Tuesday, August 31, 2010  

Here's how much my sore shoulder improved since last night: after I got up this morning, it was 20 minutes before I even remembered I had a sore shoulder (shampooing my hair in the shower was what brought it back to me). It feels about 90% better now. So the massaging and yoga yesterday, plus a little bit of time, was enough.

I ran a new route with my running buddies today, one which we had never tried before. It was a pretty route, with some nice views of the town spread out before us, but we paid the usual price for nice views, in the form of some ferocious hill-climbs. What's worse, both my running buddies really liked the route, so I have to assume we'll be running that one again in the future. Worse still: I can't complain about the person who proposed that we check out that route -- because it was me.

Why do I have to be so damn creative?

When people who are having a hard time controlling their blood sugar introduce themselves on the diabetes forums and ask for suggestions, they almost invariably present their dilemma in the same basic format. First, they talk drugs. When they were diagnosed, they were put on metformin. Then their doctor kept increasing the dosage of metformin until they couldn't take the gatrointestinal consequences. Then their doctor started prescribing a variety of other medications. But whatever they take, their blood sugar keeps climbing. So now their A1c results are looking awful, and they'd like to do something to turn this worsening situation around. So, what can they eat that will save the day?

And there the story kind of trails off. They already know that drugs alone will not solve their problem, so that's out. Obviously, that leaves only diet as a potential change they can make in their lives. They certainly can't think of anything else that might be worth a try. That's it: drugs and diet. End of story.

This is weird. Of the three things you can do about Type 2 diabetes (exercise, diet, and drugs), the last and least important of them is always highlighted as if it were crucial, while the first and most important of them is seen as not quite worth mentioning.

If we narrow the focus of diabetes management to glycemic control, and ignore the whole issue of cardiovascular health (which is a mighty big issue to be ignoring, considering that cardiovascular disease is the biggest and deadliest diabetic "complication" of them all), then there is a possibility of having success with diet and no exercise, and a somewhat smaller possibility of having success with drugs and no exercise. But if you want to control your blood sugar and improve your cardiovascular health, neither diet nor drugs are going to do it for you. If you want real success, which I am crude enough to define as "not getting sick and dying", exercise is not optional. So why do we always let people get away with talking as if it were?

Of course, in terms of managing health, not everyone defines success as "not getting sick and dying". Much of the health care industry seems content to define success as having good numbers on the last lab report that was done on you before you died. Well, for patients who are willing to adopt that view of the matter, I guess exercise is optional after all. The lab doesn't know if your numbers are looking better because you're actually living a healthy life, or because you're using drugs to manipulate your body chemistry.

Your body, however, does know the difference between health and doping, and sometimes what the body thinks is going on matters a lot more than what we think is going on. It would be nice to assume that what we think is going on is all that matters, but that's not how the universe works, is it?

As the physicist Richard Feynman put it (in commenting on the bureaucratic decision-making that led ot the Challenger space shuttle disaster), "For a successful technology, reality must take precedence over public relations, for nature cannot be fooled." 

Monday, August 30, 2010  

Yesterday, my "rest" day for the week, I helped a friend move into a new place. Well, no matter how you look at it, carrying heavy things does not really count as rest. I wasn't concerned that the day would tire me out very much (once you get into the habit of running at least 4 miles a day, your stamina starts to get pretty good after a while), but I was very concerned about giving myself an overstrain injury, and waking up with semi-paralyzed back this morning. As a precaution against that, I stopped to do stretching exercises a few times during the day. Also, I made a conscious effort to go slow, move carefully, and keep my spine straight. It worked -- at least so far as my back was concerned. My back feels fine today.

My right shoulder is a different story. There's a very localized pain (and sensitivity to pressure) right along the top of the shoulder. I think that means I strained a tendon that wraps over the shoulder and attaches to the arm muscles; I've had that type of injury before, though not on the same shoulder. Still, it doesn't hurt all that badly, so I figure I got off easy. I thought that the run today might make it better (or maybe worse), but it had no noticeable effect either way.  In my yoga class tonight I made a few modifications to the program (a couple of the poses were too hard on my sore shoulder -- though I was surprised how many I could do without much difficulty). I also massaged my shoulder with a Thera-cane today. All these things are good, but none of them give you an instant cure. When part of me is sore, I figure it's going to be sore for at least a day, no matter what I do.

But really, I need to keep this in perspective. After a weekend in which I did 8.3 miles of trail-running, a 2-mile walk, and 4 hours of moving furniture and heavy boxes, I'm doing pretty well if the only thing that hurts is my right shoulder, and even that doesn't bother me enough to keep me from running or doing yoga.

In short, I think I'm more resilient than most people my age, and I'm going to try to stay that resilient for as long as I can. It's probably easier at 53 than it will be when I'm 63. On the other hand, come to think of it, it's easier at 53 than it was at 43. I was a wreck when I was 43. Maybe age isn't the only thing that matters.

Here's an alarming headline (from Medscape): "Pediatric Eye Removal Rarely Inappropriate".

Isn't that just a little harsh? If they were just talking about pediatric voice-box removal I'd be willing to hear them out, but eyes?

It turns out that the headline doesn't mean what it sounds like. They aren't trying to say that nearly all children should have their eyes removed. The actual claim here is that, if you take a second look at cases where children's eyes actually were removed, it nearly always turns out that the pathology report bears out the diagnosis on which the decision was based (usually a malignancy).

Perhaps Mr. David Douglas, author of the article, would claim to be surprised that his headline could be misunderstood by anyone. Even so, if he saw an article headed "Castration of Health Journal Authors Rarely Inappropriate" I bet he'd get all upset.

Incidentally, removal of the eyeball is known to surgeons as "enucleation". I was trying to look up the term, and instead of Googling it (which had been my intention), I accidentally entered it as a search term on the YouTube site rather than the Google site. Learn from my mistakes, people: do not look up "enucleation" on YouTube! You really don't want to see what they have to show you on that subject.

On Saturday, the local running club held a race at Spring Lake; I knew it wasn't my kind of race (the distance was only 3.4 miles, and I knew it was a race for serious competitors), but I knew a few people in it, so I hung around for a while to observe the proceedings, before I took off on my own for an 8-mile trail run.

Every once in a while I take the opportunity to watch what I would call real runners demonstrating how it's done. It's inspiring, and discouraging at the same time. I don't look remotely like these guys, either in motion or at rest, and it's hard to imagine that I ever could.

Notice, for example, that in the pictures I took of them running, they look like they're running. In pictures of me running, it usually looks like I'm just walking in a hurry. I can't seem to kick up my heels the way real runners do. I try, but it doesn't feel natural to me, and unless I think about it constantly I keep forgetting to do it. (Which is too bad, because the extra speed it gives you outweighs the extra effort.)

The guy who won looked downright serene as he crossed the finish line, which is remarkable considering that he had just run at an average pace of 5:07 per mile, on a course consisting mainly of unpaved trails over uneven terrain.  

However, the next dozen runners to finish were not looking so chipper, and a couple of them fell to their knees on the grass and started retching.

I become a lot less envious of the serious runners when I see them achieving speed at a heavy cost in physical suffering. Really serious amateur athletes have an aura about them that makes you wish you could share it, but their aura doesn't gleam nearly as brightly when they're barfing in the park. All in all, I was glad that my own run that day was easier (even though it was longer), because I was setting my own pace and not trying to prove anything to the world. 

Friday, August 27, 2010  

Yesterday the US Centers for Disease Control and Prevention and the US Food and Drug Administration recommended that fingerstick devices for collecting blood samples should never be used with more than one person. The agencies said that "The shared use of blood lancing and testing devices has led to a steady rise in reports of bloodborne-pathogen infections -- mostly involving hepatitis B virus -- during the past 10 to 15 years. Such communal bloodletting occurs in settings that range from public health fairs to physician offices, but the problem is most serious in long-term care and assisted-living facilities."

Now, there's a fine phrase for you: communal bloodletting. And they're not even talking about the middle east!

I knew there were occasional episodes of "communal bloodletting" in the US, but I thought they were what we call party primaries. It turns out that things are even worse in health-care facilities.

Doesn't it seem strange that, in the year 2010, doctors and nurses would need to be told that sharing of needles is a bad idea because it encourages the spread of blood-borne pathogens? I thought that, at least since the experience of army surgeons in the civil war, doctors had not been in doubt about where infections come from, any more than they were in doubt about where babies come from.

However, it doesn't surprise me to learn that carelessness about this issue is most prevalent in places where elderly people are looked after. My first job was in a convalescent hospital, so I'm well aware of how readily the people who run those institutions  adopt the attitude that "you're old, and you're going to die anyway, so it doesn't matter how we treat you". What they seem to overlook is that we're all going to die anyway, no matter how young or old we might be at the moment -- and that the job of health care professionals is to postpone that event, not to accept it with a shrug.

I'm fearless about sharing my own pathogens with myself -- I will keep re-using a lancet until it hurts -- but on the rare occasion when I give a test to someone else, I devote a fresh lancet to the purpose. If I forgot to take this precaution, I would feel awful about it. I'm amazed to learn there are people out there doing this on purpose. You have to wonder what other common precautions in life these people are neglecting.

I wonder how often they get in traffic accidents at intersections -- how and many children they have.

Okay, my numbers are good today -- no sins to confess. I'm off to a coffee-house where some friends of mine are singing tonight. I'll play a few tunes with them as well, but it's their show. For the most part I don't have anything to do but sip my coffee and applaud now and then. Should be an easy assignment.

Thursday, August 26, 2010  

Okay, we had our heat wave, and now it's very definitely over. The fog didn't even start to break up until noon, and the temperatures stayed in the 60s. Which is fine. It had felt strange to have a summer without any really hot weather, but after a couple of days in a row of doing my lunchtime run when it was in the high 90s, August temperatures in the 60s are starting to seem like a phenomenon I could get easily get used to.

Heat isn't the most difficult condition a runner might have to struggle with. An extremely high blood alcohol level is even more challenging -- or so I gather from the this man's blog (which is called Exercising While Intoxicated ).

He has apparently been engaging in cutting-edge research on the effects which different kinds of alcoholic drinks have on the exercise experience. He sees beer as an obvious top choice ("The one we most associate with enjoying after a workout. Also can be enjoyed during a workout.") Other drinks he recommends to the distance runner are wine (reds work better, he says), whiskey, and vodka. He warns against champagne, tequila, and anise-flavored liqueurs. However, I'm not asolutely sure that I trust his judgement in these matters -- or indeed, in any matters.

He recently decided to run the 13-mile half-marathon course of the San Francisco Marathon, drinking one beer for each mile. He didn't actually do this run during the official race -- he ran it later in the day, after all the sober runners (and most of the police presence) had disappeared.

He seems to feel that the effort was a big success. He downed all 13 beers by the time he was done, and he kept them down, at least until just after he had finished running. Furthermore, he didn't get arrested or hurt, even when he impulsively ran across eight lanes of traffic leaving the Golden Gate Bridge (the nine beers he'd had by that point inspired him to find out if the view was better over there).

However, he eventually did start to get very confused, and repeatedly lost, which in part explains why it took him five hours to finish. He remembers nothing of the last two miles. He does remember asking "two cute Asian girls" to take a picture of him in Golden Gate Park after he finished, and he also remembers their horrified reaction when he started to vomit while posing for it. ("They don't even ask if I'm okay", he says. Imagine!).

What insights did the experience bring him? "It's funny how I un-blacked out right at the finish line, and all three vomits also came there at the finish line. You gotta wonder how much of blacking out and vomiting is psychological." Good point. How much of it is psychological? It's hard to know for sure, but it wouldn't surprise me to learn that drinking nearly five quarts of beer in one afternoon has effects which say more about the power of biochemistry than about the power of suggestion.

His overall conclusion is that 13 miles is too long a run for continuous beer-drinking. "But beer is a very good thing for a run of six miles or less. After those six miles, it slows you down too much and it begins to taste completely awful."

I'm not sure I can agree with his particular approach to exercise. If you're going to run 13 miles, it's nice to know that you have a reward, in the form of a bottle of something nice, waiting for you at home. But that's probably where it should be -- waiting for you at home. I don't think it should be sloshing in your hand as you bound merrily across eight lanes of bridge traffic to see if the view to the east is better than the view to the west.

I used to get upset whenever I read a report about diabetes increasing the risk of this, that, or the other unpleasant medical problem. Now I'm pretty much used to it. Name just about anything that you'd rather not have happen to your body, and someone has found evidence that it's likelier to happen, and happen sooner, if you have diabetes. (To pick just one recent example, the amyloid plaques that build up on the brain cells of Alzheimer's patients are supposedly more common among diabetes patients.)

The wear and tear on our cells (and even on the molecules within those cells) which tends to build up over the years generally happens at an increased rate if you are diabetic. Like the aging process itself, being diabetic tends to cause a general erosion of health on all fronts.

But we need to be careful about what the phrase "being diabetic" means. Most people assume it's a simple, definitional thing: if you've ever been diagnosed with diabetes, than you are "diabetic", and nothing you do will ever change that. It's like a curse, or Original Sin, or something like that. According to this view of the matter, your tissues are being worn down by a word written on a piece of paper in your doctor's file cabinet. That concept is a little too voodoo-like for me, though. It seems to me that, if I'm going to develop kidney disease or go blind, it's not going to be a word that does it to me. If being "diabetic" can do me physical harm, then being "diabetic" must be definable in terms of some set of physical conditions actually present in my body. My medical records, in of themselves, can only harm me financially. The disctintion is important, because you can't change what's going on in your medical records, but you probably can change what's going on in your body.

As a physical process rather than a specimen of health-insurance jargon, being "diabetic" means having chronic hyperglycemia -- and you can do something about chronic hyperglycemia.

So the proper response, whenever some headline announces yet another linkage between diabetes and something bad ("Study Finds Diabetics 40% More Likely to Accidentally Address Boss on E-mail Complaining About the Boss") is not to assume that they must be talking about you, and get depressed. The proper response is to think about what you're going to do to make yourself as different as possible from the people they really are talking about. 

Wednesday, August 25, 2010  

Not quite so hot today, but it did get to 97 around the time we went running at lunchtime. This sort of thing is not for the faint of heart. It's also embarassing, because even after a cooling-off period and a cool shower, I get dressed and show up back in the office still sweating profusely. This has not gone unnoticed; a couple of people I work with tease me about it regularly. I don't enjoy this, I must confess. However, it doesn't matter whether I enjoy it or not, any more than it matters whether I enjoy the exercise itself or not.

I had a sandwich for lunch. No other carbs, though. I figured the post-prandial result would be under 120. I didn't expect it to be under 100. I guess that was the effect of the run.

Sorry, no words of great wisdom tonight. I got home a bit late after going to dinner with friends. I hope it won't be reflected in an elevated fasting test tomorrow morning -- but if it is, I'll just have to take action to correct it. I've done it before and I can do it again.

Tuesday, August 24, 2010  

The temperature got to 106 degrees today, but that wasn't until around 3 PM. When I went running at lunchtime, it was a mere 98. Still a little difficult, though, I have to admit. But when the heat really hits you is after you stop running, and try to cool down. We sat down in the shade for a few minutes afterward, letting the cold cement of the bench drain the heat out of us. That was the plan, anyway, but it had limited success.

Quoting these temperatures probably gives a misleading impression, though. The low-humidity heat of coastal California is far easier to operate in than the high-humidity heat of many other places. I did a run in Austin once that seemed hotter than today's run, even though the temperatures were in the low 80s rather than the high 90s. The humidity makes it seem much hotter because your sweat doesn't evaporate, and therefore doesn't cool you. Dry heat is easier; that I can handle.

A lot of people -- people more sensible than me, I suppose -- waited for the lengthening shadows of the evening before they did their exercise for the day. (The other local advantage over Austin, weather-wise, is that in the evening it actually cools off a bit. In Austin, when I was there, you waited in vain for that to happen.)

This has no direct bearing on diabetes -- and I don't have time tonight to contrive an ingenious way of making it seem to have a direct bearing on diabetes -- but I want to talk about ambiguity in communication. When you can't figure out whether the author meant "A" or "B", whose fault is that? Yours? His? Nobody's?

I'm inclined to be a hanging judge when it comes to evaluating ambiguous communication. If you don't make it clear whether you meant one thing or the other, I'm not just puzzled -- I'm pissed off. Sending that kind of confusion out into the world to make mischief is stupid and rude. I can't see an excuse for it. Maybe it's a mistake I make, too, but if I become aware of having made it, I feel awful about it. I try hard to avoid making that mistake, and I don't take the attitude that it can't be my fault -- that anyone who wasn't sure what I meant must be dumb.

What started me off on this train of thought was not an ambiguous research report on diabetes (though heaven knows there are enough of those in the world), but rather a reference to a particular American city being in the state known (at least to the person making the reference) as "MI".

The only thing that the abbreviation "MI" definitely suggest to me is "myocardial infarction", which is the term doctors use when they fear the term "heart attack" might be too readily understood. As the designation of a state in the US, it means nothing. Or rather, it means that someone is thinking of Michigan, or Minnesota, or Missouri, or Mississippi, and it's up to me to guess which of those four possibilities he has in mind.

Of all the misdemeanors we might charge the US Postal Service with, the invention of the two-letter abbreviation system for state names has to rank at the very top. Believe me, I have tried to memorize the list, and I just can't make it stick.

I suppose there is a system to it, if one knew enough about the history of this awful idea, but most of us are only dealing with the awful consequences of this awful idea. We see a state abbreviation in isolation. Someone is mentioned in a newspaper article as being a resident of "Dormant, MI", and we have to guess which of four states "MI" might symbolize.

"MI" isn't the only one of the two-letter abbreviations which might reasonably be supposed to represent more than one state. By my count, 20 of the 50 state abbreviations are ambiguous. Apparently "AL" means Alabama rather than Alaska, and "AK" means Alaska rather than Arkansas, and "AR" means Arkansas rather than Arizona. But how would you guess that? And if you give up trying to guess, and look it up, how do you then go about memorizing it?

Obviously, in a country which has seven state names that begin with "M" (most of them consisting of letters also used in at least one of the other six) it is flat impossible to create unambiguous two-letter abbreviations for states. Therefore, assigning two-letter abbreviations to the states was a totally stupid idea in the first place, and should not have been pursued. But they went ahead with it, all the same.

Call me harsh, but my judgement is that the kind of people who would deliberately invent a system of abbreviations in which 40% of the abbreviations are ambiguous are the sort of people who don't care whether or not anyone understands what they're saying . They want to do what they want to do, and that is the only consideration that matters to them.

When reports from the world of medical research are ambiguous, I don't tend to assume that mere carelessness is the explanation (although mere carelessness is bad enough, in my view). I think ambiguity in this context is part and parcel of the "spin" that is so often utilized in an attempt to make inconclusive or meaningless results seem important. For me, ambiguity is a great big red flag, a sign of serious trouble. When you catch someone writing ambiguously about health research, I think it's appopriate to react in about the same way you would react if you found out that the person who wants to rent your guest house has done time in a federal prison. 

Monday, August 23, 2010  

Good heavens -- something like an actual summer has broken out locally. It began on Saturday afternoon, at my company picnic, when the sun came out, just as if it were August or something.

(If I had realized there were going to be hot-air balloon rides, I would have arrived earlier and got on the signup list before it was filled up. I missed my chance!)

Sunday I attended a long meditation workshop, and by the time I got to the state park to do my trail-run afterwards, it was mid-afternoon and very definitely getting warm. (I had plenty of water with me, and drank plenty of it -- no need to take foolish chances.)

I was a bit crestfallen to see, during the run, unmistakable evidence of fall colors appearing in a few of the trees. It's a bit of a shock to see autumn arriving 24 hours after summer finally did.

Today it was over 90 degrees by the time I started my lunchtime run. If this were a normal summer, I'd be used to running in that kind of heat by August, but as it was I decided I'd better take it easy.

What on earth is this "energy" thing that people have become so obsessed with lately?

A lot of popular products promote themselves as "energy drinks", but in at least some cases they must be using the word in a metaphorical sense. Energy is actually measured, at least in edible products, in calories (well, it's really kilocalories, but let's forget that for right now), and yet none of these products are sold as "calorie drinks". Some of them could honestly do so; others, such as the one illustrated below, provide only 4 calories per serving. So if it this isn't really about energy in any literal sense, just what is it about?

What these products tend to provide, with or without sugar to make the whole idea more appealing (and the "energy" label more truthful), is some combination of substances which tend to make people feel nervous and excited. Caffeine is usually included, in heavy doses, but so are other things that tend to make people excitable. Those who equate such feelings with "energy" constitute a ready-made customer base for anyone wishing to promote an "energy" drink.

How much energy do people really need, though? Unless you are trying to stay up all night studying for the bar exam, why would you need or want such a product? I don't really know, but I'm more than willing to speculate.

I think a lot of people are trying to combat fatigue. They find themselves feeling tired and apathetic a lot of the time, and although this doesn't bother them quite enough to make them wonder seriously why they feel this way, it does bother them enough to make them ready to check out a product which claims to eliminate such feelings.

But come on! If you feel exhausted all the time, how likely is it that your body is genuinely lacking in "energy"? Unless you've been through certain kinds of extreme hardship lately (such as starvation or prolonged cancer treatment), it's a safe bet that your body has all the "energy" on hand that it needs. In fact, if you are overweight, that alone rules out the possibility that you have an energy shortage in any real sense. If anything, you have an oversupply of energy, in the form of large fat deposits.

However, readiness of action is another matter. A lot of people who have no shortcomings in the stored-energy department nevertheless feel very unprepared to go out and do things which will burn up some of that surplus energy. (And when they try, they feel awful.)

I would be lying if I said I've never been in that state myself. I would also be lying if I said I've been in it in recent years.

As far as I can determine from personal experience, that state of constant fatigue is the usual and expected result of a sedentary lifestyle. If you're not getting your exercise, undesirable changes start to occur within your cells, changes which make your body very ineffective at using the energy it has on hand. If you are getting your exercise, desirable changes start to occur within your cells, changes which (among other things) make your body highly effective at using the energy it has on hand.

I remember vividly how little "energy" I felt I had, during the years when I wasn't exercising, but that listless feeling is a memory only. I have a hundred times more "energy" now that I'm actually using it.

Tonight in yoga class we tried out "Ardha Chandrasana" (it has an English translation, but I know better than to share it with the irreverent). The pose looks like this, and if it doesn't look all that difficult, please have a shot at it yourself (and be sure to hold it for six slow breaths). It turns out that running in 90-degree heat was not the biggest challenge I took on today.

The main problem is balance -- or, as I like to put it, "not falling on your ass". Well, not falling on your ass is the main problem in a lot of other areas in life, too.

Friday, August 20, 2010  

I went into the company cafeteria for lunch, and the only thing that looked good to me was a vegetable lasagna (and the side dish served with it was roasted potatoes!). Obviously a high-carb lunch. But I was curious to see if I could have that kind of lunch today and not spike. I felt as if I probably could: my fasting test had been low this morning, and I'd had a good run. So, I took a chance on it. When I did a glucose test an hour later, I was prepared for almost anything in the way of a result. I was very relieved to find it was as low as 117.

All my doctor told me to aim for was to keep my 1-hour post-prandial results under 150, but I know that 150 isn't really "normal" -- it's more like "pretty good for a diabetic". It appears from what I've read on the subject that normal, healthy, non-diabetic people seldom go above 120 after a meal. Because I think my goal should be to achieve normal numbers rather than pretty-good-for-a-diabetic numbers, I feel a lot more comfortable when my post-prandial results are under 120 than I do when they're over it.

I didn't really expect to be under 120 after eating lasagna and potatoes, and I know better than to count on that happening again. But it's nice to know that I can even come close to doing that well.

I don't want to mislead you, though -- it wasn't a big serving of lasagna, and it was a quite modest serving of potatoes. Size matters!

You know what an isotope is, don't you? Maybe not -- "isotope" is one of those words that we hear so often, we tend to assume everyone knows what it means, when in fact lots of people don't. Well, let me see if I can explain it.

An element (oxygen, say) has specific chemical properties that make it different from any other element, and those chemical properties are determined by the number of positively-charged particles (protons) in the nucleus of the atom.

An oxygen atom always has 8 protons in it -- otherwise, it wouldn't be oxygen. If it had only 7, it would be nitrogen. If it had 9, it would be fluorine. The number of protons (also known as the "atomic number") is what defines an atom as being one element or another. 

But an atom also has some uncharged particles in it called neutrons, and because neutrons have no charge, they don't affect the chemical behavior of the atom -- they only add to its mass. Most oxygen atoms have 8 neutrons, but a few have 9, or 10. These variants of oxygen are called "isotopes". Individually, they are known as oxygen-16, or -17, or -18. Those numbers represent the "atomic weight" (sum of protons and neutrons).

What's interesting about isotopes of an element, from a biological standpoint, is that your body can't tell them apart. Their chemical properties are exactly the same, and when you breathe the air, it doesn't matter which isoptope of oxygen you're getting, so long as you're getting oxygen of some kind. The difference between the isotopes of an element is that some of them are a little heavier than others (which is what allows physicists to tell them apart).

As it happens, nearly all oxygen is oxygen-16. But, because oxygen-17 is heavier, and oxygen-18 is heavier still, it is possible (with enough lab equipment and enough patience) to separate a sample of oxygen into its isotopes, and isolate a smaller sample of each one.

In the 1930s, it occured to a biochemist named Rudolf Schoenheimer (a refugee from Hitler's Germany, then living in the United States) that, if you could "label" a sample of an element with an unnatural abundance of a rare isotope, you could later track the sample to wherever it went within a living organism -- like paying ransom money in marked bills, and then tracing it to the kidnapper.

At first, the isotope Schoenheimer used was hygdrogen-2, simply because at the time it was easy to isolate. Later, as the technology of isotope-handling improved, he used nitrogen isotopes in studies of protein metabolism (protein contains nitrogen; fats and carbohydrates don't). At first he did animal studies (feeding isotope-marked food to rats, to see where the isotopes went in the rat tissues); later he progressed to studies of human metabolism.

He found some surprising things along the way. Up to that time, it was assumed that body fat was a very static thing -- if you gained weight, and didn't afterwards lose weight, the same fat molecules would sit there on your chubby thighs for years, and perhaps for the rest of your life. But Schoenheimer's tracking of isotopes within the body showed that this was not true -- body fat is a dynamic, active substance, and fat molecules are constantly entering and leaving it. When you eat isotope-tagged foods, the istopes soon show up in your body fat (even if your total body fat hasn't increased a bit). And then the isotopes are excreted or exhaled, because your body used some of those fat molecules (even if your total body fat hasn't decreased a bit).

The same with proteins: if you eat isotope-tagged proteins, the isotopes very soon start showing up in your body within proteins which aren't even the same kind of protein. The body is constantly creating, modifying, and destroying proteins; it tears proteins apart into their constituent amino acids, and then assembles different proteins from those amino acids. The recycling never stops.

In short, all of the substances which make up your body are in constant flux. The total amount of protein or fat might not change, but the molecules of fat and protein come and go all the time. Nothing remains at rest.

Now, these discoveries Schoenheimer's were exactly what no one expected. After all, why should the body act that way? Wouldn't it be simpler to just let the body's fats and proteins remain static? Juggling them constantly in this way surely cost more energy -- why bother doing it?

Apparently because, if the body's constituent molecules are constantly in flux, the body is constantly capable of adapting itself to changing circumstances. After all, the conditions of life are not static. The temperature is changing all the time. The amount of water you take in (and sweat out) is changing all the time. The amount and type of food you take in is changing all the time. The amount of physical activity you engage in is changing all the time. The amount of stress you're dealing with is changing all the time. An organism that couldn't keep shifting gears to adjust to these changes would not survive long.

I find something oddly hopeful in knowing that the human body is, to such a large extent, dynamic rather than static -- that it is constantly changing, at least at the molecular level. Diabetes is usually presented to us as a dramatic and permanent change for the worse; we shouldn't expect ever to see any improvement in it. I'm unwilling to accept that hopeless view of the matter, and I welcome any evidence which helps to undermine it -- recent evidence, or evidence 75 years old, as the case may be. It seems to me that we still haven't fully come to terms with Schoenheimer's discoveries even yet. I think we still tend to see the body as more static than it really is, and this discourages us from attempting to change what we assume cannot be changed.

Thursday, August 19, 2010  

Blood pressure is up a bit tonight, and I'm beginning to think that the best thing I can do to bring my blood pressure down is to stop reading reports coming out of the ACCORD study, that grand exercise in jumping to reckless conclusions. If watching seemingly intelligent people miss the point by a mile is irritating to you, most commentary on the ACCORD study does not make soothing reading.

ACCORD ("Action to Control Cardiovascular Risk In Diabetes") was a big clinical study which looked at thousands of Type 2 patients who were considered at high risk for cardiovascular disease. The goal of the study was to find out if "intensive" treatment to achieve tighter glycemic control (and by "intensive" they meant drugs, drugs, and more drugs) would result in fewer heart attacks. The outcome: patients getting "intensive" treatment had a slightly increased risk of heart attack, instead of the reduced risk that was evidently hoped for. (I'm sure I don't know why it was hoped for -- it has long been clear that tight glycemic control is helpful in preventing "microvascular" complications, such as kidney disease and retinopathy, but not in preventing "macrovascular" complications such as coronary heart disease. If you want to avoid those sorts of problems, you have to work on the issue at the gym and the dinner table, not at the pharmacy.)

Anyway, the ACCORD study received a lot of press attention, and the study results were framed in such a way as to make it appear the study showed that controlling your blood sugar is actually bad for you. Of course the study showed no such thing; at most, it showed that intensive drug therapy doesn't solve the problem of heightened cardiovascular risk in diabetes patients, and may make the problem slightly worse. (I say "may" instead of "does" because another study called ADVANCE contradicted the ACCORD study on this point. According to ADVANCE, intensive drug therapy doesn't actually make the problem any worse -- it just fails to make it any better.)

You would think that, after the howls of protest from diabetes patients over the way the ACCORD results have been presented in the press, commentators would start to become more cautious in what they say on the subject. Not so. Just the other day, this Medscape article discusses evidence from the ACCORD study indicating that intensive drug therapy didn't even help with microvascular complications -- and ends with this zinger:

"In ACCORD, intensive glycemic control did not lower the incidence of a composite endpoint of advanced microvascular adverse outcomes. When this finding is considered against the background of excess mortality noted in the intensively treated group, a target HbA1c level of 6% clearly is not appropriate for patients like those enrolled in ACCORD."

Aaaaaaargh!!!!  How clueless can people get?

The ACCORD study didn't find that it's bad to have an A1c target of 6%! It found that dosing people with multiple drugs in generous amounts is the wrong way to hit that target. The ACCORD study didn't even look at people who were achieving good glycemic control by changing the way they live.

Look, if somebody does a study which finds that weight-loss surgery has harmful long-term consequences, you don't report it as a study which proves that losing weight is bad for you. Discrediting a particular way of achieving a goal is not the same thing as discrediting a goal.

Why do people keep publishing this crap? And why can't they see that it's crap? I mean, you really don't have to look that closely!

But now I'm going to stop thinking about ACCORD, and see if my blood pressure comes down any. 

Wednesday, August 18, 2010  

It's not always easy fitting exercise into your day. Although I have a couple of running buddies at work, and at lunchtime I usually go running with one or both of them, sometimes we can't get free at the right time to make it work.

Today one of my running buddies was not in the office, and although the other one was seemingly free, just before we were supposed to leave she got a phone call from her boss. She communicated to me by gesture that she thought the call would be brief, so I went to the locker room to get dressed for the run, and went outside to wait for her. After a while it seemed clear that the call had not been brief, and she wasn't coming. So I took off running. Shortly after I departed, she came outside looking for me, and found me gone. So she took off -- following a different route than I had taken.

The result was that, after I had been running for about a mile, I encountered her coming the other way on a side street. So, we joined forces, and finished the run together. All's well that ends well.

Maybe this anecdote isn't so fascinating as I'm trying to pretend it is, but I think it illustrates something of importance. If you're going to make exercise a part of your day, you have to be insistent about it. When the exercise plan you started with doesn't quite work out, you have to improvise a solution. You don't just give up on the idea.

I think the reason a lot of people don't manage to exercise regularly is that they proceed from the unconscious assumption that exercise is something you do provided that the stars line up properly and nothing goes amiss. Which means, of course, that anything which does go amiss is sufficent excuse to scrap your exercise plans. You meant to exercise today, of course you did, but things just didn't work out. You were busy at the office. Your running buddy wasn't available. Your boss telephoned at an inconvenient time. Someone invited you to lunch. It started raining. You looked in your gym bag, and saw that you forgot your towel. Anything that doesn't go according to plan is sufficient reason to drop the plan entirely.

The thing is, a day is nearly always going to be filled with little surprises which tend to derail our exercise plans if we let them. Perhaps the question we need to ask ourselves is whether these little surprises would prevent us from doing something that we urgently wanted to do. Did it ever happen, even once in the course of human events, that two people heading for an illicit affair decided not to pursue it because they were busy at the office, or because one of them forgot his towel? People tend to find a way around practical obstacles, if there's something they really want on the other side of those obstacles. Perhaps we need to manage our illicit affair with exercise along similar lines.

106 is a good post-prandial result, especially considering that it followed a lunch that wasn't especially low-carb. I had a sandwich and milk, probably about 45 grams of carbohydrate. No doubt the run before lunch helped.

Tuesday, August 17, 2010  

From time to time I have seen the term "METs" used on cardio machines at the gym, but I have resisted finding out what it means. I figured I need another unit of measure in my life as much as I need another computer password in my life. I also had a hunch that METs might turn out to be like the glycemic index: a new way of stating what we already know.

However, if people doing research on exercise are going to insist on using METs, they leave me no choice but to learn the term, so that I can understand what they're talking about. Accordingly, I looked into METs, and here's what I found out.

MET stands for "metabolic equivalent of task" (sometimes it is called "metabolic equivalent" rather than MET). It is a way of quantifying the intensity of physical exertion required for a particular task, and it is expressed as multiple of the resting metabolic rate. In other words, the energy cost -- calories burned and oxygen consumed, over a given time period -- of resting is equal to 1 MET, and an activity that uses twice as much energy per minute as resting does is equivalent to 2 METs.

So what activity is rated at 2 METs? Leisurely walking (at a pace of less than 2 miles per hour). Surprisingly, writing (that is, typing at computer keyboard) comes close to this (1.8 METs).

Leisurely bicycling (at a pace of less than 10 miles per hour), on the other hand, is rated at 4 METs. Running and vigorous calisthenics are rated at 8 METs. Jumping rope is rated at 10.

Is anything rated at less than 1 MET? Yes: sleeping. It only rates 0.9 METs. Watching television, however,  rates a "1" -- exactly equivalent to rest (so long as you stay awake).

So what does the MET concept add to what we already know from reports of how many calories per hour various forms of exercise use? Well, I guess what it adds is a set of numbers that are smaller and easier to remember. Maybe that's enough.

Anyway, people doing public-health studies that look at the impact of exercise are inclined to use the concept of "MET-minutes" to sum up how much exercise people are doing, in a way which takes into account both the intensity and duration of a workout. (It's a simple enough formula: if you exercise at a MET level of 2 for an hour, that's 120 MET-minutes, but if you exercise at a MET level of 4 for an hour, that's 240 MET-minutes.)

So, if there is recommendation to get 1000 MET-minutes of exercise a week, that requirement could be met by:

I included that last item to make a point: these things may be equivalent in terms of total energy usage, but that doesn't mean they provide the same cardiovascular benefits. That is why, even if I had time to do more than eight hours of walking a week, I would still think running is a better deal.

Of course, the METs concept also suffers from the same problem as estimates of calories-per-hour for different kinds of exercise: it is based on experimental data collected on some volunteer who is not like you. The MET value is pretty imprecise in terms of applicability to individuals. It gives us a good relative basis for comparing one kind of exercise with another, but it would be reckless to conclude anything more than that from it.

What led me to give in and look up what "METs" meant was this Medscape article with the arresting headline "Higher Exercise Capacity Equals Improved Survival in Older Adults".

In the study, researchers followed 5314 men in the age range of 65 to 92 years over a period of about 8 years. Their capacity for exercise (based on their peak performance on a treadmill) was assessed in terms of METs, and the men were sorted into categories based on this. The men in these categories where then compared in terms of the ultimate measure of health, which we laymen in our simplicity tend to refer to as "not dying". An effort was made to exclude men already suffering from a known disease, so that the survival rate was being evaluated (insofar as possible) solely in terms of exercise capacity.

Given that the men were 65 to 92 years old at the start of the study, it should come as no surprise that a lot of them (almost 40%) died over the course of the next eight years. However, the death rate was not the same in all the fitness categories. Each increase of one "MET" in exercise capacity amounted to a 12% reduction in death rate.

"In terms of the graded survival benefit, those able to achieve a MET level >5.0 had a 38% lower risk of death compared with the least fit individuals, whereas the fittest individuals, those able to achieve a MET level >9.0, had a 61% lower mortality risk."

I guess I'd better keep running.

Monday, August 16, 2010  

It worries me that people tend to talk about diabetes in absolute terms, when the particulars of the disease are essentially relative, not absolute.

For example: the people whose "borderline" test results leave them unsure whether or not they have diabetes, and who (in their eagerness to get the issue resolved) make it clear that they think the world is divided neatly into people who have diabetes and people who don't even need to think about diabetes. (Look, either I have it or not! Why can't they just tell me, so I can put the whole issue out of my mind if the answer is "no"?)

I don't think things are quite so neatly arranged as that, however. What seem like distinct categories can become very hard to define when we take a closer look at them.

I think of diabetes as being like the color orange. We all think we know orange when we see it -- until we try to make a decision about which things are orange and which are not. If we're shown a picture of the visible spectrum, we feel confident about pointing to a particular patch and saying "There -- that part is orange. The color on the left of it, that's yellow. And the color on the right of it is red. But that part in the middle is definitely orange".

We can even put labels on a chart of wavelengths, and say "That section centered around 650 nanometers is what we call orange". At least, somebody did that with the spectrum above, although if you ask me the orange region is actually located a little to the left of where they marked it -- maybe 625 nanometers. Perhaps their color vision differs slightly from mine.

Okay, but even if there were no individual differences in color perception and the spectrum looked exactly the same to everyone, we would still have to make some kind of decision about where orange ends and red begins. If we zoom in on that region of the spectrum, where exactly would you put that boundary? It's in here someplace, but where?

Maybe you can do it at this scale -- but how about if we zoom in further? To my eye, at least, the orange/red border lies within the range shown below, but if you asked me five times to point to where the boundary is, I'd probably point to a different place each time.

As a practical matter, we often have to make artificial distinctions within a realm of continuous change. Either you've had your 21st birthday or you haven't, and the legal system has decided to make important distinctions based on that, even though we all know that nobody really experiences any kind of dramatic transformation on a "milestone" birthday. 

In terms of diabetes, either you've had a glucose test result above 125 or you haven't, and the health-care system (or rather the health-insurance system) has decided to treat that fact as definitive. You "have" diabetes (or not) based on the answer to that simple question. But what if they had picked 120, or 130?

In fact, the diagnosis point used to be 140. When it was redefined downward, did hundreds of thousands of Americans "develop" diabetes overnight? If had been redefined upward instead, would hundreds of thousands of Americans have been "cured"?

My problem is not that the wrong fasting number is being used as a diagnosis point (clearly, any choice would still be arbitrary and arguable). My problem is that I think we are making too much of the distinction between one part of the diabetes spectrum and another part of it. If we simplify diabetes down to the point that we declare that Larry "has" it and Harry doesn't, on the grounds that Larry's fasting test was 126 and Harry's was 124, we're missing an awful lot of the point of what's going on here. I'd say they're both looking mighty orange. How would anyone get a fasting result of 124 if his endocrine system wasn't struggling (and starting to lose the struggle)? But this point is surely going to be lost on Harry if we allow him to think that diabetes is not his issue to worry about, because he doesn't "have" it.

Not that most doctors are necessarily describing the situation as crudely as that to their patients. A lot of them are using terms such as "prediabetes" to explain that, if 124 isn't diabetes, it sure isn't normal. I'm afraid that the subleties are lost on most patients, though. I've certainly conversed and corresponded with people in the "prediabetes" limbo who imagine that what they're dealing with is not diabetes, and not anything like diabetes, and not especially connected with diabetes, and not likely to become diabetes. They're living in a mental world of absolutes; either you have diabetes or you don't, and they don't. They think they're somewhere over in the blue part of the spectrum, when in fact they're about as blue as a tangerine.

There are a lot of these "spectrum" issues associated with diabetes, in which far too much is made of artificial boundaries within a continuity of change. For example, a lot of people think any HbA1c test result that's below 7.0 is fine -- a perfect score. Well, it's better than being above 7.0, that's true. But 6.9 isn't a perfect score, and you should try to do better than that if you can. But who's going to try to do better than that, if they've got the idea stuck in their head that 6.9 = great?

Saturday, August 14, 2010  

Yesterday was a non-exercise day, with a big picnic dinner thrown in for good measure, so a fasting levelof 87 is pretty darned good under the circumstances. Still, I felt as if today was definitely the day for some endurance exercise. Specifically, a trail-run that was a little more challenging usual.

I was encouraged in this resolution by the weather, which was very nearly summer-like. I think I've mentioned that this has been an almost bizarrely cool summer in northern California, with the afternoons offering, at best, a brief break-up of the cold Pacific fog which is blanketing the landscape most of the time. Today it was warm enough that I actually needed to turn on the air-conditioner in my car on the way to the state park.

I had with me a hydration backpack and a glucose gel, and I was starting early in the afternoon, so I thought it was safe to choose one of the longer, more remote trails, which I generally have used only for long-distance training leading up to a marathon. I don't see that part of the park very often. It's pretty in there, though.

On the shorter trails, you cross paths with a fair number of hikers and runners, but on the more remote ones you only see mountain-bikers, because it's too far to go for most people who are transporting themselves on foot.

Sometimes it gets a little creepy when you realize that you haven't even seen a mountain-biker in a while, and you start to feel very much alone in the woods. What if you hurt yourself in here, and nobody comes by and finds you?

Well, I didn't hurt myself, and I enjoyed the run.

Even though the distance ended up being just short of 11 miles, I didn't feel exhausted at the end. I still had some energy to spare if I had needed more. My leg muscles were starting to get a bit sore, though, so I was glad to be finished.

I went home and had the most fantastic nap -- I'm usually not good at naps, but this one was great. It was also lengthy: I spent about three hours lying down, with alternating periods of sleep and semi-wakefulness, and feeling blissful throughout. This is one of the things I like about endurance running: the endorphins that your body generates when you exercise that long make you feel wonderful afterward, and I don't know of another way to capture that feeling (although they say heroin comes close).

Dinner was not low-carb (I even indulged in taco chips -- not one of my usual foods), but I managed to get a post-prandial result under 120, which I'm sure was also an effect of the long run. That's another thing  I like about endurance running: it lets me get away with eating such things as taco chips once in a while. A lot of people with Type 2 diabetes ask "what is okay for me to eat?" when a more realistic question to ask would be "what have I earned the right to eat?". Today I was pretty sure I earned myself some taco chips, and the test results bore this out.

I don't have to do distance running to keep my blood sugar under control, but doing it gives me options that I wouldn't otherwise have.

Thursday, August 12, 2010  

More strangeness. Yesterday I was down to 86 an hour after dinner -- this morning my fasting result was up rather than down. It sounds like a contradiction, but conceivably there was a connection. Maybe I went too low last night, and my endocrine system overcompensated for it a bit. 

This stimulated me to read up a bit on the dawn phenonomen and the Somogyi effect -- or, to give it what has apparently become its full name, "the controversial Somogyi effect". I'll get to the controversy in a minute.

Both terms refer to surprisingly elevated fasting glucose results. The difference is that the dawn phenomenon is thought to be a rise in blood glucose triggered accidentally by the routine release of certain hormones before dawn, while the Somogyi effect is thought to be a reactive rise in blood glucose in response to an episode of low blood glucose during the night.

The dawn phenomenon is almost surely the more common of the two. The endocrine system tends to releases certain hormones during the wee hours of the morning, as part of its routine process for getting us ready to face the day. Several hormones are involved, including the "stress" hormones (adrenaline and cortisol) and human growth hormone. These hormones tend to have the incidental effect of suppressing insulin release (or insulin effectiveness), and in anyone with Type 2 diabetes this incidental effect is likely to have a noticeable impact on blood glucose levels. Even people who don't have diabetes probably experience a subtle form of the dawn phenomenon, but diabetes can greatly magnify the imapct of it. If your insulin productivity and insulin sensitivity are compromised to begin with, your system can't easily cope with a situation that compromises them further. What ought to be no worse than a slight rise in blood glucose may become a real spike.

Now, about the "controversial" Somogyi effect. What Dr. Somogyi claimed was that high fasting tests were sometimes the result of an overcorrection -- a hypoglycemic episode occurred during the night, and the endocrine system overreacted to this, so that blood glucose shot up:

What makes this "controversial" is that researchers have reported that they looked for evidence of this scenario actually playing out (using continuous glucose monitoring), and didn't find it. However, I don't know how hard they looked. Specifically, I don't know how many people they tested and how often they tested them. It seems to me that the Somogyi effect is bound to be a sporadic phenomenon rather than a predictable one. I sometimes have terrible cramps in my calf muscles during the night, but I'm sure a researcher who doubted this could monitor me on quite a few nights in a row without once catching me in the act of sitting up suddenly in bed, howling and cursing. So far as I know, Somogyi never claimed that the effect he described is the only cause for high fasting glucose, or that those who experience it do so every night. Therefore, if someone looked for it and didn't see it, that doesn't necessarily mean it never happens.

Anyway, I'm inclined to think that the Somogyi effect is for real, but only happens occasionally. It may be that it happened to me last night (or rather this morning). Obviously it wasn't a very dramatic effect, as I only went up to 98, but I'm usually not that high in the morning, and I'm usually not as low as 86 after eating dinner either, so I think it's at least plausible that I became hypoglycemic during the night, and then swung a little too far the other way.

Wednesday, August 11, 2010  

Now that's just weird: my after-dinner result was lower than my fasting result was today. It was a pretty low-carb dinner, but still. My lunchtime run was a little more difficult than usual today (a very steep hill was involved); maybe that had some kind of impact. But I wouldn't expect it to make that much difference.

Well, I guess if glucose testing weren't unpredictable, we wouldn't need to do it in the first place.

My blood pressure's been rising this week -- I'm not sure why, but I think it's because of coming back from vacation and plunging back into office anxiety again.

This cartoon was making the rounds at work today:

What I like about Dilbert's boss is that you know he's about to say something awful, but when he finally says it, it always turns out to be a little worse than you expected. He doesn't just approve of faking data, he's surprised to learn there are other possibilities. I didn't even know data can be real.  What a line!

Middle-management is the apparent satirical target here, but I see a wider applicability, beyond the sphere of the business world. I think there are plenty of people involved in medical research who would be surprised to learn that data can be real.

Come to think of it, the field of medical research isn't beyond the sphere of the business world, and that's exactly what's wrong with it. Maybe Dilbert's boss was the one running the clinical trials for Avandia.

Tuesday, August 10, 2010  

Okay, there's progress. Nice to see the fasting result under 90. Also nice to see the after-lunch result under 120. Lunch included pinto beans, which some people see as a problem food because of their starch content. Well, at least it's moderated by their high fiber content.

My diet may be drifting in the direction of lower carbs, but I'm not ready to go nuts on the subject before I have to.

In yesterday's blog I was struggling to find an answer to the rather difficult question a reader posed to me, about how exactly I got myself motivated to do what was necessary to get my blood sugar under control without meds. It wasn't a question about what needs to be done -- it was a question about how you make yourself do what needs to be done.

I've pondered the question since, trying to arrive at an honest analysis of what's been motivating me. I came up with two things: shame and humor.

At the time of diagnosis, my feelings were not primarily the ones people usually talk about -- shock, fear, anger, confusion, all that stuff. For me it was all about embarrassment. My doctor had warned me of various health consequences (including diabetes) which he expected me to suffer if I didn't lose weight, and instead of losing weight I had gained more of it, thus making his prediction come true in less than a year. It doesn't get any more embarassing than that, at least so far as I know. I felt utterly, miserably ashamed of myself. And I wanted to get over being ashamed. In fact, I think I wanted to get over being ashamed more than I wanted to get over being diabetic. So, I became determined to amaze my doctor by doing much better than his other patients -- and much better than he ever imagined I would do. That was my real focus: achieving great results, more for the sake of the achievement itself than for the sake of my health. (This may be a strange way to see the problem, but it's how I saw it.) I wanted to get results that would impress, in the same way that people who do rose-gardening or quilting or restoring old cars want to get results that impress.

Once I got started down that path, and my approach started working, another motivation developed for me: humor. I began to see it as funny that I was exercising so much, and losing so much weight -- specifically because it was so unlike me to do these things. I figured I was baffling everyone around me, by transforming myself into a totally different person than they thought they knew. As time went on this basic incongruity became more amusing to me rather than less -- although I did have to keep raising the ante. I think part of the reason I ended up running a marathon was that I was trying to push the joke as far as I could. (Again, it may be a strange way to see the problem, but it's how I saw it.)

Although I would like to think that other people could adopt my view of diabetes management as a form of character-based comedy, it does sound like a pretty eccentric idea even to me, so maybe it isn't possible for other people to follow my example in that regard.

Still, I may be onto something in a larger sense. Maybe the larger issue here is what I call entertainment value. Whenever people are devoting themselves passionately to some activity, and really making an all-out effort at it, it's a safe bet that what they're doing has some kind of entertainment value for them. We all differ as to what entertains us (I'm sure that, for a mathemetician, matrix algebra is entertaining at some level, which is one of the ways you can tell the difference between a mathematician and, say, me), but whatever does entertain us, we gravitate toward it. Hobbies and even careers need to have entertainment value as a base to build on. When people get burned out in their careers, I think it's usually because whatever part of their job was the fun part for them has been minimized or removed, and they're left with the boring part of it. Leadership, at least in my opinion, depends heavily on entertainment value -- true leaders are people who are so interesting or amusing that you listen to them for fear of missing something good if you don't. (I doubt very much that history records an example of a successful leader who bored the daylights out of his followers.)

So, although I don't think everyone needs to see the kind of comedy that I see in the personal transformation that diabetes management requires, I think everyone needs to locate some kind of entertainment value in doing what's necessary. Diabetes management is the most demanding hobby there is, and as with any hobby, you need to find out how to get some fun out of it, or else you'll never put the required effort into it.

Monday, August 9, 2010  

96 is not a great fasting result; I'm still working off the effects of vacation. Probably it will be lower tomorrow morning. I'm getting back into my normal routine. Yesterday I did a long trail-run (8.6 miles), and it felt surprisingly good after nine days without running -- I didn't even feel tired at the end. And tonight I went to yoga class and worked out the last remaining kinks from my week of sleeping in a tent. I'm feeling good. So, I'm pretty sure that I'll have myself back on track shortly.

Not that I was so very bad while I was on vacation, but my exercise was reduced to about 30 minutes of cycling on most days, plus a certain amount of walking around on hilly terrain. And the meals at camp where almost always higher in carbs than anything I would have eaten at home. And, of course, I was not getting enough sleep, since I was staying up to all hours playing music every night. None of these things are good for glycemic control. Two of my fasting tests during the week were over 110, which is very high for me. When I'm at home, following my usual routine, my fasting tests are typically in the 80s. The fact that the numbers start drifting up as soon as my normal program is disrupted is a sobering reminder that my diabetes has not gone away -- it's just been kept under wraps. I can never take my eyes off it for long.

The low post-prandial result after dinner was welcome, of course, but it was a pretty low-carb dinner, so it wasn't much of a test. Tougher challenges may lie ahead. Well, if they do, then I'll just have to deal with them.

A reader who would like to do about diabetes what I'm doing about diabetes asked me, essentially, "how did you do it?". Missing the point of the question, I sent him a long description of what I did. But he hadn't asked what I did -- he had asked me how I did it. Judging from his reply to this, I now think what he meant by "how did you do it?" was "how did you make yourself do it?".

His dilemma is not that he doesn't know what he needs to do. His dilemma is that he can't find a way to convert his good intentions into actions. This seems to be an extremely common problem, among people with and without diabetes. When we know that we need to replace one set of habits with another, a huge barrier stands in our way, in the form of inertia. The human body prefers to keep on doing what it's used to doing, and it hates replacing comfortably familiar behavior with anything new, uncomfortable, and challenging.

The problem isn't that we haven't heard exercise is necessary, or that we can't persuade our brains to acccept the principle that exercise is necessary. The problem is that we can't persuade our bodies that it's time right now to get up and go to the gym and exercise.

Or, to take another case, the problem isn't that we haven't heard we need to be careful about our carbohydrate intake, or that we can't persuade our brains to accept the principle that we need to be careful about carbohydrate intake. The problem is that we can't persuade our spoon-hand that the principle applies right now to the very same big bowl of oatmeal that is sitting on the table in front of us.

These issues are a struggle for me, as they are for everyone, and if I've had more success in the struggle than some people, I guess I owe it to the world to share my secret. The catch is that I'm not sure I know what my secret is, and this makes it a difficult secret to share.

Things like this happen at an intuitive level, and people who operate intuitively (musicians and actors, for example) often don't want to examine the details of how they do what they do -- or else they try to examine the details and find that they can't. There's a great story about Sir Laurence Olivier giving the performance of his life one night in a London theater, as Othello, and then having a fit of despair in his dressing room afterwards. This astonished his fellow actors, who asked why on earth he was so upset -- he'd been brilliant, he'd been on fire, it had been his best performance ever. To which he replied, staring miserably at the wall, "I know -- but I don't know how I did it". I have found, more than once, that asking master musicians to explain how exactly they're achieving a particular effect often leaves them at a loss for words. They can't tell you how they do it, because they don't know themselves how they do it. They just do it.

I think I'm going to have to meditate for a while, and see if I can figure out what my secret is, so that I can share some kind of useful information about it. With luck, maby I'll have something tomorrow!  

How I Spent My Summer Vacation

So this is where I spent last week -- in a tent in the woods near Mendocino, California:

At least, that is where I spent those occasional episodes last week during which I was sleeping. The rest of the time I was off somewhere making music. I was at Lark Camp (a yearly gathering of traditional musicians). A lot of different traditions are represented; I go there mainly for the Irish music (here's a sample of the same, recorded at one of the evening jam sessions -- I'll link to a few other recordings as I go), but I always make a stab at playing some other things as well.

The daytimes are devoted to classes or "workshops", in which people assemble in little groups (mostly outdoors, on whatever patch of flat ground has room for a circle of folding chairs) to study particular instruments or styles. 

For example, this class, which met in front of the dance hall, was about playing Irish music on the mandolin:

The mandolin produces a rather delicate sound, so it was unfortunate that the mandolin class was placed just around the corner of the building from a klezmer class that included loud brass instruments. The mandolinists just had to tune out the tubas as best they could, and focus on their own sounds -- which I guess is good practice for the real world. 

Of course, even the klezmer band was pretty quiet compared to the Galician bagpipe band practicing down by the creek.

I liked wandering around camp and hearing the variety of sounds coming from different locations. In an otherwise quiet stretch of the woods, I heard faint music and a woman's voice calling "Listen to the bass! Listen to the bass!". She was teaching swing dance under a canopy in the distance.

Upon closer approach, the dance band turned out to be just a guitar and a bass, unamplified, in the middle of the woods. We hear so little unamplified music anymore that it's especially nice to encounter it in a natural environment, and realize how far it actually carries if you just open your ears to it.

The camp is actually three camps, and I rode my bike back and forth between them to attend the events I was interested in. My mornings were devoted to Irish music; my afternoons were an eclectic mix of whatever else I felt like trying my hand at.

The hour before dinner I always spent with the French musicians. I find their tunes pretty easy to pick up by ear (the tempos are not nearly as fast as in Irish music) -- and they're also pretty relaxing tunes to play over a glass of red wine as the setting sun is lighting up only the tops of the trees.

I even played with them for the French dance on Thursday night --  I figured they had enough accordions and bagpipes to drown out any mistakes I might make.

There were dances, concerts, and other special events in the evenings, but a lot of people spent the late hours just getting together in small groups and jamming. Evenings in coastal California are not balmy, even in August, so playing outdoors required a certain hardy spirit, backed up by layered clothing.

Those who couldn't face the chilly night air headed for the indoor sessions -- if they could find room for themselves in there. It was always worth squeezing into the indoor Irish jam, if you wanted to play something lively.

A special feature of the evening concerts that you wouldn't encounter elsewhere: when the audience consists entirely of musicians, a singer who requests the audience to sing along is sure to get a pretty good response.  

Camping, playing music till the wee hours, and eating whatever food the camp is providing all add up to a fairly chaotic program in terms of managing your health. But maybe we need to make room for a little chaos in our lives, at least on special occasions. You can't spend every day of the year focusing entirely on diabetes.

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