Whose fault is it?

A recent article entitled, Why Physicians Do Not Initiate Insulin Earlier, states the following:

The results showed that the subjects failing to initiate prescribed insulin commonly reported misconceptions regarding insulin risk (35% believed that insulin causes blindness, renal failure, amputations, heart attacks, strokes, or early death), plans to instead work harder on behavioral goals, sense of personal failure, low self-efficacy, injection phobia, hypoglycemia concerns, negative impact on social life and job, inadequate health literacy, health care provider inadequately explaining risks/benefits, and limited insulin self-management training.

So, whose fault is it that these 35% of surveyed patients think that insulin therapy is the cause of what are actually complications of poorly controlled diabetes?

I’m gobsmacked that a survey can come up with this data! Is the survey saying that it wasn’t known before that misconceptions about insulin are so prevalent?

Again, I ask, whose fault is that. In some 90 years of insulin therapy, you’d think that by now patient education would be far better than what this survey reveals.

On the other hand, despite the Internet and its information revolution, the general misconceptions about diabetes are huge! The basic difference between Type 1 and Type 2 – people can’t even get that right!

Type 1 is an autoimmune disease in which antibodies attack and result in little or not production of insulin. No definitive cause (possibly genes and some trigger) and no cure for Type 1 (and all its variants – LADA, MODY etc) at this time folks unless you have a transplant, or some other experimental therapy, which aren’t widely available.

Type 2 is caused by a number of factors, but not autoimmune disease. Sure, if you have autoimmune disease and you’re taking cortisone, that will raise your blood sugar and can bring on Type 2 Diabetes. But Type 2 is not autoimmune in nature. It’s more about fat resistance and because of it, an overabundance of insulin. More info about Type 2 and its causes can be found at Blood Sugar 101, which has by far the best info about type 2, especially the article entitled, You Did NOT Eat Your Way to Diabetes. This article should be required reading for every doctor, nurse and diabetes educator, and anyone else who has anything to say about Type 2 Diabetes, especially those who like to comment with insulting and uneducated remarks.

With all the misconceptions about diabetes, is it any wonder that some people think insulin therapy itself is some kind of fatal risk?

Come on folks! If medicine wasn’t so much about money, education would have come a lot further by now. People who didn’t want to start insulin might not have gone on to having the very complications they thought they’d have by using insulin. Crazy isn’t it?

Unexpected HbA1C Results

This is only the second HbA1c I’ve had since I’ve been on a pump, and one test I definitely didn’t want to have right now.

Since December (see prior post), I’ve been under the most incredible amount of stress.

I’ve increased my working hours from 20 in my home office to 50 per week outside, doing a favour for my best friend in running his businesses (the other director has “left”).

Then I had to deal with the sudden and unexpected disappearance of this same friend on 8th Feb, and eventual discovery that he’d been murdered.

Dealing with his distraught family, closing one business, attending the police station every day in those first couple of weeks to assist with inquiries and more has been horrid!

And as if that’s not enough, sometimes eating 2 carb-laden meals in town (when I usually do much lower carbs), including burgers, sushi, fries and worse, just grabbing a bag of crisps off the shelf when I was starving. And then ignoring the ‘test-now’ reminder on my pump because I was simply too busy. It made me very reluctant to have this test, which was already 2 months overdue and I had a big cringe with I heard the doctor’s voice on the phone this morning.

But I’d been doing combo boluses and TAG, thanks to being encouraged to learn more and understand how to do it better.

All things considered, a HbA1C of 6.8 is way better than I could have ever expected in a million years. And I’ve halved the protein I’m throwing! Wow… imagine if I could actually do my usual lower carb, wasn’t so stressed (usually raises my BG) and done combo boluses – imagine what the results would have been!

I was congratulated by my lovely family doctor, and I’m unexpectedly delighted today (you can’t imagine the numbers I was expecting). It’s still not ideal though – I’d like to be much lower – the kind of numbers research suggests causes the least long-term harm.

Definitely something to aim for!

Crazy Work Hours and Diabetes

For the first time in 30 years, I’ve taken a project working at someone else’s offices. Since 1980, I’ve been an independent consultant and I’ve worked from my home office. It suits me and I love working that way.

For the past several weeks, I’ve been involved in a project with a friend and business owner involving several serious issues with another director, who, incidentally, hates my guts. Water off a duck’s back – the feeling is mutual. What that sneaky, underhanded, thieving director has done would fill volumes. While I’ve worked hard to make sure the evidence has been handed to the authorities, it’s taken many hours of my time and energy. I also knew that at the end of it, I’d have a project to sort it all out and to manage the two stores that were born of the original partnership.

On 23rd December, that other director, after we went to the lawyers with a 50 page document I’d prepared, was forcibly removed and he now no longer has anything to do with one of the businesses. The day manager was also given a DCM (don’t come Monday). So with 2 management staff down, I’ve taken both their jobs as well as what I would have been doing for the company anyway, as a consultant. I’m now fixing the sabotage as well. It’s been a complete nightmare and thankfully after 10 days we’re finally seeing some light.

So how am I faring with my pump and diabetes while doing 10 things at once and racking up around 58 hours work a week? You’d probably be as surprised as I was.

Despite carb-laden food being almost the only options for lunches and dinners from take-away stores and restaurants (who’s had time to do grocery shopping in the last 12 days?), and add to that all the stress, crazy hours, phones jangling, faxes pouring in and more, I’m surprised that not only does my pump allow me to handle all this with ease, the numbers prove that I’ve managed pretty well, all things considered!

I was supposed to be working in the other business – a much newer place with a lovely office. I was only meant to be doing 4-6 hours a day until things were sorted and then cut it back to 2-4 hours on 2-3 days a week (I still have other clients), but no one knew what a shambles the businesses would end up in, and no one anticipated the sabotage that happened in the 10  inutes before the police took the other director away. There are still some major problems with the other business, so it’s been closed since before Christmas. Because of that I’ve been working in the original business, in a small hole, slightly bigger than a broom cupboard. Getting to that hole in the wall, you have to go through a storeroom and through a bathroom. Gorgeous it ain’t! But I can see the humour.

I’m now doing a whole bunch of things that weren’t anticipated – rosters, fixing a POS System I’ve never laid eyes on before, ordering stock, handling staff problems, directing staff, putting new procedures in place, counting cash and a whole lot more, while still doing my regular IT Consulting and being an accounting software specialist. And then there have been times staff haven’t shown up, so I’ve raced in there, after 2 hours sleep, and got on the tills to get the customers through, with the phone in one hand trying to find someone to work the shift. It never stops – it’s a 24 hour place, and very popular.

New Years Eve was another nightmare with lines out the door. Thought I’d never walk properly again with the sore legs I had from standing. (I’m usually at a desk with a screen in my face.)

The remaining director, who has been a good friend for many years, fully acknowledges the ‘conditions’ under which I’m working. Believe me, he’s paying handsomely for my services, but there are a few issues he can’t pay for, even with all the tea in China. So, I wrote him a memo. I thought you might enjoy it too. We both needed a laugh after what was a horrendous week.

Here it is…

Dear Sir Mr Boss Man, Stockholm Syndrome Black-Belt, Slave Driver,

There are several issues I wish to raise in this brief lengthy and official letter.

Due to entirely foreseen circumstances, my legs, hip and back have failed. Under the law, people with this kind of disability must be catered for. After all, you do have a stinky dirty disabled toilet right outside my office and I?m forced to listen to the entirely un-mellifluous tinkle of nature, while trying very hard to concentrate in this chaotic environment.

Further, during those times, I?m unceremoniously imprisoned in my inhumanly small, stuffy and hot oven office at the will of the tinkler. (Check the Geneva Convention laws about the minimum size of cells). I am also now living in abject fear that one day I may be imprisoned there forever, without food, chocolate or cigarettes. That would be a tragedy of the worst kind, for which my estate will be bound to sue the pants off you (I changed my will today to force them to act on my behalf).

Because of the failure of certain parts of my body, I wish to respectfully request that a supply of Nurofen or similar be paid for by the company to comply with the law and to show me the smallest measure of respect for the terrible hardships I have to endure while employed by you. Perhaps you might also consider some No-Doz, but of course this is not essential, and probably not provided for under the law.

I understand that you have now perfected the method to age someone 10 years in 8 days, and I applaud you for it, but might I ask where your integrity is with this cruel and unusual treatment of loyal, hard-working employees? I understand that it?s provided free, so I really don?t want to look such a generous gift-horse in the mouth, so to speak, but surely you?ll agree it?s a tad excessive. I only expected to be aged 5 years not 10! This kind of misrepresentation is surely punishable by the Department of Fair Trading.

Further, I will be contacting the agency that has jurisdiction over abuse of old people and slave labour. This 17 hours a day you are forcing me to work, might well be considered excessive in the Western World and could be a crime with a lengthy jail sentence. Please be on notice that you could be charged under the law, and be forced to pay compensation as well as do jail time. And because I like working here… most of the time… I will only be claiming $10M compensation (not $20M as the law provides), and recommending that you not go to jail for these heinous crimes.

I have submitted a copy of this letter to my lawyer so that you cannot force me to retire on the grounds that I am making these complaints. Please be aware that on 1st January, the Fair Work System comes into effect. It provides massive overtime for all work over the standard 38 hours per week (note, not “per day”), which an old and decrepit person like me shouldn?t be forced to do anyway. Ha, and I thought a labour government was for the people, not for employers! This is the kind of nonsense they promote when they want to get votes from rich people. I know their game. And I now know yours too.

Did Mr Gone-Director ever force anyone to work 17 hours in one day? I doubt it! Even the wicked witch Miss Director’sWife didn?t have to work the 25 hours she got paid for. Wow, Mr Gone-Director sure treated his staff well and was especially generous with them, paying them for work not done. You?d do well to do the same! As you know, I?d never claim such a thing, so perhaps some kind of bonus is in order? It?s tax deductible, you know!

I?m truly sorry I have to bring these matters to your attention, but there will be far-reaching consequences if I don?t – both for myself and my long-suffering, working-man, non-English-speaking husband and my beloved CharlyDog, who simply will not fit in my office, as promised, no matter which way I rearrange the furniture. My husband fails to understand why you are stalking me from work to home all the time. Would you care to explain that to him after the police release you on bail?

You must surely admit that you did lie about the luxurious conditions at work, didn?t you? You got me to work there under false pretences, promising me a spacious office with air conditioning and a bed for poor Charly, who now has to stay at home all alone crying because you are so cruel.

Anyway… here are my demands. And I will not budge an inch on them.

By 4pm today, I demand an occasional company-supplied packet of Nurofen, otherwise I will have no choice but to take further action.

For insurance purposes I am bound to report these nefarious activities to the police and other authoritative bodies. To that end, I have already prepared a lengthy 50+ page report with dated photo and audio evidence of the alleged jailer-tinklers and the abject conditions I must endure, which I?ve given to my lawyer, and which will be taken to the police forthwith at 4:01pm if my demands are not met.

Oh and one more thing. I have also asked Mr Gone-Director to testify on my behalf, which he is very willing to do. I may even have to get <someone else> to intervene if this keeps up. After all, Mr Gone-Director had to endure these horrendous conditions for 6 long and arduous years! No wonder he?s a bit angry now! While I?m not as childishly vindictive as he appears to currently be, I am, unfortunately, forced to make these grave complaints because you are long past the agreed 2-4 hours a day you proposed when you hired me. Your name will be dirt when this gets around the community! You can buy my silence with good quality dark chocolate.

At 4:02pm, after my report is faxed around the globe (at my own cost, of course), I am considering beginning strike action.

Yours faithfully,

Miss Brunhilde Longsuffering Hardworker,
Emotional Blackmailer (EB) and Qualified Expert Letter Writer (QELW)

TAG – Total Available Glucose

Today I was reading a blog post by Amy Tenderich over at Diabetes Mine called, Betting Our Lives on Guesses.

I made a comment as follows:

Lately I’ve been studying TAG (Total Available Glucose) of not only carbs, but protein and fat too. It’s a much better and more accurate way of bolusing for T1 than just counting carbs. I have a pump, so I do extended boluses for all but small meals and snacks. That seems to work better too.

The one thing that also drives me crazy is the inaccuracy of meters. Thank heavens we have them, but really, by now they could be much more accurate. The other one is that I wonder sometimes how some manufacturers get to their carb counts on food packs. I’m sure sometimes they’re just guessing.

TAG is a system that takes into account not only the carbs in foods but also the available glucose of protein (about 58%) and fats (about 10%) and working out boluses on that.

Not that boluses are inaccurate only because you’re not doing TAG. There’s so much more to take into account: fighting an infection, inflammation, pain, stress, weather, hormones and a whole lot more. It makes looking after diabetes, once thought of as a science, more of an art-form at times.

There’s a great discussion over at TuDiabetes. It started off about doing combo/extended boluses on a pump and evolved into a discussion about TAG. Read more about the posts in “Dual Wave Bolus”

Even if you don’t have an insulin pump, it’s well worth the read.

Stress, Weather and Basal Rates

For about 3 weeks, I’ve been so unexpectedly busy that on this fine but very hot Sunday morning, I finally get the opportunity to take stock of how my diabetes has been during that time.

I do know how much and how easily my BGLs go up with stress – any kind of stress… the kind of stress that you wouldn’t ordinarily call stress. Day to day living is a stress of sorts. Having to be somewhere on time is stress. Trying to get a job done on time, even when you have plenty of time, is stress. Being in a crowded room with the din of everyone talking, is stress. Unless you’re in a meditative state 24/7, it’s all stress of sorts. While I may be more sensitive than some, daily living does have an effect on everyone. Managing diabetes is sometimes more an art form than a science.

Put stress together with the really hot weather we have here (in Australia) over late spring and summer, and it’s time for me to take a good look at my basal rates. Weather definitely has an effect on insulin needs too.

I know my current basal rates are not serving me the best way they could at the moment.

Who’d have thought in just 3 weeks, what was once a nearly-perfect basal program, is now quite off at some times of the day?

The problem is that being as busy as I’ve been, I’ve hardly had time to notice. Yes, I’ve noticed the numbers being off, but I’ve also had a much more varied diet (read: mostly more carbs than usual) and I’m very aware of my BGLs going up some 4-6 hours after a meal that is only a tad more than would be considered ‘light’, let alone a heavier meal – that one is a disaster! Mostly after dinner, the struggle with BGLs going up consistently, so long after dinner, is something I’m not yet sure how to handle.

Despite using extended boluses over several hours, I’m thinking I have to extend any bolus I do quite a bit longer. It doesn’t matter what time I eat, it still happens around the same time later. If I skip dinner (rare), it doesn’t happen, or if I have a very light meal, it also doesn’t happen. It’s called gastroparesis – delayed stomach emptying. Many people who’ve had diabetes for a long time have it. And it’s a bitch to handle, whether you’re on a pump or on MDI.

Sometime in the next few days I have to formulate a plan to test all the basals I have right now.

Remember that on injections (MDI), you do possibly 2 injections a day and it’s pot luck whether the relatively flat-line of Levemir or Lantus can come close to what the human body really needs. This is one of the reasons a pump is so great. You can adjust your basals any way you want and have as many as you need.

If you’ve never seen basal rates for a pump, this is what mine looks like at the moment. The time indicates what time that rate starts, and it continues until the next time listed. The number next to the time is the units-per-hour of insulin. I have 6 different basal rates at the moment. After I reassess it could go to 4 or 8 or whatever I need with the rates I need for that time of day. I used to go very low around 4-6am so the reduced basal rate at that hour is great! Also remember that you’re adjusting the rate for a peak around 1-2 hours later.

Basal Rates

12:00a 1.100

01:30a 0.925

02:30a 0.750

09:00a 1.075

03:00p 0.900

07:30p 1.125

I’m fast coming to the conclusion that unless you’re a total creature of habit – go to sleep the same time, wake up the same time, eat the same things at the same time, do exactly the same thing every day, on time – then the daily, and sometimes inexplicable fluctuations in blood glucose needs quite a bit more managing. Even creatures of habit have fluctuations, but certainly not as much as if the criteria changes drastically from day-to-day. I’m definitely not a creature of habit and I wouldn’t change that for anything. You live with some things, you change others to manage diabetes. Some things are not negotiable!