Thursday, September 29, 2011

I decided to push myself a little harder today on my lunchtime run -- a very steep 5.4 mile route. Once again, my right knee (still not 100% recovered from the fall I took last Thursday) felt wobbly and weak at the start of the run, and much better as the run progressed. It was a nice day for a run, too: there was a nice cool breeze, which was a welcome change from the heat yesterday.

Still, I felt that I might be pushing things a little too much. I think I'll take tomorrow as a rest day, and give my knee a little more recovery time. 

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

Health headlines guaranteed to make nobody sit up and take notice!

Wednesday, September 28, 2011

My knee still felt good (not perfect, good) today, so I decided to risk another run -- this one a little harder. My knee did still feel a little wobbly at that start, but once I got going the run made it feel better rather than worse. I'm recovering quickly.

I don't know if I'm recovering quickly enough to sign up for the Harvest Run 10K footrace on Sunday, though. It's an annual event and I usually do it, but I'm not sure I'm going to feel like running a race by Sunday. We'll have to see.

Our late-arriving summer continues. It was a hot day for a run. 96 degrees in the late afternoon -- but a mere 90 when I went running at noon, so it wasn't that bad. We chose a shady route. Anyway, we never have much humidity around here, so it's not as bad as it sounds.

Arch West is no more! He died on September 20.

Don't recognize him? Well, perhaps you will recognize the product he introduced at Frito-Lay 47 years ago...

Yes, that's right: Arch West is widely credited as the creator of Doritos.

He died at the age of 97, a fact which led The Onion to speculate: "I'm guessing he erred more on the side of Doritos-creating than Doritos-consuming".

Mr. West's wife of 50 years, Charlotte, died the previous year. The New York Times obituary ended with this somewhat surreal detail:

When their ashes are buried together on Saturday, their daughter said, "We're going to let everyone toss in a Dorito."

Oh, no -- ACCORD is back!

ACCORD was that huge study, coordinated by researchers at Wake Forest Baptist Medical Center (in Winston-Salem, North Carolina), which compared standard diabetes care with "intensive" drug therapy aimed at controlling blood sugar more strictly. It turned out that intensive drug therapy created problems of its own, and many patients did worse rather than better when they received that sort of treatment.

The researchers could have concluded from this that intensive drug therapy wasn't the best way to control blood sugar, or at least that the particular drugs and dosages they were using were not the right ones. They didn't. Instead of saying that they hadn't been pursuing the goal of strictly-controlled blood sugar in quite the right way, they went around saying (in endless press releases and articles that have appeared at regular intervals over the past few years) that the problem was with the goal itself: tight control of blood glucose, not the treatment used to achieve it, was bad for you.

It would be bad enough if these conclusions had been published just once, but ACCORD has more lives than a cat. The study gathered a huge amount of data, and people keep on mining that data so that they can keep on publishing new papers on it every few months, all announcing the same conclusion: "Here's yet another reason to think that tight glycemic control isn't beneficial!".

For a while I tried to give the researchers the benefit of the doubt: perhaps this habit of falsely equating drugs with well-controlled glucose was practiced only by lazy science-journalists, and if I sought out the original rather than second-hand accounts of the research, I would find that the researchers themselves were actually being careful to make a clear distinction between the goal of a treatment and the treatment itself. However, whenever I manage to get a look at what the researchers themselves are saying, in their own words, I find the same maddeningly false summaries of what the data indicated.

Here, for example, is an article appearing on the web site of the Wake Forest Baptist Medical Center itself. The headline: "Blood Sugar Control Beyond Standard Treatment Does Not Improve Cognitive Decline for Older People with Diabetes".

The lead: "Intensive control of blood sugar levels beyond standard targets provides no additional protection against cognitive decline in older people with diabetes than standard treatment, according to a national study coordinated by researchers at Wake Forest Baptist Medical Center."

So here we go again! The problem isn't the particular method that's being used to control blood sugar. The problem is control of blood sugar. If you "go beyond" standard treatment in terms of glucose reduction, you reap no benefit from this; you just take on additional problems. So why bother?

If control of blood sugar were so dangerous in and of itself, non-diabetic people would be dropping like flies. How do people even survive without diabetes? Those poor souls are not just near the normal glucose range -- they're right in the middle of it!

I suppose that the researchers would heave an exasperated sigh, if they heard me ask about this, and explain to me that strict control of blood sugar is dangerous because it increases the risk of dangerous hypoglycemic episodes.

To which my answer would be: then you should use a method of controlling blood sugar that doesn't cause dangerous hypoglycemic episodes.

Another heavy sigh, as they explain to me that you can't achieve tight glycemic control without experiencing dangerous hypoglycemic episodes.

To which my answer would be: watch me! The patients who are experiencing dangerous hypoglycemic episodes are experiencing them because the "intensive" drug regimen they're on sometimes pushes them too far down. Since I'm not taking the drugs, I'm not experiencing those dangerous hypoglycemic episodes. I experience the occasional annoying hypoglycemic episode, maybe once a year, but it's not a crisis -- it's just a matter of feeling bad for a while until I can eat something and solve the problem. And plenty of people experience that sort of thing without having diabetes at all. The bottom line is that I'm maintaining better glycemic control than the intensively-treated patients in their study, without the drugs and therefore without the drawbacks.

Admittedly, what I'm doing to achieve tight glycemic control won't work for everyone, and might stop working for me, too, somewhere along the way. (It's worked for a decade, though, and I bet I can keep it working for a long while yet.)

I think it's irresponsible, and even a little nutty, for researchers to talk about tight glycemic control as if the most dangerous way of achieving it were also the only way of achieving it. If the people at Wake Forest Baptist Medical Center have nothing more useful than this to say about diabetes, I wish they would drop the subject of diabetes entirely, and go work on some other problem. Such as inventing a better snack chip.

Tuesday, September 27, 2011

I wasn't at all sure whether or not it was a good idea to go back to running today, and I have to admit that I nearly became discouraged during the first little bit of the run. It didn't feel very good, and I wondered  whether I would have to turn around and come back after a few minutes. Every part of me that had been sore since I took that fall last week was now complaining to me about the run.

However, after the first half-mile my body seemed to settle into the activity, and although I wasn't able to run fast, I was hurting less rather than more as the distance built up.

I was actually tempted to run 5 miles rather than 4, to make up for the running I'd skipped over the weekend, but I had enough sense to realize that this would be pushing it, and 4 was enough for today. I'll probably run farther than that tomorrow. My knee feels better now than it did this morning, and that has to be a good sign.

Blood-pressure is up a bit tonight -- probably because I was just reading something that irritated me greatly. Maybe I should stop reading things that irritate me greatly. That would exclude 90% of politics, however, and I wouldn't be a very well-informed voter...

Okay, this is kind of weird. A poll of American primary-care physicians, published yesterday in the Archives of Internal Medicine, found that 42% of them feel their patients receive too much medical care, not too little. And they don't just mean that their patients are receiving too much care from other doctors -- more than a quarter of them said that they themselves give their patients more care than they should.

This, of course, raises an obvious question: if doctors think the amount of care they are giving their patients is excessive, why do they continue? Apparently because the system they must work within leaves them little choice in the matter.

The doctors were asked to identify the factors which led them to "practice aggressively". The leading factors were fear of accusations of malpractice (76%), fear of poor clinical performance evaluations (52%), and not being allowed enough time with patients (40%).

Perhaps that last item seems like a contradiction of the claim that patients are receiving "too much medical care", but the explanation for the paradox seems to be that certain things doctors do are thought of as "medical care", and other things are not. Writing prescriptions for meds, ordering tests, and performing surgery... those things qualify as medical care. Talking to patients, counseling them, and following up with them on their progress... those things tend not to qualify as medical care, at least in the eyes of the health-care industry, which does its best to discourage doctors from frittering away their time on such activities.

If all the incentives are pushing doctors to write a prescription and hurry the patient out the door, then obviously there is going to be more prescribing and less conversing going on in the examining rooms. It doesn't look as if doctors can solve this problem themselves (at least they haven't found a way to solve it so far, and they don't seem to be very optimistic about doing so). I have to admit that I'm not optimistic about seeing this problem solved at the political level, either.

So I guess that leaves us patients to figure it out. We have to do enough self-education to find out what our doctors would be telling us -- and asking us -- if they were allowed to spend more time with us.

Of course, when we do this, we are at risk of getting it wrong. But that isn't exactly our fault, is it? If doctors didn't invent this system, patients sure didn't invent it either. We'll just have to do our best at the guesswork, and make an effort to ensure that it is educated guesswork, at least!

Monday, September 26, 2011

I haven't been feeling quite like my usual self since I took that fall while running last Thursday. On Friday morning, as I expected, I woke up feeling pretty stiff and sore. I found that my right knee was not just sore on the surface, where I scraped it, but on the inside, too. It wasn't hurting badly enough for me to feel that I needed to have my doctor look at it, but the knee didn't feel good when I put weight on it (especially while climbing stairs or walking uphill). I knew that I wasn't ready to handle running, or much of any other kind of exercise either.

This was certainly not the first time I'd ever taken a fall while running, but I guess it was the first time I'd done it on concrete instead of dirt, and maybe that's why the fall seemed to be a lot harder on my body -- all over my body -- than I would have expected. That concrete is a pretty unforgiving sort of material. It doesn't compress to absorb an impact the way dirt does. I'm making a mental note to land on something softer next time.

I'm trying not to let myself think too much about how the fall might have been less painful if I'd been a few years younger. It's hard to tell to what degree we really do become more frail over time, and to what degree we are simply thinking of our selves as more frail over time. There's probably nothing that makes you feel old and feeble quite like expecting to feel old and feeble.

I took Friday as a rest day. I didn't even do a blog post on Friday, as you may have noticed, but that wasn't because my aches and pains stopped me. A friend of mine was hosting a musical weekend, and I spent Friday and Saturday nights playing tunes with him and his guests (which, for me, is the best healing therapy for just about any ailment).

On Saturday afternoon I felt as if I should at least go for a walk, even though that might prove difficult. I started at the Vietnam Veterans Memorial Trail in Santa Rosa, which leads into Annadel State Park.   

At first, I was walking like your average 90-year-old, especially on the steeper parts of the trail.

On the occasions when I go into that park and I'm merely walking, not running or cycling, I often feel envious of the people who are making it more of a workout -- but I didn't really feel that way this time. I was content to walk at a snail's pace, and leave the running to others.

At least when you're walking you have more opportunity to look around, and absorb the Wizard-Of-Oz atmosphere of the woods. None of the trees got into an argument with me, I'm pleased to note.

I paused when I got to the really steep part, to ask myself if this little hike was going to make my sore knee feel better or worse. I decided that my knee was feeling better than it had at the starting point, so I might as well continue.

It was a nice day, and I got to see the usual wildlife -- apart from the snakes, and I don't really mind when I don't run across any of them.

The lake, at the top of the trail, was looking pretty, but faintly autumnal. Clouds were moving in. I was sensing that summer (which arrived late in these parts) was ending.

Actually, I like the park better in Autumn anyway.

So, I made it back out of the park with my knee-joint still working, and I think I was better for having taken the walk. Even so, on Sunday I still didn't feel able to do any exercise more strenuous than taking another walk.

Even today I didn't feel ready to go running, so I went to the gym instead for a stair-climber workout. I wondered if my knees were ready even for that, but it didn't seem to be a problem, so maybe I'm healing up well and I'll be able to run tomorrow.

Here's some News You Can't Use: a new study finds that diabetes patients who see their doctor two to four times a month achieve better glycemic control than patients who... uhm, live in the real world.

I'm sure this will be good news for Bill Gates and Warren Buffett; others may find it hard to make use of this information in their own lives. But anyway, if you could afford to see your doctor on a weekly basis, you would do better with glycemic control.

I guess you have to be your own doctor during all those weeks when you're not seeing a real one. That's what I'm trying to do, anyway.

Thursday, September 22, 2011

I went flying today. Not in an airplane, unfortunately. That would have been safer than the method I used.

I was running along a street near my workplace, on the sidewalk, minding my own business, jumping as carefully as I could over the many raised edges where tree roots had pushed up segments of the concrete... when I overlooked one of these obstacles, tripped on it, and went for a brief journey by air. 

I soon touched down. My knees took most of the punishment when I landed, but the heels of my hands are a little raw, and now (several hours later) my left side is starting to ache, so I must have pulled some muscles there (the pain isn't bad enough for it to be a cracked rib). Some aches and pains elsewhere, too.

I feel so stupid when I take a fall like that (I do it about once a year, but usually while trail-running in a place where there are rock and roots and things to trip over). After the initial pain of the hard landing, the embarrassment seems to be the worst of it. I got up quickly and started running again (that usually ends up feeling better, after a running accident, than taking a break or walking), and for a couple of miles I really wasn't feeling my scraped knees. I was just worrying about how much they would hurt when I got back to the locker room and cleaned them off in the shower. But then, during the last mile of the run, they really started to sting.

My route back to the office went past a hospital, and as the nurses are on strike in California today, I had to run with my bloodied knees through the middle of a big crowd of nurses holding picket signs. I could see that they were looking at my knee injuries, and I joked with them a little about it on the way through (I said I'd better not fall down again, because there wasn't going to be anyone to treat me if I hurt myself any worse).

Then, back to the locker room for a bit of soap and hot water -- both of which feel a lot better on itact skin than they do on bloody abrasions, but all in all the cleaning-up experience wasn't as bad as I expected. I had fallen on a clean sidewalk rather than unpaved ground, so I didn't have to remove a bunch of dirt from the wounds; a gentle cleansing was adequate.

But then I had to put my pants on, over the raw scrapes, and go in search of some bandages. The only place I knew of at work that would have first-aid supplies was a longish walk away, up a hill, with several flights of stairs to negotiate, and I have to say I didn't find the journey enjoyable, what with the fabric of my pants rubbing on my injured knees every step of the way. But eventually I was able to get my knees bandaged up properly. I couldn't find any antibiotic ointment, so I had to use an an "antibacterial gel" which apparently consisted mainly of alcohol, and hurt like blazes.

What can I say about minor injuries of this sort? You try your best to avoid them, but no matter how careful you are, they do happen once in a while. It seems to be the price of becoming an active person. Most athletic people I know experiences worse injuries than I do, and more frequently. You have to remember the bottom line: in the long run, are you better off if you're physically active (in which case you are probably going to experience various minor injuries along the way, which heal quickly) or physically inactive (in which case you are probably going to experience a gradual degradation of health, which never heals at all)?

Well, it's that time of year again. Today I phoned my doctor's office and made an appointment for my annual physical. It will be on October 5.

Of course, I'm fortunate in that I only have to go in once a year, so that my doctor can verify that I'm still on track. Most diabetes patients have to see the doctor a lot more often than I do. But I always sweat about it, mainly because I'm afraid the lab report will reveal some problem that I hadn't known was developing. Last time my A1c was 5.6, which was higher than I expected, and higher than I had seen before. I've tried to reverse that trend since, and I'm hoping to see a lower A1c result this time.

Did you know that 71% of all statistics are just made up on the spot?

Wednesday, September 21, 2011

Dinner was very low-carb, so my low post-prandial result of 95 wasn't all that startling. But I imagine it would have been a little higher if I hadn't done a hard run at lunchtime.

I was playing Irish music at a tavern on Saturday, and one of my running buddies was there. Despite a difficult lighting situation, she caught some good pictures of us.

Lighting wasn't the only photographic challenge, of course. The camera shutter that can freeze the motion of my fingers when I'm playing Irish reels has not yet been invented.

Hey, boys and girls, I think it's time I shared with you some valuable insights that I have picked up from reading reports of diabetes research over the past ten years!

I have begun to notice that many of these research reports are so much alike, they seem as if they might have been generated by a computer program which operated by plugging a few randomly-selected variables into the same basic template. I'm not going to write that program, but I think I can give the basic outline of the rules it would follow. So, here you go...

How to Write Your Own Breakthrough Research Paper on Diabetes

[Dateline: insert exotic university town, preferably in Scandinavia or Asia]

A research team at [insert name of obscure medical school] has discovered a new [protein/hormone/gene] which plays a key role in the regulation of blood glucose levels. A defect in the body's utilization of this [protein/hormone/gene] may be the ultimate cause of type 2 diabetes, and [the protein/hormone/gene] offers a promising target for development of new [pharmaceuticals/stem cell therapies] for the disease.

The researchers demonstrated that mice which had been genetically modified to be unable to utilize the [protein/hormone/gene] became obese and diabetic, so you can see that this just has to be the real cause of diabetes.

Dr. [insert exotic name] and her team expressed hope that the discovery would lead to [insert hand-waving speculation about new treatments for type 2 diabetes].

However, the researchers emphasized that [insert plea for continued funding for research into this vitally important breakthrough in our ongoing struggle against diabetes].

Tuesday, September 20, 2011

I usually do post-prandial testing after 1 hour, not 2 hours, but when the events of the day interfere with my testing schedule I sometimes do a 2-hour test. To be honest, I only do it when testing at the 1-hour point is impractical, but I guess there are good reasons why we should try a 2-hour test once in a while.

In non-diabetic people, the post-prandial glucose peak tends to occur 50 to 60 minutes after a meal, and the glucose level drops rapidly after that peak. This seems to be true in my case as well. Admittedly, there is a limit to how much glucose monitoring I can do, but I have never found any evidence that my glucose continues to increase between the 1-hour and 2-hour points. However, some people with diabetes do get a higher peak at 2 hours than at 1 hour, and this is not a good sign. If that is going on, you need to know it.

So, I'm glad that my result today was down to 99 at the two-hour point. 

I had to go running a little earlier than usual today, because I was trying to work around my meeting schedule -- but I'm glad it happened that way, because it was hot when I was running, and it got hotter later  (98 degrees by late afternoon).

After another cool summer, it's a little startling to experience a heat wave this far into September. And it seems even hotter than it is, just because it's happening right when you're expecting the weather to cool off.

Oh dear, a study in Japan has gathered further evidence of a connection between diabetes and dementia, especially in the form of Alzheimer's disease. Being diabetic seems to double your risk (as it doubles your risk of everything else, up to and including abduction by space aliens).

This sort of news always makes me want to see if there's a silver lining here. Here's the one I've found: the dementia risk is specifically increased in those with elevated post-prandial glucose -- especially if glucose is elevated at the 2-hour point.

Well, I'm not seeing that. So maybe I can avoid dementia. At least, I can avoid dementia so long as my 2-hour post-prandial results are not elevated. I guess it was just as well that my post-prandial test was delayed today.

Monday, September 11, 2011

I have to admit that I was very relieved to find that my fasting glucose wasn't any worse than 91 this morning. It was very much a social weekend, and I didn't exactly hold back at the big barbecue yesterday. The only obvious evidence of that is the weight-gain, but right now I'm focused on being a good boy and getting back on track.

Another thing I have to admit is that I did very little to observe ITLAPD (International Talk Like a Pirate Day), the annual event created in by two gentlemen from Albany, Oregon with (it would seem) a lot of time on their hands. Their actual names are Mark Summers and John Baur, but for the purposes of the present festivities they wish to be known as Cap'n Slappy and Ol' Chumbucket. As legend has it, they were playing racquetball on June 6, 1995, when one of them suffered a painful injury and growled "AAAAARRRRR!". I guess the pints afterwards did the rest, and a new holiday was born. (Not wanting to have their holiday conflict with D-Day observances, they moved the date to September 19.) Because their cause was taken up the humor columnist Dave Barry seven years later, the holiday is often mistakenly said to be his invention. Not so, he merely publicized it. These guys invented it. It is their intellectual property, if that is not too generous a term.

Their web site offers advice on how to talk like a pirate (including pickup lines, such as "Have ya ever met a man with a real yardarm?" and "Prepare to be boarded"), but I have a hard time picturing myself saying any of these things. Pirate phrases are to be spoken with bold conviction or not at all, and bold conviction isn't one of my qualities. Strutting around the office growling "avast!" and "shiver me timbers!" just didn't seem like an assignment that I could pull off.

I have often wondered how we arrived at out conventional idea of how pirates spoke. I did some research on it today, and it turns out that we owe this idea almost entirely to an English actor named Robert Newton, who portrayed pirates in several films; he invented a speech pattern that was based on the West Country dialect that he had heard during his youth in Dorset and Cornwall. Certainly a lot of pirates and English sailors came from there, so it's possible that Newton's fabricated "pirate accent" was not too far from the real thing -- at least to the extent that there could ever have been such a thing as a pirate accent. (Is there a special accent for dentists? Just asking.)

I myself speak with a blogger's accent, but it's pretty subtle if you don't know what to listen for. The main telltale is a lot of muttering and cursing about how it's getting late and I should be sleeping instead of writing about pirates.

A study conducted in Italy found that post-prandial blood glucose was a far better predictor than fasting glucose of the risk of death or "cardiovascular events". Post-prandial glucose also agreed much better with hemoglobin A1c results than fasting glucose did.

Oddly enough, the study found that testing after breakfast was also a poor predictor; to see results that agreed well with A1c results and with actual health risks, you needed to test later in the day.

Why that should be is a little hard to say. The study was conducted in Italy, where breakfast tends to be a lighter meal than it is in other countries. But is it also low-carb? Breakfast foods tend not to be. Maybe most people are better able to process carbs at breakfast than they are later in the day (I seem to be that way myself), and for this reason post-breakfast glucose has less impact one way or the other.

For a long time I was doing fasting tests only, on the theory that this would serve well enough as an early-warning system if I was getting off track. Then I started reading studies like this one, showing that fasting tests my themselves don't reveal enough about what's going on. You can continue to get good fasting tests long after your post-prandial glucose has started to spin out of control -- and apparently that's what gets you.

So I'm glad to see that my post-prandial result today was nice and low. But it was a low-carb lunch after a high-intensity workout, so I wasn't too worried about that one turning out badly.

Friday, September 16, 2011

Yesterday I gave a passing mention to the idea that the American public is overmedicated. Apparently I'm not quite as far out on a limb in thinking that as I had feared. Today I read a summary of a review article on the need for more conservative prescription policies, which appeared this week in the Archives of Internal Medicine... but I can't discuss the article quite yet, because I am distracted by that puzzling phrase "internal medicine".

What does "internal medicine" mean, anyway? I mean, what kind of medicine isn't internal? Does internal medicine simply mean every medical speciality that isn't dermatology?

My research into this matter has mostly uncovered multiple layers of confusion. "Internal medicine" appears to be one of the most ill-defined phrases known to medicine (a field that is hardly noted for its insistence upon razor-sharp definitions of terminology). Perhaps the problem is that the phrase is an English imitation of a German medical term ("innere medizin") which apparently isn't very well-defined in German, either. Anyway, here are some definitions of internal medicine that I found:

So there you have it. Internal medicine relates to adult diseases, or nonsurgical disaeases, or unusual/serious diseases, or diseases of the internal organs or internal structures. Or some combination of those things.

I guess the next step is to figure out what kind of medicine isn't internal medicine. Apparently surgery, anasthesiology, radiation oncology, pediatrics, podiatry, and dermatology are usually regarded as not belonging under the banner of internal medicine. Most of the rest of medicine, however, does seem to be internal medicine -- including endocrinology, which means that diabetes treatment does come under the heading of internal medicine. So I guess that's settled.

Okay. So anyway, the report in the Annals of Internal Medicine proposes a set of principles for doctors to follow, as a guide to "more cautious and conservative prescribing, based on recent studies demonstrating problems with widely prescribed drugs."

The report continues: "The recent spate of revelations of undisclosed and unexpected adverse effects of drugs in multiple therapeutic categories should serve as wake-up calls for our profession to take a more sober, balanced, and cautious approach to prescribing."

The principles underlying conservative prescribing include the following:

I don't know how well these principles are going to go over with doctors. That one about "respecting patients' reservations concerning drugs" is going to be a difficult idea for some doctors to accept; I have heard some amazing tales about doctors who insisted on continuing treatments with statin drugs, in the face of the most pitiful complaints from their patients who couldn't tolerate them. But maybe things will start to change, however slowly.

Thursday, September 15, 2011

What is the difference between diabetes and true diabetes? This is a question of some significance to a debate which is going on at the diabetes conference in Lisbon. Unfortunately, it's not an answerable question.

The British philosopher Antony Flew coined the term "no true Scotsman" for a particular kind of logical fallacy, which he explained by means of this anecdote:

Imagine Hamish McDonald, a Scotsman, sitting down with his Glasgow Morning Herald and seeing an article about how the "Brighton Sex Maniac Strikes Again." Hamish is shocked and declares that "No Scotsman would do such a thing." The next day he sits down to read his Glasgow Morning Herald again and this time finds an article about an Aberdeen man whose brutal actions make the Brighton sex maniac seem almost gentlemanly. This fact shows that Hamish was wrong in his opinion but is he going to admit this? Not likely. This time he says, "No true Scotsman would do such a thing."

In the "no true Scotsman" fallacy, you deal with a glaring exception to something you believe by means of a vague assertion that the exception doesn't count. Confronted with the information that a member of your church did something which you have said a member of your church would never do, you dismiss the evidence by saying that no true member of your church would do such a thing. Membership in your church is conveniently redefined so that it excludes anyone who might make your church look bad.

Apparently the "no true Scotsman" fallacy exists in medicine, too. Some doctors advocate putting all newly-diagnosed diabetes patients (and possibly pre-diabetes patients) on statin drugs, to reduce serum cholesterol, on the grounds that a diabetes diagnosis is a risk factor for coronary heart disease, and a risk factor for coronary heart disease is sufficient grounds for putting a patient on statins. Others are not so sure that this is a good idea, because clinical trials seem to show that statins increase the risk of diabetes, and are probably not good for people who have diabetes or are heading in that direction. The advocates of statins say that the people who develop diabetes after going on statins are not developing true diabetes. It's just elevated blood sugar.

Now, given that elevated blood sugar is the very definition of diabetes, it might seem a little puzzling that diabetes could be conveniently redefined to exclude elevated blood sugar if it was caused statin drugs. But that is what some of the doctors in Lisbon are suggesting.

I would have thought that no doctor would make such an argument in a public forum. Well, no true doctor.

One of my running buddies was telling me today, as we huffed and puffed our way up a big hill, about his flight back from the east coast the day before. He was seated next to a man who was engaged in medical research involving stem-cells. His work had to do with a technique for using stem-cells, placed on a tubular net of some artificial material, to grow new coronary arteries for patients whose original coronary arteries were blocked or damaged.

This fellow gave him some advice: if you are facing a prospect of having some kind of surgery which doesn't need to happen now (back surgery, for example), put it off as long as you can, because new techniques will become available in the coming years which will make these procedures safer and more effective. He said we'll eventually be re-growing damaged spinal chords, and solving other medical problems which are currently impossible to deal with. Unfortunately, I have no means of knowing how right or wrong he was about this.

The guy also mentioned that he thought the American public is hugely over-medicated. Well, he's not going to get an argument from me.

Wednesday, September 14, 2011

Jargon (the specialized language associated with a particular subject or profession) can be a big obstacle to communication, and not just in the way you would expect. It isn't simply a matter of people not knowing what an unusual term means. Often the problem is that people think they do know what it means, and they're wrong.

For example, even if you don't know much about classical music, and you therefore don't know what a cadenza is, at least you don't have any false idea of what a cadenza is; the subject is simply a blank to you. But if you don't know what an "English horn" is either, in this case the name leads you to a false conclusion: that it must be some kind of horn that was invented in England. (It's actually a kind of oboe that was invented in Poland.) 

Jargon is always at its worst when it sounds as if it has a straightforward meaning, because that straightforward meaning is usually wrong.

So it is with medical jargon. Most people don't know what an "arteriovenous fistula" is, but at least they know that they don't know what it is. In the case of "heart failure", though, most people probably assume that it means what it sounds like it would mean -- and of course it doesn't.

For years I thought heart failure meant that your had stopped beating, and if I heard that someone had died of heart failure I always thought that was an awfully vague way of putting it. Didn't everybody's heart stop beating when they died? Seemingly every death certificate in the world could be rubber-stamped "heart failure". I was wrong, of course. It turns out that heart failure does not refer to the cessation of heartbeat (that would be "cardiac arrest"); it refers instead to a chronic condition which many people live with for years.

Heart failure (also known as congestive heart failure) is abnormal weakness in the pumping action of the heart. In people with heart failure, the heart does beat, and it does pump blood -- but it doesn't pump blood robustly. It doesn't get the blood circulating at a sufficient rate to meet the body's needs.

There are various ways in which the heart can get into this kind of trouble, and various causes for it, but there are two basic possibilities. There can be a systolic (contracting) dysfunction, in which the chambers of the heart are swollen and weak, and empty less than half of their blood content during a contraction. There can also be a diastolic (expanding) dysfunction, in which the chambers of the heart are stiff and undersized, and never fill themselves up enough to be able to pump out a satisfactory blood volume during a contraction.

Heart failure leads to a variety of problems. The most obvious one is that your circulation is just barely adequate to support life under routine conditions, so any added exertion is too much -- you very easily become exhausted and out of breath when you exercise, or even when you walk across the room.

Other common symptoms of heart failure include coughing, constant fatigue, and accumulation of fluid (in the lungs, in the abdomen, in the ankles), often resulting in visible swelling. This congestion of fluid is the reason heart failure is often called "congestive heart failure".

Obviously, heart failure is a pretty serious health issue. Even if it doesn't kill you, it limits your activities severely, and often leads to hospitalization. I assume we are all agreed that heart failure is something we want to avoid. That is why we might easily become anxious or depressed at the latest news coming out of that diabetes conference going on in Lisbon this week: apparently heart failure (at a level of severity requiring hospitalization) is 2.5 times as common in people with diabetes.

To be sure, the risk of everything that might possibly go wrong in life is said to be at least 2.5 times as common in people with diabetes -- regardless of whether we are talking about coronary heart disease, foreclosure, or abduction by space aliens. So we don't necessarily need to panic over the increased rate of heart failure in diabetes patients, any more than we panic over the increased rate of everything else that's undesirable in diabetes patients.

And there's another reason not to panic over it: the rate of heart failure is only magnified in people whose diabetes is pretty far out of control. The rate of heart failure tracks rising levels of hemoglobin A1c, and the increased risk doesn't start to become significant until you are well above 7, or even 8.

So, if you can keep your A1c results below 7 (and below 6 if possible), which you certainly want to do for other reasons, heart failure does not appear to be much of a threat.

It is worth being aware of heart failure, and on guard against any indication that you might be developing it. But the mere fact that you are wearing that scarlet letter D is not enough reason to assume that heart failure is something you are likely to experience.

If you can address the other health-management issues involved in diabetes (such as preventing coronary heart disease), the more remote possibility of heart failure is probably going to take care of itself. I have decided to adopt a sensible policy of not even thinking about it, until there is some reason to believe it has become an issue for me. And I don't think it has become an issue for me yet, as I did a 5.3-mile run on cruelly steep hills today and lived to tell the tale.

Tuesday, September 13, 2011

Diabetes Epidemic on 'Relentlessly Upward Trajectory' reads the Medscape headline. This is according to officials from the International Diabetes Federation (IDF) and the European Association for the Study of Diabetes (EASD), currently holding a meeting in Lisbon.

The 2011 estimate for the number of people with diabetes worldwide is 366 million (up an astonishing 28% from the 2010 estimate). "This year, 4.6 million deaths will be attributed to diabetes, with 1 person dying from diabetes every 7 seconds. Healthcare spending on diabetes has reached $465 billion."

The officials are calling for some kind of urgent action in response to the diabetes crisis, but it's hard to see what that urgent action could consist of. Researchers say that there needs to be a lot more funding for research (which is what researchers are always going to say, in any circumstances), but what should we be researching exactly? How to make new mediocre drug treatments to add to the long list of existing mediocre drug treatments?

Look, I'm as big a science fan as anyone is, and of course I think research into the cause, nature, and treatment of diabetes should continue. But I don't believe for a minute that research is going to lead to any kind of game-changing breakthrough that will halt the "relentless upward trajectory" in new diabetes cases, or render the disease harmless for the millions of people who are developing it. If we're going to do anything about the diabetes rate, we're going to have to change the way people live these days.

Yes, there is a genetic component in diabetes, but it's hardly likely that the human genome has been deteriorating at a spectacular rate. The only thing that has been changing that fast is human habits. I don't know how we go about reversing that change in lifestyle, but it's a cultural change rather than a physiological one, and "research" isn't going to turn it around.

One of the search phrases that caused Google to refer someone to my site last week was "why do diabetics get so fat". Some people would be inclined to argue that the wording of that is backwards: isn't is generally understood that you get fat and then you get diabetic? Don't we all know that, instead of diabetes making you fat, being fat gives you diabetes?

Actually, the relationship between obesity and diabetes is not at all likely to be as simple and straightforward as that. In certain people, with a certain combination of genes, obesity tends to promote diabetes. But, under certain circumstances, diabetes tends to promote obesity as well.

Various mechanisms have been proposed to explain how diabetes might promote weight gain; the two which seem most plausible to me are both related to the various regulatory roles played by insulin.

Perhaps it seems odd to refer to insulin as playing a variety of regulatory roles. Doesn't insulin just drive blood sugar downward? Well, that is one of the effects that insulin has (it stimulates cells, especially muscle cells, to absorb glucose, thuse removing it from the bloodstream), but insulin does have other effects, and this makes it very unwise to assume that we know exactly what will happen if insulin levels go up, or go down. Insulin does more than one thing, and it probably does more things than have been discovered so far.

One other thing that insulin does is to promote fat cells to convert sugar to fat, and store it. In people with Type 2 diabetes, insulin production often goes into overdrive, as the endocrine system tries to compensate for reduced sensitivity to insulin. It is highly likely that this chronic insulin overdose promotes an elevated rate of fat storage.

Insulin is also thought to play a role in regulation of appetite. The release of insulin you get shortly after you begin consuming a meal is supposed to start killing off your appetite, so that you know when to quit. But if you have become insensitive to insulin, this appetite-control mechanism can fail spectacularly, so that there is no such thing as knowing when to quit. (I remember vividly that, during the months leading up to my diabetes diagnosis, my appetite was so constant that, even while I was eating a meal, I would be looking forward to the next meal; I was never full, and of course I gained weight rapidly during this period.)

So, although weight gain tends to precede diabetes, it also tends to follow diabetes, and it can be very hard to untangle the complicated relationship between the two.

There isn't a lot of doubt that losing weight helps with diabetes management. But neither is there a lot of doubt that losing weight is harder if you have diabetes than it is if you don't. (And heaven knows it's hard enough if you don't!)

Monday, September 12, 2011

Here's the latest message sent in to Not Medicated Yet :

Hi, there, 
Please kindly check this new watch,  the price is only 1.34, pc21s, 377 battery. 
Hope you will like it.


A link to a web site appears under the signature. Think I should click on it? Or is it possible that might not be a good idea?

Maybe it would be better to exercise a bit of caution in this case. But it's nice to know that readers care enough to let me know about new watches that only cost 1.34 -- even if the battery costs 377, which does seem a little steep. It might not be, though, because, I don't know what currency is used in Nigeria.

Fall is in the air. I don't know what is burning where, but there seems to be a fair amount of smoke in the atmosphere, reddening the evening sun. It can't be drifting in from the Texas wildfires; the winds down blow that direction.

The smoke isn't nearly thick enough to interfere with breathing, so there there is no reason to refrain from exercising outdoors. I did a very hilly 5-mile run today; it felt fine. The breathing did, anyway. Yesterday was a picnic day, and I felt sluggish -- and ten pounds heavier -- when I started running. Things improved during the run, though. Things usually do improve during a run, no matter how unpromising the situation looks during the first mile. I'm glad today wasn't an exception. 

Friday, September 9, 2011

I indulged in a crab-cake for dinner, thinking of it as mainly a protein food, but I guess the breading or something else in it was adding more to the carb-count than I expected. Not that 126 is a horrible post-prandial result, but I aim for a slightly lower range than that.

Well, it's Friday, and I've heard that that excuses all sins. And if my biggest sin was eating a crab-cake, I probably wasn't the worst sinner out there this Friday night.

In other news...

Don't get mad! It's bad for your heart. Or at least it might be. 

That is the extremely tentative conclusion of a report in the Journal of the American College of Cardiology. The report describes an observational study, in which 1749 people without evidence of heart disease were subjected to a "stressful" 12-minute interview to see if they showed any signs of hostility as a result. (The great majority of them did, you may be surprised to learn.)

They were then followed up for a decade, to see if the hostile and non-hostile individuals differed in their risk of developing ischemic heart disease later on (that is, heart disease caused by arterial blockage).

It turned out that hostile people were more at risk, and that the most hostile people were most at risk. Roughly speaking, ischemic heart disease was twice as frequent in hostile people.

But how is hostility measured? Apparently psychologists use something called the Observed Hostility (OHO) scale, which is a "subscale" of the Expanded Structured Interview (concerning which I have no useful information to share). I don't know how the OHO scale works; whether a rating of 4.6 OHOs is a lot or a little is unknown to me. Also, I don't know how the original interview was made "stressful". But apparently there is some method which can be used to observe people, looks for signs of hostility, and rank them on the OHO scale.

The conclusion of the study has to be tentative because (1) nobody knows for sure what is causing the connection between hostility and ischemic heart disease, and (2) 90% of people subjected to the stress interviews became hostile, so that leaves a pretty small number of non-hostile people for comparison purposes. (And what if we later find out that the 10% of people who didn't become hostile during the stress interviews were unable to understand English, and would have become hostile if they knew what was being said to them?)

Anyway, the conclusions we draw from this study must be extremely tentative. There seems to be a connection between hostility and increased risk of ischemic heart disease, but the nature of the connection isn't established by this study. On the other hand, some would say that the nature of the connection is freaking obvious: hostility promotes stress, stress promotes heavy production of the "stress hormones" adrenaline and cortisol, stress hormones promote arterial inflammation (just as high blood pressure does), and arterial inflammation promotes ischemia in the coronary arteries. How hard is that? How surprising is that? How new is this information?

Non-hostile people don't seem to be commonplace (at least among people being subjected to stress-interviews), but apparently they're the ones who last. So, I guess the thing we need to do is develop a genial grin, and see if it helps us keep going over the long haul. It's worked for some people, why not us?

Thursday, September 8, 2011

This time I did well on both blood glucose and blood pressure (yesterday I only did well on the former). What made the difference? I'm not at all sure. But I did do some weight-lifting after work; possibly that helped with my blood pressure.

Would it surprise you to learn that my very low post-prandial test followed a big plate of noodles with pesto? It did. But maybe I should have put the word noodles in scare-quotes. These "noodles" were not made of wheat or any other grain.

Shirataki noodles are a Japanese low-carb invention, usually made from a type of yam. But there are also tofu shirataki noodles, made from soybeans; they have a limited shelf life, and they come packed in water, in a bag in the refrigerator section of the grocery store. This variety has been recommended to me as a diabetes-friendly alternative to pasta. 

Diabetes-friendly alternatives to pasta tend to be more appealing in theory than in practice, so it wouldn't have surprised me to discover that these things tasted awful, or that they weren't as diabetes-friendly as I'd been led to believe.

However, I thought I should give them a try. I've been trying to cut way down on grain-based foods lately, but like a lot of other people I find that I really miss pasta. I particularly like pesto sauce, and what are you going to put it on if you're not going to put it on pasta? So I bought a bag of these noodles and road-tested them to see if they would serve as a reasonable substitute for pasta without spiking my blood sugar.

Although I wouldn't say that these noodles taste quite like pasta, they're not bad, and they're certainly low in carbs and calories. The whole bag of noodles amounts to 40 calories and 6 grams of carbs. And my blood sugar after dinner was only 98. What more can I ask?

Well, I guess I could ask that they taste exactly like pasta without having the glycemic impact of pasta. But that would be asking a lot, and I'm happy to settle for a little less than that.

Wednesday, September 7, 2011

Blood glucose good; blood pressure not so good. I think I need to relax a little.

There's a trick that mystery writers like to use, in which the reader is encouraged to make an assumption, from the very beginning of the story, without even realizing that they are making an assumption. They think they were told the thing they are assuming. Perhaps the detective in the story also makes this assumption, for about three-quarters of the way through the book, and then suddenly realizes that he's been a fool and the main fact he had been taking for granted wasn't a fact at all. Once this false assumption has finally been brushed aside, the mystery suddenly becomes solvable.

Agatha Christie was particularly fond of this device, and she used it so boldly that many readers felt that she wasn't playing fair with them. In one of her mysteries, it eventually turns out that the narrator of the story was the murderer, but failed to mention that detail in his description of the crime. Of course, once you know that and go back to re-read the earlier part of the story, you realize how suspiciously vague the narrator had been about a few important points; the hints of deception were there, but you overlooked them. You simply took it for granted that it was against the rules for the narrator of the story to be deceiving you about what happened.

In another of her stories, a psychopath is bumping off people in an alphabetic series (the first victim's name begins with "A", the second with "B", and so on), and he's writing taunting letters to police about this scheme as it goes along. It eventually turns out that the crazed serial killer that the police are looking for does not exist. The actual killer was only interested in killing one of the victims (and had a strong motive for doing so), but he was such an obvious suspect for that one crime that he had to divert suspicion from himself by making that crime appear to be part of a series of crimes perpetrated by someone else for a different reason. But you as the reader never questioned the alphabetic scheme as presented; you just took it for granted that something emphasized so heavily in the storytelling must be the actual subject of the story, not a distraction from it.

The movie "Psycho" is another example: seeing the movie again after you know how the story comes out, you realize that you have never been given a good look at Norman Bates's mother, and you have no proof that she even exists. And yet, your initial impression was that you had seen her kill two people. Only later do you realize that you were just making assumptions about things that the camera never quite showed you.

The science of human health is, unfortunately, a lot like that. Often an idea is generally assumed to be true, despite a notable weakness in the evidence for it, and this assumption lingers on for so many years that, by the time someone finally gets around to testing the assumption (and finding it wanting), people are astonished to learn that the assumption is being questioned, and have a hard time letting go of it. But letting go of it often leads to a clearer understanding of the issues than was ever possible under the old assumption.

Medical researchers have always wondered what it is that protects women from CHD (coronary heart disease). Not that women don't have heart attacks, but they don't have them as early in life as men do. Women have to get pretty far along in years before their rate of CHD starts catching  up with the rate for men. So what is it that protects women -- and then stops protecting them?

The assumption has been, for many years, that the relevant factor is menopause. Something about the hormonal balance in pre-menopausal women protects them from CHD; after menopause, the altered hormonal balance results in a loss of whatever it is was that had been protecting women from CHD up to that point. The heart attack rate begins climbing in women, and eventually women are pretty much on par with men in that regard.

It sounds sensible enough, doesn't it? "Hormones" are the issue. People always like to blame hormones for any trend that they don't understand. How come my bright and fun-loving child turned into a sullen, miserable teenager? Must be the hormones!

Well, maybe it is the hormones, but "hormones" is a pretty vague term -- sort of like "cooties" in the language of the playground. To be more precise about it, exactly which hormones (or which ratio between two hormones) protect women from CHD, and how? And what is the nature of the change in hormone balance which removes this protection after menopause?

Well, a new study has looked into the question of women and CHD rates. It concludes that hormones are not the issue. Neither is menopause: "The long-held idea that women are protected from heart disease before they go through menopause is probably false... in fact, the new data show that aging alone explains the increasing number of cardiovascular deaths among females as they get older". This according to Dr Dhanajay Vaidya of Johns Hopkins University School of Medicine. "While it's true that the menopause is a very dramatic biologic event, nothing special happens after the menopause in terms of cardiovascular disease; hormones are fairly irrelevant... We believe the cells of the heart and arteries are aging like every other tissue in the body, and that is why we see more and more heart attacks every year as women age. Aging itself is an adequate explanation, and the arrival of menopause, with its altered hormonal impact, does not seem to play a role."

Apparently we've been looking at this entirely backwards for years. Instead of asking what factor is "protecting" women from CHD at comparatively young ages, we ought to have been asking what factor is causing men to be more vulnerable to it.

As in the mystery stories, we have made an assumption without considering it properly -- without even allowing ourselves to realize that we were making an assumption at all. The assumption was that we can define "normal" as being whatever happens to men. If women aren't having heart attacks as early in life as men are, that must be an abnormality which needs to be explained, preferably in terms of hormonal differences.

But, if you think about it, doesn't it seem a little weird to assume that the absence of heart disease is an abnormality? That isn't how we usually think about health problems. Where gender differences are not involved, our usual assumption is that good health is the norm, and bad health is a departure from the norm.

If men had fewer heart attacks than women instead of more, wouldn't we be a lot likelier in that case to assume that the absence of heart disease is the normal state of affairs? And that, if something needs explaining, it is the disease rather than the absence of it?

Dropping our false assumption does not, by itself, reveal what is causing men to have more heart attacks. But, as in the mystery stories, dropping a false assumption is often a necessary first step towards figuring out what is actually going on. Something is causing men to have an abnormally high rate of heart disease, at an abnormally early age. We need to find out what it is.

Tuesday, September 6, 2011

More whining and excuses: I'm dealing with a problem that came up, but don't want to deal with in this particular forum. I'm fine, though; probably I'll post something tomorrow.  

Monday, September 5, 2011

Today I was...

Wait a minute -- this is Labor Day, a legal holiday in the USA! I shouldn't be expected to write a blog post. That would clearly be asking far too much of me.

I'm sure I'll have something or other to report tomorrow. But at least I posted my numbers today -- so that you can see that I'm not quietly getting away with murder in the glycemic-control department while no one is looking.

Friday, September 2, 2011

This evening I went to a musical performance by other people -- but at which I knew I was going to be asked to make a guest appearance. It went fine -- I played a couple of sets and sat down; nobody got hurt. But it doesn't leave me a lot of time for blogging tonight.

So, I'll cover a couple of issues, but I'll be ridculously brief about it.

The CDC (the weirdly-named "Centers" for Disease Control) have published a report on sugar-laden soft drinks, and how much of this crap people are drinking. The answer is, lots and lots:

I don't know why there is such a large gender gap, but at most ages males take in a lot more of this stuff than females. Seemingly that offers researchers an opportunity to determine how much impact sugary drinks actually make on the rising rates of obesity and diabetes. Do the people who drink more sugar have more health problems? Probably so, but we might as well collect the data.

Maybe they should look into breakfast cereals while they're at it. Even the ones with whole grains.

Second issue: a study conducted in Costa Rica found that swapping a service of rice for a serving of beans caused a 35% reduction in the symptoms that usually precede diabetes. Apparently Costa Rica has been experiencing an increase in rice consumption which coincided with an increase in the rate of diabetes. Researches wanted to see if they could find evidence that the two things are actually connected. They found some.

Editorial Note: Part of the preceding paragraph, as originally published late Friday night, read as follows: "Apparently Costa Rica has been experiencing an increase in the diabetes rate which coincided with an increase in the rate of diabetes. Researches wanted to see if they could find evidence that the two things are actually connected." This is what happens when you write something in a hurry when you ought to be sleeping anyway. Yessir, I was raising a really profound issue there: does the diabetes rate have a connection to the rate of diabetes? You bet it does! The correlation is very close to perfect, in fact. In the cold light of day, I guess it shouldn't have seemed surprising to me that researchers were able to find a link between the two. 

Maybe we bloggers are re-creating the conditions under which novelists worked during the 19th century: in those days, novels (including those of Charles Dickens) were published in weekly or monthly installments, only to be collected into a single book much later, and the authors had to make up the book as they went along, under severe deadline pressure. The inevitable result was that authors made embarrassing mistakes, particularly in terms of inconsistent plot details -- for example, a character dying in the 8th installment and then turning up still alive in the 11th installment because the author forgot. Authors didn't get a chance to repair the damage until the story appeared in book form (if then), but I'm taking the opportunity to correct my own embarrassing mistakes as soon as I can.

Thursday, September 1, 2011

I was startled to find that my fasting result was 77 again, for the second morning in a row. This made me worry that I'd have another late-morning hypoglycemia problem, so I ate some trail mix about an hour before I went running just to be safe.

I didn't have a problem, but my post-prandial result after lunch was exceptionally low (88). It was a rather low-carb lunch, but even after a low-carb lunch, right after running, you expect to be higher than 88. I felt good, though, so wouldn't call the low post-prandial result a problem.

I've been eating less carbohydrate in general just lately, and also making that hill-climb on the bike going home from work; the combination of those two things could be pushing me into a lower glycemic range than I'm used to.

But I've also noticed that I sometimes go through temporary phases of being unusually low or unusually high, for no clear reason, and I try not to make too much of it when it happens. If you do want to make too much of it, however, you can always over-react to a temporary phase, and inject a little drama into your life.

If you're going through a phase of being unusually high, you can decide that this is the beginning of the end -- this is the point at which you start to lose control, and never get it back. It's all over! You're doomed!

On the other hand, if you're going through a phase of being unusually low, there are two ways you can play it: manic elation (in which you decide that you are cured of diabetes forever) and hypochondriac gloom (in which you decide that you have pancreatic cancer, and the tumors must be releasing a flood of insulin that's driving your numbers down).

Or, you can wait a while to see how long the phase lasts. It might end in a few more days, and leave no trace behind.

As you know, I take a keen interest in the search terms that have caused Google to refer people to my site. I might as well find out which diabetes-relevant subjects people are wanting to know more about.

One thing they certainly seem to want to know more about is the hemoglobin A1c test, which collects the hemoglobin from your red blood cells to see how much of it is glycated (bonded with sugar). Here are a couple of unusual questions on this topic:

Glycation is a slow or fast process depending on how high the temperature is and how much sugar is present. Browning food in a skillet is an example of glycation accelerated by raising the temperture. The temperature in a human body is not high enough or variable enough to have much impact on glycation, so the variable that matters is the amount of sugar present. The higher the concentration of glucose in the blood, the higher the glycation rate. Because red blood cells have a limited lifespan before being replaced, the A1c result reflects the glycation rate over the past three months or so (older hemoglobin is no longer there to be measured).

What mainly has an impact on the A1c result is the amount of glucose in the blood, on average, over the last few months. But there are some mysterious variations in glycation rate between individuals with comparable average glucose levels. Nobody knows why, but some people seem to be "high glycators". You could argue, and some people do, that this means the A1c result is "wrong" for some people. I guess it depends on what you mean by wrong. If what you're interested in is using the A1c test to estimate average blood sugar, the A1c result might be misleading for some people; if what you're interested in is finding out how much glycation has been going on, I think the A1c test is reflecting an important difference between individuals.

Another thing people want to know is what they should conclude from an A1c result in the normal range:

It depends on what you mean by "diabetic". Strictly speaking, the word refers to a symptom (chronic hyperglycemia) rather than a disease, so if you don't have chronic hyperglycemia you're not diabetic.

However! Be aware that, if you were diabetic before, and you say that you aren't diabetic now, this will drive certain people to denounce you with a fiery passion. For them, "diabetic" doesn't refer to a symptom, it refers to the disease which causes that symptom, and they become upset if anyone seems to be implying that the disease is curable. They are concerned that people are out there are selling fake diabetes cures, and must be vigorously opposed. I strongly suspect that their over-reaction to this issue has other roots, but yeah, okay, fine, diabetes is not "curable" in the sense that you can make it go away forever and forget about it. Still, there needs to be a simple way to state that you have achieved a glucose profile which is within normal bounds. There is a word for this, as a matter of fact: you can say that you're "euglycemic". The only slight disadvantage this word has is that the vast majority of people have no idea what it means.

Achieving euglycemia doesn't mean the whole diabetes issue has now vanished from your life and you don't have to deal with it anymore. It does mean, however, that you don't have to lose your health to diabetes anymore, a development which I can't help seeing as noteworthy.

Another thing people want to know more about is what drives the decision to medicate or not medicate Type 2 diabtes:

The way things used to work (ten years ago when I was diagnosed) was that doctors encouraged newly diagnosed Type 2 patients to try to control their blood sugar with diet and exercise; if this failed they were then put on medications. Because failure was so common, the tendency these days is for doctors to go straight to medication, on the assumption that patients won't succeed at lifestyle-based diabetes management and make things worse.

For those doctors who still allow diabetes patients to attempt the unmedicated approach, I don't know what their guidelines are for acceptable glycemic control. My doctor's guidance as <110 mg/dl for fasting and <150 mg/dl for post-prandial, but he described those as hard targets which I should nevertheless aim for; I'm not sure by how much I would have to miss them before he would say that medication was needed. I'm doing better than that anyway, so the issue hasn't come up.

And here's an especially interesting one:

Some would say the answer is obviously "call the doctor immediately", but nobody would ask that question in the first place if they weren't looking for something else they could do besides calling the doctor. Perhaps this is someone who can't afford a doctor visit -- or is afraid of the health-insurance consequences of being known to be diabetic.

Assuming that you have your reasons for being reluctant to call the doctor, what you need to do is find out on your own what is going on here. There are ways to do that without going on the record; you can buy a glucose tester and start collecting data on yourself. You can also buy a home test kit for hemoglobin A1c which is reasonably accurate. (Going to a medical lab sounds as if it ought to be a possibility, but many of them only do tests with a doctor's order.)

If the data you collect doesn't look good (fasting tests above 110 mg/dl, 1-hour post-prandial tests above 150, A1c tests above 6%), please see the rest of this site for suggestions on what you can do to get the numbers looking better. But if I you're not successful in that regard, I'm afraid you don't have a lot of choice but to call a doctor and fess up.

Of course, what people really want to know more about is this:

If your urine is sugary enough to give you a fan-following among the six-legged, you really need to call the doctor. It isn't a good sign.

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