Tuesday, 24 July 2012

What’s Better? High or Low?

So following on from my piece on what classifies as a hypo (you can read it here) – and the addition of the word “waffy” to the worldwide vocabulary - I thought I’d develop the idea that the patient with diabetes and the medical professionals have different opinions on what is good and what is bad. Again I’ll be basing my thoughts on my slightly messed up thinking following 30-odd years of varying control levels and judgement. I could use medical research and qualified expert opinion but why should I start doing that now?

Before we start I’ve a simple question for the fellow Ds reading this. For the non-Ds don’t give up; hopefully the rest of this piece will give you a delve into the brain of one person with diabetes – as always your diabetes may vary, so this isn’t guidance or the opinion of everyone but it’s mine and the one thing writing down my random thoughts has proven is that others think the same as me. Maybe. Sometimes. 

Anyway I promised you a simple question so here it is:
What is better to be slightly low / waffy / hypo (4mmol/L or 73 mg/dl) or to be slightly high (10mmol/L or 180mg/dl)? 

OK, you don’t have to tell anyone your answer but I’ll guide you through mine. I’ll preface this by saying that I have relatively good hypo awareness and no noticeable complications.

For me it’s going to be the low every time - apart from when driving, operating heavy machinery, unicycling across the grand canyon etc. For years the one judgement of ‘success’ of my 24/7 ‘management’ – lol there’s another lose term, was the score returned by a simple blood test that takes a mean average of my BGs for a long period. HbA1c measures your average BG for the previous eight to twelve weeks. That’s perfect you might think. Surely it’s the easiest way to look at what my ‘normal’ BG is. So for years when looking at the results Consultants (Endos) would look over their glasses at me and say “Hmm, that’s a little high, you need to bring that down”. Simple English you might think but the use of the word high when discussing HbA1c has had a huge influence on my opinion on whether it’s better to be serially-waffy or ‘high’. If I have to bring down my average then I need to get as low as I can reasonably be for a long as I can and also try to reduce the number of ketone-inducing hypers to lift the average to a more normal level.

This sat well with me as a logical practice for years before the huge head-mess from my diabetes specialist nurse who suggested that the best way to bring down my high A1c was to reduce the number of hypos and aim to lift my target BG levels. What?  How?  Yes, again, I know the logic is there but it’s erm, wrong. You can’t tell me for years my BGs are too high and then ask me to fix it by reducing the number of lows and lifting my target levels. Malfunction, brain does not compute!!

So after picking me up off the floor and explaining the logic we agreed that my high levels were due to over-treating of hypos and therefore if I had less hypos I would drink less Coke and there’d be less of a rebound. Perfect. Then I had to glide through meetings with my local GP’s Diabetes Nurse who was still in 1986 in her thinking (that was similar to mine) that if my A1c was high then I wasn’t having enough insulin. Thankfully she was happy that maybe my DSN was the one I should check anything with first.

So me and the DSN have treated the cause of the high average but she’s still contrary to me on what a dangerous level to run at is. I’d prefer to bounce along at between 4.5 and 6 (81 and 108) in my perfect D dreams, but this is ‘not good’ in her world of being trained that any hypo is evil. I’ve got relatively good hypo awareness so any waffy moments can be helped with a couple of Fruit Pastilles (3g of carbs in each) to lift me gently out of head-fuzzines.

And so we sit at seemingly opposite sides of the same desire to improve my overall control and bring my average BG to a figure that can sit comfortably on their trained measure of what will prevent ‘complications’ in the near/far future. If my BGs are high I know that blindness and imminent death will be around the corner. The proof of this conflict is when I borrow a CGM for a week. I have one coming up and once again look forward to the background trending analysis it can provide. Going off on a tangent slightly the CGM benefits this time won’t be useful in measuring a normal day as we’re off to the London 2012 Olympics for a few days on the day after I have it stuck in. Obviously when we applied for tickets we went for the high profile sports to see the world’s most talented and most famous athletes. Hence why we now will be watching the group stages of women’s basketball and women’s hockey. Hey ho, we’ll be there and I’m still pretty damn excited.

Where was I?  Ah, yes. CGM analysis. When we sit down and analyse my BGs her eyes will zoom in to anything marked red as a hypo and mine will go straight for anything in double figures. In her defence she’ll also look at those in the middle and compliment me on any that are in range; whereas I’ll ignore those and just look at the failures. She’ll come out with statements such as “Oo, you were a little low all day that day” while I’ll be looking at the same figures of between 4.2 and 5.8 (76 and 104) and think “Wow, you got it spot on that day Dave”. For me low is good because I'm now at a stage where I'm relatively comfortable how much treatment I'll need to bring it up. Treating a slight high is more of a black art with correction doses frequently ending in lows. 

So who needs retraining; me or my DSN? I know I can't be alone in my thinking but going back to the previous blog how do I persuade my healthcare professionals that all hypos aren't evil?

I absolutely love the psychology that comes with being a person with diabetes and how much of a factor in a someone's treatment it can be. As our day to day management is in our hands, it is a foolish Health Care Professional who thinks that by telling us what is 'correct' it will be enough to get us to buy into the principle. I know there are some HCPs out there who do know all this but for them to understand why takes time and reprogramming of their mind too.

To conclude what is best waffy or high? I know the real answer is that neither are good and perfect control is what we must strive for but for as long as we are told that complications (there’s that word again) arrive because of bad control which is judged by  highness on the A1c scale, I think I’ll stay tending towards the low side. DSN; I’m sorry.

PS. I hope everyone in the UK has now completed their feedback to the government on food labelling. If not, why not?  Go here. Now. Thanks :)

Tuesday, 17 July 2012

The Big Event

Hello again.

Just a short one today to say look here, yes here.  You’ll then find my review of Diabetes UK’s first Big Event.  It had a few trade stands and a selection of 19 lectures and discussions delivered by healthcare professionals and other people with diabetes – and sometimes that was the same person ☺

I hope you enjoy it although I apologise if it’s a bit long – I do tend to ramble a bit as you might have realised by now.

Before you go though I’ve got a request for my UK readers – Hi there.  The government has a consultation in place at the moment relating to food labelling. If like me you like your carbohydrate values shown on your food then you need to tell them before they swap them for some simplistic traffic light symbols.  I’m not sure how the pump’s bolus wizard would handle me telling it that the item I was holding had ‘amber’ carbohydrates.  And maybe you’d like it to be compulsory to show total carbs per packet or item rather than just per 100g leaving you to guess how heavy something is.  If you would, tell them.  Tell them now.  The consultation ends on 6th August 2012 so I’m afraid this isn’t something you can put off to do later.  It won’t take long. Just do it. NOW! HERE!

Hope you have a good week.


Tuesday, 10 July 2012

What Is A Hypo?

Most regular readers of the blog (there are at least six of you I think) will be experts on the whole diabetes 'thing' through either living it or living very closely to someone with it.  So asking the title question of this blog might seem a little strange.  But it's been puzzling me for a while so I thought I'd take this moment to have a ponder and think it through.

In true high school essay stylee I'll start by looking at the dictionary definition and then break this down as to why it might not be the case.  So using the modern equivalent of the OED we shall see what Wikipedia has to say on the matter:

"Hypoglycemia, hypoglycæmia or low blood sugar (not to be confused with hyperglycemia) is an abnormally diminished content of glucose in the blood. The term literally means "low sugar blood" (Gr. υπογλυκαιμία, from hypo, glykys, haima). It can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose to the brain, resulting in impairment of function (neuroglycopenia). Effects can range from mild dysphoria to more serious issues such as seizures, unconsciousness, and (rarely) permanent brain damage or death."
Blimey, that's a bit scary! But having such a clear definition should make it easy to answer the standard clinician's question asked in many appointments: "How many hypos do you have?" or "When was your last hypo?" But that's the problem, for me, and I'm guessing other people with diabetes, it's not that simple.  In a 24 hour period I may bounce a few times into a state that might be medically classed as 'hypo' but a quick treatment with either a couple of sweets or my scheduled meal means that it doesn't really cause a pulse on my 'that was a hypo' radar. More that it was a low that needed dealing with in a mild and not overly urgent way. 

For me answering the question I'd search my not vey brilliant memory for moments where I had to either take time out of what was occurring at the time or be in such a state that it's noticeable to others. And I think that's my trigger to acknowledge. If my waffy moment (for definition of 'waffy' see here) needs the assistance of other people or triggers a 'what's he doing?' by other people then I'll classify it as a hypo.  Indeed the DVLA in the UK are primarily interested in those events they classify as 'severe hypos' that require the assistance of another person to judge whether you are a fit and proper person to drive a car. 

It may be just me but I also think it depends on the circumstances as to your judgement on the question.  As I have relatively good hypo awareness I feel able to self-classify my 'attacks' - I really hate that word by the way as it conjures up images of me waving a knife around whilst trying to find some coke to drink.  However a parent or carer can only use the numbers from the machine and behaviour judgements and so much more simply classify. i.e. 4.8 mmol/l (86 mg/dl) - "Oooo, that's a hypo. Eat!" 5.2 mmol/l (94 mg/dl) "Well done, excellent score". And here we are also ignoring the vagaries of blood glucose meters to provide an accurate yet reliable and consistent result. Read an excellent piece here for further analysis of the unreliability of BG meters results.

For me I think it comes down to a hypo being more about a feeling and brain squiggle rather than a number on a machine.  I think I've mentioned before the flaws in the judgement provided by a single HbA1c reading and similar rules apply to BG readings.  I was discussing Adam (my pump) with a friend at the weekend who is a teacher and I was giving an example of the bolus wizard to show how it calculates insulin dosage based on carbs and BG.  So I did an obligatory test and it came out at 9.9 mmol/L.  To which the teacher exclaimed that that seemed very high and wasn't I concerned?  I then explained that it was a couple of hours after a bran loaded breakfast, I'd lowered my basal because of having an active morning, I was being pretty active on the touchline and IOB suggested it was pretty good.  So as always it's everything in context.  A 4.2 just before dinner for me is slightly lower than I'd like but not overly bad.  But a 4.8 an hour after I've eaten with plenty of insulin stacking up is a much bigger worry.

So in summary, and to answer my opening question; I don't really know.  I know you've read this far hoping for the magic answer but I must apologise and explain I truly believe its a personal judgement.  As always 'your diabetes my vary' so if a doctor asks you how many hypos you've had ask them to clarify what they mean before giving them an answer close enough to the truth so that you can both work on reducing them even further.  For me it will still remain classified by the treatment type:
*1 Fruit Pastille (FP) = 3g carbohydrate
Four FPs or less = waffy. 
Five to seven FPs = mild hypo. 
Eight FPs or more or a can of Coke (not Diet) + abusing random people = hypo worthy of note + apologies aplenty required.

I hope that was helpful although I'll admit it was lacking in ultimate clarity and guidance.  Sorry. 

Finally today I'd like to dedicate this blog to an old friend of mine that sadly passed away just before the weekend. Back in my youth I took a year out before heading to university to help look after a wonderful man called Mayo who had Duchenne Muscular Dystrophy and was studying at Leeds University.  As a country lad who'd just turned 18 he gave me a whole new slant on life and always had a positive outlook even if he'd been dealt a very bad hand of cards from the start.  His disease meant he was restricted in movement but not in any why in his mind.  He was at true gent who always looked for the best in everyone and I feel honoured to have had a chance to share a part of his life with him.  My thoughts and prayers at this time go to his wonderful family who were also some of the most friendly and warm people I have ever met.

It's at times like this when as a diabetic of the modern era i must take the time to realise that it's not all bad and the medicine and technology of the modern age make my condition something I can manage in a relatively unobtrusive way.

Dave xxx