (hoping to trick my liver into cancelling any DP action). BG stayed above 9.0 right up until lunch. The following day saw me needing 10u for a single slice of breakfast toast (that's 5x my usual amount)!

While waiting for our new fridge to be delivered, I posted a moan on a forum describing recent events, and suggesting that the Diabetes Gremlins had perhaps snuck in at night and replaced the Lantus in my cartridge with water. Someone happened to ask if there might be any problem with the way the insulin had been stored. Hang on a minute... "While waiting for our new fridge to be delivered...".

And then it all fell into place. Our fridge has been a bit flaky for some time, maybe even a year. Mostly keeping things cool, sometimes getting a little enthusiastic and getting really cold, other times appearing to warm things up, but never actually completely broken. The light had stopped coming on a week or so ago and we'd decided that enough was enough and ordered a new one. I was down to the last cartridges in the box of both Lantus and Humalog and it seems that the fridge's repeated misbehaviour had substantially affected the insulin's potency. The box of Lantus was the older of the two, so my guess it that it was pretty much shot. The newer Humalog left to fight the BG battle on its own at half-strength. Another one to add to the 'watch list': Count carbs, consider food absorption properties, check basal level, consider level of activity, rotate sites, make sure fridge is working.

I've ditched the suspect cartridges and with nice new fresh ones things have quickly returned to normal. Well today at least.

Not always easy

I'm having a slightly difficult time at the moment. Not really, but I've just had a whole load of weeks with almost bewilderingly good control. I have a blog post brewing called something like 'How much I love my Accu-Chek Expert' that I'm hoping to add later this week.

Things never stand still with diabetes though. It's a constant grind of getting it to work OK, then things seeming to change for no readily apparent reason, then working out what these 'new rules' mean while enduring days of chaotic numbers, then getting it to work OK again... and on... and on... and on...

I just read a quotation that someone posted on a forum which so eloquently summed up this feeling that I wanted to share it here:

“And even the constant need for decisions might be tolerable, if only the results were predictable. Few things generate burnout like the awful frustration of having followed instructions and done everything just right and still to be failing to get the diabetes into control. At those times it seems no use to continue to try.

Think how discouraging it is to fail at something you really wanted to do. Then consider what it must feel like to be failing at something you didn't want to do in the first place.”

Joan Williams Hoover

Diabetes is enough to drive you nuts

I came across this description from DiabetesDaily (a largely US-based diabetes community/forum/collection of blogs) today:

Diabetes is a complicated and unforgiving disease. To manage successfully, it requires knowledge, problem-solving skills, and a reservoir of patience. Even then, life happens and throws everything into chaos.

It pretty much sums up my day yesterday.

Diabetes hasn't made me smile in a long time, but some results yesterday were so crazy, so illogical, so utterly ridiculous that I found myself grinning all over my face this morning.

I've been having a pretty good run of results in the last few days - now that the craziness and unpredictability of Christmas eating has passed. I began yesterday morning with a bg of 8.0mmol/l (144 for US readers). A bit on the high side, but not too bad. I had a pretty standard low GI breakfast (two slices of Burgen toast) one that I know usually behaves itself and left my usual 45 minutes between bolus and eating. By mid-morning I had spiked way up to 14mmol/l (252). Took a correction and was nicely back in range with a 7.2 (130) before lunch. I put the spike down to a little liver-dump tomfoolery and left it at that.

For lunch I had two slices of Burgen again, low fat mayo and some leftover chicken. Plus a smallish Clementine to finish. Left 15 minutes between bolus and eating (which is usually enough at lunchtime for the Humalog to get going). Carbs-wise that makes around 35g so I bolused at my usual ratio (4u). 30 minutes later I'd only risen by a tiny 0.2mmol/L (meter inaccuracy notwithstanding). BUT two hours after lunch I checked again and had shot up to 15 (270).

So let's get this straight... I ate completely familiar foods, counted the carbs, took usual doses and in both cases ended up spiking to the sort of level I'd usually like to avoid.

At this point, our evening meal looked like a scary prospect. The girls were given horse-riding lessons from grandparents at Christmas so they were going to be back late and hungry. We'd decided to pick up food from the chip shop to make things easy. So this meal is massively high in carbs AND high in fat AND on a day when the usual rules seem not to apply. Hmmmm tricky! But what could I do except use my usual (and often fairly successful) approach of a stab-in-the-dark at the carbs and a 60:40 split dose 60% before eating and the rest an hour or so later.

Pie and chips. Carbs were estimated at 140g (I know... I know...). 10u up front with a pre-meal reading of 4.3 (78). An hour later I was up to 7.5 (135) and took the second half of the split - 3u to allow for being slightly close to the edge before the meal. At three hours after eating I had dropped back to 5.2 (94) still had a fair amount of insulin on board so had a couple of leftover Christmas chocolates to play safe. Went to bed at 11pm at 5.9 (106) with a reported 1.5u of active insulin according to Colin (my Accu-Chek Expert). I figured that at least some of the evening meal was still chugging through my system, delayed by the amount of fat involved so left it at that, trusting the chips to see me through the night.

I woke at 5am. This is very unusual for me, and I immediately assumed that my BG must have dipped into hypo during the night. A blood test revealed 5.7 (103) so I just went back to sleep.

Woke this morning to a reading before breakfast of 5.5mmol/L (99) and it was then I started grinning. Both my low fat, lowish carb, low GI meals in the day had ended badly, but a pie & chips blowout followed by chocolate and a glass or two of wine had resulted in spectacularly good levels. This is the mystery of diabetes. This is why it drives us crazy.

Now I'm not suggesting we all eat pie & chips constantly from now on, but after yesterday it is quite tempting :)

The amazing amazing DOC

As 2010 draws to a close I find myself looking back over the last 12 months and in particular the changes to my experience of diabetes. Emotionally sensitive readers, or those who find gushing saccharine-sweet outpourings a little cloying may want to look away now.

As the year began I was just doing what I always did to keep my diabetes under control. It worked, more or less, most of the time. There were a few too many highs, a few too many lows, the constant contradictory feeling that things could be better and that things were as good as could be expected while retaining any semblance of a normal life. I think this feeling plagues many who live with diabetes. The suspicion that if you had more self control or were willing to give up treats/flexibility/various major food groups and could commit to live an identical gram-perfect life every day your control would finally be sorted. Except that you can't. And let's face it even if you did you'd be pretty miserable, or at the very least pretty difficult to be around.

So I pottered along happily enough, thinking that things were OK. In a way I suppose they were. Then in February I had my unfortunate event (apologies to Kermode and Mayo's Wittertaining podcast) which, without boring you with details involved at various points: a massive hypo, loss of speech function, a suspected stroke and a trip to A&E. Suddenly the goalposts shifted and control which was 'good enough' was no longer good enough.

At about that time we began looking around online for people writing about their life with diabetes. There were a few European blogs, seemed to be almost nothing in the UK and quite a large number in the US. So we decided to begin our own blog - somewhere to share our experiences, rant, weep and post questions. Mostly writing for ourselves, but with some small hope that our shared experiences might offer support to others living with or affected by diabetes.

Life, like drawing is often a case of 'the more you look, the more you see'. Almost as soon as we had started writing about our own experiences we began to get feedback, comments and contact from a huge network of online PWD (people with diabetes). We began to have contact with well-established blogs, busy forums and frantic tweeterers from all over the globe. Before long I came across the term DOC (the Diabetic Online Community), or to give it it's official US-style title the Awesome DOC.

Steady now. Here's where it's going to get mushy.

You guys are amazing. Absolutely, completely and staggeringly amazing. Helpful, supportive, full of empathy, encouragment and very, very funny. Wise without being pushy. Full of advice but empty of 'rules and regulations'. I learned more tips, tricks, approaches and strategies in 6 months' contact with this online community than I have in maybe 15 years of appointments with Consultants, Registrars, Diabetes Specialist Nurses and Dieticians. I have been supported by people living with all different types of diabetes and have finally began to understand a little about life with type 2. Crucially all information is always suggested from the basis that everyone is different, there is no one-size-fits-all approach which will work. No overtones of judgement. A recognition that everyone will manage in their own way, with their own targets. Their own truimphs, failures and weaknesses. That we are all struggling against this common enemy on our own unique body-shaped battleground.

It struck me earlier in the year when the kids were listening to the Glee soundtrack (don't ask me which one), that the DOC should have Bill Withers' 'Lean on Me' as its anthem (a power-chord laden reworking by Blunt Lancet, naturally)...

Sometimes in our lives we all have pain
We all have sorrow
But if we are wise
We know that there's always tomorrow

Lean on me, when you're not strong
And I'll be your friend
I'll help you carry on
For it won't be long
'Til I'm gonna need
Somebody to lean on

If there is a load you have to bear
That you can't carry
I'm right up the road
I'll share your load
If you just call me

So just call on me brother, when you need a hand
We all need somebody to lean on
I just might have a problem that you'd understand
We all need somebody to lean on

I still have ups and downs, hypos and hypers, but these seem fewer and further between. Thanks to the advice and support I have been given from people I have never met (nor in many cases am I ever likely to) I can honestly say that I have never felt so in control of my diabetes in all the years since diagnosis. I am not due to have an HbA1c until around April but my monthly averages for the last five months hover around 6.9mmol/l which, if the conversion formula is to be believed, equates to an HbA1c of around 5.9%. That's a full 1% drop since my last one.

So thank you all. Here's to a happy, healthy and spectacularly well controlled 2011 for everyone.

Advice for new diabetics in one sentence

A few days ago Tim on Shoot up or Put Up posted a thread which asked, 'If you were presented with a newly diagnosed diabetic and had to give them your advice in one sentence, what would it be?'.

It was an interesting question to be asked. Diabetes can feel very complex and difficult to understand at times. In all the months, weeks and years since diagnosis I don't think I've ever got to the point of feeling I really understand it completely. There's always something new to learn. A new explanation for those confusing 'out of the blue' results. A new approach. Another lightbulb moment. So to try to distil everything you've picked up into one handy phrase is quite tricky.

There were some interesting and inspiring responses. Things about living life to the full. Being able to take control of the condition. Never letting it stop you from doing anything. Mine, by contrast seems rather dull, but it contains 5 little nuggets that I'm very glad I was told, or really wish I had been told at the beginning of my diabetic life:

Sometimes it won’t feel like it but this is something you can control - just count carbs, test lots, carry sweets and keep asking questions.

For starters, I know that sometimes however hard I try, my control seems to go all over the place. It's no fun battling relentless highs, persistent lows or perhaps worse, the zig-zag rollercoaster of overcorrection from one to the other. Aside from the physical grottiness of it, there is the emotional upheaval and the dark looming cloud of complications to add to the fun.

But...

It might be hard work, it takes a lot of effort, a little willpower and just a smattering of gut-instinct but diabetes is something you can control. Well most of the time anyway. As a type 1 it is a matter of matching the insulin I take with carefully counted (or more usually wildly guestimated) carbohydrates. A little systematic testing after meals can help to identify different and/or unexpected absorption patterns of different foods, pizza... Weetabix... you know the sort of thing. Then I have to decide whether I'll just avoid those choices entirely or work ways around the problem with timing/dose-adjustment. More testing helps me understand the effects of exercise on my blood glucose levels and combat those with altered doses and/or fast-acting carbohydrate for the rest of the day.

Writing everything down, not just BG (blood glucose) levels, but insulin doses, carbohydrate eaten at meals, exercise etc has helped me spot patterns this year that I'd struggled with for years.

If you have not been offered carb counting yet and you are injecting insulin I would urge you to ask your team about it. If for any reason it is not available in your area (and I'm not sure how this can be the case!) the online BDEC course might help. To be honest, even if you are type 2 and not on insulin, it seems to me that carb counting and using a meter to see what happens when you eat different amounts (and different types) of carbohydrate can only help you see how your body reacts and tweak your diet accordingly to aim for the challenging target BG levels we are set.

One of the most significant changes for me this year though has been to compare notes with other diabetics. I've never sought out the voluntary-group-tea-and-biscuits(!) sort of arrangements, but there are several thriving online forums (including one supported by Diabetes UK) where you can share experiences, rant, ask questions and generally converse with other people who are facing the same challenges as you every day. A trouble shared and all that.

Life with diabetes can feel hard at times, or impossible, or unfair. But all we can do is just keep on digging in and working to get the best control we can one day at a time.

I wonder what your advice to the newly diagnosed would be?