Saturday, February 27, 2010  

Ah, that's better -- fasting result back in the low 80s. Supposedly anything under 100 is normal, but not everyone agrees on that point. Even if we accept it as true, I still figure I might as well stay under 90 if I can -- and I usually can.

It seems that most healthy, non-diabetic people have fasting levels in the low 80s, so that's what I'm aiming for. My assumption is that the best thing to do if you have diabetes is to make yourself as much like someone who doesn't have diabetes as you possibly can. If you can't "cure" it, making it completely undetectable is the next best thing.

The weather forecast called for a 50% chance of rain, and I decided that this meant it was going to rain half of the day. It rained in the morning, therefore I decided it was going to clear up after lunch, and planned a trail-run for the afternoon. Purists might fault with my logic in this case, but I was right in my prediction: it did clear up in the afternoon, and rather spectacularly, too. So I headed down to the state park for a run, and I took my camera with me.

There weren't many people on the trails today, probably because I hadn't let the community in on my prediction of a clear afternoon, and most people had made other plans by the time it became obvious that it was actually a good day to go out and get some fresh air.

There weren't even many people at the lake, which is seldom a lonely place, as all the trails in the park lead there.

The green phase of the year in California does not last very long, so I try to enjoy it while it lasts.

Altogether this was a much better way to get my exercise done than going down to the gym, so I'm glad that the weather cooperated with me so well!

Friday, February 26, 2010  

Huh? What? 98?

My elevated fasting result this morning (18 points higher than yesterday, and after a day of low-carb eating and a 5 mile run!) caught me unprepared. But then, the morning itself caught me unprepared. I overslept, woke up in a panic about being late, and raced through my morning routine. Whenever that happens to me, my fasting result turns out to be higher than I'm expecting (exactly what causes that, I don't know, but I suspect adrenaline plays a role in it).

Anyway, I don't think the increase is significant unless it persists. The repeatability-problem that glucose meters suffer from can be enough to explain a single, atypical result. I just have to make sure there isn't a general upward trend.

The storm arrived on cue today -- no actual lightning, but a real onslaught of wind and rain. I was very glad not to be out in that. But around 5 PM the skies cleared and the world was beautiful. I'm hoping for nice weather tomorrow (despite the forecast of more rain), or Sunday anyway, so that I can get in a good trail-run.

Having identified myself online as a diabetes patient, I get a fair amount of e-mail from organizations that think they know what my problems are, and wish to help me overcome them. I'm not sure I'm entirely flattered by all of the assumptions they are making about me. Sometimes the subject line is as much of the message as I ever get around to reading. I certainly didn't get very far into the one called "Regain Your Lost Health and Apperance", or the one called "Could You Have An Eating Disorder?"

Some kind of morbid curiosity made me open "New Top Secret Recipe", but it seemed to exist for the sake of tricking me into clicking a link which I would probably regret clicking, not least because the top secret recipe was described in this way: "Todd's latest creation: Kraft Deluxe Macaroni & Cheese! Save money by cloning the best mac & cheese kit with two kinds of cheese." Perhaps the recipe would have turned out to be as awesome as the computer virus I would have acquired by following the link, but as far as I'm concerned that secret recipe is going to remain secret.

And then there was today's message: "Skinny Chicks Don't Eat Salads". This one is intriguing enough that I think I will quote from it at some length. It comes from one Kelly Jennings of Rodale Books, and it opens as follows:

"Dear Tom, 

Does this sound familiar?

You wake up after a late night spent with a pint of Rocky Road ice cream or a jar of marshmallow cream. To avoid any more calories, you replace breakfast with a tanker load of coffee. Lunch gets back on track with a big healthy salad ... but somehow, you're not satisfied. Then the cravings kick in. Chocolate chip cookies ... sugary candy bars ... frothy iced caramel mochachinos ... you can't resist. And worst of all, you find that once you start, you just can't stop. And you wake up back where you started."

Actually, Ms. Kelly Jennings of Rodale Books, it does not sound familiar, but thank you for painting such a vivid portrait of the loser you imagine me to be.

She continues: 

"And that's how salads get you into big fat trouble.

But now, you can eat "normal" food and be thin, too! It all starts with stepping away from the salad mentality and learning the truth about what makes us crave what we shouldn't eat and why eating what we shouldn't isn't so bad for us. 

Everything you need to know to stop starving, start eating the foods you love, and still lose all the weight you want is inside ..."

Hmmm. I wonder if eating a jar of marshmallow cream before bed counts as an example of eating "normal" foods? More likely it's only an example of the kind of decadence that people like me fall into, after we have fallen victim to "the salad mentality". I guess I need to find out more information about that one. Fortunately, there's a way to do so!

"Order Skinny Chicks Don't Eat Salads

In this smart, sassy guide, famed Los Angeles nutritionist Christine Avanti reveals the fail-proof eating plan she has developed after nearly 20 years in the field -- a program that effortlessly turns her weight challenged clients into skinny ones."

Uh-oh. She's sassy. Not always a good sign. The word itself means so many different things (rude, jaunty, chic, you name it) that it ends up meaning nothing, but the word has become a marker for a particular brand of insincerity. It is used by someone who isn't a publicist about as often as the word "paresis" is used by someone who isn't a doctor.

"Skinny Chicks Don't Eat Salads is unlike any other diet plan that you've ever tried -- because it's not a diet. Instead, the Skinny Chicks program helps you lose weight by keeping you satisfied -- and never letting you feel hungry or undernourished."

Well, in at least one way, it's very much like every other diet plan: they all claim to be unlike any other diet plan because they aren't really diets at all. (What are they, then? Zoning ordinances?)

"With this tested and proven program, you'll discover what Skinny Chicks know:

That wisecrack about The Carb Conspiracy is ambiguous; it could mean that we're being misled into eating too many carbs, or too few of them. The latter seems more probable, in light of what little other evidence about the Skinny Chicks program I have been able to dig up, but it could be intended to mean both. Every diet book author needs to spend a lot of time excoriating all the other diets that a potential customer might have failed at. It's a formal requirement of the genre -- as inevitable as the modulation to the dominant key in a classical symphony, or the unmasking of the killer at the end of a murder mystery. When it comes to selling a diet, everyone is following the same playbook (right down to the part about claiming that this diet, unlike other diets, isn't a diet).
"Skinny Chicks Don't Eat Salads is about giving your body what it really needs, when it needs it... It will change the way you eat forever by arming you with all the tools you need to be a lifelong Skinny Chick:

Before you know it, you'll be a Skinny Chick just like the hundreds and hundreds of clients Christine has helped in her private practice."

I don't mean to be a pessimist, but I don't really think I'm going to become a skinny chick (or should I say Skinny Chick ?) before I know it, no matter what non-diet I am following.

Leaving gender issues aside, I suppose it is possible that famed Los Angeles nutritionist Christine Avanti has discovered a practical plan for helping women (and men who want to become women) lose weight and keep it off, despite eating the foods they love and never being hungry. Right. It's possible. But how likely is it? How much should I trust someone who is trying to tantalize me with the possibility of losing 7 pounds a week, and who does not blush at assembling such outrageous oxymorons as "non-strenuous exercise"? If Christine Avanti isn't a total con artist, she's working awfully hard at looking like one.

I don't think that the combination of condescension and bad writing has ever greatly appealed to me, but if I ever did like it, I have certainly stopped liking it now, and it is getting on my nerves more and more over time -- possibly because the internet has so greatly increased my exposure to unwanted sales pitches.

In theory, what the internet has given us is a fantastic opportunity for people to share information. But most of the potential information-sharers have seen it only as a fantastic opportunity to try to make money off of people they'll never meet (legally or illegally, whichever is more convenient). The idea of making money off people you'll never meet does not seem to inspire great respect for those people, and it shows. It shows way too much, if you ask me. I'm really getting to hate these people.

Thursday, February 25, 2010  

Nice weather -- sunny, 61 degrees. I was a little overdressed for my run today, thinking it would be colder. It was nice, but I've gone running every day since last Friday, so today was my last run before I get to take another rest-day, and I have to admit I wasn't feeling terribly energetic. I was feeling very much ready for a break, in fact. Well, I've got one! And not a moment too soon, because thunderstorms are in the forecast for tomorrow.

When I was originally diagnosed I started exercising five days a week, and at that time that seemed like a very heavy burden to me. Now I exercise six days a week, and I'm generally not finding it difficult. It would make me feel very lazy and weak to do only five.

Sometimes I have flirted with the idea of abandoning rest days, and simply exercising daily without exceptions. However, when I've experimented with that idea, I found that I couldn't handle it. I don't know whether the barrier is physical or mental, but I can't seem to overcome it, whatever it is. I need a day of rest, or at least I want a day of rest so much that it amounts to a need. Even if exercising 7 days a week didn't do me any physical harm, I would probably begin to feel trapped by it, and start seeing exercise as an affliction rather than as a mostly-enjoyable element of my routine activities. If I can't afford to injure myself with my exercise (so that I can't continue it), neither can I afford to make myself hate my exercise (so that I won't continue it).

I went to the eye-doctor for my annual exam this afternoon. The prescription for my contact lenses fluctuates from year to year, usually getting worse, but this time it was slightly better than before.

But before we could get to the eye-chart phase of the exam, I had to go into the darkened room for the glaucoma test (the puff-of-air-hitting-the-eyeball test, which is pretty awful for jumpy people like me, but at least I got a good score on it) and the new camera that snaps a laser-lit photo of the inside of your eyeball, so that they doctor can look for evidence that anything dreadful is happening in there.

That's not my eye, it's just an example of what the pictures look like. My pictures were bigger, more detailed, had more green in them, and generally looked like the surface of one of the less healthy-looking moons of Saturn as photographed by a NASA space probe. I found it difficult to look at them while waiting for my eye doctor to summarize what he was seeing in them, because everything in the pictures looked weird to me.

He said my eyes looked normal and healthy. He explained about some of the defects (macular degeneration, torn retinal tissue, bleeding in the blood vessels of the eye) that he looks for, particularly in people with diabetes, but I still don't know what these defects would have looked like if they had been there. If the pictures of my eyes were examples of what a healthy retina looks like, I'd hate to see how weird the images would have been if anything was wrong.

Although I have so far escaped all of the routine upleasantness of diabetes, there is one problem that I can't seem to escape -- the fear, every time I have a medical exam of any kind, that this will be the exam that first reveals some kind of irreversible deterioration in my health due to diabetes. It doesn't matter how many times I have gone in for an exam and gotten a clean bill of health. It doesn't matter how many scary symtpoms (such as my hematuria episode earlier this month) have turned out to be nothing. I can't help worrying that this time it will be different. This time the test will reveal something bad, and it will be all downhill from there.

It keeps not happening, though. Long may it continue not happening!

Wednesday, February 24, 2010  

We had sunny weather today during our run, and after we were safely done it rained pretty hard. Then it cleared up again as I was going home in the evening, and the setting sun lit up the landscape beautifully. So I took some pictures.

And this view gave me an idea -- an idea about the laws of probability, and our insufficient respect for them. According to modern physics, everything in the universe is governed by probabilities rather than certainties. Most people hate that idea, particularly in connection with health matters. They don't want to be told that doing thus-and-so will "reduce your risk" of cardiovascular disease -- they want a money-back guarantee that if they won't have a heart attack if they follow the recommended regimen. (If there's no certainty, why bother? Won't you end up kicking yourself for having exercised and eaten your vegetables, if you end up having a coronary anyway?).

Because we want certainty or nothing, we not only become intolerant of uncertainty, we tend to perceive more of it than is there. We tend to develop an inflated notion of how much uncertainty there really is in a real-world situation.

So anyway, I took some pictures of the landscape to the east of my workplace tonight, with the idea of blowing them up later to examine their finest details:

Note the tiny, barely visible image of a pine tree marked by the arrow. I took a couple of pictures of the same view, and they look quite alike. But if you blow up the images to get a closer look at that one little pine tree...

...and you keep zooming in on it, eventually you get to the point where you are able to see the patterns of individual pixels which make up the image (if it were a film camera instead of a digital camera, something very similar would be happening with film grains instead of pixels). And when you compare the pixels in one picture of that tree to the pixels in the other, you find that, at that level, the images are not the same. Standing back, across the room from your PC screen, these two will look the same (the pixels "add up" to the same image exactly) but a careful, pixel-by-pixel comparison shows that they really don't match at all.

The differences have nothing to do with movement of the tree; there was no wind and the tree was holding very still for me. But there are only so many photons that make it through the lens of the camera during the brief period of exposure, and a different set of them get through each time, so at the pixel level you get a unique picture each time. The behavior of atoms and photons is governed only by laws of probability, not by absolutely predictable rules, and when you look close enough, you can see the effect of that -- a slightly different hand of cards is dealt each time. But we usually don't examine a photograph at the pixel level (or the film-grain level), so two exposures of the same subject taken under the same conditions look exactly alike to us. The minor differences between the two photos get "averaged out", and they end up having no effect at all on our visual experience. Technically, those differences exist; experientially, they don't.

Now, there are those who claim that the fundamental uncertainty about what happens at the atomic level means that "anything is possible" and "nothing is real", and they assume that this justifies all kinds of magical thinking about health. (Deepak Chopra, for example, feels that the uncertainty principle of quantum physics means that anything at all can happen, including personal exemption from the aging process.) But it seems to me that these folks are missing an important point about the laws of probability, and are greatly exaggerating the amount of uncertainty that is actually involved in the uncertainty principle. The fact that we cannot predict what any individual atom in a thrown baseball is going to do doesn't mean that we can't predict what a thrown baseball is going to do. The farther you get from the tiniest details, the more the combined probabilities add up, and the less "uncertainty" remains for us to be uncertain about.

For example, when I was photographing that landscape, it is quite true to say that the result was unpredictable at the pixel level -- any two pictures of the same scene would have countless pixel discrepancies. But that doesn't mean I could have taken four photographs in rapid succession and found that two of them showed the landscape I was looking at, the third showed the interior of a barbershop in Davenport, Iowa, and the fourth showed an alarming closeup of Bozo the Clown. We know that's not how the world works.

A little uncertainty about what any individual atom or photon is going to do is hardly significant, considering how many atoms and photons we're dealing with and how those individual uncertainties cancel one another out. In principle, every atom in the chair I'm sitting on could decide to move in the same direction, and as a result I could be hurled violently at the ceiling... but you know as well as I do that it just isn't going to happen.  The atoms in my chair are going to keep on bouncing around randomly against one another the way they have always done. The photons randomly entering my camera lens are going to keep on forming patterns which, collectively, look like whatever I was pointing the camera at. At least, I hope so.


Tuesday, February 23, 2010  

I had to be true to my nature: I couldn't just leave it undetermined whether or not my doctor had received my urinalysis results from last week, and whether they were normal. I phoned his office this morning (imagining, as I always do, that maybe this time I'll think of a way to trick the system into letting me talk to a live human -- and failing at it once more) and left a message asking about the test results.

I knew I wasn't going to hear back right away -- probably not until mid-afternoon. I went for a run at lunchtime, even though it was raining and I knew I'd be running alone (my running buddies aren't into that kind of thing). It wasn't that bad, really -- it was a steady rain but not very heavy (it's raining much harder tonight, while I'm safely indoors and dry). The running clothes I brought today were warm enough for the conditions. Still, I did feel sorry for myself a bit, and I thought I was being rather heroically self-sacrificing, to be out there running in the rain all alone, when nobody else was out exercising. The hot shower afterwards was fantastic, of course -- nothing like running in the rain to make you appreciate hot water.

So I got back to my desk and, as always, struggled with the drowsiness that descends upon me at 1 PM. (Oh, how I wish the siesta tradition had taken root in the USA.) But the ringing of my telephone brought me to full alertness. It was my doctor, saying that he was sorry not to have called me earlier, but he'd gotten busy, and anyway the urinalysis results were entirely normal.

He said it looked as if the hematuria episode was just a minor incident (he didn't say a passing incident, he knew better than to say that to a smart-aleck like me) of the kind that is likely to happen once in a while to anyone whose lifestyle is as active as mine is. He said I should just keep doing what I'm doing, and he'll do another urinalysis when I come in to see him next September just to make sure it isn't a recurring problem.

He did ask about what big exercise events are on my schedule. I told him that I haven't been in the mood for extreme sports-challenges lately, that I haven't really done an organized event since the half-marathon on October 31, that I'm not doing the marathon this year, and that lately I'm just doing my usual running (4 to 5 miles on weekdays, plus a trail run of 7 to 9 miles on the weekend). He seemed satisfied that that was a good plan. Nothing in excess, you see. (Maybe 7 to 9 miles sounds to you like the very definition of excess, but I've been doing that so long that it just doesn't scare me anymore.)

I suspect that, through this whole incident, while I have been worrying about what terrible hidden medical problem might have caused the hematuria, he has been worrying about a very different possibility: that I would let my concern about this issue spook me into giving up exercise. Well, I won't do that. But I think I've been taking on certain exercise challenges (marathons, 100-mile bike rides, etc.) that were well in excess of what I needed to do, just to prove to myself that I was capable of doing them and living to tell the tale. Having proved that point to myself several times over, I'm now feeling the need to be a little more moderate, just to make sure I don't overdo it and give myself an injury I can't recover from. I know several athletes who overdid their favorite sport, can't practice it it anymore, and now have a hard time staying fit. I don't want to go that route.

Exercise is a paradoxical thing. It's actually a little bit destructive, and that's desirable up to a point. For example, weight-lifting damages your muscle fibers-- and that is considered a good thing, because the body's repair processes leave those refurbished muscle fibers stronger than they were before they were damaged. Aerobic exercise, properly done, pushes your cardio-pulmonary system slightly beyond its capacity -- and the result is that it expands its capacity. (Yesterday I went running with a heart-rate monitor on, and my peak heart rate was lower than it used to be 5 years ago when I was running -- more slowly -- up those same hills.)

Exercise is most useful when it is abusing you a little bit. But when exercise is abusing you a lot -- causing damage that is likely to accumulate, because the body cannot quickly repair it -- exercise becomes counterproductive. Figuring out how to strike the balance between exercise that's hard enough on you to cause beneficial adaptations to occur, but not so hard that it causes permanent damage to occur, is a challenging assignment. But that's the assignment I've got, and I'm trying to do the best I can with it.

Monday, February 22, 2010  

The weather was dark and dreary over the weekend, and I didn't get inspired to go for a trail run, as I usually do on weekends. I ended up doing the same 5.3-mile neighborhood run on both days, trying my best to run during a period when it wasn't raining. I pretty much succeeded, although a little bit of rain fell on me during yesterday's run. I didn't get much pleasure out of my running on either day; it felt like a chore. If you are surprised by my implication that a five mile run could be anything but a chore (and an unusually tedious and uncomfortable chore, at that), I guess you'll just have to take my word for it that a person can learn to derive pleasure from running. (It does take time, though. At the beginning it's a chore every time.)

It was a little easier to enjoy today's run; there was brilliant sunshine, but the air was cool and seemed to contain more oxygen than usual. Very invigorating.

No word from my doctor about the urinalysis results. The simple thing to do in this case is to assume that this means he got the results, the results were normal, and he thinks we can all forget about the whole thing and move on. However, to assume that would be to abandon my faith in the power of bureaucratic error. How do I know that the lab even did the urinalysis, much less that it sent the results to my doctor? For all I know, he doesn't know I went in to do the test in the first place. And if he doesn't know that, there might not be anything flagged to remind him to follow up on the matter, and find out why the results never came to him.

Even so, it may be that sheer fatigue with the issue will make me drop it. I don't know what the probability is that the lab people actually did what they were supposed to do, but it's probably above 50 percent. Anyway, I've seen no further evidence of hematuria during the last two weeks. I suppose I would have seen some if there was a continuing problem. 

I hate this kind of muddle, but I'm starting to think that maybe it's not my job to eliminate it from the earth.

Saturday, February 20, 2010  

Those who do research into matters of health and disease like to complain about patients who embrace some remedy, diet, or theory based on "anecdotal evidence". We are supposed to be aghast at the very idea of anyone's accepting as fact stories that they have heard from other people. The objection I have to this attitude is that, in matters of health, all evidence is anecdotal evidence.

What we usually mean by "anecdotal evidence" is any report of someone's personal experience (first-hand, second-hand, or even worse).  We mean a story which begins something like this:

There are certain obvious problems here. First of all, how reliable is the person telling the story?  (Or, in the case of a second-hand account, how reliable is the person they heard it from?) By "reliable" I don't merely mean "honest". Even honest people distort things unconsciously, especially when they are trying to make a point or simply tell a story in an interesting way. It's usually hard for us to judge the accuracy of a story we're told.

An even bigger problem: what has been left out of the story? Even if the details provided are correct as far as they go, we might interpret them very differently if we knew certain things which we aren't being told (either because the teller of the story doesn't know them, or doesn't think to mention them).

The medical researcher's view is that such tales are worth nothing and should be ignored. If you are going to listen to your hairdresser's account of her experience with a particular diet, you might as well listen to her account of being abducted by aliens while you're at it. Forget about what your hairdresser says! Listen to the experts. Listen to the research. This sounds reasonable enough, but there turn out to be practical problems here.

One is that it is by no means easy for patients to discover what "the experts" and "the research" have to say. Expert opinion can be found in favor of (and also against) almost any idea about health that you care to mention. And research findings are generally not available to members of the general public (except as filtered by news publications which delight in dumbing-down, simplifying, and freely interpreting whatever it was that the researchers actually reported). Unless you can afford to subscribe to a great many expensive medical journals, and have the patience to decipher the language in which medical research is described, you aren't going to get any detailed information on what the researchers did or what they observed.

But even if we had the opportunity to read the original research papers, we would still be dealing with the same problems which plague anecdotal evidence as it's usually defined: we don't know how accurately the story is being told to us, and we don't know what is being left out.

Case in point: last April it was revealed that the "Australian Journal of Bone and Joint Medicine", which appeared to be a legitimate, peer-reviewed scientific journal, was actually created and run by the pharmaceutical company Merck, and existed only to publish articles favorable to Merck products. The thing is, actual doctors and scientists allowed their names to be used in this enterprise (they were listed as peer-reviewers, though they reviewed nothing), so that the journal would look genuine. Apparently this was not the only fake medical journal created by the pharmaceutical industry.

The Merck case was newsworthy because it seemed so startlingly brazen. Almost any kind of corruption that's less blatant than that has become accepted as normal. For example, a lot of research is funded on the understanding that the results will remain secret unless and until the pharmaceutical company that is funding the research decides to publish. So that's how you get evidence of effectiveness for a drug: do five studies, and if one of the five shows positive results, publish that one and suppress the other four. If all five fail, do a sixth. Whatever it takes. But don't keep giving funding to scientists that get negative results, because that would encourage the wrong behavior. You want to make sure the scientists understand what the "right" answer is, so that they will be likelier to find that answer. This process is largely invisible to the public, although occasionally some scientist writes an editorial to the effect that maybe we should think about finding a different way to get research funded, since this isn't exactly science, in the strictest sense, if you want to get fussy about things like "ethics" and "reality" and so on.

If patients have little opportunity to learn the details of medical research (and the forces that interfere with it), they have even less opportunity to learn about the internal politics of large institutions (such as the FDA, ADA, AMA, and so on) which influence health-care policy in the US. We don't know who is pressuring whom to do what. When clinical guidelines are issued for health recommendations or for treatment of a particular disease, we don't know to what degree that policy was influenced by lobbyists for industries with something at stake in the matter.

Because of all this, I would argue that patients cannot choose between anecdotal evidence and objective evidence. They can only choose between one kind of anecdotal evidence and another kind. No matter whom you choose to listen to, you're taking a chance that you are being given inaccurate, biased, or incomplete information. That being the case, it is not entirely unreasonable if you trust your hairdresser more than you trust strangers whose industry affiliations you know nothing about. This is especially true if you and your hairdresser both suffer from the same medical problem and want to compare notes on it.

The thing is, life itself is anecdotal by nature, so anecdotal evidence is not always irrelevant to it. To be sure, individuals vary, so there is always a strong possibility that someone else's anecdotal experience won't apply to your own. But, if you differ from your hairdresser, you also differ from that statistical abstraction known as the average patient, who exists nowhere but in the imagination of the medical researcher. At least, when you compare yourself with your hairdresser, you have some clear idea of how much you are like her, and in what ways. How much you are like the statistically average patient is harder to gauge. (For starters, do you have one testicle and one ovary? The statistically average patient does.) And if you are doing something (or considering doing something) very different from what the average patient does, you might be sailing into waters that the researchers have not charted. My own approach, and my own results, have been pretty far from the mainstream, so I'm inclined to feel that my anecdotal evidence is worth something even though it is not (and cannot be) reflected in any study of a large number of diabetes patients.

I'm certainly not building up to an endorsement of the idea that all research should be ignored and all personal anecdotes should be accepted uncritically. I'm just saying that I understand why people want and need (and are not crazy to seek) anecdotal evidence which just might give them a useful suggestion. Not something to believe, but something to try. If it works for someone you know (and they seem intelligent and sane to you), you might as well try it and see if it works for you. As grounds for trying out an approach to caring for a chronic health condition, you could do worse than "this helped my sister's husband".

Friday, February 19, 2010  

That's more like it. Fasting glucose 85. Post-prandial glucose 108, after dinner. It was a low-carb dinner, so it wasn't much of a challenge, but it was also a non-exercise day, and I'm always glad when I can do well on a non-exercise day.

I earned my rest day, I think. I've been running like crazy over the last six days -- and I plan to do at least some running tomorrow (a lot if the weather is good, a little if it's raining).

I didn't hear anything from my doctor today about the urinalysis. What does that mean? Here are the possible explanations:

  1. The lab didn't provide the urinalysis results to my doctor yet, although they said they would do it today.
  2. My doctor wasn't working today, or for some other reason didn't have an opportunity to call me with the results.
  3. The results were fine, and my doctor assumed he didn't need to call me unless the results were bad.
  4. The results were fine, but my doctor wanted to wait until the urine culture results came in, so that he could give me the total results.
  5. The results were bad, but my doctor wanted to wait until the urine culture results came in, so that he could give me the total results.
  6. I dreamed this entire story. None of it actually happened.

I'm leaning towards number 6.

I have always been glad that I took on the assignment of learning to play a musical instrument some years before I took on the assignment of learning to play -- or rather to manage -- diabetes. My struggles with the fiddle taught me a lot of things that were worth knowing. For one thing, it taught me that some things are a lot harder to control than diabetes is. (You think bringing down your fasting results is a challenge? Go learn to bring down your little finger on a high B, right on pitch, and then we'll have a chat about what's challenging what's not.)

The musical learning process also taught me:

Playing music regularly gets you accustomed to the idea of confronting and overcoming difficulties. You gradually get out of the habit of thinking "I'm having trouble doing this -- obviously it can't be done!" and into the habit of thinking "I'm having trouble with this -- what's getting in my way, and how am I going to get it out of my way?".

An example is ready to hand, certainly. I have before me the list of fiddle tunes that I must get ready to play in the spring concerts of the San Francisco Scottish Fiddlers (April 30 - May 2). The list includes 25 tunes in total. Most of them I don't know. There are six that I have played in other concerts (long ago) and can easily relearn, but that leaves 19 others that I have to learn pretty much from scratch. (By "learn", I mean "learn by heart", because I won't be playing from sheet music on stage.) Does that sound like an unreasonably difficult assignment? It isn't, really, if you break it down properly.

First, you assemble the sheet music for all the tunes (or get the practice CD which our music director made of all the tunes -- I've ordered my copy). Then you start practicing them every night. You can't play them up to speed at first, so you set a metronome for a very slow tempo -- however slow it needs to be for you to be able to play the tune. If the tempo you can handle now is 60 beats per minute, you write down 60, and tomorrow you play it at 60 and then try it at 64 to see if you can manage it. If so, you cross out 60 and write down 64. You keep that up for a while, gradually increasing the tempo, and then you go to the first group practice and see if you can play the tune (slowly) with other people. Then you see if you can play it a little faster with other people. Then, in April, you go to the first full rehearsal, and see if you can play it at a more realistic tempo (100 or more, let's face it). If you can't, you work on it at home so that you'll do better at the next full rehearsal the following week. And by the time you do the last full rehearsal, you find that you no longer need sheet music to remind you how the music goes, and you can play it at a wicked fast tempo, and you're ready to face the public.

Which is not to say that you won't encounter obstacles along the way! There's a particular tune I'm working on now (an American fiddle tune by Paul Gitlitz, called "Flying Home to Shelley"); I like it and want to be able to play it fast, but I'm having some trouble with it. Tunes are like tongue-twisters -- they put you in a situation where it's hard to fight the impulse to do exactly the wrong thing. There are two of those situations for me in this tune. In the first one, my fingers desperately want to substitute an F for the indicated G:

In the other case, my fingers want to substitute an A for the indicated B:

Why my fingers want to play the wrong notes in these places, I do not know and won't try to figure out. The important thing is that I've identified my weaknesses in this tune, and can now go to work on eliminating them. Sometimes I practice those two bars over and over and over, training my fingers to get used to playing the right notes instead of the wrong one. "Woodshedding" is what our music director calls this process; whatever you call it, you need to identify the places where your natural habits or instincts are steering you wrong, and go to work very diligently on solving that problem. I've been through the process too many times to doubt that I will solve my problems with this tune. It's not easy to do, but (like they say in the Nike ads) you just do it.

It's because this kind of experience is so useful that I think it should be taken up more generally. My belief is that, when  you are diagnosed with Type 2 diabetes, you should be handed a glucose meter and a musical instrument and told that you have to get really good results from at least one of them. I think most people would take the easier route.

Thursday, February 18, 2010  

This morning I thought, "That's not fair! Why is my blood sugar up today? I didn't eat more carbs yesterday!". And then I said to myself, "Who are you kidding? Of course you did!".

I did, all right. I just forgot about it. That's why we have glucose meters: to remind us that the laws of nature remain in operation whether we are paying attention to them or not. Or, as Philip K. Dick once put it, "Reality is that which, when you stop believing in it, doesn't go away".

Not that 94 is so bad, but I've been doing better than that lately and should get back to doing so.

Today was the big day -- my trip to the lab to give them a urine sample which I'm hoping will not turn out to contain anything strange. I prefer to think that the hematuria episode I experienced after a 13-mile run on February 6th was nothing more than a temporary trauma, and that it has healed up without leaving behind any traces that will show up in the lab report. The earliest I will hear anything about the test results is tomorrow. Apparently the "urinalysis" part of the test (which I assume includes detection of red blood cells in the urine) will have a result by tomorrow, but the "culture" part of the test (which I assume looks for signs of infection) takes 48 hours.

I'm not especially concerned about the culture, because I have never believed that I had an infection (in the bladder, kidneys, or anywhere else). But I would very much like to receive confirmation that there isn't some kind of low-level bleeding going on, which that 13-mile run happened to intensify to the point that I could detect it with the naked eye. Since I never believed I had a kidney stone either, low-level bleeding would only have so many possible explanations, and it's hard not to allow oneself, in the wee small hours of the night, to think about the grimmer possibilities. I don't think I'm being any more neurotic about this than the average person is, when they're waiting for information about a symptom that probably means nothing but could mean cancer. It gets your attention, let's put it that way.

At least I have made it a fair test. My doctor asked me not to take a break from running during the period leading up to the test, and I haven't. If anything, I have run more than usual recently. Over the past six days I have run every day, for a total distance of 34 miles. (I usually run 25 to 30 miles over the same period.) I haven't seen any further signs of hematuria. My urine certainly hasn't been red, although I've been fretting constantly about whether it is yellower than it ought to be. I don't, in fact, have any idea how yellow one's urine ought to be.

Anyway, I'll be glad to be able to stop worrying about what color my urine is, and get back to worrying about how sugary my blood is. The latter issue seems to me less mysterious, and more controllable. Urine is just weird.

There was some kind of building maintenance work going on at the lab, with guys on ladders working on the wiring in the ceiling. I was told to go into the bathroom, urinate in a little sterile cup, and put my sample in the little door in the bathroom wall. I did, but when I opened that little door on the inside of the bathroom, the equivalent little door on the outside of the bathroom popped open, giving the workmen a good view of the situation. Okay, guys, nothing to see here -- get on with what you're doing. I'm sure that the female patients who showed up there today were even more pleased with the situation than I was.

Wednesday, February 17, 2010  

I didn't mention it last night, but I was a little stressed about a task that I knew would be waiting for me at work this morning: I was making a presentation at a meeting, and the meeting included both local people (in the room with me) and overseas people (sitting in an office in Scotland, listening to my voice on the phone and watching the slides I was showing on their computer screens).

I used to be fairly comfortable making presentations, back in the days when I had to do it often, but it's been a long time since I had to do one, so I felt a bit of the novice's anxiety today. And I had other reasons for feeling uncomfortable with the assignment. One was that I find it very hard to talk to people I can't see, especially when there are a bunch of them. I like to be able to read their reactions, and when I just have to wait until I'm done with the presentation to find out whether they have been nodding their heads in agreement with me, or perhaps shaking their heads in disbelief at how badly I have got it wrong, my stress level is sure to rise. Also, I was painfully aware that the ideas I was proposing were based largely on guesswork; my audience included people who knew more about the situation than I did, and would certainly be able to tell whether or not my guesses were good ones.

It turned out, after I was done, that they thought I had hit the nail right on the head, and the two people in my audience who had the most expertise on the subject both expressed strong agreement. I felt a wave of physical relief that was like crossing the finish line of a marathon. But then a bunch of other people had minor questions to ask, and at that point I was feeling so overwhelmed by the buildup and release of stress that I simply couldn't process what they were saying -- I could hardly make any sense of their questions, or provide any kind of meaningful answers. Fortunately, we ran out of time and the conference room had to be used for another meeting.

It was nice that I was able to do the main task -- that is, put together a good presentation and win support from the key players involved -- but not so nice that I became so stressed over it that I was almost struck dumb at the end.

Then I was reminded of John M. Kennedy, the cardiologist who gave a lecture on stress and heart disease at my workplace back in June of 2008. He pointed out that, no matter how good you are about diet and exercise and cholesterol management, uncontrolled stress can still make you a sitting duck for a coronary.  At the time, he was working on a book about how to prevent heart attacks by taking regular "BREATHE breaks" to get your stress under control. Apparently he's finished his book, but his web site gives enough information about it that maybe it would be possible to implement the program on that basis alone:

There's also a short video (mainly intended to promote his abilities as a guest speaker), which perhaps was of special interest to me because it consists mostly of footage from the same lecture I attended, with the back of my head featured in several shots (and my bald spot less prominent than it now is, less than two years later).

I'll have to start taking BREATHE breaks and see if I can cope with work stress a little better. According to Dr. Kennedy, it's a life-or-death matter.

Speaking of stress: tomorrow I'm planning to go in for that urinalysis to make sure that the hematuria episode I experienced recently was just a minor trauma that is now healed. I do have some anxiety about that, because most of the other possible explanations for the episode seem to be ruled out at the moment, and the few that are left aren't pretty. I hope I will be able to get a reassuring answer about that, and without too much delay.

Oh, no! I just found out that there's a date conflict between The Relay (that is, the huge relay race from Calistoga to Santa Cruz, which I've participated in for the last two years) and the spring concert series of the San Francisco Scottish Fiddlers (which I began participating in back in 1993). I had to choose between these two things, and I chose the concerts. Opportunities to run in a large and unusual race come up more often than opportunities to play in a large and unusual concert.

Exercise is important to me, of course, and I try not to let other things get in the way of it. But the point of exercising is to have more life, and the point of having more life is to make more music, so music is the thing I do allow to get in the way of exercise.

Not, of course, that I will give up exercise while the concerts are going on. I'll fit it in somehow. Even during the winter retreat in the country with the Scottish Fiddlers this past weekend, I got out and ran quite a lot, when it would have been a lot easier to stay indoors with the music-making all day. I think I found the right balance between the two. At least I didn't get tired of making music, even when I was doing it well past midnight. (There's a great paradox for you: the more you exercise, the less of a problem you have with fatigue.)

Tuesday, February 16, 2010  

My holiday weekend was a pretty indulgent period in terms of food intake, and although I tried to make up for it by doing more running than usual (a total of 22 miles spread over the three days), I thought that tonight I should do a repeat of the dinner and post-prandial test that I did last Wednesday. That was a rather low-carb dinner, so I decided to make it more challenging this time by adding a bar of dark chocolate (24 grams of carbohydrate, according to the label). The outcome: after an hour my blood sugar was 114. Well within guidelines for diabetes patients, and probably within the normal range for non-diabetic people. So I continue to think I have this situation pretty much under control.

The gorgeous, un-wintry weather continued today: sunny, clear, and surprisingly warm (it hovered around 71 degrees for most of the afternoon, and humidity was high). In fact, the long-sleeved running shirt I brought for my lunchtime run was a little excessive, and I had a hard time cooling down afterwards. The forecast is for more of the same tomorrow, so I'm going to bring something a little lighter to wear.

An excerpt from the "Periods of License" chapter of The Golden Bough, Sir James George Frazer's classic study of primitive customs:

We have seen that many peoples have been used to observe an annual period of license, when the customary restraints of law and morality are thrown aside, when the whole population give themselves up to extravagant mirth and jollity, and when the darker passions find a vent which would never be allowed them in the more staid and sober course of ordinary life. Such outbursts of the pent-up forces of human nature, too often degenerating into wild orgies of lust and crime, occur most commonly at the end of the year, and are frequently associated, as I have had occasion to point out, with one or other of the agricultural seasons, especially with the time of sowing or of harvest.

Now, of all these periods of license the one which is best known and which in modern language has given its name to the rest, is the Saturnalia. This famous festival fell in December, the last month of the Roman year, and was popularly supposed to commemorate the merry reign of Saturn, the god of sowing and of husbandry, who lived on earth long ago as a righteous and beneficent king of Italy, drew the rude and scattered dwellers on the mountains together, taught them to till the ground, gave them laws, and ruled in peace. 

The early Christian church found a solution to the problem of winter "periods of license" that tended to get out of control: they moved the feast of the nativity to the time of the winter solstice, and at the stroke of a pen (or quill, I guess) the annual winter celebration was repurposed as a religious holiday. To some extent this worked; once the Saturnalia was transformed into "Christmas", the celebrations of it gradually became less raucous. The only people who now think of the winter holiday season as a time "when the darker passions find a vent" are the police -- and even thay are thinking only of the domestic quarrels they must break up, and not of "wild orgies of lust and crime".

In our own mild way, though, we do continue the tradition of "outbursts of the pent-up forces of human nature" on designated special occasions. It's just that the pent-up forces we release these days tend to relate to dessert, and the special occasions on which we release them tend to happen more than once a year.

I think that there is a basic human need for "special occasions" on which we break our own rules; the only problem is that it's too easy to convince yourself that every occasion is a special occasion. The winter retreat I just attended seems like a special occasion to me, but I attended a very similar sort of event at the beginning of January, and that seemed like a special occasion too -- as did Christmas in December, and Thanksgiving in November, and my trip to Scotland in October. At least once a month, I become convinced that I have just landed in the middle of a special occasion, and the rules have changed accordingly. Fighting that tendency to give oneself too many exemptions is one of the great challenges of diabetes management.

Monday, February 15, 2010  

A very busy weekend. This was the annual weekend in the country of the San Francisco Scottish Fiddlers, which is held at a church retreat facility located in the Russian River valley near Healdsburg, California.

I suppose any kind of church retreat center is likely to be in a lovely location, but a lovely location that's surrounded by vineyards and wineries is even better.

Boy did we luck out with the weather this year! It was raining when we arrived on Friday, but for the rest of the weekend it beautiful (once the morning fog had burned off). In the afternoons it became warm enough that some couldn't waste the opportunity to eat lunch outdoors in February.

I was staying in the ranch house...

...which is a very nice old building, but could have been a problem, considering how late some of the younger guests stay up making music in the parlor downstairs. But my room was pretty far down the hall, and the sound-insulation was pretty good, so they didn't keep me awake. 

There is no formal program to the weekend -- people just gather in groups big or small to make music together, and if what they were playing in the big jam session in the ranch house didn't appeal to you, you could find (or create) a different kind of session someplace else. People got together wherever they could find room, to play whatever they wanted to play that wasn't being played already.

It wasn't all instrumental music-making -- there were also singing sessions late at night.

One of the things people like to do at an event like this is to step outside their accustomed musical roles, and try something different. For example, on Sunday morning our music director, the fiddler Alasdair Fraser, put down his fiddle and sat down at the piano keyboard instead.

I guess my biggest trip outside my comfort zone was writing and performing a comic song duet at the Sunday night singing session. The most uncomfortable aspect of it was that I had to get another singer and a guitarist convinced that my hyper-complicated song was performable and would actually be funny. Our hasty rehearsals (and my hasty rewrites) did not seem to point toward success, but somehow it all went splendidly when we finally had an audience to play to, and we got a quite a lot of laughter and applause.

Despite all the music-making, I did manage to set aside sufficient time for some good long runs (9 miles on Saturday morning, 6 miles on Sunday morning, and 7 miles this afternoon). As it happens, they serve very good food at that place, and I was eating a lot of it, so I knew that I couldn't afford to short-change myself on exercise. In addition to the exercise, I joined those who were going on walks in the afternoon. The one on Saturday was a pretty easy stroll -- but a purposeful one, as we were heading to a winery just down the road.

The walk on Sunday was a more vigorous hike in the hills.

That was with a friend of mine, who had with him a walking stick (or so it appeared), which turned out to be a fighting stick that he uses for Aikido. When we got to an enclosed meadow, he did some fighting practice, making alarming movements with the stick. I backed off considerably until he was done.

I think all this physical activity made it possible for me to keep my blood sugar under control despite my increased food consumption. The worst fasting result I saw was 93.

Thursday, February 11, 2010  

I will be going out of town tomorrow, getting an early start on the holiday weekend. This is the annual Winter Weekend of the San Francisco Scottish Fiddlers. We'll be taking over Rancho Obispo, a lovely place out in the hills and vineyards near Healdsburg, which belongs to the Episcopal Diocese of California and normally hosts church groups holding retreats (but has somehow learned to put up with a big, chaotic bunch of fiddlers once a year).

Anyway, I'll mostly be playing music day and night for the next 72 hours or so. I'll keep up with the exercise, but I won't be keeping up with the blogging. Don't expect me back until at least Monday.

My workday was a little chaotic, and I didn't get outside to run at lunchtime. I substituted a gym workout. I'm hoping to get in a good run tomorrow morning, though it might have to be in the rain.

I went by the doctor's office today to pick up the lab paperwork I need for the urinalysis test that I'll be taking next week to verify that this hematuria thing is cleared up. It was in a sealed envelope. I mean, the paperwork was in a sealed envelope, not the hematuria. I got the paperwork home and noted that it omits certain items of information which I would not have regarded as optional (such as where I'm supposed to go for the test -- I'm not sure I feel like driving randomly around town asking who wants my urine).

The form does, however, have a section headed "Patient Demographics", with some specifics on me (including my date of birth, followed by my age for the benefit of those who aren't good at subtraction). So at least it's clear that I have the right paperwork. And the form also has this line:

Specimen Source: Specimen Source
                           Clean Catch Urine

You see, they want a clean catch. None of this wetting-your-pants-and-wringing-them-out nonsense for them! And no using your coffee mug either, even if you did give it a quick rinse first. A clean catch, got it? Clean.

Okay, I get the message, and I'll give them the cleanest catch I possibly can. I don't know whether this is a catch-and-release program or what, but I guess they will explain it to me when I get there (assuming I can find out where "there" is). But the form also includes a line which is a little harder to interpret:

Laboratory Specific Question: Patient Fasting? ___ Yes ___ No

Neither box is checked. So am I supposed to fast, or not? I'm guessing that it isn't necessary, since they're looking for blood, and having breakfast would probably make no difference either way for non-vampires. Maybe the boxes are unchecked because someone at the lab is supposed to ask me whether or not I fasted. It sort of implies that they think it matters, doesn't it? But if there's a "right" answer, maybe they should have told me up front what it was.

You know, I work with engineers -- mostly software engineers -- and they generally do not have a reputation as great communicators. But let me tell you, the communication barrier between engineers and the rest of humanity is the thinnest imaginable gauze compared to the brick wall that stands between the health care industry and the public it serves. There is something that happens to the brains of people who become involved in that industry that renders them incapable of conveying even the simplest information clearly. Asked what they do for a living, they might say something along the lines of "I'm 43 and I don't live in Germany". Thanks, that clears things up immensely.

Anyway -- as of today, I started to get more relaxed about the hematuria episode. A couple of times in the bathroom today I even forgot to get nervous about what color my urine was going to be. I'll still be nervous next week when I'm waiting to hear whether the urinalysis revealed anything troubling that needs to be investigated, but what can I say? I'm a nervous guy. If most things in life didn't scare me I wouldn't be me. 

Wednesday, February 10, 2010  

Lately, with fasting blood sugar averaging 85, I've been neglecting post-prandial testing -- on the plausible-sounding (but not necessarily reliable) assumption that my morning numbers wouldn't be this good if I was spiking at other times. 

I've been feeling guilty about behaving this way, mainly because I'm not setting a very good example, but also because I know that, if I do start to lose control of my blood sugar, the post-prandial results will probably go up before my fasting tests do. If I don't do post-prandial tests from time to time (to make sure my fasting test results are not misleading me), I may miss an early warning. And, where diabetes is concerned, missing an early warning usually makes any problem a lot harder to solve.

So, I did a couple of post-prandial tests after dinner, and got results of 106 (after one hour) and 102 (after two hours). I usually do post-prandial testing after one hour rather than two, even though two hours is the standard recommendation these days. One hour was what my doctor told me when I was diagnosed 9 years ago, and my own experiments on myself confirm that I'm higher after one hour than after two (some people are higher after two, apparently).

To me it just makes sense to test at a time when you know you're going to be closer to your peak. The question is sometimes debated rather heatedly on the dLife forum, so I tested both times tonight, just to be sure. Because the two-hour result didn't surprise me, I don't think two-hour testing is something I'm going to do often. The only thing surprising about the one-hour result was that it was so low. This doesn't suggest that anything bad has been going on while I wasn't looking, so to speak, but maybe the meal was too low-carb to be a fair test. I'll have to try testing after other kinds of meals.

I had fish tacos for dinner, by the way. The tortillas were of the low-carb, high-fiber persuasaion, or so the label said. They certainly did taste dull, I'll give them that. And to judge from the result, they certainly didn't hit me with a big sugar-wave when they broke down in my stomach. Who knows what the result would have been if I'd put rice in the tacos, but rice is something I don't eat a lot of nowdays.

Another run today, this time slightly longer, and this time with a running buddy involved. (Yesterday I was running alone and could set my own pace.) Fortunately, today my running buddy had a story she wanted to tell me, so as a practical matter she couldn't speed up too much and pull away from me. It was a good pace, and I think fairly typical for me. Anyway, the run didn't cause me any trauma -- or any hematuria. Not any naked-eye hematuria, at any rate. The lab might have a different tale to tell next week, after they get done squinting at my urine sample held up beside a paint-chart or whatever it is they do -- but for now, it looks like I'm free and clear. If that's the phrase I want.

Tuesday, February 9, 2010  

After my hematuria episode on the weekend, which I described yesterday, I was feeling decidedly nervous about going for my first run since then. I didn't want to be jarring my kidneys today. On the other hand, if I babied myself too much, I wouldn't know whether the episode was truly over or not. My doctor told me to go back to doing what I had been doing before. Today was a test, and it wouldn't be a fair test if I didn't do the sort of run I usually do on my lunch break.

I tried to run at a pace that is normal for me. I also tried to concentrate on not tensing my lower back, which I suspected had been a contributor to my problem on Saturday. I felt fine during and after the run -- which by itself proved nothing, as I had not felt that anything was wrong during and after Saturday's run (until I noticed the evidence in passing, so to speak).

Going in to the men's room later to see what, if anything, the running had done to the tint of my urine, I was about as relaxed as I would be walking on stage for my Carnegie Hall debut. Well, I passed the test. I was going to say that I passed with flying colors, but I guess that suggests the opposite of my meaning. I don't want to send any more colors flying, and I'm pleased to report that I didn't do so on this occasion.

This doesn't entirely free me from anxiety on the subject, but it helps. I'll need to do a long run on the weekend, if I'm actually going to continue my normal habits, and I'll be nervous about that, too.

The actuaries at the federal Centers for Medicare and Medicaid Services have found that 2009 saw the largest one-year jump ever measured in the cost of health care nationwide. Total spending on health care in the United States, public and private, amounted to $2.5 trillion -- which means that 17.3% of all money spent on the anything at all in the United States now goes to pay for health care.

I don't know what percentage of the increased cost of health care is actually related to health care in any legitimate way (it's never easy to tell how much of the money involved in any large enterprise is being siphoned off for no purpose other than to make a few rich people richer), but I'm generous enough to assume that the percentage isn't zero. Some portion of the increase in spending on health care probably reflects an actual increase in the amount of health care that people need. We're getting sicker, in other words, and a lot of the health problems we're having are chronic conditions that require care over a period of many years.

So which disorders are we spending our $2.5 trillion on? I have been comparing lists of the costliest diseases, as compiled by various watchers of the health care industry, and most seem to agree with the list that Forbes magazine compiled based on 2005 data.

  1. Heart conditions
    (including coronary heart disease, heart attacks, chronic heart failure, and rhythm & valve disorders)
  2. Trauma
    (broken bones most commonly)
  3. Cancer
    (breast and prostate cancer being the costliest)
  4. Mental illness
    (mood disorders and Alzheimer's/dementia being the costliest)
  5. Respiratory illness
    (asthma being the costliest)
  6. Hypertension
    (we spend a lot on those pills)
  7. Joint disorders 
    (arthritis is the commonest, but still accounts for only about a quarter of the total)
  8. Diabetes
    (one of the fastest-growing health problems in the developed world)
  9. Back problems
    (often impossible to treat, always impossible to ignore)
  10. Childbirth
    (even normal childbirth is expensive) 

It may seem surprising that diabetes only ranks 8th, behind asthma and arthritis and so on, but in this ranking only the costs of direct diabetes care (mainly medication) are considered. A lot of the health problems that diabetes can lead to are not counted under that category. And, of course, people with diabetes are much likelier to have heart disease, depression, and hypertension, which rank 1st, 4th, and 6th. So, we're doing our part.

Because the rates of diabetes and other chronic illnesses are going up in the US, I guess we know one reason why health care costs might be on the rise. It used to be considered a no-brainer that lifestyle was playing a role here, but lately a lot of people have become angrily insistent that "lifestyle" diseases are not lifestyle-related at all -- they're purely genetic. So, if these diseases are getting more common, the explanation can't be that people have developed poor health habits; it must be that, for the last few generations, only families with bad genes have been reproducing. You have to wonder how they got together on that (especially as it has to have started before Facebook), but apparently they did. 

It's scary to depend on a health care system that doesn't seem capable of supporting the burdens it must carry. I guess that's one of the reasons I'm trying to reduce my dependency on it, by staying as healthy as I can using the tools that are available to me. Maybe, if I don't burden the system with problems that I can handle on my own, it will still be there by the time I need it to help me with the kind of problem I can't handle on my own.

Monday, February 8, 2010  

What follows could easily come under the heading of "too much sharing", but if I'm going to blog about a health issue I'm going to have to violate certain standards of good taste now and again. Read on, or don't, at your own discretion.

I had a minor health alarm over the weekend. It's very likely nothing important (that's what my doctor told me today, so I'm not just guessing), but you'll see why I found it disturbing at the time. On Saturday morning I went running with a friend of mine who's training for a marathon. I'm not training for that marathon myself, thank heaven, but he was only doing 13 miles on Saturday, and I figured I could handle that -- even though he's a better runner than I am and I knew that keeping up with him would be hard for me. During the run, whenever I started falling behind him I would concentrate on correcting my running form. My natural tendency is to stand up too tall when I run (everyone says it looks like I'm speed-walking). I know this isn't the "right" way to run, but it's what my body seems to want to do. Anyway, I find that I can always get some more speed if I crouch down a little more than feels comfortable to me, and lean forward with my back straight. So, on Saturday I kept doing this whenever I fell behind him. However, every time I did this to help me catch up, holding that position would strain my lower back, so I tended to do it long enough to catch up, and then relax for a while to give my lower back a break.

I finished the run feeling a bit tired and sore, but no worse than I would expect to, after a run of that length. I certainly didn't feel that anything was wrong with me. But when I got home, I found that there was a little bit of blood in my urine. Not so much blood that I was immediately sure that's what I was looking at, but not so little that I could convince myself my urine was just dark yellow and I was imagining things. There was definitely some bright red in there.

Now, I have always heard that distance runners sometimes experience this alarming symptom, and ever since I took up distance running myself I have been waiting for the day I would experience it myself. I have been in considerable suspense about what my reaction would turn out to be. To speak true, I figured it wasn't unlikely that I would scream like a girl and then pass out on the bathroom floor. This did not happen, I am darned proud to tell you, but maybe it would have, if the color had been stronger. I think I had always pictured a pretty solid red in my mind.  But even a touch of red is upsetting, obviously, especially if you've never seen it before in your life. Naturally I was anxious to discover whether my urine was going to be more red or less red the next time.

The thing is, I had rather a long and anxious wait for "the next time". I was pretty dehydrated from the run (I'd lost four or five pounds), so I had to drink a lot of water and wait a long time before I could produce a second sample for comparison. That one was definitely yellow, not red. After two or three hours my urine was quite pale, almost colorless. No visible redness has appeared since. I had no other symptoms, nothing that might point to a bladder infection, kidney stones, or any other potential cause of blood in the urine. I felt fine. Anxious, but fine.

To me, the speedy disappearance of the bleeding, and the lack of any other symptoms to explain it, seemed to go a long way towards confirming that the bleeding was probably some minor trauma caused by the run. But even if that was the explanation, I still didn't know what the implications would be for me. If this happens to distance runners a lot, what are distance runners supposed to do about it? Grin and bear it? Give up running for a month and then build back up slowly? Give up running forever? If I kept running, would this keep happening to me every time I did a long one?

Also, the fact that my attempts at correcting my running form put a strain on my lower back (where the kidneys are) made me wonder whether this means that running with correct form is, in my case, an injurious thing to do. It wouldn't be the first time I discovered that my body doesn't like doing things in the manner which others consider normal and correct.

Since my diabetes management system is so heavily dependent on exercise, I have always tended to worry about the possibility that an injury of one kind or another will force me to give it up. If I couldn't exercise, I might be able to succeed through heavy restriction of carbohydrates in my diet, but if that didn't work I'd have no options left but to go on metformin or something (and hope that I'm one of the lucky people who don't get serious side effects from it). And even if ultra-low-carb dieting or meformin "worked", they would only be working in terms of glycemic control -- they wouldn't be protecting my cardiac health. Believe me, I've tried living without exercise, and I have my reasons for doubting I can stay healthy that way.

So, when I left a message for my doctor describing what happened, I was worried that, even in the best-case scenario I could envision (that is, the bleeding was just a consequence of the run), he might tell me that I would need to give up running and find some other way to get my exercise. Which would be tough, because running is (for me, anyway) an especially convenient form of exercise. You can do it almost anywhere, with minimal equipment, and the intensity of it makes me feel that I'm getting more bang for my buck. I think an hour of running is worth two hours of cycling, and when you're trying to fit exercise into a busy schedule, time-efficiency really does matter.

Sunday was my rest day anyway, and I certainly wasn't tempted to make it anything but a rest day under the circumstances. In fact, I was nervous about going anywhere or doing anything that might put any kind of strain on the kidney area. A long drive didn't seem any more attractive a proposition than doing another 13-mile run. My main activities were staying hydrated and worrying. I had no idea that urinating could be such a suspenseful activity; it's kind of hard to do it at all, when you're nervously waiting to see what color it is going to be. I think I'm going to be a long time getting over that.

I didn't get a chance to talk to my doctor until early this afternoon, and I certainly wasn't going to do my usual lunchtime run without discussing it with him first. When I finally did speak with him, he agreed that, because I only saw blood in my urine immediately after a long run, and not before or since, the bleeding was probably caused by bruising of the kidneys (or some other minor trauma) due to the run. He told me to wait at least a week, and then come in for a urine test. If he tested my urine now, it would probably test positive for red blood cells regardless of whether I could see any unusual color or not, but after a week the blood should be undetectable. If it turns out not to be, he will have to investigate further and see what else might be going on.

I asked him what this meant in terms of running. Did I have to take a break from running, and if so, for how long? He seemed surprised that I would even ask. He told me not to change anything about my running habits, even though they probably did cause the bleeding episode. "You see how infrequently it happens?" he said. I hadn't thought of looking at it that way. I guess he's balancing the issue of occasional minor kidney trauma, if I keep doing what I'm doing, against the across-the-board health catasrophe that he foresees if I stop doing what I'm doing. Also, in all likelihood, he wants the urine test he gives me next week to be a fair and realistic test, which it won't be if I change my habits in preparation for it.

After work I went to the gym, and I just couldn't bring myself to do a treadmill run today. I used the stair-climber instead (I'll run tomorrow, I promise), hurried to the bathroom for an anxious confirmation of how that affected my urine color (not at all), and then took off for my yoga class. I was very, very tempted to tell my yoga teacher that tonight I shouldn't do any twisting poses or other poses that stretch the kidney area. But that wouldn't be following my doctor's advice to continue my usual activities. Also, I imagined myself trying to explain to her why I shouldn't do those things, and I didn't like the way this imaginary conversation played out. So, I just did whatever she said to do, which of course included a lot of poses that stretched the kidney area, and afterwards I hurried to the bathroom for an anxious confirmation of how that affected my urine color (not at all).

So I guess tomorrow I owe it to myself to do a real run, and then hurry to the bathroom for an anxious confirmation of how that affected my urine color. Stormy weather is forecast for tomorrow, but I'll run somewhere -- either outside or on a treadmill -- and get the suspense over with. But I guess the suspense won't really be over until I get the results of that urine test next week, and find out if there's more going on here than meets the eye.

Thank you for your patience in reading this far, if you have. If anyone who is getting the story here for the first time feels that I should have shared it with them sooner (my dinner hosts on Saturday evening, say), I guess I should explain that the current color of one's urine turns out to be a more difficult subject to discuss socially than you would suppose -- especially at a point when you haven't yet had a chance to discuss it professionally.

Friday, February 5, 2010  

As I went out to do my lunchtime run, the sky looked like it was in the mood to make trouble...

...but it didn't. Another rain-free run!

I'm not sure I'll be so lucky tomorrow. The forecast: thunderstorms, and a 90% chance of rain. Oh well, I can't go on being lucky forever.

I guess I can't go on being lucky forever in terms of health, either, seeing as nobody can. The best we can do is to stay lucky for as long as possible. That's true whether you have diabetes or not, of course. Nobody's health plan includes an Immortality Option. The human body, like any other machine, breaks down eventually, and keeping up with the oil-changes only carries you so far. The goal is not to keep your machine running literally forever, but to get more miles out of it than the average owner does.

I've had a pretty good run so far. I'm now beginning my 10th year of controlling diabetes without medication, and my current 30-day average for fasting glucose is 85. To be capable, at this point, of keeping my fasting average under 90 seems like a pretty solid challenge to the conventional wisdom about diabetes (that it's bound to get worse and worse over time, and that any attempt to control it without medication will fail after a few years). I don't know how long I can continue to do this, but then, I've never known how long I would be able to continue to do this. I didn't know whether my approach would work for two years and then fail -- or four years, or eight years. Maybe it's all going to fall apart a year from now, or three years from now. Who knows?

On the other hand, it's not getting harder for me to control my blood sugar over time. It's actually easier for me now than it was during my first few years. If things were falling apart for me in some non-obvious way, wouldn't glycemic control be getting increasingly difficult for me?

The only health issue I still have trouble controlling is weight. That issue will be with me for life, I expect!  

Thursday, February 4, 2010  

I was a good boy yesterday, in terms of carbohydrate intake, and I more or less took it for granted that my fasting test result would be down instead of up today. I suspect the reason it was up was that I suffered a bad bout of insomnia last night, and hardly managed to sleep at all. I did manage to re-read rather a lot of "Life With Jeeves", but that was little consolation to me today, when I was struggling to stay alert at my desk after lunch. Here's hoping I sleep better tonight!

I lucked out with the weather again today! A Pacific rainstorm was predicted to get here at midday, which of course is when I usually go running. Well, the sky looked very threatening indeed during my run, but mother nature waited for me to finish. It sprinkled a bit during the last mile, but that was all. Then, after I was done, the dam burst. Eight hours later, it's still pouring. That's fine with me -- get all that water out of the atmosphere now! I'd like to be able to have a dry run, so to speak, tomorrow as well.

Apparently the popularity of long-distance running is still growing. During 2009, 468,000 people in the USA crossed the finish line of a marathon race (26.2 miles). That's an increase of about 10% over the previous year. Women continue to make up an increasingly large percentage of marathon runners; over 40% of marathon finishers in 2009 managed to do it without any help from a Y chromosome.

Not so very long ago, running a marathon was looked upon as a kind of daredevil stunt -- a highly dangerous activity. Well, it was dangerous in the early days; more than one runner died training for the first modern marathon race, at the 1896 Olympics in Athens. Since then, we've learned a little more about how to prepare for such a strenuous event, building up to it gradually with increasingly long training runs. These days, the assumption tends to be that anyone who wants to run a marathon can do it if they train properly. Oprah did it, after all.

I'm interested in the phenomenon of "impossible" things which become possbile once enough people have managed to do them. The history of classical music is, to a large extent, the history of composers writing works which are initially regarded as "unplayable", even though (these days) every musician is expected to be able to master them. It may take a while before a musician is found who can actually play the new and unplayable piece -- but once somebody has been successful at playing it, the stigma of unplayability is gone, and the next generation of musicians takes it for granted that the piece is playable; therefore, they simply don't have the same troubles with it that earlier musicians did.

It's impossible for me to know, one way or the other, but I strongly suspect that this general principle applies very often in diabetes management. Could it be that a lot of people succeed at it because they start with the assumption that it can be done, and a lot of people fail at it because they start with the assumption that it probably can't?

Wednesday, February 3, 2010  

Well, the expected rainstorm did blow into town last night, but it did its thing and moved on. By lunchtime the weather was dry. Both of my usual running buddies were ready and willing to join me in a brisk run. More brisk in their case than in mine, I might as well admit. One of them was complaining of a cold, and the other was complaining of a sore knee, but if this slowed them down at all, the only sign of it was that I didn't start to fall very far behind them until after the first 2 miles.

Sometimes it is worth looking into the history of anything that you don't like in its present form -- because it may turn out that it used to be a whole lot worse. Glucose testing would be an example of that, I think.

A lot of people hate glucose testing, perhaps more because they are disturbed by the idea of pricking their fingers than because of the actual pain involved. I can't say I enjoy the process myself, but neither can I say that it bothers me greatly. Usually it just doesn't hurt all that much. A dispenser of dental floss has more power to alarm me than a glucose test-kit does.  Still, I must take these people at their word: they say they hate glucose testing, and no doubt they do. Maybe they would hate it less, though, if they compared it to previous methods of measuring glucose levels.

Before there were blood-test strips, there were urine-test strips. A painless alternative, admittedly, but also a very inadequate one. For one thing, urine testing gave only a very rough idea of how much sugar was in your blood, and an outdated idea at that: it took a long time for a change in blood sugar to show up as a change in urine sugar. Urine test strips gave no numerical data; they merely changed color, and you had to interpret the meaning of that color change as best you could. And if you were color-blind, your best was probably not very good.

Before there was urine testing, there was urine tasting. No, that is not a typo. In 17th century London, Dr. Thomas Willis diagnosed his patients as diabetic if their urine tasted sweet to him (hence the term "diabetes mellitus", which essentially means a flow of honey). I certainly can't work up much nostalgia for that era of glucose testing.

And before there was urine tasting, there was nothing at all. People with diabetes simply became very ill, went into a coma, and died. The only way the disease was even recognizable as diabetes was that the dying patient produced abnormal amounts of urine, and the urine tended to attract ants and bees.

To me, it seems that our current system of testing is pretty good in comparison to what went before it. Maybe we'll have a better system some day (although the alternatives currently under development, such as contact lenses with telltale color patches, sound awfully lame), and maybe we won't. For now, I'm perfectly willing to start my day with a pricked finger -- especially if it means I don't have to taste anything else before I taste my breakfast.

Tuesday, February 2, 2010  

Again, nice running weather at lunchtime. No rain; cool but not cold; a light overcast, and even a bit of sun. I saw my shadow, anyway.

I'm not confident that tomorrow will be equally nice. The weather blowing in from the coast, around sunset, was looking a little Gothic.

The arrival of these clouds late in the day does not seem to point towards sunny weather tomorrow.

After the experience I had running in the rain a couple of weeks ago, I'm not sure I'm ready to sign up for more of that. If it's raining tomorrow, it's a gym day.

Today a woman with Type 2 posted a question on the dLife forum about how dangerous eating ice cream is. Her husband insists that she shouldn't have it, but she WANTS it!!!!!!!! (Her typography, not mine). She was hoping she could settle their dispute by asking a bunch of anonymous strangers if it was okay for her to eat ice cream.

I'm not sure exactly how she saw this playing out, but I guess the scenario was supposed to be that we would all tell her it's safe for her to eat ice cream, and then she would show our comments to her husband, who would say "OK, I guess they must know", and get off her back. (No doubt, like most people, her husband is always ready to abandon a strongly-held opinion as soon as he discovers that some people don't share it.)

But the real problem here is not the impracticality of hoping that a marital dispute can be resolved by persuading strangers to take your side in the matter. The real problem lies in asking someone (anyone!) if it is okay for you to eat ice cream.

There are such things as questions which shouldn't be asked at all, either because they are inherently meaningless (Richard Dawkins offers "Why are unicorns hollow?" as an example of that sort of question) or because nobody you ask is going to be capable of providing a useful answer. "Is it dangerous to eat ice cream?" is close to meaningless, and even if you nudge it in a more meaningful direction by changing it to "Is it dangerous for me to eat ice cream, given my diabetic condition?", it's not the sort of question that others can answer for you with any confidence. I don't know if you can handle eating ice cream, and your doctor probably doesn't know either.

Your glucose meter, however, does know. If you really want to know whether or not your system can process a bowl of ice cream without undesirable consequences, you don't ask around for opinions -- you eat a bowl of ice cream and test your blood sugar to see what effect the ice cream had.

Nobody would ever post the question "Is it okay to wear pants with a 32-inch waist?" on an internet discussion board, because it's obviously not a matter of opinion, and certainly not a matter of universal principle. It's okay for some people to wear pants with a 32-inch waist. Want to know if you're one of those people? Reach for the tape measure, not for moral support. Opinions count for nothing here.

It's surprising how often people with diabetes assume that they should be seeking opinions and theories but not seeking evidence. Opinions and theories can sometimes be worth gathering, but the main reason they are worth gathering is that you can test them against the evidence. If you're not interested in gathering evidence, opinions and theories are not going to do you much good, because you'll never be able to distinguish between the ones that work for you and the ones that don't.

Got to go now -- I'm in the market for a new pair of running shoes, and I need to post a question on the Runner's World forum about whether or not 11 is a good size.

Monday, February 1, 2010  

No rain today, despite the forecast! It was cool, with a light overcast and the sun peeking through it now and then. Good running weather.

I thought I'd done a pretty hard run on Saturday, but it turns out that my running buddy who's training for the Napa marathon was doing a run twice as long at the same time. And he was doing it in the same park, too. We worked out that we'd used the same trails at least part of the way, but we never encountered each other. The thing is, when I go for these long lonely runs in that park, I often do have little surprise encounters with people I know -- him included, a few times. I've run into his wife on the trails once or twice as well, and various people from work. It's funny to be out there in the middle of the woods and suddenly hear yourself greeted by the voice of somebody from the office.

There are a lot of very active people in my workplace. It's a hotbed of exercise junkies -- certainly more so than in any other place I've ever worked. I have often wondered exactly why that is. The company encourages this sort of thing -- there are locker rooms and showers and exercise classes there, and it's considered normal rather than eccentric for people to work out at lunchtime (managers included). I assume the company benefits in various ways from having healthy employees. Still, it's hard to believe that this many of my coworkers would be exercising this hard just because the company approved of it. They're always doing footraces and long-distance bike rides and triathlons and wilderness adventures. On Monday, those little "what-did-you-do-over-the-weekend?" conversations involves some pretty dramatic stories. There's a culture of exercise in place there, and that makes a huge difference.

We are herd animals, after all. If your peers are doing something, then doing it seems normal and comfortable to you. If none of your peers are doing it, then doing it seems strange and uncomfortable. Maybe we just reached a tipping point somewhere along the way -- there were enough active people in the company that it started catching on, and people started thinking "why not sign up to ride a bike around Lake Tahoe?" instead of "why on earth would anyone sign up to ride a bike around Lake Tahoe?".

I try not to forget that the situation in my workplace is unusual -- that most people have a much harder time fitting exercise into their day than I do, and also have a much harder time feeling motivated to do that exercise (because no one else around them is doing it). My advice is to find some peer pressure. Find active people to hang around with, and let them talk you into doing things you never thought you'd do. It's good for you. 

Older Posts:

January 2010
December 2009
November 2009
October 2009
September 2009
August 2009
July 2009
June 2009
May 2009
April 2009
March 2009
February 2009
January 2009
December 2008
November 2008
October 2008
September 2008
August 2008
July 2008
June 2008
May 2008
April 2008
March 2008
Jan/Feb 2008