Tuesday, January 31, 2012

Despite the good workout and good glucose numbers, this was a weird day in terms of health. 

Last night I was wondering what, exactly, I had done to strain my left thumb, which was becoming increasingly sore. Had I used my left hand to carry something heavy in an awkward way? I couldn't remember having done anything which could have injured my thumb. But surely I had done something, because it felt so bad.

This morning, my thumb was hurting worse -- to the point that using it for routine actions, such as those involved in getting dressed for work, was very difficult. It was only after I arrived at work that it began to dawn on me that maybe this wasn't a strain injury. My thumb was slightly swollen and slightly red, and was warm to the touch, and it was becoming stiff. I was reminded -- very vividly, and very uncomfortably -- of a type of local infection I'd had some years before.

"Cellulitis" is the term for a bacterial infection of this type. Unlike an abscess, it is not concentrated at one focal point -- it is distributed throughout a range of connective tissue cells under the skin. It is caused by bacteria (typically Streptococcus or Staphylococcus) entering through some break in the skin (even a very small break, as in the case of an insect bite). Unfortunately, cellulitis has a tendency to spread and cause widespread tissue damage, if it is not treated with antibiotics. And, of course, like everything else people would rather not experience, cellulitis is more common in people with diabetes.

As it happens, I had recently had a painful (but not very large) scrape on the knuckle of my left thumb. It was healing nicely, and the pain and swelling were on the opposite side of the thumb from the scrape. But perhaps some bacteria had entered my thumb through that scrape, and had established a beach-head on the other side of it. The more I thought about it, and the more I confirmed by observation and experiment that my thumb was indeed swollen and resistant to movement, the more concerned I became that I had a local infection which might, with alarming speed, spread and become destructive. Also, my thumb was starting to go beyond being sensitive to pressure or motion -- it was starting to be sore even when it was at rest and not being touched by anything.

And yet -- at the same time, I had to admit that the swelling was not especially dramatic; unless you compared my left thumb to my right, you might not even notice it. The same with the redness. My glucose tests today did not show the kind of elevated results that can be triggered by an infection (the low result after lunch is not strange: it was a low-carb lunch eaten right after a hard run, so I would expect it to be low). If I went in to the doctor's office with symptoms as subtle as this, would they even be able to see what I was talking about? Would they laugh me out of the place, and tell me to come back when I had some real symptoms? I hesitated to call the doctor's office for an appointment.

I tried applying ice to my thumb a couple of times, to see if that made it feel better or made the swelling go down. No luck there; ice didn't make my thumb look or feel any better.

Maybe this kind of thing is harder for guys. We don't want to ask for directions, we don't want to ask the man at the harware store which aisle the sprinklers are on, and we definitely don't want to make a doctor's appointment to inquire into a minor symptom which may very well turn out to be nothing. (Women who chortle at men for their reluctance to do these things may be unaware of how badly men who ask for help are usually treated.)

Anyway, I finally broke down, called my doctor's office, dealt with voice-mail systems and office workers (who did not share information with one another and therefore had to keep asking me questions I had already answered), and ultilmately secured an appointment for 3:10 PM today.

In the meantime, I did my lunchtime run, hoping that the increased circulation which comes with regular exercise would help combat the infection (and would not, instead, distribute pathogens throughout my body). The run seemed to lessen the pain in my thumb (probably due to the endorphin rush that comes with hard exercise).

My own doctor wasn't in the office today, so I saw someone else. To my relief, she didn't dismiss my complaint as ridiculously minor. After a bit of poking and prodding (does this hurt? how about this?) she agreed that it did look like a case of cellultis, caught at an early stage, and that it should be treated. She mentioned the case of another patient she'd seen recently -- his only wound was a small scratch on his hand, but he'd ended up with an infection that spread all the way to his shoulder. Best to treat a thing like this as soon as possible, she said. She wrote me a prescription for an antibiotic, and I've started taking it.

I hope that my thumb will be feeling better by morning. At any rate, the doctor predicted that the infection would subside quickly. May she be proved right!

It's amazing how quickly you can go from feeling healthy and strong to feelingly appallingly vulnerable. A little scrape on your thumb, and the next thing you know you have an infection that could fly out of control overnight and require something unpleasant (surgery, burial, that sort of thing). Most of the time I feel bulletproof, but the instant something goes wrong I feel like the frailest fern in the whole forest.

Monday, January 30, 2012

Now here's an interesting phrase: "hypoglycemia exercise nostalgic depression". Someone out there entered that as a search string over the weekend, and Google referred them to me. Clearly this is a person who has a lot of issues to deal with.

I can only guess at the state of mind of a person who would type "hypoglycemia exercise nostalgic depression", hit Enter, to wait to see what the internet might have to say about this tangle of subjects. Fortunately, guessing on the basis of very insufficient information is something I'm pretty comfortable doing. So here's my guess: this is a diabetes patient who is depressed because he or she is nostalgic for the day when they could exercise without experiencing hypoglycemia. Or something like that.

Nostalgia is an interesting word -- to me, anyway, and I'm going to see if I can make it interesting to you. These days, the meaning of the word has been watered down so thoroughly that, to most people, it means a half-ironic enjoyment of the fashion and pop culture from some earlier period. But the word "nostalgia" was introduced to the world as a medical diagnosis; it was thought of as a disease rather than a party theme.

The physician who concocted the term (in 1688) was Johannes Hofer, and he used it to describe a condition typically affecting soldiers. Up to then, the condition was usually called mal du Suisse (Swiss illness), because it was often seen in Swiss soldiers-for-hire who were fighting in lowland areas of Europe, far from their mountainous homeland. The condition was an intense homesickness, which went beyond low morale and often manifested itself as a physical illness. A good medical term needs to have a basis in Latin or Greek (or both, as in the case of diabetes mellitus), so Hofer assembled the word nostalgia from two Greek words meaning "homecoming" and "ache".

Nostalgia lasted quite a long time as a medical diagnosis, but physicians eventually began to see it as just a stage, or symptom, of the larger problem of depression. Once nostalgia ceased being a diagnostic term (somewhere in the mid-20th century), the word became available for metaphoric use, and the meaning of the word drifted (and expanded). It has come to mean any sort of sentimental longing for past conditions which are no longer available to us.

This sort of longing can even attach itself to undesirable conditions from the past -- thus the term nostalgie de la boue (nostalgia for the mud). People can become just as nostalgic for a time of poverty and struggle as they can for a time of comfort and security. This accounts for the staying power of Henri Murger's "Scenes from the Bohemian Life", which inspired Puccini's opera "La Boheme" and later inspired the Broadway musical "Rent". (Is being poor really all that fun? Perhaps not, but being young and poor can seem that way, once you are no longer either of those things.) The past can haunt us simply because it is the past: we know that we can't restore it, and that alone is enough to make us yearn for it, even if we clearly remember everything that was wrong with it.

Of course, it is not really the conditions of the past that we wish we could have back -- it is our youth, along with the innocence of youth. We would like to be that young again, and we would also like not to know now what we did not know then. The "nostalgic" feeling evoked by seeing old video footage of the Beatles on the Ed Sullivan show has very little to do with changes in the pop music industry since 1964, and quite a lot to do with changes in us since 1964. During the 48 years that have elapsed since that footage was taken, we have had to confront problems which, 48 years ago, we didn't know were part of the deal. Wouldn't it be nice if we still didn't know?

Diabetes is, of course, one of those problems which, 48 years ago, most of us didn't know was part of the deal, and I think a lot of people do suffer from a pretty intense nostalgia for the pre-diagnosis phase of their lives. If only they could set the clock back, and return to that simpler and more innocent time -- when the day did not begin with a blood test, and every meal did not have to be evaluated in terms of the potential threat it might represent!

Most of the possible emotional reactions to having diabetes are pretty unhelpful, and need to be suppressed. I take a particularly dim view of that famous "anger" over the unfairness of the diagnosis (which is an awfully mean-spirited attitude to take, as it boils down to: "health problems usually go to those who deserve them, but in my case a mistake has been made"). Nostalgia for the days before diagnosis is at least not insulting to other patients, so to that extent it is a healthier reaction than anger, but it's still a pretty useless reaction to have. After all, what exactly are you going to do with all this heartbreaking nostalgia for a past that cannot be recaptured? You're not going to write "La Boheme" (Puccini beat you to it by 116 years), so it's pretty unlikely that you are going to find a useful outlet for your impossible yearning to be young and carefree and falling in love in Paris on Christmas Eve. Might as well put aside the impossible yearning to go back in time, and instead deal with the things that are likely to arise in your actual life from here on.

The impracticality of nostalgia, at least in the case of nostalgia for a time before diabetes, extends even beyond the impossibility of setting the clock back and living your earlier life over. What exactly are people yearning to recapture? A time when they were healthier? Or merely a time when health was something they didn't think about?

Some years back, you would eat lunch without worrying about the impact of the big cheeseburger and the big mound of french fries and the big strawberry milkshake. But that doesn't really mean you could do that, it just means you did do that. Do not confuse a time when consequences weren't immediately visible to you (because you weren't testing your blood) with a time when consequences did not yet exist. Very often, the thing that actually changes in our lives after diagnosis is not what's happening to us -- what changes is that we are now aware of what is happening to us, whether we want to be or not.

I am fairly well protected from nostalgia for my pre-2001 days, because I am conscious of having been less healthy then than I am now. Being obliged to adopt a regular exercise routine (one of the most important consequences of diagnosis) has made me feel better rather than worse. I wasn't really having such a great time then, so it wouldn't be easy for me to look back and cast a wonderful romantic aura over the days preceding my diagnosis.

However, people whose health has become worse since they were diagnosed -- or who had formed a strong emotional bond with cinnamon rolls, and have never recovered from having to give them up -- may find that nostalgia of the most painful kind has seized control of their hearts. The lost youth that they cannot get back continues to haunt them; they cannot stop longing for that which they know is now forever out of reach. What can they do with these hopeless romantic yearnings?

Well, that is what "La Boheme" is for. 

Thursday, January 26, 2012


Some more of the search strings that caused Google to refer people to my site...

"do all diabetic people are medicated"

Not all diabetic people are medicated, though I can understand why the public would get that impression. Most of the information that comes at us about diabetes is sponsored, one way or another, by drug companies.

I am assuming that, by "diabetic people", we mean "all people who were ever diagnosed with diabetes, even if their blood sugar is normal these days". Using this definition, some diabetic people are not medicated, because they don't need to be medicated, because in a stricter sense they are not diabetic: they manage to keep their blood sugar level within the normal range, without drugs. Helping people do that is what this web site is all about.

It is often claimed that controlling diabetes without medication is possible only during a comparatively short phase following diagnosis. The disease then "progresses", and drugs become necessary. Maybe so, but I'm still in this short phase, and it's been almost 11 years since I was diagnosed.

I think that, for a lot of people, the expectation that the disease will progress and drugs will become necessary is a self-fulfilling prophecy. People who expect to fail are always right -- because those are always the ones who give up. People who assume that success is a real possibility are less likely to fail, because they are less likely to give up.

"a1c vs weight"

There is no direct relationship between hemoglobin A1c (that is, hemoglobin that has sugar bonded to it) and body weight. There isn't even, in most people, much of an indirect relationship.

But elevated hemoglobin A1c is an effect of diabetes, and obesity increases your risk of developing Type 2 diabetes. If gaining weight pushes you into diabetes, your A1c result will go up along with your weight. Also, weight loss can alleviate Type 2 diabetes, so in some cases hemoglobin A1c will decline as body weight declines.

However, these are very broad generalizations. Most people will not be able to track any close relationship between changes in their weight and changes in their A1c results.

"help i pee too much but i don't want to get medicated"

Clearly a serious problem, but perhaps not clearly enough defined. I don't know why this person is peeing too much, or what medication this person fears having to take for it.

But, for the sake of argument, let us assume that the cause is uncontrolled diabetes and the medications required would be oral diabetes drugs.

I can understand why you don't want to take oral diabetes drugs. I don't want to take them either, so I know how you feel (even though I pee just the right amount). Well, if you don't want to take the meds, then you need to work your blood sugar down into the normal range, so that you don't need to take the meds. But if, as things stand now, you're afraid to get far from the bathroom, you may have a lot of work to do in the area of blood sugar reduction. Possibly you will have to take the medications for a while, like it or not, even if your ultimate goal is to control your blood sugar without meds and you're very serious about achieving that goal.

The thing is, very high blood sugar (high enough to cause abnormally frequent urination) is harmful, so you can't let it continue for very long. Get it under control as soon as you can, no matter what it takes to do that. Once it's under control, you will be in a better position to make choices about how you are going to keep it under control.

"what are causes for chronic diarrhea in a medicated diabetic"

Many diabetes medications cause diarrhea and other problems in the digestive tract, in at least some of the patients who take them. Drugs which can have this effect include:

The first family of drugs on that list works by interfering with the digestive process, so it's hardly surprising that diarrhea might result. The other three families of drugs don't work that way, so it's a bit creepy that they would have diarrhea as a side effect; it suggests that they might have far-reaching effects on the body that no are not sufficiently known.

However, some people who have been diabetic for many years experience a form of "diabetic diarrhea" that seems to be caused by the disease itself, not by the medications for it. Specifically, the cause is thought to be damage to the nerves that control the digestive tract, as a result of long-term exposure to high blood sugar levels.

Yet another reason to keep blood sugar under control!  

I may not get to do a blog post tomorrow -- I'm heading out of town tomorrow night for a birthday party. It's my father's 85th. I hope I inherited his good genes, because I already know I inherited his bad ones, and I need to have something to balance them out if I'm going to make 85 myself!

Wednesday, January 25, 2012

I did two post-prandial tests rather than my usual one today -- and the only reason I took the second one, in the evening, is that I'd temporarily forgotten that I had already done one after lunch. The difference between the two results is interesting.

It seemed to me, before I'd pondered the matter in light of the test results, that the result should have been higher after lunch, not after dinner, because lunch was high-carb and dinner was low-carb. Was the unexpectedly low result after lunch simply the result of my eating lunch immediately after running?

But then I thought about it some more. Lunch was "high-carb" in the sense that it included a scoop of steamed rice. But it was a very modest scoop of rice (I scooped it myself); it was not the usual foothill of the stuff you usually end up with when someone else is filling your plate for you. And was dinner really all that low-carb? I had a prepared salad which included grilled pears. Not a huge amount grilled pears, I hasten to add, but this was definitely a salad with fruit in it. And the dressing tasted rather sweet, so there was probably sugar added to that as well. So perhaps it's not so surprising that the result after dinner was higher. (Not that 127 is terribly high; I was just wondering about the disparity between the two results.)

We can't really expect to get to the bottom of most glucose-meter surprises, but it's always worth thinking about them, to make sure we have as good a handle on the situation as we ought to.

You have probably heard that keeping the brain active (most famously by means of crossword puzzles, though other brain-activating passtimes seem to work too) prevents Alzheimer's disease, or at least reduces the risk of it. Perhaps you are skeptical that this could actually work, however. 

After all, Alzheimer's disease is thought to be caused by plaques (deposited layers) on the brain, of a substance called beta amyloid (it's a "peptide", meaning it's a kind of junior protein). If the problem is caused by chemical deposits accumulating on the brain, how can the problem possibly be prevented by taking on mental challenges? Won't the deposits form (or fail to form) regardless of whether or not you ever spend a minute trying to think of an 8-letter word that ends in "e" and means a person acting for another?

Most of us tend to think that material substances are one thing and activities (especially mental activities, but probably physical activities too) are quite another. The two things seem fundamentally different and unrelated. It's hard for us to believe they can be connected. It's hard for us to understand how exercise could make changes in the physical substance of the body, or how solving puzzles could make changes in the physical substance of the brain. And yet, researchers keep finding evidence that behavior (including mental behavior) can induce changes in the body which are directly observable and measurable. Some new evidence of this has now emerged in the case of mental activity and Alzheimer's.

First, some background. A diagnosis of Alzheimer's disease that is based only on analysis of symptoms is always considered a tentative diagnosis. If you want to be able to say for sure if someone who seems to have Alzheimer's actually does, you need to examine the patient's brain and check for those amyloid plaques. The trouble is, checking the brain for amyloid plaques is usually possible only during an autopsy, so the definitive diagnosis of Alzheimer's disease is also a posthumous diagnosis. This doesn't exactly make it easy to study the disease in living people.

In recent years, however, it has become possible to detect amyloid plaques using a non-surgical method. Researchers at the University of Pittsburgh developed a compound which binds with beta amyloid and can be made visible on a PET scan. Give the patient an injection of this compound, and if the patient has amyloid placques building up on the brain, a PET scan will show them as bright patches of red.

This makes it possible to conduct research on Alzheimer's in living subjects, by using PET scans of the brain to track the development of amyloid plaques over time. It is also possible to compare individuals with and without the disease, to see what differences exist between them. A new study which made that kind of comparison has found evidence that mental activity influences (or rather prevents) the buildup of such plaques. People whose lives have included a lot of "cognitvely stimulating" activity (which includes not only solving puzzles, but also reading and writing and maintaining a diabetes blog) are the people least likely to experience a buildup of amyloid plaques on the brain -- and are therefore the people least likely to suffer from Alzheimer's disease.

Of course, this finding only raises questions about how mental activity prevents plaques from building up on the brain. I want to know the answer to that as much as anyone does -- but until we understand this better, it's certainly worth knowing that mental activity apparently has this useful effect.

So: if you want to avoid Alzheimer's (which, I have no doubt, is more common in diabetes patients -- because everything that people don't want is more common in diabetes patients), get out there and do something clever tomorrow. And the next day. Repeat as necessary.

Oh -- and the 8-letter word that ends in "e" and means a person acting for another is "delegate".

Someone from my birthplace (the city of Concord, California) has been arrested for murdering her boyfriend -- formerly thought to have died of natural causes. Apparently the police have found reason to think that she actually suffocated the guy. She looks like too nice a girl to have done anything like that, but you never can tell, can you? 

Sweet as she may look, I think her name (Dava Alizabeth-Ann Steen) is something of a tipoff. I can accept "Dava", but "Alizabeth"? That has to mean trouble.   

Tuesday, January 24, 2012

After a rainy weekend, the weather was fine for a run today, so I did a pretty long one, at least for a weekday lunchtime run. That was probably part of the reason for the low post-prandial result after dinner -- but it was also a low-carb dinner, so it wouldn't have been a very high result anyway.

A study has found that diabetes patients who receive monthly lifestyle counseling achieve their goals for hemoglobin A1c, blood pressure, and LDL cholesterol much faster than patients who are advised by a physician at intervals of more than 6 months:


Time to goal
(counseling at 1-month intervals):

Time to goal 
(counseling at >6-month intervals):


3.5 months

22.7 months

<130/85 mmHg

<1 month

5.6 months

<100 mg/dl

3.5 months

24.7 months

As for the rate of failure to achieve these goals at all, it increases steadily as the time between counseling sessions increases.

The goal for hemoglobin A1c (<7%) is a modest one, at least for patients with Type 2 diabetes, who (for the most part) don't have to face the same insulin safety issues that Type 1 patients need to worry about. If patients whose doctor visits are more than 6 months apart take more than six times as long to get their A1c below 7% as patients who receive monthly counseling, then it seems clear that most patients need monthly counseling, not once or twice a year doctor visits.

But, to me, the real lesson here is this: nearly all of these patients are presumably being prescribed diabetes drugs, but the ones who get frequent lifestyle counseling are doing six times as well as those who don't. If drugs were sufficient for successful diabetes management, all of the patients would find it equally easy to hit their goals. The fact that monthly lifestyle counseling enables people to hit their goals six times sooner suggests to me that lifestyle is more important to success (and drugs less important) than people have so far been willing to admit.

Oh dear: more embarrassment for America, when our embarrassment cup already runneth over! This is Oklahoma State Senator Ralph Shortey. He just introduced Senate Bill 1418, which outlaws the manufacture or sale of food products containing aborted human fetuses.

If it's depressing to be reminded so often that legislators are unwilling to do anything about actual problems, we at least have the comfort of knowing that they are always willing to do something about problems that they simply made up.

Perhaps we can hijack Senator Shortey's overactive imagination, and use it for our own purposes. If there's some food you have a lot of trouble resisting, why not tell yourself that your culinary nemesis is illegal in Oklahoma?

Of course, for this approach to work, you have to live outside Oklahoma, in a state where no such legislation exists. A state such as my own state of California -- where the legislators don't care enough to protect us from such threats, and few of the available snack foods are cannibalism-free.

I wish I lived a lot farther north -- at least, I wish that tonight.

Yesterday the sun experienced a massive flare, with a coronal mass ejection.

Here's a video of the event.

The wave of charged particles from that solar flare is hitting the earth's upper atmosphere tonight, and creating bright auroras in northern regions. But I'm not seeing anything here, and my latitude is too low (38 degrees) to have any real hope of that. Apparently the Scandinavian countries are getting a pretty good show tonight.

Monday, January 23, 2012

97 is not an especially stellar fasting result; maybe I had too many carbs yesterday. But if I'm going to blame anything for the higher-than-usual morning number, I think I'll blame the insomnia I suffered from last night. Pretty maddening. I'm sure I drifted off a few times, but it sure did seem as if I was awake most of the night. There was some thunderstorm activity going on -- which is uncommon here, and maybe that was enough to put my nervous system into an overactive state.

Lack of exercise over the weekend was definitely not the problem. I ran 8 miles on Saturday, and 5 on Sunday.

Bad news about Dapagliflozin, the new diabetes drug...

Last week the FDA declined to approve it. They asked Bristol-Myers Squibb and AstraZeneca (the two pharmaceutical companies that are jointly developing the drug) to provide more data about its risk/benefit profile. 

Dapagliflozin addresses the problem of diabetes in a whole new way: by interfering with the normal functioning of the kidney. We usually think of the kidney as a filter for the blood, but its operations are a good deal less simple and passive than that description makes it sound.  The kidney does some very sophisticated chemical sorting. When blood flows through the kidneys, some ingredients of the blood are allowed to pass out of the blood and into the urine, while other ingredients -- the keepers, so to speak -- are returned to the blood supply. 

In carrying out this chemical sorting process, the kidney uses various functional proteins to latch onto particular blood components and drag them into one bucket or the other. The protein which latches onto glucose and drags it into the "keeper" bucket is SGLT2 (a sodium-glucose transporter).

Dapagliflozin works by inhibiting SGLT2, so that glucose passes into the urine instead of being hauled back into the bloodstream. (Some urinary excretion of glucose happens anyway, especially when the concentration of glucose in the blood is extremely high; Dapaglifllozin forces more of this to happen, and at comparatively low glucose levels.) The bottom line: Dapagliflozin helps you transfer glucose from the plumbing of your cardiovascular system to the plumbing of your home.

From my own (possibly warped) perspective, the idea of interfering with normal kidney function -- on the assumption that the interference will produce one desirable effect, and zero undesirable ones -- is clearly a high-risk endeavor. What if it turns out that the kidney, or some other organ, also uses SGLT2 for some other purpose? What if suppressing the effect of SGLT2 has additional consequences which we have not foreseen? What if taking Dapagliflozin reduces your blood sugar only at the cost of causing other health problems?

Which brings us to the question of why the FDA declined to approve the drug. It seems that some experts within the FDA are concerned about what appears to be a five-fold increase in the risk of breast cancer and bladder cancer in those who take Dapagliflozin.

The drug makers say that the elevated cancer risk isn't for real. It was just their bad luck that some of the people who took Dapagliflozin in the clinical trials had cancers developing in them already, which were not discovered until after they took the drug. (How they know this is a little unclear; could it be that they are saying this is true simply because they wish it to be true?)

Some members of the FDA committee were also dissatisfied with the information the drug makers had supplied about the drug and its mechanism of action (one panel member called this "shocking"; I am not in a position to say how easily that panel member is shocked).

However, the drug does still have supporters within the FDA, and further clinical trials may yet save it. Certainly they need to deal with that cancer issue; a little thing like that can be all it takes to make people nervous about an otherwise enticing product. If those fears can be put to rest, perhaps Dapaglifllozin will rise again. I'm not especially interested in taking it myself, at least while I still have workable alternatives to drugs. But if I do need pharmaceutical help later, it would be good to have a variety of options. I'd like those options to be non-carcinogenic, if that's not asking too much.

I have a suggestion for the makers of Dapagliflozin: please give your drug a name that is easier to say and easier to type. It's even worse than that other new drug I've been hearing about, called Mycoxafloppin (but I heard about it from an unreliable source and it might be just a joke).

Friday, January 20, 2012

A busy Friday; I decided to take my rest day now instead of on the weekend. Well, I'll make sure I get in a good workout tomorrow.

No time for a real blog this evening. I attended a house-concert, preceded by a teaching session, followed by a jam session, all given by the fiddler Tony DeMarco here in Sonoma County tonight. 

Tony is an Italian-American from Brooklyn who doesn't quite fit most people's preconceived idea of what an Irish musician would look like (or talk like), but he's greatly admired among Irish musicians, not only in New York but in Ireland as well. He is known as a specialist in the Sligo style (that is, the regional style of fiddling that comes from County Sligo, on the northwest coast of Ireland -- right next to County Mayo, where my mother's family came from).

It was a fine evening, but now I need to sleep.

Thursday, January 19, 2012

The rain finally arrived today, and rather than go running in it I headed for the gym. It gave me a chance to meditate a little on a subject that has been much discussed lately: members of my health club are getting a little concerned about the lack of crowding there.

Perhaps that seems paradoxical. People who not only belong to health clubs, but actually use them, tend to complain about how overcrowded the gym always gets at this time of year. The New Year's resolution season, which begins on January 2nd and ends on (if not before) Valentine's Day, is the time of year when you are most likely to find that somebody else has already snagged the gym equipment you were planning to use. After the arrival of spring, and the departure of the last remaining resolutions, the gym settles down to a normal level of traffic. 

But this year, things are different, at least at my health club. There seems to be none of the usual winter crowding. It might seem as if we should just enjoy the convenience and comparative quiet, but it feels strange, and people are worrying about what it means.

Probably what it means is that a lot of people are broke. My health club is more expensive than the one I used to go to; its chief advantage (aside from being very close to where I live, and right across the street from where I work) is that it's cleaner and better-maintained. But maybe a lot of people are finding that they can no longer afford to belong to a gym that's cleaner and better-maintained. Actually, a lot of people are probably finding that they can no longer afford to belong to a gym at all.

What worries the members of my health club is that, if membership is going into decline, the health club may go broke and shut down, or may decide to jack up its rates (which, of course, would probably not be a good long-term solution to the problem of customers departing because they can no longer afford the current rates).

It may be that money is not really the issue here -- or not the main issue. Perhaps, for some other reason, people are giving up on the idea of exercise for health. Bombardment with pharmaceutical advertising (whether it reaches people by way of Paula Deen or through more traditional channels) could be playing a role in this. Perhaps the public has simply come to accept, without question, the notion that there are such things as wonder drugs, and that one can always fall back on them. If that is the case, why take charge of your own health, especially when it's a lot of trouble to do so?

But I suspect money really is the issue, to a large extent. Gyms aren't the only places that are less crowded than they used to be. A lot of doctor's offices have been getting a bit quieter, too. If people were abandoning the gym because they had decided to rely on prescription drugs to keep them healthy, you'd think they would be going to the doctor more, not less. But that doesn't seem to be what is happening. People are spending less on health care these days -- not because they are healthier, but because they have less money to spend. Checkups are more infrequent. Treatments are postponed, or omitted entirely. Your doctor prescribes four meds for you, and naively assumes that you are going to take all of them, but in fact you go to the pharmacy and buy the two cheapest ones. (I'm describing life in the United States, of course -- readers in the civilized world must take my word for it that this is the way we Americans live.)

I like to claim that exercise is not only the most effective of all medications, but also the cheapest. You can always step outside your front door and go for a run, for free. However, I have to admit that this oversimplifies certain practical details. I didn't go outside and run today, did I? And all that discouraged me was a little bit of rain. Most people face more serious obstacles to outdoor exercise than that, at this time of year. Also, some people live in places where there is no safe location to run outdoors, regardless of the weather conditions. And exercising inside your own home might not be all that practical either, especially if the neighbors in the downstairs apartment become impatient with your evening jumping-jacks. A lot of people are just not going to exercise at all, if they don't have a convenient and comfortable and well-equipped place to do it. So, it's a bit of a problem if people can't afford to go the gym.

Of course, not being able to afford to exercise is an even bigger problem if you can't afford medical care, either. So I hope people manage to find a way, even in these hard times, to get their blood pumping a bit. We need it, and we need it now more than ever.

For people whose problem with gym attendance relates to motivation rather than financial difficulty... there's an app for that!

A new iPhone application called GymPact has been created, which tracks your gym attendance, and takes a little bit of money away from you for every promised gym visit that you miss. GymPact keeps some of the money, and gives the rest to those who actually kept their gym appointments.

GymPact was inspired by a psychological theory to the effect that unwillingness to lose money is a stronger motivator than the desire to be rewarded with money. Well, I guess GymPact addresses both kinds of motivation (the people who don't go to the gym lose money, and the people who do go to to the gym gain money).

GymPact's business model does seem to rely pretty heavily on the willingness of a large number of people to put up money on the assumption that they are going to go to the gym, when in fact they're not likely to do any such thing. Well, gyms have been using that business model for a while now, and it seems to work for at least some of them!   

Wednesday, January 18, 2012

Many years ago, I used to work with an engineer who came from a place which we later learned to call "the former Yugoslavia". His manner of speaking English tended towards sudden, brief outbursts which were rather startling in both form and content. It was like a new kind of poetry, in which a maximum of suggestion was achieved with a minimum of words. A sort of conversational haiku. My favorite example of this was a remark he made to me while he was handing out cigars in the office to celebrate the birth of his son: "These friend of mine once, he have a heart attack on a girl!".

Nothing led up to this 13-word anecdote, and nothing followed from it. He just tossed it out there, for me to make whatever I could of it. I haven't been able to forget it since.

Speaking in a foreign language seems to promote the formation of this sort of poetry. Apparently, compressing a long question into a short search string can have a similar effect.

Yesterday, looking through the list of search strings that have caused Google to refer people to my site, I came across a real gem:

Forget the diabetes part of the question for the moment -- I love the surreal implication that the underwear in question is capable of independent movement, so that the ant can "follow" it wherever it may roam.

Even if the idea here is that the owner of the underwear is merely dragging it across the ground, to watch the ant follow it, it's still a pretty striking mental image.

But, leaving the poetic aspect of this search string aside, I suppose it is closely related to another question I see a lot, about ants and bees being attracted to the urine of diabetes patients. Surprising as it may seem, this can actually happen, and it was how diabetes was recognized and diagnosed in ancient times. When your blood sugar is above the normal range, your kidneys try to alleviate the problem by filtering sugar out of the bloodstream and dumping it into the bladder. When this happens, the urine can become sugary enough to attract insects. In the days before home glucose meters were available, diabetes patients used test strips to measure sugar in their urine, in the hope that this method would give them a resonably accurate idea of how much sugar was in their blood. Sometimes it did, but it's not a terribly reliable indicator.

I am not sure that high blood sugar is ever going to attract ants specifically to your underwear (unless you combine loss of glycemic control with loss of bladder control). However, if ants are showing an interest in your underwear, and you have no other way to account for your stardom in the insect world, you might as well make the effort to get tested and see if anything unusual is going on. Anyone who is worried about possibly having diabetes (even for seemingly implausible reasons) should stop worrying and start verifying. 

Another search string:

Well, that's good. When your kidneys are working overtime to flush the excess sugar from your blood, you urinate abnormally often. That's why frequent urination is considered a warning sign of diabetes.

When urination becomes less frequent, it may be an indication that blood sugar is being brought back under control. However, once your blood sugar has been far enough out of control for frequent urination to be an issue, haven't things already gone beyond the point where your condition can be called "pre" diabetes? The fact that your morning sickness has abated doesn't necessarily mean you have transitioned from pregnancy to pre-pregnancy.

Most authorities would say "no" and leave it that, but I don't like rounding answers down to "no" or up to "yes".

Anything that affects your blood sugar has a little bit of an effect on how much of the hemoglobin in your red blood cells is glycated (glycated hemoglobin is what the A1c test measures). How much of an effect, though? Not enough of an effect for the A1c test to be able to tell the difference. The test result only measures to the nearest tenth of a percent, and that's a bigger change than one meal would be able to make.

Look at it this way: if you get on board a jumbo jet wearing denim instead of polyester, does this affect the total weight of the aircraft? Well, yes -- we know it has to have some kind of effect on the total weight. But we also know that the difference is so tiny, compared to the total weight of the aircraft, that nobody is going to be able to weigh the aircraft so as to detect the difference, and the plane's flying characteristics won't be changed enough for any pilot to notice it.

In practical terms, a difference that is unmeasurably small is the same thing as no difference.

Good. For a fasting glucose test (first thing in the morning, before eating anything), a result of 79 mg/dl is normal. You'd have to get up to 100 to be considered abnormally high, and up to 126 before you could be diagnosed with diabetes on that basis alone. 

Both are caused by the harmful effect of abnormally high blood sugar over prolonged periods (the nephrons in your kidneys and the retinas in your eyes are both especially vulnerable to tissue damage caused by excess sugar), so your risk for both problems goes up as your A1c results go up.

Bring down your average blood sugar. The main things you can do to achieve that are to exercise a lot, limit your intake of carbohydrates, and lose weight if you are obese.

The list of things you shouldn't do when you have Type 2 is longer than the list of things you should do. Here is an incomplete sampling of things not to do:

Tuesday, January 17, 2012

It turns out that she does.

That is, Food Network star Paula Deen -- who thinks there is no recipe that can't be improved by adding another stick of butter and another cup of sugar -- does have Type 2 diabetes, and has been concealing that fact for years, and has signed a deal with a pharmaceutical company to act as a paid promoter of a drug used to treat Type 2 diabetes. 

So, the rumor mill was accurate in every detail except one (the pharmaceutical company involved is Novo Nordisk, not Novartis -- and when the names are that similar, I'm not even sure it counts as a mistake, under the circumstances).

Yesterday I suggested that we wait to see what information she presents today, and how she presents it, before we make any judgments about her. Well, we waited -- so now I guess it's judgment time!

My own judgment is that, when Paula Deen was diagnosed (three years ago, by her account), she recognized instantly that she had every reason to keep her diabetes a secret for as long as she could. She had experienced a lot of success, and had made a lot of money, out of presenting herself and her cooking in a certain way, and she didn't want to screw it all up now. She had become a media star by selling a highly specific fantasy: that extreme self-indulgence at the dinner table was cute and funny and harmless. Could her fans continue to enjoy that fantasy, if they knew she was diabetic? Better not to find out.

Her own explanation for her long silence about the diagnosis is that she didn't have much of an understanding of the disease when she first learned she had it, and she needed time to develop some kind of useful message to present to the public. "I wanted to bring something to the table when I came forward".

More cynical observers have suggested that she was actually waiting for something else: an opportunity to make money instead of losing it when her secret came out. Today, by a wild coincidence of timing, Novo Nordisk launched a web site, called Diabetes in a New Light, which features Paula Deen very prominently. The site will tell her story, provide diabetes-friendly recipes which do not use glazed doughnuts as a staple ingredient, and advise diabetes patients on how to stay healthy. But, to my eye, the site appears to be dedicated to the proposition that the way to stay healthy is to take Victoza, the diabetes drug for which Paula Deen is the new celebrity spokeswoman.

The simultaneous unveiling of the disease and the drug-company deal would be enough to make even the most determined Pollyanna suspect a bit of opportunism here. One video I saw today compared Deen to a "war profiteer". Perhaps that's going a bit too far; I doubt very much that Paula Deen has been consciously waging a two-stage campaign against her fans -- selling them diabetes first, so that she can sell them diabetes drugs later. But I also have some doubts about the sincerity of her presentation today. 

Call me cynical, but her on-camera performance seemed to me to be all about crafting her image and manipulating her audience, and not at all about accepting responsibility or facing reality.

She claims that she has been urging moderation on her viewers all along. I'm not in a position to assess that claim (not having been a follower of her show), but it's hard to see a cook who adds a pound of sugar to a recipe that already contains two dozen Krispy Kreme doughnuts as the patron saint of moderation. There is a pretty large gap between what she claims to have been saying all along and what people think they heard. Would she ever have become a Food Network star in the first place, if people who watched her show had picked up the impression that moderation-in-all-things was her primary message?

The only area where she clearly comes down on the side of moderation, if you ask me, is in the lifestyle changes she reports making. These look pretty moderate to me. Minimal, even, although the details are vague. She is, for example, "cutting back" on her consumption of sweet tea (that is, the extremely sugary iced tea which probably helps make America's southern states the obesity capital of the world), and she has been exercising (that is, walking on a treadmill). No doubt about it, these are steps in the right direction. But after three years with the disease, maybe it's time for her to make something bigger than baby steps in the right direction. Walking on a treadmill and "cutting back" on something you shouldn't have at all are better than nothing, but they're not likely to be enough -- with or without Victoza.

Sorry to be so negative, but I'd say my worst-case-scenario for Paula Deen's announcement (that is, that she will use her celebrity status to reassure the public that diabetes isn't a serious problem so long as you take your drugs and "cut back" on your sweet tea) has pretty much come to pass.

Astonishingly, we finally got some cold weather her in Sonoma County! Cold by local standards, anyway. There was actual frost on the grass this morning; I saw it with my own eyes. And when I went running today, in shorts and a t-shirt, it took me a couple of miles of running to warm up enough to be comfortable. Not only that, there might be actual precipitation coming our way!

I'd better bring some more layers of running-clothes to work with me tomorrow. (And I'd better resign myself to running alone, because my running buddies at work are no fans of running in the rain.)

Monday, January 16, 2012

Well does she, or doesn't she?

Since last spring, rumors have been circulating that Paula Deen, the celebrity chef who thinks glazed doughnuts make excellent hamburger buns, has developed Type 2 diabetes.

The source of the rumor seems to have been the National Enquirer -- perhaps not always the most cautious of news sources. But the rumors have intensified, and CBS News (among others) is now repeating the story. Deen herself has been unwilling to comment so far, but apparently she will give an interview on the subject Tuesday, on the Today Show.

Part of the rumor is that Deen has signed a valuable contract with Novartis, which will make her the spokeswoman for the Novartis drug that she is using to control her blood sugar. Novartis denies the story. However, those who believe it anyway have been quick to condemn her for the arrangement (the gist of their objection is that she got rich promoting unhealthy food, and is now going to get richer promoting medication for the disease caused by her unhealthy food).

I think her critics may be jumping the gun a bit here, as we don't know for sure that she has diabetes, or how long she's had it if she does. I guess we'll know more tomorrow. For today, my question is: does it matter whether she has diabetes or not, and do we have a right to know about it (and judge her for it)?

Being famous is not enough, in itself, to make the private details of your life a matter of legitimate public interest. Not all "sex scandals" deserve to be scandals. A politician's sex life usually doesn't (or at least shouldn't) have any impact on the voting public, so it's usually not possible to argue, with a straight face, that it's any of our business what they get up to.

The usual counterargument to this is that journalistic coverage of a politician's sex life is justified, if said politician has been making a campaign issue of his supposed moral superiority to rival candidates, or if he has seen hypocritically condemning or persecuting private citizens for doing in their own bedrooms the same things that he does in airport men's rooms. When the hypocrisy is carried to extremes, even the personal history of the candidate's spouse might be seen as a legitimate target for scrutiny (for example: one of the current presidential candidates has advocated criminalization of things known to have been done by his own wife). But if a politician hasn't been creating an aura of fake purity for himself, or attacking others for their private behavior, it's hard to see why we have a legitimate gripe if he turns out not to have practiced strict abstinance before marriage and strict monogomy after. Still, politicians who haven't condemned anyone else's sex life are usually treated just as badly as those who have, when embarrassing details come to light. (Remember Congressman Weiner? No leniency for him! But he had a funny name, which is another way to justify prying into a politician's private life.)

Well, sex scandals are as old as the hills, but now we have something new: a diabetes scandal!

Actually, I'm not sure this is unprecedented. But I don't know of any prior case in which it was regarded as scandalous that a celebrity had diabetes. The excuse for regarding it as a scandal, and not as a personal health issue which she has a right to keep private, is that Paula Deen allegedly (1) has been influencing the public to eat in an unhealthy way which promotes diabetes, and (2) has been concealing the fact that eating that way gave her diabetes and she herself can no longer eat the foods she is promoting.

Anthony Bourdain (a celebrity chef that I find hard to warm to, though some people admire him) has attacked Paula Deen in the past (calling her "the most dangerous person in America" for her influence on American eating habits), and now he is being asked to comment on the situation, and he has not been reluctant to do so: "When your signature dish is hamburger in between a doughnut, and you've been cheerfully selling this stuff knowing all along that you've got Type 2 Diabetes... It's in bad taste if nothing else. How long has she known? I suspect a very long time. On Tuesday when she announces it, it'll be to say I just got diagnosed... Al Roker won't be asking her how long she's known. I don't think people will press that issue.... Clearly this has been coming for a while. She's been looking for ways to position herself. Is she really going to be selling the cure now? Or will she back off for a decent interval? I take no pleasure in it. There ain't nothing funny about Diabetes."

I have not been paying a great deal of attention to Paula Deen (nothing personal -- there are mighty few developments in pop culture to which I have been paying a great deal of attention), but it is not possible to live in the United States and not have a certain basic familiarity with her personality and her culinary aesthetic. 

Hers is clearly an aesthetic of excess -- almost comical excess, as if she spent her evenings drinking with friends and laughing up a storm as they all try to outdo each other in dreaming up ways to cram ever more calories into familiar dishes. For example, if you make a lasagna caserole according to her recipe, you add 8 cups of cheese to it -- and then you deep fry the thing.

Her recipe for bread pudding involves (among other things) 2 dozen Krispy Kreme doughnuts, a can of sweetened condensed milk, a stick of butter, rum, two cans of fruit cocktail, and an entire pound of powdered sugar. 870 calories per serving.

Food writers complain that Paula Deen doesn't just celebrate excess in some of her recipes -- she celebrates it in nearly all of them. (Elizabeth Kelly: "Sure, I'm one of the first people to say that a healthy diet has room for splurges. My beef with Paula Deen is that, in an age where colon cancer, heart disease, and obesity are real threats that loom large, her recipes as a whole collection suggest that you splurge every day, and at every meal.")

To play devil's advocate for a moment, even the most ardent fan of Paula Deen need not eat like that all the time -- and for all we know she doesn't eat that way herself, and never did. Maybe she reserves these calorie bombs for special occasions and expects us to do the same. She is not a thin woman, but neither does she appear to be as severely overweight as I would expect from someone whose typical dinner is deep-fried lasagna, with Krispy Kreme bread pudding for dessert. Perhaps Paula Deen has been taking it for granted that nobody in their right mind uses this sort of recipe routinely.

There is also the issue of what causes Type 2 diabetes -- a slightly more complex question than it is being made to appear, in all these discussions of Paula Deen and her rumored diagnosis. The degree of genetic vulnerability to the disease appears to vary widely from person to person. Some people can stay slim and nevertheless develop Type 2. Some people can eat Paula Deen's recipes every day and nevertheless not develop Type 2, no matter how much weight they gain.

Still, though, it's hard to argue that Paula Deen does not promote overeating of a kind which puts people at heightened risk for Type 2 and other health problems. If it turns out that she is diabetic, and that she is going to promote a diabetes drug (while continuing to promote overeating!), I think it will be reasonable to cry foul. I would hate for her fans to get the impression that overeating is still funny and cute even when you're diabetic -- because, so long as you're taking the same meds Paula Deen is on, overeating can't hurt you.  

On the other hand, if she finds a more responsible way to deal with this issue, perhaps we should not be in too much of a hurry to shoot her down. I don't want to see a trend developing in which merely being diabetic is regarded as a terrible moral failing and a legitimate source of scandal. Let's wait and see how she handles this. 

Friday, January 13, 2012


The mysteriously-named Centers for Disease Control (how many of them are there, anyway?) has concluded (have concluded?) that murder, for the first time in 45 years, dropped off the CDC list of the 15 leading causes of death in the United States (based on statistics for the year 2010). It seems that pneumonitis (a respiratory illness that mainly strikes the elderly) claimed 15th place, and pushed murder down to 16th.

A mere 16,065 Americans were murdered in 2010 -- less than half as many as killed themselves that year -- and that's just not enough to get you into the top 15. I'm not a booster for murder (except in certain cases), so I'm not especially heartbroken to learn that murder has dropped off the list. But I was curious about what the top 15 causes of death were, and how common each of them was in 2010.

Well, there were 2,400,000 deaths in the United States in 2010, and there's how the deaths (at least those that made the top 15 list) broke down, by the number of deaths and by percentage of total deaths:

Cause Deaths %
(1) Heart disease 595,444 24.8
(2) Cancer 573,855 23.9
(3) Chronic lung diseases 137,789 5.7
(4) Cerebrovascular diseases (strokes) 129,180 5.4
(5) Accidents 118,043 4.9
(6) Alzheimer's disease 83,308 3.5
(7) Diabetes 68,905 2.9
(8) Nephritis and related kidney diseases 50,472 2.1
(9) Influenza and pneumonia 50,003 2.1
(10) Suicide 37,793 1.6
(11) Septicemia 34,843 1.6
(12) Chronic liver disease and cirrhosis 31,802 1.3
(13) Hypertension and hypertensive renal disease 26,577 1.1
(14) Parkinson's disease 21,963 0.9
(15) Pneumonitis (inflammation of lung tissue)  17,001 0.7

Between them, cancer and heart disease accounted for nearly half (48.7%) of all deaths in 2010. These are the heavy hitters when it comes to causes of death.

After that, the percentages drop precipitously. The third leading causes of death (chronic lung diseases) acounted for only 5.7% of the total.

Diabetes, perhaps surprisingly, acounted for only 2.9% of all deaths. We have to be cautious in interpreting that figure, however. No doubt many people who had diabetes were described as having died of something else (a heart attack, a stroke, kidney disease), but that doesn't mean diabetes wasn't a contributing factor to the conditions that were listed as the leading cause of death.

Accidents, at 4.9%, were well ahead of diabetes, but still a surprisingly uncommon cause of death. Considering what my typical experience of driving is like, no matter where I'm going or when I'm going there, I've almost got into the mental habit of assuming that an accidental death is what's ahead for me, just because the risk of it looks so high. I guess appearances are deceiving.

Perhaps my biggest fear is that the ultimate cause of my death will seem so ironic that I'll make the news. I'll be out there in the state park one weekend, trail-running so that I don't die of diabetes or heart disease, and I'll be killed by a mountain lion or killer bees or something, and reporters for the local paper will get to write headlines such as "Health Nut Gets Eaten".

It's a comfort, though, to know that my risk of being murdered is less than 1% now. As for my risk of murdering anyone else, the CDC didn't publish any figures on that, but I hope that's low as well.

Thursday, January 12, 2012

Today I read a couple of articles about medical research into exercise issues. One of them reports Very Low Risk of Sudden Death in Long-Distance Running Events. You might get the opposite impression from reading headlines about runners who died during a marathon or half-marathon, but bear in mind that about two million people a year run in these races, and it would be pretty hard to have two million people do anything without a few of them dying while they were doing it.

If someone in your town experiences cardiac arrest while climbing stairs or raking leaves, it probably won't be front-page news. It will, on the other hand, be front-page news if any runner in a marathon or half-marathon race experiences cardiac arrest -- thus creating the impression that running in such races is a very risky thing to do.

However, it turns out that the actual rate of such occurrences is only 1 per 100,000 runners in a full marathon, and considerably less than that in a half-marathon. Other, seemingly less extreme physical activities are significantly more hazardous than that. One of the researchers was quoted: "You're much less likely to have a cardiac arrest as a middle-aged marathon runner than you are as a college athlete, as somebody who's doing triathlons, or even as somebody who's out doing casual recreational jogging. One of the big take-homes is that marathon running is safe and appears to be very well tolerated."

This doesn't mean I'm going to go sign up to do another marathon. I've done four, and although none of them made me fear that I was on the verge of cardiac arrest, all of them made me hurt, and after the last one (which was the hardest one, mainly because it rained the whole way) I began to think that a half-marathon is about as big a running challenge as I really felt like taking on. I'm not ruling out the possibility of ever doing another full marathon, though, so I guess I'm glad to hear that the sudden-death risk involved is only one one-thousandth of one percent.

The other article was about a Swedish study which found that physical inactivity is a "universal cardiovascular risk factor"; if you don't want to have a heart attack, you need to move your body around. The researchers found that having an occupation that involved moderate physical activity was as useful as what we usually call "exercise". Their final comment: "If we want to support healthy longevity, we should put a stop to the pandemic of 'sedentarism.'"

The management at my company seems to have decided, in a small way, to put a stop to the pandemic of sedentarism among our employees. There is now a sort of fitness competition going on among the employees at various company work-sites. It was launched on Tuesday. Here's something from the web site for the event:

All it really amounts to is that employees at the various work sites log their daily exercise on a company web site, and competitive comparisons are made. Although different kinds of exercise are logged in different ways, it all gets translated into "miles", as if everyone were running or walking (people who are doing aerobics or team sports log the amount of time they spent, and this gets converted by a formula into mileage). There is some long-term target of I-forget-how-many thousands of miles, and it's a race to see which local team gets there first. The distance is represented graphically by a winding route from somewhere in Alaska to somewhere in South America, and a map shows the progress of the various teams along that route.

Our local team is in the lead, so far:

A lot of people exercise at lunchtime where I work -- because we happen to be set up very well for that. We have a basketball court, a soccer field, a baseball field, a gym, and lots of safe and pleasant routes in the neighborhood for walking and jogging and cycling. Unless it's raining, I'm never the only employee out there running at lunchtime.

Considering how much milder the weather is here in coastal California than it is in, say, Colorado, it isn't surprising that we've got a good lead on the other teams so far. But the race just got started, and plenty of people don't even know about it yet. There are several work sites that don't even have a participating team -- yet. We'll see what happens when the China sites get on board!

Well, anyway, I'm sure I'll do my part to help our team win. I don't think we actually win anything, though -- except in medical terms. If "not dying" counts as a reward, we get that one.

Wednesday, January 11, 2012

The American Beverage Association is extremely unhappy with the posters for New York City's anti-obesity campaign -- and a lot of other people are probably not thrilled about them, either.

The ABA says that the campaign's "scare tactics" are creating an inaccurate picture of the impact of soft drinks.

City officials, meanwhile, are sticking to their guns. They say that more than half of New Yorkers are fat, that 10% of New Yorkers already have Type 2 diabetes, and that it's time to do something to reverse the current trend towards increasing incidence of obesity and diabetes. They say that the doubling of the size of a serving of French fries, and the quadrupling of drink sizes, at fast food chain restaurants over the past 50 years must account for at least part of the problem. So, the obvious thing to do is to force people to be more conscious of fast-food supersizing, and its potential consequences.

One can imagine these subway posters causing some New Yorkers to jump to a few questionable conclusions...

However, the poster doesn't actually say any of those things. What it does say is that average portion size has been increasing, that diabetes incidence has increased along with it, that Type 2 diabetes "can" lead to amputations, and that cutting your portions will cut your risk. None of that is terribly controversial, really. I think the real problem people have with the poster is the photograph of the amputee, which reminds people (more forcibly than they would like) of one of the worst-case scenarios for obesity and diabetes.

I don't know how helpful or unhelpful it is to show people scary reminders of what diabetes can lead to. I tend not to dwell too much on that sort of thing -- and maybe I shouldn't have included this poster even for the sake of discussion, if I'm going to continue to boast of this site's being a "non-depressing guide to Type 2 diabetes".

Terrorizing people in the hope of making them change their behavior does not always work. Scary warnings about health can have unintended effects: if you make the subject so unpleasant that people don't even want to think about it for a moment, they may take refuge in denial. Exposure to ugly realities doesn't always make people resolve to prevent such consequences in their own lives; sometimes they simply become fatalistic.

Look how many hospital nurses smoke!

This winter's warm, dry weather here on the California coast has been so consistent for so many weeks now that I think we have to say it is now officially ridiculous.

I took that photo on Saturday, but nothing has changed since:

Whenever a snowstorm happens in the eastern half of the US, some people take that as proof that global warming is a purely imaginary phenomenon. But global warming doesn't mean the end of hot and cold spells, it just means an increase in average temperature -- and even the increase in the average is unevenly distributed. A lot of the measured warming is happening in the arctic, so far. But it sure seems like a lot of it is happening around here, too -- at least in the winter. The local trend here, in recent years, seems to be extreme moderation, if that isn't too paradoxical a phrase. A sort of determined mildness has been hovering over California, opposing any tendency for temperatures to get very low in winter or very high in summer.

Keeping track of weather fluctuations is like keeping track of blood sugar fluctuations. An unusually high or low result, on one atypical day, is not the main thing to pay attention to. What's the trend? Is the running average rising or falling? That's what you want to focus on. If the trend is going up, it does no good to point triumphantly to your lowest result of the month, as if that invalidated all higher results.

Forget the outliers; concentrate on the average.

Tuesday, January 10, 2012

In all the political fights over stem cell research during the last several years, I think I have got into the habit of regarding stem cell research as a social issue rather than a scientific one. Hypothetically, it might some day lead to useful medical treatments, but that would happen in the far future if it happened at all. During my lifetime, it was just a symbolic battle about whether or not scientists would be allowed to lay the groundwork for such future breakthroughs. I didn't think I would live to see stem cell research leading to any practical applications. I still thought that the research should continue; I just didn't think it would pay off for my own generation.

Well, maybe things are happening a little faster than I thought they would. A team of researchers from the University of Illinois at Chicago, working with patients at a military hospital in China, is experimenting with a stem cell therapy for Type 1 diabetes, and the preliminary results show real promise. I hasten to add that they haven't "cured" anyone of Type 1 diabetes, but they did measure three kinds of desirable changes in the patients they treated: improved C-peptide levels, reduced need for insulin, and reduced hemoglobin A1c. Presumably, further experimentation will reveal ways of building on this partial success.

The big problem with developing any sort of treatment for Type 1 diabetes has always been that it is an auto-immune disease, in which healthy cells (in this case the beta cells in the pancreas which produce insulin) are attacked by the body's immune system. Anything doctors try to do to revive or replace the patient's damaged beta cells is seemingly a doomed effort, because the immune system will still go right on attacking the beta cells, knocking out the new or revitalized ones, and completely undermining the treatment, regardless of how the treatment works. All auto-immune diseases present this same basic problem: what difference does it make how you try to undo the damage caused by the immune system, if the immune system is going to turn right around and cause the same damage all over again? It has long been hoped that therapies using stem cells would provide scientists with a way of getting around this problem. That much I knew, but until today I didn't know what the strategy was.

What the researchers are doing is collecting healthy stem cells from umbilical-cord blood, and using them to "teach" the T cells of the patient's immune system to behave properly and stop knocking out beta cells.

The treatment was most effective in patients who still retained some fraction of their insulin-producing capacity (in follow-up 12 weeks after treatment, they had reduced their median daily insulin dosage by 38%). But even the more severe cases, who could not produce insulin at all, experienced a 25% reduction in insulin dosage and a substantial reduction in HbA1c -- and this was so because they had now started producing insulin! Not as much insulin as their bodies needed, perhaps, but for these particular patients to be able to produce insulin at all was a remarkable improvement.

We shouldn't get too excited about this research until it has had some confirmation. It was a very small study, after all. And allow me to mention delicately, in passing, that some amazing research "breakthroughs" in this field have turned out to be fraudulent (remember Woo-Suk Hwang, sentenced to prison in connection with his faked cloning research?). I would really like to see this study replicated by some other team, in some place other than a Chinese military hospital.

I should acknowledge, though, that this research, even if it is totally legit and is going to lead to great things, probably holds no promise for those of us with Type 2 diabetes -- even those who have diminished insulin productivity and take insulin injections to make up for the loss.

You see, in Type 2, any loss of insulin productivity is due to causes other than an auto-immune reaction. It does no good to
"teach" your T cells not to attack your beta cells, if they were never doing that in the first place. So, if this research really is good news for diabetes patients, it is only good news for patients with the Type 1 variety.

Well, the Type 1 patients could use a break. They represent a small -- and perhaps shrinking -- minority of diabetes patients, and they tend to feel that they are a forgotten minority. They fear that the Type 2 majority is getting all the attention from researchers, and that not enough people are working on a Type 1 cure. Well, some people are working on it.

Monday, January 9, 2012

Although I am tempted to comment further on the odd results of my glucose-profile experiment last Friday, I think I might as well resist the temptation. The seemingly immediate glucose peak (15 minutes after I finished dinner!), with all subsequent results lower than that, still seems almost inexplicable to me, and I wonder if it was in fact uncharacteristic of my usual glycemic response. I guess the only way to find out is to run repeated experiments, but it's not an experiment I find easy to do (watching the clock that intensely drives me crazy), so I'll wait a while before trying again.

Some creepy news about statin drugs: data from the Women's Health Initiative indicates that post-menopausal women who take statin drugs to lower their cholesterol experience a 48% increase in their risk of developing diabetes.

Other studies have suggested an association between statin drugs and diabetes risk, but the new study shows a much stronger association than researchers have seen before. Does that mean the new study found something that earlier studies missed? Or does it mean the new study overstates a danger which other studies correctly assessed as low?

Being prejudiced against statins myself (mainly on the basis of having watched their impact on friends and relatives who were not able to tolerate them), I am well prepared to accept the former interpretation rather than the latter. That's prejudice talking, as I've already admitted. It could be that diabetes risk is elevated, for reasons unrelated to the statin drugs themselves, in certain people who are likely to be taking statins. For example: if doctors are likelier to prescribe statins to women whom they already suspect are headed for diabetes, then this alone would be enough to skew the results. Perhaps the issue is not that statins increase your chances of becoming diabetic, but rather that being seen by your doctor as a canditate for diabetes increases your risk of being prescribed statins! I'm not saying that's necessarily true -- I'm just saying it's one of the reasons why we shouldn't read too much into the results of a single study.

Still: if statins might increase your diabetes risk, and are known to cause other serious problems (such as exhaustion and dread, from what I've seen) in patients who don't tolerate them well, and there are better ways to improve our lipids profile, which have positive side effects instead of negative ones... why go with statins as your first choice? Why start with the pharmacy when you might do much better at the gym?

My New Year's Resolution for 2012 is to inflict painful injuries on each person who tells me that the world is scheduled to end in 2012.

Of all the things that irritate me about the supposed Mayan prediction of a 2012 apocalypse (and there are endless layers of stupidity surrounding this issue), perhaps the worst is that the critical date doesn't arrive until late December -- which means I'll have to spend a whole year hearing about this.

There is no evidence that the world will end in December 2012, or that the Mayans ever said it would, or that the Mayans were any good at predicting the downfall of civilizations (including their own). So why do we have to keep hearing about this? Why didn't the two heavily-publicized doomsday predictions in 2011 result in doomsday prophets being laughed off the cultural stage for good? Apparently people get some kind of thrill out of this stuff, so they shrug off each no-show apocolypse and move on to worrying about the next one.

Well, if you're looking for an apocolypse to become hysterical about, and you don't want to wait a whole year for it, help is on the way...

...in the person of a preacher named Ronald Weinland, of Grace Communion International, a.k.a. the Worldwide Church of God. I'm sure you'll remember him vividly as neighbor Fred Mertz on the old I Love Lucy show. (No, wait, that was William Frawley.) He says that the actual end of the world is going to take place on May 27. Not only that, he has predicted a bunch of other calamities which will happen before then -- including the collapse of the United States and a nuclear war. Oh, and also, all the people who mock his prophecy will die of cancer before May 27.

It's going to be a busy spring for me, I can see that. But perhaps not for the reasons Ronald Weinland thinks! 

Friday, January 6, 2012

Okay, to recap: earlier this week I started trying to explain why I do my post-prandial tests just one hour after a meal, even though nearly everyone else waits two hours. My rationale was that I want to see how high my glucose gets at its peak, and testing after two hours would never reveal that, because my peak comes much earlier. Based on my own prior experience of testing at various intervals after a meal, I thought my peak occurred at the one-hour point. (By the way: for me, the one-hour point means one hour after I stop eating, not an hour after I start eating -- I realize that some define that differently.)

I started hearing from other people who say their glucose peaks occur much later than mine do -- at the 2-hour point, or even later (especially following a high-fat meal). Well, if that's the case, then it does make sense for them to test later than I do.

However, it's been a long time since I squandered a bunch of test strips to get a more high-resolution picture of my glycemic profile. I thought I would do that tonight, and see if my peak had moved to a later time. Well, it didn't -- but the results were pretty surprising, all the same.

I had a hard time deciding what sort of meal to use for the experiment. Eventually I went to the upscale grocery near my house and bought one of their ready-made packaged meals (this one was called Lemon Rosemary Chicken Dinner). It consisted of a pretty generous serving of chicken breast meat in a lemony sauce which I took to be pretty high in fat, presented on a bed of what I took to be risotto (it was actually quinoa, but it tasted like risotto and I was sure there was a lot of starch in it). So, I figured it was a meal high in calories, and protein, and fat, and carbohydrate -- a suitable glycemic challenge all around.

One factor which might be significant here: I stopped at the gym for a weight-training workout after work; conceivably that had an impact on the results.

One thing that didn't have an impact was alcohol. I had no wine with dinner (a practice I don't always recommend, especially on Fridays, but I didn't want to complicate the experiment by introducing an extra variable that affects blood glucose).

I tested my glucose just before dinner, to establish a baseline. The result was 86. Okay, great. Let's see how much higher I go after dinner.

I decided to test at 15-minute intervals for the earlier part of the test. So, I tested 15 minutes after dinner, and the result was 126.

This rather startled me. 126 isn't terribly high, but I had been 40 points lower before dinner! Isn't that a pretty spectacular rise, in only 15 minutes? I could understand seeing that steep an increase, if I'd eaten a bunch of pure sugar. But starch moderated by fat? That ought to be digested fairly slowly. If I was up to 126 after only 15 minutes, how freaking high was I going to be when I got to the peak?

Then I tested at 30 minutes, and the result was 111.

Now, that is a bit weird. Was the peak already over, and was I already on the downhill side of it? That seemed almost impossible.

At 45 minutes, the result was 117. Well, that was higher than 111, but given the rather loose variability of glucose meters, the difference between 111 and 117 might be meaningless. Anyway, the result was lower than the result I'd got from the 15-minute test. Could it be possible that my peak now occurs only 15 minutes after a meal?

After one hour, I was down to 93. It was looking more and more as if my peak had occurred in less than an hour!

Well, to make a long story short, over the next two hours my glucose fluctuated in the 80s and 90s; it never hit 100 again. And at the three-hour point, it settled back to exactly where it had been before I ate dinner: 86.

Okay, so I don't have a late peak in the two-to-three hour range -- that only confirms what I expected. But a peak at or near the 15-minute point? That is downright bizarre.

I'm not going to analyze it tonight, though. I'll sleep on it. Maybe some inspiration about what it means will come to me in a dream.

Hey, wait a minute! I just realized that, during the nearly 11 years since diagnosis, I can't remember ever having a single dream related to diabetes! My dream life is still stuck where it's always been: plane crashes, malfunctioning toilets, and when-animals-attack. 

Okay, so the answer isn't going to come to me in a dream. I'll have to do research or something.

Thursday, January 5, 2012

I think I may have been premature in writing about the timing of post-prandial tests on Tuesday, and again yesterday. Initially I was just trying to explain my atypical practice of testing 1 hour after a meal, because a reader had asked about it. I'm hearing from other readers now about the wide variations they have experienced in the timing of their glucose peaks (it seems to be pretty common to find that the peak is delayed a long time -- sometimes a very long time -- after a high-fat meal).

I've decided that the whole subject is extremely complicated and I'd better not say anything else about it until I have gathered a lot more information. I'll follow up on this eventually, but don't hold your breath waiting for me to get back to you on this!

So let me write about a topic that is somewhat easier to pin down: Starbucks.

I think the reason for the huge popularity, in recent years, of coffee bars in general, and Starbucks in particular, is that people feel they have a need for a treat which doesn't seem all that sinful. Eating handfuls of Halloween candy on the way to work in the morning would make you feel like a weak, bad person -- so that's not the sort of treat most of us are seeking. However, stopping by Starbucks on the way to work in the morning and swallowing 16 ounces or more of some espresso-based liquid confectionery does not make you feel weak or bad. Its main effect on you is to make you feel employed.

There is something about the atmosphere inside a Starbucks coffee shop that makes you feel as if being there is nothing for you to be ashamed of -- this is the sort of thing that responsible adults do. Responsible adults with jobs. Responsible adults who are not just sipping on cafe mochas -- they are also, at the very same time, catching up on their e-mail, calling their sales reps to arrange customer meetings, or updating their PowerPoint slides for the big checkpoint meeting today (so that they can explain why their department isn't the one to blame for fact that the new software won't meet its release deadline). The air in the room seems to be swirling with professionalism and caffeine in equal proportions.

The grown-up atmosphere that Starbucks creates in its coffee shops tends to give us a vague impression that nothing we order in there is going to be all that bad for us. It's a treat, but it's a pretty harmless treat. Harmless even if you have diabetes.

Is that impression accurate? Well, it depends on what you order. I will leave the muffins and scones and coffee cake out of this (I assume you realize that those things are very high-carb), and concentrate on the cofee drinks. It is possible to get your caffeine hit at Starbucks without absorbing a lot of carbs in the process -- but it is also possible to get clobbered with a huge carbohydrate payload that you didn't realize was there.

For example: you probably realize there would have to be some carbohydrate in anything called a "Peppermint White Chocolate Mocha", but you might not realize just how much...

Most Type 2 diabetes patients are going to have a hard time processing 78 grams of carbohydrate in a cup of coffee, even if they are not using it to wash down a blueberry muffin that is large enough to use as a footstool. So it appears that we need to think about what sort of order we place at the espresso bar, and what the glycemic impact of that drink will be. If you're going to order one of the more sugary offerings there, it might be better to do it on a suitable occasion (right after finishing a marathon, for example -- that would be a good time).

Here is a comparative listing of Starbucks espresso drinks, in ascending order to carbohydrate content (all figures are for the "Grande" size of 16 ounces). Brace yourself: the range is larger than you would expect...

I'm not saying you shouldn't go to Starbucks, or even that you shouldn't ever order anything from the bottom half of the list. But know what you're getting into!

Wednesday, January 4, 2012

Blood pressure much better tonight. Good news, of course -- except that I have no idea what the reason for the improvement is.

Regarding yesterday's blog post about the timing of post-prandial tests, Bob Fenton pointed out to me that variations in the timing of glucose peaks from one person to another (and from one meal to another, for the same person) can be rather large. He reports experiencing significantly later peaks than mine, especially when the "pizza effect" plays a role (this is a delayed emptying of the stomach, caused by some kinds of high-fat meals -- and it can cause a glucose peak to be postponed and/or lengthened). He occasionally conducts an experiment in which he sacrifies a lot of test strips in order to test at five-minute intervals after a meal, so that he can find out where his peak really is. And where it really is for him is later than where (according to my own experiments) it really is for me.

Well, yesterday I was writing about a personal choice (testing one hour after a meal, not two) and justifying it in terms of personal characteristics (I tend to peak about an hour after a meal). I wouldn't want anyone to assume that what is true for me must also be true for them, because there really is a lot of individual variation involved in this sort of thing.

So, don't take my word for it. If you can afford to sacrifice some test strips, experiment with testing at intervals after a meal, and find our where your peak is. If you can afford to sacrifice even more test strips, try it again with a different kind of meal, to see if there is a pizza effect (or bacon effect, or rice effect, or whatever) that influences the timing of your peak.

Although I have done simpler experiments quite recently, in which I simply confirmed that I am consistently higher at one hour than I am at two hours, it has been a while since I have tested at short intervals, to confirm that my peak is usually near the one-hour point. Maybe I should try that out soon.

I guess we've come full circle: an obesity study published yesterday in the Journal of the American Medical Association took a very close look at the bodies of patients on different kinds of diets, and found that what causes the body to store excess fat is not the proportions of fats/carbs/proteins in the diet -- it's excess calories.

I guess it was bound to happen, if we waited long enough. For years, we were told that body fat was just a matter of basic thermodynamics: consume more calories than you burn, and you gain weight -- consume fewer calories than you burn, and you lose weight. It's so simple! So obvious! No one should have any trouble losing weight, now that we know the secret! But, of course, people who knew the secret still had plenty of trouble losing weight.

The body is programmed to add body fat whenever food is abundant (on the assumption that food will soon become scarce), and then to hold onto its fat stores as long as it can (on the assumption that food might not be abundant again for months). Not that the body uses magical means to achieve these goals, mind you; it adds body fat by ramping up your appetite, so that you take in more calories, and then it "defends" body fat by ramping down your metabolic rate and activity level, so that you burn fewer calories. (Sometimes it also defends fat by burning muscle proteins for energy instead -- so that you become weaker as you become larger.)

For most people in the first world, food is never scarce, so their bodies are constantly trying to add fat, and they are in a constant (and often unsuccessful) struggle to fight the trend. When you tell them that weight control is a simple calories-in, calories-out equation, they become extremely frustrated by their inability to solve this supposedly simple problem. This makes them sitting ducks for anyone promoting a theory which claims that calories aren't the issue.

So, in recent years, we've been told that calories don't matter, and that something else does. What exactly is this "something else", which matters so much more than calories do? Well, it depends on whose theory you're hearing about at the moment. There are all sorts of diet plans to choose from, most of which pin the blame for obesity on a particular kind of food (grains, sugars, animal proteins, saturated fats, unsaturated fats, whatever), and advocate for sharp reduction or outright elimination of that kind of food from the diet. All these diet plans have fans and detractors -- people who say "it worked for me!", and people who say "it didn't!". But, if the JAMA study is not mistaken, any one of these plans works for those who can use it to reduce total calorie consumption, and doesn't work for those who can't. It's really the calories that matter after all.

Back to square one!

Local weather: more of the same. Impossibly beautiful.

Which means, of course, that we are almost certainly headed for a drought year. But that doesn't mean we can't enjoy this very mild winter for what it is. 

Tuesday, January 3, 2012

Two more parties over the weekend! Christmas was over, but occasions for over-eating were not. And then, of course, I got back to work today, and found that it was somebody's birthday and we were going to have cake in the afternoon. I had to draw the line at that, although I was under a lot of pressure. Everyone else was one aisle over, gathered around the cake and calling loudly for me to come join in the chocolate symbolism. I said "no, thank you, I can gaze sadly at the cake perfectly well from here". Ha, ha, that Tom is so funny.

Don't know why my blood pressure is up tonight. I'll try to think more happy thoughts. Or at least stop thinking about cake.

A reader wrote to me, asking why I do my post-prandial testing after only one hour, when everybody else seems to do it after two hours. It was a fair question, all right, because I did a web search on the subject of post-prandial testing, and found that, indeed, nearly everybody else in the world does seem to wait two hours, not one.

I gave her the short explanation: when I was first diagnosed (almost 11 years ago), my doctor told me to do the test after one hour, and during the years since then nobody ever told me that two hours had become the norm, so I kept doing what I had been doing all along. However, I promised to discuss the subject in a little more detail, in tonight's blog.

As fate would have it, I was diagnosed (and instructed to test one hour after meals) just months before the American Association of Clinical Endocrinologists issued guidelines on post-prandial testing which, apparently, are the source of the two-hour approach which seems to be universally recommended to Type 2 diabetes patients these days. 

Still, that was in 2001, and 2001 was rather a long time ago now. My doctor certainly could have told me, at some point during the years since then, that two-hour post-prandial testing had become the norm, and I ought to switch to that approach. He never did that. Why not? I don't know, since I've never discussed the issue with him, but I can think of three possible explanations:

  1. He forgot that he had told me to test after one hour, so he assumes I am testing after two hours, like everybody else. (This one seems far-fetched.)
  2. He disagrees with the AACE recommendations on two-hour testing, and thinks one-hour testing is more useful -- at least in my case. (This is a little more likely, for reasons I'll get to shortly.)
  3. He has been pleased with my record of consistently good glycemic control, and he doesn't want to mess with success. (This seems the likeliest of the three explanations; doctors are practical people, and they tend to assume that a patient who is doing unusually well should be encouraged to continue doing whatever he's doing.)

It seems to me that, before we decide when to test, we need to be clear about why we test. What are we trying to find out, and how do we plan to use the information when we get it?

One possible reason to do post-prandial testing is for purposes of diagnosis. Are you diabetic or not? A normal fasting result proves nothing. A fasting test (typically included in the lab-work for a routine physical) can be a pretty poor early-warning indicator, because your fasting level is often the last thing to go. When people are becoming diabetic, they often continue to get normal fasting tests for a long time after their glucose has started going very high after meals. A better early-warning indicator would be a measurement of how high their glucose gets when their endocrine system is being "challenged" by a meal.

But if you already know you have type 2 diabetes, diagnosis is no longer what it's about. You test because you want to know how well you're doing. And you want to know how well you're doing so that you can change habits that drive your test results in the wrong direction, and reinforce habits that drive your test results in the right direction.

You test so that you can steer the ship, in other words. If you look at it that way, you will understand that there is no point in testing if you don't change course when the ship is heading for the rocks. Also, there is no point in testing if it doesn't show you where the rocks are. You want the best information you can get, and you want to do something with it when you get it.

Post-prandial highs are important not because they are evidence that you have diabetes, but because post-prandial highs can be directly harmful. Everybody's glucose rises after a meal, but in non-diabetic people it doesn't rise all that much, and it subsides quickly. Here's a graph, showing how blood glucose rises and falls in a sawtooth pattern over the course of a day:

Sorry, I realize that this is a rather busy graph. It has three traces on it, but ignore the upper and lower ones, as they represent the extremes within a population -- the bolder black trace in the middle represents the average glycemic profile of a healthy non-diabetic person. Note that, about an hour after each meal, glucose rises sharply to a peak (usually in the vicinity of 120 mg/dl). It then falls back rather steeply, and two hours after a meal it has fallen most of the way back to the minimum level (around 80). This is what "normal" looks like, in terms of blood glucose. My aim as a diabetes patient is to get my own blood glucose profile looking as much like that as I can -- even though the tendency, in anyone who has been diagnosed with type 2 diabetes, is to have peaks after meals which go higher than that, and decline more slowly than that.

The same guidelines that advise patients to test at two hours also advise them to try to get a two-hour result that's under 140. A commendable goal, as far as it goes -- but I don't think it goes far enough. If you're only down to 140 after two hours, then you're probably a lot higher than that at one hour. And that's a problem, because there is evidence that "glucotoxicity" (the harmful impact of excess glucose on tissues -- especially certain tissues which are especially sensitive to it, and that includes the beta cells in your pancreas that produce your insulin supply) begins to operate at about 140 mg/dl. I don't want glucotoxicity to be operating in me any more than I can help, so I want to be under 140 at the peak, not just an hour after the peak, when it's sure to be lower.

Actually, it's not quite true to say that glucose is sure to be lower at two hours than at one hour -- in some people, it is actually higher at two hours. I'm not one of those people, though; I've done a fair number of experiments on myself, in which I tested after one hour and after two hours. In fact, I did that today, because I knew I'd be blogging about this. And today, as usual, I found that the second test gave a lower result (dropping from 112 to 91).

So, if I want to keep myself safe, by preventing my glucose profile from shooting above the 140 mark at any point, then the thing to do is to test at the point when glucose is likely to be at its highest. For me, that's about an hour after a meal. So I think the one-hour plan that my doctor originally advised really is the best plan for me, even if he would advise two hours to a patient newly diagnosed today (because that has become standard practice).

One more thing: an important purpose for post-prandial testing is to assess the glycemic impact of specific foods. Can your system handle rice, without spiking? How much rice? What kind of rice? If you need to know how well you can handle a "risky" food, post-prandial testing is the only way to find out -- and I don't think you'll really find out unless you look at the peak. And the peak ain't at the two-hour point. Not in my case, anyway.

I was invited to try an on-line app from WebMD called the WebMD Symptom Checker. But as soon as I saw the graphic that appears when you launch the thing, I thought, "No need to run the app; I can already see what this guy's problem is".

On Saturday, the weather being beautiful, I went on a long trail-run in the state park (about 10 miles). Seemingly every able-bodied person in town was there on the trails, running or hiking or mountain-biking, so to escape the crowds I choose a trail that goes into a remote region of the park where I don't go very often. As I got deeper into the recesses of the park, I encountered fewer and fewer people. Around the point I got amongst the redwoods, I began to feel that I was a rugged adventurer, out there all on my own. Nobody else was tough enough to get this far into the woods!

Immediately after thinking that thought, I encountered a young couple coming the other way. They were pushing a baby in a stroller.

Monday, January 2, 2011


I've got one more day off, and the weather's still beautiful. The temperature got up to 65 degrees on New Year's Day (which, for those who live outside the the Fahrenheit States of America, is a little over 18 Celsius -- comfortable by almost any standard). Anyway, I think I'm going to spend the day visiting friends I don't often get to see. Sorry -- not a blogging day!

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