Thursday, June 30, 2011

Interesting that my blood pressure this evening was lower than usual, and my pulse higher. The measurement was taken about an hour after weight-lifting, which probably has something to do with it. But I shouldn't try too hard to figure it out. There seem to be even more factors affecting blood pressure than factors affecting blood sugar, and that's saying something.

126 is a higher post-prandial result than I've typically been getting lately, but I know why it happened: a ripe banana in the cafeteria was calling out to me, and I heeded its siren song. 

I don't have bananas often, but I'd like to retain the right to have one once in a while, and I figured after exercising there was only so much harm it could do.

Probably the best time for me to have a banana would be before exercising -- provided I eat it early enough before exercising, so that I'm not still digesting it while working out. I might have one before the Kenwood Footrace on Monday.  It's a very hilly and humbling 10 kilometer footrace held every year on the 4th of July. There are always several other people I know running in that race, which is both good and bad: it makes the race a nice social occasion, but it also gives me an opportunity to compare my performance with theirs, and be reminded of what a slow runner I am. Well, who knows, maybe I'll be faster this year. Stranger things have happened! (Not much stranger, though.)

I read an article today about pediatricians recounting telephone calls they have received in the middle of the night from worried parents whose questions really could have waited until daytime (and perhaps forever). Questions asked during the wee hours included:

My favorite, though, was a call received at three o'clock in the morning from a very manly father wanting to know if his 5-month-old son's breasts were too large. (Although gynecomastia, as it's called, is considered normal in male infants, I can understand a father wanting to ask a doctor about it. What cracks me up is the idea of his stewing about it for five months, and then finally having a panic-attack about it at 3 AM.)

Wednesday, June 29, 2011

The idea that Type 2 diabetes is a single disease is unlikely to be anything more than a convenient fiction. Type 2 is defined more or less by default: if your blood sugar is high, and you don't have Type 1 (the auto-immune form of the disease, in which the immune system goes haywire and attacks the beta cells in your pancreas), then whatever mysterious problem is causing your blood sugar to be high has to be called something, so let's agree to call it Type 2.

For a while it looked as if the nature (if not the precise cause) of Type 2 was fairly well understood. Doctors had a clear picture of the type of patient who developed the disease, and the course the disease took:

  1. The disease develops comparatively late in life (certainly after 40), and the risk of it goes up the older you get.
  2. The disease develops in people who are overweight and sedentary. Presumably excess body fat causes the disease somehow.
  3. The disease begins with the development of "insulin resistance", a tendency of the body's cells to become insensitive to the hormone insulin. Insulin is supposed to stimulate the cells to pull sugar out of the bloodstream; therefore, when the cells become insensitive to insulin they don't absorb enough sugar, and sugar builds up in the bloodstream.
  4. Chronic high blood sugar has a harmful effect on the beta cells in the pancreas, and as a result, insulin productivity declines. Not only is the patient not sensitive enough to insulin, the patient isn't producing enough insulin, either. Thus a vicious cycle develops, tending to drive blood sugar higher and higher over time. The disease "progresses" and becomes increasingly uncontrollable.
  5. Losing weight and exercising both tend to improve insulin sensitivity, and can therefore be used to control the disease and retard its progression. However, most patients soon need oral medications, then more oral medications, then insulin. Then nothing works and the patient's health falls apart.

The problem with this highly specific narrative is that a fair number of diabetes patients don't seem to fit the profile. The people who get diagnosed with the diease are not all alike, and their experience of the disease is surprisingly variable. What "works" for one Type 2 patient doesn't work for another. Perhaps this shouldn't surprise us, given the complexity of the genetic situation. It is beyond question that genes play some role in determining your risk of developing Type 2, but it's not as if there is one gene that is "The Gene For Type 2". Many genes have been found to be strongly associated with the disease. (The last time I saw a list, there were 18 genes on it -- but new ones are discovered so often that I'm sure the figure is larger now.)

I repeat, none of these genes is THE gene. None of these genes makes it certain that you will become diabetic; they just increase your risk. It is generally assumed that these genes make you vulnerable to developments which can nevertheless be prevented through careful management of lifestyle ("genes load the gun, lifestyle pulls the trigger" is the usual metaphor). But different people get different combinations of these genes. Perhaps those who inherit only a few of them can hope to avoid the disease if they avoid being fat and sedentary, while those who inherit most of them are so vulnerable to becoming diabetic that there may be nothing they can do to keep themselves truly safe. Since it isn't yet clear what these genes do to increase your diabetes risk, I'd say we are a very long way from having a comprehensive understanding of Type 2 diabetes. I would bet big money that Type 2, when we understand it more fully, will turn out to be a family of roughly similar diseases, not a single disease.

Meanwhile, the people who don't fit the profile of the typical Type 2 patient have to contend with a health care system (and a society) hell-bent on forcing them into that profile whether they fit it or not.

I happened to be talking on Sunday to one of these outliers -- a fellow who seemed altogether too thin, too young, and too active to develop Type 2, but developed quite a serious case of it -- and today I heard from a reader of this blog whose story is eerily similar. This does happen; these people exist. I don't know how many of them exist, but how rare can they be, if I hear essentially the same story from two people within a period of four days? And I don't even get out that much.

I'm sure it helps doctors to be aware of how Type 2 most typically presents itself, but it becomes a bit of a problem when the typical pattern is regarded as if it were universally applicable. Atypical patients count, too.

Public health messages on the subject of Type 2 have given most people the impression that diabetes is nothing more than a symptom of being fat, and that diabetes patients need only lose weight to eliminate the problem. So firmly fixed is this idea in the popular imagination that many people, upon meeting a thin person with Type 2, quickly recover from their confusion and advise the thin person to lose weight.

I'm not sure I see this problem going away until researchers finally solve the puzzle of the 18+ genes associated with what we call Type 2, and figure out how many different diseases are sailing under that flag. I hope that day comes soon.

However, I do have a suggestion for thin active people with Type 2, for those social situations in which someone is making false assumptions about the nature and cause of their health problem. Head them off by blurting out the following: "Oh, no, I have Type 4 diabetes... Yeah, I know, not many people have heard of it yet. They didn't even know it existed until last year! It's really too complicated to go into here, I'll bore you to death if I try to explain it."

And a few years from now it might turn out that you weren't even lying!

Tuesday, June 28, 2011

Strange: a rainy day. We aren't supposed to have that kind of weather in June, around here. The rain stopped around the time we usually run at lunchtime, and I decided to chance it -- though my running buddies, who hate running in the rain, were nowhere to be found. It stayed dry for most of the run, but then the rain started up again while I was still a mile from the locker room. Oh well, I can run in the rain; I just feel sorry for myself when I do it.

The internet gives us all an opportunity for the kind of social mixing that used to take place on the bus, back in the days before most people figured out how to create a life for themselves in which they didn't have to ride the bus. But the people you think you're avoiding by not riding the bus are all over the internet, often intruding into conversations which they would otherwise have no opportunity to join. So what have you really escaped from? Not much!

What brought this to mind was looking at the comments posted on YouTube music videos. I don't usually read such comments (it's another form of not riding the bus, I guess), but every once in a while I get curious enough, or at least careless enough, to give them a glance -- usually to my regret. Well, here's your dose of bathos for the day: six comments posted on one such video that I stumbled across this evening, while looking for something else.  

I always like to review the search strings that caused a search engine to refer people to my site, in the hope that I can provide a belated answer to the questions implicit in their searches. Here's the latest crop:

People are always trying to dream up some reason or other why their A1c test, which is higher than they want it to be, is probably wrong. Some mysterious factor must have been artificially inflating the result! So far as I know, depression doesn't have that effect on an A1c result, at least not directly. If being depressed makes you overeat and avoid physical activity, then those factors could increase your A1c result. But in that case, what really is causing the increase is the lifestyle change, not the mood change.

Lunar eclipses don't affect the A1c test either, by the way.

Well, inflammation is something that does affect the A1c test -- but not in the sense that it makes the test read falsely high. Inflammation increases your insulin resistance, which increases your blood sugar level, which increases destructive glycation, and that increases your A1c test. Anything which triggers an inflammatory response (the flu, periodontal disease, stress) can increase your blood sugar and therefore increase your A1c result.

If you mean a Hemoglobin A1c test, no. 4.9 is normal.

If you mean a plain old Hemoglobin test, the bottom of the normal range is 13.5 for men and 12.0 for women. A result of 4.9 would be anemia, and probably pretty severe anemia, but I don't know whether or not it would be fatal. It doesn't sound promising, though.

I discussed this on June 24; I guess all I can say to someone who wants to try a starvation diet, without taking the simple expedient of first being captured on the battlefield by the Werhmacht, is: good luck, and let me know how it all worked out.

Good luck, and let me know how it all worked out.

Why was this referred to my site? I guess I must be an example of the stigma that is attached to men. Well, maybe it serves us right.

I'm feeling guilty about being amused by this. The idea here seems to be: "I'm not curious about what's actually going on with my blood sugar, because I don't care about my health (or, for that matter, the health of my baby); I just want to figure out how to fool the doctor so that I don't have to listen to a lecture about my health habits". I don't think there is any way to cheat on the Oral Glucose Tolerance Test that pregnant women are usually given, but if I knew of a way, I don't think I would share it.

Find out what's actually going on, and deal with it. Or not -- but if there are other people involved in this, such as unborn children, then deal with it. It's surprising how many people with diabetes assume that happens to them is none of anybody's business, even those closest to them and most dependent on them.

The mechanism most often discussed is "insulin resistance" -- a gradual decline in your sensitivity to insulin. The decline can proceed from various causes, but the common ones are obesity, lack of exercise, sleep deprivation, chronic inflammation, and a general genetic predisposition to insulin resistance.

In at least some patients, the mechanism is a gradual decline in the capacity to produce insulin. Apparently this can sometimes occur without a previous decline in insulin sensitivity. However, it can also occur (and probably occurs most often) as the result of declinining insulin sensitivity and a corresponding rise in blood sugar. High blood sugar is harmful to the cells in the pancreas which produce your insulin supply.

"Prediabetes" is best thought of as simply an early stage of Type 2 diabetes. Some people say no, it's a separate disease, but those people have not yet explained the amazing coincidence by which people stop being prediabetic and start being diabetic on the same day.

These are normal readings. The 89 is unusually low, but not harmfully low.

Not acceptable. If that's the kind of result you see after you eat cereal, then stop eating cereal. You don't want to be over 149 an hour after a meal, and a more truly normal level would be 125.

Most people peak 50 to 60 minutes after a meal. To peak at 45 doesn't strike me as freakish.

If you think medication is all you need to stay healthy, then it's a pretty safe bet that nothing is going to prevent you from going into diabetes. But I'd guess that metformin is the medication that is likeliest to be prescribed for you in the attempt to put off that development as late as possible.

They do have side-effects, including common ones such as chronic diarrhea and a rare ones such as sudden death. But what's wrong with them, as I see it, is that the best-case scenario (in which they normalize your blood sugar) encourages you to think that you've got your health problems totally under control, so you don't need to do anything irksome, such as exercising. Diabetes drugs tend to make your lab report look better without necessarily making you healthier or less likely to drop dead. You have to do more than pop pills if you want to get your health back -- but a lot of people don't do more, because the lab report convinces them that they've solved their problem.

This whole web site is devoted to answering that question; look around.

I haven't heard of people feeling exuberant after a heart attack, but I suppose it can happen. Don't carry it too far, though.

Google is sending the wrong people to me, clearly. I think these are the people posting YouTube comments on songs.

Monday, June 27, 2011

My schedule today was pretty bad, and I never found an opportunity to a post-prandial test; however, with a fasting test result of 78, the post-prandial result probably wouldn't have been that bad. I guess the reason the fasting test was low is that I did a long trail-run yesterday, and had a low-carb dinner afterward. Not wishing to push my luck, I turned down a tempting offer of bresh-baked strawberry scones in the evening. It's not always easy being a good boy...

Monday used to be my rest-day from exercise, and I guess maybe it should be again. I did manage to get to yoga class in the evening; at least yoga has a certain strength-training element to it.

These days we have a three-tiered system for getting the word out about the latest diabetes research:

  1. The researchers publish a paper, probably in a medical journal to which you could never afford to subscribe, and they let the science journalists see a copy of it.
  2. The science journalists, who believe that readers are incapable of taking an interest in any research unless they are told exactly why they should care about it, make up a reason to care about it -- and then describe the research as if it supported that idea.
  3. Bloggers rush in to say, "No! No! That's not what the researchers found!".

Zach Weiner has summed up the first two stages of the process memorably:

I sometimes participate in the third stage of the process, although I choose my battles. I don't comment on every piece of research that doesn't quite mean what it sounds like, but sometimes (as in my June 24th blog on the WONDER CURE FOR DIABETES) I do put my two cents in. Whether I do or don't depends on how worried I am about the likely effect of the popular interpretation of the research on diabetes patients generally.

A Medscape article that I read today raised my worry level fairly high, as it seems likely that the popular-press interpretation of the story is going to be EXERCISE MAKES NO DIFFERENCE FOR DIABETES PATIENTS.

The actual headline that Mescape used was ACTID Results Emphasize Diet Alone Over Diet and Exercise. The article reports on a British study which looked at three groups of patients newly diagnosed with Type 2 diabetes, to track their progress and compare their results. One group received "standard care", another received intensive coaching on diet, and a third group received coaching on both diet and exercise. The latter two groups did better than the first, in terms of Hemoglobin A1c results and other measures; people in the standard-care group saw an increase in A1c in the first six months, while both of the other two groups saw a slight reduction.

But there's the startling part: both of the other two groups saw a slight reduction, and the reduction was about the same either way. People in the diet & exercise group didn't do any better than the diet group! Inevitable conclusion: exercise didn't matter!

Rather than rant about this, let me just list some issues which we should not ignore while we're deciding what we think this research means:

In presenting these results at the ADA conference in San Diego yesterday, Dr. Robert Andrews of the University of Bristol tried to forestall misinterpretations of the findings. "We're not saying that exercise isn't useful, it simply didn't improve the parameters that we measured. There is clear evidence out there that individuals who exercise have reduced rates of cancer, reduced mortality, and other benefits from exercising, such as enhanced sense of well being." Okay, good. And let's keep in mind that "the parameters that we measured" did not include the risk, over an extended period, of experiencing unpleasant consequences such as, you know, death and that type of thing.

You could argue that it isn't Dr. Andrews' fault if people draw the wrong conclusions; he's going out of his way (in the ADA meeting, anyway) to contradict the impression that his data shows exercise to be useless.

On the other hand, if you're going to present results which seem to show that diet is effective and exercise is not, you ought to be doing a more direct comparison between the two than was done in this case. Of course, making such a comparison would require you to round up a group of diabetes patients who are willing to do some serious exercise; perhaps that was the stumbling block which prevented a direct comparison from being made.

Friday, June 24, 2011

I haven't had a rest day since last Friday, so seemingly I'm due. But my running buddies both wanted to go out for a run today, and peer pressure is what it's all about, so I went. I'll do my resting tomorrow. Saturday's a good day for it, after all.

It was a pretty hard run, and my lunch was quite low-carb, so that explains the low post-prandial result.

I first heard about the WONDER CURE FOR DIABETES from a friend who doesn't even have diabetes himself; apparently it has received a lot of publicity in press outlets not normally associated with health news. Today there were some people buzzing about it in the diabetosphere, and as usually happens when anyone threatens to give encouraging news to diabetes patients, many diabetes patients are suspicious and hostile and in a big hurry to conclude that the researchers are trying to deceive us with their irresponsible talk about "cures" for an incurable disease.

To be fair, the actual title of the relevant research paper is not WONDER CURE FOR DIABETES; research publications tend not to go in for tabloid headlines in block capitals. The actual title is Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol.  Although the results reported are certainly dramatic (restoration of normal insulin productivity in the pancreas and normal insulin sensitivity in the liver), there are some good reasons to be cautious about making too much of these findings.

First of all, the sample size was laughably small: only eleven patients participated in the study. When conventional ideas about a disease are overthrown, it usually isn't on the basis of a data set on that modest scale.

Second, the patients in the study may be atypical; they were extremely obese, and it might be unwise to generalize from their experience to the diabetic population as a whole.

Third, the treatment consisted of diet that was extremely restrictive (600 calories a day!). Indeed, the whole purpose of the study was to determine whether or not it was possible to replicate the anti-diabetic effects of weight-loss surgery without actually performing the surgery. If patients starve themselves to something like the same degree that bariatric surgery patients are forcibly starved by means of interior remodeling, do they experience similar benefits? Apparently they do.

However, it's a little hard to imagine someone who is not residing in a clinic (or in San Quentin), under close supervision, adhering to a 600-calorie diet even for a few days. And even if will-power were not an issue, it's a little hard to imagine someone functioning on a 600-caloriie diet. Even people who don't exercise must at least be capable of physical movement of some kind. The study seems to show that this doesn't have to be a lifetime committment -- that people get a long-lasting benefit from having gone on the 600-calorie diet even for a few months.

The idea behind this treatment is that type 2 diabetes is mainly the result of decreased insulin production in the pancreas, and that the cause of that problem is an accumulation of fat in the pancreas; the extreme calorie restriction eliminates the pancreatic fat and therefore eliminates the diabetes. To me it seems doubtful that pancreatic fat is the one and only cause of type 2 diabetes. That might be true in some cases (and perhaps it is especially true of the obese patients included in this study), but I am not at all convinced that it is true for everyone.

I'd say it's a little early to be drawing any conclusions from this study. Let's try to learn from it what we can, and withold judgment.

I was sent some photographs from the big music-party I went to last Saturday. We started out as a smaller group, playing in a restaurant in Inverness, California (it's In Marin County, near Point Reyes)...

...and later relocated to a back yard that was walking distance from there.

Some of these people I knew fairly well, others I didn't, but of course that doesn't matter when you're making music. Which, of course, is most of the point of making music. 

So what's the tie-in to diabetes management, Tom? I guess that making music is one of the things you get to do, if you don't die. Keep on doing what's necessary to not die.

Thursday, June 23, 2011

Okay, here's your good news for the day, courtesy of Reuters Health Information:

Free-Swimming Robot Camera May Ease Intestinal Exams
A tiny, free-moving capsule camera with fins can be swallowed and controlled remotely, and researchers say it may one day make stomach exams much easier to handle.

I can hardly wait!

Speaking of creepy technological developments in the medical field...

I read today that Hollywood, always a hotbed of creative originality, currently has eight different film versions of Mary Shelley's 1818 novel Frankenstein in the works.

No one understands better than I do how hard it is to keep coming up with something new (blogging on a single subject is not for the faint of heart, folks!). But Frankentstein was published 193 years ago, and has been told on the silver screen many, many times before. I suppose that the opportunity for improved special effects is always going to tempt directors to have another go at an updated version. But eight updated versions? What is going on here?

It's not as if Frankenstein is everyone's favorite book. Most people find it mighty hard to read Shelley's novel nowadays; the highflown romantic language takes some getting used to, and so does the structure of the story, which begins very unexpectedly as a series of letters from an arctic explorer to his sister in London. If the novel has been popular as a subject for movies, it isn't because (as in the case of the Harry Potter and Lord of the Rings movies) millions of people had read the book and were aching to see a film version. Most movie versions of Frankenstein jettison large chunks of Shelley's plot, and perhaps most of her point as well. It is a book honored for its mystique rather than for its actual contents.

Part of the mystique is the bizarre back-story of its creation. Mary Shelley (then named Mary Godwin, and only 17 years old) became the lover of the poet Percy Bysshe Shelley. He was already married, by the way. In 1816 they went on a tour of Europe, and spent a summer near Geneva as the guest of Lord Byron. However, that was the famous "year without a summer", because the volcanic erruption of Mount Tambora had filled the world's atmosphere with dust; the weather was so bad that their planned outdoor activities were canceled. Gathered around a log fire in the Villa Diodati, they read ghost stories and discussed recent experiments on electricity and its effect on animal tissues. Byron proposed that they hold a competition in writing a tale of the supernatural. Mary's contribution concerned a doctor who assembles a body from dead tissue and reanimates it. Later she expanded this tale into a novel, and published it (anonymously, at first) in 1818.

This much of the back-story is well-known; but critics (especially feminist critics) think that some other important details of Mary's life contributed to the story.

After the visit to Lord Byron's villa, Mary and Percy returned to England, where she gave birth to Percy's child -- which lived only two weeks. Later that year Percy's wife committed suicide, and he and Mary were legally wed. 

But let's hear a little more about that child. The baby was born two months premature, and obviously faced an uphill struggle if it was to survive. But Percy showed no interest at all in his child's welfare. In fact, he abandoned Mary temporarily, to pursue a love-affair (with her step-sister!). Amazing as it seems, Percy and Mary were ultimately reconciled, and married, and had other children. But it can hardly be irrelevant to Frankenstein that, while writing the novel, she bore a child which was rejected by its father, and then died. In the novel, Victor Frankenstein rejects the creature to whom he has given life, and as a result he is pursued and haunted by the creature forever after.

Perhaps it is worth quoting, at some length, the passage in which Victor Frankenstein recounts the "birth" of his creature, to give an idea of how heavily Shelley emphasizes the theme of parental rejection:

"I saw the dull yellow eye of the creature open; it breathed hard, and a convulsive motion agitated its limbs. How can I describe my emotions at this catastrophe, or how delineate the wretch whom with such infinite pains and care I had endeavoured to form? His limbs were in proportion, and I had selected his features as beautiful. Beautiful! Great God! His yellow skin scarcely covered the work of muscles and arteries beneath; his hair was of a lustrous black, and flowing; his teeth of a pearly whiteness; but these luxuriances only formed a more horrid contrast with his watery eyes, that seemed almost of the same colour as the dun-white sockets in which they were set, his shrivelled complexion and straight black lips.

The different accidents of life are not so changeable as the feelings of human nature. I had worked hard for nearly two years, for the sole purpose of infusing life into an inanimate body. For this I had deprived myself of rest and health. I had desired it with an ardour that far exceeded moderation; but now that I had finished, the beauty of the dream vanished, and breathless horror and disgust filled my heart. Unable to endure the aspect of the being I had created, I rushed out of the room and continued a long time traversing my bed-chamber, unable to compose my mind to sleep...

I started from my sleep with horror; a cold dew covered my forehead, my teeth chattered, and every limb became convulsed; when, by the dim and yellow light of the moon, as it forced its way through the window shutters, I beheld the wretch -- the miserable monster whom I had created. He held up the curtain of the bed; and his eyes, if eyes they may be called, were fixed on me. His jaws opened, and he muttered some inarticulate sounds, while a grin wrinkled his cheeks. He might have spoken, but I did not hear; one hand was stretched out, seemingly to detain me, but I escaped and rushed downstairs. I took refuge in the courtyard belonging to the house which I inhabited, where I remained during the rest of the night, walking up and down in the greatest agitation, listening attentively, catching and fearing each sound as if it were to announce the approach of the demoniacal corpse to which I had so miserably given life.

Oh! No mortal could support the horror of that countenance. A mummy again endued with animation could not be so hideous as that wretch. I had gazed on him while unfinished; he was ugly then, but when those muscles and joints were rendered capable of motion, it became a thing such as even Dante could not have conceived."

Note that the creature's impulse to smile and reach out to its "father", as a child would do, only disgusts the man and sends him flying from the room. The horror here is in Frankenstein's reaction to the creature -- not in the creature itself (although, traumatized by this rejection, the creature will later become vengeful).

The complaint is often heard that people incorrectly refer to the creature, not his creator, as Frankenstein. But this confusion arises mainly because Frankenstein never gives his creature any name at all; it is all part of his rejection of what he has made. The creature remains to him an object -- a "wretch", a "monster", a "demon", but never a living being to whom he owes any loyalty or responsibility. This point is so strongly made by Shelley that her story is probably a cautionary tale of a slightly different kind than most people think. The main point of Frankenstein may not be that it is dangerous to tinker with the forces of nature, but that it is dangerous to run away from your responsibilities -- because some responsibilities simply cannot be run away from.

Maybe it's about time for a film version of Frankenstein to highlight the issue which, for Shelley, seems to have been most important. Perhaps one of the eight films currently in development will have a go at that.

But the popular appeal of the story clearly has little to do with Mary Shelley's literary intentions. What is it about the basic Frankenstein story that speaks to us?

My guess is that it has something to do with an ambivalence which people feel about science, and particularly medical science. We want it to produce miracles (knowing as we do that we might need one, sooner or later), so to a degree we sympathize with Victor Frankenstein in his quest to create life artificially. We want to see that assemblage of dead tissue wake up and open its eyes. And yet, at the same time, we fear the unintended consequences of miracle-working. In most tales of the supernatural, when a magic wish is granted, you can bet that there will turn out to be a catch, and that the catch will have horrible consequences.

Such tales do have a point -- up to a point! If the idea is that we should be cautious in accepting what look like medical miracles, and should evaluate their risks and benefits carefully, I can't argue with that. If the idea is that any medical innovation is a bad idea, then I'm ready to argue.

We all have to draw the line somewhere, in terms of risk/benefit analysis, and we are not all going to draw the line in the same place. I'm not willing to risk having eye surgery to correct my vision, but lots of people feel comfortable with that. I'm surprised that anyone at all is willing to risk having radical weight-loss surgery, but it's their decision. I don't want to make treatments unavailable to other people just because they sound creepy to me.

I guess we all get to decide on where our personal threshold is for the Frankenstein factor. So far, I'm more cautious than most people about these things. But I can't promise that I won't change my tune, if I end up having physical problems which prevent me from exercising, and I have to re-think this whole diabetes-management deal. Maybe, some day, I'll end up begging my doctor for a treatment which would seem horrifyingly unnatural to me now. And if I get to that point, I don't want a crowd of angry torch-bearing villagers to storm my doctor's castle and tell him not to do what I want.

Wednesday, June 22, 2011

Today, during our lunchtime run, my running buddies had pulled ahead of me, but then I caught up to them because they had stopped by the side of the road. The drama of nature was unfolding before them. A mama quail was trying to get her brood of tiny quail chicks herded back under a bush, but several of them had tumbled off the sidewalk into the gutter, and they were so small that the curb was a gigantic wall to them, which they couldn't get over.

One of my running buddies is so soft-hearted about defenseless animals that recently, on a rainy day, I actually saw him bend over and pick up an earthworm from a walkway, and move it to the lawn so that it wouldn't be stepped on. The baby quail were tugging on his heartstrings even harder than the worm had (being non-repulsive and all), and he was trying his best to help the chicks get up on the curb. He couldn't catch them, but he found a rock and moved it up against the curb, so that they could use it as a step-ladder, and tried herding them towards it. Unfortunately they were having trouble grasping the step-ladder concept -- they climbed the rock, all right, but only to get over it and down the other side, and continue running away from him. Then a scrub jay, which had been observing all this activity, swooped down, grabbed one of the chicks, and took off with it to eat it for lunch. Somehow my running buddy concluded that this was his fault -- he had attracted the scrub jay's attention to the chicks, with tragic results!

I'm more of the no-use-crying-over-spilled-milk type, to be honest. Anyway, we concluded that we couldn't to anything to save the day, and continued with our run. We had been shown a little lesson in nature's strange combination of beauty and cruelty. For every cute baby animal there is a predator waiting to devour it. Whatever we find beautiful in nature is paired with, and endangered by, something ugly. We'd like to be able to see only nature's beautiful aspect, not its cruel aspect -- but that option doesn't seem to be available to us. Life is a package deal. Enjoy the good parts while they last -- and try to make them last longer.

Our run, after we continued past the quail crime-scene, went up to the Paradise Ridge winery, where we stopped briefly to take in the panoramic view of the valley to the west. As usual when we run up there, we joked about wanting to take a break while we were there and do some wine-tasting. Suddenly I remembered that tonight was one of their "Wines & Sunsets" events, and I decided to come back in the evening and join all the other people sitting on the decks and balconies, watching the sun set over the valley and sipping wine.

The recent heat wave is over; the weather was only mildly warm. Perfect for sitting outdoors in the evening with a cool glass of wine, looking out over the vineyard from whence it came.

After such a cool and rainy spring, it was nice to have the opportunity to indulge in a little bit of mild California hedonism.

Every day should be like this, I guess that's my bottom line.


Tuesday, June 21, 2011

Sorry, sorry! I dropped off the radar screen last week, with no blog updates, and no explanation of why I had stopped doing them. This happened for reasons beyond my control, but it had nothing to do a health emergency involving me or anyone else. The problem was technological, not medical.

Last Thursday, as I was preparing a blog post, I suddenly lost my DSL connection to the internet. After a while I realized that I hadn't just lost my internet connection; I couldn't get a dial tone on the telephone. The land line to my house had gone out.

One would think that it would be easy to get such a problem corrected quickly, but I have been trying ever since to get AT&T to listen to me about the problem, which they said didn't exist. They kept insisting that they had tested the line and it was fine. If I had a problem, it must be my problem, on my equipment. In order for them to be right, my telephone and my DSL box would both have to fail simultaneously. Not a very plausible scenario, but apparently they considered anything to be more likely than that they were mistaken about my line being in perfect working order.

It wasn't until this evening that they finally consented to send someone out to check the line. He immediately established that there was, indeed, no signal getting as far as my house. Off he went to a switching station about 500 yards away, where he discovered that the wire that goes to my house had been accidentally pulled out (by a technician repairing a different line), and it was just hanging there. He plugged it back in, and suddenly my connection at the house was restored. This leads me to wonder what their "test", which convinced them that the line to my place was in fine shape, actually consisted of. I'm not sure that it's as thorough a test as it might be, if an unplugged wire is too subtle a flaw to be detected by means of such a test.

The most infuriating of the many infurtiating things they said to me about this, over the course of the past several days, was in a phone message they left me at my work number, after their "testing" convinced them that the line was fine: it mentioned that they had tried to leave me a message on my home phone, but "apparently you don't have an answering machine". In fact I do have an answering machine, but it's hard to leave messages on it when the line to my house is disconnected.

Note to AT&T: the fact that you hear a "ringing" sound when you call a number does not mean that a phone is actually ringing on the other end (especially when the person who lives there keeps telling you that the line is dead). That ringing sound proves nothing more than that the phone network is trying to make a phone ring. I'm not sure why AT&T needs me to explain this to them, 135 years after Alexander Graham Bell made his first phone call, but no one can accuse me of being unwilling to share knowledge with those who are in need of it.

During my five-day struggle to get AT&T to pay attention to my description of what was actually happening, instead of clinging to the hypothesis they had dreamed up when they called my number and heard a ringing sound, I was not so completely wrapped up in my frustration and resentment that I didn't notice the metaphorical significance of all this. I was not a consumer in this situtation -- I was a patient. A patient confronted with a medical bureaucracy which has already made up its mind about him, and therefore will not take in any information he provides which does not support the assumptions already established.

This is what scares us about medical bureucracies, and makes us fear to change doctors. We want to know there is at least one human being involved in our medical care who isn't just going to ignore what we say because it isn't what they expect to hear. We want to have someone to talk to who has enough personal acquaintance with us to see us as an individual rather than a category.

"Diabetes patient" is about as bad a category as you could possibly be linked to, in terms of the assumptions typically made about people in that category (socially, at least, and in some cases medically as well). To be seen as a faceless representative of the "diabetes patient" category is no way to be respected or believed. 

I usually emphasize the importance of not being the typical diabetes patient, but I must admit that sometimes this isn't enough -- we must also avoid being seen as the typical diabetes patient.

I'm sure there was no way I could have persuaded AT&T to drop their assumptions and listen to me, since I don't know anyone who works there. But what if I did know someone who worked there? Then I could have had a way to slip through their corporate defenses, and get someone to listen to me; the problem would then have been solved a lot quicker.

Just to be clear: what I'm proposing here is not so much "find a nice doctor" as "establish some credibility with your doctor". The latter is a more challenging task than the former, and takes longer, but it's an important aspect of diabetes management which usually goes unrecognized.

The FDA has decided to start putting scarier warning labels on cigarettes:

This is done in other countries already; I don't know with what success.

If they've got a diabetes-related warning label planned for Cinnabon, I don't want to see it. Not having tried one of their cinnamon rolls since my diagnosis, I thought I would look up the nutritional data to see if they're really all that bad:

Yeah; pretty bad. But I don't want to see any photographic evidence of what happened to the extremeties of somebody who ate too many of these things.

I usually test at the 1-hour point rather than the 2-hour point, but at the 1-hour point this afternoon I was having a one-on-one meeting with a new project manager at work, and I didn't feel like interrupting the conversation to take a blood sample. I figure it's not the best way to introduce yourself to someone who is going to be leading your team. As I've said before, I don't keep the diabetes issue a secret at work, but neither do I make a display of it, especially in front of employees I don't know well.

What I do put on display at work, apparently, is the exercise program that I use to keep the diabetes from being a problem. We're having a bit of a heat wave currently (it was 94 degrees this afternoon), and all sorts of people (including someone passing in the hall whose name I do not know) asked me if I'm going to go out for my usual lunchtime run in this weather. Well, I wasn't, but only because I had a meeting that was scheduled inconveniently; I was planning to run in the evening -- preferably after it had cooled down a bit. Interesting, though, that this is the thing people notice about me at work, whether they know me or not.

And I did go for a run in the evening, down a road with a lot of shade trees. And on the way back, I was halted in my path by a speciimen of wildlife, wandering ahead of me on the side of the road. The animal had its back turned to me, but this fact was not as reassuring as it might have been, given that the animal in question was a skunk.

I decided to pause for a while,and let him continue rambling on, in the hope that he would turn aside and leave the road to me. Eventually he did turn aside, and disappear into some tall grass at the side of the road. But once I lost sight of him, I found it difficult to go running past that point, not knowing whether he was hiding in there, and possibly preparing himself to act as the skunk equivalent of a sniper. He didn't.

Wednesday, June 15, 2011

Astrology is always better when it's funny on purpose...

That's my horoscope from The Onion. So this is not serious astrology, and you shouldn't make any life plans based on it, as you would with honest-to-goodness reliable astrology.

Warmer still, today; it got up to 89 degrees. We chose one of our hilliest running routes (it goes up a road called "Ridgeview Drive", and it's called that for a reason) -- not because we wanted to make things especially hard for ourselves in the heat, but because there was more shade on that route than on any other. Every time we got into the shadow of a clump of trees, we wanted to linger there for a while.

Even though the run was little more than 5 miles, I did start to feel a little worried during it that I hadn't brought a water bottle with me. I guess we've reached that transitional point in the year. It was only on Monday that I realized I no longer need to put on even a light jacket when I leave the house in the morning. Now it's getting warm enough that a 5-mile run is beginning to seem like a dehydration hazard. Time to start carrying that water bottle!

On the dLife forum today, someone who was complaining of intermittent (but intense and disabling) pain in the hands mentioned that "My family say it is diabetes related and there's nothing I can do".

I don't know which irritates me more: the common assumption that diabetes is the only possible cause of every problem that arises in the life of a diabetes patient, or the assumption that any problem caused by diabetes is hopeless of remedy.

Amateur diagnosticians (whose knowledge of diabetes can usually be summed up as "it's bad and it has something to do with sugar") are always ready to put two and two together: "I know that you have diabetes, therefore I know the explanation for every bad thing that ever happens in your life. If you fall off a train platform, I will conclude that diabetes made that happen somehow."

The trouble with this simple assumption is that people who don't have diabetes have been known to experience health problems. Pain in the hands, surprisingly enough, can occur in non-diabetic people, from a variety of causes. If sore hands can have causes other than diabetes, then it is not reasonable, in the case of a person with diabetes and sore hands, to take it for granted that their diabetes is the only possible explanation for their sore hands.

As for the supposed hopelessness of any health problem associated with diabetes, I think this is a pretty clear case of self-fulfilling prophecy. It's true that we don't often hear about success stories in this regard; but is that because improving the situation is impossible, or is it because people discouraged by predictions of inevitable failure don't try very hard to succeed?

If you insist on telling people that they are doomed, that nothing they do to improve the situation can possibly work, then naturally they give up, and your prediction comes true. But that doesn't mean your psychic powers were exceptionally good; it just means that your interference in the situation was exceptionally harmful.

Tuesday, June 14, 2011

Oh boy, it's getting still warmer -- into the mid-80s today. Everyone was outdoors in the evening.

The Scottish expatriates I work with, who have been waiting a very long time for the California weather they were promised, are finally getting some of it. (Of course, the California weather they were promised is actually southern California weather, and this is northern California. Too bad they didn't check with me about that before moving here.)

The lunchtime run seemed hotter than it was, simply because we had a cool and rainy spring and my body's hasn't yet adjusted itself to the concept of warmth. I hope it manages to recalibrate itself before we have any 100 degree days.

One of my running buddies has presented me with a dilemma. He thinks we ought to run another marathon.

What he means by that is complicated, and would be hard to understand if you've never run a marathon yourself. He means that he wants to run another marathon -- but he can't just go do that on his own, without dragging anyone else into it.

He knows that he can't face doing all the required training (which is quite difficult and time-consuming) unless he's training with someone else for the same race. Most marathon runner are this way, I should point out. I'm that way. It takes a tougher person than I am to just go and train for a marthon all by yourself, with nobody else putting any pressure on you to do what needs to be done.

He also knows that I've been tempted by the idea of doing at least one more marathon -- mainly because my most recent marathon, in miserable rainy weather, was such a disappointing experience that I hate to have that be my last one. I have reservations about the idea, however. Marathon-running is really hard on you, and I've come to wonder whether the benefits you get from such an extreme endurance sport really compensate for the wear and tear on the body. At this point he's not interested in my doubts, however. Since he needs someone else to be training with him, giving him the peer pressure he needs to keep with the program, he figures I'm the obvious person to fill that role. After all, I've done it more than once before. He's the one who talked me into running my first marathon (the California International Marathon, in Sacramento in 2005), and of course we trained for it together and ran it together.

He's also trying to enlist another one of our running buddies, through the devious method of talking to each of us separately and then telling each of us that the other one is far more enthusiastic about the idea than we ever said we were. Surely he must know by now that we compare notes after he talks to us! But I guess we have come to see his chicanery in these matters as a forgiveable weakness.

I'm not yet ready to make a decision on this, but I'm thinking about it somewhat seriously. I guess I miss the intense focus of marathon training -- the shared challenge of it. I'm just not sure I miss the sore hip-joints, that's all.

Anyway, if I'm going to run another marathon, the one I'm most tempted to run is the one in Healdsburg on October 16. If I decide to do that one, I'll have to start training around mid-July.

When you run a marathon in the fall, the training takes place in the summer, which is both good and bad. You don't have to cope with doing long training runs in the rain and cold, but you do have to cope with doing long training runs in the heat, which can be a pretty serious challenge.

The training schedule for that race would as shown in the table below (the numbers are running distances in miles; "gym" means any kind of workout that isn't running; all Mondays are rest days).

Week Tue Wed Thu Fri Sat Sun
July 11 - 17 3 5 3 Gym 7 Gym
July 18 - 24 3 6 3 Gym 12 Gym
July 25 - Aug 7 3 6 3 Gym 13 Gym
Aug 8 - 14 3 7 4 Gym 10 Gym
Aug 15 - 21 3 7 4 Gym 15 Gym
Aug 22 - 28 4 8 4 Gym 16 Gym
Aug 29 - Sep 4 4 8 5 Gym 12 Gym
Sep 5 - 11 4 9 5 Gym 18 Gym
Sep 12 - 18 5 9 5 Gym 14 Gym
Sep 19 - 25 5 10 5 Gym 20 Gym
Sep 26 - Oct 2 5 8 4 Gym 12 Gym
Oct 3 - 9 4 6 3 Gym 8 Gym
Oct 10 - 16 3 4 2 Rest Rest RACE

Am I ready to take this on? I'm not yet sure. I've got some time to decide, but marathons are the sort of events you need to make up your mind about well in advance.

Monday, June 13, 2011

Why is my fasting test in the 90s today, when lately it has been in the 80s or lower, and I did a tough 8.3-mile trail run yesterday? The two likeliest explanations are:

It could be both. Or neither. Anyway, my post-prandial test was good today, so I assume I haven't thrown my system out of whack.

The weather is getting more June-like. 79 degrees today, and predicted to be 83 tomorrow. During yesterday's trail run, I found the meadows yellow with wildflowers. Allergies not too bad, though, considering!

You know what today is? Monday the 13th! And you thought Friday the 13th was unlucky! Assuming, of course, that you're enough of a dope to think that one square on a calendar is any less "lucky" than another one is.

Even if mathematicians had never worked out and tested the laws of probability, the basic silliness of the "luck" concept would still have to be pretty obvious to anyone who really thought about it. Yes, unpredictable things sometimes work out well for us, and sometimes work out badly, but any pattern we claim to find in this is pure fantasy.

The idea of "luck" arises from the observation that fortunate or unfortunate outcomes often bunch up; the sprained thumb and the surprise thunderstorm and the problem with your starter motor all happened to you on the same day, and all this has to mean something. But there's nothing significant or surprising about that. There is no reason to expect that, in the operations of chance, good luck and bad luck will occur in regular alternation; if it were that predictable, we wouldn't call it chance. What we get, instead of good and bad outcomes alternating regularly, is an abundance of winning streaks and losing streaks, which occur randomly, and don't mean a thing. Unfortunately for us, the pattern-matching part of the human brain stubbornly refuses to accept this obvious fact of life.

Nothing is random and meaningless (says this primitive application program running in the background of our brain's operating system)! There's got to be a reason why it rained on your picnic and was sunny the next day! There's got to be something you can do prevent that sort of thing from happening next time! There's got to be something you can do, some happy thought you can think, or some lucky object you can carry, that will make your "luck" improve. Thus the casino industry is able to continue flourishing, even though it is no secret that the odds are stacked against the customer. People on a winning streak think there's a way for them to keep it going; people on a losing streak think there's a way for them to turn it around before their money is gone. So they stay, and they play, and they pay.

My mother knew a card-player who carried around a small dark oval thing in her purse, and put it on the table next to her when she played. "That's my lucky raisin," she would explain.

I don't know how she came to realize that this particular raisin, out of all the raisins that had ever played a role in her life, had the power to alter events so that she would be dealt a stronger hand of cards than the other players. Did she try carrying around other raisins, with disappointing results, before she finally found the right one? How did the power of the right one reveal itself to her? And how exactly did she think the raisin did what it did? What was the mechanism of action? Was the raisin consciously trying to help her win? Were the cards saying to themselves, "Uh-oh, we'd better deploy ourselves in a more favorable sequence -- the raisin is here!"?

The idea of a day being lucky or unlucky is particularly hard to fathom. If the day is lucky in general, then everyone has to win the card game, everyone has to snag that great parking space right in front of the restaurant, and every applicant for that new job in marketing has to get it. Furthermore, the weather has to be good (not just here, but everywhere, since it's the same day everywhere), and there can be no accidents or crimes or deaths. No tearful romantic breakups, either. Everybody wins! (But if it's an unlucky day, everybody loses.)

You see what I mean? If you really thought about these things, you'd soon enough recognize their absurdity. But we usually don't think about these things -- much to the delight of those who would like to take advantage of this naivete of ours. They can't get over what a golden opportunity we're giving them, to play on our anxieties about issues we can't fully control (our health, in particular), and separate us from our money.

Because, when confronted with something which we can't reliably observe or predict, we are primed to imagine a meaningful pattern where none exists, we are very easily manipulated by someone who presents us with a pattern and says "Look how well it fits!".

They should be careful not to overplay their hand, however. Sometimes, in their eagerness to find some pattern that we will agree to believe in, they present us with too many different patterns, and we start to get the impression that they are just making things up at random, hurling at us every idea they can think of, and hoping that something will stick.

Such is the case, I'm afraid, with Tom Om, a German chiropractor, spiritual healer, and Reiki Master, who proposes to eliminate our health problems through an amazingly varied combination of ideas. Reiki, I should mention, is a traditional Japanese healing practice, but Tom Om has found a way to combine it with western religion, to produce "Christ Reiki" and "Angelic Healing Codes". Also astral projection and reincarnation, and various practices from India (not to mention the lost continents of Atlantis and Lemuria). Also concepts of ESP/spiritualism, such as Akasha, and "Starseed Master Codes". Most important of all, perhaps, is the concept of 12-strand DNA.

We all know (don't we?) that DNA has only two strands. Well, the kind we are familiar with has only two strands, but there should be twelve, and would be, if it had not been for interference from alien beings who are up to no good. Let me quote a bit from Tom Om. Fasten your seatbelts, ladies and gentlemen:

The DNA was/is manipulated by ET's to gain power over the planet. But what do they want why is this time line so important? As I mentioned in my last DNA Healing Secrets, an important Stargate (templar complex) is going to open now.

And whatever group controls the planetary templar complex when this star gate (some call it Amenti gates) will open in 2012 , will have dominion over the planet and also will have access to the core universal star gates in Mintaka, Orion. The last time Amenti opened , pole shift occurred due to intruder manipulation, and would have again, if guardians, who protect the human race, had not been intervened.

So, as you can imagine, there are many things going on, which you might not even dream of. But this is not important.

Important is your personal vibration, which you should raise in order to stay in tune with the storyline happening around us, whether you are aware of it or not.

You have to re-connect to your soul purpose, your Higher Self. And one of the most effective methods are DNA activations, which you will receive with a guide on how to re-connect to your Higher Self and further crucial breathing exercise instructions.

What are you waiting for?

Activate your potential NOW!

In the next mail we talk about the parallel earth, and why they have already been manipulated by 'Dark Forces' and already living under the 'One World Order', which is under ongoing operation here.

Well, who among us, confronted with the mysteries and unpredictabilities of diabetes management, has not been tempted to think that this whole problem must be the work of sinister extra-terrestrials who have manipulated our DNA strands? And that the only way to regain control of the situation is to unite Chistianity and Spritualism with the traditions of Japan, India, and Atlantis, and then do breathing exercises? It sounds like a very complicated thing to put into practice, but fortunately Tom Om has many DVDs to sell you which will explain how to do it. So, as he so rightly asks, what are you waiting for?

If you're waiting for me to give you link to this craziness, I'm not going to. I'm sure you only have to sit still, and Tom Om will find you.

But maybe I shouldn't choose an example so obviously silly, just because I find it amusing. None of us will fall for everything -- but all of us are capable of falling for something; sooner or later someone will sucker us into perceiving a non-existent pattern in random data, and leverage our credulity into profit for themsleves -- if we don't constantly fight our own impulse to see things that aren't there.

A large portion of everything you will ever read about health in general, and diabetes in particular, is either speculative or fictional; regardless of whether or not it is true, the real reason you're hearing about it is that someone has decided it would be to his financial advantage to have it believed.

Except, of course, in the case of this blog, as I derive no financial advantage from it at all. If anything I tell you is wrong, it won't be because I'm trying to sucker you; it will be because someone succeeded in suckering me. I'll try not to let it happen too often.

But don't trust anyone too much. Last week half the news outlets on the planet were taken in by a creepy story about a mass grave being discovered in Texas. It eventually turned out that the only evidence for this mass grave was a phone call to the police from a woman who said she was -- wait for it! -- a psychic. And the cops not only believed her, they brought in the FBI, and told reporters all about what they expected to find when they dug up the back yard of a man whose only crime was to be living near enough to the psychic for her to be able to describe his house. The fact that she offered a detailed description of the property was, to the cops, more than enough to establish her credibility; the only thing she was wrong about was that little detail about there being dozens of murder victims buried there.

Ain't that always the way! You get one little thing wrong, and then some cynic like me comes along and tries to make it look as if you don't know what you're talking about.

Friday, June 10, 2011

I decided to take my rest day today rather than tomorrow, because it was sunny today and I didn't feel like taking my sunburned head outside to run. But tomorrow I'll put on a hat and a bunch of sunblock and go do a long trail run.

You don't get to choose your genes. Usually you don't even get to know your genes. You inherit a combination of them, after all; some from your mother's side of the family, and some from your father's side. I spent yesterday hoping that my longevity genes, at least, came from my father's side.

But since you can't choose your genes, and you can't do anything about it if you happened to get the wrong ones, your genes should not be your center of attention.

People with diabetes need to distinguish very clearly between the things they can't do anything about, and the things they can do something about -- and put their attention on the latter. There's a rather large practical difference between feeling unhappy that your boat is leaking and bailing out the boat.

Exercise Reduces Silent Brain Infarcts reads the delightful Medscape headline. I would certainly like to have as few brain infarcts as possible, be they silent or noisy. Even the silent ones can be pretty bad, can't they?

It turns out that an "infarct" is a localized area of tissue death, which occurs when an arterial blockage causes a localized area of tissue to be deprived of blood (and therefore deprived of oxygen). When the tissue affected by such an event is myocardial tissue (that is, heart muscle), this is called a myocardial infarction by doctors, and a heart attack by everybody else. Heart attacks tend to be noticed (although sometimes people who feel awful for a day or two don't realize that a minor heart attack was the reason). Apparently brain infarcts, however, can be "silent" -- people don't feel anything when they happen. But that doesn't mean they are harmless.

"These silent strokes are more significant than the name implies because they have been associated with an increased risk of falls and impaired mobility, memory problems, and even dementia as well as stroke," says Dr. Joshua Willey of Columbia University in New York.

The study tracked 1200 people over a six-year period (most were about 70 at the end of that period), and studied them for evidence of "silent brain infarcts". About 16% of them did show such evidence. It turned out that people who engaged regularly in moderate to intense exericse had about half as much risk of silent brain infarcts as those who engaged in light exercise or none.

I never thought that light exercise was enough, at least for people with diabetes. This is further confirmation!

I think I'll do an extra-hard run tomorrow.

Thursday, June 9, 2011

I took the day off from work today, and went down to San Francisco for a small family gathering.  

Despite the ever-reliable fog pouring in through the Golden Gate, I managed to get a bit of a sunburn, because the temperature was comfortable enough for sitting outdoors, and I did a little too much of that.

We had lunch at the Swan Oyster Depot, a fresh-seafood place which is an old San Francisco institution, but which I had not been to before. If they wanted to change their name to The Diabetes Solution, they wouldn't be lying -- I doubt I've ever been offered such an easy way to get my protein without getting a wagon-load of starch and fat along with it. Fancy that: you can have a bunch of prawns and crab-meat assembled atop a mound of lettuce instead of a mound of rice!

Still, it was a big lunch, and I was feeling faintly uncomfortable because I hadn't been able to stick to my original plan of going for a run early in the morning before I drove down to San Francisco. (I just didn't get up early enough to fit it in.) I would need to work out after I got home in the evening.

I managed to get home before sunset, and go for an outdoor run without having to carry a flashlight. It was a hard, hilly run -- but rather to my surprise, despite the big lunch, I felt energetic throughout the run and finished it a couple of minutes faster than I usually do.

Then: time for dinner. What could I risk having? I figured that, since my big lunch had been mostly protein rather than carbs, and I'd just done a really tough, hilly 5.3-mile run, I could probably get away with having a big bowl of split-pea soup. I like the stuff, but it's pretty carb-heavy, and I'm often worried about having it for fear that the diabetes gods will become angry and punish me. But on this occasion I got away with it. Boy did I get away with it! 88 mg/dl is almost absurdly-low for a post-prandial result, whatever you're eating. I guess exercise really does provide the benefits we're told it provides -- if you keep doing it long enough!

Maybe that's the problem diabetes patients run into with exercise: they never give themselves the opportunity to find out what exercise can really do for you, if you exercise hard enough and keep doing it for a long time.

Wednesday, June 8, 2011

More nice sunny weather, without being too warm for comfortable running. Long may this trend continue!

Apparently the "rapture" nonsense on May 21 didn't bring enough shame on Northern California; now the Dry Creek School District in Roseville is asking the parents of elementary school students to specify whether their child was delivered vaginally or by caesarean section, and why.

An offended mother of one of the students has been asking the school district to explain why they need to ask such an intrusive question. Although the school district has been unwilling to speak with her about the matter, it has reportedly been offering to reporters the excuse that gathering this information enables them to determine which students have "birth defects".

It's a fascinating idea. Birth defects are determined by how the baby is delivered? Who knew? I thought embryonic development determined that. I thought the baby you got was the one that was in there, regardless of what extraction method was used. I wasn't prepared to hear that a baby might have one head if it's delivered vaginally, and two heads if it's a caesarian -- but apparently that's the way it works, at least in Roseville, California!

I also thought that, if a child had a birth defect serious enough to have an impact on participation in school, this could probably be detected without investigation into the history of anyone's birth canal. But apparently I was wrong about that, too.

For me, what this story illustrates is that the temptation to treat people as if they were things is alarmingly strong, and the temptation seems to be especially powerful when matters of health are under discussion. Giving bureaucrats the power to indulge that temptation is never a good idea. If the Dry Creek School District gets away with this, what will be the next phase?

I will be disappointed if no one's career ends over this. Whether Congressman Weiner sends naughty pictures of himself to a woman not his wife is immaterial to me, but when school district officials start experimenting with totalitarianism someone needs to call a halt. 

Is medicine one of the "hard" sciences? 

The hard sciences are the ones that can be objectively verified. Physics and chemistry are unquestionably hard sciences, because they deal with ideas that can always be put to the test -- in a particle accelerator, in a test tube, or possibly down at the bomb range -- and found to be true or untrue. This makes the hard sciences very scary to engage in: whatever ideas you put out there can be looked into by experimentalists, and bluntly refuted if they're wrong.

Science gets softer when it studies subjects which don't lend themselves to experimental verification. Your hypothesis explaining dinosaur exctinction might sound plausible, and might agree well with the evidence we have, but it's not as if you can check it out by recreating the events of 65 million years ago in the lab. If you're wrong, perhaps nobody will be able to prove that you're wrong during your lifetime.

Psychology and sociology are as soft as science gets -- not only because of the practical/ethical limitations on experimentation, but also because emotional bias is inescapable in these areas. Most people have no great emotional investment in molecular structure, but everyone (including scientists) has strong personal feelings about what people are like, and strong personal opinions about how societies should be run. And why fight the impulse to inject these personal views into your conclusions, when nobody can prove you wrong anyway? If you disagree with Einstein about the time-dilation effect, there are ways to find out which of you is right; if you disagree with Freud about the Oedipus complex, it is simply your word against his, from now until the day when the last member of Freud's cult has finally died.

Of course, scientists who work in the soft-science fields hate being categorized as second-class citizens within the scientific community, simply because they work on problems that are harder to verify than covalent bonds are. But I think this impaired credibility is, quite legitimately, the price to be paid for working in a field which leaves so much room for interpretation that it also leaves plenty of room for bias, wishful thinking, social prejudice, and uncheckable error.

But where is medicine located on this hard/soft spectrum? Is medical science hard science?

Medical science deals with a lot of things which are measurable, certainly. That pushes it toward the hard end of the hard/soft specturm. But medical science also deals with living human beings, and everything that goes wrong with them (including mental and behavioral problems), so it suffers from many of the same uncertainties and bias problems that social science does. How seriously can we take medical research under the circumstances? A large proportion of medical research studies could be boiled down to: "Phenomenon X is more likely to occur in people who are in Situation Y. Having pointed that out, we would now like to tell you about an unrelated and reckless conclusion which we have just jumped to."

What brought this to mind was an article in Medscape, although it is an article about psychology -- the softest branch of medicine. Anyway, the headline read: Schoolyard Bullies More Likely to Abuse Partners. "What a startling revelation", I thought. Who could have predicted that people who are abusive at an early age would turn out to abusive at a later age? Well, come to think of it, anyone could have predicted it. But at least we now have confirmation of this extremely unstartling fact.

Of the risk factors that increase your chances of becoming an abusive spouse (including being a victim of parental abuse, or being a witness to spousal abuse early in life), having been a bully yourself is the strongest predictor of all: it makes you four times as likely to become an abusive adult partner.

But what do we make of this association? Here's what Dr. Jay Silverman had to say: "It was somewhat surprising that the effect for bullying was so much more powerful than many of the other issues we typically consider... The take-home message is that bullying should be an important consideration when we're thinking about reducing gender-based violence in adults. We really need to look at bullying also through that lens."

Come again? We can prevent gender-based violence in adults by calling a halt to schoolyard bullying?

I'm all for calling a halt to schoolyard bullying, but not because I think it causes the bullies to beat their wives twenty years later. I see no justification, in the statistical correlation of youthful bullying with adult bullying, for the assumption that the former causes the latter.

I have an alternative hypothesis which fits the data equally well. Here it is: some people are bullies, and they stay that way their whole lives. Either they end up beating their wives, or they end up interrogating the parents of a schoolchild on whether the kid's birth was vaginal.

Tuesday, June 7, 2011

The sun came out today, as we knew it was bound to do sooner or later, making the landscape cheerful without unduly heating up the atmosphere. So it was a nice day for running. We chose one of our less-common running routes -- one which goes through the grounds of a hospital. Sometimes, when we run the "hospital route", as we call it, I imagine a scene in which we are jogging past the emergency-room entrance just as a heart-attack patient is being carried in, and the victim glances sadly at us from his gurney, thinking that if he'd been doing what we're doing, he might not be in this mess. However, I suppose if this scenario ever does play out, it might be spoiled for me by some minor detail. For example, it might turn out that the victim is wearing sweaty running clothes, and he clearly was doing what we're doing when the heart attack happened. Or, it might turn out that a second glance at the patient reveals that the patient is me. Be glad you don't have my imagination: every idle daydream takes me on a journey into the twilight zone.

But while we're on the subject of heart-attack worries, a team of British researchers thinks they have found a clue to the slightly mysterious link-up between diabetes and coronary heart disease. (I mean, come on: why would those two things be connected? No mechanism which would enable one problem to cause the other suggests itself.) The new thinking on this subject relates to a highly specific variant of LDL cholesterol in which three rather than two proteoglycan binding sites are exposed. Perhaps I should back up a little.

LDL, or "low-density lipoprotein", is a variety of cholesterol which is typically called "bad cholesterol". (In the diabetes class I was sent to after diagnosis, I was advised to remember the "LD" as standing for "Lousy Deadly" rather than "Low Density".) The reason LDL is seen in such a negative light is that it tends to form deposits on the walls of your coronary arteries (that ones that keep your heart muscle working). When the deposits get so thick that the blood flow to your heart muscle becomes dangerously restricted, you start getting crushing chest pains and seeing yourself do this:

Not a good place to be, obviously, and we're advised that diabetes patients must work harder than anyone else to avoid going there. But why, exactly, does the status of being diabetic heighten the risk of coronary heart disease? Given that cholesterol is a fatty substance, and diabetes is a disease of sugar regulation, why should people with diabetes be any more likely than the rest of the population to experience a dangerous buildup of cholesterol deposits on the arterial walls? What has sugar got to do with it, in short?

The researchers were studying a particular variant of LDL cholesterol which is more abundant in people with diabetes. This variant of LDL is modified by glycation (that is, by reaction between a sugar and a protein). In this particular case, a chemically "aggressive" sugar molecule known as MG (for methylglyoxal) modifies LDL, and changes its properties.

The modified LDL is smaller, and people with diabetes have more of it because their blood glucose levels are elevated and they therefore experience more glycation in general (as reflected in the elevated Hemoglobin A1c test results which most diabetes patients have).

The researchers decided to study this modified form of LDL, to see in what other ways it is modified, apart from its being smaller. Perhaps the modified LDL had some other special properties which promoted coronary heart disease; if so, that would be a likely explanation for elevated CHD risk in diabetes patients.

Well, it turned out that the modified LDL does have a special property -- a super-power, if you will. It's stickier.

Proteins contain features known as proteoglycan binding sites; these can be used to bind the protein to other substances. (Often this is done for a good purpose -- for example, strengthening connective tissues such as cartilage.)  Apparently there are seven different possible varietes of proteoglycan binding sites; depending on the way the protein molecule is folded up, different binding sites are exposed to adjacent molecules. The number and type of binding sites exposed on the protein molecule determine how sticky it is, and what it is likeliest to stick to.

It turns out that normal LDL has two of these binding sites exposed; the modified form of LDL exposes a third site as well -- and that third site if of a type which has a special affinity for arterial walls!

When glycation by GM modifies the LDL, it not only becomes stickier, it develops a particular kind of stickiness which makes it bind itself firmly to the walls of the arteries. Because people with high blood sugar have more of this type of super-sticky LDL, they are more likely to have dangerously thick deposits on the arterial walls, and are therefore more likely to develop coronary heart disease.

Mystery solved!

Well, maybe. This kind of thing takes a lot of study to confirm. But it does make more sense than anything else I've heard proposed as an explanation for the diabetes/heart-attack link.

I guess I should admit that there is one thing I really like about this research, and one thing that makes me skeptical of it.

What I like about it is that it suggests that controlling blood sugar is enough to eliminate the extra dose of heart-attack risk that comes with being diabetic. I'm exercising regularly, and I'm maintaining normal glucose levels; therefore, my cardiac risk is probably not elevated, and might even be lower than average.

What makes me skeptical about this research is that it's a little too neat: the studies I've read have all suggested that, even in well-controlled diabetes, there is still an elevated cardiac risk associated with the disease, and glycemic control alone doesn't get rid of it. Even if modified LDL cholesterol, resulting from high blood sugar levels, is a major contributor to cardiac risk associated with diabetes, it doesn't seem as if it can be the entire explanation -- otherwise, good glycemic control would be enough by itself to take care of the problem.

However, as I often have to remind myself, research which comments on "well-controlled" diabetes patients often applies that term very loosely indeed, so that anyone whose blood sugar isn't raging wildly out of control is categorized as if their blood sugar were normal, and misleading conclusions are drawn from that. Perhaps the studies which seem to show that the mere status of being a diabetes patient is hazardous, no matter how well you control your blood sugar, never actually looked at any diabetes patient whose blood sugar was normal instead of not-that-bad-under-the-circumstances.

Monday, June 6, 2011

A bleak June it has been so far! Gray skies and frequent rain has been the weather pattern here for several days.

Yesterday I did a 7.6 mile trail-run, and after delaying as late into the morning as I could, in hope that the rain would stop, I decided I was just going to have to get wet. If I had waited another hour, I would have been able to do the run in a dry state, but I didn't know that, and anyway I couldn't wait because I had something else to do in the afternoon. Well, I didn't get that wet, because the rain was already getting lighter by the time I started.

Today, however, although it was cloudy and gray (and awfully cool for June), and I managed to get my daily run completed without getting rained on. Another one of life's little victories!

When I report on my running, it of course creates the impression that I am an extremely active person -- a dynamo of energy, restlessly burning off calories all day long!

Unfortunately, this is not the case.

I am good about exercising regularly, and most of my workouts are pretty tough: on a typical weekday I run 4 or 5 miles outdoors (and all the routes around here involve steep hills). On the weekend I usually do one rest day and one longer workout (typically a trail-run of 7 miles or more).

The rest of the time, though, I'm afraid I am exceptionally sedentary. My job is mainly done sitting in front of a computer. In the evening I spend more time sitting in front of the computer (doing this blog, among other things). And my hobbies, apart from outdoor activities, are not terribly physical. Much as I would like to think that playing the fiddle counts as exercise, I have discovered by means of heart-rate monitoring that it does very little to challenge my cardiovascular system (even when I'm playing really fast, my heart rate only goes up to a whopping 64).

The amount of exercise I'm doing seems to be getting the job done in terms of glycemic control. For example, the soup I had for lunch today had rice in it, but all the same my post-prandial glucose level only went up to 97 -- which many people with Type 2 would be happy to get as a fasting result, much less a post-prandial result after a meal that included any rice at all. So, my exercise program (even though it is combined with a largely sedentary lifestyle) seems to be working well as a diabetes management plan.

But is it really?

So far as anyone can tell from glucose test results, and A1c test results, and lipids test results, I'm doing fine. But what about the elephant in the room that we try not to talk about? I mean the heart-attack thing. That little old myocardial-infarction issue that we try not to think about, even though we all know that anyone with diabetes automatically carries an elevated risk for it. Is my exercise program adequate to prevent that?

What brings this to mind is a study I read about today on the deadly effects of sedentary habits -- even in people who exercise.

The study found a strong correlation between large amounts of time spent on watching TV or other sedenty passtimes and the risk of death from various causes, especially heart disease. Apparently watching 7 hours of TV a day virtually doubles your cardiac risk -- and getting in a daily workout does not eliminate the risk.

As it happens, I don't own a TV; I got rid of mine years ago, feeling distressed at the amount of time I had been wasting on it -- only to replace it with the World Wide Web! I now devote about as much time to my computer as I once did to my TV, the chief difference being that the time doesn't feel quite so wasted, since I get to decide what's on it. But whether the time feels wasted or not, the time is certainly spent in a sedentary state.

If this report is right, I'm going to have to start getting out of my chair more often.

Here's a nice optical illusion. Notice that this image contains -- or at least seems to contain -- some areas that are bright green, and also some that are sky blue. And if I told you that the "green" and "blue" areas are actually the same color, you would of course reject that idea firmly. The contrast between the green and the blue is too strong -- there's simply no way it can be an illusion!

But suppose we take a closer look, isolating two portions of the image -- one rectangle which is crossed with many "green" lines, and one crossed with many "blue" ones. Notice that the "green" lines alternate with orange ones, and the "blue" lines alternate with magenta ones. You eye does not judge the "green" and "blue" in isolation -- it is contrasting them with orange lines in one case, and magenta lines in the other.

Taking a closer look at those rectangles. The squares on the left illustrate the "green" and the "blue" (which look identical if you just look at the squares). When contrasted with the orange and magenta, they don't look identical, although they don't seem as different as they did in the larger image, do they?

If we move those rectangles up against one another, so that the "blue" and "green" come into direct content, you will notice that there is no visible edge of discontinuity where they come together. The "blue" and "green" really are the same color.

What the illusion is based on is the heavy use of orange and magenta lines, in what looks like a regular pattern. But the regularity of the pattern is broken in the "blue" areas, which seem blue only because the "green" appears where the orange should be, and the magenta appears where the "green" should be; the brain becomes confused about what is being contrasted against what.

Tricky things, these human brains! Or, to put it another way, a mind is a terrible thing to trust. Our brains are always being fooled accidentally, and sometimes they are being fooled deliberately by someone who hopes to gain something by it.

Adult life is all about discovering where our illusions are, and resisting them as best we can. This is true for everyone, but it's especially true for anyone with a common chronic disease, because belonging to that club means belonging to a "market". People know that there are millions of diabetes patients out there, and soon to be millions more. And some of those people are lying awake tonight thinking, "How can I separate all those suckers from their money?".

Friday, June 3, 2011

You know, that wasn't exactly a low-carb lunch -- it included some roasted potatoes. But only 94 an hour later! I'd just gone for a run before I ate (there'd been a break in the rain), and the exercise must have helped a little more than I was expecting it to. But 94! That seemed too good to be true.

As always happens when I go through a trend of getting unusually good results, I started wondering if there's something wrong with my meter. But I have two meters (both of them OneTouch Ultras), one at home and one at the office. They seem to agree well with each other. Historically, they have agreed well with lab results. There is no reason to assume that my string of low post-prandial results, even when the meal was not low-carb, is a false result. As far as I can tell, I just happen to be going through a phase of unusually low post-prandial blood glucose.

But I'll probably soon go through a phase of getting results that are higher than I'm expecting, not lower than I'm expecting. These things happen with type 2. You just have to work through those phases, relying on the general principles which you are applying to the problem of glycemic control, and try to steer your results in the right direction.

But what should you do when your results are lower than you're expecting? The temptation, always, is to decide that you have essentially got rid of your diabetes and can do whatever the hell you feel like now (which is exactly how the geniuses of Wall Street were thinking in 2007: history is over, and we can now bet everything on the assumption that the housing market will forever go up instead of down!).

Although the geniuses of Wall Street never learn their lesson (for them, criminal stupidity leads to bailouts & bonuses, not penalties & prison), for diabetes patients the next lesson and the next penalty are not likely to be long deferred. So, we can't afford to let ourselves indulge in what Mr. Greenspan called irrational exuberance. A string of good results? Great. Enjoy it while it lasts. But keep an eye on it, because the laws of nature say it won't last forever. And diabetes patients, unlike the geniuses of Wall Street, are largely free of the delusion that they enjoy a special exemption from the laws of nature.

Here's an unlikely search-phrase which caused Google to refer someone to my site: "why doesn't sugar give ants inflammation". To which I say: what makes you so sure it doesn't?

For all I know, ants are running around in a state of constant inflammation. They look as if they are, anyway. They might do better if they would leave the sugar alone; maybe they'd live longer than 2 or 3 months if they did. Take this guy -- does he look inflammation-free to you?

I think that's one ant who could afford to lay off the sugar and eat some protein.

A new study from Japan looked at the effect of what I was about to call second-hand smoke, until I realized that it was really third-hand smoke. The study looked at adult women whose fathers (not their mothers) had been smokers while they were still in the womb. So this is a study of how a female fetus was affected by second-smoke to which her mother was exposed, because her father was a smoker.

And how did the impact of this smoke manifest itself? The women whose fathers smoked during their gestation experienced menopause a year earlier on average than the women whose fathers had not smoked.

Now, how's that for an ironclad scientific result, certain never to be overturned by subsequent investigation? I'm sure there could have been no error in the way the data was gathered and interpreted, and I'm sure the women who participated in the study will not be found to have differed from the broader population in any significant way. Fathers, beware! Smoke, and your future daughters will experience menopause at 50 instead of 51! And how will you dry their tears then?

Thursday, June 2, 2011

The skies were threatening rain all day, but hardly any of it fell, and we had a nice, dry, comfortably-cool run. Not the sort of weather we look for in June, in these parts, but it will do. Any weather that lets me go for a run without freezing, getting drenched, or collapsing from heat-stroke is pretty good weather, really.

It was a big day for health graphics!

First, the USDA, which has long been warning that the famous "food-pyramid" is about to be replaced with a new graphic which would better illustrate dietary guidelines, unveiled the "My Plate" icon:

I wonder how much in-fighting took place behind the scenes before the final version was approved. My suspicion is that neither the size nor the color of the protein wedge were quite what the beef-industry lobbyists wanted. Choosing a shade of purple which does not occur in nature was probably someone's idea of a reasonable compromise.

Even more exciting: we have a new nausea scale! 

This is the Baxter Retching Faces scale, also known as BARF; it was developed by Amy Baxter and colleagues (pediatric oncologists seeking tools to help them manage nausea in children undergoing chemotherapy). The idea is to have kids choose the face which best represents how far along they are on the scale of nausea. The BARF scale is obviously inspired by the Wong-Baker scale.

What's that? You say you're unfamliar with the Wong-Baker scale? Perhap you're not familiar with it by name, but you may have seen it; it's a graphical tool which doctors in emergency rooms use when they are trying to get patients explain how much pain they are having:

Allie of the Hyperbole and a Half blog complains that the faces don't match the descriptions (face 3 would be more accurately summarized, she thinks, as "Huh. I never knew that about giraffes"), and that neither the faces nor the descriptions cover the range of pain very realistically. She has proposed an alternative pain scale, with more expressive faces and descriptions such as "I am actively being mauled by a bear":

Probably she's right, but I'm not sure I want to see her go to work on improving the BARF scale.

I've never seen a scale of this kind for diabetes patients, and it occurred to me that maybe I ought to invent one, before somebody beats me to it. However, when I tried it, I soon realized why no one else had come out with one: it wouldn't make for an arresting graphic, since most people feel the same whether their blood glucose level is 90 or 240. So, I don't think my diabetes health scale is likely to catch on; your doctor is probably not going to ask you how you're doing with reference to these faces:

We're all in there someplace, but it's hard to know exactly where, on the basis of anything we can feel. If you really want to know, you need to make use of technology.

Wednesday, June 1, 2011

Once again, the wet weather discouraged me from running at lunchtime (it cleared later, and I was able to run under more favorable conditions in the evening).

The company cafeteria's only appealing choice at lunch today was a curry -- so I ordered it, even though I knew they were going to pour it over a mountain-range of rice. I tried my best to leave as much of the rice on the plate as I could, without actually sacrificing the curry. It was brown rice, but I know how little difference that usually makes in terms of glycemic impact. So, even though I tried to minimize the rice intake, I was bracing myself for a high post-prandial test result later (especially as I didn't run before lunch, as I usually do). Imagine my relief at finding that I'd only gone up to 110!

It would be far too easy to conclude from this that I'm now officially bulletproof -- that I can eat anything I want and get away with it. In the past, I have been willing to jump to such conclusions (only to discover, soon thereafter, that my confidence was ill-founded). These days I'm more careful about overinterpreting one surprisingly good test result (or, for that matter, one surrpisingly bad one).

The most I can conclude from this is that, at least some of the time, I can eat a dish with rice in it without spiking my glucose afterward -- provided that I make an effort to eat only some of the rice. But I'm pretty sure it would be a bad idea to start eating platefuls of rice, on the assumption that I can handle it now, and not check afterwards to see how I did.

One of the harder lessons to learn about diabetes management is that, although it's important to watch the trends in your blood glucose, and note how those trends relate to your habits, it is a bad idea to make too much of any trend, good or bad, and a really bad idea to assume that any trend you have noted will continue. You can't stop watching the trends, because they can change so easily. There's nothing wrong with my taking satisfaction in having got away with rice today, but there would be something very wrong with my concluding that rice can no longer harm me.

To assume that you understand diabetes too well to need to keep a close eye on short-term trends is like assuming that you understand driving too well to need to do it with your eyes open.

Diabetes May Shorten Working Life says the Medscape headline, and I hasten to explain that they mean this is a bad thing.

Apparently a new study in France is confirming what other studies have confirmed in the USA: people with diabetes often drop out of the workforce prematurely due to disability brought on by diabetes complications.

Okay, great; I suppose it's a good thing that someone is gathering evidence for this unsurprising idea. But it's hard for me to see that the information will be used for anything, apart from reinforcement of employers' prejudice against employees with diabetes.

I never tried to hide my diabetes diagnosis from my employer, but I haven't changed jobs since diagnosis. I wonder what I'll have to deal with, if it becomes necessary for me to find a new employer?

I don't know that sort of realities people run into when they are forced into this situation. I hope I don't have to find out. But I have my speech ready, if I ever have to use it. Ten years after diagnosis, I can still maintain normal blood sugar without medication, because I exercise a lot. I don't think I'm as expensive a propostion to take on as most employees who don't have diabetes. So let's focus on that, shall we?

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