Taking a Break

This blog will be taking the month of August as a long vacation. During part of the month I will be traveling to music festivals in Ireland, but even during those weeks when I am here in California and within easy reach of the internet, I won't be blogging. Blogging as frequently as I do has become a bit overwhelming to me lately, and I'm afraid I will burn out completely if I don't take a long break from it now. I don't expect to update this page until September 1st, so I hope that my readers won't forget that my blog exists between now and then! 
 

 

Another Calorie-Burning Disappointment

Tuesday, July 31, 2012


You Can't Work It Off

Whenever I read about a health research study, the first thing I think about is "what false interpretation is going to be placed on this in non-technical news accounts?". The particular research that is giving me that concern today is one on "Hunger-Gatherer Energetics and Human Obesity". The study compared the Hadza, a hunter-gatherer population in Tanzania (known for being both lean and physically active) with more modernized populations (known for being fat, and often assumed to be inactive). A sophisticated measurement process was used to determine how many calories per day everyone was burning. The idea, of course, was to show that the Hadza are thinner than we are because they are burning more calories per day than we are.

Well, surprise, surprise! It turns out that, despite all the time they spend walking around gathering food, the Hadza don't burn more calories per day than the rest of us. Energy expenditure per day is pretty constant from one population to another, even though the Hadza seemingly are doing a lot more stuff than we are. The body cranks up (or throttles back) its calorie consumption rate as it chooses, partly by adjusting its metabolic rate, and people with very different lifestyles can end up burning calories at similar rates. Whatever the reason is for the Hadza being leaner than we are, it isn't that their calorie burn rate is higher.

So what will people make of this finding? What I am afraid will happen is that people will conclude that exercise is useless. If being more active doesn't make you thinner, what's the point of exercising? But, of course, the idea that exercise is the key to weight loss was always nonsense. Anyone who has gone through the experience of training for a marathon -- with the longer practice runs getting up into the 15-20 mile range during the month before the race -- knows how unrealistic it is to expect that doing a lot of exercise is going to make you lose pounds. I have long wished that people would stop promoting exercise as a weight-loss method, because that's the one health benefit it doesn't provide, and people lose all the benefits it does provide if they give up on it as soon as they notice that it doesn't help you lose weight.

But there's another way to misread this study result, and some have already made it: if total calories burned isn't the important issue in body weight, then obviously the important issue must be total calories swallowed. This sounds reasonable -- but then, so did the now-discredited notion that total calories burned was the most important issue.

There is plenty of evidence to suggest that what you eat matters more than how many calories you take in. It seems to me that the next step is to find out how the Hadza diet differs from our diet. I'm guessing it won't turn out that they're eating a lot of refined carbs. 


Improving the Olympics

For as long as the Olympics continue, people will be arguing about which sports should or shouldn't be included. I was surprised to learn that, in the original games in ancient Greece, at least one competition was decidedly non-athletic: there was a poetry competition included! Not only that, the poetry competition was included in the first modern re-creation of the games in 1896 -- and it remained a part of the games until 1948. (I don't know why the poetry event was dropped after 1948, but perhaps the problem was that too many of the entries submitted were about a man from Nantucket.)

But if the Olympics want to broaden the event to include competition that have never been part of the games before, I think I have found the perfect addition: bee-bearding.

The goal of bee-bearding, so far as I can ascertain, is to cover your body with more bees than any of your challengers can manage to attract. The beekeeper in the photo (Lu Kongjiang) was competing in a bee-bearding event in Shaoyang, China last year. And he didn't even win! The winner was Wang Dalin, who managed to attract to his body a bee-population weighing 59 pounds. But I have not been able to find a photo of that, nor have I been able to ascertain whether or not Wang Dalin was diabetic. A lot of people seem to think that this is what happens to diabetes patients as soon as they walk outside.

If bee-bearding ever does become an Olympic sport, you can bet people will start accusing diabetic competitors of gaining an unfair advantage by not taking their meds. That's why I want to see this event become an Olympic sport: it would be nice to have a non-doping scandal for a change, wouldn't it?


Streamlining Diabetes Treatment

Monday, July 30, 2012


New Government Commission = Good News?

Sometimes news is announced in such a way as to suggest that everyone in the world is sure to agree that it is a very welcome development. Which makes it hard for me, because I'm usually the one person in the world who isn't so sure.

The title alone of this Medscape article is enough to provoke a faint twinge of skepticism: "New Government Commission Could Streamline Diabetes Care". This relates to H.R. 2960 (the National Diabetes Clinical Care Commission Act), a bill inching its way through Congress. Some veteran observers of the activities of government commissions might be inclined to wonder how likely it is that creating a new one is really going to "streamline" anything.

For me, though, the major concern isn't that the new government commission might fail to streamline diabetes care; I'm more worried about what will happen if it succeeds. What will this "streamlined" diabetes care be like? What changes are likely? And what does streamlining mean, anyway?

Well, in a sense, it doesn't matter what streamlining means, because Medscape is using the word in their headline but Congress apparently isn't using it in the bill. Still, it seems as if streamlining is an actual goal in this case, whether it is called that or not, so it's worth pondering what it means.

Streamlining in the literal sense means to change the contour of an object so that it offers the least possible resistance to a liquid or gas flowing around it -- in other words, to streamline something is to smooth or simplify it, so that drag is minimized. This engineering term is used metaphorically in regard to government or corporate organizations, in the sense of simplifying them to make them operate faster or more efficiently.

So I ask myself, is the main problem with diabetes care right now that it isn't simple enough -- that too many complexities are taken into account, and therefore decisions about care aren't made as predictably and as rapidly as they ought to be? I am not at all convinced that this is the real problem. If anything, I think that the trend in recent years has been towards excessive simplicity. Doctors have been increasingly pressured to stop thinking about their diabetes patients as individuals with a unique set of needs and capabilities, and just stick to the playbook. (A playbook which is all about prescribing more and more drugs over time, it is almost needless to say.) Isn't it pretty likely that this government commission will only intensify the pressure to adhere to a one-size-fits-all formula for proper diabetes treatment? That, at least, is what worries me about this idea.

In all fairness, though, I should mention that everyone besides me seems to be thrilled:

And here's a summary of the bill itself (from the Congressional Research Service, a non-partisan arm of the Library of Congress):

National Diabetes Clinical Care Commission Act -- Establishes within the Department of Health and Human Services (HHS) the National Diabetes Clinical Care Commission to evaluate and make recommendations regarding better coordination and leveraging of federal programs that relate in any way to supporting appropriate clinical care for people with pre-diabetes and diabetes.

Sets forth the duties of the Commission, which shall include:

  1. evaluating HHS programs;
  2. identifying current activities and critical gaps in federal efforts to support clinicians in providing care to people with pre-diabetes and diabetes;
  3. using outcomes-based registry data to evaluate various care models and methods;
  4. evaluating and expanding education and awareness to health care professionals regarding clinical practices for the prevention of diabetes and the precursor conditions of diabetes; and
  5. developing and testing appropriate methods for outreach and dissemination of educational resources related to diabetes prevention and treatments.

Requires the Commission to submit to the Secretary and Congress an operating plan for carrying out the activities of the Commission that includes specific activities the Commission plans to conduct and a budget for such activities.

Now was that vague and boring enough for you? I have a feeling that the people who have praising this bill to the skies have been given some kind of private assurances by the congressional sponsors about what it really will amount to, and are reacting to those private assurances rather than to anything that's in the bill.

I found the full text of the bill on a site which gave me temporary access and then "timed out", so I don't know how to give you a lasting link to it. But the only thing I found in it that seems much more interesting than the summary I've given above is the idea that "patient advocates" will be among the many people that the commission is supposed to include as voting members. It sounds as if the patient advocates will be vastly outnumbered by doctors and bureaucrats, but apparently they will have a chance to say something in Washington, and that's better than nothing.

However, I take a mighty pessimistic view of this whole enterprise. It seems to me that, even if this new commission does not end up being entirely captured by the pharmaceutical industry, it will (at best) devote itself to the needs and limitations of the Average Diabetes Patient, or whatever they imagine the Average Diabetes Patient to be.

My whole diabetes management program, ever since I was diagnosed in early 2001, has been about trying not to be anything like the Average Diabetes Patient. Won't the commission and I be at cross-purposes? Theoretically not, if their operation is truly going to be "outcomes-based". If my "outcome" is a fasting BG of 85 mg/dl and a post-prandial BG of 100 mg/dl, more than eleven years since diagnosis, seemingly an outcomes-based enterprise will want to take a close look at what I'm up to. But I know, and you know, that they'll figure out how to dismiss me as irrelevant. I'm not the Average Diabetes Patient, after all, so who cares what my story is?

Grumble, grumble.


Still Healing Up

Recovery from the injury I described on July 22nd continues, slowly. I was able to go to my Monday-night yoga class tonight. However, my teacher knew about my injury, and chose to give us a lot of poses that put very little pressure on the hand. It wasn't a severe challenge. However, I know that I did some things that I couldn't have done a few days ago, so I'm making progress.

I hope I'm soon recovered enough to get back to weight-training. Falling behind on that is a pretty frustrating thing. You can lose a lot of ground in a short time!   


The Diabetes Olympics!

Friday, July 27, 2012


Does it Matter Who Sponsors the Olympics?

Oh, dear: not everyone is happy with the heavy sponsorhip presence of junk-food companies at the 2012 Olympic Games in London.

The English medical journal The Lancet greated the games with an editorial titled (somewhat waggishly) "Chariots of Fries" :

"The Games should encourage physical activity, promote healthy living, and inspire the next generation to exercise. However, marring this healthy vision has been the choice of junk food and drink giants -- McDonald's, Coca-Cola, and Cadbury's -- as major sponsors of the event. Health campaigners have rightly been dismayed. On June 20, the London Assembly (an elected body that scrutinises the work of the Mayor of London) passed a motion urging the International Olympic Committee (IOC) to adopt strict sponsorship criteria that exclude food and drinks companies strongly associated with high calorie brands and products linked to childhood obesity. Meanwhile, the UK's Academy of Medical Royal Colleges has said that the presence of McDonald's and Coca-Cola at the 2012 Games sends out the wrong message to children. Indeed, their presence is hardly subtle. The new two-storey McDonald's restaurant at the Olympic Park in Stratford will be the biggest in the world. It will serve up to 1200 customers an hour and make 3 million pounds selling fast food during the Games. Cadbury's has joined forces with McDonald's to offer what it states on its website will be the "perfect snack" to enjoy whilst watching the Games -- a chocolate bar-ice cream concoction with a whopping 395 calories per serving. Coca-Cola, meanwhile, has raised its profile considerably by branding the Olympic torch relay."

The editorial appeared in an issue of The Lancet which also included multiple articles on physical inactivity (and the health problems caused thereby). Doctors and public-health officials who see the Olympics as an opportunity to inspire millions of people to become more physically active tend to feel that the opportunity is lost, if the message of the Olympics seems to be "you're not consuming enough sugar!".

Of course, I'm about as willing as anyone else is to deplore what has happened to the Olympics generally...

...however, in terms of inspiring people to become more active, I'm not absolutely sure that the Olympics would do the trick even if the games weren't being sponsored by SugarCrapCorp and Amalgamated Hydrogenated Industries. The problem is that the athletes participating in the Olympics are so much better than any of us could ever be, they don't even seem to belong to the same species as the rest of us.

I wonder if people aren't likelier to be inspired to become more active, not by watching televised superheroes doing the impossible, but by watching local non-Olympians doing their best.

However, that doesn't mean it makes no difference that the Olympic Games have been so thoroughly hijacked by corporate interests -- and specifically by corporations that seem to have business plans that hinge on making people fat and sick.

Of course, it used to be that the Olympic Games were hijacked more often by nationalistic jingoists than by international corporations, and that wasn't a barrel of laughs either. Who knows -- maybe someday we'll have an Olympic Games event that is mainly about what the athletes are doing.


Can Exercise Be Bad?

Thursday, July 26, 2012


Going Too Far With Exercise

The recovery of my sore left hand (from the fall I took while trail-running on Sunday) has been proceeding awfully slowly. I'm not disabled by it exactly, as I can do most things that I need to do, and it doesn't hurt when I'm not trying to do anything with that hand. I tend to forget about it, actually, until I try to do something simple such reaching back to put on my seat belt, and suddenly I discover that the necessary grabbing motion hurts like blazes now. Well, maybe not like real blazes, but like metaphorical blazes. It hurts, anyway. I want it to start hurting less than this really soon.

Maybe what I'm experiencing is an example of the harm that can be done by exercising too much. Some research papers last month raised the issue of health problems caused by over-exercising, and of course these papers were much-discussed, as they seemed to some people to offer an excuse for not exercising at all, and seemed to other people to offer proof that a minimal exercise program was better than a challenging one.

A Mayo Clinic paper entitled "Potential Adverse Cardiovascular Effects From Excessive Endurance Exercise" suggests that there may be a point at which adding more exercise to your weekly schedule does more harm than good. As usually happens in these matters, the authors of the paper are more cautious in presenting their case than the journalists who summarize their ideas for a wider audience. The paper goes out of its way to avoid suggesting that exercise is a bad thing:

"Regular exercise is one of the cornerstones of therapeutic lifestyle changes for producing optimal cardiovascular (CV) and overall health. Physical exercise, though not a drug, possesses many traits of a powerful pharmacological agent. A routine of daily physical activity (PA) stimulates a number of beneficial physiologic changes in the body and can be highly effective for prevention and treatment of many of our most prevalent and pernicious chronic diseases, including coronary heart disease (CHD), hypertension, heart failure, obesity, depression, and diabetes mellitus. People who exercise regularly have markedly lower rates of disability and a mean life expectancy that is 7 years longer than that of their physically inactive contemporaries. Accordingly, physicians are increasingly prescribing regular exercise training (ET) for their patients. However, as with any pharmacological agent, a safe upper-dose limit potentially exists, beyond which the adverse effects (musculoskeletal trauma, metabolic derangements, CV stress, etc) of physical ET may outweigh its benefits."

Before we over-interpret this, we need to keep some issues in mind -- chief among them that nobody is claiming that excessive exercise is worse than no exercise -- the latter is a definitely worse.

Here's a graph which shows that, at least for "vigorous" exercise (how that is defined, I cannot tell you), the benefits seem to peak when you reach the point that you are averaging 50 to 60 minutes a day: 

The higher you go on this graph, the more you are reducing the risk of death from all causes -- which means that you'd have to drop all the way to the bottom to be doing as badly as people who aren't exercising. So let's keep that in mind, okay? But the other thing I notice about this graph is that the benefits for more moderate exercise do not seem to peak anywhere below two hours of exercise a day. I think most of us who exercise regularly are pretty safe, on that basis.

Of course, I'm not sure whether the kind of running I do counts as "vigorous" here. I'm not fast, so maybe only the real runners are truly vigorous. But even if my less impressive running performance counts as vigorous, most of my runs take less than an hour, so seemingly I'm at the benefit peak. And if what I do doesn't count as vigorous, I could do a lot more of it per day and still not be at the benefit peak.

The rest of the paper goes into excruciating detail about the many subtle indicators which clinicians can use to spot potential heart trouble, and the tendency of these indicators to be elevated in extreme endurance athletes. Okay, fine -- but if these indicators were really leading to all that much trouble, I think the traces on the graph above would be plunging to the basement as they proceeded to the right.

In short, it seems to me that the mortality trends pretty much rule out the possibility that endurance exercise is a bad thing on balance. I'm sure it's possible to get too much of it, but I don't think I am doing that, and I don't think most endurance athletes are, either.

I just need to learn how not to fall down and hurt my hand while I'm running. If I can master that, I should be good to go.
   


Cause of Diabetes No. 5127

Wednesday, July 25, 2012


Dropping in at Paradise

After work I stopped by the Paradise Ridge winery, conveniently located a mile from my workplace, for a social evening at one of their Wednesday-night "Wines & Sunsets" evenings on the balcony -- one of the great perks of living in this area.

As you can probably tell from the picture, their wine-making talents were not wasted on me. Expect tonight's blog post to be comparatively brief, and perhaps not very deeply analytical.


Diabetes and... Air Pollution?

Health-news articles can be sorted into a fairly small number of categories, I find. Two categories that are especially common, at least among articles related to diabetes, are the "diabetes causes everything" articles and the "everything causes diabetes" articles. 

The typical "diabetes causes everything" article tells us about a study which reveals that yet another health problem has turned out to be more common in people with diabetes. Frozen shoulder? Blame diabetes. Can't pronounce the word "chinoiserie"? Better check your glucose. Lost your car keys? Diabetes patients do that all the time. Accidentally sawed your left arm off? We've been seeing a lot of that among diabetes patients. And so on.

The typical "everything causes diabetes" article tells us about a study which reveals that yet another factor has been identified which increases your odds of developing diabetes, and suggests that we ought think about the risks before... owning a parakeet, having a fourth child, sleeping on flannel sheets, or whatever else supposedly increases your risk. (I made those examples up, by the way -- I don't know that any of those things has been accused of causing diabetes.)

The trouble with both kinds of articles is that they show an association (often a comparatively weak association) between two things, and suggest a cause-and-effect relationship between them which might be imaginary. 

Occasionally an association between two things is so strong that a cause-and-effect relationship is hard to deny. Mesothelioma (a form of cancer occurring in the chest cavity) is rare... in everyone except those who have had a lot of on-the-job exposure to asbestos; in that case, the connection isn't too hard to figure out, and only a lawyer for the asbestos industry would have trouble grasping it.

However, most articles which claim to that some factor or other causes diabetes are referring to a much weaker association. If you compare chefs to football coaches and find that diabetes is 15% more common in one of those two groups, exactly what have you discovered? That one of those two professions "causes" diabetes -- or that there is some other difference between people in those professions which makes one of them 15% likelier than the other to become diabetic?

This study, for example, aims to show that air pollution causes diabetes (apparently by promoting chronic inflammation).  But the study pursues that goal by comparing diabetes rates between middle-aged women living in an industrial area of Germany and women living in rural areas in Germany, and finding that the women in the industrial area had a higher diabetes rate (or at least were diagnosed with diabetes at a higher rate).

But what does that prove about the relationship between air pollution and diabetes? Not much, really. If air pollution were the only difference between life in an industrial area and life in a rural area, the study might have something to tell us about the relationship between air pollution and diabetes. But other differences between industrial and rural areas almost certainly exist.

The diabetes rate was assumed to be identical with the rate at which the patients were diagnosed by doctors with diabetes. This is a questionable assumption, because people living in rural areas often have less access to medical care and less frequent doctor visits, so they are less likely to be diagnosed with diabtes even if they have it. Also, the study did not control for lifestyle factors such as diet. So who knows what else was different between the patients, besides how polluted the air in their neighborhood was?

It is not impossible that air pollution is a factor in raising the risk of diabetes in urban areas, but it takes more than a study like this to make that claim plausible.


News that Isn't New,
Mysteries that Aren't Mysterious!

Tuesday, July 24, 2012


Recovery Continues...

I'm healing up from the fall I took while trail-running on the weekend; my sore left hand is slowly getting stronger and hurting less. I'm able to use it a little more forcefully. I was able to get my tight-fitting running shoes on today, and go for a run (no problem with my feet -- my hands were just too sore yesterday to apply the necessary force). I wasn't a great runner today, but nothing hurt.

My fasting test this morning was higher than I would have expected, given that I'd had a pretty low-carb dinner last night. Why the increase? I have no idea, really. I said yesterday, when my numbers were low, that if they'd been high I would have blamed it on my injury, and that this should be a warning to me against blaming high numbers on any excuse I can seize on. Obviously I can't change my position on that issue so soon, so I'll just have to say I don't know why I was elevated this morning, and hope to be lower tomorrow.


Vive la Difference!

From time to time, I read a news item from the world of medical research which discusses some phenomenon which is said to be leaving scientists baffled. And my reaction is to wonder where their bafflement is coming from, seeing as the oddity in question has been much-discussed (and, at least in my view, satisfactorily explained) already.

That was my reaction to a Medscape article entitled Job Stress Strains a Woman's Heart, But No One Knows Why. 

I beg your pardon: everyone knows why. At least, everyone who has looked at the relationship between stress and heart disease knows why.

A few years ago my company hosted a health lecture by a cardiologist (John M. Kennedy) who was then about to publish a book ("The 15 Minute Heart Cure") about controlling stress as a means of preventing heart attacks. In his lecture, he said that, in terms of prevention of heart disease, the medical profession was weirdly fixated on one problem which is associated with a high risk of heart disease (elevated serum cholesterol), while ignoring a separate issue which is at least as important, if not more so: the harmful effects of stress on arterial health.

He said that stress promotes the excessive production of "stress hormones" (such as adrenaline and cortisol), and that these hormones have inflammatory effects on the arteries and therefore promote the buildup of cholesterol plaques on the arterial walls. The inflammatory effects are both direct (like excessive insulin levels, excessive stress-hormone levels tend to inflame the arterial walls) and indirect (stress hormones promote high blood pressure and other problems which also have an inflammatory effect on arterial walls). His book is about using relaxation techniques ("breathe breaks") as a means of reducing stress.

What is held to be mysterious in the new study is not so much that women are affected by job stress, but rather that women are affected differently by certain kinds of job stress than men are. It seems that a man's heart health is endangered if he has a demanding job in which he feels powerless, but not so much if he has a demanding job in which he has more autonomy. Women, however, experience negative effects on their heart health from a demanding job, even if they do have more autonomy.

For heaven's sake, how much imagination does it take to figure this out? What the scientists have uncovered here is not a difference in the way men and women react to stress -- it's a difference in what men and women find stressful.

Perhaps what stresses men out worst of all is feeling that they are powerless on the job, and what stresses women out worst of all is something else -- such as (I'm taking a wild leap of imagination here) feeling that they will be judged  by a more demanding standard than their male peers are?  Whatever the exact reason for it, it seems to me that what the researchers have identified here is a tendency for women to experience stress, not only in situations which also have that effect on men, but in situations which men are less bothered by.

If researchers find it baffling that men are especially stresed out by a feeling of powerlessness, then they have never been men, and probably haven't met too many of them either.


Taking a Fall

Monday, July 23, 2012


I suffered an injury while running over the weekend -- nothing that requires professional intervention, but I might as well talk about it, as that is what's been on my mind today.

How it Happened

Nearly every weekend I go trail-running at a nearby state park, and every time I do it, I worry about tripping over a rock or an exposed tree-root and taking a nasty fall. The reason I worry about this happening is that it does happen once in a while, despite all my attempts at being careful. It happens something like once a year... and I was about due.

It was hot and I was running at mid-day, so I chose the shadiest trail available. l was running downhill on a trail through the woods that was shady enough for obstructions to be hard to spot. I caught my foot on something (I don't know what) and went flying.

I am not able reconstruct the sequence of events very clearly. Seemingly I came down first on my hands, because that's where the deep scrapes were. There were more superficial abrasions in various other places, including my right knee, my left thigh, and on the back of my shoulders. That last detail puzzled me when I was trying to put together what had happened afterward, but I must have rolled over after I hit the ground, and slid on my back a bit before I came to a full stop. The back of my shirt was more caked with dirt than the front of it, even though I seemingly landed face-down initially.

A woman who as hiking on the trail and saw me fall asked me right away if I needed her to call for help to get me out of there. It was a good question; when I first started moving again, I had no idea how badly I might be hurt, and had to experiment cautiously with the use of each limb to make sure I hadn't broken a bone or something. Ultimately I told her that I thought I was able to keep going, and continue running back to my car.

Damage Assessment

I'll spare you any ugly closeups of the wounded patches on the heels of my hands, but I have a lot of this kind of light scouring elsewhere:

Those lighter abrasions aren't really causing me much discomfort, at least now that I've got them cleaned up (when you fall down while trail-running, cleaning the dirt out of your scrapes is definitely not the fun part of the adventure).

Even the deeper scrapes on the heels of my hands are not that uncomfortable, and they're small enough that a standard-issue Band-Aid covers them adequately.

What is bothering me is that, in coming down so hard on my hands, I caused gave myself a slight sprain, particularly in my left thumb. I can move the thumb, but stretching it much in any direction hurts, and applying any muscular exertion with my left hand hurts more. In effect, my left hand has no strength. This morning, I struggled for a long time trying to twist the plastic cap off a half-gallon jug of milk; just holding the jug steady with my left hand while I twisted the cap with my right was more than my left hand wanted to do. I can do some things pretty easily (typing is not a problem -- which is good, because I spend my workday at a computer keyboard), and I can play the fiddle (although the notes that require me to stretch my left hand cause a new and unusual strain). But I knew, from the start of the day, that I wasn't going to be able to go running at lunchtime -- because I knew that I wasn't going to be able to get my running shoes on.

I actually have to strain quite a bit squeezing my heels into my running shoes at the best of times, and these are clearly not the best of times. I knew that I wasn't going to have enough strength in my hands to get those shoes on. I resolved to work out at the gym after work, but the shoe problem was still going to be there, so I went to the store before I went to the gym, and bought some cheap laceless deck shoes which I was pretty sure I could put on without too much trouble. (This trick worked -- but I hope that by tomorrow I'll have regained enough strength in my hand to put on real running shoes again.)

The good news: I wasn't feeling stiff and sore anywhere but in my hands, so I feel able to exercise -- in principle!

Risk/Benefit Analysis

You may well ask, if trail-running carries such a high risk of falling down and getting injured, why do it? Wouldn't it be better to confine myself to safer forms of exercise?

Well, a risk/benefit analysis isn't worth anything unless you look at all the risks and benefits -- not just the obvious ones. Exercise always involves some risk of injury; you can get a running injury even if you only run on a treadmill and you never fall off it. Unfortunately, the risk of injury tends to rise as exercise becomes more entertaining. The guys at work who play basketball at lunchtime sure seem to be having a lot of fun, and a lot of knee surgery as well. Biking is fun, but undoubtedly carries a risk of an accident (where I live, it mainly carries a risk of being run over by a drunk driver -- we've been having a lot of that lately). Trail-running is more fun than running on streets, and certainly more fun than running on a treadmill, but it does carry a heightened risk of tripping and falling.

You could argue that having fun is not what my exercise program is supposed to be about -- it's intended to help me keep my blood glucose within the normal range, and it doesn't need to be enjoyable to achieve that goal. Or does it?

So long as we're noting risks, let's not overlook the commonest risk associated with any sort of exercise program: the risk that you will stop doing it. If you exercise on the principle that fun is irrelevant, and that exercise shouldn't be anything other than unpleasant and boring, it is not too likely that you're going to keep up with your exercise program over the long haul. Show me a diabetes patient who isn't trying to learn how to get some enjoyment out of exercise, and I'll show you a diabetes patient who isn't going to be exercising a year from now.

I have found that I like trail-running, a lot more than I like running on pavement, even though the distances are usually longer. The run that resulted in my injury over the weekend was 8.3 miles, and the distance didn't seem excessive because I was running through woods and fields, and there was some pleasure in it for me. I need to have at least some of the exercise I do seem entertaining, you know what I mean?

And so, even though trail-running carries an extra risk of accident, I think giving it up would carry an unacceptable risk of another kind. Diabetic burnout -- that dangerous psychological reaction a lot of patients have, which causes them to become so weary of diabetes management that they give up on it entirely --could very easily be triggered by a boring exercise program. And safe exercise programs tend to be boring. It's too bad, but that's how it is!

Further Deep Thoughts

There's nothing quite like a temporary disability to scare you into brooding about what your life would be like if the disability were permanent. Spending a day unable to use my left hand for anything requiring a strong grip has been disturbing. When your hand hurts enough to force you to wear different clothes than you intended to (just so you can be sure of getting them on and off), life is a very different experience. A lot of people have arthritis that limits them in the same way I'm limited today -- who's to say this will not happen to me in the future, and not just for a day or two?

For the present, I'm just hoping that tomorrow my hand will be noticeably recovering. Tonight I'm using ibuprofen and ice to hurry the recovery along. 

Oh, and one more thing. As I have a lot of abraded skin on me at the moment, you might expect that this would produce an inflammatory response which would diminish my insulin sensitivity and give me higher glucose test results today. As it happens, my results were good. If they had been bad, though, I would have blamed the results on my body's reaction to the accident -- probably incorrectly. That's something we need to think about, when we're trying to make sense of the fluctuations in our glucose results. There are always so many reasons we can think of for glucose to be high, other than the reason that's usually the most likely (you ate too much starch, right?). Before blaming a high result on an injury or a headcold or hot weather, we need to ask ourselves if those things have happened to us in the past without driving up our glucose results. It's just as important to remember what hasn't spiked you in the past as to remember what has.


Good Test, Bad Test

Friday, July 20, 2012


What's the Right Way to Screen for Diabetes?

Perhaps nothing better illustrates how poorly Type 2 diabetes is understood, to this day, than the continuing controversies about which lab test should be used to diagnose it.

There are three measurements commonly used as a screening test for diabetes:

I would rank the first test as unquestionably the weakest of the three. When a patient is developing diabetes and gradually losing glycemic control, fasting glucose is often the last thing to go. If doctors screen for diabetes using a fasting test, they are testing the patient's blood at the one time of day when the result is likeliest to give a false impression of normality. A lot of diabetes patients go undiagnosed for years, because their fasting tests don't give the game away. So, the fasting test is not a very effective way to screen for diabetes. The only reason it is still used is because it's cheap and convenient.

The hemoglobin A1c test is a much better indicator of glycemic control overall. If your blood glucose is normal in the morning but elevated after meals, the A1c test result is going to be elevated. Whatever happens to your glucose at any time of day has some impact on the test result. Some have argued that the A1c test is "unfair" because some people get a higher A1c result than others, for the same average blood glucose level, so it shouldn't be used for diagnostic purposes. Well, the test measures how much of your hemoglobin is glycated (bonded with sugar), and glycation is the measure of how much harm your blood glucose is doing to you. It may be "unfair" that some people suffer more harm from a given glucose level than others do, but it's not "unfair" diagnose diabetes based on how much glucose-related harm is being inflicted on them. That's sort of why we give a damn about diabetes in the first place, remember?

The Oral Glucose Tolerance Test or OGTT is a kind of torture-testing; it isn't really intended to find out what your blood glucose levels are typically like, but rather to find out how well your system can cope with being hit by a tidal wave of glucose. When you take the test, you have to swallow 75 grams of glucose (more, in some versions of the test), and if that sounds easy and pleasant you haven't tried it. A lot of patients find it nauseating to swallow that much pure glucose at once, and have difficulty keeping it down. As a means of probing the weaknesses in a patient's glycemic control system, the OGTT does seem more thorough than any other test -- but is it necessary to take things this far? If your A1c result is normal, then your blood glucose level on average is within bounds; does it really matter that much if you can't handle 75 grams of pure glucose, if you don't normally ingest 75 grams of pure glucose?

My vote is for the A1c test. But not everyone agrees! An article in Diabetes Care entitled Hemoglobin A1c Versus Oral Glucose Tolerance Test in Postpartum Diabetes Screening found fault with the A1c test. The study authors found that a lot of women, after giving birth, passed the A1c test but not the OGTT. They see this as evidence that there is something wrong with the A1c test.

Well, maybe. It seems to me that a patient who can pass an A1c test but not an OGTT test is not diabetic, but rather at risk of becoming diabetic. It indicates that their glycemic regulatory system doesn't provide them with as much of a safety margin as they would like to have; they're getting by, so far, under ordinary circumstances, but they might not be able to handle an extreme challenge.

But you see what I mean, I assume, about the confusing nature of Type 2 diabetes. On what basis do we say we have it? Does a patient somehow qualify as diabetic, even if their blood glucose is normal so far, simply because they can't maintain normal glucose levels under extraordinary circumstances which don't actually exist in their lives?

I'm sure it's worth finding out if you have any early warning signs that you're likely to become diabetic later on. But I'm not sure that an A1c test which fails to indicate you're diabetic right now, if you really aren't, is letting you down in any significant way. 


Drinking Candy

Thursday, July 19, 2012


Super-Low Post-Prandial

Only 80 mg/dl after dinner? That may seem weirdly low, but it's not inexplicable. I had a lot of exercise today (a difficult, hilly run of more than five miles -- and then, just before dinner, weight-training at the gym). And the dinner was very low-carb: meat and vegetables, no starch. I would expect my result after dinner to be low. Not necessarily that low, but low.


Sports Products Under the Microscope

One of the remarkable things that happens to people when they make some kind of substantial alteration in their lives (going to college, leaving college, starting a career, changing careers, getting married, buying a house, having children) is that they become part of the target market for products which they might not have known existed before.

This is especially true when you take up regular exercise. Suddenly there are a lot of companies trying to sell you a bewildering variety of sports-related products.

Take up cycling, and there is almost no end to the products you will soon find yourself buying. Bike clothes, bike helmets, bike shoes, bike gloves... but that's only the beginning. Rear-view mirrors that clip on to your sunglasses. GPS devices to tell you how far you've gone (and, if you're lucky, where you are). Headlamps and blinking tail-lights for night riding. Tire pumps and repair kits and tools of all sorts. Chain lubricants and chemical cleaners that are probably illegal to use within city limits. Backpacks and hydration bags. Racks for attaching your bike to the back of your car. Special devices for tying your bike securely to the rack on the back of your car.

Running is a little less equipment-intensive than cycling, but still there are a lot of things to spend money on (expensive shoes, shorts, shirts, headgear, and GPS gadgets).

And what all sports have in common is the large set of products designed for the inside of you rather than the outside of you: the sports drinks and supplements which are supposed to protect you from dehydration, restore your electrolyte balance, charge you up with energy, and enhance your performance.

Well, just in time for the Olympics, the BMJ (formerly the British Medical Journal, but now just "BMJ" because initials are cooler when they don't stand for anything) has published a collection of highly critical articles about sports drinks and related products which claim to enhance sports performance. This shotgun blast of articles is too big and complex for me to summarize fairly, but I guess my unfair summary would be: "The companies that make these products are selling them with claims which they cannot back up, except by citing research which is shoddy and/or corrupt."

The fruity colors of these products send a powerful subliminal message (that they're a kind of liquid candy), while the advertising for these products sends a powerful overt (but usually untrue) message that there's little or no sugar in them.

Of course, if you are running a marathon, somewhere between mile 10 and mile 15 you probably are going to need to get some sugar into your system, and a sports drink might be an excellent way to accomplish that. But, of course, most of the people to whom these products are marketed are not going to be running a marathon -- they're going to be walking a mile or two. And those people definitely don't need a sugar infusion.

One of the BMJ articles is called "The evidence underpinning sports performance products: a systematic assessment". The conclusion:

"There is a striking lack of evidence to support the vast majority of sports-related products that make claims related to enhanced performance or recovery, including drinks, supplements and footwear. Half of all websites for these products provided no evidence for their claims, and of those that do, half of the evidence is not suitable for critical appraisal. No systematic reviews were found, and overall, the evidence base was judged to be at high risk of bias. Half of the trials were not randomised, and only 7% reported adequate allocation concealment. We found only three trials that were reported with sufficient details to be judged high quality and free from bias."

Another article was called "The truth about sports drinks". The conclusion:

"A team at the Centre of Evidence Based Medicine at Oxford University assessed the evidence behind 431 performance enhancing claims in adverts for 104 different sports products including sports drinks, protein shakes and trainers.

If the evidence wasn't clear from the adverts, they contacted the companies for more information. Some, like Puma, did not provide any evidence, while others like GlaxoSmithKline -- makers of Lucozade Sport -- provided hundreds of studies.

Yet only three (2.7%) of the studies the team was able to assess were judged to be of high quality and at low risk of bias. They say this absence of high quality evidence is 'worrying' and call for better research in this area to help inform decisions."

  

Another article: "Commentary: role of hydration in health and exercise". This article concludes that the makers of sports drinks are promoting mythology to the effect that athletes need to consume large quantities of sports drinks before they are even thirsty:

"Humans do not regulate fluid balance on a moment to moment basis. Because of our evolutionary history, we are delayed drinkers and correct the fluid deficits generated by exercise at, for example, the next meal, when the electrolyte (principally sodium but also potassium) deficits are also corrected.1 As a result, there is no need to completely replace any fluid deficit as it develops either at rest or during exercise. Instead people optimise their hydration status by drinking according to the dictates of thirst.

Over the past 40 years humans have been misled -- mainly by the marketing departments of companies selling sports drinks --to believe that they need to drink to stay 'ahead of thirst' to be optimally hydrated. In fact, relatively small increases in total body water can be fatal. A 2% increase in total body water produces generalised oedema that can impair athletic and mental performance; greater levels of overhydration result in hyponatraemic encephalopathy -- severe cerebral oedema that produces confusion, seizures, coma, and ultimately death from respiratory arrest."

Another article on the same subject: "To drink or not to drink to drink recommendations: the evidence".  

"An important consequence of drinking to thirst is that a substantial body mass loss is likely to occur. However, drinking according to the dictate of thirst throughout a marathon seems to confer no major disadvantage over drinking to replace all fluid losses,  and there is no evidence that full fluid replacement is superior to drinking to thirst. A meta-analysis of cycling studies concluded that drinking either more or less than to thirst impairs exercise performance. This analysis also found that up to a 4% body mass loss did not alter out of door cycling performance. Nor do the world's best marathoners maintain their body mass within current recommended ranges of 2-3% during successful marathon racing. This evidence and the finding that the athletes who lose the most body mass during marathon or ultra-marathon races and Ironman triathlons are usually the most successful, would suggest that there exists a tolerable range for dehydration that may not negatively impact on running performance. Perhaps this mass loss might even confer an advantage by preventing a substantial increase in body mass because of the 'overconsumption' of large volumes of fluid."

Look, I understand the appeal of these products as well as anyone does. When you're exercising a lot, and wishing you were better at it, it is incredibly tempting to think that you can gain an advantage by purchasing a bottle of candy-colored sweetness, brimming with mystery ingredients which will somehow enhance your performance.

But if you're not doing endurance sports (in other words, if your workout doesn't last 90 minutes or more) you don't need a sports drink at all. A walk in the park, or even a five-mile run, does not even bring you close to needing a sports drink -- especially if you have diabetes.

In short, sports drinks can have their uses under certain very demanding conditions, but for most people (including most people who exercise regularly) there is no need for these things.
 


Questions from the Outside World

Wednesday, July 18, 2012


Things people have been wondering about this week, if the phrases they googled are any indication...

"why diabetic make you pee to much"

When your blood circulates through your body, it gets filtered through some tiny structures in your kidneys known as renal tubules. If the concentration of sugar in the blood going through those tubules is a lot higher than normal, this causes water to flow in through the walls of those tubules (due to a phenomenon known as osmotic pressure). Because of this influx of water into the tubules, more fluid is excreted out of the kidneys and into the bladder than would normally occur.

It takes a lot of extra sugar to make this happen, so don't assume your blood sugar is normal just because you're not making extra bathroom visits. You can be abnormally high without being high enough to experience excessive urination.

"a1c test doesn't replace daily testing"

You're right, it doesn't. Because the A1c test result changes slowly, in response to trends in glucose levels averaged over a period of a few months, it is useless for assessing the short-term impact of anything. If you want to know how a 15-mile bike ride or a bowl of chili affects your glycemic control, you need to use a glucose meter to figure that out.

Look at it this way: a corporation may make a big public fuss over its annual report, but trust me: in between those annual reports, it is also keeping track of income and expenditures over the short term -- because you can't run a business by taking your eye off the ball for a whole year and hoping it all comes out right when the year is over.

"at what acid # does your dr turn you into the insurance company"

I'm not sure what this person means by "acid #", but the tone of the question is telling. Readers living outside the USA will just have to take my word for it that this paranoia about what our doctors might tell our insurers is perfectly normal here. This is how we live now.

"feel bad but not diabetic"

As diabetes is usually discussed as if it were the ultimate source of all health problems known to man, I guess it's kind of refreshing to hear that there are other ways to feel bad!

"my bp 131/81 should i go to hospital"

That doesn't seem necessary to me. They tell us these days to aim to keep blood pressure under 120/80, but 131/81 is not exactly an emergency. (But I am assuming the units used here are mmHg. The usage "go to hospital" seems to point to someone in the UK, where perhaps blood pressure is measured in different units?)

"74/40 blood pressure with a 140 pulse is that okay"

No. The blood pressure is awfully low (unless you're using units other than mmHg), and the pulse is awfully high.

"the kenwood footrace seems longer than a 10k"

No question about that. It's because of all the hills. But it really is only ten kilometers.

"word for when your sugar drops too low"

The word is hypoglycemia. The "hypo" part means not enough of something (as opposed to "hyper", which means too much of something) . The "glycemia" part refers to the amount of sugar (specifically glucose) in your blood.

"what chromosome is diabetes found on"

Please stop thinking about it that way! There isn't "a gene for diabetes". There are many genes (I believe that more than 20 of them have been found by this point) that increase your risk of diabetes, but there isn't one gene on one chromosome which determines whether you become diabetic or not.

Even people who have the bad luck to inherit several of the diabetes-associated genes might still escape the disease, if they exercise regularly and manage to avoid obesity. Genetics is not the only issue involved. (But some people who are slender and active can nevertheless become diabetic; sometimes the combination of genes you inherit is so toxic that there's no way to keep yourself safe.)

"wheat in america causes diabetes"

Perhaps that's a trifle simplistic. However, it would be hard to argue that the rise of grain-based foods in the human diet, owing largely to the rise of grain-milling technology, has not played a role in changing Type 2 diabetes from a rare disease to a common one.

"stress affect a1c"

If the stress lasted a few months, maybe. Stress has a tendency to suppress insulin sensitivty, and that in turn tends to elevate blood glucose, and that in turn tends to drive the hemoglobin A1c result upward. But this only matters to the A1c test if the stress is chronic. If you were stressed out on the day you went to the lab for your A1c test, that wouldn't be significant.

"what does a hemoglobin a1c of 9.5 mean"

That your blood glucose level has been much, much too high of late, and it is doing damage. You need to bring it down as soon as you can.

"doctor wants to treat type 2 diabetes with meds but you don't"

If you don't want to be medicated for your Type 2 diabetes, you need to show your doctor such impressive progress (in terms of lab results, and also in terms of changing your lifestyle for the better) that he would be missing the opportunity of a lifetime if he didn't let you show him what you can do without meds.

"is 6.2 ac1 test good" & "is a1c of 6.2 normal"

It's not normal (my lab says the normal range of a Hemoglobin A1c test only goes up as far as 5.6).

Some would call it "good (for a diabetes patient)", but I aim for "normal" rather than "good (for a diabetes patient)".

"what do you mean the word hemoglobin"

Hemoglobin is a protein molecule which humans and other animals use as a vehicle for transporting oxygen through the bloodstream and delivering it to cells that need it, all over the body.

Because hemoglobin is a blood protein, it's easy to collect a sample of it. For this and other reasons, hemoglobin is commonly collected and analyzed, to determine how much of it is glycated (bonded with sugar). In non-diabetic people, about 5% of hemoglobin is glycated hemoglobin, also known as hemoglobin A1c; the percentage is usually higher in diabetes patients, and is interpreted as an index of how well blood glucose levels are being kept under control. 


Remission of Diabetes

Tuesday, July 17, 2012


But What Does it Mean?

I saw the word "remission" used in a medical article, and thought I should find out what, exactly, it means. Here are some of the definitions I found:

Okay, that seems consistent enough for all practical purposes. Remission of a disease means a subsiding (not necessarily complete or permanent) of symptoms -- or a period during which that occurs.

However, it is a mighty broad term, encompassing everything from temporary relief to full recovery, so anyone using the word in a scientific context had better be prepared to say what they have in mind when they use the word remission.

The article that sent me off on this snipe-hunt for the meaning of remission was one entitled "Diabetes Remission After Gastric Bypass: BMI Not Predictive". It seems that Body Mass Index (a measure of fatness which compares weight to height, and is famously problematic because it assumes all body mass is fat rather than muscle) is not a good predictor of whether or not gastric bypass surgery will result in remission of diabetes.

The most important factor, in determining the prospects for remission, was how badly the insulin-producing capacity of the beta cells in the pancreas had been compromised by the time the surgery took place. Although, contrary to legend, beta cells can be replaced by the body, they are replaced exceedingly slowly (and high blood glucose knocks out the new ones just like it knocked out the old ones), so it would probably take a very long period of normal glycemia before there was any significant restoration of insulin-producing capacity. For all practical purposes, a patient whose insulin-producing capacity has been severely reduced is not very likely to be making a comeback in this area.

I was intrigued to see the particular definition of remission that was used in this case: "remission was defined by the researchers as the withdrawal of diabetic medications". That means I've been in remission for 11 years now! Well, strictly speaking, it doesn't mean that -- because in my case diabetic medications were not so much "withdrawn" as "never prescribed in the first place", but perhaps the purists will not insist too strictly on the language of the definition, and agree to let me say that I'm in remission.

Of course, even by the most optimistic interpretation of what the word remission means, being in remission doesn't mean you're off the hook for good. Unlike some diabetes patients who had gastric bypass surgery at the right time, and went into remission, I have to work at staying in remission, and work at it forever. That's the bad news; the good news is that I haven't allowed surgeons to do any major remodeling of my digestive tract, so I'm not dependent on surgeons to keep doing the same kind of follow-up work on my stomach that they used to do on Michael Jackson's face.


Stupidity Embraced!

Schoolchildren in the State of Louisiana can now read in their science textbooks that the Loch Ness Monster is real, and is in fact a plesiosaur -- a surviving species from the age of dinosaurs! And that this proves (somehow) that there is no such thing as evolution!

Of course, having photographed the monster myself during a trip to Scotland in October of 2009, I was under the impression that it was a cloud rather than a plesiosaur. But I might have got it wrong.

Anyway, far be it from me to argue with the science textbooks of the proud state of Louisiana, so I guess they have a point. We aren't a part of nature. Biology doesn't apply to us. Make a note of that, in case some high-falutin' college-educated doctor ever tries to give you medical treatment developed from research on animals, of all things! Animals have no connection with us whatsoever.

 
   


Doctor Bills of the Living Dead

Monday, July 16, 2012


Bariatric Surgery Doesn't Reduce Health-Care Costs?

However hard we try to be properly skeptical when reading about medical research, to some degree we have to take a leap of faith about the way the researchers crunched their numbers. We may raise an eyebrow at the way the researchers designed their study or the way they interpreted the meaning of the results. But as for the results themselves, we have to assume (not being in possession of the raw data) that they gathered the numbers carefully and are reporting them honestly. Every once in a while, though, the researchers let something slip out which raises troubling questions about the credibility of their bean-counting.

A veterans-hospital study found that bariatric (weight-loss) surgery, performed on a patient population that was predominantly elderly and male, yielded no reduction in the patients' health-care costs during the years following surgery. This outcome was considered surprising, as bariatric surgery has lately been seen as a miracle cure for all sorts of chronic health problems, and some studies (of patient populations that were younger and less predominantly male) had seemed to show at least some reduction in health-care costs resulting from such surgeries.

What could the reason that, in this case, the cost-saving advantage was not there? The study authors suggested various reasons, including that the patients in this study were in worse health to begin with than the patients in earlier studies.

But then there's this: "Dr. Sax mentions a possible subtle explanation for the findings: the death rate among the nontreated control patients was nearly twice that of the patients who had surgery. 'In other words, 50 more surgical patients were alive to consume resources during the 6 years studied,' he concludes."

Let me get this straight: the comparison between the health care costs of patients who did or didn't have the surgery did not take into account the fact that some of the patients were dead?

How that can be regarded as "a subtle explanation" for the study results is a little hard to fathom. Is there anything less subtle than the distinction between a living patient and a dead one? (Granted, I've met a few people who tended to blur the distinction a bit, but in most cases it's pretty clear-cut.)

This isn't a case of comparing apples to oranges -- it's a case of comparing zebras to rocks. Even in America, dead people don't rack up a lot of medical expenses (although I'm sure the health care industry is doing its best to change that). How anyone with even a tenuous connection to reality could think that it is meaningful to compare health-care costs for living people to health-care costs for formerly-living people is beyond me.

Perhaps this particular kind of mental decay is bound to overtake people sooner or later if they get too involved in statistical analysis. When all you're doing is manipulating numbers, on the assumption that the numbers mean something, perhaps you are inevitably going to reach a point where you are no longer able to notice that your numbers have become hilariously disconnected from the reality you imagine them to represent.

There are people who think that mathematics is beautiful in and of itself, regardless of whether it has any connection with phenomena of the real world. Those people need to concentrate on pure mathematics, I'm afraid, and stay away from science. Applied mathematics (as in the case of math used to analyze research results) has to apply to something; if it doesn't, but you pretend it does, you end up causing a lot of confusion and trouble in the world. 

Dr. Sax must have gone pretty far around the bend, if he was able to blurt out that remark about living patients consuming more resources than dead ones, wtihout recognizing the absurdity of what he was saying. But I wonder how often results are just as screwed-up as that, without the researchers involved blutring out anything which gives the game away!


About Today's Test Results

Nothing too surprising here. Sunday's meals were probably a little too high-carb, especially considering that it was my rest day from exercise, so it makes sense that my fasting test was a little higher than usual. And my lunch today was pretty low-carb, so it makes sense that my post-prandial test was lower than usual.

I always try to give a little thought to my test results. There's not much value in doing the tests at all, otherwise. I imagine some people test just so that, if they start flying out of control, they'll recognize the disaster as it's happening -- and because that's all they're looking for, they won't give any thought at all to a non-disastrous result.  I think it's also worth paying attention to variations within the normal range. Knowing what tends to push your numbers up and what tends to push them down is always worth knowing.   


Breakfast, Trails, & Mysterious Chemicals

Saturday, July 14, 2012


A Low A.M. Post-Prandial, Yay

Glucose virtually unchanged from fasting level to post-breakfast level; one more confirmation that my system is better able to process carbs, and prevent glucose spikes, in the morning than at any other time of day! (And breakfast included toast, so it wasn't a low-carb meal.)

I'm grateful for this pattern of mine, because it means I can have a breakfast that includes what I think of as breakfast foods (toast, for example). No Eskimo breakfast for me; I don't have to be gnawing on seal blubber or whatever it is that I'd have to learn to like if, like so many other people, my carb-tolerance was lower in the morning rather than higher. Not that I should be pushing my luck too far: adding fried potatoes, and orange juice, and sweetened yogurt to the toast would not be a good habit to get into. But it's nice to be able to be able to get away with eating breakfast foods at breakfast. There is probably a universal tendency to crave carbs more in the morning than at any other time (at least, that tendency is present in me, and if I am not the accepted template for what counts as universal, who is?), so I'm glad that I can indulge that particular craving without getting a big post-prandial spike.

However, in addition to being grateful for this pattern of mine, I am also a little puzzled by it. How come I'm like that, when other people apparently are not? It could be that the people who say they spike most easily in the morning are just not allowing for the fact that breakfast is their highest-carb meal. I doubt that, though -- a lot of them say that they spike after breakfast even when they are careful about carbs. One possibility is that, because I exercise so much, my muscles start the day with depleted sugar-stores and readily soak up blood glucose to replenish their supplies (then, later in the day, they're less eager to soak up glucose because breakfast solved the problem already). That's just a guess, though, and perhaps not a very likely one.

Oh well -- I guess for now I'd just better take note of the pattern I'm seeing, and work with it. Maybe someday I'll know the explanation for it; and maybe I never will.


Hitting the Trails

The heat wave being over, I figured that today (with temperatures warmish but not hot) I could handle a longer trail-run than I dared to attempt in the challenging heat on Wednesday evening. I ended up doing an 8.2-mile route through the state park.

I made up the route as I went along, as usual. When I start a trail run, I never really know how strong I'm going to feel once I get warmed up, and consequently I never know how long a route I am really prepared to handle. So, even though I start with a particular route in mind, I'm always ready to make a decision every time I come to fork in the trail, about whether I want to change my route to make it shorter or longer than the one I had in mind at first.

Today I had been planning to do a route that's a little under 7 miles, but thought I might shorten it if I wasn't feeling good (which was certainly a possibility; I'd been to a Friday-night picnic and indulged myself pretty generously). To my surprise and relief, I felt strong today, and after a few miles of continuing to feel strong I decided to make the route a little longer instead of shorter.

I didn't regret it; I didn't end the run feeling exhausted or hurting. I got the formula right: push yourself just hard enough to make the hot shower afterward feel fantastic, but not hard enough to make yourself feel bad after you get out of the shower. I am proud to say that I get that formula right a lot more often than I get it wrong.  


But What About the Drug Potential?

It worries me that every investigation into the biochemical underpinnings of diabetes seems to be focused entirely on the possibility of using this information to create the next billion-dollar drug.

Researchers at UC San Diego have discovered a chemical related to regulation of the human biological clock -- a chemical which is also thought to play a role in diabetes. The reason for the connection is that the body's biological clock controls such things as glucagon (the hormone which causes the liver to release stored glucose into bloodstream), in order to prevent hypoglycemia during overnight fasting. A protein called cryptochrome regulates both the biological clock and the release of glucose from the liver. And now the researchers have discovered that another, smaller protein molecule (which they've called "KL001") regulates the activity of cryptochrome. "Now Kay and his team have discovered a small molecule -- one that can be easily developed into a drug -- that controls the intricate molecular cogs or timekeeping mechanisms of cryptochrome in such a manner that it can repress the production of glucose by the liver." (Emphasis added -- although the rest of the article certainly does not hang back from mentioning the "opportunities for novel therapeutics".)

So there we are: the minute we discover a molecule which plays some kind of regulatory role relevant to diabetes, and before anyone has quite figured out how it works or what it does (or what else it does!), everyone wants to turn it into a drug.

You know, people, we didn't even know that KL001 existed until this week -- is it not perhaps a little bit premature to be drawing up plans to turn it into a consumer product?

Maybe it would be a good idea to gain a thorough understanding of KL001, and cryptochrome, and the role that both of them play in glycemic regulation, before trying to use pharmaceuticals to replace them, enhance them, or block them. The law of unintended consequences applies even more forcefully to newly discovered things than it does to familiar things.

What should scientists do with a newly discovered molecule which seems very relevant to diabetes? Well, what should they do with a newly discovered life from from outer space? Should they learn more about it, or should they try messing with it to see what happens?


When Insulin Attacks!

Thursday, July 12, 2012


Insulin Can Be a Dangerous Friend

I think we need to get rid of this "insulin = good" equation.

I realize that a lot of doctors think the opposite is true: we've got to help people see insulin in a more positive light, because a lot of Type 2 diabetes patients who really need to start taking insulin don't want to do it. The idea of taking regular injections of anything strikes them as a creepy development which will impair their quality of life, and the idea of injecting insulin in particular is depressing because it strikes them as evidence that they have "failed" as diabetes patients. Their doctors would like to see insulin relieved of all this emotional baggage, and seen for what it is: a perfectly natural compound which every human body needs to produce, but which some human bodies don't produce enough of.

I will certainly grant that insulin is a perfectly natural compound which every human body needs to produce. I will also grant that some human bodies don't produce enough of it to maintain normal glycemic control.

However, we need to distinguish between "enough insulin to maintain normal glycemic control" and "a normal level of insulin".

In patients with metabolic syndrome (the underlying problem that drives people into Type 2 diabetes -- although it's still a problem even if it never goes that far), it takes a lot more than a normal level of insulin to maintain normal glycemic control. Because people with metabolic syndrome lose sensitivity to insulin, they end up needing to produce abnormally large amounts of insulin just to get their cells to absorb glucose and remove it from the bloodstream. In other words, they suffer from hyperinsulinemia (chronically high insulin levels).

Even worse, people with metabolic syndrome don't lose insulin sensitivity in all their tissues. It is their muscle cells that become insulin-resistant. Their fat cells generally do not become insulin-resistant. The result is that glucose is not absorbed by their muscle cells, to be stored as glycogen and burned to fuel physical activity -- instead it is absorbed by fat cells, which convert it to fat, swell up with the stuff, and then try to retain it as long as they possibly can. For this reason, metabolic syndrome promotes obesity.

To live in a state of hyperinsulinemia has unfortunate effects -- weight gain being the one that's immediately obvious. But there are other effects which are harder to track (but probably more harmful). There is every reason to think that hyperinsulinemia promotes heart disease.

One recent study in Canada found that metabolic syndrome caused an accelerated development of aortic stenosis (a narrowing of the aortic valve in the heart, which restricts the heart's pumping capacity). This was true whether or not the patients had elevated LDL cholesterol levels. Not only that, statin drugs tended to make the problem slightly worse rather than better!

Abnormally high concentrations of insulin in the blood tend to promote plaque buildup on arterial walls, whether cholesterol is elevated or not. The issue, apparently, isn't how much cholesterol is there -- the issue is whether or not the cholesterol that is there forms deposits on the arteries. And more deposits form when insulin is elevated than when it isn't.

So, when we say that we "need" more insulin because the body isn't producing "enough" of it, we need to ask how much is enough. Some people "need" more insulin even though they have a normal level of it, or more than a normal level of it -- because of their lost sensitivity to insulin.

Now, this is a complex issue, I realize. Many people with Type 2 diabetes end up producing less inuslin than normal, not more, because a period of elevated blood sugar has harmed the beta cells in their pancreas. Patients in that situation need insulin shots just to get them up to a normal level. I don't mean to suggest that people whose insulin levels are abnormally low should not take whatever injections are needed to correct for that problem.

However, if patients are already hyperinsulinemic, giving them even more insulin (or giving them oral diabetes drugs which cause them to produce more insulin themselves), just to overpower their insulin resistance, could set them up for heart disease.

For this reason, I think patients with Type 2 diabetes who are very insensitive to insulin should work on building up their insulin sensitivity once more. It can be done, after all: both weight loss and exercise tend to increase insulin sensitivity, which is presumably why weight loss and exercise both tend to improve glycemic control. And if you can achieve good glycemic control and maintain it long enough, the very slow process of regeneration of beta cells may eventually restore to you your lost insulin productivity, at least to some degree.

Sometimes, when you think the solution to your insulin problem is to have more of the stuff, the real solution is to need less of it. 


You're Doing It Wrong!

Wednesday, July 11, 2012


My Criticism Problem

For the most part, California has been spared the heat waves that have rolling through the rest of the USA lately, but it was pretty warm today (93 F), and neither my running buddies nor I felt like going out for a hilly run in it. I decided to put it off till the evening, when it would presumably be cooler.

After work I drove over to the state park for a trail run (as shady a trail-run as I could arrange). It wasn't much cooler when I got there, as it turned out, although the temperature did drop down to about 80 by the time I finished the run.

All trails leading into the park begin with a long, difficult climb, and after you're done climbing, most trails end up converging on Lake Ilsanjo. The high-school and junior-college cross country track teams were training in the park tonight, so when I got to the lake I found it was full of teenage athletes enjoying a swim as their reward from having run up all those hills to get there.

Their track coaches were standing there, and one of them is someone I know because he also works at my company, so I stopped very briefly to chat with him. I've had conversations with him about running, and I've confessed to him my problems with running form, and he's given me advice -- but I've never actually run under his observation. So, as I said goodbye and took off running again, I felt uncomfortable about being under his critical scrutiny. Sure enough, he called some corrective advice out to me. Which I'm sure was well-intended and also perfectly correct advice -- but I couldn't have felt more mortified.

It's a problem I have: I find it unbearable to have someone criticize what I'm doing, especially while I'm still doing it. "Defensive" doesn't even begin to describe my reaction. The humiliation I feel under those circumstances is crippling; sometimes it is so painful and stressful for me that I have to stop whatever I'm doing, because I literally cannot go on. (This vulnerability of mine has, to put it mildly, not made it easy for me to take music lessons, and even the mild feedback you from a yoga instructor can be enough to stress me out.)

In this case, the obvious thing to do was to keep running, since he wasn't following me and I'd soon get out of earshot. But I knew I was visible for a long time as I was getting away from him, and I felt like I was on stage, screwing up my violin recital.

Then, he and some of his students took off running, and they caught up to me and passed me about half a mile from the lake. I was very afraid he was going to offer more criticism in passing, but he just said hi. Okay, that I could handle. Of course it was a little embarrassing to be left behind as the real runners went by at a much more respectable pace, but that I'm pretty much used to that sort of thing by now.

Then I thought about the embarrassment I felt eleven years ago, when my doctor left me a phone message saying that I had become diabetic (exactly what he had predicted would happen if I didn't lose weight, and of course I had gained instead). His message instructed me to make an appointment with him to discuss the new lifestyle I was going to be adopting. Fortunately, there was a significant delay between his phone message and my office appointment, so I had a chance to figure out how I was going to deal with the humiliation factor.

If this was going to be a matter of him lecturing me about all the things I was doing wrong in my life, I felt as if I might curl up and die on the spot. And that would be bad because, although I haven't thought of an ideal way that I want to die, I certainly don't want it to happen while I'm in my doctor's examining room, wearing one of those hospital gowns and nervously glancing at the the array of latex fashion-accessories his nurse has layed out on the counter for the occasion of my visit. Nope: however and wherever I'm going to die, dying from embarrassment under those circumstances is not what I have in mind.

So, I had to take the initiative. I had to go into that appointment feeling as if I still had some kind of personal autonomy, and even a little bit of dignity, despite the unpromising circumstances. I knew I couldn't go in there as an ignoramus who has no understanding of what he needs to do, and is waiting to be given instructions. Instead, after frantic internet research, I went in saying "here's what I'm already doing; do you think this is the right approach?". For the most part, he did think it was the right approach, although he cautioned be that some of the literature I had read (suggesting that a high-carb diet was actually good for diabetes patients) was leading me astray. He signed me up for a diabetes class, but otherwise encouraged me to keep doing what I had already started doing, especially in terms of exercise.

Now, he probably had serious doubts that I actually would continue doing what I had already started doing; persistence is perhaps not a trait he sees a lot of in his practice. But at least he gave me a chance to succeed under my own initiative, which was what I needed.

Whether that is the right approach for doctors to take in all cases, I am unable to say. But it was the right approach to take with me. I'm the sort of patient who can't take criticism, but is willing to work hard on his own, to avoid having something to be criticized for. 


Too Much Sitting

Tuesday, July 10, 2012


Sedentary Behavior & Life Expectancy

You know what's the trouble with doctors who do research on the negative health effects of sedentary behavior? They don't always define "sedentary behavior" in such a way that I come out not being guilty of it.

Now, you might think that, as a guy who ran more than five miles on his lunch hour today, and also stopped by the gym after work for some weight lifting, I could not possibly be accused of "sedentary behavior". But, as a matter of fact, some health researchers would nevertheless call me sedentary, because of the amount of time I spend (both at work and at home) in a seated postiion.

The sad fact is that number of hours a day I spent sitting in front of a computer is scary to contemplate. And it appears that prolonged sitting can be harmful in and of itself, even if you spend some of the non-seated portion of your day jogging your way up super-steep hills in the noonday sun, as I did today.

This study looked at the influence of prolonged sitting life expectancy in the USA, and found that Americans would live 2 years longer if they reduced their seated time to <3 hours a day, and would live 1.4 years longer if they reduced their time watching TV to <2 hours per day.

Of course I would like to think that the beneficial effect of spending an hour or two exercising would cancel out all harmful effects of spending several hours sitting in front of a computer, but apparently there is a limit to how much sitting-time can be canceled out by an episode of sweating-time.

At work, I try to avoid letting the sitting-in-front-of-a-computer episodes drag on too long; I get restless and get up and walk around. (Now that, because of the office remodeling project under way, I have to walk over to a different building to use the bathroom, I'm seeing that as an opportunity -- and drinking plenty of fluids, so that these visits to the other building are as frequent as possible.) At home, though, I have an alarming tendency to just sit there, trying to figure out what to talk about on my blog for the day. Which I guess is a little ironic, considering what I decided to talk about on my blog today.


More on Glycosuria

The urine questions just keep coming. Yesterday two searches on "if your ac1 is 7 but no sugar in your urine are you a diabetic" and on "will a diabetic still have glucose in urine when medicated" resulted in referrals to this site yesterday.

Look, people: the urine thing is about ancient history. Diabetes is not longer defined in terms of what's going on in your urine. It used to be, because that used to be the best that doctors could do before any measurement technology existed to test what was going on in your blood. Glycosuria, or abnormally sweet urine (sweet enough to attract insects, anyway) was recognized as a warning sign of diabetes. (When your blood sugar gets high enough, some of the sugar leaks through your kidneys and into your urine.)

However, the comparative sweetness of your urine is only a rough indicator of what's happening in your blood. If you want to know what's really going on, you need to have your blood tested, not your urine. A urine test might be a cheap and simple opportunity to pick up a hint that there is too much sugar in your blood, but it's not the most reliable indicator. Plenty of people with diabetes could escape diagnosis for years, because their blood sugar is not far enough out of control to result in glycosuria so far.

As for whether glycosuria will appear if you're not medicated, that will depend on how well you manage your condition without meds. Regardless of what dire predictions someone might make about this situation, you might be able to control your blood sugar well enough that you will never even come close to glycosuria. That won't mean you are "cured", and no longer have diabetes; it will simply mean that your glycemic control is good enough to make your urine lack flavor.

It might also be that your glycemic control is mediocre rather than good.  An A1c result of 7 is mediocre, but probably not high enough to trigger glycosuria. 

Anyway, the world has moved on. Diabetes is really about what's going on in your blood, not about what's going on in your urine. 


Fake Health Claims & Exercise Inconvenience

Monday, July 9, 2012


Pfizer Yanks!

The trouble with reading news headlines on web pages, with the screen constantly rearranging itself and partially blocking the page with popup windows, is that you tend to catch a brief glimpse of half a headline, without realizing at first that you're not seeing all of it.

That is why I was startled by the headline "Pfizer Yanks Breast, Colon" today. Wondering how Pfizer might be accomplishing that, I took a second and more careful look at the headline, and this time I saw a more complete version of it. "Pfizer Yanks Breast, Colon Claims for Centrum Vitamins".

It seems that the naughty pill-monger has been caught (by Center for Science in the Public Interest) making improper claims that their vitamins promote "breast health", "colon health", and other desirable things. Apparently CSPI feels that such claims need to be substantiated by evidence, and Pfizer has reluctantly agreed to stop making these claims in packaging and advertising. At least, they are doing it in the case of the claims about prevention of breast cancer and colon cancer; some other health claims which CSPI finds equally objectionable (having to do with eye, heart, and bone health) are not being dropped. 

So my original reading of the headline might not have been so far off as I thought. I think Pfizer is doing a wee bit of yanking after all.

Oh, wait a minute... somehow that reminds me of my favorite medical news story from last week, which I forgot to mention before. Did you know that teenagers who send each other naked pictures of themselves are likelier to sexually active than teenagers who don't do this? Yes, amazing but true!


Exercise and Inconvenience

My approach to managing diabetes is so dependent on exercise that I sometimes forget how dependent it also is on being able to exercise conveniently.

Probably most people can fit in exercise on the weekend -- but how do you find room for it Monday through Friday, when you're most likely working and perhaps handling a lot of other weekday tasks as well?

I am pretty lucky in this regard. First of all, I live just a little more than a mile from my workplace (and from my gym, which is across the street from my workplace). Therefore, travel time is negligible to either destination, and doesn't eat up a chunk of my day.

Also, as I've mentioned before, my workplace accommodates and even promotes fitness. There are locker rooms at work, and nobody objects to the time I devote to my daily run at mid-day.

And, on top of everything else, I live in northern California, where the climate is mild enough to accommodate outdoor exercise year-round. I do sometimes take to the gym when it's raining, but it really doesn't rain all that much in these parts.

But sometimes it takes only a tiny glitch to mess up my system. This month there is a bunch of remodeling going on at the workplace, and the locker room in my building is no longer available to me. I have to use a different locker room in another building, and it's smaller and more crowded and generally inconvenient to use. It takes longer to get in and out of there. Today my running buddy almost took off on the run without me, because I was late and he thought I wasn't coming. And I also had trouble afterward, getting to the cafeteria before it closed.

If even a small change like that throws my system out of whack, imagine how hard it is for people who don't have any locker room at all at their workplace, and have a long commute home, and  then have to take care of various other domestic duties before they can even think about heading to the gym. And by the time they're free to do that, either they're feeling exhausted from the stress of their day or the gym is closing. I guess this is why a lot of people get up before the sun in order to get their daily exercise out of the way before anything else can derail their plans. But some people (me, for example) find it awfully hard to get up early enough to do things that way.

And now I'm concerned because I'm going to be spending some time in Ireland during August, attending two music festivals. How exactly am I going to get daily exercise into whatever else is going on (such as, possibly, a lot of eating and drinking)? Where there's a will there's a way, but I'm sure it's not going to be easy to arrange. Travel of any sort is the enemy of daily exercise.

Anyway, I should try to remember, whenever I hear about how little most people exercise, that for a lot of people it's extremely hard to find a way to fit exercise into their lives.


Yet More Urine Questions!

Friday, June 6, 2012


Sugar & Urine & That Sort of Thing

I take a great interest in the search-engine phrases that throw up this site as a reference, as it gives me some idea what issues people out there are wondering about. Mainly, it seems, they're wondering about urine. 

Because diabetes (or at least poorly-controlled diabetes) causes blood sugar to leak through the kidneys and into the urine, diabetes has been recognized (since ancient times) by the sweetness of the urine produced by diabetes patients. Do I hear you asking, with a raised eyebrow, how the ancients just happened to notice this particular flavor enhancement? Well, for the most part, it was ants and bees that did the noticing. When your urine started drawing a crowd, in the insect world at least, this was considered a sign that you had become diabetic.

I see a lot of search phrases related to this issue, phrases which mention insects and diabetes and urine in combination. Sometimes they give me the impression that people are a little confused about this issue. Lately there have been a lot of searches having to do with insects being attracted to the underwear of diabetes patients (I can shed no light on that one). And a search phrase that came up today took the issue to a whole new level of confusion: "what happens if i pee on ants". (I'm not sure what happens; why not try it and let me know how it goes?)

Here are a few other urinous search phrases that came my way lately...

"having 4 plus sugar in my urine does it surely mean diabetes"

Abnormal leakage of blood sugar through the kidneys and into the urine is called glycosuria. Normally the kidneys don't let very much sugar get into the urine, but this situation changes when blood sugar is abnormally elevated. Glycosuria is usually considered a symptom of diabetes, because the other things that can cause it (a kidney condition known as renal glycosuria, and sometimes the medications for a bladder infection) are pretty uncommon.

The test for glycosuria usually gives results either in mg/dl or in mmol/l (divide the former by 18 to get the latter, or multiply the latter by 18 to get the former).

The upper limit of "normal" for sugar in the urine is defined a little differently by different labs. Some say the upper limit of normal is 0.8 mmol/l (15 mg/dl). Certainly anything above 1.4 mmol/l (25 mg/dl) is considered abnormal -- and anything higher than 3.0 mmol/l (54 mg/dl) is considered a sign of diabetes.

If you got a result of "plus 4" (which I am guessing means ">4 mmol/l", or 72 mg/dl), that would seemingly be a strong indication of diabetes.

However, glycosuria is treated these days as a warning sign of diabetes rather than diagnostic of diabetes. Diabetes is actually diagnosed based on what's going on in your blood rather than your urine. So, a glycosuria test that reads abnormally high will probably lead your doctor to test your blood for more definitive evidence of diabetes -- which, at that level of glycosuria, is pretty likely to be found.  

"i have tested my urine and it says im not diabetic"

Whoa! When your urine starts talking to you, it means you've got bigger problems than diabetes.

I don't think it is possible to say, on the basis of a urine test result in the normal range, that you are not diabetic. Sugar levels in urine are at best a rough indicator of sugar levels in blood, and in any case, sugar levels in blood and urine are pretty volatile. In the fluctuations that take place over the course of a day, you might be in the normal range at least part of the time, and for that reason it is quite possible to have a problem with control of your blood sugar which is not captured by a given urine test on a given day.

Many cases of diabetes go undetected for a long time because patients who have lab work done annually manage to squeak by for a year or two, just because their fasting levels are still under control. That is why the hemoglobin A1c test, which is influenced by average blood sugar levels over time, is a better way to screen for diabetes. A single urine test result that looks okay proves nothing; the A1c test result is more meaningful, because the A1c test is harder to fool.

Anyway, it is going way too far to say that your urine is telling you you're not diabetic. Urine doesn't talk that way.

"if a diabetic's sugar is high do they get rid of drugs faster"

Wow -- I didn't know Lance read my blog!

Too soon? 


Invasion of the Western Diet

Thursday, July 5, 2012


Tradition!

In all parts of the world, it seems, local populations living in a pre-modern state have developed a traditional diet that works for them. The remarkable thing is that the nature of this traditional diet varies enormously from place to place, and yet people living a traditional life seem to be able to stay healthy on their local diet, whatever it is. Depending on where they are, they might be eating a diet consisting mainly of meat and animal fat, or a diet that is largely vegetarian, but whatever they're doing, it works for them, and protects from the "diseases of affluence" which are far more common in more modern industrial nations. 

But then, when they become westernized and start eating more like Americans and Europeans, all of a sudden they start developing diabetes, and coronary heart disease, and all the other chronic health problems which are the sad medical hallmarks of civilized living.

You can watch this trend in action now. This study looked at Chinese people who were living in Singapore, and found that those who had adopted the habit of eating at American-style fast-food restaurants at least twice a week had a 27% increased risk of diabetes, and a 56% increased risk of dying from coronary heart disease. (The researchers have suggested that the large increase in CHD risk might be driven by trans fats, which are unregulated in Singapore restaurants.)

A more dramatic example is offered by oil-rich states in the Persian Gulf. The six nations of the Gulf Cooperation Council (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates) have adopted a westernized lifestyle: high-calorie diets, lots of sugar and other refined carbs, and sedentary habits (work is for foreigners to do). In consequence, people living in those countries have developed an extraordinarily high rate of diabetes. About 20% of people in these countries have diabetes (much higher than the American rate of 9.6% -- which is considered by many an epidemic!).

I don't know what the traditional diet indigenous to this region might have been like, but I would bet big money that High Fructose Corn Syrup did not play a large role in it, and neither did trans fats (artificially hydrogenated oils).

This sort of thing has happened again and again in world history: a traditional food culture is eclipsed when "modern" foods become available, and diseases which used to be rare suddenly become the norm. The problem is that more than one thing is changing at the same time, so it's impossible to know which factors actually upped the disease risk. Maybe so, but which factors are present in the modern western lifestyle and not in other lifestyles? That's where to look if you want to compile a list of Things Not To Do.


Testing Today

I thought my post-prandial test after lunch was a bit higher (137) than it should have been. I had a sandwich, but no other significant carbs in the meal, and I usually get a lower result after eating a sandwich (especially when the meal happens right after running). So, I did a test in the evening, right after resistance-training and a low-carb meal (chicken and spinach). This time the result was only 99.

Carbs matter, I guess!


Holiday

Wednesday, July 4, 2012


Yeah, I did the Kenwood Footrace this morning, and yeah I was slow again. But at least I felt good, and the weather was beautiful -- sunny, clear, warm, but not too hot for running. But it's a holdiay, and now I've got to go see if I can get somewhere near the fireworks.


Pre-Race Jitters

Tuesday, July 3, 2012


Night Before the Kenwood Footrace

The Kenwood Footrace is tomorrow -- it happens every year on July 4th (that's the Independence Day holiday in the USA).

It's a tough race (lots of hill-climbing), but it's pretty, and like pretty things in general it is also popular. I always do it, even though it makes me nervous. Last year my time was the slowest ever, and it made me feel like an old man. I'm hoping I do at least a little bit better than that this time. There are always a fair number of people I know participating in the race, so it's a race that makes me feel a little exposed.

I've made my preparations, anyway. I have my race number -- and it's hanging on my front door so that I don't forget it tomorrow morning.

I've got the timing-chip accessory attached to my new running shoes, so that my running time is recorded properly. And my new running shoes are broken-in just enough to be race-ready, but not so broken-in that they have lost their spring.

I also picked up the race T-shirt, which provides further evidence that the Kenwood Race is now competing with San Francisco's Bay to Breakers race in the effort to come up with the most embarrassing possible T-shirt designs. This year's design is an homage to 1960s counterculture, or at least to those members of it who were too stoned to notice that they had no sense of design or color.

I'm not 100% immune to 1960s nostalgia, but this isn't the aspect of it that I respond to. I don't know where I'm going to wear that shirt, but I guess I could just declare it a running shirt and wear it only when I'm running. It's when you're going to be hanging around in one place, holding still enough for people to get a good look at your T-shirt, that something like this becomes a problem.

Now the big challenge is to actually get out of bed early enough to show up in Kenwood in time for the 7:30 AM race start. Maybe I'd better get some sleep...   


Things People Wonder About the A1c Test

Monday, July 2, 2012


Yeah, I know it's weird that my glucose tested lower after breakfast than before it, but weirdness happens. My glycemic control system seems to be most responsive in the morning. That means I can tolerate more carbs at breakfast than later in the day, which is a lucky thing for me, because most of the foods I want to eat in the morning are not low-carb. (I don't mean I'm eating a big bowl of Cap'n Crunch, mind you, but my stomach greatly prefers toast to sausages.) Many people with Type 2 diabetes are less tolerant of carbs in the morning than later in the day, so I'm glad I don't have that problem to deal with!


Let me review some recent search terms that sent people to my site; this particular set mainly revolve around the hemoglobin A1c test.

"what causes an a1c above 6"

The only thing the hemoglobin A1c test tells you directly is what percentage of your hemoglobin is glycated (glycation means unwanted bonding of sugar to proteins -- it's harmful, and it's one of the main reasons diabetes is harmful). If your test result is above 6, then more than 6% of your hemoglobin is glycated.

Because we all have at least some sugar in our blood, nobody's hemoglobin is free of glycation, so it's impossible to get an A1c result of zero. The normal range depends on how your lab defines "normal" for its A1c test method; my lab defines 4.8 to 5.6 as the normal range. More broadly, the normal range is often described as anywhere from 4 to 6. But anything above 6 is generally recognized as an elevated value, if not quite a diabetic value.

What causes the result to be elevated is a rate of glycation which is elevated. The body replaces hemoglobin (and other proteins) over time, so that the older and more glycated stuff is taken out of circulation; this recycling process is what usually prevents the A1c result from climbing above 6. However, if your glycation rate becomes accelerated, the recycling process can't quite keep up with it, and the A1c result goes up.

What causes the glycation rate to be elevated is an elevated concentration of sugar in the blood. And by "sugar" I don't just mean glucose; fructose, which your glucose meter cannot detect, also causes glycation, and in fact causes more glycation than glucose does. Limiting fructose in the diet is therefore important to your A1c result even though it doesn't affect your glucose meter results.

How do you limit dietary fructose? Well, we get some fructose from fruit, but these days most people get a lot more of it from sugar added to processed foods, so that's the most useful place to cut back on it.

"a1c test 6 weeks or 3 months"
"a1c time weighting"

This is a little complicated; bear with me.

Hemoglobin, the blood-protein which is measured by the A1c test, has a limited lifespan, because it is found in red blood cells, and red blood cells only last about three months before they are replaced. It is for this reason that the A1c test is often said to reflect average conditions over 3 months preceding the test. This oversimplifies the situation, however.

If all red blood cells were replaced simultaneously, and this happened once every three months on a known schedule, the A1c test could be administered on the day before all the cells were replaced, and in that case the test truly would reflect conditions over the preceding three months. That's not how it actually works, however. Red blood cells are recycled continuously; each day a small fraction of them are recycled.

So, if you take the test today, what can we say about the age of the red blood cells that are present in your blood? Well, it varies. Some of them are brand new, some are a month old, some are two months old, and some are very nearly three months old. But the distribution is uneven:

Because younger red blood cells are over-represented in the A1c test, and older red blood cells are under-represented, the test result is "weighted" toward the most recent month -- in other words, the test result tends to reflect conditions a month ago better than it reflects conditions three months ago.

The practical consequence of ths "weighting" toward the most recent month is that, if your glycemic control has been unusually good in recent weeks, the test result will be better than you'd expect, based on what was going on over the entire three months. (Of course, if your glycemic control has been unusually poor in recent weeks, the rest result will be disproportionately impacted by that, too!)

In short: the month before you're going to be taking an A1c test is the worst possible time to go on a Caribbean cruise.

"can you reverse effects of glycation by giving up sugar"

No doubt it would help to give up sugar (and limit your consumption of starches), so that the glycation rate falls and the protein-recycling process has a chance to catch up with it. But to say that this "reverses effects of glycation" might be an overstated claim. One of the "effects of glycation" is to promote the proliferation of toxic compounds known as AGEs (advanced glycation end-products), and these little nasties can cause harm to issues and organs -- harm which might not go away once you've lowered your blood sugar. Whether or not the body's healing processes will undo this harm, I don't know. But at least there won't be any more of this harm going on, if you can normalize your blood sugar and therefore normalize your A1c result.

"if you manage diabetes without medication will you live longer"

I hope that's true. At any rate, I'm going to be really pissed off if it's not.


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