Wednesday, November 30, 2011

I was upset to find my fasting result above 100 this morning (high for me, and slightly above normal for anyone), partly because I couldn't see any obvious explanation for it. I'd had a low-carb dinner, and I'd woken up feeling hungry (which usually means I'll get an unusually low fasting result). The best two explanations I could think of were: (1) I'd had a problem with insomnia last night, and the lack of sleep may have had an effect, and (2) I'd done an unusually difficult run the day before; perhaps this, plus my low-carb dinner, had set me up to go low during the night, and my liver had tried a little too hard to compensate for it.

These things are never really knowable, no matter how practiced you become at monitoring your own patterns. So, I didn't know whether the unusually high fasting result today was a sign of trouble or a passing oddity. I was relieved to find that my result after lunch hadn't spiked any higher than 110 mg/dl -- which is well within normal limits for a post-prandial test.

Still, my elevated result in the morning (combined with my Thanksgiving weight gain) made me feel that today, of all days, I must not succumb to any temptation to eat a high-carb snack. Which meant, of course, that temptations were bound to be offered to me...

To one side of my cubicle sits Michele, who is an expert maker of chocolate desserts and often brings samples of her art into the office.

Across a narrow isle from my cubicle sits Keith, who keeps a bowl of chocolate candies on his desk, and refills it constantly for the benefit of anyone who wants to stop by and have some (I guess it's his way of staying popular, and to judge by the number of visitors he receives every day, it seems to be working).

Clearly, I sit in a dangerous vicinity of the office, on any day of the year. And today, alas, was Keith's birthday. To celebrate the event, Michele brought in a rack of mini-cupcakes.

I knew they were going to be giving Keith a birthday card, and consuming the cupcakes, at 2:30, and I thought I was in the clear because I was going to be in a meeting at that time. But the meeting ended soon enough that I returned to my desk while they were still gathered around his desk, and there will still several cupcakes left.

And they started trying to insist that I participate in the treat. You know the routine. They're really good, Tom! Are you sure you won't have just one?

I made my excuses as well as I could, but they're a tough crowd. Keith stays in shape, but he seemingly wants to make sure nobody else can.

Well, I stood my ground. No cupcakes for me. In the evening, I thought I'd better take another post-prandial test to see if I was still on track: a nice low 89.

But will this translate into a low fasting result, or will there be another surprising high tomorrow? Time will tell.

Diabetes isn't fun, exactly, but in a way it adds a kind of suspense and excitement to days which would otherwise be routine.

Tuesday, November 29, 2011

When I look over the daily list of internet searches which have turned up references to this site, I am sometimes puzzled by the patterns I see. One such pattern is the constant recurrence of one particular Hemoglobin A1c test result: 6.2%. When people have questions about their A1c result, they are referred to me routinely if the result happens to be 6.2, but almost never if it is any other value. If people are out there trying to find out what a value of  6.3 means (or 7.6, or 8.1), they aren't being sent to me. Only if it's 6.2. It can hardly be the case that 6.2 is the only result that people are Googling, so I am left with the assumption that Google sees my site as pertaining more to a result of 6.2 than to any other possible result. I don't know why that would be the case (at least before tonight -- this blog post will at least make all those search results seem justified). 

Most of the search strings that mention an A1c of 6.2 suggest confusion or anxiety about whether or not such a result indicates diabetes: 

To me, such questions sound a lot like "At 5 ft 10 in, am I tall?". Tallness is a comparative thing. You're taller than some people, and shorter than others. The closest we can come to defining "tall" as an absolute is to find out what the average height is for your gender, age group, and nationality, and see whether you're above or below that midpoint. But if you're not very far above it, there is going to be room for reasonable people to disagree about whether or not you exceed average height by a wide enough margin to count as "tall". A height of 5 ft 10 in is perfectly average in the United States; it is below average in much of Scandinavia, and above average in much of South America. By this comparative measure, an American of average height would be "tall" in Peru, but just a little "short" in Sweden. I'm not suggesting, of course, that tallness is non-existent, or that tallness is a meaningless concept. (When, on the flight to Idaho last week, a basketball team boarded the plane, walking in a crouch to keep from banging their heads on the ceiling, I immediately thought: "Hey, these guys are really tall". As you can see, very little escapes the notice of this shrewd observer of the human scene.) I am merely pointing out that tallness is a matter of degree, and it is very difficult (not to mention silly) to attempt to define, very precisely, the point at which tallness begins.

Diabetes, too, is a comparative thing -- a matter of degree. There aren't any people who have no sugar in their blood. We can't live without it, after all. We all have a certain amount of it. Most people don't have very much of it (they go through daily cycles, with peaks somewhere around 125 mg/dl and valleys somewhere around 80). And then there are people who have far more of it (with peaks above 200 mg/dl, or 300, or 400) -- and it makes them sick. But it's not as if these are the only two possibilities -- any more than the human population is divided into those who are 5 ft tall and those who are 7 ft tall. In between the normal blood-sugar cycle and raging diabetes there stretches a spectrum of somewhat-elevated blood sugar -- and what do we call that?

I don't think it is especially helpful to become obsessed with defining the precise point at which slightly elevated blood sugar becomes "diabetes" -- mainly because I'm afraid that most people think you can ignore the issue entirely, so long as it is just one point shy of the "diabetes" dividing-line. When people ask "is this diabetes or isn't it?", I think what they really mean "is it okay for me to pretend that this very obvious indication of trouble is unimportant?".

Let me indulge my fondness for household metaphors for a moment, and talk about water-heaters. (These are sometimes called "hot water heaters", but I've never understood why: hot water doesn't need heating, does it?) Would you say that all water-heaters are divided into two categories: those that are working perfectly, and those that are entirely broken? It seems to me that there is a middle ground. It's possible that you might start to find next week that, when you take your morning shower, you have to push the mix farther and farther toward "hot" in order to get a shower temperature that's warm enough for you. And the week after that, you might find that the shower temperature is just a little cooler than you like it even when you have pushed the mix as far towards "hot" as it will go. Would you, at that point, bring a thermometer into the shower with you, collect some data, and do a Google search asking if this means your water heater is technically "broken"?

Come on. Who cares whether it is "broken" according to some arbitrary standard? Obviously something is wrong with it. Obviously it is struggling to achieve the target temperature, and not quite succeeding. Obviously you need to find out what's going wrong with your water heater, because you have cold showers in your future if you don't.

Diabetes is like that. If your endocrine system is no longer capable of maintaining a normal blood sugar cycle, then something is going wrong with it, and you might as well face that reality and deal with it. A committee of doctors and health-insurance industry representatives can get together and hammer out an agreement about the point at which the problem can be called "diabetes", but who cares where they draw that line exactly? Elevated blood sugar -- even if it is only mildly elevated -- indicates that there is a problem, and your endocrine system is having a hard time compensating for that problem. Better to deal with the problem now than to waste a year fretting about what the problem should be called.

Another search phrase which caused Google to refer someone to this site yesterday was "wrong answer". Man, what have I ever done to Google?

Monday, November 28, 2011

Okay, I'm back. I was at a family Thanksgiving gathering in Mountain Home, Idaho, that lasted most of the past week. For the benefit of readers outside the USA, I should mention that Thanksgiving is an American holiday which, whatever it might theoretically be about, is actually about going to the home of someone you are related to, and hanging around eating lots and lots of food for and hours and hours. (And if the gathering is taking place a long way from home, as it was in this case, the festival may last for days rather than hours.) So, late November tends to be a challenging time of year for Americans with Type 2 diabetes. It's a time when you're pretty likely to lose control of your blood sugar, or your weight, or both.

Clearly I lost control of my weight, gaining four pounds during the week. Did I lose control of my blood sugar as well? Not quite, but it wasn't an easy challenge to meet.

The disruptions involved in air travel (including the disruption of your exercise program) are hard enough on your blood sugar; add to that an extended family gathering, during a holiday defined almost entirely by food, and you're looking at a pretty serious challenge to glycemic control. My first two fasting tests during the trip were higher than I'm comfortable with (101 and 104), but after that I was down below 95 where I belong. That drop certainly wasn't the result of dietary restraint, so it pretty much had to be the result of my determination to keep exercising during my visit.

Idatho is just a little bit colder than California in late November, so we spent most of our time indoors, where it was warm, eating and drinking. We did leave the house for a while every day -- to go running, in my case, although most members of the family thought walking was as much exercise as they really needed. Maybe it was, for them. I needed a bit more, especially under the circumstances.

As my sister's house was pretty far out of town, there was a lot of open space for me to go running in.

There wasn't a lot of risk of getting run over by a car while I was running; the main hazard was accidentally stepping into a badger hole and breaking my ankle, or being being blown over by the icy cold wind. I managed to avoid both of those risks, and returned home without any serious injuries.

The mountains to the east had acquired a patina of snow shortly before I arrived in Idaho, and I became a bit obsessed with photographing them as the light and weather changed -- like Monet painting that same haystack over and over.

Now I'm home, and enjoying the life-in-California benefit of running with only one layer of clothing on instead of three.

My low post-prandial result of 82 after lunch today was the result of testing after a low-carb meal, and of eating that meal immediately after going for a run. But it was reassuring that I was able to pull off a post-prandial result that low after eating anything at all. So, glycemic control seems to be restored -- now all I have to work on is weight control.

Thanksgiving Week 2011

I'm going to be in Idaho on a visit this week, and I will not be doing any blogging. They don't have the internet there, it's all just sagebrush and moonrises.

I will continue exercising, of course -- and I hope I have packed enough layers of running clothes, because the last time I went there during Thanksgiving week, the weather was a wee bit colder than what I'm used to here in California. In fact, I seem to recall that, every time I went out for run, I required a lengthy defrosting period in the shower afterward just to restore myself to a state of anatomical completeness. Apparently, when you go far enough inland to escape the moderating influence of the Pacific Ocean, temperatures become highly volatile, and by November they start dropping pretty low.

It will be a family visit -- with the Thanksgiving holiday happening right in the middle of it -- so I assume that the week will consist of a long series of temptations to extreme dietary sin. We'll see how well I do!

Friday, November 18, 2011

What are scientists supposed to do when the data they have gathered says the exact opposite of what they had assumed it would say? Doctors doing research on CHD (coronary heart disease) are now confronted with this very situation. It seems that the survival rate after a first MI (myocardial infarction -- also known as a heart attack) is worst for those with the smallest number of CHD risk factors. The survival rate improves, consistently, as more risk factors are added.


The study looked at the records of half a million heart-attack patients, to see how many of them subsequently died in the hospital, and to find out how their CHD risk factors correlated with their mortality rate.

The five CHD risk factors under consideration were hypertension (high blood bressure), cigarette smoking, dyslipidemia (abnormal levels of cholesterol and triglycerides), diabetes, and a family history of heart disease. Some of these risk factors are pretty common, and fewer than 15% of CHD patients had none of these risk factors -- but those were the very patients who experienced the highest mortality rate in the study!

The results broke down as follows: the in-hospital mortality rate was 14.9% for those with zero risk factors, 10.9% for those with one, 7.9% for those with two, 5.3% for those with three, 4.2% for those with four, and 3.6% for those with all five. The trend is amazingly consistent: more risk factors means lower mortality.


This trend doesn't make sense in any obvious way; surely we would expect higher mortality, not lower, in patients with multiple risk factors. How on earth could the risk be lowest in those with all five risk factors, and more than four times as high in those with no risk factors at all?

Before we jump to the conclusion that we've been wrong from the start about what constitutes a "risk factor", let us be clear about definitions. A "risk factor" for CHD is only an indicator of how likely you are to develop CHD, not necessarily an indicator of how well you will do in the hospital, after you have already developed CHD and it has just given you your first heart attack. Since all of the patients involved in this study had already had a heart attack, they all had CHD, so their "risk" of CHD was 100%. The whole issue of "risk factors" for CHD had already become a moot point.

Still, though! It seems awfully paradoxical that having multiple CHD risk factors would equate to lower mortality following a heart attack. Why do patients with no risk factors face the highest probability of dying? It would make more intuitive sense to us if patients with more risk factors experienced the worst and most deadly heart attacks, while those with no risk factors would have the mildest and least deadly heart attacks. Apparently it doesn't work that way.

Now that this paradox has come to light, scientists have to find a way to explain it. There seem to be three competing explanations...

One hypothesis is that there is separate type of CHD which is caused by something we haven't yet identified (so the usual risk factors aren't relevant to it), and this "new" CHD is deadlier than "classic" CHD. The people without CHD risk factors are the ones getting this special kind of CHD, hence their higher mortality rate.

Here's the problem I see with that explanation: we have no reason to suppose that this "new" CHD, if it exists, is less common in people with more risk factors for "classic" CHD. If there is a "new" CHD, caused by something unrelated to the classic risk factors, I would expect the rate of this disease to be independent of those risk factors, not minimized by their presence.  If the classic risk factors aren't relevant to "new" CHD, shouldn't the "new" CHD be about as common in people with five risk factors as it is in people with zero risk factors?

Another hypothesis (which seems a little more plausible to me) is that patients with multiple risk factors receive different treatment after a heart attack (and different preventive treatment before it)  than patients without risk factors, and this difference of treatment accounts for the difference in survival rates. Maybe people with risk factors for CHD have been taking more precautions (such as daily low-dose aspirin), and this makes a heart attack more survivable when it finally happens than it would otherwise have been. People who lack CHD risk factors are going to be caught unprepared when they have a heart attack, so they're less likely to survive it.

A third hypothesis (and the most likely one, I think) has to do with the age of the patients in this study. Those with multiple risk factors tended to have heart attacks at younger ages. The CHD patients with all five risk factors were almost 15 years younger, on average, than patients with zero risk factors. Maybe what the study really shows is that (1) having more risk factors means hastening the onset of CHD, (2) hastening the onset of CHD means that you'll be younger when your first heart attack occurs, and (3) a heart attack is less likely to kill a younger patient than an older one.

It is almost (but perhaps not quite) needless to say that this doesn't mean it's better to have all five risk factors, so that you can have your heart attack while you're still young enough and strong enough to survive it. It's not as if CHD is guaranteed  to give you just one heart attack, and you might as well "get it out of the way" while you're still spry.

I think it is safe to say that the zero-risk-factor patients in this study, who didn't have heart attacks until they were in their early 70s, had a better plan than the five-risk-factor patients, who had heart attacks while they were in their mid 50s -- even though surviving a heart attack in your mid 50s is easier to do. This was a study of first heart attacks, after all, not a study of the total lifetime impact of heart disease. Who knows how many more heart attacks the patients in their mid 50s might have before they hit 70, and how poor the odds might be that they will survive all of them?

I doubt very much that, in the final analysis, people who have heart attacks earlier in life end up having longer lifespans. If the data turns out to show that early heart disease is the key to longevity, though, I'll have to look more closely into the matter.

It's always worth paying attention when the data tells us the opposite of what we expect, but when it happens, we need to be careful about what conclusions we draw from it.

Thursday, November 17, 2011

Okay, so is there a way to treat claudication due to symptomatic aortoiliac PAD (or proximal PAD) that works better than endoluminal revascularization?

Yeah, I'm sure we've all wondered that.

The answer happens to be "yes", but perhaps the answer would be more meaningful if I explained what the hell the question means. Here's a glossary:

Okay, then. Cycling back to the original question: if it hurts every time you walk, because the arteries that supply blood to your legs are partially blocked, is there a better way to treat the problem than to have a surgeon go on a virtual-reality tour of your arteries and insert drinking straws into the sections that are getting pinched off, so that the arteries are propped open and the blood flows better?


By this point I'm almost too tired to continue the discussion, but these findings (which I have made such an excruciating effort to translate into English) come from a medical study with the ridiculous name of "CLEVER!"

At least, that is what it's called in this article. I have established that CLEVER really is the acronym by which the study wants to be known (it stands for "CLaudication: Exercise Versus Endoluminal Revascularization), but I haven't been able to establish that they really want an exclamation point added to the end of the name -- an addition which I think can wait until the musical based on the study makes its Broadway debut.

Anyway, CLEVER (if not CLEVER!) really is the name of the study. And the study tried to do what (just yesterday) I was complaining that researchers don't like to do: find out if exercise works better than more conventional medical treatments, such as drugs and surgery. And yeah: exercise (walking in this case) worked better than going on a Fantastic Voyage into patient's arteries and bracing them open with little tubular retaining walls.

The study's bottom line was that both stenting and walking are superior to drug treatment, but walking is the best of the three. There is a slight problem, of course, with getting people to walk -- especially people with PAD, for whom walking is difficult by definition. Walking works as a treatment, but it's not necessarily easy for people to persevere with it in the early stages, while the problem is still present and causing them pain.

Maybe that's an indication that people should be active before they develop PAD, so that they can prevent it from happening at all? Seems like a plausible idea to me.

Sometimes I am very surprised by the Google searches that yield up a reference to my site. I can understand why an inquiry about "diabetes" or "blood sugar" would lead Google to assume that my site could be the right place to find such information. But sometimes Google also refers people here for information about an obscure subject which I mentioned just once, in passing, a year or two ago. And sometimes the only connection I can see between my site and the search phrase is a single word which I have occasionally used. Anyway, here are three search phrases which people have Googled, resulting in a reference to my site. And the more I think about them, the weirder they seem:

I assume the word "medicated" is the only reason for the Saddam Hussein question -- which I cannot answer. I have little information (or curiosity) about that man's final days. If he was given any medications, they don't seem to have had much of a mellowing effect on his personality, but for all I know that was Saddam at his most amiable.

The phrase "animated dried seaweeds" is a little hard to account for -- at least the "animated" part. I did mention dried nori seaweed once (because I thought some people would find it useful as a low-carb wrap), but I don't see how animation could have anything to do with it, unless animated dried seaweeds play some kind of role in the Spongebob Squarepants show.  (I have seen very little of that show; I realize that some adults enjoy it, but to be honest I suspect them of enjoying it with chemical help.)

That third phrase, "graphs showed women should not join the army", really raises the strangeness level to poetic heights. What sort of "graph" would demonstrate that women should not join the army?  Rising levels of dissatisfaction with barracks life on the Y axis, plotted against rising levels of estrogen on the X axis? I'm pretty sure that's a graph I haven't ever presented in these pages. But I have presented some graphs, and maybe that's all it took for my site to seem relevant to that search. Perhaps there is a real shortage of web sites aiming to prove, by graphical methods, that women should not join the army, and Google became a little desperate for suggestions (and when Google gets desperate, Google comes to me!).

Wednesday, November 16, 2011

For some reason I had sore quadriceps muscles today -- I don't know why; you'd think they would have hurt after Sunday's 7-mile run if they were going to hurt at all, not after yesterday's much shorter run. I think I still am feeling a few lingering effects of the virus I had last week (a lot of people experience muscle soreness for a while after a viral infection). Anyway, I wasn't sure I was feeling ready for a run today, so I took the easier option of a gym workout in the evening. Maybe I'll be ready for something more strenuous tomorrow.

Let's talk about atrial fibrillation for a moment. An odd phrase, that: does it mean that your foyer is fluttering? Well, only in the most metaphorical sense. The "atrium" in this case is the upper chambers of your heart, and the "fibrillation" is a lack of regularity and coordination in the way those chambers contract. When you have atrial fibrillation, your heart has lousy rhythm, and the chaotic timing of your heart's contractions results in inefficient pumping. This can promote the formation of blod clots, possibly leading to strokes. Not a good thing, clearly, although atrial fibrillation is a condition which many people live with for years before it does any detectable harm to them.

I mention the problem not because I have it, or because I am worried about getting it. I mention it because of a remarkable discovery about it which emerged recently from the Framingham Heart Study: atrial fibrillation shows no significant association with insulin resistance.

I'm stunned. I've never heard of a case before in which researchers went looking for a link between insulin resistance and some other health problem, and didn't find it. I thought insulin resistance was supposed to be the root of all evil, and here they found a health problem that's independent of it!

On the other hand, the study only found that atrial fibrillation isn't associated with insulin resistance -- they didn't find the same thing in regard to diabetes and obesity, both of which are associated with atrial fibrillation. It had been thought that insulin resistance was what made the connection between these things, but apparently not. Diabetes and obesity are associated with atrial fibrillation for some other reason that is still unexplained.  That being the case, I assume it's all right to offer a wild guess at an explanation, and see if anyone can turn up evidence in favor of it. Here's my own wild guess: lack of exercise promotes atrial fibrilliation and obesity and diabetes, so there's a lot of overlap between the people who have these problems. I can't prove this, of course.

What makes it difficult to prove a connection between lack of exercise and any specific health problem is that a lack of exercise is now the norm. The majority of people in our society are pretty inactive. Yeah, you see people jogging and riding bikes every day, but their numbers are pretty small compared to the squadrons of people who are watching them go by from a seated position while munching on a muffin at the coffee shop. Most of what we do, we do while sitting down.

Because lack of exercise is the rule rather than the exception in our society, it can be very difficult to pin down the effects that it has on health. In the case of a minority activity, the situation is easier to clarify. Only a tiny percentage of the population is employed in the coal-mining industry, for example, so it's pretty simple to contrast the health of coal-miners with the health of non-coal-miners, and see if any respiratory diseases are concentrated in the former population rather than the latter. If most people were coal-miners, this sort of thing would be harder to sort out; people might think that black-lung disease is just something that tends to happen to you by the time you're 40.

But sedentary living is so commonplace now that any health problems it causes are also very commonplace in the population as a whole. They are "normal" problems. We expect them; when they happen, we think "I must be getting old" rather than "I must be doing something wrong".

In principle, it ought to be possible to study people who do exercise a lot, and compare their health with the population as a whole, to see if they exhibit a strange lack of "normal" problems. Researchers do not seem to be very inclined to do this. Why not? Partly because of the difficulty of rounding up enough active people for a study; partly because of the difficulty of verifying how much people actually exercise; partly because most researchers think active people are so atypical as to be irrelevant. Why study them, if they're not like most people? Although I'm sure most researchers would concede that it's better to be active, I'm equally sure that they are resigned to the idea that people are never going to get much more active than they are at present, so the issue is of little practical importance. The results is that we don't learn nearly as much about this issue as we could learn, and should learn.

Tuesday, November 15, 2011

A difficult schedule today prevented me from doing my usual 1-hour post-prandial test, so I did a 2-hour, and got a result of 90. I assume the 1-hour value would have been over 100, since lunch did include a small amount of rice. But if I was down to 90 after 2 hours, I probably wasn't hitting the ceiling after 1 hour.

Is the world ready for "in vitro meat"?

Mark Post, a vascular biologist at the University of Maastricht in the Netherlands, is developing a stem-cell based process to grow meat in the lab. Not to grow animals in the lab and use their meat, mind you -- he wants to eliminate the middle-man, and grow meat in glass vessels rather than in the bodies of actual animals.

By the way, the phrase "in vitro" means "in glass" -- as opposed to "in vivo", which means "in a living thing". In vivo meat is the kind you're used to; in vitro meat is the kind that gets born in a Petri dish. ("Cultured meat" is apparently the term that the nascent industry hopes will catch on, but unless pearls are involved I doubt it will happen.)

Meat-creating technology is still at the experimental stage, and the samples produced so far are very thin strips of tissue, not much bigger than postage stamps. Assemble a few thousand of these strips in layers, however, and you've got yourself a pork chop. This hasn't actually been attempted yet, but Dr. Post thinks he can do it in the coming year. This will simply be a "proof of concept" exercise, to show that the thing can be done, and the project will be so labor-intensive that he estimates the cost of the first in vitro hamburger will be $345,000. Clearly, the process will have to become a lot more automated before in vitro meat becomes affordable. But who knows? A lot of the 20th century's most advanced technology eventually became cheap and widely available; perhaps the same will happen with this. Perhaps everyone who made room on their kitchen counter for a bread machine will soon be clearing space beside it for a meat machine.

Why bother with any of this, you ask? It might seem, at first glance, that creating a hamburger by growing thin layers of stem cells and gathering them into a large mass is a silly undertaking. It might also seem that way at second glance, to speak frankly. But the seventh or eighth glance might persuade us that there is something to this.

The argument in favor of in vitro meat is that it would be better for the health of the planet and for the health of the consumer. In vitro meat production would have (or at least might have) much less environmental impact than current methods of factory farming (which are becoming unsustainable); it would also give scientists a lot of opportunity to tinker with the nutritional content of the meat.

I am not ready to take it for granted that a network of meat-growing factories would have less environmental impact than our current network of factory farms. Maybe they would, and maybe they wouldn't; let's not jump to conclusions. When we assess the environmental impact of a new technology (electric cars, say), we often leave a lot of issues out of consideration (such as where the electricity will come from and how cleanly it will be generated). The total environmental impact of a meat-growing technology would involve a lot of issues, and we need to consider them all. (For example, do we know for a fact that the new meat factories would smell any better than the existing factory farms? You might want to know that before they build one in your town.)

However, the petri dishes presumably wouldn't have to be drenched in antibiotics (the way factory-farmed animal populations are), so there would be at least one advantage. Another claimed advantage is that scientists will be able to engineer the meat to be healthier than the kind of meat that is made of animals -- altering, for example, the relative abundance of two kinds of fats, one of which is currently regarded as a "good" fat and the other as a "bad" one. We really don't seem to be closing in on a scientific consensus about which foods or macronutrients truly are good or bad, so I don't know how the food engineers can be so sure they're inventing a healthier meat. However, it's always possible that they can invent a variety of meats, each designed to conform to a different nutritional theory, so that believers in different nutritional theories can choose the one that sounds best to them.

I guess what interests me about this story is that everything about it is funny -- particularly the practical obstacles. One of these is that, because there is no actual blood circulating in the "meat", it doesn't look like meat (it's colorless, and described rather optimistically as looking like "scallops"), and reportedly it doesn't taste much like meat either. "It's not very tasty yet," Dr. Post concedes; "That's not a trivial thing and it needs to be worked on." He's right; it's not a trivial thing. If there's one thing you can say for sure about food, it's that people tend to care what it tastes like.

And then there's this: "Like all muscle, these lab-grown strips also need to be exercised so they can grow and strengthen rather than waste away. To do this Dr. Post exploits the muscles' natural tendency to contract and stretches them between Velcro tabs in the Petri dish to provide resistance and help them build up strength."

My goodness -- if the thought of growing meat in the lab isn't weird enough for you, the thought of forcing it to work out certainly is. (And it could get weirder than that: how long do you suppose it will be before someone finds a commercial application for this flesh-fabricating technology which has nothing whatsoever to do with the pleasures of the table?)

Anyway, I also think there could be a lot of unknowable medical risks involved in creating meat in the lab, not matter how much it exercises. I hope this idea doesn't get far.

The company newletter published some photos of the environmental project I volunteered to work on, back on November 4th. I'm at the upper right in this one.

As you can see, it was all very easy. I'm surprised my back ached at all after such a light assignment.

Monday, November 14, 2011

I'm pretty well back on track. On Sunday I wasn't necessarily feeling at the very top of my game, but I did feel ready to head down to the state park and attempt a hilly 7-mile trail run. It worked out -- I finished the run without feeling bad. (It helped that the weather was perfect -- sunny and beautiful but comfortably cool.) If anything, I ran faster during the last two miles of the route, once I realized I was going to make myself late for an Irish music session I was supposed to be taking part in that afternoon. I managed to get home, get a hot shower, and drive myself and my fiddle down to Cotati to arrive at the session only 15 minutes late -- which, for musicians, nearly qualifies as punctual.

I wasn't feeling exhausted from the run, and I'm sure nobody could have guessed that I had been running through the woods around Lake Ilsanjo during the previous hour. I wasn't too tired from the run to play well -- in fact, playing was easier than usual because I was enjoying the warm glow of endorphins from the run, which is very relaxing. How well you can play on a given occasion is determined primarily by how much you can relax. The ideal plan for me would be to run about six miles before any public performance. It's just hard to arrange, personal schedules being what they are; I guess that's why so many musicians use narcotics instead.

My low post-prandial test today (90 mg/dl) was the result of a lunch that was light on carbs and followed a good workout. No mystery there, and probably no evidence that whatever was causing me to have hypoglycemia last week is still operating.

Saturday, November 11, 2011

I am pretty much recovered from whatever I came down with on Thursday night (if indeed the problem had not started affecting me earlier -- conceivably my strange glycemic lows earlier in the week could have been caused by the early stages of a viral infection). My low post-prandial results tonight might make it appear that the strange lows are continuing, but this was after an exceptionally low-carb dinner, so a low result would be expected.

My plan for the day was to go do a long trail-run today, because (in the morning, at least) I felt like I was recovered enough to do an endurance workout. But when push came to shove, I found that I wasn't really feeling ready for that. I figured I would be better off if I did an easier gym workout today, and waited to see if I can do a long trail-run tomorrow. So I went with Plan B.

Anyway, I'm feeling better.

Thursday, November 10, 2011 -- Sick Day

I came down with some kind of fever last night, didn't sleep a wink, and woke up feeling awful. I need a rest!

Wednesday, November 9, 2011

Okay, more on my journey back to glycemic stability...

After the carbs I took in last night to correct for the low, I was afraid my fasting test would be high this morning. 90 isn't bad at all.

I tried to duplicate yesterday's meals today, as closely as possible, so that post-prandial tests could be validly compared. The result after lunch was 88 (compared to 119 yesterday), so there still seemed to be a tendency to go unusually low -- perhaps this was due to a slightly exaggerated insulin response? Easy to guess, hard to know.

The result after a low-carb dinner was 109 -- low for someone with diabetes, but still within the realm of normality, and certainly very different from last night's result of 67. Also, I didn't start feeling strange after that, and I was able to go to the gym and work out without feeling hypoglycemic.

So, whatever mysterious forces were working to push my blood sugar down yesterday seem to have subsided.

Does the pancreas have "moods", sometimes producing a lot more insulin than it ordinarily would under the same circumstances? If so, does something happen that triggers this? It wouldn't surprise me to discover that such a phenomenon exists -- and it also wouldn't surprise me to discover that it hasn't been studied in any depth. The kind of hypoglycemia I experience occasionally (discomforting but not dangerous, and pretty easily remedied) is not likely to attract as much research funding as a more serious health problem. Very likely nobody knows why this kind of thing happens.

I think I pulled an abdominal muscle during my weight-training workout tonight. Great. That's a type of injury that I get very easily -- at least when I do weight-training -- and recover from very slowly. I may have just bought myself six weeks of soreness.

I know I should do weight training, but I hate it, and a big part of the reason I hate it is that I so easily strain my abdominal muscles when I do it. I didn't think I was doing anything extraordinary -- or even anything very different from last time -- but I'm feeling pretty bad. I hope I'm wrong about this...

More search strings that led Google to refer people to this site -- together with my comments:

"if my sugar reading is 325 is it dangerously high"


"blood sugar is fine but i urine alot"

Diabetes mellitus is not the only disorder that can cause excessive urination. Ask your doctor what else it might be.

"why is urine of a diabetic person with uncontrolled blood sugar..."

No doubt this oversized search phrase would have got to the point eventually, and I imagine that the point would have been about why such a person's urine would be sugary. The reason is that, when your blood sugar is extremely elevated, and your endocrine system can't bring it down in the usual, insulin-mediated way, your kidneys try to come to the rescue by filtering sugar out of your blood and dumping it into your urine. There's only so much that can be achieved in this way, though; the sugar level in your blood remains high -- just not as high as it would be if that relief-valve weren't there.

"scared of going to doctor for diabetes"

I think some people are more afraid of being labeled as diabetic than they are of being diabetic. It follows naturally that untreated diabetes is less scary to them than treated diabetes, because treated diabetes involves letting a doctor find out what's going on. And how can you let a doctor know what's going on, without letting the entire evil infrastructure of the health insurance industry know what's going on? Getting your name on the diabetes blacklist is probably like getting your name on the TSA no-fly list: once you're on it, there's no possibility of getting off it.

Well, scary as it may be to go talk to a doctor about diabetes, it isn't as scary as living with untreated diabetes. So, if you can't face getting your diabetes treated by a doctor, you'd better be very serious indeed about treating it yourself. Buy a meter and get to work!

There are some medical headlines which, as soon as I see them, I recognize as being far more interesting than the article they accompany could possibly turn out to be. Today I spotted a pretty extreme example of the genre:

No, it isn't about furtive eye-contact with your doctor. But I'm not going to reveal to you what it is about. So good luck getting any sleep tonight!

Tuesday, November 8, 2011

After being bothered by my unusually high fasting result of 100 mg/dl yesterday, I hoped to get a substantially lower fasting result today. And by golly I did. End of story, right? Clearly I was back on track: stabilized once more, and back in my familiar groove.

Because of a hectic schedule at work, I couldn't do my usual lunchtime run, but even so, my test after a moderate-carb lunch was 119 -- which is within the normal range for a non-diabetic person. So there you go: further proof of my wonderful glycemic stability today.

Then came dinner.

It was a low-carb dinner (salmon, green beans, and a handful of toasted almonds), but I need to point out here that eating a low-carb dinner is not the same thing as taking a shot of insulin. It won't push your blood sugar very high, but there's no reason to expect that it will drag your blood sugar down.

Anyway, I tested an hour after eating this meal (thinking I was just about to leave for the gym), and the result was 67.

This seemed implausible, as I wasn't feeling hypoglycemic (yet). Was there something wrong with that test strip? Was it a bad reading? I tested again. This time the result was 64. Apparently it wasn't a bad reading; I really was going low. And if I was that low after a meal, I clearly must be heading into a hypoglycemic episode, even though I wasn't feeling it yet.

I figured it would be crazy to go to the gym without doing something about the situation first. I didn't want to over-react to it, though, so I decided to see if a moderate response would do the trick. I tried a bar of dark chocolate that had only 24 grams of carbs (which is comparatively low for a chocolate bar). I waited to see how that would affect me -- but after a while I did start feeling hypoglycemia symptoms (at this point the idea of going to the gym was pretty unthinkable; I was feeling too weak and shaky). So I upped the ante, with toast and honey -- and this eventually made me feel okay.

Once I felt okay, I went to the gym for a fairly hard workout on the stair-climber; the uncomfortable feelings of hypoglycemia did not return. Problem solved, I guess.

After eating all those late-evening carbs, I won't be surprised if I get a high fasting test tomorrow -- but hypoglycemia is kind of an emergency, or at least it feels like an emergency, and you do whatever it takes to make that unspeakably disquieting feeling go away.

Now, why did this happen today? It's easy to hypothesize that, after a weekend of indulgence and a high fasting level which worried me, I tried too hard to bring my blood sugar down in a hurry, and this triggered the hypoglycemia somehow.

The trouble with this tidy and superficially-plausible notion is that it doesn't fit in very well with my previous experience of hypoglycemic episodes. I have them infrequently, and I can detect no pattern to them; they can happen at any time, and under any circumstances. If I do a very long run during marathon-training, I can expect to start feeling hypoglycemic somewhere around mile 13, if I don't take in any sugar before that point. But obviously that is an extraordinary situation; hypoglycemic episodes that occur during routine daily activities seem to be utterly unpredictable. I don't know why these things happen when they happen, and I don't know why they don't happen during the 363 or 364 days of the year when they don't.

Monday, November 7, 2011

As a diabetes poster-child, I'm kind of falling down on the job at the moment. I'm not supposed to get fasting test results above the low 90s, and I got a 100 this morning. Not only that, I know why I did, and I don't have a good excuse.

I went wine-tasting over the weekend, and although the wine itself wouldn't have driven up my blood sugar, there's nothing like a day spent wine-tasting to make you lose your inhibitions about what you're going to eat. The bottom line is that I ate way too many carbs. The wine-tasting was on Saturday, but I was still eating high-carb leftovers on Sunday, too, so I compounded the sin. I did do a long trail-run yesterday (7.3 miles), but it wasn't enough to cancel out my high-carb indulgences over the weekend, and it all caught up with me this morning.

Today I had a fairly low-carb lunch (after nunning) and got a good post-prandial result of 111. Dinner was low-carb, too, so I am hoping to see my fasting result significantly lower tomorrow.

I always feel bad about having to report disappointing results -- especially when the disappointing results are clearly my own fault. I'm supposed to be setting an example here, after all. But nobody's perfect, and it might be that setting an example of perfection would be more irritating than helpful. Anyway, I'm human, even though I try to conceal that fact to whatever extent I can.

It rained on Saturday, and cleared for a while on Sunday morning, so my trail-run in the state park took place in a bright and glittering world, with the sunlight sparkling on wet leaves everywhere I looked.

It was a little cold (although probably a lot warmer than it was in most of the rest of the country), but for outdoor exercise I think nothing beats a sunny-but-cold day.

I like the way moss on the rocks and tree-trunks suddenly bursts into colorful prominence just after it rains.

I'm glad I get such a charge out of exercising outdoors -- because exercising indoors bores me pretty easily, and I'm not sure I'd be able to keep doing so much of it, if I always had to do it in the gym.

Friday, November 4, 2011

If you're bored with your office job, you can always spend an afternoon ditch-digging, as a way of regaining your perspective.

I had an opportunity to do that today. Periodically, my company and two other local companies (Medtronic and JDS Uniphase) contribute some employee volunteers to work on environmental projects. What it amounts to is that you spend about half of a workday far from the office, cleaning up the environment in one way or another. I haven't volunteered for one of these projects lately, and I felt I was about due. Also, the projects I have done in recent years have been pretty easy ones (cleaning up litter off the beaches, that kind of thing), so I figured I was due to volunteer for a hard one. Well, today's project was a hard one, all right.

We were building a bioswale -- and no, I hadn't heard that word before, either. A bioswale is a special kind of drainage ditch, designed to remove pollutants from surface runoff. The ditch is wide, and it doesn't run downhill at too steep an angle, and it is layered with specially-chosen varieties of compost and plants. The idea is to (1) slow down the water flow as much as possible, and (2) filter the water through a dense biomass of plants and micro-organisms which are capable of breaking down pollutants in the water into less harmful forms.

In cross-section, it looks something like this:

Before you get the compost in place and the plants growing in it, it looks something like this:

But, eventually, it resembles a more natural channel:

The bioswale we were working on is located in Guerneville, California, on the Russian River. It will channel runoff from the city streets and parking lots down to the river. Runoff from surfaces used by cars tends to be saturated with pollutants of various kinds; our bioswale is one of many along the Russian River which limit the impact of runoff pollutants on the river (and, of course, the Pacific Ocean, which is pretty close by).

Although a deep trench was already in place (dug by a backhoe, I believe), it did not have the gently-sloping banks that a bioswale requires. Also, the downhill slope of the trench had to be finely adjusted to get the water flow right. So, we had to get down in this deep and narrow trench with shovels, and gradually shave layers of dirt off the walls of it to get the angle right. By the time we had accomplished that, the bottom of the trench was filled with soil that had to be dug out and tossed up onto the banks (and then raked to get the height of the banks right).

I didn't bring a camera, but (apart from a few details of historical costuming), the operation looked almost exactly like this:

People tried to persuade me to take breaks from shoveling to do the easier tasks (raking and such), but I found that shoveling -- even though it was the hardest work in terms of energy expenditure -- seemed to be the least traumatic task, in terms of its impact on my shoulder (which has an iffy rotator cuff and can easily get sore). Tossing the shovelfuls of dirt up onto the high bank put a strain on my back, and I'm a little concerned about how I will feel when I get out of bed tomorrow morning. The next morning after any kind of uncharacteristic physical activity can be challenging, and the next morning after an afternoon of ditch-digging could be especially so. I tried to mitigate the risk; shortly after I was done, I went to the gym to sit in the hot tub and do a lot of stretches. I also did a lot of shoulder rotations, and used a Thera Cane to do pressure-point massage on my back. I'm not completely free of worry about what the morning will bring, but I think it will probably be okay.

I know it sounds like a crazy thing to sign up for, especially when you're over 50, but most of the other volunteers were middle-aged as well, and my impression was that they, like me, feel that it's better to stay active -- even if you're at risk of overdoing it once in a while -- than to become so inactive that walking to the corner and back begins to qualify as overdoing it.

It's a balancing act that I'm constantly involved in now: how do you make sure that your program of physical activity is challenging enough to be doing you some serious good, but not quite so challenging that it's doing you some serious harm?

You sort of have to feel your way. Nobody can really tell you how to do it.

Thursday, November 3, 2011

I am always on my guard when I see an article with a title such as "Top Ten Myths About ______". 

When people refer to an idea as a "myth" (in the sense of "an unproved or false collective belief"), they often mean that they don't like the idea but can't be bothered to disprove it; calling it a myth is about as much work as they feel like doing.

If you want to discredit ideas you dislike, without expending the appropriate amount of effort, it is very appealing (and easy) to add them to a list of obviously incorrect notions, and consign the list as a whole to the category of myth. With any luck, people will read your list of myths too hastily to notice that some of the items you've slipped in there are only "myths" because you say they are.

Calling a belief a "myth" is not good enough, in my view. If you have nothing more to offer than an opinion (about a subject on which reasonable people disagree), don't pretend to be simply stating the facts. A belief doesn't become a myth merely because it isn't your own belief; either show that the belief is wrong or admit that you simply want it to be wrong.

I won't go so far as to say that everyone who compiles a list of myths is out to deceive people, but it's generally not a good sign. Obviously I have a suspicious nature. Rather than deny it, I will note that suspicion is often justified, and that having a suspicious nature is likelier to be a help than a hindrance in modern life. So, let me apply my natural suspiciousness to the list of Diabetes Myths outlined by the American Diabetes Association on their web site.

They lead off with "Myth: Diabetes is not that serious of a disease". They go on to explain why diabetes is a serious disease -- but to whom would this come as startling news? If a myth is "an unproved or false collective belief", then surely one of the requirements for a myth is that people have to believe it, and I don't think many people believe this one. What is this even doing here?

"Myth: If you are overweight or obese, you will eventually develop type 2 diabetes." They go on to explain that obesity is a risk factor for type 2 diabetes, but not the only one, and that most overweight people never develop type 2 diabetes. Fair enough, I guess, but I'm not sure the public really believes that all fat people become diabetic.

"Myth: Eating too much sugar causes diabetes." Here we have a tricky ambiguity of wording. Does this mean "eating too much sugar is the only cause of diabetes", or does it mean that "eating too much sugar is one of the things that can cause diabetes"? In a genetically susceptible person, eating too much sugar (or anything else) can trigger diabetes. Calling this a myth is misleading.

"Myth: People with diabetes should eat special diabetic foods." They go on to say: "A healthy meal plan for people with diabetes is generally the same as a healthy diet for anyone -- low in fat (especially saturated and trans fat), moderate in salt and sugar, with meals based on whole grain foods, vegetables and fruit." 

Before discussing that, let me quote the "myth" which follows it:

"Myth: If you have diabetes, you should only eat small amounts of starchy foods, such as bread, potatoes and pasta." They go on to say "Starchy foods are part of a healthy meal plan.  What is important is the portion size.  Whole grain breads, cereals, pasta, rice and starchy vegetables like potatoes, yams, peas and corn can be included in your meals and snacks. The key is portions. For most people with diabetes, having 3-4 servings of carbohydrate-containing foods is about right. Whole grain starchy foods are also a good source of fiber, which helps keep your gut healthy."

Okay, here we are closing in on the American Diabetes Association's sore point: a lot of people criticize them for recommending carbohydrate-dense fruit and whole grains to diabetes patients who are ill-equipped to handle such foods. The ADA's defense is to dismiss the entire issue as mythology, and it doesn't seem to me that their defense is very convincing -- especially considering that they call it a myth that such foods should be eaten in "only small amounts", and then go on to state (twice!) that portion sizes have to be limited. If you're going to quote a "myth" and then offer a contrasting summary of the "facts", the latter should not resemble the former.

And now, for a refreshing descent into absurdity:

"Myth: You can catch diabetes from someone else." Once again, it's not a myth if no one believes it, and nobody believes this one. Surely it was included merely for the sake of making other items on the list seem implausible by association.

This isn't the whole list, but it's enough to give you the flavor of the thing. I am remain as suspicious as ever that the whole point of this enterprise is to dismiss concerns which the ADA would rather not confront, by associating them with silly ideas that nobody believes anyway.

Wednesday, November 2, 2011

A rainstorm is predicted to blow in from the Pacific tomorrow, but you'd never guess it from today's weather -- clear and sunny and warm. I wasn't able to do my run at the usual time, because of a lunchtime meeting, but I did manage to sneak out for a run later, and the world was beautiful.

I chose an especially hilly route, to give myself a hard workout after a day in which I was almost constantly seated. And then, after a late-afternoon run, I came home and had a dinner that was quite low-carb, so the low post-prandial result isn't too surprising.

Here's an interesting search term that somebody Googled and were sent here: "blood sugar: 7.1 unmedicated better than 6.1 medicated?". I'd like to see if I can figure out what they were thinking.

The first mystery to solve is what the numbers "7.1" and "6.1" mean. The person does call this "blood sugar", but let's face it: most people are pretty casual about how they describe medical test results, and it could easily be that they are actually thinking of results from the hemoglobin A1c test (which doesn't measure blood sugar, but does give you a basis for estimating what has been going on with your blood sugar lately). The numbers aren't right for blood sugar measurement as it is done in the United States (anyone who ever got a blood sugar test result of 7.1 mg/dl was probably pronounced dead a few minutes later). Outside the U.S., however, blood sugar is most often measured in mmol/l, and in those units 6.1 and 7.1 are realistic values, equivalent to 110 and 128 in U.S. measurements.

(Units of measure cause so much confusion on diabetes-related web sites that I think I will now start specifying the units of measure for my daily stats -- as I have done for today's results.)

Even assuming we all know what units of measure are involved, are we talking about fasting tests here, or post-prandial tests? It makes a big difference.

But maybe the real issue here is not so much the units of measure involved -- maybe what matters is the concept of a given result being "better", if it is achieved without drugs, than a lower result achieved with drugs.  On the surface of it, the idea might seem ridiculous: surely what we care about is results, not the means used to achieve them! Surely a higher blood sugar result can't be considered better than a lower one, just because the lower one was brought about by pharmaceutical means!

Well, I don't think the idea deserves to be dismissed as ridiculous on the face of it. I don't necessarily think it's valid, but it's worth discussing.

In some cases, the "better" results achieved by chemical intervention aren't worth it -- either because the undesirable effects of the drug outweigh the benefits, or because the "better" results simply make your lab report look like the lab report of a healthy person, without actually making you healthy. Cholesterol-lowering drugs are of questionable value for both of those reasons. We know that certain kinds of cholesterol levels are associated with heart disease, but the mechanism that connects the two is not really understood -- we don't know why high cholesterol is a marker for cardiac risk, therefore we don't know whether reducing cholesterol artificially will actually reduce cardiac risk (it might be no more useful than dealing with an overheating engine by disconnecting the temperature gauge).

In the case of blood sugar, however, it does seem clear that elevated blood sugar is not just a "marker" of diabetic complications -- it seems to be a direct cause of them, simply because elevated blood sugar increases the rate of glycation (the undesirable bonding of sugar to proteins), and therefore causes harm to tissues throughout the body.

Therefore, in the case of blood sugar, a lower result is desirable in and of itself.

If you can get normal blood sugar results without drugs (as I have been able to do, so far), it is better to do it that way, because:

However! If you can't achieve normal blood sugar levels without drugs, then it becomes harder to argue that taking the drugs would not be worth it. A little elevation of blood sugar I would accept. But significantly elevated blood sugar is a problem, because it tends to increase over time. High blood sugar has a toxic effect on the cells in your pancreas which produce your insulin supply. After a long period with elevated blood sugar, your insulin-producing capacity tends to go into decline. This, of course, pushes your blood sugar even higher -- so it becomes a vicious circle. The trend toward elevated blood sugar becomes self-reinforcing. This seems to be the reason why most people with Type 2 diabetes get worse over time. If you don't fight the tendency, the tendency fights you. If you can't achieve normal or near-normal glycemic control without drugs, you have to be willing to give diabetes drugs some serious consideration.

It's not an issue I've really had to confront yet. When I don't like my results, I go to work on them, and so far I've been able to steer them back on course. If the day comes when I try to do that and it doesn't work, I will have to revisit my just-say-no approach to diabetes drugs.  

Tuesday, November 1, 2011

Doctors are making fun of the ICD-10 (more properly, the International Classification of Diseases and Related Health Problems, 10th Revision). This is an elaborate system of codes which represent all the possible diseases and injuries with which a patient might be diagnosed. And when I say elaborate, I mean elaborate. The ICD-10 has become notorious for its nearly-insane attention to detail -- which makes it about five times as long as the ICD-9 which it replaces.

The reason doctors are concerned about the introduction of the ICD-10 is that they are expected to learn these codes, and use these codes. Reimbursement from Medicare and health plans may soon be refused, if doctors do not use the ICD-10 codes when they make a diagnosis. But doctors are having a hard time understanding how they, or anyone else, could possibly use a coding system of such ridiculous complexity.

For example, in the ICD-10 there isn't a single code that covers all injuries caused by an animal. In fact, there isn't a single code for all injuries caused by a duck. After all, a duck might injure different people in different ways! If a duck bites you, the diagnostic code for your injury is W6161XA. But if the duck strikes you, the diagnostic code is W6162XA.

I don't know how often ducks injure patients by striking them, but when and if that ever happens, rest assured that the ICD-10 will have a code for it. Similarly detailed attention is given to other potential animal aggressors, including cows and dolphins.

Naturally, the ICD-10 is not satisfied to use a single code to represent injuries caused by walking into things. Did you walk into a wall? A lamp-post? Furniture? There's a code for each thing you can walk into. There's also a code (V9114XA, in case this applies to you) for being crushed between a sailboat and a water-craft that isn't a sailboat.

And if your water-skis catch fire, rest assured that any burns you may suffer from this unfortunate occurrence will be uniquely represented by the code V9107XA. 

But what if your snowshoes catch fire, I hear you asking? Is there a code for burns resulting from that? I have not been able to verify that there is -- but I assume that there has to be.

Other problems which I imagine would have diagnostic codes of their own might include:

I have long been fascinated by this kind of thing -- this urge to develop an exhaustively complete catalog of all possibilites. It so often afflicts those who work for the government or for other official bodies with some kind of authority. They always seem to imagine that they can sit down at a conference table and make up a set of rules which encompasses every single thing that might ever happen. This is so flagrantly imposible that you wonder how they can fool themselves into thinking otherwise.

I once saw a set of rules, created by the Homeowner's Association for a condominium development, listing all the specific things that the residents must not do in the parking lot. "Repairing aircraft engines" made the list. This made me wonder how they had even thought of that -- and also made me wonder why repairing submarine engines was apparently okay (since they hadn't forbidden it). They didn't forbid the residents from operating a petting zoo in the parking lot, either, so I guess they would have been okay with that as well.

Another example I once saw was a list of exceptions to the Buy American Act (a law which sought to encourage the goverment to buy its goods from American suppliers). The exceptions included "altar linen", "cobra venom", "microscope slides", and two different substances that are used to induce vomiting in victims of poisoning. I don't know how much cobra venom the government actually buys, but you can see how they might have a hard time buying it locally, so I guess it's okay with me that they are allowed to import the stuff if they need it. But what kind of meeting could it have been, where the assembled bureaucrats tried to think of all possible exceptions which the law might need, and came up with a list which included both altar linen and cobra venom? I mean, who are these people?

Apparently most doctors and hospitals are woefully unprepared for full adoption of the ICD-10, so I don't know how smoothly the transition to the new set of diagnostic codes is going to go. But if, during the next year or two, your doctor starts asking you amazingly detailed questions about exactly how the duck did this to you, you'll know the reason why!

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