Monday, January 31, 2011

When I started exercising regularly (after the diabetes diagnosis), and discovered that I enjoyed outdoor exercise a great deal more than I enjoyed the indoor equivalent, I began to be much more interested in the weather than I ever had been before. These days, I often plan my weekends around whatever the weather forecasters are predicting. This doesn't always work out, of course.

This past weekend, the forecast was for good weather on Saturday and stormy weather on Sunday. Although the weather was actually gray and drizzly on Saturday, I figured I'd better do my long run then, because it was only going to get worse on Sunday. So, I did a 7.8-mile trail on Saturday, figuring the light rain was better than the thunderstorm I'd encounter if I waited till Sunday.

But the heavy rain all happened on Saturday night -- and on Sunday the clouds parted...

Everyone in town, it seemed, headed down to the park for a little outdoor activity in the sunshine.

There may have been a few people (and dogs) who stayed home, but not many.

Call me sentimental, but I find it heart-warming, encouraging, inspiring (choose any two adjectives) to see large numbers of people moving around outdoors under their own power, enjoying the fresh air and the sunshine and the world around them.

I had only left myself time for a short run Sunday, but I did my best to enjoy it while it lasted.

Today the weather was even nicer -- nothing but blue skies and nice, cool oxygen.

Today's blood pressure reading isn't the lowest I've ever reported here, but today's resting pulse probably is. 39! I don't know how to account for that. I did go to yoga class tonight, but it doesn't always have that kind of effect on me.

Last week I was talking about a study of glucose profiles in non-diabetic people. One of the findings in that study which surprised me a little had to do with average time between a meal and the resulting glucose peak. The test subjects often reached a post-prandial glucose peak in 45 to 50 minutes rather than an hour.

This seemed surprisingly early to me. I have always claimed (based on limited data, I admit) that my own peaks tend to occur 1 hour after a meal. Certainly I am higher after 1 hour than after 2 hours (I have enough data to say that much with confidence), but is my peak truly at the 1-hour point, or does it happen slightly earlier than that?

Given the cost of test strips, I haven't been doing a lot of minute-by-minute testing to get an exact time figure. You'd have to sacrifice a lot of test strips on one meal (and then do it again on several more meals) before you could say that you had truly figured this out. Variations in test-strip accuracy, variations in meals, and variations in your physiological responses add so much random noise to the results that you have to average out a lot of tests to see a pattern emerge clearly. I haven't done all that. A few times I have done tests at intervals after the same meal, to get a rough idea of how my glucose rose and fell over time, but as the results didn't seem to be contradicting my impression that I peaked in 1 hour, I didn't try to arrive at a more precise figure. Was I wrong about this? Was I peaking earlier without knowing it?

Then I took a second look at the data in the study. Only for certain kinds of meals did the test subjects have a peak that arrived more than 5 minutes before the 1-hour point. For the "controlled" meals in the study, the carbohydrate content was always 50 grams, but the amount of protein and fat varied. The only one of the meals that produced a significantly early peak (43 minutes!) was a breakfast which consisted only of rice pudding. The other meals, which balanced the carbs with protein and fat, produced peaks in the range of 55 to 59 minutes.

However, in the "free-choice" meals, where the subjects ate whatever they wanted without having to give a report on it, the peaks frequently occurred in the 45-to-50 minute range. The most reasonable interpretation, or so it seems to me, is that meals dominated by carbs tend produce an earlier peak, and that the test subjects tended (when they were allowed to eat whatever they wanted) to eat meals in which carbs predominated.

Today I put this theory to the test. After lunch, I tested twice, at 45 minutes and 60 minutes. It was an unusual lunch: in an effort to reverse my recent weight-gain, I put together a lunch which consisted mainly of vegetables (broccoli, carrots, cauliflower, cherry tomatoes), plus some blueberries and almonds. This wasn't a big, high-calorie meal, but (apart from the fat in the almonds) it was dominated by carbs. Probably that is why I was able to detect an early peak: my glucose meter read 107 at 45 minutes, but only 96 at 60 minutes.

Neither of those readings is high, I'm pleased to note, but there's no question that 107 is higher than 96. Admittedly, the variability of my glucose meter could account for some of that difference (or even all of it). In any case, I suspect that the peak wouldn't have arrived early if I hadn't added those blueberries to the mix.

Not that I ate a huge serving of blueberries, I hasten to add. This was a modest lunch. Serving sizes matter: if I had eaten the same foods, but in much large quantities, I would probably have seen a much higher glucose peak.

Of course, it also helped that I had just run four miles. The meal after a workout is the one where I can get away with the most.

Friday, January 28, 2011

No blogging for me today -- I'm going out of town, to help celebrate the 84th birthday of someone whose longevity genes I hope I inherited.

Thursday, January 27, 2011

Just before I left the locker room at work to go running today, someone told me that a mountain lion had been spotted in the neighborhood the day before. It was lurking around the elementary school next door (the same school which I run past every day, on my way out the back gate). I guess if I were a mountain lion I'd lurk there, too.

I decided to go out for the run anyway. School was in session, so I figured I didn't need to run faster than a mountain lion, I just had to run faster than the first-graders. It all worked out.

But maybe that's why my blood pressure is up tonight.

Diabetes patients seeking to achieve normal blood glucose levels are often blocked by a surprising obstacle: the difficulty of finding out what "normal" means in this context.

The concentration of glucose in human blood fluctuates constantly, in response to many factors which we know about (and, very likely, a few other factors which we don't know about).  This volatility is not, in itself, an indication of diabetes -- healthy, non-diabetic people experience it every day.

Because BG is not a fixed quantity even in the healthiest individuals, defining "normal" BG is tricky. You can't just pick a number and say "normal BG is 88 -- everyone should be at 88 all the time", because no one is at 88 all the time, and there's no point in creating a definition of "normal" which classifies the entire population as abnormal.

It might seem as if one could solve the problem quite simply by stating a range of values, and declaring that everyone should be somewhere within that range all the time. But this doesn't work, either. Is a reading of 117 in the normal range? Well, yes and no. If you just ate breakfast, 117 is normal. If you're just about to eat breakfast, 117 is high. 

At least the fluctuation of blood glucose in non-diabetic people does exhibit certain standard patterns. People begin the day with a comparatively low blood glucose level, and after that, each meal triggers a rapid increase -- followed by a somewhat slower decline. During the night's long period of sleep (with no food intake), the glucose level drops to the low level at which the next day begins.

This kind of vague, non-quantitative description gives us no standard against which to judge our success or failure at glycemic control. Obviously there is a practical need for a definition of "normal" which can be expressed in simple numbers (and can be remembered by patients). Doctors have done their best to oblige.

When I was diagnosed in 2001, I was told that I should aim to keep my fasting tests under 110 and my one-hour post-prandial tests under 150. (A lot of people these days are told that their post-prandial tests should be taken after two hours rather than one, and that they should keep the value under 140 rather than 150.) My doctor said that these were "hard targets" but I should do my best to hit them.

For a long time I assumed that these targets represented "normal" blood glucose levels; that is, healthy non-diabetic people might routinely get a fasting result of 109 or a post-prandial result of 149, and it wasn't a sign of trouble brewing, it was simply normal. However, as I read more about diabetes, I began to get the impression that my target values might not be "normal" values -- that they might merely be "not-bad-for-a-diabetes-patient" values. So I started to become increasingly curious to know what "normal" really looked like. If you monitored the blood glucose of a healthy non-diabetic person as it rose and fell over the course of a day, what sort of results would you see?

It seems little enough to ask, doesn't it? Surely this information was known, and it should be easy enough for me to find it. One would think a graph of a normal blood-glucose profile would be the most common illustration you would find in almost anything written about diabetes. And yet I found it puzzlingly difficult to find this kind of graph -- or if I did find it, the author presenting the information would be maddeningly vague about whether the graph as shown defined normalcy or was simply an example of what was observed in one patient -- perhaps a diabetes patient.

Perhaps the reason I wasn't finding that kind of graph is that it's difficult to collect enough data to generate that kind of graph. However, the recent tecnological improvements in CGM (continuous glucose monitoring) have made it easier to do studies in which a comparatively large number of people are monitored constantly, and an average glucose profile is built up from the data collected. Unfortunately for my purposes, such studies are usually done on diabetes patients (to study the impact of therapies). However, there has been some work done on establishing what "normal" is. An example of that kind of study is described in a PubMed paper entitled Continuous Glucose Profiles in Healthy Subjects under Everyday Life Conditions and after Different Meals.

This is a study of 24 healthy individuals (12 male and 12 female), with an average age of 27. They wore CGM devices to monitor their blood glucose over a five-day period. For two of those days, the test subjects were in an institutional environent and ate breakfasts and lunches prepared for them (the prepared meals all included 50 grams of carbohydrate, although the protein and fat content varied), and they ate a free-choice dinner from a buffet. The subjects later spent two days on their own, eating whatever they wanted to under real-life conditions.

So what did their glucose profiles look like? Well, we have to begin by acknowledging that individual variation was substantial. For example, here's a comparison between two individuals. (This graph shows how they compare on one of the "real-life" days of the study, so they weren't eating the same kind of foods, and can't be expected to have the same peak levels.) In general, they both tend to rise to a level somewhere between 110 and 130 after meals, and they tend to drop to about 80 aftewards.

Note that it isn't possible to carry the generalizations any further than that. One isn't consistently higher than the other. "Subject 19" goes about 20 points higher after breakfast, "Subject 3" goes about 20 points higher after lunch, and the subjects both hit the same peak (about 125) after dinner. "19" seems to take longer to settle down after breakfast and lunch, but settles faster after dinner and has a lower fasting level.

What happens if we take an average of all subjects? The darkest trace on the graph shows the average value of all subjects, while the traces above and below it show the average of subjects with unusually high results and subjects with unusually low results.

It's surprising how much variation there is here, given that these are young, healthy, non-diabetic people. It would be interesting to find out (though I don't expect to) whether the subjects that are in the higher range have a higher risk of diabetes or other problems later in life. But let me zoom in on that graph a little bit, and place yellow bars on the peaks and valleys of overall average only.

If we focus on the overall average (the dark trace), we find that post-prandial peak values are in the range of 110 to 125, and that these peaks fall below 100 relatively rapidly (in about an hour, at least for breakfast and lunch). They then decline, more slowly, to a level of about 80. During the night, they stay near 80 the whole time. So there's your description of what "normal" means -- assuming, of course, that you are willing to go with the assumption that the overall average in this study should be our definition of normalcy!

What if you're not willing to go with that assumption? The people with higher results went higher than 140 after lunch, and higher than 150 after breakfast and dinner! Is it okay if we call that "normal"? On the other hand, the people with the lower results were in the 80-90 range after meals. Should we call that "normal", just to give ourselves something to strive for?

I'm going to step in and make a judgment call here. The overall average values -- with fasting results near 80 and post-prandial peaks below 125 -- are hereby officially declared to be the definition of normal blood glucose. Why am I choosing that as the definition of normalcy? Simple: because my test results today were normal by those standards. I'm nothing if not rigorously scientific.

The same study includes a lot of other data which I don't have time to explore here, but here's an illustration that shows another way to look at the results. Instead of asking what high and low values the subjects hit, we could ask how much time they spent in particular ranges...

So there's food for thought! Regardless of how high the subjects' results were at maximum, on average they spent 80% of their time at 100 or less. They only spent about 20% of their time in the 100-140 range, and they spent almost none of their time above 140. So, we don't just have to think about how high we go -- we also have to think about how long we stay there.

Wednesday, January 26, 2011

Not bad glucose results today, after whatever was going on last night.

Today I was back on my usual schedule, with a run at lunchtime -- and in this case it was an exceptionally long and hilly run. My lunch afterwards was probably a little higher in carbs than the dinner which, last night, resulted in a post-prandial result of 138, but nevertheless the result this time was 30 points lower. Dinner last night followed no workout, and lunch today followed a very intense workout; whether that is enough to account for the difference, I don't know. But I also felt better today than I did last night, and presumably that is a factor, somehow or other.

Day-to-day variations in glucose are often mysterious; we need to focus on the long-term trends instead, which is easy to say and tough to do. I tell other people never to stress out about one unexpected result, but I stress out about an unexpected result whenever I get one myself. Various explanations of this quirk of mine are possible, but "hypocrisy" seems like the simplest and best.

I'm told that a lot of diabetes patients are upset by the ignorant remarks people make to them about diabetes. Before I carry this discussion even an inch further than that, I would like to pause and acknowledge that people make annoyingly stupid remarks to everyone about everything.

We can all be categorized in various ways (according to our occupation, ethnicity, political or religious views, and so on), and anyone who meets us and is struggling to carry on a conversation with us is pretty sure to make some dopey remark or other, based on their assumptions about people in our category. People may not make the same dopey remark to a schoolteacher that they make to a Navy lieutenant, but it's a safe bet that both schoolteachers and Navy lieutenants hear certain dopey remarks often, and are probably growing weary of them. No one is safe from this kind of thing.

Suppose you are an Irish catholic cop, and you're tired of being reminded that people make foolish assumptions about Irish people, and catholics, and cops. Does this mean that annoyances of that sort would not arise for you, if you were a Jewish professor of physics (because, after all, nobody has any mistaken ideas about Jews, or professors, or physics)? No, it does not.

Not one of us is so nondescript that people can't place us in some category, and then make uninformed comments about people in that category. Merely being male or female is enough to lead some people to assume they already know your strengths, weaknesses, preferences, and willingness to ask for directions.

Getting back to ignorant remarks about diabetes, I think we should not find it surprising that ignorant remarks are often heard on this subject, given that diabetes is a difficult, highly specialized, almost arcane subject... and yet it is also perceived to be an "issue" of general public interest. Few people know much about the subject, yet everyone feels that the subject is relevant to them as members of society. It's an extraordinary situation, really.

If it were thought that all of society somehow had a stake in the subject of diatonic harmony, and countless news stories were giving out dumbed-down explanations of what diatonic harmony is, musicians would have to resign themselves to hearing a great many dumb remarks on that subject. Fortunately or unfortunately, nobody thinks that diatonic harmony is an "issue" which public policy needs to address, and which citizens need to know about. However, these days everyone thinks diabetes is an "issue" (because of concerns about the growing financial burden of diabetes on society), so we're all supposed to have political opinions about the problem and what should be done about it. And political opinions need to be based on information (preferably false information, but information of some kind). Hence all the news stories explaining (usually in an over-generalized and misleading way) what diabetes is and what causes it. If all this did not result in people making ignorant remarks about diabetes, it would be a miracle.

Interestingly, there seems to be a schism between Type 1 and Type 2 diabetes patients; they're both upset about the ignorant remarks they hear, but for slightly different reasons.

Type 1 patients are upset by the assumption that they have the far more common Type 2 -- or that whatever people have heard about Type 2 is applicable to all cases of diabetes. Some Type 1 patients are so unhappy about being confused with Type 2 patients that they want Type 1 to be given a different name that makes it seem unrelated to Type 2. 

Type 2 patients, on the other hand, are upset by the unfairness of certain assumptions made about them -- and are also offended by the efforts of Type 1 patients to distance themselves from Type 2 patients.

Other resentments enter into this. Because Type 1 is inherently more unstable than Type 2, and is therefore harder to manage, some Type 1 patients feel that Type 2 patients have it easy, and are spoiled children who don't have a clue how lucky they are or how challenging "real" diabetes can be. Also, because Type 1 is rarer than Type 2, patients with Type 1 feel that their disease is "invisible" and that research into it is underfunded.

But the thing that really upsets people is the "blame" issue. The general public's notion of diabetes is as follows: people become diabetic because they ate too much sugar (or too much of something, anyway) and got fat as a result, and this made them diabetic. Type 1 patients protest, "But that's only true of of Type 2 patients, who have a lifestyle disease!", and Type 2 patients protest, "But that's not true of anyone-- diaabetes is a genetic disease rather than a lifestyle disease!".

Well, it's certainly valid to say that Type 1 diabetes is not a "lifestyle disease". It's an autoimmune disease, meaning that it develops when a genetically-determined hypersensitivity of the immune system results in a damaging over-reaction to some environmental stimulus. (The stimulus, in the case of Type 1, may be a virus, but nobody knows.) Anyway, the over-reaction destroys insulin-producing cells in the pancreas. If your genes make you vulnerable to this development, then it's going to happen sooner or later, and there's nothing you can do to prevent it. Exercise all you like, stay as thin as a supermodel -- it still doesn't make any difference. If that immunological reaction is going to happen, it's going to happen (usually before your 25th birthday, though some people manage to avoid it longer than that).

Then there's Type 2. Because Type 2 diabetes has a genetic component (it definitely runs in families, and the diabetes rates are much higher in some ethnic populations than others), many Type 2 patients would say it's wrong to link the disease with lifestyle, and particularly with obesity. They point out (often quite heatedly) that people occasionally develop Type 2 despite being slender and athletic -- which, if we are to believe everything we hear, means that lifestyle has nothing to do with diabetes.

To me, that argument seems equivalent to arguing that, if some people drown in the bathtub without ever having visited the ocean, it means that the ocean and drownings are unconnected with one another. Really? Maybe it would be more accurate to say that certain factors raise the risk of drowning, and that swimming in the ocean is one of those factors -- a fact which remains true no matter how many swimmers have gone in the ocean without drowning, and no matter how many people have drowned without going in the ocean. 

The usual conception of a simple, one-way relationship between obesity and diabetes (that is, someone gets fat, and this makes him diabetic -- which means that his disease is his own damn fault) is certainly oversimplified. Insulin resistance seems to interfere with appetite control, in such a way as to make people constantly hungry -- which means that obesity could be a result of diabetes rather than a cause of it. The scenario might be that, instead of getting fat and then becoming diabetic as a result, people develop diabetes (or an underlying problem which triggers diabetes) and then gain weight as a result. It might be that way, but that doesn't mean it necessarily is that way. If obesity plays no role in causing diabetes, then losing weight shouldn't alleviate diabetes -- but it does, so maybe obesity really does play a role in causing diabetes. I can accept a claim that the interaction between obesity and diabetes is complex and confusing, but to claim that diabetes causes obesity, and can't be caused by it, seems to me more like wishful thinking than a reasonable interpretation of what we know.

The usual public-health message about preventing diabetes by avoiding obesity probably does encourage a simple-minded blame-the-victim mentality. However, I'm not sure the basic premise is entirely wrong. Maybe we could prevent a lot of diabetes cases by avoiding obesity -- even though avoiding obesity may be a great deal harder for some people than others, for reasons which aren't entirely their fault.

What puzzles me about this whole issue is that I don't seem to run into a lot of trouble with the blaming-and-shaming tendency which other diabetes patients resent so bitterly. Why don't I? There could be a lot of possible reasons. One is that I don't have to spend as much time around stupid people as some diabetes patients are obliged to do. (My job and my hobby interests both result in my associating primarily with the non-stupid.) Another possible reason is that I'm not visibly unhealthy, and many people around me don't realize I have diabetes, therefore I don't get a lot of unsolicited inputs on the subject. Another possible reason is that people who notice how much I exercise are intimidated by this, and don't venture to offer me health advice for that reason.

But still another explanation is possible! Maybe I don't take personally, or even notice, whatever blaming-and-shaming activity is in the air around me, because I'm just not that insecure about the issue.

I'm not especially defensive about my diabetes. I accepted, years ago, that I developed diabetes because I recklessly allowed that to happen to me. And so what? I don't feel guilty about it. I feel embarrassed about it, on those infrequent occasions when I think about it, but not guilty. I didn't quite know what I was getting into; I lost control of my health, without fully understanding how serious the consequences could be, or how soon those consequences could arrive. But once they did arrive, I accepted the new situation for what it was, and moved on from there. I skipped the denial-and-anger phase which, supposedly, every diabetes patient goes through (and which some diabetes patients seem to get mired in for years). My focus was on improving the situation, not on complaining about the unfairness of it. (Maybe it helped that I never had any expectation of life being fair -- it must be hard to be one of the people who do expect that!)

Of course, if my attempts to improve the situation had failed, I might very well have focused on complaining about the unfairness of it instead, for want of anything better to do. But I was lucky enough to find that my attempts to improve the situation succeeded. Which, if you like, is yet another proof that life is not fair!

Tuesday, January 25, 2011

Just as my unusually low post-prandal result after dinner last night was not proof that the fenugreek seeds I'd consumed along with it are effective at bringing down my blood sugar, the unusually high post-prandial result after dinner tonight is not proof that the fenugreek seeds I consumed along with it are ineffective at bringing down my blood sugar. There are two many variables involved to draw conclusions about what any single result means.

I didn't think my dinner was high in carbohydrates, but I'll concede that it was higher than last night's dinner. A more significant variable was that I hadn't gone running at lunchtime; I didn't go to the gym until after dinner. So, I didn't have any recent exercise effect helping me out. Also, I felt a little bad tonight -- not anything specific, and not anything serious enough to stop me from going to the gym. But I wasn't feeling at my best, perhaps because my usual routine of daytime exercise had been disrupted.

So, fenugreek seeds may or not help me in terms of long-term averages, but whether they do or not, I am still going to have good and bad days. It seems to be part of the deal with diabetes. (And with everything else.)

As I'm not having any success in shedding the pounds I gained during the Christmas season, maybe it is time for me to stop focusing on which foods to eat (always a great preoccupation for dieters and diabetes patients alike) and concentrate instead on serving sizes.

After all, if the servings are small enough, it may not matter too much what you're eating exactly.

Worried about the fat content of the goodies on the antipasto platter? Well, no need to worry when it's an inch across.

Afraid to have tacos because of all that starch in the tortillas? Fear not!

Concerns about the sugar content of fruit nectar can be dismissed if the fruits are small enough.

And when the salad is this size, you could even have seconds!

You might even be able to get away with cookies and pecan pie, if you can get the dimensions right.

Sorry, I was just messing with you. Those are the amazingly convincing miniature food sculpures of Kim Burke.

Monday, January 24, 2011

More experimentation with the sprouted fenugreek seeds. I ate some before going to bed last night, and this morning I had a low fasting result of 81. I didn't have any of the seeds at breakfast or lunch, and my fasting test after lunch was 124 -- but then I did have some with dinner, and my fasting result after dinner was 89.

I hasten to add that this cannot be taken as proof that fennugreek seeds necessarily exert any downward pressure on my blood glucose level. Let's take today's results one at a time:

Fenugreek seeds might be helping me and might not, but I don't have nearly enough evidence yet to assert that they are. They certainly don't seem to be hurting me, though, so it seems worthwhile to continue experimenting with them.

The only point on which I can be very definite here is that I am no fan of the bitter flavor of fenugreek seeds. They desperately need to be mixed with something tastier. In Indian cuisine, of course, they are mixed with something tastier -- they are typically included in curries.

I did learn two interesting facts about fenugreek tonight. First of all, the peculiar name of the plant comes from the Latin "foenum graecum" -- which means "Greek hay".

The second interesting fact is that fenugreek is "frequently used by lactating women to increase milk supply". So far I have not noticed that fenugreek has any such effect on me, but I will monitor the situation carefully, and I promise to share any interesting facts which may leak out in regard to this important issue.

December was wet and cold, but January's weather has been almost ridiculously sunny, and of late it's also been ridiculously warm as well.

On Saturday we had the kind of weather you hope to get in May.

I don't go for a hike, exactly, though I did go for a walk at Lake Sonoma on Saturday. It wasn't long enough or hilly enough to be called a hike; it was just a photo-opportunity. It was my rest day for the week.

On the way back from the lake I visited the Everett Ridge winery, and even at sunset it was still quite warm enough for them to be pouring wine on the balcony outdoors, overlooking the Dry Creek Valley. 

I assume this is why everyone moves to California -- or used to, back in the days when the Golden State was seen as a place of economic opporunities, not just a place of weather opportunities. People are so picky these days: they want sunshine and a job, not just sunshine.

I'm trying to concentrate on enjoying the current weather, but the doomsayers have been stirring up fear of another drought. Maybe this is going to be a "La Nina" year! I should explain that a "La Nina" year is the dry counterpart to a wet and stormy "El Nino" year. Both of these are aspects of the Pacific Ocean's strange, bipolar climate, which is driven by the flipping back and forth of high-pressure and low-pressure zones in the South Pacific. This whole phenomenon used to be known as the Southern Oscillation, but that phrase wasn't exactly a headline-writer's dream. Anyway, the weather that rolls in from the Pacific during a given year tends to go to extremes (either lots of rain, or almost none). Lately journalists have adopted the folk terminology used in South America to describe the ocean's meteorolgical mood-swings. If this is a La Nina year, we may have already seen about as much rain as we're going to, at least until next fall.

Well, if it is a La Nina year, I can't do anything about the problems that will result from it, but I can at least enjoy the advantages that result from it. Sunny warm weather in January: what's not to like? 

Yesterday, while I was trail-running in the local state park, one of my running buddies was doing the same thing (but not with me, and we didn't cross paths -- it's a big park). He was doing a long run (about 13 miles, trying out a half-marathon course through the park that will be used in a race later this year). Somewhere along the way he started thinking about Jack LaLanne, the fitness guru who got America interested in exercise 60 years ago. And when he got home from his run, he was informed by his wife that Jack LaLanne had just died, at the age of 96.

The average person in this situation would think that this extraordinary coincidence was evidence of ESP or some other supernatural phenomenon. Fortunately, Mike is an engineer, so he's capable to looking a little deeper into a coincidence. He started wondering why he had thought of Jack LaLanne while he was running. And it wasn't hard to arrive at an answer. He had encountered on the trail a man with whom he is slighly acquainted; this is a man in his 80s who is still highly athletic -- you often see him in the park mountain-biking or jogging. Every time Mike sees this man he thinks of Jack LaLanne, and of course he did so on this occasion, too. It happens to him all the time. It's just that, this time, it happened to be on the day that Jack LaLanne died.

I bet there are people out there reacting to the news of LaLanne's death by saying: "See? He did all that exercise and he still died anyway, just like everyone else!". Well, not quite. Everyone dies, but not everyone dies after 96 years of vigorous, active life. Apparently Jack LaLanne was still working out, almost to the very end. He finally succumbed to a case of pneumonia.

I don't know that it's necessary to do absolutely everything that Jack LaLanne did in order to live a long and healthy life (I think he allowed himself to go a little crazy with the supplements, for one thing), but it's hard to argue with a guy who found an approach to living that worked well for him -- and continued to work well for him for very nearly a century.

Friday, January 21, 2011

Once again: beautiful, spring-like weather, perfect for running. And the forecast is calling for more of the same:

I think I should try to fit a hike in over the weekend. Who knows how long this false spring will last? It wouldn't surprise me if we had weeks of rain heading this way between now and March. You've got to take your opportunities when they arise.

Another metaphor ruined! In the past I have casually stated that excess sugar in the blood has an effect similar to that of sugar in the gas tank of a car (in other words, it gums up the works). It turns out there's a problem with this comparison: excess sugar in the blood may gum up the works, but sugar in the gas tank apparently doesn't.

The legend, in case you've never heard it (because you've never lived next door to an obnoxious guy with an expensive car), is that sugar poured into a gas tank will dissolve in the gasoline, flow to the engine, and coat the moving parts with a sticky residue which, after the engine is shut down, hardens into a cement-like substance which cannot be removed. Replacing the engine is the only remedy. Carrying out this sinister plan is apparently a widespread fantasy among people who happen to know a jerk with a sports car.

Well, the people at Snopes looked into this, and found that it doesn't work that way. Strange as it seems, sugar doesn't dissolve in gasoline; the sugar crystals would just sit there in the gas tank, like grains of sand, rather than flowing to the engine. If they did travel to the engine, they could do the same kind of abrasive damage as any other kind of grit entering the engine -- but the car's fuel system is filtered to prevent that sort of thing from happening. A large amount of sugar placed  in the gas tank might clog a fuel filter, but  there doesn't seem to be any way for it to destroy the engine in the manner usually described.

Okay, so sugar isn't quite the threat to motor vehicles that we imagined it was, because sugar doesn't dissolve in gasoline. Unfortunately, sugar does dissolve in blood, and it does travel freely throughout the body, and it does have plenty of opportunity to gum up the works. I had the right idea, but the wrong metaphor.

Wait -- hold on a minute. Am I right in calling it "unfortunate" that sugar dissolves in blood? If sugar didn't dissolve in blood, that might be a problem, too.

Maybe we ought to spend more time thinking about how the body works, and why it works the way it does, if only to get a sense of perspective on health problems. More perspective certainly seems to be needed. Even diabetes patients who have got past the "why me?" stage are nevertheless likely to feel a bit irritated with Mother Nature for not having designed the human body and its regulatory systems more carefully. After all, if sugar is so destructive, why do we have it floating around in our blood in the first place? It just seems like a poor design decision.

However, when nature's designs seem ill-conceived to us, it's usually because we don't appreciate the difficulty of the problem nature was trying to solve. That's why I think everyone with diabetes should be obliged to attend engineering meetings from time to time. I attend them often, and it's been a big help to me, in terms of understanding diabetes. Once you gain some exposure to the engineering process, and you begin to see the human body as an engineering project, it becomes a lot easier to understand (and even to accept) the way things are, physiologically speaking.

You see, attending an engineering meeting is a quick way to learn the difference between an ideal engineering project and every real one that ever happened. The ideal engineering project is easy to describe: we're seeking the best possible solution to a clearly-defined problem, and we don't have to struggle against any limitations (we have all the time and money and staff we need). We know exactly what the requirements are, and the requirements don't conflict with one another. Also, we are not constrained by anything that happened in the past -- we can start from scratch, and get everything just the way we want it.

Okay -- that's what the ideal engineering project is like. Here's what a real one is like: we're seeking an acceptable solution to a problem which is imperfectly defined (and might be redefined while we're working on it). We aren't going to have enough time or money or staff to do it as well as we'd like to. We know what some of the requirements are, and of those, some are in conflict with one another. We have to base our work on previous work, and there will be a limit to how much we can change things.

Mother Nature is constantly involved in engineering projects, and these projects are definitely of the real rather than ideal variety. Nature must work with the parts on hand, adapting them as much as genetic variation will allow (which is a tighter restriction than most people realize). Nature must work within all sorts of limitations (for example, the need to maintain body temperature within a certain range). Above all, nature must find an acceptable compromise between conflicting requirements.

The problem of conflicting requirements is the trickiest aspect of an engineering project. Engineering meetings are full of talk that boils down to "if we do this, we'll have a problem with A, but if we don't do it, we'll have a problem with B". Every design idea that creates an advantage in one area creates a disadvantage in another area, so you have to settle on a compromise solution of some kind. And it's often hard to be sure what the best compromise is. (Should we simplify this design so that it uses fewer parts, to cut costs? Or would the re-design effort cost us more money than the reduced part-count would save?)

Mother Nature does her best to find the right kind of compromise solution to each engineering problem that comes up. But the solution that "works", as Mother Nature defines success, is the solution that results in survival to breeding age. Whether it results in a comfortable life for middle-aged people is not a big factor in her decision-making. In any case, she can't guarantee good results even to young people. A successful design is not necessarily a fool-proof design -- it's just a design that works better than any other design has.

Take, for example, the immune system. It's pretty clear what sort of compromise Mother Nature had to make there: if the immune system is too sensitive, too reactive, it tends to go haywire and damage the body's own tissues (resulting in, for example, MS). But if the immune system isn't reactive enough, the result is the extreme vulnerability to infection which we see in AIDS patients. Mother Nature tries to set up the immune system to the level of sensitivity that will allow as many people as possible to avoid both infections and MS. But it isn't possible to eliminate either problem entirely, without making the other one worse.

Supplying the body's various tissues with chemical fuel (and with the oxygen needed to burn that fuel) is one of the biggest engineering headaches Mother Nature has to deal with. These are dangerously reactive substances to be transporting around in the bloodstream, and no method of doing it is going to be perfectly safe. Nature uses a combination of slow-burning (but more efficient) fuels, known as fats, and fast-burning (but less efficient) fuels, known as sugars. Both have their problems. Fats can interfere with signaling that needs to go on within cells, and they can also form deposits in undesirable locations. Sugars tend to bond themselves to proteins, interfering with functioning of the proteins (and also triggering formation of other, unwanted substances). And oxygen, which is used to burn both kinds of fuel, is a generally corrosive element, doing harm of every sort in every location it can reach. Instead of being surprised that Mother Nature hasn't found a way to use these substances so that they never do us any harm at all, we should be surprised that the methods she has chosen work as well as they usually do, for as long as they usually do. It's a wonder any of us make it to 30, if you really think about it.

Nature's system of glucose regulation is (in part) designed to maintain a concentration of glucose in the blood which is high enough to satisfy energy requirements but low enough to prevent the glucose from doing harm at a faster rate than the body's protein-recycling process can repair it. But that is only a part of what the insulin-based regulatory system has to accomplish, and the design of the sytem has to meet several other needs as well. It's a complicated system -- and when you have a complicated system, you know there are going to be a lot of different ways that it can fail. A certain amount of risk of developing Type 2 diabetes is apparently an inescapable part of being human, given the way the human body's regulatory systems work. That risk is pretty low in a state of nature, but in modern times we have magnified that risk through changes in the way we live.

That is why I think it is a little unfair to criticize Mother Nature for not having given us bodies which can easily adapt to inactivity, obesity, and a heightened intake of starch without becoming diabetic. Mother Nature works slowly, and we have changed the design requirements much too fast. It's as if an engineering team had been asked to design a video camera, and now, shortly before the project is supposed to be completed, they find out that the camera is supposed to work under water. If it's not fair to pull that kind of switch on engineers, it's not fair to pull it on Mother Nature, either.

So don't complain about how poorly Mother Nature has met the engineering challenge of designing an invulnerable human body, unless you're sure you could do it better.

Thursday, January 20, 2011

A study by researchers at the University of Lausanne, Switzerland, found increased risk of depression among teenagers who spend a lot of time on the internet -- and also among teenagers who spend no time on the internet.

At first glance it sounds as if the researchers discovered that it's depressing to be a teenager (which, if you ask me, is like discovering that it gets dark at night), but hold on a minute -- the depression risk was elevated among "heavy users" and "non-users", but not among "regular users".

Regular users were considered to be teenagers who used the internet several times per week, but not more than two hours a day. The researchers concluded that "both heavy Internet use, and non-use, could serve as signals that a teenager is having a hard time". So long as your teenager uses the internet regularly, but no more than two hours a day, things are okay. So the trick, if you want to be a good parent, is to make sure your teenager is using the internet just enough. (Unless, of course, you're a believer in Amy Chua's "Tiger Mother" theory of child-rearing, in which case a depressed teenager is exactly what you're looking for.)

Get this, though: "However, the average depression scores among non-users, regular users and heavy users alike were all toward the lower end -- between 1 and 2 on a scale of 1 to 4, with 1 being 'not depressed at all.'" So, the study did not find high rates of depression, on average, in any category of user or non-user. It's just that the rates were lower among regular users than among heavy users or non-users.

Then, the kicker: the data was collected in 2002, after the rise of the internet, but before the rise of such internet time-sinks as Twitter and Facebook. "Many teenagers now may spend much more time online, and the definition of 'normal' time could also be different." Yes, I imagine that it could be.

I guess one of the lessons here is that, if you're going to publish a study on the social impact of a popular new technology, you should not collect the data and then wait nine years to publish it.

But, even leaving the issue of timing aside, this looks to me like soft science at its very softest. Asking teenagers to fill out a survey on how depressed they are, and how much they use the internet, will give you information which you can call "data" if you like. But how well does this "data" match reality, and even if the match is good, what does it mean? It's anybody's guess, really.

Spending too much time on the internet depresses me, but mainly because it means I'm neglecting other things which would probably be more fun.

There are a couple of fiddle tunes I should be practicing at this very moment, and I'm not!

Beautiful running-weather today. Sunny, clear, calm, and cool but not cold. Employees were outside walking at lunchtime who normally don't do that -- it was too nice outside not to be outside.

One of my two regular running buddies at work has been on a diet since Christmas and has lost 10 pounds; now his pace had picked up, and he's running us to exhaustion. We're trying to address the problem by tempting him with chocolates and other treats, but I'm not sure it's working. We may have to try something else.

My low post-prandial result didn't surprise me much: it was a low-carb lunch, after a fast-paced run.

I tried a little spoonful of the sprouted fenugreek seeds. I'd been warned that they have a bitter taste, and by golly they do. Not terribly bitter -- it's not like chomping down on aspirin tablets -- but I don't think I'll be eating them by themsleves in future. They'd probably be fine in a stew or something.

One thing that depresses me more than excessive internet usage is the idea (promoted, I regret to say, by professionals who should know better) that "prediabetes" is something very different from "diabetes".

To me, the distinction between prediabetes and diabetes is similar to, and certainly not more dramatic than, the difference between an infant and a child.

No doubt it is possible to draw up definitions of "child" and "infant" which very clearly demarcate the difference between them. For the sake of argument, let's say that an infant is a child that isn't yet old enough to walk. But there you go: an infant is a child. A specific type of child, of course (one too young to be ambulatory), but a child all the same. You might have to treat a child differently after it's no longer an infant (specifically, you might need to do a little more in the way of surveillance), but that doesn't mean that an infant and a child are two different life-forms, as different as a horse and a salmon.

Suppose you have twin boys. Someone asks you if you have any children, and you say no, thinking to yourself that the twins aren't walking yet, so they're infants. Are you lying? I'd say yes. The twins might be infants until they start walking, but that doesn't mean they aren't children, too. And elevated glucose might be "prediabetes" before it hits the magic number (currently the magic number is 126 mg/dl, though it's changed before and could change again), but that doesn't mean it's not diabetes, too!

If prediabetes is not a form of diabetes, then we ought to be able to describe prediabetes in a way which distinguishes it very clearly from diabetes. Here are some of the questions that such a description would need to answer:

I have not heard or read any defintion of prediabetes which takes on any of those issues. As far as I can determine, the difference between prediabetes and diabetes is that, one morning, you go into the lab for a fasting blood glucose test, and your result is 126 instead of 125.

Oooooooh! They're as different as night and day, aren't they? A horse and a salmon are practically twins, by comparison!

A friend of mine who has been studying Aikido for many years recently passed the big test, and is now entitled to wear the black belt. He sent me some photos of himself demonstrating the required skills.

As Aikido is the most philosophical (and, in a way, pacifist) of the martial arts, I believe his black belt signifies that he can now be referred to as Agent 007(a) -- Licensed To (Not) Kill.

Any mention of martial arts reminds me that a long-running thread on the dLife forum is mistakenly entitled "Marital Arts", which must be a great disappointment to those who check it out and find out that it's people talking about karate. I've pointed out the error, but they won't correct it. Oh, well. Maybe some marriages aren't as easily distinguished from karate as they ought to be.

Wednesday, January 19, 2011

Nice running weather today, sunny and clear and beautiful. A trifle chilly, at first, but it seemed to warm up remarkably as soon as we started climbing the first steep hill. After the run, when I'd had a shower and I went back upstairs to the office, my shirt was pock-marked with little patches of sweat, the way it is after a run in the summertime. I was actually a little over-dressed for the run -- I'll have to bring a lighter running shirt tomorrow!

We often use the word "reality" to refer to whatever disappoints us. If it is considerably less interesting or attractive than we would want it to be, then it must be "reality".

Scientists, however, don't see things that way. Scientists tend to feel that the real world we inhabit (and the real universe in which it is located) are far more fascinating than any dopey little story people might make up to explain things to children. Scientists just can't get enough of reality; it's the least boring thing around, as far as they are concerned. Because scientists spend their time investigating what they consider the coolest possible subject (reality), they tend to become irritated when it is brought to their attention that most people would rather hear about stupid bullshit.

Astronomers, in particular, are used to dealing with an awe-inspiring subject, and lately with beautiful pictures of it. For example, a tiny moon flying over the planet Mars...

...or a larger moon casting a shadow on the vastly larger planet Jupiter...

...or the gigantic star-nursery in the Orion nebula...

...or the beautiful and inconceivably gigantic galaxy NGC1345.

It's worth taking a second look at that picture, because some amazing things are included in it. You're actually seeing objects at wildly different distances, which happen to occupy the frame because they lie in the same direction.

That star in the upper right is "close" to us, in the sense that the light from it takes less than a thousand years to get here. The galaxy which occupies most of the picture is 85 million light-years away; when that light started its journey towards earth, dinosaurs had not yet gone extinct. But those tiny-looking reddish galaxies in the back are hundreds of millions of light years away -- which means that, when the light from those galaxies started its journey toward earth, dinosaurs did not yet exist. And the reason those galaxies look so much redder than the nearby one is that, given the overall expansion of the universe, more distant galaxies are moving away from us faster, and this stretches out their light waves in the same way that the soundwaves from an ambulance's siren get stretched out as it passes us and recedes into the distance (so that the sound drops in pitch).

Imagine what it is like for astronomers, who are used to dealing with amazing information like this, to have to answer questions about, of all subjects, astrology. It's a bit of a shock to the system -- like asking Julia Child how to adapt classic French recipes to use more readily-available ingredients, such as Velveeta and Fritos.

Earlier this month, an astronomer named Parke Kunkle was interviewed by the Minneapolis Start Tribune, and as often happens to astronomers, he was asked about astrology. And he did what astronomers always do in that irritating situation -- he tried to explain, as quickly as he could, why astrology is dumb. An astronomer could spend hours going over all the reasons why astrology is dumb, but they usually try to keep it short (because they find the subject an annoying waste of their time). So, they mention a few of the more obvious conflicts between astrology and reality. One of these conflicts (which I first learned about in the 1970s -- this is not news, folks!) has to do with "precession". Precession is the slow wobble in the earth's rotation, which causes the north pole to point at different stars during different historical eras. This wobble has thrown off the traditional assignment of "sun signs" to particular birth dates. You may think you're an Aries because you were born on March 22, but in modern times, the sun is actually in Pisces on March 22. Kunkle also mentioned that, during a part of the year, the sun passes through the obscure constellation of Ophiucus, yet nobody is told that Ophiucus is his sign.

Lest the point be lost, let me reiterate that he was only mentioning the sort of thing that other astronomers mention every time an impish or naive journalist drags them into a chat about the zodiac. These issues have been brought up a thousand times before. It's never made any difference, of course; a substantial minority of Americans have always continued to "believe in" astrology (whatever they mean by that exactly), and they're not going to give it up just because it makes a poor fit with astronomical facts. Let astronomers say what they will -- people who like to read their horoscope while sipping their morning coffee are still going to do it.

Seemingly, all parties to this dicussion had long ago settled into an established pattern: astronomers continued debunking astrology, and astrology fans continued ignoring the astronomers. Everyone was playing his assigned role. But, for reasons which defy explanation, this time there was a huge reaction. The story began circulating on the internet that astronomers in general, or Kunkle in particular, had called for a revision of the Zodiac, with the traditional signs given new dates and a 13th sign added to acknowledge the sun's passage through Ophiucus. Astrology fans were in turmoil -- what if they were the wrong sign? What did this mean for them?

The phenomenon of a minor news story "going viral" (because millions of people are reacting to it on line, and telling their friends about it) is sometimes deeply puzzling, because the "news" that people are reacting to is not really news. The surprise is not so much that people are reacting intensely to an unimportant issue, but rather that people are reacting all of a sudden to a long-existing issue. If they were going to get excited about this subject, they've had years in which to do it. Why now?

Astrologers were astonished by the reaction to Kunkle's "news" which wasn't news. Over the years they have offered various rationalizations whenever the precession problem has been cited as an issue which undermines their credibility; these rationalizations have always seemed sufficient in the past to get them off the hook, at least with astrology fans. But astronomers, too, were astonished by the reaction -- after decades of saying the same thing over and over, they don't see why one more astronomer saying it one more time has touched off a frenzy. And anyway, the reason astronomers bring up the precession problem is not to call for revised astrological charts, but rather to highlight the weakness of astrologers' methods in general.

For once, astronomers and astrologers have something to agree about: they can't understand this sudden excitement over an issue that's as old as the hills.

Of course, the precession problem isn't the most important reason for doubting astrology. The whole conception of astrology is fundamentally silly, and there is no reason to think that it has any meaningful predictive power or provides any useful insight into personality. (James Randi used to do a marvelous demonstration in which he would give a roomful of students their individual horoscopes to read. He would ask them if their horoscopes described them well, and the strong consensus would be that they did indeed. Then he'd ask them to compare their own horoscopes with those received by others in the room. They'd all been given the same one.)

Astrology is a joke, if you judge it scientifically, but maybe there's no point in judging it scientifically. My view is that astrology is a game, and (as with other games) either you find it entertaining or you don't.

What astrology fans don't understand about astronomers is why astronomers are so hostile to astrology. They seem to hate it. It's okay for them not to be interested in it, but why do they have to be so irritated by it? What has astrology ever done to them? I don't think it's that hard to understand, really. Astronomers are routinely engaged with a subject so awe-inspiring that it almost causes them physical pain to watch that beloved subject being trivialized and turned into something dopey and childish and small.

The sheer scale of the visible universe makes it ridiculous to think of it as a mere device for generating advice to inhabitants of one planet on whether or not this is a good week to make a decision about a possible career change. As Richard Feynman put it, "the stage is too big for the drama".

In matters medical rather than astronomical, it is, alas, not always so easy to distinguish between reality and bullshit. That is because, in matters medical, there is often a great deal of money to be made from bullshit, and it is therefore worth taking a great deal of trouble to dress up bullshit as actual science. For example, the great vaccine scare of recent years ("vaccinations cause autism!"), which has caused vaccination rates in some countries to drop to dangerously low levels, was the result of discredited research paper which we are now told was not just bad science, but was actually an "elaborate fraud" from which the perpetrator planned to make a fortune. When you're evaluating medical information, there is no such thing as being too careful.

Because diabetes is a common disease, and an incurable one, and people are already used to spending considerable money on trying to manage it (often without great success), diabetes patients are considered an excellent "market". The perfect market, actually. No wonder vast numbers of people are trying to make a buck out of us. Some of them are fairly obvious scoundrels, but others appear to have all the credentials they need to be taken seriously. How are we to know who's telling us the truth?

The only ace we have up our sleeve is this: when it comes to diabetes, health claims for a product or treatment are usually easy to test. We're already in the habit of collecting data on ourselves, so if we try something new which is supposed to be good for diabetes patients, it's pretty easy for us to check and see if that is true.

Not all the diabetes remedies we are offered are expensive. Cinnamon? Bitter melon? Rooibos tea? You can afford to try those things, and see if you can find any evidence that they help you.

I don't feel that way about bariatric surgery. It will certainly be easy enough to tell whether having your stomach stapled is bringing down your blood sugar, but the surgery isn't cheap, and if you decide you don't like it, you're still stuck with it. (In fact, you may be stuck with a lifetime commitment to having further stomach surgeries performed from time to time.) But an affordable herb that you can find at the Asian food shop downtown? That's worth checking out.

Someone on the dLife forum was talking about sprouted fenugreek seeds; supposedly these bring down your blood sugar (or don't -- it depends on whom you ask). After work today I picked up a bag of the seeds for $4.49, and now they're soaking in the sprouter on my windowsill. Do I "believe in" this remedy? No. Belief isn't what it's about. I accept that there is some nonzero possibility that eating sprouted fenugreek seeds will bring down my blood sugar, and I'm curious to see if I can find any evidence of that. If I can't find any evidence of it, I'm only out $4.49. I can handle that. It's all for science!

Sometimes things that are said to work really do work, at least to some degree. On January 7, I reported on a "Diabetic Friendly" vegetable pilaf which claimed to be "low glycemic" despite what seemed like a generous serving of grains. My post-prandial glucose after that dish had been only 110, seemingly confirming the claims made for the dish. It's hard to generalize from a sample size of one, however, and I knew I'd want to test that dish again to see if my result was 160 the next time.

Well, I tried it again tonight, and the post-prandial result was 119. A bit higher, but still not bad. Apparently it really is possible to make a diabetic-friendly pilaf.

And now I notice that one of the ingredients is fenugreek!

Tuesday, January 18, 2011

From time to time, I like to review the search phrases that have caused my blog to be cited by Google or other search engines. In some cases the wording of these search phrases can be a bit puzzling, and in some cases it's hard to see why Google thought my blog could be relevant. But perhaps if I ponder these search phrases long enough I can gain some understanding of what the people who visit this site really want to know.

So, let me review some of the more interesting recent searches...

"what happened to abe's body after a month"

I assume this refers to Abe Ramos. In a special feature that I wrote in October, I described the remarkable weight loss (and muscle gain) that enabled him to stop taking diabetes medications. Perhaps this search request was made by a person trying to locate my feature on Abe. On the other hand, maybe it was someone seeking an update on Abe's story, since I haven't said anything about him recently. 

I did contact Abe today, and things are still going fine for him. He had an A1c test at the start of the year, and the result was normal; on that basis his doctor is willing to let him continue with the unmedicated approach. (That's actually quite a step forward for his doctor, who was originally pessimistic about Abe's ability to handle this problem without drugs.)

Abe still doesn't feel that he's quite reached his ideal body weight yet, but he figures it will be easier to get there now that the holidays are over (apparently my little Christmas-cookie drama last month struck a very familiar chord with him). He's also looking forward to the evening light of springtime, when he'll be able to fit more running into his schedule. Currently he feels that his exercise mix is skewed too much toward weight-lifting and not quite enough toward running (I've got the opposite problem!). Anyway, he didn't feel as if he had anything to report, but the old saying that no news is good news applies with special force to diabetes. In fact, where diabetes management is concerned, no news is sometimes big news.

"blood sugar said 260 2 hours after dinner what does this mean"

It means that your diabetes is not under good control.

Your blood sugar shouldn't be over 140 two hours after a meal (some would say it shouldn't even be over 120). So, if it's going up to 260 after dinner, you must (at the very least) try eating a different kind of dinner (more modest in size, and certainly more limited in carbohydrate content).

Other things you can do: exercise often, shed any excess weight you're carrying, and (if those things aren't enough to correct the situation) take appropriate medication.

"hemoglobin a1c result 6.2 what does this mean"

It means that 6.2% of the hemoglobin in your red blood cells is "glycated" (that is, sugar-coated). The more sugar there is in your blood, the more sugar sticks to your hemoglobin (converting it to a form of sweetened hemoglobin known as "A1c"). 

If your hemoglobin didn't get recycled periodically (red blood cells get replaced after about three months), the hemoglobin A1c test result would be constantly going up over your lifetime. Reclycling keeps the number from climbing endlessly. In non-diabetic people, only 5% or 6% of hemoglobin is glycated. In diabetic people, typically more than 6% of hemoglobin is glycated, because their blood is more sugary and glycation is happening at a faster rate.

High rates of glycation cause a lot of serious health problems (the famous diabetic "complications"), so the risk of complications go up as your A1c result goes up. 6.2% is slightly above normal, but it's a better result than most diabetes patients are able to achieve. If you bring down your average blood sugar and keep it down over a period of months, your A1c result will come down, because your old red blood cells are getting replaced, and the new ones aren't being glycated as heavily as the old ones were.

"how much can i reduce my risk of complications if i lower my a1"

Obviously they meant to say "if I lower my Hemoglobin A1c result". Well, this issue has been looked into. The DCCT (Diabetes Control and Complications Trial) looked at four common complications of diabetes: retinopathy (an eye disorder), neuropathy (a nerve disorder), and nephropathy and microalbuminuria (both kidney disorders). The risk of these disorders is not zero even for people who don't have diabetes, but higher-than-normal A1c results multiply that small but unavoidable risk into a large but avoidable risk. The graph below illustrates the rising risk for each complication as A1c increases. The "relative risk" numbers on the vertical axis are multipliers of the normal risk. So, if you follow the risk line for retinopathy, you will see that the risk is about equal to "1" (that is, the normal risk level) if your A1c result is 6, but if your A1c result is 10 the risk is almost 8 times as high, and if your A1c result is 12, the risk is about 20 times as high. Because the risk lines aren't straight lines (they curve upward instead), the risk increases disproportionately as A1c goes up.

Turning the relative-risk factor into actual odds (what are your chances of getting retinopathy?) is impractical if you don't have the data on what the normal risk level is, and in any case the odds increase over time. However, I've been told that if your A1c result remains at 12 over a ten-year period, you are virtually certain to have retinopathy when that ten-year period is over.

Draw your own conclusions...

"fasting glucose 90 early sign diabetes naturopathic"

Unless the rules have changed, a fasting glucose level of 90 is considered to be normal, not an early sign of diabetes.

"floyd landis resting pulse"

On May 26, 2010, I commented on Floyd Landis (the disgraced bicycle racer who lost his Tour de France title in a doping scandal), and also mentioned that my own resting pulse (not Floyd's) was 46 that day. I don't know what Floyd Landis's resting pulse is, but it's probably lower than mine. At least it probably was. He has behaved so badly since the scandal started that he's probably living in fear of being struck by lightning, and that kind of thing can raise your resting pulse significantly.

"polygons of nature"

In a somewhat silly blog post on January 30, 2010, I mentioned a Chinese engineer who "reinvented the wheel" by constructing a bicycle in which the wheels were in the shape of Reuleaux polygons rather than circles. Whether such polygons exist in nature I don't know, but anything that happens to be a surprisingly good solution to an engineering problem usually turns out to exist in nature.

"waiting room psychiatry drapetomania video"

Believe it or not, there's a connection between these two search phrases. In a blog post of Sept 25, 2009, I was poking fun at an author who claimed there is a disease (he calls it "orthorexia") which consists of excessive concern with making healthy eating choices. I began by mentioning the unpleasant history of people inventing psychiatric disorders to describe behavior they don't like (such as "drapetomania", which existed only in the South and consisted of a slave's unwillingness to remain in captivity). I argued that excessive concern with healthy eating was a less common problem than insufficient concern with it, and suggested that the latter problem could be called "pizzarexia". I didn't make a video on the subject, however, so in that regard the person who entered this research was probably disappointed in me.

"my gluclose was 134 after lunch and was 78 7 hours later"

A post-prandial result of 134 is usually considered acceptable for a person with diabetes, although some would disagree. From what I have read, it appears that non-diabetic people don't go any higher than 120 after a meal; arguably, we should try to hit that lower target. However, it matters what you're doing to hit that lower target. If you're taking insulin or other glucose-reducing medications, aiming low can trigger an over-correction which leads to hypoglyemia. This is not a concern for me, as I'm not medicated and I don't experience dangerous lows (I've experienced a few uncomfortable lows, but discomfort and danger are too different things, and the discomfort is both infrequent and easily remedied).

The result of 78 "7 hours later" implies that this person had lunch but skipped dinner; if so, I'm not terribly surprised that their blood sugar dropped to 78. I don't see it as a problem (78 is not hypoglycemia), but skipping dinner sounds as if it could have an unfortunate impact on the life of the spirit. If skipping dinner tends to drive you to reckless anger and impulsive acts of violence, please eat something, for the greater good of society.

"type 2 diabetic insulin resistance how could it be that glucose"

How could it be that glucose what? I don't know how it could be that glucose.

People need to learn to write shorter search strings. Apparently, if you enter a really long one, the search engine discards the latter part of it. As in this case, the truncated search string may not quite get to the point before it is brought to a premature close. The effect can be more or less equivalent to "And now, ladies and gentlemen, I, Hercule Poirot, can at least reveal that the murderer was none other than".

If you begin with unimportant words, you may lose the important ones that eventually follow.

"new research studies based on more than 22000 people is showing"

Is showing what? Once again, someone's overlong search string didn't get to the point fast enough, and the browser threw away the most important part of the question. I do write fairly often on research studies.

"what happens when low blood pressure is 74/45"

I don't know what happens, although I have heard that fainting is a possibility. Blood pressure below 90/60 is generally considered to be abnormally low. It's not a problem I've had to deal with; most people with diabetes have blood pressure which is above rather than below the normal range.

There are medications for low blood pressure, although it's sometimes possible to deal with the problem simply by taking in more water and more sodium. On the whole, low blood pressure seems to be a concern not mainly because of any harm it can do directly, but because it may be a warning sign of other serious health problems.

Monday, January 17, 2011

My office was closed today for the Martin Luther King holiday, which was just as well, as it allowed me to sleep late and recover from a weekend crowded with music-making. Last night, after attending a Burns Supper in Petaluma, I drove down to San Francisco to participate in a great Irish music session which lasted until the wee hours. I don't know how I pulled off a fasting test as low as 79 after the big dinner last night (which was a buffet -- in other words, I haven't a clue what I ate), but I did it somehow.

Still, no use pushing your luck, even when your luck is with you. Also, I wanted to take advantage of the beautiful, spring-like weather we're having right now. So, I went to the state park for a trail-run. This is what January should be like all the time, if you ask me. I felt as if I could see the grass-blades growing, as they eagerly soaked up the sunlight.

Lately, running has seemed like a real chore to me, and I didn't realize how much the cold, wet, gray weather was contributing to that feeling. This weekend, it was sunny and surprisingly warm, and I was downright enjoying my running.  Even on the hillier trails, it made me feel great to be out there sweating in the sunshine. I thought "this is how running must feel to real runners". (I don't see myself as a real runner -- I'm a guy who runs a lot, which is a very different thing.)

Because the weather was so fantastic, I wasn't the only one who thought of going to the park today. There were a lot of people on the trails, and at one point I had a chance encounter with a friend who was mountain-biking there.

In a dark corner of the woods I also encountered some odd specimens of wildlife, including this banana slug, which was six inches long. Yes, you read that right. In California, we like our invertebrates to be on the large side -- and I'm not just talking about the state legislature.

I'm not sure I can come up with any logical reason why exercising outdoors is any better for you than running on a treadmill at the gym, but it certainly feels better, and perhaps the psychological advantage translates into a physiological one in some way. Of course, there's also the practical advantage that, if you find a way to exercise that's pleasurable, you do it more.

So here's to pleasurable exercise!


Friday, January 14, 2011

A reader of this site is feeling very disappointed because, despite all his efforts at keeping his blood sugar under control without medication (and his success at it, for a few years), he is not getting acceptable results anymore, and is now forced to start taking metformin. He can't help seeing this development as a kind of failure.

Well, it's not a failure. The word "failure" suggests far too much in the way of moral judgment. I would be willing to call this a failure if he wasn't trying, but he was. Unfortunately, when it comes to diabetes, you always have to face the possibility that trying your very best might not get you the results you're hoping for.

Nothing that I recommend on this site is guaranteed to work for everyone, and even if you find that it does work for you, it isn't guaranteed to work forever. It won't work forever for me, either, but so far I've been lucky, and I'm trying to make my luck last as long as I possibly can.

When it comes to health, nothing works for everyone, and nothing works forever. That's what makes us mortal beings. We do the best we can, but in the long run we can't really control our fate. You know what they say about the best-laid schemes of mice and men.

Or perhaps you don't. Well, if you don't, I'm well-positioned to fill you in.

The famous phrase about those best-laid schemes comes from a poem by the great Scottish poet Robert Burns, and this weekend I am participating in a Burns supper (a Scottish social event in which people gather in January to celebrate Burns's birthday and listen to his poems and songs). My contribution to the supper will be to deliver the "Toast to the Immortal Memory of Robert Burns".

As Burn wrote his poems and songs in the lowlands Scots dialect of his day, they tend to need a lot of explanatory footnotes, if not outright translations, for modern American readers. His song "Auld Lang Syne" is, believe it or not, easier to understand than many of his works. (You could translate the title literally as "Old Long Since", but "For Old Time's Sake" is closer to the meaning.)

The line about the best-laid schemes of mice and men appears in a poem with the improbable title "To a Mouse" (and the even more improbable pronunciation "To a Moose"). Burns, who was by profession a farmer rather than a poet, wrote the poem one day in the fall of 1785, when he was ploughing a field, uprooted a mouse's nest, felt bad about terrifying the poor creature, and brooded on the idea that his own life was every bit as vulnerable as the mouse's was.

The poem has endured, despite the puzzling dialect in which it is written, for several reasons. One is the surprisingly friendly way in which Burns addresses the mouse as an equal (a "fellow mortal"), another is the heartbreaking way in which Burns eventually realizes that he and the mouse really are equal (and that the human "advantage" of greater consciousness only gives him more awareness of all the things he has to worry about). But what really makes it a great poem is the peculiar music in the way Burns uses those unfamiliar dialect words -- so that, even if you're consulting a translation, you have to go back to the original to perceive the warmth and humor with which Burns makes his points.

Let me make it easy for you: here's the Burns original in boldface, with my translation in parentheses.

To a Mouse

On Turning Up Her Nest With the Plough, November 1785

by Robert Burns

Wee, sleekit, cow'rin, tim'rous beastie,
O, what a panic's in thy breastie!
Thou need na start awa sae hasty
Wi bickering brattle!
I wad be laith to rin an' chase thee,
Wi' murdering pattle.
(Tiny cowering frightened creature, what a panic's in your little breast! No need to run squeaking away, I'd be the last to run and chase you with a murdering shovel.)
I'm truly sorry man's dominion
Has broken Nature's social union,
An' justifies that ill opinion
Which makes thee startle
At me, thy poor, earth born companion
An' fellow mortal!
(Oh, come on -- you don't need a translation of this verse!)
I doubt na, whyles, but thou may thieve;
What then? poor beastie, thou maun live!
A daimen icker in a thrave
'S a sma' request;
I'll get a blessin wi' the lave,
An' never miss't.
(No doubt you sometimes steal, but what of it? Poor creature, you must live! An occasional ear of corn in a bunch is little to ask; I'll get a blessing with what's left, and never miss it.)
Thy wee-bit housie, too, in ruin!
It's silly wa's the win's are strewin!
An' naething, now, to big a new ane,
O' foggage green!
An' bleak December's win's ensuin,
Baith snell an' keen!
(And your little house in ruin! Its fragile walls strewn to the winds! And now there's no wild grass left to build a new one from, and December's winds coming on, hard and keen!)
Thou saw the fields laid bare an' waste,
An' weary winter comin fast,
An' cozie here, beneath the blast,
Thou thought to dwell,
Till crash! the cruel coulter past
Out thro' thy cell.
(You saw the fields laid bare and waste, and weary winter coming fast. You thought to live cozily there, beneath the storm-winds, till crash! the cruel plough-blade passed through your home.)
That wee bit heap o' leaves an' stibble,
Has cost thee monie a weary nibble!
Now thou's turned out, for a' thy trouble,
But house or hald,
To thole the winter's sleety dribble,
An' cranreuch cauld.
(That little heap of leaves and stubble cost you many a weary nibble! Now, for all your trouble, you're turned out of house and home, to endure winter's sleet and rain and cold frost.)
But Mousie, thou art no thy lane,
In proving foresight may be vain:
The best-laid schemes o' mice an' men
Gang aft agley,
An' lea'e us nought but grief an' pain,
For promis'd joy!
(But, little mouse, you're not alone in finding it useless to look forward. The best-laid schemes of mice and men often go astray, and leave us only grief and pain, for promised joy!)
Still thou are blest, compared wi' me!
The present only toucheth thee:
But och! I backward cast my e'e,
On prospects drear!
An' forward, tho' I canna see,
I guess an' fear!
(Still you are blessed compared with me! Only the present touches you. But oh! I cast my eye back on dreary prospects! And though I cannot see forward, I guess and fear!)

So that's what can happen to the best-laid schemes of mice and men. You figured out what you needed to do to keep youself safe, and you did it to the best of your ability. But now, just when you think things are under control and you're all set, disaster strikes.  There's nothing you could have done to prevent it from happening; in fact, you couldn't even see it coming.

Diabetes, unfortunately, is like that -- the disease itself, and the milestone stages of it, can arrive as unexpectedly as a plough blade crashing into a mouse's nest. We may have done our best to create a safe situation for ourselves, but there's no guarantee that our best will turn out to be good enough. And even if we're lucky, we can't know how long we will continue to be lucky. Anything can happen. We can only do our best, hope for the best, and enjoy what we have while we still have it. 

Gosh, that poem sounds really depressing when you translate it and analyze it. But that's the trouble with translating and analyzing poetry: the emotional tone of the thing gets altered in the process. This is a gentler poem than I'm making it seem, provided you're listening more to the lilting music of Burns's words than to the troubled thoughts that inspired him to write those words down.

Of course, Burns wasn't arguing that mice shouldn't build nests, that men shouldn't plough fields, and that the best-laid schemes of mice and men weren't worth making in the first place. We still have to try. We just can't know how well things will turn out. And we shouldn't blame ourselves if they don't turn out the way we hoped they would.

Thursday, January 13, 2011

Yesterday a guy wrote into the dLife forum, saying that his father is 53, has Type 2 diabetes, and has a healthy lifestyle, with lots of exercise. He wanted to know what his father's life expectancy is, given these circumstances.

It occurred to me that this question might conceivably have some personal relevance for me, given that I'm a 53-year-old man, that I have Type 2 diabetes, and that I have adopted what I consider a healthy lifestyle, with lots of exercise. I thought maybe I ought to look into this question.

Believe it or not, I've never looked into it before. Not that I have ignored the health consequences of diabetes which might limit my longevity -- far from it! -- but I never sought a direct answer to the question, "How long does a man with Type 2 diabetes typically live?".

Part of the reason I've never looked for an answer to this question is that I'm aware of what a slippery concept life-expectancy can be. One obvious reason for this is infant mortality, which skews the life-expectancy figures in a misleading way. In a society (or a historical era) with a high rate of death from childhood diseases, average life-expectancy might be something like 50 -- thus creating the false impression of a society in which there are no old people. Actually, though, the people in such societies who survive childhood, and get a chance to become adults, may live a lot longer than 50 years without bringing the average up. This kind of confusion often arises when Social Security is discussed in America -- we are told that Social Security was created during an era when life expectancy was low, so people didn't live more than a couple of years past retirement. Not true, of course, but it's easy to see why people think that. When you talk about life-expectancy, you need to be clear about whether you mean life-expectancy at birth, or life-expectancy measured from some later starting-point.

Today I read a 2007 report on a Dutch study of the effect of diabetes on longevity. It's a bit complicated, but here's the bottom line: a man who has already survived to the age of 50 can expect to live to the age of 78.8 years (on average) if he doesn't have diabetes, or to the age of 71.3 years (on average) if he does.

What interests me here is not the absolute numbers, because these have to be of questionable relevance when you're looking at the average of many values. The fact that the average male diabetes patient dies at the age of 71 doesn't mean I will. What interests me more is the 7.5-year difference between diabetic and non-diabetic longevity. Apparently the penalty for being an average male diabetes patient is seven and a half years of life.

The message I take away from this is not that I'm going to die at 71, or that I'm going to die seven and a half years earlier than I would have if I'd never become diabetic. The message is that, if I don't want to pay a 7.5-year penalty for having diabetes, I'd better make sure I don't allow myself to become the average male diabetes patient.

A lot of people don't realize that being the average patient is a matter of choice. It is, though, to a large extent. The reduced life-expectancy with diabetes relates mainly to the increased risk of cardiovascular disease -- and there are things you can do about that. (Or not. Most people go with "not".)

If you ask me, a necessary part of diabetes management is to find out what the average patient does, and then do something else. Perhaps anything else.

Anyway, I am doing something else, and I hope it works out. So far, so good.

By the way, the diabetes penalty for women is a little higher -- 8.2 years instead of 7.5 -- but even with that larger penalty, women with diabetes still live 5 years longer than men with diabetes.

Maleness is not a disease exactly, but it's definitely hazardous to your health.

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

Recent health headlines show that health researchers and health journalists are still willing to work hard to prove that things are pretty much the way you think they are.

Wednesday, January 12, 2011

I couldn't sleep last night. Not that I was agonizing over some issue I'm worrying about; I simply couldn't sleep, for reasons unknown. I felt that I needed sleep, and it was frustrating not to be able to settle down into it. Anyway, that may be part of the reason my fasting test was a bit higher than usual today. Well, I hope I do better tonight!

It's awfully early in the year to be making predictions, but I'm going to go out on limb, and say whom I expect to win the 2011 Ig Nobel Prize for Medicine.

In case you are unfamiliar with the Ig Nobel Prizes, they are awarded every year by the Annals of Improbable Research, a humor magazine for scientists which reports on real but extremely strange research efforts -- or, as they express it, "research which makes people LAUGH and then THINK".

The 2010 prizes included these choice items:

There is plenty of time left for someone to earn the 2011 Ig Nobel Prize for Medicine, but I nevertheless predict that it will go to Christian Stevns Hansen, Louise Holmsgaard Faerch, and Peter Lommer Kristensen, of Hillerod Hospital in Denmark, for their research showing that it is not possible to get drunk by submerging your feet in alcohol.

Perhaps it hadn't ever occurred to you to think that it was possible to get drunk by submerging your feet in alcohol. It certainly isn't an excuse I've ever used. However, there is apparently an urban legend, popular in Denmark, to the effect that alcohol can be absorbed through the skin and transferred to the bloodstream -- and that the feet are for some reason especially susceptible to this. Step into a puddle of vodka while barefoot, and pretty soon you're unconscious and people are posing in funny pictures with you.

My guess is that the reason this urban legend manages to continue being a legend (in Denmark, anyway) is that there really aren't that many opportunities to test it. I can't remember the last time I found a puddle of vodka blocking my path, so that I had no choice but to wade through it. And I can't recall that even the most solicitous party-host has ever offered me a liquor foot-bath. And when I buy wine (for home use, or for taking anyplace else), I never think "Hey, I bet this expensive Alexander Valley Cabernet, which won a double-gold at the Sonoma Harvest Fair, and got 91 points from the Wine Spectator, would be really good for soaking my feet in!". 

But the Danes believe that circumstances can arise in which you might immerse your feet in alcohol. And if you do, watch out! Next thing you know, your friends are using your head for an art project and you won't even realize it until the next day.

This particular urban legend seems like a pretty silly idea to be taking the trouble to investigate, but the good doctors of Hillerod Hospital in Denmark did take the trouble, and they found out that soaking your feet in vodka doesn't make you drunk, because skin (on the feet or elsewhere) doesn't absorb alcohol. If you want to get alcohol into your bloodstream, you must either swallow it or inject it.

Why did the doctors even think this legend was worth looking into? Apparently because there have been a few cases of people working in breweries or distilleries in Denmark who got into trouble for being drunk on duty, and whose defense was that their feet had been exposed to alcohol on the job, which resulted in them having a high blood-alcohol level without having had anything to drink. No, the doctors say -- that's not how it works. If this guy got too much beer into his system at a barbecue, it wasn't by spilling the stuff into his sandals:

Well, science marches on. But maybe this story illustrates something significant about our relationship with medical science. We seem to be ready to believe just about anything we hear about human physiology, no matter how little sense it makes, and no matter how improbable it is on the face of it.

That a startling claim flies in the face of everything else we've ever heard on the subject makes it seem more plausible to us rather than less. We like to be told that we're finally being let in on a secret which some powerful corporate lobby is trying to conceal. We're more likely to believe a statement about corn flakes if it is presented as What Kellogg's Doesn't Want You To Know!

I'm sure that many people in Denmark, upon hearing that a team of doctors has performed experiments demonstrating that you can't drink through your feet, are rejecting the finding decisively. It's not what they exptected or wanted to hear, and what better reason does anyone need for rejecting a research finding?

Of course, I'm aware that there is a lot of corruption in medical research. Some research findings really are fictions, created to further the interests of the companies that financed the research. Sometimes, the only way to get at the truth is to search for it through a process which begins with rejection (or at least questioning) of much of what we've always been told. But I don't think we should swing all the way over into a system in which we take it for granted that whatever the experts say is wrong must be right. It's not that simple.

Tuesday, January 11, 2011

Good numbers today. I exercised hard, and had a light lunch afterward (a Thai curry soup). The soup didn't seem high-carb to me -- there was a very small amount of potato in it, but I guess there couldn't have been too much else in the way of starch, if my fasting result was only 108 afterward.

It was difficult to make myself go running today -- my running buddies were both unavailable, so I had to go alone, and it was not only cold but forecast to begin raining soon. However, I lucked out; the rain didn't start until after I was safely back indoors, taking a hot shower. The only real mishap was that I had to run past a skunk that someone had very recently run over, and it was a little overpowering. The kind of shallow breathing that we try to practice when there's a dead skunk close at hand is a little difficult to accomplish when you're running on a hill. I got a pretty good whiff. Several pretty good whiffs, actually. I guess that's one advantage of exercising in the gym: no skunks! Maybe gyms should advertise that advantage more.

The other day, the company newsletter at work included a little article entitled Tips for Starting Exercise Program in the New Year.  It begins:

The new year often begins with people dedicating themselves to improved fitness, yet many don't know how to get started. For long term success with a new routine, consider following these steps.

Yes, it's one of those articles consisting almost entirely of a bulleted list. Some of the bullet points make sense to me; others are perhaps not quite so useful as the anonymous author intended.

Hmmm. This sounds good, in principle, but people who already have "an activity they like" which is strenuous enough to count as exercise are probably already doing it about as often as it is practical to do it. Let's face it, there are only going to be so many opportunities to ski or go ballroom dancing over the course of a week. That's the tricky thing about exercise as a daily health regimen: it's not always going to be beach volleyball. A lot of the time you're going to need to make yourself do it even when "a chore" is exactly what it feels like. If you like swimming better than you like cycling or running, and you have some place convenient where you can swim, then I agree it's better to swim than to do cycling or running. But this carries you only so far in the direction of mitigating the "chore" issue. What people need, more than anything else, is to find a way to get some satisfaction, however muted, out of the chore-like routine workouts that they do between their occasional bouts of fun exercise. (One way to get some satisfaction out of it is to think of it as preparation -- you're getting in shape to be able to do the kind of exercise which you actually think of as fun, on the rare occasions when you actually get to do it.)

The next suggestion makes more sense:

I can't argue with any of that; it's what I've been telling people for years.

This makes sense, but there's a pitfall here. A lot of people hear "start slowly and build up gradually" and think it means "start slowly, find a pace that's comfortable for you, and then linger there for a few years". The trick is to make small gains, but to make them persistently. Tacking a little more distance onto your jogging pays big dividends eventually, but only if you keep on raising the ante. And you have to raise it pretty often. This is an especially big issue in terms of strength-training: if you're still lifting the exact same weights you were lifting six months ago, you're not gaining anything, because your body is used to those weights now, so lifting them isn't causing any adaptive changes to occur.

I have a regular schedule for weekday exercise -- I go running at lunchtime with a couple running buddies from work. I also go to a weekly yoga class. Yes, it's helpful to have exercise time entered on your calendar. However, I have no clue what they mean by "several shorter workouts". A workout is a strenuous thing; you can't do it in your office clothes. You sweat a lot, and then you take a shower. Dry clothing is nature's way of telling you that, whatever you've just been doing, it wasn't a workout. Maybe what they mean by "several shorter workouts" is going for a brief walk around the building whenever you get a chance. I suppose that's better than nothing, but I wouldn't call it a workout.

I have noticed the "Balanced Choicse" signage in the cafeteria, but am unable to detect any significant differences in the food itself. Anyway, this kind of thing strikes me as the emptiest kind of chatter. There is universal agreement that athletes need to fuel their bodies properly, and zero agreement about what that might mean.

Okay, here's where I have to part company with them. Show me a man who exercises only when he's feeling up to it, and I'll show you a man who doesn't exercise.

This "listen to your body" meme (which athletes hear all the time) sounds reasonable, until you remember what sort of things your body actually tells you if you listen to it. Of course, I may have a distorted perception of this issue, because the kind of things my body says to me may be totally different from what most people's bodies say to them. But here are some typical comments from my body:

"Slouch! Go ahead, slouch! Slouch deeper!"
"Stay in bed until at least 1 PM!"
"Have a cinnamon roll!"
"Better yet, have two cinnamon rolls!"
"Don't go outside and work out! Curl up in the recliner instead!"

If your body doesn't talk to you this way, then all right, I guess you can go ahead and listen to your body. But you sure as hell wouldn't want to listen to mine.

My body begins nearly every workout with great reluctance, and often with anxiety and an upset stomach. I am able to exercise precisely because I have stopped listening to the opinions my body offers me on this topic.

Look, if I'm truly in such poor health that my body can't stand a workout, my body won't just whisper to me that a workout would be a bad idea -- it will stop me from doing the workout at all. This seldom happens. Usually when I'm feeling a little under the weather, a workout (no matter how resentfully my body begins it) soon makes me feel better. When I'm feeling a lot under the weather, I don't even try to work out, because I know my body wouldn't let me anyway.

So, forget "listening". It's okay to skip a workout when your body simply can't work out, but it's not okay to skip a workout whenever your body is suggesting more agreeable ways to spend the next hour. Once you start down that path, your exercise program is history.

Monday, January 10, 2011

I'm sure it seems weird that I could get a post-prandial result lower than the fasting result I got the same day, but this does happen to me from time to time, and I don't think it's too hard to explain in this case.

The low post-prandial result probably occurred because (1) I had a hard run at noon, (2) I had a light lunch after the run, and (3) I had a low-carb dinner. 

My fasting test was a little higher than usual (quite often I'm below 90 in the morning), and the explanation for that might simply be the expected random variations in meter accuracy. It wouldn't surprise me too much to learn that my meter had slightly overstated my fasting level, and slightly understated my post-prandial level. Anyway, I don't see any big surprises here, and I'm more or less satisfied that my glycemic control today was good.

I'm less satisfied with myself in the area of weight control. Christmas is over and it's time to get rid of the holiday pounds, but I seem to be gaining instead of losing. Reversing that trend is easier said than done, of course, as you have perhaps had occasion to notice yourself.

When you are first diagnosed with diabetes, you begin with the impression that weight control and glycemic control are closely inter-related, and that there is no conflict between them -- anything you do to improve in one area will also give you an improvement in the other area. That may actually be true when you're starting out, and you have a lot of progress to make in both departments. Once you get both problems under a reasonable degree of control, though, and you start to work on fine-tuning your results to optimize them, it can seem as if the two goals are, at least to some degree, in conflict. For me, at least, the low-carb approach that helps me with glycemic control tends to make weight control a lot harder, and the low-fat approach that helps me with weight control make glycemic control a lot harder. This isn't true for everyone, from what I've heard, but unfortunately I've got to deal with what's true for me.

I saw a post on a diabetes forum from a patient whose endocrinologist was insisting that she adopt a diet which was both low-carb and low-fat. She was supposed to make sure that fat accounted for less than a third of total calories. It wasn't clear what the proportions of protein and carbohydrate were supposed to be, but carbohydrate wasn't supposed to be a big part of the remaining calories.

Well, if less than a third of total calories are supposed to be from fat, then the combination of protein plus carbohydrate would have to account for more than 66% of total calorie intake. That being the case, it's a little hard to see how she could have arranged for her diet to be low in carbs as well. Protein doesn't tend to travel alone; most foods that are high in protein are also high in fat or high in carbohydrate. If more than 66% of her calories are to come from protein plus carbohydrate, and she's supposed to be on a low-carb diet which is also a low-fat diet, then she seemingly has to eat a lot of foods which consist of protein and very little else. Unfortunately, nature doesn't seem to have designed a lot of foods that consist of protein and very little else.

The story reminded me of a what a family member told me about driving a bus for a living, several years ago. He was getting in trouble at work for not being able to arrive at the bus stops on schedule. He protested that this was unfair: the bus schedule was unrealistic -- it didn't allow enough time to get from one stop to another. Finally a manager agreed to ride on his bus all day, so that she could see for herself if this was true. He drove like hell all day, frantically trying to keep the schedule, and he still had trouble arriving at the bus stops on time. At the end of the day he said, "You see how it is now, don't you?". Her reaction, now that she had seen the reality of his situation with her own eyes, was to write him up for driving too fast. He was still in trouble for driving too slowly, but now he was also in trouble for driving too fast. The bus-company manager was clearly a sister under the skin to the community of endocrinologists, who think nothing of giving patients two conflicting goals and then criticizing them sharply for not meeting both of them.

A friend of mine (he has Type 1 diabetes, but I'm sure people with Type 2 sometimes encounter this sort of thing) reports that he was sternly reprimanded, in the same office visit, for (1) not taking enough insulin, as his A1c results were too high, and (2) taking too much insulin, as he was experiencing hypoglycemic episodes. The art of endocrinology, for many practitioners, seems to consist of constructing a perfect system in which the patient is always wrong, no matter what the patient does. Being able to take it for granted that 100% of patients are in the wrong 100% of the time is probably a great stress-reliever for endocrinologists, but I'm not sure it's doing all it can for patient care.

I don't know what the solution to this problem is, unless it's to make a rule that you can't practice endocrinology unless you have a serious endocrine disorder yourself. I'm sure that would go a long way towards helping endocrinologists get a clue, but it would probably be impractical, in that it would lead to a serious shortage of endocrinologists. Still, maybe it would be better, on the whole, for there to be a small number of endocrinologists who've got a clue than for there to be a large number of endocrinologists who haven't got a clue.

I've never consulted an endocrinologist myself, so I'm relying on reports from other people about how endocrinologists operate, and those reports may be biased. So maybe I'm being terribly, terribly unfair to endocrinologists. Maybe. Still, all things considered, I'm glad that I don't need an endocrinologist now, and I'm working hard at not needing to get one in the near future.

Friday, January 7, 2011

First, let me get this out of my system:

Thank you.

The biggest impact that modern communications technology has on our daily lives may be the way it enables countless strangers to communicate with us and, if they choose, to deceive and swindle us. We are constantly besieged by people promoting products and ideas of questionable value.

Their methods of approaching us are not always as sophisticated as one might expect them to be, given the software tools which they now have at their disposal. Even when I receive a message that greets me by name, the content often makes it clear that they don't know whom they are addressing. For example, this e-mail, which I received today:

Not again! Everyone wants to turn me into a sexier woman than they imagine me to be now. I must have a reputation as a real crone, if this many people have heard that I desperately need a makeover to unleash the hot chick that dwells within.

But can their program really give me this kind of transformation?

Well, let's look into this a little deeper.

The "revolutionary new approach" that is being touted by the Slim Calm Sexy program is so new and revolutionary that its origins trace back to the Indus Valley civilization of 3000 BC. Yes, we're talking about yoga.

As it happens, I do yoga, but without any expectation that it's going to turn me into a slim, calm, sexy woman (and I'm not absolutely sure it's having that effect on the other students in my yoga class -- even the female ones).

I do yoga as preventive maintenance (and sometimes corrective maintenance). Yoga helps me keep my muscles and joints strong and flexible enough to be able to keep up the fairly intense exercise schedule which I use to manage my diabetes. And when I sometimes I overdo the exercise a bit, and feel stiff and sore, yoga helps me recover quickly from that kind of setback. Yoga has also helped me get rid of some chronic back and neck problems that used to give me a lot of trouble.

Of course, the fact that I happen to be using yoga as preventive maintenance does not mean that no one could use it for other purposes. But the sales-talk about calories burned by yoga versus running is pretty ridiculous. What kind of "session" of yoga would burn as many calories as a good run? If I'm going to do a four-mile run and you're going to do enough yoga to burn as many calories as I do, you'd better have a lot of time on your hands. Regardless of how strenuous yoga sessions theoretically could be, I know how strenuous they typically are, and there's no comparison to running. I think the only way to look at this realistically is not to count yoga as a workout. If the only exercise I do all day is yoga, I have to count that as a rest day.

All in all, I cannot buy into the idea that yoga is going to make me a slim, calm, sexy woman. I suspect that I'm about as fetching as I'm going to get, and the world is just going to have to deal with that.

Contrary to the impression I may be giving here, I don't automatically reject and ridicule every idea about healthy living that comes my way. I'm simply aware that a lot of strangers are out there trying to make a buck by lying to me -- and that even the ones who aren't lying may be wrong. Therefore, I try to maintain a healthy skepticism about such matters. I'm more willing than you might think to give other people's health ideas a try (provided they're not self-evidently stupid -- which is why I needn't give homeopathy a try). Still, the only point of giving someone's idea a try is to put it to the test; there's no point in using an herb which someone says will bring your blood sugar down, unless you're going to make a fairly serious effort to determine whether or not it worked. Listen to suggestions, yes -- but don't embrace them uncritically.

For example, I find some advantages for me in a vegetarian diet, but there's a problem: vegetarian foods typically lean towards the high-carb end of the nutritional spectrum. That doesn't mean a vegetarian diet has to be high-carb -- but it tends to be high-carb unless you're mighty careful about it, so vegetarianism is not necessarily going to be a practical solution for someone with diabetes. Although some people are making an effort to address this issue, it's hard to know whether the solutions they are coming up with are good enough.

So, I was intrigued to see this vegetarian entree in the store, which claims to be a "Diabetic Friendly", low-glycemic vegetable pilaf. I decided to try it, just to see what my glucose meter had to say about these claims.

I liked it a lot (I was afraid it would taste like a cardboard replica of pilaf, but it tasted like the real thing). Still, based on how it looked and tasted, I was afraid it would drive my blood sugar over 150. Nope -- 110!

Of course, that's a single experimental outcome, and there's no guarantee that it will always work quite so well for me. But it does seem promising. Maybe vegetarianism and diabetes management are not quite so incompatible as it sometimes seems. Maybe! Further investigation is needed. There could be other reasons why this dish is not the right thing for me to be eating. Still, in terms of glycemic control it doesn't seem like a bad deal.

Thursday, January 6, 2011

I just noticed that I have been dating my January blog entries "2010". I guess I had better start making that "2011", hadn't I? People are going to start thinking I'm getting old and forgetful.

People often post questions on the on-line diabetes forums which boil down to this: "if I'm having such-and-such problem, is it my diabetes that's causing it?".

The list of problems which people think might be caused by diabetes appears to be endless. (My misdating of recent blog entries? Clearly a diabetes symptom! Non-diabetic people don't forget things or make mistakes.)

Today I saw a dLife forum post in which a newly-diagnosed diabetes patient whose sleep was being disturbed by anxiety nightmares about work, and about college, wanted to know if diabetes was the likely cause of this problem.

I think the likeliest explanation for anxiety nightmares among diabetes patients who are working and going to college is that they are working and going to college. The stress of getting a diabetes diagnosis doesn't make it any easier to cope with the stress of working and going to college, obviously, and it might be that a person who could cope with any two of those issues cannot deal with all three and still get a good night's sleep. But if diabetes is giving you nightmares, it's probably only in an indirect sense: it would be more accurate to say that worrying about diabetes (while also worrying about other things as well) is giving you nightmares. I don't think there is a particular blood sugar level which causes you to have a terrifyingly realistic dream in which you show up to take the bar exam and suddenly realize that you have forgotten to study for it and aren't wearing any clothes. That's not how diabetes works, at least in my view.

The thing is, if you have diabetes, any health problem you experience is likely to be blamed on diabetes by one expert or another. Diabetes is a blame-magnet. It's an all-purpose explanation for any unpleasantness which enters your life.

You've become allergic to walnuts? Blame diabetes.

You've forgotten one of the thirty-seven passwords you've been obliged to adopt over the past year? Definitely diabetes.

You're going bald? What else could explain that, besides diabetes?

When I had my frozen-shoulder problem in 2007, the company doctor (whose job it was to sign a paper certifying that my problem could not possibly be a work injury) blamed it on diabetes. I had never claimed that the injury was work-related, but I was annoyed at having it falsely blamed on diabetes for legal reasons.

Why do I say that the company doctor was "falsely" blaming my shoulder problem on diabetes? Well, for startes, my blood sugar has been kept within normal, non-diabetic bounds for nine years without medication, which does tend to raise awkward questions about how diabetes could be destroying my shoulder. But even if we leave that fact aside (which the doctor was certainly willing to do), it seems pretty damned obvious that, if diabetes had been causing my shoulder-joint to degenerate, a brief period of physical therapy would not have been enough to make the problem go away, and stay away. My shoulder should be worse than ever now, if the mere status of having once been diagnosed with diabetes is enough to rot your joints away.

Nobody knows exactly what causes "frozen shoulder" (more formally, adhesive capsulitis -- an inflammatory condition of the shoulder joint which is extraordinarily painful and debilitating). The problem has been observed to be more common among diabetes patients -- but name me a health problem which hasn't been observed to be more common among diabetes patients! The fact that frozen shoulder is statistically associated with diabetes doesn't prove that it's caused by diabetes. It's just as likely (or more likely, if you ask me) that frozen shoulder, being an inflammatory condition, triggers diabetes instead of being triggered by it, and that is why the problem is statistically linked with diabetes.

Diabetes is statistcally linked to all sorts of problems, and we shouldn't be too hasty in concluding why that might be so. If diabetes is statistically linked to poverty (and it is), does this mean that being poor makes you diabetic, or that being diabetic makes you poor? Or both? Or neither? It's risky to jump to conclusions about what these statistical associations might mean.

When you delve into health statistics, looking for connections between one issue and another, you are pretty sure to find that any and every health problem is more common among diabetes patients than among the rest of the population. But this may simply mean that diabetes is a marker of poor health in general. Does this connection arise because diabetes makes you unhealthy, or because being unhealthy increases your risk of diabetes? Probably both, speaking generally -- but the connection between any specific health issue and diabetes is likely to have a unique explanation which we don't yet fully understand.

Whenever you are tempted to assume that a health problem you're experiencing is caused by diabetes, remember to pause for a moment and ask yourself: does this kind of thing ever happen to people who don't have diabetes? Unless we diabetes patients have cornered the market on anxiety nightmares and frozen shoulder (and it doesn't appear that we have), let's not be so quick to assume that there can be only one explanation for our troubles.

Wednesday, January 5, 2011

Once again: a sunny, clear, winter's day -- cold by local standards, but only cold enough to make a mid-day run seem exhilirating. More of the same predicted for tomorrow. With weather like this, who needs the gym?

I'm not sure why my systolic blood pressure is up tonight, but maybe it's because of my annoyance with the subject discussed below.

Tonight I visited the web site, and it invited me to take an on-line survey about how well I'm managing my diabetes. I generally dislike these surveys, but on a whim I decided to take this one, and see what happened. I figured that, if it was as bad as I expected, I could at least have the satisfaction of complaining about it here.

The first page is headed "Managing Diabetes HealthCoach -- Get a Personalized Action Plan". It's a little unclear who is behind this thing. The copyright holder is "Health Grades Inc.", and the URL begins with "". It looks like a scam of some kind -- clearly we're not dealing with the Mayo Clinic here. But maybe they have something interesting to tell me.

The first question is easy: "Are you taking this for yourself or for someeone else?". I choose "Self". Then I am asked my gender and age. (Yes, I know that should be "sex" rather than "gender", but that's how they stated the question.)

Now comes the first difficult question: "Have you ever been treated for diabetes by a doctor?". Why is that difficult? Because I don't know what they mean by "treat". I have a doctor who diagnosed me with diabetes, and advised me on how to manage it. He never gave me anything but advice, though, and I suspect that most people would only say I'd been "treated" for a disease if I'd been given drugs or surgery for it. So, have I really been "treated"? I decide to say that I have.

"Do you have a regular doctor or clinic you go to?". That's easy: yes.

Second difficult question: "What are you taking for your diabetes?". The choices offered are:

The last of these answers is obviously the correct one in my case, but I can't choose it without wondering if unpleasant false conclusions will be drawn from it.

Now it gets hopelessly muddled: "Are you and your doctor keeping track of the following?". The choices offered are:

This is exactly how you don't word a survey question! Am I and my doctor "keeping track" of an issue? Well, if I'm keeping track of it and my doctor isn't, or vice versa, is the correct answer "yes" or "no"?

I answer "no" to low blood sugar symptoms and emergency department visits. I haven't been having a problem with low blood sugar symptoms, and I haven't had any emergency department visits, therefore my doctor and I have had nothing to "keep track of" in this regard. But will points be taken away from me because I don't review these non-issues with my doctor? Should I say that my doctor and I do "keep track of" non-issues, because I know that we would discuss them if they ever became relevant? I decide against it.

Next: "What's your success rate at meeting your goals for these?". The choices offered are:

The allowed answers range from low to high, and I choose "high" for all. In this case I don't see the need to exclude low blood sugar symptoms and emergency departement visits, because my goal was not to have to worry about these things at all, and I haven't had to worry about them, so I've met my goal.

"How are you doing with the following lifestyle issues?" The issues are:

I check "not an issue" for smoking, and "successfully managing this" for the other items. You could argue that I'm not currently doing so well on the weight issue, but I'm still within the bounds my doctor set for me, so I think the answer I chose is closer to reality than any of the other possible answers that were allowed. I later learned that I slightly misunderstood the choice between these possible answers. Apparently the top score goes to those who answer "not an issue" to all five of these things. I'm not sure what it would mean to say that getting regular exercise was "not an issue" for me, but apparently that is what I was supposed to answer if I wanted a top score. I exercise all the time; to say that it exercise is "not an issue" for me would seem to suggest that I don't need it, don't do it, and don't think about it. But that would have been the correct answer -- in the sense that it's the answer the survey designer was fishing for, and would have chosen for me if I had been allowed to describe what I'm doing.

"Do you get the following at least once a year?". The choices offered are:

Okay, here it gets complicated. I answer "no" to "complete foot exam", "urine test for kidney damage", and "review of blood sugar log". But this isn't because of any neglect on my part or my doctor's part. I used to review my blood sugar records with my doctor, but after 9 years of normal lab fasting tests and normal A1c tests, it just doesn't seem necessary (to him or to me) to review a log of glucose meter results; he knows I'll tell him if there are any new developments in that area. I get a physical exam once a year, but he doesn't include a urine test or a "complete foot exam" because my lab work has been too consisently normal for these things to seem necessary. In other words, my "no" answers to all three of these questions are actually evidence of how well I'm doing, but I have a feeling they will nevertheless count agaisnt me in the survey.

"Do you use any over-the-counter medicines, herbal remedies, supplements, or alternative therapies to manage your diabetes?". I say no. On my doctor's advice I do take a vitamin tablet and a daily low-dose aspirin -- but not specifically to manage my diabetes. I do yoga, but that's just to preserve my flexibility despite all the exercise I do, not to manage my diabetes. I'm not sure I see the point of asking this extremely broad question if only a yes/no response is permitted. What does a "yes" tell them? And should I have said "yes" because of the vitamins, aspirin, and yoga even though I don't see them as playing a direct role in diabetes management?

"Using the 10-point scale below, where 0 is "not at all happy" and 10 is "completely happy", tell us how happy you are with your diabetes management, and how happy you think your doctor is with it." I give a "10" for both. My doctor just tells me to keep doing what I'm doing.

"Would you like to receive the 'Focus On: Diabetes' e-newsletter from Harvard Health?". One is tempted to say yes -- but the fine print under that says that I will also be contacted for market research studies and so on. So I say no.

Okay, now I get their overall assessment of me:

Okay, I'm "GOOD" in every area. Not "EXCELLENT", but it turns out that they aren't into excellence -- the only grades they give out are "GOOD", "FAIR", and "NEEDS WORK". So, in terms of verbal categorization, I did as well as it was possible to do.

However, when I get to the more specific analysis of my answers, it turns out that I didn't get anything like a perfect score. They did, indeed, subtract points for all of my honest answers which I feared would be misinterpreted. They just didn't subtract quite enough points to drag me down from "GOOD" to "FAIR".

Even though this survey didn't come out as bad as the one I took a few years ago, which rated my cardiac risk high because I "wasn't taking my diabetes medications" (the survey designer simply took it for granted that medications had been prescribed for me), it still reminded me why I hate this kind of thing.

Filling out a multiple-choice survey form is an activity certain to maximize miscommunication. The questions and/or the allowable answers are always so ambiguous that the results are sure to be misleading to at least a small degree, and probably to a very large degree in many cases. Also, there is a certain amount of rigging (conscious or unconscious) that goes on whenever a survey is designed. Like a magician who says "pick a card, any card" while artfully wedging into your fingers the one card he wants you to get, a survey designer tries to force-fit your thoughts and feelings into the narrow box he has prepared for them.

I don't know what the actual purpose of this survey was (maybe luring me into putting myself on their e-mail list was the only goal they had in mind), but I don't think it exactly changed my life. Whether it would change anyone else's, I don't know.

Tuesday, January 4, 2011

As previously noted here, I take an interest in the search requests which (according to the statistics I get from my Internet Service Provider) caused my blog to turn up in search engine results. The main reason I take an interest in this is that it's completely baffling, and I know I'll never understand it, but I can't let it go.

It worries me that some of the search requests people have entered make such a poor match to my site that the people who entered them must have been very disappointed when they got here. Which, of course, raises the issue of why a search engine would have led them here in the first place, given what they said they were looking for. For example: "cartoon overestimate own abilities". The connection between that search string and this site is not entirely obvious to me, unless the connection is that I sometimes include cartoons in my blog and I tend to overestimate my own abilities.

The other day someone entered "28.7/46.7=". Well, it's probably too late now, but the answer is 0.61456, in case that person is still lurking here waiting for enlightenment.

Today an especially good search-request turned up: "how does a female walking gate effect orgasmic". Good question! I'm sure many of you have wondered that, but were too bashful to ask anyone. I'm a little surprised to be the one who is now tasked with providing an answer, but -- believe it or not! -- I think I have some information to share. Today I was reading an article in Medscape entitled "Gait Speed Linked to Survival in Older Adults"; it seems that if you compare people's walking gaits, you can make a pretty accurate estimate of how long they will live, based on how fast they're walking. Now, if a faster walking gait means you're going to live longer, then it stands to reason that women who walk faster are going to have more opportunities to experience the zenith of bliss, simply because they're going to spend more time being alive and less time being dead. (By all accounts, dead women are more frustrated in that department than anyone else is.)

So there you have it! I wish all the questions that came my way were so easily dealt with.

It was sunny and wonderfully clear today, but cold by local standards, especially for running outdoors in shorts. I felt pretty under-dressed at the start. It didn't really matter -- the run was hilly and the exercise warmed us up. After the first mile the goosebumps on my legs sort of faded away.

This kind of weather is actually great for running. The cold air is invigorating and the world is beautiful. I'm glad I don't live where people are poking around in the snow this week to find out what happened to their cars.

Yesterday had an interesting astronomical significance: the earth was closer to the sun than it had been in a year.

Does that sound backwards? A surprising percentage of adults (even adults who managed to make it through elementary school) think that it gets cold in the winter because winter is the time of the year when the earth is farthest from the sun. As an explanation for seasonal weather changes, this obviously makes no sense: in January it gets cold in the northern hemisphere, and hot in the southern hemisphere (it's summer in Australia right now). If the earth-sun distance was what made the seasons, January would be summer everywhere, not just south of the equator, as the earth's orbit cannot be simultaneously near the sun and far from it. The seasons occur (and occur at different times in different hemispheres) because the earth's axis of rotation is tilted, not vertical; at this time of year the northern hemisphere is tilted away from the sun, so the sun doesn't rise as high in the sky, and its rays hit us at a lower angle (through a thicker layer of atmosphere).

We learned all that in school, of course, but a lot of us forgot it. If you polled people on the street, most people would say we're closer to the sun during the summer, not the winter.

There are a lot of these popular misconceptions floating around in our culture. Here are some old favorites:

The thing is, most of these popular misconceptions arise not because people leap to absurd conclusions, but because they have been told these things by seeming authorities (including, I'm sorry to report, schoolteachers), and haven't heard anything to the contrary.

A lot of what most people believe about diabetes is as mythical as the examples I've given above, or is at least highly questionable. But I'm afraid it's getting late and I don't have time to explore that theme further today.

Monday, January 3, 2011

Even in the winter, there are days that are just too nice to to be anywhere but outdoors. Today was such a day. The latest storm off the Pacific (which blew on on Saturday) was gone entirely; the sun was shining, the air was calm, and by noon it was warm enough to go for a run wearing shorts rather than ski-pants. The rest of the world may be coping with floods and blizzards, but for today it's mighty nice in Northern California.

I figured I'd forget about the gym and seize the opportunity to exercise outside, like so many other people were doing.

There was enough time this afternoon to fit in a long trail-run at the state park, because I had today off work. Apparently that was true for a lot of people. I had plenty of company in the woods, in the form of runners...

...and mountain-bikers...

...and other species harder to identify. Some of the monster mushrooms in there looked as if they could serve as furniture.

I never feel like doing a short run when the weather is beautiful. Today even the mud-puddles looked pretty...

...and even the steepest hills felt easy to climb.

The thing is, I still felt a bit sore in the legs from my hike on Thursday, and if the weather had been dreary that would probably have been enough to discourage me from doing a long run today. But I knew I'd be going to the yoga class today, so I'd be able to get the kinks out of my muscles if the run turned out to be hard on me. Well, the run wasn't very hard on me, and the yoga class did make my muscles feel better. So, all's well that ends well.

Up to now, it has been assumed that the reason Type 2 diabetes is linked to kidney disease is simply that delicate structures within the kidney (such as the glomerulus -- a knot of capillaries which acts a blood-filter) are damaged by exposure to high blood sugar. Well, maybe they are, but it turns out that there is another issue, entirely distinct from blood sugar, which can interfere with the kidney's ability to perform its filtration duties properly.

That issue is insulin resistance. It turns out that kidney cells are not so passive as they were once believed to be -- they don't just sit there on automatic pilot, constantly filtering the blood in the same way at all times. According to this report from ScienceNews, one type of cell within the kidneys, called a podocyte, is now known to be triggered by insulin -- and to stop working properly when it is not triggered by insulin because of insulin resistance. The research was conducted by pediatric nephrologist Richard Coward and colleagues at the University of Bristol in England.

Podocytes are special octopus-like cells which wrap their microscopic tentacles around capillaries (the smallest blood vessels) in the kidney:

Apparently the podocytes use their tentacles to perform a highly sophisticated form of filtering -- they allow water and waste products to pass into the urine, but they block certain other substances (such as proteins) which are supposed to remain in the blood. The usual sign that they are failing in this effort is the detection of abnormal amounts of protein in the urine (the protein commonly tested for is albumin).

"Since earlier research had suggested that podocytes might be sensitive to insulin, Coward and his colleagues suspected that insulin resistance might damage these filtration cells and therefore underlie kidney damage common to people with diabetes. To test that hypothesis, the team genetically engineered mice to have podocytes lacking insulin-receptor proteins. In these mice, podocytes were largely unable to bind to insulin needed to orchestrate the use of glucose in the cells. Within several weeks the animals showed damage to the podocyte 'tentacles', allowing leakage of albumin proteins into the urine. Podocytes unable to use insulin also eventually showed increased cell death and accumulation of compounds such as collagen. Coward says this damage showed up even though the mice didn't have high blood sugar, or hyperglycemia, suggesting that insulin resistance plays a role in kidney disease brought on by diabetes."

Up to now, nephrologists (doctors specializing in kidney diseases) have focused on glycemic control as the way to prevent diabetic nephropathy. If insulin resistance can harm the kidneys even in people with good glycemic control, then obviously glycemic control alone is not good enough. 

Naturally, doctors are already leaping to the conclusion that this means they need to develop a new drug which specifically targets the podocyte insulin-signaling pathway. I'm not quite ready to go there myself, yet. If you ask me, this looks like further evidence (of which there is already more than enough) that insulin resistance can have harmful effects (heart disease, for example) even in people whose glycemic control is good -- and that people with Type 2 need to focus on improving their insulin sensitivity, rather than taking drugs to bring their blood sugar down by other means.

What is most novel about this research is that it's the first clear indication that the kidney needs to be stimulated by insulin to perform its job. In other words, the kidney is a dynamic organ, one which responds to changing conditions -- not a passive screen for filtering the blood the same way at all times. "We've always thought about the kidneys as a static barrier," says nephrologist Alessia Fornoni of the University of Miami. "But when you think about it, practically all the protein we take in will eventually pass by the kidneys and stress out the filtration barrier." Coward theorizes that insulin energizes podocytes to prepare them for such stress. "After a meal you get a rise in insulin from the pancreas but also a rise in filtration rates in the kidneys," he says.

Okay, so kidney function depends in part on insulin sensitivity -- and if you're not doing what you can to boost your insulin sensitivity, you're not entirely dealing with your diabetes. What does that tell us, in practical terms?

Well, one of the things it tells us is what our grandmothers would have been happy to tell us: "It's a beautiful day! Go outside and play!".

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