Friday 9th December 2011 - HbA1c day!

The last few weeks have passed very much in a blur; my feet have barely touched the ground. And, as a consequence, I haven’t been as loyal to my blog as I could have been! But, today I had another diabetic clinic at the hospital, and earlier in the week I browsed an online diabetes forum on which I used to be a prolific poster and have been inspired once again to write.

As per usual it’s been a bit of a rough old ride. I’ve had a few breakthroughs (namely waking up with perfect blood sugars on at least 3 occasions) and a few lows (actual – in the form of hypoes - and metaphorical: just being generally fed up with the whole thing, the latter not being conducive to my writing)

On Thursday I played a (very giggly!) game of netball and then went to watch the Nutcracker ballet at the Busan Cultural Centre. However, in the excitement of getting ready for the ballet I forgot to adjust my insulin to accommodate the exercise and then had not one, but two, hypoes while out. I got incredibly frustrated with myself: it’s such a simple thing to forget to do! Unfortunately, in situations like that, excitement just gets in the way of being a good diabetic!

My foray onto the diabetic forum was a bit of an eye opener. I found a thread on which people were comparing their waking blood glucose levels. As you know if you have read my previous posts, I struggle with my morning blood sugars. It was a shock to me. So many people wake up with pitch perfect blood sugars. I was seriously impressed. But then my wonder turned to jealousy, and my jealousy to frustration and my frustration kick-started something in me: I think it’s called motivation?! Anyway… I thought: “If they can do it why can’t I? I’m going to whip my levels into shape if it kills me.” This, however, remains to be seen. The reaction of my doctor today at my inability to control my over-night blood sugars seemed to be somewhere between amusement and sincere understanding. He said, with a smile, “Stress!” and, pointing to an array of particularly high readings, laughed and said, “Very stressed!” Oh dear… He did go on to explain what I know – but what never ceases to annoy me – that environmental factors have an impact too. But that doesn’t really help…

So with that, back to today and my clinic. It began at 8 o’clock this morning when I arrived at Haeundae Paik hospital for my blood test. As usual, I drank as many bottles of water as I could cope with en route to the hospital to make sure my veins were nice and plump. On the bus on the way, following my normal two pieces of toast and marmite, I had the sinking feeling that the blood test should have been a fasting one. However, I pushed the thought out of my mind and just carried on. Once there I handed my piece of paper to the receptionist and was motioned straight over to the phlebotomist. The transaction was quick and painless and I was walking back out of the door 5 minutes later. So refreshing! At home, getting blood out of me could be like getting blood from a stone; here, they seem to have the knack!

After that I went to school only to return at 2:30 for my appointment. Today, it went well. Maybe I’m just getting used to it, I knew where to go for what and managed to pay (extortionate amounts of money) and exchange my prescription for insulin pens as if I had been born here. Well. Nearly! The doctor was all smiles and proudly presented the results of my blood tests to my on the computer screen. My HbA1c was 7.7%, down from 8.4%, which is something to celebrate. My target is 7.0%. My blood pressure is fine. My thyroid function is now fine after upping my dosage, my kidney function and cholesterol levels are also good. So right there, in that short paragraph I have written are many reasons to be upbeat. I just need to remember that in the weeks to come. After 16 years of diabetes, I am still relatively healthy if dependent on a whole variety of pills and potions to keep me alive. I keep wondering when my time will come, when my luck will run out, and this is where I have to keep my chin up and not let it all bog me down. I am trying very hard to implement a small facet of the Buddhist teachings into my being: living for now. If it were that easy I would already be doing it; it’s not and I’m not but I will keep trying.

Tuesday 9th November 2011

So. My dreams of good blood sugars on Tuesday morning were rudely interrupted by a hypo at 3 am. My own fault: I had dinner and injected the normal amount of insulin, forgetting to adjust it to accommodate for the effects of the gym earlier in the evening. I made the same mistake at breakfast on Tuesday morning and ended up hypoing again at school later in the day. As I said yesterday, I prefer hypoing to being high (although I would get hung, drawn and quartered if my doctor at home heard me say that...) so, to be honest, I got through the day feeling pretty apathetic towards it all.

And then... Today I had a minor breakthrough! The other day I decided to put my night time basal dose up by one unit, from 19 to 20. So far I've not noticed any difference but I woke up this morning with a blood sugar of 68. Now, officially, a hypo begins at 72, so anything lower than that is technically a hypo, but I was just so relieved not to be in the 300's that I really didn't care that I had to have a carton of orange juice with my breakfast, in fact, I quite enjoyed it! And the rest of the day has been good too. My body seems to understand what's expected of it for once!While I hypoed once more (4 hypoes in 2 days is NOT good really...) my blood sugars have not gone out of range the other way all day.

I even went to the gym this evening and, for once, the exercise made my blood sugars do what they should do: fall. Before I went I was 124 (perfect for exercise, although I've only recently realised this, before I would always have eaten something sugary to stave off a hypo; I've discovered I don't need to do this) and now, post-exercise, I am 98, a perfect pre-dinner level. Wow. So tonight I'm going to bask in the glory of a whole day of in-range blood glucose levels and I'm also going to congratulate myself for making myself actually do some exercise over the last few weeks. Maybe that extra nighttime unit coupled with a bit of almost-regular exercise really is the magic formula? For now it is anyway, and I'm going to enjoy it while I can!

Monday 7th November 2011

It’s been a while since my last post. I was trying to think about why and I guess there are a few reasons. One is that it’s been a school holiday and I’ve been away. So that’s my excuse for all 5 weekdays last week! As for the other days… Well. After my last post I started feeling pretty despondent with it all. This isn’t abnormal. This comes and goes and it’s something I live with, even though I’m not sure I will ever get used to it. Then there’s the very simple fact that, actually, I don’t always want to think about my diabetes. Sometimes, just sometimes, it’s nice to pretend that it doesn’t exist. Or at least not give it the satisfaction of acknowledging its presence!  See, to me, my diabetes is like a person. It’s my shadow, only it doesn’t need the sun to be there. Sometimes it gets so big that it blocks my view of everything else. And sometimes I like to gag it and squish it into my pocket. One day, I may even manage to make a friend out of it. But that day is not here yet!

To be honest the despondency is still with me a little. Over the week I was away I barely gave my diabetes a thought, other than to test my blood to check in and to inject accordingly. I had a few hypoes, but then I did a lot of walking. Hypoes frustrate me but their symptoms are short-lived. Once I’ve shovelled sugar in my mouth I generally start to feel human reasonably quickly. They’re not a good thing; too many can lead to diabetics losing their hypo-awareness symptoms, but high blood sugars are another story. They scare me. And they make me feel horrible. So a week with decent blood sugars and a few hypoes sprinkled into the mix was, overall, great.

However, this morning the monster reared its head again. I went to bed with a blood sugar just a little higher than I would have liked and woke up sky high: the curse of work is back. I don’t know what happens. I’ve talked already about stress hormones and that’s the only explanation I can come up with. I don’t mean I spend my life at work perpetually stressed; I don’t. Or even that I dread going to work; I don’t. But my body seems to silently react. It’s a sniper attack from within. Maybe it’s adrenaline, I don’t know. But whatever it is I just don’t know how to combat it. I’ve just been to the gym so I’m hoping that tomorrow morning I will miraculously awake from my slumber to be greeted by a shadow that is behaving itself. I’m not sure my chances are too good. Cross your fingers everyone!

Tuesday October 25th 2011

Time seems to be passing by in a blur at the moment! Where has the last week gone?

I spent the weekend, after my post on Saturday morning, pretending not to be diabetic… I have come to the conclusion that micro-managing my blood sugars doesn’t provide the answers so I thought I would try the opposite: letting go of the reins slightly. Turns out that’s not the way to do it either!

I’m sure not everyone with diabetes struggles to the extent I do. But I can never work out why I do. Sometimes I think it’s a personality flaw; like I said above, trying to control it so tightly that it’s impossible to control it at all Other times I think it’s my career choice. What makes teaching such a great job is the fact that no two days are ever the same. Unfortunately that has dire consequences for me in terms of my diabetes. I’ve often thought about trading it in for a more sedentary, more predictable, daily grind and while I know that it wouldn’t keep me on my toes I can’t help thinking that maybe, just maybe, my health is more important? Yet other times still I think it’s just the way it is: maybe my body just won’t do what it’s told. I am an Arian after all and I whole heartedly second Bette Davis (a fellow Arian) when she said, “I don’t wish to be told what to do.” And, I guess, that takes me full circle, back to that good old personality flaw…

So as I said, I spent the duration of the weekend burying my head in the sand, as I genuinely think is sometimes called for. I can’t recall my BG levels (although I did test and take my insulin; unfortunately I have to do these even when in denial!) but I’m pretty sure they weren’t pretty. I had one too many beers on Saturday evening and got a McDonalds on the way home (why oh why are they 24 hour here?!) although I did only eat half of it as on my return from a toilet trip my Shanghai McChicken Burger had mysteriously disappeared…

Today my BG levels have actually been ok. I’m still at a loss as to my overnight levels though: on Monday night I woke up at 5am mid-hypo, a sure-fire sign that my overnight basal dose is too high. This morning I woke up with NG levels that were also too high. Not ketone high but high enough not to be good. So this poses the same question again: am I hypoing in the night? More 3am testing is the only answer.

I came home today after school with intentions of going to the gym. I made an executive decision not to test before I went. Only because I find it very easy to talk myself out of exercising. Although writing it down now does make me realise this is not really a sensible way to do things. I got into the gym, warmed up, ran a little and started feeling very dizzy. I almost made myself carry on as I thought it might be due to high BG levels or even lack of water today, but something made me stop and I’m glad I did: my BG was 54, well within hypo limits. I slowed the treadmill down and drank my juice fully intending to carry on (I was in stubborn I’m-here-and-I-don’t-want-to-be-defeated-by-my-blood-sugars mode) but slowly I realised that continuing would be a very silly idea. I had visions of fainting and the outcomes were not to be entertained. I went back upstairs with my tail between my legs. I will try again tomorrow. If I have the energy after Parents’ Evening that is…

I have been thinking over the last few days about the effect writing this blog has had so far. I can only think of the positives. So far I don’t feel under pressure to write (even though tonight’s post is feeling a little rushed; I’m absolutely exhausted!) and writing things down is having a somewhat cathartic effect on me. Writing things down has always helped, but as I said in my first post, I’m not sure my writing outlets have always been healthy ones…. Also I have had so many positive comments, online and in person, from people who have read my posts. If I can make more people aware of diabetes (although I hope not in a negative way, I wouldn’t want people to think that diabetics need constant sympathy or monitoring – even though I think, maybe, that is the way my posts make it seem!!) then I feel I have done something worthwhile in my writing. And finally, the communications channels that have opened up as a result make it worth it on their own. Having honest, meaningful discussions with people I know helps me no end. And I’m not sure that I would be able to start those without this.

Saturday 22nd October

And so, at 10:30 on a Saturday morning I’ve already been on a rollercoaster ride of emotions!

Yesterday was my lovely mum's birthday. This morning I received an email from her and it really made me wish I'd been able to spend at least some of her birthday with her. The pros and cons of being so far from England I guess...

The last couple of days have been a bit funny; I began the week tired because of the school camp followed by a weekend away and I ended the week absolutely exhausted because of bouncing blood sugars.

On Thursday evening I went to the gym again. But this time I had a snack and covered it with insulin in the hope that the insulin would prevent my BG rising, as I explained in my last post. It worked in the short term, when I tested after exercising my blood sugars were on the low side of perfect, absolutely fine for before dinner. I ate and injected, reducing my RAI dose by 10% to allow for the exercise and when I woke up in the night I was, again, sky-high. I still don’t understand why this peak is occurring in the night.

Yesterday I had an almighty hypo in the afternoon. As often happens after a hypo, my BG then shot up: before dinner I was in the high 200s. J and I went to a colleague’s house for dinner (and had a lovely time!) but due to the hypo and possibly eating a little too much I woke up this morning with a BG level of 324: way out of range. As usual, this made me feel awful, both physically and mentally. For the last few days my eyes have been feeling ‘funny’: just slightly strained and out of focus. It might be that my prescription has changed but in my head it’s always the onset of diabetic complications. This morning was no exception. My eyes felt blurry, my throat was dry and my head was thumping. It was half 7 so I got up, did my basal injection and took a shot of RAI to correct my levels before going back to bed. I dozed off and on for a couple of hours but couldn’t really relax; I was feeling very frustrated. It seems that the more I try with my blood sugars the more confusing it all gets and the more out of control they get. At that point I was ready to give up.

Often, at this point, I let myself wallow and I end up getting upset and being moody. But today I remembered my blog and I decided that today was not going to be one of those days! I was lying in bed, listening to the music J had put on, dozing and willing the insulin to work. I was frustrated as I’d planned to go to the gym when I woke up, but rather than getting annoyed I decided to go later. Small things you’re probably thinking, but when my blood sugars play up I can find it very difficult to be rational where my mood and my diabetes are concerned.

About an hour ago I tested again, and this time I was 174, still a little high but much better than 300. I used my App to email myself the data from and am going to spend a little time later trying to see any patterns in my BG levels. Then I had breakfast and decide to write this short entry before the day starts properly. As if to match my mood, the weather has been horrible the last day or so: constant driving rain, grey skies and cold! Tonight, the firework festival in Busan starts, if it is not too wet! Hopefully later we will go and watch the show. I am undecided as to whether I will drink: alcohol affects BG levels and at the moment I feel like they’re just bad enough already.

Wednesday 19th October 2011

The last couple of days have been an examples of the “quirks” that diabetes can throw into the mix, just to make things that little more complicated!

In my last post (or maybe the one before?!) I said that exercise lowers blood sugars. Now, this is the theory! Aside from a known exception this is the effect exercise SHOULD have on the blood sugar levels. Unfortunately, my body doesn’t seem to be aware of this! I’ll explain from the beginning, but before I do I will explain a little about how insulin works and the effects of exercise… In the words on Jennifer Aniston, “Here’s the science bit, concentrate!”

We eat food to give us energy and in our bodies that food is broken down into glucose. Glucose gives our cells the energy they need to function. But in order for our cells to utilize the glucose they need insulin: insulin acts as the key to allow glucose into the cells, without it the glucose floats around in the blood system doing all sorts of damage to the body’s organs.

As a diabetic, I need to give my body just the right amount of insulin to let the glucose into my cells; your bodies cleverly do this for you to an amazing level of precision. When the glucose can’t get into the cells a diabetic will feel lethargic and, if left untreated will start to lose weight rapidly as the body tries to get energy from whatever sources it can, beginning with the fat surrounding more muscles, before eating away at your muscles and eventually the organs themselves. The levels of glucose in the blood will rise to a dangerous level, generating ketones (which are a by-product of your body burning its own fat) and can eventually lead to a coma. When I was diagnosed I was very close to being comatose. My BG was 44.4; incredibly high!

But that’s an aside… A diabetic should only exercise when their BG levels are near to ‘normal’. This is because when you exercise, your cells use up energy. In order for the glucose in your blood there needs to be enough insulin in your body to allow the glucose into your cells. If a diabetic exercises when they do not have enough insulin to take the energy from the glucose available, the body begins to use the fat stores for energy, not a problem in itself for this short period, but it results in the BG levels rising instead of falling. A bit complex, and to be honest I think it does my good to write all of this down again; it’s easy to forget!

So now onto the last couple of days:

On Monday night, as I said I would, I tested my BG before bed, during the night (at around half 3 when a motor cyclist decided to do laps around our apartment building) and in the morning. This is what I found: before bed on Monday my BG was 269 (14.9), far too high so I corrected by giving myself 1.5 units of RAI. On waking I was 170 (9.4), still a little high but roughly consistent with my 3am test, which was 138 (7.6). I have converted into mmol/L because I still find it easier to analyse them in this format.

Given that I think my correction factor is 3mmol/L for every unit of insulin, giving myself 1.5 units of insulin with a BG level of 14.9 should mean that my BG levels stabilise at around 10.5. Mine went down to 7.6, which is a little lower than I would have anticipated. This, on its own, may mean my correction factor is incorrect and that actually 1 unit of insulin lowers my BG by more than 3 mmol/L, or, because it was more than four hours since my RAI dose, it could mean that my overnight basal dose is too high. (Rapid Acting Insulin has a profile of around 4 hours and the basal insulin’s job is to keep my BGs stable without food or RAI, the two work together as the graph below shows:)

BUT then, on waking, my BG had gone UP again, by 2 mmol/L which, on its own, would suggest that my basal dose is not high enough. Together, I have no idea what to do with these two bits of contradicting information! I need to continue as I am doing, and hopefully some sort of pattern will come to light.

But it doesn’t stop there. Last night, when I got in from work I went to the gym. I tested before I went and I was 166, a perfectly acceptable level to go to the gym on. So I went, and afterwards I was 169. I ate dinner and gave myself my RAI according to my App, reducing it by two units to allow for the exercise, the effects of which can last up to 24 hours.  Before bed I was 202, a little high but again because of exercising I decided not to correct, thinking my BGs would fall over night. But when I woke up at half past two and tested I was 334! And I have no idea why… It could be to do with my basal dose not being right, but 132 is a massive rise, much bigger even than the previous night. My App told me to correct, so I did and I woke up with a BG of 155: much more respectable but still a little higher than I ought to be.

So basically, as it stands, I’m a little stumped. I am going to try and repeat my tests tonight and see what happens. The only way to know for sure is to build up data over a period of time. It’s just frustrating, especially at this point, when it doesn’t look like there is any rhyme or reason to any of it! Even just in the space of 2 days my App sstats have changed. My % of hypoes has gone down to 9% but my ketone warnings have increased from 0 to 2%. Although it’s easy to be sneaky and try not to test at the times which may result in unwanted readings! For the sake of this bog at least, I will try to be honest with myself.

I was just thinking too how, psychologically, the new units of measurement give me a larger window of acceptable blood sugars: in mmol/L the acceptable range is 4 – 7; in mg/dL the equivalent is 72 – 126! While I know that they are the same a margin of 54 seems much easier than one of 3!

Monday 17th October 2011

A few days have passed since my last post; I thought that might be the case what with a school camp and a weekend away. As it’s been so busy it’s passed in a bit of a blur, and I always find it hard to reflect accurately on the ups and downs of each day. I even find it hard on a day to day basis to be accurate I guess… Once I’ve gotten over a drama it can be quite hard to revisit!

The camp, in terms of my diabetes was quite challenging. I had a lot of hypoes. But then I was expecting this. It’s happened before and my daily control is not good enough on a normal day, let alone on one that as far out of the norm as a school residential, to enable me to pre-empt the effects of what I am doing. It's not that I'm not trying, but I do find it difficult. You see stress plays a major part in my control. The hormones your body releases when you are feeling stressed inhibit the action of the insulin, thus making blood sugar levels rise. But then exercise (or constantly being on-the-go) has the opposite effect: yet more variables to add to the balance and ones I find almost impossible to work out as it stands.

The good thing is that I’m getting to grips with the new units of measuring my BG levels. I am almost completely weaned off my old (wonderful!) BG meter and am now relying on my new simpler meter combined with my App. I am still being very diligent in recording everything on the App, which is where I usually fall down after a week or so. But a week in and I am still going, maybe there’s hope?!

The weaning process has been slow and I have been well and truly out of my comfort zone. At first every time I looked at the screen and saw a 3-digit number I panicked! Slowly the reverse is becoming true! Now, a 2-digit number is starting to represent a hypo so I am getting there! I am, at the moment being very general with my understanding of the readings: a number below 100 is heading into the hypo regions; a number in the 100s is acceptable and anything above 200 is bad.  This is not strictly right, but a ball-park figure is good enough for me at the moment.

The App is great for three reasons:

 1, when I enter my BG reading into it, it automatically tells me how much insulin I would need to take to correct it back to an acceptable range. If it is too high that is. If the correction dose is small I can tell that it’s only just out of range without really understanding the exact value of the reading in old money. Going the other way, once the reading hits 72 mg/dL a red warning flashes up telling me to eat – quickly!

The second reason is that when I open the App it tells me immediately how much insulin is still acting in my body. This is approximate s it is highly unlikely that I set the meter up perfectly to begin with, but again, it gives me some sort of idea. If I am hypoing and I still have 6 units of insulin, say, on board, that is not a good thing! It means if I don’t eat enough I will be more than likely to have another hypo later. It is very clever though. It logs my hypos and if I have had a hypo within the last 6 hours is adjusts my dose accordingly by giving me slightly under the dose it would normally recommend (there is also a box to tick if you have had “More than 2 drinks in the last 4 hours”; normally at that point I am no longer testing my BG!)

Thirdly, it does all sorts of number crunching with the data. So far it is looking like this:

·         My average BG reading is 147 mg/dL

·         Number of readings: 46

·         Ave no. of readings per day: 6

I have always been told off for testing too much. I never really understood why this was a bad thins, other than the possibility of micro-managing my BG levels, until I did 5-day DAFNE – dose adjustment for normal eating – course where I was told how precious our finger tips are. Without actually saying it, I think the nurse was referring to potential future eye problems and this scares me. I now never use my index fingers to test. In her words, “they are too precious.”

·         Ideal readings (72-144): 39% (At least there are some!)

·         Ketone warnings (>306): 0%

This is a good things. Ketones are nasty little blighters. They lead to something called ketoacidosis which causes a diabetic’s blood to turn acidic and it has all sorts of dire consequences. Ketones are a problem when BG levels are high and often occur when we are ill. Being ill is a lot more complex for someone with diabetes, especially where vomiting is concerned: not being able to hold down food is a big problem.

·         Hypo warnings (<72): 12%

This needs to be lower. Ideally 0%.

·         Estimate HbA1c: 6.7%

Now. This is good. But as my doctor once told me, just having good numbers doesn’t mean it’s actually good. It could just be this low due to the number of hypoes I’ve had, the good old law of averages!

According to www.diabetes.co.uk your HbA1c is:

“HbA1c occurs when haemoglobin joins with glucose in the blood. Haemoglobin molecules make up the red blood cells in the blood stream.

When glucose sticks to these molecules it forms a glycoslated haemoglobin molecule – also known as A1c and HbA1c. The more glucose found in the blood, the more haemoglobin will be present.

Due to the fact that red blood cells survive for 8-12 weeks before renewal, by measuring HbA1c ,an average blood glucose reading can be returned.

 For non-diabetics, the usual reading is 4-5.9%. For people with diabetes, an HbA1c level of 6.5% is considered good control, although some people may prefer their numbers to be closer to that of non-diabetics.

 People at greater risk of hypoglycaemia, may be given a target HbA1c of 7.5% to prevent too many low blood sugars from occurring.

HbA1c refers to glycated haemoglobin, which identifies average plasma glucose concentration.”

Basically, it measures the amount of glucose that is being carried by the red blood cells in the body and because they live for around three month it gives you an average picture of your BG levels over this time. If your BG levels are consistently within range, your HbA1c will reflect this. Unfortunately, if your BG levels bounce from hyper to hypo, your HbA1c will also, more than likely, be close to being within range. Therefore, the bouncing is the thing to avoid…

So. From here on in, my targets are to avoid hypoes and (still!) to get my morning BG levels down to within the acceptable range. This morning they were high (around 14 in mmol/L, I did test in mg/dL but the numbers escape my brain on recall!) Tonight I am going to test before bed to see what happens over night. And, if I remember, I will leave my meter in the loo so if I get up in the night I can test. We’ll see!