Friday, April 29, 2011

For me, breakfast is the meal least convenient for post-prandial testing -- when the hour comes up and it's time to test, I'm typically engaged in doing something else, at least on a weekday. If I'm on the way to work, or at work and on the way into a project meeting, I'm not going to interrupt myself to take a test. The most convenient meal for testing purposes is usually lunch, so that's when I usually do my post-prandial test for the day. If not lunch, then dinner. But very seldom breakfast.

No doubt it's a pretty bad idea to exempt breakfast from post-prandial testing. For me, and for most people, breakfast is typically the most carbohydrate-intensive meal of the day. When the digestive tract is just waking up, it apparently prefers to deal with easily-digested nutrients; starchy foods (such as cereal or toast) are particularly appealing at that time. And many people with type 2 diabetes report  (though this has never seemed to be true of me) that they are more prone to post-prandial spiking early in the day -- that is, the amount of carbohydrate they can "get away with" in a meal is lowest in the morning. If breakfast foods tend to be carb-intensive, and many people are at their most carb-intolerant in the morning, then breakfast is clearly a high-risk meal, which should not be excluded from post-prandial testing.

That issue has been nagging at me a bit lately, so I made a special effort this morning to arrange my morning activities so that a post-prandial test could be fitted in.

The result I got was a pretty good compromise between what I hoped for and what I expected: 117. This is (as I hoped) within the realm of normal, non-diabetic glycemic response. On the other hand, it is (as I expected) a little higher than most of  the results I have been getting after lunch lately. After all, I usually eat lunch right after running, when my insulin senstivity is bound to be highest. Also, the wheat toast this morning made my breakfast more high-carb than my lunch usually is. So, it makes sense that my result after breakfast was a bit higher than the kind of result I usually see after lunch.

However, it's a certainly a reflief that the result was only 117. It's pretty typical for healthy, non-diabetic person to go up to 125 or so after a meal, so if I'm keeping under that level I'm doing well. Still, I shouldn't over-generalize from one test result. I'll have to do this more often, won't I?

By the way: that pulse reading for this evening is legit. I sometimes get down to the low 40s.

Perhaps I'll be able to retire from blogging soon: "New Online Resource Will Correct Misinformation on Type 2 Diabetes", says an article in Medscape. "A new online resource for information about type 2 diabetes mellitus -- aimed at helping patients with diabetes, their caregivers, and their physicians sift through the clutter of information on the Web for reliable up-to-date information and research -- will be available in June".

This new online resource was announced in San Diego this week, at the 20th Annual Meeting and Clinical Congress of the American Association of Clinical Endocrinologists. I don't know what the web address for the new site will be, but apparently the way to keep informed about progress on the matter will be to visit the main AACE site from time to time, and watch for an announcement of the site launch.

Here are some comments from Dr. George Grunberger, one of the sponsors of the new site: "Ninety percent of people get their health information via the Internet and, on a good day, 20% is reliable. Inaccurate or incomplete information can lead to unnecessary stress or confusion for people living with type 2 diabetes. We need to make it easier for healthcare professionals, patients, and caregivers to access reliable sources of information, which can form a foundation for treatment and care decisions."

Well, that sounds sensible enough. But here's my question: why are we still waiting for this, in April of the year 2011?

The issue they are trying to address here is not a new development, and the internet is not a new invention. Both the problem and the most practical solution to it have long been self-evident. Let me put it this way: if I reviewed a list of milestone dates in the history of automotive technology, I doubt very much that I would come upon an item that read "1948: Ford introduces brakes". But one of the milestones in medical history is apparently going to be "2011: Doctors think of a way to share information about diabetes with people who have diabetes".

For years, doctors have been complaining that patients are educating themselves about diabetes by reading on-line articles of dubious origin and even more dubious accuracy. But what else can patients do? They need information, and if they're not getting it from their doctors, they need to get it from somewhere. Why shouldn't they go to the place where they can be sure of finding a lot of information for free?

In theory, doctors could simply spend enough time with patients to make sure all their questions about diabetes management are fully answered. But is there anyone on earth who thinks doctors can actually do that? Unless you're the private physician of a national dictator somewhere, and your practice consists of a single patient, there is not going to be enough time for one-on-one knowledge transfer from doctor to patient. Diabetes management is too complicated, and too changeable over time, for that to be a practical solution.

A far simpler solution would be to hand the patient a good book about diabetes as soon as the patient is diagnosed. I don't think that happens often, though. Perhaps some doctors are giving their patients books, but from what I've heard it isn't common. I'm not sure why not, but I'm guessing it's because doctors have been unable to identify a book which they thought was good enough, and they didn't have time to write one themselves. This, of course, raises the interesting question of how patients are supposed to make their way through the voluminous literature of diabetes, if their own doctors can't locate anything worthwhile in it.

Another solution would be to sign the patient up for a training class on the subject of diabetes management. The trouble with this solution is that it requires a good class to be available for the patient to take, and sometimes that won't be the case. However, there was such a class available for me to take, and this was the solution my doctor chose. It worked out well, but a class doesn't continue forever, and once it has concluded you spend the rest of your life coming up with questions which you should have asked while the class was still going on. Also, research continues, fad diets come and go, new gadgets and lab tests become available, interesting things are learned about genetics and lifestyle, and alarming things are learned about medications and their side effects. You need to keep up with all this new information as it comes in.

If doctors are going to make information about diabetes freely available to their patients, covering as much detail as patients wish to investigate, and updating the information to keep it current with the latest developments, then a web site is obviously the best solution. This should have been done at least a decade ago.

Well, better late than never. At least, I hope so. I am reserving judgment on whether this web site will actually fill the need, until I get a look at it, and find out what the endocrinologists really mean by "correcting misinformation". That could turn out to mean just about anything. Everyone on the internet, no matter how flagrantly insane, thinks he is only correcting misinformation. And we all get to decide whether or not we think this claim is valid.

Speaking of insane people -- whenever I read a detailed description of a mental disorder of any kind, I become increasingly uncomfortable, because the characteristics associated with this particular disorder always seem to have a disturbing personal familiarity. Reviewing a list of behaviors which may indicate the onset of Alzheimer's disease, I inevitably think, "Hey, wait a minute, I do that... and sometimes I do that, too".

Most of the things which we think of as mental disorders are simply exaggerated versions of quite ordinary flaws. We all forget where we left our car keys from time to time, don't we? (But it has to be said that forgetting whether or not you own a car is a little more serious).

So, anyway, when I read about this simple quiz which pediatricians are supposed to administer to parents, in order to screen for the possibility of autism in their children, the first thought that popped into my mind was this: if they asked my father these questions about me today, what would they conclude from his answers?

Regarding that last question, I'm not at all sure what the "correct" answer is. If I were in the habit of saying "gaga", would that increase or decrease the probability that I'm autistic? Anyway, I don't say "gaga" (with or without "Lady" as a prefix). However, I have been known to say bye-bye, and I don't know if that's good or bad. Regarding the other questions, I'm not at all sure that I do the normal thing often enough to make my father feel confident in saying that I do.

So now I'm left wondering: would I make the cut? 

Thursday, April 28, 2011

It was a beautiful day -- sunny and clear and breezy enough to keep the temperature comfortable for outdoor exercise. And my right leg, which was hurting a lot on Sunday, is feeling even better today than it did yesterday, so running was not a problem at all. And on top of that, I got a couple of difficult problems solved at work this morning.

So, what with all that, I am quite un-depressed today. I guess that makes it the perfect day to take on the subject of diabetes and depression. Sometimes I'm too depressed to talk about depression, because it's depressing, but today it seems pretty safe to do so.

Diabetes and depression are notoriously connected, and there has always been a nagging, unresolved question about this: what is causing what? Does diabetes cause depression directly? That is, does elevated blood sugar (or some other aspect of being diabetic) have an effect on mood all by itself? Or do people with diabetes get depressed simply because it's depressing to have a serious incurable disease? For that matter, being depressed make you diabetic somehow?

A study last year claimed to find "Compelling Evidence" supporting a bi-directional relationship between depression and diabetes. That is, people who are depressed first are likelier to become diabetic than people who are not depressed, while people who are diabetic first are likelier to become depressed than people who are not diabetic. Either problem can bring on the other, seemingly. That's an intriguing coincidence, is it not? Does it mean that we're looking at two unrelated risk factors here -- something that goes with being diabetic and increases your risk of depression, and something entirely different that goes with being depressed and increases your risk of diabetes?

Or could it be that there's a single factor, common among diabetes patients and depression patients alike, which increases the risk of both problems?

If there is one risk factor which points in both directions, I have a guess as to what it might be. I'll get to that shortly.

A more recent study assessed the success of a program of "cognitive behavioral therapy", or CBT, which aimed to address the problem of depression among diabetes patients through a combination of telephone-delivered counseling and pedometer-monitored walking. The result was an overall improvement in health, including mental health, although not an improvement in glycemic control: "This program of telephone-delivered CBT combined with a pedometer-based walking program did not improve A1c values, but significantly decreased patients' blood pressure, increased physical activity, and decreased depressive symptoms... The intervention also improved patients' functioning and quality of life."

Could it be that depression was reduced simply because the patients were going for walks? I don't regard a walk as sufficiently intense exercise to get the job done, so far as diabetes is concerned, so I'm not surprised that an improvement in A1c values did not occur. But maybe the patients' depression was relieved simply because they were more active than they had been before?

My own experience strongly suggests that exercise is an anti-depressive therapy of great effectiveness. I'm not exactly free of depression, but I'm a regular Pollyanna compared to what I was like before I started taking up exercise on a routine basis. My experience also suggests that exercise is an anti-diabetes therapy of great effectiveness: ten years of unmedicated diabetes and I can still pull off a fasting test below 80 now and again, even though I've been having great difficulty with weight control this year.

Excercise has helped me enormously with both mood control and glycemic control. It seems highly probable to me that, if depressed people tend to become diabetic, and diabetic people tend to become depressed, then physical inactivity is a likely explanation in both cases.

Depressed people tend to become inactive (and diabetic). Inactive people tend to become depressed (and diabetic).

It all fits together quite neatly, if you ask me. Nothing to be surprised about here.

Wednesday, April 27, 2011

I was afraid my sore right leg would feel worse today, after yesterday's return to running (slow and cautious running, but running nevertheless). However, today it actually felt better. Today I decided to risk a run which was a little longer, and do it a little faster. Still no painful consequences!

I'm continuing to do the specific yoga stretches which are recommended for this type of injury, and it does seem to be helping a lot. Considering how much my leg was hurting on Sunday (when I didn't even exercise), it's remarkable to be feeling this much better, even though I've started running again.

The short-term problem with my right leg distracted me from the longer-term problem with my right shoulder -- but that's been getting better, too. I've been doing physical therapy exercises (shoulder rotations at various angles) and it seems that this has been gradually wearing away the adhesions in the shoulder-joint which must have been building up lately. It takes a lot of shoulder rotations to smooth out that kind of buildup, but if you remain patient and continue doing them long enough, eventually you feel better. The trick is not to forget the whole issue, and give up on the therapeutic streches and exercises, as soon as the situation becomes more tolerable. It's like antibiotics: if you stop taking the pills as soon as you start to feel better, you're likely to regret it. The trick is not to become forgetful, and abandon the treatment before it has had enough time to heal you thoroughly.

I remember how painful and crippling "frozen shoulder" is, from when I had a bad case of it in 2007, and I definitely don't want to go through that again. (It was the other shoulder that time, oddly enough.) I also know that it takes a long time to correct the problem, so it takes a bit of dedication to stick to the task, and get the job done properly.

I guess getting older is like moving into an old house: you have to resign yourself to doing more maintenance tasks than you'd have to do if you were inhabiting a newer model. Well, actually, you don't have to do the maintenance: you can just give up and let the roof fall in. Best not to, though.

Not that 54 is old, exactly! But it's certainly old enough for you to be getting a lot of sobering reminders that 54 is not young, either -- especially if you're exercising a lot, and have to keep aches and pains from getting in your way. Maybe that's why older athletes are becoming increasingly fascinating to me. When I see people a decade or two older than me who are better than I am at running and cycling, I figure that's who I need to learn from. At least I can hang around them, and hope that the aura will rub off on me somehow.

Someone on a diabetes forum recently reported that she had broken out in hives after eating sugar, and wanted to know if this was a symptom of diabetes. I can see how she might come to think so: diabetes is often talked about as if it were an allergy to sugar. If you have an allergic reaction and you recently consumed sugar, doesn't it make sense to put two and two together?

Not really. First of all, diabetes is not an allergy to sugar; it is a defect in the mechanism which is supposed to regulate the concentration of sugar in the bloodstream. Second, being allergic to sugar is not possible, as far as I can determine.

An allergy, as it is usually defined, is an undesriable immune reaction triggered by exposure to a protein. As sugar is not a protein, I don't think there can be any such thing as a sugar allergy. If you buy sugar in a form which contains traces of protein (stray pollen grains probably have this effect on honey), you could be allergic to those traces of protein, but that wouldn't really be a case of "sugar allergy", any more than it would be a case of "tea overdose" if someone put arsenic in your morning cup of Earl Grey. 

But even if it were possible to have an allergic reaction to sugar, it wouldn't necesarily follow that any allergic reaction you have after eating sugar was caused by the sugar. Identifying the actual cause of an allergic reaction can be surprisingly difficult to do. We are constantly being exposed to potential allergens, in the food we eat, the air we breathe, and the objects we touch. An outbreak of hives which followed sugar consumption must have followed several other things as well -- so how do we know it was the sugar, and not something else, that caused the reaction?  If you had an allergy attack during a visit to Seattle, on a rainy Tuesday, after having lunch at a Chinese restaurant, while you were wearing a wool sweater, what are you allergic to? Rice? Soy sauce? Seattle? Rain? Tuesdays? Wool sweaters? Something else? 

There is a standard test which doctors use to identify the cause of an allergy, in which a grid of scratches are made on the skin of the patient's back, and a drop of solution containing a potential allergen (ragweed pollen, say) is placed on each scratch. If a hive forms under a particular  scratch, the patient is allergic to the substance that was applied to that scratch. (This was done to me when I was a child, and it was established that I was allergic to pollens from several grasses and trees. It was also established that I didn't like being tested in this way.)  I don't know if it's a good idea for amateurs to conduct such a test on themselves at home, but I suppose I might try it if I suspected I was allergic to something and wanted to verify it. I don't think I'd bother in the case of sugar, though.

The problem of pinpointing the cause of an allergic reaction is just an example (and a pretty mild example) of the difficulty of establishing any other kind of cause-and-effect relationship in matters of human health. If your headache went away after you ate a squash-blossom salad, that doesn't begin to prove that squash blossoms are an effective headache remedy. If your child was diagnosed as autistic after being vaccinated, that doesn't begin to prove that vaccines cause autism. If you got an unexpectedly low blood-sugar test result after eating spicy chili, that doesn't being to prove that spicy foods reduce blood sugar. It takes a lot of long-term data-gathering and analysis to establish connections of that sort.

Unfortunately, we have to live in the short term, and react to whatever data is immediately available to us. The temptation to jump to conclusions is very, very strong. And I do it, too -- just as much as anyone else.

I just make sure I talk myself out of it later.

Tuesday, April 26, 2011

When the running injury I was suffering from late last week felt much worse rather than better on Sunday (making me wonder if I'd have to give up running for a long time) I did some research into it. It's a specific type of injury known as piriformis syndrome, common among runners and cyclists, who tend to get a kind of unbalanced development of the piriformis muscle (the muscle that you use to move your hip forward), and this stresses the sciatic nerve where it passes through your pelvis. It turned out that the the type of physical therapy which is needed to heal this injury is identical with a couple of yoga poses, so last night I had my yoga teacher guide me through those poses. It seemed to help a lot.

I hadn't gone running since Saturday, but today I felt better and I decided to risk doing a very cautious (and unusually slow) run. It worked out. My hip still felt pretty good afterwards. If I keep doing the yoga stretches, I believe I can fix this problem without having to give up running. (Which is good, because I feel bad when I don't run.)

But what a strange day it was! Let me put it this way: no matter how much you may admire these guys, you would probably rather not see them showing up at your workplace and strapping on their oxygen masks as they go inside.

This morning there was an explosion at my workplace, though luckily not in my building. From my office, I didn't even hear the blast; I just heard the emergency announcements. The affected building was soon evacuated. (I didn't take these photos; they're from the local paper.)

People who had been chased out of their offices had nothing to do but stand around and watch the firefighters enter the building, which didn't seem to be on fire but still contained a lot of white smoke from the explosion.

At the time, nobody knew anything about what was going on inside the building. Were people hurt? If so, who was hurt, and how badly? 

Then, when you see someone come out on a stretcher -- who is that?

More than three hours went by before we got a very clear idea of what had happened. Two employees were hurt, one of them critically. He had been cleaning piece of production equipment used for molecular beam epitaxy (a process for creating microcircuits by depositing ultra-thin layers on a crystalline surface), when the equipment exploded, for reasons not yet known. He had severe burns on the face and torso, and was airlifted to the UC Davis Medical Center burn unit.

Another employee had a head injury when the explosion dislodged something which fell on her. She was taken to a hospital, but was able to go home later. One of the firefighters was injured as well, but press accounts were unclear about the nature of the injury. He as examined at the scene. My speculation is that his problem may have been exposure to toxic smoke.

Unfortunately, the chemicals that are required to manufacture microcircuits can be highly toxic (one of the most common ingredients is a compound of gallium and arsenic, for example). Although these chemicals end up being pretty safe once they are stabilized in the completed circuit, they are certainly not safe when an explosion turns them into smoke and scatters them around an occupied building.

82 employees who were otherwise unharmed had been, at least potentially, exposed to the smoke. This afternoon, a kind of emergency clinic was set up in the building where I work, so that these people could be evaluated. 20 of them, who had experienced some kind of respiratory problems from the smoke, had to undergo an "extensive decontamination" procedure. They were scrubbed down and their clothing was taken off the site in plastic bags to be analyzed (they had to be given other clothes to go home in). Also, 9 of the emergency responders were given the same decontamination treatment.

The building was not reopened today; they're saying 10 AM tomorrow at the earliest. The explosion was small, but they have to look for structural damage. Then there's the whole question of verifying that the building isn't still harboring toxic residues from the blast.

And yet -- life goes on. Those of us who work in other buildings were scarcely impacted. The people who were injured were people I didn't know. The business of the day continued. I went running at lunchtime as usual, and apart from the news helicopter hovering over the stricken building (apparently in the hope that something else would blow up, and they'd catch it on film) everything seemed normal. It was a pleasant, sunny day. It's on pleasant spring days like this that nature teaches us her harshest lesson: no matter what happens to us, life goes on. 

Monday, April 25, 2011

Today is my 54th birthday. It is the oldest I have ever been.

I am celebrating tonight, mainly by not writing a blog post. (Failing to write a blog post might not be your idea of a celebration, but that would be because you don't have a lot of experience of blogging.) Anyway, I plan to be back tomorrow night.

Friday, April 22, 2011

After yesterday's run, which was a pretty hard one (very steep climbs) my right leg and hip were sore, and they stayed sore all day. I didn't feel as if I could handle running (I was afraid it would make things worse), so I went to the gym in the evening instead. Some of the weight-lifting machines I was using did put a little bit of strain on the sore points, but it seemed to stretch them out in a way which would probably be helpful. Then I used an elliptical trainer for the aerobic workout, figuring that would be a smooth, non-percussive sort of activity which would also be therapeutic. It seemed to work; my leg and hip feel better now than they have all day.

When you exercise all the time, you have to be very conscious of these minor strain injuries -- preventing them if you can, healing them up quickly if you can't prevent them. You can't afford to let them get worse and worse, so that you can't exercise at all. But the real art to this is not simply "resting up" completely, any time something is sore, because (at least in my experience) becoming suddenly inactive creates new problems instead of solving the existing one. You need to find a way to stay to keep exercising (though perhaps not as intensely as usual) while you are healing.

Active healing, in short.

I've tried passive healing, and it was a major disappointment. Lying on the couch doesn't get the job done.

Thursday, April 21, 2011

Fasting glucose a bit higher than I like to see it. Everything else improved. You can't always get everything right at once, but I guess it's what we need to aim for.

Time once again for a review of search strings! I mean those phrases which people used in searches that led them to my site.

The longer search strings here are truncated, either because the search engine they were using only used the first n characters, or because only the first n characters are reported to me. So, in some cases I must use my imagination to figure out what someone was trying to say. But I would have to do that anyway in some cases, owing to spelling/grammar issues.

That you're taking medication for a disease, rather than trying to heal it or manage it by some other means, such as (in the case of type 2 diabetes) exercising and limiting your carbohydrate intake.

Whatever you want it to mean, these days -- people use it with a variety of meanings, which causes much confusion.

Diabetes comes from an Ancient Greek word which literally means "passing through". It would be a little too blunt to translate this as "pissing", yet that is unquestionably what the word refers to. Any disease which leads to frequent urination can be called diabetes. One such disease, diabetes insipidus (a pituitary disorder), causes frequent urination without elevating your blood sugar. A disease in which the frequent urination is caused by elevated blood sugar is called diabetes mellitus, which literally means "pissing honey".

If diabetes by itself is a symptom (frequent urination) rather than a specific disease, then diabetes mellitus is also a symptom (chronic elevated blood sugar) rather than a specific disease; more than one disease can cause that. However, the sepific diseases that cause diabetes mellitus are also called diabetes mellitus (althogh they distinguished from one another by meaningless descriptors such as "type 1" and "type 2".

So: if you normalize your blood sugar after diagnosis, do you still have diabetes mellitus? Not if you take the strict definiton of diabetes mellitus as a symptom, because that symptom is gone. If you take "diabetes" or "diabetes mellitus"to mean the specific underlying disease that was elevating your blood sugar before, it is probably still there.

If a very large amount of sugar builds up in the blood, and your body can't get rid of it in the usual way (by using insulin to force it into your muscle and fat cells), your kidneys try to come to the rescue, by filtering the sugar out of the blood and dumping it into your urine. In this situation your urine can become sweet enough to attract swarms of ants and bees, which was how ancient doctors recognized the condition.

I'm guessing they meant to say "without urine being abnormally sugary", and the answer is yes. Until your diabetes gets pretty far out of control, bees won't even give you the time of day.

Reliable for what? Actually, I'm unable to think of anything that a fasting blood sugar taken 7 months ago would still be reliable for. Nostalgia, maybe? My fasting blood sugar 7 months ago today was only 78. Ah, for those golden days!

If you have type 1 diabetes, you can't be medicated without insulin.

I discussed this in detail in my blog post of January 27, but it basically looks like this:

One thing is clear: if you're taking it right after getting out of the shower, you should also be out of bed. But beyond that it's hard to say what's right for you.

The trick about the fasting glucose test is that you take it at a time of day when you are probably not at your most alert and focused. If it's not always the first thing you do after getting out of bed, you can easily forget to do it, perhaps thinking of it after you have started eating breakfast (at which point, by definition, it is too late). I also think the test is of questionable value if you delay it long after getting out of bed, and have already been going about your morning activities. I'd say the safest bet is to do it right after you get up, and before you do anything else at all.

I see no reason to do it before getting out of bed, unless you think that will help you remember to do it.

Calm down! 6.2 is not that bad. It's slightly above normal, and bringing it lower than 6 would be a good idea if you can manage it. The main things you can do about it are: "more exercise" and "less carbohydrate".

I'm currently engaged in some very serious research into that very question, and although there is, as yet, no definitive answer (because I'm not dead yet), I have established this much: a type 2 diabetic can live at least 10 years and 2 months not taking pills.

That seems fine to me, assuming it dropped below 100 pretty soon after the run was over. Your heart rate can go a lot higher than 117 during a hard run, but once you stop running, your heart rate should begin to fall in a matter of seconds, and in a matter of minutes it should be below 100.

This is where you really don't want me as your role model, because I never got a reading like that, and if I did I would probably soil my pants -- which is really not all that helpful in an emergency.

I guess my next move would be to dial 911, but perhaps that would be going too far. Calling your doctor wouldn't be going too far, though, in my opinion.

I may have gone as high as 325 before diagnosis, without realizing it, but by the time I owned a glucose meter I was already under better control than that. I think the highest reading I ever saw was 212, back when I was naive enough to assume that "Lite" yogurt probably didn't have a significant amount of sugar in it.

The post-prandial target my doctor gave me was <150 after 1 hour, so 149 squeaks by. But 117 after one hour is better (in fact, it's normal, not just "pretty good for someone with diabetes", so that's what you want to aim for.

Breakfast is a tricky meal for diabetes patients, though. Because carbs are easy to digest, and digesting is more of a strain early in the morning, traditional breakfast foods tend to be high-carb. Its' not surprising that you had more trouble with breakfast than with dinner.

Many drugs can raise your blood sugar, but Claritin (which you should buy under its generic name Loratidine, because it's a lot cheaper) is not on the list. However, that is only true if it's Loratidine and nothing else. Sometimes Loratidine is sold as "Claritin D" or somesuch -- which means Loratidine combined with other drugs, and the other drugs may very well raise your blood sugar. So beware of that!

I take it straight, throughout the spring allergy season, and it doesn't seem to affect my blood sugar. 

Mention that some people actually manage to lead pretty healthy lives after a diabetes diagnosis, and then refer them to my site. I'll take it from there.

My guess is that the question should read "if they over-medicate?". Well, what happens is that they have episodes of hypoglycemia, which could be merely uncomfortable, but could also be genuinely dangerous.

That's one of the the reasons why I think the unmedicated approach is preferable. People on medication have to walk a tightrope: they worry that they're not taking enough, and at the same time they worry that they're taking too much. I'm glad to be spared that kind of anxiety.

This is hard to pin down. Supposedly, getting down to 50 mg/dl will kill off some brain cells, so you don't want to do it often. Getting down to the 30s is pretty dangerous. Getting down to the 20s seems to be extremely dangerous, although a friend of mine has done that and survived. Others have done that and not survived.

It's not an illusion. Your car really isn't moving. Start the engine.

Wednesday, April 20, 2011

Well, ale-night last night didn't hurt me too badly in terms of glycemic control, but it didn't help with weight control.

Life would be so much simpler if I didn't like food...

Being an unmedicated diabetes patient, I sometimes feel like a puzzled outsider in diabetes-land. It seems as if there is a whole subculture surrounding diabetes medications -- a subculture which I know nothing about. It's like a religion that I haven't joined. Walking past the church, I hear the sound of the service going on inside, but if I peek in from the front door, to find out what's happening in there, I can't make sense of it, because I don't know what the rituals and the holy words mean.

Nor am I all that eager to learn! The service doesn't look all that interesting to me, and I'm not in a hurry to be indoctrinated into the sacred mysteries. I might have to be, somewhere down the road, but I'd rather wait and deal with it then. In the meantime, being unchurched, as it were, is quite a time-saver. And probably a money-saver as well, because I hear that the parishioners down at Our Lady Of Rosiglitazone have to pay a hefty tithe.

However, from time to time, I read up on studies comparing one diabetes drug to another. (Studies comparing diabetes drugs to lifestyle-based therapies are seldom done, apparently because the comparison tends to cast an unflattering light on the drugs.) Even though I'd rather not take any medications at all, I take it for granted that some are better than others, so I might as well know something about how the available drugs stack up against one another.

However, it cannot be said that research comparing diabetes drugs to one another makes good light reading:

"In general, the risk of death from any cause and a composite CV-event end point went up significantly in association with glimepiride, glibenclamide, glipizide, and tolbutamide use, compared with metformin, while gliclazide and repaglinide were on a par with metformin for those risks, among the >107 000 patients who started on the drugs as monotherapy between 1997 and 2006."

They've said a mouthful there, all right. To me, that flurry of artificial names (tolbutamide indeed!) is like one of those long lists of characters that appear at the beginning of a Norse saga:

"Skirfir, Virfir, Skafith, Ai.
Alf and Yngvi, Eikinskjaldi,
Fjalar and Frosti, Fith and Ginnar;
So for all time shall the tale be known,
The list of all the forbears of Lofar."

What do you do with a list of names like that? Memorize them, on the assumption that they'll become important later? Pass over them, hoping they are only going to be mentioned this one time and never again? Do I really need to remember "Eikinskjaldi"?

Or "glimepiride"?

Well, one possible reason to remember glimepiride (if not Eikinskjaldi) is that, according to a recent study, glimepiride and several other diabetes drugs increase cardiovascular risk, at least in comparison with taking metformin alone. However, diabetes patients are typically prescribed these drugs along with metformin, so it doesn't seem as if taking metformin alone (on the grounds that it's safer from the standpoint of cardiovascular risk) is all that practical a plan.

Isn't it funny how so many diabetes drugs seem to increase your risk of cardiovascular disease! You might even call it ironic, considering that cardiovascular disease is the most serious consequence of having diabetes. (If your doctor prescribes a medication for migraine, you don't expect to find out that one of its listed side-effects is "headache".) The only diabetes remedy I know of which has the side-effect of reducing your risk of cardiovascular disease is exercise; apparently diabetes drugs either increase it or don't affect it.

Even those diabetes drugs which increase your risk of cardiovascular disease don't increase it by a huge amount, but obviously it's preferable, all else being equal, to choose drugs which don't increase the risk at all. All else is not equal, however. Increased cardiovascular risk is just one of many issues that complicate the question of which diabetes drugs to take. (Another such issue, for some patients, is "how much would it bother you to live in a chronic state of gastrointestinal distress?")

In 2009, Consumer Reports published a guide to diabetes drugs, which includes a lot of common-sense information -- including how much the various drugs will cost you. Here's their price guide, with their best buys highlighted. They recommend metformin, combined with glipizide or glimepiride if metformin alone isn't enough:

Notice the astonishing range of prices there, particularly when you compare name-brand to generic versions of the same pill. $18 a month for metformin if it says "metformin" on the bottle, and $154 a month for metformin if it says "glucophage" on the bottle? 

The newer drugs, which don't yet have generic versions available, tend to be the most expensive ones (but Consumer Reports argues that they aren't any better, and in some cases are worse).

Of course, the glipizide and glimepiride that they're recommending are two of the drugs which stand accused of increasing your risk of cardiovascular disease. But probably the idea here is that a patient who actually cared about that would be doing something besides taking pills.

If you're taking pills and exercising, you can probably cancel out the increased risk of cardiovascular disease caused by the pills. That is why, if I have to take pills later myself, it won't mean that I can stop exercising. If anything, it will mean that I need exercise more than ever -- even though exercise alone is no longer sufficient to get the job done for me.

But, as I said, I'm not in a hurry to join that particular church, even if I can find one that doesn't demand a generous tithe from me.

Happy birthday to the Hubble Space Telescope! The HST celebrated its 21st today, by snapping this photo of a pair of galaxies interacting gravitationally, and stretching themselves out of shape in the process.

Show me a man who thinks fantasy is interesting but reality is not, and I'll show you a man who hasn't taken a very close look at reality.

Tuesday, April 19, 2011

Various Shakespearean actors are quoted as having said, on their deathbeds, "Dying is easy, comedy is hard."

My version of that is: "Glucose control is easy, weight control is hard".

I didn't make either kind of control any easier for myself this evening, as I met some friends for dinner at the brewpub. Ale Night is not a frequent event for us, but I'm sure it has an impact. Oh well, I'll deal with the consequences tomorrow, whatever they are, and take it from there.

I think I've discovered a new medical condition, a syndrome which we can begin referring to by its acronym (MGHDS), which I will explain shortly. I come to this conclusion from having read the news yesterday about Lazar Greenfield, MD.

Dr. Greenfield has attained (or should I say had attained?) considerable stature in the medical profession. He is a very prominent researcher, educator, and author on the subject of surgery. For many years he chaired the surgery department at the University of Michigan in Ann Arbor. He invented the Greenfield vena cava filter (a device which is used to prevent pulmonary embolism in surgery patients). He was recently been elected president of the American College of Surgeons (ACS) -- a post from which he found himself obliged to resign on Sunday. He is 76 years old, a factor which may not be entirely irrelevant to this story.

Why did so distinguished a surgeon have to resign, under public pressure, as president-elect of the ACS? Because he has developed MGHDS, would be my answer. The more immediately intelligible answer is: he could not stop himself from making some unfunny and embarassing jokes in public, offending a great many women and (so far as I can see) cracking up nobody.

Male Geriatric Humor Deficiency Syndrome (MGHDS), as I have chosen to call it, is a compulsive behavior pattern, often seen in elderly men, in which a patient with little or no sense of humor insists upon making what he believes are jokes, despite the consistently unamused reactions of all who are exposed to his would-be witticisms.

I could be in error in thinking of MGHDS as specifically a male problem; I have only my own observations to guide me. All I can say is that I have noticed men with this problem, and not women. I don't mean that old women are necessarily better at coming up with something funny to say than old men are, but old women don't seem to suffer from the old man's compulsion to make a joke whether or not they've thought of a good one.

So, even if the ineptitude of MGHDS comedy is not gender-specific, the weirdly insistent nature of it (often in the face of overt disapproval) almost certainly is. Anyone who has traveled by air more than a few times has surely had the experience of waiting in the security line behind an old married couple, and overhearing her begging him not to make any bad jokes about having a bomb, and then (minutes later) overhearing him make a bad joke about having a bomb. The increasing severity with which airline security people respond to this behavior ought to have eradicated it by now. And yet, the dumb jokes continue, and probably will do so for as long as old men are permitted to fly.

Although most men who suffer from MGHDS have a limited outlet for their cringe-inducing essays in standup comedy (waitresses seem to bear almost the entire brunt of it), the effects can be more far-reaching in those cases where onset of MGHDS unhappily coincides with elevation to a publicly prominent role, as in the case of Dr. Greenfield's election as president of the American College of Surgeons.

The particular attempt at comedy which proved so disastrous for Dr. Greenfield involved an editorial he wrote for an ACS newsletter earlier this year, unfortunately on St. Valentine's Day. The holiday inspired him to write a humorous piece (he thought it was humorous, at any rate -- a view not widely shared) on the subject of...

Wait a minute. Can we please have it understood that I'm quoting Dr. Greenfield's clumsy ramble into the minefield of gender comedy only because otherwise this story will be unintelligble? Thank you.

Dr. Greenfield took as his point of departure some research which seemed to show that "Female college students having unprotected sex were significantly less depressed than were those whose partners used condoms." Greenfield suggested that semen contained mood-enhancing substances such as oxytocin,  serotonin, and melatonin, and that women deprived of contact with semen were also deprived of the emotional benefits which semen provided. His speculations on this topic ranged rather widely; he said that heterosexual women who lived together tended to get their menstrual cycles into synchronization but lesbians did not, and suggested that this was because lesbians were deprived of exposure to semen. (How he established that lesbians don't experience synchronized menstruation, or that this is a major source of disappointment in their lives, I am unable to say.) He concluded brightly, "So there's a deeper bond between men and women than St. Valentine would have suspected, and now we know there's a better gift for that day than chocolates".

All in all, it sounds like Sterling Hayden's character, the mad Air Force general, in Dr. Strangelove, rambling on about women supposedly seeking his "essence"...

...with one important exception: Hayden's character was pretty funny.

Greenfield described his essay on what women really need as "a light-hearted attempt to highlight some of the new findings that nature provides to promote stronger bonding between men and women", but readers of Surgery News were not amused. Female readers were for some reason particularly annoyed by it. The editorial was seen as crude, irresponsible (in its apparent recommendation against condom use) and misogynistic. That the president of the ACS could feel comfortable indulging in this sort of humor in public seemed, to many women, to be symbolic of something larger and more sinister at work. Women surgeons cited the editorial as evidence that their profession was dominated by an openly sexist old-boys' network. At least one female surgeon resigned from the ACS in protest. (Also: of all the disappointing substitutes for chocolate which we have been offered over the years, the one Dr. Greenfield proposed was surely the least inviting.) There was simply too much wrong with his "light-hearted" essay; it was inevitable that the ACS would grow weary of defending him and pressure him to resign.

Conceivably Dr. Greenfield's humor might have been more readily forgiven if it had actually been funny -- but let us remember that we are talking about a man who is presumably an MGHDS sufferer. For such a man, the questions "is this joke funny?" and "is it a good idea to make this joke in public?" would never arise. As far as MGHDS sufferers are concerned, it is a given that old men should make jokes whenever possible, even if (and perhaps especially if) they are aware that nobody wants them to. For a man with MGHDS, the issue is never whether a joke is unfunny and stupid, but whether it is unfunny and stupid enough.

Although I'd like to think that I will not succumb to MGHDS myself, I guess I wouldn't know it if it I did, would I? Which means that I perhaps already have. Maybe I need help, or soon will. There needs to be a foundation of some kind to support MGHDS sufferers (heaven knows there would be no shortage of appropriate celebrity spokesmen), but before that can happen, the existence of the syndrome needs to be acknowledged by the medical community. Maybe I should make that my cause.

I don't know whether or not I can succeed in getting MGHDS recognized as a legitimate medical diagnosis, but if that ever happens, I know what the next development will be: six months later, I'll see a headline in Medscape that reads "Study: Diabetes Raises MGHDS Risk".

Monday, April 18, 2011

Suppose you were a space alien sent to do a quick examination of planet Earth and report back to your superiors on a single issue of great interest to them. They are planning to take over the place, and they're trying to decide on where to locate their primary base. They want to put it somewhere in the western half of North America, but they want to make sure it's in a location which has high annual rainfall (yours being a water-loving species). They want you to find a location with a high year-round rainfall rate.

Not having learned any human languages, you can't just consult the local weather records. Also, you don't have time to hang around and observe the weather for a year to find out how much rain falls during that time in various places. You can't just choose a place where it's raining now, either, because that might be atypical weather for that location. So, you come up with an ingenious and simple scheme for figuring this out indirectly: you notice that humans build a lot of fences, mostly of wood, and that the fences are assembled using metal nails. So, in the middle of the night, you confiscate fences in various locations, and fly them home for analysis. Your assumption is that the fence with the rustiest nails will have come from the location with the highest annual rainfall.

Although the fence from Seattle has nails that are pretty rusty, you decide that the nails are just a little rustier in the fence that you swiped from Phoenix, Arizona, and you recommend that location to your superiors.

Now, where did you go wrong? Pay attention, because this is important if you want to gain a better understanding of the Hemoglobin A1c test.

Water promotes rust, certainly. If you want to keep nails from rusting you have to keep them dry. Nails usually don't get rusty sitting in a hardware store, but put them in a fence outdoors and they do tend to rust. Annual rainfall in an area might very well determine how rusty the nails in a fence will get.

However, rust develops slowly over time. Nails in a new fence might not be very rusty even in a rainy location, and nails in an old fence might be extremely rusty even in a dry location. Unfortunately, the fence you swiped in Phoenix was a great deal older than the one you swiped in Seattle, so the amount of rust on the nails was not adequate evidence on which to base your estimate of annual rainfall in the two places. The comparison you made was meaningless, and it led you to a false conclusion. Your career as a planetary location-scout may well be at an end, once your bosses relocate to Phoenix and start waiting for it to rain.

What led me to make up this weird story was a search string which, apparently, gave somebody a reference to my site. The search string was "The a1c testing measure more new cells or old?".

It's an important question, and one which people tend to overlook when they are trying to come up with an oversimplified explanation of what the A1c test tells us.

Obviously the hemoglobin A1c test measures all the red blood cells, young or old, that are included in the sample; it cannot distinguish between hemoglobin from young cells and hemoglobin from old ones. It only distinguishes between hemoglobin that is glycated (encrusted with glucose, that is) and hemoglobin that isn't. Because your blood cells vary in age, and because the test treats young and old blood cells alike, this introduces some difficulties into any attempt at evaluating what the test result "means" about your recent health history -- for the same reason that the varying age of fences might mislead aliens who attempt to deduce rainfall rates from the amount of rust on the nails in those fences.

Red blood cells have a limited lifespan. They are often said to last "three months", but the actual range is usually 100 to 120 days. When you take an A1c test, some of the blood cells in the sample will be 101 days old, and some will be 33 days old, and some will be 2 days old. So, when people tell you that the A1c test reflects what your average blood sugar has been "over the past three months", this is obviously a simplification of a far more complex reality.

The idea that the A1c can tell you what your average blood sugar was over the past three months would be more accurate if all of your blood cells had been replaced at the same time, three months ago, and your sample was taken just before they were all replaced again. But it doesn't work that way; cells are being replaced all the time. In order for the test to truly reflect what your average blood sugar was three months ago, all the blood cells that were in your system three months ago would need to be there still (most aren't), and all the blood cells that were in your system two months ago would need to be there still (many aren't), and all the blood cells that were in your system one month ago would need to be there still (some aren't).

The A1c test, if we compare it to my story of aliens stealing fences, is stealing more young fences than old ones. Although that fact can be corrected for, to a degree, in the formula you're using to estimate average blood sugar from the test result, your estimate will still be influenced more by what was going one month ago than by what was going on three months ago, simply because the blood cells that were around three months ago are mosty not included in the test. The way this is usually expressed is that the test result is "weighted" towards the most recent month.

But another complication enters the picture: not everyone's fences -- blood cells, I mean -- are replaced at the same rate. If you have a health condition which causes your blood cells to be replaced more often than usual, your A1c test will include younger cells than usual. Cells which are not as rusty -- not as glycated, I mean -- as one might expect. If you estimate average blood sugar based on unusually young cells, you may come up with an unrealistically low value, just as the aliens underestimated rainfall in Seattle by looking at a fence that was too new.

Although the A1c test does give us a good comparative sense of how we're doing (if it's rising from test to test, something is probably not right, and you need to figure out what it is), expecting it to translate very precisely into average blood sugar is expecting too much. A lot of people are surprised by their A1c result, because it doesn't seem to fit with what they think their average blood sugar has been over the past three months. It could be that they're simply mistaken about what their average blood sugar has been (they really don't know what's going on while they sleep, for example), but it could also be that the A1c doesn't track average blood sugar as accurately as they've been led to believe.

There are odd disparities (including racial disparities) in the relationship between average blood sugar and A1c results. This could be because different people have different glycation rates for the same level of blood sugar, or because some people's red blood cells are replaced unusually early or late, or because of some other variation between people which we haven't figured out yet.

Anyway, my point is that expecting the A1c test to translate exactly to average blood sugar is like expecting rusty nails in a fence to tell you the average rainfall in Seattle. It's just not that simple!

I was planning to do a 7 mile trail-run over the weekend. Circumstances got in the way of that goal on Saturday, so it would need to happen on Sunday. In fact, it would need to happen early in the morning on Sunday, because I was expected by lunchtime in Oakland, which is a long drive.

It was nice to be in the park so early, while the morning fog was still pouring over the hills.

I think of it as California doing its Ireland impersonation.

There was a half-marathon race going on there at the time, and although I wasn't part of it (I didn't fancy adding another 6 miles to my distance that day), I did cross paths with some of the runners along the route. The race had a staggered start (with runners taking off in groups every five minutes) so that people weren't bunched up dangerously on the narrower trails. By the time any of the runners came my way, they were either solo runners or just a couple of friends keeping together.

It was kind of a nice compromise to be out there when the race participants were, sharing in the experience to a degree, but not having as many miles to cover as they did.

For distance running, a cool foggy morning like this one is just about ideal.

It might look as if a long-distance cross-country run, especially when you don't have a running buddy keeping pace with you, would be a terribly lonely thing to do, but it doesn't really feel that way. There's just a little touch of adventure to it, if you're alone and not absolutely sure that you haven't strayed off the course...

...but as soon as you spot some other runners you feel greatly reassured, and you feel like you're part of a group event again.

And you always seem to encounter a lot of other people as you get closer to the finish line.

I went and watched some of them crossing the finish line, and envied their obvious feeling of satisfaction.

I'm not saying that my envy was so strong that I felt bitter regret at not having signed up for this race, but it did make me think maybe I would do it next year.

And I am signed up for a different half-marathon, a month from now. I guess maybe I'd better start doing some training for that. The 7-miler I did on Sunday isn't a bad start, but I should do a few runs that are at least 10 miles long before that race.

Friday, April 15, 2011

Ah, April 15! The annual tax-filing deadline. Except that it isn't, this year. Apparently there is a holiday called Emancipation Day which is celebrated in Washington DC (I'm unfamiliar with it -- the holiday, that is, not the District of Columbia), and as Washington is the seat of the federal government, today is a federal holiday, and the federal tax-filing deadline has been extended to Monday the 18th.

However, this extension does no one any good. The deadline for state tax filing isn't extended -- and you have to do your federal tax filing first, because the state filing is partly based on the federal one.

So, the federal extension of the tax-filing deadline is a policy which sounds like it's doing everyone a big favor, but turns out not to make any difference once you look at the details. Well, it's a good thing that other government policies aren't like that.

"Patients With Diabetes Lack Knowledge About Hypoglycemia" says the headline of a report coming out of the annual meeting  in San Diego of the American Association of Clinical Endocrinologists (AACE). Some highlights:

"A national online survey of more than 2530 adults living with type 2 diabetes mellitus in the United States reveals that many patients remain uneducated about the risks for hypoglycemia.
The survey also highlighted why hypoglycemia may be more of a health hazard than previously reported, as patients said they often experience low blood sugar during daily activities such as working and driving. In the survey, 55% of respondents said they had experienced at least 1 episode of hypoglycemia. Of 702 patients with diabetes who reported hypoglycemia, 42% had experienced low blood sugar symptoms while working, 26% while exercising, and 19% while driving. The fact that patients with diabetes experience hypoglycemia while working and driving is especially problematic, as these activities require focus and concentration, and experiencing hypoglycemia during driving can be life-threatening..."

I am always suspicious of surveys based on questionnaires, largely becaue I am always suspicious of questionnaires.

The typical survey question is either so poorly expressed that we can't be sure what is meant by it, or so biased that we feel we are being herded toward a conclusion. Either way, it would be rash to draw any conclusions from the answers it provokes.

My bad attitude on this subject goes back a long way. In fact, it dates back to the first written exams I encountered as a schoolboy, when I was not long out of kindergarten. One in particular galls me to this day. It was a beginning arithmetic exam. The page showed a series of pictures of groups of objects -- five drums, four apples, six books, and so on. The student was supposed to count these objects and write down the total for each type. But how was the exam question stated? It didn't say "How many drums are there?", nor did it say "Count the drums". What it said was "Find the numeral".

Find the numeral.

Now, what the hell kind of a pathetic excuse for an English sentence is that? Have you ever said anything like that to anyone? Can you imagine circumstances in which you would? If someone told you to "find the numeral", would you have any idea that they meant "count these things"?. Do you even use the word "numeral", except in the phrase "Roman numerals"?

Since the only numerals I'd ever heard of were Roman, and since I'd been instructed to "find the numeral" in the picture, I assumed that V's and X's and I's were hidden somewhere in the pictures, and I was supposed to spot them. Laugh at me all you like, but according to the dictionary I was right in my interpretation of the instructions, and the author of the exam was wrong.

Why does our language include the two similar words "numeral" and "number"? We wouldn't need both, if they meant the same thing. And they don't. A numeral is defined as "a conventional symbol representing a number". In other words, a numeral is not a quantity -- it's a way of symbolizing a quantity (as, for instance, "V" stands for a quantity of five in Roman numerals). We tend to blur the distinction, using "5" to designate both the Arabic numeral 5 and the quantity of five which that numeral represents. Still, if you actually use the word numeral (as in "find the numeral"), you are definitely talking about a symbol rather  than a quantity.

As for the word "find", it can sometimes be used to mean "calculate", but you can only calculate a number. You can't calculate the symbol of a number, any more than you can "calculate" which leaf symbolizes Canada. If you are shown a picture and told to find a symbol in it, then this is a problem in recognition, not calculation.

So, I set about trying to spot the hidden numerals in the pictures. With the drums in the first picture, it was easy: they had that zigzag pattern along the sides (that is, the ties holding the drumheads on), and I figured those were hidden Roman numerals. So I heavily darkened the "V" shapes in those zigzag lines with my pencil, to show that the hidden numerals had not escaped my notice, and moved on to the next question. There I ran into the cruel reality of exams: the first question is easy, but then they become increasingly difficult. I could find nothing that looked like a hidden numeral in the apples. My system broke down completely at this point, and I failed the assignment, obviously. Nothing to be ashamed of in that, of course! I may not have understood the question, but at least I understood English, which was more than you could say for the author of that exam. 
For me, most questionnaires bring back unpleasant memories of that find-the-numeral test. A survey question is seldom precise and unambiguous. To some extent you have to take a guess at what they mean by it. And you have no way of knowing how good your guess is -- you just have to choose an interpretation of the question and do your best to answer it on those terms. And because the people administering the questionnaire have no way of knowing what sort of guess you made, they can't be sure they are interpreting your answer correctly. In other words, the whole enterprise of asking people to fill out questionnaires is often of very doubtful value.

Another problem is the format in which the questionnaire allows you to answer. If it's a fill-in-the-blank test, you may have no clue to what type of answer they are looking for -- and a clue to that is often required, owing to ambiguity in the wording of  the question. If it's a multiple-choice test, you at least get a clue as to what they meant by the question, but your possible answers are limited, and often more than one answer is arguably correct. (Often, in this situation, the possible answers are just as ambiguous in meaning as the original question was -- so you not only are guessing at what they meant by the question, you are also guessing at what they meant by the answers.) True/false questionnaires are even worse, because you always end up having to decide whether a statement which is largely true but not perfectly true counts as untrue, in the mind of the person asking the question.

Surveys which purport to show that most people are terribly ignorant always make me suspicious -- and sometimes my suspicions are publicly vindicated. Some years back, a lot of people were frigthened by a survey result which seemed to show that a very large percentage of Americans think the Nazi holocaust never happened. It turned out that it was a poorly-worded question on the survey which created that impression; when the survey was repeated with the question stated more clearly, the rate of holocaust denial dropped overnight, as if everyone had been forced to watch Schindler's List between the first survey and the second.

An especially popular type of survey is the "can-you-believe-our-kids-are-this-dumb?" survey, which demonstates (or so we are told) that huge numbers of American students cannot answer the simplest imaginable questions. For example, we are regularly told that millions of American students cannot find their own country on a map of the world; this seems so far-fetched to me that I would really like to see the test being administered, and find out how that question was put to people. I'm going to have to assume that there's a problem in the question itself, until someone proves otherwise to my satisfaction.

Well, anyway, returning to the news about how American diabetes patients are frighteningly ignorant of hypoglycemia, let me examine some of the specific claims being made, and then mention some of the skeptical thoughts which they bring to mind, at least for me.

What does "the risks for hypoglycemia mean"?

Does it mean the risk that you will experience hypoglycemia, or the risk that you will suffer other health problems as a consequence of hypoglycemia?

Is it surprising that people would experience low blood sugar during daily activities?

Had someone been assuming that daily activities confer immunity from low blood sugar?

Both diabetic and non-diabetic people sometimes experience low blood sugar during daily activities. For non-diabetic people it is often nothing more than an unpleasant feeling which soon passes, and causes no serious consequences -- and it is often nothing more than that for diabetic people, too!

And how low is "low", anyway? Low enough to make you feel bad for 15 minutes? A mauvais quart d'heure, as the French say? Feeling weak and shaky for a little while is not necessarily a medical emergency -- and a lot of people with diabetes feel that way when their blood sugar isn't even low, in any clinical sense -- it's just lower than usual for them, or falling faster than it usually does.

Also, does the remark "patients said they often experience low blood sugar during daily activities" mean that they have this experience routinely, or does "often" simply mean that, if it happens to them at all, it is not atypical for it to happen during daily activities? If you had two lows last year, and one of them happened at work, does that mean you "often" have lows at work?

I'm dying to know how this question was presented. Was it a multiple-choice question, with plausible alternatives presented, or were people simply asked if they could name the leading cause of hypoglycemia?

The leading cause of hypoglycemia -- indeed, the only cause of it -- is glucose leaving the blood supply faster than it is entering the blood supply, over a prolonged period. But from that starting point, you have to consider the various factors which might limit the entry of glucose into the blood supply (such as fasting and alcohol intake) as well as the various factors which might accelerate removal of glucose from the blood supply (such as injected insulin, natural insulin, prolonged exercise, and oral diabetes medications).

My own experience (which is limited in that I haven't taken injected insulin or oral diabetes medications) suggests that hypoglycemic episodes sometimes occur for an obvious reason (while training for a marathon, I would suddenly become hungry and weak somewhere around mile 13, and have to take in some sugar to correct the problem), but would also sometimes occur for absolutely no reason that made any sense. As far as I can tell, every once in a while we just experience an unpredictable low, under circumstances which never caused a low in the past.

Perhaps I would have missed the thing about "skipping meals", too, unless it was offered to me as a multiple-choice question. It's not that I can't understand how skipping a meal could have that result; it's just that I never skip meals (in fact, it's extremely hard for me to resist eating between meals), so it's not even an issue I would think about if nobody prompted me to think about it. Obviously it does me no harm to ignore the possible effect of a skipped meal on glycemic control, since the situation doesn't actually arise in my life. If you life in Tahiti, it is safe to go through life not giving a thought to the dangers represented by blizzards and avalanches.

I wonder how, exactly, the question was presented to them. As stated here, this does make them sound pretty ignorant -- but, as with my own tendency to ignore the potential impact of skipping meals (because I don't skip meals), maybe 46% of patients with type 2 are ignoring the potential impact of exercising (because they don't exercise). I don't know if it would be true to say that 46% of patients with type 2 don't exercise, but it sure seems plausible to me, and if they don't do it, they don't have to worry about the possible consequences of doing it. (In theory, they have to worry about the consequences of not doing it, but something tells me they aren't fretting too much about that one, either, and anyway it has no bearing on hypoglycemia.)

It doesn't matter what the most common symptoms of hypoglycemia are. The full list of hypoglycemia symptoms that have been experienced by someone or other is as long as your arm, and I don't care about any of the ones that I don't experience myself.

I never exerpienced dizziness when my blood sugar was low. My symptoms are: (1) sudden intense hunger, (2) nervousness and anxiety, (3) shakiness, and (4) weakness. Other people experience a different set of symptoms, and I feel confident that they don't care about which symptoms I get -- they only care about the symptoms they get.

In any case, we all know how hypoglycemia affects us, so why should we care about, or even remember, the different ways in which it can affect people besides ourselves? Perhaps the 22% of respondents who didn't know hypoglycemia can cause dizziness in some poeple don't happen to be among those people?

I don't know what would lead 39% of respondents to think that thirst was the primary symptom of hypoglycemia, but perhaps the common awareness that excessive thirst can be a sign of diabetes led some people to make that guess. Again, since I don't know how these questions were presented to people, I am hesitant to judge their answers too harshly.

In any case, no matter how big a problem hypoglecmia is for some people, it isn't a problem for me. If I'm going on a long run, I carry a glucose gel just in case the need arises, but it seldom does arise, and if it happens it's an easy problem to solve. I just don't have to pay much attention to this issue. Could it be that some people who took the survey didn't know much about hypoglycemia because they don't need to know much about hypoglycemia? If it were a big problem for them, they probably would know a little more about it!

Thursday, April 14, 2011

Just two days ago I was commenting on research reports which emphasize relative risk numbers instead of absolute numbers, to make their findings seem more significant. ("HOMICIDE RATE UP 100% IN CENTERVILLE!" is a little more attention-grabbing than "there were two homicides in Centerville in 2010, and one homicide in 2009".)

Even though I'm very aware of how misleading such statements can be, I still fall for them as easily as anyone else does -- at least at first, before I've had time to take a closer look at the modest data that usually lies behind the bold headline. So, I have to admit to being alarmed, at first, by this article entitled "Increased Risk of Pancreatic Malignancy in Diabetes", and its finding that the overall risk of pancreatic malignancy is "66% higher in diabetic men and 43% higher in diabetic women than in gender-matched controls".

Any mention of pancreatic cancer immediately reminds me of a conversation I had with a surgeon, about 25 years ago. This was a social conversation, not a medical consultation. I happened to ask him what was his least favorite type of surgery to perform, and he replied "pancreatic cancer",  firmly and without hesitation. When I asked why this was the worst operation of all, from his point of view as a surgeon, he said "It's complicated, it takes several hours, it's exhausting, and the patient's going to die". You could accuse him of exaggerating on that last point; after all, the survival rate for pancreatic cancer isn't zero! But it's only 4%, so he wasn't exaggerating by much.

I guess I can see why an operation which is extremely difficult, and offers very little hope of saving the patient, would be a surgeon's least favorite way to earn his salary.

That converation has stayed with me ever since, and because I now have the mental habit of seeing pancreatic cancer as an especially hopeless form of the disease, I tend to flinch at any suggestion that I might be more susceptible to it than other people are. And this article says I'm 66% more susceptible to it than other people are!

However, if we forget the relative-risk numbers, which sound so awful, and look at the actual rates at which people develop pancreatic cancer, the picture is not quite so alarming. For non-diabetic men, the incidence of pancreatic cancer is 1.88 per 10,000 patient-years, and having diabetes only increased that incidence to an average of 3.34 per 10,000 patient-years (it was lower than that for men under 65).

So, even among diabetes patients, this is a pretty uncommon form of cancer. If you tracked a thousand men over a ten-year period, you would expect two of them to develop pancreatic cancer if they were non-diabetic, and three of them to develop it if they were diabetic. Those aren't exactly terrifying odds. Of all the problems that diabetes might cause for me, pancreatic cancer is among the least likely.

The more interesting question here, in my view, is why diabetes increases the cancer rate. No one knows the answer to that, and this new report doesn't express an opinion. It could be that high blood sugar causes it directly (especially as diabetes increases the risk for some other kinds of cancer). But if we concentrate on the specific issue of pancreatic cancer, what might diabetes be doing to that organ? Overstressing it, perhaps, by causing it to produce abnormally large amounts of insulin to counteract insulin resistance? (It is worth mentioning, in this context, that the data on increased pancreatic cancer risk in diabetes comes almost entirely from people with Type 2, not Type 1.)

Another possibility occurs to me, cynic that I am: could it be that widely-prescribed diabetes drugs, some of which act directly on the pancreas to stimulate insulin production, are doing something to stress that organ, and make it slightly more cancer-prone? I'm only throwing this idea out there as a possibility -- a possibility which, I'm fairly sure, will not be looked into.

In any case, the numbers aren't really dramatic enough to justify a whole lot of further investigation.

I may be in a tight spot for a little while: one of my two regular running-buddies at work is in China, and the other is currently en route to a camping trip in Death Valley. I'm going to have to get out there and run without peer pressure!

Oh well -- I've done it before, and I can do it again.

Wednesday, April 13, 2011

Now we're asked to believe that moderate consumption of coffee slightly increases your risk of hypertension -- but heavy consumption of coffee doesn't! 

That, at least, was the conclusion of a massive "meta-analysis" of previous studies of the subject, put together by researchers at the Department of Epidemiology at Michigan State University. "The results suggest that habitual coffee consumption of >3 cups/day was not associated with an increased risk of hypertension compared with <1 cup/day; however, a slightly elevated risk appeared to be associated with light-to-moderate consumption of 1 to 3 cups/day." 

I'm torn here. On the one hand, I'd like nothing better than to believe that drinking lots of coffee is better for you than drinking a moderate amount. On the other hand, it doesn't seem especially plausible.

By the way: if 3 cups of coffee sounds more than "moderate" to you, be aware that the autors of the study were using "cup" as a literal unit of measure (8 ounces). The typical single serving of coffee at chain coffee shops these days is at least 2 cups, so you don't have to spend the whole day at Starbucks to get yourself into the heavy-consumption category -- where, apparently, you will be safe from hypertension.

Okay, if they say that's what they found, I guess they must have some kind of justifaction for it. The actual data they disclose, however, is confusing and  seemingly contradictory, so it's hard for me to understand exactly how they boiled it down it into the conclusion that moderate consumption of coffee is slightly risky but heavy consumption is not.

Assuming for the moment that their analysis is completely on-target, what could explain such a result? If coffee consumption increases your risk of hypertension, why would that effect go away once coffee consumption had gone above a certain level? It's hard to think of an explanatory model for this. Could it be that there are two ingredients in coffee, one of which raises blood pressure while the other lowers it, and the latter effect starts to cancel the former when the dosage gets high enough? It seems a little far-fetched.

There are, of course, a lot of reasons to wonder if their conclusions might not be completely on-target.

That's quite a number of reasons to regard the new study as questionable. Of course, the biggest limitation of all here is that the effect of coffee on the risk of hypertension appears to be quite modest at worst. Not only does this mean that the "signal" is not standing out very clearly from the "noise" (see yesterday's blog for a study of this issue) -- it also means that the linkage between moderate coffee-drinking and hypertension may not be strong enough to be worth making a big fuss about.

However, I am glad to have this study, questionable though it is, for the same reason that I am glad to have studies saying that I don't have to give up wine.

People with diabetes have to give up a lot of things. (Just today, for example, some of my coworkers enjoyed the pleasure of not going outdoors in the cold wind, with rain threatening, and running five miles -- but I passed up on this very appealing opportunity.) We ought to be allowed a few vices, surely. We want to be able to have our coffee at breakfast and our wine at dinner. So my message to the research community is this: please keep doing studies purporting to show that these things are okay. The research needn't be very good, or even very plausible; just make sure it gets enough press attention!

I saw another research report today which I thought, judging from the headline, was also going to be good news tailor-made for me: it said that the elevated risk of coronary heart disease associated with diabetes didn't apply to all patients, only to those with "early onset" of the disease. Great, I thought!

Then I found out that their definition of "early" onset was before age 60.


Tuesday, April 12, 2011

I want to talk a little bit about cataracts, vegetables, meat, and signal-to-noise ratio. Maybe I'd better start with the last of those.

Signal-to-noise ratio (SNR for short) is usually mentioned in connection with recorded sound. It's the ratio between the power of the desired signal and the power of all unwanted signals, known collectively as noise. The higher the SNR, the better, because a  high SNR means that the desired signal is very strong, and the noise signals are very weak.

If you've ever heard music recordings made in the 1920s, or listened closely to the soundtracks of movies from the dawn of the talking-picture era in Hollywood, or tried listening to a too-distant radio station, you know what a low SNR is like: lots of extraneous hissing and crackling and interference, with the desired signal barely making itself heard over the static. With the introduction of digital recording techniques, all that is changed; these days, SNR is typically so high (because the noise level is so low) that a very wide range of loudness can be captured: the same movie soundtrack can give us whispers and breathing and the faintest possible rustling of silk clothing (none of this obscurred by tape hiss) in one scene, and then a terrifyingly loud artillery barrage in the next scene. The higher the SNR is, the more "room" there is for a wide range of sound levels.

Although the SNR concept may seem a little abstract, the truth is that we all have an instinctive grasp of it. If you're having a conversation at a crowded restaurant, no one needs to explain to you that you need to talk louder because there's a lot of background noise. And what are you doing when you start talking louder to be heard? Increasing your SNR, of course.  As the level of background noise goes up, your voice has to get louder to rise above it. When you leave the restaurant, and go from a noisy environment to a quiet one, you start talking softer immediately, because it's immediately apparent that the noise level has dropped and you no longer need to shout to stay above it.

But the SNR concept also applies to things besides sound -- because noise can be, for example, visual noise. Vintage photographs, with their film-grain and dust and scratches on the negative, can almost block our view of the subject of the picture. What exactly is in the foreground of this one, for example?

Scientists are always struggling with SNR. Astronomers looking at images of a very distant and faint object need to use a lot of noise-reduction tricks in processing the image, so that the object stands out more from its background of random speckles, like dust on the image. This sort of thing is similar to what Mr. Dolby does to eliminate noise in recorded sound. I'm sure that medical imaging involves noise-reduction processing as well.

Even Rosanlind Franklin's famous "Photo 51", her X-ray diffraction image of the DNA molecule (which enabled Watson and Crick to beat her to the Nobel prize, when a researcher who disliked Franklin showed them the photo without her knowledge), certainly looks as if it could use a little sprucing-up in the SNR department. It has been called the most significant picture in the history of science, but looking at the gray and grainy thing today, it's hard to understand how it could have helped anyone figure out the structure of anything.

SNR is also an issue with data. In fact, just about any kind of data can have a problem with low SNR -- meaning that the pattern you are trying to identify in the data is so weak that it's in danger of getting lost in the noise. This is especially true of the kind of data which is collected in medical studies.

Suppose you are conducting a two-year study to determine if Twinkies cause heart attacks. Whether your study involves feeding Twinkies to some test subjects and not to others, or involves asking people if they eat Twinkies or not, it is exceedingly unlikely that you'll find the rate of heart attacks is 100% in the Twinkie group and 0% in the non-Twinkie group. Of course, if it did come out that way, it would be an example of extremely high SNR: the "signal" (that is, the pattern of heart attacks occurring in all Twinkavores) would stand out boldly against the low-noise (or rather no-noise) background of the heart-attack-free control group. But don't count too much on this happening. It's far more likely that there will be a small number of heart attacks in both groups, and you'll have to argue that the rate of heart attacks is slightly lower in the non-Twinkie group (and that this slight difference is significant).

Of course, if you're not an especially honest person, you could keep very quiet about the absolute numbers, and emphasize relative-risk numbers instead, to make things seem more dramatic. Noting that you observed 4 heart attacks in the Twinkie group but only 2 in the non-Twinkie group, you could simply announce that this means Twinkies "double your heart attack risk".

Well, maybe they do. But when you're only talking about a few heart attacks in either group, this data set clearly doesn't have a very high SNR. What you've got here, at best, is a small signal trying to emerge from a sea of noise. And what does the "noise" consist of? Well, the other nine thousand factors that increase or decrease heart-attack risk!

It's not likely that the people in your study are exactly alike except for eating or not eating Twinkies. If there are a couple of extra heart attacks in the Twinkie group, there could be a lot of possible explanations for that besides Twinkies. The signal here is too weak, too deep in the noise, for you to be drawing any dramatic conclusions from it. If other studies find the same pattern, maybe it means something, but if the pattern is always weak (with the signal barely standing out from the noise), maybe it doesn't mean a lot.

Okay, so there's my roundabout introduction, trying to explain what SNR is. And now: the reason I brought it up in the first place. I read about a research project tonight which reminded me of how important it is to keep the SNR issue in our minds when we evaluate reports of new research findings. The headline that caught my eye was "Vegetarian Diet Linked to Lower Cataract Risk".

It's a British dietary study which followed people for 15 years and concluded, "People who don't eat meat have a significantly lower risk of developing cataracts," to quote  Naomi Allen, an epidemiologist at the University of Oxford, and co-author of the study.

How much lower? Supposedly the results translated to a 30% to 40% lower cataract risk among vegetarians and vegans compared with the biggest meat eaters. But there you go: those are relative-risk numbers, not absolute numbers -- which is often a warning sign that someone is trying to distract you from the low SNR of the data. What were the absolute numbers?

Unfortunately, it's hard to get a precise idea of this from the summary article I was able to get hold of. We're told that "more than 27,600 people" joined the study somewhere between 1993 and 1999, and their medical records were monitored between 2008 and 2009, and "almost 1500" developed cataracts during that time period, whatever the time period exactly was. Without knowing how far they are stretching the terms "more than" and "almost", I have to conclude that this means 5% of the study participants developed cataracts. But apparently the rate was "about" 6% for meat eaters and "about" 4% for vegans.

Okay, so you see the SNR problem here: we're not talking about a large effect. The "signal" is mighty close to the "noise" here, if the widest disparity we can find is between a 4% chance and a 6% chance. It would not be astonishing to find that some non-dietary factor accounted for the difference. (In fact, it would be unsurprising if that were the case, since an earlier study in India produced data skewed in the opposite direction, with cataract risk slightly higher in the vegetarians rather than the meat-eaters.)

Even if diet is indeed the factor that caused the vegetarian contingent to have a slightly lower cataract risk, it's still unclear whether the reason for this difference was that meat had a harmful effect, or that vegetables (which the vegetarians and vegans obviously ate more of) had a protective effect.

An expert who was not involved in the study has commented on it, and his name (a treasurable one in my opinion, though perhaps he feels differently) is Dr. Jack Dodick. (Sounds rather like a reading primer to be used in an adult literacy class for adults only.) Anyway, he chairs the department of ophthalmology at New York University Langone Medical Center, and he feels that the new study still leaves a lot of questions unanswered. He says that "we don't know what influences cataracts. It may be more lifestyle." Whether nutrition really plays a role in cataract risk is still not clear cut, he said. He accepts the general view that everyone will develop a cataract if they live long enough. "It's the most performed operation in the U.S.," he says. "Approximately 3.5 million cataract surgeries are performed a year." What does he recommend to reduce the risk of early-onset cataracts? "The top of my list would be always protect eyes against ultraviolet rays when outdoors... The moral of the story is, live life in moderation... A healthy active lifestyle with exercise might decrease the risk of cataracts."

I don't know if Dr. Dodick is correct in his conclusions, but it does seem wise to avoid making too much of a study which finds that a 6% risk might possibly be changed to a 4% risk if you redesign your life. Of course, it may well be that avoiding meat consumption really is a healthier choice, but in this case the signal doesn't stand out far enough above the noise to support any bold conclusions on that issue.

Monday, April 11, 2011

Don't know why my blood pressure is up tonight, but the low post-prandial result after lunch is nice, especially considering that it wasn't all that low-carb a lunch (the soup had noodles in it).

I keep going through this same scenario over and over: I start getting discouraged by the contrast between the large amount of time I spend on this blog and the very small size of my readerhsip. I start to tell myself that it's not worth it, I'm not actually doing any good, etc. And at that point I always hear from a diabetes patient who says I've actually helped them improve their health. Then then I'm forcibly reminded that, so long as some people are benefiting,  it's worth making an effort.

Tonight I got a message from a reader in Australia (hence the units of measure, which American readers may find unfamiliar):

"Hi there,

I emailed you just after I was first diagnosed with diabetes back in December 10. You were very reassuring in your advice and I just wanted to give you an update after my first 3 monthly blood test (medication free).

I have during this time lost 13.9 kgs and have another 11.5 to go.  I'm going to the gym 4 days a week and walking hills, etc on the w/ends with my family (which we all love!)

My AC1 at diagnosis was 9.7%.  It is now 5.6%.  My total cholesterol has come down to 2.7 from 3.8 and my triglycerides are down to 1.5 from 4.5 (I will see if I can go off medication soon).

I'm seeing the Dr tomorrow night to officially get my results, but the nurse said, he's very impressed!

The BEST thing is that I feel fantastic!

You are inspirational.

Kind regards etc."

So there you have it: incontrovertible proof that I'm inspirational! More importantly: further evidence that I'm not the only person in the world for whom this kind of thing is possible.

Some people are unhappy about too much attention being given to those diabetes patients who achieve a dramatic improvement in their numbers -- this is seen as a problem, because not everyone can achieve it, and there is concern that those who can't achieve it will get depressed if they have to hear about those who can. This reaction reminds me of those people who sulk when others announce a new job or wedding plans (though I hesitate to make this comparison, because I'm not sure there is anyone left who realizes adults aren't supposed to act that way).

I see it differently. In matters of health, there are no guarantees, only probabilities. We find out what usually works, and we do that. Or, in more desperate cases, we find out what sometimes works, and do that. Whatever approach gives you your best odds of success (even if the best odds you can get are under 50%), that is the approach you take. And it seems to me that it's far better to guide people toward the best-odds approach, without being able to promise them anything, than to downplay any possibility of success, and leave everyone so discouraged that nobody succeeds.

People are being diagnosed with diabetes every day, and they tend to be scared and easily discouraged. They need to know -- sometimes they desperately need to know -- that someone out there is actually having some success at this. They're not necessarily asking for a guarantee; they just want to know that they have a fighting chance, and it would be a terrible thing to leave them with the impression that they really don't.

So, when someone is thoughtless enough to do better at diabetes management than ourselves, we should do the same thing that we are expected to do when somone is thoughtless enough to tell us that they're getting married, starting a new job, having a baby, or otherwise achieving what they wanted: say "Congratulations!".

Not bad weather here over the weekend... I decided to spend some time outdoors in the pollen --  in the sunshine, I mean.

You can practically see the pollen hanging in the air at this time of year.

So far this spring, the Loratadine pill I've been taking every night before going to bed has been fending off any serious allergy problems. Currently my biggest symptom is the murky film that keeps forming on my contact lenses, so that I have to keep taking them out and cleaning them. Probably I'll have to deal with worse than that before my season ends (around mid-June). Still, my allergy problems aren't half as bad as they used to be, probably because I spend a lot of time exercising outdoors now and my system has more time to get used to the pollen.

Have you ever wondered if, in considering treatment options for a particular disease, doctors recommend one option to their patients but choose a different one for themselves when they have that disease? Well, some researchers at Duke University wondered if that could be true, and their research seems to show that it is.

It's not as if there is a huge, night-and-day difference between what doctors recommend to others and what they choose for themselves, but the difference is big enough to require some kind of explanation. What the researchers found was that, in trading off reductions in the risk of death against increases in the risk of serious side-effects which would impair quality of life (as in the case of cancer treatment requiring a colostomy), doctors were more likely (on their own behalf) to choose the option with higher quality of life even if it meant an increased death risk; for their patients, they tended to go for minimum death risk even if it meant reduced quality of life.

What would be the reason for this? Nobody knows, of course (the researchers found the pattern but not an explanation for it). I can see two likely contributing factors. First, the natural tendency many of us have to be more cautious on behalf of others than we are on our own behalf (we tend to assume that others are not ready to take on quite as much risk as we are). Second, because of the ever-present concern about malpractice lawsuits, doctors probably tend to favor whichever choice is least likely to make them look bad in court. If you advise a patient to select the cancer treatment with the 60% survival rate instead of the one with the 70% survival rate, doesn't that mean you're recklessly playing with people's lives? Well, not necessarily, if the treatment with the 70% survival rate is terribly hard on people, but what if the jury sees it differently?

Of course, a third possibility is that quality-of-life issues start to seem more significant when the life involved is your own. My mother (a nurse) used to say, whenever doctors at her hospital talked about "manageable" pain, "You know what manageable pain is? Somebody else's!".

Friday, April 08, 2011

Well, there's one for the books: my fasting result and my post-prandial result were exactly the same. As a post-prandial result, 95 is quite low (not shockingly low for the circumstances, though -- the meal was low-carb and it followed a hilly run).

However, as a fasting test result, 95 is higher than I like it to be (I aim for the low 80s). I'm not quite sure why the fasting test was up, unless it was that I had a late supper last night. Clearly I wasn't having a problem by lunchtime, but it bothers me that I've had three fasting tests above 90 this week. Maybe I've been better about carb-cutting earlier early in the day, and worse about it at supper.

It was breezy and cold for our lunchtime run once more, but that's good running weather if you're dressed for it, and I more or less was. The rain didn't start until we were safely back indoors.

I have to admit that I've been very lucky with running weather this year: even though it's been a very rainy winter and spring, and I've done a lot of running outdoors, I haven't had to do much of my running in the rain.

I guess I'm slow to catch on, but after all these years with the disease, I didn't know that there was an international symbol of diabetes. Well, there is, and this is it:

I guess I must have known that there was an international symbol of diabetes, but I didn't know it was a featureless blue circle. I thought it was something like this:

At any rate, I thought it must have something about it which suggested a connection to diabetes. Admittedly, diabetes isn't the easiest thing in the world to symbolize, but surely it is possible to do a little better drawing a blue circle and calling it a day.

Maybe this would do:

Thursday, April 07, 2011

Well, that's more like it. Fasting test and post-prandial test were quite normal and non-diabetic.

Of course, that could be nothing more than my meter reading a little low today. However, I have adopted a policy of assuming that measurement errors occur only on days when the readings are higher than expected. When a reading is just where I want it to be, I assume it's dead-on accurate. I prefer to think of this attitude of mine as "positive and hopeful". Scrupulous critics would describe it as "childish and stupid", and they would be right, but we all have to be childish and stupid some of the time. The challenge is to limit the number of issues we are allowed to be childish and stupid about. That is why it's good that so many people have the outlet of politics.

Last night's storm came to nothing. It was overcast in the evening, and breezy, and the prediction was that the rain would begin around midnight. But this morning I looked out the window and saw that it was sunny and clear and the ground was not wet.

Even so, the prediction for today was for rain, and possible thunderstorms. Not a bit of it. Sunny all day. There was a cold wind, but it never blew any stormclouds into town. Some of the fleecy cumulus clouds were trying their best to transform themselves into anvil-shaped T-storm cells, but there wasn't a big enough temperature difference between the low and high altitudes to allow them to carry it off.

So, we did our usual lunchtime run. Fortunately I had a warmer running shirt today, and the wind didn't freeze me.

I recently heard some dietary advice which was, if nothing else, original: instead of eating food, you are supposed to imagine eating food. The idea is that, if you imagine this fantasy meal vividly enough, eating it in your mind's eye (or rather in your mind's mouth) will be enough to fool your brain into thinking you ate it in reality; your impulse to eat will be satisfied, and you will stop being hungry.

I don't have time at the moment to evaluate the plausibility of this particular diet plan, but when I heard about it, I felt as if I ought to be creative enough to come up with an idea just as original, if I set my mind to it. So I did set my mind to it, and here's what I've come up with so far: a diet plan based on the idea that we can't help overeating because food is too good-looking these days. I've seen enough cookbooks from the 1940s to know that food used to be pretty ugly stuff, which I figure has to be part of the reason that people were skinny then. (The fact that they couldn't get hold of very much of it may have been a significant factor as well, I realize.)

Anyway, the problem we face today is that food isn't ugly enough. We need to learn how to make food that diminishes our hunger as soon as we get a good look at it. But what are the secrets of making food look bad?

Color alone can be effective. And it doesn't have to be as dramatic or as exotic as this this squid stew.

Even as familiar a dish and spaghetti and meatballs can be off-putting, if the pasta sauce is the color of a Bandaid.

Artfully queasy color combinations can even make desserts look a little frightening...

...and this is especially true if the dish has structural flaws as well.

In fact, if the presentation is poor enough, you might need to alter the color at all.

Of course, the use of unfamiliar Asian ingredients is also very helpful...

...especially if their unfamliarity as foodstuffs is combined with a disturbing familiarity in other spheres.

Even a matter as simple as the shape of a chocolate dessert can exert a restraining influence on the appetite.

A little too much creative imagination can also quell hunger; for example, an impulse to take the already-questionable Scotch Egg concept to new heights of excess...

...or the impulse to use food as a model of geologic disturbances, such as volcanoes...

...or the kind of creative exuberance that can produce such entrees as the Meat Baby.

Of course, as a practical matter, it does seem to take more time and effort to create ugly foods than to create appetizing ones; a lot of us don't have the kind of daily schedule that would permit us always to have something hideous in the oven. But we can photograph our uglier creations, and post them on the kitchen wall -- indeed, on every wall in the house. Once you have filled your life with appetite-killing visual reminders of how repulsive food can be, you will find that weight loss suddenly becomes easy.

Well, that's the theory, anyway. And I'm sure it's just as good as the theory that one can lose weight by eating imaginary food instead of real food.

Wednesday, April 6, 2011

Two days in a row with fasting tests above 90, for no reason that I can figure out. Not that 92 or 93 is actually bad, I realize. But healthy, non-diabetic people tend to get fasting tests in the vicinity of 82, and since those are the people I'm trying to emulate, I prefer to see my fasting tests in the 80s if I can. 

The strange thing is that my recent post-prandial results have been lower than usual, not higher than usual. I don't know of any factor that would elevate fasting tests without elevating post-prandial tests, unless being short of sleep can do that. If so -- well, that's the story of my life. It is my tragedy to be a nocturnal person living in a diurnal society. I get perky at midnight, and comatose in the early afternoon.

It would be convenient to blame my early-afternoon sleepiness on the lunchtime run I do nearly every day, were it not for the fact that I also get sleepy in the early afternoon if I haven't done a lunchtime run!

I did do a lunchtime run today. It was still sunny and clear, even though a storm is supposed to come in from the Pacific late tonight. There was a chilly wind blowing, though. I was too lightly dressed for it. I saw sunshine out the window this morning, and I packed some light, summery running clothes in my gym bag to take to work with me today. It turned out that the view out the window was misleading; it may have been sunny, but it sure wasn't summery. Oh, well; you can't always get these things right. At least I didn't get rained on!

It's supposed to rain tomorrow, though. I might run in the rain anyway (although I know my running buddies won't do it with me, if it's raining). But maybe I'll go to the gym in the evening instead. I haven't done any weight-training lately, and I should remedy that.

Here's an exercise benefit you might not have known about: regular exercise preserves (and even builds) heart muscle mass, which otherwise tends to decline with age.

It works even if you start late in life. So get yourself out there and start moving!

Tuesday, April 5, 2011

A lot of diabetes patients seem to feel that they have a kind of political duty to get fighting mad whenever anyone says anything about diabetes which implies that he might not fully share their own views on the subject. And how dare he?

The offense can be very minor -- a single word will do it. "Cure", for example, is a fighting word, unless you're talking about a future cure. You musn't say that any treatment we know about today can be seen as a cure in any sense. Even if you did something which brought your blood sugar all the way down to the normal range, and kept it there, whatever it was you did must not be called a cure.

Strictly speaking, a "cure" is only a treatment for something, regardless of how well it works or how long it lasts. But the popular assumption is that a "cure" rids you of a condition completely and permanently -- so, if you ever make even the most casual suggestion that some people can be considered "cured" of diabetes, be prepared for a furious backlash.

Unfortunately, even if you are careful to avoid saying "cure", and try to substitute some other word which seems less provocative to you, people will still get just as angry as if you had said cure, because they assume you are thinking cure even though you don't say cure.

Somebody on a diabetes blog is trying to encourage people to write angy letters to Reader's Digest because of the use of the phrase "reverse diabetes" as a main title in books and newsletters, such as "YOUR TOTAL GUIDE TO BLOOD SUGAR CONTROL"...


The standard visual tropes are all there (young white woman grinning delightedly at what her bathroom scale is telling her; elderly ethnic couple grinning delightedly at how fun exercise is; plate of cookies which we're led to believe are delicious but nonfatal). But the subtitles surely indicate that these are not pulbications about how you can get "cured" of diabetes and never have to think about it again. These are publications about how to "control" your blood sugar, or to lower it by 25% in 12 weeks (which, in some cases, would fall short of what is actually needed). Anyway, these publications are obviously offering advice (good or bad -- I can't tell from here) about how to make your diabetes better than it is, not how to bid farewell to it forever.

Why the fuss about the word "reverse", then? Why is that something to write angry letters about?

For many diabetes patients, the disease gets slowly but steadily worse over time: they gradually develop a loss of insulin sensitivity, a loss of insulin productivity, elevated fasting glucose, elevated A1c, and increasing evidence of diabetes complications.

But, in some cases, patients manage to turn this trend around, and start getting better rather than worse in these areas. Although it isn't extremely common for patients to turn the progression around in this way, it does happen, and it probably could happen more often than it does if more people were aiming for it -- which means that it needs to be more widely discussed. But, in order for it to be discussed, it has to be called something. What do you call this reversal in the usual direction of diabetic progression? Well, how about "reversal"?

To say that diabetes is "reversed" may not make it immediately clear to people what, exactly, is involved -- but I can't think of a brief conversational term to use here which would be any clearer. So what is so very irritating about saying "reversed"?

What irritates me is the way diabetes patients get into protest mode whenever anyone dares to say anything encouraging about the subject. Could it be that what's really behind their reaction is not what they claim? I wonder if their actual, unstated position is this: "My diabetes is getting worse rather than better. If someone else's diabetes is getting better rather than worse, I don't want to hear about it, and I shouldn't have to. So shut up about it!"

More search strings! These are phrases which people used in searches that led them to my site. I like to riff on these a bit from time to time.

HbA1c is a common abbreviation for hemoglobin A1c, which is also known as glycated hemoglobin, glycosylated hemoglobin, A1c, and Hb1c. (Why so many names for one thing? Probably because everything they say about scientists being terrible communicators is true.)

Hemoglobin is a protein in red blood cells. In the lab, you can separate hemoglobin into various subfractions, and the subfraction called hemoglobin A1c (and so on) consists of whichever hemoglobin molecules are "glycated" (that is, they have glucose bonded to them). The percentage of total hemoglobin that is glycated is the test result; it indicates how much glycation in general has been going on in the patient's bloodstream lately, and this percentage can be used to estimate average blood sugar.

Better in what sense? That's like saying that a telescope is better than a microscope -- it depends on what you wanted to look at. A telescope will give you a pretty good look at the Andromeda galaxy, but it's not going to tell you much about the wee beasties living in a drop of pond water.

The A1c test is better at giving you an overall picture of how well you're controlling your blood sugar on a long-term average basis, with all times of the day or night included in the equation -- but it's no good at telling you how that casserole you had for dinner impacted your blood sugar.

Daily glucose testing is better at helping you measure the immediate impact of a meal, or the short-term impact of a change in habits, but it's useless at uncovering anything that might be going on unobserved between tests.

So you need both kinds of tests.

I don't think children should own cars, whether they are fat or thin. But this is the kind of statistic which, even if it's true, means nothing by itself. What percentage of children who are not overweight own cars?

That's the normal glucose profile for someone who doesn't have diabetes. It doesn't sound as if you have a lot to worry about.

Definitely not normal, and not good even if you have diabetes. What was for breakfast, I wonder? Most traditional breakfast foods are very high-carb, probably because most people gravitate towards easily-digested foods in the morning, and nothing is more easily digested than carbohydrates: cereal, toast, muffins, that sort of thing. 

Because it's dumb? That would be my guess.

The acronym stands for Non-Insulin-Dependent Diabetes Mellitus (that is, Type 2), and it was adopted (together with IDDM, or Insulin-Dependent Diabetes Mellitus -- Type 1) because it was felt that the old names for Type 1 and Type 2 diabetes ("juvenile diabetes" and "adult-onset" diabets) did not make a clear enough distinction between the two diseases. (Some people develop Type 1 as adults, and these days some people develop Type 2 as children.)

Unfortunately, NIDDM is no better in this regard, since some people with Type 2 do take insulin! It also encourages people to assume (incorrectly) that any situation in which you need insulin is Type 1. In fact, some doctors speak of "Type 2 turning into Type 1" when a Type 2 patient needs to start taking insulin -- and at this point, as George Orwell put it, words and meaning have parted company.

Type 1 and Type 2 are dumb terms also, because they don't tell you anything (I often think that the doctor who chose those terms was named Seuss). If the names are going to be as empty of meaning as that, why not call the two diseases Speeny and Wooba?

My suggestion is that we call them pancreatic diabetes (for Type 1) and metabolic diabetes (for Type 2), but I'm not holding my breath waiting for that to happen.

This can't have been intended as a question about window furnishings. Running will not hang drapes around your diabetes -- that much I have established through experimentation.

If "curtail", in the sense of "restrict or limit", is what was intended here, than I have to believe the answer is yes. Running certainly has had a limiting effect on my own diabetes.

What do you mean, "even"? Is the implication here that sweet urine naturally attracts everyone, and the only suprise is that it attracts ants, too?

My urine doesn't seem to have a fan following among the six-legged, but that's because I don't let my blood sugar get high enough for my kidneys to skim it off and dump it into my bladder. Things might change, of course, if I lose control later.

Certainly it's different with ants than with humans: ants only know you when you're down and out.

You're asking the wrong guy.

Duly noted. (Why Google referred them to me is a little hard to understand, though.)

That you shouldn't have eaten the

Monday, April 4, 2011

Around 4 AM on Saturday, I woke up with a really nasty cramp in the calf muscle of my left leg, which seemed to go on for a record-breaking period of time. When the pain finally stopped, I was left with something to worry about as I tried to go back to sleep: after a cramp as severe and lengthy as that, my leg would probably be very stiff and sore afterwards. Not a problem for Saturday, as I had already been planning to make it my rest day for the week. But I was signed up to run a race on Sunday. What could I do to prevent this from being a problem?

 I decided that, although I obviously wasn't going to do any kind of strenuous workout on my rest day, I did need to put my sore leg muscle to some kind of use. So, I went to the park, but limited my activities to walking around (slowly, and not too far) taking pictures. Because I parked my car at the top of a very steep hill, I knew that just returning to my starting point, no matter how slowly I did it, would give my stiffened calf muscle a good stretching. It worked, I'm pleased to say -- during the race on Sunday I felt not the slightest lingering effect from the cramp.

Of course, just being outdoors in weather as good as this is probably therapeutic in itself.

It seemed as if everyone in town was outdoors getting some fresh air and sunshine.

One of the things I like about going to the park, and seeing all these people there getting their circulation going, is the extremely wide range of fitness on display. Some of them look as if this might be their first time off the couch since October, and others look as if they're training for an Ironman Triathlon. But the're all out there, doing whatever they can.

That's all I'm asking: get out there and do whatever you can.

I did what I could during the race on Sunday. The race results haven't been posted, and I ran it as a two-man relay, so it's hard for me to break out whatever my contribution was. There's no question that my running buddy was a lot faster than I was, but we were just doing it to do it, and do the best we could with it.

They call the race the Loop de Loop; it's put on every year by the local running club, and advertised with the encouraging motto "It doesn't have to be fun to be fun!".

What they're hinting at in their slogan is that this is no easy race; the course involves steep climbs, rocky trails with lots of trip-hazards, and (at this time of year) plenty of mud to slip and slide in. Fraidy-cat that I am, I was extremely worried about taking a fall (as I saw more than one other runner doing, and as I had done before myself), and I just couldn't bring myself to run very fast, even when I was heading downhill and it would theoretically have been easy.

The race course is 7 miles long, but you have to run it twice. Some people do both loops, to make it a 14-mile run, but a lot of people form two-person relay teams to divide it up. My running buddy did the first loop, and we figured it would take him at least an hour to finish it. I went for a walk while I was waiting for him to come back, to give that questionable calf muscle one more stretch, and then did a half-mile warmup run. He returned in about an an hour and five mintues, and I took off. 

It was a fine day for a run, and a beautiful day on beautiful trails, but I hardly had a chance to notice the world around me, other than the little patch of trail that was immediately in front of my feet. Don't Trip! Don't Trip! Don't Trip! A tape-loop of that phrase was running in my brain the whole time. I did stumble a bit, here and there, but I didn't take any falls.

The nice thing was that, because I was concentrating so hard on trying to run fast without falling down, I really didn't have any free attention to devote to the idea that this was hard. One of the big challenges of exercise is to learn to get excited by it and involved in it, instead of detaching yourself from it mentally so that you can concentrate on feeling sorry for yourself. This is mainly a psychological issue rather than a fitness issue: no matter how fit you are, exercise is still going to be difficult if all you're thinking about during it is how difficult it is. Participating in a race, particularly as part of a team, gives you something else to focus on. The time goes by very fast, because you're trying to beat the clock and it seems as if the clock is racing ahead of you. I certainly didn't run the loop as fast as my running buddy did, but I ran it faster than I ordinarily would have by myself, and it seemed like a much more intense workout than I'm used to getting. I had a pretty good runner's high for the rest of the day. (I felt good today, too. And my systolic blood pressure was unusually low tonight.)

I'm going to have to do these event more often. It may seem impractical, as so many organized events of this sort are fund-raisers for a cause, and you have to pay a hefty registration fee to participate in them. But there are also cheap events, put on by running clubs and cycling clubs. The registration fee for this one was only $10. I can afford that, and anyway it benefited a cause I believe in: the cause of Tom Not Having A Heart Attack. Neglecting that cause might prove costly in the long run.

Of course, there are other views:

Friday, April 1, 2011

I was going to provide some completely false and ridiculous new information about diabetes here, as an April Fool's prank, and then reveal that I was only kidding about it. But then I decided that this was not such a good idea. First of all, false stories tend to get circulated widely (much more widely than true ones), and this continues long after the stories have been been widely debunked (do a search on "Mencken bathtub hoax" sometime, if you doubt me).

Also, you can read false and ridiculous information about diabetes any old time. It's not as if you have to wait for the first day of April to get the opportunity.

Tell you what: let's pretend I did write such a piece, and it was very clever and funny, and you nearly fell for it, for a while, but then you started to become suspicious just before I admitted it was all just a joke. It may seem crazy for a writing project to exist only as a hypothetical text that could have been written, but I'm not sure it's any crazier than Fantasy Football.

Yesterday I was trying to promote the idea that your DNA is not your destiny; that diabetes may be strongly associated with certain genes, but this doesn't mean there's nothing for you to do but crawl into a hole and die if you seem to be carrying those genes; that what you do is as important as what you are. Perhaps this would be a good time for me to give you some reasons to think that this is true.

For some time now, the Joslin Diabetes Center in Boston has been giving out medals to people who have lived with Type 1 diabetes for 50 years. Even though Type 1 is usually diagnosed quite early in life, surviving five decades of it is regarded as no small achievement, as Type 1 is usually more severe than Type 2 and considerably harder to manage.

Recently some researchers got the idea of studying the Joslin "medalists", to try to find out what made it possible for them to stay healthy while their peers were succumbing to diabetic complications. Dr. George L. King and colleagues studied 351 patients who had received medals between 1997 and 2007; their average age was 67.5 years, and their average time since diagnosis was 56.5 years (in other words, they had been diagnosed at age 11 on average).

So what sort of shape were these patients in, after 50 years with the most severe variety of diabetes? Well, they turned out to have surprisingly low rates of the more common diabetes complications, such as nephropathy and retinopathy. This has already led researchers to start speculating about some kind of strange, mysterious "protective factor", presumably genetic, and apparently rare, that allows a small subset of Type 1 diabetes patients to spend 50 years with the disease and not suffer the typical consequences. Strangely enough, for these lucky patients there was no clear correlation between complications and hemoglobin A1c test results. However, there was a clear correlation between complications and advanced glycation end-products (AGEs -- the nasty chemicals that get produced as an indirect result of glycation). It was as if some patients, for reasons entirely mysterious, had fewer AGEs hanging around in their systems, and therefore suffered less harm from being diabetic, and even from having high blood sugar, than other patients did.

It may have seemed natural to the researchers to jump to the conclusion that these "lucky" patients were reaping the benefit of having some kind of specific genetic advantage which has not yet been identified. I'm not quite ready to go there myself. What if there is some other difference, a non-genetic difference, between the "lucky" patients and the "unlucky" ones?

What if the supposedly "lucky" patients, who are still alive and kicking after 50 years with Type 1 diabetes, are doing something right?

I'm not saying I can prove that lifestyle rather than genetics is making the difference here. But it might be, and there are some indications that it is.

Several studies (admittedly, studies of Type 2 rather than Type 1) have found that differences of lifestyle have a big impact on either preventing or mitigating diabetes.

For example, the Malmo study in Sweden, which found that lifestyle interventions were more successful than "usual care" in preventing men with glucose intolerance from becoming diabetic -- and also found that glucose-intolerant men in the lifestyle-intervention group had mortality rates, 12 years later, no worse than men with normal glucose tolerance.

The Da Qing study in China found that lifestyle intervention (particularly exercise) produced a significant reduction in progression to diabetes:

The Diabetes Prevention Study found that the lifestyle-intervention group were more successful at remaining diabetes-free than the control group, and that the difference became larger as time went on:

The similarly-named Diabetes Prevention Program study also found that the incidence of diabetes was lower in those who had been in a lifestyle-intervention program -- lower, in fact, than those who had been treated with metformin: 

Now, I don't know for a fact that the "lucky" patients who won the Joslin medals for living 50 years with Type 1 diabetes were, in fact, reaping the benefits of their lifestyle rather than their genetic "luck". But it does seem to be a possibility -- and a possibility which the researchers are entirely overlooking.

Comparing Type 1 patients with Type 2 patients is obviously a questionable practice, and I won't push this comparison any further. But when we see data showing that lifestyle intervention works -- and works better than metformin -- I think we ought to pay just a little more attention to than we generally seem to be doing now.

Nearly all diabetes research papers seem to be written on the assumption that research which leads to a patentable drug is the only kind of research that matters. Well, it's the only kind of research that matters to the people who are doing the research, but it's not the only kind of research that matters to people who are trying to live with diabetes.

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