Wednesday, August 31, 2011

It was a strange day. My glucose was pretty low this morning; 77 isn't hypoglycemia, but it's an unusually low fasting result. I don't know how much that had to do with what happened four hours later, but it was probably relevant.

I was in a meeting which ran slightly overtime, and I had to hurry straight from the conference room to the locker room downstairs, to get dressed in time for my daily run. (When you're meeting up with other people to go running, you need to be punctual.) During the meeting, I'd been feeling increasingly hungry. Now, as I got dressed for the run, the feeling of hunger was so strong that I began to regret that I'd had no time to get hold of some kind of snack earlier. In fact, I started having doubts about whether or not I could complete a run of any distance. I was starting to feel not only hungry but also a bit weak and shaky.

I had a little bit of internal psychological conflict over this; I tried to tell myself that I was being a baby, and blowing this out of proportion. I was just a little hungry, and the feeling would probably vanish as soon as I started running. But what if it got worse instead?

Finally I had to admit that I felt so unsteady that this really had to be hypoglycemia, and I needed to do something about it if I was going to go ahead with the run. I told my running buddy that I was feeling hypoglycemic and I'd better get a snack before we started; if I didn't I'd be afraid to attempt the run. So, I went to the snack station down the hall, got hold of some chocolates, and snapped them up like a hungry dog. (My frantic effort at tearing open the plastic wrapper surely counted as a hypoglycemic symptom all by itself.) Almost immediately I started to feel better, I guess partly from relief at knowing I had addressed the problem.

Let's be realistic: it takes a little while for even the most sugary snack to hit your bloodstream. If you feel that kind of instant relief, just because you know you took in some sugar, it certainly suggests that there's a large element of psychology in whatever is going on. But it's hard to untangle perception from reality in these matters. Maybe your body turns off the hypoglycemic emergency symptoms as soon as it knows you've done what was necessary.

Anyway, after only a slight delay (maybe 5 minutes) we started the run, and I felt fine throughout it. During the first steep climb I felt strong, and I was extremely thankful I'd had the chocolate.

Lunch afterward was not large, but it was not low-carb either (a soup with noodles in it), so I wondered if that plus the chocolate I'd had earlier would combine to give me a high post-prandial result. Nope: it was only 92. Well, if I only went up to 92 after noodle soup, then I think it's safe to say that I actually had dropped fairly low, and that I had not over-corrected for it.

I worried all afternoon about being hypoglycemic again for the tough bike-ride going home, so I ate some trail-mix in the late afternoon to make sure. In the event, the bike-ride was fine.

So what brought all this drama about? To start with, I should note that hypoglycemic episodes in unmedicated people can be very mysterious events; often it is hard to see what could have triggered them. But in the present case, I have to assume this happened because I have just started making some dietary changes -- definitely cutting down on grain-based foods in my diet -- and it's likely that my body was caught unprepared for this, and as a result my blood sugar dropped a little too fast for comfort.

It wouldn't surprise me at all if I swing in the opposite direction tomorrow (because my system is trying to solve the problem I had today), and I get a higher fasting test than usual instead of a lower one. Well, any change that the body isn't expecting can provoke odd reactions in the short term; what really matters is what kind of equilibrium I can settle into after a little more time goes by.

But if I'm going to be biking to and from work, and running at lunchtime, I'd like to avoid experiencing too much more of this hypoglycemia business. I don't think it's actually dangerous to me, but it's an awful feeling and I truly hate it. It reminds me a little bit of the emotional toll that serious asthma takes on you: it is mighty unpleasant to have to be constantly thinking about breathing; it should just happen, with no effort or worry required. Maintaining an adequate level of glucose in the bloodstream is like that -- it should just happen (and when it doesn't, life suddenly becomes a very different experience).

Tuesday, August 30, 2011

Every once in while I hear about a health proposal that sounds so strange, I wonder whether it is intended as a joke. (Several years ago, a few of the more enthusiastic proponents of statin drugs were talking about adding statins to municipal water supplies, and to this day I have no idea to what degree they were serious about it.) If yesterday's report from the Paris cadiology conference, on the health-promoting power of chocolate, didn't strike you as far-fetched enough, today's news from the same place just might.

The news has to do with a proposed pill which contains a combination of drugs to treat the most common cardiovascular health problems. The "polypill" would contain a beta blocker, ACE inhibitor, diuretic, statin, and aspirin. The proposal is, at the very least, to prescribe this pill to everyone thought to be at risk of cardiovacsular disease, and perhaps to prescribe it automatically for everyone over 55, as the first line of defense in terms of preventing cardiovascular disease.

Salim Yusuf, a Canadian doctor, addressed the assembled heart doctors in Paris: "...on current evidence, I think we should be using the polypill if it's available in very high-risk people, like in secondary prevention. Why would you not use it? You would be giving it as separate pills in these people anyway, so you might as well give it as a single pill. It will improve adherence and substantially reduce the cost. I also think there are other high-risk groups in primary prevention, such as severely hypertensive patients, of whom a large number also have dyslipidemia. High-risk diabetics or those with multiple risk factors should also be candidates for the polypill."

Yusuf suggested the pill might also be right for patients over 55 with moderately-elevated risk factors. "We have to think of the polypill not as a pill, but as part of a strategy to completely change our approach to prevention. Instead of saying lifestyle first and drugs next, why don't we say that drugs are the basis, then get the patients contemplating prevention, and then get them to modify their lifestyle. Maybe that will work, because the reverse strategy hasn't."

When I read that awful phrase "why don't we say that drugs are the basis", I felt as if Dr. Yusuf had reached all the way across the Atlantic from Paris to stick his finger in my eye. I suppose I should try to take these things less personally... but them's fightin' words in this here town, buckaroo.

It seems to me that Dr. Yusuf is addressing us from an alternate universe in which the only thing wrong with the health care system is that doctors pay too much attention to lifestyle and not enough to drugs. I wonder what it's like to live on his home planet...

To be sure, in the unlikely event that he should ever read my blog, he would certainly think that I'm the one who's dwelling in an alternative universe -- a fantasy realm in which patients are actually willing to change their lifestyle in order to improve their health.

Maybe we're both right, in a way. No doubt there are plenty of patients out there who, for one reason or another, aren't going to change the habits which contributed to their current health problems, and can't be treated at all unless they're treated with drugs. But when I say that they won't change their habits "for one reason or another", I have in mind a specific reason why many of them will not: nobody is giving them any reason to think it would work if they did.

I insist that there really are such things as patients who are willing to change their habits in order to get their health back. Since I started this blog, I have heard from enough of them to be convinced that they exist. Sure, readers of my blog are probably atypical diabetes patients, and I'm sure Dr. Yusuf has a lot of patients who would never read my blog a second time -- patients who, for example, would rather die than exercise (and who do just that, right on schedule). The fact that those patients are numerous doesn't mean everyone is just like them. Some of us aren't like them at all. We may be atypical, but that doesn't mean we don't exist, or don't matter.

Some proportion of diabetes patients (and it might be a larger proportion than Dr. Yusuf imagines) are willing to do what's necessary to control their condition without drugs. But the ones I hear from are very nervous about it, because everything they're hearing from their doctors makes it sound as if they can't possibly succeed at it and that they're fools to try. The most encouraging input they ever get is that it might work fairly well for a while, before it inevitably fails.

If the message people are getting is that lifestyle-based diabetes management (which is, let us admit it out loud, not easy) is also a doomed undertaking which will surely make the patient regret all the futile effort he invested in it, then I don't think we should be too surprised if people fail at it. Of course they fail: they've been told discouraging things about it, they're being told it won't work... so, as soon as the going gets tough, they give up.

When people who have run into frustrating problems with their diabetes management ask me for suggestions, there always seems to be an undercurrent of fear in what they say, and it's a very specific fear: they're afraid that they may be kidding themselves -- that they may be trying to do something which is in fact completely impossible, and that when their failure finally becomes undeniable, they'll feel like they've made fools of themselves trying to succeed. Losing control of your health is bad enough, but losing your dignity on top of it is even worse. If the real choice is between being sick and being both sick and embarrassed, why not choose the former, especially if it's less trouble?

We diabetes patients don't talk about this issue much (if at all), but I think our underlying fear of looking like idiots is a major issue for a lot of us. We don't want to have regrets about whatever we decide to do, and we're afraid there's a lot of regret-potential in any attempt to take charge of our own health and improve it. If we declare that we're going to succeed where others have failed, and then we go ahead and fail, won't we look like total losers? Won't we look much worse than if we had just quietly done the usual thing? And won't we bitterly regret every minute we ever spent exercising, and every baked potato we ever passed up, once we realize that we could have just taken a handful of pills?

Allow me to point out, ladies and gentlemen, that we need to be careful about how we think about success and failure. If you try to control your blood sugar by jogging and giving up baked potatoes, and it turns out that this isn't enough to get your numbers where they need to be, this does not mean that you shouldn't have tried it, or that you would have done better by not exercising and eating baked potatoes and swallowing handfuls of pills.

Look, if swallowing handfuls of pills and doing nothing else about your diabetes actually worked, diabetes wouldn't be a serious health problem, now would it? People certainly wouldn't be dying of it, or becoming disabled by it. The answer to the good doctor's rhetorical question "why don't we say that drugs are the basis?" is "because we've seen what happens to patients treated on that assumption!".

The things you need to do to control diabetes without drugs are the same things you need to do while you control diabetes with drugs. Since you have to do these things anyway, you will have no cause to regret doing these thing if it later turns out that they aren't enough by themselves to solve the problem. 

Monday, August 29, 2011

I have never been any good at guessing people's ages, and I usually deal with this handicap socially by trying to ignore age altogether. My work life and social connections cover a wide range of ages, and I try my best to pretend that everyone who isn't clearly at one extreme or the other of the age spectrum is just "an adult", with no age in particular. I like to think of age as being something that gets in your way if you think about it but doesn't if you don't.

In other words, the minute you start thinking "I'm too old to do this", you instantly become too old to do it -- but you wouldn't have become too old to do it if you hadn't let yourself think that. It's not that I really believe we can become immortal just by failing to notice the passage of time, but I tend to feel that paying a lot of amxious attention to the passage of time is morbid and destructive. I think it causes a lot of people to give up and get "old" (that is, weak) during a time of their lives when they actually could be strong.

I am not yet persuaded that there is anything wrong with my viewpoint on this, but in the past few years it has become trickier to maintain that viewpoint. The problem (at least so far) has nothing to do with anything that's been happening to my own health. I ran 7 miles yesterday, and 5 today, and rode a bike home from work (up a steep hill), and went to yoga class and was limber enough to do what needed to be done there. Glycemic control is still good. Seemingly I'm doing fine. I look at myself in the mirror and can't see that I'm looking old -- apart from the snowy beard and the solar panel I'm developing on the top, both of which have happened to younger men than me:

What's making it tricky for me to maintain my dismissive attitude about age is that people whom I think of as being, roughly, my contemporaries (all those "adults" with no particular age that I know) seem to be suddenly turning old. I don't mean gray-at-the-temples old, I mean old old. When I talk to acquaintances whom I haven't seen in half a year or more -- people who never seemed to change much during the many years I've known them -- I'm shocked to find many of them looking a lot older, and behaving older. All of a sudden they seem weak and timid. Which, of course, makes me wonder if they're thinking exactly the same thing about me!

A mirror gives us a heavily-retouched and glamorized notion of what we look like; in a mirror we are never as fat or wrinkled as we would appear in a camera view-finder or, even worse, in a friend's eyes. So, it can be a little scary to run into people you don't see all that often. When someone at a Christmas party looks a lot older than they had at the same party the previous year, you know that time is catching up with them at high speed -- and that it could be doing the same thing to you, without your realizing it. Who knows just how flattering the filter is that gets in between me and my bathroom mirror?

Sometimes the issue that makes a social gathering disturbing is not age exactly, but something which we usually think of as age-related. I recently attended a gathering at which there were several people that I have known a long time, but don't see often, and I couldn't help dwelling on a single thought practically the whole time -- how did everybody get so fat? What on earth happened here?

Actually, it wasn't everybody. But this was not a very large gathering, and no less than five people there had gained a very large amount of weight within the last year or two -- enough to make them seem like different people.  But those who hadn't gained a lot of weight, hadn't gained any, so far as I could notice. The crowd seemed to be divided into two distinct camps: those whose weight was stable, and those whose weight was ballooning out of control.

As it happens, I didn't express this observation aloud at the time. Some people would, though not American people. I used to work with a guy from the Phillipines who thought there was nothing uncivil about opening a conversation with the question "Why did you get so fat?" and refusing to settle for an evasive answer. Those who grew up on these shores are a little more inihibited in these matters, so I didn't quiz the people there about why some of them looked the same as before, and some of them now had abdomens which entered the room a second or two before they did. I couldn't stop wondering about it, though.

The impression a lot of people have is that there is a natural tendency to gain weight slowly (maybe a pound or two a year), and by the time you're middle-aged it adds up -- and voila, you're fat. If that is true, I bet it's only true on average. I think the reality is that some people are weight-stable and others experience periods of dramatic, out-of-control weight gain, and all this averages out to an unrealistic picture of a society in which everyone gains weight, but very slowly.

I'm currently reading a book, suggested by a reader of this blog, which explores some of the reasons for these strange, rapid weight increases. However, I'm not finished with it, and I think I'm going to have to spend a fair amount of time analyzing the author's ideas before I want to form a judgment about them, so I'll say no more about the subject for right now.

Always a day-brightener: another study saying chocolate is good for you.

At a gathering of cardiologists in Paris today, British researchers reported on a study comparing the health of people who eat a lot of chocolate to people who don't. Their conclusion?  Compared to those who ate chocolate the least, those who ate chocolate the most had 29% less risk of stroke, and 37% less risk of cardiovascular disease. (Oddly, the impact of chocolate on the risk of diabetes differed between the sexes. In men, chocolate reduced the diabetes risk; in women it made no difference one way or the other. No one knows why a gender-difference of that kind should exist.)

Now the bad news: this study was a meta-analysis. The researchers don't gather new data, they just combined a whole lot of data collected in many earlier studies. Because the people who conduct a meta-analysis must make arbitrary decisions about what data to include and what data not to include, the process is extremely vulnerable to selection bias (conscious or unconscious). A meta-analysis can usually be counted on to confirm whatever the people running the study had believed all along. I think it is likelier than not that the present meta-analysis was done by people who went looking for data showing that chocolate is beneficial, and found it. That doesn't mean they're wrong; it just doesn't add anything new or surprising to the discussion. Stating that "the average of these pro-chocolate results is itself a pro-chocolate result" doesn't seem all that revelatory to me.

Still, it's nice to know that there were enough pro-chocolate studies in existence to a support a meta-analysis of this kind; maybe chocolate really is as helpful as it appears to be. But if chocolate is helpful, why is it helpful? What does it do, exactly, to protect us from strokes and cardiovascular problems?

Nobody really knows for sure, but it is thought that the helpful ingredients in chocolate are the polyphenol compounds contained in the cocoa solids. Assuming that is true, dark chocolate with a high percentage of cocoa is most helpful. Milk chocolate is less helpful. So-called "white chocolate" is probably useless; it's made from cocoa butter rather than cocoa solids, and that's not the same thing. So, go for the dark and bitter. (Those of us who have the good luck to be oriented toward the dark and bitter already don't need to make any adjustments.)

But what exactly do the polyphenols do to protect us from strokes and heart attacks? Things get a bit vague here, but it is thought that the polyphenols "increase the bioavailability of nitric oxide" -- a compound which can have both positive and negative effects, but is believed (in this connection) to have beneficial effects on blood platelets and blood vessels, and to reduce blood pressure, serum cholesterol, and insulin resistance.

The downside of chocolate from a diabetic point of view hardly needs pointing out: it is usually crammed with sugar. But the forms of chocolate that really uphold the dark-and-bitter principle (72% cacao bars, that kind of thing) are less sugary than most. Still, we're talking candy here. For people with diabetes who want to see if they can get some of the health advantages of cocoa solids without eating sweets, maybe the solution is to work cocoa solids into foods that don't need to be sweet. The mole sauce used for meat dishes in Mexico, which usually contains cocoa, might be a useful example of this idea.

I'll look into it, and let you know if I find anything useful.

Friday, August 26, 2011

No exercise today, but I still pulled off a much lower post-prandial result than I did (following a hard run) yesterday. Why the difference? Well, today I tested after a low-carb meal, and yesterday I tested after a high-carb meal. What do you know: apparently carbs matter!

The ancient Romans were a superstitious bunch, and they believed in omens -- trivial events of today which, if properly interpreted, predicted important events of tomorrow. Furthermore, they believed that omens could be forced to operate in reverse: you could prevent a future calamity by preventing the omen that was thought to warn of it.

The most famous example of this was the Roman belief that, if a bride stumbled on the threshold when entering her husband's house for the first time, the marriage would be an unhappy one. The very practical Romans found a solution to this problem: have the groom carry the bride across the threshold, so that she has no opportunity to stumble. Prevent the omen from manifesting itself, and you prevent he problem which the omen would have foretold. It all sounds perfectly reasonable, does it not?

The Romans seem not to have noticed that, although this wedding-day precaution had become routine, people were still experiencing marital unhappiness. Superstitious people do not subject their ideas to critical analysis. Once they have made an assumption, they cling to it forever; they don't think of asking themselves later whether the assumption might have been hasty and ill-considered.

Although we modern folk like to think that we are far less superstitious and silly than the ancient Romans were,  it seems to me that we are sometimes pretty hasty in assuming that we know the meaning of biochemical omens of future health, and pretty naive in thinking we can we can prevent bad health by manipulating the omens associated with it.

When we hear that people with a particular disease have low levels of some vitamin or hormone in their blood, do we not immediately leap to the conclusion that taking supplemental doses of that vitamin or hormone will prevent the disease? (We usually don't pause to consider the possibility that low levels of that vitamin or hormone might be a symptom of the disease rather than the cause of it.)

When you go looking for the solution to a problem without first making sure that you understand what the problem is, it isn't very likely that the solution you find will turn out to be a good one. For example: as soon as it was realized that coronary heart disease was caused by cholesterol deposits on the arterial walls, people started worrying about blood cholesterol levels, and they jumped to the conclusion that heart disease could be prevented by reducing dietary intake of cholesterol.

Actually, most cholesterol in the blood is manufactured within the body, not ingested. The real problem seemingly has to do with how much cholesterol the body produces (and what kind), and how much of that cholesterol actually gets deposited on arterial walls. If cholesterol consumption isn't the real problem, you can't expect to solve the problem by giving up eggs.

I'm not saying that a problem necessarily becomes easy to solve after you understand it, but you certainly aren't likely to solve it before you understand it. We need to resist the temptation to leap to a solution before we have figured out what problem we are solving.

Which brings us to the latest Omega-3 fatty acid study. In recent years we have given up the idea that all fats are evil, and replaced it with an only slightly more nuanced view in which some fats are bad and others are good. The trouble is, we're having a hard time establishing which are the good fats and which are the bad fats. Opinions vary on this, and they change over time. For a long time, saturated fat was the arch-villain and monounsaturated fat was the hero. In more recent years, these roles have been shifting. It now appears that trans-fat (that is, artificially hydrogenated vegetable oil) has taken over the villain role, and the new hero is a family of compounds known as Omega-3 fatty acids. Many foods and supplements are promoted heavily on the basis of their Omega-3 content, as if it were universally agreed that the only way to be healthy is to make sure you're getting enough of this stuff.

Apparently the brain makes use of these Omega-3 fatty acids in some way; it is thought that they are essential for proper functioning of the nervous system, and that various neurological problems and mood disorders may be linked to a deficiency of Omega-3s.

One of the Omega-3 fatty acids (docosahexaenoic acid, also known as DHA) is of particular interest because of the way it is concentrated in the brain. Now a study of military suicides found that (1) DHA levels are low in military personnel generally, and (2) DHA levels are even lower in military personnel who commit suicide than in those who don't. From this, people are already concluding that low DHA levels make people suicidal, and that military diets need to be changed so that the troops get more Omega-3s.

I am willing to concede that it might actually be just that simple: soldiers don't get enough Omega-3s in their meals, and the less they get, the higher their risk of suicide.

However, I am certainly not going to take it for granted that it's that simple. The connection between low DHA levels and military suicide could be more complicated and indirect than that.

Do we know for sure that the only factor influencing DHA levels in the blood is dietary intake of Omega-3 fatty acids? (Let's not forget how the dietary cholesterol story turned out!) If the nervous system uses DHA for some purpose, maybe it is capable of breaking it down into something else, and thus reducing the DHA level. Perhaps, when people are depressed or under stress, the DHA level is reduced, regardless of dietary intake of Omega-3s. It's not as if suicidal soldiers differed from non-suicidal soldiers only in terms of DHA levels, and not in any other way. They were also likelier than non-suicidal soldiers to have seen fellow soldiers wounded or killed. Perhaps the soldiers who were most likely to commit suicide were also the soldiers who had experienced the most combat stress, and the stress had the effect of lowering their DHA levels in some way.

We need to be on our guard whenever these reasonable-sounding and attractively simple assumptions are put forward. Often they don't work out so well in reality. For example, when the role of anti-oxidant compounds in protecting cells was discovered, everyone assumed that taking supplemental anti-oxidants would protect us from various diseases. The idea seems to make a lot of sense... on paper.... but experiments aimed at verifying this protective effect of these supplements have failed to uncover any evidence of it. No one is sure exactly why anti-oxidant supplements don't work, but it seems that they don't. (It may be that eating foods which contain natural anti-oxidants works better than the supplmenents do; I don't think that idea has yet been tested, so keep eating your vegetables and hope for the best.)

In addition to my usual reasons for taking a cautious and skeptical view of health research, I think there is an additional reason to be dubious in this case. This was not a study of suicide in the general population; it was specifically a study of military suicide. The present rate of suicide and mental illness in combat veterans is seen as a serious problem, and an embarrassing problem. It makes people uncomfortable to think about it. Perhaps there is a powerful desire, on the part of a lot of people (inside and outside the military) to redefine this problem as something else -- anything else -- than what it looks like. How much nicer it would be if this has to do with nutrition, rather than with the ordeals we are putting our soldiers through! How appealing to think that a daily dose of fish oil or flax seeds might make this issue go away, and take it off our consciences!

Science is never at its most reliable when people have a strong emotional preference for the result of a study come out a certain way.

Thursday, August 25, 2011

Every once in a while I risk having an unusually high-carb meal because I think the circumstances are favorable for me to get away with it (just after a hard workout, for example), and in fact I generally do get away with it. I didn't quite get away with it today. I treated myself to a large, ripe, sweet banana with my lunch, and my glucose went up to 142 an hour later, which is higher than I like to go.

142 is a little under the post-prandial maximum that my doctor asked me to aim for, but I actually aim for a lower result than that. Non-diabetic people don't go higher than about 125 after a meal, and when it comes to glycemic management, I've decided that my role-models should be people who don't have diabetes. The more I can be like them, the better.

Okay, Tom: be more cautious next time. Just because your fasting test was unusually low doesn't mean you can get away with anything you feel like trying to get away with.

Why is the prevalence of diabetes increasing? This issue is usually discussed as if there were nothing mysterious about it: it's because people are fatter. Everyone knows that, right? Fat people get diabetes, and we have more fat people now, so we have more diabetes cases now. If there is any mystery to be solved, it has to do with why people are getting fatter (is it fast food restaurants that are to blame, or high-fructose corn syrup in processed foods?).

Well, hold on a moment. There is a connection between obesity and diabetes, but the exact nature of that connection is far from thoroughly understood, and it may be a very complicated relationship. There are reasons to think that diabetes (or at least insulin resistance) promotes weight gain, so it could be that we've been a little confused about what is causing what. It could also be that some other problem which promotes diabetes also promotes weight gain, and that is the main reason diabetes and obesity tend to travel together.

I doubt very much that we are ever going to narrow this down to a simple cause-and-effect relationship between a single issue and diabetes; it is far more likely to be a tangled interaction between multiple factors.

But one factor which could be as important as obesity tends to be mentioned far less often than obesity is, as a possible cause of diabetes: physical inactivity.

John Thyfault, a professor of internal medicine and nutrition/exercise physiology at the University of Missouri, has been researching the matter, and he says that physical inactivity disrupts glycemic control and plays a key role in the development of Type 2 diabetes: "We now have evidence that physical activity is an important part of the daily maintenance of glucose levels. Even in the short term, reducing daily activity and ceasing regular exercise causes acute changes in the body associated with diabetes that can occur before weight gain and the development of obesity."

Thyfault's research showed that healthy individuals who restricted their physical activity over a period of a few days soon showed higher post-prandial glucose spikes (the increase in glucose, in response to digesting a meal, was soon twice as large). "A single bout of moderate exercise can improve the way the body maintains glucose homeostasis (blood glucose regulation) and reduce PPG, but becoming inactive for a short period of time quickly disrupts glucose homeostasis... This study shows that physical activity directly impacts health issues that are preventable."

My own period of reduced physical activity could not honestly be described as lasting a couple of days. Several years is more like it. Perhaps my diabetes diagnosis in 2001 was pretty much inevitable, under the circumstances. But I've been exercising ever since, and it does help a lot.

I wouldn't want to go so far as to say that the obesity/diabetes link is illusory -- that it's a mere artifact of a far more significant relationship between inactivity and diabetes. But when the "diabetes epidemic" is up for discussion, obesity is always mentioned -- as if there were no doubt that obesity is the one and only cause of Type 2 -- and inactivity is often ignored altogether, except as a contributor to obesity. The situation seems very unbalanced to me.

Dr. Thyfault's research is not the only indication we have that physical inactivity impairs glycemic control. One of the difficulties with establishing the "Glycemic Index" of foods is that GI is determined by taking an average of various people's post-prandial response to a standard test food -- and individual responses are all over the map, because GI varies inversely with fitness level!

If the evidence shows that physical fitness determines post-prandial glycemic control, and that even a brief period of inactivity impairs glycemic control in people who are neither diabetic nor obese, then it seems likely that inactivity is playing a very important role in diabetes prevalance -- and it's about time we started paying more attention to the issue.

Wednesday, August 24, 2011

I usually test 1 hour after a meal rather than two hours, but the one-hour point found me in the middle of a project meeting, so I waited. Well, if I was only at 96 after two hours, I probably wasn't all that high after 1 hour. You can't count on that, though, so I try to do the 1-hour test as often as I can.

Am I ever going to learn to like climbing that hill on the bike on the way home from work? Perhaps not, but this time I made a conscious effort at relaxing during the climb. I told myself not to fight the hill, but simply to climb it, at whatever pace I could maintain without tensing up and feeling bad. The result, so far as I could judge, was that I wasn't much slower -- but I felt a lot better. Okay, I'll try to apply that lesson to future hill-climbs. What Yogi Berra said of baseball is probably just as true of cycling on hills: it's ninety percent mental, and the other half is physical.

The corporate culture where I work favors physical activity. Several cubicles in my office had bicycles parked in them today -- not because there is no place to park a bike outdoors, but because these are fancy lightweight carbon-fiber racing bikes that cost their owners too much money for them to be let out of sight. And some of these people are pretty high-level managers.

At lunchtime, lots of people are outside running and cycling and participating in exercise classes.

It's not as if employees are told that they need to be in shape to work there, or are put under pressure to sign up for a workout class. But there is a kind of subliminal message constantly being communicated: it's okay to exercise, it's good to exercise, we respect people who exercise, we promote people who exercise. Not that being in shape is enough to get you a high-level job, but I can't help noticing that the people they give high-level jobs to tend to be in shape. You don't see a lot of couch-potatoes rising to great heights in the organization.

It's been a very lucky thing for me that this is the prevailing attitude where I work. Nobody has ever given me crap about running at lunchtime -- and I know that, at many companies, such a routine would be seen as self-indulgent and weird. I'm sure the company benefits by this: people who exercise a lot tend not to be out sick all the time, and they tend to be energetic, forceful, focused employees.

But I try to remind myself, from time to time, that a lot of people with diabetes don't have it so lucky -- in trying to integrate exercise into their lives, they run into far more opposition and inconvenience than I ever do.

In medical research, what exactly does it mean to say that a difference in health outcomes between two groups (say, people taking a medication and people not taking it) is "statistically significant"? Roughly speaking, it means the difference is large enough that it is unlikely to have come about merely by chance.

Suppose a researcher claims to have found that people who eat rhubarb live longer than people who don't eat rhubarb. What's the first question you want to ask? That's right: how much longer did the rhubarb-eaters live? And the reason you want to know this is not just that you're trying to decide how much extra life you'd need to get out of the deal, in order to have an adequate motive to eat rhubarb. You're also wondering if the longevity-enhancing effect of rhubarb is real or imaginary.

If rhubarb-eaters live 10 years longer on average, that is an impressively large difference, and it encourages us to take seriously the possibility that rhubarb really does extend longevity.

If rhubarb-eaters live 10 days longer on average, that is a very small difference, and we shrug it off as meaningless example of random variation between two groups of people. We wouldn't be surprised if, repeating the experiment, we found that this time people who didn't eat rhubarb lived 10 days longer. When the difference is that small, it probably isn't for real; whatever small difference we find is probably nothing more than the kind of small-scale variation you'd expect to find in comparing any two groups of people.

So far, I've been speaking in generalities -- and I'm not going to stop now, because I don't want to explore the details of how scientists decide what qualifies as statistically significant  (although I note in passing that this issue is what researchers are fussing about when they discuss the "P values" in their data).

To keep it at a more general level, when patients taking Treatment A do slightly better than patients on Treatment B, but the difference is not "statisically significant", there is a good chance that Treatment A is really no better, but the people taking Treatment A happened to be a little healthier (or luckier) during the time you were running the experiment. If the difference was large enough to be statistically significant, it would be more likely that Treatment A really was superior.

The etiquette of research allows for a published paper to report statistically insignificant results, so long as it acknowledges their insignificance. "Insignificance" is a slightly misleading choice of words, of course. Statistically insignificant results are not necessarily meaningless results (maybe Treatment A really is a little better); it's just that the probability of their being meaningless is too high for it to go unmentioned. Doctors are not going to be inclined to recommend a treatment which doesn't provide a benefit large enough to qualify as statistically significant. Statistically insignificant results don't really merit a great deal of attention.

Still, scientists don't like to wrap up a research project by saying "we didn't find anything worth mentioning" or "this new drug is a waste of money". So, statistically insignificant results do get reported, and we need to be careful about making too much of them.

Which brings us to a Danish study which did some follow-up work on patients whose had been given "intensive treatment" as soon as their diabetes was discovered. The idea was to check and see if two common diabetic complications (peripheral neuropathy and peripheral arterial disease) were less common in those patients. The answer was: a little bit, but not by enough to qualify as statistically significant. "We found no statistically significant effect of intensive multifactorial treatment on the prevalence of diabetic peripheral neuropathy and peripheral arterial disease compared with routine care."

The same type of disappointing result has been found in studies of such patients, in regard to other health problems (such as heart disease).

The study, or at least the summary of it that I read, was not very forthcoming with details about the "intensive treatment", or how successful it was in terms of short-term glycemic control. But studies of this kind have usually been about drug therapy rather than lifestyle therapy in the past, so until I hear otherwise I must assume that "multifactorial" means "multiple drugs".

Studies of this sort tend to create the unfortunate impression that controlling your diabetes doesn't help. We shouldn't jump to to that conclusion, especially since we are told little or nothing about how well the patients in the study actually did control their diabetes. The studies do seem to show that writing more prescriptions for more drugs doesn't help (or helps so little that the result does not rise to the level of statistical significance), but let's not forget that writing prescriptions and controlling diabetes are too vastly different things. 

Tuesday, August 23, 2011

Perhaps today's seismic news is a good reminder of the hazards of over-generalizing. No doubt about it, an earthquake in Virginia is bound to startle people who had long ago made up their minds that an earthquake is something that happens in California.

To be sure, an earthquake is less likely to occur in Virginia than in California. Unfortunately, our brains seem to be hard-wired to translate "less likely" into "doesn't happen", and then we are confused and perhaps outraged when the less likely thing does happen.

If you have never smoked, and you develop lung cancer anyway, I'm sure you will feel as if you've been cheated and lied to. You did what you were told, and what did it get you? Nothing. Promises have been broken! The laws of nature have been violated! Actually, no -- lung cancer was always a possibility, whether you smoked or not. The risk is lower if you don't smoke, but it isn't zero. Still, whenever we hear of a case of lung cancer in a non-smoker, we react as if such things are not supposed to be possible, and we start to wonder if doctors have it all wrong about smoking and cancer.

This sort of all-or-nothing thinking, in which people convert probabilities into certainties, and "less risk" into "no risk", can be a very misleading guide to health issues -- even for doctors. For example, coronary heart disease in middle age is usually thought of as a man's problem, because men have a higher rate of it. That doesn't mean it can't happen to women, and that warning signs of it in female patients should be explained away as something less serious.

And, of course, the association between obesity and diabetes should not be oversimplified to "fat people always become diabetic and thin people never do". It's not that simple, folks...

It can be difficult to state a question in an absolutely clear and unambiguous way. Every time you ask a question, there's a good chance that it will be misinterpreted. The answer you'll get may actually be an answer to a different question than the one you thought you were asking. 

For example: "can a dinner mess up a glucose test?". This was a search string to which Google responded with a reference to my site. It looks simple enough, but I don't really know what was meant by it. 

For starters, what is the definition of "mess up"? For some people, a glucose test is messed up if the result is inaccurate. For others, a glucose test is messed up if it tells them, quite accurately, something they don't want to hear.

Some people test to find out what's going on, others to be reassured that they don't need to worry about what's going on. The latter group tend to be constantly seeking a reason to conclude that an undesirable result can be ignored, because something probably went wrong with the test process. The meter was, no doubt, fooled by some factor which interfered with measurement and made the blood sample seem more sugary than it was...

And then there is the question of the time-difference between the dinner and the glucose test. Can a dinner happening when mess up a glucose test happening when? Are we talking about a post-prandial test (one hour, or possibly two, after dinner)? Or are we talking about a fasting test the following morning? A dinner would certainly affect the former, and might affect the latter. 

A dinner cannot "mess up" a glucose test (in the sense of invalidating the result), but it can mess up the the test in the sense of causing the result to be higher than you want it to be. This is mainly true of a post-prandial test, but even a fasting test the next morning might be higher than usual if you had a big, carb-heavy dinner the night before. 

If this question expresses a concern about a doctor-ordered lab test happening the next morning, I would certainly expect that the fasting result would be higher if you went to the pizza parlor the night before the test than it would if you didn't. If "messed up" means elevated, the pizza dinner might very well mess up the test. However, if you do go to the pizza parlor for dinner, and the result is higher than usual, the result is not "messed up" in the sense of being unreliable or meaningless; it does reveal something about you. Even the morning after a big meal, a non-diabetic person is not likely to have an elevated fasting test result. If your result is elevated the morning after a big dinner, that tells you something. Just how much it is elevated tells you more.

Of course, if your typical dinner takes place at the pizza parlor, the dinner does not mess up the test result in any sense; your fasting result the next morning might be higher than your doctor would like it to be, but it probably won't be any higher than usual, so the test is in every way a true reflection of how you're doing. But if a big, high-carb dinner is not typical for you, your fasting result the next day might very well give a misleadingly negative impression of how well you're doing in general.

Of course, none of us what to let our doctors see a test result which makes us look worse than we are. But a test result that gives a sad but accurate picture of us is "embarrassing", not "messed up". 

Another search string which, for some reason, Google regarded as pertinent to my site was: "thinking is for people without internet".

Maybe so. But judging from what I've seen, some people with internet should give it a try, too.

Monday, August 22, 2011

I often allow people to talk me into trying my hand at outdoor activities which I'm not experienced in or comfortable with; in general I have benefited by this, so long as the adventure they're proposing is not something unreasonably difficult or dangerous. But sometimes it's hard to tell, going into it, whether or not that line is being crossed, and for that reason I sometimes approach the event with a fair amount of nervousness.

So, I'm relieved to report that the night-kayaking activity on Tomales Bay on Saturday turned out to be safe, fascinating, and not terribly difficult or uncomfortable.

Tomales Bay is a long, straight, narrow inlet on the Pacific coast north of San Francisco. It is actually an earthquake fault (the famed San Andreas) with seawater in it. Land to the west of it is moving north relative to the land east of it, and as these masses grind past each other there are occasional violent slips. The southeastern tip of the bay was the actual epicenter of the 1906 seismic event which most people think of as the "San Francisco earthquake". At the epicenter, you can still see an old fence with a dramatic offset where one section of land slid to the north, carrying with it the fenceposts that were embedded in it.

Our evening kayak excursion involved just a small part of the bay, near the opening to the Pacific.

I have always understood that Tomales Bay is where the Great White Sharks of the northern California coast go to breed, but one of my kayaking companions told me this is a myth. "It's too shallow for them," he said. Well, it certainly seemed that way on Saturday; it was low tide, and the eelgrass reached up to the surface of the water in a lot of places. But I believe there is a channel running down the bay that's about 30 feet deep; seemingly enough of space for even a very large and expressive shark couple to hook up. I admit that the mechanics of shark love are a little unclear to me; I know that the male shark has, in place of anything you or I would recognize as conventional male equipment, a pair of articles called "claspers", but I've never seen a how-to manual on their use. In short, I don't know how much room they'd need, but if 30 feet of water doesn't cover it, I think they need to dial it back a bit.

Anyway, sharks were not the creatures we were there to see (nor did we see any, I report without regret). Oddly enough, the organisms we did go there to see are usually invisible.

They are called dinoflagellates, and they are a tiny form of marine plankton. It's hard to decide whether to call them plants or animals; some are green with chlorophyll, and they photosynthesize just like plants do. They do move, however, and the non-green variety live by eating other plankton, both of which behaviors seem pretty animal-like.

They produce a dangerous neurotoxin, and the toxin can accumulate in shellfish which feed by filtering plankton out of the water. During periods when there are a lot dinoflagellates in the water, it is hazardous to eat shellfish. Local waters are monitored by health departments to avoid this kind of problem.

But the thing that interested us about these creatures is something else that dinoflagellates do: they give off light when agitated. "Bioluminescence" is the scientific term for the phenomenon. At night, when the dinoflagellate count is high, running your hand through the water produces a cloud of tiny, blue-white sparks. Breaking waves, or the wake of a boat, also produce the same glow:

I don't know if the dinoflagellate count is high enough right now for shellfish to be dangerously toxic, but it's high enough to produce eerie lighting effects, so we wanted to check it out.

We arrived at the the launch ramp around sunset. It was cloudy but, to my surprise, not windy or cold (a lucky break, and seemingly a rare one in that area). Because the bay is so narrow, it's usually easy to see the hills on the far side of it, and the islands in the middle.

Of course, getting kayaks and their crew into the water is a bit of an operation. There were four of us, and although two of us had had considerable kayaking experience, not one of the four of us had done any night kayaking. A certain feeling of unease was in the air.

However, it was comforting to see that a lot of other people were doing the same thing. At this time of year there are professionally organized kayak excursions aimed at showing people the bioluminescence. We were the only amateurs out there, but I had been expecting we'd be the only people on the water at all. Seeing a couple of organized groups get into the water before we did made what we were about to do seem less insane.

I didn't dare take a camera into the kayak (it would certainly have got a lot of saltwater on it), so you must rely on my vivid powers of description for a sense of what the rest of the evening was like.

Once we were in the water and under way, I was startled at how comfortable and easy it was -- although my steering efforts were clumsy enough to provoke occasional outbursts of mockery from more experienced hands, and I can't say that these became any less frequent over the course of the evening. Still, all in all, it was pleasant to be on these calm waters, and not fighting a wind.

The small islands in the middle of the bay were home to a dense population of sea birds (you wondered how the trees remained upright with so many large birds roosting on their branches). Apparently there was also a population of harbor seals; in the fading light we couldn't see them on the shore, but we could see the heads of the "sentries" sticking out of the water (seals hovering on the periphery of the island to keep intruders away from the pups). We tried to keep distant enough from them to keep them happy.

The friend who had proposed the trip in the first place said "It's nice now, but once it's really dark it's going to get all Blair-Witchy, I just know it". Well, it did and it didn't. It got a little creepy, but not seriously scary. That wouldn't have been the movie reference I'd select.

While there was still some light, we saw a lot of moon jellies (large jellyfish that are common in that area) and kept our hands off them. We explored the western shore, visited a few inlets, talked to a some people camping in a cove, talked to some of the people in the other kayaking groups, went north for a while. But we didn't want to get all that close to where the bay opens to the Pacific. We headed back, and stepped ashore in a lonely cove for a bio-break. While doing what I was there for, I looked up and saw, staring back at me from the underbrush, two blue eyes brightly reflecting the light of my headlamp. We had a discussion about what sort of creature it was; someone said a squirrel, but I thought the eyes were too far apart for that, and the animal too steady in its movements. I thought it might be a racoon, but someone told me their eyes always look red under similar circumstances. I never did find out; it just hissed some remark about its precious and withdrew into the darkness.

Up to that point we'd seen no bioluminescence, and I was assuming that it wasn't a good night for it and we wouldn't see any, but it just hadn't been quite dark enough. Now, as we got back in the boats, we found that putting a paddle in the water caused a little cloud of soft light to appear in the water instantly, with a few brilliant sparks from the brighter or larger dinoflagellates. (If you watch an individual one, it stays lit for about one second, but there is continuous light for as long as you're moving something through the water.) We found that, with our headlamps off, we could see each other's kayaks in the dark because the wake and bow wave of each kayak was glowing. It's an otherworldy-experience.

Why do the dinoflagellates light up like this when something moves in the water near them? You'd think it would only make it easier for them to be found in the dark by the tiny fish that eat them. It turns out that the light serves a kind of burglar-alarm function. It actually pays for a cloud of dinoflagellates to light up the water when a tiny fish swims into their midst -- because the light makes it easy for big fish to find, and eat, the tiny fish. When a tiny fish finds itself suddenly lit up like that, it is less likely to stay and dine than to depart for fear of being dined upon.

On the way back we passed the islands again, and I thought the birds would be quiet by now, but there were the most bizarre noises coming from there. You'd think it was monkeys rather than birds. Also, sounds that to my ear were like someone knocking wood blocks together. Whatever creatures were living on that island, I think they were building furniture.

And then fish started leaping out of the water, some of them covering considerable horizontal distance. I didn't think we had flying fish this far north, but they did seem to move that way. A fish leaped straight over one of the kayaks and slapped the leg of the guy operating it.

I had been worried about the possibility of getting lost in the dark, and not being able to find our way back to our departure point. It wasn't a problem, however; most of the shore was quite dark, and the cluster of lights near the launch ramp stood out too well to be missed.

We were out there for something like three hours, and as paddling is not an activity I'm used to, I was very worried that I would wake up Sunday morning with arms half-paralyzed by pain and cramping. No matter how hard you try to stay in shape, any physical activity that you are not acclimated to can cause you a lot of suffering the next day. Fortunately, that didn't happen. My arms were sore the next day, but only the kind of mild soreness you would expect after a weight-lifting workout that was a little tougher than you're used to. I was still feeling it a bit today, but yoga class in the evening helped with that.

So, all in all, I enjoyed it and would do it again -- provided I could be sure we'd enjoy the same calm conditions next time, too. I want to go back to the Island of the Furniture-Building Monkeys and find out what is actually going on there.

Sunday was my rest day from exercise -- and I went to a pot-luck party, too, so I wasn't surprised that my fasting test was 95 -- higher than I like it, but technically normal. My post-prandial test after lunch exactly the same! But that followed a hard run, which changes everything.

Friday, August 19, 2011

On Wednesday I told you about being shown a new running route near my workplace, which followed an open-space trail I had not known existed. Today (running on my own, as my running buddies were either busy or nursing an injury) I decided to try that route again, before I forgot where it was. But I thought that, just to make it interesting, I should run the loop in the opposite direction this time. This turned out to be a less clever idea than I had supposed it to be.

It's a funny thing -- when you follow a trail with someone who knows the way, it all looks so straightforward. My memory from Wednesday was that there'd been a single, fairly straight path, with no devious twists and turns, and no side-branches which forced you consider which trail was the right one.

But today, going the opposite direction, things didn't look as familar as I expected, and about two-thirds of the way along, I was startled to find that the trail split four ways. I hadn't remembered that at all. There was a path to the right, one that went pretty straight ahead, and two that went sharply left. I chose the straight-ahead option; it looked more worn than the others, and I figured it just had to be the main trail. I am now aware that it wasn't, and I should have turned right.

After a while I started to come to places that just didn't look familiar at all. The open space wasn't that big, though. Most of the time I could hear road traffic somewhere nearby. Surely, if I just pushed on in what seemed roughly the right direction, I would come to a road?

Nothing I tried worked; paths that looked well-traveled petered out in the middle of the woods, or came to a fence with no openings anywhere along it. I certainly wasn't going to hop over into somebody's back yard and hold negotiations with their pit bull. After several exploratory routes (shown in red below, based on my later reconstruction) failed me, my frustration started turning into something closer to alarm. I was on my lunch hour, for crying out loud, and I was lost and couldn't get out of the woods. And I was getting hungry, too.

Eventually I decided that the best thing I could do was give up on completing the route in my intended direction, retrace my steps, and go back the way I came. Fortunately, I was able to do that without getting lost yet again.

With all my wandering around in the trees (and thorn bushes, and poison oak), the abondoned route ended up being about a mile longer than it would have been if I had completed it without getting lost.

I got back to work, showered and dressed as fast as I could, and raced to the cafeteria, getting there just in time to see them shutting the doors on me. 

Someone in the office took pity on me (probably there was desperation in my eyes) and gave me a banana. I was also able to get hold of some trail mix. A high-carb lunch, then, but at that point I probably needed it; I was feeling a trifle hypoglycemic. I didn't check, but it probably it didn't spike me, since me evening post-prandial test was only 100.

And I still liked this better than going to the gym!

Just to show you how bad I am at learning from experience, I have agreed to go on a night-kayaking adventure tomorrow with the same running buddy who introduced me to that open-space route on Wednesday. I probably won't get lost as long as I stay with him.

It sounds stupid, I realize. But, looking back on the ten years since my diabetes diagnosis, the cost/benefit analysis seems to speak for, not against, my policy of letting friends talk me into outdoor activities which I'm not sure I'm comfortable with.

Either the sharks will get me or they won't. If I don't do any blog posts next week, notify the coast guard.

Thursday, August 18, 2011

I did not ride my bike to work this time. My excuse is that I had to go in early, for a 7 AM meeting, and it was looking as if I'd be late if didn't drive. It made me feel weak and cowardly, though.

I tried to make up for this, when I went running at lunchtime, by choosing a running route that involved an exceptional amount of climbing on steep hills. I'd better ride the bike tomorrow, though. I don't have an early meeting to get to, so I won't have an excuse.

It is State Fair season, and you know what that means: people strolling around in the sunshine eating calorie-dense foods which they would not (I assume) think of eating under any other circumstances.

Foodstuffs which you would not have thought could be deep fried (including sticks of butter, appartently) are available in that form at State Fairs. You can also obtain such decadent treats as glazed donut cheeseburgers...

...and chocolate-dipped bacon...

...and super-sugary desserts...

...and a log or spiral of who-knows-what on a stick.

Not only that, if politicians are at your State Fair, you can watch them trying to prove they're just like you, by sampling the kind of food which they assume you eat daily. Here's Michele Bachmann (who is hoping to become the next President of the United States) showing us how to eat a foot-long corn dog:

She also tried to teach her husband the technique, but it looks as if he's being too aggressive, and needs to relax a little.

Okay, so what is all this about? (I don't mean the Bachmanns and their corn-dog issues, I mean the State Fair food phenomenon in general). Why do we have this compulsion, at least on certain occasions, to eat something specifically because we feel it's not good for us? 

I don't think people do this stuff because they are going around craving deep-fried candy bars 364 days of the year, and then, on the day when they walk through the turnstiles at the fairgrounds entrance, they suddnely cave in and let themselves have one.

There is something about a holiday event that makes people feel they're not really participating in it if they don't indulge themselves in some dramatic way. If you're not breaking any rules, you can't be having any fun, now can you?

Of course, for someone with diabetes, rule-breaking doesn't have to take an especially flamboyant form. A banana (and I mean a plain old banana, as nature made it, not a banana that has been dipped in chocolate and breaded and deep-fried) might be as wild an indulgence for us as a syringe of heroin would be for Marion the Librarian.

So maybe we don't really have to go to the state fair, or don't have to eat a fried twinkie on a stick if we do go. We can do our thrill-seeking in less dramatic ways...

Eat a couple of extra cornflalkes or something. Knock yourself out!

Wednesday, August 17, 2011

A tiny taste of adventure today. My lunchtime run today was a route rather different from any of our established routes through the neighborhood. This one included a dirt path through an open-space area that I didn't know existed. Even my running-buddy who told me about it had some difficulty finding it (we ran down a couple of wrong cul-de-sacs before we eventually located the trail entrance). Here I was, thinking we were in the middle of a thoroughly developed suburb, and suddenly we're on a trail, seeing nothing but trees in any direction. My running buddy, being more attuned to these things than I am, spotted some edibles along the way: blackberries and small ripe plums. We stopped long enough to sample them. The plums were especially good. A little later we came upon a herd (or is it flock?) of wild turkeys. Then all of a sudden we're back on the street again, with cars rushing past us. It all seemed a bit unreal -- going from one suburban neighborhood to another, with a brief detour into Narnia or something along the way.

But I like my workout to include a touch of unreality sometimes, which I guess is why I like outdoor exercise a lot more than going to the gym. The gym is all reality, all the time.

Looking back on it, I'm surprised that he was able to convince me to try this route at all, considering the way he had described it to me. "We head down Hidden Valley, like we were going to the cemetery, only before the cemetery we take the path through the open-space, and come out by the hospital on Chanate, and end up at the coroner's office." It was a cheery scenario all right: head toward the cemetery, turn off by  the hospital, end up at the coroner. I said we all end up at the coroner, but did it have to be today? Neverthelss, I went. As I've said before, the foundation of my exercise program is my willingness to be talked into stuff. (Perhaps emboldened by his success, he suggested that I join him this weekend for some night kayaking on Tomales Bay, the notorious breeding ground of the Great White Shark; I haven't agreed to that one yet, but negotiations are continuing.)

Well, at least we had a chance to taste some plums and berries on the way to the coroner. And how often do you get to say that?

An issue which comes up frequently, whenever the high cost of health care is up for discussion, is "defensive medicine". We've all heard about doctors ordering expensive tests that aren't needed, just because they're afraid they will later be hit with a malpractice lawsuit, and be made to look negligent in court for not having ordered every possible test. This issue is usually presented in a way which implies that doctors are being paranoid about this, and they should knock it off. Aren't they over-reacting? Is the risk of being sued for malpractice really all that high?

Before I answer that question, try to imagine how high you think the risk is. Imagine that you're a family-practice physician (one of the least-sued specialties in medicine). What do you estimate would be the probability that you would be hit with at least one malpractice suit during your career? Would you guess 5%? Perhaps 10%? Higher than that?

Well, apparently the actual answer is 75%. That's according to a recent article in the New England Journal of Medicine, which looked at the prevalence of malpractice lawsuits and the ways in which this affects doctors.

If you're a doctor who is hoping never to be sued for malpractice, the most you can hope for (assuming you have chosen a "safe" specialty) is a 25% chance of succeeding at that. And your chance is even slimmer if you have entered one of the riskier specialties. For brain and heart surgeons, it drops to about 1% (in fact, for those specialties, the risk of being sued during just one year of practice is nearly one in five).

In short, most doctors do get sued.

We might use the word "paranoid" when people worry excessively about threats which are either imaginary or highly unlikely, but we don't call people paranoid when the thing they are worried about is, in fact, probably going to happen to them. If the statistics say that most doctors can look forward to being sued at least once, it is not unreasonable for them to be anxious about the possibility.

Some would argue that doctors are, neverthless, too worried about this. After all, doctors usually win such lawsuits. 78% of malpractice suits result in no jury award, out-of-court settlement, or other payment to the plaintiff. This is not to say that the people who sue doctors have not suffered any injury or illness; it's just that they aren't able to show that their injury or illness was the doctor's fault. Surgery, for example, is always risky. The fact that an operation didn't go well is not, by itself, an indication that the surgeon did something wrong. Despite the popular impression that anyone can buy a pair of crutches, file a frivolous lawsuit, and make a fortune, the court system does not have a track record of awarding damages to every patient who has had a poor outcome from medical treatment.

So, if doctors typically prevail in court, and have malpractice insurance to cover them in case they don't prevail in court, shouldn't they just stop worrying about malpractive lawsuits? Easier said than done, it seems. It turns out that people really, really don't like being sued.

The fact that doctors have malpractice insurance, and are likelier to win a malptractice case than to lose it, does not mean that being sued is an easy, enjoyable, affordable, risk-free adventure. Being sued is time-consuming, upsetting, and costly (even if you have an insurance policy which supposedly protects you). Being sued can also be damaging to one's professional reputation, regardless of whether you win or lose. I wouldn't want to go through that myself, so I'm not surprised that doctors don't want to either.

To be sure, actual malpractice does happen (life-threatening medical errors are a surprisingly common occurrence in the USA), and the odd thing is that most victims of it don't sue anybody. For whatever reason, the people who actually go so far as to sue their doctors tend to be victims of bad luck rather than bad care, and are unable to foresee that this distinction will become obvious in court. When your baby is born without legs and you decide that you can at least get rich suing everyone who was working in the delivery room, you are likely to discover that it doesn't work that way: judges and jurors are aware that there isn't a way to deliver a baby that will retroactively undo the embryological problems that have been developing over the past nine months.

However, there are always exceptions. If some plaintiffs come into court imagining that they are participating in a TV game show, some juries probably come into court imagining the same thing. There is always a risk that the jury will side with the unfortunate patient, without much caring whether or not the patient's problems were caused by anything that the doctor did wrong. No doubt some jurors think that they should act as legal Robin Hoods, robbing from the rich and giving to the poor, without worrying too much about how their verdict will affect the doctor's reputation.

So, despite everything doctors can do to protect themselves from the impact of the malpractice threat, they still feel anxious and vulnerable. Surely this has an impact on the way doctors practice medicine -- and not just in the ways that people usually think of when they talk about defensive medicine.

In regard to care for chronic conditions such as diabetes, hypertension, and cardiovascular problems, doctors often have to choose between what conventional wisdom recommends (namely, boatloads of drugs) and what works best if done right (namely, lifestyle modification). People who actually manage to turn their lifestyle around can certainly have better health outcomes than people who rely on drugs. But a lot of the people who try to turn their lifestyle around fail at it, for whatever reason. And if you let them fail at it before putting them on drugs, they might be worse off than if you put them on drugs immediately.

If you're a doctor who's losing sleep about the risk of being sued, are you going to feel confident about giving your patients a chance at success (or failure!) at a lifestyle-based approach to controlling their condition? Or are you going to be so worried about how your decisions might be made to look to a jury that you don't dare do anything "unconventional"? Think about it: if some society of endocrinologists has ruled that newly diagnosed diabetes patients should not be given a chance at lifestyle-based diabetes therapy, and should instead be put on drugs immediately -- but you decide to approach the problem in a different way, isn't it going to be pretty easy to persuade a jury that you've been performing some reckless, goofy experiment, with a human life at stake?

Perhaps that is why I keep hearing from diabetes patients who strongly wish to control their diabetes with diet and exercise rather than drugs -- and are getting nothing but opposition and discouragement from their doctors. To be sure, in some cases they have eventually been able to change their doctors' negative attitudes, by demonstrating a level of success and committment which cannot be ignored. But it's hard to achieve that with a doctor who obviously thinks you are sure to fail, and is beginning to make you lose confidence yourself.

My own doctor never discouraged me from trying a lifestyle-based approach, and in fact that was what he recommended from the start. But that was ten years ago. Since then, it appears to me that there has been growing pressure on doctors to conform to specific guidelines, probably backed up by a growing threat of losing a malpractice suit some day if they do anything that defies convention. If I were diagnosed this year instead of in 2001, would he still be able to give me that chance, or would his hands be tied?

One thing is clear, though: if your doctor gives you a chance to succeed with a lifestyle-based approach to diabetes management, you'd better succeed pretty quickly. My lab report, six months after the initial diagnosis, was so dramatically improved that my doctor couldn't help being favorably impressed. If I hadn't achieved that, though, I'm pretty sure he would have been afraid to let me run along any further without medication. If you have the opportunity, it is probably a brief opportunity -- so make sure that you make the most of it!

Tuesday, August 16, 2011

Remember this?

It was a standard test pattern used in television broadcasting in the old days. What was the point of it? Well, when you were broadcasting from a TV studio, you wanted a quick way to test the image quality of the camera. Was it capturing an image in focus, with proper light levels and contrast, and with shapes and angles undistorted? It simplified things to have a standardized image to point the camera at, so that you could make sure that the details of this familiar image where all coming through normally. If you just pointed the camera at whatever was handy (a bowl of petunias one day, a stack of books the next), you wouldn't be comparing the image with a familiar standard, and if there was a problem you might overlook it.

Consistency is important in testing. If you don't do your glucose testing the same way every time you do it, you have no way of knowing whether it means anything to compare one test result with another. (Am I really doing better today than yesterday, or am I just doing the test differently?)

I try to be consistent about how I test my glucose, but sometimes that can be hard to achieve. For example, I usually do post-prandial tests an hour after a meal, not an hour and a quarter after a meal. But sometimes life (and project meetings) can get in the way of our testing schedule, and today I was obliged to test 15 minutes late.

Well, if I was only at 98 by then, I couldn't have been very high 15 minutes earlier. After all, it was a pretty low-carb lunch, and I had gone running just before that.

Those are my excuses, and I think they're fairly good ones. On the other hand, the main purpose of testing (at this point in my diabetes journey, anyway) is to keep a close eye on trends -- and you can't really do that if you aren't testing in a consistent way.

So, I try to maintain a regular test pattern, even though it isn't always practical.

To judge from the Google searches that bring up my site, there seem to be a lot of people out there anxiously trying to figure out what their A1c test result says about their average blood sugar level. Well, there's a pretty simple formula for figuring that out, and I'll explain how to use it. Just how accurately and usefully that formula reflects reality is another question, however.

If you live in the United States and measure blood sugar in mg/dl, here's how you figure "eAG" (estimated average glucose):

  1. Multiply your A1c result by 28.7.
  2. Subtract 46.7 from that.
  3. The result you get is eAG in mg/dl.

For example, if your A1c result is 8.5, your eAG is 197 mg/dl. (But I hope you're doing better than that.)

People living outside the United States mostly measure blood sugar in mmol/l. Here's the alternative process:

  1. Multiply your A1c result by 1.59.
  2. Subtract 2.59 from that.
  3. The result you get is eAG in mmol/l.

For example, if your A1c result is 8.5, your eAG is 10.9. (Again, I hope you're doing better than that.)

Or, if you don't trust your mathematical skills, you can refer to this chart, which I have computed for you, probably without making many mistakes:

Hb A1c % eAG mg/dl eAg mmol/l
3.9 65 3.6
4.0 68 3.8
4.1 71 3.9
4.2 74 4.1
4.3 77 4.3
4.4 80 4.4
4.5 82 4.6
4.6 85 4.7
4.7 88 4.9
4.8 91 5.1
4.9 94 5.2
5.0 97 5.4
5.1 100 5.5
5.2 103 5.7
5.3 105 5.9
5.4 108 5.5
5.5 111 6.2
5.6 114 6.3
5.7 117 6.5
5.8 120 6.7
5.9 123 6.8
6.0 126 7.0
6.1 128 7.1
6.2 131 7.3
6.3 134 7.5
6.4 137 7.6
6.5 140 7.8
6.6 143 7.9
6.7 146 8.1
6.8 148 8.2
6.9 151 8.4
7.0 154 8.6
7.1 157 8.7
7.2 160 8.9
7.3 163 9.0
7.4 166 9.2
7.5 169 9.4
7.6 171 9.5
7.7 174 9.7
7.8 177 9.8
7.9 180 10.0

And here's a less high-resolution guide to the higher reaches of A1c results, in out-of-control diabetes:

Hb A1c % eAG mg/dl eAG mmol/l
8.0 183 10.1
9.0 212 11.8
10.0 240 13.4
11.0 269 15.1
12.0 298 16.5
13.0 326  18.1

But hold on a minute...

Before you decide to put total faith in my tables, or in the formula they are based on, let's be clear that "eAG" is an estimate rather than a measurement. (If it were a measurement, they could drop the "e" and just call it AG.) The distinction is important. There can be a sizeable difference between (1) measuring something and (2) estimating something based on assumptions which you think are reasonable.

In no sense is the A1c test literally a measurement of average blood glucose. It can't measure that and doesn't try. What the test measures is the percentage of your hemoglobin that is "glycated" (bonded with sugar).

It is generally true that people with higher blood glucose levels have more heavily-glycated hemoglobin in their red blood cells; for this reason, the A1c result provides us with a reasonable basis for estimating average blood sugar (using the formula I described earlier). However... the estimate may be rougher than you would expect, because the formula has a big limitation: it assumes that people are all alike in terms of their physiology, and that the relationship between glucose levels and glycation rates is exactly the same in every human being. This is no more than a convenient fiction, obviously. People are not all alike. That doesn't mean the formula is wrong in your case, but it isn't necessarily right, either.

Two people with the same average blood glucose level could get different A1c results, for a variety of reasons, ranging from differences in age or race to differences in the turnover rate of red blood cells. Like it or not, individuals differ in their physiological traits; and these differences can affect the relationship between glucose levels and glycation rates. Some people are thought to be "high glycators" -- experiencing more glycation than other people at the same blood glucose level. Why that should be true is hard to say. Perhaps there is some mechanism which is supposed to inhibit glycation, and in some people it doesn't work as well as it should. Nobody knows.

To me, the important question here is this: if the relationship between glycation and average blood sugar is not always reliable, which of these two things matters more? In other words, if I am a "high glycator", and my A1c result is higher than other people with the same average blood glucose would get, does this mean I shouldn't worry (because my glucose is actually lower than the A1c result would suggest), or that I should worry, (because my glycation rate is higher than my glucose results would suggest)?

When it was discovered that some racial minorities get higher A1c results than white patients with the same glucose levels, the knee-jerk response in some quarters was to complain that black patients were being "unfairly" or "falsely" diagnosed with diabetes because the A1c test wasn't accurate for them. Well, maybe. But if glycation is a good index (and a known cause) of diabetic health problems, shouldn't the A1c result be taken more seriously than glucose results when the two seem to be in conflict, not less seriously? I'm not saying that the answer to this rhetorical question is definitely known -- I'm just pointing out that there is an alternative explanation for the racial disparity in A1c results, and this alternative explanation has the advantage of explaining something else: why black diabetes patients tend not to do as well as white diabetes patients whose condition seems comparably severe and who seem to be getting comparable treatment. If the A1c test shows that you have a bigger problem than it would otherwise seem, maybe you do have a bigger problem than it would otherwise seem.

Many of us, browsing through the table above, are bound to feel that this can't be right -- we're sure that our average glucose level isn't really as high as the estimate that was calculated from our A1c result. And maybe it isn't! But even if it isn't, I think we should take the A1c result seriously, as an indicator of our glycation rate (and therefore of our risk of diabetic health problems).

Here's my bottom line on this confusing issue: if your A1c result is higher than your glucose tests led you to expect, devote more energy to bringing your A1c result down than to arguing that there must be some mistake here because it just isn't fair.

If life were fair, you wouldn't have developed diabetes in the first place. Leave fairness out of it!

Monday, August 15, 2011

I always do a lot of running on hills, and I always find it difficult: I just can't help slowing down a lot on the steeper climbs. But over the past few days I've noticed that the steep parts aren't bothering me as much as they did before.

It may be that my recent reintroduction of cycling into my life is paying a benefit. I'm not doing any long rides so far, but I've certainly been climbing steep hills on the bike. Could it be that this is having a cross-training effect, and making it easier for me to climb steep hills on foot? It seems possible. I remember that I was running better a couple of years ago, and at the time I was doing the bike-commute pretty regularly. Maybe one thing helps me with the other.

I can't say that climbing hills on a bike is making it any easier, so far, for me to climb hills on a bike. But I've only just started. Anyway, the good cyclists have a saying about learning to climb hills on a bike: it never gets any easier, you just do it faster. Sounds kind of depressing if you take it the wrong way.

But maybe, if you let go of the idea that climbing hills ought to be easy, and resign yourself to the idea that climbing hills is hard but you're going to do it anyway, the experience of climbing hills loses its fearful, miserable aspect. If I'm running up a hill and thinking about how hard it is, I suffer a lot of emotional torment; if I run up the same hill in a distracted state because I'm thinking about something else, I sometimes find myself at the top of the hill and realize with a start that I didn't suffer any emotional torment on the way up, because I wasn't paying attention. I'm not saying I achieve that every time, but it used to be that every hill-climb had me in a state of agonized self-pity all the way up, and these days I sometimes completely forget to feel sorry for myself, and thus have a much easier time of it. Anything that makes it possible for that to happen is a good thing.

Somebody did a search on "why is hemoglobin more affected by glycation than other protein?" and Google sent them my way. It's an interesting question -- interesting, that is, for what it reveals about the hazards of making a big fuss about a subject without ever explaining why that subject is important. Many people with diabetes assume that the reason we hear so much about the hemoglobin A1c test is that glycation of hemoglobin is far more significant than glycation of anything else.

So far as I know, hemoglobin is not more affected by glycation (undesirable bonding with sugar) than other proteins, nor is glycation of hemoglobin more important than glycation of other proteins.

Hemoglobin is a blood protein; it is easily collected, and has a comparatively rapid replacement rate (because of the limited lifespan of the red blood cells in which hemoglobin is found). For those reasons, hemoglobin is a convenient protein to measure if you want to get find out how much glycation (and therefore how much hyperglycemia) a patient has been experiencing lately. The glycated fraction of hemoglobin is known as hemoglobin A1c, so that is the name of the lab test that is most commonly used to measure glycation in diabetes patients.

Other proteins can be used to figure out how much glycation has been going on recently. Fructosamine is an example. Fructosamine has a faster replacement rate than hemoglobin, so the fructosamine test reflects a shorter period of recent time. The fructosamine test is used when doctors want to look at a narrower window of time (to evaluate the patient's response to a new medication, for example).

Anyway, the glycation rate of any protein is a useful indicator of how well someone's diabetes is controlled, and hemoglobin is a useful protein (but not the only one) for this purpose.

Sunday, August 14, 2011

My biggest diabetes challenge is parties -- and I've been to two of them in as many days. On Friday evening I was at a picnic, and on Saturday evening I was at a birthday party.

I'm usually pretty safe when I'm preparing a meal for myself, or even ordering one in a restaurant. But put me in front of a picnic table or buffet table that is groaning under the weight of all the treats everyone has brought to the event, with a glass of wine in my hand to cloud my judgment, and I'm in a bit of trouble.

Experience has shown me that there is a limit to how much restraint I am going to exercise in these situations. The best effort I can make is to concentrate more on the high-fat goodies than on the high-carb ones; I have never attended a party and just nibbled on sprigs of parsley the whole evening.

To make up for the two-day dose of party food, I got in a lot of exercise this weekend. I did a 7.7-mile trail run on Saturday, and 6.6-miler on Sunday. I didn't have the illusion that this amount of running would burn off all the calories I took in from the party food, but I think it burned off some of those calories, and boosted my insulin sensitivity as well. At least, my test results today were consistent with that assumption.

You can't be a diabetes superhero every day of your life, but on the days when you're not, you don't have to give up entirely, and just resign yourself to complete loss of control. When you know you're going to be no angel, figure out a way to the soften the impact of whatever devilishness you can't talk yourself out of. If it's going to be a weekend of heavy-duty eating, make it a weekend of heavy-dutry exercise as well. It won't necessarily be enough to give you results in the normal range, but making an effort is always better than making no effort.

Friday, August 12, 2011

Sorry, can't be doing the blogging thing today -- possibly I'll do a rare Saturday post to make up for it!

Thursday, August 11, 2011

I gave the bike-commute idea another try. I can't say I liked the dreaded hill-climb at the end of the day any better this time, or that I looked any less bedraggled when I got home. Well, whatever doesn't kill us makes us stronger.

Actually, I'm not sure anyone has proved that maxim. Perhaps it is only true up to a certain age. Once you reach that age, whatever doesn't kill you, kills you the following week. But have I reached that age yet, or not? No doubt that age is different for different people, so it's kind of hard to recognize it when you get there. I guess I have to keep experimenting, and see what happens.  That's the trouble with this healthy-living thing: we just have to take our best guess and see how well it works out. Or, as I have written in another context:

"For, to test your health habits, there's one thing to try:
live your life over different and see if you die."

See how good-humored I'm staying about all this?

The weather around here this week may not be August weather as most people think of it, but at least it's consistent weather. Here's the forecast for the next 5 days:

Sunny, clear, 76 degrees -- for five days in a row.

It certainly has been nice running weather. And even that awful hill-climb going home on the bike would be a lot harder in real summer weather. So, although it seems strange to be having such a mild summer (especially when the rest of the country has been experiencing such severe heat waves), I'm not going to look a gift-horse in the mouth.

I am used to explaining the difference between Type 1 and Type 2 diabetes by saying that the former is an auto-immune disease (that is, a disease which is caused when the patient's immune system mistakenly attacks one of the body's own cell types), and the latter is not. Apparently it's not that simple: researchers are finding evidence that Type 2 also involves an auto-immune reaction -- or at least it often does.

In the case of Type 1, the auto-immune aspect of the disease has been clear for a long time: the immune system kills off the great majority of the beta cells in the pancreas, so that the patient can no longer produce insulin. This typically happens at a very young age, suggesting that whatever triggers the reaction (a virus, perhaps?), it must be something people are usually exposed to before they reach adulthood.

The auto-immune aspect of Type 2 is not quite so straightforward, and researchers are only beginning to untangle it. At the heart of the issue is the puzzling relationship between Type 2 and obesity. Why is the disease so strongly associated with excess fat (particularly excess abdominal fat)? And given the strength of that  association, why isn't it more consistent? Many obese people never develop Type 2 diabetes, and some people develop Type 2 diabetes without ever having been obese. Obviously there isn't a simple cause-and-effect relationship going on here, but if something more complicated is involved, what exactly is driving it?

The mystery of how some thin people manage to develop Type 2 is probably a question for another day and another avenue of investigation, but the mystery of how some fat people (but not others) develop Type 2 is probably explainable in terms of an auto-immune reaction -- specifically, an auto-immune reaction to fat cells.

Researchers comparing obese individuals with and without insulin resistance have found a difference between them: those with insulin resistance have antibodies produced by the immune system -- antibodies which are absent in those who are not insulin resistant. These antibodies attack fat cells -- not necessarily killing them, but causing them to become inflamed and insulin-resistant.

What might trigger the body to produce anti-bodies that have an inflammatory effect on fat cells? The idea I have seen proposed is that, when abdominal fat becomes excessive, fat cells in the abdominal region don't have enough room to expand; these overcrowded fat cells become distressed and inflamed, and (in some people, but not others) this triggers an auto-immune response to the fat cells which ends up making the situation worse. Presumably, a genetic difference causes some people to react in this way, while others do not.

If this hypothesis is true, it certainly clarifies the oddly inconsistent relationship between obesity and Type 2: obesity makes some people diabetic and not others because some people are genetically predisposed to have an auto-immune reaction to abdominal fat, and others are not.

Experiments have shown that, in rats, insulin resistance associated with obesity can be greatly reduced by means of a drug which inhibits production of those antibodies. However, don't get excited by the prospect of a new and more effective diabetes drug -- the drug used in the experiment suppresses the immune system in other ways, too, and it would be too dangerous to use it as a diabetes therapy in humans. (Apparently the safety standards that are applied to lab rats are not as conservative as the standards applied to those with access to legal counsel.)

Conceivably, knowing that an auto-immune reaction is involved (or is often involved) in causing Type 2 diabetes will eventually lead to effective new drug therapies, but it doesn't looks as if that day is fast approaching. It seems to me that the short-term prospects are for (1) a better understanding of the disease, and (2) a better understanding of how lifestyle choices affect it. I'm not going to hold my breath waiting for anything more miraculous than that to emerge from this research.

Wednesday, 10, 2011

I spent the past week, at camp, using a bicycle as my primary means of transportation, and it occurred to me that I ought to get back into cycling to work. The problem with the bike-commute idea for me is not that it's a long distance (it's only a mile and a half, for heaven's sake) but that it involves an insanely steep hill-climb at the end of the day. I really dread climbing that hill, partly because it seems ridiculous to do a right as short as that and walk in the door with my clothes drenched in sweat:

In other words, the discomfort of ride seems out of proportion to its exercise value.

On the other hand, the downhill ride to work in the morning is little more than an invigorating dose of fresh air, and it allows me to start my work day feeling far more energetic than I normally would. So, there are pluses and minuses to this commute idea.

I used to do a lot of distance cycling, and I've been toying with the idea of getting back into it; maybe cycling up that hill in the evenings will force me to build up my cycling muscles again, so that I can get in shape for longer rides.

At least the evening improved after I dried off from the ride home; I met some friends at the Paradise Ridge winery for the "Wines & Sunsets"  event and we sipped Sauvignon Blanc as the day drew to a close.

All in all, not a bad day.

Tuesday, August 9, 2011

I was afraid that I would have trouble getting back into running, after a vacation week during which I did almost no running at all (relying on a moderate daily dose of cycling to get my exercise needs met), but running since camp has actually felt pretty good. I did a 7-mile trail run on Sunday and it seemed short, to my surprise. I would have made it longer, but I was pressed for time.

The weather has been very comfortable -- barely warm, certainly not hot. The morning fogs have been thick and cold, as if the ocean was at the foot of my driveway instead of 20 miles to the west. The rest of the country has been having an exceptionally hot summer. Not so in these parts! We've had just one heat wave, and it was short. Last summer was also exceptionally cool here. I wonder if there is long-term trend going on, with much of the country heating up and this part of coastal California cooling down. However, I realize that two years is a pretty brief period to be using to draw conclusions about long-term climate trends.

My haul of e-mail while I was out of town included an offer from someone wanting to place ads on this site and someone offering "Max-Gentleman Enlargement Pills". Perhaps it was an unfortunate coincidence of timing that brought me those two messages at the same time, but I'm afraid that the latter is influencing my reaction to the former. I don't feel as if it would be safe to reply to such a message, even to say "No thanks".

This site does not currently have a large enough audience for it to be worth it to an advertiser to pay me any significant amount of money. Plus, I'm sure the ads would mostly be for things I'm not especially in favor of. It seems to me that running ads would have to amount to selling my soul for a pathetically low price.

We're all human, and if this site ever becomes popular enough for me to be able to make an income from it, I might be unable to resist the temptation. But that day has not arrived. Right now I have integrity but no money; later I might have money but no integrity. I'm not sure that a transitional state during which I have neither money nor integrity interests me all that much.

Aaaaaarrrrgh! The bastards are at it again! I go out of town for a week, and while my back is turned they publish this: "No Clear Benefit for Tight Blood Glucose Control in T2DM". By this point it is almost needless to mention that this inflammatory headline appears over an article which shows no such thing. It certainly isn't the first time that this has happened! Studies of this exact sort, presented in the same wildly irresponsible way, have become something of an industry in recent years.

The study (or rather the survey of multiple prior studies) didn't actually look at tight blood glucose control -- it looked at intensive drug treatment aimed at producing tight blood glucose control (regardless of whether or not it worked). The idea was to compare the heavy drug treatment to more moderate drug treatments. Nobody took the trouble to look into other approaches to glycemic control (presumably because everyone knows there aren't any other approaches to look at -- heavy drug therapy and moderate drug therapy are, after all, the only possibilities open to us).

My problem, as always in these cases, is not that I object to the study itself -- if somebody wants to compare high-dosage drug treatment to low-dosage drug treatment, he is welcome to do so. But the results of such a study, whatever they are, should not be presented as if they showed that the goal of the treatment was bad in and of itself.

If researchers find that higher doses of antibiotics don't work better than conventional doses, they don't publish their results under headlines stating that controlling infections isn't worth doing. But whenever researchers find that more intensive drug therapy for diabetes doesn't seem to improve matters much, they invariably announce that improved glycemic control -- not a particular drug therapy aimed at improving glycemic control -- has been shown to be worthless. What exactly is the matter with these people? To be doing the work they're doing, didn't they have to go to school or something? Can they really be that clueless?

Listen, you jerks: you didn't show that controlling blood glucose is worthless. You showed that doing it by means of heavy drug therapy has serious drawbacks -- the main one being a tendency toward dangerous hypoglycemic episodes. Perhaps that should have set your minds working on the question -- is there a way to control blood sugar that doesn't involve a tendency toward dangerous hypoglycemic episodes? If you had come to me, I could have made some suggestions that would have set you on a more fruitful path of investigation.

I wish I could ignore these people (as paying attention to them is very bad for my blood pressure), but this blog exists largely for the purpose of undoing a tiny bit of the harm they are doing in the world, so I guess I have no choice but to keep track of their misbehavior.

Monday, August 8, 2011

If you're wondering where I was last week, was right here...

...or at least very nearby. I was attending Lark Camp, an annual gathering of musicians in the woods near Mendocino, California.

Musicians of every kind (classical, jazz, bluegrass, you name it) like to hold these sorts of events, in which people get together in a remote location and spend several days concentrating on music to the exclusion of all else. Being that deeply immersed in music over the course of a week, with no non-musical distractions, is an exceptionally satisfying experience, one which every musician craves. It's not really possible to convey this to non-musicians, I realize.

Typically there is a fairly narrow musical focus to such events. Lark Camp is unusual in this regard: it is extremely eclectic, featuring workshops on musical traditions of many different countries. There is a huge amount of variety. Styles represented there this year included Irish, French, Breton, Hawaiian, Balkan, Greek, Turkish, Appalachian, blues, swing, Cajun, and many others. These people were playing corridos (Mexican ballads), if I remember correctly.

There isn't a great deal of indoor space at the camp, so most workshops and jam sessions happen outdoors, wherever people can find room to set up a circle of chairs. The trick was finding a space that was flat enough for the chairs not to tip over; the local terrain is more vertical than horizontal. Wherever there was a big enough patch of level ground, musicians were assembled on it.

This shady corner, for example, was where the French musicians were to be found. I usually joined them there in the evenings, for a relaxing session of playing waltzes and bourees, while we sipped wine and waited for dinner. I learned enough of their music in this way that I was able to join them in playing for the French dance on Thursday night.

Sometimes the amount of musical contrast within a comparatively small space became a little startling. In the mornings, for example, our Irish music workshop took place outdoors, on the front steps of the dance hall; meanwhile, just around the corner of the building, also outdoors, a klezmer band was practicing, with tubas and horns and wailing clarinets. Somehow we trained our ears to hear what we were doing and not hear what they were doing. Or else we laughed about it when it became absurdly un-ignorable.

At evening concerts you would often see a group of musicians that you had heard practicing, off in the woods, as you were on your way somewhere else during the week; now you had a chance to hear what they'd been working on. This marimba ensemble, for example, I would hear every afternoon playing in a forest clearing as I rode past them on my bike; on Friday before dinner I finally heard them and saw them from up close:

Although Irish music is big at Lark Camp, and it was my highest priority, I also wanted to include a little variety. I attended a class in Breton music before lunch, and in the afternoon I attended an "old time" fiddling class (that is, American fiddle tunes primarily from Appalachia), taught by the genial Hank Bradley. He began by explaining that he'd taken a bad fall last October, requiring surgery on his hand, and had been unable to play at all for six months; now he was in recovery mode, and he had to warm up slowly and gradually every time he played. This, plus his hyper-relaxed demeanor, naturally led us to expect that he would be a slow and faltering player.

Then he started playing, and within a minute his bow arm was moving so fast that my camera shutter was unable to capture it...

...and of course he was just getting started.

Despite my dabbling in French, Breton, and Old Time music during the daytime, I mostly devoted the night-time to playing in the Irish jam sessions (there were usually two or three of them going on at the same time).

But so much for the musical side of things. How well did I do in terms of diabetes management at Lark Camp this year?

Last year I had been unhappy with the elevated fasting results I was seeing, and I wanted better results this time. My assumption was that my disappointing results last year resulted from three contributing factors: too much carbohydrate consumption, too little exercise, and too little sleep. I resolved to improve in each area if at all possible. 

I knew that food was going to be the biggest challenge. It isn't at all practical to prepare your own meals at camp, so you pretty much have to go with what they give you. But there is a certain amount of choice, and usually the amount of choice is sufficient to allow you to eat a meal without wildly overdoing the carbs. It wasn't that I couldn't limit my carbs last year -- the problem was that I didn't. I let the vacation mentality take me over completely. This year I exercised considerably more restraint.

Exercise is difficult to fit into the camp experience, because there's so much else going on, day and night, and you don't want to miss any more of it than you have to. My solution to the problem has always been to bring a bike and use that, rather than the shuttle bus, to get back and forth between the two separate camps where I take classes. It's fairly hilly riding, so it's good exercise. But last year, my class schedule didn't give me enough time on the bike -- about 30 minutes a day when I clearly need 60. This time I deliberately contrived a class schedule that required me to spend twice as much time on the bike. On the one day when I drove into town on an errand, and missed my morning bike ride, I did a half-hour run to make up for it (the only running I did the whole week, which is mighty unusual for me).

Sleep is inevitably a problem when you're staying up late to play in jam sessions, and you don't have the opportunity to sleep late in the morning. This year I simply took fewer classes, and opened up a sizeable  gap in the afternoon so that I could take a nap every day.  This seemed to help me greatly -- I wish I could do it every day of the year. (We need a siesta revival!)

So, did my improvements in these three areas give me better control of blood sugar this year? Yes, they did. My worst fasting result, on Wednesday, was 100 -- but all the others were in the 80s or low 90s. Last year I had repeated fasting results above 110, which is just not acceptable to me.

Last year, I wondered if my high fasting results indicated that glycemic control was becoming harder for me as I got older. I think what really happened last year was that I didn't do what was necessary. This year I did what was necessay, with better results.

Going to an event such as Lark Camp, in which you are inevitably living in different way than you would at home, is bound to be a challenge in terms of diabetes control. The trick is to take on the challenge, instead of ignoring it or giving up on it.

Of course I gained weight -- but that much I was more or less resigned to. Now I must go to work on fixing that problem...

July 29 - August 7, 2011


As I explained in Thursday's post, I will be in the woods near Mendocino, California for a little while -- making music night and day (which is good) and not in touch with the outside world (which is better) and not blogging (which is best of all).

The world will have to get along without me for a while!

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