5.3

The last HbA1c I had before starting on the pump was 5.8 % (Nov. 14 2005). In April this year, when I started pumping, the aim of my diabetes nurse and I was to try to increase this just a little (to 6.0 %) to see if this would also eliminate some of the nasty lows that had experienced. While these nasty lows were not that numerous after the switch to Lantus 3 years ago, they would occasionally show their ugly face, usually leading to a trip to the ER or a visit from the paramedics in our home, so I sure would like to get rid of those.

As described in previous posts, the switch to the pump still has to prove its worth in relation to lows. Because of that I wasn't too surprised to see a slight decrease in my HbA1c at my endo appointment in the end of June, almost 3 month after pump start. At that time it was 5.7 %, which would be great if it wasn't because of all the lows it included.

Last week I mailed another sample for HbA1c-analysis. Sunday evening I went into my web health portal to see if the result was back yet. It was. I have an appointment with my diabetes nurse this Thursday, and I am looking forward to see her reaction to the result. 5.3 % it said, which is the lowest it has been since I moved to Odense in the beginning of 2001.
My HbA1c results the past 2 years

Before that I had results as low as 5.1 %, which at that time was more a concern to my doctors than to me, because I didn't had that many low, and certainly not as many requiring assistance in their treatments as I have had afterwards, even with higher A1c's.

I will have to admit that the perfectionist inside me most certainly aims for an A1c that is normal, i.e. in non-diabetic range (4.6-6.4 % as far as I remember from patophysiology classes). Not at any costs though. The current 5.3 % result, while in this range, stores too many low lows. I cannot remember ever having tested, or even being able to test, at 1.1 (20) or lower (my meter just reads LO for values of 1.1 and below) in all the years I was on MDI. I have already lost count on the number of times this has happened while on the pump, but it is at least a handful of times. Of course these lows are somehow outweighed by the highs that has also been present, especially after soccer games, but that just shows that the BG-curve has not leveled out as much as anticipated. Hopefully this will happen with time, but it is a bit difficult to be patient, when you were promised results, potentially within 3 months.

It may sound like I am all negative about the pump and the promises that comes with it. That is not the case. I certainly see advantages with this therapy as well. I am probably just, still, a bit frustrated by the fact that I cannot seem to get a hold of things with CSII, and that it regularly causes issues that are not only troublesome but also scaring at times. I hope that my next A1c will be as great as this one, only without the hypoglycemic backside of the result :-)

Winter is coming

The past night we changed from summer time to winter time. While it is lovely to have your weekend extended by 1h – especially when you have attended a party (soccer season winding-up party) on Saturday night – and I am looking forward to be able to go to work in daylight, at least for a couple of weeks, it is getting darker and colder outside. Winter is coming. The weather forecast for the week to come had sleet in it. Like the roads and bike tracks aren’t slippery enough as they are now with all the wet, fallen leaves lying around!

I don’t know about you, but for me there has always been a good correlation between required insulin doses and season of the year. I tend to need more insulin during the winter months, probably because I am not as active as in summer. I still ride my bike to work every day during the winter, and this year I have also, besides the weekly indoor soccer practise, resumed swimming again, so it is not like I am totally inactive. Still, compared to the summer, where I usually have two soccer practises, 1 game, and extra bike rides “for fun” on the program, winter does not entail as much physical activity. When on MDI I would usually have to increase my Actrapid (Regular) doses by a couple of units with each meal, the Lantus dose in general staying the same.

The past night we changed from summer time to winter time. While it is lovely to have your weekend extended by 1h – especially when you have attended a party (soccer season winding-up party) on Saturday night – and I am looking forward to be able to go to work in daylight, at least for a couple of weeks, it is getting darker and colder outside. Winter is coming. The weather forecast for the week to come had sleet in it. Like the roads and bike tracks aren’t slippery enough as they are now with all the wet, fallen leaves lying around!

I don’t know about you, but for me there has always been a good correlation between required insulin doses and season of the year. I tend to need more insulin during the winter months, probably because I am not as active as in summer. I still ride my bike to work every day during the winter, and this year I have also, besides the weekly indoor soccer practise, resumed swimming again, so it is not like I am totally inactive. Still, compared to the summer, where I usually have two soccer practises, 1 game, and extra bike rides “for fun” on the program, winter does not entail as much physical activity. When on MDI I would usually have to increase my Actrapid (Regular) doses by a couple of units with each meal, the Lantus dose in general staying the same.

Approaching the first winter with the pump, I am looking forward to see, whether the tendencies noticed on MDI do also apply to CSII, or if that is just another set of experiences that I can forget all about in relation to diabetes management. Starting on the pump was like starting from base once again. Of course, some of the experiences that I had build through 16+ years of diabetes would still apply, but the vast majority of them had to be modified.

Resuming swimming has been a challenge. I have about 18 years of swimming experience, 12 of these with diabetes, but the last 3 or 4 years I haven’t really made it to the swimming facilities. This winter I have decided to give it another try, though. I work on the University, and students as well as staff are allowed to use its swimming facilities for free at hours when no teaching takes place there. For the staff, Mon-Fri from 7:00-8:00 AM and Fridays between 12:00 and 1:00 PM are available. The morning hours are a no-go for me. When it is dark outside, I cannot get myself out of bed before absolutely necessary, and as I have a 30 minutes bike ride to reach the University, I would have leave home at 6:30 AM or something like that to take advantage of the morning swimming hours. The hour on Friday noon is not ideal either, but I am working at getting into a routine that allows it. So far (3 attempts) I haven’t had too much success. I thought I could use the same strategy that I used for soccer practise in the spring: I would have a small snack, accompanied by a small bolus (<>r at 12:35). Hmm, another indication that I was low. I did not expect to see the number I did on the meter, though. Sure I felt the weakness you do when you are low, but other than that I didn’t feel too impeded by it. Until I saw the number, that is! 1.6 (29)! Damn, grab glucose tabs and M&M’s in my back and start chewing. Slowly made the 700 m walk back to my office, cursing and wondering whether I should make a stop at the canteen. I decided not to stop at the canteen - my hypoglycaemic brain couldn’t handle that challenge - and headed straight to my office and my lunch box and sugary cola. It took me a good 45 minutes to get back to my normal self. Why does it have to be so difficult to succeed? With 3 failed attempts, I am now considering not to do the extra snack-bolus thing before swimming. My guess is that it may prevent me from going low, but is also likely to leave my above 11 (200) when I finish, and that is really not in my interest either, as by that time I am usually hungry because I will normally have lunch around 12:00-12:30 PM. Maybe this is just another one of the choices between cholera and the plague that diabetes offers you?

Up front on diabetes research and development

A couple of weeks ago I got a call from my diabetes nurse. She told me that the hospital had started an innovative collaboration with a private company. The “aim” of this collaboration was to develop a sort of a “single use pump”, a device to be put onto the skin to deliver insulin for 3 days, after which it should be replaced. The company was not really into diabetes and insulin treatment, and thus they would like to discuss the features and possibilities of this device with patients and caretakers. Therefore the company had asked the hospital to arrange for a meeting with a host of diabetics, half being pen-users and half being pumpers. If I was interested, I was invited to participate in this meeting. I thought that sounded interesting, and figured that I would be able to make arrangements in order to leave work a little earlier on the day of the meeting, so I accepted the invitation. “Great, you will receive a letter from H (chief physician on the endocrinology ward of the hospital, and apparently consultant for the company on this project) with more information about the meeting”.

The letter informed us that apart from us as patients, the three diabetes nurses that are involved in pumping and H himself would participate in the meeting. Apparently the company, in collaboration with the hospital, had developed a new insulin pump that would go into clinical trials at the hospital next year. As the company was new on this field, without much experience with insulin treatment, they would like diabetics to advise them about views on pumps in general, as well as evaluate their prototype regarding the idea behind the concept, the design, and other wishes or needs in connection to pump treatment. They would want to present the prototype and get a patient to try it. That sure sounded interesting!

Yesterday was the day for the meeting. This was the first meeting in Odense that the company and hospital would host. We were 8 diabetics on pumps, the three nurses, H – attending another meeting simultaneously, and two representatives from the company. H opened the meeting by welcoming the company representatives and us, describing us as part of the elite of diabetics, people who were on top of their diabetes management (nice to know :-) although I am not sure how much insight he actually has on this, as I don’t think that he is a consulting doctor anymore). By the company representatives request we introduced ourselves to them and each other, on camera because they needed to be able to take our opinion back to their engineers. It turned out I was among people, who had been diabetics for as long as 50 years! A few had lived with this disease for 35+ years, one of them having had a pump for more than 20 years (several different types along the way).

When the representatives presented this new “single use insulin pump” to us, they soon learned that some parts of the concept/design was not ideal. We also had to turn our minds into not seeing this new product as an insulin pump in line with the pumps that we use, but rather sort of an insulin pen based infusion-device. It is an oval-shaped, wireless, plastic device with an electronic part that is reused when the “pump” is replaced. It is filled with insulin from an ordinary insulin pen – a very smart feature in my opinion. On its backside it is covered with an adhesive, and to insert the devise, you attach it to your skin, pres a button to introduce the needle into your skin, and remove said button, so that you are left with only this 7.5 x 5 cm (2.95 x 1.97 inches) and about 0.7 cm (0.3 inches) thick oval shaped devise. 20 minutes after insertion the “pump” will start infusion of insulin at a pre-set basal rate. A button on the devise allows you to administer boluses, each press on the button will release 1 U of insulin. The “pump” will continue working until empty, or about 3 days, at which time it will alarm you by vibrations, sound and light, to make you replace it. As you might have guessed by now, said presentation (of which I have only reported the most essential parts) led to quite a few points of criticism and comments. The devise did not enable you to change the basal rate, nor did it allow administration of “odd” numbers of units for boluses. This of course should be seen in the light of the target group of patients for this devise: Diabetics currently on a pen regimen, who may not yet be fit to take the full step into pumping, or who attends a hospital without the economic potential to pay for a pump (in DK, pumps and pumping supplies are financed by the hospital treating the patient) – this devise is supposedly cheaper than regular pumps although, of course, more expensive than traditional pen-treatment, and otherwise might benefit from a “near-pumping” regimen.

I tried the prototype on, without a needle in it, and it was actually surprisingly comfortable to wear, despite its size. I would like to show you a picture of it, but I will refrain from that as I am not sure whether the company has otherwise gone public with their new concept yet – and I wouldn’t want to give their idea away now, would I :-) We all filled a questionnaire about our own way of treating our D as well as our thoughts about the new devise, its advantages and limitations. The company representatives expressed that they had greatly benefited from the meeting, being a bit surprised about our main point of criticism (the lack of the possibility to change the basal rate as needed), and they would take our response into consideration in the ongoing development of the devise.

H returned to close the meeting by handing us another questionnaire, this one being related to his own project on developing a sensor to alarm diabetics about hypoglycaemia – also an interesting project indeed. The nurses handed out envelopes containing a tube to sample blood for an HbA1C and a question about our quality of life before and after the pump. This is for their continual specification on the regulation of pump users. Thus, this was an afternoon of multiple questionnaires as well as a demonstration that the hospital, and especially H, is up front in research and development when it comes to diabetes :-)

Damn diabetes

I guess the title of this post eloquently expresses what I, along with all other members of the OC, feel about this disease from time to time! My need to express myself in this way now emanates from its interference with my plans and performance this weekend.

I hate when an out-of-range BG-reading requires me to change or postpone my plans! Yesterday we had the final game of the fall season. It was a morning game starting at 10 o’clock (very wet grass and temperatures slowly creeping up from 5 degrees Celsius – something like 41 degrees Fahrenheit – but actually it wasn’t that bad playing in shorts!). My fasting BG at 7:45 AM was a little higher than I like it to be: 9.9 (178). I didn’t correct for that though, as I knew I had a hard game coming up. However, when I tested 1.5 h later, getting ready to go out to the field to start the warm-up, I had dropped to 2.9 (52). I changed the temp basal rate from 60 % to 0 % for 90 minutes, while I chewed down glucose tabs and banana. Out on the field we got the line-up. I was to start as left defender. Certainly not a favorite position for me, but to the long line of injuries, especially among our regular defenders, our coach apparently saw no other option than to place me there. So, I started warming up, not feeling too fit due to the low start, but hoping that it would improve before the game started. It didn’t. My legs felt more and more heavy, my passes were generally off, and 10 minutes before game start I capitulated and found my meter again: 2.4 (43). Not good! There was no way I would be able to get it up to 6.0 (108), where I like to be during soccer, before the game started :-( Our coach changed the line-up and I sat down, exhausted and pissed at the D, finding more glucose tabs, juice and müslibars to elevate the BG, while wondering what the hell had happened to my solid breakfast that should definitely have had time to take its effects before I left the house 5 minutes before our time of meeting prior to the game (it was a home game, being played just across the street where I live, so there are only about 1.3 km [0.8 miles] from my front door the locker room where we meet before games). About a quarter of an hour into the match, after having consumed an additional 40 grams of CHO or so, I was slowly climbing to 3.2 (58). By the end of the first half I could start my warm-up for the second time that morning, so that I could replace one of our wings at the break.

The damn diabetes precluded me from playing a full match of soccer! More than anything, I hate when diabetes prevents me from doing things that I like to do, e.g. play soccer. Also it is frustrating that hypos or hypers occurring before or during a game affects your performance negatively. I ended yesterdays game on a fair 8.0 (144) at 12 o’clock, but I sure didn’t play the best I could. By the way we lost the game 2-1 despite having had our opponents very well matched during most of the game :-( I got myself a strained inner ligament in my left ankle, but because it was only minutes after I had finally made my entrance to the game, I continued playing and the pain went away, but as you may guess it returned once the joint cooled down after the game. Today it is sore, but there has hardly been any swelling, and I can move around although it hurts like hell if I have been sitting too long ;-)

I guess the winter break for soccer has come on an appropriate time point. The current situation for our team is 5 knee injuries, 1 hand injury (soccer induced!) and then at least a handful of “minor” injuries of fibers in thighs, groin issues, inflamed toes and strained ligaments. That is actually a whole team out with injuries - we are a poor crowd! Anyway we don’t start practicing indoor until next week, so my ankle has a couple of weeks to recover – hopefully :-) Hopefully the D will not interfere as much with my performance in the indoor games either!

Reflection

The soccer season is coming to an end. We play the final game this Sunday. If we win, we end third and collect a cash prize to make our ending-party even better :-) Approaching the end of the out door soccer year makes me reflect upon the seasons (spring and fall) as a whole.

I entered a new club in the spring and felt welcome there from the first minute. A couple of team mates from my former club are in this new club too, and that made the transfer a bit easier – at least I only had to learn about 20 new names in stead of 22 ;-) I am proud of the fact that I fairly quickly entered the team for the games, having only missed 4 games or so (of 20) over the two seasons in total, and three of these were due to me having other appointments on game days. Given that we are more than 20 players, occasionally our coach have had to drop players, so being picked for the team on those occasion feels extra good.

This year was also my first of combining CSII management of my diabetes with soccer. Before that I had about 15 years of experience in handling insulin dosing with injections around practise and games. I was comfortable with that, and although it did not always work out quite as would have liked it too, it usually did not cause too many problems. Exchanging Insulatard for Lantus as my basal insulin three years ago didn’t cause any changes around soccer, other than making it a bit easier to manage in some situations. Starting pumping back in April this year, however, is another story! I felt quite helpless not really knowing how to handle things around soccer. This of course was due to lack of experience, but also because I knew the theory behind pumping, the pharmacokinetics of NovoLog that I was now totally dependent upon and needed to learn my response to, and not least the fact that I did not feel like wearing the pump while playing soccer. Practise quickly turned out not to pose any problems, as my theory about giving a small bolus along with a snack about an hour before starting practise worked very nicely, without causing too many lows during practise or highs post practise. Games turned out to be a tough challenge, though. It was, and actually still is, not at all an easy task to make things work without too large fluctuations in BG levels, and I have expressed my frustration about this several times on this blog. In the summer break my diabetes nurse and I agreed that I should try to wear the pump while playing. That prompted finding a way to wear the pump in order to protect it against the hits of close encounters with the field, ball and other players that occurs in the heat of competition, without affecting my free movability. After a few unsuccessful attempts, the sports pack entered the scene and solved the problem in an acceptable way. I must admit, though, that I would still prefer to play without wearing this. Anyway, the next challenge was to find out how to regulate basals around games. This challenge has yet to be solved completely. For the first game of the fall season I was able to wear the Guardian RT sensor, which provided me with very useful information about BG trends during games, and gave me some ideas on how to fit the basals to counteract large fluctuations. Still, theory and actual occurrences are not always the same. I have only had a few successful game days BG-wise in the current season, and it bothers me because even though I may not see the high BG until after the game, being too high or too low surely affects my performance. The issue have mostly been high BG’s, especially towards the end of the game and immediately after. I am annoyed by the fact that I still haven’t been able to figure out how to avoid the spikes towards the end and immediately after games, without having to battle low blood sugars during warm-up and the first part of the games. It is not that I had perfect sugars for games when I was doing MDIs, but the post-game highs never really went above 13.0 (234), whereas with the pump 15-18.0 (270-324) are the typical results. An example of this is from one of the games this fall. I played most of the game, being replaced about 15 minutes before the end of the game. At that time I tested and got a perfect 6.3 (113). Knowing that it was likely to rise, but also wanting to risk going low, I entered a small bolus, 0.8 U (1U will usually drop me 2.7-3.0 mmol/l [49-54 points]). The game ended, we did a short evaluation of it and then headed for the showers and victory beers. Out of the shower, I did a quick test just to be sure I wasn’t too low. About 45 minutes after the perfect 6.3 (113) and 0.8 U bolus, I was at….. 15.7 (283)! Where did that come from? I had not had anything to eat or drink other than lots of water, and the result had me turn down the beer offer outside the locker room, as I did not want to make it even harder to get back into range again.

The series of examples of severe BG changes in relation to soccer while being on the pump is already long. Why is it that I can start out with a 4.7 (85), just a little lower than I would like, thus eating a couple of glucose tabs and a small banana, and then two hours later, after a full warm-up and only 15 minutes break during the 90 minutes game, landing at 16.8 (302)? I just don’t get it!

Anyway, now the indoor soccer season is coming up, and I look forward to that. Not only because I like the technical aspect of indoor soccer, but I also anticipate that it will be somewhat easier to manage BG-levels for this, as the games usually are no more than 7-15 minutes each. Thus, disconnecting for games should not be an issue, and as for practise I may wear the pump or disconnect by the same procedure as I used for outdoor practise back in spring. Time will tell which it will be :-)

60 million blogs

Sunday evening, in a news-program on one of the Danish TV-channels, there was a feature on web-blogs and blogging. The feature was about what blogs and blogging is, and how it has become increasingly popular to share thoughts and experiences with the rest of the world on the Internet, regardless you being a big company or a "“small" Mr. or Ms. "“Nobody"”. This is also the case in DK. Said TV-station started web-blogs via their home-page not too long ago, the aim being that people could discus different topics with the different hosts of the station, and it has been a success. The feature ended with interviews with two Americans, one who had quit his job to be a fulltime blogwriter, and another who was just about to quit her job for the same reason. The speaker announced that world wide an anticipated number of 60 million blogs are now available on the Internet! 60 million blogs! I am just glad that I found the host of D-blogs about a year ago. The number of D-blogs that I have bookmarked in my browser since then has increased. I am no longer able to follow them all every day, but in any idle moment I the up-dates :-) I have (and still do) very much enjoyed reading, writing and commenting on D-related struggles of/in an understanding audience. Doctors, relatives, friends, colleagues and others can express understanding, but in reality we all know that they do not have any chance of really understanding what we go through with the D - just as we do not really have a chance to understand how the our D affects our parents, siblings, significant other...…. Therefore it is a relief to blog in a community where members have felt this disease on their own bodies, whether that be as diabetics themselves or as close relatives.

So happy blogging fellow D-bloggers! Together we are strong :-)

Time to blog

I admit it, I am not good at squeezing in time to up-date my blog every day, or even every second day :-) Thus, again it has been more than 2 weeks since my last post. Not that there hasn’t been something to blog about during these weeks, there has actually been plenty, time and blogging-discipline just haven’t been on my side ;-)

Speaking of discipline, yesterday my soccer team and I had an important game. Our aim this season is to end third. We do not have the potential nor the desire to advance to the national series (Danmarksserien), which the winner of our pool will do and number to have to go into play-off games for. We do think that we have the potential to end third, though, and since this position also means a cash prize, it motivates us even more. Yesterday’s game was against a team that we knew we could defeat (we won 4-1 last time). However, at the moment we have a number of injuries, the last one occurred within this week, among our defenders. Unfortunately, two of our most stable defenders were not able to attend the game due to other appointments that they had agreed upon months ago. Therefore, in reality we had only one defender left for at least 3 positions, so Tuesday’s practice was used to try to figure out who could fill the 2 two other positions of the defence. It was difficult, and we could certainly have used Thursday’s practice as well, but as this was the last practice of the month, it was dedicated to five-a-side with the boys. I was among those tested for a marking player’s position on Tuesday, but I hoped that could avoid that position in the game. Everybody was exited about the line-up when our coach started his tactical presentation prior to the game. And guess what, I was handed one of the marking player’s positions! His reason for handing me this position was my discipline. He told me that in contrast to some of my team mates he was confident that I would fill the position handed, because when he game me directions I would follow them the best I could. I guess that it is true, although I am still far more confident playing forward or wing. Anyway, I played the full match as marking player yesterday and it went okay. Actually, together with our defensive midfielder I was appointed our team’s WOM (woman of the match, we vote about this after each game, and yesterday 7 different players were nominated, so Stine and I won with just 3 votes each). Our coach once again praised my discipline after the game, immediately nick-naming me Andreas Brehme (German defender from the late 80’s and 90’s, German soccer is known to be very disciplined).

Honored about the compliments from my coach, I can’t help thinking about the basis of this discipline capability of mine. Actually, I am quite confident that the most important reason for this comes from me being diabetic. Think about it; everything about diabetes and diabetes management is somewhat build upon discipline. We need to acquire at least some discipline to remember shots, boluses, tests, and to occasionally resist food-related temptations. Though it is a somewhat boring word, discipline can enable us to feel okay most of the time and take part in the activities that our non-D friends indulge in. Apparently this acquired discipline is useful in other aspects of life too, although we may not give it many thoughts :-)

By the way, yesterday’s game was the first one this year that my BG seemed to act okay before, during and after. Starting at 8.5 (153) and ending at 5.8 (104) about half an hour after the final whistle of the game, I was thrilled that for once I didn’t seem to spike uncontrollably just after. I therefore found it appropriate to celebrate – the BG success and the result of the game (2-2 after having been down with 2 at the break) – by having a beer with my team mates before we returned to Odense (it was an away-match). Now, why is it that one is never allowed to celebrate a success without being haunted by it afterwards? The game and the beer kept my BG on the low side the rest of the evening, and this morning too. Damn it, I just had one single beer, something that usually makes me go high rather than low, and I had had plenty of water during the match and ate something before the beer too, why does it have to slap me in the face like that?

I will stop my rantings for now. I may not post that often, but when I do, I write a lot :-)