Shoot Up or Put Up

I rave about my pump and CGMS. My personal experience is that they’ve enabled me to keep my HbA1c at a very happy level for over 2 years, reduce the range of my blood sugar swings and reduce the number of hypos I experience. And now science agrees with me!

The latest research from JDRF shows that using a continuous glucose monitor regularly (at least 6 days a week) increases diabetes control and enables patients to maintain good control long term. This is exactly my experience.

My consultant never looks convinced when I tell him that I need to wear my CGMS pretty much all the time to achieve excellent results. He seems to think that I should be able to use it occasionally to get an idea of what’s going on, and then fly blind the rest of the time. My view is that CGMS is a tool I use to manage my diabetes day in day out, not something I dip into once a month to see how I’m doing.  Now science agrees with me:

“patients averaging at least six days per week of CGM use had substantially greater improvements in HbA1c compared with those who used the devices less often”  http://www.jdrf.org/index.cfm?page_id=112539

The other interesting bit from the study is the proof that the behaviour of the patient is as important in this as the technology:

“…the study found that regular use of blood glucose testing prior to beginning CGM therapy was an excellent predictor of regular CGM use and thus of improvement in glucose control” http://www.jdrf.org/index.cfm?page_id=112539

Yes CGMS is a great tool, but it is just that, a tool not a cure. I’d argue that if you were blood testing regularly prior to starting using CGM you’re probably someone who is used to putting the effort in to take control of diabetes. Common sense says a more advanced set of tools like CGMS is going to be most effective in someone who is used to making the most of the treatments available to them. I like it when science and common sense agree, it makes me feel that all is right in the world!

Hopefully this research will really help strengthen the argument for all those who are currently lobbying the NHS or insurance companies to provide them with access to CGMS. Good luck to you all!

I went to London for work yesterday. Not a major event really, I go a few times a month and it’s only a couple of hours by train. For some reason though the world was against me yesterday.

- 0630: Leave the house.

- 0635: Return to the house having remembered that I haven’t picked up my meter.

- 0705: Get to the station and ladder my tights getting out of the car.

- 0715: Get on the train and spill my hot coffee on my leg, luckily though I haven’t changed the laddered tights yet, so at least that’s something.

- 0800: Go to the bathroom to change my tights. Somehow during this escapade I manage to pull my infusion set out.

- Because I’m a bit of an idiot and am allergic to carrying lots of junk around I don’t carry a spare infusion set when I’m only out for the day – bad diabetic!

- Because I’m not a complete idiot, I do carry a syringe so that I can get insulin out of the pump should I accidentally remove an infusion set on a train.

- 0805: Stop muttering about the infusion set nightmare and get on with dealing with it.

- 0806: Realise I’ve forgotten what it’s like to use a syringe in public – the man opposite me looks at me a bit strangely as I disassemble my pump and use the syringe to draw insulin out of the reservoir.

- 0807: Wimp out of starting a diabetes education session with the man opposite as my brain is occupied with calculating how much to inject to compensate for the basal I’m going to miss, conscious that I have an important meeting at 1100 that I don’t want to hypo in.

-  0808: Realise that my diary is back-to-back with meetings pretty much all day which will make injecting every couple of hours a bit of a nightmare. Decide to keep an eye on CGMS, aim to inject every 2 hours and deal with problems as they arise.

- 0820: Realise that for all the time I’ve been dealing with the infusion set issue and wondering how I’m going to keep myself alive for the next 12 hours the woman across the aisle has been doing her make up. Why can’t my life be that simple?

- 1127: CGMS alarms to tell me I’m high. Normally I’d press a button for a quick bolus of insulin and no one would notice, but my only way of getting insulin is to take my pump apart and use a syringe. I decide that my kidneys won’t fry from sitting in excessive glucose for the 30mins it’ll take to finish this meeting.

- 1200: Most important meeting of the day is over and CGMS shows 14.6. I resist the instinct to just press a button on my pump and get the syringe out again for a splash of insulin to correct the high and some more basal to cover the next few hours.

- 1405: Why can I smell insulin? So that I can keep track of how much insulin I’ve injected, I’ve been bolusing the same amount on the pump every time I inject. This info is incredibly helpful but as the infusion set isn’t actually in my skin all this insulin is running down my leg and my tights smell of insulin. Nice!

The day continues – check CGMS; thank the god of diabetes tech for CGMS which makes this whole palaver slightly easier; inject; do my job; repeat.

- 2000: Arrive home and insert new infusion set, I feel whole again! Blood sugar is 13.8 which isn’t at all bad after a busy day of managing with only fast acting insulin and a syringe.

- 2245: Jump out of bed to put a couple of new syringes in my handbag for any future emergencies.

- 0257: Remember that I know someone in the London office who also has a pump and who could probably have given me an infusion set. Idiot!

I’m Alison’s pump. She talks about me a lot so I’ve hi-jacked the blog to tell my side of the story. I don’t have long because we’re not apart often so I’ll get straight to it.

I’ve been with Alison for over 2 years now and overall I’d say we get on well. She’s a very enthusiastic owner, she makes me blush at times the way she raves about how fantastic I am. And so she should, I have integrated CGMS, I’m at the forefront of diabetes tech. Personally I don’t think she uses all of my capabilities – I’m sure she could spend more time downloading and analysing all the data I collect for her but apparently she has a life she wants to live.

Most of the time I get to sit in pride of place on her waistband, although don’t think I haven’t noticed that for parties that involve a posh frock I’m relegated to the bra, out of sight. That doesn’t do a lot for my ego.

This job has some good perks. She’s taken me white water rafting, sailing and on safari. I like it that she never leaves me behind although it was a little embarrassing when she spotted one of my friends in the middle of the Costa Rican jungle. Despite it’s owner speaking no English I had to endure the shame of her and Alison attempting to compare pumps via the medium of mime. I was willing my battery to run out so I didn’t have to witness the humiliating spectacle any longer.

I don’t want to sound ungrateful, Alison’s a good owner, but she can be a little hard to live with at times.  

She has a tendency to shoot the messenger. I can’t predict how she’s going to react when I have to tell her that her blood sugar is too high, it’s like Russian roulette. If we’re in public I’m generally safe, she’ll acknowledge the high and put some more insulin in quickly and discretely. If we’re alone it’s a more hit and miss affair. Sometimes its fine, other times there’s furious muttering and occasional violence. Thankfully she’s only thrown me on the bed so far but she does talk about pitching me out of the window which I think is an unnecessary over-reaction. At times like this I fear for my safety.

There’s one thing though that hurts above all else. She thinks I don’t know, but I’ve seen her looking round at other pumps, seeing if there’s anything better on the market, eyeing up my replacement. I know I’ve got less than 2 years until I’m out of warranty and then what? I need to start planning for my future.

The things I know about Alison you wouldn’t believe. We’re rarely apart; I know everything about her, what I’ve told you so far is just a taster. If you want the more salubrious bits, please send money. I have to fund my retirement somehow.

If my inbox is anything to go by, how to secure NHS funding for insulin pumps and/or CGMS is a bit of a hot topic at the moment. There aren’t any magic answers, and personal experience taught me that tenacity and perseverance were pretty key to winning the battle, so for what its worth, here are my thoughts.

Understand the product – what is it that you want and why? How will you use this kit to improve your control or your quality of life? Be clear in your own mind about the benefits to you. Speak to the local rep – could you maybe trial the CGMS for a week to see if you like it and if it makes a difference to you? Take a look here for what I think are the main benefits to me.

Understand the market – what guidelines are out there? For pumps, INPUT have a great summary of the guidance.  For CGMS, there is very little guidance out there so you’ll probably need to fight on an individual basis. Medtronic have a summary of what little guidance exists.

Get your healthcare team on side – if your consultant is vehemently anti-pumps I’d recommend you find a new one. Try INPUT to find out who in your area has a good reputation for supporting pump use.

If your diabetes team just need a bit of gentle persuasion, show them the evidence. The download-able marketing literature from Medtronic covers the basics and quotes some of the major research projects that prove the benefits of CGMS. If you want more detail, try here for a reasonable summary of the research.

Use the suppliers - at the moment there’s only Metronic who provide CGMS in the UK. Contact them and ask to speak to your local rep. See if they know of any Drs in the area who are pro CGMS. When you know which clinic would suit you, head down to your GP and explain why you’d like to be referred for your diabetes care to that particular clinic.

The Dr says its too expensive – “Every time I have brought up continuous glucose monitoring with my diabetes nurse, she has said there is no way the NHS would cover it (no point even trying, apparently)”. To be blunt, it isn’t the job of your Dr or nurse to decide what the NHS will and won’t fund. Their job is to work with you to decide what is clinically the best treatment for you. Your local primary care organisation decides what they will and won’t fund, based on NHS guidelines or on an individual assessment of your case.

With your healthcare team on side, you now need to get financial approval. In the UK this will come from your local primary care organisation (PCO) - basically the NHS body who use our taxes to commission healthcare from hospitals and other providers on our behalf – in England and Scotland they’re called Primary Care Trusts (PCTs), Wales have Local Health Boards (LHBs) and Northern Ireland have Health and Social Services Boards (HSSBs). So we don’t lose the will to live amongst the complexities of the NHS, from now on I’ll call them PCOs.

If they agree that what you’re asking for is medically necessary, your Dr should write to your PCO to request that they fund the treatment. Ask for a copy of this letter, that way you know who its gone to and can chase it directly rather than via your Dr.

Personal experience showed that it took my PCO 6 weeks to respond to a letter. If I took that long at work to respond to a letter, I’d be sacked. I now give the PCO 2 weeks to respond, and then give the addressee of the letter a gentle nudge via phone or email. “I’m just calling re X to check you’ve got all the information you need” is a good opener – it brings it to their attention and means you get to know early on if they need more info.

Question, question, question. Without wanting to tar everyone with the same brush, we do seem to have a culture of prevarication in the NHS and a desire to do anything other than actually make a decision. Don’t be afraid to ask questions. Do they have everything they need to make a decision? If not, what else do they need? When can you expect a decision? Who will make the decision? What criteria will they use? What’s the appeals process?

Have your evidence – you want this, so make it as easy as possible for them to say yes.

Are there any NICE guidelines? If so, be clear about what they are and how you meet them. If there aren’t you need to point out this is not a general policy decision they’re making for everyone in the PCO area, this is something they should decide based on the merits of your case.

What are the consequences of not funding this request? eg severe hypos impacting on your ability to work, fear of night-time hypos as you live on your own. If you’re a woman, talking about the impact of poor diabetes control on any imminent planned pregnancy soon gets attention.

I felt I was being fobbed off and generally ignored when I applied for funding, so I went straight to the top and emailed the Chief Exec, cc my local MP. I explained the issue and that I felt I wasn’t getting a good quality service. The Government promises patient choice within the NHS, but I felt my PCO wasn’t making appropriate efforts to enable this.

There aren’t any simple answers to getting funding for CGMS, it is a battle but as more people fight that battle it will get easier. To summarise, here are a few things that I think are important:

• Be clear about what you want and how it will benefit you in the short and long term
• Get the support of your medical team – if they won’t support you, consider finding a new team
• Gather the evidence to show that what you’re asking for actually works - if you’re struggling, ask the suppliers to provide you with the evidence – this is their product, they should be able to point you to the research that shows that it works
• Keep the pressure on - you want this funding so you need to drive it through the system. Find out who is dealing in your PCO and speak to them regularly. Understand the process and always know what the next step is. 
• If you’re not getting anywhere, escalate. Writing to the Chief Exec and getting your local MP on board generally helps to clear any blockages. 

That’s what worked for me. If there’s anyone else out there with pearls of wisdom on how to get NHS funding, please share!

Wizards and quidditch and death eaters abound in the UK this week as the latest Harry Potter hits our screens. If pushed, I will admit to having read all the books and I will be going to see the film, but I won’t be fighting off the hoards of teenage girls to see it this week. I think I can wait a while until the mayhem calms down a little. 

Wizardry is an often overlooked tool in diabetes care. In fact, when I mused about pumps the other day, I completely omitted to mention the mystical marvels of the bolus wizard. Now is the time to correct such an omission (thanks to Roger for pointing it out).

The ultimate book of spells for young wizards acquiring their first pump is Pumping Insulin by John Walsh . It was here, before I’d even attended the Hogwarts Academy for Novice Pumpers that I first discovered the wonders of the bolus wizard.

Basically, once you’ve programmed it with a few ratios – worked out either through a spell provided in Pumping Insulin or with some help from your mystic master (otherwise know as a diabetes specialist nurse) – it’s up and running.

You simply tell the pump what your blood sugar is and how many carbs you’re planning to eat and it makes a recommendation about how much insulin you should take. It cleverly takes into account any other insulin it knows you’ve taken recently so you don’t dose twice for the same high.

Here comes my second admission of this post, not only do I quite like the Harry Potter books, I also rather arrogantly thought I had no need for a bolus wizard. I’d been flying high on the diabetes broomstick for many, many years. I could calculate how much insulin I needed for a bowl of pasta as quickly as Hermione can say “Expelliarmus!” . I didn’t need a machine to tell me how to reverse the impact of the “too much ice cream/not enough insulin” spell.

Listen carefully; you won’t hear this often…I was wrong. My bolus wizard is far more accurate than my previous finger-in-the-air type guessing. That’s not to say I treat it with the reverence of Dumbledore and never challenge its’ teachings. It doesn’t know I have a game of quidditch or a battle with some death eaters planned, so sometimes I’ll knock a bit off the recommendation to allow for that. Equally, if the CGMS tells me I’m rising faster than the Snitch in the final seconds of a game, I’ll add in extra insulin for that.

Overall though, it’s marvellous. And it feels like a real step towards an artificial pancreas. If we already have a machine with the ability to calculate insulin requirements based on glucose level, it isn’t a huge leap to automate that process.

The elves tell me that many people on pumps don’t use their bolus wizard. Perhaps, like me, they felt they were wise enough without it. I can hear the legendary words of Dumbledore now “use the wizard my friend, it will guide you on your journey”.

Omnipod pod and PDM

I have a couple of friends who are in various stages of getting themselves insulin pumps (do I really go on about it that much??). Having had similar conversations with each of them about what’s currently on the market in the UK, I thought a quick overview of some interesting recent developments in the UK pump market might be useful.

Bear in mind I’ve only used a Medtronic Paradigm pump, my thoughts below are based on reading reviews and publicity material, playing with samples at conferences and talking to people. This isn’t a scientific, double blind randomised control trial, it’s just my musings.

The Omnipod is a step nearer to the UK

Our friends over the pond have had the tubeless Omnipod for a couple of years now. The overall impression from people who use it seems to be very positive (save for a few reliability problems early on that seem to have now died down).

Personally I like the idea but have reservations on two fronts – firstly the pod is pretty large to have attached to you at all times. On a standard pump when you disconnect to shower or whatever you’re left with an infusion set roughly the size of a 10p. As you don’t remove the Omnipod pod for the entire 3 days until you replace it with the next pod you’re permanently attached to something roughly the size of half a small apple. My other concern is the tubelessness. My pump is attached by a piece of string which does have the unexpected benefit of my not being able to forget it or lose it easily. I don’t have to remember to pick it up before I run out the door as it’s attached to me. As the Omnipod is tubeless, that means you have to remember to carry the remote to do any dosing. Not an insurmountable problem I’m sure, just something that concerns me.

Insulet Corp recently gained a CE mark for the Omnipod, meaning that they can now sell it throughout the European Union. News reports say “the product will be available to a limited extent in selected markets in 2009 with broader availability in 2010“. Always good to see more choice on the market. One interesting issue for Omnipod entering the UK market may be their website – their .co.uk address is currently owned by a company that “specializes in mid-20th century designer furniture and distinctive accessories”!

Paradigm Veo

The Paradigm Veo is already here!

Having had to wait impatiently for the Omnipod to hit the UK shores (and it’s still not here yet), it was a nice surprise to see that we actually got the Medtronic Paradigm Veo in the UK before our American cousins.

The Veo is an upgrade to the existing Medtronic Paradigm Real Time – it has some tweaks to the CGMS but it’s big new feature is that if you fail to respond to the CGMS hypo alarms it will suspend insulin delivery for 2 hours to help reduce the risk of severe hypoglycaemia. Thankfully severe overnight hypos haven’t been an issue for me since I was a teenager struggling with ye olde insulins of Ultratard and Actrapid, but if this had been available back then it would have been life changing for me. For more detailed info try the INPUT blog.

Accu-Chek combo system

New combined approach from Accu-Chek

Pumps are very personal things, what suits you depends on what kind of life you lead, what you like, what you don’t like etc. What’s really exciting at the moment is the diversity in the types of pumps and features that are available, we’re really starting to see a market where each supplier has a defining feature whether that’s the lack of a tube, integrated CGMS,  great remote functionality or the ability to give really small doses of insulin like the Animas 2020 . The next step has to be to get all the good stuff into one pump. For what it’s worth my wish list includes:

• CGMS. This is my “must have” pump feature. I’m not interested in having it as a separate device, that’s just too much stuff to carry. It has to be integrated.
• A remote with full functionality would be handy – so I can hide my pump in my bra when I’m wearing a nice dress and not have to fish it out at the table to change my basal rates.
• If I’m carrying a remote, it’d be nice for it to have built in glucose meter so that’s one less thing to carry.
• I’m surprisingly ambivalent about tubing. If I could get over the fear that I’m going to find myself on a train to London having left the only way of controlling my pump on my bedside table – and they could make the pod smaller – I’d certainly think about going tubeless. It’s not a big deal for me though; the tubing on my pump isn’t something that really bothers me.

Here endeth my thoughts for the day. Comments?

For reasons unbeknown to most people I recently decided to graph my HbA1c results over the last few years.

The graph is quite astonishing. It starts with peaks and troughs, rising above and below 7% but never really settling. It reflects the reality of my diabetes a couple of years ago – I could get my HbA1c down to about 6.5% but it was a struggle. Quality of life really suffered, hypos increased and it was really hard work. That meant that I couldn’t sustain the effort needed to keep it that low, I always reverted back to normal life which meant an HbA1c of 7 ish, not bad but not what I was looking for.

About a third of the way in the graph plummets, like a lemming off a cliff. That’s the change between my HbA1c of 7.3% in Jan 07 and my HbA1c of 6% in June 07 just 4 months after I started using my Medtronic Paradigm pump and CGMS.

I fought for the pump and CGMS because from the research I’d done I believed they were the tools I needed to help me get tighter control. HbA1c levels of people with a working pancreas are generally around 6.2% or lower. In my dreams that’s what I wanted to achieve. On injections I once managed to get as low as 6.2% but it was a blip and certainly not something I could sustain.

So the graph shows that I could get lower than I’d ever done before with my new pump, but was that just the placebo effect? Diabetes is pretty boring, requiring attention day in, day out so it’s only natural that any change in treatment would re-ignite my interest and make me try harder for a while. But look at the graph, from a couple of months after starting the pump until the present day it’s virtually flat. I’ve been flatlining for over 2 years. I can’t sustain artificially high levels of interest in something for that long. And I can confirm that I’m not dead, so the only explanation for the flatlining is that I’ve finally found a tool that gives me the ability to control my diabetes as I want to.

I’ve never graphed my results before, unsurprisingly the urge has never taken me. Having done it, I’m amazed by the story it tells. I hadn’t realised quite how much my results bounced before I got the pump, when I see that picture I recognise the struggle between trying so hard to drive down the result and then taking my foot off the gas and seeing it bounce back up again. For over a year now I’ve had the feeling that my diabetes is reasonably settled. I still have bad days, random blood sugars, hypos, times when I forget to bolus and times when I’ve had enough of the whole thing, but they’re much rarer now.

The graph shows that I seem to have the tools and approach I need to have good control and quality of life. It took a lot of hard work to get it working for me, but what a difference the right tools make!

We Brits like to whinge about the NHS. It’s apparently inefficient with long waiting times and poor service. Yet despite its faults, I’m a fan. Why? Good or bad?

I’ve always been generally supportive of the concept of the NHS, but this support has grown over the last few years, partly driven by greater exposure to private healthcare systems through the internet. What really made me sit up and think was the realisation that in the current climate, I might be worried about my job security, but the issue of losing private healthcare coverage if I were to lose my job doesn’t feature on my agenda. Equally, I’ve never contemplated how I’m going to be able to afford my next bottle of insulin and I’ve never made healthcare choices based on what’s on special offer in the pharmacy.

In the UK we have the National Health Service. Free at the point of use, which is why I’ve never had the worries above. However, it is not, contrary to popular myth, free. In 2007 the NHS annual budget was £104 billion, which works out at a cost in tax of around £1,800 per person in the UK.

Many things infuriate me about the NHS. The fact that it takes over a week to type a letter and that healthcare for chronic conditions like diabetes is generally delivered 9-5, Mon-Fri (we still don’t seem to have worked out that patients have jobs too).

Another issue with a state run system is that it’s hard to find a clear motivator for overall improvement. Private providers drive for efficiency so that they can increase profits. The NHS doesn’t have profit, indeed if it doesn’t spend its allocated budget in a particular year it tends to be clawed back, meaning a huge drive to spend as the end of the financial year approaches. Good use of tax payers’ money? I think not.

So it has it’s faults (believe me, I could go on!), but as someone with a chronic condition I believe the concept of the NHS is a solid starting point from which we can improve.

I have the luxury of knowing that while I live in the UK, being able to afford basic life support like insulin will never be an issue for me. Most of the issues I have with the NHS I can fight to change. My own personal behaviour influences how people react to me, so I can manage their expectations . When I don’t feel I’m getting good care eg I want a pump and CGMS and can’t get one, I appeal. I work the system. I gather my facts and drive the organisation to consider my case, bringing in whoever I need to support my case, be that the Chief Exec, my MP or the press.

I admire the way a lot of American patients manage their healthcare providers like they’d manage any other supplier. In the UK, we don’t generally do this. There’s a perception that patients should be grateful for what care they get because it’s free (it’s not, its £1,800 a year, you’re paying for it!). Therefore many people don’t feel it’s appropriate to question or challenge the system. As customers, we’re not particularly demanding of the NHS.

I believe a change in the way patients act would help to improve the NHS. I treat my healthcare team like any other supplier I interact with – my bank, solicitor, electric company, car dealership etc. I try to build a good relationship whilst making my expectations clear. I provide constructive feedback – positive and negative so that they can improve. I’m conscious of my obligations – I turn up punctually to appointments armed with the relevant data. I act like an equal partner in the relationship but I have to admit, it takes a strong person to do it and it can be quite a battle to overcome a sometimes overpoweringly paternalistic approach!

But when it comes down to it, as someone with a chronic disease, I chose the cosy state owned option complete with all its faults. Why? Because I was gobsmacked when I read about people in one of the world’s richest countries, the good old US of A not knowing where their next bottle of insulin was coming from and having to balance the cost of diabetes medication against other essentials like food.

That, for me, is too great a price to pay. The NHS has many flaws but does react to pressure if push comes to shove and while we work to improve it, people are still receiving good basic healthcare. The NHS gets my vote.

The CGMS was screaming away at 3am this morning. It woke the husband first who then woke me to discover I was low.

I was in usual “I’m fine, honestly I’m not hypo” mode while husband was trying to force juice down my neck. Even I have to admit, he and the CGMS were right.

I have two comments on this episode. Firstly, this is the first middle of the night low I’ve had for ages, I haven’t had one since I started blogging and it must be over a month before that. Secondly, while husband was fighting with slightly incoherent wife it appears I shouted several times “I’ve lost my blog, I can’t find it”. I thought blogging was meant to help, not pray on my subconscious mind and cause hypos!

The interweb gets a bad name when it comes to health – you can’t trust it; the information on it isn’t checked; it’s dangerous to take health advice from people you’ve never met and whose qualifications you don’t know; and finally it’s full of nutters claiming you can cure diabetes by eating radish (for the record, you can’t).

I’m a sensible girl so why have I got myself mixed up with something so dangerous? A couple of years ago I read an article in a magazine (paper, remember that? It came before the interweb) about CGMS. It sounded interesting so I started digging around online. I did the vast majority of the research into my pump and CGMS online – from reading about the product, to understanding what the NHS criteria were for funding pumps. Then I used it to source the research that showed it works to support the business case I was wrote to get the NHS to fund it.

But it was when I got the pump that the interweb really came into its own. When I knew it was on its way I found a great insulin pump forum  in Canada full of people who use pumps. They recommended a good book to get me started (paper again, it’s not dead yet!). I bought the book online because wasn’t available in the UK, read it and by the time I went to my pump training I had a pretty good idea of what was going on.

I’ve never asked someone online how much insulin I should take or whether I should reduce my basal rate before I go to bed. But I have asked whether they find Special K breakfast cereal sends them through the roof for no good reason (answer, yes, and adding almonds to it helps slow it down because the fat slows the carbs down – genius).

I’ve also asked how I can wear my pump and go white water rafting (answer, buy an Aquapac  waterproof case for it – genius).

Without asking I’ve picked up some ideas on how I might deal with my dawn phenomenon and some tips on how to bolus for pizza. I’ve also learnt that lots of you use those little kiddie juice boxes to treat hypos – genius. How did I survive for 25 years without having them hidden under my bed?

But perhaps the most important thing I’ve learnt is that everybody has those days where you’ve done everything by the book but you’re a 16 for no reason and nothing you do will bring it down. Or those days where you seem to no longer need  insulin as you’re constantly hypo and nothing you do will get you above a 4. I’ve learnt that sometimes they just happen. Because it’s Tuesday. Because there’s a full moon and the wind is blowing from the east. Because that’s just diabetes for you. It’s nice to know I’m not alone.