Friday, October 29, 2010

Today was essentially a second moving day at work, since I had to unpack the things I packed yesterday. Well, I don't especially like moving, but I'm in a better location now. If I'm not right by a window, at least I can see a window. A set of windows, actually, with redwoods standing in front of them and a hillside visible in the distance. I can see what's going on with the weather as my lunchtime run approaches.

Because it as raining this morning, my usual running buddies declined to go with me, even though the rain was coming to a halt just as our running time approached. They thought it would start raining again as soon as we started our run. Well, to be honest, I thought that would happen too. The difference was that I was willing to go running whether it happened or not. It's all part of the great diabetes experience: suddenly, rain is no longer an issue!

Another diehard runner went with me -- one who usually doesn't run with me (and probably won't again, because he likes to go faster than I can go, and he had to hang back today in order for me to keep up with him). Fortunately, mother nature didn't call our bluff; a very few raindrops fell on us. It was comfortable weather for a run. The sun even made an effort at breaking through the clouds a couple of times.

I'd love to share with you some words of wisdom about diabetes tonight, but the truth is that I went to a party to play Irish music with a bunch of excellent musicians, and now it's very late, and that is that. I'll have to get back to you on Monday.

Thursday, October 28, 2010  

Oh, no! Moving day!

I'm not moving from my home, just moving into a different office at work. I didn't have to pack up my whole life in boxes today, just my whole working life. Most of the heavy stuff is going to be moved for me tomorrow morning. But it became necessary for me to move a few bulky and awkward items myself today. And the whole process of boxing up the contents of an office (and particularly the process of crawling around under desks, disconnecting cables) always carries a risk that you will strain something or other, and wake up the next morning with crippling pains in your back.

To tell you the truth, I think that any activity you're not used to doing carries a big risk of that sort of morning-after injury. Even a really good athlete -- in one sport! -- is likely to regret trying his hand a little too enthusiastically at a different sport. I don't care how good you are at basketball, the morning after your first day of snow-boarding is probably going to be a memorable one.

Moving from one office to another is not snow-boarding, but it does have a certain amount of potential to generate invisible trauma. In the past, I have certainly had to deal with flare-ups of pain in my back, neck, and shoulders which were pretty seriously disabling. I'm very conscious of the need to avoid that kind of thing if at all possible -- and not just because I don't like pain. Having a serious physical disability, even temporarily, is the last thing you need if you're trying to control Type 2 diabetes and your primary therapy is exercise.

Well, I did what I could to prevent moving day from harming me. For one thing, I had a good exercise break in the middle of it -- more than 4 miles of running. And afterwards, I went to a yoga class in the evening which stretched out all my body parts considerably.

Although I'm not a promoter of yoga specifically, I do promote the idea that people need to do some kind of body-maintenance work, to keep their spine straight and their joints flexible.

Like it or not, the human body is a mighty vulnerable thing. Almost anything you do with it has the potential to harm it, and if you don't make a conscious effort to fight that tendency, you end up turning into the kind of person you feared becoming when, as a child, you contemplated your elderly relatives, and wondered what had turned them into such crabby and miserable people. I'm not claiming that the frailty of age is entirely avoidable, of course. But some people avoid a lot more of it than others, and if you get an opportunity to watch old people who have been doing yoga or Tai Chi for a long time, you will come to realize that there's a lot you can do about this problem, if you're willing to work at it.

Yoga, Tai Chi, and Pilates are the best known of these maintenance disciplines (others worth looking into are Breema and Feldenkrais, and probably a dozen others I'm not familiar with). Your decision to go with one or another of these methods might hinge on nothing more momentous than convenient availability of a class, or a personal preference for one method over another. I think they all have benefits.

For that matter, you might benefit from doing any kind of stretching routine recommended to you by a personal trainer or physical therapist. The main thing is to be doing something to promote flexibility and core strength, so that your body becomes less liable to experience painful flare-ups after any kind of unusual physical activity.

Bottom line: if it keeps you safe from injury on moving day, it's probably a good idea.

Wednesday, October 27, 2010  

My usual window of opportunity for running during the daytime was squeezed out of existence today, because it was sandwiched in between two meetings, and the first of the two meetings ran too far overtime. So, I figured I'd run after work.

When I got home from work and started getting dressed to run, it didn't really seem like a great time to go running, and I had to overcome various mental objections first. It was getting cold, and threatening rain -- so, I dressed for the weather. Also, I was hungry, and afraid either to eat something now (and maybe get an upset stomach while I was running) or to stay hungry (and maybe run out of energy during the run) -- so, based on prior experience, I started the run without having anything to eat first, knowing that the exercise would kill my appetite for a while. Also, I was afraid I wouldn't be able to finish the run before it was dark -- so, I carried a light with me.

Once I had eliminated all my excuses for not running, I finally started the run. And it turned out to be a really nice run. I didn't just feel good after it was over, I felt good during most of the run itself. Even the hard parts -- and the middle two miles of this route are very hard indeed (there's a huge hill to climb). I didn't feel miserable during any of it, and I felt good during most of it.

Almost never does a run (unless it's a marathon) end up being as hard as I'm afraid it's going to be before I start. It's sort of like stage fright: being on stage is never as bad as waiting to go on stage.  The anticipation is the worst part. But the next time, you have to go through the whole cycle of anticipation once again. A good experience on stage doesn't make your stage fright disappear forever; it just makes you feel more sure that you'll find a way to cope with it.

I think we need to retire the word "sweets". The first thing people should be told, when they're diagnosed with diabetes, is that this means they must stop using that word immediately. Not for the reason you probably think, though.

I'm not saying that diabetes patients must stop saying "sweets" because I want them to stop eating sweets, and I imagine that forbidding them to talk about sweets will make them forget that such foods exist.

No, my concern is that the very concept of "sweets" (at least as a nutritional term rather than a coookbook term) is dangerously misleading. Nearly all diabetes novices assume that having diabetes means you must "cut down on sweets". Sweets are the problem. People with diabetes can't have sweets.  Stay away from the chocolate-chip cookies and lemon squares, and you'll be okay.

In terms of glycemic control, however, sweets are not significantly worse than (or even different than) starchy foods such as rice, corn, and wheat. Starches, properly considered, are made out of sugar, and are turned back into sugar right after you swallow them. Starch consists of a bunch of glucose molecules chained together. The starch may not taste sweet to us while the chain is still linked up, but digesting starch soon cuts all those glucose molecules loose from the chain. The process doesn't take very long, either. Chewing a starchy food for an abnormally long time can be enough to make it start tasting like sugar, because your saliva gets the starch-breakdown process started almost at once.

It's true that eating candy will soon launch a small sugar-tsunami into your bloodstream. But it's also true that eating tortillas will do the same thing. In the case of the tortillas, the wave may hit you a little later -- but the wave will be as big, or very likely bigger. Serving sizes for starchy foods tend to be larger than for sweets, and they typically deliver more sugar to your bloodstream for that reason. If you think that refraining from sprinkling sugar on your cornflakes makes it okay to eat cornflakes, bear in mind that the cornflakes are going to contribute far more sugar to your bloodstream than a spoonful of sugar would. If you had to choose between a spoonful of sugar and a bowl of cornflakes, you'd be better off (at least in terms of glycemic control) to eat the sugar and skip the cornflakes.

The trouble with letting new diabetes patients think that they must get the "sweets" out of their diet is that it encourages them to concentrate on a secondary issue instead of a primary issue. Most people get the majority of their carbohydrates in the form of starch. If you're looking for a place to cut the carbs, wouldn't that be a more sensible place to start? If you were trying to cut the Air Force budget, buying cheaper uniforms is probably not where you would find your best opportunity for cost reduction, because that's not what they spend most of their money on.

Tuesday, October 26, 2010  

The weather was even better for a run today than it was yesterday. It was still sunny and clear, but there was a chilly autumn breeze, sending the fallen leaves swirling around our feet as we ran. I was slightly under-dressed for the weather -- it's time for me to break out the warmer running clothes I put away during the summer. Doing a lot of outdoor exercise makes you more aware of, and more sensitive to, the changing seasons. I know I watch the weather forecasts far more attentively than I ever used to do before I started running.

Another seasonal note: we crossed paths with a herd (or flock, or whatever the word is) of wild turkeys during the run. In fact, we divided them, because most of them dodged left and one of them dodged right. Maybe we separated him from the rest of the tribe, and made him an outcast. I don't know enough about turkey social hierarchies to know how badly we may have compromised his status in the community. We meant no harm, but that's what invaders always say, isn't it?

At lunchtime, there was only one dish on offer in the cafeteria that appealed to me, and it had rice in it -- but not a very large amount of rice, so I decided it wasn't too risky a choice. The post-prandial result (123) wasn't at all bad for a meal that included rice. But the zero-rice, low-carb lunch I'd had the day before only pushed me up to 90. The bottom line: the rice did make a difference, but not more of a difference than I could handle. A larger serving of rice, though, would have been a problem.

Most of the time, when you are offered any rice at all, you are offered a mountain of the stuff (often inextricably merged with the rest of the meal, so that it's hard to impose your own version of portion control on it). Most of the time I have to pretend that I have a deadly rice allergy and must avoid it entirely, just because it's so hard to obtain a small serving of rice. Usually you get a pound of it or nothing.

It's unfortunate: a lot of ethnic foods that I like are impractical for me because of the massive rice overdose they are typically combined with. Things would be a lot simpler for me if they would just put the curry on one side of the plate and the rice on the other, and let me decide how much of the latter to integrate into the former. But explaining that to restaurant employees is not something I usually want to put myself through.

Of course, any restaurant owner will tell you that restaurants will be perfectly delighted to accommodate special requests. Anyone who has actually eaten in a restaurant may find that hard to believe. I find it hard to believe, anyway. My experience is that, if you ask restaurant employees to do anything outside their usual routine, they generally forget to do it. Force of habit is too strong. And I'm too fearful of retribution ever to send anything back to the kitchen, no matter how much it differs from what wanted.

Which, I guess, explains why I'm not much of a restaurant patron. Out-of-town visitors who come to me for a guidance on where to have dinner are usually asking the wrong person.

Let's face it: restaurants are not terribly diabetes-friendly places. When low-carb weight-loss dieting was fashionable, restaurants became -- briefly -- a little easier to deal with for people who need to keep an eye on their starch intake. But those days are over, and restaurants have once again become starch warehouses, sliding baskets of bread and taco chips in front of us just to keep us busy while we're waiting for the actual meal to arrive. (And if I've given you the impression that I'm good at ignoring a basket of taco chips that has been put in front of me, along with a little bowl of salsa or guacamole, I've given you the wrong impression.)

So, it's just as well that I don't go to restaurants a lot.

I almost didn't succeed in talking myself into going ot the gym in the evening for my weight-training workout. Hadn't I already done a five-mile run, on steep hills, earlier in the day? Wasn't that enough, for heaven's sake? But I said I was going to try to make room in my life for weight-training as well, and I feel I should make an earnest attempt at that.

I'm not the only person in the world who is doing both aerobic exercise and weight-training, after all, and it's thought to be better for people with Type 2 diabetes to do both. So, after a bit of dithering, I told myself that I was being a baby and should just go down the hill to the gym and get it over with. So I did.

It's not that big a deal, really. I'm just resisting it, and pretending that it's a more serious inconvenience than it really is.

Monday, October 25, 2010  

Only 90 after lunch? Well, it was a pretty low-carb lunch, and I'd just done a hilly run.

The fasting result of 86 was more surprising, actually. Yesterday was my rest day from exercise, and it was also an Irish-music night in San Francisco. Neither of those things is always a recipe for a good fasting result the next morning, but sometimes things work out. Maybe a good dose of music-making benefits me as much as a good dose of exercise.

Running in the rain was not quite so easy on Saturday as it had been on Friday, because it was real rain this time, and because it was a long run (8 miles, partly on trails and partly on paved paths). It was funny to be running on a route through an empty park which is normally crowded with walkers, runners, and cyclists. I only crossed paths with a very few diehards. Today, though, running was a lot more pleasant. Sunny and clear, but also pleasantly cool. Weather doesn't get any more perfect than that for exercising outdoors.

Today someone in the locker room at work (who doesn't run as often as I do, and likes to tease me for overdoing it -- as he sees it) was asking me if I did a run during the rainy weekend. I said yes, I did an 8-miler. He said "Man, you are insane!". I told him I do take one day off from exercise every week, but rarely more than one. He clearly thought this was not only insane, but pretty sad. I don't really know him very well, apart from these brief locker-room conversations, but I figured the time had come for me to explain things to him a little more. I told him that I had become diabetic almost ten years ago, but found that I could normalize my blood sugar without taking medications, if I did the right things -- and daily exercise was the most important of those things. This seemed to surprise him, and perhaps confuse him. I was pretty sure I saw the unspoken question in his eyes: "why not just take the drugs instead?"

I didn't have time to provide him with an explanation, so we left it at that for now. It's hard to explain this even to people who know a lot more about diabetes than he does. I guess what it comes down to is that I think exercise is adding to my quality of life rather than subtracting from it -- and drugs would probably do the opposite. 

Although I admit that it has sometimes been difficult for me to talk myself into doing my daily exercise, I always feel better after a workout. Would I feel better after taking a dose of diabetes meds? I doubt it. I just Googled the phrase "metformin side effects", and the first page I found began with the statement: "Although most people tolerate metformin well, there are some potential side effects of the medication". Scrolling further down the page, I find it reported that the medication causes diarrhea in 53.2% of people. Now, when I was in school, 53.2% of people constituted a majority. Am I to understand that "most people" now means "46.8% of people"? Or that "most people tolerate metformin well" is a reasonable paraphrase of "a majority of people who take metformin get diarrhea"? Sorry, I just can't see it that way. I realize that it's possible I'd be one of the lucky people who can take these diabetes drugs and not suffer unpleasant side effects from them, but it seems a little out of character for me. And even if the meds didn't make me feel worse, there's no reason to suppose that they would make me feel better. There has to be a reason why metformin never caught on as a recreational drug.

So, if exercising makes me feel better and meds wouldn't, I think there is a big quality-of-life advantage to me in making exercise the central focus of my diabetes management program.

Also, I think there is a false equivalency involved in seeing diabetes medications as an alternative to exercise -- since the drugs can't do all the things for you that exercise can. For example, diabetes drugs (even if they succeed in reducing your blood sugar to normal) can't reduce your risk of heart attack to normal. Most of the cardiac risk that comes with diabetes can't be eliminated simply by getting your blood sugar under control; if you want to complete the job, and work on both your blood sugar and your cardiovascular health, exercise is going to have to be part of the deal. 

In other words, whether or not exercise can normalize your blood sugar, you still have to do it anyway. So why not make the most of it, and see if you can use it to (among other things) normalize your blood sugar? Regular exercise is like killing two birds (actually a whole flock of them) with one stone, and I'd rather seize the opportunity while I have it.

I realize that the cost/benefit analysis I'm doing here would point to a different decision for some people -- especially people who feel that the phrase "daily exercise" carries enough doom and menace to make "chronic diarrhea" sound, in comparison, like a day at the beach. (Not that the beach is necessarily the best place for someone with chronic diarrhea, but you know what I mean.) I thought, when I started my exercise program, that I hated exercise as much as anyone alive, but there may well be people who hate it more than I ever did. For them, it might not be possible to achieve the feeling of satisfaction I get from the do-it-yourself aspect of using exercise in this way. Also, they might not get to the point where feeling good after a workout seems to make up for the way they feel during a workout.

I don't expect to succeed in selling my approach to everyone. However, I don't think I'm "insane" to take this approach, and when people tell me that I am, I will at least speak up for myself. I think we're all entitled to do that much!

Friday, October 22, 2010  

I did fulfill my vow to go running in the rain, but it wasn't as big a challenge as I thought it might turn out to be, because it was a very light rain. If it had been any lighter, I would have had to abandon the word "rain" and describe it as high-viscosity fog or something. It was refreshingly cool without being miserably cold and wet. All rain should be like that.

I had a big (but pretty low-carb) salad for dinner, so the low post-prandial test result makes sense.

Maybe this is going to strike you as pretentious beyond belief, but I read a medical article which reminded me of Plato's "Allegory of the Cave". To take the pretentiousness down a notch, let me confess that I haven't read Plato's original commentary on the subject -- I'm relying on summaries provided by later and more understandable authors.

Anyway, according to Plato, his teacher Socrates used the cave story to illustrate a problem with which philosophers must come to grips.  He asked us to imagine a group of prisoners held captive for life in a cave. They are tied to a row of chairs, facing a cave wall. They aren't allowed to turn around and see what's behind them, but if they could do so, they would see that there is a bonfire on a ledge far behind them. Somewhat closer behind them, but below the ledge, are pantomime artists and puppeteers, holding up pasteboard props that have been cut out in the shapes of people, animals, furniture, and other objects. They hold these things up in front of the fire, but behind the heads of the prisoners, to cast shadows on the cave wall.

The puppeteers enact scenes in this way, which the prisoners watch, having nothing else to look at. Because the prisoners watch this shadow-play their whole lives, and are never allowed to turn around and see the puppeteers or their props or the fire, they come to see the shadows on the wall as real things (and in some cases living things). That's their idea of reality, because it's the closest thing to reality they ever get exposed to. They can't grasp that the shadow figures on the wall are flat and unreal (and are merely an illusion projected by something else behind them), because they have no basis for comparing the shadow figures to anything else.

Ah, but suppose one of the prisoners escapes! On his way out of the cave, he sees the bonfire, sees the puppeteers, sees the props, and suddenly realizes that there's a reality above and beyond the shadow-play he's been watching all this time. He sees through the whole trick! He sees past the illusion, into the reality behind it. He has become a philospher, according to Socrates. And as a philosopher, isn't it his duty to return to the cave, and explain to the other prisoners what their real situation is, and help them escape from it just as he did?

Although the cave allegory presents a rather extreme and unrealistic set of circumstances, it does a wonderful job of capturing something which, in less extreme form, amounts to life as we know it.

We are all, to some extent, likely to be prisoners of our own experience -- our situation inevitably limits our vision. We see what's in front of us, we accept it as real, and we interpret it in light of what we know (or think we know). People living under dictatorships come to believe the most absurd propaganda, simply because they hear it all the time and they never hear anything else. They aren't given the opportunity to turn around and watch the puppeteers, so to speak. But that experience isn't confined to people living under dictatorships, is it? Everyone's in some kind of cave. Our situation, whatever it is, confines our perceptions and limits our understanding.

Often the cave we're stuck in is created primarily by our jobs. There's nothing quite like a career for giving you tunnel vision. Most of us are pretty isolated from the experience of people who make their living in a very different way than we do. Even within the same corporation, you may find that marketing people and product-development people each regard the other as tiresome obstructors of the real work of the organization. They are each in their own caves, watching their own shadow-plays. How could they be expected to understand each other?

So what has this got to do with any kind of medical article, you're wondering. Well, I'm coming to that. The article (which I found in Medscape, but apparently came originally from Expert Reviews: Endocrinology & Metabolism) is by Marie T. Brown and Derek LeRoith, and is entitled Overcoming Challenges in Type 2 Diabetes Management to Improve Patient Outcomes. It is based on a survey of studies done over the past four years, and it aims to "identify and discuss the challenges facing healthcare professionals and patients in reaching glycemic targets".

In fact the article is far more concerned with the challenges facing healthcare professionals than the challenges faced by patients; if anything, patients are themselves presented mainly as challenges to healthcare professionals. Although nothing in the article was of much practical use to me as a patient, I did find it intriguing for the insight it gave into diabetes as it appears from a doctor's perspective. Here was a peek into the cave where the doctors sit bound to their chairs! Here was my chance to see the shadow-play of diabetes as doctors see it.

The article begins with the usual acknowledgment that things are looking really, really bad in regard to diabetes and public health in the United States (diabetes has become an epidemic, diabetes patients aren't doing well, fewer than half of patients meet minimal goals for glycemic control, and so on). And, as usual, this bleak situation is not quite bleak enough to startle the authors into fundamentally questioning our current approach to diabetes care. We aren't going about this the wrong way, we just need to become... uhm... better at doing what we're already doing. And this should be possible, because there are more drugs available now than there used to be.

The main problem, apparently, is that patients aren't reliable enough about taking their drugs. The more medications doctors prescribe for patients, the worse the patients get at remembering to take all of them when they're supposed to!

The emphasis on drugs is so heavy in this article that I thought it might be enlightening to save it to a text file and use a search tool to find out how frequently certain crucial words appear in the article. The result turned out to be even more lopsided than I thought.

"Exercise" is mentioned twice. "Diet" is mentioned twice. "Weight loss" is mentioned once.

Pharmaceuticals are mentioned more than one hundred times.

I don't have an exact count of the references to diabetes drugs, because I got tired of the exercise not too long after the accumulating total passed the century mark. But before I gave up the effort I counted 22 instances of the word "medication", 12 instances of "drug", and countless references to the names of individual drugs and families of drugs (including, but certainly not limited to, 13 instances of "sulfonylurea", 14 instances of "thiazolidinedione" or "TZD", and 36 instances of "metformin").

When an article aims to present a comprehensive review of what can be done about Type 2 diabetes, and it ends up mentioning exercise twice while mentioning drugs over a hundred times, I think it is fair to say that the authors have somewhat narrowed their view of the matter at hand. They are in the cave, and they are facing the cave wall, and the shadow play enacted for them by the puppeteers of the pharmaceutical industry is all that they can see. They are not about to turn around and get a good look at the puppeteers waving those pill bottles around in the firelight. The shadow play is what they're watching, and it is holding them utterly spellbound.

Even when the article appears to show promising signs that the authors are considering making a break for it, and exiting the cave (or at least turning around to see what's going on behind them), the hope is soon extinguished. For example, under the heading The Patient, we read this: "The patient is an integral part of the T2DM management team and should be empowered, via appropriate training, to prevent or treat their hyperglycemia. A lack of diabetes education can lead to poor disease understanding and ineffective diabetes care on the part of the patient." Okay, that sounds pretty good. But the discussion which follows this introduction is devoted entirely to a single issue: "Patient adherence to medication". That may be what "empowerment" looks like inside the cave, but out here in the daylight we see it a little differently.

To be fair, the article does mention later that patients should be sent to classes where they can learn about the importance of "diet, exercise, and smoking cessation". But given where the emphasis of the article overwhelmingly lies, I think it would do no harm for such a class to be attended by the authors. I'm not convinced that they have learned as much about the importance of these things as they would like patients to learn.

Of course, if the authors ever read my criticism of their article, they could turn the tables on me and point out that I, too, am in a cave -- that I, too, am a prisoner of my own experience, and can't see beyond it. And the infuriating thing is that they'd be right!

Thursday, October 21, 2010  

So now we're getting real fall weather. By the time of our lunchtime run, it was still foggy and in the 50s. That's fine. It's good running weather.

There was a little rain tonight, and probably there will be some more tomorrow. Neither of my usual running buddies will be at work tomorrow, so I'll have to run by myself. And in the rain, probably. But I'm tough. I can do it. At least, I've done it before, which means I can probably do it again.

Having experimented successfuly with chana dal (a variety of lentil from India, which looks like yellow split peas and is renowned for its diabetes-friendly qualities) I decided to make a vegetable stew using a different kind of Indian lentil I had bought recently at an Asian market. This one is called Masoor, and I've had a very hard time discovering any information about it. It's smaller and browner than Chana Dal, and it doesn't require as much cooking (that alone could be taken as a warning sign that it probably has less fiber and more glycemic impact). Although there was a lot of Masoor in the stew I made, and presumably a fair amount of carbohydrate, my 1-hour post-prandial result was 129. Not perfect (I define perfect as under 120, because I think that's the kind of result non-diabetic people usually see), but pretty darned good, all things considered.

Oh, I forgot to mention -- it tasted good, too. Some people think that matters, when you're talking about food.

If this happened in a novel, you probably wouldn't find it believable: a drug is developed which is sold to men, for treatment of a condition which is not serious (and in fact doesn't really need to be treated at all), and the drug costs about $50 a month, and it has to be taken over a period of years before it produces even a mild improvement in the condition it is prescribed for. Even so, the drug is a commercial success. And then, on top of everything else, it turns out that the drug increases the risk of erectile dysfunction. And the men keep right on taking it anyway.

Such is the peculiar story of Finasteride, also known as Propecia. The drug blocks an enzyme called 5-alpha reductase. Why block this enzyme? Because it turns garden-variety testosterone into the more powerful form known as dihydrotestosterone. Why prevent that from happening? Because dihydrotestosterone is known to cause, among other things, male pattern baldness.

You see, even though baldness is a normal characteristic of adult males (about half of men are balding by age 50), many men feel so miserable about losing their hair that almost anything they can do to alleviate the condition seems worth doing. Even if it means cutting down on their supply of male hormones. Even if it might threaten their ability to have erections. (Ladies, please stop claiming that men only think about one thing!) Call them hypersensitive, but a lot of men really, really don't want to go bald.

I'm not wild about it myself, to be honest. Many years ago I thought I was safe from it, because my father's hair was so thick (which it still is, and he's 83), but I have since learned that what your father's hair looks like is no guarantee of what your own hair will look like at his age. My hair is currently at the stage where I look pretty well covered, in photographs taken at a low enough angle...

...but when the camera is allowed to have a higher vantage point, my emerging solar panel can easily be seen peeking through the foliage. Clearly, I'm on my way.

I'm not thrilled by the idea of losing my hair, but I'm trying not to be neurotic about it. I realize that a lot of men look good without hair. My concern is that I think the men who look good without hair happen to have very smooth and symmetrical craniums -- and I'm pretty sure my own is going to turn out to be mottled and lumpy and vaguely depressing to all who see it, like a shopping center that's going under and can't afford to repair the damaged asphalt in its parking lot. You shudder and drive past it to find a better a place to shop. (Don't tell me you don't know what I'm talking about here!)

But you have to keep these things in perspective. If I had my choice, I would stay young and thick-haired forever, but that is not one of the choices open to me, and I'm not going to pretend that it is a choice open to me, just because some mad scientist has found a way to interfere with the processing of male sex hormones within the human body.

The law of unintended consequences really comes into its own when people start monkeying around with hormones. We like to think of each hormone as doing one thing, because it makes the natural world seem comfortingly simple to us -- but it's delusional thinking, if you ask me. Hormones do all kinds of things, and we probably haven't discovered half of the things they do. Messing with your hormones is an exceedingly risky business, and you shouldn't do it, unless you have a damned good reason to do so and there's no safer option open to you.

Which, of course, is how I also feel about messing with the hormones that regulate blood sugar. Do it if you must, but it's dishonest to claim that you must, if you haven't yet tried the less invasive options.

Wednesday, October 20, 2010  

Good, the diabetes gods didn't punish me for Ale Night. My glucose this morning was 87.

I notice, however, that my fasting test result after a low-carb dinner was 126, as compared to only 100 after a comparatively high-carb lunch yesterday. There's no accounting for these variations, really, because so many factors could be relevant. However, the pattern I've been noticing is that my post-prandial tests are lowest after lunch. The likely reason for that difference is that I usually go for a run just before lunch. Therefore, lunch is the meal that I eat precisely when the insulin-sensitizing effect of exercise is at its peak. It takes a couple of days for that effect to wear off entirely, but it's strongest within the first couple of hours. If I'm going to indulge in carbohydrate-rich foods, I guess that's the safest time to do it.

Nobody's talked me into doing another marathon -- so far -- but I did sign up to do the Apple Hill Harvest Run, an 8.5 mile footrace on November 7. It's up in Camino, in the California gold country. It looks like a pretty route. It also looks like a difficult route (quite hilly), but I'm fairly used to that.

It's near the Sierras, but not in the Sierras. The elevation of the starting point for the race is only slightly over 3000 feet -- not enough for you to feel the difference when you're running. (The Lake Tahoe region, which is nearby, is another matter entirely, with elevations in the 6000 to 8000 foot range. I know from experience that exercising there takes some getting used to.)

Camino is a long way to go for a race that isn't a marathon (or even a half-marathon), but my brother happens to live on the route, which simplifies the logistics of participating in the thing considerably.

I saw a plaintive posting on the dLife forum from someobody who is newly diagnosed with diabetes and is now looking forward to Halloween with the kind of anticipatory dread which most people would reserve for bladder surgery. Their question boiled down to: "I can't imagine not eating candy on Halloween, therefore I know I will be eating candy on Halloween. So what kind of candy can I eat?".

It was a reminder to me that we will soon be heading into the worst time of the year for people with diabetes. Halloween is only the opening skirmish. Greater battles are to come: Thanksgiving, followed by various Christmas parties (and trays of holiday goodies brought into the office), followed by Christmas, and then -- just when you thought you had survived it all -- New Year's Eve.

If you have diabetes, it is the time of year for being told that
"one little piece of pie is not going to kill you" -- and then being told the same thing the next day, and the next, and the next, during a rather extended season of compulsory merry-making.

Come on! It's Christmas, for crying out loud! Lighten up! One little piece of cake isn't going to kill you!

One little armload of sugar-cookies isn't going to kill you!

One little plate of fudge isn't going to kill you!

One little flagon of cocoa topped with marshamallows isn't going to kill you!

One little knoll of mashed potatoes isn't going to kill you!

One little hillock of puff pastry isn't going to kill you!

One little platter of Angie's Double Chocolate Decadent Dessert Squares isn't going to kill you!

And so it goes. They're right, of course: one of these indulgences is not going to kill you. It takes several. And, from the end of this month to the end of this year, we will all be offered several.

The dietary restraint that makes for good diabetes management requires three levels of fortitude. First, you have to pass the easiest test, which is to go into a grocery store and not buy anything you know you shouldn't eat. At least nobody is following you around in the store, trying to sweet-talk you into adding forbidden items to your cart. (Or, if someone is doing that, you didn't plan your shopping expedition as carefully as you ought to have done.)

Second, you have to pass the more difficult test of sitting at a restaurant table and telling the waitress that, although the buttery gnocchi alla Romana with garlic bread, followed by the creamy zuppa Inglese for dessert, which she is strenuously recommending (and which some others at the table are ordering without a qualm) certainly do sound delicious... you believe you'll be having a salad instead, with a small cup of soup.

But those two tests of your strength are child's play compared to the third and greatest of them, which is to run the gauntlet of the holiday season, with one person after another holding a platter of treats under your nose and declaring that you must have some, because it's Christmas, for heaven's sake, and because eating it won't prove fatal to you (at least not immediately, while they're still around to have to watch).

I see no solution to the holiday-treat problem -- I am merely letting off steam. Maybe that's all we can do about it.

Tuesday, October 19, 2010  

Well, I managed to get my fasting test under 90 this morning -- that was an improvement. And the low post-prandial test after lunch seemed like a minor miracle, since it involved a sizeable serving of beans. But before lunch I did a pretty hard run (with loads of hill-climbing), so maybe that allowed me to get by with it.

Beans are kind of hard to classify, in terms of diabetic dieting. Their carbohydrate content is lower (and their fiber content far higher) than a comparable serving of a grain (such as rice). That sounds reassuring, and yet, all the same, beans do provide a pretty significant payload of carbohydrates. Plenty of diabetes patients find that including a serving of beans in a meal is liable to spike their blood sugar later. I seem to be able to tolerate beans better than a lot of people, but not 100% of the time. Beans are among those foods which I can often, but not always, get away with consuming. Beans are usually okay for me -- I just can't count on that!

Dinner was potentially a challenge. This was Ale Night -- an off-calendar holiday which I practice, about once a month, with two friends who used to work in my office. We went to this cozy little tavern in Occidental, CA:

I resisted the temptation to order fish and chips (reputed to be very good, but I wouldn't have been able to resist eating more chips than my system could handle, and I knew that wouldn't be a good idea). Instead I had a low-carb dinner: fish and a salad.

Unfortunately, there's no way for me to pretend that the ale itself was low-carb. I hope I don't pay too high a penalty for that in my fasting test tomorrow morning. Wine is usually a better choice for me, but ale-night is ale-night, and we don't do it all that often (the last one was about six weeks ago). If I try to play the role of Diabetic Superman every day, without giving myself occasional breaks from the effort, I'll probably go nuts and then give up the effort altogether.

If my fasting test tomorrow screams "Tom had too much ale last night!", I'll just have to get back on track, and do better the next day.

Monday, October 18, 2010  

I wasn't happy with the fasting result this morning -- I felt sure that I should have done better than that, especially after doing a long trail-run on Sunday. But I guess that long trail-run inspired me to try to get away with having too much to eat later on. Also, I didn't as much sleep over the weekend as I had intended to.

At least it was reassuring that the post-prandial result wasn't elevated.

After the long spell of unseasonably hot weather, it was comfortably mild on Saturday, and on Sunday morning it was raining. I felt instinctively that the rain would stop, and when it did (late in the morning) I headed down to the state park to do a trail run. Of course, the rain resumed as soon as I started running -- that is how life works, we all know that. Still, after about 40 minutes, the rain stopped once more, and I decided to make it a long run. It was nice to be running in cool weather again.

My run ended up looking impressive when I mapped it on the satellite photo of the region. It looks like I covered a territory about the size of Connecticut, but actually the distance was 9 miles.

A couple of years ago, when I was marathon-training, I wouldn't have regarded a 9-mile run as a very long one, and I wouldn't have made the mistake of thinking it entitled me to have anything extra to eat. Lately I haven't been doing anything much longer than 9 miles, and I guess this is changing my perspective. Well, I'd better change it back!

Often people write to the dLife forum saying essentially this: "I am allowed to eat 45 to 60 grams of carbohydrate per meal, but when I do, my blood sugar goes up to over 200! What am I doing wrong?".

Well, obviously, what they are doing wrong is giving someone else the authority to tell them how many carbs they are "allowed" to have in a meal (and then assuming that, whatever theory their medical advisor is using, reality ought to conform to it).

I doubt that anyone writes in to an allergy web site saying "My doctor says I'm allowed to eat mussels, but when I do, my throat swells up and I start suffocating and I have to be taken to the emergency room. What am I doing wrong?". When it comes to allergies, people are inclined to assume that their experience is valid and meaningful, even if their experience doesn't conform to what their doctor expected would happen to them. In other words, when reality and theory are in conflict, it isn't reality that has to back down. Your doctor might not know that you're allergic to mussels, but your throat does, and in that situation you have no choice but to pay attention to what your throat is telling you.

People don't seem to feel this way about diabetes. When their doctor tells them one thing and their glucose meter tells them something else, they don't know what to think. What can be the explanation for this disparity, they wonder? After all, their doctor has been to medical school, and their glucose meter hasn't. Don't they have to assume that their doctor is right and their glucose meter is wrong? Or that they themselves have done something wrong in trying to follow their doctor's advice, and that is why the result is bad?

Sorry, that's not how it works. It's true that your doctor has been to medical school and your glucose meter has not. On the other hand, your glucose meter has up-to-the-minute data on what is actually going on your bloodstream, your doctor does not. Your meter has no theoretical understanding of diabetes, but it does know how much glucose is in your blood, and you ignore that information at your peril.

Maybe some people can handle 45 to 60 grams of carbohydrate per meal. But you're not "some people". You're you. And if your meter says that you can't handle that much carbohydrate, then you can't handle that much carbohydrate. End of discussion!

That doesn't mean it is impossible that you could ever become capable of handling that much carbohydrate. Perhaps if you exercised more, or lost weight, or got your sleep apnea under control, or made some other beneficial change, you would become capable of handling the amount of carbohydrate which (according to your doctor's theory) you ought to be able to handle.

But if your meter says you can't handle it now, please listen to your meter. Diabetes management has to be reality-based, not theory-based.

Friday, October 15, 2010  

The soup I had for dinner had noodles in it, so I guess 133 isn't a bad post-prandial result -- although I prefer to keep my post-prandial results under 120 if I can, and often I can. You might well say, "If you wanted a result under 120, you shouldn't have eaten a soup that had noodles in it!". True, except that I've been able to stay under 120 eating that same soup in the past. Well, having got away with something in the past doesn't mean you'll always get away with it in the future. That's what keeps diabetes management interesting.

My doctor considers anything under 150 normal for a 1-hour post-prandial result, but from what I've read, non-diabetic people don't usually go over 120, so I'm trying to use that as a benchmark. I hit that target pretty often, but I missed it tonight. I thought the long run before dinner would be enough to cancel out the impact of the noodles. Not entirely!

I meant to go to the gym to do a strength-training workout this evening, but what with my long run in the evening, and other things I needed to do, I ran out of time for it. To some degree I can excuse that on the grounds that my yoga class last night counts, at least to some degree, as a strength-training workout. But it's not quite the real thing, so I'd better do some real weight-lifting over the weekend.

Rather than run at lunchtime, I went to the state park to do a trail-run late in the day. It was still pretty warm for running (in the high 80s). Well, I carried water, and I coped with the heat well enough.

Tonight I thought it would be interesting to reconstruct my trail-run by mapping it on satellite photos, and see if that gave me any kind of new perspective on the thing.

I parked my car by the dam at Spring Lake, and started an out-and-back route. Actually, I improvised the route as I went along, making impulsive decisions about where to turn whenever I came to a fork in the trail. I know the park well enough that I can do that without worrying about getting lost, or about commiting myself to a longer route than I have time for.

Up to this point I am on the border between the park on the right and residential neighborhoods on the left, but eventually I'm in the woods (and grateful for the shade).

There were a bunch of teen-aged runners on the trails, training for a cross-country race. They weren't there to make me feel old and fat, that was just a side-effect.

I did the steep climb up to the dam at Lake Ilsanjo, and started looping back to my starting point.

My run looks a little longer when viewed from orbit than it seemed at ground level. So, to that extent, the satellite view makes my run seem more impressive. But I have to say that the satellite view greatly understates the difficulty of the run in another regard: seen from up there, the terrain looks one hell of a lot flatter than it does from ground level!

No matter how comfortable you get with running on flat terrain, climbing over hills really puts you in your place.

The ancient Greeks defined the difference between tragedy and comedy in an interesting way: tragedy showed you human life as humans saw it, while comedy showed you human life as the gods saw it -- from a safe distance, and with a great deal of ironic detachment. The struggles were the same in either case, but when viewed from close up they looked serious, and when viewed from a safe distance they looked silly. Maybe the same distinction applies to the satellite view versus the ground-level view. Zeus would tell you that I did something absurd and inconsequential today, but I believe and hope that I did something significant and useful. We'll see who's right in the end!

Thursday, October 14, 2010  

It was supposed to cool down today, but it didn't. Temperatures in the 90s again. It made for a difficult lunchtime run. For that matter, it made for a difficult yoga class in the evening. Okay, Mother Nature: you've had your joke. It's mid-October, and it's time for you to knock this off! 

If this trend doesn't reverse itself pretty soon, people are going to have to wear much skimpier Halloween costumes than usual. I think this is one year when the naughty-French-maid outfits are going to sell a lot better than the wicked-witch outfits.

On the dLife forum today, I saw a post from someone who had signed up for a "diabetes walk" event, but then couldn't bear to go through with it -- particularly the part about wearing a special Red Strider cap which was supposed to signify that you're a proud diabetic: "I am not proud of having this disease... I am proud to have control over it now, but I don't know if I will ever be able to hold my head up and say 'I am a diabetic'."

How has it come to this, that we are supposed to define ourselves by our diseases, and show the world that we're proud of having them? And by the way: why should we be proud of having them?

If you ask me, pride is an overvalued trait. The only basis for pride that I can understand is personal achievement, and yet it seems that the things people usually take pride in are things that they did nothing to achieve. Being proud of winning a gold medal in the Olympics makes sense, but if you're proud because you are from the same country as someone who won a gold medal in the Olympics, aren't you being just a little over-imaginative? (I mean, what was your contribution to the Men's 5,000 Meter?)

It seems misguided to apply "pride" not to what you've done but to what you are -- and especially misguided to apply it to your health problems. Why be proud of them? It's not as if they were goals you set for yourself, and are darned pleased to have accomplished.

I suppose that, logically, it's more reasonable to be proud of having diabetes than to be proud of the country, city, or family you happen to have been born into. You may or may not have "achieved" diabetes, but the odds of your having achieved it are a lot higher than the odds of your having arranged the circumstances of your own birth. Still, even if you did contribute in some way to the development of your diabetes, I don't see why this is something to dwell on now, much less something to boast about or build your identity upon.

The thinking here seems to be that there are only two attitudes which one can adopt about having diabetes: either you're proud of it, or you're ashamed of it -- and to be ashamed of it would be unhealthy and weak and wrong! Therefore, the only choice open to any self-respecting person is to take pride in it. Be proud of who you are!

Well, wait a minute. What gives someone else the right to tell me that having diabetes is "who I am", and that I should take pride in it? And what gives them the right to decide that pride and shame are the only two possible reactions I can have to being diabetic?

People have all sorts of health problems, and they aren't urged to take "pride" in all of them. So far, at least, people are under no pressure to wear special fashion accessories to symbolize their pride in having periodontal disease, lactose intolerance, irritable bowel syndrome, insomnia, celiac disease, or adhesive capsulitis. And if there is a special parade for people with hemorrhoids, I don't want to attend it, and I don't want to know what they add to their wardrobe for the occasion.

Once upon a time, sharing with the world more information about your health problems than the world needs to know was not expected of you, and was not even considered good manners. When President Lyndon Johnson, recovering from gall bladder surgery in 1965, hiked up his shirt to let the news photographers have a good look at his surgical scar, it forever cemented his reputation as a boorish hick (and gave cartoonist David Levine a golden opportunity: in his rendering of the scene, the president's scar was shaped like Viet Nam).

If you're not comfortable showing the world your surgical scar -- or wearing symbolic clothing to demonstrate that you're having trouble controlling your blood sugar -- then I don't see why anyone should expect you to do these things.

For that matter, I don't see why anyone should expect you to run around telling everyone that you're diabetic. I haven't been secretive about it myself, but I only discuss it when I feel the need to explain my situation to somebody, and I have enough of their time and attention to be able to explain it thoroughly. If I don't have enough of their time and attention, I don't go into it -- I just say "no thanks, carrot cake is not what I need today" and let them guess why it isn't. Most people have such a poor understanding of what diabetes is that to announce yourself as diabetic to the world at large is not necessarily going to clarify your situation very much.

If you want to manifest your "pride" in some category into which you happen to fall, there are plenty of other areas to focus on. For example, I found out today that you can purchase a button which manifests your pride in being a meat-eater:

Even better, you can purchase T-shirts which declare your stance on local athletic rivalries -- including this generic one from the folks at The Onion:

But if having an endocrine disorder which causes chronic hyperglycemia is supposed to be a point of pride, I'd like to hear more about why that should be so.

Wednesday, October 13, 2010  

More hot weather today, to make running a little more difficult than usual. But all's well that ends well -- later in the day the temperature dropped to the comfort zone, and I went where all right-thinking people in my community go on Wednesday evenings in warm weather: to watch the sunset from the patio of the Paradise Ridge winery.

Some would argue that neither a beautiful sunset nor a nice glass of Zinfandel actually solves anything, but I'm of a different opinion. I think my day ended far better than it began. That's my story and I'm sticking to it.

I'd like to continue the discussion I started yesterday, about insulin as a very mixed blessing.

As I said in my October 12th blog, a lot of people with Type 2 who supposedly don't produce enough insulin (in the sense of "not enough to prevent high blood sugar") also produce too much insulin (in the sense of "too much to be considered normal and harmless"). When you become insensitive to insulin, your pancreas pumps out abnormally large amounts of it, to try to compensate for the problem. If you can't make enough extra insulin to compensate for the problem, you become diabetic, and then (perhaps) medical science steps in, to expand your insulin supply even further. But what if this approach solves one problem by creating another?
High blood sugar might seem, at first glance, to be such a serious problem that anything you do to bring it down is bound to be worth the risk. If normalizing your blood sugar means living in a chronic state of hyperinsulinemia, so what? Chronic high blood sugar would be even worse! 
Well, even if that is true (and for all I know it is), I still am not comfortable with the idea of simply accepting chronic hyperinsulinemia and its risks, without even considering what those risks are, and without seeking ways to reduce or avoid them. Before I'm going to choose to live in a hyperinsulinemic state, I want to think about what I'm getting into, and whether or not I have any other options.
There are three problems with hyperinsulinemia which, at least in my view, make it seem like a dangerous long-term strategy for glycemic control: (1) it promotes cardiovascular disease, leading to strokes and heart attacks, (2) it promotes weight gain, and (3) it promotes insulin resistance -- the very problem which it is supposed to overcome. There may be other problems with hyperinsulinemia, but those are the three which concern me.

It may seem surprising that having extra insulin in your bloodstream could have any of these harmful effects. Isn't insulin just a chemical signal which drives your blood sugar downward? Well, it's a chemical signal, all right -- and driving your blood sugar downard is, indeed, one of the things that insulin does. But hormones tend not to have just one effect, even if we would like to think that they do, for the sake of simplicity. Simple stories are always more appealing to us than complicated ones, but I'm afraid that insulin is a complicated story.

In addition to stimulating muscle cells to absorb glucose (thus bringing down your blood sugar), insulin also stimulates the liver to generate and release fatty acids into the bloodstream. Insulin stimulates fat cells to absorb these fatty acids and store them as fat -- and it even stimulates fat cells to absorb sugar and turn that into fat. Even worse, insulin inhibits the burning of fat for energy. (All of these things promote weight gain, obviously.)

Then there's the most paradoxical effect that insulin has: it "downregulates" a cell's response to insulin, in terms of the cell's absorption of glucose out of the bloodstream, for a period of hours. What this means is that, the more heavily and frequently you expose your cells to insulin, the less insulin-sensitive they become. This isn't a problem for most people, because in most people insulin production is modest and episodic. But if you're dosing yourself generously with insulin (or with drugs which cause your pancreas to produce more insulin), the result is to make you less and less sensitive to insulin. It seems that hyperinsulinemia is a vicious circle: its purpose is to overcome insulin resistance, but it creates more insulin resistance in the process.

As if those problems weren't enough, hyperinsulinemia also has an inflammatory effect on the walls of blood vessels, and this promotes serious cardiovascular problems. Insulin resistance (and the hyperinsulinemia it produces) has long been known to be an independent risk factor for coronary heart disease; in fact, the whole concept of "metabolic syndrome" arose from research (by Gerald Reaven, among others) into the question of why heart attacks often happen to people who seemingly lack risk factors for heart disease. It turned out that those people did, in fact, have a risk factor in common -- hyperinsulinemia resulting from insulin resistance. The same goes for strokes, too. Insulin resistance (even in non-diabetic people) increases the risk of stroke -- and it does that independently of any other other factors which might be expected to put you at risk for a stroke.

So what am I saying here -- that insulin is bad, and that no one should seek to have more of it than nature is providing?

No, I'm not saying that. I'm just saying that abnormally high levels of insulin in the blood are known to have undesirable effects, some of which are quite dangerous, and that trying to control diabetes that way sounds like a high-risk strategy to me. Whether the problems it creates are less serious than the problems it solves is, I suppose, debatable. However, I don't envy a debater whose task it is to convince people that heart attacks and strokes aren't serious.

Admittedly, not everyone who has Type 2 diabetes is necessarily hyperinsulinemic. It is believed that Type 2 patients typically generate abnormally large amounts of insulin at first, but after a period of years their insulin productivity tends to decline, and it usually ends up being lower than normal, not higher than normal. If the aim of the treatment is merely to give the patient a normal level of insulin, I can hardly object to that. But if the aim of the treatment is to give the patient more insulin than a healthy non-diabetic person would ever have, then I think a little bit of cost-benefit analysis has to be done. It still might be worth going ahead with that kind of therapy, if you can't find any other solution. But should it really be your first choice?

It seems to me that hyperinsulinemia is more realistically seen as one of the problems of diabetes than as one of the potential solutions to diabetes. If a patient is not making "enough" insulin to normalize his blood sugar, then the thing that needs to change may be how much insulin he needs, not how much insulin he has.

It seems to me that, when our "need" for insulin is growing out of bounds, the first solutions we should reach for are those which reduce that need, not those that satisfy it:

I guess what I'm trying to do here is to explain why I'm taking my particular approach to diabetes management. If I didn't explain this, you might assume it was because I was born with an instinctive fondness for doing 4-mile runs, on steep hills, when it's 90 degrees outside -- or perhaps because I am unaware that cinnamon rolls taste good. Not so, I promise you! If I thought I'd do better by letting the pharmacy handle this, that is exactly what I would do. The problem is that, so far as I can see, letting the pharmacy handle it doesn't seem to work out very well for most diabetes patients.

Good diabetes management is an inside job. I'd prefer not to have to do that job, if I really had a choice, but I know better than to outsource it.

Tuesday, October 12, 2010  

We're having truly ridiculous weather this week:

We did our lunchtime run a half-hour early today, just to try to get it done before it became too hot. This is not what mid-October is supposed to be like, even in California.

I had a really awful case of insomnia last night. I did get an hour or two of sleep, but that was about it. This is a problem for me, because I want to write about something complicated tonight, and I know I can't stay up late enough to finish it, because I desperately need a good night's sleep this time to make up for last time. I'll get as far along with it as I can.

There is a tendency, in most literature about diabetes, to mention insulin in a way which suggests that insulin is entirely beneficial, and that diabetes is essentially a situation in which the patient isn't producing enough of this wonderful substance. In other words, if diabetes is the problem, insulin is the solution. Therefore, it seems to diabetes patients that any treatment which increases their insulin supply (either with supplemental injections of insulin, or with drugs which stimulate the pancreas to produce more insulin) has to be a big step in the right direction. 

I am unable to see it that way, because I don't think insulin is a purely beneficial substance. I'm not picking on insulin: I simply don't believe that purely beneficial substances exist. Name anything which it is harmful to have too little of in your bloodstream (sodium, Vitamin A, iron, glucose) and it is also harmful to have too much of it in your bloodstream. People have died from drinking too much water, for crying out loud. Therefore, I think we need to be cautious about treating insulin as a unique case of "more is always better". For some people, more insulin is the perfect solution to their problem. For others, more insulin is the problem.

Some people with diabetes can't produce normal amounts of insulin (this is true of people with Type 1, and it is true in some fraction of Type 2 cases). But there are plenty of people with Type 2 (or "pre-diabetes", or "metabolic syndrome", or "insulin resistance", or whatever phase of Type 2 you want to name) who produce abnormally large amounts of insulin. And yet, very confusingly, these people are often described as not producing enough insulin. So which is it? Do they produce excessive amounts of insulin, or do they not produce enough insulin?

Well, in a way, both halves of the paradox are true, depending on what you mean by the word "enough". If you think of insulin purely in terms of its effectiveness in holding down blood sugar to the normal range, then having "enough" insulin means that you have whatever amount of insulin it takes to normalize your blood sugar. Defining "enough" that way leads to some mighty strange situations, however. If your tissues have become so insensitive to insulin that it takes five times as much insulin to normalize your blood sugar as it takes to normalize the average person's blood sugar, then you could produce four times as much insulin as the average person, and still have it said about you that you aren't producing enough insulin -- and that you ought to be medicated until you have five times as much insulin as the average person, not four times as much.

Type 1 patients obviously have to inject insulin, since they can't produce any insulin of their own, but they only inject enough insulin to give themselves a normal insulin supply. When people with Type 2 are treated with insulin shots, or with oral medications which increase the insulin productivity of the pancreas, this is not necessarily a case of compensating for lost insulin productivity, and bringing up the patient's insulin supply to a normal level. Some Type 2 patients are already producing insulin in abnormally large amounts -- and they still are being medicated to enlarge their already-large insulin supply. (And insulin dosages are often higher for Type 2 patients than for Type 1 patients!)

Of course, none of this would matter, if insulin were as purely beneficial as we like to pretend. So what if you need five times as much insulin as other people? If that's what it takes, that's what it takes! The more insulin, the better, in your case.

But, as I said, no substance is purely beneficial. If you don't concentrate exclusively on the issue of glycemic control, then there is such a thing as having too much insulin. The medical term for this condition is "hyperinsulinemia", and it is not by any means a trivial matter.

The insensitivity to insulin which characterizes Type 2 diabetes causes the pancreas to try to compensate for it by releasing abnormally large doses of the stuff. This process begins long before you are diagnosed with Type 2. In fact, so long as the compensatory strategy keeps working, there is no way to detect that you have Type 2 -- your blood sugar doesn't get elevated enough for you to be diagnosed with the disease. This state of affairs, sometimes called "metabolic syndrome", can last for many years without ever turning into detectable diabetes. But that doesn't mean it's harmless! The hyperinsulinemia takes its toll in other ways. Excess insulin in the bloodstream apparently has an inflammatory effect on the blood vessels. This promotes plaque buildup, blood clots, and blockages which lead to strokes and heart attaks. Even if your insulin resistance never makes you diabetic, the hyperinsulinemia that it produces can do you very serious harm.

Therefore, I would argue that the solution to the problem of needing more insulin than you can produce is, in some cases, not to increase the amount of insulin you have, but rather to reduce the amount of insulin you need. When demand exceeds supply, it's often the demand that needs to change, not the supply.

That's about as far as I can get tonight, but I plan to say more about the subject as soon as I can.

Monday, October 11, 2010  

Wow -- how's that for a post-prandial result? 86. And I had a serving of peas with lunch, too. No other foods with a significant carb content, though, which I guess is why I was able to get away with eating the peas.

On Saturday there was a big (in every sense) cycling event in Sonoma County: Levi Leipheimer's King Ridge Gran Fondo. Apparently Gran Fondo is Italian for Big Ride. This ride was big in that the longest of the three routes was slightly over 100 miles, and also in that about 6,000 cyclists participated in the event. I wasn't participating myself, and I had something else to do later in the day, but since I knew some of the people participating in the event, I got up early in the morning to go take some photos of it.

It was certainly a beautiful day for a bike ride -- after a wintry August, we are now having a decidedly summery October.

I have done "century" bike rides before, but I've been so focused on running rather than cycling lately that I wouldn't have dared to attempt this one (also, I knew that the route included a couple of brutal climbs). But I did feel just a touch of envy as I watched the endless stream of cyclists gliding past the vineyards on their way to the scenic roads along the coast.

Later that day, I was one of a small group of musicians hired to play Irish music at a party which a man in Kenwood was throwing for his wife's 50th birthday. I wish I had brought a camera to photograph that event. It took place in a remarkable location which is hard to desribe -- a ring of trees within a deeply shaded canyon, with one huge tree in the center, its trunk wrapped by a crescent-shaped wooden platform, which served as a stage for us to play on. It looked like a scene from The Lord of the Rings. A temporary dance floor had been set up in front of the tree, and a couple of dance teachers instructed the guests in doing Irish set dances, for which we then provided the music. I was skeptical that the guests would actually cooperate in this effort, but after a few drinks they threw themselves into it, and a good time was had by all.

The other three musicians were actually from Ireland, and they were puzzled as to why an American man married to a woman from England would want to have a party in which the music was Irish. I tried my best to explain to them that, in America, cultural identity tends to be something you choose, perhaps temporarily, not something you get stuck with. (I didn't try to explain to them why the food served at the party was Mexican. "It tastes good" would be about as much explanation as the average American would demand, and I wasn't sure I could come up with anything better than that.)

As fiddling was the only exercise I had on Saturday (while friends of mine were pedaling their way up Coleman Valley Road, climbing all the way from the coast up to Occidental, heaven help them), I thought I had better give myself a serious workout on Sunday morning. So, I did a hilly, 9-mile trail run. I had to start slow, because I wasn't really feeling ready for a hard run at first, but I felt better and better as I went along. The warm weather didn't bother me; I was carrying plenty of water. The world was looking beautiful to me, and even at the end I wasn't very tired.

And then I went to the office. How's that for an anti-climax? Going in to work is not my usual Sunday routine, but I had a difficult deadline to meet today, and I knew I would never make it if I didn't put in some hours at work yesterday. So I did what was necessary.

Can a virus make you fat? This article in WebMD says it can.

Apparently a common respiratory virus known as Adenovirus-36 (Ad-36 for short) has been statistically linked with obesity. 30% of obese people have been infected with Ad-36, but only 11% of lean people have. Experiments with monkeys show that the animals gain weight after being deliberately exposed to the virus.

But how could a virus possibly do this? The claim is that the virus affects stem cells -- increasing the number of them which turn into fat cells, and also increasing their fat-storage capacity. Magdalena Pesarica  presented these findings to a national meeting of the American Chemical Society in Boston: "We're not saying that a virus is the only cause of obesity, but this study provides stronger evidence that some obesity cases may involve viral infections," Pasarica says in a news release. "We would ultimately like to identify the underlying factors that predispose some obese people to [the effects of] this virus and eventually find a way to treat it."

From the mechanism described, it's obvious that infection with a virus which causes you to increase your count of fat-storage cells would increase the likelihood of obesity (simply because, when you take in excess calories, your body has more places to store them away). However, it doesn't seem to me that the virus is exerting magical powers here, and making obesity inevitable. The virus may give you more places to store fat, but it's still up to you to decide how much of a calorie surplus to take in.

All sorts of ideas have been put forward to explain why weight control is harder for some people than others, and this is one more of those ideas. Very likely it's correct, as far as it goes, but I hope people don't resign themselves to obesity on the assumption that a bad cold they suffered ten years ago has brought this upon them, and now there's nothing they can do about it. 

Friday, October 8, 2010  

Okay, I tried to take some active inspiration today from Abe's story (which I presented in Wednesday's blog) -- in two ways. Each way had a connection to one of my two running buddies at work.

One was to follow up on the discussion I had yesterday, with my running buddy who was telling me about a slightly different approach to weight-lifting which she and her husband have been doing (light weights, but enough repititions to make it hard to finish them all). Even though I had a music rehearsal to get to after work, I managed to squeeze in a visit to the gym, and tried out her approach. It was interesting: you use weights light enough that the first few reps seem absurdly easy. Somewhere around rep number 15, it begins to dawn on you that your muscles are really starting to burn and it's not going to be easy to get to rep number 30.

After the workout, I was reconnecting with memories of weight-training in the past -- recalling that feeling of mild soreness in the muscles which is oddly pleasant. It stays with you just enough to keep reminding you that you had a workout, but not enough to actually disable you from doing what you want to do. I was worried, at first, that having the workout just before a music rehearsal might have been foolhardy (I was afraid my arms would be to unsteady to hold the fiddle and bow steady), but when I actually played the instrument it was fine. And the rehearsal went well. A small group of us are playing Irish music at someone's big birthday party tomorrow. It's an outdoor party, so I hope the weather is warm -- playing the fiddle with cold fingers can be a hellish experience.

The other way in which I tried to take some inspiration from Abe's story involved my other regular running buddy at work, who was running with me today. He likes big athletic challenges (he's doing a 100-mile bike race tomorrow, for example), and he likes talking me into participating in such things with him (he was the one who talked me into doing my first marathon with him, and he's currently trying to talk me into doing another one next spring). But he's been complaining lately that he's gained weight, and can't seem to get rid of it, and this is hampering his athletic performance. So I challenged him to a weight-loss competition, with a target weight-loss figure, and a target completion date, and probably some significant money riding on who did better. 

He didn't exactly jump at the opportunity. He raises various practical objections, one of them being that he needed to lose more pounds than I did, so it wouldn't be fair. I said we don't have to define it as a competition to reach a certain weight, but a competition to lose a certain number of pounds -- probably 15, since that's about as far as I'd like to go. He said (as if it were a flaw in my scheme) that he wanted to lose 20. I laughed at this, and told him there's nothing saying that if we both lose 15 pounds as a result of the challenge, he has to stop there and can't continue losing the remaining five -- on his own time, so to speak. He then made a very artful change of subject.

In short, I don't think I really had him sold on the idea. But I told him that I wasn't willing to discuss the marathon any further until we had resolved this matter first. So, if he doesn't rise to the occasion and agree to take me on in the weight loss challenge, at least he'll be forced to stop cajoling me into running the marathon in March.

The thing is, I think I'm right to connect those two issues. If I am going to run another marathon, I'm going to want to do it at a lower weight, and see if that makes it any easier on the body.  I've been feeling that running would be a lot easier if I shed some more pounds, but I've been having trouble doing so. Making a competition of it might be what I need to get focused and make progress.

Thursday, October 7, 2010  

What a shame -- now I have to go back to writing about me. Telling Abe's story yesterday instead of my own was a nice break. And it was a pretty good story, I thought. Diabetes patients who lose 100 pounds, become athletic, and convince their doctors to take them off metformin are not encountered every day of the week.

However, if I treat Abe's diabetes journey as a good story and nothing more, than I'm not going to benefit by it. So, I have to ask myself the obvious question: is Abe doing something that I'm not doing?

I might not see a need to ask this question, if all of my test results were exactly where I wanted them. But the uptick in my A1c test result (from 5.3 a year ago to 5.6 last month) has put me in the mood to wonder what might have caused it, and to question my assumptions about how well I had everything under control. I certainly don't want to interpret this as a sign that my pancreas is wearing out, or that some other invisible and unavoidable decay is going on (once you let yourself think that way, the doomsayers' prophecies of "progression" become self-fulfilling). No, my first assumption has to be that, if my A1c went up, it was because I wasn't doing all that needed to be done. So where might I be falling short?

I don't think diet was an area in which I left myself down (apart from my reckless eating habits while I was on vacation in August). In recent months I've become more cautious about carbohydrate consumption, not less. It's always possible to fool yourself about such things, but I'm reasonably sure that I've been doing well on that score lately.

Sleep could be the problem area. Although I'm no longer struggling with sleep apnea, the struggle with my nocturnal nature gets harder and harder over time. I am at my most alert late at night. If my schedule were utterly free, I probably wouldn't ever go to bed before 2 AM. Every night I have a battle to make myself fall asleep. I have no trouble dozing just after lunch (how I wish the siesta were an American custom!); dozing at midnight is what I have trouble with. But maybe I haven't been fighting this problem as hard as I once did, and can get back on track.

But what Abe's story really brought to my mind was the possibility that, for all the running I do, I have still been trying to get by with an incomplete exercise program. He's been putting a lot of emphasis on weight-lifting, and in recent years I've been skipping weight-lifting entirely because (1) I thought I was doing fine without it, and (2) I don't enjoy it. But the increase in the A1c test could be an indication that I'm not doing as well without it as I imagined. And, as Abe would probably tell me, the fact that I don't like weight-lifting is only an excuse, not a legitimate obstacle (and he's not into excuses).

As I like to tell others, when you need to do something but don't want to do it, the trick is to find a way to like doing it. Maybe I need to find a way to like weight-lifting.

While running today I talked to one of my running buddies about this. She doesn't like weight-lifting either, but she has been doing it regularly because she thinks it helps her with running and other things. She told me about a different approach to weight-lifting which she and her husband adopted 3 or 4 months ago (based on advice he received from a physical therapist). Instead of using heavy weights and doing a dozen or so reps (which I thought was simply the way it's done), they cut back on the weight enough to be able to do 30 or more repetitions in a row. You get about as tired either way, by the time you finish your reps, and she said that for a month or two they thought this approach wasn't making any difference. But now, she tells me, she feels as if it is working better than the old approach was. She doesn't think her muscles are bigger, but they're firmer -- less fatty. Her clothes fit better.

Since I usually exercise outdoors rather than indoors, I can't do a weight-training workout unless I make a special trip to the gym before or after work, and fitting that into my schedule can be tricky. But, again, that's more of an excuse than an obstacle.

It won't be easy, since I have a music rehearsal to get to tomorrow night, but I'm going to try to fit in a gym workout tomorrow after wrok, and see if I can get the ball rolling on this weight-lifting thing. Maybe I could do it before work, but that might take a genuine miracle. We'll see.

Tuesday, October 6, 2010  

Abe Ramos, a reader of this blog, has made it possible for me to share his inspiring story with you -- and I bet you're already bracing yourself for a story about a guy who has done something spectacular which you couldn't do in a million years!

That's the trouble with inspiring stories, isn't it? The fact that they're amazing is what gets us interested in them in the first place, but as soon as we've heard the amazing story, we decide that it's a too amazing -- at least, too amazing to be relevant to our own lives. "It's great that he could do that, but I'm not like him", we think to ourselves. So, in the end, are we truly inspired, or are we merely impressed?

Being impressed is the reaction you have when you watch somebody win an Olympic gold medal in gymnastics. It doesn't make you think, "Hey, I bet I could do that!". (If you thought you could do it, you wouldn't have been impressed.) Being inspired is different. When you are inspired by something, you breathe it in. (That's the literal meaning of inspiration, by the way: inhaling.) Inspiration means accepting an influence from outside yourself, and letting it become a part of you. You metabolize it, so to speak.

So, as you read Abe's story, please try to cross that boundary between passive admiration and active inspiration. Think about letting some part of his story become part of your story. That's what I will try to do, anyway, and I hope you will too. I don't want you saying afterward, "Yeah, I read that story... but I didn't inhale".

When Abe sent me some photos from the Camp Pendleton Mud Run in June (an event which people sign up to do in 5-person teams), I assumed I knew which member of the team he was. The guy on the right, almost certainly. I mean, if you had to guess which was the guy who was getting himself in shape in order to bring his Type 2 diabetes under control, wouldn't you pick the guy on the right in this photo?

But I knew that diabetes can surprise you, so I asked him to confirm that he is the guy on the right. And it turns out that he's actually the other fellow.

Huh? What? This guy? This young athlete with the high-definition biceps? He's the Type 2 patient in this group?

I started to think that maybe there was a more dramatic story here than I had quite grasped. Abe helped me grasp it a little better by sharing some photographic evidence of how far he has come since he was diagnosed:

How's that for a before-and-after picture pairing? Would you even recognize them as the same person?  (Abe is reluctant to use the word "after", as he says that diabetes patients "never really get to a finish line", but I don't think pictures get any more "after" than this one.) And it's worth pointing out that the transformation captured here is not an extremely lengthy one. The diabetes diagnosis which made him decide to lose weight and get in shape dates back only to April of 2009. You're looking at a metamorphosis which happened in little more than a year.

Abe describes himself as an all-or-nothing guy, who does something thoroughly or not at all, and based on the photographic evidence before me I am inclined to take his word for it. Anyway, I wanted to find out more about Abe's story (partly because I was disoriented to think that this was someone who listed me among his inspirations, when he has clearly achieved more than I have, and in less time). He kindly agreed to fill me in.

Abe is disarmingly candid about what preceded his entry into the world of Type 2 diabetes: at the point he was diagnosed, he says that he ate "garbage", drank "way too much beer", and never did any exercise. Unlike many Type 2 patients, he doesn't try to lay 100% of the blame for what has happened to him on his chromosomes: "My genetics loaded the bullets in the gun, but my lifestyle pulled the trigger," he says.

His weight had climbed to the vicinity of 260 pounds during the run-up to his diagnosis. He knew, just as everyone else knows, that this kind of weight-gain can have serious long-term health consequences, but he didn't realize that the consequences could arrive as early as age 34. The diabetes diagnosis came as a serious shock. Even so, he admits that by that point he was already concerned about what was happening to his health. His weight gain was already changing his life for the worse. Sleep apnea had turned him into "a zombie" (I can relate!), and outdoor activities which he had once enjoyed were only a memory. Climbing stairs -- or even descending them -- made him gasp for breath. He may not have realized that he had diabetes, but he realized that all was not well.

When the diagnosis came, he experienced many of the standard-issue emotional reactions (such as shock and anger), but he managed to skip the most dangerous one: denial. From the start he was determined to face the situation and get control of it. Which was a good thing, because facing up to what his doctor had to say to him took a fair amount of determination. "The Doc laid it out for me. What foods I couldn't have anymore. What meds I needed to start taking immediately. What would happen to me if I didn't comply with his every command. He put the 'fear of God' in me that day. I am not going to lie; fear was a motivating factor -- and still is (although not nearly as much) in trying to get a handle on my diabetes".

However, Abe found other motivating factors. "I was also motivated to change my life for other reasons; to be around to spend time with my family and friends (apparently some of them actually like me). To turn my life around."

He also looked for ways to turn his self-perceived weaknesses (stubbornness and egocentricity) into strengths. The stubbornness helped him stand his ground with his doctor (who seemingly did not have great faith in Abe's ability to get his diabetes under control through lifestyle changes). The egocentricity (by which he seems to mean nothing more grave than vanity) helped him stay the course with his diet and exercise program, because he wanted to be able to buy fashionable clothes and look good in them.

I can't see vanity as a sin, particularly for a diabetes patient who can use it to motivate himself to live a healthy life. If vanity enables you to get in shape, then you will not have been vain in vain!

I must say that it puzzles me when I hear gym members make comments about the other members whom they catch checking themselves out in the mirror -- as if people shouldn't care whether or not they are making progress! Show me a guy who lifts weights but never checks himself out in the mirror, and I'll show you a blind man.

If Abe feels he's being egotistical to want to be in great shape, then maybe the rest of us with Type 2 should strive to be a little more egotistical.

Okay -- are you feeling intimidated yet? Good, you're normal. Let's continue with Abe's story.

"How did I turn my life around? First off, I realized that the only way to change my life was not to treat this as a diet, a.k.a. a brief modification that would quickly revert back to my old routine. It had to be a lifestyle change. That is the only way to battle this lousy disease. I read, researched and educated myself about diabetes."

Educating himself about diabetes led him in the same direction which it leads everyone who is truly paying attention: he knew that he had to get into shape.

"Next, I put one foot in front of the other. I could barely walk around the block when I first started. I was too heavy to even jog. Through trial and error I discovered what foods were good for my BG levels and which ones weren't. I harassed my medical group for as much blood testing supplies as I could get. How can we diabetics figure out what is ok for us to eat without knowing how it affects our BG levels? Portion control was huge. I realized that we eat with our eyes as much as we do our stomachs. I cut back on my carbohydrates (including my beloved rice and beans), I became best friends with veggies. I put together a support team (including my wife, my family, doctors, friends and some great people on e-forums like dLife). Finally, I also became one with exercise. I haven't gone more than 2 days without running or lifting weights in over a year and a half. As much as holding down the couch came as second nature, I get agitated if I am not exercising. A body in motion tends to stay in motion. Like you said, ironically, being diagnosed as a diabetic ended up forcing me to get into the best shape I have ever been in."

By late May of 2009, he was posting on the dLife forum, reporting remarkable progress. His weight was already down to 222 pounds, and his initial fasting level (174 -- precisely the same as my own at diagnosis, I mention irrelevantly) was now averaging 100. His 2-hour post-prandial results were down to the range of 100-115. He was on Metformin, but had high hopes of being able to stop taking it (and getting the resulting diarrhea out of his life) once he could demonstrate enough improvement to his doctor.

I first heard from him in June of 2009, at which point he was both proud of his progress and frustrated that he nevertheless needed to stay on meds for the time being: "I am currently on 1000 mg of metaformin per day (2x 500 mg) and taking high blood pressure medication as well. My doctor was adamant about putting me on meds, so in the end I did not resist. Anyway, I made it clear to him that if I stuck with my lifestyle change (as opposed to "diet") and I saw significant results I wanted to get off of medication. My doctor has agreed to this and since I have seen amazing results already, I am very hopeful that I can get off the medication(s)."

His amazing results soon included a spectacular drop in his A1c result, from 8.1 upon diagnosis in April 2009 to 5.5 in July. (I'll bet that one made his doctor do a double-take when he received the lab report! Very, very few patients ever achieve that degree of reduction in so short a time.)

In October of 2009, Abe (who had been barely capable of taking a walk around the block in the spring of that year) ran his first 5K footrace (that's slightly over 3 miles). I checked the results of that race, and was greatly relieved to see that his running pace was comparable to my own -- then! (I'm sure he could beat the pants off me by today, at the rate he's been progressing.)

The following month he was finally able to convince his doctor that it was okay for him to stop taking Metformin -- which means that, on Thanksgiving this year, he will be be celebrating his one-year anniversary of freeing himself from the need to take diabetes medications.

I don't think he's been standing still since then. "I have never been so determined to accomplish anything in my life as I am right now. Today, things are going well, and one day that might change. But I can only live for today and to do the very best that I can to fight this disease off for another day. Don't let the bad stuff get to me too much; get right back up when I get knocked down. I am incredibly hard on myself, so I also make sure that I have to allow myself to celebrate the successes, big and small. I hope that anyone reading your incredible blog (educational, entertaining and inspirational), especially those who doubt that they can achieve success, at least consider the fact that Diabetic Medical Convention isn't always correct. YOU HAVE TO TAKE AN ACTIVE APPROACH TO YOUR OWN CARE. NO ONE ELSE CAN DO IT FOR YOU, NOT YOUR DOCTOR, NOT A SIGNIFICANT OTHER. YOU AND ONLY YOU! Being positive, eating right, exercise, testing, having a support team and not getting down when you screw up can help you live a long and successful life with Diabetes. It doesn't have to be a gradual (or quick) descent into pain, failure and an early death. Positivity and success IS an option."

Having achieved such a remarkable level of success, Abe is feeling inclined to share the wealth, and not just in this blog post. He would like to offer in-person encouragement to diabetes patients who doubt that they can do anything like what he has done. He is hoping to create a local diabetes support group in Orange County, California, where he lives (he hasn't been able to find such a group in his area, so he figures the sensible thing it to set one up himself). If you are interested in communicating with him about that, his e-mail address is:

I warned Abe that people who were impressed by his achievement might neverthless assume that it must have been easy for him -- that he has some kind of supernatural gifts which enable him to do things which others cannot do. He rejects this idea with great firmness.

"Has it been easy? No. I might have lost 60 pounds in 4 months and 100 pounds in about 9 months, but it was never easy. It takes managing your disease one day at a time. Especially at the beginning when we get so caught up in how much we need to lose or what horrible dreaded thing can happen to you.

Same with the exercise. I could barely walk around the block a couple times without getting winded (and I am a slow walker). I was too heavy to even do a slow jog as it would hurt my knees. I started with baby steps. 20 minutes walking on the treadmill. Then it was 30 mins. Finally, after one month of my exercise consisting only of walking on the treadmill, I finally introduced jogging (no more than a couple minutes at a time). I remember the first time my sister dragged me out jogging at the park. 3 miles, we walked the first half. I jogged the last half and felt like I was going to die. But I also knew that the odds of me dying were a lot higher if I chose not to run.

Seriously, look at my 'before' pic. I was no athlete. I am not special. I merely refuse to accept excuses from myself. I am sure that there are plenty of people who read this blog who for whatever reason cannot get off meds or have some sort of physical disability that makes strenuous exercise very difficult. That's all ok. Just remember, that any exercise is better than none at all. Push yourself and you'll be surprised at the positive results."

If you're feeling slightly humbled by Abe's story, I have to admit that I share the feeling. Apparently he was able to learn something from me, in the early stages of dealing with his diagnosis, but it looks like it is now time for me to start learning from him.

I think I see some weight-lifting in my future...

Tuesday, October 5, 2010  

Does the phrase "bury the lead" (sometimes spelled "bury the lede") mean anything to you?

Maybe not -- it's from the professional jargon of journalists, and it has only leaked out into the general culture to a minor extent. To reporters, the lead (or lede) is the main point of a story, the thing that's so important that you ought to begin with it. Readers of newspaper articles are notoriously impatient, and if you delay getting to the point, you may lose the reader's attention. If you begin with some matter of secondary importance, and postpone the matter that is of primary importance, this is looked upon by other journalists as a beginner's mistake. You obviously don't know how to write an article, because you buried the lead.

However, the practice of burying the lead may not always be an amateurish blunder. Sometimes it might be a way of whitewashing awkward facts (that is, facts which are embarrassing to the powers that be). If you bury the lead deeply enough, you can prevent that awkward fact from making any impression -- but you can still claim that you didn't conceal the awkward fact, since you did get around to mentioning it eventually, toward the end of the story (secure in the knowledge that many readers never get that far).

Of course, it's always a matter of opinion what part off the story truly qualifies as the lead. If I accuse someone of burying the lead, he can always say that he simply disagrees with me about what the lead is. Who am I to tell him that he emphasized the wrong thing?

Indeed, I have no credentials or authority to accuse anyone of burying the lead. I can't help noticing it, though, when I think I've spotted somebody doing exactly that.

Here's an example (you knew I had an example): this Medscape article entitled All Diabetics Over 40 Should Be on Statins, EASD Told.

The article describes a presentation, by Dr. John Betteridge of University College London, to the European Association for the Study of Diabetes at their meeting in Sweden last week. He argued that everyone over 40 with diabetes (regardless of whether it's Type 1 or Type 2) should be put on statins. He said that statins are safe and effective and that complaints about their side effects are false. He deplored the tendency of patients to stop taking the drugs -- the ungrateful wretches! (I'm not actually quoting him on that last bit.)

And at the very end of the article we find this footnote about Dr. Betteridge: "Betteridge has received honoraria for lectures and attendance at advisory boards and some research funding from AstraZeneca, Bristol-Myers Squibb, Kowa, Merck Sharp & Dohme, and Pfizer."

Okay, so Dr. Betteridge is taking money from the companies that make statins, and traveling the world telling doctors that they have to prescribe statins even for patients who don't want to take them -- but you don't find this out unless you read all the way to the bottom of the article. Call me paranoid, but I think that qualifies as burying the lead.

I'm not impressed that statins are "effective" in the sense that they make your lab numbers look good, because there is reason to doubt that they are effective in the more important sense of preventing you from having a heart attack and dying. Also, I'm unscientific enough to take seriously the testimony of three men I know very well who have told me that taking statins made them feel so awful that they simply couldn't continue living under that burden. (After one of them rebelled and stopped taking the pills, I heard him laugh -- for the first time in a year.) I'm not claiming that statins make everyone feel like they're dying (some people tolerate them very well), but the fact that I know three people who were affected that way makes me extremely unready to sympathize with someone who is advocating the categorical prescription of statins to reluctant patients while, quite coincidentally, he is taking money from the companies that make those drugs.

Look, I'm a diabetes patient over 40, and I'm not taking statins or any other meds. My labwork last month showed my LDL cholesterol as 86 and my HDL cholesterol as 52. I don't think I need statins, Dr. Betteridge, and I'd like to know who you think you are to tell my doctor to force them on me.

Don't diabetes patients have enough problems already, without having to deal with this kind of thing?

Monday, October 4, 2010  

Aaaargh! I wasn't expecting my fasting test should be as high as 98 this morning. After all, I ran a 10K race (that is, 6.2 miles) in the morning yesterday, and I didn't think I overdid the carbs afterward, either.

On the other hand, I certainly didn't overdo sleep, and lack of sleep tends to exert upward pressure on blood sugar. On weekends I usually sleep late in the morning, to catch up on whatever sleep I feel behind on during the work week. This weekend I got up early both days, because I had things to do. I think I'd better make this blog post a short one, so that I can get to bed at a decent hour tonght.

As for the race, it was nice -- the weather was cool and comfortable, several people I knew were running in it, and I felt good during the run. I was hoping I'd do better than last year, when my finishing time was 57:01, but in that respect I was disappointed -- my time was 57:32. Well, that's pretty close, obviously, and it's better than I did the year before last. But I felt as if I were running faster this time, and I'm disappointed that it was a false impression. I was going to use age as an excuse ("I'm too old to make progress on speed!"), but my next-door neighbor, who was something like four minutes behind me last year, was so much faster this year that she beat me this time, by nearly a minute -- and she's older than me. Maybe I'd better take some lessons from her.

The race course included an out-and-back extension -- just before the turnaround you started encountering the people who were ahead of you coming the other way, and after the turnaround it was the people who were behind you that you encountered. Human nature being what it is, you get slightly alarmed when you start noticing people ahead of you who look older and heavier than you -- and then you start feeling smug when you notice people behind you who look young and athletic. (These reactions are immature and stupid, of course, so let's pretend I didn't admit to them.)

One person that I saw coming the other way made a vivid impression on me: a young man in a wheelchair, who looked like he had more problems to cope with than the inability to walk. A couple whom I took to be his parents were with him, but they weren't pushing his wheelchair, just following it, keeping an eye on him. There was enough twisting going on in his upper body to make it clear that propelling himself forward in his wheelchair was no easy task for him. But runners were calling out encouragement to him, and his face was filled with joy.

Being great at it isn't the point. Doing it is the point.

Here is Phobos, one of the two moons of Mars.

It's not a very large object, as moons go, and I just figured out that, if I visited Phobos, and started running, and kept running until I had run all the way around it and returned to my starting point... it wouldn't be the longest route I had ever run. It would fall about five miles short of a marathon.

This probably isn't the sort of thing you think about when you see a photograph of an astronomical object, but I like to keep things in perspective, and one of the ways I do that is to compare everything to everything else. It's not a habit which helps you develop a quiet mind, I must admit. Call it a blessing or call it a curse; that's the way my mind works, whether I want it to or not. Think of it this way: I compare everything to everything else, so you don't have to!

Friday, October 1, 2010  

The dLife people sent me a request that I take a short on-line survey the other day. It took me a while to make up my mind to participate in it, because I was offended by the last one they sent me, which bumped me out of the survey half-way through it because I was giving the "wrong" answers. (The fact that I wasn't on medication apparently put me outside the mainstream, to such a degree that they didn't want my answers lousing up their data.)

I was curious, though, to find out what they were driving at in the new survey, so I decided to go through with it. The questionnaire turned out to be as short as they promised; I'll give them that. In fact, it was shorter than they promised. It was so short that I wondered what value it could have for them.

It asked if I was male or female, and what type of diabetes I had. Simple enough. They asked how long ago I was diagnosed (nearly 10 years). They asked what kind of diabetes gadgets I owned. I accidentally answered this one incorrectly by clicking on the wrong button, I afterwards realized. (I then took the survey again, to correct this wrong answer, but I have no idea whether or not they are able to recognize that the second survey was a correction of the first.)

They asked what medications I'm taking. I answered "None", which might possibly be why so few questions were asked after this point. Anyway, they then wrapped up the survey by asking for my e-mail address (which I wasn't too worried about disclosing, since they had it already), and asking which of three Apple gadgets I owned (none). And that was it.

The main difference between this survey and the last one was that they didn't explicitly tell me they were ending the survey at this point because my answers indicated I wasn't the sort of person they wanted information about. They may, in fact, have been operating on precisely the same principle this time, but if so, they decided to be more tactful about it.

So what did they learn about me from this survey? That I'm a guy, that I was diagnosed with Type 2 almost 10 years ago, that I'm not on medications and don't own an iPhone or an insulin pump. What the hell they can do with that, I don't know, but they would probably have asked for more information if they hadn't been disappointed by what little I told them.

I have always disliked participating in surveys, and up to now my stated reason for this reaction is that I always feel they're trying to shoehorn my opinions into artificially simple categories. But maybe what really bothers me about it is the condescension involved in asking for personal information without being willing to disclose why you're collecting it, how you're interpreting it, or what you're planning to do with it.

They're probably not planning to do anything with it in my case, though. I don't take enough drugs or buy enough gadgets to qualify as an interesting person.

Someone on the dLife forum managed to raise a diabetes question the other day which I have never heard raised before: how do you wear an insulin pump if you're a nudist?

It does seem like a tough problem to solve. If you have no belt to hook it to, and no pocket to stash it in, where does the pump go? Perhaps the solution might differ depending on the gender of the nudist (which was not revealed in this discussion). I was prepared to argue that Ned the Nudist might actually have something to hook it to, or that Nadine the Nudist might actually have somewhere to stash it. But, without knowing whether it was a Ned or a Nadine who was raising the matter, I wan't sure how to proceed.

Perhaps it's just as well that I didn't put my two cents in.

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

Recent headlines from Medscape, proving that scientists have not stopped engaging in research that is unlikely to yield startling results:

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