Getting animated

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

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

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

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

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

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

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

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

That's all folks!

Why I decided to stop being ‘a diabetic’ - Guest post for DiabetesUK

Words are powerful things.

I had a very interesting conversation with the very lovely Lesley Jordan of INPUT in October last year which made me focus on something I had been mulling over for some time.

It’s odd, because I’ve seen it discussed online and in social media before, often with a level of passion and sometimes outrage that has made me think, ‘Why are you letting yourself get so wound up about that?’

I think it began to make more sense to me when I considered the subject in the light of the way I think about my own diabetes, rather than the words or terms other people might use in conversation or in the media. I think to get too stressed or riled up about what other people say is counterproductive, but I have come to see that it is very important for me to choose my words carefully for the little voice in my head.

I know, I know. Many of you are rolling your eyes, and someone almost certainly just said ‘Oh good GRIEF!’. But bear with me here...

Living with a long term condition like diabetes is hard work. There will be days when you might just breeze along quite happily, barely giving it a second thought, but there will almost certainly be other times when it is a lonely, grim and gruelling marathon – and everything is up hill. It is well established that diabetes and depression often go hand in hand and it is important that we protect ourselves and our sometimes fragile senses of self-esteem. One of the most successful ways of doing this seems to be ‘cognitive behaviour therapy’ (CBT) and an important CBT technique is to adjust your inner voice to help you see situations more clearly and more positively.

I think in words. Conversations with myself. In all the countless interactions I have every day with my diabetes I hear my inner voice commenting on what I am doing. If I am not careful, the background to my every day can become a relentless tide of negativity and judgement.

“I have to test my blood...”
“My control is *terrible* at the moment, my BGs have been really bad...”
“Well I really messed up that carb count there. I should have weighed it, I bet I go hypo later...”

And all of this spills over into any conversations I have with other people too.

So I have been trying to make tiny changes to the language I use with myself and with others when I talk about my diabetes. These seem so tiny and insignificant that it is hard to believe that they could matter at all, but we have a rich and subtle language and every word we choose conveys complex messages to those around us and to our own subconscious.

So now I am no longer saying I am ‘a diabetic’ – a label which defines me, instead I am a ‘person with diabetes’ – person first, diabetes second.

I am trying not to think about ‘good’ or ‘bad’ blood glucose or HbA1c results. Instead I think of them as being ‘in range’ or a ‘work in progress’.

If you ‘test’ your blood glucose then you can pass or fail that test, so it is better to ‘check’ or ‘measure’ your blood glucose. Check your blood glucose level to give you information about what to do next. Check, respond, move on.

Don’t try to ‘control’ your diabetes, ‘manage’ it instead – there are often factors that affect your blood glucose levels that are outside of your direct control (an unexpected liver dump or some other diabetes randomness), but you can use your skills and knowledge to manage those changing circumstances as best you can.

Even terms like ‘should do’ or ‘should have’ can imply some sort of personal failure if something doesn’t quite go to plan. ‘Can do’ and ‘will do’ are more positive alternatives.

There are also changes you can make in the way you think about food, and talk about it with other people. ‘I can’t eat that’ implies that I am being prevented from doing something and that I’m not in control of the decision. ‘I am not going to eat that, because reducing my carb intake makes my diabetes easier to manage’ or even simply ‘I don’t eat that’ puts me back in control – I am making a choice at that moment and I know why I am making it. Next time I can choose again, perhaps differently, but it is always my choice.

As I say, these changes are tiny. It is hard to believe that they would have any effect at all, but little by little they are helping me engage with my diabetes in a more positive way.

What helps you stay positive?

Cook & Count Carbs - App Review

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

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

Real food, made from real ingredients. Lovely.

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

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

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

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

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

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

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

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

Final score: 5/5

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

Diabetes and Anger -- Is There a Deeper Connection?

Two years ago, I wrote a blog post about diabetes and anger. In that post, I explored a lot of the day to day reasons why a person with diabetes might feel anger, and frustration. In fact, there are many reasons why a person with diabetes would, indeed, become angry. Those reasons can be varied, including anger at oneself for 'failing' to prevent the disease, to anger at family for not understanding or patrolling/policing the person with diabetes' behavior, etc. These are common types of anger: the anger that results from struggling to cope with a new and changing environment, for which we might have little control. (You can check out that blog post link, above, for a more in depth look at that topic.)

However, little did I realize that I was going to get such a huge response from the public -- but not about anger in this usual, common sense -- but anger in the chronic and mental health sense. Folks from all over the country have poured out their hearts to me in sheer frustration and worry over their loved ones, from sons to spouses, to friends. From lay people, to mental health professionals as well.

I must emphasize here, that I am NOT a mental health professional. I am not a medical expert of any kind, or a scientist. I am just a person with diabetes, with a blog. A person who loves learning every day, researching my own condition, and learning how to live and cope with it. Anything I say here is information you must take to your own clinician, or consult with your own mental health professional. It is also information that anyone can research on their own: never take my word for anything. Always be a skeptic.

Now that we have gotten that out of the way, let's start with the ways in which diabetes can clinically affect our moods.

Day to Day Blood Glucose Swings

When our blood sugars are not within normal or euglycemic boundaries (i.e., between 70-120 mg/dL, or 3.9-6.7 mmol/L), our mood and emotions will be altered. In some extreme cases, a person who, for example, experiences severe low blood sugar may become angry and even combative, or violent, or may seem 'drunk.' A person who experiences high blood sugar may experience sadness and depression, inability to concentrate, fatigue, etc. The root of all these glucose related mood swings has to deal with their association with the neurotransmitters in our brains, and how those in turn, communicate messages to our nerve cells about mood, appetite, and even sleep. Dealing with these states of mind is challenging, and can be tiring for the person with diabetes, as well as bring on a short temper. To top it off, having a negative disposition may also bring on bad blood glucose numbers, creating a vicious cycle that feeds off itself.

Chronic Mood Swings

The problem with being on this persistent 'roller coaster' of high and low blood glucose swings is that it can be bring about permanent, and chronic, mental health problems. Problems such as clinical depression, anxiety, anger, and a whole host of mental health conditions, like bipolar disorder.

According to a study on "Diabetes and Psychiatric Disorders," by the Indian Journal of Endocrinology and Metabolism, "Diabetes and psychiatric disorders share a bidirectional association -- both influencing each other in multiple ways." So much so, that apparently scientists back in the late 1800s found diabetes to be a disease which had been present in families with a pronounced history of mental health problems, so that insulin shock therapy was used as a treatment for mental health disorders even as shortly as insulin was isolated for the first time.  (Yes, insulin has a role in mental health, and even in the development of such diseases as Alzheimer's.)

This study further points out that there are several ways in which both diabetes and mental health problems can show up:

• As two parallel conditions, which developed independently of each other, with no apparent connection;
• As a complication of the diabetes, or as a complication of the mental health problem: type 2 diabetes may lead to depression, as well as depression may lead to type 2 diabetes, for example;
• As a product of hypoglycemia or hyperglycemia (and ketoacidosis), such as the development of chronic anxiety;
• And as a result of taking various medications for treating mental health -- many of these medications can lead to a triggering of a type 2 diabetes diagnosis. 

In my personal and anecdotal experience, I am a person who suffers from dysthymia. Dysthymia is a type of low grade, long term depression, which can subside and be in the background, for much of one's life. It is much milder than regular depression. However, in situations in which I have had an undiagnosed, and chronic health condition, such as hypothyroidism, or type 2 diabetes -- the imbalances in health provoked episodes of severe depression. The conditions influenced my depression and worsened it. In this way, uncontrolled diabetes can worsen or complicate a mental health condition that is already present, making overcoming of both conditions a challenge. 

It could very well be that the sudden and deep mood changes many persons with diabetes have experienced were the result of these drastic, and long term changes in blood glucose influencing an already underlying mental health problem -- especially if the diabetes was left undiagnosed or untreated for an extended period of time. It is particularly difficult for a person with diabetes that is weighed down by these mood changes, to find the motivation and positive inclination to manage their health condition. Quality of life tends to be reduced, and so does optimism, which can lead to development of unsavory habits, such as uncontrolled diet, smoking and drinking -- habits which can exacerbate mental health problems and lack of control, to an already breaking point. 

How Do We Help? 

In my previous blog post on anger, I noted several ways in which we could be of support to a person who was being burdened every day by the management of their diabetes. Being a good listener, helping a person cook meals, and being empathetic, are all proper ways in which we can deal with a loved one's chronic health condition. The Behavioral Diabetes Institute provides resources for us to utilize when we are overcome by our day to day emotions when managing diabetes, and may feel burnt out, or depressed. 

However, there are situations in which we need to be more proactive in identifying the mental state of our loved ones. Understand that, outside of a rare and severe hypoglycemic event, violent and aggressive behaviors are NOT standard complications of diabetes. These are not typical or normal behaviors for a person with diabetes. (Grouchiness is.) If a person you love is experiencing warning signs of serious mental health problems, you might need to have a conversation with them about visiting a mental health professional. This is an intimidating task, and there are suggestions out there, on how to broach the subject. 

The National Alliance on Mental Illness (NAMI) has a good Resource Guide for Families Dealing with Mental Illness. In it, they address what to do for 'crisis intervention,' when a person's behavior is particularly violent, or out of control:

If the individual with mental illness is in danger of physical injury, if his or her behavior is out of control or others are in danger, it is important to know what steps to take. Plan ahead by locating available sources for help: your emergency phone number (911), police or sheriff department number, Community Mental Health crisis or emergency number, name and phone number of a mental health professional, friends or neighbors who may be of help, and the nearest NAMI affiliate. Keep these numbers posted by the telephone. 

Any behavior such as this, that falls outside of both a mental health disorder, or a severe hypoglycemic episode, is unjustified violence, and should never be tolerated. Do not put up with it. 

. . .

Mood swings can be a standard part of diabetes mellitus and its attendant blood glucose fluctuations. However, when chronically unregulated, these blood glucose fluctuations can bring about more serious mood disorders. These mood disorders are NOT a standard symptom of day to day diabetes management, and will usually not ameliorate on their own. If you are living with a person who has become unpredictable, or violent, due to a potential mental health disorder, please seek help from your local community mental health centers, a mental health professional, or from your family physician.

The Big EDUAD Timesulin Giveaway!

I know... I know... You wait weeks for a post then three come along all at once!

Those of you with memories as bad as mine will doubtless have forgotten that I wrote some time ago about Timesulin, an ingenious replacement insulin pen cap. While not a fully equipped dose memory device the Timesulin is brilliant in that it does solve the main challenge of "Did I take my insulin just now or not?".

There are different versions to fit the pens for most popular UK insulins and the device works by displaying how long it has been since the last dose was taken. A quick glance will tell you whether it was 5 minutes or 4 hours and Hey Presto! No more missed-dose vs double-dose conundrums.

Cleverly the device does not need to you interact with it in order to register the injection, it 'knows' when you take the lid off the pen. And even more clever, it allows you to take a quick peek at how much insulin is still in the cartridge without registering that as a dose. Which is a great touch and kinda lets you know that at least some of the people who developed it have T1 themselves.

The lovely folks at Timesulin have offered us three, yes THREE! Timesulin caps to you, dear readers. If you would like a chance of winning one, please just send your name by the end of January to mike[at]everydayupsanddowns.co.uk or leave a comment below. I'll put all the names in a hat and draw the three lucky winners on 1st February 2014, then Timesulin will send you whichever cap suits your insulin free of charge.

Good eh!

So drop me an email and good luck :)

Lantus 0.5 unit pen at last - Pendiq Intelligent Insulin Pen

Lantus 0.5 unit pen at last - Pendiq

I *love* the DOC.

No really.

I absolutely love, love, *love* the DOC.

Just a quick glance at Twitter and I can be cheered, encouraged, supported, made to laugh and occasionally brought to tears all at once. Other times you go looking for some lightweight wit and wisdom, or just to see what folks are up to and suddenly discover some weighty new piece of research, campaign to fight for or better still... everyone's favourite diabetes benefit an exciting-sounding new gadget.

Before Artoo became my constant companion a couple of years ago, I wrote quite a few posts about Lantus basal insulin. I spent quite a bit of time trying to wrestle Lantus into submission, and eventually we got to the stage where we muddled along bearably, but it's fair to say that one of my main motivators for starting pump therapy was to get 'proper' basal coverage, that accurately reflected the ebb and flow of my body's rhythms over a 24 hour period.

Comparing notes with other users it seems I was not the only person to be frustrated by Sanofi's rather less than enthusiastic approach to insulin delivery. Most of the injection pens that fitted Lantus were, frankly, nasty. And none of them offered doses in increments smaller than 1 unit. This might be OK if you are on higher doses, but many T1s are quite sensitive to insulin. I'm not quite sure how small children cope, for example. The minimum dose adjustment could well be a significant percentage of the total.

The other pen-related problem I had fixed around the same time related to my terrible memory. It may be hard to believe it you do not live with diabetes yourself, but after a few thousand injections they can become so automatic that you barely think about them. Sometimes you have absolutely no idea whether you have injected your dose or not. I changed bolus (mealtime) insulin to Humalog to get hold of a pen with a 'dose memory' the Humapen Memoir so that if I was ever unsure I had some means of checking that didn't involve me having to write something down, which I was just as likely to forget to do... Or possibly even to remember to write it down, but then forget the actual injection. See what I mean about my memory? Hopeless! Sadly the Humapen Memoir has since been taken off the market and it looks like its development has been abandoned. So now the only memory-enabled pen available on prescription in the UK is the NovoPen Echo.

But...

Thanks to a Twitter conversation I chanced upon earlier this week, I now know there is an alternative. And a very interesting alternative it looks to be too.

Enter Pendiq, the Intelligent Insulin Pen

Pendiq is a new breed of injection device from Germany initially launched in 2011 and relaunched in 2012. Such is the ruthless efficiency of German engineering that this pen boasts not just 0.5u accuracy but increments of 0.1u (from 0.5u upwards). Delivery is unlike any other pen I am aware of - dial up the dose on the display, press the button and a precision motor delivers the insulin at 2/u per second. The pen stores and displays around 2 months worth of injection doses and timings on an LCD screen and the website boasts all sorts of download opportunities and compatibility with logging software such as SiDiary. The battery is rechargeable and the device seems to be compatible with 'standard' insulin pen needles. The Pendiq is compatible with Lilly and Sanofi-Aventis insulins, which means that both Lantus and Humalog doses are now available on MDI in 0.1u dose increments. Heck you can even choose from five funky colours!

Unfortunately there is a snag. Isn't there always? It seems the Pendiq is not currently available on prescription in the UK. It looks like you can buy it via the website, but with the shipping/delivery it will set you back almost €185 (around £150). So not cheap... by any means. You would also probably be wise to speak to your DSN/hospital/clinic to get there guidance if you were tempted to spring for one before you part with any cash.

If you'd like more information, visit www.pendiq.com

Nano technology, non-invasive BG monitoring and smart insulin

There are some diabetes-tech buzzwords that always attract my attention. Thanks to a tweet from Nick Guerin (@Typeaware) I was treated to a triple-whammy this morning.

We have come painfully close to a 'non-invasive' BG monitor (or even better CGM) once or twice before, but it is good to see that the search continues. To be honest the breathalyser-style BG monitor (which still uses a single-use 'strip') interests me less than Smart Insulin, which I think is probably my most favouritest 'wildest tech fantasy come true' product of all time ever - see here.

"A team at North Carolina State University believes so. Prof Zhen Gu and his team are working on a couple of different systems which may achieve this ideal – effectively creating an artificial replacement to the beta cells in the islets of the pancreas, which would normally release insulin to counter high glucose levels.

"Our overall aim is to create 'smart delivery' systems for insulin provision," says Gu. "What I mean by that is that insulin is delivered at the right time, via a safe approach – avoiding too much or not enough dosage – and in a way which requires only small formulations."

One of the team's ideas in development is an injectable nanoscale sensory network, announcing earlier this year that such a system maintained normal blood sugar levels for up to 10 days in type 1 diabetic mice. The "nano-network" degrades to release insulin when glucose levels are high and the researchers are currently trying to optimise it to respond as quickly as pancreatic islet cells do naturally in the body, and to make it more biocompatible with human tissue."

And wouldn't you know it those pesky diabetic mice have beaten us to it again.

Full article is here:
TheGuardian.com - Nanomedicines set to revolutionise the treatment of diabetes