Whole Blood or Plasma?

Mary, Mary quite contrary
How does your meter read?
With millimoles ,
Or milligrams
And clinical accuracy?

Mary Mary quite contrary
What does you meter mean?
Glucose in blood whole?
Or from the plasma sole
It's average your A1c?
With Apologies to Northerner: imitation is the sincerest form of flattery! (I don’t think it scans as well as your poems)

Any PWD on the internet soon realises that different parts of the world use different measurements for blood glucose readings. In the US, some parts of Europe and the Middle East they use milligrams per decilitre. In the UK , some parts of Europe and many places that are English speaking (Canada, Australia etc) they use millilmole per litre. To be awkward in France they use grams per litre.
It’s easy to change between the two, there are many convertors on the web but all you have to do to convert mmol to mg/dl is to multiply by 18, if you want to convert mg/dl to mmol/l you divide by 18. After a while you become bilingual.


But there is another difference that isn’t so obvious. When we measure our glucose we use whole blood from a capilliary. When a laboratory measures blood they measure the levels in the plasma.
For many years all the blood glucose meters reported the glucose level as in whole blood but this was not the same as a laboratory measurement would be. A laboratory plasma measurement would be about 12% higher than a whole blood one. In recent years some manufacturers have included a calculation (done automatically) that works out what the plasma reading would be and displays that as its reading.

Imagine you have 2 meters, both perfectly accurate (of that later) one whole blood, one plasma calibrated. You do a test with same spot of blood.
If it were plasma calibrated and it read 72mg/dl, the whole blood meter would read 64.3mg/dl.
So what constitutes a hypo depends upon what meter you are using.

When people in different countries are writing about their levels, they may not be using meters calibrated in the same way.It is important to know what type of meter you have because some blood glucose targets are written to reflect whole blood readings whilst others are written for plasma, if you are reading targets written for whole blood, they may be too low for people using plasma calibrated meters.

In the US all modern meters give plasma readings but in Europe some give plasma and some whole blood, and it’s not always easy to find out which does what. If you want to find out you may have to search.The place I found mine was not with the meter instructions but in very tiny print in the leaflet that comes with the testing strips.

In the UK, the manufacturers have been changing over the years and now according to DUK they all use plasma except for for those made by of of the largest manufacturers Roche ie Accu chek meters. DUK says that ‘ Roche is in the process of adjusting their meters to give results as plasma values, which they hope will be completed before the end of 2009.’ So if you have an Accu chek in the UK read the strips leaflet carefully.

I think that France may well be in the exactly same postion as the UK but I haven’t been able to find out about all makers. My old Meter, an Accu chek go used whole blood measurements, this is no longer made and I don’t know what the newer ones use. (in France they market the Nano and the Nano-performa). The newer Lifescan meters are plasma calibrated (one touch ultra meters). I couldn’t find a definitive answer for the Abbott meters (Optimum plus and Freestyle Papillon). In the UK all Abbott meters are plasma calibrated and I found this statement on the Swiss site ‘ont déjà programmé leurs systèmes de mesure de glycémie pour indiquer des valeurs plasmatiques comme celles relevées sur les lecteurs de laboratoire.’

This chart shows equivalents in mg/dl and mmol for both whole blood and plasma calibrated meters.

Of course even when you know what the meter reads, it’s not necessarily very accurate. They are allowed to be up to 20% out,. There is a convertor on the Lifescan website which demonstrates this clearly.So with that reading (4mmol) you could either be quite hypo and need some glucose quickly , just at a ‘safe’ level or have a very normal blood glucose reading!
And if you find that your HbA1c doesn’t really reflect what your meter has been telling you, perhaps this built in inaccuracy is a possible reason.

This post isn't really applicable to the UK anymore as all new meters are plasma calibrated

Chocolates

Christmas is coming and I decided to try to make the lowest carbohydrate truffles I could (without using lots of 'chemical' ingredients)

This is what I did.

Ingredients

110grm dark choc (72%) (might get away with 1 bar at 100gm)

125 ml whipping type cream (it would be better in the UK as I can only get longlife/slightly soured here)

30gm unsalted butter.

a few teaspoons of liqueur, I used mandarine

Method

Chop the chocolate finely

put cream in saucepan and bring to boil

Add the chocolate a little at a time beating hard with each addition.

(When I got to the last addition I must have had the heat too high and it split. I got the electric whisk out and whisked the mixture, this saved the day.)

Put in fridge to cool for about 10-15 min

Cut butter into small bits, gradually whisk into the chocolate.

Add some liqueur to taste.

For presentation

A few walnuts chopped

some cocoa powder

some more melted chocolate (to make 'filled' chocs.)

Let harden in fridge for a while, then use a teaspoon to make rough balls onto a clingfilm covered plate.

to make filled chocs, melt chocolate and spoon into bottom to moulds, cool, then pipe in blobs of mixture, and cover with more melted chocolate.

(this can get very messy, with chocolate everywhere, including on the floor, on the taps and on the fridge door, just cross your fingers that the phone doesn't ring and that the postman doesn't choose this moment to arrive with a parcel .)

Put in fridge for a couple of hours to harden again. Then roll in chopped nuts or cocoa.

The number of carbs depends upon the quality of the chocolate and how sweet your liquer is. The higher the quality of the chocolate, the lower the carb content. For some people they may be too rich and too bitter. They're what you would have with an after dinner coffee, not for nibbling.

For less bitter chocolates, you could use a lower percentage chocolate, you could add a little icing sugar (but both would result in higher carb content) or if you don't mind using it you could try adding some splenda.

I was pleased with the chocolate moulds, it was the first time I'd used them. Now to think of some alternative fillings.

Oh and because they're made of fresh cream, they won't keep and lowish carb or not, I can't eat that many!

Anyone want a chocolate?

Mutiny to Monastery (an afternoon stroll)

I love walking, the area round here is great for reducing blood glucose levels, it's very hilly.Yesterday was a lovely day so we decided to stop being lazy and make use of the unseasonable weather.It was just a local walk, using a guidebook from the tourist office.10k (and 300m climb)
We started in a corner of town containing solemn reminders of events that took place in WWI

Le Champ des martyrs croates.

It is a little known fact that Villefranche de Rouergue was the first town in France to be liberated from the Germans in 1943!

Unfortunately, the freedom only lasted a day, but some feel that it was instrumental in demonstrating that resistance was possible and leading to the development of resistance in the Aveyron.

The insurrection was started by a small group of conscripts from the present day countries of Bosnia and Croatia They had been rounded up and forced to join the German army. They were sent to a training camp in Villefranche. The instigators persuaded their compatriots to support them in a mutiny against their German officers. Their goal was to approach French liberation movement and Anglo-America, and then to go back to their homeland

On the night of September 16th, the mutiny began The mutineers executed five German officers, held many other Germans, and successfully established control over the entire garrison. By 08:00 a.m. they controlled the town. Unsurprisingly,the Germans quickly sent in reinforcements and fighting went on for a day. An Iman was also brought into persuade the less committed mutineers to return to the fold. At least 16 of the mutineers were executed , five or 6 escaped, one of whom joined the fledgling local resistance, over 800 were sent to labour camps, some 565 volunteered to join labour gangs on the Siegfried line, the remaining 250 were sent to concentration camps: few survived the war. The dead were buried in what became known as the Martyrs field.

In the 1950s a Yugoslavian sculptor created a memorial to the dead.. a woman bringing the first apples of the season to the grave of her dead son. The politics of the day prevented the statue leaving Yugoslavia and it wasn't until 2006 that it came to Villefranche and the area turned into a memorial garden

After the a few moments of quiet reflection we were on our way. Our route, was a bit like that followed by the Grand Old Duke, we went up the hill, we went down, then after skirting round the bottom of the hill we went back up it and back down again!

Some views.

The Bottom of the hill.

Half Way up

Almost At the top

The view towards the medieval village of Villeneuve from the other side of the hill.

On the way back we met an very noisy donkey... who was it decided that donkeys say 'hee haw'? this one most definitely roared.

And then the strangest of signs to spot in the Aveyronese countryside

And it wasn't someones sense of humour!

Towards the end of the walk we passed through the the necessary but ugly industrial area which is a common feature on the outskirts of most French towns. We took no pictures of fromage de france or the sausage factory .We were drawn to what appeared to be a monastery overlooking the prefabricated factory buildings. As we got closer we heard the sound of music from the church. It was the community singing the office. We didn't go in, but stood outside for a while, finishing out walk as we started with quiet reflection.

World Diabetes Day

It was good fun to join in with people from all over the world and take part in the Big Blue Test . I'm very certain that exercise plays an important part in my control. My glucose levels tell me when I've been lazy but I've often got the impression that, I'm a bit unusual, that other people don't really think it makes much difference. Diet is what matters most, not what you do. In fact, when I posted details of the test on one forum, I was really disapointed, the only response. was a couple of metaphorical yawns concerning the whole idea of World diabetes day

Here are my results.
Before 14 minutes exercise

After 14 minutes exercise

So a drop from 6mmol to 4.3mmol, a distance of 5.5 laps, thats 1.39 miles and 67 kj -I think that was about 160 calories.Just slightly under 10 min miles, which is very fast for me. The test was probably a bit close to lunchtime but I was pleased to only fall to 3.8 later in the afternoon (so a small bit of aero with a cup of coffee was all that was needed to keep me going 'till dinner.

I uploaded my results to the site, at that time there weren't that many so it was great to log back on this morning and find lots had taken part. There were of course lots of results from the US, but there were lots of other countries represented Saudi, the Philipines, Germany, the Netherlands, the UK and South Africa were some I noticed.What struck me straight away was that so many people had seen falls in such a short period of time. Some were totally surprised, others very happy. There were all sorts of activities. People were hula hooping on the wii fit, walking, biking, running , stair climbing, house cleaning, playing with children, skipping, chopping wood and doing exercises in a chair. Some people did far more than 14 minutes, long bike rides, runs and walk

What an eye-opener. Before exercise, 147, after walking on treadmill for 14 minutes, 108. What an incentive to take care of myself while I am in early stages

My exercise was folding laundry as I am not able to exercise heavily, started with 8.6 mmol/L and after 14 minutes it was 6.7 ;

how amazing112 and 106 after 14 minutes of walking on the treadmill. With one added note, I had a late lunch ( I was less than an hour post meal) so my BG should have been going up.

I was 139 and after 14 minutes on the exercise bike was 93! I find that if I pedal really, really hard I can get my BG down in about 10 minute.

Well Done Everybody

Looking at all the figures I thought I'd try and put them together to show how effective the short period of exercise had been, It's not a scientific exercise, people whose levels had gone up might not have posted their results, others might not have paticipated because they had previously seen their levels rise with exercise. I only included people who seemed to have done the 14 minutes (I left out those that said they did longer)

Then I put the results in order of the first reading and plotted the results on a graph.

I think this exercise really showed how well exercise works for many of us with Diabetes, thankyou Manny Hernandez andTu Diabetes.
http://tudiabetes.com/forum/topics/the-big-blue-test-on-world?id=583967%3ATopic%3A794026&page=5

World Diabetes Day Part 2
In the evening we went to Cahors to see the lit up Marie and bridge. Unfortunately the filters weren't really strong enough for the job and my camera wan't really up to it either. It was also pity that there wasn't anything to tell people why the lighting had been altered. When we crossed the bridge a local was obviously a little puzzled. He kept stopping and peering over the parapet at the lights perhaps wondering as to why they weren't as bright as usual. Later in the restaurant we talked to the waitress. She knew about it as it had been on the local radio.

Pont Valentre

Blue Tree (It was in front of one of the main floodlights)

Blue Town Hall

Just a spoonful of sugar.

The other day I looked up my blood test result for my first fasting glucose test, it was 3.85 g/l.
My French lab reports the results in g/l  rather than the milligrams per decilitre  used in the US or  mmol/l used in  the UK.

5mmol/l in the UK would be 90mg/dl in the US  but when I visit my French doctors I would say 0.9 g/l
(and sometimes I give the mmol/l figure and cause great confusion)

  I started thinking what exactly did that mean?
 Somehow grams and litres, being everyday measurements makes it much clearer than either millimoles per litre or milligrams per decilitre.

Here's a litre of blood!

Our bodies contain about 5-6 litres of blood

The teaspoon below contains just under 4 g of sugar, so slightly more than the 3.85g/l   that I had in my blood the morning I was diagnosed.
 Not very much really; dissolve it in one litre of water and it would barely sweeten it to taste. I would have had about 5-6 times that in my whole body (in the UK that equates to about 21.5 mmmol/l)

This spoon contains about 1.26g. If you have that much in each litre of blood and you were fasting it would be enough to be diagnosed  with diabetes (7mmol/l)

Its incredible, how such small amounts make such big differences.

Tomorrow is World Diabetes Day, I'm going to join in the 'big blue test' http://tudiabetes.com/forum/topics/the-big-blue-test-on-world : testing my blood glucose, followed by 14 minutes of exercise, I'm going to see how far I can run on the treadmill in that time.

Later if the weather's not too atrocious , we're driving to Cahors, where they're lighting the the Marie and the Pont Valentré in blue. It's about 60km and not the best of roads, but OH was easily persuaded as it's a good excuse to visit our nearest Indian curry house.

(I'll get back to the glucose variations soon, it's a hard one to write)

Ups and Downs.

How much do they matter? (part 1)
In an earlier blog I pointed out some of the reasons that people using insulin can have rollercoaster blood glucose levels from time to time, is it these variations that lead to complications?

I got interested in this after seeing a study in this month’s Diabetes care which investigated the association of A1C levels and fasting plasma glucose (FPG) with diabetic retinopathy and how well the two measures discriminated between people with and without retinopathy. Out of the 1,066 individuals, 11% them had retinopathy. (Retinopathy was defined as level 14 or above on the Early Treatment Diabetic Retinopathy Study severity scale. Level 14 equates with mild non proliferative retinopathy.) They found that HbA1c was the better discriminator and that the steepest increase in retinopathy prevalence occurred in people with a relatively low A1C of ≥5.5%.

At first sight it seems quite shocking, retinopathy with a Hb A1 of 5.5%, that’s well within my laboratories normal range . On reflection, it shouldn’t really cause any surprise as the DCCT (Diabetes Control and Complications Trial) showed a small number of subjects with complications at this level. The probability of it progressing is small, but that ‘chance’ still exists.
A small number, but it represents real people who wonder why it had to happen to them.

It happened to me, I was horrified to be told that I had some mild background retinopathy. I had been diagnosed for 4 years, I had checks every year for 3 years with nothing found. Then, before going on the pump. I had to have an extra check using fluorescein dye. This was a compulsory part of the procedure in France, and is because many people going onto pumps have quite high glucose levels. The change to pumping can lower levels rapidly and this can cause rapid progression of retinopathy. The angiogram, would show if care was necessary in reducing levels. My 'problem' wasn't high levels though but hypos and an active lifestyle. Both my doctor and I thought that it would be a formality. Fortunately, the changes were slight, but they were clearly there.

In her blog,* Jenny Ruhl discusses some theories why a person with a lowish HbA1c might develop retinopathy. She points out that an HbA1c can be the result of very different day to day patterns of glucose levels.

Two patterns that would result in the same Hb A1c, one clusters around the mean, the other has far larger glycemic excursions

She suggests that the ‘normal people’ in the study who had early retinopathy might have higher postprandial levels (fuelled by a high carbohydrate diet) followed by lower levels, such people could be be experiencing ‘oscillations that veered between 75 and 150’.( 4.2 and 8.3).
In contrast she suggests that people who control their diabetes well might different patterns. She describes a ‘ pattern in which the blood sugar stays near 112 (6.2mmol) all day long,' or alternatively , one with a relatively high fasting glucose of about 110 (6.1mmo) ,very narrow fluctuations at meal time, perhaps up to 120(6.6mmol) and then back down to 90(5mmol) . This she suggests is a pattern achieved by reduced carbohydrates plus necessary oral medication or insulin..
She implies that day to day and within day glucose variability as characterised by the first pattern might help to explain the incidence of retinopathy at relatively low HbA1c levels . In other words the ups and downs are important.

Jenny Ruhl advice is to’ keep track of your post-meal highs and keep them under 140 mg/dl as much as possible’ and this is surely the safest course and what most of us try to do. By doing this the overall average blood glucose level and presumably the Hb A1c is kept down. Yet increasingly some doctors and diabetes authorities are saying that those people who don’t need to adjust insulin doses should be concerned with the overall HBA1c and not the day to day variation. Moreover, there are many people, particularly type 1s who find it very difficult to limit their glucose excursions to a narrow band, too low post prandial levels, too low levels before exercise or before bed can result in serious hypos, a much more immediate complication. Thinking about this lead to some big questions
· Is day to day and within day glucose variability more significant or as significant as HbA1c in the development of complications?
· Is it the same answer for both micro and macro vascular complications?
· Is there a difference between type 1 and 2 (LADA, MODY???)
Back to my personal interest.
When background retinopathy was discovered my HbA1c taken a week before was 4.9% Since diagnosis it had been in the low 5s. I rarely had recorded glucose levels over 140, I had a fair number of hypos, almost always during exercise and very quickly remedied. At the time I was going to bed at about 80mg/dl...so for at least 10 hours of the day my level was ‘normal’ .
Now it is possible that the retinopathy was there before diagnosis and only became visible with the more detailed examination. Was I simply unlucky, or did the blood glucose excursions to below 70mg/dl and back up to normal levels play a part?
I’ve been trying to find the answers to those questions.
Like everything, it seems to depend on who you ask! (Or rather what you read)
To be continued...........!

* http://diabetesupdate.blogspot.com/2009/10/does-55-a1c-predict-retinopathy.html

Toussaint

Happy Halloween!
A poster with a grinning pumpkin welcomed us to the supermarket for the weekly shop. Unlike in the UK, it's rather incongruous,the US traditions for Halloween haven't yet become commonplace here. Inside the supermarket there is one stand with an assortment of witches hats, skeletons and plastic spiders,but one feels that they aren't big sellers. There are pumpkins on sale but most will get used for soup. The parents of children with diabetes here are lucky.They don't yet have to cope with the problems of what to do about the tacky sweets associated with trick or treating

But this time of year is very important here. November 1st is Toussaint, All Saints day.In English , All Hallows,(the origin of Halloween). The following day is All souls. Half a century ago it was celebrated as a solemn festival in Anglican churches, the service finishing with a rousing chorus of 'For All the Saints'. Today its less evident , times have changed. My grandchildren will attend a church party set up to counter the attractions of more secular Halloween activities with their emphasis on witches, ghosts and evil.

It is the church festivals which dominate here.
Outside the supermarket, in a large area of the market and outside every florist are pots and pots of Chrysanthemums. The beautiful displays look lovely in the autumn sunshine.
(If you visit at this time, please don't buy a pot for a French friend). These flowers have one destination;the cemetery. The chrysanthemum is a symbol of immortality. It flowers in the last quarter of the year and resists frosts. Toussaint also marks the turn of the year towards winter,
'A la Toussaint le froid revient,
et met l'hiver en train'
The chrysanthemum's bright petals will be sign of hope in the autumnal fogs to come.

In the week leading up to Toussaint families visit the family graves, and sepulchres, weeding the surrounds, cleaning the stonework, making everything spick and span . The new pots of flowers are placed around the tomb.Those who are too far away from home do not forget, often organising a florist to do the job for them. The cemeteries gradually become a blaze of colour.

As November 1st is a bank holiday, family gatherings take place with those that can, returning to their home towns and villages for the day.
Traditionally, on the day itself masses take place in the churches followed by prayers for the dead in the cemeteries, though in villages like ours, the priest has to spread his services thinly so some services now take place later in the week.

This is a lovely festival, bringing together the generations. It's not sad, not so much a day of mourning. There is no sense of evil or fear connected with the cemeteries. It's a time of remembrance, a time to honour one's dead ancestors and celebrate the family.
Will it survive the pressure of consumerism with it's plastic spiders,dangling skeletons, swag bags and tacky sweets?
I hope so.

Osteoporosis ,No Joking matter

Sadly on some diabetes forums , some posters, mainly men, think that as they have no signs of osteoporosis now, they’re not at risk. The very idea has become a joke Some of them may not be at high risk but unfortunately their comments may well be read by those most definitely at risk.

Osteroporosis means porous bones. Your bones lose internal strength through demineralisation. Inside they become like a honeycomb with gradually less and less strength. Even slight falls or bangs can result in a fracture, Spinal bones become squashed or compressed because of their reduced strength.resulting in curvature of the spine and loss of height.

I don’t find it funny when I see my mother . She suffers from a combination of osteoporosis and osteoarthritis. She’s tiny, fragile, she no longer looks like my mother. She has lost about 10 inches in height through the disintegration of her spine. In daily life it is the arthritis that causes the pain but it is the osteoporosis that has sapped her confidence and destroys her quality of life. She lives in fear, she’s scared to move, afraid of a hip fracture. She’s right to be, her mother died following a hip fracture as do the incredible number of 1150 people a month in the UK.

Many people are at risk even without considering their diabetes. Conditions such as celiac disease , hyperthyroid or a mismatched dose of thyroxine for hypothoid, a genetic history, an early menopause are just some of the risk factors. All women have a 50% chance of some degree of it in old age; the risk for men is less at about 10%. Most won’t know they’ve got it until they start to lose height, or suffer their first break. Saying,’ well I’ve been on this diet for 6 months and don’t see any sighs of osteoporosis is meaningless.’

What’s this got to do with diabetes?
Diabetes however may be an additional risk factor In the case of diabetic women a study found women with Type 1 were 12 times more likely to have had a fracture compared to women without diabetes. Studies have found long term bone loss in type 1 so it does seem that people with Type 1 are at risk of osteoporosis

The studies are less clear for type 2 If you are male and have been overweight, you may have some protection as the extra weight may have strengthened your bones in the same way as weight bearing exercise . Men as a whole are less likely to develop it as they tend to have bigger frames

However, the Iowa study found that women with type 2 on oral medications, or insulin had an increased risk of fractures. A meta analysis in the BMJ covering both diabetic men and women , type 1 and 2 also showed an increased risk of fracture for both genders, but why is unclear. It could be because of diabetic retinopathy, peripheral neuropathy, and cerebral stroke or hypoglycemia, increasing the risk of falling.
http://care.diabetesjournals.org/content/24/7/1192.full
http://aje.oxfordjournals.org/cgi/content/full/166/5/495#BIB42

If you are at risk you can do something about it?

1) The best thing is to work on prevention whilst young by building up strong healthy bones. It is in childhood that most bone development takes place but peak bone density may not be reached until 30. So what you do in your teens and early twenties is important. If you build stronger bones in the first place they are less likely to become osteoporotic.
2) Even if you’re older you can do something. Bone loss is gradual, the same factors that build healthy bones also protect against loss.

Factors that may help increase bone strength

Exercise:
weight bearing exercise like walking, running , dancing, even walking from the shops carrying the shopping . This seems to be really important. Good for bones, for heart and for blood glucose contro.For bones exercise such as cycling and swimming are less good as they are non weightbearing.

Calcium
Women between the ages of twenty to forty typically require a recommended daily allowance (RDA) of 1000 mg/day in the UK, as age increases so does the recommended dose of calcium required. For women over 40 years of age, who are not taking hormone replacement therapy the recommended calcium dose is 1200 mg/day in the UK . For Women 40 and above who take hormone replacement therapy the recommended daily allowance of calcium is slightly lower at 1000 mg/day. The recommended calcium daily allowance for women over sixty is 1200 mg/day. 20% of women don’t have nearly enough in their diet.
Good sources of calcium are dairy products such as milk, cheese and yoghurt. Calcium is also found in canned fish with bones, such as sardines. Other sources of calcium include green leafy vegetables (such as broccoli and cabbage, but not spinach), soya beans and tofu
So eat your dairy and your greens!

Vitamin D get outside in the sun during the summer months (but sensibly. The Cancer research organisation says that the amount needed to synthesize vit D is less than the amount needed to cause sunburn. A British study by the Health research forum recommends that people in the UK should put on sun-cream only after they have been in the sun for five to ten minutes, in order to allow vitamin D to be made in the skin)
Good food sources are oily fish and eggs.
Protein :
People need sufficient protein to establish strong bones and studies have shown that low protein diets in older people are associated with fractures.

Factors that may cause increased bone demineralisation (bone loss)
(the controversial bit)

Smoking (thats not controversial)

High protein diets
Some high protein diets have been shown to cause people to excrete more calcium than normal through their urine. Over a prolonged period of time, this may increase a person's risk of osteoporosis. However, it might depend upon the actual diet. (how much protein, what type and what other things are eaten)
There was a recent study where subjects ate a reduced- calorie, high protein diet which included 3 dairy servings. The results showed increased urinary calcium excretion but at same time provided improved calcium intake and attenuated bone loss. This continued both during the 4 month weight loss phase and the following 8 months of 'weight maintenance' The principle researcher said 'The combination and/or interaction of dietary protein, calcium from dairy, and the additional vitamin D that fortifies dairy products appears to protect bone health during weight loss. NB Fresh milk is not fortified with vit d in the UK
(Thorpe)
People at risk who adopt this diet need to investigate very carefully there is a plethora of contrary information. Some high protein diets have very little calcium intake. (but I think it's the same message as above..... Eat your dairy and greens!

Ketogenic diets
These are also very controversial and may be high protein as above or normal protein and high fat.
Children on ketogenic diets for epilepsy (high fat, adequate protein and low carb) even though carefully supervised have had problems with bone demineralisation. A six year study at John Hopkins university showed of 28 patients, 6 experienced fractures( Groesbeck) .Morbidly Obese children on a similar diet wee also found to have experienced bone loss.( Willi)

Personally I'm not a dietitian or a doctor but I'd be very wary of putting a child with diabetes on this type of diet without expert advice . I'd also be very careful if I were a young person in my teens or twenties and still to reach peak bone mass.

In older adults there very little evidence available , certainly no long term evidence. and whats available is equivocal. A 3 month study of the effect on bone turnover and a low carb diet found no difference (Carter). However a 6 month one led by Westman found there wa an increase in urinary excretion of calcium and uric acid, possibly resulting from ketosis, proteinuria, or weight loss. (Yancy et al)
A paper by SA Bilsborough and TC Crowe discusses the possible problems (p401). It’s worth reading if you’re considering this type of diet.
Low-carbohydrate diets: what are the potential short and long-term health implications?
Shane A Bilsborough and Timothy C Crowe

(available in full but PDF doesn't seem to link why??)
References:
Matthew P. Thorpe et al, A Diet High in Protein, Dairy, and Calcium Attenuates Bone Loss over Twelve Months of Weight Loss and Maintenance Relative to a Conventional High-Carbohydrate Diet in Adults1–3, Nutr. 138:1096-1100, June 2008
DK Groesbeck, RM Bluml, EH Kossoff Long-term use of the ketogenic diet in the treatment of epilepsy. Developmental Medicine and Child Neurology, 2006 - Cambridge Univ Press
Steven M. Willi*, et al The Effects of a High-protein, Low-fat, Ketogenic Diet on Adolescents With Morbid Obesity: Body Composition, Blood Chemistries, and Sleep abnrmalities Pediatrics: 1998, pp. 61-67
Eric C. Westman et al: Effect of 6-Month Adherence to a Very Low
Carbohydrate Diet Program The American journal of medicine, 2002
J. D. Carter The effect of a low-carbohydrate diet on bone turnover
Osteoporosis International. Sept 2006

I was very lucky!

If you have frequent urination,
If you drink a lot, have a dry mouth
If you have recurrent thrush
If you are losing weight

EVEN IF YOU ARE THIN,TAKE EXERCISE,AND THINK YOU EAT A HEALTHY DIET
GO TO YOUR DOCTOR. DON'T PUT IT OFF .

if you have previously been diagnosed with type 2 (particularly if you were not overweight at diagnosis) and find it difficult to control your diabetes with oral medications and diet, ie you have very high glucose readings, and are rapidly losing weight without really trying.
Insist that you see a specialist and are checked properly.

I know of several people who like me ignored diabetes symptoms, finding reasons to explain them away because they didn't fit the right categories.. Recently I came across Lees story as
told here in Mens Health 'Undiagnosed diabetes nearly killed me' 'http://www.malehealth.co.uk/userpage1.cfm?item_id=2891 I read it and realised how similar his story was to mine. Sadly his diagnosis came perhaps at a slightly later stage.
He hadn't heard of LADA, nor had I.
Why should we ? Unless you actually search for ityou're unlikely to find it on the general information sites . I did check my symptoms of various websites and realised they were those of diabetes but even then I was confused. I read statements like this
The ADA says:
'Type 1 diabetes is usually diagnosed in children and young adults, and was previously known as juvenile diabetes.'
I was in my 50s
The site also has a risk test for type 2, I did it
I was low risk.

Diabetes UK says:
'Type 1 diabetes develops if the body is unable to produce any insulin. This type of diabetes usually appears before the age of 40. '
I was well over 40.
Type 2 diabetes develops when the body can still make some insulin, but not enough, or when the insulin that is produced does not work properly (known as insulin resistance). In most cases this is linked with being overweight. This type of diabetes usually appears in people over the age of 40.
I was over 40 but was not overweight, I was thin and getting thinner.
Other sites stress the rapid onset:
About .com
'The symptoms of type 1 diabetes usually develop quickly and over a brief period of time. '
The longer I left it, the easier it was to rationalise, it did not cause a rapid crisis

I've explained my rationalisations in an earlier post , but basically they were that I was too old, too thin , too physically active. I hadn't ended in hospital, I couldn't have type 1. If I had by any chance got type 2, the treatment was to lose weight(I'd done that) and eat a healthy diet and exercise (I did that ) so why bother the doctor. Besides the symptoms came and went.... this latter seems to happen frequently from anectotal reports but I have only seen it once mentioned in the scientific literature.

None of the statements from the Diabetes organisations and information sites are completely true. By trying to give simple information, they omit the common exceptions.

• ‘The incidence rate of insulin-dependent (Type I) diabetes mellitus is bimodal: one peak occurs close to puberty, and the other in the fifth decade.’ (Karjalainen et al New England Journal of Medicine 1983.. pre definition of LADA !)
• There is a percentage of people (can't find the figure at the moment) diagnosed with type 2 who are not overweight. (A proportion of these may have LADA)
• The classic rapid onset is often seen in childhood type 1, but even then not always. In older people the onset is very ofen (but again not always) a slower onset . LADA is defined by slow onset.

Perhaps LADA affects such a small number it would only confuse

Well if this were the case, one could understand not mentioning the possibility, but according to Swansea university 10-13% of those people diagnosed with type 2 in the UK have the antibodies connected with LADA. Action LADA says 'This form of latent autoimmune diabetes of adults (LADA) is found in about 10% of initially non-insulin requiring diabetes patients and is therefore probably far more prevalent than classic type 1 diabetes. Joslin puts the figure at between 5% and 30% depending on the population. Its not rare.

OK but if you had gone to the doctor then you would have found out sooner

Possibly, and some people are very lucky and find a doctor who investigates. As my French doctor immediately diagnosed LADA this might well have been true....but I was in DKA by the time he saw me and he was a specialist.
Sweet Magazine this month tells of a young woman diagnosed at 28 . She was a yoga teacher and was losing weight, felt hungry and dizzy. She visited her GP several times but he thought that she was too old to develop type 1. Eventually she looked so ill her mother(a nurse) went with her to the GP and her glucose level was tested. She had a level of 30mmol but amazingly the GP didn't believe the result and sent her away again. Her sensible mother took her to A&E where she was immediately put on an insulin drip.(Sweet, Oct/Nov 2009)
Hopefully cases like this are rare, but this young woman wasn't even 30 yet deemed by her doctor to be too old for type 1. Unfortunately,I've read of many people who have had problems in getting a diagnosis. There are several similar stories told on the various diabete's forums to the one above. Quite frequently people are at first diagnosed with type 2 and then find that oral medications don't work for long. Sometimes they are considered to be uncompliant. On more than one occasion I have read that a person has ended up in hospital with DKA before they were diagnosed correctly.

GPs are not specialists, information on LADA is available but you need an interest and time to investigate. I feel strongly that the diabetes organisations should do more to make both the public and GPs aware of the possibility of LADA (and other possibilities such as MODY).

Why Wholegrains?

On a forum a poster wrote the following question.

Can someone please tell me the secret ingredient that's found in in wheat that I can't get from far healthier sources elsewhere? It must be a secret, no one has been able to answer that question up till now. Are we really advocating that refined carbs are better than fibrous, organic vegetables?


Of course it was a loaded question, I don't think anyone advocates refined carbs not yet wheat as the sole grain. What is frequently suggested is to eat whole grains. My answer was quite long, probably too long and took a long time to write (twice because Windows decided to switch off to install upgrades in the middle of it) so as I had intended to blog today I'm using my answer with a bit added as a blog .

I don't think I've ever read it suggested to substitute refined grains for vegetables. What is suggested is that there are health benefits from minimally processed whole grains*(see Slavin below for definition, history of processing , summary of possible benefits and mechanisms) This is far too difficult to summarise so you'll have to read the paper.

Wheat is of course only one type of grain, there are many others. Some I've never heard of , let alone used. I've included the latin names to help me, because the French names are bound to be different!
Amaranth* (Amaranthus spp.),Barley (Hordum vulgare) ,Buckwheat *(Fagopyrum esculentum) Bulgur (Triticum ssp.)(derived from wheat), Corn* (Zea mays mays), Farro / Emmer (Triticum turgidum dicoccum); Grano (Triticum turgidum durum) (Durum wheat 'berries') ;Kamut® Grain (triticum turgidum turanicum) an 'ancient' variety of wheat ;Montina* (Indian rice grass) ;Millet* (Panicum miliaceum) ;Oats (Avena sativa) ;Quinoa* (Chenopodium quinoa)not botanically a true grain but normally counted as one. ;Rice* (Oryza sativa) ;Rye (Secale cereale) ;Sorghum / Milo *(Sorghum spp.) ;Spelt (Triticum aestivum spelta) ;Teff* (Eragrostis tef)(principle source of nutrition for 2/3 of Ethipians!) ;Triticale (x triticosecale rimpaui) modern hybrid of durum wheat and rye ;Wheat (Triticum aestivum; Triticum turgidum) ;Wild Rice *(Zizania spp.)
With all those to choose from, wheat is definitely not the only source of wholegrain. Anyone with coeliac or a gluten intolerance might like to know that according to the wholegrain council those marked with an asterick are gluten free.

It is possible that the suggested health benefits are entirely due to their fibre content. If so then it is of course possible to eat enough vegetables to do this.
I decided to work out just how much:First problem, how much fibre is recommended? The UK suggestion is 18g; however the BNF feels that this is too low suggesting 30g. The WHO recommends an RDA of between 20g and 40g. I have rather arbitrarily used 25g; this is higher than the UK suggestion but the median rec. for women from WHO, though still lower than that suggested for men .
Using a British online source (and different sources will produce different figures) I chose a selection of common vegetables, mostly green but added red peppers and aubergine to widen the variety. After selecting 800gm worth I had reached the British target amount but widened my source to include nuts as these are another nongrain source of fibre. Fifty grams of nuts and still there was still less than 25g of fibre, so I turned to fruit choosing avocado , low in carb but high in fibre. I also counted the carbs; this selection has a carb content of 33 so just over Bernstein’s limit.
Spinach 100 g fibre 2.4g carb 3.75
Broccoli 100g fibre 2.6 g carb 2.1
Cauliflower 100g fibre 1.6 carb 2.7g
Aubergine 100g fibre 2.3 carb 2.8g
Red pepper 100g fibre1.6 carb 6.4g
Savoy cabbage 100g fibre 2.8 carb 3.5g
Courgette 100g fibre 1.2 carb 2.2g
Mixed salad 100g fibre 3g carb 3.4g
Almonds 50g fibre 4.2 carb 4.25g
Avocado 100g fibre 3.4 carb 1.9g

But how many people eat this amount ? The five fruit and veg a day, advice assumes a total of 400grams a day but is set alongside advice to eat starchy carbs, preferably whole grains. You have to eat an awful lot of 'fibrous organic vegetables'.
Even with a mixed diet including grains, legumes , fruit and vegetables many of us probably fall short but it is certainly much easier.
I realised I was a bit low and have tried to include more high fibre legumes recently.

It maybe that not all fibre is beneficial for all purposes. Possibly different types of fibre are useful in specific areas. Beta glucans seem to be beneficial in cardiovascular health, major sources are barley and oatmeal. Residual starch may be beneficial for lipid control and glucose stability, and probably is important for colonic health, this is chiefly found in whole or partly-milled grains and seeds, pulses, and cooked and cooled (retrograded) potatoes. (and some processed breakfast cereals)This becomes difficult to test and to separate out and often results in fairly artificial types of experiments but there have been many. of varying quality. (and the literature search would take a long time!) some of these are summarised by Oldways and the Wholegrain council in the link below.
One recent study did attempt to separate the effects of fibre from wholegrain to that of fibre from other sources in the incidence of colonic cancer. (Schatzkin et al)In this prospective cohort study, total dietary fiber intake was not associated with colorectal cancer risk, whereas whole grain consumption was associated with a modest reduced risk.According to the researchers ”These findings suggest that whole-grain components other than fiber — e.g. vitamins, minerals, phenols, and phytoestrogens affect colorectal carcinogenesis.”

As suggested above .There may be health benefits in whole grains caused by something other than the fibre. It maybe a combination of phytonutrients or vitamins, or minerals etc acting synergistically , ie the whole package (and of course different whole grains will vary, it’s not just wheat!) The Slavin paper discusses this.

Slavin J Nutrition Research Reviews,Vol17:99-110, May 2007Whole Grains and HealthReprinted @http://www.wholegrainscouncil.org/files/SlavinArticle0504.pdfSchatzkin et al., Am J Clin Nutr., 85: 1353-1360, 2007Dietary fiber and whole grain consumption in relation to colorectal cancer in the NIH-AARP Diet and Health Study[urlhttp://www.wholegrainscouncil.org/files/WGResearchSummary_WGCJan09.pdf]Recent research into wholegrains and health from Oldways and the Wholegrain Council (up to you to decide on validity,and check out its origins and funding)http://www.ajcn.org/cgi/content/abstract/85/5/1353[/url]

Windsor Half Marathon

Exercise alone might not make you lose weight but it certainly helps.
I was a proud Mum when I got to the finish sometime after my daughter and OH. She completed the Windsor half marathon in 2hr 26min. Since February she has lost 60lbs in weight by eating a healthy diet (Weightwatchers) coupled with regular training for this event. Like many women she had put on weight during her first pregnancy and didn’t lose it before the second. After three pregnancies she had become very overweight. She started training with 2 min walk, 30 seconds run. Gradually, as the weight came off and she got fitter the running times increased. On event day she ran the whole 13 miles with no walking breaks,. She crossed the finish line side by side with her father.
As for me, well I finished but was very,very slow(though there were still quite a few finishing after me). I hadn’t really trained properly and I was hampered by poor glucose control. The event started at the difficult time for me of 1pm ie lunchtime. I had breakfast at about 9.30am and had planned to eat a cereal bar before the start. With 20 minutes to go, I tested my levels...3.9mmol, far too low but on top of this no cereal bar: OH had checked my bag into the baggage store and I'd forgotten to take it out. I set a low temp basal and took some dextrose but it wasn’t a good way to start. Psychological or not I felt low and very heavy legged. For the first five miles I did a lot of walking. When I spotted my family at the side of the course I stopped and almost gave up then and there butafter dithering for a few minutes decided to carry on for a bit. Round the corner, out of sight, I checked my glucose level, too low and I would have given up. It was 5.6mmol, so why did I feel so b......y awful? New tactics were called for.. I used my emergency hypo gel (15g carbs) and then upped my basal rate back to almost normal.(85%) I had some strange idea in my head that I might not have enough circulating insulin but in retrospect I don’t think that was logical.

Strangely, it worked and the last part of the run, seemed much easier and I felt much happier. I was still slow but I stopped going backwards and caught and overtook several people before the finish.
I’m now determined not to let my training slide again, and I’d hoped that I would be able to work towards the London marathon in April. Sadly that’s not to be as I’ve just received my 5th rejection in a row. That means I’ll get a place for the 2011 event (you get an automatic entry after 5 ballot rejections) so I’ve got 18months to train for it.

Whilst Others Debate Swine Flu vaccine.......

My local fishmonger has the answer

Apparently a 'nutritionist' at Montpelier hospital says that to strengthen the immune system we need a lot of zinc. Oysters are one of the best sources
The good doctor also suggests eating cheese like Roquefort and the crust on Camembert for their useful bacteria plus fruit and veg for vitamin C, red fruits for beta carotene and kiwis for vitamin E.

Your mileage may vary!

Quackometer

Most of us use a certain amount of scepticism when looking at medical websites and when reading the views of 'alternative' practitioners. There are a number of 'quackwatch' sites which seek to expose some of the more brazen con artists but not all of the possible suspects have reached enough notoriety to be covered on their pages..
This site http://www.quackometer.net/?page=quackometer
contains a fun gadget (to be taken seriously?... well that's up to you!) It tries to assess whether a website or an individual might be a medical quack. The more canards, the greater the possibility of some sort of quackery.
I had some fun putting in several names that have recently appeared as 'gurus' on diabetes forums. Their scores (out of 10) ranged from 1 (almost respectable) to a certain Austrian doctor who received 7 canards and made it to number 3 on today's high score list. I thought this was probably going to be the highest result. Then, after scanning through some recent postings on a diabetes forum , I put in the name of the author of a book on coconut oil that had been recently mentioned by a poster. I'd never heard of him before but I hit the jackpot... this gentleman now has the honour of topping todays high score list with a whopping 9 canards.
For comparison I put in my own favourite writer /researcher on diabetes nutrition. , Dr G Slama . He has edited a series of conference reports sponsored by Danone, so this might have raised suspicion. This was noted, but still zero canards.
I also put in the whole grains council website and Oldways (advocate of the Med diet) ... both of which I used a lot recently and Diabetes.org.uk. Fortunately none of them had any canards.

Now, you have to use your own judgement and be skeptical of the skeptics but whose advice would you follow, someone with no canards or someone with nine?
Why not try the site for yourself?

All in the Mind?

Yesterday was supposed to have been decision day, to run the Windsor half marathon or to cry off. We sent off out entry forms with plenty of time to get the training in and it was to be a family affair, myself and OH plus our daughter. What we forgot about was the Summer temperatures , this year a minicanicule. Trying to run when its above 30C and theres no shade is not sensible, after all, even Paula Radcliffe can't cope with heat.
We've upped the training in the last couple of weeks but yesterday was the crux, if I could run or run/walk 2 circuits of our 8km riverside circuit then I'd be OK. The circuit is actually a figure of 8 and includes 3 bridges so its not easy to cut short the run if you're on the 'wrong' side of the river.
We set off, in opposite directions, we run at different speeds so we don't run together.
The first half mile , fine, breathing well, a bit slow but that didn't matter.
Then a thought... you didn't check your blood before you started. I automatically felt for my waist pack ,Oh ***! .
Pack complete with meter, dextrose and car key was still sitting on my seat in the car.
What to do?
No use going back to the car;.....no key.
Go on then I'd at least meet OH who had the other car key.
The problem was I always need a dextrose at 2 miles and I wouldn't meet him until just after that and then still had to get back to the car.
Nothing to do but to carry on.
I ran quite well for a while but towards the 2 mile point my legs began to feel tired. The heat (though far less than a couple of weeks ago) was beginning to bother me, I was sweating, starting to find breathing a bit more difficult. I must be going low, I need a dextrose tablet.
Carry on, where was that husband ?
I REALLY NEED SOME SUGAR NOW.
At last OH came into sight. I told him what had happened and that I needed the car keys. He gave them to me and off he ran with a cheery wave.
Now I felt very sorry for myself, ... didn't he realise I might pass out? . Why didn't he come back with me?
I slowed down, walking rather than running. I realised I was about to go past the hospital. Half of me thought that it might be a good idea to go in and up to the diabetic ward and ask for some sugar. The other half was far too embarassed to do it. I carried on, half running, half walking, and eventually reached the bridge and crossed over, not too far back to the car. My Garmin told me I'd taken over 15min to do the last mile.
I got there, checked level ..... um, 6.1mmol, 6.1mmol !
Not low at all, in fact rather higher than I usually run at.
Sheepishly I locked the car and went back to the riverside. What to do? If I continued in the direction I'd been going I'd not meet OH and I now have both car keys. I decided to run back towards him. A couple of hundred meters along the bank and there he was, that was quick!
Half a mile after giving me the key, he'd begun to worry about having left me .He decided the only thing to do was to carry on, but he had to run as fast as possible.
For both of us that was the end of the run., neither of us felt like going on. He'd done 8k I'd done about 5.5k. No long run, we'll have to try again midweek.

But what about my glucose levels, was I really low at one point and my liver helped out, perhaps the worry had sent them up, or did I just feel low because I thought I should be low? Was it all in my mind?

(It didn't go down afterwards either, it was 7.5mmol before lunch, stayed 'up' all afternoon, then I took off my pump to have a bath and afterwards it had gone down to 4.2mmol.... very strange things blood glucose levels!)

Aligot

That can’t be good for you!

photo :wikipedia

It's hard to avoid aligot around here.

Restaurants serve it by the bucketful, confit de canard and aligot, saucisse and aligot , rosbeef d’aubrac and aligot. Tourists can’t get enough of it and often take home small tubs from the market at 5€ a throw. The locals like it as well and many of the fetes serve it as part of the traditional menu every year. If you have a deep enough wallet, and book well enough in advance you may partake of a 3* version chez Michel Bras. The tourist office has even produced a jolly song proclaiming its virtues

http://www.aveyronet.com/fr/index.php/2007/08/13/331--mp3-l-aligot-saucisse-en-chanson

So what is it?........... well basically mashed potato and cheese, for some comfort food par excellence, alternatively a dietitians nightmare!
With the aid of a very large wooden spoon boiled potatoes are beaten into submission together with some tomme, crème fraiche and a bit of garlic. Posh versions might have a sprinkle of nutmeg. The tomme is the secret ingredient, it's a very young cheese (3-4days) purists contend it must be Tomme de Laguiole. There is some mystic about the mixing process and to do it correctly your spoon has to follow a figure of eight so many times one way, followed by so many times in the opposite direction. Its hard work on the arms and takes some time. When it’s ready the potato mixture becomes a shiny mass with a gluey consistency that comes away from the side of the pot and sticks to the spoon. The market vendors raise their spoons a metre high to demonstrate elasticity of their product. The cheesy potato strings stretch from vat to spoon without dropping or breaking. Well made aligot is dolloped onto the plate or into a takeaway box, then can be cut away from the rest in the vat with scissors.
The origins of this dish go back many centuries. It comes from the high plateau of the Aubrac and was probably the type of dish eaten by shepherds on cold (and it gets very cold) winter nights. Before M. Parmentier persuaded the French that potatoes were edible, the dish was made with bread. Some people say that it was originally made by monks. These monks ran refuges for pilgrims on the Camino de Santiago. Aligot was probably very welcome on that very high and lonely part of the walk. Almost every ‘pilgrims menu’ now serves it, as we found when we did that part of the Camino last year and most people seem to love it.
Luckily, I’m not one of the majority. I hate the gloopy stuff. It’s just as well, it's high fat, high carb and all that beating will surely have done strange things to the starch structure . Would the broken starch molecules be very easily digested so therfore it's high gi? Or would all that fat in the cheese and creme fraiche slow digestion ? It’s probably like pizza, several hours later the blood sugars would rise with a vengeance to remind you of what you’d eaten earlier. Perhaps it just raises the blood glucose and keeps it raised for a long time. Undoubtably however you tried to give bolus insulin for it, you'd get it wrong.
For someone with diabetes aligot is perhaps not an ideal choice. For other people, given today’s mainly sedentary lifestyles, it’s perhaps better kept for high days and holidays. For many it would prove to be extremely fattening if eaten regularly.

But the food was originally fit for purpose. A hot, cheap dish, made from local ingredients that ‘stuck to the ribs’. It provided the energy necessary for herding animals on a cold draughty hillside or for walking many kilometres over rugged and difficult terrain.
There aren’t really good and bad foods, no food that should be demonised. It just depends on what you are going to do when you've eaten it. Common sense really.

Edit: Other half told me I wasn't being entirely honest. I may hate aligot but I love another dish made with very similar ingredients... tartiflette: sliced potatoes, onions and lardons fried together in a little oil, then baked in a dish with reblochon cheese. Its great after a days skiing and I make it perhaps once or twice during the year. I don't eat a huge portion and it surpringly hasn't been too disastrous on glucose levels but I wouldn't eat it in the days before a cholesterol test. Its not the sort of thing I'd write in a food diary for my diabetologue either ;fortunately she's not likely to read it here .

Eat What You Like! :Just Cover It with Insulin

How often have you heard that?

Sometimes from other people who take insulin, who perhaps say it without really thinking. Sometimes ,and suprisingly often, from people who don't have to take it in a rather derogatory fashion. Just take more insulin, no problems! The implication is that its a very simple equation and that glucose levels are easily control .

I think some people have a mental image a bit like this

If you eat more carbs then you simply tale more insulin like this

You soon realise that this idea is far too simplistic. Taking insulin is only part of the equation and to get things right everything has to be right. The right amount of insulin for the carbohydrate intake and taken at the right time for the type of carbs, are they low or high GI, the amount of protein might make a difference to some people ,and is there more than the normal amount of fat? If so that might slow down your digestion and the insulin might take effect before the carbs are absorbed.

Have you done some exercise ?, will that make you go hypo later?
Are you about to do some exercise? would it be better to start with higher glucose levels? (and do you really want to have to make that decision now?.... you know it might pour with rain soon!)
What is your blood glucose level before eating? ..... too high? Too low?
Whats the time of the month (if you’re a woman) will you need a bit more insulin?

Have you got an infection or illness? Again a bit more insulin perhaps , but how much?
Are your stress levels high? .... are you about to drive through spaghetti junction in the rush hour?
Is your basal right and able to deal with the glucose from your liver?
I’m sure you can think of others but the picture now looks less like a seesaw and more like this

If you get everything exactly right , glucose levels on target , happy smiley face!

GREAT
But too much insulin, too few carbs, unplanned exercise, plus a hypo from the day before this is what might well happen .

Hypoglycaemia
On the other hand if you plan to go to the gym, so reduce your insulin a bit, eat some extra low gi carbs but get stuck in that traffic jam, causing stress this may be the result.

Hyperglycaemia

JUST COVER THE CARBS?

Simple?
Its no wonder that sometimes levels are a bit like this

(photo wikipedia )

(with thanks to Jopar for reminding me of all the multitude of things we have to get right, every single day and to Tubs for reminding me how I hate that expression!)

.

Label Reading ( or the difficulty of choosing a savoury snack)

I don't actually eat many prepackaged foods but when I first developed diabetes, I spent hours studying the labels on those that I did, trying to make the best choice. I still do this when I go to the UK as there are always lots of enticing new products in the supermarket, though often they don't live up to the packet blurb. Like many people I'm a creature of habit so don't have to label read so much now and shoppings a lot faster.
That is until something I buy regularly is out of stock., then it's label reading time again.
Today it happened with the Palmiers, savoury cheeesy biscuts.
Now these are not a healthy food, they are a calculated indiscretion. Quite frequently I go for a run or swim in the late afternoon, then its time to cook dinner . By this time blood glucose is often low In the 20 minutes or so so before serving up its time to pour a glass of wine, and I 'need' a little 'something' to stop my BG going through the floor (well thats my excuse, my diabetologue doesn't agree ) This is where these little biscuits come in.The label tells me they are 46% carbs, (but they are very light), they'e a bit high in lipids and probably too much salt but all they contain is flour, cheese, butter, sunflower oil and some seasoning. They are similar ingredients to the cheese straws I used to make. Not that good, but not horrendous either.

So what to get when there are no Palmiers. It probably took me ten minutes. There were lots of packets to choose from.
The first one had 76%. carbs- a bit high ;
the next contained palm oil-don't want that;
a third hydrogenated and partially hydrogenated fat .(trans fat) -no thanks;
sirop de glucose fructose... I assume thats high glucose fructose syrup, definitely rejected.
Almost all had huge ingredient lists complete with chemical cocktails of flavourings and preservatives. I think I went through almost all the savoury 'snack items' and didn't think I could compromise on any. Just as I was going to walk away, I found a new product: petites tuiles aux 4 cereales: 60% carbs but a whole packet only has 75g, 22% fat but mostly unsaturated and 6% fibre.They contain corn, wheat oat and rice ;sunflower oil : fermented pasturised cream (sour cream?) cracked black pepper and salt. Are they any good, I don't know yet, they'll probably taste like cardboard. If I do like them and they don't cause blood glucose havoc they won't have any next time.

The horrifying thing was what was in most of the products. It's a tiny market here compared with the UK but a growing one.