Tuesday, November 30, 2010

Well, today's glucose tests are a little more in line with my expectations than yesterday's were. Now that things are more on track, I need to focus on keeping them on track.

If I said that people don't take comedy seriously enough, would you misunderstand me? (You'll have to be patient with me tonight -- it will take a while before it becomes clear where I'm going with this.)

Actors always lament that they never win awards, or gain much respect, for playing comic roles -- even though comic acting is more challenging. As the saying goes (attributed to various great actors on their deathbeds), "Dying is easy, comedy is hard". Comedy may not get much respect in general, but the greatest artists (in the fields of literature and drama, at least) have always been comic artists. When "serious" works are misunderstood, they are mainly misunderstood because the author's humor is misunderstood.

Shakespeare wrote both comedies and tragedies, but he always put a lot of humor in both. In his day, the main difference between a comedy and a tragedy was how many characters were still alive at the final curtain -- neither type of play was supposed to be humorless. Even Shakespeare's grimmest tragedies are full of jokes. Jokes which might go over our heads today (innuendo tends to become opaque after a generation or two), but jokes nevertheless. And the works of art which come closest in stature to Shakespeare's plays -- the operas which Mozart wrote to texts by Lorenzo DaPonte -- were all sex-comedies.

The great novelists were also humorists, though we tend to overlook that today. Dickens, even in his most sentimental tales of endangered children, seldom can resist an opportunity for comedy. Melville's Moby Dick includes all sorts of outrageous wisecracks, even if you'd never understand them without help from the footnotes. For example: "In this world, head winds are far more prevalent than winds from astern (that is, if you never violate the Pythagorean maxim)." It turns out that the Pythagorean maxim was "never eat beans", and I hope I don't need to explain this one any further.

Jane Austen, often seen as a romance novelist, was actually a specialist in the genre known as "comedy of manners". In an early chapter of Pride and Prejudice, her heroine, Elizabeth Bennet, is at a dance, and has the bad luck to overhear a man pronouncing judgment on her looks:

"'She is tolerable, but not handsome enough to tempt me.' Mr. Darcy walked off; and Elizabeth remained with no very cordial feelings toward him. She told the story, however, with great spirit among her friends; for she had a lively, playful disposition, which delighted in anything ridiculous."  

Here Jane Austen overturns our expectations about how her romantic heroine might react to being slighted. This is not a wilting flower, who runs away in tears when her feelings are hurt. This is someone smarter, funnier, and generally more interesting than we were expecting. Jane Austen is trying to explain to us how grown-ups ought to behave, by drawing a contrast between those who do a worse job of it than we thought they would, and those who do a better job of it than we thought they would.

I guess that's the most difficult thing to get people to understand about comedy: it's there to teach us something. Something important, as a matter of fact. If grownups did know how to behave, comedy would never have been invented in the first place. Comedy exists (and needs to exist) because a lot of people don't recognize that their behavior and their feelings are irrational and absurd. Comedy warns us against making fools of ourselves, by making us laugh at other people making fools of themselves. Comedy demonstrates to us how undignified our more childish or unreasonable feelings are, by showing us how goofy those feelings look when someone else is having them.

I thought of this recently when someone on the dLife forum, who thought he'd been leading a healthy life and was stunned by his diabetes diagnosis, asked when he could expect his anger to go away (as it was causing him trouble in his personal life). I told him that his anger would go away when he became capable of seeing his anger as absurd (after all, no one gave him diabetes, and he has no one to be angry at -- so what does it even mean to say that he's angry?). I suggested that he take a step back from his own life, and view himself as a character in a movie comedy, preferably played by Joe Pesci, who is constantly angry even though he has no one in particular to be angry at, and I predicted that his anger will go away when he can start laughing at this character instead of sympathizing with him.

I don't know whether he believed me or not, but I meant what I said. This "anger" which so many people with diabetes say they are experiencing seems to me a symptom of a serious lack of comic perspective. They need to get over it. It is a very dangerous thing to let yourself be ridiculous without letting yourself know that you are being ridiculous.

Yes, we're all ridiculously irrational and childish in our initial reactions to things. Bang your knee on the leg of a table, and you get angry. How dare that table leg hide itself there, waiting for you to bang your knee on it! But, of course, the table leg wasn't actually scheming against you, and once you've recovered from the shock of banging your knee, you will probably come to realize that there is no point in nursing a long-term grudge against a piece of wood. So it is with a diabetes diagnosis: we weren't expecting it, and we don't want it, and our shock-reaction might very well consist of getting "angry" (even though we have no one to be angry at). But, if we have learned the lessons that comedy has been trying to teach us all our lives, we soon realize that being "angry" at diabetes is just as absurd as being "angry" at a table-leg.

If, up to this point, you haven't been paying attention to all the valuable lessons that comic artists from Shakespeare to Austen to Abott and Costello have been working so hard to teach you, start now. A deficiency of wit is a very serious handicap in life, and it's hard to have that handicap and diabetes at the same time. Choose one or the other, folks!

Monday, November 29, 2010

Okay, how can I make sense of today's glucose test results?

They're not typos; my test result after lunch really was 80, and my fasting test really was 97. But both results surprised me. I would have found them less strange if they had been swapped. I expected to get a result below 90 in the morning, and I expected to get one above 90 after lunch -- not the other way around.

Why was my fasting test higher than expected? I didn't think there was any lingering effect from Thanksgiving overindulgence, and I'd been a good boy on Sunday (with a longish trail-run and, I had thought, commendable restraint at the dinner table afterward). What pushed me higher than I expected to go? Conceivably a virus. The cold I'd been coping with on Saturday seemed to be gone on Sunday, but it's possible that, even though I felt better, there was still a virus in me and it was having an impact. But it's also possible for there to be that much random variation in a glucose meter measurement, so maybe my meter just happened to overstate the value a bit today.

The low result after lunch is not completely implausible -- it was a pretty low-carb lunch, and I ate it immediately after a difficult, hilly run. But I still wouldn't expect it to be much lower than 100. I do know of a possible source of measurement error, though: I had put my glucose meter down next to my laptop PC at the office, and the exhaust from the PC's cooling fan was blowing on it, warming it up. It wasn't that hot, but it was warmer than usual, and maybe it was warm enough for the measurement accuracy to be affected.

So, my suspicion is that my meter was giving me an artificially high reading this morning, and an artificially low one after lunch. But it's all guesswork.

I suppose the significant thing is that both results were within the normal range (although not by much, in the case of the fasting test), and I should try to have a little faith that my results will be more in line with my expectations tomorrow.

My trail-run on Sunday was a treat, partly because I felt a lot better than I had on Saturday, and partly because the rain stopped and the skies cleared and the world was beautiful.

Also, I chose a really nice route to run, with a lot of variety. I was able to experience the spooky dark woods...

...and then brilliant sunlit clearings...

...and also, in between, soft-focus landscapes by THOMAS KINKADE, Painter of Light:

Metabolic Syndrome Not Directly Tied to Decreased Quality of Life, says the Reuters Health headline. They are quoting from a report in the International Journal of Obesity.

"Contrary to other findings, metabolic syndrome, per se, doesn't seem to impair health-related quality of life (HRQoL), researchers report in a November 2nd online paper in the International Journal of Obesity. Nevertheless, Dr. Marion L. Vetter told Reuters Health by email, "Although metabolic syndrome itself was not associated with worse quality of life, depression, obesity, and other comorbidities that are prevalent in this population were associated with impaired quality of life."

"Comparison of those with and without metabolic syndrome showed that the condition had no effect on HRQoL. Increasing obesity and diabetes status didn't modify this relationship..."

"The findings need to be confirmed in larger studies, but Dr. Vetter concluded, 'Healthcare providers should address these conditions that commonly cluster with metabolic syndrome'."

Okay, I get it. Metabolic syndrome itself doesn't affect your life in a negative way, but the conditions that you also have if you have metabolic syndrome do affect your life in a negative way. So doctors should concentrate on addressing those other conditions.

This raises a question: why do those other conditions "commonly cluster with metabolic syndrome"? Suppose that metabolic syndrome does not invariably cause those conditions, but it increases the risk of them. In that case, we can expect to see more of those problems in people with metabolic syndrome -- and that is exactly what we do see. That doesn't prove that metabolic syndrome tends to cause those problems -- maybe those problems tend to cause metabolic syndrome. But it seems to me that the connection between them is unlikely to be a meaningless coincidence.

We can't take it for granted that correlation of one thing with another tells us what the cause/effect relationship is between them. On the other hand, we can't take it for granted that an imperfect correlation between them means there is no cause/effect relationship between them.

It's a mighty messy business, this science thing!

Saturday, November 27, 2010

I'm back in town, recovering from the holiday feast, and also recovering from the renewal of my cough. (Half the members of my extended family had some version of it, and although they claim to have caught it from me in the first place, I seem to have caught it back from them during the holiday -- which I don't think would be possible unless they had altered the virus a little bit while they had custody of the thing.)

I got back in town yesterday just in time to go for a 5-mile run before I ran out of daylight. At first I was doubting that I was well enough to do it, and then (as always) I started feeling better once I started running. Funny how that happens.

But then I woke up feeling bad today, and spent most of the day resting indoors where it was warm. (Outside it was cold and rainy.) Eventually I went to the gym for a workout, around 5 PM. Then I felt better!

The weather is supposed to improve tomorrow, and my plan is to go for a trail-run in the morning if I have any strength at all.

I don't blog on the weekends anymore, but because holiday activities have kept me away from my computer since Tuesday, I thought I would check in to confirm that I made it through the holiday, and didn't die of a pumpkin-pie overdose or anything like that. However, I don't think I'll do a serious post until Monday.

This is a weekend over which most diabetes patients should draw a veil anyway. What happens in Vegas or Thanksgiving, stays in Vegas or Thanksgiving!

Tuesday, November 23, 2010

You want to know why my blood pressure is down tonight? It's because I'm taking tomorrow off work to get ready for Thanksgiving, and to hell with everything else! (Except, of course, for sharing with you my nearly-coherent thoughts on diabetes management.)

The rain stopped this morning, and we went for a run at lunchtime -- but it was a bit chilly for the clothes we had on.

I'm talking California-cold, of course, not rest-of-the-world-cold. But we were dressed for California-warm rather than California-cold, not having received the memo about the descent to the forties which the meteorologists had scheduled for us today. There was a brisk breeze from the north, too. We never really warmed up. I'm glad we chose our shortest route.

A few years ago I was in Idaho at this time of year, and I found out what it was like to go for a run in the kind of weather that the rest of the world calls chilly. It was an eye-opener, all right (I won't discuss the things it closed). But I wore a lot more layers when I was running there than I did today. Tomorrow I'm wearing a heavier running outfit, definitely.

The interesting thing about optical illusions, at least to me, is how powerfully they continue to fool your eye even after you understand the nature of the illusion. That is, even after you know that the "curved" lines are really straight, they still look curvy to you, and you can't fight the illusion.

In this picture, for example, the beans (they look like almonds to me, but they've been called beans by people who should know) are not moving. This is not an animated graphic. If you pick one bean (or almond), and stare at it hard enough, and make an effort to keep your eyes from moving, the motion stops. But the instant you relax that effort, they start moving again! 

And in the picture below, the horizontal lines don't look level -- except for the one at the bottom, they all seem to be leaning down the the left or to the right. They aren't, though.

If you move the reference line up, you find that all of the horizontals really are horizontal. But you can't make them look horizontal to your eye, which insists on seeing them leaning one way or the other!

Okay, Tom -- quick! Think of a reason why optical illustions are relevant to diabetes!

Well, I guess what optical illusions illustrate is that, when your brain arrives at a conclusion about whatever data you're taking in, it converts that conclusion into a perception. Even if that conclusion is based on a faulty interpretation of some stray bit of incomplete data, the conclusion turns into a belief about the world around us, and then all our sensory experience is filtered through that belief.

Once your brain has decided the line can't be straight, your eye can't see that it's straight. Once your brain has decided that a field of stationary objects is floating around, your eye can't see that they're standing still.

We like to say that seeing is believing, but very often it's the other way around: believing is seeing! Or, at the very least, what you believe places a limit on what you can see.

It often seems to me, when I read the questions people post on diabetes forums, that these are people grappling with a terrible and confusing disconnection between what they believe or expect, on the one hand, and what they observe, on the other. When that happens, the questions they pose often boil down to: how can this possibly be true? This is crazy! It doesn't make any sense!

It's crazy because they expected something else to happen. It doesn't make any sense because it contradicts their assumptions.

There is a danger inherent in using "not what I expected" as the definition of "crazy": it makes it hard for us to take in new information and figure out what it means. Newly-diagnosed diabetes patients, who are trying to get a grip on this complicated subject of diabetes, and have been misled by the oversimplifiers, are especially vulnerable in this regard.

Recently a novice diabetes patient on the dLife forum reported getting an unexpectedly high glucose test result; feeling that the test must be in error, they repeated it twice, and were startled to find that three tests yielded three different answers! It was crazy! How could that be? What was wrong with their meter?

However, of the three reported results, the highest was only 6% above the middle one, and the lowest was only 6% below the middle one. In other words, the meter was showing perfectly normal variability. To a more experienced person there would be nothing odd about this; to a novice who assumes that "168" always means exactly "168", never "167" or "169", normal variation looks very abnormal indeed. From there, it can be very easy to jump to the conclusion that unwelcome data is crazy and meaningless and we can ignore it.

So, my main piece of advice to novice diabetes patients is not to allow your assumptions or expectations to overrule your observations. If there is a mismatch between what you expect and what you see, don't allow your brain to substitute what you expect for what you see. Don't let yourself see the lines as curvy if you know they're straight.

My second piece of advice to novice diabetes patients, at least if they participate in online forums, is illustrated by this protest sign:

Here are some fun facts about prescription drugs, from the Helpful Figures website:

Monday, November 22, 2010

If you're trying to motivate people to achieve something out of the ordinary, you have to confront what I call the Outlier Dilemma. (In statistics, an outlier is something that lies extremely far from the average.)

To state the dilemma as simply as I can: if you report someone's remarkable accomplishment, are you "inspiring" people, or are you reminding them that they aren't remarkable themselves? If the accomplishment of the hero in your story is actually amazing enough to make people sit up and take notice, it's also amazing enough to make people doubt that they could accomplish something similar. I discussed this problem last month, in my profile of Abe Ramos, who lost 100 pounds after his diabetes diagnosis and was able to get off the meds in the process. My own transformation after diagnosis was less dramatic than his, but still unusual enough to qualify me as an outlier in my own way.

The best example of an outlier that I know of is the marathon runner Fauja Singh. If you are not familiar with his story, you might misidentify him in a group photo, such as the one below. Just pick the one who appears least likely to be physically capable of finishing a 26.2-mile run. That would be him.

A guy in his 90s who runs marathons to raise money for charity is seemingly just the sort of person who should be held up to us as a model of determination, healthy living, and any other virtue we might want to cultivate. But how can we aim to be like him? He's such an extreme case! He isn't just doing what we assume few people in their 90s can do -- he's doing what we assume no people in their 90s can do.

He's the very definition of an outlier -- off by himself at the narrowest tail of the bell curve. We assume that, if we don't see a bunch of other nonagenarian marathon runners out there with him, there must be a reason.

Yes -- but what is that reason? How we feel about Fauja Singh's story depends a lot on how we explain why his story is so different from what we would expect.

Normally, people who live to see their 90s at all (and the average person doesn't) have, by that point, developed either enough bone-and-joint problems, or enough heart-and-lung problems, or simply enough old-and-tired problems to make participation in endurance sports impossible. No matter how well you look after yourself, the machine is bound to be too worn out for marathon-running by the time you enter your tenth decade of life.

But if that's what happens to old people, why didn't it happen in his case? And what lesson do we draw from that?

We could simply assume that he is the beneficiary of some kind of freakish, one-in-a-million combination of lucky breaks. If that is the case, then there is nothing at all to learn from his story (except that, once in a great while, everything works out perfectly for somebody's health).

Swinging to the opposite extreme, we could seize on something or other about his life that we find distinctive, and attribute his success entirely to that.

Two factors often mentioned are Singh's religious devotion and his vegetarianism. Singh on his first marathon: "I didn't feel tired at all and could go on running with everyone else. I found it peaceful as I could talk to God while running." Singh on his diet: ""I start my day with a cup of tea and a few pinni [tiny cakes]. For lunch, I like to have one chapatti [flatbread] with daal [stewed lentils] and vegetables. But I always have ginger curry for dinner, which is the secret of my strength." There you go: ginger curry. The secret!

I'm not sure that having ginger curry for dinner every night really is the secret, or that religious meditation is, either, but both may point to something significant -- a disciplined mind. Here is someone who is able to stick to his plan, and focus on what he's doing, without being bothered that it's repetitious. Maybe that kind of stability and discipline make for long-term health.

Another possible factor to think about is Singh's slender frame. He's nearly six feet tall, but reportedly weighs less than 120 pounds. His running trainer is impressed not so much by what Singh eats, but how little of it he eats, even during marathon training. Slender people have always dominated the ranks of distance runners -- and the ranks of long-lived people, too. If you're going to do distance running in your 90s, being thin is bound to help.

Singh, a runner in his youth, made an unexpected return to running late in life, and he did it as the solution to a personal problem. When he was 81, his wife died, and one of his sons died around the same time. He left his native India to live with another son in England, and found himself with nothing to do all day but think about his grief. Unable to speak English, he felt isolated. He looked around him, and decided that old people in England were ailing and unhappy because they ate a rich diet and were physically inactive. He took up running again, found it therapeutic, and gradually began doing more and more of it.

Eventually, he ran his first marathon (London in 2000) at the age of 89. By the age of 94 he had run six more marathons, four of them in London, one in Toronto, and one in New York (which was apparently not a good idea, as his Sikh turban was misinterpreted there and some of the spectators heckled him). Elsewhere, he was a crowd favorite, and in 2004 he even gained a corporate sponsor, when Adidas featured him in its "Impossible Is Nothing" ad campaign. (However, he reportedly turns over most of these earnings to charity: "What will I do with the money? To be able to run at this age is a reward in itself. God is watching me, please give this money to those who need it.")

At 99, Singh appears to have given up the full-marathon distance; his most recent reported race was a half-marathon (a mere 13 miles!). Well, let's cut him some slack: most people start slowing down a bit as their 90s draw to a close, and he's as human as the next guy. It would be hard to see that number 100 rushing at you without thinking that maybe it was time to take it easy for a while. (Of course, if running half-marathons is your idea of taking it easy, you're still something of an outlier.)

But what is the lesson we should draw from his example? I don't think it's as simple as "some people just get lucky" (although luck surely had to play some role in his avoidance of debilitating illnesses or injuries during his long life). I don't think it's as simple as ginger curry, either.

But I do think it's significant that he figured out what worked for him, and kept doing it. He may have been in a fortunate situation (no cancer, no osteoporosis, no cardiac arrhythmia, no arthritis), but his steady habits, and his focused pusuit of what would make him feel better and stronger, certainly enabled him to make the most of his good fortune. Some people could ruin even the most favorable health situation, without half trying; he kept it going instead.

So, yes: he had good luck on his side, and not everyone has that. But he also made the most of the luck that came his way, and not everyone does that.

I couldn't run at lunchtime today, because of a meeting at work that was awkwardly timed. I ended up doing my run on a treadmill at the gym. It a new treadmill, and I was so focused on getting its basic controls working the way I wanted that I didn't even pay any attention to the fact that it had a high-resolution TV screen in front of me, and I didn't know how to control what it was showing. I was planning to ignore it anyway, and I didn't want to stop the treadmill to fuss with the TV controls, so I just let it play.

It turned out to be set up to show me the Food Network, or Food Channel, or Sugar/Fat Media Alliance, or whatever it is they call it. During the first part of my run they were showing me vivid images of how candy and ice cream are made. Then there was a segment in which celebrity chefs were asked to talk about the best desserts they'd ever tasted, with lingering food-porn closeups of oozing masterpieces in which alternating layers of chocolate and butter melted slowly into a unity.

Thanksgiving is still three days away, but the Temptation Gauntlet has already started!

It rained all day Saturday -- which was fine, because (1) it was my weekly rest day from exercise, and (2) I was recovering from my on-again, off-again, cough-again virus, and didn't feel like going outside anyway. But when the rain stopped on Sunday, I was feeling stronger, so I decided I was ready to go trail-running. I'm glad I didn't let the opportunity slip, because the landscape always seems beautiful to me after a storm passes through.

The air feels so clean after a storm that I feel as if I'm getting more oxygen from it, therefore running is easier.

There was a lot of standing water on the trails. Well, I'm willing to jump over puddles, or step through them if I have to.

I was surprised to notice that Mount St. Helena, in the distance, had received a dusting of snow on Saturday night. But that made sense of the startling chilly breeze that was blowing.

I think the drop in temperature is part of the reason I've gained a few pounds. For a while there, I was sweating enough when I ran to be losing a lot of water weight each day. No more! I'm hydrated now, all right. If I want to get my measured weight down, I'll have to lose fat pounds, not fake pounds.

Friday, November 19, 2010

Late last night, the cough that I thought I had recovered from came roaring back; I woke up feeling congested and vaguely ill. Obviously I had some kind of virus still in me. On the other hand, I figured that if I had a serious viral infection, my fasting test would have been a lot higher than 74. 

So, I went to work, and went for my usual run at lunchtime despite the threat of rain. As so often happens in this situation, I worried that I was making a mistake to go running when I wasn't feeling very well, and might end up making myself sicker -- but once I started running, I found that the exercise was making me feel better and stronger. I was still pretty slow, but at least I felt better. And the rain held off, for the most part, until we were finished. It drizzled on us a bit, but nothing serious. (Then, once we were safely inside, it started pouring, a coincidence which I always find very satisfying when it happens.)

The 1-hour post-prandial result of 131 after lunch was within the bounds my doctor had set for me, but higher than the <120 target which I aim for and often hit. Maybe the virus contributed to that, I don't know.

Yesterday, when I was reviewing search strings that related to the hemoglobin A1c test, I finished with this one, which I didn't have time to address yesterday:

Unfortunately I don't think I have time to deal with it today, either. I'm going to have to do some research homework on this issue. It's a complicated one.

Although the A1c test result is supposed to have a predictable linear relationship with average blood sugar, so that you can relate one to the other using a simple formula, there is growing evidence that the formula doesn't apply to everyone. Some people are "high glycators" -- that is, they get a higher A1c result than would be expected from their blood sugar results. A reader pointed out to me that I may be an example of this phenomenon, as my most recent A1c result does not seem to square with my glucose tests around that time. Whether or not the high-glycator phenomenon is happening to me, the question is well worth asking: why does it happen to anyone? What causes this? And what does it mean for those affected by it? The research reports I've seen so far don't paint a very clear picture of what's going on. I think I'm going to have to work on finding out more about the issue, and revisit the subject later.

Last night I visited the One Hundred Pushups website, which encourages people to get strong by gradually building up the number of pushups they can do, with an ultimate goal of doing 100. (Doing 100 at once, I mean -- not as a lifetime total.)

Anyway, I decided to take their initial test to see where I stood. The test is simply to do as many "good-form" pushups as you can, so that you can figure out what category you belong in for the purposes of their training program.

I did 25. Or so I thought. Let's just say that I did 25 of what I imagined to be "good-form" pushups. Unfotunately, it seems that I was mistaken. Upon closer examination, their description and video illustration of a proper pushup is considerably harder than what I was doing, since your body is apparently supposed to come all the way down to contact the floor before you can start raising yourself back up. Last night I found that I couldn't do that kind of pushup at all, but that was right after I did 25 of my kind of pushups, and my arms were tired. So tonight I gave it another shot. I found that I could do 13 of them before I flamed out.

Well, 13 is a long way from 100, but we all have to start somewhere, don't we?

Of course, one thing which might make me better at doing pushups is to develop better breathing tecnhiques. The guys at Found Footage Festival are currently featuring highlights from a  remarkable fitness video which you should check out. I hope you find this as inspiring as I did. After seeing it, you may not think of respiration in quite the same way next time you work out.

Thursday, November 18, 2010

I looked a bit deeper into the history of search phrases which have brought people to this site. At least, I went back farther in time, and collected more search strings. I thought that doing this might give me a better idea of what questions people are trying to get answered.

I found that a surprisingly large number of these questions revolve around the Hemoglobin A1c test. People are mighty confused about several issues related to this subject. Ironically, the test which is arguably the most important thing for a diabetes patient to understand may also be the thing which diabetes patients understand least.

I thought I would group together some of these search strings, and see what I can do to answer their literal or implied questions.

To begin with, a lot of people simply want guidance on what sort of reaction they ought to have to the test's numerical result:

A hemoglobin A1c result of, say, 7 means that 7% of the hemoglobin in your red blood cells is glycated (that is, sugar-encrusted). In a normal, non-diabetic person, the result is not too far from 5%. Exactly where you want to draw the line between normal and abnormal is, to some extent, a matter of opinion. The lab I go to defines the numerical ranges as follows:

4.8 - 5.6% Normal
5.7 - 6.4% Increased risk of diabetes
>6.4% Diabetes
>6.9% Poorly-controlled diabetes
>10% OMG!

All right, I made up the last one; the others are legit. Regarding that 5.7 to 6.4 range, some would call that "prediabetes" instead of "increased risk of diabetes"; others would call it "stop kidding yourself, you're diabetic and you'd better do something about it while you still can". Most patients, however, call it "nothing to worry about, because the doctor didn't come right out and call it diabetes".

It does unless the lab made a mistake -- a thing which does occur now and then. Patients assume it is always a mistake when the result is high; this is a comforting thought, but it's statistically unlikely.

If you say so. Why should data have any meaning that you'd rather not hear? 

It places a limit on how long you can avoid disability and death. Apart from that, it's no big deal.

Red blood cells have a limited lifespan before they are recycled (and, of course, once they are recycled they no longer are around to have an impact on the test result). Because the red blood cells are not all recycled at the same time, working out what time period the test covers is a complicated mathematical problem. The short answer is that the test reflects conditions in your blood over the last three months or so. However, the most recent month has a bigger influence than the months before it, because some of the blood cells that were in your blood two or three months ago have already been recycled, and they no longer "count".

The same way getting older influences the aging process. The binding of sugar to proteins is the definition of glycation. If there were no sugar in you, the glycation rate would be zero, because no sugar would be binding to proteins. The more sugar you have in your blood, the higher the glycation rate is.

This was apparently reported to me in truncated form. If the original question was "how long after bg spikes does it take for a red blood cell to become glycated?", I don't know the answer. If the question is "how long after bg spikes does it take for a red blood cell to recover from being glycated?", the answer appears to be "never". Once a protein is glycated, it stays glycated until the body recycles it, and replaces it with a sugar-free version.

Ah, a history question! A1c testing doesn't go back as far one might expect. In 1958, Huisman and Meyering used chromatography (a method of separating the components of a chemical mixture into a kind of spectrum) to identify various subtypes of hemoglobin. I don't know what arbitrary identifiers were used for the other subtypes, but the subtype that happened to be designated A1c turned out to have sugar bonded to it. (For all that the name mattered, they might as well have called it Betty.) In 1969, Samuel Rahbar found that this particular subtype of hemoglobin was more abundant in diabetes patients. The idea of using a test of Hemoglobin A1c abundance as a measure of glycemic control in diabetes patients only dates back to the work of Anthony Cerami and Ronald Koenig in the late 1970s. The idea of using the test to diagnose diabetes is very recent indeed, and in fact some still resist the idea on the grounds that there isn't enough consistency in the way different labs do the A1c test.

Every day has some effect on total glycated hemoglobin -- usually an effect so small that it won't be enough to change the number that is reported to you by the lab. Maybe a really bad day could do it. A bad week could certainly do it.

There were quite a number of search strings indicating that people are wondering if something other than average blood sugar might be causing them to have a high A1c result.

That last one is clearly a case of wishful thinking carried to preposterous extremes. The others have some degree of legitimacy, but perhaps not in the way that the people posing the question were thinking. Inflammation and hormonal changes can affect the A1c result, but not in a misleading way -- they affect your A1c result simply by raising your blood sugar. To the extent that "the amount of insulin" means that you're not producing enough of it, or not taking enough of it, then the amount of insulin would make our A1c result go up by making your blood sugar go up. It wouldn't give you a false high result.

However, the question of whether "any other factor" can change the A1c result appears to be a legitimate one. Some people get a higher A1c result than others without having a higher average blood sugar level than others. (In general, African-Americans tend to get higher A1c results than European-Americans with similar glucose test results.) No one knows why. The leading theories are:

  1. A subtype of hemoglobin which doesn't relate to glycation is similar enough to hemoglobin A1c that testing can't distinguish between the two -- and some people have more of that mysterious subtype than others do.
  2. Some people get misleadingly higher A1c test results than others do, because their red blood cells live longer than other people's red blood cells do, and this skews the results.
  3. Some people have a higher glycation rate than other people with same average blood sugar -- for reasons unknown.

If either of the first two explanations is the correct one, then at least some people are getting A1c results which overstate the danger they are in. If the third explanation is correct, then a high A1c result is equally dangerous regardless of whether or not your glucose test results seem to match it. 

Well, this is the Big Question, isn't it? But I'll have to discuss it later -- probably tomorrow. It's getting late.

Wednesday, November 17, 2010

I'm not sure why my fasting test was so low this morning, but I'll take it. Sometimes I think my endocrine system just gets into the mood to be low (or high) for a while. Last week, when I was dealing with a cold, some of my numbers were higher than usual. Now that I'm over it, my numbers are lower.

It was another day of perfect running weather: sunny, beautiful, comfortably cool. I kept up with my running buddies a little better than I usually manage to do.

If you've ever wondered what writing a daily blog is like, it's kind of like this:

I have a job, so that occupies my day, and after work I often want to go do something other than sit at my computer writing (about a goddam disease, of all things!) -- so that occupies my evening, as well. This makes me one of the few diabetes patients who, instead of whining about how hard it is to fit exercise into his daily schedule, whines about how hard it is to fit writing into his daily schedule.

Tonight, for example, someone who lives near me was hosting an Irish/Scottish music session, so I went over to her house and contributed my fiddle to the ensemble. (We also had a flute, accordion, dulcimer, cello, bass guitar, and additional fiddles.) It was a nice session, more relaxed than such things usually are. Instead of fast-and-furious reels, we did a lot of the slower and more lyrical tunes. Good for the blood pressure.

So now I'm home, and it's late, and I'm sleepy, and I'm not coming up with much to say about diabetes. Sorry, I'll try to do better tomorrow!

Tuesday, November 16, 2010

Would you buy this?

On November 10, a message suggesting that diabetes patients check out this product was posted on dLife.com. On November 11, the same message, repeated word for word, was posted on diabetesforums.com. Although that kind of repeated messaging understandably raises suspicion that an organized sales campaign is taking place in disguised form, the person who posted these messages doesn't seem to have an axe to grind, or any history of pushing products on diabetes forums. The suggestion was apparently offered quite innocently. Or perhaps "naively" is the word I'm looking for here.

The product in question contains many different ingredients, but two of those ingredients (frankincense and myrrh) are featured so prominently on the label that it's hard to miss the implication that those are the ingredients that matter. Frankincense and myrrh are mentioned in the bible, after all, and that alone is enough to prove that they have magical properties, is it not? To be sure, water is mentioned in the bible, too -- which may be more to the point, as this is a homeopathic remedy, and in a homeopathic remedy the active ingredients are diluted so heavily in water that they may be virtually absent from the final product.

For the record, fankincense and myrrh are both aromatic resins; they have long been used to make incense and perfumes, and have also been used in folk medicine to treat various conditions (though apparently not neuropathy).

However, if there is any reason to believe that rubbing aromatic resins on your hands and feet will do anything useful about the nerve damage which causes the symptoms of diabetic peripheral neuropathy, I haven't heard it, and I don't expect that I ever will hear it. This is the sort of thing that you take on faith or not at all. Alas, taking implausible things on faith is not one of my strong suits.

I haven't experienced neuropathy myself, and based on what I've heard about it I am hoping not to. By all accounts it is a really bad deal: constant pain in response to no actual stimulus, combined with numbness to genuine trauma (resulting in unperceived and therefore untreated tissue injuries). And the available treatments for it are of limited effectiveness. It sounds pretty awful, all right. In fact, it sounds like the sort of thing that might make a person absolutely frantic for relief of any kind, including the placebo-effect relief which one might obtain, for a while, by spending $29.95 on a two-ounce bottle of sunflower oil infused with a heavily-diluted mixture of aromatic resins.

The person who suggested this product on diabetes forums may have been innocent, but I have to wonder how innocent the people were who came up with the idea of making it and selling it to desperate people for $15 an ounce.

Some years ago, an elderly Chinese man I knew told me about someone in Hong Kong who was a great healer, and had cured an ill friend of his in San Francisco over the phone, simply by transmitting his healing force "through the wires". Without even stopping to think about what I was saying, I remarked that a phone call from Hong Kong to San Francisco wouldn't go through wires -- the sound of the man's voice would be encoded digitally onto a microwave signal transmitted to a communications satellite, and... at which point the fellow became angry and exclaimed "There are many things that are not known, but that does not mean they are not true!". No, it doesn't mean that they are not true. It doesn't mean that they are true, either. Maybe it's true, and maybe it's not. So, you have to ask what the odds are.

Of the two possibilities here (either somebody has found an effective way to treat neuropathy through topical application of sunflower oil infused with a diluted mixture of aromatic resins, or somebody has found a way to cheat suffering people out of $29.95), which do you think is more probable? I'm guessing it's the latter. I can't prove I'm right, but I'm not going to lose a whole lot of sleep over the possibility that I'm wrong.

And if I develop neuropathy some day, and become so frantic for relief that I spend good money on a fake cure, it won't prove that I'm wrong in what I'm saying today. If anything, it will confirm what I'm saying today: that painful medical problems can make people desperate -- and that some people see the desperation of others mainly as a financial opportunity.

Monday, November 15, 2010

Yikes! A typographical error made it appear that my fasting result on Friday was 788. Actually it was 88. I hope nobody took that number literally, and concluded that my approach to diabetes management isn't practical because the results are too inconsistent.

There's nothing wrong with this blog that couldn't be solved by having someone else write it.

The weather's still sunny -- and surprisingly warm for the week before Thanksgiving (it got up to 83 degrees this afternoon).

On the weekend I went trail-running in the state park, and was pleased to see that things are starting to get slightly green in there.

I know that's not what happens in the fall elsewhere, but it's what happens in northern California; the rain from last weekend was enough to get some grass sprouting on the hillsides.

We actually do get a little bit of fall color around here, but you have to look for it in the vineyards rather than the woods.

I'm glad that the necessity of exercising regularly has given me the opportunity to be so much more a part of the natural world and the changing seasons than I used to be. I think it's therapeutic to be outdoors a lot. I don't know why it is, but it is.

My internet service provider makes available to me various statistics about usage of this site. Some of these statistics are easy to misinterpret. "Hits", for example, is a very misleading indicator, because a single person visiting your site just once can increase the hit-count by dozens. (For example, if there are a lot of pictures displayed on the page, each graphic file is counted as a separate "hit" when it loads).

A  more meaningful statistic is "visits"; that number doesn't get inflated by the presence of graphics or hyperlinks on a page. One visitor opening your page once counts as just one visitor. By that more conservative measure, I conclude that this site's readership (however devoted) is small. Laughably small, by the standards of commercial sites.

However, it's not quite so small as it used to be. For a long time I received about 50 visits a day. Over the last three months it has gradually increased to about 150. By the standards of successful web sites, 150 visitors a day is virtually zero. (Perhaps that is why nobody is asking me to put their advertisements on the site.) But, as I have said in other contexts, it doesn't matter how slow a start you make, so long as you keep on making small improvements.

Perhaps the most puzzling kind of information my ISP shares with me is a listing of the search terms which have caused a search engine to direct people to my site. Some of these search terms are exactly the sort of thing you would expect ("non medicated diabetic", for example). Others, however, caught me very much by surprise.

I thought it might be interesting to list some of the search terms that have brought people to this site, and comment on them just in case the people who found me that way come back, and are still waiting for an answer.

Search Term

My Comments

do it yourself electronic devices

I don't remember commenting on this subject. I have said that diabetes management is the ultimate in do-it-yourself projects, and I'm sure I have mentioned electronic devices, but that's it. Look elsewhere!

7.0 a1c result bad

That's how Frankenstein's monster would put it, but some see it as a matter of opinion. The general advice given to diabetes patients is to keep the A1c result under seven -- and as far below seven as you can safely do it -- because when hemoglobin glycation reaches 7%, that's when the risk of diabetes complications starts climbing more steeply. But if your current result is 9, it would be a lot better to be at 7. Still, once you get to 7, see what you can do to bring it down further.

breakfast lunch glu-

Yes, both breakfast and lunch can raise your blood glucose level. Dinner can have this effect as well. Even snacks can be enough!

if hemoglobin a1c is 7.3% person have diabetes or not

If your hemoglobin A1c result is 7.3%, then yes, you have diabetes (and not terribly well-controlled diabetes, either -- see what you can do to get it below 7). An A1c result of 6.5% is generally regarded as high enough to justify a diagnosis of diabetes.

blood pressure 121 over 81 pulse 58

Not bad. The standard we're supposed to be aiming for these days is <120/80, but 121/81 is so close to the target that it would be churlish to carp at it. I did better than that myself tonight, but sometimes I do worse. So many things affect blood pressure that it's hard for me to believe that anyone gets it right every time.


"Cho" is a pretty vague abbreviation, I'd say. I'm sure I've mentioned cholesterol, and probably chocolate. But if this was from somebody who wants to sing in a chorus, I probably disappointed them.


Why anyone would do a Google search on a hyphen, I'm sure I don't know. But when someone does so, Google apparently sends them my way. I suppose that means I use more hyphens than other web authors do. But is that a problem, or just something that makes me special?

can an a1c test be results be a mistake

Yes. However, the impulse to assume that an A1c result is a mistake is a bigger mistake. The lab can be wrong, but it usually isn't. The funny thing about our instinctive reaction to a disappointing test result ("maybe the result is wrong!") is that we don't have that reaction when the test result isn't disappointing. When the glucose meter tells us what we want to hear, we have total faith in its reliability. The question of reliability only arises when we don't like the result. This is the same problem which causes so much trouble in scientific research: when you don't like the result, you search for potential sources of error, but when you like the result you just accept it as true.

how hard is to be a runner with type 2 diabetes

I don't think it's any harder than to be a runner without type 2 diabetes. However, I'm not medicated for the condition, and I'm not sure how much difference the meds would make. Some people taking diabetes medications seemingly need to make various adjustments and precautions in order to participate in endurance sports, such as long-distance running or cycling. I know that some diabetes medications give you diarrhea, and I have a hard time imagining how you could successfully combine running with the runs, so to speak -- but I've been lucky enough not to have research that issue personally. Perhaps a better question to ask is "how hard is it to be a sedentary person with type 2 diabetes?", and the answer to that seems to be "about as hard as it gets".

how to lower a1c faster

The fastest way to reduce your A1c would be do identify all the things that tend to bring your A1c result down, and do all of them. The list would include weight loss, aerobic exercise, strength-building exercise, and carbohydrate reduction. It would also include insulin and various oral medications, but for various reasons I have preferred to avoid those -- if you want the fastest possible A1c reduction, though, you may need to get your pharmacist involved in the project.

can episodes of hypoglycemia mean that you're a pre diabetic

I don't know. My impression is that hypoglycemia can happen to anybody, and I don't understand why it would happen more often (rather than less often) to a prediabetic person. But this is a corner of endocinology which I have rather neglected, for the very selfish reason that I haven't had a lot of trouble with hypoglycemia myself. I guess you'd better ask someone more responsible!

if your a1c is equal to 7 what would it be the average on a dai

I suspect that you were thinking "what would be the average blood glucose level, in mg/dl, on a daily basis". If so, the formula is to multiply the A1c result by 28.7 and subtract 46.7 from the result. Therefore, an A1c result corresponds to an average blood glucose level of 154.2 mg/dl. However, it's worth pointing out that this formula applies to some people better than others. For reasons no one understands, the relationship of average glucose to A1c result differs significantly between one ethnic population and another. Anyway, what matters about the A1c result is not what average glucose level it corresponds to, but what degree of risk of diabetes complications it corresponds to. Bring it down!

I guess I'll revisit this subject in the future, and offer further comments on the search terms that seem to have brought people here.

Friday, November 12, 2010

Apparently this ridiculously beautiful weather is going to continue for a while...

Both of my usual running buddies at work were unavailable today, so I went running by myself. It was just as well, because I could set my own pace, and that helped me cope with a minor injury -- some kind of muscle strain in my right thigh which developed during Wednesday's run, and is still with me. It's odd -- I don't feel it at all for a long time, and then suddenly one or two strides hurt it. I suppose that means muscle spasms are happening at unpredictable intervals. Today I only felt it a couple of times, and only while running fast downhill, so I guess it's healing. Well, it can heal some more tomorrow, because I won't be running.

When your diabetes-management program depends heavily upon exercise, you have to devote a lot of attention to the issue of sport injuries -- preventing them if you can, and healing them if you must. So far, things have worked out pretty well for me in that regard, but it's the sort of thing you have to keep an eye on.

Little Evidence of a Long-Term Benefit of Exercise on Depression reads the headline; what lies behind it is an analysis of existing research on the subject by a Danish doctor, Jesper Krogh, who thinks too much has been made of the benefits of exercise with regard to depression: "From a clinician's perspective, it is important to emphasize that exercise cannot substitute antidepressants, and the scientific evidence of an antidepressant effect of exercise is small... Given the hype of exercise for depression, we expected to find many studies on this subject. Digging into the material, we only found 13 properly conducted trials, and still the majority of these would not be called high-quality trials," said Dr. Krogh.

To cut a long story short, Dr. Krogh finds (after discarding most studies as insufficiently rigorous) that patients suffering from depression experience only a modest improvement in their condition when they are put in exercise programs, and even that modest improvement diminishes over time.

Not that Dr. Krogh is anti-exercise: "On the other hand, it is important to emphasize that some patients might benefit from exercise as an 'escape' or as a coping mechanism. Secondly, we know that patients with depression have an increased risk of lifestyle-associated diseases (diabetes and cardiovascular disease), and they should at some point be encouraged to pursue exercise on that background... A lot of preclinical research indicates that exercise produces some of the same benefits as antidepressant medication, such as increased neurogenesis and higher levels of monoamines. Unfortunately, it has not been possible to replicate these findings in humans."

Still, Dr. Krogh's bottom line is that, if you think you can cure depression by taking the patient to the gym, you'd better think again.

I don't think he's necessarily wrong. However, I think we need to be clear about definitions here. Dr. Krogh is talking about depression as doctors think of it, not as you or I think of it. He's not talking about being in a sorrowful or pessimistic mood. He's talking about clinical depression, which is another kettle of fish.

Clinical depression is a long-term medical condition, not a reaction to the events of life. If you're grieving over the death of someone close to you, or feeling awful about being out of work, that's not considered clinical depression -- that's just a normal human response to a painful situation. Clinical depression isn't a response to anything in particular, and it isn't just sadness (even though persistent sadness is part of the picture).

Clinical depression involves an overall loss of vitality. Clinically depressed people are, above all, tired. Nothing energizes them. They are unable to experience pleasure ("anhedonia" is the psychiatric term). They are unable to take an interest in subjects and activities which once excited them. Nothing excites them now. They feel "empty". Nothing matters, nothing is important, and nothing is interesting. If they become suicidal, it's not so much because life seems unbearable to them, but rather because life seems pointless to them: if there's nothing rewarding or interesting about it, why should they bother with it? Why should this wearisome activity continue? What difference does it make whether they're here or not?

Clinical depression doesn't always lead people to jump off a bridge, but it does disrupt their lives, careers, and relationships. If you have clinical depression, everyone who knows you is likely to be aware that there is something seriously wrong. If you ever seek help for the problem, it will probably be because the people around you insisted on it.

This is not what most of us mean when we talk about being depressed. For most of us, depression means feeling sad -- and usually feeling sad about something. Depression is what we call it when regret about the past, disappointment in the present, or anxiety about the future has put us in a gloomy or self-pitying mood. Some of us slip into this mood more easily than others do, of course, and we might be said to have a "depressive" personality for that reason, but that's still not the same thing as clinical depression.

Unfortunately, the word "depression" covers both the vernacular meaning (feeling blue) and the medical meaning (not having enough energy to care whether you live or die). Therefore, when we talk about depression, we're not all talking about the same thing.

I find it plausible that someone with a problem as severe as clinical depression would not be able to get rid of it just by exercising. However, that doesn't mean exercise can't help us with depression in the ordinary sense. If you tend to get into a bad mood easily, exercise can be very helpful in keeping that tendency under control. At least, that has been my experience. I am far less susceptible to downward mood swings now than I was before I started my exercise program. That may not be the medical miracle that Dr. Krogh was expecting, but it's a pretty big step for me.

Thursday, November 11, 2010

Words matter. Sometimes they matter more in practice than they really ought to in principle, but they matter.

Here's a little anecdote that shows how the choice of a single word can make a big difference. Tonight I went to a yoga class downtown. The parking situation isn't very good there on Thursday nights, so I had to park some distance from the yoga studio, and when I left the class at 9 PM, I had to walk down an unlit and deserted backstreet to get to my car. And as I approaced a very dark corner, I became aware that two guys were standing there. They were engaged in conversation, but I couldn't hear what they were saying at first, and I felt uncomfortable about the way they were stationed in that unlikely location, as if they were waiting for me or someone else to come by. What were they doing there? People didn't hang around on that dark corner for conversation, or at least I'd never seen anyone doing so before. Were they up to no good? Should I think about finding some other way to get to my car, without walking past them? Was it worth turning around and making a detour around the block?

In those situations you look for clues -- some tiny strand of evidence that might help you decide what sort of people you're dealing with. But clues were scarce in this case. I could barely see the guys. I couldn't tell how old they were, what they looked like, or how they were dressed. I wasn't even sure that there were only two of them. As I approached them, I strained to hear at least a few words of their conversation, hoping to catch something that would either warn me to get the hell out of there or encourage me to keep on walking to my car.

And then I heard one word -- just one word -- that one of the men was saying, and I instantly relaxed, convinced the conversation these guys were having was not the sort of conversation that would occur between two men loitering on a dark corner with criminal intent.

The word was... "infrastructure".

People with diabetes tend to fret about words quite a lot. Certain words have the power to get diabetes patients into fierce disputes over what, precisely, those words mean. "Cure", for example -- don't get them started on that subject if you don't have a lot of time to spare! "Lifestyle" can be dangerous, too. 

Of course, there is a reason why diabetes patients tend to make a lot of fuss and bother about words. Diabetes can be an expensive disease (expensive for individuals, and increasingly expensive for society as diabetes prevalence continues its alarming growth). Lately there is a lot of concern about whose "fault" the diabetes epidemic is, and especially about who will pay for it. This puts diabetes patients on the defensive, and people who are on the defensive tend to become hypersensitive to language. People feel as if controlling the vocabulary of the debate is essential to winning the debate. The result is that diabetes patients tend to become peculiarly insistent on using one word over another.

I can't find it at the moment, but recently someone on the dLife forum was seeking reassurance that, based on their test results, they really had prediabetes rather than diabetes. They reported that their doctor seemed to dislike their use of the term "prediabetes", perhaps because he thought they wouldn't take the problem as seriously if it were called that.

Well, I can certainly understand the doctor's point of view. He's probably had plenty of other patients who made much of the distinction (such as it is) between diabetes and prediabetes, and it's a safe guess that such patients have not done well. I think the distinction is legalistic and largely unreal, and has done a lot of harm to a lot of people.

The underlying problems which cause Type 2 diabetes (diminished sensitivity to insulin, and diminished production of insulin) can, depending on their current degree of severity, cause extreme elevation of blood glucose, mild elevation of blood glucose, or no elevation of blood glucose. We can make up separate names for those situations, and in fact we have done so ("diabetes", "prediabetes", and "metabolic syndrome"). We can also call in the lawysers to draw up definitions that specify where one ends and the next begins. But does that mean we have discovered three entirely different diseases, which were once mistakenly lumped together?

The same coven of experts who decided where the dividing line belonged between prediabetes and diabetes could, with equal clarity, place a dividing line between "infancy" and "childhood" -- so that every youngster would belong unmistakably to one category or the other. But would doing so really create two unrelated life forms, "infants" and "children"? Using words to categorize things does not alter physical reality. Nature would not know we had decided that infants and children were two distinct species. The reality would continue to be that infants are very similar to children. (In fact, they're so similar that, if you watch an infant long enough, guess what it turns into? You guessed it -- a child!)

I was once corrected by an expert who stated that, contrary to my belief, prediabetes is not considered a form of Type 2 diabetes. And I thought, it is not considered a form of Type 2 diabetes by whom? What nitwit is out there denying the obvious close relationship between these two things? And what other obvious relationships are they denying? That ice is a form of water, perhaps? If prediabetes and diabetes are two different diseases, not two stages of the same disease, it is exceedingly difficult to explain how everyone manages to get cured of one on the same day that they contract the other. This kind of thing is too stupid even to discuss.

Of course prediabetes and diabetes are two stages of the same disease. If there is a meaningful distinction to be made between them, it is that prediabetes is easier to get under control than diabetes is. Therefore, it is urgent -- extremely urgent! -- for anyone diagnosed with prediabetes to get it under control immediately -- while it's still comparatively easy to do so. But a lot of people don't do this (and I know, because I'm personally acquainted with some people in this situation), simply because they think "prediabetes" means "not nearly serious enough to be called diabetes". Their plan is to wait until the problem spins wildly out of control, and then try to do something about it. By that point it will be called diabetes, so they'll know they have no choice but to do something about it. The only problem is that, by that point, doing something about it will have become considerably more difficult to accomplish. That is why conscientious doctors are unhappy with the term prediabetes. It should mean "do something now!", but most patients assume it means "do something later".

So, as I said, words matter. Unfortunately, when it comes to diabetes, words tend to matter in a highly destructive way. The words we reach for, to make us feel better about the situation, are the same words that tempt us to let the situation get worse.

Wednesday, November 10, 2010

I'm continuing to feel better; my cough is receding, I'm running faster, and my fasting tests are getting back to the 80s where they belong. I even decided that I had it in me to go to the gym after work for some weight-lifting.

I recently moved into a new cubicle at work, and one of the advantages of my new location is that I can see a window from there. And it's a nice view, of some redwood trees near the building and a hillside in the middle distance.

It's good to be able to keep an eye on the changing weather conditions outside, especially when you're planning to go out for a run sometime during the day, and you hope to be able to choose the right time to do it. 

Today, however, any time would have been the right time for a run; the weather was splendid. The rain late yesterday cleared every spec of dust out of the atmosphere. The sunshine was brilliant and the hilltop views were crystal clear. In fact, we chose a running route that took us up the hill to the Paradise Ridge winery, so that we would have an inspiring view of the valley to the west.  

By the late afternoon, the sunshine streaming in the window almost made the office seem like a beautiful place.

Hollywood cinematographers go to a lot of trouble to create that kind of lighting artificially, but once in a while it happens in the real world, and I try to appreciate it when it does.

Today I saw a medical headline which could have qualified for my "News Of The Unsurprising" feature yesterday: Sex and Drinking Alcohol More Common in Children Who Dislike School. Some British researchers made a study of naughty students (aged 11 to 14) who do what they oughtn't, and discovered that such students tended not to like school. The students also tended to be unhappy at home (often reporting that they were unable to talk to their parents).

Okay, so what are we to conclude from this? That drinking makes you dislike school? That disliking school drives you to drink? That not getting along with your parents leads to early sex? That early sex prevents you from getting along with your parents? That not being able to drink with your parents leads to having sex with the school?

Most medical research is at least a little like this. One variable is found to be associated with another variable, or two variables, or three variables, and we don't really know what the connection is between them, but we're more than willing to guess.

Which brings me to the other medical headline I saw today: Child Abuse Linked to Increased Risk for Type 2 Diabetes in Adults.

All my skeptic's alarm-bells went off the instant I read that headline. Unless you have found a way to abuse children at the cellular level, I couldn't see how you could do anything to them that would directly turn them diabetic. There had to be another variable involved.

And almost instantly I thought of what that other variable might be. Diabetes rates track obesity rates pretty reliably; if abused children are likelier to become diabetic as adults, could it be because they are also likelier to become obese as adults?

I didn't have too long to wait for an answer to that. After six paragraphs explaining that physical or sexual abuse of children increases their risk of diabetes in adulthood (and that there is a "dose response relationship" between the severity or frequency of abuse and the diabetes risk), the authors note that abused children also have higher rates of obesity in adulthood.

Case closed!

Well, actually, maybe not. The researchers say that obesity can only account for 60 to 64% of the linkage between child abuse and adult diabetes. The remaining 36 to 40% is unaccounted for. The researchers suggest that stress (known to be a contributor to diabetes, and also known to be associated with a personal history of child abuse) may explain the rest of the linkage.

Of course, we can all come up with our own private theories about why abused children are likelier to become obese. We won't be able to prove them, but what does that matter? Our theories sound convincing to us, and they fit the evidence to our own satisfaction, therefore we feel that we have proved them.

That's what it always comes down to with medical research. The results of any study can be summarized as: "Thing A is associated with Thing B, and this means I'm right about what I've been saying for years". 

Tuesday, November 9, 2010

It may be that I was taking a little too much blame yesterday for my elevated fasting test. I have been dealing with a cold virus, after all, and even though it's a pretty mild case, most people find their glucose elevated at such times. (Most people with diabetes, anyway; people without diabetes don't usually get a chance to find out what's going on with their blood sugar when they have a virus.)

At this point, my cold has progressed past the sore-throat stage, and my only symptom now is a cough. The congestion has moved down to the lungs. But it's not very heavy congestion, and it's not a very bad cough. I'm not hurting. I was able to run today, and I felt more energetic than I did yesterday.

Anyway, I'm feeling better than I did over the weekend, and my glucose numbers are coming down. It's all part of the diabetes game, I guess. It's probably best not to get too attached to the idea that you have total control over this thing.

It was a beautiful day for a run -- at least when we actually did run. It was sunny and clear, with a cool breeze blowing the autumn leaves about. By the time we were done, it was clouding up, and an hour or two later there was a downpour. I always get a great sense of satisfaction when we hit it lucky in that way. My luck wasn't with me on the weekend, clearly, but I try to appreciate it whenever it's around.

Here's a headline which, at first glance, seems a trifle far-fetched: Study Links Analgesics in Pregnancy to Male Reproductive Disorders. You would think that a pregnant woman could take pain-relievers without having to worry that this was going to cause her husband to suffer any kind of reproductive disorder. And you'd be right to think so, because it turns out that isn't the issue. The person affected is not her husband but her son.

"Use of analgesics such as acetaminophen, aspirin and ibuprofen during pregnancy may partly account for a sharp increase in male reproductive disorders in recent decades, according to a study published on Monday. The research found that women who took a combination of more than one mild analgesic during pregnancy had an increased risk of giving birth to sons with cryptorchidism."

I'm sure you already know what cryptorchidism is, but I had to look it up. According to Wikipedia: "Cryptorchidism is the absence of one or both testes from the scrotum. This usually represents failure of the testis to move, or "descend," during fetal development from an abdominal position, through the inguinal canal, into the ipsilateral scrotum. About 3% of full-term and 30% of premature infant boys are born with at least one undescended testis, making cryptorchidism the most common birth defect of male genitalia. However, about 80% of cryptorchid testes descend by the first year of life (the majority within three months), making the true incidence of cryptorchidism around 1% overall."

Well, maybe that's the incidence overall, but apparently the incidence is higher in boys whose mothers took multiple pain-relievers.

However bizarre and unexpected this seems (why, after all, should taking common headache remedies during pregnancy have anything at all to do with when or if your son's testicles descend?), it seems to be just one more in a long list of unforeseen consequences of medications which seemed safe when they were introduced.

I recently found out that I have to worry about my hips disintegrating on me, because during childhood I suffered from asthma, and I used an inhaler. Some people are now having to get hip replacements as early as their twenties, because of these steroid inhalers. Nobody knew when the inhalers were introduced that they could be this harmful.

I'm not claiming that anyone should have known that over-the-counter painkillers would make it hard for the next generation to have a next generation, or that asthma inhalers for children would cause devastating injury later in life. There was probably no way that anyone could have known these things.

But that's what scares me: no one could have known. The long-term consequences of drugs are not really discoverable, except through the experimental method of dosing a generation with them, and waiting to see what happens. And even when it does happen, you may have a very hard determining whether or not the drug is the actual cause of whatever outcome you see. Consequences are not always as obvious as they were in the case of Thalidomide (the drug which was prescribed to pregnant women in the late 1950s and caused thousands of severe birth defects).

A drug which affects human physiology significantly in one way is awfully likely to affect human physiology in other ways as well. However much we want a drug to relieve a particular symptom or cure a particular disorder -- and do nothing else! -- the odds are heavily against things working out that way. Even our own naturally occurring hormones usually have multiple effects on us, not just one effect. Breaking into the chemical conversation which goes on within a living body is an unavoidably risky business, and it can take a mighty long time for the nature of those risks to become clear. The newer a drug is, the more reason we have to fear that we will eventually discover something really awful about it.

That's why I take such an unenthusiastic view of the usual approach to diabetes management, which amounts to drugs, drugs, and more drugs. Do we know even half of what these drugs will do to us? Very likely not.

And now, it's time once again for...

Recent health headlines show that research is still continuing into questions which, so far as I can see, answer themselves.

Monday, November 8, 2010

I don't know if it "serves me right", exactly, but my elevated fasting result this morning isn't too surprising. After participating in the Apple Hill Harvest Run on Sunday morning, I felt too strong an urge to reward myself for what I'd been through by indulging in high-carb comfort foods later in the day.

My defense, to the extent I have one, is that it wasn't at all an easy run for me to do. It was an 8.5-mile course, which is not in itself unusually hard for me, but the last three of those miles involved a 600-foot climb, and that's pretty tough. I wasn't feeling my best, either. My on-again, off-again virus from last week had seemingly come back, and I had some cold symptoms -- too mild to stop me from doing ordinary activities, but significant in terms of running a race. And on top of everything else, the weather was pretty awful.

It rained continuously throughout the race. There were occasional strong gusts of wind that would knock a few gallons of cold water off the trees and onto us. (Exactly what you don't need when you're fighting off a virus, I realize.) And there was rather a long interval before the race began, during which we had to stand around in the rain, waiting for the starting gun. It was a relief when the race finally standard -- at least running helped take the chill off you. But it took me a long time to get really warmed up, and I felt pretty weak during the first half of the run.

The route went by the home of my brother and his wife, who waited for me under their umbrellas to snap a photo as I went by. I tried to look strong for them. I guess it wan't a bad effort, considering how I actually felt -- but it has to be said that when I'm truly at my best, I don't look quite so much like Willie Nelson as I do here.

Because the first half of the race was the easy part, and I felt poorly during it, I was very worried about how well I would handle the hard part at the end. Fortunately, by then I was feeling stronger. I wasn't fast, but I was feeling a lot better than I had earlier, so when I finally got to the big climb I had been dreading, it turned out not to be half as hard on me as I expected it would be.

Considering the amount of climbing involved, and also considering how I felt, my only ambition for the race result was to finish in less than 90 minutes. I met that modest goal (finishing in 85:12), but 62% of the other runners did better than that. I like to think I could do better than that myself, if I do that race again sometime, when I'm feeling better and the weather is more pleasant. Maybe I'll have another try at it next year.

After the race I got back to my brother's, and took a hot shower which was about as luxurious a treat as anyone on earth needs (or, so far as I know, gets). Maybe that alone should have been my reward. If it had, my fasting test this morning would have been lower!

Well, at least my post-prandial test after dinner was within bounds. I'm hoping for a better fasting result tomorrow.

If only the race could have taken place the day before -- when the weather along the route looked like this!

Except for the time when I was running the race, the weather was gorgeous during my visit to the Apple Hill area. Sunny, clear, and warm -- with the fields and vineyards displaying handsome fall colors. Usually the weather for the race is like that, too. Well, better luck next time.

While I was there, my brother's wife taught me a very clever technique for decorating eggs. It's a little tricky, but not as hard as you would guess from looking at the results. 

Maybe this isn't the traditional time of year for decorating eggs, but if you're going to learn how to do it right, maybe it's a good idea to do your learning before Easter. I suspect Martha Stewart doesn't until Thanksgiving to try out pumpkin pie recipes.

Thursday, November 4, 2010

Well, whatever was making me feel so bad last night did, indeed, go away. Maybe I just needed more sleep. Well, if so, I got it, and I felt a lot better today -- even during my lunchtime run. And my glucose test results were back to normal, too. Even my blood pressure is down.

I have no idea what was wrong with me last night; I just felt awful for a while, in a vague sort of way ("malaise", I believe, is the term). To me, this is one of the great mysteries of health -- one which I don't expect will ever get solved. Why does a basically healthy person, on an ordinary day, once in a while suddenly feel sick and drained of energy for no obvious reason, and with no consequences the next day? Did I have some kind of virus that my immune system was able to knock out? Was it psychosomatic? (That's a much-misunderstood word, by the way: a psychosomatic illness is not an unreal illness which the patient imagines he is suffering -- it is an illness of the body which is somehow triggered by a state of mind.) My strong feeling that I wasn't well could, I supose, have been some kind of mental aberration -- but that wouldn't explain the elevated blood sugar (following a meal which should not have produced any such result). I don't know what was going wrong with me last night, but something physical was going on. I'm just glad it's over, whatever it was.

So now I'm feeling up to the weekend activities ahead of me. Tomorrow I'm heading up to gold-rush country, to visit my brother and his wife, and to participate in the Apple Hill Harvest Run on Sunday. I've never done that race before, and now that it's nearly upon me I am starting to get just a tiny bit concerned about how difficult it might turn out to be. The distance (8.5 miles) is not what concerns me; I often do a trail-run that long or longer on the weekends. But I was just looking at the elevation profile, and my oh my -- this race might not be an easy one!

The race begins with five and a half miles of downhill running -- all the better to encourage you to overdo it and tire yourself out -- and finishes with 3 miles of steady climbing, with an altitude gain which appears to be nearly 600 feet. For comparison purposes, the Kenwood Footrace (which most runners see as a challenging race because of its hilly course) features climbs of equal distance but only 350 feet of elevation gain. This one is not going to be a walk in the park.

However, I need to keep this in perspective. It may not be a walk in the park, but it's comparable to many a run in the park that I have done. My trail-runs in Annadel State Park (and, in fact, many of my lunchtime runs in the neighborhood where I work) feature climbs just as steep, if not quite so long. Clearly I can do this. It's just that, in a race, you want to be able to do it reasonably fast, and I'm not sure that's going to happen for me on Sunday. Not that it really matters how well I do -- except that, at the emotional level, it does! This is the sort of race that mainly attracts serious runners, and I'm going to be trying to keep up with some really fast people. I don't want to be one of the last few people stumbling across the finish line.

Oh well, I'll give it my best shot, and whatever happens, happens. At least it will be far enough from home that I probably won't know any of the other runners. So, if I disgrace myself, nobody will know about it except the internet. (I'll admit to whatever happened when I get back on Monday.)

The current forecast for Sunday indicates that it will probably be raining. Well, I can handle running in the rain. You get pretty sick of it during a marathon (as I found out in the 2009 Napa Marathon), but for a shorter run it mainly provides some welcome cooling. Welcome during that final three-mile climb, anyway!

More Drugs Do Not Always Mean Better Care, according to a report in Medscape. A pair of studies has found that, when Medicare cuts reimbursements for prescription drugs, doctors prescribe fewer drugs -- but patients don't do any worse as a result. Why not? Apparently because a lot of drugs are prescribed needlessly, and when reimbursements are cut, doctors sacrifice the needless drugs in order for patients to get that ones that are actually necessary. And the needless drugs are often a lot more expensive than the necessary ones, so the price difference can be pretty big.

This is thought to have some relevance to the odd paradox that Americans pay more for health care than people in other developed nations, but tend to receive poorer health care and have wose health outcomes.

I'm going out of town tomorrow, and I'm not going to be blogging from the road. I'll be back on Monday!

Wednesday, November 3, 2010

I'm feeling ill this evening. I'm not sure what it is, but it came on rather rapidly around dinner time (although I don't think I ate anything that disagreed with me). Even though my dinner was certainly not high-carb, I had a 1-hour test results that was extraordinarily high for me. Waiting another hour only brought it down to 133, which some people would call normal, but is certainly higher than I would expect.

Most of the day I felt good (even while doing a pretty hard run at lunchtime); the only problem was that I slept poorly last night and was drowsy in the afternoon.

Being sick in any way can drive up your blood sugar, and I guess that's what I'm dealing with. At the same time, I feel as if this is a very temporary condition, not the start of the flu or anything like that. I hope I'm right!

Tuesday, November 2, 2010

A big training event, with visiting engineers from all over the globe, dominated my workday, and I thought it was going to prevent me from doing my lunchtime run -- but the schedule worked out just right for me to be able to fit it in. And I'm glad it worked out, because it was a really beautiful day for a run. Sunny, clear, calm, and about 70 degrees. This is the kind of November weather that makes people think living in Calfornia might be a good idea.

And in the evening: voting! Ours is the kind of ballot that makes people think living in California might not be such a good idea. Lots of complicated ballot measures to figure out, sponsored by who knows what conspiracy of swine. It can take a while to figure out how wide you think the spread is between what the initiative says it aims to do and what it really aims to do. To help you sort that all out, the voter's guide includes arguments for and against each ballot measures, most of them written by people who think that HEAVY USE OF SCREAMING BLOCK CAPITALS IS THE BEST WAY TO GET THROUGH TO REALLY DENSE PEOPLE LIKE ME!!!!!

I dealt with this burdensome task the same way I did in the last election: at sunset I had dinner outdoors (it was warm enough for that) on a balcony overlooking a golf course, and filled out my sample ballot over dinner. It all seemed so comfortable and civilized, and helped me ignore the suspicion that I was probably being grossly deceived about what most of the ballot measures would actually do. I had my decisions filled in before the waitress brought the check. And afterwards I voted for real, being careful not to listen to any of those demoralizing radio broadcasts from the east coast, saying "don't bother, Californians -- the election is over!".

The marijuana-legalization measure appears to be headed for defeat. Our absurd (but financially useful) hypocrisy about this matter can continue. A friend of mine is in the recession-proof business of selling supplies to home growers: that's what layed-off people do to survive recessions around here, so his business booms when all other businesses go bust. Well, if continuing our half-hearted prohibition of the evil weed keeps prices high enough to help a bunch of outsourcing victims hang on a little longer, maybe it's of some use.

I saw two Medscape articles today on studies which tried to establish that changing the mix of fats in the diet has health benefits. One study seemed to find what it was looking for, and the other didn't. However, neither study involved enough test subjects to support a very firm conclusion, at least in my view.

The more successful of the two studies looked specifically at adding monounsaturated fats to the diet. This was a very small Canadian study (only 24 test subjects!). The study involved replacement of 13% of daily carbohydrate with monounsaturated fat (from avocados or sunflower oil). The result was a 20% reduction of LDL ("bad") cholesterol, and a 12% boost in HDL ("good") cholesterol.

The less successful of the two studies was larger (417 test subjects), and it tried to demonstrate that reducting saturated fatty acids in the diet of obese people would improve their sensitivity to insulin. Various types of diets which reduced saturated fat intake were tried. Unfortunately, none of them improved insulin sensitivity in obese people.

Because of the linkage between obesity and insulin resistance (including amelioration of insulin resistance following weight loss) it has long been assumed that fat plays a role in insulin resistance. The current thinking is that fat within cells somehow interferes with intra-cellular signaling, and thus causes the cell to respond ineffectively when its insulin receptors are stimulated. And that may well be true -- but it apparently does not follow that reducing your intake of saturated fat will do anything to improve matters.

Well, it's the same situation we face with cholesterol: it seems so reasonable to assume that eating less of it will result in your having less of it clinging to the walls of your arteries -- and yet it doesn't seem to work that way.

It seems just as reasonable to assume that eating less fat will result in less fat hanging around inside your cells, screwing up the intracellular signaling that ought to make the cell respond properly to insulin. And yet, it doesn't seem to work that way, at least in people who are obese.

Monday, November 1, 2010

A busy weekend for me, with lots of music-making. But I didn't neglect exercise. Yesterday, taking advantage of a break in the rain, I went to the state park to do a trail-run. I carried a camera with me.

This time, instead of just photographing the landscape, I also took photos of the reflections in the puddles along the trail. The air was so calm that there were no ripples on the surface of the water, and the reflected tree branches were eerily sharp.

The reflected sky was highly vivid also.

If you find those images slightly disorienting to take in, wait till you see my Halloween costume!

Having got a long run out of the way (a little over 7 miles), I then felt ready to face Halloween. I was planning to play at an Irish session at a pub in San Francisco, and I knew that many of the other musicians were going to be in costume.

Not wishing to wear a costume that was disappointingly ordinary, I showed up as a distinctly creepy bar patron with a squashed little face.

All I did was cover my actual face and paint a different one on my forehead, but it looked so odd that about half the people there found it hilarious, and the other half were pretty disturbed by it. (For me, those two things add up to a successful Halloween costume.)

I couldn't see very well through the scarf that was covering my face, but I was able to play, and that was what I was there to do.

I was able to see well enough to be quite aware that the table in front of me was covered with Halloween candy and cupcakes. I managed not to eat any of them. I'm not promising to do that well at Thanksgiving and Christmas, but I managed to survive the first of the season's Ordeals Of Sugar.

It's a historic week for us in these parts. Tonight the San Francisco Giants won their first World Series, and tomorrow we vote to legalize marijuana.

Actually, the latter is looking pretty doubtful at this point. Amusingly, a lot of the people who make at least part of their living from California's number one cash crop are against legalization, fearing that prices will drop steeply once that crop is no longer outlawed. Prohibition has always been America's preferred solution to the problem of making sure crime pays, but usually this aspect of the matter is decently concealed from view. Now that it's pretty nearly out in the open, it provides an entertaining spectacle for those who appreciate the finer points of hypocrisy. 

I don't have a dog in this fight; my drugs of choice are legal ones. (I tend to feel that anyone who doesn't get what he needs from coffee and wine has not learned how to shop for either of them.) But I am struck by many people I have known over the years who have surprised me by admitting their regular marijuana use over periods of many years, during which time they were holding down jobs, paying their bills, raising their kids, and not driving their Toyotas into oncomming traffic. Admittedly, I'm not the shrewdest observer of telltale signs of drug use, but if people whom I know pretty well can smoke marijuana regularly for years without my noticing anything amiss in their lives, maybe this whole Reefer Madness thing has been just a little bit overblown. Certainly it's hard to make a case that marijuana has had a more harmful impact on this country in recent years than, say, French fries (the latter are, of course, a notorious gateway drug -- study after study has found that most heroin addicts tried fries first!).

But I love it that the suppliers of a popular consumer product are in favor of keeping that product illegal. Tomorrow we find out whether or not they're going to continue having things their way. If they lose, it will be interesting to see who ends up taking the business away from them. It will also be interesting to see what happens to prices when the people who grow marijuana become subject to the same market pressures as the people who grow artichokes.

Maybe grocery shopping is about to become a different experience entirely! Maybe. I have my doubts that the ballot measure is going to pass. Although nothing in politics is 100% reliable, the impulse to make hypocritical moral judgments on other people's habits comes pretty darned close.

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