Tuesday, May 31, 2011

After doing a long trail run in the evening yesterday, I found that, when the time for my lunchtime run came around, I wasn't feeling much like going for another run only 16 hours after the last one. Fortunately, it was a rainy day, so I had an excuse not to go running at lunch. That gave me a little recovery time; after work I went to the gym for some weights and aerobics, and afterwards (the best part of the deal) sat in the hot tub to soothe the joints and muscles that were still feeling a little sore from the trail-run. Because of the holiday I missed my usual Monday-night yoga class, so I didn't get my usual therapy for whatever I overdid on the weekend, and sitting in hot water felt very therapeutic. My joints and muscles are certainly feeling a lot better now than they were earlier in the day.

In the locker room at the gym, someone I knew from work was having a discussion with someone I didn't know, about a sports injury that the stranger had in his right leg -- they were discussing possible stretching exercises which would heal that kind of muscle trauma. After the stranger left, the guy I knew made some comment along the lines of "yeah, we're getting old, all right!", but I pointed out that there's a subtle difference here which we need to focus on.

When we were children, and we heard our parents talking to people over 40 (relatives or friends, it didn't matter), we were amazed at the degree to which their conversation was all about who was dead, who was dying, who was sick, who was in the hospital, and who had what creepy-sounding health problem. It seemed to be a window into a different world: didn't they know any healthy people? Weren't they interested in anything besides disease and decay? Did growing older automatically transform you into a melancholic who knew far too much about medical procedures?

One of the signs that you're getting older is that, when you get together with your contemporaries, you find that you, too, are talking more and more about health issues. But, to my mind, there's a world of difference between talking about what the best way is to heal your running injuries and talking about where's the best place to go for dialysis.

Yeah, okay, I've graduated to the stage where life revolves around the ongoing battle with the forces which are trying to tear down my health. And I not only talk about this struggle, I come home from work and write about it in the evenings -- how sad is that? But if I'm focusing on it more than most people would like to do, at least I'm dealing with the issue on my own terms. Better to act than to react, I say.

My goodness -- the World Health Organization has announced that cell phones should be assigned the category of "Group 2B", meaning that they are possbily carcinogenic to humans! This is probably wrong (some studies show that brain-cancer risk is elevated among cell-phone users; other studies show that it isn't), but the feeling within the W.H.O. is that the supposed linkage between cell-phones and brain cancer might be legitimate, and we should play it safe until we know more.

The biggest problem with the idea of a linkage between cell-phone use and brain cancer (apart from the lack of consistent evidence in support of it)  is that the signals produced by cell-phones are in the category of "non-ionizing" radiation. That is, the radio-frequency signals produced by cell-phones are less energetic than gamma rays, X-rays, and even light, so they don't have the capacity to induce chemical changes in DNA. And if they can't do that, how can they cause cancer? In theory, a cell-phone can cause a small degree of heating within your head -- but not as much heating as wearing a hat would cause, and nobody seems to be worrying about a linkage between hats and brain cancer.

However, it is possible that cell-phone usage is linked with brain cancer for reasons which have nothing to do with the signals emitted from the devices! I think there is room for a very different explanation. If brain-cancer risk is elevated among regular users of cell-phones, I say that the cause is not the radio-frequency signals. The cause is the quality of the conversations these people are having.

Unfortunately, I have no explanation ready for the tendency of all conversations conducted over a cell-phone to be both much louder and much stupider than other conversations. However, we all know that this is the case, and it doesn't seem unreasonable to me to suppose that having loud, stupid conversations on a routine basis may have a toxic effect.

All right, it's a silly hypothesis -- but sillier hypotheses than that have managed to capture a lot of press attention lately. 

Monday, May 30, 2011

Rather unstable weather for the holiday weekend; there was a fair amount of sunshine, but there always seemed to be a looming threat on the horizon.

No one appreciates a dramatic sky better than I do, but it does make it hard to be confident about committing to a long run outdoors.

It had looked as if the rain was over, and the hardier souls in town started showing up at the lake to get some exercise. They soon came to wonder if they had made a mistake, as the dark clouds started closing in.

Everyone united in one thought: should we make a run for it back to the car? 

But a benevolent weather-goddess looks over those who exercise regularly; the threat of rain was a bluff. It looked scary, but nothing happened.

I finished my run in a dry state -- or at least in as dry a state as someone like me can end a run that involves scrambling up a lot of steep hills.

I thought I'd had too many carbs earlier in the day, so I had a very low-carb dinner; that, in combination with the long run earlier, explains why my test result after dinner was only 93.

Okay, here's another line that someone recently entered in a search engine, with my site turning up as a result:  "ac1 is 6.2 and blood glucose is 102 do i have diabetes". It sounds like a simple emough question, doesn't it? Surely it should be possible to get a simple, yes-or-no answer to this question!

Well, it is possible to get a simple answer ("no"), but as so often happens with simple answers, it is not an especially useful answer, and it doesn't get you any closer to the truth of the situation. It is a "correct" answer in a lawyer's sense of correctness -- in other words, if you care passionately about formality, and you don't care at all about reality, then it is correct enough for your purposes.

Deciding who does and doesn't have diabetes can be a surprisingly difficult problem. Strictly speaking, the term "diabetes" by itself describes a symptom rather than a disease: chronic hyperglycemia. If your blood glucose level is abnormally elevated on a routine basis, you are "diabetic". But more than one disease can cause you to have that problem, and one of those diseases (which we usually call "type 2 diabetes", as if that clarified anything) develops gradually, so that there is a long phase during which the symptom of hyperglycemia is mild or intermittent.

If we arbitrarily set some glucose level as the diagnosis point for diabetes (and we have: a fasting level above 125 mg/dl is regarded as diagnostic of diabetes), then plenty of people whose blood glucose level is rising above normal will be told that they don't have diabetes because they haven't hit 126 yet (or, to speak realistically, haven't been observed to hit 126 yet). But for heaven's sake: healthy, non-diabetic people usually have fasting test results in the low 80s; it is absurd to think that nothing is seriously amiss if you're at 125 instead of 126. You wouldn't even be above 100 if something wasn't going wrong with the regulatory system that controls your glucose levels. To say that anything below 126 isn't diabetes is almost like saying that any tumor smaller than 8 mm isn't cancer -- wouldnt' it be better to start dealing with the problem in the early stages, instead of waiting for something more dramatic and decisive to happen?

If we are more interested in understanding the disease processes which cause Type 2 diabetes than in defining the requirements for membership in the Type 2 club, then we need to look at what's going on during that phase during which the diagnosis point has not yet been reached. But who's going to study that phase, if we arbitrarily decided that it isn't diabetes? And what patient will take the problem seriously, after being told that it isn't diabetes?

To me is seems worse than useless to sort all of humanity into two simple categories -- diabetic and non-diabetic. Plenty of people inhabit a gray area in between, and it's an area we need to know a lot more about.

Friday, May 27, 2011

Recently I heard from a reader with Type 2 diabetes (so far unmedicated) whose A1c results and fasting glucose test results have not been terribly high (mostly below the diagnostic threshold for diabetes, as a matter of fact). But this reader, who would like to do better, had a highly specific question for me: Can I shave off 15% from the readings?

I don't know if that is possible or not (although, for reasons I'll get to  later, I think the answer is probably "yes!"). I can't claim to know the answer to that. However, like most other humans, I hate saying "I don't know", especially when I am approached by someone who needs some practical advice and thinks I might be smart enough to be able to provide it. If I am asked for advice, I want to sound wise and well-informed, not confused and ignorant. At the very least, I want to say something more helpful than "I don't know".

And this isn't just my problem, as a non-doctor struggling to understand diabetes through a combination of personal experimentation and amateur scholarship. A doctor wouldn't be able to answer this question either -- but a doctor would be even more uncomfortable than I am about answering it with "I don't know"!

The reason no one can answer this question is that the answer depends on a lot of things that nobody (including a doctor) knows or will be able to learn:

And then there are a few questions that have to do with character and feelings rather than medical facts:

Doctors face a serious dilemma in terms of encouraging patients to rise to the challenge of diabetes management (particularly if it is to be done without medication). They're afraid of being too encouraging, and also afraid of not being encouraging enough. However, when they consider the risks involved in defending themselves in court in the event of a malpractice suit, to be too encouraging probably seems like the riskier position to take. Why predict success, especially if you think the risk of failure is high? Wouldn't it be safer to assume the patient won't succeed, and prescribe heavy medication from the start? Wouldn't that look, to a jury, like the more responsible thing to do?

Trust me, doctors see a lot of discouraging cases of diabetes patients who don't achieve good glycemic control. They can't tell how many of these failures occur because the patients did what they were supposed to do and it didn't work, and how many occur because the patients never did what they were supposed to do. The only thing the doctors know for sure is that they're not seeing enough success stories to make them feel optimistic about this. To them, assuming that the patient will succeed is assuming too bloody much. Not all doctors feel this way (my own doctor encouraged me to pursue the lifestyle-based approach which I have chosen, even though my own track record at the time cannot have been much of a confidence-booster for him). But a great many doctors do feel pessimistic about their patients' odds of success, and are afraid to make any rosy predictions about what their patients will be able to achieve.

I can understand why a lot of doctors feel this way. However, my personal situation (as a diabetes patient who has maintained good glycemic control for a decade without drugs, and who might be doing a lot worse right now if he had been discouraged from trying hard to achieve that) leads me to see the problem differently.

To me, the worst-case scenario is certainly not that some diabetes patients are going to be encouraged to expect more success than the future actually holds for them. To me, the worst-case scenario is that many diabetes patients, who could greatly improve their health and greatly reduce their risk of diabetes-related health problems, won't do what it necessary to achieve that, because they haven't been given enough encouragement to think that this is possible.

I vividly remember my own early days with diabetes, when I read every magazine article on the subject hoping to find at least some reason to think that my lifestyle-based approach had a chance of working. I kept finding comments suggesting that it worked for a while, and nobody seemed to think that it would work for very long. Most commentators on the subject seemed to think that it usually worked for a year or two, and the outside limit of how long it could work seemed to be ten years. As a result I spent ten years waiting for my approach to fail, but it never did, and I finally passed the ten-year mark in February. That was the point at which things were definitely supposed to fall apart, if they hadn't earlier. But they haven't.

I find that a lot of Type 2 patients are willing to do what's necessary to achieve healthy glycemic control -- so long as they think it's actually possible for them. They are afraid of investing a lot of effort and faith in a fool's errand, only to find out later that it was known to be impossible from the start, but nobody told them. I don't think Type 2 patients are necessarily looking for an ironclad guarantee that they will succeed, but they sure would like to know that success is possible. They want practical hope, but they don't want delusional hope.

My own view is that success has to be considered possible, since I was successful under unpromising circumstances. My fasting blood glucose was under 90 this morning, and it was 174 when I was diagnosed in February of 2001. This leads me to think that a 15% reduction is fasting glucose, without help from diabetes drugs, is not too much to expect. It did happen, therefore it can happen.

However, to keep things in perspective, I have heard from people whose fasting tests were never as high as 174, and who have had more difficulty than I did, achieving a smaller reduction. This is where those unknown and unknowable variables come in. You can't know, going into this, how much opposition you're going to face from a genetic predisposition which is trying to push you in the wrong direction. 

Here's how I see it: what will happen if we do encourage people to think they can succeed, and what will happen if we don't?

It seems obvious to me that the second of those two options is not the desirable one. However, the second of those two options is the one that the health care industry seems to favor. Apparently it is considered worse to raise hopes which won't be fulfilled in all cases than to crush all hope wherever it is found. At least, if you predict failure and discourage attempts at success, you can be pretty sure of being right. Predicting success would make you wrong in at least some cases; do you really want to take that risk? Well, I do, but a lot of doctors don't.

I have to admit that my own experience has given me a bias; I tend to assume that what worked for me will work for others, even though I know that, in some cases, it won't. But in which cases will it work any worse than giving up? I'd rather fail knowing that I had honestly tried to succeed than spend the rest of my life wondering if success might have been available to me, had I had enough confidence to reach for it.

To me, reducing fasting glucose by 15% seems like a realistic goal, and even a modest one. It ought to be achievable. I hate to think that anyone would hold back from trying to achieve that, because they hadn't been given enough encouragement to think it was possible!

Thursday, May 26, 2011

My back continues to improve -- still a little stiff, but getting better, and not interfering with any activities. I don't think these little setbacks are avoidable; I'm just glad I get over them quickly. And I continue to think that I get over them quickly because I remain active, instead of surrendering to them and taking to my bed to recover.

I risked some pasta at lunch, figuring that my 4.4 mile run beforehand would enable me to get away with it. I did get away with it (a post-prandial reading of 120 is normal). I've been eating some very low-carb meals lately, but I don't want to make every meal like that if I don't have to.

Yesterday I reacted (at length) to one of the search phrases that caused search-engines to refer people to my site. Tonight I thought I'd give shorter reactions to a longer list of such search phrases.

I'm inclined to doubt it, unless you brush your teeth with honey and swallow it. Toothpastes tend to be sweetened with sugar substitutes (such as saccharin) rather than sugar, and even if your brand of toothpaste contains some sugar, it probably doesn't contain much, and you probably don't use very much of it, and you probably don't swallow the stuff anyway.

I assume that was meant to be "episode", before the search engine truncated it. It's never been very clear to me what people mean by a diabetic "episode" (or "reaction"). Do they mean a high? A low? Bad news about what's happening to health plan premiums?

I'm sure its always possible for your body to feel like it's being attacked. 

Sorry to hear it.

Sometimes, mainly after having an intense workout or receiving good lab results.

For reasons which I described in an essay last year, Alcohol has a temporary effect of driving your blood sugar downward. Because this effect isn't fully predictable, and doesn't last in any case, it is hard for insulin users who drink much alcohol to know how much insulin to give themselves; they tend to give themselves too little, or too much.

The function of your kidneys is to filter your blood supply, extracting unwanted substances from it and dumping those into your urine. Normally, your kidneys don't allow glucose to pass from your bloodstream into the urine, so your urine ought to be sugar-free or nearly so (only tiny amounts of glucose, if any, should be present in the urine). However, when your blood glucose reaches extremely high levels, the glucose does pass through the kidneys into the urine, so that the body can get rid of the stuff. I'm not sure whether the "70" referred to above is in mmol/l or in mg/dl, but it's well above normal by either measure, and I greatly doubt that it indicates good glycemic control.

Frequent urination (with the urine sweet enough to attract bees) has been a recognized diabetes symptom since ancient times. Which leads me to the next search phrase:

"Pissing honey". Or, if that is too rough for you, "passing honey".

No; I've been managing it without medication for 10 years. Not everyone can do this, but more people can do it than think they can do it.

Because some people can't manage type 2 without medication, and some people aren't interested in managing type 2 without medication, and some people (probably the largest of the three contingents) would have been interested in managing type 2 without medication, if anyone had told them it was possible and encouraged them to try it.

Then your diabetes is getting pretty far out of control. I don't know that this is high enough to justify an emergency room visit, but it's high enough to justify a phone call to your doctor saying that whatever form of treatment you're on is not working and needs to be reconsidered. Levels of gluocse this high have a harmful effect on the beta cells in your pancreas, so allowing yourself to go this high for very long is likely to make your diabetes even worse.

When they've tried as hard as they could to get their blood glucose under control through lifestyle changes, and it's not working, and they don't feel there is anything further they could do (such as exercising more) to solve the problem without medication.

80 to 99 mg/dl was officially "normal" the last time I checked, but non-diabetic people tend to be a lot closer to 80 than to 99. If you're crowding 100, it may be a sign of trouble brewing.

I don't believe that an A1c result of 6.2% or a blood glucose result of 102 mg/dl would meet the diagnostic criteria for diabetes. But so what? These results indicate that your body is having some difficulty keeping glucose levels under control -- and the difficulty is not likely to be reduced as time goes on! Best to assume that you have a problem (even if you don't want to call that problem "diabetes" yet), and go to work on it. I don't think medication should be the first thing you try, however.

Yes. So long as there is any glucose in your blood, some amount of glycation (undesirable bonding of glucose to protein) is going on within you. The rate at which it goes on increases when your blood sugar goes up, which is why the A1c test (which measures how much of your hemoglobin is glycated) is regarded as a more or less accurate basis for estimating what your average glucose level has been recently.

Because your body gradually recycles its proteins, it can keep up with the glycation process -- so long as glycation proceeds at a normal rate. In most diabetes patients it proceeds at an accelerated rate, and the body's maintenance processes can't keep up with it -- so that, over the years, more and more of your proteins are harmed by glycation, and "complications" ensue.

I assume that the result would be a short-term increase in blood glucose. But your glucose meter knows the answer to that better than I do.

...be declared a felony? Yes.

Wednesday, May 25, 2011

I woke up before the alarm this morning, and lay there wondering how my sore back was going to do once I got out of bed and stood up. The moment of truth that would reveal how my day was going to go!

It turned out to be okay; when I stood up, I didn't get the wrenching muscle spasms that I was fearing. My back felt a little bit stiff today, but it felt better than it had yesterday. And I made a special effort to keep my spine straight today, and resist the impulse to slide into the slouching position which comes so naturally to me.

I didn't feel like it running at lunchtime today, because it was raining (and I would have been running alone if I'd gone, because my running buddies at work hate running in the rain). But the rain stopped in the late afternoon, so I went for a run in the evening. Once again I worried that my stiff back might react poorly to runnng; once again running made my back feel better instead of worse.

Why was my post-prandial result a point lower than my fasting result today?

Well, my fasting result was a little higher than usual because I went to a party last night, and I indulged a bit in party food; my post-prandial result was lower than usual because I had a very low-carb dinner. So, the two test results overlapped by 1 point. With tonight's low-carb dinner I made restitution for last night's high-carb one.

It sounds like carbon-offset trading -- and I guess it's equally open to charges of hypocrisy and corruption. I'm not suggesting that you should adopt a policy of overdoing carbs one day and cutting back heavily on them the next, but in this case, that was what I did.

Not everything I reveal here is a boast; sometimes it's a confession. I tend to assume that you understand that, but I once heard from an angry reader who assumed that if I said I ate a bowl of cereal, I meant that everyone should.

Someone was referred to this site recently as a result of entering the search-string "I have diabetes and it's depressing". (Actually what they typed was "I have diabetes and its depressing" but I'm a member of the apostrophe posse and it's hard for me to let the distinction between a possessive and a contraction be ignored.)

Anyway, it's time once again to take up the subject of diabetes and depression. I know I have discussed it more than once before, but it's a rich topic, and there are always new angles on it to be considered.

There seem to be as many reasons to find diabetes depressing as there are people with diabetes. Well, if you have a wide choice of possible reasons for finding diabetes depressing, you can afford to be choosy. Why not eliminate all of the stupid reasons to be depressed about having diabetes? That will leave you free to concentrate (more usefully, in my view) on the reasons that make some kind of sense, so that you can find a practical way to deal with them.

The stupidest reasons for finding diabetes depressing relate to people's sense of entitlement.  If you don't think you should have to settle for anything less than perfect health combined with immortality, then life anywhere besides Mount Olympus is going to disappoint you. If you weren't being depressed by diabetes, some other problem would be sure to spoil everything for you, sooner or later. I think it would be more practical to face reality, and admit that we have no reason to expect that our health will be invulnerable and our lifespan will be unlimited. If you stop acting as if someone had promised you those things, you won't find it so depressing when you don't get them.

Even worse is the assumption that considerations of fairness should apply in health matters. If your idea of an acceptable world is one in which other people develop chronic diseases and you don't (because other people deserve to and you don't), you may get very depressed once you finally grasp that justice plays no role whatever in determining who gets sick when. I wish the people who moan that it isn't fair for them to have a disease would get some kind of clue about what an ugly idea that is. If it's unfair for them to have diabetes, the clear implication is that they don't belong in the same category as other diabetes patients, who are getting exactly what's coming to them. The very idea that diseases do, or should, afflict those who deserve them is mean-spirited and childish. Let us have no more talk along those lines, thank you very much!

In another variation on the fairness theme, what a lot of diabetes patients seem to find most depressing about diabetes is knowing that most people don't have it. It's as if they're getting another slap in the face every time they're reminded that many people they know don't have to test their blood or limit their carbs or take medications. If everyone had diabetes, maybe we would take the requirements of diabetes management for granted. After all, we take the need to eat food for granted, because it applies to everyone. If diabetes patients were the only people who needed to eat to survive, and no one else needed to spend any time or money in restaurants or grocery stores, I'm sure that many diabetes patients would be saddened by every meal. How tragic, they would say, that we must cram this stuff into our mouths, when others don't have to! But it would be silly for them to look at it that way. Either learn to like doing what survival requires (as everyone has already done in regard to the requirement to eat food), or stop doing it and see how well you like non-survival. But no sniveling either way!

Now that we have eliminated the really dopey reasons to get depressed about having diabetes, let's address the ones that are a little harder to dismiss.

Diabetes does a good job of reminding people that the physical bodies they inhabit are imperfect, frail machines which need a lot of maintenance and cannot be kept running forever. The same can be said about automobiles, of course -- but most people like cars, and don't get depressed about having one. Perhaps that is because they know that cars can be replaced if necessary. A body, on the other hand, is a single, lifetime purchase; get stuck with a clunker and you have no choice but to keep it limping along for as long as you can, no matter how much time it must spend in the shop, and no matter how doubtful its reliability may be when it's on the road. 

To have diabetes is to be stuck with a clunker -- although not, by any means, the worst clunker on the lot. Most people with diabetes can lead a long and healthy life if they're willing to work at it, which is not something you can say for certain other diseases. However much you dislike having diabetes, and managing it, and worrying about it, rest assured that there are people with other health problems who wish they could trade places with you. Some people feel a surprisingly strong aversion to testing their blood, for example, but iit's really no worse a chore than, say, flossing -- and it's got to be a day at the beach compared to changing your colostomy bag. Still, plenty of people find that being stuck with diabetes is depressing, because it requires them to do things they'd rather not do, and worry about things they'd rather not worry about (which makes diabetes sound more like a job than a disease --and perhaps not entirely inaccurately).

Being stuck with a clunker is not that terrible a fate, if you can keep it running. But what a lot of people find most depressing about diabetes is the prospect of what they may have to endure when the clunker really starts breaking down: painful neuropathy, blindness, kidney failure, uncontrollable infections, amputations, heart disease. They are allowing themselves to be depressed by a worst-case scenario which, they assume, is inevitable. I don't accept that it is inevitable, and I think people would be much better off if they invested more of their energy into preventing it, and less of their energy into brooding about it.

Getting depressed about a health problem because you don't think you deserve to have it is infantile, but getting depressed about a health problem because you don't think you can do anything about it isn't a great deal better -- especially if you can do something about it, but you're too busy being depressed to attend to the matter.

I can't order people not to get depressed about being diabetic and expect it to change their feelings. But I can point out that letting yourself get depressed about being diabetic is not particularly useful, even in cases where it's not outright silly, and it would be far better to save that reaction for something more fitting, such as politics.

Tuesday, May 24, 2011

Why do there have to be so many little ways for a body to turn against its owner? This morning, seated in front of the PC in my office, thinking everything was fine, I turned in my chair to look at an instrument on a table behind me, and in the process gave my spine a little more twisting motion than it was ready for. Instantly my lower back muscles went into painful spasms, and for a moment I wasn't sure if I could even get out of my chair.

I have to assume, based on what the experts tell me about such matters, that my lower back was feeling traumatized already (most likely from the accumulated effects of not keeping my spine straight enough when I sit in front of my PC), and was ready to blow at any moment. When people throw their back out, they always say "All I did was reach down to pick up a pencil!" or whatever, as if the simple action they were performing when everything gave way was the only cause of the trouble. My back was probably just ready to have a major spasm; if twisting suddenly in my chair hadn't triggered it, something else would have.

Once the gasping-and-cursing phase was over, I got hold of the Theracane and started applying some focused-pressure massage to my back muscles. That helped. I also took some Vitamin I (that is, Ibuprofen). 

Pretty soon my back felt well enough for sitting purposes, or standing purposes (although transisitons between those states remained uncomfortable). So then I had to face the next question: with my back muscles still feeling a bit stiff and sore, would it be a good thing or a bad thing to go running at lunchtime?

This kind of muscular soreness usually gets better rather than worse when I exercise, but I can't be sure of that until I try. Rather than running at lunchtime, I could go to the gym in evening and get my exercise for the day in some milder form -- perhaps on a stationary bike or something that didn't strain my back as much as running would. Unfortunately, I had a busy evening planned, and there wouldn't be time to go to the gym. So I decided to try going for a run, and see how it felt.

At first, my stiff and sensitive back didn't appreciate the running, but after about a mile my back felt better than it had before I started running, and for the rest of the run I forgot the issue entirely. (The endorphins that are released when you exercise hard have powerful pain-killing effects, and perhaps memory-killing effects as well.) It was only after I got back to the locker room, when I bent forward while pulling off my damp running shirt, that I suddenly recalled that I had a bad back today. Oh, yeah, I remember now...

In the evening I went to a house-concert and music party with some great Irish musicians (the band Chulrua). I was slightly conscious of my stiff back most of the evening, but not so much that I couldn't enjoy the music (and especially the chance to join in a little jam session with the band afterward).

I don't think I made a mistake to run today; my back is feeling a bit stiff at the moment, but I'm pretty sure it would have anyway, and maybe it would have been worse if I hadn't run. Anyway, I'm going to take some more Vitamin I and use the Theracane, get some sleep, and hope that getting out of bed tomorrow morning will not be a long and painful process. That's always the big test of a sore back: what happens when you get out of bed? If you can handle that, you can probably handle the rest of what the day is going to throw at you. I hope can get out of bed without a lot of pain tomorrow morning. I suspect that my worries on that score are what's pushing my blood pressure up this evening.

Monday, May 23, 2011

The half-marathon (that is, the 13 mile footrace yesterday) went well for me. The weather was perfect (sunny but not too warm), the country roads were pretty, hot-air balloonists were swooping low overhead, waving at us... and best of all, I wasn't hurting (during or after the race). And if I wasn't especially fast, at least I did manage to hit the time I was aiming for.

After getting up earlier than anyone should be asked to do on a weekend, I showed up at the race start (in the small town of Windsor, California) and was once again caught up in the unique buzz of an organized footrace, which is mighty hard to describe. Suddenly (very early in the morning, when you are perhaps hypersenstive to the emotional atmosphere around you), there you are in the middle of a big crowd of athletes, and the morning air seems to be crackling with far more energy than one is used to feeling at that time of day (or really at any time of day). I tend to forget about this special atmosphere during the intervals between such events, but then I'm bowled over by it as soon as I arrive at the next one.

There were actually three races going on, with a total of 1774 runners participating (which is rather a lot of runners to be assembled in a venue as small as the town green in Windsor). 628 of them were in the 13-mile race with me; the others were in shorter races (3 miles and 6 miles). The sense of community was strong: there were contingents there from running clubs, high-school track teams, and other organizations. At least four of the other runners in my race were coworkers of mine.

I was never a fast runner, and I've been a slower one this year (because I've been carrying some extra pounds), so I figured the best I'd be able to do was to finish within 2 hours and 10 minutes -- and I was by no means confident of achieving that much. Well, it wasn't easy, but I squeaked by with a finish time of 2:09:54. Of my coworkers, two were faster and two were slower. Of the entire field of runners, 53% finished ahead of me and 47% behind me. I'm happy when no more than 60% of them finish ahead of me -- 53% seems almost like a breakthrough.

For part of the race, it appeared that I might be able to do substantially better than my target finish time of 2:10:00, but at the ten-mile point I started getting tired, and found that it took all my concentration and energy to resist the impulse to slow down considerably. So, instead of beating my target by a couple of minutes, I beat it by a whopping six seconds.

Despite the grand scale of the adventure I'd just been through, it was all over by 9:30 in the morning. That's another peculiar feature of these organized exercise events: they typically happen so early in the morning that they seem unreal, and afterward you're not sure if you dreamed them. I went home, enjoyed the unique experience which a hot shower can provide after you've run many miles, ate a bunch of carbs to replenish the glycogen stores in my muscles, and took a long nap.

Interesting detail about the half-marathon race: the first-place finisher overall was a woman. Sarah Hallas (from Petaluma) finished in 1:22:48, eight seconds ahead of the first male runner. It doesn't often happen in a big race that the runner who finishes first among the women also finishes first overall. To do that, she had to maintain an average pace of 6:19 per mile, over a 13-mile course -- which I can't begin to fathom. Maybe I've run that fast for brief periods, going downhill. But for 13 miles? Over a coursethat is not all downhill by any means?  The mind reels! My own average pace was 9:55 per mile, and it wasn't easy to go that fast.

Was it foolish to run today, right after running a half-marathon the day before? It certainly wasn't easy to run today -- with my quariceps muscles feeling a little stiff and sore, and my energy level not especially fiery. But I wasn't incapacitated, and unless I'm due for a rest day (and I usually allow myself only one of those per week), my rule is to go ahead and exercise, whether or not I feel like it, provided I'm capable of doing so. I was capable of running today, so I did it. And although it was hard to do, I wasnt sorry to have done it, especially when my post-prandial test after lunch was only 93.

You could ask what the point is of doing endurance running, in my situation. If it isn't necessary to do 13-mile runs to keep my glucose under control, and it's hard on my body, why bother with it? My answer is that it's worth maintaining a sufficient level of fitness that you can do a half-marathon once in a while, without having to do an elaborate program of training beforehand. I guess that has become my personal definition of fitness: if a friend suggests a half-marathon race coming up next month, I should be in good enough shape to be capable of getting ready for it by then. If a friend suggests a 10K race coming up this weekend, I should be in good enough shape to be capable of doing it without any special preparation at all.

But there's the catch: if I'm not taking on such challenges from time to time, I'm not going to maintain the required level of basic fitness. Knowing that I might need to be able to run a long race on short notice helps me maintain that level.

A marathon (26.2 miles) is another matter; I don't see why anyone should be in shape do one of those any old time. But a half-marathon shouldn't be so far above my usual level of effort that the prospect terrifies me. It's an arbitrary measure of fitness, obviously, and it may be far in excess of requirements, but it has proved useful to me -- which, in the highly practical world of diabetes management, is the only consideration that matters very much.

Saturday, May 21, 2011 

Yesterday I skipped blogging because I had a musical performance, and got home pretty late from it. The performance went better than I expected -- I was less nervous than I expected to be, anyway, so I was able to enjoy the experience.

I'm running a half-marathon tomorrow morning. I didn't think running today was a good idea, but I wanted to get some kind of exercise in, so I did a long walk.

That low glucose reading after dinner surprised me, even though it was a low-carb dinner. It occurred to me that this wasn't necessarily a good idea before a marathon; I did some car-loading later in the evening to make sure my reserves aren't too depleted before the race.

Well this was it -- the day of the Rapture! Which turned out to be a piece of Crapture!

Things seemed no different to me in the morning; the world was continuing, and the same people seemed to be in it. But then I looked into the details, and found that the Rapture wasn't supposed to come till 6 PM today, with a rolling wave of cataclysmic earthquakes hitting one time zone after another as the 6 PM hour arrived locally. News reports from Australia indicated nothing special had happened there, and by 3 PM it was clear that nothing had happened in Europe or the east coast of the US, either.

However, I figured that I ought to go outside with a camera at 6 PM, to see if any strange phenomena were occurring. I went to a local park and photographed the people I saw there -- that is, the evil people who weren't whisked out of their clothing and hoisted into heaven. Here are some of those people; you don't need me to tell you how sinful they are, as the pictures make it pretty clear that these are very bad characters indeed:

In other words, it was just a warm and pleasant evening in May, much like any other. I don't know why that should surprise anyone, given the long history of doomsday predictions that never come true, but fortunately for those who make a career out of terrorizing the gullible, most people have short memories -- even for failed predictions which have left conspicuous traces behind.  

Thursday, May 19, 2011

A difficult day for scheduling any exercise, but I did manage to get to Spring Lake before sunset and run around it. It was a beautiful evening for it: the sky was clear, and the air was absolutely calm. The surface of the lake was a mirror. The gym just can't compete with The World.

Until today I hadn't heard the phrase "fat network", and if someone had asked me to guess what it referred to, I would probably have asked if that is what they call the cable channel that Paula Deen's cooking show is on. But apparently there's a fat network operating inside each one of us.

An international group of scientists has found that a gene known as KLF14 (already associated with issues related to blood sugar levels and cholesterol levels) seems to function as the "master regulator" of "a whole network of other genes" in fat tissue.

The KLF14 gene is inherited through the maternal line, so if you've got a defective version of it, you've got it because it runs in your mother's family.

The complicated thing about genes is that they often regulate the expression of other genes, and the whole cascading interaction can get very complicated -- certainly more complicated than most of us imagine when we talk about having "the gene for" a particular disease. The KLF14 gene is found to regulate at least ten other "downstream" genes (and these are genes linked to HDL cholesterol, body-mass index, triglycerides, insulin levels, fasting glucose levels, and adiponectin levels), and it has somewhat weaker links to a hundred more genes.

I'm not sure that the disovery of this network of interacting genes in fat tissue has any practical value at all to anyone living with diabetes, or trying to prevent diabetes. We already knew there was a genetic component to type 2 diabetes, and I guess this gives geneticists a clearer idea of which genes are worth studying. We also knew that something was going on within fat tissue which promoted diabetes (it has been suggested that ambdominal fat functions more or less like an endocrine gland), so perhaps this gives biochemists a clearer idea of how to study that phenomenon.

So far as the general public is concerned, I'm afraid it will simply give aid and comfort to those who wish to ignore the lifestyle half of the complicated lifestyle/genetic interaction that is diabetes, and define the disease as purely genetic. Look, it's partly genetic -- but that doesn't mean it doesn't matter how you live.

This is a busy week for me, and I have a musical performance tomorrow night, so I'm going to have to cut this short. Probably no blog post tomorrow night.

Wednesday, May 18, 2011

You know, I think I may have created a false impression in yesterday's blog -- and one which could very well make you think I'm being awfully hypocritical, or at least very inconsistent, about my non-medicated approach to managing my health.

After two and a half years of ranting on and on about how much I'm opposed to taking medications so long as there's a way to get along okay without them... now, all of a sudden, I happen to read an article that mentions melatonin as a sleep aid, and on an impulse I buy some and start experimenting with it.

That's not quite the way it is, although I probably made it appear that way.

My sleep problem -- or rather my current sleep problem, as I have a long and complicated history in this regard -- really isn't a recent a development. It's been an issue for me for a long time, and over the past year I've become increasingly conscious that it's been getting worse and causing me grief. No matter how sleepy I get in the daytime, I'm absolutely alert at midnight -- which, of course, ensures that I'll be sleepy the next day, too.

It's easy to say "just go to bed and turn out the lights and close your eyes, and you'll go to sleep soon enough", but my experience is that it doesn't work that way. Going to sleep when you're not sleepy is a much more difficult challenge than staying awake when you are sleepy. And I face both of those challenges routinely, so I have a solid basis for making the comparison.

There is something wrong with my circadian rhythm; I just don't get sleepy when I should. This sort of thing is regulated by the pineal gland (buried within the brain), which is supposed to start releasing melatonin sometime after sunset, so that you can get drowsy enough to fall asleep when you go to bed. In some people this doesn't happen, and apparently I'm one of those people. Supplemental melatonin, taken before bed, is regarded as a safe and effective solution to the problem. Certainly a less problematic solution than other sorts of sleeping pills.

Because I have a distaste for the idea of being dependent on medications to assist me with the basic functions of living, I have held out for a long time against taking any kind of sleeping pill to deal with my midnight insomnia. But I wasn't finding any other approach that worked, and it was getting to the point that I was becoming very unhappy with the situation, and eager to find relief from it.

I have not claimed that I am unwilling to take diabetes medications -- just that I'm unwilling to take them before I have to. After ten years with the disease, I'm still getting better glucose test results without meds than most diabetes patients get with meds, so I feel quite justified in saying that the time has not yet come for me to think about taking diabetes drugs. I expect that day will come eventually, but I'd rather have it come a few decades from now rather than a few weeks from now.

But my sleep problem is one that I haven't been having any success with; if exercising in the daytime and sipping Rooibus tea at night was going to solve the problem, it would have happened by now. And the problem is starting to degrade my quality of life. It's just time to do something about it, and reading about melatonin yesterday made me think it was high time I tried it.

I won't make the argument that melatonin isn't really a medication. In the United States it is only an unregulated "supplement", presumably because it's a naturally-occurring component of human blood, and is also present in small amounts in various foods. But no food gives you enough melatonin to raise your blood melatonin level. In Europe, melatonin is a prescription drug (probably because of the problem I mentioned yesterday -- children are hypesensitive to it). Although taking melatonin supplements presumably does nothing more than treat me for an abnormally low level of the stuff, it's possible that there is more to the story than that. However, no one has discovered that melatonin (at least in doses of 3 mg or less) does any harm to adults. So, I'm probably pretty safe in taking it (safer than I would be in taking most diabetes medications), but as always there are no guarantees.

My experience with melatonin last night was positive. It helped me take a nap after work, and it also helped me go to sleep later in the evening when I wanted to. As a result, I was able to get up earlier in the morning than usual, and I was more alert in the daytime than I typically am. I felt better in general.

I did have some vivid dreams, including a nasty one in which a crazy woman was trying to run me off the road (she was screaming "I'm crazy!!! I'm craaaaaaazy!!!" over and over, which was kind of a giveaway). But I had been warned that intense dreaming is a common side effect of melatonin, and I guess I just have to take that in stride. Trust me, if your dreams were like mine, you wouldn't want to have more of them, but maybe that's just the price I have to pay.

My current medication list, if that's what it should be called, consists of Claritin (for seasonal allergies -- I'll be able to give it up next month), low-dose aspirin (in case all this running isn't enough), and a multivitamin (in case my diet isn't as well-balanced as I imagine it to be). I guess I can add melatonin to the evening lineup of pills, without feeling too much like a frail old man arranging a tray of all the medications he can afford this month.

Tuesday, May 17, 2011

Take a look at this label for "Lazy Cakes Relaxation Brownies". There are those who complain that the garish color-scheme and the cartoon character (that would be Lazy Larry, the very relaxed brownie) are sure to appeal to young children -- who should not be eating Lazy Cakes, if the reports coming back from hospitals are any guide.

Lazy Cakes are brownies laced with melatonin, a neurohormone (produced in humans by the pineal gland in the brain) which regulates sleep and wakefulness. It is sometimes referred to, somewhat melodramatically, as the Hormone of Darkness (because circulating levels of melatonin rise after sunset). Its most familiar medical use is as a treatment for insomnia.

Melatonin is a naturally occurring substance (found not only in humans but in animals and plants); various foods contain tiny amounts of it, although no food contains so much of it that you can raise your melatonin level by eating that food. You can, however, buy melatonin supplements in the drugstore. And you can buy them without a prescription, because meltonin is not regarded as a "drug", and its use is not legally restricted.

In Europe, where melatonin is a regulated drug, the adult prescription is typically 0.3 mg, and 3 mg at most. But Lazy Cakes contain about 8 mg of melatonin.

Melatonin dosage is a puzzling issue; in adults, melatonin (as a sleeping aid) becomes less effective, not more, if you take a very large dose of it. A dose in the standard range (0.3 to 3 mg) is effective, while a dose of 20 mg or more is not effective (except at giving you what sounds very much like a hangover). Children, however, seem to be much more sensitive to melatonin than adults are, and in children raising the dosage increases the effectiveness. The 8 mg dose contained in a Lazy Cake (which is about 25 times as much melatonin as it usually takes to help an adult fall asleep) is enough to knock them out for a good long time. Because of incidents in which children who ate a Lazy Cake (or part of one) were hospitalized after they fell asleep and could not be awakened by their anxious parents, the mayors of two Massachusetts towns are trying to ban the Brownie of Darkness.

People are making fun of the fuss over Lazy Cakes (opinion from The Onion: "Melatonin is a potent chemical that should only be available under the care of a professional GNC clerk"), but it caught my interest for a personal reason.

Sleep is always a problem for me, one way or another. In the past I have had serious problems with sleep apnea. These days I'm doing okay with regard to the apnea problem, but not with regard to the circadian-rhythm problem: I seem to be a noctunal animal. I get sleepy in the afternoon, all right, but late at night, when people are supposed to get sleepy, I'm wide awake and restless. I am typically at my most alert and perky and curious at midnight. I can go to bed, but I'll have to read for a good long while before I'll fall asleep. To some degree I have always been like this, but over the last year it has become worse. Every day, struggling with drowsiness, I tell myself that tonight it's going to be different, I'm going to go to bed early and fall asleep early. But it never seems to happen that way.

I haven't been terribly anxious about my sleep-schedule issue, because it hasn't been driving my blood glucose levels up, and I guess I had come to see that as the test of whether or not a health problem was important. But I've become increasingly uncomfortable (socially, at least) about being sleepy when I should be alert, and alert when I should be asleep, and I'm feeling the need to make a change here.

So today, after work, I went to the drugstore and bought some melatonin pills. I came home with them and was too curious to wait -- I took a pill at once, to see if it made me sleepy. Well, I did get sleepy after taking it, although my impression was that I was sleepy anyway (the sun was still above the horizon, after all -- too early for me to be alert!). I then took a nap that ended up lasting about 90 minutes. Afterward I got up, still feeling sleepy, but once I sat down at the computer keyboard to start writing this blog, I was soon wide awake again.

The thing is, the dose was 3 mg rather than .3 mg, for these and any other melatonin pills I could find. In Europe that's seen as a maximal dose (and it's equivalent to almost a third of a Lazy Cake!). Should I take another one before going to bed, after I'm done writing this and I'm feeling perky? I think I'll chance it this time, but it's probably best to take it only when it's time to retire for the night.

Other research is coming in fast and furious, showing the many ill effects of sleep deprivation. One ill effect I hadn't ben aware of: weight gain. Apparently, being sleep-deprived slows down your metabolism, so that you don't burn as many calories, and you gain weight. Maybe that's why weight control has become such a struggle for me over the past year or so.

Anyway, I'll continue to experiment with the melatonin, and see if it improves things. But I won't give it to any young children.

Monday, May 16, 2011

My schedule was very awkward today and I didn't have the opportunity to do a post-prandial test. I did manage to fit in a workout, though. Due to unseasonably rainy weather I did my running on a treadmill, which I hate, but I just couldn't face running in the cold rain today.

The weekend was busy. As the half-marathon race is next weekend, I decided to do a really long trail run on Saturday to make sure I had the stamina. It was fiercely steep (the first 5-mile stretch was one endless climb), and the route I chose ended up being as long as the race will be -- 13 miles. And the race will be on roads rather than rocky trails, with almost no hill-climbing. So, I guess I've already done something harder than the race will be.

I felt okay during most of the run, but in the last couple of miles I started feeling weak and hypoglycemic, so I took a glucose gel. Even with the help of the gel, I still felt pretty weak finishing the run. But I felt okay afterward, so no harm done.

Sunday I went down to Berkeley to buy a new fiddle -- I wanted something with a mellower sound than I was getting. I tried out quite a few of them, but one stood out consistently from the crowd, and I brought it home.

Here it is resting in its crib, still wrapped in its swaddling clothes. I'm sure I'll soon be boasting that it learned to talk far earlier than anyone else's instrument did (and said far more clever things besides).

When people encounter the dreaded dawn phenomenon (or the Somogyi effect, which in principle is a slightly different thing, but is very hard to distinguish from the dawn phenomenon), they tend to feel that this issue is not merely frustrating -- it is also mysterious, paradoxical, unfair, and wrong. It shouldn't happen! Why does mother nature let it happen? And the implicit answer ("because mother nature hates you") holds very little appeal for most of us.

Both the dawn phenmenon and the Somogyi effect refer to increases in blood glucose levels which occur shortly before sunrise, or at any rate while we're sleeping, and which cause us to have a fasting glucose level which seems to us mysteriously elevated (especially as it's higher than it was when we went to bed, and we didn't get up for a midnight snack). Let me see if I can explain the difference between them. The dawn phenomenon results from what is apparently a normal part of the body's regulatory procedures (a slight increase in glucose to make sure we're energized for our morning activities, despite having had no food in several hours) -- except that in people with type 2 diabetes it tends to be overdone. The Somogyi effect, on the other hand, refers to a reactive change, in which the body over-corrects for a hypoglycemic episode which occurs during the night, and floods our system with more glucose than is needed to solve the problem. Either way, the idea is that the endocrine system tries to raise blood glucose a little bit and goes too far, with consequences which we discover when we take our fasting test the next morning. As the two problems are so similar, let me lump them together and give them a single acronym: MGO (which, of course, stands for Morning Glucose Outrage).

It's not hard to understand why people are frustrated by MGO, but why do they see it as mysterious and paradoxical and unfair? ("I swear I didn't eat anything after dinner!" they cry, as if everyone assumes they must have.)

When people see an unsurprising thing as weird and baffling, it is usually because they are making an assumption (perhaps unconsciously) which isn't justified. In such a situation, it can be helpful to figure out what, exactly, you are assuming -- and then take that assumption to its logical conclusion, and see what its consequences would be.

The unconscious assumption made by people who find MGO inexplicable and strange is that any increase in blood glucose must result directly from digestion of a recent meal. If they haven't had anything to eat since supper the night before, how can their blood glucose possibly have gone up? There's only one way for glucose to enter the bloodstream, and that's eating something. And they didn't eat anything! So how can it be possible for their blood glucose level to have gone up? It doesn't make sense!

If something that actually happened doesn't make sense, then you overlooked something. What people overlook in this case is that digestion of a recent meal is not (and could not be) the only way for glucose to enter the bloodstream.

But let's pretend that the assumption is correct: glucose only enters the bloodstream from the digestive tract, while a meal is being digested. During a prolonged fast (as during sleep), no glucose enters the bloodsteram. If this assumption were true, what would the consequences be?

Clearly, the consequences would be death for every one of us, and very soon. Glucose is constantly leaving the bloodstream (because the brain, the liver, and the muscles absorb it to use it as an energy source). If glucose is not entering the bloodstream as fast as glucose is leaving the bloodstream, then the glucose level drops after a meal, and keeps on dropping, until there is no glucose left in the bloodstream. If people sleep for anything like 8 hours, then while they are unconscious their blood glucose will drop until they fall into serious, life-threatening hypoglycemia. If they don't die the first night, they probably will on some other night very soon.

As Homo sapiens is not yet an extinct species, there must be some other route by which glucose can enter the bloodstream, even when you haven't eaten in several hours.  And we know what that other route is: the liver.

One of the liver's many important jobs is to keep us from dying of hypoglycemia between meals. The liver is, among other things, a storage bin for glucose (the gluocose is stored in another form, called glycogen, but glycogen is just a bunch of glcuose molecules chained together to keep them from reacting with other molecules -- when the liver releases glycogen, it breaks up into glucose molecules and enters the bloodstream in that form). But what controls the release of glucose from the liver? That would be glucagon -- a hormone which is, in a practical sense, the opposite of insulin. Where insulin tends to drive glucose levels down, gulcagon tends to drive glucose levels up, by stimulating the liver to release stored glucose.

So, the liver plays just as important a role as the stomach in contributing glucose to the bloodstream. The problem is that we have a very clear, interactive relationship with the stomach, and we have no such relationship with the liver. We are always aware of what we're putting into the stomach, but we haven't any idea what the liver is up to. Even if we know that the liver contributes glucose to the bloodstream, we tend to forget about it. And then, when our fasting tests are up, we protest that we didn't have a midnight snack -- as if nothing else could have contributed to the result.

But what, specifically, could explain MGO? If your glucose is under good control while you're awake, what could possibly be causing it to go haywire while you're asleep?

Here we get into a second unjustified assumption, made by those people who have a rough understanding of the role played by the liver, and the glucagon horomone which stimulates it, in glycemic control. The assumption is that the endocrine system works like a conventional thermostat -- turning on the furnace only when the temperature is too low, or turning on the air conditioner only when the temperature is too high. In other words, insulin is only released when your glucose level is too high, and glucagon is only released when your glucose level is too low.

If the endocrine system really did work that way, changes in glucose levels would be too abrupt, and too extreme. Wild swings would be the norm.

What happens instead is that the body is always producing at least a little insulin and at least a little glucagon. The endocrine system adjusts blood glucose levels by fine-tuning the ratio of insulin produced to glucagon produced. Because these two hormones with opposite effects are balanced against each other, the endocrine system can control things with more precision, instead of flailing around.

Well, that's how it's supposed to be, anyway. But when a system is based on balancing too opposed things against each other, what happen when one of those two things is working properly and the other isn't?

In Type 2 diabetes, the insulin-based regulatory mechanism (which drives blood glucose down) is not working quite right, while the glucagon-based regulatory system (which drives blood glucose up) is working perfectly. Is it any surprise that this unbalanced situation results in a bias towards elevated blood glucose levels?

If people with Type 2 diabetes, senstivity to insulin is typically reduced, and capacity to produce insulin is often reduced as well. But the regulatory mechanism which controls blood sugar levels is based on the assumption that you have a normal senstivity to insulin (or that, if you don't, you can at least crank out enough extra insulin to make up for the loss of sensitivity). Unfortunatley,  these assumptions can be quite wrong in the case of many Type 2 patients.

So, a trend toward Morning Glucose Outrage probably indicates that you are either experiencing a decline in insulin sensitivity or a decline in insulin productivity. The former, at least, may be correctable, but the latter seems to be a tendency which occurs normally as we get older. Some diabetes drugs are designed to stimulate the pancreas to make more insulin; whether or not this "wears out" the pancreas is a matter of controversy,and I don't pretend to know the answer. It does seem to me, though, that improving insulin sensitivity seems like a far more practical goal than trying to improve insulin productivity (if you can get your insulin sensitivty close enough to normal, you may not need to be able to produce extra insulin to compensate for the loss of sensitivity).

The causes of Morning Gluose Outrage are not hard to understand in principle, but they are very hard to observe and measure in specific cases. Having a rough knowledge of the concepts involved does not always reconcile us to the specifics as they affect ourselves!

Friday, May 13,  2011

I'm making this my rest day for the week, instead of tomorrow, because I've planning to do a long trail-run tomorrow. If ever there is a day when I can afford to skip working out, it's a day when my fasting test is 74 and my post-prandial is 99. Anyway, it might not be safe to exercise today -- it's Friday the 13th, after all!

Actually, I find superstition irritating, and I like to discredit it when the opportunity arises. Was Friday the 13th so bad for me today? Test results were excellent. An instrument microphone I ordered last week arrived today, and I'm very satisfied with it. My company reported its financials for the past half-year, and the results were very good -- the profit-sharing dividend will be a nice one. (In the past, these announcements have sometimes been about layoffs rather than bonuses; I like it better this way.) A music-buddy of mine at the office got a promotion today; that's good for him, but maybe that's the bad news for me today, since it could mean that in his new job he'll have less time to make music with me. Well, if that's as bad as the news gets today, Friday the 13th has been oversold as a source of menace.

Since most of us get too much e-mail, the people who send it ought to be more aware of the value of an intriguing subject line.

Most of us open our e-mail inbox, scan down the "From" column, and see the names of every company we've ever bought anything from, together with every club we've ever joined and every organization we've ever communicated with. And these are not people familiar with the expression "less is more", either; if we're hearing from them at all, we're probably hearing from them several times a week. If they are expecting us to open these messages, then it's in their best interest to choose a subject line which makes us want to read further. Often the subject line is all we need to see to convince us that, if we delete the message unread, we won't be missing much.

These two today, for example, did not make the cut:

When the subject is "Enter email subject here", it's hard to believe that the sender devoted a great deal of thought to the message.

But in terms of off-puttingness, that pales in comparison to "It's an Oral Care Battle of the Sexes!". I have absolutely no idea what lies behind that bizarre come-on -- and I'm certainly not planning to find out!

Every once in a while, somebody notices a relationship between some subtle detail of individual anatomy and the risk of developing a particular health problem. Perhaps you've heard about the connection (which sounds ridiculous but has been widely confirmed) between creased earlobes and increased risk of coronary heart disease. I would prefer for it to turn out that this sort of thing is nonsense -- since it certainly sounds like nonsense -- but connections of this sort often turn out to be verifiable, if not necessarily easy to understand. The likely explanation is that these seemingly unimportant anatomical variations happen to serve as markers of a genetic (or hormonal) variation which can also have consequences of a more serious kind.

An especially trivial-seeming anatomical oddity which has been much examined has to do with finger length. Is your ring finger longer than your index finger? In men it usually is -- apparently because higher testosterone levels during embryonic development tend to result in a longer ring finger. A ring finger shorter than the index finger (common in women but not common in men) seems to correlate with lower testosterone levels.

Today I read about a study which says that having a ring finger much longer than your index finger indicates not only increased exposure to prenatal testosterone, but also an increased risk of amyotrophic lateral sclerosis, also known as ALS (or, in the US, Lou Gehrig's disease) -- a deadly disease of the motor neurons. Even among women, who typically have shorter ring fingers than men, and generally have a lower ALS risk than men, the ALS risk is highest in those with the longest ring fingers.

Of course I had to check out my own hand (just as you are probably doing now). I found that, although my ring finger is longer than my index finger (possibly indicating heightened ALS risk), it's only a little longer. The paper I read wasn't specific about actual ratios, so I don't know if my ring/index finger ratio is actually long enough to make me a sitting duck for ALS -- or perhaps just barely long enough to qualify me as a guy?

Well, at least I haven't got creased earlobes. Maybe that will be enough to see me through!

Thursday, May 12, 2011

Predicting your glucose fluctuations is like predicting the weather: you rely on patterns which usually hold true, but don't always. It's fair to say that, given today's clear skies, high pressure, low humidity, and warm temperatures, it's mighty unlikely to rain tomorrow. But that doesn't mean it can't rain tomorrow, it just means that rain tomorrow has a very low probability. Bet on a sunny day tomorrow and you'll probably win. But maybe not.

Blood glucose levels fluctuate in much the same way that weather fluctuates -- following predictable patterns to a certain extent, but also surprising you greatly once in a while. Tonight I had a remarkably low test after dinner (85). Last night I had a higher test after dinner (119). Neither value is abnormal, but 85 is quite unusually low after eating, and 119 is a little higher than usual for me lately. Now, what I want to know is, why was I unusually low tonight, and not last night (when it would have made sense)?

Last night I had dinner right after doing a difficult, 7.6-mile trail run -- tonight I had dinner about five hours after doing a much shorter and easier road run. My dinner tonight was about equal to last night's in terms of carbs. And although I had a low carb lunch today, one of my coworkers had a little birthday celebration in the afternoon, and I must confess that I had a piece of cake. So, if anything, the 85 after dinner should have happened last night, not tonight.

You can never really figure these things out with any certainty, because too many factors that you can't measure exert an influence on your blood glucose. The best explanation I can come up with is this: during the trail run yesterday evening, my glucose may have dropped a bit low without my sensing it, and my liver may have overcompensated for the problem by releasing something from its supply of stored glucose. And perhaps tonight my glucose dropped a little low in the evening again, but not as low as last night, so my liver didn't react to it -- and so I started digesting dinner at a point when my glucose level was lower than it was when I started digesting dinner last night. In other words, the amount of glucose produced by the two dinners was about equal, but this amount was added to two very different starting levels.

When medical researchers present a brief verbal summary of what they learned from a study, with no exact numbers quoted, the impression given is often dramatic out of all proportion to the actual nature of the data collected. I'm sure the researchers involved would say that there's nothing wrong with this, so long as the exact numbers are given somewhere later in the article, and people are free to examine them and compare them to the non-numerical summary comments. Well, I say there is something wrong with it, because (1) readers may see only the verbal summary (perhaps because everything else was filtered out of the press account they read), and (2) there is no significant moral difference between lying about the numbers you found and creating a false impression of what sort of numbers you found (would an honest person ever seek to do either?).

When I read an article saying that people who eat fava beans have fewer heart attacks, or that living near a car-wash increases your risk of glaucoma, or that epilepsy is more common in people whose mothers ate Cheez Whiz during pregnancy, I first allow myself to absorb the overall impression that the authors are trying to convey -- and then I ask myself what sort of numbers they would need to have found, in order to justify the impression that their summary is giving me. And then I look at the actual numbers, and am usually disappointed.

Here are some of the non-quantitative comments from an article entitled More Lithium in Drinking Water Equals Lower Suicide Rates:

'Geographical areas with higher natural lithium concentrations in the drinking water have lower mortality rates from suicide, according to new research published in the May issue of the British Journal of Psychiatry. The finding, similar to that from 3 different countries on different continents, adds to the evidence that lithium in the drinking water may have beneficial effects for mental health, Nestor D. Kapusta, MD, from the Medical University of Vienna, Austria, and colleagues write. Dr. Kapusta, a psychiatrist who is engaged in suicide research and prevention, noted that many questions about suicide remain unanswered despite 100 years of research by the likes of Emile Durkheim, Sigmund Freud, and Alfred Adler. "One of the most interesting questions for me is why is the geographical distribution of suicides so persistent over decades in many countries? Why do we have regions which seem to be 'suicide geysers,' while others seem protective?" he said.

To evaluate the association between local lithium levels in drinking water and suicide mortality, Dr. Kapusta and his team examined a nationwide sample of 6460 lithium measurements and then compared suicide rates across 99 districts in Austria. They found that the overall suicide rate and the suicide mortality ratio were inversely associated with lithium levels in drinking water.'

Because lithium salts are widely used to control mood disorders, it does not seem unreasonable to me to look for evidence of a possible relationship between local suicide rates and local concentrations of naturally-occurring lithium salts in the water supply. However, there is no getting around it: if you're going to talk about "suicide geysers", then you are leading people to assume that the range of regional variation in suicide rates is extremely wide -- that some places are suffering from constant suicide epidemics, while in other places all is bliss. You are also leading people to assume that, if these "suicide geysers" occur in areas where there is little or no lithium in the water, then the effect of naturally-occurring lithium on mood disorders must be extremely powerful.

Okay, so how well does this general impression match up with the actual data which Nestor D. Kapusta, MD, is relying on to back him up?

'In the 10 most lithium-depleted regions in Austria, the suicide rate was 16 per 100,000, whereas in the 10 most lithium-rich regions; the suicide rate was just 11 per 100,000.'

Huh? In the worst areas, the suicide rate was .016% instead of .011%, and you're calling that a "suicide geyser"?

I don't think I went into this with any preconceived idea of what the exact figure would be for a typical local suicide rates, or how much worse the rates would be in more depressing regions. But if the range is .011% at best and .016% at worst, I don't see how that can be considered an impressively wide range of variation. A suicide rate of less than 2/100ths of 1 one percent might not be optimal, but I can't see anything especially geyser-like about it.

But perhaps it all depends on your attitude. The article included a photo of Nestor D. Kaputsa, MD, and it certainly doesn't look as if he's being deprived of his lithium.

I'm getting well-water at home, and I don't know if it contains much in the way of lithium salts, but it seems to contain an extraordinary abundance of every other mineral salt known to chemistry, so probably my own lithium needs are being met. I guess that explains my Pollyanna-like personality. I'm cheered up even by pictures of stellar explosions.


Wednesday, May 11, 2011

Well, I went ahead with it -- we went to the state park after work for a long trail-run. Always nice to be running in fields full of wildflowers (lupines, mainly) lit by the evening sun.

After a stressful day the run left me feeling a bit fatigued, but at least it gave me an excellent blood-pressure reading! And I felt that I needed a longer run today. With the half-marathon coming up on May 22, I figure I should be putting in some extra miles to build up my stamina a bit.

For a while it looked as if I wouldn't have to bother about the May 22 half-marathon, owing to reports that the world is going to end on May 21. However, it turns out that there are reasons to doubt that any such thing will occur.

The fuss about May 21 is owing to this genius:

His name is Harold Camping, and he's a religious broadcaster based in (must I admit this?) northern California. To be fair to him, he doesn't really say that the world is ending on May 21. According to him, the world won't end until October; all he's saying is that the Rapture is going to happen on May 21. He's predicted this before (in 1994, for example), and it didn't happen, but this time he means it, this time he's really really sure! And at the age of 89, he may be a little impatient to see it happen pretty soon.

Of course, if all that's happening on May 21 is the Rapture, I think it's pretty safe to assume that I'll still be here to participate in the half-marathon the next morning. Not that I understand the mechanics of the Rapture particularly well, but from what I've heard about the people who are expecting to be whisked out of their clothes, and squirted out of this vale of tears like so many watermelon seeds, it doesn't seem like the sort of club in which I would qualify for membership. 

So, come May 22, I expect I'll still be around, inhabiting the same physical body and wearing visible clothes, and running my half-marathon along with all the rest of the left-behind crowd -- putting in the miles as we race towards Armageddon. 

Doomsday cults always add an interesting symmetry to society. Most people live as if they think their lives will go on, largely unchanged, forever (which is impossible), but the end-times crowd chooses to live as if the world will end in a week or two (which is highly unlikely). The strange thing is that these seemingly opposite points of view seem to produce the same behavioral outcomes. The larger group neglects issues which have a long-term impact on them, because they prefer to believe that such impacts won't really happen (at least to them); the smaller group neglects issues which have a long-term impact because they think there is no long term.

I think that, in regard to staying healthy (and I include emotional health in that) it is better to try to face reality: we are not going to live forever, and we can't alter that basic fact of life. But if life isn't going to go on forever, just because we'd like to think so, neither is it going to end in a rain of fire this year, just because some cranky old man with a radio station in California likes to think so.

Our life may be long, and it may be short, but the biggest factor influencing that is what we choose to do about it. Maybe we should focus on that!

Tuesday, May 10, 2011

Another nice day for running; sunny and 70 degrees. And there was less pollen in the air today, so I felt able to choose a longer, hillier route than yesterday.

Tomorrow, if all goes according to plan, we're going to do a longer run after work (a trail-run in the state park). Sunset isn't until 8:12 PM tomorrow, so there will be enough time to get in a fairly lengthy run before dark.

We used to have a routine custom of going trail-running on Wednesday evenings during the summer. We didn't do it last summer (partly because we didn't have a summer last year, at least in this area -- it was cool and cloudy for about three months, as if we were in San Francisco), but I've been missing those evening adventures and I'm pushing to revive the tradition. There used to be another group from work who would go mountain-biking in the park on Wednesday evenings, and we'd usually encounter them somewhere along the way. I don't know if they're still doing that, but maybe I'll find out tomorrow. It was always a nice touch: out there on a seemingly deserted trail in the middle of nowhere at sunset, you'd turn around and find yourself face to face with somebody from the office. It was pleasantly disorienting.

I wouldn't have been able to do it tonight -- I had to stay late for a phone conference with someone in China. And tomorrow I have to come in early for a phone conference with someone in Scotland! If the operations of a company are going to be this global, it's too bad the world can't have a single time zone. I'd be okay with having my workday start at midnight, since that is when I start to perk up anyway. But perhaps not everyone in California would agree with me about that.

Okay, if you were looking for the smoking gun, maybe this is it. Continuing Medical Education, or "CME", is both an obligation for doctors (to keep themselves informed of recent developments in their field) and a billion-dollar industry. A sponsored industry. The classes may be presented by universities, but more than half of the funding for them comes from the pharmaceutical and medical-device industries.

Some people worry about that cozy arrangement. If the education that doctors are receiving is heavily financed by those with a financial motive to steer doctors toward a particular treatment, is it not obvious that doctors will receive an education which is heavily biased in favor of that treatment?

It seems to be obvious to the doctors themselves. A survey of 770 physicians found that a very large majority of them (88%) felt that commercial support of the CME courses could cause the education they were getting to be biased.

So they want commercial support of CME to cease, right? Uhm, no. Less than half of them thought that commercial support of CME should be reduced, and only a small minority (15%) thought it should eliminated.

Okay, what gives? If commercial support of CME is causing a bias problem, why not get rid of the commercial support, so that doctors can receive unbiased training?

Because doctors are now spending $1400 a year on CME, and it is thought that they'd have to spend $3500 a year on CME if it did not have commercial sponsorship from the makers of pharmaceuticals and medical devices. In order for doctors to feel it was necessary to make an expensive change, the existing situation would need to be quite exceptionally bad. Most doctors seem to think that the bias problem, though real, is comparatively small, and that they themselves are crafty enough to see through it (even though their colleagues might not be). So why not just live with the problem instead of correcting it -- especially if correcting it was going to cost them $2100 extra per year?

Okay. I'm not sure I'd be in a hurry to fork over $2100 for the sake of a more objective education myself, so I can see why doctors might be similarly reluctant.

However, I think it is extremely unlikely that the bias which CME sponsors introduce into the education of doctors is as subtle and small as doctors would like to imagine. In a survey article I read last October, entitled Overcoming Challenges in Type 2 Diabetes Management to Improve Patient Outcomes, exercise was mentioned twice, and pharmaceuticals were mentioned more than one hundred times.

This is not the kind of bias that I would call subtle.

Monday, May 9, 2011

I did a fair amount of belated birthday celebrating over the weekend. On Saturday I abandoned the human race to go wine-tasting.

Wait a minute -- I mean I abandoned the Human Race (a local 10K footrace that's a charity fund-raiser) to go wine-tasting. That race is a little frustrating to participate in, because the route includes trails that are too narrow for the number of people who sign up for the event, and you can't get around the walkers. So I decided to skip the race, and do the next best thing for my heart: taste Pinot Noirs and Zinfandels. (To be fair to myself: I did get in a four-mile run before I left for the wineries, and I ran the next day, too.)

Even if my weekend partying did push my weight back up a couple of pounds, I'm pleased to see that it had no impact on my glucose numbers today. Only 83 in the morning, and only 87 after dinner. 

The low number in the evening was partly owing to my choosing an unusually low-carb dinner, but I'm sure I also had some help from the residual effects of running -- not so much today's run, which wasn't especially demanding, but yesterday's, which was a hilly trail-run just under 10 miles in length. (I wanted to get a long run in this weekend, because I'm signed up for a half-marathon race on May 22.)

Rain had been forecast for yesterday, but it turned out to be mainly sunny, with a lot of fleecy cumulus clouds to send dramatic shadows sweeping across the landscape.

Green hills are such a temporary phenomenon around here that I try to savor the experience of looking at them. And I take a lot of pictures. 

Green fields are an even briefer phenomon around here, so I was patient in enduring the long climb to the top of the hill where I could overlook the park's big central meadow, from which the green will soon have faded away. I got caught up in watching the alternating sweeps of sun and shadow across the meadow below me.

I always try to capture that view photographically, and never succeed, but I think I got a little closer this time than usual.

Oh dear: stress causes diabetes!

At least that is what this study found. Stress has long been recognized as a promoter of heart disease, but apparently the idea that sress can also promote diabetes is a new one and hasn't been investigated much. 

It seems to make perfect sense that stress would increase the risk of diabetes, given that the "stress response" (in which cortisol and other chemical nasties are released into the bloodstream during emotionally trying times) is already known to have a degrading effect on insulin sensitvity.

Of course, talking about reducing your stress level and doing it are two different things. Maybe I didn't set a good example of that myself tonight, as I skipped my usual Monday night yoga class because I wanted to go to the symphony. 

Well, there are many paths to stress reduction, and attending a great musical performance could be one of them. They were playing two Russian spectaculars: the Tchaikovsky Piano Concerto No. 1, with Jon Nakamatsu as the fearless soloist, and the Mussorsky/Ravel Pictures at an Exhibition, in the Ravel orchestration, which I had never heard live before (and it needs to be heard live, because no recording captures all of Ravel's ingenuities of orchestration).  

Afterwards: blood pressure okay. So there you go: sometimes what you need is a trail-run, sometimes what you need is yoga, and sometimes what you need is music.

Thursday, May 5, 2011

86 degrees again today -- but it got warm earlier than yesterday, so we were running in warmer weather this time. Even so, I thought I was doing better than yesterday in terms of battling the effects of pollen in the air. That was true up until the point, a little over a mile from the finish, when I passed I guy who was taking a weed-whacker to a dense patch of tall grass. That always gets me! There's nothing like a weed-whacker to bring on allergy symptoms. It was harder going after that, but I didn't have that much farther to go, and the worst hill-climb was already behind me.

Today is Cinco de Mayo, so it was Mexican food in the cafeteria. Mexican food tends to be high-carb, but after a hard run I figured I could get by with it if I was very careful about portions -- and proportions. I was right; my post-prandial result was 111, and that's a normal non-diabetic result.

I like Mexican food, but I tend to save it for the recovery meal after a hard workout. For any other occasion, the amount of starch involved is usually too much.

There are certain medical buzzwords which we hear so often, we don't pause to ask ourselves if we have any idea what they mean. The one which comes to my mind today is "metabolism". What is it, exactly?

Clearly metabolism has something to do with the basic inner workings of a living body, and clearly it describes something which is thought to vary from person to person (any reference to "your" metabolism implies that yours is special to you, and isn't just like everyone else's). Okay, then, everyone who's alive has a metabolism, but not the same metabolism. That doesn't get us very close to an understanding of what metabolism is.

Dictonary definitions of metabolism are variable enough to leave us wondering if even the biologists have made up their minds what they mean by the word. The broadest definitions of the word say that metabolism refers to the chemical processes that maintain life. "The complete set of chemical reactions that occur in living cells", for example. This is a little unsatisfying, because it seems to leave no room for individual variation.

If metabolism is just a categorical term for all of cellular chemistry, then how can "your" metabolism be different from anyone else's? We're all the same species, and our cells use the same chemical reactions. It's not as if you have iron-based hemoglobin in your blood cells, while your weird uncle Henry has a copper-based alternative which makes his blood green.

Other definitions of metabolism get a little more specific: "the sum of the processes in the buildup and destruction of protoplasm; specifically the chemical changes in living cells by which energy is provided for vital processes and activities and new material is assimilated". Also: "The sum of the processes by which a particular substance is handled in the living body".

So, metabolism refers to the ways in which an organism uses and transforms the substances it takes in. It can be roughly divided into two categories: "catabolism" (the breaking down of substances, to obtain energy or raw material from them) and "anabolism" (the construction of new chemical structures, such as proteins, for growth or maintenance of tissues). Catabolism is about taking  things apart, and usually produces energy; anabolism is about putting things together, and usually consumes energy. (If "anabolism" reminds you of the phrase "anabolic steroids", it should -- anabolic steroids are hormones that stimulate growth or renewal, which is why athletes hope to get stronger muscles from taking them.) All of this chemical activity, this breaking down and building up of molecules, and this acquisition or consumption of energy, comes under the general heading of metabolism.

Which leaves us with the earlier question unsanswered: if all of this chemical activity is going on within everyone alive, how can "your" metabolism not be like that of every other living human? Something is obviously being left unstated here.

That unstated something has to do with the rate at which all of this chemical activity is going on -- when they say "your" metabolism, they probably mean your metabolic rate. The chemical reactions are the same in everybody, but they may be boiling furiously in one person and barely simmering in another.

Of course, to talk about an individual having a metabolic rate suggests that all the chemical reactions going on in that person's cells are going on at the same rate -- if you have a "slow" metabolic rate, then every reaction is happening slowly. I'm not at all sure that this is true; it seems likely that some reactions would be more active than others.

Still, I'm sure there are ways to come up with a simple, single measure of metabolic rate -- monitoring respiration to determine total energy utilization, for example. Such a measure wouldn't capture everything, but it would give us a basis for categorizing people by overall metabolic rate, and making rough comparisons between the categories.

What brings all this to mind is an article entitled "Increased Metabolic Rate Linked to Accelerated Aging". This concerns some research (reported recently in the Journal of Clinical Endocrinology and Metabolism) suggesting that "higher metabolic rates predict early natural mortality" and that "higher energy turnover may accelerate aging in humans".

"We found that higher endogenous metabolic rate, that is how much energy the body uses for normal body functions, is a risk factor for earlier mortality," said lead author Reiner Jumpertz, MD, from the National Institute of Diabetes and Digestive and Kidney Diseases in Phoenix, Arizona. "This increased metabolic rate may lead to earlier organ damage (in effect accelerated aging) possibly by accumulation of toxic substances produced with the increase in energy turnover... The results of this study may help us understand some of the underlying mechanisms of human aging and indicate why reductions in metabolic rate, for instance via low calorie diets, appear to be beneficial for human health."

Good, I was about to ask what anyone can do to reduce their metabolic rate, if this is the key to living longer. Apparently reducing calorie intake can accomplish that. Plenty of other studies have shown that calorie restriction lengthens life (in all animal species), and maybe the reason why is that it reduces the metabolic rate.

But what about exercise? Doesn't the energy expendicture during a workout raise the metabolic rate? Well, Dr. Jumpertz is on top of the situation: "It is important to note that these data do not apply to exercise-related energy expenditure. This activity clearly has beneficial effects on human health."

Well, that's reassuring for those of us who exericse regularly. But wait a minute -- why is the metabolic rate increase that comes with exercise not harmful, if the metabolic rate increase that comes with digesting a big meal is harmful?

I don't have any explanation from Dr. Jumpertz for this seeming paradox, but perhaps I can make a good guess.

The increase in metabolic rate (and heart rate, and respiration rate, and everything-else rate) which comes with exercise is temporary. People who work out daily have a higher metabolic rate during their workout -- but they tend to have a lower metabolic rate the rest of the time.

Once I started exercising regularly, my resting heart rate started getting lower and lower. These days, it's typically in the 50s when I'm sitting down -- and in the 40s when I'm lying down. I don't know that this reduced heart rate really does correspond to a lower metabolic rate, but I hope that it does, and it seems like a reasonable assumption.

It's hard to measure metabolic rate, and it's hard to know whether you have brought your metabolic rate down, as seems to be required for a long life. But it seems as if I'm doing the right things. I hope that impression is correct!

Wednesday, May 4, 2011

It did get to 86 degrees today, exactly as predicted. 86 is not really that warm, especially in the blessedly low humidity of California, but I certainly noticed the difference during today's run; or at least after it. I couldn't stop sweating, even after taking the coldest shower I could stand. Fortunately I didn't have any early-afternoon meetings to attend, so I could sit at my desk and wait for my shirt to dry off and my forehead to stop dripping. Oh well -- the warm weather is just getting started; I'll get used to it.

I think all the pollen in the air is affecting my running performance. My asthma is so mild these days that I'm largely unconscious of it, but running up the steepest hill today, I slowed down for it a lot more than usual. The amount of oxygen my lungs can process is just a little bit below my normal range. Still, running felt okay in general. I didn't feel like I was doing anything dangerous -- just that I was doing something very difficult. Since running is never easy for me, even at my best, this is not too shocking a sensation to have to deal with.

However, I'm a little worried about the half-marathon on May 22 -- I hope I'm not too compromised by pollen when that happens!

The headline New Salt Paper Causes Controversy caught my eye. I hadn't been aware that anyone was making paper out of salt. Or that anyone was even making paper that was salty. What was the goal here? To make it possible for yesterday's newspaper to serve as tonight's seasoning? And what sort of "controversy" had been ignited by this new product?

I admit I was a little disappointed when it turned out that the controversy was over a research paper, on the subject of salt. However, I became more intrigued when I saw what was involved.

The research paper, published today in JAMA (Journal of the American Medical Association) by Dr Katarzyna Stolarz-Skrzypek (of the University of Leuven, Belgium) and colleagues, looked at the health effects of salt consumption, and raised doubts about current campaigns to reduce salt consumption in the general population. Unsurprisingly, the paper is being denounced by some of those who have been leading such cut-the-salt campaigns. The air is filled with fighting words!

This isn't an entirely new disagreement, but it has usually been kept pretty quiet, so in a sense the "controversy" is new. For as long as long as the medical establishment as a whole has been warning us to cut down on salt in the diet (because of the asssociation betweeen sodium and hypertension), individual doctors have been committing the occasional heresy of admitting that this seems to be true only for a minority of us -- about 20% of people are "salt responders", meaning that a diet too high in sodium drives their blood pressure up. For everyone else dietary sodium is not what makes the difference (that is, if your blood pressure is normal, salty foods won't push it skyward, and if your blood pressure is high, cutting out salty foods won't bring it down).

In a sense, there is no real difference of opinion here: I don't think it's really in dispute that sodium intake matters much more for some people than for others. However, there are doctors who feel that, since it is very difficult to determine who is a "salt responder" and who is not, the right approach, from a public health standpoint, is to get everyone to go on a low-sodium diet. That way, we help everyone who really is a salt responder, and we do no harm to the rest of the population.

Well, maybe it depends on your definition of "no harm"!

I am not a neutral observer of this disagreement. I have been hoping all along that the salt-is-the-root-of-all-evil campaign would have some kind of very serious setback, and that the salt-is-okay-for-most-people faction would triumph. I'm not sure that that is what has happened here, but you may as well know where my prejudice lies.

You see, considering how many other dietary issues I'm obliged to be careful of, I simply don't want to be bothered with sodium reduction on top of everything else. Take away my pancake breakfasts and pasta dinners if you must, but please let me at least have my damned soy sauce. Grant me that much, for heaven's sake! I'm not asking for the moon here!

A lot of the foods I like are high in sodium -- including foods that are otherwise blameless from a diabetes-management standpoint. If I find a soup or a curried-vegetable dish that I like, and that doesn't spike my glucose, I don't want to have to sactifice it to the Carrie Nations of the anti-salt holy war. Which is why I welcome any development which seems to indicate that those people are wrong, or at least that they are going too far, recommending restrictions to millions of people who won't benefit from them.

That's more or less what the Belgian researchers claim to have discovered. They don't dispute that some people can benefit from a low-sodium diet, but they say that low-sodium diets, applied to a general population (not just people with certain specific medical problems) produced only a "very small" reduction in blood pressure, and produced no reduction in mortality (ineed, for those on the most sodium-restricted diets, cardiovascular mortality was higher rather than lower).

One of the authors of the study is quoted as follows: "What our study basically shows is that it might not be right to impose a general reduction on sodium intake. We are not negating previous studies, and I think sodium restriction is meaningful for patients who already have hypertension and perhaps for patients with heart failure, but there are very few arguments showing that reducing salt intake in the general population would result in substantial benefit."

Guess how the advocates of sodium-reduction-for-all are reacting to this study?

Did you guess that they would be beside themselves with fury? If so, you guessed right.

Dr Graham MacGregor, who has led a campaign in the UK to reduce the sodium content of foods, says that the new paper is paradoxical, unreliable, biased, harmful, badly written, impossible to decipher, and has severe methodological problems. He adds, for good measure, that "JAMA has published a lot of controversial papers about salt. I really don't think this is worth paying attention to. They are trying to create a stir... This will not divert us from reducing salt intake worldwide. At a high-level meeting of the World Health Organization, salt reduction has been recommended as the next thing after tobacco reduction because it's so cost-effective to implement and so easy to do."

Obviously, MacGregor protests too much, and although I can't give up the pleasure of catching him at it, I also have to admit that it doesn't prove he's wrong. Anyone whose favorite cause is being described as not worth the trouble is going to over-react; that's just human nature, whether the cause involved is worth the trouble or not.

I don't know why JAMA would want to be "creating a stir" by publishing a research which shows the population as a whole does not benefit from sodium reduction; presumably they thought the research was valid or they wouldn't have published it. But that, of course, does not prove that the new research is right.

Although controlling blood pressure has not been easy for me, I am pretty convinced (from tracking my blood pressure over time) that my blood pressure mainly reflects how much I'm exercising and how much stress I'm feeling. If sodium is a factor, I don't think it's a major one. So long as I can keep my blood pressure under reasonable control without adopting a flavor-free diet, I'm going to continue to rest my hopes on the idea that I don't need to make a big cut in my sodium intake. Any researcher who lends support to that plan is a hero to me, until he's proven to be a fraud.

Tuesday, May 3, 2011

It's warming up -- 80 degrees today. Sunny and beautiful. The air was so clear that we diverted our running route to go up the hill to the Paradise Ridge winery, so that we could pause at the top to look at the view of the valley to the west. Fantastic!

I drove out of town tonight after work, to play music with some friends, so I don't have a lot of time to post my thoughts here before retiring for the night.

But maybe that's what I should share some thoughts about: the time-management problem which diabetes represents.

I often wonder if the main explanation for "diabetic burnout" -- the tendency of diabetes patients to say "oh, to hell with it!" one day, and stop managing their condition -- is simply that people become resentful of the way diabetes management competes with other priorities when they are trying to schedule their daily activities.

It isn't that diabetes management necessarily takes up large amounts of time -- it's more likely to cause trouble by laying claims on a particular time period, however short, which could far more conveniently be spent doing something else. Glucose testing, for example: if you're not living an extremely secluded life, the time when the test comes due is likely to be when you're busy doing something else, under the observation of someone else to whom you don't want to display your blood-testing activities. My diabetes is not a secret at work, but all the same, I'll be damned if I'm going to do a blood test while my boss is sitting in my office talking to me about a work project. I'm fairly sure that, if people see me running every day and they know why, that seems admirable to them -- but if they see me testing my blood and they know why, that has got to seem pretty creepy. And if you don't want to test in front of other people, you really have to put a lot of cunning into planning your day.

In terms of diet, diabetes management often means saying goodbye to convenience foods which others might rely on to fit a meal into a frantic schedule. Chopping up vegetables for a stir-fry takes time which you may feel you don't have; turning into the drive-in lane at a fast food restaurant and ordering a burger and fries does not.

Because I rely on exercise so much for my own diabetes management program, fitting my daily workout into my schedule is a perpetual chore -- sometimes a bigger chore, or so it seems, than the workout itself. On weekdays I try to do a run at lunchtime if at all possible, but sometimes that's hard to arrange that because of conflicts with meetings at work. And if I go to the gym after work, I have to think about whether I'm too hungry to work out without having dinner first. But if I eat dinner first, then I can't work out immediately after eating (that makes me nauseous). So then I have to figure out how long I can delay working out, while still giving myself enough time to finish before the gym closes.

Although all this crafty manipulation of my schedule, to make time in it for diabetes management, has more or less become second-nature to me, I can understand why people might get thoroughly sick of it, and decide that a life organized in this way isn't really a life.

I guess the best advice I can give is to see it as a challenge you give yourself every day, and take some pleasure in it when you succeed. It's like completing the New York Times crossword puzzle. (At least, I assume it's like that; completing that puzzle is not something I can claim to have accomplished. It's a skill that I was too busy managing my blood sugar to master.)

Monday, May 2, 2011

When I hear about a diabetes patient who died, and I find out that he was the same age as me, I usually get depressed. 

I'm not absolutely consistent about it, though.

The weekend weather was amazing.

I simply had to get in some trail-running, with the weather as beautiful as it was, even though I was slightly pressed for time. I managed to squeeze in an 8.5 mile trail-run in the state park on Sunday.

I actually meant it to be a 7-mile run, but I was improvising a new route which turned out to be longer than I thought. I had to push myself hard to speed up, so that I could get the run over with on time (I was due at an event out of town later that afternoon). Well, I made it. And the run felt good; the soreness in my right leg that I was suffering from the previous weekend was entirely gone.

It was a nice place to be. I saw some interesting wildlife, including wild turkeys, a juvenile fox, and a small but fast-moving snake shooting downhill in the middle of the trail, which I'm afraid was probably a rattler. I yielded the right-of-way to him and moved on without pausing to confirm the identification.

Also, there were squads of people were out hiking, biking, and running. Fortunately, there were fewer than usual of those people ("equestrians" may not be the right word for them) who have access to a horse and imagine that they're in control of it. Altogether, a great day for being outdoors.

The part at the end of the run where I really needed to speed up was the shadiest and easiest part of the route, so it wasn't that hard to pick up the pace.

Running felt good today, too. I was afraid that I might find it hard, after doing a longer run yesterday, but it was fine.

My low post-prandial test result after lunch (only 89!) isn't too startling. I ate lunch right after running, which boosts your insulin sensitivity -- and I was probably still geting an extra benefit in that department because of the long run the day before. And on top of all that, lunch was a pretty low-carb salad. So, I figured it would be 100 or less.

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