It's Getting Better: thoughts for World Diabetes Day 2020

November is Diabetes Awareness Month, and as happens every year in the first half of the month, leading up to World Diabetes Day on November 14th, there is a growing frenzy of activity and excitement in the online world of diabetes. This year, that online world is the only forum in which the diabetes community can interact to any extent, and so this frenzy and hyperactivity seem particularly intense. Moreover, we are approaching the centenary of the discovery of insulin therapy (January 11th 1922), so no doubt next year’s WDD celebrations will be even bigger and better, not least because we can all hope that celebrations will by then be back in the physical world, rather than the virtual one.

Amidst all the frenzy, it’s a good moment to ponder developments in the world of diabetes, in its treatment and care. In so doing it is impossible to avoid noting how much has changed in recent years, and difficult to avoid the conclusion that the pace of that change is accelerating.

My own thoughts at this time of the year are always shaped by the awareness that I am approaching another anniversary of my own diagnosis, my “diaversary”, which falls on December 19th, this year marking 23 years since I was joined for the second half of my journey through this world by my unwanted friend. Any reflections on what is going on in the diabetes world are necessarily shaped by thoughts on the passing of time, and the increasing longevity of my life with diabetes - I have lived around one third of my life, and more than half of my adult life, with diabetes.

So, in the words of the late, great David Bowie’s last big hit before his premature passing, Where are we now?

I find it very hard to resist being bullish in my response, not least given that healthcare in general is under unprecedented logistical and financial pressure from the global pandemic. In saying so, however, I must qualify it with the very significant caveat that my thoughts apply to those like me living in a prosperous country which provides free healthcare for all. I am painfully aware that any bullishness does not apply to much of the world, including parts of the world like the USA where the state’s prosperity should enable universal healthcare to be a reality. So the thoughts that follow are made in the full and somewhat guilt-ridden awareness of my own relative good fortune.

When I was diagnosed in 1997, diabetes care and therapy had already advanced significantly beyond what many of my friends who have lived with diabetes for far longer than me can remember. A good diabetes friend, of similar age to me but living with Type One since the age of 2, has lived from the days of testing by urine strips and injecting with large syringes, to nowadays using an insulin pump and a CGM. He keeps an impressive personal archive of some of the primitive-looking gadgetry that kept him alive in his early days.

My introduction to diabetes came when injection pens with pre-filled cartridges were fully established, and small electronic meters providing rapid and accurate figures on blood glucose level from a finger prick test had become the norm, albeit fairly recently. More importantly in some ways, I came in at a time when advances in insulin types were starting to give far greater flexibility by mirroring with increasing accuracy the workings of the pancreas. Within a year or two of my diagnosis, I had moved to the basal-bolus régime which is essentially the one that I follow to this day. So things were already pretty good for a Type One here in the UK, and I never at any time felt threatened by it; however, better days were to come!

I am in no doubt that the biggest technological advance in recent years has been the arrival of non-invasive blood glucose monitoring giving more than just a snapshot of levels, and giving it in such a way that it can be done unobtrusively, frequently and painlessly: I refer, of course, to low-cost continuous monitoring devices, and in particular to the FreeStyle Libre flash monitoring system. The advances in diabetes technology have been stunning, and are accelerating as they become cheaper in real terms: this mirrors the way that, in our everyday lives, we all now keep in our pockets a mini computer of infinitely greater power, capacity and capability than the lumbering desktop with its hefty CRT screen that sat on our desks back in 1997. 

Commercially available devices have in turn been the stimulus for creativity and amateur expertise which has enabled patients to drive progress towards closed loop systems, with the prospect of a widely available de-facto artificial pancreas now looking more achievable than the proverbial “ten years from now” cure.

Alongside medical technology, information and communication technology has also made an astounding difference to those of us living with diabetes. When I was diagnosed I felt very much “at the mercy” of diabetes, and therefore very reliant on the input of the doctors and nurses assigned to my care. 1997 was very much in the pre-internet age (I first went “online” in early 1998, and as such I was an early adopter of home computing at a time when the internet was seen by many as the province of nerds and teenagers). My knowledge of diabetes at diagnosis was minimal, and beyond what HCPs told me, my only source of information was the printed word in books and magazines. What a different world it is now, with our first port of call on a medical issue being, for better or worse, Dr Google. These days, a person newly diagnosed would be signposted to a vast amount of information, to websites, to YouTube videos, to blogs, to peer support groups and a whole lot more. The problem must be to decide which resource is good, which is bad and which is ugly.

However, I believe that an equally important change in recent years is not a matter of kit and technology, but rather a far less tangible change of attitude on the part of both those living with diabetes and those who care for them. The irony is that this, too, has been driven by technology. There are still some who decry the influence of the internet in general and social media in particular, but what strikes me in the context of diabetes is that people have used technology in a very human and personal way, and that it has built bridges and brought people together in a way that harnesses the best that technology has to offer with the best and simplest of human virtues: friendliness.

Back in 1997, I would never have believed how connected we were all destined to become. I would never have believed that I would be talking, during a global pandemic, to people all over the world in little boxes on my computer screen, or that I could be constantly conversing in real-time written messages with friends. These days, my best source of “breaking news” is my best diabuddy whom I only know because we both have diabetes and started talking about it on Twitter. When anything good or bad happens in the news, or in either of our lives, our first response is to message one another. Many other people with diabetes enjoy similar, relatively new, but close, friendships.

But it’s not just peer-to-peer: we in the UK are privileged to have an online diabetes community in which patients and healthcare professionals interact freely, safe in the knowledge that each has something equally important to bring to the relationship: lived experience on the part of the patient and clinical expertise on the part of the professional. I count myself blessed with the personal friendship of many HCPs whose initial connection to me was through the diabetes community.

The community has no leaders as such, but is led by many: I shall deliberately avoid mentioning names, but we all know that there are doctors, DSNs and pharmacists of national professional repute who freely share their expertise and time online, yet just as importantly they share their lives, their interests, their passions and much more from well beyond their professional lives. Likewise, we all know that there are people with diabetes - and parents of children with diabetes - who freely share the experience and know-how that comes from living with diabetes, yet also their own personalities, their lives, their passions and much more, again from well beyond their lives with diabetes. During the pandemic, we have seen individual initiatives, notably by the organisers of the weekly tweetchat, like Zoom quizzes and the Fantasy Football league, and also larger initiatives like the Art1st Project, run by a coalition of people with diabetes and healthcare professionals. What these have in common is that they are about the people, not the condition, and it is this generosity of spirit that has enabled the community to flourish despite the inevitable fragmentation that has resulted from its growth in numbers. Alongside the partnership between patients and HCPs, the diabetes charities, Diabetes UK, JDRF, and DRWF have also become part of the community, not least through the personal and personable engagement with patients by their staff and leaders.

The blend of timeless human virtues - kindness, sharing, listening - with technology has given us a world unrecognisable from that of only a decade or so ago. Spending so much time alone at home this year, as we have all been compelled to do, I have come quite close to feeling grateful to diabetes for giving me some of the best friends I have ever made. 

When we finally emerge into the post-Covid world - sooner rather than later, we hope - it will be in many ways different, but we can surely hope that the blend of technology-driven remote connectivity and the warm relationships that technology has help to foster will leave us with the best of both worlds.

I was going to entitle this post Where are we now, taken from that rather bleak but wonderful Bowie song referenced earlier, but given that the announcement of a breakthrough on a Covid-19 vaccine came after I had started writing it, but before I finished it, another song came into my head, and I prefer to leave that as my customary song title for this post: the uplifting 1969 classic by (Mama) Cass Elliot which speaks, I hope, of where we are heading in the pandemic, and in diabetes care: It’s Getting Better.

Happy World Diabetes Day, everyone! With thanks to all who are working so tirelessly to support people with diabetes.

People places and events from my world of Diabetes

Join Together: Why GBDoc is alive and well....and matters

This coming week, Saturday, March 7th to be precise, marks the 5th anniversary of the first significant #GBDoc social gathering of people with diabetes, held at the old headquarters of Boots the Chemist in Nottingham. The second one happened a year later, on Saturday February 27th 2016.

The Group photo from Day Two of #PWDC16

Organised by the then lead organiser of GBDoc, (the online community of people living with diabetes in the UK) this so-called “Un-Conference” was truly an iconic event for many people, myself included.

A session at #PWDC16 on diabetes and sport, led by Paul Swann

The 5th anniversary brings into sharp focus how much has changed over those five years. With so many of the current users of GBDoc being much newer to the group, and the majority of those who pioneered it back in the early days now seldom taking an active part, it is now harder to characterise such a large and diverse group of people as a “community”. The idea of gathering them all in one place for a meet-up is now fanciful, yet the demand for TAD tickets proves that there is a real appetite among people with diabetes to meet each other. 

Add to that the inevitable fragmentation that occurs in any group as it expands, the differences of motivation, the clashes of style and personality, and it is no surprise that some now consider the idea of an online-based community to have outlived its usefulness. This is, I think, mistaken, very unfair on those who are trying to keep its sense of entity (especially Paul Sandells and Julie Barcroft and their team who work so hard to promote and organise the weekly tweetchats), and very unfortunate for those who have yet to be diagnosed with diabetes, or to discover the benefits of associating with others living with the condition. More of that later.

First of all, a little history, which may be of interest to those who have discovered the hashtag #GBDoc or the tweetchats more recently:

Diabetes communities, and online diabetes chat are older than many might think: Local support groups have been around for years, and people with diabetes, and parents of children with diabetes, had been talking to each other online, sharing experiences and providing mutual support since the early days of social media. Closed Facebook groups existed, and forums (remember the term chatroom???) gave people a chance to ask and answer questions. 

However, GBDoc as a named and identifiable community was formed in 2012 by a gentleman diagnosed with Type One in middle age who was an enthusiast of social media and was seeking ideas and support for living well with diabetes. He chose Twitter because of its open access and simplicity and launched a weekly tweetchat on Wednesdays at 9pm, which quickly grew in popularity as more and more discovered it. It had a website, and its own Twitter account, which is still there, but dormant - @theGBDOC, and this community grew rapidly and was soon imitated in other countries. 

The gentleman concerned conducted the chats himself, became known to many and organised the two meet-ups, but unfortunately conflict and controversy arose between him and some members of the community over time. Without ever announcing it, he stepped aside from the de facto leadership of the community in July 2017 and has remained absent from social media ever since.

Nevertheless, the two real-life meet-ups that he organised, in March 2015 and February 2016, were outstandingly successful and life-changing for many - including me. I am far from alone in having made some very close and enduring friendships from those two events and the sense of togetherness from being in a room full of fellow diabetics for the first time was remarkable and unprecedented. 

Five years on, we should not just dismiss the old GBDoc like an ill-advised dalliance. It was wonderful for a while and many of us owe something of a “thank you” to the founder of GBDoc for the fact that we know each other.

The #GBDoc label was “rescued” in July 2017 by a small group of people who had been alerted to discontent and misgivings surrounding the founder. These people were trying to save the idea of an identifiable community yet without running it, and as the individual who offered publicly to reveal plans to save the tweetchat and the hashtag, I and the others were accused of trying to “take over”. It was a very uncomfortable time, and I was grateful for the many words of support that eventually came from well-wishers, especially when others involved revealed who they were. We set up the @GBDoctchost account as a result, and it is still used to this day.

So how is #GBDoc now? Why is it that many people - myself included - have drifted away from the tweetchats over time?

Well firstly and most simply, it’s that people move on. Stuff happens: relationships, babies, jobs - life! Moreover, many of us who live with diabetes spend more than enough time thinking about it without wanting to add a sometimes contrived and at times repetitive conversation at an artificially chosen time and place. I myself am often otherwise occupied on a Wednesday evening.

However, we MUST remember that this feeling is a product of time, and that there will always be people new to diabetes who might relish the chance to “chat” with others in a safe, supportive and accessible place, with no need to ask to “join” a group. So we mustn’t knock it just because we don’t have time or have become become bored with it.

Secondly and more contentiously, I think that some conflict and discontent is inevitable over time, often stemming from that most basic and universal of human instincts: jealousy. People don’t like leaders and some resent those who style themselves as advocates. They build them up, then knock them down. Yet a “community” cannot exist without a measure of leadership. A tweetchat needs an organiser, and just because somebody organises doesn’t necessarily mean that he or she is “taking over”. Unfortunately, that is how it is perceived.

Thirdly, there’s the question of sheer size. For my own part, I always start to feel ill at ease in any group that becomes too large and/or too noisy. So I find myself estranged from the idea of a “community”. I don’t actually like the word, because I resist being categorised and labelled. This is why what was rescued in July 2017 was just a hashtag, and it is when people start to regard it as something more than a hashtag that problems start. If an individual or group of individuals become too associated with a community, it assumes too much of their identity, and accusations of cliques inevitably follow. Twitter often looks like a clique, given the way that it can quickly become a private conversation between a few conducted in a public place. It often feels like you’re in a room on your own watching a group of others having fun and laughing loudly. Not their fault but that’s the way it can appear.

A growing community also inevitably becomes fragmented, and dominated by those who say most. Individual differences are inevitable, so it behoves everyone to ensure that they don't regard themselves as guardians of the truth or the “right” way to do anything. Unfortunately, Twitter gives a perfect platform for people to “speak” without thinking. Things that in the past would have been just a matter of self-contained annoyance or private amusement become a public proclamation, with an air of authority and permanence that comes from the strange hybrid of communication that it is - writing as if speaking.

What have I learned from GBDoc? Above all, I have been strongly reminded about difference. Same condition, 100s of ways of handling it:

There will be some who want to hang out with others on social media, but 1000s more who don’t.

There will be some who want to meet up socially with others living with diabetes, but 1000s more who don’t.

There will be some who welcome in the community all types of diabetes, some who don't. 

There will be some who want to be all “woe is me” about the burden of life with diabetes, and others who want to be all “no big deal” about it. 

There will be some who want to be humorous and witty about it, and others will not find it funny. 

There will be some who care passionately about language and terminology, and some who don't give a hoot. 

There will be some who want to embrace technology and push the boundaries of innovation, and others who want to keep it simple.

There will be some who welcome the presence of HCPs in the community, and some who want it as a safe place for patients only. 

I could go on.

I guess the thing about a diabetes community is that the very randomness of the condition means that as a group it is more diverse than other groups to which we might be attracted. Groups consisting of people with a common interest, hobby or profession will inevitably attract a certain “type”, whereas there is nothing that unifies those with diabetes except diabetes.

And as I am fond of saying, this is a major strength, but strengths are very often also weaknesses. A diverse community with 1000s of personalities, tastes, experiences and opinions is unusual and precious, yet also a potential tinderbox for conflict.

For that very reason, I shall continue to cherish #GBDoc, but avoid over-involvement in every discussion, avoid the temptation to opine about everything, and hope that others will do likewise.

Oh, and in keeping with my tradition (which some probably find really annoying) I need a song title for this post. How about Join Together, one of the Who’s later and lesser known songs, from 1972? Some pertinent words in there:

Do you really think I care

What you eat or what you wear?

Won't you join together with the band

There's a million ways to laugh

Ev'ry one's a path

Come on and join together with the band

You don't have to play

You can follow or lead the way

Oh won't you join together with the band

We don't know where we're going

But the season's right for knowing

Oh won't you join together with the band

It's the singer not the song

That makes the music move along

Oh won't you join together with the band

This is the biggest band you'll find

It's as deep as it is wide

Come on and join together with the band

A collage of Day One at #PWDC16 - courtesy of Nichola Davis

"Do the Right Thing" - Getting insulin injection technique right

Well, January is nearly gone, and this is my first new blog post of 2019. It’s been a busy time for me, and it promises to be a busy year, not least in the world of diabetes which has become such a big part of my life in retirement.

One of the things that has occupied some of my time and attention this month has been starting my role with the newly re-constituted @FIT4Diabetes Board, a group of healthcare professionals who work under that banner, supported by Medical Technology Company Becton Dickinson, to promote best practice in technique and safety for those receiving and administering insulin injections.

FIT Board Members

I was pleased, but frankly somewhat surprised and flattered, when I was asked late in 2018 to join the FIT Board as a patient representative. I am aware that I am one of the longstanding members of the online diabetes patient community, known directly or online to many fellow people living with the condition; I am also aware that I have been something of a minority voice in that community as one of those happily managing their condition by multiple daily injections rather than an insulin pump. The very nature and demographic of the online world gives a false impression of the ubiquity of pump and diabetes technology use.

Moreover, I am also very aware that I am no expert in diabetes, despite my 21 years of living well with it. Indeed, I have often said that I’m not really very interested in diabetes, nor do I have any great enthusiasm for clever technological solutions. I am very interested in people, and in doing my bit to support and contribute to the greater good, and so my participation in #GBDoc is based very much on an interest in the people with diabetes, rather than the condition per se.

However, having attended the first meeting of the FIT Board, I have realised that I do have something to contribute to this group and their work. At our meeting, we started with an illustrated presentation about best practice in injection technique: not the most comfortable viewing when sitting there as the only patient accompanied by three DSNs, two pharmacists and a GP! I watched with a mixture of amusement and embarrassment as one by one, my occasional or permanent bad habits in diabetes management were exposed:

Wash hands? X.

Change needle every time? X.

Rotate injection sites? X.

Prime the pen? X.

Wait ten seconds before withdrawing needle? X.

Dispose of used needle immediately in a sharps container? X.

OK, so some of these I am better with than others, but I doubt if many longstanding PWD could in all honesty tick every single one, every single time. My excuse? Well, it’s that life gets in the way! We’re often told that diabetes shouldn’t stop you leading a full and normal life, and I have certainly lived as full and as normal a life since diagnosis as before it.

However, “normal life” is often very busy: I think back to my hectic working days as a teacher, often in work from 7:30am until 6pm, with literally no break. Lunch was often snatched on the go, and dressed in a suit, with formal shirt and tie, eating in a crowded school canteen or grabbing a sandwich during a lunchtime meeting is not conducive to good injection technique. It’s hardly easy carefully to choose the right site, prime the pen, leave it in for 10 seconds etc. More likely grab the pen - untuck shirt under table - jab - pen back in pocket with top on over needle. And all that was until very recently (with the arrival of FreeStyle Libre) preceded by a messy finger prick test!

I am also very aware that discreet and hurried injecting is, rightly or wrongly, rather easier for a man than a woman: a dress and tights, still commonly a staple of formal dress for women in the workplace, gives no opportunity for easy, dignified exposure of a suitable injection site, and it is small wonder that many women with diabetes inject through tights – far from ideal, but a pragmatic compromise.

But does it matter?

Well, since my watching that awkward presentation at the FIT meeting, I have to say yes. Confession time: I have become very aware that the flabby bits above my waistline are not just a touch of middle-aged spread, but actually a textbook example of Lipohypertrophy, lumps under the skin caused by accumulation of fat cells at the site of insulin injections. Not life-threatening, far from the worst of the secondary issues which can arise from living with diabetes, but nevertheless  a very real and creeping threat to living well on insulin injections.

I wonder whose tum that is?? !!

Lipos develop because of poor site rotation over the years, and injecting into them significantly reduces the effectiveness of insulin, caused by irregular and incomplete absorption rates. Since that meeting two weeks ago, I have been carefully avoiding those over-used sites, and guess what? My insulin requirement has fallen, quite significantly!

I genuinely think that Lipohypertrophy is the Cinderella of diabetes issues. We PWD are all so bothered about avoiding hypos, dealing with the uncomfortable highs, pursuing elusive “flat lines”, over-reacting to the TMI that many of us now get from our Libres and CGMs, that we overlook the insidious damage that we are doing to our too-easy-to-reach tummies.

And judging by the responses to a quick Twitter poll that we did after the meeting, checking our injection sites and advising on injection technique are a frequently missing part of our consultations with HCPs in clinic.

Perhaps it’s time we all started to think rather more about injection technique, site rotation, size of needles etc. I spent the first 20 of my 21 years with diabetes using the 8mm needles that were the norm back in 1998, blissfully unaware that current thinking among experts is that 4mm are best for everyone, regardless of their BMI. And whilst my eyes are screened annually, my feet jabbed at every visit, questions asked about my “control”, my highs and lows, my erectile functioning, etc., nobody has ever asked about, let alone examined, my (frankly rather unattractive) midriff.

So please look out for tweets and posts from my wonderful colleagues on @FIT4Diabetes. They have been brilliant in not making me feel guilty about my own shortcomings in technique, but I have to say that, thanks to them, I’m going to try very hard to Do the Right Thing.

There you go, a title for this post  - from a song, as always: a classic from the heyday of Mick Hucknall’s Simply Red. Click on the title and enjoy a bit of 90s nostalgia, then sing it to yourself while you inject.

Patience.....or patients?

It's an old joke, based like many on the rich supply of homophones in the English language:

“You need patience to be a doctor” 😂😂😂

Or is it patients? Hahaha.

Well of course, you need both. A doctor with no patients would be rather pointless, whilst a doctor with no patience would be, well, unlikely to succeed.

But this post is about the role of patients in healthcare, specifically in respect of diabetes, as it's the area I know a bit about. Regular readers of my blog will know that all my posts have to have a song title, so please....have a little patience. Or maybe some patients?

I've noticed much discussion on the role of patients in diabetes care ever since I started using the informal diabetes peer support network known as GBDOC around 5 years ago. In diabetes, especially Type One diabetes, the role of the HCP is to teach the skills needed to live with the condition, then to leave it to us patients to get on with it. 

The skills and knowledge required are daunting and all-too-familiar to those of us who have had to learn them: calculating, checking, testing, guessing, and judging; handling and operating advanced, expensive pieces of kit; and above all self-administering constantly varying doses of an expensive and potentially lethal drug whilst continually monitoring its short and long term effects.

In the case of those diagnosed in childhood, this expertise is learned and practised by parents and carers, then handed over to the child, often at a fairly tender age, to allow them to live as normal a life as possible as a teenager. Is it any wonder that people with Type One are so often exceptionally resourceful, composed, capable, balanced and empathetic individuals?

People with diabetes, and parents of children with diabetes, are, in effect, experts in the condition. Now of course, that is to an extent true of any medical condition. If something affects you or your loved ones, you very quickly know all there is to know about it. Fifteen years ago, I and my family suddenly became very knowledgeable about embolization and stereotactic radiosurgery when my son suddenly presented with a previously undiagnosed life-threatening arteriovenus malformation. He owes his life to the NHS, a pioneering German radiologist at the Walton Centre in Liverpool and radiographers at the Hallamshire in Sheffield. Seven procedures on his brain virtually eliminated the risk of a fatal haemorrhage.

But there's a crucial difference: in my son's case, as in most other diseases and conditions, all we could do was stand and watch in awe and fear as the doctors, nurses and radiologists did their thing. The expertise was manifestly theirs, even if the unwanted knowledge was ours.

Whereas with diabetes, it's the patient (or parent) who is the expert. S/he administers the treatment, assesses its effects and adjusts it constantly according to a range of factors – and does so 24 hours a day, 365 days a year, for life. Input from HCPs is minimal compared to that of the patient.

Which is why - and I apologise if this sounds pompous - I was elated by a response I received when recently I was given the opportunity to speak to members of my local CCG in support of the widening of access to CGM, flash monitoring and insulin pumps on the NHS in my home area. I spoke about the life-changing benefits, both physical and mental, that I and many others have experienced from self-funded use of the FreeStyle Libre to help monitor blood glucose levels. At the close of the meeting, a senior member of the CCG, a GP with forty years experience in general practice, referred to my submission as that of an “expert patient” and urged his colleagues to take strong note of my input in reaching their forthcoming decisions on access to FreeStyle Libre sensors on prescription. I walked out of that meeting feeling valued, understood and supported, because a man whom I respect and consider to be an expert in medicine had acknowledged me to be an expert in my own very small way.

So therein, surely, lies an important way forward for diabetes care. Of course we require education and training by experts,  both initially and when necessary along the way, rather like a pilot learning to fly. But once we can fly – and most Type Ones are pretty good at that “flying” – we just need the appropriate support, checks and the latest equipment where feasible, and an acknowledgement that we know pretty well how to get safely through our days and nights of flying. Judgements and criticisms from those who - to extend the metaphor – know how to fly but have never actually flown, are most unhelpful.

As we enter Diabetes Week 2018, I am delighted to report a growing awareness of patient expertise and its role in diabetes care. A small but influential band of doctors - known as the #DocsOfGBDoc - and their DSN colleagues have engaged with the online patient community through #GBDoc chats both structured and unstructured in a spirit of cooperation, professional inquizitiveness and humility, to the extent that I and others consider them to be friends, and many users of the #gbdoc know them better than their own HCPs.

Of course HCPs should not feel compelled to interact informally with patients, especially their own patients. There is a place for professional distance and those HCPs who use social media such as GBDoc should be aware that eloquent, plausible  and forceful patients may not necessarily represent the majority and can become disproportionately influential at the expense of a more reticent minority.

However, I salute those HCPs who do engage with the patient community and thank them all for their friendship and support. Perhaps they could remind others that patience and patients both have a crucially important part to play in healthcare.

We Are(n't) Family

You know sometimes there are incidents whose significance doesn’t dawn on you until you reflect on them in a quiet place on your own some time later?

Well I had one of those this last Friday, April 27^th 2018.

I had enjoyed a lovely evening of food and chatter with three friends at a restaurant near Victoria Station in London. There was me, Ellie, Steph and Izzy. We had spent the evening eating, drinking and chatting - nay gossiping - and laughing, and the time had come to pay the bill. Cue further laughter and chit-chat as we tried to work out who had eaten and drunk what. Our waitress for the evening had done a good job in striking the balance between efficient service and friendly banter, without being too intrusive, but when we were about to leave she couldn’t resist the temptation to ask: what was the connection between the four of us?

I guess most groups in a restaurant on a Friday evening are easy to read - intimate couples, celebrating families, boisterous work colleagues - but she clearly couldn’t work us out. “Have a guess”, I said, and her unconvincing guesses included father and three daughters, a boss and his employees: both basically saying “old guy with young women” But she had to give up, and was then visibly struck when we said that we were just friends from different parts of the country who share a medical condition.

All very obvious really, but the more I think about it the more it serves as yet another reminder of what a precious thing the diabetes peer support network known as the #GBDOC is. To a muggle like that waitress, it is clearly puzzling to see the likes of me socialising with the likes of Ellie, Steph and Izzy. Whereas to us, it’s just, well, what we do.

And of course that was just the start of it. The four of us were gathering for a weekend centred around the third TADtalk event, a day-long meet-up of people with diabetes organised by an endocrinologist from Portsmouth who happens to believe - passionately - in the power of connectivity among those who share a condition and those who help them to live well with it.

I, and many others have written and spoken about the power of peer support before, so in that sense this post is repetition of, or at least a variation on, a familiar theme. However, every time I meet with my fellow diabetics in groups large or small, every time I exchange easy banter with them on Twitter, I am reminded just how precious this phenomenon has become to me and to many others.

I will not describe the TADtalk event in detail, as others have already done it better than I can in tweets, or for example in this post by the organiser, but I will just remind myself and others that I have the good fortune to be part of something very special. As I adjust to retirement from a long career in a people centred job in which I was surrounded and kept young at heart by some wonderful young people, I now find myself surrounded - often virtually, but sometimes literally – by dozens of friends who have nothing else in common other than a pesky, 24/7, potentially life threatening medical condition. We are young and not-so-young, female and male, rich and poor, shy and extrovert, gay and straight, black and white, religious and secular. In short, we are people. The thing about Type One diabetes is it does not discriminate. So neither do we.

And the point is really this: with most of these people, I hardly ever talk about diabetes these days. Of course if the need and occasion arises, they are a wonderful, wise and well-informed source of information and support about every aspect of living with diabetes. But above all, we are just friends who chat, laugh and cry together like friends do. Or perhaps more accurately, like families do. Because for me, that is how the GBDOC feels, and I make no apologies if this sounds cheesy in the afterglow of such a fun weekend. We are indeed an extended family, and like any family we sometimes fall out, we sometimes bicker, but in the end we know that blood sugar is thicker than water.

As Sister Sledge put it: We Are Family, and I for one am grateful that I have "got all my sisters, brothers, aunts, uncles, cousins and whoever with me."

This post comes with my thanks and greetings to all these #FacesOfGBDoc both those who were present last weekend and those who were unable to join in. Here they are - an update to this picture will be posted on Twitter when I have added all later additions to this picture:

Reflections of My Life: Growing old with Type One Diabetes

Reflections of My Life. This sounds a bit personal and heavy, but it doesn’t signify any particular change of mind-set.

It’s just that I’ve perhaps had more time for thinking in recent months, and together with a few unrelated events and changes in my life, it’s led to a blog post forming in my mind. As always, I’ve given it a title from a song, and this one is a real favourite of mine. It’s a track by Marmalade, a somewhat under-rated Scottish band who spanned the late 60s into early 70s with a series of songs that saw them grow from beginnings in fairly bland 60s “pop” into a versatile, musically and lyrically literate outfit. This one is a real gem from early 1970, a song as wistfully reflective as the title suggests.

So what’s this post all about? Well, I guess it’s about growing old, and in particular growing old with diabetes. And why now?

Well, I’ve been doing a lot of digging recently.

There’s been a lot of literal digging, as we have just moved into a new home with a very large, undeveloped garden. I’ve been out in all weathers, patiently and methodically creating two long, undulating borders along the sides of what was a rectangular lawn. It’s the sort of task I love. Easily defined, constructive and with a visible and measurable outcome, it gives me fresh air, exercise, stable blood sugar and lots of thinking time. I have also been delighted by the extent to which people on twitter have enjoyed following the progress of my work. Simple pleasures.

My Growing Border

Then there’s been some metaphorical digging as I make similarly slow but equally steady and rewarding progress indoors, uncovering the full extent of my family, past and present. I’ve been building a family tree on Ancestry for several years now, tracing back my own and my wife’s forebears, but a particular meet-up with cousins from two generations on my father’s side has led me to propose and organise a gathering to celebrate the centenary of my paternal grandparents’ wedding, in April 2019. This has re-connected me with 8 first cousins with whom I had been in minimal contact, and to hear about their lives and their families has been a great pleasure and also a reminder that we are all growing older together. I am, with the help of my cousins, planning quite a party.

So I was thinking about all this whilst digging away at my lawn, when at some point in recent days I saw this post from the wonderful @LisWarren, one of the many great friends that I’ve made in recent years though the online diabetes community:

With her 50+ years of living with Type One and tireless advocacy work, Lis is, along with @PeteDaviesType1 and @apatrickmooney a shining reminder to all of us that diabetes is no barrier to a long and healthy life, but she is right to draw attention to the fact that the very success of treatment and care for Type One diabetes since the discovery of insulin therapy in 1924 inevitably leads to there being a growing cohort of older people with Type One. The discredited epithet “juvenile” for Type One still persists enough to sometimes give the impression that it is a young peoples’ condition, which it of course isn’t. And therein lies a challenge for all of us who live with diabetes. We’re very good at self-care, but how good will be at it in old age?

My own “reflections of my life” in recent months inevitably include an awareness of the ageing process, and whilst I am not and never have been, one to dwell on doom and gloom, I nevertheless cannot help but wonder what it will be like to live with Type One at an advanced age.

My own parents both enjoyed good physical health and led active lives well into old age, but if one fear does haunt me it is that of succumbing to the Alzheimer’s Disease which turned my late mother, once a lively, witty and energetic schoolteacher, into first a grotesque caricature of her former self and then an unrecognisable and unrecognising shell of a human being, whose death at 85 in 2013 was a merciful release both for her and her family. I was not a blogger at the time of her decline and death, but it is a story that I may tell on here one day: to end up as utterly helpless and unaware in the final years of life as she did, and to become totally dependent upon others for diabetes management is a very sobering thought for me.

As I wrote in this recent post about technology and diabetes, I accept that I am too old to have any prospect of being cured of Type One, and I also accept that whilst the health of older people is much better than it was even in the recent past, I will over the years that I have left become weaker, frailer, more forgetful, less capable and so more dependent upon others.

But let this not end on a gloomy note. I am very well thank you, busy creating a garden, building a family tree, collecting and posting photos for daft #GBDOC collages and organising events for my family and others. And many of my friends, especially those in the diabetes community, are a lot younger than me. So I am a long way, I hope, from being “put out to grass”.

And at the risk of repeating the conclusion from that recent post, I have great faith in technology to help me both with my life in general and with diabetes management. I feel blessed to be young enough to have embraced the revolutionary changes in ICT that have swept through our lives over the past couple of decades. It is easy to think of smartphone addiction, social media and the like as a young peoples’ thing, but these gadgets and gizmos which we all love so much will be a massive boon in old age that my parents’ generation have in many cases missed out on. I imagine the care homes of the distant future being full of old folk, still sitting around on chairs as they do today, but all clutching a tablet or smartphone and fully engaged with and enjoying stuff like silly videos on You Tube, gifs and viral posts on social media. And hopefully, they will be a lot happier for it. Technology and old age certainly do mix.

For those with diabetes, is it too much to ask that access to technology - pumps, CGMs, closed loops and the like should perhaps be regarded less as “just for younger PWD” and more as a priority for those of more advanced years.

Now, back to the digging….

I'll be There for You

2017 has certainly been a significant year for me. Full retirement and a house move are pretty big events, so the year hasn’t exactly been quiet. Indeed I feel well and truly shaken out of any sense of drift or complacency, and grateful that I’ve been able to make these significant changes in my life at a time of my choosing, and with enough physical and mental energy to embrace them as new challenges rather than feeling “put out to grass”. I am certainly not daunted by having turned 60 - I have a nice sense of entering a new phase of life.

I never planned it this way, but I have to say that my relatively recent discovery of the online diabetes community has been a tremendous help in enabling me to feel re-invigorated and re-energised at this time of my life. I thought it appropriate to post some thoughts on this informal peer support community to mark a notable milestone in my life with Type One diabetes.

It’s twenty years on December 19th since I was diagnosed with the condition (an incorrect diagnosis of Type Two in the first instance - I've told that story here), shortly after the landmark birthday of 40 years. Of course that has to go down as a big negative in my life: developing an incurable, life-changing and potentially life-threatening medical condition at around the halfway point of a typical lifespan is not what anyone would choose for a happy and contented life.

Yet when I think about what I have done this past year alone, it is hard to avoid thinking that my life might now be rather dull without diabetes. I know that there are people out there who resent positivity about diabetes, so let me apologise to them, acknowledge how lucky I am to be able to live well with the condition, and ask that we accept that everyone has their own way of dealing with what happens to them. My own approach is, and always has been, to look for silver linings. And getting to know so many others who have, or live with people who have, diabetes has certainly been a silver lining for me. Some of the greetings I received from diabuddies via Twitter on my 60th birthday were wonderful, so thank you - you know who you are.

In 2017, diabetes has given me opportunities and experiences which have filled the potential void caused by retirement from a busy people-centred job: speaking engagements at #TADtalk2017, at the FreeStyle Libre factory, at the All-Party Parliamentary Group at Westminster and live on Breakfast TV would all have seemed like bizarre dreams a few years ago. And then there’s the real-world meet-ups: this year alone, I have spent lovely times in groups large or small in Oxford, Manchester, Amsterdam, Witney, Bakewell, London and Birmingham with friends from all over the UK and beyond, who were in all cases complete strangers until very recently. And most days I spend time on Twitter in conversation, sometimes serious, sometimes frivolous, with others all over world whose only connection with me is a shared medical condition. My horizons have expanded immeasurably thanks to an annoying and sometimes dangerous medical condition.

Yet it hasn’t been all sweetness and light. Wherever two or three gather together, they will disagree about something, and the diabetes community is no exception to that. It’s human nature, after all. The online community hasn’t been the happiest of places at times this year, and I have found myself the subject of some hostility, in particular over two issues:

Firstly, it became apparent in July that there was significant controversy and lack of confidence surrounding the so-called GBDOC and its founder and hitherto de facto leader. With trust in the brand and its weekly tweetchats severely eroded, I found myself as one of a well-meaning group of people who attempted to guide the community into a more collective and inclusive ownership, rather than being a mouthpiece for one individual. Although our moves were widely accepted, appreciated and recognised they nevertheless caused a degree of resentment in some quarters and unwarranted accusations of a “takeover”. 

Those who felt so threatened by this appeared not to acknowledge that nothing happens in a group large or small without someone taking the initiative, and that taking the initiative does not necessarily imply power grabbing or ego tripping. I hope that the continued existence of a warmly supportive GBDOC community and of weekly tweetchats under the community account @GBdocTChost led by volunteer hosts serves as powerful reassurance to those who feared a takeover. I would like publicly to thank in particular @Jules1315 @type1bri and  @Type1Adventures for their work in ensuring that this happened and continues to happen. Public-spirited, generous-minded and supportive individuals every one of them.

Then secondly came another source of controversy sparked by the decision in September by the NHS to add FreeStyle Libre sensors to the approved tariff for free availability on prescription. Although this development was the result of many months of hard work by groups and individuals, notably our very own NHS Sugar Doc @parthaskar, I was inevitably associated with the decision given my longstanding public endorsement of the Libre, my consequent attendance at events run by its manufacturers Abbott, my speaking to a parliamentary committee about it and my TV appearance on the day of the announcement. Understandably, I again felt the resentment of those unhappy with the decision, and even found myself and others accused, laughably, of “taking payment in little brown envelopes” from the manufacturers.

With some folks fearing that availability of the Libre on prescription would lead to reduced availability of CGM and other diabetes technology, or criticising the fact that Abbott have a monopoly on flash glucose monitoring, or unhappy that NHS availability was leading to delays in supplies for those still self-funding, and valid concerns arising with the use-by dates on sensors, it seemed for a while as if the funded availability of a new device which had been so very helpful to so many, including me, was the work of the Devil himself. And as so often in life, the quietly contented were drowned out by the noisily disgruntled, which must have been disheartening for those who had worked so hard to make it happen. The Libre, like insulin pumps, like CGM, is not for everyone, but at least we are moving towards a situation whereby it should be available to all, regardless of ability to pay. Had social media been around at the time, I am quite sure that some might have been equally angry about the first insulin pens, pumps and meters. Change of any kind is seldom universally welcomed.

Again, however, as time has passed and things settled down, more positive voices have come to the fore, and we reach the year’s end with the online diabetes community very much alive and well. My hope for 2018 and my next 20 years of living with diabetes is that people will come to accept that differences of opinion, factions and groupings are an inevitable part of any group of people. The wonderful thing about the GBDOC is that the very randomness of diabetes produces an online community which is by definition random (albeit including only those who use social media). So it would be a pretty odd, and frankly dull place if we all agreed about everything.

Other groups of which I am part consist of very differing people, some of whom I like a lot, some of whom I am indifferent to, and some of whom I disagree with. But that doesn’t mean I necessarily want or need to criticise those with whom I don't get on; indeed I have massive respect for those whose opinion differs from mine on all sorts of issues. In the real world, I just sit in a different part of the room from those with whom I differ significantly, and the GBDOC rightly consists of people who sit in different corners of the virtual room. I tend to “sit” with those who actually don't talk about diabetes that much. I just like having friends who “get it”, and I enjoy talking to them about other areas of mutual interest, with the comforting feeling that I am hanging out with folk who have such a big thing in common with me. It is a joy to me to share cat pictures or things like this year's #BaublesOfGBDoc with a group.

But we all use #gbdoc in different ways and rightly so: some talk enthusiastically on social media about pumps, ratios, doses, CGMs, closed loop systems etc, and I admire them for it and enjoy their enthusiasm and expertise.  But it’s not for me. Others use social media as an outlet for their woes and frustrations, and whilst I don't tend to do that, I do try to be a virtual shoulder to cry on and greatly value that opportunity. Some, including me, post images of their triumphs and I for one derive great pleasure from seeing other peoples' success. There's a word for it: confelicity. It saddens me when I read suggestions that to do this is selfish because it causes distress to others: nobody forces anyone to be on social media, and there’s always a mute button if others’ way of saying and doing things causes stress or offence.

When push comes to shove, we are all on the same side and it is a constant pleasure to me to see such a diverse group of people being a real source of company, friendship and support to others. It’s what friends do; as the theme song says I’ll be there for you. And I for one am glad that so many others are there for each other and for me. 

Here's to the next 20 years. 

GBDOC

In the past couple of days it has become clear that there are significant and serious concerns about the GBDOC, relating to questions about the financial and business affairs of the founder of the formalised community. This comes on top of unease about the crowdfunding appeal for the third PWD conference in August and unhappiness with some comments used by him on social media.

The gentleman concerned still has the opportunity to respond if he wishes to do so, and if he does, we should all look at what he says with an open mind. I am not alone in knowing little of the detail surrounding this situation, but it is clear that a large number of users of the online community have lost faith in its founder and de facto leader, and he has as yet failed to respond to concerns widely raised.

I write as a very committed participant in the community over the past four years or so, but I am well aware of others whose use of social media for peer support long predates mine, and indeed the existence of the GBDOC. I have no authority other than relative seniority of age and length of association, but I have been party to, indeed have instituted, much discussion on Twitter over the past 24 hours about the future of GBDOC.

I have been encouraged but not at all surprised by the depth of feeling and good sense that has been so apparent. It is clear that I am far from alone in my love for the community, and I am keen to play my part.

May I above all suggest that we be very wary of quick decisions and hasty judgements?

The community clearly has a life of its own regardless of any “owner” or social media account and of course hashtags belong to everyone and no one. As such the online community will flourish and prosper, but like any community it needs some sense of direction and a degree of centralisation or else it will fragment.

I hope that we can allow the tweetchats to happen more or less normally for the next two weeks. I understand that Ros (@Type1Adventures) and Bri (@type1Bri) had agreed to host the next two weeks and that should go ahead as planned. Ros and Bri are active, supportive stalwarts of the GBDOC who have both done great things for pwd in their local areas as well as online. I cannot think of better hosts.

They have both said that they will host under their own accounts using the #GBDOC hashtag, and having acknowledged the issues at the start of the hour, I think we should all chat as normal, if interested in the topics.

We could then, perhaps, have a separate chat about what to do next. The hashtag has been much discussed already, as has the idea of shared/rolling hosting, charity involvement etc. A poll might be worthwhile, but surely not until we've all had time to think.

The GBDOC is very precious to me, as I have said many times. It need not be complicated, controversial or divisive. It has flourished (unlike, for example, its French counterpart) because a lot of us talked about stuff other than diabetes and as a result became above all a group of friends. I have made some wonderful friends through this community – we just happen to have a medical condition in common. I hope it will stay that way.

Thank you all for your thoughts on this matter; please respond with your honest and considered thoughts if you wish to do so, but take your time.

Adrian Long 

Sa Jeunesse

Sa Jeunesse. Your youth. A French song title for this diabetes-themed post. It's a song wrtten and performed by that incomparable Franco-Armenian nonegenarian chanteur Charles Aznavour, a singer-songwriter sadly under-recognised in the English-speaking world. It's a eulogy of youth, and as such is a song tinged with melancholy about the passing of time: the title comes as the end of a refrain that exhorts young people to make the most of their youth while they can: Il faut boire jusqu'à l'ivresse sa jeunesse: drink up your youth until you're drunk on it. 

Not a bad piece of advice in my view, but I'm more inclined to say enjoy every part of your life, because in many ways, the best is yet to come as well as being in the past.

Aznavour is clearly troubled by the ageing process: some of his best known songs like Hier Encore and La Boheme express the nostalgic regrets of a middle aged man who wishes he was young again, and in so doing, he gives voice to feelings that we all experience to some extent. Where did our life go? It's a theme as old as time itself.

All this came to my mind recently when reading a blog by Amber, one of my gbdoc friends, called Diabetes is an invalid excuse, a cri de coeur from a young person suffering from diabetes burnout. In it, Amber makes reference to the fact that as a teenager she can't easily do what young people want to do - go out, party, stay out late, drink. This got me thinking about the differing burden of diabetes at different ages, an idea which has come into my mind a lot in recent years, as I have got to know so many fellow Type Ones who, unlike me, were diagnosed as children or teenagers. For them, it is very difficult to "drink of the fountain of youth".

I've said it before in blog posts: I feel lucky to have missed diabetes as a child, teenager or young adult, so I am no expert on life as a Type One at those ages. However, it seems to me self-evident that there are multiple extra issues with the condition for those who are diagnosed young. 

For very young children, of course, the issues are for the parents as much as the child. I shudder to think of the worry and heartache felt by parents having to deal with such a fickle condition, and in effect needing to act as the child's pancreas. I entirely understand why a prominent member of the GBDOC, parent of a T1D child, styles herself Understudy Pancreas, and I can well imagine the multiplied worry when a child starts school, or moves from primary to secondary. 

But let's not forget the child! How difficult it must be to be fussed over, to be told not to do this, or be careful when you do that. Childhood has become so risk-averse in modern times, but for the diabetic child there's a whole extra layer of risk, and it's a real risk as well.

Then there's teenagers. Imagine being landed with a condition that inhibits your freedom just at the time in your life when you want to start to express that freedom. Imagine the difficulty of taking over your own testing and insulin dosing after your parents had been doing it. Imagine the daft and often downright nasty things that get said at school to kids who inject themselves, prick their fingers and sometimes start acting strangely. Imagine the extra complications to sleepovers, sport, parties, trips and holidays. And all of this before we even mention the effect of growing up, puberty and hormones. All of it more fraught with complications for girls than boys.

Then for mid and later teens, the expected lifestyle is so fundamentally incompatible with diabetic life that I really feel for them. I wasn't exactly  wild in my Sixth Form and student days, but nevertheless enjoyed my fair share of late nights, missed meals and generally carefree spontaneity. If a young diabetic wants to enjoy drinking and clubbing, the hazards are self-evident. And goodness knows how awkward it must be explaining the injections, or worse still the pump and tubing, to someone on one of your first dates. "Don't touch me there.....you'll rip my tubing off!" "Take your hands off my...Libre!"

Even for younger adults, diabetes is no friend. Busy lives, building a career and setting up home all carry risks, and what about parenthood? I hear many a tale of sleepless nights with new babies made worse by diabetes. And let's not even mention the potential minefield of pregnancy. I so admire the women I know who have trodden that path with diabetes in tow...

I guess what I'm saying is that Type One diabetes is best suited to sedate middle age - which is the age I was when I got it. Through #GBDOC I have in recent years got to know many other Type Ones, nearly all younger than me and the majority of them female. Unsurprisingly, most of them seem to have a more difficult time with diabetes than I normally do, but then I'm a man in my fifties who leads a pretty sedate and largely predictable life. Type One, male and middle age are a good match  I think.

So I guess this post could be termed The Seven Ages of Diabetes. There are, I know, potential problems with every age, and I prefer not to think about my old age and diabetes (imagine becoming forgetful about injections....aaargh!). Perhaps I should just conclude by once again thanking all the Type Ones of every age whom I have got to know through #GBDOC, whose willingness to share their experiences of diabetes has taught me so much about the condition we all share. I salute each and every one of you, whatever your age.

Hi-Ho Silver Lining

Like an essay handed in at the last minute, here is my offering for #DBlogWeek.

It's been a busy week for me at work and at home, so not much time for blogging, but having been invited to a conference in Stockholm for diabetic bloggers, I would feel bad if I let the week designated for DBloggers pass by unmarked by me.

So here are a few, not very original, thoughts arising from my unexpected invitation from Abbott to a be part of a gathering of bloggers from across Europe in Sweden's Summer Night City at the start of June.

I put out a tweet this past week saying that the #GBDOC was "the silver lining of the cloud of diabetes". Unsurprisingly it got some likes and approving comments, which is hardly remarkable - flattery will get you anywhere!

But I do mean it. For about 16 of my 18 years with diabetes, my attitude to the condition was one of "just get on with it". I couldn't be bothered with it, to be honest, and so just did what was necessary to stay well and enable me to live my life much as I always had done. I was pretty successful in so doing, and therefore had no want or need for much support from others. I certainly wasn't very interested in talking about it and had no particular interest in meeting others with the condition.

Nobody, therefore, is more surprised than me to find myself now so involved in the wonderful online-based but very real world of the #GBDOC. Like most of its users, I am unclear how or even when I started to get involved, but I know that I am now a fairly prominent presence in a community of people united by their affliction with an ever-present, incurable, but ultimately manageable condition.

Through this community, I know that at almost any time of day or night, I can say something on Twitter and someone, somewhere will respond in a friendly and positive manner. And if I, or anybody else, tweets anything that remotely suggests unhappiness, discomfort or difficulty, it is certain that others will be quick to offer help, support, advice and good humour - and in saying that, I hope that I am as much a provider of that support as a recipient of it.

This, then, is indeed the silver lining to the cloud that threatens to block out the sun from our lives. I cannot now imagine life without such easy access to friendship and support, and I regard the #GBDOC as a great vindication of the often-maligned online world, in that those I have got to know through the filter of social media have invariably turned out to be just the same in real life as they are online. Many of us have met up in real life, notably at two successful national meet-ups of the #GBDOC, and of course in a couple of weeks' time I will be joining some whom I already know and others whom I don't at a European bloggers' event.

It is truly remarkable where diabetes and Twitter have taken me, and I cannot help but smile when I think that just because I chose to associate with a few fellow sufferers from diabetes, and to sing the praises of a new glucose monitoring device - the FreeStyleLibre - I am about to be flown to a country I have never visited before to meet with people I don't know, or I haven't known for long, to spend a couple of days talking about a condition that I spent sixteen years trying to ignore. 

Such are the serendipitous, and sometimes welcome, twists and turns of life, even at the age of nearly 60. Thanks to diabetes and the #GBDOC, my horizons have broadened, and I have new friends of all ages at a time in life when often the number of friends and contacts tends if anything to decrease. And all because I suffer from an annoying, very dangerous, ever-present and incurable medical condition. For me at least, the cloud of diabetes does indeed have a silver lining for which I am humbly grateful. Hi-ho, Silver Lining !