Measure and improve – the technical jigsaw behind my blood glucose management

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Combining technologies in a neat arrangement to monitor blood glucose in near real time for better management strategies.

Most of my work revolves around business strategy, and so the words of Peter Drucker are never far in the background. Drucker is widely regarded as the father of modern business thinking, and it was he who coined the phrase that if you can’t measure it, you can’t improve it.

As a fundamental principle, I find it especially relevant as I work to get on top of my diabetes. I’ve been using Abbott’s Freestyle Libre for a couple of years now and it has been a revelation. It’s so much more convenient than the eight or more fingerpick tests each day, and it presents the graphical picture of blood glucose as it changes. That is a big step forward. Everything I say here relates to the original Libre sensor. Abbott are now pushing the Libre2 updated device but I have not yet transferred onto that.

I found that the available info from Libre prompted me into a discipline of scanning regularly and frequently, and that has helped me to appreciate the direction of travel as well as the absolute value of a blood glucose reading. The habit formed with the help of my Apple Watch which I had set up for the timer to buzz on my wrist every thirty minutes. Very discreet and a subtle prompt to use the iPhone app to scan the Libre.

 The screenshot shows that like investments, BG readings can fall as well as rise, and sometimes quite quickly which has big downsides. If I am working quietly at home, I will shorten the scan frequency to 20 minutes and I get a good insight from that. There are times, though, when that doesn’t work – like in business meetings where it is just inconvenient or disruptive, or on long car journeys where it is actually illegal.

Enter the next discovery – the MiaoMiao transmitter. This small device is about the same depth as the Libre sensor and with a suitable aftermarket strap can clip over the sensor. Not too bulky and once set up (that’s a whole new chapter yet to write) works pretty well. It works with a separate app on the iPhone, I use xDrip4iO5 but there are others that do a similar job on iOS or Android.

Best of all it can use a workaround to export the BG reading as a short calendar event, which is where the Apple Watch comes back into play. It creates a calendar event every five minutes and the event text can be set to shows the trend and numerical change from the last reading. In the image, it shows that four minutes ago BG was 5.4 mmol/l and had fallen 0.2 in the five minutes prior to that. That insight is priceless because if rapid change is happening particularly if BG is falling, then a quick response can prevent a hypo.

In the car, with the right technology, it gets even better. I drive a 2019 VW Golf (a brilliant piece of kit anyway) and with CarPlay I can see calendar items on the screen. As with the watch, every five minutes I can see my BG and if it is starting to move then I can do something about it. In this case I can see that a few minutes after the watch reading I am still fluctuating around the 5.5 level, and so in pretty good shape.

That has been the biggest single change in removing the guesswork on long journeys – before this I would often play safety first and eat snacks during the trip that would send me into high BG territory which takes a long time to correct with additional insulin once the journey is over.

It helps at work too – a quick glance at the watch and I know if I should grab a biscuit to go with the next coffee to keep me in range, or more likely to avoid the biscuit and avoid going into the high sugars territory. Similarly on a bike ride or canoe trip when putting in the physical effort and scanning every 20 or 30 minutes isn’t really practical, this is a real asset.

The engineer in me can’t resist interpreting the data and so I have learned so much more about how my body reacts to different situations, different foods, and how to have finer control over the condition.

This setup is a lash-up of different bits of gear and software, but it has really helped me get on top of things. I’m sure the manufacturers will develop and stitch things together in future product releases, but I’m really pleased in my own small way to experiment with this stuff and help to move the thinking forward.

 

Life after Libre – updated

I’ve been using Libre for around five months now and it is great. Convenience and frequency of testing and the insight into rising or falling sugars is a big step forward.  When Abbott had problems with distribution at the end of the year I didn’t imagine how much I had formed new routines around the scanning and how different it would feel without the sensor.

Back to finger-pricking then, and that of itself is a pain. Testing is much more involved than a casual swipe of the iPhone under and armpit but one gets used to that. Fewer tests a day and the static nature of each result leaven me less informed. The most telling difference of me is the awareness of control – the time in target statistic has become my go-to measure, and without the Libre’s continuous record it can’t be assessed.

Single point tests are ok at the time, but I found myself wanting to test again in 30 minutes to see where I was heading. The single most useful insight the Libre gave was into overnight profiles.  This helped me to know what was going on whilst sleeping, adjust evening sugar levels to get the best balance and avoid waking up with low sugars which had become a regular experience. It even prompted discussion with the specialists to change my basal insulin type for a slightly longer lasting alternative. The effects have been good so far and I feel better balanced and controlled, which would have been really tough on the intermittent finger-prick tests.

It’s only a week, but I miss the Libre already and hope that Abbot get their act together soon. It is a really useful part of my new regime.

Update – a few months after this post was originally published, there was a change of eligibility criteria in my area and after a long process of demonstrating high levels of finger-prick testing I was admitted to the prescribed programme. Since then I have been a continuous user and can’t imaging life without the better insight and awareness that the Libre system provides. 

More posts will follow as I reflect on how it goes and how it evolves.

Sweet times in America?

Travelling as a type 1 diabetic can throw a few extra variables into the mix. My last trip to the US really took me by surprise and will reset my plans for future visits.

Time zone shifts are tricky anyway, but with more frequent finger prick tests it is possible to manage more or less on an hour-by-hour basis. A previous trip during a trial of the Freestyle Libre was a revelation, but I’m not on the qualifying list yet so its back to the stabbing process.

The difference I found in America was the inaccuracy of my lifetime of carb counting. I made my standard estimates for a slice of bread, a bowl of fruit and yogurt, a burger with fries, a bottle of Sam Adams, and found my BG readings constantly high.

I typically take 40 to 50 units of Humalog a day and that covers 160 to 200 grams of carbs at an average BG of around 7 mmol/l. On my week in America I averaged 80 units a day. By my standard carb counting this was covering around 150 grams of carbs and yet my average BG was more than 13mmol/l. Something was out and it can only be the sugar content of what I was eating.

Throughout the week I was careful – no donuts, avoid the coffee creamer, moderate portions etc. It’s really tough to load the insulin doses when a lifetime of caution to minimise hypos has drummed in the opposite behaviours. 

I found that once the BG readings got high, it was very tough to get them back down. The two-hour effect time of Humalog led me to a strange world of scheduled testing and re-dosing, even through the night.

The only answer, I think, is experience. I may be doing more business in the States, so will need to travel there more often. Over time I will calibrate the body systems and the management processes and hope to find a better balance on future visits.

Which brings me back to the Libre – business travel doesn’t make finger pricking easy or convenient, and so the more constant monitoring offered by the Libre would be welcome. If only to hit rising sugars earlier and prevent rather than recover from high readings.

Some things just work

Ever had that itch where you know the ideal solution is out there somewhere but you can’t quite find it? I had this recently, and then, almost by chance, found it was beside me all the time. 

I travelled a lot this year and tried hard to find my ideal rig. I like backpacks for the freedom they give when walking through the airport. I have an overnight backpack that is a real favourite, but that can’t do the extended trips. I read articles and reviews and bought a highly recommended 35l Osprey backpack. It worked very well for a three-day run, but there was something just not quite right. It’s a big bag to manoeuvre if all you need is a charger on the bus. 

Another trip followed quickly, and I explored the wheelie/laptop bag combination. I looked at a few without getting inspired, and so with time pressing I went back to some old friends – an Antler wheelie bag has been a solid servant for nearly 20 years and is pretty much bullet-proof. I also use a Muji clamshell bag when heading into the city. In combination they sit together really well and with some unexpected little features.

The wheelie bag is 49 x 35 x 22 which sets it nicely inside the TSA limits and is also a fair bit smaller than many other “approved” bags. I was only slightly smug on a recent pass through Boston Logan on a packed domestic flight where bags were being pulled for gate-stowage. They waved me through.

The clamshell has an outside pocket to stash a magazine or other small stuff without unpacking the whole thing and the metal handles are just wider than the handle struts on the wheelie.

This means that one handle can slot through and “clip-in” the two bags so they are pretty solid as I walk the corridors. This is a really neat accidental feature that is so useful. I can detach the bag to have by my feet whilst the wheelie is in the locker. It takes up minimal room yet holds my iPad, notebook, meds, chargers etc, all close at hand. That means minimum fuss which is a travel stance I like a lot.

It’s simple things like that which appeal to me – and when stuff just works, I keep going back to it.

Multi-use gear – how many is enough?

I really like equipment that can do more than one thing as a way of reducing what I carry. I have always tried to travel as lightly as I could, but there is no escaping the need for gear that works well once you get there.

I can keep the clothing to a minimum with a few well chosen items. Colleagues lug a large overnight bag or bursting wheeled carry-on as I feel quietly smug about my lightweight backpack as we are sprinting for a connection.

Let’s park the whole business laptop thing for a moment. Right now the centre of my universe is the phone. Especially now I have started to use it as an e-reader.

I figured out years ago that books are bulky and awkward. The obvious Kindle alternate is a great reading experience – size, weight and screen are all well tuned. It’s just another piece of kit (plus another charger) at the security scanner. I like it a lot but just couldn’t persuade myself to add extra items.

The iPad worked well for many years with the Kindle app and became my book of choice. It is slightly bigger, slightly heavier and a bit more obvious on a crowded subway train. Almost but not quite brilliant.

Lately, I have been trying the iPhone 7 as an alternate. The Kindle app still works fine, it is compact in the hand and discreet when everyone is thumbing theirs on the subway. I also love the accessibility on a plane – I can grab it from my back pocket without having to climb up to the overhead locker. Not even the Kindle can do that. But it doesn’t have the paper-wight screen…..

Early signs are good. I’ll see how I go for a couple of trips on the super-light packing list that is now an iPhone 7, an iPad with remote desktop app (in lieu of the laptop) and a charger cable. Minimalism sounds great but can I make it work? Watch this space.