Diabetes Blogs

This is the first in a series of blog posts about the most common diabetes myths.

This is something you see all the time in the media, in general news reports, newspaper articles and the implication is everywhere, even if the words aren't.  Type 2s are made to feel like its their own fault they got diabetes because if you get fat, you get diabetes, right?

Wrong.

The phrases used are very subversive along the lines of "There is a link between obesity and diabetes".  Well yes there is, but the implication we seem to be bombarded with is that obesity causes diabetes.

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The name was coined (very wittily I thought) long ago on another forum by TerryG and it's now applied universally within DSF to that species of GP's Practice Nurse "who sees the diabetics".  What gets into these women to turn them into Nursie Nightshade?  I'm sure any forum member would recognise the species.  The ones who try to insist that young diabetic women of child bearing age go onto statins, the ones who "discourage testing" because "it's bad for you and you don't need to know", the ones who are just plain ignorant and the ones who sneer at their patients as though they are either naughty children or dotty old folks.  Hba1c too high?  Oh naturally the patient is non-compliant, off munching copious bars of Cadbury's Dairy Milk the minute they leave the surgery.  Total Cholesterol too high?  Naturally the patient is spending every meal time wallowing in grease.  I could go on, but as I said before most diabetics know the type.  A comment from another member of the forum around the same age as myself regarding her nurse "she's horrible" turned my thoughts to my own last "diabetic review".  I thought I'd escaped and that my own nurse was of a better educated, more sympathetic variety, but since my last appointment I am none too sure.  Perhaps that's just a little unfair, because she does seem to know a lot more about diabetes than a lot that we hear about in the forum. 

Going back to diagnosis she was very helpful and nice.  Though I have always been somewhat annoyed that it was she who labelled me T2.  A label I now cannot shed as far as my medical records are concerned.  As far as I can see it was only pinned on me because of my age and has since precluded me from ever getting a DAFNE or similar course, even if they were on offer in this area, which they're not... but leaving that aside she was very good back then and was also very good when I wanted to change to basal bolus rather than mixed insulin.  Plus, when I once handed her a list of questions I wanted answered she was gracious enough to admit she didn't know the answers and referred me to the DSN at the hospital (who actually wasn't much use, but that's another story). 

No, what I find difficult is the implied criticism that permeated the conversation at my last review.  I thought we'd got onto a level of mutual respect, but perhaps it was just a veneer.  Back at my 2^nd Hba1c after my diagnosis she tutted and humphed about the result, which was 7.8 and yes, even ignorant as I was back then I knew it was "not good".  I couldn't understand it because I really had been sticking to the diet that the dietitian had told me I must stick to.  Maybe the odd lapse over Xmas?  So instead of saying "But that's ridiculous, I've really been trying to stick to this diet I'm told I must follow".  I just shifted uncomfortably in my chair, felt ashamed and said "Well, it is a bit close to Xmas and you know....." leaving the sentence trailing guiltily in the air.... Yes, of course it must be my fault! 

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In May this year I was concerned about the post prandial spikes I was having.  If I took enough rapid to iron them out I was going hypo later on before my Novorapid had finished working.  I understood that Apidra had a faster peak and less of a tail so I asked to change to Apidra.  My nurse was in agreement and prescribed me a box of five Solostar pens.  I checked specifically to ensure that the Novofine needles I was using were compatible with the Solostar pen and was assured that they were.

 

When I started using the pens I noticed a severe leakage when withdrawing the needle from my abdomen.  I had never noticed this with Novorapid flexpen or the Novopen 4, nor with Levemir pre filled pens (or indeed, previously when I was using the Optiset pen with Lantus).  I continued to use the Apidra Solostar pen for approximately three days, during which time my BGs were raised and by this time I was completely convinced that this was because I was not getting full delivery of the dialled dose.  I was, however, unsure as to exactly by how much the dose fell short.  I telephoned my nurse and after consulting with her I started on a fresh pen.  Just in case, I placed the original pen back in the fridge.

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There seems to be endless controversy surrounding the diet that is best for diabetics.  I read several forums but post mainly in one, with the odd comment elsewhere if I feel particularly strongly.  The main bone of contention seems to be whether or not to low carb and denigrating the advice so often given by NHS professionals to eat “starchy carbs with every meal”.  It causes endless dispute in online forums to the point that people argue and flounce and leave and get a tad nasty. 

 I subscribe to the “eat to your meter” brigade.  In other words “if a food doesn’t spike you then it’s fine, if it does then either don’t eat it or limit it”.  My meter is my best friend.  This is true of all diabetics, including those like myself on insulin only, but perhaps more so for Type 2 diabetics who have to rely to a greater degree on their diet for control.  So, after six years of listening to the same old stuff, why have I suddenly seen another aspect of the issue and why have I been moved to write about it?

 Perhaps because of a minor storm in a teacup that blew up fuelled by a DAFNE graduate who maintained that they could eat whatever they want whenever they want.  It wasn’t so much that statement that grated, because after all, that’s the whole premise of carb counting and DAFNE in particular.  No, it was the further presumption that those of us who like to have tight control live like a bunch of monks, getting excited about a lettuce leaf and denying ourselves any pleasure whatsoever in food, or indeed life!  It came as a bit of a shock, if for no other reason than I consider that I have always been something of a gourmet and that I recognise that I’ve never eaten better than I have since diagnosis.  My diet is so eclectic, embracing every cuisine from Britain to the Far East by way of Europe and every continent between.  The world provides my menu.  I like nothing more than trying out new recipes and new ingredients.  I look forward to planning a week’s meals, or more properly a weekend’s meals, when I have the leisure to experiment and the time to prepare things.  I can then freeze half the finished result to eat during the working week.  The only difference in being diabetic, as far as I am concerned, is that I look for ways to adapt the recipes to lessen their impact on my BGs.  It’s surprisingly easy, a tweak here a tweak there and hey presto, a diabetically friendly meal. 

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The T2 "You don't need to test" Myth.

There were 2 studies published in 2007 and 2008 which appear to be used as the main justification for the claim "you don't need to test" in relation to Type 2 diabetics.  These studies were both flawed in this reasoning and their conclusions incorrect.

The DIGEM study published in 2007 by Farmer et al started out with the objective of using Self Monitoring of Blood Glucose (SMBG) to reinforce the prescribed dietary advice, using 3 BG readings each on 2 days per week.  However the patients were told not to change their diet because of the results they obtained and were encouraged to stick more rigidly to the prescribed diet.  
"They were also given training and support in timing, interpreting, and using the results of their blood glucose test to enhance motivation and to maintain adherence to diet, physical activity, and drug regimens" [1]

However, because the HbA1c of the patients did not improve as a result of testing, their conclusion was that SMBG does not help to lower HbA1c.

This is a flawed conclusion.

It merely demonstrates that getting patients to test while instructing them to do nothing about the major cause of high BG (meal choices) does not help reduce HbA1c.  The patients were told not to change anything, but to stick more rigidly to what they were already doing.  It appears to be rather obvious to most laymen that simply recording data while preventing any change to the underlying causes does not help to reduce problems.

Since no change was observed in relation to the HbA1c of the patients in the study, it would appear to demonstrate that the prescribed diet does not help reduce HbA1c.  This is not surprising.  The dietary advice from the British Dietetic Association, echoed by Diabetes UK and other organisations is to base meals on starchy carbohydrates.  Since carbohydrates raise blood glucose levels and as a result, contribute to the HbA1c this dietary advice is clearly not designed to reduce HbA1c.

The ESMON study published in 2008 came to the same flawed conclusion as the DIGEM study, but for different reasons.  It also concluded that SMBG increased rates of depression in patients.

Their method can be seen from this quote:
"They were asked to monitor four fasting and four postprandial capillary blood glucose measurements each week. They were advised on appropriate responses to high or low readings. Such advice included the need for dietary review or the suggestion of exercise (such as walking) in response to high readings." [2]

Notice that there were 4 fasting and 4 post-meal readings.  Unless the post-meal readings were all at breakfast, there is no relationship between the before and after BG of a meal.  The post prandial readings were then likely to be unrelated to anything else and if the BG was high before the meal, this would tell the patient nothing about the cause of the high BG.  As any scientist or statistician knows full well, a single spot check proves nothing.

Also, because of the unpredictable nature of Dawn Phenomenon, a fasting reading on its own demonstrates very little.

Also due to the reliance on dietitians in other areas of the study's methodology, it would appear that "dietary review" involved discussion along the lines of reinforcing the prescribed dietary advice.

How the patient is supposed to gauge the effects of exercise based on a post prandial BG, unrelated to the exercise session without any readings before or after the exercise itself is not explained.  Presumably this was to reinforce the slight difference to BG made by exercise for the following 48 hours, although this can be wiped out by unwise dietary choices.

So again, this study was attempting to reinforce the standard dietary advice, which is not aimed at reducing HbA1c.

The reason for the increased levels of depression then is easily explained.  When these patients obtained out of range BG readings, they undertook dietary review, reinforcing a diet which is not aimed at reducing BG levels which then did not help to reduce BG.  So the patients were sticking more rigidly to their dietary plan, more rigidly to their medical advice and failed to see any improvement.  Then they got depressed.

One respondent to the BMJ site on this topic recommended the study for a "no s**t sherlock" award.


The method of SMBG recommended by diabetics across the world via the web is usually summarised by Jennifer's Advice:
http://www.diabetes-support.org.uk/joomla/jennifers-advice
Increasingly, it appears, people are also recommending pre-meal BG readings to compare with the post-meal readings in order to see the change in BG rather than absolute numbers.  This gives a better indication of the effect of the meal.

The important thing about this approach is the emphasis on learning from those BG readings to govern future food choices.  As time progresses the patient learns more about the effects of food.  But the more intensive the testing, the more effective the process.  Using SMBG a couple of days per week is not effective since the patient does not learn anything the rest of the time and may be elevating their BGs as a result of  unwise dietary choices.

Key to the control of BG, as shown by all those who have used Jennifer's Advice is the control of carbohydrate intake.  This does not specifically mean carbohydrate avoidance, but a tailoring of the diet to the quantities and types of carbohydrates which can be tolerated by the individual.

Over 6 years I have seen a great many Type 2 diabetics try Jennifer's Advice and achieve massively improved HbA1c results.  I have not seen any patient who has given it a serious try, who did not have an improved HbA1c.

Perhaps someday, a researcher will bother to ask a well controlled Type 2 how to study the effects of SMBG.  The study would then involve more intensive testing with a premeal test and both 1-hour and 2-hour postprandials.  There would be groups which performed this level of testing for 1,2 or 3 meals per day and a group which also did additional tests at other times.  The study would obviously show an improvement in HbA1c over a 3 month period - better still 6 months to allow the patients to learn and improve from that learning.  From the results of such a study it would be possible to work out the most cost-effective way of helping patients to self-educate over a period of months

So in summary, these two studies do NOT prove that SMBG does not work.  It proves instead:
1)  The specific methods and purposes of SMBG used in the DIGEM and ESMON studies do not help to lower HbA1c
2)  The prescribed diet based on starchy carbohydrates does not help to reduce HbA1c.

 

 

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What is Second Life?

This question comes up time to time since we have a few people on Second Life in recent months and it get a mention in the forums occasionally. So I thought I should put up a blog post to explain.

Second Life (SL) is an online 3D virtual world. For most of the time DSF members use it as more of a 3D chatroom than anything else, although we have not quite got around to using microphones yet. However there's more to it than that.

To get started in Second Life you need to visit http://www.secondlife.com , create an account and download the software. The account name you create cannot be your real name and will be the name you appear as in-world. Its also your login. So when you start Second Life on your computer, you will log in with that name.

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Since I am flying today, I've been checking up on the current restrictions for airport security and checking through my hand luggage for any stray items from previous trips.

All very logical, but I am certain that at least 2 people in the queue for security ahead of me will not have done.

I went to the Liverpool passport office yesterday.  You now have to go through a metal detector on the way in.  There's a long queue before the metal detector so you know whats coming well in advance.  To pass the time you can read the notices advising you that if you joke about having a bomb you will get arrested.

So after 5 minutes of shuffling along to get to the metal detector, the prat in front of me gets to the front and suddenly realises that he might have to empty all 27 of his pockets and take the bag off his shoulder.  Then he goes through the metal detector and sets it off anyway.

I set it off as well which is odd because I had gone through without setting it off the day before.  But at least I had not wasted everyone else's time simply by doing 5 seconds of preparation while I was waiting.

You get the same in supermarkets as well of course.  Its always been women as well in my experience.  The blokes always have a wallet in hand before the start.  But after shoving through 400 items (and packing 50 of them), there is a moment of stunned realisation that she might actually have to pay for this stuff.  This means unearthing the handbag from underneath that two bags that she has actually got around to packing, then rummaging around in the 4 tons of assorted hankies and other crap to find the purse.  Then there's the inevitable hunt for the last penny.

I go through, have my card in the PIN machine before the till jockey has finished announcing the total, telling them that I don't want cashback thanks, well before being asked and constantly packing while the machine farts around.  By the time the receipt comes out, I have hold of everything and am itching to leave.

So here's some tips for airport security.
1)  Empty your pockets into your bag or jacket BEFORE you go to the security point if you don't want to hear obscenities muttered behind you.
2)  Take your bloody jacket off BEFORE you go to the security point.  Its not rocket science.
3)  Your passport and boarding pass should be in your hand, not at the bottom of your cavernous handbag.  Yes those notices telling you to have those items to hand DO apply to YOU as well.
4)  If your watch, belt, glasses or jewelry have ever set off a metal detector in the past, hows about taking them off this time?

If you are unwilling or unable to follow these simple instructions, kindly tell the security people that you are carrying a bomb.  Then some helpful security types in rubber gloves will take you to a small room for a chat and get you the hell out of my way.

Airport security - doesn't affect my BG but it plays hell with my BP.

Mention going somewhere on business and people immediately think in terms of the exotic and start comparing it in their heads to some form of holiday or short break.

Nah.

These things are never fun, as anyone who has done a few will tell you. Off to Milan this week for an overnight stay and meeting. What this means in effect is the following...

You go to the airport and have to hang around bored for an hour after check in, get on a plane which may sound exciting for anyone who doesn't fly much but its as exciting as getting on a bus after a while. You arrive eventually at a hotel and have enough time for a coffee or one beer. Spend an hour looking for the one TV channel in English, shaking your head at some of the more bizarre TV shows they have in that country (The german TV gameshow "Strip" being a classic). Then maybe get prepared by reading some dull papers and get some sleep. Up and breakfast then off to a meeting.

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From another site: 

Give this a try. It really works.

1. First of all, pick the number of times a week that you would like to have chocolate (more than once but fewer than 10)

2. Multiply this number by 2 (just to be bold)
  3. Add 5

4. Multiply it by 50 -- I'll wait while you get the calculator

5. If you have already had your birthday this year add 1759 .
If you haven't, add 1758.

6. Now subtract the four digit year that you were born.

You should have a three digit number

The first digit of this was your original number
(i.e., how many times you want to have chocolate each week).

The next two numbers are YOUR AGE! (Oh YES, it is!!!!!)

I've recently started making clothes again in Second Life. Part of the reason for this is that we have extended DSF island to the extent that it costs $8 USD per month. Half of the island is free, but we are having to pay for the other half.

However with a little effort and a bit of startup cash, its possible to make money from Second Life. In fact there are now millionaires who have made their fortune from SL and other virtual worlds. One of the first who was publically known is Ansche Chung who I heard about 3 years ago. She made a million dollars (US), moved to china and set up a business employing at least 9 people purely making money out of virtual worlds, with SL being the main one.

So if other people can do it then it should be possible for me to make enough money from SL to be able to pay for the island.

In the next week I intend to set myself up in a shop, selling clothes. So how did I get to this point?

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