Wednesday, March 31, 2010  

A remarkable streak of luck: three days in a row that featured heavy rain, and in all three cases the rain didn't happen during my lunchtime run. The skies certainly were threatening rain today, and they made good on the threat -- but not until my run was over and I was safely back indoors. There's only one way to interpret this: mother nature wants me to keep running!

I hope my luck continues tomorrow. It should -- the forecast is for clouds but no rain.

This is the second week in a row with my running buddies out of town. I've been running by myself every day. Harder than I thought it would be, to tell you the truth. Of course it's nice to be able to set your own pace -- but what I really need is someone to stop me from doing that!

In news coverage of clinical studies of drug effectiveness, an important fact tends to get lost in the shuffle: drugs which are found to be "effective" are usually not found to be as effective as lifestyle changes.

An example of this phenomenon was reported in The Lancet late last year: the Diabetes Prevention Program, a randomized, long-term clinical trial, found that lifestyle interventions and treatment with metformin were both effective at preventing Type 2 diabetes in at-risk adults.

The thing is, lifestyle intervention turned out to be about twice as effective as metformin was!

If the study had compared two drugs, and had found that one was twice as effective as the other, this difference would have been perceived as the most important finding of the study. We would have been told that the less effective drug should be dropped, and the more effective one should be used instead. But nobody is going to look at it that way if the more effective option is not a drug but a way of living.

I can understand why doctors, whose experience of trying to persuade patients to change their habits has perhaps been rather dispiriting, would not put most of their attention on a treatment option which relies on the willingness of patients to go to the gym when they'd rather go to Pizza Hut.

Still, I don't think it's too much to ask for doctors to consider saying to their patients, "If you're not interested in adopting healthy habits of living, I can give you pills instead -- but I should warn you that the pills are only half as likely to work, so it really wouldn't be ethical for me to recommend them to you".

The thing is, if this is not stated explicitly, most patients will assume that the probabilities are the other way around -- that the pills are twice as likely to work, not half as likely to work.

In most people's minds, pills qualify as medical treatment, and exercise qualifies as a fashion statement. If doctors don't explain to them that this assumption is wrong, they'll never realize it on their own.

Tuesday, March 30, 2010  

I thought I'd have a lower fasting result than that this morning, because I was such a good boy yesterday. I had a hard run at lunchtime (5.7 miles and very hilly), followed by a low-carb lunch, and a low-carb dinner. I went to bed thinking I would wake up with a blood sugar of 80 or lower.

But I felt bad last night (like I was coming down with a virus), and maybe that had an impact. When I woke up I no longer felt like I had a virus, which of course was good news -- but I didn't feel hungry, and when I don't wake up feeling hungry, I'm pretty sure not to get a fasting result of 80 or lower.

Nobody's blood sugar is completely predictable, on matter how carefully you're tracking what you eat and how much exercise you're doing. Mine has become increasingly predictable in recent years -- I usually know what to expect, and I'm usually not very surprised. But I do get surprised now and again. Well, it keeps me interested, and that's a good thing.

I like to keep my diastolic blood pressure below 80, so I'm not pleased to see it at 83 tonight, but I know the reason for it -- a situation at work which I thought was resolved last week, and which blew up on me again today. Oh well. I can't really do anything about the situation, so I guess I'd better start working on doing something about my reaction to it!

Unpredictable weather this week. Both today and yesterday, we had periods of sunshine alternating with sudden bursts of heavy rain and hail. This makes it difficult to commit to a long lunchtime run, to say the least, but I ran yesterday and I ran today, and my luck was with me both times. The clouds parted for me like the Red Sea.

The weather forecast calls for more rain tomorrow, and maybe thunderstorms. I'm not worrying too much about the latter. Thunderstorms aren't entirely unknown in coastal California, but they're decidedly uncommon, and most of the ones that are predicted fail to show up. I may get caught in a downpour if I run tomorrow, but I don't think I'll get struck by lightning.

More coffee research! A small study of coffee-drinkers in Germany found that coffee-drinking has beneficial effects -- specifically, a reduction in inflammation and oxidative stress, and an increase in HDL ("good") cholesterol. So says Dr. Kerstin Kempf of Dusseldorf University. And who am I to disagree? My day begins tomorrow with back-to-back project meetings, and I plan to get a large cup of coffee on the way there.

No, I don't take this kind of thing terribly seriously. I like coffee, and I'm always pleased to be offered evidence (however weak) that this mild vice of mine is actually good for me. I also like garlic, and for that reason I'm always pleased to be reminded that garlic has "mild antibiotic properies". I'm sure somebody has done a study proving that eating olives reduces your chances of developing Alzheimer's -- a conclusion which you accept uncritically if you like olives, and ignore if you don't like olives. That's how it works. A great deal of medical research exists for the purpose of encouraging people to think that the things they are going to do anyway count as therapeutic.

With all the volatile weather this week so far, it's almost hard to believe how pretty it was on the weekend. On Saturday I did a long trail-run, on a trail which I haven't been on lately because I didn't think its steep slopes were safe while they were still muddy. I figured it was time to revisit that trail.

Once I got out of the woods and into the meadows, I was in brilliant sunshine.

And the wildflowers were starting to bloom, too.

No doubt we'll have that kind of weather once again, very soon. But this week: storms. I'll cope with that as well as I can!


Sorry, no time to blog until at least Tuesday. Help, help! I'm overscheduled!

Friday, March 26, 2010  

You've probably heard before about the gradual trend, in recent decades, towards larger portion sizes in restaurant meals, prepared foods, and recipes. But two obesity researchers have now taken the search for evidence of this in a rather surprising direction.

That's right: they examined paintings of The Last Supper, to see what happened to portion sizes over the centuries.

Brian Wansink of Cornell University and his brother Craig (a minister and professor of religious studies) reasoned that artists have been depicting that meal for at least a thousand years, and that an interesting trend might emerge if they tracked changes in the food that was represented on the table. And an interesting trend did emerge, or at least so they claim. They reported a 23% increase in serving size for bread, and a 69% increase for the main course, from the oldest paintings to the most modern ones. (Plate size increased by 66%.)

I'm not sure how they did the "main course" comparisons, given that most early renderings of the scene showed only bread and wine. But over the years, other ingredients were added. Including surprising ones, such a sheep's head... 

...and what appears to be a chihuahua:

The Wansink brothers reported that most of the increase occurred after 1500 (most of mine occurred after 1500, too, so I think they're probably right). And then it kept building up, to level we see in the modern versions:

Just kidding, that's not a depiction of The Last Supper (although it wouldn't surprise me to learn that it was somebody's last supper).

Is any of this on the level? It certainly wouldn't be hard to poke holes in the Wansinks' methodology, but if they have in fact identified a real phenomenon, at least we can say that there's one bad dietary trend which cannot be blamed on McDonald's. Their own hypothesis is simply that food became more abundant or affordable over the centuries, and notions of what was an appropriate portion size began to evolve. Well, the evolution has continued.

My own last supper (that is, the supper I had last night) ended up being higher in carbs than I had expected -- it was a restaurant meal, a Mongolian stir-fry, and it turned out to have a bunch of noodles mixed into it. I assume that's what led me to have a fasting test in the 90s this morning instead of the 80s. We'll, I'll try to do better next time.

I had a beautiful run today -- sunny and clear, but with a cool breeze. Ideal. I hope we have more of the same tomorrow, because I've got a trail-run planned.

Thursday, March 25, 2010  

Running has felt pretty good to me this week, even though my usual running buddies are both out of town, and I've had to go it alone without anyone to inspire me. I've been dealing with a stressful situation at work, and I've been relying on my lunchtime run for stress reduction. Today the situation I was feeling stressed about at work seemed to be more or less resolved, and I think that's why my blood pressure is down so much tonight.

Dicey weather today: sunny part of the time, then a sudden downpour. When it came time for me run at lunchtime, it was raining a little bit, and I had no idea whether it was about to get worse or better, but I took my chances. I got a little wet during the first 5 minutes; then it cleared and the world was beautiful.

That's the golf course that we go running past on the route we take most frequently from work. Nice neighborhood. A little further on I startled a wild turkey that wasn't expecting me. Gobble-gobble, and off he goes. Five minutes later he probably forgot he ever saw me. I'm sure he's not blogging about me now. Turkeys really live in the moment. All the more reason for me to question the idea that living in the moment is some kind of ideal state we must strive for. I mean, why? Who says? I've given up on living in the moment, myself. My goal is to live in next Tuesday night. It keeps me going, what can I say?

Like India before it, China is discovering the penalty of affluence: according to a report published today by the New England Journal of Medicine, China has now surpassed India to become the world leader in diabetes cases.

A study conducted by Dr. Jiang He of Tulane University tested a nationally representative sample of 46,000 people in China, in order to determine the prevalence of the disease there. Based on the results, an estimated 92 million people in China have diabetes, and nearly 150 million more are headed that way. Chinese citizens with diabetes tend to be the more affluent members of the society: they live in cities, have a higher calorie intake, a lower level of physical activity, and a larger waistline.

One of the problems with the relentless expansion of "Western" lifestyles into every corner of the globe is that, eventually, there will no counterexamples for us to look at. Once a fundamentally unhealthy life has become the norm everywhere, will we even be aware that other possibilties exist -- or once did? 

Wednesday, March 24, 2010  

Glycemic regulation is a more complicated thing than we usually acknowledge...

This diagram (swiped from a Medcape article) illustrates the body's regulatory response to hypoglycemia. The dark arrows indicate causation, and the white arrows represent the change that is caused -- either an increase in something (represented by an up-arrow) or a decrease in something (represented by a down-arrow). For example, at the top, hypoglycemia causes an increase in epinephrine (and glucagon, and growth hormone, and cortisol) and causes a decrease in insulin. And all of those changes trigger other changes.

I think pictures like this one help explain why diabetes is such a difficult condition to analyze. Every change in blood glucose (or in any characteristic that has an impact on blood glucose) triggers a cascade of secondary and tertiary changes. So many factors are in play here, and they vary so much from person to person (or from day to day) that the net effect of any change can never be predictable. It would impossible to say with any precision what will happen if you start taking a particular medication or supplement, or change your diet in a particular way.

I am not saying it doesn't matter what you do. I'm just saying that, whatever you decide to do, it's going to be necessary to check your approach against reality. Does it cause an improvement in something you can measure? I mean, it may well be true that apple cider vinegar can help some people control their blood sugar, but that doesn't matter if it doesn't help you. It's worth gaining some kind of theoretical understanding of the issues involved in diabetes, but the more you look into diabetes, the more issues turn out to be involved, and the more room for doubt there is about any recommended regimen. At the end of the day you have to go with what you can measure.

Unfortunately, the effect of a change is sometimes hard to verify. You can easily tell how your approach to diabetes management is affecting your blood sugar in the short term (and of course that is important), but you can't easily tell how it is affecting your arteries in the long term (and that is important too). One of the reasons I put so much emphasis on exercise is that it's the only therapy that is known to be capable of helping me in both areas. But of course there are no guarantees! I'm only trying to pay attention to the odds, and act accordingly.

March 23, 2010


Now, don't you go thinking I'm a unique case!

I'm afraid that you might be tempted to think exactly that, simply because you haven't often heard about anybody successfully controlling Type 2 diabetes without medication. If my story is nothing like the typical one, doesn't that simply mean there must be something peculiar about my metabolism, and my case is therefore irrelevant to yours?

If you are looking at it that way, a lot of what I'm trying to do here is probably self-defeating. You won't watch my example and think "I bet I can do that, too!" -- any more than you will watch Ricky Jay doing card tricks and think "Well, that looks easy enough!".

Therefore, I think it would be helpful for me to tell other people's stories, not just mine. Other people besides me are succeeding at getting Type 2 under control without medication. I hear from them from time to time, so I know I'm not alone in this. They have their own stories to tell.

Today I'll share with you one such story.

TG (whose real name is Rufus T. Firefly, but I don't traffic in real names here) is one of those people who thought he had no reason to worry that diabetes might be in his future. No family history, for one thing. No personal history of serious health problems, either. And no history of obesity. He seemed not to be suffering from the health challenges we normally associate with diabetes. "My blood pressure has always been fine," he notes. By his mid 50s, he admits, was perhaps carrying a bit of a bulge that hadn't been there in earlier decades. "But at 6 feet tall, and about 185 pounds, I never really considered my weight to be a problem." According to some versions of the height/weight charts, that doesn't even qualify as overweight, much less obese. So, why should he have worried that he would ever have trouble with his blood sugar?

Actually, there were a few subtle indications that all might not be well with TG's health, but these are the sort of things that look a lot clearer in hindsight than they did at the time. "I had been told over 15 years ago that my cholesterol was "borderline high" (total cholesterol somewhere around 200, with the "good cholesterol or HDL being abnormally low -- around 30)."

As it happens, low HDL is a common trait in people who are predisposed to develop Type 2 diabetes, but he didn't know that; few patients are ever told that this could be a warning sign. He thought the main issue was not that he had low HDL, but that he had high LDL. "My response was to adjust my diet by pretty much cutting out all 'red meat', as well as whole eggs, opting for chicken, turkey, fish, and egg whites instead. My cholesterol numbers seemed to stay about the same year after year -- not getting any worse, but not really improving, either. But my doctor seemed to think that was ok, so I didn't give it much thought."

TG's workplace offered an annual health screening service (height, weight, BMI, body fat percentage, blood pressure, cholesterol, fasting blood glucose), and he usually participated. "Over the years, my fasting blood sugar was gradually getting higher, but it was still always under 100, which I was told was good. They always mentioned that my cholesterol was 'borderline high', and I might want to think about getting more exercise. Sometimes I would take that advice to heart... for about a month or so, and then I would return to my normal routine, which is a fairly sedentary lifestyle."

The association between sedentary habits and diabetes is as strong as the association between obesity and diabetes, but for some reason obesity receives almost 100% of the attention in this regard. It was only natural for TG to underestimate the risk involved in settling back into his normal routine. It might help a bit to exercise, but he had no reason to think it would be very harmful not to.

Then things started to get a little creepy. "In May 2009 at the annual office health screening, my fasting blood sugar was 107 -- up from 98 the previous year. I was told that I might want to follow up about that with my doctor, since although that was not yet in the range of being 'diabetic', the trend was definitely drifting higher."

After further testing, his doctor told him he had an average blood glucose level above 100, indicating 'pre-diabetes'. "He said this was a common condition that many folks started to develop as they got older, but at this stage, we would just keep an eye on it, and if/when it progressed past the pre-diabetes stage, we'd talk about other options at that point. His only other advice was to cut out sugary sodas (which I have never consumed anyway), cut down on 'sugary deserts', and maybe try increasing my level of physical activity. When I asked for more guidance, he referred me to a diabetic educator."

As often happens, his doctor understimated the emotional impact of news which he assumed was less than devastating. "I walked out of my doctor's office in a bit of a daze. I felt like I had been completely blind-sided by this."

It's bad enough to be diagnosed with a problem you had long been worrying about; to be diagnosed with a problem you thought you didn't need to worry about at all can be extremely disorienting. "My impression was that this was just 'happening' to me, and it sounded like it was inevitably going to lead to 'full blown diabetes', at which point the medical community would be able to do something for me (i.e. prescribe medications). Until then, I could try modifying my diet, but it didn't sound like that was going to do much other than perhaps forestall the inevitable. How depressing!"

His visit with the diabetic educator was a bit more helpful; she explained to him some of the nuts and bolts of glycemic regulation, discussed prevention of 'complications', and taught him to use a glucometer. Armed with the information she gave him, he attacked the problem with the fury of the convert: testing 5 times a day (a fasting test, post-prandial tests after each meal, and a bedtime test), keeping a food diary, and looking patterns in the data he was collecting.

"I noticed pretty quickly that there were certain foods that tended to 'spike' my blood sugar fairly high (up into the 140-150 range), and/or caused them to stay at a high level for a longer period of time. These included things like pasta, rice, most hot and cold breakfast cereals, potatoes, most kinds of breads, and some fruits. I initially just stopped eating those things altogether -- which made up about 70% of my normal diet! I started living primarily on salads and low-carb protein shakes. My fasting blood sugars started responding, and I also quickly started losing weight. When I had a return visit to the diabetic educator a couple weeks later, she was a bit alarmed at my rapid weight loss, and mentioned that I might try re-introducing some of the foods I had crossed off my list, but to be more aware of 'portion control'. She also brought up the E word again (exercise)."

This is what it has come to in modern America: the F-word seldom needs to be called the F-word anymore, but exercise requires a euphemism.

Realizing that his diet wasn't sustainable over the long term, he started scouring the internet for ideas, and was amazed at how many hits came up when he Googled diabetic diet. "I found lots of stories of folks who were struggling as well, but every once in a while, I'd come across a 'success story' -- someone who had effectively reversed the inevitable. The successes seemed to be achieved by one of two ways -- either by adopting a highly restrictive low carb/no carb diet, or by including regular and, by my standards, rather intense, exercise programs into their daily routine. I'd already made quite a few modifications to my diet, and I knew that I would probably not be able stick with more severe dietary restrictions for the rest of my life."

One of the resources TG got connected with early on was this site. "This has been amazingly helpful, educational, and inspiring for my own efforts, and I started exploring the 'more exercise' option a bit more seriously. Like so many others, I had a gym membership which I rarely used, but now that I had the 'fear of God' in me, I decided to try that again."

His new committment to fitness was not, at first, a roaring success. He went to the gym and didn't know what to do when he got there. His initial workouts were not very strenuous, he was only doing them 3 times a week, and they didn't yield any obvious benefits. Disappointed at not seeing a change in his blood sugar, he started to lose motivation, and started missing workouts. Then he thought of a way to improve the situation. "I decided to find a personal trainer. That was one of the best decisions I made. I found a good trainer who worked with me 2 days a week for 6 weeks, and outlined a 5-day program for me. It consisted of 3 days of aerobic/cardio training, and 2 days of strength/resistance training, about 45 minutes at each session. To increase efficiency, and also avoid boredom, the specific exercises are changed every 4 weeks. And by having an appointment to meet the trainer at least twice a week, I was less apt to 'skip' any of the times at the gym. And when I started showing up at the gym more frequently, I actually started meeting a few other folks who always seemed to be there at the same time each day, and were about my same age and fitness level. A group of three of us decided to start working out together regularly. It's much easier to make it to the gym if you know there are others waiting on you to start their workout as well."

Like me, TG had discovered the awesome power of peer pressure. And, like me, he discovered that exercising more (because peer pressure is making you do it) can have a measurable impact. "By the second month of that program, my blood sugars were consistently lower. My fasting numbers started to dip below 100, and even my post-meal readings were starting to come down a bit."

Then he became a bit frustrated. "I hit a kind of 'plateau' around the 4th month. I was maintaining my blood sugars, but they didn't seem to be getting any better. I just had assumed they would continue to decrease, and I was expecting to get my fasting blood sugars down below 90 consistently -- but that just wasn't happening. I knew that I was 'healthier' in general, and getting stronger, but I also started feeling a bit 'deprived' with the whole diet thing, especially when I wasn't getting the dramatic progress with my blood sugars I had been expecting."

Around the fifth month, TG had a follow-up visit with his doctor, including lab work. The good but unsurprising news was that his estimated average blood glucose was now below 100 (his A1c was 4.9). "But the real shocker to me was with the cholesterol numbers. Not only was my total cholesterol down (from over 200 to less than 150), but the 'good cholesterol' HDL was up in the 'normal' range for the first time ever."

The positive reinforcement from the lab results was very helpful. "That was enough to keep me motivated to stick to this regimen. I actually started enjoying the sessions at the gym, and usually went 6 times a week. I made it through the dangerous holiday seasons (Thanksgiving, Christmas, and New Year's) relatively unscathed."

"Sometime around mid-February, some 9 months after beginning this program, I noticed that my fasting blood sugars started getting lower again, to the point where they are now consistently in the mid-80s. I've been able to indulge in some of the foods on my 'forbidden list' on occasion without suffering any consequences in terms of fasting bs. (There are still a few things that my system doesn't seem to be able to handle, such as pasta, bagels, and most hot cereals, so they remain on the 'forbidden list'). I've even had to miss several days at the gym here and there for various reasons, and my fasting blood sugar levels still are staying below 90. My current weight has leveled off at about 165, and I've been able to maintain that without feeling 'deprived' in terms of my diet."

TG acknowledges that his success story is not the most dramatic one around: "I am one of the lucky ones who was able to catch this pretty early on." On the other hand, despite that advantage, it clearly took a lot of time and effort for him to get the results he wanted. Even in a comparatively "mild" case, only the most persistent people succeed.

So here's the bottom line according to TG: "I'm now convinced that regular exercise is the key to my success, and I'm committed to sticking with it. If/when my current regimen ever stops yielding these same results, the first thing I'll do is increase the frequency, duration, and/or intensity of the workouts."

Monday, March 22, 2010  

Oops! I was on such a roll there, with a series of fasting results below 80, and now 94. Not too hard to explain that one, I guess. Yesterday was my rest day from exercise, and rather than spending my day of rest nibbling watercress and sipping ice-water, I went down to San Francisco for a couple of Irish music sessions at a couple of pubs. And at one of them I had the dinner that was on offer to the musicians: Irish soda bread, and a stew with potatoes in it. I didn't eat all that much, but it was high-carb food. Also, I got home late, so I didn't get a lot of sleep either. It all adds up.

Oh well -- you've got to participate in the things you like to do, otherwise it's not worth the effort of doing the healthy thing the rest of the time.

The increase in my blood pressure is explainable, too! It was not a great day at work. This morning someone someone sent to me (and to eight or nine other people) a message stating that the approach I'm taking on my project cannot possibly succeed. As a result, way too much of my time today was taken up with crafting a defense. In these situations, the person singled out always sees far more drama and importance in the thing than anybody else does. The other people he sent his message to probably didn't even read far enough into it to see his prediction that I'm doomed to fail. Nobody commented on his message, or followed up with me about it. I still had to reply, but after reconsideration I threw away the wordy self-defense I prepared at first, and simply sent out a bullet-list summary, pointing out that I'm carrying out the plan that the project team gave me, that nobody thinks it's a perfect plan but it's the best we can do with the resources we have, that I'm trying to do something about the specific problem he mentioned, and that the problem he mentioned is only one issue among many which must be prioritized.

I hate to say how long it took me to cut my response down to that simple list of factoids. Even going out for a run at lunchtime (a rather hard, hilly run, on a warm sunny day) wasn't quite enough to force me to relax and achieve some persepctive on the thing.

Here's the perspective: someone who probably wasn't thinking much about what he was saying sent a message about me to a bunch of people who probably didn't much care what he had to say. And the only one who let his blood pressure get disturbed by the whole thing was me.

I've got to stop doing that, somehow!

Saturday, March 20, 2010  

When I got to the state park to do my trail-run, I took a look at the trees under which I was parking my car, and I thought, "Uh-oh. Maybe this is not the ideal place for someone with spring allergies to go for a run".

I didn't realize, when I moved here 14 years ago, that Sonoma County, California boasts the highest pollen count in the United States. (I don't know if we're truly Number One in that regard, but it seems like an unlikely object of civic boosterism, so I'm going to assume we wouldn't make the claim if there were no basis for it.) Starting my run from underneath a grove of trees that were dropping pollen like snow, I think I was operating under a psychological disadvantage. Running felt very, very hard at first -- probably because I expected it to.

But once I actually got into the state park and started climbing the hills, I seemed to get into a different environment -- one without a lot of visible pollen around -- and I soon relaxed and started feeling better. My main concern was not tripping over the many rocks and roots sticking out of the trail.

It's so hilly in there that there is no easy route to take, and you just have to accept that.

And once you have accepted that there is no easy route, it becomes fun to make your choice among the many hard routes you could be taking. I seldom have a specific route chosen when I start a trail run, and stick to it -- I like making up mind at each fork in the trails which way I'm going to go.

Part of the reason that I like to make up my route as I go along is that I never know for sure how energetic I will feel once I get a few miles into the run. Today I started out feeling weak and wanting to keep the run short, but after a while I felt much better, and I decided I was capable of doing a longer route. So I took the Richardson Trail up over the hills, even though I knew it would make my run nearly 9 miles long. I didn't regret the decision -- it was a good run.

After the run I had to keep cleaning gunk off my contact lenses all evening, but that was as much allergy trouble as I had to deal with. I hope the rest of the allergy season is this mild. The real test will be in about a month -- that's when the pollens I'm most allergic to will be blowing around . Whether it's an easy season or a tough one, I'll deal with it somehow.

Friday, March 19, 2010  

I couldn't face a fifth day in a row of running in the neighborhood around the office, so I went to a park in the evening and did my running there, where I would see more trees and fewer cars. Then I got home, took a shower, put something in the oven, settled down in front of the computer, caught up on a few things, and (thinking that a lot of time had passed since I'd finished the run) took my blood pressure. My systolic pressure reading was much lower than usual, and my resting heart rate higher than usual. Wondering why that was, I suddenly looked at my watch and realized that I had finished my run at the park only 45 minutes earlier. I usually don't measure my blood pressure less than an hour after exercising. Well, I guess it's only right to measure it under a variety of circumstances.

Of course, exercise actually raises your blood pressure while you're doing it, but afterwards it drops dramatically. What's important is that, over the next 24 hours or so, your blood pressure is lower than it would be if you never did the exercise.  The main reason high blood pressure is bad (according to a cardiologist I know) is that it stresses the walls of your blood vessels, and constant stress of this kind promotes inflammation. It's worth having some temporary stress during a workout, if the end result is reduced stress the rest of the time.

Researchers at the University of Saarland in Saarbruken, Germany, have discovered that erectile dysfunction is a strong predictor of trauma and death due to cardiovascular disease. Both ED and CVD are associated with dysfunction in endothelial cells (the cells which line the blood vessels in both men and women, and which have an additional and more exciting job to do in men), so it was considered likely that having ED would serve as an indicator that a man was at heightened risk of having a cardiovascular "event" (heart attack or stroke). And so it proved to be, when the medical histories of men with and without ED were compared. Over the 2-year period studied, men with ED were twice as likely to die as men without ED.

It might not seem easy to find any moral uplift (you should pardon the expression) in this story, but maybe I can find it.

Being sedentary and/or overweight can do a lot of harm to us; unfortunately it's largely invisible harm -- it accumulates slowly and also imperceptibly. We don't sense it happening. It does nothing to get our attention, until the day finally comes when it decides to see if it can kill us. It would be helpful to have a canary in the mine, as it were -- some kind of conspicuous indicator of what is going wrong which occurs well before the problem has reached the point where an ambulance needs to be called.

So, maybe it's a good thing if doctors have a legitimate basis for telling men with ED that this problem indicates poor cardiovascular health, so they'd better adopt healthier habits, and shape up before it's too late.

Unfortunately, in the brave new world we inhabit, patients have been trained to assume that, when a symptom appears which indicates an underlying health problem, we don't need to address that underlying health problem -- we only need to find a medication which relieves the symptom and hides the underlying health problem. In the case of ED, that medication is Viagra.

Viagra thus joins the ranks of those medications whose real effect is to conceal a problem rather than to do anything about it. I'm afraid that many if not most drugs which aim to give you better lab results fall into this category. (We can't give you healthier arteries, but we can sure give you better-looking medical records!)

Still, a few men with ED will probably adopt healthier lifestyles if their doctors explain to them what's happening, so I guess this kind of research isn't useless.

Thursday, March 18, 2010  

Spring is well under way, and there's an abundance of pollen in the air -- get in your car, and you see it deposited on your windshield. I'm already taking Claritin (or rather Loratidine, which is the same stuff under a generic name and at a much lower price) to deal with it.

My seasonal allergies aren't nearly as bad as they used to be before I took up outdoor exercise, but they do have an impact. My springtime asthma, which is so mild now that I'm quite unaware of it most of the day, makes its presence felt when I run. Today, during my lunchtime run, I was really struggling. I wasn't slower than last week, when I ran the same route, but the perceived level of effort required to climb those same hills was a lot higher this time.

During childhood I had asthma severe enough to cause a couple of prolonged hospital stays, and I remember it getting bad enough that walking across the room was more exertion than I could handle. This helps me keep things in perspective. My allergies are having an impact on me right now, but if the extent of the impact is that it's a little harder than usual for me to run 4.4 miles on hilly terrain, I guess that's not really so bad.

I ended up not participating in any music-making last night, even though it was St. Patrick's Day, and I felt a bit cheated. Tonight some friends of mine were playing at a restaurant, so I went to hear them. I probably could have maneuvered my way into playing with thim if I had showed up with an instrument, but I decided that would be a bit presumptuous. I was content to be part of the audience.

I knew it was a good restaurant (run by a family from Tibet), but I was afraid I'd end up eating a meal that was way too generous with the carbs and calories (a high-fat curry over rice or something). It turned out they had a practical alternative to that: a cup of bean soup and a very good salad.

It's always nice to find a restaurant meal that tastes good but doesn't make you ashamed of having ordered it.

Wednesday, March 17, 2010  

I got out of bed this morning, staggered to the bathroom, got my glucose meter out of the drawer I keep it in, did a test, and read a result of 67.

Huh? What? 67? This didn't seem at all plausible. I hadn't eaten a lot the night before, but I hadn't starved myself either, and I was pretty sure I would have felt a lot hungrier than I did if my blood sugar really was that low.

I decided that the result was probably in error. Maybe I had used the one test strip in the package that had something wrong with it, and was biased to read low. So, I tested again, and this time I got the kind of result I'd been expecting: 82. So I told myself that 82 was probably a much more accurate number, and went on with my morning business.

I have to admit that my reasoning in this case might not stand up to close scrutiny. 

Comparing two pieces of data, and deciding that one of them is wrong because it doesn't match your expectations, is a risky business. It's a notorious problem in science -- usually referred to as "confirmation bias". Any observation or measurement can be doubted, but in fact we only doubt the ones that don't match our expectations. When we get a result which confirms what we already thought, it doesn't occur to us to double-check it. When we get a more surprising result, we look for reasons why it could be wrong -- and we generally find them. If we looked for reasons why the results which don't surprise us are wrong, we could probably find those, too, but in that case we don't look.

Therefore, observation is always biased in favor of confirming the expected. "Double blind" studies (in which both the test subjects and the scientists collecting the data on them are kept in the dark about who got the placebo and who got the real medication) are an attempt to eliminate confirmation bias. But, of course, only certain kinds of experiments can be made on a double-blind basis. For ordinary observations in our daily lives, confirmation bias cannot be eliminated. In fact, it rules.

Given the amount of random variation that can occur in glucose meter readings, I would have had to use 10 test strips and take an average of the results to be able to say with reasonable confidence what my actual blood sugar level was this morning. The average of the only two readings I actually did take is 74.5. Maybe that was the actual value, or close to it; it's impossible to know.

My main reason for rejecting the initial result as improbably low was that I wasn't experiencing the feelings I would expect to have if my blood sugar really were below 70. Admittedly, I once got a reading of 60 without feeling hypoglycemic, but that was during a long bike ride, and anyway it never happened again. Ordinarily, if I get low, I feel it unmistakbly. Or at least, I think that I do. But what if I sometimes get low without feeling it, and don't realize it because I'm not checking then? There's really no way to know for sure.

However, after testing my blood sugar for 9 years now, under various conditions (including various states of health), I think I've become a reasonably reliable judge of what's going on. I'm certainly not infallible, but I do my best to get it right. 

Tuesday, March 16, 2010  

I heard today from a reader who, for the past ten months, has been working diligently at doing pretty much what I'm doing. Although his results have been good by most people's standards (his fasting results have not been much over 100), they haven't been quite as good as mine, and he's been a bit frustrated at being stuck at a plateau -- not able to make any further progress in bringing his results down to a truly normal level.

Well, apparently his patience finally payed off. Now he's finding that it's pretty easy for him to achieve fasting tests in the low 80s. He doesn't know what changed (he's following the same diet and exercise program as before), but he's finally able to get the kind of results he wanted. In fact, he's finding that he can get those results even when he indulges himself to an extent that he couldn't have got away with before -- so now his main challenge is not to let himself get too reckless, and ruin it.

What might have changed that could make glycemic control easier for him than it was before? I don't know. I have ideas on the subject, but no proof that my ideas are valid, and maybe there's no point in reviewing them here. Let's just say that, however mysterious the mechanism behind it may be, it seems to be the case that, if you do a really good job of managing Type 2 diabetes, and you keep at it long enough and consistently enough, some kind of physiological changes become established, and those changes make blood sugar easier to control. It is certainly easier for me to control my blood sugar than it used to be (and I was diagnosed 9 years ago, so we're not talking about a passing phase).

I'm not claiming this means "anybody can do it". We're not all alike. Maybe no two cases of Type 2 are precisely alike. But my experience, and the experience of others I've heard from, suggests that persistence can pay off in dramatic ways. Therefore, no matter how frustrated you are that you're doing everything you possibly can and your results are still not improving, you need to keep at it. I don't know what the odds are that you'll actually see that kind of turnaround if you keep trying to achieve it. I only know that your odds of achieving it are zero if you give up, and better than zero if you don't.

Monday, March 15, 2010  

Yesterday, determined to start moving my weight down were it belongs, I ate a light lunch and a light dinner, and went to bed feeling hungry. I also woke up this morning feeling hungry, and I guess I must have been hungry while I was asleep, too, because I had a food dream.

It was a very realistic dream. I was at work, and people kept offering me plates of high-fat foods. I kept refusing, and they kept pushing. Toward the end of the dream I was alone in a conference room with a manager (a real person, who doesn't actually work there anymore but was probably cast for this role in my dream simply because he was fat). He was pushing a plate of salami slices and soft savory cheese at me. He kept saying I had to try some, expecially the cheese, it was the best thing he'd ever tasted. Eventually I gave in, and tasted the cheese, and I was thinking, "He's right! This is the most delicious cheese in the world! I want to have lots more of it!" when the clock radio woke me up.

The day improved from there. More beautiful weather. I had a good run at lunchtime. The grass is green and flowers are blooming. People are going outdoors, and even taking off jackets.

Not a bad day, considering it was the Ides of March! We're told to beware them. Or beware it. What does this phrase mean, though? What exactly is -- or what exactly are -- the Ides?

Roughly speaking (I'll get to the nuances later), the Ides means the 15th of the month. We all know (don't we?) the story of Julius Caesar being warned by a seer to "beware the Ides of March". Shakespeare took this plot detail from the ancient historian Plutarch. According to Plutarch, Caesar decided to ignore the warning, and even joked with the seer about it upon encountering him in the streets of Rome on March the 15th. "Well, the Ides of March have come!" he said, to which the seer replied that they had come, but had not yet gone. Moments later, Caesar met a group of senators in the street who asked him to join them for an improvised meeting, and led him aside into a back room of the Theater of Pompey. There they stabbed him to death.

None of this explains what I most want to see explained about this famous phrase: the grammar of it. If Caesar really said "The Ides of March have come", then "the Ides" (whatever it means exactly) is a plural. But how can that be?

You wouldn't say "the 15th of March have come" (or at least I hope you wouldn't). You'd say "the 15th of March has come". But if "the Ides" means "the 15th", the plural construction raises the question of how many 15ths the month of March was thought by the Romans to contain.

My casual research has uncovered that "the Ides of March" is a rendering of the the Latin phrase "Idus Martiae", and that "Idus" didn't always mean the the 15th. In some months it meant the 13th. The Romans, whose taste for the over-complicated was apparently not satisfied by their nightmarish grammar, had a ridiculously elaborate way of identifying the days of the month. Days were numbered backwards from three crucial days of the month known as the Kalends, the Nones, and the Ides. The Kalends always meant the first day of the month, but depending on which month it was, the Nones could be the 5th or the 7th, and the Ides could be the 13th or the 15th. In March the Ides meant the 15th day. Other days were identified by how many days they were before one of the named days. I swear I am not making this up, and I'm even leaving out one of the more confusing details of the backwards-counting system.

For reasons which I am unable to imagine, this system of calendrics persisted for a long time after the fall of Rome, and even by Shakespeare's time the term "Ides" was still familiar enough to theater audiences that it required no explanation.

But still, my main question remains. If "the Ides" identifies one day in a month, why is it plural? How many Ides are there in March? What would one Ide be? 

Apparently there was some kind of religious ritual observed mid-month in Rome (the Idus Martiae was dedicated to Mars, the god of war). Perhaps "Ides" actually referred to ceremonies performed at that time, or to activities of some other kind that could be thought of in plural form. That's just a desperate speculation on my part -- I haven't been able to find out.

This is what drives me crazy about people who write explanations. What on earth is the point of writing an explanation in which you explain everything except the really puzzling part? And they do it every time!

Take that classic question, "why is the sky blue?". Every science textbook explains about the scattering of light by the atmosphere, and how shorter wavelengths are scattered more, which means that there is more light scattered "at the blue end of the spectrum". And they expect nobody to notice that this explanation makes absolutely no sense -- because blue is NOT at the end of the spectrum! Violet is. Violet has a shorter wavelength and is presumably scattered more. If their explanation is valid, the sky should be violet. What they always fail to mention is that, in a sense, the sky IS violet -- that is, there is more violet light than blue light coming at us when we look up at the sky. But the human eye is far more sensitive to blue light than to violet light. (If you ever get a chance to see an actual spectrum, you'll notice that the blue band looks bright and the violet band is so dim you can barely see it.) If we were equally sensitive to blue and violet, the sky would appear more violet than blue, but we're not. I guess the people who offer science students this lame non-explanation would protest that the story gets complicated if you mention violet. I stand by my protest that, if you don't mention violet, the story is meaningless swill. It would be better to offer no explanation at all than to offer a totally stupid explanation, but the totally stupid one is what is offered, in one textbook after another.

I think dumbed-down explanations do a lot of harm in this world -- not least to diabetes patients. I suppose my life will go on about the same whether or not I ever do get a clear explanation of why a term that means "March 15th" is a plural, and most people's lives will go on about the same whether or not they ever hear a plausible explanation of why the sky is blue. But if people with diabetes are given poor explanations of diabetes, this is likely to have an impact.

Diabetes patients who post questions on the dLife forum often show unmistakable signs of having been given a dangerously simplified picture of the disease they are expected to manage. They think it's about genetics and nothing else, or they think it's about weight and nothing else, or they think it's about food and nothing else. They ask how they could possibly wake up with higher blood sugar than they went to bed with, since they didn't eat anything during the night (the fact that this seems paradoxical to them shows how little they have been told about how the body regulates glucose levels).

One of the things I try to do on this site is to explain some of the details that are typically omitted for the sake of keeping the story as simple (and meaningless) as possible. But I haven't uncovered all the details that are being left out, so I can't do this all by myself. I wish the medical profession would try a little harder in this area. It matters.

Saturday, March 13, 2010  

Not bad weather today, here in the wine country...  

It was almost hard to remember what a cold, wet, dreary day Friday had been.

Perhaps because the morning was so beautiful, or perhaps for some other reason, the farmer's market was more crowded than I have ever seen it.

It was as if a rumor had got out that some new crop disease was on the loose, and people thought they were scrambling for the last fresh produce they would see this year.

After I bought some vegetables there, I went for a trail run. A very hilly run, but I found the hills easier than usual -- I suppose because the gorgeous weather put me in a good mood.

Later in the afternoon I was driving through Alexander Valley, where the fruit trees are already in bloom. Winter's over, definitely.

Tomorrow we have the stupid time change. On the plus side, it means there will be late sunsets, giving me extra daylight to put to good use after work. On the minus side, the absurdity of Daylight Saving Time bothers me more the more I think about it. To me, DST is the chronometric equivalent of painting a house by lifting the entire building and waving it back and forth in front of a stationary paintbrush.

Okay, so the sun rises earlier in the summer. That's not a national emergency. We can cope with it. And there have to be better ways to cope with than forming a global conspiracy to pretend that 6 AM is 7 AM for half of the year!

Friday, March 12, 2010  

I rained all day, and it was raining so hard at lunchtime that I couldn't even come close to persuading myself to go outside and run. I resigned myself to going to the gym after work (never my first choice, but sometimes it needs to be done). Then things suddenly improved -- by 5 PM it stopped raining, and the skies started to clear. I was able to fit in an evening run before it got dark. It was a little cold, but putting on another layer of clothing took care of that. It ended up being a nice run.

During the final mile, while I was climbing the mother of all hills, someone driving past me honked. I didn't get a good look at the driver, but I know who it most likely was, based on the model and color of the car. Usually I don't even have that much to go on. When you do a lot of running on the streets in the same neighborhood where you work, you have a lot of these puzzling encounters with passing drivers. You seldom can see their faces well enough to recognize them, but presumably they wouldn't be trying to get your attention if they didn't recognize you. So, you wave at the passing car -- and then feel embarassed by the possibility that you don't know them at all and they were honking at somebody else. 

After the run I cooked up a bunch of chana dal (a legume from India which looks like yellow split peas, but is more closely related to garbanzo beans). I had bought a bag of it at a local Asian market. I'd left it soaking overnight (otherwise it takes too long to cook), and as it was simmering I added chopped vegetables to the broth. It was good. I had bread with it -- a very dense loaf from a local artisan bakery, made with various whole grains. Despite providing a fair amount of carbohydrate, the meal was very high in fiber -- and presumably high in "resistant starch". Anyway, I did a 1-hour post-prandial test, and the result was only 104. The fact that I had done a 5.3-mile run earlier in the evening probably contributed to that low score, but I'm sure my choice of foods was significant too.

Chana dal is often recommended to people with diabetes as the starchy food which is least likely to spike their blood sugar. It seems to work for me, anyway.

As a statement of the bloody obvious, it would be hard to top this headline from Reuters Health Information: Pain in Both Knees Predicts Higher Risk of Impaired Function.

The article begins, somewhat shamefacedly, "Not surprisingly, people with pain in both knees are more likely to develop functional problems compared to those with pain in one knee only, according to a report in the February 26th online issue of Arthritis Care & Research."

No, it really isn't all that surprising, now that I come to think of it. I guess I'd probably have an easier time getting around on one bad knee than on two. But that's just me speculating -- who knows what the reality might turn out to be, if a bunch of research money was spent on finding out for sure? Maybe it would turn out that people with two bad knees have the advantage over people with one bad knee, because of... uhm... symmetry or something.

But the researchers were able to confirm that there is a definite disadvantage in having two bad knees rather than one. In fact, they were even able to quantify the difference: "The findings indicate that patients with unilateral pain are half as likely as those with bilateral pain to have low physical functioning." Get that? Having two bad knees is twice as likely as having one bad knee to cause impaired functioning. So now we know.

Dr. Daniel K. White, from Boston University School of Medicine, was the lead author of the study. He told Reuters Health: "Our primary finding was that persons who had pain in both knees were more likely to develop a low level of functioning and were less likely to recover from a low level of functioning over time compared with persons with one painful knee. We, like many clinicians, expected this finding."

So it seems that "many" clinicians (not all, but many) thought it would turn out that having two bad knees is worse than having one bad knee. I imagine that "many" clinicians are feeling pretty smug right about now, and are probably engaging in some pretty rough teasing of their colleagues who had predicted things would turn out the other way.

You might expect that Dr. White and his colleagues were doing pioneer work here. Not at all. He said that "previous studies have looked at the implications of one versus two painful knees on function, though this was not the primary focus. Our study is novel given that we focused our question on if pain in one versus two painful knees differs independent of knee pain severity on function." They didn't cut corners on their research, either. This wasn't one of those small-scale studies with only 20 or 30 subjects examined. They looked at data on 2069 participants in an arthritis study. Even so, Dr. White doesn't feel that this study closes the book on the subject. More research is needed. Dr. White says that many questions remain to be addressed.

I'm sure he's right. Maybe, once the knee situation is more fully clarified, he can finally settle that perennial controversy about blindness in one eye versus blindness in both eyes. Who knows which of those two might turn out to be worse?

Thursday, March 11, 2010  

Hold on to your hats! A revolution is under way!

"Like the glycemic index, resistant starch info is going to revolutionize how we view starches."

That's Janis Roszler, moderator of the dLife Forum, defending dLife's rather gushing endorsement on Tuesday of a diet book which emphasizes the importance of resistant starch (and recommends a commercial product called Hi-Maize which people can use to add resistant starch to baked goods). Forum members, suspicious that they were being subjected to spam in disguise, or at least over-credulous journalism, started a fiery debate on the subject which is still going on.

Leaving aside the question of whether dLife is or isn't carrying water for the publishers of the diet book or the makers of Hi-Maize, I would like to concentrate instead on the glycemic index and resistant starch.

I guess it would be reckless for me to criticize others for stating the obvious and pretending it's a startling revelation -- since I live in a glass house myself, in that regard. Well, I'm going to be reckless. I'm having a very hard time seeing what is "revolutionary"  about the glycemic index or resistant starch.

The glycemic index is a number assigned to a specific food, which is supposed to tell us (at least in relative terms) how strongly that food tends to raise blood sugar in the average person.

In practical terms, what the glycemic index tells us is:

(1) Foods containing little carbohydrate tend not to raise the average person's blood sugar as much as foods containing a lot of carbohydrate. (Whoa! Who saw that coming?)

(2) Foods containing carbohydrate which is hard to digest ("fiber", "resistant starch", etc) tends not to raise the average person's blood sugar as much as foods containing only carbohydrate which is easy to digest. (Another stunning revelation!)

In short, what the glycemic index tells us is what we already knew.

I haven't been able to find a clear definition of the distinction between "resistant starch" and "fiber". Both terms refer to carbohydrates that humans can't easily digest; apparently fiber is almost entirely indigestible, while resistant starch is partially digestible. One of the things that interferes with digestibility, in resistant starch, is the mechanics of the way the food is packaged by mother nature: the skin on a bean, or the intact outer shell of a whole grain. These things shield the starch from the digestive process, so that a lot of it passes through the small intestine without breaking down.

Resistant starch obviously has less glycemic impact than easily-digested starch, and it seems to have a moderating effect on the impact of other carbs in a meal. It is also thought to have other specific health benefits. Because of all this, it's considered a good idea for anyone with Type 2 to get more resistant starch into his diet.

And how do you get more resistant starch into your diet? Mainly by eating beans -- the most abundant source of the stuff, by a subtantial margin. Which is fine with me, because I happen to like beans. The other potential sources are less generous, and in some cases less appealing. (Green bananas? I am eager to partake!)

But what does all this amount to? Specifically, how does it qualify as "revolutionary"? As far as I can see, this whole complicated business of "glycemic index" and "resistant starch" boils down to these four words: better beans than rice.  

You really don't have to look up your foods in a table of GI numbers; you just have to be conscious of what sort of foods they are. And if you do spend time looking up your foods in a table of GI numbers, be prepared for one non-surprise after another. I guess what has soured me on the whole GI thing is that I thought looking up the numbers would yield a few startling revelations -- foods that had a much higher or lower index than their carb content and fiber content would lead one to expect. And it kept not happening. So why was I looking up these numbers? Where was the big payoff? Where was the revolution? If there was a stirring call to storm the barricades here, I missed it entirely.

What seems to have stirred the most suspicion of the dLife article was the mention of Hi-Maize, a commercial product. I wasn't all that bothered by this, or all that excited by it either. Hi-Maize is a variety of corn starch which contains an unusually large amount of resistant starch. (The makers of the stuff say it's not Frankenfood -- they just found a way to breed a variety of corn that contains more resistant starch than usual.) The idea is to add Hi-Maize to recipes for baked goods, replacing some of the flour in the recipe; presumably this will result in baked goods that are less challenging to diabetes patients.

Well, if you don't like beans any more than I like green bananas, perhaps Hi-Maize would be your best opportunity to get more resistant starch into your meals. Probably not a bad idea. But revolutionary?

I suppose the reason people can't be talked out of overselling is that they have absolutely no idea how counterproductive it is. 

Wednesday, March 10, 2010  

It was a bit cold for our lunchtime run today, but it was sunny, and the chill seemed to wear off as soon as we started climbing the first hill.

We chose a route which we used to take all the time, but seldom do these days. One nice thing about it is that the route cuts through the grounds of the nearest hospital, and somehow it feels like good luck (or a pleasant contrast, or something of the kind) to go running so closely past a hospital, knowing that we're feeling fine and we're not going to have to spend the night there, or even go in for outpatient treatment. Sometimes doctors and nurses are standing around outside (it used to be that a lot of them would be taking a cigarette break, but that era seems to be over), and they usually cheer us on a little, or at least greet us pleasantly. I sometimes get the impression that it's a relief to them to see us. Oh, look -- here comes somebody who isn't sick! How non-depressing!

When I first started running with coworkers at lunch, I remember feeling so overburdened by the difficulty of keeping up with them that, by the time we got onto the hospital grounds, I would think, "Well, if I'm going to have a heart attack, I guess I couldn't choose a better place to have it than right here by the emergency-room entrance". These days passing the hospital doesn't remind me that I might have a heart attack, it reminds me that I'm doing what's necessary to avoid having a heart attack. It sounds like a subtle distinction, but the feeling is entirely different.

The recent earthquake in Haiti was far less severe than the recent earthquake in Chile, and yet the loss of life was far higher in Haiti. The most recent death count I could find for Chile is 708; the figure for Haiti is variously estimated, but seems to be about 200,000.

Why were there hundreds of times as many deaths in Haiti, if the earthquake was less severe? The reason for the difference seems to be infrastructure. For one thing, buildings are constructed in accordance with good safety codes in Chile. In Haiti they are not. The result is that Chile was able to survive an earthquake of staggering dimensions, while Haiti was reduced to rubble by a comparatively moderate one.

Not long ago I was talking to someone who used to live in Haiti (her husband was occupying a diplomatic post there). I asked her, basically, what is wrong with that country? Why can't Haiti ever seem to do anything right? She replied by describing Haitian society as she saw it, without offering any theory as to how Haitian society came to be that way. She said Haiti is a very poor society, but also a very stratified society, in which nearly everybody is looking down on somebody else. There is no collective pride, only the kind of individual pride that comes from a sense of superiority to whomever is a little farther down the ladder than you are. Because of the general poverty, simply having a job of any kind is enough to confer a kind of aristocratic status on you -- and also a sense of aristocratic privilege. If you have a job, you must be an important person. A very important person. A person who is, in fact, too important to work.

Clearly, a society in which everyone who has a job is too important to work is not a society in which anything is going to be done very well, so it should come as no surprise that Haiti is not a shining example of disaster preparedness. No doubt the Haitians rationalized their attitude to the subject: there's no predicting the forces of nature, and no fighting them. Whatever is going to happen is going to happen. No use worrying about it. No use doing anything about it, either. Besides, doing something about it would be work, and I'm too important to work.

It would be nice to think that Haiti's current national emergency might shock the Haitian people into re-considering the habits of thought which made their countury so vulnerable to it in the first place. I'm not sure I expect to see that happen, though. Feeling besieged by fate tends to strengthen people's entrenched attitudes. The more desperate the need for change, the greater the resistance to it. Sadly, the long-term impact of this disaster may well be to reinforce everything that is wrong with Haitian society, so that the place becomes even more chaotic and vulnerable than it is today. Chilean society, on the other hand, is likely to be reinforced in its commitment to doing the sensible thing.

It seems to me that there is an obvious analogy here between the health of a society and the health of an individual. You can adopt a devil-may-care attitude (if some disease is going to kill  you, there's nothing you can do to avoid it, so just relax and forget about the issue) or a more responsible attitude (even if there is no perfect precaution available, do what you can to minimize the risk, and to mitigate whatever bad outcomes can't be avoided entirely). The cautious approach doesn't guarantee success, and the reckless approach doesn't guarantee failure. But which approach would you bet on, if you had to put your money up? 

Your money, or perhaps your life?

Tuesday, March 9, 2010  

Okay, this morning my fasting test was back down where it belongs. Nobody gets a perfect score every time; the trick is to make a course-correction as soon as you start seeing your results climbing any higher than you want them to be. Yesterday's reading of 95 disappointed me and I wanted to knock it down. I exercised a little more than usual, and ate a little less than usual (particularly less carbohydrate), and voila: 84.

I didn't always have such demanding standards. I can remember how excited I was, during an earlier stage of my diabetes journey, when I got a fasting test of 100. My doctor had advised me to try to get it below 110, so in a sense I had succeeded already -- but I had the notion then that 100 was not merely within the range of what my doctor considered acceptable for a diabetes patient -- I thought 100 was a perfectly normal fasting result, which any healthy non-diabetic person would get.

Actually, a healthy non-diabetic person tends to get fasting results in the low 80s. I didn't realize that at the time. I thought 100 was a perfect score.

Still, when I started getting results below 100, I gradually started altering my expectations. After a few years I started to feel that a result below 95 was what I really wanted, and should try to achieve. I couldn't always achieve it, but as long as my fasting average was below 95 I was happy.

In recent years, it was brought to my attention that a truly normal fasting average would be in the 80s -- specifically, the low 80s. And that has gradually become my current idea of a satisfactory result. Anything above 85 makes me think I should have tried harder, and should make an effort to do better next time.

Admittedly, the day to day fluctuations (or test-strip to test-strip fluctuations) in the accuracy of a home glucose meter raise doubts about the actual significance of minor variations such as those I am tracking and fretting over. It isn't impossible that my glucose reading was actually lower yesterday, and higher today, even though the meter said it was the other way around. I don't believe it, though. I am seldom very surprised by these fluctuations -- for the most part, my results are up a bit when I expect them to be, and down a bit when I expect them to be. Even when a result surprises me, a moment's thought usually suggests a reasonable explanation for it. (There's nothing like an elevated meter reading for making you remember a high-carb food item which you would otherwise have forgotten you had eaten.)

Even if, on some days, my glucose meter is misleading me into being too self-critical (or too self-congratulatory), over the long haul it's not going to steer me too far wrong. Because the errors average out over time, I have decided that the most practical course is for me to pretend that my meter is always entirely accurate -- that if my fasting result is up 5 points, that means I did something wrong and should try to correct it, and if my fasting result is down 5 points, that means I did something right and should do more of it. Over time, I'll be right about this more often than I'm wrong about it -- which is all that an intelligent gambler wants or needs.

Monday, March 8, 2010  

Considering that I did a long trail-run yesterday afternoon, I could have expected my fasting test to be low today. But this time I actually expected it to be up a bit, and it was. Blame it on poor planning of my Sunday schedule, into which I tried to fit too many activities. After the trail run, which of course depleted my energy stores, I took a quick shower and headed off to a music session without having a meal first. My dinner was delayed until I was pretty much starving. And then, of course, I ate too much (including potatoes and peas). Too many carbs.

I tried to make up for it, to some extent, by running hard at lunchtime today. There was a cold wind blowing, and sometimes that can be invigorating for a runner -- it seems like you're getting more oxygen, somehow.

Another motive I had for running hard was that a storm was approaching (I could see clouds in the distance with sheets of rain falling from them) and I wanted to finish my run before those clouds caught up with me. I managed it.

This was a kind of pre-Saint-Patrick's-day weekend, with a lot of Irish music going on. A family from Ireland who live in my neighborhood hosted a party on Saturday, with a lot of really good musicians invited.

One of the things I like about this kind of social music-making is that it gives people of different generations (who, in any other context, might seem to have nothing in common and nothing to talk about) an enjoyable way to interact.

Perhaps what the world needs is more innocent fun.

And now for some guilty fun. Tell me I have a sick sense of humor if you like, but I think the little photo below is hilarious, at least in the context.

Well, gosh, what do you think? Has this guy been successful in helping suicidal teens cheer up, or hasn't he?

He's certainly made my day, I'll give him that much.

Friday, March 5, 2010  

I have been getting notices at work telling me that I have too much unused vacation time on the books, and should do something about it. In theory that means I need to take a vacation, but planning one of those is very difficult currently, due to the project I'm working on. I think for now my solution will be to take an extra day off, here and there, whenever a good opportunity arises.

So, I took today off. I spent it trail-running in the state park, and then taking care of some errands that needed doing, and finally working on music. I have a lot of music to memorize for the concerts coming up soon, and some of the music is difficult to learn because of "crooked" rhythms (meaning that the beat changes unexpectedly, and everything doesn't come out even). I mean, it's not Stravinsky or anything, but one of the fiddle tunes changes its time-signature eight times one page of music, which for this amateur player is a lot to deal with. It's nice to have an uninterrupted block of time to work on these things -- breaking the harder passages down into small and simple fragments, and then putting them back together.

Dr. Elbert Huang of the University of Chicago did a study last year on the fast-rising incidence of diabetes in the US, and the impact of this increase on Medicare and other health programs. His conclusion: by 2034, expect the number of Americans with diabetes to increase from 24 million to 44 million. He predicts that this will have a disastrous effect on Medicare, and on health-care costs generally.

You have to wonder how such a trend could be under way, in light of the new politically-correct spin on Type 2 diabetes -- that it's a genetic disease, quite unrelated to lifestyle.

A lot of diabetes patients would strongly prefer to believe that nothing they could have done would have prevented them from becoming diabetic. The reasons why they want to believe this are not hard to understand: they don't want to be blamed for having a disease, and they feel picked-on whenever the disease is described as a preventable problem. Apparently Dr. Huang didn't get the memo about this, as he persists in saying such things as "we know we can prevent diabetes through diet and exericse".

I can understand why people get hypersensitive about a situation in which they face moral disapproval (real or imagined) for having an illness. I'm willing to stipulate that, in general, blaming people for being sick is not nice, regardless of how they came to be sick. No thinking adult should need to be told the rules: you don't ask a woman with lung cancer whether she smokes, you don't ask a man with AIDS about his sex life, and when you meet someone who needs a liver transplant you don't say "How come? Do you drink a lot?".

However -- addressing legitimate public-health issues regarding a disease is not the same thing as shaming people for having that disease. If millions of cases of diabetes can be prevented, it would be criminal to pretend otherwise, just to spare the feelings of those who have diabetes already. Should we stop trying to prevent new AIDS cases, just because it makes those who failed to prevent it look bad?

I can see no justification for adopting a comforting fable about diabetes being a purely genetic, non-preventable disorder. It seems plainly impossible for that tale to be true.

Those who would have us see diabetes as purely genetic ought to be explaining to us how the genes which cause the disease are managing to proliferate so rapidly. One would expect it to take many centuries for the human gene pool to be transformed to that degree. Evolution doesn't work fast (and its general tendency is not to make disease-causing genes more common over time). So what's been happening here? Have people with diabetes been breeding like bunnies, while non-diabetic people remained childless? If so, how was all that arranged?

Obviously your genetic inheritance plays a role in determining whether you become diabetic or not, but to suggest that it's a solo role is pretty ridiculous.

When we read about a gene "for" a particular disease, we need to understand that this is a kind of shorthand, alluding to an issue far more complex than it sounds. Think about it: how can anyone be born with a gene "for" breast cancer, and yet not develop breast cancer for years and years? You have the gene right from the start, so you seemingly ought to have breast cancer from the start, too, or at least by the time you complete your development into an adult. Why doesn't it work that way?

Because you don't really have a gene "for" breast cancer. You have a gene which causes a vulnerability in one of the body's cancer-fighting mechanisms. Cells mutate and try to become cancerous pretty often; usually the body is able to intervene and stop this development at a very early stage. But suppose a genetic defect renders the body incapable of stopping a particular kind of cancer cell from growing. Then, if the right mutation occurs, and the right kind of cancerous cell is formed, the body will be unable to prevent the situation from getting out of control. You don't have a gene for a particular cancer, you have a gene for the inability to knock out that particular cancer if it ever does show up. 

It seems to be a roughly similar situation with diabetes. Many genes are associated with Type 2 diabetes, and of course they are there from the start. And yet, the disease usually doesn't develop until one is well along in life, and some people who carry the genes never become diabetic at all. Clearly, genes or no genes, something has to happen along the way that alters the situation. You don't have genes "for" diabetes, you have genes that weaken the endocrine system's ability to cope with certain challenges that it may or may not have to face. We don't yet know what all of those potential challenges are, but there is no question what the most common one is: a prolonged period of weight gain and insufficient exercise. It has been demonstrated pretty clearly that getting in shape often prevents the disease (and that getting in shape after diagnosis often ameliorates it). How could that be so, if lifestyle never played any role in causing diabetes?

Yes, yes, I know, there are a few skinny, active people who become diabetic. And what of it? I didn't say that being a couch potato was the only challenge that your endocrine system might not be able to handle, if you have the wrong genes. I just said it was the most common one, at least in countries where the dominant lifestyle involves a lot of eating and a lot of sitting down. We didn't always live this way, and in the days when we didn't, diabetes was less common.

I realize some people argue that diabetes isn't actually becoming more common, we're just becoming more adept at diagnosing it. This very unconvincing argument seems to me to show just how desperately some people want to cling to the idea that diabetes is gene-related but not lifestyle-related. Let's be realistic: it isn't that hard to diagnose diabetes -- and hasn't been for a mighty long time now. If doctors say they're seeing more diabetes than ever (and in younger patients than ever), I don't think it's because they're reading the lab results more carefully than they used to, and I don't think it's because people who lack diabetes genes have stopped reproducing. I think it's because we've got a public-health problem to deal with here -- and that it would be better to face reality and deal with it.

Thursday, March 4, 2010  

Due to a copy-and-paste error, my blog entry yesterday claimed that it was Tuesday. Actually, yesterday was Wednesday. We apologize for any confusion this may have caused.

After yesterday's (that is, Wednesday's) meteorological strangeness, we had perfect weather for a run today -- brilliant sunshine and cool, clear air.

Nice to see the sun setting later and later in the day. I look forward to having enough light to do a long run after work, rather than at lunchtime. During the summer I like to go trail-running on Wednesday evenings. Some people I work with go mountain-biking in the state park then, so every once in a while I'll be running through the woods and have a chance encounter with someone from the office. And it makes me feel like we're recognizing each other as fellow members of a secret society -- the Holy Order of Those Who Work Out.

In today's issue of the satirical on-line magazine The Onion, ("America's Finest News Source"), their "American Voices" column (a fake man-on-the-street interview feature) notes that "The recent earthquake in Chile shifted the axis of the earth 3 inches and made the day 1.26 microseconds shorter", and asks "What do you think?". One of the people interviewed says "Now when am I supposed to find time to go to the gym?".

The Onion often covers health and fitness issues in its satirical survey of modern life. Some sample headlines:

And, of course, their unforgettable summary of an inconclusive investigation into the relationship between polyphenols and cholesterol: "Study Finds Jack Shit".

One of their recent stories was entitled Fork Manufacturer Introduces Fifth Tine To Accommodate Growing American Mouthfuls:  "In an effort to keep pace with the rapid growth of American mouthfuls, flatware manufacturer KitchenMaster announced yesterday the addition of a fifth tine to its line of dinner forks. 'These days, a traditional four-tined fork is just not enough to handle the quantities of food people shove down their throats,' said company spokesman Ken Krimstein, holding up a fork supporting six separate tortellini, two turkey sausages, and some mashed potatoes. 'To stay relevant to our customer base and bring back some of those who have given up on using utensils entirely, this was an adjustment we just had to make.' Krimstein added that the augmented forks would soon be followed by 25 percent deeper spoons and 3-gallon gravy boats."

Their article "Choosing A Health Club" offered several valuable pointers:

The secret of satire is that it's only funny if there is some truth in it. Not necessarily a lot of it, but some. Occasionally satirists include more truth in the mix than we can comfortably handle, but I think the laughs are worth the sting. We need satire: it's our opportunity to hear what's too harsh to be mentioned, but too important to be left unsaid.

Wednesday, March 3, 2010  

Apparently a very heavy rainstorm blew through town last night;  more than one coworker told me today that the noise of the rainfall woke them up at 2 AM. I'm proud (and rather surprised) to report that I slept through all that. In the morning, it was sunny, so I figured it was safe to plan on a lunchtime run.

When I got out there, I found that the sky was a very mixed-up combination of bright blue skies and ominous, towering clouds. Hoping for the best, I took off running, and after about a mile I suddenly found myself under a very small, isolated stormcloud -- which not only dumped rain on me, but dumped hail on me as well. (Small hail, though -- nothing big enough to hurt.) After 5 to 10 minutes, the micro-storm was over, and I was running in the sunshine again. This wouldn't be so weird elsewhere, but the weather in coastal California is usually not that volatile -- or that localized. A coworker who took off running the same time I did, but went south instead of north, didn't even know that any rain had fallen until he heard it from me afterwards. If I had run any other route I would have stayed dry. It seems so weird to me to think that, during your lunch break, you can get far enough on foot to cross into and out of different weather system.

Well, even though I got a little wet, I enjoyed today's run a lot more than my treadmill run yesterday. I just don't like running in place.

There's a funny phenomenon that often happens with world records in sports: once somebody finally breaks a record that has stood for a long time, the new record is then broken again -- almost immediately.

In 1954 Roger Bannister was the first to run a mile in under four minutes. Even though he was breaking a world record that had stood for 9 years, it was only 46 days before another athlete ran a mile faster than Bannister had just done.

Or take Charles Lindbergh's famous flight in 1927 -- the first non-stop flight from New York to Paris.

How much time went by before a second pilot did the same thing? Only 14 days. (And only 37 days before a third pilot did it.)

It seems that doing what has never been done before removes the intimidation factor, and in effect gives other people "permission" to think that they are able to do the same thing. So then they go out and do it. Why not? Obviously it can be done, if someone else has already done it first! But the situation is less hopeful if you don't have before you the example of someone else who has succeeded in doing what you're afraid might be impossible.

That's why I think diabetes patients -- and their doctors! -- need to be more aware of success stories. They need to see examples of diabetes patients who have done better than their doctors would ever have predicted they could do.

These thoughts were prompted by a woman who wrote in to the dLife forum today to report that her husband was diagnosed in October with Type 2. His numbers were so bad at the time of diagnosis (fasting glucose of 266, A1c of 12.3) that his doctor told him that he would have to be put on oral medication, and stay on it for life -- because it wouldn't be possible for someone in his situation to control his diabetes with diet and exercise alone. Nevetheless, he and his wife did a kind of family lifestyle makeover, with a new diet and regular exercise. He lost 56 pounds. Now his doctor has had to take him off the oral medication because it was making him seriously hypoglycemic. Without the meds, his fasting glucose and post-prandial glucose are now within the normal ranges, and his A1c has dropped from 12.3 to 5.5.

I don't know how many diabetes patients can actually do that, but I'm pretty sure more of them can do it than think they can do it. I'm also pretty sure that most people who are told by their doctors that they can't do it are not going to try very hard to do it.

We need to stop this low-expectations thing, somehow. It's not helping!

Tuesday, March 2, 2010  

It was raining hard this morning, and I didn't feel like running in that downpour, so I went to the gym and ran on a treadmill -- very definitely my least favorite kind of running. And while I was suffering through my four miles, I saw through the windows of the gym that the rain had stopped, and the skies were clearing. When I left the gym, I stepped into dazzling sunshine. If I had waited half an hour to start my run I would have had great weather!

The forecast is for another rainstorm to come in tomorrow. I don't think I can face a second treadmill run in two days, so I might run outdoors even if it's raining. The things I do, just to avoid disability and death!

I had a music lesson tonight, and my teacher gave me an exercise to work on that was exceptionally difficult -- a real challenge to finger coordination. The finger equivalent of a tongue-twister, actually. He told me not to try to do the whole exercise at once. I should break it down into small pieces and work on those small pieces individually. Just play the first four notes, over and over. Then play the next four notes, over and over. Later I can try welding the first four to the next four, but not until I'm comfortable doing just four at a time.

That's the essence of musical education, right there. You want to learn how to do something very complicated and difficult? Break into pieces that are simple and easy. You might have to break it down quite a lot before you've actually got hold of a fragment that can be called simple and easy, but that's the essence of the enterprise. You work on small pieces of the puzzle at first; only later do you start assembling them into a complete picture.

I've tried to apply that approach to diabetes management, and I think it has helped me a lot. Music lessons have taught me the value of small goals. It's all very well to talk about the dramatic improvements that you hope to make in your health over the long term, but let's face it: life is lived in the short term, and what we really need are good short-term goals. If you want to bring your fasting average down 30 points, so that your doctor will let you stop taking pills those wretched pills that are giving you diarrhea, focus for now on bringing it down 5 points. You can get to the other 25 points later, but for now, focus on the first 5, because you can probably achieve that much impovement before you lose interest. And when you achieve that, you will be emboldened to go to work on the next 5 points.

If you're out of shape and you can only handle 15 minutes of exercise per day, fine -- do that 15 minutes for now. And then notice how, after a while, 15-minute workouts don't seem as hard as they did at first -- which means it's time to try 20 minutes. And, lo and behold, you just did 20 minutes and you didn't die! So do that for a while, and when you get to the point where you're pretty sure 25 minutes won't kill you, try 25.  That was my story, quite literally, around the time of diagnosis. During the years since then I have run four marathons, and have done at least five bike rides that were 100 miles or more. But at the point I started from, I was pretty sure that more than 15 minutes of exercise would kill me. That's the beauty of the small goal: over time, it allows you to make to make amazing amounts of progress, without being overwhelmed at any point along the way.

Look at virtuoso musicians, Olympic athletes, magicians, or anybody else who seems to you to command superhuman skills -- and realize that they achieved whatever they have achieved by breaking down a difficult assingment into small, manageable pieces. They may have worked harder on those small pieces than most people would be willing to do, but to the extent that they have a "secret", that is their secret. That is how it is done. 

So, my advice (apart from taking music lessons, so that you really get what this is about) is to push your long-term goals off into the back of your mind, and instead concentrate on some short-term goal which you actually can achieve in a short time. You can more on to the next short-term goal later, but for now, focus on the modest little goal that is before you. 

Monday, March 1, 2010  

Aarrrgh! Weight going back up. I guess I'd better launch another vegetarian phase. Eating animal foods may be good for glycemic control, but it's awful for weight control. For me, anyway. Some people do okay with it, obviously. But, as I have had occasion to point out once or twice before, this diabetes-management thing isn't always about doing what works for somebody else.

Vegetarian foods don't have to be high in carbohydrates, but they very often are. To put it in practical terms, if I assemble a vegetarian dinner and a non-vegetarian dinner without thinking hard about carbs, the vegetarian one will usually have more carbohydrate and the non-vegetarian one will usually have more calories. For me, at least, the goals of weight control and glycemic control always seem to be in conflict. No doubt it would be possible to strike a perfect balance somehow, but I don't think I've hit on the right method yet. 

Today the weather was gray and dismal, but yesterday, when I went down to San Francisco yesterday to play some music, I actually needed to turn on the air conditioner in my car on the way there. You know it's a warm February day when it's wam even in San Francisco, a city built directly under a stationary fogbank.

I managed to get into two different Irish music sessions in two different pubs. At the afternoon session, most of the musicians were quite young. That usually means very fast tempos, and it did this time. The average age was higher at the evening session, but the tempos were almost as fast. This may explain why my right shoulder was sore afterwards. (It was still sore today, but I did some shoulder rotations and yoga, and it's feeling better now.) My bowing arm got a little more of a workout than it was ready for, perhaps. 

The blurring of my hands in these photos gives you some indication. I didn't play hard when I was just faking it, of course, but when we played tunes I knew well, I tore into them as intensely as I could. That's when you're actually most relaxed, strange as it seems. (When your'e least relaxed is when you're playing something very slow, but that wasn't an issue yesterday.)

I generally don't hurt myself from overplaying these days. I used to, mainly because I didn't relax my right forearm enough when bowing fast, and I would get shooting pains from my wrist to my elbow. I overcame that difficulty eventually, and now I can usually play for hours and not have a problem. Why was it any different yesterday?

A couple of factors might have made it harder for me. One was that I was playing with a new, lighter bow which I bought a couple of weeks ago; I'm not fully used to it yet, but I like its agility, and that tempted me into doing pushing things a little harder than I usually would. Also possibly relevant: I was a newcomer to the afternoon session, and I was more than 25 years older than most of the other musicians there. This probably gave me a subconscious impulse to show them that I could play as fast as them. I tend to play fast anyway (or so I gather from the complaints of fellow fiddlers who would prefer that I take it down a notch), but I'm especially fast when I'm feeling the need to prove myself. It's silly to react this way, I realize. There was no particular need to prove anything yesterday -- it was just a friendly jam session, and more welcoming than such things normally are in America (it was more like the atmosphere of a relaxed session that you would find at a pub in Ireland or Scotland). Next time I go, I will presumably be past that hurdle, and I'll be able to relax more and not get a sore shoulder afterwards.

I seem to spend a lot of my time these days just keeping the machine working: exercising to deal with my cardiovascular and endocrine issues, and then doing stretching and yoga and physical-therapy exercises to deal with my joint and skeletal issues... and, in addition to everything else, thinking all the time about these issues and how I'm going to manage them while still finding time for life. Some people find it impossible to balance those things: they feel that maintaining the machine subtracts so much from their experience of life that it isn't worth doing. They'll do what they enjoy instead -- and if that means they have a shorter lifespan, at least the years they have will be pleasurable for them. It's not an unreasonable choice, especially for a person who hates jogging (and loves donuts) a lot more than I do. We all have to draw the line somewhere, and each of us will likely draw it in a different place. So far, I'm quite willing to do the maintenance, but I'm also quite willing to grant to anyone else the right decide how much maintenance they are willing to do. 

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