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.