Blogging about medical results seems to be a flavour of the week at the moment amongst some of my co-bloggers and there also seem to be a fair number of people in the world googling my blog looking for Diabetes and DAFNE, so here goes, my turn....

It has now been 4 and a half months since I did a course on diabetes called DAFNE (Dose Adjustment For Normal Eating). It was the most concerted bit of diabetes training that I had done since 1976 (when I was diagnosed at the age of 12 and hospitalised for a bit more than a week).

Just before I started DAFNE I had an HbA1c test, which measured my average diabetes control over the previous three months.  My result was 7.0.

4.0 to 6.0 is a normal reference (non diabetic) reading.
6.1 to 7.0 is classed as very good.
7.1 to 8.0 is adequate.

Two days ago I had another test done and my result was.... pause for drum roll... 7.0.

Ahem. No change.

Hmm. On the face of it, five days of training in the DAFNE course and a whole new regime of diabetes management that leads to no change in HbA1c might seem disappointing. Certainly I would have been happy to have seen an improvement. (And it's definitely possible for me to get better results. My best ever reading was 6.6. The worst was 7.2.)

However, in defence of DAFNE (which I still think is one of the most worthwhile things I've done in relation to diabetes management), I can say the following:

  • I've quite consciously been following modified DAFNE control targets to avoid low blood sugars as much as possible. This is intended to ensure that I regain recognition of low blood sugar symptoms. This is working.
  • I've not had a single 'ga ga' hypo since I started DAFNE. (A 'ga ga' hypo is one with severe symptoms where it takes serious effort on my part or third party assistance for me to recover.) That's partly because of the slightly higher targets mentioned in the previous point, but substantially due to my much greater understanding of where my blood levels are - and where they are likely to go over the next four hours - that DAFNE has given me. Avoiding 'ga ga' hypos is a good thing. Even though I'm proposing some changes below, it's extremely important to me to keep this benefit.
  • The Standard Deviation (variation) of my readings has improved. Before DAFNE the Standard Deviation (fluctuation) of my glucose levels was 4.9. whereas when I checked it a few months into DAFNE, my SD was 3.1. My average reading may be relatively similar, but my highest readings these days is likely to be about 13, whereas in the past I would sometimes (every 2-4 weeks) get as high as 19 or more, and regularly (every couple of days) I'd find myself well over 16. It has now been two weeks since I last had a reading of 16. HbA1c tests are likely to miss this improvement.

The most valuable thing that DAFNE has given me is a good picture of the way food and insulin work over time. Whilst it's still true that on some days my blood glucose is unpredictable, it's normally true that I can picture the curve as meals and insulin injections interact. It's also clear to me that Novorapid (a fast acting insulin) acts over a four hour period, and Levemir (a long acting insulin) might peter out after 11 hours or so. (That's a lot less than Levemir's official 24 hour timescale, but the 'dawn' effect may be making it hard to judge this accurately.)

Going forward:
  • Even though 7.0 is officially counted as 'very good', it's only on the upper edge of that category, and I know I can do better.
  • If my blood glucose happens to be unexpectedly high, the DAFNE correction can be 'Stately as a Galleon' (a Joyce Grenfell reference): it can take four hours to get back to normal. I'm contemplating amending the standard DAFNE correction rules. During the day (when I'm awake), I'm thinking of ramping up the correction dose ratio a bit. This will likely lead to: a) a faster drop, coming back to normal in about 2 hours instead of 4, but then, at about the one-two hour mark, I'll need to take a cushioning small snack of 1-2 CPs to stop me going too low. The idea is to halve the amount of time spent with a high reading but still not veer into a hypo. I'll have to be extremely careful about this. I don't want to go back to the zig-zag, up and down pattern that my control showed pre-DAFNE. If I can't manage this properly, I'll revert to the DAFNE rules.
  • Now that I can watch the curve as food and insulin interact I can see that some foods have 'high loadings'. Essentially that means a high Glycaemic Index. Some foods send me through the roof in the 1-4 hours after a meal. Pure DAFNE (which doesn't really incorporate GI) says I can eat anything I want. I may go high after some or all of my meals, but DAFNE will eventually bring me back to normal. The high readings after meals are 'an unavoidable limitation of current insulins', and so you simply don't test during those peaks.

    I'm not going to accept that. I am going to take an interest in where my blood levels peak after meals and try to moderate the peaks. That will have some consequences. It will mean avoiding or reducing meals loaded with fast acting carbohydrates. I'm not going to be so drastic as to practically eliminate my carbohydrates altogether (although there are some people, with allergies etc. who make much more drastic changes to their diets). But I'm going to tweak things.

I've made some interesting discoveries about how certain foods raise my blood sugars:
  • A single OatBrit with milk seems OK. (That's probably unsurprising.)
  • A morning's worth of cappuccinos with occasional single blocks of chocolates will lift my level up. (That's probably unsurprising, although strictly speaking the number of carbos in the milk and chocolate isn't real high.)
  • The seafood salad provided by the Sushi store at the Knox Shopping Centre is notionally free of carbohydrates, but actually contains 2CPs (20g CHO).
  • Naan bread and Indian food with white rice is devastating. Pizza is worse.
  • But Singapore Noodles aren't so bad (roughly 4CPs - 40g CHO per take away box, and I don't rise above about 8 mmol/l blood sugar.

Over time I'm going to build up a better list of what sends me off the scale and set some limits: no more than half a piece of naan. No more than xx grams of white rice. Etc..

My next HbA1c reading will be in mid March, just before I visit my Endocrinologist. Given that an HbA1c covers a period of three months, it'll overlap this week's reading. But it would be tidy if my reading was as close as possible to my reading the last time I saw him: 6.6.

And one final comment: a repetition: even though my diabetes was considered to be well controlled, DAFNE was extremely valuable. Doing the course should be compulsory for people with Type 1 Diabetes.

Endeavour Replica, Melbourne
'Stately as a Galleon'. This isn't a galleon: they were bigger ships with several decks. This is the mast of the replica of the HMB Endeavour. It can probably turn around in less than four hours: but in bad weather it probably takes as long to turn this ship around as it takes DAFNE to turn around a high blood glucose reading.

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Anthony Holmes January 17th, 2008 08:38:50 PM

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