Wednesday, February 29, 2012

February 29 -- a date that doesn't happen any old year. But this is a leap year, so we get a 29th this month.

One of my running buddies celebrated his 13th birthday today. You'd never know it to look at him. But he only has a birthday every four years, so the numbers are a little deceptive:

The composer Gioachino Rossini is only having his 55th birthday today -- even though he was born in 1792.

Rossini was famous for his sense of humor. There's a nice anecdote about a group of musicians who informed Rossini that they were raising funds to put up a statue of him, in his home town of Pesaro, Italy. He asked them how much money it was going to take, and when the amount turned out to be a lot more than he had been expecting, he exclaimed: "Give me the money and I'll stand on the pedestal!".

Well, once again I got a higher-than-usual fasting result today, just when I seemingly ought to be getting a lower-than-usual fasting result. I ate pretty light yesterday, had two hard workouts (one running and one with weights), went to bed feeling hungry, and woke up feeling hungry. I thought I'd be around 80. Instead, 100.

Well, based on the experience of other people I've heard from, it could be that going to bed hungry is no longer a winning formula for me. I am hesitant to adopt this view, but just in case this is a new and unwelcome trend developing, I thought I'd try having a snack before bed: a small packet of trail mix, supposedly providing 16 grams of carbohydrate (3 of them in fiber form). About equivalent to one slice of bread.

If I get a lower fasting result tomorrow, that might mean the late snack is now a good idea for me (it wasn't before). But you don't want to draw broad conclusions from a small sample size (particularly a sample size of 1!).

So now I'm brooding again, as I often have in the past, about the problems of perception that are involved in steering your way through the obstacle course of diabetes management. It is so easy to misread the signals, and draw the wrong conclusions from what little data you have.

Which of the red dots is larger? The one on the right, of course. Except that they're the same size. The one on the left looks a little smaller because your brain can't help comparing both of them to the blue circles around them, and the larger blue circle on the left makes the red dot in the middle of it look smaller by contrast. 

You might say that this illusion (known as the DelBoeuf illusion) illustrates my problem in regard to my "high" fasting result of 100. A lot of people with diabetes would be perfectly content with a fasting result of 100; it all depends on what you're comparing it to. I'm comparing it to the lower numbers I more typically get, so to me 100 is high. People who typically get a higher number would compare 100 to that higher number, and 100 would seem low to them. It's the same red dot either way, but I'm comparing it to a smaller blue circle than others would.

Perceptual problems can be hard to fight even when you're fully aware of them. I know that the image below is steady -- it's not flexing. But it looks as if it's flexing.

The illusion of motion is triggered by my eye scanning around the picture; if I stare hard at any square within the picture and don't allow my eye to wander from that point, the "motion" ceases. But the minute I stop doing that, the illusion of motion starts up again, and becomes impossible to ignore.

With diabetes, it is often possible to "perceive" something vividly even though the perception is entirely unreal; knowing that it is unreal doesn't really undermine the perception. I suspect that most diabetes patients think that they can tell (roughly) how high their blood sugar is by the way they feel. I myself often have this impression, but it's been wrong often enough in the past for me to realize that I am only fooling myself about this.

I don't have a direct sense of my blood sugar level; the "feelings" I associate with low blood sugar or high blood sugar are probably the result of my knowledge of how such things have affected me in the past. I don't really "feel" what my blood sugar is, but my feelings sometimes make me aware of issues which might contribute to what my blood sugar is. I associate feeling hungry with low blood sugar, but that association is not dependable; this morning I felt hungry and wasn't low. I thought I was "feeling" that my blood sugar was low; actually I was feeling that I was hungry, and being hungry doesn't always mean that my blood sugar is comparatively low.

Lucky, lucky, lucky! Yesterday the rain didn't begin until after I finished my run, and today the rain stopped before I started my run. It was cloudy and (by local standards) cold, but it was dry. This is what we hope for.  

Tuesday, February 28, 2012

Just yesterday I was saying that post-prandial tests can always surprise you; I forgot to add that fasting tests can do the same thing.

I thought sure I'd have a fasting result in the low 80's today, and instead I got 101. Yesterday I had a light lunch and a light dinner, a good workout, and no bedtime snack of any kind. But some would say that was the problem: they have found that going to bed with too empty a stomach only sets them up for a higher result in the morning. That is generally not true for me, but it's always possible that it could start being true for me, even though it wasn't before.

Things can always change. That's why we keep testing: first to find out what our patterns are, and then to make sure our patterns aren't changing. If I continue to have a problem with fasting results that are higher than expected, a midnight snack might turn out to be a good idea. But I'm not going to have one tonight, to see if I can get a good fasting test tomorrow without it.

I certainly did enough exercise today -- a long and hilly run, and a harder than usual weight training workout in the evening.

At the gym tonight, doing my weight-training workout, I was thinking once again (as I nearly always do) about why I've always been so much less comfortable with weight-training than with aerobic forms of exercise. I know that other people must share some of the same discomfort with it that I feel.

A big part of that discomfort has to do with the idea that strength-training is for the already-strong. The people who seemingly ought to be doing it are the people who look like this:

What business do the rest of us poor schlubs have, invading their corner of the gym and pretending we can do what they're doing? It's hard not to feel like an impostor, working out in the midst of the real weight-lifters, and hoping they aren't noticing how much less we can lift than they can.

At an intellectual level, I understand that everyone has to start somewhere. Somebody whose muscles look like this... 

...was probably not born with them. He had to do a lot of weight-lifting before he started looking anything like that. Well, actually, he also probably had to inject a lot of anabolic steroid hormones, but my point is that he must have been a weakling at some point in his history, so I shouldn't have to be ashamed of starting where he started, instead of where he left off.

However, whatever my intellectual understanding of the issue may be, my feeling is that weight-lifting is an activity best left to the superheroes, and that I can only make a fool of myself by pretending that I can get involved in it.

I guess you could say the same thing about running -- and I run all the time, so I'm not being very consistent about this. But I see a lot more over-40, overweight, overstressed people on the jogging path than I ever see on the weight machines, so on the jogging path I feel as if I belong, and on the weight machines I feel like a joke.

I know that some older people who don't look like Olympians do lift weights, but I often wish that more of them hung out at my health club.

Well, I guess I just have to get over this, somehow.

Anyway, I was reading a lengthy article on exercise and Type 2 diabetes in Diabetes Care, and it did say that the combination of aerobic exercise with strengh training is more effective than aerobic exercise alone. Any exercise-centric program for managing Type 2 really ought to include strength training for maximum effectiveness.

The article also cited some research on which approach to strength-training is most effective. Their recommendation, based on that research, is:

I had lately been doing two sets of 12 repetitions for each exercise; tonight I tried out the recommended approach, and did three sets of 10. For most of the exercises, I increased the weight a little from what I was used to, because I didn't have to do more than 10 reps per set.

It was a more difficult workout than I was used to, but it felt better when I was done, and my blood pressure and pulse were exceptionally low afterward, which is a good sign. I'll try continuing with that program, and see what happens.  

Monday, February 27, 2012

Well, perhaps May isn't quite here after all. It was a nice sunny day today, but the air was about twenty degrees cooler than last week. Still, that only meant it was in the 50s. You could run comfortably enough, in shorts and a T shirt. (The only difference was that, when you first walked outside in your shorts and T shirt, you didn't want to hang around too long out there in the breeze before you started running.)

Rain is expected tomorrow -- we'll see if I'm tough enough to go running in it. I'll be alone if I do; my running buddies hate running in the rain.

Time once again to review the web-browser search texts that have yielded up my site as a result.

I assume this means: can the result of a hemoglobin A1c test change over the course of one month. Well, yes, it can -- but it probably won't change very much.

The A1c test examines a sample of the hemoglobin in your red blood cells to see how much of it is "glycated" (sugar-coated). Glycation is a slow, gradual process. Replacement of red blood cells is also a slow, gradual process (a red blood cell lasts about three months in your bloodstream, before it is replaced and can no longer affect the results of your A1c test). The A1c result reflects how sugary your blood has been lately, on average, but if your blood sugar becomes significantly less sugary (or more sugary), it takes a while before the A1c result begins to reflect that change.

Generally speaking, the A1c result is regarded as an indicator of average blood sugar over the past three months. It isn't considered worthwhile to do the test more than once every three months, because the result isn't likely to change very much over shorter intervals.

Suppose you're marking the height of your five-year-old daughter on a doorframe, every six months or so. She wants you to measure her height today. You tell her no -- you just measured it two weeks ago, and you want to wait longer than that. This doesn't mean that she hasn't experienced any growth over the past two weeks. No doubt there has been a small amount of growth, but the difference is going to be so small that it will be hard for you to measure it, and hard to mark it distinctly on the doorframe. When you're tracking something that changes slowly, you don't check it often.

If you're not happy with your A1c test result and you want a do-over, wait for the next three-month interval to come up. Re-testing within the same month will probably yield about the same result as you got before.

I assume this means "if there was a pill that provided the same health benefits as exercise".

Well, it doesn't really matter what life would be like if we had such a pill, because we don't have such a pill. There has been some optimistic talk about drugs which might someday provide some of the health benefits of exercise, but these things are in the early stages of investigation and may not turn out to work as well on humans as they do on lab rats.

We might as well engage with the real world, because the fantasy world in which you can take exercise in pill form does not seem likely to come true soon.

Join the club. Everyone is confused by post-prandial blood glucose at least some of the time.

The two most important variables which affect your glucose level after a meal are (1) the total amount of carbohydrate included in the meal, and (2) your degree of sensitivity to insulin at the time (which can fluctuate widely, and is greately affected by exercise, hydration, inflammation, insomnia, and other health issues).

But sometimes your post-prandial result is just going to be weird, for no reason that you can discover. It's high when you expect it to be low, and vice versa.

Human physiology is variable, and you have to expect the unexpected sometimes.

What you should do is stop saying that your blood sugar is normal. It must be a little elevated (although perhaps not when you're checking it) for you to be getting an A1c test result above 6.

Not that 6.2 is a terrible result; it isn't regarded as high enough to get you diagnosed as diabetic. But any elevation of blood sugar should be taken as a sign that trouble is brewing, and that something needs to be done about it as soon as possible, so that the situation doesn't get worse.

Elevated blood sugar is the sort of problem that tends to spin out of control, because elevated blood sugar has undesirable effects (including damage to insulin-producing beta cells in the pancreas) which make it all the harder to bring blood sugar levels back down where they belong.

The longer you wait to do something about elevated blood sugar, the greater the risk that, when you finally try, you won't succeed. Take it seriously, and act immediately -- even if it's only a little high. If you wait until everyone agrees it's very high, it may then be too late to act.

Who knows what this person was thinking, but I'm afraid the thought might have been "does taking diabetes medication make it all right to eat a lot of sugar?".

No diabetes medication is so effective, by itself, that taking the medication lets you off the hook in terms of lifestyle adjustments. You still have to exercise and be cautious about what you eat. Since you have to do those things anyway, I figure it's best to do those things well enough to be able to get along without the medications for as long as you can -- sparing yourself the expense and side effects involved.

Anyone can experience hypoglycemia, whether they have diabetes or not.

If you have diabetes, and you're taking insulin or oral diabetes drugs, you're likelier to experience hypoglycemia, and also likelier to experience a severe episode of it.

If you have diabetes, but you're undmedicated, you will experience hypoglycemia less often and less severely. It will be annoying and uncomfortable when it does happen, and it will make you nervous, but it is unlikely to put you in real danger. At least, that has been my experience.

Some useful advice from XKCD:

Friday, February 24, 2012

Honest, I don't know why my fasting test was as high as 97 this morning; I thought I'd be in the 80s. I was in the 80s yesterday, after all, and I thought I'd done everything right to get a repeat performanace.

Well, glucose readings, and particularly fasting readings, always have the potential to suprise us. If we get it right most of the time, that's the best we can probably hope for.

At least my post-prandial test after dinner was low. But it was a pretty low-carb dinner.

I was reading a blog post (admittedly not a very recent one) by a chef with diabetes, who gave it the rather inflammatory title "6 Reasons A Diagnosis of 'Borderline Diabetic' is Worse Than Cancer."

Now, clearly, in choosing that title he was being deliberately provocative, in order to capture the attention of potential readers. He could hardly have thought that this statement was literally true. Let's face it: the list of things that are "worse than cancer" is not very long, and borderline diabetes is not on it.

But he does make some valid points. A diagnosis of cancer is clear, and real, and taken seriously -- meaning that the doctor forms an urgent plan of action, and the patient knows what's at stake.

A diagnosis of "borderline diabetes" or "pre-diabetes" is vague, and hypothetical, and not taken seriously -- meaning that the doctor typically does not form an urgent plan of action, and the patient typically has no clue what's at stake (until it's too late).

The author is bitter over the opportunity he feels he lost, because he simply didn't understand the situation, and didn't realize he could have done something about it, if he had acted sooner than he did.

Unfortunately, the chef does little to boost his credibility when he comments, "I quit smoking after getting the information on what it could really do to you. I mean, really. I quit cold turkey, almost 3 years ago. Once I had the information I needed, it was easy." He wrote this in 2011, so he is asking us to believe that, until 2008, he was uninformed about what smoking can do to you. Then somebody finally spilled the beans, and he quit. Sorry, but I cannot regard this as a plausible chronology. There is no such thing as an adult who never heard what smoking can do to you before 2008. I'll believe in Bigfoot before I believe in that.

However, I am pretty willing to believe that he was never given any "actionable intelligence" about what a diagnosis of borderline diabetes means, and what can be done about it, and what happens if you do nothing about it.

It does seem remarkable to me that diabetes (a common disease, a serious disease, an expensive disease, a common cause of death -- and a great contributor to other causes of death) does not provoke the urgent, let's-nip-this-in-the-bud approach that cancer provokes. Pre-diabetes (or "borderline diabetes") is to full-blown diabetes what a small cancerous tumor is to a large one. Cancer treatment is all about detecting tumors while they are still small, and treating them aggressively -- in the hope that they won't get a chance to become big tumors, and spread.

If cancer were treated the way diabetes is, patients with small tumors would be told to stop whining, and come back when they had a tumor big enough to be worth the trouble of treating.

I have absolutely no clue why the health-care industry has chosen to take this attitude about the early stages of diabetes, and has not chosen to take this attiude about the early stages of cancer. But that's where we are.

Thursday, February 23, 2012

Well, well -- fasting test back down where I want it to be. Post-prandial test a little higher than I like to be, but still within normal bounds.

The weather here in Sonoma County is still a lot more like May than February. Sunny, clear, temperatures in the high 70s. I wore a sleeveless running shirt today, and had no regrets on that score.

Research results are sometimes surprising, and sometimes decidedly unsurprising. Do these findings stun you?

But sometimes research results are surprising enough to make us wonder if we are understanding them properly. So it is, I think, with research connecting diet sodas to increased risk of heart attacks and strokes.

The study followed 2564 "older adults" in New York City for ten years, and found that those who drank diet soda every day were 44% more likely to have a stroke or a heart attack than those who did not drink diet sodas.

The first question that comes to mind is: did the diet soda itself cause these people to have strokes and heart attacks? Or was there something else about the diet soda drinkers that made them likelier to suffer those health problems? (If fatter people are likelier to drink diet sodas, then perhaps the habit of drinking diet soda is simply a marker of obesity, and correlates with cardiovascular problems simply because obesity correlates with cardiovascular problems.)

But the researchers say they took differences in body weight I (and other factors, such as diabetes and exercise habits) into account -- and that the results still indicate a 44% increase in the risk of cardiovascular problems, for regular drinkers of diet sodas.

A lot of research studies have been associating diet sodas with various health problems, or with various markers of potential health problems. Diet sodas have also been accused, by various studies, of promoting high blood pressure, high blood sugar, and the buildup of abdominal fat.

Is it really the diet sodas? Or is it just that the people who drink diet sodas regularly are different from people who don't, and the difference (whatever it is) makes people more vulnerable to health problems?

If the real problem is the diet sodas, we are left with the challenge of figuring out what it is about diet sodas that causes health problems for us. Caffeine? Artificial sweeteners? Carbonation? Acidity?

Some people see artificial sweeteners as a problem, because the sweet taste fools our senses and triggers insulin secretion, in a situation where insulin secretion is not actually needed -- and insulin secretion stimulates the body to store excess calories as fat. (The weight-loss theory promoted by Dr. Atkins and others is that insulin is the culprit in weight gain, and that the way to halt weight gain is to eat in the whatever way stimulates the least insulin secretion.)

My suspicion is that people are going to continue arguing about this for years, if not decades, before any firm conclusions can be reached. But it sounds as if drinking diet sodas frequently might not be the harmless vice we tend to assume it is.

Apparently, people who provide advice to those seeking improved fitness tend to be a little more blunt in Ireland than they are around here...

...but feel free to consult Ruth Field, a.k.a. The Grit Doctor, if you think you are ready to face her tough-love approach to running for health.

An actor named Daniel von Bargen, not known to me but apparently well known to many (mainly because he played a supporting role on the Seinfeld TV show), is in critical condition in a New York hospital. It's surprising that he's alive at all, considering that he shot himself in the head. The reason he wanted to kill himself was that he couldn't cope with his diabetes. He was scheduled for surgery, expected to have his toes amputated, and didn't want to deal with the situation any more. He said he was tired, and I imagine he was.

I'm not sure I know how to extract any kind of non-depressing message from this story. It's never a lot of fun to hear about diabetes patients whose attempts to stay healthy have gone terribly wrong. 

On the other hand, I have no information at all about kind of diabetes von Bargen has, or how long he's had it, or how he's been managing it. Maybe his situation is so unlike my own that I don't have to worry about the possibility of his experience prefiguring mine.

At any rate, I'm going to try to make sure my situation stays as different from his as I can possibly make it, for as long as I can make that happen.

Wednesday, February 22, 2012

Hmmmm, not entirely thrilled with the fasting result of 95. I like to stay below that number. Post-prandial wasn't bad, though, and I had a good run today, so I hope to get a better result tomorrow morning.

The weather was ridiculously nice today. The high temperature was 79 degrees. The running shirt I brought to work with me in my gym bag was a little too warm for the occasion. It seemed like almost everybody at work got outside at lunchtime, even if only to eat lunch outdoors. But there were lots of runners, cyclists, and soccer players.

This is what February should be like, but I guess in most places February is never like this. I try not to take the local advantages for granted. Around here, winter is usually over by President's Day, to the extent that winter happens at all.

Okay, some more research has come out saying that fructose doesn't make people gain weight, or at least doesn't make them gain any more weight than other sources of comparable calories.

According to the Annals of Internal Medicine, studies in which two groups of people ate diets with the same number of calories, but one group's diet was especially rich in fructose, found that the high-fructose group did not gain more weight than the other group. High-fructose diets only resulted in greater weight gain, compared to a low-fructose control group, if the experiment was set up so that the high-fructose group added fructose without taking away anything else to compensate for the added fructose. In other words, fructose or no fructose, you only gain more weight if the total calorie count is higher. Fructose does not promote more weight gain than other foods do, when calorie counts are similar.

The reason this issue was investigated at all is that people have become very suspicious of that industrial product known as HFCS (high-fructose corn syrup, a sweetener manufactured through chemical processing of corn starch). HFCS is immensely popular with the processed-food industry, for two reasons:

Soft drinks tend to contain a lot of HFCS; so do many snack foods. However, HFCS is found in many products which many consumers naively assume to be free of it -- such as bread and dried fruit. Because HFCS is added so generously to so many of the items we find on grocery store shelves, per-capita sugar consumption has gone way up over the past few decades. Obesity and diabetes have gone way up, too, and there has long been suspicion that one trend is driving the other. Hence the concern: is fructose, and the high-fructose corn syrup which adds so much fructose to the modern diet, somehow making people gain weight and become diabetic? Is there something about fructose which makes it more harmful than other sugars?

The name "high-fructose corn syrup" can be a little misleading; it usually isn't a great deal higher in fructose than table sugar is. But the issue is a little complicated, so let me lay out some of the details:

Why, exactly, would fructose be worse than glucose from a health standpoint? Presumably because fructose is processed differently by the body than glucose is. Fructose doesn't trigger insulin secretion, and it is processed in the liver; these issues make people think of fructose as different, and perhaps dangerously different, than other forms of sugar.

Well, if that is true, researchers sure have been having a hard time proving it. If you control for total calorie intake, fructose doesn't promote weight gain compared to other calorie sources.

But there's the catch: the problem may be that, outside of a research lab, we don't correct for total calorie intake when we consume HFCS -- because HFCS is hidden in foods which we don't suspect of containing it. Hidden HFCS adds calories to foods, and if it doesn't occur to us to correct for that, we gain weight.

I could be wrong, but my suspicion is that the real problem with HFCS is not its molecular structure but rather its invisibility. If HFCS were as conspicuous as a pile of whipped cream on top of a dessert, we might be more careful with it. But we don't notice it, so we consume a lot of it.

Some people hypothesize that fructose promotes insulin resistance (I'm not sure I understand how they think that works, I'm just mentioning the idea for whatever it is worth). However, the new study looked at weight gain rather than insulin resistance, so I don't know if there's anything to that idea.

I think it would be wise to cut down on HFCS, if only because of the calories it adds to foods. Unfortunately, the produce section might be the only part of the grocery store where the food doesn't have HFCS hidden in it.

My favorite headline of the day: 

And not a moment too soon! 

Tuesday, February 21, 2012

My holiday weekend included excursions into the great outdoors and the also into the great indoors. Outoors first.

On Sunday the weather was much too beautiful for me not to do a trail run in the state park.

As I've mentioned before, I often run into coworkers on the trails who are there doing the same thing. So, when I saw this couple approaching along the trail, and they looked a little familiar from a distance...

...I was not completely amazed when they got closer and I realized that I knew them. I had even run in a few races with them before: Takashi (a coworker, relocated here from Japan) and his wife Hiromi.

They seemed to think it was a very amusing coincidence that they ran into me on a remote trail, but I'm pretty used to that kind of thing happening. 

As I was carrying a camera with me this time, they also used it to take a snapshot of me.

They were heading the opposite direction, and their car was parked nowhere near mine, so we didn't join forces; we continued along out separate paths. My route ended up being 8 miles.

I seem to have a physical need to get outdoors often; I'm glad I live in a place where it's usually easy and comfortable to do that. I'm not sure February in Buffalo would work out quite so well for me.

My journey into the great indoors took the form of a Burns Night supper -- a Scottish custom which is often practiced by expatriate Scots in this and other countries. It is a somewhat formal dinner combined with a program of music, poetry-reading, and toasts, all of it related to the Scottish poet and song-writer Robert Burns.

Strictly speaking, Burns Night is January 25, the date on which Burns was born in 1759, but this particular supper (which took place at the Camillia Inn in Healdsburg, California) was delayed till February. I thought it was worth waiting for, though. Three musicians that I knew but hadn't seen in several years took part in the event. Shelley played the harp and Chris played the flute and smallpipes.

Rod was the master of ceremonies, read the poems, sang the songs, and occasionally picked up an instrument (in this case, he was trying out my fiddle). 

None of those three live near me, which is the reason I haven't seen them in so long, but Malcolm is local, and is my usual playing partner in this sort of thing.

He played pennywhistles, smallpipes, and later the highland bagpipes (during those parts of the ceremony that called for a mighty blast of sound). 

One of the essential ingredients of a good Burns Night is alcohol. The lowland Scots dialect in which Burns wrote (believe it or not, "Auld Lang Syne" is one of his more understandable lyrics, to an American ear) is intimidating if you're too sober; it takes a drink or two to get people relaxed enough to reconcile themselves to the idea that they're only going to understand a fraction of what they're hearing. So, the evening began with the guests chatting and sipping wine...

...while we played old Scottish tunes nearby.

The evening program included a fair amount of poetry reading...

...and formal toasting...

...and informal music-making.

One of the great advantages musicians have going for them is that it's very easy, when they encounter one another after a long separation, to re-establish contact instantly by making music together, as if they had never been apart. Before things got under way, I told Shelley that I wanted to play an old tune called "Crossing to Ireland" during supper, which I knew would sound great with a harp accompaniment; to my relief, she knew the tune. And when we played it at supper, it turned out that Chris knew it too, and he joined us on flute. All this unfolded naturally, without a rehearsal, and I didn't feel nervous about it at all.

I enjoy music-making a lot more when it is a social activity, a way for people to have fun together rather than a way for people to "perform" to an audience. If you can make music in that spirit even though there actually is an audience there to hear it, you sort of get the best of both worlds. But, for me, the interpersonal communication between musicians is the more important of the two. Conversation is a hit-and-miss affair; music is far more reliable.

Which reminds me of my favorite anecdote from music history. It concerns the pianist Dorothea von Ertmann, one of the greatest pianists of the early 19th century. She was especially admired for her interpretations of the music of her friend Beethoven. ('She plays your music better than the men' wrote the composer's nephew once, in one of the "conversation books" Beethoven was forced to use after he became deaf.) 

She was also one of the very few human beings who ever managed to sustain an untroubled friendship with the hot-tempered composer. Long after his death, she shared a bittersweet memory of him.

"Never will I forget what warm and close affection Beethoven showed to me and to my family. Therefore I could not understand at all that after the death of my dearly beloved child he did not visit me."

But eventually the composer, so awkward and difficult in most social situations, did appear. He greated her silently, sat down at the piano, said 'Let us speak to each other by music', and improvised at the keyboard for more than an hour.

"Who could describe such music? I felt as if I were listening to choirs of angels celebrating the entrance of my poor child into the world of light. In this way he said much to me, and gave me consolation. When he had finished, he pressed my hand sadly and went away as silently as he had come."

Monday, February 22, 2012

President's Day

I have a holiday from work today. I think I'm going to make it a holiday from blogging as well. Can I do that? I can do that, right?


Friday, February 17, 2012

We have a hormone to discuss, but first let's get some terminology straight. Which will take a while. 

Hormones are chemicals produced in one part of the body which travel through the bloodstream and deliver "signals" to other parts of the body. The glands that make up the endocrine system (the pancreas, the thyroid, the pituitary, and so on) secrete hormones into the bloodstream to regulate processes going on throughout the body. However, the endocrine glands are not the only parts of the body which can secrete hormones. The digestive system can also do it, for example. 

The intestine is a rather more sophisticated organ than we tend to give it credit for; in addition to breaking down food to extract nutrients from it, the inestine also plays a complex regulatory role. One of its regulatory functions is to secrete the hormone GLP-1 when it is digesting food. (Whether GLP-1 counts, strictly speaking, as a hormone or as something analogous to a hormone is an issue I have decided not to have a headache over -- for present purposes I'm calling it a hormone.)

That abbreviation GLP-1  stands for "glucagon-like peptide 1", and perhaps you're thinking that the longer name doesn't clarify matters as much as you were hoping it would. Well, let's take the name apart. 

First of all, what is glucagon? It's a hormone that you might think of as anti-insulin. Just as insulin drives blood sugar down (by stimulating your muscles to pull glucose out of the bloodstream), glucagon drives blood sugar up (by stimulating your liver to release stored glucose into the bloodstream).

But GLP-1 isn't glucagon, it is only "glucagon-like". It resembles glucagon chemically, and yet it doesn't have the same effect as glucagon. More on that in a moment. 

And what is a peptide? You might say it's a sort of junior-sized protein. Like a protein, a peptide is a sequence of amino acid molecules chained together and folded into some kind of structure. The only difference between a peptide and a protein (and it's a mighty vague difference) is that, in a peptide, the sequence is shorter and the structure is less complex. There seems to be no exact definition of how big a peptide has to be before it graduates to the status of a full protein. Anyway, many hormones are peptides, and glucagon is one of them. (But, again, the peptide known as GLP-1 is not glucagon -- it is merely glucagon-like.)  As for the "1", I assume it is there to distinguish the original glucagon-like peptide from the disappointing sequels that came out later. 

A further complication I should mention: some hormones are 'peptide hormones', and some are 'steroid hormones'. The difference is structural and practical: steroid hormones can pass through cell membranes, which means that they can get inside a cell and function within it; peptide hormones can only affect a cell from the outside, by triggering  the hormone receptors on the outside of the cell. This is how glucagon operates -- by attaching itself to certain receptors on the outside of the cell that are designed to "fit" glucagon. (A peptide hormone is like a key that fits a certain kind of lock on the cell wall.) 

Anyway, back to GLP-1 -- which, it turns out, functions as an impostor. It impersonates glucagon, and takes its place. It can latch onto a liver cell's glucagon receptors, so that real glucagon is elbowed aside and can't do its job. But GLP-1 doesn't do glucagon's job, because it isn't glucagon -- it is only glucagon-like. It does not actually stimulate the liver cell to do the things that glucagon would stimulate it to do. Essentially, GLP-1 nullifies glucagon, by occupying its place without performing its function. It's as if we sent a hundred impostors to Washington DC to impersonate the U.S. Senate, not with the goal of pushing through a particular legislative program, but simply with the goal of making sure the U.S. Senate did nothing at all. The difference is that filling the Senate with inert replacements wouldn't make a noticeable difference, while replacing glucagon with a glucagon-like peptide that doesn't work like glucagon can make a big difference.

GLP-1 does not merely have the effect of nullifying glucagon's impact on liver cells, by the way. It has other effects on other cells. It causes the pancreas to produce more insulin, and it causes the muscle cells to become more sensitive to insulin. All of the effects that GLP-1 has tend in one direction: they all tend to bring down the level of sugar in the bloodstream. However, there is a safety mechanism involved, because the increase in insulin production stimulated by  GLP-1 takes place only if blood sugar is elevated -- which means that GLP-1 does not accidentally produce hypoglycemia. It reduces your blood sugar, but the full effect of the reduction happens only if your blood sugar is currently high.

Now, if you are in the pharmaceutical industry, you look at these facts about GLP-1 and you start to see visions of money piling up to the sky. It sounds as if GLP-1 is the ultimate drug for Type 2 diabetes. It counteracts both of the major issues involved in the disease (insufficient sensitivity to insulin, and insufficient production of insulin); it blocks the liver from releasing excessive glucose into the bloodstream;  it has a safety feature that prevents insulin production from increasing too much for current conditions. And the body produces GLP-1 naturally, so it must be safe! We just have to find a way to give people more of it!

Well, not so fast. Production of GLP-1 by the intestine is a business which has to be delicately managed. Intestinal cells must release as much GLP-1 as the situation calls for, but no more. The intestinal cells have to keep adjusting the amount of GLP-1 they are secreting. The stuff doesn't last long; it breaks down rapidly after it is secreted (release a given amount of it into the bloodstream, and two minutes later half of it is gone). The intestinal cells must keep on secreting more of it, so long as more is needed. That kind of fine-tuned, constantly fluctuating secretion is a very different thing than taking a dose of something at bedtime.

Obviously there are some serious practical obstacles involved in turning GLP-1 into a medication. For starters, it can't be taken orally, because peptides are broken down by digestion. And taking it by injection leaves other problems unsolved. If you simply inject natural GLP-1 intravenously, it breaks down in minutes. Injecting it subcutaneously (into abdominal fat, for example) makes it last a little longer, but the half-life is still only about an hour. What you have to do is produce something which is similar to GLP-1 but less volatile, so that you don't have to keep taking fluctuating amounts of it all day. And, because people don't like to give themselves shots, you are a lot likelier to have a popular product if it only needs to be injected at long intervals.

The pharmaceutical industry has been trying pretty hard to solve these problems, and the result is a family of drugs known as GLP-1 analogs. Examples include exenatide (sold as Byetta), liraglutide (sold as Victoza, and lately promoted by Paula Deen), albiglutide (not yet approved), and taspoglutide (not yet approved, and now in trouble). These drugs are taken by subcutaneous injection, some of them only once a day, and some of them only once a week.

The GLP-1 analogs work rather well, bringing down blood sugar levels and HbA1c test scores more effectively than most diabetes drugs. And their side effects are said to be "well-tolerated". But here we must pause to take a careful look at what lies behind a glib and pleasant-looking phrase. "Well-tolerated" side effects are to the pharmaceutical industry what "manageable" pain is to doctors: both of these adjectives mean "experienced by someone other than me". The side effects of GLP-1 analogs include nausea and vomiting, and I'm not sure I would want any drug-company spokesman deciding for me how well I was able to tolerate nausea and vomiting caused by their product. In the case of one recent clinical trial for a GLP-1 analog, a fair number of the test subjects dropped out of the trial rather than continue demonstrating how well-tolerated the drug was.

The French pharmaceutical company Ipsen thought it had a winning formula for a GLP-1 analog which only had to be injected once a week. The new drug, called taspoglutide, was bought by another drug company (Roche), which was taking it through clinical trials. The trials showed good results, in terms of ameliorating Type 2 diabetes, but disturbingly bad results in terms of patients discontinuing the drug because they couldn't stand the nausea and vomiting involved. Roche was so disappointed by this outcome that they abandoned the drug and returned it to Ipsen. Ipsen is still hoping to get it approved.

Perhaps you're wondering why GLP-1 analogs cause nausea and vomiting, if natural GLP-1 does not do this. Well, keep in mind that natural GLP-1 is normally secreted in small, fine-tuned dosages, during digestion of a meal, and that the substance breaks down quickly in the bloodstream. Is it surprising that the body would tolerate natural GLP-1, but not tolerate a chemical similar to GLP-1 which does not break down quickly, and is injected in a dosage large enough to last all day, or even all week?

This is the fundamental problem involved in any attempt to create diabetes drugs. The body's glycemic regulatory system is the most delicately balanced, interactive, constantly self-adjusting mechanism conceivable. When we attempt to replace a system as sophisticated and active as that, with something as crude and inert as a shot containing a week's supply of a fake hormone, we should not be shocked to discover that the result doesn't feel quite the same as natural good health would.

This is not to say, of course, that GLP-1 analogs should never be used, or that I will never need to use them myself. Maybe they'll be working a little better by the time I need to consider them. It's just one more example of my reasons for preferring, while I still can, to find solutions to the diabetes problem which involve working with my body's existing regulatory system, flawed as it is. It would have to be a lot more flawed than it is now before injections that make me throw up would start to look like a better option.  

Thursday, February 16, 2012

For several decades, doctors have been treating hyperactive children with, of all things, stimulants -- without having any idea why drugs which seemingly ought to increase hyperactivity often have the effect of reducing it. I don't know what made doctors think of trying this approach in the first place (perhaps it came about by accident), but once they found out that it works, they kept on using it, in the hope that some day they would find out why it works.

(By the way: when I say that the treatment "works", all I mean is that it suppresses hyperactivity in the short term. I don't know whether or not it's a great idea in the long term. I've always heard that kids who receive this treatment grow up to become amphetamine addicts, but supposedly there's a good body of research which shows that the long-term risk of addiciction is actually lower with the stimulant treatment than without it.)

Anyway, now they've found out why it works -- or so we are asked to believe, in an article entitled  "Mystery of Psychostimulant Paradox Solved". However, if you ask me, that title raises expectations which the article can hardly be said to fulfill. The new research into this issue (or at least the article summarizing the research) seems to leave the mystery very much intact.

The introduction seems promising enough: "Psychostimulant drugs are effective for the treatment of attention-deficit hyperactivity disorder (ADHD) because when they activate the dopamine D4 receptors in the basal ganglia and thalamus, they depress, rather than enhance, motor activity, new research shows."

Okay, I'm with them so far. Stimulants have the effect of depressing motor activity in hyperactive kids instead of, as we would expect, enhancing it. That's the paradox, all right. That's the mystery we've been wanting to see solved. So what's the solution, then?

It turns out that that the authors think they've already stated the solution. That's it. When the psychostimulants activate dopamine D4 receptors, the result is the opposite of what you'd expect. Mystery solved! The doctors interviewed in the article seem very pleased that we finally have an explanation for this.

To which my rejoinder is: what explanation? I don't think I heard one. Saying that something weird happens because something weird happens is not an explanation; it's a tautology. (A tautology is an assertion, such as "my father is a man", which merely restates information already available without adding to it or clarifying it.)

I think most fans of detective fiction would reject, pretty firmly, the notion that restating the mystery is the same thing as solving it. We don't expect Sherlock Holmes or Hercule Poirot to explain the murder of Lord Thwombley by saying that "somebody must have killed him", and then call it day. That much can be said of any murder victim. The questions we want the detective to answer are how he was killed, why he was killed, and by whom he was killed. Simply stating that he was killed does not make you a great detective. Simply stating that stimulants sometimes have an anti-stimulant effect does not mean you have solved the mystery of why stimulants sometimes have an anti-stimulant effect.

The new research was done on rats, by the way, not on hyperactive children, and it's not terribly clear what the rat research actually shows. Do stimulants always have this depressant effect? Do they have a depressant effect on the thalamus and basal ganglia, but a stimulant effect on other parts of the nervous system? Does the pattern described apply to some rats and not others? Do stimulants only have a depressant effect on hyperactive rats, or on all rats? ADHD patients are known to have a defect in a gene which controls the D4 dopamine receptor -- does this cause them to respond differently to stimulants than other people do?

I don't find the answers to any of these questions in the article. It seems to me that we're left where we started: wondering why stimulants sometimes have an anti-stimulant effect.

Of course, it does often happen that drugs have unexpected effects. Probably every drug has unexpected effects -- including effects which seem quite unrelated to the main effect. (I was once prescribed a medication which was intended to cure ringing in the ears, but also caused abdominal cramps. It turned out that, in my case, it only did the second of those two things.)

I tend to be very conscious of the unforeseen ways in which medications can effect us, and I tend to doubt that we can find out through theoretical reasoning (or even through experiments on rats) exactly what a drug is going to do to us. The only way to find out is to take the drug, and wait to see what happens. The problem is that you might have to wait many years before you get your answer, and by then you might be regretting the experiment. We just don't know that much about how drugs work, or what effects they might have on different people in different circumstances.

Hence my tendency to feel that, when we are dealing with a health problem which might be treated in various ways, prescription medications are not necessarily the solution we should try first.

Wednesday, February 15, 2012

I stopped weight-training a couple of weeks ago, when I had cellulitis infection in my left thumb, and didn't want to put any extra strain on my hand. But my hand is so completely back to normal that I felt very much overdue to get back to the gym and do a little muscle-refurbishment, if not actual muscle-building. Fortunately, I hadn't lost anything during the time off; I felt strong -- at least for me!

After weight-training I like to sit in the hot tub for ten or fifteen minutes. The hot-tub at my gym is outdoors -- and rather a long walk from the locker room, which means that you have to get wet taking a shower beforehand, and then take your wet body outdoors for a walk, on a February night. Admittedly, we're talking about a February night on the California coast, not on the shores of Lake Michigan, but it's still not the easiest thing to do. Anyway, it was worth it; I felt very refreshed by it, and my blood-pressure reading after I got home was better for it.

On January 5, I wrote about the startlingly high carb count in many Starbucks coffee drinks (I found a dozen of them for which the carbohydrate content, in the 16-ounce "grande" size, was in the range of 40 to 78 grams).

Well, Starbucks may be taking things to the next level; they're introducing a new size called the "trenta". Unlike "vente", "trenta" actually means something: it's Italian for "thirty". But the serving size is actually thirty-one ounces, so it should properly be called the "trentuno". No doubt they thought "trenta" would be easier to say, but what prevented them from making it thirty ounces rather than thirty-one, if they were going to call it "thirty" in Italian? For that matter, why use Italian at all, if they think their customers can't pronounce it?

Apparently the trenta is being rolled out gradually; it began to appear in the southern states last month, and is now showing up in Starbucks shops in California. Some places won't see it until May. Perhaps you should begin fasting now to get ready for it. I calculate that the Peppermint White Chocolate Mocha will provide 151 grams of carbohydrate in that size. But wait a minute -- I think that drink is only available around Christmas. You may have to settle for the Salted Caramel Mocha (a mere 127 grams -- so low, you can use the drink to wash down biscotti).

Actually, I'm not sure that Starbucks is offering its higher-calorie drinks in the trenta size. Probably they won't offer any drink in the trenta size if it contains over 100 grams of carbohydrate and they are required to admit that it does. Some states are now requiring Starbucks (and other such businesses) to list the nutritional facts about their offerings, and Starbucks tends to respond to this by eliminating over-generous serving sizes for calorie-dense products.

That's kind of an interesting commentary, right there. Starbucks is happy to sell a product when customers don't know how it will affect them, but refuses to sell that same product if customers are going to be given this information. I'm sure that Starbucks is not alone in responding to such regulations in this way. Perhaps the main value in regulations of that sort is not their impact on the choices consumers make, but rather their impact on the choices consumers are offered.

So far as I know, there isn't any state which has passed a law saying you can't sell a 31-ounce Salted Caramel Mocha that provides 127 grams of carbohydrate per serving. But some states have passed laws saying you can't do that without telling your customers you're doing it, and a lot of businesses don't like that deal, for some reason.

I'm in favor of businesses being able to sell customers what customers want to buy from them, but there needs to be a certain amount of honesty involved in the transaction, on both sides of the sales counter. Maybe Starbucks should follow the lead of the industry that's selling breakfast cereals to children -- at least in that case it's pretty obvious what's up.

Tuesday, February 14, 2012

First of all, happy Valentine's Day -- the most mysterious of holidays!

(I found that charming picture on Passive Aggressive Notes .)

Valentine's Day was originally called Saint Valentine's Day, but who was Saint Valentine? It turns out that there were at least three early martyrs named Valentine, and it's not clear which of them the day was named for (anyway, the Vatican eventually removed the day from the list of such observances).

The association between the holiday and romantic love is of even murkier origin. Chaucer got the ball rolling, by linking the day with courtship in one of his poems, but his reference to the holiday was a bit unclear and he seems to have had in mind May rather than February. The whole thing may be nothing more than a misunderstanding that never got corrected.

But at least the holiday wasn't cooked up by the greeting-card industry, which is what I expected to learn when I looked into it. Holidays always make me cynical, I just can't help it.

Even the linkage of Valentine's Day with gifts of candy and flowers goes back a long way; nothing modern about it. But there is something modern about anxiety that candy is not good for us. People worry about that now in a way that they once didn't. People with diabetes are particularly likely to fret. I guess that is why the dLife folks sent me a link this morning saying that, Yes, I CAN have chocolate!

It's one of those annoying "slide show" features in which you have to keep clicking and waiting for pages of ads to load in order to read the next paragraph. Google gives preference, in its search results, to on-line articles that are created in this form, apparently because (1) it forces people to see more ads than they otherwise would, and (2) Google hate us all, and doesn't want the experience of reading an on-line article to be enjoyable for a single one of us. This sort of thing drives me crazy, but in the present case I am even more annoyed with the content than I am with the form.

"Dark chocolate has a low glycemic index and won't spike blood sugar"? One wonders on which planet those words were written.

Some dark chocolates don't push your blood sugar as high as milk chocolates would, but that doesn't mean they don't elevate your blood sugar, and that they can't easily elevate it to abnormal levels. To claim that dark chocolate has a low glycemic index and won't spike blood sugar is like saying that water has a low suffocation index and won't drown you. Such a claim is meaningless.

There's an amount of water that will drown you and an amount of water that won't; similarly, there's an amount of dark chocolate that will spike your blood sugar and an amount that of dark chocolate that won't. Unfortunately, the amount of dark chocolate that won't is (1) impossible to determine except by experiment, and (2) probably a lot smaller than the amount of dark chocolate which will be eagerly consumed by everyone who reads an article saying that dark chocolate has a low glycemic index and won't spike your blood sugar.

I like chocolate as much as anyone, and when I first started reading that it was good for me, I did some experimentation to find out if the darkest varieties are indeed as free of glycemic consequences as I had been encouraged to believe. I found that they aren't. Even dark chocolate has sugar in it, after all; it affects me pretty much the way anything else with sugar in it affects me. That doesn't mean I can never eat it, but it does mean that I'm going to have to keep its carbohydrate content in mind; eating it along with other carb-dense foods is clearly not a good idea, and eating it without having exercised earlier in the day is probably not a good idea either. Yeah, I can have chocolate, but only so much of it, and only when other circumstances (including the rest of the meal) are not pushing my blood sugar up to begin with.

What drives me nuts about saying that dark chocolate "won't spike blood sugar" is that most people will take it at face value. If it won't spike blood sugar, why would anyone need to be careful with it?

Monday, February 13, 2012

Monday the 13th! I can't imagine why more people aren't scared of this date. Friday the 13th is a day at the beach by comparison, but that's the day people treat as if it were the big threat.

If you have a health condition which requires you to exercise regularly (diabetes, for example, or membership in the human race and that type of thing), you have to find a way to make exercise a habitual, automatic behavior. This turns out to be somewhat easier said than done, however, at least for most people. 

Exercise has become a habitual and automatic behavior for me, fortunately, but it was not always so, and I know how hard it is for people to get themselves into that mode. No doubt it is especially hard for diabetes patients, who typically are asked to start an exercise program just at the point in their lives when they are beginning to feel sure that they are no longer physically capable of doing so.

I suspect that Type 2 diabetes does something extra to people, beyond the health effects that are usually noted, which makes exercise difficult. It is not scientific to say this, and I certainly can't prove it, but I suspect that some defect of energy metabolism in people with Type 2 makes a given workout harder for them than it would be for a non-diabetic person of the same weight and apparent fitness level. Either that, or Type 2 enhances the functioning of the brain's self-pity center. In any case, exercise can be a daunting ordeal for Type 2 patients, and they often find it very hard to drag themselves out to the gym or the bike path, when it would be ever so much nicer to curl up right there on the sofa.

Overcoming one's internal resistance to working out is both essential and, for many people, terribly difficult. Is there any way to reduce the difficulty?

I think that the secret of success is to avoid seeing exercise as an "extra" activity which is distinct from your daily activities --and in fact competes with them for time. It shouldn't be an annoying distraction which you have to force yourself to deal with, so that you can get it out of the way and go back to the real business of living. It should be to be part of the real business of living. For one thing, exercise should be a part of your social life. Instead of treating it as an irksome duty which eats up time that you would rather spend with your friends, why not exercise with your friends?

Immediately you're thinking "Hey, if you knew my friends, you'd know better than to make that suggestion!". Admittedly, your current crop of friends might not be a very active bunch, at least not now. But perhaps some of them have been thinking of getting themselves into better shape; perhaps they could be persuaded to take up jogging or cycling, or going to the gym, or at least walking -- if only they had a buddy to do this with them and help keep them motivated. And there is also the possibility of cultivating new friends who have a little more get-up-and-go.

What brings these thoughts to mind is the way I spent the early afternoon yesterday. Saturday had been my rest day for the week, and I wanted to get in a long trail-run on Sunday. Around noon I drove over to the state park to go trail-running, and just as I was arriving there I spotted a familiar figure -- one of my running buddies from work was running along the side of the road. (He lives next to the park and had started running from his house.) 

I slowed down, rolled down the car window, and got his attention. He said he would wait for me while I was parking my car. We hadn't made any plans to meet up that day, but now that we'd achieved a rendezvous by accident, it seemed as if we might as well run together, especially as he was already headed the direction I had been intending to take. We agreed on a route through the park which would take him eventually back to his house.

The distance for that route is slightly over 9 miles, and it's quite hilly, but having someone to talk to while we were huffing our way over the ridges would be bound to make the run seem shorter for both of us. And it did; the time flew by. There were lots of other people on the trails. Along the way we passed two other people from work: first a cyclist, and then a runner (the latter was out running with his teen-aged son, and I remembered that I had seen him running there last weekend, too). I felt like I was part of a community of exercise, a little sub-culture of its own operating up there on the trails.

The previous weekend, too, I'd gone on a bike ride in Dry Creek Valley with friends from work. There are more opportunities to do this sort of thing than you might think. You just need to look for them, and be open to the possibility of trying them out.

I admit that exercising with others is not always practical, especially if there is a huge disparity between their fitness level and your own. You may have to be a bit careful about whom you choose to work out with. But it sure makes things easier, if you can make it happen. When exercise is an interruption of your social life, it's hard to find time for it; when exercise is a part your social life, it's easy to find time for it.     

Friday, February 10, 2012

No, that's not a typo; my fasting and post-prandial test results today were both 84.

I'd been unhappy with the higher numbers I'd seen yesterday, and I was trying to do something about it, using my top-secret, ultra-sophisticated formula for glycemic management (that is, "more exercise, less starch"). It just worked a little better than I expected.

The low post-prandial test is not entirely inexplicable; after all, it followed a low-carb lunch -- and that lunch followed a hilly, hard run of a little over five miles. It's not surprising that the result was lower than last night's 142, which followed no exercise and a higher-carb dinner. But to be 58 points lower is a pretty big drop; maybe it's an indication of how much difference exercise makes for me.

A new report from the Centers for Disease Control says that doctors are now prescribing exercise to their patients more often than they used to; in 2010, a third of patients who saw a doctor were advised to exercise more, compared to less than a quarter of patients a decade earlier.

At least, an article on WebMD says that the CDC reported this. The CDC itself seems to be unaware of that.

This happens surprisingly often. A website such as Medscape or WebMD publishes an article summarizing a new report from the Centers for Disease Control, and the summary (not the report itself, the summary of it) is quoted and re-quoted endlessly on other health sites and news sites. However, the summary does not link to the original CDC report it is describing, and in fact the CDC report cannot be found anywhere on the web. The CDC's own site does not provide it, or even mention it. Apparently everyone knows about the CDC's new report, except the CDC.

I've seen this happen often enough that I've been working on theories to explain it. Here are some possibilities:

That last theory has the ring of truth, at least for me. In my attempts to find the new report on the CDC site, I was browsing through an alphabetized list of "Staying Healthy" issues, looking for the magic word exercise. Naturally, I looked in the "E" section of the list. It wasn't there.

It turns out that you have to look in the "P" section. You know: "physical activity". Because that's the term that most human beings use for exercise, isn't it? (Just like they refer to movies as "Moving Picture Plays", the term under which librarians like to index cinema-related books and articles.)

Not that looking under "physical activity" got me anywhere, either. But the fact that I was looking for "exercise" under "E" when I should have been looking under "P" sapped my confidence in my ability to find anything on the CDC site. So, for all I know, the new report on doctors and exercise may exist. I just can't find any trace of it.

I find it much less frustrating to look for scientific studies on the Onion site. Their studies may just be satire, but at least I can find them.

Well, anyway, doctors are prescribing exercise more often these days; I know because the CDC is rumored to have issued a report that says so.

Thursday, February 9, 2012

A distracted day. Schedule problems today made it hard for me to fit in exercise -- I finally made it to the gym after dinner. Running at lunchtime would have been better, as it was a gorgeously sunny day, but there wasn't time.

I was unhappy about that after-dinner glucose result of 142. It met my doctor's target of <150, so it's not exactly a failure --but a truly normal, non-diabetic result an hour after a meal would probably be under 125, and I try to hit the tougher target as often as I can. Typically I succeed.

Why was I higher than usual after dinner? Well, I admit I had what I thought was a small amount of corn with the meal. Not as small as it needed to be, perhaps, but I thought it was quite modest. Of course, the dinner and the test happened before I worked out, and it's probably only when I've worked out recently that I can get away with foods such as corn and rice -- even in modest servings. The boost in insulin sensitivity that I get after a good run often enables me to get low post-prandial results even after eating grains, and I keep having to learn that the same thing doesn't happen in all circumstances. If I haven't done a good run in more than 24 hours, grains are definitely a high risk food.

After I got back from the gym, I measured again to make sure nothing weird was happening to elevate my blood sugar; the result was 97. That was reassuring. (The timing was almost two-and-a-half hours after the meal.)

The blood-pressure reading of 97/67 seems improbably low, but I'm going to assume it's valid and not test again to confirm it. That, too, was taken after the workout, and maybe after the ideal amount of delay following the workout. (Things might be different a few hours later, but I'm not going to find out!)

Today is the 11th anniversary of my diabetes diagnosis. Maybe I was thinking I ought to come up with more stellar results today, to mark the occasion, and that's why I'm unhappy even though my results are within the targets my doctor gave me 11 years ago.

I guess a more healthy attitude for me to take would be to congratulate myself on still being able to hit my doctor's targets, without meds, 11 years after diagnosis -- when "everyone knows" it's impossible for anyone to achieve this, without meds, even 10 years after diagnosis.

But the reason I'm still able to hit my doctor's targets after 11 years is that I get worried every time there's any trend in the wrong direction, and I get myself back on track. If you don't worry, you don't get back on track. So I'll continue worrying, but try not to let the worry get too far out of control.

Any time I read about a neurological or mental disorder, I conclude that I suffer from that same disorder. It almost doesn't matter what the disorder is, because there seems to be no failing of the human brain or nervous system which produces symptoms that I never have.

At work today I moved an engineering diagram that had been sitting on my desk, and I saw a small yellow Post-It note stuck to the desktop beneath it. The only thing that was written on the Post-It note was a man's name. The name did not seem familiar to me. It was written in pencil, and seemingly in haste, although the handwriting was recognizably my own. For whatever reason, I had recently felt the need to capture that name on paper for later reference, but now I was unable to remember who this man was, or why I had written his name down.

Was this someone at work that I was supposed to get in touch with? If so, why was I supposed to get in touch with him? Had he asked me a question, and was he now waiting impatiently for me to answer it? Had he made a request which I'd forgotten to do anything about? Or was he perhaps someone whom I'd been told could help me out with a work problem? There must have been some reason why I wrote his name down, but now the reason escaped me entirely. It would have been helpful if I had written down something other than his name, but I hadn't done so -- perhaps because I'd felt confident at the time that I would remember what this was about.

Eventually I remembered: it was the name of a musician who had been mentioned to me by another musician at work, with the suggestion that I should check out the guy's web site, because of all the unusual musical instruments he had collected. But it was a little disturbing to have such a hard time recalling what the note was about.

And now I read this: Four Simple Questions May Identify Mild Cognitive Impairment. A study of the early signs of Alzheimer's disease finds that, for all the elaborate questions doctors ask elderly patients in order to idenitfy those with mental impairment, it turns out that asking just four questions is usually all it takes to seal the deal. And here are the questions:

  1. Does the patient repeat questions/statements in the same day? 
  2. Does the patient have trouble remembering the date, year, and time?  
  3. Does the patient have difficulty managing finances?  
  4. Does the patient have a decreased sense of direction?  

I'm not sure I can give a firm "no" to any of those, although I'm fairly close to it in the case of the second question. Give me enough time to think about it, and I can almost always figure out the year, often the date, and occasionally even the time. For the others, though, I'm in pretty rocky shape.

Alzheimer's it is, then! No wonder I can't remember why I wrote somebody's name on a Post-It note and stuck it to my desk.  

Wednesday, February 8, 2012

Hmmm, fasting test of 95. The very upper limit of what I consider acceptable. Strictly speaking, anything up to 99 is currently defined as "normal", but most truly normal people (that is, most healthy people who don't have diabetes) usually start the day in the low 80s. I prefer to be under 85 if I can manage it, and I'm disappointed when I'm not under 95. I probably had too many carbs last night. Well, I'll see if I can do any better tomorrow morning.

The post-prandial result of 106 was good, though. And blood pressure is good. Two out of three ain't bad. 

If you are overweight, how likely is your doctor to advise you to try dieting and exercising to do something about it -- or even to mention your weight at all? 

It turns out that the answer depends, to a pretty substantial degree, on whether your doctor is built like this...

...or like this:

A new study finds that doctors who are of normal weight are more likely than overweight or obese doctors to diagnose obesity, and also more likely to advise patients to make lifestyle changes for the sake of weight control.

This is not exactly a startling revelation (it very nearly merits inclusion in my News of the Unsurprising series), but it's worth thinking about all the same -- because there are more possible explanations for the phenomenon than we might think of immediately.

The explanation I thought of immediately was doctors' fear of being perceived as hypocrites.

For a fat doctor to urge fat patients to lose weight would surely invite rebellious thoughts, and even retaliatory comments. "If losing weight is so important, and so easy to accomplish, why haven't you done it?"

For a fat doctor to advise fat patients on specific methods of losing weight would surely inspire such questions as "And how well did that approach work for you, doc?".

Throwing stones is a famously risky undertaking for those who live in glass houses; no doubt this explains at least some of the reluctance of overweight doctors to discuss obesity with their patients. But there may be other reasons why overweight doctors don't want to go there.

One reason could be that many overweight doctors who have tried to shed pounds through diet and exercise -- and failed -- see no point in handing out advice which didn't work for them, and presumably won't work for their patients either.

Another reason could be that overweight doctors have persuaded themselves that their own weight problem isn't severe enough to be unhealthy; as a result, when they see similarly overweight patients, they think "Well, they're no fatter than I am, and I'm okay!". The trouble with this game is that the patient is playing it, too. Patients look at their overweight doctor and think "Well, he's as fat as I am, so I must be okay!".

I am no stranger to this issue myself. If I were having any sucess in getting rid of my holiday pounds, you can bet I'd be crowing about it, and urging you to do what I'd done. But my lack of success at that is making me want to avoid discussing body weight altogether. If I later succeed at it, though, watch out! I'll become really insufferable on the subject. 

Tuesday, February 7, 2012

It was a rainy morning, but there was a break in the weather around lunchtime, and I was able to persuade two of my running buddies to chance going outside.

Of course, once we got about two miles from shelter, it started sprinkling. I thought they would really hold it against me if we got soaked. Luck was with me, though -- the sprinkling never amounted to anything, and we got back to work pretty dry. The rain didn't really get started up again until later in the afternoon.

In principle, running in the rain is not that bad, but a lot of us hate it nontheless. A big part of the problem is that running in wet clothes, and particularly wet shoes, is uncomfortable and can cause chafing. I'm glad we didn't have to deal with that today. However, I am more resigned than my running buddies are to the idea that we all have to run in the rain once in a while, even in a drought year.

Get ready for the sugar cops!

Professors Robert H. Lustig, Laura A. Schmidt, and Claire D. Brindis at the University of California at San Francisco have published a commentary in the journal Nature entitled "Public health: the toxic truth about sugar", in which they state that added sweeteners pose dangers to health that justify controlling them like alcohol or tobacco.

Let me say at once that I doubt this proposal will get far. For one thing, the sugar industry is huge.

Let's see -- in a fight between three professors of medicine and a big, rich, powerful industry, who do you think is going to win?

Also: even without the power of the sugar-industry lobby, regulating the American public's consumption of sugar sounds about as realistic as regulating the American public's practice of consensual sex. Still, considering how recklessly the latter idea has been embraced by some of the 2012 presidential candidates (when they weren't busy embracing anything else), I suppose I shouldn't rule out the possibility that someone will end up trying to use the force of law to reverse America's alarming trend toward higher and higher rates of sugar consumption. (For many Americans, sugar added to foods which don't naturally contain it provides half of their daily calorie requirement.) 

Dr. Lustig says we are now seeing "the toxic downside" of excess sugar consumption; he says that "there has to be some sort of societal intervention. We cannot do it on our own because sugar is addictive. Personal intervention is necessary, but not sufficient."

We cannot do it on our own. This is clearly a tragic view of the situation: mankind is helpless in this matter. We are in the grip of the sugar monster and we can do nothing about it. We are sugar zombies, staggering through life with no goal other than to seek out and consume the sucrose and fructose of the living.

We have become so used to living in a sugar-saturated world that we cannot see beyond the sweet white walls of our glycemic prison!

But I'm not sure I buy this view.

Obviously people have become hooked on sugar, and obviously they are consuming far more of it than they realize (because the makers of many processed foods have been sneaking it into products which most people don't imagine are sweetened at all, and have been adding much more of it to sweet products than most people think they do). But isn't it possible that educating the public about such matters would be a better plan that trying to place legal controls on how much sugar people can have?

The Los Angeles health program Choose Health LA has been running ads explaining how much sugar is being added to foods -- particularly soft drinks:

Of course, even educational campaigns are opposed by the sugar and beverage industries, but not nearly as fiercely as laws regulating sugar consumption would be. And laws of that sort would be opposed by many members of the public, too, regardless of whether they are sugar addicts or just liberty-loving citizens who don't want no government telling them they can't eat crap.

Also, there is the class issue to be considered. When the government tries to regulate the private behavior of citizens, it usually turns out that only the behavior of working-class people is actually regulated. When California's state government came up with the idea of promoting better eating habits by placing a special tax on snacks, the inevitable happened: people noticed that the tax applied to Dorritos, but not to caviar, and rebelled. I expect the same thing would happen with any attempt to crack down on sugar consumption. You know as well as I do that the law would end up affecting you if you wanted to buy a bag of these...

...but wouldn't affect you if you wanted to have your servants whip up a batch of these.

I think the whole idea of using laws to try to force people to eat less sugar is exactly the sort of notion that can seem sensible if you are a tenured professor, and thus don't have to live with the rest of us, out here in the real world.

That doesn't mean I think it is undesirable, or even impractical, to try to do anything to change America's sugar-addicted culture. I just think persuasion is, in the long run, likely to be more effective than coercion.   

Monday, February 6, 2012

It was a very musical weekend. I managed to fit in my exercise as well (a bike ride on Saturday, and a run on Sunday), but over the course of the weekend I also went to no less than three Irish jam sessions. One was in Inverness (in Marin County), another was in Berkeley, and the one yesterday in Sonoma. The latter was an alternative to the Superbowl, for those of us who thought playing tunes would be more fun than watching the game. Or, as SMBC put it:

My general rule is that, when I have a choice between observing an activity and participating in an activity, I go for the latter. (I'm no good at poker, but I'd much rather play it than watch strangers play it on television.) When people get together socially, I figure they should be doing something, not watching something. Going on a bike ride with your friends among the vineyards of Dry Creek Valley is a social event. Playing tunes with your friends is a social event. But watching television? That's probably not a social event -- unless it's understood that you get to talk back to the television uninhibitedly, and you do a lot of it.

Of course, at most Superbowl parties I've been to, the game was the least important element in the event, so maybe people are actually following my rule, without admitting it openly. 

It must be admitted that, where musicians gather to play tunes, high-calorie snacks are not much less abundant than they would be at a Superbowl party. However, when you're busy playing a musical instrument, your hands aren't free to shovel nachos into your mouth, so the event ends up being healthier by accident.

Just what we need: another study saying that SMBG (self-monitoring of blood glucose) is not useful for Type 2 diabetes patients who aren't taking insulin. 

Researchers in Amsterdam performed a meta-analysis of existing studies that had gathered data on how well Type 2 patients were doing over a period of at least a year, using hemoglobin A1c test results as a primary indicator of sucess, but also looking at other issues. Their conclusion: the patients who used SMBG did somewhat better at the six-month point (A1c down by 0.26 on average), but after a year their advantage dwindled to a statistically insignificant 0.1 -- in other words, the advantage is small at first, and then fades away, so it's not worth doing. The researchers also concluded that after a year there was no significant advantage in patient satisfaction or health, either.

Medscape reported this research under the infuriating headline "Self-Monitoring Not Helpful for Type 2 Diabetes". The original paper, as published by the Cochrane Library, used the more neutral title "Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin" -- but its conclusions were no less ruthless: unless the patient is taking insulin, SMBG isn't worth doing. Let's not spend money on it.

Needless to say, the health insurance industry -- or, as I prefer to designate it, the health-care prevention industry -- has been delighted by studies of this sort, and has already been using them as an excuse to eliminate reimbursements for testing supplies. These days, most people with Type 2 have to bear the financial burden of testing their blood to stay healthy.

I, however, am not delighted at all by such studies. I'm not disputing their data (yeah, I'm sure the average Type 2 patient doesn't do terribly well with the assignment), but I think we need to be very careful about how we interpret that data, and what we claim it means.

To conclude, from the high failure rate of diabetes patients, that testing doesn't work is like concluding, from the mysterious popularity of horrible-looking facial piercings, that mirrors don't work.

Trust me, mirrors do give you excellent information about what your face looks like. What you do with that information, however, is up to you. If you choose to ignore what your mirror is telling you, the mirror is not to blame.

And so it is with glucose monitoring. The information that glucose meters give you may not be quite as accurate as the information a mirror gives you, but it's pretty good information, and it ought to be more than sufficient to help you stay on track. If most people get off track, particularly after 6 months have gone by, that is not necessarily an indication that glucose meters can't provide what is known in Washington DC as "actionable intelligence". Actionable intelligence is only useful it is acted upon.

I'm realistic enough to admit that the average Type 2 patient is probably going to gather test data and then do nothing about it. But I'm also idealistic enough to insist that patients who really are willing to do something about it should be given the opportunity.

Couldn't doctors at least give patients the chance to prove themselves? If patients fall off the wagon later, you can take their test strips away then. But please don't do it before they've had a chance to show that they're serious about this! 

Friday, February 3, 2012

A great fasting test result today, and a great blood pressure result as well. Splendid; blood pressure has been up a bit lately and I've been hoping to get that under control.

The result after lunch wasn't as low as I often see (especially when I have lunch right after a hard run), but it's within the normal range even so. And lunch included some fruit. If you can have fruit in a meal and still get a normal post-prandial glucose level, you're not doing too badly.

Okay, here's my get-rich-quick idea: diabetes glasses!

They look like ordinary eyeglasses, or rather sunglasses -- with a pronounced green tinge. When you put them on, food which actually looks like this...

...starts to look like this:

When you are wearing the glasses, baked goods look moldy and toxic. But the glasses only make green vegetables look fresher!

And here's what makes it such a great money-making scheme: although the glasses make use of an ordinary green filter which is available at a very low price, the glasses cost $279.99 a pair!

There's only one possible flaw in this otherwise foolproof plan: taking off eyeglasses is pretty easy. If potential customers are aware of that fact, might that make them reluctant to buy?

Well, those of us who are trying to resist the lure of the bakery need some kind gimmick to help us out. We can't use the kind of pitiful mental mental imagery that people use when they're trying to prevent themselves from eating meat.

Although a lot of people are unhappy about our largely-rainless winter here in Sonoma County, it's pretty hard not like these clear sunny days if you do a lot of outdoor exercise. I treated myself (yes, that's what it felt like -- a treat) to an extra long run, climbing up over the biggest hill in the vicinity and enjoying the panaroma of the valleys to the east and west of the ridge road.

I'm planning to do a bike ride tomorrow with some friends from work, in Dry Creek Valley, a very pretty wine-growing area near Healdsburg. If you ever plan to come to this area to tour the wineries, Dry Creek Valley is the place to go if you ask me. You'll have a better time there than in Napa, and spend less money. (I'm not saying you won't spend a lot, just that you'd spend even more in Napa.)

Thursday, February 2, 2012

The antibiotics are working; my sore thumb isn't sore at all now, and the swelling is finally diminishing as well. Apparently I got lucky; my doctor says infections in the hand can be very hard to get under control. For that very reason, punching people in the teeth can be an extremely bad idea. I wasn't planning to do that anyway, and perhaps you weren't either, but it's certainly information worth having. Don't say you never learned anything practical from me!

Well, I guess it's time once again for... occasional survey of medical headlines that won't turn anybody's expectations upside down! Researchers and journalists continue to investigate health issues which don't seem all that mysterious; I guess someone has to do it.

Perhaps I should say a little more about Frito-Lay chips not being all natural...

Some of Frito-Lay's chips (specifically their Sun Chips and Tostitos) are marked with this label:

However... according to a proposed class-action lawsuit filed in a Brooklyn federal court, these chips actually contain ingredients that are not found in nature!

The plaintiff in the suit, Chris Shake, paid a higher price (10 cents per ounce) for the "All Natural" chips, and is angered by the discovery (apparently confirmed by lab tests) that the chips contain ingredients (such as corn and vegetable oil) made from genetically modified plants. Mr. Shake calls the product labeling deceptive. Frito-Lay, on the other hand, says that their labeling "complies with all regulatory requirements."

So who's right? Well, they both are.

When a company that's been accused of wrongdoing emphasizes that it is in compliance with "all regulatory requirements", it usually means that aren't any significant regulatory requirements involved. And so it proves in this case: there are no regulatory restrictions on what can be called "natural", because the regulators have never created a legal definition of the word.

If Frito-Lay wanted to include chunks of styrofoam in a bag of chips, they could call the stuff "all-natural" without breaking any rules. Federal regulators would object to the styrofoam, I assume -- but they couldn't object to it on the grounds that styrofoam isn't natural, because (as far as they are concerned) the world "natural" has no definite meaning.

If we want to define "natural" very strictly, so that it only includes what nature creates without human intervention, then there wouldn't be many "natural" foods available to us. Berries and mushrooms gathered in the forest would be natural, but berries and mushrooms grown on a farm would not. Most of us wouldn't define natural that strictly, however. I think I would define a "natural" food as being one which nature could produce without human assistance -- even if nature didn't.

Defenders of genetically modified foods like to claim that they are not doing anything different from what plant-breeders and animal-breeders have been doing for centuries. After all, a Granny Smith apple differs genetically from whatever the original wild apple was like before human beings started cultivating apples. Therefore, a Granny Smith apple is "genetically modified". Why all the fuss about the more modern techniques of doing the same thing?

The trouble with this argument is that it is transparently untrue. A Granny Smith apple tree doesn't contain genes that were transplanted from a wildly-unrelated life form. No old-school horticulturalist ever tried putting genes from an arctic fish into a strawberry plant to improve its resistance to cold. If such things could be done using the old-fashioned methods, they would have been, and nobody would have bothered inventing a new approach. There's just no getting around it: what genetic engineers do is fundamentally different from what breeders have done in the past.

I would be willing to bend my definition of "natural" so far as to include cultivated plants which look or taste different from the wild originals that the plant-breeders started with. At least the plant-breeders were working within the range of genetic variability that nature provided, so the end result was one which evolution could have produced if things had worked out that way. But I would not be willing to bend the definition so far that it included bio-engineered plants containing genes that could never have found their way into those plants through evolution or any other natural process.

Admittedly, I don't know that it is necessarily wrong or dangerous to create genetically modified foods. Maybe the genetic engineers are right in thinking that what they are doing is safe, and cannot have any surprising and unwelcome consequences for us later on (how they could know this is a little unclear to me, but they seem very confident on this point and it's possible that they're right). However, I think consumers should be allowed to make their own risk assessment, and decide for themselves whether they want to eat genetically modified foods or not. And they can't do that, if the product labeling calls something "all-natural" when it's about as natural as a cell-phone.

I do realize, of course, that class-action lawsuits of this sort are nearly always about enriching attorneys rather than protecting consumers, and the idea that large numbers of people need to be compensated for the price differential between Tostitos and Dorritos is a little ridiculous. On the other hand, lawsuits are the classic American method of correcting problems which regulators ignore. This lawsuit is part of the grand tradition. If we really disapproved of these lawsuits as much as we pretend to, we would insist that legislators and regulators do their damned jobs. But we don't, and they don't. Therefore: lawsuits. 

Whether consumers will actually be harmed by gentically modified foods is not really the issue. The issue is that consumers have a right to decide what they are willing to risk -- and they are denied that right, if the processed-food industry is permitted to conceal what's in their products.

Oh, and another thing: I ought to mention that, no matter how natural a corn chip might be, it's still not the ideal food for diabetes patients. If you're going to have them at a Superbowl party this weekend, please run at least 8 miles beforehand.

Wednesday, February 1, 2012

Well, after I started taking the antibiotics yesterday for the cellulitis infection in my thumb, my thumb was less sore this morning, and it became even less sore over the course of the day -- that symptom is almost entirely gone now. The swelling and other indicators are still there, but if the pain is disappearing this quickly, I am pretty confident that everything else will also be back to normal soon. Three cheers for sulfamethoxazole-trimethoprim (known to all its friends as Bactrim)!

So, you see, the impression I often give in my blog, of being violently opposed to the pharmaceutical industry and all its works, is a misleading one. I have no objection whatsoever to using pharmaceuticals -- when they are the best solution to a particular health problem.

What I'm opposed to is assuming that pharmaceuticals are the best solution, in cases where that is not true. I am unaware of anything that works better than antibiotics, when the problem is an infection. When the problem is diabetes, however, the best solution is not always the one they're selling down at the pharmacy. And even if you really do need the drugs, drugs alone are not enough. You still have to do all the other stuff, no matter how many pills you take. So why not do all the other stuff, and see if you can do it so well that you don't need the pills? If nothing else, it's cheaper...

Today's date is a palindrome: 2-1-12, a fact which was mentioned at work this morning, at the start of a meeting.

If you ever wondered what kind of people I work with... well, that gives you a pretty good idea. By golly, we haven't been this excited since the last square-root date (3-3-09)! And we'll have to wait till 2016 for the next one of those, so l guess we'd best enjoy palindrome day while we can. By all means celebrate it, but celebrate it in moderation, like a good diabetes patient.

By the way, there is one palindrome word which not only reads the same forwards as backwards, it also reads the same upside down. The word is NOON. But don't sprain your neck trying to confirm that I'm right about that.

The American Heart Association has identified seven measures of cardiovascular health which we should all strive to achieve. They are: 

  1. Not smoking
  2. Body Mass Index below 25
  3. Regular exercise
  4. At least 3 servings of fruits and vegetables daily
  5. Total cholesterol below 200 mg/dL
  6. Blood pressure below 120/80 mm Hg
  7. Fasting plasma glucose levels below 100 mg/dL

Some of these criteria -- well, most of them, actually -- are pretty hard to meet. Is it worth it? If you do manage to meet them, how much difference does it make?

Well, a new study confirms that, the more of these criteria you meet, the lower your risk of death from cardiovascular disease or from other causes. Those who meet at least five of the seven criteria have a 78% lower risk for all-cause mortality, and an 88% lower risk of mortality from cardiovascular disease.

That's the good news. The bad news is that not many people are able to hit very many of these targets.

In the study (which tracked the health of 7622 adults), only 13.8% of study population met five of the seven metrics. (Only 1% of the population met all seven of them.)

I don't meet all of them myself. My Body Mass Index is a little over 26, not under 25.

And my blood pressure -- which, for a while, was usually under the 120/80 limit -- has been over that limit pretty often of late. I usually do okay on the diastolic value (the second number), but I'm often over 120 on the systolic. It used to be said that the diastolic number is the one that counts, but some recent studies have been saying that systolic pressure is just as significant a predictor of cardiovascular problems as diastolic pressure, so you can't give yourself a passing grade if only the diastolic value is good.

I'm tempted to blame the holiday season for both my BMI and BP scores, but there's a limit to how far I can press that excuse. (Especially a month after the holiday season is over!)

Of all the criteria, "not smoking" is the only one that's ridiculously easy (at least, to someone who is not already enslaved to nicotine, which is said to be the most difficult of all addictions to break). Why anyone is even tempted to smoke is hard for me to fathom, but a lot of things which I find unappealing are popular, so I have to assume there is something in it for people. Whatever reward it's giving them, though, it seems to come at a high price in cardiovascular mortality (some doctors think all the emphasis on lung cancer as a consequence of smoking is misguided; smokers usually die of something else first).

Eating fruits and vegetables is pretty easy too (although, if you're diabetic, it's going to have to be more vegetables than fruits).

But the other five items on the list are pretty hard to achieve, so I'm not surprised that only 1% of people achieve all of them. Different people probably find different targets challenging (exercising regularly has become second nature to me, but for a lot of people that would probably be the most challenging of the seven). One way or another, there are daunting challenges on that list for almost everybody.

However, the mortality statistics do seem to tell us pretty firmly that hitting those targets is worth doing if we possibly can. I guess we'd better give it a really good try.

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