Reviewing my review

So today was the day. My long awaited (and only slightly delayed) annual review. As far as I can tell most, possibly all of the old clinicians have left the hospital I attend, so there were new faces to meet. 

It was great. My appointment started promptly and my discussions with Dr S were unhurried and thorough. A little too thorough, perhaps. Apologies if you were after me, I think I stayed and chatted for a bit longer than I usually would. 'Smile and nod' this wasn't. It felt more like a fruitful exchange of information. And if Dr S was bored senseless and wished I would get lost, she certainly gave nothing away. 

I was pleased to learn that my HbA1c had dropped from 7.1% to 6.3% (45mmol/mol in new money). Dr S pointed out that that was the sort of level at which they get begin to get concerned about the number of hypos that might be involved, but thankfully I'd taken a sheaf of printouts showing that I'm having far fewer these days. Other results showed an unexpected drop in cholesterol to 4.7 (with an improvement in the lipid panel split of 2.1 HDL, 2.3 LDL and 0.7 Trigs - yes I realise that doesn't add up, calculated values sometimes don't it seems). Blood pressure, while occasionally higher than ideal, is generally low enough at either end of the day to pass muster. 

I should take this opportunity to thank the Diabetes Online Community for their amazing support and encouragement over the last year or two. Forums, blog posts and comments left here have had a major impact on the way I am able to manage my diabetes. Things that I had thought impossibly illogical for years have been made much clearer. You guys rock!

And as for the *big question*? Well as I talked through pretty much all the issues I still have with Dr S, we agreed that all of them would be easier to handle on a pump. I have booked an appointment with a DSN to talk pumps, Levemir and other options. 

Watch this space. 

D-Tracker Review - Diabetes UK iPhone App

I was asked a few weeks back if I would take a sneaky-peek preview of the new Diabetes UK iPhone App by Public Zone and write a review of it. In a proper bloggy 'disclosure' type way I should point out at this point that I have not been paid to write this review and although approached to be part of a focus group earlier in the project (I was not able to take part) I have had no part in the development of the app. The app is a free download in the iTunes App Store. What follows is simply my own appraisal having tinkered with the app this weekend. No more, no less. I should probably also point out that I am fairly picky by nature and can almost always find fault with anything. If you want to know my general feeling read the 'overview', if you want a fuller breakdown of what I thought proceed to the nitty gritty.

Overview
D Tracker is an application that allows you to record all sorts of Diabetes-related information on a variety of Apple devices (iPhone, iPad and iPod Touch running IOS 4.2+). I am not sure if the intention is to create versions for other mobile device architectures eg Android, but I guess a successful launch could lead to other versions.

I've had various periods of diligent record-keeping and complete data deserts in my time. But what I do know from experience is that keeping an accurate record of, at the very least, your BG, doses, food intake and level of activity/illness is hugely helpful in trying to spot patterns and improve diabetic control. After a period of recording in notebooks I have in more recent years converted to recording electronically. And the ability to do so quickly and easily with something that is in my pocket anyway makes an app potentially an ideal solution.

I am aware as I write this, that Diabetes UK have had a pretty tricky job on their hands in putting this app together. They represent all different types of people diabetes, from the regular types one and two to other more exotic versions. They also deal with anyone from the newly diagnosed to old hands like me. Parents and carers of diabetic children or relatives. Occasional record keepers and data junkies. 

I have to say, with a few reservations, that I think they've done a great job. There are some great fresh ideas here, and some really useful tools that I've not seen in other recording apps, or at least not all in one place. I think this is part of the challenge in developing a new app. There are plenty of others already available, so the trick is doing everything well and also trying to bring something new.

Data entry and editing is easy enough, and there is a LOT of data that you can enter and track. From the obvious blood glucose and insulin doses to carbs, ketones, calories and weight. You can even record how you are feeling at any entry to track the effect of mood and stress levels. Adding a note (which you can even share with Facebook or Twitter of you are so inclined) allows you to record any other info relating to the entry.

Recorded results can be shown on either daily or per-week graphs on which you can show any or all of the data you have recorded by way of colour coded data points and (in some cases) connecting lines that show the trend. The list view is just that, a vertical scrolling list of the records. It might have been nice to have an option for a tabular format, but I suppose with the number of data entries that can be stored in each record a table was felt impractical.

I particularly liked the way that different records can be flagged as 'talking points'. These are then stored as a list (in folders if you want to organise things still further) for later reference in the 'My Health' section.

Another first, and stroke of genius I felt, was that you can take a photograph as part of a record. I was taught to count carbs at diagnosis, but I realise that this is not the case for everyone, particularly type 2s. If estimating carbs on a plate at 50 yards is not second nature to you, you could simply photograph what you ate, record your BG levels and then have that image to refer back to when trying to analyse the results that follow.

Now this being a Diabetes UK sponsored app (and free to boot) you will not be surprised to hear that here are links and contact details to DUK and the Careline; and yes, even a 'donate now' button to support the Charity's work - but these are very low key and certainly do not get in the way of the app's main functionality. There are also very useful pieces of pop-up explanatory text every so often providing extra information about weight, BMI and so on, with links to the DUK website. 

The 'My Health' section allows you to keep track of all sorts of other bits of info, your latest HbA1c for example, neatly date-stamped when the entry was created or updated. You can also keep track of forthcoming appointments, contact details and so on, keeping all your diabetes stuff in one place for easy reference, and perhaps even 'in case of emergency' use. 

The nitty gritty
So far, so good. But here is where I put on my picky hat. Sorry about that. There are lots of different diabetes and weight-monitoring apps on the market, and I think this app does what it sets out to do. Depending on the level of data analysis you are after, the D Tracker will either suit you, or not. 

One of the strangest things about the app for me is that there are almost no user-definable settings or adjustments that can be made to tailor it to your own preferences. Weight must be entered in stones and pounds. Ketones must be entered in mmol/L. Even the 'How are you feeling' choices are predefined and unchangeable. 

I also have a bit of a problem with the graphs. This always seems to be an aspect of these apps that I struggle with. For a start the graphs only ever show in portrait orientation, and at the scale of the single day graph, each day is so long that if takes fully five screens' width to get from midnight to midnight. Five. Added to this the vertical scale is fixed to the apps max and min values. In BG terms this runs 0-33mmol/L which, combined with that long x-axis made some rather erratic entries I made look reassuringly flat. The problem is exacerbated by the fact that the graphs can carry lots of different data sets, depending on what you elect to track, so there is no information shown about what the y-axis represents. I can't tell whether I was high or hypo, only get a vague sense of whether I was going up or down. Some colour-coded dotted horizontal markers for max/min or target levels which turned on and off with their respective data would have been a great help. On the graphs, some data points are joined by lines, others (insulin doses for example) are shown as data points only. Oddly it was decided to track carbohydrate consumption with a trend line linking different meals in the day. I'm not entirely sure why that was. 

The 'week' view gives a list of days with their data either averaged (eg blood glucose) or shown as totals (eg insulin doses). This data can also be shown on a graph, again without the benefit of a y-axis legend. There  is no apparent data analysis for a wider scope than a calendar week. If you want to see how things shape up over 14, 30, 60 or 90 days you would need to get your calculator out. More detailed number crunching for BG data, to offer Standard Deviation for example, is not available.  

While I love the 'Save as a talking point' feature, I do wish it was not restricted to individual records. More often than not, what I find I want to discuss is a whole day's worth of results, or at very least a sequence of before and after. 

The real disappointment for me as far as this app goes though is this - there is no way of exporting your carefully recorded data at all. The best you can do is to email yourself an image of one of the less than perfect graphs. Different BG recording apps seem to take different approaches to data export. Some link you in to online accounts where your data can be uploaded, others (including my favourite) allow you to simply email yourself a copy of the tabular data and a .csv file that (depending on your level of geekery) you could import into a spreadsheet program and manipulate to your heart's content. The D Tracker offers neither. If I record my data with it I cannot print out my results and take them to my next clinic appointment. If I want to leave the data with my team, I'd need to leave my device. 

Conclusion
I think the D Tracker is a great first effort from Diabetes UK. They, and their developers are to be congratulated on providing a very useful tool for monitoring a very complex condition. There are some great features and functions here, and some very interesting new ideas. I'm sure many will find it a great help, and I look forward to seeing new and improved versions in the future. 

Final score: 3.5/5

Get the Diabetes UK D-Tracker App free here.

Diabetes Mellitus

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia and results from defective insulin production, secretion, or utilization.

Pathophysiology and Etiology

• There is an absolute or relative lack of insulin produced by the beta cell, resulting in hyperglycemia.
• Defects at the cell level, impaired secretory response of insulin to rises in glucose, and increased nocturnal hepatic glucose production (gluconeogenesis) are seen in type 2 diabetes.
• Etiology of type 1 diabetes is not well understood; viral, autoimmune, and environmental theories are under review.
• Etiology of type 2 diabetes involves heredity, genetics, and obesity
  
  

Type 1 Diabetes Mellitus

Type 1 diabetes mellitus was formerly known as insulin dependent diabetes mellitus and juvenile diabetes mellitus.

• Little or no endogenous insulin, requiring injections of insulin to control diabetes and prevent ketoacidosis.
• Five to 10% of all diabetic patients have type 1.
• Etiology: autoimmunity, viral, and certain histocompatibility antigens as well as a genetic component.
• Usual presentation is rapid with classic symptoms of polydipsia, polyphagia, polyuria, and weight loss.
• Most commonly seen in patients under age 30 but can be seen in older adults.

Type 2 Diabetes Mellitus

Type 2 diabetes mellitus was formerly known as noninsulin dependent diabetes mellitus or adult onset diabetes mellitus.

• Caused by a combination of insulin resistance and relative insulin deficiency- some individuals have predominantly insulin resistance, whereas others have predominantly deficient insulin secretion, with little insulin resistance.
• Approximately 90% of diabetic patients have type 2.
• Etiology: strong hereditary component, commonly associated with obesity.
• Usual presentation is slow and typically insidious with symptoms of fatigue, weight gain, poor wound healing, and recurrent infection.
• Found primarily in adults over age 30; however, may be seen in younger adults and adolescents who are overweight.
• Patients with this type of diabetes, but who eventually may be treated with insulin, are still referred to as having type 2 diabetes.

Prediabetes

Prediabetes is an abnormality in glucose values intermediate between normal and overt diabetes.

Impaired Fasting Glucose

• A new category adopted by the American Diabetes Association in 1997 and redefined in 2004.
• Occurs when fasting blood glucose is greater than or equal to 100 but less than 126 mg/dL.

Impaired Glucose Tolerance

• Defined as blood glucose measurement on a glucose tolerance test greater than or equal to 140 mg/dl but less than 200 in the 2-hour sample.
• Asymptomatic; it can progress to type 2 diabetes or remain unchanged.
• May be a risk factor for the development of hypertension, coronary heart disease, and hyperlipidemias.

Gestational Diabetes Mellitus

• Gestational diabetes mellitus (GDM) is defined as carbohydrate intolerance occurring during pregnancy.
• Occurs in approximately 4% of pregnancies and usually disappears after delivery.
• Women with GDM are at higher risk for diabetes at a later date.
• GDM is associated with increased risk of fetal morbidity.
• Screening for GDM for all pregnant women other than those at lowest risk (under age 25, of normal body weight, have no family history of diabetes, are not a member of an ethnic group with high prevalence of diabetes) should occur between the 24th and 28th weeks of gestation.

Diabetes Associated with Other Conditions

• Certain drugs can decrease insulin activity resulting in hyperglycemia- corticosteroids, thiazide diuretics, estrogen, phenytoin.
• Disease states affecting the pancreas or insulin receptors- pancreatitis, cancer of the pancreas, Cushing's disease or syndrome, acromegaly, pheochromocytoma, muscular dystrophy, Huntington's chorea.

Changes, uncertainty and what to do next

I had my appointment through for my Annual Review a few days ago (due early April). A change of staff at the clinic has meant that they have got rather behind. A week or so ago I called to see how things were going and I was offered an appointment in a cancellation slot. As a result I guess I'm feeling that this appointment represents my 'chance' to make some changes that I've been mulling over and I want to make the best of it.

For many years I just attended my annual reviews in a smile and nod frame of mind. If I mentioned a problem, whatever response I got was either something I had tried myself and knew didn't work, or seemed to relate to an entirely different set of circumstances. These days I like to go armed with a few thoughts, questions and, sometimes, requests for new things. This is easy enough when you have heard of a thing that seems to solve, very neatly, a problem you are having. When I had a period of time struggling to remember whether I'd injected or not, a pen which recorded doses and timings automatically was an ideal solution.

So ever since my appointment came through I have been wondering what to do next. There have been whole weeks recently where I've been grin-inducingly happy about my levels. Weeks with no hypos at all. Weeks with very tight control and few if any results outside my target range. Periods where I have felt that I'm winning.

But the weeks when it is not like that suggest that it can be even better.

I've been wondering about my basal for almost all of the time we have been writing this blog. If you are a regular reader, you must be sick of it. The problem is that sometimes it works brilliantly. And sometimes it doesn't. There is an alternative analogue basal (Levemir) about which I have heard Very Good Things for a long time. One of the apparent benefits of Levemir is that it is more responsive to change than Lantus, which can take a day or two to settle into a dose change. Another factor is that it can work well split into two doses. I tried this with Lantus but it didn't work for me. A person's basal requirement is unlikely to be exactly uniform throughout the whole 24 hours. The opportunity to have 2 phases of basal insulin, perhaps one with a bit more, one with a bit less, combined with the rise-and-fall activity profile of the insulin itself gives you a few more options. The job of basal insulin is to hold you steady while your liver is deciding whether to trickle a bit more or a bit less glucose out at that time of day.

Of course the most flexible, tweakable and tailorable basal pattern would be achieved with a pump. To be honest the most flexible, tweakable and tailorable delivery of any insulin would be a pump. About a year ago I wrote a post about not wanting one. In the 12 months since, I've changed my mind perhaps 100 times about whether pumping is right for me. That's before we even get to the question of whether or not any funding-application I made would be supported.

In the last few weeks it's been going round and round in my head again. Benefit. Drawback. Benefit. Drawback. I think I'm now prepared to accept that the fear of 'attachedness' would come to nothing. Everyone seems to have it beforehand, and no one seems to care after about a week. At least not enough for it to detract from the positives they are experiencing. But I still do have genuine concerns over delivery failure and finding good spots for an infusion site (one side of my abdomen is a bit dodgy absorption-wise with some lipohypertrophy from years of lazy overuse).

At the end of the day it feels like any change in regimen has a benefit vs hassle balance that needs to be weighed. If I went Levemir I'd be adding an extra basal injection at some point in the evening. Mostly this would be fine, but some nights it could get right in the way. And any change of insulin would require a fair bit of faffing about getting the doses and timings right. I could, unlike Lantus, get access to a 0.5unit delivery device which recent experience suggests could be well worth having.

Switching to pumping, of course would involve faffing of a whole different order of magnitude. But the potential benefits that I've read about so often still shine out from behind the wall of uncertainty and concern in my head.

I just don't know.

Update: D-Art Day : The path of least resistance

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.

New big meal strategy: thirds

Following on from my recent moan about errant BG levels during holidays I posted on a forum that sometimes it seems to come down to a choice between food variety and good levels. If I stick to basically the same meals week after week and use tried and tested doses I tend to have far more consistent results.

This is, of course, blindingly obvious.

But it's not really an ideal long-term solution is it? In fact it reminds me a little of a joke by Tommy Cooper: "I went to my doctor the other day and said, It hurts when I do this" [briskly raises left arm above his head] "He said, Well don't do it then". Trouble is I really like food, so the wider variety and range of quantities I can eat the better - not necessarily all the time, but certainly every now and then. But these occasional guilty pleasures are not at all enjoyable if they always result in disastrous BG levels.

Part of the frustration stems from the fact that my insulin:carb ratio which in theory should allow me to eat pretty much whatever I like, seems to be less than predictable in certain circumstances. Almost everyone, I suspect, who adjusts doses this way will be familiar with the experience of counting carbs in an unusual meal carefully, taking the 'right' dose, only for BG chaos to follow. This can be particularly frustrating where I know I can achieve pretty good results for notoriously difficult meals (pizza or fish and chips for example) if I eat the 'usual' amount and take the 'usual' split dose, even if the actual carbs involved are not measured or counted very accurately at all.

A few very interesting comments came out of my forum post. I'm always suspicious of 'rules of thumb', but someone remembered a suggestion from John Walsh's excellent 'Using Insulin': Take your weight in pounds and halve it, then use that figure as grams of carbs - this gives a good indication of the meal size above which your insulin:carb ratio may well break down. It might not work for everyone, but it's pretty much bang-on for me. Someone else suggested that above a certain point they found they needed to add approximately a third to the calculated dose for it to work well.

Last night, we had a mixture of 'heat it and eat it' ready meals from the supermarket, and I ventured a pudding too. Overall mine ran to just over 90g carbs with a fairly high fat content. Not horrendously high carb load, but enough in recent weeks to cause problems. I decided to experiment with the new 'adding a third' approach and split the dose as if I were eating fish and chips. The results were excellent - 4.8mmol/L (86) before the meal, 5.0mmol/L (90) at one hour and 6.2mmol/L (112) at just over two hours. By hour three I was still pottering along at 6.1mmol/L (110) with a mix of the split doses still active. By suppertime I'd dropped back to 4.7mmol/L (85). That's a little low to go to bed on, so I had a small snack to prevent a dip overnight. FBG this morning was 5.0mmol/L (90). Cracking!

It's a bit early to believe that this will solve all my problems for unusual
meals in the future, but it's certainly a system I'll try again.