From July 29 to August 9 this blog will be...  

I will be in the woods near Mendocino, California for a huge gathering of musicians known as Lark Camp. It's an annual event, and I take part in it when I can (this year, it turns out, I can).

Mainly it's just an opportunity to spend some time outside of cell-phone range, not thinking about diabetes (or at least not blogging about it), and not thinking about work, either.

The people who go there play "traditional" music, but the traditions represented are numerous. Looking over the workshop schedule, I note that there are classes in Greek fiddle, Dobro guitar, Swedish fiddle, Irish tenor banjo, pennywhistle, ensemble singing, and Brazilian Choro music -- and that's just the classes that start at 9 AM. Things start to get a little eclectic later on (Turkish, Arabic, Cajun, Klezmer, Hawaiian, etc).

I naturally spend a lot of time with the people doing Irish music, since that's what I know, but I also make a point of trying my hand at something unfamiliar. Here we're playing for a Serbian dance a few years back.

It's not exactly easy making the transition from Irish dance music to Serbian dance music (the latter almost sounds like it's from the Middle East rather than Europe), but I ended up being glad I took a chance on it. The dance ended up being a great event, and I felt that I made a contribution to it despite having only a few days to get ready for it, and playing music in an unfamiliar style.

There's always a lot of dances going on, especially in the evening, and I usually seize the opportunity to join the dance bands. I think it's very rewarding to play for dancers -- particularly when you're playing music in an unfamiliar style. When you're not quite sure how the music should go, the dancing tells you, somehow.

But what I enjoy most of all is the Irish jam session before dinner. It's fun to play music you're not familiar with, but it's also very relaxing to take a break from that, and play music you are familiar with. (However, that isn't really the reason this event is known as Happy Hour.)

Another thing I like about the camp is that, in addition to unusual musical styles, you also get exposed to a lot of musical instruments you don't often see. The washtub bass, for example.

Because the camp is really three camps, a few miles apart, and I ride my bike back and forth between them (on a hilly unpaved road) to get to various events over the course of each day, I end up getting my exercise in without having to make a special event of it. So, it's a healthy kind of vacation (assuming I can avoid eating too much.)

The other thing that's healthy about it, of course, is that it's a chance to relax and not agonize over how my project at work is going. That's got to be worth something!

Wednesday, July 28, 2010  

I'm about to go on vacation, as described above, and I'm struggling to get a lot of things done (at work and at home) to be able to make a clean getaway. I'll have to leave the daily blogging aside until I get back on August 9.

Tuesday, July 27, 2010  

The biggest problem with reading reports from the world of medical research is not that you have to figure out the meaning of a lot of unfamiliar terms (that's what Wikipedia is for) -- no, the biggest problem is figuring out what kind of spin-doctoring is being used to make it sound as if the results of the study actually justify the author's conclusions about it.

I am not alone in being concerned about this. "Spin" (defined as a distortion which makes insignificant information appear noteworthy) is beginning to be perceived as a serious problem in medical research -- so serious that researchers are beginning to do studies of spin itself as an independent phenomenon. Thus, this Medscape article "Reporting and Interpretation of Randomized Controlled Trials With Statistically Nonsignificant Results for Primary Outcomes".  

The authors examined reports of RCTs (randomized controlled trials) conducted in 2006, and found 72 in which the object of the study yielded no statistically significant results. In these cases, did the authors come right out and say "We looked for evidence of XYZ, and we didn't find squat"? Or did they give their report a misleading summary, to make it look as if they struck gold?

The authors broke down the incidence of spin by the sections of the reports in which they found it:

Section of Research Report Incidence of Spin
Title 18%
Results 29.2%
Results (in Abstract) 37.5%
Discussion 43.1%
Conclusions 50%
Conclusions (in Abstract) 58.3%

Also worth noting: more than 40% of the reports featured spin in at least two sections. All in all, a pretty damned high spin-rate, if you ask me.

The big surprise for me is that the incidence of spin was lowest in the title -- seemingly the area in which temptation would be greatest. But now that I think about it, I suppose you really don't need to spin the title; if you just call it "Citrus Consumption and Arthritis", the reader's imagination will do the spinning for you, and leap to the conclusion that you found clear evidence of a connection between those two things. It's in summarizing your conclusions about the study that you really have to get your hands dirty, and make assertions which your own data don't support.

Why do the authors do this? Apparently because they are under pressure to get papers published, and the jounals think negative results aren't worth publishing (which is like a trial judge thinking that evidence exonerating rather than implicating the defendent should be excluded). This issue of publication bias is a serious problem in and of itself (if the 2 studies that find a drug is effective get published, and the 12 that find it isn't effective never see the light of day, the world gets a rather misleading picture of the state of research on the subject, does it not?). But if the bias of journal editors in favor of positive results also leads to authors dressing up failures to look like successes, and citing worthless data as if it meant something, all for the sake of getting papers published, the problem is even worse than we thought.

Because of all these concerns, I am inclined to read reports of research with a suspicious attitude, ever alert for signs of spin-doctoring.

For example, take this article: "Low Rate of Serious Complications and Deaths With Bariatric Surgery". It sounds reassuring; I had been hearing horror stories about the long-term consequences of these surgeries (including the need for repeated surgeries). But I had also heard that such problems are getting no official recognition because "follow-up" on surgical patients covers too limited a time period to pick up on such issues. So, very clearly, the critical question to ask about this new study (which claims to have found such surgeries to be adimirably safe) is: over how long a period did they study the patients? And if the answer to that question is included somewhere in the report, I'm damned if I can find it.

The closest thing I can find to a statement on the subject is this weaselly passage: "Short-term morbidity was evaluated in 15,275 patients undergoing gastric bypass, sleeve gastrectomy, and laparoscopic adjustable gastric band placement from 2006 to 2009." Okay, I give up: what does "short-term" mean? A week? A month? Three years? Does "2006 to 2009" refer to the range of dates over which patients were tracked, or does it simply refer to the range of dates over which surgeries were performed?

As far as I can determine, the study which finds that bariatric surgery has a low rate of serious complications did not consider any issuses besides how well patients are able to handle the surgery itself and its immediate aftermath. What the impact of a stomach redesign is on people's lives in the long term (whether they have to come back for repeated surgeries, for example) is not addressed here. As a guide to decision-making about whether or not the surgery is a good idea, this study tells us very little, yet to all appearances it tells us everything we need to know.

But at least the study is unlikely to be biased: it was done by the Michigan Bariatric Surgery Collaborative, and I'm sure they have no axe to grind in this matter.

Monday, July 26, 2010  

Yesterday was not only a rest-day from exercise, it was also a two-pub day (I went down to San Francisco to play in Irish music sessions in a couple of places, and in one of them I had Irish stew and Guiness). So my fasting test of 89 isn't bad, considering, but the weekend didn't help my weight any.

I was pleasantly surprised that my post-prandial test after lunch was as low as 102 -- I had a big bowl of minestrone, and there was pasta in it. Not a whole lot of pasta, but pasta nevertheless. Some claim that pasta has a lower glycemic impact than bread, but I think that's only true if the pasta isn't cooked until it's soft -- and the pasta in a bowl of minestrone is usually about as soft as pasta gets. Lunch was right after a hard run, though -- that might have given me an advantage in coping with the carbs.

What kind of summer is this? The morning fog didn't even start to burn off until 4 PM, and it stayed cool all day. Similar weather is predicted for tomorrow and the next day. The rest of the country has been having a hot summer, by all accounts, so I don't know why northern California should be shivering under gray skies. It feels as if we are still waiting for spring to arrive. Not that I especially enjoy extreme high temperatures, but it feels a little weird not to experience any in July. The transplanted Scots I work with are getting very puzzled. This is not the California they thought they were moving to.

It does make it easy to do a noontime run, though!

Nothing is less inspiring than a conflict between two parties who are both wrong. I'm not talking about foreign affairs; the particular conflict I am thinking of is the one between (1) people without diabetes who say that those who do have diabetes are entirely to blame for being diabetic because they "ate too much sugar", and (2) people with diabetes who say that diabetes was forced on them because the disease is entirely gene-based and no other factor plays a role in causing it.

Passing moral judgment on others for having health problems is certainly not a useful tool in promoting public health, because people who have been put on the defensive are less likely, not more likely, to see things clearly and make sensible choices. And I think that is exactly what's going on in the case of the people who argue passionately that diabetes is a genetic disease, and it's not their fault that they have it, and lifestyle is not relevant to it. They've been backed into a corner, and they're so desperate to claw their way out of there that they're willing to ignore reality entirely.

A large number of genes have been identified as increasing your risk of becoming diabetic. But obesity and lack of exercise also increase your risk of becoming diabetic. In most people it's probably a combination of unlucky genes (which we don't have a choice about) and unfortunate habits (which we do have a choice about) which turn a diabetes risk into a diabetes reality. Yes, some people with excellent genes can get very fat without ever becoming diabetic, and some people with horrible genes can get very diabetic without ever becoming fat. But for most people the situation is mixed, and you can't reduce it to a simple statement such as "he ate too much sugar".

By the way, although it sounds appropriate for excess sugar consumption to be a cause of diabetes, those who have looked for a specific link between sugar consumption and diabetes have generally found that eating too much of anything, with resulting weight gain, is all it takes. You can apparently get just as diabetic from eating too many barbecued pork ribs as you can from eating too many cookies.

Anyway, all this moralistic talk about whose "fault" diabetes is needs to be toned way down. It's pointless, and it puts people so much on the defensive that they start denying that lifestlye is even relevant to diabetes -- which is dangerously crazy thinking and should not be encouraged.

People trying to manage diabetes need to be aware of all the factors that contribute to it -- not just the factors that can't be blamed on them.

Friday, July 23, 2010  

Oh, no! The latest Medscape article begins with the headline, "Sitting a Risk Factor for Death".  If you sit, you die.

What they mean, of course is that some people sit more than others, and some people die more than others, and  -- no, wait, that can't be quite right either. Nobody dies more than others. The death rate is pretty reliably 100%, and this holds true both for the seated and the erect.

Apparently when they talk about the "death rate" for different people, they're not talking about the likelihood of dying eventually, but rather the likelihood of dying within a limited period, such as a year. And by that definition, the death rate is higher if you do a lot of sitting. This is alarming news for someone like me, who spends most of his workday sitting in front of a computer, and too much of his evening doing the same thing at home.

This was a 14-year study, conducted by the American Cancer Society, with data from 53,440 U.S. men and 69,776 women who were 50-74 years old when the study began in 1992. The study looked into how much of people's leisure time was spent sitting. Specifically, the particpants were asked,  "During the past year, on an average day (not counting time spent at your job), how many hours a day did you spend sitting (watching television, reading, etc.)?"

The outcome? People who spent at least 6 hours of their daily leisure time sitting died sooner than people who sat less than 3 hours. The effect is more severe if you don't exercise, but the effect is still there, either way. Sitting itself is somehow harmful to health, even if you exercise when you're not sitting.  For unknown reasons, the effect is stronger for women than for men, but both sexes are seriously impacted by prolonged sitting.

Specifically, the impact of sitting at least six hours (as compared to sitting less than three hours) was as follows:

Well, I might get away wiith all the time I spend sitting in front of a computer, by virtue of being a guy and exercising a lot. Buit maybe I should get up and pace around a little more. Otherwise I'll join the other baby-boomers memorialized in Roz Chast's famous cartoon...

Thursday, July 22, 2010  

I couldn't join my running buddies today because of an inconveniently scheduled meeting which I needed to attend. Someone else in the office wanted to go for a run with me later in the afternoon, and then he got called into a meeting and couldn't do it. So I decided to go to the park for a trail-run after work. I even had trouble doing that, because on the way there I got caught in a bad traffic jam caused by a road-repair project of which I had been unaware. Sometimes it's amazing how many obstacles a day can throw into your path when you're trying to fit in a good workout.

Eventually I did get to park my car and go for a run, with enough daylight left to complete it, but it was fairly late by the time I started. That wasn't a problem, really. I like the colors and shadows that turn up with the sun is getting low in the west. Also, the temperature gets comfortably cool. I think it's a great time for a run.

To be sure, it can begin to seem lonely in the park, if you aren't seeing many other people on the trails. You start to wonder what you could do about the situation if you hurt yourself in here, with nobody around to help you. And from time to time you hear a noise behind you, and for a moment you're sure it's a mountain lion, which is an awful feeling. But I scared the hell out of a deer who thought I was a mountain lion, so it's only fair that I ought experience a few scares myself.

I don't know why the evening light makes the world seem so much more benign to me, but it does.

Dinner was pretty low-carb, so the low post-prandial test restult isn't too surprising. But I did have one of the plums my neighbors gave me from their tree. I'm rationing those out to myself in small doses.

Meanwhile, here's the latest from The Onion:

Wednesday, July 21, 2010  

I had lunch in the company cafeteria -- a big Chinese chicken-salad plate. It came with a piece of garlic bread, and I ate the bread, but it wasn't a big piece of bread, and the salad ingredients didn't seem all that high-carb to me (although sometimes you can't tell -- the dressing may have been sugary, for example). Anyway, I was hoping to get a post-prandial result below 120 -- especially after such a low fasting result this morning. Well, test results can always surprise you -- that's why we keep collecting them. 

At this point, stress may be a bigger factor for me than carbs.

Where I work, most people are assigned to "projects" -- they work on a team that is creating a new product (or revamping an old one). Projects are temporary; once the product is introduced, the team is broken up and the team members are assigned to other projects. But during the time that you're working on a project (and it can last more than a year), that's your whole job and your whole world. And some projects are very, very difficult for everyone involved. This is especially true of projects which are launched with ambitious goals at a time when business is booming, and later have to be kept going somehow during a period of recession and layoffs.

The project I'm now working on began life at a company facility in Europe which cut so many employees last year that the project had to be moved elsewhere. Actually, it was moved to two elsewheres (part of the work is being done in China, but the part of it that I'm involved in came to California). Some of the original European employees who were willing to relocate to California are still involved, but for the most part the project was handed off to new people -- which is always challenging, since you come into the project with a lot of questions, and the people who could have answered them don't work here anymore. Also, the scale of the project is out of proportion to the number of people actually working on it. (I was added to the team to take on tasks which would normally be shared by three or four people.)

So, many people working on the project are stressed out about it. Actually, all of them probably are, but some of them are unable to hide it. Sometimes our project meetings are punctuated by brief but startling outbursts, from people whose frustration and anxiety can no longer be contained. I haven't been guilty of any outbursts in meetings, but I've been getting very gloomy, and having trouble sleeping, and sometimes coming into the office in the morning feeling queasy with dread. I'm nervous when I answer the phone or open my e-mail, because I take it for granted that this can only be bad news.

Well, we had a project meeting this morning, and one of the more frustrated team members was not there this time. It was announced that he would not be coming into the office anytime soon. Today he woke up before dawn feeling terrible, and his wife was so alarmed at how bad he looked that she drove him to the emergency room. There he had a heart attack (the best place to have one, really, if you're going to have one at all -- the doctors said he probably wouldn't have survived it if it had happened at home). The doctors were able to resuscitate him, and performed some kind of procedure to relieve the blockage. Apparently he's doing okay for someone in that situation, but it's obviously a very dangerous situation to be in, and I think he's still in intensive care.

I suspect I wasn't the only team member who left the conference room wondering who would be next, and whether I could do anything to make sure it wouldn't be me.

As luck would have it, I was feeling a rather strong ache in my left wrist this morning, which I blamed on my watchband being too tight. I was loosening my watch and massaging my wrist, trying to persuade the pain to go away, when I heard the heart-attack story. And then I started wondering if the ache in my wrist was "referred pain" that actually related to something far more serious than a tight watchband. I'm not claiming that this makes sense, of course; so far as I can determine, an isolated pain in the left wrist is not a probable sign of myocardial infarction. It's just the thought that popped into my mind. I guess I knew it was a bogus thought, since it didn't discourage me from going for my lunchtime run, and charging up the first hill as best I could. But even though I went ahead with the run, I was thinking about heart attacks, and what it would be like to have one, and in particular what it would be like to have one while running outside, and being found unconscious on the road, and then perhaps waking up a day later in the ICU and discovering that you can no longer remember how you spell your name.

But there were other thoughts that came to me, too. One was that, even on the hardest climbs, running wasn't that hard. My wrist might be aching, but my heart wasn't. I actually felt okay. I could do this and live to tell the tale. And if I could run up steep hills without feeling chest pains, maybe I had a little more protection from waking up in the middle of the night with chest pains than the average person. (As for the wrist pain, it faded over the course of the day, and it probably really was caused by the tight wristband.)

In the afternoon, meditating on these matters, I decided that I should take warning. All of us on the project need to stop stressing out about this thing. We'll do what we can, and whatever we can do will just have to be good enough. It's not worth having a heart attack over it.

I'm going on vacation at the end of next week, and I had been fretting about whether or not I can really get done all the things that I thought I needed to get done before leaving town. I think my attitude now is: I will get done what I can before I leave town, and then I will leave town without a backward glance and spend some time forgetting where I work.

Tuesday, July 20, 2010  

Cool! We went running through a graveyard today.

Wait, I can explain. My running buddies and I have certain established running routes through the neighborhoods around our workplace. We've made up names for them for easy reference (our top five are called "Golf-course", "Hospital", "School", "Montecito", and "Fountaingrove"). We meet outside before we run, and while we're doing a little preliminary stretching we discuss which route we want to do this time (based partly on how much time we have and how energetic we're feeling). I sometimes think the main reason we keep following familiar routes is that it saves time if we pick an existing route which we all recognize by name, rather than proposing a new route and trying to describe it. However, I tend to get a little weary of doing the same routes repeatedly, and from time to time I suggest trying something new. Today I thought it would be nice to head out to the cemetery.

It wasn't so much that I particularly wanted to run amongst the headstones. What I wanted was to take Parker Hill Road down to Chanate, and from there to Hidden Valley, and from there to North Street, and then back to Chanate, etc -- but it was a lot easier to say "the cemetery", and the rest more or less followed. So we went there. And when we got to the graveyard, we wanted to avoid a stretch of high-traffic, no-shoulder roadway there, which meant that running through the graveyard was a much safer option than running around it. So, we ran through it.

I'm not entirely clear in my mind about whether it is any more improper to run through a graveyard than it is to walk through a graveyard. I mean, we weren't running on the graves -- we stuck to the footpath wherever there was one, and the path was clearly intended for people to get around in there on foot, with no rules that I know of regarding how fast people were allowed to do so. But it wouldn't surprise me to learn that some people would take offense at the presence of runners in a graveyard, perhaps on the assumption that running is some kind of frivolous entertainment which should not be practiced in a serious place. Well, there's not really anything you can do in life without causing some people to take offense, so I'm not sure it's worth trying. Anyway, in we went.

As usual, my running buddies were ahead of me, and as I followed them through the graveyard, I was repeated puzzled by the many twists and turns in the route they selected. Were they trying to find a particular grave? Were they trying to add to the mileage of an already long run? Actually, I found out later, they were just trying to find a way through the place, and were stymied by the maze-like arrangement of the paths through it. Since I was only trying to follow them, without regard to other possible paths, I didn't even notice the problem they were trying to solve. And at the end, when we could see the road right in front of us, there seemed to be no path that connected with it, so we ran across the grass, even though this was a section in which the headstones were all lying flat and it was hard to run through without stepping on any graves accidentally. (I was not worried about how the dead would see this, but very worried about how any chance observers from the world of the living might react.)

Anyway, we got through. And I'll say this for the dead: they're far more polite and quiet than the living drivers who passed us on the road. No screaming or anything. Three cheers for the dead!

It was a pretty hard run, so I figured I could have a sandwich for lunch without getting a high post-prandial result. And so it proved: 111 after an hour. But I didn't push my luck: dinner was a salad.

"Patients With Diabetes Have Alternatives to Rosiglitazone, Experts Say" reads the Medscape headline. Rosiglitazone is popularly known as Avandia, and is under a cloud because of studies claiming that it raises cardiac risk significantly. (That it doesn't reduce cardiac risk is already enough of a scandal, in my opinion, for any diabetes drug -- but doctors seem to have agreed to overlook that particular elephant in the room, with regard to this and every other diabetes medication.) Anyway, the experts are telling us that patients who are afraid to continue taking Avandia (or whose doctors are afraid to continue prescribing it) still have alternative methods of controlling diabetes available to them. And the listed alternatives are... six other classes of drugs. Not exercise. Not weight loss. Not dietary changes. Drugs.

Thank you, experts, for that clarification! Otherwise, people taking Avandia might have assumed they neeed to rethink their entire approach to the problem.

Monday, July 19, 2010  

It was warm today, and after our lunchtime run I sat down for a while with my two running buddies, on a bench in the shade, to cool off. Sweat was dripping off me, but (although they complained about how difficult the run had been), they looked as if they hadn't done anything more strenuous than grocery shopping. By the time we got up, there was a little puddle of sweat on the ground in front of my place on the bench, and no visible sign that even a drop had fallen off either of them.

Okay, I guess I know why I get dehydrated so easily.

I meant to do a post-prandial test after lunch today. Then I got interrupted -- called to a meeting in another building. When it dawned on me (in the middle of the meeting) that it was time for the test, I was a long walk from where my meter was, and there was no way I could just disappear and go take care of that. So I settled for testing after dinner. My dinner was a mixed bag of picnic leftovers -- medium-carb, I'd say. There was some pasta included in it. 118 isn't a bad result after even a small amount of pasta.

Would it be so very wrong to give diabetes patients some straight talk? It seems as if what most people hear from their doctors is heavily filtered -- "translated", so to speak, by which I mean transformed from a description of reality into a simple-minded fiction which is assumed to be the limit of what patients can understand.

One case in point is the effort to redefine the Hemoglobin A1c test result as "estimated average glucose", which I cannot believe anyone sees as a step in the right direction. The only thing the A1c test actually measures is how much of your hemoglobin is sugar-frosted. (This has some connection with average blood glucose, but it's misleading to suggest that a given A1c result reliably equates to a particular average glucose level.) If you told patients what the test really measures, and explained that having 7% or more of your hemoglobin encrusted with sugar puts you seriously at risk for blindness and amputations and suchlike things, I think they could grasp what's at stake.

But even more strange to me is the seeming reluctance of doctors to tell patients what the normal range of blood glucose is. Somebody posted a question on the dLife forum recently, saying that his blood sugar always seems to test in the 70 to 90 range, and asking for advice on how to get his results "back to normal". Huh? The 70 to 90 range is normal. It turns out that he was advised to aim for 90 to 120, and he assumed that anything below 90 was a problem.

I don't know for sure why he was advised to aim for the 90 to 120 range; it may be that his doctor feared he would have hypoglycemic episodes if he aimed for anything below 90. It could also be that his doctor assumes no diabetes patient will ever get results below 90, and it's more "realistic" to set a more modest goal. But come on: 70 to 90 is within the normal range, and it's even in the healthier part of the normal range. Giving patients the impression that being in the 70s is dangerous and bad does not look to me like a public service.

I think it would be far better to admit that the normal range extends down to 70, and that being in the lower part of the normal range is a good thing -- and then, if necssary, explain why it might cause problems for some patients to try to get themselves into that low a range.

But to make patients who are in the best possible range worry that they're in an abnormal range and should be trying to elevate themselves out of it -- that's inexcusable!

Sunday, July 18, 2010  

90 isn't a bad fasting test, especially considering that yesterday was my non-exercise day for the week, and I not only rested, I went to a picnic. (Actually, I went to see a show at Woodminster Amphitheater, an outdoor stage in the Oakland hills. But it's all about the picnic, unless the show is an unusually good one -- as it happened to be this time.) Anyway, I felt as if I really ought to make my trail-run a bit difficult today, to make up for my calorie intake yesterday (with no exercise to counteract it).

It was a hot sunny day hereabouts -- just the sort of weather to disourage the faint-hearted from hitting the trails. Well, that was okay with me -- I like it when there aren't too many people in the park.

I tried to choose trails that would keep me in the shade as much as possible...

...but of course there's a limit to how much you can do that. It's not all woods -- there are sunny meadows to get through too.

After the first mile, which is never easy, I discovered that I actually was feeling strong today, and enjoying the run. I had plenty of water with me. So as I ran along, coming to the occasional fork in the trail and having to decide to take the longer or shorter of the alternatives, I choose the longer one, and my run ended up being over 9 miles long.

The only thing that bothered me was worrying about tripping on a rock or a protruding root. When the branches overhead are casting a lot of crooked shadows on the ground in front of you, the visual clutter becomes confusing and it's very easy to overlook an obstacle and stumble on it. I didn't take any falls today, though.

At one point I heard the sounds of animal movements off to the side of the trail, and worried for a second or two what it was -- but it just turned out to be some wild turkeys.

Even though the run was long, I am pleased to report that I felt better and more energetic during the last mile than I had during the first mile. Nothing was sore afterwards. In terms of trail running, that's about as good as it gets. Even though this run was nearly as long as the one that wiped me out last Sunday, I felt fine afterward this time, and I'm sure the reason for that is that I stayed on top of hydration much better this time.

Friday, July 16, 2010  

Okay, reality starts to assert itself once more! 

It was beginning to look as if I could eat any kind of meal I wanted and still get a 1-hour post-prandial result under 120. Not this time! I ate an Indian dish which I actually thought wasn't all that bad, carb-wise -- but it did include some potato dumplings, and that was probably the deal-breaker. (A lot of people say that nothing pushes their blood sugar up quite like potatoes -- it seems as if potato starch gets digested faster, and hits your bloodstream harder, than any other kind.)

My 1-hour result was 147. Although it met my doctor's target range requirement (<150), I wasn't happy with it. I feel more comfortable keeping it under 120, because that's where the non-diabetic people hang out, and it's best to be with them if you can.

I decided to check again at two hours, just to make sure it was indeed lower then, and I got a result of 116. Some people claim that anything under 140 at the two-hour point is normal. I'm not so sure about that, but 116 is certainly better than 147.

Maybe I would have handled a potato dish better if I'd had it right after I ran at lunchtime, but I can't take that for granted. I think I may try an experiment. I'm planning to do a long trail-run on Sunday -- I'll do that, and then have a baked potato and see what happens. I would like to be able to find a way to let myself have a baked potato once in a while (it's not something I usually risk, but it would be nice to know if I can get away with it occasionally, under special circumstances).

I usually do a long run on weekends; maybe I should make a practice of saving up my carb-cravings and indulge them then. But only if I can gather some proof that it's something I can actually get away with! I'm fairly sure I could have got away with a baked potato after last Sunday's ridiculous run, which ended up being 10.6 miles, but what I need to know is what I can get away with after a 7 mile run, because my weekend trail run is usually not much longer than that.

Deep thought for the day:


Thursday, July 15, 2010  

70 is a very low fasting result for me, and I don't really know why I got it. I go through phases of surprisingly low results now and then, and I usually don't know why. I did have a pretty low-carb dinner last night, but that's not enough to explain it; I've certainly had low-carb dinners before without getting a fasting result of 70 the next morning.

Like most diabetes patients, I have an instinctive genius for finding a way to interpret good news as if it were bad news. So, whenever I go though one of these phases of getting lower results than I'm expecting, the thought crosses my mind that one of the things which can cause your blood sugar to drop unexpectedly is a fast-growing tumor in your pancreas. Then I get a grip on myself and say, "Knock it off, Tom, we've been through this before and it's not cancer, it's just a good test result, so shut up and be happy about it".

But I have no idea why these low-glucose phases start and stop the way they do. It usually seems to me that they end for no better reason than they started. However, maybe I'll watch this one more closely, and see if I can figure out what's going on -- or even figure out how to keep it going.

Dinner was pretty low-carb tonight -- I made a vegetable curry and added crab-meat to it. There was some carbohydrate in the curry sauce and in some of the vegetables, but not too much. Lunch was pretty high-carb, by contrast. Well, I got away with pasta for lunch yesterday and only went to 105 -- and that was after a shorter run than I did today.

But I don't think my fasting test is going to be 70 again tomorrow, no matter how well I got away with my high-carb lunch today.

Meet Thomas Willis, MD:

He's the English doctor who put the "mellitus" in diabetes mellitus. In his 1674 book Pharmaceuitice rationalis, he included a chapter on diabetes, explaining that there were really two forms of the disease. Not the two that you're thinking of, though! Diabetes at the time was defined as a disease which caused excessive urination. Willis found that, in some patients with this problem, the urine they produced was "wonderfully sweet", whereas other patients produced just as much urine but came up short in the flavor department. He described the former condition as diabetes mellitus ("mellitus" meaning "honey-like") and the latter condition as diabetes insipidus ("insipidus" meaning "lacking in flavor").

Of course, what most of us want to know is what inspired Doctor Willis to be conducting taste tests on his patients' urine in the first place. In fact, the wine-lovers among us would like to know if these were blind tastings, or if Willis allowed himself to know whose urine he was sipping, and thus allowed himself to be influenced by his feelings about the personalities involved (perhaps he unconsciously took away sweetness points from the urine of patients he found abrasive!). Also, what did he use as a palate-cleanser between tastes?

Alas, the story of Willis's introduction to urine-tasting is lost to history, or at least to my investigation of history. I went so far as to download a photographic reproduction of Pharmaceuitice rationalis, hoping to get the story of the good doctor's eureka moment in his own, 17th century words, but I was wasting my time. I'm sorry to report that the title of his book is not the only part of it that's in Latin. We don't know, or at least I don't know, why he decided that, if you're going to study patients who produce a lot of urine, you need to be prepared to wet your whistle with the stuff.

At any rate, Thomas Willis was a highly distinguished physician and scientist in his day (his investigations of diabetes impressed people enough that diabetes was, for a time, known as Willis's disease), and his terms diabetes mellitus and diabetes insipidus are, rather amazingly, still in use today. (By the way, diabetes insipidus is a pituitary disorder that has nothing to do with blood sugar; it just happens to resemble diabetes mellitus in that patients produce a lot of urine. In 1674, taste-testing was the only way to tell the two diseases apart.)

Well, three cheers for technology. I'm glad we live in an era when chemical analysis can be done by means of electronic devices and not by saying "Hey -- does this urine taste funny to you?".

Wednesday, July 14, 2010  

I have been getting pretty good post-prandial test results, but mostly I've been getting them with low-carb meals, or at least moderate-carb meals. I decided to challenge myself with a high-carb meal today, and see how well my system handled it.

Actually, the "decision" was made on impulse. After I got back from running at lunch, I went into the cafeteria, saw that one of the offerings was a vegetable-pasta, and decided to try it. My fasting result was so low this morning that it seemed as if I was never going to get a better opportunity. I also had a small carton of milk along with the pasta, which added another dozen grams of carbohydrate to my lunch. Way too much for most people with Type 2, and I was afraid it might turn out to be too much for me, but the result an hour later was only 105.

Of course, in some ways I stacked the deck in favor of a low result. My high-carb lunch immediately followed a hard workout (the run was quite hilly), and it occurred on a day when I started out with an exceptionally low fasting result.

The likely explanation for the low fasting result this morning -- assuming it wasn't just the ordinary variability of the meter -- was that lunch and dinner yesterday were both pretty low in carbs. This raises the question: would my lunch and dinner yesterday have both been low in carbs, if I hadn't decided a little over two weeks ago to get back into the habit of doing post-prandial testing?

Part of the reason we do glucose testing is to find out what's going on. But an equally important part of the reason for doing it is that, if you know you're going to be testing yourself, you automatically modify your behavior so as to get a good result. This is especially true if you're going to be sharing your results with the whole world, as in my case.

When I decided that just doing fasting tests was good enough, I made that decision based on the assumption that my fasting results were excellent and there was probably no room for improvement. If, after I resumed doing post-prandial testing, my fasting results started going down, this would be an indication that I hadn't really been doing my best before, and there was room for improvement.

Well, I just looked at my fasting average over various periods, and it sure looks as if my fasting average has been dropping ever since I decided not to rely entirely on fasting tests:

Period Fasting Average, mg/dl
Last 60 days 85 
Last 30 days 85
Last 14 days 83
Last 7 days 81

In all fairness, I think you have to concede that my fasting average was pretty darned good to start with, especially considering that I was diagnosed 9 years ago (with a disease which, according to what everyone tells me, always gets steadily worse over time). But the rapid drop in my fasting average, from a seemingly stable 85 down to 83, and then 81, suggests that there was indeed room for improvement, and that I made that improvement, simply because I thought someone might be looking over my shoulder at the results.

Of all the issues impacting diabetes management, human nature is probably the most important -- and least regarded. Somehow or other we have to include it in the equation.

Apparently the dLife forum banned one or two of its crazier participants (the people I was complaining about yesterday). Maybe this will improve things there, but I suspect that it will take longer for gun-shy people to return to posting than it will for a new crop of crazy people to arrive and launch a new cycle of crayness once again. 

Tuesday, July 13, 2010  

I felt stronger today, and I felt I was ready to go back to my usual routine of running at lunch. I wasn't very fast, but I managed to get in a solid run without feeling bad, which was my modest goal for today. Tomorrow I'll probably run a bit farther.

The dLife website weighed in today on the carbohydrate content of various alcholic drinks. It's surprisingly hard to find this kind of information, so I hope their facts are right:

Drink Carbohydrate (g)
Glass of dry champagne 1
Manhattan 3
Dry white or red wine 3 - 4
Traditional margarita (tequila, orange liqueur, lime juice) 7.5
Apple martini 8
Guiness stout 10
Beer 12 - 13
Screwdriver 13
Sherry 14
Cape Codder 17
Commercial margarita (made from a mix) 29
Pina colada 32
White Russian 39.4

Well, I think I've been choosing correctly, if only by instinct: my first choice is wine, followed by beer, and mixed drinks generally don't interest me (particularly in the form of an "apple martini", whatever that is -- surely that's not something that James Bond would drink, either shaken or stirred).

If a margarita prepared one way is four times as carb-heavy as a margarita prepared another way, it sounds like it's pretty hard to know what you're getting when you order a mixed drink. Better to stick with wine.

I'm afraid that dLife's forum is dying. The insistent evangelists for this or that diet theory have made themselves so obnoxious and tiresome that most people are afraid of posting anything at all there. Only newcomers dare to ask a question, and then when they see the discussion turn into some kind of ridiculous dogfight, they disappear forever. And one or two of the people posting there seem to be psychiatric cases who have gone of their meds, with no particular agenda apart from hostility.

Not everyone who posts on the dLife forum is mentally disturbed, of course; but it seems that everyone who is mentally disturbed posts on the dLife forum. Well, pretty soon they'll have it to themselves.

For centuries (going back not only to H. G. Wells but to Plato) people have debated the moral implications of invisibility: just how badly would people behave if they knew their behavior would go unobserved?  Up to now the issue has been pure speculation, because we are still waiting for the first Invisible Man, so there has been no opportunity to test our assumptions. But the anonymity of the internet seems to be a reasonable stand-in for invisibility in the debate, and it seems that anonymity unleashes some pretty unpleasant things in people. Not only can they be more reckless and childish and hostile on line than they would ever dare to be in real life -- they can also be more stupid and boring, too! It's the latter sin that grates on me the most. If they must be rude, couldn't they be rude in a more interesting way?

Monday, July 12, 2010  

Yesterday's unplanned running adventure seemed to take a lot out of me -- literally. There's no doubt I was dehydrated, as I sustained a temporary loss of six pounds of water weight. I was drinking lots of water afterward, but it takes a long time to get rehydrated, and even after you've replaced all that lost fluid, the feeling of being "drained" persists into the next day. I still felt wiped out when I woke up this morning (so much so that I forgot to do a fasting test -- something I seldom overlook). At lunchtime today I didn't feel like I was ready to handle running again. I decided to opt for a lighter workout, at the gym after work (and by then I was feeling a bit better anyway).

During that frantic run yesterday, I thought the reason I was getting exhausted was that I was trying to run at a faster pace than I could handle. Well, no doubt that was part of it, but the main issue was probably that, by running too fast on a warm summer afternoon, I was making myself sweat too heavily, and not taking in enough water to compensate. I don't know whether I was actually getting hypoglycemic at the point I took the glucose gel -- probably not, looking back at it, because I wasn't feeling a sudden intense hunger, just a sudden loss of energy. Probably dehydration alone was enough to account for my feelings. (But I don't think it was a mistake to take the glucose -- I was certainly not properly fueled-up for a hard 10.6-mile run.)

My low post-prandial result of 100 isn't too surprising -- it was a pretty low-carb lunch.

My low resting pulse of 44 is slightly surprising, but I do get down that low sometimes. And I measured it after I'd come home from my yoga class, and I was pretty relaxed.

Odd confession: I think I miss the kind of extreme fatigue that comes from really hard endurance sports. I used to do a lot of long-distance cycling, and later marathon training. When you do a workout that's lengthy enough and difficult enough to really empty your gas tank, the extreme fatigue afterward has its pleasurable side. You feel almost feverish, as if you were coming down with a virus, which doesn't sound like it could be a pleasant sensation -- and yet there's a strange euphoria mixed with it. And you sleep deeper that night, and have interesting dreams. (Although I would have preferred that my dreams last night had involved no gunfire, and particularly no gunfire directed at me.)

Since the 2009 Napa Marathon (more than a year ago), I haven't been doing anything quite hard enough to get me into that extreme-fatigue zone, except for a half-marathon last October. I make a habit of doing a long run on the weekend, but that's usually 7 or 8 miles, at an easy pace. Yesterday's run (10.6 miles, with heat and big hills and a lot of time pressure) pushed me into that zone, and I appreciated the memories it brought back.

Sunday, July 11, 2010  

"Oatmeal: Good or Bad?" is the question posed by this post on Dr. William Davis's Heart Scan blog. Spoiler alert: he thinks it's bad. Specifically, he thinks it's bad because oatmeal has too severe a glycemic impact.

"Try this: Have a serving of slow-cooked (e.g., steel-cut, Irish, etc.) oatmeal. Most people will consume oatmeal with skim or 1% milk and some dried or fresh fruit. Wait an hour, then check your blood sugar.

If you are not diabetic and have a fasting blood sugar in the "normal" range (<100 mg/dl), you will typically have a 1-hour blood glucose of 150-180 mg/dl--very high. If you have mildly increased fasting blood sugars between 100 and 126 mg/dl, postprandial (after-eating) blood sugars will easily exceed 180 mg/dl. If you have diabetes, hold onto your hat because, even if you take medications, blood sugar one hour after oatmeal will usually be between 200 and 300 mg/dl.

This is because oatmeal is converted rapidly to sugar, and a lot of it. Even if you were to repeat the experiment with no dried or fresh fruit, you will still witness high blood sugars in these ranges. Do like some people and pile on the raisins, dried cranberries, or brown sugar, and you will see blood sugars go even higher."

This struck me as a bit overstated. But he did say "Try this", after all, so I thought I would try it.

I had thought I still had some Irish steel-cut oats in the pantry; it turned out that I didn't. I did have some McCann's Irish oatmeal, but it was the faster-cooking variety (I had bought it by mistake once, thinking it was McCann's steel-cut oats). This worried me, because quicker-cooking oats are digested faster, so I could expect that the glycemic impact would be even worse than what Dr. Davis was predicting. Half the rationale for eating steel-cut oats is that they're more slowly digested and are less likely to cause a glucose spike (the other half of the rationale is that they taste 100% better than the quick-cooking varieties). Well, I decided to go ahead with the experiment anyway; if I got a bad result I would later repeat it with steel-cut oats to see how much difference it made.

I prepared a single serving as defined on the package (half a cup of dry oatmeal, cooked in 1 cup of water). I did add milk, but no dried fruit (I didn't have any, and Dr. Davis said the impact would be about the same without it). I didn't add sugar, either. Then I waited for the hour to be up, so I could test my blood sugar.

The suspense was terrible, of course. Would my post-prandial blood sugar be in the 150-180 range, as predicted for non-diabetic people? Would it be well above 180, as predicted for diabetic people?

Actually, it was 109. Hmmmm.

Obviously, there are some weaknesses in my experimental method. I used fast-cooking oats rather than the slow-cooking variety recommended, and although it is probably reasonable to expect that slow-cooking oats would have produced a lower result, not a higher one, we can't take this for granted. Also, I added no dried fruit.

But let's be fair. Davis himself says explicitly that the result will be in the same range even without the fruit. And he certainly doesn't suggest that oatmeal is acceptable so long as it's the fast-cooking variety. In fact, he illustrates his oatmeal-is-bad blog post with a photo of a box of quick-cooking oats.

So, I think my experiment was a reasonable test of Dr. Davis's predictions regarding 1-hour post-prandial blood sugar following consumption of one serving of oatmeal. And it seems that his prediction is not accurate in my case.

Please don't think that I'm some kind of oatmeal partisan. It's not like I'm eating the stuff all the time. I don't know how long that can of steel-cut oats had lasted me, but it was probably well over a year, and I'm sure it's been at least two months since I used the last of it (not only that, I completely forgot that I had run out of it). I like oatmeal, especially the slow-cooking kind, but I don't have it often. I've been reluctant to make it a routine breakfast, and for the very same reason that Dr. Davis would cite: the glycemic impact of all those carbs. But the glycemic impact is apparently not nearly as servere, at least in my case, and at least on this particular morning, as Davis predicted.

But, as they say, more research is needed.

I had a bit of an adventure today. I would have preferred not to have it, but we don't always get to choose our adventures.

I drove to the nearby state park early this afternoon; by "nearby" I meant that it's 5.3 miles from my front door, a fact which will become relevant shortly. I was intending to do a trail run. Not a terribly long one, but I felt that yesterday's 6.1-mile fell slightly short of being my challenging run for the week, especially as it didn't involve very steep climbs. So I figured I'd run a particular trail loop there, which I knew was a little over 7 miles long, and included tougher hills than anything I did yesterday.

I parked my car in a shady spot by the side of the road near the park, and as I was taking out of the car the things that I needed to have with me on the run (and locking in the trunk the things I didn't need to have with me), I allowed myself to get distracted from my normal checklist process. And the result was that, shortly after I locked up the car, it dawned on me that the spare car key which normally hangs on a chain around my neck while I'm running was, in fact, not around my neck -- which meant that I had just locked it in my car.

Other interesting things that I had locked in my car included my wallet, my money, my AAA card, and my cell phone. This left me with few options in terms of summoning assistance.

I figured my best option was to run home, where I knew I had a house key hidden; I could get inside and use the home phone to call AAA. So, I ran home. It was only 5.3 miles, and I had been planning to run farther than that anyway. It was a terrible climb to get there, though, and I arrived drenched in sweat.

So I called AAA and explained my problem. They said they could help me. They said their expert at breaking into cars would be there in half an hour. I said, you have to make it an hour -- I have to run over five miles to get there, and I'm already tired. (I would have asked my next-door neighbors for a ride there, but I saw them driving away just as I got back home, so I knew they weren't available, and I couldn't think of anyone else who was around today.) The AAA guy said that they don't make appointments to meet people at a specified time; they will only send someone out on an immediate, emergency basis, and if he gets to your car and you're not there, he won't wait for you longer than about 5 minutes. I said "But I can't get there that soon! I can't run that fast!" The guy on the phone had to consult with his superiors more than once before they finally agreed that they would cancel the call to the truck, and then place the call again later, so that I'd have enough time to run there. I begged him not to forget to place that call later, refilled the water in my Camelback, and charged off on the 5.3 mile run back to my car.

I was optimistic at first, because there would be a lot of downhill running, and I thought it would be easy for me to speed up. For a while, it was. But after a couple of miles I started feeling bad, and realized that I was in danger of running out of energy. Probably my blood sugar was low. (If I had known I was going to be running 10.6 miles today, under great time pressure, I would have eaten more beforehand.) I stopped and swallowed a glucose gel that I had on me, and swallowed a lot of water in case that was the real issue (dehydration can mimic hypoglycemia remarkably well). I started running again, with difficulty, but it got easier after a while.

Still, I became convinced that I was falling behind schedule, and I pushed myself very hard trying to make sure I got there before the AAA guy did. (Needlessly, of course, since he actually arrived almost 30 minutes after I did, but I had no real information about his likely arrival time, and I was working to a worst-case scenario.) As I stood around waiting for him to arrive, I felt pretty bad -- fatigued, shaky, and worried. What if I'd already missed him? What if the dispatcher forgot to place the call? I had no means of communication, and there was nobody around to ask for help. I had no food (the glucose gel I'd consumed was the only one I had on me) and limited water. As I waited, my initial feeling of being overheated eventually gave way to a feeling of being chilled. I knew I couldn't face running (or even walking) back up the big hill to go home again. This was awful! I need hardly mention how much I was kicking myself over making the stupid mistake that landed me in this situation.

Well, when the AAA guy arrived, he was able to get my trunk unlocked in a few minutes, and that was where my car keys were. Having the basic problem solved triggered a remarkable improvement in how I was feeling, not just emotionally but physically. I was now free to drive home and have some real food, and rest from my larger-than-planned exertions.

Well, I guess I've learned a lesson that I won't soon forget. I think it will be a long time before I again allow myself to become so absent-minded while I'm locking up the car for a run.

Saturday, July 10, 2010  

A busy day. I had to get on the road early: I was playing at an outdoor concert, in a city park in Vallejo, and I needed to drive down there in time for the sound-check in the morning. Not that the sound-check actually started on time, or anywhere near it, but if I'd been late it would have started right on time. I know how these things work.

The city of Vallejo has achieved some unwelcome fame in California (and perhaps nationally, for all I know) because of the bankruptcy of its city government. So if the city is broke, how can they afford to hire a stageful of Scottish fiddlers to come to town and play a concert in one of their parks? Easy: we were doing it for free. We owed them a favor, because they had let us use one of their buildings for free, for a series of concert rehearsals in April.

As concerts go, it was a fairly relaxed affair. The weather was comfortable (sunny but not hot, and there was a roof over the stage that kept us in the shade); the audience was attentive and appreciative. But even so -- there is something about performing on stage, no matter how relaxed the atmosphere may seem, that is exhausting out of all proportion to the physical effort involved. It's the concentration, I guess, and the constant mental struggle between the natural impulse to tense up and the need to relax so that you can play the notes. The concert was fun, it went well, and I was glad I particpated -- and even so, when it was over I was extremely eager to get home and take a nap. Which I did. And I was glad I participated in that, too.

But all good things, including naps, must come to an end, and then you have to get outside and run six miles. So I did. By the time I actually hauled myself to the park and started running, the sun was very low on the horizon, the shadows were long, the light was golden, and the air was cooling down. Perfect running conditions. It was a longish run (almost the same distance as the 10K race I did on the the 4th of July), but it didn't seem hard.

That's interesting -- my post-prandial result was only 94. I would have expected that if it had been a very low-carb meal, but I would describe it as medium-carb at best. However, I ate dinner shortly after I got back from running, and I was feeling quite hungry, so the run might have brought me to a pretty low glucose level by the time I ate.

I was just reading a dispute about how big the glycemic impact of oatmeal is; I may have some for breakfast tomorrow and see what how it affects me. If I find out anything interesting I'll let you know.

Friday, July 9, 2010  

I decided to take my rest day today rather on the weekend, just because I'm busy. I'll be busy tomorrow, too, but less so.

I've been doing post-prandial tests after lunch and dinner, but not after breakfast. I've been telling myself that it's usually inconvenient to test after breakfast, because I tend to be otherwise engaged an hour after breakfast. But today I decided that this isn't true. The truth is that I've been avoiding testing after breakfast not because it's always inconvenient, but because breakfast is usually my most carb-heavy meal, and I'm been afraid to find out that I'm not getting away with this nearly as well as I would like to think I am.

So, today I put a high-carb breakfast (which included three pieces of toast with peanut butter) to the test, and it worked out fine. 123 after a meal with three pieces of bread in it is fine by me, anyway.

Plenty of people with Type 2 find that they can't eat bread without spiking, unless they eat an unsatisfyingly tiny serving of it, or they eat a special low-carb version of it which doesn't really taste like bread. It drives them crazy, at least if they're really fond of bread (and I am). So, it's nice that I can include bread in a meal without spiking. But I'm sure some would argue that I ought to give it up anyway, because if I keep eating it, the carbs will worsen my condition, and then I'll get bad glucose numbers whether I eat bread or not.

The low-carb people are pretty insistent that grains directly cause diabetes; they like to present an alternative history of the world in which grains did not become a significant part of the human diet until well into the 20th century, and ever since we made that mistake it's been diabetes, diabetes, and more diabetes. This puzzles me greatly, if only because bread and porridge and suchlike foods are mentioned so often in the literature of earlier centuries -- sometimes much earlier centuries. Bread is mentioned frequently and prominently in the bible (wasn't that miracle supposed to involve loaves and fishes, not meatballs and fishes?). And what were all those millers and bakers doing in slightly more recent centuries, if there was no market for grains or baked goods? Seems like a lot of thankless effort, to be setting up all those waterwheels and grindstones and brick ovens, in a society that didn't eat grain-based foods. Or take that alleged wisecrack of Marie Antoinette's, to the effect that, if the people had no bread, then "let them eat cake" -- how could that quote have been so widely circulated, in a time and place where it made no sense, since people ate neither bread nor cake?

Granted, the refining of grains (filtering out the bran, to improve the shelf life of the flour) is a more recent development, and doubtless an unhealthy one. But to hear the low-carb people tell it, meat was almost the only thing people ate before the second world war. And I don't buy it.

I think the most important thing that changed during the 20th century was how much people were eating. That change, at least, can be documented; the ever-expanding notion of what consitutes a "serving" has left behind a trail of evidence, in everything from recipes to juice glasses. If there's a dietary explanation for the rising incidence of diabetes, I think it's likelier to be quantitative than qualitative.

There's a particular sub-genre of diabetes-forum posts which intrigues me: the post from a woman seeking advice on how to manage her husband's diabetes. (It's never a husband seeking advice on how to manage his wife's diabetes.)

I saw one of these posts the other day, and it included this marvellous sentence: "We are trying to control his sugar with diet".  She went on to explain that controlling his sugar with diet is hard to accomplish, because he eats such large amounts of food. She wanted some advice on what sort of diet he could be on which wouldn't leave him feeling hungry. But my mind kept going back to that amazing sentence.

"We"! I love it. We are trying to control his sugar with diet. One way or another, it probably sums up an entire marriage in nine words, but what does it actually mean?

Well, there are a lot of different things that it could mean. For example: 

  1. "My husband is determined to control his blood sugar with diet, and as a supportive spouse I am naturally interested in doing whatever I can to assist him in his quest to find the best way to do that."
  2. "My husband has expressed a certain vague willingness to control his blood sugar with diet, but he seems to be leaving it up to me to figure out how to make that happen."
  3. "My husband has not explicitly rejected the idea of controlling his blood sugar with diet, so my plan is to figure out what he needs to do and see if I can make him do it."
  4. "I wish my husband would control his blood sugar with diet."

I'm afraid that I've listed them in order of increasing probability. If the guy is genuinely involved in the effort to control his blood sugar with diet, why isn't he the one seeking information on how to do it? The fact that she has to ask these questions for him doesn't make it seem that he's tackling the problem with much dedication. If I visited an internet forum for elk-hunters, I doubt that I would see a post there from a woman whose husband wants to become an elk-hunter, but is leaving it to her to investigate the subject and present him with a plan for getting started in the sport. When people are truly interested in something, they tend to do their own research. They're too hungry for information to be willing to wait around while someone else gathers it for them.

I have to assume in this case that she is the one who's interested in the subject -- probably because she thinks it's her job to be interested in it. Men and women alike seem to buy into the notion that the subject of health lies within the female domain. Women, not men, are supposed to know all about diseases, remedies, and preventive measures.

Therefore, the woman of the house is responsible for maintaining the health of each member of the family (whether they cooperate with her or not). Many wives try to fulfill this unreasonable expectation when their husbands develop a chronic disease, but in the case of diabetes it's pretty much impossible. Everything you do (or don't do) affects your diabetes; for someone else to manage your diabetes, you would have to be under round-the-clock supervision and control. As a general rule, other people can manage your diabetes for you if you're in a coma, but if you're up and around, the only person who can manage your diabetes is you.

It's all very well for a wife to try to figure out what kind of diet to put her overeating husband on, but if he really wants to eat something that she thinks he shouldn't eat, trust me: it's going to get eaten. Maybe it's going to get eaten while she's not around to see it, but it's going to get eaten.

I hate to think of anyone taking on the frustration of trying to manage someone else's diabetes for them. It's an impossible situation: you can't win, and when you lose, it looks as if the whole problem is your fault. Do not sign up for this, ladies!

Thursday, July 8, 2010  

Today my run before lunch was easier, but my post-prandial result after lunch was lower -- presumably because the carb count in the meal was lower this time. I can't quantify it, because it was a salad-bar lunch. There were some high-carb ingredients in the salad (including a little pasta), but the total amount of starch couldn't have been very high.

Jenny Ruhl's suggestion that the Glycemic Index is a scam, promoted by industries adversely affected by the popularity of low-carb diets, stirred up an angry debate on the dLife forum. The GI clearly has its defenders, who say it's a useful tool that helps them with glycemic control. They acknowledge that the inconsistent GI values assigned by various authorities to the same food is a bit of a practical problem (which number should we believe?), but they say that the thing to do is to stick with the most reputable authority involved in all this: the University of Sydney, Australia.

Okay -- so I went to their web site. I selected "GI Database", and entered "Russet Potato" as my search term. Here are the results I got:

150 g Serving of Russet Burbank Potatoes GI
Baked without fat 111
Unpeeled, cooked in microwave for 18 min 77
Baked without fat 56
Baked without fat, 45-60 min 78
Baked without fat 94

So, you see, all the consistency problems disappear if you rely on a single, reputable authority on the subject of GI values. For a 150-gram serving of Russet Burbank potatoes baked without fat, the GI value is only 56. Or else it's 78. But maybe it's 94. Unless it's 111.

Now, I honestly have no idea what is going on here -- why the University of Sydney would report four different GI values, ranging from 56 to 111, for the same amount of the same food, cooked in the same way. If they have an explanation for these extreme discrepancies, they aren't providing it on the results page.

Their FAQ page discusses inconsistencies, but in a way which leaves it unclear whether they are talking about inconsistencies within their own reported results, or inconsistencies betweeen their results and those reported by others. The general drift of their comments makes it appear to me that they are merely serving as a clearing-house for data gathered by others, and they are presenting that data as found, without comment about where it came from or why it's contradictory.

If that's the most reliable source we have for consistent GI values, then I have a hard time understanding how the glycemic index can serve as an especially helpful guide to meal planning.

I don't endorse the conspiratorial view of the glycemic index as a deceptive tool of agricultural interests, but I continue to see it as a great big mess. It sounds good in principle -- a useful way to distinguish foods with a high glycemic impact from foods with a lower glycemic impact. In practice, it seems to be confusing, frustrating, and ultimately a waste of time.

Wednesday, July 7, 2010  

Slightly warmer weather today, and a much harder run -- very hilly. But I was the one who chose the route, so I can't whine about its difficulty. My running buddy decided that I was trying to kill her. If I was, it didn't work -- she zoomed up those hills and finished well ahead of me. I think we'll do something easier tomorrow.

Lunch included a sandwich, and probably 45 g of total carbohydrate, so a post-prandial result of 125 is pretty good, considering. But I prefer to be under 120 if I can manage it. Of course, I'm likelier to manage it when bread isn't part of the meal.

Let's talk about legumes.

Strictly speaking, a legume is any plant of the family Fabaceae, but we generally use the word to mean the dry fruits of certain of those plants: peas, beans, lentils, soy, chickpeas, and peanuts.

A common (if odd) feature of these fruits is known as dehiscence, which means a natural tendency to open along a seam and split in half. If "split peas" ever made you wonder (as they made me wonder when I was a child) who was given the tedious job of sawing them in half, and why this was thought to be worth the trouble, rest assured that many legumes are born ready to split, and don't need a lot of encouragement to do so. They want to be soup.

In most of the world's traditional cultures, legumes play a much larger role in the diet than they do in the developed world (where they tend to be looked down upon as "the poor man's meat"). This scornful attitude may be misguided, given that the countries where people eat more legumes than we do also tend to have lower rates of chronic diseases than we do.

According to a report in the American Journal of Clinical Nutrition, "The nutritional profile of beans shows that they have much to offer; beans are high in protein, low in saturated fat, and high in complex carbohydrates and fiber. Beans are also a good source of several micronutrients and phytochemicals. Soybeans are unique among the legumes because they are a concentrated source of isoflavones. It has been hypothesized that isoflavones reduce the risk of cancer, heart disease, and osteoporosis, and also help relieve menopausal symptoms. Although there is much to learn about the effects of isoflavones on chronic disease risk, this area of research holds considerable potential. Given the nutrient profile and phytochemical contribution of legumes, nutritionists should make a concerted effort to encourage the public to consume more beans in general and more soyfoods in particular."

But what led me to bring up legumes today was another report in the same publication: Legume and soy food intake and incidence of type 2 diabetes in the Shanghai Women's Health Study. This is a large study of 64,227 Chinese women, who were studied over a period of more than 4 years. The women were sorted into categories by their consumption of legumes, and the women in these categories were tracked to see how many of them developed diabetes. Consistently, diabetes incidence rates declined as legume consumption increased. This was true for legume consumption in general, and also for true for individual varietes of legumes -- but some varieties had more impact than others. Peanuts had the smallest effect, and soybeans the largest. The "relative risk" for diabetes (where 1.00 represents the risk associated with the lowest level of legume consumption) was 0.62 for high consumers of legumes in general, and 0.53 for high consumers of soybeans in particular. "In summary, we found that consumption of legumes was inversely associated with the risk of type 2 DM in this population. Our results add to evidence that shows a beneficial effect of the consumption of legumes in the development of type 2 DM."

Exactly why legumes are helpful in preventing diabetes is not very clear at this point, but the evidence seems to say that, for some reason or other, they are.

Still, what if it's too late to prevent type 2? Once you're already diabetic, do legumes then become a problem food, because of their carbohydrate content? Well, that can be an issue. Legumes are generally not as high in carbs as grains are -- and the fiber in them has a moderating impact on the carbs they provide. Still, a big bowl of pea soup can definitely be a high-carb proposition. You need to keep an eye on serving sizes, and you also need to choose your legumes wisely.

My favorite legume is one from India called chana dal, which you can find in Asian markets. It looks like yellow split peas, is very good in soups and stews, and seems to have a lower glycemic impact than most other legumes, presumably because of its high fiber content.

Tuesday, July 6, 2010  

Suddenly the weather cooled off. The fog came in from the coast before dawn, and it lingered most of the day. I had to wear a heavier shirt for running today than I am accustomed to wearing in July. Running is easier in cool weather, though, so it's not a problem, it's just a bit strange at this time of year.

I don't know why my fasting result was up a bit today, but it may have because I overslept and woke up in a panic. That adrenaline rush when I wake up late has a tendency to give me a slightly elevated result. Not that 93 is especially bad, but I try to keep it under 90 these days.

107 after dinner is fine, though.

They'll never run out of health issues to do research studies on, because there are so many pairs of things which you can check out for hitherto-unnoticed connections. Is epilepsy more common in people who hate squash? Is a preference for the color red associated with an increased rate of hip fractures? Do people who lift the lid on the rice before it's finished cooking turn out to have more strokes?

I saw an article today entitled Male Pattern Baldness Linked to Metabolic Syndrome. Apparently, if you're a guy and you have androgenic alopecia (that is, baldness triggered by testosterone), your risk of developing metabolic syndrome is more than doubled. (And the more severe the hair loss, the greater the risk.) This study joins others which have found bald men to be at heightened risk for a variety of other problems associated with heart disease, including obesity, hypertension, and abnormal lipid profiles.

Why, though? That's not so clear.

Androgenic alopecia is believed to be caused by a genetic sensitivity of the hair-follicles to a form of testosterone known as DHT. Men whose heads remain thoroughly covered don't necessarily have less testosterone than the rest of us; they just don't happen to have the genes that make their hair follicles sensitive to the stuff. However, among those who do have the genes, the degree of baldness is probably affected by the amount of testosterone. To have detectable baldness at all may indicate that your testosterone level is at lease slightly above average. My own situation can still be described (probably for another year or so) as "thinning" -- which, given that I'm 53, probably doesn't put me very high on the testosterone curve. A guy who's got a fully-installed solar panel up there by age 40 may have a little more of the crazy-juice flowing.

Still, though, the results of the new study are a little puzzling -- they imply that more testosterone is a problem, at least in terms of metabolic syndrome. Which is puzzling, because a lot of people think low testosterone can cause metabolic syndrome and diabetes. (But I always found that idea hard to accept, as it would imply that nearly all women should have diabetes.)

Of course, it's always possible that the researchers have it backwards: maybe metabolic syndrome is causing baldness, and not the other way around. Maybe metabolic syndrome does something which makes your hair follicles even more sensitive to testosterone than your genes are programming them to be.

I don't really expect this research to lead to great things, but you never know.

Reviews of Video Games We Didn't Finish Reading (from The Onion / AV Club ):

"Watching a tortured teddy bear blow his brains out is somewhat less hilarious than Naughty Bear seems to think." 

I'm sure the rise of violent, idiotic entertainment correlates as well with the diabetes epidemic as anything else does. Let that be the next thing we study!

Monday, July 5, 2010  

The low post-prandial result was unsurprising, because it followed a low-carb dinner, and dinner was right after a workout.

I spent the Fourth of July holiday just like everyone else did:

Well, maybe not everyone else, but lots of people. Independence Day is probably the biggest day of the year for organized footraces. The one I was in, the Kenwood Footrace, has been held annually since 1972, and it's a popular one, especially considering what a small town it is held in. There were 714 runners in the 10K race (the one I as in), and another 452 people doing the 3K distance.

I decided to carry my camera with me and snap pictures as I went. It didn't exactly help me concentrate on maintaining a fast pace, but capturing the experience in images while it was going on was entertaining, and made the race seem shorter.

This race begins early (at 7:30 AM), and often there's a morning chill that makes it hard to stand around in skimpy running clothes while you wait for the starting gun. But this year it was comfortably warm from the start, so I knew it would be pretty hot by the time we got to the top of the first hill.

When you have 700+ people on narrow country roads, you know you're not going to have a huge amount of elbow room, especially near the start.

Gradually it thins out a little, as people settle into their own pace, and the crowd gets sorted into those who gaze at scenery and those who don't.

One of the things I like about this race is the ever-changing environment. For a while you're in the shade of big oak trees...

... and a minute later you're in the sun, among the vineyards, climbing a hill...

...and then you're in in the woods, climbing another hill.

Getting to the top of the last climb, I couldn't help noticing that the morning sun was getting a bit intense. Fortunately, there was a water station just after this.

For a while we were off the public roads, and going through vineyard paths that never see any traffic besides the winery's tractors and trucks.

And then came a very welcome downhill section. Getting to the reservoir at the bottom of the hill is an encouraging sign -- it won't be long now.

Ah, yes -- a glimpse of the finish line in the distance.

So how did I do? Nothing to brag about: my time was 61:01. Of the six previous times I had run that race, I was faster than that three times, and slower than that three times. There's never much variation: it always takes me about an hour. (I'm just not good at climbing all those hills!) Taking pictures probably distracted me enough to slow me down a bit this year -- last year, with no camera, I was faster by a minute and a half.

One thing was a big relief: this year I didn't have any pain or stiffness anywhere -- I seem to be learning how to run without giving myself running injuries. I didn't feel especially fatigued, either. My only problem was that, whenever I started trying to push myself to go faster, I would start to feel faintly nauseated and gassy, and I'd have to back down on my pace just to settle my stomach. Either real runners don't have that problem, or real runners learn to ignore it. I'm not sure it's something I can learn to ignore; never once in my life has an upset stomach failed to capture my attention. Maybe I'll just have to keep running at my own pace (by "my own pace" I mean "whatever pace doesn't make me feel sick") and be satisfied with the result.

Apart from the momentary nausea when I tried to push myself to run faster, the run made me feel food. A careful comparison of my face at the starting line with my face at the finish line gives some hint of this, I think. A lot of endorphins must have been released in between.

It would be nice to be able to run faster too, but it's not the main thing.

Saturday, July 3, 2010  

Yesterday's low post-prandial result was after a low-carb dinner. For the sake of contrast, today I thought I'd see what kind of result I would get after a high-carb breakfast. I went out for coffee this morning, and had a muffin. I don't mean a little apricot-sized muffin, like the ones people used to make in the days when grandma was a girl. I'm talking about a modern muffin, which is to say a big muffin -- the kind which, viewed objectively, looks as if it is probably intended to serve as an ottoman rather than as a single-serving food item. It even had some kind of brown-sugar crust on top. I didn't eat anything else with it that could have moderated the impact of all those carbs. An hour later, I tested my glucose and got 129.

Some would call that result perfectly fine, and I was relieved that it wasn't higher. For someone with Type 2 diabetes it's a good result. Still, for someone without Type 2, anything over 120 (even after eating a great big muffin) is probably not normal, and I'm doing my best to impersonate someone without Type 2. So, I shouldn't make a habit of experimenting with monster muffins (unless, maybe, I'm fueling up for a long-distance run a few hours later -- which today was not the case).

No exercise today -- I was resting up for tomorrow morning, when I'll take part in the Kenwood Footrace, a 10K which is run every year on the 4th of July. This will be the seventh year in a row that I've run it. It's a difficult race because the course is so hilly, and I'm lucky if I can finish it in less than an hour. My results in years past have been:

If you're not a runner, you'll have to take my word for it that these are not impressive results. I stake my claim to impressiveness solely on the fact that I keep on doing it. And the reason I keep doing it is that, despite the difficulty of the course, I think it's a fun race. It's in a pretty area, and there are always a lot of enthusiastic participants. The fact that it's on Independence Day (a very popular day for races) makes it seem more festive. And then you have the rest of the day to relax and celebrate. Which is what I intend to do.

Nice to see that my blood pressure seems to be trending downward. I don't want to have a stroke and then have to learn everything over again. (But if I have to, I'm ready.)

Friday, July 2, 2010  

My running buddies weren't working today, and I had an errand to run at lunch anyway, so I didn't run at lunchtime as usual. What with one thing and another, I didn't go running until a few hours after dinner. The low post-prandial result might seem surprising under the circumstance (since I wasn't getting any help from short-term exercise effects). However, the explanation is pretty simple: it was a very low-carb dinner. I had Ahi tuna steak with a salad. The cherry tomatoes in the salad were the closest thing to a sugar-bomb in the whole meal, and there weren't very many of them. If I'd had a baked potato or a plate of pasta, the result would have been different, but this was a meal that seemingly couldn't have spiked anybody.

You could argue (and some people I know of definitely would argue) that the lesson here is obvious: make every meal a low-carb meal. Well, it may come to that someday, but I don't want to do it before I am forced to. So long as I can maintain control without giving up starches entirely, I'd like to be able to continue to include things such as bread and noodles in my diet. The other day I got a low result after eating gumbo with rice in it, after all, and I wouldn't have wanted to sacrifice the gumbo just because it included some rice.

I've been suffering a bit from insomnia the last few nights, and after dinner I got sleepy enough that I felt I needed a nap before I could go running.

A nap sounds so good in theory, and sometimes it's what you need, but there's a big drawback (at least for me) in going to sleep while the sun is up: when I wake up from it, I have a hard time returning to any kind of activity; I feel sluggish and I get a slightly upset stomach. I certainly don't feel like going outside for a run. And I didn't tonight.

But it had to be done. I was tempted to make today my rest day instead of tomorrow, but that wasn't practical. I need to use tomorrow as a rest day because I'm running in a 10K race on Sunday, and you need a rest day before something like that. And I don't take two rest days in a row unless I'm sick. I needed to run today, whether I feel like it or not. So, I dragged myself outside for a run. Eventually (well into the second mile) I got over feeling bad. And I started appreciating the world around me. Sunset is a great time to run, especially when you're running on a ridge line between two scenic valleys. As usual, by the time I was finished with the run I was glad that I had done it.

"Is Triennial HbA1c Screeing Too Frequent?" asks a headline in Medscape today. A study done in Tokyo found that, when healthy middle-aged adults have a hemoglobin A1c test "screening" test with a result below 6%, screening them again in 3 years (as recommended by the ADA) will turn up few cases of diabetes. The study tracked more than 16,000 people over a 3-year period, to find out how likely it was that repeated screening tests would turn up a case of diabetes (defined, for the purpose of the screening test, as an A1c value of 6.5% or higher).

It turned out that the risk of a patient hitting the diagnostic threshold of 6.5% varied greatly, depending on what their A1c result was at the start of the three year interval:

Baseline A1c,% Diabetic after 3 years
<5.5 0.05%
5.5 - 5.9 1.2%
6.0 - 6.4 20.2%

The risk is low for people whose A1c result is under 5.5. Once they hit 6.0, though, the risk starts climbing steeply. The authors of the study think this means we don't need to repeat the screening test so often.

One factor which needs to be considered, though, is that the test was done in Japan. In countries where people are a bit bulkier, the risk ratios might be a significantly higher.

Thursday, July 1, 2010  

Despite the small number of data samples, it looks as if a pattern is developing: post-prandial glucose is lower if the meal is immediately after my daily workout than if there's a delay. Today I ran at lunchtime, and had dinner 6 hours later -- the result was 126, as compared to 98 yesterday, when the meal immediately followed a run.

Dinner was spinach lasagna -- but a fairly low-carb version of lasagna (supposedly 26 grams of carbohydrate per serving, if the packaging can be believed). I also had 2 fried eggs while I was impatiently waiting for the lasagna to heat up in the oven. Not the sort of meal that I would expect to have a big glycemic impact.

Not that 126 is much of a spike -- it's within the bounds set for people with diabetes, and only 6 points higher than what seems to be normal for people without diabetes. I'm just comparing this result to yesterday's, and thinking about possible reasons for the difference.

Today I tried out that "Iskiate" drink before running (chia seeds soaked in water to make a gel, with lime juice and a little sugar). However, today might not have been the right day for the experiment. A small crisis that arose at work this morning was stressing me out, and making me feel bad. The drink didn't make me feel any worse, but didn't make me feel any better, either. I didn't notice any special burst of energy. I felt better towards the end of the run than I did at the start, but I always do. The only unusual effect that the drink seemed to have on me is that it killed my appetite. Usually I'm hungry after a run; today I was uninterested in lunch, and ate mainly because I thought I'd regret it after a few hours if I skipped the meal. I did feel hungry in the evening, though.

I'll keep experimenting with Iskiate to see if there are any benefits for me. Maybe it will have more of an energy-boosting effect on a day when I'm not stressing out, or when I'm doing a longer run. I'm also curious to see if the appetite-killing effect will be repeated. My appetite is one of the most reliable things about me, and it would be very useful to me to have a way of curbing it.

"No Benefit of Supplemental B Vitamins in Diabetic Nephropathy" says the headline in Medscape

Someone had noticed that (1) high homocysteine levels were associated with increased risk for diabetic complications (2) B vitamins tend to reduce reduce plasma homocysteine levels, and also tend to improve endothelial (blood-vessel) function. It seemed reasonable to assume that giving diabetes patients B vitamins would reduce complications. The "Diabetic Intervention with Vitamins to Improve Nephropathy (DIVINe)" trial was an attempt to prove that a particular diabetic complication (nephropathy -- kidney disease, to you and me) could be prevented or ameliorated by giving diabetes patients large doses of B vitamins.

The measure of success or failure in this experiment was "GFR" (glomerular filtration rate, an indicator of healthy kidney function, which is lower in people with kidney disease). GFR was measured in the patients at intervals of 18 and 36 months. If things worked out as expected, the diabetes patients who took the B vitamins would, over these intervals, not experience a drop in GFR, or at least wouldn't experience as large a drop as the patients who were not taking the B vitamins.

The results could be charitably called "mixed". The patients taking the B vitamins did, indeed, have lower homocysteine levels. But it didn't do them any good. So far as nephropathy was concerned, they did worse rather than better. Their GFR results dropped more, not less, than the GFR results of those not taking the vitamins! As if that weren't bad enough, the patients taking the vitamins also had twice the rate of cardiovacular problems (including heart attacks). The authors of the study conclude with great disappointment that high doses of vitamins are not only unhelpful, they seem to be actively harmful. (But they can't resist bragging about the reduced homocysteine levels, as if to say that it was a successful operation even though the patient died.)

So, once again, medical science learns that, just because a high number on a lab report is associated with a health problem, we are not safe in assuming that reducing that number will solve the health problem.

But I love the parting shot with which the report concludes: "Therefore, patients should be cautioned against the use of high doses of B vitamins. This is especially important in our Internet era, in which patients assemble their own evidence from dubious sources."

I would like to ask the authors for an example of a source that isn't dubious. I guess they'd say that their own study was an example of a non-dubious source, since the remedy they were studying was not a patented pharmaceutical product, and in any case they were going public with the information that their experiment had failed. And they'd have a good deal of justice on their side, I have to admit.

But it seems a little harsh to make that crack about patients "assembling their own evidence", when patients clearly have no other choice, given the culture of rampant and unashamed corruption which appears to dominate medical research today (see my discussion of "ghost-writing" on June 29th). When medical researchers, medical schools, and medical journals agree to give the pharmaceutical companies absolute authority to rewrite the narrative of science as they see fit, patients have no alternative but to make an end-run around the barriers that have been put in their way. Yeah, they'll get it wrong a lot of the time, but will they do any better if they just accept whatever Merck tells them?

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