Thursday, April 29, 2010  

The weather was sunny and clear, and I decided I was ready to do a hilly outdoor run. My foot didn't bother me during the run. It didn't feel entirely normal, but it wasn't causing me pain. And I wasn't any slower than I usually am on that very difficult route.

Then I drove to the final concert rehearsal, in Vallejo -- and found that, although it was clear everywhere else, it was pouring rain in Vallejo. An isolated storm seemed to be hovering over the town, unwilling to move on. Driving toward that isolated storm at 6 PM, with the sun behind me, I was looking into a bright double rainbow. It was a nice touch, and (I thought) a good omen.

It wasn't an easy rehearsal. Rehearsals are tiring at the best of times, and this one had a lot of emotional intensity to it. Alasdair, our music director, has been in Scotland visiting Bob (his dad) in the hospital. At the start of the rehearsal, we got the bad news: Alasdair had just telephoned to say that Bob had died.

Bob had often played in our concerts before, and had been planning to play in this one. He was a well-known and well-loved member of our organization, so this was not easy news to hear. And, although Alasdair was adamant that we should go head and do the concerts without him (and was also adamant that Bob would have wanted the same thing), it wasn't easy to move on past that moment and start rehearsing numbers for the concert. After a moment of silence, we played Bob's signature tune (a march which Alasdair had written and named for him). That melody is so firmly associated with Bob now, we automatically start playing it if his name is mentioned. We've decided to add it to the concert program: we'll play it at the end, as a tribute to him. I think the plan is for us to march out of the theater, playing it as we go.

Playing his tune seemed to help us a lot in dealing with the news of his death. We were able to refocus our energy, and get on with the rehearsal. It was made clear to us that we would be letting down Bob, and Alasdair too, if we didn't proceed with the concerts and make them into a celebration. So, a celebration is what we will make of them.

This reminds me of a question I often ask myself: how do non-musicians stand it? I used to be a non-musician, and I certainly couldn't stand it, so I did something about the problem. But a lot of non-musicians never do anything about the problem. They show up at a party without any musical instrument, and the only thing they contribute to the evening is conversation. And when something dramatic and upsetting happens, they can't express their reaction to it in anything but words. Words which might not be up to the task. As Robert Schumann said, music doesn't express feelings that are too vague for words -- it expresses feelings that are too precise for words.

Well, from now through Sunday there will be not time for me to blog (or do anything else that isn't about the concerts). It will be an extraordinary experience, an intense experience, and it will leave me feeling pretty wiped out. But I wouldn't miss it. I wouldn't want to experience that kind of intensity every day, but I guess I need to experience it occasionally.

I'll try to be a good boy during the next 72 hours -- but it's going to be one long buffet between now and Sunday night. We'll see how well I cope with the temptations that will surround me.

Wednesday, April 28, 2010  

My foot was feeling better today, and I might have tried running outdoors if the weather looked more promising (there were repeated downpours). I went to the gym in the evening once again, but this time I ran on the treadmill instead of using the stair-climber, and it didn't bother my foot. If the weather clears tomorrow (and it's predicted to), I'll do an outdoor run. I won't be running very fast, I don't think, but that's not what matters. You have to think in the long term, when you're exercising for your health. You want to be able to keep on doing it. No point in running faster than your body is ready to handle, and turning yourself into a former runner. The world is full of former runners. A lot of them were fast, once.

On the PLoS website I found an article entitled "The Effect of Rural-to-Urban Migration on Obesity and Diabetes in India: A Cross-Sectional Study". The rapid economic transformation of India has resulted in a lot of relocation, and a lot of changes in lifestyle; the authors of the study were curious to see how this was reflected in medical statistics.

Generally, what they found was that people still living in rural areas were healthier than long-term urbanites or those who had recently migrated to an urban area. Here are the comparative statistics for obesity and diabetes (for men, although the figures for women are said to show a similar pattern):

Urban Migrant Rural
Obesity Rate 41.9% 37.8% 19.0%
Diabetes Rate 13.5% 14.3% 6.2%

For other data, there was a curious gender difference. Rural men had lower blood pressure, lipids, and fasting blood glucose than urban or migrant men -- but these figures were about the same for women regardless of where they lived. Nobody knows why. It seems odd that, among women, location should matter greatly in terms of obesity and diabetes, but not in terms of blood pressure, lipids, and fasting blood glucose.

The study did not attempt to determine what exactly it was about urban versus rural living that caused the rates of obesity and diabetes to be more than twice as high. I don't know what people in India start doing differently when they move to the city. Do they become less active? Do they start going to Pizza Hut instead of making curry at home? Do they eat what they were eating before, but more of it (simply because they have more money to spend)? It's hard to say.

The trouble with doing any kind of health study is that it can never be rigorously controlled. You can't raise people in cages, after all. Your knowledge of how they actually live can never be complete. 

There certainly does seem to be a trend, though, all over the world, for a period of urbanization and industrialization to be closely followed by a period of rising obesity and diabetes. Whatever it is that people start doing once they abandon their rural roots, it isn't especially good for them.

It's all about music, now. I'm taking the next two days off work, to concentrate on preparing for final rehearsal tomorrow and the first concert on Friday. I may blog tomorrow if I have time, but after that I'm going to be too wrapped up in the concerts until Monday. 

Tuesday, April 27, 2010  

Rainy weather today, so I figured I'd go to the gym instead of running. Also, I stubbed my toe on a rock during the trail-run on Sunday, and it's bruised up rather dramatically. It doesn't hurt me a tenth as much as you would imagine if you saw it. And I'm not showing you any pictures of it. (The truth? You can't HANDLE the truth!). But it's just as well if take a short break from running, and let it heal up a bit.

Chaos! My life is chaos! Well, my life is always chaos during the week leading up to our spring concerts, but it's been a lot worse than usual this time.

Our music director and star soloist, Alasdair Fraser, is in Scotland dealing with a family emergency, and it has become increasingly evident over the course of the past week that he would be unable to return to the U.S. in time to lead our concerts this weekend. I was initially very resistant to the idea of our going ahead and doing the concerts without him, because I didn't think it would be possible to find anyone who could take his place. I felt it would be my duty to participate in the concerts if they weren't canceled, and try to help make them work, but I was pessimistic about our chances of success, and I was getting very discouraged and depressed about the whole thing.

I finally started to see things in a more positive light this evening, when I received word that Alasdair had found a solution to our problem, by persuading the excellent fiddler Ryan McKasson to step in for him. The fact that he can handle the solos isn't even the most important part of the good news. The important part is that most of us have known Ryan for many years, and respect him, and like him. Alasdair couldn't have chosen a musician better qualified to lead us in a concert and make us feel comfortable about putting on a show under difficult circumstances. So, it's a big load off my mind. Now I can start to relax about the concerts, and invest the kind of energy into them that they require. I'm still going to be exhausted when we're done with the last concert on Sunday, but now I think I'll be exhausted and proud, not exhausted and embarassed. Big difference there! A concert is not like running a marathon, where you're proud of having got through it even if you turned in a lousy performance. A concert is either good or bad, and if it's bad, no excuse is adequate. But if Ryan is leading us, I don't think we'll need any excuses. It's a great relief.

Now I can go back to worrying about work, like normal people do.

Does saturated fat in the diet really cause heart disease? There are those who argue that this idea is merely dogma, accepted because "everyone knows" it's true, not because there is good evidence that it's true.

It's hard to tell whether the people who argue this are cranks or prophets, but I'm finding myself increasingly willing to consider the possibility that they're on to something.

However, I only said "possibility". It's mighty hard to arrive at any firm conclusion about the relationship between diet and health. If you compare the eating habits of one society versus the eating habits of another society, you get one answer; if you compare individuals within a single society you get a different answer. Which answer is right? I wish I knew.

My experience suggests that the cholesterol levels I see on my lab report are not strongly affected by how much or how little saturated fat I eat. The big factor seems to be how much exercise I'm getting, not how much cheese. But I don't really know, and over time my confusion only increases.

I guess that's why I focus so much on exercise. I know what it does for me, and doesn't do for me. With food you're never sure!

Monday, April 26, 2010  

Happy birthday from me...

I was out of town celebrating my 53rd this weekend. Although sipping good wine wasn't all I did, I have to admit that it played a role.

The weather over the weekend was decidedly summery -- even in San Francisco, not a town known for its summery weather. On Saturday morning the nicer neighborhoods were full of athletic activity. People really work out there -- and they don't necessarily need to go to a gym to do it. In that kind of terrain, a stroll through the neighborhood is more or less equivalent to a session on an aerobic machine. I saw more people running on these stairs than walking on them.

It's an interesting spectacle in San Francisco, all those people moving back and forth along the shoreline near the Presidio, with Alcatraz and the Golden Gate in the background, and no doubt whatsoever about which of these people are the locals, because their fitness level is so much higher. To buy a house in San Francisco, it isn't enough to meet the financial qualifications -- I believe you're legally required to look good in your running clothes, too.

I had a pretty active weekend (including a 9 mile trail run yesterday) so I decided to make today my rest day. I still went to yoga class in the evening, but that's body maintenance rather than exercise. It does have some value in terms of strength training, though.

An article in Medscape is entitled "A1c Levels: Is Lower Always Better?". The author, Gregory A. Nichols, summarizes a recent study which looked at long-term data on several thousand Type 2 patients who had either switched from oral medication to insulin, or from one oral medication to several. The patients were followed over a period of  years, until they either died or adopted a different treatment. The aim of the study was to determine whether reducing your A1c level below 7 does more harm than good, as some studies have suggested, or if lower really is better. What I find most interesting about the study is that it focused on death rates as an inarguable criterion of health. (Many studies look at a particular lab test and assume that you must be healthier if the results of that test have become more like normal readings.)

The study's results are rather murky and hard to summarize, but it appears that the risk of death was higher in insulin users who brought their A1c down to 6.4% than in those who only brought it down to 7.5%. This was not the case for those who weren't using insulin, however. Why this difference? Nobody knows. It is suspected, but not definitely known, that the explanation is higher risk of extreme hypoglycemia among insulin users. Naturally, the risk is highest in those who take insulin in greater amounts, so if hypoglycemia is what was increasing the risk of death, I guess it makes sense that the death risk was highest among those with lower A1c results. However, since the study did not collect data on rates of hypoglycemia (or even data on cause of death!), it's hard to say for sure if this explanation is right.

So, anyway, bringing down your A1c below 7 seems to be the safe thing to do if you're not taking insulin, but perhaps not the safe thing to do if you are.

I'm not sure I understand the point of a medical study which tracks the histories of several thousand diabetes patients (all the way to their graves, in some cases) and then can't tell you what they died from or whether they had a lot of trouble with hypoglycemia. So I'm not sure this study is as illuminating as it might be.

On the other hand, it does give some degree of support to the position I've been arguing for all along: it makes a difference how you bring down your A1c level. The question worth asking is not "Is it safe and useful to bring your A1c down?", but "What method of bringing your A1c down is safest and most useful?". Most studies of A1c reduction only compare one kind of drug therapy to another, as if nothing else worked. I'm sure it's worth knowing how different drugs compare with one another in this regard, but it would be worth a lot more to know how well people do when they use something other than drugs to bring their A1c levels down.

Thursday, April 22, 2010  

Sunny and beautiful today. It was a busy day, and fitting in my lunchtime run wasn't easy, but I'm glad I managed it.

Just got back (mighty late) from another concert rehearsal. Our music director, Alasdair Fraser, was supposed to be there to lead the rehearsal, but he was detained in Scotland -- and not just because that Icelandic volcano shut down the airspace in Northern Europe. He is there visiting his father, Bob Fraser (also known as Bob the Bass). Bob usually comes to California to participate in our spring concerts, but last week he fell prey to an infection serious enough to hospitalize him. Ours being an extremely resourceful (and technically savvy) musical community, we managed to have Alasdair lead the rehearsal anyway, by means of video-conferencing over the internet. Obviously it is not the ideal way to lead a rehearsal of a large and complicated musical ensemble, but it worked better than you would think. It was a rather amazing experience to do this -- with us playing in an auditorium in Vallejo, California, and him listening to us from his father's house in Stirling. He couldn't hear every nuance of what we were doing, but we certainly didn't seem to be able to get away with much. The musical sins he called us on (such as smoothing over the rhythmic "snaps" without which Scottish music doesn't sound Scottish) were exactly the same things he would have corrected if he had been there in person. If we felt fatigued by the time the rehearsal was winding down, around 10 PM, we couldn't feel too sorry for ourselves when we looked at the screen and saw Alasdair, with the window over his shoulder starting to glow blue with the light of dawn. What a surreal experience the whole evening was!

Alasdair's wife was at the rehearsal, and videotaped us all sending get-well wishes to Bob Fraser -- and playing his theme song (a march written for him by Alasdair, which we all knew because we played it in a concert a couple of years ago). She's planning to post the video on YouTube, so that Alasdair can take a laptop in to show it to Bob in the hospital. We're hoping that will help him pull through.

These days we tend to think of technology as doing more to separate people than to bring them together. Tonight it didn't seem that way.

Oh dear: more problems associated with diabetes drugs! An article in Medscape discusses a serious side-effect of metformin which apparently hasn't received as much attention as it ought to.

The meformin side-effects which people tend to worry about are lactic acidosis and gastrointestinal distress. We are told that people shouldn't make such a big fuss about either of these problems. Lactic acidosis is extremely rare as a side-effect of metformin, if the drug is properly used. Of course, if it does happen, lactic acidosis stands a pretty good chance of killing you. That tends to make people worry about it. But the risk of anything like that happening is comfortingly low.

You certainly can't say that the risk of digestive distress is low if you take metformin; that's why sourpusses like me tend to complain that going to the pharmacy to get a prescription filled for metformin is like "buying diarrhea". But this problem can be mitigated (especially if you slowly build up the dosage and give your body time to get used to it). Just how much mitigation is enough... well, it seems to me that that's a personal decision. Maybe we all have our own concept of how much diarrhea is too much, and I just happen to be hypersensitive on that particular issue. (To be fair, some people who take metformin experience little or no gastrointestinal trouble as a result. For some people, it's just not a signficant issue.)

But then there's another problem with metformin, which is both very serious and not especially rare. Taking metformin prevents  absorption of vitamin B12, and leads to a deficiency of that vitamin in about 30% of the people who take metformin regularly over a period of many years (and of course many people with Type 2 do exactly that).

Because the body is able to store up a supply of vitamin B12 for a long period, any change in diet or medication which results in deficient intake of the vitamin will not manifest itself as a deficiency disease for a long time. But, of course, people typically take meformin for a long time, and during the years they are taking it, their stored supply of vitamin B12 may eventually run out.

Here's where it gets interesting: the reason that vitamin B12 is regarded as extremely important is that, if you run out of it, this results in nerve damage. And the nerve damage produces symptoms which can easily be mistaken for diabetic neuropathy! Because the problem is misdiagnosed, the B12 deficiency is never really addressed, and the nerve damage is allowed to get worse. (Unfortunately, nerve damage tends not to heal -- the most you can usually hope for is to stop it from getting any worse.)

Now there's an ugly irony: millions of people are taking a diabetes drug which (over the long haul) causes a serious health problem which everyone assumes is caused by their diabetes and not by the medication they're taking for it.

No, I'm not saying that nobody should take metformin. But problems like this remind us that altering our body chemistry by taking pills often produces unintended and possibly dangerous consequences. That approach shouldn't be the only one we are willing to try.

Don't expect to be blogging tomorrow -- I've just got too much going on!

Wednesday, April 21, 2010  

More good luck with weather! It was raining this morning, but it stopped before it was time to go running. I even saw my shadow a few times.

An article published in Medscape today reports that all the extra sugar that is being pumped into our food lately is not having a good effect on our health. A study that looked at the eating habits of more than 6,000 American adults has found that people are eating much more "added sugar" than they used to. The added sugar consists mainly of HFCS ("high-fructose corn syrup"), a factory product which is created through chemical modification of corn starch -- and is added generously to just about every commercial food you can think of. It is manufactured in plants such as this one in Cedar Rapids, and transported around the country in tanker trucks.

And where are those trucks taking it? To just about any company that makes the food you buy in grocery stores and chain restaurants. HFCS doesn't just go into soft drinks. It's in ketchup, corn flakes, stuffing mix, crackers, cough syrup, salad dressings, soups, lunch meats, and also in such rather surprising places as "Sara Lee Heart Healthy Whole Grain Bread".

So much sugar is being slipped into the American diet in this way that "added sugar" now accounts for about 15% of our total calorie consumption.

One result of the increase in added sugar is simply an increase in daily calorie intake -- which may be all the explanation we need for the steady increase in average body weight that has been taking place in recent years. But the study found that obesity is not the only health issue that becomes more common as people consume more added sugar. People who eat more of this added sugar also have higher triglyceride levels and lower HDL ("good cholesterol") levels. Considering that high TG levels and low HDL levels are classic makers of metabolic syndrome and cardiovascular disease, it seems clear that the mania for sweetening the food supply is having a harmful effect on public health.

I'm sure the food industry would claim that they are merely giving the public what it wants -- if unhealthy amounts of HFCS are being ingested daily, blame the consumers, not the poor innocent corporations that provide the stuff! This way of looking at it might be easier to take seriously if HFCS were mainly being sold as an independent product, and consumers were coming home from the grocery store with a bottle of HFCS as routinely as they bring home a carton of milk. But that's not how it works. HFCS doesn't get into the American diet because consumers are drizzling it onto their hamburgers. People don't set out to buy HFCS, and in fact they usually have no idea how much of it they are consuming. It wouldn't occur to them to suspect that there might be HFCS added to a loaf of bread, or to a bag of dried fruit. (If it seems to you that your weight has become harder to control over time, even though you are eating the same kind of foods you always did -- perhaps the reason is that those foods only look the same!)

Let's call a spade a spade. The industry is sneaking HFCS into the food supply. And that kind of activity does not come under the innocent label of "giving the public what it wants" -- especially when that part of the public which knows it doesn't want HFCS has a hard time avoiding the stuff.

Hmmm. Here's a woman walking on "DigiLegs":

I don't know who invented DigiLegs or why, but YouTube has several videos of people walking on them. I'm sure it would be easy enough to find out more about these things -- but I'm not going to. Sometimes I feel that YouTube videos should be appreciated in the same way as bel canto operas or the films of David Lynch. That is, full comprehension is neither necessary nor desirable.

I guess somebody was just giving the public what it wants.

Tuesday, April 20, 2010  

Volatile weather today! During the luncthime run today we experienced a little of everything -- light rain at first, then scattered clouds, then heavy clouds and a cold wind, then warm sunshine. It was as if a week had passed while we were running four miles. And after we were finished running, and safely back indoors: very heavy rain, with episodes of hail. So we really lucked out, to go running when we did.

Today is Hitler's birthday -- a beautiful opportunity for everyone else whose birthday it is (Ryan O'Neal, for example) to think about how seriously we ought to take astrology.

If today is your birthday, the stars think you should spend some time working on impulse control. Look deeply into your own heart, and you will find that you don't really need to invade Poland, you just want to. I myself decided today that I was not going to invade Poland, and look how much my blood pressure came down! (But my birthday isn't for a few more days, and perhaps that is why it was such an easy decision for me.)

I wish I had something more insightful and diabetes-relevant to share with you today, but I'm short of time and I've got a bunch of concert tunes to practice before bed. (I wonder how people who don't sign themselves up for blogging and concerts spend all that free time they must have?)

Monday, April 19, 2010  

Ever since the volcano in Iceland shut down European airspace last week, I have been wondering why the volcano in Iceland keeps being referred to, in every news report, as "the volcano in Iceland". I thought: come on, guys! Doesn't it have a name, for heaven's sake? If it has a name, why not use it?

Today I found out that it does have a name: Mt. Eyjafjallajokull.


A cloudy cool day today, with storms predicted for tomorrow. But yesterday the weather was really stunning.  

Not only sunny, but warm -- in the high 70s.

And a lot of wildflowers blooming.

Pretty much everyone who was capable of movement (even if it was wheelchair-assisted movement) was outdoors enjoying the sunshine.

I was out there with them, of course, but I also spent a fair amount of time in the great indoors, getting myself ready for the spring concerts -- which are now twelve days away. I've used a highlighter to mark the passages that I'm still having trouble remembering correctly, and I am repeating them endlessly, drilling them into my head. In less than two weeks they need to come very naturally to me. I won't have any sheet music on stage.

In a way it's silly to invest this much effort in mastering a music program which I am going to do in three concerts over one weekend, and then be done with it. Well, it's a peak experience; that makes it worth doing. We need peak experiences once in a while. It's not good for us to go through the whole year without doing something that we're afraid we can't accomplish. That's why marathons were invented, for example. (Although I suppose I shouldn't talk, as I'm not planning to do a marathon this year.)

Remember that pivotal scene in The Godfather, when Michael Corleone, the good boy in the family up to that point, suddenly presents his brothers with a plan for assassinating a New York police captain? When they tell him that this sort of thing just isn't done, he explains his view of the matter: "Where does it say that you can't kill a cop? Tom, wait a minute, I'm talking about a cop that's mixed up in drugs... I'm talking about a dishonest cop... Now, a crooked cop who got mixed up in the rackets and got what was coming to him -- that's a terrific story. And we have newspaper people on the payroll, don't we Tom? They might like a story like that."

No arguing with that. Newspaper people have always liked a story like that, and always will -- mainly because everybody likes a story like that.

Under most circumstances, we don't like to think about death or any other misfortune which might befall us -- but it become positively enjoyable to hear about the death or misfortune of someone we've heard of but don't know personally, especially when it makes "a terrific story". And, as Michael Corleone recognized, what makes a tragic story terrific is the impression that somebody's downfall is an example of poetic justice rather than bad luck. We like to think that people got what was coming to them -- that, if they met a bad end, it was because they were asking for it. By re-imagining the world as a place where everything happens for a reason, we give ourselves the comfort of knowing that nothing very bad will happen to us -- because, as everyone knows, we haven't got it coming to us.

You really can't apply this interpretation to the misfortunes of people you actually know (trust me: your friend who has just lost a job, a spouse, or a leg does not want to hear you tell them that everything happens for a reason). It is from strangers that we must receive this kind of consolation. Celebrity strangers, usually, but whole classes of people we know almost nothing about can serve the purpose also. If something bad is happening to them, and we can tell ourselves that they had it coming, we couldn't be more pleased. And we really don't care if the story is true or not -- a "terrific" story need not be a true one, and in fact many of the best ones are pure fiction.

Take, for example, the oft-told tale about Mama Cass and the ham sandwich.  In 1974 Cass Elliot, who had sung with the "Mamas and the Papas" during the 1960s, was pursuing a solo career, with considerable success. Having just performed the last in a series of sold-out shows at the London Palladium, she returned to the Mayfair appartment she was borrowing from Harry Nilsson, went to bed, and died in her sleep from a heart attack. (The autopsy showed clearly that a heart attack had been the cause.) However, before any medical evidence had actually been looked at, a reporter was able to persuade someone in the police department to speculate about what the cause of death might have been. He said that a half-eaten sandwich had been found in the apartment, so perhaps she had choked on that.

By the time the autopsy showed that that there was no food lodged in the singer's throat (it wasn't her trachea that was blocked, it was her coronary arteries), the rumor that she had choked on a sandwich had already been heard by pretty much everyone on the planet. It was joked about quite a lot, then and later, and it became solidified in the popular imagination as a fact. To this day, if you ask almost anyone what they know about Cass Elliot, they will tell you that she was a pop singer in the 60s who was really fat and died choking on a ham sandwich. (The insistence on the sandwich being specifically a ham sandwich seems to have been the result of people trying to make the original rumor sound funnier -- a ham sandwich, get it, oink oink?)

Now, I realize that 32-year-old women don't die of heart attacks very often, and it's quite possible that Cass Elliot's weight (or some other aspect of her lifestyle) was a contributing factor in her death. But that's not good enough for us, is it? We want a terrific story. We want to think of her choking on a ham sandwich. We want her to be summed up in the headline "Fat Singer Dies As She Had Lived -- Stuffing Her Face Like A Greedy Pig!".

I understand why people have this feeling, but I don't think it's a healthy feeling, and I think maybe we should resist the impulse. When bad things happen to us, we don't want people to say we had it coming, so we ought to exercise a little restraint in jumping to the same conclusion about others. Admittedly, there are a few famous people whose future calamities I expect to enjoy -- because they are really bad people for whom no misfortune could be undeserved. But if we are inclined to say "they had it coming" about pretty much everybody, we ought to dial it back just a trifle. Before we say that someone who died at 32 got what was coming to them, we'd better be able to accuse them of something more serious than having been fat!

Friday, April 16, 2010  

More beautiful weather; sunny and in the high 60s. I'm not sure why I had such low blood pressure in the evening; probably because this happened to be a low-stress day at work.

I had a nice run at lunchtime, but the need to clean my contact lenses repeatedly afterward served as a reminder that I ran out of Claritin a couple of days ago, and haven't had time to get to the drugstore and buy some more.  Must do that tomorrow!

If you have spring allergies, there's something you need to know about Claritin: you can't take it on an ad hoc basis (like popping aspirin only when you have a headache). Claritin needs to build up in your bloodstream, so you have to keep taking one of them each day, and continue taking them daily for as long as your allergy season lasts. If you're not taking Claritin this way, don't bother taking it at all.

My own allergy season doesn't really hit its peak until the end of this month, but I need to be gearing up for it. Especially as the peak will coincide with the concerts coming up; I don't want to be having allergy problems while I'm trying to concentrate on playing.

Although Claritin (actually Loratadine, the generic name under which you can buy it cheaper) doesn't provide anything in the way of prompt temporary relief, it does have one huge advantage over most allergy medications: it doesn't put you to sleep. Give me a Benadryl capsule, and you might as well put me on a stretcher.

Here's something most of us assume is true, and apparently isn't: that reducing the prevalence of smoking and obesity in our society would result in lower overall health care costs to society at large.

Special taxes have long been imposed on tobacco, and this has always been justified by the assumption that tobacco users run up higher health-care costs than other people, and ought to be taxed more heavily than other people for that reason. From time to time, proposals are made for similar taxes on snacks and fast-food restaurant meals. If, in the long run, society must pay the price for people's bad health habits, society ought to be reimbursed by those who are refusing to give those habits up. It's only fair, right?

Well, maybe not. Studies of the issue have tended to find that smokers and obese people do indeed tend to develop serious chronic diseases and die young. But that's the point: they die young. Caring for their health problems is expensive in the short term, but once they die the expenses stop. Compare that to what might happen if they avoid those chronic diseases! If they live right, maybe they'ill hit their 80s without developing diabetes or any kind of serious cardiovascular trouble. What then? Maybe they'll hang around for years, developing some kind of serious dementia, and needing to be institutionalized. Unless they're rich, society is probably going to pick up the tab for that. And it's probably going to be a bigger tab than they would have run up as lung cancer patients or diabetes patients earlier in life.

I hate the idea that it's in society's best interests to encourage people to lead unhealthy lives, so that they'll never live long enough to develop Alzheimer's. And anyway, it could be that having an unhealthy population costs us in ways which we don't yet know how to account for. I find it a little hard to believe (or at least distasteful to believe) that society comes out ahead on the deal if most of its middle-aged members are in a state of physical decline.

Perhaps I'm influenced more by emotion more than logic here, but I hope someone will find a way to show that society doesn't benefit from the ill-health of its population. The idea is so repulsive that I'd very much like to see it disproved.

Thursday, April 15, 2010  

Nice running weather today, but I had to run alone at lunchtime. My running buddies at work were both here today, for the first time in weeks, but they were also both stuck in meetings at lunchtime. I'm usually pretty lucky that way -- the meetings I have to attend generally happen early in the morning, so that people I'm working with in Scotland and China can join in by phone (it's the best time-zone compromise with California).

Today my two big challenges happened after work. First, I had to get to to the concert rehearsal on time tonight (in Vallejo, unfortunately -- not an easy commute from where I live and work). And then, when I got to the rehearsal, I had to play from memory all through it.

Strictly speaking, I didn't have to do play from memory tonight (although a lot of people at the rehearsal tried it along with me). We actually have two more rehearsals before we are absolutely required to give up the "wee dots" (a gently derisory Scottish term for sheet music). Our group is so large for this year's concerts that we'll be very crowded on stage, and we simply won't have enough room for music stands. And anyway, the kind of traditional music we do should not be played from a printed score (which works okay for a symphony but not for a jig). In traditional music, the only options you can properly take are (1) play it by heart, if you know it by heart, (2) fake it convincingly, or (3) sit quietly and wait until you get a chance to play something you know. It's hard to apply these principles to a great big complicated concert, in which most of the participating musicians had to learn most of the music specifically for the event -- but apply them we must.

To be honest, I really wasn't ready to play from memory tonight, but I did it anyway. Perhaps I should explain that.

Certainly I was tempted to make things easier on myself, and cling to the sheet music for at least one more rehearsal. Why take off the training wheels before I was forced to, especially when I knew I wasn't ready to do it? That's easy enough to explain: because I knew I would never be ready to do it, if I kept putting if off.

If I kept procrastinating about putting aside the sheet music, I would finally have to do it in front of a concert audience. And that's not the right time to come to grips with the problem of playing from memory. It's hard enough to do it in rehearsal, for crying out loud! Trying it out for the first time in front of a paying audience is just not right.

I was pleased to discover that quite a lot of the concert music gave me very little trouble in terms of playing from memory. But some of it gave me quite a lot of trouble -- far more trouble than I had imagined it would, to speak the truth. It was embarrassing to be floundering around so badly, knowing full well that most of my mistakes (including some high notes which were wrong to an almost gruesome degree) were quite audible, at least to the musicians sitting close to me.

But now I have a more exact idea of where my weaknesses are than I did before, because I put myself through the humiliation of screwing up in front of witnesses who would be knowledgeable (and therefore harsh) judges of the matter. This will help me work on the problems that I encountered in tonight's rehearsal, and whittle away at them, so that they aren't still a problem for me when we face the public at the first concert on April 30.

Can I draw a diabetes-relevant moral from all this? I think I can. I usually can.

Taking the easy way out is usually a bad choice, and not just because it tends to yield disappointing results. Taking the easy way out is also boring, and when you are faced with a choice, the boring choice is usually not the right one. You don't learn anything at all from doing the boring thing, the easy thing. And you don't benefit from it, either.

Do the difficult thing, not the easy thing. Do the unusual thing, not the boring thing. Do what no one expects you will do. 

I can't promise that doing something interesting and unusual is guaranteed to be the right choice for diabetes management. But doing something commonplace and uninteresting is pretty much guaranteed to be the wrong choice for diabetes management. Doing what the average person does about diabetes is not what you should be aiming for. You want to be trying harder than they are, and putting demands on yourself which they would not dare to take on. 

Wednesday, April 14, 2010  

Mostly sunny today, but with some towering cumulus clouds around that looked as if they wanted to drop some rain on us. No problem: we ran in between them, and stayed dry the whole way.

Mea culpa: I am very energetic when it comes to digging up facts of interest, and very impatient with documenting where I found them and justifying my belief that they are reliable. I have to fit my blogging into a rather overscheduled life (at this very moment I should very definitely be doing something else -- specfically, practicing a bunch of concert music which I am going to try to play entirely from memory at a rehearsal tomorrow night). If I had to treat a blog post as a kind of term paper, footnoting everything, I just wouldn't do it at all, because I wouldn't be able to set aside that much time.

My hasty, impulsive style of research is a legitimate factor for you to consider in deciding how much you believe what I have to say. So, the way to take my presentation of the science behind diabetes management is this: "Maybe he's right, and maybe he's full of it (he's an amateur, after all), so I'm going to have to treat what he's saying as unsupported opinion, until such time as I can verify it myself somehow".

I only want you to consider what I'm saying -- not to take it on faith. See if you can find out whether what I'm saying is true for me is actually true for you. In the end, that matters more than anything else does.

I've been wondering when it might begin to dawn on the health-insurance industry (or the health-care prevention industry, as some of us think of it) that maybe, just maybe, cheating their customers is not the only way (or even the best way) to cut costs.

The ounce-of-prevention/pound-of-cure equation seems not to be covered in the business schools (it can't be medical schools) where the people who run these companies receive their education. For decades now, they've continued clinging to a reimbursement structure which pays for high-cost disease treatments but not for low-cost disease prevention. The disease treatments for many diseases which could have been prevented, but weren't, tend to get really expensive after a while, but when that happens the insurers figure they can forget about getting rid of the disease and go to work on getting rid of the customer. No one could accuse them of not pursuing the latter strategy with sufficient zeal, but despite their best efforts they still end up paying out a lot of money for care of chronic (but preventable) illness.

Well, if any disease stands a good chance of making them change their approach, diabetes is it. The disease is expensive to care for, preventable in a great many cases, and sweeping the nation. If the health insurance industry has any regard at all for its future, the health care industry needs to be thinking about how to prevent diabetes.

With that goal in mind, UnitedHealth Group announced today that it is launching something called the Diabetes Prevention and Control Alliance. As part of the program, they will reimburse the local Y when their customers go there to participate in the YMCA's Diabetes Prevention Program, a lifestyle-adjustment plan which has been shown to reduce participants' risk of developing diabetes by more than 50%.

UnitedHealth says that this is "the first time in the country that a health plan will pay for evidence-based diabetes prevention and control programs".  Well, better late than never, guys!

Future breakthroughs planned by the health insurance industry include walking upright, taming fire, and coming in out of the rain.

Tuesday, April 13, 2010  

Ah, much nicer weather today. It inspired me to go for a longer, more challenging run at lunchtime than usual. It felt good to do it, and it helped relax me about a meeting I would be attending at 3 PM, which I was not entirely looking forward to. The meeting turned out to be more positive and productive than I expected it to be, but also more tiring (it was supposed to end at 4:30 and ended up continuing to 5:45). I felt a little weary by the time it was over, but not half as weary as I would have been if I had not done a hard run at lunchtime. It's one of the great paradoxes of exercise: burning energy gives you energy, and not burning energy exhausts you like nothing else can.

I think by now most of us are aware that "PIN number" is a totally stupid expression, since the N in PIN already stands for "number", and "PIN number" in unabbreviated form would have to be rendered as "personal identification number number". But we can't stop saying PIN number, can we? Because "pin" is already a word meaning "device designed to extract the greatest possible pain from the smallest possible injury", and we can't use the acronym in conversation without doing something to indicate that we mean something else by it.

Until recently (and by "recently" I mean half an hour ago) I didn't realize that the phrase "GLUT-4 transporter", which I used in passing yesterday, is as stupid in its way as "PIN number". You see, GLUT-4 means "glucose transporter, type 4", so a GLUT-4 transporter would be a "glucose transporter type 4 transporter". However, I think I see why people don't just say "GLUT-4" and leave it at that, any more than they say "PIN" and leave it at that.

GLUT-4 is actually the name of a protein. (The gene that encodes this protein in humans is SLC2A4, in case you want to experiment at home.) Why refer to it as a "transporter" if it's a protein, you ask? Well, keep in mind that the body uses proteins as tools. Each protein has a job to do, usually having something to do with the protein's molecular shape, and some proteins are rather active in their jobs. GLUT-4, as it happens, has a transportation job. Specifically, it has the job of moving glucose molecules from the outside of a cellular wall to the inside of it. When a cell (specifically, a muscle cell or fat cell) needs to transfer glucose from the surrounding bloodstream to the cell interior, GLUT-4 is tasked with making that tranfer happen.

Cells couldn't function (or survive) if the cellular walls were impermeable, like sheets of plastic. Nor could cells function (or survive) if the cellular walls were as permeable as a volleyball net, allowing just about anything to drift into the cell or drift out of it. What makes cells successful is that the cellular walls are selectively permeable. Cells are able to decide what enters or leaves the cell, and when. A cell can decide when it's time to absorb whatever it's short of, or expel what it has too much of. And it uses "transporter" proteins to drag molecules through the cellular wall.

When a muscle or fat cell decides that it's time to absorb some glucose from the bloodstream, GLUT-4 is the transporter protein it uses for the purpose.

Of course, I'm being a bit cheeky in saying that the cell "decides" it's time to absorb some glucose. What really happens is that the cell receives a message saying it's time to absorb some glucose, and that message comes in the form of an insulin molecule, which is released into the bloodstream and sooner or later bounces up against one of the insulin receptors which line outside of the cellular wall. The insulin receptor, upon being triggered by the insulin molecule, launches several "protein activation cascades". One of these cascades (symbolized by curving arrows in the picture above) has the effect of waking up the glucose transporters (which tend to hibernate in the interior of the cell) and sending them flocking to the cellular walls, so that they can drag some blood glucose inside. Other cascades triggered by the insulin receptor have the ultimate effect of converting the imported glucose into other forms: glycogen (for short-term energy storage), pyruvate (for immediate energy use), and fatty acids (for long-term energy storage).

What I've described above is the way things are supposed to work, and they work more or less that way even if you have Type 2 diabetes. However, if you have Type 2, none of this works quite as well as it ought to. The problem which is usually called "insulin resistance", and which I prefer to call insulin insensitivity, was long assumed to occur because the insulin receptor was somehow not being triggered by the insulin molecules which came into contact with it. The current thinking seems to be that the problem lies deeper inside the cell -- that the chemical signaling which is supposed to make all those "protein activation cascades" happen within the cell is somehow being interfered with. The insulin receptors are being triggered, all right, but not enough is happening as a result. Because of the cell's muted response to the insulin trigger, the cell does a comparatively feeble job of pulling in glucose and performing the necessary transformations on it. (It's not clear what is preventing this whole process from running as robustly as it ought to; it may be that fat within the cell is dragging the process down somehow.)

Whatever it is that slows down the insulin-triggered cascades within the cells of people with Type 2, exercise is known to counteract it. During exercise, the cells actually start making more GLUT-4, so that they can absorb more glucose and obtain more energy. The GLUT-4 that is produced in this way is not permanent, but it does persist for a day or two, and the result is that people who exercise regularly tend to be more responsive to insulin than people who don't. This goes on in everyone, not just people with Type 2. Testing of the "Glycemic Index" of various foods on non-diabetic test subjects shows that the effective index varies widely among individuals -- and the more you exercise, the lower the index is going to be for you. The difference may not be very important if you're not diabetic, but it sure is important if you are.

The thing about exercise is that it places intense demands on the body's ability to make use of chemical energy -- and the more you exercise, the more the body changes itself in order to adapt to those demands. It strengthens its muscle fibers, it expands its blood vessels, and it adds to the inventory of protein "tools" (such as transporters) that it uses to move glucose around. These adaptive changes are extremely beneficial in managing Type 2 diabetes (and in managing health in general). And exercise is, so far, the only way to make those changes happen. There isn't a pill you can take instead. Maybe there will be, someday (I've heard about research on rats which seems to be aiming in that direction), but if I were you I wouldn't wait for it. For now, at least, you probably need to get out in the fresh air and move around a bit.

Monday, April 12, 2010  

It rained heavily last night, and much of this morning -- including a heavy downpour about 10 minutes before my lunchtime run. But the rainfall was becoming episodic, and I decided to take a chance. The outcome: no rain at all during the first three miles of my run, and only a light rain thereafter. Mother nature is trying to encourage me.

Looking for a starchy food that you might be able to tolerate? Get thee to an Asian market and buy some of this stuff:

Chana dal is a skinned and split chickpea, of the "Desi" variety grown in India. (It also travels under other names, such as Bengal gram dal and cholar dal.)

Compared to the "Kabuli" variety of chickpea, which is what we usually encounter in the US and Europe, chana dal has a nuttier flavor and a considerably improved nutritional profile. Chana dal is seemingly a high-carbohyrdate food -- and yet it has a low glycemic impact, apparently because it is also has a lot of fiber and protein in it. (And a lot of "resistant starch"? I haven't been able to confirm that, but it's likely.)

On the minus side of the sheet, you have to soak it overnight or it will take a long time to cook. But it makes a filling, low-glycemic stew if you cook it in broth and throw in some vegetables. A 2-pound bag of it cost me $3.29. What's not to like? (Well, if you hate chickpeas, I guess there's something not to like, but I like chickpeas, and I like chana dal better.)

It goes without saying -- or ought to, anyway -- that you shouldn't take my word for it that chana dal has a low glycemic impact. It might not have a low glycemic impact for you. It's worth a try, though.

Because my site is, to such a great extent, about the beneficial effects of exercise on Type 2 diabetes, and because not many people who might be interested in that topic are aware that my site exists, I thought I should check out what sort of information turns up when you do a Google search on "diabetes exercise".

The first unsponsored link that came up was this page on It's an article entitled Diabetes and Exercise, and it's in Q&A form. It begins by disposing of the "What is diabetes?" question, and then answers the question "How can exercise help my diabetes?", in these three sentences:

"Exercise can help control your weight and lower your blood sugar level. It also lowers your risk of heart disease, a condition that is common in people who have diabetes. Exercise can also help you feel better about yourself and improve your overall health."

I don't know about you, but when I ask a "how" question, I'm not looking for that kind of vagueness. After all, the question wasn't "can you list some benefits of exercise, without explaining anything about how exercise makes those things happen?". Admittedly, we don't know as much as we'd like to about how exercise does what it does -- but it's not as if we know nothing.

I have some other problems with that answer. For one thing, why begin the answer with "exercise can help control your weight", when both theory and experience tell us that exercise is not nearly as helpful in this area as most people expect? I admit that the promise is offered much more cautiously here than it usually is, but listing it first rather undermines the caution.

Anyway, that's not the main problem here. What bothers me most is the explanation that exercise can "lower your blood sugar level". As an answer to the question "how can exercise help my diabetes?", it is awfully close to a tautology.

A tautology is a statement which is empty of meaning, either because it merely restates information already implicit ("my father is a man") or because it merely lists alternative possibilities, one of which must be true ("either the economy will improve this year or it won't"). Sometimes a tautology has a little bit of meaning, at least by implication ("war is war" is understood to mean "don't idealize a thing which is ugly by definition"), but that's not the usual case. For me, a tautology usually serves as a warning sign that I am listening to somebody who feels he ought to say something but has nothing to say -- or as a warning sign that I am listening to somebody who doesn't respect his audience enough to want to provide an answer with any substance to it.

If the question is "how can exercise help my diabetes?", then the answer that diabetes can "help control your blood sugar" is a tautology -- since diabetes by definition is a loss of control over blood sugar, and anything that "helps my diabetes" is, pretty much by definition, something which can help control blood sugar. If you asked a police chief how the new program he's proposing would bring down the crime rate, and he said "by reducing the number of crimes taking place", would you feel that this answer shed a great deal of new light on the issue? I'm guessing you would not.

I hate this kind of thing. The question being asked here is an extremely important one -- a matter of life and death, to speak plainly. Giving a feeble, tautological answer to it is simply not right (especially when you're Google's number 1 search result on the subject!).

For the record:

Would the people at object that a detailed answer of this kind is too long? Yeah, maybe it is. Maybe someone who does a Google search on "diabetes exercise" isn't nearly curious enough about the subject to be able to be willing to read more than three sentence about it. Probably such a person is merely killing time, and would have been just as likely to do a search on "cute baby animal photos" instead.

We musn't treat the issue as if it were important or anything!

Saturday, April 10, 2010  

Today was a pretty exact re-creation of last Saturday: I meant to get out and run, wasn't feeling energetic, was discouraged by the weather, waited all day for the weather to improve (with less success this time), finally went out running around 5 PM, ran the same route -- and almost as soon as I started running, I started feeling better than I'd felt all day. Although the weather was no better than it had been in the morning, suddenly it seemed brisk and invigorating instead of cold and gloomy. The gray skies seemed poetic instead of grim. Planet Earth seemed like a rather nice home for mankind.

And, of course, after the run, the usual improvements occurred: hot water felt better, dinner tasted better, and music sounded better. Not the music I've been practicing today, necessarily, but Mr. George Frideric Handel is on my CD player at the moment, and he's doing a fine job. I feel a certain kinship with him because once, at a church in Ireland, I saw on display an organ keyboard on which Handel had played during a visit there in 1742 (he gave the premiere of Messiah in Dublin rather than London). No one else was around in the chapel at the time, and I couldn't resist touching the ivory keys on which his fingers had played so long ago. Tonight, after the run, I'm feeling like he's my pal as I listen to his Solomon, and if he were here I'd ask him what I most want to know about his gift for creating expressive countermelodies to a vocal line: "How the hell did you learn to do that?". And he'd probably tell me, too. That's how close we are.

Obviously it's time for me to say something about endorphins -- those feel-good substances which the body tends to produce during exercise, and which can yield a remarkable improvement in attitude.

The word "endorphin" translates roughly as "inner morphine". Endorphins are opioids (opiate-like substances) produced endogenously (within the body). They stimulate the same hormone receptors that morphine or heroin do -- and result in a similar feeling of pleasure and well-being. They are produced by the pituitary and hypothalamus during exercise, pain, excitement, and consumption of spicy foods (which explains how people get hooked on the latter). And, of course, you get an intense (but regrettably brief) hit of endorphins during orgasm.

Endorphins were discovered in the 1970s by researchers who were originally trying to figure out why all human beings, all over the globe, have receptors for opiates -- which hardly makes sense when you consider that opium poppies are not distributed nearly as widely as humans are. It turned out that our "opiate receptors" are actually receptors for the internally-produced endorphins; the opiates just happen to be similar enough to endorphins to be able to stimulate endorphin receptors.

The trouble is that real endorphins break down as soon as they have triggered an endorphin receptor. Opiates don't behave that way -- they latch onto an endorphin receptor and keep on stimulating it for a long period. This over-stimulation of endorphin receptors is thought to be the reason that opiates are dangerously addictive. Real endorphins have a milder impact, and don't lead to anything comparable to narcotic addiction. However, the psychological impact of getting an endorphin hit every time you exercise helps to make exercise habit-forming.

The fact that the body releases endorphins when we exercise is probably an indication that the body wants us to exercise. The promise of being rewarded with endorphins makes it just a little easier to get off the couch. Still, overcoming the laziness threshold, and actually starting the workout that you are intending to do, remains a challenge, no matter how experienced a connoisseur of endorphins you are. I still must constantly remind myself that exercise will feel better after I'm a few minutes into it.

I wonder if endorphins are more habit-forming for some people than others -- and if the ones who most easily get hooked on them are the ones who become athletes. Well, even if that is the case, I'm still pretty sure that endorphins can be helpful to anyone.

Friday, April 9, 2010  

The gorgeous weather continued today. Brilliant sunshine, clear air, 68 degrees. It's not expected to last through the weekend, though, so I'm glad I got out there for a good run while I had the opportunity.

Went to a concert tonight (Kevin Burke's Open House, playing in Sebastopol), and last night I went to a rehearsal for the SF Scottish Fiddlers concerts. Finding time to do blog posts here is a real challenge. I guess I should be grateful that things have reached a point where managing diabetes is not as big a challenge for me as telling you about it.

This is glycogen. Complicated, ain't it?

All those threads fanning out from the core of the glycogen molecule are actually chains of glucose molecules. Here's a slightly closer view of a few of those threads.

When your bloodstream has too much glucose circulating in it, your body needs to get rid of it. Well, not get rid of it -- it's a precious resource -- but rather put it in storage, so that it's not just swirling around causing trouble. What needs to happen is for the body's cells to start engaging in "glycogen synthesis" -- the process of chaining together a whole lot of glucose molecules and building glycogen out of them.

Glycogen is the body's storage medium for glucose. It's the stable, "safe" way to package up glucose. Individual glucose molecules would be too reactive, too ready to attach themselves where they don't belong, but glycogen keeps its head down and minds its own business. A cell doesn't have to worry too much about having glycogen as a houseguest. So, during glycogen synthesis, the body's cells (especially muscle and liver cells) absorb glucose from the bloodstream, in order to assemble it into glycogen. The catch is that the cells only do this when they are stimulated by insulin -- which means that, if your cells are insensitive to insulin, they don't do as much glycogen synthesis as they ought to. Consequently, some amount of the glucose which the cells ought to extract from the bloodstream simply continues circulating -- in its unsafe, reactive form.

Of course, this description leaves unanswered the obvious question of why the cells become insensitive to insulin. Well, a lot of people are working hard at finding an answer to that quesition, but it's not as easy to answer as one might hope. All sorts of theories have been proposed. The current consensus seems to be that Type 2 interferes with the chemical signaling that has to go on within the cells (in order for the cells to respond appropriately when they are exposed to insulin). What interferes with signaling within the cells? Fat, seemingly, but that just raises the question of why fat within the cells does this to some people and not others.

I don't know whether the underlying mechanism that drives all this is going to be explained in my lifetime or is simply going to remain mysterious for as long as I'm around to wonder about it. It would be nice to know the cause of the problem more exactly. However, I know what I can do about the problem, which is really more important.

Thursday, April 8, 2010  

"I want magic!" says Blanche DuBois in Tennessee Williams's 1947 play A Streetcar Named Desire. So far as I can determine, the playwright thought of her as a sympathetic character, and perhaps a few members of the audience do as well. I can't stand her, myself. She is easily the most irritating major character in theater history, and I'm convinced that the play would never have become a success if audiences didn't enjoy taking sides with Stanley Kowalski in his abuse of her. Anyway, Blanche wants magic. Not reality! Magic. She is quite determined to avoid facing up to anything that is actually going on in her life. Perhaps the reason she makes most of us so desperately uncomfortable is that she embodies, rather grotesquely, our own reluctance see things as they are and face up to our problems. She just carries it farther than we do. Several miles farther, I'd say.

I guess my biggest objection to Blanche is that I don't believe she has no choice but to live a sordid actual life, while taking refuge from it in fantasies and lies. It always seems to me that nobody has backed her into the corner she finds herself in; she's there because that is where she decided to go. If she were more realistic, maybe she could put together some kind of satisfactory life for herself. Facing reality might not be easy, but it would surely get better results for her than living constantly in fantasyland (which, by the end of the play, lands her in an insane asylum).

It seems to me that, in our collective quest for the secret of healthy living, we often take a very Blanche-like approach to the matter. We want magic. We want miracles. We want to be told that somebody's found a special kind of radish that grows only in Madagascar, and if you eat an ounce of it every day you never have to die. Being given more realistic information about which behaviors will slightly reduce your risk of dying is not good enough. We want magic, or nothing.

Because we are known to have this attitude, people who are trying to mold our behavior (for our own good) often promise us magic, quite untruthfully. They know that people won't exercise to get the benefits that exercise actually does provide, so they tell people exercise will make them lose weight. This is nonsense, of course -- even professional athletes don't exercise enough to lose weight from that alone. People lose weight from eating less food, not from exercising. Unfortunately, if you promise people magic, in order to make them adopt some desirable behavior, they tend to abandon that behavior as soon as they realize that the magic isn't happening. People who have been falsely informed that exercise will make them lose weight are going to decide pretty quickly that "exercise doesn't work". So they give it up -- and lose the benefits that exercise actually does provide!

Those who have been trying to get people to adopt a balanced diet -- including an adequate amount of vegetables and fruits -- are inclined to make dramatic promises. An especially common promise, in recent decades, has been that the phytochemicals, anti-oxidants, and other substances found in various plant foods will protect you from cancer. Discouragingly, recent studies that have looked for the anti-cancer effect of fresh produce have been unable to find it. These have been small studies, however. Now a very large one (The European Prospective Investigation Into Cancer and Nutrition, involving nearly half a million people) has looked intensely at the issue of diet and cancer risk. Their conclusion, as reported in the Journal of the National Cancer Institute, is that, for every extra 200 grams of fruits and vegetables you eat per day (that's 1.5 to 2 servings), you reduce your cancer risk by... 4%.

Hmmm. 4%. Not that impressive, is it? Especially considering that, like Blanche DuBois, we want magic -- or nothing.

So do we conclude that fruits and vegetables "don't work", and give up on them? No, say the authors of the study -- eating a balanced diet, with plenty of fruits and vegetables, is still the right thing to do, for other reasons (largely related to cardiovascular health), and a 4% reduction of cancer risk is better than a 0% reduction of cancer risk. (And if you add more than 2 servings, the risk is reduced more.) Still, people who had been led to believe that eating their broccoli would be enough to vanquish The Big C are pretty sure to be disappointed to learn how small a difference eating their broccoli actually makes in terms of cancer risk.

The biggest problem here, of course, is our tendency to think like Blanche DuBois -- our unreasonable insistence upon being presented with magic rather than reality. But those who try to exploit our Blanche DuBois tendencies, by offering us magic which is unlikely to come true, have a lot to answer for as well. The fact that there are other (and more reality-grounded) reasons to eat fruits and vegetables is going to be forgotten, once people react in disgust to their discovery that the anti-cancer effects of fresh produce have been oversold.

I don't know what the solution is for this problem, but I'm pretty sure it lies in the direction of being more truthful rather than less.

Wednesday, April 7, 2010  

Hmmm -- 86 ain't bad, especially after a pub night. Maybe I had a pub night coming to me.

Once again I had raw vegetables for lunch (with some Kalamata olives thrown in for decadence); I came home from work feeling pretty hungry. I decided to do some extra glucose testing (before and after dinner) to see if anything unusual was going on. The results were:

All of those numbers are comfortably within target ranges (although the one-hour result was probably higher than what a non-diabetic person would get). Dinner included small potatoes (baked) and refried beans, so it wasn't a low-carb meal. I earned my numbers pretty fairly.

So I guess the take-away lesson is that it's okay to have a pub night once in a while. Especially if you run 5.7 miles and have raw vegetables for lunch the next day. 

You know, the weather wasn't half bad today.

It was so nice outdoors that I did an extra-long run at lunchtime (largely the same route as the one I showed pictures of in my April 3 blog post). Dazziling sunshine, temperatures in the high 60s. This is what spring is supposed to be like.

I want to talk about the fetishization of medical test results, which I think has become a problem for patients and doctors alike.

To fetishize anything is to project onto it an intense significance which it doesn't naturally possess. Originally the term referred to the tendency, among primitives, to define some object as being the habitation of a potent spirit, or as having magical powers. These days we seem to use the term mainly in a sexual sense, to refer to the tendency of many individuals to develop an erotic fixation on something not regarded by most people as sexy or even pleasant.

But non-erotic fetishes are commonplace too. People seem to have a natural tendency to invest great symbolic significance in things, and then to become so fixated on the symbol that they forget about the reality it is supposed to represent. This sort of thing doesn't exactly help people keep their priorities straight.

Patriots who fetishize the flag may forget, in their zeal to protect the symbol of their country from symbolic harm, to wonder if maybe they could also care just a little bit about what is actually being done to the actual country. Church authorities who make a fetish of their organization's public image may forget, in their zeal to prevent a child-molestation scandal, to consider doing something to prevent child molestation itself. That's the trouble with concentrating on symbols and images: it makes us forget that reality matters, too. I guess another way to say it is that we get into the habit of thinking that we only we need to take care of the symbol or the image -- if we can get that looking just right, then reality will simply take care of itself. Which, of course, it won't.

Nobody is more in favor of testing than I am, but I try to keep in mind that testing matters only insofar as it tells us what is going on inside us; any attempt on our part to change our test results is helpful only insofar as it causes better things to be going on inside us. But we lose sight of these principles when we fetishize test results. When patients and their doctors start treating a test result as if it had magic powers, they become obsessed with making the numbers look good -- on the naive assumption that any method used to make those numbers look good is going to produce great health benefits.

As I have had occasion to say here before, this is like assuming that you can make your child smarter by breaking into the school's record office in the middle of the night and altering his grades. A medical test result is not a voodoo doll; it doesn't exert magical powers, and manipulating test results does not necessarily change the underlying reality.

Unfortunately, a lot of medications seem to be good at manipulating test results, and not so good at making people healthy. If all you want is to prevent your cholesterol from making your lab report look bad, Lipitor is all you need. If you want to prevent your cholesterol from killing you, though -- that's another matter entirely!

Diabetes drugs have similar problems. If you want a drug that will drive your A1c test result down, there are several kinds of drugs which will do that. The catch is that, even if they do bring down your blood sugar, they will do little or nothing to bring down your cardiac risk (which is more than doubled in people with diabetes, even if it is well-controlled). Bringing down your numbers is not the only thing that matters; it also matters how you brought them down.

We get so fixated on test results -- as abstract numbers -- that we tend to think, as soon as our blood sugar descends to the normal range (no matter how we achieved this) that we have already done everything that needs to be done. Well, if we achieved it by manipulating our body chemistry, we probably have not done everything that needs to be done.

Thinking that you don't need to exercise so long as you take enough pills is like thinking that you don't need to bathe so long as you use enough perfume. Concealing a problem is not the same thing as correcting it. But it's hard to appreciate that distinction, if you have fetishized test results to the point that you think it doesn't matter how the results were achieved.

These thoughts were prompted by a post on the dLife forum from someone who was worried about whether a recent period of reckless "cheating" which elevated their daily glucose tests was going to show up on their A1c later (they feared that it would, in which case they would have to kick themselves). Why wait, I wondered? If you're going to kick for yourself for cheating, and you know you cheated, kick now. It's not as if the cheating will turn out not to have happened, it the A1c test turns out not to reveal it. But that's how we see things when we fetishize a test result. If I cheated in the woods and the A1c test wasn't there to hear it, it didn't make a sound! The A1c result looks okay, therefore the cheating wasn't detected, therefore it didn't happen -- because the number is all that matters!

I can't quite see it that way. The fact that we got away with something, in the eyes of our doctor, does not mean we got away with it in the eyes of nature. Reality still counts for something, no matter how well we manipulate the things which symbolize that reality.

Tuesday, April 6, 2010  

Beautiful weather today, and a nice run at lunchtime. After my run I had another raw-vegetable lunch -- and then had another workout in the evening, which consisted of hoisting pints over dinner at a local brewpub. We'll see how much of a price I pay for that, when I do my fasting test in the morning!

More bad news on drug side-effects. Apparently a lot of prescription medications tend to promote weight gain -- and some of the worst offenders are typically prescribed for people who are already overweight. That's according to a report from Ingrid Kohlstadt of the American College of Preventive Medicine, which appeared on Medscape late last month: "Several classes of medications act centrally to alter the hypothalamic satiety and appetite centers, through mechanisms not yet fully elucidated. Medications can change the amount and type of food that a person selects. Such food-drug interactions are covered only modestly in the medical literature, suggesting that they may be underrecognized."

Part of the problem is that, if a drug is going to increase appetite and thus promote weight gain, it's going to take time for this effect to become obvious -- and clinical trials of medications usually don't last long enough to rack up unmistakable evidence of such a trend. Even in cases where a drug is widely understood to increase appetite and promote weight gain, doctors usually don't mention this to patients.

One category of medications which exhibit this problem is (you knew this was coming!) diabetes drugs. Insulin increases appetite, and so do drugs (such as the sulfonylureas and thiazolidinones) which stimulate insulin secretion.

Another problematic category is hypertension medications (which, of course, are often prescribed for people with diabetes). Beta-blockers, calcium channel blockers, alpha-andenergic blockers, and some kinds of diuretics can all promote weight gain.

Antihistaimines and steroid hormones can also be problematic in terms of weight control.

However, I'm not taking any of these drugs, so I guess I have no excuse.

Monday, April 5, 2010  

Yesterday was my rest day from exercise, and I also had rather a late dinner last night, so it's not too surprising that my fasting test was up a bit (it had been 84 yesterday).  I hope to see it below 90 tomorrow, though.

Today I took to the office a bowl of vegetables to have for lunch (zucchini, cherry tomatoes, mushrooms, cucumber -- also some nuts). One of my running buddies has been making a habit of bringing a bowl full of vegetables and fruit to work every day. It was her husband's idea; in the mornings he puts together a supply of these things for each of them. It sounded like a good idea to me, and I thought I'd try it. I usually eat lunch after I come back from running, and there's nothing like running to make you feel as if it's okay to eat a high-calorie meal afterwards. So, that's probably the highest-calorie meal of my day, and I could afford to lighten it a bit. I figured it would be better for me if I started bringing to work a lunch that was heavy on the fiber and vitamins, and light on the calories and carbs.

I was a little worried that this sort of luch, especially after a hard run, would leave me feeling too hungry. Well, I did get hungry later in the afternoon, and out of curiosity I measured my glucose when I got home: 89. I don't know how much higher it would have been if I'd had a richer lunch, but 89 certainly isn't hyperglycemia. I wasn't that hungry.

The phrase "raw vegetables" doesn't have a great deal of box-office appeal, I realize; most of us want nothing to do with vegetables that aren't drowning in some kind of heavy sauce. A dish that includes vegetables is reckoned a failure if you can taste them. My compromise today was to sprinkle tamari on them (it's a kind of soy sauce). Of course, this meant that my low-calorie lunch was not a low-sodium lunch. Maybe my systolic blood pressure would have been lower tonight without the tamari. Well, there's a limit to my saintliness. I ran 5+ miles and then ate raw vegetables -- that will have to be good enough for today. But maybe I can come up with an alternative dressing that's less salty -- lemon juice and pepper, or something.

Saturday, April 3, 2010  

I had a really hard time talking myself into running today. Part of the reason is that I was waiting for the weather to improve. Unlike yesterday, it wasn't a rainy day, but it was cloudy and there was a cold wind blowing, and after what I thought was the decisive arrival of spring, I didn't feel like bundling up in layers to go running. Maybe things would improve if I only waited.

But I don't think that's all there was to it. I just wasn't in the mood for any more exercise today. I was feeling lazy and irresponsible. I hate to shatter anyone's illusions by admitting this, but the truth is that that lazy feeling is not entirely unknown to me. Couldn't I just forget about exercise today, and take my Sunday rest day ahead of schedule?

Well, even though I am not immune feeling lazy, I have also trained myself to be immune to the idea that my feelings should play a role in determining whether I'm going to exercise or not. Exercise is like showing up at work on Monday morning: how you feel about it is not the issue. You don't do it because you're in the mood to do it, you do it because it needs to be done.

So, anyway, I waited until the clouds broke up and the cold wind died down, and went for a run around 5:30 PM. I took a camera with me. I was running from home, and I used a road that follows a ridge line with nice views of the valleys to the east and west.

To the east, it's mostly undeveloped.

To the west, there's a view of the town off in the distance.

In roughly the same direction, you can see a large building with a red roof. It's the building I work in. When I run along this road on my lunch break, I always like to catch this glimpse of the office from a couple of miles away; somehow it gives me a comforting sense of perspective on whatever is going on in there to stress me out. It all seems far away and long ago and not very important. (Unfortunately, I don't retain this perspective when I get back in there.)

The downhill part presents its own challenges. I'm not sure why, but running downhill can be very hard on your knees. The temptation to speed up too much, just because you can, needs to be resisted.

Heading west, into the sun. It was at this point that I remembered that I hadn't put on any sunglasses before I left the house.

Heading north, and starting the fearful climb. I remember vividly how difficult it used to be for me to walk up this section, before I got diabetes and had to start running up it.

And it only gets steeper from there. Finally, I turned north and started climbing back to my place, at the top of the hill.

So then I was done, and felt much better than I'd felt all day. I had spent several hours thinking that I just wasn't ready to exercise, but five minutes after I started running I felt fine. That's how it usually works out, when I don't feel strong enough to exercise. The only times that this hasn't worked out was when I had a virus; it seems when your body is fighting a viral infection, exercise generally doesn't have the invigorating effect you're hoping for. But the rest of the time, the cure for feeling unable to exercise is to get off the couch and do the damned exercise already.

Why I have to keep re-learning that lesson, I cannot say.

Friday, April 2, 2010  

The two most common statements made in postings on the dLife forum are probably "I guess I'm in denial" and "I can't seem to get motivated". But there's no doubt about which question is most commonly asked there: "Is this normal?".  

An amazing variety of situations can cause people to think that the most urgent question about what's happening to them is whether it's "normal" or not. Some examples from dLife postings follow.

  1. A newly diagnosed patient:
    Sometimes I feel so scared and alone. Is this normal?
  2. A patient whose doctor said not to eat anything after midnight:
    I didn't ask him or anything, but is this normal diabetic routine??? I know it's needed for BFS levels but do others still fast @night as well???
  3. A patient who has been having dizzy spells:
    I'm getting confused and scared at the same time... when it is not a feeling that i'm going to fall it is a feeling of floating. Is this normal?
  4. A patient who has been drowsy of late:
    This sleepiness is scaring me, has anyone experienced this normal????
  5. A patient whose doctor and nurse-educator are providing almost no information, and seem to feel no sense of urgency about getting the situation under control:
    Is this normal to start slowy?
  6. A woman whose husband had just started taking insulin:
    He has this horrible gas... He is killing the rest of us in the house!  Is this normal?

The implication in each case seems to be that the situation is acceptable if, and only if, it happens often enough for it to be considered "normal". In other words:

  1. I don't mind feeling scared and alone, so long as I know that other people feel scared and alone. Then it's okay.
  2. I'm not willing to give up my midnight snacks, just because my doctor says it's necessary for me, unless everyone else reassures me that it's necessary for them, too.
  3. I won't regard dizzy spells as a sign of anything going wrong, so long as I know that others are dizzy.
  4. I won't regard chronic sleepiness as a sign of anything going wrong, so long as I know that others are sleepy.
  5. I won't mind that I'm getting my health care from uncommunicative people who don't care what happens to me, so long as I know that this is commonplace.
  6. It's okay for my husband's horrible gas to be killing the rest of us in the house, provided most other households have to endure this when someone in the family is on insulin.

In short, we put an awful lot of value on "normal". The fact that a problem, no matter how awful, is considered "normal" is enough to reconcile us to it. The fact that a problem, no matter how trifling, is not considered "normal" is enough to make us feel that there's no reason on earth why we should have to put up with it.

And when we want to express strong disapproval of some idea or behavior, what do we say? We say that this it isn't normal to think or behave that way. Once, a woman I worked with was semi-stalking a guy who worked in the same office. She asked him what he'd been doing at such-and-such a place the night before -- and she knew he'd been there because she saw his car out front and the license plate matched. He could have replied by saying it was not her business to be tracking his movements after hours, but he made his answer a little more cutting by saying "Normal people don't memorize their coworker's license plates". And he was right -- this is not a commonplace behavior pattern. In theory, that is not a value judgment, just an observation. But of course it is always a value judgment in our society to say that something is not normal .

But what exactly does "normal" mean? I hate to break it to you, but it means this:

Take any kind of data that clusters around an average value (cranial circumference, for example), and in most cases the values will show a pattern of probability which is variously called the standard distribution, Gaussian distribution, or "bell curve".

Without going into all the details of how the numbers are crunched, it's a safe bet that most of the data is going to fall within that blue section in the middle. The values that lie within one "standard deviation" above or below the average (the center point of the curve) are probably going to account for 68.2% of all the data. These values are generally considered "normal". Data values that are higher or lower than that become increasingly uncommon as they get increasingly far from the average.

Here's a real-world example: a series of 20 fasting glucose tests that I reported here in March. The values were: 81, 81, 91, 91, 81, 88, 94, 77, 75 ,74 ,82 ,79 ,82, 87, 86, 77, 81, 84, 95, 89.

For those 20 values, the mean (average) is 83.7, and the standard deviation is 6.15 for those values. Therefore, we expect that about 68% of those values will be no lower than 77.6 (the mean minus the standard deviation) and no higher than 89.9 (the mean plus the standard deviation). And that is pretty much what happens! 14 out of 20 values (70%) do indeed fall within that range, and that's certainly close enough to 68%, given the small sample size. So, the standard distribution is a pretty accurate reflection of the variations in my test results. Therefore, during the time period covered by this data, here's what counts as "normal" fasting blood sugar for me: 83.7, plus or minus 6.15. Coincdentally, this data of mine happens to make a pretty good match to the equivalent data for the non-diabetic populaiton, so what's been normal for me lately is also pretty close to "normal" in a broader sense. But I only used these numbers because they were conveniently in front of me; I could have used daily odometer readings from my car, or something else that showed routine variation, to show how the bell curve works.

This "normal" distribution doesn't necessarily mean that all the data is, or should be, within that blue section in the middle. It just means that we expect to find most of the data there, and less of the data above or below it. This says nothing about whether being in the middle is good or bad. In some cases (IQ scores, say, or income levels) people feel no objection whatsoever to being an outlier on the high end of the range of values. For most things, though, people don't want to be exceptional. They want to be normal. They want to fall within that blue section in the middle.

In matters of health, it is often better to be in the middle of that blue section, huddling near the mean, but not always better. Sometimes being far from the mean might be an advantage, or at least not a disadvantage. Is it necessarily bad to be taller or stronger than the average person?

Being left-handed is not "normal", because right-handedness is far more common. But is left-handedness really a pathology, or is it simply uncommon? It requires you to live in a world where the scissors are hard to use, but apart from that it doesn't seem to make much difference.

For that matter, being "normal" is not always desirable. At this point, divorce is "normal", and obesity is on the way to becoming so. Does that mean these are good things?

It is worth knowing what is "normal" -- but it is also worth thinking about whether "normal" is a good thing. We tend to assume that, at least in matters of health, "normal" means the same thing as "ideal". Often it does. Sometimes it doesn't.

It seems particularly ill-advised, at least to me, for anyone with diabetes to frame a health concern primarily as a question about whether this or that is "normal". Having diabetes is not normal (not yet, anyway, but we're working on it). Very little of what you'll experience with diabetes is "normal" for people who don't have diabetes. And the fact that something you experience is "normal" for people who actually do have diabetes doesn't mean it's perfectly fine and you needn't try to do anything to change it.

The last thing anyone should want to be is a "normal" diabetes patient. That's not a bell curve you want to take up residence in the middle of. Better to be an outlier, leading a different life from the one the medical profession thinks is probably in store for you.

Thursday, April 1, 2010  

A busy day -- even though I didn't go to work.

I took today off, partly because tonight was our first rehearsal for the San Francisco Scottish Fiddlers concerts (which are now a month away). I wanted to squeeze in some more practice on the concert music, so that I'd be as ready as possible for the rehearsal tonight. I also wanted to do a trail-run today, as the weather promised to be beautiful (and was). I also wanted a day off.

After breakfast I got right to work on the fiddle tunes, and after I'd practiced the entire concert program I headed over to the state park for a run. It was sunny and cool. Everywhere around me, brilliant green foliage still glistening with last night's rain.

This kind of lush greenery is a very temporary thing in California, and I like to luxuriate in it as much as I can while it lasts.

It's so much easier for me to do a long workout when I'm outdoors enjoying the natural world. Even on the steepest, nastiest climb, I was thinking "This isn't so hard!". This is the kind of diabetes therapy I like. Others can choose for themselves, of course.

After I got back home from the run, I intended to practice the concert music some more, but I was feeling so sleepy that I figured what I really needed to do (since I was going to have a long drive to and from the rehearsal) was to take a nap. So I did, and then left for the rehearsal, feeling rested if not necessarily prepared.

The rehearsal went well for me generally, but I was caught by surprise when it turned out that our music director, Alasdair Fraser, wanted much faster tempos than I was expecting on a couple of difficult tunes. I was really floundering on those, at the speeds that turned out to be required. Well, now that I know what's required, I know what I have to work on for the second rehearsal next week. I'll use a metronome, and gradually increase the speed every time I practice those tunes.

I'll get there -- it's just a matter of breaking down the assignment into manageable steps. It's like any other difficult assignment. And at this point in my life, I'm not all that scared of difficult assignments!

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