Monday, February 28, 2011

The low result after lunch was a little surprising to me, as lunch had included a serving of blueberries. But it wasn't a huge serving, and I seem to tolerate blueberries better than most kinds of fruit, in terms of glycemic control. The rest of the lunch was pretty low-carb (a salad and a small serving of mixed nuts), which was why I thought I could risk having some fruit with it. Also, I'd just been running before lunch, and I'd done a long trail-run the day before, so I figured my system was primed to absorb some sugar.

I don't eat a lot of fruit, but I like it, and I like to treat myself with it when I feel the conditions are favorable. Apparently they were extremely favorable today. But if conditions seem to be exactly the same a week from today, and I eat the same lunch, I could get a considerably higher test result. You can never really be sure what's going to happen with your blood sugar, which is what makes diabetes-management such an involving hobby.

No blood-pressure reading today, because my meter seems to be dying, has trouble inflating, and then just gives me vague error messages. I guess I'll have to spring for a new one.

I got up early on Saturday morning and peeked out the window, hoping to see a winter wonderland out there, but it turned out that the weather-prophets had been wrong. Apparently those few fast-melting snowflakes that had swirled around us on Friday afternoon were the full extent of our much-anticipated blizzard.

Even the Mayacamas Mountains, which had been snow-capped last weekend, were considerably thawed-out by Saturday. Only Mt. Saint Helena, off to the north, still had a wintry look. 

So now we're back to California's version of February: sunshine and green grass.

Well, there are worse fates.

The cold virus which has been struggling to take possession of me for more than a week made yet another attempt on Saturday: I felt run-down and weak, with the beginnings of a sore throat, and I couldn't face going for a run outside. Instead I did a very minimal workout (30 minutes on the stair-climber in the gym).

On Sunday, though, I felt better again. I went to the state park for a trail-run. I wasn't sure which route I would do, because I wasn't sure how strong I would feel once I started running. As it turned out, I felt pretty good, so I ended up doing a 9.3-mile route.

It was a busy day in the park. Everyone who had been hoping to see the park transformed into a Christmas-card scene decided that they might as well go there anyway, and enjoy it for what it was.

I like it when there are a lot of people using the trails; it makes me feel like I'm part of something. When I'm more or less alone in the park, I feel more like I'm left out of something.

I particularly like it when I see people exercising in the park who are clearly not finding it easy to do so. They may be overweight, and they may be puffing mighty hard as they haul themselves up those hills, but by golly they're getting the job done all the same.

One of the curious byproducts of the diet wars has been a scouring of the historical (and archeological) record, in an effort to determine what people used to eat back in the days when people had not yet learned to argue about what people should eat.

The basic idea here is that people have started eating the wrong things in recent years (grains are often cited as the main problem area), and this explains the rise of the modern "diseases of affluence" (obesity, heart disease, diabetes, and so on). If we want to avoid those sorts of chronic health problems, which used to be rare, we must recapture the eating patterns which prevailed in more innocent times. In other words, we need to figure out what sort of diet is "natural" for humans, because nature has presumably adapted us to do well on that sort of diet. And the only way to find out what is natural for us is to find out how people ate during more primitive eras.

The concept makes sense at a shallow level, but you can't think about it for long before you start to notice that it involves a lot of assumptions. For example, it assumes:

I'm not saying that all these assumptions are wrong, but any one of them could be wrong, and some of them look pretty doubtful on the face of it. For starters, I find it hard to believe that theories about what we should eat are a new development in human history. Humans have probably been expressing opinions about nutrition (and everything else) for as long as humans have had the power of speech. I have to assume that, in every human society, eating habits have been influenced by culturally-transmitted ideas about what sort of food was healthful; therefore, diet would have to vary from one society to another. I also have to assume that eating habits have been influenced by whatever kind of food was readily available in a given time and place, regardless of how healthful it was (or was thought to be).

I am also skeptical of the claims, frequently heard, that major elements of our diet were introduced very recently. For example, some of the low-carb fundamentalists would have us believe that people started eating grains somewhere around World War II, a claim which seems to be handily contradicted by a great deal of literature, going back at least as far as the bible. Those are the extremists, admittedly, but advocates of a "paleo" diet (that is, a diet based on what we suppose were the staple foods of prehistoric tribes) have also over-reached a bit, if the archaelogical evidence is to be believed. Apparently people started grinding up grains and tubers for food more than 100,000 years ago.

To be sure, we can't know whether grains made up a large, small, or moderate share of the calorie intake of primitive societies that gathered or cultivated them. Nor can we know whether societies that gathered or cultivated grains were typical or atypical in their time. The fact that we find evidence of some prehistoric people grinding grains does not tell us whether or not all prehistoric people did so. We don't even know, in the case of those who did it, how heavily they relied on it to feed themselves. They might have done it only on Memorial Day, for all we know. Still, it seems that grinding grains for food goes back a very long way, which does tend to undermine the assumption that it isn't "natural" and everyone should knock it off.

So far as I can see, human diet has always varied rather wildly from one time and place to another; I doubt that there is one "natural" way for humans to eat. People adapt to the conditions in which they find themselves. Whether your tribe is located in Greenland or Kenya is probably going to play a major role in determining whether you eat more whale blubber than chickpeas or the other way around -- and this reveals very little about what you should eat if you live in Philadelphia. People seem to be able to survive on a variety of different diets, and our attempts at figuring out which of those diets is the best of the lot have been hopelessly muddled. (You can "prove" the superiority of any diet you choose, if you select your data carefully enough -- and this is very often done.) 

However, even if grains have been part of the human diet for many thousands of years, and even if we are wrong to suspect that excluding them from the human diet would prevent diabetes or any other disease, we do have to take very seriously the potential problems of eating a diet high in grains if you already have diabetes.

Once you have been diagnosed with diabetes, you sort of have to drop the issue of what worked for the average cave-man, and start figuring out what works for you.

Friday, February 25, 2011

The weather forecast had said that there was a chance of snow here today -- which, in these parts, is a rare enough event to make people giddy with excitement (much to the disgust of those who grew up in places where snow was not only routine but downright oppressive, and who can't understand why we are making so much of the lightest possible dusting of powder).

As it turned out, most of the day the sky was clear and blue, which does not promote precipitation no matter how cold it is. But around 2 PM it clouded up and a few snowflakes fell. That episode ended so quickly that most people at the office were unaware of it, and doubted reports from those of us who had noticed it.

But at 4 PM there was a slightly larger snowfall, and everyone noticed. A lot of people went outside in an unsuccessful attempt at photographing the phenomenon. They were unsuccessful because the snowflakes were not only sparse but were also moving so fast in the wind that the camera shutter couldn't capture them; also, they melted as soon as they touched anything. But the atmosphere was festive all the same.

A few of my photographs managed to catch some visible streaks as the snowflakes blew past the lens.

Laugh at us all you like -- we don't often get to see a snowflake, and when we do, we make a fuss over it. My own concept of snow is founded almost entirely on the Charlie Brown Christmas Special; I have very little else to go on.

Probably I didn't really miss out on all that much; I imagine that snow is something you can get very tired of in a very short time. Those of us who don't have to live with snow can't help romanticizing it. Spending a winter in North Dakota would probably cure me of that tendency, but I've never done that, so I am presently uncured.

My fasting result this morning wasn't as low as I like it to be (too many carbs last night, I expect), but my result after lunch was gratifyling low, espcially considering that I had soup with potatoes in it, and this was a non-exercise day.

There's still a possibility of a real snowfall tonight. As I write, it's 10 PM and the temperature is 33 degrees outside. It could get cold enough tonight that, if any snow falls, it will gather on the ground instead of melting as soon as it touches down. There might be a white carpet on the ground when I wake up. I hope so; it would give me a chance to see the local landscape in a new light.

If that happens, I will certainly go for a hike or a trail run in the local state park, and see what the place looks like under such atypical conditions.

Thursday, February 24, 2011

I guess I need to make this comparatively brief, as I went to a house concert tonight (with Jamie Laval and Richard Mandel) and it's getting late.

(And by the way, it sure is nice to hear unamplified music in an intimate setting. Let there be more house concerts!)

A cold air mass is rushing down the Pacific coast from Alaska, and there has been talk of our possibly getting some snowfall tomorrow. Today, however, it was nothing worse than rain -- and the rain didn't really get started until my lunchtime run was ending, so I only got a little bit of rain on me. I like rain if it happens when I'm not outside in it, so the timing was pretty nice for me.

An anagram, in case you don't know, is a word or phrase constructed by rearranging the letters of another word or phrase. For example, Thin Wagons and Hating Snow are both anagrams of Washington.  Making anagrams can be fun, if it turns out that the anagram has some kind of surprising relevance to the word from which it is derived. But making anagrams is also hard work, and if you'd rather not work at it, there is a website which you can use to generate all the possible anagrams of a given word.

For example, I found that the possible anagrams of the word  "diabetes" include these:

The last one has a certain relevance, as Type 1 diabetes develops when the beta cells in your pancreas die. But you stand a better chance of finding something relevant if you start with a longer phrase. I tired "prediabetic" and got:

When I ran "type two diabetes" I got:

That last one refers to me, I believe.

I tried "metformin", and found two results that were faintly disturbing:

The phrase "dawn phenomenon" yielded a couple that seemed pertinent:

But my favorite results came when I entered the phrase so often heard from patients on diabetes forums, "guess I'm in denial":

There's got to be some wisdom hidden in there, but it's getting late and I'm to sleepy to figure it all out.

Wednesday, February 23, 2011

This morning I thought that my hard-won victory over that cold virus over the weekend had proved to be only temporary. I was feeling pretty lousy this morning. Once again, the feeling that I was coming down with a very unpleasant fever was impossible to ignore. I had some doubts about feeling up to doing my usual lunchtime run.

But then I realized that, if I was honest with myself, I actually felt capable of doing the run -- I just didn't feel capable of doing it up to speed. So I told my running buddies at the outset that I wasn't even going to attempt to keep up with them this time. And I didn't keep up with them, at least not after the first mile. But it was a beautiful day (a little cold, at first, but it only seemed cold for the first quarter-mile or so), and once I started running, I started feeling better almost immediately. And I continued to feel better after the run was over. So I guess I scared the virus away once more.

In Indian cooking they use an extraordinary number of different kinds of legumes. Until you shop at an Asian foodstore you have no idea how many variations on the lentil or the chickpea there are -- in a countless shapes, sizes, and colors. Here are some that I have on hand:

These high-fiber, moderate-carb legumes are seen as diabetes-friendly alternatives to rice or potatoes in curries and stews. Chana Dal (in the center of the picture) is particularly renowned as India's gift to diabetes patients, but I like to try out other varieties to see if they work for me, too.

The dark brown ones at the top of the picture are known as Kala Chana (at least, they are known as that to the people who sold me a bag of them -- the multiplicity of languages in India ensures that every foodstuff from that part of the world travels under many names). Anyway, Kala Chan apparently does work for me; I made a vegetable stew with it tonight, and my post-prandial result was only 111.

A study conducted by the Department of Veterans Affairs Medical Center has found that the risk of eventually developing diabetes rises surprisingly steeply as Hemoglobin A1c results rise above 4.9. Yes, you read that right: anything above 4.9 is associated with at least a slight increase in the risk of becoming diabetic later in life.

Apparently the usual definition of the 4 to 6 range on A1c tests as "normal" needs to have a footnote tied to it. The 5 to 6 part of that range is associated with an increased risk of becoming diabetic later.

For a moment, reading this disturbed me; the first thought to enter my head was, "Wait a mintue -- nearly all of my A1c tests over the past decade have been higher than 4.9!". But then I remembered that had already been diagnosed as diabetic before any of those A1c tests had been given to me. So why, exactly, was I scared by the thought that, if I weren't careful, I might be diagnosed with diabetes a little further down the road?

Okay, so my fear was a little silly -- like worrying that I might have to endure the rigors of puberty some day.

Been there, done that!

Tuesday, February 22, 2011

Considering how much time diabetes patients spend fretting about worst-case scenarios, I think it would be a good idea for us to appreciate and enjoy whatever good news comes our way in terms of health. Controlling your diabetes is often going to be a frustrating assignment, and even a maddening one. But when things go the way you want them to, be sure to stop and savor that moment, and get the full benefit of it.

I'm in a good mood at the moment, largely because my long holiday weekend worked out better than expected in terms of health. It's a long story and I'll try to make it non-boring.

Last Friday evening, I arrived at Bishop's Ranch (outside Healdsburg, California) for the winter retreat of the San Francisco Scottish Fiddlers. This is an annual event that I have been going to for years. It has very little in the way of an agenda; it's just an opportunity, once a year, for musicians who don't necessarily live near each other to get together an make music in a peaceful location in the Sonoma Country wine country.

If the weather is good, you can go outside for a walk in the Russian River Valley.

But you can also go into the ranch house...

...and gather around the big fireplace and make music.

The trip ought to be one of the highlights of the winter for me, but when I arrived at the ranch on a rainy Friday evening, I had good reason to be worried that things were not working out well for my health that weekend. Carrying my luggage upstairs, I was feeling a disturbingly familiar set of symptoms, including a sudden onset of fatigue, a headache, and the mild but troubling beginnings of a sore throat. Obviously my immune system was fighting off a virus. A nasty cold had been cutting a swath through the workforce at my office lately, and I had certainly been exposed to it repeatedly in recent days.

I thought: this is it! I've caught that bug everyone has been talking about, and now I'm going to be sick the whole weekend and miss out on everything I came here to do. I'll spend my time here in my room alone, shivering under blankets, listening to the distant sounds of everyone else making music until the wee hours. I was starting to get mighty discouraged and depressed about everything.

However, I thought there was at least a chance that I could beat this thing. What could I do to improve my odds? I decided to take an extreme measure: not staying up late on Friday night. There would be plenty of other opportunities to make music and socialize, provided I didn't let myself get sick. So, I went to bed early (early for a musician away from home, anyway) and got some sleep. In the morning I felt a little better, instead of (as I expected) a lot worse. So then I took my other extreme measure: after breakfast, I took off for a long run.

I'm sure most people would have told me that this was exactly what I should not do if I wanted to avoid being miserably ill the whole weekend. The rain had stopped, but it was pretty cold, and I was still feeling fatigued. To go for a long run now, exhausting myself and chilling my body down, would surely weaken my defenses and give the virus every encouragement to reproduce wildly and knock me flat.

Well, that's the conventional wisdom, but my experience has been that exercise nearly always makes me stronger rather than weaker, and that it's precisely when I'm not sure I'm feeling up to a workout that I need a workout most. Not that I go running when I'm unquestionably ill already, and it seems likely that I'll collapse on the jogging trail if I try it. I just take the attitude that, if I were actually ill enough for exercise to do me more harm than good, my body would simply stop me from doing it. Being unable to enjoy it is not the same thing as being unable to do it. So off I went down the twists and turns of Westside Road.

I wasn't sure how far I was going to run when I started, but as I went along I started feeling stronger, and I eventually decided to go all the way out to Wohler Bridge (4 miles from the ranch) and back. It seemed worth doing, because I'd had a pretty high-carb breakfast, and I wanted to burn it out of my system.

At the bridge, someone from the Bishop's Ranch who was driving back from an errand in town was surprised to see me so far out there, and offered me a ride back if I needed it. I said no, this was all intentional. (And by the way, I was not in the least tempted by the offer of a ride -- by this point it felt good to be doing what I was doing.) So I turned around and made the return trip back to the ranch.

By lunchtime, I had already got my workout for the day taken care of, and it had been a good solid 8-mile run, and I felt a lot better for having done it. I did feel tired, but it was the good-tired feeling you get from a challenging workout, not the miserable-tired feeling you get from a viral infection. The endorphins from the run definitely put me in a good, mellow mood for the afternoon and evening music-making. I was much less worried about getting sick. I could relax and enjoy the event.

I felt even better on Sunday morning, which was cold but very clear and sunny.

The early-morning sunshine was lighting up the frosty grass brilliantly.

Because I'd done an 8-miler the day before, I figured I would do a shorter run this time, and not wear myself out too much. But once I started running, I immediately realized that I felt a lot stronger than I had the day before, and I really wanted to go all the way out to the bridge again. So I did, and it felt better (and shorter) the second time.

On the way back, as the fog that had been hugging the mountain peaks began to burn off, I realized that something very unusual (for these parts) had occurred: the Mayacamas Mountains to the west, which separate the Sonoma and Napa valleys, were white with snow. It's amazing how much bigger they look when there's snow on them.

Despite the snow on the mountains, the weather was mild at the ranch on Sunday afternoon, and some of the musicians were even playing outdoors just to show that they could do it.

Anyway, by the time I was done with that second long run, nothing remained of the feeling of oncoming illness which had bothered me so much on Friday.

Perhaps I over-reacted to this good news: I stayed up very, very late that night (and rather far into Monday morning, if the truth be told). But I was playing and talking with musicians I seldom get to see (some of them no more than once a year), and I wasn't going to waste any of the opportunity now that I was feeling better.

So far I have dealt with only one health issue connected with the weekend. It was the issue I was most focused on, because I didn't want the event ruined. But certainly the weekend involved a couple of other health challenges, which most people would regard as far more important: surrounded as I was by lots of good food that was already paid for, and was layed out before me in buffet form, was I going to lose control of both my blood sugar and my weight? 

Well, in the event, I didn't do too badly. My highest fasting test was 95 (that was Saturday morning, after a Friday which involved no exercise and a big pot-luck dinner after everyone arrived at the ranch). Despite the seemingly continuous eating, I managed to keep my blood sugar within acceptable (if not ideal) bounds. And I didn't gain any weight, either -- which, under the circumstances, may qualify as a miracle.

That's a lot to achieve, if you think about it. I managed to have the full experience that everyone else was having. I partied with the best of them. And I didn't pay a terrible price for it.

Well, some of you would argue that I did have to pay a terrible price for it, because I achieved it by doing two 8-mile runs on the same weekend. I guess I'll just have to ask you to take it on faith that, once you're used to it, long-distance running no longer comes under the "terrible price" heading. Maybe I have to do more than other other people do in order to enjoy the same party they're enjoying, but at the end of the day I can say that I was able to have at least as good an experience of the occasion as other people did, and maybe better.

The good news even continued today. I went in for an eye exam this afternoon -- and that is always a likely occasion for a diabetes patient to find out that he isn't doing quite so well as he thought he was.

My eye doctor did some fairly thorough testing, including a glaucoma test (apparently my eyeball pressure continues to be comfortably within the lower part of the normal range). He also did a retinal scan, which returns colorful and grotesque images which seem to portray the surface of one of Jupiter's less respectable moons, as captured by a passing NASA space probe. I always look with horror at these images of what's going on inside my eyes, but my doctor said firmly that everything was normal. He even gave me a little tour of my own eyeballs, telling me exactly what he would expect to see if diabetes (or anything else) were wreaking havoc there, but he wasn't seeing any such thing.

For all I know, tomorrow or the next day will bring me dreadful news about my health. But at the moment I'm doing fine, and that's what I want to focus on for the time being.

Friday, Feburary 18, 2011

The low post-prandial result today was unusual, especially after a bowl of soup that had some potato in it. But I had felt exceptionally hungry before lunch (in fact, for more than an hour before lunch), so I was probably a bit hypoglycemic, and the amount of cabohydrate in my lunch was just barely enough to correct for it.

Hypoglycemia hasn't been much of a problem for me, but I do get low once in a while. Why today? Who knows. Nothing unusual going on today. I didn't even work out. Of all the puzzling phenomena involved in diabetes management, hypoglycemic episodes are perhaps the most puzzling of all, at least to me. When you get an unusually high result, it's seldom hard to figure out why; when you get an unusually low one, it's seldom easy.

I'm off to the country now -- not very far into the country, but far enough to get away from the distractions and irritations of modern life, and concentrate on nothing but making music with my friends, and going outside for walks when the rain stops.

The only problem is that there will be a lot of good food there; I will probably do fine in terms of glycemic control, but weight control may be a little more challenging. I hope I can avoid bringing a couple of extra pounds back with me!

Thursday, February 17, 2011

I wasn't happy to have an unusually high fasting result this morning, but the news today wasn't all bad. At least my post-prandial test result was good. And my lower back, which has been giving me a fair amount of pain this week, is much better today -- pretty close to a full recovery. I'm not worried that it will get in my way during this weekend's activities.

It's likely, I'm ashamed to say, that my higher-than-usual fasting result this morning (96) might have a lot to do with my lower-than-usual fasting result yesterday (74). Whenever I get a fasting test below 80, I start feeling invincible, and I immediately become less cautious about carbohydrate intake. I never learn! Which is why I always have to test. Without my meter to take me down a peg, my complacency would become permanent, but my good control would not. Diabetes is an ever-changing thing, and you can never take your eye off it for long.

Somebody on the dLife forum, who had started on metformin and wasn't seeing signs of improvement yet, posted a question recently about how long it takes for significant and "lasting" improvement to occur. Lasting! My goodness. I thought this was like a novice rodeo rider asking how long it takes before the bull settles down into a relaxed pose and stops jumping around like that. Diabetes is not a problem that you fix completely one day, leaving yourself free to move on to the next project. The variables that influence blood sugar are numerous, they change unpredictably, and they interact with one another in mysterious ways. Also, we change, and our behavior changes, and our stress level changes, and the weather changes... I'm not sure that "lasting" is a meaningful word in diabetes management.

Anyway, I'll try to do better tomorrow.

The institution known as the Centers for Disease Control (which seems hell-bent on keeping that mysteriously pluralized name, no matter what I say on the subject) issued a report yesterday on the state of health of the American public. Apparently we're not doing so great, but let's start with the good news. The prevalence of high serum cholesterol has been dropping very significantly in recent years:

And so it ought to be: there has been an extraordinary increase in use of the cholesterol-lowering drugs known as statins (which are now the most frequently prescribed of all medications). Fully half of the male population in the age range of 65 to 74 is on statins! For the pharmaceutical companies, it's like having a license to print money.

Well, with all those millions of people taking statins, and their cholesterol readings coming down, we must be seeing a big drop in the rate of heart disease! Right? Aren't we?

Well, no. Heart disease rates are the same or higher.

Huh? Everyone's on statins, and their cholesterol readings are down, but heart disease rates aren't falling? How can that be?

Well, there are a couple of possible explanations:

  1. Statins don't really work, in any meaningful sense -- they make your lab report look better, but they don't actually improve your health. You're still as vulnerable to heart disease as you would be if you didn't take the statins.
  2. Statins work, but they can't overcome the set of other problems (obesity, diabetes, and hypertension) that are pushing people towards heart disease. Without statins, the heart disease rate would be even higher than it is now.

Cynic that I am, the first explanation looks pretty plausible to me (and some studies back it up), but it is probably true that we will never reduce heart disease rates so long as those other risk factors (obesity, diabetes, and hypertension) are still on the rise.

Certainly America has been gaining weight recently (and it's interesting that the obesity is higher in men, since most men would have predicted it would be higher in women):

Although obesity rates aren't as high in children as in adults, the rate is increasing faster for children, so they're doing their best to catch up:

Diabetes prevalence has, of course, also been increasing in recent years. But, strangely enough, it hasn't been increasing in people aged 45-64 years. It's the people under 45 and over 64 who have increased their representation in the diabetic population. I don't know why middle-aged people haven't been able to keep up. What's their deal?

Hypertension has been increasing, too, even though doctors have been prescribing antihypertensive medications like nobody's business:

Oddly enough, women have a higher rate of hypertension than men, even though women have a lower rate of obesity. What accounts for this? Well, I can't say for sure, but I have a guess: fewer women than men are getting regular exercise:

However, I'm not sure that either women or men can congratulate themselves on their high rate of exercise. The fraction of the general population that is getting an ammount of exercise which is considered adequate for good health is 22%, and the level doesn't rise to 30% even among young men, who are the most active subgroup.

However, it should be noted that the exercise rate -- feeble though it certainly is -- is higher than it used to be. It may be hard to believe that America has become less sedentary in recent years, but apparently it has. We just have a little room for improvement, that's all.

The CDC report also shows other depressing trends -- rising health-care costs, more people losing their health insurance, and more people delaying or avoiding necessary medical treatment because they can't afford it. But at least we have the comfort of knowing that a lot of important people are working hard at making sure that nothing is done about any of these problems.

My feeling is that, if we want to stay as healthy as we can, we should pretend that we're living on a desert island -- and try to figure out how we would solve the problem of staying healthy if we had to do it all by ourselves.

Because maybe we do.

Wednesday, February 16, 2011

Dinner last night was pretty low-carb, and I got up a little earlier than usual today; those two things are the likeliest explanation for the fasting test below 80 this morning.

The weather was dramatic today: periods of sunshine alternating with downpours of rain and hail, and occasionally high winds. We went for a run when the sun came out, and of course the clouds gathered again as soon as we were far from shelter. Fortunately, we finished the run before the rain had really started up again. We barely got wet. The wind chilled us down pretty thoroughly, though. The hot shower afterward was much appreciated.

My lower-back problem wasn't fully healed today, but it was certainly better than yesterday, and my lunchtime run improved it further. I'm feeling pretty confident that I'll be fine by the weekend. Which is good, because I'm spending the weekend at a country retreat with a bunch of musicians, and I want to be feeling well enough to enjoy myself. I'll show you a few pictures from the same event last year.

We'll be staying at the Rancho Obispo, near Healdsburg. This is about as close as I get to the experience of English country-house visiting.

I expect we'll be hiking around a lot in the daytime (usually our hikes end up at one of the wineries in the area).

And apart from the hiking, we'll be playing music much of the day and most of the night.

This sort of weekend can be hard on your back, or hard to enjoy if your back is hurting when you get there. So, I'm trying to get my spine into the healthiest possible condition between now and Friday.

I'm always intrigued by the reports I receive on internet search-engine phrases which led readers to my site, and from time to time I like to try answering the questions which seem to be implicit in these search-terms.

So, here are are new batch of search-terms, and my reactions to them.

There is nothing of great significance here. Biochemists studying hemoglobin used a chromatography process to break up the hemoglobin sample into "fractions" -- various sub-types of hemoglobin. The fraction that was glycated (bonded to sugar) happened to have been designated "hemoglobin A1c". Presumably there are fractions called A1a and A1b, but I don't know what they are like. A1c receives a lot of attention because the amount of it present in a blood sample is an indicator of how much glycation has been going on, which in turn is an indicator of how much sugar has been present in the blood lately.

Quicker than what? Quicker than un-glycated hemoglobin? No. The body recycles its proteins, and hemoglobin (which is found in red blood cells) gets reycled pretty fast, because red blood cells have a short lifespan of three to four months. But when a red blood cell is replaced, the whole thing is replaced, not just the glycated molecules in it. The new red blood cells are born in a more innocent state, full of unglycated hemoglobin.

"Dangerous" is going too far, but 6.2 involves a little bit more risk than 6 -- just as 6 involves more risk than 5.5, and so on. The risk of various health problems which are usually called "diabetic complications" goes up as A1c goes up. However, the rising risk-curve gets pretty steep around 7, so "dangerous" isn't too strong a word to apply to the state of being above 7. Being at 6.2 isn't ideal, but it's not terribly hazardous either.

That's a trend you want to stop in its tracks. One of the unfortunate effects of elevated blood sugar is toxicity to the beta cells in your pancreas which produce your insulin supply. It's a vicious cycle, obivously: the more insulin you need, the more you lose the ability to produce it. If your A1c result is rising, your blood is becoming more sugary over time, and you need to be doing more to bring your blood sugar down.

Because the A1c test examines hemoglobin molecules to see what percentage of them are "glycated" (bonded to sugar), and because glycation reactions occur slowly, and aren't reversed (except in the sense that the glycated hemoglobin is eventually discarded and replaced by new, unglycated hemoglobin), the A1c test reflects long-term accumulative trends, not momentary fluctuations and disturbances. I don't think that your adrenaline level at the time you take an A1c test is going to make a difference to the test result. However, if you are habitually in a state of stress, and your adrenaline level is typically high, this could have an impact on your A1c result -- but only because it would tend to raise your blood sugar. That is, adrenaline wouldn't give you a false high result, but it might give you a genuine high result.

I can't begin to make sense of this.

I don't recommend them.

See my earlier essay on the subject of diabetes and alcohol.

Sorry, but we need to remove "permanent" from that phrase. You can boost your insulin sensitivity, all right (a good workout will do it), but don't expect the effect to be permanent. The reason that "regular exercise" is always recommended, rather than just plain "exercise", is that the benefits of exercise are temporary effects. The boosting of insulin sensitivity by a workout fades gradually over a period of 24 to 48 hours. Maybe the boosting of insulin sensitivity due to weight loss can be permanent -- but not if the weight loss isn't permanent!

I guess it means that your arteries are coated with sugar. I haven't heard that the arterial walls tend to develop an encrustation of sugar (in the same way that they develop an encrustation of cholesterol), but the protein molecules in all our tissues (including the arterial walls) can become "glycated" (bonded to sugar) in a way which prevents them from carrying out their proper functions within cells. The problems that this can lead to are too numerous to list -- that's why diabetes has so many "complications".

I suspect this comes from someone who thinks that the so-called "epidemic" of obesity and diabetes is a fiction created by journalists, or at least is greatly overstated. This is a very common reaction to any new and unwelcome development which people wish they weren't hearing about. Darn those journalists! Always making up alarmist headlines about problems that don't even exist!

Well, it certainly does happen, from time to time, that a news story receives attention way out of proportion to its actual significance. For example, the "Y2K" computer problem at the start of the year 2000 was an actual issue that had to be addressed, but it didn't need to be covered in a way which suggested civilization was about to collapse. Whether the rising incidence of obesity and diabetes are receiving too much attention (or too little, or just enough) is a difficult question to answer decisively, but it would be nutty to suggest that this isn't a serious problem which we ought to be doing something about.

I have to assume that this refers to doctors (young or old) who lived in ancient times, not to very old doctors living today. As I have mentioned more than once here, largely because I like to make jokes about it, doctors in ancient times recognized diabetes by the sweetness of the patient's urine -- either by tasting it themselves, or by noting the interest that ants and bees tended to take in the matter.

Spinach probably doesn't have much effect on GLUT-4, but first let me explain that GLUT-4 is a "transporter" molecule which serves to pull glucose into muscle cells (when the cell is stimulated by insulin). Having more GLUT-4 in your muscle cells makes them more responsive to insulin. (Exercise stimulates production of GLUT-4, which is at least part of the reason that exercise boosts insulin sensitivity.)

Because the reactions which ultimately result in production of GLUT-4 are partially driven by Alpha-Lipoic Acid (ALA), many people think you can get more GLUT-4 by getting more ALA into your body. The body actually makes its own ALA, but you can get more of it by taking it as a supplement or by eating foods which contain it. Spinach does contain ALA. Therefore, eating spinach will cause your body to produce more GLUT-4, and thus increase your insulin sensitivity -- right? Well, let's hold on a minute here. Spinach contains some ALA, but not as much as meats do -- and anyway, there's no way to know if taking in ALA in your diet really will result in a significant increase in GLUT-4 production and insulin sensitivity. The idea sounds sensible enough, but ideas that sound sensible don't always play out the way we expect in living organisms.

See my essay "The Kitchen Sink". The sink is my favorite metaphor for explaining diabetes.

The answer to this question used to be "when the patient has been given an opportunity to achieve glycemic control without medication, and has not had any success at it". Lately, the answer tends to be "immediately upon diagnosis".

The theory here is that, although many diabetes patients could achieve glycemic control without medication if they did the right things, most patients won't do the right things, and delaying medication for such patients allows further damage to occur. In what I consider a particularly sad irony, an endocrinologist who strongly advocated for this policy of immediate medication once admitted in an interview that he thought 60% of his patients wouldn't need medication if they lost weight and exercised, but he knew they wouldn't.

Such prophecies tend to be self-fulfilling, unfortunately. It's impossible to know how much harm is being done by doctors' low expectations of patients, but I suspect it's a lot.

Tuesday, February 15, 2011

I woke up this morning (no, this is not the start of a blues song) and thought that my lower-back pain was greatly improved. But after moving around for a few minutes, I decided it wasn't.

Then I did some yoga stretches, and thought that they had helped. A little later, after getting out of the shower, I decided that they hadn't.

These cycles continued all day: I kept thinking my back was feeling better, then it would suddenly go into muscle-spasm mode. I decided to go ahead and run at lunchtime, and during the run and shortly afterwards my back felt better than it had all day. But after I sat down at my desk it stiffened up again. None of this was unbearable; I just wished I wasn't having to deal with it.

Oh, well, that's the way it is with a human body: sometimes it's going to hurt. I just have to move forward on the assumption that what has helped me heal this sort of injury in the past (stretching and staying active) will help me this time, too -- and that what hasn't helped me in the past (resting up) won't help me this time, either. I did a lot of stretching today, and I did a hilly 4-mile run. At the moment (9:26 PM) my back feels pretty good. I hope it stays that way, but there are no guarantees.

A movie critic once wrote, in reference to a bad Marlon Brando movie, "Brando wouldn't be Brando if you could count on him". Similar things have been said about Bob Dylan. I guess similar things could be said about life.

Until today, I was wholly unaware of the existence of a baked good known as the whoopie pie:

It is also known as a black-and-white, a bob, a gob, or a BFO (for Big Fat Oreo). It is a cookie-like assemblage of mound-shaped cakes separated by a sweet, creamy filling.

The history of the woopie pie is disputed; both Maine and Pennsylvania claim to be the birthplace of the thing. The Pennsylvania Dutch Visitors Bureau claims that the pie was invented in the 1960s, and then was brought to Maine by Amish groups who settled there; but this idea is stoutly resisted in Maine, where it is claimed that a bakery there started making whoopie pies in 1925. Wikipedia's history of this particular baked good states: According to food historians, Amish women would bake these desserts (known as hucklebucks at the time) and put them in farmers' lunchboxes. When farmers would find the treats in their lunch, they would shout "Whoopie!"

Yes, you can see how that would happen. It's a story that has the ring of truth.

What makes the whoopie pie newsworthy is that the State Legislature of Maine, having no issues of a more urgent nature to grapple with, has been trying to declare that the whoopie pie is "the official state dessert", a designation which we must assume carries with it both privileges and burdens. The legislative bill which would accomplish this was introduced earlier this month, "with bipartisan support" (clearly the idea is as popular as it is important). The backer of the bill arranged for a man dressed as a whoopie pie to appear at a hearing recently. It certainly sounds as if the Voice of the People has spoken on this issue.

And yet, wouldn't you know it -- there are dissenters! This opinion piece from the Kennebec Journal decries "hyperglycemic hype" which ignores issues of obesity and diabetes.

I find myself a little conflicted about issues such as this. On one point I am clear -- a state legislature simply has to have more important things to do than ponder the official or unofficial status of the whoopie pie -- but the rest of this is murky.

I guess what makes me uncomfortable is the implication that the whoopie pie promotes obesity and diabetes simply because it is sugary. In other words, pizza couldn't play any role in promoting obesity or diabetes -- only desserts can do that.

The popular association of obesity and diabetes with "sugar" can be dangerously misleading. Millions of people think that if you don't eat "sweets" you're in no danger of developing diabetes. This is not at all true. You can get just as obese and diabetic by overindulging in whole wheat bread as you can by overindulging in whoopie pies -- yet most people imagine that whole wheat bread can do them nothing but good.

I can't be enthusiastic about promotion of whoopie pies by a state legislature, but neither am I enthusiastic about the idea that demonizing particular foods (while ignoring the potential disadvantages of other foods) is helpful.


Monday, February 14, 2011

The trouble with having a physical body (don't get me wrong -- I don't mean to suggest that I'd be happier as a ghost) is that you are obliged to live in it all the time -- not just when you want to. Even when your body is undergoing repair and it's not really ready for use, you still have to live in it. What prompts this thought is the lower-back pain I've been experiencing for the last few days.

First, to put this in perspective, let me admit that the back pain I'm dealing with now is a good deal less serious than what I used to have to deal with, in the days before I was diagnosed and starting forcing myself to stay active. In my pre-exercise days, I had some really crippling episodes of pain and muscle spasms in my back, and those episodes would last several days. In more recent years, my episodes of back trouble have been less frequent, less prolonged, and less severe. I'm really not suffering that badly today; I can work, and I can exercise. But certain commonplace movements, such as climbing into a car or bending over to pick something up from the floor, now have the power to seize my full attention. It's okay for me to be bent over, and it's also okay for me to be standing up straight, but making a transition between those two states tended to be a rather startling experience today. 

My back started hurting on Saturday morning, after I moved a bulky and awkward (though not terribly heavy) piece of furniture. The soreness persisted, and I could tell I'd be stuck with it for a while. But what about my workout for the day? I had taken Friday as a rest day, so I didn't feel that I could skip exercising altogether on Saturday, no matter how much my back was complaining. I ended up doing a run, but a much shorter one than normal for me, and at a slow pace.

In the evening my back started feeling slightly better, and I more or less forgot about the issue, because I went to a party with a bunch of musician friends, and we started a jam session which went on for hours. When it looked as if the energy in the room was finally starting to flag, I looked at my watch, expecting that it was perhaps midnight by now. It was nearly 3 AM. And I suddenly remembered, to my horror, that I had agreed to go on a long trail-run in the state park with a friend of mine on Sunday morning -- which it now already was. 

Fortunately, the run wasn't until 10:30 AM, so I did manage to fit in a little shut-eye in between the party and the park. Which was good, because this was a run which demanded alertness: we were on very rough, rocky trails, with a million opportunites to trip and take a nasty fall. I warned my friend that I'd been dealing with a back problem, and I figured the run would either make it feel better or worse -- and if the run made it worse, I'd have to give up on it and head home. 

Well, the running seeemd to make my back feel a bit better. It helped that the weather was great -- clear air, brilliant sunshine, and temperatures just cool enough to make running comfortable, without being cold.

The world was beautiful, and I couldn't imagine a better way to spend the day than running on those rock-strewn trails through the woods. So, I ran the entire route he had in mind -- all nine miles of it.

Later in the day, my back was still doing okay, and I was ready to believe that the whole back-pain episode was winding down and would soon be over. This morning, though, my back was unhappy again, and I had to make another decision about exercise.

Our lengthy series of sunny, spring-like days (which had lasted more than two weeks) finally came to an end last night, when a rainstorm blew in from the Pacific. It's predicted to be rainy all week, and it was certainly rainy today. After all that great weather lately, I couldn't face running in the rain. Also, after yesterday's long run I thought I could afford to do a lighter workout today. So, I went to the gym and did 30 minutes on the stair-climber. Then I sat in the hot tub and did some yoga stretches in the hot water, to see if I could get the muscles around my spine to relax and unclench. It seemed to help. Of course, yesterday's run also seemed to help, too, so it's hard to say. But tonight my back feels a lot better than it did this morning, and I hope it will tomorrow morning as well. We'll have to wait and see. Whatver sort of condition my body is in tomorrow, I'll still have to live in it.

I'm sure that most wise advisors would tell me that I handled my weekend badly in every possible way: 

  1. I should not have moved a bulky piece of furniture on Saturday morning, given my history of lower-back problems.
  2. I should not have gone for a run (even a short run) on Saturday afternoon, if my back was sore.
  3. I should not have gone to the party on Saturday night, or at the very least I should have come home from it early, rather than making music until almost three o'clock.
  4. I should not have done even a short, easy run on Sunday morning, much less a 9-miler over rough trails.
  5. Once my back started bothering me, I should have spent the whole weekend resting, so that my back could recover.

Perhaps my wise advistors would be right about all this, but I don't think I would have followed such advice, and not just because I'm willful and stubborn, but because my own experience does not support the assumption that physical inactivity is helpful or practical. So here are my counter-arguments:

  1. Moving bulky, awkward pieces of furniture is one of those tasks in life which must be done from time to time, and unless you have been officially declared to be disabled, you sort of have to stop whining and move the damned furniture.
  2. Exercise has been the key to managing my diabetes from the start, and I don't skip a planned workout if I can help it. Having a sore back doesn't rise to the level of force majeure (the sort of calamity that is regarded as nullifying contractual obligations).
  3. Life has to go on. Being able to go to a party with other musicians and play music until the wee hours is one of the reasons I want to be alive rather than dead. I'll give up cinnamon rolls if that will help me live longer so that I can make more music (which matters to me a lot more than cinammon rolls ever did), but don't ask me to give up things that help make living longer worth giving up cinnamon rolls.
  4. Having done no workout on Friday and a very minimal one on Saturday, I was due for a challenging workout on Sunday. I do a long workout on the weekend if there's any possibility at all of fitting it in -- and if I skipped it every time I wasn't sure I was feeling up to the task, it would never, ever happen.
  5. Before I was diagnosed with diabetes and started exercising regularly, I was always willing to treat back pain with lots and lots of therapeutic rest. And with what result? I would be in severe pain for days, and then start recovering slowly. If my experience means anything, rest is the most over-rated form of therapy there is. I recover faster if don't rest than if I do.

 So there!

Friday, February 11, 2011

Home glucose testing is plagued by practical difficulties which must weaken our confidence in the accuracy of the results -- and I'm not just talking about the limitations of the meters themselves. If the same meter were used only under laboratory conditions, in a temperature-controlled environment, with trained technicians following a standardized routine for the test every time, the results might be considerably more stable and accurate than they tend to be in the real world.

Unfortunately, we don't take these tests under laboratory conditions. We take them in our homes, in our offices, on airplanes, in public bathrooms, or wherever else we happen to find ourselves when it's time to take a test. People test at picnics and Little League games. They test while on camping and fishing trips (whether the temperature happens to be 38 degrees or 98 degrees at the time). They test by the side of the road during long-distance running and cycling events. They test at the theater and in the concert hall. In general, they test while they are otherwise engaged in living their lives, which means that the various activities of life (working, playing, resting, shopping, waiting in line at the Department of Motor Vehicles) are not canceled so that testing can be conducted under ideal conditions.

None of this should be news, and yet the makers of glucose meters seem to be catching on to it rather tardily. Some of the instructions they give their users seem to be based, however unconsciously, on the assumption that the meter will, in fact, be used in a laboratory and not at a barbecue. And medical researchers are only now getting around to investigating the consequences of this.

Late last month, Diabetes Care reported on some research conducted in Japan into the issue of glucose meter accuracy under real-world conditions. The test subjects (who were healthy and non-diabetic) took glucose tests before and after handling food -- specifically, they were peeling fruit. Before handling the fruit, their meter readings were close to 90. Afterwards, the residue of fruit on their fingertips caused very high false readings: 360 mg/dl after peeling a grape, 180 after peeling a kiwi, and (in what has to be my favorite typographical error of the year so far), "170 mg/dL on average after peeing an orange". 

But the high readings after peeling (or peeing) fruit are not the real suprise here! The surprise is that cleaning the fingers with alcohol swabs (recommended by the meter manufacturer) didn't solve the problem. Alcohol turned out not to remove enough of the fruit residue to normalize the test results -- even when the test subjects swabbed five times before testing. The only way to avoid getting a false high reading after peeling fruit was to wash the hands with water.

I can't believe that we had to wait till 2011 for someone to look into this matter. But now that someone has, it turns out that alcohol is not what you want to wash your fingers with before testing. Tap-water is what you need. (This, of course, assumes that testing takes place only in situations where you've got tap-water handy.)

I have often wondered about this issue of waterless hand-cleaning before taking a glucose test, and whether or not it removes sugar residues or other residues which might derail a measurement. Still, I never took the trouble to perform systematic experiments and find out for myself. I've just always assumed that water was required. Well, apparently it is.

I wonder what other commonplace problems give people inaccurate results on their glucose tests. I have heard of a few other oddities. One is that, if you decide to repeat a test, you're not supposed to take another blood sample from the same finger you just used a few minutes ago -- a localized tissue reaction to the earlier wound will temporarily distort the glucose reading of a second sample taken from the same immediate area.

Another problem, I'm told, can arise if you squeeze your finger too hard when you're trying to get a big enough sample of blood from a small wound -- apparently a hard squeeze will change the ratio of plasma to serum, or something like that, and throw off the results. (However, I have no idea how hard "too hard" is, so I don't know whether I am adhering to this guideline or not.)

Maybe the best we can do is to o be as consistent as we possibly can about the way we test -- so that our results, even if they are biased in a particular direction, will at least have the same bias, and can at least be meaningfully compared with one another.

I guess the other thing we can do is make sure we never pee an orange, as the Japanese researchers found that this pushes you from 90 to 170 in no time.

Thursday, February 10, 2011

Thank you, to those readers who sent me congratulations on the anniversary I wrote about yesterday. It's awfully easy, when you're doing this sort of writing, to feel as if you're just talking to yourself. If I can encourage even a handful of diabetes patients to do what everyone else is telling them they can't do, it will be worth the trouble. But it's nice to get confirmation that someone is paying attention!

It may be true that curiosity killed the cat, but I suspect that more human lives have been shortened by a lack of curiosity than by an excess of it. Diabetes patients, at least, can hardly afford to be incurious about the disease they are managing. 

It's never easy to understand why other people are bored by subjects you find fascinating, or vice versa. This is a challenge to the imagination which I am unable to meet; I can't picture what it would be like to find science boring. But I know that a lot of people do find it boring, and if they happen to have diabetes, this puts them into a rather difficult position. 

If you lack scientific curiosity, your attitude about diabetes management becomes "please don't bother me with these tedious technical details, and please don't expect me to conduct experiments on myself -- just tell me what I need to do". Well, what you need to do is become interested in the technical details, and become willing to conduct experiments. Those are basics, not frills. There is no shortcut to effective diabetes management which bypasses them. 

For some health problems, it may be possible for experts to give out a set of simple, non-technical instructions on how to deal with it, secure in the knowledge that these instructions are appropriate for everyone who has this particular problem. "Apply an ice pack to it for 15 minutes, four times a day, and take Ibuprofen in the adult dosage printed on the package; if it starts turning black call your doctor." That kind of thing. But is diabetes like that? I think not. 

To say that you have Type 2 diabetes does not describe your health situation very specifically. It indicates that your endocrine system is having some degree of difficulty in maintaining normal glycemic levels, through some combination of impaired insulin sensitivity and/or impaired insulin productivity, caused by some combination of factors, and probably accompanied by some combination of other health problems such as hypertension and dyslipidemia. To assume that everyone with Type 2 is in roughly the same situation, and will therefore benefit from the same recommendations, is to assume far too much.

But the scientifically incurious are inclined to assume exactly that. The questions that they post on the diabetes forums make it clear that they think their questions have simple, universally applicable answers. I'm talking about such hardy perennials as "How many grams of carbohydrate can I have in a meal?". It's like asking what size shoes you can wear; the answer is going to have to vary from person to person.

Too much advice about diabetes management boils down to a set of half-truths which may be applicable to somebody -- but probably not to you. These vague rules of thumb lead inevitably to people making horrifyingly risky assumptions (for example, that bread can't raise their blood sugar unduly if it's made from whole grains).

If you want to manage your diabetes effectively, despite the complexities and unknowns which make the disease vary from person to person (and from day to day for the same person), the last thing you need is a collection of simple, memorable rules of thumb. What you actually need are algorithms.

An algorithm is something generally used in mathematics and computer science -- it's a method of arriving at an answer by following a set of instruction steps. But it's a little more flexible than it sounds, because the series of instructions can branch off in different directions, depending on the answers to certain simple questions.  Algorithms are often created in the form of a flow chart, in which arrows connect the sequence of instructions.

The XKCD site provides this humorous example of an algorithm:

In this case the branching at "Does it taste good?" is treated as a joke, since either answer leads to the same next step. In a proper algorithm, you follow different paths depending on the answer.

Here is my (slightly) more serious algorithm for daily fasting glucose testing:

What I'm oversimplifying in this algorithm is the process by which you decide what you may have done wrong to get a bad result, or what may have done right to get a good result. Here is where your scientific curiosity needs to kick in: you need to be extremely aware of all the factors that can impact your blood sugar, and you must be willing to do enough systematic experimentation to find out what moves your results in the right direction and what moves your results in the wrong direction.

The beauty of this algorithm is that it leaves you enough flexibility to adapt to changing circumstances. The potential problem with this algorithm is that, if you don't have enough scientific curiosity to be fully engaged with the subject, you won't work hard enough at sorting out what you're doing wrong and what you're doing right. You'll just buy some whole-grain bread and call it a day.

Unfortunately, I don't know how to instill curiosity in people who don't have it by nature. But if you don't have it, I hope you'll work on developing some. It's a useful thing to have.

Today's lunchtime run ended up being an interesting experiment: I ran the exact same very hilly 4.6-mile route today that I ran yesterday, but with a different running partner.

My running buddy yesterday (who was out of town today) pulled so far ahead of me that I gave up trying to catch up to her, and simply ran at my own pace (which, on this route, turned out to be 10:23 per mile).

Today's running buddy (who was out of town yesterday) had contracted a bad cold last week, hadn't run since then, and still had a cough. He's usually very fast, but because he was in a weakened state today, I was actually able to keep up with him. This time my pace was 10:01 per mile.

Even though, yesterday, I was trying at first to keep up with someone running faster than that, I ran slower -- at least on average, because I slowed down after I gave up on keeping up with her.

Today, trying to keep up with someone who was running slower, I ran faster -- because I never gave up on keeping up with him. Not only that, today's run felt a little easier to me, even though I was going faster. It's amazing how powerful these psychological factors can be.

And if anyone out there is disappointed to learn how slow my running pace is on hilly terrain, allow me to point out that I never claimed to be a good runner -- I just do it a lot!

Wednesday, February 9, 2011

Special Feature

Ten years ago tonight I learned that I had diabetes. It seems like an appropriate occasion to look back on my first decade with the disease, and what has happened to me along the way. In doing so, I must overcome a considerable literary challenge: there is no story arc here, because most of what happened to me during those ten years (relevant to diabetes, anyway) happened very early on.

Essentially I experienced half a year of making dramatic changes in my life, followed by nine and a half years of trying to prevent any further changes from occurring.

I well remember coming home from work on a chilly Friday night ten years ago, feeling battered by the world in general.

Earlier that week I'd gone in for an annual physical exam, and although I was feeling better than I had been feeling six months earlier, now that I was being treated for my sleep apnea, my doctor was not at all satisfied with my state of health. He had been highly displeased to find that I was still gaining weight instead of losing it, and he was making grim predictions about the direction I was heading. "We're looking at a disaster here!", he had said. I don't remember all the health problems he'd predicted I would be experiencing soon, but diabetes was certainly on the list. And that conversation had not even been based on up-to-date lab results, which he didn't yet have at that point.

It hadn't been a good week in any other way, either, and I came home from work feeling tired and sorry for myself, and looking forward to the weekend mainly as a chance to curl up with a good book and hide from the wider world and the cruel demands it was making on me.

So now, as I came home, I looked into my darkened kitchen, I saw a red LED winking at me from a distance, and realized that I had a phone message. Without even turning on the lights, I went to sit by the answering machine and listen to the message in the dark. (I don't know why that detail has stayed with me so vividly -- that I listened to the message in the dark -- but it has.) The message, of course, was from my doctor, and listening to it in a dark room made it seem more spooky -- although it was already spooky enough.

He said, "Tom, I just got back your lab results, and your blood sugar is way too high. Last time it was 101, and this time it was 174! I want you to call the office and make an appointment with me as soon as possible, so that we can discuss the diet and exercise program you're going to be going on, unless you want to be dependent on diabetes drugs for the rest of your life."

He spoke these words very emphatically, no doubt in an effort to convey the seriousness of the issue, but in my weary and self-pitying state he sounded thoroughly exasperated with me, and perhaps a little disgusted. (And not without reason, if that indeed was the way he felt.)

My emotional response to this was perhaps more remarkable for what I didn't feel than for what I did. Most of the reactions to a diabetes diagnosis which others insist "we all go through" were not my reactions at all. I didn't become weepy or angry. I wasn't shocked, and I didn't disbelieve what I was hearing. I wasn't even epecially fearful; concern over what this new disease might do to my health was not uppermost in my mind.

What was uppermost in my mind was embarrassment. I felt completely ashamed of myself. I accepted without argument (and I still do, by the way) that this calamity had happened to me because I had allowed it to happen to me. My doctor had warned me that diabetes was a likely outcome if I didn't lose weight and start exercising, and I had not taken these corrective actions.

There was no way to claim that this was a shocking surprise, or that it "just happened" for no reason in particular. Nor was there any basis for moaning that this was "unfair". No disease is "fair", but there wasn't anything more unfair than usual about my developing a health problem which I probably could have prevented but didn't. (I'm not saying that the disease is preventable in everyone's case, but I believe, on the basis of compelling evidence, that it could have been prevented in mine.)

I realize that many people with Type 2 diabetes feel very strongly that the disease is never preventable, that it is purely genetic, that lifestyle plays no role in it, that having diabetes is never anyone's fault, and that it is inappropriate and counterproductive for diabetes patients to feel ashamed of having "let themselves become diabetic". I don't quite share this viewpoint; I believe that some people have the genetic deck stacked so heavily against them that diabetes becomes inevitable for them, no matter how they live their lives -- but I also think that many cases of diabetes could be prevented, that my case was one of them, and that my shame at having "let myself become diabetic" actually ended up being a useful motivator. Something needed to change, and if I hadn't felt so humiliated about my situation, I might not have changed it.

Well, that was an exciting weekend, all right, even though all of it was spent doing frantic internet research on diabetes. I wasn't trying to find out what my doctor could do about my diabetes, as I assumed he already had that pretty well figured out. What I wanted to know was what I could do about my diabetes. My chief motivation was to find something I could do to regain the initiative, and stop feeling so humiliated, weak, helpless, and stupid. I so dreaded the upcoming meeting with my doctor that I couldn't bear to go in there unprepared, having learned nothing and done nothing about my problem. I didn't want to go in there and say, "Okay, what am I supposed to do about this?". I wanted to develop a plan of action, start putting it into effect, and then go in to see my doctor and say "Okay, here's what I'm already doing about this. Is this a good plan? Is there anything else you want me to do about it?".

Basically, I wanted to regain my dignity. I suppose that, at some level, I also wanted to regain my health, and get control of my diabetes so that I wouldn't die from it or have to let a surgeon cut off any parts of me to save the rest of me. But (implausible as it may seem) the only thing I really felt strongly about was regaining my dignity. I wanted to get myself into a situation where I didn't have to be ashamed of the way I was living. I wanted to look like an example of good health, not an example of poor lifestyle choices.

Which was a tall order, because at the time I looked like this:

Well, we all have to start somewhere.

My weekend of researching diabetes was a bit disorienting, because opinions about how to treat the disease seemed to be wildly divergent. All of them could be summarized roughly as follows:

Everything you have been told about diabetes management is a pile of crap. The so-called "experts" will tell you (on the basis of flimsy evidence or none) that the proper way to control your blood sugar is [insert controversial regimen here], while the only approach that has been demonstrated to produce satisfactory results is [insert controversial regimen here].

Diet was the main point of contention. Everybody had their own formula for a "diabetic diet", and claimed that every rival formula was pathetically old-fashioned, dangerously radical, or the sinister invention of lobbyists for some industry or other.

Frustrated by the seeming impossibility of figuring out who was right about dietary issues, I focused on trying to figure out if there were any points about which there was general agreement. Was there anything which everyone agreed would be helpful?

It turned out that there were two things I could do which everyone seemed to think would help me: losing weight and exercising regularly. Okay, then! Those would be the things I would focus on.

Of course, if you're going to pursue the goal of losing weight, you'll have to make some kind of decision about diet. In theory, you could simply eat whatever food you've been eating lately, and eat considerably less of it, but I wanted a more specific plan than that. So, I settled (somewhat arbitrarily) on a low-fat vegetarian diet. A fairly high percentage of my calories were coming from carbohydrates, but my calorie count was so reduced that I may have ended up carb-cutting even so. Anyway, I started losing weight.

I also started exercising, and I hate to tell you how modest were the amounts of exercise which made me feel, at the time, as if I were shooting dice with sudden death. Fifteen minutes on the stair-climber at the gym seemed like a daredevil feat to me; it was hard to imagine that I would be able to handle any more than that anytime soon. But I kept at it, and tried to raise the ante very gradually -- after a while I amazed myself by surviving twenty minutes on the stair-climber.

After a few weeks of this program I bought a glucose meter, and my fasting tests were already down to the 130s.

So when I finally made it into my doctor's office to talk about my diabetes, I had a better story to tell my doctor than I'd ever had before. I was losing weight, I was improving my exercise endurance, and I was bringing my fasting results down. How could he help being impressed? He may have had doubts that I'd stick with the program, but he couldn't say I wasn't doing the right things. He did, however, sign me up for a class on diabetes management, and he predicted I would find that my carbohydrate-rich diet would need a bit of adjustment if I was really going to get things under control.

The class he sent me to used Gerald Reaven's book "Syndrome X" as a basic text. Reaven is the Stanford endocrinologist who identified the health isssue which, these days, is more commonly called "metabolic syndrome" -- insulin resistance and the other tag-along health problems which lead to Type 2 diabetes and coronary heart disease. His recommended diet was low in carbs and high in fat, though not as radical on either count as the Atkins diet and some other low-carb diets. I modified my diet accordingly, and found that although the added fat tended to slow down my weight loss, the reduced carbohydrate tended to improve my blood-sugar results.

Anyway, I kept on ratcheting up my exercise program (adding weight-training to the mix, on my doctor's suggestion), and after I'd lost a certain amount of weight I decided that exercise was something I could do outside the controlled and semi-private environment of the gym. I started running outdoors, and cycling with a friend of mine who was an enthusiast of long-distance cycling. The first ride with him was 20 miles, and I was stunned to think that I was capable of riding that far; I little imagined how much farther than that he was planning to push me over the next few years.

On June 9, 2001, exactly four months after my diagnosis, I went in for some lab-work to see what changes I had accomplished. And what dramatic changes they were:

HDL ("good") cholesterol remained low at 33, but my doctor said this value was largely determined by genetics. He doubted I could ever raise it any higher than 37, but wasn't worried about it because I had improved the other numbers dramatically. I should just keep doing what he was doing. He didn't mention anything about putting me on diabetes drugs.

In a sense, the story ends here, because nothing terribly dramatic happened after that. I kept doing what I was doing, but as time went on I did more of it.

I continued to lose weight and exercise. Eventually I started participating in organized exercise events. My cycling friend talked me into longer and longer bike rides (sometimes by means of lying to me about how long a particular ride would be). In 2002 he persuaded me to do a 72-mile ride around Lake Tahoe, and later that year he talked me into doing my first "century" (a 100-mile bike ride). I was to do several more of these over the next few years.

I also started participating in running events. I did my first 10K race (6.2 miles) on Thanksgiving morning of 2003, on Ocean Beach in San Francisco.  I was to do many more 10Ks, and later started doing longer trail-running events, such as this one on Angel Island in San Francisco Bay:

I also did a memorable bike ride on Catalina Island:

I started running at work during my lunch hour, as a lot of other people at work did. At first I did this by myself, fearing that I wouldn't be able to keep up with anyone else, but eventually I acquired running buddies and started running with them regularly. In 2005, one of these running buddies at work talked me into running my first marathon.

Although that first marathon didn't succeed in killing me, it was hard on me, and I felt a desire to prove that I could run it faster and with less pain. The three marathons I've run since then have not entirely succeeded in demonstrating that point -- particularly the 2009 Napa Marathon, which took place in miserably wet weather and was so not-fun that it seems to have put me off marathoning for now. But I'm still tempted, and might do another.

The thing is, after all this time I've spent exercising regularly, I still approach each workout with at least a little bit of dread. Is this going to make me feel awful, I wonder? Well, the first five minutes of it are always awful. But the rush of endorphins you get when you're exercising hard make you feel pretty great. If you doubt the effectiveness of endorphins as a mood-altering drug, all you have to do is compare pictures of me before and after a footrace:

Despite the predictions I've read, to the effect that lifestyle-based diabetes management works for a few years and then fails, my lab results since then have generally been better rather than worse.  My most recent results (in Sepetember of 2010) were as follows:

When my HDL finally started rising, after a couple of years, I asked my doctor why he thought it had gone higher than he'd predicted it would ever go for me; he said "When I predicted that I didn't realize you were going to exercise this much!". Throughout the last ten years I have consistently felt that exercise was more important to what I was doing than any other factor was.

I've experimented with different approaches to diet since then, with no obvious effect on my cholesterol readings, but with opposing impacts in two other areas: the high-fat, low-carb approach tends make glycemic control easier and weight control harder; it's the other way around with the low-fat, high-carb approach. I haven't yet found an ideal diet which helps me with both goals, but the search continues.

So what now? I have read that lifestyle-based diabetes management works for a maximum of ten years, so I guess I'm supposed to fail spectacularly at this point. (My doctor says that we don't have evidence of failure after ten years, we just haven't collected evidence of success after ten years.) I've heard from at least a few people who have managed to control their diabetes without medication for longer than ten years, so I'm going to move forward on the assumption that it can be done, and see what happens. That's been my approach all along, and it's worked so far, so I see no reason to change now.

I don't know what percentage of Type 2 diabetes patients could do what I've done and get equally satisfactory results (sometimes nature is pushing you too hard in the other direction), but I suspect that a lot of them could, and I also suspect that the reason they aren't doing it is that they're not getting enough encouragement. People have very low expectations of what they can achieve, largely because the experts seem to have the same low expectations. Who wants to work hard at something which they've heard won't work anyway?

It's largely because I think people need more encouragement that I set up this site in the first place. I don't necessarily want to set myself up as the example of what everyone else should do (in terms of diabetes management, what works for one person will not necessarily work for everyone else). But I do want to provide evidence that, if you ignore the prophets of doom and concentrate on doing whatever you can to improve your health, you just might succeed at it.

Tuesday, February 8, 2011

Well, that's an improvement -- 89 fasting. I can probably do better than that, though, and I hope I will tomorrow morning.

Dinner was pretty low-carb (a salad without a lot of starchy extras, and a piece of broiled halibut), so the low result afterward was not surprising.

When I went out running at lunchtime I found out that, although the weather was just as sunny as it had been during the spring-like weekend just past, it wasn't nearly as warm. There were some fierce gusts of wind that seemed to take your body temperature down ten degrees in an instant. I had a long-sleeve running-shirt on, but it didn't make any difference to the wind-chill effect. Still, in much of the country right now I'd need to wear a parka to go outside at all, so I should just be grateful that exercising outdoors instead of on a treadmill is a practical option for me. (I fear I will never learn to like treadmills.)

The Food and Drug Administration announced today that it has added 13 drugs to its "watch list" of drugs suspected of causing serious health problems. One of them is the diabetes drug Pioglitazone, better known in the U.S. as Actos. What health problem is Actos supsected of causing? I can tell you in one word: rhabdomyolysis. If you're taking Actos, watch out for any sign of rhabdomyolysis

What's that? You're not familiar with rhabdomyolysis? Well, it's the breakdown of muscle tissue, resulting in the release of muscle proteins (particularly myoglobin, illustrated below) into the bloodstream. The kidneys, which must filter out all that extra myoglobin, can be damaged if too much myoglobin is present. If you notice that protein molecules shaped like this are accumulating in your bloodstream, call you doctor immediately:

What's that? You need to know what symptoms to look for? Well, unfortunately, rhabdomyolysis is one of those conditions that produces a bunch of symptoms which could also be produced by many other conditions: soreness and weakness in muscles, nausea, confusion, irregular heartbeat, and coma. Rhabdomyolysis is typically caused simply by injury to muscle tissue in an accident (it is a pretty common problem among survivors of an earthquake or a bombing). But it can also be caused by chemical means, as in the case of addicts and users of prescription medications.

In 2008, Actos was the tenth-best selling drug in the U.S., with sales exceeding $2.4 billion. I believe we can count on one thing: the FDA will be under staggering pressure to take Actos off the watch-list and declare that it does not cause rhabdomyolysis. Maybe you'd better take a look at your own blood and find out if you can spot any myoglobin in there. (Warning: it probably isn't as conspicuously colorful in its wild state as it is in the illustration above, so be sure to look very, very carefully.)

Keeping your muscle tissue in a healthy (and well-used) state is a pretty crucial factor in diabetes management; if it turns out that Actos does, indeed, inflict chemical damage on muscle tissue, I hope I won't have to listen to people claiming that it's somehow "worth it".

I am often surprised by the willingness of people to ignore serious problems with diabetes drugs, in the very same areas where such drugs should be helping rather than hurting. Some diabetes drugs seem to increase, rather than decrease, your risk of having a heart attack -- but supposedly they are "worth it". Worth it how? The increased risk of a heart attack is the most serious of all diabetes "complications", and I can't see how any diabetes drug can be regarded as effective if it doesn't reduce that risk. How can a diabetes drug be worth it, if it doesn't help you in the area where you need help the most?

But I shouldn't even be raising such concerns. Drugs come to be regarded as "worth it" because they make a number on a lab report look better. Whether this actually results in improved health is nobody's business.

Monday, February 7, 2011

Whoops -- how did my fasting level get to 97 all of a sudden, after being in the 80s for several days in a row?

Actually, it's not hard to guess what happened. Sunday afternoon I went for an unusually long trail run (about 10 miles); then I went to a party, and arrived there feeling extremely hungry. The party food was very high-carb, but because of the long run I felt that my system could take the carbs, and even needed them. Not an entirely false notion, perhaps, but it looks as if I got carried away with the idea, and pushed things a little farther than was wise. Hydration may have played a role, too -- after a long run on an unseasonably warm day, I was probably a bit dehydrated, and that does tend to suppress insulin sensitivity. It all adds up to a higher fasting result today than I am comfortable with.

97 is still within the target range my doctor gave me, and it's even within the range usually called "normal" (though just barely), but I've chosen more ambitious goals for myself. I don't like to be above 90, and I really don't like to be above 95.

So, I decided to take a bit of corrective action today. After a pretty hard run at lunchtime, I had a light lunch (raw vegetables and some Marcona almonds). The result was that my post-prandial test was 92 -- five points lower than my fasting result had been this morning!

I think it's likelier than not that my fasting test will be lower tomorrow. But if it isn't, I'll just have to keep working at it.

After very nearly a decade with diabetes (Wednesday will be the 10th anniversary of my diagnosis), this is still the way things are for me:

  1. I cruise along thinking I'm doing fine.
  2. I get complacent about my apparent ability to get away with just about anything.
  3. Suddenly my test results start heading in a bad direction.
  4. I have a moment of panic ("I'm losing control, just like the experts said I would!").
  5. Roused from my complacency, I take corrective action.
  6. Things get back on track.
  7. The whole cycle repeats.

Actually, that's how it is for everyone with diabetes, except that a lot of people seem to skip Step 5. I'm not saying that's always the reason people lose glycemic control and can't get it back (sometimes nature is stronger than we are), but I get the impression, from what I read on postings on the diabetes forums, that a lot of people are following a very different cycle:

  1. My results are bad.
  2. They get worse.
  3. I wonder what my doctor should be doing about this.

Sometimes, of course, people get stuck in that version of the cycle through no fault of their own, and I suppose that someday I will, too (probably when my hips or knees give out and I can't exercise anymore, but who knows what the last straw might turn out to be?).

Still, though, I think huge numbers of diabetes patients are throwing in the towel much too soon. Your diabetes is never going to be controlled as well by your doctor as it can be controlled by you.

Here's how I see it: your blood sugar can be managed by a doctor about as well as the landing of an aircraft can be managed by a traffic controller issuing instructions over the radio to a terrified passenger who is filling in for a pilot who died during the flight. Maybe it will work out, but do you think it will work out as well as it would have if the pilot were landing his own airplane? There are limits to what can be achieved by someone issuing instructions from a distance; things go a lot better if the person who's actually on the scene is able to act on his own initiative. So, if there's still a possibility that you can fly this plane yourself, it's too early to give up and hand the problem over to the control tower. 

If a sports fan is someone who manifests his interest in athletic activity by gazing at it from a seated position, than I'm not a sports fan. For me, therefore, Superbowl Sunday is not quite the earthshaking event that it has become for many people. Even if it were, I think I would have been tempted by the ridiculously fine weather on the weekend to spend Sunday afternoon enjoying the great outdoors. I suspected others might feel the same way, so when I went trail-running on Sunday, I wasn't surprised to find that there were plenty of other people out there with me.

On Saturday the temperature reached 80 degrees -- not your usual February weather, even in this neck of the woods. On Sunday, it reached 81. There's got to be something wrong with your personality if that kind of winter weather doesn't give you at least a slight urge to get outdoors and move around a little.

There were plenty of people hiking, running, and mountain-biking in the state park.

Things did not change markedly as game time came and went. There were still plenty of people out on the trails, soaking up the sunshine, after the game was under way.

There's something about exercising outdoors in beautiful weather -- it makes you feel as if you can rise to any challenge.

I didn't feel particularly robust when I started, but I felt better and better as I went along, and instead of choosing a comparatively short route through the park (maybe 6 miles) I chose a longer one (nearly 10 miles). It looked to me as if other people were feeling the same way.

The party I went to larter on Sunday was not a Superbowl party -- it was actually a gathering of musician friends who were interested in doing something else. So, instead of staring at a TV screen showing remote images of people we didn't know playing a game, we sat in a room with people we did know playing music. Seemingly a healthier arrangement altogether. The hitch was that the foods you eat at a non-Superbowl party are just as high-carb as the foods you eat at a Superbowl party.

Thursday, February 3, 2011

Is worrying useful? Generally not. Is it avoidable? Generally not. Hence our dilemma.

Those who have been diagnosed with diabetes tend to spend a lot of time worrying about the bad things that can happen to a person as a result of having this disease. But that doesn't exactly put diabetes patients in a unique situation, does it? Aren't all the other members of the human race worrying about their health, too?

From what I've read in the diabetes forums, it seems as if a lot of diabetes patients feel that their situation is unique. People who don't have diabetes have nothing to worry about. They're not at risk for anything -- while diabetes patients are at risk for everything.  Ah, the tragic unfairness of it all!

At least, that's the impression they give. Their worrying seems to be tinged with resentment: why should they have to worry, when everyone else's life is worry-free? It's as if they could live with the health risks associated with diabetes, so long as they knew the entire population faced the same risks. The upsetting thing is that most people don't face those risks. It just ain't right!

I don't see it that way. It's not as if non-diabetic people have no reason to fear that anything will go wrong with their health. Being non-diabetic does not confer immortality on anyone. There's a lot of health data suggesting that, diabetic or not, everybody has health problems, and everybody dies. Here's part of a classic article from The Onion explaining that:

There's no reason to compound your anxiety about your health with anger, on the assumption that you're being singled out, and nobody's scared but you. Trust me, non-diabetic people have their own fears to deal with.

The health problems that are caused by diabetes are, for the most part, the same sort of degenerative health problems that can happen to anyone who lives long enough. It's just that diabetes increases the risk that those problems will develop when you're 50 instead of 80. That is why diabetes is sometimes described as a kind of accelerated aging: it intensifies the wear and tear on body tissues which would be occurring anyway. (But how much does it intensify this wear and tear? Not much, if you can control your diabetes well enough.)

When we think of certain disorders (such as retinopathy, kidney disease, and coronary heart disease) as "complications of diabetes", we begin to assume that non-diabetic people have zero risk of developing such problems. This is not the case. Non-diabetic people face a lower risk, not no risk. In the case of coronary heart disease (which is, after all, the most important of the "complications"), some non-diabetic people face quite a high risk. It's true that coronary heart disease is the leading cause of death for people with diabetes -- but it happens to be the leading cause of death for people without diabetes, too.

Being diabetic increases the risk of heart disease, all other things being equal. But that just means you shouldn't allow all other things to remain equal. Diabetes is actually one of the smaller risk factors for heart disease, and the larger risk factors are things that can be remedied. Get in shape, get your lipids and blood pressure under control, and stay away from tobacco, and you will probably have done enough to level the playing field (or even to tilt it to your advantage).

Certainly diabetes is a huge challenge to your health, but at least it's a challenge you can do something about. That isn't the case with a lot of diseases. A cancer patient who does everything right is probably not going to get nearly as large a benefit from it as a diabetes patient who does everything right. I don't know of any disease besides diabetes in which the patient has so much control over events.

Not that a diabetes patient, or any other sort of patient, has total control over events. We do the best we can, and we wait to find out how well it worked. It might not have worked quite as well as we had hoped, but it probably worked a lot better than inaction would have.

And it seems to me that anything we are doing about diabetes is better than sitting around worrying about diabetes. Worry is an extremely unproductive (even counterproductive) mental activity. Whatever mental energy you are putting into worrying about the situation would be better invested in figuring out if there's something more you could be doing about the situation.

Of course, it's easy to say "stop worrying", and difficult to do it. The tendency to worry seems to be hard-wired into us, and the mere fact that we've come to recognize that worry is unhelpful and depressing doesn't necessarily help us get out of the habit. It seems as if we always need to be worrying about something.

Well, maybe I've found a solution to that problem. Go ahead and worry -- but worry about something stupid. Worry about something that doesn't matter. Worry about something which (1) you won't be able to do anything about if it happens, and (2) won't happen.

I didn't invent this solution, of course. Plenty of other people found it before me: those people (in every era) who think the end of the world is fast approaching. This sort of thing has been going on for a mightly long time; countless dates in the historical past were predicted to mark the end of the world, and for each date a cult formed and prepared itself for the end. Then the end didn't come. To the extent that anyone truly believes this kind of thing, I assume it is mainly escapism ("I've made a terrible mess of my life, but it doesn't matter! I don't have to face up to any of it, because the world's ending next month!"). But it also seems likely to me that a lot of people who can't get out of the habit of worrying may simply be choosing the elegant solution of continuing to worry, but worrying about the silliest issue available.

Thus we have the people who say the world will end on December 21, 2012, because the Mayan "long count" calendar ends on that date. It almost goes without saying that this idea is breathtaking in its stupidity:

All in all, it's a perfect doomsday scenario: it's all very theatrical and exciting, and it's also untrue.

So, if you can't stop worrying about diabetes, my advice is to start worrying about the end of the world on December 21, 2012. That will keep your brain's worry center busy for almost two more years. (And then, when that date arrives and nothing happens, you can latch onto another doomsday scenario -- there is never a shortage of them.)

I don't mean that you should divert your attention entirely from diabetes, of course. But when you think about diabetes, try to engage the part of your brain that is more interested in doing something about the situation than agonizing over the situation.

Wednesday, February 2, 2011

Here's a secret: it doesn't have to be all diabetes, all the time. Not that you can just forget you have diabetes and stop dealing with it, of course -- but you can find ways to take care of your diabetes and do fun things as well. Diabetes is like a job: it demands a lot of your time and effort, but you don't have to be at work all the time. Provided you've done what you were supposed to do about your diabetes today, you can probably pursue other interests as well, and maybe even have some spontaneous fun.

Today I wasn't able to go running at lunchtime, so I needed to do a gym workout in the evening. But an opportunity to do something else arose. A musician friend of mine, who works with me now since he was transferred from Scotland to California, is also an old friend of Mike Katz, who plays the highland bagpipes with the Battlefield Band, a Scottish traditional group:

The band is touring California right now; they had no concert tonight, and they were relaxing here in the wine country today. My friend arranged for the two of us to meet up with the band members and have a little jam session with them in a local pub. If you play Scottish music, as I do, this is not the sort of opportunity that you pass up, regardless of what else is going on.

However, I wasn't just going to go without exercise today just because I had something else to do. On the way to the pub I stopped at the gym (I've just realized how "on the way to the pub I stopped at the gym" sounds, but I'm not changing it), and I managed to fit in a hellish 4-miler on the treadmill and still have enough time for a shower and dinner before going to the pub. That's how dedicated I am, you see. I don't know why running on a treadmill is so much harder on me than running outdoors, but it is, and I felt like I was making a major sacrifice to do this. But having made that sacrifice, I felt very much entitled to go do something fun.

And fun it certainly was. These are really terrific musicians. Mike Katz plays the pipes, but also plays quieter instruments when the fiddlers are playing.

Actually, all of them play the bagpipes, and proved it at least once over the course of the evening, but Ewen Henderson mainly plays fiddle... does Alasdair White.

Here's a video of them playing together, just to give you some idea of what kind of players I was being allowed to sit in with tonight.

Their guitarist, Sean O'Donnell, also happens to be an accomplished billiard player, so he spent more time at the pool table than at the session table, and I didn't capture a photo of him. But someone there did use my camera to capture some photos of me playing in the session.

Not that I can actually play at their level of musicianship, but they were nice to me and I gave it my best shot.

The pub patrons gave us all a warm reception, and when we played a set of waltzes, some of them got up and danced to it, which is always a nice thing to see. Nearly all of the repertoire is dance music, even if most people today don't know the dances, so it's nice to see a bit of spontaneous dancing take place.

And no, I didn't have as much to drink as you are guessing from looking at all those pints on the table. No worries about being able to drive home safely.

Tuesday, February 1, 2011

That's funny: 135 after dinner, when the exact same dinner has resulted in a much lower number in the past. Why the difference?

Well, if we knew the answer to that, diabetes would not be the ever-fascinating mystery that it is, now would it? Just think how bored we might get, if we always understood what was going on.

Next week I will be celebrating the ten-year anniversary of my diabetes diagnosis. Perhaps "celebrating" is not quite the word I'm looking for here, but it's not as inappropriate a word as it could have been, if things had worked out badly for me than they have.

Milestones are always a good opportunity for a progress check, so next week I'll be reflecting on where I am and where I've been -- and also on where I would be, if the doomsayers had been right in their predictions.

Being a technical writer by profession, I am painfully aware of how difficult it can be to express an idea (even a simple idea) unambiguously. Unless you are very careful, anything you say is likely to have two or more possible meanings. And most people are not even slightly careful about that sort of thing.

The people who are least careful about that sort of thing, oddly enough, tend to be people with a lot of technical knowledge. They have a strong tendency to express themselves in language which is subject to multiple interpretations. They assume that their intended meaning is obvious -- no one could think they meant anything else. They also assume that any details they omit can easily be guessed at by others. Such assumptions are, of course, not warranted. (My theory about why they do this is that technical people operate by considering many ideas and then firmly rejecting the wrong ones. For them, a rejected idea has ceased to exist; therefore it isn't necessary to distinguish wrong ideas from the right idea.)

So -- if you tell people to test their blood sugar an hour after a meal, what exactly do you mean?

Let's say I start eating lunch at 12:00 and I finish eating lunch at 12:15. Do I test at 1:00? At 1:15? At 1:07:30? When does the clock start running?

For a long time I assumed that "1 hour after a meal" means "1 hour after you finish a meal". My reasoning was straightforward: words have meanings, and the meaning of "after" is not "during". Therefore, if a one-hour time period is supposed to intervene between a meal and a test, all 60 minutes of that hour are supposed to occur subsequent to the meal. If you start the clock on that hour at 12:00 instead of 12:15, then 25% of that hour elapses during the meal, not after the meal.

But a lot of people (some of them doctors), who are perhaps newcomers to the English language, think that "after a meal" means "after the point at which you hadn't yet started that meal". Their conception seems to be that a meal occupies a single instant in time, and when the firsk forkful reaches your mouth, that instant is over. Not everyone thinks that way, of course. (At least I hope not. I'd hate to think that no one understands English.) So it's important to know what, exactly, people have in mind when they use the seemingly simple phrase "after a meal".

Unfortunately, when doctors and scientists talk about post-prandial glucose tests, they usually give no hint as to when they think the clock starts. The paper on glucose profiles which I was discussing yesterday gives considerable attention to the elapsed time before a glucose peak occurs, but I am completely unable to figure out when they think the clock started on that elapsed time. So, the data which they have gathered so carefuly ends up being meaningless, except for its comparative value (the meals in which carb calories were a higher percentage of total calories tended to produce an earlier peak).

Fortunately for me, I'm such an impatient eater that it probably doesn't make that big a difference when the stopwatch begins ticking. But some people eat slowly. I suspect that eating slowly is not an extremely common trait among diabetes patients, but there must be some diabetes patients who eat slowly, and they need to be given a clearer idea of what they're supposed to be doing when it comes to post-prandial testing. 

And now, chaning the subject just slightly, here's some practical wisdom about endocinology from SMBC:

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