Happy New Year!

Monday, December 31, 2012

I have some holiday activities to do today and tomorrow -- I'll plan on being back with a proper blog post on January 2nd of the new year.

Big Questions!

Friday, December 28, 2012

My Gray Friday

A dark gray day, chilly and threatening rain. After yesterday's beautiful weather, I knew my run today would seem a little bleak. Well, I got it done. And sometimes a chilly gray day is a little easier for running, anyway. Better to have that muscle-generated heat doing a necessary job of maintaining body temperature, instead of generating needless waste-heat for the body to get rid of.

I foolishly let myself run out of test strips yesterday, and didn't manage to pick up any before the pharmacy closed. So, I didn't start the day with a fasting test, but I did manage to get to the drug store today and get some. Now I'm all set. Me and my test strips, ready to face the world!

Questions From Readers

In this blog I often answer the implied questions I find in people's Google search requests, but it's less common for me to answer the more direct questions I have received in e-mails from readers. Tonight I thought I would take a few of those on -- even though I'm afraid that, for these particular questions, the answers I have aren't as satisfying as my readers were probably hoping they would be.

Insulin Production

One reader wants to know more about the loss of insulin productivity in people with Type 2 diabetes. How do you find out how much you have lost in this area? Is it measurable? And why should there be any further loss, in people who have got their blood sugar under control?

Insulin, the hormone which (among other things!) stimulates cells to absorb glucose out of the bloodstream, is produced by the beta cells in the pancreas. The beta cells are the cells that are knocked out by the auto-immune reaction which causes people to develop Type 1 diabetes. If that happens to you, your pancreas is going to produce no insulin, or so little insulin that it might as well be none. That is why Type 1 is such a severe form of diabetes. People with Type 2 don't have that sort of auto-immune reaction; in Type 2, the situation is more complicated.

In Type 2, production of insulin by the beta cells is not destroyed, and it might not even be diminished. (Many people with Type 2 produce abnormally large amounts of insulin.) The real problem, at least initially, in Type 2 is a loss of sensitivity to insulin, so that the cells have to be stimulated with a larger dose of insulin before they will absorb as much glucose as they should. Seemingly this wouldn't be a problem, so long as the beta cells can keep producing enough extra insulin to correct for the loss of sensitivity. However, in people with Type 2, the insulin-producing capacity of the beta cells often diminishes over time. The beta cells may be producing insulin, but they aren't producing enough of it to keep blood glucose under control. Why does insulin productivity decline? Part of it may be a naturally-occurring decline, caused by nothing more than the aging process. But it is important to remember that high blood glucose levels have a toxic effect on the beta cells; a lot of the decline in productivity, in Type 2 patients, is often a consequence of poor glycemic control. (That is why it is important to get glucose under control as soon as possible after diagnosis with Type 2: to prevent more damage to the beta cells.) Also, it is possible that the need to produce extra insulin eventually causes the beta cells of people with Type 2 to "wear out". I have heard that this notion has been discredited, and also that it hasn't (and also that nobody knows whether it is true or false).

All this information about insulin productivity in Type 1 and Type 2 patients comes out of research studies. Outside of a research setting, most patients don't get their insulin productivity measured (except once, perhaps, if there is some doubt about whether the patient has Type 1 or Type 2).

Insulin is apparently a difficult compound to detect and quantify chemically, so lab tests for it usually measure C-peptide instead -- a chemical byproduct of insulin synthesis, which is more easily measured by the lab. The C-peptide test is what you might be given as a way of establishing if you have Type 1 or Type 2. But it's unlikely that a Type 2 patient will be given further C-peptide tests to track what is going on with insulin productivity over time. (I have never had the C-peptide test myself, and most Type 2 patients haven't had it either. We can only guess at how much insulin productivity we have lost.)

For that matter, we can only guess at how much insulin sensitivity we have lost. Measuring insulin sensitivity is even more difficult (that is, expensive) than measuring insulin productivity; most patients never have their insulin sensitivity measured. I certainly haven't.

This is what makes Type 2 diabetes such a confusing disease to manage: your blood glucose level is determined by the interaction of two fluctuating quantities (your insulin productivity, and your insulin sensitivity), and most patients never have either of those factors measured! Like it or not, we have to make it through the diabetes obstacle-course with a blindfold on.

Of those two factors, the one we have the most control over is insulin sensitivity (which can be boosted by exercise, and often by weight loss). Insulin productivity is often described as something which, once lost, cannot be regained. This isn't quite true -- the body replaces beta cells slowly, but it does replace them, so maintaining excellent glycemic control over a period of years will apparently win you back at least some of your lost insulin productivity. But the key to achieving that, during the years that you are waiting for it to happen, is to keep glucose under control (by boosting your insulin sensitivity and by limiting your carbohydrate intake).

Hypoglycemia in the Gym

Another reader has been having a great deal of trouble with exercise-induced hypoglycemia. This reader cannot seem to get through a post-breakfast workout without going low after 45 minutes (regardless of what was for breakfast, apparently), and is hoping that I have some practical tips on preventing this sort of thing.

I'm afraid I'm going to be a real disappointment on this issue. I rarely experience exercise-induced hypoglycemia myself, unless it's a real endurance workout (a run over 12 miles, something like that). My usual explanation for this is that I'm not on any glucose-lowering medications, so hypoglycemia isn't a problem for me. But that explanation doesn't help me much here -- because the reader asking this question isn't on diabetic medications either!

My guess is that this is a reader whose beta cells are still quite robust, and are capable of pumping out insulin in generous quantities. Once exercise starts boosting insulin sensitivity, that generous insulin dosage becomes far more effective than it usually is, and the result is a low. What to do about it? Possibly this is a problem which will resolve itself with time, once the body is more accustomed to regular exercise, but obviously a short-term solution is needed. I'm not sure I have any suggestions that will solve the problem, but I'll mention what comes to mind.

One possibility is to experiment with exercising at a different time of day. I realize that a lot of people prefer to get their workout taken care of in the morning (or may even feel that they can't fit it in, at any other time) but I suspect that a morning workout can be a high-risk workout in terms of hypoglycemia. My post-prandial glucose is lower after breakfast than after other meals, and other people experience that too. Perhaps lunchtime or evening exercise would work better.

Another thing to experiment with would be shorter workouts, especially if it's possible to distribute the day's exercise workload across a few shorter workouts instead of one long one. I realize exercising more than once per day doesn't sound too practical -- but I mention it for whatever it might be worth. Even if only one workout per day is feasible, it might be worth experimenting with a short workout (perhaps an unusually intense one) and then trying to gradually build up its duration over a period of weeks, to see if the body can be trained to accept longer workouts without going low.

Another possibility, and perhaps the most practical one, would be to sip a drink with some sugar in it (not much, just some!) while working out, to hold hypoglycemia at bay without going too far in the opposite direction. I would normally use a sugared drink only during an endurance workout, and even then I wouldn't start with it -- I'd wait until I was pretty sure I needed it. But if you get hypoglycemic after a 45-minute gym workout, you might need it a lot sooner than I would need it.

I hate hypoglycemia myself, so it's awkward for me to say that anyone else should cheer up about having it often. But it does seem to have a bright side: it probably indicates the presence of healthy beta cells, even if those beta cells have not yet learned how to play well with others!

Gated Insanity

Some people in Italy are concerned about a recent increase in the rate at which women in Italy are murdered (typically by their husbands). The problem is actually not that big by American standards (the homicide rate is more than 4 times higher in the USA than in Italy), but the Italians are accustomed to their lower homicide rate, and seeing it go up makes them get all nervous and look for explanations. And one Italian commentator thinks he has found the explanation. That would be Piero Corsi, a Catholic priest:

Corsi has considered, and rejected, the possibility that more women are being murdered because there is something wrong with the guys who are killing them. That can't be it. No, the women are being murdered because they asked for it. They aren't good wives. They dress immodestly. They don't discipline their children. They don't serve their husbands hot meals. They need to understand that they are provoking the violence that is visited upon them. He included these thoughts in a Christmas message to his parishioners.

To his surprise, some people have objected to his ideas. He has had to suffer the annoyance of being questioned and even challenged by unsympathetic reporters (one of whom, Corsi said, "must be gay" -- so you can see how wrong that reporter was).

What is interesting to me about this story is Corsi's capacity to be startled that anyone might question his opinion. If he says that the person at fault in a murder is the victim (at least, so long as it's a female victim), then everyone should just accept that. He is a priest, after all! How dare anyone doubt him?

This kind of story seems to play out constantly these days. With the "mass media" dying out, replaced by specialized media on cable channels and web sites, people are able to live their lives within narrow, enclosed information communities (usually defined by a religious or political ideology), avoiding all interaction with people who don't share their views, and avoiding all exposure to information which doesn't support their views. But, every once in a while, word gets out about their views, to the horror of the outside world. And somehow it always comes as a shocking surprise to them, that other people might disagree strongly. It surprises them even if they are public figures -- such as members of the legislature or the clergy, whom one might expect to be in touch with a variety of people, simply from the nature of their careers. In fact, they have been able to avoid that sort of thing entirely. You can do that now; you can live in an information bubble.

It seems to me that what these enclosed information communities have done is to give people permission to go insane, without getting any warning messages from those around them that they are carrying things much too far and need to get back down to earth.

It's a worrisome trend. And although it doesn't play out quite so dramatically in the medical world as it does in the religious and political worlds, the trend seems to be operating there as well. Adherents to a particular dietary theory or a particular approach to treating diabetes seem to be increasingly unaware that alternative ideas even exist.


Midwinter Questions

Thursday, December 27, 2012

Winter Wonderland Lite

Coastal California does not experience winter as most people think of it -- which is mostly a very good thing. Of course, we do miss out on the picturesqueness that is found elsewhere. I took a walk in the park today and found that the winter landscape around here looks remarkably like the spring version:

The only visual clue that it wasn't March was that people had jackets on. (And to be honest, if they had left their jackets at home, they really wouldn't have suffered all that much.)

Even though it was a beautiful day, I didn't feel like running outdoors again after yesterday's 9-mile run. I did my workout in the gym instead. At least I got in some resistance training that way.

I have been looking over the latest questions from the internet searchers, and I'm finding that the hemoglobin A1c test is the subject attracting most of the attention.

"can a person have a 6.2 a1c and still have neuropathy"

Yes. High blood sugar is not the only cause of neuropathy (nerve damage); a wide range of health problems (vitamin deficiency, kidney disease, lupus, AIDS, and so on) can cause neuropathy. If your hemoglobin A1c result doesn't seem high enough to account for the problem, perhaps the problem was caused by something else -- or perhaps your A1c used to be a lot higher than that, and the damage was done then.

"a1c is 6.2 but not diabetic what is happening"

What is probably happening is that you're becoming diabetic and you haven't yet completed the process. An A1c result of 6.2% isn't high enough to support a diagnosis of diabetes (you need to get to 6.5% for that), but it is somewhat elevated, and it indicates that your endocrine system is starting to have trouble controlling blood sugar levels. This is the sort of problem which tends to get worse over time, so it's best to do something about it while it's still comparatively easy to do something about it.

"how much will a1c lower with weight loss"

Impossible to say. There is no direct relationship between weight loss and hemoglobin A1c. Weight loss often improves insulin sensitivity, and an improvement in insulin sensitivity usually improves glycemic control (at least to some degree), and any improvement in glycemic control results (at least to some degree) in lower A1c test results. But nobody can tell you that losing X pounds will bring your A1c down by Y points. That's why you still have to exercise, whether you lose weight or not -- there's no telling how much weight-loss alone will do.

"can you have normal a1c and hyperinsulinemia"

Sure. In fact, some people have a normal A1c result because they have hyperinsulinemia (which is an abnormally high production of insulin, caused by the body's attempt to compensate for a loss of sensitivity to insulin). It's only when this compensation strategy starts to break down that A1c starts to go up.

"calculation of a1c weighted to past 2 to 4 weeks"

An A1c test collects hemoglobin (a protein found in red blood cells) and determines how much of it is "glycated" (bonded with sugar). In the average non-diabetic person, about 5% of hemoglobin is glycated, but for people with diabetes the percentage is usually above 6%, because when your blood is more sugary, your hemoglobin gets more exposure to sugar and therefore becomes more sugar-encrusted. The test result therefore gives a rough indication of what your average blood sugar has been lately. Because red blood cells have a limited lifespan (about three months), the test tends doesn't reflect blood sugar levels from longer ago than three months. Also, because a lot of the red blood cells that were around more than a month ago have already been recycled by the time the test sample is collected, conditions during recent weeks have a disproportionate influence on the test results. It's best not to make too much of this, but it does mean that if you've been doing unusually well or unusually badly in recent weeks, this change will be strongly reflected in the result.

"is a1c dangerous when it is 12 what can happen"

Of course it's dangerous! It's dangerous enough when it's over 7 -- but only pit-bull dangerous; at 12 it's white-shark dangerous. What can happen? Various horrible health problems which I try not to dwell on here, since I'm claiming to offer the world a non-depressing diabetes site. If you're at 12, start working very hard on getting it a lot lower than that. 12 is not something to mess with.

"is an a1c affected by infection"

Not usually, and not certainly directly. The inflammatory response triggered by an infection can suppress insulin sensitivity, and raise blood sugar as a consequence -- but the infection would have to go on for a long time in order to have much impact on an A1c test. A chronic infection (such as periodontal disease) might possibly do it. But don't use that cold you had last week as an excuse to dismiss an increase in A1c as irrelevant; a short-term infection isn't going to make much difference.

"should non-diabetic get an a1c test"

It depends on what "non-diabetic" means. If it means "I haven't been officially diagnosed as diabetic", then that alone doesn't mean much; everyone is non-diabetic in that sense, until they find out they aren't. If you have any reason to suspect that you might be diabetic, the A1c test would be the best way to find that out. You probably need your doctor's cooperation for that, however. I don't know how accurate the home-test A1c kits are.

"do diabetics pee alot even if suger is not high"

Only if they have some other condition, aside from diabetes, which promotes excessive production of urine.

"what would happen if you drank diabetic piss"

You would never find love.

The Post-Christmas Challenge

Wednesday, December 26, 2012

Getting Back on Track

I was a pretty bad boy at Christmas dinner yesterday, or rather during the long run-up to Christmas dinner yesterday, sitting at a snack-covered table, downing wine to help me endure the conversation's inevitable political phase, and indulging in most of the carbohydrate-rich goodies that were within reach. I did go for a run on Christmas morning, but not a very long one, and certainly not long enough to make up for my indulgences later, so I was expecting my fasting test this morning to be elevated. Well, it was elevated, at 108 mg/dl, but it could have been worse (and to be frank, I was fearing it would be worse). And my weight is climbing, of course.

This is not an easy time of year for diabetes patients, and the day after Christmas is not an easy day. It's a day for reviewing the harm we've done ourselves in order to be part of the holiday celebration, just like normal people, and a time to figure out how we're going to get things back on track.

I was curious to see how high my blood sugar would go after breakfast. (Had the impact of Christmas reduced my capacity to process the carbs in what is, after all, the most carb-intense meal of the day?) I was a little startled to see that it returned back to 108 an hour after breakfast. However, my system has a track record of processing carbs better in the morning than it does later in the day.

I had the day off work, so I figured I had better take the time to do a very serious workout today -- a workout which would send my body a message that Christmas is over and it's time to get back to basics. As it wasn't raining today (in fact, it was clear and beautiful, despite weather forecasts to the contrary), I went to the state park for some trail-running.

I started out with the intention of running a 7-mile route, and hoping I could handle that much (my left hip had been sore for the last couple of days, and also I was feeling a bit bloated and weak from the holiday after-effects). Once I got started, though, I started to feel pretty strong. So I chose a longer route through the park, one which would add a couple of extra miles.

It was beautiful in the park -- the recent rains had produced an explosion of greenery. The temperature was about 50 degrees, which is comfortable for running if you're dressed properly for it, and I was. I didn't get tired or sore during the run, which was nice. I was certainly ready for the run to be over when I made it back to my car, but that was more a matter of mood than of physical limitations. I could have run further if I had needed to do it. That in itself was a nice feeling: I ran 9 miles and wasn't exhausted!

In the evening I thought I would check my blood sugar again after dinner. This time the result was 122, even though it was a lower-carb meal than breakfast had been, and I had done a long trail-run in the afternoon. Still, 122 is within the normal range for a post-prandial result, so there was no reason to be disappointed.

Of course, I still have to get rid of the extra pounds I've put on, but in terms of glucose control I think I'm moving in the right direction.


Friday, December 21, 2012

Let It Rain, Let It Rain, Let It Rain!

It was raining so hard, all morning, that I thought there would be no possibility I would want to do an outdoor run today. However, it thinned down to a very light drizzle in the afternoon, and I decided it was worth a chance. So I managed to get in a good long run, and it never started raining hard again while I was out there. I was chilly and damp when I got back, of course, but that only made the hot shower afterward more wonderful. Almost every hard run is worth it for the shower, I find. Even a full marathon is largely redeemed by the shower you take afterward, so long as you've got enough hot water to last you 30 or 40 minutes.

The Christmas music at work today went splendidly, probably better than it ever has in the past (and we've been doing this for 16 years now). There were eight musicians, and probably a better lineup of musicians than we've had before. Two flutes, two fiddles, French horn, trumpet, guitar, and upright bass. First we played in the cafeteria, at the holiday breakfast gathering (a lot of employees bring their children for this, so the cuteness quotient was very high in the office today), then we wandered around from building to building and floor to floor, playing a few tunes at each stop. We seemed to have an especially appreciative audience this year. One person whom we encountered unexpectedly, and who pronounced himself impressed, was the number two executive in the corporation (I hadn't even known he was on the site -- we're not the corporate headquarters).

I felt more comfortable playing the tunes this year than I ever have before, and I was happier about how we were sounding than I ever was before. I even felt okay about the "Chipmunk" song, and that's saying something. All in all, a very nice ending to the working year. Maybe that's why my blood pressure was so low tonight: 116 over 67! Most of the time, only people with clean consciences get that kind of result.


No Mayan Apocalypse So Far

It's getting late, and so far the earth has not been destroyed; probably it isn't going to happen today. Except, of course, in the limited sense that The Onion has in mind:

The real event today, of course, was the winter solstice -- the point at which the days stop getting shorter. All cultures have celebrations at this time of year (probably including the Mayans, who I assume would be puzzled by our silly notion that this was a day they would have feared). Because people were celebrating anyway, at this time of year, the Christian church placed Christmas in late December (the bible doesn't say when Jesus was born, but makes it pretty clear that it wasn't in the winter).

Of course, if you're using primitive systems of measuring time, you have to get a few days past the solstice before it becomes clear that the days really are getting longer -- which is why the church chose December 25th and not December 21st. But we have better tools available to us now, so we know the tipping point is today, not next Tuesday. From here on, the days get longer. It's not necessarily going to get warmer soon (there's a lag-time involved), but we can see the light at the end of the seasonal tunnel. We'll get through this!

Not that there's much to get through, here in California, other than some rain and wind and a few nights that are cold by local standards (though not by the standards of most other regions). Still, the sunshine will come back, and that's a development worth welcoming.

Also, there's a newly discovered monkey species (the "lesula"), so how bad can the year 2012 be?

Especially when the lesula looks notably more human than Wayne LaPierre, reasonable voice of the National Rifle Association?


A Dark and Stormy Night

Thursday, December 20, 2012

A Pico-lypse

I had thought this wouldn't be a day for outdoor exercise, owing to the weather forecast, but when lunchtime rolled around I decided to go for an outdoor run, even thought the sky looked mean and I knew a rainstorm was heading this way. The weather-radar images on line made it look as if the storm was still far enough up the coast that I guessed it wouldn't arrive soon enough to catch me before I finished. I guessed right. So, in the evening, I was sitting here at the computer, not at the gym, when the earthquake hit.

It wasn't much of an earthquake, obviously, since I'm still here at my computer. The magnitude was only 2.4. The epicenter was quite close, however (3 miles to the north). An earthquake is like thunder: the closer it is, the more distinctly focused it is. A rumbling, gradual buildup and falloff indicates it's far away. But this was so sharp (like a single blow of something hitting the house) that at first I didn't think it was an earthquake at all -- I thought a large tree-branch, dislodged by the storm, had fallen on the roof. The main thing that made me think it could be an earthquake was the way it rattled the glassware in the kitchen, which seemed more seismic than arboreal. I checked the USGS earthquake site, and confirmed it was the former.

Probably somebody is going to try to tell me that the Mayan Apocalypse prophecy wasn't false, just slightly exaggerated. There was a storm, and there was an earthquake -- what more do you want?

Backing Down

The American Diabetes Association is issuing new clinical practice guidelines next month, and they will include an interesting change involving regulation of blood pressure. Keeping systolic blood pressure (the first number in the systolic/diastolic pair) under 140 has long been recognized as necessary to good cardiovascular health -- but how much lower? In recent years it has often been assumed that the goal should be extra-low for people with diabetes, who tend to be especially at risk for cardiovascular disease. Recommendations to diabetes patients have typically been to keep systolic pressure under 130 (or even under 120) -- which usually means prescribing drugs to reduce blood pressure, because most diabetes patients can't hit those more aggressive goals with lifestyle adjustments alone.

However, the ADA has now decided that the results of chasing these more aggressive goals don't seem to pay off for the patient population. The rate of strokes is slightly reduced, but not enough to make a measurable difference to mortality. And treatments designed to chase those aggressive goals can increase the risk of other problems. Anyway, the ADA now thinks that keeping systolic pressure under 140 is good enough, and it's not necessary for diabetes patients to keep increasing their medication dosages to get under 130.

I'm no longer on the ACE inhibitor I used to take for blood pressure; I get better results with exercise than I ever did from Monopril. I usually, but not always, can stay under 130/80, and often under 120/80. So it looks as if I'm doing fine in terms of hypertension, if being under 140 is good enough to avoid an increased mortality risk.

The ADA is also using its clinical guidelines to try to clean up the mess they created with earlier guidelines on blood glucose testing (which encouraged health insurers to categorize glucose test strips as a needless luxury). However, from what I've seen of their attempt at clarification, they still have some clarifying to do.


Christmas Music

Tomorrow, which is the last working day at my company before the holiday shutdown, is the day that some of us become strolling players, going from building to building playing Christmas tunes. There will be eight of us this year (two fiddles, two flutes, trumpet, French horn, guitar, and bass). I think I'd better go practice now before going to bed -- it's my last chance to learn that "Chipmunk" Christmas song in the painfully awkward key of A-flat. It's the price I have to pay, if I'm going to play the Christmas songs I actually think of as Christmas songs!


The Stupid Apocalypse

Wednesday, December 19, 2012

Another 394 Years Wasted!

At an office meeting this morning, there were some jokes about the "Mayan Apocalypse" on Friday, which would possibly get us off the hook for our project deadlines. I participated in the joking, but then felt a little guilty for even taking this seriously enough to bother making up jokes about it. The topic is inevitable; we can't resist the impulse to mention it. But why can't we? By this point everyone knows, or at least should know, how utterly dumb the whole "Mayan Apocalypse" thing is, and the people I work with aren't dopes. I'm not a dope myself. But, against my better nature, here I am, talking about it as if it were a thing worth being talked about.

The dumbness first. The Mayans had a complex system of calendrics which is hard to translate into our own terms. For example, they had a 360-day year called a tun, but they knew that a real year is five-and-a-quarter days longer than that, so their tun calendar interlaced with others which made up for the difference (a little more neatly than our leap-year system does).

They also had units to measure time periods much longer than a year. One of these was the b'ak'tun, or long-count cycle (each one lasts about 394 years). The starting point for their dates was the presumed creation of the world, which they thought was more than 5000 years ago; counting from their Year Zero, we are now approaching the end of the 13th b'ak'tun. End-times enthusiasts would have us believe that this means the world will end on Friday. There are one or two flaws in this argument, however:

Of course, after Friday comes and goes with the world still in existence, people will forget about this apocalypse and move on to the next one. There's always another end-of-the-world scenario waiting in the wings. The world was supposed to end last year, too (and not once but twice!). Most religions feature some version of "eschatology" -- a set of beliefs about the end of the world, often presented as a desirable outcome. Even people who don't have any conventional religious beliefs like to imagine that the world is about to end in some other way. Perhaps a dark planet, unknown to astronomers so far, is hurtling towards earth to smash us to atoms. People just love this crap, for some reason. Why, though? What is the appeal?

I think I found the answer yesterday while I was walking across a parking lot to my car. I was leaving an appointment at the local gastroenterology center. I'm due for another screening colonoscopy, and it's happening next month, and I was going in for a briefing on how I'm to prepare and what to expect ("loads o' fun!" would be the short answer). And the happy thought entered my head that maybe I wouldn't even have to go through with it. Why not? Mayan Apocalypse!

And that's the happy thought that people are using at work to get them through one more day. Maybe it doesn't matter if we can't meet the deadline on the software build. Why not? Mayan Apocalypse! Just as people take a look at their financial situation and think "I might win the lottery!", they look at the future events they don't want to deal with and think "The world might end first!". It's a pretty weird way to comfort ourselves, but we do it.

However, I think we should only allow ourselves to do it in a joking way. Maybe it's one way we can cope with our fears for the future, but it shouldn't be the only way. I mean, there's always the lottery.

The Unmedicated

Tuesday, December 18, 2012

We Are Not Alone!

A lot of the input I get from health literature and web sites suggests that, in controlling my blood glucose levels by means of behavioral adjustments rather than drugs, I am doing something highly unusual -- so unusual, in fact, as to be almost freakish. Apparently I'm all on my own out here; nobody else is doing this. This is a little discouraging, as it suggests that writing about my approach is pointless: nobody besides me is ever going to be doing it, so who cares what I'm doing or how well it works?

I am reluctant to accept this view of the matter, but so far I haven't been able to gather much evidence to the contrary. I've heard from a enough people who are doing what I'm doing to convince me that such people exist. But how many of them exist? Such people are seldom studied by researchers -- so they might as well not exist, as far as the health care establishment is concerned. However, every once in a while researchers take an interest in them, and learn a few interesting things. One such study was recently published in JAMA.

Although diabetes patients who are taking the unmedicated approach are certainly in the minority, they are not so tiny a minority that it is pointless or impossible to study them, as is often assumed. The study authors say that they make up about 16% of the diabetic population. Furthermore, comparing diabetes patients using "intensive lifestyle intervention" to patients who receive standard diabetes care (drugs, then some more drugs, then some more drugs) indicates the unmedicated patients do better, and sometimes are able to achieve "remission" of diabetes (that is, to revert to normal blood glucose levels, or at least to blood glucose levels that are not elevated enough to meet the diagnostic criteria for diabetes).

That's the good news; the bad news is that, although the lifestyle-intervention patients are a lot likelier to achieve remission of their diabetes than patients who receive standard care, their rate of success tends to diminish over time:

It is a little discouraging to see how many unmedicated patients are unable to keep their success going for more than a year or two -- but perhaps we shouldn't overlook the fact that after four years they are still doing a lot better than the standard-care patients are. Changing your health habits certainly doesn't ensure success, but at least it's more successful than what most patients do, and we shouldn't lose sight of that.

In a couple of months I will be concluding my twelfth year since diagnosis, and the lifestyle-intervention approach is still working for me. Why doesn't it work for twelve years for everybody? I don't know, but it could be that my "secret" is this: I kept at it. No doubt that is unfair to some people, who kept on exercising and saying "no" to cinnamon rolls, and still couldn't keep their winning streak going. But I'm pretty sure that some percentage of the people who saw their success evaporate were not sustaining the lifestyle changes which gave them their initial good results. In other words, we shouldn't get too discouraged by the failure rate -- there's always a possibility that persistence will pay off.

And anyway, the lifestyle adjustments are still worth doing, and necessary to do, even if they aren't enough by themselves to normalize your blood sugar. If your blood sugar is above normal, your need to exercise and watch your carbohydrate intake becomes more urgent, not less!


'Tis the Season

Monday, December 17, 2012

Holidays, Depression, and Mythology

I have always understood that the suicide rate peaks around the winter holidays. You've probably heard that too. It's a popular idea, and articles in the press reinforce it. It's a story people like repeating, both because it seems a little strange and ironic (people kill themselves more at a time of celebration than at other times of year?) and because it also, in a way, makes sense. After all, when you're sad, a celebration which puts you on notice that other people are having fun (and you're not) could easily be depressing. For many people, what is Christmas but a reminder that their own family isn't like the ones they see on the television? And what is New Year's Eve but a reminder that they aren't sexy young party-animals? Also, the holidays have a way of reminding people of their financial limitations, which is also discouraging. It's easy to imagine getting depressed at this time of year, so when we hear that the suicide goes up in the winter, we buy it -- without demanding evidence.

It turns out that whole story is pure fiction. The suicide rate does fluctuate seasonally, but it's generally lower than average, not higher than average, at this time of year. Nevertheless, according to the Annenberg Public Policy Center, press reporting continues to repeat the false story that the Christmas season is suicide season. This is a problem, not only because it's generally undesirable for press accounts to spread false information, but because suicide is a problem highly vulnerable to the power of suggestion. In many countries, suicide has sometimes become a kind of fad, particularly among young people -- there can be localized suicide epidemics, in which one suicide brings on another. Obviously news stories suggesting that everyone else is doing it can promote just that sort of chain reaction.

Currently, the news media are providing us with a reason to get depressed: the latest shooting rampage, at an elementary school in Newtown, Connecticut, last Friday. This time the victims included 20 young children. Despite my not having a TV set at home, I was aware of the story. What I was not aware of, until I visited my father yesterday and saw what was being shown on his TV, was the extent to which the story was being obsessively, relentlessly covered, as if nothing else were happening in the world. It was a lot more depressing seeing the story that way than simply reading brief accounts of it online.

An interesting detail has emerged from the depressing coverage. There was initial confusion about what gun was used, but the current report is that it was a Bushmaster AR-15. And here is how that gun is advertised to potential buyers:

As you can see, this is more than a firearm: it is personal salvation, to insecure guys who need to buy something that will help them feel like real men (and who may not be able to afford a Ferrari).

It is a given in American politics that nothing can be done about the problem of gun violence -- certainly nothing which limits anyone's right to own military-style assault weapons. We must accept these shooting rampages as the price of freedom, and as the price of helping weak men feel tough. Admittedly, there are people right now calling for gun control, but that always happens after the latest shooting rampage, and nothing ever comes of it. So, we can't expect anything to change in terms of what sort of weaponry people are allowed to buy.

Could there be another approach that might be more practical? Tobacco isn't outlawed in the USA, after all, but the use of warning labels has discouraged its use all the same. Perhaps warning labels for guns could be used in a similar way?

Probably that wouldn't solve the problem of shooting rampages, but it would be funny, and in that small way it might help combat the problem of holiday depression!


Down the Drain

Friday, December 14, 2012

The Yellow Spiral of Surrender

It is a law of nature: allow any large, bureaucratic institution to design something, and the result will be hilariously awful. Case in point: the University of California decided that it was time to replace its old logo, which is obviously looking pretty antique (I mean, there's a drawing of a book in it, for crying out loud):

So an 11-person team spent three years working on a replacement for the old logo, and here is what they came up with after 36 months of effort:

Apparently the blue cleavage at the top was a nod to the book in the old logo (although I initially assumed it represented a blue whale's tail flukes), but the rest of the thing is pure abstraction. And pure ugly.

The University is shocked, shocked! to discover that everyone in California hates the new logo. (Actually, I'm exaggerating: polls say only 95% disapprove.) Some have said that this design would be more at home on the label of a feminine hygiene product; others have suggested that it symbolizes "flushing a Swedish flag down the toilet".

Actually, that would be pretty benign compared to what the logo apparently was intended to symbolize: academic corruption. Or rather, the university as a commercial "investment hub", not an institution of learning. Nowadays a state university system should be all about who can make money out of it. Taxpayers are supporting it, of course, but somebody else gets to get rich out of it. So maybe that yellow swirl represents our tax dollars, spiraling away into nothingness and magically appearing later in somebody's offshore bank account! It's a lot more inspiring when you think of it that way.

The reason this is relevant to diabetes (it's my job to make things seem relevant to diabetes) is that medical research cannot all be conducted by drug companies (who have been pretty shameless about skewing the science to support their financial interests). University research is supposed to be an alternative to commercial research -- a more objective alternative, with no financial interests at stake. But how can that happen, when every institution around (including publicly-supported universities) wants to be seen as an "investment hub", with dollars at stake every time they decide to publish a study which serves someone's financial interests (or suppress a study which doesn't support someone's financial interest)?

If we're going to have a state university system, and we're going to support it publicly, maybe it ought to be the sort of institution which would be most accurately represented by an old-fashioned seal with a drawing of a book on it, rather than a swooshy corporate logo.

Pain and Prejudice

Thursday, December 13, 2012

Old Hippies With Bad Hips!

The concept of "generations" (in the sense of population cohorts born in the same general period) is, to me, maddeningly vague. What range of birth dates qualifies someone as belonging to Generation X? If something happened three generations ago, how many years ago did it happen?

What bothers me about this vagueness, apart from a personal distaste for that kind of thing, is my suspicion that people take refuge in vagueness when they don't want to be held accountable for what they're saying. If the concepts you're talking about are fuzzy enough around the edges, who's to say what's true or false?

People from the Baby Boom Generation like to say that Generation Y people are the biggest narcissists ever. Funny, the Generation Y people say the same thing about the Boomers. In the absence of a clear definition of either of those generations, and also in the absence of any objective test for narcissism that I'm aware of, it's hard to see how this kind of chatter can be anything more than social prejudice masquerading as social science. And when this kind of chatter oozes its way into what ought to be hard science, that can't be a good thing.

This is perhaps what tipped me over the edge when reading about a presentation given in Florida recently to the 23rd Annual Meeting and Symposium of the American Academy of Addiction Psychiatry. The presentation was given by a Yale psychiatrist named Dr. Louis Trevisan, pictured below.

Dr. Trevisan told his audience about the serious problem of abuse of prescription pain medication among the elderly. He presented an epidemiologic study showing evidence that about 20% of people over 65 are taking pain-killers several times a week, and that elderly people who suffer from chronic pain have an 18% rate of abuse or addiction.

Trevisan proceeded to explain that the problem will get worse as baby boomers get older, because they will be more ready to take drugs than their parents were. The preceding generation were stoic about pain and averse to taking medications, but "Baby boomers are from the 'me-me' generation, interested in living longer and taking care of themselves. They were also exposed to marijuana, LSD, and other drugs, and of course, alcohol has always been there, so they are much more inclined to use drugs. They have a different attitude about using substances."

Dr. Trevisan also presented a top-ten list of warning signs to look for in elderly patients, indicating that they might be at risk of abusing analgesic drugs. The first two items on the list were "they have multiple medical problems" and "they have a higher than average incidence of chronic pain".

At this point I am finding Dr. Trevisan a rather unsympathetic figure. If the epidemiologic evidence says that a large fraction of the over-65 population has multiple health problems and is suffering so much pain that they're getting hooked on pain-killers, then clearly there's a problem here, but I'm not sure Dr. Trevisan has entirely succeeded in figuring out what that problem is. He says it's a drug problem, and implies that it's also a character problem (at least among the members of a certain population cohort). Do you suppose that it might actually be a pain problem? I think we have to consider that possibility.

It seems to me that Dr. Trevisan's portrait of the baby boomer generation doesn't stand up all that well to analysis. The comment about them being the "me-me generation" may be a very popular accusation, but I don't know what objective data he is basing it on. That boomers are supposedly "interested in living longer and taking care of themselves" does not necessarily prove, at least to me, that they are far more selfish than they ought to be. And if "of course, alcohol has always been there", then alcohol has probably been used, now and then, by other generations, including even the vastly superior generation which preceded the boomers. So it's not clear to me why alcohol belongs in the catalog of the special weaknesses of the boomer generation.

To be honest, what really turned me against Dr. Trevisan is his apparent unconcern with the human suffering that is the real issue here. But his silly ranting about boomers is what gave me a very handy excuse to dismiss him.

So, next time Dr. Trevisan, don't put your social prejudices front and center. It doesn't put people in a good frame of mind to embrace an essentially heartless argument.

But working on the heartlessness might be a good idea too.


High Today

Didn't like my glucose numbers too much today. A Christmas-music rehearsal prevented me from doing a lunchtime run, and the gym workout I did in the evening wasn't as good for me as a run would have been; my post-prandial result of 132 after dinner seemed high for what I ate. But some days are like that. I'll hope to do better tomorrow.

The slow recovery of my sore shoulder continues -- slowly. I decided to try resistance-training again tonight, skipping only the chest-presses (the only exercise with weights which really seems to aggravate the rotator-cuff problem). My shoulder feels good now; let's hope it still does in the morning. If it doesn't get worse tomorrow, I guess I'm okay to do weight-training now.



Wednesday, December 12, 2012

Starch Worship

It's been a high-carb evening, but not in terms of what I've been eating -- only in terms of what I've been reading about. Carbs, carbs, and more carbs. Even the pictures I've been looking at are near-pornographic photos of baked goods.

First, I read a report that global warming is coming for our carbs. Apparently wheat, corn, and rice (which account for a majority of the calories the human population takes in) are heat-sensitive crops; they are already being affected by climate change, and are expected to suffer in the coming years. Wheat is particularly vulnerable to higher temperatures; wheat production has already declined by more than 5 percent, and is forecast decline by 23 to 27 percent by 2050. Perhaps we are all about to go on low-carb diets, whether we like the idea or not.

Of course, replacing grains in our diet with meat might not be the easy solution we imagine it to be. We get our meat (these days, anyway) from animals that feed on grains rather than greens. If grains are in short supply, factory farms will cease to exist -- which in principle sounds like a good thing, but soon we may have to pay the extra costs of grass-fed meat whether we want to or not, because no other kind will be available.

My guess is that we will make up for the problem by finding or developing other grains that will withstand higher temperatures. The pasta and bread might not be as good, once wheat is largely excluded from it, but we'll find a way to keep eating it.


Another study I read tonight says that reducing carbohydrate intake in the diet increases insulin sensitivity. Boy, is it a weak study, though! A small number of people, tracked over a short period of time, and the improvement detected was minor. A study that proves nothing at all. What a waste of time and money; why do people bother with this sort of thing?

Another supposedly important study which doesn't tell me much relates to the compounds which glucose breaks down into within the body, and the problems that those compounds can cause. Apparently glucose is broken down into "dicarbonyl sugars", including one known as "glucosone", which goes through some further degradation (by means of a process known as "C1-C2 transposition") and then starts latching onto proteins within the body, by mains of a "Maillard reaction", which results in "nonenzymatic browning". This whole process, perhaps surprisingly, is the same process which causes bread to develop its beautiful brown crust.

Yes, strange as it seems, the lovely, delicious, aromatic browning process which goes on in a loaf of bread (accelerated by the heat of the oven) goes on (more slowly) within us. And the result is that a lot of proteins within our bodies also have a beautiful brown crust. In other words, these are glycated proteins -- such as hemoglobin A1c. The problem with this is that what promotes a wholesome appearance in the bakery may not promote wholesome functioning within a human body. Proteins don't work the way they're supposed to when they are caramelized. We probably taste better to the shark that eats us, but otherwise the accelerated glycation that occurs when blood sugar is elevated is not beneficial.

Nonenzymatic browning is pretty, though -- at least in baked goods. There's no getting around that.

Browning inside the human body, though -- that's apparently not such a pretty thing. Anyway, it doesn't have pretty consequences, so we need to do what we can to minimize it.

Not Seeing Clearly

Tuesday, December 11, 2012

Vision Troubles on the Rise

Over the course of our very young century to date, prevalence of "nonrefractive visual impairment" has increased significantly, and the problem is being attributed to diabetes, the prevalence of which has been increasing at almost the same rate during the same period.

I should explain that nonrefractive visual impairment means vision problems which are not attributable to lens distortion. In other words, we're not talking about myopia or astigmatism here, we're talking about problems with tissues of the eye (such as the retina) which are vulnerable to the toxic effects of diabetes. These problems are becoming more common, apparently because diabetes is becoming more common.

Since 1999, prevalence of nonrefractive visual impairment has increased 21%, and prevalence of diabetes has increased 22%. There you go: case closed!

Actually, no one can claim that this kind of correlation is enough to make one thing the cause of another. Diabetes and eye problems are not the only two phenomena that have been exhibiting this trend. Obesity has been ramping up in the same way, over the same time period, and in the same places. So has sugar consumption, especially in soft-drink form. Couldn't we argue just as reasonably that Pepsi is what is causing eye problems?

The assumption, of course, is that the chain of causation goes like this: increasing consumption of sodas and other sugary foods causes obesity, and then the increasing prevalence of obesity causes diabetes, and then the increasing prevalence of diabetes causes nonrefractive visual impairment. I'm not claiming that these assumptions are wrong; they do at least make sense. However, it takes more than two graphs going up simultaneously to prove that one thing is causing the other. For all we know, vision problems are somehow causing diabetes, and diabetes is causing obesity, and obesity is causing people to crave Pepsi. I'm not saying that this inverted chain of causation is right, I'm only saying that this sequence is just as well-supported by mere correlation as any other sequence would be. Correlation is a good starting point, in terms of figuring out how one thing relates to another, but it's never enough. If diabetes prevalence correlates with obesity prevalence, how do we know if obesity causes diabetes or diabetes causes obesity? (Actually, both are probably true!). You need more than correlation to say what causes what.

The particular eye problems under discussion here (such as retinopathy) tend to develop only in people who have been diabetic for a long time, and we have plausible explanations for how diabetes could cause those problems. So, I'm pretty willing to accept that diabetes really is causing these particular eye problems.

Still, we have to be careful when correlation is presented as evidence that A causes B. Maybe B causes A, or C causes both!


Censors Always Triumph!

Dr. Yoni Freedhoff, who writes the Weighty Matters blog, was invited last month by the Ontario Medical Association to give a talk at a "food industry breakfast symposium on health and nutrition policy". However, he was dis-invited at the last minute, without explanation but presumably because somebody from the food industry had checked out his blog, and had discovered that he often writes critically of the food industry, and in particular of the food industry's tendency to (1) market sugary foods directly to children, and (2) mislead adults about the supposed health benefits provided by those sugary foods.

Having been deprived of the opportunity to give his talk as originally scheduled, he has now taken his revenge by creating a video version of the talk and posting it on YouTube, where it is now being heard by a lot more people than would have heard it at the symposium. It's only 13 minutes long, and it's pretty interesting; do check it out.

It's funny how slow some people have been to adapt to the realities of the digital age. Politicians still think that, in addressing one particular audience, they can slander people who aren't present, and the latter will never find out about it. (After all, when you attack working-class people in front of an audience of wealthy donors, it's not as if some busboy is going to capture a smart-phone recording of your remarks and share them with the world.) Similarly, if you can prevent a doctor from saying anything critical about your industry at a breakfast symposium, that is the end of the matter; it's not as if he's going to take the speech you prevented him from delivering and put it on the internet instead.

Face it, people: it is the year 2012. Word gets out.


No Fasting Necessary

Monday, December 10, 2012

Lunchtime Fun

Apparently more rain is on the way, but it was gorgeous outside today, so I'm glad I was able to take advantage of the perfect whether to go for a run at lunchtime. Blue skies, temperatures in the sixties, no wind, and brilliant sunshine lighting up all the greenery that has burst forth from the recent storms. (Other places may be green in July and brown in December, but in northern California it's the other way around.) Lots of people were outside walking or running, refusing to let a beautiful day go to waste.


Fasting & the A1c Test

An internet searcher asked recently "why dont we need to fast for an a1c test". There seem to be a thousand ways for patients to misunderstand what a hemoglobin A1c test measures. It isn't necessarily their fault, though: a lot of them misunderstand the test because they are told misleading things about it.

You don't need to fast for an A1c test for the same reason that you don't need to fast before having your height measured. The A1c does not measure anything which fluctuates on a short-term basis in response to whatever you've eaten in recent hours.

You do have to test for a blood glucose test, because that test measures something which does fluctuate on a short-term basis in response to whatever you've eaten in recent hours.

The reason people confuse these two very different kinds of tests is that they are told a lot of misleading things about what an A1c test is for. Most people think it measures their blood glucose level, or at least their "average" blood glucose level; it's only natural that they would think the same fasting requirement which applies to a blood glucose test would also apply to a test which (or so they have been led to believe) measures blood glucose.

Actually, the A1c test collects hemoglobin (a protein, found in red blood cells, which plays a crucial role in delivering oxygen to tissues throughout the body), and sorts the hemoglobin by subtypes with different characteristics. The subtype of hemoglobin known as "A1c" is hemoglobin that has been "glycated" -- that is, encrusted with sugar. Everybody's hemoglobin sample includes a little bit of hemoglobin A1c, because everybody's hemoglobin molecules occasionally get sugar bonded to them. This bonding occurs spontaneously whenever protein is exposed to sugar, and it can't be avoided, because everyone needs to have at least some sugar in their blood to survive. However, if your blood isn't excessively sugary, only about 5% of your hemoglobin in sugar-encrusted. That is, hemoglobin A1c represents only about 5% of your total hemoglobin. The rate doesn't increase over time, because (like other proteins) hemoglobin is recycled by the body. The red blood cells which contain the hemoglobin are replaced (after a lifespan of about 90 days) with clean new sugar-free cells.

However, when your blood becomes more sugary, the rate at which hemoglobin becomes bonded to sugar increases. Because of this accelerated bonding, people with diabetes often get A1c test results which are higher than 5%, or even higher than 7%.

The reason the rate of glycation matters is that it tends to have a damaging effect on tissues and organs, so it's important to slow the glycation rate down enough for the body's repair processes to be able to keep up with it. The reason we want to bring our A1c test results down to the normal range, or very close to it, is that the lowered A1c score will indicate that the glycation rate has been reduced enough to protect us from the harm that accelerated glycation can cause. However, the reason we are given as the motive for bringing down A1c test results is that this will prove our glucose levels are under control.

A1c test results are certainly affected by average glucose levels, but the relationship between those two things is a little inexact (the formula which relates average blood sugar to A1c score is more accurate for some people than others). In any case, the encrustation of hemoglobin with sugar is a very slow, gradual process, which builds up gradually over the 90-day lifespan of a red blood cell. What you had for breakfast on a given morning has too small an impact to be measured. So: no need to fast!

December 7, 2012

Can't Do It Today!

Early Christmas party tonight -- get back to you next week!

The Season

Thursday, December 6, 2012

That Time of Year Again

The weather would have been all right for running at lunchtime today, but I had a Christmas-music rehearsal to attend at that time, so I had to do an evening workout in the gym instead.

This will be the 16th year in a row that a small group of us have played Christmas music at the office, on the last workday before the holiday shutdown. Our work site is a big place -- there are four large buildings, and we stroll around from location to location, playing three or four tunes in each spot and then moving on to another department. It takes most of the morning.

Employees have come and gone over the years, and I just realized that this year I will be the only person playing who has done it all 16 of those years.

The nature of the ensemble changes from year to year; this time we will have two flutes, two fiddles, a trumpet, a French horn, and a guitar. We always have a few rehearsals -- not that our arrangements are all that complicated, but we don't play together otherwise, and we don't play Christmas music at all for 11 months out of the year, so we need the practice (also, two of the musicians are brand new this year, and they need the opportunity to practice with us).

Christmas music certainly has its pitfalls. It is harder to play these tunes than it ought to be in theory, simply because it's not the kind of music that you're used to playing, so you're always rusty on it. I never feel less competent as a musician than when I'm playing Christmas music at the office, even though the tunes are slower and simpler than any of the Irish reels and jigs I usually play.

There are a lot of pitfalls to Christmas music, actually. Some people hate it, for one thing (a coworker who overheard the sound of our rehearsal drifting out of the conference room was apparently grumbling about it -- I don't know how seriously). And even people who like Christmas music, or some of it anyway, often disagree about which carols are the good ones and which ones are awful. This calls for some delicate negotiation during rehearsal -- and, as in any negotiation, you can't have it all your way. If I want to play this, apparently I'm also going to have to play this.

But Christmas in general has a lot of pitfalls, doesn't it? You can't really filter out the parts you don't like, or can't handle. You sort of have to accept it for what it is, and survive it as best you can. Anyway, as the saying goes, it comes but once a year.

Headline Hype

Wednesday, December 5, 2012

Foggy Non-Rain, Perfect for Running!

The rain was falling as forecast this morning, but as lunchtime approached it faded away to nothing. It was still very foggy, and it felt as if it might start raining again at any moment, but I decided to take a chance on going for a run, and it worked out fine. I took the scenic route, with a huge hill-climb, and was rewarded with one of my favorite kinds of scenery: trees fading into invisibility they recede into the fog -- like a Japanese painting.

Actually, that is a Japanese painting -- I didn't have a camera with me. But if Hasegawa Tohaku had lived in 21st century California instead of 16th century Japan, he would still have painted something like that today.


What Causes It

I'm always scanning through reports on health research, especially if it seems pertinent to diabetes, and when an article catches my eye, I try to figure out if the details of the story justify the headline. Often they don't, as far as I'm concerned. A surprising number of these articles could be summarized as follows: "Scientists did something weird to mice in a lab, and found that doing this weird thing gave the mice Disease X (or protected them from Disease X). This suggests a possible causal or protective mechanism for the disease, which could be relevant to development of the disease in humans as well." But the headline that goes on the article is something like "Cause of Disease X Identified" or "Disease X Cure Discovered".

For example, I saw one article today with the headline "Discovery: First evidence of What Causes Diabetes". Really? First evidence? Haven't we been reading quite a lot about "evidence of what causes diabetes" over the years? I mean there seem to be a lot of weird things you can do to mice to make them diabetic, resulting in articles saying that this or that is what causes diabetes. Anyway, what causes diabetes this time is a protein that the body uses for iron transport. This protein has the capacity to damage the beta cells in the pancreas, so that insulin productivity goes into decline. It turns out that it's possible to genetically alter mice so that they don't have this iron transport protein. Researchers at the University of Copenhagen have done this, and they found that mice altered in that way don't develop diabetes. So there you are. The iron transport molecule is "what causes diabetes".

This leaves a few questions unanswered, if you ask me. If the iron transport protein is "what causes diabetes", and we all have that iron transport protein, why don't we all have diabetes? Are diabetes patients all people who took too much iron? And since when is declining insulin productivity necessarily the first thing that happens when people are developing Type 2 diabetes? Lots of people with Type 2 diabetes suffer from hyperinsulinemia (excessive insulin production, designed to overcome declining sensitivity to insulin). Abnormally low insulin productivity may not occur until someone has had diabetes for years, so it can't be the one and only cause of the disease.

I tracked the story down to an article on the University of Copenhagen website which goes into more detail. (By the way, their choice of title is the more modest "Cause of diabetes may be linked to iron transport".) Some of the details in the article seem to confirm what's being reported (taking iron supplements supposedly increases your diabetes risk), but some of them indicate that there's a pretty serious circular-reasoning problem going on here. We're told that "inflammatory signal substances" around the beta cells are elevated in people with diabetes, and these signal substances have the effect of accelerating the activity of the iron transporter, and this is what causes the damage to the beta cells.

Okay, hold on a minute -- the iron transport protein is what causes diabetes, by damaging beta cells, but it does this because its activity is accelerated by the presence of inflammatory signal substances which are produced in people with diabetes. In other words, this thing which is supposedly the cause of diabetes doesn't have a way to cause diabetes except in people who already have diabetes. Makes perfect sense.

Yeah, maybe I'm missing something here. But it sure sounds to me as if what the researchers found is that the iron transport protein plays a role, in some circumstances, in damaging beta cells in diabetes patients. Putting it any more dramatically than that seems awfully hard to justify.

Well, I guess it is justified by the necessity, as publishers see it, of making sure articles get noticed.

Caution: Paradoxes Ahead

Tuesday, December 4, 2012

Stormy Weather

Northern California has been getting drenched in rain over the past several days; a series of storms has been rolling down the coast from Alaska. There has been a lot of flooding, plus the usual downed trees and power outages. On Sunday afternoon, somewhat unexpectedly, the rain stopped and it became sunny and beautiful. I seized the opportunity to go the state park for a trail run (it was gorgeous in there, once I came to accept the fact that the trails had temporarily become creeks from all the runoff, and I was going to have to be in ankle-deep water about half the time).

Yesterday it was still beautiful, and I had a nice outdoor run yesterday too -- all the better to see all the downed trees. But the next storm in the sequence rolled in today, so rather than go out in the rain I settled for a gym workout -- which isn't really the same. I greatly prefer outdoor exercise, when it's practical. Rain is expected tomorrow, too, unfortunately. Maybe I can get enough willpower together to run in the rain tomorrow, rather than do two gym workouts in a row.

Sometimes the toughest part about maintaining an exercise program is to be ready to adapt it to circumstances, instead of following the impulse to abandon it whenever circumstances make it less convenient or less comfortable.


A Consumer Paradox!

A management consulting firm called Accenture has done a study on the subject of controlling health-care costs (which are notoriously out of control in the USA -- no country spends more on health care, or gets less for its money, than America does). The people at Accenture were particularly interested in the problem, as they see it, of patients not being very willing to accept changes in health care which would make it more affordable, and they have reported the sad, sad results of their investigations in a report called "Reconciling the Great Healthcare Consumer Paradox: Are consumers willing to change to get what they want?". Not to prolong the suspense too much, the answer appears to be "no". A majority of health care consumers are selfish and immature little brats who cling to stupid old-fashioned notions about how health care should be provided (I am perhaps reading between the lines a bit here -- they didn't say it quite like that).

The "paradox", as Accenture sees it, is that "consumers know what they want, but don't do what it takes to get there". What it takes to get there, apparently, is that patients should be willing to switch to a different doctor or hospital (less than 30% want to do that), and they should be willing to have their questions and concerns addressed by a software application (72% want a human being to be involved), and they should be willing to have their "routine" office visits handled by a "nurse practitioner" (59% want to see a real doctor).

Where did Accenture manage to hire people who were incapable of understanding why patients might express the attitudes summarized here? Was the report written by people who have never experienced medical care themselves, and are consequently baffled as to what the fuss is about? (And apparently they haven't experienced software applications, either.)

I don't know what a "nurse practitioner" is, exactly, but if it was another word for "doctor" we wouldn't be discussing nurse practitioners as cheaper alternatives to real doctors. Anyway, when people have a doctor's appointment, they expect to see a doctor. The people at Accenture might feel comfortable talking dismissively about "routine" office visits, but I've never had an office visit that seemed routine to me, and since those "routine" office visits might be the patient's only brush with health care in a year or more, it is pretty likely that the patient will have questions and concerns about their health. When you have questions and concerns about your health, who do you ask? Most people ask a doctor. Being told you can't see one because your situation is too "routine" for that is a little alarming. The message seems to be: let's not squander medical resources on people who aren't sick yet. Go and get really sick, so that you're worth a doctor's time!

If Accenture wants us to share their disgust with the patient population, they are going to have to demonstrate a few things which they haven't demonstrated. One is that, although patients have been seeing real doctors and taking their questions to human beings rather than software applications for many years now, the universe has changed in some way which makes that approach impossibly expensive now. Another thing they need to demonstrate is that, in countries where health care is less expensive yet more effective, the system works because everyone is already making the same sacrifices that are now being urged on Americans. In Europe, in other words, you have to change doctors if they tell you to, and you can't take your questions to a human being, and when you go in for a doctor visit you don't see an actual doctor.

Those things might all be true, for all I know, but until Accenture shows me that they are true, I cannot even begin to take their point of view seriously.

Outside the Box

Monday, December 3, 2012

Connecting the Dots

The term "thinking outside the box" dates back to management training programs from the 1970s, in which students were asked to solve the "nine dots" puzzle. A simple matrix of nine dots is shown, outlined by a box:

The student are to connect all of these dots using just four straight lines, without lifting the pen off the page or retracing any lines. When the students can't see a way to do any better than this...

...the instructor triumphantly unveils the solution, which involves drawing lines which extend beyond the boundaries of the box:

The students are then taunted for having assumed that the lines couldn't extend beyond the box, when nobody had explicitly said they couldn't. Properly chastened, the students can now face the world, unburdened by artificial limits on their thinking.

Am I the only one who finds this sort of thing enormously irritating? The test is deliberately designed to mislead the students into misunderstanding it. The students assume that the box represents a limit, not because they are foolish or unimaginative people, but because they are taking a pencil-and-paper test and they therefore accept the visual conventions of such tests. (If it was a fill-in-the-blank test, would the students be faulted for having assumed that the blank was where the answer was supposed to go?) Boxes drawn around things are conventionally used to represent limits or borders. If this one serves some other purpose, what is that purpose? What is the box doing there, except to create the false impression of a limit?

Even if the box were not there, talking about "connecting" dots strongly implies that the dots are end-points, as if we were stringing wires between telephone poles. The idea of "connecting dots" -- with a line which extends well beyond the point it connects to, and then stops for no reason -- doesn't make sense in those terms, so we don't think of it.

If you didn't want to make the students think of the dots as end points, you wouldn't talk about connecting dots -- you would talk about drawing a straight line which passes through those dots.

So, the "nine dots" puzzle is contrived deliberately to fool people into seeing a problem the wrong way, so that the instructor can smugly inform them that they should have seen it a different way. (Attention management training gurus: this is why people don't like you.)

Much as I hate the supercilious way in which this concept is usually communicated, at its core there is something of value in it: our habit of accepting conventions without even being conscious of doing so can sometimes limit our ability to see a situation for what it is. Accepting conventions means accepting limitations, and sometimes those limitations are needless and counterproductive.

Sometimes a scientific mystery of long standing can be solved just by dropping a conventional assumption. In 19th-century physics, light was assumed to be propagated by means of an invisible medium known as the "luminiferous ether". Then the Michelson-Morley experiment showed that the ether didn't even exist, and physicists were pleased to discover that, once they abandoned the assumption, the propagation of light became easier to explain, not harder. But the old assumption that the ether existed had prevailed for a long time, holding back science because scientists couldn't see anything outside that particular framework.

Health science is also often held back by unhelpful assumptions which persist for years, preventing people from seeing a problem outside the framework of a particular assumption. For example: the issue of heart-attack rates being lower in women. For a long time it was assumed that women had some kind of "protective" factor which prevented them from having heart attacks -- but that they lost their special advantage, whatever it was, after menopause. It turns out that women, like men, face an increasing risk of heart disease as they age, and menopause itself does not accelerate the increasing risk. We were looking at the problem backwards. The question should not have been "what is protecting women from heart disease?" (since when is lack of a disease an anomaly which needs to be explained?). The question should have been "what is putting men at risk for heart disease?". The answer hasn't been found yet (although testosterone is an obvious suspect), but at least we're starting to ask the right question. The reason we were asking the wrong one, all these years, is that we tend to assume that men exemplify whatever is "normal" -- therefore, when we notice that men have more heart attacks than women, we don't ask what is odd about men that increases their risk, we ask what is odd about women that reduces their risk. Weird as it may sound, we are so primed to equate maleness with normalcy that we are even willing to call heart attacks normal so long as men are the ones getting them.

Diabetes therapy is boxed-in by two major assumptions which are seldom questioned. First, there is the assumption that "treatment" (of any serious disease, including diabetes) consists of either drugs or surgery -- there is no third possibility. Second, there is the assumption that diabetes always gets worse rather than better, no matter what anybody does -- this is called "being realistic" (when it ought to be called "making a self-fulfilling prophecy").

My website is intended to combat both of those assumptions. I'm feeling a little outgunned, but I'm doing what I can.

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