DUKPC 17 – The highlights*

(*Side note – there were not lowlights).

As some of you may know, last week I had the absolute joy & honour of attending the Diabetes UK Professional Conference as a blogger – and it was incredible. With the atmosphere buzzing, energetic and intense, the 3 days consisted of back-to-back presentations, introductions to many influential & passionate people, and insight into some inspiring new research & advice aimed towards HCPs (health care professionals) specialising in diabetes care.

Over the next few weeks, I plan to write more about some of the individual sessions/topics which really engaged me, and that I felt I ‘got a lot out of’ – but to begin with, I’m going to give an overview of some points shared throughout the conference that really struck me. Now most of these phrases have been ‘tweeted’ in one way or another amongst the other hundreds of #DUKPC tweets I threw out there over the 3 days – but I think these ones deserve a little more attention than just 140 characters. They cover several different issues, from exercise with T1D to rage bolusing (you’ll see!) – but hopefully, you’ll find them interesting and/or, like me, relatable…!

‘Refuelling after exercise & T1D is like filling a bath tub without a plug’

Starting off with exercise and T1D, I thought this analogy from Dr Alistair Lumb was spot on – and important to remember. Lumb explained all sorts of interesting bits, such as why anaerobic vs. aerobic exercise often give rise to different effects on blood glucose, or which blood sugars are ‘OK’ or a ‘no-no’ for a PWT1 (person with T1D) to exercise on (both of which I’ll expand upon on another post). Another point Lumb also emphasised was that if a PWT1 carries out sustained exercise for a long time – chances are that by the end, they’re going to need some glucose – and a lot of it. This is because during exercise, our bodies pull two types of sugar from various sources for energy (glucose from the blood, and stored glycogen from the liver and muscles), which inevitably leads to a fall in blood glucose. Now for someone without T1D, this isn’t a problem, as a fall in blood glucose will trigger the pancreas to release the glucagon needed to raise them accordingly (glucagon converts stored glycogen back into usable glucose). However, this (kind of important) mechanism won’t be triggered in a PWT1 – so it’s often up to us to do it ourselves – cue the post-exercise carb-binge.

‘Little & often vs carb-loading & crashing’

Continuing with the exercise theme, I was interested to hear the suggestion that in many cases, instead of carb-loading to raise your blood sugars before starting exercise (which is often followed by a blood sugar crash mid-exercise), it can be preferable to take the ‘little & often approach’ and munch on some carbs every 20 minutes or so throughout exercise. Now as you can probably see from chart below, the little & often approach does seem to give riselittle and often to a much more desirable BS pattern than the classic ‘stuff your face and then go running’ approach I’ve tried all too often – however, as a few people highlighted to me on Twitter, is it realistic to expect people to stop every ½ hr or so on their 90 minute bike ride to take some food on board? Perhaps not, but perhaps continuously sipping on some Lucozade or popping glucose tablets etc. would work well for some. The way I see it, T1D & exercise is different for everyone, and will always take a bit of trial & error – but it’s great to have new options to consider.

‘I think it’s tragic that my daughter has had more hours of driving lesson than my (T1D) nephew has had of structured education’

Now this quote from Lindsay Oliver really got me – which I think is because when you hear it, it just sounds ridiculous – but yet it’s true for so many patients. Couple this with another strong point made by Melissa Holloway below, and I think it’s clear why this point bothered me so much:

‘Diabetes is a lifelong disorder; treatment demands are all day, every day – yet PWD rarely spend more than 2-3 hours per year with a HCP’

I’ve had T1D for 12.5 years now, and wasn’t offered structured education until August 2015 (which I’ll just add looks like I’ll be able to attend this September – so that’s 2 years of waiting lists and some ‘gentle’ reminding/chasing from myself to get to this point). And to be honest with you – I still don’t know my ‘right’ insulin correction rates. I didn’t know until I discovered Instagram that many PWD have different carb counting ratios at different times of the day. Heck – I’d never heard of the phrase ‘dawn phenomenon’ until I started describing my symptoms of rising morning bloods sugars on an online diabetes forum. But the more I think about this, if I’m honest – the more I wonder if this is OK? Should I have been left to figure out these things by myself? Or should I have been offered structured education the second I moved to MDI – and even offered a refresher course every year or so as my body & insulin requirements changed? I’m sure this isn’t the case for all patients, and I know many who have had wonderful experiences of structured education and support from HCPs – but if this was something that could be offered earlier to all PWD, that would be swell.

new blue circle
One of my favourite slides (M. Holloway)
‘Technology is only as good as the person using it’

I guess this point spins off from the role of structured education too. Put it this way – if someone handed me an insulin pump tomorrow and told me to ‘just get on with it’ – I’d probably cry. The ‘diabetes tech’ available these days is extraordinary – and I’m very, very grateful to be managing my T1D at a time where there are so many gadgets and technical developments out there – but, as Stephanie Amiel highlighted, I think it’s also important not to diminish the role of education when using these things. Take my Libre for example – amazing, life changing piece of kit, in my opinion – but it didn’t come without a bit of figuring out. The trend arrows it shows, for example – working out either how much to eat, or insulin to take, when my arrows are either horizontal, at a 45◦ angle, or shooting straight up or down as if my blood sugars about to rocket off the scale– took a lot of trial and error (and hypos. Ohh, the hypos!) To be honest, I still haven’t got it down to a fine art – but perhaps, for example, this transition to the Libre would have been smoother if I’d been able to sit and discuss how to deal with these changing arrows with someone who knew their stuff.

‘Diabetic foot ulcers worse than some cancers’

This isn’t nice, and I know many will squirm at the mention of feet – but it’s important. This phrase, presented by Solomon Tesfaye, represents how some feel about diabetic neuropathy, and it concerned me. He quoted that 140 amputations take place in the UK every week due to diabetic neuropathy, and this is increasing. He also mentioned how some studies showed that close to 50% of patients arriving at clinic with foot ulcers saw a 5 year mortality rate. Apologies for the horrible stats – but it’s a scary reality that needs to be addressed.

As a PWT1 myself, I’ll be the first to admit that I didn’t realise how serious diabetic neuropathy was – as far I was concerned, my GP tickled my foot every 6 months, and that was that. But it turns out that there’s much more to it, and there are lots of little ‘warning signs’ to look out for – hard skin, swelling, pins and needles, loss of feeling etc. I plan to do a separate post on this – but just to say that if you do notice anything unusual or not quite right with your feet, please do tell your Doctor. Don’t be shy – shove your feet right in front of them (I’m sure they’ll love it) – it’s important. That figure of 140 needs to go down, not up.

(Side note – Diabetes UK are hot on this right now, and have included a leaflet on simple steps for healthy feet in their latest issue of Balance magazine, which I’ve linked here. Check it out for further information on how to keep those footsies in tip top condition.)

‘More insulin doesn’t necessarily bring you down faster – it just brings you down further’

And to finish – probably my favourite message of the week from Pratik Choudhary‘s presentation – and we’re talking rage bolusing. Now I’d never heard of this term before this week (rookie?), but I absolutely love it. Basically – it describes the action of bolusing/injecting out of frustration/anger/being damn fed up with your high blood sugars – when perhaps you don’t need to. The result? A whopper of a hypo 2 hours later. Sound familiar?!

I do this a lot. Too much, in fact, and I’m pretty certain my ‘pre-empted bolusing’ has increased since using the Libre. Although the best part of using an FGM/CGM (flash/continuous glucose monitor) is being able to see your blood sugars all of the time, this is also the worst part of it – because 9 times out of 10, your body doesn’t respond to the insulin as quickly as you’d like it to, and can lead to patients over-correcting.

I often ‘rage bolus’ the most after a carb-heavy meal where, after carb-counting my food as carefully as possible, I watch my blood sugars rise to 13, 15, 17 mmol/l in the hour following my meal, and basically, get pretty annoyed. As I’m sure is the case for many others, I struggle to sit and watch my bloods sugars rise and rise and do nothing about it – and so at this point, I usually ‘correct & inject’ (that’s got a nice ring to it, hasn’t it?). But when you think about it – that’s probably not often the right thing to do – because I actually have injected the correct amount already before the meal (by carb-counting it) – and the insulin is (slowly but surely) working its way around my body – but annoyingly, when it comes to which out of carbs and insulin will affect my blood glucose levels the fastest – the carbs will win.

Unfortunately, although faster acting insulins are being researched (please, please please!) currently they are just not fast enough to always stop our blood sugars from spiking. One way to tackle this of course is to pre-bolus (inject in advance of the meal to give the insulin time to act). Now I’m all up for pre-bolusing – but let’s be real here – sometimes, it’s just not that practical. You don’t always know what you’ll be eating, when you’ll be eating – or have a clue how many carbs will be in what you plan to eat. So it’s tricky – but I guess the thing I’ve learnt from this (well – am trying to learn – developing the willpower to not correct my soaring blood sugars of 17 mmol/l straight away is proving difficult!) – is to try and be patient, as overloading my body with more and more insulin will not, like Pratik said, bring me down to my desired blood glucose level any quicker. Instead, when the insulin does finally kick into gear, it will bypass the lovely 5 mmol/l I’m aiming for, and go straight to the 2’s – which certainly isn’t what we want, either.


^^ A few pics of us having fun ‘nd all that  

2 thoughts on “DUKPC 17 – The highlights*

  1. Fantastic summary. Really interesting about the carbohydrates and exercise. I heard some conflicting messages about carbs and exercise while I was there, but what you’ve described makes good sense to me.


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