Speed boats and oil tankers - Guest post for Diabetes UK

My ups and downs have been a little more up and down of late (read for most of this year, it's still early Spring, right?). Not exactly disastrous, but I've not really managed to ever get things into any kind of groove for more than a week at a time. A bit wearying to say the least.

Part of me knows the best way to improve things is to go back to basics and do some fasting basal tests and tweak my basal profiles based on actual information rather than the (un)educated guesswork I've been relying on for a while. Another part of me is having enormous difficulty summoning up any enthusiasm, since I know that the summer holidays are coming and I'm likely to stop going to the gym for a couple of months which will have a knock-on effect in itself.

So I'm spending my time grumbling and hurrumphing instead (my family are so lucky!).

On the plus side it does give me a chance to jot down this analogy that I've been meaning to for some time. It's something that usually strikes me when my BG levels are a bit errant, and insulin and food are just not playing nicely.

When it comes to trying to balance the effects of food and insulin on blood glucose levels (well and everything else.. but specifically food and insulin), one thing that makes it very tricky is the difference in the speed of action of carbohydrate and insulin. It's not enough to accurately match the dose of insulin to the amount of carbohydrate you are eating - you have to try to ensure that the two act more or less together to reduce BG wobbliness (technical term).

Almost all carbohydrate is very much in the speedboat class. Fans of glycaemic index tables (GI) might agonise over whether something is high GI, medium GI or low GI, but in my experience the differences equate to something being 'almost instantaneous', 'really very fast indeed' or only 'very fast'. Not a great deal of protection against the ravages of a post-meal spike, either physiologically, or that emotional kick in the guts of seeing your levels rise from a decent pre-meal number well into double figures an hour or so later. From the very first mouthful those big outboards start roaring and the carbs go zipping and zooming about, gleefully spraying glucose in their wake.

Insulin, on the other hand - even the fancy schmancy 'rapid acting' analogues can seem painfully slow to get going. More like one of those behemothic oil tankers or container ships. With a great groaning and clanking, the thrum of the plunger on an insulin pen or pump delivers the dose and then... Nothing. Watch and wait. Is it an illusion? Is it actually moving yet? Nope. Still can't see anything happening.

Vooooom! Swish! The carbs go tearing past again. Running rings around the slumbering giant.

This is particularly the case for me when I am waiting for a correction dose to kick in. I've had to stop myself from checking post-correction BGs before an hour has elapsed. Any less than that and the chances are my BG will be almost unchanged. An hour! Thanks Novo Turgid - not exactly breakneck.

Of course... one of the things about an oil tanker is that once it is moving, there's not a lot you can do about it. All those stories about them needing however many hundred nautical miles to slow down or turn a corner. And so it can feel with rapid insulins.

Nothing... nothing... nothing... Ah good, movement! Good... All good, back into range. Right that's enough now thanks... STOOOOOOOOOP!

But on and on, the dose lumbers forward - an unstoppable force. All-ahead full. The tanker has now run straight over those speedboats crushing them to matchwood and we could very well be steering directly toward Port Hypo.

Corrections can be a tricky course to navigate. Artoo tries to help by offering a suggestion of 'Active insulin' - how much dose is still working away, but there are *many* variables to factor into that equation. Sadly I find Artoo's attempts to be the vaguest of indications at best, and often wildly inappropriate to the particular circumstances of the moment.

Patience is the skill I have to master. I am always trying to remind myself that while the spike in my blood glucose levels may have happened in only 45 minutes or so, the insulin correction will only have stopped after something like 4 or 5 hours. If I get impatient and overcorrect in the meantime I am likely to cause myself another problem (and more wobbles) by overdoing it.

Aye aye, Cap'n.

Hands up who thinks kids with diabetes deserve decent care and support in schools

I was diagnosed at 21, during the final year of my degree. Not perfect timing I suppose, but I recognise that I had it a whole LOT easier than the thousands of kids who are diagnosed at a very young age and who have to try to balance life with type 1 diabetes alongside the unpredictability, raging hormones, growth spurts and peer pressure of school life.

I. Cannot. Imagine. It.

So hats off to Diabetes UK for their 'Make the Grade' campaign which aims to improve the support offered to children with diabetes in schools.

If you'd like to find out a little about what they are doing and why it is so important, they have produced a nifty piece of You-Tubery here:

https://www.youtube.com/watch?v=IDsUSoDtyjM

The "I can..." of insulin pumps - Diabetes Week 2014

The theme of this year's Diabetes Week is 'I can...'. Here's a guest post I was invited to write for the Diabetes UK blog.

When I was thinking about this year's theme of 'I can' I was reminded of a conversation I had with someone last week about insulin pumps. It was something that they were being encouraged to consider, but like pretty much everyone else (myself included) their initial reaction was uncertainty. Uncertainty over being connected to something 24 hours a day. Uncertainty about relying on a fragile piece of technology to keep them alive. Uncertainty about how it would make them feel and how others might view them. Uncertainty over whether it would actually improve anything at all. In short, they didn't really think it was for them.

I know those feelings well. I had them all, and many more besides. I was 'pump averse' for many years. My clinic suggested that it might help with my recurrent hypoglycaemia, but could never really articulate how that might happen. All I could see was a big bunch of (what I thought were) downsides.

In the end, for me, it was reading the experiences of pump users online that convinced me to give it a go. The day to day nitty gritty of how it helped them. Now I'm not saying that insulin pumps are for everyone. Some people wouldn't want to touch one with a barge pole, others do just fine on Multiple Daily Injections and are completely happy as they are. But if it is something you are considering, here are a few 'I can's that an insulin pump has given me to add to your thinking:

If I want to go to bed at 5.0mmol/L, I can.
Ahhhhh basal! I have been through quite a few basal insulins in my 25 years of pancreas-impersonation. In the old days we were always advised to have a snack before bed. Why? Well because in all likelihood your basal-du-jour was going to be a bit over-enthusiastic in the early hours and could well plunge you into an overnight hypo. It was many years before I discovered 'basal testing' (systematically adjusting your basal insulin by fasting tests so that it just holds you steady) but try as I might, even with fancy schmancy analogues I could only ever get my basal 'near enough' on MDI. A bit too much here, not quite enough there... make up the differences with meal doses and guesswork. With a pump, the flexibility of multiple basal patterns which can be tweaked and changed with almost infinite precision mean that I can adjust things so that I am actually starting from a level playing field. To my mind, basal is the bedrock of my BG levels. If my basal is out, even by just a little bit, my meal doses and corrections just do not play fair. So I no longer have to worry about stocking up on carbs before bed, because my basal insulin should hold me level and when I need less insulin overnight I get less. Where I need more just before breakfast, I get more.

If I want to give a really accurate dose, I can.
My doses on MDI were often a bit 'ballpark' to be honest. I have always counted carbs and altered my doses based on what I am eating, but I usually rounded up or rounded down to make things easy. Plus I would use insulin:carbohydrate ratios that meant I didn't have to get a calculator out all the time. The Accu-chek Expert was a great tool on MDI for tweaking doses, but I was still using a 'whole unit' pen so there was a degree of rounding even then. Now I can bolus in decimal places. And those tiny tweaks of insulin here or there do seem to make a difference. True enough my carb estimates are still often done by eye, but at least one part of the puzzle is now being calculated and delivered precisely.

If I want to stop here for lunch, I can.
This was the biggest surprise for me. Rediscovering spontaneity. I began pumping with an fairly entrenched anxiety about being hooked up to something 24/7. I know almost no one who has not had that when considering an insulin pump. Many people say that within a few weeks (days for some people) they become completely at one with their new robot pancreas and never give it a second thought. I can't say that it was quite so quick for me, but certainly in less than six months I had stopped noticing being attached at all and my emerging 'unthought' behaviours (like automatically hooking it to a t-shirt when getting changed) meant I never really gave Artoo another thought. If you are newly on an insulin pump and it still feels a bit of a nuisance or 'in the way' hang in there. Where was I? Oh yes... Spontaneity. So I was well prepared to dislike being attached, but I really hadn't expected that attachment would turn out to be such a bonus. Out on a wander on holiday... get a bit distracted and it takes rather longer than anticipated... Oh this pub looks nice, shall we stop for lunch? What would have always previously been "No we can't, I didn't bring my pens with me" has simply become "Yes!". Wherever we are now I always have my 'kit' with me, and while I used to like the idea of being able to leave all this stuff on a table and just walk around 'like a normal person', personally I have come to realise that I feel much more 'normal' if I can eat whatever I fancy whenever I want to, without having to remember to bring a case full of gubbins with me everywhere.

If I want to have 20 boluses/corrections/snacks in a day, I can.
Well strictly speaking I always could have, of course. But in reality I never did. There is something so easy and effortless about push-button dosing that I am far more likely to add in a fraction of a unit here or there during a day when I recognise that I probably wouldn't have bothered to get a pen out, airshot, dial up and inject. This has increased freedom around snacks too. Where I previously found them just to be too much of a hassle on MDI, almost always resulting is a BG wobble in one direction or other (depending on whether I had bothered to bolus or not) I've had much more success with the effortless mini-doses a pump offers. It's easier, so I bother to do it.

If I want to run a marathon (or just vacuum the stairs), I can.
Again, this was something I more or less tamed with MDI, but the additional options available on a pump, like the ability to set a 'temporary basal rate' for several hours, have added considerable 'polish' to many of those day-to-day conundrums of physical activity. I am far less likely to see my BG levels dip below my target range when exercising these days and I'm buying far less Lucozade!


Just a few things of the top of my head. I'm sure most people on pumps could write their own list. Of course diabetes is still annoying and frustrating quite a lot of the time. A pump is not a magic bullet and it still involves a fair bit of faffing about. But for me having a pump has made a tighter set of BG levels more possible, with less effort and far, far fewer nasty lows.

If you are struggling with wrestling your diabetes into some sort of submission and have been offered a pump as a possible way forward I'd suggest giving it a go.

If I can do it... You can.

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

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

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

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

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

Simple, effective and no equipment needed.

When things are going wrong - DBlog Week Day 4

Diabetes Blog Week Day 4 Mantras and More. Yesterday we opened up about how diabetes can bring us down. Today let’s share what gets us through a hard day. Or more specifically, a hard diabetes day. Is there something positive you tell yourself? Are there mantras that you fall back on to get you through? Is there something specific you do when your mood needs a boost? Maybe we've done that and we can help others do it too? (Thanks to Meri of Our Diabetic Life for suggesting this topic.)

Living with diabetes can be a very lonely struggle at times. When it's behaving and doing more or less as it's told it's not too bad. But when you are struggling to make sense of it from day to day and when everything you try just results in more chaos and apparent BG randomness it can be very difficult to catch your breath. Erratic blood glucose levels are physically and emotionally draining. Often compounded by a little nagging voice in your head whispering about the possible damage you might be doing, and what troubles these levels may be storing up for the future.

It's not easy to get through those days, but I think for me it's a combination of grim determination, digging deep and just carrying on carrying on.

As for mantras and words of wisdom? I'm afraid I can't offer any of my own. So instead, unashamedly, I am going to cheat. Here are some from other people:

"It's not about how hard you hit. It is about how hard you can get hit and keep moving forward" (Rocky Balboa via Grumpy Pumper).

"Yes, you can." (sorry Mr Obama).

"You play the hand you're dealt, and you play it to the best of your ability. The rest is irrelevant." (or some other variation of it).

And of course... The very first thing that popped into my head when I read the topic. Always remember:

"You can do this" (Thanks Kim - youcandothisproject.com)

Ups and Downs - DBlog Week Day 3

It's day 3 of Diabetes Blog Week 2014 (Thanks Karen!). May is Mental Health Month so now seems like a great time to explore the emotional side of living with, or caring for someone with, diabetes. What things can make dealing with diabetes an emotional issue for you and / or your loved one, and how do you cope? (Thanks go out to Scott of Strangely Diabetic for coordinating this topic.)

I'm a bit late posting on today's topic which has given me a chance to browse around a few posts on the link list. One of the strengths of the Diabetes Online Community is the sense of shared experience. Shared struggle. I have read some heartbreaking posts today, but I've also read many that have just made me think, "Yup! Me too." What might have been a difficult topic has actually been hugely encouraging.

The emotional effort of living with a long term condition cannot be underestimated. It is really great to see its importance increasingly recognised in recent years both by clinics, HCPs and by patients themselves.

Like many people I am mostly fine most of the time. But I think everyone who lives with diabetes for any length of time will be familiar with those days when it just seems too much to carry. The weight of it unbearable. The prospect of managing another day with it almost impossible.

So what drags me down? What is my particular trigger?

Well you don't have to read many posts or tweets of mine before I'm moaning about chasing the moving goalposts.

Here's an example. Three consecutive Wednesdays. Each start with a breakfast of 30-35g carbs (2 slices of the same brand of bread, toasted). Then a trip to the gym - 25 minute medium pace run and 10 minutes light weights/core. Lunch is two more slices of the same bread as a sandwich and a medium-sized apple. Evening meal will contain around 50-60g carbs and is likely to be one of 5-10 tried and tested family faves. There is just enough variation to keep me sane, but a clear attempt to reduce the huge number of variables involved so that doses/approaches that have been carefully tweaked *should* give reasonable results. Should being the operative word. Here's what happened:

The eagle-eyed among you may have spotted that the second Wednesday didn't quite go to plan. The first was not too shabby at all, while the third was just bewilderingly level.

And yet did pretty much the same things, in the same way.

I put just the same amount of effort in. I played my part. But for no discernible reason my basal requirement altered dramatically around Wednesday #2. So then it's back to basal tweaking for the next 5-6 days (often much longer) with all the 'out of range' results and uncertainty that entails until yesterday when it began to fall back into place. 

Tomorrow? Who knows!

I've been chasing these changes back and forth for months. For years actually. Some times I get some stability for several weeks on the trot. But not often. And I recognise that I am incredibly lucky to have it so good.

But this is the grind for me. The thing that can wear me down. The actual doing of the routine is not so bad. Some routine, occasional special occasions/treats/holidays, then back to routine. That always seems doable.

But putting in all the effort and getting a BG roller coaster back seems less than fair. Not exactly a reward for any self-control I may have mustered. And every time the goalposts chase off into the distance it's more effort, more tweaking, more testing. And all the while, more out of range results and the spectre of diabetes-related nasties prowling around the edges of my consciousness.

But... And it's a BIG but...

Every time I rant about the frustration of having to fix something I haven't broken - EVERY time - someone will be there, day or night, from one corner of the world or another, to offer support, sympathy, smiles.

This is the beauty of the DOC. We are stronger together.

Poem: Helpful comments - DBlog Week Day 2

Today's DBlog Week challenge is to write a post as a poem. Here goes...

Helpful comments

Was it because
You had too many cakes?
Or ate too many sweets,
Is that what it takes?

My Grandmother had it
And she lost her eyes.
My Uncle's feet fell off
To everyone's surprise.

Can you eat that?
Can you eat that?
Can you really eat that?
Can you eat that?
Should you eat that?
You shouldn't eat that!

Injecting yourself?
I don't think I could
I'd rather die...
(Well actually, you would!)

Increased risk
Of heart attack, stroke,
Kidney failure, blindness,
Body broke.

What was this high from?
And why there that low?
You simply must
Try harder, you know.

Can you eat that?
Can you eat that?
Can you really eat that?
Can you eat that?
Should you eat that?
You shouldn't eat that!

Thanks for your help folks,
But can I suggest
You think before speaking
We're trying our best.