Rage Bolus - a Christmas classic

Disney Pixar's Inside Out. One of my absolute favourite films.

I've seen a few things about rage boluses in recent months and it did that rare thing of making me think, "I should write a post about that".

I can't remember exactly when I first came across the term 'rage bolus', but I think it was quite soon after discovering of the power of peer support and shared experience. I am almost certain that it came from that most legengary of #DOC legends, Kerri Molone Sparling's Six Until Me, and I'm pretty sure that it was Kerri who came up with the phrase originally.

If you live with diabetes and use insulin, even if you've never heard it before, you will instantly know exactly what is meant by a rage bolus. It was phrase that made me go, "Aha! Yes!! I know that thing." Type 1 diabetes can be incredibly frustrating to live with. For all the illusion of 'diabetes maths', and there is no question that sometimes carb ratios and insulin sensitivity factors can and do work (some days / most of the time / once in a blue moon), it is also absolutely the case that there's a lot more going on than food + dose = reliable results. And when things go a bit off track you can feel that you have got it wrong (and sometimes you have!). A sense of personal failure. Feeling like an idiot. So frustrating. Other times you know that you have done all the things you are supposed to do (scrupulously counted carbs in a carefully chosen, healthy meal that you've eaten many times before with reliable results) and still your BG ends up in chaos. Doubly frustrating. Or you just decided to treat yourself (after all everyone else with their functioning pancreases and none of this to worry about were having a lovely time) and then you see it all coming back to slap you in the face, even though you tried your best to work it out. Triply frustrating.

Sometimes there are only so many small, carefully-calculated, properly-spaced correction doses you can try and wait grinding your teeth and stewing in double figures for hours (or days) willing your BGs to stop inexorably rising or stubbornly unmoved before you go OH FOR GOODNESS SAKE and whack in a big ole slosh of insulin to try to get things moving downwards.

And as we approach Christmas I am aware that we are heading into 'rage bolus' season. Meals are likely to be less predictable. Less easily guessed or measured. You may have a little sniffle, or be drinking sugary alcohol, be surrounded by endless nibbles, or be less active than usual, or exposed to any number of other factors that might make decent dose-guesswork much harder.

Let me just be perfectly clear about this - rage boluses are generally a terrible idea. They almost always result in hypoglycaemia, sometimes in a really nasty and stubborn and/or scary low. And crashing from one out of range BG to another at the other end of the scale is likely to make you feel even more frustrated, annoyed and difficult to live with.

So why do we do it to ourselves?

Because, frankly, sometimes it WORKS. And like an addicted gambler feeding endless coins into our BGs fixed-odds betting terminal we have reached the end of balanced and logical assessment of likely outcomes. Sometimes high BGs are the result of a significant underestimation of carbs. Or perhaps it's a dose that hasn't absorbed properly. There are circumstances where we are in 'insulin deficit' of a number of units. And where the food already eaten is still feeding glucose into the bloodstream, and where a dose isn't likely to reach maximum effect until an hour after you grit your teeth and go for it, there can be long, long hours between a measured, cautious correction dose and seeing any effect at all.

Repeatedly, I have heard respected diabetes clinicians suggest that one of the reasons that rage boluses are a bad idea is that taking more insulin doesn't make it act more quickly, it only makes you fall further in the end which leads to likely hypoglycaemia. I think it would be much easier to resist the rage bolus urge if this was actually true. The simple, demonstrable fact is that taking a larger BG correction does make it act faster to reduce high BGs. We know this because we see it happen. And to pretend that it doesn't really isn't going to help me in a consultation. If I take a 0.5u correction dose (as suggested by my pump or smart meter) then after a reasonably predictable onset time I will have a proportion of that 0.5u available to act on my errant BG. If I take a 5u correction, after the same onset time I will have much more circulating insulin available. It may not be exactly mathematically 10x as much, but it will be more. And If I've rage-bolused before and checked after 30 minutes, then an hour, an hour and a half... I will have seen this happen.

Rage boluses do reduce high BG faster.

It's just that they also add chaos onto more chaos.

Sometimes I will make this calculation in my head:

OK so I've currently got annoyingly high BG. I also have some insulin already on board. Along with that, I also have half a meal which I may (or may not) have hoplessly inaccurately estimated that is feeding more glucose in. Some of which will be accounted for by the dose that's already acting. Or possibly it won't. Solution? I'll dose a big ole slug of insulin in now to get things moving in the right direction over the next 2 hours, then depending on how things go I will eat some extra carbs later on to mop up the last bits of the dose.

I mean... what could possibly go wrong?

I once referred to this frustrated act-and-counteract ballet as uncertainty tennis (particularly where my guesses and second-guesses follow in double-quick time and everything overlaps far more quickly that it can possibly have had enough time to actually take effect).

Try to give yourself some head-space this Christmas. Give yourself a little more leeway. Perfection is an illusion. BG perfection doubly so. No one wants to live with a grumpy pancreas-impersonater muttering and grumbling after every meal.

And if possible try to resist the rage bolus urge. Except for the times when it works perfectly and brings you back neatly into mid-range. I mean... those are just awesome! (and incredibly unlikely)

No two days - Diabetes Week 2018

Ugh. Good morning to you too.

Apparently this week is Diabetes Week.

Me neither.

If I get the chance I will try to rattle in a post about the excellent #languagematters work that is being launched this week which hopefully will provide useful pointers to healthcare professionals and people living with diabetes who are trying to have more positive, more enabling, less stigmatising conversations.

In the meantime I have other things on my mind. Because as I posted recently on Twitter my diabetes has been behaving in a peculiarly cantaknerous way recently and I don't see why I should suffer that alone, so I'm inflicting it on you lot.

We've toyed with a few different straplines for our blog over the years, before we settled on the current one, "Because no two days with type 1 diabetes are the same. Except when they are." Which I liked because it was a) slightly annoying and b) didn't really make much sense. Both attributes shared by type 1 diabetes itself.

It is part of the unending joy of playing at being your own pancreas that you are perpetually caught in the tension between the illusion of 'diabetes maths' (deliver x units of insulin to process y grams of carbohydrate plus or minus z percent for activity/illness/alcohol/whatever) and the reality of living with a condition where the sheer bewildering number of variables that might combine, contradict, multiply or cancel each other out, when trying to calculate a precise (or sometimes wildly guessed) insulin dose, mean that it can be extremely difficult to work out why things have gone well, or not quite so well.

As a defence, some of us pancreas pretenders with a few years under our belts attempt to find some ways of reducing the number of variables without expiring from sheer boredom. It's a kind of coping strategy and it can work quite well up to a point. I have eaten pretty much the same breakfasts and lunches for more years than I care to remember. A regular rhythm with slight differences for weekdays and weekends (craziness!) but generally, more often than not, a known number of slices of a single brand of bread along with a medium-sized apple at lunchtime, and a not very adventurous range of fillings/toppings. It is functional eating. Designed to be predictable. Well tested. Evening meals I tend to eat a much wider variety.

And this regularity provides a useful touchpoint. Because as I said this strategy is only successful 'up to a point'. And that point is where something else changes. You have the normal food, you take the normal dose alongside the normal background insulin and the normal level of activity. But suddenly you see anything but normal blood glucose outcomes. If everything is changing all the time, with all sorts of different meal choices/fat contents/dose requirements, it is much harder for me to spot when my diabetes has joyfully shifted the goalposts (again!) and when I need to slightly adjust basal dose or meal/correction ratios.

I've been happily using this technique for years now. And my diabetes and I have got into a sort of gently seething stalemate. I fix the ratios/basal/correction factor. A week or two pass... a small basal tweak is required... then another... then another... And every month or three perhaps a larger overhaul might be required. The basal pattern might slightly change shape, or carb ratios and correction factors may need to be adjusted. Blood glucose normality (Ha! By which I mean the generally expected levels of BG chaos) resumes. Up a bit... Down a bit... Down a bit... Back up a bit. And so my diabetes world turns.

Something odd
More recently I have been seeing something much more unusual, unexpected and irritating going on. But such is the chaotic and fickle nature of living with type 1 diabetes, that it's taken me a while to even spot it was happening, and realise that over the past 2-3 months it has been developing into a bit of a pattern.

The perils of CGM
In a sense, I wonder if I might have spotted it sooner if I'd had less access to CGM. It sounds bizarre, but the difference for me between living with CGM and living without it is that CGM frees me from needing my diabetes to behave predictably. I am able to roll with it and adjust as I am going along much more freely. But that freedom, ironically, may come at a price. Without CGM, I need my diabetes to be much better behaved. I need to know that I can do x and (more or less) expect y to happen without watching it unfold, or being alerted if things are going off-track. I've only been wearing CGM occasionally this year, but it's probably been 50-60% of the time. And that's a lot of weeks of 'adjusting on the go'. Having run sensor-free for 2-3 weeks I realised how much I had lost my fingerstick BG mojo (especially after a full year with quite heavy CGM/Libre use in 2017).

When the weirdness started happening and I was wearing sensors I just worked around it. It has only been since running sensor-free for a few weeks that I've needed to look at the root cause to try to get things back onto an even keel when I'm not able to watch what's going on between the dots.

Pattern spotting
What seems to be happening for me recently, at lunchtime and even moreso for evening meals, is that the speed of absorption of previously predictable meals has substantially changed. While I used to be able to take doses all up front with 20-30 minute delay before eating at lunchtime, and immediately before eating evening meals, I am now needing to use dual waves to substantially delay insulin delivery so that the late arriving food still has insulin available.  What had been happening was a post-meal period where an initial sharp BG rise was followed by a prolonged dip (needing multiple carb top-ups to prevent hypos while the meal dose was working at full strength) followed by a later rise into double figures as the food absorbed when the insulin was on it's way out. Many T1s will be familiar with this 'pizza effect' where the fat delays carb absorption - but suddenly I was seeing it with previously very predictable and cooperative foods.

I can't explain why this has suddenly become necessary. I'm not sure I even care to be honest. Especially since breakfast seems to have been entirely unaffected and is proceeding as it always has. Typical type 1 diabetes. It can't actually make sense. It just has to set new 'rules' for that thing, but leave that other thing as it was. And in another month? It could all change again!

The good news is that I have made some decent progress in the past few days to find a set of splits and timings of dual wave doses that seem to be working better for lunches and evenings (and reduced dose ratios to boot). I will pop a sensor to see a bit more detail in the next few days.

Hope the BG gremlins are giving you all a bit of peace.

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...

 

Your Diabetes May Vary (again!) - BG variation after food

Two different carbohydrates, yesterday. (CC)

Which would hit your bloodstream faster, a banana or a biscuit? Pure glucose or a slice of white bread?

Well, in news that will come as a bit of a shock to some (and not at all to others), you can't actually know without checking for yourself.

Anyone with diabetes who has spent much time monitoring blood glucose levels before and after meals (especially if they have then compared their results with anyone else), may well already be familiar with this conversation: Person A: "I find porridge is great in the morning, it releases really steadily until lunchtime"
Person B: "Really?!? I can't go near porridge - it hits me like a train. All breakfast cereal does. Which is odd really, because Mars bars cause me no BG problems at all" etc etc. Rinse. Repeat.

Well a recent study published in 'Cell' by the Weizmann Institute of Science has demonstrated once and for all what we pancreatically-challenged types have suspected for a long time. That blood glucose responses to different foods are infuriatingly and often bewilderingly individual.

The study took 800 people without diabetes, around 54% of them were overweight and 22% classified as obese (with a BMI of over 30 kg/m²). They were connected to a Continuous Glucose Monitor for a week at a time, but the CGM was 'blinded' so participants had no way of seeing what was happening to their levels. CGM consists of a small sensor placed under the skin which records interstitial glucose values every 5 minutes, 24 hours a day. These values generally lag behind true blood glucose values by 10 minutes or so, but give a complete picture of what is happening before and after food and during sleep. People in the study recorded their food intake, levels of activity and so on using a smartphone app. They followed their normal routine, and ate as they normally would with the exception of breakfast, where they were assigned one of 4 standardised meals containing 50g of carbohydrate.

If you have spent much time online, sharing experiences with people with diabetes you may get a nice warm fuzzy feeling of "Aha! I *knew* it!" at the results. Here are a few things that came out of the research that caught my eye:

Responses to different foods were highly individual. Many people's BG rose rapidly after a standardised glucose meal as you would expect, but others were relatively untroubled by pure glucose, while eating bread sent their BG levels through the roof.

A graph comparing two participants shows an almost exact inverse response between, for example, cookies and bananas. In the light of this, any lists of 'foods which release slowly' can only ever be viewed as a general guide. Your own response to any food could well be very different.

In general, people who had higher BG responses after eating carried more weight than those with lower responses. The paper doesn't offer any thoughts as to whether these higher BGs make people put on weight, or whether the excess weight causes the elevated post-meal BGs, but in either case this association did not just occur at the extreme ends, but as a continuous range across the various weights.

The highest post-meal responses 'significantly correlated' with elevated (but still non-diabetic) HbA1c, waking glucose level, BMI and also age - all known to be risk factors for developing Type 2 diabetes. It looks to me like these are people whose metabolisms are already beginning to struggle.

Perhaps unsurprisingly, post-meal responses were shown to be very different to the same foods if eaten after resting/sleeping vs after exercising. Apparently the Pope is also Catholic.

A 100 people took part in a further study which allowed the researchers to develop an algorithm that successfully predicted post-meal BG responses from a variety of clinical, physical and 'microbiome' (eg gut bacteria) factors. Personalised diets were then able to reduce post-meal BGs effectively. In the Diabetes Online Community we simply call this ‘eat to your meter’.

The scientists wonder if working directly on reducing post-meal BGs would, over time, reduce some of the other associated risk factors including reducing weight, HbA1c and lowering risk of fatty liver disease.

What do I think this means for me?
Well first of all, it helps me realise that it's not just me being 'weird' after all. Different people really do react differently to different foods. Sometimes in completely inexplicable ways. I spent almost 20 years eating things that had been recommended as 'slow release' before beginning to systematically test my own responses to foods and discovering a few surprises and several absolute shockers that I had always believed were 'pretty safe'.

In general, it is easy to see that the proportion of carbohydrate in a meal could have a fairly direct impact on post-meal BGs, but this research goes some way to explain many of those 'Huh??!?' moments, and demonstrates that there's a lot more to it than that for each individual.

People make a lot of noise over 'low carb' vs 'high carb', but in truth, those definitions are of little interest to me. What I'm after is a varied, enjoyable, sustainable, LOW BG SPIKE diet that suits *me*. This research encourages me to continue looking for it.

"Your Diabetes May Vary", and all that.

64 Days with the Medtronic 640G: Ep 8 Fine-Tuning SmartGuard

For all the times when SmartGuard has worked brilliantly for me (and there are - too many to count), there have also been a number of situations in which it seemed to make a bit of a mess of things. Overshooting and leaving my higher than I'd like... kicking in when a hefty carb load was just about to arrive and stopping basal for that 30 minute minimum (during which time I would be having a high glucose alert)... or cancelling various parts of dual and square wave boluses which I then may not spot until slightly too late.

I'm sure each user would have their own list - but these are my own #SmartGuardFails and some of the techniques I have tried to fine-tune the alerts and levels to work around them. It's interesting how irritating these odd occasions can be, and I suspect it is only because, well for me anyway, SmartGuard has worked so *brilliantly* for so much of the time that they really stand out.

If you have any MM640G SmartGuard tips and tricks of your own (or any other comments or questions), please leave a comment below.

Diabetes breakups

I'm sorry. I wish it hadn't come to this, but I'm afraid it's over between us.

I don't know why you are looking so surprised - you must have known this was coming after how things have been between us over the last few weeks.

We've been inseparable for so long now. Hardly a day has gone by in the last 5 years when I've been apart from you. All those times we've shared. All those adventures. All those scrapes we have got through together. And now it's come to this.

I know the polite thing to say is that this is down to me, but we both know that isn't the case here. It's not me, it's you. You've changed - and not in a good way. It's not just me that thinks so. Our friends have noticed the change in you too. And I'm afraid I can't go on living with you like this. You have let me down, when I needed you most. And then when I forgave you and tried to go on as before - you just went and let me down again, and again. And now I hardly even recognise you. I just don't know who you are any more.

Maybe you are looking for someone else? Someone with deeper pockets maybe? I hope you'll find someone for your future, but I know for certain that it isn't me - not while you are behaving like this.

And it breaks my heart, because we have been in this together for so long. Perhaps I came to rely on you too much? There were times when I thought I could accomplish anything as long as you were by my side. But now? Now I'm just waiting to be let down. Waiting to be abandoned. I can't trust you - and I can't be with someone that I can't trust.

I'm not angry I'm disappointed. And angry.

So I'm sorry, but I've found someone else.


For those who have *no* idea what I am going on about... after many years of faithful togetherness it seems that Fruit Pastilles (my pocket-based hypo remedy of choice) have changed their formulation. Over the last fortnight I've had to ditch large parts of several packets which became an unusable gooey mess covered in irremovable tinfoil, occasionally plastered to the inside of my jeans pocket. Nice. The worst discovery was during a training run for my forthcoming 10km road race in support of INPUT. Feeling a bit low and discovering half the remaining pastilles rendered useless 5km from home put me in a pretty tight spot for my run back.

Possibly one of the most inexplicably stupid things I have ever done diabetes-wise

My blood glucose readings, yesterday.

Well... here's a thing. And I still can't actually quite believe that I did what I seem to have done.

The setup
Last night we had a smallish portion of spaghetti as our evening meal. This I realise for many would be a complete no-no, but pasta has typically not been the nightmare for me that it is for many. After little experimentation and tweaking I have managed to work out a reasonably successful strategy so it no longer fills me with dread - we eat it maybe once a month.

My approach (depending on recent results) usually involves a 2.5 hour dual/combo bolus at 60:40 for the calculated dose plus an extra 1u. Previously I'd also needed an extra unit up front too, but had dropped that about 9 months ago following some post-meal dips.

More recently my previously solid post-meal performance has been *slightly* marred by a smallish rise something like 4-5 hours after eating (when the majority of the bolus was waning) so yesterday I decided to rejig my approach a little since I have a Libre sensor in at the moment and can watch what's happening. So last night I went for the calculated dose+1u as 40:60 over 3.5 hours and added the extra unit up front and watched and waited.

Annoyingly I was starting from 8.3, but spaghetti often takes a while to get going for me so I wasn't unduly worried. Stayed pretty steady for the first hour then rose gradually by about 1.5mmol/L towards hour 2. Stupidly during this time I decided to confuse matters by bolusing and nibbling on some snacks that were circulating. By about 3hrs after eating I was 5.2 with vertical down arrows (and DW still chugging away) so I gulped some precautionary Lucozade. Headed off the hypo fine, but then my BG rose and flattened at 8.5-9.5 for an hour and a half (presumably spaghetti kicking in at this point). Then inexplicably at 4.5hrs post-prandial (10.30pm) I had another unexpected BG 'kick' up to something like 11.5 so, getting a little frustrated, I whacked in another unit despite considerable IOB (insulin on board). Sat and waited until midnight and the Libre trace was pretty flat in the 10s-11s - no sign of the 1u or IOB making any impact. Just after midnight I topped-up my IOB to make it the 2u I had intended to go to bed on to counteract the remaining spaghetti fallout.

Just to recap: Spaghetti is usually pretty predictable and not a problem. Added complication of snacking/bolusing/dose stacking/dipping/(over)treating *and* trying a new system all at the same time.

But we've STILL not got to the stupid thing...

The stupid thing
One of the great things about the Libre for me is the ability to see what's going on overnight. And also that if I happen to wake, even for a moment, I can scan and check levels in a way that I simply *do not* do if it requires me to fingerstick test.

I checked at 4am and had been pretty much flatlining around 9.5 since 1am. No insulin left on board. I consulted Artoo who suggested a correction of just over a unit, but I wanted to err on the side of caution so I went for a manual bolus of 0.9u (about two thirds of the recommendation).

I woke three hours later a little groggy and scanned for the Libre to read 'LO'. Artoo showed nearly 2 units of insulin on board.

Ehhhhh????

Checked downstairs via BG meter which confirmed BG was 2.2mmol/L. Bewildered and glugging Lucozade I tried to make sense of the situation...

Checking my bolus history I read that at 4am I had bolused not a cautious 0.9u, but 6.0u. Six units. SIX! My BGs had, not surprisingly, dropped off a cliff around 5.30am.

I simply cannot understand how I managed to do that. Even though one figure is very like an upside-down version of the other, I can't believe I could have made that error as all the buttons etc would be on the wrong side of my robot counterpart if I was holding the pump upside down.

But however it was that I managed to construct that error, there seems no denying that I did it.

And it's not one I'm wanting to repeat any time soon!

6.5% A1c target - A reply to a comment that got out of hand

I've had a couple of comments on my post about the proposed new HbA1c to aim for in the draft NICE guideline that is currently out for consultation. I was rattling in a 'quick' reply, when I thought - this is *ridiculous*. I can't even see this any more in this tiny box - so I've decided to post it here instead :)

Here are the comments:

Tamer Hassan said...
how do you achieve these numbers?

thanks

Tim said...
These numbers are impossible to reach...
Or at least give me some suggestions on how to reach these levels. Thanks.
Tim

'How to reach these numbers' is a question for your healthcare provider really. Don't just ask some random nutter on the Internet! However (and desperately trying to avoid sounding like Mr Smug of No 22 Smug Gardens, Bigheadshire) I have had a sub 6.5% HbA1c for over 3 years now, so I know that it *is* possible if only perhaps for the lucky few. Plus I've never had fewer hypos in my life with diabetes either - so it's not that I am 'paying' for A1c improvements with the hefty cost of Severe Hypoglycaemia.

I cannot really tell why some people seem to put in so much effort and get such scant rewards, and that is why I think individualised targets are SO important.

But it does seem pretty clear to me that the closer you can get to those standard-issue BG targets (5-7mmol/L waking, 4-7mmol/L pre meals and <9mmol/L by 2 hours after meals) for as many days in the week as you can manage, the closer you will get to these kind of tough, aspirational, borderline non-diabetic A1c targets. My own HbA1c has fallen by around 1.5% in recent years, and I think only around 0.5% of that is attributable to the pump - though Artoo has gone a LONG way to reduce my number of irritating low-level hypoglycaemia dips. When I look back over the changes that I have made in recent years I can see a few things that I think were important. I don't offer these as any kind of guide or advice - it's just what I did.

1. Education. Get access to proper structured education regarding diabetes management. In the UK we have DAFNE which is highly thought of, but other options are available. Things that should be included (in my opinion) are:
   
   1. carbohydrate counting, working out how to check and change insulin:carb ratios for different times of the day
   2. SMBG technique - when to test and what to do with the results *including* basal testing to PROPERLY adjust basal on an ongoing basis
   3. correction factors - when and how to correct (with insulin or fast-acting carbs) to aim bring you back into range without jumping aboard the gluco-coaster
   4. exercise and alcohol
   5. dealing with illness
   If structured education courses are not available in your country/area you can do a lot worse than buying 'Think like a pancreas' (Scheiner), 'Type 1 Diabetes' (Hanas) or 'Pumping Insulin' (Walsh/Roberts) which cover much the same ground. Though the benefit of peer support in group sessions should not be underestimated. Alternatively look at the free BERTIE online course.




2. Test more often AND RECORD THE RESULTS. Find some way of keeping notes daily as you go along. What you are eating, units and timing of doses (how long before... split doses...), exercise, mood, everything! Without a fairly detailed set of records I find it impossible to see what is going on. Personally I still love mySugr for this.




3. Gadgets - seek out new tech that can help you manage your diabetes more easily. It might be a 0.5u pen; a smartphone tracking app, or copy of 'Carbs and Cals'; or it might be a BG meter with a bolus wizard so that you can have properly fine-tuned ratios without having to worry about keeping the maths easy. Additionally, ask your clinic about access to Insulin Pump therapy and CGM.




4. Seek peer support - join a forum or two, join Twitter, read some blogs (thanks!) or even *crazy!* join a local group and meet face to face. Living with diabetes is tough, but it's even harder if you are battling on your own. For everyone there's a little corner of the internet that can provide support, encouragement and shared experiences.

At the end of the day we each have to find our own balance between living a life and managing our diabetes. Somewhere in the middle you'll find your perfect A1c and it won't drain all the joy out of life to reach it.

Good luck :)

Uncertainty Tennis

I found myself playing 'uncertainty tennis' again earlier this week. Perhaps you don't call it that... 'paranoia ping-pong' maybe? Or possibly 'confusion Kerplunk'. On the other hand - perhaps it's just me... And no one else ever catches themselves doing this?

The game begins some time before it starts, usually at least a day before, often more. You make a treatment decision based on what we long-term pancreas impersonators hilariously think of as 'what normally works', except that, on that day, it doesn't. Undaunted, you take some more insulin and/or carbs that 'should sort this out'. Except that it doesn't either. Or the next thing. Or the next.

Now that the groundwork is in place, the game can begin in earnest. Evenings are my favourite time to play, since that is the time of day when I eat the widest variety of meals often with the highest carb load.

Play.

First serve the other day was a carefully carb counted plate of pasta. A meal I have often eaten without suffering undue BG chaos for many years (yes I know... odd isn't it). Bolus delivered and food eaten. 15 all.

An hour an a half later, since things have been a bit unreliable over the last couple of days I decide I should check post-meal just to see how things are going. BG well into double figures. Darn. And pasta has a reputation for being very slowly absorbed too! And I didn't even muck about with extended bolus, blah blah blah. 15-30.

Now I know that the meal dose is still chugging away. But I also know that I really shouldn't have shot up this much by now. Artoo thinks there is plenty of IOB (insulin on board), but from experience it seems that would only be the case if I'm 8 or 9 at this point, rather than 12-point-annoying. Override the advice and whack in another unit. 30 all.

Another hour passes and I come over all hungry. Hmmm. Best be on the safe side. Low 10's. Well OK. Not low then. Still quite a lot of IOB though. And I *did* override. Sit tight or do something else? Pasta will still be going strong right now, won't it? Will it? 40-30.

Then a stunning approach shot... 20 minutes later and for reasons I can never fully explain I pop in another .7u - Deuce.

The crowd gasp! I've stopped testing now and I'm playing on instinct...

Too much IOB now surely? 2 Fruit Pastilles.

Then a minute later another one.

Still don't want to test. Too many out of range numbers today and I just don't want to see another in either direction... It's like whatever action I've just taken immediately feels wrong so I have to counteract it before it has a chance to take any effect.

Third of a unit.

Swig of lucozade.

Biscuit.

Too much surely?! Half a unit. The crowd are in their feet... (I'm milking it for comic effect now).

Finally after several hours, I can resist it no longer. I check again. 5.whatever with umpty units IOB, plus the last few lots of feverish carb corrections and whatever pasta remains still ticking away. Not only that, but (based on which part of the last two day's numbers I consider to still be applying tonight) I could quite possibly expect to rise, or fall, OR stay perfectly level overnight.

So bedtime looms and I have to decide whether to take it to the tiebreaker and wait up for some (most?) of the IOB and/or onboard carbs to work their way out along with whatever I decide to guess at to mop up the remaining IOB.

Or I simply munch a little something, retire, and hope for the best!

I am fully aware that my evenings of 'uncertainty tennis' are largely my own doing. Without a CGM, and when things have shifted such that I have little confidence in what I think ought to happen with a dose or correction I find it all too easy to slip into a rapid rally of insulin and carb corrections.

It would be easier to resist if I hadn't had so many evenings when 'just leaving well alone' meant I spent 4 hours in double figures only to eventually correct with what I had thought of doing in the first place. That and the fact that I've played some amazing games in the past where I've aced a high or low BG into flatline submission with some audacious... erm... 'shots' (sorry!).

Strawberries and cream anyone?

The 'busy bar staff' tip - DBlog Week Day 5

Today's topic for Diabetes Blog Week is all about hint and tips - Share the (non-medical) tricks that help you in the day-to-day management of diabetes.  Tell us everything from clothing modifications, serving size/carb counting tricks to the tried and true Dexcom-in-a-glass trick or the “secret” to turning on a Medtronic pump’s backlight when not on the home-screen (scroll to the bottom of this post). Please remember to give non-medical advice only! (Thank you Rachel of Probably Rachel and Kelley of Below Seven for this topic suggestion.)

Busy bar staff. Bustling restaurants. "Diet coke please" I shout over the ruckus at the bar and hope that the person taking the order heard properly and is being careful to put their thumb on the right button on the nozzle. But then, some time later a BG test reveals that it was the regular, full-on, carb-laden version instead. Never a happy moment. And the uncertainty of it *always* crosses my mind when I order a diet drink in a bar or restaurant.

Many people seem able to taste the difference between the two, but I've never been able to be sure. I knew for years that you can use urine glucose testing strips to check, but I never quite got around to going and getting any. But the solution is actually far simpler than that. In the unlikely event that anyone reading hasn't had this idea themselves already, here's a tip I picked up a year or two ago from a forum which I have used ever since:

Whenever I get my diet drink order, I just dip my finger in the top of my drink. Within a few moments the liquid will begin to dry. A full-sugar drink will make your fingers go sticky whereas a diet drink won't (the gaps between my fingers seem particularly good at sensing the stickiness).

Simple, effective and no equipment needed.

Getting animated

I was remembering back to my heady art college days recently, particularly some early experiments with animation. Animators at the Disney studios developed 12 principles of diabetes animation in the 1930s, including anticipation, follow through, slow in/slow out and, of course, squash and stretch. All these seem to have an uncanny resemblence to how my blood glucose levels have been behaving.

From time to time (read more or less constantly) I seem to go through periods of change where I need tweak various doses, ratios and settings in order to get them to behave normally*, so that the dose and timing of insulin for a meal which worked perfectly last week might be expected to work again for the same meal this week - in the SAME way (craziness!).

* I realise, of course that this has no actual meaning in day-to-day diabetes management terms. But it is, nevertheless, a nice idea.

An obvious one might be during a period of illness. You expect your insulin requirements to increase at some point, to some unknown level... but it's very difficult to actually anticipate with any certainty what the change might be and when it might happen. Even with illness, some coughs and colds behave completely differently to others BG-wise. Some are all up front. And it's only later when the sore throat appears that you understand why you've been fighting double figures (200s for US readers) for days. Other times you can have all the symptoms of a stinking cold, but BG just potters along entirely unaffected. Then if you have needed to up all your basals and/or doses, you know that at some (again unknown) point in the future you will need to rein them all back in again or you'll be landed squarely in hypo-central.

Another favourite is a fall-off of gym visits during a school holidays. I'm just coming into that now - the girls break up for Easter today. As the rhythm of the house changes I find it all but impossible to get up and out early enough to get to the gym and still be able to start work on time. For the first week things often toddle along as normal, but then one day in week two BAM! It's as if my insulin has turned to water. So I try to make sensible, small changes to basals. Enough to have an effect, but not so much as to go too far the other way. The constant balancing act. This usually involves a frustrating few days of doing battle with double-digit readings, however careful I am being with food and carb counts.

More recently I have also noticed an unusual phenomenon which I will be watching with interest this time. In animation 'slow in/slow out', 'squash and stretch' and 'follow through' refer to a more realistic way of handling movement. Movement tends to begin gradually, then accelerate, then slow again into changes of direction. You can almost feel it in yourself as you move about. Squash and stretch and follow through relate to the way animated objects often appear more satisfying if there is a little elasticity added. Rather than just stopping hard at the end-point there's a little extra movement beyond it and then a bounce-back to rest.

This seems to be exactly what happens with my dose tweaks too. I battle with highs for days struggling to find the right level of increase. Then I find it and I get perhaps a day or two of good numbers. But then I seem to get a little 'bounce back' and have a day of low readings where I have to dial the adjustments back down again to counter. And then things settle. At least for a while... before we're off again.

I think it's important for Healthcare Professionals to understand the relentlessness of these daily adjustments when they peer rather disparagingly at a printout of ropey numbers. There is no 'right' set of ratios and correction factors, only 'right for now'. This darned condition doesn't stand still for a minute and all the time you are playing catchup you are logging results that are outside of what you'd like to see, not because you are not trying hard or putting the effort in, but just because the rules have changed. Again. If I get a settled week or two I count myself lucky. But I know that membership of #teamsmug is usually very short lived.

That's all folks!

Cook & Count Carbs - App Review

I was really happy to be asked to take a look at a new app for iPhone (an Android version is coming soon) which immediately sounded like a Very Good Idea.

More and more these days we are reminded that heavily processed foods, while convenient, are generally poor food choices. Even without the revelations regarding the 'so hungry I could eat a horse' frozen-microwaveable-lasagne-for-one fiasco, most of us realise that food genuinely tastes better and is much better for us when it isn't jam-packed full of chemicals from the darkest corners of the periodic table in order to give it a half-life on the shelves, or permit a 'low fat' (don't get me started) label on the front.

Real food, made from real ingredients. Lovely.

For those of us juggling busy lives and diabetes though there is the added complication that those nasty chemical-laden packaged foods tend to come with a very handy grid of information providing the all important carb count. Cooking from scratch is great, but trying to get an even vaguely accurate carb-count for what ends up on the plate can be a bit of a bind. Well not any more!

Cook & Count Carbs focusses on doing one thing well. It doesn't fuss about with calories or offer nutritional info about fats, proteins or other micronutrients*, but allows you to very quickly look up individual ingredients or build complete recipes and then work out carbs-per-portion for however many people you are dividing it between. (*Update: The app has since been upgraded/updated to allow you to track calories/fats/proteins/fibre and other details if you would like to, or just stick to carbs-only)

I have fallen foul of the promise of carb-lookup functionality a few times before. Some apps use lists which are based largely on foods and brands only available in the US, others require an active network-connection to access the data. My favourite waste of time so far was an app that allowed you look up a huge range of ingredients but only allowed you to indicate quantity by 'serving'. So you could choose one, two or nine 'servings' of wholemeal pasta and get a carb count, but absolutely nowhere did it specify how much pasta one should cook for an individual 'serving'. Utterly useless.

Thankfully C&CC is a lot better thought-through than that. There is a pretty comprehensive list of ready-made choices for both raw and cooked foods, all available by weight (grams or ounces depending on user preference). Brilliantly the app also allows you to define your own 'custom' ingredients from the food-labels on the stuff that you actually buy if that turns out to be missing, or significantly different from the predefined list. And you can use it anywhere... fully networked city centre apartment or a farmhouse in the back of beyond.

You carry on adding as many ingredients as you want to and then flick to the 'total' screen which allows you to divide the whole recipe into as many servings as you are expecting. This number isn't fixed, so if you decide to divide into more or fewer portions later on, or the next time you prepare the meal, you can easily get an updated count.

You then have the option of saving your recipe to refer back to in your 'My recipes' section. You can add a photo of what it should look like and even add detailed notes on how to prepare the recipe if you wish. One slight quirk is that you can only edit a recipe you have previously saved if you have added at least one 'Method' entry. Once you have done that (even if it only says 'Method' ) an edit icon appears below the recipe and you are able to amend and update any quantities, add or remove ingredients and then save a new version if desired. For keen social media types there is also the option of sharing via Twitter.

Also inbuilt into the app are a collection of existing recipes from starters, mains and puds to low carb & gluten free, as well as an 'info' page with articles, tips and additional information.

The interface is quick and intuitive and I have found it equally handy for a quick 'ready-reckoner' look-up of an individual ingredients as well as calculating more complex and complete meals. It is hard to imagine how the app could be improved - and that is a very rare thing for me to say. At the current price of £3.99 it is not the cheapest, but if you like the idea of cooking from scratch without the mathematical acrobatics it is well worth considering for the price of a couple of coffees.

Final score: 5/5

Disclosure: Deborah Wilder and Health Apps Ltd very kindly offered me a free copy of the app for review, which I was allowed to keep. I was not asked or paid to write this post, and only did so because I thought the app was bloomin' marvellous!

The consistency conundrum

Christmas is an interesting time of year to play at being your own pancreas.

The main Christmas Day meal itself is usually *ahem* relatively easy (especially since I adopt the traditional standpoint of 'no carbs count' for Christmas and birthdays). As meals go, it is big... it is rich... and it will probably involve a pudding the size of a bowling ball... But it is basically just a roast dinner and it is only one day - and you can't expect perfection all the time right?

However, on an alarming number of occasions either side of the 'big day' I find myself faced with my own particular food nemesis - a creaking table full of buffet nibbles. Each little carb-laden, high-fat morsel smiling sweetly up at me daring me to have a go. A festive tipple or two to blur my judgement and weaken my self control and you can see that these meals fall firmly into the 'high risk' category.

Which is quite an odd way to look at food really... But I've been doing it so long that I hardly realise I am doing it.

Over the years it has seemed logical to me that consistency in terms of food intake is likely to be a good strategy for Blood Glucose results. It makes sense surely? Eating similar quantities of similar foods should allow me to try out a number of dose and timing variations until I find one that works. Then I can eat that same meal any time, and get perfect results. Tried. Tested. Predictable. Easy! Other meals are much harder to calculate (read: wildly guess) and almost come with an inbuilt expectation of BG chaos. If you are going to enjoy these... you do so knowing that levels are likely to be less than perfect.

Except that it doesn't actually work like that. At least not for me, or perhaps just not all the time. And when it doesn't work like that... When an 'old faithful' lets you down catastrophically, while in the same week a 'wild stab-in-the-dark' guessfest comes out not too bad, you begin to wonder why you are bothering to make those careful choices in the first place.

When it comes to playing the BG boardgame (not so much Snakes and Ladders as Spikes and Hypos perhaps?), my diabetes, like some cantankerous elderly maiden aunt who hit the sherry early on is a big ole cheat. Not averse to completely changing the rules when it suits, or simply behaving in a completely baffling way. Even *if* I were to eat exactly the same items of food, in exactly the same quantities every single day. Even then, I still could not expect 'perfect' BG levels (whatever that means) to last for long. The consistency conundrum is simply that carbs, doses and timings are only a small part of the picture. There are a lot of other factors in play that can combine (or conflict) to significantly alter the outcomes for the most self-disciplined diet.

Douglas Adams summed up living with type 1 diabetes pretty well:

“The nearest approach the Guide makes to this matter is on page seven-thousand-and-twenty-three, which includes the words “expect the unexpected.” This advice has annoyed many Hitch-Hikers in that it is ‘A’ - glib, and ‘B’ - a contradiction in terms. In fact, the very best advice it has to offer in these situations is to be found on the cover. Where it says, in those now notoriously large and famously friendly letters, 'DON’T PANIC'.”
Douglas Adams, The Hitch-Hiker's Guide to the Galaxy.

In my heart I know that trying to reduce the number of variables involved in juggling my BGs is the 'percentage approach'. After a few days of winging it I usually have had enough misses for the illusion of SWAG invincibility to have worn off.

So I'm reeling my choices back in again, and aiming to lose some of the wilder swings I've seen over the past week or two. It will always be a balancing act. Along the line between complete dietary freedom at one end and monk-like self control at the other there is a place where each person with Type 1 Diabetes will feel comfortable, both with the food they are enjoying, the effort they are putting in and the results they are seeing.

Good luck in finding your own balance.

Ho ho ho-peful

Artoo and I began our little adventure just over a year ago. It has been as steep a learning curve as anyone ever suggested it might be. At times it has felt like I was newly diagnosed all over again, and despite 20ish years of experience with injections, there were weeks when that knowledge seemed to count for almost nothing.

A year ago I noted that in hindsight, perhaps beginning to completely change insulin delivery method immediately before one of the most challenging and notoriously chaotic times if the year foodwise might seem a little foolhardy. But in the current challenging financial climate it would be a brave man who would turn down the offer of NHS funding for an insulin pump without a very good reason.

Last Christmas was, if I'm honest, a bit of a mess BG-wise. Much as I stand by the general assertion among people living with diabetes that there are two days (Christmas and birthdays) on which and any carbs eaten don't count, the perfectionist in me delights in giving myself a kicking whenever dodgy results appear. Even when (and perhaps especially if) I'm sort of expecting them. I didn't get myself into any serious bother last December, but it was certainly not my finest hour. Since the Summer, and especially since changing the sets I use to Silhouettes (with occasional Quickset), Artoo seems to have really got into his stride. I had a pleasant surprise with an A1c improvement at my annual review, and if anything averages and SD have been slightly better since (with the occasional lapse obviously!).

I'm not naive enough to expect a Christmas entirely without an errant reading (or 10), but my trust in Artoo's judgement and general ability to accurately correct my mistakes has never been higher. As long as I can weather the basal-tweaking turbulence when the lack of gym visits kicks-in I am hopeful that I might be able to enjoy a few treats here and there over the festive period (along with the inevitable selection of wildly non-standard meals) and still keep a relatively decent hold of things. I can but hope.

Thanks to everyone who has visited and commented on our blog this year. It has been an eventful and exciting one in many ways and it has been lovely to share it with you all.

Have a brilliant Christmas and here's to unexpectedly good results this festive season and rock-steady BGs for 2013 all round.

Seeing red: Food labelling, traffic lights and missed opportunities

My heart rate was significantly raised this morning while at the gym. Not because of my less than challenging treadmill pace, but because of a news item that came onto breakfast TV about the new food labelling system that is expected to be in place by the Summer of 2013.

I wrote about the public consultation on the subject that took place in July 2012. At that stage I was full of giddy optimism that my eloquently worded appeal would result in a Marvellous New World of clearly labelled, impeccably helpful packaging that assisted the entire UK in making better food choices, but in particular supported the millions of people living with (or at risk of developing) diabetes of one form or another - something upward of 5% of the population by 2010's numbers. The people for whom this stuff really matters.

The precise details of the new front of pack splodges are still being worked out, but from what I've read my life is about to get just a little bit more difficult and I'm going to be very grateful that my phone has a calculator on it.

I don't really have a particular problem with the traffic light system as an infographic device, my concern is based mostly on the information that the current systems display, and in particular the obsession with listing 'of which sugars'.

Let's just get this straight, 'of which sugars' is an almost entirely useless piece of information. Well, not quite. If you were comparing two products side by side that were virtually identical in all other respects, then perhaps 'of which sugars' might be worth casting an eye over.

The Really Big Problem is that most people *think* they know what 'of which sugars' means. People will believe (because they have always been told that this is the case) that all food with lots of sugar in it will zoom straight into the bloodstream, while food with no added sugar will be absorbed more slowly. Like most of the best misconceptions this opinion persists because it is almost true. Food with a large amount of added sugar is likely to hit your bloodstream fast. But there are many many foods which are broken down significantly faster than sucrose. And the REALLY Really Big Problem is that many of the foods that break down in the gut faster than sucrose (table sugar) are the very same ones that people think of as being 'healthy'. Brown or wholemeal bread, for example... Pretty much any breakfast cereal you can think of... Mashed or baked potato...

The Glycemic Index (or more helpfully the Glycemic Load which takes portion size into account) is a measure of how disruptive a food is likely to be to blood glucose levels. To measure GI a smallish number of test subjects are usually given 50g in carbohydrate of a particular food and then their blood glucose levels are measured to establish how fast the energy in the food hits the bloodstream. Simplistically, all carbohydrate is made up of units of monosaccharides (glucose) joined up in chains. The easier it is to break down the chains into glucose, the faster it will be absorbed. On the GI scale, pure glucose scores 100. Sucrose, table sugar scores a 'moderate' 60. Despite it's 'starchy' reputation the carbohydrate in wheat is very readily broken down and there is far less difference between white and brown versions than we might hope for - exact values will vary, but wholemeal bread is likely to be between 68 and 78. Yes, that's right... gram for gram of carbohydrate it's faster than sugar. When you begin to look at breakfast cereals things get even more bizarre as far as the 'of which sugars' is concerned. Cornflakes weigh in at a blistering 77-93, while Crunchy Nut drop a little at 72 and Frosties score a mere 55. These breakfast cereals will be slowed a little when eaten with milk, but completely counter-intuitively the ones with added sugar are *slower* than those without, presumably because the corn itself is so darned fast.

That's not to say that any of the foods I mentioned are necessarily 'off limits' for a person with (or without!) diabetes - but I really think we need to get over our obsession with sugar in this country and especially where food labelling is concerned. A low 'of which sugars' does not make something OK. It cannot be relied upon as a marker of how quickly the carbohydrate in a food will pass into your bloodstream at all. And for a T1 person playing at being their own pancreas, or a T2 attempting to eat in a way which helps their wonky metabolism this stuff really matters.

From a carb-counting type 1 perspective the proposed changes are also incredibly inconvenient. This fatuous obsession with the display of 'sugar content' means that prepackaged foods will, most likely, no longer display total carbohydrate content per portion, certainly not on the front of the packs. Sainsbury's made this change some time ago adopting a 'traffic light' system and it bugs me every time I need to eat something of theirs. I find myself scrabbling around on the back of the pack for the 3.5pt 'per 100g' details then have to fish out a calculator and endure some mathematic acrobatics to evaluate what my portion of a 326g pack will end up being in terms of carbohydrate. And it used to be just written there in big letters 'per serving'.

Of all the groups of people in the UK with a borderline obsessive interest in what food contains, the ones who stand with furrowed brow in supermarkets poring over pack labelling smallprint more often than perhaps any others are those living with diabetes. This initiative *could* have made our lives easier, it could have included GI indications as standard, and scored total carbohydrate as a proportion of Guideline Daily Amounts so that people went easier on carbs generally. Who knows - that could have saved 1000s of people from developing T2D in the first place if their metabolisms are already beginning to struggle. Instead we are stuck in the same old rut of sugar=bad, fat=bad, carbs=good which just isn't helping anyone.

I await next summer's pack designs with a heavy heart.