Another Non-invasive BG Meter?

Stumbled across this yesterday. I'd heard rumours of this new non-invasive BG monitor a while back, but it looks like they are gradually creeping towards a finished product.

It's not a continuous monitor (so can't offer trend arrows on the device or any kind of automatic alerts) but *is* measuring blood glucose values so, perhaps, might be sufficient for DVLA. Measurements look to take 10s and are made by passing radio waves through thin areas of skin such as your ear lobe, or more likely that stretchy bit between your thumb and fingers.

Results are displayed on the device and can be blue-toothily uploaded via a smartphone/tablet app to a cloud-based software platform. The app promises to use the uploaded data "to calculate and forecast immediate trends in your blood glucose levels, allowing you to adjust your food or medication intake according to your activities or how you are feeling". Sounds promising, but a bit wishy-washy and vague in terms of what that might actually *mean*.

The non-invasive nature means, of course, that you could monitor your BG many more times a day without burning through strips. Ideal when waiting for BGs to come up (or start dropping) and allowing some of those 'sugar surfing' techniques (is it just me whose toes curl every time I hear that phrase?). Also pretty handy for testing on-the-go in situations where fiddling with strips and lancets is impossible, much like Abbott's Libre.

Currently in clinical trials and the website suggests it may be available for pre-order (whatever timescale that means!) at some point in 2016

Another to go on my long list of possible 'ones to watch'.

More details at www.gluco-wise.com/

Disclaimer. I have no relationship with the manufacturers of this device and I've not been paid to write this post or publicise the product in any way.

64 Days with the Medtronic 640G: Ep 9 Review - the best and worst of the MM640G

Well, this is it. The last of my posts covering my time with the Medtronic MiniMed 640G. Thank you so much for bearing with me over the last few months. Normal wittering will be resumed shortly. However, as seems to be the way of things with blockbuster franchises (HA!) I have split this last episode into two parts. Part (i) covers all the little niggles and irritations I had while using the MM640G, while part (ii) looks at the things I loved, and reviews my results including reductions (if any) in hypoglycaemia and an HbA1c I had done at the end of my time using the pump. HbA1c is the test which measures how much of the glucose in your blood stream has stuck to red blood cells. It is often used as a measure of your likelihood of developing the long term complications of diabetes.

For those who really can't bear wading through all those minutes of video I will summarise the results below. The video gives a lot more detail though, and features a fluffy bunny. What's not to like?!

When it comes to the things I really liked/disliked about the MM640G you will need to bear in mind that I am comparing to a MiniMed Veo. All of the really good stuff about pumps generally - precise basal patterns, advanced dual and square wave bolus options for tricky meals, ease of use, bolus calculator, temporary basal rates, precision of doses and correction factors, blah, blah, blah... are already assumed to be present and correct. Some of the things I loved about the MM640G are precisely because they fixed annoyances I found with the Veo. But more on that later. First:

The worst of the Medtronic MiniMed 640G

Those who have read any of my reviews before will know that I can get unreasonably irritated by the slightest things. It will come as no surprise then, that while I generally loved the MM640G both with and without sensors, there were a few things about it that drove me nuts.

1. Pump lock
   After a few minutes the pump automatically locks and most interactions require you to play an annoying 'press the right button' game. This is no good if you are in a hurry, and is not an option that can be turned off.
   
2. Change of orientation
   It's now 'portrait' not 'landscape'. As someone who wears an insulin pump on my belt this is a bit awkward.
   
3. No small versions
   Medtronic have now abandoned plans to produce a smaller version of the pump. All MM640Gs will now have the little sticky-up bit to accept the larger reservoirs. The smaller reservoirs can still be used, but at present, with approximately 35u/day usage, the 'how full is my reservoir' icon on my status bar is pretty much permanently red.
   
4. Sensor overtape irritation
   The glue used on the sensor overtapes (and also the little patch that holds the sensor down initially) caused a red rash to appear after a couple of days of wear. Initially it was only toward the end of a sensor but in the end it began pretty much at day 2. I used an alternative dressing, but even that was pretty itchy. Weird - because I don't usually react to adhesives at all.
   
5. Sensor swap delays
   From start to finish swapping a sensor takes around 3 hours to begin providing new continuous data. That's a looooooong time!
   
6. Occasional sensor lag
   Mostly I found the sensor accuracy was brilliant. But sometimes, particularly if I treated a low to try to fix a below target BG reading, the sensor was a little slow in responding (perhaps 30 minutes behind reality). Additionally calibrations by BG meter do not necessarily reach up to match sensor glucose and BG fingerstick value, but often end up with some odd half-way house. If the sensor glucose value had drifted a little there were even occasions where calibration triggered an 'alert before high' which was doubly annoying.
   
7. Sensor Glucose Review
   The one-day graphs which allow you to flick back through previous days' results show no indication of SmartGuard interactions or insulin doses. Makes them about 10% as useful as they could have been.
   
8. Home screen without sensors
   For no apparent reason, the icons in the status bar do not align neatly when using the MM640G without sensors. There's a gap where one of the sensor icons(!) would go, which makes it look untidy and poorly considered. The enormous dotted line 'we have no BG information to show you' panel where recent meter BG readings go (when not using sensors) also irritated me more than strictly necessary. Just doesn't feel like the visual look of the home screen for most UK users, who will be using the MM640G without sensors, was given enough finesse.
   

Watch the video

The grumbles, gripes, and irritations - everyone will have their own, I'm sure.

The best of the Medtronic MiniMed 640G

Whether you use the MM640G with sensors or not there is a LOT to like about it. There are all sorts of little, pleasing improvements in the interface and options that make a massive difference. Add the wizardry of SmartGuard into the mix and things are taken to another level - but even without there are lots of tasty treats for non-sensor users.

1. Setting basals and temp basals
   There are now up to five basal patterns on the MM640G, and brilliantly you can copy entire patterns from one 'slot' to another to experiment with and then switch back if you need to later. The patterns also come with helpful names to keep track of which are which: Work Day, Day Off, Sick Day, Pattern 1, Pattern 2. Which pattern is set is not marked on the home screen, but thankfully setting any of them does not cause the 'alert circle' to appear like it did on the Veo.
   
   Temp basals can now be set in 15 minute increments for more precision and alter up and down by 5% at a time making them much quicker and less fiddly to set.
   
2. No TBR 'chime'
   Setting a Temporary Basal Rate no longer causes the pump to issue a useless wittery alert tone every hour, which means you can ACTUALLY USE THEM OVERNIGHT! In even better news - the end of a TBR is now indicated by a single beep. Brilliant!
   
3. Different Alert Tones
   There are now a series of different alert tones to indicate different things. There were a few on the Veo, but so many overlapped with either 'pip-pip-pip' or 'naah-naah-naah' that I find it much easier to work out what is going on on the MM640G without having to check the pump for 'information' alerts and being alerted (ha!) to things that actually require action. The ability to increase volume has also significantly improved.
   
4. No lockout during bolus delivery
   It is possible on the MM640G to do rather more things during the time while a reasonable sized bolus is being delivered - for example you can set a TBR. The Veo made you wait until the bolus had finished before allowing you to do anything (other than stop the bolus!). This meant I could group my pump interactions together and then get on with life, rather than having to wait around tutting.
   
5. Screen visibility in sunlight
   Really, really good - especially compared to some other colour-screen diabetes gadgetry I have tried. Not perfect from every angle, but really easy to turn a little and see very clearly even in direct sunlight.
   
6. Remote boluses from BG meter
   Not a full remote control with bolus wizard, but a really useful standby when digging your pump out from within clothing is impractical or inconvenient.
   
7. Waterproof
   Now rated as IPX8 - up to 12 feet of water for up to 24 hours.
   
8. SmartGuard - overnight hypoglycaemia
   Unsurprising if you have watched my Overnight Hypoglycaemia post, but SmartGuard overnight for me was a real stand-out winner. No readings at all for 9 weeks below 3.5mmol/L overnight, and hardly any below 4.0mmol/L. Some nights almost no basal insulin required, and others requiring my more 'usual' 6-7 units at night. Looking at the results it's hardly surprising I had so many problems and so much Severe Hypoglycaemia during my years on Lantus!
   
9. SmartGuard - results overall
   When compared to averaged results from 10 weeks of Libre sensors (the only other 24 hour data I have) time in hypoglycaemia fell by 90% during my 9 weeks with the MiniMed 640G. At the same time my overall levels, as measured by HbA1c fell by 0.3%. And all this with less effort and very little 'alarm fatigue'.
   

Watch the video

Improvements to the pump (with and without sensors) and the all important results.

Conclusion

It has been a great privilege to experience the MM640G system, and for me the results were spectacularly good. The comparison with Libre data is an interesting one, particularly where hypoglycaemia is concerned. Times wearing a Libre sensor were previously my 'best ever' results-wise. The ability to spot hypos coming during the day and try to head them off (I generally scan a Libre sensor something like 30-40 times a day), plus the ability to spot low levels overnight and make hurried basal rate changes meant that I generally had fewer hypos on a Libre than I would normally. And yet when compared to these data, the MM640G system reduced my time spent in hypoglycaemia by 90%. To be clear, that means that for every 10 minutes I spent below 4.0mmol/L trying my very hardest with a Libre sensor, I would spend only one minute when using SmartGuard. That and my HbA1c dropped over the same period from 6.3% to 6.0%. 0.3% - it's not a huge margin, but those fractions are pretty tricky to shave off once you get down below 7.0 in my experience.

My only hint of melancholy about the whole experience is, of course, the eye-watering cost of full-time sensor coverage (approx £3,500 per year inc transmitter). It's not something we as a family can afford, and full time CGM on the NHS is reserved for those who really need it most - and rightly so.

It feels a little like being given a chance to live in a multi-million pound mansion and drive an Aston Martin for a few weeks to see how I like it. I may think it's brilliant - but the reality is that it's not really an option that is really open to me long-term.

I have a pump clinic coming up in a week or two and will see what they say about the results - particularly my unpredictable and occasionally lengthy periods spent below 4.0 overnight. These do nothing to help my efforts to keep my Imparired Awareness of Hypoglycaemia under control. I may ask about the possibility of part-time sensor coverage. Even a few months in a year would make a massive difference (as long as the transmitter continued to function, of course).

My Veo is nearing the end of its warranty period, so I am looking to the future. I have some thinking and some sums to do after this experience - depending on what my clinic say.

Final verdict (with sensors and SmartGuard): 5/5
Final verdict (without sensors): 4/5
Final verdict (considering self-funding sensors): 4/5*

* because of Dexcom's more 'stretchable' reputation when it comes to sensor life

Disclaimer: I was offered a trial of the Medtronic MiniMed 640G system for 64 Days with full sensor coverage so that I could share my opinion and experience good or bad. I was not paid to write this post, and if I had thought the pump was terrible I would have written that. I was encouraged (not required) to post video blogs about my experience, but Medtronic did not have any control over what I posted.

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.

64 Days with the Medtronic 640G: Ep 4 SmartGuard vs Mountain

We have just returned from a wonderful holiday among the Black Mountains, Brecon Beacons and Cambrian Mountains in the middle of Wales. The weather was as mixed as you might expect, but we did grab the opportunity of one of several gloriously sunny days to walk the popular path up Corn Du and Pen Y Fan which the walking guide proclaims to be 'the highest peaks in southern Britain' (presumably Snowdon counts as ooop North).

It seemed like a reasonable 'test case' for SmartGuard and exercise for me. Things were a little complicated by a fairly active morning with a fairly hefty Temporary Basal Rate which I had slightly overdone so as to be confident to drive, meaning that I approached lunchtime in pretty much double figures (180ish for US readers). Often I would choose to reduce my pre-exercise meal bolus a little, because I tend to get very sensitive to any active insulin once I start moving. I didn't want to do that this time though as I was fairly high to start with and in some dim corner of my mind there is something squirreled away about exercising at high levels being Not The Best Idea.

So there you go... the scene is set, the reality TV style 'manufactured peril' is in place (Solemn face to camera... 'But exercising at those levels, and with all that insulin on board - just what will happen')...

Let the drama unfold.

Oh, and as if that were not enough excitement, you may notice I am sporting an impromptu 'holiday beard' in this video. Feel free to express your opinion, hilarity or horror at this unexpected turn of events by voting #beardyes or #beardno in the comments.

Thanks, as ever, for watching.

Any questions or comments, please leave them below.


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Half unit Lantus insulin pen free on prescription - at last!

Thanks to Twitter's @ColonelBlightly for use of the pic.

About bloomin time!

I had heard about this some months ago, but then promptly forgot about it.

In April 2014 Sanofi launched the JuniorStar, a 1-30u insulin pen that can be used with Lantus (glargine) insulin and delivers doses in 0.5u increments. Woooo hooooo!

During my least years on MDI, wrestling Lantus into submission was more or less a full-time hobby. My basal requirement changes frequently in response to a wide range of factors (differences in general activity levels, warmer/cooler weather, or more frequently... just because it feels like it). On pump these tweaks are easier to manange, but more than once on Lantus I would seem to find myself in a position where a change of a whole unit up or down was just a bit too much, and I would have to settle for a Hobson's choice dose. It was particularly frustrating because of the 'some units are more equal than others' weirdness that I frequently see when my basal insulin dose is just a little bit out. A unit too much or too little of Lantus over 24 hours could leave me scoffing a massive stack of carbs to stave off relentless lows, or chasing high BGs with units and units of extra rapid-acting insulin corrections.

Diabetes is biology, not maths - and we can't always expect the numbers involved to behave in a predictable, logical way. This will be news to none of you.

So HURRAH to the fine French pharma folks for finally stepping up to the plate and launching a 0.5u pen. Mysteriously though Sanofi are yet another pharma company to market a half unit pen with a 'Junior' mindset (NovoNordisk did the same with the NovoPen Echo). It is as if only children could possibly find a use for half-unit increments. I can only hope that adult patients will not have difficulty* in accessing this potentially very useful addition to their Diabetes Gubbins stockpile.

EDIT: *Due to the ridiculous immediacy of the flow of information in the Twit-o-sphere, having posted this just a few minutes ago someone has already pointed out that the JuniorStar can be obtained directly from Sanofi, without the need to jump through tortuous prescription hoops and bothering your surgery/clinic. Simply contact the Sanofi helpline. Thanks to @davidcragg for the tip :)

Bubble, bubble, tubing trouble

Looking at my stats it seems Artoo has been having a bit of a run of form recently. Not without a wobble here and there obviously (let's not be silly) but certainly a decent punt at things on the whole, and far fewer eye watering levels in the 20s than in any of the months since I started on an insulin pump (which were never really part of my MDI experience). According to the funky monthly reports on my current BG logging app of choice (the excellent mySugr - 'making diabetes suck slightly less') my purple patch seems to date back to October. I even seemed to manage Christmas with fewer Quality Street induced gaffes than I would normally expect. Generally average BG in the high 6's low 7's (108-126), with an SD around the mid 2's (36). This makes me happy.

Aside from me taking a *very* long time to get used to the whole pumping business (Artoo was very patient with me) I believe there are a couple of changes which have helped me, so I'm posting this insufferably smug blog entry just in case there are any frustrated insulin pumpers who stumble upon it that are putting in all the effort but not seeing the results they are hoping for.

Firstly, September was the time that I switched infusion sets. I'd been having a fair few failures for some months, but only in amongst a majority of set changes that worked perfectly. At the time it was less obvious, but looking back, a readings/recoveries from mid 20s almost every month were messing things up for me. If you are getting set failures/site issues more than a couple of times a year it could well be worth asking your clinic/DSN/endo what alternative lengths and types of infusion sets are available to you. I've not had *one* site failure in the past four months - and aside from the lack of eye-frying levels, it also makes me feel a lot better about the whole business of diabetes day to day (as hard as I try not to part of me always takes these out of range disasters as a sort of personal failure).

Secondly, and my initial reason for writing this post, I think I have cracked the 'bubbles in the tubing' problem. Maybe not 100%, but pretty darned close. I'm not sure how common this is, but throughout my first year on a pump I was occasionally victim of a 'phantom bubble of doom'™. I'd fill the reservoir with room-temperature insulin as advised, having first moved the plunger up and down to lubricate the inside of the reservoir. I'd flick and jiggle for all I was worth until I was absolutely sure that there were no bubbles in the insulin. Fit the reservoir to the pump, and prime with the pump vertical, tapping all the while to ensure that any rogue bubble-ettes got expelled in the priming, and then connect everything up happy in the knowledge that I had achieved the perfect bubble-free set change. BUT. The next day, look at the reservoir and BAM, there it was a big, fat, lurking, bubble of doom. Ready and waiting to find its way into the tubing at some inconvenient moment and then effectively deprive me of basal for an hour or two. Or mess up a meal bolus. Or both. I do try to check my tubing a few times a day but these suckers are hard to spot. And just as frustrating as the high BGs they caused - was not knowing where they were coming from! I was as sure as I can be that they were not there when I changed the set. They just seemed to be emerging out of nowhere with an evil glint in their eye overnight.

I did discover a suggestion on You Tube, which I won't link here as it was a complete disaster for me. The technique (described as something like 'degassing the reservoir') involved creating a fairly strong vacuum in the insulin vial by repeatedly drawing air out of it until you could do no more. Do not try this! My experience is that reservoirs are just not designed to operate under that kind of pressure. On more than one occasion (and I only tried it about 3 times!) the o-rings failed and insulin began to leak 'behind' the plunger while the reservoir was in use. Complete BG chaos. But it did get me thinking...

If you too suffer from occasional 'phantom bubbles of doom' - here's what seems to be working for me. When you draw up the insulin into the reservoir it is usual to first inject air into the vial, equivalent to the insulin you are about to withdraw, to equalise the pressure. Instead of this only inject half of the air into the vial. Additionally you should make sure that you inject the air with the vial downward, then invert the whole caboodle to draw up the full insulin amount. Then flick and jiggle any bubbles that have crept in as normal. Disconnect the reservoir first, to allow the air pressure in the vial to normalise again. It seems that the very slight vacuum created is not enough to worry the o-rings, but is sufficient to make the insulin less 'aerated' in the reservoir. Or something. Anyhow, it seems to be working!

Obviously... Disclaimer, disclaimer. Not medical advice. Consult a qualified person. Don't try this at home. Read the documentation supplied with your pump. Simply reading this blog post may void your warranty etc etc.

If you have any top tips that you have discovered for yourself - please share them below :)

The diabetic half hour

Just having to rattle this one down. I've got several other 'proper' posts jostling in my head, but this one has just emerged and rudely pushed its way to the front...

Is it just me or do many other diabetics seem to spend an interminable amout of time just waiting around? I'm not talking those charming hours spent in the cosy nooks of a doctor's surgery or the peace and tranquility of a clinic waiting room - I just mean the day to day business of pretending to be a pancreas. The waits I am talking about always seem to last about 'another half an hour'.

Wake up, test BG, bolus, pour coffee. Look at watch and think, "Better wait about half an hour for that insulin to realise it's meant to be doing something useful before I take the rash action of eating something."

Lunchtime, test BG, bolus, see above...

48 minutes after lunch. Hmmmm I wonder if I guessed that dollop of whatever right. Bit early yet, better wait about half an hour before testing to allow for the dose/food to get going.

Oops, got that wrong. 9.something... If I walk to the shops that'll sort that out. Back from the shops. Wonder if that worked. Better leave it about half an hour for that sort of low-level exercise to have any effect I suppose.

Evening meal (inexplicably spared the need for a pre-meal half hour wait). Look at watch, 56 minutes since finishing. Bit early yet. Better leave it about half an hour before seeing how things are going.

Bedtime. Dual wave finished some time ago but there are still a fair few units (and some takeaway) doing their thing. Better leave it a while before turning in. There... was that long enough? Ah no... that was only 27 minutes, better leave it about another half an hour.

I'm sure if I had all those back and added them together I'd have about twice as many hours in the day! And half an hour is not quite enough time to do any one thing, but slightly too long to do nothing. It's a time period where it's easy to get distracted and forget what you were supposed to be doing (waiting to eat after bolusing is a nightmare for this).

And a lot can happen in half an hour, diabetically speaking. You can be waiting to give it long enough to check and all the while your BGs can be rocketing skyward. 30 minutes of rapid climb meaning it'll take even longer to resolve.

Case in point yesterday: I had tested to find a couple of low level dips in the morning where I'd underestimated the level of activity and not sufficiently reduced basal. In the afternoon I feared the same was happening again, but rather than testing I just topped up here and there with a sip of Lucozade or a fruit pastille. Before evening meal I was an entirely self-inflicted 12.2 (220). Not ideal. In an attempt to speed the return to better levels I left Jane washing up (sorry about that) and went for a brisk 40 minute walk. Once back I waited for things to settle (about half an hour, of course) but then found that rather than improving things I was up to a wince-inducing 24.8 (446). Frustratingly I rarely feel any symptoms with quick rises into kidney-frying territory so I had waited none-the-wiser while my liver had decided that my BG was far too high to be walking about and what I really needed was an additional surge of glucose. Great. Thanks for that.

On the other hand I had changed set just before evening meal so maybe it was nothing to do with the walk and it was just a set failure?

A full 5 unit correction administered there was nothing to do but wait and see if thigs got better or worse. Ready yet? Nope, not long enough. Another half hour should do it... (I always seem at least twice as eager for a correction to start working as it is able to start reducing BGs).

Thankfully I did come down overnight, and very smoothly too. Artoo earning back my trust with a 6.5 (117) at 2am, followed by another 6.5 (117) on waking this morning.

Yet another day when I would *love* the immediacy of feedback that a Continuous Glucose Monitor offers. Ah well, without a lottery-win (unlikely as we don't do it) that isn't going to happen with the current pricing structure.

iBGStar Review - blood glucose meter for iPhone / iPod Touch

I was delighted to be invited in January 2012 to be one of the first people in the UK to use and review the iBGStar - a blood glucose meter by Sanofi Aventis designed to work with an iPhone or iPod Touch. The agency that sent me the meter and asked me to provide feedback prior to the UK launch and swore me to secrecy until today, when it becomes available for purchase in Boots. I was provided with an iBGStar and a supply of strips free of charge, and I've not been paid to write this review or say anything, good, bad or otherwise - what follows is just my opinion after a few weeks' use. To save my fingers I'll lazily just be saying iPhone from now on. If you've got an iPod Touch you'll need to do a little mental inline editing.

I should start by saying that I reeeeeally wanted to like this meter right from the outset. The designer in me has long had a love for that fine fruit-based technology company. I've been logging all my BG results on Apple products for years and the idea of a meter which plugs straight into an iPhone or iPod Touch has immediate appeal.

First impressions
The first thing you notice is that it is absolutely tiny! There's also a pleasing 'Apple' influence to the general design. The shiny curved edges on the front, the smooth nicely shaped matt-finished reverse side and, perhaps nicest of all, the fact that the on-off 'button' is seamlessly built into the front fascia of the device. The designers have also bothered to build-in a nicer-than-expected screen on the front of the meter which displays results and a small animated prompt during BG tests which means that it is perfectly possible to carry out a test whether the meter is connected to your iPhone or not (handy if, for example your phone ran out of charge when you were out for the day). First impressions? Even before I'd got a strip out of the pot - this is going to be amazing.

How small is small?
By my reckoning it's about 55mm by 24mm (including the dock connector). Everything about this meter is smaller. The strips are smaller, the pot they come in is smaller. The supplied finger pricker (more about that later) is small too. The supplied black zip-up case is perhaps 50%-60% the size of a standard Roche Accu-Chek one and maybe 70% the size of the case for the Contour-Link meter that works with 'Artoo' my pump. If you took the strips, fingerpricker and iBGStar loose in a coat pocket they would take up very little room. The iBGStar aligns well with the width of my iPhone4 and is just slightly narrower than my 1st Gen iPod Touch. Of course you don't keep it connected to your mobile device the whole time, and with another nice touch they provide a small cap to cover the dock connector which doubles as a little clip to secure the meter and stop it getting lost in the bottom of a pocket or bag if you take it 'loose'. The advantage of this tininess, of course, is that it makes it much less hassle to take your meter with you. And you don't have to worry about all the careful logging etc when you are on the run, unless you want to. The iBGStar can be used perfectly well on its own and will remember and allow you to refer back through several readings on the device itself (it stores 300). When you have a bit more time you can sync with your iPhone and add any insulin doses/carbs/notes to keep your records up to date. If you were having a period of lazy no-logging the 'unplugged' iBGStar helpfully displays an average figure when first turned on allowing you to keep a general eye on things. To get the most of the meter though, you'd want to download and use the iBGStar App.

The iBGStar App
Downloadable free of charge from the App store, compatible with iPhone, iPod Touch and iPad. Requires iOS3 or later. I haven't tested any iCloud-based shenanigans for people with multiple devices, so I cannot confirm or deny whether the iBGStar App would allow you to use several devices concurrently. Having taken a while to find a logging app that suited me I was a little worried that the iBGStar app might be a bit clunky, but was pleasantly surprised. Data entry is slick and easy and individual records consist of tabbed 'cards' which can be flicked through on the home screen. Easy enough to add and edit things like insulin dose and carbs eaten, while a series of 'notes' can be added from a prepopulated menu of food/exercise/dose/meds/general. There are some pretty sensible entries already there 'ate fatty food', 'light exercise' and so on, but you can edit and amend any of the pre-defined choices to make the app work for you. You can also add any extra ones that you might find helpful. There are some other sweet personalisation touches too. For example you can choose the 'background theme' to the home screen from six choices (cityscape, beach, forest...) and as you flick through the result cards watch the sun rise, set and the stars come out depending on the time that the BG reading was taken. I liked the zoomable 'scatter graph' in the data analysis section too, which colour-codes readings above and below the target range you specify. You can also view averages, numbers of tests and even Standard Deviation (how raggedly spread out or tightly packed your results are) over 7, 14, 30, 90 days or a custom range. Critically it is also very easy to email-out the results data, including all notes, carbs and doses for printing and waving in front of your Doctor or DSN. The only tiny quibbles I had with the app were that it did not allow fully pump-friendly dose recording (Artoo does meal doses to two decimal places, the iBGStar App only allows one) and the 'logbook' view is a bit limited showing BG results only - with the 'expanded view' being particularly useless and simply showing the same BG data a bit more spaced out rather than revealing data for doses, carbs etc.

Taking a test
The supplied finger pricker is er... a bit flimsy. It's servicable enough and at least has a variable depth setting, but lacks the smooth solid action of my Accu-Chek MultiClix and has a slightly worrying, plasticky, 'cracker novelty' feel to it. It stayed in the box. The sample size is a modest 0.5 microlitres, strips don't need coding and results take around 6 seconds. One slightly surprising irritation was that the strips felt like they were the 'wrong way round' in the pot. Unlike any other meter I've had the 'sample' end of the strips for the iBGStar are not the end that you grab hold of, so each time you get a strip out you need to turn it around before pushing it into the meter. The strips themselves are also a fairly uniform black so it's not always immediately obvious which end is which. There is a tiny notch in the 'meter' end, but in low light and for overnight tests this was a full 'lights-on' meter. I also found it slightly tricky to apply the sample in that the finger-to-strip alignment seemed to need to be a bit more precise, and the strips themselves a little less 'slurpy' than other meters I've used. If you use the meter plugged into your iPhone and with the iBGStar app running you get a little swooshy animation on the phone screen after the 'apply sample' prompts. I preferred to use the meter separately and then plug it in to sync data and log meal and/or other details. The iBGStar has a rechargeable battery and is supplied with a mains charger or can be charged via computer USB port. I have a fairly intensive testing schedule but a full charge still lasted my me a good two or three weeks. Helpfully the iBGStar begins to show remaining charge as a percentage once you have dipped below 50%.

Accuracy
So far, so good. If I were finishing the review here it would be a straight 4.5 stars. Unfortunately though I have a nagging worry. Quite by chance, when I was asked to review the iBGStar I had recently switched from an Accu-Chek Expert to a ContourLink (the latter sends results to Artoo via bluetooth). When I switched between those two meters, out of interest I did a couple of tests between the two. Now I had three meters on the go, and strips for all of them, so I did a few random tests across them all. Now at this point I must absolutely stress that these tests are in no way 'properly' scientific. The sample size is one - me. I do not have access to any lab results for any of the blood samples so I can never know which of the meters, if any, was ever giving a truly accurate result. All meters are permitted to have a 20% variation from a lab result (there's a whole blog post right there) so any result could be a bit high on one, a bit low on another. All I can say is that I got a larger-than-average drop of blood, stuck a strip into all three meters, tested and compared the results. To begin with it was all hunky-dory. But then I noticed a test where the iBGStar read quite a bit higher than the Contour. A few more tests followed and by and large the Contour and Expert were closer together, the iBGStar almost always higher. And the higher the level, the more extreme the variation. As a pattern I actually liked that predictability. I know people who find their correction doses less and less effective as their BG rises. A meter that reads a little higher at higher levels could be ideal - set the correction factor appropriately and you would automatically get a more effective correction when you needed it. Sadly though I soon found the results that broke the pattern. Results with larger differences at lower levels, and results will almost no difference at higher levels. I mentioned this in my 'feedback' to the agency who had sent me the iBGStar and had fantastic customer service experience from Sanofi Aventis who sent me a new meter along with some control solution and asked for the old one back so that they could have a look at it. I've not heard whether they found anything, but the results with the new meter (which passed the control solution test) are very similar to the first.

Once I had the replacement I spent a couple of days cross-testing the three meters just to double check before I mentioned this experience here. There were 22 tests taken over a 2 day period including before and after meals, before and after exercise and overnight. For what little they are worth here's what I found when I looked at the results:

• In general terms the iBGStar read the highest averaging 8.9mmol/L (160mg/dl) and the Contour the lowest averaging 7.7mmol/L (139). The Expert averaged 8.0mmol/L (144).
• The average difference between the iBGStar and the Contour was +1.29mmol/L (+23mg/dl)
• The average difference between the Expert and the Contour was +0.35mmol/L (+6mg/dl)
• Notwithstanding the official 20% 'acceptable' variation, I consider +/-0.5mmol/L (9mg/dl) to be a better indication for my own purposes of whether or not readings are 'more or less the same'
• Only 18% of results between the IBGStar and Contour were within 0.5mmol/L
• Between the Contour and Expert a much more respectable 73% came within 0.5mmol/L (with more than a quarter of results coming within 0.2)
• As soon as differences between meters reach +/-1.5mmol/L (27mg/dl) it begins to make a difference of almost half a unit on an insulin dose or correction for me. An extra 0.5u when I don't need it could even risk dropping me into a low level hypo
• Over the 2 days 37% of readings on the iBGStar were 1.5mmol/L or more higher than the Contour
• There were no readings that showed that much variation between the Contour and Expert. None.
• The single worst difference was 10.5mmol/L (189) on the Contour vs 15.8mmol/L (284) on the iBGStar - a difference of 5.3mmol/L (95), that's more than 50% of the reading - the Expert read 11.2 (202).

Again I must stress that these are just my own not-very-scientific results. I have no idea which results, if any, were the 'real' ones, but the variation in the iBGStar and the lack of variation between Contour and Expert cast a shadow of doubt over the iBGStar for me. It may just be something to do with my blood chemistry and the iBGStar's strips - I have no idea. I may be the only person in the UK who would find this variation.

Conclusion
I really like this meter. It's small, nicely designed. The app is great, very easy to use and ticks almost all the boxes for me. I successfully used it on its own for a week and a half, even after I had noticed its tendency to read a little high. I simply reduced my 'usual' correction factor to take into account the possibility that the meter might think I'm higher than others I have used before. At the end of the day BG meters for use at home are only ever going to give you a general guide as to your levels. If you read the small print in the handbooks they never pretend to do anything else. Back in the real world though, I do need my meter to perform as consistently as possible. If it's going to have a quirk, that's fine - but it has to be a reliable quirk. My life 'playing at being a pancreas' is full of enough variables without adding another into the mix. I'm sure the iBGStar will work well for many people - unfortunately I'm not one of them.

Final score: 3/5

UPDATE: Sanofi checked the first meter and gave this response.

Rediscovering porridge

Someone I 'met' on a forum who started on an insulin pump a year or so before me said that in some ways she had to relearn much of what she thought she knew about her diabetes. Many tried and tested observations, and theories as to what was happening seemed no longer to apply. Switching to a pump so fundamentally 'changed the rules' that almost everything had to be evaluated from scratch.

I've had a glimpse of what she meant recently when I decided to retry porridge (oatmeal for US readers) as a breakfast choice.

I've always quite liked it in the winter and it has a reputation for being helpful cholesterol-wise. Mostly though it has a reputation for releasing its carbohydrate slowly and steadily which is very useful if you are trying to keep BG (blood glucose) levels after meals under control. For many years I ate cereals for breakfast, basing my choices on what I had been told - this is low GI, that is slow absorption, blah blah blah...

For many, many diabetic years I tested primarily before meals with ad-hoc other tests if I 'felt funny' or needed to drive. This was OK in its way, but never really let me see or evaluate what was happening after eating different foods. I didn't look at those choices critically enough for them to make any real sense. It was only really after 'meeting' folks with Type 2 Diabetes online who have food choices as their primary weapon in the struggle to control BGs that I realised how little I knew from testing about what to expect from different foods.

GI values are all very well, but they are only an average from a pretty meagre sample. And averages (as anyone with a BG meter can tell you) can hide a multitude of sins.

Having embarked on some after-breakfast testing a few years ago I quickly determined that all cereal is evil. There was just none that I found I could eat and remain in single figures (below 10.0mmol/L 180mg/dl) at 1-2 hours after eating. Porridge seemed a particularly bad example. I may as well have been eating jam.

So I concluded that for me porridge was not slow release at all, and stuck to Burgen soya and linseed toast with much better results.

I knew that at least part of the problem was a 'gap' in basal coverage that made breakfast particularly tricky time for me. I took my Lantus at breakfast time and while the last dose had faded and the next dose was still dragging its heels in 'onset' I had perhaps an hour with less basal insulin than I needed.

The pump of course, has fixed this. Continuous almost infinitely tweakable rolling patterns of basal insulin trickles can allow for the most challenging of basal requirements.

Once I had a basic basal pattern working OK I began to wonder whether I might be able to cope with a little porridge every now and then. The first few results are very encouraging. This morning I rose from 4.7 (85) before breakfast to 6.9 (124) an hour and a half later.

Porridge it seems is back on the menu. Score 1 for teampump.

Pumping for two months - A little bit of everything

Artoo and I have been pottering along for almost two months now, and what with the New Year and everything it feels like about time for a bit of a catch-up. 

Anyone reading who has watched my transition from pump-averse to pumper might be interested in how I have found it in practice. If you have wondered whether pumping might be right for you,  but don't really like the idea, I suspect this might be doubly so. 

Before Artoo and I hooked up I had read a lot of accounts of people who almost immediately felt 'at one' with their new robot pancreas. People who almost forgot it was there pretty much from day one and while most report that it takes a bit of work to get a pump set up and working well the physical 'attachedness' side of things seems to evaporate. I wish I could say that I felt just this way, but I don't. Not quite anyway. *Almost* all the time attachedness is of little or no importance. I've had nights of uninterrupted sleep. No-one around me has batted an eyelid whenever I've  disconnected or reconnected in public (at the gym for example). Now that I've worked a way of hanging Artoo horizontally on my belt I no longer get dug/pinched in the side every so often. But in spite of all that there are still a few times every day when being attached by a short string to a lump of plastic is a tiny bit annoying. Most regularly i feel this while getting changed, but also occasionally just getting tubing caught on things. I even managed to pull a set out while hoiking up my trousers one day. Almost nothing, but I certainly couldn't say that I 'completely forgot it was there after a week'. 

On the other hand, of course, I have already realised that the 24-hour attachment also offers distinct advantages. I arrived at a meeting not long after a meal only to find that some tasty nibbles had been provided. On MDI I would have had to politely decline, but because Artoo goes everywhere with me I was able to guess the carbs, bolus, and get stuck in! And lie-ins... Aaaaaah! Lie-ins. Since moving my basal injection to the mornings I had needed to keep regular morning hours whether work day or weekend, within an hour or so. But now that my basal is automatically following a predetermined pattern I can sleep in as long as I fancy. 

One thing I hadn't quite expected was how quickly the set-changes would come around. Every two to three days sounded like almost never compared to 4-5 times every single day. In reality though they are quite a bit more of a faff than a single pen-injection. The sets hurt a bit more going in. You have to be quite careful and methodical to make sure you avoid bubbles and so on when setting up the reservoir. Added to that every single set change carries with it a 2-hour period of uncertainty, anxiety almost. Has it worked OK? Is the insulin being delivered? As advised, I make the changes before meals to ensure a proper 'test' but this also means that any slight miscalculation in the meal bolus can look like a potential dodgy insertion. I'm getting better at sensing whether sets 'feel' right in the first few minutes and I've only had one or two that I've replaced within the first hour or two, but it's not something that applies on MDI. 

One peculiar observation from the first few weeks. I know two others who started pumping at almost exactly the same time as me and all of us had the same, rather odd phenomenon in the first few weeks. People often need quite a lot less insulin when pumping, so it's usual for your team to suggest a new total daily dose, basal and bolus ratios. In the first week these new levels behaved pretty well for each of us, but then, quite suddenly at around 7-10 days we found our BG results creeping upward and each of us had to significantly change what had worked fine the week before to establish a new 'normal'. Not sure of it's just coincidence, but if you are about to start pumping it might be one to watch out for. 

And what about levels? After all that's the whole point of the exercise... During these two months I've had a bit of everything. Normality, illness, gym, no gym and of course, every diabetic's favourite mental obstacle-course... Christmas. Even in these early weeks I can see improvements. Fewer hypos and fewer and lower highs. And I have to remind myself that I am comparing with MDI results gained while using the Accu-Chek  Expert, which (once I had it set up right) provided a general 'smoothing out' from the levels I achieved before that. 

I've had some spectacular successes, and a few (largely self-inflicted) disasters too. The subtlety of delivery options is a fantastic addition to the arsenal. I still need to do a little more experimentation, but already the potential is plain to see. Most obviously, almost none of the doses I give these days are in whole units. It's always a decimal point here or there, and while my carb guestimates may be no more accurate, at least the doses are more precise so it's one error rather than two. 

I had expected dual and square waves to be useful for 'tricky' meals, but I hadn't realised how handy they would be at other times. If I'm at the lower end of my range before eating I can just ease the dose in (or just a part of it) over 30 minutes to take the edge off. I'm getting better at remembering TBRs (temporary basal rates) too. I always knew these would be brilliant, but as my experience grows I've seen afternoons playing in the band (with a heady mix of physical effort followed a while later by bursts of stress and adrenaline) that I know from experience would have meant a hypo/high shuffle on MDI pass with bewilderingly serene BGs. Only a couple of days ago we ventured to Bristol's new 'all you can eat' world food market for a leisurely, and not insubstantial, slap-up food fest. Duals and squares (and a few good guesses) left me scratching my head when the awaited BG carnage failed to arrive. 

I've had disasters along the way. For every success there have been wrong guesses and hasty corrections needed. I think it's quite funny, given that it looks like Artoo may well give me my best year of control for a very long time in 2012 that my very first test of the year (at 0.58 this morning) was 17.8 (320). 

Ah well... What's life without a few ups and downs. 

Neither one thing nor the other

Well... a few weeks into the holiday period and things haven't completely fallen apart control-wise. Yet. We had some time away in Cornwall and perhaps because I feared the worst I've returned feeling that it worked out pretty well. Oddly I seemed to fall exactly between two possible Lantus doses. A unit down and sugars stayed grump-inducingly high, a unit up and I had to fire-fight hypos with regular medicinal ice creams. You can guess which one I opted for. Oh for a half-unit delivery device for Lantus!

When we returned home I dropped Lantus back down, expecting (with more usual meal choices) that things would settle. But oh no... not a bit of it. Diabetes often seems deliberately contrary, confounding whatever expectations I have of what will probably happen next in the general scheme of things. So I reduced Lantus by the one unit which had meant I was needing to drop meal doses by 20-30% and expected that the hypos would disappear, which they did. And then some. After two days consistently in the teens I put Lantus back up again and waited for the hypos to reappear. They haven't. And neither am I needing to reduce meal doses to avoid them any more. If anything I seem to be running slightly high more often than not.

Maybe it was the sea air? The sand between my toes? We did a bit of wandering about, but certainly not what you'd call 'exercise' in any energetic sense of the word. Whatever it was the hyper-sensitivity I had to insulin in Cornwall has mysteriously evaporated and the same doses are now behaving very differently.

To add to the nagging voice in my head about these recent slightly higher levels, my appointment for annual review has just come through. Ideally I'd like to have a few very tightly controlled weeks in the run up to my HbA1c. After all I've had a few in recent months.

How hard can it be?

Waiting for the storm

Things have been going quite well for me control-wise recently. Monthly averages not too shabby, and particularly over the last few weeks where my meter shows an average of around 6.4mmol/L (115 for US types) with hardly any hypos by my standards, and an SD between 2.0 and 2.7. The Accu-Chek Expert is the first meter I've had that shows 'Standard Deviation'. A mathematical concept slightly beyond my meagre adding-up ability, I gather that it demonstrates the variance in a set of numbers above and below the average. Neatly it also reports it in the same units, which means that you can get an idea of the general 'spread' of your BG results. The smaller the SD the more tightly grouped the results (which is a good thing in terms of BG results fact fans). An average of 6.4 and 2.5 SD would mean that almost all of my 14-day results including the post meal ones lie between 3.9 (70) and 9.9 (178). For me that is smile-inducingly good.

But last Friday was the end of term.

I'd been watching its approach like a ink-black cloud on a summer's day horizon. Hoping that it would not mean what I feared it might. Regular readers will know quite how well I've done with holiday periods recently. In short, not very.

So I'm steeling myself for a slightly wobblier period over the next few weeks. Last summer I seemed to manage pretty well, though I think my control has improved since then. At least when the kids are off school over the summer I have a few more weeks to try to find the new rhythm. I'm hoping it will just be a matter of getting some sort of holiday basal working to account for lack of gym visits, and that the new big meal strategy will continue to work its magic. Maybe.

I'll let you know how I get on.

Learning to love my Aviva Accu-chek Expert

I was given an Aviva Accu-chek Expert handset and have been using it for a little over 4 months now. I wrote a review a month in to the experience with a few reservations, but as time has gone on and settings have been tweaked and refined I've come to love it. It doesn't work perfectly and the bolus advice it provides is not faultless, but when life is relatively steady (and my basal is behaving itself) it has given me whole weeks of astonishingly good BG levels.

Take yesterday as an example: I'd been a bit on the low side the night before, going to bed at 4.1mmol/L (74 for US readers), so I tested at 2.30am to see if my little carb top-up had worked and was pleasantly surprised to read 5.9 (106). I was even happier reading the same 5.9 at breakfast. Left my usual delay between bolus and eating, had some toast and went to the gym. The Expert allows me to adjust breakfast bolus on gym days with a 'health' option, a percentage reduction for 'exercise 1', I've set -25% for the gym and -10% for more general pottering as 'exercise 2'. By lunchtime I was 4.2 (75). Not bad. Now because that's a bit 'near the edge' the Expert automatically deducts a proportion of lunch bolus to attempt to get me to the mid-point of my desired range (4-8mmol/L or 72-144). My pre-dinner test was 6.5 (117). Result! I like to keep an eye on post-meal spikes most days, and tested an hour after eating in the evening to find 6.2 (112). The meal was pretty low GI so I figured it still had a fair amount of carbs to release. Additionally we were meeting some friends for a couple of pints while the kids were out at a club, any rise from the beer ought to be handled by the potential over-enthusiasm of my evening Humalog. My bedtime test was a smile-inducing 5.9 (106).

A whole day and I'd guess I didn't go much above 8 (144) (hard to be sure as I didn't test at the likely peak after lunch). Neither did I hypo, despite a session at the gym. What US CGM wearing pumpers would call 'bolusing a no hitter'.

Now anyone who has read my last post will know that this doesn't happen all the time. When life is a bit more chaotic, when basal-needs change, when overall levels of activity rise or fall those carefully tweaked settings are just a little off. Not much but enough to put you on the glycaemic rollercoaster of guessing, double guessing, highs, lows, chaos and confusion. What US blogger Scott so accurately described last week as low blood sugars, guilt and fear.

After 20 odd years of handling all the calculations and adjustments by myself I'd guess I'd got pretty good at knocking a unit off here, adding one on there to try to match the constant ebb and flow of life and BG levels. Every so often I'd get a day just as good yesterday. What I've noticed since using the Expert though is that these days are no longer a shock. They are not normal by any means, but having been as rare as hen's teeth, I can now find weeks where I get several on the trot.

I'm continuing to experiment with settings for illness, and I clearly need to do a lot more work to handle the wider-scope shifts in routine that caused me so much trouble during April.

There are still a few things I'd change about the Expert, but it's certainly won me round and I'd highly recommend it.

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.

Owning your targets

I replied to a forum thread today, and only as I was posting did it strike me that I've completely changed the way I view my blood glucose target range in the last year or so. A mother with a teenage type 1 diabetic daughter was expressing concern about the extra fingerstick blood glucose tests, basal testing etc that would be part and parcel of her move to pump therapy. She then said she had to text to remind her daughter to do a test, and text back the results. It made me wonder how that felt for a young person. Whether they would feel that the tests were for them at all.

And then I realised that was exactly how I had felt about these things too.

The recommended levels for adults with type 1 diabetes in the UK are 4-7 mmol/L (72-126mg/dl) before meals and less than 9mmol/L (162mg/dl) by two hours after meals. This is, frankly, a tiny target to try to hit. To be honest the permitted percentage of inaccuracy on a BG meter is 10%. So the meter itself is only accurate to one sixth of the target range some of the time. I've had 20-odd years of consultants telling me that I was 'doing fine', but 'should try to have not quite so many highs and avoid those lows'. I've always just smiled through gritted teeth at such comments. "There speaks a person" I would say to myself, "who has never tried to guestimate the carb load and absorption rate of a meal, and tried to match it precisely with the activity profile of an insulin injection, taking into account any abnormal activity level during the day." If they wanted me to hit their stupid target, they should have made the darned thing a bit bigger.

In a small, but incredibly crucial way though, my mindset has changed. The shift was so slight I only noticed it when trying to look at the same issue from someone else's point of view. The range, is still as tiny, but it is now my range. Whereas before I would grumpily think, "well that's just impossible... I'll aim for 4-10, but for you to ask me to do any more than that is just unreasonable" I now see 4-9 as my target for me.

I've never tested so much in all my 20 years with diabetes as I have over the last 14 months. I've never voluntarily gone without so many meals to check on my basal insulin's activity. In all likelihood I would not be doing so without meeting other diabetics online. Diabetics who hit their own tiny target ranges. Not every day, but often enough to prove that it is at least possible.

Once you understand that the target (whatever you decide that it is) is your own, all the effort required to aim for it, and let's not pretend that is isn't a LOT of effort, somehow becomes much easier.



Edit: Just re-visiting this post after several years and I have realised that in the time in between I have altered and changed my targets on more than one occasion. And this is fine too. Currently I'm finding 4-10 gives me less opportunity to berate myself over high readings with an additional soft lower limit of 5 which I will treat as if low to give myself a little more wiggle room. What's important is that I feel these are what I have decided to do for me. Not some impossible nonsense handed down from on high.