Go Your Own Way

 

I developed Type One Diabetes just over 26 years ago, in December 1997. I have often said that it was a good moment to join that “club that nobody wants to join” in terms both of my own age and circumstances (I was aged 40, married with three children, settled in life and work) and in terms of diabetes management and treatment (beyond the days of glass syringes, primitive inaccurate blood tests etc.)

Yet even since 1997, things have got markedly better, with the past decade or so having brought two significant advances: The first a quantum leap forward in technological support for those living with the condition; the second the growth of diabetes peer support communities linked by social media networks.

The advances in diabetes technology were neatly highlighted by the nice coincidence that my most recent “diaversary” just before Christmas (19^th December, marking 26 years of the condition) coincided with the final announcement of NICE guidelines about the use of closed loop technology for those in the UK living with Type One, the culmination of a remarkably quick process which started with the arrival of the first mass market non-invasive glucose monitor - the FreeStyle Libre - ten years earlier. Those of us living with Type One under the care of the NHS are indeed blessed with a level of support for our condition which is the envy of the world. The leadership and accessibility of Partha Kar has been instrumental in making this happen, however much he protests that he is “just doing his job”

The growth of peer support fuelled by social media connectivity shows no sign of slowing down, and has achieved a good deal, albeit that the sheer numbers involved mean that it has lost its early intimacy and has inevitably led to a degree of empire building and thinly disguised rivalry between individuals and groups.

These two advances mean that nobody can deny that here in the UK, people living with Type One are well served by the healthcare system and by the community of people living with the condition who are keen to share experiences, expertise and friendship.

And yet…

There is increasingly a nagging feeling in my mind that I’m being left behind, a feeling complicated by the sense that I’m actually perfectly happy to be left behind. What’s going on? It doesn't quite make sense, so permit me to explain.

Forgive the self-analysis here, but in general terms, I like to believe that I am fairly adaptable to changing times. Although I grew up in the pre-digital age, I have embraced that revolution with appreciation rather than the resentment and bewilderment which I often see in others of my own age, let alone those older than me. I do not eulogise the “good old days”, but rather I positively enjoy and greatly appreciate the comfort and convenience of the world in which I am growing old. I spend way too much of my life glued to my phone, like the overgrown kid that I am. I am fully “digitised”

I therefore had no hesitation in taking up Abbott's groundbreaking FreeStyle Libre at the earliest opportunity, and in subsequently embracing its evolution into a de facto CGM using my smartphone rather than the reader. Moreover, I was among those singing the praises of this device from its earliest days thanks to my early adoption of the online diabetes community which coalesced from around 2012 onwards. It was the diabetes community that first alerted me to these advances in technology, and it remains a source of great pride to me that I played a small but significant part in the campaign to get this life-changing technology onto the NHS prescription tariff in 2017.

However, I now find myself being left behind as others embrace pumping for insulin delivery and closed loop systems to automate this process to a good extent. I feel a bit like the man who bought a top-of the range VHS video player in the late 1980s and refused to embrace DVDs, or the man who bought a stack of DVDs and CDs in the 1990s and now refuses to subscribe to Spotify or Netflix.

I am, by nature, a creature of habit with little taste for adventure and no thirst for the unknown. The facts about me speak for themselves: I’ve been married to the same woman for 40+ years; lived in the same town for 36 years; taught in the same school for 36 years; banked with the same bank since I left university; I’m now driving my 6^th successive Mitsubishi; I’ve been with 02 since it was BT Cellnet, firmly wedded to Android rather than Apple, and I feel guilty and disloyal whenever I am eventually persuaded to change energy supplier in search of a cheaper deal. I am inertia personified in some respects.

Small wonder, then, that I am perfectly happy with “just” my insulin pens: I know what I like and I like what I know could have been coined to describe me.

I have therefore watched with interest rather than envy as the Type One world has gone closed loop crazy. Social media timelines are filled with posts testifying to the life-changing effect of what some term an “artificial pancreas”, with screenshots of flat overnight blood sugar lines or of Strava maps telling the world that its author has been on a run freed from the need to fret about its effect on sugar levels. To be honest, these have started to become something of a bore.

And here I sit, armed only with my FreeStyle Libre and my ageing insulin pens, with a time in range of around 75%, an Hba1c of around 50 and no enduring sense that my life has been ruined by diabetes. Do I want an insulin pump? Do I want it to be linked to a CGM to take over the management of my diabetes?

The truthful answer is “I’m not at all sure I can be bothered”. I’ve got better things to do with my life than to learn the ins and outs, the tips and tricks of a pump when my own tried and tested “hit and hope” methodology continues to serve me well. Yes, I get hypos and hypers, but armed with a Libre I can and do correct with micro doses or snacks in a manner which works well for a largely home-based retired life. If I were still working, I’m pretty sure that I might think rather differently.

However I do often wonder why, if all this automation is supposed to be so liberating, it appears to occupy so much of peoples’ time and energy. I never see any posts by people - still the majority - using MDI, and I sense that’s at least in part because many of them, like me, prefer to just inject and get on with their lives. My strategy for living with diabetes has always been to keep it in the background where it belongs.

So am I opposed to the continued rollout of technology? Absolutely not. I firmly believe in “each to their own”, and I am well aware that there are many for whom a more automated approach is a godsend. And they are NOT all youngsters – I know many PWD of my age and older who swear by the life-changing benefits of looping.

Will I continue to resist the use of a pump and an HCL? I don’t know – ask me again every few years!

Do I think there are other issues, at least as urgent, arguably more, that perhaps should get the same level of effort, publicity and indeed funding that have driven the “rise of the machines”?

I most certainly do.

I’ll pick out three:

Firstly, I'd like to see the spread of non-invasive glucose monitoring on prescription to those living with Type Two diabetes. The phrase knowledge is power is often applied in a healthcare context, and despite the recent progress in linking CGM to insulin delivery, I still believe that knowing BG levels and their predicted direction of travel, and knowing what the effects of different foods and levels of exercise have on blood sugar levels provides for many the key to better understanding of, and hence better self-management of all types of diabetes.

Secondly, I'd like a reform and standardisation of the education given to people with diabetes at or soon after diagnosis. Another over-used cliché springs to mind - “education, education, education”, and I have a strong sense that there is huge variation on the availability, timing and delivery of education, and that the DAFNE and DESMOND models, with their somewhat rigid teachings, have been allowed to dominate to the exclusion of more streamlined models better suited to this age of busy lives and flexible working hours.

Thirdly, I would love to see a real and sustained investment in the understanding and treatment of the hitherto under-reported psychological aspects of living with such a burdensome and stigmatising condition. The recent publication of the parliamentary report into disordered eating among those living with Type One shone a light on this scandalously neglected issue. This one is close to my heart, as my best friend is among those affected and among those most engaged in the calls for better understanding and more integrated care, but it struck me very strongly how many other names and faces familiar to me from the online communities have been to some extent living with this debilitating and dangerous add-on to Type One.

So there we are: the outlook for people with Type One is vastly better today here in the UK than it was even 25 years ago, let alone a century ago when insulin therapy changed Type One from a death sentence to a manageable burden. Yet this situation brings its own challenges at a time of ever-increasing demands upon the limited resources of any healthcare system, the NHS more than any. I hope that we can continue to roll out pumps and loops to all who need or indeed want them, but at the same time, I hope that we in the UK will also count our blessings and make sure that other deserving, and in many cases more urgent, calls on scarce funds can be met.

I close by reiterating what is often said, but is so important: Your diabetes, your way. There’s enough factionalism out there, and this post is absolutely NOT intended to criticise those who have shown such drive and enthusiasm for the advance of technology, be they patient advocates or healthcare professionals. These people have been truly heroic and have achieved unimaginable progress in a remarkably short time.

But we must remember that, just as in everyday life where not everybody wants a smartphone, a smart TV, state-of-the art satnav and suchlike, not everyone wants their diabetes to be managed by technology. How many programmes on your washing machine do you actually use? How many apps on your smart TV do you completely ignore? And do you never get irritated by the constant bleeps and warnings, the sheer information overload, given by modern cars? Technology is wonderful, but can be too much of a good thing for some.

It's the same with diabetes technology: an insulin pump with closed loop is not much help if you live with diabulimia.

I am not extreme on this, but I do hope that other urgent needs of the diabetes community will not be overlooked or underfunded amidst the scramble for diabetes tech. Despite what the hashtag says, diabetes tech can wait - for some of us.

As the song (and my title of this post) says, Go Your own Way - and I’ll go mine.