Another Christmas party

Boston Harbour, June 2015

You may have noticed that I haven't been reading as many books as usual. This is, in part, due to two new podcasts which have taken the place of my regular audiobook listening, but also because I've been generally doing jobs that need doing or watching films on DVD instead of reading. The films I've seen in December have been rather good too: Mr Holmes (Ian McKellan as Sherlock Holmes is 93 and looking after bees), Amy (Amy Winehouse sings beautifully but is troubled and it doesn't end well), Key Largo (Humphrey Bogart and Lauren Bacall act their socks off), London Road (a musical about the Ipswich prostitute murders, much better than it sounds), Dawn of the Planet of the Apes (humans vs apes and, like Amy, it doesn't end well), And When Did You Last See Your Father? (based on a book by the poet and author Blake Morrison about the death of his father with an absolutely stellar cast).

Aside from my DVD watching it is that time of year again, holidays are approaching and overpriced Christmas celebrations abound. Despite the opportunity to attend at least six of these due to being part of the Venn diagram of intersecting Dietitians, Diabetes teams, Hospitals and Badminton Clubs, I elected this year to attend just one event, with the Diabetes team in the hospital where I work. In fact I've also signed up for the Christmas event organised by badminton club #2 but this has been postponed until January, a strategy of which I thoroughly approve.

So, posh overpriced Christmas dinner event with the Diabetes team took place in a marquee to allow the upmarket venue to rake in even more money from punters determined to celebrate Christmas in the way that seems to have become compulsory - dinner, entertainment, disco. We had a local DJ running the entertainment part, which involved an element of competitiveness in order to win various prizes that I didn't want - but I know I am not the typical attendee. As usual, I wasn't drinking, which I have to admit spoils the fun a bit because I start to tire of pissed-up young women squealing in excitement and falling off their vertiginous heels. What a spoilsport I am, not wanting to spend the evening with the aim of consuming as much alcohol as is practically possible.

My abstinence also backfired when I was nominated as the 'Leader of the table'. The DJ/host invited each table to nominate their leader for unspecified duties at a later time, and I was unanimously elected, with the justification that my sobriety would enable us to win whatever prize was on offer without effort. One competition involved answering ten questions in a minute in order to win £1000, and my protests that I was a really poor choice for this kind of quiz went unheeded. In the event I wasn't chosen to compete, thank goodness. Most of the others on the table knew 8 or 9 of the answers even though they had quaffed a good deal of strong drink; I managed about 5 due to my complete ignorance of any music or TV or 'celebrities' that may have appeared since 1990. For goodness sake, I've only watched one TV programme in the last five years. The other duty of the 'Leader of the table' was to compete in a dance-off, and the less said about that the better. We didn't win anything.

My last complaint about the event (oh, how negative I am) was that the disco included only recent tunes. My preference is obviously for an era when they knew how to write catchy songs that are great for dancing, the obvious exceptions being Come On Eileen and anything that has actions associated with it (the Macarena, and that one where you sit down and pretend to be rowing etc). Where were the 80's hits? Even Abba would have been welcome. I did my best however, and the Lady Shoes left my feet suitably bruised and painful. So that's it for this year's festive dancing.

On a more positive note - I discovered that the computer system that mysteriously calculates annual leave days has clearly uncovered more goat entrails, because although I thought I had virtually no days left until March, in fact I have a bit more than a week! I am torn between the idea of having an extra week skiing (I already have a week booked late in the season) or concentrating on getting my house into a fit state for civilised habitation. Skiing or house? House or skiing? I have a feeling that skiing will win. Seize the day and all that, who knows how long I will be able to maintain this glorious level of fitness?

The scratch choir I joined has delivered its festive message to two churches and one hospital, and the clarinet group has also contributed to a lovely concert alongside flutes and saxophones led by our enthusiastic music director. I have also consumed one festive lunch at work, and at the time of writing there's one badminton match and a couple of quiet days at work remaining before all is suspended for the holidays, although Parkrun is still happening on Boxing Day and I'm intending to be there.

A very Happy Christmas to one and all.

What I've been reading

His Last Bow
by Sir Arthur Conan Doyle

narrated by Simon Vance

"These mysteries involve the disappearance of secret plans as well as of a lady of noble standing; the curious circumstances of Wisteria Lodge and of the Devil's Foot; as well as the story His Last Bow, the last outing of Holmes and Watson on the eve of the First World War."

Conan Doyle is still trying to end the sequence of stories by bringing Holmes out of retirement to participate in a story called 'His Last Bow', but no, there's still one more book to go. These stories are still pretty good although I'm getting the hang of working out what the solution to the mysteries might be before they are revealed.

The Drowned World
by J. G. Ballard

narrated by Julian Elfer

"Fluctuations in solar radiation have melted the ice caps, sending the planet into a new Triassic Age of unendurable heat. London is a swamp; lush tropical vegetation grows up the walls of the Ritz and primeval reptiles are sighted, swimming through the newly formed lagoons."

An interesting book and, unusually, I didn't think it worked all that well in audio form. I'm not sure why, but it didn't keep me wanting to hear more, although somehow I thought that it should. Maybe I'm giving J. G. Ballard the benefit of the doubt because I still remember how powerful the audio version of 'Empire of the Sun' was, which I listened to more than 15 years ago on cassette in the car commuting between Manchester and Liverpool. I don't remember the plot of that book, just the fact that it gripped me, so maybe I should listen to it again?

From Here, You Can't See Paris
by Michael Sanders

"Whether uncovering the darker secrets of making foie gras, hearing a chef confess his doubts about the Michelin star system, or absorbing the lore of the land around a farmhouse kitchen table after a boar hunt, the author learned that life in Les Arques (population 159), a hilltop village in a remote corner of France untouched by the modern era, was anything but sleepy."

I do feel that this is a bit of a tired format - an individual goes to France (or Spain, or Italy) for whatever reason, discovers very interesting things particularly focussing on food, thinks it will be fascinating to other people, writes a book. Perhaps Peter Mayle was the first with his Year in Provence, and I remember finding that book captivating. Since then there have been endless repeats, and while this one isn't bad, there's nothing to lift it above the ordinary.

The Case Book of Sherlock Holmes
by Sir Arthur Conan Doyle

narrated by Simon Vance

"Includes the case of an eminent physiologist inexplicably savaged by his faithful wolfhound, of the priceless stolen Crown diamond found in the pocket of a peer, and of the mysterious figure who means to buy Mrs Maberley's house and all of its contents, whatever the cost."

So the odyssey is over, 58 hours 4 minutes of high class audio book is finished. I have to admit that this last lot of stories is the weakest, but nevertheless a worthy finale. The first of the series was published in 1887 and the last story of this last book came out in 1927 - an extended period of which I was previously unaware. It's been a blast.

Turbulence

Back garden in May 2015

It's coming up to the end of the year, and I have so many treats to look forward to in the coming months. A walking holiday, a whisky tasting, the annual Lola II and Mr M Film Festival, a posh dinner that's already arranged, lots of badminton, maybe some running, the international badminton competition in Birmingham, skiing in France - and all of that in just the first three months of the new year.

The national and international news contrasts with my anticipated pleasures. The floods are terrible, but the international refugee situation and our 'interventions' are unbearable. It has reached the point where I can manage to listen to no more than half the news before I have to switch it off. I've always been somewhat of a pessimist - or a realist, as I tend to rationalise my outlook. Humanity in its individual form can be uplifting or depressing, but as a population seems to me to have little to recommend it. Looking beyond the small range of my personal contacts, towards those who wield 'power' either in politics or religion or business, reality looks bleak to me.

I may be wrong, but I think there might have been a golden age last century when integrity was a trait that was admired, if not rewarded. There was a sense of right and wrong. To be sure, people still suffered pain and poverty, but role models existed and there seemed to be something to aspire to. Now that I'm pondering the matter, it is possible that my upbringing sheltered me from some of the seedier aspects of society, but I believed that there was some depth to thought and behaviour, where now everything seems so shallow. I can't tolerate most broadcast and print media any more. The majority of politicians now seem to be overtly corrupt and self-serving, where they at least used to be ashamed when their misbehaviour was found out. The current government brings back vividly the strength of my loathing of the Thatcher government and its values of greed, rewarding of privilege, and disregard for anyone unlucky enough to be stupid or poor. You pay rich people more to get them to work harder, and you pay poor people less.

One thing I didn't understand at that time, the mid 1980's, was how society has to be political in order to function, The truth has little value; the end justifies the means. If your business is precariously balanced so that you might succeed or you might fail, the last thing to do is be truthful with your customers, suppliers and employees. Tell them about your predicament and suppliers and employees will fear they may not be paid; customers that they may not receive the goods. All will desert you and you will most definitely go under. No, you have to pretend to be successful, and then you stand a chance, but if you then fail you are blamed for not being honest with those people who would have made certain that you would have failed if you had been honest. This applies not only to businesses, but to societies, economies and markets.

The Labour party leader, Jeremy Corbyn, seems to me to be a man of principles. I agree with many of his views, and if his own party and the media supported him he could be Prime Minister. But they will not, his truths would be shouted down, his every move would be sabotaged by his own party as well as the opposition. And this certainty makes me sad: that human nature requires politicians to mislead and distort and 'spin' in order to prevent us destroying them. I do not like the human race very much as a population, although there are individuals that I like very much.

Sometimes I am glad that my life is time-limited, while at the same time wondering what will happen in a hundred, two hundred, a thousand, ten thousand years. Will we find a way to harness nuclear fusion to power our future? Will we self-destruct in a cataclysm of nuclear armaments? Will the population exceed the capacity of the Earth? What would the first Homo Sapiens have thought of how we live today? Or the people living at the time of the Roman Empire? Did they wonder how people would live in a thousand years?

So much for my existential musings. On Tuesday I went out to buy things from Halfords because I had been given a voucher for 25% off, and I managed to buy the things I wanted, which is very unusual. On the way I noticed that Clarks were having a sale and I found and bought a pair of shoes that were exceptionally comfortable (E width fitting) for a bargain price. Then I had a very sad telephone conversation sitting in the car in the carpark before going into Sainsburys for a few things and knocking a bottle of red wine off an end-of-aisle display where it spectacularly shattered on the floor. A very nice member of staff was on the scene in an instant, allowing me to apologise before making my getaway towards the bakery section where I bought myself a gratuitous cream cake as consolation. All this in the space of 60 minutes.

Tuesday

Harrogate, July 2015

Tuesday is my 'day off'. Except some Tuesdays it doesn't feel like a day off at all.

08.30 Wake up nice and late - it is my day off after all. Leisurely breakfast - almost too leisurely because I nearly didn't leave myself enough to time to get to my first appointment of the day.

09.40 Dentist. Two weeks ago the hygienist and dentist recommended longer sessions three times a year for the hygienist, and because they are so convincing and because I don't want all my teeth to fall out I agreed. This brief appointment was because the dentist found a suspicious patch on my tongue and wanted to check it out two weeks later. All is well.

09.50 My favourite greengrocer's shop. Buy fruit: satsumas, russet apples (you don't see them very often nowadays) and ridiculously large sharon fruits that are slightly past their best.

10.10 Bank #1. Mum and dad have now registered their Lasting Power of Attorney for financial affairs, and I have to try and set myself up as their attorney within the banking system. There is nobody at the desk where staff loiter near the door so I take the opportunity to get the cashier to update my bank book from a little-used account and ask her for help with the LPoA business. She is useless, so I decide not to talk to her about updating the little-used account to a more modern one that pays a modicum of interest. I phone mum to get more details about what she was told we should do in the bank to get this sorted.

10.30 I go home again because I realise that I might do better with the official documents about my status as attorney. Pick up official documents and go back to town.

10.45 Bank #2. I don't have an account at this bank, but I am lucky because I find someone who a) knows what a LPoA actually is and b) is happy to refer me to the person who knows how to deal with the bank systems. She photocopies merrily for about 10 minutes before asking which branch the LPoA will be registered at. I phone mum for a second time. The bank lady carries on photocopying and says she can't fax the documents because of confidentiality, but she will post them to the branch. We hope for the best.

11.15 Back to Bank #1. This time, someone is staffing the desk near the door and has heard of a LPoA, but the person I need to speak to is busy. She seems to have a clue, so we agree which modern account paying a modicum of interest will replace my little-used account. Then I am handed over and my new friend types and clicks for about 20 minutes without stopping (I kid you not). I am asked periodically for various items of personal data (mum's date of birth, postcode etc.) and then it's over, and I am an attorney with Bank #1. I phone mum again to let her know of my outstanding performance and incredible success, but she wisely has gone out.

11.40 I go home because I realise that I have left my glasses there. Pick up glasses and go back to town.

12.00 Optician. I am here for a contact lens and sight test. We agree that it's better wearing contact lenses than glasses when running, especially in the rain. After the usual tests I am reassured that my distance and near sight are fine with both contact lenses and glasses, but then she makes me read the super small letters anyway, seemingly for fun. I humour her and get them all right, so that's good. No changes to prescription. I pick up a new batch of contact lenses.

12.40 On my lovely Tuesdays not at work I am treating myself to lunch at various different Leamington cafes and restaurants. Today I have chosen Elma, which is an establishment serving broadly East Mediterranean food in a location which has changed hands more than the average number of times recently, suggesting one of those spots that is a little bit doomed from the start. I choose the Express Lunch which is a delicious chicken stew with rice and a mint tea. I am alone in the restaurant from start to finish. Not a good sign.

14.00 I have been planning meals for the rest of the week and realise that I really need some ingredients from the supermarket rather than just the greengrocer, so it's a trip to Sainsburys.

15.00 Get back, put everything away and make an enormous batch of minestrone soup, inspired by the rind of Parmesan that was lurking in the fridge along with an elderly salami. Consider going out to town again to post passport that needs renewing (unable to do this sooner because passport is needed for identity checks relating to LPoA) but decide I've been into town enough today.

16.00 Lady arrives to give me a proper sports massage in the comfort of my own home. During massage discuss classical music and early 80's rock music, whether I can be bothered to run any other 10k races, how boring it must be to train for a marathon, where to buy running shoes and what sort to get, express surprise at extent of knotted muscles in shoulders, agree that it's better wearing contact lenses than glasses when running especially in the rain, suggest she comes to Monday night badminton to give massage tasters in order to rustle up business.

16.30 Mobile phone rings during massage. Ignore it.

17.00 Shower to remove massage oil. Feel about 2 inches taller for approx 30 minutes before normal slumped posture kicks in again. Decant minestrone into pots for the freezer and do the washing up. Turn on the computer for the first time today and delete all the spam. Write encouraging email to other joint attorneys (Lola II and Sister D) about how dealing with the banks went. Browse blogs and Facebook.

17.45 Remember to listen to the message on my phone, which is from the optician pointing out that while I paid for my contact lens check (I get my sight test for free) I neglected to pay for the contact lenses and can I please give them a call. Too late, they're closed now.

18.30 Jump into car and head off to local university for buffet followed by Diabetes Education Club. I am cornered by one of the team who asks if I am interested in teaching Healthcare Assistants and Practice Nurses on a new one-day course they are developing to help prevent diabetes. I say yes even though I don't really understand what I'm supposed to talk about and my job doesn't currently cover diabetes prevention. I can always sort it out later when she sends more details.

19.15 Diabetes Education Club is all about the paediatric service delivered within the Trust. I was in two minds about attending because I don't do paediatric diabetes, but I thought it would be interesting and I was right. The secondary care paediatric service has about 200 patients, of whom 97.5% have Type 1 diabetes, and 25% use insulin pumps. Among various other statistics and guidelines I picked out the fact that there is no robust evidence in favour of structured education, although it is not clear whether evidence exists that does not support such education or whether there is an absence of evidence either way. It was similarly stated that there is no robust evidence for weight loss and dietary advice for paediatric Type 2's. We can be fairly certain that this indicates an absence of trials, probably because numbers are still so few. I wanted to hear a bit about guidelines for transition between paediatric and adult services, but guidelines covering Transition issues are apparently going to be published separately and cover all chronic health conditions, which I suppose makes sense.

21.00 Home again. Think about doing a couple of the jobs on my enormous list of things that could be done on Tuesdays while I'm not at work. Have a half-hearted bash at a couple of them before going to bed to read, and then listen to some of the amazing podcasts that are out there on the BBC iPlayer - John Finnemore's Double Acts stands out at the moment, along with the whole back catalogue of Soul Music and The Infinite Monkey Cage, plus I've just discovered Adam Buxton is podcasting again, and there's a 'companion' podcast to This American Life called Israel Story.

22.30 Sleep. Another 'day off' is over.

I'm aware that certain readers are in awe of the amount I can get done in a day. Just to reassure you: on other Tuesdays I do absolutely bugger all.

Run, Forest, Run

The River 'Jump', Run Forest Run, November 2015

It feels as though I've been building up to this for ever, because it has been a year since the idea of taking part in this event occurred to me. A year ago I was part of the support team, serving bacon butties and cake to around 40 runners who had run 5k from the village of Chiddingfold to a nearby bit of woodland, then gone round an obstacle course before running 5k back to the start. This event was named 'Run, Forest, Run' which is a reference to the classic movie Forrest Gump - you'll have to look it up if you haven't seen the film. At that time, as you can read in my contemporaneous report, I dismissed the idea almost immediately.

Run Director Bruce
and Timekeeper Freya

Back then I hadn't been running for very long, but as I continued to surprise myself by keeping up with the running program I decided it would be a challenging but achievable target to work up to. Also, because the organisers are my friends, it would be less daunting than a public event run by strangers. So at the weekend I packed a wide range of clothes to address as many types of weather as I could imagine, and took myself down to Surrey (stopping en route for a quick visit to mum and dad, who are remarkably well at the moment).

Lola II and Mr M were there too - naively I thought it was for the social aspect and as a public-spirited gesture to our organising friends. In fact, I found out it was only in order to support me, so I am very grateful. They were allocated marshalling duties in the forest obstacle course at the log pickup and deposit.

Log pickup marshal Lola II

Race Relations Officer Mr M

The weather this autumn has been unseasonably mild - until the weekend arrived and forecasts were for plummeting temperatures. Knowing how Lola II fares in the cold (hint - not very well) I was slightly concerned for her, and also for myself, not wanting to freeze during the running either. In the end we were both fine, and it was the mud rather than the cold that slowed me down. Although it didn't actually rain, the going was 'soft' underfoot. At the point where the mud came over the top of my shoes I decided that I would focus on remaining upright rather than clocking a fast time.

The Forest Marshalling Team

So now I've done a competitive 10k plus obstacle course race, and in fact my time was perfectly decent especially taking into account the sections where it was so slippery that I could barely walk let alone run. We had a good laugh about the obstacles afterwards - my short stature put me at a significant disadvantage when it came to climbing over bars and jumping across streams. I'm planning to carry on running, but I think I'll stick to 5k Parkruns for the time being.

Study Day

Part of Rugby School, May 2015. I really like the slanty windows

I have mentioned carbohydrates on here so many times - they are the mainstay of the British diet in the form of cereal, bread, potatoes, pasta, rice, pastry and flour as well as all the sweet and sugary food and drink, fruit, milk and yogurt. Carbohydrate is also the dietary component that raises blood glucose in people who have diabetes, which can cause poor health in the long term. For this reason, we are coming round to the idea that it makes no sense to encourage people with diabetes to eat lots of carbohydrates.

A reduction in consumption of sugary food and drink has always been advocated, and not just for people with diabetes. This is why the 'traffic light' labelling system on the front of some food packets includes the amount of sugar. But starchy carbohydrate and natural sugars in fruit and dairy products were not restricted in the past, despite the fact that they are also converted to blood glucose when they are digested. Glucose from starchy food, fruit, milk and yogurt enters the bloodstream a bit more slowly than glucose from sweet things, that's all. But if you don't have diabetes, you only really need to care about sugar.

So when people with diabetes come to see me, they always know that they're not supposed to have sugary foods, and they commonly mention that they have been told that brown, wholemeal or granary bread is good for you, as well as lots of fruit. Sometimes they say they can't have bananas or grapes. They have usually picked up this information from non-specialist Dietitians or nurses in their GP practice, or from friends and relations with diabetes.

It now seems to be accepted among Dietitians that limiting all types of dietary carbohydrate (not just sugars) is a valid and beneficial approach for people with diabetes, and very recently Diabetes UK seems to have accepted this idea and at last - at last! - the dietary advice on its website has changed. It used to recommend that carbohydrate foods should make up a third of your diet, or up to 14 portions of starchy carbohydrate a day. Now the same web page suggests you should 'try' to have some wholegrain carbohydrate every day, but acknowledges that you may be advised to reduce the amount of carbs that you eat.

Carbohydrate intake is only half the story; the other factor that leads to raised blood glucose in Type 2 diabetes is insulin resistance, which is often caused by excess weight around the waistline. Most people with Type 2 diabetes are overweight or obese, so I try to recommend that my patients replace the carbs with vegetables that are lower in calories than carbs, which should result in a calorie deficit and very welcome weight loss. Reducing carbohydrate intake reduces blood glucose levels on a day-to-day basis, and losing weight lowers blood glucose in the long term by reducing insulin resistance,

There are some who are not particularly overweight, and therefore cutting the calories from carbohydrates needs to be balanced by an increase in calories beyond what vegetables can provide. For these people we have up to now suggested protein and healthy unsaturated fats: monounsaturated (from olive and rapeseed), polyunsaturated (from sunflowers and corn) and omega 3 (from oily fish, nuts and seeds).

Diabetes Specialist Dietitians are generally a mild-mannered lot (as are most Dietitians). However, there is a militant faction of Dietitians who declare that not only is there no evidence of harm from saturated fats (derived from animal sources), but that these fats are positively beneficial. They promote a low carb high fat (LCHF) diet, and not just any fat, but saturated fats.

The difficulty is that these LCHF people are either deluded or they are visionaries, and we have no certain evidence to tell us which. On Friday I attended a study day where one of the highlights was a debate between a leading proponent of LCHF and a respected academic research Dietitian. Both argued their case admirably, although unfortunately the advocate of the LCHF diet was a little less articulate and let herself down with a couple of poor examples that weakened her case for me. In the end, the consensus is still that we believe saturated fat promotes cardiovascular disease, but there's a chance that it doesn't. Unfortunately it is impossible to conduct human trials that are sufficiently long-term, randomised or blinded to give us the evidence we need, especially as people eat food not nutrients.

The study day also included discussions about the pros and cons of weight reduction through surgery or extreme calorie restriction, the 5:2 fasting diet, a protocol for adjusting diabetes medication in a weight loss programme, and the AGM of the Diabetes Dietitians' Specialist Group.

The session about the 5:2 diet was presented by the Dietitian who invented it within the setting of breast cancer management, and she made the point that there are now three times as many books about the diet than there were participants in the trials that supported it. The diet she invented involved two consecutive days of very low calorie intake separated by five days of 'normal' eating, whereas the common version now in the public domain has separated these two fasting days. Evidence is scanty, trial participants were all women (breast cancer, remember), and the end message was that we have no long term evidence about either benefit or harm. It's pretty unlikely to do any damage (unless there is blood glucose lowering medication or insulin in the mix) so if it works and people lose weight then we're fine with that.

The other diet discussed was the 'Diabetes Reversal' diet pioneered in Newcastle, which involves restriction to 800 calories a day. The rationale for this was because people who have bariatric surgery for weight loss and who have Type 2 diabetes often experience sudden remission in their diabetes and normal blood glucose levels immediately post-surgery. The researchers wanted to investigate whether this outcome was due to extreme caloric restriction alone, or something else to do with the surgery.

Their original study put people on the diet for 8 weeks and required a portion of vegetables every day alongside meal replacement products, and it showed impressive results. They have followed this up with a bigger study - the biggest research grant ever awarded by Diabetes UK - which is for 12 weeks' restriction with meal replacements only. All the information about the original diet is in the public domain on their website, so anyone can try it, and a number of our patients have done so. We are now considering how to support our patients if they were to choose this option for weight loss.

The other sessions I attended at the study were interesting but not remarkable. Back at work, this blog comprises the main reflection I have carried out on the day's experiences. My colleagues are working on a way to offer people a choice of weight loss pathways and I'm planning to use their approach in my service, once they have ironed out the wrinkles.

Diwali

Southall, November 2015

Our new data projector has been installed at work!! All those months of nagging and chasing have paid off, and at last we are able to display Powerpoint in our education room, along with videos and other Internet content. It's only taken about 18 months to achieve, and I'm delighted. My joy is somewhat diminished by the others in the department commenting that now they'll be able to watch TV at lunchtime. I'm hoping that they're joking, but I'm not sure that they are...

Meanwhile, I have been to That London again, this time entirely avoiding the horror of M&M World and instead having a lovely time celebrating Diwali with food and fireworks. For a few years Lola II and Mr M have made an annual pilgrimage to Southall which puts on a fine show for the festival of lights, and I joined them in an absolutely delicious Indian meal followed by standing on the railway bridge playing with sparklers and watching all the many different fireworks displays that are visible from that standpoint. I ignored Guy Fawkes night this year but I do enjoy a firework display, and ten simultaneous displays is even better.

I got there slightly early, and being the kind of obsessive Dietitian that I am, I made a point of checking out some of the specialist produce on offer in the local emporia. While I know a fair amount about Indian produce, the fresh green veg is a bit of a mystery, so I took lots of photos and I will have to do a bit of research later.

What I've been reading

The Valley of Fear
by Sir Arthur Conan Doyle

narrated by Simon Vance

"A brutal murder in an English country house leads Sherlock Holmes to unravel the grim and gruesome story of the Valley of Fear."

I imagine Conan Doyle still resisting the pressure to produce yet more of these dratted Sherlock Holmes stories, so in this book he created a mystery murder that is solved by the end of the first half of the book, and then spends the second half writing a story that he actually wants to write. Which is perfectly fine by me, even though the fact that it is set in America makes the narrator's job a bit more difficult.

Twilight
by Stephenie Meyer

"When Isabella Swan moves to the gloomy town of Forks and meets the mysterious, alluring Edward Cullen, her life takes a thrilling and terrifying turn. With his porcelain skin, golden eyes, mesmerizing voice and supernatural gifts, Edward is both irresistible and impenetrable."

I picked this up on a whim from a big box of free books, because in its day it gained a reputation for being as good as Harry Potter and because the films made of the story are supposed to be excellent. Well, it is not as good as Harry Potter, nowhere near as good. It is actually quite boring for 80% of the way through, then there is one huge exciting action-packed event for about 20 pages, and then it gets boring again. I really won't be reading any more of the series and I will be putting it back into the box of free books where it came from.

Equal Rites
by Terry Pratchett

narrated by Celia Imrie

"Right before the wise old wizard Drum Billet died, he passed on his magical staff of power to the newborn eighth son of an eighth son. Unfortunately, Drum Billet never bothered to check the gender of the newborn baby, and it turns out it was a girl."

After all those years of attempting but failing to read his works, I've turned into someone who actually likes Terry Pratchett. However, Audible should be ashamed of the audio quality of this book, which sometimes sounds like it was recorded at the bottom of a well, and at other times includes strange pauses in the narration. Despite these issues I did enjoy the overt and the implied humour - at one point I got the distinct impression that he was describing Discworld magic in the same terms as particle physics.

The War of the Worlds
by H. G. Wells

narrated by B. J. Harrison

"Giant cylinders crash to Earth, disgorging huge, unearthly creatures armed with heat-rays and fighting machines. Amid the boundless destruction they cause, it looks as if the end of the world has come."

To be honest, it isn't really a very good book, even though it's well known enough to be called a Classic. The story is told in a rather pedestrian way, nothing much happens and there's virtually no change of pace from start to finish. I wouldn't have minded much if the Martians had won, I didn't care about the narrator's missing wife, and it wasn't even a War - certainly the native humans did nothing but get killed or run away. It highlighted a bit about life at a time when horses pulled buses and flying machines hadn't been invented, but that's all it has to commend it.

Reverse Your Diabetes
by David Cavan

"Based on the latest research and proven results, this clear and effective programme outlines the key steps you need to take to turn around your health, and tackles the myths and misinformation that surround type 2 diabetes."

Obviously this is a work book, but it recommends something that is causing some controversy in the world of diabetes and lifestyle - reducing or limiting dietary carbohydrate. [I think the subject might need its own blog post quite soon, maybe after a study day I'm attending this week.] Apart from the carbohydrate thing, it covers every relevant aspect of Type 2 diabetes in a readable and not over-long book, and encourages people with the disease to take control by learning what they can do to improve their own situation, and then planning and making sustainable changes where they can. This is the textbook for my approach to diabetes. If only change were as simple as reading a book.

Nothing interesting at all

Mr M took this photo somewhere, August 2014

I'm sitting here thinking about what to write, but I can't talk about the main things I'm involved with at work and at home, either because of professional confidentiality or just because they're not appropriate for a public blog. So I'm left with a few inconsequential happenings - the boiler's had its annual service, I've made lentil soup, I took some garden rubbish to the tip, I had a massage. I sewed a bit more of the dress I'm making for sister D. I met a friend in Birmingham and saw the remodelled station with its John Lewis (good) and new branch of Wasabi food outlet (better).

I've written enough about badminton and running, books get their own post, and the films I've watched have been OK but nothing special. So what's left? Honestly, I don't know. I haven't done anything particularly interesting recently. The new car is running fine. The garden is running wild. The house still needs loads of work doing. I haven't been on holiday. The clocks went back so it's dark really early.

M&M World. Just Don't.

I did go down to That London for a family event, and Lola II and Mr M took the opportunity to expose me to M&M World, which is four enormous floors of M&M branded tat right next to Leicester Square in the heart of the West End. They justified this 'experience' by saying that they are educating me in the ways of London folk, but I would prefer to stay thoroughly provincial and never see M&M World ever again. But I've given you a nice picture of Lola II and Mr M in front of the rainbow of pick 'n mix M&Ms.

All of a sudden, out of the blue, something slightly interesting happened at work - the IT guy turned up with four large monitors for us to replace the tiny ones we've been using and which work perfectly well. We beg, plead and pray for a data projector, but without even asking we get replacement monitors; it's very peculiar. And not really that interesting after all. Sorry about that. If we're lucky, something properly interesting will happen next week.

Two busy weeks

View of Chicago, June 2015

Remind me - what day is it? What am I supposed to be doing? Where should I be?

I like it when my days are full and it's busy, lots to do, people to see. A long afternoon stretching out with nothing scheduled and I get a little twitchy. But I have made a rod for my own back and overdone it a bit recently.

Of course, part of the problem is the extra-curriculars. If I hadn't agreed to be part of both Ladies and Mixed badminton teams, and continued to attend two different clubs, there would be a bit less badminton in the evenings. If I hadn't volunteered to do this 10k + obstacle course run in November, I wouldn't be doing so much running (although I haven't had time or strength to run for about two weeks). I've joined the work choir again this year, and we're having weekly rehearsals again. The basics of the choir practice haven't changed - a lovely leader with much more enthusiasm than musical knowledge who has again chosen carols that are pitched a bit too high for any of us to sing comfortably. I've admitted that I can play the piano in the hope that she will let me at least pick out the notes to help those singing the harmonies, but she hasn't yet called on me for assistance so I sing along with the rest.

So that's Monday to Thursday evenings fully committed most weeks - when I'm not playing or singing I'm too tired to run or even cook. At the weekends I sometimes run (I am very excited that I've now managed to do Parkrun 5k in under 30 minutes for the first time!), and plan and prepare meals for the whole week, assisted by the fact that I don't eat much on badminton nights and we've managed to get sponsorship for our structured education so that some Thursday lunches are provided. Which brings me on to work - there's quite a lot happening there too. The main thing is that we've been Windows Sevened. Is Windows 7 a verb? Yes, it is.

Apparently a few key people were aware this was in the pipeline but I was notified by email one afternoon that it was happening that night, so the next morning the Windows 7 tech team turned up to make sure everything was running as it should. Of course it wasn't. The basics were in place so we could use email, MS Office and most of the systems used everywhere in the Trust, but the specific diabetes systems were all over the place. The Windows 7 team asserted that they hadn't been told about any of those systems, while our team claimed that everything had been fully declared in advance.

Most of it has now been sorted out, the one remaining issue being an application that is used to download the data from a certain type of blood glucose meter and insulin pump, which is needed on six computers but is only working on one - mine. So every time a download is needed, my computer has to be used - actually that's not quite true, some of the meters can be downloaded onto a laptop, but only some of them and then we can't print anything. Chasing the Windows 7 team about this has been entirely fruitless - they are refusing to fix anything until the manufacturers of the software have sorted out how to download the data to a secure networked drive. It's very frustrating.

Would you like an update on progress towards having a ceiling-mounted data projector connected to a net-enabled computer? This is something that I asked about shortly after I started working in the Centre nearly two years ago. I started to make more of a fuss about it a year ago, and those holding the reins of power finally caved in and we started to apply for funding in December last year. The funds we targeted are in a specific charitable account that is managed entirely within the Diabetes service, which contained enough money to pay for the equipment, and our application met all the necessary criteria. Despite all this, we were up against a particular 'Jobsworth' character in hospital management - during the ten months that has elapsed one episode that stands out was when this person sent all the forms back to us by post because one box had not been ticked.

We were told, finally, that the whole scheme could go ahead about a month ago, but nothing has happened yet. Up to this point I have managed to resist becoming involved, mainly because I have no status with this charitable fund so could play no part in the application, but also because I knew the whole thing would wind me up - and it certainly has done that. I could hold off no longer, so now I am phoning our IT department and the equipment supplier at least twice a week until the ruddy thing is installed. I'm aiming to get it done before the first anniversary of the application starting. I am not confident that this is possible, not least because the quote is nearly a year old and I expect prices may have changed.

Meanwhile, my weighing scales have broken. I got in touch with people in the relevant department who arrived commendably promptly but were unable to fix the problem, so the scales have gone away with them. They were incredibly pessimistic about them ever coming back, and told me not to expect anything for a number of weeks. The scales were also provided by the Friends of the Hospital's charitable funds. It is sad to think that a department in a teaching hospital uses charitable funds for weighing scales and data projectors, but there are far worse troubles in the NHS than these minor issues. The NHS is pretty much broke, as far as I can tell from media reports.

My joy at having Tuesdays off has abated, but again it's my own fault. The DESMOND education that I am now qualified to deliver is also delivered by a different team, and I have long wanted to sit in on one of their courses to see how they do it and steal any good ideas. The disadvantage to this plan is that they deliver their courses on Tuesday mornings, so my lovely free Tuesdays have disappeared for the last two weeks while I watched them perform. I did get a few good ideas, but I'm still looking forward to a lie-in on a Tuesday. This coming Tuesday I've arranged for the boiler to be serviced at 9 o'clock. I should have asked for an afternoon appointment...

Alongside all of this bureaucratic mayhem I am still seeing patients, and our group education continues. Some of the patients on the very low carb diet are doing really well, everyone else is struggling as people will struggle when they try to changes habits of a lifetime. I'm getting a bit more proficient with insulin pumps, and was edged out of my comfort zone when I was asked to stand in for a nurse with one patient - this means advising on changing insulin dosage based on results of blood glucose monitoring, and is a bit scary. Luckily a nurse was around - in fact she was in the room using the software that only works on my PC - and helpfully chipped in now and again to agree with the advice I was giving, so that helped my confidence a lot.

Vroom beep beep

The car-buying ordeal is over. I have a car. It is a SEAT Ibiza, and it is white. At this point, I should include a stylish photo of me and the car, but for some reason I have not been taking many photos lately and I keep forgetting to do it during the daytime. So instead, I bring you a scarecrow dressed as a chef with a sheep under one arm.

Harrogate, July 2015

It only took about six weeks to buy the car, and a lot of that was waiting because the most suitable was one being returned by a customer who replaces their car every year. I cannot believe that some people go through this every year, but maybe it's easier if all you have to do is choose the colour and accessories and hand over the cash on a monthly basis.

I got through three different salesmen in the week before taking delivery of my white car. I liked the first chap best, but he suddenly disappeared without trace (they weren't telling me where he went) and I got his manager next. He then delegated to a third salesman, who actually warned me in advance that he was leaving - he said it wasn't my fault when I asked. He told me that before this job he'd played rugby to a pretty high level, so he was moving to a job where he'd only have to work normal hours 5 days a week. Car salesmen work ridiculously long hours.

Cars, then. I'm not really interested in cars, I just want them to start up reliably when I turn the key, drive where I want to go without breaking down, and play my ipod through their speakers. So my total requirements included 5 doors, petrol engine, ipod connection. One reaches a compromise on age, mileage and cost. Fact: new SEAT Ibiza cars come in red unless you pay extra for another colour. Whoever first bought mine paid a premium for it to be white, and added mudflaps. I think the rest is standard.

Despite being standard specification, this car is more technologically advanced than anything I have in my house, including the laptop computer I'm typing on. I needed help to set it up and a lesson in how to use it before I drove it away. I will have to practise using the various features, especially the satnav thingy that also controls the music system and even lets me use my phone handsfree. There is a manual for the car, a manual for the satnav and a manual for the radio. I will be doing some more reading this weekend, except it is a bit boring so it may take a few weeks before I am competent to Bluetooth successfully. Whatever that entails.

The particular surprises I discovered when eventually I was shown 'my' car were not only the fancy shmancy satnav (which I'd been told about), but it also has parking proximity beeping sensors, and cruise control! This is a basic small car - cruise control used to be the domain of the travelling salesman doing 50,000 miles a year on motorways, not commuting up the road or the odd trip to Sainsburys. I have a proper long motorway journey coming up soon, so I'll give it a try then.

Update a few days later: I have now used the satnav thingy in earnest to find the location of my most recent badminton match, and it was rather good, unlike the match which we lost fairly comprehensively. Another good thing is that I have discovered one of the numbers on the fascia display tells me how many miles it will be before my fuel runs out (I don't yet know how accurate it is). More good news: the rear windscreen wiper works and all the interior controls light up with the headlights - these things are good because they are things that the previous car had stopped doing. I wouldn't be surprised if there is a beep if I open the door before I've turned the headlights off - I haven't tried it yet, but the Golf stopped doing that years ago.

A slightly less good thing is that as soon as the car is put in reverse the audio is muted in favour of the beepy parking proximity sensors. This is fine when you're listening to music or the radio, but I don't want to miss bits of my latest audio book just because I'm going backwards, so now I have to stop the ipod before putting the car in reverse gear. But maybe it will stop me hitting things when going backwards. I have never hit anything going backwards before, but you never know.

I very much doubt that in just under a week I have discovered all the things that this miracle of modern engineering can do. In future posts I may be moved to add footnotes of this variety: "You know my new car, well you'll never guess what it did yesterday..."

Getting things done

Peckover House, August 2014

The garden has been in need of attention for months now. It's not work that I particularly enjoy, although after everything has been cut back to within an inch of its life I take satisfaction in the brief period of orderliness before everything gets out of control again or the weather turns nasty and I don't go into the back garden for six months. It's a blessing that I don't have a front garden. Anyway, this was the weekend when I made a start, and managed about a quarter of the work needed. I could imagine making a resolution to do just an hour a day to keep things ticking over, but it's the sort of resolution that I know is worthless.

Not much else that is blog-worthy has happened. I have continued to do too much in the way of exercise, but have curbed my worst excesses and even left badminton much earlier than usual on Thursday. It occurred to me that I have been playing competitive badminton for about 25 years, first in Manchester and then here, and it isn't until now that I have regularly been picked for the 1st team. And it isn't because I have improved compared with my peers, it's more a reflection of the decline in popularity of badminton, and perhaps also my choice of club which contains rather a lot of 'veteran' players. Anyway, we won our first match despite my partner and I having met only a week ago.

At last I have returned to four-day working, and I have a long list of things that are awaiting my attention because I can't get round to them at the weekend. For my first day I took the garden waste to the tip, spent a long time continuing the process of buying a car (at least one further instalment will be forthcoming in this saga), spent an age on the hideous process of sorting out car insurance, did some cooking, some paperwork and that's all there was time for. Not many things get crossed off a long list in a single day, but it felt good.

On the list of other things going on: an update on the clarinet group. We had a bit of a hiatus after the hugely successful open air summer concert we put on in the rectory garden together with the flute and the saxophone group. First week back, and some new music (including top Christmas hits), with some parts specially written for me! It was lovely to play something a little bit challenging, and I may even try to fit in some practice, which I didn't need for any of the previous pieces. It's such good fun that I even imagined one day I might find time to source a new mouthpiece for my mothballed saxophone and join that group as well. Maybe one day.

What I've been reading

The Book of You
by Claire Kendal

"Being selected for jury service is a relief. The courtroom is a safe haven, a place where Rafe can’t be. But as a violent tale of kidnap and abuse unfolds, Clarissa begins to see parallels between her own situation and that of the young woman on the witness stand."

Absolutely not a book I would have chosen, but at the place where I worked one day a week they get through a lot of books so they offered a few to me. I gave this one a try and got away with it, but I don't enjoy reading about cruelty and abuse and feeling really tense, and the story isn't that good anyway - I didn't like any of the characters, not even the 'good' guy or the heroine. I avoid horror films for the same reason - some people must like feeling scared, but it would just give me nightmares. I won't be trying this experiment again.

The Return of Sherlock Holmes
by Sir Arthur Conan Doyle

narrated by Simon Vance

"The great Sherlock Holmes is back from the dead and devoting his life once more to examining the criminal complexities of the capital."

Poor old Conan Doyle wasn't allowed to kill off his hero, and here he is writing another lot of short stories to the same formula. Holmes: crime-solving genius, Watson: well-meaning duffer, with a side order of wily criminals and desperate clients and bumbling policemen. I love it.

Ten Things I Love About You
by Julia Quinn

"Annabel Winslow is in a pickle. Having newly arrived in London for her first season and being in possession of a voluptuous figure, is being openly courted the the Earl of Newbury, who is at least 75 and a nasty brute to boot."

Another ridiculous mock-Regency romance. Half way through I was determined to give up this author because all her books are fundamentally the same, and I may still pack it in. But I did enjoy it in the end. It's just that there are much more worthy and thoughtful books on my shelf waiting to be read, and spending time on this insubstantial fluff feels like a wasted evening.

Rabbit, Run
by John Updike

narrated by William Hope

"At twenty-six Harry 'Rabbit' Angstrom is trapped in a second-rate existence, stuck with a fragile, alcoholic wife, a house full of overflowing ashtrays and discarded glasses, a young son and a futile job."

What an excellent writer, and what a shame he has written such a horrible book. I was transported by the imagery he uses and his skill with words - wonderful, brilliant writing - but the people he has created and imbued with life are so mean, selfish and ignorant. Nobody is given any generosity of spirit and the lives they lead are bleak. Maybe this was the reality of life in 1959, and maybe I'm limiting my horizons by not wanting to read about it but I do want just a little bit of joy in my reading matter, and this has close to none.

Tom Brown's Schooldays
by Thomas Hughes

"The book is semi-autobiographical and is based on Hughes’ own experiences at Rugby school, including his respect for his schoolmaster Dr Thomas Arnold, who is portrayed as the perfect teacher in Hughes’ novel."

When I started this book it felt very much like reading a set text for English at school: a worthy book with plenty of material for O level essays. Despite the language and attitudes to class and religion typical of a book written in 1857, it improved no end as I went along. I enjoyed setting the scenes of school life into the same Rugby School I visited earlier this year, and relished the detailed descriptions of the life of public schoolboys so different from my schooldays forty years ago, and even more different from what I imagine schools are like today. It is a historical document as much as anything else, and that is the most fascinating part - how our values and attitudes have changed, and how much our present has derived from its past! I am almost ready to write that O level essay...

Pumping insulin - Part 2

Coombe Abbey, June 2015

In part 1 I wrote about the basics of how a pump works in comparison with using insulin pens and MDI - multiple daily injections. Now we come to how I got on with the course, and some fancy features of the pump in more detail.

Tube or Not Tube?

The course I attended was run by a company whose pump delivers insulin to the cannula via a tube. Other pumps, like Mr M's, combine the pump and cannula in one unit and you stick the whole lot onto your body and control it from a separate handset. The pumps that we were using also had a handset that duplicated the interface on the pump and communicated with it via Bluetooth. The benefit of this approach is that when you administer insulin you can leave the pump in whatever inaccessible place you have stashed it - such as in your pants. Some pumps don't have this convenience, so you have to retrieve the actual pump in order to deliver insulin. You probably don't want to be fishing down the front of your trousers at the dinner table so your options for carrying the pump are more limited, and slinky dresses present a similar problem.


Here's a slightly blurry picture - the handset is on the left, and the pump with its tube is on the right.

There are a few different cannula types to choose from, but they all require you to stick a needle into your body. We were given the opportunity to try two types, one inserted manually and one using an insertion gadget, and I was very surprised that I hardly felt the insertion at all. You load the insulin into the pump either using a pre-filled cartridge or by filling the reservoir yourself with a syringe and a vial of insulin. Then you have to prime the tubing to fill it with insulin, connect the tube to the cannula and fill the cannula with insulin, and then it's all set and ready to go. The whole process takes a few minutes, which isn't long, but I imagine could be very annoying if it needs to be done at an inconvenient time.

Obviously I wasn't delivering any insulin through the cannula (I produce my own very nicely, thank you), and we weren't given strips to test our blood glucose. But we were given a pump to wear and encouraged to go through the process of estimating carbohydrate and programming a dose of insulin using the pump or its handset. This is something I'm pretty familiar with given that I've been interested in diabetes for some time above and beyond what the job requires.

12 hours connected to a pump

At dinner we were encouraged to estimate the carbohydrate portions and pretend to bolus insulin using the pump. I tend to forget that most normal people don't do this every now and again just for fun - for some it was actually the first time! We shared our guesses about the carbs in various dishes, and established the kind of variation in estimation that you get when there's no correct answer. But then one of the most enthusiastic pump reps suggested that to try and estimate carbs more accurately we should ask the chef, and then went as far as to haul the chef out of the kitchen to talk to us.

I had a problem with this. "Do you expect the chef to be more skilled at carb counting than a room full of diabetes healthcare professionals, including Diabetes Specialist Dietitians?" I wanted to know. Undaunted, the rep persisted in asking the chef his opinion on the goat's cheese tartlets. The chef obligingly came up with a figure. I continued to make myself unpopular. "What are you basing that figure on?" I asked. "Is it the pastry? How much does the pastry weigh?"

At this point there was a murmur from the room. My questions were perceived as 'a bit much' by some of the other delegates, and sympathy was building for the chef. He was prepared to take me on, though. He said, "I'm basing it on the pastry, and the cheese, and the onion."

"The cheese? But cheese doesn't contain any carbs..."

At this point the enthusiastic pump rep proposed a vote of thanks to the chef, we all complimented him on the delicious spread, and he was hastily bundled out of the room, poor man. Nobody wants a smartarse Dietitian making a chef look like he doesn't know his carbs from his elbow.

Pump features

Lots of the two-day course covered the range of sophisticated features available on this particular pump, many of which are possible on most pumps on the market. These features are designed to help the user decide on the dose of insulin, and deliver it over a period of time rather than in a single injection.

There are quite a number of factors that influence the delivery of insulin in addition to the quantity of carbs eaten - the type of carbohydrate (sweet, starchy, liquid) what is being eaten alongside the carbs (especially fat, protein and fibre content of food and drink), the size and duration of the meal (quick breakfast before work or three leisurely courses at a dinner party), time of day, ambient temperature, whether the user is ill or well, the menstrual cycle, the site of the cannula, planned activity or alcohol, recent past activity or alcohol, whether there has been low blood glucose in the last 24 hours... the list goes on. All of this should be considered before you can even take a bite. It's a massive overhead for something that most of us take for granted as we tuck into our food without a second thought.

The help that most pumps give is confined to the maths involved in applying a ratio of insulin to carbs and adjusting it for the factors given above. The 'bolus advisor' comes up with a suggested number of units of insulin to be injected, which the user can accept or overrule. Then the user can decide how those units should be delivered.

There are three different ways to deliver the insulin. A standard bolus just squirts all the insulin required over a few seconds, much as an insulin pen or syringe would. An extended bolus allows you to spread out the insulin over a longer period of time. You can have it delivered at a constant rate for the whole period of time you select, or you can combine the standard and extended bolus and specify 30% (or 50% or 70%) to go in straight away as a standard bolus and the rest extended over however many hours you want. This type of  'multiwave' or 'dual wave' bolus is for foods that are digested quite slowly (low glycaemic index or low GI), usually because a large amount of carbohydrate is combined with a lot of fat and protein. Fish and chips, pizza, pasta in a cheesy or creamy sauce and curry are the main culprits.

The third insulin delivery option is the super bolus. It's used less than the other bolus types, and is a more extreme version of the multiwave bolus for food that is digested quickly (high GI). It's a little bit complicated because it involves the background insulin that is usually not included in calculations around food. Remember, the background level is programmed automatically to feed insulin dripwise over 24 hours. For these high GI meals (think candyfloss, Halloween or birthday party) you calculate the insulin needed for the food, then you add on the amount of insulin that you'd be getting from background insulin for the next 2 (or 3) hours and give that whole amount up front. Then you turn off the background insulin for 2 (or 3) hours. It gives you a big 'kick' of insulin with the sugary food then turns it off so you don't go low later on.

Other features that may be used more often than the different bolusing options are the different basal profiles and temporary basal rates. The basal insulin is the background 'dripwise' insulin, and the rate it is delivered is programmed into the pump as a 'basal profile'. This generally varies hour by hour, giving a little more insulin in the early hours of the morning for example, when blood glucose naturally rises as the body prepares for waking. You may have different basal profiles if you work different shifts, for example, or if your routine and pattern of activity varies between weekdays and weekends. Temporary basal rates (TBR) can be handy if you are ill and you need more insulin, or if you are exercising and you need less. A TBR is selected for a number of hours rather than for a whole day.

Conclusions

Writing this pair of posts has reminded me just how much is involved in managing diabetes day-to-day, with or without a pump. It's a lifetime's work - I have left out far more in these 'essays' than I have been able to include. For example, how do we decide on how much background insulin to program into the pump, or how much to give for food? How do people manage sport or illness or pregnancy or holidays or airports? What if you get it wrong, or drop the pump or handset in the toilet, or run out of insulin or needles or test strips? What if you can't do maths, or read, or you live in prison, or are homeless? These are all matters for other blog posts on other days.

I complained to the last group we had for structured education that they had an advantage over me, because I can't experiment and test out my dietary theories. I can estimate carbs in meals and suggest matching insulin doses and bolus types as much as I like, but I will never know if I am right. Obviously they showed no sympathy (and I expected none), but having diabetes is a process and a lifestyle and a challenge as much as a diagnosis, and one that takes a lot of effort and commitment to master.

A pump doesn't cure diabetes, but it can help. There are other technologies being developed including the holy grail of the 'Artificial Pancreas' which is intended to match the natural pancreas even more closely, but even that won't detect blood glucose or deliver insulin in the non-diabetic physiological manner. Glucose-detecting contact lenses or wrist-watches have been proposed, but these are all sticking plasters on the gaping wound that is Type 1 diabetes, and we are nowhere near any sort of cure, or even identifying a cause.

Pumping insulin - Part 1

Coombe Abbey Hotel and Conference Centre, June 2015

This pair of posts have been brewing for a very long time, mainly because it's an interesting but a complicated subject, and I wanted to make sure I covered as much as possible in one go. Mr M has written a guest post about his insulin pump, and reading back over that gives quite a comprehensive view of pumping. On the course I attended I discovered there is much more to say, and I won't even be covering everything in these two posts. For more information from people with greater expertise, go to the INPUT website.

The insulin pump course I attended took place almost immediately after my extended (TEN DAYS!) U.S. holiday and before my Solitary Holiday, and was held in a very posh hotel and conference centre constructed within a former Abbey with adjoining Country Park. There were no bedrooms, only 'bedchambers'. Initially I wasn't going to be staying overnight because it is well within commuting distance of home, but the company who organised the whole event contacted me shortly beforehand to say that some attendees had dropped out but their rooms were booked and paid for, so I might as well use one. Which was nice, because dinner was included and I probably wouldn't have stayed for that if I weren't staying overnight.

Insulin Pumps and Insulin Pens

In the UK, insulin pumps are only available to people with Type 1 diabetes, i.e. their pancreas is completely broken and not producing any insulin. As a Type 1 without insulin you end up dead before too long, so you have to inject a modified synthetic insulin into subcutaneous fat, which most people do using 'pen' devices. There are different types of synthetic insulin which have been designed to enter the bloodstream from the subcutaneous depot at particular rates. There are a rare few people who haven't moved on from bovine or porcine insulin and some who even use old-fashioned hypodermic syringes, but these are a tiny minority.

A working pancreas responds automatically to blood glucose levels, secreting exactly the right amount of insulin to maintain blood glucose within the ideal range. The person with diabetes has to take on the role of the pancreas by measuring capillary blood glucose via a finger-prick, then guessing at what blood glucose levels will do next, and injecting insulin according to their guess. Insulin pen users inject a long-acting insulin once or twice a day and rapid-acting insulin at mealtimes or with snacks, or else a twice-a-day mixture of long- and short-acting insulins.

The insulin pump is designed to try and mimic the physiological action of a working pancreas more closely. It contains a reservoir of rapid-acting insulin, and a background rate is programmed to inject this dripwise at an adjustable rate instead of the daily or twice-daily injections of long-acting insulin. With food there is the same process of estimation and guesswork about what blood glucose is likely to do, and the user tells the pump how much insulin to deliver from the same reservoir of rapid-acting insulin.

The pump delivers its insulin into subcutaneous fat via a cannula, which is a hollow needle made of metal or teflon that you insert into your body. The cannula stays in place for only two or three days otherwise you risk irritation around the insertion site and the formation of lipohypertrophy, which is a lump caused by insulin being delivered into a specific location for too long. Available sites are round the abdomen, the top of the buttocks, back of arms and sides of legs as long as there is a decent covering of fat - the same locations as for standard insulin injections.

Benefits and drawbacks

We often come across people in our service who are desperate to have a pump because they think it will make their diabetes management easier. In fact a pump is no easy option, and if you don't put any effort into managing diet and insulin and lifestyle then your outcomes will be as bad or worse than on multiple injections with an insulin pen. None of the benefits I list below relate to doing less work in managing calculations and all the rest of the overheads associated with doing the job of your defunct pancreas.

So what are the pros and cons of pump vs pen? The obvious disadvantage of the pump is that you're attached to it 24 hours a day, although you can remove some pumps for bathing or swimming or sports for up to an hour. Some people don't have any sort of a problem with having a pump attached to them day and night, at work, in bed, on holiday, doing sport - everywhere. Some people just don't like the idea, and ladies who want to wear figure-hugging clothing or a bikini may not be keen to display their condition. It's a very individual choice.

Disconnect the pump for more than an hour and you start to risk rising blood glucose levels, because you don't have any long-acting insulin in your system. After about four hours insulin-free there is the further risk of developing ketoacidosis, which is unpleasant at best and life-threatening at worst. So another disadvantage is that if anything goes wrong with the pump or your cannula or your insulin, you'd better have a back-up option handy or you might find yourself in A&E. If you're away from home, even on a short trip, you may find the journey cut short or have to make a whole lot of calls or trips to hospitals or pharmacies unless you carry spare equipment with you.

One clear advantage of the pump is fewer injections - in the three days that one cannula lasts you might expect to give at least 12 injections using a pen, and probably more. Another advantage of the pump is the ability to reduce your dose of insulin as well as increase it - with a pen, once the injection is given you can't dial the dose down. The third main advantage is that the background dose can be varied in a diurnal pattern that better matches the body's requirement for insulin, and the fourth advantage is that insulin to match food can be delivered in an adjustable dose over a period of time, which better mimics the action of a working pancreas compared with one or more isolated injections. Lastly, insulin pens only allow administration of insulin in whole (or occasionally half) units, while the pump can deliver much smaller amounts.

Other pump features

The pumps on the market also have no end of other features that are useful rather than necessary, like alarms, and the ability to download data from the handset and pump for viewing in all sorts of different ways designed to help you improve your carb counting and insulin delivery. The software for the pump that nearly all our patients use has some further features such as the ability to create a new profile by adjusting the background insulin up or down by a percentage - the alternative would be to change each of the 24 hourly settings using the pump or handset menus. The main feature that this pump lacks is the ability to upload all its data to the Internet so that it can be accessed anywhere. In our department we can only view the data on the specific computer that it's downloaded to, although we're working on a networked option so at least we can see the data on more than one computer in the building.

Mr M has a number of objections to the way the the software for his pump works that are probably a bit too technical to discuss here. I expect there are annoying features with every pump and handset. We recently held a session where we invited all the different pump manufacturers to show us their wares in an afternoon, and while they all do roughly the same job they are all quite different.

Coming soon: Part 2 of the Pumping Insulin series covers my own experience on the course, including wearing a pump myself for 12 hours.